Transcript DIAGNOSTIC TESTS FOR ORTHOPEDIC CONDITIONS

TESTS FOR
ORTHOPEDIC
CONDITIONS
Gilbert Madriaga, PTRP
With excerpts from Prof. Mitch Encabo’s files
LEARNING OBJECTIVES
At the end of the session the students should be able to:

Define diagnostic tests and special tests

Explain the purpose of diagnostic tests and special
tests
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Determine principles involved in special tests
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Determine guidelines and contraindications in
performing the tests
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Explain the significance of tests for orthopedic
conditions
DIAGNOSTIC TESTS
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Individual tests that are used to focus the examination
Detects conditions not appropriate for physical therapy
management
Help identify the specific nature of a condition by
gathering data from the examination
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History
OI and palpation
Flexibility and muscle tests
Special test
Functional assessment
Laboratory procedures
DIAGNOSTIC TESTS

Special Test
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Tests that determine whether a particular type of
disease, condition, or injury is present
Also known as:
 Clinical accessory tests
 Provocative or structural tests
PURPOSE
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To confirm a tentative diagnosis
To make a differential diagnosis
To differentiate between structures
To understand unusual signs
To unravel difficult signs and symptoms
PRINCIPLES
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Inflamed structures
Compressed structures
Vascular disorders
Contractures and tightness
Muscle paralysis
Miscellaneous tests
PRINCIPLES
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Inflamed structures
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Active contraction of an inflamed structure
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stretch of inflamed contractile or relatively non-contractile
tissues
PRINCIPLES
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Compressed structures
 A maneuver that causes an inflamed structure to be compressed
will elicit pain
 Additional pressure applied over a trapped or compressed neural
structure results in an increase in the neuropathic pain or
neurological symptoms
 When a maneuver relieves the pressure over a compressed
neural structure there is a relief of the neuropathic pain or
neurological symptoms
PRINCIPLES

Vascular Structures
 Compression of a peripherally located artery diminishes blood
flow distal to the site of compression
 Results in:
 Disappearance of a distal pulse
 Appearance of signs and symptoms of vascular ischemia
 When arterial compression is released or removed, arterial
circulation is immediately reestablished
 Immediate change of skin pallor to flushing or redness
PRINCIPLES

Contractures and Tightness
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A tight muscle will pull the joint in the direction of
its primary action
A muscle tightness or contracture will lead to LOM
in the direction opposite the primary action of the
affected muscle
PRINCIPLES
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Contractures and Tightness
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When a tight or contracted muscle is forcibly
lengthened or stretched, pain will be felt along the
tight muscle or its tendon
When the forcibly lengthened muscle is placed in
a shortened position, pain immediately disappears
PRINCIPLES
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Paralysis
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In the presence of paralysis the body attempts to
find a substitute muscle or movement to
compensate for the lost function
GUIDELINES
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Does not necessarily rule out a disease or
condition if tests are negative
Should not be used in isolation
Tests are only adjuncts to the physical
examination and clinical history
Do not perform all the tests
Most special tests have not been tested for
validity and reliability
GUIDELINES
Test Selection
 The test has a very sound basis
 The reliability of the test is backed up by
extensive research
 Applicability of the test
 Popularity of the familiar test
 Ease of application
 Identify if the test is a duplication or
modification of established tests
Cervical Region
Cervical Region
History
Initial Hypothesis
Patient reports diffuse nonspecific
Mechanical neck pain[1]
neck pain that is exacerbated by neck Cervical facet syndrome[2]
movements
Cervical muscle strain or
sprain
Patient reports pain in certain
postures that is alleviated by
positional changes
Upper crossed postural
syndrome [3] [4]
Traumatic mechanism of injury with Cervical instability, especially
complaint of nonspecific cervical
if patient reports that
symptoms that are exacerbated in the dysesthesias of the face
vertical position and relieved with the occur with neck movement[5]
head supported in supine position
Cervical Region
History
Reports of nonspecific neck pain
with numbness and tingling into
one upper extremity
Initial Hypothesis
Cervical radiculopathy
Reports of neck pain with bilateral Cervical myelopathy
upper extremity symptoms and
occasional reports of loss of
balance or lack of coordination of
the lower extremities
Cervical Region
Spurling vs. Distraction test
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Spurling’s test/ Foraminal Compression Test
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Pressure on nerve root
Radicultis: pain in dermatomal distribution of the
nerve root affected
Distraction test
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Alleviate radicular signs
Lhermitte’s test
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Meningeal irritation or cervical myelopathy
Cervical region
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Other tests
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ULTTs
Shoulder abduction test
Vertebral artery test
Sharp-Purser test
Thoracolumbar region
History
History
Initial Hypothesis
Reports of restricted motion of the
Zygapophyseal joint
lumbar spine associated with low back pain syndromes [8] [9]
or buttock pain exacerbated by a
pattern of movement that indicates
possible opening or closing joint
restriction (ie, decreased extension,
side bending right, and rotation right)
Reports of centralization or
Discogenic pain[10]
peripheralization of symptoms during
repetitive movements, or prolonged
periods in certain positions
Thoracolumbar region
History
History
Reports of lower extremity
pain/paresthesias that are greater than the
low back pain. Patient may report episodes
of lower extremity weakness
Initial Hypothesis
Sciatica or
lumbar
radiculopathy[11]
Pain in the lower extremities that is
exacerbated by an extension posture and
relieved by flexion posture of the spine
Spinal
stenosis[12]
Thoracolumbar region
History
History
Patient reports recurrent locking, catching,
or giving way of the low back during active
motion
Initial Hypothesis
Lumbar
instability [13] [14]
Reports of low back pain that is exacerbated Muscle/ligament
by stretch of either ligament or muscles.
ous sprain/strain
Also, possibility of pain with contraction of
muscular tissues
Neurodynamic tests in the
lumbar spine
Slump test
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Most common neurological test for the lower
limb
Reproduction of patient’s pathological
symptom
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Nonpathological responses
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Pain or discomfort T8-T9
Pain or discomfort behind knee and hamstrings
Restriction of passive joint motions
**hands behind the back
Hamstring Tightness vs Sciatic
Nerve irritation
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Straight Leg Raise (SLR)
Lasegue’s Test
Hamstring Tightness
Sciatic nerve irritation
SLR
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0°-35°
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35°-70°
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Slack in sciatic arborization taken up during this
range. No dural movement
35°- tension at sciatic roots
Sciatic roots tense over IV disc during this range. Rate
of deformation diminishes as angle increases
70° - L5, S1, S2 completely stretched
70°-90°
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Practically no further deformation of roots occurs
during further SLR
SLR
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Considerations for
patients with L4-L5
disc herniation
(nerve roots L4-S3)
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Central protrusion
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Intemediate protrusion
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Pain on low back
Pain low back and leg
Lateral protrusion
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Posterior leg, pain below
the knee
SLR
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Well-leg raising test of
Fajerstajn/ cross over
sign
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Large IV disc
protrusion, medial to
the nerve root
(Woodhall and Hayes, 1950)
SLR variants
Joint
Hip
Knee
Ankle
Foot
Toes
Nerve
Bias
SLR
Flx and
Add
Ext
DF
SLR2
Flx
SLR3
Flx
SLR4
Flx
Ext
DF
Eversion
Ext
DF
Inversion
Ext
DF
Inv
Extension
Sciatic
Tibial
Sural
nerve and nerve
nerve
tibial
nerves
Common
Peroneal
Nerve
Prone Knee Bending
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Indicates L2 or L3 nerve root lesion
Also stretches femoral nerve
45 to 60 seconds
Brudzinski-Kernig test
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Brudzinski
Kernig
Brudzinski-kernig
Dural/ meningeal Irritation
Nerve root Irritation
Range of motion
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Schober’s Test
10 cm above
5 cm below
Range of motion
Intrathecal Pressure
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Milgrams Test
Hoovers Test
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Malingerer
5-10 cm
30 seconds
Narrowing of IV foramina
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Quadrant Test
Narrowing IV foramen
Facet problems
Facet Problems
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Stork Standing Test
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Stress fracture of pars interarticularis
Tests for lumbar instability
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Lumbar instability
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During movement, the patient loses the ability to
control movement for a brief time (ms) or the
segment is structurally unstable
Segmental Instability test
Pheasant Test
Tests for Muscle Tightness
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Thomas test
Ober test
90-90 SLR Test
Rectus Femoris Test
Clinical decision making
on what special tests to
use for patients with LBP
ORTHOPEDIC TESTS
FOR THE SHOULDER
History
Patient reports of lateral/anterior shoulder pain
with overhead activities or demonstration of a
painful arc
Initial Hypothesis
Possible subacromial
impingement [4] [5]
Possible tendonitis[6]
Possible bursitis[6]
Patient reports of instability, apprehension, and
pain with activities most often when shoulder is
abducted and externally rotated
Shoulder instability[4]
Possible labral tear, if
clicking is present [7]
[8]
Decreased ROM and pain with resistance
Possible rotator cuff
or long head of the
bicep tendonitis[9]
History
Initial Hypothesis
Patient reports of pain and weakness with
Possible rotator cuff
muscle loading, night pain. Age >60
tear [6] [9]
Patient complaints of poorly located shoulder
Possible adhesive
pain with occasional radiation into elbow. Pain is capsulitis[10]
usually aggravated by movement and relieved by
rest. Age >45. Females more often affected than
males
Patient reports of a fall on the shoulder followed Possible AC sprain[4]
by pain over AC joint
Patient complaints of upper extremity heaviness Possible thoracic
or numbness with prolonged postures and when outlet syndrome [11]
[12]
lying on involved side
Possible cervical
radiculopathy [6] [13] [14]
Range of Motion
Apley’s Test for the shoulder
Tests for Impingement
Test for impingement
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Neer
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Jamming of greater tuberosity against the
anteroinferior border of the acromion
Hawkins-Kennedy
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Pushes supraspinatus to anterior surface of the
coracoacromial ligament and coracoid process
Tests for muscle/ tendon
pathology
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Suprapinatus Test or Empty Can Test
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Tear of supraspinatus tendon or suprascapular
nerve
Drop Arm Test
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Rotator cuff tear
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> 50+
Younger people
Bicipital Tendinitis
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Speeds test
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Inflammation of bicipital tendon (tendinosis or
paratenonitis)
Yergasons test
Subscapularis
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Lift off sign
Shoulder Instability
Unstable
Stable
Apprehension and Relocation
Feagin’s test
Sulcus test
Labral Tears
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Clunk test
O Brien’s test
ORTHOPEDIC TEST
FOR THE ELBOW
Medial and Lateral Epicondylitis
Tennis Elbow
Tennis Elbow Test
 Cozen’s Test
 Mill’s test
 Method 3
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Maudsley’s test
(Fairbank and Corlett, 2004)
Golfers Elbow
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Golfer’s Elbow Test
ORTHOPEDIC TEST
FOR THE WRIST AND
HAND
Overuse Injuries
Ligament rupture
Conditions Determined on OI
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Dupuytren’s Contracture
Heberden’s and Bouchard’s nodes
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Finkelstein Test
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Phalen’s Test
Prayers Test
Anterior Interosseous Nerve
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Froment’s Sign
Froment’s Test
ORTHOPEDIC TEST
FOR THE HIP AND
PELVIS
Sacroiliac Joint
Hip Joint
Sacroiliac Dysfunction vs Hip
Muscle Spasm
Patrick’s Test or FABER Test
 Hip joint affectation
 Iliopsoas spasm
 Sacroiliac joint spasm
Sacroiliac Dysfunction
HUWAG PO
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SI Gap test
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Unilateral gluteal or posterior leg pain
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SI Rock test
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Pain in SI jt
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Sprain anterior sacroiliac joint
Stress sacrotuberous ligaments
Gaenslen’s test
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Pain over LE being tested
Ipsilateral SI joint lesion
Hip pathology or L4 nerve root lesion
CHD
Barlow’s test
Up to 6 months “Click of dislocation”
Ortolani’s test
Click of reduction
CHD
Galleazi Sign
“Alli’s test”
Effective from 3-18 mo
Telescoping sign
Gluteus Medius Weakness
Trendelenburg Test
ORTHOPEDIC TEST
FOR THE KNEE
Knee Instability
Patellofemeral Problems
Functional tests
History
Patient Reports
Initial Hypothesis
Patient reports a traumatic onset of Possible ligamentous injury [1] [2]
knee pain that occurred during
(anterior cruciate)
jumping, twisting, or changing
Possible patellar subluxation[2]
direction with foot planted
Possible quadriceps rupture
Possible meniscal tear
Patient reports traumatic injury that Possible PCL injury (posterior
resulted in a posteriorly directed
cruciate)[3]
force to tibia with knee flexed
Patient reports traumatic injury that Possible collateral ligament injury
resulted in a varus or valgus force (fibular or tibial)[3]
exerted on the knee
History
Patient Reports
Patient reports anterior pain with
jumping and full knee flexion
Initial Hypothesis
Possible patellar tendonitis [2] [4]
Possible patellofemoral pain
syndrome [5] [6]
Patient reports swelling in knee
with occasional locking and
clicking
Patient reports pain with prolonged
knee flexion, during squats, and
while going up and down stairs
Possible meniscal tear[7]
Possible loose body within knee
joint
Possible patellofemoral pain
syndrome [5] [6]
Patient reports pain and stiffness in Possible osteoarthritis (OA) [8] [9]
the morning that diminishes after a
few hours
Inspection and Palpation
Inspection and Palpation
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Ballotement Test
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Floating of patella
Trophic Skin Changes
Trophic Skin Changes
Trophic Skin Changes
Palpation
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Anterior pain
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Inferior pole of the patella
Patellar tendinitis
Patellofemoral Dysfunction
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Grind test/ Clarke’s
Test
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Clarke’s test
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Control pressure applied
Patellofemoral dysfunction
Knee Instability
Common tests performed on
the knee
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One-plane medial instability
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One-plane lateral instability
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Varus stress
One-plane anterior instability
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Valgus stress
Lachman test; drawer test
One-plane posterior instability
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Posterior sag; drawer test
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Anteromedial rotary instability
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Anterolateral rotary instability
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Pivot shift test
Posteromedial rotary instability
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Slocum test
Hughston’s posteromedial drawer test
Posterolateral rotary instability
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Hughston’s posteromedial drawer test
Knee instability
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Test unaffected knee first
Muscles must be relaxed
Appropriate stress must be applied gently
Observe the degree and quality of opening
(endfeel)
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Abrupt stop or endfeel – ligament is intact
Soft or indistinct endfeel – ligamentous injury
Acute or chronic?
ONE PLANE ANTERIOR
INSTABILITY
Anterior drawer test
Ant Drawer Test for the
knee
Anterior drawer test
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Normal movement – 6mm
If the test is positive, ff may be injured:
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ACL
Posterolateral capsule
Posteromedial capsule
Medial capsule (deep fibers)
ITB
Posterior oblique ligament
Arcuate-popliteus complex
Lachmann test
Lachmann Test
Lachmann test
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Best indicator of injury to the ACL
Positive sign indicates injury on the ff
structures:
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ACL
Posterior oblique ligament
Arcuate-popliteus complex
ACL Tear
Modified Lachmann Test
One plane posterior instability
tests
PCL Tear
Posterior Drawers Test
Godfrey’s test
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
Posterior drawer test
Following may be injured:
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Posterior cruciate ligament
Arcuate-popliteus complex
Posterior oblique ligament
ACL
Meniscal Tear
Meniscal Tear
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Mc Murray Test
Lateral Meniscus
Medial Meniscus
Collateral Ligament Tear
Valgus Stress Test
Collateral Ligament Tear
Varus Stress Test
Meniscal and Collateral Tear
Apley’s Compression-Distraction test
 Compression-Menisci
 Distraction – Collateral
ORTHOPEDIC TEST
FOR THE ANKLE AND
FOOT
Ankle Sprain
Achilles tendon Tear
OI and Palpation
Tibialis Posterior Tendinitis
Ankle Sprain
Talar Tilt
Ant. Talofibular ligament
Calcaneofibular lig.
Anterior Drawers
Achilles Tendon Rupture
Thompson’s test
Simmond’s test
Tests for nerve pathology
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Chvostek test
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CN7 Pathology
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Tinels sign for th elbow –
Cubital tunnel syndrome/ulnar
nerve pathology
Tinel’s Sign for the wrist- CTS
/ Median nerve pathology
Evidence Based Practice and
the Diagnostic Process
Reference standard (+) Reference standard (-)
Diagnostic Test
(+)
False positive results
True positive results
A
B
Diagnostic Test
(-)
False negative results
C
True negative results
D
Fritz, J.M. and Wainner, R.S. Examining Diagnostic Tests: An Evidence Based
Perspective, Phys Ther.2001;81:1546-1564
Evidence Based Practice and
the Diagnostic Process
Statistic
Acronym
Sensitivity
Sn N Out
Specificity
Sp P In
Description
If sensitivity is high [Sn] a
negative result [N] is useful
for ruling out [Out] the
condition
If specificity is high [Sp] a
positive result [P] is useful for
ruling in [In] the condition
Sackett et. al (1992), Clinical Epidemiology, A Basic Science for Clinical
Medicine: 2nd Ed
Evidence Based Practice and
the Diagnostic Process

Example: Value of Clinical Test for Subacromial
Impingement Syndrome
 Hawkin’s test was most sensitive (92%)
 Hawkin’s test had low specificity (25%)
 Drop arm test was most specific (97%)
 Drop arm test had low sensitivity (9%)
•The drop arm test was specific revealing that a positive test will confirm
Subacromial impingement syndrome, its sensitivity was poor meaning
That it had a high number of false negative result
•The high sensitivity is indicative that a negative Hawkin’s Test can be used
For ruling out subacromial impingement syndrome; its low specificity states
That a positive Hawkin’s test had little meaning
Evidence Based Practice and
the Diagnostic Process
Statistic
Sensitivity
Specificity
Positive
likelihood ratio
Negative
likelihood ratio
Formula
Description
100% x a/(a+c) Given that the individual
has the condition , the
probability that the test
will be positive
100% x d/(b+d) Given that the individual
does not have the
condition , the
probability that the test
will be negative
Sensitivity/
Given a positive test
(1-specificity)
result , the increase in
odds favoring the
condition
(1-sensitivity)/ Given a negative test
specificity
result , the decrease in
odds favoring the
condition
Evidence Based Practice and
the Diagnostic Process
Likelihood Ratio
Positive
LR
>10
Negative
LR
<.1
5-10
2-5
1-2
.1-.2
.2-.5
.5-1
Description
Large/ conclusive shifts in
probability
Moderate shifts
Small shifts
Small, rare
Fritz, J.M. and Wainner, R.S. Examining Diagnostic Tests: An Evidence Based
Perspective, Phys Ther.2001;81:1546-1564
Statistic
Formula
Description
Overall
Accuracy
(a+d)/
(a+b+c+d)
The proportion of
test results that are
correct
Positive
predictive
value
1/(a+b)
Given a positive test
result , the
probability that the
individual has the
condition
Negative
predictive
Value
d/(c+d)
Given a negative
test result, the
probability that the
individual does not
have the condition
REFERENCES

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
Orthopedic Physical Assessment by David J. Magee
Orthopaedic Physical Examination: An Evidence-based approach for
physical therapists
Fritz, J.M. and Wainner, R.S. (2001) Examining Diagnostic Tests: An
Evidence Based Perspective, Physical Therapy (81), 1546-1564
Calis et. al, Diagnostic Value of Clinical Test for Subacromial Impingement
Syndrome, Rheumatic Dis; 2000, 59:44-47