Specialized musculoskeletal examination

Author(s): Robert A. Lavin, MD

Originally published:09/20/2013

Last updated:03/24/2017

1. OVERVIEW AND DESCRIPTION

Specialized musculoskeletal tests

  1. Examine the structural integrity of joints, muscles, and tendons
  2. Assess joint stability, strength, and provoke pain from damaged and inflamed musculoskeletal structures
  3. May elicit a painful response from damage to adjacent joint-associated structures (bones, muscles, tendons, ligaments, joint capsules, labra, and synovia)
  4. Should always be performed within the context of a complete history and physical exam, including mechanism of injury, psychosocial history, and functional impairments

A complete review of all of these tests is beyond the scope of this article. This review emphasizes commonly cited tests for cervical, shoulder, pelvis and hip disorders, as these are areas of greatest clinical complexity where combinations of special tests may be more accurate.

2. Relevance to Clinical Practice

Patient is standing in anatomical position for all tests unless otherwise stated. The authors’ decision to include specific tests was primarily based on frequency cited in the literature, validity and clinical utility. Blank boxes indicate an absence of specificity/sensitivity data.

BODY PART
Test Structure being assessed Maneuver Positive Response Sensitivity
Specificity
(%)
Ref.

CERVICAL
Spurling’s/Foraminal Compression
nerve root compression
Neck extended,  laterally flexed and compressed by examiner Pain distant from neck in radicular distribution 30-77
92-100
1,2,3
Lhermitte’s sign
dural/meningeal irritation of spine
Neck is flexed with hips flexed and legs extended. Pain radiates down spine into arms or legs. < 28 97 1,2,3
Shoulder Abduction
radicular compression
Abduct arm on affected side and rest hand on head. Decrease in radicular symptoms 43-50
80-100
1,2,3
Brachial Plexus Tension
radicular compression
In supine position, depress shoulder, then abduct, extend, and externally rotate arm, supinate forearm up to but do not induce pain, then extend elbow and wrist. Radicular symptoms – cervical flexion and lateral bending toward contralateral arm may exacerbate radicular symptoms; lateral bending toward ipsilateral arm may reduce radicular symptoms. 77

94

1,2,3
Cervical Distraction
radicular decompression
Examiner lifts patient’s head, supporting patient’s chin and occiput with each hand. Reduction in radicular symptoms 26
100
1,2,4

THORACIC OUTLET
Adson’s
thoracic outlet syndrome
Examiner palpates radial pulse. Rotate and extend patient’s head toward affected side, extend arm on affected side and patient takes deep inspiration. Loss of radial pulse. 94
18-87
1,2,4

SHOULDER
Hawkins-Kennedy Impingement
Supraspinatus tendinitis
Arm flexed forward at 90 degrees then forced internal rotation of shoulder Pain due to supraspinatus tendon impingement by coracoacromial ligament 47-88
26-89
5,6,7
Jobe (Empty Can)
Supraspinatus tendinitis/rotator cuff tear
Shoulder abduction to 90 degrees in neutral and resisted downward by examiner. If no pain, then internally rotate arm and move anteriorly 30 degrees. Pain due to supraspinatus tendon impingement or muscle tear 31-99
39-100
5,6,7
Neer Impingement
Supraspinatus tendinitis, biceps tendinitis, inferior instability of humeral head in glenoid fossa, adhesive capsulitis, arthritis
Stabilize posterior scapula, internally rotate arm and forcibly forward flex shoulder Pain due compression of anterior acromion and greater trochanter of humerus 54-83
10-95
5,6,7
Gerber Lift-Off
Subscapularis strength/tendon rupture
Internally rotate shoulder so that hand is behind back with palm facing away from back, then patient pushes away from back against resistance. Weakness 6-92
23-95
2,5,6
Hornblower’s
Teres minor strength
Abduct arm to 90 degrees and flex elbow to 90 degrees, then patient rotates arm externally against resistance. Weakness 95 – 100
92 – 93
2, 5
Speed’s
Bicipital tendinitis (long head)
Shoulder is forward flexed to 90 degrees. Forearm is supinated and elbow is extended. Resistance is applied downward. Tenderness/pain localized to the biceps groove 28-71
35-85
2,5,6
Drop Arm
Rotator cuff tear
Shoulder is abducted to 90 degrees passively by examiner, then patient lowers arm slowly Inability to lower arm or severe pain 8-74
66-98
2,5,6
O’Brien’s
AC joint and labral pathology
Shoulder flexed to 90 degrees and the elbow fully extended, the arm is adducted across midline with the shoulder internally rotated (thumb points down). The patient then resists downward force against flexion. The test is repeated with the shoulder externally rotated (palm points up). Pain with shoulder in internal rotation (thumb down); no pain with external rotation (palm up) 21-100
14-98.5
1,6
Apprehension (Crank)
Anterior instability
Patient lies supine, abduct arm to 90 degrees and flex elbow to 90 degrees, then externally rotate shoulder 90 degrees. Apprehension due to sensation of imminent anterior dislocation of humeral head out of glenoid fossa. 29-72
42-96
2,6

LUMBAR
Lasegue’s (Straight Leg Raising)
L5 -S1 Radiculopathy
Patient supine and passively flex hip. Hip should be internally rotated and adducted, and knee extended. When patient complains of pain or tightness, lower leg then (a) flex cervical spine and/or (b) flex ankle. Reproduction of pain and/or paraesthesias radiating below the knee at 30 to 70 degrees hip flexion. If no pain below the knee, then consider tight hamstring muscles or SI joint pathology. 72-97
10-66
1
Crossed Straight Leg Raise
Lumbar Radiculopathy
Patient supine and passively raise unaffected contralateral leg with knee extended (similar to maneuver in straight leg raising test). Pain and paraesthesias radiating down affected leg 22-29
88-100
1
Femoral Nerve Traction
Mid-lumbar radicular compression
Lying on unaffected side with lower leg slightly flexed and back straight. Upper symptomatic leg is extended at hip then knee is flexed. Radicular symptoms over anterior thigh, may extend down medial calf in L2 – L4 distribution. 2

PELVIS
Gillet’s (Stork)*
SI joint pathology
Patient stands and the bilateral posterior superior iliac spines (PSIS) are palpated, then the patient stands on one leg and flexes the non-weight-bearing hip and knee. The PSIS does not move on the non-weight-bearing leg relative to the PSIS of the weight-bearing leg. The PSIS on the non-weight-bearing leg normally moves inferiorly relative to the PSIS on the weight-bearing leg. .28-.57

.56-.80

2,8
Gaenslen’s SI*
joint pathology, Hip joint pathology, L4 root lesion
Patient supine with one side at the edge of the exam table. The leg closer to the middle of table maximally flexes hip and knee so the lumbar spine is stabilized and flattened against the table. Contralateral hip extended off the side of the table with the knee flexed and force exerted on the knee further extending this hip. Variation: side lying with the flexed leg down and examiner pulls extended leg backward. Pain in hip joint, SI joint, or referred pain/paraesthesias in distribution of L4 root .27-.81

.16-.89

2,8
Posterior Shear (Thigh Thrust)*
SI joint pathology
Patient supine with tested side hip and knee flexed. Examiner applies force through femur. Pain localized to ipsilateral SI joint .26-.99

.39-.84

2,8
Distraction (Gapping)*
SI joint pathology
Patient supine and force directed in posterior and lateral direction is applied through bilateral anterior superior iliac spines (ASIS). Pain occurs over the affected SI joint.  The examiner should avoid causing pain over ASIS during this maneuver. Pain attributed to stretching anterior SI ligaments .11-.80

.65-.91

2,8
Patrick’s (FABER)*
Hip joint pathology, Tight iliopsoas, SI joint pathology
Patient supine with hip Flexed, ABducted, and Externally Rotated (FABER) with the foot placed just proximal to the contralateral knee. Examiner forces ipsilateral leg into additional external rotation and abduction while stabilizing contralateral ilium so the leg falls to the level of the contralateral leg. Leg remains elevated due to hip joint pain, tight iliopsoas muscle, or low back, buttock, or SI joint pain. .42-.81

.08-.89

2,8
Piriformis
Tight piriformis muscle, sciatic pain
Patient lying on side with test leg up, hip flexed to 60 degrees, and knee flexed. Examiner immobilizes the upper hip and forces the test leg down. Pain noted over buttocks in distribution of the piriformis muscle, and the sciatic nerve may be impinged. 2

HIP
Thomas
Hip flexion tightness
Patient lies supine holding both hips and knees maximally flexed with lumbar spine flat against exam table, then the patient extends one limb. If the extended limb cannot fully straighten or the lumbar spine extends during this maneuver, then the test is positive for ipsilateral hip flexion contracture. 2
Ely
Rectus femoris tightness
Patient lies prone and knee is passively flexed. Ipsilateral hip flexes 2
Ober’s
Iliotibial band tightness
Patient lies on side. Lower leg has hip and knee flexed, and upper leg, which is being tested, is flexed at the knee. The hip of the upper leg is abducted and extended. Upper leg remains abducted and is unable to be lowered to the table. 2
Trendelenberg
Weak gluteal muscles
Patient stands on affected side with opposite leg non-weight bearing Hip/pelvis on non-weight-bearing side drops relative to weight-bearing side, indicative of weak gluteal muscles on weight-bearing side. 72.7
76.9
1

KNEE
Lachman’s
Anterior Cruciate Ligament (ACL) pathology
Patient supine with knee flexed 30 degrees and heel on exam table. Examiner immobilizes femur with one hand and translates tibia forward with other hand. (Note: There are multiple modifications of this test.) Soft end feel suggestive of injury to ACL, posterior oblique ligament, or arcuate-popliteus complex. 60 – 100
55-100
2, 9
McMurray’s
Meniscus pathology
Medial Meniscus: Patient is supine. Hip and knee are fully flexed, while ankle and tibia are externally rotated. This external rotation is maintained while knee is extended. Lateral meniscus test is similar with ankle and tibia internally rotated and internal rotation is maintained during knee extension. Pain, click/pop/thud, or inability to fully extend the knee are all positive for lateral or medial meniscus pathology. Medial Test
16-88
50-98;
Lateral Test
25-79
20-94
2, 10
Anterior Drawer
Anterior Cruciate Ligament pathology, posterolateral capsule, posteromedial capsule, medial collateral ligament, iliotibial band, posterior oblique ligament, arcuate-popliteus complex
Patient supine, hip flexed to 45 degrees with knee flexed to 90 degrees. Examiner sits on foot with hands behind proximal tibia and provides anterior force in repetitive rocking motion while evaluating displacement. Posterior drawer test involves similar positioning with use of posterior force on proximal tibia Increased tibial displacement compared to contralateral knee is suggestive of partial or complete ACL tear or laxity. Generally, additional structures are damaged along with the ACL for the test to be positive. The Posterior Drawer test assesses posterior cruciate ligament  and popliteus injuries. 18-95
23-97
1,2,9
Pivot Shift
Anterior Cruciate Ligament pathology, posterior lateral capsule, arcuate-popliteus complex, lateral collateral ligament, iliotibial band
Patient supine with hip flexed and abducted 30 degrees. Extend knee, internally rotate foot, then flex knee while applying valgus stress. Initially there is subluxation, and when knee is flexed tibia reduces on femur 29-98
89 – 100
1,2,9

* There are no imaging “gold standard” for sensitivity and specificity for SI joint pathology, so these tests are compared to the ability of anesthetic injections to block pain symptoms.

3. Cutting Edge/Unique Concepts/Emerging Issues

Accuracy, reproducibility, and validity of individual tests are controversial, although combinations of tests are likely to be more accurate. Individual tests probably detect pain from more than one pathoanatomical structure; therefore, multiple tests performed in the context of an overall examination are more useful than relying on a single test to diagnose a specific structural pathology. Comparison with contralateral side or limb may also be helpful. Three or more positive tests for SI pathology improves predictive power compared to intra-articular injection tests. Evaluation of combinations of specific musculoskeletal tests for improved diagnostic accuracy and validity is an emerging area of research.

4. Gaps in Knowledge/Evidence Base

Wide ranges of values for sensitivities and specificities reflect problems with quality and standardization.

Quality of studies can be problematic because:

  1. Blinded studies are rare.
  2. Few studies use appropriate comparison groups.
  3. Acuity, severity, and age of populations tested affect findings.
  4. Recruitment bias in surgical populations that are preselected for likely pathology.
  5. Use of different musculoskeletal test criteria to determine a positive test (e.g., any pain, localized pain, weakness)
  6. Lack of standardized physical examinations and variations in test maneuvers.
  7. Sensitivity and specificity are based on different validating criteria (imaging, surgical findings, response to injections). There is no gold standard because structural abnormalities noted on imaging studies may not correlate with physical exam findings, and the validity of joint injections is uncertain since adjacent structures may also be inadvertently anesthetized.
  8. Interpretation of specialized musculoskeletal tests depends on proper technique, skill, experience, and clinical judgement.
  9. While use of multiple provocative tests is probably more predictive of pathology, the exact combination and number of provocative musculoskeletal tests to improve diagnostic accuracy remains unclear.

References

  1. Braddom RL. Physical Medicine and Rehabilitation. 4th ed. Philadelphia, PA: Elsevier; 2011:20-25, 817-911.
  2. Magee DJ. Orthopedic Physical Assessment. 6th ed. St. Louis: Elsevier; 2014.
  3. Ghasemi M, Golabchi K, Mousavi SA, Asadi B, Rezvani M, Shaygannejad V, Salari M. The value of provocative tests in diagnosis of cervical radiculopathy. J Res Med Sci. 2013;18:S35-8.
  4. Malanga GA, Landes P, Nadler SF. Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician, 2003;6:199-205.
  5. Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008;42:80-92.
  6. Hegedus EJ. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br. J Sports Med. 2012;46:964-969.
  7. Michener LA, Walsworth MK, Doukas WC, Murphy KP. Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Arch Phys Med Rehabil. 2009;90(11):1898-903.
  8. Szadek KM, van der Wurff P, van Tulder MW, et al. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. Journal of Pain. 2009;10:354-368.
  9. Jackson JL, O’Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med. 2003;139:575-588.
  10. Hing W, White S, Reid D, et al. Validity of the McMurray’s test and modified versions of the test: a systematic literature review. J Man & Manip Ther. 2009;17:22-35.

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Original Version of the Topic

Robert A. Lavin, MD, Ryan K. Murphy, DO. Specialized musculoskeletal examination. 2013/09/20.

Author Disclosure

Robert A. Lavin, MD
Nothing to Disclose

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