9/21/2017 Ovid: Operative Techniques in Orthopaedic Surgery

Editors: Wiesel,, Sam W.

Title: Operative Techniques in Orthopaedic Surgery, 2nd Edition

Copyright ©2016 Lippincott Williams & Wilkins

> Table of Contents > Volume 1 > Part 1 ‐ Sports Medicine > Exam Table for Sports Medicine

Exam Table for Sports Medicine

Examination Technique Illustration Grading &

Significance

The Shoulder

Range of The examiner Average normal

motion (ROM) observes active ROM: forward
and passive flexion 180
ROM for degrees,
forward abduction 180
elevation (20 to degrees,
30 degrees in adduction 50
sagittal plane), degrees, internal
external rotation at the
rotation and side 80 degrees,
internal external rotation
rotation (both at the side 90
at side and 90 degrees. Loss of
degrees of ROM may
abduction). indicate adhesive
capsulitis,
rotator cuff
pathology
(tendinitis or
rotator cuff
tear),
degenerative
changes. ROM is
compared to
contralateral
side. Patients
with
impingement
may have limited
internal rotation
from posterior
capsular
tightness. Active
motion is
typically more
painful than
passive motion,
especially in
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descending phase
of elevation.

Jobes sign Arm is placed in Weakness or pain

(“empty can” 90 degrees of represents
test) elevation in the dysfunction of
scapular plane the supraspinatus
with the hand tendon.
in the thumbs‐
down position.
Manual
resistance is
provided by the
examiner to
elevation and
weakness or
pain is
recorded.

Resisted Arm is placed in Weakness

external full adduction, represents
rotation in elbows are bent dysfunction or
adduction at 90 degrees, tearing of the
and the infraspinatus
shoulder is tendon.
internally
rotated 20 to
30 degrees.
Manual
resistance is
provided by the
examiner to
external
rotation, and
weakness is
recorded.

Apprehension With the Patients with

test patient supine, anterior
the arm is instability will
passively have
abducted to 90 apprehension in
degrees and this position. This
externally will resolve with
rotated. The posterior force
examiner can on the proximal
then push the humerus.
proximal
humerus
posteriorly
(relocation).

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Kim test With the A sudden onset of
patient seated, posterior
the arm is shoulder pain is
placed in 90 considered a
degrees of positive test
abduction and result. A positive
the elbow and Kim test is
hand are suggestive of a
supported by posterior inferior
the examiner. labral tear or
An axial and subluxation.
upward
elevating force
of 45 degrees is
applied to the
distal arm while
an inferior and
posterior force
is applied to
the proximal
arm.

Neer Passive Presence or

impingement elevation of the absence of pain
sign arm while or facial grimace.
stabilizing the This maneuver
scapula compresses the
critical area of
the supraspinatus
tendon against
the anterior
inferior
acromion,
reproducing
impingement
pain. The pain
will resolve
following
subacromial
lidocaine
injection.

Hawkins sign The examiner Presence or

forward flexes absence of pain.
the shoulder to This maneuver
90 degrees and compresses the
then passively supraspinatus
internally tendon against
rotates the the
shoulder. coracoacromial
ligament,
reproducing the
pain of
impingement.
High sensitivity

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but low
specificity.

Painful The patient is Abduction is

abduction arc asked to abduct compared to the
the arm in the contralateral
coronal plane. side. Pain from
60 to 120 degrees
(maximally at 90)
suggests
impingement.
Patients may
externally rotate
at 90 degrees to
clear the greater
tuberosity from
the acromion and
increase motion.

Yergason test Resistance of Positive or

attempted negative. A
forearm positive test is
supination with defined as one in
the elbow which the patient
flexed to 90 experiences
degrees and the shoulder pain in
forearm in a the bicipital
pronated groove with this
position maneuver.
Suggestive of
biceps
tendonopathy in
appropriate
clinical context.

Lift‐off test Arm is brought Ability to

into maximal maintain active

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passive internal maximal internal
rotation behind rotation with
the back with hand off the
the hand off lumbar spine
the spine by without
the examiner; extending the
the examiner elbow. Inability
releases the indicates
hand in this impaired
position. subscapularis
function.

Belly‐press Hand is placed Ability to

test on abdomen; maintain
patient presses maximum
abdomen with internal rotation
flat hand and without the
attempts to elbow dropping
keep arm in posterior to the
maximum midsagittal plane
internal of the trunk.
rotation and Inability
the elbow indicates
anterior to the impaired
mid‐sagittal subscapularis
plane of the function.
trunk.

Napoleon test The patient Negative test:

(modified presses his or the patient is
belly press) her hand able to “strike
against the the pose.”
belly at the Intermediate
umbilicus. The test: wrist flexed
wrist should be 30 to 60 degrees.
straight and the Positive test:
elbow in front wrist flexed 90
of the body. degrees and

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This creates the elbow posteriorly
classic pose positioned.
seen in pictures Negative test:
of Napoleon. less than 50% of
the subscapularis
tendon is torn.
Intermediate
test: more than
50% of the
subscapularis
tendon is torn.
Positive test: the
entire
subscapularis
tendon is torn.
With a significant
subscapularis
tendon tear the
patient flexes
the wrist, the
elbow drops
backward, and
the posterior
deltoid acts to
pull the hand
against the belly.

Bear hug test The patient Negative test:

places the hand the physician is
of the affected unable to pull
extremity on the patient's
the opposite hand off the
shoulder. The shoulder. Positive
elbow is test: the
elevated in a physician is able
forward to pull the
position and patient's hand off
the wrist and the shoulder. The
fingers are bear hug test is
straight and the most
collinear. The sensitive test for
physician an upper
attempts to subscapularis
pull the hand injury (eg, a
off the patient's partial tear
shoulder while involving the
the patient superior aspect
resists. of the
subscapularis
tendon).

External Arm is Inability to

rotation lag positioned in maintain the
sign full adduction shoulder in a
with the elbow fully externally
at 90 degrees rotated position

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of flexion and indicates is
the shoulder in positive for
maximal significant
external dysfunction or
rotation by the tearing of the
examiner. infraspinatus
Inability of the muscle.
patient to
maintain
shoulder in an
externally
rotated position
is recorded.

Hornblower Arm is Ability to fully

sign positioned in 90 externally rotate
degrees of in an abducted
abduction with position indicates
the elbow good teres minor
flexed to 90 function.
degrees and the Weakness or
shoulder in inability to
neutral achieve full
rotation. external rotation
External in abducted
rotation of the position indicates
shoulder to a teres minor
position of full dysfunction or
abduction‐ tearing.
external
rotation is
performed and
weakness or
inability to
achieve full
external
rotation is
noted.

ROM The examiner Normal ROM is 0

observes active to 150 degrees
and passive flexion‐
ROM (flexion‐ extension, 80
extension of degrees
the elbow, pronation‐
rotation of the supination;
forearm) and functional ROM is
compares it to 30 to 130 degrees
the uninjured flexion‐
side. Palpable extension, 50
and auditory degrees
crepitus should pronation‐
be noted. supination.
Locking of the
elbow could
represent loose

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bodies. Stiffness
may indicate
intrinsic capsular
contracture.

Effusion The examiner Most clinicians

palpates the simply grade as
posterolateral none, mild,
gutter of the moderate, large.
elbow and Normally, fluid is
ballotes the not present.
soft tissue. Effusion indicates
intra‐articular
irritation and
may be
consistent with a
loose or unstable
osteochondritis
dissecans lesion
or loose body.

Capitellum Examiner's Most clinicians

tenderness thumb pushes just grade this as
against the none, mild,
posterior moderate, or
capitellum significant pain.
while taking Tenderness may
the elbow be present with
through a range

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of motion of osteochondritis
flexion to dissecans.
extension.

Active Forearm Most clinicians

radiocapitellar pronation and just grade this as
compression supination with none, mild,
test the elbow in moderate, or
full extension is significant pain.
performed. This test loads
the
radiocapitellar
joint in
pronation. Pain
on pronation that
is reduced in
supination may
be present in
osteochondritis
dissecans.

Milking With forearm Maneuver

maneuver fully supinated, eliciting pain,
elbow is placed apprehension, or
in greater than instability is
90 degrees of indicative of
flexion. The ulnar collateral
examiner pulls ligament (UCL)
on the patient's insufficiency.
thumb. Posterior bundle
of anterior band
of UCL.

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The Knee

ROM The examiner Normal ROM is 0

observes to 145 degrees
passive and and 60 degrees of
active ROM— pronation and
flexion‐ supination. Loss
extension; of extension
pronation‐ (flexion
supination. contracture) is
frequently
present. Loss of
pronation is less
common. May be
due to capsular
irritation, loose
bodies, or
displaced
chondral flap.

Lachman test With the knee Anterior

flexed 30 displacement
degrees, the more than the
examiner normal side
stabilizes the indicates an
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thigh with the anterior crucial
hand that is ligament injury.
closest to the
head and uses
the other hand
to passively
displace the
proximal tibia
anteriorly.

Posterior With knee in 70 0

= no abnormal
drawer test to 90 degrees translation; 1 = 1
of flexion, a to 5 mm; 2 = 6 to
posterior‐ 10 mm (but
directed force medial tibial
is applied to plateau [MTP]
the proximal not beyond
tibia. medial femoral
condyle [MFC]); 3
= >10 mm, or
translation of
MTP beyond MFC.
When compared
to contralateral
knee, may be
indicative of
posterior
cruciate
ligamentdeficient
knee.

Varus and A valgus and Classically,

valgus laxity varus force is displacement of
applied to the <5 mm is
knee in both 30 considered a
degrees of grade I injury, 5
flexion and full to 10 mm a grade
extension. II injury, and >10
mm a grade III
injury. Opening
in full extension
implies a
combined injury
to the collateral
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ligament and at
least one
cruciate
ligament.

Dial test With the Difference of

patient in more than 10
prone position, degrees at 30
the tibia is degrees is
externally consistent with
rotated at 30 injury to
and 90 degrees. posterolateral
The foot‐to‐ corner (PLC).
thigh angle is Difference of
compared more than 10
between the degrees at 90
two legs. degrees is
consistent with
injury to PLC and
posterior
cruciate
ligament.

Varus With the Suggestive of

recurvatum patient supine, posterolateral
test the examiner rotatory
lifts both feet instability of the
by the big toes knee.
and watches for
varus
angulation,
hyperextension,
and external
rotation of the
tibia.

McMurry test With the A click produced

patient supine by the McMurray
and the knee test usually is
acutely and caused by a
forcibly flexed, posterior
the examiner peripheral tear of
can check the the meniscus and
medial occurs between
meniscus by complete flexion
palpating the of the knee and

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posteromedial 90 degrees.
margin of the Popping, which
joint with one occurs with
hand while greater degrees
grasping the of extension
foot with the when definitely
other hand. localized to the
Keeping the joint line,
knee suggests a tear of
completely the middle and
flexed, the leg anterior portions
is externally of the meniscus.
rotated as far Thus, the
as possible and position of the
then the knee knee when the
is slowly click occurs may
extended. As help locate the
the femur lesion. A positive
passes over a McMurray click
tear in the localized to the
meniscus, a joint line is
click may be additional
heard or felt. evidence that the
The lateral meniscus is torn;
meniscus is a negative
checked by McMurray test
palpating the does not rule out
posterolateral a tear. A
margin of the palpable or
joint, internally audible pop in
rotating the leg combination with
as far as pain is
possible, and considered
slowly positive. Results
extending the are variable, but
knee while a positive
listening and McMurray test is
feeling for a indicative of a
click. With the meniscus lesion
knee maximally and not a
flexed, it is chondral lesion.
extended to 90
degrees while
applying
internal
rotation and
valgus force to
the foot and
ankle. Repeat
with external
rotation and
varus force.

Apley grind With the When the

test patient prone, ligaments have
the knee is been torn,
flexed to 90 pulling the leg
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degrees and the upward and
anterior thigh is rotating it usually
fixed against are painful.
the examining When the foot
table. The foot and leg are
and leg are pressed
then pulled downward and
upward to rotated, popping
distract the and pain
joint and localized to the
rotated to joint line usually
place rotational indicate a torn
strain on the meniscus.
ligaments.
Next, with the
knee in the
same position,
the foot and leg
are pressed
downward and
rotated as the
joint is slowly
flexed and
extended.

The Hip

ROM The hip is Loss of motion is

flexed to its often associated
maximum with arthritis.
extent and the
examiner
records the
degrees of
flexion. The hip
is then flexed
to 90 degrees
and passively
internally and
externally
rotated.

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Abduction The hip is May create

external passively forced symptoms
rotation test into maximal associated with
abduction with posterior joint
external pathology by
rotation. compression, or
anterior
pathology by
anterior
translation of the
femoral head.

C sign Patient cups Common

hand above observation with
greater patients
trochanter, describing
gripping fingers interior hip pain.
into groin.

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Log roll test With the Most specific test

patient supine, for hip joint
the affected leg pathology since
is simply rolled femoral head is
back and forth. being rotated in
relation to the
acetabulum and
capsule without
stressing any of
the extra‐
articular
structures.

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Patrick test Patient is Pain may be felt

(Faber test) supine on with the
examination downward stress
table and on the flexed
placed such knee. Pain in the
that one half of posterior pelvis
the buttock is may be
off the table considered
while the positive for the
ipsilateral leg is pain coming from
placed in a the sacroiliac (SI)
figure 4 joint. Indicative
position on the of SI
other abnormalities or
(extended) iliopsoas spasm.
knee. The
pelvis is
stabilized with
one of the
examiner's
hands and a
downward force
is applied to
the flexed knee
with the
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examiner's
other hand.

Ober test Patient is The test is

placed in positive when the
lateral upper knee
decubitus remains in the
position, with abducted
the down hip position after the
and knee flexed hip is passively
for stability. extended and
The examiner abducted and
flexes the other then adducted
hip to 90 with the knee
degrees and flexed. Used to
then abducts evaluate iliotibial
the hip fully band tightness.
and extends the If, when the hip
hip past neutral and knee are
with the knee allowed to
in 90 degrees of adduct while the
flexion. The hip hip is held in
and knee are neutral rotation,
allowed to the knee adducts
adduct while past midline, the
the hip is held hip abductors are
in neutral not tight; if the
rotation. knee does not
reach to midline,
then the hip
abductors are
tight.

Impingement The hip is A more sensitive

test passively forced test for detecting
into maximal hip joint
flexion, irritability. This
adduction, and is associated with
internal impingement
rotation. findings but is
positive with
most sources of
hip pathology.

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Anterior Firm digital Applying pressure

compression pressure over to block the
of the the anterior hip snapping of the
iliopsoas capsule may tendon
tendon block the substantiates the
snapping. diagnosis.
However, often
this maneuver is
uncomfortable
and not well
tolerated by the
patient.

Squeeze test Supine subject The presence or

actively absence of pain
attempts is noted.
adduction by Strength is
squeezing legs graded as mild
against (minimal loss of
resistance strength);
provided by moderate (clear
examiner. loss of strength);
or severe
(complete loss of
strength). Pain

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with or without a
strength deficit
implies adductor‐
related groin
pain.

Hamstring Patient lies Mild: minimal

strength prone. Patient loss of strength;
attempts knee moderate: clear
flexion against loss of strength;
resistance. severe: complete
loss of strength.
Severe injury
implies proximal
avulsion.

Passive Patient Apparent

hamstring performs a hamstring
stretch hurdler's flexibility is
stretch. compared to the
uninjured side.
An obvious
increase in
apparent
hamstring
flexibility of
injured extremity
implies proximal
avulsion.

Passive The subject lies The presence or

adductors supine. The absence of pain
stretch examiner either is noted. Pain
abducts the leg localized to the
or places the adductor implies
leg in a figure 4 adductor‐related
position. groin pain.

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Scour test With the Pain or any

patient supine, clicking,
the hip is catching, or
maximally other associated
flexed and mechanical
adducted. The symptoms
hip is rotated suggest
while applying intraarticular
downward pathology.
pressure on the
hip joint
through the
femur.

Single‐leg The patient The test is

stance test stands on the positive if a
affected leg distinct drop of
with the non‐
contralateral supported pelvis
leg flexed to 90 is noted,
degrees at the indicating
knee. The abductor
position is held weakness on the
for 30 seconds supported
or longer. (single‐leg
stance) side.

External Patient is The pain from

derotation supine on the abductor
test examination weakness may be
table with the reproduced in
hip flexed to 90 the lateral aspect
degrees and of the hip. The
externally power can also

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rotated to 30 be graded and
degrees. The compared to the
patient is then contralateral
asked to normal side. Any
internally weakness would
rotate the hip indicate abductor
to neutral insufficiency.
against
resistance
provided by the
examiner.

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