Orthopaedic Tests, Signs, and Maneuvers





This chapter identifies the many names used in orthopaedics to describe tests, signs, and maneuvers that are synonymous with other names having the same definition and meaning. This occurs as a reflection of the influence of educational institutions around the country in that the names of prominent physicians are named for these examinations, along with generic names given to describe a test, sign, or maneuver. Eponyms are routinely used in the physical evaluation process. Familiarity with the names and techniques enables physicians and assistants to accurately record an orthopaedic examination. When more than one name is given for a single definition, the synonym follows at the end of the definition.


The physical examination may be simple visual observation, noting the way a patient walks (gait) or the manner in which the upper and lower limbs are used. The range of motion of the joints may be guided and recorded by the examiner. Palpation is the use of hands in determining firmness, shape, and motion of a part. Auscultation usually involves a stethoscope to listen to heart and lung sounds as well as pulses in taking blood pressures. All of these can stand alone or be combined to aid in diagnosis.




  • A test may be part of the physical examination in which direct contact with the patient is made, or it may be a chemical test, radiographic examination, or other study. All tests described in this chapter relate to the physical examination only.



  • A sign may be elucidated by a test, maneuver, or simply a visual observation, for example, a list. It is an indication of the existence of a problem as perceived by the examiner. The terms sign and test are often interchanged.



  • A maneuver is a complex motion or series of movements used as either a test or treatment. It is also referred to as a method or technique.



  • A phenomenon is any sign or objective symptom; it is any observable occurrence or fact.



This chapter presents the many categories of tests, signs, and maneuvers. An alphabetized list is presented first to guide the reader to the appropriate section. The categories are neck, back, shoulder, upper limbs, hands, hips, lower limbs, knees, feet and ankles, neurologic, metabolic, general, gait, scales and rating, and other examinations. A table of knee examinations is included. Scales and ratings, as pertains to outcomes assessment as well as degree of impairment, are listed along with a grading system for spinal cord injury.


In addition to many new terms, a table has been included on knee instability tests, an area that receives much attention. Scales and ratings, as pertains to preoperative and postoperative assessment of joints and degree of functional impairment, have been expanded to include a neurologic assessment grading system for spinal cord injury.


Tests, Signs, and Maneuvers





  • Abbott method (back)



  • abduction sign (shoulder)



  • abduction external rotation test (shoulder)



  • Achilles bulge sign (feet, ankles)



  • Achilles squeeze test (lower limb)



  • active compression test (shoulder)



  • active glide test (knee)



  • Addis test (lower limbs)



  • adduction sign (shoulder)



  • Adson maneuver or test (neck)



  • Allen maneuver (neck)



  • Allen test (hands)



  • Allis maneuver (hips)



  • Allis sign (hips)



  • ambling (gaits)



  • American Shoulder and Elbow Surgeons (scales and ratings)



  • American Spinal Injury Association (ASIA) scale (scales and ratings)



  • Amoss sign (back)



  • André Thomas sign (hands)



  • Anghelescu sign (back)



  • ankle clonus test (neurologic)



  • Anstrom suspension test (back)



  • antalgic (gait)



  • antecedent sign (general)



  • anterior cruciate ligament instability (knee)



  • anterior drawer sign (feet, ankles)



  • anterior slide test (shoulder)



  • anterior tibial sign (lower limb)



  • anvil test (neck; hips)



  • Apley scratch test (shoulder)



  • Apley test (knees)



  • apprehension test (shoulder)



  • arthrometer test (knees)



  • artifact (general)



  • ataxic (gaits)



  • axial compression test (hand)



  • Babinski reflex (back)



  • Babinski sign (neurologic)



  • ballotment test (hands)



  • ballotable patella sign (knee)



  • Barlow test (hips)



  • Barthel index (neurologic)



  • bayonet sign (knees)



  • Beevor sign (neurologic)



  • Beighton laxity score (scales and ratings)



  • Bekhterev test (back)



  • belly press test (shoulder)



  • bench test (back)



  • benediction attitude sign (hands)



  • benediction sign (hands)



  • Bigelow reduction maneuver (hips)



  • Booth test (shoulder)



  • Boston carpal tunnel questionnaire (hand)



  • bounce home test (knees)



  • Bouvier maneuver (hands)



  • bowstring sign (back)



  • Boyes test (hands)



  • Bozan maneuver (hips)



  • bracelet test (hands)



  • Bragard sign (back)



  • British test (knees)



  • Brudzinski sign (neck, neurologic)



  • Bryant sign (shoulders)



  • bulbocavernosus reflex (neurologic)



  • bulge sign (knee)



  • café-au-lait (general)



  • Callaway test (shoulders)



  • camelback sign (knees)



  • Carducci test (hands)



  • carpal compression test (hands)



  • Chaddock sign (neurologic)



  • Chapple test (hips)



  • Charnley hip scale (scales and ratings)



  • Chicago test (back)



  • Chiene test (hips)



  • Childress test (knee)



  • Chvostek sign (metabolic)



  • circumduction (gaits)



  • circumduction maneuver (hands)



  • circumduction test (shoulder)



  • claw hand sign (hands)



  • Cleeman sign (lower limb)



  • clinical disease activity index (CDAI) (systemic)



  • Codman sign (shoulders)



  • cogwheel phenomenon (general)



  • Coleman lateral standing block test (feet, ankles)



  • commemorative sign (general)



  • Comolli sign (shoulders)



  • confrontational test (hands)



  • contralateral straight leg raising test (back)



  • Coopernail sign (back)



  • costoclavicular maneuver (neck)



  • Cotton test (feet, ankles)



  • Cozen test (back)



  • Cozen test (elbow)



  • cram test (back)



  • crank test (shoulder)



  • cross-body abduction maneuver (shoulder)



  • cross-chest test (shoulder)



  • cross-over test (knee)



  • Dawbarn sign (shoulders)



  • Dejerine sign (back)



  • Demianoff sign (back)



  • Desault sign (hips)



  • Destot sign (hips)



  • Deyerle maneuver (hip)



  • Deyerle sign (back)



  • Dial test (knee)



  • dimple sign (feet, ankle)



  • dimple sign (neurologic)



  • disease activity score 28 (DAS 28) (systemic)



  • doll’s eye sign (neurologic)



  • Doyle index (systemic)



  • drive through sign (shoulder, elbow, knee)



  • drop-arm test (shoulder)



  • drop-back phenomenon (knee)



  • double camelback sign (knee)



  • double PCL sign (knee)



  • drawer sign (knee; feet, ankles)



  • drawer test (shoulder)



  • Dugas test (shoulders)



  • Duchenne sign (hands)



  • Duncan Ely (knee)



  • Dupuytren sign (general)



  • Durkan test (hands)



  • Earle sign (hips)



  • East Baltimore maneuver (hips)



  • elbow flexion test (elbow)



  • Elson middle slip test (hands)



  • Ely test (knee)



  • Erichsen sign (back)



  • extension lag (knee)



  • external rotation drawer test (knee)



  • external rotation recurvatum test (knee)



  • extrinsic tightness test (hands)



  • FABERE test (back)



  • FADIRE test (back)



  • Fairbank sign (knee)



  • fan sign (neurologic)



  • Fellar patellar score (scales and ratings)



  • femoral nerve traction test (back)



  • Fick angle (gaits)



  • figure 4 test (knee)



  • Finacetto sign (knee)



  • finger to nose test (neurologic)



  • Finkelstein sign (hands)



  • flexion rotation drawer test (knees)



  • foot slap (gait)



  • forced adduction test (shoulder)



  • Forestier (back)



  • Fouchet sign (knee)



  • Fournier test (neurologic)



  • Fowler maneuver (hands)



  • Fowler test (shoulder)



  • Frankel scale (scales and ratings)



  • Fränkel sign (neurologic)



  • Froment sign (hands)



  • fulcrum test (shoulder)



  • Gaenslen sign (back)



  • Galeazzi sign (hips)



  • gear-stick sign (hips)



  • Gerber test (shoulder)



  • Gilliat tourniquet test (hand)



  • Glasgow coma score (scales and ratings)



  • gluteus maximus (gait)



  • gluteus medius (gait)



  • Godfrey test (knee)



  • Goldthwait sign (back)



  • Gordon reflex sign (neurologic)



  • Gower sign (general)



  • grand piano sign (knees)



  • gravity stress test (elbow)



  • Green-Anderson growth chart (scales and ratings)



  • grimace test (knees)



  • grip-strength test (hands)



  • Guilland sign (neurologic)



  • Halstead test (neck)



  • Hamilton test (shoulder)



  • Harris-Beath footprinting mat (feet)



  • Harris hip scale (scales and ratings)



  • Hawkins impingement sign (shoulder)



  • head tilt sign (neck)



  • heel-bisector method (neurologic)



  • heel height difference (knee)



  • heel-to-buttocks difference (knee)



  • Helbing sign (feet, ankles)



  • Helft test (knee)



  • hemodynamic test (general)



  • Hirschberg sign (neurologic)



  • Hoffmann sign (neurologic)



  • Homan sign (lower limbs)



  • hook test (elbow; feet, ankles)



  • Hoover test (back)



  • hop test (knee)



  • hornblower sign (shoulder)



  • Hueter sign (general)



  • Hughston jerk test (knee)



  • Huntington sign (neurologic)



  • Hutchinson sign (hands)



  • hyperabduction test (neck)



  • hyperextension test (neck)



  • impingement sign (shoulder)



  • impingement test (shoulder)



  • internal-rotation drawer test (knees)



  • International Classification for Surgery of the Hand in Tetraplegia (hands)



  • intrinsic tightness test (hands)



  • inverted radial reflex (back)



  • J sign (knee)



  • Jansen test (hips)



  • Jeanne test (hands)



  • Jendrassik maneuver (back; neurologic)



  • jerk test (shoulder)



  • Jobe test (shoulder)



  • Kanavel sign (hands)



  • Kapandji thumb opposition score (hand)



  • Keen sign (feet, ankles)



  • Kernig sign (neurologic)



  • Kerr sign (neurologic)



  • Kim test (shoulder)



  • Kleinman shear test (hands)



  • Klippel-Feil sign (neurologic)



  • knee instability tests (knees)



  • Knee Society clinical rating system (scales and ratings)



  • King maneuver (hips)



  • Kocher maneuver (shoulders)



  • Kujala score (scales and ratings)



  • Lachman test (knees)



  • lack of extension sign (knees)



  • Langer line (general)



  • Langoria sign (hips)



  • Lasègue sign (back)



  • Laugier sign (upper limbs)



  • lead line (metabolic)



  • Leadbetter maneuver (hips)



  • Lefkowitz maneuver (hips)



  • Leichtenstern sign (neurologic)



  • Léri sign (neurologic)



  • Lhermitte sign (neurologic)



  • Lichtman test (hands)



  • lift-off test (shoulder)



  • Linder sign (back)



  • list (back)



  • load-and-shift test (shoulder)



  • long finger extension test



  • long tract sign (neurologic)



  • Lorenz sign (back)



  • loss of extension test (knee)



  • Losse test (knee)



  • Lovett test (hands)



  • Ludington sign (shoulder)



  • Ludloff sign (hips)



  • Lynholm knee-scoring scale (scales and ratings)



  • Mackiewicz test (back neurologic)



  • Magnuson test (back)



  • Maisonneuve sign (hands)



  • Malnutrition Universal Screening Tool (MUST score) (systemic)



  • Marie-Foix sign (feet, ankles)



  • Marshall knee-scoring scale (scales and ratings)



  • Marvel test (shoulder)



  • masses sign (hands)



  • Matles test (feet, ankles)



  • Mazur ankle rating (scales and ratings)



  • McBride test (foot)



  • McCarthy sign (hips)



  • McElvenny maneuver (hips)



  • McMurray test (knees)



  • Mendel-Bekhterev sign (neurologic)



  • medial subluxation test (knees)



  • Mennell sign (back)



  • Merke sign (knee)



  • Merle d’Aubigne and Postel hip scale (scales and ratings)



  • Meryon sign (metabolic)



  • Meyn and Quigley maneuver (upper limbs)



  • Michele buckling sign (back)



  • Michele flip sign (back)



  • Milch maneuver (shoulder)



  • Milgram test (back)



  • military brace maneuver (back)



  • Mills test (upper limbs)



  • Mimori test (shoulder)



  • Minor sign (back)



  • modified lift-off test (shoulder)



  • modified Mayo wrist score (hand)



  • Moro reflex sign (neurologic)



  • Morquio sign (neurologic)



  • Morton test (feet, ankles)



  • Medical Research Council sensory grade (neurologic)



  • Mulder sign (feet)



  • Murphy sign (feet, ankles; hand)



  • Nachlas (back)



  • Naffziger sign (back)



  • Napoleon test (shoulder)



  • Neer impingement sign (shoulder)



  • Neer impingement test (shoulder)



  • Nélaton line (hips)



  • Neri bowing sign (back)



  • Neviaser test (shoulder)



  • Norton scoring system (scales and ratings)



  • no touch test (knees)



  • nuchocephalic reflex (neurologic)



  • O’Brien test (shoulder)



  • O’Connell test (back)



  • O’Driscoll SLAP test (shoulder)



  • Ober test (hips)



  • objective sign (general)



  • obturator sign (hips)



  • Olerud-Molander ankle score (ankle)



  • Oppenheim sign (neurologic)



  • Ortolani test (hips)



  • Oshsner clasping test (hand)



  • overhead exercise test (neck)



  • Oxford Knee Score (knee)



  • P4 pain score (systemic)



  • paper pull out test (hand)



  • paratonia (neurologic)



  • Parvin maneuver (upper limbs)



  • patellar apprehension test (knees)



  • patellar glide test (knee)



  • patellar grind test (knee)



  • patellar retraction test (knee)



  • patellar tilt test (knees)



  • patient-reported outcome measure (PROM) (systemic)



  • patient-reported outcome measurement information system (PROMIS) (systemic)



  • Patrick test (hips)



  • Patte sign (shoulder)



  • Payr sign (lower limbs)



  • pedobarography (foot)



  • pelvic rock test (back)



  • percussion test (hand)



  • Phalen test and maneuver (hands)



  • piano key sign (hands)



  • Piotrowski sign (neurologic)



  • piston sign (hips)



  • pivot-jerk test (knees)



  • pivot-shift test (knees)



  • Pitres-Testut sign (hand)



  • Pollock sign (hands)



  • Popeye deformity (upper limbs)



  • posterior drawer test (knees)



  • post-total hip internal rotation (hip)



  • posterior lift-off test (shoulder)



  • posterolateral instability (elbow)



  • postural fixation (back)



  • pronation sign (neurologic)



  • prone external rotation test (knees)



  • prone hanging test (knees)



  • pseudo-Babinski sign (neurologic)



  • pseudostability test (hand)



  • push-pull test (shoulder)



  • quadriceps test (general)



  • quadriceps active test (knees)



  • Queckenstedt sign (neurologic)



  • radialis sign (neurologic)



  • Raimiste sign (neurologic)



  • Raynaud phenomenon (general)



  • release test (shoulder)



  • relocation test (shoulder)



  • reverse Bigelow maneuver (hips)



  • reverse pivot-shift test (knees)



  • Romberg test (neurologic)



  • Roos test (neck)



  • Roux sign (hip)



  • rubber band sign (shoulder)



  • Rust sign (neck)



  • sag sign (knee)



  • sagittal stress test (feet, ankles)



  • Sarbo sign (neurologic)



  • scaphoid test (hands)



  • scapular assistance test (shoulder)



  • scapular dyskinesis sign (shoulder)



  • scapular sign of Putti (shoulder)



  • scapular winging sign (shoulder)



  • Schlesinger sign (lower limbs)



  • Schobers test (spine)



  • Schreiber maneuver (neurologic)



  • scissors (gaits)



  • screw-home mechanism (knee)



  • Seimon sign (neck)



  • Semmes and Weinstein monofilament test (scales and ratings)



  • Sharp-Purser test (neck)



  • shuck (hand)



  • shuffling (gait)



  • Silfreskiöld test (feet, ankles)



  • simplified disease activity index (SDAI) (systemic)



  • Slocum test (knees)



  • Smith maneuver (hips)



  • Smith and Ross test (hand)



  • Smith-Peterson test (back)



  • somatic sign (general)



  • Soto-Hall sign (back)



  • Speed test (shoulder)



  • spilled teacup sign (hands)



  • spine sign (back)



  • sponge test (back)



  • Spurling test (neck)



  • stairs sign (neurologic)



  • standing apprehension test (knees)



  • station test (neurologic)



  • Steinmann test (knee)



  • Stimson maneuver (hips)



  • stoop test (back)



  • straight leg raising (SLR) test (back)



  • Strümpell confusion test (neurologic)



  • Strunsky sign (feet, ankles)



  • succinylcholine test (neurologic)



  • sulcus sign (shoulder)



  • swallow-tail sign (shoulder)



  • symmetrical extension test (knee)



  • table top test (hand)



  • talar tilt test (feet, ankles)



  • tendon reflexes (neurologic)



  • tenodesis test (hands)



  • Tensilon test (metabolic)



  • Terry-Thomas sign (hand)



  • Thessaly test (knee)



  • Thomas sign (hips, neurologic)



  • Thomas squeeze test (feet, ankles)



  • thumbnail test (knees)



  • thumb-to-forearm test (neurologic)



  • tibial sag sign (knees)



  • tibialis sign (neurologic)



  • tilt test (knees)



  • Tinel sign (neurologic)



  • toe spread sign (feet, ankles)



  • too many toes sign (feet, ankles)



  • Toronto test score (shoulder)



  • total hip arthroplasty outcome evaluation (scales and ratings)



  • tourniquet test (lower limbs)



  • towel clip test (knees)



  • Trendelenburg gait (hips)



  • Trendelenburg test (hips)



  • triple compression (hand)



  • Trotter bulge test (knee)



  • tuck sign (hands)



  • Turyn sign (back)



  • two-point discrimination test (hands)



  • ulna fovea sign (hands)



  • valgus stress test (elbow, knee)



  • valgus thrust (knee)



  • Valsalva maneuver (back)



  • Vanzetti sign (back)



  • varus recurvatum test (knee)



  • varus stress test (knee)



  • vertical patella test (knees)



  • Waddell sign (back)



  • Walker-Mureloch wrist sign (metabolic)



  • Wartenberg sign (hands)



  • Watson test (hands)



  • Wellmerling maneuver (hips)



  • wet leather sign (hands)



  • Whitman maneuver (hips)



  • Wilson sign (knees)



  • WOMAC (scales and ratings)



  • Wright maneuver or test (shoulder, neck/test)



  • wrinkle test (neurologic)



  • Wu sole opposition test (feet, ankles)



  • Yergason test (shoulders)



Neck


( Fig. 4-1 )




  • Adson m. (test): for scalenus anticus (thoracic outlet) syndrome, noted on obliteration of radial pulse; upper limb to be tested is held in dependent position while head is rotated to the ipsilateral shoulder while inhaling.



  • Allen m.: for same diagnosis as Adson m., except the forearm is flexed at right angle with the arm extended horizontally and rotated externally at the shoulder, with the head rotated to the contralateral shoulder.



  • anvil t.: for vertebral disorders; a closed fist striking blow on top of the head elicits pain in the vertebra(e).



  • costoclavicular m.: for thoracic outlet syndrome; pulling shoulders and chin back at the same time reduces the radial pulse when arm is by side; also called military brace m.



  • Halstead t.: for thoracic outlet; the standing patient keeps arm by side while pulse is taken; extending neck and turning head to opposite side obliterates pulse.



  • head tilt s.: seen in a complete brachial plexus injury, the head tilts to the side opposite the injury.



  • hyperabduction t.: for thoracic outlet syndrome, after obtaining the patient’s radial pulse the shoulder is abducted to greater than 90 degrees with extension. The patient is instructed to take a deep breath and hold. A positive test is a decrease in radial pulse intensity.



  • hyperextension t.: for thoracic outlet; both arms are fully abducted after confirming radial pulse with arms at side. The pulse is obliterated on the affected side.



  • overhead exercise t.: for thoracic outlet syndrome; the hand is held overhead and making repeated fists results in immediate soreness in the forearm muscles; also called Roos t.



  • Rust s.: for osteomyelitis or malignant disease of the spine; the patient supports head with hands while moving body.



  • Seimon s.: for fractured odontoid in small child; child cries if sat upright without support to head and neck.



  • Sharp-Purser t.: for chronic subluxation of the first on second cervical vertebra; with the patient sitting, the head is tilted forward and then backward with the examining finger on the first cervical spinous process to detect slippage.



  • Spurling t.: for cervical spine and foraminal nerve encroachment; compression on the head with extension and rotation of the neck causes radicular pain into the upper extremities. Often helpful in distinguishing pathologic conditions of the neck from shoulder conditions when symptoms are found in the shoulder.



  • Wright m.: in thoracic outlet syndrome, downward pressure on shoulder with shoulder being pulled back obstructs the radial pulse; also called costoclavicular m.






Fig. 4-1Cervical radiculopathy. A , Herniated disk compressing nerve root. B, Spurling maneuver. Hyperextension of neck and rotation and tilt toward the side of lesion cause radicular pain in neck and down arm.

(Netter illustration from www.netterimages.com . © Elsevier Inc. All rights reserved.)


Back





  • Abbott method: for scoliosis of the spine; traction is applied to produce overcorrection, followed by casting.



  • Amoss s.: for painful flexure of the spine; pain is produced when the patient places hands far behind body in bed and tries rising from supine position to sitting position.



  • Anghelescu s.: for testing tuberculosis of the vertebrae or other destructive processes of the spine; in the supine position the patient places weight on head and heels while lifting body upward; inability to bend the spine indicates an ongoing disease process.



  • Anstrom suspension t.: for sciatica; while tapping on the affected area of the lumbar spine the patient will have pain while standing, but not if suspending weight using arms to hold the spine in suspension.



  • Bekhterev t.: for nerve root irritability in sciatica; while sitting up in bed, the patient is asked to stretch out both legs; with sciatica, patient cannot sit up in bed this way but can only stretch out each leg in turn.



  • bench t.: for nonorganic back pain; in normal hip motion, the patient should be able to bend over and touch the floor kneeling on a 12-inch high bench; not being able to do so implies a nonorganic (or psychologic) back pain; also called Burns t.



  • bowstring s.: with leg raised with knee bent in same position, pain is felt in the back of the limb pressing on the central popliteal fossa. Increased pain is a sign of nerve irritability depending on position of the patient. Also called cram t., Forestier t., and Deyerle t.



  • Bragard s.: for nerve or muscular involvement; with the knee stiff, the lower extremity is flexed at the hip until the patient experiences pain; the foot is then dorsiflexed. Increased pain points to nerve involvement; no increase in pain indicates muscular involvement.



  • Chicago t.: to distinguish between back strain with muscle spasm and disk disease without spasm, the patient kneels on a chair and attempts to touch the floor. With muscle spasm the patient has difficulty; also called Bench Burn disease. Note: this same test is also used to study the way the patient returns to a more erect position. Slow movement implies an emotional component.



  • contralateral straight leg raising t.: for sciatica; when the leg is flexed, the hip can also be flexed, but not when the leg is held straight. Flexing the sound thigh with the leg held straight causes pain on the affected side. Also called Fajersztajn crossed sciatic s.



  • Coopernail s.: for fracture of pelvis; ecchymosis of the perineum, scrotum, or labia indicates a pelvic fracture.



  • Cozen t.: to distinguish sciatica from muscle spasm, the supine patient is assisted in sitting up with the knees out straight. An inability to do this without flexing the knee implies nerve irritation or muscle spasm in the lower limb.



  • cram t. (bowstring t.): for radiculopathy, with the patient supine the examiner does a passive straight leg raise on involved side and if the patient has radiating pain the examiner then flexes the knee to approximately 20 degrees to reduce the pain. Pressure then applied to popliteal area to reproduces radicular pain.



  • Dejerine s.: for herniated intervertebral disk causing radiating limb symptoms; a Valsalva maneuver, such as coughing, sneezing, or straining at stool, accentuates the symptoms.



  • Demianoff s.: for differentiation of pain originating in the lumbosacral muscle from lumbar pain of any other origin; the pain is caused by stretching of the lumbosacral muscle.



  • Duncan Ely: for rectus femoris spasticity, in prone position knee is flexed rapid flexion meets resistance whereas slow flexion meets less resistance.



  • Erichsen s.: in sacroiliac disease, when the iliac bones are sharply pressed toward each other, pain is felt in the sacroiliac area.



  • FABERE t.: for testing lower back or sacroiliac joint disorder by using a forced position of the hip; the patient crosses the leg with the foot of the affected side resting on the opposite knee, then in extension by pressing down on the knee. FABERE is an acronym for f lexion ab duction e xternal r otation in e xtension; also called Patrick t., figure of 4 t., and LaGuerre t.



  • FADIRE t.: forced position of the hip causing pain. An acronym for f lexion ad duction i nternal r otation in e xtension; also called Patrick t. and FADIRE s.



  • femoral nerve traction t.: for radiculopathy of the second through fourth lumbar nerves; with patient prone, the knee is flexed and hip extended causing back or thigh pain; also called also called Mackiewicz t.



  • Forestier t.: for early ankylosing spondylitis, in free lateral bending, the early ankylosing spondylitis (AS) patient has palpably firm muscle due to contracted dorsolumbar muscles on the concave side.



  • Gaenslen s.: for sacroiliac disease; pressure on hyperextended thigh with the opposite hip held in flexion elicits pain on the affected side over edge of bed, indicating a sacroiliac problem.



  • Gillet test: for sacroiliac hypermobility and pain, with the patient in the standing position, the examiner places one thumb on the superior sacrum and the other on the posterior superior iliac spine (PSIS). Patient is then asked to flex the right hip to 90, with lowering of PSIS normally observed. Also known as march test, stork test.



  • Goldthwait s.: for distinguishing lumbosacral from sacroiliac pain; with the patient supine, the leg is raised with one hand while the examiner’s other hand is placed under the patient’s lower back. Leverage is then applied to the side of the pelvis. If pain is felt by the patient before the lumbar spine is moved, the lesion is a sprain of the SI joint; if pain is not felt until after the lumbar spine is moved, the lesion is in the SI or lumbosacral articulation.



  • Hoover t.: for a supposed malingering back disorder; while lying supine, the patient is asked to raise one leg with the knee straight and with the examiner holding the opposite heel. Any active effort to do this will result in pressure of the opposite heel against the examiner’s hand. The lack of such effort implies malingering. Excessive pressure of the heel against the examiner’s hand implies abdominal muscle weakness.



  • inverted radial reflex: for cervical spondylotic myelopathy (cord compression); there is spontaneous flexion of the digits when the brachialis reflex is being tested.



  • Jendrassik m.: to help distract the patient or to help determine presence or absence of a weak reflex, patient is asked to push hands together or lock fingers and pull hands apart while reflex is tested; also called reinforcement m.



  • Lasègue s.: for sciatica; flexion of thigh on hips is painless, and when the knee is bent, such flexion is easily made. If painless, there is no hip joint disease. If test produces pain when the knee is straightened, nerve root irritation or lower back disorder may be present; also called straight leg raising t.



  • Linder s.: for sciatica; with the patient sitting or recumbent with outstretched legs, passive flexion of the head will cause pain in the leg or lumbar region.



  • list: said of a patient who leans to one side or another when standing or walking; most commonly seen in lumbar disk disease.



  • Lorenz s.: for ankylosing spondylitis and Marie-Strumpell disease; ankylotic rigidity of the spinal column, especially thoracic and lumbar segments.



  • Magnuson t.: for malingering; put an x mark on spot where patient reports pain. At a later time in the examination, test for tender points by palpation. The patient indicating pain not including that mark implies malingering.



  • Mennell s.: for spinal problems; examiner’s thumb is taken over the posterosuperior spine of sacrum outward and inward for noting tenderness, which may be caused by sensitive deposits in gluteal aspect of posterosuperior spine; ligamentous strain and sensitivity.



  • Michele buckling s.: for sciatica; the continued straight-leg raising past the point of nerve irritation will cause the patient to flex the knee if he or she has true sciatica.



  • Michele flip s.: for sciatica; the sitting patient who has the flexed knees passively extended will lean backward if true sciatica exists.



  • Milgram t.: for a lesion within the dural sac; while lying supine, the patient flexes both hips so that the knees are straight and both feet are lifted by only several inches. If the patient is able to hold this position without pain for 30 seconds, there is no problem within the dural sac. However, a positive test may occur for both intrathecal and extrathecal disorders.



  • military brace maneuver: for thoracic outlet syndrome, the person first stands in a relaxed posture, with the head looking forward. They then depress and retract the shoulders as if standing at attention in a military brace. Production of symptoms is a positive sign.



  • Minor s.: for sciatica; patient rises from sitting position supporting body on healthy side, placing hand on back, and bending affected leg, revealing pain.



  • Nachlas t.: sacroiliac disorder, the prone patient has the knee flexed to a right angle with pressure against the anterior surface of the ankle and the heel is slowly directed straight toward the ipsilateral buttock. The contralateral ilium should be stabilized by the examiner’s other hand. If a sharp pain is elicited in the ipsilateral buttock or sacral area, a sacroiliac disorder should be suspected.



  • Naffziger t.: for sciatica or herniated nucleus pulposus; nerve root irritation is produced by external jugular venous compression by examiner.



  • Neri bowing s.: for sciatica; the standing patient with knees extended is asked to bend forward. Knee flexion implies sciatica.



  • O’Connell t.: for lumbar nerve irritability. With knee extended, both lower limbs are raised to maximum hip flexion to the point of pain; lowering the unaffected limb will exacerbate pain in sciatica.



  • pelvic rock t.: for sacroiliac joint disorder; forcible compression of the iliac crest toward the midline will produce pain.



  • postural fixation: a sign noted on range of motion of the back; any postural deformity (stiffness) noted does not reverse with range of motion.



  • Smith-Peterson t.: for sacroiliac joint origin of pain; with one hand under the spine the opposite hand raises the leg. If the hamstrings are tight, apply posterior leverage to the pelvis. Pain prior to lumbar movement can be present in both lumbar and sacroiliac joint disorders. If this occurs at the same level for both legs, sacroiliac disease is implied.



  • Soto-Hall s.: for lesions in back abnormalities; with the patient supine, flexion of the spine beginning at the neck and going downward will elicit pain in the area of the lesion.



  • spine s.: for poliomyelitis; the patient is unable to flex the spine anteriorly because of pain.



  • sponge t.: for detecting lesions of the spine; the examiner passes a hot sponge up and down the spine, and the patient feels pain over the lesion.



  • stoop t.: for spinal stenosis; with persistent walking the patient will begin to stoop forward to reverse lumbar lordosis and improve spinal space. Likewise, in a sitting position the patient will lean forward.



  • straight leg raising (SLR) t.: for determining nerve root irritation; the supine patient elevates the leg straight until there is back or ipsilateral extremity pain or until the pain is increased with dorsiflexion of the foot; also called Lasègue s.



  • Turyn s.: for sciatica; when examiner bends the patient’s great toe dorsally, pain is felt in the gluteal region.



  • Valsalva m.: for determining nerve root irritability within the spinal canal. This maneuver is also used for many other unrelated reasons. Taking a deep breath and bearing down, such when lifting a heavy object, elicits pain.



  • Vanzetti s.: for sciatica; the pelvis is horizontal in the presence of scoliosis. In other scoliotic conditions, the pelvis is inclined as part of the deformity.



  • Waddell s.: for nonphysical-origin back pain; pressure on tender area results in jump-away pain in excess of that expected for level of disease, implying a strong emotional component. The term Waddell has commonly been used on other areas to reflect the same implications.



Shoulder





  • abduction external rotation t.: abduct shoulder to 90 degrees with elbow at 90 degrees. On external rotation, pain without apprehension implies rotator cuff disorder. Apprehension implies anterior instability.



  • abduction s.: for subacromial impingement or pathologic conditions of the rotator cuff; the examiner places the shoulder in 90 degrees abduction and 30 degrees flexion and then internally rotates arm, producing pain.



  • active compression t.: with the arm at 10 degrees adduction, 90 degrees forward flexion, and maximal forearm pronation, pain with resistance to downward force is correlative with a superior labrum anterior to posterior lesion; also called O’Brien t.



  • adduction s.: for acromioclavicular joint disease; the shoulder is abducted 90 degrees, brought horizontally forward 90 degrees, and then flexed maximally forward, producing pain at the acromioclavicular joint. Also called cross-body adduction t.



  • American Shoulder and Elbow Surgeons shoulder score (ASES) : for assessment of pain and shoulder function, individual scores ranging from 0 to 5 for ten specific activities combined with a pain scale 0 to 50 that comprise a composite score 0 to 100 points.



  • anterior slide t.: while patient is sitting, humeral head is pressed anteriorly with examiner’s hand, resulting in increased pressure if anterior capsular laxity exits.



  • Apley scratch t.: the patient is asked to put hand behind the back and elevate the hand as far as possible as when trying to scratch the midback. A measurement of shoulder extension combined with internal rotation is measured by the thoracic level at which the finger can reach, typically T7. A reasonable measure of internal rotatory shoulder strength as well.



  • apprehension t.: for anterior subluxing or dislocating shoulder; the arm is held abducted and extended while in external rotation, best completed in a supine position. The patient is apprehensive in a positive examination. Placing a posterior directed force at the proximal humerus may relieve the feeling of shoulder instability experienced by the patient, further confirming the instability.



  • belly press t.: for ruptured or neurologically impaired subscapularis; patient is unable to hold hand on abdomen when hand is forcibly being pulled away or unable to compress belly and actively forward push the elbow against resistance. Also called anterior lift-off t. and Napoleon t.



  • Booth t.: for transverse humeral ligament rupture; with pressure on biceps groove, the arm is abducted and externally rotated. A snap indicates subluxation of the biceps tendon caused by ligament insufficiency. Also called Marvel t.



  • Bryant s.: for dislocation of the shoulder with lowering of the axillary folds, as noted on visual examination.



  • Cahill and Palmer t. for quadrilateral space syndrome, forward flexion and/or abduction and external rotation of the humerus aggravate the symptoms.



  • Callaway t.: for dislocation of the humerus; the circumference of the affected shoulder measured over the acromion and through the axilla is greater than that on the opposite, unaffected side.



  • circumduction t.: for posterior shoulder instability; to bring the shoulder passively from an abducted and extended position to anterior adduction position results in subluxation in the provocative anterior position. Not to be confused with circumduction maneuver for the knee to determine torn meniscus.



  • Codman s.: for rupture of the supraspinatus tendon; the arm can be passively abducted without pain, but when support of the arm is removed and the deltoid muscle contracts suddenly, pain occurs again.



  • Comolli s.: for scapular fracture; shortly after injury, there is triangular swelling, reproducing the shape of the body of the scapula.



  • crank t.: for anterior shoulder instability; the supine patient has the shoulder abducted and externally rotated. On full external rotation, there is apprehension and resistance, similar to apprehension test.



  • cross-chest t.: for acromioclavicular joint arthritis; passively or actively bringing the affected arm across the chest causes pain in the acromioclavicular joint region. Also called cross-body abduction m., forced adduction t., and cross-body adduction t.



  • Dawbarn s.: for acute subacromial bursitis; with arm hanging by side, palpation over the bursa causes pain; when the arm is abducted, pain disappears.



  • drawer t.: for shoulder instability; the patient may be sitting or lying. The scapula and clavicle are held securely in one hand and the head of the humerus in the other; the humeral head is pushed forward and backward to compare the two sides for crepitus and ligamentous stability. Also called load and shift t.



  • drop-arm t.: for rotator cuff tear; the patient is unable to actively control bringing the arm down from a full abducted position past 90 degrees. The arm drops at 90 degrees. This test is best performed with a local anesthetic injected into the subacromial space.



  • Dugas t.: for dislocation of the shoulder; placing hand of affected side on opposite shoulder and bringing elbow to side of chest, a dislocation may be present if the patient’s elbow will not touch side of the chest; also called Dugas s.



  • Fowler t.: for anterior shoulder instability; patient lies supine and the shoulder is held in an abducted and externally rotated position using the edge of the examining surface as a fulcrum. Posterior force is then applied to the humerus. Relief of apprehension is a sign of anterior instability; also called push-pull t.



  • fulcrum t.: for anterior-inferior shoulder instability; patient lies supine and the shoulder is held in an abducted and externally rotated position. The arm is then further abducted and extended using the edge of the examining surface as a fulcrum (support).



  • Gerber t.: for subacromial impingement; forward elevation of the arm while adducted and internally rotated causes anterior shoulder pain.



  • Hamilton t.: for luxated shoulder; a rod applied to the humerus can be made to touch the lateral condyle and acromion at the same time to determine a dislocation.



  • Hawkins impingement s.: for rotator cuff disorder; forward flexion of humerus to 90 degrees followed by horizontal adduction and internal rotation produces pain.



  • hornblower s.: a patient with a rotator-cuff tear of the infraspinatus or teres minor is unable to bring both hands to the mouth without abducting the affected arm, indicating a weakness of external rotation. Also seen as weakness of external rotation at 90 degrees of abduction; also called Patte s., trumpet s.



  • impingement s.: the examiner forces the shoulder into flexion and internal rotation with downward pressure on the acromion produced by the other hand. Pain is a positive sign of impingement.



  • impingement t.: after a subacromial injection of an anesthetic such as lidocaine, the shoulder becomes pain free or significantly less painful when taken through the motion to produce the impingement sign. A positive result may indicate bursitis, impingement, or rotator cuff disease.



  • jerk t.: for posterior shoulder instability; when the supine patient has the shoulder flexed to 90 degrees with the elbow at 90 degrees, pressure in a posterior direction causes a jerk or jump with subluxation. By bringing the humerus out of flexion and back midline at 90 degrees of abduction, the humeral head will noticeably “clunk” back to its reduced position within the glenoid.



  • Jobe t.: for supraspinatus pathologic conditions; standing patient is asked to actively abduct the shoulder to 90 degrees and forward flex 30 degrees with thumbs down. Pain occurs if patient is asked to push arm toward the ceiling; also called supraspinatus isolation t.



  • Kim t.: for posteroinferior labral pathologic conditions. Pain is elicited through an arc of motion with the examiner placing an axial force on a forward-flexed shoulder.



  • Kocher m.: for reducing anterior dislocations of the shoulder; done by abducting the arm, externally rotating, adducting, and then internally rotating.



  • lift off t.: for rupture of the subscapularis in the shoulder, when placing the back of their hand on the middle of their back the patient in unable to lift their hand from their back.



  • load-and-shift t.: with the patient supine and the shoulder slightly abducted on the edge of the examining table, the humeral head is shifted anteriorly and posteriorly while the forearm or scapula is stabilized by the examiner’s opposite hand. This is a method of determining shoulder joint laxity or instability when compared side to side.



  • Ludington s.: for integrity of the long head of the biceps tendon; patient interlocks hands overhead and then presses hands together. Failure of biceps contraction implies long head rupture.



  • Milch m: for anterior shoulder dislocation reduction; with one hand on the acromion to support thumb pressure on humeral head, the arm is abducted and externally rotated followed by pressure on humeral head to reduce over glenoid rim.



  • Mimori t.: for superior labral tears; the sitting patient has the shoulder abducted to 90 to 100 degrees, externally rotated with the elbow at 90 degrees, and the forearm supinated. If there is an increase in pain with forearm pronation, the test is positive for a tear.



  • modified lift-off t.: inability to keep the arm in a position posterior to or not touching the back when placed there by the examiner and released, indicating weakness or a pathologic condition of the subscapularis.



  • Napolean t.: for subscapularis rupture, with the patient’s hand placed on their abdomen, they cannot resist the examiner pulling the hand away from the abdomen.



  • Neer impingement s.: for rotator cuff disorder; examiner passively flexes humerus to maximal forward flexion with one hand while depressing the scapula with the other to produce pain.



  • Neer impingement t: injection of the subacromial bursa eliminates pain elicited with Neer s. The terms Neer test and Neer sign are often used without discrimination.



  • Neviaser t.: for proximal triceps tendonitis; with shoulder fully adducted, tenderness over origin of triceps is increased with subsequent active elbow extension against force.



  • O’Brien t.: for superior labral tear the patient points the thumb down with the shoulder flexed to 90 degrees and adduct across midline. Resistance against further shoulder flexion causes pain with the thumb pointing down. If pain was present with the thumb down but relieved with the thumb up, it is considered a positive test.



  • O’Driscoll superior labrum anterior to posterior (SLAP) t.: for SLAP tear. With the patient supine, the examiner abducts the shoulder to 90 degrees and allows external rotation of the shoulder to its natural limit. The shoulder is then elevated. A click may be palpated, or pain may be produced. The shoulder is then returned following full overhead elevation, again looking for pain or a click.



  • posterior lift-off t.: for rupture of subscapularis muscle; weakness of internal rotation is demonstrated by inability of patient to lift hand from back. Also called modified lift off t.



  • push-pull t.: for anterior shoulder instability. Also called Fowler t.



  • release t.: for anterior instability of the shoulder; supine patient with arm abducted at 90 degrees and maximally externally rotated with posterior direct pressure on humeral head is comfortable. Release of humeral head pressure causes apprehension or subluxation; also called apprehension t.



  • relocation t.: for occult anterior shoulder subluxation in throwers; patient lies supine, the shoulder is held in abducted and externally rotated position using the edge of the examining surface. Posterior force is then applied to the humerus with relief of pain apprehension or symptoms of shoulder instability. Less specific when pain is the only symptom.



  • rubber band s.: weakness and pain with resisted external rotation with the humerus slightly abducted and hands facing forward indicating infraspinatus tendon pathologic condition.



  • scapular assistance t.: for shoulder impingement syndrome. The examiner elicits pain with forward flexion of the humerus to 90 degrees with internal rotation. A positive test occurs when there is relief of pain when this maneuver is repeated while holding the scapula against the posterior chest wall.



  • scapular dyskinesis s.: with active forward elevation of the arm comparing to the opposite side, the side with rotator cuff impingement, instability, or neurologic injury will often show a noticeable asymmetry of scapular function manifested most often by a medial border of the scapula winging or protruding. Although sensitive, this sign is not particularly specific for any pathologic condition.



  • scapular sign of Putti: for contractures about the scapula; when the arm is forcibly drawn into the chest and externally rotated, the superior lateral side of the scapula wings out; also called Putti s.



  • Single Assessment Numerical Evaluation (SANE) : for quantitatively assessing patient’s improvement following procedures; patient is asked “How would you rate your affected joint/region as a percentage of normal (0 to 100% scale with 100 being normal)?”



  • Speed t.: for proximal long head of biceps tendonitis; anterior proximal humeral pain created with humerus forward flexed against force while elbow is in full extension.



  • sulcus s.: for inferior shoulder instability; a downward longitudinal force is applied to the humerus of a resting arm with relaxed shoulder girdle, creating a noticeable sulcus between the acromion and the humeral head. The thumb of the opposite hand can press into the lateral subacromial area, indicating a developing sulcus.



  • swallow-tail s.: for deltoid muscle function; extension of both arms posteriorly results in a lag on the side that has axillary nerve palsy.



  • Toronto test score : to predict recovery from infant brachial plexus injury; active movements of the elbow flexion/extension, wrist extension, fingers extension, and thumb extension graded from 0 to 2 for a cumulative score 10. Score 3.5 or less at 3 month predicts poorer outcome.



  • Yergason t.: for pathologic conditions of the proximal long head of biceps or subluxation of the long head of the biceps tendon; while pulling distally on the elbow, the patient holds it flexed at 90 degrees with supination and forced external rotation of the shoulder against resistance by the examiner. Painful subluxation of the tendon can be palpated.



Upper Limbs and Elbow





  • Cozen test: for tennis elbow (lateral epicondylitis); the examiner stabilizes the patient’s elbow with the thumb while palpating the lateral epicondyle. The patient is then asked to actively make a fist and pronate their forearm, then radially deviate and extend the wrist as the examiner applies a counterforce. Pain near the lateral epicondyle signifies a positive test.



  • elbow flexion t.: for cubital tunnel syndrome (ulnar nerve compression at elbow); the examiner holds the elbow in passive maximal flexion. Tingling in the ring and little finger is positive for ulnar nerve irritation.



  • gravity stress t.: for medial instability; the supine patient has the externally rotated arm out over the edge of the table. With elbow at 20 degrees, the weight of the forearm reveals the laxity.



  • hook t.: While the patient actively supinates with the elbow flexed 90 degrees, an intact hook test permits the examiner to hook his or her index finger over and behind the intact distal biceps tendon in the antecubital fossa. Inability to “hook” the tendon indicates a distal biceps rupture.



  • Laugier s.: for a displaced distal radial fracture; condition in which the styloid process of radius and ulna are on same level.



  • lateral key pinch s.: for ulnar nerve palsy wherein the patient must compensate for index finger adductor tendon flexor loss by pressing the thumb on the radial side of the index finger.



  • Meyn and Quigley m.: for dislocation of the elbow; the patient lies prone with the arm resting on the examining table and the elbow flexed at 90 degrees. The forearm is pulled distally while the opposite hand guides the olecranon.



  • Mills t.: for tennis elbow; with wrist and fingers fully flexed and the forearm pronated, complete extension of the elbow is painful.



  • Parvin m.: for dislocated elbow; the patient lies prone with the arms and forearm over the edge of the examining table. Traction is applied on the wrist in a distal direction while the opposite hand pushes on the anterior distal arm in a posterior direction.



  • Popeye deformity: loss of continuity of either the proximal or distal attachments of the biceps brachii resulting in a balled-up appearance of the biceps in the front of the upper arm similar to the depicted flexed biceps muscle of the cartoon caricature after which it is named.



  • posterolateral instability of elbow: for lateral ulnar collateral ligament laxity; with patient supine, shoulder flexed to 90 degrees, elbow extended, the forearm is supinated with a concurrent valgus stress. The instability will increase at 40 degrees of elbow flexion. Also called pivot shift of elbow.



Hands and Wrist





  • Allen t.: for occlusion of radial or ulnar artery; a method of determining if radial and ulnar arteries communicate through the two palmar arches. Both arteries are occluded digitally. First one artery is released, then the other, to observe pattern of capillary refill in the hand. This can be performed with a Doppler placed on the digits during test. The test is valuable prior to an invasive procedure on the arteries at the wrist.



  • André Thomas s.: in low ulnar nerve palsy; in an effort to extend the fingers, flexing the wrist using the tenodesis effect will increase the claw.



  • axial compression t.: for thumb carpometacarpal joint arthritis; thumb is compressed with rotation causing pain in that joint.



  • ballottement t.: assesses triquetrolunate dissociation; stabilize the lunate with one hand, the triquetrum with the other. Displace one from the other dorsally and volarly. If there is crepitus, pain, and extreme laxity, the test is positive.



  • benediction attitude s.: for paralysis of the anterior interosseous branch of the median nerve; in the resting hand the index finger and thumb are held in full extension.



  • benediction s.: in low ulnar nerve palsy; there is metacarpophalangeal hyperextension, proximal and distal interphalangeal joint flexion in the fourth and fifth digits, and the index and middle fingers are relatively spared.



  • Boston carpal tunnel questionnaire: for pre and post-operative assessment of carpal tunnel syndrome; functional status assessed on a scale of 0 to 40 (eight items rated 0 to 5) and symptom severity rated on a scale of 0 to 55 points for pain (eleven items rated 0 to 5).



  • Bouvier m.: in low ulnar nerve palsy; passively preventing metacarpophalangeal hyperextension will allow proximal and distal interphalangeal extension.



  • Boyes t.: for boutonnière deformity; with full extension of the proximal interphalangeal joint of the finger, there is decreased distal interphalangeal flexion compared with the contralateral finger.



  • bracelet t.: for early rheumatoid arthritis involving the distal radioulnar joint; compression of the lower ends of the ulna and radius elicits moderate lateral pain.



  • Carducci t.: for boutonnière deformity; with full metaphalangeal and wrist flexion there is 15- to 20-degree loss of proximal interphalangeal extension compared with the contralateral finger.



  • carpal compression t.: compression of the carpal tunnel for as long as 30 seconds will produce or exacerbate symptoms of carpal tunnel syndrome. A sphygmomanometer bulb can gauge the proper pressure of approximately 150 mm Hg.



  • circumduction m.: for the thumb; any general test or motion involving a rotation action of a group of joints; a range-of-motion examination.



  • claw hand s.: in lower ulnar nerve palsy, there is metacarpophalangeal hyperextension with proximal and distal interphalangeal flexion, and intrinsic minus posture in all palmar digits. These may be static or dynamic.



  • confrontational t.: for intrinsic muscle weakness of the hand; the strength of specific muscle or muscle groups is compared by pressing the thumb or finger against opposite thumb or finger in a fashion to produce resistance against those muscles. Weakness is indicated by an inability to oppose the compared digits with equal strength (i.e., one side gives out).



  • Duchenne s.: in low ulnar nerve palsy with extrinsic muscles intact; the ring and little fingers will claw with metacarpophalangeal hyperextension and flexion of the middle and distal phalanges.



  • Durkan t.: median nerve compression for 30 seconds at the wrist exacerbates symptoms in carpal tunnel syndrome.



  • Elson middle slip t.: for ruptured central extensor tendon slip of the proximal interphalangeal (PIP) joint; the finger is flexed to 90 degrees. If the central slip is intact, the patient can extend the PIP joint, but the distal interphalangeal (DIP) joint is flail. Otherwise, the PIP joint will not have extension power, and the DIP joint will extend while in that position.



  • extrinsic tightness t.: to assess extrinsic extensor tendon adherence or foreshortening; passive metacarpophalangeal (MCP) joint flexion will cause MCP joint hyperextension. MCP flexion will force the PIP joint into extension.



  • Finkelstein s.: bending the thumb into the palm to determine synovitis of the abductor pollicis longus tendon to wrist. Passively flexing and ulnar deviating the wrist with the thumb in full opposition will elicit pain over the first dorsal extensor compartment in de Quervain disease.



  • Fowler m.: for testing rheumatoid arthritis; tight intrinsic muscles in ulnar deviation of the digits and a heavy, taut ulnar band are demonstrated when the digit is held in its normal axial relationship.



  • Froment s.: for ulnar nerve loss; there is paralysis of the adductor pollicis and first dorsal interosseous and second palmar interosseous. The flexor pollicis longus flexes the interphalangeal joint up to 90 degrees to effect power pinch. Also called paper pull out test.



  • Guilliatt tourniquet t.: to diagnose carpal tunnel syndrome; a tourniquet is placed on the upper arm of affected limb. Inflate cuff to a point above the systolic pressure to 220 mm Hg. Arm pain normally occurs within 2 to 3 minutes. Tingling in the median nerve distribution of thumb, index, and long finger will occur in 30 to 60 seconds in carpal tunnel syndrome.



  • grip-strength t.: to measure the strength of coordination of intrinsic and extrinsic finger and thumb flexors; a grip dynamometer is used.



  • Hutchinson s.: seen in malignant melanoma; lesion under a fingernail or toenail in which the pigment extends into the proximal nail fold.



  • intrinsic tightness t: to assess adherence or contracture of intrinsic muscles with metacarpophalangeal joint passively extended. Active or passive proximal interphalangeal flexion is limited.



  • Jeanne t.: in ulnar nerve palsy; with adduction, pollicis dysfunction with metacarpophalangeal hyperextension will result with key pinch or gross grip.



  • Kanavel s.: for infection of a tendon sheath; there is a point of maximum tenderness in the palm 1 inch proximal to the base of the little finger. In pyogenic tenosynovitis, the four signs are a flexed position of the finger, symmetric fusiform enlargement of the fingers, marked tendon sheath tenderness, and pain on passive digital extension.



  • Kapandji thumb opposition score: for ability to oppose thumb; with fingers extended, increasing ability to oppose from base of index to the finger tip, graded 1 to 3; 4, opposition to long finger tip; 5, opposition to ring finger tip; 6 to 8, opposition from tip of little finger to base; 9, opposition to palm distal to flexion crease; 10, opposition to palm proximal to flexion crease.



  • key pinch: the strength in the ability to grasp, as in holding a key; see also pulp pinch.



  • Kleinman shear t.: to assess triquetrolunate disability. Stabilize the lunate with a thumb placed on the dorsum of the lunate. If the test is positive, the pisotriquetral joint is pushed dorsally from the volar side with pain, crepitus, and increased motion.



  • Lichtman t.: in nondissociative midcarpal instability; a painful clunk is elicited with passive (and sometimes active) ulnar deviation of the wrist. The clunk occurs as the hamate reduces on the triquetrum and the entire proximal row rotates rapidly from its flexed to an extended position.



  • long finger extension t.: for radial (supinator) tunnel compression; the patient holds wrist at 30 degrees extension while extending all fingers. The examiner attempts to press on the dorsum of the long finger to produce the dorsal forearm symptoms.



  • Lovett t.: for boutonnière deformity; with full metaphalangeal and wrist flexion there is decrease in proximal interphalangeal extension strength compared with the contralateral finger.



  • Maisonneuve s.: for Colles fracture; there is marked hyperextensibility of the hand.



  • masses s.: in ulnar nerve palsy; there is flattening of the metacarpal arch and hypothenar atrophy caused by intrinsic dysfunction with loss of metacarpophalangeal flexion of the fifth digit.



  • modified Mayo wrist score: for assessing wrist pain, assesses flexion and extension arc, grip strength, and ability to resume activities; evaluator assesses pain intensity (25 points), functional status (25 points), range of motion (25 points), and grip strength (25 points) to tabulate a composite score out of 100. Higher scores indicate better result.



  • Murphy s.: for scaphoid fracture or lunate dislocation; tapping on the index metacarpal head causes pain with navicular fracture and tapping long finger metacarpal head causes pain with lunate dislocation.



  • Oshsner clasping t.: for high median nerve paralysis; the index finger will not flex when clasped hands are brought together.



  • paper pull out t.: for instability metatarsal phalangeal joint due to volar plate disruption, while standing on piece of paper under the affected part the examiner can pull out the paper.



  • Phalen t. or Phalen m.: for carpal tunnel syndrome; irritation of the median nerve is determined by holding the wrist flexed or extended for 30 to 60 seconds, reproducing symptoms.



  • piano key s.: test for distal radioulnar joint instability; the wrist is pronated, the radius and ulna are grasped in examiner’s hands, and moving each bone up and down relative to the other, a painful movement indicates instability.



  • Pitres-Testut s.: for ulnar nerve paralysis; the patient is unable to make a cone shape with the hand and fingers because of intrinsic muscle weakness.



  • Pollock s.: in high ulnar nerve palsy; inability to flex the distal interphalangeal joints of the fourth and fifth digits with paralysis of the flexor digitorum profundus to fourth and fifth digits.



  • Prehension t.: the ability to grasp with the fingers and thumb in opposition.



  • pseudostability t.: for carpal bone stability; in the normal wrist, if the hand is held in one hand and the distal forearm in the other, there is a normal anterior posterior translation. This translation is lost in carpal bone instability.



  • pulp pinch: the strength in the position one would use to pick up a piece of paper. See also key pinch.



  • scaphoid t.: for dynamic scapholunate instability; the examiner places his or her thumb under the scaphoid tubercle, moving wrist from ulnar to radial deviation. The scaphoid flexes against the thumbs in an upward push causing a painful clunk at the scapholunate articulation; also called a Watson t.



  • shuck t.: for perilunate instability examiner hold wrist in flexion and patient extends fingers. For TFCC instability, examiner holds radial side wrist held in one hand and puts anterior posterior force on distal ulna.



  • Smith and Ross t.: for boutonnière deformity; with passive metaphalangeal joint and wrist flexion, there is passive posterior interphalangeal extension if the central slip is intact, and a greater than 20-degree lag if there is central slip rupture.



  • spilled teacup s.: in perilunate dislocation; the lunate will assume a volar flexed posture as seen on lateral radiographs. A spectrum exists from normal lunate position to complete volar dislocation of the lunate.



  • table top t.: for timing of surgery in Dupuytren contracture; the patient has limitation putting hand flat on table top.



  • tenodesis t.: to check structure integrity of the extrinsic extensors; extreme wrist flexion will passively extend the metacarpophalangeal joints, whereas wrist extension will allow passive digital proximal and distal interphalangeal flexion. This is due to resting tension of extrinsic extensor and flexor groups, respectively.



  • Terry Thomas sign: for scapholunate ligament disruption, separation of the lunate from the scaphoid seen on AP radiograph.



  • tuck s.: the puckering seen just proximal to a mass of chronically inflamed dorsal tenosynovium. This is accentuated by digital extension and commonly seen in rheumatoid arthritis.



  • two-point discrimination t.: measures innervation density under the skin. Static two-point discrimination t. is for slowly adapting fibers; moving two-point discrimination t. is for rapidly adapting fibers. It is the ability to distinguish one point and two points with eyes closed. (Normal range is 1–5 mm.)



  • ulnar fovea s.: for split tear of the ulnar triquetral ligament or foveal disruption of the radial ulnar ligament; direct pressure between the flexor carpi ulnaris and the distal ulnar styloid (fovea) produces exquisite pain.



  • Wartenberg s.: for intrinsic muscle weakness of the hand; while the fingers are extended there is an inability to bring together the ring and little finger. In ulnar nerve palsy with interosseous paralysis, there is an inability to adduct the extended fifth digit to fourth digit; also called oriental prayer s.



  • Watson t.: for scapholunate instability; the examiner can elicit a painful wrist click by compressing the scaphoid while the patient moves the wrist; also called rotary click t.



  • wet leather s.: subcutaneous palpable crepitus or squeaking with movement of tendons affected by tenosynovitis.



Hips





  • Allis m.: for reduction of anterior hip dislocation; the supine patient has the knee flexed, hip slightly flexed with longitudinal traction, and an assistant stabilizes the pelvis while applying a lateral traction force to the medial thigh. The surgeon then adducts and internally rotates the femur.



  • Allis s.: for femoral neck fracture or congenital dislocation hip; there is relaxation of the fascia between the crest of the ilium and the greater trochanter.



  • anvil t.: for early hip joint disease or diseased vertebrae; a closed fist striking a blow to the sole of the foot with leg extended produces pain in the hip or vertebrae.



  • Barlow t.: for dysplastic hip in infants; holding the symphysis pubis to sacrum with one hand, the opposite hip is flexed and an attempt is made to dislocate the hip. Pulling the hip back up or abducting the hip should produce a perceptible reduction.



  • Bigelow reduction m.: for posterior dislocation of the hip. The hip is flexed and adducted. While traction is maintained, the femoral head is levered into the acetabulum by abduction, external rotation, and extension of the hip.



  • Bozan m.: for reducing femoral neck fractures; a large swathe is placed around the crest of the ilium of the affected limb and a small swathe in the inguinal fold; traction, abduction, and internal rotation forces are then applied.



  • Chapple t.: for infant congenital hip dislocation; the hips cannot be abducted past 45 degrees while in flexion.



  • Chiene t.: for determining fracture of the neck of the femur by use of a tape measure.



  • Desault s.: for intracapsular fracture of the hip; alternation of the arc described by rotation of the greater trochanter, which normally describes the segment of a circle, but in this fracture, rotates only as the apex of the femur rotates about its own axis.



  • Destot s.: in a pelvic fracture; there is the formation of a large superficial hematoma beneath the inguinal ligament and in the scrotum.



  • Deyerle m.: for femoral neck fracture reduction; patient placed in traction with over-distraction and external rotation. The leg is then internally rotated with some traction release and inward pressure on the greater trochanter to reduce and impact fracture site.



  • Earle s.: for pelvic fracture; bony prominence or hematoma associated with tenderness on rectal examination.



  • East Baltimore m.: for posterior hip dislocation; two-person reduction maneuver with patient supine and hip in 90 degrees flexion. Also called East Baltimore lift.



  • Ely t.: for determining tightness of the rectus femoris, contracture of the lateral fascia of the thigh, or femoral nerve irritation; with patient in prone position, flexion of the leg on the thigh causes buttocks to arch away and leg to abduct at the hip joint; also called Nachlas knee flexion t.



  • Galeazzi s.: for congenital dislocation of the hip; the dislocated side is shorter when both thighs are flexed to 90 degrees, as demonstrated in infants; in an older patient, a curvature of the spine is produced by shortened leg.



  • gear-stick s.: for femoral head deformity of dysplastic hip or Legg-Calvé-Perthes disease; thigh abduction is full in flexion, but as the hip is extended with the hip abducted, there is impingement between the greater trochanter and ilium.



  • Jansen t.: for osteoarthritic deformity of the hip; the patient is asked to cross the legs with a point just above the ankle resting on the opposite knee. If significant disease exists, this motion is impossible.



  • King m.: for femoral neck fracture reduction; on fracture table, the affected leg is in traction with pressure placed on the posterior thigh with internal rotation. Lateral traction with a groin sling may be added.



  • Langoria s.: for symptoms of intracapsular fracture of the femur; relaxation of the extensor muscles of the thigh is present.



  • Leadbetter m.: for slipped capital femoral epiphysis or femoral head fracture; injured hip is flexed to 90 degrees and manual traction applied to axis of the flexed thigh with adduction. The leg is then circumducted slowly to abduction maintaining internal rotation, and then the thigh and leg are brought down to the horizontal level.



  • Lefkowitz m.: for posterior dislocation of the hip. The patient’s hip and knee are flexed, with the patient’s leg over the provider’s flexed knee. A downward force is applied to the patient’s foot while the provider raises the knee, reducing the hip.



  • Ludloff s.: for traumatic separation of the epiphysis of the lesser trochanter; swelling and ecchymosis are present at the base of Scarpa triangle, together with inability to raise the thigh when in a sitting position.



  • McCarthy s.: for labral tears; with both hips flexed the patient’s pain is reproduced by extending the hip in external rotation first, followed by extending the hip in internal rotation. Also, there is inguinal pain with flexion, adduction, and internal rotation.



  • McElvenny m.: for femoral neck fracture reduction; with 36- to 45-kg traction, the hip is abducted and internally rotated. Medial to inferior force is produced over the greater trochanter, and then the hip is adducted.



  • Nélaton l.: for detecting dislocation of the hip; there is a line from the anterosuperior iliac spine to the ischial tuberosity, which normally passes through the greater trochanter. Term is also used in radiology.



  • Ober t.: for tight tensor fascia lata; with patient lying on side with hip and knee flexed, the opposite hip is extended while the knee is flexed. Inability to place the knee being tested on the table surface indicates a tight fascia lata.



  • obturator s.: inward rotation of the hip so that the obturator internus muscle is stretched. Results may be positive in acute appendicitis.



  • Ortolani t.: for congenitally dislocated hip; an audible click is heard when the hip goes into the socket as noted in infancy. If the sign is elicited, the dislocation should be corrected at that time to avoid hip dysfunction later; also called Ortolani click.



  • Patrick t.: for pathologic conditions of the sacroiliac joint; the patient’s hip is placed into abduction, flexion, and external rotation, and pain is elicited with further forced abduction. Also called FABERE t.



  • piston s.: for congenital dislocation of the head of the femur; if positive, there is up-and-down movement of the head of the femur; also called Dupuytren s.



  • post-total hip internal rotation t.: for assessing hip dislocation risk after capsular healing; hip is flexed to 90 degrees and then internal rotation to end point. Internal rotation of 15 degrees or less indicate that hip dislocation precautions can be discontinued.



  • reverse Bigelow m.: for anterior dislocation of the hip; two maneuvers are done, both starting in hip flexion and abduction. In the first maneuver, while lifting the lower leg of the supine patient, there is a quick jerk on the flexed thigh; the second maneuver involves traction in the line of deformity with the hip then being adducted, sharply internally rotated, and extended.



  • Roux s.: in a pelvic lateral compression fracture, there is a distance between the greater trochanter and pubic spine on the affected side.



  • Schobers t.: for assessing lumbar spine mobility and diagnosing ankylosing spondylitis; Patient is instructed to move from the erect standing to maximally bent forward position as the examiner measures distance change (cm) between a horizontal line at the height of the lumbosacral junction and a second horizontal line 10 cm above the lumbosacral junction.



  • Smith m.: for reduction of femoral neck fractures; thigh is externally rotated and placed in traction, then fully abducted, internally rotated, and subsequently adducted.



  • Stimson m.: for posterior hip dislocation; the patient is placed prone on a table with the involved hip flexed and the opposite hip extended. With the involved knee flexed downward, pressure is applied to the calf, resulting in reduction of the dislocation.



  • Thomas s.: for hip joint flexion contracture; when the patient is walking, the fixed flexion of the hip can be compensated by lumbar lordosis. With the patient supine and flexing the opposite hip, the affected thigh raises off the table; also called Strümpell s. and Thomas t.



  • Trendelenburg t.: for muscular weakness in poliomyelitis, ununited fracture of the femoral neck, rheumatoid arthritis, coxa vara, and congenital dislocations. With the patient standing, weight is removed from one extremity. If gluteal fold drops on that side, it signifies muscular weakness of the opposite weight-bearing hip; also called Trendelenburg s.



  • Wellmerling m.: for femoral neck fracture reduction; the affected hip is overdistracted by 0.64 cm (¼ inch) in external rotation, and the foot is then internally rotated and traction released.



  • Whitman m.: for femoral neck fracture reduction; the hip is flexed and then extended with traction being applied and the normal hip abducted. The affected side is then abducted and a spica cast applied.



Lower Limbs





  • Achilles squeeze t.: for Achilles tendon rupture; with patient prone and knees flexed, squeezing the calf muscle fails to produce plantar flexion of the ankle joint; also called Thompson t. and Simmons t.



  • Addis t.: for determination of leg-length discrepancy; with patient in prone position, flexing the knees to 90 degrees reveals the potential discrepancies of both tibial and femoral lengths.



  • anterior tibial s.: for spastic paraplegia; involuntary extension of the tibialis anterior muscle when thigh is actively flexed on the abdomen.



  • Cleeman s.: for distal fracture of femur with overriding of the fragments; shows creasing of the skin just above the patella.



  • Homan s.: pain in calf on dorsiflexion of foot (active or passive). Once considered a reliable test in diagnosing deep vein thrombophlebitis but no longer considered valid.



  • Payr s.: early sign of impending postoperative thrombosis, indicated by tenderness when pressure is placed over the inner side of the foot.



  • Schlesinger s.: for extensor spasm at the knee joint; with patient’s leg held at the knee joint and flexed strongly at the hip joint, there will follow an extensor spasm at the knee joint with extreme supination of the foot.



  • tourniquet t.: for phlebitis of the leg; tourniquet is applied to the thigh and pressure gradually increased until the patient complains of pain in the calf; result is compared with the effect on the opposite leg.



Knees


( Table 4-1 )




  • active glide t.: the appearance of lateral excursion of the patella greater than proximal excursion, with quadriceps contraction, indicates an increased functional Q angle.



  • anterior cruciate instability t.: with the knee flexed, a supine patient extends the knee slowly with the foot against the table surface; there is a sudden anterior shift of the tibia. This test might be confused with a quadriceps active test for posterior cruciate ligament injury, which gives the same forward motion of the tibia on the femoral condyles, but from a posterior subluxed position to a reduced position. In the case of the anterior cruciate instability test, the forward motion of the tibia begins from a position of a reduced joint and subluxes anteriorly.



  • Apley t.: for differentiating ligament from meniscal injury; with a prone patient and the knee flexed 90 degrees, tibial rotation while applying compression results in pain caused by meniscal pathologic findings and is generally specific to the side of the meniscal injury. Articular injury or chondromalacia may result in a positive Apley t.; also called Apley grind t.



  • arthrometer t.: mechanical testing device for measuring anteroposterior ligament stability of the knee. The arthrometer is most often used in a physician’s office to document the outcome of anterior cruciate ligament replacement surgery.



  • ballotable patella t.: for knee effusion; with knee extension, pushing patella onto distal femoral surface results in rebound caused by swelling.



  • bayonet s.: lateral placement of infrapatellar tendon with a valgus knee produces a bayonet appearance in the quadriceps-patellar-tendon complex.



  • bounce home t.: for bucket-handle tear of meniscus; passive pressure past maximum active extension results in a bounce back to more flexion.



  • British t.: for knee pain or injury; compression of patella during active quadriceps contraction as knee is extended elicits pain. Generally specific for patellofemoral chondromalacia or pathologic condition.



  • bulge s.: for knee effusion; fluid is pressed into the superior pouch and then medially or laterally, resulting in a fluid bulge.



  • camelback s.: an unusually prominent infrapatellar fat pad of the knee and hypertrophy of the vastus lateralis.



  • Childress t.: for torn meniscus; when duck walking, the supporting leg will have pain on the side of the torn meniscus.



  • cross-over t.: for anterior cruciate ligament laxity; with patient’s permission, the examiner stands on the foot of the affected side of standing patient. When the patient attempts to cross the opposite leg over the knee there is a sense of the knee feeling unstable.



  • dial t.: for posterolateral corner and posterior cruciate instability; isolated posterior cruciate instability will allow 15 degree plus increased passive external rotation of the foot and ankle when the knee is flexed at 90 degrees. Posterolateral corner instability will have 15 degree or greater increased external rotation of the foot and ankle at 30 degrees; also called Cooper t.



  • double camelback s.: prominence of a high-riding patella and infrapatellar fat pad, producing the appearance of a camelback.



  • double PCL sign: on magnetic resonance imaging there appears to be two posterior cruciate ligaments due to a displaced bucket handle meniscal tear seen on midline sagittal images of the knee. There is a low-signal-intensity band that is parallel and anteroinferior to the ligament.



  • drawer s.: may be anterior or posterior for ligamentous instability or ruptured cruciate ligaments; with the patient supine and knee flexed to 90 degrees and the foot plantigrade on the table, the sign is positive if the tibia can be delivered either anteriorly or posteriorly beyond normal when compared with the uninjured knee. Excessive anterior drawer indicates an incompetent anterior cruciate ligament whereas excessive posterior drawer is a sign of posterior cruciate ligament injury.



  • drive through sign: described in posterior knee arthroscopic portal, easier insertion is a sign of posterior cruciate ligament injury. In shoulder arthroscopy the ability to easily pass the scope at the level of anterior band of the inferior glenohumeral ligament is a sign of shoulder laxity. In elbow arthroscopy, if a ligament or other structure that would restrict vision is ruptured, it will allow for further arthroscopic advancement.



  • drop-back phenomenon: for posterior cruciate rupture; posterior sag of tibia in relationship to distal femur when knee is flexed and patient is at rest; also called sag s.



  • extension lag: a sign of patella or quadriceps tendon rupture; there is an injury-related change in the ability of the patient to actively extend the knee.



  • external rotation drawer t.: with the foot held in external rotation, an anterior drawer test is completed. A slight increase in anterior drawer is found in normal knees, whereas a larger amount of anterior laxity is indicative of anterior cruciate ligament and medial collateral ligament injury.



  • external rotation recurvatum t: with the patient supine, lifting the entire leg off the table by the great toe results in a posterior sag and external rotation of the tibia in reference to the normal alignment of the leg, indicating a posterior cruciate ligament tear with or without a posterior lateral ligamentous injury as well.



  • Fairbank s.: for subluxating patella; with the affected knee in extension the examiner pushes the patella in a lateral direction, causing apprehension.



  • figure 4 t.: placing the knee in a figure four position, the lateral collateral ligament (LCL) can often be palpated coursing from the fibular head to the lateral epicondyle and checked for integrity. When injured, this position puts stress on the LCL and can result in pain in the presence of an injury to the lateral and posterolateral ligamentous structures.



  • Finacetto s.: Lachman test with tibial subluxation beyond the posterior horns of the meniscus indicates a severe anterior cruciate ligament deficiency and instability.



  • flexion rotation drawer t.: with the knee extended and the thigh relaxed, there is anterolateral tibial subluxation. The knee is gradually flexed with reduction of the subluxation occurring at approximately 30 degrees of flexion. Roughly synonymous with pivot shift test as it relates to evidence of anterior cruciate ligament insufficiency and is less painful to most patients. Also called Noyes t.



  • Fouchet s. (Allis t.): for tibial or femoral insufficiency, with the patient supine and knees flexed with equal rotation of the tibia, a short tibia can be distinguished for a short femur.



  • Godfrey t.: for posterior cruciate ligament laxity; with patient supine and the knee and hip flexed at 90 degrees and the examiner supporting heel, the proximal tibia is more posterior on the affected side. Best seen on a side-to-side comparison; also called sag t.



  • grand piano s.: the appearance of the trochlear surface after the anterior femoral cut has been made in preparation for the femoral prosthetic component. If the rotation of the femoral guide is correct, that cut surface should have two times greater exposed bone on the lateral than on the medial side, appearing like a grand piano seen from above.



  • grimace t.: for knee pain or crepitus; if compression of the patella elicits pain or crepitus is noted, the patient will grimace.



  • heel height difference: for knee flexion contracture; prone patient in knee extension has different level of heels; also called prone hanging t.



  • heel-to-buttocks difference: for swelling or obstruction of flexion; the heel is further from the buttocks in flexion compared with the unaffected side; also called symmetrical extension t.



  • Helft t.: for proximal tibiofibular instability; the standing patient is asked to gradually flex the involved knee. If laxity exists the person will cross the opposite leg and foot behind the affected knee to stabilize it.



  • hop t.: for anterior cruciate examination; patient hops forward on affected knee. Ability to do this is one sign of adequate anterior cruciate stability. Also called one-legged hop t.



  • Hughston jerk t.: for anterolateral instability of the knee; noted by starting at 90 degrees flexion with tibia internally rotated and applying valgus force while rotating fibula medially. There is a jerk at approximately 20 degrees from full extension.



  • internal-rotation drawer t.: with the foot internally rotated, an anterior drawer test should in a normal knee result in less anterior displacement, whereas a looser drawer is found in anterior cruciate ligament–deficient knees. Also called anterior drawer s.



  • J s.: bringing the knee into extension results in a lateral deviation of the patella thought to reproduce the track of an inverted J, which may indicate patellar instability or maltracking.



  • Lachman t.: with the patient supine and the knee flexed to 20 degrees, the tibia is pulled anteriorly. A lack of a solid endpoint to when the anterior cruciate ligament (ACL) reaches its limit of length indicates a probable ACL tear. It is important to always compare the injured knee to the normal knee to determine the extent and feel for a normal end-point. Also called Noulis t.



  • lack of extension s.: a perceptible lack of passive full extension in the early postinjury period following an anterior cruciate ligament (ACL) tear; the possible result of soft tissue impingement in the intercondylar notch from the tibial sided remnant of the torn ACL.



  • loss of extension t.: for anterior cruciate injury, in the absence of extensor mechanism injury, when compared to the uninjured knee the patient is unable to fully extend the knee when in a supine position.



  • Losse t.: for posterolateral laxity; the supine patient has the affected knee held at 30 degrees flexion with the distal leg on the examiner’s chest and the examiner’s opposite thumb behind the head of the fibula and fingers on the patella. As the thumb pulls the fibular head forward, the knee is gradually extended and a shift should occur as the plateau subluxes anteriorly.



  • McMurray t.: internal and external tibial rotation while moving from a starting point of maximal flexion into extension results in pain isolated to the side of meniscal pathologic condition. In general, internal rotation of the tibia results in lateral meniscus tear symptoms whereas external rotation results in medial meniscus pathologic symptoms; also called McMurray s.



  • medial subluxation t.: for tight lateral patellar retinaculum; the patella is pressed in a medial direction with the knee at full extension and then at 30 degrees of flexion. More than 15 mm of medial displacement in flexion implies that the patella tracks laterally because of a tight retinaculum.



  • Merke s.: for meniscal tear; the standing patient will have a meniscal tear on the medial side if there is pain on internal rotation, and a tear on the lateral side if there is pain on external rotation.



  • no touch t.: for checking patellar stability after total knee joint replacement and for anterior cruciate instability; with the patient supine and the knee flexed, there is a sudden anterior shift of the tibia when the patient extends the knee slowly with the foot on the surface; also called quadriceps active t.



  • patellar apprehension t.: pushing patella laterally, the most common direction of instability, results in patient apprehension for symptoms of patellar instability.



  • patellar glide t.: for maltracking of the patella; the sitting patient is asked to extend the knee and the tracking of the patella is observed. Maltracking is typically in a lateral direction.



  • patellar grind t.: described as being for chondromalacia patella; this is a nonspecific test in which the patella is pressed into the trochlea on active or passive knee extension from flexion. Pain may be from the patella or from regional synovium; also called Fouchet s.



  • patellar retraction t.: for synovitis; compression of patella causes pain when the patient attempts to set the quadriceps muscles with the knee in full extension.



  • patellar tilt t.: for lateral retinacular tightness; examiner tries to lift up the outside edge of the patella (kneecap) using his thumb. The patella should not be pushed to the inside or the outside. Inability to lift implies tight retinaculum.



  • pivot-jerk t.: a lesser utilized test for anterior cruciate ligament insufficiency wherein the knee goes from a position of anterolateral femoral tibial reduction to an anterolateral shift when taking the knee from flexion to extension while applying a valgus movement with internal tibial rotation. Also called pivot shift t.



  • pivot-shift t.: with the knee extended, the examiner internally rotates the leg and with a valgus stress gradually flexes the knee. There is a shift at 30 to 40 degrees of flexion, from anterolateral subluxation to a reduced knee, which is the result of the mechanical advantage of the hamstrings in pulling the tibia posteriorly behind a flexed knee. Patient relaxation is key for optimal results, and, although it can be achieved outside the operating room, results are best noted under anesthesia. Also called MacIntosh t.



  • posterior drawer t.: with the hips at 45 degrees and the knees flexed at 90 degrees the examiner sits on the foot and pushes the tibia backward; also with the hips and knees flexed at 90 degrees the heels are held together and the two knees observed for comparison of relative posterior sag of the tibia.



  • prone external rotation t.: for posterior cruciate knee rupture; with the patient prone and knees flexed at 30 degrees, the test is considered positive for rupture if the foot externally rotates more than 15 degrees compared with the normal side. Increasing the flexion to 90 degrees with an accompanying further increase of external rotation difference, when compared side to side, indicates the presence of a posterior cruciate ligament injury as well; also called dial t.



  • prone hanging (prone hang) t.: for knee flexion tightness, with patient prone, knee resting on the end of the examination table, the height of the heels is measured.



  • quadriceps active t: with the patient supine, the involved knee is flexed at 90 degrees and the foot rests on the table. With one hand, the examiner supports the thigh and palpates the relaxed quadriceps muscle; the other hand stabilizes the foot. When the patient is asked to slide the foot down the table, the proximal leg is pulled forward to its posteriorly subluxed resting point by the patellar tendon, indicating a posterior cruciate tear with resulting posterior sagging of the leg.



  • reverse pivot-shift t.: with the patient supine, the lateral tibial plateau shifts from posterior subluxation to reduction as the knee is brought from flexion to extension. Also called Jacob t. and jerk t.



  • sag sign: for posterior cruciate rupture, with the patient supine and the knee flexed to 90 degrees, the tibial appears more posteriorly displaced compared to the unaffected knee.



  • screw-home mechanism: the small degree of external rotation that occurs as the knee is brought to the last few degrees of extension.



  • Slocum t.: for rotary instability of the knee; the examiner pulls on the upper calf of a supine patient with the knees flexed 90 degrees. Then, while sitting on the patient’s foot, the examiner pulls anteriorly, comparing the amount of give with the foot turned in 15 degrees neutral and turned out 30 degrees.



  • standing apprehension t.: for anterior cruciate laxity; with patient standing and knee slightly flexed, examiner’s hand holds the knee firmly with the thumb pushing the lateral femoral condyle medially, resulting in motion.



  • Steinmann t.: for medial meniscal tear; on the supine patient the knee is held flexed at 90 degrees, the calf held firmly, and the tibia rotated internally and externally. Sharp medial pain implies a meniscal tear.



  • symmetrical extension t.: a noticeable difference in the back of the knee to examination table with the patient in the supine position or in prone heel height indicates an extension deficit that can be the result of contractures, bucket-handle meniscal tears, mechanical block, or ligamentous injury. Also called lack of extension test for ACL injury.



  • Thessaly t: for meniscal injury; with support, the patient stands and rotates the knee and body internally and externally three times, keeping the knee flexed at 20 degrees. Joint-line discomfort medial or lateral is a positive test.



  • thumbnail t.: for patellar fracture; fracture is felt as a sharp crevice when the examiner’s thumbnail is passed over the subcutaneous surface of the patella.



  • tibial sag s.: a noticeable posterior sag of the tibia in reference to the femoral condyles with the knee flexed 90 degrees and the foot plantigrade on the examination table. This test and sign is best noted when both limbs are symmetrically placed and a side-to-side difference is visualized. This may be thought of as a passive posterior drawer.



  • tilt t.: for lateral retinacular tightness; examiner tries to lift up the outside edge of the patella (kneecap) using his thumb. The patella should not be pushed to the inside or the outside. Inability to lift implies tight retinaculum.



  • towel clip t.: for patellar subluxability in joint replacement surgery; the vastus medialis and medial retinaculum is approximated to the medial border of the patella using a towel clip or a stitch. The knee is taken through a range of motion. Any elevation of the medial edge of the patella is considered a positive test for a tight lateral retinaculum.



  • Trotter bulge t.: for knee swelling; massaging pressure on medial side of knee may make swelling move superiorly so that pressure from above may make fluid more apparent on return to medial side.



  • varus recurvatum t.: for posterior lateral instability, with the patient supine, the examiner presses down on the distal femur while hyperextending the knee and applying a varus stress.



  • valgus stress t.: although this term is commonly applied to the knee, the test may also be done on the elbow. The upper part of the limb is supported while a laterally directed force is produced on the distal limb. If knee laxity is found in full extension, both the anterior cruciate and medial collateral ligaments are compromised. If there is laxity at only 30 degrees, there is an isolated medial collateral ligament tear.



  • valgus thrust t.: for isolated medial collateral ligament rupture, the knee is flexed at 30 degrees and with the examiner’s hand on the lateral knee there is sudden lateral pressure applied to the ankle.



  • varus stress t.: although this term is commonly applied to the knee, the test may also be done on the elbow. The upper part of the limb is supported while a medially directed force is produced on the distal limb. If knee laxity is found in full extension, both the anterior cruciate and lateral collateral ligaments are compromised. If there is laxity at only 30 degrees, an isolated medial collateral ligament tear or posterolateral corner injury is likely.



  • vertical patella t.: during knee joint replacement surgery the patella is initially everted to 90 degrees in relation to the femoral component and then translated medially so that its lateral border is past the middle of the intercondylar groove of the femoral component while still everted. The inability to translate it past the midpoint of the intercondylar groove of the femoral component suggests a tight lateral retinaculum.



  • Wilson s.: with knee extended from 90 degrees to 30 degrees with valgus stress and internal rotation of the foot, a click is heard in cases of osteochondritis dissecans. The pain is relieved by externally rotating the tibia. Loss of the sign is an index of healing.


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Dec 24, 2021 | Posted by in ORTHOPEDIC | Comments Off on Orthopaedic Tests, Signs, and Maneuvers

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