EPC Orthopedic Maneuvers

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Spurling's Maneuver

The neck is extended, side-bent, and rotated to the painful side; then put an axial pressure on the top of the head. The sign/maneuver is positive if pain radiates down the ipsilateral arm; if there is pain only in the neck, this is not a positive sign. A positive Spurling's maneuver is suggestive of a cervical radiculopathy.

Maual Muscle Testing: Deltoid

Have the patient place their shoulder into full abduction and then pull down (adduct) the arm and "break" the contraction. The muscle is primarily innervated at the C5 level by the axillary nerve.

Manual Muscle Testing: Extensor Carpi Radialis (longus and Brevis)

Have the patient extend their wrist and, while bracing the forearm, will "break" the contraction by putting pressure on the hand and forcing flexion of the wrist. This can also be done by having the patient place their forearm on an exam table and pressing down on the extended wrist. The student should know that this muscle is innervated primarily at the C-6 level by the radial nerve.

Manual Muscle Testing: Triceps

With the patient seated or standing with the shoulder in forward flexion and elbow in an extended position.The student will then brace the upper arm and attempt to flex the elbow. You may not be able to "break" this muscle. This muscle is innervated at the C7 root level by the radial nerve.

Manual Muscle Testing: Abductor Pollicis Brevis

Habe patient palmar abduct the thumb and then force the thumb into adduction with pressure over the metacarpophalangeal (MCP) joint with bracing of the hand.The student should know that this muscle is innervated at C-8/T-1 root levels by the median nerve.

Manual Muscle Testing: First Dorsal Interosseous

Have patients fully abduct the first digit of the hand; they will then brace the patient's hand and attempt to adduct the patient's finger while using their own abducted finger to do this, thus comparing their abduction to the patient's. The student should know that this muscle is innervated by C8/T1 nerve roots and by the ulnar nerve

Range of Motion: Scapula

elevation and depression, protraction and retraction, and using the glenoid as a point of reference, upward and downward rotation- passively moving the scapula through these motions. The student should know that weakness of the serratus anterior causes limitation of scapular protraction and upward rotation, thus causing scapular winging ; this should also be demonstrated by having the patient push against a wall with shoulder flexion and elbow extension.

Range of Motion: Glenohumoral Joint

Demonstrate abduction and adduction, internal and external rotation, and forward flexion and extension. The student should know that limitation in most motions with pain is consistent with adhesive capsulitis (frozen shoulder).

Range of Motion: Elbow

Flexion, extension, pronation, and supination

Range of Motion: Wrist

Flexion, extension, radial and ulnar deviation

Range of Motion: Hand

Flexion and extension of the MCP and DIP joints and abduction and adduction of the MCP joint. Demonstrate the actions of the intrinsic muscles (lumbricals and interrosei) on finger flexion and extension; these actions are: simultaneous flexion of the MCP joint and extension of the PIP and DIP joints.

Muscle Stretch Reflexes: Biceps

Strike on the biceps tendon at the elbow. The elbow should be in approximately 90 degrees of flexion with the hand pronated. The student should know that this reflex primarily assesses the C5 nerve root.

Muscle Stretch Reflexes: Brachioradialis

Strike the brachioradialis tendon as it inserts on the radius ; the elbow should be in approximately 90 degrees of flexion with the hand pronated. The student should know that this reflex primarily assesses the C6 nerve root.

Muscle Stretch Reflex: Triceps

Strike the triceps tendon at the elbow. This should be done with the shoulder abducted to approximately 90 degrees and with elbow flexed to approximately 90 degrees. The student should know that this reflex assesses, primarily, the C7 nerve root.

Empty Can Test

The shoulder is abducted approximately 90 degrees and forward flexed about 30 degrees. The humeral head is internally rotated (the thumb is down). The patient then abducts the shoulder against resistance supplied by the examiner. The student should know that pain in the shoulder constitutes a positive test and is suggestive of supraspinatus trauma (tear, tendonitis, or tendonosis). The student should also know that, in cases of complete supraspinatus tear, the patient will not either be able to keep their shoulder in this position or that this will be very weak.

Allen's Test

The patient is instructed to first open and close their fist several times; when the fist is closed, pressure is applied distally, at the wrist, to the radial and ulnar arteries to occlude them. When the patient opens their hand, pressure is released from one of the arteries and the hand should be noted to flush immediately. The test is repeated with the other artery. The student should know that this is a test to evaluate the blood supply to the hand and that if the hand does not flush or reacts slowly, the artery is likely partially or completely occluded or that there may be an incomplete anastomosis from a congenital anomaly.

Lift-Off Test

The patient, standing or seated, is instructed by the student to place the dorsum of their hand in their back pocket or in the small of their back (internally rotated). The patient then tries to lift their hand off their back (internal rotation). The student should know that this is a test for subscapularis function and that failure to be able to do this indicates injury to the subscapularis muscle. They should also know that the subscapularis is the major internal rotator in glenohumeral motion and that, if when doing this, there is medial winging of the medial scapula, and this is suggestive of an injury to the rhomboid muscle.

Neer's Sign

With the patient in a seated position, the scapula is depressed with one hand while the arm is elevated with the other. The student should know that this compresses the greater tuberosity of the humerus against the anterior acromion and causes pain in persons who have a rotator cuff tear or impingement syndrome.

Hawkin's Test

The student forward flexes/elevates the patient's shoulder to 90 degrees, flexes the elbow 90 degrees, and places the forearm in a neutral rotation position. The humerus is then forcibly internally rotated, with the arm supported. Pain indicates a positive test. The student should also know that this pain indicates a rotator cuff tear or impingement syndrome and that the position drives the greater tuberosity farther under the coracoacromial ligament, similarly reproducing the pain of impingement.

O'Brien's Test

The examiner stands behind the patient; patient forward flexes the arm to 90 degrees with the elbow fully extended and adducts 15-30 degrees medially; the arm is then internally rotated so the thumb is pointed down ; the examiner then applies downward force to the arm . This force is also applied with the arm in the same position with the palm supinated (and the thumb pointed upward). If the patient has pain with the first maneuver and less or no pain with the second maneuver, the test is positive. The student should know that pain localized to the acromioclavicular (AC) joint or the top of the shoulder indicates an AC joint abnormality and that pain or clicking sensation inside the glenohumeral joint indicates labral pathology, such as SLAP (Superior Labrum Anterior Posterior) or Bankart (anterior labral) tears.

Tennis Elbow Test

The patient's forearm is stabilized and is instructed to make a fist and extend the wrist. When the patient has done so, pressure is applied by the student to the dorsum of the wrist with their other hand in an attempt to force the wrist into flexion. If the patient has tennis elbow (lateral epicondylitis), he will experience a sudden increase in or onset of pain at the site of the common origin of the wrist extensors (the lateral epicondyle). The student should know that this test is designed to reproduce pain of lateral epicondylitis, also known as tennis elbow, and that patients with lateral epicondylitis should also have pain on palpation of the lateral epicondyle.

Yergason's Test

The elbow is flexed to 90 degrees and the forearm is pronated ; the examiner asks the patient to supinate the forearm and the examiner resists the patient's supination effort. A positive test occurs with pain at the bicipital groove and is suggestive of injury, synovitis, or tear of the tendon sheath or possible fracture of the lesser humeral tuberosity. The test is negative in a partial or complete rupture of the supraspinatus tendon.

Speed's Test

The patient flexes the shoulder, with the elbow extended and the forearm supinated , against the examiner's resistance . The test is positive with pain localized to the bicipital groove and is suggestive for subacromial impingement.

Phalen's Test

The patient is seated and holds the elbow in relaxed extension , then allows gravity to move the wrists into full flexion for approximately one minute. A positive test is when numbness and/or tingling occur in a median nerve distribution and is suggestive of median nerve pathology, possibly carpal tunnel syndrome.

Tinel's Test

The examiner percusses at the patient's distal wrist crease and toward the area between the thenar and hypothenar eminences in line with the metacarpal of the long finger. A positive test occurs when reproduction of pain or paresthesias/numbness is noted in a median nerve distribution and is suggestive of medial nerve pathology, possibly carpal tunnel syndrome.

Drop Arm Test

The patient elevates both arms into full vertical abduction and then slowly lowers the arms to 90 degrees and holds them in this position. A positive test : the affected arm will drop to the patient's side or a gentle downward tap on the wrist will cause the arm to drop. A positive test indicates a full thickness tear of the supraspinatus

Crossover Test

The examiner passively adducts the patient's arm across the chest wall with the humerus parallel to the floor so that the free hand of the examined arm rests on the opposite shoulder. A positive test: Pain in the AC joint with end-range adduction, and indicates AC joint pathology

L'Hermitte's Sign

The patient's neck is passively flexed anteriorly. A positive test: "electric like" sensations down the spine or extremities, and indicates spinal cord pathology, most commonly multiple sclerosis

Manual Muscle Testing: Biceps

C5-6 Musculocutaneous nerve. The arm to be examined is at the patient's side, with the elbow flexed at 90 degrees, and the forearm supinated with the palm facing up. The examiner supports the elbow with one hand while the other rests on the distal volar forearm. The patient is asked to flex the elbow against resistance.

Schober's Test

From the standing position, measure 10 cm. superiorly from the base of S-1 (dimples of Venus); the patient will then be instructed to flex their spine forward and the student will measure the new distance between these points. A normal result is greater or equal to 14 cm. distance between the two points while in flexion. A lower measurement suggests restricted flexion of the lower lumbar spine and can be found in ankylosing spondylitis.

Trendelenberg Test

From the standing position and behind the patient, have the patient stand on one leg and observe the iliac crest of the contralateral side. The test is positive if the contralateral iliac crest drops lower than the ipsilateral (standing side) iliac crest. A positive test suggests weakness of the ipsilateral gluteus medius muscle.

Homan's Sign

This test is done in the supine position. The student will passively dorsiflex the ankle and evaluate for pain in the calf and posterior knee. This test has been classically described as being positive in patients with deep vein thrombosis.

Manual Muscle Testing: Quadriceps

From the sitting position, the patient will extend the knee and attempt to flex the patient's knee. You will often not be able to "break" this muscle contraction. This is an L-2,3,4 muscle and is innervated by the femoral nerve.

Manual Muscle Testing: Anterior Tibialis/Tibialis Anterior

In the standing position, ask the patient to stand on their heel and dorsiflex their ankle. Apply pressure to the dorsum of the foot and push the foot to the ground. (This is an L-4-5 muscle and it is innervated by the peroneal/fibular nerve

Manual Muscle Testing: Extensor Hallucis (Longus and Brevis)

From the seated or supine position , the patient will be instructed to extend the metatarsophalangeal (MTP) joint of their great toe. Flex the toe by applying pressure on the proximal phalanx. This is an L-5 muscle that is innervated by the peroneal/fibular nerve.

Manual Muscle Testing: Gluteus Medius

The patient will be sidelying and then instructed to fully abduct their leg. Then apply pressure distal to the knee and attempt to force it into adduction. This is an L-5 muscle that is innervated by the superior gluteal nerve.

Manual Muscle Testing: Gastrocnemius

Standing on one leg, the patient will place one finger on a table to balance, stand on one leg, keep their knee straight , and then go up on their toes (plantar flex) ten times This S-1 muscle is innervated by the tibial nerve.

Range of Motion: Hip

Flexion (knee must be flexed), and extension (hip must be off the table) (abduction and adduction , internal and external rotation.

Range of Motion: Knee

With the patient seated, demonstrate flexion and extension of the knee.

Range of Motion: Ankle and Foot

Ankle dorsiflexion and plantar flexion, ankle inversion and eversion, and, with holding and stabilizing the calcaneous, forefoot supination and pronation. The most common type of ankle sprain is in inversion.

Muscle Stretch Reflexes: Knee/Patellar

Strike the patellar tendon below the patella with the patient in the seated position. This mainly assesses the L-4 nerve root.

Muscle Stretch Reflexes: Ankle/Achilles

Strike the Achilles tendon with the patient seated, prone, or kneeling. This mainly assesses the S-1 nerve root.

Babinski

Stimulate, with a sharp object, the plantar surface of the foot and describe a positive response (which is: an initial extension movement of the MTP joint of the great toe, often, but not always, followed by a spreading of the other toes. A positive Babinski sign is strongly suggestive of an upper motor neuron lesion.

Anterior Drawer Test for the Ankle

With the patient seated, supine, or prone, will place the ankle in neutral to slight plantar flexion and will then translate the talus anterior to the tibia. This is a test for anterior instability of the ankle , that the anterior talofibular ligament is the most commonly injured ligament in the ankle, and that laxity may indicate a tear of the anterior talofibular ligament.

Thompson Test

Place the patient in the prone position with the foot extending over the end of the examination table. The calf muscles are then squeezed in the middle one third of the calf below the point of widest girth. A negative test is passive plantar flexion movement and a positive test, which indicates Achilles tendon/heel cord rupture, results in no foot or ankle motion with squeezing of the calf. Plantar flexion of the foot with a squeeze of the calf requires an intact soleus musculotendinous unit.

Collateral Ligament Testing

Stabilize the knee both above and below it; for LCL, the student will place a varus stress on the knee at both 0 degrees and 30 degrees of flexion; for the MCL, the student will place a valgus stress on the knee at 0 and 30 degrees of flexion, respectively. If the knee gaps medially with valgus or laterally with varus, this is suggestive of a collateral ligament injury. Flexing the knee to 30 degrees helps to isolate the collateral ligaments and that laxity in full extension often suggests a combination injury involving the collateral ligament and possible cruciate ligament as well. Laxity is graded as grade I for 5 mm. opening, grade II for 10 mm. opening, and that over 10 mm. is grade III.

Pivot Shift

In the supine position; pick up the patient's leg at the ankle, the knee will then be flexed by placing the heel of the other hand behind the fibula over the lateral head of the gastrocnemius. As the knee is extended, the tibia is supported on the lateral side with a slight varus strain applied. A strong valgus force is placed on the knee by the upper/superior hand; in a positive test, at approximately 30 degrees of flexion, the displaced tibial plateau will suddenly reduce. The presence of a positive test is usually indicative of an ACL tear and that, in a conscious person, may reflect the patient's inability to protect the knee, which is suggestive of a less likely positive outcome of non-surgical treatment.

Straight Leg Raise

This test is done with the patient in the supine position and with the pelvis level. The leg is elevated until the knee begins to bend or the patient reports severe back or buttock pain. The SLR test is positive when the supine leg is elevated to between 30 and 70 degrees and pain is produced/reproduced down to the posterior thigh below the knee. Pain beyond 70 degrees of leg elevation is not believed to be due to nerve tension. Pain on the symptomatic side when the leg on the asymptomatic side is raised is suggestive of lumbar disk herniation.

Femoral Nerve Stretch Test

The patient is prone and the knee is passively flexed with the examiner's hand at the patient's ankle; the hip is then passively extended by placing the examiner's hand anteriorly, and superior to the knee, on the patient's distal thigh and lifting the leg upward, off of the exam table. A positive test is pain in the anterior thigh or low back; the pain is believed to be due to stretching of the irritable femoral nerve when the L2, L3, or L4 nerve roots are compressed. This test can also be positive if the patient has a lumbar radiculopathy and lumbar disk herniation, with femoral neuropathy, hip pathology, or tight iliopsoas and/or rectus femoris muscles.

Patrick FABERE Test

The patient is supine on a level surface with the pelvis level. The hip is placed in flexion,abduction,external rotation and then the foot is placed on/just above the opposite knee. The examiner then presses downward on the flexed knee and simultaneously presses on the opposite ASIS. A positive test is when the patient experiences pain (if in the low back, this is suggestive of SI joint disease and if in the inguinal area, it is suggestive of hip or surrounding soft tissue pathology.)

Lachman's Test

With the thigh supported and the thigh muscles relaxed, the knee is flexed passively to 15-25 degrees; the distal femur is grasped from the lateral side with one hand and the proximal tibia from the other side with the opposite hand. Maintaining the knee in a neutral position, the examiner pulls anteriorly on the tibia while stabilizing the femur. A positive test occurs when there is increased tibial translation, indicating a partial or complete disruption of the anterior cruciate ligament.

McMurray Test

The patient is supine, the knee is flexed to its maximum capability (at least 90 degrees if possible); the foot is held by grasping the heel; the foot is then externally rotated and the knee is gradually extended while maintaining the tibia in external rotation (to test medial meniscus) ; the same maneuver can also be done while rotating the foot internally (lateral meniscus). A medial or lateral click and/or pain are suggestive of a tear of the meniscus.

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