Musculoskeletal Examination

442 Gait Chapter 14 Figure 14.17 Weakness of the quadriceps may be compensated Figure 14.18 The compensated Trendelenburg gait is for by the patient pushing the thigh backward following characterized by the trunk deviating over the hip during stance heel-strike when quadriceps function is necessary. phase to make up for weakness of hip abduction. This gait pattern may also be noted in patients with a painful hip, in on the abnormal side. This can be accomplished by which case the stance phase duration will be markedly reduced. hip hiking or circumducting the hip on the good side during swing-through. To allow for weight bearing hip in stance phase. It appears as if the patient is on the affected side, the patient will walk on the ball bending the trunk to the side, away from the weak of the foot (primary toe-strike). hip during weight bearing (Figure 14.19). Some pa- tients may compensate for this by flexing their trunk Hip over the weight-bearing hip. This is called a compen- sated Trendelenburg gait. A compensated Trendelen- Antalgic Gait burg gait results from weakness of hip abduction or a painful hip. You can differentiate the cause of this gait The patient with the painful hip due to osteoarthri- pattern by observing the duration of the stance phase tis, for example, will make every effort to reduce the on the abnormal leg. With a painful gait, the stance amount of time spent weight bearing on that side. The duration is reduced. Weakness has a lesser effect on trunk is thrown laterally over the hip during weight stance duration. bearing. This is done in an effort to reduce the com- pressive force of the abductor muscles of the hip dur- Weakness of the hip extensors, seen frequently in ing weight bearing. This is known as a compensated myopathies, results in the trunk being thrown poste- Trendelenburg or lurch gait (Figure 14.18). The hip is riorly at heel-strike, when the hip extensors are nor- maintained in a relaxed position of external rotation mally most active. during swing phase. Heel-strike is avoided. Weakness Abnormal Range of Motion Weakness of the hip abductors, seen frequently in Loss of hip extension that occurs due to a hip flex- patients with poliomyelitis, results in a Trendelen- ion contracture, for example, will cause a functional burg gait. This is characterized by abduction of the shortening of the patient’s leg. An increase in the

Chapter 14 Gait 443 ing late stance phase, when the hip is normally in extension. Figure 14.19 The uncompensated Trendelenburg gait is Leg Length Discrepancy characterized by adduction of the hip, which appears as if the patient is moving the trunk away from the weight-bearing side Leg length discrepancy may be absolute or relative. during the stance phase. This results from weakness of hip Absolute leg length discrepancy results from a length- abduction. ening or shortening of the extremity due to bony in- jury or disease. For example, a fracture that unites lumbar lordosis will develop so that upright posture the femur in a shortened position will result in an of the trunk can be maintained. The patient may walk absolute shortening of the extremity. A femoral pros- with the foot plantar flexed on the shortened side to thesis that is too long for the patient will result in an increase the functional length of the leg. Increased absolute lengthening of the extremity. knee flexion will occur on the contracted side dur- Relative leg length discrepancy is due to postural abnormalities such as scoliosis, sacroiliac dysfunc- tion, joint contractures, varus and valgus abnormali- ties, and neuromuscular dysfunction. For example, a hip flexion or knee flexion contracture causes a rela- tive shortening of the extremity. An equinus deformity causes a relative lengthening of the extremity. When the discrepancy is greater than 13/4 in., the patient attempts to lengthen the short limb by walking on the ball of the foot. When the short limb is in the stance phase, the patient must swing-through the long limb without catching the toe on the ground. The patient does this by hip hiking or circumducting the extremity on the swing-through side (see Figures 14.15 and 14.16). When the leg length difference is less than 13/4 in., the patient will drop the pelvis on the affected side to functionally lengthen the short extremity. This is accompanied by lowering of the shoulder height on the same side.

444 Gait Chapter 14 SAMPLE EXAMINATION History: 20-year-old male Presumptive Diagnosis: Acute marathoner presents with a compartment syndrome secondary to 2-week history of right leg pain which he calf inflexibility. was initially able to “run through,” but now his symptoms prevent him from Physical Examination Clues: continuing to run. He has had no prior 1. Male, indicating a possible tendency trauma. He has a past history of hamstring pulls in previous running toward decreased musculoskeletal seasons. flexibility. 2. “Good muscle definition” implying a Physical Examination: Well-developed, decrease in inherent musculoskeletal well-nourished male with good muscle flexibility. definition. Manual muscle testing 5/5 3. Limited dorsiflexion of the ankle throughout the lower extremity. There is further indicates a lack of flexibility. no tenderness on palpation. He has As a result, the tibialis anterior is limited dorsiflexion of the right ankle to required not only to act against 0 degree and straight leg raise to 50 gravity when actively dorsiflexing the degrees on the right. All other range of ankle with each stride, but also to motion was within normal limits. overcome the resistance of the tight Mobility testing was intact in the ankle calf muscles that are inhibiting normal and knee. ankle dorsiflexion. This predisposes the patient to suffer an “overuse” failure of the anterior musculature.

Appendices Appendix 1 Physical findings in abnormal conditions of the musculoskeletal system Muscle tendon injury Tender without swelling, mild spasm First-degree, mild No ecchymosis Second-degree, moderate No palpable defect Active contraction and passive stretch are painful Third-degree, complete Tender with swelling Ligament injury Mild to moderate ecchymosis First-degree, mild Moderate spasm Possibly palpable discontinuity Second-degree, moderate Extremely painful with passive stretching and attempted contraction Joint motion limited Third-degree, complete Bone injury Extreme tenderness with swelling Contusion May be severe bleeding and possible compartment syndrome with loss of sensation and pulse Fracture distally Palpable defect with bunching up of muscle tissue Stress fracture Complete loss of muscle function No change in pain with passive stretch Minimal or no swelling Local tenderness Increase in pain with passive and active range of motion Minimal bruising No instability or functional loss expected Moderate swelling with ecchymosis Very tender, more diffusely tender Range of motion very painful and restricted due to swelling Instability may be recognized Functional loss may result Severe swelling and ecchymosis or hemarthrosis Structural instability with abnormal increase in range of motion Possibly less painful than second-degree tear Localized tenderness With or without ecchymosis Subcutaneous swelling No palpable discontinuity Localized to diffuse tenderness Deformity and/or instability Palpable discontinuity in accessible areas Ecchymosis Possible neurovascular compromise Localized tenderness with overlying swelling and redness Increased pain with vibration or ultrasound applied to bone Certain locations are very common (i.e., tibia, fibula, metatarsals, femur) 445

446 Appendices Appendix 1 (Continued) Swelling, redness of joint, frequently symmetric Muscle tendon injury Synovitis, systemic disease common Inflammatory joint disease May see subcutaneous nodules on extensor surface Severe joint deformities are common Noninflammatory joint disease Valgus deformities are common Extensor tendon ruptures may be noted Metabolic joint disease Compression neuropathy with loss of sensation and muscle strength may be noted Nerve compression or radiculopathy Muscle weakness and restricted range of motion Pain worsens with activity Myofascial pain (trigger points) Acute swelling and redness, asymmetrical involvement Neoplasm Hypertrophic joint without destruction Common pattern “capsular,” which is painful on range of motion Infection Weakness and tightness of muscles crossing involved joints Reflex sympathetic dystrophy Pain lessens with activity Acute: Less than 3 months after injury Stiffness in the morning; fusion of joint may eventually occur Varus deformity may occur Abnormal crystals in the joint fluid Very painful, red and swollen joints Loss of range of motion Systemic disease common Joint destruction may be severe Pain, weakness, sensory loss, reflex loss and paresthesias in the dermatomal and/or myotomal distribution of the affected nerve; degree of loss of function may be mild or complete Stretching the nerve may increase pain Tapping over the nerve may result in distal tingling (Tinel’s sign), especially if regeneration is occurring Tenderness in a characteristic location of certain muscles Palpation of this location causes referred pain to a distant site A taut band, or sausage-like piece of muscle can often be palpated and may cause a twitch of the muscle when plucked like a guitar string The affected muscle is usually unable to relax fully and therefore passive stretch is limited and painful Unremitting pain, often awakens patient from sleep, no comfortable position to relieve pain Palpable mass if accessible and advanced Fracture (pathological) if bone involved Fever, weight loss, and fatigue Possible neurovascular compromise Swelling, redness, warmth, and tenderness Fever and fatigue Loss of joint range or motion with characteristic fluid findings in affected joint Painful compression, active and passive range of motion of involved muscle Pain, warmth, swelling, redness Light touch is very painful Increased hair growth Mild stiffness of joints

Appendices 447 Appendix 1 (Continued) Pain is extremely severe Subacute: 4–12 months after injury Increased joint stiffness with loss of range of motion Passive range of motion is very painful Chronic: More than 1 year after injury Cool and pale or cyanotic discoloration Less swelling Less pain (usually) Periarticular fibrosis Marked limitation in range of motion No swelling Pale, dry, and shiny skin Appendix 2 Range of motion of the extremities. Joint Motion Range (degrees) Shoulder Flexion 0–180 Elbow Extension 0–60 Forearm Abduction 0–180 Wrist Internal (medial) rotation 0–70 External (lateral) rotation 0–90 Thumb Carpometacarpal Flexion 0–150 Extension 0 Metacarpophalangeal Interphalangeal Pronation 0–80/90 Digits 2–5 Supination 0–80/90 Metacarpophalangeal Extension 0–70 Proximal interphalangeal Flexion 0–80 Distal interphalangeal Radial deviation 0–20 Hip Ulnar deviation 0–30 Abduction 0–70 Adduction 0 Opposition Tip of thumb to base or tip of fifth digit Flexion 0–50 Extension 0 Flexion 0–90 Extension 0–20 Flexion 0–80 Extension 0–45 Abduction/Adduction 0–20 Flexion 0–110 Extension 0 Flexion 0–90 Extension 0–20 Flexion 0–120 Extension 0–30 Abduction 0–45 Adduction 0–30 External (lateral) rotation 0–45 Internal (medial) rotation 0–45

448 Appendices Appendix 2 Range of motion of the extremities. Joint Motion Range (degrees) Knee Ankle Flexion 0–135 Extension 0 Subtalar Forefoot Dorsiflexion 0–20 Toes Plantar flexion 0–50 First metatarsophalangeal Inversion 0–35 First interphalangeal Eversion 0–15 Second to fifth metatarsophalangeal Inversion 0–5 Eversion 0–5 Inversion 0–35 Eversion 0–15 Flexion 0–45 Extension 0–70 Flexion 0–40 Flexion 0–40 Extension 0–40

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Index Note: Italicized b, f and t refer to boxes, figures and tables abdominal muscles, 103, 105f alignment tests, foot, 422–8 tarsal tunnel syndrome, 416–17 abductor pollicis brevis, 277f flexible versus rigid flat foot, 422–8 neurological examination, 416 abductor pollicis longus, 277f forefeet-heel alignment, 425 abnormal gait, 438–43 leg-heel alignment, 425 motor, 416 medial longitudinal arch, 422, 425 reflexes, 416 ankle, 439–40 tibial torsion, 427 sensation, 416 causes of, 439t observation, 382–4 foot, 439–40 alignment tests, hip, 328–32 palpation of, 384–99 hip, 442–3 apparent leg length discrepancy, 331 dorsal aspect, 388–91 knee, 440–42 Craig test, 331–3 lateral aspect, 391–5 Achilles tendon, 395 test for true leg length, 328–30 medial aspect, 384–8 rupture, 417 plantar surface, 396–7 Thompson test for, 423f Allen’s test, 289 posterior aspect, 395–6 acromioclavular joint, 141, 145–6, 166–7, anatomical snuffbox, 245 toes, 397–9 angle of anteversion, 331 paradigm for overuse syndrome, 431f 186–7 angle of Louis, palpation of, 48–9 passive movement testing, 399–408 acromioclavular shear test, 186–7 ankle, 379–431 physiological movements, 399–405 acromion process, 146 dorsiflexion, 399–400 active compression test of O’Brien, 184–5, abnormal gait, 439–40 eversion, 402–3 active movement testing, 399 extension of metatarsophalangeal 190f alignment tests, 422–8 active movement testing, 26–30 joint, 405 flexible versus rigid flat foot, 422–8 flexion of metatarsophalangeal joint, ankle, 399 forefeet-heel alignment, 425 cervical spine, 53–8 leg-heel alignment, 425 404–5 medial longitudinal arch, 422, 425 forefoot eversion, 403 backward bending, 57–8 tibial torsion, 427 forefoot inversion, 403 forward bending, 54–6 anterior drawer of, 423f inversion, 400–402 lateral bending, 58 bony structures, 384–97 plantar flexion, 400 elbow, 210–11 body of talus, 389, 390f subtalar eversion, 403 foot, 399 calcaneus, 395 subtalar inversion, 403 hand, 251–2 cuboid, 391–2, 393f pronation, 382 hip, 302–6 cuneiform bones, 385, 386f radiological views, 429–30f abduction, 304, 305f fifth metatarsal, 392–3 range of motion, 448t adduction, 304, 306f first metatarsal joint, 385, 386f referred pain patterns, 416 extension, 304, 305f first metatarsophalangeal joint, 385, resistive testing, 408–16 flexion, 302, 305f ankle dorsiflexion, 410–12, 413f lateral rotation, 304, 306f 386f ankle plantar flexion, 410 medial rotation, 304, 306f inferior tibiofibular joint, 388, 389f subtalar eversion, 412–14 knee, 351–3 lateral malleolus, 391, 392f subtalar inversion, 412, 413f lumbosacral spine, 103–5 medial malleolus, 384 toe extension, 415–16 rotation, 58 medial tubercle of calcaneus, 396 toe flexion, 414, 415f shoulder, 154, 160–61 metatarsal heads, 396–7 sample examination, 428b temporomandibular joint, 87–92 navicular tubercle, 385 soft-tissue structures, 387–97 assessing freeway space, 90–91 peroneus tubercle, 391, 393f anterior talofibular ligament, 393–4 closing of mouth, 89 sesamoid bones, 396, 397f brevis tendons, 394–5 lateral mandibular deviation, 90 sinus tarsi, 389–90 calcaneal bursa, 395 mandibular measurement, sustentaculum tali, 385 calcaneofibular ligament, 394 functional anatomy of, 379–80 deltoid ligament, 387 91–2 inversion stress test, 424f dorsalis pedis pulse, 391 measurement of overbite, 91 longitudinal arch, 381f extensor digitorum brevis, 391, 392f measurement of overjet, 91 mobility testing of accessory movements, extensor digitorum longus tendon, 391 opening of mouth, 88–9 extensor hallucis longus, 390 protrusion of mandible, 89 406–8 flexor digitorum longus, 387 swallowing and tongue position, 92 cuboid-metatarsal joint, 407 flexor hallucis longus, 388 thoracic motion, 58 fibula at inferior tibiofibular joint, 406 long saphenous vein, 387–8, 389f upper cervical spine, 58 fibula at superior tibiofibular joint, 406 peroneus longus, 394 wrist, 251–2 first cuneiform-metatarsal joint, 408 plantar aponeurosis, 397 acute single supratolerance, 2 metatarsals, 408 posterior talofibular ligament, 394 Adam’s apple, 47 traction of first metatarsophalangeal posterior tibial nerve, 388 adductor longus muscle, 298, 300f retrocalcaneal bursa, 395, 396f adductor pollicis, 279f joint, 408 tendocalcaneus, 395 adductor tubercle, 344, 345t traction of subtalar joint, 407 Adson’s maneuver, 191–2, 195f traction of talocrural joint, 406–7 alar ligament stress tests, 76–7 nerve compression test, 416–17 peroneal nerve compression, 416

454 Index Ankle, (Cont.) bone, 5–6 intervertebral mobility testing, 59–60 tibialis anterior tendon, 390 bone injury, 445t extension, 59 tibialis posterior, 387 bounce home test, 369–71, 373f flexion, 59 brachial artery, 204 lateral bending, 59–60 structural integrity tests, 417–22 brachial plexus, 64–5 rotation, 60 anterior drawer sign, 420 inversion stress test, 420 median nerve, 65 lateral view of, 79f stress fracture test, 420–21 radial nerve, 65 neurological examination of, 64–74 test for Morton’s neuroma, 421 ulnar nerve, 65–6 Thompson test for Achilles tendon brachialis, 218f brachial plexus, 64–5 rupture, 417 brachioradialis, 218f root level, 64–74 reflex, 223, 224f upper limb tension test, 65–6 subjective examination, 384 brevis tendons, 394–5 observation, 34–6 tests for upper motor neuron Buerger’s test, 422 palpation of, 36–7 bullfrog eyes, 341f anterior aspect, 46–53 involvement, 417 Bunnel-Littler test, 285, 287f posterior aspect, 37–46 transverse arch, 381f bursae, 12–13 passive movement testing, 58–62 ankle dorsiflexion, 410–12, 413f radiological views, 79 ankle jerk, 418f C5 root level, 68, 69f referred pain patterns, 78f , 79 ankle plantar flexion, 410 C6 root level, 68, 70f resistive testing, 62–4 annular ligament, 207, 208f C7 root level, 68, 71f cervical extension, 62–3 anserine bursa, 346–7 C8 root level, 68, 72, 72f cervical flexion, 62 antecubital fossa, 203 calcaneal bursa, 395 lateral bending, 64 anterior cruciate ligament insufficiency, calcaneal valgus deformity, 18f rotation, 63–4 calcaneofibular ligament, 394 sample examination, 80 377b calcaneus, 395 soft-tissue structures, 44–6, 51–3 anterior drawer test, 355, 356f capitate, 245–6, 247f carotid pulse, 51 anterior stability tests, shoulder 179–81 carotid pulse, palpation of, 52 greater occipital nerves, 46 carotid tubercle, palpation of, 47–8, 49f levator scapulae, 46 Crank test, 180–81 carpal bones, 235–6 ligamentum nuchae, 46 relocation test carpal joints, 262 lymph node chain, 51 Rockwood test, 179–80, 185f carpal tunnel, 240, 241f , 283f parotid gland, 52–3 anterior interosseous nerve, 227 carpal tunnel syndrome, 282t, 292 scaleni muscles, 51 anterior stability tests, 366–7 carpenter’s knee, 344 semispinalis capitis, 45 anterior superior iliac spines, 101–2, 296–7 carpometacarpal joint, 447t semispinalis cervicis, 45 anterior talofibular ligament, 393–4 cartilage, 6–7 sternocleidomastoid muscle, 51 anterior view, 20–23 caudal glide, 165 suboccipital muscles, 44–5 Apley test, 371, 373f cervical disc, herniated, 81 trapezius muscle, 44 apprehension test, 180–81, 186f , 371, cervical spine, 34–81 Spurling test, 74–5 subjective examination, 36 374f accessory movements of, 61–2 transverse processes of, 42 articular cartilage, 7 active movement testing, 53–8 trigger points, 53 articular pillar upper cervical instability testing, 75 backward bending, 57–8 cervical traction, 61 palpation of, 42 forward bending, 54–6 chondromalacia patellae, 339 posteroanterior unilateral pressure on, lateral bending, 58 chronic repetitive submaximal tolerance rotation, 58 61 thoracic motion, 58 load, 2 Aspinall’s transverse ligament test, 75, 76f upper cervical spine, 58 Clarke’s sign, 371 atlas, 31 alar ligament stress tests, 76–7 clavicle, 49–50, 145 axilla, 151–2 anteroposterior view of, 78f claw hand, 282, 285f axis, 31 bony structures, 37–44, 47–51 claw toes, 398 articular pillar, 42 clunk test, 183, 187f Babinski’s response, 422f carotid tubercle, 47–8 coccyx, 98–100 backward bending, 57–8 clavicle, 49–50 collagen, 4–5 first cricoid ring, 47 compartments, 248–51 cervical spine, 57–8 first rib, 50 compensated Trendelenburg gait, 442–3 lumbosacral spine, 108–9 hyoid bones, 47 compression of spine, 29 backward-bending test, 115 inion, 37 conditioning, 4f baker’s cyst, 351f mastoid processes, 38 congenital hip dysplasia, 334b Bakody’s sign, 77 medial border of scapula, 44 contusion, 445t ballotable patella, 374, 375f occiput, 38 coracoid process, 146–7 barrel chest deformity, 23f ribs, 50–51 cortical bone, 6 benediction hand, 236, 284f spine of scapula, 43–4 Craig test, 331–3 biceps, 149 spinous processes, 38–42 Crank test, 180–81 load test, 184, 189f sternal angle, 48–9 cremasteric reflex, 129, 130f muscle and tendon, 203–4 sternoclavicular joint, 49 cross-flexion test, 186, 190f palpation of, 150f superior nuchal line, 37 cubital fossa, 203 reflex, 224f suprasternal notch, 48 cuboid, 391–2, 393f reflexes, 223 thyroid cartilage, 47 cuboid-metatarsal joint, 407 speed’s test, 187–8 transverse processes, 38 cuneiform bones, 385, 386f tension test, 183–4, 188f distraction test, 75 cylinder grip, 290f Yergason’s test, 187–8, 192f biceps brachii, 218f , 222f biceps femoris, 349–50 bicipital groove, 147 body chart, 16f body of talus, 389, 390f

Index 455 de Quervain’s test, 285 lateral aspect, 205–7 Fabere test, 328 deep fascia, 13 posterior aspect, 208–10 facet joints, palpation of, 42 deep tendon reflexes, 29 paradigm for inflammatory disease, Fairbanks test, 371 deltoid, 149 fascia, 13 234b Feagin test, 181, 187f shoulder abduction, 172f passive movement testing, 211, 214f femoral artery, 298, 299f trigger points, 157f physiological movements, 211–13 femoral head, ventral glide of, 312–13 deltoid ligament, 387 femoral nerve, 298, 300f dependent rubor, 422 extension, 213 femoral nerve stretch test, 132, 134f dermatomes, 119–25, 182 flexion, 211–13 femoral triangle, 298, 299f distal interphalangeal joint pronation, 213 femoral vein, 298, 300f flexion, 267 supination, 213 fibrocartilage, 7 traction of, 262 radiological views, 231, 233–4f fibroelastic cartilage, 7 distal interphalangeal joint extension, 258 range of motion, 447t fibular head, 347–9 distal interphalangeal joint flexion, 256–8 referred pain patterns, 231, 233f fifth metatarsal, 392–3 distraction test, 29 resistive testing, 217–18 finger extension, 268 cervical/thoracic spin, 75 soft-tissue structures, 203–5, 207, 210 fingers, 241–2 hip, 312 annular ligament, 207, 208f knee, 371, 373f biceps muscle and tendon, 203–4 abduction, 281t sacroiliac, 136 brachial artery, 204 adduction, 281t shoulder, 165 cubital fossa, 203 distal interphalangeal joint extension, temporomandibular joint, 93 humeroradial bursa, 207 dominant eye, 15–16 lateral collateral ligament, 207 258 dorsal glide of humeral head, 166 medial aspect, 204–5 distal interphalangeal joint flexion, dorsal interossei, 271f medial collateral ligament, 204, 206f dorsal tubercle of radius, 245 median nerve, 204 256–8 dorsalis pedis pulse, 391 olecranon bursa, 210 extension, 281t dorsiflexion, 399–400 triceps, 210 first carpometacarpal abduction, 258 Dowager’s hump deformity, 26f ulnar nerve, 204, 206f first carpometacarpal adduction, 258 drop arm test, 190 wrist extensor-supinator, 207, 208f flexion, 281t wrist flexor-pronator, 205, 206f metacarpophalangeal abduction, 256, elastin, 8 subjective examination, 201–3 elbow, 199–234 tennis elbow test, 231, 232f 257f trigger points, 210, 211f metacarpophalangeal adduction, 256, active movement testing, 210–11 Ely’s test, 327, 329f bony structures, 205–7, 208–9 empty can test, 189 257f entrapment neuropathies, elbow, 224–30 metacarpophalangeal joint flexion, lateral epicondyle, 205, 206f anterior interosseous nerve, 227 medial epicondyle, 204, 205f ligament of Struthers, 226 254–6 olecranon, 208–9 median nerve, 224–7 opposition, 259 olecranon fossa, 209 posterior interosseous nerve, 230 proximal interphalangeal joint radial head, 205–7 pronator teres syndrome, 226–7, 228f supracondylar ridge, 204, 205, 205f , radial nerve, 229–30 extension, 258 Saturday night palsy, 230 proximal interphalangeal joint flexion, 206f supinator syndrome, 231f ulna border, 209 ulnar nerve, 227–9 256–8 extension, 219–20 entrapment neuropathies, hand 277–82 range of motion, 447t flexion, 218–19 median nerve, 277–8 thumb interphalangeal joint flexion test, 229 Phalen’s test, 278 forearm pronation, 220 Tinel’s test, 277 flexion/extension, 261 forearm supination, 221–2 tourniquet test, 277–8 thumb metacarpophalangeal extension, functional anatomy of, 199–200 ulnar nerve, 278–82 golfer’s elbow test, 231, 232f compression at Guyon’s canal, 282 260 mobility testing of accessory movements, dorsal cutaneous, 280 thumb metacarpophalangeal flexion, 259 Erb-Duchennes palsy, 184f Finkelstein’s test, 285 213–17 erector spinae muscles, 100 first carpometacarpal abduction, 258 dorsal glide of radial head, 216–17 eversion, 402–3 first carpometacarpal adduction, 258 dorsal glide of radius, 217, 218f extension, 213, 219–20 first carpometacarpal joint, traction of, lateral glide of ulna, 214 extension intervertebral mobility testing, medial and lateral gapping, 214–16 262 medial glide of ulna, 214 59 first carpometaphalangeal joint, ulnar glide traction of elbow joint, 214 extension moment, 437 traction of humeroadial joint, 216, extension of metatarsophalangeal joint, of, 263 first cricoid ring, palpation of, 47, 48f 217f 405 first cuneiform-metatarsal joint, 408 ventral glide of radial head, 216–17 extensor carpi radialis brevis, 266f first metacarpal, 244–5 ventral glide of radius, 217, 218f extensor carpi radialis longus, 266f first metatarsal joint, 385, 386f neurological examination, 222–30 extensor carpi ulnaris, 266f first metatarsophalangeal joint, 385, 386f entrapment neuropathies, 223–4 extensor digitorum brevis, 391, 392f motor, 222 extensor digitorum longus tendon, 391 traction of, 408 reflexes, 223–4 extensor hallucis longus, 390 first rib observation, 200–201 extensor retinaculum, 248, 249f overview, 139 eye, dominant, 15–16 palpation of, 50, 51f palpation of, 203–17 ventral-claudal glide, 62 anterior aspect, 203–4 fist power grip, 290f flat back deformity, 25f flat foot, 422 flexed leg, lateral/medial rotation of, 363t flexibility tests, 324–8, 365 Ely’s test, 327, 329f Ober’s test, 324, 327 Patrick’s test, 328, 329f piriformis flexibility test, 327–8

456 Index flexibility tests (Cont.) palpation of, 384–99 pronation of, 214f piriformis test, 327 dorsal aspect, 388–91 range of motion, 447t Thomas test, 324 lateral aspect, 391–5 supination of, 214f medial aspect, 384–8 forefeet-heel alignment, 425 flexible flat foot, 422, 425f plantar surface, 396–7 forefoot, 380 flexion, 211–13, 218–19 posterior aspect, 395–6 eversion, 403 flexion intervertebral mobility testing, 59 toes, 397–9 inversion, 403 flexion moment, 437 range of motion, 448t flexion of metatarsophalangeal joint, paradigm for overuse syndrome, 431f vagus, 426t passive movement testing, 399–408 valgus, 426t 404–5 physiological movements, 399–405 forward bending, 54–6 flexor carpi radialis, 240, 265f cervical spine, 54–6 flexor carpi ulnaris, 238, 239f , 265f dorsiflexion, 399–400 lumbosacral spine, 105–8 flexor digitorum longus, 387 eversion, 402–3 forward head posture, 26f flexor digitorum profundus, 240, 267f extension of metatarsophalangeal Fowler test, 181 flexor digitorum superficialis, 240 fractures, 445t flexor hallucis longus, 388 joint, 405 freeway space, 90–91 flexor pollicis brevis, 274f flexion of metatarsophalangeal joint, Froment’s sign, 280 flexor pollicis longus, 273f foot, 379–431 404–5 Gaenslen’s sign, 134, 135f forefoot eversion, 403 gait, 432–44 abnormal gait, 439–40 forefoot inversion, 403 active movement testing, 399 inversion, 400–402 abnormalities in, 438–43 alignment tests, 422–8 plantar flexion, 400 causes of, 439 subtalar eversion, 403 foot and ankle, 439–40 flexible versus rigid flat foot, 422–8 subtalar inversion, 403 hip, 442–3 forefeet-heel alignment, 425 pronation, 382 knee, 440–42 leg-heel alignment, 425 radiological views, 429–30f leg length discrepancy, 443 medial longitudinal arch, 422, 425 referred pain patterns, 416 tibial torsion, 427 resistive testing, 408–16 compensated Trendelenburg, 442 bony structures, 384–97 ankle dorsiflexion, 410–12, 413f definition of, 435 body of talus, 389, 390f ankle plantar flexion, 410 determinants of, 435–7 calcaneus, 395 subtalar eversion, 412–14 foot slap, 439 cuboid, 391–2, 393f subtalar inversion, 412, 413f lower extremity, 432–4 cuneiform bones, 385, 386f toe extension, 415–16 lurch, 442 fifth metatarsal, 392–3 toe flexion, 414, 415f normal, 435–8 first metatarsal joint, 385, 386f sample examination, 428b primary toe-strike, 440 first metatarsophalangeal joint, 385, soft-tissue structures, 387–97 sample examination, 444b anterior talofibular ligament, 393–4 stance phase, 435, 436f 386f brevis tendons, 394–5 steppage, 439 inferior tibiofibular joint, 388, 389f calcaneal bursa, 395 swing phase, 435, 436f lateral malleolus, 391, 392f calcaneofibular ligament, 394 gastrocnemius, 349–50 medial malleolus, 384 deltoid ligament, 387 gastrocnemius-semimembranosus bursa, medial tubercle of calcaneus, 396 dorsalis pedis pulse, 391 metatarsal heads, 396–7 extensor digitorum brevis, 391, 392f 351 navicular tubercle, 385 extensor digitorum longus tendon, 391 genu valgum deformity, 18f , 23f peroneus tubercle, 391, 393f extensor hallucis longus, 390 genu varum deformity, 18f , 23f sesamoid bones, 396, 397f flexor digitorum longus, 387 genus recurvatum deformity, 25f sinus tarsi, 389–90 flexor hallucis longus, 388 Gerber’s test, 190, 194f sustentaculum tali, 385 long saphenous vein, 387–8, 389f Gerdy’s tubercle, 347 forefoot, 380 peroneus longus, 394 glenohumeral joint, 141, 142f functional anatomy of, 380–82 plantar aponeurosis, 397 gluteus maximus, 303f longitudinal arch, 381f posterior talofibular ligament, 394 golfer’s elbow test, 231, 232f midfoot, 380 posterior tibial nerve, 388 gracilis muscle, 346 mobility testing of accessory movements, retrocalcaneal bursa, 395, 396f gravity test, 356 tendocalcaneus, 395 greater occipital nerves, 46, 84 406–8 tibialis anterior tendon, 390 greater trochanters, 297–8 cuboid-metatarsal joint, 407 tibialis posterior, 387 greater tuberosity of humerus, 146 fibula at inferior tibiofibular joint, 406 structural integrity tests, 417–22 grinding test, 371, 373f fibula at superior tibiofibular joint, anterior drawer sign, 420 growth-plate cartilage, 7 inversion stress test, 420 Guyon’s canal, 282, 284f 406 stress fracture test, 420–21 first cuneiform-metatarsal joint, 408 test for Morton’s neuroma, 421 hallux valgus deformity, 22f , 386f metatarsals, 408 Thompson test for Achilles tendon hamate, 242–3 traction of first metatarsophalangeal hammer toes, toes, 398, 399f rupture, 417 hammertoe deformity, 22f joint, 408 subjective examination, 384 hamstring jerk, 363 traction of subtalar joint, 407 tests for upper motor neuron hand, 235–92 traction of talocrural joint, 406–7 nerve compression test, 416–17 involvement, 417 active movement testing, 251–2 peroneal nerve compression, 416 toes, 397–9 anterior aspect tarsal tunnel syndrome, 416–17 transverse arch, 381f neurological examination, 416 foot flat, 435, 436f lateral compartment, 240–42 motor, 416 foot slap, 439 medial compartment, 238–9 reflexes, 416 forearm sensation, 416 observation, 382–4

Index 457 middle compartment, 239–40 compartments, 248–51 frog-lateral view of, 333f anterior view, 282t extensor retinaculum, 248 functional anatomy of, 293–5 bony structures, 238, 242–8 fingers, 241–2 internal rotation of, 325t flexor digitorum profundus and Koch model, 294f capitate, 245–6 mechanical model, 295f dorsal tubercle of radius, 245 superficialis, 240 mobility testing of accessory movements, first metacarpal, 244–5 hypothenar eminence, 239 hamate, 242–3 medial compartment, 238 310–13 interphalangeal joints, 247–8 palmar aponeurosis, 240 lateral distraction, 312 lunate, 245 palmaris longus, 239–40 traction, 311 metacarpophalangeal joint, radial artery, 240 ventral glide of femoral head, 312–13 thenar eminence, 241 neurological examination, 323–4 246–7 triangular fibrocartilaginous complex, motor, 323 nails, 248 referred pain patterns, 324 phalanges, 247–8 243 reflexes, 323 pisiform, 242 ulnar artery, 238 sensation, 324 radial styloid process, 243 ulnar nerve, 238 observation, 295 scaphoid, 243 subjective examination, 237 palpation of, 296–302 trapezium, 243–4 tests for joint flexibility/stability, 285–9 anterior aspect, 296–300 trapezoid, 243–4 Allen’s test, 289 posterior aspect, 300–302 triquetrum, 242 Bunnel-Littler test, 285, 287f side-lying position, 302 ulna styloid process, 242 retinacular test, 288 paradigm for osteoarthritis, 334b dermatomes, 282t scaphoid-lunate dissociation test, passive movement testing, 307–13 Finkelstein’s test, 285 peripheral nerves, 326t functional anatomy of, 235–6 288–9 physiological movements lateral aspect, 243–5 heel-off, 435, 436f abduction, 308, 309f medial aspect, 242–3 heel-strike, 435, 436f adduction, 308, 309f mobility testing of accessory movements, hemiplegia, 187f extension, 307–8 herniated cervical disc, paradigm for, flexion, 307 261–3 lateral rotation, 310 neurological examination, 276–84 81 medial rotation, 308–10 hindfoot eversion, 403 radiological views, 333 entrapment neuropathies, 277–84 hindfoot inversion, 403 range of motion, 447t motor, 276 hindfoot pronation, 434f resistive testing, 313–24 sensation, 276–7 hindfoot valgus, 426t abduction, 315, 317f , 318f observation, 236–7 hindfoot varus, 426t adduction, 319, 320–21f overview of, 139–40 hip, 293–334 extension, 314–15, 316f palpation of, 237–51 external rotation, 319, 321f , 322 anterior aspect, 238–42 abduction of, 325t flexion, 313–14 posterior aspect, 245–51 abnormal gait, 442–3 internal rotation, 322–3 paradigm for carpal tunnel syndrome, active movement testing, 302–6 sample examination, 334b soft-tissue structures, 298, 302 292b abduction, 304, 305f adductor longus muscle, 298, 300f passive movement testing, 252–63 adduction, 304, 306f femoral artery, 298, 299f extension, 304, 305f femoral nerve, 298, 300f mobility testing of accessory flexion, 302, 305f femoral triangle, 298, 299f movements, 261–3 lateral rotation, 304, 306f femoral vein, 298, 300f medial rotation, 304, 306f inguinal ligament, 298, 299f physiological movements, 252–61 adduction of, 325t piriformis muscle, 302 physiological movements, 252–61 alignment tests, 328–32 sartorius muscle, 298, 300f apparent leg length discrepancy, 331 sciatic nerve, 302 fingers, 254–61 Craig test, 331–3 subjective examination, 295–6 pronation, 252 test for true leg length, 328–30 trigger points, 302, 303–4f radial deviation, 253–4, 255f bony structures, 296–301 hip joint, anteroposterior view of, 333f supination, 252 anterior superior iliac spines, 296–7 Homan’s sign, 421, 424f ulnar deviation, 254, 255f greater trochanters, 297–8 hook grip, 290f wrist extension, 253 iliac crest, 296 Hoover test, 132 wrist flexion, 253 iliac tubercle, 296 hornblower’s sign, 191, 195f posterior view, 282t ischial tuberosity, 301 housemaid’s knee, 344 radiological views, 291 posterior superior iliac spines, Hughston jerk test, 369, 370f referred pain patterns, 289–91 Hughston posterolateral test, 369, 371f resistive testing, 264–76 300–301 Hughston posteromedial test, 369 distal interphalangeal joint, 267 pubic tubercles, 297 humeral head, dorsal/versal glide of, 166 finger extension, 268 sacroiliac joint, 301 humeroradial bursa, 207 interossei, 269–70 classic Koch model, 294f humeroradial joint, traction of, 216, opposition of thumb and fifth finger, dermatomes, 326t extension of, 325t 217f 276, 281t external rotation of, 325t humeroulnar joint, 199, 200f proximal interphalangeal joint flexion, flexibility tests, 324–8 hyaline cartilage, 7 Ely’s test, 327, 329f hyoid bone, palpation of, 47 267–8 Ober’s test, 324, 327 hypothenar eminence, 239 thumb abduction, 274–6, 281t Patrick’s test, 328, 329f thumb adduction, 276, 281t piriformis flexibility test, 327–8 thumb extension, 270, 274, 281t piriformis test, 327 thumb flexion, 270, 281t Thomas test, 324 soft-tissue structures, 238–45, 248– flexion of, 325t 51 anatomical snuffbox, 245 carpal tunnel, 240

458 Index iliac crest, 96, 296 medial glide of tibia, 357, 359f L4 root level, 121–2, 126f iliac tubercle, 296 patellar mobility, 357–8, 359f , 360f L5 root level, 122, 127f iliocostalis lumborum muscle, 108f posterior glide of tibia, 356 labral tears, 183 iliocostalis thoracis muscle, trigger points traction, 355 Lachman test, 366 ventral glide of tibia, 355, 356f lateral alar ligament stress tests, 76 in, 107f neurological examination, 363–5 lateral bending, 58 iliotibial tract, 349 infrapatellar nerve injury, 364 impingement syndrome, 143 motor, 363 cervical spine, 58 infection, 446–7t reflexes, 363 intervertebral mobility testing, 59–60 inferior lateral angle, 98, 99f sensation, 363–4 lumbosacral spine, 109–10 inferior instability tests, 181 observation, 339 lateral border of scapula, 151 inferior tibiofibular joint, 388, 389f , 406 palpation of, 340–51 lateral collateral ligament, 207 inflammatory joint disease, 446t anterior aspect, 340–44 lateral distraction, 165 inflammatory reaction, 2 lateral aspect, 347–9 lateral epicondyle, 205 infrapatellar nerve injury, 364 medial aspect, 344–7 lateral femoral condyle, 347 infraspinatus muscle posterior aspect, 349–51 lateral femoral epicondyle, 347 paradigm of ligament injury, 377b lateral gapping, 214–16 shoulder external rotation, 175f passive movement testing, 353–8 lateral malleolus, 391, 392f trigger points, 156f patella, 338f lateral mandibular deviation, 90 infraspinatus spring back test, 190–91, patellofemoral articulation, 336f lateral pinch, 290f patellofemoral joint test, 371–4 lateral rotation lag sign, 190 195f physiological movements, 353 lateral tibial plateau, 347, 348f inguinal ligament, 298, 299f posterior cruciate ligament, 337f lateral tubercle, 347, 348f inion, palpation of, 37 posterior stability test, 367–9 lateral view, 20–25 interossei, 269–70, 271f posterior view, 336f latissimus dorsi, 151 interphalangeal joints, 247–8, 447t posterolateral stability test, 369 leg, length discrepancy, 443 intrathecal pressure, 132–4 posteromedial stability test, 369 leg-heel alignment, 425 intrinsic minus hand, 282 radiological views, 375–6 levator scapulae inversion, 400–402 range of motion, 448t palpation of, 46 inversion stress test, 420 referred pain patterns, 364–5 scapular elevation, 176f ischial tuberosity, 98, 99f , 301 resistive testing, 358–61 trigger points, 155f rotation, 362–3 Lhermitte’s sign, 77 jaw sagittal view of, 376f lift-off test, 190, 194f closing, 94 sample examination, 378b ligament injury, 445t jerk, 94 soft-tissue structures, 342–51 ligament of Struthers, 226 opening, 93–4 common peroneal nerve, 349 ligaments, 7–8 pens anserine bursa, 346–7 ligamentum nuchae, palpation of, 46 Jobe relocation test, 181 biceps femoris, 349–50 Lister’s turbercle, 245, 246f Jones fracture, 393 bursae, 343–4 long saphenous vein, 387–8, 389f gastrocnemius, 349–50 longissimus thoracis muscle, 108f knee, 335–78 gastrocnemius-semimembranosus longitudinal distraction, 166 abnormal gait, 440–42 lordosis, 33 active movement testing, 351–3 bursa, 351 lower abdominal skin reflex, 129 anterior cruciate ligament, 337f gracilis muscle, 346 lower extremity, 432–4 anterior stability tests, 366–7 medial collateral ligament, 345–6 lower limb, cutaneous innervation of, 123f anterolateral instability test, 367 medial meniscus, 345 lumbar plexus, 118 anteromedial instability test, 367 patellar ligament, 343 lumbar spine, 31–3 anteroposterior view of, 375f pes anserinus, 346 lumbosacral plexus, 118, 122t bony structures, 340–49 popliteal artery, 351 lumbosacral spine, 95–138 adductor tubercle, 344, 345t popliteal fossa, 350, 351f active movement testing, 103–5 fibular head, 347–9 popliteal nerve, 351 iliotibial tract, 349 popliteal vein, 351 backward bending, 108–9 lateral femoral condyle, 347 quadriceps muscle, 342–3 forward bending, 105–8 lateral femoral epicondyle, 347 sartorius muscle, 346 lateral bending, 109–10 lateral tibial plateau, 347, 348f semimembranosus muscle, 351 rotation, 110 lateral tubercle, 347, 348f semitendinosus muscle, 346 bony structures, 96–103 medial femoral condyle, 344 subjective examination, 339–40 anterior superior iliac spine, 101–2 medial tibial plateau, 344 tests for joint effusion, 374–5 coccyx, 98–100 patella, 340–2 tests for meniscal damage, iliac crest, 96 tibial tuberosity, 342 inferior lateral angle, 98, 99f buckling of, 338 369–71 ischial tuberosity, 98, 99f concave surface of menisci, 336f tests for stability/structural integrity, posterior superior iliac spines, 97–8 extension of, 360–62, 363t pubic tubercles, 103, 104f flexibility tests, 365 365–6 sacral base, 98, 99f flexion of, 363t trigger points, 351, 352f sacroiliac joint, 98 functional anatomy of, 335–9 knee jerk, 363 spinous processes, 96–7 joints, 17–18 Koch model, 294f transverse processes, 97 lateral view of, 376f kyphosis, 19, 20f femoral nerve stretch test, 132, 134f medial and lateral stability test, 369 Hoover test, 132 mobility testing of accessory movements, L1 root level, 119, 122t, 124f intrathecal pressure test, 132–4 353–8 L2 root level, 119, 122t, 124f mobility testing, 110–15 lateral glide of tibia, 357, 359f L3 root level, 120, 122t, 125f medial and lateral gapping, 356–7

Index 459 accessory movements, 112–13 medial longitudinal arch, 422, 425 neoplasm, 446t intervertebral mobility, 111 medial malleolus, 384 nerve compression, 446t sacroiliac joint examination, 113–15 medial meniscus, 345 nerve compression test, 416–17 neoplasm of, 138b medial tibial plateau, 344 nerve stretch testing, 29 neurological testing, 118–30 medial tubercle of calcaneus, 396 neurological examination, 28–9 L1 root level, 119, 122t, 124f median nerve, 65, 204, 224–7 L2 root level, 119, 122t, 124f meralgia paresthetica, 324 C5 root level, 68, 69f L3 root level, 120, 122t, 125f metabolic joint disease, 446t C6 root level, 68, 70f L4 root level, 121–2, 126f metacarpals, 246, 247f , 248f , 262 C7 root level, 68, 71f L5 root level, 122, 127f metacarpophalangeal abduction, 256, C8 root level, 68, 72, 72f lumbar plexus, 118 cervical spine, 64–74 lumbosacral plexus, 119 257f S1 root level, 122–5, 128f metacarpophalangeal adduction, 256, brachial plexus, 64–5 S2 root level, 122t upper limb tension test, 65–6 S2-S5 root levels, 125 257f elbow, 222–30 superficial reflexes, 127–30 metacarpophalangeal joint foot, 416 observation, 95 hand, 276–84 palpation of, 95–103 extension, 271f , 276f entrapment neuropathies, 277–84 anterior aspect, 101 range of motion, 447t motor, 276 posterior aspect, 95–101 traction of, 262 sensation, 276–7 side-lying position, 101 metacarpophalangeal joint flexion, 254–6 knee, 363–5 passive movement testing, 110–15 metacarpophalangeal joints, 246–7 infrapatellar nerve injury, 364 radiological views, 138 metatarsal heads, 396–7 motor, 363 resistive testing, 116–8 metatarsals, 408 reflexes, 363 trunk extension, 118 metatarsophalangeal joint sensation, 363–4 trunk flexion, 116 extension of, 405 lumbosacral spine, 118–30 trunk rotation, 116–18 flexion of, 404–5 T1 root level, 72–4 sacroiliac joint tests, 134–6 mid stance, 435, 436f T2-T12 root level, 74 Gaenslen’s sign, 134, 135f mid-abdominal skin reflex, 129 noninflammatory joint disease, 446t Patrick’s test, 134, 135f midcarpal joint, traction of, 261 sacroiliac distraction test, 136 midfoot, 380 Ober’s test, 324, 327 spondylolysis tests, 136 moment, 432, 437 observation, 14 slump test, 130–2 Monteggia fracture, 200 occiput, palpation of, 38, 38f soft-tissue structures, 100–103 Morton’s neuroma, 421, 424f olecranon, 208–9 abdominal muscles, 103, 105f Morton’s toe, 397 olecranon bursa, 202f erector spinae muscles, 100 Moulder’s click, 421 olecranon fossa, 209, 210 piriformis muscle, 101, 102f mouth Oppenheim’s test, 417, 422f psoas muscles, 103, 105f closing of, 89 opponens digiti minimi, 280f quadratus lumborum muscle, 100–101 opening of, 88–9 opponens policis, 280f sacrotuberous ligament, 101, 102f movement diagram, 27f opposition, 259 sciatic nerve, 101, 102f multidirectional instability tests, 181–3 osteoarthritis, 334b supraspinous ligament, 100 multifidi muscles, trigger points, 107f overbite, measurement of, 91, 92f straight-leg raise test, 130 muscle, 8–10 overjet, measurement of, 91, 92f subjective examination, 95–6 muscle pathology tests, 190–91 overuse syndrome, 431f trigger points, 103 drop arm test, 190 lunate, 245, 246f Gerber’s test, 190 pad-to-pad pinch, 290f lurch gait, 442–3 hornblower’s sign, 191, 195f pain, 2 lymph node chain, palpation of, 52 infraspinatus spring back test, 190–91, palmar aponeurosis, 240 lymphatic system, active movement testing, palmar interossei, 271f 195f palmaris longus, 239–40 103–5 lateral rotation lag sign, 190 palpatory examination, 30 lift-off test, 190, 194f paradigms, 3 MacIntosh test, 367 muscle tendon injury, 445t parotid gland, palpation of, 52–3 mandible muscle-fascicle arrangements, 11f pas planus, 422 muscles, 8–10 passive mobility movement testing, 28 measurement of, 91–2 musculoskeletal system, 4–13 passive movement testing, 27–8 palpation of, 85 components of, 4–13 protrusion of, 89 ankle, 399–408 manual muscle testing, 29 bone, 5–6 elbow, 211 masseter bursae, 12–13 foot, 399–408 palpation of, 86 cartilage, 6–7 hand, 252–63 trigger points, 88f fascia, 13 hip, 307–13 mastoid processes, 84 ligaments, 7–8 knee, 353–8 palpation of, 38, 39f muscle, 8–10 lumbosacral spine, 110–16 McMurray’s test, 369, 372f synovium, 12–13 mobility testing of accessory movements, medial border of scapula, 151 tendons, 10–12 medial collateral ligament, 204, 206f , overview of, 1–3 59–62 myofascial pain, 446t cervical spine, 60–62 345–6 myofibril, 10f cervical traction, 60 medial epicondyle, 204, 205f intervertebral mobility of cervical medial femoral condyle, 344 nails, 248 medial gapping elbow, 214–16 navicular tubercle, 385 spine, 59–60 neck, anterior-posterior relationships, 35f thoracic spine movements, 60 Neer impingement test, 188, 193f passive physiological movements, 59

460 Index passive movement testing, (Cont.) piriformis test, 327 reflex sympathetic dystrophy, 446t shoulder, 162–7 pisiform, 242, 243f reflex testing, jaw jerk, 94 temporomandibular joint, 92–3 pivot shift, 338 reflexes, 223–4 distraction of TMJ, 93 pivot shift test, 338, 367, 368f mobility testing of accessory plantar aponeurosis, 397 biceps, 223, 224f movements, 93 plantar flexion, 400 brachioradialis, 223, 224f passive physiological movements, plicae, 374 hamstring jerk, 363 92–3 popliteal artery, 351 knee jerk, 363 wrist, 252–63 popliteal fossa, 350, 351f sensation, 223–4 popliteal nerve, 351 triceps, 223, 225f patella, 341f popliteal vein, 351 relocation test, 181 patella alta, 341f positive Trendelenburg, 295 resisted movement testing, 28 patella baja, 341f posterior drawer test, 356 resistive testing, 28 patella grind test, 371 posterior instability tests, 181 elbow, 217–18 patellar mobility, 357–8 posterior interosseous nerve, 230, 231f foot, 408–16 patellofemoral arthritis test, 374 posterior superior iliac spines, 97–8, patellofemoral joint, 376f ankle dorsiflexion, 410–12, 413f patellofemoral joint test, 371–4 300–301 ankle plantar flexion, 410 posterior talofibular ligament, 394 subtalar eversion, 412–14 apprehension test, 371, 374f posterior thorax, overview of, 35f subtalar inversion, 412, 413f Clarke’s sign, 371 posterior tibial nerve, 388 toe extension, 415–16 test for plica, 374 posterior view, 17 toe flexion, 414, 415f Waldron test, 374 power grips, types of, 290f hand, 264–76 pathological reflex testing, 29–30 primary toe-strike, 440 distal interphalangeal joint, 267 Patrick’s test, 134, 135f , 328, 329f pronation, 199 finger extension, 268 pectoralis major, 148 interossei, 269–70 shoulder adduction, 173f definition of, 433 opposition of thumb and fifth finger, trigger points, 159f forearm, 220 pelvis, 31–3 measurement of, 213 276, 281t anteroposterior view of, 333f passive movement testing, 252 proximal interphalangeal joint flexion, examination of, 19 pronator teres syndrome, 226–7, 228f peroneal nerve, 349 proximal interphalangeal joint 267–8 peroneus longus, 394–7 flexion, 267–8 thumb abduction, 274–6, 281t peroneus tubercle, 391, 393f traction of, 262 thumb adduction, 276, 281t pes anserine bursa, 346–7 proximal interphalangeal joint extension, thumb extension, 270, 274, 281t pes anserinus, 346 thumb flexion, 270, 281t pes planus deformity, 21f 258 hip, 313–24 phalanges, 247–8 proximal interphalangeal joint flexion, abduction, 315, 317f , 318f Phalen’s test, 278, 284f adduction, 319, 320–21f physical examination, 14–30 256–8 extension, 314–15, 316f anterior view, 20–23 psoas muscles, 103, 105f external rotation, 319, 321f , 322 concepts, 1 pterygoid muscles flexion, 313–14 correlation, 30 internal rotation, 322–3 definition of, 1 palpation of, 85–6 knee, 358–61 deviations from the norm, 17–20 trigger points, 90f lumbosacral spine, 116–18 dominant eye, 15–16 pubic tubercles, 103, 104f , 297 trunk extension, 118 lateral view, 20–5 trunk flexion, 116 objective examination, 15–30 Q angle, measurement of, 342 trunk rotation, 116–18 observation, 14 quadratus lumborum muscle, 100–1 shoulder, 168–76 paradigms, 3 scapular elevation, 172–4, 176–7f , posterior view, 17 radial artery, 240 purpose of, 1 radial collateral ligament, 207 180t sitting posture, 26–30 radial deviation, 253–4, 255f scapular protraction, 174–7, 178–9f , radial head, 205–7 active movement testing, 26–30 180t compression, 29 dorsal glide of, 216–17 scapular retraction, 174, 178f , 180t deep tendon reflexes, 29 ventral and dorsal glide of, 261 shoulder abduction, 169–70, 172–3f , distraction, 29 ventral glide of, 216–17 manual muscle testing, 29 radial nerve, 65, 229–30 180t nerve stretch testing, 29 radial nerve stretch test, 67f shoulder adduction, 170–71, 173–4f , neurological examination, 28–9 radial styloid process, 243, 244f , 277f palpatory examination, 30 radiculopathy, 446t 180t passive mobility movement testing, 28 radiocarpal joint, traction of, 261 shoulder extension, 169, 171f , 180t passive movement testing, 27–8 radius shoulder external rotation, 172, 176f , pathological reflex testing, 29–30 dorsal glide of, 217, 218f resisted movement testing, 28 ventral and dorsal glide of, 261 180t sensory testing, 29 ventral glide of, 217, 218f shoulder flexion, 168–9, 170f , 180t structural examination, 16–17 rectus abdominis, trigger points in, 106f shoulder internal rotation, 171–2, subjective examination, 14–15 referred pain patterns, 78f , 79 pinches, types of, 290f cervical spine, 78f , 79 175, 180t piriformis flexibility test, 327–8 elbow, 231 temporomandibular joint piriformis muscle, 101, 102f , 302 foot, 416 hand, 289–91 jaw closing, 94 knee, 364–5 jaw opening, 93–4 shoulder, 194, 196f wrist, 263–4 retinacular test, 288 retrocalcaneal bursa, 395, 396f reverse Lachman test, 367, 369f rhomboid muscles, trigger points, 158f rhomboideus major, 151, 177f

Index 461 rhomboideus minor, 151, 177f greater tuberosity of humerus, 146 latissimus dorsi, 151 ribs, palpation of, 50–51 lateral border of scapula, 151 pectoralis major, 148 rigid flat foot, 422, 425f medial border of scapula, 151 rhomboideus major, 151 Rockwood test, 179–81, 185If spine of scapula, 149–50 rhomboideus minor, 151 Roos test, 194 sternoclavicular joint, 145 rotator cuff, 152–3 rotational alar ligament stress tests, 76 suprasternal notch, 145 serratus anterior, 152 rotator cuff, 142, 152–3 external rotation view, 196f sternocleidomastoid muscle, 148 rounded shoulders, 26f functional anatomy of, 141–3 subacromial bursa, 154 rounded thoracic kyphosis, 20f internal rotation view, 196f trapezius muscle, 148 Rowe multidirectional instability tests, magnetic resonance image, 196f structural stability and integrity tests, mobility testing of accessory movements, 183, 188f 179–83 165–7 anterior instability tests, 179–81, S1 root level, 122–5, 128f acromioclavular joint, 166–7 S2 root level, 122t, 125 caudal glide, 166 185f S3 root level, 125 dorsal glide of humeral head, 166 inferior stability tests, 181 S4 root level, 125 scapula, 167 multidirectional instability tests, S5 root level, 125 sternoclavicular joint, 166–7 sacral base, 98, 99f traction, 165 181–3 sacroiliac distraction test, 136 ventral glide of humeral head, 166 posterior instability tests, 181 sacroiliac joint, 98, 301 muscle pathology tests, 190–91 subjective examination, 144 sacroiliac joint examination, 113–15 neurological examination, 177–9 supraspinatus impingement tests, 188–9 motor, 177 test for tendinous pathology, 187–8 backward-bending test, 115 reflexes, 177 tests for acromioclavular joint, 186–7 lumbosacral spine, 134–6 sensation, 177 tests for labral tears, 183 observation, 143–4 thoracic outlet syndrome tests, 191–4 Gaenslen’s sign, 134, 135f palpation of, 144, 151 trigger points, 154, 155–9f Patrick’s test, 134, 135f anterior view, 145–9 shoulder abduction test, 77, 78f sacroiliac distraction test, 136 lateral aspect, 152–4 shoulder dislocation, apprehension test for, spondylolysis tests, 136 medial aspect, 151–2 posteroanterior spring of sacrum, 115 posterior aspect, 149–51 180–1 seated flexion test, 115 paradigms, 198 shoulder joint, 141 standing flexion test, 113 passive movement testing, 162–7 sinus tarsi, 389–90 stork test, 114 physiological movements, 162–5 sitting posture, 26 sacrotuberous ligament, 101, 102f abduction, 163 skeletal muscle, 8–10, 11f , 12t sacrum, posteroanterior spring of, 115 extension, 163 skull, overview of, 35f sarcomeres, 10f flexion, 162–5 SLAP lesions, 183–6 sartorius muscle, 298, 300f , 346 lateral rotation, 164–5 Saturday night palsy, 230 medial rotation, 163–4 active compression test of O’Brien, scaleni muscles, 86 radiological views, 196f , 197 184–5 palpation of, 51–2 range of motion, 447t scaphoid, 243 referred pain patterns, 194, 196f biceps load test, 184 scaphoid tuberosity, 272f resistive testing, 168–76 biceps tension test, 183–4 scaphoid-lunate dissociation test, 288–9 scapular elevation, 172–4, 176–7f , SLAP prehension test, 185–6, 190f scapula stability test, 187 Slocum test, 367, 368f scapulae, 19 180t slump test, 133f lateral border of, 151 scapular protraction, 174–7, 178–9f , speed’s test of biceps, 187–8 medial border of, 44, 151 spherical grip, 290f mobility testing of, 168f 180t spine spine of, 43–4, 149–50 scapular retraction, 174, 178f , 180t examination of, 19 scapulohumeral rhythm, 141 shoulder abduction, 169–70, 172–3f , overview of, 31–3 sciatic nerve, 101, 102f , 302 spine of scapula, 43–4, 149–50 scoliosis, 19, 19f 180t spinous process of C2, palpation of, 38, semimembranosus muscle, 351 shoulder adduction, 170–71, 173–4f , semispinalis capitis, 84 40f palpation of, 45 180t spinous process of C7, palpation of, 42 semispinalis cervicis, 84 shoulder extension, 169, 171f , 180t spinous processes palpation of, 45 shoulder external rotation, 172, 176f , semitendinosus muscle, 346 of lumbosacral spine, 96–7 sensation, 276–7 180t palpation of, 38, 41f sensory testing, 29 shoulder flexion, 168–9, 170f , 180t posteroanterior central pressure on, 61 serratus anterior, 152, 178f shoulder internal rotation, 171–2, of thoracic spine, 42–3 sesamoid bones, 396, 397f transverse pressure on, 61–2 Sharp-Purser test, 75 175, 180t spinous processes of C7, palpation of, 41f shoulder, 141–98 sample examination, 197b spondylolysis tests, 136 active movement testing, 154, 160–1 scapula stability test, 187 Sprengel’s deformity, 21f bony structures, 145–7, 149–51 SLAP lesions, 183–6 Spurling test, 74–5 acromioclavular joint, 145–6 squinting patellae, 22f , 332, 341f acromion process, 146 active compression test of O’Brien, steppage gait, 439 bicipital groove, 147 184–5, 190f sternal angle, palpation of, 48–9, 50f clavicle, 145 sternoclavicular joint, 139 coracoid process, 146–7 biceps load test, 184, 188f mobility testing of, 166–7 biceps tension test, 183–4, 188f palpation of, 49, 50f , 145 SLAP prehension test, 185–6 sternocleidomastoid muscle, 35f , 148 soft-tissue structures, 148–54 palpation of, 51 axilla, 151–2 stork test, 114 biceps, 149 straight-leg raise test, 29, 130 deltoid, 149

462 Index stress fracture, 445t palpation of, 84–6 neurological examination of, 64–74 stress fracture test, 420–21 anterior aspect, 85–6 brachial plexus, 64–5 structural examination, 16–17 posterior aspect, 84–5 root level, 64–74 subacromial bursa, 154 upper limb tension test, 65–6 subacromial space, 143 passive movement testing, 92–3 subjective examination, 14–15 distraction of TMJ, 93 observation, 34–6 suboccipital muscles, 44–5, 84 mobility testing of accessory palpation of, 36–7 subscapularis muscle movements, 93 passive physiological movements, anterior aspect, 46–53 shoulder internal rotation, 174f 92–3 posterior aspect, 37–46 trigger points, 158f passive movement testing, 58–62 subserous fascia, 13 reflex testing, 94 radiological views, 79 subtalar, range of motion, 448t resistive testing, 93–4 referred pain patterns, 78f , 79 subtalar eversion, 403, 412–14 resistive testing, 62–4 subtalar inversion, 403, 412, 413f jaw closing, 94 cervical extension, 62–3 subtalar joint, traction of, 407 jaw opening, 93–4 cervical flexion, 62 sulcus sign, 181 soft-tissue structures, 84–6 lateral bending, 64 superficial fascia, 13 special questions, 84 rotation, 63–4 superficial reflexes subjective examination, 83–4 sample examination, 80 cremasteric reflex, 129, 130f trigger points, 86–7 soft-tissue structures, 44–6, 51–3 lower abdominal skin reflex, 129 tendinitis, common locations, 286f carotid pulse, 51 mid-abdominal skin reflex, 129 tendocalcaneus, 395 greater occipital nerves, 46 upper abdominal skin reflex, 127–9 tendons, 10–12, 203–4 levator scapulae, 46 superior nuchal line, palpation of, 37, tennis elbow test, 231, 232f ligamentum nuchae, 46 teres minor, 175f lymph node chain, 51 38f thenar eminence, 241 parotid gland, 52–3 superior tibiofibular joint, fibula at, 406 Thomas test, 324 scaleni muscles, 51 supination, 199, 213, 252 Thompson test, 417, 423f semispinalis capitis, 45 thoracic motion, 58 semispinalis cervicis, 45 forearm, 221–2 thoracic outlet syndrome tests, 191–4 sternocleidomastoid muscle, 51 supinator muscle, 222f Adson’s maneuver, 191–2, 195f suboccipital muscles, 44–5 supinator syndrome, 230, 231f Roos test, 194 trapezius muscle, 44 supracondylar ridge, 204, 205, 205f Wright’s maneuver, 192, 196f spinous processes of, 42–3 suprahyoid muscle, palpation of, 86 thoracic spine, 34–81 Spurling test, 74–5 supraspinatus impingement tests, 188–9, active movement testing, 53–8 subjective examination, 36 backward bending, 57–8 transverse processes of, 42, 43 193f forward bending, 54–6 trigger points, 53 Neer impingement test, 188, 193f lateral bending, 58 upper cervical instability testing, 75 supraspinatus test, 189, 193f rotation, 58 thoracic vertebrae, 31 Yocum test, 188, 193f thoracic motion, 58 three-jaw chuck, 290f supraspinatus muscle upper cervical spine, 58 thumb, 270–6 shoulder abduction, 172f alar ligament stress tests, 76–7 abduction, 274–6, 281t trigger points, 155f anteroposterior view of, 78f adduction, 276, 279f , 281t supraspinatus test, 189, 193f bony structures, 37–44, 47–51 carpometacarpal, 447t supraspinous ligament, 100 articular pillar, 42 extension, 270, 274, 281t suprasternal notch, 48, 145 carotid tubercle, 47–8 flexion, 270, 281t sustentaculum tali, 385 clavicle, 49–50 interphalangeal, 447t swallowing, 92 first cricoid ring, 47 metacarpophalangeal, 447t sway back deformity, 25f first rib, 50 opposition with, 281t synovium, 12–13 hyoid bones, 47 opposition with fifth finger, 276 inion, 37 range of motion, 447t talocrural joint, traction of, 406–7 mastoid processes, 38 resisted test, 274 talus, 433f medial border of scapula, 44 thumb interphalangeal joint tarsal tunnel, anatomy of, 421 occiput, 38 teeth, palpation of, 85 ribs, 50–51 flexion/extension, 261 temporalis spine of scapula, 43–4 thumb metacarpophalangeal extension, spinous processes, 38–42 palpation of, 85 sternal angle, 48–9 260 trigger points, 89f sternoclavicular joint, 49 thumb metacarpophalangeal flexion, temporomandibular joint, 82–94 superior nuchal line, 37 active movement testing, 87–92 suprasternal notch, 48 259 thyroid cartilage, 47 thyroid cartilage, palpation of, 47, 48f assessing freeway space, 90–1 transverse processes, 38 tibia closing of mouth, 89 distraction test, 75 lateral mandibular deviation, 90 intervertebral mobility testing, lateral glide of, 357, 360f mandibular measurement, 91–2 medial glide of, 357, 360f measurement of overbite, 91 59–60 posterior glide of, 355 measurement of overjet, 91 extension, 59 ventral glide of, 355 opening of mouth, 88–9 flexion, 59 tibial torsion, 427 protrusion of mandible, 89 lateral bending, 59–60 tibial tuberosity, 342 swallowing and tongue position, rotation, 60 tibialis anterior tendon, 390 lateral view of, 79f tibialis posterior, 387 92 movements, 60 Tinel’s sign, 229, 230f , 283f bony structures, 84–5 Tinel’s test, 277 functional anatomy of, 82–3 tip pinch, 290f observation, 83

Index 463 toe extension, 415–16 elbow, 210 valsalva maneuver, 77, 134, 135f toe flexion, 414, 415f hip, 302 varus, 437 toe-off, 435, 436f knee, 351 varus strain, 358f toes, 397–9 triquetrum, 242 varus-valgus stress, 214–16, 356–7 trunk extension, 118 ventral glide of humeral head, 166 claw toes, 398 trunk flexion, 116 vertebral artery test, 77 hammer toes, 398, 399f trunk rotation, 116–18 vitamin C, 4 range of motion, 448t torticollis, 24f ulna waiter’s tip posture, 184f tourniquet test, 277–8 lateral glide of, 214, 215f Waldron test, 374 traction, 165, 215f medial glide of, 214, 216f wall push-up test, 187, 191f transverse ligament test, 75 Wartenberg’s sign, 229 transverse processes ulna border, 209 Watson’s test, 288–9 of C1, 84 ulna styloid process, 242 wipe test, 374, 375f of cervical spine, 42 ulnar artery, 238, 239f Wolff’s law, 6 of lumbosacral spine, 97 ulnar collateral ligament, 204 Wright’s maneuver, 192, 196f of thoracic spine, 43 ulnar deviation, 254, 255f wrist, 139–40 transverse processes of C1, palpation of, ulnar nerve, 65–6, 204, 206f , 227–9, anterior aspect, 282t 38, 40f 238 dermatomes, 282t trapezium, 243–4 ulnar nerve stretch test, 67f extension, 253, 264, 281t trapezius middle fibers, 177f uncompensated Trendelenburg gait, extensor-supinator, 207, 208f trapezius muscle, 84, 148 flexion, 253, 263–4, 265–6f , 443f palpation of, 44, 45f upper cervical instability testing, 75 281t scapular elevation, 176f upper cervical spine, 58 flexor-pronator, 205, 206f trapezoid, 243–4 upper extremity, overview of, posterior view, 282t Trendelenburg’s test, 328, 329f range of motion, 447t triangular fibrocartilaginous complex, 243 139–40 triceps, 210, 223, 225f upper limb tension test, 65–6 Yergason’s test, 187, 192f trigger fingers, 268f Yocum test, 188, 193f trigger points, 446t valgus, 437 valgus strain, 357f