The 3 Minute Musculoskeletal amp Peripheral Nerve Exam -Alan Miller

THE 3-MINUTE MUSCULOSKELETAL & PERIPHERAL NERVE EXAM

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THE 3-MINUTE MUSCULOSKELETAL & PERIPHERAL NERVE EXAM III Alan Miller, MD Pain Fellow Jefferson Pain Center Thomas Jefferson University Hospital Philadelphia, Pennsylvania Kimberly DiCuccio Heckert, MD Stroke Rehabilitation Fellow Kessler Medical Rehabilitation Research and Education Center University of Medicine and Dentistry of New Jersey Newark, New Jersey Brian A. Davis, MD Associate Professor Departments of Physical Medicine and Rehabilitation and Anesthesiology and Pain Management PM&R Director Sports and Spine Care Programs Davis Medical Center University of California Sacramento, California New York

Acquisitions Editor: R. Craig Percy Cover Design: Gary Ragalia Copyeditor: Joann Woy Compositor: Patricia Wallenburg Printer: Malloy Litho Visit our website at www.demosmedpub.com © 2009 Demos Medical Publishing, LLC. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or trans- mitted in any form or by any means, electronic, mechanical, photocopying, record- ing, or otherwise, without the prior written permission of the publisher. Medicine is an ever-changing science. Research and clinical experience are continu- ally expanding our knowledge, in particular our understanding of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and pub- lisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of the publication. Every reader should exam- ine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Library of Congress Cataloging-in-Publication Data Miller, Alan, 1978– The 3-minute musculoskeletal & peripheral nerve exam / Alan Miller, Kimberly DiCuccio Heckert, Brian A. Davis. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-1-933864-26-6 (pbk. : alk. paper) ISBN-10: 1-933864-26-5 (pbk. : alk. paper) 1. Musculoskeletal system—Examination. 2. Nerves, Peripheral—Examination. I. DiCuccio Heckert, Kimberly. II. Davis, Brian A. III. Title. IV. Title: Three-minute musculoskeletal and peripheral nerve exam. [DNLM: 1. Musculoskeletal Diseases—diagnosis. 2. Peripheral Nervous System Diseases—diagnosis. 3. Musculoskeletal System—physiopathology. 4. Peripheral Nerves—physiopathology. 5. Physical Examination—methods. WE 141 M647z 2009] RC925.7.M555 2009 616.70076—dc22 2008019619 Special discounts on bulk quantities of Demos Medical Publishing books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. For details, please contact: Special Sales Department Demos Medical Publishing 11 W. 42nd Street, 15th Floor New York, NY 10036 Phone: 800–532–8663 or 212–683–0072 Fax: 212–941–7842 Email: [email protected] Made in the United States of America 09 10 11 5 4 3 2

I would like to thank my beautiful wife Carly, wonderful son Alex, and Mom and Dad. I love you all and thank you for your love and support. Guy, thank you for being a mentor and valued friend. —Alan Thanks Alan, for asking me to write this book with you. I thank God for granting me the privilege to care for patients and for leading me to the greatest field in medicine. I’d like to dedicate this book to the patients who have made my work meaningful, my teachers and mentors who fostered my passion, my family for their endless support, and my husband Chris for his constant love and encouragement. —Kimberly I would like to thank my wonderful wife, Edith Bautista, MD, and my incredible children, Gabrielle and Nathaniel, for their support during this project. I would especially like to posthumously thank Dr. Scott Nadler for teaching me the skills that are presented in this book. —Brian

The authors wish to acknowledge the teaching and mentorship of Gerald J. Herbison, MD as providing the inspiration for this book. His approach to the examination and physical diagnosis of patients serves as a foundation for all Jefferson graduates throughout their careers. This book reflects the authors’ strong desire to assure that his methods are widely available and pre- served for future physicians. We express our thankful apprecia- tion to Dr. Herbison for his guidance, training and commitment to the education of physicians. Alan Miller, MD Kimberly DiCuccio Heckert, MD

I I I ACKNOWLEDGMENTS We would like to acknowledge the following individuals, without whom this work would not be possible: Nethra Ankam, MD; Anna M. Barrett, MD; Steve Dana; Mehul Desai, MD; Carolyn Forsman, MD; Jeff Gehret, DO; Stanley Jacobs, MD; Brian Kucer, MD; Ralph Marino, MD; Andrew McArdle; John L. Melvin, MD; Carly Miller, MD; Craig Percy; and C.R. Sridhara, MD. • Illustrations in Chapters 1 through 8 were created by Steve Dana, University of California at Davis, Mediaworks. • All photographs were taken by Alan Miller, MD. • The back and hip examination in Chapters 1 and 2 were devel- oped largely from materials originally created by Gerald J. Herbison, MD, Thomas Jefferson University Hospital. • Figures of the brachial plexus (page 148) and lumbosacral plexus (page 155) are courtesy of Andrew McArdle (posters@ ajmcardle.me.uk). • Chapter 5 was adapted from materials generously provided by Carson Schneck, MD, Temple University Hospital. • Chapter 6 was adapted with permission from the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury with the assistance of Ralph Marino, MD and Lesley Hudson. • The authors wish to thank the University of Washington and Drs. Carol Tietz and Dan Graney for the use of their muscu- loskeletal images. These illustrations, which appear on pages 226–237, are from the University of Washington Musculoskeletal Atlas: A Musculoskeletal Atlas of the Human Body, Carol Teitz, MD and Dan Graney, PhD, © 2003–2004. • The Department of Rehabilitation Medicine at Thomas Jefferson University Hospital provided assistance in the devel- opment of the manuscript for this book. ACKNOWLEDGMENTS I vii

• The authors also wish to acknowledge the generous contribu- tion of funding for illustrations and artwork provided by the Department of Physical Medicine and Rehabilitation at the University of California at Davis. viii I ACKNOWLEDGMENTS

I I I CONTENTS xi xiii Introduction Quick Reference Guide by Diagnosis 1 87 1 Joint Examination 125 2 Muscular Examination 143 3 Reflex Examination 167 4 Peripheral Nerve Examination 183 5 Gait and Posture 195 6 Spinal Cord Injury Examination 221 7 Reference Tables and Resources 239 8 Musculoskeletal Atlas 269 9 Muscle Tables Index CONTENTS I ix

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I I I INTRODUCTION Countless physicians, medical students, and therapists can describe a similar experience at one time or another during their training: a patient is behind the door in an examination room and the daily schedule has the words “shoulder pain” listed as the chief complaint. Depending on one’s experience or comfort level, many questions may immediately flood one’s mind regarding how to approach the patient: What are the various causes of shoulder pain? Is the pain really coming from the shoulder? What structures are important in the shoulder? What aspects of the physical examination will help distinguish one shoul- der problem from another? The patient is waiting, but suddenly the approach for deter- mining bicipital tendonitis versus rotator cuff pathology (which was once apparent), becomes elusive. Until one’s own approach is fully developed, it can be difficult to keep it all together. Trainees frequently do not have offices, and medical profes- sionals often do not have personal libraries at their immediate disposal, at least not immediately before they are asked to evalu- ate a patient. This is the reason that lab coat pockets are stuffed with papers, notes, and personal digital assistants. As time pro- gresses and skills are developed, we depend on these aids less and less (although many physicians practicing more than 20 years continue to post important charts and diagrams on their office walls), yet we have a great need for quick and easy access to infor- mation for patient care. It was for this reason that the authors decided to condense a large volume of clinical pearls into a pocket format for easy access. We have organized this material such that the answers to INTRODUCTION I xi

questions regarding patient evaluation—as in the painful shoul- der example mentioned above—can be found in 3 minutes or less. After all, the patient is waiting. It is our hope that you will find this book useful in your train- ing and practice as you seek to give patients the very best care. Alan Miller Kimberly Dicuccio Heckert Brian A. Davis xii I INTRODUCTION

I I I QUICK REFERENCE GUIDE BY DIAGNOSIS Neck and Shoulder 10 If you suspect . . . 13 1. Joint/muscle Restriction: 13 Range of Motion 14 14 2. Cervical Radiculopathy: 15 Spurling’s Test 15 16 3. Rotator Cuff Dysfunction: 19 Drop Arm Test Resisted External Rotation 16 Resisted Internal Rotation 17 Patte’s Test 17 Empty Can Test Lift-Off Test 18 Modified Yergason’s Test 20 4. Impingement Syndrome: 18 Hawkins’ Test 19 Neers’ Test 19 Scouring Maneuver 20 5. Acromioclavicular Joint Dysfunction: 20 Apley’s Scarf Test 21 Active Compression (O’Brien’s) Test 6. Bicipital Tendon Injury: Yergason’s Test Modified Yergason’s Test Speed’s Test 7. Intrinsic Shoulder Dysfunction: Active Compression (O’Brien’s) Test Apprehension Test Relocation Test QUICK REFERENCE GUIDE BY DIAGNOSIS I xiii

Surprise (Anterior Release) Test 21 8. Thoracic Outlet Syndrome: 22 22 Adson’s Maneuver 23 Allen’s Test 23 Costoclavicular Test 24 Roos’ Test Wright’s Hyperabduction Test 26 31 Elbow 31 32 If you suspect . . . 33 32 1. Joint/muscle Restriction: 44 Range of Motion 35 2. Epicondylitis: 43 Cozen’s Test 44 Wrist Flexion for Medial Epicondylitis 40 40 3. Ligamentous Laxity: Medial Ligamentous Laxity Lateral Ligamentous Laxity 4. Ulnar Nerve Irritation: Tinel’s Sign of Ulnar Nerve Froment’s Sign Wrist/Hand/Fingers If you suspect . . . 1. Joint/muscle restriction: Range of Motion Tight Hand Intrinsics Test (Bunnel-Littler’s Test) Thumb Axial Grind Test 2. Median Nerve Irritation: Tinel’s Sign of Median Nerve at Wrist Modified Phalen’s Test xiv I QUICK REFERENCE GUIDE BY DIAGNOSIS

Reverse Phalen’s Test 41 Carpal Compression Test 41 3. de Quervain’s Tenosynovitis: Modified Finkelstein’s Test 43 Low Back and Hip 47 54 If you suspect . . . 56 60 1. Joint/muscle Restriction: 61 Range of Motion Ober’s Test 53 Ely’s Test 53 Thomas’ Test 60 Modified Ely’s Test 64 2. Sacroiliac Dysfunction: 54 Yeoman’s Test 54 Gaenslen’s Test 62 Modified Gaenslen’s Test FABRE/Patrick’s Test 55 56 3. Iliotibial Band Syndrome: 57 Ober’s Test 61 Noble’s Compression Test Modified Ober’s Test 52 59 4. Nerve Root Irritation: Straight Leg Raise Test 47 Slump Test 64 Femoral Nerve Stretch Test Modified Femoral Nerve Stretch Test 5. Facet Joint Disease: Lumbar Facet Grind Test Thoracic Rotation 6. Hip Pathology: Range of Motion FABRE/Patrick’s Test QUICK REFERENCE GUIDE BY DIAGNOSIS I xv

Knee 66 If you suspect . . . 71 72 1. Joint/muscle Restriction: 72 Range of Motion 73 76 2. Cruciate Ligament Instability: Anterior Drawer Test 73 Pivot Shift Test 74 Posterior Drawer Sign 74 Lachman’s Test 75 Apley’s Distraction Test 75 76 3. Meniscal Pathology: McMurray’s Test 76 Test for Lateral Stability Joint Line Tenderness Test 78 Test for Medial Stability Apley’s Grinding Test 82 Apley’s Distraction Test 82 4. Nerve Irritation: 83 Tinel’s Sign of Peroneal Nerve 84 at Fibular Head 85 Foot and Ankle 85 If you suspect . . . 86 1. Joint/muscle Restriction: Range of Motion 2. Achilles Tendinopathy: Achilles Tendon Palpation Squeeze Test (Thompson’s Test) 3. Ligamentous Injury: Ankle Anterior Drawer External Rotation Test Talar Tilt Test 4. Nerve or Fascia Irritation: Plantar Fasciitis Test Tarsal Tunnel Test (Tinel’s Sign of Tibial Nerve at Ankle) xvi I QUICK REFERENCE GUIDE BY DIAGNOSIS

THE 3-MINUTE MUSCULOSKELETAL & PERIPHERAL NERVE EXAM

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1CHAPTER I Joint Examination

I I I CONTENTS Introduction 6 SHOULDER EXAM 8 Introduction 10 Range of Motion of the Cervical Spine and Shoulder 11 Palpation of the Shoulder 12 Cervical Spinous Process Exam 13 Spurling’s Test 13 Drop Arm Test 14 Resisted External Rotation 14 Resisted Internal Rotation 15 Patte’s Test 15 Empty Can Test 16 Lift-off Test 16 Hawkins’ Test 17 Neer’s Test 17 Scouring Maneuver 18 Crossed Arm/Adduction/Apley’s Scarf Test 18 Yergason’s Test 19 Modified Yergason’s Test 19 Speed’s Test 20 Active Compression (O’Brien’s) Test 20 Apprehension Test 21 Relocation Test 21 Surprise (Anterior Release) Test 22 Adson’s Maneuver 22 Allen’s Test 23 Costoclavicular Test 23 Roos’ Test 24 Wright’s Hyperabduction Test 25 ELBOW EXAM 26 Introduction Range of Motion of the Elbow 2 I 1 JOINT EXAMINATION

Palpation of the Elbow 27 JOINTS Cozen’s Test 31 Wrist Flexion for Medial Epicondylitis 31 Tinel’s Sign of Ulnar Nerve at Elbow 32 Medial Ligamentous Laxity 32 Lateral Ligamentous Laxity 33 WRIST/HAND/DIGIT EXAM 34 Introduction 35 Range of Motion of the Wrist and Digits 36 Thumb Motion 37 Wrist/Hand/Digit Palpation 40 Tinel’s Sign of Median Nerve at Wrist 40 Modified Phalen’s Test 41 Reverse Phalen’s Test 41 Carpal Compression Sign 42 Clamshell (Wrist Extensors) 42 Reverse Clamshell (Wrist Flexors) 43 Tight Hand Intrinsics Test (Bunnel-Littler’s Test) 43 Modified Finkelstein’s Test 44 Froment’s Sign 44 Thumb Axial Grind Test 45 LUMBOSACRAL SPINE AND HIP EXAM 47 Introduction 47 Range of Motion of Hip and Low Back 47 T-L-S Spine Flexion 48 T-L-S Spine Extension and Rotation 48 T-L-S Spine Lateral Bending 49 Hip Internal Rotation 49 Hip External Rotation 50 Hip Flexion 51 Hip Extension 52 Palpation of the Low Back and Hip 52 Lumbar Spinous Process Exam 53 Lumbar Facet Grind Test 53 Yeoman’s Test Gaenslen’s Test CONTENTS I 3

Ober’s Test 54 Noble’s Compression Test 54 Straight Leg Raise Test 55 Ely’s Test 56 Slump Test 56 Femoral Nerve Stretch Test 57 Leg Length Discrepancy 57 Femoral Anteversion 58 Hoover’s Sign 58 THE HERBISON 3-MINUTE BACK EXAM 59 Thoracic Rotation 60 Thomas’ Test 60 Modified Gaenslen’s Test 61 Modified Ely’s Test 61 Modified Femoral Nerve Stretch Test 62 Modified Ober’s Test 62 Hip Range of Motion Test 63 Straight Leg Raise Test 64 FABERE/Patrick’s Test 65 KNEE EXAM 66 Introduction 67 Range of Motion of the Knee 70 Palpation of the Knee 70 Suprapatellar Compression Test 71 Patellar Ballotment 72 Anterior Drawer Test 72 Pivot Shift Test 73 Posterior Drawer Sign 73 Lachman’s Test 74 McMurray’s Test 74 Test for Lateral Stability 75 Joint Line Tenderness Test 75 Test for Medial Stability 76 Apley’s Grinding Test 76 Apley’s Distraction Test Tinel’s Sign of Peroneal Nerve at Fibular Head 4 I 1 JOINT EXAMINATION

FOOT AND ANKLE EXAM 77 JOINTS Introduction 78 Range of Motion of the Ankle 79 Palpation of the Ankle 82 Achilles Tendon Palpation 82 Squeeze Test (Thompson’s Test) 83 Ankle Anterior Drawer 84 External Rotation Test 85 Talar Tilt Test 85 Plantar Fasciitis Test 86 Tarsal Tunnel Test (Tinel’s Sign of Tibial Nerve at Ankle) CONTENTS I 5

I I I INTRODUCTION Accurate evaluation of the joints is critical to determining the cause and subsequent treatment of musculoskeletal disorders. As examiners, we must train our eyes and hands to detect clinically significant side-to-side and person-to-person differences. We must also be able to detect differences in the “feel” of a joint. For example, the end range of a shoulder with adhesive capsulitis can feel very different from that of a shoulder with glenohumeral arthritis. We must recognize that the average range of motion of joints may vary according to range, gender, and other factors. For example, the range of motion of the thoracolumbar spine can be limited by lordosis or kyphosis in older patients. Young clinicians should devote a significant amount of practice time in this area. The approach to evaluation of joints presented in this book fol- lows the order commonly used by musculoskeletal clinicians: inspection, palpation, range of motion (ROM), and finally special tests and provocative maneuvers. A specialized integration of these is provided for a streamlined assessment of the low back and hip. 6 I 1 JOINT EXAMINATION

For tests pictured in this book, arrows have been superim- JOINTS posed over photographs to help demonstrate the test being per- formed. Arrows have been rendered either black or white to aid in visualization against the photo image. Examiner Motion Arrows with a solid tail represent the direction of motion of the examiner. Patient Motion Arrows with a dashed tail represent the direction of motion of the patient. INTRODUCTION I 7

I I I SHOULDER EXAM Introduction Exam of the shoulder includes inspection, passive and active range of motion (ROM), strength testing of the muscles acting across the shoulder, palpation, and, when indicated, provocative maneuvers to reproduce a complaint or symptom in order to bet- ter define the problem generator. A thorough neck exam should also be performed to evaluate for cervical causes of shoulder or upper limb pain. Evaluation of elbow structures may also be war- ranted. Inspection: Begin by looking at the shoulder region with the patient relaxed and standing when possible. Compare to the con- tralateral shoulder, noting shape, size, color, or positional differ- ences. Observe the position of the scapula at rest and compare to the contralateral side. Specifically evaluate the resting scapula for medial/lateral or superior/inferior positional differences. The shoulder of the dominant side is typically lower than the non- dominant side at rest. Range of Motion (ROM): Observe the patient actively moving the upper limb to produce the maximal amount of flexion, extension, abduction, and internal and external rotation about the shoulder joint. Check to see if the ROM can be passively increased with each plane of movement. A difference between passive ROM (examiner assisted) and active ROM (patient initiated) may help differentiate between muscle weakness and joint contracture. If it is suspected that ROM is limited by spasticity, passively move through the range as slowly as possible to limit the spastic component. Evaluate the patient moving his hands from resting to a “hands-on-hip” position. Note any deviation from side to side. Evaluate scapular motion with flexion, abduction, and adduction. Passive exam maneuvers should be performed with the examiner stabilizing the scapula. Internal and external rotation should be evaluated with the shoulder and elbow both at 90°, as this allows for direct glenohumeral joint evaluation. 8 I 1 JOINT EXAMINATION

Palpation: The shoulder joint should be palpated for point ten- JOINTS derness along the glenohumeral joint line (anterior and poste- rior), the scapula, and the tendinous insertions of the rotator cuff. The acromioclavicular (AC) joint, sternoclavicular (SC) joint, and biceps tendon should also be palpated. The shoulder should be passively moved through the full range of motion (and pal- pated) while feeling for crepitus, clicks, and clunks. SHOULDER EXAM I 9

Range of Motion of the Cervical Spine and Shoulder Flexion Extension Rotation Lateral bending 0–45° 0–45° 0–70° 0–40° Flexion Extension External rotation 0–180° 0–45° 0–90° Internal rotation Adduction Abduction 0–90° 0–45° 0–170° 10 I 1 JOINT EXAMINATION

Palpation of the Shoulder JOINTS Acromioclavicular ligament Coracoclavicular ligaments Clavicle Coracoacromial ligament Pectoralis minor (cut) Coracoid process Subscapularis Humerus muscle (cut) Coracobrachialis muscle Long head of biceps Short head of biceps (cut) Shoulder Anterior View Acromion Clavicle Supraspinatus muscle Scapular Subscapularis spine muscle (underneath Infraspinatus humerus) muscle Humerus Teres minor SHOULDER EXAM I 11 muscle Scapula Deltoid muscle (cut) Shoulder Lateral View

Clavicle Supraspinous fossa Acromion Supraspinatus muscle (cut) Subacromial bursa Greater tubercle Scapular spine Infraspinatus Scapula / infraspinatous muscle (cut) fossa Rhomboid Latissimus dorsi muscle Humerus Teres minor Triceps muscle muscle (cut) (cut) Teres major muscle (cut) Shoulder Posterior View Cervical Spinous Process Exam Patient: Sits or stands, neck maxi- T1 mally flexed. Examiner: Observe cervical spine from lateral view during maximal flexion and extension. Consistent with: The most supe- rior prominent fixed point pal- pated on the cervical spine with the neck in flexion is most consis- tently the spinous process of T1. May be differentiated from C7 spinous process as C7 is typically more mobile and moves anteri- orly on extension. Note: Cervical and thoracic levels may be identified by counting up or down spinous processes. 12 I 1 JOINT EXAMINATION

Spurling’s Test JOINTS Patient: Sits upright on exam table, extends neck 30°, looks to one side. Examiner: Create an axial load by press- ing downward on the top of the patient’s head with mild to moderate force. Positive test: Reproducible pain/numbness radiating to one or both upper limbs in a radicular distribution. Consistent with: Pain or paresthesias radiating to the shoulder or upper limb may imply irritation of a nerve root from the cervical spine. Localized neck pain may suggest facet or posterior element disease. Note: Caution should be used in patients with stenosis, arthritis, and compression fractures. Drop Arm Test Patient: Sits or stands. Examiner: Abduct arm to 90° in the coronal plane; then horizon- tally adduct to 45° and ask patient to slowly lower arm. Positive test: Severe pain, or patient unable to lower arm in a controlled manner on affected side. Consistent with: Rotator cuff tear or significant tendinopathy. SHOULDER EXAM I 13

Resisted External Rotation Patient: Begins seated with elbows at side and flexed to 90°. Patient actively exter- nally rotates shoulder. Examiner: Stand at side and actively resist external rotation. Positive test: Patient has weakness and/or pain on affected side. Consistent with: Rotator cuff or poste- rior deltoid dysfunction. Resisted Internal Rotation Patient: Sits, elbows at side, elbow flexed, actively internally rotates shoulder. Examiner: Stand at side and actively resist internal rotation at distal forearm. Positive test: Patient has weakness and/or pain on affected side. Consistent with: Rotator cuff tendinopa- thy and/or subscapularis dysfunction Note: 1. Other muscles, such as pectoralis major and teres major, contribute to internal rotation and may affect strength if dysfunc- tional. 2. Trapezius weakness may destabilize the scapula and cause false weakness of the internal rotators. 14 I 1 JOINT EXAMINATION

Patte’s Test JOINTS Patient: Sits, elbow flexed to 90°; shoulder abducted to 90° and externally rotated so that the fist is up. Patient attempts to further externally rotate. Examiner: Resist external rota- tion with one hand while sup- porting the elbow with the opposite hand. Positive test: Pain in the shoulder or scapular region with some preserved strength or inability to keep arm in external rotation. Consistent with: Tendonitis (pain/some preserved strength) or rupture (lowering of the arm) of the infraspinatus or teres minor tendons. Empty Can Test Patient: Shoulders abducted Pain to 90° and angled forward 30°, elbows fully extended, and forearms fully pronated (thumbs down as if turning a can upside down). Examiner: Apply downward force to the patient’s distal forearms, while patient attempts to resist. Positive test: Patient’s shoulder pain is reproduced. Consistent with: Supraspinatus tendinopathy. SHOULDER EXAM I 15

Lift-off Test Patient: Stands or lies prone, the arm is internally rotated and elbow is moder- ately flexed, with the dorsum of the hand touching the mid-lumbar spine. Examiner: Instruct patient to lift the hand away from the back. Positive test: Inability to lift the dorsum of the hand off the back against gravity or minimal resistance from examiner, or restriction is noted compared with contralateral side. Consistent with: Weakness of the subscapularis, latissimus dorsi, or rhomboids. Note: 1. The test may be attempted when standing. 2. Patient may attempt to substitute triceps/elbow extension if subscapularis, latissimus dorsi, or rhomboid is weak. Hawkins’ Test Patient: Flexes elbow and shoulder Pain to 90°, with shoulder internally rotated such that the fist is down. Examiner: Stabilize patient’s arm by holding proximal to the elbow while applying tension on the anterior dis- tal forearm to maximally internally rotate the shoulder. Positive test: Reproduces patient’s shoulder pain in the area of the acromion. Consistent with: Impingement syndrome. 16 I 1 JOINT EXAMINATION

Neer’s Test JOINTS Patient: Extends elbow and Pain pronates forearm (thumbs down). Examiner: Lift the patient’s arm in flexion and 30° in the coronal plane, passively extending the shoulder to end range. Positive test: Patient’s shoulder pain is reproduced. Consistent with: Impingement syndrome. Note: Examiner may wish to also stabilize scapula with other hand to further impinge the supraspinatus. Scouring Maneuver Starting position Patient: Flexes both elbow and shoulder to 90°; shoulder abducted and internally rotated such that the fist is down (same as in Hawkins’ test). Examiner: Passively internally rotate arm while moving the shoulder from flexion into extension while stabilizing the scapula. Positive test: Patient’s shoulder pain is reproduced. Consistent with: Impingement syn- drome. Final position SHOULDER EXAM I 17

Crossed Arm/Adduction/ Apley’s Scarf Test Patient: Sits or stands. Pain Examiner: Flex shoulder to 90° and bring arm horizontally across the chest so the arm is moved toward the contralateral shoulder. The examiner feels the ipsilateral acromioclavicular (AC) joint. Positive test: Pain, shifting, or a click at the AC joint. Consistent with: Acromioclavicular joint dysfunction. Yergason’s Test Patient: Sits on exam table or chair with the arm resting at side; elbow flexed to 90° and forearm pronated. Examiner: Grasp patient’s forearm just proximal to the wrist and resist active supination. Positive test: Pain located in the bicipital groove. Consistent with: Bicipital tendonitis/tendinopathy. Note: See the modified Yeagerson’s test for additional evaluation of bicipital tendon subluxation and the subscapularis. 18 I 1 JOINT EXAMINATION

Modified Yergason’s Test JOINTS Patient: Sits on exam table or chair with elbow flexed to 90° and fore- arm pronated. Examiner: Grasp patient’s arm just proximal to the wrist and resist active supination and external rota- tion. Palpate bicipital tendon. Positive test: Pain located in the bicipital groove or palpable bicipital subluxation is noted. Consistent with: Bicipital tendinopathy, tendon subluxation, and/or subscapularis injury. Speed’s Test Pain Patient: Flexes shoulder to 50°, with elbow in extension and wrist in supination. Examiner: Provide downward force on the arm to attempt to extend the patient’s shoulder. Positive test: Pain in the area of the bicipital tendon. Consistent with: Bicipital ten- donitis. SHOULDER EXAM I 19

Active Compression (O’Brien’s) Test Patient: Positions upper limb with shoulder flexed to 90°, horizontally adducted to 15°, and maximally inter- nally rotated and elbow fully extended. Examiner: 1. Apply a downward force to the distal forearm against maximal resistance of the patient. 2. The above is repeated with shoulder externally rotated. Positive test: Pain or audible click at the acromioclavicular joint or at the glenohumeral joint. Consistent with: Acromioclavicular joint dysfunction if pain in AC joint, or superior labral anterior posterior (SLAP) pathology if pain at the glenohumeral joint. Apprehension Test Patient: 1. Lies on table, with arm hanging off edge. 2. Shoulder is abducted to 90°, elbow flexed to 90°, and shoulder maximally externally rotated. Examiner: Further externally rotate shoulder by applying posteriorly directed force on the distal forearm with one hand and anterior force on the proximal arm. Do not go beyond the patient’s pain threshold. Positive test: Reproduces the patient’s pain, or gives the patient the “apprehension” of reproduction of their pain or the feeling that their shoulder will dislocate or “pop out of the socket.” Consistent with: Anterior shoulder laxity or instability. 20 I 1 JOINT EXAMINATION

Relocation Test JOINTS Patient: 1. Lies on table, with half of arm hanging off edge. 2. Shoulder is abducted to 90°, elbow flexed to 90°, and shoulder maximally externally rotated (same as the Surprise test). Examiner: 1. Stabilize patient’s arm by holding the wrist. 2. With the palm of the hand, direct a posterior force to the glenohumeral joint. Positive test: Pain and/or sense of shoulder instability decreases or the range of motion increases. Consistent with: Anterior shoulder laxity or instability Surprise (Anterior Release) Test Patient: 1. Lies on table, with half of arm hanging off edge. 2. Shoulder is abducted to 90°, elbow flexed to 90°, and shoulder maximally externally rotated (same as the Relocation test). Examiner: Perform relocation test and then suddenly release force on glenohumeral joint. Positive test: Return of symptoms of pain or instability. Consistent with: Anterior shoulder laxity or instability. SHOULDER EXAM I 21

Adson’s Maneuver Patient: Rotates head to side with neck extended. Shoulder at 45° abduction and elbow freely extended. Patient inhales and holds to maximum inspiration. Examiner: Palpate bilateral radial pulses. Positive test: Pulse disappears when maneuver is performed, and/or patient reports numbness or tingling in the limb. Consistent with: Scalene compression of the brachial plexus or great vessels. Allen’s Test Patient: Abducts shoulder to ~90°, flexes elbow to ~60°. Examiner: Grasp patient’s distal forearm and passively internally rotate and extend the shoulder while palpating the radial pulse. Positive test: Pulse diminishes or disap- pears when patient’s head turns away. Consistent with: Vasogenic thoracic outlet syndrome with loss of pulse, neurogenic thoracic outlet syndrome with numb- ness/tingling. 22 I 1 JOINT EXAMINATION

Costoclavicular Test JOINTS Patient: Stands or sits. Examiner: 1. Stand behind patient and pal- pate both radial pulses with patient’s shoul- ders in 10°–20° of extension. 2. Patient then thrusts out chest. Positive test: Disappearing palpable pulse and/or arm/forearm numbness. Consistent with: Compression of brachial plexus or great vessels between ribs and clavicle. Roos’ Test Patient: 1. Abducts both arms to 90° and flexes elbows to 90°. 2. Patient then rapidly opens and closes hands for 30–180 seconds. Examiner: Observe patient’s hands. Positive test: Reproduction of symptoms should be accompanied by pallor of the affected hand. Discontinuation of test should cause symptoms to decrease and/or hand to return to normal color. Consistent with: Thoracic outlet syndrome. SHOULDER EXAM I 23

Wright’s Hyperabduction Test Patient: Stands with elbow flexed to 90°. Examiner: 1. Palpate radial pulse and slowly abduct and flex patient’s arms to >130°. Examiner may wish to auscul- tate radial pulse with a stetho- scope. Positive test: Disappearing palpable pulse, arm/forearm numb- ness, or a bruit. Consistent with: Compression of great vessels between ribs and clavicle (pulse change or bruit) or compression of the brachial plexus (numbness). 24 I 1 JOINT EXAMINATION

I I I ELBOW EXAM JOINTS Introduction The elbow exam consists of inspection, palpation, and ROM, as well as an evaluation of the strength of muscles that act across it. Inspection: Observe for swelling, effusion, erythema, or defor- mity, using a side-to-side comparison. Palpation: Lay a hand gently over the elbow to detect warmth, comparing to contralateral side. Palpate the following structures, noting any pain: medial and lateral epicondyles, olecranon process and olecranon bursa, forearm flexor and extensor ten- dons, and triceps tendon. An elbow effusion is best evaluated by palpating for fullness around the triceps tendon posteriorly. At the radial head/radiocapitellar joint, evaluate for click- ing/grinding/subluxation with all movements of the elbow joint. Feel for crepitus, clicks, and clunks with the joint as a whole dur- ing movement. Other structures to palpate are the distal biceps tendon, and the ulnar and radial collateral ligaments. All elbow maneuvers and ROM may be performed with the elbow on the table to stabilize both elbow and shoulder. Active flexion should be evaluated with the forearm fully pronated and supinated. End ROM should also be noted, as hyperextension is often associated with ligamentous laxity. Pronation and supina- tion should also be evaluated at maximum flexion and extension. ELBOW EXAM I 25

Range of Motion of the Elbow Flexion Extension 0–150º 0–10º Supination Pronation 0–80º 0–70º (evaluated with the (evaluated with the elbow flexed to 90º) elbow flexed to 90º) 26 I 1 JOINT EXAMINATION

Palpation of the Elbow JOINTS Lateral Medial Radius Ulna Median nerve Anterior interosseous branch of median nerve Biceps brachii Pronator teres tendon (cut) Medial (ulnar) collateral ligament Lateral (radial) collateral ligament Medial epicondyle Lateral Ulnar epicondyle nerve Median nerve Humerus Elbow Anterior View (in supination) ELBOW EXAM I 27

Radial styloid Ulnar styloid Posterior antebrachial Dorsal ulnar cutaneous nerve cutaneous nerve Radial nerve Ulna Radius Ulnar nerve Annular ligament Olecranon bursa Humerus Triceps tendon Elbow Posterior View (cut) Radial nerve 28 I 1 JOINT EXAMINATION

JOINTS Median nerve Dorsal ulnar cutaneous nerve Anterior interosseous branch of median nerve Ulna Radius Medial (ulnar) Interosseous collateral ligament membrane Anterior humeral fat pad Olecranon bursa Posterior Ulnar nerve humeral fat Medial epicondyle pad Humerus Elbow Medial View ELBOW EXAM I 29

Dorsal ulnar Dorsal radioulnar cutaneous nerve joint Ulnar nerve Superficial radial nerve Ulna Radial nerve Anular ligament Radius Lateral (ulnar) Biceps muscle collateral ligament (cut) Lateral Humerus Radial nerve epicondyle Triceps muscle (cut) Elbow Lateral View 30 I 1 JOINT EXAMINATION

Cozen’s Test JOINTS Patient: Flexes elbow to ~60° on lap or table and fully extends wrist. Examiner: Forcibly flex the extended wrist. Positive test: Pain at the lateral epicondyle during resisted extension. Consistent with: Lateral epicondylitis of the elbow. Note: You may use the Clamshell test on page 42 to increase resistance. Wrist Flexion for Medial Epicondylitis Patient: Flexes forearm to ~50° on lap or table and fully flexes wrist. Examiner: Forcibly extend the flexed wrist. Positive test: Pain at the medial epicondyle. Consistent with: Medial epicondylitis of the elbow. Note: You may use the Reverse Clamshell test on page 42 to increase resistance. ELBOW EXAM I 31