Special Test For Orthopaedic Examination 4th MASUD

Jeff G .
Ko n i n, P h D, ATC, PT, FACSM, F N ATA

Professor a n d C h a i r, Physica l Thera py Department
U n ivers ity of Rhode I s l a n d
Ki ngsto n, R h o d e I s l a n d
Adj u nct Professor, Department o f Fa m i l y M e d i c i n e
Pri m a ry Ca re Sports M e d i c i n e Fe l l ows h i p
B rown U n iversity
Providen ce, Rhode I s l a n d
Den i se Le bsack, P h D, ATC
School o f Exe rcise & N utriti o n a l Sciences

Associ ate Professor, Ath l etic Tra i n i n g
San Diego State U n i versity

S a n Diego, Ca l ifornia
Al ison R. S nyd er Va l i e r, P h D, ATC, F N ATA

Professor, Ath l etic Tra i n i n g Prog ra m s
Department o f I nterd i sci p l i n a ry Hea lth Sciences
Assi sta nt D i recto r, Research S u p po rt
Research Professor, School of Osteo pat h i c M e d i c i n e in Arizo na
A. T. Sti l l U n iversity
Mesa, Arizo n a
J e ro m e A. "Ja i " lsear, J r., M S, PT, LAT, ATC

Co-Owner, S h o re l i n e Physical Thera py
Wi l m i ngton, N o rth Ca ro l i n a
H o l ly B rader Marakovits, M P H , RN, BSN, ATC

Coa uthor of Seco n d a n d Th i rd Editions
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N a mes: Ko n i n , J eff G ., a u t h o r. I Lebsack, Den ise, a u t h o r. I Va l i e r, Al ison
Title: Special tests fo r orthopedic exa m i nation I J eff G . Kon i n , Denise

Snyder, a u t h o r. I lsear, Jerome A., J r., 1 967- , a u t h o r.
Lebsack, A l i s o n Snyder Va l i e r, Jerome A. "Ja i " lsear, J r.

Description: Fou rth edition. I Tho rofa re, NJ : SLACK I n corporated, [201 6l I
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DEDICATION
To John Bond,
may yo u r next phase of life bring you
-Jeff G. Konin, PhD, ATC, PT, FACSM, FNATA

much h a p p i ness a n d s uccess.
To my stu d e nts,
who re m i n d me why I l ove tea c h i n g .
-Denise Lebsack, PhD, A TC
To my fa m i ly, fri ends, a n d co l l eagues.
-Alison R. Snyder Valier, PhD, ATC, FNATA

You a l l b r i n g much h a p p i ness to my l ife.
To M itzie, Brooks, Ha rrison, a n d Ja ckso n,

fo r being such true bl essi ngs in my life.
-Jerome A. "Jai" /sear, Jr., MS, PT, LAT, ATC
CONTENTS
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Foreword by Edwa rd G . McFa r l a n d, M D . . . . . . . . ... . . . . . .. . . . . ...
. . . xxv
Section 1 : Tem poro m a n d i b u l a r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chvoste k's S i g n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Loa d i n g Test . . . . . . . . . . . . . . . . . . ......... . . . . . . . . . . . . . . . ..... . . . 4

Pal pation Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 2: Cervica l S p i n e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Ve rtebral Artery Test . . . . . .............. . . . . . ..................8

Fora m i n a l Co m p ression Test (S p u r l i ng) . . . . . . . . . . . . . . . . . . . . . . . 10
Fora m i n a l Distraction Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Va lsalva's M a n e uver . . . . . ........... . . . . . ...... . . . . . . . . . . . . . 15 .
Swa l l ow i n g Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 7
T i n e l 's S i g n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Section 3 : S h o u l d e r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Em pty Ca n (S u p ras p i n atus) Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Ye rg ason Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Speed's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . 27
L u d i n gton's Sign . . . . . . . . . . . . . . ...... . . . . ..... . . . . . . . . . . . . . . . . 29

Drop Arm Test . . . . . . . . . . . . . . . ..... . . . . . ... . . . . . . . ..... . . . . . . . 31
Latera l Sca p u l a r S l i d e Test (LSST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Apl ey's Sc ratch Test . . . . . . . . . . ........... . . . . . . . . . . . . . . . . . . . . . 36

Cross-Over I m p i n g e m e nt Test . . . . . . . . .. . . . . . . . . ..... . . . . . . . . . 39
Posterior I m p i ngement Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
N eer I m pi n ge m e nt Test . . . ... . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . 44
Hawki ns-Ke n nedy I m pi ngem ent Test . . . . . . . . . . . . . . . . . . . . . . . . 4 6
Sternoclavi c u l a r (SC) J o i nt Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . 48
viii Con tents
Acro m i oclavicu l a r (AC) J o i nt Distraction Test . . . . . . . . . . . . . . . . . 49

Acro m ioclavi c u l a r (AC) J o i nt Co m p ression Test (S hear) . . . . . . . . 50
Piano Key Sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Apprehension Test (Anterior) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
A p p re h e n s i o n Test (Posterior) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
S u l c u s S i g n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Anterior D rawer Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Posterior D rawe r Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Jobe Relocation Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Su rprise Test (Active Release Test) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Fea g i n Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Load a n d S h ift Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
G r i n d Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
C l u n k Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Cra n k Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
O'Brien Test (Active Co m p ression) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
I
B ra c h i a P l exus Stretch Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Adson's M a n e uve r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
A l l e n's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Roos Test (Elevated Arm Stress Test) . . . . . . . . . . . . . . . . . . . . . . . . . . 90

M i l itary B race Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Gerbe r's Test (Lift-Off Test) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
J e rk Test (Posterior Stress) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Pa infu l Arc Sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Section 4: E l bow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 01
Resistive Te n n i s El bow Test (Cozen's Test) . . . . . . . . . . . . . . . . . . . . 1 02
Resistive Te n n i s El bow Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 04

Pass ive Te n n i s El bow Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 06
Golfer's El bow Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 08
Hyperextension Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 0
Con tents ix
E l bow Flexion Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Va rus Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Va l g u s Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 14
Ti n e l 's S i g n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Pi n ch G r i p Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Section 5 : Wrist a n d H a n d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 21
Ta p or Percussion Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 22
Co m p ression Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 24
Long F i n g e r F l exion Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 25
F i n kelstei n Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 27
P h a l e n Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 29
Reve rse P h a l e n Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 32
Ti n e l 's S i g n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 34
Froment's S i g n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 37
Wri n kl e Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 39
D i g ital A l l e n 's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 41
B u n n e l Littler Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 45
M u rp hy's S i g n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 47
Watson Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 48
Va l g u s Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Va rus Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 53
B a l l ottement Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 54
Section 6: Thoracic S p i n e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 57
Ke rn ig/Brudzi nski S i g n s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 58
Late ra l a n d Anterior/Posterior R i b Co m p ression Tests . . . . . . . . 1 61
I n s p i ration/Ex p i ration B reat h i n g Test . . . . . . . . . . . . . . . . . . . . . . . . 1 63
Section 7: L u m b a r S p i n e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 65
Va ls a l va's M a n euver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 66
Stoo p Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 68
H o over Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 70
x Contents
Ke rn ig/Brudzi nski S i g n s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 73
90-90 Stra i g ht Leg Raise Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 76
Bowstring Test (Cra m Test) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 78
Sitti ng Root Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 81
U n i l atera l Stra i g ht Leg Raise Test (Laseg u e Test) . . . . . . . . . . . . . 1 83
B i l atera l Stra i g ht Leg Raise Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 87
We l l Stra i g ht Leg Raise Test (Crossed Stra i g ht Leg Ra ise) . . . . . 1 89
S l u m p Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 91
Thomas Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 95
S p r i n g Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 99
Trendel e n b u rg 's Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Sto rk Sta n d i n g Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Section 8: Sacral S p i n e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Sacroi l iac (S I) Joint Fixation Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
G i l let Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Sacroi l iac (S I) Joint Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Sq u i s h Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Yeoma n's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Gaensle n's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Patrick o r FAB E R Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Lo ng-Sitt i n g Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Section 9 : Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Hip Sco u ri n g/Q u a d ra nt Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Cra i g 's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
90-90 Stra i g ht Leg Raise Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Patrick or FAB E R Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
Trendel e n b u rg 's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Obe r's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Pi rifo r m i s Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Thomas Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Contents xi
Ely's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

Femoral N e rve Tra ction Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Section 1 O : Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Pate l l a Te ndo n/Pate l l a Ligament Length Test . . . . . . . . . . . . . . . . 270

Pate l l a r A p p re h e n s i o n Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
B a l l ota ble Pate l l a o r Pate l l a Ta p Test . . . . . . . . . . . . . . . . . . . . . . . . . 275
Swee p Test (Wi pe, Brush, B u l g e, o r Stroke Test) . . . . . . . . . . . . . . 277
Q-An g l e Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
M e d i a l - Late ra l G r i n d Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
B o u n ce H o m e Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Pate l l a r G r i n d Test (C l a r ke's S i g n) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Re n n e Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
N o b l e Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
H u g h ston's P l i ca Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Godfrey 90/90 Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
Posterior Sag Test (G ravity D rawe r Test) . . . . . . . . . . . . . . . . . . . . . 297
Reve rse Pivot S h ift (Ja ko b Test) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Anterior La c h m a n 's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Anterior D rawer Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
I
S l o c u m Test With I nte r n a l Tibia Rotation . . . . . . . . . . . . . . . . . . . . 308
S l o c u m Test With Exte r n a l Tibia I Rotation . . . . . . . . . . . . . . . . . . . 3 1 0
Pivot S h ift Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1 2
J e rk Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
Posterior D rawe r Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1 9
H u g h ston Postero m ed i a l D rawer Test . . . . . . . . . . . . . . . . . . . . . . . 321
H u g h ston Posterolateral D rawer Test . . . . . . . . . . . . . . . . . . . . . . . . 323
Posterior Lach m a n's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Exte r n a l Rotation Recu rvat u m Test . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Dial Test (Ti b i a l Exte r n a l Rotation Test) . . . . . . . . . . . . . . . . . . . . . . 329
Va Igus Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Va rus Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
xii Con tents
McMu rray Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .340

Apley Co m p ression Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .344
Ste i n m a n 's Te nderness D i s p lacement Test . . . . . . . . . . . . . . . . . . . 347
Thessaly Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Obe r's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
Quad Active Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
Lel l i Test fo r Anterior Cru ciate Liga ment (ACL) I nj u ries . . . . . . .360
Section 1 1 : A n k l e a n d Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
H o m a ns' S i g n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .364
Anterior D rawer Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .366
Ta l a r Tilt Test (I nversion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
Ta l a r Tilt Test (Eversion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
Thom pson Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Ta p or Percussion Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
Feiss Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
l nterd i g ital N e u ro m a Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380

Co m p ress ion (Sq ueeze) Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Long Bone Co m p ression Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
Swi n g Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
Kleiger's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
Ti n e l 's Sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
Section 1 2 : Conte m porary Special Tests . . . . . . . . . . . . . . . . . . . 393
I m p i ngement Red uction Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394

Wa l ki n g Arm Stress (WAS) Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
F i n g e r Extension Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Fl exo r Pro n ator Syn d ro m e Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .402
Ta rsa l Twist Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .404
Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407

ACKNOWLEDGMENTS
W h e n t h e concept o f t h i s h a n d y g u i d e t o s p e c i a l tests w a s con
ceptu a l ized at Seacrets i n Ocea n City, M a ry l a n d, i n 1 995, none of us
ever d reamed we wo u l d be writi n g a fo u rth e d i t i o n s o m e 2 0 yea rs
late r.
We conti n u e to exte n d o u r g ratitude to each of you w h o h ave
re m a i n e d s u p p o rtive of the p roj ect. Without yo u r conti n u ed va l u
a b l e feed b a c k, we wo u l d not be a b l e to s u ccessfu l ly l a u n c h a n
i m p roved vers i o n . The wo r l d o f hea lth ca re i s c h a n g i n g i n s o m a ny
ways, a n d l i ste n i n g to yo u r m a ny i d e a s co n t r i b u tes to t h e va l u a b l e
i m p rove m e nts that w e t r y t o m a ke with e a c h u pd ated e d i t i o n . I t i s
t r u l y wonderfu l t o ta l k to s o m a n y o f y o u w h o g et excited a bo u t
t h e w a y t h i s h a n d bo o k h e l ped you g et t h ro u g h c l a ss ro o m l a bs a n d
tests, c l i n i c a l i ntern s h i ps, a n d u l ti m ately yo u r certification exa m .
T h e sto ries t h a t m a n y o f yo u h ave s h a red a bo u t t h i s b o o k bei n g
t h e m ost used a n d m o s t h e l pfu l t h ro u g h o ut yo u r c a re e r i s very
h u m b l i ng.
Twenty yea rs wo r k i n g w i t h the s a m e p u b l i s h e r i s a l so q u ite a n
acco m p l i s h ment. Kudos t o t h e peo p l e a t S LAC K I n corpo rated. We
re m a i n i n d e bted to J o h n Bond (C h i ef Conte n t Ed itor) a n d Pete r
S l a c k ( P res i d e nt) fo r bel ievi n g i n o u r i deas a n d trusti n g o u r fo re
s i g ht. To t h i s day, t h e i r s u p po rt and fri e n d s h i p a re seco n d to n o n e.
O u r s i n ce re tha n ks g o to J e n n ife r Ca h i l l (Se n i o r Project Ed ito r) a n d
A p r i l B i l l i c k (Ma n a g i n g Ed ito r) fo r a l l o f t h e i r h a rd wo rk o n t h i s p roj
ect. M ost of a l l, to B r i e n C u m m i n g s (Sen i o r Acq u i s i t i o n s Ed ito r) fo r
j u m p i n g on boa rd l i ke a c h a m p i o n a n d e n s u ri n g that we a l l stayed
on ta s k- n ot an easy t h i n g to do with a tra n s i t i o n of a ut h o rs res i d
i n g i n d iffe re nt geog ra p h i ca l t i m e zo nes. Despite tec h n o l ogy a n d its
a dde d ben efits, l o n g d i sta nce co l l a boration sti l l poses c h a l l e n g es.
S p e c i a l t h a n ks g o to the contri b utors who perfo r m e d the s i g
n ifi c a n t l egwork i n resea rc h i n g t h e m ost c u rrent peer- reviewed
m a n u scri pts fo r the s peci a l tests i n c l u d ed in t h i s e d i t i o n : Ke l sey
P i c h a , MS, ATC, a n d Ste p h Tri g sted, MS, ATC . U n d e r the g u i d a n ce
of A l i s o n Va l i e r, w h o s p e a r h e a d e d t h i s fo u rth e d i t i o n , Ke l sey a n d
Ste p h perfo r m e d ted i o u s, yet va l u a b l e, work contri b u t i n g t o a
s i g n ifi c a n t revi s i o n i n t h e fo rmat of t h i s e d i t i o n . Th i s ti m e - c o n
s u m i n g a n d d eta i l e d p rocess p l ays a vita l ro l e i n t h e recog n it i o n o f
evi d e n ce-based p ractice. I n a d d it i o n , we wo u l d l i ke to t h a n k Casey
H i l l, D PT, a n d J u st i n J a c a p r a ro, ATC, C PT, S PT, fo r t h e i r a s s i sta n ce
i n reviewi n g t h e text, fi g u res, a n d videos. F i n a l l y, we wo u l d l i ke to
xiv Acknowledgments
t h a n k S h a n n o n Matheny a n d D o u g l a s Pizac for g raciously pos i n g a s

exa m i n er a n d s u bject fo r i m ages a n d vid eos.
-Jeff G. Konin, PhD, ATC, PT, FACSM, FNATA

-Denise Lebsack, PhD, ATC
-Jerome A. ''Jai" /sear, Jr., MS, PT, LAT, ATC

ABOUT THE AUTHORS
Jeff G . Konin, PhD, ATC, P T, FACSM, FNATA i s a Professor a n d t h e C h a i r
o f the Physical Thera py Department a t the U n ivers ity o f R h o d e I s l a n d
i n K i n g ston, R h o d e I s l a n d . One o f the orig i n a l a uthors o f this textbook,
D r. Ko n i n is reco g n ized as a Fe l l ow by both the American Co l l eg e of
Sports Medicine a n d t h e Nati o n a l Ath l etic Tra i n e rs' Association fo r h i s
contri butio n s.
D r. Kon i n has p reviously held the positio n s of Di recto r of Ath l etics
at Eastern Co n n ecticut State U n iversity, Fa cu lty and Vice C h a i r of
Orthopaedics and Sports M e d i c i n e at the U n iversity of South Florida
( U S F), Executive Di recto r of the Sports M e d i c i n e a n d Ath l etic Rel ated
Tra u m a (SMART) I n stitute at U S F, D i rector of the G ra d uate Ath l etic
Tra i n i n g Prog ra m at U S F, a n d Health Sciences Fa c u l ty a n d Assista nt
Ath l etic Di recto r fo r Sports Medicine at Jam es Madison U n iversity.
D r. Kon i n is a l s o fo u n d i n g partner i n The Rehberg Ko n i n G ro u p, a fi rm
p rovi d i n g co n s u lt i n g in the a reas of sport safety and ed u cation, a n d
a fo u n d i n g m e m ber o f S port Safety I nternati o n a l , s pecia l izing i n the
del ivery of sport safety ed u cati o n a l resou rces.
D r. Ko n i n's p u b l ished wo rk a n d i nvited p rese ntations h ave focu sed
i n the a rea of sports m e d i c i n e with a p a rticu l a r i nterest in i nj u ry p re
vention and s po rt safety. He has s h a red his expertise at p rofessi o n a l
conferences t h ro u g hout the U n ited States, a s we l l a s i n Austra l ia, N ew
Zea l a n d, Ita ly, N o rway, Rom an ia, E n g l a nd, a n d Austria. H is experi
ences have i n c l uded servi n g o n the medical staff fo r t h e 1 996 Olym pic
Games a n d a s a medical coord i nator fo r the USA Wheelcha i r R u g by
Pa ra ly mpi c Tea m .
Denise Lebsack, PhD, ATC h a s been a n Associate Professor o f Ath l etic

Tra i n i n g i n the School of Exe rcise & N utriti o n a l Sciences at San Diego
State U n iversity (SDSU) s i nce 1 994. During much of that time s h e h a s
se rved as the Ath l etic Tra i n i n g Prog ra m D i recto r, a n d h a s coord i n ated
3 sepa rate Self Study Reports fo r the Ath l etic Tra i n i n g Education
Prog ra m's acc red itation. As pa rt of that p rocess and her ro l e as an
ath l etic tra i n i n g e d ucator, D r. Le bsack h a s deve l o ped a p h i losophy
that seeks to optim ize student learn i n g and ed ucati o n a l outcomes.
Her goal i s to p rovi d e students with educati o n a l too l s that aid i n the
learn i n g p rocess and that i n sti l l aca d e m i c i n q u i ry a n d u n d e rsta n d i n g .
W h e n D r. K o n i n fi rst a p p roached h e r with t h e orig i n a l b o o k i d ea, s h e
xvi About the A uthors
i m med iately knew it was a p roject that fit perfectly with her educa
tiona l p h i losophy a n d goa l s fo r her stude nts.
In kee p i n g with these goal s, D r. Le bsack was a l so a n a u t h o r fo r a
2-disc CD-ROM series on spec i a l tests u sed d u ri n g the i nj u ry eva l ua
tion p rocess that i n corporated video d e m o n stration a n d a n ato m i c a l
re p resentation o f a positive test res u lt. H e r i nterest i n i n structi o n a l
tech n o logy led t o seve ra l p u b l ished a rticles eva l uati ng the effec
tive n ess of tec h n o logy in the classroo m . G iven her resea rch a n d
experience as a n ed u cator, s h e w a s i nvited t o be a G u est Editor fo r
the Journal of A thletic Training's S peci a l I s s u e o n "At h l etic Tra i n i n g
Ed ucation" (2002;3 7 [4] ) . She h a s a l so coa uthored t h e textbook The
A thletic Trainer's Guide to Strength and Endurance Training.
D r. Le bsack c u rrently spends her time focused o n the class room
a n d e n g a g i n g stu d e nts i n the learn i n g p rocess. S h e se rves a s a fa cu lty
advisor fo r the SDSU stu dent organ ization Future Ath l etic Tra i n e rs'
Society, a n d actively p rom otes ath letic tra i n i n g education in the com
m u n ity. She has beco me a big proponent and s pokes person fo r men
ta l health awa re ness for both student-ath l etes a n d ath l etic tra i n i n g
stu d e nts. Outside o f wo rk, h e r t i m e i s spent enjoy i n g t h e adventu res
of ra i s i n g her 2 teenagers, A n n a m a rie a n d EJ.
Alison R. Snyder Valier, PhD, ATC, FNATA i s a Professor fo r the Post

Professi o n a l Ath l etic Tra i n i n g Prog ra m a n d Doctor of Ath l etic Tra i n i n g
Prog ra m a t A . T. Sti l l U n ive rsity (ATS U) i n Mesa, Arizo n a . S h e a l so se rves
a s the Assistant D i recto r of Resea rc h S u p po rt t h ro u g h Research,
G ra nts, and I nfo rmation Tec h n o l ogy Systems, a s we l l a s a research
fac u lty i n the School of Osteopath ic M e d i c i n e-Arizona, at ATS U.
D r. Va l i e r received h e r BA d e g ree i n psycho logy a n d p hysica l edu
cation fro m Whitman Co l l eg e (Wa l l a Wa l l a, Wa s h i ngton) a n d h e r MS
i n exe rcise p hys i o l ogy at the U n iversity of To ledo (To l edo, Oh io). I n
add ition, s h e received h e r P h D i n exe rcise science fro m t h e U n ivers ity
of To ledo, where she m aj o red in a p p l ied phys i o l ogy a n d co m p l eted
a m i n o r in h u m a n a n ato my. D r. Va l i e r co m p l eted a Post- Doctora l
Research Fe l l ows h i p i n C l i n ical Outco mes Research, with em phasis
o n the eva l uation of patient-repo rted o utco mes i n stru m e nts and
e p i d e m i o l ogy, awa rded to h e r by the Natio n a l Ath l etic Tra i n e rs'
Association Resea rch a n d Education Fo u n d ation (NATA REF). Her fe l
l ows h i p has s h a ped her tea c h i n g a n d resea rch e m p hasis, w i t h m o s t of
h e r foc u s on c l i n ical outcomes assessme nt, patie nt-repo rted outcome
About the A uthors xvii
measu res, health-re l ated q u a l ity of l ife, sports i nj u ry e p i d e m i o l ogy,

a n d q u a l ity i m p rovement. S h e p resents a n d p u b l ishes on these top
ics reg u l a rly and i s a Fel l ow of the NATA. Over the yea rs, D r. Va l i e r
has se rved the p rofession i n m a ny ways, i n c l u d i n g being a m e m
ber o f the NATA Pro n o u n cem ents Co m m ittee, NATA REF Research
Co m m ittee, and the Rocky M o u n ta i n Ath l etic Tra i n e rs' Association
(RMATA) Progra m m i n g Co m m ittee. S h e a l so se rves a s the Co-C h a i r
o f the Arizona Ath l etic Tra i n e rs' Association Governm enta l Affa i rs
Co m m ittee a n d se rved as the C h a i r of the Free Com m u n ication
p rog ra m fo r t h e RMATA fo r severa l yea rs. D r. Va l i e r l ives i n G i l be rt,
Arizona, with her h u s band, Sean, a n d son, Al be rt.
PREFACE
The fo u rth edition of Special Tests for Orthopedic Examina tion was
designed to fo l l ow o u r i n itial g o a l s of p rovi d i n g a s i m p l e pocket-sized
m a n u a l fo r practica l learn i n g p u rposes. Co n s i stent with p revious edi
tions, we u pd ated the content by both re m ovi ng a n d adding a few
tests. And i n kee p i n g with the tra d ition of e n h a n c i n g each version,
the fo u rth edition featu res i m p rove m e nts that we think wi l l be we l l
received. L i kely t h e bigg est c h a n g e that you wi l l notice i s t h e i n c l u
sion o f a section titled " Evi dence" where w e have h i g h l i g hted sys
tematic revi ews, meta-a n a lyses, or s i n g l e a rticles that have add ressed
the re l i a b i l ity a n d/or d i a g n ostic accu racy of the special tests. We've
i n c l uded evi dence in t h i s edition as a response to o n e of the most
co m m o n req uests we received fro m fo r m a l reviews and i nfo rmal
feed back. You wi l l n ote that some tests h ave evid e n ce a n d others d o
n ot. Some o f the evi dence i s i n s u pport o f tests a n d some is n ot. The
ra n g e o r s p read of some of the d ia g n ostic accu racy va l u es i s wide
and this may m a ke some rea d e rs a l ittl e u n s u re of whether o r not to
use a p a rti c u l a r test. Consistent with p revi o u s editions of this text, we
d o n't m a ke the decision o n w hi ch tests to use fo r the c l i n i c i a n beca use
there a re m a ny consid erations that come i nto play when sel ecti ng a
test. F u rther, we p u r posefu l ly d i d not exc l u d e tests without evidence
to s u p port their effectiveness beca use c l i n ical d iscussion has favo red
t h e i r e m p i rical use. Once a g a i n, we c h a l l e n g e each of you to come to
yo u r own co n c l u s io n s, a n d perhaps fo r m u l ate yo u r own resea rch to
su pport or refute tests with l i m ited or no evid e n ce. W h i l e in past edi
tions we h ave a l ways conti n u ed to d e m o n strate these 3 - d i m e n s i o n a l
tests as best w e ca n i n a 2-d i m e n s i o n a l fo rm at, t h i s e d i t i o n i s accom
pan ied by a n c i l l a ry material ava i l a b l e o n the p u b l is h e r's webs ite
depicti n g videos fo r each test. The add ition of the videos s h o u l d h e l p
c l i n i c i a n s with bette r u n d e rsta n d i n g the test motion a n d perfo r m i n g
them accu rate ly. It i s o u r h o pe t h a t y o u wi l l a p p reciate this m u c h
needed, extremely h e l pfu l a d d ition.
SPECIAL TESTS: A KEY CLINICAL SKILL

Webster defines the word "special" as "d isti n g u ished by some u n usu
a l q u a l ity" a n d "d esig ned for a particu l a r pu rpose or occasio n;' a n d the
word "test" as "a critica l exa m i nation, observation, o r eva l uation:'
I n a ny orthoped ic eva l uation p rocess, t h e use of s peci a l tests
assists to p rovid e critica l info rmation l ea d i n g to, confi r m i ng, ru l i n g i n ,
xx Preface
ru l i n g o ut, a n d m o n ito r i n g the status of a p a rticu l a r d i a g nostic co n d i

tion. It i s n o wo n d e r then t h a t i n the d a y o f d i a g n ostic i m a g i n g a n d
advan ced tec h n o l og i c a l i nterventions c l i n i c i a n s often resort t o t h e
basic s ki l l s o f m a n u a l exa m i nation fo r a s e n s e o f comfort d u ri n g t h e
exa m i nation p rocess.
As stated in the p revi o u s 3 editions of this text, spec i a l tests a re
merely o n e p a rt of the eva l uation p rocess that a l s o re l ies heavily o n
h i story ta ki n g, sym pto m s, d i a g n ostic fi n d i n gs, a n d o t h e r i nfo rmation
fro m the patie nt, among m a ny other co m po n e nts. Yet i n the a l g o
rit h m i c a p p roach to determ i n i n g what m u scu l os ke l eta l a n d/or neu
ro logical structu res may o r may not h ave been d a m aged, key spec i a l
tests often co m e i n h a n dy.
It is i m portant to fu rther e l a b o rate on h ow we as a u t h o rs chose to
i n c l u d e the s peci a l s tests wit h i n the book, a n d h ow we s u g g est you
use the i nfo rmation to be effective a s a c l i n icia n . The co m p i lation of
the tests in t h i s book refl ect a n u m ber of ways of t h i n ki n g . Fi rst, tests
i n c l uded a re ones that the ed itors have seen co m m o n ly docu m e nted
a n d descri bed in n u m e ro u s orthopedic a n d sports medicin e-rel ated
textbooks as we l l as t h ro u g h c l i n ical p ra ctice experi ences. S i n ce the
fi rst edition of this book, there h a s been adva n cement i n t h e study
of these tests, h owever, we sti l l h ave a long way to go. As you exp l o re
the selectio n of special tests, you wi l l fi nd that some tests h ave been
stu d i ed and we know m o re a bout thei r a b i l ity to rule i n and rule out
co n d itions now t h a n befo re. You wi l l a l so fi n d that many tests have
not been stu d ied. W h i l e we d o n't know a bout the re l i a b i l ity, va l i d
ity, o r d i a g nostic accu racy o f t h e s e u n exa m i n ed special tests, they
a re conti n u a l ly p u b l ished a n d ta u g ht i n cu rricu l a a n d used i n c l i n ica l
p ractice. I n c l u s i o n of these tests may not seem to j ive with the cu rrent
agenda of evidenced-based m e d i c i n e, yet h ow can one c h a l l e n g e
a c l i n i c i a n who reg u l a rly u s e s a p a rti c u l a r s peci a l test a n d h a s accu
racy i n d i a g n ostic decision m a k i n g and treatment i ntervention that
i s p a rti a l l y a res u l t of the s peci a l test a n d its fi n d i n g s o r lack the reof?
G iven t h i s fact, we wi l l conti n u e to i n c l u d e u n exa m i ned spec i a l tests
in hope that either one day such tests wi l l h ave d e m o n strated va l i d ity,
re l i a b i l ity, a n d/o r d iag nostic accu racy or we as i n d ivi d u a l ly ta l e nted
c l i n ic i a n s with i n o u r own rig hts wi l l co me to rea l ize the fu ncti o n a l
i t y o f t h ese test may n ot be s i m ply cla ssified a s "yes, it works" o r "no,
it does n't wo rk:' After a l l, p a rt of evidence-based medicine is a l so to
determ i n e the "h ow's" a n d "when's''. H ow do swe l l i n g, pa i n , a n d ra nge
of m otion l i m itations i n fl ue n ce the effective n ess of a special test?
H ow does the experience of the exa m i n i n g c l i n i c i a n i n fl u ence the
Preface xxi
fi n d i ngs? What a bout the c l i n icia n's h a n d size, heig ht, sett i n g, a n d
even beds i d e m a n n e r when perfo r m i n g a test? T h e s i m p l e message
h e re i s that reg a rd l ess of h ow much evi dence i s reviewed a n d wh ic h
wa y the evi de nce poi nts, some speci al tests may o r may n o t wo rk i n
t h e h a n d s o f d iffe rent i n d ivid u a l s o r with d iffe rent patient p resenta
tions. And, the ava i l a b l e l iterat u re i s not exh a u stive i n co nsideri n g a l l
o f these situations. Once a g a i n , i n t h e word s o f D r. J o e G i eck, "At fi rst
you do what you're ta u g ht, a n d then you do what works:'
W h i l e it is o u r bel ief that each c l i n ic i a n s h o u l d j u d g e fo r h i m - o r
h e rself whether there i s benefit o f u s i n g a p a rticu l a r test i n a s pecific
c l i n ica l c i rc u m sta n ce, m a k i n g i nfo rmed decisions i s i m po rta nt, too.
Ove r the yea rs, diffe rent resea rch tea m s have eva l u ated m a ny of the
tests i n c l u d ed i n this book, a n d we fee l that it i s usefu l to c l i n ic i a n s
t o h ave exa m p les o f the ava i l a b l e i nfo rmation t o h e l p i n decision
making. Evi de nce ca n help i nfo rm c l i n ical decisions. So, fo r the fi rst
ti me, we h ave i n c l uded evi dence reg a rd i n g re l i a b i l ity, sen sitivity, a n d
s pecificity o f t h e s peci a l tests, where ava i l a b l e.
Reca l l that re l i a b i l ity refe rs to the re p rod u c i b i l ity of the test a n d i s
captu red w i t h va rious statistica l mea s u res s u c h a s t h e i ntraclass cor
re lation coefficie nt, refe rred to as the I CC, a n d the Ka ppa coefficie nt.
Rel i a b i l ity ca n be co m p uted fo r m u lt i p l e scores fro m one rate r, ca l l ed
i ntra rater re l i a b i l ity, or it can be ca l c u l ated between m o re than o n e
rater, ca l l ed i nterrater re l i a b i l ity. Rel i a b i l ity va l u es c l oser t o 1 s u g g est
m o re re l i a b i l ity in the sco r i n g system t h a n va l u es closer to zero. Let's
co nsider the Ober's Test that is used to test fo r i l ioti b i a l band tig ht
ness. One study has fo u n d that the i ntra rater re l i a b i l ity of the Ober's
Test is .90, wh i c h s u g g ests that the test is h ig h ly re l i a ble.
Sens itivity a n d s pecificity speak to t h e d i a g n ostic accu racy of
mea s u rement o r scree n i n g tools, i n c l u d i n g spec i a l tests. Sensitivity
speaks to o u r a b i l ity to r u l e out a health co nd ition, s u c h as a l i g a ment
tea r, whereas s pecificity helps u s r u l e i n a hea lth co n d ition. Va l u es fo r
sens itivity a n d specificity m a y be re ported d iffere ntly, but g e n e ra l ly
a re i n the ra nge of 0 to 1 00, with va l u es closer to 1 00 havi n g g reater
d i a g n ostic a b i l ity t h a n va l u e s closer to 0. Let's co n s i d e r the Anterior
Lac h m a n's Test that i s used to check fo r a nterior cruciate l i g a ment
(AC L) tears. Two rece nt m eta-a na lyses reported the sens itivity a n d
s pecificity o f t h e Anterior Lac h m a n's Test. W h i l e the repo rted va l
ues fro m these meta-a n a l yses a re s l i g htly d ifferent, with sens itivity
re ported as 8 1 a n d 8S a n d s pecificity as 8 1 a n d 94, t h e va l u es i n either
case a re, g e n e ra l ly speaking, high. The high sensitivity of the Anterior
Lac h m a n's Test mea n s that a neg ative fi n d i n g co u l d rule out a n ACL
xxii Preface
tea r. The h i g h specificity of the Anterior La ch m a n's Test me an s that a

positive fi n d i n g could r u l e i n a n ACL tea r. W h i l e there a re other va l ues
that help with eva l uating the d iag nostic accu racy of tests, such as
l i ke l i h ood ratios a n d positive a n d negative p red ictive va l u es, we have
focused o n sensitivity and s pecificity beca use they a re co m m o n l y
re ported i n d i a g n ostic accu racy stu d i es a n d t e n d t o be co n stant
across m u lt i p l e sa m p les and popu l ations. Other i n d ices m u st be c u s
tom ized for the s a m p l e of i nte rest, based on the expected p reva l e nce
of the co n d ition of interest with i n the p o p u l ation fro m w h i c h the
sa m p l e was d rawn.
Beca use t h i s i s not meant to be a research text, but i n stead a q u ic k
resou rce fo r c l i n i c i a n s, it wi l l be h e l pfu l t o d e s c r i b e o u r p rocess fo r
evi de nce selection a n d p resentation. We co u l d h ave cond u cted o u r
search i n m a ny ways. After ca refu l t h o u g h t a n d consideration, we
focused on an a p p roach to fi nd the best type of s u m m a ry evid e n ce
ava i l a ble. S u m m a ry evidence, s u c h as fro m syste matic reviews a n d
meta-a n a l yses, typica l l y is co n s i d e red t o h ave a h i g h l evel o f evid e n ce
a n d is the type of evi dence we s o u g h t to i n c l u d e i n the book. I n iti a l ly,
we sea rched major search e n g i nes, s u c h as Pu bMed, fo r key words
that i n c l uded the test n a m e, body pa rt o r body reg i o n eva l uated,
and i nj u ry. Other key words i n c l uded spec i a l tests, orthoped ic tests,
p rovocative tests, sensitivity, s pecificity, a n d re l i a b i l ity. O u r search
ing p rod u ced n u merous a rticles fro m which to d raw i nformation.
Whenever poss i b l e, we have re ported evi dence fro m syste matic
reviews and meta-a na lyses. H oweve r, not all special tests h ave been
stu d ied and of those that have been stu d i ed, not a l l h ave been p a rt
of a syste matic review or meta-a na lysis. So, when we d i d n't fi n d evi
dence fro m a syste matic review o r meta-a na lys i s, we selected a cou
ple s i n g l e stu d ies and h ig h l ig hted thei r fi n d i n g s. O n ce a rticles we re
ide ntified, we p u l led basic i nfo rmation a bout the stu d i es, i n c l u d i n g
a ny i nfo rmation o n re l i a b i l ity, sens itivity, a n d s pecificity, a n d p u t it
i nto a ta b l e fo r easy viewi n g . Eve n t h o u g h we h ave i n c l u ded evid e n ce
i n t h i s edition, it's i m portant to n ote that editi n g t h i s text does not
re nder us a uthorities of spec i a l tests, but rather p roviders of i nfo rma
tion. As one kn ows, pee r-reviewed m a n u scri pts can be d i scu ssed in
fo r u m s of p rofess i o n a l s who d o not ag ree o n the i nterpretation of the
m a n uscript, the statistic used, a n d sometimes even the accu racy of
the conclusions. Dete rm i n i n g whether o r not a spec i a l test referred to
i n t h i s book should be used by a c l i n ic i a n o r not i s beyo n d the g o a l of
t h i s book. It i s our bel ief that each c l i n ic i a n should j u d g e fo r him- o r
h e rself a s t o whether o r n o t a p a rti c u l a r test i s fo u n d t o be u sefu l i n
Preface xxiii
certa i n c i rcu m sta n ces with i n h i s o r her own ortho ped ic assessment,
and we have p resented evidence to h e l p in m a k i n g that j u d g ment.
It i s also i m portant to co nsider where a spec i a l test fa l l s in the
overa l l concept of evi dence-based p ractice. Most medical and health
care p rofess i o n a l s believe that i n add ition to the act u a l resea rc h
based fi n d i n g s rel ated to a spec i a l test, tec h n i q ue, o r i n tervention,
there a re oth e r i m po rta nt factors that exist that assist i n d eterm i n i n g
what act u a l l y co n stitutes a s "g ood" overa l l evidence. S pecifi ca l l y, the
experi ence a n d expertise of a n i n d ivid u a l c l i n ician, a n d the perceived
and act u a l va l u e a s repo rted by the patie nt, both play an i nteg rated
ro l e in esta b l i s h i n g a fi n a l d etermi nation. Th u s, to reite rate, it i s d iffi
c u l t with m a ny of these special tests to s i m ply co n c l u d e whether one
"wo rks" o r "d oes n't wo rk:'
I n s u m m a ry, the fo u rth edition was needed a n d b r i n g s some new
featu res fo r the rea der. We've e njoyed putting it together! As a l ways,
we re m i n d you that special tests a re m e rely a piece of the puzzle
that ass ist i n the eva l uation p rocess. W h i l e yo u p i ece yo u r puzzles
toget h e r, we hope that this n ew edition wi l l p rovide you with a h an d y
t o o l fo r p ro b l e m solvi ng.
-Jeff G . Konin, PhD, ATC, P T, FACSM, FNATA

-Denise Lebsack, PhD, ATC
-Jerome A. "Jai" /sear, Jr., MS, PT, LAT, ATC

FOREWORD
I t i s a special h o n o r fo r me t o write t h e Fo reword t o t h i s b o o k fo r
several rea sons. Fi rst, I have known D r. Kon i n fo r m a ny yea rs p rofes
s i o n a l ly, and h e has asse m bled an experie n ced g ro u p of a u t h o rs
who have co n s i d e ra b l e expertise i n the exa m i nation of patients with
m u s c u l os ke l eta l co m p l a i nts. Their scho l a rs h i p and i nteg rity i s without
re p roa c h .
T h e seco nd reason i s t h a t a s a n a uthor o f t h i s Fo reword I a m join
i n g d i sti n g u ished n a mes l i ke Cra i g Deneg a r, P h D, PT, ATC, F N ATA; J i m
And rews, M D; a n d M a r k M i l ler, M D ! Ve ry fl atte r i n g .
T h e t h i rd rea son i s t h a t the physical exa m i nation i n orthoped ic
s u rg e ry h a s fo r a long time been a favo rite fi eld of i nterest fo r me.
What sti m u l ated me to be i nterested i n this to pic was that m a ny of the
physical exa m i nation tests that I was ta u g h t a s a medical student, a s
a n orthoped ic reside nt, a n d a s a sports medicine fe l l ow s i m p l y d i d not
seem to be h e l pfu l in c l i n ica l p racti ce. For exa m p l e, l i ke m a ny peo p l e I
was ta u g ht that a S peed's Test was d i a g n ostic of biceps te n d o n p rob
lems, but m a ny of the patients who had a positive test were fo u n d to
have n o biceps te n d o n path o l ogy at all when a n a rth rosco py wa s per
formed. M a ny had other pathologies that wo u l d exp l a i n their "biceps
pa i n :' It i s now a p p reciated that a nterior s h o u l d e r pain can be d u e
t o stiffness, a rth ritis, rotato r c u ff synd ro mes, o r a ny n u m ber o f oth e r
pat ho l og i es. W h e n scientifica l ly stu d ied, the l iteratu re d e m o n strates
that the S peed's Test has l a rgely low sensitivity o r s pecifi city fo r biceps
disord e rs. I sti l l use a S peed's Test j u st fo r fu n but d o not hang my hat
on a ny d i a g nosis u s i n g that test a l one. The a uthors correctly state a n d
demonstrate a g a i n i n t h i s b o o k t h a t a correct d i a g nosis sta rts with a
ca refu l h i sto ry a n d thoro u g h exa m i n ation, but one m u st know how to
do the exa m i nation fi rst.
Which b r i n g s me to what i s wo nderfu l a bout the new fo rmat of
t h i s book. The a uthors h ave not lost the m a i n goal of havi n g a h a n dy
g u ide that defi n es a s pecific test a n d that s h ows one h ow to perform
the test. I t i s a g reat book fo r the pocket o r wh ite coat to refe r to at
short n otice. This a p p l ies to every joint fro m the fi n g e rtips to the toes
i n c l u d i n g the s p i ne. As a resu lt, this book sti l l has a p peal fo r a nyo ne
who d oes m u s c u l os ke l eta l m e d i c i n e, whet h e r n ovice o r expe rienced
i n the fi eld.
The seco n d wo n d e rfu l t h i n g a bout t h i s book i s that the a u t h o rs
u pd ated it with new tests a n d re m oved some p rove n not to be h e l p
fu l . It is not a stati c but a dyn a m i c book i n that reg a rd . There a re new
xxvi Foreword
fi g u res i n t h i s book a n d new i nformation; it is not j u st a re hash of o l d

informatio n . T h e m o s t i m portant a d d ition i n t h i s e d i t i o n o f t h e book
i s t h e i n c l u s i o n of scie ntific i nfo rmation a bout the c l i n i cal u sefu l ness
of the tests. When tea c h i n g stu d e nts, reside nts, o r a nyo n e else a bout
m u scu l os ke l eta l exa m s, I te l l them there a re 3 leve l s. The fi rst i s to
learn what the name of the test is a n d h ow to d o it. The n ext i s to
know the mea n i n g of the test a n d what i s a positive test a n d what i s a
negative test. The t h i rd l evel is to know h ow to i nterpret the test a n d
h o w accu rate it i s i n h e l p i n g t o m a ke the d i a g n osis. T h i s t h i rd l eve l i s
w h a t i s exciti n g a bout t h i s book beca use it hel ps a nyo n e d o i n g these
exa m i nations u n dersta n d why the res u l t may o r may not esta b l i s h a
d i a g n osis. Some tests a re g reat for m a k i n g a d i a g nosis a n d some sti n k.
As the a u t h o rs say, it is u p to each i n d ivi d u a l to use the tests a n d to
get a n i m p ress ion of what wo rks a n d what does not work. Th i s book
reinforces those i m p ressions with h a rd data to g ive the exa m i n e r a
g u i d e as to whether to trust a test or n ot.
The m u scu l oskel eta l exa m i nation i s a dyna m i c s ki l l that d oes not
stay static; our a p p reciati o n of what works and what does not work
a l so c h a n g es as m o re exa m i nation tests a re descri bed and a s m o re
tests a re stu d i ed scie ntifical ly. Th i s book n ow does it a l l : how to per
form a n d to u n d ersta n d the m u sc u l os ke l eta l exa m i nation for the
beg i n n e r, the "expe rt;' a n d everyon e i n between.
-Edward G . McFarland, M D
The Wayn e H . Lewis Professor o f S h o u l d e r S u rgery
Department of Orthopaedic S u rgery
The J o h n s H o p k i n s U n iversity
Baltimore, M a ry l a n d
Temporomandibul ar
Guide to Figures
d e n otes patient's m ovement
d e n otes exa m i n e r's m ovement
d e n otes ta p p i n g
denotes p a l pation
denotes sta b i l ization
Konin JC, Lebsack D , Snyder Valicr AR, lscar JAJr.

Special Tests}Or Orthoptdic Examination, Fourth Edition (pp 1-6).
© 2016 SLACK Incorporated.
2 Section 1
CHvosTEK 's S1GN

TEST POSITIONING
The s u bject ca n either sit o r sta n d .
ACTION
The exa m i n er taps over the ma ssete r m u sc l e a n d pa roti d g l a n d
(Fig u re Tl - 1 ) .
F i g u re Tl - 1 .
POSITIVE FINDING
Twitc h i n g of t h e fac i a l m u scl es, especia l l y the masseter, i n d icates
positive fi n d i n g s fo r fa c i a l n e rve pathol ogy.
SPECIAL CONSIDERA TIONS/COMMENTS

Twitch i n g of the fac i a l m u sc l es may a l so be a res u lt of low ca l c i u m
leve l s i n the b l ood. A pos itive fi n d i n g o f t h i s natu re has a l so been
referred to a s a Weiss S i g n .
Temporomandibular 3
REFERENCES
H a s a n Z U , Absa m a ra R, A h med M . C h voste k's s i g n i n paed iatric p ra ctice.
Curr Pedia tr Rev. 2 0 1 4; 1 0(3): 1 94- 1 97.
Ku g e l b e rg E. The m e c h a n i s m of C h voste k's s i g n . AMA A rch Neural
Psychia try 1 95 1 ;65 (4) :5 1 1 -5 1 7 .
U rba n o F L. S i g n s of hypoca l c e m i a C h voste k's a n d Tro u ssea u 's s i g n s.
Hosp Physicia n. 2000;36(3) 43-45 .
4 Section 1
LOADING TEST
TEST POSITIONING
The s u bject sits u prig ht in a cha i r.
ACTION
The exa m i n er p l aces a cotton ro l l between the m o l a rs on the u n i n
vo lved side a n d i n stru cts the s u bject to b ite d own fo rcefu l ly.
POSITIVE FINDING
The re porti ng of pa i n on the i nvo lved side by the s u bject i n d icates
a positive fi n d i ng, whi ch may be refl ective of an a nteri orly d i s l ocated
d i sk.

The s u bject may be i n stru cted to chew on the cotto n as o p posed
to fo rcefu l ly biti n g down . A positive fi n d i n g fo r p a i n may s u g g est a ny
n u m be r of temporoma n d i b u l a r pathologies.
REFERENCES
C h i n L P, A ke r F O, Za rri n n i a K. The viscoe l a stic p ro p e rties of t h e h u m a n
tem poro m a n d i c u l a r j o i nt d i s k. J Ora l Maxillofac Surg. 1 996;54(3)3 1 5 -
3 1 8.
H u d d l eston S l ater JJ, Vi sscher CM, Lo bbezoo F, N a e ij e M The i ntra-a rticu l a r
d i sta nce with i n t h e TMJ d u ri n g free a n d loaded c l o s i n g move m e nts.
J Den t Res. 1 999;78 ( 1 2) 1 8 1 5- 1 820.
J o n s s o n C, Ecke rd a l 0, l s b e rg A Th i c kn e s s of the a rti c u l a r soft t i s s u e of t h e
te m po ra l com p o n e n t i n te m po ro m a n d i b u l a r j o i nts w i t h a n d with
o u t disk d i s p l a c e m e n t Ora l Surg Med Ora l Pa thol Oral Radio! Endod
1 999;8 7 ( 1 ) :20-26
N a e ij e M, H ofm a n N. B i o m ec h a n i cs of the h u m a n te m poroma n d i b u l a r
j o i n t d u ri n g c h ewi n g J Den t Res. 2003 ;82(7):5 28-5 3 1 .
N i c ke l J C, Iwa s a ki LR, Beatty MW, M a rx D B . La boratory stresses a n d trac
ti o n a l fo rces o n t h e TMJ d i sc s u rface J Den t Res. 2004;83 (8) 65 0-654.
Wa l i l ko T, B i r C, Godwi n W, Ki n g A Relati o n s h i p betwee n te m po ro m a n
d i b u l a r j o i n t dyn a m i cs a n d m o u t h g u a rd s : fea s i b i l ity o f a test m et h o d .
Den t Tra umata! 2004;2 0 (5) 2 5 5 -260
Temporomandibular 5
PALPATION TEST
TEST POSITIONING
The s u bject sits u p rig ht i n a c h a i r.
ACTION
The exa m i n e r faces the s u bject a n d p l aces h i s o r h e r fifth d i g its i n
t h e s u bject's ea rs. T h e s u bject is i n structed t o repeated ly o p e n a n d
close the m o u t h w h i l e the exa m i n e r a p p l ies p ress u re i n a n a nterior
d i rection using the pads of the fifth d i g its (Fig u res T1 -2A and T1 -2B).
Figure T1 -2A.
6 Section 1
Figure T1 -2B.
POSITIVE FINDING
The s u bject's report i n g of p a i n or d i scomfort d u ri n g the o p e n i n g
a n d c l o s i n g o f the mouth when p res s u re i s a p p l ied i n d i cates a posi
tive test. This may be a res u lt of i nfl a m mation to the synovi u m of the
temporoma n d i b u l a r joint (TMJ ) .

The s u bjective re porti ng of pa i n ca n be a res u l t of any pathology
to the TMJ.
REFERENCES
C h a s e DC H e n d l e r B H . S p e l l i n g re l i ef fo r TMJ t ro u b l e s . Pa tient Care.
1 988;2 2 ( 1 2) 1 5 8.
H a l ey D P, S c h iffm a n E L, L i n d g re n B R, A n d e rs o n Q, A n d re a s e n K. The re l a
ti o n s h i p betwe e n c l i n i ca l a n d M R I fi n d i n g s i n pat i e n ts w i t h u n i l atera l
te m poroma n d i b u l a r j o i n t pa i n . J Am Den t Assoc 200 1 ; 1 3 2 (4) 476-48 1 .
H u d d l e ston S l ater JJ, Lo b bezoo F, Va n Se l m s M K, N a e ije M Recog n it i o n of
i ntern a l d e ra n g e m e n ts. J Ora l Reha bil. 2004;3 1 (9) 85 1 -854.
Please see videos on the accompanying website at

www.healio.com/books/specialtestsvideos
Cervical Spine
Guide to Figures
d e n otes p a l pation
d e n otes sta b i l ization

Special TestsJOr Orthopedic Examination, Fourth Edition (pp 7-19).
8 Section 2
VERTEBRAL ARTERY TEST

TEST POSITIONING
The s u bject l ies s u p i n e, a n d the exa m i n er sits with both h a n d s
II
s u pport i n g the s u bject's head.
ACTION
S l owly exte nd, rotate, a n d l atera l l y flex the s u bject's cervi ca l s p i n e
t o e a c h s i d e . T h e n observe the s u bject fo r d izzi n ess, b l u rred vision,
nysta g m u s, s l u rred speech, o r loss of consci o u s n ess ( Fi g u re CS2- 1 ) .
E a c h position s h o u l d be h e l d fo r a p p roxi m ately 30 seconds.
F i g u re CS2- 1 .
POSITIVE FINDING
Dizz i n ess, b l u rred vision, nysta g m u s, s l u rred s peech, or loss of
consci o u s n ess a re i n d i cative of p a rti a l o r co m p l ete occl usion of the
vertebral a rte ry.

The afo re m e n t i o n e d s i g n s a n d sym pto m s s h o u l d be co n s i d e red
contra i n d icat i o n s fo r treat m e nts s u c h a s tract i o n and j o i n t m o b i l i
zat i o n s .
Cervical Spine 9
REFERENCES
Cote P, Kreitz BG, Cassidy J O, Th i e l H . The va l i d ity of t h e exte n s i o n - rotation
test a s a c l i n ica l s c ree n i n g p roced u re befo re n e c k m a n i p u l a t i o n : a sec
o n d a ry a n a lys i s J Ma n ipula tive Physiol Ther 1 996; 1 9 (3) 1 5 9- 1 64.
L i c h t PB, C h riste n s e n HW, H o i l u n d -Ca r l s e n PF. Ca rotid a rtery b l ood
II
fl ow d u ri n g p r e m a n i p u l ative test i n g . J Ma n ipula tive Physiol Th er
2002;25 (9) :5 68-5 72
M itc h e l l J, Kee n e D, Dyso n C, H a rvey L, P r u vey C, P h i l l i ps R. l s cervica l s p i n e
rotation, a s u sed i n t h e sta n d a rd ve rte b roba s i l a r i n s uffi c i e n cy test,
a s soci ated with a m ea s u rea b l e c h a n g e in i ntracra n i a l ve rte b ra l a rtery
b l ood fl ow? Man Ther 2004;9 (4) 220-2 2 7 .
Westaway M D, Stratfo rd P , Sym o n s B. F a l se-neg ative exte n s i o n/rotation
p re- m a n i p u l ative scree n i n g test o n a patient with an atretic and hypo
p l a stic ve rte b ra l a rte ry. Man Ther 2003;8 (2) 1 20- 1 2 7.
Za i n a C, G ra nt R, J o h n so n C, Da n s i e B, Tay l o r J , S pyro p o l o u s P The effect
of cervica l rotation on b l ood fl ow i n t h e contra l ate ra l ve rte b ra l a rte ry.
Man Ther 2003 ;8(2) 1 03 - 1 09.
10 Section 2
FORAM INAL COMPRESSION TEST (SPU RLING)

TEST POSITIONING
With t h e s u bject seated comfo rta b l y, t h e exa m i n e r rests t h e
II
vo l a r s u rface of b o t h h a n d s o n top of t h e s u bject's head ( F i g u re
CS2-2A) .
F i g u re CS2-2A.
ACTION
The exa m i n er a p p l ies a d ownwa rd p ress u re w h i l e the s u bject l at
e ra l ly flexes the head. The test is repeated with the s u bject l atera l ly
fl exing to the o p pos ite side. Latera l fl exi o n may be performed both
actively and passively ( Fi g u re CS2-2 B).
Cervical Spine 11
II
Figure CS2-2B.
POSITIVE FINDING
D u r i n g the a p p l ication of com pression, a reporti ng of p a i n i nto t h e
u pper extre m ity towa rd the same side t h a t the h e a d i s latera l ly flexed
is positive. Th i s i n d i cates p ress u re o n a nerve root, which can be co r
related by the dermato m a l d i stribution of the pa i n .

Preca u t i o n s (a n d possi b l y avo i d a n ce) s h o u l d be ta ke n with
co m p re s s i o n of t h e verte b r a l a rea with a s u bject w h o h a s been
d i a g n o sed with co n d it i o n s such a s osteoa rth r i t i s, r h e u m a t o i d
a rth ritis, oste o p o ro s i s, a n d s p i n a l ste n o s i s . The exa m i n e r s h o u l d
pe rfo r m t h e verte b ra l a rtery test a s a screen p r i o r t o a d m i n iste r i n g
t h i s s peci a l test.
12 Section 2
EVIDENCE
R u b i n ste i n et a l S h a bat e t a l (20 1 1 )

(2007)
II
St udy d e s i g n Syste m a t i c review C ross-secti o n a l
Co n d it i o n s Cervi ca l Cervi ca l
eva l u ated rad i c u l o pathy ra d i c u l o pathy
St udy n u m be r 4
Sa m p l e s ize 257
Rel i a b i l ity N ot eva l u ated N ot eva l u ated
S e n s itivity 50 to 1 00 95
Spec ificity 86 to 1 00 94
REFERENCES
Dvo ra k J E p i d e m i o l ogy, p hysica l exa m i n a t i o n , a n d n e u rod i a g n ostics.
Spine (Phi/a Pa 1 976) l 998;23 (24) 2663-2672
Levitz C L, Re i l ly PJ, To rg J S . The pat h o m ec h a n ics of c h ro n ic, recu rrent,
cervi ca l n e rve root n e u ra p ra x i a . The c h ro n i c b u rn e r syn d ro m e . Am J
Sports Med. 1 997;25 ( 1 ) 73-76.
M a l a n g a GA The d i a g n o s i s and trea t m e n t of cervi ca l ra d i c u l o pathy. Med
Sci Sports Exere. 1 997;29(7 Su p p l ) S236-S24 5 .
R u b i n ste i n S M , Pool J J , va n Tu l d e r MW, R i p h a g e n I I , d e Vet H C A syste m
atic revi ew of t h e d i a g nostic a cc u ra cy of p rovocative tests of t h e neck
fo r d i a g n o s i n g cervica l ra d i c u l o pathy. Eur Spine J. 2007; 1 6(3):3 07-3 1 9.
S h a bat S, Leit n e r Y, David R, Fo l m a n Y The corre l a t i o n betwe e n S p u r l i n g
test a n d i m a g i n g st u d i e s i n d etect i n g c e rvi ca l ra d i c u l o pa t h y.
J Neuroimaging. 20 1 1 ;22(4)3 75-378
S h a h KC, Raj s h e k h a r V R e l i a b i l ity of d i a g n o s i s of s oft cervi ca l d i sc p ro l a pse
u s i n g S p u r l i ng's test Br J Neurosurg. 2005 ; 1 8(5) 480-483
S p u r l i n g RG, Scovi l l e WB. Latera l r u pt u re of the cervi ca l i n te rve rte b ra l
d i s ks . Surg Gyn eco/ Obstet. 1 944;78:3 5 0-3 5 8 .
To n g H C, H a i g AJ , Ya m a kawa K . The S p u r l i n g test a n d cervi ca l ra d i c u l o pa
thy. Spin e (Phi/a Pa 1 976). 2002;2 7 (2) 1 5 6- 1 5 9.
U c h i h a ra T, F u r u kawa T, Ts u ka g os h i H. Co m p re s s i o n of b ra c h i a ! p l ex u s
a s a d ia g nostic test o f cervi ca l cord l e s i o n . Spine (Phi/a P a 1 976)
1 994; 1 9 ( 1 9) 2 1 70-2 1 7 3 .
Cervical Spine 13
FORAM INAL DISTRACTION TEST

TEST POSITIONING
With the s u bject seated, the exa m i n e r places o n e h a n d u n d e r the
II
s u bject's chin a n d the other h a n d a ro u n d the occ i p ut (Fig u re CS2-3 ) .
Figure CS2-3.
ACTION
The exa m i n e r s l owly d i stra cts the s u bject's head fro m the tru n k
w h i l e t h e s u bject rem a i n s i n a rel axed positi o n .
POSITIVE FINDING
The fi n d i n g is positive when existi n g co m p l a i nts of pa i n decrease
o r d i sa p pea r d u ri n g the d i straction. This i n d icates that a n erve root
co mpress ion may exist w h i l e the s u bject s u sta i n s n o r m a l postu re
a n d/o r positio n i n g .
14 Section 2

Distraction of t h e ce rvi cal a rea fo r the assessment of a n e rve root
i m p i n g e ment s h o u l d not be performed on a s u bject who has ver
te b ra l i n sta b i l ity. Any i n c rease in p a i n may i n d icate m u scu l a r a n d/
II
or l i g a mento u s da mage. The exa m i n e r s h o u l d perform the Ve rtebral
Artery Test as a screen prior to a d m i n iste r i n g t h i s spec i a l test.
EVIDENCE
Wa i n n e r a n d G i l l R u b i n ste i n e t a l
(2000) (2007)
Study d e s i g n Literatu re review Syste matic review
Cond itions Cervi ca l Cervica l
eva l u ated ra d i c u l o pathy ra d i c u l o pathy
Study n u m be r 2 2
Rel i a b i l ity Ka ppa = .5 Not eva l u ated
S e n s itivity 40 44
S pec ificity 1 00 90 to 97
REFERENCES
Kru se-Los i e r B, Meye r U , F l o re n C, J oos U . I nfl u e n ce of d i stract i o n rates
on the tem poro m a n d i b u l a r j o i n t positi o n a n d ca rti l a g e m o r p h o l ogy
in a ra b b it model of m a n d i b u l a r l e n g t h e n i n g . J Ora l Maxillofa c Surg.
200 1 ;5 9 ( 1 2) : 1 452- 1 459.
Rat h o re S. U se of M c Kenzie cervica l p rotocol i n t h e treat m e n t of rad i c u l a r
n e c k pa i n i n a m a c h i n e o p e rator. J Ca n Ch iropr Assoc 2003;47(4) 2 9 1 -
297.
R u b i n ste i n SM, Pool JJ, va n Tu l d e r MW, R i p h a g e n 1 1 , d e Vet H C A syste m
atic review of t h e d i a g n ostic a c c u racy of p rovocative tests of t h e neck
fo r d i a g n o s i n g cervi ca l rad i c u l o pathy. Eur Spine J 2007; 1 6(3)3 07-3 1 9.
Wa i n n e r RS, F ritz J M , l rrg a n g JJ, Bo n i n g e r M L, De l i tto A, A l l i s o n S. Re l i a b i l ity
a n d d i a g n ostic a c c u racy of t h e c l i n ic a l exa m i n at i o n a n d patient self
re port m ea s u re s fo r cervi ca l rad i c u l o pathy. Spine (Phi/a Pa 1 976).
2003;28 ( 1 ):5 2-62
Wa i n n e r RS, G i l l H. D i a g n o s i s a n d n o n o p e rative m a n a g e m e n t of cervi ca l
ra d i c u l o pathy. J Orthop Sports Phys Ther 2000;3 0 ( 1 2) 728-744
Cervical Spine 15
VALSALVA 1S MAN EUVER

TEST POSITIONING
T h e s u bject i s seated. T h e exa m i n e r sta n d s n ext t o the s u bject.
ACTION
The exa m i n er a s ks the s u bject to ta ke a deep b reath a n d h o l d
w h i l e bea ri n g down, a s if havi n g a bowe l m ovement.
II
POSITIVE FINDING
I n c reased p a i n d u e to i n c reased i ntrath eca l p ressu re, wh ic h may
be seco n d a ry to a space-occ u pying lesion, hern iated d i s k, t u m o r, o r
osteop hyte i n the cervi ca l c a n a l , i s a pos itive fi n d i n g . Pa i n may b e
l oca l ized o r refe rred t o the co rres p o n d i n g dermatome.

The i n c reased p ress u re may a lter ve n o u s fu nction a n d cause d izzi
ness or u n conscious n ess. The exa m i n e r s h o u l d be p repa red to steady
the s u bject.
EVIDENCE
Wa i n n e r et a l (2003)
Study d e s i g n D i a g n ostic accu racy
C o n d iti o n s eva l u ated Cervica l ra d i c u l opathy
S a m p l e s ize 82
Rel i a b i l ity Ka ppa = .69
S e n s itivity 22
S pec ificity 94
REFERENCES
C h i l d s J O. O n e o n o n e . Th e i m pact of t h e Va I s a I va m a n e uver d u ri n g res i s
ta n c e exe rc i se. Strength Con d J 1 999;2 l (2) 54-5 5
Oyste KH, N ewki rk KM . P n e u m o m e d i a sti n u m i n a h i g h s c h o o l footba l l
p l ayer a case re port J A thl Tra in. l 998;3 3 (4)3 62-3 64
16 Section 2
Fo lta A, M etzg e r B L, Therrien B. P reexist i n g p h ys i c a l a ctivity l evel a n d

ca rd i ova s c u l a r res ponses a c ross t h e Va l s a lva m a n e uver. Nurs Res.
1 989;38(3) 1 3 9-43 .
G o l d i s h G D, Q u a st J E, B l ow JJ, Ku s kows ki MA Post u ra l effects on i ntra
a bd o m i n a l p ress u re d u ri n g Va l s a lva m a n e uve r. A rch Phys Med Rehabil.
II
l 994;75 (3) : 3 24-327
Ko l l ef M H , N e e l o n - Ko l l ef RA P u l m o n a ry e m bo l i s m associated with t h e a ct
of d efecat i o n Hea rt L ung. 1 9 9 1 ;20(5 Pt 1 ) 4 5 1 -4 54
L u Z, Metzg e r B L, Therrien B. Eth n i c d iffe re n ce s in physiolog ica l res p o n ses
a ssoci ated with t h e Va l s a lva m a n e u ver. Res Nurs Hea th. l 990; 1 3 ( 1 ) 9-
1 5.
Metzg e r B L, Th e r r i e n B. Effect of position on c a r d i ova s c u l a r res p o n s e d u r
i n g t h e Va I s a I va m a n e u ve r. Nurs Res. 1 990;3 9 (4) 1 98-202.
N a l i boff B O, G i l m o re S L, Rose nt h a l MJ Acute a uto n o m i c res ponses to
post u ra l c h a nge, Va l s a lva m a n e uver, a n d paced b reat h i n g in o l d e r
type I I d i a betic m e n . J A m Geria tr Soc. 1 993;4 1 (6) :648-6 5 3 .
N o r n h o l d P Decreased ca rd i a c o u t p u t fro m Va l s a l va m a n e uver. Nursing.
1 986; 1 6 ( 1 0) : 3 3 .
O'Co n n o r P, Sfo rza G A , F rye P Effect of b reat h i n g i n st r u cti o n o n b l ood p res
s u re res p o n ses d u ri n g i s o m etric exerc ise. Phys Ther. l 989;69 (9)75 7-
76 1 .
P i e rce MJ, Wees n e r C L, A n d e rs o n AR, A l boh m MJ P n e u m o m ed i ast i n u m
i n a fe m a l e t ra c k a n d fi e l d ath l ete a c a s e report J A th l Tra in.
l 998;3 3 (2) : 1 68- 1 70.
R u b i n ste i n SM, Pool JJ, va n Tu l d e r MW, R i p h a g e n 1 1 , d e Vet H C A syste m
atic review of t h e d i a g nostic a c c u ra cy of p rovocative tests of t h e neck
fo r d ia g n o s i n g cervi ca l ra d i c u l o pat hy. Eur Spine J 2007; 1 6(3):3 07-3 1 9.
Te nto l o u r i s N, Tsa po g a s P, Pa paza c h o s G, Kats i l a m b ros N . Co rrected QT
i nte rva l d u ri n g t h e Va l sa lva m a n euver i n d i a betic s u bjects. Diabetes.
2000;49(5) 1 68 .
Th e r r i e n B. Position m o d ifies ca roti d a rte ry b l ood fl ow ve l o c ity d u ri n g
stra i n i n g . Res Nurs Health. 1 990; 1 3 (2) 69-76
Wa i n n e r RS, F ritz JM, l rrg a n g JJ, Bo n i n g e r M L, Del itto A, A l l i s o n S Re l i a b i l ity
a n d d i a g n ostic a c c u racy of t h e c l i n i ca l exa m i n a t i o n a n d patient self
re port m e a s u re s fo r cervi ca l ra d i c u l o pathy. Spine (Phi/a Pa 1 976).
2003;2 8 ( 1 ) 5 2-62
Cervical Spine 17
SWALLOWING TEST
TEST POSITIONING
The s u bject i s seated. The exa m i n e r sta n d s n ext to the s u bject.
ACTION
The exa m i n er asks the s u bject to swa l l ow.
II
POSITIVE FINDING
I n c reased p a i n or d iffi cu lty swa l l owi n g (dysp h ag ia) ca u sed by
a nteri o r cervica l s p i n e obstructi o n s, s u c h as vertebral s u b l uxations,
osteop hyte p rotrusion, soft tissue swe l l i n g, or t u rn e rs i n the a nterior
ce rvi ca l s p i n e reg ion, i s a positive fi n d i n g .

Be certa i n t h e s u bject's head i s neutra l beca use swa l l ow i n g
beco mes m o re diffi c u l t w i t h the n e c k extended.
REFERENCES
H i n d s N P, Wi l e s CM Assess m e n t of swa l l owi n g a n d refe rra l to s peech a n d
l a n g u a g e t h e ra p i sts i n a c u te stroke. QJM 1 998;9 1 ( 1 2):829-835
l l bay K, Evl iyaog l u C, Et u s V, Ozka ra ka s H , Cey l a n S. A b n o r m a l bony
p rotu b e ra nce of a n terior a t l a s ca u s i n g dys p h a g i a . A ra re co n g e n ita l
a n o m a ly. Spinal Cord 2004;42 (2) 1 2 9- 1 3 1 .
M e n g N H , Wa n g TG, Lien I N . Dys p h a g i a i n patie nts with b ra i n ste m stroke
i n c i d e n ce a n d o utco me. Am J Phys Med Rehabil. 2000;79(2) 1 70- 1 96.
S ri n iva s P, George J Cervi ca l osteoa rt h ropathy: an u n u s u a l c a u s e of dys
p h a g i a . Age Ageing. l 999;28 (3) :3 2 1 -322.
Te ra m oto S, F u ku c h i Y Detect i o n of a s p i ration and swa l l owi n g d i so rd e r in
older stro ke patients: s i m p l e swa l l owi n g p rovocati o n test vers u s wate r
swa l l owi n g test Arch Phys Med Reha bi/. 2000;8 1 ( 1 1 ) 1 5 1 7- 1 5 1 9.
To h a ra H , S a i t o h E, M ays KA, Ku h l e m e i e r K, Pa l m e r J B. Th ree tests
fo r p red i ct i n g a s p i ra t i o n w i t h o u t v i d eofl u o rog ra p hy. Oysphagia.
2003 ; 1 8(2) 1 26- 1 34.
Wi n s l ow C P, Wi n s l ow TJ , Wax M K. Dys p h o n i a a n d dys p h a g i a fo l l ow i n g the
a nteri o r a p p roa c h to the cervi ca l s p i n e . Arch Otola ryngol Hea d Neck
Surg. 200 1 ; 1 2 7 ( 1 ) : 5 1 - 5 5 .
Wu MC, C h a n g YC, Wa n g TG, Li n LC Eva l uati n g swa l l ow i n g dysfu nction
u s i n g a 1 00-m l water swa l l owi n g test Dysphagia. 2004; 1 9 ( 1 ) :43-47.
18 Section 2
�----- T1 N E L 1S S1GN
TEST POSITIONING
The s u bject ca n sit or l i e s u p i ne.
II ACTION
The exa m i n e r gently taps the cervica l a rea near Erb's poi nt, which
can be fo u n d a nterior to the tran sverse p rocess of C6, a p p roxi m ately
2 cm s u perior to the l ocati o n of the clavi c l e (Fig u re CS2-4) .
F i g u re CS2-4.
POSITIVE FINDING
A s u bjective re porti ng of a c h a n g e i n sensation to the u p per
extre m ity o n the i p s i l atera l side resu lting i n i n c reased pa i n o r a bse nt/
d i m i n is h ed sensation is a positive fi n d i ng, i n d icati ng b rach i a ! p l exus
pathol ogy.

Th i s a rea is bel ieved to be where the p roxi m a l portion of the
brachia I p l exus i s m ost su perficia l . A pos itive fi n d i n g s h o u l d be com
b i ned with a co m p l ete cervi cal nerve root assessment prior to a ny
i nvo lved pathology to the b rac h i a I p l exus.
Cervical Spine 19
REFERENCES
H owa rd M , Lee C , De l l o n AL. Doc u m e ntation of b ra c h i a I p l ex u s co m p res
s i o n (i n the t h o ra c i c i n l et) uti l iz i n g p rovocative n e u rose n s o ry a n d
m u s c u l a r testi n g . J Reconstr Microsurg. 2003 ; 1 9(5)303-3 1 2 .
I d e M, I d e J , Ya m a g a M, Ta ka g i K . Sym pto m s a n d s i g n s o f i rritation
II
of t h e b ra c h i a ! p l ex u s i n wh i p l a s h i nj u ries. J B o n e Join t Surg B r.
200 1 ;83(2):226-229.

Shou l der
Guide to Figures

21-100).
Special Testsfor Orthoptdic Examination, Fourth Edition (pp
22 Section 3
EM PTY (AN (SU PRASPINATUS) TEST

TEST POSITIONING
The s u bject sta n d s with both s h o u l ders a b d u cted to 90 deg rees,
h o rizonta l ly a d d u cted 30 deg rees, a n d i n terna l l y rotated so the s u b
ject's t h u m bs face the fl oor ( Fi g u re 5 3 - 1 ) .
F i g u re 53-1 .
ACTION
The exa m i n er res i sts the s u bject's atte m pts to actively fo rwa rd
e l evate both s h o u l d e rs.
POSITIVE FINDING
I nvo lvement of the su p ra s p i n atus m u sc l e a n d/or ten d o n is s u s
pected with noted wea kness a n d/or a re port of pa i n .

Altho u g h the Em pty Ca n Test is co m m o n l y performed with the
s u bject sta n d i ng, the test may a l so be performed with the s u bject
seated. Wea kness of the s u p ra s p i n atus m u sc l e may be a res u lt of
s u p rasca p u l a r n e rve i nvo lve m e nt. Reported pa i n may be i n d i cative
of ten d i n itis a n d/or i m p i n g ement.
Shoulder 23
EVIDENCE
H e g e d u s et a l (2008) Heged us (20 1 2)

Study d e s i g n Syste m atic review Syste matic review
Co n d it i o n s M ixed cond iti o n s M ixed c o n d itio n s
eva l u ated (eg, i m p i n g e m e n t ( e g , s u p ra s p i n at u s
syn d ro m e a n d path o l ogy, s u bacro m i a l
rotator cuff i m p i n g e m e n t, rotator
pathol ogy) cuff pat h o l ogy)
Study 1 13
n u m be r
S e n s itivity 44 to 5 3 1 9 to 99
S pec ificity 82 to 90 3 0 to 1 00
REFERENCES
H eged u s EJ . Wh i c h p h ys i c a l exa m i n at i o n tests p rovi d e c l i n ic i a n s with
t h e m ost va l u e when exa m i n i n g t h e s h o u l d e r? U pdate of a syste m
atic review with m eta-a n a lys i s of i n d ivid u a l tests. Br J Sports Med.
20 1 2;46 ( 1 4) 964-978
Heged u s EJ , Goode A, Ca m p be l l S, et a l . Physica l exa m i n a t i o n tests of the
s h o u l d e r: a syste m atic revi ew with m eta-a n a lys i s of i n d ivid u a l tests.
Br J Sports Med. 2008;42 (2):80-92; d i s c u s s i o n 92.
H o l t by R, Razmj o u H . Va l i d ity of t h e s u p ra s p i n a t u s test a s a s i n g l e c l i n i c a l
test i n d i a g n o s i n g patie nts with rotator c u ff pat h o l ogy. J Orthop Sports
Phys Ther 2004;34(4) 1 94-200.
ltoi E, Ki d o T, Sa n o A, U raya m a M, Sato K. Wh i c h i s m o re u sefu l , the "fu l l
ca n test" o r t h e "e m pty ca n test," i n d etect i n g t h e torn s u p ra s p i n at u s
te n d o n 7 A m J Sports Med. 1 999;2 7 ( 1 ) 6S-68
Row l a n d s L K, We rtsch JJ, P ri m a c k SJ , S p re itze r AM, Roberts MM. Ki n e s i o l ogy
of the e m pty can test. A m J Phys Med Reha b/I. l 995;74(4) :302-304
24 Section 3
YERGASON TEST
TEST POSITIONING
The s u bject sits with the el bow flexed to 90 deg rees a n d sta b i l ized
a g a i nst the thorax. The fo rea rm i s in a pronated positi o n . The exa m
iner places one hand along t h e s u bject's fo rearm and the other hand
o n the p roxi m a l portion of the s u bject's h u merus, n e a r the b i c i p ita l
g roove ( Fi g u re S3-2A).
F i g u re S3-2A.
ACTION
The exa m i n er resi sts the s u bject's attem pt to actively s u p i nate the
fo rea rm a n d externa l l y rotate the h u merus ( Fi g u re S3-2B).
Shoulder 25
Figure S3-2B.
POSITIVE FINDING
Pa i n that is re ported to exist in the a rea of the bici p ita l g roove is a
positive fi n d i n g that may i n d icate b i c i p ita l ten d i n itis.

This is a d iffi c ul t test to perform. One may be j u st as accu rate to
assess bici pita l tend i n itis by s i m p l y p a l pati n g the long head of the
biceps te n d o n i n the b i c i p ita l g roove.
EVIDENCE

Study d e s i g n Syste matic review M eta-a n a lysis
C o n d iti o n s La b ra l pat h o l ogy B i ceps te n d i n opathy
eva l u ated
Sa m p l e size 246
Re l i a b i l ity Not eva l u ated N ot eva l u ated
S e n s itivity 1 2 to 43 1 2 .4
Spec ifi city 79 to 98 95.3
26 Section 3
REFERENCES
Ca l i ? M , A kg u n K, B i rta n e M , Ka ra ca n I , Ca l i ? H , TUzu n F. D i a g n ostic va l u es of
c l i n ica l d i a g nostic tests i n s u ba c ro m i a l i m p i n g e m e nt syn d ro m e . A n n
Rheum Dis. 2000;5 9 ( 1 ) :44-47.
G u a n c h e CA, Jones DC C l i n i ca l test i n g fo r tea rs of t h e g l e n o i d l a b r u m .
A rthroscopy 2003 ; 1 9(5) 5 1 7-5 2 3 .
H eged u s EJ Wh i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n ic i a n s with
t h e m ost va l u e when exa m i n i n g t h e s h o u l d er? U pdate of a syste m
atic review with m eta-a n a lys i s of i n d ivid u a l tests. Br J Sports Med
2 0 1 2;46 ( 1 4) :964-978
H eged u s EJ, Goode A, Ca m p be l l S, et a l . Phys i c a l exa m i n a t i o n tests of t h e
s h o u l d e r: a syste matic review w i t h m eta-a n a lys i s o f i n d ivid u a l tests. Br J
Sports Med 2008;42(2) 80-92; d is c u s s i o n 92.
Ye rg a s o n RM S u p i nation s i g n . J Bone Join t Surg Am 1 93 1 ; 1 3 1 60.
Shoulder 27
5PEED 1S TEST
TEST POSITIONING
The s u bject is seated or sta nd i n g . The i nvo lved s h o u l d e r is fl exed
to 90 deg rees, the el bow i s fu l l y exte n d ed, a n d the fo rea rm i s su pi
nated . The exa m i n e r p l aces o n e h a n d along the vo l a r as pect of the
s u bject's fo rea rm a n d the oth e r h a n d o n the p rox i m a l as pect of the
s u bject's h u merus near the a rea of the b i c i p ita l g roove (Fig u re 53-3).
Figure S3-3.
ACTION
The exa m i n e r resi sts t h e s u bject's atte m pt to actively flex the
h u merus fo rwa rd.
POSITIVE FINDING
Te nderness a n d/or p a i n i n t h e b i c i p ita l g roove is a pos itive fi n d i n g
that m a y s u g g est b i c i p ita l te n d i n itis.

The exa m i n e r s h o u l d ca refu l l y watc h that t h e fo rea rm i s s u p i
nated a n d that t h e s u bject does n ot use a ccessory m u sc l e s t o
m a s k a ny exist i n g wea kness. A l t h o u g h t h i s test i s p r i m a r i l y u s e d
28 Section 3
to eva l u ate the biceps tendon, Speed's Test h a s a l so been used to

eva l u ate s u p e r i o r l a b r u m a nterior to poste r i o r (SLAP) l e s i o n s a n d
s u ba c ro m i a l i m p i n g e m e nt.
EVIDENCE
H e g e d u s et a l (2008) Heged us (201 2)

Study d e s i g n M eta-a n a lysis M eta-a n a lysis
C o n d iti o n s La b ra l pat h o l ogy La b ra l pathology
eva l u ated (eg, S LA P tea r) (eg, b i ceps
te n d i n opathy)
Rel i a b i l ity Not eva l u ated N ot eva l u ated
S pec ificity 61 78
REFERENCES
Ca l i ? M , A kg u n K, B i rta n e M , Ka raca n I , Ca l i ? H , TUzu n F. D i a g nostic va l u es of
c l i n i ca l d i a g n ostic tests i n s u b a c ro m i a l i m p i n g e m e n t syn d ro m e . A n n
Rheum Dis. 2000;5 9 ( 1 ) 44-47
C l a rn ette RG, M i n i a c i A C l i n i ca l exa m of t h e s h o u l d e r. Med Sci Sports
Exerc 1 998;3 0 (4 S u p p l):S 1 -56.
G u a n c h e CA, J o n e s DC C l i n i ca l testi n g fo r tea rs of t h e g l e n o i d l a b r u m .
A rthroscopy 2003; 1 9 (5) 5 1 7-5 2 3 .
H e g e d u s EJ W h i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n ic i a n s with
the most va l u e when exa m i n i n g t h e s h o u l d e r? U pd a te of a syste m
20 1 2;46 ( 1 4) 964-978
Br J Sports Med 2008;42 (2):80-92; d i s c u s s i o n 92.
Mason JM. S h o u l d e r i nj u ry wate r p o l o 5 84. Med Sci Sports Exerc
1 997;29(5): 1 0 1 .
R u s s OW I n -sea s o n m a n a g e m e n t of s h o u l d e r pa i n i n a c o l leg i ate swi m
m e r a tea m a p p roa c h . J Orthop Sports Phys Th er. l 998;27(5)3 7 1 -376.
Shoulder 29
LUDI NGTON 1S SIGN

TEST POSITIONING
The s u bject sits or sta n d s w h i l e the exa m i n e r sta n d s d i rectly
b e h i n d the s u bject. The s u bject i nterlocks the fi ngers and p l aces
them o n the s u perior/posterior as pect of the head.
ACTION
The exa m i n e r pa l pates the l o n g head of the biceps te n d o n b i l ater
a l ly w h i l e the s u bject contracts both the l eft a n d rig ht biceps brac h i i
m u sc l es s i m u lta neously ( Fi g u re 53-4) .
Figure 53-4.
POSITIVE FINDING
I n c reased pa i n is i n d i cative of a biceps b ra c h i i l o n g head te n d i n i
tis. Decreased te n s i o n of t h e te n d o n with p a l pation may i n d i cate a n
i n a b i l ity o r a p p rehension o f t h e biceps b rac h i i t o contract fo rcefu l ly.
30 Section 3

The s u bject s h o u l d be s u re to sta b i l ize the h u meral head d u ri n g
t h e contractio n a n d a l l ow fo r the h a n d s t o p u s h i nto the sta b i l ized
h u mera l head. N o ten s i o n may be the res u l t of a biceps b rach i i l o n g
h e a d r u pt u re.
REFERENCE
L u d i n gton N A R u pt u re of t h e l o n g h e a d of t h e b i c e p s fl exo r c u biti
m u sc l e . A n n Surg 1 92 3 77 (3);35 8-3 6 3
Shoulder 31
D ROP ARM TEST

TEST POSITIONING
The s u bject is seated or sta n d i n g .
ACTION
The exa m i n er passively a b d u cts the s u bject's i nvo lved a r m to
90 deg rees a n d then i n stru cts the s u bject to s l owly l owe r the a r m to
the side (Fig u res 53-SA a n d 53-SB).
Figure 53-SA.
Figure 53-SB.
32 Section 3
POSITIVE FINDING
The s u bject is u n a b l e to slowly return the a rm to the side a nd/or has
sign ificant pain when atte m pting to perform the task. Th is is i n d i cative
of rotator cuff path o l ogy.

If the exa m i n er s u s pects rotator cuff pat h o l ogy prior to perform
ing t h e test, he o r she s h o u l d p repa re to ra p i d l y assist the s u bject in
the eve nt that the s u bject d oes experience a n i n a b i l ity to control the
a d d uction movement of the a r m .
EVIDENCE

Study d e s i g n Syste matic review Syste m atic review
C o n d iti o n s Impingement I m pingement
eva l u ated a n d rotator cuff and rotator cuff
te n d i n o pathies te n d i n o pathies
S e n s itivity 8 to 3 5 2 4 t o 74
S pec ificity 88 to 1 00 66 to 93
REFERENCES
Ca l i � M , A kg u n K, B i rta n e M , Ka raca n I , Ca l i � H , TUzu n F. D i a g nostic va l u es of
c l i n i ca l d i a g n ostic tests i n s u b a c ro m i a l i m p i n g e m e n t syn d ro m e A n n
Rheum Dis. 2000;5 9 ( 1 ) 44-47
H e g e d u s EJ W h i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n ic i a n s with
the most va l u e when exa m i n i n g t h e s h o u l d e r? U pdate of a syste m
atic revi ew with m eta-a n a lys i s of i n d ivid u a l tests. Br J Sports Med
20 1 2;46 ( 1 4) 964-978
Shoulder 33
LATERAL SCAPULAR SLIDE TEST ( LSST)

TEST POSITIONING
Position 1 : The s u bject sta n d s with a r m s re l axed at the s i des.
Position 2 : The s u bject sta n d s with h a n d s o n t h e h i ps and s h o u l
ders i n 1 0 deg rees o f exte n s i o n .
Positi o n 3 : The s u bject sta n d s with s h o u l d e rs a bd u cted t o
90 deg rees a n d maxi m a l ly i ntern a l ly rotated.
ACTION
Position 1 : The exa m i n e r meas u res the d i sta nce from the i nferior
angle of the sca p u l a (i nvolved side) to the s p i n o u s
p rocess o f the thoracic verte b ra i n the same h o rizonta l
p l a n e (th i s verte b ra wi l l be u sed as the reference ve r
tebra fo r a l l 3 positions) (Fig u re 53-6A) . This is repeated
o n the u n i nvolved side. The d iffe rence between sides
i s used fo r the o bjective assessment.
Position 2 : Repeat the same action a s i n Position 1 ( Fi g u re 53-68).
Position 3 : Repeat the same action a s i n Position 1 (Fig u re 53-6().
Figure S3-6A.
34 Section 3
F i g u re 53-68.
F i g u re S3-6C.
POSITIVE FINDING
A side-to-side d iffe rence of > 1 .5 cm is co nsidered a pos itive LSST,
i n d icati ng sca p u l a r a sym m etry seco n d a ry to wea kness of the sca pu
l a r sta b i l izers.
Shoulder 35

The re l i a b i l ity, sens itivity, a n d s pecifi city of t h i s test i n assessing/
p red icti n g s h o u l d e r dysfu nction h ave been q u estioned. Beca use t h i s
test i s co nsidered a sem i-dyn a m i c test o n ly, it may n o t accu rate ly
assess the sta b i l izing strength of the sca p u l a r m u sc l es. I t may m o re
accu rate ly assess genera l asym metri es, l e a d i n g the c l i n i cian to fu rther
assess the u n d e rlyi n g ca use of these asym metries (eg, motor control,
o r lack thereof; i nfl exi b i l ities; thoracic s p i n e/postural deviati ons).
EVIDENCE
S h a d m e h r et a l (20 1 4)
Study d e s i g n C ross-sectio n a l, repeated m ea s u res
C o n d iti o n s eva l u ated Sca p u l a r positi o n i n g
Re l i a b i l ity Positi o n 1 : i ntra c l a ss corre l atio n ( I CC)
= 87.
Positi o n 2 : ICC = .77

S e n s itivity Not eva l u ated
S pec ificity Not eva l u ated
REFERENCES
C rotty N M , S m it h J Altera t i o n s i n sca p u l a r position with fati g u e: a study i n
swi m m e rs . Clin J Sports Med 2000; 1 0 (4) 2 5 1 -258.
Ki b l e r WB. The ro l e of t h e sca p u l a in ath l etic s h o u l d e r fu ncti o n . A m J
Sports Med l 998;26(2) :325-3 3 7
Kos l ow PA, Prosser LA, Stro ny GA, S u c h ec ki S L, Matti n g l y G E . S pec ifi c ity
of t h e latera l sca p u l a r s l i d e test in asym pto matic com petitive ath l etes.
J Orth op Sports Phys Th er. 2003;33 (6) :3 3 1 -336.
O d o m CJ , Tay l o r AB, H u rd CE, Oe n e g a r CR. M e a s u re m e n t of sca p u
l a r asym m et ry a n d assess m e nt o f s h o u l d e r dysfu nction u s i n g t h e
l atera l sca p u l a r s l i d e test a re l i a b i l ity a n d va l i d ity study. Phys Th er
200 1 ;8 1 (2) : 799-809.
S h a d m e h r A, Aza rsa M H , J a l a i e S I nte r- a n d i ntra rater re l i a b i l ity of m o d i
fi ed latera l sca p u l a r s l i d e t e s t i n hea lthy at h l etic m e n . Biomed Res lnt.
2 0 1 4;20 1 4:384 1 49.
36 Section 3
APLEv 'S SCRATCH TEST

TEST POSITIONING
The s u bject may sit or sta n d . The exa m i n er sta n d s n ext to the
s u bject.
ACTION 1
The s u bject is i n stru cted to ta ke one h a n d a n d to uch the o p pos ite
s h o u l der. Repeat with the other h a n d to the o p pos ite side (Fig u re
S3-7A) .
F i g u re S3-7A.
POSITIVE FINDING 1
Asym metrica l res u lts fro m side to side a re positive. The i n a b i l ity
to to uch the o p posite s h o u l d e r is i n d i cative of l i m ited g l e n o h u m e ra l
a d d u ction, i nte rnal rotation, a n d h o rizonta l fl ex i o n . L i m its i n sca p u l a r
p rotraction m a y a l s o p rod u ce asym metrica l res u lts.
ACTION 2
The s u bject is then i n structed to p l ace the a r m overhead a n d reach
b e h i n d the neck a s if scratc h i n g the u p per back. Repeat with the
o p pos ite side (Fig u re S3-7B).
Shoulder 37
Figure 53-78.
POSITIVE FINDING 2
Asym metri cal res u lts fro m side to side a re positive. Decreased
motion o n one side i s i n d i cative of l i m ited g l e n o h u meral a b d uction
and exte rnal rotation, a n d sca p u l a r u pwa rd rotation and e l evation.
ACTION 3
The s u bject is then i n structed to p l a ce the h a n d in the s m a l l of the
back a n d reac h u pwa rd a s fa r a s poss i b le. Repeat with the o p posite
side (Fig u re S3-7C).
Figure S3-7C.
38 Section 3
POSITIVE FINDING 3
Asym metri cal res u lts fro m side to side a re positive. Decreased
motion o n one side i s i n d i cative of l i m ited g l e n o h u mera l a d d uction
and i ntern a l rotation, a n d sca p u l a r retraction and d ownwa rd rotati o n .

Each of these m ovem e nts is a n active test of the fu nct i o n a l m o b i l
i t y o f the s h o u l d er. Ca re s h o u l d be ta ken t o isolate m oveme nts that
a re restricted . It i s not u n c o m m o n fo r a s u bject to have s l i g htly
g reater restriction on the d o m i nant s h o u l d e r a s co m pa red to the
n o n d o m i n a nt s h o u l d er due to i n c reased m u sc l e mass o n the d o m i
n a nt side. Fo r the l atte r 2 test co m p o n ents, the tester can correlate
the t h u m b of the s u bject with the level of the s p i n o u s p rocess being
reac h ed fo r assessment comparisons ove r time. The exa m i n er s h o u l d
a l so assess sca p u l a r a sym m etries t h a t m a y be present with g l e n o h u
meral moti o n .
REFERENCES
B u c h berg e r OJ The p reva l e n ce of s u bsca p u l a ri s dysfu n cti o n i n a baseba l l
po p u l at i o n . Med Sci Sports Exerc 1 999;3 l (5) S262
Endo K, Yu kata K, Ya s u i N . I nfl u e n ce of age o n sca p u l a-t h o ra c i c orie nta
ti o n . Clin Biomech (Bristol, A von) 2004; 1 9 ( 1 0) : 1 009- 1 0 1 3 .
Shoulder 39
(ROSS-OVER I M P I NGEM ENT TEST

TEST POSITIONING
The s u bject sits. The exa m i n er sta n d s with one h a n d on the pos
te rior a s pect of the s u bject's s h o u l d e r to sta b i l ize the tru n k and t h e
ot her h a n d g ra s p i n g the s u bject's el bow o n the test a r m .
ACTION
With the s u bject's tru n k sta b i l ized, the exa m i n er passively a n d
maxi m a l l y h o rizonta l l y a d d u cts the test s h o u l d e r (Fig u re 53-8).
Figure 53-8.
POSITIVE FINDING
Su perior s h o u l d e r pa i n is i n d icative of acro m i o c l avicu l a r j o i nt
pathol ogy. Anterior s h o u l d e r p a i n is i n d icative of s u bsca p u l a ris,
s u p ra s p i natus, a n d/or biceps long head pathol ogy. Poste rior s h o u l
d e r pa i n i s i n d i cative o f i nfraspi natus, teres m i n o r, a n d/o r posterior
caps u l e pathol ogy.
40 Section 3
SPECIAL CONSIDERA TIONS

Alth o u g h the test is co m m o n ly performed with the s u bject seated,
the test may a l so be performed with the s u bject in a s u p i n e positi o n .
EVIDENCE

Conditions I m pingement S u p ra s p i n a t u s
eva l u ated a n d rotator cuff and rotator cuff
pat h o l og ies te n d i n o pa t h i es;
a c ro m ioclavi c u l a r
osteoarth ritis
Re l i a b i l ity N ot eva l u ated N ot eva l u ated
S e n s itivity 23 to 82 2 2 to 77
Specificity 28 to 82 6 1 to 79
REFERENCES
Berg EE, C i u l l o JV A c l i n i ca l test fo r s u pe r i o r g l e n o i d l a b ra I o r s u perior l a b r u m
a nte rior- poste r i o r (SLAP) l e s i o n s . Clin J Sport Med 1 998;8(2) 1 2 1 - 1 23 .
Ca l i ;; M , A kg u n K, B i rta n e M, Ka raca n I , Ca l i ;; H , Tuzu n F . D i a g n ostic va l u e s of
c l i n i ca l d i a g n ostic tests in s u b a c ro m i a l i m p i n g e m e n t syn d ro m e A n n
Rheum Dis. 2000;5 9 ( 1 ) :44-47 .
H eged u s EJ W h i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n i c i a n s w i t h
t h e m ost va l u e w h e n exa m i n i n g t h e s h o u l d e r? U pd ate o f a syste m
2 0 1 2;46 ( 1 4) :964-978
H eged u s EJ, Goode A, Ca m p be l l S, et a l . Physica l exa m i n a t i o n tests of t h e
Sports Med 2008;42 (2) 80-92; d is c u s s i o n 92.
Shoulder 41
POSTERIOR I M P I NGEM ENT TEST

TEST POSITIONING
The s u bject l ies s u p i n e on a ta ble with the test s h o u l d e r placed i n
9 0 t o 1 1 0 d e g rees o f a bd uction a n d 1 0 t o 1 5 deg rees o f exte n s i o n .
The test el bow i s fl exed t o 90 degrees. T h e exa m i n er s i t s o r sta nds.
The exa m i ner's d i stal h a n d g rasps the s u bject's wrist a n d h a nd, and
the p roxi m a l hand g ra s ps the s u bject's el bow (Fig u re S3-9A) .
Figure S3-9A.
ACTION
The exa m i n er s l owly rotates the s u bject's s h o u l d e r i nto maxi m a l
externa l rotati o n ( Fi g u re 53-98).
42 Section 3
F i g u re 53-98.
POSITIVE FINDING
Reprod uction of the su bject's pain i n the posterior a spect of the
shou lder is i n di cative of rotator cuff a n d/or posterior l a b ra l pathol ogy.

Th i s test s h o u l d not be confused with the A p p re h e n s i o n Test o r
Rel ocation Test. The Poste rior I m p i n gement Test wi l l re p rod u ce pos
te rior s h o u l d e r pa i n , whereas the Appre h e n s i o n and Relocation Tests
wi l l re p rod u ce a nterior s h o u l d e r p a i n a n d a p p re h e n s i o n . C l i n i cal ly,
the Posterior I m p i ngement Test wi l l often correlate h i g h ly with the
s u bjective co m p l a i nts of poste rior/s u perior shoulder pa i n d u ri n g the
l ate cocki n g to acce l e ration p h a se of t h rowi n g o r swi n g i n g i n the
overhand ath lete.
Shoulder 43
EVIDENCE
M e i ster et a l (2004)
C o n d it i o n s eva l u ated Rotato r cuff a n d l a bra I
path o l o g ies
Rel i a b i l ity Not eva l u ated
S e n s itivity 76
S pec ificity 85
REFERENCES
M e i ster K, B u c kl ey B, Batts J The poste r i o r i m p i n g e m e n t s i g n : d i a g no
sis of rotator c u ff and poste rior l a b ra l tea rs seco n d a ry to i n tern a l
i m p i n g e m e n t i n ove r h a n d ath l etes. A m J Orthop (Belle Mead NJ)
2004;3 3 (8) 4 1 2-4 1 5 .
Wa l c h G, Bo i l e a u P, N o e l E , D o n e l I ST I m p i n g e m e n t o f t h e d e e p s u rfa ce
of the s u p ra s p i n a t u s te n d o n o n the poste ros u pe r i o r g l e n o i d ri m : a n
a rt h rosco p i c stu dy. J Shoulder Elbow Surg. 1 992; 1 (5):23 8-245
44 Section 3
N EER I M PI NGEM ENT TEST

TEST POSITIONING
The s u bject s its or sta n d s with both u p per extrem ities rel axed. The
exa m i n e r sta n d s with one h a n d o n the sca p u l a (poste riorly) and the
ot her h a n d g ra s p i n g near the s u bject's el bow (anterio rly) .
ACTION
With the s u bject's sca p u l a sta b i l ized, the exa m i n e r passively a n d
maxi m a l l y fo rwa rd-fl exes the test s h o u l d e r ( Fi g u re 5 3 - 1 0).
F i g u re 53- 1 0.
POSITIVE FINDING
S h o u l d e r pa i n a n d a p p re h e n s i o n a re i n d i cative of s h o u l d e r
i m pi ngement, particu l a rly o f t h e su p ra s p i n atus a n d biceps l o n g
head tendons.

A fa l se-pos itive test may be e l i cited if the s u bject h a s l i m ited fo r
wa rd flexi o n to the exte nt that a n ato m ical i m p i n g e ment is not the
l i m iting factor.
Shoulder 45
EVIDENCE

C o n d iti o n s S u ba c ro m i a l M ixed cond iti o n s
eva l u ated i m p i n g e m e nt ( e g , s u bacro m i a l
i m p i n g e m ent,
biceps
te n d i n opathy)
S pec ificity 53 60
REFERENCES
Ca l i ;; M , A kg u n K, B i rta n e M , Ka raca n I , Ca l i ;; H , TUzu n F. D i a g nostic va l u es of
c l i n i ca l d i a g n ostic tests in s u b a c ro m i a l i m p i n g e m e n t syn d ro m e . Ann
Rh eum Dis. 2000;5 9 ( 1 ) 44-47
Cava l l o RJ, S peer KP. S h o u l d e r i n sta b i l ity a n d i m p i n g e m e n t i n t h rowi n g
ath l etes. Med Sci Sports Exerc 1 998;3 0 (4 S u p p l ) : S l 8-S 2 5 .
Heged u s EJ W h i c h p hys ica l exa m i n a t i o n tests p rovi d e c l i n ic i a n s w i t h
t h e most va l u e w h e n exa m i n i n g t h e s h o u l d e r? U pdate o f a syste m
20 1 2;46 ( 1 4) 964-978.
Ki rkley A, Litc hfi e l d RB, J a c kows ki OM, Lo I K. The u s e of t h e i m p i n g e m e n t
test a s a p red i ctor o f o utco m e fo l l ow i n g s u b a c ro m i a l deco m p re s s i o n
fo r rotato r cuff te n d i n o s i s . A rth roscopy 2002; 1 8 ( 1 ) 8- 1 5 .
N e e r CS I I . Anterior a c ro m i o p l a sty fo r t h e c h ro n i c i m p i n g e m e n t syn
d ro m e in t h e s h o u l d e r: a p re l i m i n a ry re port. J Bone Join t Surg Am
1 97254( 1 ) 4 1 -5 0
Za s l av K R . I nte r n a l rotation res i sta nce stre n g t h test: a n ew d i a g n ostic test
to d iffe re n t i ate i n t ra-a rti c u l a r pat h o l ogy fro m o u t l et ( N e e r) i m p i n g e
m e nt syn d ro m e i n t h e s h o u l d e r. J Sh oulder Elbow Surg. 200 1 ; l 0 ( 1 ) 2 3 -
27.
46 Section 3
H AWKI NS-KENN EDY I M PI NGEM ENT TEST

TEST POSITIONING
The s u bject s its or sta n d s with both u p per extrem ities rel axed. The
exa m i n e r sta n d s with one h a n d g ra s p i n g the s u bject's e l bow and the
ot her h a n d g ra s p i n g the s u bject's wrist, both o n the test arm.
ACTION
The exa m i n er flexes the e l bow to 90 deg rees, fo rwa rd -fl exes t h e
s h o u l d e r t o 90 deg rees, a n d then i nterna l l y rotates the s u bject's test
s h o u l d e r ( Fi g u re 5 3 - 1 1 ) .
F i g u re 53-1 1 .
POSITIVE FINDING
S h o u l d e r pa i n a n d a p p re h e n s i o n a re i n d i cative of s h o u l d e r
i m pi ngement, pa rtic u l a rly o f t h e s u p ra s p i natus te n d o n .

Th i s test te n d s to be the m ost sens itive fo r assessi n g s u bacro m i a l
i m p i n g em ent.
Shoulder 47
EVIDENCE

C o n d iti o n s S u ba c ro m i a l S u bacro m i a l
eva l u ated i m p i n g e m e nt im pingement
S pec ificity 59 56
REFERENCES
Ca l i � M , A kg u n K, B i rta n e M , Ka raca n I , Ca l i � H , TUzu n F. D i a g nostic va l u es of
c l i n i ca l d i a g n ostic tests in s u b a c ro m i a l i m p i n g e m e n t syn d ro m e . Ann
Rheum Dis. 2000;5 9 ( 1 ) 44-47
De Wi l d e L, P l a s s c h a e rt F, Berg h s B, Va n Hoecke M, Ve rstraete K, Ve rd o n k
R . Q u a ntified m ea s u re m e n t o f s u b a c ro m i a l i m p i n g e m e n t J Shoulder
Elbow Surg. 2003; 1 2 (4) :346-349
H a w ki n s RJ , Ke n n edy J C I m p i n g e m e n t syn d ro m e in ath l etics. A m J Sports
Med 1 980;8 (3): 1 5 1 - 1 5 8 .
Heged u s EJ W h i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n i c i a n s with
the m ost va l u e when exa m i n i n g t h e s h o u l d e r? U pd a te of a syste m
20 1 2;46 ( 1 4) 964-978
Heged u s EJ, Goode A, Ca m p be l l S, et a l . P hysica l exa m i n a t i o n tests of
t h e s h o u l d e r: a syste matic review with m eta-a n a lys i s of i n d ivid u a l
tests. B r J Sports Med 2008;42 (2):80-92; d i s c u s s i o n 92.
Ki rkley A, Litc hfi e l d RB, J a c kows ki OM, Lo I K. Th e u s e of t h e i m p i n g e m e n t
test a s a p red i cto r o f o u tco m e fo l l ow i n g s u b a c ro m i a l d e co m p re s s i o n
fo r rotato r c u ff te n d i n o s i s . A rth roscopy 2002; 1 8 ( 1 ) 8- 1 5 .
M a c Do n a l d P B, C l a rk P, S u t h e rl a n d K. An a n a lys i s of t h e d i a g n ostic
a cc u ra cy of t h e H awki n s and N e e r s u ba c ro m i a l i m p i n g e m e n t s i g n s .
J Shoulder Elbow Surg. 2000;9(4) :299-3 0 1 .
Stru h l S. Anterior i ntern a l i m p i n g e m e nt: a n a rt h rosco p i c o b s e rvati o n .
A rthroscopy 2002; 1 8 ( 1 ):2-7.
Va l a d i e A L I l l , J o b e CM, P i n k M M , E km a n E F, J o be FW A n atomy of p ro
vocative tests for i m p i n g e m e nt syn d ro m e of the s h o u l d e r. J Shoulder
Elbow Surg. 2000;9 ( 1 ) : 3 6-46
48 Section 3
STERNOCLAVICU LAR (SC) J O I NT STRESS TEST

TEST POSITIONING
The s u bject sits with the i nvo lved a r m re l axed at the side. The
exa m i n e r sta n d s in fro nt of the s u bject, p l a c i n g one h a n d on the
p roxi m a l end of the s u bject's clavi c l e and the other h a n d o n the s p i n e
o f the sca p u l a (Fig u re S3- 1 2).
F i g u re 53-1 2.
ACTION
The exa m i n er a p p l ies gentle inferior a n d posterior p ressu re on the
clavicle, noti ng a ny m ovement at t h e SC joi nt.
POSITIVE FINDING
Pa i n a n d/or m ovement of the clavicle i n d i cates a n SC l ig a m e n t
sprain, poss i b l y i nvo lvi n g the costoclavi c u l a r l iga ment.

Th i s test s h o u l d not be performed if there is o bvi o u s SC joint
deform ity. Ca ution should a l so be used if a n i nj u ry to the trachea
reg ion i s s u s pected i n add ition to SC pathol ogy.
Shoulder 49
ACROMIOCLAVICULAR (AC) J O I NT DISTRACTION TEST

TEST POSITIONING
The subject sits with the i nvolved arm relaxed at the side and the
el bow flexed to 90 deg rees. The exa m i ner sta nds on the involved side
and holds the s u bject's arm near the el bow crease with one hand. The
examiner's other hand is placed over the i nvolved AC joint (Fig u re 53- 1 3).
Figure 53- 1 3 .
ACTION
The exa m i n er a p p l ies gentle d ownwa rd p ressu re on the a rm, n ot
i n g a ny m ovement at the AC joi nt.
POSITIVE FINDING
Pa i n a n d/o r movement of the sca p u l a i nferior to the clavicle i s
positive, i n d icati n g A C a n d/or coracoclavicu l a r l i g a ment s p ra i n s.

Th i s test s h o u l d n ot be performed if a ny o bvi o u s AC j o i nt d efo r
m ity exists.
REFERENCE
C h ro n o po u l u s E, Ki m TK, P a r k H B, As h e n b re n n e r D, M c F a r l a n d EG.
D i a g n ostic va l u e of p hysica l tests fo r i s o l ated c h ro n i c AC l e s i o n s . A m J
Sports Med 2004;32(3) 6 5 5 -66 1 .
50 Section 3
ACROMIOCLAVICU LAR (AC) JOINT

COMPRESSION TEST (SH EAR)
TEST POSITIONING
The s u bject sits with the i nvo lved a r m re l axed at the side. The
exa m i n e r sta n d s o n the i nvolved side, p l a c i n g one h a n d o n the s u b
ject's clavicle a n d the other h a n d on the s p i n e of the sca p u l a (Fig u re
5 3 - 1 4) .
F i g u re 53- 1 4.
ACTION
The exa m i n er gently s q ueezes the h a n d s together, noti n g a ny
m ovement at the AC joi nt.
POSITIVE FINDING
Pa i n a n d/or movement of the clavi c l e is a pos itive i n d icati o n of a n
A C a n d/or coracoclavic u l a r l i g a ment s p ra i n .

Th i s test s h o u l d n ot be performed if t h e re is o bvi o u s AC j o i nt
deformity.
Shoulder 51
REFERENCES
C h ro n o po u l u s E , Ki m TK, P a r k H B, As h e n b re n n e r D , M c F a r l a n d EG.
D i a g n ostic va l u e of p hysica l tests fo r i s o l ated c h ro n i c AC l e s i o n s . A m J
Sports Med 2004;32(3) 6 5 5 -66 1 .
Lee M P. D i a g n ostic va l u es of tests fo r a c ro m i o c l a vi c u l a r j o i n t pa i n : a case
re port J Ha nd Ther 2004; 1 7 (4)4 2 7-428.
O ' B r i e n SJ, Pa g n a n i MJ, Fea ly S, McG lyn n S R, Wi l s o n JB. The a ctive com
p re s s i o n test: a n ew a n d effective test fo r d i a g n o s i n g l a b ra l tea rs a n d
a c ro m iocl avic u l a r j o i n t a b n o rm a l ity. A m J Sports Med 1 998;26(5) 6 1 0-
61 3.
52 Section 3
PIANO KEY SIGN

TEST POSITIONING
The s u bject sits with t h e i nvo lved l i m b rel axed at the side or sta n d s
fac i n g the exa m i n e r.
ACTION
The exa m i n e r a p pl i es d ownwa rd pressu re to the s u bject's d i sta l
clavicle i n a n i nferior d i recti o n (Fig u re 53 - 1 5).
F i g u re 53-1 5 .
POSITIVE FINDING
The exa m i n er is a b l e to use i nferior p ress u re to d e p ress the clavicle
i nto its normal rest i n g position a n d s u bseq uently watch the clavicle
e l evate again once the p ressu re i s re m oved. This fi n d i n g i s i n d i cative
of the i n sta b i l ity of the AC joint o n the i nvo lved side.

The exa m i n e r s h o u l d a l ways use a b i l atera l co m pa rison when
assess i n g the ra n g e of e l evation a n d d e p ress i o n of the i nvolved c l avi
c l e. S i g n ificant clavicu l a r e l evation may a l so i n d i cate coracocl avi c u l a r
j o i n t i nvolvem ent.
Shoulder 53
APPREHENSION TEST (ANTERIOR)

TEST POSITIONING
The s u bject l ies s u p i n e on a ta ble.
ACTION
With the s u bject's i nvolved s h o u l d e r in 90 deg rees of a bd uction
and the el bow i n 90 deg rees of fl exion, the exa m i n e r s l owly exte rn a l ly
rotates the s h o u l d e r (Fig u re 5 3 - 1 6).
Figure 53- 1 6.
POSITIVE FINDING
A pos itive fi n d i n g for t h i s test can be i nterpreted if the s u bject
looks a p p re h e n s ive o r expresses fee l i n g s of a p p re h e n s i o n towa rd
fu rth e r m ovement in the externa l l y rotated d i rectio n . This test i s
u sed t o m i m ic t h e positi o n i n g a n d m ovement o f a n a nterior d i s l oca
tion of the g l e n o h u mera l joi nt, t h u s recreating a s u bject's episode of
i n sta b i l ity.

S i m p l e i n d i cation o r re port i n g of a p p re h e n s i o n to a m ovement
d oes not n ecessa rily i n d i cate a d i s l ocati o n of the g l e n o h u meral joi nt.
54 Section 3
EVIDENCE

C o n d iti o n s I n sta b i l ity M ixed cond iti o n s
eva l u ated (eg, S LA P tea r a n d
i n sta b i l ity)
S e n s itivity 50 to 72 66
S pec ificity 5 6 to 99 95
REFERENCES
G a g ey OJ, G a g ey N . The hypera bd u ction test J Bone Join t Surg Br
200 1 ;83 ( 1 ):69-74.
G u a n c h e CA, J o n e s DC C l i n i ca l testi n g fo r tea rs of the g l e n o i d l a b r u m .
A rthroscopy 2003; 1 9 (5) 5 1 7-5 2 3 .
Heged u s EJ W h i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n ic i a n s with
20 1 2;46 ( 1 4) 964-978.
Br J Sports Med 2008;42 (2) 80-92; d i s c u s s i o n 92.
Ki rkley A, N o nwei l l e r B, Lo I KY, Woo lfrey M Va l i d at i o n of t h e a p p re h e n
s i o n re l ocation a n d s u rprise tests i n t h e d i a g n o s i s o f a nterior s h o u l d e r
i n sta b i l ity. J Bone Join t Surg B r l 997;7 9 B (S u p p l 1 ) 75
Lo I K, N o nwe i l e r B, Woo l frey M, Litc hfi e l d R, Ki rkley A An eva l u at i o n of
t h e a p p re h e n s i o n , re l ocation a n d s u rprise tests fo r a nterior s h o u l d e r
i n sta b i l ity. A m J Sports Med 2 004;32(2) 3 0 1 -307.
M a h a ffey BL, S m it h PA S h o u l d e r i n sta b i l ity i n yo u t h ath l etes. A m Fa m
Physicia n. 1 999;5 9 ( 1 0);2 7 73-2782; 2787.
Wi ntze l l G . La rsson H , La rsso n S . The Ba n ka rt and H i l l -Sa c h s l e s i o n
d etected i n t h e a p p re h e n s i o n test p o s i t i o n b y t h e u s e o f o p e n M R I
a n d i ntrave n o u s contrast i n t h e u n sta b l e s h o u l d e r. J Bone Join t Surg
Br. l 997:79-B(2S) 254
Shoulder 55
APPREHENSION TEST ( POSTERIOR)

TEST POSITIONING
The s u bject l ies s u p i n e on a ta ble. The exa m i n er g rasps the s u b
ject's el bow with o n e h a n d a n d sta b i l izes the i p s i l atera l a n d i nvo lved
s h o u l d e r with the other h a n d .
ACTION
The exa m i n er places the s u bject's i nvo lved s h o u l d e r in a position
of 90 d e g rees of fl exion a n d i ntern a l rotation while a p plyi n g a poste
rior force t h ro u g h the l o n g axis of the h u merus (Fig u re 53-1 7).
Figure 53-1 7.
POSITIVE FINDING
A pos itive fi n d i n g fo r t h i s test can be i nterpreted if the s u bject
looks a p p re h e n sive o r expresses fee l i n gs of a p p rehension towa rd fu r
ther m ovement in t h e poste rior d i recti o n . Th i s test is used to m i m ic
the positi o n i n g a n d m ovement of a posterior d i s l ocation of the
g l e n o h u meral joi nt, thus recreating a s u bject's episode of i n sta b i l ity.
56 Section 3

S i m p l e i n d i cation o r re port i n g of a p p re h e n s i o n to a m ovement
d oes not n ecessa rily i n d i cate a d i s l ocati o n of the g l e n o h u m e ra l joi nt.
EVIDENCE
Heged us (20 1 2)
Study d e s i g n Syste matic review
C o n d it i o n s eva l u ated I n sta b i l ity
Study n u m be r 1
S e n s itivity 19
S pec ificity 99
REFERENCES
Cava l l o RJ , Speer KP. S h o u l d e r i n sta b i l ity a n d i m p i n g e m e n t i n t h rowi n g
a t h l etes. Med Sci Sports Exerc 1 998;3 0 (4) 1 8-25.
Heged u s EJ Which p hys ica l exa m i n a t i o n tests p rovi d e c l i n ic i a n s with
20 1 2;46 ( 1 4) 964-978
Tza n n es A, Paxi n o s A, Ca l l a n a n M, M u rre l l GA A n assess m e nt of t h e i nter
exa m i n e r re l i a b i l ity of tests fo r s h o u l d e r i n sta b i l ity. J Shoulder Elbow
Surg. 2004; 1 3 ( 1 ) 1 8-23.
Shoulder 57
5 U LCUS SIGN
TEST POSITIONING
The s u bject sits with the fo rea rms a n d h a n d s resting in the l a p.
The exa m i ne r sta n d s with the p rox i m a l h a n d g ra s p i n g the s u bject's
sca p u l a (su perio rly) a n d the d i sta l h a n d g ra s p i n g the s u bject's e l bow
(Fig u re 53-1 8).
Figure 53- 1 8.
ACTION
With the sca p u l a sta b i l ized, the exa m i n er a p p l ies an inferior (dis
traction) force with the d i sta l h a n d .
POSITIVE FINDING
Excessive i nferior h u meral head tra n slation with a visi ble a n d/or pal
pable "step-off" o r "s ulcus" deform ity i m m ed iately i nferior to the acro
mion (latera l ly) is indicative of i nferior and/or m u ltid i rectional insta b i l ity.

A positive s u l c u s s i g n at rest may i n d i cate excess ive ca psu l a r
stretc h i n g . T h i s m a y a l so be acco m p a n ied b y a n e u rologica l stretch
to structu res of the b rach i a ! p l exus.
58 Section 3
EVIDENCE
Tza n n es et a l (2004) N a ka g awa et a l

(2005)
Study d e s i g n Re l i a b i l ity Ra n d o m ized
contro l led tri a l
C o n d iti o n s I n sta b i l ity La b ra l pat h o l ogy
eva l u ated
S a m p l e s ize 13 54
Rel i a b i l ity ICC = .60 N ot eva l u ated
S e n s itivity Not eva l u ated 17
S pec ificity Not eva l u ated 93
REFERENCES
Co l e BJ, Rodeo SA, O'Brien SJ, et a l . The a n ato my a n d h i stol ogy of
t h e rotator i n te rva l ca p s u l e of t h e s h o u l d e r. Clin Orthop Re/a t Res.
200 1 ; l (390) 1 2 9- 1 3 7 .
N a ka g awa S, Yo n e d a M, H a ya s h i d a K , O bata M, F u ku s h i m a S, M iyaza ki
Y. F o rced s h o u l d e r a b d u ct i o n a n d e l bow fl exi o n test: a new s i m p l e
c l i n ica l test t o d etect s u perior l a b ra l i nj u ry i n t h e t h rowi n g s h o u l d e r.
A rthroscopy 2005;2 1 ( 1 1 ) : 1 290- 1 2 9 5 .
Tza n n es A, Paxi nos A, Ca l l a n a n M, M u rre l l GA An assess m e n t o f t h e i nter
Surg. 2004; 1 3 ( 1 ) 1 8-23.
Shoulder 59
ANTERIOR D RAWER TEST

TEST POSITIONING
The s u bject l ies s u p i n e with the g l e n o h u mera l joint positioned
at the edge of the ta ble. The exa m i n e r sta n d s next to the i nvo lved
s h o u l d e r, p l a c i n g one h a n d a ro u n d the h u merus below the s u rg i c a l
n e c k . T h e o t h e r h a n d sta b i l izes the sca p u l a by p l a c i n g the fi n g ers
b e h i n d the s u bject o n the s p i n e of the sca p u l a and the th u m b ove r
the coracoid p rocess (Fig u re 53-1 9).
Figure 53- 1 9. N ote: Sta b i l ize at t h e coracoid process a n d t h e s p i n e

of t h e sca p u l a .
ACTION
The s u bject m u st rem a i n re l axed w h i l e the exa m i n er passively
a bd u cts the g l e n o h u meral joint 70 to 80 deg rees, fo rwa rd-flexes 0 to
1 0 deg rees, and externa l ly rotates 0 to 1 0 d e g rees. W h i l e sta b i l izi n g
the sca p u l a , the exa m i n e r fi rmly g l ides the h e a d o f the h u merus a nte
riorly a n d a p p l ies s l i g ht d istraction to the g l e n o h u meral joi nt.
POSITIVE FINDING
I n c reased a nterior tra n s lation of the h u meral head re lative to the
sca p u l a/g l e noid fossa may be i n d icative of a nte rior i n sta b i l ity. The
s u bject may exh ibit a p prehension if the test i s positive. A b i l atera l
comparison s h o u l d be used for a m o re accu rate assessme nt.
60 Section 3
EVIDENCE
M u n ro a n d Heged us et a l Heged us
H e a l y (2009) (2008) (20 1 2)
Study d e s i g n Syste m atic Syste matic M eta-a n a lysis
review review
Conditions SLAP l e s i o n s La b ra l La bra I
eva l u ated i n teg rity i n teg rity,
biceps
te n d i n o pathy
Study 3 4 4
n u m be r
Re l i a b i l ity N ot eva l u ated N ot eva l u ated N ot eva l u ated
S e n s itivity 5 to 78 5 to 78 17
Spec ificity 82 to 93 82 to 93 86
REFERENCES
Heged u s EJ Wh i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n ic i a n s with
t h e most va l u e when exa m i n i n g t h e s h o u l d e r? U pd ate of a syste m
2 0 1 2;46 ( 1 4) 964-978
H eged u s EJ, Goode A, Ca m p be l l S, et a l . Physica l exa m i n a t i o n tests of t h e
Sports Med 2008;42(2)80-92; d is c u s s i o n 92.
M c Q u a d e KJ , M u rt h i AM Anterior g l e n o h u m e ra l fo rce/t ra n s l at i o n b e h av
i o r with a n d wit h o u t rotator c u ff contract i o n d u ri n g c l i n ic a l sta b i l ity
test i n g . Clin Biom ech (Bristol, A von) 2004; 1 9 ( 1 ) 1 0- 1 5 .
M cQ u a d e KJ, S h e l l ey I , Cvitkovic J Patte r n s o f stiffn ess d u ri n g c l i n i ca l
exa m i n a t i o n of t h e g l e n o h u m e ra l j o i n t Clin Biomech (Bristol, A von)
1 999; 1 4(9) :620-627
M u n ro W, H e a l y R. The va l i d ity a n d a c c u ra cy of c l i n i c a l tests u sed to d etect
l a b ra l pat h o l ogy of the s h o u l d e r-a syste matic revi ew. Man Ther.
2009; 1 4(2): 1 1 9- 1 30.
Wa n g Y, Wa n g H , Do n g S, et al. C l i n i ca l study o n t ra u matic a nte r i o r
i n sta b i l ity o f s h o u l d e r [a rt i c l e i n C h i n ese] Zhonghua Wai Ke Za Zhi.
1 998;36 ( 1 0) 588-590
Shoulder 61
POSTERIOR D RAWER TEST

TEST POSITIONING
The s u bject lies s u p i ne. The exa m i n er sta n d s next to the i nvo lved
s h o u l d e r, h o l d s the s u bject's arm at the e l bow, pass ive ly a b d u cts the
s h o u l d e r to 3 0 to 70 deg rees, and h o rizonta l ly flexes the s h o u l d er
20 to 3 0 deg rees. The s u bject's el bow i s fl exed i n a re laxed positi o n .
T h e exa m i n er sta b i l izes the sca p u l a b y p l a c i n g the other h a n d poste
rior to the s h o u l d e r joint ca psu l e with the t h u m b ove r the cora coid
p rocess (Fig u re 53-20).
Figure 53-20.
ACTION
W h i l e sta b i l iz i n g the sca p u l a, the exa m i n e r a p p l ies d ownwa rd
p ressu re, p u s h i n g the h u meral head posteriorly. The exa m i n e r notes
a ny posterior m ovement of the h u meral head.
POSITIVE FINDING
I n c reased posterior i n sta b i l ity of t h e h u meral head re l ative to the
sca p u la/g l e no i d fossa may be i n d icative of posterior i n sta b i l ity. The
s u bject may exh ibit a p p rehension if the test i s positive.
62 Section 3

A b i l atera l co m pa rison s h o u l d be u sed for a m o re accu rate assess
ment.
REFERENCES
E m e ry RJ, M u l l aj i AB. G l e n o h u m e ra l j o i n t i n sta b i l ity i n n o r m a l a d o l escents.
I n c i d e n ce and s i g n ifica n ce. J Bone Join t Surg Br 1 99 1 ;73 (3) 406-408
M cQ u a d e KJ , S h e l l ey I, Cvitkovic J Patte r n s of stiffn ess d u ri n g c l i n i ca l
exa m i n a t i o n of t h e g l e n o h u m e ra l j o i n t Clin Biomech (Bristol, A von)
1 999; 1 4(9) :620-627
Shoulder 63
JOBE RELOCATION TEST

TEST POSITIONING
The s u bject l i es s u p i n e with the test s h o u l d e r i n 90 deg rees of
a bd u ction a n d fu l l exte rnal rotati o n . The exa m i n er sta n d s with t h e
d i sta l h a n d g ra s p i n g the s u bject's wrist a n d h a n d . T h e exa m i n er's
p roxi m a l h a n d is p l a ced ove r the s u bject's h u meral head (anterio rly)
(Fig u re 53-2 1 ) .
Figure 53-2 1 .
ACTION
The exa m i n er a p p l ies a posterior fo rce to the h u meral head, w h i l e
the exa m i n er externa l ly rotates the s u bject's h u merus.
POSITIVE FINDING
A red uction of p a i n a n d a p p rehension, a n d co m m o n l y a n i n c rease
in s h o u l d e r exte rnal rotation, a re i n d i cative of a nterior i n sta b i l ity.
64 Section 3

Th i s test s h o u l d be performed i m mediately fo l l owi n g the a p pre
hension test. Pa i n associated with the J o be Rel ocation Test that
fo l l ows a positive Anterior Apprehension Test may be associated
with any n u m be r of pathologies n ot l i m ited to a nterior i n sta b i l ity.
H owever, if p a i n is seen with a n Anterior Appre h e n s i o n Test a n d s u b
sides with a s u bseq uent Jobe Rel ocation Test, it is q u ite poss i b l e that
any pain was i n fa ct associated with a g reater than n o r m a l a nteri o r
g l id i n g o f the h u meral head.
EVIDENCE
Tza n n es et a l Heged us e t a l Heged us

(2004) (2008) (20 1 2)
Study d e s i g n Re l i a b i l ity Syste m atic M eta-a n a lysis
review
C o n d it i o n s Sym pto m atic I n sta b i l ity I n sta b i l ity
eva l u ated shoulder
pati e n ts
Re l i a b i l ity ICC = .3 1 to N ot eva l u ated N ot eva l u ated
.71
S e n s itivity N ot eva l u ated 30 to 8 1 65
S pec ificity N ot eva l u ated 44 to 99 90
REFERENCES
H a m n e r D L, P i n k M M , J o b e FW. A mod ification of t h e re l ocati o n test:
a rt h roscopic fi n d i n g s associ ated with a pos itive test J Shoulder Elbow
Surg. 2000;9(4) 263-267
Heged u s EJ Wh i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n i c i a n s with
the m ost va l u e when exa m i n i n g t h e s h o u l d e r? U pdate of a syste m
20 1 2;46 ( 1 4) 964-978
Shoulder 65
H eged u s EJ, Goode A, Ca m p b e l l S, et a l . P hysica l exa m i n a t i o n tests of t h e

s h o u l d e r a syste matic review w i t h m eta-a n a lys i s o f i n d ivid u a l tests.
Ko l be l R. A mod ifi cati o n of the re l ocati o n test a rt h rosco p i c fi n d i n g s a s so
c i ated with a positive test J Sho ulder Elbow Surg. 200 1 ; 1 0 (5)49 7-498
Lo I K, N o n we i l e r B, Woo l frey M , Litc hfi e l d R, Kirkley A A n eva l u at i o n of
t h e a p p re h e n s i o n , re l ocation a n d s u rprise tests fo r a nterior s h o u l d e r
i n sta b i l ity. A m J Sports Med 2 004;3 2 (2) 3 0 1 -307.
Tza n n es A, Paxi n o s A, Ca l l a n a n M, M u rre l l GA An assess m e n t of the i n te r
Surg 2004; 1 3 ( 1 ) 1 8-23.
66 Section 3
S U RPRISE TEST (ACTIVE RELEASE TEST)

TEST POSITIONING
The s u bject l i es s u p i n e with the test s h o u l d e r i n 90 deg rees of
a bd u ction a n d fu l l exte rnal rotati o n . The exa m i n er sta n d s with t h e
d i sta l h a n d g ra s p i n g the s u bject's wrist a n d h a n d . T h e exa m i n er's
p roxi m a l h a n d is p l a ced ove r t h e s u bject's h u meral head (anterio rly)
(Fig u re S3-22A).
F i g u re S3-22A.
ACTION
The exa m i n e r a p p l ies a poste r i o r fo rce to t h e h u m e r a l head
while externa l l y rotat i n g t h e s u bj ect's h u m e r u s . Then, the exa m i n e r
q u ickly re m oves t h e p rox i m a l h a n d fro m the h u m e ra l head ( F i g u re
S3-22B).
Shoulder 67
Figure 53-228.
POSITIVE FINDING
A s u d d e n ret u r n of sym pto m s that we re e l i c ited fro m t h e
A p p rehension Test i s i n d icative o f a nterior i n sta b i l ity.

The S u rprise Test is m e rely a n exte n s i o n of the Rel ocation Test
a n d s h o u l d t h e refo re be performed i m med iately fo l l ow i n g t h e
A p p re h e n s i o n a n d Rel ocation Tests, respective ly. If the s u bject dem
o n strates severe a p p rehension a n d i n sta b i l ity sym pto m s with the
A p p re h e n s i o n Test, the Su rprise Test should not be performed so a s
n o t t o tra u m atize (or l ose ra pport w i t h ) the s u bject.
68 Section 3
EVIDENCE

C o n d iti o n s I n sta b i l ity I n sta b i l ity
eva l u ated
S pec ificity 89 to 99 86
REFERENCES
H eged u s EJ Wh i c h p h ys i c a l exa m i n at i o n tests p rovi d e c l i n i c i a n s with
20 1 2;46 ( 1 4) 964-978
Lo I K, N o n we i l e r B, Woo lfrey M, Litchfi e l d R, Ki rkley A A n eva l u ation of
t h e a p p re h e n s i o n , re location and s u rprise tests fo r a nterior s h o u l d e r
i n sta b i l ity. A m J Sport Med 2004;3 2 (2) 3 0 1 -307.
Tza n n es A, Paxi n o s A, Ca l l a n a n M, M u rre l l GA A n assess m e n t of t h e i nter
Surg. 2004; 1 3 ( 1 ) 1 8-23.
Shoulder 69
�----- F EAG I N TEST

TEST POSITIONING
The s u bject sta n d s with the i nvo lved a r m a bd u cted to 70 to
90 deg rees. The e l bow is exte nded a n d a l l owed to rest on the exa m
i n er's s h o u l d e r. The exa m i n e r sta n d s to the side of the s u bject and
clasps h i s o r h e r hands together a ro u n d the u p per a n d m i d d l e t h i rd s
o f the h u merus.
ACTION
The exa m i n er atte m pts to g l i d e the h u m erus in an a nterior a n d
i nferior d i rection ( Fi g u re 53-23).
Figure 53-23.
POSITIVE FINDING
Excess ive g l id i n g of the h u m erus (as co m pa red to the non i nvo lved
side) may be i n d i cative of a nterior a n d/or inferior g l e n o h u meral
i n sta b i l ity.
70 Section 3

The s u bject may a p pear to be a p p re h e n s ive when perfo r m i n g t h i s
test. If so, the exa m i n er ca n co n c l u d e o n l y t h a t the test i s n o t sensi
tive enough to assess i n sta b i l ity u n l ess the exa m i n e r i s able to j u d g e
accessory motion co m pa red t o the n o n i nvo l ved s i d e . A p p re h e n s i o n
a l o n e ca n not be u s e d t o p redict g l e n o h u m e ra l i n sta b i l ity.
REFERENCE
B re n n e ke S L, Reid J , C h i n g R P, Whee l e r DL. G l e n o h u m e ra l ki n e m atics a n d
ca p s u l o- l i g a m e n t o u s stra i n res u lti n g fro m laxity exa m s . Clin Biomech
(Bristol, A von). 2000; 1 5 ( 1 0) :735-742
Shoulder 71
LOAD AN D S H I FT TEST
TEST POSITIONING
T h e s u bject sits with n o u p per tru n k sta b i l ization a n d t h e i nvo lved
a rm resting at the side. The exa m i n e r sta nds s l i g htly beh i n d the s u b
ject w h i l e sta b i l izing the clavicle a n d sca p u l a with one h a n d . With
the other h a nd, the exa m i n e r g rasps the s u bject's h u meral head with
the t h u m b posteriorly. The exa m i n er's re m a i n i n g fi n g e rs a re l ocated
a nteriorly (Fig u re 53-24) .
Figure 53-24.
ACTION
The exa m i n er p l aces an axi a l load a l o n g the shaft of the h u merus
( l oad) i n a n attem pt to co m p ress the h u mera l head i nto the g l enoid
fossa. With the load a p p l ied, the exa m i n er tra n s l ates the h u meral
head, first a nteriorly (shift) a n d then posteriorly (s hift).
POSITIVE FINDING
An a nte rior or posterior tra n s lation of the h u mera l head g reater
than 25% of the d i a m eter of the h u meral head when a load i s a p p l ied
i s co nsidered to be a positive test. The test s h o u l d be repeated b i l ater
a l ly fo r comparative fi n d i ngs.
72 Section 3

Tra n s lation between 25% a n d 50% h a s been descri bed as b e in g
a g rade I positive test. G reater t h a n 50% tra n s lation associated with
a s u bseq uent red uction of the h u meral head i s considered g rade I I,
whereas the same a m o u nt of tra n s lation without red uction is recog
n ized a s g rade I l l and the m ost serious type of a s h ift.
EVIDENCE
Tza n n es et a l (2004)
Study d e s i g n Rel i a b i l ity
C o n d it i o n s eva l u ated I n sta b i l ity
Rel i a b i l ity ICC = .68 to .79
REFERENCES
B u rka rt A, De b s ki RE, M u sa h l V, M c M a h o n PJ G l e n o h u m e ra l t ra n s l at i o n s
a re o n ly pa rti a l ly restored after repa i r of a s i m u l ated type I I s u pe r i o r
l a b ra I l e s i o n . A m J Sports M e d 2003;3 l ( 1 ) 5 6-63
Cava l l o RJ, Speer KP. S h o u l d e r i n sta b i l ity a n d i m p i n g e m e n t in t h rowi n g
ath l etes. Med Sci Sports Exerc 1 998;30(4) 1 8-25.
Fitzpatrick MJ, Ti b o n e J E, G ross m a n M , McGa rry MH, Lee TQ. Deve l o p m e n t
o f cadaveric m o d e l s o f a t h rower's s h o u l d e r. J Shoulder Elbow Surg.
2005; 1 4( 1 S u p p l S) 49S-5 7S
M c M a h o n PJ, B u rka rt A, M u sa h l V, D e b s ki RE. G l e n o h u m e ra l tra n s l at i o n s
a re i n c reased after a type I I s u p e r i o r l a b r u m a nte rior-poste rior l e s i o n : a
cadaveric study of seve rity of p a s s ive sta b i l ize r i nj u ry. J Shoulder Elbow
Surg. 2004; 1 3 ( 1 ) 3 9-44
Tza n n es A, Paxi nos A, Ca l l a n a n M, M u rre l l GA An assess m e n t of t h e i nter
Surg. 2004; 1 3 ( 1 ) 1 8-23
Shoulder 73
G R I N D TEST
TEST POSITIONING
The s u bject l ies s u p i n e on a ta b l e with the s h o u l d e r a b d u cted to
90 deg rees a n d the e l bow flexed to 90 d e g rees on the i nvo lved side.
The exa m i n er g rasps the s u bject's e l bow with o n e h a n d a n d the s u b
ject's p rox i m a l h u merus with the other h a n d (Fig u re 53-25).
Figure 53-25.
ACTION
The exa m i n er a p p l ies co m p ress ion to the g l enoid l a b r u m w h i l e
atte m pting t o rotate the h u meral h e a d 3 6 0 deg rees a ro u n d the s u r
face of the g l e noid fossa.
POSITIVE FINDING
A pos itive fi n d i n g of a g r i n d i n g or cl u n ki n g sensation may be
i n d icative of a g l e noid l a b r u m tea r to the specific l ocati o n that is
being co m p ressed.

Th i s test s h o u l d be perfo rmed ca refu l l y beca use the a p p l ication of
excessive pressu re combi ned with rotation may fu rther d a m a g e the
g l enoid l a b r u m .
74 Section 3
C LU N K TEST
TEST POSITIONING
The s u bject lies s u p i n e on a ta ble. The exa m i n e r p l aces o n e h a n d
o n the poste rior a s pect o f the s u bject's h u meral h e a d a n d the other
hand p roxi m a l to the s u bject's e l bow joint along the d i sta l h u merus
(Fig u re S3-26A).
F i g u re S3-26A.
ACTION
The exa m i n er passively a bd ucts a n d externa l ly rotates the s u b
ject's a r m overhead a n d a p p l ies a n a nte rior fo rce to the h u merus.
(The exa m i n er may a l so choose to i nterna l l y rotate the h u m erus at
the same time the a nterior fo rce i s being a p p l ied.) The exa m i n er then
c i rc u m d u cts the h u meral head a ro u n d the g l enoid labrum ( Fi g u re
53-268).
Shoulder 75
Figure 53-268.
POSITIVE FINDING
A pos itive fi n d i n g of a g r i n d i n g o r cl u n ki n g sensation may be
i n d icative of a g l e noid l a b r u m tea r.

The s u bject may a p pea r to h ave a pos itive test or eve n s h ow
a p p rehension i n t h i s position if an u n derlying a nterior a n d/or i nferior
i n sta b i l ity of the g l e n o h u m e ra l joint exists. This test i s most a p propri
ate fo r asses s i n g s u perior l a b ra l tea rs beca use the i nfe rior portion of
the l a b r u m i s n ot i n contact with the h u meral head while the h u mer
us is positioned in fu l l a b d uction a n d externa l rotati o n . Beca use of
the nature of t h i s a n ato m i c a l positio n i ng, it is poss i b l e to expe rience
a fa lse-negative test if the s u bject h a s an i nferior l a b r a l tea r.
76 Section 3
EVIDENCE
H e g e d u s et a l (2008)
C o n d it i o n s eva l u ated La b ra l pat h o l og ies
Study n u m be r 1
S e n s itivity 44
S pec ificity 68
REFERENCES
Fe i n ste i n WK, Licht m a n OM Recog n iz i n g a n d treati n g m i dca rpa l i n sta b i l
ity. Sports Med A rth rosc. l 998;6(4) :2 70-277
Heged u s EJ, Goode A, Ca m p be l l S, et a l . P hysica l exa m i n a t i o n tests of t h e
s h o u l d e r: a syste matic review w i t h m eta-a n a lys i s o f i n d ivid u a l tests.
Br J Sports Med 2008;42(2) :80-92; d i s c u s s i o n 92.
Ki m SH, Park JC, Pa r k JS, O h I. Pa i nfu l jerk test a p red i ctor of s u ccess i n
n o n o p e rat ive treat m e n t o f p a i nfu l i nfe rior i n sta b i l ity o f t h e s h o u l d e r.
Am J Sports Med 2004;32 (8) 1 849- 1 8 5 5 .
Shoulder 77
( RAN K TEST
TEST POSITIONING
With the s u bject sta n d i ng, the exa m i n er p l aces the d ista l h a n d
o n the s u bject's el bow a n d the p rox i m a l h a n d o n the s u bject's p roxi
mal h u m erus and then passively el evates the s u bject's s h o u l d e r to
1 60 deg rees i n the sca p u l a r p l a ne.
ACTION
With the d i sta l h a nd, the exa m i n er a p p l ies a load a l o n g the l o n g
a x i s o f the h u merus w h i l e t h e p roxi m a l h a n d exte rn a l ly (Fig u re
S3-2 7A) a n d i ntern a l l y ( Fi g u re 53-2 7 8) rotates the h u m e rus.
F i g u re S3-27A.
78 Section 3
Figure S3-27B.
POSITIVE FINDING
Pa i n a n d/or c l i c k i n g a re i n d i cative of g l e noid la b ra I pathol ogy.

Th i s test can a l so be performed i n the s u p i n e position s h o u l d
a p p rehension o r m u scle g u a rd i n g be a concern i n the sta n d i n g posi
tion. L i ke m ost tests fo r labral pathol ogy, the sensitivity of this test is
q u esti ona ble.
EVIDENCE

C o n d iti o n s La b ra l pat h o l og i es La b ra l pat h o l og ies
eva l u ated
S e n s itivity 1 3 to 8 1 34
Shoulder 79
REFERENCES
G u a n c h e CA, J o n e s DC C l i n ica l testi n g fo r tea rs of t h e g l e n o i d l a b r u m .
A rthroscopy 2003; 1 9 (5) 5 1 7-5 2 3 .
Heged u s EJ W h i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n i c i a n s with
20 1 2;46 ( 1 4) 964-978.
Br J Sports Med. 2008;42 (2) 80-92; d i s c u s s i o n 92.
Li u SH, H e n ry MH, N u cc i o n S L. A p ros pective eva l u ation of a new physi
ca l exa m i n a t i o n i n p red i cti n g g l e n o i d l a b ra l tea rs. A m J Sport Med.
l 996;24(6) 72 1 -725.
Pa re ntis MA, Mohr KJ , E I Attra c h e NS. Di sord e rs of the s u perior labrum review
a n d treatment g u id e l i nes. Clin Orthop Re/a t Res. 2002;(400) 77-87
80 Section 3
O ' BRIEN TEST (ACTIVE COMPRESSION)

TEST POSITIONING
The s u bject sits or sta n d s with the test s h o u l d e r in 90 d e g rees of
fo rwa rd fl exion, 30 to 45 d e g rees of h o rizonta l a d d u ction, a n d maxi
mal i ntern a l rotation. The exa m i n er sta n d s with one hand g ra s p i n g
the s u bject's test wrist (med i a l ly) ( Fi g u re 53-28A) .
F i g u re S3-28A.
ACTION
The s u bject h o rizonta l l y a d d u cts a n d flexes the test s h o u l d er
a g a i nst the exa m i n er's m a n u a l res i sta nce. The test i s then repeated
with the s u bject's arm in an externa l ly rotated position (Fig u re
53-28B).
Shoulder 81
Figure 53-288.
POSITIVE FINDING
Pa i n a n d/or p o p p i n g that i s p resent i n the i ntern a l ly rotated posi
tion but a bsent i n the externa l ly rotated position i s i n d icative of a
S LAP lesion.

The O'Brien Test is considered to be the most accu rate test fo r
assessi n g S LAP lesions; h oweve r, the sensitivity of t h i s a n d other S LAP
lesion tests a re q u esti o n a b l e. To m o re c l osely s i m u late the ecce ntric
traction associated with the mecha n i s m of i nj u ry rel ated to SLAP
lesions, the exa m i n er may wish to s l owly m ove the s u bject's a r m fro m
a flexed t o a n exte nded position w h i l e res isti ng h o rizo ntal a d d uction
and s h o u l d e r fl exi o n .
82 Section 3
EVIDENCE

C o n d iti o n s S LA P l e s i o n SLAP l e s i o n
eva l u ated
S pec ificity 1 1 to 98 37
REFERENCES
G u a n c h e CA, J o n e s DC C l i n i c a l testi n g fo r tea rs of t h e g l e n o i d l a b r u m .
A rthroscopy 2003; 1 9 (5) 5 1 7-5 2 3 .
Heged u s EJ W h i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n ic i a n s with
20 1 2;46 ( 1 4) :964-978
Heged u s EJ , Goode A, Ca m p be l l S, et a l . Physica l exa m i n a t i o n tests of t h e
s h o u l d e r: a syste m atic revi ew w i t h m eta-a n a lys i s of i n d ivid u a l tests.
McFa r l a n d EG, Ki m TK, Savi n o RM C l i n ica l a ssess m e n t of t h ree co m m o n
tests fo r s u perior l a b ra l a nte rior- poste r i o r l e s i o n s . A m J Sports Med
2002;3 0 (6) 8 1 0-8 1 5 .
O'Brien SJ, Pa g n a n i MJ, Fea ly S , McGlyn n S R, Wi l s o n J B. T h e a ctive com p res
s i o n test: a n ew a n d effective test fo r d i a g n os i n g l a b ra l tea rs a n d a c ro
m i oc l avic u l a r joint a b norma l ity. A m J Sports Med 1 998;26(5) 6 l 0-6 1 3 .
Pa re ntis M A , J o be C M , Pi n k M M , J o be F W A n a n ato m i c eva l u ation o f t h e
a ctive com p res s i o n test J Shoulder Elbow Surg. 2 004; 1 3 (4) 4 l 0-4 1 6.
Stetso n WB, Te m p l i n K. The c ra n k test, t h e O'Brien test, and routi n e mag
netic reso n a nce i m a g i n g sca n s i n t h e d i a g n o s i s of l a b ra l tears. A m J
Sports Med 2002;30(6) 806-809
Shoulder 83
B RACH IAL P LEXUS STRETCH TEST

TEST POSITIONING
The s u bject sits. The exa m i n e r sta n d s n ext to or b e h i n d the s u bject
and places one h a n d o n the side of the s u bject's head and the other
h a n d o n the s h o u l d e r of the same side.
ACTION
The exa m i n e r latera l ly flexes the s u bject's head w h i l e a p plyi n g
gentle d ownwa rd p ress u re o n the s h o u l d e r (Fig u re 53-29).
Figure 53-29.
POSITIVE FINDING
Pa i n that rad iates i nto the s u bject's a r m o p posite to the l atera l ly
fl exed neck i n d icates a positive fi n d i n g .

If pa i n is i n the neck o n the side towa rd l atera l fl exi on, a p i n c h ed
n e rve or fa cet joint i m p i ngement may exist. Th i s test s h o u l d not be
performed if a cervi ca l fractu re o r d i s l ocatio n i s s u s pected.
84 Section 3
REFERENCES
Ba l ste r S M , J u l i GA U p per t ra pezi u s m u s c l e a ctivity d u ri n g t h e b ra c h i a !
p l ex u s te n s i o n test i n asym pto matic s u bjects. M a n Ther 1 997;2(3) 1 44-
1 49.
M a c ki n n o n SE. Pat h o p h ys i o l ogy of n e rve co m p re s s i o n . Ha n d Clin.
2002; 1 8(2) 23 1 -234.
Shoulder 85
ADSON 1S MANEUVER
TEST POSITIONING
The s u bject sits or sta n d s. The exa m i n er sta n d s with fi ngers ove r
the rad i a l a rtery (dista l ly) (Fig u re S3-30A) .
Figure S3-30A.
ACTION
The exa m i n e r externa l l y rotates a n d exte n d s the s u bject's test a rm
w h i l e pal pati n g the rad i a l p u l se. The s u bject then exte nds a n d rotates
the neck towa rd the test a rm a n d ta kes a deep b reath ( Fi g u re S3-30B).
86 Section 3
F i g u re 53-308.
POSITIVE FINDING
A d i m i n ished or a bsent ra d i a l p u l se is i n d i cative of thoracic outlet
syn d ro m e, seco n d a ry to co m p ressi o n of the su bclavi a n a rtery by the
sca l e n e m u sc l es.

Th i s test assesses va scu l a r structu res o n l y a n d h a s a h i g h i n c i d e n ce
(> 5 0%) of fa lse- positive fi n d i ngs. The exa m i n e r s h o u l d record the
rate a n d rhyt h m of the p u l se a s red u ced o r a ltered, a s o p posed to one
that i s co m p l etely d i m i n ished.
Shoulder 87
EVIDENCE
P l ewa a n d D e l i n g e r N o rd et al (2008)
( 1 998)
Study d e s i g n C ross-secti o n a l C ross-sectio n a l
C o n d iti o n s Thoracic o u t l et Thoracic o u t l et
eva l u ated syn d ro m e syn d ro m e
Rel i a b i l ity N o t eva l u ated N ot eva l u ated
S e n s itivity Not eva l u ated N ot eva l u ated
S pec ificity 89 to 1 00 80
REFERENCES
N o rd KM, Ka poor P, F i s h e r J, et a l . Fa l se positive rate of t h o ra c i c o u t l et
syn d ro m e d i a g n ostic m a n e uvers. Electromyogr Clin Neurophysiol.
2008;48(2) 67-74.
P l ewa MC, Oe l i n g e r M . The fa l se-pos itive rate of t h o ra c i c o u t l et syn
d ro m e s h o u l d e r m a n e uvers in h ea lthy s u bjects. A ca d Emerg Med.
l 998;5 (4) 3 3 7-342
Raya n GM, J e n s e n C. Th oracic o u t l et syn d ro m e : p rovocative exa m i n a
t i o n m a n e uvers i n a ty p i c a l po p u l atio n . J Sh oulder Elbow Surg.
l 995;4(2) : 1 1 3 - 1 1 7.
88 Section 3
ALLEN 1S TEST
TEST POSITIONING
The s u bject sits or sta n d s with the test s h o u l d e r in 90 d e g rees of
a bd u ction a n d exte r n a l rotation, a n d the el bow in 90 d e g rees of fl ex
i o n . The exa m i n e r sta n d s with fi n g ers ove r the rad i a l a rtery (dista l ly).
ACTION
The s u bject rotates the neck away fro m the test a r m w h i l e the
exa m i n er pal pates the rad i a l pu lse ( Fi g u re 53-3 1 ) .
F i g u re 53-3 1 .
POSITIVE FINDING
A d i m i n ished or a bsent ra d i a l p u l se is i n d i cative of thoracic outlet
syn d rome.

Th i s test assesses va scu l a r structu res o n l y a n d h a s a h i g h i n c i d e n ce
(> 5 0%) of fa lse- positive fi n d i ngs. The exa m i n e r s h o u l d record the
rate a n d rhyt h m of the p u l se a s red u ced o r a ltered, a s o p posed to one
that i s co m p l etely d i m i n ished.
Shoulder 89
REFERENCES
Fes s l e r R D, Wa kh l oo A K, La nzi n o G, G uterm a n LR, H o p k i n s L N . Tra n s ra d i a l
a p p roa c h fo r ve rte b ra l a rt e ry ste n t i n g : tec h n i ca l c a s e re p o rt.
Neurosurgery 2000;46(6) : 1 5 24- 1 5 28; d i s c u s s i o n 1 5 2 7- 1 5 2 8 .
Owe n s JC, B l a n ey LF, R o o s D B . Thora c i c o u t l et syn d ro m e . Bull S o c ln t Ch ir
1 966;25 (5) 547-5 5 5
90 Section 3
Roos TEST (ELEVATED ARM STRESS TEST)

TEST POSITIONING
The s u bject sits or sta nds with both shou lders in 90 degrees of abd uc
tion a n d external rotation, and the el bows in 90 degrees of fl exion.
ACTION
The s u bject ra p i d l y opens a n d cl oses both h a n d s for 3 m i n utes
(Fig u res 53-32A and 53-32B).
F i g u re S3-32A.
F i g u re 53-328.
Shoulder 91
POSITIVE FINDING
The i n a b i l ity t o m a i nta i n the test position, d i m i n i shed motor
fu ncti o n of the h a n d s, pain, a n d/o r loss of sensation in the u p per
extre m ities a re i n d i cative of thoracic outlet syn d rome seco n d a ry to
n e u rovascu l a r co m p ro m i se.

Th i s test eva l u ates both n e u ra l a n d va scu l a r structu res a n d i s
considered t o be the most accu rate c l i n ical test fo r assess i n g thoracic
outlet syn d rome. An exa m i n e r may fi n d m u scle fat i g u e p resent when
perfo r m i n g the Roos Test fo r a n otherwise hea lthy p o p u l ation and
should therefo re use caution when documenting s u c h fi n d i n g s with
potential path ologica l ly i nvolved s u bjects.
EVIDENCE
P l ewa a n d D e l i n g e r N o rd e t a l (2008)
( 1 998)
Study d e s i g n C ross-secti o n a l C ross-sectio n a l
C o n d iti o n s T h o r a c i c o u t l et Thoracic o u t l et
S e n s itivity Not eva l u ated N ot eva l u ated
REFERENCES
H owa rd M , Lee C, De l l o n AL. Doc u m e ntation of b ra c h i a I p l ex u s co m p res
s i o n (i n the t h o ra c i c i n l et) uti l iz i n g p rovocative n e u rose n s o ry a n d
m u s c u l a r testi n g . J Reconstr Microsurg. 2003 ; 1 9(5)303-3 1 2 .
N o rd K M , Ka poor P , F i s h e r J , e t a l . Fa l s e positive rate of t h o ra c i c o u t l et
syn d ro m e d i a g nostic m a n e uvers. Electromyogr Clin Neurophysiol
2008;48(2) 6 7-7 4.
Owe n s JC, B l a n ey LF, Roos D B . Thora c i c o u t l et syn d ro m e Bui! Sac ln t Ch ir.
l 966;25 (5):547-5 5 5
92 Section 3
P l ewa MC, Oe l i n g e r M. The fa l se-pos itive rate of t h o ra c i c o u t l et syn

d ro m e s h o u l d e r m a n e uvers in hea lthy s u bjects. A ca d Emerg Med
l 998;5 (4) 3 3 7-342
Roos OB. Co n g e n ita l a n o m a l i es associated with t h o ra c i c o ut l et syn
d ro m e . A n ato my, sym ptoms, d i a g n o s i s , a n d treat m e n t A m J Surg.
l 976; 1 3 2 (6) 7 7 1 -778
Roos OB. Expe rience with fi rst ri b resect i o n fo r t h o ra c i c o u t l et syn d ro m e .
A n n Surg. 1 9 7 1 ; 1 73 (3) 42 9-442
Roos OB. H i storica l pers pectives a n d a n ato m i c c o n s i d e rati o n s . Thoracic
o u t l et syn d ro m e. Semin Thora c Cardiovasc Surg. l 996;8(2) : 1 83- 1 89.
Roos O B . Pathophys i o l ogy of c o n g e n ita l a n o m a l i e s in t h o ra c i c o u t l et
syn d ro m e . A cta Ch ir Be!g l 980;79(5) 3 5 3 -3 6 1 .
Roos OB. Thoracic o u t l et syn d ro m e . Rocky Mt Med J l 96 7;64(2) 49-5 5 .
Roos O B . Tra n saxi l l a ry a p p ro a c h fo r fi rst ri b resect i o n t o re l i eve t h o ra c i c
o u t l et syn d ro m e . A n n Surg. l 966; 1 6 3 (3 ) 3 54-3 5 8
Roos D B, Owe n s J C Th o ra c i c o u t l et syn d ro m e . A rch Surg. 1 966;93 ( 1 ) 7 1 -
74.
Shoulder 93
M I LITARY B RACE POSITION

TEST POSITIONING
The s u bject sta n d s i n the a nato m i c a l positi o n .
ACTION
The exa m i n e r sta n d s b e h i n d the s u bject a n d u n i l atera l ly assesses
the ra d i a l p u l se. The s u bject's same a r m i s then passively exte nded
a n d a bd u cted to 3 0 d e g rees by the exa m i n er while the s u bject s i m u l
ta neously hyperexten d s the head a n d neck ( Fi g u re 53-33).
Figure 53-33.
POSITIVE FINDING
A d i m i n i shed or a bsent ra d i a l p u l se may i n d icate potential tho
racic outlet syn d ro m e.

The exa m i n e r s h o u l d assess rate a n d rhyt h m of the p u lse a n d n ote
any c h a n g es. Th i s assessment s h o u l d be co m pa red b i l atera l l y. Th i s
test i s a l s o ca l l ed the Costoclavicu l a r Syn d ro m e Test, as it i s b e l i eved
a positive fi n d i n g may be rel ated to a co m p ression of the s u bclavi a n
a rtery a s it trave l s u n d e r t h e clavicle a n d ribs.
94 Section 3
G ERBER 1S TEST ( L I FT-O FF TEST)

TEST POSITIONING
The s u bject sits or sta n d s with the h u merus i ntern a l l y rotated
a n d the h a n d placed b e h i n d the back. The exa m i n er sta n d s d i rectly
b e h i n d the s u bject ( Fi g u re S3-34A) .
ACTION
The exa m i n er a s ks the s u bject to l ift the h a n d off the back ( Fi g u re
53-348).
F i g u re S3-34A.
Fig u re 53-348.
Shoulder 95
POSITIVE FINDING
A tea r or wea kness of the su bsca p u l a r i s is s u s pected if the s u bject
ca n n ot lift the h a n d off the back.

Some s u bjects may fi n d t h i s positi o n i n g u n co mfo rta b l e, so it i s
s u g g ested t h a t it be u s e d o n ly i n peo p l e w i t h accepta b l e i ntern a l
rotation ra n g e o f m oti o n .
EVIDENCE

C o n d iti o n s Rotator cuff Rotator cuff
eva l u ated pat h o l ogy pathology
S e n s itivity 1 7 to 92 6 to 69
S pec ificity 60 to 98 23 to 90
REFERENCES
H eged u s EJ . Wh i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n i c i a n s with
20 1 2;46 ( 1 4) 964-978
Br J Sports Med. 2008;42 (2) :80-92; d i s c u s s i o n 92.
96 Section 3
J ERK TEST ( POSTERIOR STRESS)

TEST POSITIONING
The s u bject is seated. The exa m i n e r sta n d s beh i n d a n d to the
side of the s u bject ( Fi g u re 53-35A), with o n e h a n d sta b i l iz i n g the
s u bject's sca p u l a and the other hand s u p porti n g the s h o u l d e r in
i nter n a l rotation a n d 90 deg rees of fl exion and the e l bow i n position
of 90 deg rees of fl exi o n .
F i g u re S3-3SA.
ACTION
The exa m i n e r pass ive ly m oves the s u bject's a r m i nto h o rizontal
a d d uction while a l so placing a n axial load o n the h u merus (Fig u re
53-35B).
Shoulder 97
F i g u re S3-35B.
POSITIVE FINDING
Posterior i n sta b i l ity is s u s pected if the s u bject experi ences a p a i n
fu l o r n o n p a i nfu l c l u n k.

It is i m portant to be s u re the s u bject is rel axed so the passive
motion a n d axi a l load can be a p p l ied correctly. Ad d it i o n a l ly, s u bjects
with a positive test s h o u l d a l so be eva l u ated fo r a postero i nferior
l a b ra l tea r.
EVIDENCE
H e g e d u s et a l (2008)
C o n d it i o n s eva l u ated La b ra l pat h o l og ies
Study n u m be r 2
S e n s itivity 2 5 to 73
S pec ificity 80 to 98
98 Section 3
REFERENCES
H eged u s EJ, Goode A, Ca m p b e l l S, et a l . P hysica l exa m i n a t i o n tests of t h e
s h o u l d e r a syste matic review w i t h m eta-a n a lys i s o f i n d ivid u a l tests.
Br J Sports Med 2008;42(2) 80-92; d i s c u s s i o n 92.
Ki m SH, Pa rk JS, J e o n g WK, S h i n S K. Th e Ki m test a n ove l test fo r poste ro i n
fe rior l a b ra I l e s i o n o f t h e s h o u l d e r-a com pa rison t o t h e j e r k test A m J
Sports Med 2005;33 (8) 1 1 88- 1 1 92.
Shoulder 99
PAI N F U L A RC SIGN
TEST POSITIONING
The s u bject a n d the exa m i n er sta n d fa c i n g each other.
ACTION
The exa m i n er a s ks the s u bject to actively a bd u ct the a r m (Fig u re
53-36).
Figure 53-36.
POSITIVE FINDING
I m p i n gement is s u s pected if the s u bject repo rts p a i n when reach
i n g 60 to 1 20 deg rees of a r m a bd u cti o n .

Altho u g h t h i s test ca n be co m p l eted i n a sta n d i n g position, it i s
a l so poss i b l e fo r s u bjects t o pe rform t h i s test i n a seated positi o n .
Ad d itional ly, pa i n experie n ced o u t s i d e o f the 6 0 - to 1 20-deg ree
ra n g e a re co n s i d e red a neg ative res u l t fo r i m p i n g e m ent.
1 00 Section 3
EVIDENCE

C o n d iti o n s Impingement I m pingement
S e n s itivity 1 O to 74 53
REFERENCES
Heged u s EJ . Wh i c h p h ys i c a l exa m i n a t i o n tests p rovi d e c l i n i c i a n s with
20 1 2;46 ( 1 4) 964-978.
Br J Sports Med 2008;42(2) 80-92; d i s c u s s i o n 92.
Kes s e l L, Watson M . The p a i nfu l a rc syn d ro m e . C l i n i ca l c l a s s ifi cati o n a s a
g u i d e to m a n a g e m e nt. J Bone Join t Surg Br. 1 9 77;5 9 (2) 1 66- 1 72.
Pa rk H B, Yo kota A, G i l l H S, E l Ra s s i G, McFa rl a n d EG. D i a g nostic a c c u racy
of c l i n i ca l tests fo r the d iffe re n t deg rees of s u b a c ro m i a l i m p i n g e m e n t
sy n d ro m e . J Bone Join t Surg Am. 2005;87 (7) 1 446- 1 45 5 .
Please s e e videos o n the accompanying website at

Elbow
Guide to Figures
d e n otes exa m i ner's m ovement
Lebsack D , Snyder Valicr AR, lscar JAJr.

u""'P'"" �xa'""'a;''"' Fourth Edition (pp 101-120).
1 02 Section 4
RESISTIVE TEN N I S E LBOW TEST ((OZEN 1S TEST)

TEST POSITIONING
The s u bject sits. The exa m i n e r sta b i l izes the i nvo lved el bow w h i l e
p a l pati n g a l o n g the l atera l epico n dyle (Fig u re E4- 1 A) .
F i g u re E4- 1 A.
ACTION
With a cl osed fist, the s u bject p ro n ates a n d rad i a l ly devi ates t h e
fo rea rm a n d exten d s the wrist a g a i nst the exa m i ner's res i sta nce
(Fig u re E4- 1 B).
Elbow 1 03
Figure E4- 1 B.
POSITIVE FINDING
A re port of pa i n a l o n g the lateral epicondyle reg ion of the h u mer
us or o bjective m u sc l e wea kness as a res u l t of co m p l a i nts of d i scom
fo rt may i n d icate l atera l ep icondyl itis.
REFERENCES
B u d off J E, N i rsc h l R P. Offi ce exa m i n a t i o n of t h e e l bow h ow p rovocative
tests ca n h e l p c l i n c h the d i a g n o s i s Consulta n t. 200 1 ;4 1 :7
Pete rson M, B u t l e r S, E r i ks s o n M, Sva rd s u d d K. A ra n d o m ized contro l l e d
tria l o f exe rci s e ve rs u s wa it- l i st i n c h ro n i c te n n i s e l bow (l atera l e p i c o n
dylosis). Ups J M e d Sci. 1 1 6 (4) 269-279
1 04 Section 4
RESISTIVE TEN N I S ELBOW TEST

TEST POSITIONING
The s u bject s its. The exa m i n e r sta b i l izes the i nvolved el bow with
one hand and places the pa l m of the oth e r h a n d o n the d o rs a l a s pect
of the s u bject's h a n d j u st d i sta l to the p rox i m a l i nterp h a l a n g e a l joint
of the t h i rd d i g it (Fig u re E4-2).
Figure E4-2 .
ACTION
The s u bject exte n d s the t h i rd d i g it a g a i nst the exa m i n e r's resis
ta nce.
POSITIVE FINDING
A re port i n g of pa i n a l o n g the l atera l epicondyle reg i o n of the
h u merus o r o bjective m u scle wea kness a s a res u l t of co m p l a i nts of
d i sco mfo rt may i n d icate l atera l epicondylitis.
Elbow 1 05

C l i n i c i a n s h ave re ported d iffe rentiati n g between the exte nsor
ca rpi rad i a l i s l o n g u s (res ista nce ove r the seco nd m etaca rpa l ) a n d the
exte nsor ca rpi ra d i a l i s b revis ( res i sta n ce ove r the t h i rd metaca rpa l ) .
Alth o u g h t h i s may be poss i b le, often b o t h may present w i t h a posi
tive fi n d i n g and the a rea of local pa l pa b l e tenderness is at o r n ea r the
l atera l ep icondyle.
REFERENCE
B u d off J E, N i rs c h l R P. Offi ce exa m i nation of t h e e l bow h ow p rovocative
tests ca n h e l p c l i n c h t h e d i a g n o s i s Consulta n t. 200 1 ;4 1 I
1 06 Section 4
PASSIVE TEN N I S ELBOW TEST

TEST POSITIONING
The s u bject sits with the i nvo lved el bow i n fu l l exte n s i o n .
ACTION
The exa m i n e r passively p ro nates the fo rea rm a n d fl exes the s u b
ject's wrist (Fig u re E4-3A) .
F i g u re E4-3A.
POSITIVE FINDING
A reporti ng of p a i n a l o n g the l atera l epicondyle reg i o n of the
h u merus may i n d icate l atera l epicondyl itis.

The exa m i n e r may a l so pa l pate the i nvo lved l atera l epicondyle
reg i o n d u ri n g the test to assess the tig htness of the common exte n
sor te n d o n orig i n . Th i s test may a l so be performed with the el bow in
flexi o n ( Fi g u re E4-3 B).
Elbow 1 07
F i g u re E4-3 B.
1 08 Section 4
GOLFER 1S E LBOW TEST

TEST POSITIONING
The s u bject sits or sta n d s a n d m a kes a fi st on the i nvo lved side.
The exa m i n er fa ces the s u bject and pa l pates along the med i a l epi
condyle. The exa m i n er's other h a n d g rasps the s u bject's wrist (Fig u re
E4-4A) .
F i g u re E4-4A.
ACTION
The exa m i n er pass ive ly s u p i nates the fo rea rm a n d extends the
e l bow a n d wrist (Fig u re E4-4B).
Elbow 1 09
Figure E4-4B.
POSITIVE FINDING
Co m p l a i nts of d i sco mfort a l o n g the med i a l a s pect of t h e el bow
may be i n d icative of med i a l ep icondyl itis.

Pa i n a l o n g t h e med i a l e p i condyle reg i o n of the i nvo lved el bow
may a l so be caused by structural d a m a g e to the u l n a r nerve o r the
u l n a r co l l atera l l i g a m ent. It i s i m po rta nt to assess each of these struc
tu res prior to m a k i n g any concl u sive dete r m i nati o n s fro m t h i s test
a l one.
1 1O Section 4
�---- HYPEREXTENSION TEST

TEST POSITIONING
The s u bject sits or sta n d s with the el bow fu l ly exte nded a n d the
fo rea rm s u p i n ated. The exa m i n er grasps the d i sta l h u merus at the
a reas of the m e d i a l a n d l atera l e p i condyles with one h a n d while the
ot her h a n d g rasps the d i sta l fo rea rm of the s u bject ( Fi g u re E4-5).
F i g u re E4-5.
ACTION
The exa m i n er passively exte n d s the e l bow u n t i l no fu rther motion
i s ava i l a ble.
POSITIVE FINDING
E l bow extension beyo nd 0 deg rees is co n s i d e red hyperexte n s i o n .
A positive fi n d i n g o f hyperexte n s i o n may be attrib uted t o a t o r n o r
stretched a nterior ca psu l e o f t h e e l bow.

Assess i n g t h i s motion s h o u l d a l ways be performed b i l atera l l y to
d ete r m i n e the n o r m a l ra n g e of motion fo r the i n d ivid u a l s u bject.
Hyperexte n s i o n fi n d i n g s may va ry d e p e n d i n g o n the type of e n d
fee l n oted.
Elbow 111
ELBOW F LEXION TEST

TEST POSITIONING
The s u bject may sit o r sta n d . The exa m i n er sta n d s next to the
s u bject.
ACTION
The s u bject is i n stru cted to maxi m a l ly fl ex the el bow a n d h o l d t h i s
position for 3 t o 5 m i n utes ( Fi g u re E4-6) .
Figure E4-6.
POSITIVE FINDING
Rad iati n g pa i n i nto the m e d i a n n e rve d i stribution i n the s u bject's
a rm a n d/or h a n d (ie, l atera l fo rea rm or tip of t h u m b, i n d ex a n d m i d d l e
fi nger, l atera l half o f i n d ex fi n g e r) i s a positive fi n d i n g . A pos itive test
i s i n d i cative of c u b ita l fossa syn d rome.

Th i s test may a l so be i n d i cative of u l n a r nerve com p ro mise i n the
u l n a r g roove if rad iati n g pa i n exte n d s i nto the s u bject's u l n a r ne rve
d i stribution (ie, t h e fifth d i g it a n d the m e d i a l a s pect of the fo u rth
d i g it) .
1 12 Section 4
EVIDENCE
Och i et a l (20 1 1 ) N ova k et a l ( 1 994)

St udy d e s i g n D i a g n ostic D ia g n ostic
a c c u racy a c c u racy
C o n d it i o n s C u b ita l t u n n e l C u b ita l t u n n e l
Re l i a b i l ity N ot eva l u ated Not eva l u ated
S e n s itivity 36 3 2 t o 75
S pec ificity 1 99
REFERENCES
B l a c k BT, Ba rron OA, Tow n s e n d P F, G l i c ke l SZ, Eaton RG. Sta b i l ized s u bc u
ta n e o u s u l n a r n e rve tra n s position w i t h i m med iate ra n g e o f m oti o n :
l o n g -term fo l l ow- u p. J Bone Join t Surg A m 2000;82-A ( l l ) 1 544- 1 5 5 1 .
C o h e n MS, G a rfi n S R . N e rve co m p re s s i o n syn d ro m e s : fi n d i n g t h e c a u s e of
u p per-extrem ity sym ptoms. Consulta n t. 1 997;3 7 (2) 24 1 -254.
N o rk u s SA, Meyers M C U l n a r n e u ropathy of the e l bow Sports Med
1 994; 1 7 (3) 1 89- 1 99.
N ova k CB, Lee GW, M a c ki n n o n S E, Lay L. P rovocative testi n g fo r c u bita l
t u n n e l syn d ro m e . J Ha n d Surg Am 1 994; 1 9 (5) :8 1 7-820.
Oc h i K, H o ri u c h i Y, Ta n a be A, M o rita K, Ta ked a K, N i n o m iya K. Co m pa rison
of s h o u l d e r i ntern a l rotation test with t h e e l bow fl ex i o n test i n t h e
d i a g n o s i s o f c u b ita l t u n n e l syn d ro m e J Ha n d Surg A m 20 1 1 ;36(5)782-
787.
Elbow 1 13
VARUS STRESS TEST

TEST POSITIONING
The s u bject sits with the test el bow fl exed from 20 to 30 deg rees.
The exa m i n e r sta n d s with the d i sta l h a n d a ro u n d s u bject's wrist (l at
e ra l ly) a n d the p roxi m a l h a n d ove r the s u bject's el bow joint (med i a l ly)
(Fig u re E4-7).
F i g u re E4-7.
ACTION
With the wrist sta b i l ized, the exa m i n e r a p p l ies a va rus stress to the
e l bow with the p rox i m a l h a n d .
POSITIVE FINDING
As co mpared to the u n i nvolved e l bow, l atera l el bow pa i n a n d/or
i n c reased va rus movement with a d i m i n ished o r a bsent e n d point is
i n d i cative of damage primarily to the rad i a l (l atera l) co l l atera l liga ment.

The exa m i n e r m u st avoid a l lowi n g the h u merus to i ntern a l ly o r
externa l ly rotate d u ri n g t h i s test beca use t h i s wi l l g i ve the i l l u sio n of
i n c reased va rus m ovem ent.
1 14 Section 4
VALG US STRESS TEST

TEST POSITIONING
The s u bject sits with the test el bow fl exed from 20 to 30 deg rees.
The exa m i n er sta n d s with the d ista l h a n d a ro u n d the s u bject's wrist
(med i a l ly) a n d t h e p roxi m a l h a n d ove r the s u bject's el bow j o i nt (l ate r
a l ly) ( Fi g u re E4-8) .
F i g u re E4-8.
ACTION
With the wrist sta b i l ized, the exa m i n er a p p l ies a va l g u s stress to
the e l bow with the p roxi m a l h a n d .
POSITIVE FINDING
As co m p a red to t h e u n i nvo l ved e l bow, m e d i a l e l bow a n d/or
i n c reased va l g u s m ove m e n t with a d i m i n i s h e d o r a bsent e n d po i nt
i s i n d i cative of d a m a g e to p r i m a r i ly t h e u l n a r ( m ed i a l ) co l l atera l
l i g a me nt .
Elbow 1 15

The exa m i n e r m u st avoid a l lowi n g the h u merus to interna l ly o r
externa l ly rotate d u ri n g t h i s test beca use t h i s wi l l g i ve the i l l u s i o n of
i n c reased va l g u s m ovement.
EVIDENCE
E l l e n becker a n d Boeckm a n n
( 1 998)
C o n d it i o n s eva l u ated M ed i a l e l bow l a xity
Rel i a b i l ity ICC = .33 to .6
REFERENCES
B u d off J E, N i rs c h l R P. Offi ce exa m i n a t i o n of t h e e l bow: pa l pation a n d
i n sta b i l ity tests. Consulta n t. 200 1 ;4 1 (6) 8 78-886
E l l e n becke r TS, Boeckm a n n RR. l n te rrater re l i a b i l ity of m a n u a l va l g u s stress
test i n g of the e l bow j o i nt a n d its re l a t i o n to an o bjective stress ra d i
o g r a p h y tec h n i q u e i n p rofessio n a l baseba l l pitc h e rs . J Orthop Sports
Phys Th er 1 998;2 7 ( 1 ):95
I n o u e G, Kuwa h ata Y S u rg i ca l re pa i r of tra u matic m e d i a l d i s r u pt i o n of t h e
e l bow i n com petitive ath l etes. Br J Sports M e d 1 995;29(2) 1 3 9- 1 42.
O'Orisco l l SW C l a s s ifi cati o n and eva l u ation of rec u rrent i n sta b i l ity of t h e
e l bow Clin Orth op. 2 000;3 7034-43 .
S c h n e n c k R J r, e d . A thletic Tra ining a n d Sports Medicin e. Rose m o n t, I L:
A m e rica n Aca d e m y of O rt h o p e d i c S u rg e o n s ; 1 997.
1 16 Section 4
�----- T1 N E L 1S S1GN
TEST POSITIONING
The s u bject is seated with the el bow i n s l i g ht fl exion, a n d the
exa m i n e r i s sta n d i n g with the d i sta l h a n d g ra s p i n g the s u bject's wrist
( l atera l ly) .
ACTION
With the wrist sta b i l ized, ta p the u l n a r ne rve in the u l n a r n otch
( between the o l ec ra n o n p rocess and m e d i a l epicondyle) with 1 or
2 fi n g e rs ( Fi g u re E4-9) .
Fig u re E4-9.
POSITIVE FINDING
Ti n g l i n g a l o n g the u l n a r d i stribution of the fo rea rm, ha nd, a n d
fi ngers i s i n d icative o f u l n a r n e rve co m p ro m i se.
Elbow 1 17

A positive fi n d i n g can be related to traction of the u l n a r nerve
fro m a va l g u s force or it can be rel ated to some type of co m p ression
of the n e rve itself, a s wou l d be seen with infl a m mation s u r ro u n d i n g
t h e a rea. Perfo r m a n ce o f a b i l atera l assessment is reco m me n d ed fo r
compa rison of res u lts.
EVIDENCE
Beekm a n et a l Cheng et al (2008)

(2009)
Study d e s i g n C o h o rt D iag n ostic
accu racy
C o n d iti o n s U l n a r n e u ro pathy Ca rpa l and c u bita l
eva l u ated at the e l bow t u n n e l syn d ro m e
S a m p l e s ize 1 92 1 69
Rel i a b i l ity N ot eva l u ated Not eva l u ated
S pec ificity 53 99
REFERENCES
A l fo n s o M l , Ozw i e rzy n s ki W. Ti n e l 's s i g n t h e rea l ities. Phys Med Rehabil
Clin N Am l 998;9(4) 72 1 -736.
Bee kma n R, Sc h re u d e r A H , Roze m a n CA, Koe h l e r PJ, U itd e h a a g B M . The
d i a g nostic va l u e of p rovocative c l i n i ca l tests in u l n a r n e u ro pathy at the
e l bow i s m a rg i n a l J Neural Neurosurg Psych ia try 2009;80 ( 1 2) 1 3 69-
1 3 74.
B l a c k BT, Ba rron OA, Tow n s e n d P F, G l i c ke l SZ, Eato n RG. Sta b i l ized s u bc u
ta n e o u s u l n a r n e rve tra n s position w i t h i m m e d i ate ra n g e o f m oti o n .
Lo n g -term fo l l ow- u p J Bone Join t Surg A m 2000;82-A( l l ) 1 S44- l 5 5 1 .
C h e n g CJ , M a c ki n n o n - Patte rson B, Beck J L, M a c ki n n o n S E . Scratch col
l a pse test fo r eva l u ation of carpal and c u bita l t u n n e l syn d ro m e . J Ha nd
Surg A m 2008;33 (9) 1 5 1 8- 1 5 24.
O'Arcy CA, McGee S Does t h i s pati e n t h ave ca rpa l t u n n e l syn d ro m e ?
JAMA 2000;283 (23):3 1 1 0-3 1 1 7.
O u rka n JA A n ew d i a g n ostic test fo r ca rpa l tu n n e l syn d ro m e . J Bone Join t
Surg Am l 992;73 (4) 5 3 5 - 5 3 8
1 18 Section 4
G a rfi n ke l MS, S i n g h a I A, Katz WA, A l l a n DA, Res h eta r R, Sc h u m a c h e r H R J r.

Yoga-ba sed i nterve n t i o n fo r carpa l t u n n e l syn d ro m e a ra n d o m ized
tria l . JAMA l 998;280 ( 1 8) 1 60 1 - 1 603.
G i a n n i F, M o n d e l l i M, Passero S P rovocative tests in d ifferent sta g e s of
c a r p a l t u n n e l syn d ro m e . Clin Neurosurg. 200 1 ; l 03 (3) 1 78- 1 8 3 .
Ki n g e ry W S , Pa rk K S , Wu PB, D a t e ES. E l e ctro myog ra p h i c m oto r Ti n e l 's
s i g n i n u l n a r m o n o n e u ro p a t h i e s at t h e e l bow Am J Phys Med Reha bil.
l 995;74(6) 4 1 9-426.
Ku h l m a n KA, H e n n e ssey WJ Sensitivity a n d s pec ifi c ity of carpa l t u n n e l
syn d ro m e s i g n s . A m J Phys Med Rehabil. l 997;76(6)45 1 -45 7.
M o n s iva i s JJ, Sun Y. Ti n e l 's s i g n o r p e rc u s s i o n test? Deve l o p i n g a bette r
method of evo ki n g a Ti n e l 's s i g n . J Sou th Orthop Assoc 1 997;6(3) 1 86-
1 89.
M o n ta g n a P, L i g u o ri R. The m oto r Ti n e l 's s i g n : a u s efu l sign i n e n t ra p m e n t
n e u ropathy7 M uscle Nerve. 2000;23 (6):976-978.
Pea rce JM Ti n e l 's s i g n of fo rm icati o n . J Neural Neurosurg Psychia try
1 996;6 l ( 1 ) :6 1 .
S p i c h e r C, Ko h ut G, M i a uton J At w h i c h stag e of s e n s o ry recove ry ca n a
ti n g l i n g s i g n be expecte d ? A review a n d p ro posa l fo r sta n d a rd ization
and g ra d i n g . J Ha n d Ther 1 999; 1 2 (4) 298-308
Sto l p-S m it h KA, Pascoe M K, Og b u rn P L J r. Carpa l t u n n e l syn d ro m e i n
preg n a n cy freq u e n cy, seve rity, a n d p rog n o s i s . A rch Phys Med Rehabil.
1 998;7 9 ( 1 0): 1 285- 1 287.
Elbow 1 19
P I NCH G RI P TEST
TEST POSITIONING
The s u bject may sit or sta n d . The exa m i n er sta n d s next to the
s u bject.
ACTION
The s u bject is i n stru cted to p i n c h t h e tips of the t h u m b a n d i n d ex
fi nger together (Fig u re E4- 1 0).
Figure E4- 1 0.
POSITIVE FINDING
The i n a b i l ity to to u c h the pads of the t h u m b a n d i n dex fi nger
together d e m o n strates a positive fi n d i n g . To u c h i n g the pads of the
t h u m b and i n d ex fi n g e r i n d i cates fu nction of the a nteri o r i nterosse
ous n e rve between the 2 heads of the pronator m u sc l e.

The a nterior i nterosseo us ne rve is a branch of the m e d i a n nerve
(Cl to C8, Tl ) that i n n e rvates the p ro n ator q u a d ratus, fl exo r p o l l icis
l o n g u s, a n d the fi rst a n d seco n d co m p o n e nts of the flexo r d i g ito r u m
p rofu n d us.
120 Section 4
REFERENCE
Th u rsto n A, La m N . Res u l ts of o p e n ca rpa l t u n n e l re lease: a co m p re h e n
s ive, retros pective s t u d y o f 1 88 h a n d s . A ust N Z Surg. l 997;67(5)283-
288.

Wrist and Hand
Guide to Figures

u""'P'"" �xa'""'"'''"' Fourth Edition (pp 121-155).
SLACK Incorporated.
1 22 Section 5
TAP OR PERCUSSION TEST

TEST POSITIONING
The s u bject may sit or sta nd with the affected fi n g e r extended. The
exa m i n e r sta n d s in fro nt of the s u bject.
ACTION
The exa m i n e r a p p l ies a fi rm ta p to the e n d of the fi nger b e in g
tested ( Fi g u re W H S - 1 A) . As a n a l ternative m etho d t o ta p p i ng, the
exa m i n er may use a percussion h a m m e r (Fig u re WH S-1 B).
II
F i g u re WH5-1 A.
Wrist and Hand 1 23
II
Figure WHS-1 B.
POSITIVE FINDING
Pa i n at the s ite of i nj u ry i n d icates a fractu re. The v i b ration of tap
ping a l o n g the long axis of the bone wi l l exa ggerate pa i n at the
fractu re s ite.

Th i s test s h o u l d not be performed if there is a n o bvi o u s deformity.
1 24 Section 5
COMPRESSION TEST
TEST POSITIONING
The s u bject may sit or sta nd with the affected fi n g e r extended. The
exa m i n e r sta n d s in fro nt of the s u bject.
ACTION
The exa m i n e r h o l d s the d ista l p h a l a nx a n d a p p l ies co m p ress i o n
a l o n g the l o n g a x i s of the bone o f the fi n g e r being tested (Fig u re
WHS-2).
II
F i g u re WHS-2.
POSITIVE FINDING
Pa i n at the site of i nj u ry i n d icates a fractu re.

REFERENCE
Tetro AM, Eva n off BA, H o l l st i e n S B, G e l b e r m a n R H . A n ew p rovocative
test fo r ca rpa l t u n n e l syn d ro m e . Asses s m e n t of wrist fl ex i o n a n d n e rve
co m p ressio n . J Bone Join t Surg Br l 998;80(3) 493-498
Wrist and Hand 1 25
LONG F I NGER F LEXION TEST

TEST POSITIONING
The s u bject may sit or sta n d .
ACTION
1 . The exa m i n er sta n d s i n fro nt of the s u bject a n d h o l d s the s u b

ject's fi ngers i n extension, exce pt fo r the fi nger being tested .
2. The exa m i n er isol ates the d i sta l i nte rpha l a n g e a l joint by sta bi
l izi n g the metaca rpo p h a l a ngeal joi nt, p roxi m a l i nterp h a l a n g e a l
joi nts, a n d m i d d l e p h a l a n x o f the fi n g e r bei n g tested.
3 . The s u bject is i n stru cted to flex the fi nger being tested at the
II
d i sta l i nterp h a l a n geal joint (Fig u re WH5-3A) .
F i g u re WHS-3A.
4. N ext, the exa m i n er isol ates the p rox i m a l i nterp h a l a ngeal joint
by sta b i l iz i n g the m etaca rpo p h a l a ngeal joint a n d the p roxi m a l
p h a l a nx. T h e s u bject i s t h e n i n stru cted t o flex the p roxi m a l
i nterp h a l a ngea l joint (Fig u re WH5-3B).
126 Section 5
II
F i g u re WHS-38. N ote: Sta b i l ize at t h e p roxi m a l j o i nt.
POSITIVE FINDING
If the s u bject is u n a b l e to flex the p roxi m a l i nterpha l a n g e a l joi nt,
then both the fl exo r d i g ito r u m p rofu n d u s a n d t h e flexo r d i g ito r u m
s u perficia l i s m u sc l es' te n d o n a n d/o r n e rve a re co m p ro m ised. If the
s u bject i s a b l e to flex the p rox i m a l i nterp h a l a n g eal jo in t but is u n a b l e
t o flex the d i sta l i nterp h a l a n geal joi nt, then o n l y the fl exo r d i g ito ru m
m u sc l e's te ndon a n d/o r nerve a re co m p ro m i sed.

The exa m i n er s h o u l d a l ways perform passive fl exion to both the
prox i m a l a n d d i sta l i nterpha l a n g e a l joi nts to be s u re that a n i n a b i l ity
to fl ex these joi nts is not rel ated to soft tissue tig htness or joint restric
tions. This test s h o u l d n ot be repeated m u lt i p l e t i m es if a te ndon
r u pt u re is s u s pected.
Wrist and Hand 127
F I N KELSTEI N TEST
TEST POSITIONING
The s u bject sits o r sta n d s and fo rms a fi st a ro u n d the t h u m b. The
exa m i n er sta n d s with the p rox i m a l hand g ra s p i n g the s u bject's fo re
arm a n d the d i stal h a n d g ra s p i n g the s u bject's fi st.
ACTION
While sta b i l izing the s u bject's forea rm with the p roximal ha nd,
u l narly deviate the s u bject's wrist with the d i sta l hand (Fig u re WH5-4A).
II
F i g u re WH5-4A.
POSITIVE FINDING
Pa i n ove r the a b d u ctor p o l l icis l o n g u s a n d extensor pol l icis b revi s
te ndo n s d i sta l l y is i n d icative of tenosynovitis i n these te n d o n s (de
Q u e rva i n's d i sease).
128 Section 5

Th i s test may c reate pa i n i n u n i nvo l ved t i s s u es. The exa m i n e r
m a y a l so fi n d t h a t s i m p l e pass ive u l n a r deviation m a y be s l i g htly
u n co mfo rta b l e fo r eve n those without pathol ogy. If d e Q u e rva i n's
d i sease is s u s pected, b u t pa i n is not fo u n d with u l n a r d eviati o n ,
t h e n the exa m i n e r ca n h a v e t h e s u bject rad i a l l y d evi ate a g a i n st
resista nce i n a n atte m pt to re p rod u ce contracti l e-associ ated pa i n
( F i g u re W H 5 -4B).
II
F i g u re WH S-48. N ote: Exa m i n e r resists active ra d i a l deviati o n .
REFERENCES
Dawson C, M u d g a l CS Sta ged d e s c ri pt i o n of t h e F i n ke l ste i n test J Ha n d
Surg Am 2 0 1 0;35 (9) 1 5 1 3 - 1 5 1 5 .
E l l iot BG. F i n ke l ste i n 's test: a descri ptive e rror t h a t ca n p rod u ce a fa l se
pos itive. J Ha n d Surg Br. l 992; 1 7(4) :48 1 -482.
M u rta g h J . De Q u e rva i n 's ten osynovitis and F i n ke l ste i n 's test A ust Fa m
Physicia n. l 989; 1 8 ( 1 2): 1 5 5 2 .
Wrist and Hand 129
P HALEN TEST
TEST POSITIONING
The s u bject sits o r sta n d s with the d o rsa l a s pect of both hands in
fu l l contact so that both wrists a re maxi m a l l y fl exed (Fig u re WHS-5).
II
Figure WHS-5.
ACTION
A steady co m p ressive fo rce is a p p l ied t h ro u g h the s u bject's fo re
a r m s so the s u bject's wrists a re maxi m a l l y flexed fo r 1 m i n ute.
POSITIVE FINDING
N u m bness a n d ti n g l i n g i n the m e d i a n n e rve d i stribution of the
fi ngers (ie, t h u m b, i n dex fi n g e r, m i d d l e fi n g e r, a n d l atera l a s pect of
t h e r i n g fi n g e r) a re i n d i cative of ca rpa l t u n n e l syn d ro m e seco n d a ry to
med i a n n e rve co m p ression.

Pa i n i n the wrist a rea, without com p l a i nts of ra d i ati n g pa i n d i s
ta l ly towa rd t h e h a n d a n d fi n g e rs, may be i n d i cative of ca rpa l b o n e
pathol ogy.
130 Section 5
EVIDENCE
Wa i n n e r et a l El Miedany Ma and
(2005) et a l (2008) K i m (20 1 2)
Study d e s i g n D ia g n ostic D i a g n ostic D iag n osti c
accu racy accu racy accu racy
Co n d it i o n s Cervic a l Carpa l t u n n e l Ca rpa l
eva l u ated ra d icu l o pathy syn d ro m e a n d tunnel
o r ca rpa l ten osynovitis syn d ro m e
tunnel
syn d ro m e
Sa m p l e size 82 232 38
II
Rel i a b i l ity Ka ppa = .79 N ot eva l u ated Not
eva l u ated
S e n s itivity 77 Carpa l t u n n e l : 84
47
Te n osynovitis:
92
Spec ificity 40 Carpa l t u n n e l : 87
17
Te n osynovitis:
87
REFERENCES
B u rke OT, B u r ke MA, Be l l R, Stewa rt GW, M e h d i RS, Ki m H J S u bj ective
swe l l i n g a n ew s i g n fo r ca rpa l tu n n e l syn d ro m e . A m J Phys Med
Rehabil. l 999;78(6) 5 04-5 08.
E l M ieda ny Y, As h o u r S, Yo u ssef S, M e h a n n a A, M e ky FA C l i n ica l d i a g no
sis of ca rpa l t u n n e l syn d ro m e : old tests- n ew c o n ce pts. Join t Bone
Spine. 2008;75 (4) :45 1 -45 7 .
G h ava n i n i M R, H a g h i g hat M . Ca rpa l tu n n e l syn d ro m e rea p p ra i s a l of five
c l i n ica l tests. Electromyogr Clin Neurophysio/. l 998;3 8(7):43 7-44 1 .
Ke n i sto n RC, Nat h a n PA, Le k l e m J E, Loc kwood RS. Vita m i n B6, vita m i n
C , a n d ca rpa l t u n n e l syn d ro m e : a c ross-secti o n a l study o f 44 1 a d u lts.
J Occup Environ Med 1 997;3 9 ( 1 0):949-959
M a H , Ki m I. The d i a g nostic a s s e s s m e nt of h a n d e l evat i o n test in carpa l
t u n n e l syn d ro m e . J Korean Neurosurg Soc 2 0 1 2;5 2 (5 ) :472-475
Wrist and Hand 13 1
M o n d e l l i M, Passero S, G i a n n i n i F. P rovocative tests i n d i ffe rent sta g e s of

c a r p a l t u n n e l syn d ro m e . Clin Neural Neurosurg. 200 1 ; l 0 3 (3) 1 78- 1 8 3 .
O p o rto LM, Pe rez A A , N avaj a s RF, P u e rta AG. D i a g nostic va l u e o f sym p
to m s a n d c l i n i ca l exp l o ration i n ca rpa l t u n n e l syn d ro m e [a rti c l e i n
S p a n i s h ] . Reha bilita ci6n. 1 997;3 l ( 1 ) 23-27
Pa d u a L, Pa d u a R, A p r i l e I , Pasq u a l etti P, To n a l i P; fo r the Ita l i a n CTS St u d y
G ro u p. M u l ti perspective fo l l ow-u p o f u nt reated ca rpa l t u n n e l syn
d ro m e : a m u lticenter stu dy. Neurology 200 1 ;5 6 ( 1 1 ) 1 45 9- 1 466.
R e m p e l D, Titti ra n o n d a P, B u ra stero S, H u des M , So Y Effect of keyboa rd
keyswitch d e s i g n on h a n d pa i n . J Occup En viron Med 1 999;4 l (2) 1 1 1 -
1 1 9.
Sei l e r J G . Ca rpa l t u n n e l syn d ro m e : u pdate on d i a g n ostic test i n g a n d treat
m e n t o pti o n s . Consulta n t. l 997;3 7 (5) : 1 2 3 3 .
Sza bo RM, S l ate r R R J r, Fa rve r T B , Sta nton DB, S h a r m a n W K . The va l u e
II
o f d i a g n ostic test i n g i n c a r p a l t u n n e l sy n d ro m e . J Ha n d Surg
l 999;24(4) : 704-7 1 4.
Tetro AM, Eva n off BA, H o l l st i e n SB, G e l berm a n RH. A n ew, p rovocative
test fo r ca rpa l t u n n e l syn d ro m e : assess m e n t of wrist fl ex i o n a n d n e rve
co m p re s s i o n . J Bone Join t Surgery Br. 1 998;80 (3)493-498
Va l d e s K, La Stayo P. The va l u e of p rovocative tests fo r the wrist a n d e l bow
a l ite rat u re review. J Ha n d Ther. 2 0 1 3;26 ( 1 ) 3 2-42; q u iz 43.
Wa i n n e r RS, Fritz J M , l r rg a n g JJ, D e l itto A, A l l i s o n S, Bo n i n g e r M L.
Deve l o p m e n t of a c l i n i ca l p red ictio n ru l e for t h e d ia g n o s i s of ca rpa l
t u n n e l syn d ro m e . A rch Phys Med Reha bi/. 2005;86(4) 609-6 1 8.
1 32 Section 5
REVERSE PHALEN TEST

TEST POSITIONING
The s u bject sta n d s or sits with the p a l m e r a s pect of both h a n d s i n
fu l l contact so both wri sts a re maxi m a l l y extended.
ACTION
A steady co m p ress ive fo rce is a p p l ied t h ro u g h the s u bject's fo re
a rm s so that the s u bject's wrists a re maxi m a l ly exten d ed fo r 1 m i n ute
(Fig u re WHS-6).
II
F i g u re WHS-6.
POSITIVE FINDING
N u m bness a n d t i n g l i n g i n the med i a n n erve d i stribution of t h e
fi ngers (ie, t h u m b, i n d ex fi n g e r, m i d d l e fi nger, a n d l atera l as pect of
the ring fi nger) a re i n d i cative of ca rpal t u n n e l syn d rome seco n d a ry
to med i a n n e rve co m p ressi o n .

Pai n i n the wrist a rea without com plai nts of radiating pain dista l ly
towa rd the hand and fi ngers may be indicative of ca rpa l bone pathology.
Wrist and Hand 1 33
EVIDENCE
El M i e d a n y et a l (2008)
C o n d iti o n s eva l u ated Carpa l t u n n e l syn d ro m e a n d
ten osynovitis
Sa m p l e size 232
Re l i a b i l ity N ot eva l u ated
S e n s itivity Ca rpa l t u n n e l : 42
Te n osynovitis: 75
Spec ifi city Ca rpa l t u n n e l : 3 5
II
Te n osynovitis: 8 5
REFERENCES
E l M i e d a n y Y, As h o u r S , Yo u s sef S , Me h a n n a A , M e ky F A C l i n i c a l d i a g n os i s
o f c a r p a l t u n n e l syn d ro m e : o l d tests-n ew c o n c e pts. Join t Bone Spine
2008;75 (4):45 1 -45 7 .
G h ava n i n i M R, H a g h i g hat M . Ca rpa l t u n n e l syn d ro m e : rea p p ra i s a l of five
c l i n ica l tests. E!ectromyogr Clin Neurophysiol. l 998;38(7) :43 7-44 1 .
Ka n a a n N, Sawaya RA Ca rpa l t u n n e l syn d ro m e : m o d e r n d i a g n ostic a n d
m a n a g e m e n t tec h n i q u e s . B r J Gen Pract. 200 1 ;5 1 (465) 3 1 1 -3 1 4.
134 Section 5
�----- T1 N E L 1S S1GN
TEST POSITIONING
The s u bject sits next to a fl at su rfa ce.
ACTION
The exa m i n e r taps the vo l a r a s pect of the s u bject's wrist ove r the
a rea of the ca rpa l t u n n e l ( Fi g u re WHS-7).
II
F i g u re WHS-7.
POSITIVE FINDING
Co m p l a i nts of t i n g l i ng, p a resthesia, or p a i n by t h e s u bject i n the
a rea of the th u m b, i n d ex fi n g e r, m i d d l e fi n g e r, a n d ra d i a l one-half of
the ring fi n g e r signal a positive test. Th is may be i n d i cative of a com
p ress ion of the med i a n n e rve i n t h e carpa l t u n n e l o r ca rpal t u n n e l
syn d rome.

A positive Ti n e l 's s i g n at the wrist may a ppea r if the m e d i a n ne rve
is d i s r u pted at a ny point of its path. The refo re, a positive fi n d i n g
shou l d wa rra nt the exa m i n e r t o assess the i nteg rity o f the med i a n
nerve a t the e l bow, s h o u l d e r, a n d n e c k t o r u l e out ot h e r pat h o l og i es.
Wrist and Hand 1 35
EVIDENCE
M a a n d Ki m C h e n g et a l Wa i n n e r e t a l
(20 1 2) (2008) (2005)
Study d e s i g n D i a g n ostic Di a g n ostic D i a g n ostic
accu racy accu racy accu racy
C o n d iti o n s Ca rpa l t u n n e l Carpa l a n d Carpa l t u n n e l
eva l u ated syn d ro m e c u b ita l t u n n e l syn d ro m e
syn d ro m e a n d cervic a l
ra d i c u l o pathy
Sa m p l e size 38 1 69 82
Re l i a b i l ity Not eva l u ated N ot eva l u ated Ka ppa =
II
.35 to .47
S e n s itivity 82 32 4 1 t o 48
Spec ifi city 89 99 5 8 to 67
REFERENCES
A l fo n s o M l , Dzwierzy n s ki W H offm a n-Ti n e l 's s i g n t h e rea l ities. Phys Med
Reha bi! Clin N Am. l 998;9(4) 72 1 -736. v.
Ba i l ie DS, Ke l i ki a n AS. Ta rsa l tu n n e l syn d ro m e : d i a g n o s i s , s u rg i ca l tec h
n i q u e, a n d fu n cti o n a l outcome. Foo t A n kle lnt l 998; 1 9(2):65-72
Ca m p b e l l LS. Co m m e nta ry o n c a r pa l -tu n n e l syn d ro m e [o rig i n a l a rt i c l e
a p pea rs i n A m J Nurs l 993;93 (4) :64] ENA 's Nursing Sca n i n Em ergency
Care. 1 993;3(5) 5 .
C h e n g CJ, M a c ki n n o n -Patte rson B, B e c k J L, M a c ki n n o n S E . Sc ratc h col
l a pse test fo r eva l u at i o n of c a r pa l and c u b ita l t u n n e l syn d ro m e . J Han d
Surg Am. 2008;33 (9) 1 5 1 8- 1 5 24.
D'Arcy CA, McGee S . Does t h i s patient h ave carpa l t u n n e l syn d ro m e ?
JAMA. 2000;283 (23) :3 1 1 0-3 1 1 7 .
El M i ed a ny Y, As h o u r S, Yo u s sef S, Me h a n n a A, M e ky FA C l i n ic a l d i a g n os i s
o f ca rpa l t u n n e l syn d ro m e o l d tests- n ew co n c e pts. Join t Bone Spine.
2008;75 (4) :45 1 -45 7.
G h ava n i n i M R, H a g h i g hat M . C a r pa l t u n n e l syn d ro m e rea p p ra i s a l of five
c l i n ica l tests. E!ectromyogr Clin Neurophysiol. l 998;3 8(7) :43 7-44 1 .
G o l o bo rod ' ko SA P rovocative test fo r c a r p a l t u n n e l syn d ro m e . J Ha nd
Ther 2004; 1 7 (3) :344-348
136 Section 5
Katz J N , Los i n a E, A m i c k BC 1 1 1 , Fossel A H , Bessette L, Ke l l e r RB. Pred i ctors

of o u tco m e s of ca rpa l t u n n e l re lease. A rth ritis Rheum. 200 1 ;44(5) 1 1 84-
1 1 93 .
Ku h l m a n KA, H e n n e ssey WJ . S e n s itivity a n d s pec ifi c ity o f ca rpa l t u n n e l
syn d ro m e s i g n s . A m J Phys Med Reha bil. l 997;76(6):45 1 -457.
Le B l o n d RF. C l i n i ca l d i a g n o s i s of c a r p a l t u n n e l syn d ro m e . JA MA.
2000;284( 1 5) 1 924- 1 9 2 5 .
L o r d R W J r. H ow a c c u rate a re t h e h i story a n d p hys ica l exa m i n a t i o n i n
d i a g nosi n g ca rpa l t u n n e l syn d ro m e ? J Fa m Prac. 2000;49 (9)782-783
M a H , Ki m I. The d i a g n ostic a s s e s s m e n t of h a n d e l evat i o n test in carpa l
t u n n e l syn d ro m e . J Korean Neurosurg Soc. 2 0 1 2;5 2 (5 ) :472-475
M o l d aver J . Ti n e l 's s i g n . Its c h a racte r i stics a n d s i g n ifica n ce. J Bone Join t
Surg Am. l 978;60(3)4 1 2-4 1 4.
N i s h i kawa T, Ku rosa ka M, Mita n i M, Mats u ba ra N, H a ra d a T, M izu n o K. U l n a r
II
b u rsa d i ste n t i o n fo l l owi n g vo l a r s u b l uxat i o n o f t h e d i sta l ra d i o u l n a r
j o i n t after d i sta l ra d i a l fra ct u re: a ra re c a u s e o f c a r p a l t u n n e l sy n d ro m e .
J Orthop Tra uma. 200 1 ; 1 5 (6) :45 0-45 2 .
Sei l e r JG. C a r pa l t u n n e l syn d ro m e : u pdate o n d i a g n ostic test i n g a n d
treatment options. Consulta n t. 1 997;3 7 (5 ) 1 2 3 3
S h e rg i l l G, Bo n n ey G, M u n s h i P , B i rc h R. T h e ra d i a l a n d poste r i o r i nterosse
ous n e rves. Resu lts of 260 repa i rs. J Bone Join t Surg Br 200 1 ;83 (5) 646-
649.
Wa i n n e r RS, F ritz J M , l rrg a n g JJ, D e l itto A, A l l i s o n S, Bo n i n g e r M L.
Deve l o p m e n t of a c l i n ica l p red ictio n r u l e fo r t h e d i a g n o s i s of ca rpa l
t u n n e l syn d ro m e . Arch Phys Med Rehabil. 2005;86(4) 609-6 1 8
Wrist and Hand 137
F ROMENT 1S SIGN
TEST POSITIONING
The s u bject may sit o r sta n d . The exa m i n er sits next to the s u bject.
ACTION
The s u bject is i n structed to h o l d a p i ece of paper between the
t h u m b a n d i n d ex fi n g e r. The exa m i n e r then tries to p u l l the paper out
(Fig u re WHS-8).
II
Figure WHS-8.
POSITIVE FINDING
Flexion of the d i sta l inte r p h a l a n g ea l joint of the s u bject's t h u m b
i s i n d icative o f a d d u ctor p o l l i c i s m u sc l e p a ra lys i s d u e t o u l n a r nerve
d a mage.

S i m u lta n eous hype rexte nsion of the m etacarpo p h a l a ngeal joint of
t h e t h u m b is i n d i cative of u l n a r ne rve co m p ro m i se. Th i s is known a s
J e a n n e's S i g n .
138 Section 5
REFERENCES
Dru ry W, Ste rn PJ . F ro m e n t's p a p e r s i g n a n d Jea n ne's s i g n - u n u s u a l etio l
ogy. J Ha n d Surg Am. l 982;7(4) 404-406
G o l d m a n S B , B ri n i n g e r TL, Sc h ra d e r JW, C u rt i s R, Kocej a OM A n a lys i s of
c l i n ica l m otor testi n g fo r a d u lt patients with d i a g nosed u l n a r n e u
ropathy at t h e e l bow A rch Phys M e d Reha bi/. 2009;90 ( 1 l ) 1 846- 1 8 5 2 .
Lorea P , Sch u i n d F. Fa l se a n e u rysm a p pea ri n g a s d e l ayed u l n a r n e rve
pa l sy after " m i n o r" p e n etrati n g tra u m a in t h e fo rea r m . J Tra uma.
200 1 ;5 1 ( 1 ) : 1 44- 1 45
R i c h a rd s o n C, Fa b re G. F r o m e n t's s i g n . J A u diov Media Med 2003 ;26 ( 1 ) :34.
II
Wrist and Hand 139
WRIN KLE TEST

TEST POSITIONING
The s u bject sits near a fl at s u rface.
ACTION
The s u bject's fi ngers a re p l a ced i n warm water fo r a p p roxi mately
1 0 m i n utes (Fig u re WHS-9). On re mova l, the exa m i n er assesses the
s k i n a ro u n d the p u l p a rea fo r a ny wri n kl i n g .
II
F i g u re WHS-9.
POSITIVE FINDING
A positive test is seen when the i nvolved fi n g e r s h ows no s i g n s of
wri n kl i n g, i n d i cating denervated tissue.
SPECIAL CONSIDERA TIONS

This test can be u sed a s a n assessment tool fo r docu m e nt
i n g peri pheral ne rve reg e n e ration by way of p u l p-a rea wri n k l i n g .
F u rthermore, s u b m e rs i o n o f the fo u rth d i g it may a l l ow fo r o n e to
d i sti n g u i s h between med i a n a n d u l n a r n e rve pathol ogy.
1 40 Section 5
REFERENCES
Fa l a n g a V The "wri n kl e test" c l i n i ca l u s e fo r d etect i n g ea rly e p i d e r m a l
res u rfa c i n g J Derm a to/ Surg Oneal. 1 993; 1 9 (2) 1 72- 1 7 3 .
Va s u d eva n T M , va n Rij AM, N u ka d a H , Tayl o r P K. S ki n wri n kl i n g fo r t h e
a ssess m e n t o f sym pathetic fu nction i n t h e l i m bs . A ust N Z J Surg.
2000;70(1 ) : 5 7-59.
II
Wrist and Hand 141
DIGITAL ALLEN 1S TEST

TEST POSITIONING
Both the s u bject and exa m i n er may sit o r sta n d .
ACTION
The s u bject is i n stru cted to m a ke a fist seve ra l t i m es i n s u ccess ion
to "p u m p" the b l ood out of the h a n d a n d fi n g e rs. The s u bject i s then
i n stru cted to m a i nta i n a fi st while the exa m i n er co m p resses the ra d i a l
a rtery a n d t h e u l n a r a rtery ( Fi g u re W H S - 1 OA) . A s t h e s u bject rel axes
the h a n d ( Fi g u re W H S - 1 O B), the exa m i n er re leases p ress u re from
o n e a rtery at a t i m e a n d observes the co l o r of the h a n d a n d fi n g e rs
(Fig u re W H S - 1 OC).
II
Figure WH5-1 0A.

1 42 Section 5
II
F i g u re WHS-1 08.
F i g u re WH5-1 0C.
Wrist and Hand 1 43
POSITIVE FINDING
A d e l ay i n or a bsence of fl u s h i n g of the ra d i a l or u l n a r half of the
h a n d a n d fi n g ers i s i n d i cative of partial o r co m p l ete occl u sio n of the
ra d i a l o r u l n a r a rteri es, respective ly.

This test s h o u l d a l ways be pe rformed a n d co m pa red b i l atera l ly. If
a positive fi n d i n g i s p resent b i l atera l ly, the exa m i n er s h o u l d consider
b ra c h i a ! a rtery i nvo lveme nt.
EVIDENCE
Lev i n so h n et a l ( 1 991 )
Study d e s i g n
C o n d iti o n s eva l u ated
Sa m p l e size
D i a g n ostic accu racy
A rtery occ l u s i o n
40
II
Spec ificity 80
REFERENCES
As h be l l TS, Kutz J E, Kl e i n e rt H E. The d i g ita l A l l e n test. P!ast Reconstr Surg.
1 967;3 9(3)3 1 1 -3 1 2 .
F u h r m a n TM, Rei l l ey TE, P i p p i n WO. Co m pa ri s o n of d i g ita l b l ood pressu re,
p l ethys m og ra p hy, a n d the m od ified A l l e n ' s test as mea n s of eva l uati n g
t h e co l l atera l c i rc u l at i o n t o t h e h a n d . Anaesth esia. 1 992;4 7 ( 1 l ) 95 9-96 1 .
G e l b e rm a n R H , B l a s i n g a m e J P. The t i m e d A l l e n 's test. J Tra uma.
1 98 1 ;2 1 (6) :477-479
La n n i H A, S m it h SG. A l l e n 's test: fa ct o r myth 7 Respir Care. 200 1 ;46 (3) 2 74
Levi n s o h n OG, Gordon L, Sess l e r D I . The A l l e n 's test: a n a lys i s of fo u r meth
o d s . J Han d Surg A m 1 9 9 1 ; 1 6 (2) 2 79-282
McCo n n e l l EA C l i n i ca l d o's a n d d o n'ts. Perfo rm i n g A l l e n 's test. . . . w h et h e r
u l n a r a n d ra d i a l a rteries a re pate nt. Nursing. 1 997;2 7 ( 1 l ) 26
Pe l m ea r P L, Ku s i a k R. C l i n i ca l assess m e n t of h a nd-arm vi b ration syn d ro m e .
Nagoya J M e d Sci. 1 994;5 7 (S u p p l ) 27-4 1 .
1 44 Section 5
P i stori u s MA, P l a n c h o n B. D i a g n ostic i m porta nce of d i g ita l topog ra p h i c

assess m e n t o f Rayn a u d 's p h e n o m e n o n . A p ros pective study o f a pop
u l ation of 5 2 2 patie nts [a rti c l e i n F re n c h ] . J Mai Vase 1 995;20( 1 ) 1 4-20.
Scave n i u s M, Fa u n e r M, Wa l t h e r-La rsen S, B u c h wa l d C, N i e l se n S L. A q u a n
titative A l l e n 's test Ha nd 1 98 1 ; 1 3 (3):3 1 8-3 20.
Stead SW, Sti rt J A Assess m e n t of d i g ita l b l ood fl ow a n d pa l m a r co l l at
e ra l c i rc u l at i o n . A l l e n's test vs. p h oto p l ethys m og ra p hy. ln t J Clin Monit
Comput 1 985;2 ( 1 ) 29-34
S u g awa ra M , Og i n o T, M i n a m i A, I s h i i S D i g ita l i s c h e m i a in baseba l l p l ay
ers. Am J Sports Med l 986; 1 4(4) : 3 2 9-334
Thom pson CE, Stro u d S O A l l e n's test a too l fo r d i a g n o s i n g u l n a r a rtery
tra u m a . Nurse Pract 1 984;9 ( 1 2) 1 3 , 1 6- 1 7
We n d t J R. D i g ita l A l l e n 's test a s a n a dj u n ct i n d i a g n o s i s of poss i b l e d i g ita l
n e rve l a c e rati o n s . Plast Reconstr Surg. 1 99 1 ;88(4) 73 9-740
II
Wrist and Hand 1 45
B U N N EL LITTLER TEST
TEST POSITIONING
The s u bject sits with the metaca rpo p h a l a ngeal joint of the i nvo lved
d i g it in s l i g ht exte n s i o n .
ACTION
The exa m i n er passively flexes t h e p rox i m a l i nterpha l a n g e a l joint
of the same ray a n d assesses the a m o u nt of p roxi m a l i nterp h a l a ngeal
joint fl exi on ( Fi g u re W H S - 1 1 A) . The exa m i ne r then passively fl exes the
meta carpo p h a l a ngeal joint s l i g htly a n d again assesses the a m o u nt of
flexio n at the p rox i m a l inte r p h a l a n g ea l joint (Fig u re WHS- 1 1 B).
II
Fig u re W H 5- 1 1 A. N o t e : M etaca rpo p h a l a n g e a l j o i n t sta b i l ized i n

exte n s i o n .
1 46 Section 5
II
F i g u re W H S - 1 1 B.
POSITIVE FINDING
A pos itive fi n d i n g is revea l ed if the p rox i m a l i nterp h a l a ngeal j o i nt
d oes not flex w h i l e the m etaca rpo p h a l a ngeal joint is i n a n exte nded
positi o n . If the p roxi m a l inte r p h a l a n g e a l j o i nt does fu l ly flex once the
metaca rpo p h a l a n geal joint i s s l i g htly flexed, i ntri nsic m u scle tig ht
ness can be assumed. By contra st, if fl exi o n of the p roxi m a l i nterp ha
langeal joint re m a i n s l i m ited o n ce the m etacarpo p h a l a ngeal joi nt i s
s l i g htly flexed, ca psu l a r tig htness can be assu med.

Ca re s h o u l d be ta ken by the exa m i n er to reta i n exte n s i o n a n d then
fl exion of the m etacarpo p h a l a ngeal joint while a l so testing i n each
position to assess true p roxi m a l i nterp h a l a ngeal joint moti o n .
Wrist and Hand 147
M U RPHy's SIGN
TEST POSITIONING
The s u bject may sit o r sta n d . The exa m i n e r sta n d s i n fro nt of the
s u bject.
ACTION
The s u bject is i n stru cted to m a ke a fi st. The exa m i n er n otes the
position of the t h i rd metacarpal ( Fi g u re WHS- 1 2).
II
Figure W H S - 1 2.
POSITIVE FINDING
If the s u bject's t h i rd metaca rpal is l eve l with the seco n d a n d fo u rth
metaca rpa l s, a d i s l ocated l u n ate i s i n d icated .

With n o r m a l a nato m i c a l a l i g n me nt, the position of the l u n ate
m a kes the t h i rd metaca rpal a p pea r l o n g e r t h a n the others when a
fist is made. Thus, a lteri n g the position of the l u nate i n an a nte rior o r
poste rior d i recti on wi l l a l low fo r the t h i rd metaca rpal t o s l i d e m o re
p rox i m a l l y.
1 48 Section 5
WATSON TEST
TEST POSITIONING
The s u bject sits. The exa m i n er uses o n e h a n d to sta b i l ize the d i sta l
fo rea rm at the d i sta l rad i a l u l n a r j o i nt w h i l e g ra s p i n g the sca phoid
bone of the s u bject with the other h a n d ( Fi g u re WH 5-1 3A) .
II
F i g u re WH5-1 3A.
ACTION
The exa m i n er m o b i l izes the sca phoid bone a nte riorly a n d poste
riorly w h i l e u l n a rly and rad i a l ly deviat i n g the s u bject's wrist (Fig u re
WHS- 1 3 8) .
Wrist and Hand 149
11
.·
Figure W H S- 1 3 8 . Note: Sca p h o i d is m o b i l ized a nterior/posterior
w h i l e t h e wrist is deviated.
POSITIVE FINDING
Positive fi n d i n g s i n c l u d e a pa l pa b l e s u b l uxation a n d red uction of
t h e sca p h o id, a n d may be fe lt if a n u n d erlyi ng carpal l i g a ment tea r i s
p resent.

This test is easier to perform when the exa m i n e r g rasps the sca ph
oid o n the vo l a r a s pect with the t h u m b. The Watson Test may a l so be
refe rred to a s the Sca p h o i d S h ift Test.
EVIDENCE
LaStayo a n d H owe l l ( 1 995)

C o n d i t i o n s eva l u ated Wrist pa i n
S a m p l e size 50
S e n s itivity 69
Spec ifi city 66
1 50 Section 5
REFERENCES
B i c ke rt B, S a u e rb i e r M , G e rm a n n G . C l i n i ca l exa m i n at i o n of t h e i nj u red
wrist [a rti c l e in G e rm a n] Zen tra lbl Ch ir 1 997; 1 2 2 ( 1 l ) 1 0 1 0- 1 0 1 5 .
Hwa n g JJ, G o l dfa rb CA, Ge l be rm a n R H , Boye r M l . The effect of d o rsa l
ca rpa l g a n g l io n exc i s i o n on t h e sca p h o i d s h ift test. J Han d Surg Br
1 999;24( 1 ) 1 06- 1 08.
La n e LB. The sca p h o i d s h ift test. J Han d Surg. l 993; 1 8 (2)3 66-368.
La Stayo P, H owe l l J C l i n i ca l p rovocative tests u sed in eva l u ati n g wrist
p a i n a descri ptive stu dy. J Ha n d Ther 1 995;8( 1 ) 1 0- 1 7.
Prosser R, H a rvey L, La Stayo P, H a rg reaves I , Sco u g a l l P, H e rb e rt RO.
P rovocative wrist tests and MRI a re of l i m ited d i a g n ostic va l u e fo r
s u s pected wrist l i g a m e n t i nj u ries: a c ross-secti o n a l stu dy. J Phys/other
2 0 1 1 ;5 7 (4) 247-2 5 3 .
S a u e r b i e r M, Tra n kl e M , E rd m a n n 0, M e n ke H , G e rm a n n G . F u n ctio n a l
II
o utco m e with sca p h otra peziotra pezo id a rt h ro d e s i s i n t h e treatment
of Ki e n boc k's d i sease sta g e I l l . A n n Plast Surg. 2000;44(6) 6 1 8-6 2 5 .
Ti e l -va n B u u l M M , Bos K E , D ij kstra P F, va n Beek EJ , B roe k h u ize n A H . Ca rpa l
i n sta b i l ity, t h e m i ssed d i a g n os i s i n patients with c l i n i ca l ly s u s pected
sca p h o i d fra ctu re. Injury 1 993;24(4) 25 7-262
Va l d e s K, La Stayo P The va l u e of p rovocative tests fo r the wrist a n d e l bow
a l iterat u re review. J Ha n d Ther. 20 1 3;26 ( 1 ) 3 2-42; q u iz 43.
Wo lfe SW, G u pta A, Cri sco JJ I l l . Ki n e m atics of the sca p h o i d s h ift test.
J Ha n d Surg Am. l 997;22(5):80 1 -806.
Wrist and Hand 151
VALG US STRESS TEST

TEST POSITIONING
The exa m i n er m a i nta i n s sta b i l ization of the p rox i m a l bone between
t h e t h u m b a n d fo refi n g e r and g rasps the d i sta l bone ( u s u a l l y the
bones com prisi n g a hinge joi nt) .
ACTION
The exa m i n er p rovides a va l g u s fo rce to the joi nt, creati ng a fu l
cru m while atte m pting to "ga p the joi nt" (Fig u re W H S - 1 4A) .
II
Figure W H 5 - 1 4A.
POSITIVE FINDING
Any excessive g a p p i n g that is noted when compared to the u n i n
vo lved side may i n d icate a co l l atera l l i g a ment tea r.
1 52 Section 5

The exa m i n er s h o u l d perform t h i s test with extre me ca re so n o
fu rth e r d a m a g e i s created w i t h the va l g u s stress t h a t i s a p p l ied. Th i s
test ca n a l so be performed a t the metaca rpo p h a l a n g e a l j o i n t o f t h e
t h u m b, where excessive j o i n t m ovement wo u l d i n d icate a n u l n a r col
l atera l l i g a ment tea r, co m m o n ly refe rred to a s "s kier's t h u m b" ( Fi g u re
W HS- 1 48).
II
F i g u re WHS-1 48.
Wrist and Hand 1 53
VARUS STRESS TEST

TEST POSITIONING
The exa m i n er m a i nta i n s sta b i l ization of the p rox i m a l bone between
t h e t h u m b and fo refi n g e r a n d g ra s ps the d i sta l bone (usua l ly bones
co m p r i s i n g a hinge joi nt) .
ACTION
The exa m i n e r p rovides a va rus fo rce to the joi nt, c reati ng a fu l c r u m
w h i l e atte m pt i n g t o "ga p the joi nt" ( Fi g u re W H S - 1 5).
II
F i g u re WHS-1 5.
POSITIVE FINDING
Any excessive g a p p i n g that is noted when compared to the u n i n
vo lved side may i n d icate a co l l atera l l i g a ment tea r.

The exa m i n e r s h o u l d perform t h i s test with extrem e ca re so n o
fu rther d a m a g e i s created w i t h the va rus stress t h a t i s a p p l ied.
1 54 Section 5
BALLOTTEMENT TEST
TEST POSITIONING
The s u bject sta n d s or s its. The exa m i n er uses h i s or her t h u m b
a n d i n d ex fi n g e r t o sta b i l ize t h e l u nate b o n e o f t h e s u bject's i nvo lved
hand.
ACTION
W h i l e sta b i l izi n g the l u nate bone, the exa m i n er uses h i s or h e r
other h a n d t o gently m ove t h e p i sotri q u etra l co m p l ex u p a n d d own
a g a i nst the l u n ate bone (Fig u re WHS- 1 6).
II
F i g u re W H S- 1 6.
POSITIVE FINDING
A pos itive test is i n d icated when the s u bject fee l s p ain , crepitus i s
p rodu ced, o r excessive joint laxity i s observed . Positive fi n d i n g s sug
g est l u n otriq u etra l d i ssociation o r l i g a ment d a m a g e o r laxity.

The a rea may be point te nder so the test i n g motion s h o u l d sta rt
g rad u a l ly.
Wrist and Hand 1 55
EVIDENCE
LaStayo a n d H owe l l ( 1 995)

C o n d iti o n s eva l u ated Wrist pa i n
Sa m p l e size 50
S e n s itivity 64
Spec ifi city 44
REFERENCES
LaStayo P, H owe l l J C l i n i ca l p rovocative tests u sed in eva l u ati n g wrist p a i n
a descri ptive study. J Ha nd Ther 1 995;8 ( 1 ) : 1 0- 1 7.
Prosser R, H a rvey L, La Stayo P, H a rg reaves I , Sco u g a l l P, H e rbert R D .
II
P rovocative w r i s t tests a n d M R I a re o f l i m ited d i a g n ostic va l u e fo r
s u s pected wri st l i g a m e n t i nj u ries: a c ros s-secti o n a l stu dy. J Physiother
2 0 1 1 ; 5 7 (4) 247-2 5 3
Va l d e s K, La Stayo P Th e va l u e o f p rovocative tests fo r t h e wrist a n d e l bow
a l iteratu re review J Ha n d Ther 20 1 3;26 ( 1 ) 3 2-42; q u iz 43

Thoracic Spine
Guide to Figures
Snyder Valicr AR, !scar JA Jr.

Fourth Edition (pp 157-163).
1 58 Section 6
KERNIG/8 R U DZI NSKI SIGNS

TEST POSITIONING
The s u bject lies s u p i n e with h i s or her h a n d s cu p ped b e h i n d the
head. The exa m i n e r sta n d s n ext to the s u bject.
ACTION
The s u bject is i n stru cted to flex the cervical s p i n e by lift i n g the
head. Each hip i s u n i l atera l ly flexed to n o m o re t h a n 90 d e g rees
by the s u bject. The s u bject then fl exes the knee to n o m o re than
90 deg rees. The o p pos ite leg rem a i n s o n the exa m i n i n g ta b l e (Fig u re
TS6- 1 ) .
II
Figure TS6-1 .
POSITIVE FINDING
The test is confi rmed by i n c reased pa i n (that is either local ized o r
rad i ates i nto the l ower extremity) w i t h neck a n d h i p fl exio n . T h e pa i n
i s re l i eved when the k n e e i s flexed. T h e pa i n i s i n d i cative o f m e n i ngeal
i rritation, n erve root i m p i ngement, o r d u ra l i r ritation that i s exag g e r
ated by elongating the s p i n a l cord.
Thoracic Spine 1 59

The co nsid e rations a re s i m i l a r to the stra i g ht leg raise test except
the neck is fl exed a n d the h i p is actively flexed. The neck fl exion
co m ponent of this test was deve l o ped by Ke rnig, and the h i p flexi o n
co m ponent w a s deve l o ped by Brudzi nski.
EVIDENCE
T h o m a s et a l B i l avsky e t a l
(2002) (20 1 3)
Study desig n D ia g n ostic D iag n ostic
accu racy accu racy
C o n d iti o n s M e n i n g itis M e n i n g itis
eva l u ated
II
S e n s itivity Ke r n i g sig n = 5 Ke r n i g s i g n = 5 1
Brudzi n s ki s i g n = 5 Brudzi n s ki s i g n =
53
S pec ificity Ke r n i g sig n = 95 Ke r n i g s i g n = 95
Brudzi nski sig n = 95 Brudzi n s ki sign = 78
REFERENCES
B i l avs ky E, Lei bovitz E, E l ko n -Ta m i r E, F r u c h t m a n Y, lfe rg a n G, G re e n berg
D. The d i a g n ostic a c c u racy of t h e 'c l a s s i c m e n i n g e a l s i g n s' i n c h i l d re n
with s u s pected bacte ria l m e n i n g it i s . fur J Emerg Med 2 0 1 3;20(5) 3 6 1 -
363.
B rody I A, Wi l ki n s R H . The s i g n s of Ke r n i g and Brudzi n s ki . A rch Neural.
1 969;2 l (2) 2 1 5-2 1 8 .
Me h n d i ratta M M , N aya k R, G a rg H , Ku m a r M, Pa n d ey S A p p ra i s a l of
Ke r n i g 's a n d B r u dzi n s ki's s i g n in m e n i n g itis. A n n India n A cad Neural.
20 1 3 ; 1 5 (4) 287-288
P u l l e n R L J r. Asses s i n g fo r s i g n s of m e n i n g it i s . Nursing. 2 004;34(5) 1 8.
T h o m a s KE, H a s b u n R, J e ke l J, Q u a g l i a re l l o VJ The d i a g n ostic a c c u ra cy of
Ke r n i g 's s i g n , Bru dzi n s ki's s i g n , a n d n u c h a l rig i d ity i n a d u lts with s u s
pected m e n i n g itis. Clin Infect Dis. 2002;3 5 ( 1 ) :46-5 2
1 60 Section 6
Ve rg hese A, G a l l e m o re G. Ke r n i g 's a n d B r u dzi n s ki's s i g n s rev i s ited . Rev

Infect Dis. l 987;9(6) : 1 1 87- 1 1 92.
Wa rd MA, G reenwood TM, Ku m a r D R, Mazza JJ, Ya l e SH. Josef Bru dzi n s ki
a n d Vlad i m i r M i kh a i l ovich Ke r n i g s i g n s fo r d i a g n o s i n g m e n i n g itis. Clin
Med Res. 20 1 0;8 ( 1 ) 1 3 - 1 7 .
Wa rte n be rg R. Laseg u e s i g n a n d Ke r n i g s i g n; h i storica l n otes. AMA Arch
Neural Psych ia try 1 95 1 ;66 ( 1 ) 5 8-60.
Wa rte n b e rg R. The s i g n s of B r u dzi n s ki a n d of Ke r n i g . J Pedia tr
l 950;3 7 (4) 679-684
II
Thoracic Spine 161
LATERAL AND ANTERIOR/POSTERIOR

RIB COMPRESSION TESTS
TEST POSITIONING
1 . The s u bject lies su p i ne. The exa m i n e r sta n d s n ext to the s u bject
and p l aces a h a n d o n either side of the affected rib(s) ( Fi g u re
TS6-2A) .
II
Figure TS6-2A.
2. The s u bject lies su p i ne. The exa m i n e r sta n d s next to the s u bject
and p l a ces one h a n d over the affected r i b (s) and the other h a n d
poste rior t o t h e r i b c a g e (Fig u re TS6-2 B).
1 62 Section 6
F i g u re TS6-2 B.
II
ACTION
1 . The exa m i n e r co m p resses the l atera l a s pect of the ri b cage b i l at
e ra l ly a n d then q u ickly re leases.
2. The exa m i n er co m p resses the r i b cage anterior to poste rior a n d
q u ickly re leases.
POSITIVE FINDING
Pa i n with co m p ression or release of p ress u re i n d i cates the possi b i l
ity o f a r i b fra ctu re, r i b co ntusion, o r costoc h o n d ra l separation.

Th i s test is contra i n d icated if there is a n o bvious deform ity or pos
s i b l e l u n g tra u m a . A mod ification to this test i s known a s the Anterior/
Posterior R i b Co m p ress i o n Test.
REFERENCE
F e n g J , H u T, L i u W, et a l . The b i o m ec h a n ica l , m o r p h o log ic, a n d h i sto
c h e m i ca l properties of the costa l ca rti l a g e s in c h i l d re n with pect u s
excavatu m . J Pedia tr Surg. 200 1 ; 3 6 ( 1 2) 1 770- 1 776.
Thoracic Spine 1 63
I NSPIRATION/EXPI RATION BREATH ING TEST

TEST POSITIONING
The s u bject may sit or sta n d . The exa m i n e r sta nds next to the
s u bject.
ACTION
The s u bject is i n stru cted to b reathe i n a n d out norma l ly a n d then
take a deep b reath fo l l owed by ra p i d exp i ration.
POSITIVE FINDING
N o r m a l b reat h i n g that is ra pid a n d s h a l l ow is i n d i cative of a r i b
fra ctu re. Pa i n w i t h deep i n s p i ration may s u g g est a r i b fractu re, costo
c h o n d ra l separation, o r exter n a l i ntercosta l m u scle stra i n . Pa i n with
forced exp i ration may i n d icate costoc h o n d r a l separation or i nte r n a l
II
i ntercosta l m u sc l e stra i n .

With a r i b fractu re o r costoch o n d ra l separation, there is a l so pa i n
with co u g h i ng, s n eezi ng, a n d torso m ovement. D i s p l a ced r i b frac
t u res may jeopard ize the fu nction of the l u n g s and s h o u l d be treated
a s a medical e m e rg e n cy.
REFERENCES
Boy l e R K. Co u g h stress r i b fra ct u re i n two o bstetric patients: case re port
a n d pathophys i o l ogy. ln t J Obstet A nesth. 1 998;7 ( 1 ) 54-58
Ka r l s o n KA Rib stress fra ct u re s in e l ite rowe rs. A case s e ries a n d p roposed
m e c h a n i s m . A m J Sports Med l 998;26(4) 5 1 6-5 1 9.
Litc h J A, Tu g gy M. Cou g h i n d u ced stress fra ct u re a n d a rt h ro pathy of t h e
ribs at ext re m e a ltitude. /nt J Sports M e d 1 998; 1 9(3) 220-222
Potte r MJ, Litt l e C, Wi l s o n - M a c Do n a l d J Thora c i c fra ct u re d i s l ocati o n s
without ve rte b ra l c l i n ica l s i g n s . Injury 2003;34( 1 2) 942-943 .
Roberge RJ, M o rg e n stern MJ, O s b o r n H . Co u g h fra ct u re of t h e r i b s . Am J
Emerg Med 1 984;2 (6) 5 1 3-5 1 7.

Lumbar Spine
Guide to Figures
Konin JC, Lebsack D , Snyder Valier AR, lsear JAJr.

Special Testsfa r Orthopedic Examination, Fourth Edition (pp 165-207).
1 66 Section 7
VALSALVA 1S MAN EUVER

TEST POSITIONING
The s u bject s h o u l d sit. The exa m i n e r sta n d s next to the s u bject.
ACTION
The exa m i n er a s ks the s u bject to ta ke a deep b reath a n d h o l d
w h i l e bea ring down, a s if havi ng a bowe l m ovem ent.
POSITIVE FINDING
I n c reased p a i n d u e to i n c reased i ntrath eca l p ressu re, wh ic h may
be seco n d a ry to a space-occ u pying lesion, hern iated d i s k, t u m o r, o r
osteop hyte i n the cervi ca l canal, i s a positive fi n d i n g . Pa i n may b e
l oca l ized o r refe rred t o the co rres p o n d i n g dermatome.

The i n c reased p ress u re may a lter ve nous fu nction a n d cause d izzi
ness or u n consciousness. The exa m i n e r s h o u l d be p repa red to stea dy
II
the s u bject. It i s i m portant to n ote that this test is a l so used to identify
potentia l h e r n i ated d iscs i n the l u m ba r s p i ne. I n creased p a i n i n the
l u m b a r reg ion of the spine while perfo r m i n g the Va lsalva's M a n e uver
may i n d i cate a herniated d i sc. In genera l , t h i s i s a very g e n e ra l , non
descri ptive, p rovocative test.
EVIDENCE
Wa i n n e r et a l (2003)
C o n d it i o n s eva l u ated Cervica l ra d i c u l o pathy
Rel i a b i l ity Ka ppa = .69
S e n s itivity 22
S pec ificity 94
L umbar Spine 1 67
REFERENCES
C h i l d s J O. O n e o n o n e . Th e i m pact of t h e Va I s a I va m a n e uver d u ri n g res i s
ta n c e exe rc i se. Strength Con d J 1 999;2 l (2) :54-5 5
Oyste KH, N ewki r k KM P n e u m o m e d i a sti n u m i n a h i g h s c h o o l footba l l
p l ayer a case re port J A thl Tra in. l 998;3 3 (4)3 62-3 64
Folta A, Metzg e r B L, Th e r r i e n B. P reexi sti n g p h ys i c a l a ctivity l eve l a n d
ca rd i ova s c u l a r res pon ses a c ross t h e Va l s a lva m a n e uver. Nurs Res.
1 989;38(3) 1 3 9- 1 43 .
G o l d i s h G O, Q u a st J E, B l ow JJ, Ku s kows ki MA Post u ra l effects on i ntra
a bd o m i n a l p ress u re d u ri n g Va l s a l va m a n e uve r. Arch Phys Med Rehabil.
l 994;75 (3 ) : 3 24-327
Ko l l ef MH, N e e l o n - Ko l l ef RA P u l m o n a ry e m bo l i s m associated with t h e a ct
of d efecat i o n . Hea rt L ung. 1 99 1 ;20(5 Pt 1 ) 4 5 1 -454.
Lu Z, Metzg e r B L, Therrien B . Eth n i c d iffe re n ce s in p hysi o l o g ica l res pon ses
a ssoci ated with t h e Va l s a lva m a n e u ve r. Res Nurs Hea th. l 990; 1 3 ( 1 )9-
1 5.
Metzg e r B L, Th e r r i e n B. Effect of position on c a r d i ova s c u l a r res p o n s e d u r
i n g t h e Va I s a I va m a n e u ve r. Nurs Res. 1 990;3 9 (4) 1 98-202.
N a l i boff BO, G i l m o re S L, Rose nt h a l MJ Acute a uto n o m i c res ponses to
post u ra l c h a n g e, Va l s a lva m a n e uver, a n d paced b reat h i n g in o l d e r
type I I d i a betic m e n . J A m Geria tr Soc. 1 993;4 l (6) :648-6 5 3 .
N o r n h o l d P Decreased ca rd i a c o u t p u t fro m Va l s a l va m a n e uver. Nursing.
1 986; 1 6 ( 1 0) : 3 3 .
O'Co n n o r P , Sfo rzo G A , F rye P Effect o f b reat h i n g i n st r u cti o n o n b l ood p res
II
s u re res p o n ses d u ri n g i s o m etric exerc ise. Phys Ther l 989;69 (9)75 7-
76 1 .
P i e rce MJ, Wees n e r C L, A n d e rs o n AR, A l bo h m MJ P n e u m o m e d i a sti n u m
i n a fe m a l e t ra c k a n d fi e l d ath l ete: a c a s e report J A th ! Tra in.
1 998;33 (2) 1 68 - 1 70.
R u b i n ste i n S M , Pool JJ, va n Tu l d e r MW, R i p h a g e n 1 1 , d e Vet H C A syste m
atic review of t h e d i a g nostic a c c u ra cy of p rovocative tests of t h e n e c k
fo r d ia g n o s i n g cervi ca l ra d i c u l o pathy. E u r Spine J 2007; 1 6(3):307-3 1 9.
Te nto l o u ris N, Tsa po g a s P, Pa paza c h os G, Kats i l a m b ros N . Co rrected QT
i nte rva l d u ri n g t h e Va l sa lva m a n e uve r i n d i a betic s u bjects. Dia betes.
2000;49(5 ) : 1 68.
Th e r r i e n B. Position m o d ifies ca roti d a rte ry b l ood fl ow ve l o c ity d u ri n g
stra i n i n g . Res Nurs Heath. l 990; 1 3 (2) 69-76.
Wa i n n e r RS, F ritz JM, l rrg a n g JJ, Bon i n g e r M L, Oel itto A, A l l i s o n S Re l i a b i l ity
a n d d i a g nostic a c c u racy of t h e c l i n i ca l exa m i n at i o n a n d patient self
re port m ea s u re s fo r cervica l ra d i c u l o pathy. Spine (Phi/a Pa 1 976).
2003 ;28 ( 1 ) 5 2-62
1 68 Section 7
STOOP TEST
TEST POSITIONING
The s u bject is asked to wa l k briskly fo r 1 m i n ute.
ACTION
The exa m i n e r assesses fo r t h e on set of p a i n in the buttocks a n d
l owe r l i m b a reas. If p resent, the s u bject fo rwa rd-flexes the tru n k
(Fig u re LS7- 1 ) .
II
F i g u re LS7- 1 .
POSITIVE FINDING
Pa i n i n the buttocks a n d l ower l i m b a reas b ro u g h t on by brisk
wa l ki n g that i s soon re l i eved with fo rwa rd-fl ex i n g of the tru n k i s an
i n d icati o n that there i s a re latio n s h i p between the n e u rogenic i nte r
m itte nt c l a u d ication, postu re, a n d wa l ki n g.

A positive test ca n be reco nfi rmed by positi o n i n g the patient back
i nto tru n k extension, which may rep ro d u ce the pai nfu l sym pto ms.
L umbar Spine 1 69
REFERENCES
Dyc k P The stoo p-test i n l u m ba r e n t ra p m e n t ra d i c u l o pathy. Spin e (Phi/a
Pa 1 976) 1 979;4( 1 ) 89-92
Laess0e U, Vo i g ht M . Mod ification of st retc h to l e ra nce in a stoo p i n g posi
tion. Sca n d J Med Sci Sports. 2004; 1 4(4) 23 9-244
Porter RW S p i n a l ste n o s i s a n d n e u ro g e n i c c l a u d icati o n . Spine (Phi/a Pa
1 976). 1 996;2 l ( 1 7) 2046-205 2
II
1 70 Section 7
�----- H OOVER TEST

TEST POSITIONING
The s u bject re l axes i n a s u p i n e position on the ta b l e w h i l e the
exa m i n er places both of the s u bject's heels i nto the pa l m of the exa m
i n e r's hands (Fig u re LS7-2A) .
II F i g u re LS7-2A.
ACTION
The s u bject is a s ked to pe rform a u n i l atera l stra i g ht leg ra ise
( Fi g u re LS7-2 B).
L umbar Spine 171
F i g u re LS7-2B.
POSITIVE FINDING
The i n a b i l ity to l ift the leg may refl ect a n e u ro m uscu l a r wea kness.
A positive fi n d i n g i s a l so n oted when the exa m i n e r d oes not fee l
II
i n c reased p ress u re i n the p a l m t h a t u n d e r l ies t h e rest i n g leg.

Typica l ly, when the ra ised leg is wea k, p ress u re u n der the resting
ca lcaneus wi l l i n c rease i n a n atte m pt to l ift the wea k leg. When t h i s
i n c rease i n pressu re i s n o t fe lt, it co u l d i n d i cate a lack o f effo rt b y t h e
s u bject. The refo re, t h i s test s h o u l d be performed o n b o t h s i d e s t o test
co nsistency of effo rt.
EVIDENCE
McWh i rter et a l (201 1 )

St u d y d e s i g n Co h o rt
C o n d iti o n s eva l u ated F u n cti o n a l wea kness
Sa m p l e size 337
S e n s itivity 63
Spec ifi city 1 00
1 72 Section 7
REFERENCES
Ari eff AJ The H oove r s i g n a n o bjective s i g n of pa i n a n d/o r wea kness i n
t h e b a c k o r l ower ext re m ities. Tra ns A m Neural Assoc 1 96 1 ;86 1 9 1 .
H oove r CF. A n ew s i g n fo r t h e d etect i o n of m a l i n g eri n g a n d fu nctio n a l
p a re s i s o f t h e l ower ext re m ities. JAMA l 908;Ll (9)746-747
Koe h l e r PJ, O ku n MS. I m porta nt o b s e rvati o n s p r i o r to the d e s c r i pt i o n of
t h e H oove r s i g n . Neurology 2004;63 (9) : 1 693- 1 69 7
M cWh i rter L, Sto n e J , S a n d e rcock P , Wh ite l ey W H oover's s i g n fo r t h e d i a g
n o s i s o f fu n cti o n a l wea kness: a p ro s pective u n b l i n d ed c o h o rt s t u d y i n
patie n ts w i t h s u s pected stroke. J Psychosom Res. 20 1 1 ;7 1 (6) :384-3 86.
Pea rson C M . Diffe re n ti a l d i a g n o s i s of n e u ro m u sc u l a r d i sease by c l i n i ca l
eva l u ati o n . A rch Phys Med Rehabil. l 966;47(3) : 1 2 2- 1 2 5 .
Ziy I , Dj a l d etti R L , Zo l d a n Y , Avra h a m M , M e l a med E. D i a g n o s i s o f " n o n
o rg a n ic" l i m b pa re s i s b y a n ovel o bj ective m otor a s s e s s m e nt: t h e
q u a ntitative H oove r test J Neural. l 998;245 ( 1 2):797-802
II
L umbar Spine 1 73
KERNIG/B R U DZINSKI SIGNS

TEST POSITIONING
The s u bject lies s u p i n e with h i s or her h a n d s c u p ped be h i n d the
head. The exa m i n e r sta n d s next to t h e s u bject.
ACTION
The s u bject i s i n structed to fl ex t h e cervi ca l s p i n e by lift i n g the
head. Each hip i s u n i l atera l ly fl exed to no m o re t h a n 90 d e g rees by the
s u bject. The s u bject then fl exes the knee to n o m o re t h a n 90 deg rees.
The o p posite leg rem a i n s on the exa m i n i n g ta b l e (Fig u re LS7-3) .
II
Figure LS7-3.
POSITIVE FINDING
The test is confi rmed by i n c reased pa i n (that is either local ized o r
ra d i ates i nto the l ower extre mity) with n e c k a n d h i p fl exi o n . T h e pa i n
i s re l i eved w h e n the knee i s flexed. T h e p a i n i s i n d i cative o f m e n i n g e a l
i rritation, nerve root i m pi n g e m ent, o r d u ra l i rritation t h a t is exag g e r
ated by elo ngati n g the s p i n a l cord.
1 74 Section 7

The co n s i d e rations a re s i m i l a r to the stra i g ht leg raise test except
the neck is fl exed a n d the h i p i s actively flexed. The neck fl exion
co m ponent of this test was deve l o ped by Ke rnig, and the hip flexi o n
co m ponent w a s deve l o ped by Brudzi nski.
EVIDENCE
T h o m a s et a l B i l avsky e t a l
(2002) (20 1 3)
Study desig n D ia g n ostic Di a g n ostic
accu racy accu racy
C o n d iti o n s M e n i n g itis M e n i n g itis
eva l u ated
S e n s itivity Ke r n i g sig n = 5 Ke r n i g s i g n = 5 1
II
B r u dzi n s ki s i g n = 5 Brudzi n s ki sig n = 5 3
S pec ificity Ke r n i g sig n = 95 Ke r n i g s i g n = 95
Brudzi nski sig n = 95 Brudzi n s ki sig n = 78
REFERENCES
B i l avs ky E, Lei bovitz E, E l ko n -Ta m i r E, F r u c h t m a n Y, lfe rg a n G, G re e n berg
D. The d i a g n ostic a c c u racy of t h e 'c l a s s i c m e n i n g e a l s i g n s' i n c h i l d re n
with s u s pected bacte ria l m e n i n g itis. fur J Emerg Med 20 1 3;20(5) 3 6 1 -
363.
B rody I A, Wi l ki n s R H . The s i g n s of Ke r n i g and Brudzi n s ki . A rch Neural.
1 969;2 l (2) : 2 1 5-2 1 8 .
Me h n d i ratta M M , N aya k R, G a rg H , Ku m a r M, Pa n d ey S A p p ra i s a l of
Ke r n i g 's a n d B r u dzi n s ki's s i g n in m e n i n g itis. A n n India n A cad Neural.
20 1 3 ; 1 5 (4) 287-288
P u l l e n R L J r. Asses s i n g fo r s i g n s of m e n i n g it i s . Nursing. 2 004;34(5) 1 8.
T h o m a s KE, H a s b u n R, J e ke l J, Q u a g l i a re l l o VJ The d i a g n ostic a c c u ra cy of
Ke r n i g 's s i g n , Bru dzi n s ki's s i g n , a n d n u c h a l rig i d ity i n a d u lts with s u s
pected m e n i n g itis. Clin Infect Dis. 2002;3 5 ( 1 ) :46-5 2
L umbar Spine 1 75
Ve rg hese A, G a l l e m o re G. Ke r n i g 's a n d B r u dzi n s ki's s i g n s rev i s ited . Rev

Infect Dis. 1 987;9 (6) 1 1 8 7- 1 1 92 .
Wa rd M A , G reenwood T M , Ku m a r D R, Mazza JJ, Ya l e S H . J osef B r u dzi n s ki
a n d Vlad i m i r M i kh a i l ovich Ke r n i g s i g n s fo r d i a g n o s i n g m e n i n g itis. Clin
Med Res. 20 1 0;8( 1 ) 1 3 - 1 7
Wa rte n be rg R. Laseg u e s i g n a n d Ke r n i g s i g n ; h i storica l n otes. AMA A rch
Neural Psychia try 1 95 1 ;66 ( 1 ) 5 8-60
Wa rte n be rg R. The s i g n s of B r u dzi n s ki a n d of Ke r n i g . J Pedia tr
l 95 0;3 7 (4) :679-84
II
1 76 Section 7
90-90 STRAIGHT LEG RAISE TEST

TEST POSITIONING
The patient l ies s u p i ne, sta b i l izing both h i ps at 90 deg rees of fl ex
i o n with both ha nds. The knees a re bent in a re l axed positio n . The
exa m i n e r sta n d s next to the patient ( Fi g u re LS7-4A) .
II F i g u re LS7-4A.
ACTION
The patient is i n stru cted to actively exten d one knee at a t i m e a s
m u c h a s possi b l e (Fig u re LS7-4B) .
POSITIVE FINDING
If the knee i s flexed g reater than 20 deg rees, the h a m stri n g s a re
considered tig ht.
L umbar Spine 1 77
Figure LS7-4B.

When assess i n g t h i s test, ca re s h o u l d a l ways be ta ken to be con
s i stent with the position of the pelvis so testing measures ca n be
II
repeated with re l i a b i l ity.
REFERENCES
Ca m e ro n O M , B o h a n n o n RW. Relatio n s h i p betwee n a ctive knee exte n s i o n
a n d a ctive stra i g ht l e g ra i s e test m ea s u re m e nts. J Orth op Sports Phys
Ther 1 993; 1 7(5) 25 7-260
D ra per DO, Ca stro J L, Fe l a n d B, Sc h u l t h ies S, Egg ett D. S h o rtwave d i at h e r
my a n d p ro l o n g e d stretc h i n g i n c rease h a m stri n g fl ex i b i l ity m o re t h a n
p ro l o n g ed st retc h i n g a l o n e . J Orth op Sports Phys Th er 2004;34 ( 1 ) 1 3 -
20.
G a b be BJ, Be n n e l l K L , Waj swe l n e r H , F i n c h C F. Re l i a b i l ity of co m m o n
l ower extrem ity m u s c u l o s ke l eta l s c ree n i n g tests. Phys Th er Sport.
2004;5 (2) 90-97
Gajd osi k R L, Rieck MA, S u l l iva n D K, Wig ht m a n S E. Co m pa ri s o n of fo u r c l i n i
ca l tests fo r a ssess i n g h a m stri n g m u sc l e l e n g th J Orthop Sports Phys
Ther. 1 993; 1 8(5):6 1 4-6 1 8
Tafazzo l i F, La m o n ta g n e M M ec h a n i ca l behavio u r of h a m stri n g m u sc l es
i n l ow- b a c k pa i n patie nts a n d control s u bjects. C/in Biom ech (Bristol,
A von). 1 996; 1 l ( 1 ) 1 6-24.
1 78 Section 7
BOWSTRING TEST ((RAM TEST)

TEST POSITIONING
The s u bject l ies s u p i n e.
ACTION
The exa m i n e r performs a passive stra ig ht leg ra ise on the i nvolved
side ( Fi g u re LS7-5A). If the s u bject re ports rad iati n g p a i n with the
stra i g ht leg ra ised, the exa m i n er then flexes the s u bject's knee to
a p p roxi mately 20 d e g rees i n a n atte m pt to red uce pai nfu l sym pto m s
(Fig u re LS7-5 B). T h e exa m i n er t h e n a p p l ies p ress u re t o the p o p l itea l
a rea i n a n atte m pt to rep rod u ce the rad i c u l a r pa i n .
II
F i g u re LS7-5A.
L umbar Spine 1 79
Figure LS7-5B.
POSITIVE FINDING
Pa i n fu l ra d i c u l a r reprod uction fo l l ow i n g popl itea l co m p ress ion
i n d icates te nsion o n the sciatic nerve.

It is i m po rta nt fo r the exa m i n er to m a i nta i n the same d e g ree of the
s u bject's hip fl exion when fl exion of the knee is performed.
II
EVIDENCE
S u p i k a n d Broom ( 1 994)
Study d es i g n D i a g n ostic accu racy
C o n d i t i o n s eva l u ated Lu m ba r d i sc h e r n iation
S a m p l e size 50
Re l i a b i l ity Not eva l u ated
S e n s itivity 69
Spec ificity Not eva l u ated
1 80 Section 7
REFERENCES
H e rro n LO, P h e a s a n t HC. B i l ate ra l l a m i n otomy a n d d i scecto my fo r seg
m e nta l l u m b a r d i sc d i sease. Deco m p res s i o n with sta b i l ity. Spine (Phi/a
Pa 1 976) 1 983;8( 1 ) 86-97
S u p i k L F, B room MJ Sciatic te n s i o n s i g n s a n d l u m ba r d i sc h e r n i a t i o n .
Spine (Phi/a P a 1 976) 1 994; 1 9 (9) 1 066- 1 069
II
L umbar Spine 181
SITTING Roar TEST

TEST POSITIONING
The s u bject sits with the h i p a n d knee flexed to 90 deg rees a n d the
cervica l spine i n fl exio n .
ACTION
The s u bject actively exten d s the knee (Fig u re LS7-6A) .
II
Figure LS7-6A.
POSITIVE FINDING
The s u bject who a rches backwa rd a n d/or com p l a i n s of p a i n i n the
reg i o n s of the buttocks, poste rior t h i g h , a n d calf d u ri n g knee exten
s i o n d e m o n strates a positive fi n d i n g fo r poss i b l e sciatic ne rve pain.
1 82 Section 7

Th i s test ca n be rep rod uced with the exa m i n e r pass ively extend
i n g the s u bject's knee. Tru e sciatic p a i n s h o u l d sti l l cause the s u bject
to react. H oweve r, if the exa m i ne r's actio n s d i stract the s u bject fro m
being awa re of the a rea being tested, the s u bject may res pond dif
fe rently. For exa m p l e, if the exa m i n e r sta b i l ized a n d too k n ote of the
foot d u ri n g extension of the knee, the s u bject may be u n awa re that
the exa m i n er i s rea l l y test i n g fo r sciatic te nsion (Fig u re LS7-6B).
II
F i g u re LS7-6B.
REFERENCE
Lew PC, B r i g g s CA Relatio n s h i p betwe e n t h e cervi ca l com p o n e nt of
t h e s l u m p test a n d c h a n g e i n h a m stri n g m u s c l e te n s i o n . Ma n Th er.
l 997;2 (2) :98- 1 05.
L umbar Spine 1 83
U N I LATERAL STRAIGHT LEG RAISE TEST

( LASEG U E TEST)
TEST POSITIONING
The s u bject is s u p i n e with both h i ps a n d knees extended. The
exa m i n er i s sta n d i n g with the d i sta l hand a ro u n d the s u bject's heel
and the p rox i m a l hand o n the s u bject's d i sta l t h i g h (anteriorly) to
m a i nta i n knee exte n s i o n .
ACTION
With the s u bject co m p l etely re laxed, the exa m i n er s l owly raises the
test leg u n t i l pa i n o r tig htness i s n oted ( Fi g u re LS7-7A) . The exa m i n e r
s l owly l owers the l e g u n t i l t h e p a i n o r tig htness resolves a n d then
d o rsifl exes the a n kle ( Fi g u re LS7-7B) a n d i n structs the s u bject to flex
the neck (Fig u re LS7-7C).
II
F i g u re LS7-7A.
1 84 Section 7
F i g u re LS7-7B.
II
F i g u re LS7-7C.
L umbar Spine 1 85
POSITIVE FINDING
Leg a n d/or l ow b a c k pa i n occ u r r i n g with d o rs ifl exi o n a n d/
o r n e c k fl exi o n i s i n d i cative of d u ra l i nvolve m e nt. A lack of p a i n
re p ro d u ction w i t h d o rs ifl ex i o n a n d/o r n e c k fl ex i o n i s i n d i cative of
e i t h e r h a m st r i n g tig htness or poss i b l e l u m ba r s p i n e or sacro i l iac
j o i nt i nvo lve m e nt. Ad d i t i o n a l ly, pain occ u rr i n g at hip flexi o n a n g l e s
g reater t h a n 70 deg rees i s i n d i cative of l u m ba r s p i n e o r sacroi l i a c
j o i nt i nvolve m ent. I f t h e latter i s dete r m i ned, p roceed t o t h e b i l at
eral stra i g h t leg raise test to d iffe rentiate between l u m b a r s p i n e a n d
sacro i l i a c j o i n t i nvo lve m e nt.

The s u bject m u st be co m p l etely re l axed beca use contraction of
t h e h i p flexor m u scles co u l d i n crease the stress placed on the l u m
ba r s p i n e a n d sacro i l ia c joi nt, t h u s creati n g fa lse- positive fi n d i ngs.
Ad d itional ly, d u ri n g the U n i l atera l Stra i g ht Leg R a i se Test, p a i n may be
n oted i n the contra l atera l leg a n d/o r l u m ba r s p i n e. This fi n d i n g s h o u l d
be refe rred t o a s a positive C rossed Stra i g ht Leg R a i s e Test.
II
EVIDENCE
Devi l l e et a l Gabbe et al M aj l e s i e t a l
(2000) (2004) (2008)
Study d e s i g n M eta-a n a lysis Re l i a b i l ity Case
control
C o n d iti o n s H e r n iated Scree n i n g Lu m ba r
eva l u ated d iscs d i sc
h e r n iation
Study n u m be r 11
Sa m p l e size 15 75
Re l i a b i l ity N ot eva l u ated ICC = .9 1 N ot
eva l u ated
S e n s itivity 91 N ot eva l u ated 52
Spec ificity 26 N ot eva l u ated 89
1 86 Section 7
REFERENCES
Ca m e ro n OM, B o h a n n o n RW, Owe n SV I nfl u e n c e of h i p position o n
m ea s u re m e nts o f stra i g h t l e g ra ise test. J Orthop Sports Phys Th er.
1 994; 1 9 (3) 1 68- 1 72.
C h ow R, Ada m s R, H e rb e rt R. Stra i g ht l e g ra i s e test h i g h re l i a b i l ity i s n ot a
m otor m e m o ry a rtefact. A ust J Physiother 1 994;40(2) 1 07 - 1 1 1 .
Devi l l e WL, va n d e r Wi n d t OA, Ozafe ra g i c A, Beze m e r PO, Souter LM. The
test of Laseg u e : syste matic review of t h e accu ra cy in d i a g n o s i n g h e r n i
ated d i scs. Spine (Phi/a Pa 1 976) 2000;25 (9) 1 1 40- 1 1 47 .
Ga b be B J , Ben n e l l K L , Waj swe l n e r H , F i n c h C F. Rel i a b i l ity o f co m m o n
l ower extre m ity m u sc u l os ke l eta l scree n i n g tests. Phys Ther Sport.
2004;5 (2) 90-97.
l d ota H , Yos h i d a T C l i n i ca l s i g n ifi ca n ce of the stra i g ht-leg-ra i s i n g test.
Nihon Seikeigeka Ga kka i Zassh i. 1 99 1 ;65 ( 1 1 ) : 1 0 3 5 - 1 044.
I g l e s i a s-Ca s a rru b i a s P, A l d ay-A nzo l a R, R u iz- Lopez P, Gom ez- Lopez P, Cruz
Be rto l o J, Lobato RO. La seg u e's test a s p rog nostic fa ctor fo r patients
u n d e rg o i n g l u m ba r d i sc s u rg e ry [a rti c l e in S pa n i s h] . Neurocirugia
(Astur) 2 004; 1 5 (2) 1 3 8- 1 43.
Ko h l boeck G, G re i m e l KV , P i ot rows ki WP, et al. P rog n o s i s of m u ltifa cto
ri a l o utco m e in l u m b a r d i scecto my a prospective l o n g it u d i n a l st udy
II
i nvesti gati n g patie nts with d i s c p ro l a pse. C/in J Pa in. 2004;20 (6) 45 5 -
46 1 .
te b kows ki WJ Presence a n d i nte n s ity of t h e Laseg u e s i g n i n re l a t i o n to
the s ite l u m ba r i nterverte b ra l d isc h e r n i a t i o n [a rti c l e in P o l i s h ] . Ch ir
Na rzadow Ruch u Ortop Pol. 2002;67(3) 265-268.
M aj l e s i J , Togay H , U n a I a n H , To p ra k S . Th e s e n s itivity and s pecific ity of t h e
S l u m p a n d t h e Stra i g ht L e g Ra i s i n g tests i n pati e n ts w i t h l u m ba r d i sc
h e rn i a t i o n . J Clin Rheumato/. 2008; 1 4(2) 87-9 1 .
M e n s J M , Vlee m i n g A, S n ij d e rs CJ, Koes BW, Sta m HJ Re l i a b i l ity a n d va l i d
ity o f t h e a ctive stra i g ht leg ra i s e t e s t i n poste rior pelvic pa i n s i n c e
p reg n a n cy. Spine (Phi/a P a 1 976) 200 1 ;26 ( 1 0) 1 1 6 7- 1 1 7 1 .
Mesza ros TF, O l s o n R, Ku l i g K, Cre i g hto n 0, Cza r n e c ki E. Effect of 1 0%,
30%, a n d 60% body we i g ht tra cti o n on the stra i g ht leg ra i s e test of
sym pto matic patie nts with l ow b a c k pa i n . J Orthop Sports Phys Th er
2000;3 0 ( 1 0) :595-60 1 .
N eto T, J a c o b so h n L, Ca rita A l , O l ivei ra R. Re l i a b i l ity of t h e Active Knee
Exte n s i o n Test and t h e Stra i g ht Leg Ra i s e Test in s u bjects with fl exi b i l
ity d efi cits [pu b l i s h ed o n l i n e a h ead o f p r i n t Octo ber 3 0 , 20 1 4] . J Sport
Reha bi/. d o i 1 0 1 1 23/j s r.20 1 4-0220.
Wa rte n be rg R. Laseg u e s i g n and Ke r n i g s i g n ; h i storica l n otes. AMA Arch
Neural Psych ia try 1 95 1 ;66( 1 ) 5 8-60
L umbar Spine 1 87
B I LATERAL STRAIGHT LEG RAISE TEST

TEST POSITIONING
The s u bject l ies s u p i n e with both h i ps a n d knees extended. The
exa m i n er is sta n d i n g with the d i sta l hand o r fo rea r m a ro u n d o r u n d e r
t h e s u bject's heels a n d the p rox i m a l h a n d o n the s u bject's d i sta l
t h i g h s (anteriorly) to m a i n ta i n knee exte n s i o n .
ACTION
With the s u bject co m p l etely re l axed, s l owly ra ise the legs u ntil pa i n
o r tig htness i s noted ( Fi g u re LS7-8) .
II
Figure LS7-8.
POSITIVE FINDING
Low back p a i n occ u rring at h i p fl exion a n g les less t h a n 70 d e g rees
i s i n d icative of sacroi l i a c joint i nvo lve m e nt. Low back pa i n occ u r r i n g
at h i p fl exi o n a n g les g reater t h a n 70 deg rees i s i n d i cative o f l u m ba r
s p i n e i nvolvement.
1 88 Section 7

The exa m i n er m u st use proper body mechan ics when perfo r m i n g
this test t o avoid i nj u ry seco n d a ry t o l ifti n g the weig ht o f both legs.
The exa m i n er s h o u l d a l so n ote a ny excess ive pelvic m otion that may
i n d icate the s u bject's d i sco mfort a n d/or mecha n i c a l co mp e n sation
associated with the test.
REFERENCES
Ba ltaci G, U n N , Tu nay V, Bes l e r A, G e rc;:eker S Co m pa ri s o n of t h ree d if
fe re nt s i t a n d rea c h tests fo r m ea s u re m e n t of h a m stri n g fl exi b i l ity i n
fe m a l e u n ivers ity st u d e nts. B r J Sports Med. 2003;3 7 ( 1 ) 5 9-6 1 .
H u n t OG, Zu b e r b i e r OA, Kozl ows ki AJ, et a l . Re l i a b i l ity of t h e l u m ba r
fl exi o n , l u m ba r exte n s i o n , a n d p a s s ive stra i g h t l e g ra i s e test i n n o rm a l
p o p u l at i o n s e m bed d e d with i n a co m p l ete p hysica l exa m i n at i o n .
Spine (Phi/a Pa 1 976) 200 1 ;26 (24) 2 7 1 4-2 7 1 8
M e n s J M , Vlee m i n g A, S n ij d e rs CJ, Koes BW, Sta m H J Va l i d ity of t h e
a ctive stra i g ht l e g ra ise test fo r m ea s u ri n g d i sease seve rity i n patients
with poste rior pelvic pa i n afte r p reg n a n cy. Spine (Phi/a Pa 1 976)
2002;2 7 (2) 1 96-200.
II
O'S u l l iva n PB, Bea l e s DJ, Beet h a m J A, et a l . A l te red m otor control strate
g ies in s u bjects with s a c ro i l i a c J o i nt pa i n d u ri n g the a ctive stra i g ht-leg
ra i s e test. Spine (Phi/a Pa 1 976) 2002;2 7 ( 1 ) : E l -ES.
Rade M, Kb n b n e n M, Va n n i n e n R, et a l . 20 1 4 yo u n g i nvest i g ato r awa rd
wi n n e r: I n vivo m a g n etic reso n a nce i m a g i n g m ea s u re m e n t of s p i n a l
cord d i s p l a c e m e n t i n t h e t h o ra co l u m ba r reg i o n o f asym pto matic
s u bjects: pa rt 2 : co m pa ri s o n betwee n u n i latera l and b i latera l stra i g h t
l e g ra i s e tests. Spine (Phi/a Pa 1 976). 3 9 ( 1 6) : 1 294- 1 300.
Reba i n R, Baxte r G O, M c D o n o u g h S The p a s s ive stra i g ht leg ra i s i n g test
in the d i a g n os i s a n d trea t m e n t of l u m ba r d i sc h e r n i a t i o n : a s u rvey of
U n ited Ki n g d o m osteopat h i c o p i n i o n a n d c l i n i ca l p ra ctice. Spine (Phi/a
Pa 1 976) 2003;28 ( 1 5) 1 7 1 7- 1 724.
L umbar Spine 1 89
WELL STRAIGHT LEG RAISE TEST

(CROSSED STRAIGHT LEG RAISE)
TEST POSITIONING
The s u bject lies s u p i n e on a ta b l e. The exa m i n e r p l aces o n e h a n d
o n the a nterior a s pect o f t h e u n i nvolved leg s l i g htly s u perior t o the
knee a n d t h e other h a n d a ro u n d the heel of t h e i ps i l atera l calcane us.
ACTION
The exa m i n er passively fl exes the s u bject's u n i nvo lved h i p w h i l e
m a i n ta i n i n g the k n e e i n a n exte nded position (Fig u re LS?-9) .
II
Figure LS7-9.
POSITIVE FINDING
Co m p l a i nts of p a i n on the i nvo lved side i n d icate a positive test a n d
m a y be rel ated t o verte b ra l d i s k d a mage.
1 90 Section 7

Th i s test was fi rst descri bed by Faje rsztaj n but is a l s o known as a
p rostrate leg ra i s i n g test, Lherm itte's test, or a cross-over s i g n . When
t h i s test i s performed, a d u ra l stretch i s a p p l ied to both sides of t h e
l owe r ext remity. The refore, co m p l a i nts o f pa i n may be n oted i n a
rad icu l a r m a n n er.
EVIDENCE
Dev i l l e et a l (2000)
St u d y d e s i g n Syste matic review
Co n d it i o n s eva l u ated H e r n iated d i scs
St u d y n u m be r 6
Rel i a b i l ity N ot eva l u ated
S e n s itivity 29
Spec ificity 88
II REFERENCES
Devi l l e WL, va n d e r Wi n d t DA, Dzafe ra g ic A, Beze m e r PD, Bouter LM. The
test of Laseg u e : syste matic review of t h e a c c u ra cy in d i a g n o s i n g h e r n i
ated d i scs. Spine (Phi/a P a 1 976) 2000;25 (9) 1 1 40- 1 1 47.
G ajd o s i k R L, Rieck MA, S u l l iva n D K, Wig htm a n S E . Co m pa ri s o n of fo u r c l i n i
ca l tests fo r assess i n g h a m stri n g m u sc l e l e n g t h . J Orthop Sports Phys
Th er 1 993; 1 8(5):6 1 4-6 1 8.
J o n s s o n B, Stro m qvist B. S i g n ifi ca n ce of a persistent positive stra i g ht leg
ra i s i n g test after l u m ba r d i sc s u rg e ry. J Neurosurg. 1 999;9 1 (1 S u p p l) S 0-
53.
J o n s s o n B , Stro m qvist B. T h e stra i g ht l e g ra i s i n g test a n d t h e seve rity of
sym pto m s i n l u m ba r d i s c h e r n iati o n . A preoperative eva l u ati o n . Spin e
(Phi/a Pa 1 976). 1 995;20( 1 ) 2 7-30.
Reba i n R, Baxte r G D , M c Do n o u g h S. The p a s s ive stra i g ht l e g ra i s i n g test
in t h e d i a g n o s i s a n d treat m e n t of l u m b a r d i sc h e r n i a t i o n : a s u rvey of
U n ited Ki n g d o m osteopat h i c o p i n i o n a n d c l i n i ca l p ractice. Spine (Phi/a
Pa 1 976) 2003;28 ( 1 5) 1 7 1 7- 1 724
Wood h a l l B, H ayes GJ The we l l -leg ra i s i n g test of Faj e rsztaj n in the d i a g
n o s i s o f ru pt u red l u m ba r i nterve rte b ra l d i s c J Bone Join t Surg Am
l 950;32A(4) 786-792
L umbar Spine 191
SLUMP TEST
TEST POSITIONING
The s u bject sits on the end of the ta b l e a n d l e an s fo rwa rd w h i l e the
exa m i n er h o l d s the head a n d c h i n u p rig ht (Fig u re LS7-1 OA) .
Figure LS7- 1 0A.

II
ACTION
Any sym pto m atic c h a n ges repo rted by the s u bj ect a re n oted.
The exa m i n e r then flexes t h e s u bject's neck and assesses fo r a ny
c h a n g es i n sym pto m s ( F i g u re LS7- 1 0 B ) . If no c h a n ges a re n oted,
the exa m i n e r pass ively exte n d s one of the s u bject's knees (Fig u re
LS7- 1 OC). Ag a i n, sym pto matic c h a n g es a re assessed. With no n oted
c h a n g es, the exa m i n e r t h e n passively d o rsifl exes the s u bject's a n kl e
w h i l e t h e k n e e rem a i n s exte nded ( F i g u re LS7- 1 OD). The s u bject i s
t h e n ret u r n e d t o t h e o ri g i n a l "s l u m p" position a n d t h e test i s repeat
ed fo r t h e other l e g .
1 92 Section 7
F i g u re LS7-1 0B.
II
Fig u re LS7- 1 0C.

L umbar Spine 1 93
F i g u re LS7- 1 0D.
POSITIVE FINDING
A co m pl a i nt of sciatic-type p a i n or a ny rep rod uction of sym pto m s
i s i n d icative o f a pos itive test.

The exa m i n er s h o u l d n ote the location of the sym pto matic c h a n g
es beca use t h i s i s often the s ite o f a d u ra l stretc h . Others h ave
II
descri bed t h i s test whereby t h e s u bject actively m oves the knee a n d
a n kl e a s o p posed t o pass ive m ovem ent.
EVIDENCE
G a b b e et a l (2004) M aj l esi et a l (2008)

Study d e s i g n Re l i a b i l ity Case contro l
Conditions S c ree n i n g Lu m ba r d i sc
eva l u ated h e r n iation
S a m p l e size 15 75
Re l i a b i l ity ICC = .92 Not eva l u ated
S e n s itivity N ot eva l u ated 84
Spec ifi city N ot eva l u ated 83
1 94 Section 7
REFERENCES
Ga bbe BJ, Be n n e l l KL, Waj swe l n e r H , F i n c h CF. Rel i a b i l ity of co m m o n
l owe r extre m ity m u sc u l os ke l eta l scree n i n g tests. Phys Ther Sport.
2004;5 (2) 90-97
J o h n s o n E K, C h i a re l l o CM The s l u m p test the effects of head and l ower
extre m ity position o n knee exte n s i o n . J Orth op Sports Phys Th er
1 997;26(6)3 l 0-3 1 7.
Lew PC, Briggs CA Relati o n s h i p betwee n t h e cervi ca l com p o n e n t of
t h e s l u m p test and c h a n g e in h a m stri n g m u sc l e te n s i o n . Ma n Th er.
1 997;2 (2) 98- 1 05.
M aj l es i J , Tog a y H , Una Ian H , To p ra k S . Th e s e n s itivity and s pecific ity of the
S l u m p and t h e Stra i g ht Leg Ra i s i n g tests in pati e n ts with l u m ba r d i sc
h e r n i a t i o n . J Clin Rheumato/. 2008; 1 4(2) 87-9 1 .
Pa h o r S, To p p e n b e rg R. An i nvestigation of n e u ra l t i s s u e i nvo l ve m e n t i n
a n kl e i nve rs i o n s p ra i n s . Man Ther 1 996; 1 (4) 1 92 - 1 97
Sta n kovi c R, J o h n e l l 0, M a l y P, Wi l l n e r S U s e of l u m b a r exte n s i o n , s l u m p
test, p hysica l a n d n e u ro l o g i ca l exa m i n at i o n i n t h e eva l u at i o n of
patie n ts with s u s pected h e r n i ated n u c l e u s p u l po s u s . A p ros pective
c l i n i ca l study Ma n Ther l 999;4( 1 ) 25-32
We b r i g h t WG, Ra n d o l p h BJ, Perri n OH. Co m pa ri s o n of n o n ba l l istic a ctive
II
knee exte n s i o n in n e u ra l s l u m p position a n d static st retc h tec h n i q u e s
o n h a m stri n g fl exi b i l ity. J Orthop Sports Phys Ther 1 997;2 6 ( 1 ) 7- 1 3 .
Wh ite M A , Pa pe K E . The s l u m p test. A m J Occup Th er l 9 92;46 (3) 2 7 1 -2 74.
L umbar Spine 1 95
THOMAS TEST
TEST POSITIONING
The s u bject lies s u p i n e with both knees fu l l y flexed a g a i nst the
ch est a n d the buttocks near the ta b l e edge. The exa m i n er sta n d s with
o n e hand o n the s u bject's l u m ba r spine o r i l iac crest to m o n itor l u m
ba r lordosis or pelvic tilt, res pectively (Fig u re LS7- 1 1 A) .
F i g u re LS7- 1 1 A.
II
ACTION
The s u bject s l owly l owers the test leg u ntil it is fu l ly re l axed o r u nt i l
e i t h e r a nte rior p e l v i c ti lti n g o r a n i n c rease i n l u m ba r l o rdosis occu rs
(Fig u re LS?- 1 1 B).
1 96 Section 7
Figure LS7- 1 1 B.
POSITIVE FINDING
A lack of h i p exte nsion with knee fl exion g reater t h a n 45 d e g rees
i s i n d i cative of i l io psoas m u scle tightness. Fu l l h i p exte n s i o n with
II
knee fl exion less than 45 deg rees is i n d i cative of rectu s fe moris
m u sc l e tig htness. A lack of hip extension with knee flexi o n less t h a n
45 deg rees i s i n d icative o f i l i o psoas a n d rectus fe moris m u scle tig ht
ness. H i p exte r n a l rotation d u ri n g a ny of the p revio u s sce n a rios is
i n d i cative of i l ioti b i a l band tig htness.

I n c reases i n a nterior pelvic tilt a n d l u m ba r l o rdosis m u st be
e l i m i n ated to p reve nt fa lse-neg ative fi n d i n gs. To fu rther confi r m t h i s
assessme nt, the exa m i n e r can s i m ply a p ply p ress u re o n the l owe r l e g
i n a n effo rt t o l ower it b a c k t o the ta ble. A return o f l u m ba r l o rdosis
wi l l i n d i cate a positive fi n d i n g .
L umbar Spine 1 97
EVIDENCE
G a bbe et a l (2004)
St u d y d e s i g n Re l i a b i l ity study
C o n d iti o n s eva l u ated Scree n i n g
Sa m p l e size 15
Rel i a b i l ity ICC = 63 to .75
.

Spec ifi city Not eva l u ated
REFERENCES
B a r l ett M D, Wo lf LS, S h u rt l eff DB, Sta h e l i LT H i p fl exion co ntractu res
a co m pa ri s o n of m ea s u re m e n t methods. A rch Phys Med Rehabil.
l 985;66 (9) :620-625
E l a n d DC, S i n g l eton TN , Co n a ster R R, et a l . The " i l i a c u s test" n ew i nfo rma
t i o n fo r t h e eva l u ation of h i p exte n s i o n dysfu n cti o n . J A m Osteopa th
Assoc 2002; 1 02 (3) 1 3 0- 1 42.
Ga b be BJ, Be n n e l l KL, Waj swe l n e r H , F i n c h CF. Rel i a b i l ity of co m m o n
l ower extre m ity m u s c u l os ke l eta l scree n i n g tests. Phys Th er Sport.
2004;5 (2) :90-97
II
H a rvey D. Asses s m e n t of the fl exi b i l ity of e l ite ath l etes u s i n g the mod ified
Th o m a s test Br J Sports Med 1 998;3 2 ( 1 ) 68-70.
H a rvey OM. F l exi b i l ity of e l ite ath l etes u s i n g the m od ified Th o m a s test
Med Sci Sport Exerc l 997;29(5):2 7 1 .
Koya m a H , M u ra ka m i K, Suzu ki T, S uza ki K. P h e n o l b l o c k fo r h i p fl exo r
m u s c l e s p a stic ity u n d e r u l t ra s o n i c m o n itori n g . Arch Phys Med Rehabil.
1 992;73 ( 1 l ) 1 040- 1 043.
Lee LW, Ke rri g a n D, Casey M D, De l l a C roce U . Dyn a m i c i m p l icati o n s of h i p
fl exi o n contract u re s . A m J Phys Med Rehabil. l 997;76(6) 502-508
M a rg o K, D rez n e r J , Motzki n D. Eva l u ation and m a n a g e m e n t of h i p p a i n
a n a l g o rith m i c a p p roa c h . J Fa m Pract. 2003;5 2 (8) 607-6 1 7 .
N a rva n i A A , Ts i r i d i s E, Ke n d a l l S, C h a u d h u ri R, Th o m a s P A prel i m i n a ry
re port o n p reva l e n ce of a ceta b u l a r l a b r u m tea rs i n s po rts patients with
g ro i n pa i n . Kn ee Surg Sports Tra umata/ A rth rosc 2003 ; 1 l (6):403-408
Re i m a n M P, Goode A P, H eged u s EJ, Coo k CE, Wri g ht AA D i a g n ostic accu
ra cy of c l i n i ca l tests of t h e h i p: a syste matic review with meta-a n a lys i s .
B r J Sports Med 20 1 3;4 7 ( 1 4) 893-902
1 98 Section 7
S c h a c h e AG, B l a n c h PD, M u rp h y AT. Relation of a nte rior pelvic t i l t d u r

i n g ru n n i n g to c l i n i c a l a n d ki n e m atic m ea s u res of h i p exte n s i o n . Br J
Sports Med. 2000;34(4) 2 7 9-283
Tyl e r T, Zoo k L, B ritt i s D, G l e i m G . A n ew pelvic tilt d etecti o n device
roe ntg e n og ra p h i c va l i d a t i o n and a p p l ication to a s s e s s m e n t of h i p
motion i n p rofess i o n a l ice h o c key p l ayers. J Orthop Sports Phys Th er
l 996;24(5)303-308
Wi nte rs MV, B l a ke CG, Trost JS, et a l . Pass ive vers u s a ctive st retc h i n g of h i p
fl exo r m u sc l e s i n s u bjects with l i m ited h i p exte n s i o n : a ra n d o m ized
c l i n ica l tria l . Phys Th er. 2 004;84(9) :800-807
Yo u n g W, C l oth i e r P, Ota g o L, Bruce L, Li d d e l l D. Acute effects of static
stretc h i n g o n hip fl exo r and q u a d riceps fl exi b i l ity, ra n g e of motion a n d
foot s peed i n kicki n g a foot ba l l . J Sci Med Sport. 2004;7 ( 1 ) :23-3 1 .
II
L umbar Spine 1 99
SPRING TEST
TEST POSITIONING
The s u bject lies p ro n e a n d the exa m i n er sta n d s with the t h u m b
(Fig u re LS7- 1 2A) o r hypot h e n a r e m i n e n ce (specifica l l y t h e pisifo rm)
over the s p i n o u s p rocess of a l u m ba r verte b ra (Fig u re LS7- 1 2 B) .
Figure LS7- 1 2A. II
Figure LS7- 1 2B.

200 Section 7
ACTION
Apply a d ownwa rd "s pri n g i ng" fo rce t h ro u g h the s p i n o u s p rocess
of each verte bra to assess posterior-a nterior moti o n . Th i s action
shou l d be repeated fo r each tran sve rse p rocess to assess rota ry
moti o n .
POSITIVE FINDING
I n c reases or decreases i n motion at o n e verteb ra co m p a red to
a n other a re i n d i cative of hype r m o b i l ity or hypo m o b i l ity, respective ly.

Rotati o n a l accessory m ovement ca n be co m pa red at each l evel
by perfo r m i n g t h i s test to the tra n sve rse p rocess o n each side of o n e
verte b ra l leve l .
REFERENCES
B i l l i s EV, Foster N E, Wri g ht CC Re p rod u c i b i l ity a n d repeata b i l ity e rrors of
t h ree g ro u ps of p hysiot h e ra p i sts i n l ocati n g s p i n a l l eve l s by pa l pati o n .
II
M a n Ther 2003;8(4) 223-232
C h a n s i ri n u ko r W, Lee M , Lati m e r J . Contri bution of pelvic rotation to l u m
ba r poste ro a n t e r i o r m ove m e nt. Man Ther 200 1 ;6(4) 242-249
Ed m o n d ston SJ, A l l i s o n GT, G regg CD, P u rd e n SM, Sva n s s o n G R, Watson
AE. Effect of positi o n o n t h e posteroa nterior stiffn ess of t h e l u m ba r
s p i n e . Ma n Ther 1 998;3 ( 1 )2 1 -26.
Lat i m e r J , Lee M, Ad a m s R. The effect of t ra i n i n g with fee d b a c k on
p h ys i ot h e ra py stu d e nts' a b i l ity to j u d g e l u m b a r stiffn ess. Ma n Th er
1 996; 1 (5) 266-270
Nyl a n d J , J o h n so n D Co l l eg iate footba l l p l ayers d i s p lay m o re a ctive
cervica l s p i n e m o b i l ity t h a n h i g h s c h o o l foot ba l l p l ayers. J A th l Tra in.
2004;39(2) : 1 46- 1 5 0 .
Petty N J . The effect of posteroa nterior m o b i l i s a t i o n o n sag itta l m o b i l ity of
t h e l u m ba r s p i n e . Man Th er. 2000; 1 ( 1 )25-29
Petty NJ, M a h e r C, Lati m e r J , Lee M . M a n u a l exa m i n a t i o n of accessory
m ove m e nts-see ki n g R l . Man Ther. 2002;7 ( 1 ) : 3 9-43
S h i r l ey D, E l l i s E, Lee M. The res p o n s e of posteroa nterior l u m ba r stiffn ess
to repeated l o a d i n g . Ma n Ther 2002; 7 ( 1 ) : 1 9-2 5 .
L umbar Spine 20 1
----- TREN DELEN B U RG 1S TEST

TEST POSITIONING
The s u bject sta n d s on o n e l ower extre m ity ( Fi g u re LS7- 1 3A) .
II
F i g u re LS7- 1 3A.
ACTION
The s u bject re m a i n s i n this position for a p p roxi m ately 1 0 seco n d s
a n d then switc h es extrem ities.
POSITIVE FINDING
A positive fi n d i n g is seen when the pelvis on the u n s u p po rted side
d rops n oticea bly l ower t h a n the pelvis o n the s u pported side ( Fi g u re
LS7- 1 3 B) . Th i s i n d icates a wea kness of the g l uteus m e d i u s m u scle o n
t h e s u p po rted side. Fig u res LS7- 1 3C a n d LS7- 1 3 D s h ow the posterior
view.
202 Section 7
Figure LS7- 1 3 B .
SPECIAL CONS/DERATIONS/COMMENTS
With a neg ative test, the g l uteus med i u s o n the s u pported side wi l l
perform a reve rse action beca use t h e su pported fem u r i s sta b i l ized.
II
Th is wi l l a l low fo r the u n s u p po rted pelvis to re m a i n l evel with the
s u pported pelvis. With a wea k g l uteus m e d i u s o n the su pported side,
the u n s u p po rted pelvis d rops as the m u scle fat i g u es. Th is test may
a l so i n d icate a n u n sta b l e hip on the su pported side.
EVIDENCE
Rei m a n et a l (20 1 3)
St udy d e s i g n M eta-a n a lysis
Co n d it i o n s eva l u ated G l utea l te n d i n opathy
St u d y n u m be r 3
Sa m p l e s ize 78
S e n s itivity 61
Spec ificity 92
L umbar Spine 203
Figure LS7- 1 3C.
II
Figure LS7- 1 3 D.
204 Section 7
REFERENCES
Asaya m a I , N a ito M , F uj i sawa M, Ka m be T Relati o n s h i p betwe e n ra d io
g ra p h i c m ea s u re m e nts of reco n st r u cted h i p j o i n t position a n d t h e
Tre n d e l e n b u rg s i g n . J A rthroplasty 2002; 1 7 (6) :747-75 1 .
B i rd PA, Oa kley S P, S h n i e r R, Ki rkh a m BW P ros pective eva l u at i o n of
m a g n etic reso n a n c e i m a g i n g a n d p hys ica l exa m i n a t i o n fi n d i n g s i n
patients with g reater t ro c h a nte ric pa i n syn d ro m e . Arth ritis Rheum
200 1 ;44(9) 2 1 3 8-2 1 45
H a rdcastle P, N a d e S The s i g n ifica n ce of t h e Tre n d e l e n b u rg test J Bone
Join t Surg Br 1 985;67(5) : 74 1 -746.
Re i m a n M P, Goode A P, H eged u s EJ, Coo k CE, Wri g h t AA D i a g n ostic accu
ra cy of c l i n ica l tests of t h e h i p: a syste matic review with m eta-a n a lys i s .
B r J Sports Med 20 1 3;47 ( 1 4) 893-902.
Tre n d e l e n b u rg F. Tre n d e l e n b u rg's test 1 89 5 . Clin Orthop Re/a t Res. 1 998;
(3 5 5 ) 3 - 7
Va s u d eva n P N , Va idya l i n g a m KV , N a i r P B . C a n Tre n d e l e n b u rg 's s i g n be
pos itive if the h i p i s n o r m a l ? J Bone Join t Surg Br 1 997;79(3) 462-466.
Yo u d a s JW, M a d s o n TJ, H o l l m a n J H . U sefu l ness of t h e Tre n d e l e n b u rg test
fo r i d e ntification of patie nts with h i p j o i nt osteoa rt h ritis. Physiother
Theory Pra ct. 20 1 0;26(3) 1 84- 1 94.
II
L umbar Spine 205
STORK STAN DING TEST

TEST POSITIONING
The s u bject sta n d s on one leg with the sole of the n o nwe ig ht
bea ri n g foot rest i n g o n the m e d i a l a s pect of the knee of the we ig ht
bea ri n g l i m b (Fig u re LS7- 1 4A) .
Figure LS7-1 4A. II

ACTION
The s u bject m a i nta i n s b a l a nce on o n e leg a n d then s i m u lta n e o u s l y
performs a s l i g ht l u m ba r extension m ovement (Fig u re LS7- 1 4B). T h e
test i s repeated b i l atera l ly.
206 Section 7
F i g u re LS7-1 4B.
POSITIVE FINDING
Co m p l a i nts of p a i n i n the l u m ba r reg ion may be rel ated to the p a rs
i ntera rticu l a ri s reg ion, which is someti mes associated with spon dy
II
l o lysis.

This test is a l s o refe rred to as the One-Leg Sta n d i n g Lu m b a r
Exte nsion Test. T h e exa m i n e r s h o u l d assess the l evel o f e a c h pelvis
d u ri n g the test. C h a nges i n the pelvic l eve l s rel ated to g l uteus m e d i u s
m uscle wea kness may p resent t o the exa m i n er as a fa lse i n d icator of
poor p ro p riocepti o n . There is no idea l t i m e fra m e fo r the length of
m a i nta i n ed one-legged ba l a n ce. The exa m i n er s h o u l d n ote a ny b i l at
e ra l d i screpancies that exist.
REFERENCES
M a rg o K, D rez n e r J , Motzki n D. Eva l u ation a n d m a n a g e m e n t of h i p p a i n
a n a l g o rith m i c a p p ro a c h . J Fa m Pract. 2003;5 2 (8) 607-6 1 7.
N a rva n i AA, Ts i r i d i s E, Ke n d a l l S, C h a u d h u ri R, Th o m a s P A prel i m i n a ry
re port o n p reva l e n ce of a ceta b u l a r l a b r u m tea rs i n s po rts patients with
g ro i n pa i n . Kn ee Surg Sports Tra umata/ A rth rosc 2003 ; 1 l (6):403-408
L umbar Spine 207
P e l te n b u rg AL, E r i c h WB, Bern i n k MJ, H u isve l d IA S e l ecti o n of ta l e nted

fe m a l e gym n a sts, aged 8 to 1 1 , on the b a s i s of m otor a b i l ities with
s pec i a l reference to b a l a nce a retros pective stu dy. /n t J Sports Med
1 982;3 ( 1 ):3 7-42
S c h a c h e AG, B l a n c h PD, M u rp h y AT Re l a t i o n of a nte rior pelvic t i l t d u r
i n g ru n n i n g to c l i n i c a l a n d ki n e m atic m ea s u res of h i p exte n s i o n . Br J
Sports Med 2000;34(4) 2 79-283
Tyl e r T, Zoo k L, B ritt i s D, G l e i m G . A n ew pelvic tilt d etect i o n d evice:
roe ntg e n og ra p h i c va l i d a t i o n and a p p l i cation to a s s e s s m e n t of h i p
motion i n p rofess i o n a l ice h o c key p l ayers. J Orthop Sports Phys Th er
l 996;24(5):3 03-308
Wi nters MV, B l a ke CG, Trost J S, et a l . Pass ive ve rs u s a ctive stretc h i n g of h i p
fl exo r m u sc l e s i n s u bjects with l i m ited h i p exte n s i o n a ra n d o m ized
c l i n i ca l tria l . Phys Th er 2 004;84(9) 800-807
Yo u n g W, C l oth i e r P, Ota g o L, Bruce L, Li d d e l l D. Acute effects of static
stretc h i n g o n hip fl exo r and q u a d riceps fl exi b i l ity, ra n g e of motion a n d
foot s peed i n kicki n g a foot ba l l . J Sci Med Sport. 2004; 7 ( 1 ) 23-3 1 .
II

Sacral Spine
Guide to Figures
21O Section 8
SACROI LIAC (S I ) J O I NT FIXATION TEST

TEST POSITIONING 1
The s u bject sta n d s with the SI j o i nt exposed. The exa m i n er sta n d s
b e h i n d the s u bject w i t h the t h u m bs ove r the posterior s u perior i l i ac
s p i n e s ( P S I S) (Fig u re SS8- 1 A) .
II
F i g u re SSS-1 A.
ACTION 1
The exa m i n er s h o u l d n ote whether the PSIS a re l eve l .
POSITIVE FINDING 1
If the poste rior i l i ac s p i n e s a re not l evel, t h e SI joi nts a re asym
metrica l, i n d icat i n g fixation o n one side o r the other.
SPECIAL CONSIDERA TIONS/COMMENTS 1

Having the s u bject actively flex one h i p a n d then co m pa r i n g the
l eve l of the P S I S o n each side has been descri bed a s a G i l l et test.
Decreased or m i n i m a l i nfe rior m ovement of the S I joint o n the fl exed
side i n d i cates a hypo m o b i l e joi nt.
Sacral Spine 21 1
EVIDENCE
Leva n g i e ( 1 999)
Study d e s i g n C ross-sect i o n a l
C o n d it i o n s eva l u ated Low back pa i n
Rel i a b i l ity ICC = .70
TEST POSITIONING 2
The exa m i n er then p l aces o n e t h u m b ove r the P 5 1 5 on the rig ht o r
l eft side, a n d the oth e r t h u m b over the 52 s p i n o u s p rocess. Repeat o n
the other side (Fig u re 558- 1 B ) .
II
Figure 558-1 B .
2 12 Section 8
ACTION 2
The s u bject is then i n stru cted to actively flex each h i p o n e at a
time with the knee bent to 90 deg rees. Co m pa re to the ot her side
(Fig u re 558- 1 C).
Fig u re SSS-1 C .
II POSITIVE FINDING 2
When the s u bject fl exes each h i p, the t h u m b ove r the poste rior
s u perior i l iac spine should d ro p rel ative to the s p i n o u s p rocess. If
there i s n o change o r the t h u m b m oves s u perio rly, hypo m o b i l ity i s
i n d icated .
TEST POSITIONING 3
The exa m i n er may then l eave the one t h u m b ove r the sacra l spi
nous p rocess a n d m ove the ot h e r t h u m b to the isch i a l tu berosity.
Repeat on the other side ( Fi g u re 558- 1 D).
Sacral Spine 2 13
Figure 558-1 D.
ACTION 3
The s u bject is i n stru cted to a g a i n active l y fl ex o n e h i p at a t i m e
w i t h the k n e e bent t o 90 deg rees. Co m p a re t o t h e ot h e r s i d e ( F i g u re
558- 1 E).
II
Figure 558- l E.
2 14 Section 8
POSITIVE FINDING 3
When the s u bject a g a i n fl exes each h i p, the t h u m b ove r the i sc h i a l
t u beros ity s h o u l d m ove i nfe rio rly. If the t h u m b m oves s u periorly,
hypo m o b i l ity is i n d icated .

Some a u t h o rs have refe rred to t h i s series of tests as the h i p fl exio n
test. Essent i a l l y, the same m ovement i s being performed a n d the
d iffe rence i n assessment i s based on the l a n d m a rks that a re being
pa l pated a n d observed fo r m ovement patte rns.
REFERENCES
Leva n g i e P K. F o u r c l i n i ca l tests of s a c ro i l i a c j o i n t dysfu n ct i o n : t h e associa
t i o n of test res u lts with i n n o m i n ate tors i o n a m o n g patie nts with a n d
without l ow b a c k pa i n . Phys Ther 1 999;7 9 ( 1 l ) 1 043- 1 05 7 .
va n d e r Wu rff P, M e y n e W, H a g m e ij e r R H . C l i n i ca l tests o f t h e s a c ro i l i a c
j o i n t M a n Th er 2000;5 (2) 89-96
II
Sacral Spine 2 15
G I LLET TEST
TEST POSITIONING
The s u bject sta n d s w h i l e the exa m i n e r p a l pates the P S I S b i l atera l ly.
ACTION
The s u bject flexes o n e h i p a n d b r i n g s the knee to t h e ch est w h i l e
t h e exa m i n e r m a i nta i n s p a l pation t o e a c h PSIS a n d assesses overa l l S I
m ovement (Fig u re SS8-2A).
F i g u re SS8-2A.
II
POSITIVE FINDING
A positive s i g n is n oted if the PSIS on the i ps i l atera l side of the knee
being fl exed does not m ove o r m oves m i n i m a l ly i n the inferior d i rec
tion (Fig u re SS8-2 B).
216 Section 8
F i g u re SS8-2 B.
The PSIS on the side of the h i p being flexed s h o u l d m ove s l i g htly
a nteriorly d u ri n g active hip flexi o n .
EVIDENCE
II Study d e s i g n
va n d e r W u rff et a l
(2000)
Syste matic review
Sza d e k e t a l
Syste matic review

(2009)
C o n d iti o n s S I j o i n t m o b i l ity SI j o i n t pa i n
eva l u ated
Rel i a b i l ity Ka ppa = .02 to .22 Not eva l u ated
S e n s itivity N ot eva l u ated 43
S pec ificity N ot eva l u ated 68
Sacral Spine 217
REFERENCES
Ca r m i c h a e l J P. I nter- a n d i n t ra exa m i n e r re l i a b i l ity of p a l pation fo r s a c ro i l i a c
j o i n t dysfu nction J Manipula tive Physiol Th er 1 987; 1 0 (4) 1 64- 1 7 1 .
D reyfu s s P, D rye r S, G riffi n J, H offm a n J , Wa l s h N . Pos itive s a c ro i l i
ac s c ree n i n g tests i n asym pto matic a d u lts. Spine (Phi/a Pa 1 976)
1 994; 1 9 ( 1 0) : 1 1 3 8- 1 1 43 .
Leva n g i e P K. F o u r c l i n i ca l tests o f s a c ro i l i a c j o i n t dysfu n ct i o n : t h e associa
t i o n of test res u lts with i n n o m i n ate tors i o n a m o n g patie nts with a n d
wit h o u t l ow b a c k pa i n . Phys Ther 1 999;7 9 ( 1 l ) 1 043- 1 05 7 .
M e ij n e W, va n N ee rbos K , Aufd e m ka m pe G, va n d e r Wu rff P l ntraexa m i n e r
a n d i nte rexa m i n e r re l i a b i l ity o f t h e G i l l et test J Manipula tive Physiol
Ther 1 999;2 2 ( 1 ) :4-9
Sza d e k KM, va n d e r Wu rff P, va n Tu l d e r MW, Z u u rm o n d WW, Pe rez RS.
D i a g nostic va l i d ity of criteria fo r s a c ro i l i a c j o i n t p a i n a syste matic
review J Pa in. 2009; 1 0 (4) 3 54-368
va n der Wu rff P, H a g m e ij e r RH, Meyne W C l i n i ca l tests of the s a c ro i l i a c
j o i n t A syste matic method o l o g ica l review Pa rt 1 : Rel i a b i l ity. M a n Ther
2000;5 ( 1 ) 3 0-36
II
218 Section 8
SACROI LIAC (S I) JOINT STRESS TEST

TEST POSITIONING 1
The s u bject l ies su p i n e. The exa m i n er sta n d s n ext to the s u bject
a n d, with the arms crossed, p l aces the heel of both h a n d s o n t h e
s u bject's a nte rior su perior i l iac s p i n e s ( Fi g u re SS8-3A).
II
F i g u re SS8-3A.
ACTION 1
The exa m i n e r a p p l ies o utwa rd a n d d ownwa rd pressu re with the
heel of the h a n d s.
POSITIVE FINDING 1
U n i l atera l p a i n at the SI joint or i n the g l utea l or leg reg ion i n d i
cates a n a nterior S I l i g a ment s p ra i n .

The s u bject may com p l a i n of p a i n that co u l d be re l ated to SI joint
c omp ress i o n .
Sacral Spine 219
EVIDENCE
va n d e r W u rff et a l Sza d e k e t a l (2009)

(2000)
Study d e s i g n Syste m a t i c review Syste matic review
C o n d iti o n s S I j o i n t pa i n SI joint pain
eva l u ated
Rel i a b i l ity Ka ppa = .36 to .69 N ot eva l u ated
S e n s itivity N ot eva l u ated 26 to 60
S pec ificity N ot eva l u ated 73 to 8 1
TEST POSITIONING 2
The s u bj ect l i e s o n t h e s i d e . The exa m i n e r sta n d s n ext to t h e s u b
j ect a n d p l a ces both h a n d s, o n e o n top of t h e ot h e r, d i rectly ove r
t h e s u bject's i l i a c c rest. Repeat o n t h e o t h e r s i d e ( F i g u re 558-3 8 ) .
II
F i g u re 558-3 8.
220 Section 8
ACTION 2
The exa m i n er a pp l ies d ownwa rd p ressu re. Co m p a re to the ot h e r
side.
POSITIVE FINDING 2
I n c reased p a i n or p ress u re is i n d icative of SI joint pathol ogy, pos
s i b l y i nvo lving the posterior S I l i g a m ents.

d i straction o r gapping. Th i s positi o n i n g i s a l so refe rred to a s the
Co m p ressi o n Provocation Test.
EVIDENCE

(2000)
Study d e s i g n Syste matic review Syste matic review
Conditions S I j o i n t pa i n SI joint pain
eva l u ated
II
Re l i a b i l ity Ka ppa = . 1 6 to .77 N ot eva l u ated
S e n s itivity N ot eva l u ated 60 to 69
S pecifi c ity N ot eva l u ated 69 to 70
Sacral Spine 22 1
TEST POSITIONING 3
The s u bject l i es s u p i ne. The exa m i n e r p l aces both h a n d s on the
l atera l as pect of the s u bject's i l i ac crests (Fig u re SS8-3C).
Figure SS8-3C.
ACTION 3
The exa m i n er a p p l ies i nwa rd a n d d ownwa rd pressu re.
POSITIVE FINDING 3
II
I n creased pa i n or p ressu re is i n d i cative of SI joint pathology, pos
s i b ly i nvo lvi n g the posterior S I l i g a m e nts.

The s u bject may com p l a i n of pa i n that could be rel ated to SI joint
d i straction o r g a p p i n g .
222 Section 8
TEST POSITIONING 4
The s u bject lies p ro n e. The exa m i n er p l aces both h a n d s, o n e o n
to p o f the other, over the s u bject's sacru m ( Fi g u re SS8-3 D).
F i g u re SSS-3 0.
II
ACTION 4
The exa m i n e r a p p l ies d ownwa rd pressu re, creati n g a shear of the
sacrum o n the i l i u m .
POSITIVE FINDING 4
Pa i n at the SI joint is i n d icative of SI joint pathol ogy.

c omp ress i o n . Test positi o n i n g 4 may a l so be referred to a s the Sacra l
Th rust Provocation Test.
Sacral Spine 223
EVIDENCE

(2000)
Conditions S I j o i n t pa i n SI joint pain
eva l u ated
Re l i a b i l ity Ka ppa = .30 to . 3 2 N ot eva l u ated
S e n s itivity Not eva l u ated 53 to 63
Specifi city Not eva l u ated 2 9 to 75
REFERENCES
La s l ett M . Evi d e n ce-based d i a g n o s i s a n d treat m e nt of t h e p a i nfu l s a c ro
i l i a c j o i nt. J Man Manip Ther 2008; 1 6 (3) 1 42- 1 5 2 .
La s l ett M, A p ri l l C N , M c Do n a l d B, Yo u n g S B . D i a g n o s i s o f s a c ro i l i a c j o i n t
pa i n va l i d ity o f i n d ivid u a l p rovocat i o n tests a n d com posites o f tests.
Man Ther 2005; 1 0 (3) 207-2 1 8.
La s l ett M, Wi l l i a m s M . The re l i a b i l ity of s e l ected pa i n p rovocation tests fo r
s a c ro i l ia c j o i n t pat h o l ogy. Spine (Phi/a Pa 1 976). 1 994; 1 9 ( 1 l ) 1 243 - 1 249.
Lev i n U , N i l s s o n -Wi km a r L, Ste n st ro m C H , L u n d e be rg T Re p rod u c i b i l ity of
m a n u a l p res s u re fo rce on p rovocat i o n of t h e s a c ro i l i a c joi nt. Phys/other
Res ln t. 1 998;3 ( 1 ) 1 - 1 4
II
:
St u be r K J S pec ificity, s e n s itivity, a n d p red i ctive va l u es of c l i n i ca l tests of
t h e s a c ro i l i a c j o i nt: a syste matic revi ew of t h e l ite rat u re . J Ca n Ch iropr
Assoc 2007;5 l (1 ) :30-4 1 .
D i a g n ostic va l i d ity of criteria fo r s a c ro i l i a c j o i n t p a i n a syste matic
revi ew. J Pa in. 2009; 1 0 (4) : 3 54-368
j o i nt. A syste matic method o l og ica l revi ew. Pa rt l • re l i a b i l ity. Ma n Ther
2000;5 ( 1 ) : 3 0-36
va n d e r Wu rff P, Meyne W, H a g m e ij e r RH. C l i n ica l tests of t h e s a c ro i l i a c
j o i nt. M a n Ther 2000;5 (2) 89-96
224 Section 8
SQUISH TEST
TEST POSITIONING
The s u bject l ies s u p i n e on the ta b l e w h i l e the exa m i n e r p l a ces a
h a n d on each of the i l iac crests a n d the a nte rior s u perior i l i ac s p i n e s
o f the s u bject ( Fi g u re SS8-4) .
II
F i g u re 558-4.
ACTION
The exa m i n er co m p resses d ownwa rd a n d i nwa rd at a 45-deg ree
a n g l e a l o n g the i l iac crest a n d a nterior s u perior i l iac s p i n e b i l atera l ly.
POSITIVE FINDING
S u bjective com p l a i nts of p a i n a re n oted as pos itive fi n d i n g s a n d
m a y be fo u n d a nteri orly o r posteriorly.

Th i s test assesses the sta b i l ity of the poste rior S I l i g a ments but a l so
d i rectly a p pli e s co m p ress ive fo rces to the a nte rior SI joi nt. Th u s, the
l ocation of pa i n should be n oted a n d correl ated with a ny a d d it i o n a l
fi n d i n g s.
Sacral Spine 225
YEOMAN 1S TEST
TEST POSITIONING
The s u bject l ies p rone on the ta ble.
ACTION
The exa m i n er passively fl exes t h e s u bject's knee to 90 d e g rees
w h i l e s i m u lta neously exte n d i n g the i psi l atera l h i p (Fig u re SS8-5A) .
F i g u re SSS-SA. II
POSITIVE FINDING
A re porti ng of p a i n d u ri n g t h i s test is considered to be a pos itive
s i g n . Pa i n in the S I joint may be rel ated to a nterior S I l i g a ment pathol
ogy. Pa i n i n the a nterior thigh reg ion may be re lated to hip flexo r
m u scu latu re tig htness or fem o ra l ne rve ten s i o n .

The exa m i n e r s h o u l d pay attention to the position of the s u bject's
tru n k beca use tru n k rotation may be used to co m pensate fo r posi
tions of d i sco mfo rt. Co m pensato ry m ovement such a s tru n k rotation
may res u l t i n a fa lse-negative test fi n d i n g ( Fi g u re SS8-5 B).
226 Section 8
F i g u re SSS-SB.
REFERENCE
Wa l s h MJ Eva l u a t i o n of o rt h o p e d i c test i n g of t h e l ow b a c k fo r n o n s pec ifi c
l owe r b a c k pa i n . J Ma n ipula tive Physiol Ther 1 998;2 1 (4) :232-236
II
Sacral Spine 227
GAENSLEN 1S TEST
TEST POSITIONING
The s u bject lies on the side of the u n i nvolved leg ( l ower leg). With
the i nvo lved leg ( u p p e r leg) in s l i g ht hype rextension, the s u bject then
flexes the hip a n d knee of the u n i nvo lved side towa rd the ch est.
ACTION
The exa m i n e r sta b i l izes the s u bject's pelvis a n d fu rther exte n d s the
s u bject's i nvo lved leg (Fig u re SS8-6) .
II
F i g u re 558-6.
POSITIVE FINDING
Pa i n i n the S I reg i o n is co n s i d e red a positive fi n d i n g a n d may be
associated with S I joint dysfu n cti o n .

The s u bject may report pa i n i n the h i p o r a nterior t h i g h reg i o n .
This may be rel ated t o h i p joint pathol ogy, a nte rior t h i g h m u sc u l a t u re
te nsion, or L4 n erve root te n s i o n . Th i s test can be performed with the
s u bject i n a supine position; h owever, the exa m i n er should be ca u
tious of a fa lse-negative test due to the i n a b i l ity of o bta i n i n g e n o u g h
i nvo lved leg h i p exte n s i o n .
228 Section 8
EVIDENCE

(2000)
Study d e s i g n Syste matic review Syste matic review
C o n d iti o n s S I j o i n t pa i n SI joint pain
eva l u ated
Re l i a b i l ity Ka ppa = .6 1 to . 72 N ot eva l u ated
S e n s itivity N ot eva l u ated 5 0 to 7 1
S pec ificity N ot eva l u ated 26 to 79
REFERENCES
La s l ett M . Evi d e n ce-based d i a g n o s i s a n d treat m e n t of t h e p a i nfu l s a c ro
i l i a c j o i nt J Man Manip Th er 2008; 1 6(3): 1 42- 1 5 2 .
La s l ett M, A p ri l l C N , M c Do n a l d B, Yo u n g S B . D i a g n o s i s o f s a c ro i l i a c j o i n t
p a i n va l i d ity o f i n d ivid u a l p rovocat i o n tests a n d com posite s of tests.
Man Ther. 2005; 1 0 (3) 207-2 1 8.
La s l ett M, Wi l l i a m s M. The re l i a b i l ity of s e l ected pa i n p rovocation tests fo r
s a c ro i l i a c joi nt pat h o l ogy. Spine (Phi/a Pa 1 976). 1 994; 1 9 ( 1 l ) 1 243 - 1 249.
II Stu ber KJ S pec ificity, s e n s itivity, a n d p red i ctive va l u es of c l i n i ca l tests of

t h e s a c ro i l i a c j o i nt: a syste matic review of t h e l iteratu re. J Ca n Chiropr
Assoc 2007;5 1 ( 1 ) :30-4 1 .
D i a g n ostic va l i d ity of c rite ria fo r s a c ro i l i a c j o i n t pa i n : a syste m a t i c
review J Pain. 2009; 1 0 (4)3 54-3 68
va n der Wu rff P, H a g m e ij e r R H , Meyne W C l i n ica l tests of t h e s a c ro i l i a c
j o i n t A syste matic method o l o g ica l review Pa rt 1 : re l i a b i l ity Man Ther
2000;5 ( 1 ) : 3 0-36
va n der Wu rff P, Meyne W, H a g m e ij e r RH. C l i n i ca l tests of t h e s a c ro i l i a c
j o i n t M a n Th er. 2000;5 (2) 89-96
Sacral Spine 229
PATRICK OR FA B E R TEST
TEST POSITIONING
The s u bject l ies s u p i n e on the ta ble.
ACTION
The s u bject fl exes, a b d u cts, a n d externa l l y rotates the i nvo lved leg
u ntil the foot rests o n the top of the knee of t h e n o n i nvolved l ower
extre m ity (Fig u re 558-?A) . The exa m i n e r then s l owly a b d u cts the
i nvo lved l owe r extremity, b r i n g i n g the knee closer towa rd the ta b l e
(Fig u re 558-7 8).
II
F i g u re SS8-7A.
230 Section 8
F i g u re 558-78.
POSITIVE FINDING
A positive fi n d i n g is revea l ed when the i nvolved l ower extre m ity
does not a bd u ct below the l evel of t h e n o n i nvolved l ower extremity.
This may be i n d i cative of i l io psoas, S I , or eve n h i p joint a b norma l ities.
II FAB E R is a n acronym for the i n itial positi o n i n g of the s u bject (fl ex
i o n F, a b d uction AB, externa l rotation ER).
=
EVIDENCE
= =

(2000)
Conditions S I j o i n t pa i n S I j o i n t pa i n
eva l u ated
Re l i a b i l ity Ka ppa = .38 to .62 N ot eva l u ated
S e n s itivity Not eva l u ated 63 to 1 00
Spec ificity Not eva l u ated 1 6 to 77
Sacral Spine 23 1
REFERENCES
B ro l i n s o n PG, Maccoux DA, G u nter MJ G ro i n p a i n -foot ba l l Med Sci
Sports Exerc. l 997;29(5 ) 3 0
C i b u l ka MT, De l itto A A co m pa ri s o n o f two d ifferent m e t h o d s to treat h i p
pa i n i n ru n n e rs . J Orthop Sports Phys Ther 1 993; 1 7(4) 1 72 - 1 76.
C l i bo r n e AV, Wa i n n e r RS, Rhon D I , et al C l i n i c a l h i p tests and a fu n cti o n a l
s q u a t test i n patie nts with knee osteoa rt h ritis: rel i a b i l ity, p reva l e n ce
of positive test fi n d i n g s, a n d s h o rt-te rm res po n se to h i p m o b i l izati o n .
J Orthop Sports Phys Ther 2004;34 ( 1 l ) 676-685
M i tc h e l l B, Mccro ry P, B r u k n e r P, O'Don n e l l J , Co l s o n E, H owe l l s R. H i p j o i n t
pat h o l ogy: c l i n i ca l presentation a n d corre l a t i o n betwe e n m a g n etic
reso n a nce a rt h rog ra p hy, u l tra so u n d , and a rt h roscopic fi n d i n g s in 25
con sec utive cases. Clin J Sport Med 2003; 1 3 (3) 1 5 2- 1 56.
Ross M D, N o rd e e n MH, B a r i d o M Test-retest rel i a b i l ity of Patri c k's h i p
ra n g e o f m ot i o n test i n hea lthy co l l ege-a g e d m e n . J Strength Cond
Res. 2003 ; 1 7 ( 1 ) : 1 5 6- 1 6 1 .
Stre n d e r LE, Sj o b l o m A, S u n d e l l K, Ludwig R, Ta u be A l nte rexa m i n e r re l i
a b i l ity i n p h ys i c a l exa m i n a t i o n o f patients w i t h l ow b a c k pa i n . Spine
(Phi/a Pa 1 976). 1 997;22 (7) 8 1 4-820.
D i a g n ostic va l i d ity of c rite ria fo r s a c ro i l i a c j o i n t pa i n a syste matic
review J Pa in. 2009; 1 0 (4) 3 54-368
II
j o i n t A syste matic method o l o g ica l review Pa rt 1 : Rel i a b i l ity. M a n Ther
2000;5 ( 1 ) 3 0-3 6
;
232 Section 8
LONG-S ITII NG TEST

TEST POSITIONING
The s u bject l i es s u p i n e with both h i ps a n d knees extended, a n d
the exa m i n er sta n d s w i t h t h e t h u m bs o n the s u bject's med i a l m a l l e o l i
(Fig u re 558-8A) .
II
F i g u re SSS-SA.
ACTION
The exa m i n er pass ive ly fl exes both knees a n d h i ps (Fig u re 558-88)
and then fu l l y exte n d s and com p a res the position of the med i a l m a l
l eol i rel ative t o e a c h o t h e r (Fig u re 558-8C) . T h e s u bject then s l owly
assu mes the l o n g-sitti ng position, a n d the m a l l e o l a r position i s re
assessed (Fig u res 558-80 a n d 558-8E).
Sacral Spine 233
F i g u re SSS-SB.
II
F i g u re SSS-SC.
234 Section 8
F i g u re SSS-SO.
II
F i g u re SSS-SE.
POSITIVE FINDING
A leg that a p pears l o n g e r i n the s u p i n e position but s h o rter i n the
l o n g-sitt i n g position i s i n d i cative of a n i p s i l atera l a nteriorly rotated
i l i u m . Conversely, a leg that a p pea rs s h o rter in the s u p i n e position
but longer i n the l o n g-s itti n g position i s i n d icative of a n i ps i l atera l
posteriorly rotated i l i u m .
Sacral Spine 235

Marking the reference point of meas u rement on t h e m a l l e o l i with
a pen may i n crease the re l i a b i l ity when co m pa r i n g positi o n s of leg
length.
EVIDENCE
va n d e r W u rff et a l (2000)
C o n d i t i o n s eva l u ated SI j o i n t m o b i l ity
Study n u m be r 1
Re l i a b i l ity % a g re e m e n t = 40
Spec ificity Not eva l u ated
REFERENCES
Be m i s T, Da n i e l M . Va l i d a t i o n of t h e l o n g -s itti n g test o n s u bjects with i l io
s a c ra l dysfu nction J Orth op Sports Phys Th er l 987;8(7) : 3 3 6-345
II
j o i n t A syste matic method o l o g i c a l review Pa rt l • re l i a b i l ity. Ma n Ther
2000;5 ( 1 ) : 3 0-36

Hip
Guide to Figures
Konin JG, Lebsack D, Snyder Valicr AR, !scar JA Jr.

Special TestsJOr Orthopedic Examination, Fourth Edition (pp 237-268).
238 Section 9
�-- H I P SCOURING/QUADRANT TEST

TEST POSITIONING
The s u bject l ies s u p i ne. The exa m i n e r sta n d s on the i nvo lved side
a n d passively flexes a n d a d d u cts the s u bject's h i p. The s u bject's knee
i s a l so p l aced i n fu l l fl exion ( Fi g u re H9-1 A).
F i g u re H9- 1 A.
ACTION
The exa m i n e r a p p l ies d ownwa rd p ress u re a l o n g the s h aft of the
fe m u r while s i m u lta n eously add ucti n g a n d externa l ly rotati n g the
hip (Fig u re H 9- 1 B). The exa m i n er then a d d u cts a n d interna l l y rotates
the h i p w h i l e m a i nta i n i n g d ownwa rd pressu re (Fig u re H 9- 1 C). Th i s
m ovement is re peated 2 t o 3 times w h i l e the exa m i n e r notes a n y
u n u s u a l m ovement (ie, catc h i ng, g r i n d i ng) o r s u bject a pp re h e n s i o n .
Hip 239
Figure H9-1 B.
Figure H9-1 C.
POSITIVE FINDING
Pa i n or a p p re h e n s i o n is i n d i cative of h i p joint pathol ogy, such
a s a rth ritis, osteoc h o n d ra l defects, avasc u l a r necrosis, o r aceta b u l a r
l a b r u m d efects.
240 Section 9

Th i s test is not very s pecific fo r identifyi n g structural d a m a g e a n d
s h o u l d be u sed with caution t o avoid ca u s i n g fu rther p a i n a n d/or tis
s u e da mage. I m a g i n g tests a re h e l pfu l too l s to use in fo l l ow- u p of a
positive h i p sco u r test acco m p a n ied by u n exp l a i ned h i p joint a n d/or
rad iating leg pa i n .
EVIDENCE
Re i m a n et a l (20 1 3)
Study desig n Syste matic review
C o n d iti o n s eva l u ated H i p pat h o l og ies
Study n u m be r 1
S e n s itivity 50
S pec ificity 29
REFERENCES
M a rg o K, D rez n e r J, Motzki n D. Eva l u a t i o n a n d m a n a g e m e n t of h i p pa i n :
a n a l g o rith m i c a p p roa c h . J Fa m Prac 2003;52 (8) 607-6 1 7.
M itc h e l l B, Mccro ry P, B r u k n e r P, O'Don n e l l J , Co l s o n E, H owe l l s R. H i p
j o i n t pat h o l ogy: c l i n i ca l p resentation a n d corre l ation betwee n m a g
netic reso n a nce a rt h rog ra p hy, u ltraso u n d , a n d a rt h rosco p i c fi n d i n g s i n
25 con sec utive c a s e s . Clin J Sport M e d 2003; 1 3 (3) 1 5 2- 1 56.
N a rva n i AA, Ts i r i d i s E, Ke n d a l l S, C h a u d h u ri R, Th o m a s P. A prel i m i n a ry
re port o n p reva l e n c e of a ceta b u l a r l a b r u m tea rs i n s p o rts patients with
g ro i n pa i n . Knee Surg Sports Tra umata/ A rth rosc 2003 ; 1 l (6) :403 -408.
Re i m a n M P, Goode A P, Heged u s EJ, Cook CE, Wri g ht AA D i a g n o st i c a c c u
ra cy o f c l i n ica l tests o f t h e h i p a syste m atic review w i t h m eta-a n a lys i s .
Br J Sports M e d 2 0 1 3;47 ( 1 4) 893-902
Hip 24 1
(RAIG 1S TEST
TEST POSITIONING
The s u bject l ies prone with the affected leg's knee fl exed to
90 deg rees. The exa m i n er sta n d s on the i nvo lved side a n d p a l pates
the g reater trocha nter (Fig u re H 9-2A).
Figure H9-2A.
ACTION
The exa m i n er then passively i ntern a l ly a n d extern a l ly rotates the
fe m u r u ntil the g reater trocha nter i s para l l e l with the exa m i n i n g ta b l e
( Fi g u re H9-2B). A t t h i s poi nt, the s u bject i s asked t o h o l d the h i p i n t h i s
position w h i l e the exa m i n e r measures the a n g l e between the l o n g
a x i s o f the l ower leg a n d the perpe n d i c u l a r a x i s t o the ta b l e w i t h a
g o n i o m eter ( Fi g u re H 9-2C).
242 Section 9
F i g u re H9-2B. N ote: I nterna l/exte r n a l rotation of t h e h i p u n t i l t h e

g reater troc h a nter i s p a ra l l e l with t h e t a b l e .
1 5 deg rees; fe m o r a l
retrove rsion < 8 d e g rees.
F i g u re H9-2C. N o t e : Fe m o ra l a n teversion >
POSITIVE FINDING
If the measured a n g l e is g reater t h a n 1 5 deg rees, fe m o ra l antever
s i o n i s i n d i cated. If the meas u red a n g l e i s less t h a n 8 deg rees, femoral
retrove rsion i s i n d i cated . I n creased fe moral a nteversion leads to toe
i n g - i n and s q u i nti ng patel lae. Femoral retrove rsion leads to a toei ng
out positi o n . Both of these may lead to l ower extrem ity m a l a l i g n ment
a n d s u bseq uent pat h o l og i es.
Hip 243

A seco nd exa m i n e r may be usefu l to h o l d the s u bject's h i p a n d
leg i n t h e designated position w h i l e t h e fi rst exa m i n e r meas u res t h e
a n g le. Th i s test is a l so known as the Ryder M e t h o d fo r me asu rin g
fe m o ra l a nteversion a n d retrovers i o n .
REFERENCES
D u n n O M . A nteve rsion of t h e n e c k of t h e fe m u r; a method of m ea s u re
m e n t J Bone Join t Surg Br 1 95 2;34(2) 1 8 1 - 1 86.
Ryd e r CT, Cra n e L. Mea s u ri n g fe m o ra l a nteve r s i o n ; t h e p ro b l e m and a
method. J Bone Join t Surg Am. l 953;3 5 (2) 3 2 1 -328.
244 Section 9
90-90 STRAIGHT LEG RAISE TEST

TEST POSITIONING
Test s u bject lies s u p i ne, sta b i l iz i n g both h i ps at 90 d e g rees of
fl exion with both h a nds. The knees a re bent in a rel axed positi o n . The
exa m i n e r sta n d s next to t h e s u bject (Fig u re H 9-3A) .
F i g u re H9-3A.
ACTION
The s u bject is i n stru cted to actively exten d o n e knee at a t i m e a s
m u c h a s possi b l e (Fig u re H 9 - 3 B ) . T h e test i s performed b i l atera l ly.
Hip 245
Figure H9-3B.
POSITIVE FINDING
If the knee i s flexed g reater t h a n 20 deg rees, the h a m stri n g s a re
considered tig ht.

When assess i n g t h i s test, ca re s h o u l d a l ways be ta ken to be con
sistent with the position of the pelvis so that testing measu res can be
repeated with rel i a b i l ity.
REFERENCES
Ca m e ro n OM, B o h a n n o n RW. Rel ati o n s h i p betwe e n a ctive knee exte n
s i o n a n d a ctive stra i g h t leg ra i s e test m ea s u re m e nts. J Orthop Sports
Phys Th er 1 993; 1 7(5) 2 5 7-260
D ra pe r DO, Ca stro J L, Fe l a n d B, S c h u lthies S, Egg ett D. S h o rtwave d iathe rmy
and p ro l o n g ed stretc h i n g i n c rease h a m stri n g fl exi b i l ity m o re t h a n p ro
l o n g e d stretc h i n g a l o n e . J Orthop Sports Phys Ther 2004;34( 1 ) 1 3-20.
Ga b be BJ, Be n n e l l KL, Waj swe l n e r H , F i n c h C F. Re l i a b i l ity of co m m o n
l ower extrem ity m u sc u l os ke l eta l s c ree n i n g tests. Phys Th er Sport.
2004;5 (2) 90-97
Gaj d os i k R L, Rieck MA, S u l l iva n D K, Wig ht m a n S E. Co m pa ri s o n of fo u r c l i n i
ca l tests fo r a ssess i n g h a m stri n g m u sc l e l e n g t h . J Orthop Sports Phys
Ther. 1 993; 1 8(5) 6 1 4-6 1 8.
Tafazzo l i F, La m o n ta g n e M M ec h a n i ca l behavio u r of h a m stri n g m u sc l e s
i n l ow- b a c k pa i n patients a n d c o n t r o l s u bj ects Clin Biomech (Bristol,
A von) 1 996; 1 1 ( 1 ) 1 6-24.
246 Section 9
PATRICK OR FA B E R TEST
TEST POSITIONING
The s u bject l ies s u p i n e on the ta ble.
ACTION
The s u bject fl exes, a bd u cts, a n d extern a l ly rotates the i nvo lved leg
u ntil the foot rests on the top of the knee of the n o n i nvo lved l ower
extre m ity (Fig u re H 9-4A) . The exa m i n e r then s l owly a b d u cts the
i nvo lved l ower extre mity, b r i n g i n g the knee closer towa rd the ta b l e
(Fig u re H 9-4B) .
F i g u re H9-4A.
Hip 247
F i g u re H9-4B.
POSITIVE FINDING
A pos itive fi n d i n g is revea led when the i nvo lved l owe r extre m ity
d oes not a bd uct below the l evel of the n o n i nvo lved l ower extre m
ity. Th i s may be i n d icative of i l i o psoas, sacro i l iac, o r even hip joint
a b norma l ities.

FAB E R is a n acronym for the i n itia l positi o n i n g of the s u bject (flex
i o n F, a b d u ction AB, externa l rotation ER).
= = =
EVIDENCE
Co n d it i o n s eva l u ated H i p path o l o g ies
Study n u m be r 4
S pec ificity 1 8 to 75
248 Section 9
REFERENCES
B ro l i n s o n PG, Maccoux OA, G u nter MJ G ro i n pa i n -footba l l . Med Sci
Sports Exerc l 997;29(5 ) 3 0
C i b u l ka MT, Oel itto A A co m pa ri s o n of two d ifferent methods to treat h i p
pa i n i n r u n n e rs . J Orthop Sports Phys Ther 1 99 3 ; 1 7 (4) 1 7 2 - 1 76.
C l i bo r n e AV, Wa i n n e r RS, Rhon D I , et a l . C l i n i c a l h i p tests a n d a fu nctio n a l
s q u a t test i n patie nts with knee osteoa rt h ritis: re l i a b i l ity, p reva l e n c e
o f pos itive test fi n d i n gs, a n d s h o rt-te rm re s p o n s e to h i p m o b i l izat i o n .
J Orth op Sports Phys Th er. 2004;34( 1 l ):6 76-685
M i tc h e l l B, McCro ry P, B ru kn e r P, O'Do n n e l l J , Co l s o n E, H owe l l s R. H i p j o i n t
pat h o l ogy c l i n ic a l p rese ntat i o n a n d corre l a t i o n betwe e n m a g netic
reso n a n ce a rth rog ra p hy, u ltraso u n d , and a rt h rosco p i c fi n d i n g s in 25
consec utive cases. Clin J Sport Med 2003 ; 1 3 (3): 1 5 2 - 1 56.
Re i m a n M P, Goode A P, Heged u s EJ, Cook CE, Wri g h t AA D i a g nostic a c c u
ra cy of c l i n ica l tests of t h e h i p a syste matic review w i t h m eta-a n a lysis.
Br J Sports Med 2 0 1 3;47 ( 1 4) 893-902
Ross M O, N o rd e e n MH, Ba rido M . Test-retest re l i a b i l ity of Patri c k's h i p
ra n g e of m ot i o n test i n hea lthy co l l ege-aged m e n . J Strength Con d
Res. 2003; 1 7 ( 1 ) : 1 5 6- 1 6 1 .
Stre n d e r LE, Sj o b l o m A, S u n d e l l K, Ludwig R, Ta u be A l n terexa m i n e r re l i
a b i l ity i n p h ys i c a l exa m i n a t i o n of patients with l ow b a c k pa i n . Spine
(Phi/a Pa 1 976) 1 997;22 (7) 8 1 4-820.
Hip 249
�---- TREN DELEN B U RG 1S TEST

TEST POSITIONING
The s u bject sta n d s on one l ower extrem ity (Fig u re H 9-SA) .
Figure H9-5A.
ACTION
The s u bject re ma i n s in t h i s position for a p p roxi m ately 1 0 seco n d s
a n d then switches extrem ities.
POSITIVE FINDING
A positive fi n d i n g is seen when the pelvis o n the u n s u p po rted side
d rops noticea b l y l ower than the pelvis o n the su pported side (Fig u re
H 9-S B). This i n d i cates a wea kness of the g l ute u s med i u s m u sc l e o n
the su pported side. Fig u res H 9-SC a n d H9-S D s h ow the posterior
view.
250 Section 9
F i g u re H9-5B.

With a neg ative test, the g l uteus med i u s o n the s u pported side wi l l
perform a reve rse action beca use t h e su pported fem u r i s sta b i l ized.
Th is wi l l a l low fo r the u n s u p po rted pelvis to re m a i n l evel with the
s u pported pelvis. With a wea k g l uteus m e d i u s o n the su pported side,
the u n s u p po rted pelvis d rops as the m u scle fat i g u es. Th is test may
a l so i n d icate a n u n sta b l e hip on the su pported side.
EVIDENCE
Study desig n M eta-a n a lysis
Co n d it i o n s eva l u ated G l utea l te n d i n opathy
Study n u m be r 3
S a m p l e size 78
S e n s itivity 61
S pec ificity 92
Hip 25 1
F i g u re H9-5C.
F i g u re H9-5D.
252 Section 9
REFERENCES
Asaya m a I , N a ito M, F uj i sawa M, Ka m be T Relati o n s h i p betwee n ra d i o
g ra p h i c m ea s u re m e nts of reco n st r u cted h i p j o i n t position a n d t h e
Tre n d e l e n b u rg s i g n . J A rth roplasty 2002; 1 7 (6)747-75 1 .
B i rd PA, Oa kley S P, S h n i e r R, Ki rkh a m BW P ros pective eva l u at i o n of
m a g n etic reso n a nce i m a g i n g a n d p h ysica l exa m i n a t i o n fi n d i n g s i n
patients with g reate r troc h a nteric pa i n syn d ro m e . Arth ritis Rheum.
200 1 ;44(9) 2 1 3 8-2 1 45
H a rdcastle P, N a d e S. The s i g n ifica nce of t h e Tre n d e l e n b u rg test J Bone
Join t Surg Br l 985;67(5 ) 74 1 -746.
Re i m a n M P, Goode A P, H eged u s EJ , Coo k CE, Wri g h t AA D i a g n ostic a c c u
ra cy of c l i n ica l tests of t h e h i p: a syste matic review w i t h m eta-a n a lysis.
Br J Sports Med 2 0 1 3;47 ( 1 4) :893-902
Tre n d e l e n b u rg F. Tre n d e l e n b u rg 's test: 1 89 5 . Clin Orth op Re/a t Res.
l 998;(3 5 5 ) :3-7
Va s u d eva n PN, Va idya l i n g a m KV, N a i r P B . C a n Tre n d e l e n b u rg 's s i g n be
positive if t h e h i p i s n o rm a l ? J Bone Join t Surg Br l 997;79(3) :462-466
Yo u d a s JW, M a d s o n TJ , H o l l m a n J H . U sefu l ness of the Tre n d e l e n b u rg test
fo r i d e ntification of patie nts with h i p j o i n t o steoa rt h ritis. Physiother
Theory Pract. 26(3) : 1 84- 1 94.
Hip 253
Osrn 's TEST

TEST POSITIONING
The s u bject lies on the side with the h i ps a n d knees exte n d ed so
that the test leg is s u perior to the n o ntest leg. The exa m i n er sta n d s
b e h i n d the s u bject w i t h the p rox i m a l h a n d sta b i l iz i n g the pelvis a n d
the d i sta l h a n d s u pporti n g the l ower leg ( Fi g u re H 9-6A) . T h e k n e e of
the test leg is fl exed to 90 deg rees.
Figure H9-6A.
ACTION
The knee of the test leg is fl exed to 90 deg rees. With the pelvis sta
b i l ized to p reve nt ro l l i n g, a bd u ct a n d exte n d the test h i p to position
the i l ioti b i a l band beh i n d the g reater trocha nter (Fig u re H 9-6B). Then
a l l ow the leg to s l owly l ower (ad d u ct).
254 Section 9
F i g u re H9-6B.
POSITIVE FINDING
The i n a b i l ity of the leg to add uct a n d to u c h the ta b l e is i n d icative
of i l ioti b i a l band tig htness (partic u l a rly the tensor fasciae l atae) . The
leg wi l l react l i ke a "s p r i n g board " beca use the leg rem a i n s a b d u cted
in m i d -a i r (Fig u re H 9-6C) .
F i g u re H9-6C. N ote: The wei g h t of t h e leg d rops t h e leg towa rd t h e

t a b l e.
Hip 255

It is i m portant to a pply a d ownwa rd fo rce on the i l i u m near the
c rest while a l l owi n g the leg to a d d u ct. Th i s wi l l p revent l atera l ti lt
i n g (ie, i nfe rior m ove me nt) of the pelvis on the side of the test leg,
which co u l d g ive a fa lse-negative resu lt. Ad d itional ly, it i s i m portant
to e n s u re co m p l ete re l axation of the hip a b d u ctor m u scles. It may
be h e l pfu l to h ave the s u bject actively add uct the test leg i nto the
s u p port hand a n d then re lax to i n h i b it hip a b d u ctor m u scle g u a rd
ing. This test was orig i n a l ly descri bed by Ober to be performed with
the knee fl exed to 90 deg rees. H oweve r, it has been mod ified (ie,
M od ified Ober's Test) beca use it is believed that a g reater stretch i s
p l aced o n the i l ioti b i a l ba nd w h e n the knee i s i n a n exte nded posi
tion. F u rthermore, perfo r m i n g this test with the knee i n fl exion p l aces
g reater te nsion o n the fe moral ne rve, req u i ri n g the exa m i n er to be
cog n iza nt of a ssociated n e u rological co m p l a i nts.
EVIDENCE
Reese a n d B a n d y Ferber et a l (20 1 0)

(2003)
St u d y d e s i g n Re l i a b i l ity C ross-secti o n a l
Cond itions l l ioti b i a l band l l i oti bia l b a n d
eva l u ated t i g h t n ess t i g h t n ess
Sa m p l e s ize 61 300
Re l i a b i l ity l ntra rater re l i a b i l ity l nterrater
= .90 a g re e m e n t = 97.6%
S e n s itivity Not eva l u ated Not eva l u ated
Spec ifi c ity Not eva l u ated Not eva l u ated
REFERENCES
Ferber R, Ke n d a l l KO, M c E l roy L. N o rm ative a n d critica l c rite ria fo r i l ioti b i a l
ba n d a n d i l i o p s o a s m u s c l e fl ex i b i l ity. J A thl Tra in. 20 1 0;45 (4)344-348
F redericson M, Wh ite JJ, M a c m a h o n JM, A n d ri a c h i TP. Q u a ntitative a n a ly
s i s of the re l a tive effective n es s of 3 i l i oti b i a l ba n d st retc hes. Arch Phys
Med Rehabil. 2002;83 (5) : 5 8 9-5 92.
256 Section 9
Gaj d o s i k R L, Sa n d l e r M M , M a r r H L. I nfl u e n ce of knee positi o n s a n d g e n d e r

o n t h e O b e r test fo r l e n gt h o f t h e i l i oti b i a l ba n d . Clin Biomech (Bristol,
A von) 2003; 1 8 ( 1 ) : 7 7-79.
G a uta m VK, A n a n d S . A new test fo r est i m a t i n g i l ioti b i a l ba n d contractu re.
J Bone Join t Surg Br l 998;80(3) 474-475
M a rg o K, D rez n e r J , Motzki n D . Eva l u ation a n d m a n a g e m e n t of h i p pa i n :
a n a l g o rit h m i c a p p roa c h . J Fa m Prac 2003;5 2 (8) 607-6 1 7 .
M e l c h i o n e W E , S u l l iva n M S . Re l i a b i l ity o f m ea s u re m e nts obta i ned by u se
of a n i n stru m e n t d e s i g n e d to i n d i rectly m ea s u re i l ioti b i a l ba n d l e n g t h .
J Orth op Sports Phys Th er l 993; 1 8 (3):5 1 1 -5 1 5 .
O b e r F B . The ro l e of t h e i l ioti b i a l a n d fa s c i a l ata a s a fa cto r i n t h e c a u sa t i o n
o f l ow- b a c k d i s a b i l ities a n d sci atica . J B o n e Join t Surg. 1 936; 1 8: 1 0 5 .
R e e s e N B, B a n d y WO. U s e o f a n i n c l i n o m ete r to m ea s u re fl exi b i l ity o f t h e
i l ioti b i a l ba n d u s i n g t h e O b e r test a n d t h e mod ified O b e r test d iffe r
e n ces i n m a g n it u d e a n d re l i a b i l ity of m ea s u re m e nts. J Orthop Sports
Phys Th er 2003;3 3 (6) : 3 26-3 3 0 .
Wi n s l ow J , Yod e r E. Pate l l ofe m o ra l pa i n i n fe m a l e ba l l et d a ncers: corre l a
t i o n w i t h i l i oti b i a l ba n d tig htness a n d t i b i a I exte rna l rotat i o n . J Orthop
Sports Phys Th er 1 995;22 ( 1 ) 1 8-2 1 .
Hip 257
P I R I FORMIS TEST
TEST POSITIONING
The s u bject lies on the n o ntest side with t h e test leg i n 60 degrees
of h i p fl exion and rel axed knee flexi o n . The exa m i n er sta n d s with the
p roxi m a l h a n d o n the s u bject's pelvis ( l atera l ly) and the d i sta l h a n d
o n the s u bject's k n e e (latera l ly) (Fig u re H 9-7).
F i g u re H9-7.
ACTION
With t h e s u bject's pelvis sta b i l ized, a p p l y an add uction (down
ward) fo rce o n the s u bject's knee.
POSITIVE FINDING
Ti g htness or p a i n i n the h i p a n d b uttock a reas is i n d icative of p i ri
fo r m i s tig htness. Pa i n i n the b uttock and posterior t h i g h i s i n d icative
of sciatic ne rve i m p i n g e ment seco n d a ry to p i rifo r m i s tig htness.
258 Section 9

Th i s test may a l so be performed with the s u bject s u p i ne. It i s
i m po rta nt fo r the exa m i n e r t o differentiate between s u bjective com
p l a i nts of pain that may be re ported i n the hip a rea but a re not actu
a l ly associ ated with a tight p i rifo r m i s m u sc l e.
REFERENCES
B roa d h u rst N A, S i m m o n s O N , B o n d MJ Pi rifo r m i s syn d ro m e : corre l a t i o n
o f m u s c l e m o r p h o l ogy w i t h sym pto m s a n d s i g n s. A rch Phys Med
Reha bil. 2004;85 ( 1 2) 2036-2039.
F i s h m a n LM, Dom b i GW, M i c h a e l se n C, et a l . P i rifo r m i s syn d ro m e d i a g no
s i s , t reatme nt, and o u tcom e-a 1 0-yea r study. A rch Phys Med Rehabil.
2002;83 (5) 295-3 0 1 .
F i s h m a n LM, S c h a efe r M P. The P i rifo r m i s syn d ro m e is u n d e rd i a g nosed.
Muscle Nerve 2003;28(5) 646-649
Stewa rt J D . The P i rifo r m i s syn d ro m e is overd i a g n osed. Muscle Nerve.
2003;28 (5 ) :644-646
Hip 259
�----- THOMAS TEST

TEST POSITIONING
The s u bject lies s u p i n e with both knees fu l l y flexed a g a i n st the
c h est a n d the buttocks n ea r the ta b l e edge. The exa m i n e r sta n d s
w i t h o n e h a n d o n the s u bject's l u m ba r s p i n e o r i l iac crest t o m o n itor
l u m b a r lordosis o r pelvic ti lt, res pectively ( Fi g u re H 9-8A) .
Figure H9-8A.
ACTION
The s u bject s l owly l owers the test leg u ntil the leg is fu l ly rel axed
or u n t i l either a nterior pelvic tilting o r an i n c rease in l u m ba r l o rdosis
occu rs (Fig u re H 9-8B).
260 Section 9
F i g u re H9-8B.
POSITIVE FINDING
A lack of h i p exte n s i o n with knee fl exion g reater t h a n 45 d e g rees
i s i n d icative of i l io psoas m u scle tightness. Fu l l h i p exte n s i o n with
knee fl exion less than 45 deg rees is i n d i cative of rectu s fe moris
m u sc l e tig htness. A lack of hip exte n s i o n with knee fl exion less than
45 deg rees i s i n d i cative of i l i o psoas a n d rectus fe moris m u sc l e tig ht
ness. H i p exte r n a l rotati o n d u ri n g a ny of the p revious sce n a rios is
i n d i cative of i l ioti b i a l band tightness.

I n c reases i n a nterior pelvic tilt a n d l u m ba r l o rdosis m u st be
e l i m i n ated to p reve nt fa lse-neg ative fi n d i n g s. To fu rther confi r m t h i s
assessme nt, the exa m i n e r can s i m ply a p ply p ress u re o n the l owe r l e g
i n a n effo rt t o l ower it b a c k t o the ta ble. A return o f l u m ba r l o rdosis
wi l l i n d i cate a positive fi n d i n g .
Hip 26 1
EVIDENCE
Co n d it i o n s eva l u ated H i p path o l ogy
Study n u m be r 1
S e n s itivity 89
S pec ificity 92
REFERENCES
Ba r l ett M D, Wo lf LS, S h u rt l eff DB, Sta h e l i LT. H i p fl exi o n contractu res:
a com pa rison of m ea s u re m e n t methods. A rch Phys Med Rehab!!.
1 985 ;66(9) 620-625.
Eland DC, S i n g l eton TN, Co n a ster RR, et al. The " i l i a c u s test" new i nfo r m a
t i o n fo r t h e eva l u at i o n o f h i p exte n s i o n dysfu n cti o n . J A m Osteopa th
Assoc 2002; 1 02 (3) 1 3 0- 1 42.
Ga b be BJ, Be n n e l l KL, Waj swe l n e r H , F i n c h C F. Rel i a b i l ity of co m m o n
l ower extre m ity m u sc u l o s ke l eta l scree n i n g tests. Phys Th er Sport.
2004;5 (2) 90-97
H a rvey D. Asses s m e n t of the fl ex i b i l ity of e l ite ath l etes u s i n g the mod ified
Th o m a s test Br J Sports Med 1 998;3 2 ( 1 )68-70
H a rvey OM. F l exi b i l ity of e l ite ath l etes u s i n g t h e m od ified Th o m a s test
Med Sci Sport Exerc l 997;29(5) 2 7 1 .
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m u s c l e s p a stic ity u n d e r u ltra s o n i c m o n itori n g . A rch Phys Med Rehabil.
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Lee LW, Ke rri g a n D. Casey M D, Croce U D . Dyn a m i c i m p l icati o n s of h i p
fl exi o n contractu res. A m J Phys Med Rehabil. l 997;76(6) 5 02-508.
M a rg o K, D rez n e r J , Motzki n D. Eva l u ation a n d m a n a g e m e n t of h i p pa i n :
a n a l g o rith m i c a p p roa c h . J Fa m Pract. 2003;5 2 (8):607-6 1 7
N a rva n i AA, Ts i r i d i s E, Ke n d a l l S, C h a u d h u ri R, Th o m a s P. A p re l i m i n a ry
re port o n p reva l e n c e of a ceta b u l a r l a b r u m tea rs i n s p o rts patients with
g ro i n pa i n . Knee Surg Sports Tra umata/ A rth rosc 2003 ; 1 l (6):403-408
Re i m a n M P, Goode A P, Heged u s EJ, Cook CE, Wri g ht AA D i a g n ostic a c c u
r a c y o f c l i n i ca l tests o f t h e h i p a syste m atic review w i t h m eta-a n a lys i s .
Br J Sports M e d 2 0 1 3;47 ( 1 4) :893-902
262 Section 9
S c h a c h e AG, B l a n c h PD, M u rphy AT. Relation of a nterior pelvic t i l t d u ri n g

ru n n i n g t o c l i n ica l a n d ki n e matic m ea s u re s o f h i p exte n s i o n . B r J Sports
Med 2000;34(4) :279-283
Tyl e r T, Zook L, B ritt i s D, G l e i m G . A n ew pelvic tilt d etecti o n d evice
roe ntg e n og ra p h i c va l i d a t i o n and a p p l ication to a s s e s s m e n t of h i p
m oti o n i n p rofess i o n a l i c e h o c key p l ayers. J Orth op Sports Phys Ther
l 996;24(5):3 03-308
Winters MV, B l a ke CG, Trost JS, et al. Pass ive vers u s a ctive st retc h i n g of h i p
fl exo r m u sc l e s i n s u bjects with l i m ited h i p exte n s i o n : a ra n d o m ized
c l i n ica l tria l . Phys Ther 2004;84(9) :800-807
Yo u n g W, C l ot h i e r P, Ota g o L, B r u ce L, Lid d e l l D. Acute effects of static
st retc h i n g o n h i p fl exo r a n d q u a d riceps fl exi b i l ity, ra n g e of motion a n d
foot s peed i n ki c ki n g a foot ba l l . J Sci Med Sport. 2004; 7 ( 1 ):23-3 1 .
Hip 263
ELv 's TEST

TEST POSITIONING
The s u bject lies p rone. The exa m i n e r sta n d s on o n e side of the
ta ble n ext to the s u bject's l eg, placing o n e h a n d ove r the i ps i l atera l
pelvic reg i o n .
ACTION
The exa m i n er passively flexes the s u bject's knee a n d n otes the
reaction at the hip joi nt. Th i s test i s re peated o n the other side fo r
compa rison ( Fi g u re H 9-9A) .
Figure H9-9A.
POSITIVE FINDING
If the h i p a l so flexes when the knee is flexed, a tight rectus fe moris
i s i n d icated (Fig u re H 9-9B).
264 Section 9
F i g u re H9-9B.

Th i s test may be u n comforta b l e when performed on a s u bject who
h a s pelvic o r sacro i l ia c dysfu nction beca use of t h e prone positi o n i n g .
EVIDENCE
Pee l e r a n d A n d e rs o n (2008)
Co n d it i o n s eva l u ated Rectu s fe m o ris fl exi b i l ity
S a m p l e size 54
Rel i a b i l ity l n tra rater: Ka p pa = .46 to .62
l n terrater: Ka ppa = .42 to .52
Hip 265
REFERENCES
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1 95 5 ;68 (9) 1 3 6- 1 3 9 .
Kay RM, Ret h l efse n S A , Ke l ly J P, Wre n TA L. P red i ctive va l u e o f t h e D u ncan-Ely
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M a rks MC, A l exa n d e r J , S u t h e rl a n d O H , C h a m be rs H G . C l i n i ca l u t i l ity of t h e
D u n c a n - E l y test fo r rect u s fe m o r i s dysfu n cti o n d u ri n g t h e swi n g p h a se
of g a i t Dev Med Child Neural. 2003;45 ( 1 l ) 763-768.
Pee l e r J , A n d e rs o n J E. Re l i a b i l ity of t h e E ly's test fo r assess i n g rect u s
fe m o r i s m u sc l e fl exi b i l ity a n d j o i n t ra n g e o f m oti o n . J Orthop Res.
2008;26 (6) 793-799.
266 Section 9
F EMORAL N ERVE TRACTION TEST

TEST POSITIONING
The s u bject lies on the u n i nvolved side with the h i p a n d knee
s l i g htly fl exed . The exa m i n e r places one hand o n the l atera l as pect of
the s u bject's i nvo lved pelvis w h i l e the other hand s u p po rts the leg
below the knee.
ACTION
The s u bject s l i g htly flexes the head w h i l e the exa m i n e r com
p l etely exte n d s the s u bject's knee a n d exte n d s the hip a p p roxi mate ly
1 5 deg rees (Fig u re H9-1 OA) . The exa m i n e r then flexes the s u bject's
knee ( Fi g u re H9-1 OB).
F i g u re H9-1 OA.
Hip 267
Figure H9- 1 0B.
POSITIVE FINDING
The motion of h i p exte n s i o n a n d knee fl exi o n p l a ces the fe moral
nerve o n stretch . S u bjective co m p l a i nts of pa i n a l o n g the anterior
t h i g h reg ion may i n d icate d ecreased m o b i l ization of the femoral
n e rve.

The s u bject's s p i n e s h o u l d be i n a n e utra l position. The l ocatio n of
s u bjectively re ported pa i n s h o u l d be ca refu l ly co n s i d e red so that the
exa m i n er ca n d iffe rentiate between nerve roots.
268 Section 9
REFERENCES
C h ri stod o u l i d e s A N . l ps i l atera l sciatica o n fe m o ra l n e rve st retc h test
is pathog n o m o n i c of an L4/5 d i s k p rotru s i o n . J Bone Join t Surg Br
1 989;7 1 (1 ) :88-89.
Dyc k P. The fe m o ra l n e rve tract i o n test with l u m ba r d i s k p rotru s i o n s . Surg
Neural. 1 9 76;3 : 1 63- 1 66.
N a d l e r S F, M a l a n g a GA, Stit i k TP, Keswa n i R, Foye PM The crossed fe m o ra l
n e rve stretc h test to i m p rove d i a g n ostic s e n s itivity fo r t h e h i g h l u m ba r
ra d ic u l o pathy 2 case re ports. Arch Phys Med Rehab. 200 1 ;82(4) 5 22-5 23

Knee
Guide to Figures
270 Section 1 0
PATELLA TEN DON/PATELLA LIGAMENT LENGTH TEST

TEST POSITIONING
ACTION
The exa m i n er meas u res the d i sta n ce between the s u perior pole
of the pate l l a a n d the i nfe rior pole of the pate l l a ( Fi g u re K l 0-1 A) . The
exa m i n e r then mea s u res the d i sta n ce between the i nfe rior pole of
I
the pate l l a a n d the ti bi a tu berc l e ( Fi g u re Kl 0- 1 B).
F i g u re K1 0-1 A.
POSITIVE FINDING
A ratio is taken between t h e fi rst a n d seco n d measu re m e nts. A
ratio g reater t h a n o n e i n d icates pate l l a baja, whereas a ratio less t h a n
o n e i n d icates pate l l a a lta.
Knee 271
Figure Kl 0-1 8.
Pate l l a a lta may p red i s pose one to i n creased i n sta b i l ity of the
pate l l ofemora l joi nt, whereas pate l l a baja may p re d ispose one to
i n c reased pate l l ofe moral co m p ress ive forces a n d re lated pathologies.
REFERENCES
H i ra n o A, F u ku baya s h i T, I s h i i T, Oc h i a i N . Rel ati o n s h i p betwee n t h e pate l
l a r h e i g h t a n d t h e d i sorder of t h e knee exte n s o r m ec h a n i s m i n i m m a
t u re ath l etes. J Pediatr Orthop. 200 1 ;2 1 (4) :54 1 -544.
Ka d a ki a N R, l l a h i OA l n terobserver va ria b i l ity of the l n s a l l-Sa l vati ratio.
Orthopedics 2003;26(3) :3 2 1 -323; d is c u s s i o n 3 2 3-324.
Li n C F, Wu JJ, C h e n TS, H u a n g TF. Co m pa ri s o n of the l n s a l l-Sa l vati ratio of
t h e pate l l a i n patie nts with a n d without a n ACL tea r. Knee Surg Sports
Tra uma to/ Arth rosc 2004; 1 3 ( 1 ) 8- 1 1 .
N eyret P, Ro b i n so n A H , Le Cou ltre B, La p ra C, C h a m bat P Pate l l a r te n d o n
l e n gth-the fa cto r i n pate l l a r i n sta b i l ity? Knee. 2002;9 ( 1 ) :3-6
Seil R, M u l l e r B, Georg T, Ko h n D, R u p p S Re l i a b i l ity a n d i nte ro b s e rver va ri
a b i l ity in ra d i o l o g i c a l pate l l a r h e i g h t ratios. Knee Surg Sports Traumata/
Arth rosc 2000;8(4) 23 1 -236.
S h a b s h i n N , Sc hweitze r M E, Morrison WB, Pa rker L. MRI criteria fo r pate l l a
a l ta a n d baj a . Skeletal Radio/. 2004;3 3 (8)445-450
272 Section 1 0
PATELLAR APPREH ENSION TEST

TEST POSITIONING
The s u bject l ies s u p i n e with both knees fu l ly extended. The exa m
iner sta n d s o p pos ite the i nvo lved side a n d p l aces both t h u m bs o n
the m e d i a l bord e r o f the pate l l a bei ng tested (Fig u re K l 0-2A) .
F i g u re K1 0-2A. N ote: The exa m i n e r sta n d s on t h e o p posite s i d e

a n d passively g l i d e s t h e pate l l a l atera l ly.
ACTION
The s u bject m u st rem a i n rel axed with no q u ad riceps contracti o n
w h i l e the exa m i n er g ently pushes the pate l l a l atera l ly.
POSITIVE FINDING
If the s u bject is a p p rehen s ive to t h i s m ovement o r contracts the
q u ad riceps m u scle to p rotect a g a i nst s u b l uxati on, the test i s i n d i ca
tive of pate l l a r s u b l uxati on o r d i s l ocati o n (poss i b l y due to laxity of the
med i a l reti nacu l u m) .
Knee 273

The action may be re peated with the knee flexed to 30 d e g rees
( Fi g u re Kl 0-2B). The exa m i n er m u st avoid excess ive l atera l pate l l a r
g l ide t o p reve nt pate l l a r d i s l ocation. T h e patient's fa ce ca n a l s o b e
watc hed fo r a l o o k o f a p p re h e n s i o n .
Fig u re K l 0-2 B i s a l so ca l l ed Fa i rba n ks Appre h e n s i o n Test ( k n e e i s
at 30 deg rees o f fl exion).
Figure Kl 0-28.
EVIDENCE
C o o k et a l (201 2)
C o n d it i o n s eva l u ated Pate l l a r fe m o r a l p a i n
syn d ro m e
Study n u m be r 3
274 Section 1 0
REFERENCES
Coo k C, M a b ry L, Rei m a n M P, H eged u s EJ Best tests/c l i n ica l fi n d i n g s fo r
s c ree n i n g a n d d i a g n o s i s o f pate l l ofe m o ra l pa i n syn d ro m e : a syste m
atic review Physiotherapy 20 l 2;98(2) 93- 1 00
D i m o n J H I l l . A p p r e h e n s i o n test fo r s u b l uxat i o n of t h e pate l l a Clin Orthop
Re/a t Res. 1 974; 1 0 3 3 9 .
N i s ka n e n R O , Paavi l a i n e n PJ, J a a kko l a M, Ko rka l a O L. Poor corre l a t i o n
o f c l i n i ca l s i g n s with pate l l a r c a rti l a g i n o u s c h a n g e s . A rth roscopy
200 1 ; 1 7(3)307-3 1 0.
Ta n n e r S M , G a rt h WP J r, Soi l e a u R, Le m o n s J E. A mod ified test fo r pate l l a r
i n sta b i l ity: t h e b i o m ec h a n i ca l b a s i s . Clin J Sport Med 2003 ; 1 3 (6) 3 2 7-
338.
Knee 275
BALLOTABLE PATELLA OR PATELLA TAP TEST

TEST POSITIONING
The s u bject l ies s u p i n e with both knees fu l ly extended. The exa m
iner sta n d s with the p rox i m a l hand over the s u p ra pate l l a r pouch
a n d the d i sta l h a n d (th u m b o r fi rst 2 fi ngers) ove r the pate l l a (Fig u re
K l 0-3) .
Figure Kl 0-3.
ACTION
Co m p ress the s u p ra pate l l a r pouch with the p roxi m a l h a nd, then
co mpress the pate l l a i nto the fem u r.
POSITIVE FINDING
Downwa rd m ovement of the pate l l a fo l l owed by a rebo u n d wi l l
g ive t h e a p pearance o f a floati ng o r b a l l ota b l e pate l l a a n d i s i n d ica
tive of moderate to seve re joint effu s i o n .
276 Section 1 0

If a ba l l ota b l e pate l l a is d ete r m i n ed, the exa m i n e r s h o u l d ta ke
g i rth measurements at the s u p ra-, m i d -, a n d i nfra pate l l a r reg i o n s
a n d co m pa re them b i l atera l ly t o m o re accu rate ly assess the seve r
ity/d eg ree of effu s i o n . Ad d itiona l ly, the exa m i n e r m u st not m i sta ke
p repate l l a r b u rsitis as a joint effu s i o n . The fo rmer wi l l p resent as a
"raw egg" ove r the patel la, but no d ownwa rd patel l a r m ovement wi l l
b e p resent. Occa s i o n a l ly, concom itant joint effusio n a n d prepate l l a r
b u rsitis wi l l be present a n d the exa m i n e r wi l l the refore be c h a l lenged
to m a ke the proper assessme nt.
EVIDENCE
Pooka r nj a n a m o ra kot et a l (2004)

Study d e s i g n C ross-sectio n a l
Co n d it i o n s eva l u ated M e n isca l i nj u ries
S e n s itivity 32
S pec ificity 1 00
REFERENCES
J o h n s o n MW Acute knee effu s i o n s : a syste matic a p p roa c h to d i a g n o s i s .
A m Fa m Physicia n. 2000;6 l (8) 23 9 1 -2400.
Poo ka rnj a n a m o ra kot C, Ko rsa nti rat T, Worata n a rat P. M e n isca l l e s i o n s i n
t h e a nterior c r u c i ate i n s uffi c i e n t knee: t h e a c c u racy o f c l i n ica l eva l u a
t i o n . J M e d Assoc Thai. 2004;87 (6) 6 1 8-62 3 .
Knee 277
SWEEP TEST (WIPE, BRUSH, B U LG E, OR STROKE TEST)

TEST POSITIONING
The s u bject l ies s u p i n e with the i nvo lved knee i n fu l l exte n s i o n .
The exa m i n er places b o t h h a n d s o n the m e d i a l a s pect o f the pate l l a .
ACTION
The exa m i n er atte m pts to "m i l k" or "swee p" a ny i ntraca p s u l a r
swel l i n g b y a p plying pressu re t o the p rox i m a l (Fig u re K l 0-4A), d i sta l
( Fi g u re Kl 0-4 B), a n d l atera l (Fig u re Kl 0-4C) as pects of the pate l l a .
Figure K1 0-4A.
278 Section 1 0
F i g u re K1 0-4B.
F i g u re K1 0-4C.
Knee 279
POSITIVE FINDING
F l u i d that accu m u l ates on the med i a l as pect of the pate l l a is rep
resentative of i ntraca p s u l a r swe l l i n g.

l ntraca psu l a r swe l l i n g can be the res u l t of d a m a g e to a ny i ntern a l
caps u l a r structu re. T h e s u bject s h o u l d m a i nta i n m u sc l e re laxation
d u ri n g t h i s test. Th i s test i s a l so referred to a s the Wi pe, Brush, B u l g e,
or Stro ke Test.
REFERENCE
Sti e l l I G , We l l s GA, G re e n berg G H , et a l . l n tero b s e rver a g re e m e n t i n t h e
exa m i n a t i o n o f patients w i t h a c ute k n e e i nj u ry. A n n Emerg Med.
1 996;2 7 ( 1 ) 1 3 6- 1 3 7.
280 Section 1 0
Q-ANGLE TEST
TEST POSITIONING
The s u bject lies s u p i n e with the h i ps a n d knees extended .
ACTION
Identify the a nterior su perior i l iac s p i n es, m i d po i n t of the patel la,
a n d the tibial tu bercle. Str i ke a line fro m the a nterior s u perior i l iac
s p i nes to the m i d po i n t of the pate l l a a n d fro m the t i b i a l tu berc l e to
the m i d point of the pate l l a . Place a g o n i o m eter on t h e knee so that
the axis i s ove r the m i d po i n t of the pate l l a , the p roxi m a l a r m i s ove r
the l i n e to the a nteri o r s u perior i l ia c s p i n es, a n d the d i sta l a rm i s
ove r the l i n e t o the ti bi a I tu bercle. The res u ltant a n g l e i s t h e Q-a n g l e
(Fig u re K l 0-5).
F i g u re K1 0-5.
POSITIVE FINDING
Q-a n g l e norms with t h e knee i n exte nsi on a re 1 3 deg rees fo r
m a l es a n d 1 8 deg rees fo r fe ma les. A n g l e s either g reater than or less
than these norms may be i n d i cative of, but alone a re not a l ways accu
rate i n p red icti ng, pate l l ofe moral pathol ogy.
Knee 28 1

Dyn a m i c Q-a n g l e measu re ments, where t h e s u bject is sta n d i n g
a n d t h e q u a d riceps m u sc l e i s i n a contracted state, m a y be m o re
i n d i cative of pate l l ofemoral fu nction a n d u n derlying l ower extre m ity
pathomec h a n ics t h a n static Q-a n g l e meas u reme nts. The accu racy
of the Q-a n g l e meas u rement has co m e i nto q u esti o n . The p roxi m a l
attachment o f the rectus fe moris m u scle i s the anterior inferior i l iac
s p i nes a n d not the a nterior s u perior i l iac s p i n es. Th i s may p rovide fo r
a n i nva l i d measu rement beca use the anterior i nfe rior i l iac s p i nes d o
not a p pea r t o fa l l i n l i n e between the a nterior s u perior i l iac s p i n e s
a n d the m i d-pate l l a .
EVIDENCE
G re e n e et a l (200 1 )
Study d e s i g n Re l i a b i l ity
Co n d it i o n s eva l u ated Pate l l a r m a l a l i g n m e n t
Rel i a b i l ity l nterobserver re l i a b i l ity: . 1 7 to .29
l ntra o bserver re l i a b i l ity: . 1 4 to .3 7
S e n s itivity N ot eva l u ated
S pec ificity N ot eva l u ated
REFERENCES
Bayra kta r B, Yuces i r I , Ozt u r k A, et a l . C h a n g e of q u ad riceps a n g l e va l u es
with a g e and a ctivity. Sa udi Med J 2004;2 5 (6)75 6-760
B i e d e rt RM, Wa r n ke K. Corre l a t i o n betwee n the Q a n g l e a n d t h e pate l l a
position a c l i n i c a l a n d a x i a l co m p uted tomog ra p hy eva l u at i o n . A rch
Orthop Tra uma Surg. 200 1 ; 1 2 1 (6) 346-349
F ra nce L, N ester C Effect of e rrors in the i d e n tificati o n of a n ato m i c a l l a n d
m a rks o n t h e a c c u racy o f Q a n g l e va l u es. Clin Biomech (Bristol, A von)
200 1 ; 1 6 (8)7 1 0-7 1 3
G re e n e CC, Edwa rd s TB, Wa d e M R, Ca rson EW Rel i a b i l ity of t h e q u a d ri
ceps a n g l e m e a s u re m e nt. A m J Knee Surg. 200 1 ; 1 4(2) 97- 1 0 3 .
G u e rra J P, A r n o l d MJ, Gaj d o s i k RL. Q a n g l e effects of i s o m etric q u a d
riceps contract i o n a n d b o d y positi o n . J Orthop Sports Phys Ther
l 994; 1 9 (4) 200-204
282 Section 1 0
H e rri n gton L , N ester C . Q-a n g l e u n d e rva l u e d 7 The re l a ti o n s h i p betwe e n

Q-a n g l e a n d m e d i a- l atera l position o f t h e pate l l a . Clin Biomech (Bristol,
A von) 2004; 1 9 ( 1 0) 1 0 70- 1 073
H o rton MG, H a l l TL. Q u a d riceps fe m o r i s m u sc l e a n g l e : n o rm a l va l u es a n d
re l a t i o n s h i ps with g e n d e r a n d s e l ected s ke l eta l m ea s u res. Phys Th er
1 989; 6 9 ( 1 1 ) :89 7-90 1 .
Hvid I , A n d e rs e n L I . The q u a d riceps a n g l e a n d its re l a t i o n to fe m o ra l tor
s i o n . Acta Orthop Scand 1 982;5 3 (4) 5 7 7-579
Lat h i n g house L H , Tri m b l e MH. Effects of i s o m etric q u a d riceps a ctiva t i o n
o n t h e Q-a n g l e i n wo m e n befo re a n d after q u a d riceps exe rc ise. J
Orthop Sports Phys Ther 2000;30(4) 2 1 1 -2 1 6.
Livi n g sto n LA The a c c u racy of Q a n g l e va l u es . Clin Biomech (Bristol, A von)
2002; 1 7 (4) 3 2 2-323; a ut h o r re p l y 323-324.
O l e r u d C, Berg P. The va riation of the Q a n g l e with d iffe re n t positi o n s of
t h e foot Clin Orth op Re/a t Res. 1 984; ( 1 9 1 ) 1 62 - 1 6 5 .
To m s i c h O A , N itz AJ , Th re l ke l d AJ , S h a p i ro R. Pate l l ofe m o ra l a l i g n m e n t
re l i a b i l ity J Orthop Sports Phys Ther 1 996;23 (3) 200-208.
Wood l a n d LH, F ra n c i s RS. Pa ra m eters a n d co m pa riso n s of the q u a d riceps
a n g l e of co l l ege-a g e d m e n and wo m e n in t h e s u p i n e a n d sta n d i n g
positi o n s . A m J Sports Med 1 992;20(2):208-2 1 1 .
Knee 283
M EDIAL- LATERAL G RI N D TEST

TEST POSITIONING
side and h o l d s the s u bject's foot. The exa m i n e r's other h a n d i s placed
ove r the joint l i n e of the knee ( Fi g u re Kl 0-6A) .
Figure K1 0-6A.
ACTION
The exa m i n er passively flexes the s u bject's h i p a n d knee maxi m a l
ly (Fig u re K l 0-68) a n d then a p p l i es a c i rcu l a r m o t i o n w i t h the tibia,
rotat i n g the tibia cl ockwise a n d cou nte rc l ockwise (Fig u re K l 0-6C).
POSITIVE FINDING
Pa i n, g r i n d i ng, or c l i c k i n g is i n d icative of a men isca l tea r.
284 Section 1 0
F i g u re K l 0-68.
F i g u re Kl 0-6C.
Va rus a n d va l g u s stress may be s i m u lta n eously a p p l ied by the
h a n d ove r the j o i nt line a s t h e knee i s passively exte n d ed (Anderson
Med i a l -Latera l Grind Test) .
REFERENCE
A n d e rs o n AF, Lipsco m b A B . C l i n i ca l d ia g n o s i s of m e n isca l tea rs descri p
t i o n of a n ew m a n i p u lative test Am J Sports Med 1 986; 1 4(4) 2 9 1 -293.
Knee 285
BOUNCE HOME TEST

TEST POSITIONING
side and cups the s u bject's foot in one h a n d . The exa m i n er's other
h a n d may be placed ove r the joint l i n e of the knee (Fig u re Kl 0-7 A) .
Figure K1 0-7A.
ACTION
The exa m i n er pass ive ly flexes the s u bject's knee a n d then a l l ows
the knee to passively fa l l i nto extension ( Fi g u re Kl 0-78).
286 Section 1 0
Figure K1 0-7B.
POSITIVE FINDING
A r u b bery en dfeel or springy block is i n d i cative of a m e n i scal tea r.

Th i s test s h o u l d be performed with caution when suspicion of a
men iscal tea r exists beca use it may not be comfo rta b l e to the patient
and co u l d potentia l ly ca use fu rther i ntern a l derangem ent.
REFERENCE
S m it h BW, G re e n GA Acute knee i nj u ries: p a rt I . H i story a n d p hysica l
exa m i natio n . Am Fa m Physicia n. 1 995;5 l (3) 6 1 5 -62 1 .
Knee 287
PATELLAR G RI N D TEST (( LARKE 1S SIGN)

TEST POSITIONING
The s u bject l ies s u p i n e with the knees extended. The exa m i n e r
sta n d s n ext t o the i nvo lved side a n d places the w e b s pace o f t h e
t h u m b o n the s u perior border o f the pate l l a (Fig u re K l 0-8A) .
F i g u re Kl 0-SA.
ACTION
The s u bject is asked to contract the q uad riceps m u sc l e w h i l e the
exa m i n er a p p l ies d ownwa rd a n d i nfe rior p res s u re on the pate l l a
(Fig u re Kl 0-8B).
288 Section 1 0
F i g u re K1 0-88. Note: The patient actively contracts t h e q u a d riceps

m u scle w h i l e t h e exa m i n e r a p p l ies a gentle d ownwa rd p res s u re on
t h e pate l l a .
POSITIVE FINDING
Pa i n with m ovement of the pate l l a or a n i n a b i l ity to co m p l ete the
test i s i n d icative of c h o n d ro m a l a c i a pate l l a .

Th i s test may be pai nfu l even fo r hea lthy s u bjects; the refo re, it i s
i m po rta nt t o b i latera l ly compare. This test may be repeated w i t h the
s u bject's knee i n 3 0 a n d 60 deg rees of fl exion to assess va ryi n g s u r
faces of the pate l l a . From a n o bjective perspective, c h o n d ro m a l a c i a
can be d etected o n ly w i t h s u rg i ca l i ntervention beca use it refe rs t o a
soften i n g of the carti lage on the u n d ersu rface of the pate l l a that i s
fo u n d with d i rect p a l patio n .
Knee 289
EVIDENCE
C o o k et a l (201 2)
C o n d it i o n s eva l u ated Pate l l a r fe m o r a l p a i n
syn d ro m e
Study n u m be r 4
S e n s itivity 29 to 49
REFERENCES
Coo k C, M a b ry L, Rei m a n M P, H eged u s E J Best tests/c l i n ica l fi n d i n g s fo r
s c ree n i n g a n d d i a g n o s i s o f pate l l ofe m o ra l pa i n syn d ro m e : a syste m
atic review Physiotherapy 20 l 2;98 (2) 93- 1 00
Fowl e r PJ, Lu b l i n e r JA The p red i ctive va l u e of five c l i n i ca l s i g n s i n t h e
eva l u ation o f m e n isca l pat h o l ogy. Arth roscopy 1 989;5(3) 1 84- 1 86.
S m it h BW, G reen GA. Acute knee i nj u ries: pa rt I. H i story a n d p hysica l
exa m i natio n . Am Fam Physicia n. 1 995;5 l (3):6 1 5-62 1 .
290 Section 1 O
REN N E TEST
TEST POSITIONING
The s u bject sta nds. The exa m i n er sta n d s in fro nt of the s u bject
and places 2 fi ngers o r the t h u m b ove r the l atera l epico n dyle of the
i nvo lved knee ( Fi g u re K l 0-9A) .
F i g u re K1 0-9A. N ote t h a t t h e exa m i n e r is a pp l y i n g press u re over

the late ra l epicondyle of the fe m u r w h i l e the s u bject sta n d s with t h e
knee i n fu l l exte n s i o n .
ACTION
The s u bject is i n stru cted to s u p port the body we i g ht on the
i nvo lved foot a n d actively flex the knee a s if perfo r m i n g a sq uat. The
exa m i n e r m a i nta i n s p ress u re with the t h u m b ove r the lateral epicon
dyle (Fig u re Kl 0-9B).
Knee 29 1
F i g u re K1 0-9B. N ote that t h e exa m i n e r is a p p l y i n g pressu re ove r

t h e lateral e p i c o n d y l e of t h e fem u r w h i l e t h e s u bject flexes t h e knee.
POSITIVE FINDING
If p a i n is p resent u n d e r the exa m i n e r's t h u m b when the s u bject's
knee is positioned i n 30 deg rees of fl exi on, i l i ot i b i a l band fri ctio n
syn d rome i s i n d icated .

At 30 d e g rees of knee fl exion, the i l ioti b i a l b a n d l ies d i rectly over
the l atera l epico n dyle. Th i s is a n active, wei g ht-bea r i n g vers i o n of the
N o b l e test.
REFERENCES
Ki rk KL, Ku k l o T, Kl e m m e W l l i oti b i a l ba n d fri ct i o n syn d ro m e . Orthopedics.
2000;2 3 ( 1 1 ) : 1 209- 1 2 1 4
Re n n e J W The i l i oti b i a l b a n d fri ct i o n syn d ro m e . J Bone Join t Surg.
1 975;5 7A(8) : 1 l 1 0- l l l l .
292 Section 1 0
N OBLE TEST
TEST POSITIONING
The s u bject l i es s u p i n e with the knee fl exed u p to 90 d e g rees. The
exa m i n e r sta n d s o n the i nvolved side and p l aces the t h u m b ove r
the l atera l epicondyle of the i nvo lved knee. The other h a n d is placed
a ro u n d the s u bject's a n kle.
ACTION
The exa m i n e r passively flexes a n d exte n d s the s u bject's knee w h i l e
m a i nta i n i n g pressu re ove r the l atera l epicondyle (Fig u res K l 0- 1 O A
a n d K l 0- 1 O B ) . N ote t h a t the fig u res a re ta ken fro m the u n i nvo lved
side to bette r s h ow h a n d p l a cem ent.
F i g u re K1 0-1 0A. N ote that t h e exa m i n e r's fi n g e rs a re o v e r t h e l a t

e r a l epicondyle o f t h e fe m u r.
Knee 293
F i g u re K1 0-1 0B.
POSITIVE FINDING
If p a i n is p resent u n d e r the exa m i n e r's t h u m b when the s u bject's
knee is positioned i n 30 deg rees of fl exi on, i l i ot i b i a l band fri ctio n
syn d rome i s i n d icated .

At 30 d e g rees of knee fl exi on, the i l ioti b i a l b a n d l ies d i rectly over
the l atera l e p i condyle. Th i s is a passive, nonweig htbea ring version of
the Re n n e test.
REFERENCE
Ca l m ba c h WL, H utc h e n s M . Eva l u at i o n of patie nts p rese nti n g with knee
p a i n pa rt I I . Diffe re n t i a l d i a g n o s i s . Am Fa m Physicia n. 2003;68 9 1 7-922.
294 Section 1 O
�--- H UGHSTON 1S P UCA TEST

TEST POSITIONING
The s u bject lies s u p i n e with the i nvo lved knee exte nded a n d
relaxed. T h e exa m i n er sta nds o n the i nvo lved s i d e a n d p l a ces t h e
h e e l o f one h a n d ove r the l atera l border o f the patel la, with the fi n
g ers of that hand positioned ove r the m e d i a l fe moral condyle. The
exa m i n e r's other hand i s placed a ro u n d the s u bject's a n kl e and foot
(Fig u re K l 0- 1 1 A) .
Fig u re K1 0-1 1 A.
ACTION
The exa m i n e r passively flexes a n d exte n d s the s u bject's knee
w h i l e s i m u lta neously i nterna l ly rotati n g the tibia and p u s h i n g the
pate l l a med i a l ly ( Fi g u re K l 0-1 1 B).
POSITIVE FINDING
Pa i n a n d/o r p o p p i n g over the med i a l a s pect of the knee is i n d i ca
tive of a n a b n o r m a l p l ica. P l ica bands may be p resent and asym pto m
atic i n a n ot h e rwise hea lthy i n d ivid u a l . Th u s, the l ocation of the band
wi l l dete r m i n e whether pate l l a tracki ng wi l l be affected.
Knee 295
Figure K1 0-1 1 B.
An a g g ressive a p p roach to assess i n g an i nfl amed p l i ca may lead to
fu rther i rritation of the structu re.
REFERENCES
Eren OT The a c c u racy of j o i n t l i n e te n d e rn e s s by p h ys i c a l exa m i n a t i o n i n
t h e d ia g n o s i s of m e n isca l tea rs. A rth roscopy 2003 ; 1 9 (8) 85 0-854
H u g h sto n JC, Whatley GS, Ood e l i n RA, Sto n e MM The ro l e of the s u p ra
pate l l a r p l ica i n i n tern a l d e ra n g e m e n t of t h e knee. A m J Orth op
1 963;5 :25-2 5 7 .
l rh a E, Vrd o lj a k J M ed i a l syn ovi a l p l ica syn d ro m e o f t h e k n e e : a d i a g nostic
pitfa l l in a d o l escent ath l etes. J Pedia tr Orthop B. 2003 ; 1 2 ( 1 ) :44-48
Ki m SJ, J e o n g J H , C h e o n YM, Ryu SW M P P test i n t h e d i a g n o s i s of m ed i a l
pate l l a r p l ica syn d ro m e . A rth roscopy 2004;20 ( 1 0) : 1 1 0 1 - 1 1 03
Zeren B, Ozte ki n H H . Sym pto m a t i c " b u c ket- h a n d l e tea r" of t h e m ed i a l
pate l l a r p l icae i n t h ree patients co n g e n ita l o r a cq u i re d ? Am J Sports
Med 2004;32 1 748 - 1 750.
Z h a o E, Da i J, Chen 0, L i n H . C l i n i ca l d i a g n ostic sta n d a rd of m e d i o pa
te l l a r p l ica syn d ro m e [a rt i c l e i n C h i nese] Zh onghua Wa i Ke Za Zhi.
l 998;3 6 (6) 3 5 5-735
296 Section 1 O
GODFREY 90/90 TEST

TEST POSITIONING
The s u bject l ies s u p i n e on a ta ble with both the h i p a n d knee of
the i nvo lved side fl exed to 90 deg rees.
ACTION
The exa m i n er passively sta b i l izes the positi o n i n g of the s u bject's
h i p a n d knee w h i l e assess i n g the location of t h e tibia a l ong the lon
g itud i n a l axis (Fig u re K l 0- 1 2) .
F i g u re Kl 0-1 2 .
POSITIVE FINDING
The recog n ition of one tibia rest i n g m o re i nferiorly than t h e con
tra l atera l side may i n d icate a posterior sag o r i n sta b i l ity. Th is may be
rel ated to the posterior cruciate l iga ment (PCL).

Th i s test m u st be performed b i l atera l ly. Applying a s u perior force
to the t i b i a fro m the poste rior a s pect may red u ce the a l ig n ment to
a n o r m a l rest i n g position if it is act u a l l y fo u n d to be sa g g i n g . It i s
i m po rta nt t o m a i nta i n neutra l t i b i a l rotation, ot h e rwise a positive
fi n d i n g may be the resu l t of a capsu l a r exte n s i b i l ity.
Knee 297
POSTERIOR SAG TEST (G RAVITY D RAWER TEST)

TEST POSITIONING
The s u bject l ies on a ta b l e with the i nvo lved knee fl exed to
90 deg rees a n d the i psi l atera l h i p placed i n 45 deg rees of fl exion
(Fig u re Kl 0-1 3 ) . The sole of the s u bject's foot s h o u l d be placed o n
the ta ble.
Figure Kl 0- 1 3.
ACTION
The exa m i n er observes the position of the tibia rel ative to the
fe m u r i n the sag itta l p l a ne. The exa m i n e r then i n structs the s u bject
to actively contract the q u ad riceps m u sc l e g ro u p in an atte m pt
to exte nd the knee w h i l e reta i n i ng h i p fl exion. The i psi l atera l foot
shou l d re m a i n on the ta b l e d u ri n g the atte m pted knee exte n s i o n .
POSITIVE FINDING
Posterior d i s p lacement of the tibia on the fem u r w h i l e the s u b
ject's q u ad riceps rem a i n s i l ent i n d icates a posterior i n sta b i l ity. Th i s
may be refl ective o f i nj u ry t o a ny o f the fo l l owing structu res: PCL,
a rcuate l i g a ment co m pl ex, a n d poste rior o b l i q u e l iga ment.
298 Section 1 O

It is i m pe rative fo r the exa m i n e r to identify a n e utra l t ib iofe moral
j o i nt position beca use t h i s test ca n be m i s i nterpreted fo r a n a nterior
i n sta b i l ity when o n e obse rves a n a nteri o r tra n s l ation of the tibia o n
the fe m u r.
EVIDENCE
M a l a n g a et a l (2003)
C o n d it i o n s eva l u ated PCL i nj u ries
Study n u m be r 1
S e n s itivity 79
S pec ificity 1 00
REFERENCES
Aki s u e T, Ku rosa ka M, Yos h iya S, Ku roda R, M i z u n o K. Eva l u a t i o n of h ea l i n g
o f t h e i nj u red poste r i o r c r u c i ate l i g a m e nt: a n a lys i s o f i n sta b i l ity a n d
m a g n etic reso n a n ce i m a g i n g . A rth roscopy 200 1 ; 1 7 (3) 264-269
G iffi n J R, Vog ri n TM, Za ntop T, Woo S L, H a rn e r CD. Effects of i n c reas
ing t i b i a l s l o pe o n t h e b i o m e c h a n i cs of t h e knee. Am J Sports Med
2004;3 2 (2)3 76-3 82.
M a l a n g a GA, A n d r u s S, N a d l e r S F, M c lea n J Phys i c a l exa m i nation of t h e
k n e e : a revi ew o f t h e orig i n a l t e s t d e scri pt i o n a n d scientifi c va l i d ity o f
co m m o n o rt h o ped i c tests. A rch Phys M e d Rehabil. 2003 ;84(4) : 5 92-603 .
Ogata K , McCa rthy J A, D u n l a p J, M a n s ke P R . Pat h o m ec h a n ics o f poste r i o r
sag o f t h e t i b i a i n poste rior c r u c i ate d efi c i e n t k n e e s . A n expe r i m e n ta l
stu dy. A m J Sports Med l 988; 1 6 (6) :630-636
S h i n o K, M i ts u o ka T, H o ri be S, H a m a d a M , N a kata K, N a ka m u ra N . The g rav
ity sag view a s i m p l e ra d i o g ra p h i c tec h n i q u e to s h ow poste r i o r l axity
of t h e knee. A rth roscopy 2000; 1 6 (6) 670-672
Stro b e l MJ, We i l e r A, Sc h u lz MS, R u sse K, E i c h h o r n HJ F ixed poste rior
s u b l u xa t i o n i n poste rior c r u c iate l i g a m e nt-defi c i e n t knees: d i a g n o s i s
a n d t reatment o f a n ew c l i n i ca l s i g n . A m J Sports M e d 2002;3 0 ( 1 ) 3 2-38
Knee 299
REVERSE P IVOT S H I FT (JAKOB TEST)

TEST POSITIONING
The s u bject l ies s u p i n e with the test knee in 40 to 50 degrees of
fl exion. The exa m i n e r sta n d s with the p rox i m a l h a n d on the s u bject's
postero lateral leg, j u st d i sta l to the pate l l a , with the t h u m b on o r
a nteri o r t o the fi b u l a r h e a d . T h e d i sta l h a n d g rasps the s u bject's m i d
foot a n d h e e l (Fig u re K 1 0- 1 4A) .
Figure Kl 0-1 4A.
AL TERNA TE TEST POSITIONING

Place the s u bject's foot between the exa m i n er's d i sta l a r m a n d
body, with the same h a n d o n the t i b i a . T h e p roxi m a l h a n d s h o u l d
be p l a ced o n the postero l atera l leg j u st d i sta l t o the kn ee, w i t h t h e
t h u m b o n o r a nte rior t o the fi b u l a r h e a d (Fig u re K l 0-1 4B).
300 Section 1 0
F i g u re K1 0-1 4B.
ACTION
The exa m i n e r exte r n a l l y rotates t h e t i b i a with o n e h a n d a n d
a p p l ies a va l g u s fo rce with t h e other h a n d w h i l e s l ow l y exte n d i n g
t h e knee. T h e s a m e p roced u re a p p l ies fo r t h e a l tern ate test posi
t i o n , except a s l i g h t axi a l l o a d i s a p p l i e d a s t h e knee i s exte n d ed
( Fi g u re K 1 0- 1 4C ) .
F i g u re K1 0-1 4C.
Knee 30 1
POSITIVE FINDING
Th i s is fi rst seen when the exa m i ner fl exes the s u bject's knee if the
latera l tibial platea u s u b l uxes poste riorly. Fu rthermore, this s u b l ux
ation is red u ced once the knee exte nds and a p p roaches a position
of a p p roxi m ately 20 degrees of fl exion. At this poi nt, the latera l tibia I
p l atea u wi l l return to a neutral position. A pa l pa b l e "cl u n k" or s h ift as
it a p p roaches extension (-20 to 30 degrees of fl exion) is in d icative of
posterolatera l rota ry i n sta b i l ity secondary to damage of primarily the
PCL, latera l co l l atera l liga ment (LCL), postero latera l caps u l e, a n d a rcu
ate com p l ex.

Th i s test is very sens itive fo r the s u bject w h o possesses a n i n sta b i l
ity. It s h o u l d be performed o n ly w i t h the s u bject rel axed beca use a s a
contraction of the s u rrou n d i n g m u sculat u re of the knee may p reve nt
a s u btle s u b l uxation and i n d i cate a negative test.
EVIDENCE
R u b i n ste i n et a l ( 1 994)
Study d e s i g n Ra n d o m ized contro l led tria l
C o n d iti o n s eva l u ated PCL i nj u ries
S e n s itivity 26
S pec ificity 95
REFERENCES
J a ko b R P, H a s s l e r H , Stae u b l i H U . O b s e rva t i o n s o n rota ry i n sta b i l
ity o f t h e latera l co m pa rt m e n t o f t h e knee. Acta Orthop Scand Suppl.
1 98 1 ; 5 2 (S u p p l 1 9 1 ) 1 -3 2
La Prade RF, M u e n c h C, We nto rf F , Lewis J L. The effect o f i nj u ry t o t h e pos
tero l a te ra l structu res of the knee o n fo rce in a poste r i o r c r u c i ate l i g a
m e n t g raft: a b i o m ec h a n i ca l st u d y. Am J Sports Med 2002;3 0:233-238.
302 Section 1 0
La Prade R F, Te rry GC. I nj u ries t o t h e postero l atera l a s pect o f t h e knee:

a ssociation of a n ato m i c i nj u ry patte r n s with c l i n i ca l i n sta b i l ity. Am J
Sports Med l 997;2 5 (4) 433-438
N i e l s e n S, H e l m i g P Poste r i o r i n sta b i l ity of t h e knee J O i nt. An expe r i m e nta l
stu dy. Arch Orthop Tra uma Surg. 1 986; 1 05 (2) 1 2 1 - 1 25 .
R u b i n ste i n R A J r, S h e l bo u rne KD, Mcca rro l l J R, Va n M eter C D , Rett i g AC.
The a c c u ra cy of the c l i n i ca l exa m i n at i o n in the sett i n g of poste r i o r
c r u c i ate l i g a m e n t i nj u ries. A m J Sports M e d 1 994;22(4) 550-5 5 7
Knee 303
ANTERIOR LACH MAN 1S TEST

TEST POSITIONING
The s u bject lies s u p i n e with the test knee fl exed to 20 to 30 deg rees.
The exa m i n er sta n d s with the p roxi m a l h a n d o n the s u bject's d i sta l
t h i g h (latera l ly) i m med iately p roxi m a l to the pate l l a a n d the d i sta l
h a n d on the s u bject's p roxi m a l ti bi a (med i a l ly) i m med iately d i sta l to
the tibia I tu berc l e (Fig u re Kl 0- 1 SA) .
Figure K1 0-1 SA.

The exa m i n e r p l a ces h i s or her fl exed knee u n d e r t h e patient's test
kn ee, with the p roxi m a l h a n d ove r the d i sta l t h i g h (anterio rly) a n d
d i sta l h a n d o n the s u bject's p roxi m a l t i b i a (med i a l ly), j u st d i sta l t o t h e
t i b i a l tu bercle (Fig u re K l 0- 1 S B) .
304 Section 1 0
F i g u re K1 0-1 5B.
ACTION
From a "neutra l " (anterior-poste rior) position, a p p l y an a nterior
fo rce to the tibia with the d i sta l hand w h i l e sta b i l izing the fe m u r with
the p rox i m a l hand. The same p roced u re a p pl i es fo r the a lternate test
positi o n i n g .
POSITIVE FINDING
Excess ive a nterior tra n s l ation of the ti bi a co m pa red to the u n i n
volved knee with a d i m i n ished or a bsent endpoint is i n d i cative of a
partial or co m p l ete tea r of the a nterior cruciate l i g a ment (ACL).

I n c reased a nterior tibia I tra n s lation is not i n a n d of itse lf i n d i cative
of ACL pathol ogy. For exa m p l e, a torn PCL w i l l a l l ow the p roxi m a l
t i b i a t o t ra n s l ate posteriorly, t h u s p rod u c i n g i n c reased a nte rior tra n s
lation d u ri n g the a nterior La c h m a n's test. M e n i scal tea r (pri m a ri l y of
the posterior horn) may a l so contri b ute to an a nte rior tra n slation.
The refo re, the presence a n d q u a l ity of the end point m u st be deter
m i ned befo re AC L i nteg rity ca n be accu rate ly assessed. Altho u g h
i n d ivid u a l s m a y choose t o a l ways use the d o m i n a nt h a n d for t h e
tra n s l ation a ssessme nt, it i s reco m mended t o sta b i l ize the t i b i a o n t h e
med i a l s i d e t o p reve nt the poss i b i l ity o f i n c reased externa l rotati o n of
the ti bia, w h i c h can contri b ute to i n c reased a nteri o r tra nslation.
Knee 305
EVIDENCE
B e nj a m i n se et a l (200 6 ) v a n Eck et al (20 1 3)

C o n d it i o n s AC L i nj u ries ACL r u pt u res
eva l u ated
S pec ificity 94 81
REFERENCES
Benj a m i n s e A, G o ke l e r A , va n d e r Sc h a n s C P. C l i n i ca l d i a g n o s i s of a n a n te
r i o r c r u c i ate l i g a m e n t ru pt u re: a m eta-a n a lys i s . J Orthop Sports Phys
Ther 2006;3 6(5) 267-288
Coo p e r m a n JM, Ri d d l e D L, Rot h ste i n JM. Re l i a b i l ity a n d va l i d ity of j u d g
m e nts o f t h e i nteg rity o f t h e A C L o f t h e k n e e u s i n g t h e La c h m a n 's test
Phys Ther l 990;70 225-23 3 .
J o n ss o n T, A l t h off B , Pete rson L , Re n strb m P C l i n i ca l d i a g n o s i s o f ru ptu res
of t h e a nterior c r u c i ate l i g a m e n t a com pa rative study of t h e La c h m a n
test a n d t h e a nte rior d rawe r s i g n . Am J Sports Med 1 982; 1 0(2) 1 00- 1 02.
Ki m SJ, Ki m H K. Re l i a b i l ity of t h e a nte rior d rawer test, t h e p ivot s h ift test,
a n d the Lac h m a n test Clin Orthop Re/a t Res. l 995;(3 1 7) 23 7-242
Ko n i g D P, Rutt J , Ku m m D, B re i d e n b a c h E. D i a g n o s i s of a nte rior knee i n sta
b i l ity Co m p a ri s o n between the La c h m a n test, the KT- 1 ,000 a rt h ro m
ete r a n d t h e u ltra s o u n d La c h m a n test [a rti c l e i n G e rm a n] . Un fa llch irurg
1 998; 1 0 1 (3) 209-2 1 3 .
Ku m a r VP, Satku K. The fa l s e pos itive Lac h m a n test Singapore Med J
l 993 ;34(6) 5 5 1 -5 5 2 .
Li u W, M a itl a n d M E, Bel l G D . A m o d e l i n g s t u d y o f pa rt i a l ACL i nj u ry: s i m u
l ated KT-2000 a rt h rom ete r tests. J Biomech Eng. 2002; 1 24(3):294-3 0 1 .
va n d e r P l a s CG, O p ste lte n W, Devi l l e WL, B ij l D, Bouter LM, S c h o lten RJ
Physica l d i a g n os i s-t h e va l u e of s o m e co m m o n tests for t h e d e m o n
stration o f a n a n terior c r u c i ate- l i g a m e nt r u pt u re: m eta-a n a lysis. Ned
Tljdschr Geneeskd 2005; 1 49(2) 83-88
va n Eck C F, va n den B e kerom M P, F u FH, Poo l m a n RW, Ke rkh offs G M .
Methods t o d i a g nose a c ute a nterior c r u c iate l i g a m e nt ru ptu re: a
m eta-a n a lysis of physica l exa m i n a t i o n s with a n d without a n a e st h e s i a .
Knee Surg Sports Tra umata! A rth rosc 20 1 3;2 l (8) : 1 895 - 1 903.
306 Section 1 0
�--- ANTERIOR D RAWER TEST

TEST POSITIONING
The s u bject l ies s u p i n e with t h e test h i p fl exed to 45 deg rees, knee
fl exed to 90 deg rees, and foot i n neutra l positi o n . The exa m i n er sits
o n the s u bject's foot with both hands b e h i n d the s u bject's p rox i m a l
I
tibia a n d t h u m bs on the tibia p l atea u ( Fi g u re K l 0-1 6).
Fig u re Kl 0-1 6.
ACTION
Apply an a nterior fo rce to the p roxi m a l t i b i a . The h a m stri ng ten
dons s h o u l d be pa l pated fre q u ently with i n d ex fi ngers to e n s u re
relaxation.
POSITIVE FINDING
I n c reased a nte rior t i b i a l d i s p l a cement as c o m p a red to the u n i n
vo lved side is i n d i cative of a p a rti a l or co m p l ete tea r of the ACL.

See Spec i a l Co n s i d e rations/Co m ments for the Anterior Lach m a n's
test. Q u a l itative assessment of the e n d p o i n t d u ri n g the Anterior
D rawer Test i s less accu rate than d u ri n g the Anterior Lac h m a n's Test.
Knee 307
Al so, there i s a g reater potential fo r a fa lse-negative fi n d i n g with t h i s

test ve rsus the Anterior Lachma n's Test, seco n d a ry to the i n c reased
potentia l fo r h a m stri ng "g u a rd i n g :'
EVIDENCE
B e nja m i n s e et a l (200 6 ) va n Eck et a l (20 1 3)

Study desig n M eta-a n a lysis M eta-a n a lysis
Co n d it i o n s ACL i nj u ries ACL r u pt u re
eva l u ated
S pec ificity 92 81
REFERENCES
Benj a m i n s e A, G o ke l e r A, va n d e r Sc h a n s C P. C l i n i ca l d i a g n o s i s of a n a n te
r i o r c r u c i ate l i g a m e n t ru pt u re: a m eta-a n a lys i s . J Orthop Sports Phys
Ther 2006;3 6(5):267-288
G ra h a m G P, J o h n so n S, Dent CM, Fa i rc l o u g h J A Co m pa ri s o n of c l i n i ca l
tests a n d t h e KTl OOO i n t h e d i a g n o s i s of a nte rior c r u c iate l i g a m e n t
ru ptu re. Br J Sports M e d 1 99 1 ;25 (2) :96-97
J o h n so n MW Acute knee effu s i o n s a syste matic a p p roa c h to d i a g n o s i s .
A m Fa m Physicia n. 2000;6 1 (8) 23 9 1 -2400.
J o n ss o n T, A l t h off B, Pete rso n L, Re n st rb m P C l i n i ca l d i a g n o s i s of ru ptu res
of the a nterior c r u c i ate l i g a m ent: a co m p a rative study of the La c h m a n
test a n d t h e a n terior d rawe r s i g n . Am J Sports Med 1 982; 1 0(2) 1 00- 1 02.
Ki m SJ, Ki m H K. Re l i a b i l ity of t h e a nte rior d rawer test, t h e p ivot s h ift test,
a n d the La c h m a n test Clin Orthop Re/a t Res. 1 995;(3 l 7) 23 7-242
va n d e r P l a s CG, O p ste lten W, Devi l l e WL, B ij l D, Bouter LM, S c h o lten RJ
P hysica l d ia g n o s i s-t h e va l u e of s o m e co m m o n tests for the d e m o n
strati o n o f a n a nterior c r u c iate- l i g a m e n t r u pt u re: m eta-a n a lys i s . Ned
TUdschr Geneeskd 2005; 1 49(2) 83-88
va n Eck C F, va n den Bekerom M P, F u FH, Poo l m a n RW, Ke rkh offs G M .
Met h o d s t o d i a g nose a c ute a nterior c r u c iate l i g a m e nt ru ptu re: a
m eta-a n a lys i s of physica l exa m i n a t i o n s with a n d without a n a e st h e s i a .
Knee Surg Sports Tra umata! A rth rosc. 20 1 3;2 l (8) 1 895- 1 903.
308 Section 1 0
SLOCU M TEST WITH I NTERNAL TIBIAL ROTATION

TEST POSITIONING
The s u bject l ies s u p i n e with t h e test h i p fl exed to 45 deg rees, knee
fl exed to 90 deg rees, and tibia i nterna l ly rotated 1 5 to 20 deg rees. The
exa m i n e r sits o n the s u bject's foot with both h a n d s b e h i n d the s u b
I
ject's p rox i m a l t i b i a a n d t h u m bs on the ti bi a p l atea u (Fig u re Kl 0-1 7).
F i g u re K1 0-1 7.
ACTION
Apply an a nterior fo rce to the p roxi m a l t i b i a . The h a m stri ng ten
dons s h o u l d be pal pated freq uently with the i n d ex fi n g e rs to e n s u re
relaxation.
POSITIVE FINDING
I n c reased a nterior t i b i a l d i s p l aceme nt, pa rti c u l a rly of the l atera l
t i b i a l condyle, as c o m p a red to the u n i nvo lved side is i n d i cative of
a ntero l atera l rota ry i n sta b i l ity (seco n d a ry to a partial or co m p l ete
tea r of p r i m a r i l y the ACL a n d postero l atera l ca psu l e) .
Knee 309

The exa m i n e r m u st avoid maxi m a l ly rotati n g the tibia beca use
t h i s wi l l tig hten most of the su rrou n d i n g structu res a n d create a h i g h
potential fo r fa lse-negative fi n d i ngs.
REFERENCES
A n d e rs o n AF, Re n n i rt GW, Sta n d effe r WC J r. C l i n i ca l a n a lys i s of t h e
p ivot s h ift tests descri pt i o n o f t h e p ivot d rawer test. A m J Kn ee Surg
2000; 1 3 ( 1 ) 1 9-23; d is c u s s i o n 23 -24.
S l oc u m DB, J a m e s S I , La rso n RI, S i n g e r KM. A c l i n i ca l test for a nte ro latera l
rota ry i n sta b i l ity of t h e knee. Clin Orthop. l 976; 1 1 8:63-69.
S l oc u m DB, Larson RI. Rotato ry i n sta b i l ity of t h e knee. J Bone Join t Surg A m
1 968;5 0(2):2 1 1 -2 1 5 .
310 Section 1 0
S LOCUM TEST WITH EXTERNAL TIBIAL ROTATION

TEST POSITIONING
The s u bject l ies s u p i n e with the test h i p flexed to 45 deg rees, knee
fl exed to 90 deg rees, and tibia externa l l y rotated 1 5 to 20 degrees. The
exa m i ner sits on the su bject's foot with both hands behind the s u b
I
ject's p roximal tibia a n d th u m bs on the tibia p l atea u (Fi g u re Kl 0-1 8).
F i g u re K1 0-1 8.
ACTION
Apply an a nterior fo rce to the p roxi m a l t i b i a . The h a m string ten
dons s h o u l d be pal pated freq uently with the i n d ex fi n g e rs to e n s u re
relaxation.
POSITIVE FINDING
I n c reased a nterior t i b i a l d i s p l aceme nt, pa rti c u l a rly of the m e d i a l
t i b i a l condyle, c o m p a red to the u n i nvolved side is i n d i cative of
a nteromed i a l rota ry i n sta b i l ity seco n d a ry to d a m a g e to p r i m a r i l y t h e
med i a l co l l atera l l i g a ment (MCL), ACL, a n d postero m e d i a l capsule.
Knee 31 1

The exa m i n e r m u st avoid maxi m a l ly rotati n g the tibia beca use
t h i s wi l l tig hten most of the su rrou n d i n g structu res a n d create a h i g h
potential fo r fa lse-negative fi n d i ngs.
REFERENCES
A n d e rs o n AF, Re n n i rt GW, Sta n d effe r WC J r. C l i n i ca l a n a lys i s of t h e
p ivot s h ift tests descri pt i o n o f t h e p ivot d rawer test. A m J Kn ee Surg
2000; 1 3 ( 1 ) : 1 9-2 3 .
S l oc u m D B , La rson R I . Rotatory i n sta b i l ity o f t h e k n e e . J Bone Join t Surg A m
1 968;5 0(2):2 1 1 -2 1 5 .
3 12 Section 1 0
P IVOT S H I FT TEST
TEST POSITIONING
The s u bject l ies s u p i n e with the test knee in fu l l extension. The
exa m i ner sta nds with the p roximal hand on the s u bject's a nterol ateral
tibiofemoral joi nt, with the t h u m b on o r posterior to the fi b u l a r head.
The d i sta l hand g rasps the s u bject's m idfoot a n d heel (Fig u re Kl 0- 1 9A) .
F i g u re K1 0-1 9A.

Place the s u bject's foot between the exa m i ner's d i sta l a r m a n d
body with the same h a n d o n the t i b i a . T h e p rox i m a l h a n d i s placed
o n the postero l atera l l eg, j u st d i sta l to the kn ee, with the t h u m b on
o r poste rior to the fi b u l a r head ( Fi g u re K l 0-1 98).
Knee 3 13
Figure K1 0-1 9B.
ACTION
I ntern a l ly rotate the ti bi a with the d i sta l h a nd, a p ply a va l g u s fo rce
with the p rox i m a l ha nd, a n d s l owly flex the knee ( Fi g u re Kl 0-1 9C).
The same p roce d u re a p p l ies fo r the a lternate test positi o n i ng, exce pt
a s l i g ht axial load is fi rst a p p l ied to the exte nded knee.
Figure K1 0-1 9C.

3 14 Section 1 0
POSITIVE FINDING
A p a l p a b l e "cl u n k" o r shift at -20 to 30 deg rees of fl exion is i n d i ca
tive of a ntero l atera l rota ry i n sta b i l ity seco n d a ry to tea ring of the AC L
a n d postero l atera l ca p s u l e.

It i s i m p o rta nt to p rovi d e t h e axi a l l o a d befo re flexi n g the kn ee,
as t h i s h e l p s to accentu ate the "c l u n k" or s h ift that wi l l fa c i l itate
d etection of a trace pivot s h ift. I t s h o u l d be n oted that t h i s test
ofte n re p ro d u ces the m e c h a n i s m of i nj u ry, w h i c h may c reate s u b
j ect a nxi ety a n d a p p re h e n s i o n , t h u s i n c re a s i n g t h e pote n t i a l fo r
fa l se-n egative fi n d i n g s . T h i s may be t h e m ost sensitive a n d accu rate
test fo r assess i n g a nteri o r t i b iofe m o ra l i n sta b i l ity. H oweve r, it is d if
fi c u l t to perfo rm a n d s u bject a nxiety red u ces t h e o p portu n ity fo r
t h e c l i n i c i a n to g a i n exp e r i e n ce as c o m p a red to a d m i n iste r i n g other
spec i a l tests.
EVIDENCE
B e nja m i n s e et a l (200 6 ) va n Eck et a l (20 1 3)

Study desig n M eta-a n a lysis M eta-a n a lys is
Co n d it i o n s ACL i nj u ries ACL r u pt u res
eva l u ated
S pec ificity 98 81
REFERENCES
A n d e rs o n A F, Re n n i rt GW, Sta n d effe r WC J r. C l i n i ca l a n a lys i s of t h e
p ivot s h ift tests descri pt i o n o f t h e p ivot d rawer test A m J Knee Surg.
2000; 1 3 ( 1 ) 1 9-23.
Benj a m i n s e A, G o ke l e r A, va n d e r S c h a n s C P. C l i n i ca l d i a g n o s i s of a n a nte
rior c r u c i ate l i g a m e n t ru ptu re: a m eta-a n a lys i s . J Orthop Sports Phys
Th er 2006;3 6(5):26 7-288.
Knee 3 15
Ki m SJ, Ki m H K. Re l i a b i l ity of t h e a nterior d rawer test, t h e p ivot s h ift test,

a n d the La c h m a n test. C/in Orthop Re/a t Res. 1 995;(3 l 7) 23 7-242
va n d e r P l a s CG, O p ste lte n W, Devi l l e WL, B ij l D, Bouter LM, S c h o lten RJ .
P hysica l d i a g n os i s-t h e va l u e of s o m e co m m o n tests fo r t h e d e m o n
strati o n o f a n a nterior c r u c i ate-l i g a m e n t ru ptu re: m eta-a n a lys i s . Ned
TUdsch r Geneeskd 2005; 1 49(2) 83-88
va n Eck C F, va n den B e kerom M P, F u FH, Poo l m a n RW, Ke rkh offs G M .
Met h o d s t o d i a g nose a c ute a nterior c r u c iate l i g a m e nt ru ptu re: a
m eta-a n a lys i s of physica l exa m i n a t i o n s with a n d without a n a e st h e s i a .
Knee Surg Sports Tra umata/ A rth rosc. 20 1 3;2 l (8) : 1 895 - 1 903.
3 16 Section 1 0
J ERK TEST
TEST POSITIONING
The s u bject l ies s u p i n e with the i nvo lved h i p fl exed to 45 deg rees.
The exa m i n er sta n d s next to the i nvo lved side and h o l d s the s u bject's
foot. The exa m i n e r's other h a n d is p l aced ove r the l atera l a s pect of
the kn ee, j u st b e h i n d the head of the fi b u l a ( Fi g u re Kl 0-20A) . The
knee may be s l i g htly flexed. (N ote: Another perk of the acco m pa ny
i n g video is that some of the 2-d i m e n s i o n a l p h otos a re h a rd to deci
pher between i n sti l l i m a g es.)
F i g u re Kl 0-20A.
ACTION
The exa m i n e r passively fl exes t h e s u bject's knee to 90 deg rees
( F i g u re K l 0-208). Then the exa m i n e r exte n d s the s u bject's knee
w h i l e a p p l y i n g a va l g u s fo rce and i nterna l ly rota t i n g t h e t i b i a
( F i g u re K l 0-20C).
Knee 317
Figure K1 0-20B.
F i g u re Kl 0-20C.
POSITIVE FINDING
A s h ift o r "cl u n k" fe lt at 3 0 deg rees of knee fl exion w h i l e t h e knee
i s being exte nded i n d i cates a pos itive test, i m p l icati ng a ntero l atera l
rota ry i n sta b i l ity. If a s h ift is p resent, it w i l l red uce on fu rther pass ive
extension of the knee.
3 18 Section 1 0

Th i s test may n ot be as sens itive as the Pivot S h ift Test.
REFERENCES
D u pont JY, Be l l i e r G . The j e r k-test i n exte r n a l rotation i n ru ptu re of t h e
a nte rior c r u c i ate l i g a m e n t Desc ri pti o n a n d s i g n ifi c a n c e [a rt i c l e i n
F re n c h ] . Rev Ch ir Orth op Repara trice Appa r M a t. l 988;74(5 ) 4 1 3 -42 3 .
G ra h a m G P, J o h n so n 5, D e n t CM, Fa i rc l o u g h J A Com pa rison o f c l i n i ca l
tests a n d t h e KTl OOO i n t h e d i a g n o s i s of a nte rior cruci ate l i g a m e n t
ru ptu re. Br J Sports M e d 1 9 9 1 ;25 (2) 96-97.
Knee 319
POSTERIOR D RAWER TEST

TEST POSITIONING
The s u bject l ies s u p i n e with the test h i p fl exed to 45 deg rees, knee
fl exed to 90 deg rees, and foot i n ne utra l positi o n . The exa m i n e r sits
o n the s u bject's foot with both h a n d s b e h i n d the s u bject's p rox i m a l
tibia a n d t h u m bs on the t i b i a l p l atea u ( Fi g u re K l 0-2 1 ) .
Figure Kl 0-2 1 .
ACTION
Apply a poste rior fo rce to the p roxi m a l t i b i a .
POSITIVE FINDING
I n c reased posterior t i b i a l d i s p l a cement as c o m p a red to the u n i n
vo lved side is i n d i cative of a p a rti a l or co m p l ete tea r of the PCL.

It is i m portant to m a i nta i n q ua d riceps a n d h a m string m u scle
rel axation d u ri n g t h i s test. While a p p l y i n g a poste rior fo rce, the exa m
iner s h o u l d ca refu l ly assess a ny posterior "ste p-off" fro m the t i b i a l
p l atea u on the fe m u r.
320 Section 1 O
EVIDENCE
Study n u m be r 6
S e n s itivity 5 1 to 90
S pec ificity 99
REFERENCES
H u g h ston J C The a bsent poste rior d rawe r test i n s o m e a c ute poste rior
c r u c iate l i g a m e n t tea rs of t h e knee. Am J Sports Med 1 988; 1 6 ( 1 ) : 3 9-43 .
Log a n M, Wi l l ia m s A, Lave l l e J, Ged royc W, F ree m a n M The effect of
poste rior c r u c i ate l i g a m e n t d efi c i e ncy o n knee ki n e m atics. Am J Sports
Med 2004;32(8) 1 9 1 5 - 1 922.
M a l a n g a GA, A n d r u s S, N a d l e r S F, M c lea n J P hys ica l exa m i n at i o n of t h e
k n e e : a review o f t h e orig i n a l test descri pti o n a n d s c i e ntific va l i d ity of
co m m o n o rt h o ped i c tests. A rch Phys Med Rehabil. 2003;84(4) 5 92-603 .
Ritc h i e J R, Be rgfe l d J A , Ka m b i c H , M a n n i n g T I s o l ated secti o n i n g o f t h e
m ed i a l a n d postero m ed i a l ca ps u l a r l i g a m e nts i n t h e poste r i o r c r u c i ate
l i g a m e nt-defi c i e n t knee: i nfl u e n ce on poste rior t i b i a l tra n s l at i o n . A m J
Sports Med l 998;26(3 ) 3 89-394.
Knee 32 1
H UGHSTON POSTEROMEDIAL D RAWER TEST

TEST POSITIONING
The s u bject l i es s u p i n e with t h e test h i p flexed to 45 deg rees,
knee fl exed to 90 d e g rees, a n d t i b i a i ntern a l l y rotated 2 0 to
30 d e g rees. The exa m i n e r sits on the s u bject's foot with both h a n d s
I
b e h i n d t h e s u bject's p roxi m a l t i b i a a n d t h u m bs o n t h e t i b i a p l atea u
( F i g u re Kl 0-2 2 ) .
F i g u re Kl 0-22.
ACTION
POSITIVE FINDING
I
I n c reased poste rior tibia d i s p l aceme nt, p a rticu l a r l y of the med i a l
t i b i a l condyle, co m pa red t o the u n i nvolved s i d e i s i n d icative o f pos
teromed i a l rota ry i n sta b i l ity (seco n d a ry to d a m a g e of p r i m a ri l y the
PCL, postero m ed i a l ca psu l e, MCL, and posterior o b l i q u e l i g a m ent).
322 Section 1 O

It is i m portant to m a i nta i n q u ad riceps a n d h a m string m u scle
iner s h o u l d ca refu l ly assess any poste rior "ste p-off" fro m the t i b i a l
p l atea u o n the fe m u r.
REFERENCES
A n d e rs o n AF, Re n n i rt GW, Sta n d effe r WC J r. C l i n i ca l a n a lysis of t h e
p ivot s h ift tests descri pti o n o f t h e pivot d rawe r test. A m J Knee Surg
2000; 1 3 ( 1 ) : 1 9-2 3 .
H u g h ston JC. T h e a bsent poste rior d ra we r test i n s o m e a c ute poste rior
H u g h ston JC, A n d rews J R, Cross MJ, Mosc h i A The c l a s s ifi cati o n of knee
l i g a m e nt i n sta b i l ities. I . The m ed ica l co m p a rt m e n t and c r u c i ate l i g a
m e nts. J Bone Join t Surg A m 1 976;S8 (2) 1 5 9- 1 72.
Knee 323
H UGHSTON POSTEROLATERAL D RAWER TEST

TEST POSITIONING
The s u bject l ies s u p i n e with the test h i p fl exed to 45 deg rees, knee
fl exed to 90 deg rees, and tibia externa l l y rotated 20 to 3 0 deg rees.
The exa m i n e r sits on the s u bject's foot with both h a n d s be h i n d
t h e s u bject's p roxi m a l t i b i a a n d t h u m bs o n t h e t i b i a l p l atea u
( F i g u re Kl 0-2 3 ) .
Figure Kl 0-23.
ACTION
POSITIVE FINDING
I n c reased posterior tibia I d i s p l a cem ent, pa rticu l a rly of the l atera l
t i b i a l condyle, co m pa red to the u n i nvolved side is i n d icative of pos
tero l atera l rota ry i n sta b i l ity (seco n d a ry to d a m a g e of the PCL, LC L,
postero l atera l ca p s u l e, a n d a rcuate com p l ex) .
324 Section 1 0

It is i m portant to m a i nta i n q u ad riceps a n d h a m string m u scle
iner s h o u l d ca refu l ly assess any poste rior "ste p-off" fro m the t i b i a l
p l atea u o n the fe m u r.
REFERENCES
A n d e rs o n AF, Re n n i rt GW, Sta n d effe r WC J r. C l i n i ca l a n a lysis of t h e
p ivot s h ift tests descri pti o n o f t h e pivot d rawe r test. A m J Knee Surg
2000; 1 3 ( 1 ) : 1 9-2 3 .
H u g h ston JC. T h e a bsent poste rior d ra we r test i n s o m e a c ute poste rior
H u g h ston JC, A n d rews J R, Cross MJ, Mosc h i A The c l a s s ifi cati o n of knee
l i g a m e nt i n sta b i l ities. I . The m ed ica l co m p a rt m e n t and c r u c i ate l i g a
m e nts. J Bone Join t Surg A m 1 976;S8 (2) 1 5 9- 1 72.
H u g h ston JC, N o rwood LA J r. The poste ro l ate ra l d rawer and exte r n a l rota
t i o n rec u rvatu m test fo r poste ro l atera l rotatory i n sta b i l ity of the knee.
Clin Orthop Re/a t Res. l 980; ( 1 47):82-87
Knee 325
POSTERIOR LACH MAN 1S TEST

TEST POSITIONING
The s u bject lies s u p i n e with the test knee fl exed to 20 to 30 deg rees.
The exa m i n er sta n d s with the p roxi m a l h a n d o n the s u bject's d i sta l
t h i g h (latera l ly) i m med iately p roxi m a l to the pate l l a a n d the d i sta l
h a n d on the s u bject's p roxi m a l ti bi a (med i a l ly) i m med iately d i sta l to
the tibia I tu berc l e (Fig u re Kl 0-24) .
Figure Kl 0-24.
ACTION
From a "ne utra l " (anterior-posterior) position, a p ply a poste rior
fo rce to the t i b i a with the d i sta l h a n d while the fe m u r i s sta b i l ized
with the p roxi m a l h a n d .
POSITIVE FINDING
Excess ive posterior tra n s l ation of the tibia (co m p a red to the u n i n
vo lved knee) fro m the neutra l position with a d i m i n ished or a bsent
e n d po i nt i s i n d icative of a pa rti a l o r co m p l ete tea r of the PCL.
326 Section 1 O

If the poste rior Lac h m a n's test is not performed fro m a neutra l
position, t h e i nvo lved knee m a y actu a l ly p resent with decreased
posterior t i b i a l tra n slation com p a red to the u n i nvo lved knee. Th i s
decrease i s most l i kely d u e t o PCL pathology that a l l ows the p roxi m a l
t i b i a t o tra n s l ate posteriorly, t h u s p rod u c i n g decreased poste rior
tra n s l ation a n d s u bseq uent fa l se-neg ative fi n d i n gs. Therefore, the
p resence a n d q u a l ity of the endpoint m u st be determi ned befo re PCL
i nteg rity may be accu rate ly assessed.
EVIDENCE
Study d e s i g n Ra n d o m ized contro l led tri a l
Co n d it i o n s eva l u ated PCL i nj u ries
S a m p l e size 39
S e n s itivity 62
S pec ificity 89
REFERENCES
Coo perma n J M , R i d d l e D L, Rot h ste i n J M . Re l i a b i l ity a n d va l i d ity of J u d g
m e nts o f t h e i nteg rity o f t h e ACL o f t h e k n e e u s i n g t h e Lach m a n's test
Phys Ther l 990;70(4) 225-233
F e l t h a m GT, A l b r i g h t J P. The d i a g n o s i s of PCL i nj u ry: l iteratu re revi ew a n d
i ntrod uction o f two n ovel tests. Iowa Orthop J 200 1 ;2 1 3 6-42 .
R u b i n ste i n R A J r, S h e l bo u r n e K D , Mcca rro l l J R, Va n M eter CD, Rettig A C
The a c c u ra cy o f t h e c l i n ica l exa m i n a t i o n i n t h e sett i n g of poste rior
c r u c iate l i g a m e nt i nj u ries. A m J Sports Med l 994;22(4) 5 50-5 5 7
Knee 327
EXTERNAL ROTATION RECU RVATUM TEST

TEST POSITIONING
The s u bject lies s u p i ne. The exa m i n er sta n d s a n d g rasps a g reat
toe with each h a n d .
ACTION
Lift both legs off the ta b l e (ve rtica l ly) by the g reat toes (Fig u re
Kl 0-2 5).
Figure K1 0-25.
POSITIVE FINDING
An i n c rease i n hype rextension a n d externa l t i b i a l rotation as com
p a red to the u n i nvo lved knee i s i n d i cative of postero l atera l rota ry
i n sta b i l ity (seco n d a ry to d a m a g e of p r i m a r i l y the PCL, LC L, postero
l atera l ca p s u l e, and a rcuate co m p l ex).

It is i m portant for the exa m i ne r to recog n ize that a positive fi n d i n g
m a y n ot be i n d i cative o f a ny path o l ogy a n d i n stead m a y s i m p l y b e
rep resentative o f o n e's n o r m a l j o i n t exte n s i b i l ity.
328 Section 1 0
EVIDENCE
Study d e s i g n Ra n d o m ized contro l led tria l
C o n d iti o n s eva l u ated PCL i nj u ries
S e n s itivity 3
S pec ificity 99
REFERENCES
Coo p e r DE. Tests fo r postero latera l i n sta b i l ity of t h e knee i n n o rm a l s u b
jects. Res u lts of exa m i nation u n d e r a n est h e s i a . J Bone Join t Surg A m
1 99 1 ;73 ( 1 ):30-36
H u g h ston JC, N o rwood LA J r. The poste ro latera l d rawer test and exte r n a l
rotati o n a l rec u rvatu m test fo r postero l ate ra l rotatory i n sta b i l ity of t h e
k n e e . Clin Orthop Re/a t Res. 1 980; 1 47 82-87.
La Prade R F, Ly 1V, G riffit h C. The exte r n a l rotation rec u rvatu m test revis
ited reeva l u at i o n of t h e sag itta l p l a n e t i b i ofe m o ra l re l a ti o n s h i p A m J
Sports Med. 2008;3 6 (4)709-7 1 2 .
La P ra d e RF, We ntorf F. D i a g n o s i s a n d t reatment of postero latera l knee
i nj u ries. Clin Orthop Re/a t Res. 2002;402 1 1 0- 1 2 1 .
Lo u d o n J K, G o i st H L, Lo u d o n KL. G e n u rec u rvat u m syn d ro m e . J Orthop
Sports Phys Ther. l 998;2 7 (5 ) :36 1 -367.
R u b i n ste i n RA J r, S h e l b o u r n e KO, Mcca rro l l J R, Va n M eter CO, Rett i g AC.
The a c c u ra cy of t h e c l i n i c a l exa m i n at i o n in t h e sett i n g of poste r i o r
c r u c i ate l i g a m e n t i nj u ries. A m J Sports Med. l 994;22 (4) :550-5 5 7
Sta u b l i H U , J a ko b R P. Poste r i o r i n sta b i l ity o f t h e k n e e nea r exte n s i o n . A
c l i n ica l a n d stress ra d i o g ra p h i c a n a lys i s of a c ute i nj u ries of t h e poste
rior c r u c i ate l i g a m e nt. J Bone Join t Surg Br 1 990;72 (2) 225-230.
Tri m b l e MH, Bishop M D, B u c kl ey B O, Fields LC, Rozea G D . The re latio n s h i p
betwee n c l i n i ca l m ea s u re m e nts o f l owe r extre m ity postu re a n d t i b i a I
tra n s l at i o n . Clin Biomech (Bristol, A von) 2002; 1 7 (4) 286-290
Knee 329
DIAL TEST (TI BIAL EXTERNAL ROTATION TEST)

TEST POSITIONING
The s u bject lies s u p i n e with t h e test knee in 30 deg rees fl exion a n d
the a n k l e i n neutra l p l a nta r flexi o n/d o rs ifl exion a n d i nve rsio n/eve r
s i o n . The exa m i n er g rasps the s u bject's d i sta l t h i g h ( poste rio rly) with
the p rox i m a l hand and the s u bject's a n kl e fro m the p l a nta r s u rface
with the d i sta l h a n d (Fig u re K l 0-26A) .
Figure Kl 0-26A.
ACTION
With the p roxi m a l h a n d sta b i l iz i n g the s u bject's d i sta l t h i g h, the
exa m i n er maxi m a l l y extern a l l y rotates the s u bject's l owe r leg ( m a i n
ta i n i n g the a n kl e i n a neutra l position) a n d measu res the a m o u nt of
externa l rotation created between the knee a n d m e d i a l border of the
foot (Fig u re K l 0-26 B).
The test i s re peated with the knee i n 90 deg rees of fl exio n (Fig u res
K l 0-26( and K l 0-260).
330 Section 1 0
F i g u re K1 0-26B.
Figure K1 0-26C.
Knee 33 1
Figure Kl 0-260.
POSITIVE FINDING
An i n crease of g reater t h a n 1 0 d e g rees of exte r n a l rotation
(as co m p a red to the contra latera l leg) at 30 degrees but not at
90 degrees i s i n d i cative of a n isol ated postero l atera l corner i nj u ry. A
g reate r-th a n - 1 0-d egree i n c rease at both a n g les is i n d icative of i nj u ry
to both the postero l atera l corner a n d PCL.

Th i s test c a n a l so be perfo r m e d i n t h e s u p i n e positi o n with t h e
knee fl exed ove r t h e s i d e of t h e ta b l e. I t h a s been proposed t h a t
t h e t i b i a l tu b e rc l e be u sed a s t h e reference p o i n t fo r m e a s u r i n g
exte r n a l rota t i o n beca u s e it i s a fixed l a n d m a r k co m p a red to t h e
m o b i l e foot.
332 Section 1 O
EVIDENCE
Kra use et a l (20 1 3)

Study desig n Re l i a b i l ity
Co n d it i o n s Exte r n a l rotation
eva l u ated
S a m p l e size 24
Rel i a b i l ity l ntrateste r ( I CC) 30 d e g rees = .83 to .86
l ntrateste r ( I CC) 90 d e g rees = .87 to .89
l nterteste r ( I CC) 3 0 d e g rees = .74
l nterteste r ( I CC) 90 d e g rees = .83
S e n s itivity N ot eva l u ated
REFERENCES
B l e d a y RM, Fa n e l l i GC, G i a n n otti B F, E d s o n LJ , Ba rrett TA I n stru m e nted
m ea s u re m e n t of the poste ro latera I c o r n e r. A rth roscopy 1 998; 1 4(5) :489-
494.
Coo per DE. Tests fo r postero l ate ra l i n sta b i l ity of t h e knee in n o rm a l s u b
jects. J Bone Joint Surg Am 1 99 1 ;73 ( 1 ) 3 0-36
Dowd G S . Reco n struction of t h e poste rior c r u c i ate l i g a m e n t I n d icat i o n s
a n d res u l ts. J Bone Joint Surg Br 2004;86 (4):480-49 1 .
Kra u s e DA, Levy BA, S h a h J P, St u a rt MJ, H o l l m a n J H , Da h m DL. Re l i a b i l ity of
t h e d i a l test u s i n g a h a n d h e l d i n c l i n o m eter. Knee Surg Sports Traumata!
A rth rosc 20 1 3;2 1 (5) 1 0 1 1 - 1 0 1 6.
La Prade R F, We ntorf F. D i a g n o s i s a n d t reatment of postero latera l knee
i nj u ries. Clin Orthop Re/a t Res. 2002;(402) 1 1 0- 1 2 1 .
Knee 333
VALG US STRESS TEST

TEST POSITIONING
The s u bject lies s u p i n e with the knee i n fu l l exte n s i o n (Fig u re
K 1 0-27A) . The exa m i n er sta n d s with the d i sta l h a n d o n the s u bject's
med i a l a n kl e a n d the prox i m a l h a n d on the knee (l atera l ly) .
Figure K1 0-27A.
ACTION
With the a n kle sta b i l ized, a pply a va l g u s force at the knee with the
proxi m a l ha nd. Th is is performed with the knee i n fu l l extension a n d
repeated with the k n e e i n 20 t o 3 0 deg rees o f flexio n (Fi g u re Kl 0-278).
334 Section 1 O
POSITIVE FINDING
Med i a l knee p a i n a n d/or i n c reased va l g u s m ovement with a
d i m i n ished or a bsent endpoint as co m pa red to t h e u n i nvolved knee
i s i n d i cative of d a mage to pri m ari l y the MCL, PCL, and posteromed i a l
caps u l e w h e n fo u n d i n fu l l extension, a n d MCL w h e n tested i n 20 to
30 deg rees of fl exion.

The exa m i n er m u st avoid a l l owing the fem u r to i ntern a l l y or
externa l ly rotate d u ri n g t h i s test beca use t h i s may g ive the i l l u s i o n of
i n creased va l g u s m ovem ent. Th i s may be acco m p l ished by u s i n g the
treatment ta b l e to h e l p sta b i l ize the s u bject's fem u r ( Fi g u re Kl 0-27C).
Knee 335
Figure Kl 0-27C.
EVIDENCE
Co n d it i o n s eva l u ated MCL i nj u ries
Study n u m be r 3
Rel i a b i l ity
ICC
F l ex i o n 30 deg rees . 5 6
F u l l exte n s i o n .68
REFERENCES
Bon ifa s i- L i sta C, La ke S P, S m a l l MS, We i s s JA Viscoe l a stic properties of t h e
h u m a n m ed i a l co l l ate ra l l i g a m e n t u n d e r l o n g it u d i n a l , t ra n sverse a n d
s h e a r l oa d i n g . J Orthop Res. 2005;23 ( 1 ) 67-76
M a l a n g a GA, A n d r u s S, N a d l e r S F, M c lea n J P hysica l exa m i n a t i o n of the
knee: a revi ew of t h e orig i n a l test d e s c r i pt i o n and s c i e ntific va l i d ity of
co m m o n o rt h o p e d i c tests. A rch Phys Med Rehabil. 2003 ;84(4) :5 92-603
336 Section 1 O
McCl u re PW, Rot h ste i n J M , Ri d d l e D L. l nte rteste r rel i a b i l ity of c l i n ica l j u d g

m e nts o f m ed i a l k n e e l i g a m e n t i nteg rity. Phys Th er. 1 989;69(4) 268-2 75
N a ka m u ra N , H o r i b e S, To ritsu ka Y, Mits u o ka T, Yos h i kawa H , S h i n o K.
Acute g ra d e I l l m ed i a l co l l atera l l i g a m e n t i nj u ry of the knee associ
ated with a nterior c r u c iate l i g a m e n t tea r t h e u sefu l n es s of m a g n etic
reso n a n ce i m a g i n g i n d eterm i n i n g a treat m e n t reg i m e n . A m J Sports
Med 2003;3 l (2) 26 1 -267.
Sawa nt M, N a ra s i m h a M u rty A, I re l a n d J Va l g u s knee i nj u ries: eva l u a t i o n
a n d d oc u m e n tation u s i n g a s i m p l e tec h n i q u e o f stress ra d i og ra p hy.
Knee. 2004; 1 l (1 ):25-28.
Knee 337
VARUS STRESS TEST

TEST POSITIONING
The s u bject lies s u p i n e with the knee in fu l l exte n s i o n (Fig u re K l 0-
28A) . The exa m i n e r sta n d s with the d i sta l h a n d o n the s u bject's l atera l
a n kl e a n d the p rox i m a l h a n d on the knee (med i a l ly).
Figure Kl 0-28A.
ACTION
With the a n kl e sta b i l ized, a pp l y a va rus fo rce at the knee with the
prox i m a l hand. This i s performed with the knee i n fu l l extension a n d
repeated w i t h the k n e e i n 20 t o 3 0 degrees o f k n e e flexi o n ( Fi g u re
K 1 0-28B).
338 Section 1 O
POSITIVE FINDING
Late ra l knee pa i n a n d/o r i n creased va rus move m e n t with a
d i m i n ished or a bsent e n d point as compared to the u n i nvolved
knee i s i n d icative of d a m a g e to pri m ari l y the LC L, PCL, and a rc u ate
co m p l ex when fo u n d at fu l l extension, a n d LC L when tested at 20 to
30 deg rees of fl exion.

The exa m i n er m u st avoid a l l owing the fem u r to i ntern a l ly or
externa l l y rotate d u ri n g t h i s test beca use t h i s may g ive the i l l u s i o n of
i n c reased va rus m ove m e nt. This may be acco m p l ished by u s i n g the
treatment ta b l e to h e l p sta b i l ize the s u bject's fem u r ( Fi g u re Kl 0-28() .
Knee 339
Figure Kl 0-28C.
EVIDENCE
Study d e s i g n M eta-a n a lysis
Co n d it i o n s eva l u ated LCL i nj u ries
Study n u m be r 1
S e n s itivity 25
REFERENCES
Bozku rt M, Yi l maz E, A kse ki D, Havitciog l u H, G u n a l I. The eva l u at i o n of
t h e p roxi m a l t i b iofi b u l a r j o i n t for patients with latera l knee p a i n . Knee.
2004; 1 l (4) 3 0 7-3 1 2 .
H i nterwi m m e r S, Ba u m g a rt R, P l itz W Te n s i o n c h a n g e s i n t h e co l l atera l
l i g a m e nts of a c r u c i ate l i g a m e nt-d efi c i e n t knee j o i nt: a n expe r i m e nta l
b i o m ec h a n i c a l stu dy. A rch Orthop Tra uma Surg 2002; 1 2 2 (8)454-45 8
M a l a n g a GA, A n d r u s S, N a d l e r S F, M c lea n J P hysica l exa m i n a t i o n of t h e
knee: a review o f t h e orig i n a l test description a n d scie ntifi c va l i d ity of
co m m o n o rt h o pe d i c tests. A rch Phys Med Rehabil. 2003 ;84(4) : 5 92-603 .
Q u a r l e s J O, H osey R G . Med i a l a n d l atera l co l l atera l i nj u ries p rog n o s i s a n d
treatment Prim Care. 2004;3 l (4) :957-975, ix.
340 Section 1 O
MCM U RRAY TEST

TEST POSITIONING
The s u bject lies s u p i ne. The exa m i n e r sta n d s with the d i sta l h a n d
g ra s p i n g the s u bject's heel or d i sta l leg (med i a l ly), a n d the prox i m a l
h a n d o n the s u bject's k n e e w i t h the fi ngers pa l pat i n g the med i a l a n d
l atera l j o i n t l i nes (Fig u re K l 0-29A) .
Fig u re Kl 0-29A.
ACTION
With the knee as fu l ly flexed as possi b l e, extern a l ly rotate the
tibia (Fig u re K l 0-298), i ntrod uce a va l g u s fo rce, a n d exte nd the knee
(med i a l men iscus). Repeat with the tibia i ntern a l ly rotated and a
varus fo rce a p p l ied to the knee ( l atera l m e n iscus) (Fig u re Kl 0-29C).
Knee 34 1
Figure Kl 0-298.
Figure Kl 0-29C.
POSITIVE FINDING
A "cl i ck" a l o n g the m e d i a l joint l i n e is i n d i cative of a med i a l men is
c u s tea r. Li kewi se, a "c l ic k" a l o n g the l atera l joint l i n e i s i n d icative of a
latera l men iscus tea r.
342 Section 1 O

The exa m i n er m u st not m i sta ke a pate l l a r "cl ick" o r "pop" fo r m e n is
cal pathol ogy. I t may be d ifficult to accu rate ly pe rform this test if
there i s a fl a p tea r of the m e n i sc u s o r excessive joint swe l l i n g that is
l i m iting ra n g e of moti o n . The exa m i n er s h o u l d a l so be sensitive with
p a l pation a l o n g the joint l i n e beca use this ca n cause s i g n ificant pa i n
t o t h e s u bject (especia l ly i f a m e n iscal tea r i s acco m p a n ied b y a col
latera l l iga ment i nj u ry) .
EVIDENCE
H i n g et a l (2009)
Study d e s i g n Syste matic revi ew
C o n d it i o n s eva l u ated M e n isca l pat h o l ogy
Study n u m be r 9
S e n s itivity 2 7 to 7 1
REFERENCES
Akseki D, P i n a r H , Ka ra og l a n 0. The accu racy of t h e c l i n i ca l d i a g n o s i s of
m e n isca l tea rs with o r wit h o u t associ ated a nterior c r u c i ate l i g a m e n t
tea rs [a rti c l e i n Tu rkish] Acta Orthop Traumata! Turc 2003;3 7 (3) 1 9 3 - 1 98.
Eva n s PJ, Be l l G D , F ra n k C Prospective eva l u at i o n of t h e M c M u rray test.
A m J Sports Med 1 993;2 1 (4) 604-608
Fow l e r PJ, Lu b l i n e r JA The p red i ctive va l u e of five c l i n ica l s i g n s in t h e
eva l u ation of m e n i sc a l pat h o l ogy. Arth roscopy 1 989;5(3) 1 84- 1 86.
H i n g W, Wh ite S, Reid D, M a rs h a l l R. Va l i d ity of the M c M u rray's Test a n d
mod ified ve rs i o n s o f t h e test a syste matic l iteratu re review. J Man
Ma n ip Ther. 2009; 1 7 ( 1 ) 22-35
Ki m SJ, Min B H , Han DY Pa radoxica l p h e n o m e n a of t h e M c M u rray test. A n
a rt h roscopic i nvest i g a t i o n . A m J Sports M e d 1 996;24 ( 1 ) :83-87
Ku rosa ka M, Ya g i M, Yos h iya S, M u ratsu H , M izu n o K. Effi cacy of t h e axi a l ly
loaded pivot s h ift test fo r t h e d i a g n o s i s of a m e n isca l tea r. lnt Orthop
1 999;2 3 (5 ) :2 7 1 -274.
M c M u rray TP. The se m i l u n a r ca rti l a g es . Br J Surg l 942;2940 7-4 1 4.
Knee 343
Metca lf M H , Ba rrett G R. P ros pective eva l u ation of 1 485 m e n isca l tea r pat
terns i n patients with sta b l e knees. Am J Sports Med 2004;3 2 (3) 675-
680.
N evs lm a l L, S kota k M, M ika P, B e h o u n e k J C l i n ica l exa m i n a t i o n of m e n i s c i
i n t h e e ra o f a rt h roscopy [a rti c l e i n Czech] Acta Ch ir Orthop Tra umata/
Cech. 2002;69(2) :88-94
Poo ka rnj a n a m o ra kot C, Ko rsa n t i rat T, Worata n a rat P. M e n isca l l e s i o n s i n
t h e a nte rior c r u c i ate i n s uffi c i e n t knee: t h e a c c u racy of c l i n i ca l eva l u a
t i o n . J M e d Assoc Tha i. 2004;87 (6) 6 1 8-6 2 3 .
S c h o l t e n R J , Devi l l e W L , O p s t e l t e n W , B ij l D, va n d e r P l a s C G , Bouter LM.
The a c c u racy of p hysica l d i a g nostic tests fo r assess i n g m e n isca l l e s i o n s
o f t h e k n e e a m eta-a n a lys i s . J Fa m Pract. 200 1 ;5 0 ( 1 1 ) :938-944
St ratfo rd PW, B i n kley J A revi ew of t h e M c M u rray test: d efi n it i o n , i nterpre
tati o n , a n d c l i n i c a l u sefu l n e s s . J Orthop Sports Phys Ther. 1 995;22(3) 1 1 6-
1 20.
344 Section 1 O
�--- APLEY COMPRESSION TEST

TEST POSITIONING
The s u bject l i es prone with t h e test knee flexed to 90 d e g rees.
The exa m i n e r sta n d s with t h e p rox i m a l h a n d o n the s u bject's d i s
ta l t h i g h fo r sta b i l izat i o n a n d the d i sta l h a n d on the s u bj ect's h e e l
( F i g u re K 1 0-3 0A) .
Figure Kl 0-30A.
ACTION
With the d i sta l h a n d, med i a l ly a n d l atera l ly rotate the tibia w h i l e
a p plying a d ownward fo rce t h ro u g h the heel.
POSITIVE FINDING
Pa i n, cl icking, a n d/or restri ctio n is i n d i cative of either a med i a l or
l atera l men iscus tea r, depen d i n g o n the l ocati o n of sym pto ms.
Knee 345

The test may be repeated with a d i straction fo rce (eg, Apley
D i stracti o n Test) a p p l ied to the a n kl e with the d i sta l h a n d (Fig u re Kl 0-
308). An i n c rease a n d/or c h a n g e i n location of p a i n is m o re i n d ica
tive of l i g a mento u s vers u s m e n isca l pathol ogy. Pa i n a n d/or c l i cking
with a co m p ression test that i s fo l l owed by a n a bsence of the same
sym pto m s with a d i straction test i s most l i kely i n d i cative of m e n i scal
pathol ogy.
Figure K1 0-30B.
346 Section 1 O
EVIDENCE
M a l a n g a et a l Pooka rnj a n a m o ra kot

(2003) et a l (2004)
Study d e s i g n Syste m atic review C ross-sectio n a l
Co n d it i o n s M e n isca l M e n isca l i nj u ries
eva l u ated pat h o l og ies
Study n u m be r 2
S e n s itivity 1 3 to 1 6 16
S pec ificity 80 to 90 1 00
REFERENCES
Fow l e r PJ, Lu b l i n e r J A The p re d i ctive va l u e of five c l i n i ca l s i g n s i n t h e
eva l u ation o f m e n isca l pat h o l ogy. Arth roscopy l 989;5 (3) : 1 84- 1 86.
Ku rosa ka M, Ya g i M, Yos h iya S, M u ratsu H , M izu n o K. Effi cacy of the axia l ly
loaded p ivot s h ift test fo r t h e d i a g n o s i s of a m e n i sca l tea r. lnt Orth op
1 999;2 3 (5 ) 2 7 1 -274.
M a l a n g a GA, A n d r u s S, N a d l e r S F, M c lea n J Physica l exa m i n at i o n of t h e
k n e e : a review o f t h e orig i n a l test descri pti o n a n d scie ntifi c va l i d ity of
co m m o n o rt h o ped i c tests. A rch Phys Med Rehabil. 2003 ;84(4) :5 92-603 .
Poo ka rnj a n a m o ra kot C, Ko rsa nti rat T , Wo rata n a rat P M e n isca l l e s i o n s i n
t h e a nterior c r u c i ate i n s uffi c i e n t k n e e : t h e accu racy o f c l i n ica l eva l u a
t i o n . J M e d Assoc Thai. 2004;87 (6) 6 1 8-6 2 3 .
Knee 347
5TE I N MAN 1S TEN DERN ESS DISPLACEM ENT TEST

TEST POSITIONING
The s u bject l i es s u p i n e with the knee i n fu l l exte n s i o n . The exa m
iner p l a ces the prox i m a l hand under the i nvo lved knee a n d g ra s ps
the a n kl e with the d i sta l h a n d ( Fi g u re Kl 0-3 1 A).
Figure K1 0-3 1 A.
ACTION
The exa m i n er passively m oves the s u bject's i nvolved knee i nto
va ri o u s ra nges of knee fl exi on, fo l l owed by a dyn a m i c m ovement
i nto i nte rnal rotation ( Fi g u re K l 0-3 1 B) a n d exter n a l rotation (Fig u re
K l 0-3 1 C).
348 Section 1 O
F i g u re K1 0-3 1 B.
F i g u re K1 0-3 1 C.
POSITIVE FINDING
A s u bject who either co m p l a i n s of p a i n d u ri n g the rotati o n a l com
ponent or lacks fu l l fl exi o n may h ave a m e n i scal tea r.
Knee 349

It is i m po rta nt to m a i nta i n q u a d riceps a n d h a m stri n g m u scle
rel axation d u ri n g this test. If the s u bject is u n a b l e to o bta i n fu l l fl ex
ion, the exa m i n er may want to perform passive i nte r n a l a n d externa l
rotati o n at the point of maxi m a l ava i l a b l e fl exion a n d assess for any
rep rod uction of pa i n .
EVIDENCE
P o o ka rnja n a m o ra kot et a l (2004)

Study d e s i g n C ross-sectio n a l
C o n d iti o n s M e n isca l i nj u ries
eva l u ated
S pec ificity 1 00
REFERENCES
Dervi n G F, Stie l l I G , Rody K, G ra bows ki J Effect of a rt h rosco p i c d e b ri d e
m e n t fo r osteoa rt h ritis of t h e knee o n hea lth-re l ated q u a l ity of l ife J
Bone Join t Surg Am. 2003;85-A ( l ) : 1 0- 1 9.
Pooka rnj a n a m o ra kot C, Ko rsa nti rat T, Worata n a rat P. M e n isca l lesions in
t h e a nterior c r u c i ate i n s uffi c i e n t knee: t h e a c c u racy of c l i n ica l eva l u a
t i o n . J M e d Assoc Thai. 2004;87 (6) 6 1 8-62 3 .
N evs im a l L , S kota k M, M ika P, Be h o u n e k J C l i n i ca l exa m i n a t i o n o f m e n i s c i
i n t h e e ra of a rt h roscopy [a rti c l e i n Czech] Acta Ch ir Orthop Tra umata!
Cech. 2002;69(2) :88-94
350 Section 1 0
�----- T H ESSALy TEST

TEST POSITIONING
The s u bject sta n d s on o n e leg with t h e knee s l i g htly fl exed
(5 deg rees) (Fig u re Kl 0-32A). The exa m i ner h o l d s both of the s u b
ject's h a n d s to p rovid e s u pport a n d ba l a n ce.
ACTION
The s u bject twists back a n d fo rth 3 t i m es, rotating the knees a n d
body i ntern a l ly a n d externa l ly (Fig u res K l 0-3 2 8 t h ro u g h Kl 0-3 2 0) .
Knee 35 1
F i g u re Kl 0-328.
F i g u re Kl 0-32C.
352 Section 1 O
F i g u re Kl 0-320.
POSITIVE FINDING
Reports fro m the s u bject of m e d i a l or l atera l joint l i n e pa i n or the
sensation of catc h i n g or locking s u g g ests a positive test a n d a n i nj u ry
to a m e n iscus.

Once the test is co m p l eted i n 5 degrees of fl exion, it is repeated i n
20 deg rees o f flexi o n . Ad d itiona l ly, i t i s i m portant t o start t h i s test o n
the u n i nvo lved leg fi rst a n d then p roceed t o the i nvo lved l e g .
Knee 353
EVIDENCE
Ka ra c h a l i o s et M i rzato l o o e i S n o e ke r et a l
a l (2005) e t a l (20 1 0) (20 1 5)
St udy d e s i g n D ia g n ostic D i a g n ostic Re l i a b i l ity a n d
accu racy accu racy d i a g n ostic
accu racy
Co n d it i o n s M e n isca l tea rs M e n isca l tea rs M e n isca l tea rs
eva l u ated
Sa m p l e s ize 21 3 80 1 21
Rel i a b i l ity N ot eva l u ated N ot eva l u ated Ka ppa = .54
S e n s itivity 5 d e g rees 20 d e g rees 20 d e g rees
fl exi o n = 65 fl exi o n = 79 fl exi o n = 67
20 deg rees and 5 1
fl exi o n = 80
Spec ificity 5 d e g rees 20 d e g rees 20 d e g rees
fl exi o n = 83 fl exi o n = 40 fl exi o n = 38
20 deg rees a n d 44
fl exi o n = 9 1
REFERENCES
Ka ra c h a l i o s T, H a ntes M , Z i b i s AH, Zachos V, Ka ra nta n a s AH, M a l izos KN .
D i a g n ostic a c c u ra cy of a n ew c l i n i c a l test (t h e Thessa ly test) fo r ea rly
d etect i o n of m e n i sca l tea rs. J Bone Join t Surg Am. 2005;8 7 (5) 955-962.
M i rzato looei F, Ye kta Z, Bayazi d c h i M, E rs h a d i S, Afs h a r A Va l i d a t i o n of the
Thessa ly test fo r d etecti n g m e n isca l tea rs in a nte rior c r u c i ate d efi c i e nt
knees. Knee 20 1 0; 1 7(3) 2 2 1 -223.
S n oe ke r BA, L i n d e bo o m R, Zwi n d e r m a n A H , Vi n c ke n PW, J a n s e n JA,
L u c a s C. Detect i n g m e n i s c a l tea rs in p ri m a ry ca re: re p rod u c i b i l ity a n d
a c c u ra cy o f 2 we i g ht-bea ri n g a n d 1 n o n -we i g ht-bea ri n g tests [pu b
l i s hed o n l i n e a h ead of p r i n t J u ly 1 0, 2 0 1 5] J Orthop Sports Phys Ther
doi 1 0.25 1 9/j o s pt20 1 5 .5 7 1 2 .
354 Section 1 O
Osrn 's TEST

TEST POSITIONING
The s u bject lies on the side with the h i ps a n d knees exte n d ed so
the test leg is s u perior to the n o ntest leg. The exa m i n e r sta n d s be h i n d
t h e s u bject with t h e prox i m a l h a n d sta b i l izi n g t h e pelvis a n d t h e d i s
ta l h a n d s u p porti n g the l owe r leg (Fig u re K1 0-33A). The knee of the
test leg i s flexed to 90 degrees.
ACTION
The knee of the test leg is fl exed to 90 deg rees. With the pelvis sta
b i l ized to p reve nt ro l l i n g, a bd uct a n d exte nd the test h i p to position
the i l ioti b i a l band be h i n d the g reater troc h a nter (Fig u re K1 0-3 3 B) .
T h e n a l low the leg t o s l owly l ower (ad d u ct) .
Knee 355
Figure K1 0-33 B .
POSITIVE FINDING
The i n a b i l ity of the leg to add uct a n d to u c h the ta b l e is i n d icative
of i l ioti b i a l band (parti c u l a rly the tensor fa sciae latae) tig htness. The
leg wi l l react l i ke a "s p r i n g board" beca use the leg rem a i n s a b d u cted
in m i d - a i r (Fig u re Kl 0-3 3C).
Figure Kl 0-33C. Note: T h e we i g h t o f t h e leg d rops t h e leg toward

the ta ble.
356 Section 1 O

It is i m po rta nt to a p p l y a d ownwa rd fo rce on the i l i u m near the
crest while a l l owing the leg to a d d u ct. Th i s wi l l preve nt l atera l tilt
i n g {ie, i nferior m ove m ent) of the pelvis on the side of the test l eg,
which could g ive a fa lse-negative res u lt. Ad d itional ly, it i s i m po rta nt
to e n s u re co m p l ete re l axati on of the h i p a b d ucto r m u scles. It may
be h e l pfu l to h ave the s u bject actively a d d uct the test leg i nto the
s u pport hand and then re lax to i n h i bit h i p a b d u ctor m u sc l e g u a rd
ing. This test was orig i n a l ly descri bed by Ober to be performed
with the knee flexed to 90 deg rees. H oweve r, it has been mod ified
{ie, Mod ified Ober's Test) beca use it is bel ieved that a g reater stretch
i s placed o n the i l ioti b i a l band when the knee i s in an exte nded posi
tion. Furthermore, perfo r m i n g this test with t h e knee i n fl exion p l aces
g reater te nsion o n the fe moral ne rve, req u i ri n g the exa m i n er to be
cog n iza nt of associated n e u rological co m p l a i nts.
EVIDENCE
Reese a n d Ba n dy Ferber et a l (20 1 0)

(2003)
Study d e s i g n Re l i a b i l ity C ross-sectio n a l
Conditions l l ioti bia l b a n d l l ioti bia l b a n d
eva l u ated t i g h t n ess tig htness
Re l i a b i l ity l ntra rater re l i a b i l ity l nterrater
= . 90 a g reement = 97.6%
S e n s itivity N ot eva l u ated N ot eva l u ated
Spec ificity N ot eva l u ated N ot eva l u ated
REFERENCES
Ferber R, Ke n d a l l KO, M c E l roy L. N o r m at ive a n d critica l criteria fo r i l ioti b i a l
ba n d a n d i l iopsoas m u s c l e fl ex i b i l ity J A th l Tra in. 2 0 1 0;45 (4)3 44-348
F red e ri c s o n M , Wh ite JJ, M a c m a h o n J M , A n d ri a c h i TP. Q u a ntitative a n a lys i s
o f t h e re l ative effective n e s s o f 3 i l ioti b i a l ba n d st retc h e s . A rch Phys Med
Rehabil. 2002;8 3 (5):5 89-592
Knee 357
Gaj d o s i k RL, Sa n d l e r M M , M a r r H L. I nfl u e n ce of knee positi o n s a n d g e n d e r

o n t h e O b e r test fo r l e n gt h o f t h e i l ioti b i a l ba n d . C/in Biomech (Bristol,
A von) 2003; 1 8 ( 1 ) 77-79
G a u t a m VK, A n a n d S A n ew test fo r esti m a t i n g i l ioti b i a l b a n d co ntractu re.
J Bone Join t Surg Br l 998;80(3) 474-475
M a rg o K, D rez n e r J , M otzki n D. Eva l u ation a n d m a n a g e m e n t of h i p pa i n :
a n a l g o rith m i c a p p roa c h . J Fa m Pract. 2003;52 (8) 607-6 1 7 .
M e l c h i o n e W E , S u l l iva n MS. Re l i a b i l ity o f m ea s u re m e nts o bta i n ed by u se
of a n i n stru m e n t d e s i g n e d to i n d i rectly m ea s u re i l ioti b i a l ba n d l e n g t h .
J Orthop Sports Phys Ther l 993; 1 8 (3):5 1 1 -5 1 5 .
O b e r F B . The ro l e of t h e i l ioti b i a l a n d fa s c i a l ata a s a fa cto r i n t h e c a u sa t i o n
o f l ow- b a c k d i s a b i l ities a n d s c i a t i c a . J B o n e Join t Surg. 1 936; 1 8 l 0 5 .
R e e s e N B, Ba n dy WO. U s e o f a n i n c l i n o m ete r to m ea s u re fl exi b i l ity o f t h e
i l ioti b i a l ba n d u s i n g t h e O b e r test a n d t h e mod ified O b e r test d iffe r
e n ces i n m a g n it u d e a n d re l i a b i l ity of m ea s u re m e nts. J Orthop Sports
Phys Ther 2003;33 (6) :326-3 3 0 .
Wi n s l ow J , Yod e r E. Pate l l ofe m o ra l pa i n i n fe m a l e ba l l et d a ncers : corre l a
t i o n w i t h i l ioti b i a l ba n d tig htness a n d t i b i a l exte rna l rotati o n . J Orthop
Sports Phys Ther 1 995;22( 1 ) 1 8-2 1 .
358 Section 1 O
QUAD ACTIVE TEST

TEST POSITIONING
The s u bject lies s u p i n e a n d flexes the knee to 90 degrees (Fig u re
Kl 0-34). The exa m i n er sta b i l izes the s u bject's foot on the ta ble.
F i g u re Kl 0-34.
ACTION
The exa m i n er a s ks the s u bject to contract or "fi re" the q u a d riceps
w h i l e t h e exa m i n e r a p p l ies cou nter p ress u re o n the a n kle.
POSITIVE FINDING
A PCL tea r is s u g gested when the tibia is d i s p l aced by m o re t h a n
2 m m d u ri n g the a c t i o n o f the test.

The exa m i n er s h o u l d c l osely watch the positi o n i n g of the s u bject's
knee t h ro u g hout the motion to accu rate ly eva l u ate d i s p lacement of
the t i b i a .
Knee 359
EVIDENCE
Study n u m be r 2
REFERENCES
M a l a n g a GA, A n d r u s S, N a d l e r S F, M c lea n J Physica l exa m i n a t i o n of t h e
k n e e a review o f t h e orig i n a l test descri pti o n a n d scie ntifi c va l i d ity of
co m m o n o rt h o ped i c tests. A rch Phys Med Rehabil. 2003 ;84(4) :5 92-603
R u b i n ste i n RA J r, S h e l bo u rne KD, Mcca rro l l J R, Va n Mete r CD, Rett i g AC
The a c c u ra cy of the c l i n i ca l exa m i n a t i o n in the sett i n g of poste r i o r
c r u c i ate l i g a m e n t i nj u ries. A m J Sports M e d l 994;22(4) 5 50-5 5 7
360 Section 1 O
LELLI TEST FOR

ANTERIOR (RUCIATE LIGAM ENT (AC L) I NJ U R I ES
TEST POSITIONING
The s u bject lies s u p i n e on a n exa m i nation ta b l e with the legs
extended. The exa m i ner p l a ces a fi st u n der the calf of the i nvo lved
leg, e n s u r i n g that the s u bject's heel re ma i n s o n the exa m ta ble.
ACTION
The exa m i ner uses h i s or her other h a n d to place a downwa rd, l i g ht
force on the d i sta l q u a d riceps of the i nvo lved leg (Fig u re Kl 0-3 5).
Fig u re Kl 0-35.
POSITIVE FINDING
The Le l l i Test is positive when the d ownwa rd, l i g ht fo rce on the
q u a d riceps does not res u lt i n the heel lift i n g off the ta ble. A positive
test s u g g ests a co m p l ete rupture of the ACL. If the foot lifts off the
ta ble, then the test s u g g ests there i s not a rupture of the AC L.
Knee 36 1

The fist u n der the ca lf se rves as a fu lcru m . Pay attention to the
a m o u nt of fo rce placed o n the i nvo lved q u ad riceps. If there i s n o rup
tu re, even a very small a m o u nt of fo rce wi l l res u l t i n the heel lift i n g
off the ta ble. If the AC L i s r u ptu red, even a l a rg e fo rce wi l l n o t res u l t
i n the heel lift i n g o ff the ta ble. Th is test i s a l s o ca l l ed the Leve r S i g n .
EVIDENCE
Le l l i et a l (20 1 4)
C o n d it i o n s eva l u ated ACL tea rs
Re l i a b i l ity Not eva l u ated
S pec ificity 1 00
REFERENCE
Le l l i A, D i Tu ri R P, S p e n c i n e r DB, Dom i n i M . The " Leve r S i g n " a new c l i n i ca l
test fo r t h e d i a g n o s i s of a nte rior c r u c i ate l i g a m e n t ru ptu re [ p u b l i s h e d
o n l i n e a h ea d o f p r i n t Dece m be r 2 5 , 2 0 1 4] Knee Surg Sports Tra umata!
A rth rosc D O i l 0 1 007/sOO l 67-0 1 4-3490-7.

Ankle and Foot
Guide to Figures
Konin JC, Lebsack D , Snyder Valier AR, lsear JAJr.

Special Testsfor Orthopedic Examination, Fourth Edition (pp 363-391).
364 Section 1 1
�----- H OMANS ' SIGN

TEST POSITIONING
ACTION
With the knee of the i nvo lved side fu l l y exte nded, the exa m i n e r
passively d o rsifl exes the s u bject's foot ( Fi g u re A F l 1 - 1 A) .
F i g u re A F 1 1 - 1 A.
POSITIVE FINDING
A p ro d u ction of p a i n i n t h e calf that is b rou g ht on by the pass ive
stretc h of the foot i nto a d o rs iflexed position i s a positive s i g n fo r
II
t h ro m b o p h l ebitis.

Pa i n may a l so be e l i cited o n p a l pation of the calf i n conj u nction
with the passive stretc h (Fig u re AFl 1 - 1 B). A pos itive fi n d i n g i n d icates
a l ife-th reate n i n g co n d ition that s h o u l d be a d d ressed by a p p ro p riate
medical perso n n e l i m mediately.
Ankle and Foot 365
Figure AFl 1 - 1 B. Note: The exa m i n er a p p l ies p ress u re o n t h e gastroc

n e m i u s m u scle w h i l e passively movi ng the a n kle i nto d o rsiflexio n .
REFERENCES
C ra n l ey JJ, C a n o s AJ, S u l l WJ . The d i a g n o s i s of d e e p ve n o u s t h ro m bosis.
Fa l l i b i l ity of c l i n i ca l sym pto m s a n d s i g n s . A rch Surg. 1 9 76; 1 l l ( 1 ) 34-3 6.
H e n riet J P. Pa i n in ve n o u s t h ro m bo s i s of t h e leg [a rt i c l e i n F re n c h ] .
Phlebologie l 992;45 ( 1 )67-76.
Levi M , H a rt W, B u l l e r H R. P h y s i c a l exa m i n a t i o n -t h e s i g n ifi ca n ce
of H o m a n ' s s i g n [a rt i c l e i n D u tc h ] . Ned Tijdsch r Gen eeskd
l 999; 1 43 (3 7) 1 86 1 - 1 86 3 .
Matt h ewson M . A H o m a n s' s i g n i s a n effective m e t h o d o f d i a g n o s i n g
t h ro m bo p h l e bitis i n bed r i d d e n patients. Crit Care Nurs. 1 983;3 (4) 64-65 .
Ng KC. Deep ve i n t h ro m bo s i s a st u d y i n c l i n i ca l d i a g n o s i s . Singapore Med
J l 994;3 5 (3):286-289
Sa n d l e r DA H o m a n ' s s i g n a n d m e d i c a l ed u cat i o n . Lancet. 1 985;
2 (8464) 1 1 3 0- 1 1 3 1 .
11
·
Wa n g CJ, Wa n g JW, C h e n LM, et a l . Deep ve i n t h ro m bo s i s after tota l knee
a rt h ro p l a sty. J Formos Med Assoc 2000;99(1 l ) 848-8 5 3 .
_
366 Section 1 1
�--- ANTERIOR D RAWER TEST

TEST POSITIONING
The s u bject is seated at t h e end of a ta b l e with the knee fl exed
a n d the i nvo lved foot rel axed in s l i g ht p l a nta r fl exi o n . The exa m i n e r
sta b i l izes t h e t i b i a a n d fi b u l a with o n e h a n d a n d g ra s ps the calca n e u s
w i t h the o t h e r (Fig u re AF 1 1 -2A). Th is m a y a l so be performed w i t h the
s u bject i n a p ro n e position (Fig u re AF 1 1 -2 B) .
Figure A F 1 1 -2A.
II
Ankle and Foot 367
Figure A F 1 1 -2 B .
ACTION
W h i l e e n s u r i n g sta b i l ization of the d i sta l tibia a n d fi bu la, the exa m
iner a p p l ies a n a nterior fo rce to the ca lcaneus a n d ta l u s.
POSITIVE FINDING
Anterior tra n s lation of the ta l u s away fro m the a n kl e m o rtise that
i s g reater o n the i nvo lved side, o p posed to the n o n i nvolved side,
i n d icates a positive s i g n fo r a poss i b l e a nterior ta l ofi b u l a r l ig a m e n t
s p ra i n .

The knee is fl exed to 90 deg rees to red u ce the ten sio n on the
g a stroc n e m i u s m u sc l e. Th i s test s h o u l d be performed b i l atera l ly fo r
comparison. Swel l i n g wit h i n the a n kle j o i nt may red uce the a b i l ity to
11
·
tra n s l ate the ta l u s a nteri orly. A mod ified version ca n be performed i n
the prone positi o n .
_
368 Section 1 1
EVIDENCE
S c h w i ete rm a n et a l Sman et al (20 1 3)

(20 1 3)
Co n d it i o n s An kl e/l owe r leg A n kl e syn d e s m o s i s
eva l u ated pat h o l og ies i nj u ry
Rel i a b i l ity N ot eva l u ated l n tra rate r re l i a b i l ity:
46% to 92%
a g re e m e n t
l n terrater re l i a b i l ity:
ICC = .06
S pec ificity 1 00 43
REFERENCES
Ba h r R, P e n a F, S h i n e J , et a l . M e c h a n ics of t h e a n terior d rawer a n d ta l a r
t i l t tests. A c a d averic study o f latera l l i g a m e n t i nj u ries o f t h e a n kl e . A cta
Orthop Scand l 997;68(5)43 5-44 1 .
Be u m e r A, va n H e m e rt WL, Swie rstra BA, J a s p e r LE, Bel koff S M . A b i o m e
c h a n i ca l eva l u a t i o n of c l i n i ca l stress tests fo r syn d e s m otic a n kl e i n sta
b i l ity. Foot A n kle lnt 2003 ;24(4) :358-363.
Co razza F, O'Co n n o r JJ, Lea rd i n i A, Pa renti Ca ste l l i V L i g a m e n t fi b re
rec r u i t m e n t a n d fo rces fo r t h e a n terior d rawe r test at t h e h u m a n a n kl e
j o i nt. J Biomech. 2003;3 6 (3 ) 3 63-3 72.
F uj i i T, L u o Z P, Kita o ka H B, A n KN . The m a n u a l stress test m a y n ot be
II
s u ffi c i e n t to d i fferentiate a n kl e l i g a m e n t i nj u ries. Clin Biomech (Bristol,
A von) 2000; 1 5 (8):6 1 9-6 2 3 .
H e rte l J , O e n eg a r CR, M o n roe M , Sto kes WL. Ta l o c r u c ra l a n d s u bta
l a r j o i nt i n sta b i l ity after l atera l a n kl e s p ra i n . Med Sci Sports Exerc
1 999;3 1 ( 1 1 ) 1 5 0 1 - 1 508.
Ka n be K, H a seg awa A, N a kaj i m a Y, Ta ka g i s h i K. The re l a ti o n s h i p of t h e
a nterior d rawe r s i g n to t h e s h a pe of t h e t i b i a I p l afo n d i n c h ro n i c latera l
i n sta b i l ity of t h e a n kl e . Foot Ankle lnt 2002;23 (2) 1 1 8- 1 2 2 .
Ankle and Foot 369
Ke rkh offs GM, B l a n kevoo rt L, Sc h re u rs AW, J a s pe rs J E, va n Dij k C N . An

i n stru m e nted, dyn a m i c test fo r a nterior l a xity of the a n kl e j o i n t com
p l ex. J Biomech. 2002;3 5 ( 1 2) 1 665- 1 670.
Li u W, M a it l a n d M E, N i g g B M . The effect of axi a l l o a d o n t h e in vivo a nteri
o r d rawe r test of t h e a n kl e j o i n t co m p l ex. Foot Ankle lnt. 2000;2 1 (5) :420-
426.
Lyn c h SA Asse s s m e n t of the i nj u red a n kl e in the ath l ete. J Athl Train.
2002;3 7 (4) :406-4 1 2 .
Ray RG, C h riste n s e n JC, G u s m a n D N . Critica l eva l u at i o n of a n terior
d rawe r m ea s u re m e n t m et h o d s in t h e a n kl e . Clin Orthop Re/a t Res.
1 997;(3 34) 2 1 5-224.
Sc hwiete r m a n B, H a a s D, Co l u m be r K, Kn u p p D, Cook C D i a g nostic
accu ra cy of p h ys i c a l exa m i n at i o n tests of the a n kl e/foot co m p l ex: a
syste matic revi ew. lnt J Sports Phys Ther. 20 1 3;8(4) :4 1 6-426.
S m a n AD, H i l l e r CE, Refs h a u g e KM . D i a g n ostic a c c u racy of c l i n i ca l tests fo r
d i a g n o s i s of a n kl e syn d e s m o s i s i nj u ry a syste matic revi ew. Br J Sports
Med 20 1 3;47 ( 1 0):620-628
Sti e l ! I G , M c Kn i g ht RD, G ree n be rg G H , N a i r RC, M c Dowe l l I , Wa l l ace GJ.
l nte ro b s e rver a g re e m e n t in t h e exa m i n a t i o n of a c ute a n kl e i nj u ry
patients. Am J Emerg Med 1 992; 1 0 ( 1 ) 1 4- 1 7.
To hya m a H , Beyn n o n BD, Re n strom PA, Th e i s MJ, F l e m i n g BC, Pope M H .
B i o m ec h a n i c a l a n a lys i s o f t h e a n kl e a nterior d rawe r test fo r a n terior
ta l ofi b u l a r l i g a m e n t i nj u ries. J Orth op Res. 1 99 5 ; 1 3 (4) 609-6 1 4.
To hya m a H , Ya s u d a K, O h ko s h i Y, Beyn n o n B D, Ren strom PA Anterior
d rawe r test fo r a c ute a nte rior ta l ofi b u l a r l i g a m e n t i nj u ri e s of t h e a n kl e .
H ow m u c h l o a d s h o u l d be a p p l ied d u ri n g t h e test? A m J Sports Med
2003;3 l (2) 226-232
II
370 Section 1 1
l ALAR Tl lT TEST ( I NVERSION)
TEST POSITIONING
The s u bject lies on the u n i nvo lved side on a ta b l e with the i nvo lved
foot rel axed and the knee s l i g htly fl exed. The exa m i n er sta b i l izes the
d i sta l tibia with one h a n d w h i l e g ra s p i n g the ta l u s with the other.
ACTION
The exa m i n er fi rst places the foot in the a nato m i c a l position (neu
tra l p l a ntar fl exi o n a n d d o rs ifl exion). The exa m i n e r then ti lts the ta l u s
i nto a n a d d u cted position (Fig u re A F l 1 -3 ) .
F i g u re A F 1 1 -3 .
II
POSITIVE FINDING
Range of motion i n the adducted position on the i nvolved foot
g reater than that of the non i nvolved foot revea l s a positive test. This
may be i n d icative of a tea r of the ca lcaneofi b u l a r liga ment of the a n kle.

The knee is fl exed to 90 deg rees to red u ce the tension on the
comparison. Perfo rm i n g t h i s test with the a n kl e i n a m o re p l a nta r
Ankle and Foot 371
flexed position places l e s s stress o n the calcaneofi b u l a r l i ga ment a n d

i n stead m a y stress the a nterior ta l ofi b u l a r l i g a ment. Swe l l i n g with i n
t h e a n kl e joint m a y red u ce t h e a b i l ity t o tra n s l ate t h e ta l u s.
EVIDENCE
Schwiete r m a n et a l (20 1 3)
Co n d it i o n s eva l u ated An kle/lower leg pat h o l og ies
Study n u m be r 1
S e n s itivity 50
S pec ificity 88
REFERENCES
Ba h r R, P e n a F, S h i n e J , et a l . M ec h a n ics of t h e a n terior d rawe r a n d ta l a r
t i l t tests. A c a d averic study o f latera l l i g a m e n t i nj u ries o f t h e a n kl e . A cta
Orthop Sca nd. 1 997;68(5 ) :435-44 1 .
F uj i i T, L u o Z P, Kita o ka H B, An K N . The m a n u a l stress test may n ot be
s uffi c i e nt to d ifferentiate a n kl e l i g a m e n t i nj u ries. Clin Biomech (Bristol,
A von) 2000; 1 5 (8):6 1 9-6 2 3 .
G a e b l e r C, Ku kla C, B reite n s e h e r MJ, et a l . D i a g n o s i s o f l atera l a n kl e l i g a
m e n t i nj u ries co m pa ri s o n betwee n ta l a r ti lt, M R I , a n d o p e rative fi n d
i n g s i n 1 1 2 ath l etes. Acta Orthop Sca nd. l 997;68 (3) 286-290
G l a s g ow M, J a c ks o n A, J a m i e s o n A I n sta b i l ity of the a n kl e after i nj u ry to
t h e latera l l i g a m ent. J Bone Join t Br l 980;62(2) : 1 96-200.
H e rte l J , D e n eg a r CR, M o n roe MM, Sto kes WL. Ta l o c r u c ra l a n d s u b
II
ta l a r j o i n t i n sta b i l ity after latera l a n kl e s p ra i n . Med Sci Sports Exerc
1 999;3 1 ( 1 1 ) 1 5 0 1 - 1 508
H o l l i s J M , B l a s i e r R D, F l a h iff C M S i m u l ated l atera l a n kl e l i g a m e n to u s i nj u ry.
C h a n g e i n a n kl e sta b i l ity. Am J Sports Med. l 995;23 (6) 672-677
Schwiete rm a n B, Haas D, Col u m be r K, Kn u p p D, Cook C D i a g n ostic
a c c u ra cy of p hysica l exa m i nation tests of t h e a n kl e/foot co m p l ex a
syste matic revi ew. lnt J Sports Phys Ther 20 1 3;8(4) :4 1 6-426.
372 Section 1 1
TALAR TllT TEST ( EVERSION)

TEST POSITIONING
The s u bject l ies on the i nvo lved side on a ta b l e with the i nvo lved
foot rel axed and the knee s l i g htly fl exed. The exa m i n er sta b i l izes the
d i sta l tibia with one h a n d w h i l e g ra s p i n g the ta l u s with the other.
ACTION
The exa m i n er fi rst places the foot in the a nato m i c a l position (neu
tra l p l a ntar fl exi o n a n d d o rs iflexi on). The exa m i n e r then ti lts the ta l u s
i nto a n a b d u cted position (Fig u re A F l 1 -4).
F i g u re A F l 1 -4.
II
POSITIVE FINDING
R a n g e of motion i n the a b d u cted position on the i nvo lved foot
g reater t h a n that of the n o n i nvolved foot revea l s a positive test. Th i s
m a y be i n d i cative o f a tea r o f the deltoid l i g a ment o f the a n kle.
Ankle and Foot 373

The knee i s fl exed to 90 deg rees to red u ce the ten s i o n o n the
comparison. Perfo r m i n g t h i s test with the a n kl e i n varyi n g d e g rees
of p l a nta r fl exi o n may assess d iffe rent co m po n e nts of the d e ltoid
l i g a ment. Swe l l i n g with i n the a n kl e joint may red uce the a b i l ity to
tra n s l ate the ta l u s.
REFERENCES
F uj i i T, L u o Z P, Kita o ka H B, A n K N . The m a n u a l stress test may n ot be
s u ffi c i e n t to d iffe re ntiate a n kl e l i g a m e n t i nj u ries. Clin Biomech (Bristol,
A von). 2000; 1 5 (8):6 1 9-6 2 3 .
L e i t h J M , Mcco n key J P, Li 0, M a s ri B. Va l g u s stress ra d i o g ra p hy i n n o rm a l
a n kl e s . Foot Ankle lnt. 1 997; 1 8 ( 1 0) 654-65 7 .
II
374 Section 1 1
�----- THOM PSON TEST

TEST POSITIONING
The s u bject lies p rone on a ta b l e with the heels p l aced ove r the
edge of the ta b l e.
ACTION
With the gastroc n e m i u s-so l e u s co m p l ex re laxed, the exa m i n er
s q u eezes the b e ll y of these m u sc l es (Fig u re AFl 1 -5).
POSITIVE FINDING
When sq u eezi ng the calf m u sc l es, a n o r m a l response wo u l d be to
II
have the foot p l a ntar flex. Therefore, a n a bsence of p l a nta r fl exion o n
squeezi ng wo u l d be a pos itive test, i n d icat i n g a poss i b l e r u pt u re of
the Ach i l les te n d o n .
Ankle and Foot 375
EVIDENCE
Schwiete rm a n et a l (20 1 3)
C o n d it i o n s eva l u ated A n kl e/lower leg pat h o l og ies
Study n u m be r 1
S e n s itivity 96
S pec ificity 93
REFERENCES
O'Brien T The n eed l e test fo r co m p l ete ru ptu re of t h e Ac h i l les' te n d o n .
J Bone Join t Surg A m . 1 984;66 (7) : 1 099- 1 1 0 1 .
Schwiete rm a n B, H a a s D, Col u m be r K, Kn u p p D, Cook C D i a g n ostic
a c c u ra cy of p hysica l exa m i n a t i o n tests of t h e a n kl e/foot co m p l ex a
syste matic revi ew. lnt J Sports Phys Ther 20 1 3;8(4) 4 1 6-426.
Th o m pson TC A test fo r ru ptu re of the te n d o a c h i l l i s . Acta Orthop Scand
l 962;3 2 46 1 -465.
Th o m pson TC, Do h e rty J H . S p o n ta n e o u s ru pt u re of te n d o n of t h e
Ac h i l l e s a n ew c l i n i ca l d i a g nostic test. J Tra uma. l 962;2 1 26- 1 29.
II
376 Section 1 1
TAP OR PERCUSSION TEST

TEST POSITIONING
The s u bject l ies s u p i n e with the affected leg exten d ed a n d the
a n kl e/foot j u st off the exa m i n i n g ta b l e. The exa m i n er sta nds at the
end of the ta b l e next to the s u bject's foot.
ACTION
The exa m i n er positions the s u bject's a n kl e i nto a maxi m a l dorsi
fl exion to opti m ize j o i nt co n g ru e n cy and a p p l ies a fi rm ta p to the
botto m of the s u bject's heel (Fig u re AFl 1 -6).
F i g u re A F 1 1 -6.
II
POSITIVE FINDING
Pa i n at the site of i nj u ry is i n d i cative of a fra ctu re. The vibration of
ta p p i n g a l o n g the l o n g axis of the bones wi l l exag g e rate p a i n at the
fractu re s ite.

Ankle and Foot 377
�------ FEISS LI N E
TEST POSITIONING
The s u bject sits on the exa m i n i n g ta b l e with the i nvo lved leg
extended. The exa m i n e r p l aces a mark at the tip of the med i a l mal
leolus a n d at the base of the fi rst metata rso p h a l a ngeal joi nt. A line i s
t h e n d rawn between the 2 poi nts a n d the exa m i n e r n otes the posi
tion of the navic u l a r tuberosity (Fig u re AFl 1 -7 A) .
F i g u re A F 1 1 -7A. N ote: The b l a c k c i rc l e d en otes t h e location of t h e

navicu l a r bone.
ACTION
The s u bject is a s ked to sta nd with the feet 3 to 6 i n ches a pa rt. The
11
·
exa m i n er e n s u res the m a rks a re sti l l positioned ove r the med i a l m a l -
l e o l u s a n d fi rst m etata rso p h a l a n geal joint a n d then a g a i n n otes the
position of the navi c u l a r tuberosity (Fig u re A F 1 1 -7B).
_
378 Section 1 1
•
•
F i g u re A F 1 1 -7B. N ote: The b l a c k c i rc l e d en otes t h e location of t h e

navi c u l a r bone.
POSITIVE FINDING
The navic u l a r tuberosity s h o u l d be i n l i n e with the other 2 poi nts.
If the navi c u l a r tu berosity i s below the l i n e w h i l e the s u bject i s seated,
the s u bject has co n g e n ita l pes p l a n u s. If the navicu l a r tuberosity is
in l i n e with the other 2 poi nts w h i l e the s u bject i s seated and it then
fa l l s below the line when the s u bject sta n d s, fu ncti o n a l pes planus i s
i n d icated.

Th i s test may denote va rying deg rees of pes p l a n u s d e pend i n g
o n h ow fa r t h e navi c u l a r d rops t o the fl oor. Pes p l a n u s m a y a l so b e
i n d i cative o f hyperpronation. A mod ified Feiss L i n e m a y be used i n
w h i c h t h e orig i n a l positi o n i n g o n t h e med i a l m a l l e o l u s i s m oved to
II
a para l l e l point on the Ac h i l les tend o n . The point on the base of the
fi rst m etata rso p h a l a n gea l joint re ma i n s the same. The new Feiss Line
goes t h ro u g h the navicu l a r i n the neutra l foot. It i s t h o u g ht that t h i s
mod ification m a y m a ke it e a s i e r fo r c l i n ic i a n s to identify h i g h -a rched
(Feiss Line a bove the navi c u l a r) a n d l ow-a rc hed (Feiss Line below the
navicu l a r) i n d ivi d u a ls.
Ankle and Foot 379
EVIDENCE
S p o r n d ly- N ees et a l (20 1 1 )

Study d e s i g n Re l i a b i l ity
C o n d iti o n s eva l u ated Navic u l a r b on e positio n i n g
Rel i a b i l ity l ntra rater re l i a b i l ity: ICC = .94
l nterrater re l i a b i l ity: ICC = .9 1
REFERENCES
Ca s h m e re TB, S m it h RM, H u nt AM Med i a l l o n g it u d i n a l a rc h of the foot:
stati o n a ry vers u s wa l ki n g m ea s u res. Foot A n kle ln t. l 999;20(2) : 1 1 2- 1 1 8.
G i l m o u r JC, B u r n s Y The m e a s u re m e n t of t h e m ed i a l l o n g it u d i n a l a rc h i n
c h i l d re n . Foot A n kle lnt. 200 1 ;22 (6) 493-498
H o l m e s C, Wi l cox D, F l etc h e r J Effect of a mod ified, l ow-dye m e d i a l
l o n g it u d i n a l a rc h ta p i n g p roced u re o n t h e s u bt l e r j o i n t n e u t ra l
position befo re a n d afte r l i g ht exe rc i se. J Orthop Sports Phys Ther.
2002;3 2 (5) 1 94-20 1 .
Ko meda T, Ta n a ka Y, Ta ka ku ra Y, F uj i i T, S a m oto N , Ta m a i S Eva l u at i o n
o f t h e l o n g it u d i n a l a rc h of t h e foot w i t h h a l l u x va l g u s u s i n g a
newly deve l o ped two-d i m e n s i o n a l coord i n ate syste m . J Orthop Sci.
200 1 ;6(2) 1 1 0- 1 1 8.
S p o r n d ly-Nees S, Das berg B, N i e l s e n RO, Boesen M l , La n g berg H . The
navi c u l a r position test-a re l i a b l e m ea s u re of t h e n a vi c u l a r b o n e posi
t i o n d u ri n g rest and l oa d i n g . lnt J Sports Phys Ther. 2 0 1 1 ;6 (3) 1 99-205.
Wi l l i a m s D, McClay I . Mea s u re m e n ts u sed to c h a racte rize t h e foot
II
a n d the m ed i a l l o n g it u d i n a l a rc h re l i a b i l ity a n d va l i d ity. Phys Ther
2000;80 (9) 864-8 7 1 .
Ya kut Y, Ot m a n S, Liva n e l i og l u A, Uyg u r F. Eva l u ation of t h e foot a rc h e s i n
ba l l et d a n cers. J Da nce Med Sci. 1 997; 1 (4) 1 3 9- 1 42.
380 Section 1 1
I NTERDIG ITAL N EU ROMA TEST

TEST POSITIONING
The s u bject sits on the exa m i n i n g ta b l e with the i nvo lved leg
extended. The exa m i n e r sta n d s next to the i nvo lved foot a n d places
one h a n d a ro u n d the metata rsa l heads (Fig u re AFl 1 -8).
ACTION
The exa m i n er s q u eezes the s u bject's metata rsa l heads toget h e r
a n d h o l d s fo r 1 t o 2 m i n utes.
POSITIVE FINDING
II
Pa i n, t i n g l i ng, o r n u m bness i n the foot, toes, or a n kl e is i n d i cative
of an i nterd ig ita l n e u ro m a . If positive, the p a i n is u s u a l l y re l i eved
when pressu re i s re l eased.

Pa i n between m etata rsa l heads is i n d icative of M o rto n's neu ro m a .
T h e m ost common l ocation i s between the t h i rd a n d fou rth metata r
sal heads.
Ankle and Foot 38 1
REFERENCES
Coug h l i n MJ, P i n s o n n ea u l t T O p e rative treat m e n t of i nterd i g ita l n e u ro m a .
A l o n g -te rm fo l l ow- u p stu dy. J Bone Join t Surg A m . 200 1 ;83 (9) 1 3 2 1 -
1 3 28.
G i a n n i n i S, Bacc h i n i P, Cecca re l l i F, Va n n i n i F. l nterd i g ita l n e u ro m a c l i n i ca l
exa m i n at i o n a n d h i sto path o l o g i c res u lts i n 63 cases t reated with exc i
s i o n . Foot Ankle ln t. 2004;25 (2) :79-84.
Sta matis ED, Ka ra b a l i s C. l nterd i g ita l n e u ro m a s : c u rre n t state of t h e a rt
s u rg i ca l . Foot Ankle Clin. 2004;9(2) :287-296
Wu K. M o rt o n n e u ro m a a n d m etata rsa l g i a Curr Opin Rh e u m a tol.
2000; 1 2 (2): 1 3 1 - 1 42 .
II
382 Section 1 1
COM PRESSION (SQUEEZE) TEST

TEST POSITIONING
The s u bject l ies s u p i n e with the affected leg exten d ed a n d the
a n kl e/foot j u st off the exa m i n i n g ta ble. The exa m i n er sta n d s n ext to
the s u bject's leg a n d n otes where the pa i n orig i n ates.
ACTION
The exa m i n er s q u eezes the ti bi a a n d fi b u l a together at some point
away fro m t h e pai nfu l a rea (Fig u re AF l 1 -9).
POSITIVE FINDING
II
Pa i n at the site of i nj u ry may be i n d i cative of a fractu re. Com p ression
of the 2 bones may exaggerate pa i n at the fracture s ite.
Ankle and Foot 383

Th i s test s h o u l d not be performed if there is an o bvi o u s deformity.
A positive test is not exc l u s ive of a fractu re. It is reco m m e n d ed that
a n x-ray be o bta i n ed when suspicion of a fract u re exists. A variation
of the Co m p ress i o n Test, a l s o ca l l ed t h e S q u eeze Test, ca n a l so be
u sed to eva l u ate syndesmosis i nj u ries. Th i s mod ification req u i res that
the co m p ress i o n be a p p l ied a bove the m i d point of the ca lf. A posi
tive test with this mod ification i s pa i n l ocated ove r the syndesmosis
l i g a m e nts.
EVIDENCE
S c h w i ete rm a n et a l Sman et al (20 1 3)

(20 1 3)
St u d y d e s i g n Syste m atic review Syste matic review
Co n d it i o n s An kl e/l owe r leg Syn d es m o s i s i nj u ries
eva l u ated pat h o l og ies
St u d y n u m be r 1 2
Sa m p l e s ize 56
Rel i a b i l ity N ot eva l u ated l n tra rate r re l i a b i l ity:
88% to 92%
a g re e m e n t
l n terrater re l i a b i l ity:
ICC .46 to .49
=
S e n s itivity 30 5 7 to 1 00
Spec ificity 93 1 4 to 63
REFERENCES
11
·
Sc hwiete r m a n B, H a a s D, Co l u m be r K, Kn u p p D, Cook C D i a g nostic
accu racy of p h ys i c a l exa m i n at i o n tests of t h e a n kl e/foot co m p l ex: a
syste matic review /nt J Sports Phys Ther 20 1 3 ;8 (4) : 4 1 6-426.
_
S m a n AD, H i l l e r CE, Refs h a u g e KM . D i a g n ostic a c c u ra cy of c l i n i ca l tests fo r
d i a g n o s i s of a n kl e syn d e s m o s i s i nj u ry a syste matic review Br J Sports
Med 20 1 3 ;4 7 ( 1 0) 620-628
384 Section 1 1
LONG BONE COMPRESSION TEST

TEST POSITIONING
The s u bject sits with the affected leg exten d ed a n d t h e foot off the
e n d of the exa m i n i n g ta ble. The exa m i n er sta n d s at the end of the
ta ble near the s u bject's foot.
ACTION
The exa m i n er a p p l ies co m p ression a l o n g the l o n g axis of the bone
of the toe o r metata rsa l being tested (Fig u re A F l 1 - 1 0) .
F i g u re A F 1 1 - 1 0.
POSITIVE FINDING
II
Pa i n at the site of i nj u ry is i n d i cative of a fra ctu re.

Ankle and Foot 385
SWI NG TEST
TEST POSITIONING
The s u bject s h o u l d sit with the foot over the edge of the ta b l e. The
exa m i n er sta n d s in fro nt of the s u bject and p l a ces both h a n d s ove r
the d o rsu m of the s u bject's foot to keep it p a ra l l e l to the fl oor. The
exa m i n er pal pates the a nte rior as pect of the s u bject's ta l u s with the
t h u m bs ( Fi g u re A F 1 1 - 1 1 A) .
Figure A F 1 1 - 1 1 A.
ACTION
Pa ssively p l a nta r flex a n d d o rs iflex the a n kl e a n d observe the level
of m oveme nt, especi a l l y with do rsifl exion (Fig u re A F l 1 - 1 1 B).
II
386 Section 1 1
F i g u re A F l 1 - 1 1 B.
POSITIVE FINDING
A pos itive test is revea l ed on resi sta nce i nto d o rsiflexion. This i n d i
cates posterior t i b i ota l a r s u b l uxati o n .

I m a g i n g tests s h o u l d a l ways be co nsidered when excessive joint
motion i s obse rved to be s u re there i s n o u n derlying fractu re.
II
Ankle and Foot 387
KLEIGER 1S TEST
TEST POSITIONING
The s u bject sits with the leg off of the table a n d the knee at
90 deg rees of fl exio n . The exa m i n e r sta b i l izes the d i sta l tibia a n d
fi b u l a with o n e h a n d a n d the med i a l a n d i nferior a s pects o f the ca l ca
neus with the other h a n d . The a n kle s h o u l d be in a neutra l ly a l i g ned
position (Fig u re A F 1 1 - 1 2A) .
Figure A F 1 1 - 1 2A.
ACTION
The exa m i n er a p p l ies an extern a l ly rotated fo rce on the ca l ca n e u s.
The test is re peated with the a n kl e i n a d o rsifl exed position (Fig u re
A F l 1 - 1 2 8) .
II
388 Section 1 1
F i g u re A F 1 1 - 1 2B.
POSITIVE FINDING
Co m p l a i nts of p a i n a l o n g the med i a l a s pect of the a n kl e when a n
externa l ly rotated fo rce i s a p p l ied i n neutra l d o rsiflexion m a y i n d i
cate a deltoid l i g a ment i nj u ry. When the a n kl e is d o rsifl exed a n d a n
externa l ly rotated fo rce i s a p p l ied, p a i n m a y b e p resent med i a l ly a n d
s l i g htly m o re p roxi m a l ly, i n d icat i n g d i stal ti bi ofi b u l a r syn desmotic
i nvo lvem ent.

The syn desmosis may be i nj u red when the foot is fixated a n d a sig
n ifica nt rotat i o n a l force i s a p p l ied. Th is is often referred to a s a " h i g h
a n kl e s p r a i n " a n d m a y be very pai nfu l t o the s u bject w h e n re p rod u c
tion of the rotati o n a l torq u e is a p p l ied.
II
Ankle and Foot 389
REFERENCES
Be u m e r A, va n H e m e rt WL, Swie rstra BA, J a s p e r L E, Bel koff S M . A b i o m e
c h a n i c a l eva l u at i o n of c l i n i ca l stress tests fo r syn d e s m otic a n kl e i n sta
b i l ity Foot A n kle lnt. 2003;24(4) 3 5 8-363
Ca n d a l-Couto JJ, B u rrow D, B ro m a g e S, Briggs PJ I n sta b i l ity of t h e ti b io
fi b u l a r sy n d e s m o s i s : h ave we been p u l l i n g in t h e wro n g d i rectio n ?
Injury 2004;3 5 (8) :8 1 4-8 1 8 .
Ki n o s h ita M, O k u d a R, M o r i kawa J, J otoku T, Abe M . The d o rsiflexion
eve r s i o n test fo r d i a g n os i s of ta rsa l t u n n e l syn d ro m e . J Bone Join t Surg.
200 1 ;83-A( l 2) 1 83 5 - 1 839.
Sei l e r H . The u p per a n kl e j o i n t B i o m ec h a n ics and fu nctio n a l a n atomy
[a rti c l e in G e r m a n] Orthopade. l 999;28 (6) 460-468
II
390 Section 1 1
�----- T1 N E L 1S S1GN
TEST POSITIONING
The s u bject typica l l y l ies s u p i n e.
ACTION
The exa m i n e r uses h i s or her fi nger to ta p ove r the med i a l a s pect
of the a n kle where the posterior t i b i a l nerve i s most s u perfic ial
(Fig u re A F l 1 - 1 3).
F i g u re A F 1 1 - 1 3 .
POSITIVE FINDING
Pa i n o r ti n g l i n g that ra d i ates a l o n g t h e pathway of the poste
II
rior t i b i a l n e rve i s i n d i cative of potenti a l ta rsa l t u n n e l syndrome.
Co m p ression of t h e poste rior tibial n e rve i n t h e ta rsa l t u n n e l wi l l
res u lt i n refe rred sym pto m s t o t h e med i a l a n d p l a nta r reg i o n s of
the foot.
Ankle and Foot 39 1

A positive test s i m p l y refe rs to the fa ct that the poste rior t i b i a l
nerve h a s b e e n co m p ro m ised. The nerve itse lf co u l d be u n derg o i n g
co mpression, a s wo u l d be s e e n w i t h infl a m mation wit h i n the tarsa l
t u n n el, or it cou l d be u n derg o i n g traction, as is the case with a hyper
p ron ated foot.
EVIDENCE
S c h w i ete rm a n et a l (20 1 3)
Co n d it i o n s eva l u ated An kle/lower leg pat h o l o g ies
Study n u m be r 1
S e n s itivity 58
S pec ifi c ity N ot eva l u ated
REFERENCES
Ba i l i e OS, Ke l i ki a n AS. Ta rsa l tu n n e l syn d ro m e d i a g n o s i s , s u rg i ca l tec h
n i q ue, a n d fu n cti o n a l o utco m e . Foot A n kle lnt. l 998; 1 9(2) 65-72.
Co u g h l i n MJ, P i n s o n n ea u lt T Operative trea t m e n t of i nterd i g ita l n e u ro m a :
a l o n g -te rm fo l l ow- u p stu dy. J Bone Join t Surg. 200 1 ;83-A(9) 1 3 2 1 - 1 3 2 8 .
Fa b re T, Piton C, A n d re 0, La sse u r E, O u ra n dea u A. Pero n ea l n e rve e nt ra p
m e nt. J Bone Join t Surg A m 1 998;80 ( 1 ) :47-5 3
Sc hwiete rm a n B, H a a s 0, Col u m be r K, Kn u p p 0, Cook C D i a g n ostic
a c c u ra cy of p hysica l exa m i n at i o n tests of t h e a n kl e/foot co m p l ex a
11
·
syste matic review !nt J Sports Phys Ther. 20 1 3;8(4) :4 1 6-426.
S h o o kste r L, Fa l ke G I , O u c i c I , M a l o n ey CT J r, De l l o n AL. F i b ro mya l g i a a n d
Ti n e l 's s i g n i n t h e foot. J A m Podia tr Med Assoc 2004;94(4) :400-403
_

Contemporary
Special Tests
Guide to Figures

Fourth Edition (pp 393-406).
394 Section 1 2
I M P I NGEM ENT REDUCTION TEST

TEST POSITIONING
The s u bject is seated or sta n d i n g with the a r m at rest a n d the
s h o u l d e r i ntern a l ly rotated ( Fi g u re CST l 2 - 1 A).
F i g u re CST1 2-1 A.
ACTION
The exa m i n er passively fo rwa rd-flexes the i nvo lved a r m w h i l e
m a i nta i n i n g s h o u l d e r i ntern a l rotation (Fig u re CSTl 2 - 1 B) . Th i s motion
i s then repeated w h i l e the exa m i n er a p p l ies a n inferior g l id e to the
h u mera l head ( Fi g u re CSTl 2 - 1 C).
Con temporary Special Tests 395
Figure CST1 2-1 B.
Figure CST1 2-1 C.

396 Section 1 2
POSITIVE FINDING
The re port i n g of s h o u l d e r j o i nt pa i n is i n d i cative of a positive test.
Pa i n repo rted d u ri n g pass ive s h o u l d e r fl exion i s i n d i cative of a pos
s i b l e s u bacro m i a l i m pi n ge m e nt. Absence of such p a i n on re peated
pass ive fl exion, acco m p a n ied by an inferior g l i d e to the h u meral
head, confi r m s structu ra l i m p i n g e m ent. Pa i n repo rted with both
pass ive s h o u l d e r fl exion and pass ive s h o u l d e r fl exio n with an i n ferior
h u mera l head g l i de red uces the l i ke l i hood of s u bacro m i a l i m p i nge
ment a n d wa rra nts fu rther eva l u ative test i n g .

Th i s test can be mod ified either by test i n g i n the fro nta l p l a n e o r
the p l a n e o f the sca p u l a o r b y p l a c i n g the s h o u l d e r i n exte r n a l rota
tion to assess va rious compon ents of the g l e n o h u meral co m p l ex fo r
i m pi n g e m ent.
WALKI NG ARM STRESS (WAS) TEST

TEST POSITIONING
The s u bject l i es rel axed a n d s u p i n e on the exa m i nation ta b l e with
a rm s at side ( Fi g u re CST l 2-2A).
Figure CST1 2-2A.
ACTION
The exa m i n er sta n d s at the head of the exa m i nation ta b l e a n d
p l aces the pa l m o f e a c h h a n d u n d e r e a c h o f the s u bject's sca pu lae
( Fi g u re CSTl 2-2 B). The s u bject i s asked to exte nd o n e a r m i nto the
ta b l e fo rcefu l ly w h i l e the exa m i n e r s i m u lta n eously a ssesses the
a m o u nt of p ress u re fe lt u n d e r the sca p u lae. The test i s repeated with
the other arm. The s u bject i s a s ked to a l tern ate exte n d i n g each a r m
i nto the ta b l e w h i l e the exa m i n er co m pa res b i l atera l pressu re a p p l ied
to the pa l m of the h a n d .
398 Section 1 2
F i g u re CST1 2-28.
POSITIVE FINDING
La ck of sca p u l a p res s u re fe lt on the contra l atera l test i n g side i s
i n d i cative o f a decreased effo rt.

S u bjects who a p p l y fo rcefu l s h o u l d er exte n s i o n i nto the ta b l e wi l l
l i kely u s e t h e contra l atera l sca p u l a fo r sta b i l ization. Th is wi l l b e n oted
by the exa m i n er. O n the contra ry, s u bjects who d o not a p ply a true
effort wi l l te nd to sta b i l ize the centra l portion of the u p per tru n k, not
a p plying u n i l atera l pressu re u n der the contra l atera l ly tested sca p u l a .
Th is test s h o u l d be used t o co nsider m a l i n g e r i n g a n d n ot t o r u l e out
any s pecifi c pathol ogy.
�---- F I NGER EXTENSION TEST

TEST POSITIONING
The s u bject is seated with the h a n d in a rest i n g positi o n .
ACTION
The exa m i n er fi rst atte m pts to passively exte nd the i nvo lved d i sta l
i nterpha l a n g e a l ( D I P) or p roxi m a l i nterp h a l a n g ea l ( P I P) joint i nto fu l l
exte n s i o n (Fig u re CSTl 2-3A). The exa m i n e r then a s ks t h e s u bject to
gently atte m pt to actively exte nd t h e i nvo lved D I P or P I P joint a g a i n st
m i n i m a l resista nce p rovided by the exa m i n er ( Fi g u re CSTl 2-3 B).
Figure CST1 2-3A.

400 Section 1 2
F i g u re CST1 2-38.
POSITIVE FINDING
I n a b i l ity to actively o r pass ive ly exte n d the i nvo lved D I P or P I P
j o i nt i s co n s i d e red a pos itive test (Fig u re CST1 2-3(). If t h e j o i n t i s
u n a b l e t o be exte nded both actively a n d passively, one m u st co nsid
e r ca psu l o l iga mento u s restricti o n s o r acute swe l l i n g a n d/or pa i n . The
a b i l ity to exte nd the i nvo lved joint passively but i n a b i l ity to exte nd
the same i nvolved joint a ctively i s l i kely i n d i cative of a n exte nsor
te ndon d is r u ption.
Con temporary Special Tests 40 1
Figure CST1 2-3C.

The exa m i n e r s h o u l d a p p l y o n l y l i g ht res i sta nce a g a i n st active
j o i n t exte n s i o n fo r t h e p u rposes of assess i n g a ny n oticea b l e con
tract i o n . M o d e rate to maxi m a l res i sta nce i s not e n c o u raged beca use
a ny te n d o n d i s r u pt i o n may beco m e co m p l i cated with i n c reased
contracti l e effo rts. I f a te n d o n d i s r u pt i o n i s s u s pected, this test
s h o u l d n ot be repeated fo r d e m o n strati o n , confi rmation, o r e d u
cati o n a l p u rposes beyo n d what i s n ecessary fo r c l i n i c a l d i a g nosis.
402 Section 1 2
F LEXOR P RONATOR SYN DROME TEST

TEST POSITIONING
The s u bject is seated with t h e i nvo lved fo rea rm rest i n g on a
ta b l e with the e l bow i n a position of 90 d e g rees of fl exi o n ( F i g u re
CST l 2-4A) .
F i g u re CST1 2-4A.
ACTION
The exa m i n e r attem pts to "s h a ke h a n d s" with the s u bject. The s u b
ject is then asked to pron ate the fo rea rm (Fig u re CSTl 2-48).
Figure CST1 2-48.
POSITIVE FINDING
Pa i n a n d/or m u scle wea kness is co n s i d e red a positive s i g n for a
fl exo r pronator m u scu l ote n d i n o u s i nj u ry.

The exa m i n e r d oes not need to a p p l y m u ch res i sta n ce w h i l e the
s u bject atte m pts to p ro nate the fo rea rm. An acute i n fl a m matory
response wi l l e l icit a pai nfu l effort o n the p a rt of the s u bject.
404 Section 1 2
TARSAL TWIST TEST

TEST POSITIONING
The patient is seated on a ta b l e with knees fl exed to 90 deg rees.
The i nvo lved a n kl e i s p l aced in ne utra l d o rs ifl exion/pla ntar fl exio n .
T h e exa m i n er sta b i l izes the rea rfoot (s u bta l a r joi nt) w i t h one h a n d
a n d g ra s ps the forefoot w i t h the o p pos ite h a n d ( Fi g u re CSTl 2-SA).
The d i sta l h a n d placement s h o u l d be in the reg ion of the ta rso meta
ta rsa l joi nts.
F i g u re CST1 2-SA.
ACTION
W h i l e e n s u r i n g sta b i l ization of the s u bta l a r joi nt, the exa m i ner
a p p l ies a m e d i a l rotatory fo rce (Fi g u re CSTl 2-S B) a n d a l atera l rota
tory fo rce (Fig u re CSTl 2-SC) t h ro u g h the m idfoot. The test i s per
fo rmed to stress the l i g a mento u s sta b i l izers of the ta loca lcaneona
vicu l a r joi nt, the c u n eonavi c u l a r joi nt, the calcaneocuboid joi nt, the
c u boideonavicu l a r joi nt, t h e c u n eocuboid joi nt, the i ntercu neiform
j o i nt, a n d the ta rso metata rsa l joi nts.
Figure CST1 2-58.
Figure CST1 2-SC.
POSITIVE FINDING
Pa i n i n the reg ion of the m i dfoot i s a positive fi n d i n g fo r a m idfoot
s p ra i n . The location of the pa i n may assist the c l i n ic i a n in identify
i n g the exact location of the i nj u ry with reg a rd to the joi nts of the
m i dfoot.
406 Section 1 2

Th i s test may a l so be performed with the patient i n the s u p i n e
o r long-sitt i n g positi o n . Th i s test s h o u l d n ot be performed if there i s
o bvious d eform ity p resent.
M i dfoot i nj u ries a re co m m o n l y fo u n d in association with l atera l
a n kl e s p ra i n s. Th i s is p a rti c u l a rly true w h e n the a n kl e is i n a p l a nta r
fl exed position a n d t h e m i dfoot i s fo rced i nto a s u p i n ation (twi st
i n g) moti o n . Ad d it i o n a l ly, i nj u ries to the m i dfoot ca n res u lt fro m
repeated tra u ma, as seen i n d i sta n ce r u n n e rs. Overuse i nj u ries to
t h e m i dfoot a re m ost co m m o n ly associated with excessive prona
t i o n d u ri n g g a it.

----- F I NANCIAL DISCLOSU RES
Jerome A. "Joi" /sear, Jr. h a s n o t d i scl osed any rel eva nt fi n a n c i a l
re l ation s h i ps.
Dr. Jeff G. Konin h a s n o fi n a n c i a l o r proprietary i nterest i n the mate

ria l s p resented here i n .
Dr. Denise Lebsack has n o fi n a n c i a l o r proprietary i nterest i n t h e

materi a l s p rese nted h e re i n .
Dr. Edward G . McFarland h a s n o fi n a n c i a l o r p ro p rietary i nterest i n

t h e materi a l s p rese nted h e re i n .
Dr. Alison R . Snyder Valier h a s no fi n a n c i a l o r p ro p rietary i nterest i n

t h e materi a l s p rese nted h e rei n .

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Jeff G .

Ko n i n, P h D, ATC, PT, FACSM, F N ATA

Den i se Le bsack, P h D, ATC

School o f Exe rcise & N utriti o n a l Sciences

San Diego State U n i versity

Al ison R. S nyd er Va l i e r, P h D, ATC, F N ATA

J e ro m e A. "Ja i " lsear, J r., M S, PT, LAT, ATC

H o l ly B rader Marakovits, M P H , RN, BSN, ATC

Copyrig ht © 20 1 6 by S LACK I n corporated

The proce d u res and practices described in this p u b l ication s h o u l d be i m p l e m e nted

Any review o r mention of specific c o mp ani e s o r products is not intended a s an

P u b l ished by: SLACK I n corporated

N a mes: Ko n i n , J eff G ., a u t h o r. I Lebsack, Den ise, a u t h o r. I Va l i e r, Al ison

Title: Special tests fo r orthopedic exa m i nation I J eff G . Kon i n , Denise

Lebsack, A l i s o n Snyder Va l i e r, Jerome A. "Ja i " lsear, J r.

For permission to reprint materia l i n a n other p u b l ication, contact SLACK I n corporated.

-Jeff G. Konin, PhD, ATC, PT, FACSM, FNATA

To my fa m i ly, fri ends, a n d co l l eagues.

-Alison R. Snyder Valier, PhD, ATC, FNATA

To M itzie, Brooks, Ha rrison, a n d Ja ckso n,

Section 1 : Tem poro m a n d i b u l a r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Loa d i n g Test . . . . . . . . . . . . . . . . . . ......... . . . . . . . . . . . . . . . ..... . . . 4

Ve rtebral Artery Test . . . . . .............. . . . . . ..................8

Em pty Ca n (S u p ras p i n atus) Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

L u d i n gton's Sign . . . . . . . . . . . . . . ...... . . . . ..... . . . . . . . . . . . . . . . . 29

Apl ey's Sc ratch Test . . . . . . . . . . ........... . . . . . . . . . . . . . . . . . . . . . 36

Acro m i oclavicu l a r (AC) J o i nt Distraction Test . . . . . . . . . . . . . . . . . 49

Roos Test (Elevated Arm Stress Test) . . . . . . . . . . . . . . . . . . . . . . . . . . 90

J e rk Test (Posterior Stress) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Resistive Te n n i s El bow Test (Cozen's Test) . . . . . . . . . . . . . . . . . . . . 1 02

Resistive Te n n i s El bow Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 04

E l bow Flexion Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Va rus Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Long F i n g e r F l exion Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 25

Reve rse P h a l e n Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 32

D i g ital A l l e n 's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 41

Va l g u s Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Va rus Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 53

Late ra l a n d Anterior/Posterior R i b Co m p ression Tests . . . . . . . . 1 61

I n s p i ration/Ex p i ration B reat h i n g Test . . . . . . . . . . . . . . . . . . . . . . . . 1 63

90-90 Stra i g ht Leg Raise Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 76

Bowstring Test (Cra m Test) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 78

Sitti ng Root Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 81

U n i l atera l Stra i g ht Leg Raise Test (Laseg u e Test) . . . . . . . . . . . . . 1 83

B i l atera l Stra i g ht Leg Raise Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 87

We l l Stra i g ht Leg Raise Test (Crossed Stra i g ht Leg Ra ise) . . . . . 1 89

Trendel e n b u rg 's Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Sto rk Sta n d i n g Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Section 8: Sacral S p i n e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

Sacroi l iac (S I) Joint Fixation Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

G i l let Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Sacroi l iac (S I) Joint Stress Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

Yeoma n's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Gaensle n's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Patrick o r FAB E R Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Lo ng-Sitt i n g Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

Section 9 : Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Hip Sco u ri n g/Q u a d ra nt Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

Cra i g 's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

90-90 Stra i g ht Leg Raise Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

Patrick or FAB E R Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

Trendel e n b u rg 's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

Obe r's Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

Alison R. Snyder Valier, PhD, ATC, FNATA i s a Professor fo r the Post

ru l i n g o ut, a n d m o n ito r i n g the status of a p a rticu l a r d i a g nostic co n d i