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ATLS OF
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Many students learn the details of skeletal anatomy but then find it dificult to relate
that knowledge to real human beings when they present for clinical examination
and assessment. This atlas aims to fill the information gap between descriptive
and palpator anatomy and to help the student make the link between the two.
It addresses the clinical appearance of normal tissues and their function, and
provides guidance on how to examine and assess normal joints.
Key features
• Introduces the basics of clinical exmination
• Provides step-by-step guidance to the clinical assessment of the peripheral
joint and their associated tissues and structures
• Details the examination of the major joints of the body one by one:
Shoulder/Elbow/Wrist/Hip/Knee/Foot and describes the normal fndings
in healthy individuals
• Emphasizes the importance of performing diagnostic movements correctly
• Addresses the common mistakes in examination techniques and explains
where people go wrong
• Profusely illustrated with high qualit photographs and diagrams
• Text design ensures that the illustrations appear close to the relevant text
This Atas of Orthopedic Examination of the Peripheral/oints will provide an
invaluable source of reference for medical students and members of all health
care professions concerned with the management of orthopedic problems.
W. B. SAUNDERS
9 780702 021244
Copyrighted Material
Atlas of Orhopedic Examination of the Peripheral Joints
Copyrighted Material
IIIl1stratiolls by: Kevin Mark
For W. 8. Sa"nders"
Editorial Director, Health Sciences: Mary Law
Head of Project Management: Ewan Halley
Project Development Mallager: Dinah Thorn
Sellior Desigller: Judith Wright
Copyrighted Material
Atlas of Orthopedic
Examination of the
Peripheral Joints
Ludwig Ombregt MD
Medical Practitioner in Orthopedic Medicine. Kanegem. Belgium;
International Lecturer in Orthopedic Medicine
Pierre Bisschop
Physiotherapist specializing in Orthopedic Medicine, Knesselare, Belgium;
Interational Lecturer in Orthopedic Medicine
� W. B. SAUNDERS
Edinburgh. London. New York. Philadelphia. 51 Louis. Sydney. Toronto -1999
Copyrighted Material
w. B. SAUNDERS
An imprint of Harcourt Brace and Company limited
C Harcourt Brace and Company Limited 199
All right reserved. No part of this publication may b
reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical,
photocopying, recording or otherwis, without either the
prior permission of the publishers (Harcourt Brace and
Company Limited, 24-28 Oval Road, London NWI 7X),
or a licence permitting restricted copying in the United
Kingdom issued by the Copyright Licensing Agency,
90 Tottenham Court Road, London WI P OlP.
First published 199
ISBN 0 7020 2124 5
British Library Cataloguing in Publication Data
A catalogue record for this bok is available from the British
Library.
library of Congress Cataloging in Publication Data
A catalog record for this bok is available from the Library
of Congress.
Note
Medical knowledge is constantly changing. A new
information becomes available, changes in treatment,
proures, equipment and the use of drugs bcome
necessary. The authors and the publishers have, as far as it is
possible, taken care to ensure that the information given in
this text is accurate and up-to-date. However, readers are
strongly advised to confiml that the infomlation, especially
with regard to drug usage, complies with the latest
legislation and standards of practice.
Printed in China
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Contents
Preface vii
Introduction ix
1. Shoulder 1
2. Elbow 21
3. Wrist 39
4. Hip 63
5. Knee 81
6. Ankle and foot 109
Index 131
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Preface
This manuscript was developed as a manual for
medical and physiotherapy students. fts purpose
is to fill the existing information and training
gap between the descriptive anatomy and the
pathology of the peripheral joints.
During our courses in orthopedic medicine
we are almost daily confronted by postgraduate
students (both physiotherapists and doctors)
who do not have practical knowledge in topo­
graphic, surface and functional anatomy. Despite
the fact that all clinical skills start with an under­
standing of the normal, the study of the clinical
appearance of normal tissues and their behav­
iour during manual examination seems to be a
grossly neglected area of medical education.
This book essentially addresses the clinical
appearance of normal tissues and their function,
and provides guidance on the examination and
assessment of normal joints. We confined our­
selves to a discussion of the most important tests
used in orthopedic medicine. They are relatively
simple to perform and have a great inter-tester
reliability. These tests (active, passive and resisted
movements) are accepted in orthopedic medi­
cine, physiotherapy and manual therapy as the
basic tests for a good clinical evaluation of the
jOint in question. This book focuses on the perfect
technical execution of the movements. Much to
our regret we have to conclude that poorly
conducted tests often give incorrect information
and therefore lead to inaccurate diagnoses. We
believe that our teaching experience may be of
great help to the reader and therefore we have
listed the errors students most frequently make
in the section on 'com.mon mistakes',
A small section on 'common pathological
situations' follows a discussion of the technical
execution of the test, and findings in normal
subjects. This section could be confusing in that
the described test is not meant to be the diag­
nostic procedure for the referred condition. A
clinical diagnOSiS does not rely on the outcome of
one single test but is made on the interpretation
of a clinical pattern (the combined outcome of a
set of clinical tests). The interpretation of patho­
logical findings and the building up of clinical
patters is not within the scope of this book.
The interested reader is referred to our clinical
reference book A System of Orthopaedic Medicine
published by Saunders in 1995. In this work, all
pathological conditions and their conservative
treatments are discussed thoroughly.
Acknowledgements
We would like to thank colleagues who are
teachers of Orthopaedic Medicine Interational
(aMI) and who provided significant help. We
are particularly grateful to Dr Eric Barbaix,
Teacher in Manual Therapy at the UniverSity
of Brussels, who acted as an excellent adviser,
providing both expertise and constructive
criticism.
The following figures have been taken from
Ombregtj, Bisschop P, ter Veer Hj, Van de VeldeT
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vIII PREFACE
1995 A system of orthopaedic medicine. W B
Saunders, London: 1.8-1.16, 1.18-1.34; 2.1, 2.3,
2.4, 2.8-2.12, 2.14-2.16, 2.19-2.21, 2.24-2.35; 3.3,
3.4, 3.6, 3.10, 3.11, 3.15, 3.16, 3.18, 3.23, 3.24,
3.27-3.60; 4.5,4.11,4.13,4.14,4.16-4.20,4.22-.32,
4.35,4.36; 5.6-5.11, 5.14, 5.18, 5.21-5.43, 5.45-5.50;
6.5, 6.1�.12, 6.16, 6.18, 6.20, 6.24-.43.
Kanegem-Tielt,1999 Ludwig Ombregt
Pierre Bisschop
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Introduction
The purpose of examination and / or testing pro­
cedures in orthopedic medicine is to examine the
fnc/ion of the different tissues of the moving
parts. The techniques are based on the principle
of 'selective tension'.
Each tissue of the body has its particular
function. It acts either as an isolated structure
or as part of a group of structures. Function
differs, depending on whether a tissue is built to
make other tissues move (musculo-tendinous
structures), to control range of movement
(capsulo-ligamentous structures), to facilitate
movement (bursae) or to activate movement
(nerve structures).
The musculo-tendinous unit has the inherent
capability to contract - it is a 'contractile tissue'­
whereas all the other structures do not possess
this capability - they are 'inert'. Contractile
structures can be tested (= put under tension)
by provoking a maximal isometric contraction.
Inert structures are tested by putting them under
maximal stretch.
Active movements
An active movement is performed as far as it
may go. It does not follow the principle of
'testing by selective tension': a lot of structures
are put under stress. The examiner not only gets
an idea of the pOSSible range of motion in the
joint (normal, limited or excessive), he is also
informed about the integrity of the musculo­
tendinous apparatus.
Passive movements
A passive movement brings a joint to the end of
the normal range. The normal amplitude differs
from the theoretical range of motion. Articular
surfaces allow a certain amount of movement,
but the movement is usually stopped as a result
of tension in the capsulo-Iigamentous structures.
The movement therefore not only informs the
examiner about the normal range, but also about
the structures that stop the movement from
going further. This happens by assessing the
end-feel of a movement which can be either
elastic (capsular), hard (bony or ligamentous) or
soft (tissue approximation).
Passive movements are good tests to examine
the inert structures and give an answer to the
following questions:
a. Does the inert structure function normally? If
not, pain may be elicited and / or the range
may have diminished.
b. Does it allow a normal range of motion? If
not, the end-feel will have changed.
From the technical point of view the examiner
should position him or herself in such a way that
the movemet can be executed over the entire
pOSSible range of motion and can be brought
to the end of the range in order to test the end­
feel. It may be necessary to fixate the subject's
body or part of the subject's limb in order to
avoid parasitary movements that would give rise
to an incorrect answer.
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x INTRODUCTION
Resisted movements
A resisted movement is meant to test the
muscular tissue only. It should be executed in
an isometric way, thereby holding the joint in
the neutral position: this puts strain on the
contractile tissue but leaves the inert structures
unattended. The test activates certain muscles
or muscle groups (� different muscles with the
same function). It informs the examiner about
the normal strength of the contraction.
Resisted movements test the contractile struc­
ture: the whole of the muscle belly, the musculo­
tendinous junction, the body of the tendon and
the insertion onto the bone. When a lesion in
one of these parts is present, the contraction will
result in pain with or withour weakness. Diminu­
tion of strength is the result of either a rupture or
of a problem with the nervouS system activating
the muscle.
The examiner should position him or herself
in such a way that he or she is stronger than the
subject: the only way to execute the movements
in an isometric way. The joint is brought into
the neutral position, allowing the inert tissues
to relax, and the subject is asked to perform a
contraction with maximal strength. The examiner
resists the movement, thereby not allowing any
articular movement at all. He or she therefore
puts his or her hands in such a way that one hand
exerts pressure while the other gives counter­
pressure.
The correctness of the technical execution of the
tests guarantees the correctness of the answer.
Further reading
Daniels L, Worthinghaus C 1995 Muscle testing. Saunders,
London
Kapandji I A 1987 The physiology of the joints, vol I.
Churchill Livingstone, Edinburgh
Ombregt L, Bisschop P, tcr Veer H, Van de Velde A 195 A
system of orthopaedic medicine. Saunders, London
Petty N}, Moore A P 1998 Neuromusculoskeletal
examination and assessment: a handbook for therapists.
Churchill Livingstone, Edinburgh
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CHAPTER CONTENTS
Surac and palpatory anatomy 1
Bony landmar1s 1
Palpation of sf tissue 3
Functional examination of the shoulder 8
Active test 8
Active elevation 8
Passive tests 9
Passive elevation 9
Passive exteral rotation 10
Passive exteral rotation with the shoulder in 90°
abduction 10
Passive internal rotation 11
Passive glenohumeral abduction 12
Isometric contractions 12
Resisted adduction 12
Resisted abduction 13
Resisted exteral rotation 14
Resisted internal rotation 14
Resisted flexion of the elbow 15
Resisted extension of the elbow 16
Spcific tests 17
Passive horizontal adduction 17
Apprehension test In exteral rotation 17
Apprehension test in interal rotation 17
Anterior drawer test 19
Posterior drawer test 19
Shoulder
SURFACE AND PALPATORY
ANATOMY
The shoulder is inextricably bound up with the
shoulder girdle, anteriorly via the clavicle and
at the posterior aspect via the scapula. These two
bony structures are easily detectable landmarks
to start the palpation of the shoulder structures.
Bony landmarks
Anterolateral (Figs 1.1 and 1.2)
The clavicle (A) is the most prominent bone
and is easily detectable because it lies subcuta­
neously. Its medial part is convex and the lateral
third is concave. Its medial end (sternal end) is
bulbous and articulates with the sternum.
The lateral end is flattened and articulates with
F
Fig. 1.1 Anterior view of the shoulder (in vivo).
1
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2 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 1.2 Anterior view of the shoulder (skeleton).
the scapula's acromion (B) which can be recog­
nized as a flat bone overlying the shoulder joint.
Palpate the anterior aspect of the clavicle and
continue further laterally until the acromial end
(C) is felt. Just lateral to it a small indentation
is palpable before the clear anterior border of
the acromion is reached. This indentation is the
anterior end of the acromioclavicular joint. By
moving the palpating finger on top of the shoulder
the acromial end of the clavicle can be felt to lie
slightly higher than the acromion. When the
finger lies in contact with the two bones - the
clavicle and the acromjon -it lies on the acromio­
clavicular joint of which the upper part of the
capsule is reinforced with the superior acromio­
clavicular ligament.
In the infraclavicular fossa just below the
concave lateral part of the clavicle a bony promi-
nence can be felt. This is the scapula's coracoid
process (D), of which only the tip and the medial
surface are palpable. They form the points of
origin for the short head of the biceps brachii
muscle and for the coracobrachialis muscle
respectively.
Place the finger on the coracoid process and go
1 cm down. Now move the finger laterally until a
sharp bony structure is reached. This is the lesser
tuberosity (E) of the head of the humerus. Palpate
this bone and feel for its lateral border - the
medial lip of the intertubercular sulcus.
Just lateral to this border lies the bicipital
groove that contains the long head of the biceps.
This intertubercular sulcus is palpable with the
thumb placed flat on it and during rotatory move­
ments of the humerus. To define the bicipital
groove, use the subject's forearm as a lever and
rotate the humerus laterally until the medial lip
of the sulcus hits the thumb; then rotate the arm
mediaJly until the lateral lip catches the thumb.
At the lateral aspect of the sulcus a greater
tubercle can be palpated. This is the greater
tuberosity (F). When moving the palpating finger
upwards a depression can be felt before the
lateral border of the acromion is reached.
Posterolateral (Figs 1.3 and 1.4)
The scapula (A) is the most important bone at
the posterior side of the thorax. It has a very
prominent spine (B) that is easy to palpate. Feel
D-
Fig. 1.3 View of the shoulder from above.
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Fig. 1.4 Posterolateral view of the shoulder (skeleton).
for the posterior margin of the spine and follow
this further laterally where it becomes more
prominent. The spine can be felt to make a 90°
forwards turn - the acromial angle (C) - before it
forms the acromion (D). Together with the acro­
mial end of the clavicle and the coracoacromial
ligament it forms the coracoacramial roof.
The spine divides the scapula into a supra­
spinous fossa (E) and an infraspinous fossa (F),
in which lie, respectively, the supraspinatus and
the infraspinatus muscle bellies.
Place the subject sitting with the arm in 90°
abduction and palpate in the supraspinous fossa
in a lateral direction. The spine of the scapula is
felt to meet the clavicle. At this point lies the
posterior aspect of the acromioclavicular joint (G)
(Fig. 1.5). Place the thumb at this point and pal­
pate simultaneously for the anterior indentation
SHOULDER 3
Fig. 1.5 Palpation of the supraspinous fossa (shoulder in
abduction).
between the clavicle and acromion. The acromio­
clavicular joint line joins these two points.
Palpation of soft tissue
Palpation of the deltoid muscle
The deltoid muscle is easy to recognize. It
forms the most important muscular mass of the
shoulder and is responsible for its round look
(Fig. 1.6). The anterior portion (A) overlies the
anterior border of the acromion and the lesser
tuberosity. The middle portion (B) lies over the
lateral border of the acramion and the greater
tuberosity, and the posterior portion (C) builds
the posterior aspect of the shoulder and covers
the lateral part of the spine of the scapula.
c
Fig. 1.6 Lateral view of the shoulder (in vivo).
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4 ATLAS OF ORTHOPEDIC EXAMINATION
Flg. 1.7 View of the deltoid muscle (during contraction).
Ask the subject to abduct the arm against
resistance. A groove (D) (Fig. 1.7) can be palpated
between the anterior and middle portions of the
deltoid. This overlies the bicipital groove.
Palpation of the supraspinatus muscle
Muscle belly and musculotendinous junction. The
subject sits with the arm in full abduction and
rested on the couch. The elbow now lies on the
same level as the shoulder. The examiner stands
behind the subject. The trapezius muscle is well
relaxed and palpation can be performed through
that muscle. Palpate for the spine of the scapula.
The muscle belly lying just above the spine of the
scapula is the supraspinatus muscle. It fills up the
supraspinous fossa. Move the palpating finger
more laterally until it reaches the corner formed
between the clavicle and the spine of the scapula.
The finger now Hes on the musculotendinous
junction of the supraspinatus, which can be felt to
continue laterally under the acromion (Fig. 1.8).
Inserion on the greater tubrosity. Now position
the subject with the forearm behind the back. The
arm is now in full internal rotation. Palpate for
the lateral border of the acromion; follow it in the
anterior direction until the corner is felt between
the lateral and anterior border and identify the
latter. Also look for the acromioclavicular joint
and keep the palpating finger lateral to it. Move
the finger forwards so that it comes to He on the
Fig. 1.8 Palpation of the musculotendinous junction of the
supraspinatus.
greater tuberosit of the humerus but is still in
contact with the acromion as well. Exert a pres­
sure vertically downwards against the humerus.
The finger now lies on the supraspinatus tendon
of which the medial border can be felt quite
clearly (Fig. 1.9).
Palpation of the Infraspinatus muscle (Fig. 1.10).
The subject is in prone lying and rests on the
elbows. The upper arm should be kept vertical
and in slight adduction. The subject therefore
leans towards the shoulder to be palpated. With
the hand he grasps the edge of the couch. This
results in some external rotation of the shoulder
as well. The examiner looks for the spine of the
scapula and palpates below it, in the infraspinous
fossa. The thumb now lies on the infraspinatus
muscle belly. Place the thumb just under the
spine of scapula and palpate more and more
laterally. A tendon will be felt that runs parallel
to this spine. This is the infraspinatus tendon.
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Fig. 1.9 Palpation of the tenoperiosteal junction of the
supraspinatus.
It can be followed until the attachment on the
greater tuberosity is found. The bone can be felt
through the tendinous mass. Palpate more later­
ally until the thumb lies on the greater tuberosity.
The tendinous structure cannot be felt any more.
Come back to the previous point where both
bone and tendon are felt. This is the insertion.
Palpation of the subscapularis tendon
The subscapularis muscle belly can only be
reached by bringing the hand in between the
SHOULDER 5
Fig. 1.10 Palpation of the tenoperiosteal junction of the
infraspinatus.
scapula and the thorax. It cannot really be
palpated. The tendinous insertion on the lesser
tuberosity, however, can easily be palpated.
The subject is in a half lying position on a
couch, the upper arm along the body and the
elbow flexed to 90°. The examiner grasps the
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6 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 1.11 Pushing the tendons of the short head of biceps
and of coracobrachialis medially.
subject's hand and brings the shoulder into a
few degrees external rotation. Place the thumb
of the other hand on the lesser tuberosity of the
humerus. lt now Lies on the insertion of the
subscapularis tendon. The contact is not direct,
because the insertion is partly covered by, on the
one hand, the tendons of the short head of the
biceps and of the coracobrachialis, both running
towards the coracoid process and, on the other
hand, the anterior portion of the deltoid muscle,
running in the direction of the acromion. Turn
the thumb so that its tip lies in the direction of
the xiphOid process of the sterum (Fig. 1.11).
Push the muscular mass forwards, flex the
thumb and come back towards the lesser tubero­
sity. The two tendons can be felt snapping away.
They now lie medially to the thumb. At the same
time, deltoid fibres have been drawn Sideways
and lie laterally to the thumb, which now is in
direct contact with the subscapularis insertion
(Figs 1.12 and 1.13).
Palpation of the long head of bicepr (Fig. 1.14)
Place the finger in the groove between the anter­
ior and middle portions of the deltoid muscle.
Move the finger anteriorly and distally. It now
lies on the bicipital groove, which is situated
more laterally than is usually supposed.
Fig. 1.12 Palpation of the subscapularis (upper part).
2
3
4
Fig. 1.13 Anterior view of the shoulder: 1 t glenoid insertion
of the biceps; 2 and 3, biceps tendon; 4, insertion of the
subscapularis muscle.
ldentify the intertubercular sulcus by placing
the thumb flat on it and by executing small
rotatory movements of the humerus. The lateral
and medial lips can be felt catching against the
thumb. In this groove lies the tendon of the long
head of biceps. It is difficult to palpate as it is
covered with a transverse ligament. Move the
thumb upwards until the upper part of the groove
is reached, just below the acromion. Ask for
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Fig. 1.14 Palpation of the long head of biceps in the sulcus.
an active flexion of the elbow and resist the
movement. Tightening of the tendon can be felt.
Palpation of the pectoralis major muscle
(Fig. 1.15)
The lateral aspect of the pectoralis major muscle
forms the anterior border of the axilla where
its inferior border can be palpated very well,
especially during resisted adduction of the arm.
The tendon inserts at the crest of the greater
tuberosity, just below the lateral border of the
bicipital sulcus.
Palpation of the latissimus dorsi muscle
(Fig. 1.16)
The lateral aspect of the latissimus dorsi muscle
builds the posterior border of the axilla. It is felt
to contract during resisted adduction of the arm.
Its insertion lies anteriorly at the crest of the
lesser tuberosity.
SHOULDER 7
Fig. 1.15 Palpation of the muscle belly of the pectoralis
major.
Fig. 1.16 Palpation of the axillar part of the latissimus dorsi.
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8 ATLAS OF ORTHOPEDIC EXAMINATION
Flg. 1.17 Anterior view of the axilla.
Palpation of the axilla
Bring the subject's arm into 90° abduction. Ask
him to press the arm downwards and resist this
movement. During palpation in the antero­
posterior direction the following structures can
be identified (Fig. 1.17): pectoralis major (A),
forming the anterior border of the axilla, the
tendon of the short head of biceps (B), the coraco­
brachialis muscle (C), and the latissimus dorsi
(D), forming the posterior border.
FUNCTIONAL EXAMINATION OF THE
SHOULDER
Introduction/general remarks
Shoulder lesions give rise to pain felt mostly in
the proximal part of the upper limb. The shoulder
examination is therefore commonly used in
the diagnosis of upper arm pain. However, the
examiner should realize that symptoms in the
region of the shoulder can also originate from
the cervical spine, the upper thoracic spine
and the shoulder girdle. The examination of the
shoulder is to be considered as an element in the
diagnostic procedures for lesions of the upper
quadrant.
ACTIVE TEST
Active elevation
POSitioning. The subject stands with the arms
hanging alongside the body. The examiner stands
behind.
Procedure. Ask the subject to bring up both arms
Sideways as high as possible (Fig. 1.18).
Common mistakes:
• The movement is not performed to the very
end of the possible range.
• The arms are brought up in a sagittal plane.
• The arms are kept in internal rotation, which
makes full movement impOSSible.
Normal functional anatomy:
• Ral/ge: 180°
• Structures il/ualued: Many structures are
committed. The movement is started by the
supraspinatus muscle and continued by the
Fig. 1.18 Active elevation of the arm.
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middle portion of the deltoid and by the long
head of biceps. Rotation of the scapula is done
mainly by the serratus anterior muscle,
supported by the trapezius muscle, especially
towards the end of range. The movement also
stretches and/ or squeezes several structures,
such as the capsule of the glenohumeral joint,
the subdeltoid bursa, and the sternoclavicular
and acromioclavicular ligaments.
Meaning. This a very non-specific test, which
is almost always disturbed when a shoulder or
shoulder girdle pathology is present. It also gives
an idea of the patient's willingness to cooperate.
Pain at mid-range may indicate a structure in
between the humeral head and the coracoacrormal
arch - either one of the tendons of supraspinatus,
infraspinatus, subscapularis, long head of biceps,
or the subacromial bursa or inferior acromio­
clavicular ligament - being painfully pinched.
The patient often avoids painful impingement by
adding an anterior component over part of the
movement.
Limitation with or without pain occurs in
shoulder arthritis or arthrosis, in certain extra­
capsular lesions and in some neurological condi­
tions causing weakness of the shoulder elevators.
PASSIVE TESTS
Passive elevation
POSitioning. The subject stands with the arms
hanging alongside the body. The examiner
stands behind the subject and takes hold of the
elbow at the distal part of the upper arm.
Procedure. Take the arm up sideways in the
frontal plane as far as possible. Allow some ex­
ternal rotation about 900 of abduction. Reaching
the end of range, give counter-pressure with the
other hand at the subject's opposite shoulder
(Fig. 1.19).
Common mistakes:
• When the arm is grasped distally to the
subject'S elbow, elbow movement prevents
assessment of end-feel.
• The arm is not allowed to exterally rotate.
Flg.1.19 Passive elevation of the arm.
SHOULDER 9
• The movement is stopped before the end of
the possible range is reached.
• At the end of range the arm is taken
backwards in a sagittal plane.
• Lnsufficient counter-pressure results in the
subject Side-flexing the body.
Normal functional anatomy:
• Rallge: 1800
• Elld-feel: elastic
• Limitillg structures:
- the axillary part of the joint capsule
- stretching of the acromioclavicular and
sternoclavicular ligaments
- the adductors and internal rotators of the
shoulder
- contact between the lesser tuberosity of the
humerus and the upper part of the glenoid
labrum.
Common pathological situations:
• The movement can be painful in subdeltoid
bursitis and i rotator cuff tendinitis, as well
as in acromjoclavicular lesions.
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10 ATLAS OF ORTHOPEDIC EXAMINATION
• LimHation occurs in arthritis and arthrosis of
the shoulder and in serious extracapsular
conditions.
Passive external rotation
Positioning. The subject stands with the upper
arm alongside the body and the elbow flexed to
a right angle. The examiner stands level with the
subject's arm and stabilizes the elbow with his
trunk. One hand is placed on the contralateral
shoulder to stabilize the shoulder girdle and
trunk; the other takes hold of the distal forearm.
Procedure. Rotate the arm outwards, meanwhile
assuring the vertical position of the humerus,
until the movement comes to an elastic stop
(Fig. 1.20).
Common mistakes:
o The shoulder girdle is not well enough fixed
so that trunk movement is allowed to happen.
o The elbow is not well stabilized so that
shoulder abduction or extension occurs.
o The movement is not performed to the end of
the possible range.
Fig. 1.20 Passive external rotation test for the
glenohumeral joint.
Normallunctional anatomy:
o Rallge: 90°
o Eldleei: elastic
• LimitiHg structures:
- the anterior portion of the joint capsule
- the internal rotator muscles of the shoulder
- contact between the greater tuberosity of
the humerus and the posterior part of the
glenoid labrum.
Common pathological situations:
• Pain on full passive external rotation is one of
the first signs of shoulder arthritis. External
rotation also stretches the acromioclavicular
ligaments and the subscapularis tendon, and
squeezes the subdeltoid bursa.
• Isolated limitation occurs in contracture of the
anterior capsule and in subcoracoid bursitis.
o The movement is markedly limited as part of
a capsular pattern of limitation of movement
in moderate or more advanced arthritis.
Depending on the condition being either
acute or chronic, the end-feel will be either of
muscle spasm or hard.
o Excessive range may indicate shoulder
instability.
Passive external rotation with the
shoulder in 900 abduction
Positioning. The subject stands with the arm
hanging alongside the body and the elbow flexed
to 90°. The examiner stands level with the sub­
ject's arm. The contralateral hand takes hold of
the elbow and brings the arm into 90° of abduc­
tion. The other hand grasps the distal forearm.
Procedure. Put the shoulder into exteral rota­
tion, meanwhile stabilizing the elbow (Fig. 1.21).
Common mistakes. If the movement is too painful
the patient will move the body backwards.
Normal functional anatomy:
o Rallge: 90°
o Elld-Jeel: elastic
• Limiting structures:
- the anterior part of the joint capsule
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Fig. 1.21 Passive horizontal external rotation.
- the adductors and internal rotators of the
shoulder.
Common pathological situations:
• The movement is limited in arthritis and
arthrosis of the shoulder and also in isolated
contracture of the anterior part of the joint
capsule.
• Excessive movement may b present in
shoulder instability.
Passive internal rotation
Positioning. The subject stands with the upper
arm alongside the body and the elbow flexed to
a right angle. The examiner stands level with
the subject's arm and stabilizes the elbow with
his trunk. One hand is placed on the opposite
shoulder to stabilize the shoulder girdle and
trunk; the other takes hold of the distal forearm.
Procedure. Bring the subject's forearm behind her
back and move her hand away from her body as
far as possible (Fig. 1.22).
SHOULDER 11
Fig. 1.22 Passive interal rotation test for the
glenohumeral joint.
Common mistakes:
• The shoulder is held in too much abduction.
• The elbow is pulled backwards, which creates
an extension of the shoulder instead of
internal rotation.
• The hand is moved upwards instead of
backwards.
Normal functional anatomy:
• Rallge: 90°
• Elld-eel: elastic
• Limiting structures:
- the posterior part of the joint capsule
- the external rotator muscles of the shoulder
- contact between the lesser tuberosity of the
humerus and the anterior part of the
glenoid labrum of the scapula.
Common pathological situations:
• Pain at the end of range may occur in lesions
of the infraspinatus and supraspinatus
tendons, and also of the acromioclavicular
ligaments.
• Pajn at mjd-range may occur in rotator cuff
tendinitis or in subacromial bursitis.
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12 ATLAS OF ORTHOPEDIC EXAMINATION
• More or less limitation is found as part of a
capsular pattern of limitaton of movement in
moderate and severe arthrits.
• Excessive range may indicate shoulder
instability.
Passive glenohumeral abduction
Positioning. The subject stands with the upper
arm alongside the body. The examiner stands
level with and behind the subject's arm. One
hand takes hold of the elbow, just above the joint.
The thumb of the other hand is placed against the
lateral aspect of the lower angle of the scapula.
Procedure. Abduct the arm slowly, meanwhile
preventing the scapula from moving (Fig. l.23).
End of range is reached when the scapula can
no longer be stabilized and starts to slip under
the thumb.
Common mistakes:
• The scapula is not stabilized sufficiently.
- Altemative technique: When the lower angle
of the scapula cannot b stabilized, the
lateral margin may be used. The scapula
can also be stabilized by placing one hand
upon the acromion.
Flg.1.23 Passive scapulohumeral abduction test for the
glenohumeral joint.
• Movement is not performed to the end of the
possible range.
Normal functional anatomy:
• Range: 90·
• Elld-feel: ligamentous
• Limiting slructures:
- the axillary part of the jOint capsule
- contact between the greater tuberosity and
the upper part of the glenoid labrum.
Common pathological situations:
• The movement is limited in shoulder arthritis.
• It may also become restricted in acute
subdeltoid bursitis.
ISOMETRIC CONTRACTIONS
Resisted adduction
Positioning. The subject stands with the arm
hanging and slightly abducted. The examiner
stands level with the subject's arm. He places
one hand against the ipsilateral hip and the other
hand against the inner aspect of the elbow.
Procedure. Resist the subject'S attempt to adduct
her arm (Fig. l.24).
Fig. 1.24 Resisted adduction of the shoulder,
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Common mistakes:
• The elbow is allowed to flex.
• Movement is allowed at the shoulder.
Anatomical structures tested:
Muscle function:
• IIportallt addllctors:
- Pectoralis major
- Latissimus dorsi
- Teres major
- Teres minor
• Less ill/portallt adductors:
- Long head of triceps brachii
- Short head of biceps brachii
- Clavicular part of deltoid
- Spinal part of deltoid.
Neural function:
Muscle
Pectoralis major
latissimus dorsi
Teres major
Teres minor
Triceps brachii
Bicps brachii
Deltoid
spinal part
davicular part
Peripheral
Pectoral
Thoracodorsal
Subscapular
Axillary
Innervaton
Radial
Musculoutaneous
Axillary
Axillary
Pectoral
Common pathological situations:
Nerve root
C5-Ce
(C6). C7. (ce)
C5-Ce
CS.(C6)
(C). C7. (C6)
C5,C6
CS.(C6)
CS.(C6)
C5-Ce
• Pain suggests a lesion in one of the adductor
muscles or in the thoracic wall.
• Weakness occurs in severe C7 nerve root palsy.
• Painful weakness is perceived in rib fractures
and more rarely in a rupture of the pectoralis
major muscle.
Resisted abduction
Positioning. The subject stands with the arm
hanging and slightly abducted. The examiner
stands level with the subject's arm. He places
one hand against the opposite hip and the other
hand against the outer aspect of the elbow.
Procedure. Resist the subject's attempt to abduct
the arm (Fig. 1.25).
SHOULDER 13
Fig. 1.25 Resisted abduction of the shoulder.
Common mistakes. Movement is allowed at the
shoulder.
Anatomical structures tested:
Muscle function:
• Important abductors:
- Deltoid
- Supraspinatus
• Less ill/portallt abductors:
- Long head of biceps brachii.
Neural function:
Muscle
Deltoid
Supraspinatus
Bicps brachii
Innervation
Peripheral
Axillary
Suprascapular
Musculoutaneos
Common pathological situations:
Nerve rot
CS, (C)
CS. (C)
es,C6
• Pain is usually the result of a supraspinatus
tendinitis, more rarely of a lesion of the
deltoid, but may also occur in subdeltoid
bursitis.
• Weakness occurs in total rupture of the
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14 ATLAS OF ORTHOPEDIC EXAMINATION
supraspinatus tendon or in neurological
conditions, such as lesions of the axillary
nerve, the suprascapular nerve or the C5
nerve root.
• Painful weakness is indicative of a recent
partial rupture of the supraspinatus tendon.
Resisted external rotation
Positioning. The subject stands with the upper
arm against the body and the elbow flexed to a
right angle. The forearm is held in the sagittal
plane, so keeping the shoulder in a neutral posi­
tion. The examiner stands level with the subject's
arm. He places one hand on the opposite shoulder
and the other hand against the outer and distal
aspect of the forearm, which he supports.
Procedure. Ask the subject to keep the elbow
against the trunk and resist the attempt to push
the hand laterally (Fig. 1.26).
Common mistakes. The subject tends to execute
the test wrongly either by bringing the shoulder
Fig. 1.26 Resisted exteral rotation of the shoulder.
into abduction or by extending the elbow, espe­
Cially when weakness is present.
Anatomical structures tested:
Muscle function:
• Important exterllai rotators:
- Illfraspinatus
- Teres minor
• Less importallt extenlOi rotators:
- Spinal part of deltoid.
Neural function:
Muscle
Infraspinatus
Teres minor
Oeltoid
Peripheral
Suprascapular
Axillar
Axillar
Inneration
Common pathological situations:
Nerve root
e5.(eG)
e5. (eGI
e5. (eG)
• Pain occurs in infraspinatus tendinitis but
may also be present in subdeltoid bursitis.
• Weakness indicates a total rupture of the
infraspinatus tendon or a neurological
condition, e.g. C5 nerve root palsy, supra­
scapular nerve palsy, neuralgic amyotrophy.
Bilateral weakness is suggestive of myopathy.
• Painful weakness is the result of a partial
rupture of the infraspinatus tendon.
Resisted internal rotation
Positioning. The subject stands with the upper
arm against the body and the elbow flexed to a
right angle. The forearm is held in the sagittal
plane, so keeping the shoulder in a neutral posi­
tion. The examiner stands level with the sub­
ject's arm. He places one hand on the opposite
shoulder and the other hand against the inner
and distal aspect of the forearm.
Procedure. Resist the subject's attempt to pull her
hand towards her (Fig. 1.27).
Common mistakes:
• The shoulder is allowed to abduct.
• Movement is allowed at the shoulder.
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Fig. 1.27 Resisted Intemal rotation of the shoulder.
Anatomical structures tested:
Muscle lunction:
• importallt i"terHal rotators:
- Subscapularis
- Pectoralis major
- Latissimus dorsi
- Teres major
• Lss importalt illternal rotators:
- Long head of biceps brachii
- Clavicular part of deltoid
Neural function:
Muscle Innervation
Subscapulars
Pectorahs major
Latissimus d
Teres major
Bicps brachii
Deltoid
clavicular part
Penpheral
Subscapular
Pectoral
Trcrl
Subscapular
Musculoutaneous
Pectoral
Nerve rot
C5C8
C5C8
(C6), C7, (C8)
C5C8
CS,C6
C5C8
SHOULDER 15
Common pathological situations:
• Pain is the result of a lesion of the
subscapularis, pectoralis major or latissimus
dorsi tendons or muscles, and more rarely of
the teres major .
• Isolated weakness occurs in total rupture of
the subscapularis tendon.
Resisted flexion of the elbow
Positioning. The subject stands with the arm
alongside the body, the elbow bent to a right
angle and the forearm in full supination. The
examiner stands level with the subject's hand.
One hand is on top of the shoulder and the other
on the distal aspect of the forearm.
Procedure. Resist the subject's attempt to flex her
elbow (Fig. 1.28).
Fig. 1.28 Resisted flexion of the elbow.
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16 ATLAS OF ORTHOPEDIC EXAMINATION
Common mistakes:
• The subject shrugs up the shoulder in the
hope of exerting more strength.
• Movement is allowed at the elbow.
• In strong subjects, flexion cannot sufficiently
b resisted if the resistance is not given
perpendicular to the subject's forearm.
Anatomical structures tested:
Muscle function:
• Imporlalll fexors:
- Brachialis
- Biceps brachii
• Less important flexor:
- Brachioradialis.
Neural function:
Musle
Peripheral
Innervation
Brachiatis
Biceps brachif
BrachioradiaHs
Musculoutaneous (radial)
Musculoutaneous
Radial
Common pathological situations:
Nerve rot
C5-C6
C5-C6
C5-C6
• Pain in the region of the shoulder occurs
when a lesion is present in either the long
head or the short head of biceps.
• Weakness is the result of either a C5 or a C6
nerve root lesion.
Resisted extension of the elbow
Positioning. The subject stands with the arm
alongside the body and the elbow bent to a right
angle with the forearm in supination. The
examiner stands level with the subject's forearm.
One hand is on top of the shoulder, the other on
the distal aspect of the forearm.
Procedure. Resist the subject's attempt to extend
the elbow (Fig. 1.29).
Common mistakes:
• Extension is allowed at the shoulder.
• Movement is allowed at the elbow.
Fig. 1.29 Resisted extension of the elbow.
Anatomical structures tested:
Muscle function:
• Most importn1Jt extellsor:
- Triceps brachii
• Less important extensor:
- Anconeus.
Neural function:
Muscle
Perpheral
Triceps brachil Radial
Anconeus Radial
Inneratin
Common pathological situations:
Nerve ro t
C7-C8
C7-C8
• Pain elicited in the shoulder region is the
result of the humerus being pulled upwards
against the acromial arch and pinching an
inflamed subacromial structure. This happens
in subdeltoid bursitis or in tendinitis of one of
the tendons of the rotator cuff.
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• Pa on extension more rarely indicates
triceps tendinitis.
• Weakness is usually the result of a C7 nerve
root palsy.
SPECIFIC TESTS
Passive horizontal adduction
Significance. This test stresses the acromioclavi­
cular and sternoclavicular joints and ligaments.
It also squeezes the subcoracoid bursa and the
upper part of the insertion of the subscapularis
tendon into the lesser tuberosity of the humerus.
POSitioning. The subject stands with the arms
hanging alongSide the body. The examiner stands
level with the subject's arm. One hand grasps the
elbow at the distal part of the upper arm. The other
hand is placed at the back of the other shoulder.
Procedure. Take the arm into abduction first and
then bring it horizontally in front of the body,
pressing the elbow towards the contralateral
shoulder (Fig. 1.30).
Fig. 1.30 Passive horizontal adduction of the shoulder.
SHOULDER 17
Common mistakes. The subject's shoulder girdle
is not well stabilized so that she may twist away
from the pressure .
Apprehension test in external
rotation
Significance. The test is performed to detect
recurrent anterior dislocation of the shoulder.
The test is positive when the patient gets the
feeling that the shoulder moves out of place, so
recognizing her symptoms.
Positioning. The subject lies supine with the
arm alongSide the body and the elbow flexed
to 90°. The examiner sits level with the subject's
shoulder. One hand is on the subject's shoulder
with the fingers anteriorly and the thumb poster­
iorly against the humeral head. The other hand
takes hold of the forearm.
Procedure. Bring the subject's arm into full
external rotation, meanwhile exerting an anter­
ior pressure on the humerus with the thumb
(Fig. 1.31). Repeat this test in different degrees of
abduction.
Apprehension test in internal rotation
Significance. The test is perforned to detect re­
current posterior dislocation of the shoulder.
The test is positive when the patient gets the
feeling that the shoulder moves out of place, so
recognizing her symptoms.
POSitioning. The subject sits on a chair, the arm
in slight abduction and the forearm behind the
back. The examiner sits level with the subject'S
shoulder. One hand is on the subject'S shoulder
with the thumb anteriorly and the fingers
posteriorly against the humeral head. The other
hand grasps the forearm.
Procedure. Bring the subject's arm into slight
abduction and ft internal rotation and exert
a posterior pressure to the humerus with the
thumb (Fig. 1.32).
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18 ATLS OF ORTHOPEDIC EXAMINATION
Fig. 1.31 The apprehension test for recurrent anterior dislocation.
Fig. 1.32 The apprehension test for recurrent posterior dislocation.
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Anterior drawer test
Significance. This test is meant to detect anterior
hypermobility in the glenohumeral joint.
Positioning. The subject lies supine on the couch
with the arm beyond the edge. The examiner
stands level with the shoulder. He stabilizes the
scapula with the contralateral hand, the thumb of
which is placed on the coracoid process and the
fingers on the acromion. The arm is brought into
about 20° of abduction and into slight fexion.
Fig. 1.33 The anterior drawer test.
SHOULDER 19
The forearm is squeezed between the examiner's
trunk and the ipsilateral arm, the hand of which
grasps the humerus in the axilla (Fig. 1.33).
Procedure. The humeral head is first brought into
its neutral position in the glenoid fossa ('loaded')
and then glided in the anterior direction.
Posterior drawer test
Significance. This test is meant to detect posterior
hypermobility in the glenohumeral joint.
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20 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 1.34 The posterior drawer test.
Positioning. The subject lies supine on the couch
with the arm beyond the edge. The examiner
stands level with the shoulder. He stabilizes the
scapula with the contralateral hand, the thumb of
which is placed on the coracoid process and the
fingers on the acromjon. The arm is brought into
about 20° of abduction and into slight flexion.
The forearm is squeezed between the exammer's
trunk and the ipsilateral arm, the hand of which
grasps the humerus in the axilla (Fig. 1.34).
Procedure. The humeral head is first brought into
its neutral position in the glenoid fossa ('loaded')
and then glided in the posterior direction and
slightly laterally.
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CHAPTER CONTENTS
Surace and palpatory anatomy 21
Anterior 21
Bony landmarks 21
Palpation of soft tissue 21
Lateral 23
Bony landmarks 23
Palpation of sof tissue 23
Posterior 27
Bony landmarks 27
Palpation of soft tissue 28
The cubital tunnel 28
Medial 29
Bony landmarks 29
Palpation of soft tissue 29
Functional examination of the elbow 31
Passive tests 31
Passive flexion 31
Passive extension 31
Passive pronation 32
Passive supination 33
Isometric contractions 3
Resisted flexion 3
Resisted extension 3
Resisted pronation 3
Resisted supination 35
Resisted extension of the wrist 3
Resisted flexion of the wrist 3
Elbow
SURFACE AND PALPATORY
ANATOMY
ANTERIOR
Bony landmarks
There are no real bony landmarks recognizable
at the anterior aspect of the elbow. Identify the
cubital fossa. Just below it and deeply through
the muscles of the anterior and upper part of the
forearm, palpate laterally for the radial head (1),
and medially for the coronoid process of the ulna
(2) (Fig. 2.1). These bony parts can be identified
more easily when considering the lateral and
medial aspects of the elbow (see below).
Palpation of soft tissue
Palpation of the biceps muscle and the
neurovascular structures in the cubital fossa
Keep the subject's elbow slightly flexed. Ask for
an active flexion and palpate meanwhile in the
cubital fossa with a pinching grip. Feel for the
bicipital tendon (Fig. 2.2, A) as an outstanding
taut structure. It runs distally to attach to the radial
tuberosity. Medial to the tendon its aponeurosis
(6) can be felt, and lateral to the tendon the belly
of the brachioradialis muscle (C). PrOXimally the
biceps broadens and its musculotendinous junc­
tion (D) can be perceived, and even more proxi­
mally its muscle belly (Fig. 2.3 and Fig. 2.2, E).
Medial to the bicipital tendon, deep under
the aponeurosis, lie the brachial artery and the
21
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22 ATLS OF ORTHOPEDIC EXAMINATION
Fig. 2.1 Anterior view 01 the elbow (skeleton).
Fig. 2.2 Anterior view of the elbow (in vivo).
Fig. 2.3 Palpation of the biceps muscle belly.
median nerve. The former is pulsating, the latter
a round strand.
Palpation of the brachialis muscle
Ask the subject to contract the biceps. Place the
thumb and fingers in the indentations on both
sides of the bicipital tendon (the lateral and
medial bicipital grooves) and now ask for an
isometric nexion. Under the fingers -and behind
the biceps tendon - the contraction of the
brachialis muscle (F) can be felt. During relax­
ation of this muscle, its belly, which runs further
distally than the muscle belly of the biceps, can
be palpated with a pinching grip. The brachialis
inserts at the ulnar tuberosity.
Palpation of the pronator teres muscle
The subject holds his elbow in 90° flexion and the
forearm in the neutral position between prona­
tion and supination. Ask the subject to pronate
the forearm and resist the movement. Palpate
with the other hand in the thick muscular mass
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Fig. 2.4 Palpation of the pronator teres muscle.
just distal to the cubital fossa (Fig. 2.4). A round
and strong muscle can be felt running from
the medial epicondyle to mid-radius. This is the
pronator teres muscle (G).
LATERAL
Bony landmarks (Fig. 2.5)
The subject holds his elbow in 90° of flexion and
the forearm supinated. The lateral epicondyle (A)
can be palpated as the most prominent bone.
From its anterior aspect originates the extensor
carpi radialis brevis muscle. The epicondylar
border continues proximally in the lateral supra­
condylar ridge (B). Level with it and from the
anterior surface of the humerus originate the
brachioradialis and, just below it, the extensor
carpi radialis longus muscles.
Palpate distal to the epicondyle for a depres­
sion -the radiohumeral joint Line (C). Its proximal
component -the lateral edge of the humeral capi­
tulum (0) - can be felt as a spherical structure.
ELBOW 23
Fig. 2.5 Lateral view of the elbow (skeleton).
The distal component -the head of the radius (£)
- is well perceivable when small rotatory move­
ments of the forearm are performed. The joint
line becomes a bit wider and thus even better
palpable when the elbow is brought towards
more extension. Feel for the lower border of
the head of the radius and place the finger just
distally to it. It now lies on the radial neck (F).
Palpation of soft tissue
Palpation of the brachioradialis muscle
(Fig. 2.6)
The subject's elbow is held in 90° flexion and the
forearm in the neutral position between prona­
tion and supination. Ask the subject to flex the
elbow and resist the movement. The contraction
of the brachioradialis muscle (A) is well palpable
and visible and the structure can, by palpation in
the posterior direction, easily be followed further
proximaUy in its course until its insertion at
the anterior aspect of the humerus, level with the
lateral supracondylar ridge.
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24 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 2.6 View of the brachioradialis muscle.
Palpation of the radial extensors of the wrist
(Fig. 2.7)
The muscles are now relaxed. Bring the subject's
forearm into supination and ask him to do a
combined active movement of extension and
radial deviation of the wrist. Just distal to the
origin of the brachioradialis muscle (A) - be­
tween this muscle and the lateral epicondyle -
the contraction of the extensor carpi radialis
longus (8) can be seen. By pressing in the pos­
terior direction, its origin can be palpated, again
at the anterior aspect of the humerus (Fig. 2.8).
Go more distally and palpate now the anterior
aspect of the lateral epicondyle (E). A flat ten­
dinous structure is recognized which is the origin
of the extensor carpi radialis brevis muscle
(Fig. 2.9 and Fig. 2.7, C).
Bring the subject'S elbow into more extension
(130-135°) and into pronation. Over the head of
the radius (F) the tendons of wrist and finger ex­
tensors (Fig. 2.10 and Fig. 2.7, D) can be palpated.
Flg.2.7 Lateral view of the elbow (in vivo),
Fig. 2.8 Palpation of the extensor carpi radialis longus
muscle.
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Fig. 2.9 Palpation of the extensor carpi radialis brevis muscle.
(.1
Fig.2.10 Palpation of the wrist extensors.
(bl
ELBOW 25
II
I
\�
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26 A T1.AS OF ORTHOPEDIC EXAMINATION
Elbow and forearm are again brought into 900
flexion and supination. Us a pinching grip and
start palpation level with the neck of the radius
(Fig. 2.11). Over a distance of 3 em downwards
Fig. 2.11 Palpation of the muscle bellies of extensor carpi
radialis longus and brevis.
Fig. 2.12 Extensors of the wrist: 1, origin of extensor carpi
radialis longus; 2. origin of extensor carpi radialis brevis; 3,
tendon of extensor carpi radialis brevis; 4. belly of extensor
carpi radialis brevis.
the bellies of bracruoradialis (superficial) and
extensors carpi radialis longus and brevis (deep)
(Fig. 2.12) can be felt, the latter especially when
the subject actively extends his wrist.
Palpation of the extensor carpi ulnaris muscle
(Fig. 2.13)
The elbow and forearm are still held in the same
starting position (900 flexion, supination). Place
the palpating finger below the lateral epicondyle
(A). Ask the subject to perform ulnar deviation
of the wrist. Tension can b felt in the tendon
of the extensor carpi ulnaris (Fig. 2.14 and
Fig. 2.13, A), which runs towards the olecranon.
Flg.2.13 View of the extensor carpi ulnaris muscle.
Flg.2.14 The extensor carpi ulnaris muscle.
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Palpation of the supinator muscle (Fig. 2.15)
Place the subject's elbow in 130135° extension
and in pronation. Identify the radius from the
radial head downwards. Identify the ulna from
the olecranon downwards. The supinator muscle
(Fig. 2.16) is known to lie in the interspace be­
tween radius and ulna, between the elbow and
Fig. 2.15 Palpation of the supinator muscle.
Fig. 2.16 The supinator muscle.
ELBOW 27
mid-forearm. Ask the subject to supinate and
resist this attempt. Contraction can b felt.
POSTERIOR
Bony landmarks (Figs 2.17 and 2.18)
Three bony prominences can be identified. On an
extended elbow they lie in one line. Laterally is
situated the lateral epicondyle (A) and medially
the medial epicondyle (B). In between lies the
olecranon (C), gross and prominent. During
flexion of the elbow the olecranon moves down­
wards which makes its apex easily palpable. In
a bent elbow the three bones form an isosceles
triangle. Between the olecranon and the medial
epicondyle lies the sulcus for the ulnar nerve (0).
Flg.2.17 Posterior view of the elbw (skeleton).
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28 ATLAS OF ORTHOPEDIC EXAMINATION
Palpation of soft tissue
(Figs 2.18 and 2.19)
Over the olecranon lies the olecranon bursa,
which is only really palpable when it becomes
inflamed and swollen.
Keep the subject's elbow flexed. Palpate for the
upper border (apex) of the olecranon. Feel just
lateral to this apex for the insertion of the tendon
Flg.2.18 Posterior view of the elbow (in vivo).
Fig. 2.19 Palpation of the triceps tendon.
of the triceps muscle (E). Move the fingers
upwards: a broad and flat tendon is felt and ends
in the musculotendinous junction (F), shaped as
an inverted U (Fig. 2.20).
Distally and slightly lateral to the olecranon
the anconeus muscle (G) can be felt during an
attempt to actively over-extend the elbow.
Palpation on a flexed elbow between the
olecranon and the medial epicondyle discloses
the sulcus in which the ulnar nerve - a soft and
round structure - can be found. It is covered by
the posterior part of the ulnar collateral liga­
ment. The nerve courses under the medial head
of the triceps musde, then behind the medial
epicondyle and then further distally in between
the two heads of the flexor carpi ulnaris muscle,
which form an aponeurotic arch.
The cubital tunnel
The cubital tunnel (Fig. 2.21) is built from the
medial epicondyle, the olecranon, the ulnar
collateral ligament and the aponeurotic arch.
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Fig. 2.20 The triceps muscle: 1, musculotendinous
junction; 2, body of the tendon; 3, tenoperiosteal inserion.
Fig. 2.21 The cubital tunnel.
J
ELBOW 29
MEDIAL
Bony landmarks (Fig. 2.22)
The medial epicondyle is recognized as a very
prominent bone, which lies just subcutaneously.
Palpation of soft tissue
(Figs 2.23 and 2.24)
Keep the subject's elbow almost completely
extended and in full supination. Move the finger
from the medial aspect of the medial epicondyle
(A) about 1-1.5 cm towards the anterior aspect.
Palpate for a tough round structure. This is the
common tendon of the flexors (Fig. 2.25 and
Fig. 2.23, B).
Fig. 2.22 Medial view of the elbow (skeleton).
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30 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 2.23 Medial view of the elbow (in vivo).
0.5 em more distally, just below the inferior
border of the epicondyle and with the elbow
slightly flexed, a thick and round muscular mass
is palpable: the musculotendinous junction of
this flexor group (C) consisting of, from medial
Fig. 2.25 The common flexor tendon: 1, tenoperiosleal; 2,
musculotendinous.
to lateral: the flexor carpi uLnaris, the palmari
longus, the flexor carpi radialis and the pronate
teres.
Lateral to the common flexor tendon the media
nerve is palpable as a round but soft structure.
Fig. 2.24 Palpation of the common tendon of the flexors.
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FUNCTIONAL EXAMINATION OF THE
ELBOW
PASSIVE TESTS
Passive flexion
Positioning. The subject stands with the arm
outstretched. The examiner stands level with
the subject's arm. He places one hand against
the back of the shoulder and grasps the distal
forearm with the other hand.
Procedure. Bring the hand towards the shoulder,
thereby stabilizing the latter, until the movement
comes to a stop (Fig. 2.26).
Common mistakes. Inadequate stabilization allows
the shoulder to move backwards.
Normal functional anatomy:
• Rm'ge: about 160°
• Elld-feel:
- in well muscled subjects: a soft stop by
Fig. 2.26 Passive flexion.
ELBOW 31
tissue approximation, the muscles of the
forearm coming in contact with the muscles
of the upper arm
- in poorly muscled subjects: a rather hard
stop of bone engaging with bone.
• Limitillg structures:
- in well muscled subjects: the muscular
masses of the upper arm and forearm
coming in contact with each other
- in poorly muscled subjects: bony contact
between (1) the coronoid fossa of the
humerus and coronoid process of the ulna
and (2) the head of the radius and radial
fossa of the humerus
- tension in the posterior part of the joint
capsule.
Common pathological situations:
• Painful limitation occurs in arthritis (as part of
the capsular type of limitation) or when a
loose body is present in the anterior part of
the jOint .
• Painless limitation is present in
uncomplicated arthrosis.
Passive extension
Positioning. The subject stands with the arm
outstretched. The examiner stands level with the
subject'S elbow. One hand stabilizes the elbow,
and the other hand grasps the distal forearm.
Procedure:
• To test the range: move hands in opposite
directions - distal hand downwards and
proximal hand upwards (Fig. 2.27).
• To test the end-feel: bring the subject's elbow
into slight flexion and move hands abruptly
but gently in opposite directions towards
extension.
Common mistakes. The elbow is not in complete
supination.
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32 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 2.27 Passive extension.
Normal functional anatomy:
• Rnllge: generally 0° in the male; in female
subjects and in hypermobile persons
overextension of a few degrees may be
possible
• Ellrl-feel: hard stop of bone engaging with
bone
• Limitiug structures:
- bony contact between the olecranon process
and olecranon fossa
- tension in the anterior part of the joint
capsule.
Common pathological situations:
• A painful limitation occurs in arthritis of the
elbow joint and also when a loose body is
present in the posterior part of the joint.
• A painless limitation is present in
uncomplicated arthrosis.
Passive pronation
Positioning. The subject stands with the arm
hanging and the elbow bent to a right angle.
The examiner stands in front of the subject. Both
hands encircle the distal forearm in such a way
that the heel of the contralateral hand is placed
against the volar part of the ulna and the fingers
of the other hand against the dorsal aspect of the
radius.
Procedure. Bring the subject's forearm into full
pronation by a simultaneous movement of both
hands in opposite directions (Fig. 2.28).
Common mistakes:
• The subject's shoulder is brought into
abduction.
• Too much local pressure on the radius/ulna
may provoke tenderness.
Normal functional anatomy:
• Range: about 85°
• End-feel: elastic
• Limiling slrllclflres: stretching of the
interosseous membrane and squeezing of the
insertion of the bicipital tendon between the
radial tuberosity and the ulna.
Common pathological situations. The movement
is painful in lesions of the proximal radioulnar
joint, in bicipitoradial bursitis and in tendinitis
of the biceps brachii at the insertion onto the
radial tuberosity.
Fig. 2.28 Passive pronation.
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Passive supination
Positioning. The subject stands with the arm
hanging and the elbow bent to a right angle.
The examiner stands in front of the subject. Both
hands encircle the distal forearm in such a way
that the heel of the ipsilateral hand is placed
against the dorsal part of the ulna and the fingers
of the other hand against the volar aspect of the
radius.
Procedure. Bring the subject's foreann into full
supination by a simultaneous movement of both
hands in opposite directions (Fig. 2.29).
Common mistakes. Too much local pressure on
the radiusl ulna may provoke tenderness.
Normal functional anatomy:
• Rallge: about 90°
• Ellrl-feel: elastic
• Umitillg structures:
- tension in the interosseous membrane, the
oblique cord and the anterior ligament of
the distal radioulnar joint
- tension in the extensor carpi ulnaris tendon
when the posterior aspect of the ulnar
Fig. 2.29 Passive supination.
ELBOW 33
notch of the radius impacts against the
stylOid process of the ulna.
Common pathological situations. The movement
is painful when the proximal radioulnar joint is
affected.
ISOMETRIC CONTRACTIONS
Resisted flexion
Positioning. The subject stands with the arm
hanging, the elbow flexed to a right angle and
the forearm supinated. The examiner stands level
with the elbow. One hand is on the distal part
of the forearm and the other hand on top of the
shoulder.
Procedure. Resist the subject's attempt to flex the
elbow (Fig. 2.30).
Common mistakes:
• In strong subjects flexion cannot sufficiently
be resisted if the resistance is not given
perpendicular to the subject's forearm.
• Movement is allowed at the elbow.
• The subject performs shoulder elevation.
Fig. 2.30 Resisted flexion.
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3 ATLAS OF ORTHOPEDIC EXAMINATION
Anatomical structures tested:
Muscle function:
• Important flexors:
- Brachialis
- Biceps brachii
• Less important fexors:
- Brachioradialis
Extensor carpi radialis longus
- Pronator teres.
Neural function:
Muscle
Innervation
Brachlalis
Biceps brachii
Brachloradialis
Peripheral Nere root
Musculocutaneous C56
Musculocutaneous C56
Radial C56
Extensor carpi radialis longus Radial C&-C7
C&-C7 Pronator teres Median
Common pathological situations:
• Pain indicates a lesion of either the biceps
brachii or the brachialis muscle.
• Painless weakness occurs in either a CS or a
C6 nerve root lesion.
• Painful weakness is suggestive of an avulsion
fracture of the radial tuberosity.
Resisted extension
Positioning. The subject stands with the arm
alongside the body, the elbow flexed to 90° and
the forearm in supination. The examiner stands
level with the elbow. One hand supports the distal
part of the forearm and the other hand is on top
of the shoulder.
Procedure. Resist the subject's attempt to extend
the elbow (Fig. 2.31).
Common mistakes:
• In strong subjects, flexion cannot
sufficiently be resisted if the resistance is
not given perpendicular to the subject's
forearm.
• Movement is allowed at the elbow.
Fig. 2.31 Resisted extension.
Anatomical structures tested:
Muscle function:
• Most important extensor:
- Triceps brachii
• Less imporfa1lt exte1lsor:
- Anconeus.
Neural function:
Muscle
Triceps brachii
Anconeus
Peripheral
Radial
Radial
InnervatIon
Common pathological situations:
Nere root
C7-C8
C7-C8
• The test is painful when a lesion of the triceps
is present.
• Weakness occurs in lesions of either the radial
nerve or the C7 nerve root.
• Painful weakness may indicate a partial rupture
of the triceps or a fracture of the olecranon.
Resisted pronation
Positioning. The subject stands with the arm
alongside the body, the elbow bent to a right
angle and the forearm in neutral position. The
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examiner stands in front of the subject. The
ipsilateral hand carries the forearm, the thenar
against the palmar and distal aspect of the radius
and the fingers against the dorsal aspect of the
ulna. The other hand reinforces: thenar on ulna
and fingers on radius.
Procedure. Resist the subject's attempt to pronate
the forearm (Fig. 2.32).
Common mistakes:
• The subject abducts the shoulder.
• Too much local pressure on the radius/ulna
may provoke tenderness.
• Movement is allowed at the elbow.
Anatomical structures tested:
Muscle function:
• Pronator teres
• Pronator quadratus.
Neural function:
Muscle
Pronator teres
Pronator quadratus
Peripheral
Median
Median
Fig. 2.32 Resisted pronation.
Inneration
Nere rool
eI7
C8T1
ELBOW 35
Common pathological situations. Pain occurs in
golfer's elbow - a lesion of the common flexor
tendon - or in an isolated lesion of the pronator
teres muscle.
Resisted supination
Positioning. The subject stands with the arm
alongside the body, the elbow bent to 90° and the
forearm in neutral position. The examiner stands
in front of the subject. The ipsilateral hand carries
the forearm, the thenar against the distal and palmar
aspect of the ulna. The thenar of the other hand is
placed against the dorsal aspect of the radius.
Procedure. Resist the subject's attempt to supinate
the forearm (Fig. 2.33).
Common mistakes:
• The subject extends the elbow.
• Movement is allowed at the elbow.
• Too much local pressure on the radius/ ulna
may provoke tenderness.
Anatomical structures tested:
Muscle function:
• Most important supitlafors:
- Supinator
- Biceps brachii
Fig. 2.33 Resisted supination.
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3 ATLAS OF ORTHOPEDIC EXAMINATION
• Less importaNt sup;lIalor:
- Brachioradialis.
Neural function:
Muscle Inneration
Peripheral Nerve root
Supinator
Bieps brachii
Brachioradialis
Radial
Musculocutaneous
Radial
C5-
C5S
C58
Common pathological situations. Pain is the result
of a lesion of the biceps or, more rarely, a lesion of
the supinator muscle.
Resisted extension of the wrist
Positioning. The subject stands with the arm
hanging, the elbow extended and the wrist in
neutral position (between pronation and supina­
tion, and between flexion and extension). The
examiner stands level with the subject's elbow.
The contralateral arm lifts and carries the elbow
and keeps it extended. The hand stabilizes the
forearm. The other hand is placed at the dorsum
of the subject's hand.
Procedure. Resist the subject's attempt to extend
the wrist (Fig. 2.34).
Fig. 2.34 Resisted extension of the wrist.
Common mistakes:
• The subject is allowed to lift the arm up.
• The elbow is allowed to flex. This can be
prevented by the examiner's arm keeping the
subject's elbow well raised.
• The wrist is not held in neutral position, which
puts stress on non-contractile structures.
Anatomical structures tested:
Muscle function:
• Imporla1lt wrist extensors:
Extensor digitorum communis
Extensor carpi radialis longus
- Extensor carpi radialis brevis
- Extensor carpi ulnaris
• Less importmlt wrist extensors:
- Extensor indicis proprius
- Extensor pOllicis longus
- Extensor digiti minimi.
Neural function:
Muscle Innervation
Extensor digitorum communis
Extensor carpI radialis longus
ExtenS carpi radialis brevis
Extensor carpi ulnaris
ExtenS indicis proprius
Extensor pUicis longus
Extensor digiti minlmi
Peripheral
Radial
Aadial
Radial
Aadial
Radial
Radial
Radial
Common pathological situations:
Nerve root
C&C8
C&C7
C7
C7-C8
C&C8
C7-8
C&C8
• When elbow pain is elicited, tennis elbow - a
lesion in the radial extensors of the wrist - is
most probable. Other possibilities are a lesion
of the extensor carpi ulnaris or of the extensor
digitorum.
• Weakness may result from a radial nerve
lesion or from either the C6 or C8 nerve root.
Bilateral weakness suggests either lead
poisoning, or bronchus carcinoma, or a more
general neurolOgical disease.
Resisted flexion of the wrist
Positioning. The subject stands with the arm
hanging, the elbow extended and the wrist in
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neutral position (between pronation and supina­
tion, and between flexion and extension). The
examiner stands level with the subject's elbow.
The contralateral arm lifts and carries the elbow
and keeps it extended. The hand stabilizes the
forearm. The other hand is placed at the palm of
the subject's hand.
Procedure. Resist the subject's attempt to flex the
wrist (Fig. 2.35).
Common mistakes:
• The subject is allowed to push the arm down.
Fig. 2.35 Resisted flexion of the wrist.
ELBOW 37
If this happens it is the result of inadequate
fixation.
• The wrist is not held i neutral position, which
puts stress on non-contractile structures.
Anatomical structures tested:
Muscle function:
• III/portallt wrist fexors:
- Flexor digitorum superficialis
- Flexor digitorum profundus
- Flexor carpi ulnaris
- Flexor carpi radialis
• Less importallt wrist flexors:
- Abductor pollicis longus
- Palmaris longus.
Neural functon:
Muscle
Inneration
Flexor digitorum superficialis
Flexor digllorum profundus
Flexor carpi ulnaris
Flexor carpi radialis
Abductor pollicis longus
Palmaris longus
Perpheral Nere root
Median C7-T1
Median C7-Tl
Ulnar C7-C8
Median C7-T1
Radial C7-C8
Median C7-Tt
Common pathological situations:
• Pain at the elbow occurs in golfer's elbow - a
lesion in the common flexor tendon.
• Weakness suggests a C7 or C8 nerve root
lesion.
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CHAPTER CONTENTS
Surface and palpatory anatomy 39
Radial 39
Bony landmarks 39
Palpation of soft tissue 40
Dorsal 41
Bony landmarks 41
Palpation of soft tissue 42
Ulnar 43
Bony landmarks 43
Palpation of soft tissue 43
Palmar 4
Bony landmarks 4
The carpal tunnel 45
The tunnel of Guyon 4
Palpation of soft tissue 46
Functional examination of the wrist 4
Passive tests of the distal radioulnar joint 48
Passive pronation 48
Passive supination 49
Passive tests of the wrist joint 49
Passive flexion 5
Passive extension 50
Passive radial deviation 51
Passive ulnar deviation 51
Passive test for the trapezium-first metacarpal
joint 51
Backwards movement during extension 51
Isometric contractions 52
Muscles controlling the wrist 52
Muscles cntrolling the thumb 55
Muscles controlling the fingers 57
Intrinsic muscles of the hand 5
Specific tests 61
Phalen's lest 61
Tinel's test 61
Grind test for the trapezium-first metacarpal
joint 62
Finkelstein's test 62
Wrist
SURFACE AND PALPATORY
ANATOMY
RADIAL
Bony landmarks (Figs 3.1, 3.2 and 3.3)
At the distal end of the radius the styloid process
(A) can be palpated. Slightly more proximally
on the radius a small groove can be found.
Just distally to the styloid process the scaphoid
(navicular) bone (B) is palpable. It can be made
more prominent by asking the subject to execute
ulnar deviation of the wrist. When the palpating
finger is on the navicular bone it lies in a de­
pression between two tendons, called the 'anato­
mieal snuffbox'. At the distal end of the snuffbox
the joint line can be palpated between the
scaphoid bone and the trapezium, especially
Fig. 3.1 Radial view of the wrist (skeleton).
39
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4 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 3.2 Bony landmarks at the radial side of the wrist (in
vivo).
Fig. 3.3 Bony structures at the radial side 01 the wrist.
when the subject moves the thumb. 67 mm
more distally another joint line is palpable - the
one between the trapezium bone and the first
metacarpal bone. This joint line is well palpable
during movement of the first metacarpal bone:
feel for the shaft of the first metacarpal bone
with one finger and move proximally towards
the base of the bone (C). The joint line can be
felt just proximally to the proximal border of the
bone, especially while the other hand moves the
first metacarpal to and fro.
Palpation of soft tissue
Place the palpating finger just distally to the
styloid process and feel for the tightening of the
radial collateral ligament during ulnar deviation.
It attaches to the scaphoid bone (Fig. 3.4).
Move the finger slightly towards the palmar
aspect. Ask the subject to extend the thumb
(Fig. 3.5). Two strong tendons can be recognized
(Fig. 3.6): first the extensor pollicis brevis (A),
which is seen to run towards the base of the
proximal phalanx. It forms the radial border of
the 'anatomical snuffbox'. Next to it the abductor
Fig. 3.4 The radial collateral ligament.
Fig. 3.5 View of the extensors and abductor of the thumb.
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Fig. 3.6 Tendons at the radial aspect 01 the wrist.
pollicis longus (B) is felt, inserting at the base
of the first metacarpal bone.
DORSAL
Bony landmarks (Figs 3.7 and 3.8)
Radius and ulna are easily palpable. The styloid
process of the radills descends a bit further
distally than the styloid process of the ulna.
The distal radioulnar joint can be recognized
by grasping the distal end of the radius with
one hand and the distal end of the ulna with the
other, and by moving both hands in opposite
directions.
The distal border of the radius is sharp and
can be felt as being the proximal border of the
Fig. 3.7 Dorsal view of the wrist (skeleton).
WRIST 41
Fig. 3.8 Bony landmarks at the dorsal side of the wrist (in
vivo).
radiocarpal joint, which has a wide joint line.
One finger-width more proximally, on the dorsal
aspect of the radius, a nodular bone can be felt.
This is the dorsal tubercle (A) of the radills
which forms an important landmark. At the
ulnar side the thick head of the ulna is palpated.
The carpal bones consist of two rows. In the
proximal row lie the scaphoid, lunate, triquetral
and pisiform bones.
Distal to the inferior border of the radius, two
bones can be palpated. The most radial one is the
already detected scaphoid bone. It is felt more
clearly during ulnar deviation of the wrist. The
most ulnar bone is the lunate bone (B), which
is palpable on a flexed wrist. Ulnar to the lunate
and articulating with the ulna lies the triquetral
bone. It is felt to move when the hand is again
brought into radial deviation.
The distal row contains the trapezium, trape­
zoid, capitate and hamate bones.
Distal and a bit more radially to the scaphoid
lies the trapezium. Between the lunate and the
base of the third metacarpal bone a depression
(C) is felt in which the capitate bone is palpable.
The capitate articulates with the base of the
third metacarpal bone (D). The bone between the
capitate and the trapezium is the trapezoid bone,
which is more difficult to palpate.
To the ulnar side of the capitate and somewhat
more distal and radial than the triquetral, the
hamate bone is felt; it articulates mainly with
the fourth metacarpal bone.
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42 ATLAS OF ORTHOPEDIC EXAMINATION
Palpation of soft tissue
Place one finger just radially to the dorsal tubercle
of the radius (A) (Fig. 3.9). Ask the subject to
make a first and to squeeze and unsqueeze it.
During this action tendinous tightening can be
felt. These are the tendons of the extensor carpi
radialis longus and extensor carpi radialis brevis
(Fig. 3.10). When the subject continues these mus­
cular contractions the tendons can be followed,
approximately 2 cm more distally, until the point
where they separate (B). The most radial tendon
Fig. 3.9 View of the extensors of the wrist (in vivo).
Fig. 3.10 The extensor carpi radialis longus (1) and brevis
(2).
(longus) (C) is felt to insert at the radial aspect
of the base of the second metacarpal bone and
the more ulnar tendon (brevis) (D) inserts at the
radial aspect of the base of the third metacarpal
bone (Fig. 3.11).
Place one finger just ulnar to the dorsal
tubercle of the radius. Ask the subject to extend
the thumb. Feel for the extensor pollicis longus
(Fig. 3.12, A) tendon, which is the ulnar border
of the anatomical snuffbox. It can be palpated
until its insertion onto the distal phalanx of the
Fig. 3.11 Palpation of the extensor carpi radialis longus.
Fig.3.12 View of the extensor poilieis longus (in vivo).
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Flg.3.13 View of the extensors of the fingers (in vivo).
thumb: the tendon turs 45° around the dorsal
tubercle of the radius, crosses over the extensor
carpi radialis longus and brevis, and goes
towards the thumb.
Palpate the dorsal aspect of the wrist while
the subject extends the fingers. Movement can be
felt of the tendons of the extensor digitorum com­
munis and of the extensor indicis proprius. When
one finger is extended at a time the different
tendons can be palpated one by one.
Place one finger just radially to the head of the
ulna. Ask the subject to extend the little finger and
feel for the extensor digiti minimi. This tendon
overlies the distal radioulnar joint.
Place one finger at the inferior and ulnar
border of the head of the ulna (Fig. 3.14, A). Ask
the subject to perform an ulnar deviation during
extension. The strong and thick tendon of the
A
Fig. 3.14 View of the extensor carpi ulnaris (in vivo).
WRIST 4
Flg. 3. 1 5 The extensor carpi ulnaris.
Fig. 3.16 Palpation of the extensor carpi utnaris.
extensor carpi ulnaris (B) is felt (Figs 3.15 and
3.16). It can be followed to its insertion at the base
of the fifth metacarpal bone.
ULNAR
Bony landmarks (Fig. 3.17)
At the distal end of the ulna the small styloid pro­
cess (A) is palpable. Just distal to it the triquetra I
bone (8) becomes prominent when the subject
moves the hand in radial deviation. When the
palpating finger is moved even more distally and
the hand is brought back to the neutral position
the base of the fifth metacarpal bone (C) is
encountered.
Palpation of soft tissue
Place the finger just distal to the styloid process
and move the subject'S hand in radial deviation.
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4 ATLAS OF ORTHOPEDIC EXAMINATION
A
B C
Fig. 3. 17 Bony landmarks at the ulnar side of the wrist (in
vivo).
Tightening can be felt of the ulnar collateral
PALMAR
Bony landmarks (Figs 3.19 and 3.20)
Radius and ulna can be identified. At the distal
and ulnar side of the ulna a bony prominence
can be felt: the pisiform bone (A). Put the inter­
phalangeal joint of the thumb onto the pisiform
and direct the thumb towards the base of the
index finger of the subject. Flex the thumb and
feel its tip touch the hook of hamate through the
muscles of the hypothenar.
Ligament (Fig. 3.18), which goes towards the A
triquetral bone. Ask the subject to move the
hand towards the ulnar side and to extend
the wrist sUghtiy. Along the distal part of the
ulna the tendon of the extensor carpi ulnaris is
palpable.
Fig. 3.18 The ulnar collateral ligament.
Fig.3.19 Bony landmarks at the palmar side of the wrist
(in vivo).
Fig. 3.20 Palmar view of the wrist (skeleton).
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At the distal end of the radius the prominent
tubercle of scaphoid (8) is well palpable. Put
the interphalangeal joint of the thumb onto the
scaphoid's tubercle and direct the thumb towards
the base of the thumb. Flex the thumb and feel its
tip touch the trapezium bone. Laterally and distal
to it lies the base of the first metacarpal (C).
When the finger moves from the scaphoid in
the direction of the index finger, the base of the
second metacarpal bone can be palpated through
the muscles of the thenar.
The carpal tunnel (Figs 3.21, 3.22 and 3.23)
The carpal tunnel lies between - on the ulnar side
- the pisiform bone (A) and the hook of the
hamate bone (8) and - on the radial side - the
tubercle of the scaphoid bone (C) and the trape­
zium bone (0).
It can be localized on the heel of the hand and
somewhat towards the ulnar side. It is covered
by the transverse ligament.
The content of the carpal tunnel is:
• the median nerve
• the flexor poll ids longus
• the flexor carpi radialis
• the flexor digitorum superfidalis and
profundus.
o
Fig. 3.21 Bony boundaries of the carpal tunnel (in vivo).
WRIST 45
Fig. 3.22 View in the carpal tunnel (specimen).
1 --
2 -
Fig. 3.23 The boundaries of the carpallunnel (righl hand,
palmar view): 1, scaphoid; 2, trapezium; 3, pisiform;
4, hamate.
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4 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 3.24 The ulnar nere passes through the tunnel of
Guyon.
The tunnel of Guyon (Fig. 3.24)
Palpate for the interspace between the pisiform
and the hook of hamate. This is Guyon's tunnel
that contains the ulnar nerve and ulnar artery
and is covered by the pisohamate ligament.
Palpation of soft tissue
(Figs 3.25 and 3.26)
Feel for the pisiform bone and place the pal­
pating finger against its proximal aspect. Ask
the subject to actively abduct the little finger. The
tightening of the flexor carpi ulnaris (A) can be
felt (Figs 3.27 and 3.28). The tendon can now be
followed distal to the pisiform until its insertion
on the base of the fifth metacarpal bone. The
pisiform is a sesamoid bone in the tendon of the
flexor carpi ulnaris.
Place the thumb radial to the previous tendon
at the distal part of the forearm. It now lies on the
tendons of the flexor digitorum superficialis (B),
Fig. 3.25 View of the flexors of wrist and fingers (in vivo).
0--
Fig. 3.26 Radial view of the wrist (in vivo).
Fig. 3.27 The flexor carpi ulnaris.
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Fig. 3.28 Palpation of the flexor carpi ulnaris.
of which the movement can be felt during active
flexion and extension of the fingers (Fig. 3.29).
In a deeper layer the presence of the flexor
digitorum profundus can be imagined.
Move the finger a bit more towards the radial
side and ask the subject to oppose the thumb
and little finger and to simultaneously flex the
wrist. The thin tendon of the palmaris longus (C)
Fig. 3.29 Palpation of the flexor digitorum supericialis.
WRIST 47
becomes prominent. It inserts into the palmar
aponeurosis of the hand. (It has to be remem­
bered that this muscle is inconstant.)
Approximately 1 cm radially to the palmaris
longus the strong and thick tendon of the flexor
carpi radialis (0) is palpable (Fig. 3.30), especially
when the subject flexes and radially deviates
the wrist. It inserts at the base of the second
metacarpal bone (Fig. 3.31).
Fig. 3.30 The flexor carpi radialis.
Fig. 3.31 Palpation of the flexor carpi radialis.
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4 ATLAS OF ORTHOPEDIC EXAMINATION
In between the palmaris longus and the flexor
carpi radialis, in a deeper layer, the tendon of the
flexor pollicis longus can be felt to move during
flexion and extension movements of the thumb
(Figs 3.32 and 3.33).
Fig. 3.32 The flexor pollicis longus: 1, level of the first
metacarpal; 2, level of the carpus.
Fig. 3.33 Palpation of the flexor pollicis longus (al the wrist).
Between the flexor carpi radialis and the
abductor pollicis longus the pulsations of the
radial artery (E) can be felt.
FUNCTIONAL EXAMINATION OF THE
WRIST
Introduction/general remarks
Examination of the wrist should include all struc­
tures that can be responsible for pain felt in the
region called 'wrist' by the patient.
This comprises the distal radioulnar joint, the
wrist joint, the trapezium-first metacarpal joint
and also the tendons that control the wrist, thumb
and fingers and the intrinsic muscles of the hand.
PASSIVE TESTS OF THE DISTAL
RADIOULNAR JOINT
Passive pronation
Positioning. The subject stands with the arm
hanging and the elbow bent to 90°. The examiner
stands in front of the subject. Both hands encircle
the distal part of the forearm in such a way that
the heel of the contralateral hand is placed on the
palmar aspect of the ulna and the fingers of the
other hand lie at the dorsal aspect of the radius.
Procedure. Bring the subject's forearm into full
pronation by a simultaneous action of both hands
in opposite directions (Fig. 3.34).
Common mistakes:
• The subject is allowed to abduct the shoulder.
• Too much pressure on the radius or ulna may
provoke local tenderness.
Normal functional anatomy:
• Ral1ge: about 85°
• Elld-feel: elastic
• Limitil1g structlres: impaction of the radius
against the ulna together with stretching of
the interosseous membrane.
Common pathological situations. Pain at full
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Fig. 3.34 Passive pronation.
range suggests arthritis or arthrosis of the distal
radioulnar joint.
Passive supination
Positioning. The subject stands with the arm
hanging and the elbow bent to 90°. The examiner
stands in front of the subject. Both hands encircle
the distal part of the forearm in such a way that
the heel of the ipsilateral hand is placed on the
dorsal aspect of the ulna and the fingers of the
other hand at the palmar aspect of the radius.
Procedure. Bring the subject's forearm into full
supination by a simultaneous movement of both
hands in opposite directions (Fig. 3.35).
Common mistakes. Too much pressure on radius
or u Ina may provoke local tenderness.
Normal functional anatomy:
• Rallge: about 90°
• Elld-feel: elastic
• Limiting structures:
- tension in the interosseous membrane, the
oblique cord and the anterior ligament of
the distal radioulnar joint
WRIST 49
Fig. 3.35 Passive supination.
- tension in the extensor carpi ulnaris tendon
when the posterior aspect of the ulnar
notch of the radius impacts against the
styloid process of the ulna.
Common pathological situations:
• Pain at full range occurs in arthritis or
arthrosis of the distal radioulnar joint and
also in tendinitis of the extensor carpi ulnaris
level with the distal end of the ulna.
• Limitation indicates a malunited Colles'
fracture.
PASSIVE TESTS OF THE WRIST
JOINT
Remark
The wrist joint has a proximal part - the radio­
carpal joint - and a distal one - the intercarpal
joint. The tests described in this chapter test
the wrist joint as a whole and do not test its
structures separately.
All movements are executed with the wrist
held in the neutral position:
• halfway between flexion and extension
• halfway between radial and ulnar deviation.
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50 ATLAS OF ORTHOPEDIC EXAMINATION
The positioning for all passive tests of the wrist
joint is the same.
Positioning for testing the mobility of the wrist.
The subject stands with the arm hanging, the
elbow flexed to a right angle and the forearm
pronated. The examiner stands next to the sub­
ject. The contralateral hand carries the subject's
forearm, which is kept between the examiner's
arm and trunk. The other hand grasps the
subject's hand distally on the metacarpals.
Passive flexion
Procedure. Bring the subject's wrist into maximal
flexion (Fig. 3.36).
Common mistakes. None.
Normal functional anatomy:
• Rallge: 85·
• Elld-feel: Elastic
• Limiling slrllcillres: stretching of the dorsal
ligaments of the carpus, of the intercarpal
ligaments and the capsules of the different
intercarpal joints.
Common pathological situations:
• Pain at the dorsal aspect occurs in a lesion of
the dorsal ligaments or the extensor tendons
of the wrist.
• Pain at the palmar aspect may occur in
periostitis, mostly of the scaphoid bone.
Fig. 3.36 Passive flexion of the wrist.
• Painful limitation may indicate arthritis,
painless limitation arthrosis.
Passive extension
Procedure. Bring the subject's wrist into maximal
extension (Fig. 3.37).
Common mistakes. None.
Normal functional anatomy:
• Range: 85·
• Elld-feel: rather hard
• Limitiug strlfctures:
- stretching of the palmar ligaments of the
carpus and of the intercarpal ligaments and
capsules
- contact of the proximal row of carpal bones
against the radius.
Common pathological situations:
• Pain at full range and felt at the dorsal aspect
may suggest a periostitis of the distal
epiphysis of the radius or a dorsal ganglion.
Palmar pain may be provoked in a lesion of
the palmar ligament of the wrist or of one of
the flexor tendons.
• Painful limitation is present in arthritis, carpal
subluxation - usually of the capitate bone­
and aseptic necrosis, usually of the lunate
bone.
• Painless limitation is typical for arthrosis.
Fig. 3.37 Passive extension of the wrist.
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Fig. 3.38 Passive radial deviation of the wrist.
Passive radial deviation
Procedure. Push the subject's wrist to the radial
side until the end of range is reached (Fig. 3.38).
Common mistakes. None.
Normal functional anatomy:
• Rallge: about 15°
• Elld-fee/: rather hard
• Limithlg structLlres: stretching of the ulnar
collateral ligament and of the extensor carpi
ulnaris.
Common pathological situations:
• Pain at the ulnar side is typical for a lesion of
the ulnar collateral ligament or the extensor
carpi ulnaris.
• Pain at the radial side may be provoked in de
Quervain's disease as the result of gliding of
the tendons of abductor pollicis longus and
extensor pollicis brevis in their inflamed
sheath.
Passive ulnar deviation
Procedure. Pull the subject's wrist to the ulnar
side until the end of range is reached (Fig. 3.39).
Common mistakes. The thumb is induded in the
movement: it should be left free to avoid exces­
sive stretching of the tendons of the extensors
and long abductor.
Fig. 3.39 Passive ulnar deviation of the wrist.
Normal functional anatomy:
• Rallge: about 45°
• Elld-fee/: rather hard
WRIST 51
• Limifillg sfmcfllres: radial collateral ligament.
Common pathological situations:
• Pain at the radial side at full range is present
in a sprain of the radial collateral ligament or
as the result of gliding of tendons in an
inflamed sheath in tenovaginitis of abductor
pollicis longus and extensor pollids brevis
(de Quervain's disease).
• Pain at the ulnar side can be elicited by a
lesion of the triangular fibrocartilaginous
complex.
PASSIVE TEST FOR THE
TRAPEZIUM-FIRST METACARPAL
JOINT
Backwards movement during
extension
Positioning. The subject stands with the arm
hanging and the elbow bent to 90° and in supina­
tion. The examiner faces the subject. One hand
grasps the hand and stabilizes it.
Procedure. The other hand moves the thumb into
extension first and then backwards (Fig. 3.4).
Common mistakes. The thumb is hyperextended
in the metacarpophalangeal joint, so that most
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52 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 3.40 Passive movement of the thumb.
stress falls on this joint and not on the trape­
zium-first metacarpal one.
Normal functional anatomy:
• Rmlge: until the movement stops
• Elld-feel: elastic
• Lill/itillg structures: stretching of the
anterolateral part of the joint capsule of the
trapezium-first metacarpal joint.
Common pathological situations:
• Pain indicates arthritis or arthrosis
('rhizarthrosis') generally of the joint between
the trapezium and the first metacarpal bones.
More exceptionaUy it is the joint between
trapezium and scaphoid bones.
• Excessive range of motion occurs after
rupture of the ulnar aspect of the
metacarpophalangeal joint capsule.
ISOMETRIC CONTRACTIONS
Muscles controlli ng the wrist
Remarks
As most muscles take their origin at the elbow
and overrun it, the subject's elbow should always
be held in extension to put maximal stress on
these structures.
All movements are executed with the wrist
held in the neutral position:
• halfway between flexion and extension
• halfway between radial and ulnar deviation.
The positioning is the same for the four tests.
Positioning for testing the resisted movements
of the wrist. The subject stands with the arm
hanging, the elbow extended and the forearm
in neutral position. The examiner stands level
with the subject's elbow. The contralateral arm
lifts and carries the elbow and keeps it extended.
The hand stabilizes the forearm. The other hand
grasps the subject's hand distally on the meta­
carpals to apply resistance.
Resisted fexion
Procedure. Resist the subject's attempt to flex the
wrist (Fig. 3.41).
Common mistakes:
• The subject is allowed to push the arm down.
jf this happens it is the result of inadequate
fixation.
• The elbow is not held in extension.
Anatomical structures tested:
Muscle functon:
• Ill/portnllt wrist fexors:
- Flexor digitorum superficial is
Fig. 3.41 Resisted flexion of the wrist.
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Flexor digitorum profundus
Flexor carpi ulnaris
Flexor carpi radialis
• Less i11lportallt wrist flexors:
Abductor pollicis longus
- Palmaris longus.
Neural (unction:
Muscle Inneration
Peripheral Nerve rot
FleIor dlgitorum superfllalis Median C7-T1
Flexor digitorum profundus Median C7-T1
Flexor carpi ulnaris Ulnar C7--8
Flexor carpi radialis Median C7-T1
Abductor pllicis longus Radial C7-8
Palmaris longus Median C7-T1
Common pathological situations:
• Pain at the wrist occurs in tendinitis of the
flexor carpi radialis, flexor carpi ulnaris and
flexor digitorum profundus.
• Weakness is found in C7 and C8 nerve root
lesions.
Resisted extension
Procedure. Resist the subject's attempt to extend
the wrist (Fig. 3.42).
Fig. 3.42 Resisted extension of the wrist.
WRIST 53
Common mistakes:
• The subject is allowed to push the arm
upwards. If this happens it is the result of
inadequate fixation.
• The elbow is not held in extension.
Anatomical structures tested:
Muscle (unction:
• ImportaHt wrist extensors:
Extensor digitorum communis
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor carpi ulnaris
• Less importnut wrist extensors:
Extensor indicis proprius
Extensor pollicis longus
Extensor digiti minjmi.
Neural function:
Muscle Innervation
Extensor digitorum communis
Extensor carpi radialis longus
Extensor carpi radialis breVIS
Extensor carpi ulnaris
Extensor indicis proprius
Extensor pollicis longus
Extensor digiti mlnimi
Peripheral
Radial
Radial
Radial
Radial
Radial
Radial
Radial
Common pathological situations:
Nerve root
CHB
CH7
C7
C7-C8
CHB
C7-C8
CHB
• Pain at the wrist is indicative of tendinitis
of extensor carpi radialis longus and/or
brevis, extensor carpi ulnaris, extensor
indicis proprius or extensor digitorum
communis.
• Unilateral weakness is caused either by a
nerve root lesion, espeCially C6 and C8, or by
a lesion of the radial nerve.
• Bilateral weakness suggests either lead
poisoning, or bronchus carcinoma, or a more
general neurological disease.
Variation: resisted extension of the wrist with the
fingers held actively ffexed
Significance. This test can be used to differentiate
between wrist extensors and finger extensors.
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54 ATLAS OF ORTHOPEDIC EXAMINATION
Active contraction of the finger flexors inhibits
the finger extensors. Absence of pain indicates
that, when a lesion is present, it lies in one of the
finger extensors.
Positioning. The subject is standing and holds the
extended arm forwards. He squeezes his bent
fingers into the palm of his hand. The examiner
stands level with the subject's arm and stabilizes
the forearm with one hand. The other hand is
placed at the dorsum of the subject's hand
(Fig. 3.43).
Procedure. Resist the subject's attempt to extend
the wrist.
Common mi stakes:
• The entire arm is lifted up.
• The elbow is not held in extension.
Resisted radial deviation
Procedure. Resist the subject's attempt to move
the hand radially (Fig. 3.44).
Common mistakes:
• The thumb is not left free, the result of which
is that the thumb extensors and abductors
become directly involved.
• The elbow is not kept extended.
Fig. 3.43 Resisted extension of the wrist with fingers
flexed.
Fig. 3.44 Resisted radial deviation of the wrist.
Anatomical structures tested:
Muscle function:
• Extensor carpi radialis longus
• Abductor pollicis longus
• Extensor pollicis longus
• Flexor carpi radialis
• Flexor pollicis longus
• Brachioradialis
Neural function:
Muscle Innervation
Extensor carpi radialis longus
Abductor poUicis longus
Extensor poliicis longus
Flexor carpi radialis
Flexor poIlicls longus
Brachioradialis
Peripheral
Radial
Radial
Radial
Median
Median
Radial
Common pathological situations:
Nerve root
C6-C7
C7-C8
C7-C8
C7-Tl
C7-C8
C6-8
• Pain is most commonly present in tendinitis
of either the extensor carpi radialis longus
and / or brevis, or the flexor carpi radialis.
• The test may also be painful in de Quervain's
tenovaginitis - a lesion of the abductor
pollicis longus and extensor pollicis brevis in
their common tendon sheath.
Resisted ulnar deviation
Procedure. Resist the subject's attempt to push
the hand over to the ulnar side (Fig. 3.45).
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Flg.3.45 Aesisted ulnar deviation of the wrist.
Common mistakes. The elbow is not extended.
Anatomical structures tested:
Muscle function:
• Importallt lIi1lnr deviators:
- Extensor carpi ulnaris
- Flexor carpi ulnaris
• Less importallt ulnar deviators:
- Extensor digitorum communis
- Extensor digiti minimi.
Neural function:
Muscle
Extensor cr ulnans
Flexor carpi ulnaris
Extensor digltorum communis
Extensor digiti miniml
Peripheral
Radial
Ulnar
Radial
Radial
Common pathological situations:
Innervation
Nerve rool
C7-CB
C7-8
C&8
C&8
• Pain is the result of tendinitis either of the
extensor carpi ulnaris or of the flexor carpi
ulnaris.
• Weakness indicates usually a CB nerve root
lesion.
Muscles controlling the thumb
Remarks
The positioning of the subject is the same for the
four tests. S is the positioning of the examiner,
WRIST 55
Box 3.1 Definitions
-
Adduction The thumb moves from a palmar position
dorsally to join the plane of the other
metacarpals.
Abuction The thumb moves In a palmar direction,
away from the plane of the other
metacarpals.
Extension At carpmetacarpal, metacarpophalan·
geal and interphalangeal joints there is a
movement in the radial direction roughly
Flexion
in a plane parallel to the plane of the other
metacarpals.
At carpometacarpal, metacarpophalan­
geal and interphalangeal joints there is a
movement in the ulnar direction roughly in
a plane parallel to the plane 01 the other
metacarpals.
except that for flexion and extension (see Box 3.1
for definitions) resistance is given at the distal
phalanx and for abduction and adduction at the
distal part (head) of the first metacarpal bone.
Positioning. The subject stands with the arm
hanging, the elbow bent to a right angle, the
forearm and hand in the neutral position, and
the thumb pointing upwards. The examiner faces
the subject. The contralateral hand carries the
subject's wrist. The other hand is on the thumb.
Resisted fexion
Procedure. Resist the subject's attempt to flex the
thumb (Fig. 3.46).
Fig. 3.46 Resisted flexion of the thumb.
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56 ATLAS OF ORTHOPEDIC EXAMINATION
Common mistakes. The thumb is allowed to
hyperextend at the metacarpophalangeal joint.
Anatomical structures tested:
Muscle functon:
• Importallt thumb flexors:
- Flexor pollicis longus
- Flexor pollicis brevis
• Less important thllmb flexor:
- Adductor poll ids.
Neural functon:
Muscle Innervation
Flexor polhcis longus
Fle)or pollicis brevis
superficial head
deep head
Adductor pollicis
Peripheral
Median
Median
Ulnar
Ulnar
Common pathological situations:
Nerve rool
C7-CS
C8-Tl
CB-Tl
CS-T1
• Pain is present in a tenosynovitis of the flexor
poll ids longus.
• Weakness is suggestive of a lesion of a branch
of the median nerve - the anterior
interosseous nerve - and, more rarely, of the
ulnar nerve.
Resisted extension
Procedure. Resist the subject's attempt to extend
the thumb (Fig. 3.47).
Fig. 3.47 Resisted extension of the thumb.
Common mistakes. Hyperextension of the first
metacarpophalangeal joint takes place.
Anatomical structures tested:
Muscle functon:
• Extensor pollicis longus
• Extensor pollicis brevis
• Abductor pollic;s longus.
Neural functon:
Muscle Innervation
Extensor poliicis longus
Extensor pollicis brevis
Abductor pollicis longus
Peripheral
Radial
Radial
Radial
Common pathological situations:
Nerve root
C7-CS
C7-Tl
C7-C8
• Pain occurs in tendinous lesions of the
abductor pollicis longus and extensor pollicis
brevis (de Quervain's disease) and extensor
pollicis longus (crepitating tenosynovitis).
• Weakness is possibly the result of a rupture of
the extensor pollicis longus. It may also
indicate a neurological condition, either of the
radial nerve or of the C8 nerve root.
Resisted abduction
Procedure. Resist the subject's attempt to abduct
the thumb (Fig. 3.48).
Fig. 3.48 Resisted abduction of the thumb.
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Common mistakes. Resistance is given on the
distal phalanx.
Anatomical structures tested:
Muscle functi on:
• Abductor pollicis longus
• Abductor pollicis brevis
• Extensor pollids brevis
• (Flexor pollicis brevis).
Neural function:
Muscle Innervation
Abductor potllciS longus
Abductor poilicis brevis
Extensor poUicis brevis
(Flexor poilicis brevis, deep head
Peripheral
Radial
Median
Radial
Ulnar
Common pathological situations:
Nerve root
C7-8
C6-Tl
C7-Tl
CB-T1)
• Pain is the result of a tendinous lesion of the
abductor pollicis longus and extensor pollicis
brevis, e.g. de Quervain's disease, or
crepitating tenosynovitis.
• Weakness occurs in nerve lesions, e.g.
posterior interosseous nerve or median nerve.
Resisted adduction
Procedure. Resist the subject's attempt to adduct
the thumb (Fig. 3.49).
Common mistakes. Resistance is given at the
distal phalanx.
Fig. 3.49 Resisted adduction of the thumb.
Anatomical structures tested:
Muscle functon:
• Importallt thlmb adductor:
- Adductor pollicis
• Less important thumb addllctors:
WRIST 57
- Flexor pollicis brevis, superficial head
- Opponens pollicis.
Neural function:
Muscle Inneration
Adductor pollicis
Flexor pollicis brevis
supelficial head
Opponens pollicis
Peripheral
Ulnar
Median
Median
Common pathological situations:
Nerve rOI
C8-Tl
C8-Tl
CS7
• Pain occurs in a lesion of the adductor
pollicis, usually in the oblique portion.
• Weakness occurs in lesions of either the ulnar
nerve or the C8 nerve root.
Muscles controlling the fingers
Resisted extension of each finger separately
Positioning and procedure. The subject presents
his hand palm downwards. The examiner stabi­
lizes the wrist with one hand. With the other,
he applies resistance to the distal phalanx of each
finger respectively (Fig. 3.50).
Fig. 3.50 Resisted exension of one finger.
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5 ATLAS OF ORTHOPEDIC EXAMINATION
Common mistakes. None.
Anatomical structures tested:
Muscle function:
• Extension of the index finger:
- Extensor indicis proprius
- Tendon to the index finger of the extensor
digitorum commun.s muscle
• Extension of the middle finger:
- Tendon to the middle finger of the extensor
digitorum communis muscle
• Extension of the ring finger:
- Tendon to the ring finger of the extensor
digitorum communis muscle
• Extension of the little finger:
- Extensor digiti mini
- Tendon to the little finger of the extensor
digitorum communis muscle.
Neural function:
Musle Inneration
Peripheral Nerve rot
Extensor indieis proprius
Extensor digitorum communis
Extensor digiti minimi
Radial
Radial
Radial
Common pathological situations:
C&8
C&8
C&8
• Pain occurs in tendinitis of the extensor
indicis proprius or of one of the tendons of
the extensor digitorum communis.
• Weakness may occur in a lesion of the radial
nerve.
Resisted fexion of each fnger separately
Positioning and procedure. The subject presents
his hand palm downwards. The examiner stabi­
lizes the wrist with one hand. With the other
hand he applies resistance to the distal phalanx
of each finger respectively (Fig. 3.51).
Common mistakes. None.
Anatomical structures tested:
Muscle function:
• Flexor digitorum superficialis
• Flexor digitorum profundus.
Fig. 3.51 Resisted flexion of one finger.
Neural function:
Muscle Innervation
Flexor digitorum suprficiahs
Flexor digitorum profundus
Peripheral
Median
Meehan
Common pathological situations:
Nerve root
C7-T1
C7-T1
• When resisted movement of one specific
finger is painful, the Ie ion, if present,
must lie in the tendon going to that
finger.
• Pain is usually the result of a lesion of one of
the tendons of the flexor digitorum profundus,
either at the wrist or more distally.
Intrinsic muscles of the hand
Remark
When the intrinsic muscles of the hand are affected,
it is usually a lesion in the dorsal interossei. These
muscles mainly abduct the fingers away from the
middle finger (Fig. 3.52, left).
There are four dorsal interossei and three pal­
mar ones. The latter adduct the fingers towards
the middle finger (Fig. 3.52, right).
These muscles can be tested by spreading the
fingers against resistance followed by squeezing
the examiner's finger. The combination of posi­
tive answers indicates which muscle is affected.
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�- f--_
I
I
I
\Hf!
I
I
I
I
I
� f 1/
Fig. 3.52 (Left) Abduction, four dorsal interossei; (right)
adduction, three palmar interossei.
The positioning is the same for all six tests.
When spreading the examiner applies resistance
at the distal phalanges. During squeezing the
examiner places his finger between the proximal
interphalangeal joints.
There are no common mistakes.
Spreading: 1/-11/
Procedure. Resist the subject's attempt to spread
the index and middle fingers (Fig. 3.53).
Anatomical structures tested:
Muscle functon:
• Interosseus dorsalis I
• Interosseus dorsalis m.
Spreading: II/-IV
Procedure. Resist the subject's attempt to spread
the middle and ring fingers (Fig. 3.54).
Anatomical structures tested:
Muscle functon:
• Interosseus dorsalis 11
• Interosseus dorsalis lV.
WRIST 59
Flg. 3.53 Resisted separation of the fingers: II-III.
Flg.3.54 Resisted separation of the fingers: I l l-IV.
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60 ATLAS OF ORTHOPEDIC EXAMINATION
Fig.3.55 Resisted separation of the fingers: IV-V.
Spreading: /V-V
Procedure. Resist the subject's attempt to spread
the ring and little fingers (Fig. 3.55).
Anatomical structures tested:
Muscle function:
• lnterosseus palmaris IV
• Abductor digiti minimi.
Squeezing: 1/-/11
Procedure. Resist the subject's attempt to squeeze
your finger between index and middle fingers
(Fig. 3.56).
Fig. 3.56 Squeezing the fingers: II-III.
Fig. 3.57 Squeezing Ihe fingers: III-IV.
Anatomical structures tested:
Muscle function:
• interosseus palmaris II
• Interosseus dorsalis II.
Squeezing: /II-IV
Procedure. Resist the subject's attempt to squeeze
your finger between middle and ring fingers
(Fig. 3.57).
Anatomical structures tested:
Muscle function:
• Interosseus dorsalis III
• Interosseus palmaris IV.
Squeezing: IV-V
Procedure. Resist the subject's attempt to squeeze
your finger between ring and little fingers (Fig. 3.58).
Flg. 3.58 Squeezing the fingers: IV-V.
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Anatomical structures tested:
Muscle function:
• Interosseus dorsalis IV
• Interosseus palmaris V.
Neural function:
Muscle
Dorsal lnlerossei
Palmar Interossei
Abductor dIgiti minimi
Peripheral
Ulnar
Ulnar
Ulnar
Innervation
Nerve rool
CBT1
C8T1
C8T1
Common pathological situations:
• Pain is usually the result of a lesion in one of
the dorsal interossei. The combination of
positive tests shows which one is affected.
• Weakness may be one of the first signs of an
amyotrophic lateral sclerosis or of
involvement of the T1 nerve root. It may also
indicate a lesion of the ulnar nerve.
SPECIFIC TESTS
Phalen's test = forced flexion of the
wrist (Fig. 3.59)
Significance. This is a compression test for the
median nerve in the carpal tunnel. Release of
Fig. 3.59 Phalen's test.
WRIST 61
the pressure causes paraesthesia in the territory
of the median nerve - 3l fingers medially and
palmar.
Positioning. The subject presents the hand.
The examiner grasps the distal forearm with the
contralateral hand. With the other hand he takes
hold of the subject's hand.
Procedure. Bring the subject's wrist passively
into full flexion and keep it in that position
for about a minute. Then suddenly release the
compression.
Tinel's test = percussion of the carpal
tunnel (Fig. 3.60)
Significance. This is a percussion test for the
median nerve in the carpal tunnel or for the ulnar
nerve in Guyon's tunnel. It should elicit par­
aesthesia in the territory either of the medjan
nerve - 3l- fingers medially and palmar, or of the
ulnar nerve - 1 1 ulnar fingers.
Positioning. The subject presents the hand palm
upwards. The examiner grasps the wrist with
one hand. The other hand uses the percussion
hammer.
Procedure. Give a slight percussion on the carpal
tunnel.
Give a slight percussion on Guyon's tunnel.
Fig. 3.60 TInel's test.
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62 ATLAS OF ORTHOPEDIC EXAMINATION
Grind test for the trapezium-first
metacarpal joint (Fig. 3. 61)
Significance. This test is meant to detect crepitus
as a symptom indicating arthrosis.
Positioning. The subject stands with the arm
hanging and the elbow 90° flexed. The examiner
stands level with the subject's hand. The contra­
lateral hand grasps and stabilizes the wrist. The
other hand takes hold of the distal part of the first
metacarpal bone.
Procedure. Exert axial pressure and circumduct
the first metacarpal bone.
Fig. 3.61 Grind lest
Finkelstein's test (Fig. 3.62)
Significance. This test is meant to confirm the
presence of de Quervain's disease. It should
be more painful than the ulnar deviation test as
described on page 51.
Positioning. The subject stands with the arm
hanging, the elbow flexed to a right angle and
the forearm pronated. The examiner stands next
to the subject. The contralateral hand carries the
forearm, which is kept between his arm and trunk.
The other hand grasps the subject's hand distally
on the metacarpals, first metacarpal included.
Procedure. Pull the subject's wrist to the ulnar
side until the end of range is reached.
Fig. 3.62 Finkelstein's lest.
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CHAPTER CONTENTS
Surface and palpatory anatomy 63
Anterior 63
Bony landmarks 63
Palpation of soft tissue 64
Posterior 66
Bony landmarks 66
Palpation of soft tissue 68
Functional examination of the hlp 69
Passive tests 70
Passive flexion 70
Passive exteral rotation 70
Passive medial rotation 71
Passive abduction 71
Passive adduction 72
Passive extension 72
Isometric contractions 73
Resisted flexion 73
Resisted abduction 74
Resisted adduction 74
Resisted extension 75
Resisted medial rotation 75
Resisted lateral rotation 76
Resisted flexion of the knee 77
Resisted extension of the knee 77
Specific tests 78
Bilateral passive medial rotation in prone
position 78
Adduction in flexion 79
Forceful upwards thrust to the heel 79
Ortolani's test 79
Barlow's test 80
Hip
SURFACE AND PALPATORY
ANATOMY
ANTERIOR
Bony landmarks (Fig. 4.1)
The inguinal fold can easily be identified. It covers
the inguinal ligament (A) that can be palpated as
a strong fibrous band.
The anterior superior iliac spine (B) is located
at the craniolatera] end of the fold. This bony
prominence forms the point of origin of both
the sartorius muscle and the tensor fasciae latae
Fig. 4.1 Bony landmarks in vivo.
C
63
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6 ATLAS OF ORTHOPEDIC EXAMINATION
muscles. The spine continues laterally and dorsally
in the iliac crest (C).
At the medial end of the inguinal fold another
bony prominence can be palpated, the pubic
tubercle (O). Normally it lies level with the super­
ior aspect of the greater trochanter. It provides
attachment for the medial end of the inguinal
ligament and for the tendon of the rectus
abdominis. The tendon of the adductor longus
originates just below this tubercle.
Palpation of soft tissue
Palpation of the supericial fexors: the lateral
femoral triangle (Fig. 4.2)
Place the palpating finger a few centimetres
distal to the anterior superior iliac spine and ask
the patient to lift and abduct the extended leg.
Two structures can be felt and I or seen, one at
Lateral
femoral
triangle
muscle
Medial
triangle
Gracilis
muscle
Fig. 4.2 Bony landmarks.
each side of the finger, forming an inverted V (the
lateral femoral triangle). The sartorius (A) is the
medial and the tensor fasciae latae the lateral
muscle (6) (Fig. 4.3). Notice also the belly of the
rectus femoris (C) a few centimetres distal to the
inverted V (Fig. 4.4).
The origin of the latter is felt deeply in the
lateral femoral triangle, about 5 cm distal to the
anterior superior iliac spine. Ask the patient to
extend the knee, bend the hip to 60' and add
some resistance. This movement makes the belly
of the muscle better visible. Palpate a bony pro­
minence - the inferior iliac spine - from which
the muscle originates.
Fig. 4.3 Lateral femoral triangle.
Fig. 4.4 Rectus femoris in the lateral femoral triangle.
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Medial femoral triangle (trigonum of Scarpa)
(Fig. 4.5)
The medial femoral triangle is defined superiorly
by the inguinal ligament, medially by the
adductor longus and laterally by the sartoriU5.
The floor of the triangle is formed by portions
of the iliopsoas on the lateral side and the
pectineus on the medial side.
Definition in vivo
To define the bely of the sartorius. Stand level with
the knee of the subject at the ipsilateral side
and face the hip. The hip is slightly bent and
slightly abducted. Keep the knee 90° flexed with
its lateral side resting against your hip.
Fig. 4.5 Anterior view of the hip muscle: 1, inguinal
ligament; 2. iliopsoas; 3, femoral artery; 4, pectineus;
5, adductor longus; 6, gracilis; 7. sartorius; 8. rectus femoris;
9, tensor fasciae latae.
HIP 65
Ask the patient to perform a flexion and lateral
rotation at the hip. The former is resisted with the
contralateral hand, the latter with the ipsilateral
one. The muscle becomes even more visible if the
subject is asked to add some flexion movement in
the knee (Fig. 4.6).
To define the adductor fongus. The starting position
is the same. Stand level with the slightly flexed
knee. The hip is slightly flexed and abducted, the
foot rests on the couch.
Place the ipsilateral hand at the inner side
of the knee and resist the add uction movement.
The adductor longus is revealed as the most pro­
minent anterior and medial structure (Fig. 4.7).
Fig. 4.6 Palpation of sartorius (muscle).
Flg. 4.7 Palpation of the adductor longus (muscle).
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66 ATLAS OF ORTHOPEDIC EXAMINATION
Palpation of the iliopsoas tendon and
neurovascular structures in the groin
The most important landmark is the femoral artery
whose pulse is easily found under the inguinal
ligament. The artery courses downwards and
slightly medially towards the tip of the triangle.
The femoral nerve can sometimes be felt as
a small and round strand rolling under the
palpating finger about one finger-width lateral
to the artery and just distal to the inguinal
ligament.
The femoral vein is medial to the artery and in
normal circumstances not palpable.
The tendon of the iliopsoas can be detected
between the femoral artery and the sartorius
muscle, just below the inguinal ligament. To
facilitate the palpation one can bring the hip
into slight flexion and slight lateral rotation. The
localization can be confirmed when the patient
is asked to flex the hip against resistance.
The muscular structure that can be palpated
deeply in the medial corner of the medial femoral
triangle is the pectineus muscle. Just medial to it
the strong adductor longus is again recognized.
Palpation of the long adductors
Muscle bellies of adductor longus, gracilis and
adductor magnus can be palpated at the medial
side of the thigh. They take origin from the pubic
tubercle (adductor longus) and the ischiopubic
ramus (gracilis and adductor magnus).
The structure that becomes visible during pas­
sive abduction of the hip is the adductor longus
(Fig. 4.8, A). Its origin at the pubic tubercle can
be palpated as a strong cord (Fig. 4.7).
Posterior to the adductor longus and slightly
more lateral the gracilis (B) can be palpated. As
this is a bi-articular structure it becomes more
stretched when the knee is extended during a
passive hip abduction. The broad and flat tendon
on the ischiopubic ramus is therefore felt to press
against the palpating finger when the knee of the
abducted leg is gradually brought into extension.
The origin of the adductor magnus is posterior
to the graCilis and anterior to the origin of the
hamstrings on the ischial tuberosity. The muscle
Fig. 4.8 Palpation of the gracilis.
is only palpable over a small extent and therefore
difficult to examine.
POSTERIOR
Bony landmarks
The iliac crests, the posterior superior iliac spine,
the trochanter and the ischial tuberosity are easy
to locate in a prone lying subject.
The iliac crests are palpated with the radial
sides of the index fingers by holding the pro­
nated hands against the lower borders of the
loins (Fig. 4.9).
Posteror superior iliac spine
The pronated hands rest on the iliac crests. The
thumbs glide in a caudal direction until they are
arrested by the bony and thick posterior superior
iliac spine (Fig. 4.9). In most individuals the lack
of fat tissue at this level can be seen as a dimple
just above and medial to the buttock.
The ischial tuberosit
Place the palpating thumbs at the dorsal and
medial side of the thighs, well below the gluteal
folds (Fig. 4. 10), and move them in a cranial
direction. The first bone that is encountered is the
ischial tuberOSity. It provides attachment for the
hamstring tendons posteriorly and the quadratus
femoris and adductor magnus medially.
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Flg.4.9 Pal pation of the posterior superior iliac spines.
Fig. 4.10 Palpation of the ischial tuberosity.
With the hip extended, the tuberosity is covered
by the gluteus maximus and adipose tissue. If
the hip is flexed, the gluteus maximus moves up­
wards and the ischial tuberosity becomes better
palpable. At the medial aspect of the tuberosity
a strong fibrous band can be felt, joining the
sacrum in a craniomedial direction. This is the
sacrotuberous ligament (Fig. 4.1 1).
Trochanter (Fig. 4.12)
Palpation of this important landmark is relatively
easy at its posterior edge, where the bone is not
covered by muscles. The upper aspect of both
trochanters should be on the same horizontal
Fig. 4.11 The sacrotuberous ligament.
Fig. 4.12 Loalization of the trohanters.
HIP 67
/
Sacrotubrous
ligament
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6 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 4.13 1, Posterior superior iliac spine; 2, gluteus
medius; 3, gluteus maximus.
level as the pubic tubercles, the coccyx and the
head of the femur.
Palpation of soft tissue
Gluteus maximus (Fig. 4.13)
The muscle belly of the gluteus maxim us and fat
deposits are responsible for the typical shape
of the buttocks. The muscle is palpable over
its entire width. Extension of the thigh brings it
into a contracted position. The upper border of
the muscle coincides with the line connecting the
upper border of the trochanter with the upper
border of the posterior superior iliac spine. The
lower border of the muscle is not the lower
border of the gluteal fold as the latter consists
merely of fat tissue.
Gluteus medius (Fig. 4.14)
Only a small part of the muscle can be palpated
between the iliac crest, the upper border of the
trochanter, the upper border of the gluteus maxi­
mus and the posterior border of the tensor fascia
lata.
Flg. 4.14 Lateral view of the hip muscles: 1. gluteus
maximus; 2, iliotibial tract; 3, tensor fasciae latae; 4, gluteus
medius.
Hamstrings (Figs 4.15 and 4.16)
Biceps, semitendinoslis and semimembranosus
originate from a common tendon at the inferior
aspect of the ischial tuberosity. If the hip is slightly
flexed, the gluteus maximus moves upwards,
exposing the ischial tuberosity so the tendon can
be palpated more easily. A resisted flexion of the
knee makes it visible.
Sciatic nere (Fig. 4.17)
The sciatic nerve passes to the leg between the
greater trochanter and the ischial tuberosity. In
a slightly flexed pOSition of the hip, this nerve is
palpable undereath the adipose tissue.
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Fig. 4.15 Palpation of the hamstrings.
2-:
Flg. 4.16 Extensors of the hlp (hamstrings): 1,
semitendinosus; 2, semimembranosus; 3, biceps femoris.
HIP 69
Fig. 4.17 The sciatic nerve: 1. piriformis; 2. gemellus
superior; 3, sciatic nere; 4, gluteus maximus (resected);
5, ischial tuberosity.
FUNCTIONAL EXAMINATION OF THE
HIP
Introduction/general remarks
Examination of the hip cannot be disconnected
from that of the lumbar spine and the sacroiliac
joints: pain in the buttock or thigh has very often
a lumbar or sacroiliac origin. Furthermore, it
is also very difficult to examine the hip without
applying stress on sacroiliac joints and lumbar
joints.
Therefore, a preliminary examination of lumbar
spine and sacroiliac joint may be appropriate to
exclude any lesion in these regions.
Most of the hip tests are executed by using the
leg as a lever.
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70 ATLAS OF ORTHOPEDIC EXAMINATION
PASSIVE TESTS
Passive flexion
Positioning. The subject lies relaxed in the supine
position. The examiner stands level with the hip.
Procedure. Both hands lift the knee upwards
towards the subject's chest until the movement
stops. Meanwhile a slight axial pressure is applied
on the femur (Fig. 4.18).
Common mistakes:
• Moving the thigh too much laterally towards
the shoulder.
• Carrying the movement too far, beyond the
range where the tilt of the pelvis starts. This is
precluded by sufficient axial pressure.
Alterative technique: one hand can be placed
under the pelvis in order to detect the start of the
pelvic tilt.
Normallunctional anatomy:
• Rat/ge: 110-130°
• Elld-fee/: ligamentous
• LimitiNg structures:
- posterior part of the joint capsule
- muscles of the buttock
- contact between labrum and neck.
Fig. 4.18 Passive flexion.
Common pathological situations:
• Too hard an end-feel on passive flexion is one
of the first signs of a osteoartmosis.
• In advanced arthrosis this movement is
markedly limited. Typically the femur moves
laterally when the flexion is forced.
• In children this abduction movement during
flexion is often the first manifestation of
Perthes' disease.
Passive external rotation
Positioning. The subject lies in the supine posi­
tion with the hip and knee bent to 90°. The
examiner stands level with the subject's hip.
One hand supports the lower leg just above
the ankle, the other hand is put at the knee and
stabilizes the femur in a vertical position.
Procedure. Rotate the lower leg inwards, mean­
while assuring the vertical position of the femur,
until the movement comes to a soft stop (Fig. 4.19).
Observe the anterior iliac spine of the opposite
side to detect the start of a lateral pelvic tilt.
Common mistakes. The leg is pushed beyond
the possible range, which causes a lateral tilt of
the pelvis.
Normallunctional anatomy:
• Range: 60-90°
Fig. 4.19 Passive external rOlation.
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• End-feel: ligamentous
• Limitillg strllctures:
- superior part of the iliofemoral ligament
- pubofemoral ligament
- tensor fasciae latae and gluteus minim us.
Common pathological situations:
• This movement can be extremely painful
and / or limited in psoas bursitis, trochanteric
bursitis and in the presence of interal
derangement in the hip.
• Children with a slipped epiphysis may
present with an increased range of external
rotation.
• In arthrosis the external rotation is usually the
last movement to become disturbed.
Passive medial rotation
Positioning. The subject lies in the supine posi­
tion with the hip and knee bent to 90°. The
examiner stands level with the subject's hip.
One hand supports the lower leg just above the
ankle, the other hand stabilizes the femur at the
knee.
Procedure. Rotate the lower leg outwards, mean­
while assuring the vertical position of the femur,
until the movement comes to a soft stop (Fig. 4.20).
Fig. 4.20 Passive interal rotation.
HIP 71
Observe the anterior iliac spine of the opposite
side to detect the start of a lateral pelvic tilt.
Common mistakes. The movement is continued
beyond the possible range, which causes a lateral
tilt of the pelviS.
Normal functional anatomy:
• Rallge: 450°
• Elld1eel: ligamentous
• Limitilg strllctures:
- the ischiofemoral ligament
- buttock muscles: gluteus maximus, gluteus
medius, piriformiS, gemelli, obturator
extemus and intemus, quadratus femoris.
Common pathological situations:
• In arthritis, the medial rotation is the most
painful movement.
• In arthrosis it is usually the first movement to
become limited.
Passive abduction
POSitioning. The subject lies in the supine posi­
tion, near the border of the couch, with the lower
leg pendent. The examiner stands level with the
subject's hip. One hand grasps the distal thigh
from the medial side. The other hand is placed on
the opposite anterior superior iliac spine in order
to stabilize the pelvis.
Procedure. The knee is abducted with the pendent
lower leg until the movement stops (Fig. 4.21).
Common mistakes:
• Carrying on abduction beyond the start of the
lateral pelvic tilt.
• Owing to tension in the hi-articular gracilis,
abduction with extended knee has very often
a shorter range of motion.
Normal functional anatomy:
• Rallge: 4500°
• End-feel: hard ligamentous
• Limiting structures:
- pubofemoral and ischiofemoral ligaments
- adductor muscles.
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72 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 4.21 Passive abduction.
Common pathological situations:
• This test may provoke groin pain in an
adductor tendinitis and trochanteric or gluteal
pain in bursitis.
• Serious painful limitation occurs in arthritis
and painless limitation in arthrosis.
Passive adduction
Positioning. The subject lies in a relaxed supine
position. The examiner stands at the foot-end
of the couch. One hand carries the heel, the other
hand lifts the extended contralateral leg to about
45° of nexion.
Procedure. Move the leg into add uction under
the extended contralateral leg until the pelvis
starts tilting laterally (Fig. 4.22).
Common mistakes:
• Carrying on adduction beyond the start of
lateral pelvic tilt.
• Adduction and medial rotation is
unintentionally added in the contralateral hip.
Normal functional anatomy:
• Range: 20-5°
• End-feel: soft ligamentous
• Limiting structures:
- superior part of the iliofemoral ligament
- iliotibial band, tensor fasciae latae superior
part of gluteus maximus and medius,
gemelli, piriformis and obturator intern us.
Fig. 4.22 Passive adduction.
Common pathological situations. When the move­
ment is painful at the outer side of the hip, a
lesion of the iliotibial tract or a gluteal bursitis
may be considered.
Passive extension
Positioning. The subject lies prone with the hip
extended. The examiner stands level with the
hip. One hand is placed on the thigh, just below
the gluteal fold. The other hand grasps the thigh
just proximal to the patella.
Procedure. Lift the knee off the couch until the
movement comes to a stop. Meanwhile press the
pelvis firmly to the couch (Fig. 4.23).
Common mistakes:
• Lack of stabilization allows the pelvis to move
upwards, causing a false interpretation of the
range of hip extension and putting stress on
the lower lumbar spine and the sacroiliac
joint.
• If the stabilizing hand is placed too high up
on the sacrum, stress will be induced at the
ipsilateral sacroiliac joint.
Normal functional anatomy:
• Range: 10-30°
• End-ee/: hard ligamentous
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Fig. 4.23 Passive extension.
• limitiNg strllcillres:
- anterior part of the capsule with the
iliofemoral, pubofemoral and ischiofemoral
ligaments
- iliopsoas muscle.
Common pathological situations:
• Extension is one of the first movements to
become restricted in arthritis and arthrosis.
• Some children have an isolated limitation of
extension.
ISOMETRIC CONTRACTIONS
Resisted flexion
Positioning. The subject lies in the supine posi­
tion with the hip flexed to a right angle. The
examiner stands level with the thigh and places
one knee against the ischial tuberosity. Both
hands are clasped at the anterior and distal end
of the thigh.
Procedure. Resist the subject's attempt to flex the
hi p (Fig. 4.24).
Common mistakes. A sudden start or sudden
stop may induce unintentional movement.
Fig. 4.24 Resisted flexion.
Anatomical structures tested:
Muscle function:
• III/portallt fexors:
- Iliopsoas
- Rectus femoris
- Sartorius
- Tensor fasciae latae
• Accessory fexors:
- Pectineus
HIP 73
- Adductor longus, brevis and magnus.
Neural function:
Muscle Inneration
Peripheral Nerve root
Iliopsoas Femoral nerve + lumbar plexus l.L3
Sartorus Femoral nerve l,L3
Rectus femoris Femoral nerve L3
Tensor fasciae latae Superior gluteal nerve LS
Pectineus Femoral + obturator nerve l,L3
Adductor longus Obturator nerve l,L3
Adductor brevis Obturator nerve l, L3
Adductor magnus Obturator + sciatic neNa L3, L4
Common pathological situations:
• A painless weakness is always a warning sign
for serious disorders: second root palsy,
nervus femoralis palsy or abdominal
neoplasma, It may, however, also be present
in psychoneurosis.
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74 ATLS OF ORTHOPEDIC EXAMINATION
• Pain alone may indicate a tendinitis of psoas,
sartorius or rectus femoris.
• Pain and weakness are found in avulsion
fractures of the lesser trochanter and anterior
superior spine.
Resisted abduction
Positioning. The subject lies supine and relaxed
with both hips slightly abducted. The examiner
stands at the foot-end of the couch and places
both hands on the lateral aspect of the lower legs,
just proximal to the ankles.
Proceure. Resist the abduction movement
(Fig. 4.25).
Common mistakes. None.
Anatomical structures tested:
Muscle function:
• Imporlanl abdlclors:
- Gluteus medius
- Gluteus minimus
- Tensor fasciae latae
- Gluteus maximus
• Accessor abdllctors:
- Piriformis
- Sartorius.
Fig. 4.25 Resisted abduction.
Neurl function:
Muscle Innervation
Peripheral Nerve rot
Gluteus medius
Gluteus mlnimus
Tensor fascae Istae
Superior gluteal nere L
Gluteus maximus (upper part)
Piriformis
Sarorius
SupeOor gluteal nerve
Superior gluteal nerve
Inferior gluteal nerve
Lumbosacral plexus
Femoral nerve
Common pathological situations:
L
L5
51
$1,52
l2, l3
• Pain may be the result of compression of an
inflamed gluteal bursa.
• Alteratively it may originate from stress
placed upon strained or inflamed sacroiliac
ligaments.
• In congenital dislocation of the hip the
movement shows some weakness.
Resisted adduction
Positioning. The subject lies supine and relaxed
with both hips slightly abducted. The examiner
stands at the foot-end of the couch and places the
clenched fist between both knees (Fig. 4.26).
Procedure. Ask the subject to squeeze the fist.
Common mistakes. None.
Fig. 4.26 ReSisted adduction.
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Anatomical structures tested:
Muscle function:
• Importallt addlctors:
- Adductor longus
- Adductor brevis
- Adductor magnus
- Pectineus
• Accessoraddllctors:
- Gracilis
- Gluteus maximus (lower part)
- Obturator externus
- Quadratus femoris
- Biceps femoris.
Neural function:
Muscle
Adductor longus
Adductor brevis
Adductor magnus
Pectineus
Gracilis
Gluteus maximus (lower pan)
Obturator extemus
Quadratus lemoris
Biceps femoris
Innervation
Peripheral Nerve rot
Obturator nerve L, L3
Obturator nerve L. L3
Obturator + sciatic nerve l3, L4
Femoral + obturator nerve L, L3
Obturator nerve L. L3, L4
Inferior gluteal nerve $1
Obturator nerve L3, L4
Interior gluteal nerve L4, L5, 51
Sciatic nerve $1,52
Common pathological situations:
• Groin pain is usually the result of an adductor
tendinitis or a stress fracture of the inferior
pubic ramus.
• Buttock pain is often the consequence of
transmitted stress to inflamed sacroiliac
joints.
Resisted extension
Positioning. The subject lies in a relaxed supine
position with the hips slightly abducted. The
examiner stands at the foot-end of the couch.
His clasped hands carry the heel and lift up the
leg (Fig. 4.27).
Procedure. Ask the subject to push the extended
leg towards the couch and resist the movement.
Common mistakes. None.
HIP 75
Fig. 4.27 Resisted extension.
Anatomical structures tested:
Muscle function:
• Gluteus maximus
• Smimembranosus
• Semitendinosus
• Biceps femoris
• Adductor magnus
Neural function:
Musce
Gluteus maximus
Semimembranosus
Semitendinosus
Biceps femoris
Adductor magnus
Inneration
Peripheral Spinal
Inferior gluteal nerve 51
SclaUc nerve 51,52
Siatic nerve 51,52
Siatic nerve
51,52
Obturator + sciatic nere l3, l4
Common pathological situations. Pain may result
from a hamstring lesion or a sacroiliac strain.
Resisted medial rotation
POSitioning. The subject lies in the prone position
with the hips slightly abducted and the knees
flexed to 90°. The examiner sits at the foot·end
of the couch, just distal to the knees, and places
both hands against the outer malleoli.
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76 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 4.28 Bilateral resisted medial rotation.
Procedure. Ask the subject to push the legs in
an outward direction, and resist the movement
(Fig. 4.28).
Common mistakes:
• Abduction of the thighs. Make sure that the
knees do not separate during the procedure.
• Lordosis of the back. This could provoke pain
from either the lumbosacral junction or the
sacroiliac joints.
Anatomical structures tested:
Muscle function:
• Tensor fasciae latae
• Gluteus medius
• Gluteus rinimus
• Add uctor magnus.
Neural function:
Muscle
Tensor fasciae latae
Gluteus medius
Gluteus minlmus
Adductor magnus
Inneration
Peripheral
Superior gluteal nere
Superior gluteal nerve
Superior gluteal nerve
Obturator + sciatic nerve
Spinal
L
L
L
l3, L4
Common pathological situations. Pain usually
results from transmitted stress to an inflamed
bursa.
Resisted lateral rotation
Positioning. The subject lies prone with the hips
slightly abducted and the knees flexed to 900,
The examiner sits at the foot-end of the couch,
just distal to the knees. With crossed arms, he
places both hands against the internal malleoli.
Procedure. Ask the subject to push the feel
towards each other, and resist the movemenl
(Fig. 4.29).
Common mistakes. Lordosis of the back may pro­
voke pain from either the lumbosacral junction
or the sacroiliac joints.
Anatomical structures tested:
Muscle function:
• IIportnllt lateral rotators:
- Piriformis
- Quadratus femoris
- Obturator internus and externus
- Gemelli
- Gluteus medius and maxim us
- Sartorius
- Iliopsoas
Fig. 4.29 Bilateral resisted lateral rotation.
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• Accessor lateral rotators:
- Adductor longus and brevis
- Pectineus.
Neural function:
Muscle Innervation
Peripheral Spinal
Quadratus femoris Sacral plexus L4, L, 51
Piriformis Lumbosacral plexus 51,52
Obturator interus Sacral plexus L5.S1,S2
Obturator extemus Obturator nerve L, L4
Gemellus superr Superior gluteal nerve L5,$1
Gemellus inferior Inferr gluteal nerve L5,51
Gluteus medius Superr gluteal nerve L4, L, 51
Gluteus maximus Inferior gluteal nerve L5,51,S2
Sartorius Femoral nere L.1
Iliopsoas Femoral nerve l, L3
Adductor brevis Obturator nerve L3.l4
Adductor longus Obturator nerve L3, L4
Pectineus Femoral nerve l, L
Common pathological situations:
• Gluteal pain is usually the result of a
compression of an inflamed bursa.
• Groin pain may b provoked in lesions of the
sartorius muscle.
Resisted flexion of the knee
Positioning. The subject lies prone with the knee
in 30° of flexion. The examiner stands level with
the thigh and leans over the subject. One hand is
on the ilium, the other presses against the distal
end of the lower leg.
Procedure. Ask the subject to flex the knee, and
resist the movement (Fig. 4.30).
Common mIstakes:
• In strong subjects the flexion of the knee can
not be opposed if the trunk of the examiner is
not positioned well over the leg.
• Hyperlordosis can provoke pain in the
sacroiliac joints or lumbosacral junction,
Anatomical structures tested:
Muscle (unction:
• Semimembranosus
Fig. 4.30 Resisted flexion of the knee.
• Semitendinosus
• Biceps femoris.
Neural (unction:
HIP 7
Muscle Innervation
Semimembranosus
Semitendinosus
Bicps lemoris
Peripheral
Sciatic nerve
Sciatic nerve
Sciatic nere
Common pathological situations:
Spinal
S1,$2
SI.$2
51.52
• Pain in the thigh is due to a lesion of the
hamstrings,
• Weakness is a common sign i first and
second root palSies.
Resisted extension of the knee
Positioning. The subject lies prone with the knee
flexed to 70°. The examiner stands level with the
thigh and leans over the subject. The ipsilateral
hand is placed on the distal end of the thigh to
stabilize it on the couch. The elbow of the other
arm is positioned ventrally around the distal end
of the lower leg.
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78 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 4.31 Resisted extension of the knee.
Procedure. Ask the subject to extend the knee,
and resist the movement (Fig. 4.31). In order to be
able to withstand even the strongest extension,
the hand of the supporting arm may grasp the
stabilizing arm.
Common mistakes:
• In strong subjects the extension of the knee
can not be opposed if the examiner is not
leaning in the direction of the subject's head.
• Hyperlordosis may elicit pain from sacroiliac
structures or the lumbosacral junction.
Anatomical structures tested:
Muscle function:
• Quadriceps femoris.
Neural function:
Muscle Innervation
Quadnceps femoris
Peripheral Spinal
Femoralis nerve L3
Common pathological situations:
• Pain in the thigh is due to a lesion of the
quadriceps.
• Weakness is the result of a third lumbar root
lesion or a femoralis palsy.
SPECIFIC TESTS
Bilateral passive medial rotation in
prone position
Significance
This test is very useful in detecting minor limita­
tions. Since both hips are examined together,
even the slightest limitation of medial rotation
or a divergence in the end-feel can be detected.
Positioning. The subject lies in the prone position
with the knees together and flexed to 90°. The
examiner stands at the foot-end of the couch,
just distal to the knees, and places both hands
against the inner malleoli.
Procedure. Rotate the thighs outwards until the
movement comes to a ligamentous stop (Fig. 4.32).
Common mistakes. Care should be taken to keep
the buttocks level during the whole procedure.
Common pathological situations:
• A minor limitation may be an early sign of
arthritis: this is the first movement to become
restricted at the onset of the disease.
• In children either a minor restriction or
change in end-feel can be the first sign of
Perthes' disease.
Fig. 4.32 Passive medial rotation.
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Adduction in flexion
Signifcance
This provocation test may be used to compress
a painful structure in the groin (psoas bursa or
tendon of rectus femoris). However, it should
be interpreted with utmost care because other
elements such as veins and lymph nodes can also
b compressed. This test also stretches several
posterior structures (capsule of the hip joint,
gluteal muscles and bursae and the sacroiliac
joint).
Positioning. The subject lies supine with the hip
flexed to a right angle. The examiner stands level
with the hip and places one hand on the lateral
side of the knee.
Procedure. Force the knee inwards towards the
contralateral iliac crest until the movement stops
(Fig. 4.33).
Forceful upwards thrust to the heel
Significance
This provocation test may be used to provoke
groin pain when an incipient aseptic necrosis
of the hip is feared.
Positioning. The subject lies supine with the hip
slightly abducted and externally rotated, and the
Flg. 4.33 Adduction in flexion.
Fig. 4.34 Forceful upwards thrust to the heel.
HIP 79
knee extended. The examiner stands at the foot­
end of the couch. One hand carries the heel and
lifts the extended leg to 45° (Fig. 4.34).
Procedure. A forceful upwards blow on the heel,
aXially in the direction of the hip, that provokes
groin pain is suggestive of an incipient aseptic
necrosis, even in the absence of radiographic
signs. Further investigation is mandatory.
Ortolani's test
Signifcance
This test is used for early detection of congenital
dislocation of the hip in babies. During the test
a subluxated hip is reduced.
Positioning. The baby lies on its back with the
hips flexed to 9° and the knees completely flexed
(Fig. 4.35a). The examiner grasps the leg in such
a way that the thumb presses on the inner side of
the thigh and the ring and middle fingers are on
the outer thigh, the tips touching the trochanter.
Procedure (Fig. 4.35b). Abduction is performed.
In a subluxated hip, resistance is felt at 4�0.
The moment the resistance is overcome, the
femoral head rides over the acetabular edge and
reduces. This is felt as a snap.
If the hip displacement is irreducible, a clear
limitation of the abduction at the pathological
side will be detected.
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80 ATLAS OF ORTHOPEDIC EXAMINATION
Ib)
Fig. 4.35 Ortolani's test for congenital dislocation of the hip: (a) position of the baby, (b) reposition of the dislocated hip by
abduction.
Barlow's test
Significance
The test is used for early detection of congenital
dislocation of the hip in babies. During the test
the hip is first subluxated and then replaced.
Positioning. The baby lies on its back, hips flexed
to 900 and the knees completely flexed. The
examiner grasps the leg in such a way that the
thumb presses on the inner side of the thigh
and the ring and middle fingers are on the outer
thigh, the tips touching the trochanter (Fig. 4.36).
Procedure. If the capsule is elongated, the
examiner can press the femoral head outwards
and backwards over the acetabular rim. This is
indicated by a click. Anterior pressure with the
fingertips behind the trochanter can then reduce
the hip.
Fig. 4.36 Barlow's test for
congenital dislocation of the hip.
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CHAPTER CONTENTS
Surace and palpatory anatomy 81
Bony landmarks 81
Palpation of the extensor mechanism 83
Palpation of soft tissues at the medial side 85
Palpation of soft tissues at the lateral side 87
Palpation of the poplteal fossa 6
Functional examination of the knee 89
Passive tests 89
Passive flexion 89
Passive extension 9
Passive lateral rotation 91
Passive medial rotation 92
Valgus strain 93
Varus strain 94
Anterior drawer test 95
Posterior drawer test 97
Isometric contractions 98
Resisted extension 98
Resisted flexion 9
Resisted medial rotation 100
Resisted lateral rotation 101
Specific tests 101
Medial shearing 101
lateral shearing 102
Provoation tests for meniseal tears 103
Speific tests for instability 104
Tests for fluid 105
Synovial thickening 107
Knee
SURFACE AND PALPATORY
ANATOMY
Bony landmarks (Figs 5.1 and 5.2)
All palpable bony parts of the knee are situated
anteriorly. Palpation is performed with the sub­
ject in the supine lying position. The knee is
either bent to a right angle or fully extended,
depending on the palpated structure.
In a flexed position of the knee, the patella can
easily be outlined. In this position the large joint
line between tibia and femur is situated about
two finger-widths below the patellar apex (A).
The inferior part of the medial femoral condyle
(6) is easily detectable as a large spherical sub­
cutaneous bony structure that borders the supero­
medial part of the joint line. The inferior part
of the lateral femoral condyle forms the superior
border of the lateral jOint line (C). Following this
condyle in a lateral and posterior direction, the
palpating finger encounters the salient lateral
epicondyle (0).
The flexed position is also suitable for the pal­
pation of the bony elements of tibia and fibula.
The sharp edges of the medial (E) and lateral (F)
tibial condyles border the joint line inferiorly
and are easy to locate. The tibial tuberosity (G),
which is found about two finger-widths below
the joint line, is prolonged into the tibial crest (H).
The head of the fibula (I) is easily palpated on
a medially rotated leg. Grabbed between thumb
and index finger it can be mobilized in an antero­
posterior direction (Fig. 5.3).
81
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82 ATLAS OF ORTHOPEDIC EXAMINATION
A B
Fig. 5.1 Bony landmarks - anterolateral view: (a) In vivo; (b) skeleton.
A B
Fig. 5.2 Bony landmarks - anteromedial view: (a) in vivo; (b) skeleton.
A
The infracondylar tubercle (tubercle of Gerdy),
which represents the insertion of the iliotibial
tract, is situated on the lateral epicondyle of the
tibia, about the width of one thumb below the
edge and just in the middle between the tibio­
fibular joint line and the tibial tuberosity. It
is identified as follows: place the thumb of the
contralateral hand on the tibial tuberosity and
the middle finger on the tibiofibular joint. The
index finger, which is slightly more proximal,
then touches the tubercle (Fig. 5.4).
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Fig. 5.3 Palpation of the fibular head.
Fig. 5.4 Palpation of the tubercle of Gerdy.
KNEE 8
Palpation of the extensor mechanism
This is performed on an extended knee.
First the muscular structures are ascertained.
Ask the patient to extend the slightly bent knee
and resist the movement.
This movement usually outlines the vastus
medialis (A), vastus lateralis (B), rectus femoris
(C) and the patellar ligament (0) (Fig. 5.5).
Then the patellar border with its tendinous
insertions are palpated. With the hip in flexion
and the knee in full extension, the patella can
b moved freely upwards and downwards in the
patellar groove. Also side gliding and tilting is
possible.
The superoposterior border of the bone and
the suprapatellar tendon can be palpated after
the lower pole of the patella has been pressed
posteriorly and upwards by the web of the
thumb of the other hand (Figs 5.6 and 5.7).
The medial and lateral edges of the patella
together with the quadriceps expansions are
palpated in the following way. With the thumb
of one hand, the patella is tilted and pushed over
Fig. 5.5 Extensor mechanism of the knee.
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8 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 5.6 Palpation of the suprapatellar tendon.
--
--
--
------
Flg.5.7 Palpation of the suprapatellar tendon. The patella is tilted (small arrows) by
pressing on the inferior pole (large arrow).
to the other side. Place the ring finger of the
other hand under the projecting edge and press
upwards, squeezing the tendinous fibres against
the posterior aspect of the patella (Fig. 5.8).
The inferior pole of the patella and the inser­
tion of the infra patellar tendon (patellar liga-
ment) are palpated in a similar way. Place one
hand just above the patella, so that the web of
the thumb can exert downwards pressure. This
stabilizes the patella and tilts the apex upwards,
so it can be palpated with more accuracy (Figs 5.9
and 5.10).
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Fig. 5.8 Palpation of the quadriceps extension.
Fig. 5.9 Palpation of the infrapatellar tendon.
KNEE 85
Fig.5.10 Palpation of the infrapalel1ar tendon. The patella
is pressed distally, which moves the inferior pole upwards
(arrows).
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8 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 5.11 The medial collateral ligament (1) and medial
meniscus (2).
Palpation of soft tissues at the medial
side
Medial collateral ligament
The medial collateral Hgament (Fig. 5.11) is a
broad, flat and almost triangular band, with a
large insertion on the posterosuperior aspect of
the medial femoral epicondyle, dose to the inser­
tion of the adductor magnus tendon. Its fibres
run obliquely, anteriorly and inferiorly, to insert
at the medial aspect of the tibia, just behind and
slightly under the insertions of the pes anserinus.
The anterior fibres of the ligament are sepa­
rated from those of the capsule. Therefore the
anterior border of the ligament can easily be
palpated on an extended knee (Fig. 5.12).
Place the thumb just medially to the patellar
tendon and in the intercondylar groove. Palpate
the bony borders of the joint line in a posterior
direction until the sharp edge of a ligamentous
structure is felt to bridge the groove. This is the
anterior border of the medial collateral ligament
(A). Continue the palpation along the joint line
and notice that the bony borders are now covered
completely by the dense ligamentous structure.
The posterior border of the ligament, however,
Fig. 5.12 Palpation of the medial collateral ligament.
can not be palpated because the posterior fibres
blend intimately with those of the posterior
capsule and with the medial and posterior border
of the medial meniscus.
Notice that the anterior border of the ligament
is situated more posteriorly than is usually thought.
Pes anseri nus
The pes anserinus (the common insertion of the
semitendinosus, the graciliS and the sartorius)
is situated under and behind the medial tibial
condyle.
Ask the patient to flex and internally rotate
the knee and resist the movement. The three
tendinous structures are easily identified from
distal to proximal (Fig. 5.13): semitendinosus (A);
graciHs (8); and sartorius (C).
Fig.5.13 Palpation of the medial tendinous structures.
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Fig. 5.14 Lateral view of the knee, showing the relations
between the lateral muscles and ligaments: 1, biceps
femoris; 2, lateral collateral ligament; 3, popliteus; 4, iliotibial
tract.
Palpation of soft tissues at the lateral
side
The lateral side of the knee forms a crossing point
of different tendons and ligaments (Fig. 5.14).
The head of the fibula is identified first. A re­
sisted flexion and/or lateral rotation brings the
tendon of the biceps femoris (Fig. 5.15, A) into
prominence. The tendon inserts at the top and
the posterior aspect of the fibular head in two
straps, one in front and one behind the insertion
of the lateral collateral ligament.
The flexion movement usually also reveals
the iliotibial tract (6) which is recognized as a
horizontal flat band between biceps and vastus
latera lis (C).
The lateral collateral ligament (Fig.5.16, A)
is palpated in the following way. Place the pal­
pating finger on the top of the fibular head (6).
Move the leg outwards, meanwhile keeping the
KNEE 87
Flg.5.15 Palpation of the lateral tendinous structures.
Flg.5.16 Palpation of the lateral collateral ligament.
foot on the couch (abduction and lateral rotation
in the hip). This movement brings the ligament
under tension. It is palpated as a tough round
structure that runs from the head of the fibula to
the lateral femoral epicondyle (C). In this pos.­
tion the ligament makes an 8° angle with the
biceps femoris tendon (D).
The intra-articular origin of the popliteus
tendon at the lateral condyle is identified as
follows.
The knee is still in a flexed position (Fig. 5.17).
Identify the lateral border of the patella. The
sharp edge of the lateral epicondyle (A) is easily
found about one finger-width below the lateral
border. Anteriorly a second bony projection is
identified as the lateral condyle (6). The groove
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88 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 5.17 Palpation of the poplitiuS tendon.
in between these bony structures forms the area
from which the tendon emerges. The latter runs
intra-articularly and deep to the lateral collateral
ligament to continue in the muscle belly that lies
deeply in the popliteal fossa under the lateral
gastrocnemius and the plantaris muscles.
Palpation of the popliteal fossa
The borders of the lozenge-shaped popliteal fossa
(Fig. 5.18) are formed by the gastrocnemii, the
biceps femoris and the semitendinosus and semi­
membranosus muscles. The bottom is formed by
the posterior capsule and the popliteus muscle.
The popliteal fossa is covered by a fascia.
The lozenge is vertically crossed (from lateral
to medial) by: the tibial nerve, popliteal vein and
popliteal artery. The common peroneal nerve
descends along the inner border of the biceps.
Palpation is performed with the subject in the
prone-lying position. The knee is slightly bent
to release the posterior fascia. A slight resisted
flexion of the knee brings the upper borders of
the popliteal fossa into prominence (Fig. 5.19).
Medially the tendon of the semitendinosus
(A) is easily identified as a round cord. The semi­
membranosus is situated deeper and has a flatter
consistency on palpation.
At the lateral side the biceps tendon (8) can
also be recognized easily. Its insertion is on the
superior and posterior aspect of the fibular head.
The junction between the semimembranosus
Flg.5. 18 The popliteal fossa: 1, biceps femoris; 2, tibial
nerve; 3, popliteal vein; 4, popliteal artery; 5, common
peroneal nerve; 6. lateral gastronemius; 7. medial
gastrocnemius; 8, semimembranosus; 9, gracilis;
10, semitendinosus.
Fig. 5.19 The popliteal fossa in vivo.
and the biceps forms the superior angle of the
fossa.
The inferior borders, which are shorter than
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Fig. 5.20 Palpation of the popliteal fossa.
the superior ones, are formed by both gastroc­
nemii (C). Their junction constitutes the inferior
angle of the lozenge. The palpation is facilitated
by a resisted plantiflexion of the foot.
The posterior aspects of medial and lateral
femoral condyles can be palpated just under
the gastrocnemii, the insertion of which is more
proximally on the condyles.
The tibial nerve is located in the centre of the
lozenge and divides it in two. The tibial vein and
the tibial artery are located medial to it.
Nerve and artery can be palpated as follows.
The patient is in the supine position, the knee
bent to a right angle and the foot flat on the
couch. The examiner sits on the couch, next to
the knee, and palpates the fossa from the medial
aspect with the ipsilateral hand (Fig. 5.20). The
nerve is felt as a hard and round structure in the
centre of the lozenge, near the upper angle.
To palpate the pulsations of the artery, the
fingers must be plunged deeper and more
medially.
FUNCTIONAL EXAMINATION OF THE
KNEE
Introduction/general remarks
The knee is the largest and most complex joint
of the human body. Because it is situated at the
ends of two long lever arms it is very well suited
KNEE 89
to clinical testing. Furthermore, the joint is
relatively uncovered by muscles which facili­
tates palpation of most structures, intra-articular
structures excluded.
One should warn against too many different
tests. It is important to realize that the quality of
a clinical examination does not depend on the
number of tests performed but on the accuracy of
performance of the most important tests.
Diagnosis of a particular lesion also does not
rely on the presence of one pathognomonic test
but on the complete clinical picture (the sum of
positive and negative answers after the perfor­
mance of a set of important standardized tests).
For instance, none of the so-called pathognomonic
meniscus tests has a high positive predicting
value (between 21 and 50%) which means that
in more than half of the subjects with a positive
meniscus test, no meniscai lesion is found on
arthroscopy. Also, the presence of a positive
instability test has only value if it is interpreted
in relation to the rest of the clinical evaluation.
PASSIVE TESTS
Passive flexion
Positioning. The subject lies in the supine posi­
tion with extended legs. The examiner stands
level with the subject's knee. One hand grasps
the distal part of the leg, just proximal to the
malleoli; the other hand grasps the knee at the
medial femoral condyle.
Procedure. Move the extended leg upwards
until the knee can be flexed with a simultaneous
movement of both hands. Once the flexion has
begun, the distal hand continues the movement
while the proximal hand just stabilizes the femur
in a sagittal plane but allows hip flexion (Fig. 5.21).
Common mistakes. None.
Normal functional anatomy:
• Range: 1700
• End-feel: soft tissue approximation
• Limitillg structures: approximation of calf
muscles and hamstrings.
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9 ATLS OF ORTHOPEDIC EXAMINATION
Fig. 5.21 Passive flexion.
Common pathological situations. Numerous con­
ditions lead to limitation in flexion of the knee:
capsular lesions, ligamentous adhesions, internal
derangement and extra-articular conditions.
Diagnosis depends on the patter that emerges
after the completion of the other tests and on
the end-feel. A spastic end-feel is typical for
acute arthritis or haemarthrosis; a hard end­
feel is suggestive of arthrosis, a springy block
indicates internal derangement and a soft liga­
mentous end-feel may b caused by ligamentous
adhesions.
Passive exension
Positioning. The subject lies in the supine posi­
tion with the legs extended. The examiner stands
level with the subject's knee. One hand grasps
the lower leg at the heel, while the other carries
the knee from the lateral side with the thumb on
the tibial tuberosity.
Procedure. Move the leg upwards. Perform a
quick and short extension movement by a simul-
taneous upwards movement of the heel and a
downwards pressure on the tibia (Fig. 5.22).
Common mistakes. The end-feel is not evaluated
because the movement is not performed pene­
tratingly enough.
Normal functional anatomy:
• Rmlge: 0° (some extension in recurvatum may
be possible)
• End-feel: hard ligamentous, almost bony
• Limiting structures:
- posterior capsule
- posterior crudate ligament
- anterior <ruciate ligament.
Common pathological situations:
• Perception of the end-feel on passive
extension is extremely important in clinical
diagnosis of knee joint lesions.
• Limited extension with a spastic end-feel in
combination with more limitation of flexion
indicates an acute arthritis.
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Fig. 5.22 Passive extension.
• Painless and slight limitation with crepitus is
typical for arthrosis.
• 10-30° of limitation with a springy block is
evidence of a displaced meniscus.
• Pain at the end of range with a more or less
normal end-feel is often seen in combinaton
with a small ligamentous problem.
Passive lateral rotation
Positioning. The subject lies in the supine posi­
tion with the knee flexed to a right angle and the
heel resting on the couch. The examiner stands
level with the subject's knee. One hand grasps
the forefot at the inner side and presses it
upwards in dorsiflexion. Place the other shoulder
against the knee, the arm under the lower leg.
and the hand under the heel.
Procedure. Perform a lateral rotation by using the
foot as a lever; the supporting arm only stabilizes
(Fig. 5.23). Fig. 5.23 Passive lateral rotation.
KNEE 91
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92 ATLAS OF ORTHOPEDIC EXAMINATION
Common mistakes. Dorsiflexion i the ankle is
lost.
Normal functional anatomy:
• Rallge: 45°
• El1d-feel: elastic Ugamentous
• Limiting structures:
- medial meniscotibial (coronary) ligament
- posterior fibres of medial collateral Ugament
- popliteus muscle.
Passive lateral rotation in prone position
The subject lies in the prone position with both
knees flexed to a right angle. The examiner en­
circles both heels and performs a bilateral exter­
nal rotation (Fig. 5.24). The range of movement
is assessed by the twisted position of the feet.
Fig. 5.24 Passive lateral rotation in prone position.
This test may b decisive in comparing the
range of external rotation.
Common pathological situations:
• Pain at the inner side of the knee may indicate
a lesion of the medial collateral ligament or
the medial coronary ligament.
• Pain at the lateral side suggests a lesion of the
popliteus tendon.
• Limitation of the movement is typical for
ligamentous adhesions of the medial
collateral Ugarent.
• Increased range of movement in the prone
position results from a laxity of the ligamentous
structures of the medial compartment and of
the anterior cruciate ligament.
Passive medial rotation
Positioning. The subject lies in the supine posi­
tion with the knee and hip flexed to right angles.
The examiner stands level with the subject'S knee.
One forearm carries the lower leg. The other
hand grasps the calcaneus from the lateral side.
Both hands clasp tightly under the heel which
is forced into dorsiflexion.
Procedure. A combined movement of both wrists
turns the lower leg into medial rotation (Fig. 5.25).
Fig. 5.25 Passive medial rotation.
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Common mistakes. The hands are placed too
distally on the foot. In order to protect the lateral
ligaments, it is important to exert the pressure
at the ankle, and not beyond the calcaneocuboid
joint line.
Normal functional anatomy:
• Range: 30°
• End-jeel: elastic ligamentous
• Limiting structures:
- lateral meniscotibial (coronary) ligament
- cruciate ligaments
- lateral capsular ligaments.
Passive medial rotation in prone position
The subject lies in the prone position with both
knees flexed to a right angle. The examiner en­
circles both heels and performs a bilateral medial
rotation. The range of movement is assessed by
the twisted position of the feet.
This test compares the range of internal
rotation.
Common pathological situations:
• Lateral pain usually indicates a lesion of the
lateral coronary ligament.
• An increased range of movement in the prone
position is indicative of laxity of the anterior
and posterior cruciate ligaments and of the
dorsolateral part of the joint capsule.
Valgus strain
Positioning. The subject lies in the supine posi­
tion with the knees extended. The examiner
stands level with the subject's knee. One hand
grasps the lower leg from the medial side just
proximal to the malleolus. The other hand is
supinated and placed at the lateral femoral
condyle.
Procedure. Lift the extended leg and apply strong
valgus pressure with the distal hand. Counter­
pressure is maintained at the lateral femoral
condyle (Fig. 5.26).
Common mistakes. None.
KNEE 9 3
Fig. 5.26 Valgus strain.
Normal functional anatomy:
• Range: no movement is possible in a normal
knee
• End-jeel: ligamentous
• Limiting structures:
- medial ligamentous complex
- cruciate ligaments
- posterior oblique ligament.
Variation of the valgus test
The test can be repeated with the knee in slight
flexion (20-30°). Here the thigh rests on the couch
and the lower leg hangs over the edge. Positioning
of the hands is the same (Fig. 5.27), as is the
procedure.
[n this position the cruciate ligaments no longer
hold both joint surfaces in firm apposition; there­
fore some movement can be elicited and more
stress is put on the medial ligamentous complex.
Common pathological situations:
• Medial pain during valgus stress is typical for
a sprained medial collateral ligament. The test
can also be positive in interal derangement
of the knee and in medial collateral ligament
bursitis.
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9 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 5.2 7 Valgus stress test in 30° of flexion.
• Increased range in 30° of flexion is typical for
a rupture of the medial compartment
ligaments.
• If valgus stress in full extension also shows an
increased range, the posterior cruciate
ligament is probably torn as well.
Varus strain
Positioning. The subject lies in the supine posi­
tion with the knees extended. The examiner
stands level with the subject's knee. The ipsi­
lateral hand grasps the lower leg from the lateral
side, just proximal to the lateral malleolus. The
other hand is pronated and placed at the medial
femoral condyle.
Procedure. Lift the extended leg and apply strong
varus pressure with the distal hand. Counter­
pressure is maintained at the medial femoral
condyle (Fig. 5.28).
Common mistakes. The knee is not fully extended
during the procedure.
Fig. 5.2 8 Varus strain.
Normal functional anatomy:
• Rallge: in a normal knee no perceptible
movement is possible
• Elld-feel: hard ligamentous
• Limiting structures:
- lateral collateral ligament
- arcuate ligament
- posterior cruciate ligament.
Variation of the varus test
The test can be repeated with the knee in slight
flexion (20-30°). Here the thigh rests on the couch
and the lower leg hangs over the edge. The ex­
aminer stands distal to the foot. Again, the lower
hand provokes a varus strain while the hand at
the knee stabilizes (Fig. 5.29).
In this position the cruciate ligaments no longer
hold both joint surfaces in firm apposition;
therefore some movement is possible and more
stress is put on the lateral ligamentous complex.
Common pathological situations:
• Lateral pain during varus stress inculpates the
lateral collateral ligament; medial pain may
accompany an impacted loose body or
impacted medial meniscus.
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Fig. 5.29 Varus stress test in 30° of flexion .
• Increased range in 30° of flexion is typical for
a rupture of the lateral collateral ligament.
• If varus stress in full extension also shows an
increased range, the posterior cruciate
ligament is probably torn as well.
Anterior drawer test
Positioning. The subject lies in the supine posi­
tion with the knee flexed to a right angle, and the
heel resting on the couch. The examiner sits on
the foot of the subject. One hand is on the anterior
aspect of the knee: apex patellae in the palm of
the hand, thenar and hypothenar making contact
with the femoral condyles. The other hand is at
the back of the upper tibia.
Procedure. Draw the tibia forwards with the
posterior hand and add a strong jerk when
the movement comes to a stop. The hand on the
patella stabilizes the thigh (Fig. 5.30).
Common mistakes. None.
Fig. 5.30 The anterior drawer test.
Normal functional anatomy:
KNEE 95
• Range: in a normal joint the tibia shifts over
only a few millimetres
• End-feel: hard ligamentous
• Limiting structures: anterior cruciate ligament.
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96 ATLAS OF ORTHOPEDIC EXAMINATION
Common pathological situations:
• Pain is indicative of a small lesion of the
anterior cruciate ligament.
• Increase in range is seen in ruptures of the
anterior cruciate ligament and I or the
posterior capsule.
Anterior drawer test in exteral rotation
Positioning. The subject is positioned as for the
previous test. The lower leg and foot are exter­
nally rotated as far as is comfortably possible.
The examiner places both hands around the
upper part of the tibia with the index fingers
on the hamstring tendons and the thumbs at the
anterior border of the joint (Fig. 5.31).
Procedure. Draw the upper part of the tibia
forwards and add a strong jerk at the end of the
movement.
Fig. 5.31 Anterior drawer test in external rotalion.
Normal findings. The range of movement in exter­
nal rotation is slightly superior to the movement
in a neutral position .
Common pathological situations. A marked in­
crease in range is indicative of anteromedial rota­
tory instability (ruptures of the anterior cruciate
ligament, the posteromedial capsule and the
medial collateral ligament).
Anterior drawer test in interal rotation
Positioning. The subject is positioned as for the
previous test. The lower leg and foot are inter­
nally rotated as far as is comfortably possible.
The examiner places both hands around the
upper part of the tibia with the index fingers on
the hamstring tendons and the thumbs at the
the anterior border of the joint (Fig. 5.32).
Fig. 5.32 Anterior drawer test in internal rolation.
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Fig. 5.33 Lachman test.
Procedure. Draw the upper part of the tibia
forwards and add a strong jerk at the end of
range.
Common pathological situations. Internal rotation
tightens the intact posterior cruciate ligament
which prevents any movement.
Variation: anterior drawer in 20· of fexion
(Lachman test)
Positioning. The subject lies in the supine position
with the legs extended. The examiner stands
level with the knee. One hand grasps the proxi­
mal tibia from the medial side, the fingers in the
popliteal fossa and the thumb at the tibial tuber­
osity. The other hand holds the distal femur from
the lateral side, the thumb just proximal to the
patella.
Procedure. Bring the knee into about 20· of Aexion
and, using both hands, displace the proximal
tibia anteriorly (Fig. 5.33).
Common mistakes. None.
KNEE 97
Normal functional anatomy:
• Range: in a normal knee only a small
amplitude of anterior glide (less than 5 mm) is
obtainable
• End-feel: ligamentous
• Umiting structures: anterior crudate ligament.
Common pathological situations. This test is pre­
ferred to detect ruptures of the anterior cruciate
ligament.
Posterior drawer test
Positioning. The subject lies in the supine posi­
tion with the knee flexed to a right angle, and the
heel resting on the couch. The examiner sits
on the foot of the subject. The heel of one hand is
placed on the tibial tuberosity and the other hand
is placed at the back of the upper tibia.
Procedure. Push the tibia backwards with a strong
jerk of the anterior hand (Fig. 5.34). The posterior
hand in the popliteal fossa discloses any eventual
movement.
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98 ATLAS OF ORTHOPEDIC EXAMINATION
I
Fig. 5.34 The posterior drawer test.
Common mistakes. None.
Normal functional anatomy:
• Range: no movement can be provoked in a
normal knee
Fig. 5.35 Resisted extension.
• End-feel: hard ligamentolls
• Limiting slmetllres: posterior cruciate ligament.
Common pathological situations:
• Pain is indicative of a small lesion of the
posterior cruciate ligament.
• lncrease in range is seen in ruptures of the
posterior cruciate ligament and/or the
arcuate complex.
ISOMETRIC CONTRACTIONS
Resisted extension
Positioning. The subject lies in the supine posi­
tion with the knee slightly bent. The examiner
stands level with the knee. One forearm is placed
under the knee with the hand resting on the
other knee, proximal to the patella. The other
hand is on the distal end of the leg just proximal
to the malleoli.
Procedure. The subject is asked to extend the knee
and to maintain extension while the examiner
pushes the lower leg down towards the couch
(Fig. 5.35).
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Common mistakes. None.
Anatomical structures tested:
Muscle function:
• Quad riceps femoris
• Tensor fasciae latae.
Neural function:
Muscle
Ouadriceps lemoris
Tensor fasciae lalae
Inneration
Peripheral Spinal
Femoralis l3
Superior gluteal lS
Resisted flexion
Positioning. The subject lies in the supine posi­
tion with the hip and knee bent to right angles.
The examiner stands level with the foot of the
subject. Both hands support the heel (Fig. 5.36).
Fig. 5.3 Resisted flexion.
KNEE 9
Procedure. The subject is asked to move the heel
downwards while the examiner applies strong
counterpressure.
Common mistakes. None.
Anatomical structures tested:
Muscle function:
• Semimembranosus
• Semitendinosus
• Biceps femoris
• Popliteus
• Gastrocnemii
• Plantaris
• Gracilis
• Sartorius
• Tensor fasciae latae.
Indirect traction on inert structures:
• Proximal tibiofibular joint
• Posterior cruciate ligament
• Posterior horn of the medial meniscus.
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10 ATLAS OF ORTHOPEDIC EXAMINATION
Neural function:
Muscle Inneration
Peripheral Spinal
Semimembranosus Sciatic nerve 51.52
Semitendinosus Sciatic nerve 51,52
Biceps femoris Sciatic nerve 51,52
Gracilis Obturator l, L3, l4
Sartorius Femoral L, L3
Tensor lasciae talae Superior gluteal L5
Popliteus TIbial l4.L5,SI
Gastrocnemii TIbial 51,52
Plantaris TIbial 51,52
Resisted medial rotation
Positioning. The subject sits with the lower
legs pendent. The examiner squats in front of the
knee. The ipsilateral hand encircles the heel from
the lateral side. The contralateral hand is placed
against the medial aspect of the forefoot and
holds the foot in dorsiflexion (Fig. 5.37).
Procedure. The subject is asked to turn the
foot inwards while the examiner applies strong
counter-pressure with both hands.
Fig. 5.37 Resisted medial rotation.
Common mistakes. Not enough dorsiflexion
makes the subject execute an inversion of the
foot.
Anatomical structures tested:
Muscle function:
• Semimembranosus
• SemHendinosus
• Gracilis
• Sartorius
• Popliteus.
Indirect traction on inert structures:
• Posterior horn of the medial meniscus.
Neural function:
Muscle Innervation
Semimembranosus
Semitendinosus
Gracilis
Sartorius
Popliteus
Peripheral Spinal
Sclalie nere
Sciatic nerve
Obturator
Femmal
TIbial
51.52
St. 52
l, L3, L4
l.L
(L'). LS, 51
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Fig. 5.38 Resisted lateral rotation.
Resisted lateral rotation
Positioning. The subject sits with the lower
legs pendent. The examiner squats in front of
the knee. The ipsilateral hand is placed against
the lateral aspect of the forefoot and maintains
dorsiflexion. The contralateral hand encircles the
heel from the medial side (Fig. 5.38).
Procedure. The patient is asked to turn the foot
outwards while the examiner applies strong
counter-pressure.
Common mistakes. [f dorsiflexion is not main­
tained, the subject will execute an eversion of the
foot.
Anatomical structures tested:
Muscle function:
• Biceps femoris
• Tensor fasciae latae.
Indirect traction on iner structures:
• Proximal tibiofibular joint
KNEE 101
Neural function:
Muscle Inneration
Biceps femoris
Tensor fasciae lalae
Peripheral
Sciatic nere
Superior gluteal
SPECIFIC TESTS
Medial shearing
Significance
Spinal
51.52
LS
This test is used to detect internal derangement
at the inner side of the knee. Pain on jerk is sug­
gestive for a minor lesion at the tibial insertion
of the anterior cruciate ligament.
Positioning. The subject lies in the supine posi­
tion with the knee flexed to a right angle, and the
heel resting on the couch. The examiner sits at the
foot-end of the couch. The heel of the ipSilateral
hand is placed at the medial femoral condyle. The
heel of the contralateral hand is at the lateral tibial
condyle. The fingers of both hands are interlocked.
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102 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 5.39 Medial shearing strain.
Procedure Apply a strong shearing strain that
forces the tibia medially on the femur (Fig. 5.39).
Common mistakes:
• The hands are not high enough on the
femur or low enough on the tibia respectively.
• The contralateral hand presses against the
fibular head instead of the lateral tibial
condyle, provoking a painful compression of
the upper tibiofibular joint.
Normal functional anatomy:
• Rallge: Virtually no movement can be elicited
in a normal knee
• Elld-feel: hard ligamentous
• Limititlg structures:
- articular surfaces
- intercondylar spines of the tibia
- menisci
- anterior cruciate ligament.
Lateral shearing
Significance
This test is used to detect internal derangement
at the outer side of the knee.
Positioning. The subject lies in the supine posi­
tion, with the knee flexed to a right angle and
the heel resting on the couch. The examiner
sits opposite the subject at the foot-end of the
couch. The heel of the ipsilateral hand is placed
at the medial tibial condyle. The heel of the
contralateral hand is placed at the lateral
femoral condyle. The fingers of both hands are
interlocked.
Procedure. Apply a strong shearing strain that
forces the tibia laterally on the femur (Fig. 5.40).
Common mistakes. The hands are not high
enough on the femur or low enough on the tibia
respectively.
Normal functional anatomy:
• Range: no movement can be elicited in a
normal knee
• End-feel: hard ligamentous
• Limiting structures:
- articular surfaces
- intercondylar spines of the tibia
- menisci
- posterior cruciate ligament.
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Fig. 5.40 Lateral shearing strain.
Provocation tests for meniscal tears
Signifcance
These tests are used to detect, by demonstration
of clicks and / or pain, meniscal tears in the
absence of actual (sub)luxations. If clicks are
detected, it is wise to examine the other limb
as well in order to eliminate non-pathological
clicks arising from tendons snapping over bony
prominences.
Test I
Positioning. The subject lies supine with the knee
fully flexed. The examiner holds his index finger
and thumb at both sides of the infrapatellar
tendon, level with the joint line. The other hand
grasps the heel (Fig. 5.41).
Procedure. The leg is rotated quickly to and fro.
When clicks are felt at the joint line, a ruptured
meniscus should be suspected.
Test" (McMurray test)
Positioning. The subject lies supine with the knee
fully flexed (heel to the buttock). The examiner
KNEE 103
Fig. 5.41 Test to detect clicks during rotation in full flexion.
holds a palpating finger in the joint line at
the side to be tested. The other hand grasps the
heel and rotates the leg fully (externally to test
the medial meniscus, interally for the lateral
meniscus).
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104 ATLAS OF ORTHOPEDIC EXAMINATION
Flg.5.42 Test to detect a click during extension movement
under external rotation.
Procedure. The examiner now slowly extends the
knee, while rotation is maintained (Fig. 5.42). As
extension proceeds, a click may be felt, usually as
the leg approaches the neutral position.
Test 11/
Positioning. The subject lies supine with the knee
fully flexed (heel to the buttock). The examiner
passes his flexed thumbtip from above down­
wards over the joint line at the affected side
(Fig. 5.43). This is easier to perform at the medial
side than on the lateral.
Procedure. A ruptured meniscus is suspected
when it is possible to hook the rim of the
meniscus and pull it downwards until it is felt
to jump back in place again.
Specific tests for instability
Signifcance
Most instability can usually be detected by the
earlier described passive movements. There are,
however, valuable specific tests: the 'jerk' test
and 'pivot shiff for anterolateral rotatory insta-
Fig. 5.43 Palpation of a displaced rim.
bility and the external rotation-recurvatum test
for posterolateral rotatory instability.
Lateral pivot shift (test of MacIntosh)
Positioning. The subject lies supine with the hip
flexed to about 30° and slightly medially rotated.
The knee is extended. The examiner supports
the patient's leg, with one hand at the foot
and the other at the knee, the thumb behind the
fibular head.
Procedure. The hand at the foot rotates the tibia
internally, while the other hand exerts a mild
valgus stress at the knee. The examiner flexes
the knee gradually, maintaining the interal rota­
tion and valgus stress. In anterolateral rotatory
instability the lateral tibial condyle will first sub­
luxate anteriorly and, at approximately 30° of
flexion, reduce suddenly backwards. This poster­
ior bouncing is seen and felt both by examiner
and subject and indicates a positive test.
The 'erk' test
Positioning. The subject lies upine with the hip
flexed to about 45°, and the knee to 90°. The
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- -
. PUSHES FORWAIlO AND APPLIES
r
_
_ A

V

A lGUS STRESS
Fig. 5.4 Lateral pivot shih. (From Magee D J 1997
Orthopedic physical assessment, 3rd adn. W B Saunders,
Philadelphia.)
examiner supports the subject's leg, with
one hand at the foot and the other at the knee,
the thumb behind the fibular head.
Procedure. The hand at the foot rotates the tibia
slightly internally, while the other hand exerts
a mild valgus stress at the knee. The examiner
ex
.
tends the knee gradually, maintaining the
internal rotation and valgus stress (Fig. 5.45). A
positive result is indicated if, on attaining about
30° of flexion, anterior subluxation of the tibia
occurs with a sudden movement, which is called
a jerk. The forwards shift can be seen and felt by
the examiner. At the same moment, the subject
will recognize the feeling of instability.
Exteral recuratum test
Positioning. The subject lies supine with both
legs relaxed and extended. The examiner grasps
the big toes.
Procedure. Both legs are lifted simultaneously
(Fig. 5.46). The amount of external rotation of the
Fig. 5.45 The 'jerk' test.
KNEE 105
tibial plateau and the degree of recurvatum are
observed. In a positive test, unilateral excess of
external rotation and recurvatum is seen.
Tests for fluid
Fluid in the knee joint is a sign common to many
disorders (traumatic, inflammatory or crystalline).
Three tests are commonly used to detect fluid.
Patellar tap
Positioning. The subject lies supine with the knee
extended or flexed to discomfort. The examiner
stands level with the knee. The web of one
hand is on the suprapatellar pouch. The thumb
and middle finger of the other hand press at
the medial and lateral recessi, just beyond the
patellar edges (Fig. 5.47).
Procedure. Manual pressure empties the recessi
and moves the fluid between patella and femur.
The index finger of the other hand pushes the
patella downwards. If fluid is present, one can
feel the patella move. When it strikes the femur,
a palpable tap is felt followed by an immediate
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10 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 5.46 Exteral rotation-recuratum test.
Flg.5.47 Testing for fluid in the joint by patellar tap.
upwards movement. This is the sensation of
an ice cube pushed downwards in a glass of
water: although the patella moves downwards,
the pressure of the fluid immediately shifts the
bone upwards against the palpating finger.
Remark: when large amounts of fluid are pre­
sent, the tap of the patella hitting the femur
cannot be felt.
Eliciting fluctuation
Positioning. The subject lies in the supine posi­
tion with the leg extended. The examiner stands
level with the knee. He places thumb and index
Fig. 5.48 Testing for fluid in the joint by eliciting fluctuation.
finger of one hand at each side of the knee,
just beyond the patella. The interdigital web I-II
of the other hand is on the suprapatellar pouch
(Fig. 5.48).
Procedure. The examiner squeezes the supra­
patellar pouch, pushing all the fluid downwards
under the patella, which forces the two fingers
of the palpating hand apart.
Visual testing by eliciting fluctuation
Positioning. The subject lies in the supine posi­
tion with the leg extended.
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KNEE 107
(01
(bl
Fig. 5.49 Visual testing for fluid by eliciting fluctuation.
Procedure. The examiner strokes in a sweeping
motion with the back of one hand over the lateral
recessus and the suprapatellar pouch. This moves
the fluid upwards and medially (Fig. 5.49a).
In minor effusion, all the fluid is moved to the
medial part of the suprapatellar pouch. The
lateral recessus is then empty and can be seen
as a groove between patella and lateral femoral
condyle. Sweeping with the back of the hand
over the suprapatellar pouch, and downwards
over the medial recessus will now transfer the
fluid laterally where a small prominence appears
(Fig. 5.49b). This is the most delicate test for
effusion in the knee joint, and will even demon­
strate 2 or 3 ml of fluid.
Synovial thickening
Synovial thickening is a vital c1inkal finding. It
indicates primary inflammation of the synovia
and differentiates this from a secondary synovitis.
Synovial swelling is best detected at the medial
and lateral condyles of the femur (Fig. 5.50), about
2 cm posterior to the medial and lateral edges
of the patella. Here the capsule lies almost super­
ficially, covered only by skin and subcutaneous
Fig. 5.50 Detection of synovial thickness.
fat. It is palpated by rolling the structures be­
tween fingertip and bone. Normally nothing
except skin can be felt. In synovial thickening, a
dense structure can be felt.
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CHAPTER CONTENTS
Surface and palpatory anatomy 109
Posterior 109
Bony landmar\s 109
Palpation of 8Ütissue 110
Lateral 110
Bony landmar\s 110
Palpation of the peronei 110
Palpatlon of the sinus tarsi 111
Palpation of the anterior talofibular ligament 111
Palpation of the calcaneofibular ligament 112
Palpation of the posterior talofibular ligament 113
Palpation of the calcaneocuboid joint and
ligaments 113
Palpation of the cuboid-metatarsal V jOint 113
Medial 114
Dorsal 116
Functional examination of the ankle and foot 116
Passive tests of the ankle joint 117
Passive plantar flexion 117
Passive dorsiflexion 117
Passive tests of the sublalar jOint 118
Varus movement 118
Valgus movement 119
Passive tests of the midtarsal joints 120
Passive dorsiflexion 120
Passive plantar flexion 121
Passive abduction 121
Passive adduction 121
Passive pronation 122
Passive supination 122
Maximal Isometrc contractions of the foot 123
Resisted dorsiflexion of the foot 123
Resisted plantar flexion of the foot 123
Resisted eversion of the foot 124
Resisted inversion of the foot 124
Specific tests 125
Combined plantar flexion-inversion 125
Combined plantar lIexioneversion 126
Anterior drawer test 126
Combined dorsiflexion-eversion 128
Strong varus movement at the ankle 129
Ankle and foot
SURFACE AND PALPATORY
ANATOMY
POSTERIOR
Bony landmarks (Figs 6.1 and 6.2)
Calcaneus, medial and lateral malleolus are
visible landmarks. The upper surface of the tuber
Fig. 6.1 Bony landmarks on skeleton.
109
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110 ATLS OF ORTHOPEDIC EXAMINATION
F
Fig. 6.2 Bony landmarks in vivo.
E
calcanei (A) can easily be palpated and forms
the basis of the triangle whose legs are formed by
the anterior border of the Achilles tendon and the
posterior aspect of the tibia.
The posterior border of the talus (B), nipped
between tibia and caleaneu, is hardly palpable
as a small crest.
Palpation of soft tissue (Figs 6.1 and 6.2)
The Achilles tendon (C) is easily visible and pal­
pable.1t inserts at the upper and posterior border
of the caleaneus.
The plantar aspect of the calcaneus is covered
by a soft heel pad (0). The tip of the lateral
malleolus is level with the lateral jOint line of
the talocaleanean joint. Its inferior border extends
about 1 em further distally than that of the
medial malleolus.
The posterior surface of the lateral malleolus
(E) carries a sulcus which contains the tendons
of the peronei. The peroneus brevis is against
the bone with the tendon of the peroneus longus
Fig. 6.3 Bony landmarks at the lateral ankle.
on top of it. The posterior surface of the medial
malleolus (F) also bears a groove in which the
tibialis posterior tendon can be palpated (see
palpation of medial structures).
LATERAL
Bony landmarks (Fig. 6.3)
The lateral malleolus (A), the base of the fifth
metatarsal (6) and the fifth metatarsophalangeal
joint (C) constitute the important bony land­
marks at the lateral aspect of ankle and foot.
From these bony points nearly all palpable lateral
structures can be ascertained.
Palpation of the peronei
(Figs 6.4 and 6.5)
About one finger-breadth under and slightly
anterior to the lateral malleolus, a bony notch can
be palpated: the trochlear process (A). Since this
prominence is situated between both peroneal
tendons, the palpating finger will be lifted off by
the hardening tendons when an eversion move­
ment is performed. The peroneus longus (6) is
plantar and the peroneus brevis (C) is dorsal to
the trochlear process. The tendon of the peroneus
longus can be followed proximally under and
behind the malleolus. The tendon of the peroneus
brevis is felt to insert on the base of the fifth
metatarsal.
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Fig. 6.4 Palpation of the peronei.
Fig. 6.5 The peroneal tendons: 1, peroneus brevis;
Z, proneus longus.
Palpation of the sinus tarsi
(Figs 6.6 and 6.7)
Starting from the anterior surface of the lateral
malleolus and moving anteriorly and medially,
the finger falls into a depression - the sinus tarsi
(A). If the finger is left in place and the foot
is inverted, the depression excavates and its
borders can be better ascertained. Just anterior
to the malleolus the lateral process of the talus (B)
is felt to press against the palpating finger. The
neck of the talus (C) is determined as the medial
ANKLE AND FOT ",
Fig. 6.6 Palpation of the sinus tarsi in vivo.
Fig. 6.7 Palpation of the sinus tarsi.
border and the anterior third of the calcaneus (0)
as the bottom of the sinus tarsi.
The sinus tarsi is also bordered by tendinous
structures: superiorly the long extensors of the
toes (E) and inferiorly the peronei (F).
Palpation of the anterior talofibular
ligament (Fig. 6.8)
The index finger is laid on the anterior surface
of the lateral malleolus. A combined plantar
flexion-inversion movement of the ankle makes
the lateral process of the talus more prominent.
The ligament is felt as a thin, flat and horizontal
structure, pressing against the palpating finger.
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112 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 6.8 Palpation of the anterior talofibular ligament.
Palpation of the calcaneofibular
ligament (Figs 6.9 and 6.10)
One finger is placed just caudal and posterior
to the lateral malleolus. The other hand encircles
the heel and provokes a varus movement in
the subtalar joint. A strong and round structure
with a slight posterior inclination is felt to press
against the palpating finger (the calcaneofibular
Ligament (A)).
Fig. 6.9 The calcaneofibular ligament can be made visible
during a strong varus movement.
|8l
Z
(b)
5 --
Flg. 6.10 Lateral and posterior ligaments of the ankle
(a) lateral view; (b) posterior view: 1, posterior talofibular
ligament; Z.calcaneofibular ligament; 3,distal tibiofibular
ligament; 4,anterior talofibular ligament; 5, posterior
tibiatalar ligament; ô, tarsal canal.
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Fig. 6.11 The posterior talofibular ligament.
Palpation of the posterior talofibular
ligament (Fig. 6.11)
Place the palpating finger deeply behind the
lateral malleolus and search for the lateral and
posterior aspects of the talus. A dorsiflexion
movement in the ankle makes the taut ligament
press against the finger.
Palpation of the calcaneocuboid joint
and ligaments (Fig. 6.12)
The examiner places the interphaJangeal joint
of his thumb on the base of the fifth metacarpal
bone and aims in the direction of the midpoint
between the two malleoli. The tip of the pal­
pating thumb now lies exactly on the lateral
calcaneocuboid ligament. In neutral position the
joint line can clearly be ascertained. The ligament
can b felt when it is brought under tension
during supination and adduction of the foot.
ANKLE AND FOT 113
Fig. 6.12 Palpation technique for the calcaneouboid
ligament.
Palpation of the cuboid-metatarsal V
joint (Fig 6.13)
The base of the fifth metatarsal bone is gripped
between the thumb and index of one hand. The
cuboid bone (medial to the metatarsal and distal
to the already identified calcaneocuboid joint
line) is gripped between the thumb and index
finger of the other hand. A translation movement
discloses easily the joint line between cuboid and
fifth metatarsal bone.
Flg.6.13 Palpation of the cuboid-metatarsal V joint.
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114 ATLAS OF ORTHOPEDIC EXAMINATION
MEDIAL
The medial malleolus, the sustentaculum tali, the
tuberosity of the scaphoid and the base of the
first metatarsal bone constitute the important
bony landmarks at the medial aspect of the ankle
and foot. The medial malleolus (Fig. 6.14, A) is
felt with ease. The sustentaculum tali (B) is found
about 2 em below the tip of the medial malleolus.
This bony prominence is better palpable if the
calcaneus is pushed into a valgus position.
The tuberosity of the scaphoid bone (Fig. 6.15,
A) is found as follows. Ask for and resist an
inversion movement of the foot which brings the
strong tibialis posterior and anterior tendons into
Flg. 6.14 Palpation of the medial malleolus and the
sustentaculum tali.
Fig. 6.15 Visualization of medial structures.
Z
Fig. 6.16 Tendons and insertions of the main invertor
muscles: 1 , tibialis anterior; Z, tibialis posterior.
prominence. The insertion of the tibialis posterior
tendon (B) is on the tuberosity (Fig. 6.16).
The tibialis anterior tendon (C) is followed
along the medial border of the foot where it is
felt to insert on a bony prominence, the tubercle
of the first metatarsal base (D). This point is the
midpoint of the medial border of the foot.
The talar head can be palpated at the midpoint
of a line joining the tip of the malleolus to the
tuberosity of the scaphoid bone (Fig. 6.17). The
talonavicular joint becomes more apparent during
an adduction movement in the mid foot.
The thick structures that are palpable just
around the inferior border of the medial malleolus
constitute the different layers of the deltoid Iiga-
Flg. 6.17 Visualization of the talar head.
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ment. They become more obvious when a varus
movement is performed.
The ligament that connects the sustentaculum
tali with the inferior surface of the navicular
bone is the inferior calcaneonavicular ligament
(spring ligament) (Fig. 6.18 and Fig. 6.19, B). It is
best palpated on a passively everted foot. Since
the insertion on the navicular bone is close to that
of the tibialis posterior tendon (A), both struc­
tures will constitute a N that can be felt during a
resisted inversion of the foot.
Fig. 6.18 Medial ligaments of the ankle: 1, anterior
tibiotalar ligament; Z, posterior tibiotalar ligament;
3,tibionavicular ligament; 4,inferior calcaneonavicular
ligament; 5, tibiocalcanear ligament.
A
Flg. 6.19 Visualization of the spring ligament.
ANKLE AND FOT 1 1 5
The following longitudinal structures can be
palpated along the posterior aspect of the medial
malleolus from anterior to posterior successively:
the tibialis posterior and flexor digitorum longus
tendons, the posterior tibial artery and the flexor
hallucis longus tendon (Fig. 6.20a).
The tibialis posterior tendon remains in contact
with the bone of the malleolus and becomes promi­
nent during an inversion movement (Fig. 6.19).
The tendon of the flexor digitorum longus is
difficult to palpate and is situated more laterally
and dorsally. Behind this tendon the pulse of the
posterior tibial artery can be felt.
The flexor hallucis longus tendon (Fig. 6.20b
and Fig. 6.21, A) is identified as follows. Place the
palpating finger between the medial malleolus
and the anterior aspect of the Achilles tendon.
Bring the foot into dorsiflexion. The tendon can
be seen and felt to move under the palpating
lBI
,.
\bl
Fig. 6.20 The tendons at the medial malleolus: 1, tibialis
posterior; Z, flexor digitorum longus; 3,flexor hallucis longus;
4, sustentaculum tali.
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116 ATLS OF ORTHOPEDIC EXAMINATION
Fig. 6.21 Visualization of the flexor hallucis longus.
finger when a passive dorsiflexion movement is
imposed on the big toe.
DORSAL
The medial and lateral malleoli are easily pal­
pated. A horizontal line drawn 2 cm proximal to
the tip of the lateral malleolus and 1 cm proximal
to the tip of the medial malleolus closely delin­
eates the inferior tibial border.
During a resisted dorsiflexion, the tendons of
the tibialis anterior (Fig. 6.22, A), the extensor
hallucis longus (8) and the extensor digitorum
longus (C) are visible. The tendon of the peroneus
tertius may be visible as the most lateral tendon
Fig. 6.22 Visualization of the extensor tendons.
C
Flg.6.23 Palpation of the dorsalis pedis arter.
running just distally to the sinus tarsi and joining
the fifth metatarsal bone.
The pulse of the dorsalis pedis artery can be
felt between the tendons of the extensor hallucis
longus and the extensr digitorum longus (Fig. 6.23).
[n about 5% of the population the artery is very
thin or even absent.
FUNCTIONAL EXAMINATION OF
ANKLE AND FOOT
Introduction/general remarks
The ankle and foot are examined with the subject
in the supine lying position.
The ankle and foot are very difficult to
examine because a great number of strong and
rather stiff structures are condensed into a small
volume. To test each structure in turn without
the help of a lever is a very difficult task and
demands a great technical ability.
The different 'joints' to examine are:
• the ankle joint
• the subtalar joint
• the 'midtarsal joints': the whole middle
structure of the foot, though consisting of
several bones and joints, functionally acts as
one integrated structure and is therefore
examined as one 'midtarsal joint'.
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The action of the contractile structures of the
ankle and foot have an influence on all the
different joints.
PASSIVE TESTS OF THE ANKLE
JOINT
Passive plantar flexion
Positioning. The subject lies supine with the leg
on the couch and the ankle in neutral position.
The examiner is distal to the foot. One hand
supports the heel, the other is at the dorsum of
the foot.
Procedure. A simultaneous movement of both
hands pulls and pushes the ankle into plantar
flexion (Fig. 6.24).
Common mistakes. None.
Normal functional anatomy:
• Rallge: the dorsal aspect of the foot falls into
line with the tibia
• Elld-feel: hard ligamentous
Fig. 6.24 Passive plantar flexion.
ANKLE AND FOOT 117
• Limiti"g structures:
- the engagement of the heel via the Achilles
tendon against the back of the tibia
- anterior tibiotalar ligament.
Common pathological situations:
• Limitation of plantar flexion is usually caused
by an articular lesion.
• Anterior pain in combination with a normal
end-feel indicates stretching of anterior
structures (capsule, tendons of dorsi flexors,
anterior tibiotalar and anterior talofibular
ligaments).
• Posterior pain is elicited when a pathological
structure is painfully squeezed between tibia
and calcaneus (bursa, insertion of Achilles
tendon, periostitis).
Passive dorsiflexion
Positioning. The ankle is in neutral position
with the heel resting on the couch. The knee
is slightly flexed. The examiner is distal to the
foot. He places one hand at the plantar aspect
of the forefoot. The other hand is at the back of
the heel.

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11 8 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 6.25 Passive dorsiflexion.
Procedure. Move the foot in the dorsal direction,
meanwhile keeping the knee in a slightly flexed
position (Fig. 6.25).
Common mistakes. None.
Normal functional anatomy:
• Rallge: the angle between the dorsum of the
foot and the tibia can be reduced to less than
90
°
• Elld-feel: hard ligamentous
• U"if;'1g structures:
- the posterior capsule
- posterior talofibular ligament
- posterior fibres of the deltoid ligament
- anterior engagement of talar neck and
anterior margin of tibial surface.
Common pathological situations:
• Limitation of dorsiflexion is caused by
articular lesions or by short calf muscles.
• Posterior pain indicates stretching of posterior
structures (capsule or tendons of
plantiflexors).
• Anterior pain is elicited when a pathological
structure is painlully squeezed between tibia
and talus (anterior periostitis or nipping of
post-traumatic fibrosis).
PASSIVE TESTS OF THE SUBTALAR
JOINT
Varus movement
Positioning. The heel rests on the couch with
the knee slightly flexed and the ankle in neutral
position. The examiner is distal to the foot and
grasps the heel between the clasped hands. In
order to avoid movements in the ankle joint
the talus is stabilized between tibial and fibular
malleoli. This is achieved by traction on the
heel and through a slight pressure with the trunk
against the patient's forefoot.
Procedure. Swing the upper half of the body
inwards (Fig. 6.26).
Common mistakes:
• Full dorsiflexion is lost.
• Uncomfortable pressure is exerted on the
calcaneus.
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Fig. 6.26 Vars movement.
Normallunctional anatomy:
• Rallge: 15--30·
• Elld-feel: ligamentous
• Limit;'lg structures:
- caleaneofibular ligament
- talocaleanean interosseus ligament
- joint capsule
- posterior fibres of the deltoid ligament.
Common pathological situations:
• A progressive limitation of varus indicates a
capsular lesion of the subtalar joint. In
significant arlhritis varus is completely lost by
a spasm of the peronei.
• Lateral pain at full range may b indicative of
a sprain of the caleaneofibular ligament.
Valgus movement
Positioning. The heel rests on the couch, the knee
is slightly flexed and the ankle in neutral posi­
tion. The examiner is distal to the foot and grasps
the heel between the clasped hands. In order
to avoid movements in the ankle joint the talus
ANKLE AND FOT 119
is stabilized between tibial and fibular malleoli.
This is achieved by traction on the heel and
through a slight pressure with the trunk against
the patient's forefoot.
Procedure. Swing the upper half of the body
outwards (Fig. 6.27).
Common mistakes:
• Full dorsiflexion is lost.
• Uncomfortable pressure is exerted on the
calcaneus.
Normallunctional anatomy:
• Rallge: 10-15°
• Elld-fee/: ligamentous
• Limiting structures:
- posterior fibres of the deltoid ligament
- talocalcanean interosseus ligament
- joint capsule.
Common pathological situations. Medial pain
may indicate a lesion of the deltoid ligament.
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120 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 6.27 Valgus movement.
PASSIVE TESTS OF THE MIDTARSAL
JOINTS
Remarks
• Because the middle segment of the foot
consists of several bones and joints it is very
difficult to assess isolated movements.
Therefore the whole middle segment is
considered as one integrated structure.
• Movements are possible in three directions
but owing to anatomical characteristics
plantar flexion is always accompanied by
some adduction, and dorsiflexion by some
abduction.
• The positioning for all the midtarsal
movements is the same.
Positioning for testing the midtarsal mobility. The
subject lies supine with an extended knee and
the foot in neutral position. The examiner is distal
to the foot. His contralateral hand encirdes the
heel and carries it. The hand also pulls on the
heel and forces it into full valgus. The ipsilateral
hand encirdes the forefoot, thumb under the
metatarsal heads and fingers at the dorsum of
the metatarsal shafts.
In this position both ankle and subtalar joints
are fully stabilized:
• The traction forces the talus into a dorsiflexed
position between the two malleoli.
• The valgus position fixes the subtalar joint.
Common pathological situations for the midtarsal
tests:
• LimHation may indicate arthritis or arthrosis.
• Painful movement with an excessive range is
typical for the beginning of a midtarsal strain.
• Localized pain indicates a local ligamentous
lesion or local periostitis.
Passive dorsiflexion (Fig. 6.28)
Procedure. Press the thumb upwards by a
supination of the wrist.
Common mistakes. The ankle and subtalar joints
are not stabilized.
Normal functional anatomy:
• Rallge: 1015°
• End-feel: hard ligamentous
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Fig. 6.28 Passive dorsiflexion.
• Umitiu8 structures:
- plantar midtarsal ligaments
- plantar fascia.
Passive plantar flexion (Fig. 6.29)
Procedure: Press the fingers downwards by a
pronation of the wrist.
Common mistakes. The ankle and subtalar joints
are not stabilized.
Fig. 6.29 Passive plantar flexion.
ANKLE AND FOOT 121
Fig. 6.30 Passive abduction.
Normal functional anatomy:
• Rallge: 10150
• Elld-feel: hard ligamentous
• Lilllilillg sln/etL/res: dorsal midtarsal ligaments.
Passive abduction (Fig. 6.30)
Procedure. Perform the abduction movement in
the wrist: the web of the thumb presses the
medial aspect of the first metatarsal bone in a
lateral direction; meanwhile the fingertips provide
counter-pressure at the outer side of the forefoot.
Common mistakes. The ankle and subtalar joints
are not stabilized.
Normal functional anatomy:
• Rallge: 10150
• Elld-feel: hard ligamentous
• Limitillg structures: medial and inferior
midtarsal ligaments.
Passive adduction (Fig. 6.31)
Procedure. Perform the adduction movement
in the wrist: the fingertips pull the outer side of
the forefoot in a medial direction; meanwhile the
fifth metacarpal bone provides counter-pressure.
Common mistakes. The ankle and subtalar joints
are not stabilized.
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122 ATLAS OF ORTHOPEDIC EXAMINATION
Fig. 6.31 Passive adduction.
Normal functional anatomy:
• Rallge: 10-15°
• End-feel: hard ligamentous
• Umitiflg structures: lateral midtarsal ligaments.
Passive pronation (Fig. 6.32)
Procedure. Perform an adduction movement in
the shoulder: the hand pulls the inner side of
Fig. 6.32 Passive pronation.
the foot downwards while the thumb pushes the
outer side upwards.
Common mistakes. The ankle and subtalar joints
are not stabilized.
Normal functional anatomy:
• Range: 30-60°
• Elld-feel: soft ligamentous
• Limitiug structures: medial and dorsal
midtarsal ligaments.
Passive supination (Fig. 6.33)
Procedure. Perform an abduction movement in
the shoulder: the thumb pulls the inner side of
the foot upwards while the fingers push the
outer side downwards.
Common mistakes. The ankle and subtalar joints
are not stabilized.
Normal functional anatomy:
• Rallge: 45-90°
• End-feel: soft ligamentous
• Limiting structures: medial and lateral
midtarsal ligaments.
Fig. 6.33 Passive supination.
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MAXIMAL ISOMETRIC
CONTRACTIONS OF THE FOOT
Resisted dorsiflexion of the foot
Positioning. The subject lies supine with the
knee extended and the foot in neutral position.
The examiner is distal to the foot. Both hands are
placed at the dorsum of the forefoot.
Procedure. Ask the patient to extend the foot
(Fig. 6.34).
Common mistakes. None.
Anatomical structures tested:
Muscle function:
• Tibialis anterior
• Extensor hallucis longus
• Extensor digitorum longus
• Peroneus tertius.
Neural function:
Muscle Innervation
Peripheral Spinal
Tibialis anterior Deep peroneal L4, (LSI
Extensor halluc!s longus Deep peroneal l4, l5
Extensor digilorum longus Deep peroneal l4, L
Peroneus tertius Deep peroneal L4, L
Flg. 6.34 Resisted dorsiflexion.
ANKLE AND FOOT 123
Resisted plantar flexion of the foot
Positioning. The patient lies supine with the knee
extended and the foot in neutral position. The
examiner is distal to the foot. One fist is placed
under the metatarsal heads while the other hand
stabilizes the distal end of the leg just proximal to
the malleoli.
Procedure. Ask the subject to plantar flex the foot
(Fig. 6.35).
Common mistakes. None.
Anatomical structures tested:
Muscle function:
• Triceps surae
• Tibialis posterior
• Flexor hallucis longus
• Flexor digitorum longus
• Peronei longus et brevis.
Neural function:
Muscle Innervation
Perpheral
Triceps surae TIbial
Tibialis posterior Tibial
Flexor hallucis longus Tibial
Flexor digltorum longus Tibial
Peronei longus at brevis Supericial peroneal
Fig. 6.35 Resisted plantar flexion.
Spinal
$1-52
L41l5, $1
L5,S1
L5,51
L, $1
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124 ATLAS OF ORTHOPEDIC EXAMINATION
Resisted eversion of the foot
Positioning. The patient lies supine with the
knee extended and the foot in neutral position.
The examiner is distal to the foot. His ipsilateral
hand is placed at the medial and distal end of the
leg just above the medial malleolus. The contra­
lateral hand is pronated and placed against the
lateral border of the foot.
Procedure. Ask the subject to push with the
outer side of the foot against the resisting hand
(Fig. 6.36).
Common mistakes. The leg is not enough stabi­
lized and an external rotation in the hip rather
than an eversion movement in the foot is
performed.
Anatomical structures tested:
Muscle function:
• Peroneus longus
• Peroneus brevis
• Peroneus tertius
• Extensor digitorum longus.
Fig. 6.36 Resisted eversion.
Neural function:
Muscle
Perooellongus at brevis
Extensor digitorum longus
Peroneus tertius
InnelVation
Peripheral Spinal
Superficial peroneal L,S 1
Deep peroneal L4,L5
Deep peroneal L4.L5
Resisted inversion of the foot
Positioning. The patient lies supine with the
knee extended and the foot in neutral position.
The examiner is distal to the foot. The contra­
lateral hand is placed at the lateral and distal
end of the leg just above the lateral malleolus.
The ipsilateral hand is placed against the medial
border of the foot.
Procedure. Ask the subject to press the inner side
of the foot against the resisting hand (Fig. 6.37).
Common mistakes. The leg is not properly stabi­
lized and an interal rotation in the hip rather
than an inversion movement at the foot is
performed.
Fig. 6.37 Resisted inversion.
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Anatomical structures tested:
Muscle function:
• Tibialis posterior
• Tibialis anterior
• Flexor hallucis longus
• Extensor hallucis longus
• Triceps surae.
Neural function:
Muscle
Inneration
Peripheral Spinal
Tibialis posferior
Tibialis antenor
Flexor hallucis longus
Extensor hallucis longus
Triceps surae
SPECIFIC TESTS
Tibial
Deep peroneal
Tibial
Deep peroneal
Tibial
L4I5, S1
L4, (LS)
L5,S1
L4, L
S1-$2
Combined plantar flexion-inversion
Significance. This movement brings all the lateral
structures of ankle and foot under stretch and is
therefore an extremely important test in sprained
ankles.
Positioning. The heel rests on the couch, the
knee is slightly flexed and the ankle is in neutral
ANKLE AND FOOT 125
position. The examiner is distal to the foot. His
ipsilateral hand fixes the leg at the distal and
medial side, The contralateral hand is placed on
the midfoot, so that the heel of the hand rests
at the fifth metacarpal bone and the fingers
encircle the medial border.
Procedure. Stabilize the leg with the ipsilateral
hand. Press the foot downwards and inwards
with the heel of the contralateral hand. Mean­
while perform a supination movement by an
upwards pulling of the fingers (Fig, 6,38),
Common mistakes:
• The lower leg is not sufficiently stabilized.
• Plantar flexion is lost.
• Supination is not conducted to the end,
• Painful pinching of the forefoot occurs.
Normal functional anatomy:
• Ralge: 6120° angle between forefoot and
lower leg
• Eld-fee/: soft ligamentous
• Limiting structures:
- anterior talofibular ligament
- lateral and dorsal calcaneocuboid ligaments
- capsule of the cuboid-fifth metatarsal joint
- peronei longus and brevis tendons
- extensor digitorum longus tendons.
r|g.6.38 Combined plantar
ftexion-nversion.
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126 ATLAS OF ORTHOPEDIC EXAMINATION
Common pathological situations:
• This movement is extremely painful in ankle
sprains.
• Excessive range is noted in total rupture of
the anterior talofibular ligament.
• In chronic ankle sprains with ligamentous
adhesions there is slight limitation with a
tougher end-feel.
• Marked limitation with a spastic end-feel is
typical for a subtalar arthritis.
Combined plantar flexion-version
Significance. This movement stretches all the
medial ligaments of the ankle.
Positioning. The heel rests on the couch, the
knee is slightly Aexed and the ankle is in neutral
position. The examiner is distal to the foot. His
contralateral hand fixes the leg at the distal
and lateral side. The ipSilateral hand encircles the
mid foot with the heel lying on the first metatarsal
bone and the fingers encircling the lateral border.
Procedure. Stabilize the leg with the contralateral
hand. Press the foot downwards and outwards
with the heel of the ipsilateral hand. Meanwhile
perform a pronation by an upwards pulling of
the fingers (Fig. 6.39).
r|g.6.39 Combine plantar 'exiorverion.
Common mistakes.
• The lower leg is not stabilized.
• Plantar Aexion is lost.
• Pronation is not performed.
• Painful pinching of the forefoot occurs.
Normal functional anatomy:
• Range: 15-5°
• Elld-feel: ligamentous
• Umiti"g structures:
- anterior part of the deltoid ligament
- calcaneonavicular ligament
- capsules of the medial midtarsal joints
- tendon of the tibialis anterior.
Common pathological situations:
• Medial pain may be caused by a lesion of the
anterior portion of the deltoid ligament or by
a tendinitis of the tibialis posterior.
• Lateral pain may indicate a painful squeezing
of the posterior talofibular ligament.
Anterior drawer test
Significance. This is a specific test for the integrity
of the anterior talofibular ligament.
Positioning. The subject lies supine and relaxed
with the knee Aexed to 90°. The heel rests on
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the couch and the foot is in slight plantar flexion.
The examiner stands at the opposite side of the
foot, level with it. One hand stabilizes the lower
leg while the other is placed at the lateral border
of the foot.
Procedure. Stabilize the lower leg. Try to move
the foot forwards in a medial direction (Fig. 6.40).
Common mistakes:
• The lower leg is not stabilized.
• There is too much plantar flexion at the ankle
joint.
Fig. 6.40 Anterior drawer test.
ANKLE AND FOT 127
Normal functional anatomy:
• Rauge: none
• Elld-feel: ligamentous
• Limiting structure: anterior talofibular
ligament.
Common pathological situations. The movement
is only possible if the anterior talofibular liga­
ment is ruptured or elongated. Movement is
indicated by a forwards shift of the lateral margin
of the trochlea tali in relation to the latera I
malleolus (Fig. 6.41).
PnletÌDt
NedÌe| -i
Fig. 6.41 Anterior drawer test.
ml ÌDg ___________
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128 ATLAS OF ORTHOPEDIC EXAMINATION
Combined dorsiflexion-version
Significance. This is a specific test to demonstrate
anterior periostitis of the fibula.
Positioning. The knee is slightly flexed and the
ankle in neutral position. The examiner is distal
to the foot. His ipsilateral hand supports the
heel and the contralateral hand is placed against
the plantar and lateral side of the foot.
Procedure. Press the foot upwards and outwards
with the heel of the contralateral hand until the
end-feel is ascertained (Fig. 6.42).
Common mistakes. The movement is not executed
firmly enough.
Common pathological situations. Lateral pain
indicates the existence of periostitis of the inferior
border of the fibula. Alternatively the pain is
caused by impingement of a thickened, hyper­
trophied talofibular ligament.
Flg. 6.43 Strong varus movement at the ankle.
Fig. 6.42 Combined dorsiflexion-version.
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Strong varus movement at the ankle
Significance. This movement tests the integrity
of the strong distal tibiofibular ligaments.
Positioning. The ankle is in neutral position and
the knee extended. The examiner is distal to the
foot. The ipSilateral hand fixes the leg at the
inner side, just above the ankle. The contralateral
hand grasps the foot at the heel.
Procedure. Force the heel with a strong and quick
thrust into varus (Fig. 6.43).
ANKLE AND FOOT 129
Common mistakes. The movement is not executed
firmly enough.
Common pathological situations:
• When there is ligamentous rupture or laXity
of the distal tibiofibular ligaments, the fibula
can be pressed outwards, a circumstance that
is detected by a palpable click when the tibia
and the fibula engage after their momentary
separation .
• In a total rupture of the anterior talofibular or
the calcaneofibular ligaments, this test will
also show laxity.
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Index
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ÍDDctVð!ÍDD,¯ó,¯b,¯b
QðÎQð!ÍDt1, b
P00UC!DtQÎlÍCS
ÍDDctVð!ÍDD, 5, b¯
Îc5ÍDDS,b¯
P00UC!Dt !cD0ÍDÍ¡Í5,¯Z, ¯b
PDÿD¡tOQDÍC Îð!ctðÎ SCÎctOSÍ5,b1
PDð!ODÍCðÎ 5DUÍÍDx, óV, +Ü
PDCODcU5DUSCÎc, Zö
PDKÌc
ðDð!DDÿ,1Ü~11b
ðD!ctÍDt0tðWct¡c5¡,1Zb~1Z¯
CDDDÍDc0 0DtS¡ÛPXÍDD·cVcI5ÍOD, 1Zö
CODDÍDc0 QÎðD!ðt ÛcXÍOD¬'Vct5ÍDD,
1Zb
CDDDÍD£0 QÎðD¡ðt Í1cXÍOD-ÍDVct5IDf
1Zb~1Zb
ÍUDC!ÍDDðÎcXðDIDð!ÍDD, 11b~1ZV
QðÎQð¡¡DD,1Ü~J1b
5QtðÍD5,126
5¡tDD@VðtU5DOVcDcD!,JZV
PDKÎcjDÍD¡
ðt!¡CUÎðt Ì£5ÍDD5,11¯,11ö
Qð55IVc0Dt5ÍÍ1cXÍDD,11¯-11ö
Qð55IVcQÎðD¡ðt lÎcXÍDD,11¯
PD!ctÍDtCIUCÍð!cÎÍ@ðDcD!5
ÎðXI¡ÿ,Vó
Îc5ÍOD5, 9
tUQ!Utc, %, V¯
PD¡ctÍDt ¡D!cIDSMOU5 DctVc Σ5¡DD5, 5
PD!ctIDt 5UQtÍDt IÎIðC5QIDc, bò¬+
ðVUÌ5IOD ÍtðC¡UtU5, ¯+
PD¡ctÍOt!ðÌDÍÍDUÎðtÎÍ@ðDcD¡
QðÎQð!ÍOD,HI
tUQUttc,1Zb,1Z¯, 1ZV
PQDDcUtD!ÍCðtCD,Zö
PtCUð¡cCODQÌcX, Vö
PID5
ðC!IVccÎcVð¡ÍDD,ö~V
Qð5SIVccÌcVð!ÍDD,V~JÜ
PXIÎÎð, ö
PXÍÎÎðtÿ DctVcÎc5ÍDD5,1+
B
ÜðtÎDW´5¡£5!, 8
ÜÍC£Q5DtðCDÍÍ
Îc5ÍOD5, á+
¡cD0ÍDÍ!Í5,óZ
ÜÍCcQ5 ÍcDDIÎ5
ÍDDcIVð¡ÍDD, 7, n, 1Ü, 1ÜJ
QðÎQð!ÎOD, 6, ö¯
!cD0DD, B
ÜÍCcQ5DU5CÎc,ZJ~ZZ
Îc5ÍDD5,Ìb, ób
QðÎQð¡IOD OÍ ÎOD@ Dcð0,b~¯
ÜÍCIQÍ!ðÎ @tDVc5,Z, 77
ÜÍCIQÍ!ðÎ!cD0DD,Z1
ÜÍCIQÍ!Dtð0IðÎ DUt5Í¡Í5,óZ
ÜtðCDÍðÎ ðt¡cty,Z1~77
ÜtðCD¡ðÎÍ5DU5CÎc
Σ5ÍDD5, á+
QðÎQð¡ÍDD,ZZ
ÜtðCDÍOtð0¡ðÎÍ5 DU5CÎc
ÍDDctVð!ÍDD,5
QðÎQð¡ÍDD,Z1, 2, Z+~Zb
ÜIDDCDU5CðtC¡DDDð,M, bó
ÜU!¡DCKQðÍD, ¯b
c
C DctVc tOO¡
Ì£SÍOD5, 14, 1b,ó+
QðÎ5ÿ,1+
Lb DctVctDDl Îc5IDD5, 1b, ó+,ób, bó
C DctVcIDO¡
Îc5ÍDD5,ó+, ó¯,bó
QðÎ5ÿ,1ó,1¯
Lö DcIVctD¡Îc5IDD5, M, ó¯,bó,bb,5.

LðÎCðD£OCUDOÍ0 jOID¡,¡1ó
LðÎCðD£DCUDO¡0 Ρ@ðDcD!,J1ó
LðÎCðD£DÍ¡DUÎðtÌÍ@ðDcD!
QðÎQð!ÍDD, 11Z
tUQ¡Ut£, 1ZV
5QtðÍD, 11V
LðÎCðDcU5,JÜ~11Ü
LðQI¡ð!c DDc
CðtQðÌ 5UDÎUXð¡ÍDD,5
QðÎQð!ÍDD, +1
LðtQðÌ DDDc5,+J
5UDÌUXð¡ÍDD, 5
LðtQðÌ!UDDcÌ
QðÎQð!ÍDD,+b
Q£tCU55ÍDD[ÎDcÌ´5 ¡c5!),61
LÎðVÍCÌc, 1-Z
LDÎΣS´ ÍtðClUt£,DðÎUDÍ!c0,+V
LDDDDD ÛcxDt!cD0DD
Ì£5ÍDD5 [@DÎÍct´5 cÎDDW], ób,ó¯
QðÎQðlÍDD, ZV
LDDDDD QIODcðÎ DctVc,8
LDtðCDðCtODÍðÌ ÌÍ@ðDcD¡,ó
LDtðCDDtðCDÍðÌÍ5DU5CÌc,ö
LDtðCDÍ0QÇ , Z
LI£QI!U5,bZ
INDEX 13
LUDÍ¡ðÌ ÍOSSð, Z1~ZZ
LUDÍ¡ðÌ!UDDcÎ, 2
LUDÍ0-Dc!ð¡ðt5ðÎ V [DÍD¡,11ó
o
D jUctVðÍD´50ÍMð5U,b1, 5, 5, b¯
¡ÍDKcÎ5¡cÍD´5!c5¡, bZ
ÎcÎ!OÍ0ÌÍ@ðDcD¡
Ìc5ÍDD5, 11V, 1Zb
QðÎQð¡ÍOD,11b~11¯
ÎcÎ!OÍ0DU5CÎc
Ì£SÍOD5, 1ó
QðÎQð¡ÍOD,á~
Ρ5¡ðÌtð0ÍOUÎDðt [OÍD!
ðt¡Dt 15, +V
ðt¡DtOSÍ5,+V
QðÎQð¡ÍDD,+J
Qð55IVc QtDDð¡IDD,+ö¬V
Qð55IVc5UQÍDð!ÍDD, +V
Qð55ÍVc¡£!5, +ö~+V
ÎI5!ðÌ!ÍDÍDÍÍDUÎðt ÎÍ@ðDcD!5,!ZV
ÎOtSðÎÍD!ctOSMI,�l
ÎOtSðÎÍ5Q£0I5 ðt¡ctÿ,11b
E
LÎDDW
ðDð!ODÿ,Z1~óÜ
ðt!DtÍ!Í5,ó1, óZ
ðt¡DtD5Í5,ó1, óZ
ÍUDC¡ÍODðÎ cxðD1ÍDð!ÍOD, óÜ~ó¯
IDDctVð!ÍOD,òb,ó¯
ISODc!OC COD!tðC!ÍDD5,óó~ó¯
QðÎQð!ÍOD,ZJ-óÜ
Qð55IVccX!cD5ÍDD,ó1~óZ
Qð55IVc ÍÎcXÍDD, óÜ~ó1
Qð55IVcQtDDð!ÍDD,óZ
Qð55IVc 5UQÍDð!ÍDD.óó
Qð55IVc!c5¡5,áÜ~ó¯
t£5Í5!c0cX!cD5ÍDD,Jb 1¯, ó+
I£5Í5!c0 ÍÎcXÍOD,1b~Jb,óó á+
IU5Î5!c0 QIDDð!ÍOD, ó~ób
I£5Í5!c0 5UQÍDð!ÍDD,ób~M
$Í¡ ¡ÍSSUc QðÎQð!ÍOD,Z1-p
LQÍQDÿ5ÍS,5ΡQQ£0,¯1
Lx¡cDSDtCðtQÍ tð0¡ðÎÍ5DI£VÍ5 DU5CÎc
ÍDDcIVð!ÎOD,M
QðÌQð!ÍOD, 2, Z+,Zb
¡cD01DÍ!Í5,bó,b+
¡cD0DD5, +Z
LX¡cD5OtCðtQÍ tð0IðÎÍ5 ÎOD@U5
ÍDDctVð!ÍDD,M,5
QðÎQð!ÍDD, Z+, Zb
¡cD0IDÍ!Í5,bó,5
¡cD0DD5.+Z
LX¡cD5DtCðtQÍUlDðIÎ5 DU5CÌc
ÍDDcIVð!ÎOD,M,bb
Σ5ÍDD5, M,b1
QðÌQð!ÎDD,Zb
!cD0¡DÍ!f,+V,bó, bb
¡cD0DD,+ó,4
Copyrighted Material
134 INDEX
Extensor digiti minimi
innervation, M, 55, 58
tendon, 43
Extensor digitorum communis
innervation, 36, 55, 5
lesions, M
tendinitis, 53, 58
tendon, 43
Extensor digitorum longus
innervation, 123, 124
tendon,. 116
Extensor hallucis longus
innervation, 123, 125
tendon, 116
Extensor indicis proprius
innervation, 36, 5
tendinitis, 53, 5
tendon, 43
Extensor pollicis brevis
innervation, 57
palpation, 40
tenovaginitis, 51, 5, 56, 57
Extensor pollicis longus
innervation, 36, 5
rupture, 5
tendon, 42-3
tenosynovitis. crepitating. 56, 57
F
Femoral arter 66
Femoral nerve, 66
palsies, 7, 78
Femoral vein, 66
Fibula
anterior periostitis, 128
palpation, 81
Fifth metacarpal bone, 43
Fifth metat8rsnl bone, 110
Fifth metatarsophalangeal joint, 110
Fingers, 57-58
resisted extension, 57-58
resisted flexion, 58
Finkelstein's test, 62
First metacarpal bone, 4, 45
First metatarsal bone, 114
Flexor carpi radialis
innervation, 37, 53, 5
palpation, p, 45
tendinitis, 53, 54
tendon, 47
Flexor carpi ulnaris
innervation, 37, 53, 55
palpation, 30, 46
tendinitis, 5, 55
Flexor digitorum longus
innervation, 123
palpation, 115
Flexor digitorum profundus
innervation, 37, 53, 58
palpation, 45, 47
tendinitis, 53
tendons, lesions, 5
Flexor digitorum superficiaJis
innervation, 37, 53, 58
palpation, 45
tendons, 46-7
Flexor hallucis longus
innervation, 123,125
tendon, 115-116
Flexor pollicis brevis, 56, 57
Flexor pollicis longus
innervation, 556
palpation, 45
tendon, 48
tenosynovitis, 5
Foot
anatomy, 10-116
combined plantar flexion-inversion,
125-126
functional examination, 116-129
isometric contractions, 123-125
palpation, 109-116
resisted dorsiflexion, 123
resisted eversion, 124
resisted inversion, 124-125
resisted plantar flexion, 123
Fourth metacarpal bone, 41
G
Gastrocnemii,88
innervation, 100
Gemellus inferior, 77
Gemellus superior, n
Glenohumeral joint
anterior drawer test, 19
hypermobility,19
passive abduction test, 12
passive lateral rotation test, 10
passive medial rotation test, 11
posterior drawer test, 19-20
Gluteal bursitis, 72, 74
Gluteal pain, 72, 77
Gluteus maxim us
innervation, 75, 77
palpation, 67, 6
Gluteus medius
innervation, 76, 77
palpation, 68
Gluteus minimus, 76
Golfer'S elbow, 35, 37
Gracilis muscle
innervation, 75, 10
palpation, 66, 8
Greater tuberosity (of head of
humerus),2
Grind test, 62
Groin
neurovascular structures, 66
pain, 72, 75, 77
pain, provocation tests, 7
Guyon's tunnel, 4
percussion, 61
H
Hamate bone, 41, 4
Hamstrings
lesions, 75, 77
palpation, 6, 6
Hands, intrinsic muscles, 58-1
Hip, 6
adduction in flexion, 79
arthritis, 71, 72, 73, 78
arthrosis, 70, 71, 7, 73
aseptic necrosis, 79
bilateral passive medial rotation in
prone position, 78
congenital dislocation, 74, 7
forceful upward thrust 10 the heel,
79
functional examination, 69-80
internal derangement, 71
isometric tests, 73-78
oSleoarthrosis,70
passive abduction, 71-72
passive adduction, 7
passive extension, 72-73
passive external rotation, 70-71
passive flexion, 70
passive medial rotation, 71
passive tests, 70-80
resisted abduction, 74
resisted adduction, 74-75
resisted extension, 75
resisted flexion, 73-74
resisted lateral rotation, 76-77
resisted medial rotation, 75-76
Humeral capitulum, 23
Iliac crests, 66
Uiopsoas muscle
innervation, 73, n
palpation, 65
tendon, 6
Iliotibial tract
lesions, 7
palpation, 87
Inferior calcaneonavicular ligament
(spring ligament), 115
Inferior iliac spine, 6
Inferior pubic ramus, stress fracture, 75
Infracondylar tubercle (tubercle of
Gerdy),82
Infrapatellar tendon (patellar
ligament), 8, 8
Infraspinatus muscle
lesions,ll
palpation, 4-5
Infraspinatus tendon, 14
Infraspinous fossa, 3
Inguinal ligament, 63
Intertubercular sulcus, 2
Copyrighted Material
Î5CDlðÎ!UDtOSlly,b¬b¯
lSCDlDQUDlCtðDUS, b
K
Kne, ö1~1ܯ
ðDðlDDy, ö1¬öV
ðDl£tlDt Utðw£t!£Sl, V>~V¯
ðDl£tDD£UlðÌ tO!ð!Dty lDSlðDlÎl!y,9
ðtlDtl!lS,M
ðtlDtDSlS,M
UlSQÌðC£U D£DlSCUS,VÜ
£Xl£D5DtS
QðÎQð!lDD,8
t0lSl£UD£UlðÎtolðllDD,1Ü
£Xl£DðÎt£CUtVð!UD l£Sl,1Ü3
ÍÌUlU,l£SlS,1Ü3¬1ܯ
ÍuDCDDDðÌ £XðDlDð!lDD, öV~1ܯ
Dð£DðOlS,M
lDQðCl£UÎ0Dl0,V+
lDS!ðDlÎlly, l£St5,1Ü~1Ü3
lDl£DðÎU£tðD@£D£Dl, M, Vå, 1Ü1~1ÜZ
lSDD£ltlC CDD!tðC!lDDS,Vö-1Ü1
[£tk l£Sl,1Ü1Ü3
Ìð!£tðÎQl VDl SDlÍl {l£Sl Dl
NðCÍD¡DSD),1Û
Ìð!£tðÎ SD£ðtlD@ ¡£Sl,1ÜZ
Ìl@ðD£D¡DUSðUD£SlDDS, M
D£UlðÎCDDQðtUW£D! Ìl@ðD£D!
tUQ¡Ut£, V+
D£UlðÎSD£ðtlD@ l£Sl,1Ü1~1ÜZ
D£DlSCðÎ l£ðtS, QtoVmðllDD !£S!S,
1Üå¬1Ü+
QðÌQðllDD,ö1~öV
QðSSlV££X!£DSlDD,V~V1
QðSSlV£ÍΣXlDD,öV~VÜ
QðSSlV£Îðl£tðÎtDlðllDD, V1~VZ
QðSSlV£D£UlðÎtolðllDD, VZ~Vå
QðSSlV£l£S!S,öV¬Vö
QOSl£DDtU tðw£tl£Sl, V¯~Vö
t0SlSl£U£Xl£DSlDD, ¯~¯ö,Vö¬V
t£SLvl£UÍl£XlDD, 7. V~1Ü
t£S5l£UÌðl£tðÌ tO!ðllDD, 1Ü1
SyDDVlðÌ lDlCK£DlD@,1ܯ
VðÎ@US l£Sl,Vå¬V+
VðtUSl£Sl, V9~V3
L
L.Ì£SlDDS, ¯ö
LðCDDðDl£S!,V¯
Lðl£tðÌ CDÌÎðlCtðÎ Îl@ðDUD!
Ì£SloDS, V+
QðÌQðIlDD,ö¯
DlQlUt£,V3
Íðl£tðÎ CDDUyΣ,ö¯
Lðl£tðÎCOtODJtyÎl@ðD£Dl, Vå
Lð!£tðΣQlCDDUyΣ,Zå,Z+, Z¯, ö¯
Lðl£tðÎÍ£DDtðÌCDDUyÌ£, ö1, öV
Lðl£tðΠͣDDtðÌ £QlCDDUyΣ,ö1, ö¯
Lðl£tðÎÍ£DDtðÎlDðD@Ì£,6
Lðl£tðÎ @ðSltmD£DlUS,8
Lðl£tðÎDðÌÎÐÎUS,1Ü~11Ü,11b
Lðl£tðÌ !lDlðÎ CDDUyΣ, ö1
Ll£tðÎ !lDlðÎ £QlCODUyl£, öZ
LðlÎSSlDUS UDtSl DUSCΣ
Î0lDDS,13
QðÎQðllDD,¯,ö
L£ðUQDlSDDlD@, M, 3å
L£SMtltmDðDl£t, ðVUÎSlDD ÍtðC!Ut0S,¯+
L£SMtlUDtOSlly{DÍ D£ðUDÍ
DUD£tUS),Z
LUDDðtSQlD£,bV
LUDðl£ DDD£
ðS£QllCD£CtOSlS, S
QðÎQð!lDD,+1
M
NðC1D!DSDSl£Sl,1Ü9
NCNUttðy l£Sl,1ÜJ1Ü
N£UlðÎCDÎÎðl£tðÌÌl@ðD£Dl
ðUD£SlDDS,VZ
DUt5l!lS,Vå
Ì£SlDDS,VZ
QðÎQð!lDD,8
SQtðlD, Vå
N£UlðÎCOtDDðty Îl@ðD£Dl,VZ
N£dlðΣQlCDDUyΣ, Z¯,ZV
N£UlðÎÍ£DDtðÌ CDDUyΣ, ö1, öV
N£UlðΠͣDDtðÌ !DðD@Σ{ltl@DDUD DÍ
hCðtQð),b3
N£UlðÎ@ðS!tmD£DlUS, 8
N£dlðÎ DðÌΣDÎUS,1Ü~11Ü, 11+, 11b
N£UlðÎ D£DlSCUS,lDQðC!£U, V+
N£UlðÎllDlðÌ CDDUyΣ,ö1
N£UlðD D£tV£,2 p, +3
ΣSlDDS, 3¯
N£DlSCUS
UlSQÎðC£d,VÛ
lDQðCl£U D£UlðÎ, V+
l£ðtS,QtDV0ð!lDD l£SlS,1Üó 1Û
N£!ðCtQOQDðÎðD@£ðÎ[DlD! CðQSUÌ£,
tUQ!ut£,3Z
NlUlðtSðÎ [DlDlS
ðtlDtlUS,1ZÜ
ðtlDtOSlS,1ZÜ
QðSSlV£ðDUUC!lDD, 1Z1
QðSSlV£ðUUUC!lDD,1Z1~1ZZ
QðSSlV£ UDtSl¡Î£XÎDD, 1ZÜ~1Z1
QðSSlV£QÌðD!ðt ÍÌ£xlDD, 1Z1
QðSSlV£QtODðllDD, 1ZZ
QðSSlV£SUQlDðllDD,1ZZ
QðSSlV£ !£S!S,1ZÜ~1ZZ
S!tðlD, 1ZÜ
NyDQð!Dy,1+
N
ÎðVlCUÎðt, 5mðQDDlU DD£
ΣUtðÎ@lC ðDyDltOQDy,1+
ΣUtOÎO@lCðÎ UlMðM, 3, 3å,5
INDEX 135
o
LDlUtð!Dt£Xl£DUS,7, ¯¯
LDlUtð!DtlDl£DUS, ¯
LΣCtðDDD
DUtSð, Zö
ÍtðClUt£, 3
QðÎQðllDD, Z¯,Zö
LQQOD£DS gÌÎlCÎS,3¯
Lt!DÎðDl´Sl£Sl, ¯V
p
lðÎDðt ðQOD£UtOSlS,+¯
lðÎDðtlD!£tOSMl,3ö¬^1
lðÎDðtlSÎDD@US
lDD£tVð!lDD,å¯,3å
QðÎQð!ÎDD, 3
l£DUDD, +¯
lð!£ÌÎð, QðÎQðllDD,öå
Íð!£ÌÌðt@tOV£,8
Íð!£ÌÎðtÎl@ðD£D! [lDÍtðQðl£ÎÌðt
!£DUDD),8, 8
Íð!£ÌÎðt!ðQ,1Ü>¬1Û
l£ClÎD£USDUSCΣ
lDD£tVð!ÎDD, ¯å,¯3, ¯
QðÌQð!lDD, b3, bb
l£C!DtðÎlS Dð[Dt DUSCΣ
ΣSlDDS,13
QðÌQð!lDD,¯, ö
tuQlUt£, 1å
Í£tOD£USDt£VlS
lDD£tVðllDD,1Zå,1Z+
QðÌQð!lDD,11Ü
l£tDD£USÎDD@US
lDD£tVðllDD, 1Zå, 1Z+
QðÌQðllDD, no
l£tDD£USl£tllUS
lDD£tVðllDD,1Zå,1Z+
l£DUDD, 11b
l£t!D£S´UlMðM,¯Ü, ¯ö
l£S ðDMttDUS,ö3
lDðΣD´S l£S!,b1
lltlÍDtDlS, ¯¯
llSlÍDtD DDD£, +1, 4, 4
llMDðDðl£Ìl@ðD£Dl, +ô
lÎðD!ðtlSDUSCÌ£
lDD£tVðllDD, 1Ü
QðÌQðllDD, 8
lDQÌll£ðÌ ðtl£ty,8
lDQÌll£ðÌ ÍDS5ð, öö¬öV
lDQÌll£ðÌ V£lD.öö
lDQÌll£USDUSCΣ,1Ü
lDQÌl!£US !£DUDD
ΣSlDDS, VZ
QðÌQðllDD,ö¯
lDS!£tlDt CðQSUÌ£, 9
lDSl£tlDt CtUClð!£Ìl@ðD£D!
ÎðXlly,Vå
ΣSlDDS,Vö
IUQlUt£,V+, V3
Copyrighted Material
136 INDEX
Posterior interossous nerve lesions,
57
Posterior suprior iliac spine, b
Posterior talofibular ligament
palpation, I13
squeezing, 126
Posterior tibial artery, 115
Pronator ter<' muscle
lesions, 35
palpation, 22-23, 30
Psoas
bursitis, 71
tendinitis, 74
Iubic tubercle, 64, 66
Q
Quadratus femoris
innervation, 75. ¯
palpation, b
Quadriccps extension. 8-
Quadriceps femoris
innervation. 78, V
lesions, 78
R
Radial artery. 48
Radial collateral ligament
palpation, 4
sprains, 51
Radial nerve lesions. 3, 36, 53, 56, 58
Radial tuberosity. avulsion fractures,
3
Radiohumeral joint line, 23
Radioulnar jOint
distal, see Distal radioulnar joint
lesions, 32, 33
Radius
distal epiphysis, periostitis, 5
dorsal tubercle, 41
neck, 23
palpation, 41
stylOid prs , 39, 41
Rectus abdominus tendon, 6
Rectus (emoris
innervation, 73
palp<tion, 6, 83
tendinitis, 74
Rhizarthrosis,52
Rib fractures, 13
Rotator cuff tendinitis, 9, 11, 16
s
51 palsies, ¯
52 palsies, 73, ¯
Sacroiliac joints, 6
inflamed, 74, 75
Sacroiliac ligaments, strained, 74, 75
S'crotuberous ligament, 67
Sartorius muscle
innervation, 73, 7, 10
lesions, 7
palpation, 63, 6, 65, 8
tendinitis, 74
Scaphoid (navicular) bone, 39, 40, 41,
4
periostitis,.
Saphoid tuberoSity, 114
Sapula, 2-3
Siatic nerve, 68
Scond metacarpal bone, 45, 47
Smimembranoslls
innervation, 77, 100
palpation, 68, 86, 88
Smitendinosus
innervation, 77, 100
palpation, 6, 88
Shoulder, 1-20
active test, 8-9
adductor muscle lesions, 13
anatomy, 1-
anterior capsule contraction, 10, 11
anterior drawer test, 19
apprehension tests, 17
arthritis, 9, 10, II, 12
arthrosis, 9, 10, 11
extracapsular lesions, 9, 10
functional eXamination, 8-20
instability, 10, 11,12
isometric contractions, 12-17
neurological conditions, 9, 14
painful impingement, 9
palpation, 1-
passive horizontal adduction, 17
passive tests, 9-20
posterior d ra wer test, 19-20
recurrent dislocation, 17
resisted abduction, 1�14
resisted adduction, 12-13
resisted exteral rotation, 14
resisted interal rotation, 14-15
soft tissue palpation, 3
Sinus tarsi, III
Spring ligament, 115
Subacromial bursitis, I I
Subcoracoid bursitis, 10
Subdeltoid bursitis, 9, 10, 12, 13, 14, 16
Subscapularis tendon
lesions, 10, 15
palpation, 5
rupture, 15
Subtalar joint
arthritis, 126
capsular lesions, 119
passive tests, 118-119
valgus movement, 119
varus movement, 118-119
Suprficial nexors, 6
Superior acromioclavicular ligament,
2
Supinator muscle
lesions, 3
palpation, 27
Suprapatellar tendon, 8
Suprascapular nerve, 14
Supraspinatus muscle
lesions, 11
palpation, 4
tendinitis, 13
tendon rupture, 13-14
Supraspinous fossa, 3
Sustentaculum tali, 114
T
T l nerve root lesions. 61
Talar head, 114
Talofibular ligament, thickened, 128
Talonavicular joint. 114
Talus, 110, 111
Tennis elbow, 3
Tenosynovitis, crepitating. 5, 57
Tensor fasciae latae muscle
innervation, 7, 76, V,10, 101
palpation,6
Teres major, 15
Thoracic wall lesions, 13
Thumb,5�57
resisted abduction, 5-57
resisted adduction, 57
resisted extension, 5
resisted nexion, 55-56
Tibia, 81
TIbial arter 89
TIbial crest, 81
TIbial nerve, 88, 89
TIbial tuberosity, 81
Tbial vein, 89
Tibialis anterior
innervation, 123, 125
tendon, 114, 116
Tibialis posterior
innervation, 123, 125
tendinitis, 126
tendon, 110. 114, 115
TIbiofibular ligament, 129
linel's test, 61
Transvers ligament, 45
Trapezium, 39-, 41,45
Trapezium-first metacarpal joint,
51-52
Grind test, 62
Trapezoid bone, 41
Triangular fibrocartilaginous complex
lesions, 51
Triceps muscle
lesions, 3
palpation, 28
rupture, 3
tendinitis, 17
tendon, 2
Triceps surae, 123, 125
Trigonum o( Sarpa, 65
Triquetra! bne, 41, 43
T rochanters
bursitis, 71, 7
Copyrighted Material
Trohanters (collld)
pain, 7
palpation.67-Q
Trohlear proC-SS, 110
Tubrcle of Gcrdy, 82
u
Ulna
palpation. 41
styloid proess, 41, 43
Ulnar arter 4
Ulnar coll.lteral ligament
lesions, 51
palpation, 28, 4
Ulnar nerve
lesions, 5, 57, 61
palpation, 27, 28, 4
v
Valgus strain, 93-94
Vars strain, 94-95
Vastus lateralis. 8
Vastus medialis, 8
w
Wrist
anatomy. 39-48
dorsal ganglion, 5
dorsal ligament lesions, 5
extensor tendon lesions, 5
flexor tendon lesions, S
forced flexion (Phalen's test), 61
functionaJ examination, 48-2
INDEX 137
ismetric contractions, 52-1
palmar ligament lesions, 5
palpation, 39
radial extensors
palpation, 24-26, 42-43
tennis elbow, 3
resisted extension, 3, 53-54
resisted flexion, 36-37, 52-53
resisted radial deviation, 54
resisted ulnar deviation, 54-55
Wrisljoint
arthritis, 50
arthrosis, 5
passive extension, 5
passive flexion, 5
passive radial deviation, 51
passive test, 49-51
passive ulnar deviation, 51
Copyrighted Material

ATLAS OF

C) rt h () I) C (j i ( Exanlirlati()n ()f tile rCri�)tlcral J()irlts
Many students learn the details of skeletal anatomy but then find it difficult to relate that knowledge to real human beings when they present for clinical examination and assessment. This atlas aims to fill the information gap between descriptive and palpatory anatomy and to help the student make the link between the two. It addresses the clinical appearance of normal tissues and their function, and provides guidance on how to examine and assess normal joints.

Key features

Introduces the basics of clinical examination Provides step-by-step guidance to the clinical assessment of the peripheral joints and their associated tissues and structures

Details the examination of the major joints of the body one by one: Shoulder/Elbow/Wrist/Hip/Knee/Foot and describes the normal findings in healthy individuals

Emphasizes the importance of performing diagnostic movements correctly Addresses the common mistakes in examination techniques and explains where people go wrong

Profusely illustrated with high quality photographs and diagrams Text design ensures that the illustrations appear close to the relevant text

This Atlas of Orthopedic Examination of the Peripheral/oints will provide an invaluable source of reference for medical students and members of all health care professions concerned with the management of orthopedic problems.

,I W. B. SAUNDERS I
Copyrighted Material

9 780702 021244

rlfrr if

12

Atlas of Orthopedic Examination of the Peripheral Joints

Copyrighted Material

IIIl1stratiolls by: Kevin Marks For W. 8. Sa"nders" Editorial Director. Health Sciences: Mary Law Head of Project Management: Ewan Halley Project Development Mallager: Dinah Thorn Sellior Desigller: Judith Wright Copyrighted Material .

B. London. Kanegem. SAUNDERS Edinburgh. New York. Toronto -1999 Copyrighted Material . International Lecturer in Orthopedic Medicine � W. Belgium. International Lecturer in Orthopedic Medicine Pierre Bisschop Physiotherapist specializing in Orthopedic Medicine. Philadelphia.Atlas of Orthopedic Examination of the Peripheral Joints Ludwig Ombregt MD Medical Practitioner in Orthopedic Medicine. Knesselare. Sydney. Belgium. 51 Louis.

photocopying. However. or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency. London WI P OlP. The authors and the publishers have. B. Note procedures. As new information becomes available. complies with the latest legislation and standards of practice. especially with regard to drug usage. mechanical. recording or otherwise. No part of this publication may be reproduced. as far as it is possible. stored in a retrieval system. or transmitted in any form or by any means. 90 Tottenham Court Road. without either the prior permission of the publishers (Harcourt Brace and Company Limited. First published 1999 ISBN 0 7020 2124 5 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library. changes in treatment. London NWI 7DX). taken care to ensure that the information given in this text is accurate and up-to-date. SAUNDERS An imprint of Harcourt Brace and Company limited C Harcourt Brace and Company Limited 1999 All rights reserved. Printed in China Copyrighted Material . Medical knowledge is constantly changing. readers are strongly advised to confiml that the infomlation. electronic.w. 24-28 Oval Road. equipment and the use of drugs become necessary. library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress.

Contents Preface vii Introduction 1. Elbow 21 39 ix 1 3. Knee 6. Hip 63 81 109 5. Wrist 4. Ankle and foot Index 131 Copyrighted Material . Shoulder 2.

providing criticism. During our courses in orthopedic medicine we are almost daily confronted by postgraduate students (both physiotherapists and doctors) who do not have practical knowledge in topo­ graphic. all pathological conditions and their conservative treatments are discussed thoroughly. who acted as an excellent adviser. The following figures have been taken from Ombregtj. physiotherapy and manual therapy as the basic tests for a good clinical evaluation of the jOint in question. A clinical diagnOSiS does not rely on the outcome of one single test but is made on the interpretation of a clinical pattern (the combined outcome of a set of clinical tests). Van de VeldeT both expertise and constructive Copyrighted Material .Preface This manuscript was developed as a manual for medical and physiotherapy students. and provides guidance on the examination and assessment of normal joints.mon mistakes'. Much to our regret we have to conclude that poorly conducted tests often give incorrect information and therefore lead to inaccurate diagnoses.passive and resisted movements) are accepted in orthopedic medi­ cine. This book focuses on the perfect technical execution of the movements. fts purpose is to fill the existing information and training gap between the descriptive anatomy and the pathology of the peripheral joints. and findings in normal subjects. We are particularly grateful to Dr Eric Barbaix. the study of the clinical appearance of normal tissues and their behav­ iour during manual examination seems to be a grossly neglected area of medical education. Teacher in Manual Therapy at the UniverSity of Brussels. A small section on 'common pathological situations' follows a discussion of the technical execution of the test.ter Veer Hj. We believe that our teaching experience may be of great help to the reader and therefore we have listed the errors students most frequently make in the section on 'com. Despite the fact that all clinical skills start with an under­ standing of the normal. This section could be confusing in that the described test is not meant to be the diag­ nostic procedure for the referred condition. We confined our­ selves to a discussion of the most important tests used in orthopedic medicine.surface and functional anatomy. They are relatively simple to perform and have a great inter-tester reliability. Acknowledgements We would like to thank colleagues who are teachers of Orthopaedic Medicine International (aMI) and who provided significant help. This book essentially addresses the clinical appearance of normal tissues and their function. The interpretation of patho­ logical findings and the building up of clinical patterns is not within the scope of this book.Bisschop P. The interested reader is referred to our clinical reference book A System of Orthopaedic Medicine published by Saunders in 1995.These tests (active. In this work.

1.20.5.4.1�.45-5.4.35. 5. 2.5. 3. 6.32. 4.24. London: 1.18. 5. 6.35. 5.18-1.6. 3.22-4.19-2.8-2.4.4.18.14-2.13.4.11. 6.43. W B Saunders. 2. 3. 3.6. 6. 2.34.23. 2.18. 4.24-{..36. 3.11.15.20.16.5.16.16.vIII PREFACE 1995 A system of orthopaedic medicine.1999 Ludwig Ombregt Pierre Bisschop Copyrighted Material .16--4.14.5.21-5.4.3. 3.8-1. Kanegem-Tielt.27-3. 2.60.16. 3. 2.43.12.6. 3. 3.6-5.24-2.4.1. 3. 2.3.14.21.4. 3.50.12.10.11.

it is a 'contractile tissue'­ whereas all the other structures do not possess this capability . limited or excessive). The normal amplitude differs from the theoretical range of motion. Copyrighted Material . It acts either as an isolated structure or as part of a group of structures. Does it allow a normal range of motion? If not. he is also informed about the integrity of the musculo­ tendinous apparatus. It does not follow the principle of 'testing by selective tension': a lot of structures are put under stress. Function differs. The techniques are based on the principle of 'selective tension'. Contractile structures can be tested ( = Passive movements A passive movement brings a joint to the end of the normal range. the end-feel will have changed. but also about the structures that stop the movement from going further. From the technical point of view the examiner should position him or herself in such a way that the movemet can be executed over the entire pOSSible range of motion and can be brought to the end of the range in order to test the end­ feel. It may be necessary to fixate the subject's body or part of the subject's limb in order to avoid parasitary movements that would give rise to an incorrect answer. Passive movements are good tests to examine the inert structures and give an answer to the following questions: a. structures). b. Each tissue of the body has its particular function. but the movement is usually stopped as a result of tension in the capsulo-Iigamentous structures. to control range of movement facilitate (capsulo-ligamentous (nerve structures). to movement (bursae) or to activate movement put under tension) by provoking a maximal isometric contraction. This happens by assessing the end-feel of a movement which can be either elastic (capsular). hard (bony or ligamentous) or soft (tissue approximation). pain may be elicited and / or the range may have diminished. Active movements An active movement is performed as far as it may go. Articular surfaces allow a certain amount of movement.Introduction The purpose of examination and / or testing pro­ cedures in orthopedic medicine is to examine the f"nc/ion of the different tissues of the moving parts. The movement therefore not only informs the examiner about the normal range. Inert structures are tested by putting them under maximal stretch.they are 'inert'. The examiner not only gets an idea of the pOSSible range of motion in the joint (normal.depending on whether a tissue is built to make other tissues move (musculo-tendinous structures). The musculo-tendinous unit has the inherent capability to contract . Does the inert structure function normally? If not.

It informs the examiner about the normal strength of the contraction. Edinburgh Ombregt L. and the subject is asked to perform a contraction with maximal strength. Churchill Livingstone. The examiner should position him or herself in such a way that he or she is stronger than the subject: the only way to execute the movements Further reading Daniels L. It should be executed in an isometric way. The joint is brought into the neutral position. When a lesion in one of these parts is present. Churchill Livingstone. the body of the tendon and the insertion onto the bone. Saunders. Diminu­ tion of strength is the result of either a rupture or of a problem with the nervouS system activating the muscle. allowing the inert tissues to relax. thereby holding the joint in the neutral position: this puts strain on the contractile tissue but leaves the inert structures unattended. Saunders. Resisted movements test the contractile struc­ ture: the whole of the muscle belly. London Kapandji I A 1987 The physiology of the joints. The correctness of the technical execution of the tests guarantees the correctness of the answer. The test activates certain muscles or muscle groups in an isometric way. tcr Veer H. The examiner resists the movement. Bisschop P. Edinburgh Copyrighted Material . Van de Velde A 1995 A system of orthopaedic medicine. the musculo­ tendinous junction. (� different muscles with the same function). London Petty N}. Moore A P 1998 Neuromusculoskeletal examination and assessment: a handbook for therapists. He or she therefore puts his or her hands in such a way that one hand exerts pressure while the other gives counter­ pressure.x INTRODUCTION Resisted movements A resisted movement is meant to test the muscular tissue only. Worthinghaus C 1995 Muscle testing. the contraction will result in pain with or withour weakness. vol I. thereby not allowing any articular movement at all.

Its medial part is convex and the lateral third is concave.1 Anterior view of the shoulder (in vivo).CHAPTER CONTENTS Surface and palpatory anatomy Bony landmar1<s 1 Palpation of soft tissue 3 1 Shoulder Functional examination of the shoulder 8 Active test 8 Active elevation 8 Passive tests 9 Passive elevation 9 Passive external rotation 10 Passive external rotation with the shoulder in 90° abduction 10 Passive internal rotation 11 Passive glenohumeral abduction 12 Isometric contractions 12 Resisted adduction 12 Resisted abduction 13 Resisted external rotation 14 Resisted internal rotation 14 Resisted flexion of the elbow 15 Resisted extension of the elbow 16 Specific tests 17 Passive horizontal adduction 17 Apprehension test In external rotation 17 Apprehension test in internal rotation 17 Anterior drawer test 19 Posterior drawer test 19 SURFACE AND PALPATORY ANATOMY The shoulder is inextricably bound up with the shoulder girdle. Its medial end (sternal end) is bulbous and articulates with the sternum. anteriorly via the clavicle and at the posterior aspect via the scapula.1 and 1. 1 Copyrighted Material . Bony landmarks Anterolateral (Figs 1. The lateral end is flattened and articulates with F Fig. 1.2) The clavicle (A) is the most prominent bone and is easily detectable because it lies subcuta­ neously. These two bony structures are easily detectable landmarks to start the palpation of the shoulder structures.

Palpate this bone and feel for its lateral border . This indentation is the anterior end of the acromioclavicular joint.the clavicle and the acromjon .it lies on the acromio­ clavicular joint of which the upper part of the capsule is reinforced with the superior acromio­ clavicular ligament. Fig. Posterolateral (Figs 1. Palpate the anterior aspect of the clavicle and continue further laterally until the acromial end (C) is felt. This intertubercular sulcus is palpable with the thumb placed flat on it and during rotatory move­ ments of the humerus. At the lateral aspect of the sulcus a greater tubercle can be palpated. This is the greater tuberosity (F).4) the scapula's acromion (B) which can be recog­ nized as a flat bone overlying the shoulder joint. Just lateral to this border lies the bicipital groove that contains the long head of the biceps. By moving the palpating finger on top of the shoulder the acromial end of the clavicle can be felt to lie slightly higher than the acromion. This is the lesser tuberosity (E) of the head of the humerus. of which only the tip and the medial surface are palpable. Feel D --/'- Fig. They form the points of origin for the short head of the biceps brachii muscle and for the coracobrachialis muscle respectively. When moving the palpating finger upwards a depression can be felt before the lateral border of the acromion is reached. Just lateral to it a small indentation is palpable before the clear anterior border of the acromion is reached.3 and 1. use the subject's forearm as a lever and rotate the humerus laterally until the medial lip of the sulcus hits the thumb.2 Anterior view of the shoulder (skeleton). Place the finger on the coracoid process and go 1 cm down. To define the bicipital groove. 1. It has a very prominent spine (B) that is easy to palpate. 1. This is the scapula's coracoid process (D).3 View of the shoulder from above. then rotate the arm mediaJly until the lateral lip catches the thumb. When the finger lies in contact with the two bones . In the infraclavicular fossa just below the concave lateral part of the clavicle a bony promi- The scapula (A) is the most important bone at the posterior side of the thorax. Copyrighted Material .2 ATLAS OF ORTHOPEDIC EXAMINATION nence can be felt.the medial lip of the intertubercular sulcus. Now move the finger laterally until a sharp bony structure is reached.

between the clavicle and acromion. The acromio­ clavicular joint line joins these two points.6). respectively. and the posterior portion (C) builds the posterior aspect of the shoulder and covers the lateral part of the spine of the scapula.5). Together with the acro­ mial end of the clavicle and the coracoacromial ligament it forms the coracoacramial roof. 1.before it forms the acromion (D).6 Lateral view of the shoulder (in vivo). The spine divides the scapula into a supra­ spinous fossa (E) and an infraspinous fossa (F). Place the subject sitting with the arm in 90° abduction and palpate in the supraspinous fossa in a lateral direction. It forms the most important muscular mass of the shoulder and is responsible for its round look (Fig. At this point lies the posterior aspect of the acromioclavicular joint (G) (Fig. The anterior portion (A) overlies the anterior border of the acromion and the lesser tuberosity. c Fig.SHOULDER 3 Fig. for the posterior margin of the spine and follow this further laterally where it becomes more prominent. The middle portion (B) lies over the lateral border of the acramion and the greater tuberosity. Place the thumb at this point and pal­ pate simultaneously for the anterior indentation The deltoid muscle is easy to recognize. Copyrighted Material . 1. The spine can be felt to make a 90° forwards turn . The spine of the scapula is felt to meet the clavicle. 1.5 Palpation of the supraspinous fossa (shoulder in abduction). 1.4 Posterolateral view of the shoulder (skeleton). in which lie.the acromial angle (C) . the supraspinatus and the infraspinatus muscle bellies. 1. Palpation of soft tissue Palpation of the deltoid muscle Fig.

Insertion on the greater tuberosity. 1. 1. Palpate for the lateral border of the acromion. Exert a pres­ sure vertically downwards against the humerus. The examiner looks for the spine of the scapula and palpates below it. Palpate for the spine of the scapula. The examiner stands behind the subject. Also look for the acromioclavicular joint and keep the palpating finger lateral to it.4 ATLAS OF ORTHOPEDIC EXAMINATION Flg. follow it in the anterior direction until the corner is felt between the lateral and anterior border and identify the latter. 1.9). A groove (D) (Fig. The finger now lies on the supraspinatus tendon of which the medial border can be felt quite clearly (Fig. Palpation of the Infraspinatus muscle (Fig. The subject sits with the arm in full abduction and rested on the couch. The subject therefore leans towards the shoulder to be palpated.8 Palpation of the musculotendinous junction of the supraspinatus.7) can be palpated between the anterior and middle portions of the deltoid. The upper arm should be kept vertical and in slight adduction. which can be felt to continue laterally under the acromion (Fig. This results in some external rotation of the shoulder as well. Now position the subject with the forearm behind the back. The subject is in prone lying and rests on the elbows. This overlies the bicipital groove. in the infraspinous fossa. Move the palpating finger more laterally until it reaches the corner formed between the clavicle and the spine of the scapula. The thumb now lies on the infraspinatus muscle belly. The trapezius muscle is well relaxed and palpation can be performed through that muscle. With the hand he grasps the edge of the couch. Palpation of the supraspinatus muscle Muscle belly and musculotendinous junction. This is the infraspinatus tendon. It fills up the supraspinous fossa.10).7 View of the deltoid muscle (during contraction). The arm is now in full internal rotation. The finger now Hes on the musculotendinous junction of the supraspinatus. Ask the subject to abduct the arm against resistance. 1. 1. 1. The muscle belly lying just above the spine of the scapula is the supraspinatus muscle. Move the finger forwards so that it comes to He on the Fig. Place the thumb just under the spine of scapula and palpate more and more laterally.8). Copyrighted Material . A tendon will be felt that runs parallel to this spine. The elbow now lies on the same level as the shoulder. greater tuberosity of the humerus but is still in contact with the acromion as well.

1. The subject is in a half lying position on a couch. can easily be palpated. Palpate more later­ ally until the thumb lies on the greater tuberosity. the upper arm along the body and the elbow flexed to 90°. The examiner grasps the Copyrighted Material . It can be followed until the attachment on the greater tuberosity is found. This is the insertion. The tendinous structure cannot be felt any more. The tendinous insertion on the lesser tuberosity. The bone can be felt through the tendinous mass. Palpation of the subscapularis tendon Fig.SHOULDER 5 Fig.10 Palpation of the tenoperiosteal junction of the infraspinatus. It cannot really be palpated. The subscapularis muscle belly can only be reached by bringing the hand in between the scapula and the thorax. however. 1.9 Palpation of the tenoperiosteal junction of the supraspinatus. Come back to the previous point where both bone and tendon are felt.

1. lt now Lies on the insertion of the subscapularis tendon. The two tendons can be felt snapping away. The lateral and medial lips can be felt catching against the thumb. Move the thumb upwards until the upper part of the groove is reached. on the one hand. insertion of the subscapularis muscle.11 Pushing the tendons of the short head of biceps and of coracobrachialis medially. because the insertion is partly covered by. 4. which is situated more laterally than is usually supposed. 1. ldentify the intertubercular sulcus by placing the thumb flat on it and by executing small rotatory movements of the humerus. Push the muscular mass forwards.6 ATLAS OF ORTHOPEDIC EXAMINATION Fig.11). flex the thumb and come back towards the lesser tubero­ sity. Turn the thumb so that its tip lies in the direction of the xiphOid process of the sternum (Fig. (Fig. At the same time. They now lie medially to the thumb. Palpation of the long head of bicepr. In this groove lies the tendon of the long head of biceps. deltoid fibres have been drawn Sideways and lie laterally to the thumb. the anterior portion of the deltoid muscle. Fig. 1.12 Palpation of the subscapularis (upper part).13). biceps tendon. on the other hand. running in the direction of the acromion. t Place the finger in the groove between the anter­ ior and middle portions of the deltoid muscle. The contact is not direct. just below the acromion. Move the finger anteriorly and distally. which now is in direct contact with the subscapularis insertion (Figs 1.14) 2 3 4 Fig. 2 and 3. It now lies on the bicipital groove. Place the thumb of the other hand on the lesser tuberosity of the humerus. the tendons of the short head of the biceps and of the coracobrachialis.12 and 1.13 Anterior view of the shoulder: 1 glenoid insertion of the biceps. It is difficult to palpate as it is covered with a transverse ligament. 1. both running towards the coracoid process and. 1. subject's hand and brings the shoulder into a few degrees external rotation. Ask for Copyrighted Material .

15 major. Palpation of the muscle belly of the pectoralis (Fig.16) The lateral aspect of the latissimus dorsi muscle builds the posterior border of the axilla. 1. an active flexion of the elbow and resist the movement. 1. Palpation of the latissimus dorsi muscle (Fig. Its insertion lies anteriorly at the crest of the lesser tuberosity. Palpation of the pectoralis major muscle Fig. Tightening of the tendon can be felt.16 Palpation of the axillar part of the latissimus dorsi. 1. Copyrighted Material . The tendon inserts at the crest of the greater tuberosity. just below the lateral border of the bicipital sulcus. 1.14 Palpation of the long head of biceps in the sulcus. especially during resisted adduction of the arm.15) The lateral aspect of the pectoralis major muscle forms the anterior border of the axilla where its inferior border can be palpated very well.SHOULDER 7 Fig. It is felt to contract during resisted adduction of the arm. 1. Fig.

Ask the subject to bring up both arms Sideways as high as possible (Fig. FUNCTIONAL EXAMINATION OF THE SHOULDER Introduction/general remarks Shoulder lesions give rise to pain felt mostly in the proximal part of the upper limb. forming the posterior border. Common mistakes: • The movement is not performed to the very end of the possible range. the tendon of the short head of biceps (B). • The arms are kept in internal rotation. Ask him to press the arm downwards and resist this movement. 1. The subject stands with the arms hanging alongside the body.8 ATLAS OF ORTHOPEDIC EXAMINATION ACTIVE TEST Active elevation POSitioning.18 Active elevation of the arm. forming the anterior border of the axilla. Palpation of the axilla Bring the subject's arm into 90° abduction. Copyrighted Material . The examiner stands behind. which makes full movement impOSSible.18). and the latissimus dorsi (D). The movement is started by the supraspinatus muscle and continued by the Flg. However. 1.17 Anterior view of the axilla. During palpation in the antero­ posterior direction the following structures can be identified (Fig. The shoulder examination is therefore commonly used in the diagnosis of upper arm pain. Normal functional anatomy: • Ral/ge: 180° • Structures il/ualued: Many structures are committed. the upper thoracic spine and the shoulder girdle.17): pectoralis major (A). the coraco­ brachialis muscle (C). 1. Fig. 1. Procedure. the examiner should realize that symptoms in the region of the shoulder can also originate from the cervical spine. The examination of the shoulder is to be considered as an element in the diagnostic procedures for lesions of the upper quadrant. • The arms are brought up in a sagittal plane.

Normal functional anatomy: • Rallge: 1800 • Elld-feel: elastic • Limitillg structures: . Take the arm up sideways in the frontal plane as far as possible. • The movement is stopped before the end of the possible range is reached. as well as in acromjoclavicular lesions. Rotation of the scapula is done mainly by the serratus anterior muscle. It also gives an idea of the patient's willingness to cooperate. The subject stands with the arms hanging alongside the body.SHOULDER 9 middle portion of the deltoid and by the long head of biceps. especially towards the end of range.19 Passive elevation of the arm. subscapularis. Pain at mid-range may indicate a structure in between the humeral head and the coracoacrormal arch . • The arm is not allowed to externally rotate. The examiner stands behind the subject and takes hold of the elbow at the distal part of the upper arm. Allow some ex­ ternal rotation about 900 of abduction. Reaching the end of range. • • PASSIVE TESTS Passive elevation POSitioning. Copyrighted Material . Flg. Meaning. and the sternoclavicular and acromioclavicular ligaments.the adductors and internal rotators of the shoulder . long head of biceps.being painfully pinched.stretching of the acromioclavicular and sternoclavicular ligaments .either one of the tendons of supraspinatus. Common mistakes: • When the arm is grasped distally to the subject'S elbow. This a very non-specific test. Lnsufficient counter-pressure results in the subject Side-flexing the body. Limitation with or without pain occurs in shoulder arthritis or arthrosis. infraspinatus. supported by the trapezius muscle. The patient often avoids painful impingement by adding an anterior component over part of the movement. such as the capsule of the glenohumeral joint.1.the axillary part of the joint capsule . give counter-pressure with the other hand at the subject's opposite shoulder (Fig. The movement also stretches and/ or squeezes several structures. or the subacromial bursa or inferior acromio­ clavicular ligament . Procedure. which is almost always disturbed when a shoulder or shoulder girdle pathology is present. elbow movement prevents assessment of end-feel. 1.contact between the lesser tuberosity of the humerus and the upper part of the glenoid labrum. Common pathological situations: • The movement can be painful in subdeltoid bursitis and in rotator cuff tendinitis. At the end of range the arm is taken backwards in a sagittal plane. the subdeltoid bursa.19). in certain extra­ capsular lesions and in some neurological condi­ tions causing weakness of the shoulder elevators.

. Common pathological situations: • Pain on full passive external rotation is one of the first signs of shoulder arthritis. until the movement comes to an elastic stop (Fig. Common mistakes: o The shoulder girdle is not well enough fixed so that trunk movement is allowed to happen. Normal functional anatomy: o Rallge: 90° o Elld-Jeel: elastic Fig. o Excessive range may indicate shoulder instability. If the movement is too painful the patient will move the body backwards. The examiner stands level with the sub­ ject's arm. 1. The examiner stands level with the subject's arm and stabilizes the elbow with his trunk. Depending on the condition being either acute or chronic. One hand is placed on the contralateral shoulder to stabilize the shoulder girdle and trunk.20 Passive external rotation test for the glenohumeral joint. Procedure. meanwhile assuring the vertical position of the humerus.the anterior part of the joint capsule Copyrighted Material .contact between the greater tuberosity of the humerus and the posterior part of the glenoid labrum. Procedure. o The movement is markedly limited as part of a capsular pattern of limitation of movement in moderate or more advanced arthritis.the internal rotator muscles of the shoulder . • Isolated limitation occurs in contracture of the anterior capsule and in subcoracoid bursitis.the anterior portion of the joint capsule . o The elbow is not well stabilized so that shoulder abduction or extension occurs. Passive external rotation with the shoulder in 900 abduction Positioning. Normallunctional anatomy: o Rallge: 90° o Elldleei: elastic • LimitiHg structures: Passive external rotation Positioning. The subject stands with the arm hanging alongside the body and the elbow flexed to 90°. 1. o The movement is not performed to the end of the possible range. the end-feel will be either of muscle spasm or hard. Put the shoulder into external rota­ tion. The subject stands with the upper arm alongside the body and the elbow flexed to a right angle. The other hand grasps the distal forearm.20). and squeezes the subdeltoid bursa. Rotate the arm outwards. The contralateral hand takes hold of the elbow and brings the arm into 90° of abduc­ tion. • Limiting structures: . the other takes hold of the distal forearm.10 ATLAS OF ORTHOPEDIC EXAMINATION • LimHation occurs in arthritis and arthrosis of the shoulder and in serious extracapsular conditions. meanwhile stabilizing the elbow (Fig.21). Common mistakes. 1. External rotation also stretches the acromioclavicular ligaments and the subscapularis tendon.

the adductors and internal rotators of the shoulder. • The elbow is pulled backwards. . • Pajn at mjd-range may occur in rotator cuff tendinitis or in subacromial bursitis. Bring the subject's forearm behind her back and move her hand away from her body as far as possible (Fig. the other takes hold of the distal forearm. Common mistakes: • The shoulder is held in too much abduction.22 Passive internal rotation test for the glenohumeral joint. Common pathological situations: • Pain at the end of range may occur in lesions of the infraspinatus and supraspinatus tendons. Common pathological situations: • The movement is limited in arthritis and arthrosis of the shoulder and also in isolated contracture of the anterior part of the joint capsule. • The hand is moved upwards instead of backwards. Fig. Normal functional anatomy: • Rallge: 90° • Elld-feel: elastic • Limiting structures: Passive internal rotation Positioning.SHOULDER 11 Fig.22).contact between the lesser tuberosity of the humerus and the anterior part of the glenoid labrum of the scapula. 1. The subject stands with the upper arm alongside the body and the elbow flexed to a right angle. Procedure. which creates an extension of the shoulder instead of internal rotation.the posterior part of the joint capsule . . Copyrighted Material .21 Passive horizontal external rotation. 1. • Excessive movement may be present in shoulder instability.the external rotator muscles of the shoulder . The examiner stands level with the subject's arm and stabilizes the elbow with his trunk. and also of the acromioclavicular ligaments. One hand is placed on the opposite shoulder to stabilize the shoulder girdle and trunk. 1.

23). Procedure.24). Procedure.contact between the greater tuberosity and the upper part of the glenoid labrum. The scapula can also be stabilized by placing one hand upon the acromion. One hand takes hold of the elbow. Abduct the arm slowly. l. The examiner stands level with the subject's arm. Common mistakes: • The scapula is not stabilized sufficiently. l. Resist the subject'S attempt to adduct her arm (Fig. Common pathological situations: • The movement is limited in shoulder arthritis. ISOMETRIC CONTRACTIONS Resisted adduction Positioning. just above the joint. • It may also become restricted in acute subdeltoid bursitis.the axillary part of the jOint capsule .12 ATLAS OF ORTHOPEDIC EXAMINATION • • More or less limitation is found as part of a capsular pattern of limitation of movement in moderate and severe arthritis. 1. The examiner stands level with and behind the subject's arm. Normal functional anatomy: • Range: 90· • Elld-feel: ligamentous • Passive glenohumeral abduction Positioning. Flg.Altemative technique: When the lower angle of the scapula cannot be stabilized. meanwhile preventing the scapula from moving (Fig. The subject stands with the upper arm alongside the body. the lateral margin may be used.23 Passive scapulohumeral abduction test for the glenohumeral joint. End of range is reached when the scapula can no longer be stabilized and starts to slip under the thumb.1. Limiting slructures: . He places one hand against the ipsilateral hip and the other hand against the inner aspect of the elbow.24 Resisted adduction of the shoulder. The subject stands with the arm hanging and slightly abducted. The thumb of the other hand is placed against the lateral aspect of the lower angle of the scapula. Excessive range may indicate shoulder instability. • Movement is not performed to the end of the possible range. Copyrighted Material . . Fig.

but may also occur in subdeltoid bursitis.(C6) (C6).SHOULDER 13 Common mistakes: • The elbow is allowed to flex.25 Resisted abduction of the shoulder. (C6) CS. (ce) C5-Ce CS.(C6) C5-Ce Common mistakes. 1. Anatomical structures tested: Muscle function: • III/portallt addllctors: • Pectoralis major Latissimus dorsi Teres major Teres minor Long head of triceps brachii Short head of biceps brachii Clavicular part of deltoid Spinal part of deltoid. The subject stands with the arm hanging and slightly abducted.25). 1.C6 CS. He places one hand against the opposite hip and the other hand against the outer aspect of the elbow. • Movement is allowed at the shoulder.Supraspinatus • Less ill/portallt abductors: .Deltoid . • Weakness occurs in severe C7 nerve root palsy.C6 Common pathological situations: • Pain is usually the result of a supraspinatus tendinitis. . more rarely of a lesion of the deltoid. C5-Ce (C6). (C6) es. Procedure. Movement is allowed at the shoulder. Less ill/portallt adductors: - Neural function: Muscle Peripheral Pectoralis major latissimus dorsi Teres major Teres minor Triceps brachii Biceps brachii Deltoid spinal part davicular part Pectoral Thoracodorsal Subscapular Axillary Radial Musculocutaneous Axillary Axillary Pectoral Innervation Nerve root Fig. • Weakness occurs in total rupture of the Copyrighted Material . (C6) C5. The examiner stands level with the subject's arm. C7. CS.(C6) CS. • Painful weakness is perceived in rib fractures and more rarely in a rupture of the pectoralis major muscle. Anatomical structures tested: Muscle function: • Important abductors: Common pathological situations: • Pain suggests a lesion in one of the adductor muscles or in the thoracic wall.Long head of biceps brachii. Resist the subject's attempt to abduct the arm (Fig. C7. Neural function: Muscle Peripheral Deltoid Supraspinatus Biceps brachii Axillary Suprascapular Musculocutaneous Innervation Nerve root Resisted abduction Positioning.

Common mistakes: • The shoulder is allowed to abduct. The examiner stands level with the subject's arm. Ask the subject to keep the elbow against the trunk and resist the attempt to push the hand laterally (Fig.g. the suprascapular nerve or the C5 nerve root. 1. The examiner stands level with the sub­ ject's arm. Common mistakes.26 Resisted external rotation of the shoulder. into abduction or by extending the elbow. The forearm is held in the sagittal plane. The subject stands with the upper arm against the body and the elbow flexed to a right angle. Painful weakness is indicative of a recent partial rupture of the supraspinatus tendon. The forearm is held in the sagittal plane. neuralgic amyotrophy. Copyrighted Material . Fig. • Weakness indicates a total rupture of the infraspinatus tendon or a neurological condition. e.26). C5 nerve root palsy. He places one hand on the opposite shoulder and the other hand against the inner and distal aspect of the forearm. The subject stands with the upper arm against the body and the elbow flexed to a right angle. He places one hand on the opposite shoulder and the other hand against the outer and distal aspect of the forearm. 1. so keeping the shoulder in a neutral posi­ tion.Teres minor - Less importallt extenlOi rotators: - Spinal part of deltoid. such as lesions of the axillary nerve. Neural function: Muscle Peripheral Infraspinatus Teres minor Oeltoid Suprascapular Axillary Axillary Innervation Nerve root e5. • Movement is allowed at the shoulder. The subject tends to execute the test wrongly either by bringing the shoulder • Illfraspinatus . • Painful weakness is the result of a partial rupture of the infraspinatus tendon. Procedure. which he supports. so keeping the shoulder in a neutral posi­ tion. Resist the subject's attempt to pull her hand towards her (Fig. supra­ scapular nerve palsy.27).(eGI e5. Bilateral weakness is suggestive of myopathy. Resisted internal rotation Positioning.(eG) Common pathological situations: • Pain occurs in infraspinatus tendinitis but may also be present in subdeltoid bursitis.14 ATLAS OF ORTHOPEDIC EXAMINATION • supraspinatus tendon or in neurological conditions. Procedure.(eG) e5. espe­ Cially when weakness is present. 1. Anatomical structures tested: Muscle function: • Important exterllai rotators: Resisted external rotation Positioning.

the elbow bent to a right angle and the forearm in full supination. Copyrighted Material . and more rarely of the teres major. One hand is on top of the shoulder and the other on the distal aspect of the forearm. • Isolated weakness occurs in total rupture of the subscapularis tendon. Anatomical structures tested: Muscle lunction: • importallt i"terHal rotators: • - Subscapularis Pectoralis major Latissimus dorsi Teres major Less importallt illternal rotators: Long head of biceps brachii .C7.C6 C5-C8 Fig.28).28 Resisted flexion of the elbow. Fig. Procedure. The examiner stands level with the subject's hand. pectoralis major or latissimus dorsi tendons or muscles. The subject stands with the arm alongside the body. 1. Resisted f lexion of the e lbow Positioning.(C8) C5-C8 CS.27 Resisted Intemal rotation of the shoulder. 1. 1.SHOULDER 15 Common pathological situations: • Pain is the result of a lesion of the subscapularis.Clavicular part of deltoid Neural function: Muscle Penpheral Subscapularis Pectorahs major Latissimus dorsi Teres major Biceps brachii Deltoid clavicular part Pectoral Subscapular Pectoral Innervation Nerve root Thoracodorsal Subscapular Musculocutaneous C5-C8 C5-C8 (C6). Resist the subject's attempt to flex her elbow (Fig.

Movement is allowed at the elbow.16 ATLAS OF ORTHOPEDIC EXAMINATION Common mistakes: • The subject shrugs up the shoulder in the hope of exerting more strength.Brachioradialis. • Weakness is the result of either a C5 or a C6 nerve root lesion. • Less important extensor: - Resisted extension of the elbow Positioning. flexion cannot sufficiently be resisted if the resistance is not given perpendicular to the subject's forearm. Neural function: Muscle Peripheral Brachiatis Biceps brachif BrachioradiaHs Musculocutaneous (radial) Musculocutaneous Radial Innervation Nerve root C5--C6 C5-C6 C5-C6 Fig. Copyrighted Material . Procedure. • In strong subjects. Common pathological situations: • Pain in the region of the shoulder occurs when a lesion is present in either the long head or the short head of biceps. Resist the subject's attempt to extend the elbow (Fig. The examiner stands level with the subject's forearm. 1. One hand is on top of the shoulder. Common mistakes: • • Neural function: Muscle Peripheral Triceps brachil Anconeus Radial Radial Innervation Nerve root C7-C8 C7--C8 Extension is allowed at the shoulder. Anatomical structures tested: Muscle function: • Imporlalll flexors: Brachialis .Biceps brachii - • Less important flexor: . 1. Anatomical structures tested: Muscle function: • Most importn1Jt extellsor: - Triceps brachii Anconeus.29). This happens in subdeltoid bursitis or in tendinitis of one of the tendons of the rotator cuff. Common pathological situations: • Pain elicited in the shoulder region is the result of the humerus being pulled upwards against the acromial arch and pinching an inflamed subacromial structure. The subject stands with the arm alongside the body and the elbow bent to a right angle with the forearm in supination. • Movement is allowed at the elbow. the other on the distal aspect of the forearm.29 Resisted extension of the elbow.

30 Passive horizontal adduction of the shoulder. This test stresses the acromioclavi­ cular and sternoclavicular joints and ligaments. the arm in slight abduction and the forearm behind the back. The examiner stands level with the subject's arm.31). SPECIFIC TESTS Passive horizontal adduction Significance. meanwhile exerting an anter­ ior pressure on the humerus with the thumb (Fig.32).SHOULDER 17 • • Pain on extension more rarely indicates triceps tendinitis. The examiner sits level with the subject'S shoulder. so recognizing her symptoms. The subject lies supine with the arm alongSide the body and the elbow flexed to 90°. The test is performed to detect recurrent anterior dislocation of the shoulder. The subject sits on a chair. The examiner sits level with the subject's shoulder. Repeat this test in different degrees of abduction. 1. pressing the elbow towards the contralateral shoulder (Fig. It also squeezes the subcoracoid bursa and the upper part of the insertion of the subscapularis tendon into the lesser tuberosity of the humerus. One hand is on the subject'S shoulder with the thumb anteriorly and the fingers posteriorly against the humeral head. 1. Common mistakes. The other hand grasps the forearm. Weakness is usually the result of a C7 nerve root palsy. POSitioning. The subject's shoulder girdle is not well stabilized so that she may twist away from the pressure. Procedure. One hand is on the subject's shoulder with the fingers anteriorly and the thumb poster­ iorly against the humeral head. The test is perfornled to detect re­ current posterior dislocation of the shoulder. POSitioning. Bring the subject's arm into slight abduction and futl internal rotation and exert a posterior pressure to the humerus with the thumb (Fig. Positioning. The other hand takes hold of the forearm. The test is positive when the patient gets the feeling that the shoulder moves out of place. Procedure. Bring the subject's arm into full external rotation. The other hand is placed at the back of the other shoulder. Procedure. 1. The test is positive when the patient gets the feeling that the shoulder moves out of place. Apprehension test in external rotation Significance.30). Fig. One hand grasps the elbow at the distal part of the upper arm. The subject stands with the arms hanging alongSide the body. so recognizing her symptoms. 1. Take the arm into abduction first and then bring it horizontally in front of the body. Apprehension test in internal rotation Significance. Copyrighted Material .

Copyrighted Material . 1. 1. Fig.18 ATLAS OF ORTHOPEDIC EXAMINATION Fig.32 The apprehension test for recurrent posterior dislocation.31 The apprehension test for recurrent anterior dislocation.

1. the hand of which grasps the humerus in the axilla (Fig.SHOULDER 19 Anterior drawer test Significance. Copyrighted Material . Posterior drawer test Significance. This test is meant to detect anterior hypermobility in the glenohumeral joint. The humeral head is first brought into its neutral position in the glenoid fossa ('loaded') and then glided in the anterior direction.33). Fig. 1. Procedure. The forearm is squeezed between the examiner's trunk and the ipsilateral arm. He stabilizes the scapula with the contralateral hand. The arm is brought into about 20° of abduction and into slight flexion. the thumb of which is placed on the coracoid process and the fingers on the acromion. The subject lies supine on the couch with the arm beyond the edge. This test is meant to detect posterior hypermobility in the glenohumeral joint. Positioning.33 The anterior drawer test. The examiner stands level with the shoulder.

the thumb of which is placed on the coracoid process and the fingers on the acromjon. the hand of which grasps the humerus in the axilla (Fig. The arm is brought into about 20° of abduction and into slight flexion. He stabilizes the scapula with the contralateral hand. Copyrighted Material . The humeral head is first brought into its neutral position in the glenoid fossa ('loaded') and then glided in the posterior direction and slightly laterally. The forearm is squeezed between the exammer's trunk and the ipsilateral arm. Positioning. The examiner stands level with the shoulder. 1. Procedure. 1. The subject lies supine on the couch with the arm beyond the edge.20 ATLAS OF ORTHOPEDIC EXAMINATION Fig.34).34 The posterior drawer test.

3 and Fig. Medial to the tendon its aponeurosis (6) can be felt. Just below it and deeply through the muscles of the anterior and upper part of the forearm. A) as an outstanding taut structure. 2.2. 2. and medially for the coronoid process of the ulna (2) (Fig. 2. PrOXimally the biceps broadens and its musculotendinous junc­ tion (D) can be perceived.2. Ask for an active flexion and palpate meanwhile in the cubital fossa with a pinching grip. Feel for the bicipital tendon (Fig.CHAPTER CONTENTS Surface and palpatory anatomy 21 Anterior 21 Bony landmarks 21 Palpation of soft tissue Lateral 23 Bony landmarks 23 Palpation of soft tissue Posterior 27 Bony landmarks 27 Palpation of soft tissue The cubital tunnel 28 Medial 29 Bony landmarks 29 Palpation of soft tissue 21 Elbow 23 28 29 31 Functional examination of the elbow Passive tests 31 Passive flexion 31 Passive extension 31 Passive pronation 32 Passive supination 33 Isometric contractions 33 Resisted flexion 33 Resisted extension 34 Resisted pronation 34 Resisted supination 35 Resisted extension of the wrist 36 Resisted flexion of the wrist 36 SURFACE AND PALPATORY ANATOMY ANTERIOR Bony landmarks There are no real bony landmarks recognizable at the anterior aspect of the elbow. Identify the cubital fossa. and lateral to the tendon the belly of the brachioradialis muscle (C). 2. Palpation of soft tissue Palpation of the biceps muscle and the neurovascular structures in the cubital fossa Keep the subject's elbow slightly flexed. It runs distally to attach to the radial tuberosity. These bony parts can be identified more easily when considering the lateral and medial aspects of the elbow (see below). Medial to the bicipital tendon. palpate laterally for the radial head (1). lie the brachial artery and the 21 Copyrighted Material . deep under the aponeurosis. E).1). and even more proxi­ mally its muscle belly (Fig.

During relax­ ation of this muscle. Palpation of the pronator teres muscle Fig. The brachialis inserts at the ulnar tuberosity.the contraction of the brachialis muscle (F) can be felt. Fig.22 ATLAS OF ORTHOPEDIC EXAMINATION Fig.1 Anterior view 01 the elbow (skeleton).3 Palpation of the biceps muscle belly. 2. its belly.and behind the biceps tendon . The subject holds his elbow in 90° flexion and the forearm in the neutral position between prona­ tion and supination. 2. The former is pulsating. Ask the subject to pronate the forearm and resist the movement.2 Anterior view of the elbow (in vivo). 2. median nerve. Place the thumb and fingers in the indentations on both sides of the bicipital tendon (the lateral and medial bicipital grooves) and now ask for an isometric nexion. Under the fingers . can be palpated with a pinching grip. Palpate with the other hand in the thick muscular mass Copyrighted Material . which runs further distally than the muscle belly of the biceps. Palpation of the brachialis muscle Ask the subject to contract the biceps. the latter a round strand.

The distal component . A round and strong muscle can be felt running from the medial epicondyle to mid-radius.ELBOW 23 Fig.5 Lateral view of the elbow (skeleton). Level with it and from the anterior surface of the humerus originate the brachioradialis and. This is the pronator teres muscle (G). Palpate distal to the epicondyle for a depres­ sion . The joint line becomes a bit wider and thus even better palpable when the elbow is brought towards more extension.the head of the radius (£) . Fig. It now lies on the radial neck (F). easily be followed further proximaUy in its course until its insertion at the anterior aspect of the humerus. just distal to the cubital fossa (Fig. 2. Ask the subject to flex the elbow and resist the movement. From its anterior aspect originates the extensor carpi radialis brevis muscle. The epicondylar border continues proximally in the lateral supra­ condylar ridge (B).the lateral edge of the humeral capi­ tulum (0) . Feel for the lower border of the head of the radius and place the finger just distally to it. LATERAL Bony landmarks (Fig.the radiohumeral joint Line (C). Copyrighted Material . by palpation in the posterior direction. the extensor carpi radialis longus muscles.can be felt as a spherical structure. The lateral epicondyle (A) can be palpated as the most prominent bone. level with the lateral supracondylar ridge. Its proximal component . The contraction of the brachioradialis muscle (A) is well palpable and visible and the structure can.4 Palpation of the pronator teres muscle. Palpation of soft tissue Palpation of the brachioradialis muscle (Fig.5) The subject holds his elbow in 90° of flexion and the forearm supinated. just below it. 2. 2.4). 2.is well perceivable when small rotatory move­ ments of the forearm are performed.6) The subject's elbow is held in 90° flexion and the forearm in the neutral position between prona­ tion and supination. 2.

By pressing in the pos­ terior direction. 2. C).6 View of the brachioradialis muscle. Bring the subject's forearm into supination and ask him to do a combined active movement of extension and radial deviation of the wrist.7.7) The muscles are now relaxed. Palpation of the extensor carpi radialis longus Copyrighted Material . 2.7.24 ATLAS OF ORTHOPEDIC EXAMINATION Fig. 2. D) can be palpated. 2. its origin can be palpated.8). Flg. Bring the subject'S elbow into more extension (130-135°) and into pronation.9 and Fig. Just distal to the origin of the brachioradialis muscle (A) be­ tween this muscle and the lateral epicondyle the contraction of the extensor carpi radialis longus (8) can be seen. Over the head of the radius (F) the tendons of wrist and finger ex­ tensors (Fig. again at the anterior aspect of the humerus (Fig. A flat ten­ dinous structure is recognized which is the origin of the extensor carpi radialis brevis muscle (Fig. 2. 2.2.8 muscle.10 and Fig. - Fig.7 Lateral view of the elbow (in vivo). 2. Go more distally and palpate now the anterior aspect of the lateral epicondyle (E). Palpation of the radial extensors of the wrist (Fig. 2.

1 (bl II I \� Fig.2.9 Palpation of the extensor carpi radialis brevis muscle.10 Palpation of the wrist extensors. (.ELBOW 25 Fig. 2. Copyrighted Material .

2. the latter especially when the subject actively extends his wrist. 3. which runs towards the olecranon.13) The elbow and forearm are still held in the same starting position (900 flexion.13 View of the extensor carpi ulnaris muscle. Flg. 2.11 Palpation of the muscle bellies of extensor carpi radialis longus and brevis. 2. 2. 4. Fig. Fig.12 Extensors of the wrist: 1. Copyrighted Material .2. belly of extensor carpi radialis brevis. 2. Over a distance of 3-4 em downwards the bellies of bracruoradialis (superficial) and extensors carpi radialis longus and brevis (deep) (Fig. A). 2. Tension can be felt in the tendon of the extensor carpi ulnaris (Fig.14 and Fig.14 The extensor carpi ulnaris muscle. Place the palpating finger below the lateral epicondyle (A). origin of extensor carpi radialis longus.A S OF ORTHOPEDIC EXAMINATION Elbow and forearm are again brought into 900 flexion and supination. 2. tendon of extensor carpi radialis brevis.13.12) can be felt.26 AT1.2. Ask the subject to perform ulnar deviation of the wrist. origin of extensor carpi radialis brevis. Palpation of the extensor carpi ulnaris muscle (Fig. supination). Flg. 2.11). Use a pinching grip and start palpation level with the neck of the radius (Fig..

F lg 2 1 7 . . Ask the subject to supinate and resist this attempt. Fig.15 Palpation of the supinator muscle. 2. Fig. Contraction can be felt.16) is known to lie in the interspace be­ tween radius and ulna. 2. 2. between the elbow and mid-forearm. In between lies the olecranon (C). Copyrighted Material . Identify the radius from the radial head downwards.15) Place the subject's elbow in 130-135° extension and in pronation.16 The supinator muscle. 2. gross and prominent.18) Three bony prominences can be identified.ELBOW 27 Palpation of the supinator muscle (Fig. The supinator muscle (Fig. Identify the ulna from the olecranon downwards. Between the olecranon and the medial epicondyle lies the sulcus for the ulnar nerve (0). Laterally is situated the lateral epicondyle (A) and medially the medial epicondyle (B). During flexion of the elbow the olecranon moves down­ wards which makes its apex easily palpable. Posterior view of the elbow (skeleton). POSTERIOR Bony landmarks (Figs 2. On an extended elbow they lie in one line.17 and 2. In a bent elbow the three bones form an isosceles triangle.

which is only really palpable when it becomes inflamed and swollen. Copyrighted Material . Keep the subject's elbow flexed.19 Palpation of the triceps tendon. It is covered by the posterior part of the ulnar collateral liga­ ment. Feel just lateral to this apex for the insertion of the tendon of the triceps muscle (E).19) Over the olecranon lies the olecranon bursa.20). Palpate for the upper border (apex) of the olecranon. The cubital tunnel The cubital tunnel (Fig. Move the fingers upwards: a broad and flat tendon is felt and ends in the musculotendinous junction (F). 2.can be found. then behind the medial epicondyle and then further distally in between the two heads of the flexor carpi ulnaris muscle.21) is built from the medial epicondyle.18 Posterior view of the elbow (in vivo). which form an aponeurotic arch. Fig.28 ATLAS OF ORTHOPEDIC EXAMINATION Palpation of soft tissue (Figs 2. Distally and slightly lateral to the olecranon the anconeus muscle (G) can be felt during an attempt to actively over-extend the elbow. 2.2. The nerve courses under the medial head of the triceps musde. the olecranon. shaped as an inverted U (Fig. 2.a soft and round structure . Flg.18 and 2. Palpation on a flexed elbow between the olecranon and the medial epicondyle discloses the sulcus in which the ulnar nerve . the ulnar collateral ligament and the aponeurotic arch.

3. Copyrighted Material .ELBOW 29 MEDIAL Bony landmarks (Fig. musculotendinous junction. Move the finger from the medial aspect of the medial epicondyle (A) about 1-1. 2. 2.25 and Fig. Palpate for a tough round structure. J Fig.5 cm towards the anterior aspect. Fig. 2. Palpation of soft tissue (Figs 2. Fig. tenoperiosteal insertion.22 Medial view of the elbow (skeleton).21 The cubital tunnel.20 The triceps muscle: 1. This is the common tendon of the flexors (Fig. 2. 2. body of the tendon. B).22) The medial epicondyle is recognized as a very prominent bone.23. which lies just subcutaneously. 2. 2.23 and 2.24) Keep the subject's elbow almost completely extended and in full supination.

Lateral to the common flexor tendon the media nerve is palpable as a round but soft structure. just below the inferior border of the epicondyle and with the elbow slightly flexed. 2.30 ATLAS OF ORTHOPEDIC EXAMINATION Fig. 2. a thick and round muscular mass is palpable: the musculotendinous junction of this flexor group (C) consisting of. Copyrighted Material . 2. Fig. 2.25 The common flexor tendon: 1.5 em more distally. 0. the flexor carpi radialis and the pronate teres. Fig. musculotendinous. tenoperiosleal. the palmari longus.24 Palpation of the common tendon of the flexors. from medial to lateral: the flexor carpi uLnaris.23 Medial view of the elbow (in vivo).

He places one hand against the back of the shoulder and grasps the distal forearm with the other hand. The subject stands with the arm outstretched. and the other hand grasps the distal forearm. the muscles of the forearm coming in contact with the muscles of the upper arm . 2.tension in the posterior part of the joint capsule. One hand stabilizes the elbow. Painless limitation is present in uncomplicated arthrosis. thereby stabilizing the latter. Common mistakes.27). 2.in poorly muscled subjects: bony contact between (1) the coronoid fossa of the humerus and coronoid process of the ulna and (2) the head of the radius and radial fossa of the humerus .ELBOW 31 FUNCTIONAL EXAMINATION OF THE ELBOW PASSIVE TESTS Passive flexion Positioning.26). Elld-feel: . Copyrighted Material . The examiner stands level with the subject'S elbow. Normal functional anatomy: Rm'ge: about 160° • • • tissue approximation.distal hand downwards and proximal hand upwards (Fig.in well muscled subjects: the muscular masses of the upper arm and forearm coming in contact with each other . until the movement comes to a stop (Fig. Procedure. Common mistakes.in poorly muscled subjects: a rather hard stop of bone engaging with bone. The elbow is not in complete supination. Limitillg structures: . The subject stands with the arm outstretched. Procedure: To test the range: move hands in opposite directions . Bring the hand towards the shoulder. To test the end-feel: bring the subject's elbow into slight flexion and move hands abruptly but gently in opposite directions towards extension.in well muscled subjects: a soft stop by Common pathological situations: Painful limitation occurs in arthritis (as part of the capsular type of limitation) or when a loose body is present in the anterior part of the jOint. • • Passive extension Positioning. • • Fig. Inadequate stabilization allows the shoulder to move backwards.26 Passive flexion. The examiner stands level with the subject's arm. 2.

27 Passive extension. The movement is painful in lesions of the proximal radioulnar joint. Bring the subject's forearm into full pronation by a simultaneous movement of both hands in opposite directions (Fig. • • Fig. Procedure. The subject stands with the arm hanging and the elbow bent to a right angle. in bicipitoradial bursitis and in tendinitis of the biceps brachii at the insertion onto the radial tuberosity. Limitiug structures: . 2. Copyrighted Material .32 ATLAS OF ORTHOPEDIC EXAMINATION against the volar part of the ulna and the fingers of the other hand against the dorsal aspect of the radius. A painless limitation is present in uncomplicated arthrosis.28).tension in the anterior part of the joint capsule.28 Passive pronation.bony contact between the olecranon process and olecranon fossa . Common pathological situations: A painful limitation occurs in arthritis of the elbow joint and also when a loose body is present in the posterior part of the joint. in female subjects and in hypermobile persons overextension of a few degrees may be possible Ellrl-feel: hard stop of bone engaging with bone • • • Normal functional anatomy: Range: about 85° End-feel: elastic Limiling slrllclflres: stretching of the interosseous membrane and squeezing of the insertion of the bicipital tendon between the radial tuberosity and the ulna. Both hands encircle the distal forearm in such a way that the heel of the contralateral hand is placed Fig. • • • Common pathological situations. Normal functional anatomy: Rnllge: generally 0° in the male. Too much local pressure on the radius/ulna may provoke tenderness. Common mistakes: The subject's shoulder is brought into abduction. 2. • • Passive pronation Positioning. 2. The examiner stands in front of the subject.

Too much local pressure on the radiusl ulna may provoke tenderness. The examiner stands level with the elbow. The subject stands with the arm hanging. the oblique cord and the anterior ligament of the distal radioulnar joint .30). Movement is allowed at the elbow. 2. 2.tension in the extensor carpi ulnaris tendon when the posterior aspect of the ulnar Fig. The examiner stands in front of the subject. Bring the subject's foreann into full supination by a simultaneous movement of both hands in opposite directions (Fig.tension in the interosseous membrane. the elbow flexed to a right angle and the forearm supinated. Common pathological situations. The subject performs shoulder elevation.29). Resist the subject's attempt to flex the elbow (Fig. Copyrighted Material . 2.30 Resisted flexion. Normal functional anatomy: Rallge: about 90° Ellrl-feel: elastic • • • notch of the radius impacts against the stylOid process of the ulna. ISOMETRIC CONTRACTIONS Resisted flexion Positioning. 2. The subject stands with the arm hanging and the elbow bent to a right angle. Common mistakes: In strong subjects flexion cannot sufficiently be resisted if the resistance is not given perpendicular to the subject's forearm. • • • Umitillg structures: . Procedure.ELBOW 33 Passive supination Positioning. The movement is painful when the proximal radioulnar joint is affected. One hand is on the distal part of the forearm and the other hand on top of the shoulder. Fig.29 Passive supination. Procedure. Common mistakes. Both hands encircle the distal forearm in such a way that the heel of the ipsilateral hand is placed against the dorsal part of the ulna and the fingers of the other hand against the volar aspect of the radius.

34 ATLAS OF ORTHOPEDIC EXAMINATION Anatomical structures tested: Muscle function: • Important flexors: Brachialis . The examiner stands level with the elbow. 2. One hand supports the distal part of the forearm and the other hand is on top of the shoulder. The Copyrighted Material .Anconeus. • • • Anatomical structures tested: Muscle function: • Most important extensor: . Resist the subject's attempt to extend the elbow (Fig.Biceps brachii - • Less important flexors: - Brachioradialis Extensor carpi radialis longus .Triceps brachii • Less imporfa1lt exte1lsor: . Painless weakness occurs in either a CS or a C6 nerve root lesion. • • • Resisted pronation Positioning.31 Resisted extension. the elbow flexed to 90° and the forearm in supination.C 7 C&-. flexion cannot sufficiently be resisted if the resistance is not given perpendicular to the subject's forearm. Common mistakes: In strong subjects. • • Common pathological situations: The test is painful when a lesion of the triceps is present. Weakness occurs in lesions of either the radial nerve or the C7 nerve root. The subject stands with the arm alongside the body.31). The subject stands with the arm alongside the body. Painful weakness may indicate a partial rupture of the triceps or a fracture of the olecranon. Neural function: Muscle InnervatIon Peripheral Triceps brachii Anconeus Radial Radial Nerve root C7-C8 C7-C8 Resisted extension Positioning. the elbow bent to a right angle and the forearm in neutral position. Procedure.C 7 Fig. Common pathological situations: Pain indicates a lesion of either the biceps brachii or the brachialis muscle.Pronator teres. Painful weakness is suggestive of an avulsion fracture of the radial tuberosity. 2. Neural function: Muscle Peripheral Brachlalis Biceps brachii Brachloradialis Extensor carpi radialis longus Pronator teres Musculocutaneous Musculocutaneous Radial Radial Median Innervation Nerve root C5-C6 C5-C6 C5-C6 C&-. Movement is allowed at the elbow.

2. 2. Movement is allowed at the elbow.33). Resist the subject's attempt to supinate the forearm (Fig.32). the thenar against the palmar and distal aspect of the radius and the fingers against the dorsal aspect of the ulna.32 Resisted pronation. Too much local pressure on the radius/ulna may provoke tenderness. Fig. Common mistakes: The subject extends the elbow. Procedure. The subject stands with the arm alongside the body. The other hand reinforces: thenar on ulna and fingers on radius. The thenar of the other hand is placed against the dorsal aspect of the radius. The ipsilateral hand carries the forearm. Common mistakes: The subject abducts the shoulder. Pain occurs in golfer's elbow . Movement is allowed at the elbow. 2. the thenar against the distal and palmar aspect of the ulna. The ipsilateral hand carries the forearm.or in an isolated lesion of the pronator teres muscle.Biceps brachii - Fig.ELBOW 35 examiner stands in front of the subject. the elbow bent to 90° and the forearm in neutral position. Procedure. Copyrighted Material . • • • Anatomical structures tested: Muscle function: • • Pronator teres Pronator quadratus. • • • Common pathological situations. Resisted supination Positioning. The examiner stands in front of the subject.a lesion of the common flexor tendon .33 Resisted supination. Resist the subject's attempt to pronate the forearm (Fig. Too much local pressure on the radius/ulna may provoke tenderness. 2. Neural function: Muscle Peripheral Pronator teres Pronator quadratus Median Median Innervation Nerve rool Anatomical structures tested: Muscle function: • eIM:7 C8-T1 Most important supitlafors: Supinator .

Extensor carpi ulnaris Less importmlt wrist extensors: Extensor indicis proprius . Resist the subject's attempt to extend the wrist (Fig. Pain is the result of a lesion of the biceps or. • • Imporla1lt wrist extensors: Extensor digitorum communis Extensor carpi radialis longus . Positioning. Procedure. The contralateral arm lifts and carries the elbow and keeps it extended. This can be prevented by the examiner's arm keeping the subject's elbow well raised.a lesion in the radial extensors of the wrist . Neural function: Muscle Peripheral Supinator Biceps brachii Brachioradialis Radial Musculocutaneous Radial Innervation Nerve root Common mistakes: The subject is allowed to lift the arm up. and between flexion and extension). • • Resisted flexion of the wrist Fig. tennis elbow . Other possibilities are a lesion of the extensor carpi ulnaris or of the extensor digitorum. which puts stress on non-contractile structures.34 Resisted extension of the wrist. The wrist is not held in neutral position. The elbow is allowed to flex.Extensor carpi radialis brevis . or a more general neurolOgical disease. 2.lIalor: Brachioradialis.Extensor digiti minimi. The subject stands with the arm hanging. more rarely. The examiner stands level with the subject's elbow.Extensor pOllicis longus . or bronchus carcinoma. the elbow extended and the wrist in Copyrighted Material .is most probable. The subject stands with the arm hanging. the elbow extended and the wrist in neutral position (between pronation and supina­ tion. • • • C5--C6 C5-<:S C5-<:8 Anatomical structures tested: Muscle function: Common pathological situations. a lesion of the supinator muscle. 2.34). The other hand is placed at the dorsum of the subject's hand. Resisted extension of the wrist Positioning. The hand stabilizes the forearm. Weakness may result from a radial nerve lesion or from either the C6 or C8 nerve root.36 ATLAS OF ORTHOPEDIC EXAMINATION • - Less importaNt sup. Bilateral weakness suggests either lead poisoning. - Neural function: Muscle Peripheral Extensor digitorum communis Extensor carpI radialis longus ExtenSO( carpi radialis brevis Extensor carpi ulnaris ExtenSO( indicis proprius Extensor poUicis longus Extensor digiti minlmi Radial Aadial Radial Aadial Radial Radial Radial Innervation Nerve root C&-C8 C&-C7 C7 C7--C8 C&-C8 C7-G8 C&-C8 Common pathological situations: When elbow pain is elicited.

Resist the subject's attempt to flex the wrist (Fig. Common mistakes: The subject is allowed to push the arm down. The contralateral arm lifts and carries the elbow and keeps it extended. 2.a lesion in the common flexor tendon. Neural function: Muscle Peripheral Flexor digitorum superficialis Flexor digllorum profundus Flexor carpi ulnaris Flexor carpi radialis Abductor pollicis longus Palmaris longus Median Median Ulnar Median Radial Median Innervation Nerve root C7-T1 C7-Tl C7-C8 C7-T1 C7-C8 C7-Tt Fig. which puts stress on non-contractile structures.35). Common pathological situations: Pain at the elbow occurs in golfer's elbow . Anatomical structures tested: Muscle function: • III/portallt wrist flexors: Flexor digitorum superficialis Flexor digitorum profundus Flexor carpi ulnaris Flexor carpi radialis • Less importallt wrist flexors: .Abductor pollicis longus . and between flexion and extension).Palmaris longus. The other hand is placed at the palm of the subject's hand. • • If this happens it is the result of inadequate fixation.ELBOW 37 neutral position (between pronation and supina­ tion. The wrist is not held in neutral position. Weakness suggests a C7 or C8 nerve root lesion. • • Copyrighted Material . Procedure. 2. The examiner stands level with the subject's elbow. The hand stabilizes the forearm.35 Resisted flexion of the wrist.

especially Fig. Just distally to the styloid process the scaphoid (navicular) bone (B) is palpable.1.CHAPTER CONTENTS Surface and palpatory anatomy Radial 39 Bony landmarks 39 Palpation of soft tissue 40 Dorsal 41 Bony landmarks 41 Palpation of soft tissue 42 Ulnar 43 Bony landmarks 43 Palpation of soft tissue 43 Palmar 44 Bony landmarks 44 The carpal tunnel 45 The tunnel of Guyon 46 Palpation of soft tissue 46 39 Wrist Functional examination of the wrist 48 Passive tests of the distal radioulnar joint 48 Passive pronation 48 Passive supination 49 Passive tests of the wrist joint 49 Passive flexion 50 Passive extension 50 Passive radial deviation 51 Passive ulnar deviation 51 Passive test for the trapezium-first metacarpal joint 51 Backwards movement during extension 51 Isometric contractions 52 Muscles controlling the wrist 52 Muscles controlling the thumb 55 Muscles controlling the fingers 57 Intrinsic muscles of the hand 58 Specific tests 61 Phalen's lest 61 Tinel's test 61 Grind test for the trapezium-first metacarpal joint 62 Finkelstein's test 62 SURFACE AND PALPATORY ANATOMY RADIAL Bony landmarks (Figs 3. It can be made more prominent by asking the subject to execute ulnar deviation of the wrist. When the palpating finger is on the navicular bone it lies in a de­ pression between two tendons. Slightly more proximally on the radius a small groove can be found. 3. 3.2 and 3.3) At the distal end of the radius the styloid process (A) can be palpated. 39 Copyrighted Material . called the 'anato­ mieal snuffbox'.1 Radial view of the wrist (skeleton). At the distal end of the snuffbox the joint line can be palpated between the scaphoid bone and the trapezium.

3.5). 3. Bony landmarks at the radial side of the wrist (in Fig. The joint line can be felt just proximally to the proximal border of the bone.the one between the trapezium bone and the first metacarpal bone.4). which is seen to run towards the base of the proximal phalanx. Two strong tendons can be recognized (Fig. when the subject moves the thumb. It forms the radial border of the 'anatomical snuffbox'. 3. 3.4 The radial collateral ligament. Next to it the abductor Fig. Fig.6): first the extensor pollicis brevis (A). 3. Fig. This joint line is well palpable during movement of the first metacarpal bone: feel for the shaft of the first metacarpal bone with one finger and move proximally towards the base of the bone (C). Copyrighted Material . Ask the subject to extend the thumb (Fig. 3. Move the finger slightly towards the palmar aspect.2 vivo). 3.5 View of the extensors and abductor of the thumb.3 Bony structures at the radial side 01 the wrist. 6-7 mm more distally another joint line is palpable . especially while the other hand moves the first metacarpal to and fro.40 ATLAS OF ORTHOPEDIC EXAMINATION Palpation of soft tissue Place the palpating finger just distally to the styloid process and feel for the tightening of the radial collateral ligament during ulnar deviation. It attaches to the scaphoid bone (Fig.

The distal border of the radius is sharp and can be felt as being the proximal border of the Fig. radiocarpal joint. The most radial one is the already detected scaphoid bone. lunate. The most ulnar bone is the lunate bone (B). triquetral and pisiform bones. which is more difficult to palpate. inserting at the base of the first metacarpal bone.8 vivo). capitate and hamate bones. 3. Bony landmarks at the dorsal side of the wrist (in pollicis longus (B) is felt.8) Radius and ulna are easily palpable. It is felt to move when the hand is again brought into radial deviation. Between the lunate and the base of the third metacarpal bone a depression (C) is felt in which the capitate bone is palpable. and by moving both hands in opposite directions. Distal to the inferior border of the radius. This is the dorsal tubercle (A) of the radills which forms an important landmark.7 Dorsal view of the wrist (skeleton). To the ulnar side of the capitate and somewhat more distal and radial than the triquetral. The distal radioulnar joint can be recognized by grasping the distal end of the radius with one hand and the distal end of the ulna with the other. two bones can be palpated.WRIST 41 Fig. The styloid process of the radills descends a bit further distally than the styloid process of the ulna. The distal row contains the trapezium. At the ulnar side the thick head of the ulna is palpated. 3. it articulates mainly with the fourth metacarpal bone. on the dorsal aspect of the radius. The capitate articulates with the base of the third metacarpal bone (D).6 Tendons at the radial aspect 01 the wrist. 3. the hamate bone is felt. which has a wide joint line. trape­ zoid. Fig. One finger-width more proximally. It is felt more clearly during ulnar deviation of the wrist. which is palpable on a flexed wrist. The bone between the capitate and the trapezium is the trapezoid bone. a nodular bone can be felt.7 and 3. Distal and a bit more radially to the scaphoid lies the trapezium. In the proximal row lie the scaphoid. DORSAL Bony landmarks (Figs 3. Ulnar to the lunate and articulating with the ulna lies the triquetral bone. The carpal bones consist of two rows. Copyrighted Material .

3. 3. The most radial tendon (longus) (C) is felt to insert at the radial aspect of the base of the second metacarpal bone and the more ulnar tendon (brevis) (D) inserts at the radial aspect of the base of the third metacarpal bone (Fig.9).11). Ask the subject to extend the thumb. These are the tendons of the extensor carpi radialis longus and extensor carpi radialis brevis (Fig. Fig.3. approximately 2 cm more distally.12 View of the extensor poilieis longus (in vivo). Feel for the extensor pollicis longus (Fig. Ask the subject to make a first and to squeeze and unsqueeze it. It can be palpated until its insertion onto the distal phalanx of the Fig. 3. A) tendon.9 View of the extensors of the wrist (in vivo).42 ATLAS OF ORTHOPEDIC EXAMINATION Palpation of soft tissue Place one finger just radially to the dorsal tubercle of the radius (A) (Fig.10). 3. 3. 3.11 Palpation of the extensor carpi radialis longus. until the point where they separate (B). When the subject continues these mus­ cular contractions the tendons can be followed.12. which is the ulnar border of the anatomical snuffbox. Copyrighted Material . During this action tendinous tightening can be felt. (2). Place one finger just ulnar to the dorsal tubercle of the radius. 3.10 The extensor carpi radialis longus (1) and brevis Fig. Fig.

thumb: the tendon turns 45° around the dorsal tubercle of the radius. Flg. 3. Palpation of soft tissue A Fig.16 Palpation of the extensor carpi utnaris. 3 . This tendon overlies the distal radioulnar joint. When the palpating finger is moved even more distally and the hand is brought back to the neutral position the base of the fifth metacarpal bone (C) is encountered.14. extensor carpi ulnaris (B) is felt (Figs 3. Place the finger just distal to the styloid process and move the subject'S hand in radial deviation. 3. Ask the subject to perform an ulnar deviation during extension. 3.13 View of the extensors of the fingers (in vivo). A).16). It can be followed to its insertion at the base of the fifth metacarpal bone. Movement can be felt of the tendons of the extensor digitorum com­ munis and of the extensor indicis proprius.3. Place one finger at the inferior and ulnar border of the head of the ulna (Fig. When one finger is extended at a time the different tendons can be palpated one by one. Place one finger just radially to the head of the ulna.17) At the distal end of the ulna the small styloid pro­ cess (A) is palpable. 1 5 The extensor carpi ulnaris. Ask the subject to extend the little finger and feel for the extensor digiti minimi. Just distal to it the triquetra I bone (8) becomes prominent when the subject moves the hand in radial deviation. crosses over the extensor carpi radialis longus and brevis. Palpate the dorsal aspect of the wrist while the subject extends the fingers. 3. The strong and thick tendon of the Fig. Copyrighted Material . and goes towards the thumb.15 and 3.14 View of the extensor carpi ulnaris (in vivo).WRIST 43 Flg. ULNAR Bony landmarks (Fig.

3.17 vivo). Fig.19 and 3. Flex the thumb and feel its tip touch the hook of hamate through the muscles of the hypothenar. At the distal and ulnar side of the ulna a bony prominence can be felt: the pisiform bone (A).19 (in vivo). Fig.20 Palmar view of the wrist (skeleton). Fig. 3. Ask the subject to move the hand towards the ulnar side and to extend the wrist sUghtiy. Bony landmarks at the ulnar side of the wrist (in Tightening can be felt of the ulnar collateral Ligament (Fig. Copyrighted Material . Along the distal part of the ulna the tendon of the extensor carpi ulnaris is palpable.3.20) Radius and ulna can be identified.18).18 The ulnar collateral ligament. Put the inter­ phalangeal joint of the thumb onto the pisiform and direct the thumb towards the base of the index finger of the subject. 3. A Bony landmarks at the palmar side of the wrist Fig. 3. which goes towards the triquetral bone.44 ATLAS OF ORTHOPEDIC EXAMINATION A B C PALMAR Bony landmarks (Figs 3.

Fig.23 The boundaries of the carpallunnel (righl hand. the base of the second metacarpal bone can be palpated through the muscles of the thenar.WRIST 45 At the distal end of the radius the prominent tubercle of scaphoid (8) is well palpable. Put the interphalangeal joint of the thumb onto the scaphoid's tubercle and direct the thumb towards the base of the thumb.21. It is covered by the transverse ligament.21 Bony boundaries of the carpal tunnel (in vivo). palmar view): 1. The carpal tunnel (Figs 3.on the radial side .23) The carpal tunnel lies between . 3.22 View in the carpal tunnel (specimen). The content of the carpal tunnel is: • • • • the median nerve the flexor poll ids longus the flexor carpi radialis the flexor digitorum superfidalis and profundus. scaphoid. Copyrighted Material . 1 --- 2 --+- o Fig. pisiform. It can be localized on the heel of the hand and somewhat towards the ulnar side.22 and 3. Laterally and distal to it lies the base of the first metacarpal (C). Flex the thumb and feel its tip touch the trapezium bone. 4. Fig. trapezium. 3.on the ulnar side . When the finger moves from the scaphoid in the direction of the index finger. 3. 3. hamate. 2. 3.the tubercle of the scaphoid bone (C) and the trape­ zium bone (0).the pisiform bone (A) and the hook of the hamate bone (8) and .

25 and 3. Place the thumb radial to the previous tendon at the distal part of the forearm. The ulnar nerve passes through the tunnel of The tunnel of Guyon (Fig.26 Radial view of the wrist (in vivo). Ask the subject to actively abduct the little finger. The pisiform is a sesamoid bone in the tendon of the flexor carpi ulnaris.24 Guyon.24) Palpate for the interspace between the pisiform and the hook of hamate.46 ATLAS OF ORTHOPEDIC EXAMINATION Fig. The tightening of the flexor carpi ulnaris (A) can be felt (Figs 3. 3. 0---1: Fig.27 and 3. Palpation of soft tissue (Figs 3. 3. Fig. Copyrighted Material .26) Feel for the pisiform bone and place the pal­ pating finger against its proximal aspect.27 The flexor carpi ulnaris. 3. It now lies on the tendons of the flexor digitorum superficialis (B). This is Guyon's tunnel that contains the ulnar nerve and ulnar artery and is covered by the pisohamate ligament. 3. Fig.25 View of the flexors of wrist and fingers (in vivo). 3. The tendon can now be followed distal to the pisiform until its insertion on the base of the fifth metacarpal bone.28).

Fig. Fig. It inserts at the base of the second metacarpal bone (Fig.31 Palpation of the flexor carpi radialis. 3.29 Palpation of the flexor digitorum superticialis.28 Palpation of the flexor carpi ulnaris. Fig.) Approximately 1 cm radially to the palmaris longus the strong and thick tendon of the flexor carpi radialis (0) is palpable (Fig.30).WRIST 47 becomes prominent. Move the finger a bit more towards the radial side and ask the subject to oppose the thumb and little finger and to simultaneously flex the wrist. 3.30 The flexor carpi radialis. In a deeper layer the presence of the flexor digitorum profundus can be imagined. The thin tendon of the palmaris longus (C) Fig. 3.31). 3. Copyrighted Material . 3. It inserts into the palmar aponeurosis of the hand. especially when the subject flexes and radially deviates the wrist.29). (It has to be remem­ bered that this muscle is inconstant. of which the movement can be felt during active flexion and extension of the fingers (Fig. 3. 3.

Bring the subject's forearm into full pronation by a simultaneous action of both hands in opposite directions (Fig. level of the carpus.33 Palpation of the flexor pollicis longus (al the wrist). the tendon of the flexor pollicis longus can be felt to move during flexion and extension movements of the thumb (Figs 3.33). 3. Common mistakes: • The subject is allowed to abduct the shoulder. Common pathological situations. Pain at full Copyrighted Material .34). The examiner stands in front of the subject. 2. The subject stands with the arm hanging and the elbow bent to 90°. PASSIVE TESTS OF THE DISTAL RADIOULNAR JOINT Passive pronation Positioning. the trapezium-first metacarpal joint and also the tendons that control the wrist. in a deeper layer. This comprises the distal radioulnar joint. thumb and fingers and the intrinsic muscles of the hand.32 and 3. 3. Procedure. Fig. Fig. Both hands encircle the distal part of the forearm in such a way that the heel of the contralateral hand is placed on the palmar aspect of the ulna and the fingers of the other hand lie at the dorsal aspect of the radius. • Too much pressure on the radius or ulna may provoke local tenderness.32 The flexor pollicis longus: 1. 3. Between the flexor carpi radialis and the abductor pollicis longus the pulsations of the radial artery (E) can be felt. level of the first metacarpal. FUNCTIONAL EXAMINATION OF THE WRIST Introduction/general remarks Examination of the wrist should include all struc­ tures that can be responsible for pain felt in the region called 'wrist' by the patient. the wrist joint.48 ATLAS OF ORTHOPEDIC EXAMINATION In between the palmaris longus and the flexor carpi radialis. Normal functional anatomy: • Ral1ge: about 85° • Elld-feel: elastic • Limitil1g structllres: impaction of the radius against the ulna together with stretching of the interosseous membrane.

Too much pressure on radius or u Ina may provoke local tenderness. The subject stands with the arm hanging and the elbow bent to 90°.the intercarpal joint. The tests described in this chapter test the wrist joint as a whole and do not test its structures separately. Copyrighted Material . Common pathological situations: • Pain at full range occurs in arthritis or arthrosis of the distal radioulnar joint and also in tendinitis of the extensor carpi ulnaris level with the distal end of the ulna. 3. range suggests arthritis or arthrosis of the distal radioulnar joint.the radio­ carpal joint . All movements are executed with the wrist held in the neutral position: • • halfway between flexion and extension halfway between radial and ulnar deviation. 3. The examiner stands in front of the subject. the oblique cord and the anterior ligament of the distal radioulnar joint The wrist joint has a proximal part .34 Passive pronation.WRIST 49 Fig.35 Passive supination. Bring the subject's forearm into full supination by a simultaneous movement of both hands in opposite directions (Fig. • Limitation indicates a malunited Colles' fracture.and a distal one . Fig. Both hands encircle the distal part of the forearm in such a way that the heel of the ipsilateral hand is placed on the dorsal aspect of the ulna and the fingers of the other hand at the palmar aspect of the radius. Normal functional anatomy: • Rallge: about 90° • Elld-feel: elastic • .35).tension in the interosseous membrane.tension in the extensor carpi ulnaris tendon when the posterior aspect of the ulnar notch of the radius impacts against the styloid process of the ulna. Procedure. Common mistakes. 3. Passive supination Positioning. PASS IVE TESTS OF THE WRIST JOINT Remark Limiting structures: .

Normal functional anatomy: • Range: 85· • Elld. Fig. • Painful limitation is present in arthritis.37).36 Passive flexion of the wrist.37 Passive extension of the wrist. Palmar pain may be provoked in a lesion of the palmar ligament of the wrist or of one of the flexor tendons. Common mistakes. 3. The examiner stands next to the sub­ ject. The contralateral hand carries the subject's forearm. usually of the lunate bone. Fig.f eel: Elastic • Limiling slrllcillres: stretching of the dorsal ligaments of the carpus. Limitiug strlfctures: . 3. None. Bring the subject's wrist into maximal extension (Fig. The subject stands with the arm hanging. • Pain at the palmar aspect may occur in periostitis. painless limitation arthrosis.50 ATLAS OF ORTHOPEDIC EXAMINATION The positioning for all passive tests of the wrist joint is the same.36). carpal subluxation .contact of the proximal row of carpal bones against the radius. None. which is kept between the examiner's arm and trunk. The other hand grasps the subject's hand distally on the metacarpals. mostly of the scaphoid bone. Common pathological situations: • Pain at the dorsal aspect occurs in a lesion of the dorsal ligaments or the extensor tendons of the wrist. Bring the subject's wrist into maximal flexion (Fig. 3. the elbow flexed to a right angle and the forearm pronated. Positioning for testing the mobility of the wrist. • Painful limitation may indicate arthritis.stretching of the palmar ligaments of the carpus and of the intercarpal ligaments and capsules . Passive extension Procedure. Copyrighted Material . of the intercarpal ligaments and the capsules of the different intercarpal joints. 3. Normal functional anatomy: • Rallge: 85· • Elld. Common pathological situations: • Pain at full range and felt at the dorsal aspect may suggest a periostitis of the distal epiphysis of the radius or a dorsal ganglion.usually of the capitate bone­ and aseptic necrosis. Common mistakes. • Painless limitation is typical for arthrosis.feel: rather hard • Passive flexion Procedure.

Copyrighted Material . Passive radial deviation Procedure. Common mistakes. Normal functional anatomy: • Rallge: about 15° • Elld-fee/: rather hard • Limithlg structLlres: stretching of the ulnar collateral ligament and of the extensor carpi ulnaris. The thumb is induded in the movement: it should be left free to avoid exces­ sive stretching of the tendons of the extensors and long abductor. Normal functional anatomy: • Rallge: about 45° • Elld-fee/: rather hard • Limifillg sfmcfllres: radial collateral ligament. • Pain at the radial side may be provoked in de Quervain's disease as the result of gliding of the tendons of abductor pollicis longus and extensor pollicis brevis in their inflamed sheath.40). Push the subject's wrist to the radial side until the end of range is reached (Fig. PASSIVE TEST FOR THE TRAPEZ IUM-FIRST M ETACARPAL JOINT Backwards movement during extension Positioning. Pull the subject's wrist to the ulnar side until the end of range is reached (Fig. Procedure.39 Passive ulnar deviation of the wrist. 3. 3. The other hand moves the thumb into extension first and then backwards (Fig.39). Common mistakes.38). 3. • Pain at the ulnar side can be elicited by a lesion of the triangular fibrocartilaginous complex. One hand grasps the hand and stabilizes it. 3. Common mistakes. so that most Passive ulnar deviation Procedure. 3. Common pathological situations: • Pain at the radial side at full range is present in a sprain of the radial collateral ligament or as the result of gliding of tendons in an inflamed sheath in tenovaginitis of abductor pollicis longus and extensor pollids brevis (de Quervain's disease).38 Passive radial deviation of the wrist. The thumb is hyperextended in the metacarpophalangeal joint. Common pathological situations: • Pain at the ulnar side is typical for a lesion of the ulnar collateral ligament or the extensor carpi ulnaris. The examiner faces the subject. Fig. The subject stands with the arm hanging and the elbow bent to 90° and in supina­ tion. None.WRIST 51 Fig.

3. • Excessive range of motion occurs after rupture of the ulnar aspect of the metacarpophalangeal joint capsule. Resist the subject's attempt to flex the wrist (Fig.41 Resisted flexion of the wrist. The other hand grasps the subject's hand distally on the meta­ carpals to apply resistance. Fig. The examiner stands level with the subject's elbow. Anatomical structures tested: Muscle function: • Ill/portnllt wrist flexors: . • The elbow is not held in extension.Flexor digitorum superficialis ISOMETRIC CONTRACTIONS Muscles controlling the wrist Remarks As most muscles take their origin at the elbow and overrun it. The positioning is the same for the four tests.41). Positioning for testing the resisted movements of the wrist. the elbow extended and the forearm in neutral position. Common pathological situations: • Pain indicates arthritis or arthrosis ('rhizarthrosis') generally of the joint between the trapezium and the first metacarpal bones.52 ATLAS OF ORTHOPEDIC EXAMINATION All movements are executed with the wrist held in the neutral position: • • halfway between flexion and extension halfway between radial and ulnar deviation. Procedure. jf this happens it is the result of inadequate fixation. Fig. Resisted flexion stress falls on this joint and not on the trape­ zium-first metacarpal one. Normal functional anatomy: • Rmlge: until the movement stops • Elld-feel: elastic • Lill/itillg structures: stretching of the anterolateral part of the joint capsule of the trapezium-first metacarpal joint. Common mistakes: • The subject is allowed to push the arm down. The contralateral arm lifts and carries the elbow and keeps it extended. The hand stabilizes the forearm. More exceptionaUy it is the joint between trapezium and scaphoid bones.40 Passive movement of the thumb. The subject stands with the arm hanging. 3. 3. Copyrighted Material . the subject's elbow should always be held in extension to put maximal stress on these structures.

Neural function: Muscle Peripheral Extensor digitorum communis Extensor carpi radialis longus Extensor carpi radialis breVIS Extensor carpi ulnaris Radial Radial Radial Radial Radial Radial Radial Innervation Nerve root CH:B CH:7 C7 C7-C8 CH:B C7-C8 CH:B Common pathological situations: • Pain at the wrist occurs in tendinitis of the flexor carpi radialis. 3.42 Resisted extension of the wrist. or a more general neurological disease. • Unilateral weakness is caused either by a nerve root lesion.42). Anatomical structures tested: Muscle (unction: • ImportaHt wrist extensors: Extensor digitorum communis Extensor carpi radialis longus Extensor carpi radialis brevis Extensor carpi ulnaris • Less importnut wrist extensors: Extensor indicis proprius Extensor pollicis longus Extensor digiti minjmi. If this happens it is the result of inadequate fixation. or bronchus carcinoma. extensor carpi ulnaris. • The elbow is not held in extension.Palmaris longus. extensor indicis proprius or extensor digitorum communis. Resist the subject's attempt to extend the wrist (Fig. This test can be used to differentiate between wrist extensors and finger extensors. Variation: resisted extension of the wrist with the fingers held actively ffexed Fig. Common pathological situations: • Pain at the wrist is indicative of tendinitis of extensor carpi radialis longus and/or brevis. espeCially C6 and C8. • Weakness is found in C7 and C8 nerve root lesions. Neural (unction: Muscle Peripheral FleICor dlgitorum superflclalis Flexor digitorum profundus Flexor carpi ulnaris Flexor carpi radialis Abductor pollicis longus Palmaris longus Median Median Ulnar Median Radial Median Innervation Nerve root C7-T1 C7-T1 C7--C8 C7-T1 C7--C8 C7-T1 Common mistakes: • The subject is allowed to push the arm upwards. or by a lesion of the radial nerve. Resisted extension Extensor indicis proprius Extensor pollicis longus Extensor digiti mlnimi Procedure. Significance. • Bilateral weakness suggests either lead poisoning. flexor carpi ulnaris and flexor digitorum profundus.WRIST 53 Flexor digitorum profundus Flexor carpi ulnaris Flexor carpi radialis • Less i11lportallt wrist flexors: Abductor pollicis longus . 3. Copyrighted Material .

Resist the subject's attempt to push the hand over to the ulnar side (Fig. Resisted radial deviation Fig. • The elbow is not kept extended. 3. 3. Common mistakes: • The entire arm is lifted up. Copyrighted Material .44). Resisted ulnar deviation Fig. Positioning. Absence of pain indicates that. The other hand is placed at the dorsum of the subject's hand (Fig. The subject is standing and holds the extended arm forwards. He squeezes his bent fingers into the palm of his hand. • The test may also be painful in de Quervain's tenovaginitis .45).54 ATLAS OF ORTHOPEDIC EXAMINATION Active contraction of the finger flexors inhibits the finger extensors. when a lesion is present.44 Resisted radial deviation of the wrist. Anatomical structures tested: Muscle function: • • • • • • Procedure. Extensor carpi radialis longus Abductor pollicis longus Extensor pollicis longus Flexor carpi radialis Flexor pollicis longus Brachioradialis Neural function: Muscle Peripheral Extensor carpi radialis longus Abductor poUicis longus Extensor poliicis longus Flexor carpi radialis Flexor poIlicls longus Brachioradialis Radial Radial Radial Median Median Radial Innervation Nerve root C6-C7 C7-C8 C7-C8 C7-Tl C7-C8 C6-C8 Common pathological situations: • Pain is most commonly present in tendinitis of either the extensor carpi radialis longus and/or brevis. 3. it lies in one of the finger extensors. Resist the subject's attempt to move the hand radially (Fig.43 flexed. 3. the result of which is that the thumb extensors and abductors become directly involved. The examiner stands level with the subject's arm and stabilizes the forearm with one hand. or the flexor carpi radialis. Resist the subject's attempt to extend the wrist.a lesion of the abductor pollicis longus and extensor pollicis brevis in their common tendon sheath. Common mistakes: • The thumb is not left free. • The elbow is not held in extension. Procedure. Resisted extension of the wrist with fingers Procedure. 3.43).

metacarpophalan­ geal and interphalangeal joints there is a movement in the ulnar direction roughly in a plane parallel to the plane 01 the other metacarpals. and the thumb pointing upwards. The thumb moves In a palmar direction. away from the plane of the other metacarpals. the elbow bent to a right angle. 3. Resisted flexion . metacarpophalan· geal and interphalangeal joints there is a movement in the radial direction roughly in a plane parallel to the plane of the other metacarpals. The elbow is not extended. • Weakness indicates usually a CB nerve root lesion. Copyrighted Material . At carpometacarpal. Common mistakes.1 Definitions - Adduction The thumb moves from a palmar position dorsally to join the plane of the other metacarpals.WRIST 55 Box 3. The subject stands with the arm hanging. Fig.8 carpi ulnans Radial Ulnar Radial Radial Flexor carpi ulnaris Extensor digltorum communis Extensor digiti miniml Procedure. the forearm and hand in the neutral position. So is the positioning of the examiner. Neural function: Muscle Peripheral Extensor Innervation Nerve rool C7-CB C7--C8 C&-{.46 Resisted flexion of the thumb. The other hand is on the thumb.3. 3. At carpometacarpal.1 for definitions) resistance is given at the distal phalanx and for abduction and adduction at the distal part (head) of the first metacarpal bone.8 C&-{. Common pathological situations: • Pain is the result of tendinitis either of the extensor carpi ulnaris or of the flexor carpi ulnaris.46). Anatomical structures tested: Muscle function: • Importallt lIi1lnr deviators: .Extensor digiti minimi.Extensor carpi ulnaris . Abduction Extension Flexion Flg. Resist the subject's attempt to flex the thumb (Fig. Muscles controlling the thumb Remarks The positioning of the subject is the same for the four tests. Positioning.45 Aesisted ulnar deviation of the wrist. The contralateral hand carries the subject's wrist.Flexor carpi ulnaris • Less importallt ulnar deviators: except that for flexion and extension (see Box 3.Extensor digitorum communis . The examiner faces the subject.

Fig. Copyrighted Material .56 ATLAS OF ORTHOPEDIC EXAMINATION Common mistakes. Anatomical structures tested: Muscle function: • Importallt thumb flexors: Common mistakes. Fig.Flexor pollicis longus . 3. • Weakness is possibly the result of a rupture of the extensor pollicis longus.48). • Weakness is suggestive of a lesion of a branch of the median nerve . more rarely. Procedure. The thumb is allowed to hyperextend at the metacarpophalangeal joint. 3. Resisted extension Common pathological situations: • Pain occurs in tendinous lesions of the abductor pollicis longus and extensor pollicis brevis (de Quervain's disease) and extensor pollicis longus (crepitating tenosynovitis).47). Neural function: Muscle Innervation Peripheral Nerve rool Extensor poliicis longus Extensor pollicis brevis Abductor pollicis longus Peripheral Radial Radial Radial Innervation Nerve root Neural function: Muscle Flexor polhcis longus Fle)(or pollicis brevis superficial head deep head Adductor pollicis Median Median Ulnar Ulnar C7-CS C8-Tl CB-Tl CS-T1 C7-CS C7-Tl C7-C8 Common pathological situations: • Pain is present in a tenosynovitis of the flexor poll ids longus.and. Resist the subject's attempt to extend the thumb (Fig.Flexor pollicis brevis • Less important thllmb flexor: - Extensor pollicis longus Extensor pollicis brevis Abductor pollic. Anatomical structures tested: Muscle function: • • • . Resisted abduction Procedure. either of the radial nerve or of the C8 nerve root. 3. 3. Adductor pollids. of the ulnar nerve. It may also indicate a neurological condition. Hyperextension of the first metacarpophalangeal joint takes place.the anterior interosseous nerve .47 Resisted extension of the thumb.s longus. Resist the subject's attempt to abduct the thumb (Fig.48 Resisted abduction of the thumb.

Flexor pollicis brevis. • Less important thumb addllctors: . Fig. superficial head . Copyrighted Material .g. deep head Radial Median Radial Ulnar C7--C8 C6-Tl C7-Tl CB-T1) Common pathological situations: • Pain is the result of a tendinous lesion of the abductor pollicis longus and extensor pollicis brevis. he applies resistance to the distal phalanx of each finger respectively (Fig.Opponens pollicis.g. The subject presents his hand palm downwards. Fig. Resist the subject's attempt to adduct the thumb (Fig. • Weakness occurs in lesions of either the ulnar nerve or the C8 nerve root. Common mistakes. Neural function: Muscle Innervation Peripheral Nerve root Adductor pollicis Flexor pollicis brevis supelficial head Opponens pollicis Median Median Peripheral Ulnar Innervation Nerve Neural function: Muscle rOOI C8-Tl C8-Tl CS-<:7 Abductor potllciS longus Abductor poilicis brevis Extensor poUicis brevis (Flexor poilicis brevis.49 Resisted adduction of the thumb. Resisted adduction Common pathological situations: • Pain occurs in a lesion of the adductor pollicis. • Weakness occurs in nerve lesions.WRIST 57 Common mistakes. e. 3. or crepitating tenosynovitis. 3. Muscles controlling the fingers Resisted extension of each finger separately Procedure. de Quervain's disease. With the other. 3. 3. Resistance is given on the distal phalanx. Positioning and procedure. e. usually in the oblique portion. Anatomical structures tested: Muscle functon: i • • • • Anatomical structures tested: Muscle function: • Importallt thllmb adductor: - Adductor pollicis Abductor pollicis longus Abductor pollicis brevis Extensor pollids brevis (Flexor pollicis brevis). The examiner stabi­ lizes the wrist with one hand.50).50 Resisted extension of one finger.49). posterior interosseous nerve or median nerve. Resistance is given at the distal phalanx.

When the intrinsic muscles of the hand are affected. The latter adduct the fingers towards the middle finger (Fig. 3.is muscle Extension of the middle finger: . Copyrighted Material .52. Resisted flexion of each finger separately Common pathological situations: • When resisted movement of one specific finger is painful.58 ATLAS OF ORTHOPEDIC EXAMINATION Common mistakes.Tendon to the index finger of the extensor digitorum commun. 3. either at the wrist or more distally. These muscles mainly abduct the fingers away from the middle finger (Fig. There are four dorsal interossei and three pal­ mar ones. if present. right). the Ie ion. • Pain is usually the result of a lesion of one of the tendons of the flexor digitorum profundus.Extensor digiti minimi . must lie in the tendon going to that finger. Anatomical structures tested: Muscle function: • • Flexor digitorum superficialis Flexor digitorum profundus.Extensor indicis proprius .Tendon to the ring finger of the extensor digitorum communis muscle Extension of the little finger: . Common mistakes.Tendon to the middle finger of the extensor digitorum communis muscle Extension of the ring finger: . None. The examiner stabi­ lizes the wrist with one hand. 3. With the other hand he applies resistance to the distal phalanx of each finger respectively (Fig. Fig.Tendon to the little finger of the extensor digitorum communis muscle.51 Resisted flexion of one finger. The subject presents his hand palm downwards. • Weakness may occur in a lesion of the radial nerve. The combination of posi­ tive answers indicates which muscle is affected. left). 3.51). it is usually a lesion in the dorsal interossei. None. Anatomical structures tested: Muscle function: • • • • Extension of the index finger: . Neural function: Muscle Peripheral Innervation Nerve root Neural function: Muscle Innervation Peripheral Extensor indieis proprius Extensor digitorum communis Extensor digiti minimi Radial Radial Radial Nerve root Flexor digitorum superficiahs Flexor digitorum profundus Median Meehan C7-T1 C7-T1 C&-C8 C&-C8 C&-C8 Common pathological situations: • Pain occurs in tendinitis of the extensor indicis proprius or of one of the tendons of the extensor digitorum communis.52. Intrinsic muscles of the hand Remark Positioning and procedure. These muscles can be tested by spreading the fingers against resistance followed by squeezing the examiner's finger.

During squeezing the examiner places his finger between the proximal interphalangeal joints. Anatomical structures tested: Muscle function: • • Flg. When spreading the examiner applies resistance at the distal phalanges. three palmar interossei. Interosseus dorsalis 11 Interosseus dorsalis lV.53 Resisted separation of the fingers: II-III. Resist the subject's attempt to spread the index and middle fingers (Fig. Spreading: 1/-11/ Procedure. Resist the subject's attempt to spread the middle and ring fingers (Fig. 3.52 (Left) Abduction. four dorsal interossei.53). 3. 3.3. (right) adduction. Anatomical structures tested: Muscle function: • • Interosseus dorsalis I Interosseus dorsalis m.WRIST 59 � f---I __ I I I I \Hf! � f 1/ I Flg. Copyrighted Material .54 Resisted separation of the fingers: Ill IV - . 3. Spreading: II/-IV Procedure. There are no common mistakes. I I Fig.54). The positioning is the same for all six tests.

Muscle function: • • interosseus palmaris II Interosseus dorsalis II. 3.60 ATLAS OF ORTHOPEDIC EXAMINATION Fig.56). Resist the subject's attempt to spread the ring and little fingers (Fig.55 Resisted separation of the fingers: IV-V.3. Procedure. Anatomical structures tested: Muscle function: • • Procedure.58 Squeezing the fingers: IV-V.57).55).57 Squeezing Ihe fingers: III-IV.56 Squeezing the fingers: II-III. 3.58). 3. Fig. Resist the subject's attempt to squeeze your finger between middle and ring fingers (Fig. Anatomical structures tested: Muscle function: • • lnterosseus palmaris IV Abductor digiti minimi. 3. Copyrighted Material . Anatomical structures tested: Fig. 3. Resist the subject's attempt to squeeze your finger between ring and little fingers (Fig. Squeezing: 1/-/11 Interosseus dorsalis III Interosseus palmaris IV. Resist the subject's attempt to squeeze your finger between index and middle fingers (Fig. 3. Flg. Squeezing: IV-V Procedure. 3. Spreading: /V-V Squeezing: /II-IV Procedure.

WRIST 61 Anatomical structures tested: Muscle function: • • Interosseus dorsalis IV Interosseus palmaris V. Give a slight percussion on Guyon's tunnel. - SPECIFIC TESTS Phalen's test = forced flexion of the wrist (Fig. or of the ulnar nerve 1 1> ulnar fingers. The examiner grasps the wrist with one hand. - Neural function: Muscle Peripheral Dorsal lnlerossei Palmar Interossei Abductor dIgiti minimi Ulnar Ulnar Ulnar Innervation Nerve rool Positioning. It may also indicate a lesion of the ulnar nerve. With the other hand he takes hold of the subject's hand. The other hand uses the percussion hammer. Give a slight percussion on the carpal tunnel. Copyrighted Material . The subject presents the hand. Bring the subject's wrist passively into full flexion and keep it in that position for about a minute. CB-T1 C8-T1 C8-T1 Common pathological situations: • Pain is usually the result of a lesion in one of the dorsal interossei. 3. 3.60 TInel's test. the pressure causes paraesthesia in the territory of the median nerve 3l-> fingers medially and palmar. 3.59) Significance. The examiner grasps the distal forearm with the contralateral hand. This is a percussion test for the median nerve in the carpal tunnel or for the ulnar nerve in Guyon's tunnel. Fig. • Weakness may be one of the first signs of an amyotrophic lateral sclerosis or of involvement of the T1 nerve root. It should elicit par­ aesthesia in the territory either of the medjan nerve 3l-> fingers medially and palmar.59 Phalen's test. The subject presents the hand palm upwards. Tinel's test = percussion of the carpal tunnel (Fig. Fig. The combination of positive tests shows which one is affected. Procedure. Procedure. Then suddenly release the compression.60) Significance. This is a compression test for the median nerve in the carpal tunnel. 3. Release of Positioning.

62 ATLAS OF ORTHOPEDIC EXAMINATION Grind test for the trapezium-first metacarpal joint (Fig. Fig. It should be more painful than the ulnar deviation test as described on page 51. Positioning. 3. first metacarpal included. Exert axial pressure and circumduct the first metacarpal bone.62) Significance. The subject stands with the arm hanging and the elbow 90° flexed. Fin kelstein's test (Fig. 3. Procedure. This test is meant to confirm the presence of de Quervain's disease.61) Significance. which is kept between his arm and trunk. The contra­ lateral hand grasps and stabilizes the wrist. 3. Copyrighted Material . Pull the subject's wrist to the ulnar side until the end of range is reached. Positioning. The other hand grasps the subject's hand distally on the metacarpals. The examiner stands level with the subject's hand. the elbow flexed to a right angle and the forearm pronated. The other hand takes hold of the distal part of the first metacarpal bone.62 Finkelstein's lest. The subject stands with the arm hanging. The examiner stands next to the subject.61 Grind lest Fig. The contralateral hand carries the forearm. 3. This test is meant to detect crepitus as a symptom indicating arthrosis. Procedure.

1 Bony landmarks in vivo. This bony prominence forms the point of origin of both the sartorius muscle and the tensor fasciae latae C Fig.1) The inguinal fold can easily be identified. 63 Copyrighted Material .CHAPTER CONTENTS Surface and palpatory anatomy 63 Anterior 63 Bony landmarks 63 Palpation of soft tissue Posterior 66 Bony landmarks 66 Palpation of soft tissue 64 Hip 68 69 Passive tests 70 Passive flexion 70 Passive external rotation 70 Passive medial rotation 71 Passive abduction 71 Passive adduction 72 Passive extension 72 Isometric contractions 73 Resisted flexion 73 Resisted abduction 74 Resisted adduction 74 Resisted extension 75 Resisted medial rotation 75 Resisted lateral rotation 76 Resisted flexion of the knee 77 Resisted extension of the knee 77 Specific tests 78 Bilateral passive medial rotation in prone position 78 Adduction in flexion 79 Forceful upwards thrust to the heel 79 Ortolani's test 79 Barlow's test 80 Functional examination of the hlp SURFACE AND PALPATORY ANATOMY ANTERIOR Bony landmarks (Fig. It covers the inguinal ligament (A) that can be palpated as a strong fibrous band. 4. The anterior superior iliac spine (B) is located at the craniolatera] end of the fold. 4.

At the medial end of the inguinal fold another bony prominence can be palpated. Fig. This movement makes the belly of the muscle better visible. forming an inverted V (the lateral femoral triangle).the inferior iliac spine . The spine continues laterally and dorsally in the iliac crest (C). the pubic tubercle (O). Two structures can be felt and I or seen. Place the palpating finger a few centimetres distal to the anterior superior iliac spine and ask the patient to lift and abduct the extended leg. Lateral femoral triangle muscle Medial triangle Gracilis muscle Fig.from which the muscle originates. 4. 4.3).2 Bony landmarks. 4. bend the hip to 60' and add some resistance.4).64 ATLAS OF ORTHOPEDIC EXAMINATION muscles. The origin of the latter is felt deeply in the lateral femoral triangle. It provides attachment for the medial end of the inguinal ligament and for the tendon of the rectus abdominis. 4.3 Lateral femoral triangle.2) each side of the finger. about 5 cm distal to the anterior superior iliac spine.4 Rectus femoris in the lateral femoral triangle. Normally it lies level with the super­ ior aspect of the greater trochanter. Palpation of soft tissue Palpation of the superficial flexors: the lateral femoral triangle (Fig. The sartorius (A) is the medial and the tensor fasciae latae the lateral muscle (6) (Fig. Palpate a bony pro­ minence . The tendon of the adductor longus originates just below this tubercle. Notice also the belly of the rectus femoris (C) a few centimetres distal to the inverted V (Fig. Ask the patient to extend the knee. Copyrighted Material . 4. one at Fig. 4.

The floor of the triangle is formed by portions of the iliopsoas on the lateral side and the pectineus on the medial side.7). Stand level with the knee of the subject at the ipsilateral side and face the hip. gracilis.7 Palpation of the adductor longus (muscle). The former is resisted with the contralateral hand. 7. adductor longus. 3. pectineus. 4. the latter with the ipsilateral one. medially by the adductor longus and laterally by the sartoriU5. 5. Fig. Fig. Definition in vivo To define the belly of the sartorius. Stand level with the slightly flexed knee. The hip is slightly bent and slightly abducted. The muscle becomes even more visible if the subject is asked to add some flexion movement in the knee (Fig.HIP 65 Medial femoral triangle (trigonum of Scarpa) (Fig. Place the ipsilateral hand at the inner side of the knee and resist the adduction movement. 4. 4. Copyrighted Material . inguinal ligament. The adductor longus is revealed as the most pro­ minent anterior and medial structure (Fig.6 Palpation of sartorius (muscle). femoral artery. The hip is slightly flexed and abducted. 6. 4. tensor fasciae latae.5 Anterior view of the hip muscle: 1. 4. 4. 9. 4. sartorius. iliopsoas. The starting position is the same. To define the adductor fongus. rectus femoris.6).5) The medial femoral triangle is defined superiorly by the inguinal ligament. the foot rests on the couch. 8. 2. Ask the patient to perform a flexion and lateral rotation at the hip. Keep the knee 90° flexed with its lateral side resting against your hip. Flg.

It provides attachment for the hamstring tendons posteriorly and the quadratus femoris and adductor magnus medially. Just medial to it the strong adductor longus is again recognized. just below the inguinal ligament.66 ATLAS OF ORTHOPEDIC EXAMINATION Palpation of the iliopsoas tendon and neurovascular structures in the groin The most important landmark is the femoral artery whose pulse is easily found under the inguinal ligament. The tendon of the iliopsoas can be detected between the femoral artery and the sartorius muscle. The muscular structure that can be palpated deeply in the medial corner of the medial femoral triangle is the pectineus muscle. well below the gluteal folds (Fig.7). The iliac crests are palpated with the radial sides of the index fingers by holding the pro­ nated hands against the lower borders of the loins (Fig. The artery courses downwards and slightly medially towards the tip of the triangle. is only palpable over a small extent and therefore difficult to examine. To facilitate the palpation one can bring the hip into slight flexion and slight lateral rotation. The localization can be confirmed when the patient is asked to flex the hip against resistance. 4. The ischial tuberosity Place the palpating thumbs at the dorsal and medial side of the thighs. The muscle The pronated hands rest on the iliac crests. As this is a bi-articular structure it becomes more stretched when the knee is extended during a passive hip abduction. Its origin at the pubic tubercle can be palpated as a strong cord (Fig. In most individuals the lack of fat tissue at this level can be seen as a dimple just above and medial to the buttock. Fig. 4. The first bone that is encountered is the ischial tuberOSity. Posterior superior iliac spine Palpation of the long adductors Muscle bellies of adductor longus. The origin of the adductor magnus is posterior to the graCilis and anterior to the origin of the hamstrings on the ischial tuberosity. 4. The femoral nerve can sometimes be felt as a small and round strand rolling under the palpating finger about one finger-width lateral to the artery and just distal to the inguinal ligament. the trochanter and the ischial tuberosity are easy to locate in a prone lying subject. The broad and flat tendon on the ischiopubic ramus is therefore felt to press against the palpating finger when the knee of the abducted leg is gradually brought into extension. The structure that becomes visible during pas­ sive abduction of the hip is the adductor longus (Fig.9). 10). A). and move them in a cranial direction.9).8. The thumbs glide in a caudal direction until they are arrested by the bony and thick posterior superior iliac spine (Fig. They take origin from the pubic tubercle (adductor longus) and the ischiopubic ramus (gracilis and adductor magnus). The femoral vein is medial to the artery and in normal circumstances not palpable.8 Palpation of the gracilis. 4. Posterior to the adductor longus and slightly more lateral the gracilis (B) can be palpated. 4. 4. POSTERIOR Bony landmarks The iliac crests. the posterior superior iliac spine. Copyrighted Material . gracilis and adductor magnus can be palpated at the medial side of the thigh.

where the bone is not covered by muscles.4.12 Localization of the trochanters. 4. At the medial aspect of the tuberosity a strong fibrous band can be felt.12) Palpation of this important landmark is relatively easy at its posterior edge.11). the tuberosity is covered by the gluteus maximus and adipose tissue. 4. The upper aspect of both trochanters should be on the same horizontal Fig.9 Pal pation of the posterior superior iliac spines.10 Palpation of the ischial tuberosity. Trochanter (Fig. Fig. With the hip extended.11 The sacrotuberous ligament. Sacrotuberous ligament Fig. If the hip is flexed. joining the sacrum in a craniomedial direction. This is the sacrotuberous ligament (Fig.HIP 67 / Flg. the gluteus maximus moves up­ wards and the ischial tuberosity becomes better palpable. Copyrighted Material . 4. 4. 4.

4.13) Lateral view of the hip muscles: 1.13 1. the upper border of the trochanter. Flg. the gluteus maximus moves upwards. 4. gluteus maximus. 4. exposing the ischial tuberosity so the tendon can be palpated more easily. tensor fasciae latae. the coccyx and the head of the femur. gluteus maximus. semitendinoslis and semimembranosus originate from a common tendon at the inferior aspect of the ischial tuberosity.14) Only a small part of the muscle can be palpated between the iliac crest. the upper border of the gluteus maxi­ mus and the posterior border of the tensor fascia lata.15 and 4. Extension of the thigh brings it into a contracted position. this nerve is palpable underneath the adipose tissue. level as the pubic tubercles. gluteus medius. Posterior superior iliac spine. In a slightly flexed pOSition of the hip. 2. iliotibial tract. 4. If the hip is slightly flexed. Sciatic nerve (Fig. The lower border of the muscle is not the lower border of the gluteal fold as the latter consists merely of fat tissue. The muscle is palpable over its entire width. 3. A resisted flexion of the knee makes it visible. 3.16) Biceps. Palpation of soft tissue Gluteus maximus (Fig.68 ATLAS OF ORTHOPEDIC EXAMINATION Fig. Gluteus medius (Fig. 4.17) The sciatic nerve passes to the leg between the greater trochanter and the ischial tuberosity. gluteus medius. 4. The upper border of the muscle coincides with the line connecting the upper border of the trochanter with the upper border of the posterior superior iliac spine. Hamstrings (Figs 4. 2.14 The muscle belly of the gluteus maximus and fat deposits are responsible for the typical shape of the buttocks. Copyrighted Material .

4. 4. Examination of the hip cannot be disconnected from that of the lumbar spine and the sacroiliac joints: pain in the buttock or thigh has very often a lumbar or sacroiliac origin. Most of the hip tests are executed by using the leg as a lever. 4. Therefore. 4.HIP 69 Fig. gluteus maximus (resected). Furthermore. piriformis.16 Extensors of the hlp (hamstrings): 1. semimembranosus. sciatic nerve.15 Palpation of the hamstrings. ischial tuberosity. 3. 3. semitendinosus. Fig. Copyrighted Material .17 The sciatic nerve: 1. 2. gemellus superior. it is also very difficult to examine the hip without applying stress on sacroiliac joints and lumbar joints. biceps femoris. a preliminary examination of lumbar spine and sacroiliac joint may be appropriate to exclude any lesion in these regions. FUNCTIONAL EXAMINATION OF THE HIP Introduction/general remarks 2-=::::jLll Flg. 2. 5.

posterior part of the joint capsule . 4. beyond the range where the tilt of the pelvis starts. Procedure. Copyrighted Material . Normallunctional anatomy: • Range: 60-90° Fig.18).muscles of the buttock . 4. Common mistakes. Normallunctional anatomy: • • • Rat/ge: 110-130° Elld-fee/: ligamentous LimitiNg structures: . the other hand is put at the knee and stabilizes the femur in a vertical position. Meanwhile a slight axial pressure is applied on the femur (Fig. 4. Typically the femur moves laterally when the flexion is forced. In children this abduction movement during flexion is often the first manifestation of Perthes' disease. The subject lies in the supine posi­ tion with the hip and knee bent to 90°. This is precluded by sufficient axial pressure.70 ATLAS OF ORTHOPEDIC EXAMINATION PASSIVE TESTS Passive flexion Positioning. until the movement comes to a soft stop (Fig. The subject lies relaxed in the supine position. Observe the anterior iliac spine of the opposite side to detect the start of a lateral pelvic tilt. The examiner stands level with the subject's hip. One hand supports the lower leg just above the ankle. mean­ while assuring the vertical position of the femur. The leg is pushed beyond the possible range. • Moving the thigh too much laterally towards the shoulder.19 Passive external rOlation. Common mistakes: • Common pathological situations: • • • Too hard an end-feel on passive flexion is one of the first signs of an osteoartmosis. Passive external rotation Positioning. which causes a lateral tilt of the pelvis. Rotate the lower leg inwards. Fig.contact between labrum and neck. Carrying the movement too far. In advanced arthrosis this movement is markedly limited.18 Passive flexion. 4. Alternative technique: one hand can be placed under the pelvis in order to detect the start of the pelvic tilt. Procedure.19). The examiner stands level with the hip. Both hands lift the knee upwards towards the subject's chest until the movement stops.

pubofemoral ligament . which causes a lateral tilt of the pelviS. mean­ while assuring the vertical position of the femur. The examiner stands level with the subject's hip. The subject lies in the supine posi­ tion. Procedure. Common mistakes. The movement is continued beyond the possible range. Children with a slipped epiphysis may present with an increased range of external rotation. 4. Rotate the lower leg outwards. piriformiS. One hand grasps the distal thigh from the medial side. quadratus femoris.superior part of the iliofemoral ligament . until the movement comes to a soft stop (Fig. Rallge: 45-00° End-feel: hard ligamentous Limiting structures: . with the lower leg pendent.20). In arthrosis it is usually the first movement to become limited. 4. The knee is abducted with the pendent lower leg until the movement stops (Fig. trochanteric bursitis and in the presence of internal derangement in the hip. • • In arthritis. near the border of the couch. In arthrosis the external rotation is usually the last movement to become disturbed. Observe the anterior iliac spine of the opposite side to detect the start of a lateral pelvic tilt. 4.HIP 71 • • End-feel: ligamentous Limitillg strllctures: . obturator extemus and intemus. Normal functional anatomy: • • • Fig. Procedure.pubofemoral and ischiofemoral ligaments . the medial rotation is the most painful movement. the other hand stabilizes the femur at the knee.20 Passive internal rotation. Owing to tension in the hi-articular gracilis. gluteus medius. Rallge: 45-60° Elld1eel: ligamentous Limitillg strllctures: . The examiner stands level with the subject's hip. Common pathological situations: Passive medial rotation Positioning.tensor fasciae latae and gluteus minim us. Copyrighted Material .adductor muscles.buttock muscles: gluteus maximus. The subject lies in the supine posi­ tion with the hip and knee bent to 90°. gemelli.21). Normal functional anatomy: • • • Common pathological situations: • • • This movement can be extremely painful and / or limited in psoas bursitis. Passive abduction POSitioning. Common mistakes: • • Carrying on abduction beyond the start of the lateral pelvic tilt.the ischiofemoral ligament . One hand supports the lower leg just above the ankle. abduction with extended knee has very often a shorter range of motion. The other hand is placed on the opposite anterior superior iliac spine in order to stabilize the pelvis.

superior part of the iliofemoral ligament . When the move­ ment is painful at the outer side of the hip. just below the gluteal fold. One hand carries the heel. • This test may provoke groin pain in an adductor tendinitis and trochanteric or gluteal pain in bursitis. Lift the knee off the couch until the movement comes to a stop. Passive adduction Positioning. stress will be induced at the ipsilateral sacroiliac joint. Common pathological situations. Normal functional anatomy: • • Range: 10-30° End-Jee/: hard ligamentous Copyrighted Material . The examiner stands level with the hip.72 ATLAS OF ORTHOPEDIC EXAMINATION Fig. gemelli. 4. Common pathological situations: • Fig. Meanwhile press the pelvis firmly to the couch (Fig. The subject lies in a relaxed supine position. a lesion of the iliotibial tract or a gluteal bursitis may be considered. The other hand grasps the thigh just proximal to the patella. Normal functional anatomy: • • • Range: 20--45° End-feel: soft ligamentous Limiting structures: . 4. • Lack of stabilization allows the pelvis to move upwards. piriformis and obturator internus. The subject lies prone with the hip extended.22 Passive adduction. If the stabilizing hand is placed too high up on the sacrum. causing a false interpretation of the range of hip extension and putting stress on the lower lumbar spine and the sacroiliac joint. 4.23).22). One hand is placed on the thigh. Procedure. Move the leg into adduction under the extended contralateral leg until the pelvis starts tilting laterally (Fig. 4. Serious painful limitation occurs in arthritis and painless limitation in arthrosis.iliotibial band. Adduction and medial rotation is unintentionally added in the contralateral hip. The examiner stands at the foot-end of the couch. Common mistakes: • • Passive extension Positioning. Procedure.21 Passive abduction. Common mistakes: • Carrying on adduction beyond the start of lateral pelvic tilt. the other hand lifts the extended contralateral leg to about 45° of nexion. tensor fasciae latae superior part of gluteus maximus and medius.

iliopsoas muscle. Neural function: Muscle Peripheral Iliopsoas Sartorius Femoral nerve Femoral nerve Femoral nerve Superior gluteal nerve Femoral + obturator nerve Obturator nerve Obturator nerve Obturator + sciatic neNa + ISOMETRIC CONTRACTIONS Resisted flexion The subject lies in the supine posi­ tion with the hip flexed to a right angle.24). Procedure. A sudden start or sudden stop may induce unintentional movement. brevis and magnus. Common mistakes. The examiner stands level with the thigh and places one knee against the ischial tuberosity. • A painless weakness is always a warning sign for serious disorders: second root palsy. Innervation Nerve root lumbar plexus Rectus femoris Tensor fasciae latae Pectineus Adductor longus Adductor brevis Adductor magnus l2.L3 L3 LS l2.HIP 7 3 Fig. Positioning.L3 l2. It may. Anatomical structures tested: • limitiNg strllcillres: . nervus femoralis palsy or abdominal neoplasma. Both hands are clasped at the anterior and distal end of the thigh.2 3 Passive extension.anterior part of the capsule with the iliofemoral.L3 L3.24 Resisted flexion. 4. Copyrighted Material . • Accessory flexors: . Some children have an isolated limitation of extension.Pectineus . pubofemoral and ischiofemoral ligaments . 4. Muscle function: • III/portallt flexors: Iliopsoas Rectus femoris Sartorius Tensor fasciae latae Common pathological situations: • • Extension is one of the first movements to become restricted in arthritis and arthrosis. however. L4 Common pathological situations: Resist the subject's attempt to flex the hi p (Fig. Fig.L3 l2.Adductor longus. also be present in psychoneurosis. 4.L3 l2.

25). None. 4. Common mistakes. Pain and weakness are found in avulsion fractures of the lesser trochanter and anterior superior spine. None. Imporlanl abdllclors: Gluteus medius Gluteus minimus Tensor fasciae latae Gluteus maximus The subject lies supine and relaxed with both hips slightly abducted. 4. Fig. Neural function: Muscle Peripheral Gluteus medius Gluteus mlnimus Tensor fasciae Istae Superior gluteal nerve SupeOor gluteal nerve Superior gluteal nerve Inferior gluteal nerve Lumbosacral plexus Femoral nerve Innervation Nerve root L5 L5 L5 Resisted abduction Positioning. Ask the subject to squeeze the fist. 4. sartorius or rectus femoris.26).26 ReSisted adduction. Common mistakes.Sartorius. In congenital dislocation of the hip the movement shows some weakness. Anatomical structures tested: Muscle function: • Resisted adduction Positioning. just proximal to the ankles. Alternatively it may originate from stress placed upon strained or inflamed sacroiliac ligaments.74 ATLAS OF ORTHOPEDIC EXAMINATION • • Pain alone may indicate a tendinitis of psoas. • Pain may be the result of compression of an inflamed gluteal bursa.25 Resisted abduction. l3 Common pathological situations: • Resist the abduction movement • (Fig. Procedure.52 l2. Gluteus maximus (upper part) Piriformis Sartorius The subject lies supine and relaxed with both hips slightly abducted. Fig. The examiner stands at the foot-end of the couch and places both hands on the lateral aspect of the lower legs.Piriformis . 4. The examiner stands at the foot-end of the couch and places the clenched fist between both knees (Fig. • Accessory abdllctors: . Copyrighted Material . Procedure. 51 $1.

52 51. The examiner stands at the foot-end of the couch. None.51 $1.52 51. Procedure.27 Resisted extension. Buttock pain is often the consequence of transmitted stress to inflamed sacroiliac joints. L3. just distal to the knees. Copyrighted Material . 4. Common pathological situations. Common mistakes. L3 L2. The examiner sits at the foot·end of the couch. L2. The subject lies in the prone position with the hips slightly abducted and the knees flexed to 90°. L5. 4.HIP 75 Anatomical structures tested: Muscle function: • Importallt addllctors: Adductor longus Adductor brevis Adductor magnus Pectineus Gracilis Gluteus maximus (lower part) Obturator externus Quadratus femoris Biceps femoris. l4 Resisted extension The subject lies in a relaxed supine position with the hips slightly abducted. • Accessory addllctors: - Neural function: Muscle Peripheral Adductor longus Adductor brevis Adductor magnus Pectineus Gracilis Gluteus maximus (lower pan) Obturator extemus Quadratus lemoris Biceps femoris Obturator nerve Obturator nerve Obturator Femoral + Innervation Nerve root Fig.52 l3. and places both hands against the outer malleoli. Ask the subject to push the extended leg towards the couch and resist the movement. L4 L4. Pain may result from a hamstring lesion or a sacroiliac strain. His clasped hands carry the heel and lift up the leg (Fig. L3 l3. L3 L2.27). L4 $1 L3. Positioning. L4 sciatic nerve Anatomical structures tested: Muscle function: • • • • • + obturator nerve Obturator nerve Inferior gluteal nerve Obturator nerve Interior gluteal nerve Sciatic nerve L2. Neural function: Muscle Peripheral Gluteus maximus Semimembranosus Semitendinosus Biceps femoris Adductor magnus Inferior gluteal nerve SclaUc nerve Sciatic nerve Sciatic nerve Obturator + sciatic nerve Innervation Spinal 51 51.52 Gluteus maximus Semimembranosus Semitendinosus Biceps femoris Adductor magnus Common pathological situations: • • Groin pain is usually the result of an adductor tendinitis or a stress fracture of the inferior pubic ramus. Resisted medial rotation POSitioning.

29). Make sure that the knees do not separate during the procedure.29 Bilateral resisted lateral rotation. The examiner sits at the foot-end of the couch. Lordosis of the back may pro­ voke pain from either the lumbosacral junction or the sacroiliac joints. Anatomical structures tested: Muscle function: • • • • Tensor fasciae latae Gluteus medius Gluteus rninimus Adductor magnus. L4 Common pathological situations.28 Bilateral resisted medial rotation. just distal to the knees. Pain usually Fig. This could provoke pain from either the lumbosacral junction or the sacroiliac joints. The subject lies prone with the hips slightly abducted and the knees flexed to 900.76 ATLAS OF ORTHOPEDIC EXAMINATION results from transmitted stress to an inflamed bursa. 4. and resist the movemenl (Fig. Copyrighted Material . Lordosis of the back. Common mistakes: • • III/portnllt lateral rotators: Piriformis Quadratus femoris Obturator internus and externus Gemelli Gluteus medius and maxim us Sartorius Iliopsoas Abduction of the thighs. Neural function: Muscle Peripheral Tensor fasciae latae Gluteus medius Gluteus minlmus Adductor magnus Superior gluteal nerve Superior gluteal nerve Superior gluteal nerve Obturator + sciatic nerve Innervation Spinal L5 L5 LS l3. Procedure.28). and resist the movement (Fig. Resisted lateral rotation Positioning. Ask the subject to push the legs in an outward direction. With crossed arms. 4. Common mistakes. Anatomical structures tested: Muscle function: • Fig. 4. 4. Procedure. Ask the subject to push the feel towards each other. he places both hands against the internal malleoli.

Neural (unction: Muscle Innervation Peripheral Semimembranosus Semitendinosus Biceps lemoris Sciatic nerve Sciatic nerve Sciatic nerve Spinal S1. The elbow of the other arm is positioned ventrally around the distal end of the lower leg.30). The examiner stands level with the thigh and leans over the subject. • • Semitendinosus Biceps femoris.S2 L3. 51 51.l4 L3.S1. 4. Positioning. Common pathological situations: • Ask the subject to flex the knee. the other presses against the distal end of the lower leg. L5. 4.3 l2. L5. Procedure. Hyperlordosis can provoke pain in the sacroiliac joints or lumbosacral junction. One hand is on the ilium. Groin pain may be provoked in lesions of the sartorius muscle. The subject lies prone with the knee flexed to 70°.$1 L5. The examiner stands level with the thigh and leans over the subject. The ipsilateral hand is placed on the distal end of the thigh to stabilize it on the couch.51 L4.1. l2.52 L5. Common mIstakes: • • Pain in the thigh is due to a lesion of the hamstrings.HIP 77 • Accessory lateral rotators: . L3 L3.$2 SI.Pectineus. 51 L5. Weakness is a common sign in first and second root palSies.S2 L2. • In strong subjects the flexion of the knee can not be opposed if the trunk of the examiner is not positioned well over the leg. L4 Fig. Anatomical structures tested: Muscle (unction: • Semimembranosus Copyrighted Material . L4 L5.52 Resisted flexion of the knee The subject lies prone with the knee in 30° of flexion. L3 Common pathological situations: • • Gluteal pain is usually the result of a compression of an inflamed bursa. Resisted extension of the knee Positioning.Adductor longus and brevis . Neural function: Muscle Peripheral Quadratus femoris Piriformis Obturator internus Obturator extemus Gemellus superior Gemellus inferior Gluteus medius Gluteus maximus Sartorius Iliopsoas Adductor brevis Adductor longus Pectineus Sacral plexus Lumbosacral plexus Sacral plexus Obturator nerve Superior gluteal nerve Inferior gluteal nerve Superior gluteal nerve Inferior gluteal nerve Femoral nerve Femoral nerve Obturator nerve Obturator nerve Femoral nerve Innervation Spinal L4. and resist the movement (Fig.51.$2 51.30 Resisted flexion of the knee.

Procedure.32 Passive medial rotation. Copyrighted Material . and resist the movement (Fig. Rotate the thighs outwards until the movement comes to a ligamentous stop (Fig. Fig. Neural function: Muscle Peripheral Quadnceps femoris Femoralis nerve Innervation Spinal L3 Common pathological situations: • • Pain in the thigh is due to a lesion of the quadriceps. The subject lies in the prone position with the knees together and flexed to 90°. In order to be able to withstand even the strongest extension. Ask the subject to extend the knee.78 ATLAS OF ORTHOPEDIC EXAMINATION SPECIFIC TESTS Bilateral passive medial rotation in prone position Significance This test is very useful in detecting minor limita­ tions. Care should be taken to keep the buttocks level during the whole procedure.32). In children either a minor restriction or change in end-feel can be the first sign of Perthes' disease. Fig. 4. even the slightest limitation of medial rotation or a divergence in the end-feel can be detected. Common mistakes. 4. 4. Common mistakes: • • In strong subjects the extension of the knee can not be opposed if the examiner is not leaning in the direction of the subject's head. Since both hips are examined together. • A minor limitation may be an early sign of arthritis: this is the first movement to become restricted at the onset of the disease. the hand of the supporting arm may grasp the stabilizing arm.31). just distal to the knees. 4. Hyperlordosis may elicit pain from sacroiliac structures or the lumbosacral junction.31 Resisted extension of the knee. Weakness is the result of a third lumbar root lesion or a femoralis palsy. Anatomical structures tested: Muscle function: • Quadriceps femoris. and places both hands against the inner malleoli. Positioning. Common pathological situations: • Procedure. The examiner stands at the foot-end of the couch.

4. even in the absence of radiographic signs. The subject lies supine with the hip slightly abducted and externally rotated. Abduction is performed. Procedure. Ortolani's test Significance This test is used for early detection of congenital dislocation of the hip in babies. 4.33). Copyrighted Material . Forceful upwards thrust to the heel Significance This provocation test may be used to provoke groin pain when an incipient aseptic necrosis of the hip is feared. Procedure. the femoral head rides over the acetabular edge and reduces. During the test a subluxated hip is reduced. The baby lies on its back with the hips flexed to 90° and the knees completely flexed (Fig. 4.34). However. knee extended. In a subluxated hip. Positioning. aXially in the direction of the hip.35a). The examiner grasps the leg in such a way that the thumb presses on the inner side of the thigh and the ring and middle fingers are on the outer thigh. Positioning.HIP 79 Adduction in flexion Significance This provocation test may be used to compress a painful structure in the groin (psoas bursa or tendon of rectus femoris). A forceful upwards blow on the heel. and the Positioning. gluteal muscles and bursae and the sacroiliac joint). Flg. a clear limitation of the abduction at the pathological side will be detected. that provokes groin pain is suggestive of an incipient aseptic necrosis. One hand carries the heel and lifts the extended leg to 45° (Fig. The examiner stands at the foot­ end of the couch.33 Adduction in flexion. If the hip displacement is irreducible. This is felt as a snap. This test also stretches several posterior structures (capsule of the hip joint. The examiner stands level with the hip and places one hand on the lateral side of the knee. resistance is felt at 4�0. The subject lies supine with the hip flexed to a right angle. Force the knee inwards towards the contralateral iliac crest until the movement stops (Fig. Fig.35b).34 Forceful upwards thrust to the heel. the tips touching the trochanter. 4. Procedure (Fig. it should be interpreted with utmost care because other elements such as veins and lymph nodes can also be compressed. 4. Further investigation is mandatory. The moment the resistance is overcome. 4.

35 Ortolani's test for congenital dislocation of the hip: (a) position of the baby. The examiner grasps the leg in such a way that the Fig. the tips touching the trochanter (Fig. Positioning. (b) reposition of the dislocated hip by abduction. 4. Barlow's test Significance thumb presses on the inner side of the thigh and the ring and middle fingers are on the outer thigh. The baby lies on its back.80 ATLAS OF ORTHOPEDIC EXAMINATION Ib) Fig.36 Barlow's test for congenital dislocation of the hip. During the test the hip is first subluxated and then replaced. Copyrighted Material .36). 4. the examiner can press the femoral head outwards and backwards over the acetabular rim. 4. hips flexed to 900 and the knees completely flexed. This is indicated by a click. Procedure. If the capsule is elongated. The test is used for early detection of congenital dislocation of the hip in babies. Anterior pressure with the fingertips behind the trochanter can then reduce the hip.

In a flexed position of the knee. Following this condyle in a lateral and posterior direction.1 and 5. The sharp edges of the medial (E) and lateral (F) tibial condyles border the joint line inferiorly and are easy to locate. 81 Copyrighted Material . The flexed position is also suitable for the pal­ pation of the bony elements of tibia and fibula. The tibial tuberosity (G). In this position the large joint line between tibia and femur is situated about two finger-widths below the patellar apex (A). Palpation is performed with the sub­ ject in the supine lying position. is prolonged into the tibial crest (H). The inferior part of the medial femoral condyle (6) is easily detectable as a large spherical sub­ cutaneous bony structure that borders the supero­ medial part of the joint line. The head of the fibula (I) is easily palpated on a medially rotated leg.CHAPTER CONTENTS Surface and palpatory anatomy 81 Bony landmarks 81 Palpation of the extensor mechanism 83 Palpation of soft tissues at the medial side Palpation of soft tissues at the lateral side Palpation of the popliteal fossa 68 89 8 5 87 Knee Functional examination of the knee Passive tests 89 Passive flexion 89 Passive extension 90 Passive lateral rotation 91 Passive medial rotation 92 Valgus strain 93 Varus strain 94 Anterior drawer test 9 5 Posterior drawer test 97 Isometric contractions 98 Resisted extension 98 Resisted flexion 99 Resisted medial rotation 100 Resisted lateral rotation 101 Specific tests 101 Medial shearing 101 lateral shearing 102 Provocation tests for meniseal tears Specific tests for instability 104 Tests for fluid 10 5 Synovial thickening 107 SURFACE AND PALPATORY ANATOMY Bony landmarks (Figs 5. which is found about two finger-widths below the joint line. the patella can easily be outlined. depending on the palpated structure. 5.3). The knee is either bent to a right angle or fully extended.2) 103 All palpable bony parts of the knee are situated anteriorly. the palpating finger encounters the salient lateral epicondyle (0). The inferior part of the lateral femoral condyle forms the superior border of the lateral jOint line (C). Grabbed between thumb and index finger it can be mobilized in an antero­ posterior direction (Fig.

1 Bony landmarks .82 ATLAS OF ORTHOPEDIC EXAMINATION A A B Fig. about the width of one thumb below the edge and just in the middle between the tibio­ fibular joint line and the tibial tuberosity. The infracondylar tubercle (tubercle of Gerdy).anteromedial view: (a) in vivo. which represents the insertion of the iliotibial tract. 5. (b) skeleton.anterolateral view: (a) In vivo. It is identified as follows: place the thumb of the contralateral hand on the tibial tuberosity and the middle finger on the tibiofibular joint. (b) skeleton. The index finger. 5. then touches the tubercle (Fig.4). is situated on the lateral epicondyle of the tibia. A B Fig. Copyrighted Material . 5.2 Bony landmarks . which is slightly more proximal.

Copyrighted Material .5 Extensor mechanism of the knee.3 Palpation of the fibular head. 5. Ask the patient to extend the slightly bent knee and resist the movement. The medial and lateral edges of the patella together with the quadriceps expansions are palpated in the following way. First the muscular structures are ascertained.5). Fig.7). 5.4 Palpation of the tubercle of Gerdy. The superoposterior border of the bone and the suprapatellar tendon can be palpated after the lower pole of the patella has been pressed posteriorly and upwards by the web of the thumb of the other hand (Figs 5. This movement usually outlines the vastus medialis (A). vastus lateralis (B).KNEE 83 Palpation of the extensor mechanism This is performed on an extended knee.6 and 5. 5. Fig. With the thumb of one hand. Then the patellar border with its tendinous insertions are palpated. the patella can be moved freely upwards and downwards in the patellar groove. 5. With the hip in flexion and the knee in full extension. Also side gliding and tilting is possible. the patella is tilted and pushed over Fig. rectus femoris (C) and the patellar ligament (0) (Fig.

Place the ring finger of the other hand under the projecting edge and press upwards.8). to the other side. -------� -----===-- -.10). so it can be palpated with more accuracy (Figs 5.6 Palpation of the suprapatellar tendon. so that the web of the thumb can exert downwards pressure. The patella is tilted (small arrows) by pressing on the inferior pole (large arrow).9 and 5. squeezing the tendinous fibres against the posterior aspect of the patella (Fig. The inferior pole of the patella and the inser­ tion of the infrapatellar tendon (patellar liga- ment) are palpated in a similar way. Copyrighted Material .---- Flg.84 ATLAS OF ORTHOPEDIC EXAMINATION Fig. 5.5. 5. Place one hand just above the patella. This stabilizes the patella and tilts the apex upwards.7 Palpation of the suprapatellar tendon.

5.8 Palpation of the quadriceps extension. Fig. 5.10 Palpation of the infrapalel1ar tendon. The patella is pressed distally. Fig. Copyrighted Material .5. which moves the inferior pole upwards (arrows).KNEE 85 Fig.9 Palpation of the infrapatellar tendon.

Its fibres run obliquely.86 ATLAS OF ORTHOPEDIC EXAMINATION Fig. just behind and slightly under the insertions of the pes anserinus. flat and almost triangular band.11) is a broad. can not be palpated because the posterior fibres blend intimately with those of the posterior capsule and with the medial and posterior border of the medial meniscus. Pes anserinus The pes anserinus (the common insertion of the semitendinosus. This is the anterior border of the medial collateral ligament (A). dose to the inser­ tion of the adductor magnus tendon. however. Notice that the anterior border of the ligament is situated more posteriorly than is usually thought. the graciliS and the sartorius) is situated under and behind the medial tibial condyle.5. anteriorly and inferiorly.12). and sartorius (C). 5.11 The medial collateral ligament (1) and medial meniscus (2). Fig. to insert at the medial aspect of the tibia.13): semitendinosus (A). graciHs (8). Ask the patient to flex and internally rotate the knee and resist the movement.12 Palpation of the medial collateral ligament. Therefore the anterior border of the ligament can easily be palpated on an extended knee (Fig. The anterior fibres of the ligament are sepa­ rated from those of the capsule. Palpate the bony borders of the joint line in a posterior direction until the sharp edge of a ligamentous structure is felt to bridge the groove. Palpation of soft tissues at the medial side Medial collateral ligament The medial collateral Hgament (Fig. 5. Continue the palpation along the joint line and notice that the bony borders are now covered completely by the dense ligamentous structure. 5. Fig. 5. 5. Copyrighted Material . The posterior border of the ligament. The three tendinous structures are easily identified from distal to proximal (Fig.13 Palpation of the medial tendinous structures. Place the thumb just medially to the patellar tendon and in the intercondylar groove. with a large insertion on the posterosuperior aspect of the medial femoral epicondyle.

17). The sharp edge of the lateral epicondyle (A) is easily found about one finger-width below the lateral border. A re­ sisted flexion and/or lateral rotation brings the tendon of the biceps femoris (Fig.5.16. The tendon inserts at the top and the posterior aspect of the fibular head in two straps. 3. 5. foot on the couch (abduction and lateral rotation in the hip). The knee is still in a flexed position (Fig. 2. A) into prominence.KNEE 87 Flg. Fig. lateral collateral ligament. Identify the lateral border of the patella.5. The head of the fibula is identified first. In this pos. 5. The lateral collateral ligament (Fig. popliteus. showing the relations between the lateral muscles and ligaments: 1. iliotibial tract. The groove Copyrighted Material .15. Anteriorly a second bony projection is identified as the lateral condyle (6). The intra-articular origin of the popliteus tendon at the lateral condyle is identified as follows.14).15 Palpation of the lateral tendinous structures. 4. Move the leg outwards. biceps femoris.14 Lateral view of the knee.5. 5. A) is palpated in the following way. It is palpated as a tough round structure that runs from the head of the fibula to the lateral femoral epicondyle (C). one in front and one behind the insertion of the lateral collateral ligament.16 Palpation of the lateral collateral ligament. Palpation of soft tissues at the lateral side The lateral side of the knee forms a crossing point of different tendons and ligaments (Fig. The flexion movement usually also reveals the iliotibial tract (6) which is recognized as a horizontal flat band between biceps and vastus lateralis (C). meanwhile keeping the Flg.5. This movement brings the ligament under tension.i­ tion the ligament makes an 80° angle with the biceps femoris tendon (D). Place the pal­ pating finger on the top of the fibular head (6).

in between these bony structures forms the area from which the tendon emerges. The semi­ membranosus is situated deeper and has a flatter consistency on palpation. 7. Medially the tendon of the semitendinosus (A) is easily identified as a round cord. biceps femoris. 9. 5. which are shorter than Copyrighted Material . popliteal vein and popliteal artery. Fig. 5. lateral gastrocnemius. 2. popliteal artery.19).17 Palpation of the poplitiuS tendon. gracilis. medial gastrocnemius. 5. The junction between the semimembranosus Flg. 1 8 The popliteal fossa: 1. tibial nerve. A slight resisted flexion of the knee brings the upper borders of the popliteal fossa into prominence (Fig. 5. Palpation is performed with the subject in the prone-lying position. Its insertion is on the superior and posterior aspect of the fibular head. The latter runs intra-articularly and deep to the lateral collateral ligament to continue in the muscle belly that lies deeply in the popliteal fossa under the lateral gastrocnemius and the plantaris muscles. The inferior borders. common peroneal nerve. popliteal vein.18) are formed by the gastrocnemii. semimembranosus.5 . 10. the biceps femoris and the semitendinosus and semi­ membranosus muscles. The bottom is formed by the posterior capsule and the popliteus muscle.19 The popliteal fossa in vivo. The popliteal fossa is covered by a fascia. 4. The common peroneal nerve descends along the inner border of the biceps. The lozenge is vertically crossed (from lateral to medial) by: the tibial nerve. 8. 5. Palpation of the popliteal fossa The borders of the lozenge-shaped popliteal fossa (Fig. semitendinosus. 3. and the biceps forms the superior angle of the fossa. At the lateral side the biceps tendon (8) can also be recognized easily. The knee is slightly bent to release the posterior fascia. 6.88 ATLAS OF ORTHOPEDIC EXAMINATION Fig.

the other hand grasps the knee at the medial femoral condyle. Common mistakes. For instance. The nerve is felt as a hard and round structure in the centre of the lozenge. One hand grasps the distal part of the leg. Move the extended leg upwards until the knee can be flexed with a simultaneous movement of both hands. none of the so-called pathognomonic meniscus tests has a high positive predicting value (between 21 and 50%) which means that in more than half of the subjects with a positive meniscus test. intra-articular structures excluded. just proximal to the malleoli. 5. Procedure. It is important to realize that the quality of a clinical examination does not depend on the number of tests performed but on the accuracy of performance of the most important tests. The examiner stands level with the subject's knee. the distal hand continues the movement while the proximal hand just stabilizes the femur in a sagittal plane but allows hip flexion (Fig. 5. The patient is in the supine position.20). Furthermore. next to the knee. Once the flexion has begun. the superior ones. Diagnosis of a particular lesion also does not rely on the presence of one pathognomonic test but on the complete clinical picture (the sum of positive and negative answers after the perfor­ mance of a set of important standardized tests). Their junction constitutes the inferior angle of the lozenge. Normal functional anatomy: • Range: 1700 • End-feel: soft tissue approximation • Limitillg structures: approximation of calf muscles and hamstrings. the joint is relatively uncovered by muscles which facili­ tates palpation of most structures.KNEE 8 9 Fig. PASSIVE TESTS Passive flexion Positioning. the knee bent to a right angle and the foot flat on the couch. near the upper angle. Because it is situated at the ends of two long lever arms it is very well suited Copyrighted Material .21). The posterior aspects of medial and lateral femoral condyles can be palpated just under the gastrocnemii. The tibial vein and the tibial artery are located medial to it. no meniscai lesion is found on arthroscopy. Also. To palpate the pulsations of the artery. FUNCTIONAL EXAMINATION OF THE KNEE Introduction/general remarks The knee is the largest and most complex joint of the human body. The palpation is facilitated by a resisted plantiflexion of the foot. One should warn against too many different tests. Nerve and artery can be palpated as follows. the fingers must be plunged deeper and more medially. The tibial nerve is located in the centre of the lozenge and divides it in two. to clinical testing. the presence of a positive instability test has only value if it is interpreted in relation to the rest of the clinical evaluation. 5. None. and palpates the fossa from the medial aspect with the ipsilateral hand (Fig.20 Palpation of the popliteal fossa. the insertion of which is more proximally on the condyles. are formed by both gastroc­ nemii (C). The subject lies in the supine posi­ tion with extended legs. The examiner sits on the couch.

A spastic end-feel is typical for acute arthritis or haemarthrosis. Procedure. 5. taneous upwards movement of the heel and a downwards pressure on the tibia (Fig. ligamentous adhesions. The examiner stands level with the subject's knee.posterior crudate ligament . while the other carries the knee from the lateral side with the thumb on the tibial tuberosity. Perform a quick and short extension movement by a simul- Common pathological situations: • Perception of the end-feel on passive extension is extremely important in clinical diagnosis of knee joint lesions.22).posterior capsule . a hard end­ feel is suggestive of arthrosis. almost bony • Limiting structures: . a springy block indicates internal derangement and a soft liga­ mentous end-feel may be caused by ligamentous adhesions. Diagnosis depends on the pattern that emerges after the completion of the other tests and on the end-feel.ruciate ligament.anterior <. The end-feel is not evaluated because the movement is not performed pene­ tratingly enough. One hand grasps the lower leg at the heel.5. • Limited extension with a spastic end-feel in combination with more limitation of flexion indicates an acute arthritis. Common mistakes. Common pathological situations. Move the leg upwards. Numerous con­ ditions lead to limitation in flexion of the knee: capsular lesions.90 ATLAS OF ORTHOPEDIC EXAMINATION Fig.21 Passive flexion. Normal functional anatomy: • Rmlge: 0° (some extension in recurvatum may be possible) • End-feel: hard ligamentous. The subject lies in the supine posi­ tion with the legs extended. Copyrighted Material . Passive extension Positioning. internal derangement and extra-articular conditions.

22 Passive extension. 5. Pain at the end of range with a more or less normal end-feel is often seen in combination with a small ligamentous problem.23). Passive lateral rotation Positioning. The subject lies in the supine posi­ tion with the knee flexed to a right angle and the heel resting on the couch.23 Passive lateral rotation. Perform a lateral rotation by using the foot as a lever. The examiner stands level with the subject's knee. Fig.KNEE 91 Fig. Place the other shoulder against the knee. 5. and the hand under the heel. • • • Painless and slight limitation with crepitus is typical for arthrosis. the supporting arm only stabilizes (Fig. the arm under the lower leg. One hand grasps the forefoot at the inner side and presses it upwards in dorsiflexion. Procedure. Copyrighted Material . 10-30° of limitation with a springy block is evidence of a displaced meniscus. 5.

The subject lies in the supine posi­ tion with the knee and hip flexed to right angles. 5. Both hands clasp tightly under the heel which is forced into dorsiflexion. Rallge: 45° El1d-feel: elastic Ugamentous Limiting structures: . Normal functional anatomy: • • • in the ankle is This test may be decisive in comparing the range of external rotation. • Limitation of the movement is typical for ligamentous adhesions of the medial collateral Ugarnent. Dorsiflexion lost. • Increased range of movement in the prone position results from a laxity of the ligamentous structures of the medial compartment and of the anterior cruciate ligament. Fig.25 Passive medial rotation. Copyrighted Material .posterior fibres of medial collateral Ugament . The range of movement is assessed by the twisted position of the feet. 5.24). 5.medial meniscotibial (coronary) ligament . The other hand grasps the calcaneus from the lateral side. Fig. • Pain at the lateral side suggests a lesion of the popliteus tendon. 5.25).24 Passive lateral rotation in prone position. Common pathological situations: • Pain at the inner side of the knee may indicate a lesion of the medial collateral ligament or the medial coronary ligament. One forearm carries the lower leg. Passive medial rotation Positioning. The examiner stands level with the subject'S knee. A combined movement of both wrists turns the lower leg into medial rotation (Fig.popliteus muscle.92 ATLAS OF ORTHOPEDIC EXAMINATION Common mistakes. Passive lateral rotation in prone position The subject lies in the prone position with both knees flexed to a right angle. The examiner en­ circles both heels and performs a bilateral exter­ nal rotation (Fig. Procedure.

5.26 Valgus strain. • An increased range of movement in the prone position is indicative of laxity of the anterior and posterior cruciate ligaments and of the dorsolateral part of the joint capsule. The examiner en­ circles both heels and performs a bilateral medial rotation.cruciate ligaments . [n this position the cruciate ligaments no longer hold both joint surfaces in firm apposition.lateral meniscotibial (coronary) ligament . One hand grasps the lower leg from the medial side just proximal to the malleolus.KNEE 93 Common mistakes. there­ fore some movement can be elicited and more stress is put on the medial ligamentous complex. Lift the extended leg and apply strong valgus pressure with the distal hand.posterior oblique ligament.cruciate ligaments . Positioning of the hands is the same (Fig. The hands are placed too distally on the foot. Passive medial rotation in prone position The subject lies in the prone position with both knees flexed to a right angle. This test compares the range of internal rotation. None.26). The other hand is supinated and placed at the lateral femoral condyle. Common mistakes. Copyrighted Material . The test can also be positive in internal derangement of the knee and in medial collateral ligament bursitis. Variation of the valgus test The test can be repeated with the knee in slight flexion (20-30°). it is important to exert the pressure at the ankle. The range of movement is assessed by the twisted position of the feet. Counter­ pressure is maintained at the lateral femoral condyle (Fig. Normal functional anatomy: • Range: 30° • End-jeel: elastic ligamentous • Limiting structures: . as is the procedure.27). 5. Here the thigh rests on the couch and the lower leg hangs over the edge. Fig. Common pathological situations: • Lateral pain usually indicates a lesion of the lateral coronary ligament. Common pathological situations: • Medial pain during valgus stress is typical for a sprained medial collateral ligament. Normal functional anatomy: • Range: no movement is possible in a normal knee • End-jeel: ligamentous • Limiting structures: . In order to protect the lateral ligaments.lateral capsular ligaments. Procedure.medial ligamentous complex .5. The subject lies in the supine posi­ tion with the knees extended. The examiner stands level with the subject's knee. Valgus strain Positioning. and not beyond the calcaneocuboid joint line.

Common pathological situations: • Lateral pain during varus stress inculpates the lateral collateral ligament.lateral collateral ligament . The other hand is pronated and placed at the medial femoral condyle. The ex­ aminer stands distal to the foot. 5. The knee is not fully extended during the procedure. Again. Variation of the varus test Varus strain Positioning.posterior cruciate ligament. Copyrighted Material .2 7 Valgus stress test in 30° of flexion. Fig. 5. The examiner stands level with the subject's knee. The subject lies in the supine posi­ tion with the knees extended. Lift the extended leg and apply strong varus pressure with the distal hand. therefore some movement is possible and more stress is put on the lateral ligamentous complex. Here the thigh rests on the couch and the lower leg hangs over the edge. just proximal to the lateral malleolus. 5. The test can be repeated with the knee in slight flexion (20-30°).94 ATLAS OF ORTHOPEDIC EXAMINATION Fig.29). If valgus stress in full extension also shows an increased range. In this position the cruciate ligaments no longer hold both joint surfaces in firm apposition.28). the posterior cruciate ligament is probably torn as well. Normal functional anatomy: • Rallge: in a normal knee no perceptible movement is possible • Elld-feel: hard ligamentous • Limiting structures: . Counter­ pressure is maintained at the medial femoral condyle (Fig.arcuate ligament . • • Increased range in 30° of flexion is typical for a rupture of the medial compartment ligaments. 5. Procedure. The ipsi­ lateral hand grasps the lower leg from the lateral side.2 8 Varus strain. medial pain may accompany an impacted loose body or impacted medial meniscus. the lower hand provokes a varus strain while the hand at the knee stabilizes (Fig. Common mistakes.

30).3 0 The anterior drawer test. Copyrighted Material . 5. 5. Anterior drawer test Positioning. Normal functional anatomy: • Range: in a normal joint the tibia shifts over only a few millimetres • End-feel: hard ligamentous • Limiting structures: anterior cruciate ligament.29 Varus stress test in 30° of flexion.KNEE 95 Fig. The hand on the patella stabilizes the thigh (Fig. 5. • • Increased range in 30° of flexion is typical for a rupture of the lateral collateral ligament. and the heel resting on the couch. Procedure. The subject lies in the supine posi­ tion with the knee flexed to a right angle. The other hand is at the back of the upper tibia. None. thenar and hypothenar making contact with the femoral condyles. Common mistakes. If varus stress in full extension also shows an increased range. One hand is on the anterior aspect of the knee: apex patellae in the palm of the hand. The examiner sits on the foot of the subject. the posterior cruciate ligament is probably torn as well. Draw the tibia forwards with the posterior hand and add a strong jerk when the movement comes to a stop. Fig.

• Increase in range is seen in ruptures of the anterior cruciate ligament and I or the posterior capsule. Common pathological situations.31 Anterior drawer test in external rotalion.32). Copyrighted Material . Procedure. Fig. 5.32 Anterior drawer test in internal rolation. The examiner places both hands around the upper part of the tibia with the index fingers on the hamstring tendons and the thumbs at the anterior border of the joint (Fig.96 ATLAS OF ORTHOPEDIC EXAMINATION Common pathological situations: • Pain is indicative of a small lesion of the anterior cruciate ligament. The subject is positioned as for the previous test. The range of movement in exter­ nal rotation is slightly superior to the movement in a neutral position. A marked in­ crease in range is indicative of anteromedial rota­ tory instability (ruptures of the anterior cruciate ligament. The subject is positioned as for the previous test. The lower leg and foot are inter­ nally rotated as far as is comfortably possible. The lower leg and foot are exter­ nally rotated as far as is comfortably possible. 5. Fig. Normal findings. 5. Anterior drawer test in internal rotation Positioning.31). the posteromedial capsule and the medial collateral ligament). The examiner places both hands around the upper part of the tibia with the index fingers on the hamstring tendons and the thumbs at the the anterior border of the joint (Fig. Draw the upper part of the tibia forwards and add a strong jerk at the end of the movement. 5. Anterior drawer test in external rotation Positioning.

KNEE

97

Procedure. Draw the upper part of the tibia forwards and add a strong jerk at the end of range. Common pathological situations. Internal rotation tightens the intact posterior cruciate ligament which prevents any movement.

Normal functional anatomy: • Range: in a normal knee only a small amplitude of anterior glide (less than 5 mm) is obtainable • End-feel: ligamentous • Umiting structures: anterior crudate ligament. Common pathological situations. This test is pre­ ferred to detect ruptures of the anterior cruciate ligament.

Variation: anterior drawer in 20· of flexion (Lachman test)
Positioning. The subject lies in the supine position with the legs extended. The examiner stands level with the knee. One hand grasps the proxi­ mal tibia from the medial side, the fingers in the popliteal fossa and the thumb at the tibial tuber­ osity. The other hand holds the distal femur from the lateral side, the thumb just proximal to the patella. Procedure. Bring the knee into about 20· of Aexion and, using both hands, displace the proximal tibia anteriorly (Fig. 5.33). Common mistakes. None.

Posterior drawer test
Positioning. The subject lies in the supine posi­ tion with the knee flexed to a right angle, and the heel resting on the couch. The examiner sits on the foot of the subject. The heel of one hand is placed on the tibial tuberosity and the other hand is placed at the back of the upper tibia. Procedure. Push the tibia backwards with a strong jerk of the anterior hand (Fig. 5.34). The posterior hand in the popliteal fossa discloses any eventual movement.

Fig. 5.33

Lachman test.

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98

ATLAS OF ORTHOPEDIC EXAMINATION

• •

End-feel: hard ligamentolls Limiting slmetllres: posterior cruciate ligament.

I

Common pathological situations: • Pain is indicative of a small lesion of the posterior cruciate ligament. • lncrease in range is seen in ruptures of the posterior cruciate ligament and/or the arcuate complex.

ISOMETRIC CONTRACTIONS Resisted extension
Positioning. The subject lies in the supine posi­ tion with the knee slightly bent. The examiner stands level with the knee. One forearm is placed under the knee with the hand resting on the other knee, proximal to the patella. The other hand is on the distal end of the leg just proximal to the malleoli. Procedure. The subject is asked to extend the knee and to maintain extension while the examiner pushes the lower leg down towards the couch (Fig. 5.35).

Fig. 5.3 4

The posterior drawer test.

Common mistakes. None. Normal functional anatomy: • Range: no movement can be provoked in a normal knee

Fig. 5.3 5

Resisted extension.

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KNEE

99

Common mistakes. None. Anatomical structures tested:
Muscle function:
• •

Procedure. The subject is asked to move the heel downwards while the examiner applies strong counterpressure. Common mistakes. None. Anatomical structures tested:
Muscle function:

Quadriceps femoris Tensor fasciae latae.

Neural function:
Muscle Peripheral Ouadriceps lemoris Tensor fasciae lalae Femoralis Superior gluteal Innervation Spinal

• • • • • • • •

l3 lS

Resisted flexion
Positioning. The subject lies in the supine posi­ tion with the hip and knee bent to right angles. The examiner stands level with the foot of the subject. Both hands support the heel (Fig. 5.36).

Semimembranosus Semitendinosus Biceps femoris Popliteus Gastrocnemii Plantaris Gracilis Sartorius Tensor fasciae latae.

Indirect traction on inert structures:
• • •

Proximal tibiofibular joint Posterior cruciate ligament Posterior horn of the medial meniscus.

Fig.5.36

Resisted flexion.

Copyrighted Material

The ipsilateral hand encircles the heel from the lateral side.SI 51.52 51. L3 L5 l4. 52 l2. Not enough dorsiflexion makes the subject execute an inversion of the foot. LS. Procedure.L5. 5. Anatomical structures tested: Muscle function: • • • • • 51. Copyrighted Material . The examiner squats in front of the knee. The subject is asked to turn the foot inwards while the examiner applies strong counter-pressure with both hands. L3.52 Semimembranosus SemHendinosus Gracilis Sartorius Popliteus.52 St. The subject sits with the lower legs pendent. L4 l2. L3.100 ATLAS OF ORTHOPEDIC EXAMINATION Neural function: Muscle Peripheral Semimembranosus Semitendinosus Biceps femoris Gracilis Sartorius Tensor lasciae talae Popliteus Gastrocnemii Plantaris Sciatic nerve Sciatic nerve Sciatic nerve Obturator Femoral Superior gluteal TIbial TIbial TIbial Innervation Spinal Common mistakes.37 Resisted medial rotation.37).52 51.52 l2. Resisted medial rotation Positioning. l4 L2. Indirect traction on inert structures: • Posterior horn of the medial meniscus. The contralateral hand is placed against the medial aspect of the forefoot and holds the foot in dorsiflexion (Fig. 5. 51 Fig.L3 (L'). Neural function: Muscle Peripheral Semimembranosus Semitendinosus Gracilis Sartorius Popliteus Sclalie nerve Sciatic nerve Obturator Femmal TIbial Innervation Spinal 51.52 51.

The fingers of both hands are interlocked. and the heel resting on the couch. Resisted lateral rotation Positioning.52 LS SPECIFIC TESTS Medial shearing Significance This test is used to detect internal derangement at the inner side of the knee. The contralateral hand encircles the heel from the medial side (Fig. 5. The examiner sits at the foot-end of the couch. 5.KNEE 101 Fig. The subject sits with the lower legs pendent. Positioning. The subject lies in the supine posi­ tion with the knee flexed to a right angle. The ipsilateral hand is placed against the lateral aspect of the forefoot and maintains dorsiflexion.38). The patient is asked to turn the foot outwards while the examiner applies strong counter-pressure. Indirect traction on inert structures: • Proximal tibiofibular joint Copyrighted Material .38 Resisted lateral rotation. The heel of the contralateral hand is at the lateral tibial condyle. Biceps femoris Tensor fasciae latae. Pain on jerk is sug­ gestive for a minor lesion at the tibial insertion of the anterior cruciate ligament. The examiner squats in front of the knee. Common mistakes. [f dorsiflexion is not main­ tained. the subject will execute an eversion of the foot. Anatomical structures tested: Muscle function: • • Neural function: Muscle Peripheral Biceps femoris Tensor fasciae lalae Sciatic nerve Superior gluteal Innervation Spinal 51. Procedure. The heel of the ipSilateral hand is placed at the medial femoral condyle.

5.102 ATLAS OF ORTHOPEDIC EXAMINATION Fig. • The contralateral hand presses against the fibular head instead of the lateral tibial condyle. 5.39). Apply a strong shearing strain that forces the tibia laterally on the femur (Fig. with the knee flexed to a right angle and the heel resting on the couch.40). The heel of the ipsilateral hand is placed at the medial tibial condyle. The examiner sits opposite the subject at the foot-end of the couch. The hands are not high enough on the femur or low enough on the tibia respectively. Procedure. provoking a painful compression of the upper tibiofibular joint. 5. Limiting structures: articular surfaces intercondylar spines of the tibia menisci posterior cruciate ligament. Common mistakes.39 Medial shearing strain. Copyrighted Material . Common mistakes: • The hands are not high enough on the femur or low enough on the tibia respectively. The fingers of both hands are interlocked. Normal functional anatomy: • Rallge: Virtually no movement can be elicited in a normal knee • Elld-feel: hard ligamentous • Positioning. The heel of the contralateral hand is placed at the lateral femoral condyle. Normal functional anatomy: • Range: no movement can be elicited in a normal knee • End-feel: hard ligamentous • Limititlg structures: articular surfaces intercondylar spines of the tibia menisci anterior cruciate ligament. Procedure Apply a strong shearing strain that forces the tibia medially on the femur (Fig. Lateral shearing Significance This test is used to detect internal derangement at the outer side of the knee. The subject lies in the supine posi­ tion.

it is wise to examine the other limb as well in order to eliminate non-pathological clicks arising from tendons snapping over bony prominences. If clicks are detected. a ruptured meniscus should be suspected. level with the joint line. meniscal tears in the absence of actual (sub)luxations.40 Lateral shearing strain. The leg is rotated quickly to and fro. The other hand grasps the heel (Fig. internally for the lateral meniscus). 5.41 Test to detect clicks during rotation in full flexion. The subject lies supine with the knee fully flexed. Fig. Test I Positioning.KNEE 103 Fig.41). 5. The subject lies supine with the knee fully flexed (heel to the buttock). The examiner holds a palpating finger in the joint line at the side to be tested. 5. by demonstration of clicks and/or pain. The examiner holds his index finger and thumb at both sides of the infrapatellar tendon. Test" (McMurray test) Positioning. Copyrighted Material . The other hand grasps the heel and rotates the leg fully (externally to test the medial meniscus. When clicks are felt at the joint line. Procedure. Provocation tests for meniscal tears Significance These tests are used to detect.

reduce suddenly backwards. The examiner passes his flexed thumbtip from above down­ wards over the joint line at the affected side (Fig. Specific tests for instability Significance Most instability can usually be detected by the earlier described passive movements. bility and the external rotation-recurvatum test for posterolateral rotatory instability. The knee is extended.5. The examiner now slowly extends the knee. while the other hand exerts a mild valgus stress at the knee. The examiner supports the patient's leg. Procedure. The hand at the foot rotates the tibia internally. As extension proceeds. valuable specific tests: the 'jerk' test and 'pivot shiff for anterolateral rotatory insta- The 'ierk' test Positioning. The Copyrighted Material .42 Test to detect a click during extension movement under external rotation. The subject lies supine with the knee fully flexed (heel to the buttock).42). 5.104 ATLAS OF ORTHOPEDIC EXAMINATION Flg. and the knee to 90°. Procedure. maintaining the internal rota­ tion and valgus stress. usually as the leg approaches the neutral position. The subject lies upine with the hip flexed to about 45°. a click may be felt. 5. In anterolateral rotatory instability the lateral tibial condyle will first sub­ luxate anteriorly and. The subject lies supine with the hip flexed to about 30° and slightly medially rotated. at approximately 30° of flexion.43 Palpation of a displaced rim.43). There are. A ruptured meniscus is suspected when it is possible to hook the rim of the meniscus and pull it downwards until it is felt to jump back in place again. with one hand at the foot and the other at the knee. while rotation is maintained (Fig. Procedure. Fig. The examiner flexes the knee gradually. Test 11/ Positioning. Lateral pivot shift (test of MacIntosh) Positioning. This poster­ ior bouncing is seen and felt both by examiner and subject and indicates a positive test. 5. the thumb behind the fibular head. however. This is easier to perform at the medial side than on the lateral.

The examiner grasps the big toes.= r- PUSHES FORWAIlO AND APPLIES A V A lGUS STRESS � � _ _ - - Fig. with one hand at the foot and the other at the knee. Tests for fluid Fluid in the knee joint is a sign common to many disorders (traumatic. 5. tibial plateau and the degree of recurvatum are observed. the thumb behind the fibular head. The examiner stands level with the knee. W B Saunders. Philadelphia. a palpable tap is felt followed by an immediate External recurvatum test Positioning. on attaining about 30° of flexion. The hand at the foot rotates the tibia slightly internally. The examiner ex. 5. Both legs are lifted simultaneously (Fig. Procedure. The subject lies supine with both legs relaxed and extended.tends the knee gradually. 5. maintaining the internal rotation and valgus stress (Fig.) examiner supports the subject's leg.KNEE 105 . Fig. the subject will recognize the feeling of instability.46).47). unilateral excess of external rotation and recurvatum is seen. The forwards shift can be seen and felt by the examiner. Procedure. The index finger of the other hand pushes the patella downwards. just beyond the patellar edges (Fig. Patellar tap Positioning. The amount of external rotation of the Copyrighted Material . In a positive test. which is called a jerk. 5. anterior subluxation of the tibia occurs with a sudden movement.45 The 'jerk' test. (From Magee D J 1997 Orthopedic physical assessment. If fluid is present. A positive result is indicated if. while the other hand exerts a mild valgus stress at the knee. The thumb and middle finger of the other hand press at the medial and lateral recessi. The subject lies supine with the knee extended or flexed to discomfort. 3rd adn. 5. Three tests are commonly used to detect fluid. At the same moment. When it strikes the femur.44 Lateral pivot shih. Manual pressure empties the recessi and moves the fluid between patella and femur. inflammatory or crystalline). Procedure. The web of one hand is on the suprapatellar pouch.45). one can feel the patella move.

The examiner stands level with the knee. The subject lies in the supine posi­ tion with the leg extended.46 External rotation-recurvatum test. Procedure. finger of one hand at each side of the knee. 5. the tap of the patella hitting the femur cannot be felt. He places thumb and index Visual testing by eliciting fluctuation Positioning. The examiner squeezes the supra­ patellar pouch. the pressure of the fluid immediately shifts the bone upwards against the palpating finger. Remark: when large amounts of fluid are pre­ sent. pushing all the fluid downwards under the patella. upwards movement. This is the sensation of an ice cube pushed downwards in a glass of water: although the patella moves downwards. Flg. Eliciting fluctuation Positioning. just beyond the patella.106 ATLAS OF ORTHOPEDIC EXAMINATION Fig.48).47 Testing for fluid in the joint by patellar tap. which forces the two fingers of the palpating hand apart.48 Testing for fluid in the joint by eliciting fluctuation. The subject lies in the supine posi­ tion with the leg extended. 5. Copyrighted Material . The interdigital web I-II of the other hand is on the suprapatellar pouch (Fig. Fig.5. 5.

50 Detection of synovial thickness. 5. 5. and will even demon­ strate 2 or 3 ml of fluid. This moves the fluid upwards and medially (Fig. covered only by skin and subcutaneous Fig. fat.KNEE 107 (0 1 (bl Fig. Synovial thickening Synovial thickening is a vital c1inkal finding. Copyrighted Material . In minor effusion. The lateral recessus is then empty and can be seen as a groove between patella and lateral femoral condyle. It indicates primary inflammation of the synovia and differentiates this from a secondary synovitis. Procedure. all the fluid is moved to the medial part of the suprapatellar pouch. a dense structure can be felt. 5. The examiner strokes in a sweeping motion with the back of one hand over the lateral recessus and the suprapatellar pouch. 5. about 2 cm posterior to the medial and lateral edges of the patella.49b). Normally nothing except skin can be felt. and downwards over the medial recessus will now transfer the fluid laterally where a small prominence appears (Fig. In synovial thickening. Sweeping with the back of the hand over the suprapatellar pouch. 5. This is the most delicate test for effusion in the knee joint. Here the capsule lies almost super­ ficially. Synovial swelling is best detected at the medial and lateral condyles of the femur (Fig.49 Visual testing for fluid by eliciting fluctuation.50).49a). It is palpated by rolling the structures be­ tween fingertip and bone.

The upper surface of the tuber Fig.1 and 6.CHAPTER CONTENTS Surface and palpatory anatomy 109 Posterior 109 Bony landmar\(s 109 Palpation of soft tissue 110 Lateral 110 Bony landmar\(s 110 Palpation of the peronei 110 Palpatlon of the sinus tarsi 111 Palpation of the anterior talofibular ligament 111 Palpation of the calcaneofibular ligament 112 Palpation of the posterior talofibular ligament 113 Palpation of the calcaneocuboid joint and ligaments 113 Palpation of the cuboid-metatarsal V jOint 113 Medial 114 Dorsal 116 Functional examination of the ankle and foot Passive tests of the ankle joint 117 Passive plantar flexion 117 Passive dorsiflexion 117 Passive tests of the sublalar jOint 118 Varus movement 118 Valgus movement 119 Passive tests of the midtarsal joints 120 Passive dorsiflexion 120 Passive plantar flexion 121 Passive abduction 121 Passive adduction 121 Passive pronation 122 Passive supination 122 Maximal Isometric contractions of the foot 123 Resisted dorsiflexion of the foot 123 Resisted plantar flexion of the foot 123 Resisted eversion of the foot 124 Resisted inversion of the foot 124 Specific tests 125 Combined plantar flexion-inversion 125 Combined plantar lIexion-eversion 126 Anterior drawer test 126 Combined dorsiflexion-eversion 128 Strong varus movement at the ankle 129 116 Ankle and foot SURFACE AND PALPATORY ANATOMY POSTERIOR Bony landmarks (Figs 6. medial and lateral malleolus are visible landmarks.1 Bony landmarks on skeleton. 6.2) Calcaneus. 109 Copyrighted Material .

The peroneus longus (6) is plantar and the peroneus brevis (C) is dorsal to the trochlear process.3) calcanei (A) can easily be palpated and forms the basis of the triangle whose legs are formed by the anterior border of the Achilles tendon and the posterior aspect of the tibia. Palpation of soft tissue (Figs 6. The tendon of the peroneus brevis is felt to insert on the base of the fifth metatarsal. Since this prominence is situated between both peroneal tendons.2) The Achilles tendon (C) is easily visible and pal­ pable. The posterior surface of the medial malleolus (F) also bears a groove in which the tibialis posterior tendon can be palpated (see palpation of medial structures). From these bony points nearly all palpable lateral structures can be ascertained. LATERAL Bony landmarks (Fig.2 Bony landmarks in vivo. The tip of the lateral malleolus is level with the lateral jOint line of the talocaleanean joint. a bony notch can be palpated: the trochlear process (A).3 Bony landmarks at the lateral ankle. on top of it. 6. Copyrighted Material .5) About one finger-breadth under and slightly anterior to the lateral malleolus. The peroneus brevis is against the bone with the tendon of the peroneus longus The lateral malleolus (A). The tendon of the peroneus longus can be followed proximally under and behind the malleolus.4 and 6. Palpation of the peronei (Figs 6. Its inferior border extends about 1 em further distally than that of the medial malleolus. 6. 6. the base of the fifth metatarsal (6) and the fifth metatarsophalangeal joint (C) constitute the important bony land­ marks at the lateral aspect of ankle and foot.110 ATLAS OF ORTHOPEDIC EXAMINATION E F Fig. The posterior border of the talus (B). Fig.1 and 6. nipped between tibia and caleaneu.1t inserts at the upper and posterior border of the caleaneus. The plantar aspect of the calcaneus is covered by a soft heel pad (0). is hardly palpable as a small crest. The posterior surface of the lateral malleolus (E) carries a sulcus which contains the tendons of the peronei. the palpating finger will be lifted off by the hardening tendons when an eversion move­ ment is performed.

6.ANKLE AND FOOT ".4 Palpation of the peronei.6 Fig. flat and horizontal structure. Fig. 6. peroneus longus. Palpation of the sinus tarsi in vivo. Fig. the depression excavates and its borders can be better ascertained. 6. Palpation of the anterior talofibular ligament (Fig. 6. 2. If the finger is left in place and the foot is inverted.6 and 6. The neck of the talus (C) is determined as the medial border and the anterior third of the calcaneus (0) as the bottom of the sinus tarsi. A combined plantar flexion-inversion movement of the ankle makes the lateral process of the talus more prominent.7) Starting from the anterior surface of the lateral malleolus and moving anteriorly and medially.5 The peroneal tendons: 1. peroneus brevis. Palpation of the sinus tarsi (Figs 6. Just anterior to the malleolus the lateral process of the talus (B) is felt to press against the palpating finger. The ligament is felt as a thin.8) The index finger is laid on the anterior surface of the lateral malleolus. The sinus tarsi is also bordered by tendinous structures: superiorly the long extensors of the toes (E) and inferiorly the peronei (F). 6.the sinus tarsi (A). Copyrighted Material . Fig. pressing against the palpating finger. the finger falls into a depression .7 Palpation of the sinus tarsi.

The other hand encircles the heel and provokes a varus movement in the subtalar joint.112 ATLAS OF ORTHOPEDIC EXAMINATION (8) 2 Fig. posterior tibiatalar ligament. (b) posterior view: 1.8 Palpation of the anterior talofibular ligament.10 Lateral and posterior ligaments of the ankle (a) lateral view. A strong and round structure with a slight posterior inclination is felt to press against the palpating finger (the calcaneofibular Ligament (A)). 6. 2.9 and 6. anterior talofibular ligament. 6. 4. (b) 5 ---711 Flg. 3. 6. during Fig. 5. tarsal canal. posterior talofibular ligament.10) One finger is placed just caudal and posterior to the lateral malleolus. calcaneofibular ligament.9 The calcaneofibular ligament can be made visible a strong varus movement. Copyrighted Material . distal tibiofibular ligament. Palpation of the calcaneofibular ligament (Figs 6. 6.

A dorsiflexion movement in the ankle makes the taut ligament press against the finger. Palpation of the cuboid-metatarsal V joint (Fig 6. 6. The tip of the pal­ pating thumb now lies exactly on the lateral calcaneocuboid ligament.12) The examiner places the interphaJangeal joint of his thumb on the base of the fifth metacarpal bone and aims in the direction of the midpoint between the two malleoli.11) Place the palpating finger deeply behind the lateral malleolus and search for the lateral and posterior aspects of the talus. Palpation of the calcaneocuboid joint and ligaments (Fig. 6. Flg. 6. A translation movement discloses easily the joint line between cuboid and fifth metatarsal bone.11 The posterior talofibular ligament. Palpation technique for the calcaneocuboid Fig.12 ligament. Copyrighted Material .ANKLE AND FOOT 113 Fig.13) The base of the fifth metatarsal bone is gripped between the thumb and index of one hand. 6. The ligament can be felt when it is brought under tension during supination and adduction of the foot. The cuboid bone (medial to the metatarsal and distal to the already identified calcaneocuboid joint line) is gripped between the thumb and index finger of the other hand.6.13 Palpation of the cuboid-metatarsal V joint. In neutral position the joint line can clearly be ascertained. Palpation of the posterior talofibular ligament (Fig.

114 ATLAS OF ORTHOPEDIC EXAMINATION MEDIAL The medial malleolus.15 Visualization of medial structures. 6.14.14 Palpation of the medial malleolus and the sustentaculum tali. tibialis posterior.15. the sustentaculum tali. tibialis anterior. The sustentaculum tali (B) is found about 2 em below the tip of the medial malleolus. Flg. 6.17).16). The insertion of the tibialis posterior tendon (B) is on the tuberosity (Fig. 6. the tuberosity of the scaphoid and the base of the first metatarsal bone constitute the important bony landmarks at the medial aspect of the ankle and foot.17 Visualization of the talar head. A) is felt with ease. The thick structures that are palpable just around the inferior border of the medial malleolus constitute the different layers of the deltoid Iiga- Fig. A) is found as follows. prominence. the tubercle of the first metatarsal base (D). The talonavicular joint becomes more apparent during an adduction movement in the midfoot.16 Tendons and insertions of the main invertor muscles: 1 . The tibialis anterior tendon (C) is followed along the medial border of the foot where it is felt to insert on a bony prominence. 6. Copyrighted Material . This point is the midpoint of the medial border of the foot. The medial malleolus (Fig. 2. This bony prominence is better palpable if the calcaneus is pushed into a valgus position. 6. Flg. 6. 6. 6. Ask for and resist an inversion movement of the foot which brings the strong tibialis posterior and anterior tendons into 2 Fig. The tuberosity of the scaphoid bone (Fig. The talar head can be palpated at the midpoint of a line joining the tip of the malleolus to the tuberosity of the scaphoid bone (Fig.

Place the palpating finger between the medial malleolus and the anterior aspect of the Achilles tendon. 6. B).ANKLE AND FOOT 115 ment. Flg. A) is identified as follows. posterior tibiotalar ligament.20b and Fig.19). The tibialis posterior tendon remains in contact with the bone of the malleolus and becomes promi­ nent during an inversion movement (Fig.21. 4.19. The tendon can be seen and felt to move under the palpating Fig.19 Visualization of the spring ligament. 6. 4. 6.20 The tendons at the medial malleolus: 1. both struc­ tures will constitute a V that can be felt during a resisted inversion of the foot. Since the insertion on the navicular bone is close to that of the tibialis posterior tendon (A). The ligament that connects the sustentaculum tali with the inferior surface of the navicular bone is the inferior calcaneonavicular ligament (spring ligament) (Fig. Copyrighted Material . They become more obvious when a varus movement is performed. 6. It is best palpated on a passively everted foot. 6. 3. Bring the foot into dorsiflexion. The tendon of the flexor digitorum longus is difficult to palpate and is situated more laterally and dorsally. 6. (s) . sustentaculum tali.18 Medial ligaments of the ankle: 1. 6. tibiocalcanear ligament. 2. 5. (b) A Fig. anterior tibiotalar ligament. the posterior tibial artery and the flexor hallucis longus tendon (Fig. 3. inferior calcaneonavicular ligament. flexor digitorum longus. 6.20a). 6.18 and Fig. 2. tibionavicular ligament. Behind this tendon the pulse of the posterior tibial artery can be felt. The flexor hallucis longus tendon (Fig.. flexor hallucis longus. tibialis posterior. The following longitudinal structures can be palpated along the posterior aspect of the medial malleolus from anterior to posterior successively: the tibialis posterior and flexor digitorum longus tendons.

the ankle joint the subtalar joint the 'midtarsal joints': the whole middle structure of the foot.23 Palpation of the dorsalis pedis artery. running just distally to the sinus tarsi and joining the fifth metatarsal bone. A horizontal line drawn 2 cm proximal to the tip of the lateral malleolus and 1 cm proximal to the tip of the medial malleolus closely delin­ eates the inferior tibial border.21 Visualization of the flexor hallucis longus. The ankle and foot are very difficult to examine because a great number of strong and rather stiff structures are condensed into a small volume. FUNCTIONAL EXAMINATION OF ANKLE AND FOOT Introduction/general remarks C The ankle and foot are examined with the subject in the supine lying position.22. The pulse of the dorsalis pedis artery can be felt between the tendons of the extensor hallucis longus and the extensor digitorum longus (Fig. the extensor hallucis longus (8) and the extensor digitorum longus (C) are visible. A). 6. though consisting of several bones and joints. finger when a passive dorsiflexion movement is imposed on the big toe. [n about 5% of the population the artery is very thin or even absent. 6.116 ATLAS O F ORTHOPEDIC EXAMINATION Fig. 6. The tendon of the peroneus tertius may be visible as the most lateral tendon Flg. functionally acts as one integrated structure and is therefore examined as one 'midtarsal joint'.22 Visualization of the extensor tendons. Copyrighted Material .23). the tendons of the tibialis anterior (Fig. The different 'joints' to examine are: • • • Fig. During a resisted dorsiflexion. To test each structure in turn without the help of a lever is a very difficult task and demands a great technical ability. DORSAL The medial and lateral malleoli are easily pal­ pated.6. 6.

ANKLE AND FOOT

117

The action of the contractile structures of the ankle and foot have an influence on all the different joints.

Limiti"g structures:
- the engagement of the heel via the Achilles tendon against the back of the tibia - anterior tibiotalar ligament.

PASSIVE TESTS OF THE ANKLE JOINT Passive plantar flexion Positioning. The subject lies supine with the leg on the couch and the ankle in neutral position. The examiner is distal to the foot. One hand supports the heel, the other is at the dorsum of the foot. Procedure. A simultaneous movement of both hands pulls and pushes the ankle into plantar flexion (Fig. 6.24). Common mistakes. None. Normal functional anatomy: • Rallge: the dorsal aspect of the foot falls into line with the tibia • Elld-feel: hard ligamentous

Common pathological situations: • Limitation of plantar flexion is usually caused by an articular lesion. • Anterior pain in combination with a normal end-feel indicates stretching of anterior structures (capsule, tendons of dorsi flexors, anterior tibiotalar and anterior talofibular ligaments). • Posterior pain is elicited when a pathological structure is painfully squeezed between tibia and calcaneus (bursa, insertion of Achilles tendon, periostitis). Passive dorsiflexion Positioning. The ankle is in neutral position with the heel resting on the couch. The knee is slightly flexed. The examiner is distal to the foot. He places one hand at the plantar aspect of the forefoot. The other hand is at the back of the heel.

Fig. 6.24

Passive plantar flexion.

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11 8

ATLAS OF ORTHOPEDIC EXAMINATION

Fig. 6.25

Passive dorsiflexion.

Procedure. Move the foot in the dorsal direction, meanwhile keeping the knee in a slightly flexed position (Fig. 6.25). Common mistakes. None. Normal functional anatomy: • Rallge: the angle between the dorsum of the foot and the tibia can be reduced to less than 90° • Elld-feel: hard ligamentous

and talus (anterior periostitis or nipping of post-traumatic fibrosis).

PASSIVE TESTS OF THE SUBTALAR JOINT Varus movement Positioning. The heel rests on the couch with the knee slightly flexed and the ankle in neutral position. The examiner is distal to the foot and grasps the heel between the clasped hands. In order to avoid movements in the ankle joint the talus is stabilized between tibial and fibular malleoli. This is achieved by traction on the heel and through a slight pressure with the trunk against the patient's forefoot. Procedure. Swing the upper half of the body inwards (Fig. 6.26). Common mistakes: • Full dorsiflexion is lost. • Uncomfortable pressure is exerted on the calcaneus.

U",if;'1g structures:
the posterior capsule posterior talofibular ligament posterior fibres of the deltoid ligament anterior engagement of talar neck and anterior margin of tibial surface.

Common pathological situations: • Limitation of dorsiflexion is caused by articular lesions or by short calf muscles. • Posterior pain indicates stretching of posterior structures (capsule or tendons of plantiflexors). • Anterior pain is elicited when a pathological structure is painlully squeezed between tibia

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ANKLE AND FOOT

119

Fig. 6.26

Varus movement.

Normallunctional anatomy: • Rallge: 15--30· • Elld-feel: ligamentous • Limit;'lg structures: - caleaneofibular ligament - talocaleanean interosseus ligament - joint capsule - posterior fibres of the deltoid ligament. Common pathological situations: • A progressive limitation of varus indicates a capsular lesion of the subtalar joint. In significant arlhritis varus is completely lost by a spasm of the peronei. • Lateral pain at full range may be indicative of a sprain of the caleaneofibular ligament. Valgus movement Positioning. The heel rests on the couch, the knee is slightly flexed and the ankle in neutral posi­ tion. The examiner is distal to the foot and grasps the heel between the clasped hands. In order to avoid movements in the ankle joint the talus

is stabilized between tibial and fibular malleoli. This is achieved by traction on the heel and through a slight pressure with the trunk against the patient's forefoot. Procedure. Swing the upper half of the body outwards (Fig. 6.27). Common mistakes: • Full dorsiflexion is lost. • Uncomfortable pressure is exerted on the calcaneus. Normallunctional anatomy: • Rallge: 10-15° • Elld-fee/: ligamentous • Limiting structures: - posterior fibres of the deltoid ligament - talocalcanean interosseus ligament - joint capsule. Common pathological situations. Medial pain may indicate a lesion of the deltoid ligament.

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His contralateral hand encirdes the heel and carries it.28) Procedure. Movements are possible in three directions but owing to anatomical characteristics plantar flexion is always accompanied by some adduction. Press the thumb upwards by a supination of the wrist. Copyrighted Material . The positioning for all the midtarsal movements is the same. The subject lies supine with an extended knee and the foot in neutral position. Therefore the whole middle segment is considered as one integrated structure.27 Valgus movement. • The traction forces the talus into a dorsiflexed position between the two malleoli. thumb under the metatarsal heads and fingers at the dorsum of the metatarsal shafts. 6. The ipsilateral hand encirdes the forefoot. PASSIVE TESTS OF THE MIDTARSAL JOINTS Remarks • In this position both ankle and subtalar joints are fully stabilized: • • • Because the middle segment of the foot consists of several bones and joints it is very difficult to assess isolated movements. The examiner is distal to the foot. Normal functional anatomy: • Rallge: 10-15° • End-feel: hard ligamentous Positioning for testing the midtarsal mobility. The hand also pulls on the heel and forces it into full valgus. Passive dorsiflexion (Fig. Common pathological situations for the midtarsal tests: • LimHation may indicate arthritis or arthrosis.120 ATLAS OF ORTHOPEDIC EXAMINATION Fig. 6. • Localized pain indicates a local ligamentous lesion or local periostitis. The valgus position fixes the subtalar joint. and dorsiflexion by some abduction. • Painful movement with an excessive range is typical for the beginning of a midtarsal strain. The ankle and subtalar joints are not stabilized. Common mistakes.

Normal functional anatomy: • Rallge: 10-150 • Elld feel: hard ligamentous • Limitillg structures: medial and inferior midtarsal ligaments. Common mistakes. The ankle and subtalar joints are not stabilized.28 Passive dorsiflexion. - Passive adduction (Fig. 6. 6. Fig. Passive abduction (Fig.31) Procedure.29 Passive plantar flexion. 6.plantar fascia.plantar midtarsal ligaments . 6. 6.30) Procedure. meanwhile the fifth metacarpal bone provides counter-pressure. Copyrighted Material . 6.29) Procedure: Press the fingers downwards by a pronation of the wrist. Perform the adduction movement in the wrist: the fingertips pull the outer side of the forefoot in a medial direction. Fig. Common mistakes. Common mistakes. The ankle and subtalar joints are not stabilized. Passive plantar flexion (Fig. Normal functional anatomy: • Rallge: 10-150 • Elld-feel: hard ligamentous • Lilllilillg sln/etL/res: dorsal midtarsal ligaments. The ankle and subtalar joints are not stabilized. meanwhile the fingertips provide counter-pressure at the outer side of the forefoot. • Umitiu8 structures: .30 Passive abduction. Perform the abduction movement in the wrist: the web of the thumb presses the medial aspect of the first metatarsal bone in a lateral direction.ANKLE AND FOOT 121 Fig.

Passive supination (Fig.32 Passive pronation. The ankle and subtalar joints are not stabilized.33 Passive supination.33) Procedure. Common mistakes. 6.32) Procedure. Common mistakes. Copyrighted Material . Perform an abduction movement in the shoulder: the thumb pulls the inner side of the foot upwards while the fingers push the outer side downwards. 6. 6. Fig. Normal functional anatomy: • Rallge: 10-15° • End-feel: hard ligamentous • Umitiflg structures: lateral midtarsal ligaments. Fig. Passive pronation (Fig. Perform an adduction movement in the shoulder: the hand pulls the inner side of Fig. 6. Normal functional anatomy: • Rallge: 45-90° • End-feel: soft ligamentous • Limiting structures: medial and lateral midtarsal ligaments. Normal functional anatomy: • Range: 30-60° • Elld-feel: soft ligamentous • Limitiug structures: medial and dorsal midtarsal ligaments.31 Passive adduction.122 ATLAS OF ORTHOPEDIC EXAMINATION the foot downwards while the thumb pushes the outer side upwards. 6. The ankle and subtalar joints are not stabilized.

(LSI l4. Fig. Both hands are placed at the dorsum of the forefoot. l5 l4.S1 L5. 6.35). $1 Flg. 6. The patient lies supine with the knee extended and the foot in neutral position. Procedure. Common mistakes. The examiner is distal to the foot. Common mistakes.35 Resisted plantar flexion.34). Tibialis posterior Flexor hallucis longus Flexor digltorum longus Peronei longus at brevis TIbial Tibial Tibial Tibial Superficial peroneal Innervation Spinal $1-52 L41l5. Ask the subject to plantar flex the foot (Fig. Copyrighted Material . 6.51 L5 L5 LS. 6.ANKLE AND FOOT 123 MAXIMAL ISOMETRIC CONTRACTIONS OF THE FOOT Resisted dorsiflexion of the foot Positioning. • • Neural function: Muscle Peripheral Tibialis anterior Extensor halluc!s longus Extensor digilorum longus Peroneus tertius Deep peroneal Deep peroneal Deep peroneal Deep peroneal Innervation Spinal Neural function: Muscle Peripheral Triceps surae L4. Ask the patient to extend the foot (Fig. None. The examiner is distal to the foot. $1 L5. One fist is placed under the metatarsal heads while the other hand stabilizes the distal end of the leg just proximal to the malleoli.34 Resisted dorsiflexion. Procedure. None. Anatomical structures tested: Muscle function: Tibialis anterior Extensor hallucis longus • Extensor digitorum longus • Peroneus tertius. Anatomical structures tested: Muscle function: Resisted plantar flexion of the foot Positioning. L4. • • Triceps surae Tibialis posterior • Flexor hallucis longus • Flexor digitorum longus • Peronei longus et brevis. The subject lies supine with the knee extended and the foot in neutral position.

• Peroneus longus • Peroneus brevis • Peroneus tertius • Extensor digitorum longus. Procedure. lS l4. The examiner is distal to the foot.36). Common mistakes. lS Resisted inversion of the foot Positioning. Ask the subject to push with the outer side of the foot against the resisting hand (Fig. Fig. Procedure. 6. 6. 6. The contra­ lateral hand is placed at the lateral and distal end of the leg just above the lateral malleolus. The contra­ lateral hand is pronated and placed against the lateral border of the foot.37).37 Resisted inversion. The patient lies supine with the knee extended and the foot in neutral position. Common mistakes. Copyrighted Material . Anatomical structures tested: Muscle function: Neural function: Muscle Peripheral Perooellongus at brevis Extensor digitorum longus Peroneus tertius Superficial peroneal Deep peroneal Deep peroneal InnelVation Spinal LS.36 Resisted eversion. Fig. The leg is not properly stabi­ lized and an internal rotation in the hip rather than an inversion movement at the foot is performed. Ask the subject to press the inner side of the foot against the resisting hand (Fig. The ipsilateral hand is placed against the medial border of the foot. 6.124 ATLAS OF ORTHOPEDIC EXAMINATION Resisted eversion of the foot Positioning. The examiner is distal to the foot. S 1 l4. His ipsilateral hand is placed at the medial and distal end of the leg just above the medial malleolus. The leg is not enough stabi­ lized and an external rotation in the hip rather than an eversion movement in the foot is performed. The patient lies supine with the knee extended and the foot in neutral position.

6. • Painful pinching of the forefoot occurs. The heel rests on the couch. S1 L4.S1 L4. Procedure. Stabilize the leg with the ipsilateral hand. Normal functional anatomy: • Ral/ge: 6G-120° angle between forefoot and lower leg • Elld-fee/: soft ligamentous • Neural function: Muscle Peripheral Tibialis posferior Tibialis antenor Flexor hallucis longus Extensor hallucis longus Triceps surae Tibial Deep peroneal Tibial Deep peroneal Tibial Innervation Spinal L4Il5. l5 S1-$2 SPECIFIC TESTS Combined plantar flexion-inversion Significance. This movement brings all the lateral structures of ankle and foot under stretch and is therefore an extremely important test in sprained ankles.38).ANKLE AND FOOT 125 Anatomical structures tested: Muscle function: • • • • • Tibialis posterior Tibialis anterior Flexor hallucis longus Extensor hallucis longus Triceps surae. Common mistakes: • The lower leg is not sufficiently stabilized. • Plantar flexion is lost. Copyrighted Material . Positioning. The contralateral hand is placed on the midfoot. position. Mean­ while perform a supination movement by an upwards pulling of the fingers (Fig. • Supination is not conducted to the end. (LS) L5. Press the foot downwards and inwards with the heel of the contralateral hand. Fig. the knee is slightly flexed and the ankle is in neutral Limiting structures: anterior talofibular ligament lateral and dorsal calcaneocuboid ligaments capsule of the cuboid-fifth metatarsal joint peronei longus and brevis tendons extensor digitorum longus tendons. 6. so that the heel of the hand rests at the fifth metacarpal bone and the fingers encircle the medial border. The examiner is distal to the foot. His ipsilateral hand fixes the leg at the distal and medial side.38 Combined plantar ftexion-inversion.

126

ATLAS OF ORTHOPEDIC EXAMINATION

Common pathological situations: • This movement is extremely painful in ankle sprains. • Excessive range is noted in total rupture of the anterior talofibular ligament. • In chronic ankle sprains with ligamentous adhesions there is slight limitation with a tougher end-feel. • Marked limitation with a spastic end-feel is typical for a subtalar arthritis. Combined plantar flexion-eversion Significance. This movement stretches all the medial ligaments of the ankle. Positioning. The heel rests on the couch, the knee is slightly Aexed and the ankle is in neutral position. The examiner is distal to the foot. His contralateral hand fixes the leg at the distal and lateral side. The ipSilateral hand encircles the midfoot with the heel lying on the first metatarsal bone and the fingers encircling the lateral border. Procedure. Stabilize the leg with the contralateral hand. Press the foot downwards and outwards with the heel of the ipsilateral hand. Meanwhile perform a pronation by an upwards pulling of the fingers (Fig. 6.39).

Common mistakes. • The lower leg is not stabilized. • Plantar Aexion is lost. • Pronation is not performed. • Painful pinching of the forefoot occurs. Normal functional anatomy: • Range: 15-45° • Elld-feel: ligamentous • Umiti"g structures: - anterior part of the deltoid ligament - calcaneonavicular ligament - capsules of the medial midtarsal joints - tendon of the tibialis anterior. Common pathological situations: • Medial pain may be caused by a lesion of the anterior portion of the deltoid ligament or by a tendinitis of the tibialis posterior. • Lateral pain may indicate a painful squeezing of the posterior talofibular ligament. Anterior drawer test Significance. This is a specific test for the integrity of the anterior talofibular ligament. Positioning. The subject lies supine and relaxed with the knee Aexed to 90°. The heel rests on

Fig. 6.39

Combined plantar 'IexiorH}version.

Copyrighted Material

ANKLE AND FOOT

127

the couch and the foot is in slight plantar flexion. The examiner stands at the opposite side of the foot, level with it. One hand stabilizes the lower leg while the other is placed at the lateral border of the foot. Procedure. Stabilize the lower leg. Try to move the foot forwards in a medial direction (Fig. 6.40). Common mistakes: • The lower leg is not stabilized. • There is too much plantar flexion at the ankle joint.

Normal functional anatomy: • Rauge: none • Elld-feel: ligamentous • Limiting structure: anterior talofibular ligament. Common pathological situations. The movement is only possible if the anterior talofibular liga­ ment is ruptured or elongated. Movement is indicated by a forwards shift of the lateral margin of the trochlea tali in relation to the latera I malleolus (Fig. 6.41).

Fig. 6.40

Anterior drawer test.

Anterior

Medi.1

-¥'i!o\Ii---'iIo

Poet.,ior ___________ .......J
Fig. 6.41 Anterior drawer test.

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128

ATLAS OF ORTHOPEDIC EXAMINATION

Combined dorsiflexion-eversion Significance. This is a specific test to demonstrate anterior periostitis of the fibula. Positioning. The knee is slightly flexed and the ankle in neutral position. The examiner is distal to the foot. His ipsilateral hand supports the heel and the contralateral hand is placed against the plantar and lateral side of the foot. Procedure. Press the foot upwards and outwards with the heel of the contralateral hand until the end-feel is ascertained (Fig. 6.42). Common mistakes. The movement is not executed firmly enough. Common pathological situations. Lateral pain indicates the existence of periostitis of the inferior border of the fibula. Alternatively the pain is caused by impingement of a thickened, hyper­ trophied talofibular ligament.

Fig. 6.42

Combined dorsiflexion-eversion.

Flg. 6.43

Strong varus movement at the ankle.

Copyrighted Material

a circumstance that is detected by a palpable click when the tibia and the fibula engage after their momentary separation . The ankle is in neutral position and the knee extended.43). The movement is not executed firmly enough. • In a total rupture of the anterior talofibular or the calcaneofibular ligaments. The ipSilateral hand fixes the leg at the inner side. just above the ankle. the fibula can be pressed outwards. Procedure. Common mistakes. Common pathological situations: • When there is ligamentous rupture or laXity of the distal tibiofibular ligaments. Copyrighted Material . Force the heel with a strong and quick thrust into varus (Fig. Positioning. The contralateral hand grasps the foot at the heel.ANKLE AND FOOT 129 Strong varus movement at the ankle Significance. 6. The examiner is distal to the foot. this test will also show laxity. This movement tests the integrity of the strong distal tibiofibular ligaments.

Index Copyrighted Material .

109-110 Capitate bone carpal subluxation.%.56.119. 73. 15-16. 53.68.54-. 24-26 Bronchus carcinoma. 31-32 passive flexion.2 Crepitus. 33 passive tests.3 Adductor brevis muscle. 51. 73 Abductor digiti minimi.53.56 Anterior superior iliac spine. 28 Arcuate complex. 9-10 Axilla.34 resisted flexion.75 Amyotrophic lateral sclerosis.malunited.53 Buttock pain. 36. 113 o De Quervain's disease. 56. slipped. 42 Extensor carpi uinaris muscle innervation.112 rupture.45 percussion (linel's test). 34.36 palpation of long head. 50 palpation.3 Coracobrachialis muscle. 57 Calcaneocuboid joint. 37 isometric contractions. 57 palpaHon.8-9 passive elevation. 65. 55 lesions. n. 36. 75. 1t7 Anterior cruciate ligaments laxity.24. 10.63-64 avulsion fractures.50 Carpal tunnel pa. 21-30 passive extension. 21-30 arthritis.41 passive pronation. 30-37 innervation. 126 strong varus movement.1-2 Colles' fracture.37.28 Cuboid-metatarsal V joint. 21-22 lesions.36.96 rupture..116-129 palpation. 31.129 Ankle joint articular lesions. 3 Acromioclavicular joint. 109-116 anterior drawer test. 32 Brachial artery.75. II ligaments.37.57 Abductor pollicis longus innervation.49 Common nexor tendon lesions (golfer's elbow).30-31 passive pronation. 71 Extensor carpi radialis brevis muscle innervation. 129 Aponeurotic arch. 126. 34 tendinitis. "129 Dorsal interossei.93 lesions.53 palsy.8 Axillary nerve lesions. 6-7 Bicipital grooves. 56. '113 Calcaneocuboid ligament.34-35 resisted supination.77 Adductor longus muscle innervation. 75. 31. 26 tendinitis. 126 combined plantar flexion-inversion. 128 combined plantar nexion-eversion. 32 arthrosis. 33-37 palpation.54. 30-37 resisted extension. 54 palpation. 3-4 Distal radioulnar joint arthrtis. 53.16--1 7. 53.34. 3 lesions. 32 Biceps femoris innervation. 21-22 6rachialis muscle lesions. 126-127 combined dorsincxion--eversion. 13.116 E c C5 nerve root Elbow anatomy. 64 Adductor magnus innervation. 16.lpation.53 C7 nerve root lesions. 2. 2.INDEX 133 A Abdominal neoplasia.61 Anatomical snuffbox.23.75. 97 Anterior interosseous nerve lesions.48-49 Distal tibiofibular ligaments.66 tendon. 33--34 resisted pronation.118 passive dorsiflexion. 36.16. 48-49 passive supination. 88 Coracoacromial ligament.32 passive supination.54 tendons.101 palpation. 26 tendinitis. 24. 116-117 Deltoid muscle lesions.66 Adductor pollicis innervation.23.49 passive tests. 21-30 EpiphysiS.ination..74 Anterior talolibular ligament palpation. 32 functional exam.55 tendon.26 tendinitis.22 BiCipital tendon. 117-118 passive plantar flexion. 9.39. 36. 87 tendon. �l Dorsalis pedis artery. 21. 37. 61 Clavicle.40 tenovaginitis. 16.14 C6 nerve rool lesions. 43.75 Cubital fossa.51.73. 14.n palpation. 57 Achilles tendon.41 Carpal bones.8 Coracoid process. 55.56. 2. 125-126 functional examination.11 Acromion.21-22 Cubital tunnel. 100.127. 53.129 sprain. 109-116 sprains.34 palsy.40 Anconeus muscle. 37 palpation.42 Extensor carpi radialis longus innervation. 54 tendons. 36. 73.35. 113 Calcaneofibular ligament palpation. 117. 36 palpation. 22 Brachioradialis muscle innervation. 54.54 palpation. 29 Common peroneal nerve.B8 Biceps muscle. 76 palpation. 57 Finkelstein's test. HI ruphlre. 49 i arthrosis.62 Deltoid ligament lesions. 21 6icipitoradial bursitis.126 palpation. 49.98 Arms active elevation. 44 lesions.80 Biceps brachii lesions. 57 lesions.119 Calcaneus.57 Adductor tendinitis. 41 subluxation. 36. 13 palpation.14 B Barlow's test.9.49 palpation. 72.35-36 soft tissue palpation. 17 C8 nerve root lesions. 51 palpation.28 Ankle anatomy. 62 Copyrighted Material .61 Abductor pollicis brevis.110 Acromial angle. 34 palpation.

123.134 INDEX Extensor digiti minimi innervation. 123.88 innervation.72.70-80 resisted abduction.57-58 resisted extension.73-78 oSleoarthrosis.54.72. 51.70. 66 Femoral nerve.36 tendinitis.75 resisted flexion.lesions.75. 75.54.43 Extensor pollicis brevis innervation. 47 Flexor carpi ulnaris innervation.. 68 Hands.66 Uiopsoas muscle innervation.125 tendon.58 tendon.70 passive medial rotation.intrinsic muscles.30. 72.68 Gluteus medius innervation.72. 100 Gemellus inferior.77 pain.114 Flexor carpi radialis innervation.66 palsies. 36.35. 123-125 palpation. 100 palpation.72 palpation.71 passive tests.57 Flexor pollicis longus innervation. 78 Femoral vein.45 tendons. 124 resisted inversion.86 Greater tuberosity (of head of humerus). 71-72 passive adduction. 54 palpation. 4-5 Infraspinatus tendon.83.71.76 Golfer'S elbow. 115 Inferior iliac spine. 43 Extensor digitorum communis innervation.77 Gemellus superior. 116 Extensor hallucis longus innervation.56 tendon.69-80 internal derangement. 48 tenosynovitis.37.78 arthrosis. 36.124 tendon. 74 Gluteal pain. 73 aseptic necrosis. 43 Fifth metat8rsnl bone.57 palpation. 37.67.68 Gluteus minimus. 12 passive lateral rotation test.40. 115 Flexor digitorum profundus innervation. 40 tenovaginitis.57 Extensor pollicis longus innervation.78 congenital dislocation.79 bilateral passive medial rotation in prone position. 110 Fifth metatarsophalangeal joint.58 lesions. 110 Fingers. 41 H Hamate bone.64 Inferior pubic ramus. 123.66 Iliotibial tract lesions.37. 61 Iliac crests.116-129 isometric contractions. 46-47 Flexor hallucis longus innervation.74.109-116 combined plantar flexion-inversion. 19-20 Gluteal bursitis. 58 tendon. 53.58 tendon.55 palpation.79-80 forceful upward thrust 10 the heel.66.81 Fifth metacarpal bone.53. 116 Extensor indicis proprius innervation. 77 palpation.58 tendinitis. 62 Groin neurovascular structures. 55 Flexor digitorum longus innervation. 14 Infraspinous fossa.2 Grind test.56 palpation.58--61 Hip.65 tendon.n Glenohumeral joint anterior drawer test. 123 resisted eversion. 75. 79 arthritis.66 Fibula anterior periostitis. 79 functional examination.37 Gracilis muscle innervation. 37.76-77 resisted medial rotation.128 palpation.109-116 resisted dorsiflexion.53. provocation tests.63 Intertubercular sulcus. 58 Finkelstein's test. 42-43 tenosynovitis.63-80 adduction in flexion.43 Extensor digitorum long'us innervation.74 resisted adduction.58 palpation.75 Infracondylar tubercle (tubercle of Gerdy).79 Guyon's tunnel.3 Inguinal ligament. 45 tendinitis.55.57-58 resisted flexion.53.115-116 Flexor pollicis brevis.45. 36. 19 hypermobility. 72-73 passive external rotation.70 passive abduction. 77 palpation. 123 palpation.54 rupture. 11 posterior drawer test.46 percussion.58 palpation.19 passive abduction test. 53.44 Hamstrings lesions. 125 tendon. crepitating.n palpation. 56. 62 First metacarpal bone.stress fracture.57 tendons.87 Inferior calcaneonavicular ligament (spring ligament).73.72. 84 Infraspinatus muscle lesions.41.23 G F Femoral artery. 125-126 functional examination. 56. 56.36. 55.45 tendon. 56 Foot anatomy. 53. 73.74-75 resisted extension.75-76 Humeral capitulum.77 Gluteus maxim us innervation.53 Gastrocnemii. 75.77 palpation.71.73-74 resisted lateral rotation.70-71 passive flexion. 46 tendinitis.53.82 Infrapatellar tendon (patellar ligament). 73. 47 tendinitis. 45 First metatarsal bone. 30.2 Copyrighted Material .72 passive extension.53. 123 Fourth metacarpal bone.10 passive medial rotation test.71 isometric tests.66 pain. 66. 54 tendon.124-125 resisted plantar flexion.58 Flexor digitorum superficiaJis innervation.76.ll palpation.

100 external recurvatum lest. 90-91 passive flexion. 104 lateral shearing test. 88 Lateral malleolus.61 Piriformis.95 Lateral condyle.see Scaphoid bone Neuralgic amyotrophy.SO palpation. 101 synovial thickening. 89-107 haemarthrosis. 95-97 anteromedial rotatory instability. 81 Lateral tibial epicondyle.94 medial shearing lest.87 Lateral femoral triangle. 66 Pectoralis major muscle lesions. 116 Lateral tibial condyle. 81-107 anatomy.81.114. 84 Patellar tap.116 Medial meniscus. 46 Pisohamate ligament.52 Midtarsal jOints arthritis. 58--61 Palmaris longus innervation. 102 ligamentous adhesions. 123.34 palpation. rupture.83 PatelJar groove. 81. 83 Patellar ligament (infrapatellar tendon).13 Peroneus brevis innervation.90 impacted loose bodies.93 Lateral epicondyle.77 Olecranon bursa. 104-105 internal derangement. avulsion fractures. 88 Popliteus muscle. 105-107 functional examination. 94 tears. provocation tests. 66-67 lschiopubic ramus.109-110.53 palpation.INDEX 135 Ischial tuberosity. 81 Median nerve. 90 displaced meniscus.56 Copyrighted Material .97-98 resisted extension.14 Neurological disease. 92-93 passive tests.22. impacted. 29 Medial femoral condyle. 24. 89-90 passive lateral rotation. 99-100 resisted lateral rotation. 47 Palmar interossei. 75. 107 valgus test.88 Medial malleolus. 41.95 M Macintosh's test.90.77-78. 28 Opponens pollicis.46 Plantaris muscle innervation. provocation tests.. 92 Medial epicondyle.81-89 passive extension. 14 L L.94 palpation.78 Pes anserinus.93 lesions.94.120 passive abduction. 94-95 Lateral gastrocnemius.30 tendon. 78 Lachman test.8 Lead poisoning.9O impacted medial. 109-110. 47 Patella.94 Medial tibial condyle.100 palpation. 57 Meniscus displaced. 57 Ortolani's test. 120-121 passive plantar flexion. 15 palpation.65 Medial gastrocnemius. 88-89 Popliteal vein.77 palpation. 100 Popliteus tendon lesions.15 palpation. 69 Lunate bone aseptic necrosis. 7.93.105-106 Pectineus muscle innervation. 93 lesions.123.90 arthrosis. tests.90 extensors palpation.8 rupture. 45 lesions. 87 Posterior capsule. 98-101 jerk test.23.79 p Palmar aponeurosis.87 rupture. 98 rupture. 124 tendon.65.120 arthrosis.3 lesions.122 passive supination. 104-105 lateral pivol shift (test oC Macintosh). 120-122 strain. 7.36. 98-99 resisted flexion. 64 N Navicular. palpation.27.77 Pisiform bone.104 Metacarpophalangeal joint capsule. 92 palpation. 87 Lateral coronnry ligament. 83. 103-104 palpation.44. 41 o Obturator extemus. 101-102 meniscal lears. 84-85 sprain. 103-104 Medial collateral ligament adhesions.73.122 passive tests. 105 fluid.88 Popliteal artery.92 palpation. 75.90 medial comparhnent ligament rupture. 53.121 passive adduction.83-84 resisted medial rotation. 116 Perthes' disease.28 fracture.93 Medial coronary ligament. 77 Obturator intern us. 27.92 bursitis. 91-92 passive medial rotation.97 Laleral collalcral ligamcnt lesions. 70. 30. 81.89-98 posterior drawer test. 36. 88 Popliteal fossa.89 Lateral femoral epicondyle.66 K Knee. 124 palpation. 53 Lesser trochanter.27. 103-. 93-94 varus test. no Peroneus tertius innervation.87 Lateral femoral condyle.96 Posterior cruciate ligament laxity. 2 Lumbar spine. tests.85 Phalen's test. 123. 110 Peroneus longus innervation. 120 Myopathy.101-102 isometric contractions.71. 96 arthritis. 74 Lesser tuberosity (of head of humerus). 124 palpation. 37.121 passive pronation. 89 Medial femoral triangle (trigonum of Scarpa). 121-122 passive dorsiflexion.104 McMurray test.81-89 anterior drawer test. 94 instability.82 Latissimus dorsi muscle lesions.

34 tendinitis. 1--8 passive horizontal adduction. 111 Tennis elbow.77 52 palsies. 81 TIbial nerve. 83--84 Quadriceps femoris innervation.73. 77 palpation.83 Suprascapular nerve.110. 100.12 isometric contractions.3 Sustentaculum tali.125 tendinitis.57 resisted extension.13 Thumb. 36. 100 lesions.128 Talonavicular joint. 1-20 active test. 10. 126 capsular lesions.64. 114.8-9 adductor muscle lesions. 41.10. 34 palpation. 11 palpation.10. 12-17 neurological conditions.89 TIbial tuberosity. 9.45 Trapezium.41 Triangular fibrocartilaginous complex lesions.63. strained.125 Trigonum o( Scarpa.11 extracapsular lesions.77 palpation. 86.15 palpation. 71 tendinitis. 10 functional eXamination.66 Posterior talofibular ligament palpation.8-20 instability. 9. 10. 11 anterior drawer test.23 Radioulnar jOint distal. 100 palpation. 125 tendon.35 palpation.64. avulsion fractures.73. 13--14 Supraspinous fossa. 83 tendinitis. 45.5-6 rupture. periostitis.88 Semitendinosus innervation.12-13 resisted external rotation. 114. 68. 40.64 Superior acromioclavicular ligament.50 Scaphoid tuberoSity. 14 Supraspinatus muscle lesions. 115 Pronator ter<.68 Second metacarpal bone. 114 Talofibular ligament. 118-119 valgus movement.123. 57 Posterior superior iliac spine.74. 51-52 Grind test.45 Trapezium-first metacarpal joint.9-20 posterior d rawer test. I13 squeezing. 27 Suprapatellar tendon. 56. 71. 62 Trapezoid bone. 126 tendon. 77.I I Subcoracoid bursitis.28 Triceps surae. 1--8 anterior capsule contraction.9.75. 30 Psoas bursitis. 41 neck. 22-23.. 13 tendon rupture.33 Radius distal epiphysis.23 palpation. 39.69 inflamed. 12 arthrosis. 72 Q Quadratus femoris innervation. 32. 77.4 tendinitis.9. 123.41 stylOid process.99.55-56 Tibia. 114 Talus. 12. 17 passive tests. 76.78 R Radial artery. 74 Rhizarthrosis.77. 67 Copyrighted Material .13 anatomy.43 Trochanters bursitis. 58 Radial tuberosity.16 Subscapularis tendon lesions. 65.74. 61 Talar head.28 rupture. 89 Tibialis anterior innervation. 57 Tensor fasciae latae muscle innervation.19-20 recurrent dislocation. 34 Radiohumeral joint line. 119 varus movement.81 TIbial artery. 56 resisted nexion. 73 palp<ltion.5�57 resisted abduction.115 TIbiofibular ligaments.75 S'lcrotuberous ligament.52 Rib fractures. 110. 17 arthritis.39--W. 39. 17 resisted abduction.10. 10. 51 Triceps muscle lesions. 129 linel's test. 13.77 Sacroiliac joints. 89 TIbial crest.14.III Spring ligament. 50 dorsal tubercle. 126 Posterior tibial artery.40 sprains.61 Transverse ligament.64 Teres major. 78. 86 tendinitis. 119 passive tests. 74 I�ubic tubercle.64 Rectus (emoris innervation.64.41. 56-57 resisted adduction. II.73.51 Radial nerve lesions.11.11.14 resisted internal rotation. 114 Scapula.47 Semimembranoslls innervation.36 palpation.see Distal radioulnar joint lesions. 114 T T l nerve root lesions. 123. 14 painful impingement. 116 Tibialis posterior innervation. 16 s 51 palsies. 81 TIbial vein. 34.9. 44 periostitis. 3-8 Sinus tarsi. thickened. 100 palpation.-. 41.66 Quadriccps extension. 15 Subtalar joint arthritis.65 Triquetra! bone. 1�14 resisted adduction. 17 tendon.88. 48 Radial collateral ligament palpation.74 Scaphoid (navicular) bone.9 palpation.101 palpation. 2 Supinator muscle lesions. 2-3 Sciatic nerve.9. 41 Rectus abdominus tendon.36 Tenosynovitis.66 Sartorius muscle innervation.115 Subacromial bursitis.15 Thoracic wall lesions. 53.136 INDEX Posterior interosseous nerve lesions.6J. 75 Sacroiliac ligaments. crepitating.68.'S muscle lesions. 19 apprehension tests. 88 Shoulder.99 lesions.56. 10 Subdeltoid bursitis. 118-119 Superficial nexors. 14-15 soft tissue palpation. 13 Rotator cuff tendinitis.

61 functionaJ examination. 52--61 palma. 36. 50 palpation. 52-53 resisted radial deviation. 46 Wrist anatomy. 36 resisted extension. 41. 50 arthrosis. 24-26. 50 dorsal ligament lesions. 51 passive tests. 36-37. 28. 61 palpation. 41 styloid process. 57. 51 Copyrighted Material . ulnar deviation. 49-51 passive ulnar deviation. 46 Ulnar coll. 56. 50 passive flexion. 50 passive extension.67-Q8 Trochlear proCL-'SS. 44 Ulnar nerve lesions. 50 passive radial deviation. 50 flexor tendon lesions. 28. 110 Tubercle of Gcrdy. 83 u Ulna palpation. 42-43 tennis elbow.lteral ligament lesions. 50 extensor tendon lesions. 39-48 dorsal ganglion. 72 palpation. 27. 39-48 radial extensors palpation. 51 palpation. 54 resisted.INDEX 137 Trochanters (collld) pain. 48-62 isometric contractions. 43 Ulnar artery. 54-55 Wrisljoint w arthritis. 83 Vastus medialis.r ligament lesions. SO forced flexion (Phalen's test). 82 v Valgus strain. 94-95 Vastus lateralis. 53-54 resisted flexion. 93--94 Varus strain.