Tester forcibly flexes the sitting patient’s internally rotated arm, while inhibiting scapular movement by pressing down on the clavicle and acromion with the other hand
Pain indicates subacromial impingement
The upright patient’s arm is passively positioned in 90° of flexion at the shoulder and elbow. The tester then forcibly medially rotates the patient’s shoulder
Pain indicates subacromial impingement
Empty Can test (Jobe’s test)
The shoulder is fully internally rotated, abducted to 90° and placed in 30° forward flexion as if emptying a beverage can. The tester applies a downward pressure as the patient attempts to maintain this position
Pain indicates impingement whereas
weakness indicates a supraspinatus tear
Internal rotation lag sign
With patient sitting, the examiner stands to the back of the patient, brings the patient’s hand behind the back and flexes the elbow to 90°, so that the back of the hand rests on the spine at waist level. Gripping the patient’s wrist, the examiner then lifts the back of the hand clear of the spine until the shoulder is in almost full medial rotation. The examiner continues to support the elbow but releases the wrist and asks patient to actively maintain this position
If the patient is unable to maintain arm position off back this is a positive test and indicates a subscapularis tear
Biceps Tendon Pathology
The long head of the biceps (LHB) tendon arises from the posterosuperior labrum and supraglenoid tubercle and lies within the bicipital groove . The sheath of the LHB is continuous with the glenohumeral joints synovial lining, thus tendinopathy and bicipital tendon sheath effusions can be seen with rotator cuff pathology as well as joint synovitis [5, 6]. Patients often report anterior shoulder pain on resisted supination of the forearm and focal tenderness over the bicipital groove. Sonography of the biceps tendon can identify tendinitis, tendon tears, rupture, and subluxation. LHB tendinitis presents with diffuse hypoechogenicity and thickening . In chronic tendinitis, the tendon may appear frayed and fibrous tissue may replace the fibers . Partial-thickness tears appear as hypoechoic areas within the tendon echotexture. Complete tendon ruptures are visualized as two tendon ends floating within a hematoma. The “empty groove” sign is an indirect sign of complete tendon rupture . Subluxation of the LHB tendon usually occurs medially, under the subscapularis tendon.
Rotator Cuff Tears and Impingement Syndrome
Impingement syndrome is the pinching of soft tissue structures between the humerus and the coracoacromial arch with movement. Rotator cuff dysfunction results in incomplete depression of the humerus in abduction. As a result, the humeral head gets closer to the coracoacromial arch causing impingement of the cuff tendons. Table 4.1 shows tests for the assessment of impingement.
Sonographic definitions of rotator cuff tears 
Type of tear
Absence of tendon fibers
Tear extending from bursal surface to articular surface
Bursal thinning on the bursal aspect of the tendon
Articular thinning at the articular portion of the tendon
Rim rent tear
Tear at the footprint of the tendon insertion
Adhesive Capsulitis (Frozen Shoulder)
In this condition, there is limited range of movement of the shoulder with both active and passive range of motion with a normal radiograph. It occurs several months to years after any cause of shoulder pain, or it can occur with systemic conditions such as diabetes.
The acromioclavicular (AC) joint is found between the lateral end of the clavicle and a small facet on the acromion of the scapula . Pain from an abnormal AC joint is reliably induced by cross abducting the shoulder. Degenerative changes usually affect this joint and can be seen on US as irregularity of the bony surfaces, joint effusions, as well as osteophytes demonstrated by hyperechoic projections.
The glenohumeral (GH) joint is formed by the head of the humerus with the glenoid cavity of the scapula . Clinically pain from the joint is elicited with both passive and active range of motion. Pain may be due to osteoarthritis or inflammatory arthritis affecting the joint. GH joint erosions can be seen by sonography as cortical defects or irregular contours of the humeral head. Osteophytes are noted as hyperechoic projections from the humeral head. Erosions >1 mm are found in up to 23% of asymptomatic individuals 20–60 years of age . Posterior transverse scan in external rotation is the most sensitive position for the detection of GH effusion and a bone to capsule distance >0.31 cm is suggestive of a pathologic effusion .
Differential diagnosis of elbow pain based on anatomical location 
Anterior capsule strain
Radial tunnel syndrome
Ulnar collateral ligament injury
Olecranon stress fracture
Lateral Epicondylitis (Tennis Elbow) and Medial Epicondylitis (Golfer’s Elbow)
Ulnar Nerve Entrapment (Cubital Tunnel Syndrome)
The ulnar nerve originates from C8 and T1 and it lies in the cubital tunnel formed by the medial epicondyle and olecranon process side by side, medial collateral ligament (MCL) along with elbow capsule as the floor and the Osborne’s ligament (cubital tunnel retinaculum) as the roof . Patients may present with acute numbness of the area of the hand supplied by the ulnar nerve (fourth and fifth digits) as well as pain in the elbow and forearm. With chronic compression, loss of motor function of the lumbricals as well as deformities can occur . On US, prestenotic dilatation indicated by a cross-sectional area of greater than 9 mm2 is suggestive of entrapment. Dynamic testing is also useful for evaluation of ulnar nerve subluxation [19, 22].
Hand and Wrist
Carpal Tunnel Syndrome (CTS)
De Quervain’s Tenosynovitis
The pulley system around the flexor pollicis longus (FPL) tendon is important for digit functioning. There are six pulleys, with the A1 pulley being the most common site for trigger finger . Patients complain of painless clicking or painful locking or catching during active flexion or extension. A painful nodule as a result of intratendinous swelling may be palpated in the line of the flexor digitorum superficialis (FDS), just distal to the metacarpophalangeal (MCP) joint in the palm. On US, trigger fingers can be visualized with thickening and hypervascularization of the A1 pulley, distal flexor tendinosis, and impingement of the flexor tendon with dynamic imaging .
Palmar Fibromatosis (Dupuytren’s Contracture, Dupuytren’s Disease)
Dupuytren’s is a fibroproliferative disorder causing permanent flexion contractures, commonly involving the fourth and fifth digits . It is associated with diabetes, alcohol abuse, smoking, HIV, epilepsy, and manual labor with vibratory exposure. On examination, thickening or a nodule in the palm can be found. It can progress and cause loss of motion of the affected fingers. Palmar fibromatosis appears hypoechoic on US and is located directly superficial to the flexor tendons with hyperemia and calcification .
Hip pain can originate within the joint itself (intra-articular) or outside the joint (extra-articular). True hip pain refers to the groin area.
Anterior Hip Pain
Provocation tests used to evaluate for hip pathology 
FABER (flexion, abduction, external rotation) test,
Lying supine the patient is instructed to place one leg in the “Fig. 4.4” position: FABER. The examiner applies a downward pressure on the leg (above the knee) of the leg that is crossed over
Pain in ipsilateral groin indicates intraarticular hip pathology; pain in sacroiliac (SI) joint is suggestive of SI joint pathology
Straight leg raise (test of Lasègue)
Patient lying supine with knee in extension, examiner raises the leg by flexing the hip and maintaining knee in extension until discomfort is experienced at the full range of motion
Pain radiating distally along the leg usually in the posterior thigh, radiating into the calf and perhaps the foot prior to the end of normal ROM (70°) indicates sciatic nerve irritation/compression
Patient lies on contralateral side of the painful side, the bottom hip and knee are flexed. The examiner passively flexes the knee to 90°, then passively extends the top hip and abducts the hip. The muscles should be relaxed and allowed to drop to the table
If the leg stays above the table, or feels tight when overpressure is applied, indicates tightness of the Iliotibial band
The examiner stands behind the patient, patient stands with the weight evenly distributed between both feet. The patient’s shorts are lowered to the point at which the iliac crest or posterior superior iliac spines are visible. The patient lifts the leg opposite the side being tested
Pelvis dropping toward the unsupported limb indicates weakness of the gluteus medius muscle
With patient sitting on a chair, the patient’s hip is flexed to about 90° and the femur is internally rotated against resistance or the leg is lifted with the knee extended
Production of deep groin pain indicates pathology of the Iliopsoas muscle’s tendinous insertion onto the lesser trochanter
FAIR (flexion, adduction, and internal rotation) test
Patient lying on side with the tested hip on top, the lower extremity is passively moved into flexion, 90° adduction, and internal rotation. The examiner stabilizes the hip and applies downward pressure to the knee to internally rotate and adduct the hip
Pain produced in the sciatic/gluteal area indicates piriformis syndrome
With the patient lying supine, the hip is flexed to about 30° with knees straight first against gravity and then with the examiner applying resistance
Pain produced in the groin or thigh indicates intraarticular hip pathology
With the patient lying supine with knees bent at the end of the table, one leg is passively flexed to the patient’s chest, allowing the knee to flex during the movement. The opposite leg (the leg being tested) rests flat on the table
The involved leg rises off the table. This indicates tightness of the iliopsoas muscles
Coxa Saltans (Snapping Hip Syndrome)
Snapping hip syndrome manifests with a palpable or an audible snap or click that occurs with movement of the hip joint. This can be divided into two types: extra-articular and intra-articular; and then further into external and internal causes. Intra-articular snapping can be caused by acetabular labral tears, cartilage defects, fracture fragments, and loose bodies [36, 37]. These patients present with mechanical symptoms such as locking or giving way . Lateral external snapping hip syndrome is caused by movement of the iliotibial band (ITB) over the greater trochanter. These patients may have tenderness over the proximal ITB, lateral margin of the gluteus maximus, or trochanteric bursa. These symptoms can be reproduced with the Ober and FABER (flexion, abduction, external rotation) tests (Table 4.4). In most cases, the diagnosis can be made clinically. If the physical exam is equivocal, then US can be used to depict snapping of the ITB or anterior gluteus maximus muscle over the greater trochanter . Anterior hip snapping is caused by abnormal movement of the iliopsoas tendon when it gets caught within the iliacus in hip flexion and snaps back in place on extension . Anterior hip snapping syndrome usually causes snapping with active movement of the hip from flexion, abduction, and external rotation to extension, adduction, and internal rotation between 30° and 45° of hip flexion. The Thomas test and Stinchfield test may also confirm pain symptoms (Table 4.4).
Rectus Femoris Tendinopathy
Rectus femoris tendinopathy can affect both the direct and indirect head and is common among athletes . Patients experience pain in the groin with jumping and running. Clinical signs include focal tenderness over the anterior-inferior iliac spine and limited hip flexion . US can demonstrate the direct head of the rectus femoris with insertion site calcification and may be amenable to ultrasound guided injection .
Femoroacetabular Hip Impingement (FAI)
FAI occurs secondary to developmental hip abnormalities and environmental factors . There are two main subtypes, Cam and Pincer type, with Cam-type impingement seen in young athletic males while Pincer-type impingement more commonly seen in athletic middle-aged women [42, 43]. Patients typically experience groin pain that is worse with prolonged sitting, prolonged walking, or hip flexion-type movements. On examination, there is decreased range of movement with passive flexion, internal rotation, and adduction of the hip. With the pincher type of FAI, hip extension and external rotation may also elicit pain.
Posterior Hip Pain
Piriformis syndrome is caused by compression of sciatic nerve in the infrapiriformis canal. This results in numbness or tingling in the buttocks along the sciatic nerve down to the posterior thigh and knee. Palpation, prolonged sitting, or muscular contraction may increase the pain. The FAIR (flexion, adduction, and internal rotation) test can reproduce symptoms (Table 4.4).
Proximal Hamstring Tendinopathy (Hamstring Syndrome)
Proximal hamstring tendinopathy produces pain in the lower gluteal region, which radiates along the hamstrings to the posterior thigh . Examination may reveal a muscular defect or tenderness over the ischial tuberosity against resisted knee flexion or hip extension and pain with passive stretching of the muscle [45, 46]. Tendinosis and calcification of the proximal hamstrings may be seen on US .
Lateral Hip Pain Syndromes
This condition is caused by entrapment of the lateral femoral cutaneous nerve, which innervates the anterolateral thigh . It is associated with wearing tight pants, belts, or girdles; and in diabetics, obese patients and occasionally with surgery. Symptoms include numbness, paresthesias, and pain over the distribution of the nerve . Conservative therapy is the usual plan of care. Sonography may be able to identify the site of nerve impingement for a targeted injection .
Lateral Hip Pain Syndrome: Gluteal Tendinopathy and Trochanteric Bursitis
Traditionally, lateral hip pain was diagnosed as trochanteric bursitis, but this diagnosis has been challenged as gluteal medius and minimus tendinopathy is felt to be the basis of lateral hip pain. Gluteal tendinopathy commonly manifests as pain and tenderness laterally over the greater trochanter and radiates down the lateral thigh. It may be aggravated by lying on the affected side or by activities that involve extending the hip such as rising to stand or walking after sitting. The resisted external derotation test from a hip that is in a flexed and externally rotated position may be positive.
Anterior Knee Pain
Patellofemoral Pain Syndrome (PFPS)
PFPS is associated with overactivity, malalignment of the lower extremity, muscular imbalance of the lower extremity, and lateral patellar maltracking . Symptoms include anterior knee pain that worsens with prolonged rest and with activities that cause an increased load on the patellofemoral joint, such as squatting, jumping, and running. The best available test for PFPS is anterior knee pain elicited during a squatting maneuver . Other findings may include vastus medialis atrophy, angular and rotational deformities of the lower extremity, patella facet or retinaculum tenderness, discomfort with displacement of the patella medially or laterally (apprehension maneuver), or crepitus with flexion. Recent literature has suggested a key role of hip abductor weakness in predisposing to PFPS [57, 58].
The prepatellar bursa is located between the subcutaneous tissue and the patella. Activity that requires prolonged or repetitive kneeling can predispose to prepatellar bursitis [59, 60]. In acute bursitis, the area may be swollen, tender, and warm to the touch. In cases of chronic bursitis, the patient may have a history of swelling and pain that waxes and wanes. The presence of significant erythema, warmth, or systemic features, such as a fever and malaise should increase suspicion for a septic bursitis. Sonography may help to differentiate swelling of the knee arising from the prepatellar bursa rather than the joint, as well as allowing needle guidance for aspiration if needed .
Ligamentous and Meniscal Injuries
Provocation tests for knee ligamentous and menisci injuries 
Anterior drawer test
With patient lying supine with hip flexed to 45° and knee to 90°, the examiner grasps the tibia just below the joint line of the knee. Thumbs are placed along the joint line on either side of the patellar tendon. The index fingers are used to palpate the hamstring tendons to ensure that they are relaxed. The tibia is drawn anteriorly
An increased amount of anterior tibial translation compared with the opposite (uninvolved) limb or the lack of a firm end point implies a strain of the anteromedial bundle of the anterior cruciate ligament (ACL) or a complete tear of the ACL
Posterior drawer test
Lying supine with hip flexed to 45° and knee to 90°, the patient’s tibia is stabilized in neutral position and then drawn posteriorly
An increased amount of posterior tibial translation compared with the opposite (uninvolved) limb or the lack of a firm end point implies a strain of the posterior cruciate ligament
While the examiner supports the weight of the leg, one hand grasps the tibia around the level of the tibial tuberosity and the other hand grasps the femur just above the level of the condyles. The knee is flexed to 20°–25°, the tibia is drawn anteriorly while a posterior pressure is applied to stabilize the femur
An increased amount of anterior tibial translation compared with the opposite (uninvolved) limb or the lack of a firm end point implies a strain of the posterolateral bundle of the Anterior cruciate ligament (ACL) or a complete tear of the ACL
With the patient lying supine and the tibia maintained in neutral position, a valgus stress is applied while the knee is flexed through its available ROM. A varus stress is applied as the knee is returned to full extension. The examiner internally rotates the tibia and applies a valgus stress while the knee is flexed through its available ROM. A varus stress is applied as the knee is returned to full extension
With the tibia externally rotated, the examiner applies a valgus stress while the knee is flexed through its available ROM. A varus stress is applied as the knee is returned to full extension
A popping, clicking or locking of the knee; pain emanating from the menisci; or a sensation similar to that experienced during ambulation implies a meniscal tear
Varus stress test
With the patient lying supine with the involved leg close to the edge of the table, the examiner supports the lateral portion of the tibia, while the other hand grasps the knee along the medial joint line. A lateral (varus force) is applied to the knee while the distal tibia is moved inward. To isolate the Lateral collateral ligament (LCL), the knee is flexed to 25°
Increased laxity, decreased quality of the end point, or pain compared to the uninvolved limb implies a strain of the LCL
Valgus stress test
A medial (valgus force) is applied to the knee, while the distal tibia is moved laterally
Increased laxity, decreased quality of the end point, or pain compared to the uninvolved limb implies a strain of the medial collateral ligament (MCL)
Patient lying supine with the knees extended. The examiner gently displaces patella medially and ask patient to contract the knee. Repeat the process with lateral displacement of the patella
Pain indicates patellar maltracking, which may give rise to chondromalacia patella