2010

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978-0-7637-5075-6
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without written permission from the copyright owner.
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Library of Congress Cataloging-in-Publication Data
Wong, Michael.
Pocket orthopaedics : evidence-based survival guide / by Michael Wong.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-7637-5075-6
ISBN-10: 0-7637-5075-1
1. Orthopedics—Handbooks, manuals, etc. 2. Evidence-based medicine—
Handbooks, manuals, etc. I. Title.
[DNLM: 1. Orthopedic Procedures—Handbooks. 2. Evidence-Based
Medicine—Handbooks. WE 39 W872p 2010]
RD732.5.W66 2010
616.7—dc22
2009017644
6048
Printed in Hong Kong
13 12 11 10 09 10 9 8 7 6 5 4 3 2 1
Author
Michael Wong DPT, OCS, FAAOMPT
Associate Professor
Azusa Pacific University
Staff Therapist
Outpatient Rehabilitation
Loma Linda University Medical Center
Staff Therapist
Corina Hills Sports Medicine
Preface

As new clinicians, one of the greatest obstacles to serving our patients best is
selfconfidence. The power of believing in oneself is a physical therapist's best
friend. Physical therapy is not just about fixing mechanical problems; it is a
beautiful collage of human relationships—the simple act of caring, listening,
and giving the patients your best. This survival guide is but a temporary
learning aide as we each walk the same scary path toward excellence. Rest
assured that each and every therapist before you once stood, knees knocking,
before a patient, not knowing what on earth was going on or what treatment to
offer. This guide will make this journey faster and more straightforward. Take
pride in your profession, take pride in your expertise, and know that there are
few professions that can offer the compassion and care that we as physical
therapists can and do every day. Go forth and make the world a better place…

Special Thanks…
To all my students who in any way, large or small, have contributed to this
work.
To Jackie, Marshall, Anne, Leslie, Ryan, Elyse, Tenny, and Tiffany for all your
help.
To Joe Godges for his advice and materials.
Additional thanks goes to Elyse Marn and Tiffany Pfeiffer for creating the
original figure drawings and photo model Jackie Brown.
Most importantly, to Tina my lovely wife, Evan my potty-trained son, and little
Andrew.
Chapter 1
Orthopaedic physical therapy: Nuts and Bolts

Research Pearls

Negative
Positive Likelihood Ratio Likelihood Interpretation
Ratio

Large and often conclusive shift in

>10 <0.1
probability that disorder is present

5-10 0.1-0.2 Moderate shift in probability

Small but sometimes important shifts in

2-5 0.2-0.5
probability

Small and rarely important shift in

1-2 0.5-1
probability

(κ) Kappa and ICC (Intraclass

<0.5 Poor reliability
correlation coefficients)

0.5-0.75 Moderate reliability

>0.75 Good reliability

Sensitivity Test's Ability to Detect Patients With Actual Disorder

SnNout Test with high sensitivity, good for ruling out disorder if test is
(Sensitivity-Negative-Out) negative
 Specificity Test's Ability to Detect Patients Without the Actual Disorder

SpPin Test with high specificity, good for ruling in a disorder if test is
(Specificity-Positive-In) positive

95% Confidence Interval Spread of scores within which 95% of the population would be expected
(CI) to fall

Statistical Significance Infers that there is a 95% probability that a true relationship exists
(p) <0.05 between results of the outcome measure

Drug Identification Quick Reference

[circled white star] “Most drug side effects are just a magnification of what it
was designed to do!”—Boissonault

Suffix Drug Class

cillin

cycline

micin

mycin anti-bacterials (Amoxicillin)

barbital barbiturates (Phenobarbital)

epam benzodiazepines (Diazepam)

olam

olol beta blockers (Atenolol)

pril ACE inhibitors (Enalapril)

ipine calcium channel blockers (Nifedipine)

sartan angiotensin receptor blockers (Telmesartan)

zosin alpha blockers (Terazosin)

statin anti-hyperlipidemic (Lovastatin)

erol bronchodilators (Albuterol)

phyilline

sone glucocorticoids (Dexamethasone)

olone

caine local anesthetic (Lidocaine)

amide oral hypoglycemics (Acetohexamide)

idine H2 blockers (Cimetidine)

Course notes, Boissonnault, Medical Screening, 2008.

Modalities 101

Ultrasound Frequency
Duty Cycle Intensity (W/cm) Treatment Time
Indications (MHz)

Soft Tissue Continuous 1-3 depending

1.0-2.5 5-10 min. (usually 8)
Extensibility 100% on depth

Pain Control 100% 1 or 3 0.5-3.0 3-10 min.

Dermal Ulcer 20% 3-3.3 0.8-1.0 5-10 min.

Surgery
20% 1 or 3-3.3 0.5-0.8 3-5 min.
Incisions

5-10 min 12Rx over 4-

Epicondylitis 20% 1 1.0-2.0
6wk period

Tendon Healing 100% 1 or 3 0.5-1.5 3-5 min.

Bone Fractures 20% 1 0.15 20 min (14-18days)

Carpal Tunnel 25% 1 1.0 15 min.

Phonophoresis 20% 3 0.5-0.75 5-10 min.

Plantar Warts 100% 1 0.6-0.8 10 min.

0.8-vertebral col. 0.5

Herpes Zoster 25% 1 1 min. per sound head
to periphery

Electrical
Amplitude Pulse Rate Pulse Duration
Stimulation Treatment Duration
(mA) (pps) (µs)
Type

TENS Comfort
80-150 50-100 20-60 min
(conventional) tingle

TENS
Strong tingle 1-10 100-300 20-40 min.
(accupuncture)

50-100
TENS (burst) *all
Comfortable cont. or 1:4 50-200 20-30 min.
TENS for pain
on/off
IFC
Comfortable 50-80 50-100 10-30 (20) min.
(pain/edema)

Russian Tetanic
50-70 150-200 20 min (10:50 on/off)
(strength) contraction

Tetany to
Russian (spasms) 50-70 50-175 1:1 to 4:12 sec on/off
tolerance

NMES (moderate Mild 150-200 (small 10:50 initially, progress to

to severe contraction 3-10 muscles) 200-350 10:30 sec on/off for 10-20
atrophy) (10% MVIC) (larger) reps

Strong 10:30 initially, progress to

NMES (minimal Same µs for small
contraction 30-80 10:10 sec on/off for 10-20
to no atrophy) or large muscles
(50% MVIC) reps

FES (See Tetanic

With orthotic during
atrophy for muscle Same Same
functional activity
parameters) contraction

Iontophoresis 10 min using 4 mA, 40 min

1-4 mA N/A N/A
(For drug push) using 1 mA

Data from: Cameron M., Physical Agents in Rehabilitation: From Research to Practice. Saunders;
2003.

Resistance Training 101

Delorme Regimen Oxford Regimen

Determine 10 RM Determine 10 RM
10 reps @ 50% 10 RM 10 reps @ 100% 10 RM

10 reps @ 75% 10 RM 10 reps @ 75% 10 RM

10 reps @ 100% 10 RM 10 reps @ 50% 10 RM

Resistance in Pounds of Thera-Band® Resistance Based on

Percent Elongation
Average Force (pounds) for Thera-Band Elastic Bands

% Elongation Yellow Red Green Blue Black Silver Gold

50% 2 2.5 3 4.5 6.5 8.5 14

100% 3 4 5 7 9.5 13 21.5

150% 4 5 6.5 9 12.5 17 27.5

200% 5 6 8 11 15 21 33.5

250% 6 7 9.5 13.5 17.5 25.5 40

Reprinted with permission from Thera-Band (www.thera-band.com).

Learning from the BEST

Characteristics of an Expert Manual Therapist

Takes into account the patient's understanding, beliefs, and feelings

 Helps shape a patient in developing and evolving understanding of problems
Reflection (reflection in action, reflection about action)
Metacognition
Well-organized knowledge/clinical patterns
Ability to generate prognosis
Ability to control the environment—efficient use of time, ability to focus on
patient in busy environment
Evaluation and use of patient illness and disease data in a context-rich
evaluation
Focused verbal and nonverbal connection with the patient
Equal importance of teaching to hands-on care
Confidence in predicting effective patient outcomes based on knowledge of
pathology and experience with the course of healing

Adapted from: Jensen GM, Shepard KF, Gwyer J, Hack LM. Attribute Dimensions
that Distinguish Master and Novice Physical Therapy Clinicians in Orthopedic
Settings. Phys Ther. 1992; 72(10): 711-722.

Clinical Reasoning in a Nutshell

“The process in which the clinician, interacting with significant others (patient,
caregivers, health care team members), structures meaning, goals, and health
management strategies based on clinical data, patient choices, and professional
judgment and knowledge.”
Hypothesis categories to be considered in evaluating a patient as a whole
person:
1. Activity and participation capability or restriction
2. Patient perspectives on their experience
3. Pathobiological mechanisms (phase of healing, pain mechanisms)
4. Physical impairments and associated structure or tissue source
5. Contributing factors

environmental
 psychosocial
behavioral
physical
biomechanical
hereditary

6. Precautions and contraindications

7. Management and treatment
8. Prognosis

Ten Steps for Clinical Reasoning

1. Ultimate goal of clinical reasoning is learning for the clinician and the
patient
2. Prepare for experiential learning by intentionally attending to and
reflecting upon your own current knowledge and skills, past experiences, and
learning related to the current patient and the clinical problem
3. Organize your knowledge base (use differential diagnosis tables, but
consider them as flexible and changeable)
4. In gathering information, ensure that you have gathered information in the 8
hypothesis categories
5. Cognition—Purposeful thought applied to perception, analysis, synthesis, and
evaluation of relevant information
6. Cognition—Link information to your experience, knowledge base, current
best relevant evidence
7. Reassess—Important for detecting errors in reasoning
8. Reflection in action—Reflect while treating or testing; constantly engage
past learning
9. Metacognition—Think about your thinking, used to detect errors or link
information (reflect on and compare existing knowledge with evolving clinical
situation)
10. Reflection on action—Reflection that takes place away from immediate
demands of clinical practice
Tissue Healing
Bone

Day 3 to 2 3 Weeks to
Days 1-3 2-6 Weeks 6 Weeks to 1 Year
Weeks 6 Months

Callus formation
Hematoma Fibrocartilage
Radiographic evidence of Ossification Consolidation/remodeling
formation formation
healing (about day 13)

Tissue Healing Summary

Exercise-induced muscle soreness 0-3 days

I = 0-2 weeks

Muscle strain II = 4 days-3 months

III = 3 weeks-6 months

I = 0-3 days

Ligament sprain II = 3 weeks-6 months

III = 5 weeks-1 year

Tendonitis = 3 weeks-7 weeks

Tendon
Lacerations = 5 weeks-6 month

Articular cartilage repair 2 months-2 years

Ligament graft 2 months-2 years

Adapted from Axe MJ, Snyder-Mackler L. Operative and postoperative

management of the knee. In: Wilmarth MA, ed. Orthopaedic Section
Independent Study Course 15.3, Postoperative Management of Orthopaedic
Surgeries. La Crosse, Wis: Orthopaedic Section, APTA Inc. 2005; 17, 2005 Dec.

FIGURE 1-1 Stages in Fracture Repair

Chiras, Daniel C. Human Biology, Sixth Edition. © 2008 Jones & Bartlett Publishers, LLC

Connective Tissue: Tendon and Ligament Healing

Days 1-6 Days 3-20 6 Months-1 Year

Proliferation Phase Collagen and Maturation Phase Type III

Inflammation Phase
ground substance production to Type I collagen

Observe for cardinal signs

Observe for decreasing Observe for decreasing
of inflammation

Calor—Heat Inflammation Inflammation

Rubor—Redness Pain Decreasing pain

Tumor—Swelling Continued decreased ROM Increasing ROM

Dolor—Pain Loss of function Improving of function

Functio lassa—Loss of Muscle atrophy Muscle atrophy

function
Strength loss Strength loss→gain
Muscle Healing

Begins 15 Min. Post

Injury Phase Is Most <3 Hours Post Up to 1 Year Post
Within 18 Hours Post Injury
Evident 4-8 Hours Injury Injury
Post Injury

Inflammatory
Degeneration phase Fibroplastic Phase Maturation Phase
Phase

Satellite cell activation

—Mononucleated reserve cells

—Only source of new fiber

formation in muscle

—Activated by damaged
muscle fibers releasing
endogenous mitogen within
18 hours of injury

Stimulated by growth factors

Myotubes mature
—Laminin into muscle fibers
(myofibers).
—Macrophage-produced
factors Single myofibers can
regenerate with
Neutrophils Regeneration complete return to
(PMN) arrive first
function.
Macrophages —Intact basal lamina acts as
within 6 hours scaffold for new myotubes Entire muscles can
regenerate
—Myoblasts proliferate and
fuse —usually surviving
peripheral cells start
—Myotubes seen within 3 - 5
regeneration first.
days post injury

—New fibers form within same

basal lamina

—Eventually split up to
become separate fibers

—Nerves reinnervate at the

 neuromuscular junction

—Re-vascularization continues
from periphery inwards

Movement Analysis and Rehabilitation

“The impairments of soft tissues induced by repeated movements and sustained
postures eventually cause a joint to develop a susceptibility to movement in a
specific direction.”
Adapted from Sahrman S. Movement Impairment Syndromes. Mosby; 2002.
1. Observe symptomatic movement.
2. Analyze movement for faulty biomechanics.
3. Hypothesize whether problem appears rooted in Directional Susceptibility to
Movement (DSM).

Excess mobility
Hypomobility
Poor motor control

4. Objectively test faulty movement.

5. Correct movement impairment: the “failed” test motion becomes the home
exercise.
[circled white star] In the “DSM/Signs” column of each of the differential
diagnosis tables, you will find the impaired movements that are most commonly
associated with that particular pathology.

Treatment-Based Classifications (TBC)

There is good emerging evidence that placing a patient based on his or her
impairments found during the objective exam into the most appropriate TBC
will result in improved care.1-6

Nine Key Thoughts Related to TBCs

1. The lumbar spine TBC is reliable and is validated.1, 2, 3, 4, 5, 6, 7, 8
2. The cervical spine TBC has been proposed.2
3. The remainder of the TBCs for each joint chapter has been proposed by the
author based on relevant studies.
4. Each treatment-based category is intentionally broad to allow for flexibility
of treatment styles and choice.
5. It is likely that a patient will fit multiple categories, but ideal to treat
prioritized by the most significant impairment related to the patient's
dysfunction.
6. It is likely that if a patient demonstrates very high disability scores and high
pain scores (VAS) that they would be appropriately placed in a pain control
category.
7. If a patient demonstrates high fear avoidance scores (FABQW>35), modified
education and intervention is recommended.
8. As a patient's impairments progress and change during the rehabilitation
process, it is appropriate for the patient to fit new treatment-based categories.
9. I believe that treatment-based categories, though broad in definition, are a
step in the right direction for helping our profession become more uniform in
our impairment-based treatment selection.

References
1. Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE.
Identifying subgroups of patients with acute/subacute “nonspecific” low back
pain: Results of a randomized clinical trial. Spine. 2006;31:623-631.
2. Childs JD, et al. Proposal of a classification system for patients with neck
pain. J Orthop Sports Phys Ther. 2004;34:686-700.
3. Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach
to low back syndrome: Identifying and staging patients for conservative
treatment. PhysTher. 1995;75:470-485; discussion 485-479.
4. Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical
therapy with therapy based on clinical practice guidelines for patients with
acute low back pain: A randomized clinical trial. Spine. 2003;28:1363-1371;
discussion 1372.
5. Fritz JM, et al. Subgrouping patients with low back pain: Evolution of a
classification approach to physical therapy. J Orthop Sports Phys Ther.
2007;37(6):290-302.
6. Fritz JM, Brennan GP, Clifford SN, Hunter SJ, Thackeray A. An examination
of the reliability of a classification algorithm for subgrouping patients with low
back pain. Spine. 2006;31:77-82.
7. Fritz JM, George S. The use of a classification approach to identify subgroups
of patients with acute low back pain: Interrater reliability and short-term
treatment outcomes. Spine. 2000;25:106-114.
8. Heiss DG, Fitch DS, Fritz JM, Sanchez WJ, Roberts KE, Buford JA. The
interrater reliability among physical therapists newly trained in a classification
system for acute low back pain. J Orthop Sports Phys Ther. 2004;34:430-439.

Physical Therapy Evaluation in a Nutshell

Give Patient
Medical screening intake forms/Region-specific screening forms/Appropriate
functional disability questionnaires

Ask and Listen

Subjective Exam/Body Chart

Red and Yellow Flag

General health screening questions and review of system questions
Screening

Severity How limited is the patient's function?

How much activity brings on the symptoms?

Irritabililty How bad does it get (0-10)?

How long does it linger?

Nature Hypothetical source structures

Stage Stage of healing

Reproducibility of the symptoms; is patient improving or getting worse

Stability
(0-100%)?

Observe, Test, and Measure

Objective exam
Use of appropriate objective testing to screen for non-musculoskeletal
pathology that requires referral
Observe patient posture, aggravating movements, directional susceptibility to
movement.
Clear possible involved joints (use of high-sensitivity tests ).
Implicate possible involved tissue (use of high specificity tests ).
Use most valid and reliable special tests.
Measure impairments objectively.

Think, Then Act

Intervention
Based on the treatment-based classification as determined by the impairments
observed during subjective and objective testing
Based on the measured impairments to be addressed
Supported by available clinical prediction rules
Home exercise program driven by the impairments to be addressed
Chapter 2
Medical Screening

Is the patient appropriate for physical therapy intervention?

1. Issue general health and region-specific screening questionnaire for patient
to fill out before evaluation.
2. Quickly scan intake form for check marks that may indicate a reason for
further investigation.
3. Screen out potential diseases that may mimic musculoskeletal pain or dys-
function.

Region-specific follow-up questions (a review of a system or multiple

systems).
Basic physical examination techniques: Palpate, Auscultate, Percuss, View
diagnostic imaging.

Based on your further investigation you must make one of the following
decisions:
Review of Systems
When should I do a review of systems?
1. If patient history demonstrates the following signs and symptoms:

General health screen

Fatigue
Malaise
Fever/chills/sweats
Nausea/vomiting
Unexplained weight change
Numbness/paresthesia/weakness
Dizziness/light-headedness
Mentation/cognition
Insidious onset of symptoms
Worsening trend related to symptoms
Increases in medication dosage for same relief
Inadequate relief of symptoms with rest
No symptom relief with positional changes

2. If objective exam reveals:

Non-mechanical-type symptom patterns

Inability to reproduce symptoms

Pain Distribution-Based Review of Systems

Pain Distribution Review of System

Cardiovascular

L/R Shoulder Pain (Blue) Pulmonary

 Gastrointestinal

Cardiovascular/ peripheral vascular

Pulmonary
Thoracic Spine Pain (Red)
Gastrointestinal

Urogenital (T-L junction)

Gastrointestinal

Lumbo-Pelvic Pain (Green) Urogenital

Peripheral Vascular

R/L Knee Pain (Orange) Peripheral Vascular

Psychologic

Endocrine
Inconsistent Symptomatic
Neurologic
Pattern
Rheumatic

Pharmacologic: adverse drug reaction

 FIGURE 2-1 System Review Color-Coded Body

Intake Forms
[circled white star] Most clinics have some type of intake form used for medical
screening. Utilize whatever is available.
The following is an example of questions from the Guide to Physical Therapist
Practice 2nd Edition, American Physical Therapy Association, 1999.
If any of the intake form items are checked off, subjectively clarify with the
following questions:
“When were you diagnosed with this problem?”
“Has it been treated? Or is it being treated?”
“How was/is it being treated?”
“Are the symptoms you have today similar in any way to the way this problem
felt when it was first diagnosed?”
“Are you currently taking any medications for this or any other disease?”

Basic Intake Form

Please check if you have ever had:

Arthritis
Broken bones/fractures
Osteoporosis
Blood disorders
Circulation/vascular problems
Heart problems
High blood pressure
Lung problems
Stroke
Diabetes/high blood sugar
Hypoglycemia/low blood sugar
Head injury
Multiple sclerosis
Muscular dystrophy
Parkinson disease
Seizures/epilepsy
Allergies
Developmental or growth problems
Thyroid problems
Cancer

Infectious disease (tuberculosis, hepatitis)

Kidney problems
Repeated infections
 Ulcers/stomach problems
Skin diseases
Depression
Other: ___________

Within the past year, have you had any of the following symptoms?

Chest pain (cardio/pulmonary)

Heart palpitations (cardio/pulmonary)
Cough (cardio/pulmonary)
Hoarseness (cardio/pulmonary)
Shortness of breath (cardio/pulmonary)
Dizziness or blackouts (neuro)
Coordination problems (neuro)
Weakness in arms or legs (neuro/rheumatologic/hematologic)
Loss of balance (neuro)
Difficulty walking (neuro/rheumatologic)
Joint pain or swelling (rheumatologic)
Pain at night (acute injury/oncologic)
Difficulty sleeping (acute injury/oncologic)
Loss of appetite (GI)
Nausea/vomiting (GI)
Difficulty swallowing (GI)
Bowel problems (GI)
Weight loss/gain (GI/oncologic)
Urinary problems (genitourinary)
Fever/chill/sweats (infection/pulmonary/oncologic)
Headaches (hematologic/neurologic)
Hearing problems (neuro)
Vision problems (neuro)
 Other: ___________

If the patient checks off any of the symptoms, please proceed to the
appropriate page for system-specific screening questions.

Review of a System
The following are some key questions/physical examination techniques for each
system that you might ask/perform to screen for non-musculoskeletal sources of
pain.

Each corresponding blue box includes drugs that may cause side
effects that manifest as symptoms in each system.

General Questions
Assess vital signs: blood pressure, temperature, pulse
Do you have fever, chills, sweating? (cancer or infection)
Have you noticed excessive, unexplained weight gain or loss? (cancer or
depression)
Have you noticed appetite loss, nausea, vomiting (cancer or depression)
Are you having trouble sleeping? (insomnia or cancer)
Have you noticed excessive fatigue, weakness, irritability? (rheumatologic,
oncologic, gastrointestinal, endocrine, neurologic)

Oncologic Questions
1. If subjective history or intake form reveals the following information:

Age over 40 years old

Personal or family history of cancer
No known cause, insidious onset of symptoms

2. If subjective history reveals the following pain patterns or types:

 Night pain
Constant intense pain/symptoms
Pain unrelieved by rest or changes in positions
Gradual, progressive, or cyclic presentation of symptoms
Pain that no longer responds to relief methods that used to work
Symptoms that persist beyond time of expected recovery
Symptoms out of proportion to the injury
Symptoms that do not fit mechanical or neuromusculoskeletal pattern
Pain described as knifelike, boring, deep, colicky, deep aching
Pattern of pain coming and going as spasms

Psychologic Questions
Do you have sleep disturbances?
How are your stress levels?
Have you noticed excess fatigue, psychomotor agitation?
Have you noticed changes in personal habits, appetite?
Have you noticed feeling depressed, confused, or anxious?

FIGURE 2-2 Palpation of Head and Neck

 FIGURE 2-3 Lymph Nodes of the Neck

[circled white star] Palpated nodes should be observed for mobility,

consistency, and tenderness.
Tenderness is suggestive of inflammation.
Fixed, firm nodes are suggestive of malignancy.

Mini-mental exam: Good for screening out those who might have cognitive
deficits Can you tell me the date including: (1 point for each correct answer)
1. Month
2. Day of the month
3. Day of the week
4. Year
5. Season
Can you count backwards from 100 by 7's? (Allow 5 answers, 1point for each
correct answer)

Results Sensitivity Specificity

7/10 correct answers 98.2% 69.2%

Depression screening:
1. During the past month, have you often been bothered by feeling down,
depressed, or hopeless?
2. During the last month, have you often been bothered by little interest or
pleasure in doing things?

>=Mild >=Moderate >=Severe >=Extreme

Score
Depression Depression Depression Depression

1(+) response
3.40 2.76 2.44 2.25
(+)LR

1(+) response
0.37 0.29 0.25 0.23
(−)LR

2(+) responses
5.40 4.61 4.32 3.89
(+)LR

2(+) responses
0.55 0.43 0.28 0.18
(−)LR

[circled white star] Good for screening out those who might benefit from
referral for multidisciplinary treatment
2(+) responses to the questions means that there is a moderate shift in
probability that the patient is mildly depressed.
2(−) responses to the questions means that there is a moderate shift in
probability that the patient does not have extreme depression.

[circled white star] Positive responses to the screening questions may be

followed up by issuing the Depression Anxiety Stress Scale (DASS-21) or Distress
and Risk Assessment Method (DRAM). Positive Scores in the severe and
extremely severe categories on the DASS-21 warrant referral to an appropriate
care provider.
[circled white star] A negative response to the screening test might be followed
by secondary assessment using the DASS-21 if the physical therapist notices the
patient failing to respond to intervention or the presence of clinical features
that suggest depression (e.g., insomnia, fatigue, weight changes).
[circled white star] Good for screening out those who might benefit from
referral for multidisciplinary treatment
Haggman et al. Screening for symptoms of depression by physical therapists
managing low back pain. Phys Ther. 2004;84:1157-1166.
Fear avoidance screening:
Use of the Fear Avoidance Back Questionnaire

FABQW Scores < 20 Not a big indicator of long-term disability

FABQW Scores > 20-35 Patient is 2.35 times more likely to have long-term disability

FABQW > 35 Patient is about 5.15 times more likely to have long-term disability

George, et al. Investigation of elevated fear-avoidance beliefs for patients with

low back pain: A secondary analysis involving patients enrolled in physical
therapy clinical trials. J Orthop Sports Phys Ther. 2008;38(2):50-58. Published
online 22 January 2008.

Neurologic Questions
Do you have headaches?
Do you have vision changes?
Do you have difficulty with speech (dysphasia)?
Do you have vertigo?
Do you have paresthesias?
Have you noticed weakness or atrophy?
Do you have involuntary movements or tremors?
Do you have radicular pain (shooting pains, lightning-like)?
Have you had seizures or loss of consciousness?
Central nervous system: (dizziness, drowsiness, insomnia,
headaches, hallucinations, confusion, anxiety, depression, muscle
weakness)

NSAIDs
Skeletal muscle relaxants
Opioids
Corticosteroids
β-Blockers
Calcium channel blockers
Nitrates
ACE inhibitors
Digoxin
Antianxiety agents
Antidepressants (TCAs and MAO inhibitors)
Neuroleptics
Antiepileptic agents
OCAs
Estrogens and progestins
 FIGURE 2-4 Sinuses for Palpation

[circled white star] Palpation over the frontal and maxillary sinuses may reveal
tenderness that is indicative of sinusitis. Refer out for appropriate care.

Sinus
Signs and Symptoms Local Pain Referral Region
Involved

Ocular abnormalities

Diploplia Behind eye

Proptosis Cheek
Teeth
Maxillary Epiphora (tearing) Nose
Retrobulbar
Nasal obstruction and rhinorrhea Upper teeth

epistaxis Upper lip

Loosening of teeth

Orbital swelling

Nasal obstruction and purulent

rhinorrhea Periorbital
Occipital
Ethmoid Ocular abnormalities Retronasal
Upper cervical
Proptosis Retrobulbar
Diploplia

Tenderness over inner canthus of eye

Nasal obstruction and rhinorrhea

Tenderness over frontal sinus Supraorbital Bitemporal and occipital

Frontal
Pus in middle meatus Frontal headache

Signs of meningitis

Adapted from Swartz MH. Textbook of Physical Diagnosis: History and Examination. 4th ed. W.B.
Saunders Company, 2001.
 HEENT (Head, Eyes, Ears, Nose, Throat): (tinnitus, loss of taste,
headache, lightheadedness, dizziness)

Salicylates
NSAIDs
Skeletal muscle relaxants
Opioids
β-Blockers
Calcium channel blockers
Nitrates
ACE inhibitors
Digoxin
Antianxiety agents
Antiarrhythmic agents
Antidepressants (TCAs and MAO inhibitors)
Antiepileptic agents

[circled white star] Absence of nasal discharge, cough, and sneezing were most
sensitive for ruling out sinusitis. Presence of maxillary toothache was most
specific (93%) for ruling in sinusitis. (+) LR 2.5, refer out for further workup if
patient's headache pain may be related to a non-musculoskeletal source.

Rheumatologic Questions
Presence/location of joint swelling?
Do you have muscle pain or weakness?
Do you have skin rashes?
Do you have any reaction to sunlight?
Do you have severe pain, numbness, or color changes in your fingers when
exposed to cold (Raynaud's phenomenon)?
Observe for nail bed changes.

Integumentary Questions
Do you have rashes or skin lesions?
Have you noticed changes in skin color?
Have you noticed any burning or itching of the skin?
Have you noticed any large areas of exfoliation of the skin?

FIGURE 2-5 Common Sites of Rheumatoid Arthritis

Have you noticed any blistering of the skin?

Have you noticed any changes in your hair or nails?

Dermatologic: (skin rash, itching, flushing of face)

NSAIDs
Corticosteroids
Opioids
β-Blockers
Calcium channel blockers
 Nitrates
ACE inhibitors
Antidepressants (TCAs and MAO inhibitors)
MAO inhibitors and lithium
Antiepileptic agents
OCAs
Estrogens and progestins

Hematologic Questions
Observe for skin color or nail bed changes.
Do you have bleeding: nose, gums, easy bruising, black tarry stool?
Hemarthrosis, muscle hemorrhage, hematoma?
Have you noticed fatigue, shortness of breath, or weakness?
Have you noticed yourself being confused or irritable?
Have you recently had headaches?

Gastrointestinal (GI) Questions

Do you have abdominal pain?
Do you have indigestion or heartburn?
Have you noticed difficulty swallowing?
Do you have nausea or vomiting?
Do you have diarrhea or constipation?
Have you noticed changes in bowel habits?
Do you have rectal bleeding or blood in stool? Black tarry stool—upper GI
bleeding
Has there been a change in shape of your stool? Pencil shaped or ribbon-like
Have you noticed skin rash followed by joint pain?

Gastrointestinal distress: (dyspepsia, heartburn, nausea,

vomiting, abdominal pain, constipation, diarrhea, bleeding)
 Salicylates
NSAIDs
Skeletal muscle relaxants
Opioids
Corticosteroids
β-Blockers
Calcium channel blockers
Nitrates
ACE inhibitors
Digoxin
Diurectics
Antidepressants (TCAs and MAO inhibitors)
Neuroleptics
Antiepileptic agents
OCAs
Estrogens and progestins
Theophylline
Cholesterol-lowering agents
Antiarrhythmic agents

Key questions for predicting musculoskeletal origin of abdominal pain

Does coughing, sneezing, or taking a deep breath make your pain feel worse?
YES
Do activities such as bending, sitting, lifting, twisting, or turning over in bed
make your pain feel worse? YES
Has there been any change in your bowel habits since the start of your
symptoms? NO
Does eating certain foods make your pain feel worse? NO
Has your weight changed since your symptoms started? NO
If patient answers as above, abdominal pain is likely of musculoskeletal origin.

Sensitivity Specificity (+) LR (−) LR

67 96 16.8 0.34

Sparkes V, Prevost AT, Hunter JO. Derivation and identification of questions that act as predictors
of abdominal pain of musculskeletal origin. Eur J Gastroenterol Hepatol. 2003;15:1021-1027.

FIGURE 2-6 Common Sites of Visceral-Referred Pain

FIGURE 2-7 Kidney Palpation

FIGURE 2-8 Liver Palpation

 FIGURE 2-9 Appendix Palpation

FIGURE 2-10 Palpation of Abdominal Aorta

FIGURE 2-11 Auscultation of Abdominal Aorta

[circled white star] Rebound tenderness is a sign of peritoneal irritation.

Palpate deeply and slowly in an abdominal area away from the suspected area
of local inflammation.
(+) test is sensation of pain on the side of the inflammation that occurs upon
release of pressure.

Abdominal Aortic Aneurysm

Risk factors:
> 65 years of age
Male (risk increase in women > 75-80 years)
(+) family history
Pulsatile abdominal mass
Bruit

Urinary (US) Questions

Do you have changes in frequency of urination?
Do you have changes in urgency of urination?
Have you had problems with incontinence? (stress vs. urge vs. mixed)
Do you have reduced caliber or force of urine stream?
Do you have difficulty initiating stream? (cauda equina)
Have you noticed color changes in your urine? (tea colored—may indicate tissue
damage)
Do you have pain with urination? (dysuria)

Genitourinary: (sexual dysfunction, urinary retention, urinary

incontinence)

Opioids
β-Blockers
ACE inhibitors
Antidepressants (TCAs and MAO inhibitors)
Neuroleptics
OCAs
Estrogens and progestins
Antiarrhythmic agents
Diuretics

Gynecologic Questions
Have you noticed or experienced any of the following?
Irregular menses, menopause
Pain with menses, intercourse
Vaginal discharge
Surgical procedures
Birth/abortion history
Spotting, bleeding—especially for the postmenopausal woman > 12 months after
last period (without hormone replacement therapy)
Date of last period

Endocrine Questions
Have you noticed changes in any of the following?
Hair and nail changes
Temperature intolerance
Cramps
Edema, polyuria, polydipsia
Unexplained weakness, fatigue, paresthesia
Carpal tunnel syndrome
Periarthritis, adhesive capsulitis

Cardiovascular Questions
Have you noticed any of the following?
Chest, neck, and/or arm pain
Palpitations
Claudication (leg pain, cramps, limping)
Peripheral edema or nocturia
Persistent cough
Fatique, dyspnea, syncope
High or low blood pressure
Differences in blood pressure from side to side with position change > 10mm Hg

Cardiac: (bradycardia, ventricular irritability, AV block, PVCs,

ventricular tachycardia)
 Opioids
β-Blockers
Neuroleptics
OCAs
Estrogens and progestins
Antiarrhythmic agents
Diuretics
Oral antiasthmatic agents
Calcium channel blockers
Digoxin
TCAs

Vascular: (claudication, hypotension, peripheral edema, cold

extremities)

NSAIDs
Calcium channel blockers
β-Blockers
ACE inhibitors
Antidepressants (TCAs and MAO inhibitors)
Neuroleptics
Nitrates
OCAs
Estrogens and progestins
Diuretics
Corticosteroids

Pulmonary Questions
Have you noticed any of the following?
Cough, hoarseness?
Sputum, hemoptysis? (earth tones/ Christmas colors may indicate tissue
damage)
Shortness of breath; wheezing?
Night sweats?
Pleural pain?
Clubbing of the nails?

Pulmonary: (bronchospasm, shortness of breath, respiratory

depression)

Salicylates
NSAIDs
Opioids
β-Blockers
ACE inhibitors

Musculoskeletal: (weakness, fatique, cramps, arthritis, decreased

exercise tolerance, osteoporosis)

Corticosteroids
β-Blockers
Calcium channel blockers
ACE inhibitors
Digoxin
Diurectics
Antidepressants
Antianxiety
Neuroleptics
Antiepileptic agents

Common Referral Patterns

Pelvic Organs
 Structure Possible Areas of Pain Referral

Lumbosacral junction

Uterus, including uterine ligaments Sacral

Thoracolumbar

Lower abdominal
Ovaries
Sacral

Lower abdominal
Testes
Sacral

Retroperitoneal Region
See Figure 2-6.

Structure Possible Areas of Pain Referral

Lumbar spine (ipsilateral)

Kidney Lower abdominal

Upper abdominal

Groin

Upper abdominal

Ureter Suprapubic

Medial, proximal thigh

Thoracolumbar

Sacral apex
Urinary bladder Suprapubic

Thoracolumbar

Sacral

Prostate gland Testes

Thoracolumbar

Digestive System Organs

Structure Possible Areas of Pain Referral

Esophagus Substernal and upper abdominal

Upper abdominal
Stomach
Middle and lower thoracic spine

Small intestine Middle thoracic

FIGURE 2-12 General Visceral Map in Backache Source: Reprinted by permission of
QUADRANT HEALTHCOM Inc. from “Extraspinal Causes of Back Pain,” Hospital
Medicine, Vol. 18, No 12, p. 95. Copyright 1982 by QUADRANT HEALTHCOM Inc.

Structure Possible Areas of Pain Referral

 Upper abdominal

Pancreas Lower thoracic spine

Upper lumbar spine

Right upper abdominal

Gallbladder
Right middle and lower thoracic spine including caudal aspect scapula

Right middle and lower thoracic spine

Liver
Right cervical spine

Upper abdominal
Common bile duct
Middle lumbar spine

Lower abdominal
Large intestine
Middle lumbar spine

Upper sacral

Sigmoid colon Suprapubic

Left lower quadrant of abdomen

Cardiopulmonary System
See Figure 2-6.

Structure Possible Areas of Pain Referral

Cervical anterior

Heart Upper thorax

Left upper extremity

 Ipsilateral thoracic spine
Lungs and bronchi
Cervical (diaphragm involved)

Diaphragm (central portion) Cervical spine

Basic Vital Signs

HR RR Systolic BP Diastolic BP Temperature

Infant 80-180 30-50 73 55 98.2

Child 75-140 20-40 90 57 98.6

Adolescent 50-100 15-22 115 70 98.6

Adult 60-100 10-20 < 130 < 85 98.6

Basic Lab Value

WBC RBC Ery-sed HCT HG Platelet

(cells/mm3) million/mm3 (mm/hr) (%) (g/dL) (ratio)

Male 5,000-10,000 4.7-6.1 Up to 15 42-52 14-18 0.9-1.1

Female 5,000-10,000 4.2-5.4 Up to 20 37-47 12-16 0.9-1.1

Blood Glucose O2 K+ Na+ Cl− Ca2+ Mg2+

(mg/dL) Sat (mEq/L) (mEq/L) (mEq/L) (mEq/L) (mEq/L)
Male 70-120 98% 3.5-5 136-145 90-110 9-10.5 1.2-2

Female 70-120 98% 3.5-5 136-145 90-110 9-10.5 1.2-2

Radiological Screening ABCs

A: Alignment

Evaluates Normal Abnormal

Supernumerary bones

Gross normal size of bones Absent bones

General skeletal architecture
Normal number of bones Congenital deformities

Cortical fractures

Smooth and continuous cortical Avulsion fractures

General contour
outlines
Impaction fractures

Markings of past surgical

sites
Normal joint articulations
Alignment of bones to adjacent Fractures
bones Normal spatial relationship
Joint subluxation

Joint dislocation

B: Bone Density

Evaluates Normal Abnormal

General loss of bone density resulting in

General bone Sufficient contrast between soft-tissue poor contrast between soft tissues and
density shade of gray and bone shade of gray bone Thinning or absence of cortical
margins

Appearance of trabeculae altered; may

Texture
Normal trabecular architecture look thin, delicate, lacy, coarsened,
abnormalities
smudged, fluffy

Sclerosis at areas of increased stress, Excessive sclerosis

Local bone
such as weight-bearing surfaces or sites
density
of ligamentous, muscular, or tendinous Reactive sclerosis that walls off a lesion
changes Osteophytes
attachments

C: Cartilage Spaces

Evaluates Normal Abnormal

Well-preserved joint spaces

Joint space Decreased joint spaces imply degenerative or
imply normal cartilage or disk
width traumatic conditions
thickness

Subchondral Excessive sclerosis as seen in DJD Erosions as seen

Smooth surface
bone in the inflammatory arthritides

Compare contralaterally for changes in thickness

Epiphyseal Normal size relative to epiphysis
that may be related to abnormal conditions or
plates and skeletal age
trauma

S: Soft Tissues

Evaluates Normal Abnormal

Normal size of soft- Gross wasting

Muscles
tissue image
Gross swelling
 Radiolucent lines
parallel to length of Displacement of fat pads from bony fossae into soft tissues
Fat pads and muscle indicates joint effusion Elevation or blurring of fat planes
fat lines
indicates swelling of nearby tissues
Radiolucent lines
parallel to bone

Joint
Normally indistinct Observe whether effusion or hemorrhage distends capsule
capsules

Normally indistinct
Observe periosteal reactions: solid, laminated, or
Periosteum Solid periosteal
onionskin, speculated or sunburst; Codman's triangle
reaction is normal in
fracture healing

Foreign bodies evidenced by radiodensity

Miscellaneous Soft tissue normally
soft tissue exhibit a water- Gas bubbles appear radiolucent
findings density shade of gray
Calcifications appear radiopaque

Adapted from Mckinnis L. Fundamentals of Muscloskeletal Imaging. 2nd ed. FA Davis; 2005, page
127, table 4-1, with permission.

Selected Conventional Radiology Exams

Spine

C-spine: Basic AP, lat, open mouth (include oblique views for imaging the neural foramen;
study i.e., radicular symptoms)

Lower C-spine Swimmer's view

L-spine: Basic
AP, lateral, coned view (include oblique views for suspected pars injury)
study
Multiple trauma Lat C-spine, chest film, AP pelvis

Shoulder

Basic study AP IR/ER

Subacromial view Scapular outlet view (impingement syndrome)

Basic study
True AP, scapular outlet, axillary
(ortho)

Scapula fx Transscapular Y

AC joint AP stress view (bilateral comparison)

Shoulder
AP IR/ER, plus axillary or transscapular Y
dislocation

Hill Sachs AP with IR

Bankart Axillary

Elbow

Basic study AP, lat

Radial head External oblique, radial head projection (for fx)

Wrist/hand

Basic study PA, lat, oblique

Scaphoid fx Scaphoid view in addition to above

Pelvis/Hips

Basic study (hips) AP, lateral frogleg (may get AP of pelvis for bilateral comparison)

Pelvic/hip trauma AP, cross-table lateral, inlet/outlet Judet

Hip dislocation AP pelvis, AP and lat hip, post reduction AP and lat hip

Femur fx AP pelvis, AP and cross-lateral femur

Knee

Basic study AP, lateral

Trauma AP, lateral, 2 obliques, tunnel

Patella sublux Sunrise (or Merchant)

Patellar articular
Merchant (or sunrise)
facets

Tibial plateau fx CT
Ankle/Foot

Basic study
AP, lateral, mortise
(ankle)

Joint instability
AP, lateral, mortise, stress views
(ankle)

Basic study (foot) AP, lateral

Adapted from course notes Ross M. Diagnostic Imaging for Physical Therapist; 2007.

General Indications for Advanced Diagnostic Imaging

Indications MRI CT NM

Evaluation of frank neurological signs—central and peripheral nervous system ++

Evaluation of spinal pathology ++ +

Internal joint derangements (ligaments, meniscii, articular cartilage, labral

++
pathology)

Inflammatory arthritis + + +

Evaluation of soft-tissue injury (including muscle injuries), tendon pathology,

++
calcified bursitis

Osteomyelitis ++ + ++
Fluid collections or infections in joints or extraarticular soft tissues; unexplained ++
soft-tissue mass

Osteonecrosis ++ + +

Complicated fractures + ++

Suspected stress, occult fracture + + ++

Complicated disease processes or findings unexplained by more conservative tests + +

Evaluation of possible neoplasm detected on conventional radiographs ++ +

Determining skeletal distribution of neoplasms or other multifocal skeletal disease ++

Note: MRI = magnetic resonance imaging; CT = computed tomography; NM = nuclear medicine (bone
scan); ++ = first choice; + = second choice (must be determined on a case-by-case basis). Adapted
from Bussières et al.; 2007.

Adapted from Bussières, et al. Diagnostic imaging practice guidelines for musculoskeletal complaints
in adults—an evidence-based approach: Introduction. J Manipulative Physiol Ther. 2007;30(9):617-
683.

Magnetic Resonance Imaging

Tissue Type T1 Weighted Image T2 Weighted Image

Cortical bone/calcium Black Black

Red marrow Gray to Dark Gray

Fat/yellow marrow Bright Gray

Ligaments and tendons Dark Dark

Muscle Gray Gray

Fluid Dark gray-black Bright

Adapted from Hayes CW, Balkissoon AA. Magnetic resonance imaging of the musculoskeletal system.
II. The hip. Clin Orthop. 1996;322:297-309.
Chapter 3
Discovering the Patient

Outcome Tools
Ideally, it would be good to use the following during evaluation, midpoint, and
discharge:
1. Region-specific disability index
2. Patient-specific functional scale (PSFS)
3. Visual analog scale for pain
[circled white star] A central tenet of evidence-based practice is to monitor the
outcomes of one's own performance.1
[circled white star] It is important to focus on patient-centered measures, such
as disability scales, instead of impairment outcomes, such as range of motion,
for monitoring outcomes.2

Disability Index Summary

Index Description Scoring Region

PSFS Lower score = more

5 self-report items disabled
Patient-Specific Lumbar,
Functional Scale (Unable) 0-10 (Fully able) scale Minimum clinically cervical, and
important difference knee disorders
Reliability 0.82- Average = PSFS score
(MCID) = 2.0
0.92

Lower score = less

perceived
improvement

15 pt global self-rating scale Scores between ±3

GROC Patients rate their own and ±1 represent
selfperception of improvement (“a small changes
Global Rating of very great deal worse”) −7 to zero All disorders
Change Reliability: (“about the same”) to +7 (“a very Score between ±4 and
not reported great deal better”) ±5 represent
 moderate changes

Scores of ±6 or ±7
represent large
changes

0 = highest level of
function

50 = lowest level of
function

Levels of Disability
NDI 10 sections
0% to 20%—minimal
Neck Disability (Highest level of function) 0-5
20% to 40%—moderate Cervical
Index (Lowest level of function)
disorders
40% to 60%—severe
Reliability: 0.50- Multiply total score by 2 to get %
0.68 disability 60% to 80%—crippled

80% to 100%—bed
bound (or
exaggerating
symptoms)

MCID = 7%-19%

ODI

Oswestry/Modified Same as above Lumbar

Oswestry Same as above
disorders
Disability Index MCID = 6%

Reliability: 0.90

Lower score = more

LEFS
disabled
20 items Lower-
Lower Extremity
LEFS score = sum of extremity
Functional Scale
(Unable) 0-4 (No difficulty) all 20 items disorders
Reliability: 0.98
MCID = 9 points

RMQ Lower score = less

disabled Scores < 4 or
Roland-Morris 24 descriptive items > 20 may not show Back disorders
Back Pain much change over
Disability 24 possible points time
Questionnaire

FABQPA

Fear-Avoidance
Back Lower score = fewer
Questionnaire Items 1-5 fear-avoidance Cervical and
Physical Activity Completely disagree 0-6 behaviors lumbar
disorders
Back pain Completely agree FABQPA = sum of
reliability: 0.77 items 2,3,4,5

Neck pain
reliability: 0.85

FABQW

Fear-Avoidance
Back Lower score = fewer
Questionnaire fear-avoidance
Items 6-16 behaviors Cervical and
Work lumbar
Same as above FABQW = sum of items disorders
Back pain
reliability: 0.90 6,7,9,10,11,12,15
Neck pain
reliability: 0.93

Lower score = more

disabled

90-100 excellent
Harris Hip Score 10 items
80-89 good Post hip
Reliability: 0.91 100 possible points replacement
70-79 fair

60-69 poor

< 59 failed

WOMAC
24 parameters
Western Ontario
96 possible points Lower score = less Hip and knee
 and McMaster (None) 0-4 (Extreme) disabled osteoarthritis
Universities Index
of Osteoarthritis

SSS 11 items Carpal tunnel

Lower score = less syndrome/wrist
Symptoms (Mildest) 1-5 (Most severe) scale
disabled and hand
Severity Scale Average of 11 items = SSS score disorders

Lower score = less

DASH
disabled
Disabilities of the
30 item self-report At least 27 items must
Arm, Shoulder, Upper-limb
be scored DASH =
and Hand Outcome (No difficulty) 1-5 (Unable) disorders
{(sum of n responses)-
Questionnaire
1}*25 n
Reliability: 0.90
MCID = 15 points

Lower score = less

SPADI
pain and disability
Shoulder Pain and Items 1-5 rated on 0-10 pain scale Summate scores and
divide by highest Shoulder
Disability Index
Items 6-13 rated on (No difficulty) possible score disorders
Reliability: 0.64- 0-10 (So difficult, required help) Multiply by 100
0.66
MCID = 10 points

Numeric pain Higher score = more

Scale 0-10 scale pain All disorders
Reliability: 0.76 MCID = 2.0

References
PSFS
Chatman A, Neel J, Hyams S, Binkley J, Stratford P, Schomburg A, et al. The
Patient-Specific Functional Scale: Measurement properties in patients with
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Stratford P, Gill C, Westaway M, Binkley J. Assessing disability and change on
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Westaway M, Stratford P, Binkley J. The Patient-Specific Functional Scale:
Validation of its use in persons with neck dysfunction. J Ortho Phys Ther.
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GROC
Deyo RA, Patrick DL. Barriers to the use of health status measures in clinical
investigation, patient care, and policy research. Med Care. 1989;27:S254-S268.
Jaeschke R, Singer J, Guyatt GH. Measurement of health status: Ascertaining
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Stratford P, Binkley JM, Solomon P. Assessing change over time in patients with
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Beurskens AJHM, de Vet HCW, Koke AJA. Responsiveness of functional status in
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NDI
Vernon H, Mior S. The Neck Disability Index: A study of reliability and validity. J
Manipulative Physiol Ther. 1991;14:409-415.
Cleland JA, Fritz JM, Whitman JM, et al. The reliability and construct validity of
the Neck Disability Index and Patient-Specific Functional Scale in patients with
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Cleland JA, Childs JD, Whitman JM. Psychometric properties of the Neck
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ODI
Fairbank JC, Couper J, Davies JB, O'Brien JP. The Oswestry Low Back Pain
Disability Questionnaire. Phys Ther. 1980;66:271-273.
Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine. 2000;25:2940-
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Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back Pain
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RMQ
Stratford PW, Binkley J, Solomon P, et al. Defining the minimum level of
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FABQ
Flynn T, Fritz J, Whitman J, Wainner R, et al. A clinical prediction rule for
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Fritz JM, George SZ, Delitto A. The role of fear-avoidance beliefs in acute low
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Harris Hip Score
Soderman P, Malchau H. Is the Harris Hip Score useful to study the outcome of
total hip replacement? Clin Orthop Relat Res. 2001;384:189-197.
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WOMAC
Bellamy N, Buchanan WW, et al. Validation study of WOMAC: A health status
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Rheumatol. 1988;15:1833-1840.
Bellamy N. Pain assessment in osteoarthritis: Experience with the WOMAC
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Bellamy N, Kean WF, et al. Double blind randomized controlled trial of sodium
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Hawker G, Melfi C, et al. Comparison of a generic (SF-36) and a disease specific
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Lequesne M. Indices of severity and disease activity for osteoarthritis. Semin
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SSS
Spies-Dorgelo MN, et al. Reproducibility and responsiveness of the Symptom
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DASH
Solway S, Beaton DE, McConnell S, Bombardier C. The DASH Outcome Measure
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SPADI
Heald SL, Riddle DL, Lamb RL. The Shoulder Pain and Disability Index: The
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Res. 1991;4:143-149.
Williams JW, Holleman DR, Simel DL. Measuring shoulder function with the
Shoulder Pain and Disability Index. J Rheumatol. 1995;22:727-732.

Numeric Pain Scale

Cleland JA, Fritz JM, Whitman JM, et al. The reliability and construct validity of
the Neck Disability Index and Patient-Specific Functional in patients with
cervical radiculopathy. Spine. 2006;31:598-602.

Subjective Exam Tips

1. Be orderly in your question asking.
2. Try to follow the same question sequence every time (to facilitate pattern
building and recognition).
3. Be compassionate, yet maintain control of the interview.
4. Be aware of the patient's narrative/story.
5. Be open minded.
6. Educate patient. Diffuse threats or false beliefs (pathology/educate patients
about their plan of care/diffuse fear avoidance).
7. Paint a picture of the patient and his or her problem to see if it matches any
patterns you already recognize.
8. Ensure that the subjective exam allows you to answer the SINSS (severity,
irritability, nature, stage and stability) questions that drive your objective
exam.
9. A fairly regimented subjective exam is useful in the early stages of learning
to facilitate systematic pattern generation and recognition. It also can be
useful for the more complicated patients.
10. As the therapist matures, a more flowing, less regimented conversation
that allows the patient to talk freely but remains skillfully under the expert
therapist's control is ideal.

Questions that the Subjective exam Should Answer

1. Subjective medical screening for red flags or follow-up questions based on
medical screening questionnaire (Is the patient PT appropriate?) See Chapter 2
system-specific screening questions.
2. How old is the patient and how active? (Age affects healing and prognosis.)
3. Job demands? (stress on patient's body and mind)
4. What is the main problem in the patient's own words/perception? (Identify
and diffuse fear-inducing concepts.)
5. Description of the location, signs, and symptoms (Hypothesize on source
structure/referral sources.)
6. Relationship of the various symptoms and signs to one another (Confirm
relationship by treatment of a key impairment and reassessing other related
pain areas.)
7. Irritability of the condition (This determines how much you can do in your
objective exam.)
8. Activities or positions that aggravate the symptoms

9. Activities or positions that ease the symptoms

10. 24-hour pain pattern (red flag screening, degenerative morning stiffness)
11. Sleep disturbances (ongoing inflammatory process resulting in night pain or
cancer red flag)
12. Current history of problem
13. Past interventions and their effects
14. Psychosocial pressures/family support (yellow flag screening)
15. Past history of problem (patterns of repeated injury or slow progression of
impairments over time)
16. Stability of the current problem
17. Patient goals
FIGURE 3-1 Body Chart Front
 FIGURE 3-2 Body Chart Rear

Discovering the person (Subjective Questioning expanded)

1. Intake form screening
2. How old are you?

Age affects prognosis in terms of tissue healing times, and the likelihood of
repetitive strain to tissue due to decreased tissue integrity.
Likelihood of cancer/osteoporosis/other systemic diseases

3. What activities/hobbies do you do regularly?

Do you exercise on a regular basis?
What is your profession, and what are its demands on the body?

All of the above affect prognosis

These questions help paint a picture of the person's overall activities and well
being.

4. What is the worst area?

Asking the patient to define the worst area can help focus the exam,
especially for those with multiple symptomatic regions.
Follow up on the pain diagram the patient has already filled out.

Subjective Question Sequence

Body chart
5. Re-establish symptom areas.
Subjective clearing—quick clear of potential pain regions and referral sources
P1: T-D-C (Type, Depth, Constancy)
Type—Please describe your symptoms.
Depth—Please describe the depth of your symptoms (deep or superficial).
Constancy—Is there a moment in the day when you do not have symptoms?
P2: T-D-C (as needed)
6. Do you feel your symptoms are related? If so, why?
7-9. Symptom behavior
Aggravating factors (Aggs)/Easing (Eases) factors for each symptom
Severity: Based on the Aggs/Eases, how severely is the problem limiting the
patient's function/impacting the patient's life?
Irritability:

How much activity does it take to aggravate symptoms?

How bad do the symptoms get, on a 0-10 scale?
 How long does it take to ease?

10. 24-hour symptom pattern: AM/PM pattern

11. Do your symptoms disturb your sleep? If so, how many times and how hard is
it to return to sleep?
12. History present: Most recent exacerbation if a reoccurring problem
When?
How?
Are symptoms currently better/worse/same? (0%-100%)
13. Previous treatments and effects
14. Psychosocial pressures/family support
Explore the context in which the patient lives, and consider its effect on
patient perceptions and prognosis.
15. History past: Past history of similar problem or any potentially related
problems
Same as above.
16. Patient Goals
Goals should be functional and measurable.
1Sackett DL, Richardson W, Rosenberg W, Haynes R. Evidence-Based Medicine:
How to Practice and Teach EBM. New York: Churchill Livingstone; 2000.
2Flynn T, et al. Spinal manipulation in physical therapist professional degree
education: a model for teaching and integration into clinical practice. J Orthop
Sports Phys Ther. 2006;36(8):577-587.
Chapter 4
Pain

Complex regional pain Syndrome (CRPS)

TBC/Special
Prevalence Symptoms DSM/Signs
tests

42% stressful
Seen an average 4.8 different Autonomic signs 98% that Education4
life event
physicians before referral to pain changed with duration of
near onset of
center1 CRPS2 Explain pain
CRPS2

41% history Skin warmer in acute

Laterality
Average of 5 different prior to and of chronic stages; Skin colder in
reconstruction
during pain center treatment1 pain before chronic stages; Edema in
training
CRPS2 acute stages2

Weakness2

17% had a lawsuit1 54% had a workers'

Pain at rest Tremor2
compensation claim related to CRPS; 77%2 Motor imagery
Exaggerated tendon
47% had physicianimposed training
Hyperalgesia reflexes2
immobilization1
94%2
Dystonia or myoclonic
jerks2

Increased warm/ Mirror

Pain deep in decreased cold therapy3
66% had myofascial component
limb temperature perception
present at evaluation1
“tearing”2 thresholds of affected Pacing
limb2 instruction

1
Allen G, Galer BS, Schwartz L. Epidemiology of complex regional pain syndrome: A retrospective
chart review of 134 patients. Pain. 1999;80(3):539-544 (16 ref.).

2
Birklein F, Riedl B, Siewek, N, Weber M, Neundorfer B. Neurological findings in complex regional
pain syndromes: Analysis of 145 cases. Acta Neurol Scand. 2000;101(4):262-269.

3
McCabe CS, Haigh RC, et al. A controlled pilot study of the utility of mirror visual feedback in the
treatment of complex regional pain syndrome (type 1). Rheum (Oxford). 2003;42:97-101.

4
Moseley GL, Hodges PW, et al. A randomized controlled trial of intensive neurophysiology
education in chronic low back pain. Clin J Pain. 2004;20:324-330.

Fibromyalgia

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

American College of Rheumatologists

(ACR)

11 of 18 ACR-identified tender
point1

1. Occiput*—at suboccipital muscle

insertions
Fatigue2
2. Low Cervical*—anterior aspects of Education
Widespread pain that the intertransverse spaces of C5-7
North America Explain pain
covers half the body1
5.0% adult women3 *
3. Trapezius —midpoint of UT
border Exercise
3 Lasting > 3 months1,4
1.5% adult men
4. Supraspinatus*—at spine near Aerobic fitness
Women 55-64 Nonrestorative sleep2 exercise5
medial border
years old most
Morning stiffness2 Quota-based
common3 5. Second Rib*—at costochondral
junctions walking
Memory and
program6
cognitive difficulties2
6. Lateral Epicondyle*

7. Gluteal*

8. Greater Rrochanter*

9. Knee—proximal to joint line

*
= bilateral

1
Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the
classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum.
1990;33:160-172.

2
Wolfe F. Fibromyalgia: The clinical syndrome. Rheum Dis Clin North Am. 1989;15:1-18.

3
White KP, Speechley M, Harth M, Ostbye T. The London Fibromyalgia Epidemiology Study: The
prevalence of fibromyalgia syndrome in London, Ontario. J Rheumatol. 1999;26:1570-1576.

4
American College of Sports Medicine. American College of Sports Medicine's Guidelines for
Exercise Testing and Prescription. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.

5
Brosseau L, et al. Ottawa panel evidence-based clinical practice guidelines for aerobic fitness
exercises in the management of fibromyalgia: Part 1. Phys Ther. 2008;88(7):857-871.

6
Holtgrefe K, et al. Changes associated with a quota-based approach on a walking program for
individuals with fibromyalgia. J Orthop Sports PhysTher. 2007;37(12):717-724.

FIGURE 4-1 Fibromyalgia Front

FIGURE 4-2 Fibromyalgia Rear
FIGURE 4-3 Positive Cognitive Reinforcement
FIGURE 4-4 Negative Cognitive Reinforcement
 FIGURE 4-5 Tissue Healing

Butler D. Explain Pain Course Notes; 2008.

Burton AK, et al. Information and advice to patients with back pain can have a
positive effect: A randomized controlled trial of a novel educational booklet in
primary care. Spine. December 1, 1999;24(23):2484.
[circled white star] Primary intervention goal is increase in activity.
[circled white star] Intervention does not focus on symptom abatement.
[circled white star] Close monitoring by the therapist may be as important as
the graded exercise itself.
FIGURE 4-6 Graded Exercise
George, SZ, et al. The effect of a fear-avoidance-based physical therapy intervention
for patients with acute low back pain: Results of a randomized clinical trial. Spine.
2003;28(23):2551-2560.
George SZ, et al. Physical therapist management of a patient with acute low back pain
and elevated fear-avoidance beliefs. Phys Ther. 2004;84:538-554
FIGURE 4-7 Graded Exposure
Linton SJ, Boersma K, Jansson M, Overmeer T, Lindblom K, Vlaeyen JW. A randomized
controlled trial of exposure in vivo for patients with spinal pain reporting fear of work-
related activities. Eur J Pain. 2008;12(6):722-730.
George SZ, Zeppieri G Jr, Cere AL, et al. A randomized trial of behavioral physical
therapy interventions for acute and sub-acute low back pain. Pain. 2008;140(1):145-
157.
Chapter 5
Temperomandibular Joint

TMJ Normal ROM

Opening 40 mm or 3 Fingers Width at DIP

Laterotrusion 6-8 mm

Protrusion 6-8 mm

Retrusion 1 mm

Occlusion

Class I Normal, 2 mm overbite, 2 mm overjet

Class II “Overbite,” > 2 mm overbite and overjet

Class III “Underbite,” < 2 mm overjet

 FIGURE 5-1 TMJ Opening

FIGURE 5-2 TMJ Closing

Common tissues for Palpation in TMJ Dysfunction

1. Temporalis and tendon
2. Masseter
3. TMJ
4. Medial Pterygoid
5. Lateral Pterygoid
6. Parotid glands
7. Sternocleidomastoid
8. Upper Trapezius
9. Levator Scapulae
10. Sub-occipital extensors (Rectus Capitis Posterior Major and Minor; Superior
Oblique Capitis; Inferior Oblique Capitis)

FIGURE 5-3 TMJ Muscles

Temporomandibular Joint Dysfunction (TMD)

Prevalence Symptoms Signs TBC/Special Tests

Pain with
chewing,
yawning,
talking, using
Pain Control/Trigger point reduction
jaw1
Stabilize
Clenching or
grinding1 Educate
3 to 9:1 female to Noises or “N” position
male3 crepitus1
Soft diet
15-40-year-old Difficulty
females8 opening mouth1 No chewing gum

33% with at least Contributing No meat

one TMD Factors1
symptom5,7 Pain in or With or without Mobilize
around the ear trauma
50% of non-patient temple or cheek Short-lip test
population may recent injury to Blow to face or
have joint sounds jaw Occlusion assessment
head/neck1
or deviations on
Fracture, Upper quarter muscle length strength
opening9 Symptoms usually
injection testing
fluctuating, self-
3.6%-7% of the limiting, and Mouth:
above patients will Dental work
remitting over opening/closing/laterotrusion/overbite
seek care due to time4,8 Forceful and overjet assessment
severity of chewing
symptoms2,6 Bitestick
Stress
Over 45 years old: “N” Position
OA of TMJ most Repetitive
common cause of loading
TMD8 1. Tongue placed on roof of mouth
Bruxing habit (like saying “N”)
(clenching or
grinding) 2. Lips together

Protrusive 3. Teeth apart

posturing with
head and neck
or mandible
Iatrogenic

1
Adachi N, Wilmarth MA, Merrill RL. Current Concepts of Orthopaedic Physical Therapy 2nd ed.
Independent Study Course 16.2.12. 2006;1-2, Othopaedic Section, APTA, Inc.

2
Dworkin SF, LeResche L. Temporomandibular disorder pain: Epidemiologic data. APS Bulletin.
1993;1210.

3
Levitt SR, McKinney MW. Validating the TMJ scale in a national sample of 10,000 patients:
Demographic and epidemiologic characteristics. J Orofacial Pain. 1994;8:25-35.

4
Randolph CS, Greene CS, Moretti R, et al. Conservative management of temporomandibular
disorders: A post-treatment comparison between patients from a university clinic and from private
practice. Am J Orthod Dentofac Othop. 1990;98:77-82.

5
Rugh JD, Solberg WK. Oral health status in the United States: Temporomadibular disorders. J Dent
Educ. 1985;49:398-404.

6
Schiffman E, Fricton JR, Haley D, Shapiro BL. The prevalence and treatment needs of subjects with
temporomandibular disorders. J Am Dent Assoc. 1989;120:295-304.

7
Schiffman E, Friction JR. Epidemiology of TMJ and craniofacial pain. In: Fricton JR, Droening RJ,
Hathaway DM, eds. TMJ and Craniofacial Pain: Diagnosis and Management. St. Louis, MO: Ishida
Euro American. 1988;1-10.

8
Solberg WK. Temporomandibular disorders. Br Dent J. 1986;3:1-14.

9
Wabeke DB, Spruijt RJ. On Temperomandibular Joint Sounds: Dental and Psychological Studies
(thesis). Amsterdam: University of Amsterdam. 1994;91-103.
Chapter 6
Cervical Region

Cervical Motion Normal range

Flexion 0-45°

Extension 0-45°

Lateral flexion 0-45°

Rotation 0-60°/80°

Outcome tools

NDI—Neck Disability Index

FABQPA/FABQW—Fear-Avoidance Back Questionnaire Physical Activity/Work

GROC—Global Rating of Change Scale

PSFS—Patient Specific Functional Scale

Reliability of Measurements of Cervical Spine Range of Motion

Interrater
Cervical Interrater Reliability Interrater reliability
Motion ROM Reliability
Joints CROM ICC (95% CI) Visual Estimate
Goniometer
Cervical Flexion 0-45° 0.86 0.57 0.42

Extension 0-45° 0.86 0.79 0.42

Lateral
0-45° 0.73 0.79 0.63
flexion

0-60
L/R
to 0.82/0.92 0.54/0.62 0.70/0.82
Rotation
80°

Moderate-good Average-moderate
Good reliability
reliability reliability

Youdas J, Carey J, Garrett T. Reliability of measurements of cervical spine range of motion.

Comparison of 3 models. Phys Ther. 1991;71:98-106.
FIGURE 6-1 The Vertebral Column and Features of Selected Vertebrae
Clark, Robert K. Anatomy and Physiology: Understanding the Human Body. © 2005
Jones & Bartlett Publishers, LLC.
FIGURE 6-2 Dermatomes of the Upper Extremity and the Cutaneous Innervation of the
Arm by the Peripheral Sensory Nerves

Spinal Reflex Reflex Reflex Reflex -

Dermatome Myotome Reflex
Levels Sens Spec +LR LR

C/S
C1 Top of head -
rotation

Shoulder
C2,3,4 Face -
elevation
 C4 Anterolateral Shoulder -
neck elevation

Lateral
Shoulder
C5 antecubital Biceps 0.24/0.10 0.95/0.99 0.80/10.0 4.9/0.91
abduction
fossa

Elbow √ +
C6 Thumb Brachioradialis 0.06/0.08 0.95/0.99 0.99/8.0 1.2/0.93
Wrist /

Elbow / +
C7 Index finger Triceps 0.03/0.10 1.05/0.95 1.05/2.0 40/0.95
Wrist √

Thumb /
C8 Fifth finger or Ulnar. -
Dev

Central
Finger
T1 antecubital -
abduction
fossa

Wainner Wainner Wainner Wainner

et et et et
al./Lauder al./Lauder al./Lauder al./Laud
et al. et al. et al. et al.

Dermatome testing 101:

1. Patient must be blinded to the side being tested. (“Please close your
eyes.”)
2. Test bilaterally within a short time span.
3. Patient should be clearly instructed on the following: “Do you feel this?
Does it feel different from or the same as the other side?”
[circled white star] Subjective report of weakness, numbness, arm pain, neck
pain, tingling, and burning tends not to be able to predict the results of
electrodiagnostic testing very well. If the signs/symptoms are denied by the
patient, there is a higher chance that nerves are not involved. If a patient
complains of burning, then there is a higher chance that nervous tissue is
involved.
Lauder TD, et al. Predicting electrodiagnostic outcome in patients with upper-
limb symptoms: Are history and physical examination helpful? Arch Phys Med
Rehabil. 2000;81:436-441.

FIGURE 6-3 CROM CS Flexion

FIGURE 6-4 CROM

 FIGURE 6-5 CROM CS Extension

Cervical AROM
Ask the patient to demonstrate cervical AROM, ask for a pain scale of 0-10
related to each motion. This is moderately reliable and should be used for
reassessment and hypothesis generation.
Using a 0-10 scale for pain during cervical AROM and overpressures:
In patients with neck pain (n = 32), interrater reliability: Moderate K = 0.36-
0.71. Pool et al.
*The general trend is moderate reliability for assessing pain with AROM with
overpressures.
In patients with headaches (n = 24), interrater reliability: Moderate K = 0.46-
0.67. Van Suijlekom, et al.
*The general trend is moderate reliability for assessing pain during cervical
AROM in patients with headaches.
Pool J, et al. The interexaminer reproducibility of physical examination of the
cervical spine. J Manipulative Physiol Ther. 2003;27:84-90.
Van Suijlekom H, et al. Interobserver reliability in physical examination of the
cervical spine in patients with headache. Headache. 2000;40:581-586.
 FIGURE 6-6 PPIVM Up Glide

FIGURE 6-7 PPIVM Side Glide

FIGURE 6-8 PPIVM Down Glide

PPIVMs: Passive Physiological Intervertebral Motion

In patients with neck pain (n = 32), Pool, et al. or non-specific neck problems (n
= 61), Smedmark, et al.
When motion limitation is the positive finding, interrater reliability: Poor.
When pain provocation (0-10 pain scale) is the positive finding related to
PPIVMs, interrater reliability: Moderate-good.
Pool J, et al. The interexaminer reproducibility of physical examination of the
cervical spine. J Manipulative Physiol Ther. 2003;27:84-90.
Smedmark V, et al. Interexaminer reliability in assessing passive intervertebral
motion of the cervical spine. Man Ther. 2000;5:97-101.
[circled white star] It is probably more reliable to base your decision on pain
provocation related to its corresponding passive physiological motion than to go
off perceived motion limitation during PPIVM testing.

Palpation
PAIVM: passive accessory Intervertebral Motion
Is palpation of the spinous processes reliable for neck pain?
[circled white star] Viikari-Juntura, et al. and Bertilson et al. demonstrated
that palpation in patients with neck and/or shoulder pain was generally
moderately reliable (K = 0.47-0.79), but shows poor reliability in headache
patients (van Suijlekom).
Bertilson actually noted that reliability generally improved if the therapist was
blinded from patient history.

Interrater
Patient Population Positive Test
Reliability

52 patients with cervical spondylosis (central PA)

24 Patients with headache (unilateral PA) Pain with palpation (central or Poor-
unilateral PA pressure) moderate
100 patients with neck and/or shoulder problems
with or without radiating pain (central PA)

[circled white star] The trend you are noticing is moderate to poor reliability of
these tests individually. I would suggest doing AROM, PPIVMs and PAIVMs,
relating pain, stiffness/abnormal resistance, endfeel, and using the various
positive findings to help “triangulate” on the location of the target treatment
zone … correlate these findings with the subjective exam as well …
Jull, et al. was able to identify in 20 out of 20 patients the appropriate joint
level where dysfunction was occurring based on the suggestions above.

Sensitivity Specificity

1.0 1.0

Jull G, Bogduk N, Marsland A. The accuracy of manual diagnosis for cervical

zygapophyseal joint pain syndromes. Med J Aust. 1988;148:233-236.
Viikari-Juntura E. Interexaminer reliability of observations in physical
examinations of the neck. Phys Ther. 1987;67:1526-1532. Bertilson B, et al.
Reliability of clinical tests in the assessment of patients with neck/shoulder
problems. Impact of history. Spine. 2003;28(19):2222-2231.
Van Suijlekom H, et al. Interobserver reliability in physical examination of the
cervical spine in patients with headache. Headache. 2000;40:581-586.

FIGURE 6-9 Cervical Central PA

FIGURE 6-10 Cervical Unilateral
Reliability κ Sensitivity Specificity (+) LR (−) LR

0.61 992 452 1.812 0.012

1
Bandiera G, et al. Canadian C-spine and CT head study group. The Canadian C-spine rule performs
better than unstructured physician judgement. Ann Emerg Med. 2003;42(3):395-402.

2
Stiell IG, et al. The Canadian C-spine rule versus the Nexus low-risk criteria in patients with
trauma. N Engl J Med. 2003;349(26):2510-2518.

Level 1 Classification: Is the Patient Appropriate for Physical

Therapy?
Red Flags for the Head and Neck Region
 Red Flag Data
Red Flag Data Obtained During Physical
Condition Obtained During
Exam
Interview/History

Sudden onset of a
Concurrent elevated blood pressure Trunk
Subarachnoid hemorrhage— severe headache
and extremity weakness, aphasia Altered
Ischemic stroke1,2 History of
mental status Vertigo, vomiting
hypertension

Vertigo that lasts for minutes (not seconds)

Dizziness Visual disturbances

Vertebrobasilar Headaches Apprehension with end-range neck

insufficiency3-5 movements
Nausea
Unilateral hearing loss
Loss of consciousness
Vestibular function abnormalities

Positive slump sign

Headache
Photophobia
Fever
Meningitis6,7 Confusion
Gastrointestinal signs
of vomiting and Seizures
symptoms of nausea
Sleepiness

Ataxia

Speech deficits
Headache
Sensory abnormalities
8 11 Gastrointestinal signs
Primary brain tumor -
of vomiting and Visual changes
symptoms of nausea
Altered mental status

Seizures

Loss of consciousness/dazed—an initial

 Dangerous injury Glasgow Coma Scale of 13 to 15
mechanism
Mild traumatic brain injury— Deficits in short-term memory
Post-concussion Syndrome— Headache
Subdural hematoma12,13 Physical evidence of trauma above the
Nausea/vomiting clavicles

Sensitivity to light Drug or alcohol intoxication

and sounds
Seizures

1
Hiroki O, Hidefumi T, Suzuki S, Islam S. Risk factors for aneurysmal subarachnoid hemorrhage in
Aomori, Japan. Stroke. 2003;34:34-100.

2
Hong YH, Lee YS, Park S. Headache as a predictive factor of severe systolic hypertension in acute
ischemic stroke. Can J Neurol Sci. 2003;30:210-214.

3
Grad A, Baloh RW. Vertigo of vascular origin. Clinical and electronystagmographic features in 84
cases. Arch Neurology. 1989;46:281-4.

4
Szirmai A. Evidences of vascular origin of cochleovestibular dysfunction. Acta Neurol Scand.
2001;104:68-71.

5
Silbert PT, Bahram M, Schievink WI. Headache and neck pain in spontaneous internal carotid and
vertebral artery dissections. Neurology. 1995;45:1517-1522.

6
Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine: A
systematic review of the literature. Spine. 1996;21:1746-1760.

7
Bruce M, Rosenstein N, Capparella J, et al. Risk factors for meningococcal disease in college
students. JAMA. 2001;286: 688-693.

8
Berger JP, Buclin T, Haller E, et al. Does this adult patient have acute meningitis? JAMA.
1999;282:175-181.

9
Snyder H, Robinson K, Shah D, et al. Signs and symptoms of patients with brain tumors presenting
in the emergency department. J Emerg Med. 1993;11:253-258.

10
Zaki A. Patterns of presentation in brain tumors in the United States. J Surg Oncology.
1993;53:110-112.

11
Forsyth PA, Posner JB. Headaches in patients with brain tumors: A study of 111 patients.
Neurology. 1993;43:1678-1683.

12
Sobri M, Lamont AC, Alias NA, Win MN. Red flags in patients presenting with headache: Clinical
indication for neuroimaging. Brit J Radiology. 2003;76:532-535.

13
Borg J, Holm L, Cassidy JD, et al. Diagnostic procedures in mild traumatic brain injury: Results of
the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med.
2004;Suppl.43:61-75.

Red Flags for the Neck and Shoulder Region

Red Flag Data Obtained During Red Flag Data Obtained

Condition
Interview/History During Physical Exam

Canadian C-Spine rules

Midline cervical spine

tenderness

Positive ligamentous
Major trauma such as a motor vehicle accident integrity tests:
Cervical fractures or
or a fall from a height with associated
ligamentous Sharp-Purser test
immediate onset of neck pain Rheumatoid
instabilities1,2,3,4,5,6
arthritis or Down's syndrome
Alar Ligament Integrity
test

Apprehension with or
inability to actively rotate
head < 45°

Gait disturbances due to

hyperreflexic lower
Older age
extremities
Cervical central cord
History of a trauma (esp. MVA or fall)
lesion7-9 Upper-extremity
Incontinence (especially hand) sensory
and motor deficits, and
atrophy

Wheezing with
auscultation when tumor
obstructs bronchus
Men over 50 with a history of cigarette smoking
May have Horner's
10 12 “Nagging” type pain in the shoulder and along syndrome
Pancoast tumor - the vertebral border of the scapula—often
progressing to burning pain down the arm into Ptosis (drooping eyelid)
the ulnar nerve distribution
Constricted pupil
 Sweating disturbances

Tender S-C joint

Insidious onset of chest pain localized in the S-C
Septic arthritis Limited shoulder
joint
movement
(A-C joint)13 History of IV drug use, diabetes, trauma,
Swelling over S-C joint
infection (especially of central venous access)
Fever

Insidious onset of spinal pain History of spinal

fracture15
> 7 million white women aged 50 years and over
14 affected at any given time Spinal bone density
Vertebral fracture
decrease by 2 standard
> 500,000 white women develop vertebral deviations = 5.8 fold
deformity for the first time each year increase in fracture rate15

1
Aspinall W. Clinical testing for the craniovertebral hypermobility syndrome. J Orthop Sports Phys
Ther. 1990;12:47-54.

2
Panjabi M (1992). In: Swinkels R, Beeton K, Alltree J. Pathogenesis of upper cervical instability.
Manual Therapy. 1996;1:127-132.

3
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to
rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-
Radiography Utilization Study Group. [erratum appears in N Engl J Med. 2001;344(6):464]. N Engl J
Med. 2003;343:94-99.

4
Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-Spine
Rule versus the Nexus Low-Risk Criteria in patients with trauma. N Engl J Med. 2003;349:2510-2518.

5
Niere KR, Torney SK. Clinicians' perception of minor cervical instability. Manual Therapy.
2004;9:144-150.

6
Delfini R, Dorizzi A, Facchinetti G, et al. Delayed post-traumatic cervical instability. Surg Neurol.
1999; 51:588-595.

7
Newey MI, Sen PK, Fraser RD. The long-term outcome after central cord syndrome: A study of the
natural history. J Bone Joint Surg Br. 2000;82:851-855.

8
Tow AM, Kong KH. Central cord syndrome: Functional outcome after rehabilitation. Spinal Cord.
1998; 36:156-160.

9
Waters RL, Adkins RH, Sie IH, Yakura JS. Motor recovery following spinal cord injury associated
 with cervical spondylosis: A collaborative study. Spinal Cord. 1996;34:711-715.

10
Spengler D, Kirsh M, Kaufer H. Orthopaedic aspects and early diagnosis of superior sulcus lung
tumor. J Bone Joint Surg. 1973;55:1645-1650.

11
Jett J. Superior sulcus tumors and Pancoast's syndrome. Lung Cancer. 2000;42:S17-S21.

12
Robinson D, Halperin N, Agar G, et al. Shoulder girdle neoplasms mimicking frozen shoulder
syndrome. J Shoulder Elbow Surg. 2003; 12:451-545.

13
Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: Review of 180 cases. Medicine.
2004;83:139-148.

14
Melton LJ. Prevalence and incidence of vertebral deformities. Osteoporosis Int. (1993); 3:113-
119.

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Ross PD, et al. Predicting vertebral fracture incidence from prevalent fractures and bone density
among non-black, osteoporotic women. Osteoporosis Int. 1993;3(3):120-126.

With permission of Joe Godges, Kaiser Permanente, Southern California Rehabilitation Specialist
Resources Page.

Level 2 Treatment-Based Classifications for Neck Pain**

Use of observed impairments to classify patients into appropriate treatment
groups

1. Mobility Classification—Findings

Recent onset of symptoms

No radicular or referred symptoms in the upper quarter
Restricted ROM with side-to-side rotation, or discrepancy in lateral flexion
ROM, or both
No signs of nerve root compression or peripheralization of symptoms in the
upper quarter with cervical ROM

Interventions

Cervical ROM
Thoracic ROM
 Mobilizations designed to improve cervical and thoracic ROM (Grades I-V)
AROM exercises
Foam roll exercises

2. Centralization Classification—Findings

Radicular or referred symptoms in the upper quarter

Peripheralization, or centralization of symptoms with ROM, or both
Signs of nerve root compression present

Wainner, et al. cluster for ruling in radiculopathy

+ Spurling A
+ ULTT
+ Neck Distraction Test
< 60° C/S rotation toward involved side

Interventions

Mechanical or manual cervical traction

Repeated movements to centralize symptoms
Multilevel cervical side glides toward the side of symptoms while in ULNT
median nerve position

3. Conditioning and Increased exercise tolerance

Classification—Findings

Lower pain and disability scores

Longer duration of symptoms/more chronic history
No signs of nerve root compression
 No peripheralization or centralization during ROM

Interventions

Strengthening and endurance exercises for the muscles of the neck and upper
quarter
Aerobic conditioning exercises

Deep Neck Flexor endurance training

1. Patient is supine, relaxed.
2. Place folded cuff under neck against occiput.
3. Inflate to 20 mmHg.
4. Instruct patient to gently nod head (cranio-cervical flexion).
5. Watch for substitution by SCM.
6. Nod to 22 mmHg; hold for 10 seconds.
7. Relax.
8. Increase by 2 mmHg to 24 mmHg; hold for 10 seconds.
9. Increase in 2 mmHg increments up to 30 mmHg.

FIGURE 6-11 Deep Neck Flexor with Stabilizer

4. pain Control Classification—Findings

High pain and disability scores

Very recent onset of symptoms
Symptoms precipitated by trauma
Referred or radiating symptoms extending into the upper quarter
Poor tolerance for examination or most interventions

Interventions

Gentle AROM within pain tolerance

ROM exercise for adjacent regions
Physical modalities as needed
Activity modification to control pain

5. reduce headache Classification—Findings

Unilateral headache (fronto-ocular region) with onset preceded by neck pain

Headache pain triggered by neck movement or positions
Headache pain elicited by pressure on ipsilateral posterior neck pain

Ruling in cervicogenic headache

Stiff/painful upper cervical spine segments C1-2

Reduced cervical flexion/extension
Muscle tightness

Zito G, Jull G, Story I. Clinical tests of musculoskeletal dysfunction in the

diagnosis of cervicogenic headache. Man Ther. 2006;11(2):118-29. Epub 2005 Jul
18.
Interventions

Cervical spine mobilizations (Grades I-V)

Strengthening of neck and upper quarter (deep neck flexor training)
Postural education

Movement Science
Movement Impairments of the Cervical Spine: DSM (Directional
Susceptibility to Movement)

Extension Rotation Flexion

Rotation-extension Rotation-flexion

**Cervical diagnosis often will have an associated scapula and/or humeral movement diagnosis

Key Tests for Movement Impairments of the Cervical Spine

Standing Posture

C/S AROM: Look at Deviation from Optimal Motion (combined)

Motion: Rotation with side bending

Shoulder AROM

Flexion: Look for pain and unwanted motion at C4

Abduction: Look for pain and unwanted motion at C/S

MMT
Supine tests Lower abdominal

Intrinsic neck flexor

MMT

Prone Tests Lower Trapezius

Middle Trapezius

Quadruped Rocking back

Neck flexion/extension

Cervical Spondylosis

Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control
Stabilization
Extension
Immobilization3,4
Increased or decreased
DTR2,5 Mobilization
exercise
Precordial pain6 Pathological reflexes (+)5 endurance

Onset: 50+ y/o2 Headache6 Osteoarthritis1 Gentle

mobilization2,4
C/S levels most commonly Vertigo6 Decreased C/S AROM and
affected: C5-6 and C6-71 PROM 2° to pain2 Traction3,4
Neck, shoulder,
and arm pain5 N/T4,5 C/S palpation,
ROM and MMT2,4
Decreased strength4
Spurling's Test2
Tender to palpation at the
level of C/S involvement2 MRI4,6

CT1,4

1
Kulkarni AG, Sabet T, Ashley H, Diwan D. Technical note: The swimmer's view for cervical facet
joint injections. Eur Spine J. 2006;15:1150-1152.

2
Magee D. Orthopedic Physical Assesment. 4th ed. St. Louis, MO: Elsevier Sciences; 2006.

3
Ozdemir H, Berligen MS, Serhatlyo S, Polat H, Ergun U, Barys N, Hardalac F. Examination of the
effects of degeneration on vertebral artery by using neural network in cases with cervical
spondylosis. J Med Sys. 2005;29(2).

4
Persson LC, Carlsson C, Carlsson JY. Long-lasting cervical radicular pain managed with surgery,
physiotherapy, or a cervical collar: A prospective, randomized study. Spine. 1997;22(7):751-758.

5
Yonenobu K. Cervical radiculopathy and myelopathy: When and what can surgery contribute to
treatment? Eur Spine J. 2000;9:1-7.

6
Zoëga B, Kärrholm J, Lind B. Outcome scores in degenerative cervical disc surgery. Eur Spine J.
2000;9:137-143.

Cervical Facet Syndrome

TBC/Special
Prevalence Symptoms DSM/Signs Tests

Extension
Pain with extension and Rotation Mobilization
rotation,8 often bilateral5
Exercise
Decreased ROM8
Pain can be gradual or endurance
Of people with chronic neck acute following a traumatic Muscle spasm
Cervical ROM1
pain, 54-60% are from facet4 incident8 upon palpation3,8
Spurling's
No gender bias, but chronic Posterior neck stiffness3,8 Possible increased
Test4,8
neck pain is more often seen symptoms with
in women Cervicogenic headache1 ULTT3,8 Palpation of
cervical spine
Often seen after whiplash Possible pain referral to Hypomobile
facets1,8
injury4,5,8 shoulder, scapular segments of
regions3,8 and UE8
PAIVM, PPIVM1
C-Spine8
Often also complain of
Sclerotomal pain ULNT8
lumbar facet problems4,5
referral patterns8

1
Cleland J. Orthopaedic Clinical Examination: An Evidence-Based Approach for Physical
Therapists. Icon Learning Systems; 2006.
2
Jensen S. Neck-related causes of headaches. Aust Fam Physician. 2005;(34):8.

3
Magee DJ. Orthopedic Physical Assessment. 4th ed. Elsevier Sciences; 2006.

4
Manchikanta L, et al. Prevalence of facet joint sprain in chronic spinal pain of cervical, thoracic
and lumbar regions. BMC Musculoskelel Disord. 2004;(5):15.

5
Manchikanta L, et al. Is there a correlation in facet joint pain in lumbar and cervical spine? An
evaluation of prevalence in the combined chronic low back and neck pain. Pain Physician.
2002;5(4):365-371.

6
Manchikanta L, et al. Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician.
2002;5(3):243-249.

7
Seferiadis A, et al. A review of treatment interventions in whiplash-associated disorders. Eur Spine
J. (2004);13:387-397.

8
Wyatt LH. Facet syndrome in the cervical spine. JACA. 2004.

FIGURE 6-12 Cervical Zygapophyseal Pain Referral Patterns*** Fukui S, Ohseto K,

Shiotani M, et al. Referred pain distribution of the cervical zygapophyseal joints and
cervical dorsal rami. Pain. 1996;68:79-83.

**Test Item Cluster (TIC) for Patients with Mechanical Neck

pain Likely to Benefit from Thoracic Manipulation
 Symptoms less than 30 days
No symptoms distal to the shoulder
Looking up does not aggravate the symptoms
FABQ Physical Activity Score less than 12
Diminished upper thoracic spine kyphosis
Cervical extension ROM less than 30°

3 (+) from TIC (+) LR = 5.5

4 (+) from TIC (+) LR = 12.0

> 5 (+) from TIC (+) LR = Infinite

FIGURE 6-13 Seated “Distraction” Graded Passive Movement V (GPM V)

 FIGURE 6-14 Supine Upper Thoracic Spine GPM V

FIGURE 6-15 Supine Middle Thoracic Spine GPM V

[circled white star] If 3 or more positive in TIC, I would strongly consider the
following techniques as the best treatment for my neck pain patients.
Cleland J, Childs J, Fritz J, et al. Development of a clinical prediction rule for
guiding treatment of a subgroup of patients with neck pain: Use of thoracic
spine manipulation, exercise, and patient education. Phys Ther. 2007;87:9-23.

*CPR: Patients Who Respond Well to Cervical Manipulation

Neck Disability Index < 11.50

Bilateral involvement pattern
Not performing sedentary work > 5 hrs/day
Symptoms eased by moving the neck
Symptoms not made worse by cervical extension
Diagnosis of cervical spondylosis

4 or more variables present patient moderately likely to respond to GPM V

Tseng YI, et al. Predictors for the immediate responders to cervical
manipulation in patients with neck pain. Man Ther. 2006;11(4):306-315.
Cervicogenic headache

TBC/Special
Prevalence Symptoms Signs
Tests

Reduce
Pain: localized to neck and
70-90% adults occipital region, projecting to Headache
report > or = one forehead, orbital region, Mobilization
Impaired rotation
headache temples, vertex, or Exercise
annually1 ears1,9,10,13 Limitations or resistance to
endurance
passive neck ROM1,2,13
0.4-15% of all Pain: precipitated or Flexion-
headaches are aggravated by specific neck Changes in neck musculature: Rotation
cervicogenic1,9 movements or sustained contour, texture, tone, or
Test16
postures10,13 response to stretch or
Females > contraction13 Cervical
Males1,4,13 Pain: constant but can be ROM6,13
intermittent, acute, or Neck muscle
Females 73% of fluctuating9,10,13 tightness/tenderness13,15 Segmental
cases14 mobility
Pain: moderate to severe, Movement abnormalities13
Managerial and tests6,13
usually dull/diffuse but can be
professional throbbing9,13 Abnormal posture6,11,12,13 MMT: neck
occupations > flexors and
blue-collar Symptoms last 4-72 hours, Distinct pathology (i.e.,
extensors6
workers13 but can last weeks9,13 fracture, bone tumor, etc.)13
Muscle
Age tends to imply Unilateral symptoms are most Decrease in short neck
endurance:
different causes common1,9,13 flexor strength and
short neck
(local, disc, facet, endurance6 Stiff/painful
upper cervical spine flexors6
osteoarthritis)14 May have dizziness, nausea,
vomiting, blurred vision, segments C1-215 Skin roll
May have history photophobia, phonophobia,
Reduced cervical test: pain6
of trauma (i.e., dysphagia9,13
MVA)5,9 flexion/extension15 Pathological
May have ipsilateral shoulder reflexes13
or arm pain1,9

1
Antonaci F, Ghirmai S, Bono G, Sandrini G, Nappi G. Cervicogenic headache: Evaluation of the
original diagnostic criteria. Cephalgia. 2001;21:573-583.

2
Astin JA, Ernst E. The effectiveness of spinal manipulation for the treatment of headache
disorders: A systematic review of randomized clinical trials. Cephalgia. 2002;22:617-623.

3
Bonfort G, Assendelft WJJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic
headache: A systematic review. J Manipulative and Physiol Ther. 2001;24(7):457-466.
 4
Coskun O, Ucler S, Karakurum B, Atasoy HT, Yildirim T, Ozkan S, Inan LE. Magnetic resonance
imaging of patients with cervicogenic headache. Cephalgia. 2003;23:842-845.

5
Drottning M, Staff PH, Sjaastad O. Cervicogenic headache (CEH) after whiplash injury. Cephalgia.
2002;22:165-171.

6
Dumas JP, Arsenault AB, Boudreau G, et al. Physical impairments in cervicogenic headache:
Traumatic vs. non-traumatic onset. Cephalgia. 2001;21:884-893.

7
Fernandez-de-las-Penas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Spinal manipulative therapy
in the management of cervicogenic headache. Headache. 2005;1260-1263.

8
Manzoni GC, Torelli P. International Headache Society classification: New proposals about chronic
headache. Neuro Sci. 2003;24:S86-S89.

9
Martellitti P, van Suijlekom H. Cervicogenic headache: Practical approaches to therapy. CNS Drugs.
2004;18(12):793-805.

10
McCrory P. Headaches and exercise. Sports Med. 2000;30(3):221-229.

11
McDonnell MK, Sahrmann SA, Dillan LV. A specific exercise program and modification of postural
alignment for treatment of cervicogenic headache: A case report. J Ortho Sports Phys Ther.
2005;35(1):3-15.

12
Petersen SM. Articular and muscular impairments in cervicogenic headache: A case report. J
Ortho Sports Phys Ther. 2003;33(1):21-32.

13
Sizer PS, Phelps V, Azevedo E, Haye A, Vaught M. Diagnosis and management of cervicogenic
headache. Pain Practice. 2005;5(3):255-272.

14
Van Suijlekom HA, Lame I, Stomp-van den Berg SGM, Kessels AGH, Weber WEJ. Quality of life of
patients with cervicogenic headache: A comparison with control subjects and patients with migraine
or tension-type headache. Headache. 2003;43:1034-1041.

15
Zito G, Jull G, Story I. Clinical tests of musculoskeletal dysfunction in the diagnosis of
cervicogenic headache. Man Ther. 2006;11(2):118-29. Epub 2005 Jul 18.

16
Hall T, Robinson K. The flexion-rotation test and active cervical mobility: A comparative
measurement study in cervicogeic headache. Man Ther. 2004;9(4):197-202.

Assessing for Upper Cervical Mobility Impairment

Flexion-Rotation Test
1. Patient is supine.
2. Examiner is at head of patient.
3. Resting symptoms are assessed.
4. Patient actively flexes neck into maximum range.
5. Examiner applies full rotational force to both sides.
6. Symptoms are reassessed during each motion.
7. (+) test with pain provocation and/or
8. (+) test if loss of 10° or greater.

FIGURE 6-16 Flexion-Rotation Test

Reliability Sensitivity Specificity (+) LR (−) LR

NT 86 100 NA NA

Hall T, Robinson K. The flexion-rotation test and active cervical mobility: A comparative
measurement study in cervicogeic headache. Man Ther. 2004;9(4):197-202.
 FIGURE 6-17 Neck Endurance

FIGURE 6-18 Neck Endurance

FIGURE 6-19 Neck Endurance

Neck Flexor Muscle endurance test

1. Patient is supine.
2. Therapist positions patient's head in full retraction and holds at about 2.5 cm
off the plinth.
3. Examiner places his or her hand under the head for knowledge of position.
4. Visually a skin fold is present in the anterior lateral neck.
5. Draw a line on this skin fold.
6. Patient is instructed to hold this position.
7. If patient's head touches your hand or skin fold is lost, instruct patient to
hold the head or tuck the chin.
8. Test is terminated if patient cannot hold position or maintain skin folds for
over a second.

Reliability K Sensitivity Specificity (+) LR (−) LR

0.82-0.911 (without neck pain)

0.671 (with neck pain) NT NT NT NT

0.852 (with neck pain)

1
Harris KD, Heer DM, Roy TC, Santos DM, Whitman JM, Wainner RS. Reliability of a measurement of
neck flexor muscle endurance. Phys Ther. 2005;85(12):1349-1355.

2
Olsen L, Millar L, Dunker J, Hicks J, Glanz D. Reliablity of a clinical test for deep cervical flexor
endurance. J Manipulative Physiol Therapeutics. 2006;29:134-138.

Tension Type Headache (Episodic vs. Chronic)

TBC/Special
Prevalance Symptoms Signs
Tests

Over all
prevalence for
episodic tension-
type headache
(ETTH) in 1 year
38.3%1
Peak prevalence
in 30-39 year old
men (42.3%) and Mobilization:
ETTH:
women (46.9%) trigger point
Caucasian > Headache frequency of greater than ETTH: therapy2
African 10 lifetime attacks, but fewer than 15
mild to moderate pain Massage2
American1 attacks per month; an average attack
intensity bilateral
duration of 30 minutes to 7 days and
Increasing nonpulsatile tight Exercise
with at least 2 quality of pain features
prevalence with band pressing endurance:
(see ETTH signs)1 tightening feeling no
increasing Isotonic
educational exacerbation by exercises2
CTTH:
level1 exercise1
Symptoms identical to those for ETTH Stretching2
Chronic tension- except that the attack frequency was Absence of features of
type headache 15 or more attacks per month for at migraine: nausea or Education:
(CTTH) 2.2% in 1 least 6 months, and 1 associated photophobia and
phonophobia1 Posture at
year1 symptom of nausea, photophobia, or
home and
phonophobia1
Higher work2
prevalence in
women1

Decreased
prevalence as
education level
increased1

1
Fernandez-de-las-Penas C, Cleland JA, Cuadrado ML, Pareja JA. Predictor variables for identifying
patients with chronic tension-type headache who are likely to achieve short-term success with
muscle trigger point therapy. Cephalalgia. 2008;28(3):264-275.

2
Hammill JM, Cook TM, Rosecrance JC. Effectiveness of a physical therapy regimen in the treatment
of tension-type headache. Headache. 1996;36(3):149-153.

3
Schwartz BS, Stewart WF, Simon D, Lipton RB. Epidemiology of tension-type headache. JAMA.
1998;279(5):381-383.

**CPR: Patients with Chronic Tension-Type Headaches Who

Have Good Short-Term Response to Muscle Trigger Point
Therapy

Headache duration < 8.5 hours/day

Headache frequency < 5.5 days/week

Bodily pain < 47 (lower bodily pain)

Vitality < 47.5 (lower vitality)

Variables present Positive likelihood ratio Probability of success (%)

4+ 5.9 87.4

3+ 3.4 80.0

2+ 1.2 58.5

1+ 1.1 56.4

Fernandez-de-las-Penas C, Cleland JA, Cuadrado ML, Pareja JA. Predictor variables for identifying
patients with chronic tension-type headache who are likely to achieve short-term success with
muscle trigger point therapy. Cephalalgia. 2008;28:264ñ275.

Cervical radiculopathy

Prevalence Symptoms DSM/Signs TBC/Special Tests

Extension

Rotation-extension

Rotation

Sensory or motor
deficits in dermatomes Pain control Centralization
and Intermittent cervical
 myotomes1,2,3,7,9,10,11 traction3,6,7,10

Restricted mobility and Repeated neck retractions

3.3 cases per
tightness3,7,9,10 20x with 1-sec. hold 1
1000 people10
Increasing Deep stabbing, Forward head Mobilization Cervical lateral
occurrence in 5th burning neck posture7,9 glides3,4
decade3 pain1,3,7,8,9,10
Decreased grip Education
MC causes: cervical Pain, numbness, or strength on affected
disc herniation, tingling in side6 Exercise
spondylosis, and ue1,3,7,9,10,11
osteophytes6,10 Weak or diminished Stretching upper cervical
UE extensors and strengthening
reflexes1,7,10,11
MC affected nerve weakness1,3,2,7,10 deep neck flexors and
roots: C6 and Decreased cervical scapulothoracic
C71,6,8 AGGs: prolonged ROM3,10 muscles3,4,6,9,10
sitting/reading,
MC motor deficit: external or lateral Wainner et al. cluster Cervical rotation assessment3
wrist extensor and rotation of spine1,9 (3,12):
finger flexor Upper Limb Neurodynamic
weakness6 EASEs: supine with 1. (+) Spurling Test (ULNT)5,9,10
head and neck
Rare etiology of supported1,8 2. (+) ULTT Distraction Test: SN = 0.4
cervical nerve root SP = 1.09,10
3. (+) Neck Distraction
variants1,6
Test Compression (Spurling)
Test: SN = 0.92 SP =
4. < 60° C/S rotation
toward involved side 0.958,9,10 Grip strength6,9

> 3 (+) tests + LR = Bakody's, Shoulder

Abduction Test or “Monkey”
6.112
sign: SN = 0.43 SP = 0.967,9,10
4 (+) tests + LR =
30.312

Diaphragmatic
symptoms with C3-C47

1
Abdulwahab SS, Sabbahi M. Neck retractions, cervical root decompression, and radicular pain. J
Ortho Sports Phys Ther. 2000;30(1).

2
Bracker MD, Ralph LP. The numb arm and hand. Am Fam Physician. January 1995.

3
Cleland JA, et al. Manual physical therapy, cervical traction, and strengthening exercises in
patients with cervical radiculopathy: A case series. J Ortho Sports Phys Ther. 2005;35(12).

4
Coppieters MW, et al. The immediate effects of a cervical lateral glide treatment technique in
patients with neurogenic cervicobrachial pain. J Ortho Sports Phys Ther. 2003;33:369-378.
 5
Dougherty P, et al. Spinal manipulation postepidural injection for lumbar and cervical
radiculopathy: A retrospective case series. J Manipulative and Physiol Ther. September 2004.

6
Joghataei MT, Arab AM, Khaksar H. The effect of cervical traction combined with conventional
therapy on grip strength on patients with cervical radiculopathy. Clin Rehabil. 2004;18:879-887.

7
Rao R. Neck pain, cervical radiculopathy, and cervical myelopathy. J Bone Joint Surg. 2002;
84A(10).

8
Shah KC, Rajshekhar V. Reliability of diagnosis of soft cervical disc prolapse using Spurling's Test. Br
J Neurosurg. 2004;18(5).

9
Tomberlin JP, Saunders HD. Evaluation, Treatment, and Prevention of Musculoskeletal
Disorders, Volume Two. 4th ed. The Saunders Group; 1995.

10
Wainner RS, Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J Ortho
Sports Phys Ther. 2000;30(12).

11
Zrinzo L, Ashkan K, Johnston F. Unusual cervical nerve root arrangement exposed during surgery:
Case report and review of the literature. Br J Neurosurg. 2004;18(6).

12
Wainner R, Fritz J, Irrgang J, Boninger M, Delitto A, Allison S. Reliability and diagnostic accuracy
of the clinical examination and patient self-report measures for cervical radiculopathy. Spine.
2003;28:52-62.

**CPR: Patients Diagnosed with Cervical Radiculopathy Most

Likely to Succeed with Physical Therapy
1. Age < 54 years
2. Dominant arm not affected
3. Looking down does not worsen symptoms
4. 50% of treatments include:

Manual therapy
Cervical traction
Deep neck flexor muscle strengthening

3 of 4 variables present +LR (5.2)

4 of 4 variables present +LR (8.3)
Cleland JA, et al. Predictors of short-term outcome in people with a clinical
diagnosis of cervical radiculopathy. Phys Ther. 2007;87(12):1619-1632.
 Spurling B test
1. Side bend and extend neck to ipsilateral side.
2. Add 7 kg of overpressure.
3. (+) if symptoms reproduced.

Reliability κ Sensitivity Specificity (+) LR (−) LR

0.60 50 86 3.57 0.58

Wainner R, Fritz J, Irrgang J, Boninger M, Delitto A, Allison S. Reliability and diagnostic accuracy of
the clinical examination and patient self-report measures for cervical radiculopathy. Spine.
2003;28:52-62.

FIGURE 6-20 Cervical Disc Pain Referral

 FIGURE 6-21 Spurling B Test

Neck Distraction Test

1. Patient is supine.
2. Examiner grasps under chin and occiput while slightly flexing patient's neck
and applies distraction force of 14 lbs.
3. (+) if symptoms are reduced.
[circled white star] You may modify this test and do it in sitting position to
make it more functional.

Reliability κ Sensitivity Specificity (+) LR (−) LR

0.88 44 90 4.4 0.62

Wainner R, Fritz J, Irrgang J, Boninger M, Delitto A, Allison S. Reliability and diagnostic accuracy of
the clinical examination and patient self-report measures for cervical radiculopathy. Spine.
2003;28:52-62.

FIGURE 6-22 Neck Distraction Seated

 FIGURE 6-23 Neck Distraction Test

Upper Limb Neurodynamic Tension Test A: Median Nerve

Bias
1. Patient is supine.
2. Scapular depression.
3. Shoulder abduction.
4. Forearm supination; wrist and finger extension.
5. Shoulder lateral rotation.
6. Elbow extension.
7. Contralateral/ipsilateral cervical side bending.

Reliability κ Sensitivity Specificity (+) LR (−) LR

0.76 97 22 1.24 0.14

[circled white star] This is a great single test for screening out presence of
radiculopathy.
Wainner R, Fritz J, Irrgang J, Boninger M, Delitto A, Allison S. Reliability and
diagnostic accuracy of the clinical examination and patient self-report
measures for cervical radiculopathy. Spine. 2003;28:52-62.
FIGURE 6-24 Median Nerve Test

FIGURE 6-25 Median Nerve Test

FIGURE 6-26 Median Nerve Test

 FIGURE 6-27 Median Nerve Test

Upper Limb Neurodynamic Tension Test B: Radial Nerve Bias

1. Patient is supine and shoulder is abducted to 30°.
2. Scapular depression.
3. Shoulder medial rotation.
4. Full elbow extension.
5. Wrist and finger flexion.
6. Contralateral/ipsilateral cervical side bending.
7. (+) test is reproduction of the patient's symptoms.

Reliability (-)
κ Sensitivity Specificity (+) LR LR

Neck pain Sandmark and Nisell NT 0.77 0.94 12.83 0.25

Predicting results of electromyography and

NT 0.44 0.22 0.12 0.85
nerve conduction studies Wainner et al.

Radiculopathy Wainner et al. 0.83 0.72 0.33 1.07 0.84

Wainner R, Fritz J, Irrgang J, Boninger M, Delitto A, Allison S. Reliability and diagnostic accuracy of
the clinical examination and patient self-report measures for cervical radiculopathy. Spine.
2003;28:52-62.
 Sandmark H, Nissell R. Validity of five common manual neck pain provoking tests. Scand J Rehabil
Med. 1995;27(3):131-136

FIGURE 6-28 Radial Nerve

FIGURE 6-29 Radial Nerve

Upper Limb Neurodynamic Tension Test: Ulnar Nerve Bias

(Unvalidated)
1. Patient is supine at one side of the table.
2. Therapist is in stride stance on the same side of table.
3. Patient's elbow is rested just below the ASIS of the therapist's hip.
4. Patient's wrist is extended.
5. Forearm is pronated.
6. Elbow is fully flexed.
7. Therapist is blocking shoulder elevation by punching into the table.
8. Add shoulder external rotation.
9. Add shoulder abduction.
10. Add cervical contralateral sidebending to add tension or ipsilateral
sidebending to decrease tension.

FIGURE 6-30 Ullnar Nerve

FIGURE 6-31 Ullnar Nerve

 FIGURE 6-32 Ullnar Nerve

FIGURE 6-33 Shoulder Abduction for Radiculopathy

Shoulder Abduction Test

1. Patient assumes a sitting position.
2. Examiner assesses resting symptoms.
3. Patient actively places his or her arm on top of his or her head.
4. Examiner then determines the presence or absence of the symptoms.
5. (+) test with reproduction of the patient's concordant pain.

Reliability κ Sensitivity Specificity (+) LR (−) LR

0.20 17 92 2.12 0.9

Wainner R, Fritz J, Irrgang J, Boninger M, Delitto A, Allison S. Reliability and diagnostic accuracy of
the clinical examination and patient self-report measures for cervical radiculopathy. Spine.
2003;28:52-62.

Cervical Myelopathy

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

MC type of spinal cord

dysfunction > 55 y/o2 Hand numbness, head pain,
hoarseness, vertigo, tinnitus,
Male > Female (smaller deafness1,2 Refer out
Flexion
canal/body ratio in males)7
Loss of hand function (e.g., Hoffman's
(+) pathological
Insidious onset (degenerative difficult to button up shirt)1,4 Reflex6
reflex1,2
and congenital)2
Urinary urgency at first, then Gonda-
UE and LE
Mild cervical compressive possible bowel and bladder Allen Sign6
DTR1,2
myelopathy (CCM) incontinence1,2
Lhermitte's
Decreased
MC age 35-45 Spastic paresis1,2 superficial Sign6

Severe CCM MC age is in the reflex1 Babinski

Gait affected1,2
elderly3 Atrophy/muscle Sign6
Symptom progression will vary2 weakness1,2
The incidence and prevalence MRI2,5
of cervical myelopathy is not UE and LE Sx1
known5

1
Magee DJ. Orthopedic Physical Assessment. Philadelphia: Saunders; 2002.

2
McCormick WE, et al. Cervical spondylotic myelopathy: Make the difficult diagnosis then refer for
Surgery. Cleve Clin J Med. 2003;70(10):899-904.

3
Browder DA, et al. Intermittent cervical traction and thoracic manipulation for management of mild
cervical compressive myelopathy attributed to cervical herniated disc: A case series. J Ortho Sports
Phys Ther. 2004;34(11):701-711.

4
Moskovich R, et al. Occipitocervical stabilization for myelopathy in patients with rheumatoid
arthritis. J Bone Joint Surg Am. 2000;82(3):349-364.
 5
Dvorak J, et al. Cervical myelopathy: Clinical and neurophysiological evaluation. Eur Spine J. Oct.
2003.

6
Cook C, et al. Orthopedic Physical Examination Tests: An Evidence-Based Approach. Upper Saddle
River: Prentice Hall; 2007.

7
Hukuda S, Kojima Y. Sex discrepancy in the canal/body ratio of the cervical spine implicating the
prevalence of cervical myelopathy in men. Spine. 2002;27(3):250-253.

Screening Out Upper Motor Neuron Pathology

Hoffman's Reflex
1. Patient is placed in a sitting or standing position.
2. Examiner stabilizes the middle finger proximally to the distal
interphalangeal joint and cradles the hand of the patient.
3. Examiner applies a stimulus to the middle finger by nipping the fingernail of
the patient between his or her thumb and index finger or by flicking the
middle finger with the examiner's fingernail.
4. (+) test is adduction and opposition of thumb and slight flexion of the
fingers.

FIGURE 6-34 Hoffman's Reflex

Reliability Sensitivity Specificity (+) LR (−) LR

NT 94 NT NA NA
 Sung R, et al. Correlation between a positive Hoffman's Reflex and cervical pathology in
asymptomatic individuals. Spine. 201;26:67-70.

Gonda-Allen Sign
1. Patient is placed in a supine position.
2. Examiner provides a forceful downward stretch or snaps the distal phalanx of
the second or fourth toe.
3. Examiner also may press on the toe nail, twist the toe, and hold for a few
seconds.
4. (+) response is the extensor toe sign (great toe extension), a similar response
to a positive Babinski Test.

Reliability Sensitivity Specificity (+) LR (−) LR

NT 90 NT NA NA

Denno JJ, et al. Early diagnosis of cervical spondylotic myelopathy: A useful clinical sign. Spine.
1991;16(12):1353-1355.

FIGURE 6-35 Gonda-Allen Sign

Ruling in Upper Motor Neuron Pathology
Lhermitte's Sign
1. Patient is placed in a sitting or supine position.
2. Patient is instructed to flex the neck with emphasis in lower cervical flexion.
3. Some examiners have advocated use of hyperextension to produce a
Lhermitte's Response.
4. Patient is queried for “electrical-type” responses during the flexion or, if
used, extension.
5. (+) test is an “electrical-type” sensation in the midline and occasionally to
the extremities during flexion.

Reliability Sensitivity Specificity (+) LR (−) LR

NT 3 97 1.0 1.0

Uchihara T, et al. Compression of brachial plexus as a diagnostic test of cervical cord lesion. Spine.
1994;19(19):2170-2173.
 FIGURE 6-36 Lhermitte's Sign

FIGURE 6-37 Lhermitte's Sign

Babinski Sign
1. Patient is placed in a supine position. The foot is held in relative neutral by
the examiner.
2. Examiner applies stimulation with the blunt end of a reflex hammer to the
plantar aspect of the foot (typically laterally to medial from heel to
metatarsal).
3. (-) test is a slight great toe flexion, smaller digits greater than great toe.
4. (+) test is if the great toe extends and separates.

Reliability Sensitivity Specificity (+) LR (−) LR

NT 80 90 8 0.05
Berger JR, et al. The “bedsheet” Babinski. South Med J. 2002;95(10):1178-1179.

FIGURE 6-38 Babinski Sign

Cervical Instability

Prevalence Symptoms Signs TBC/Special Tests

Intolerance to
prolonged static
postures2,3

Fatigue and Exercise

inability to hold Endurance
head up2
Deep neck flexor
Better with training using a
external support, pressure
including hands Poor coordination or biofeedbeack unit
or collar2
neuromuscular control, including (PBU)3,5
poor recruitment and dissociation
Frequent need of cervical segments with Soft collar1,5,7
for movement2
Respiratory Sharp pursers3,5
infection or selfmanipulation2
Abnormal joint play2
infection following
Frequent episodes Alar ligament3,5
head and neck Motion that is not smooth
of acute attacks2 Palpation
surgery1 Sharp pain, throughout range, including tenderness4,6
possibly with segmental hinging, pivoting, or
Contact Sports1 sudden fulcruming (catching or locking)2 PROM tests4,6
movements1,2
Trauma1,2 Aberrant movement2 Pressure over the
Neck pain, Z-joints4,6
MC in MVAs and headaches, Decreased cervical lordosis2,5
falls1,5,7 dizziness, Spinal stiffness4,6
fatigue3,5 Forward head posture5
17-86% of RA Passive
points present Feelings of Tightness in UT and pecs; weakness intervertebral
with subluxation weakness, of neck stabilizers3,5,7 motion4,6
between C/S instability, and
vertebrae1 “shakiness”2,3,5 “Step off” sign in X-ray1,3,5,7 Sensory, motor,
and other
Cervical trauma “Giving way,” Segmental hypermobility with neurologic
MC in C3/C4 (70%) clunking, or PPIVMs3 functions1,4,6
and C4/C51 clicking with neck
Restricted ROM due to muscle CT Scan, MRI, X-
movement5
Common in Down's guarding5 ray1,2,7
syndrome points H/O MVA, fall, or
because transverse blow to back of Midline tenderness in C/S region to Vertebral Artery
ligament is lax1,5 the head1,4,5 palpation3,7 Test5

H/O inflammatory Referred pain in shoulder and Active and passive

disorders: RA1,2,5 parascapular region3 mobility palpation
of OA, AA, C/S,
H/O poor posture Poor C/S AROM control3 and upper T/S5
and repetitive
movements or Craniocervical
aberrant Flexion Test
movements3 (CCFT) with a
PBU5
EASEs: supine
with head and
neck supported3

1
Grauer JN, et al. Predictors of paralysis in the rheumatoid cervical spine in patients undergoing
total joint arthroplasty. J Bone Joint Surg. 2004;86A(7).

2
Maekawa T, et al. Atlantoaxial arthrodesis for vertebrobasilar insufficiency due to rheumatoid
arthritis: A case report. J Bone Joint Surg. 2003 Apr;85-A(4):711-714.

3
Olson KA, Joder D. Diagnosis and treatment of cervical spine clinical instability. J Ortho Sports
Phys Ther. 2001;31(4).

4
Robert KQ, Ricciardi JE, Harris MB. Occult ligamentous injury of the cervical spine. South Med J.
2000; 93(10).
 5
Tomberlin JP, Saunders HD. Evaluation, Treatment, and Prevention of Musculoskeletal
Disorders, Volume Two. 4th ed. Chaska, MN: The Saunders Group; 1995.

6
Wenger M, Adam PJ, Alacron F, Markwalder TM. Traumatic cervical instability associated with cord
oedema and temporary quadriparesis: Case report. Spinal Cord. 2003;41:521-526.

7
Hoffman JR, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in
patients with blunt trauma. New Engl J Med. 2000;343(2):94-99.

Ruling in Upper Cervical Instability

Sharp-purser test
1. Patient is in a sitting position.
2. Neck in semiflexed posture.
3. Examiner places palm of one hand on patient's forehead and index finger of
the other hand on the spinous process of the axis.
4. Posterior translation is applied through the forehead.
5. Sliding motion of the head posteriorly in relation to axis is a positive test for
atlantoaxial instability.
6. (+) reproduction of myelopathic symptoms during forward flexion or decrease
in symptoms during anterior to posterior movement or excess displacement
during the AP movement.

Sensitivity Specificity (+) LR (-) LR

0.69 0.96 17.25 0.32

Uitvlugt G, Indenbaum S. Clinical assessment of atlantoaxial instability using the Sharp-Purser Test.
Arthritis Rheum. 1988;31:918-922.
 FIGURE 6-39 Sharp-Purser Test

FIGURE 6-40 Sharp-Purser Test

Craniovertebral Sidebending Test

Alar Ligament Test
1. Patient is in a supine position.
2. Head is in physiological neutral.
3. Examiner stabilizes axis with a wide pinch grip around spinous process and
lamina.
4. Examiner attempts to side flex the head and axis.
5. (+) if significant sideflexion occurs with empty end feel.
6. (-) if minimal sideflexion occurs with capsular end feel.

Reliability κ Sensitivity Specificity (+) LR (−) LR

Interexaminer:

-0.031 to 0.182
NT NT NT NT
Intraexaminer:

-0.022 to 0.137

Olson KA, Paris SV, Spohr C, Gorniak G. Radiographic assessment and reliability study of the
craniovertebral sidebending test. J Man Manip Ther. 1998;6:87-96.

FIGURE 6-41 Alar Ligament Test

FIGURE 6-42 Alar Ligament Test

Functional Positional Testing of the Vertebral Artery
(Rotation)
Australian Physiotherapy Association (APA). Clinical Guidelines for Assessing
Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders.
(APA; 2006).
1. Patient is in a supine position.
2. Passively rotate patient's head.
3. Hold for 10 seconds.
4. Return to neutral hold for 10 seconds.
5. Passively rotate to opposite side.
6. Hold for 10 seconds.

Reliability κ Sensitivity Specificity (+) LR (−) LR

NT NT NT NT NT

[circled white star] Use of a sustained pre-manipulation position hold of 10

seconds is also recommended before actually performing the technique.
[circled white star] If significant signs are already present during history, then
do not perform the VBI test, as it may place the patient in danger, without
offering much more information.
[circled white star] Atherosclerotic risk factors or history of repeated or
significant trauma to the neck (Mitchell, 2002), are indicators of patients who
may be of higher risk for vertebrobasilar artery dysfunction.
Kerry R, Rushton A. Decision Theory in Physical Therapy. World Confederation
for Physical Therapy 14th International Congress. Barcelona; 2003.
Gross AR, Chesworth B, Binkley J. A case for evidence-based practice in manual
therapy. In: Boyling J, Jull GA, eds. Grieve's Modern Manual Therapy—The
Vertebral Column. 3rd ed. Edinburgh: Churchill Livingstone. 2005; 569-580.
Ritcher RR, Reinking MF. Clinical question: How does evidence on the
diagnostic accuracy of the vertebral artery test influence teaching of the test
in a professional physical therapist education program? Phys Ther. 2005.
http://www.ptjournal.org/Ptjournal/Jun2005/Jun05_EiP.cfm
Mitchell J. Vertebral artery atherosclerosis: A risk factor in the use of
manipulative therapy? Physiother Res Int. 2002;7:122-135.

FIGURE 6-43 Premanipulative Hold

Whiplash-Associated Disorders (WAD)

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Mobilization

Exercise
endurance
Rotation
Education
Flexion
Pain in posterior neck/thoracic VBI testing
spine4 Pain/tenderness
upon Sharp Purser's
Stiffness in one or more Test1,7
1 million new cases of direction1,6 palpation3
WAD a year1 Alar Ligament
1
Tenderness at trigger points Muscle spasm 1
Test1,7
Possible at any age after
traumatic event Headaches6 Paraesthesia in CROM1
UE3
More women complain of Possible radiating pain to occiput, Spurling's Test1
chronic neck pain than shoulder, or parascapular regions1 3
Weakness in UE
men2
 Depression/sleep Decreased Cervical PA1,4
CROM3
disturbances6 when chronic Cervical Glides4
Ligamentous
instability6,7 Thoracic spine
PA4

Sensation/MMT1

VBI testing

1
Douglass, MB, Bope, EP. Evaluation and treatment of posterior neck pain in family practice. JABFP.
2004;7: Supplement.

2
Lankester BJA, et al. The classification of outcome following whiplash injury: A comparison of
methods. Eur Spine J. 2004;13:604-609.

3
Olivegren H, et al. The long-term prognosis of whiplash-associated disorders (WAD). Eur Spine J.
1999;8:366-370.

4
Pho C, Godges J. Management of whiplash-associated disorder addressing thoracic and cervical
spine impairments: A case report. J Orthop Sports Phys Ther. 2004;34:9.

5
Rosenfeld M. Whiplash-Associated Disorders from a Physical Therapy and Health-Economic
Perspective. Institute for Neuroscience and Physiology; 2006.

6
Seferiadis A, et al. A review of treatment interventions in whiplash-associated disorders. Eur Spine
J. 2004;13:387-397.

7
Tominaga Y, et al. Neck ligament strength is decreased following whiplash trauma. BMC
Musculoskelet Disord. 2006;7:103.

Proposed Classification for Whiplash-Associated Disorders

(WAD)

Grade Classification

0 No complaint about the neck. No physical sign(s)

I Neck complaint of pain, stiffness, or tenderness only. No physical sign(s)

 Neck complaint

IIA Motor impairment: decreased ROM, altered muscle recruitment pattern

Sensory impairment: local cervical mechanical hyperalgesia

Neck complaint

Motor impairment: decreased ROM, altered muscle recruitment pattern

IIB
Sensory impairment: local cervical mechanical hyperalgesia

Psychological impairment: elevated psychological distress

Neck complaint

Motor impairment: decreased ROM, altered muscle recruitment pattern, increased joint
position error
IIC
Sensory impairment: local cervical mechanical hyperalgesia, generalized sensory
hypersensitivity; some may show sympathetic nervous system disturbances

Psychological impairment: elevated psychological distress, elevated levels of acute

posttraumatic stress

All of WAD IIC and neurological sign(s). Neurological signs include decreased or absent
III
tendon reflexes, weakness, and sensory deficits.

IV Neck complaint and fracture or dislocation

Adapted from Sterling MA. Proposed classification system for whiplash-associated disorders:
Implications for assessment and management. Man Ther. 2004;9:66.

Vertebrobasilar Artery Insufficiency

Prevalence Symptoms Signs TBC/Special Tests

Dizziness1,2,3,4,5,6,7
 Vertigo1,4,5,6,7
Refer out
Tinnitus1,5,7
Onset: any age (trauma) or
Premanipulative hold
60+ Deafness1 Nystagmus1,3,7
Vertebral artery
y/o (degenerative VBI)1,5,7 Diplopia ,4 7 Sensory changes3
(cervical
Males affected 2:1 to
Dysarthria3,6,7 N/T6
quadrant) test3
females7
Gait
Headache2,4,6 Static vertebral artery
Left artery affected 2-3 disturbances2,3,7
test3
times Drop attacks4,7
Weakness2,3,6 Doppler US (CDU)1
more than the right6 Syncope episodes , 6 7
Increased BP7 Maximum cervical
Can be bilateral6 Nausea/vomiting , 4 5

compression test3
Tremor4

Dysphagia3

Ataxia2

1
Endo K, Ichimaru K, Komagata M, Yamamoto K. Cervical vertigo and dizziness after whiplash injury.
Eur Spine J. 2006;15:886-890.

2
Kerry R, Taylor A. Cervical arterial dysfunction assessment and manual therapy. Man Ther.
2006;11:243—253.

3
Magee D. Orthopedic Physical Assessment. 4th ed. St. Louis, MO: Elsevier Sciences; 2006.

4
Nakamura K, Saku Y, Torigoe R, Ibayashi S, Fujishima M. Sonographic detection of haemodynamic
changes in a case of vertebrobasilar insufficiency. Neuroradiology. 1998;40:164-166.

5
Ozdemir H, Berligen MS, Serhatlyo S, et al. Examination of the effects of degeneration on
vertebral artery by using neural network in cases with cervical spondylosis. J Med Syst. 2005;29(2).

6
Toursarkissian B, Rubin B, Reilly JM, Thompson RW, Allen BT, Sicard GA. Surgical treatment of
patients with symptomatic vertebrobasilar insufficiency. Ann Vasc Surg. 1998;12(1).

7
Zaytsev AY, Stoyda AY, Smirnov VE, et al. Endovascular treatment of supra-aortic extracranial
stenoses in patients with vertebrobasilar insufficiency symptoms. Cardiovasc Intervent Radiol.
2006;29:731-738.
Chapter 7
The Thoracic Region

Thoracic Spine
Red Flags for Potential Serious Conditions in Patients with
Thoracic Spine/Rib Problems

Red Flag Data Obtained During Red Flag Data Obtained During
Condition
Interview/History Physical Exam

Chest Pain

Presence of risk factors: Previous history Pallor, sweating, dyspnea, nausea,

Myocardial of coronary artery disease, hypertension, palpitations Symptoms lasting longer
infarction1,2,3 smoking, diabetes, elevated blood serum than 30 minutes and not relieved with
cholesterol (> 240 mg/dl) sublingual nitroglycerin

Men over age 40, women over age 50

Chest pain/pressure that occurs with

Stable Angina predictable levels of exertion
Pectoris4 Symptoms are also predictably alleviated
with rest or sublingual nitroglycerine

Unstable
Chest pain that occurs outside of a
Angina Not responsive to nitroglycerine
predictable pattern
Pectoris4

Increased pain with left-side lying

Sharp/stabbing chest pain that may be
Relieved with forward lean while
Pericarditis5 referred to the lateral neck or either
sitting (supporting arms on knees or a
shoulder
table)

History of fall or motor vehicle crash

Midline tenderness at level of
History of osteoporosis fracture Bruising
Spinal Prolonged steroid use Lower-extremity neurological deficits
fracture6
Age over 70 Evidence of increased thoracic
kyphosis
Loss of function or mobility

Chest pain—intensified with

inspiration

Recent bout of coughing or strenuous Difficult to ventilate/expand ribcage

Pneumothorax7
exercise or trauma
Hyperresonance upon percussion

Decreased breath sounds

Pleuritic pain—may be referred to Fever, chills, headaches, malaise,

Pneumonia5
shoulder nausea Productive cough

Severe, sharp, “knife-like” pain with

inspiration History of a recent/co-existing Dyspnea—decreased chest wall
Pleurisy5
respiratory disorder (e.g., infection, excursion
pneumonia, tumor, tuberculosis)

Chest, shoulder, or upper abdominal pain

Dyspnea
Pulmonary Dyspnea
Tachynea
embolus5
History of, or risk factors for, developing
Tachycardia
a deep vein thrombosis

Age under 40
Chest pain Type “A” male or “neurotic” female
without
cardiac High perceived level of vital exhaustion
disease8
Recent uncontrollable and undesirable
life events

Used with permission of Joe Godges, Kaiser Permanente, Southern Rehabilitation Specialist
Resources page.
1
Berger JP, Buclin T, Haller E, et al. Right arm involvement and pain extension can help to
differentiate coronary diseases from chest pain of other origin: A prospective emergency ward study
of 278 consecutive patients admitted for chest pain. J Int Med. 1990;227:165-72.

2
Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, et al. Prevalence, clinical characteristics, and
mortality among patients with myocardial infarction presenting without chest pain. JAMA.
2000;283:3223-3229.

3
Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarction:
Influence of sex, age, and risk factors. Am Heart J. 2002;144:1012-1017.

4
Henderson JM. Ruling out danger: Differential diagnosis of thoracic spine. Phys Sportsmed.
1992;20:124-131.

5
Wiener SL. Differential Diagnosis of Acute Pain by Body Region. New York: McGraw-Hill; 1993.

6
Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture in blunt trauma patients: Guidelines for
diagnosis and imaging. Injury. 2003;34:426-433.

7
Misthos P, Kakaris S, Sepsas E, et al. A prospective analysis of occult pneumothorax, delayed
pneumothorax, and delayed hemothorax after minor blunt thoracic trauma. Eur J of Cardio-thoracic
Surg. 2004;25:859-864.

8
Roll M, Theorell T. Acute chest pain without obvious organic cause before age 40: Personality and
recent life events. J Psychosom Res. 1987;31:215-221.
 FIGURE 7-1 The Ribcage Including the Sternum; The Spine; Thoracic Vertebra

Thoracic Vertebral Fracture

TBC/Special
Prevalence Symptoms Signs
Tests

Constant back pain3

Insidious onset or after
trauma3

Risk factors:2

2-3 fold increased risk in History of fracture

American women > 60 years2
History of osteoporosis
Life time risk for diagnosis: 16%
in white females2 5% in white Decreased height
males2 Physical activity

“Previous history of trauma”1 Men risk factors:2

Falls1,2 Cigarette smoking

Refer out
Benign daily activites 1 Consumption of alcoholic
Heel drop
1 beverages
Lifting light objects Moderate test4
Secondary osteoporosis decreased trunk
Bending1 Percussion
History of trauma ROM due to test
Jogging3
pain3 Neurological
Tuberculosis
Women Palpation pain screen
Peptic ulcers over spinous
50-54 yrs = 4.7%2 Hoffman
process3 sign
Obesity reduces risk
55-59 yrs = 5.8%2
Women risk factors:2 Gonda-Allen
2 sign
60-64 yrs = 6.3%
Late menarche
65-69 yrs = 13.2%2
Early menopause
2
70-74 yrs = 15.0%
Short duration of fertility
2
75-79 yrs = 22.2%
Low consumption of cheese
2 and yogurt
80-84 yrs = 50.8%

≥ 85 yrs = 50.8%2 Low physical activity

Family history of hip

fracture

Oral contraceptives and

alcohol consumption
reduces risk

1
Santavirta S, Konttinen YT, Heliövaara M, Knekt P, Lüthje P, Aromaa A. Determinants of
osteoporotic thoracic vertebral fracture: Screening of 57,000 Finnish women and men. Acta Orthop
Scand. 1992;63(2):198-202.

2
Lips P. Epidemiology and predictors of fractures associated with osteoporosis. Am J Med.
1997;103(2A):3S-8S; discussion 8S-11S.

3
Ross MD, Elliott RL. Thoracic spine compression fracture in a patient with back pain. J Orthop
Sports Phys Ther. 2008;38(4):214.

4
Sizer PS, Brismée J, Cook C. Medical screening for red flags in the diagnosis and management of
musculoskeletal spine pain. Pain Pract. 2007;7(1):53-71.
Heel Drop Test
1. Patient stands on toes, then proceeds to drop bodyweight onto heels
2. (+) test is midline thoracic spine pain
Sizer PS, Brismée J, Cook C. Medical screening for red flags in the diagnosis and
management of musculoskeletal spine pain. Pain Pract. 2007;7(1):53-71.

Percussion
1. Tuning fork over area of pain
2. (+) test is pain reproduction
Sizer PS, Brismée J, Cook C. Medical screening for red flags in the diagnosis and
management of musculoskeletal spine pain. Pain Pract. 2007;7(1):53-71.

Thoracic Outlet Syndrome

Prevalence Symptoms Signs TBC/Special Tests

Pain and heaviness in the Pain control-Modalities:

A: neurological
cervical region and arms1 heat, TENS2
(N-TOS)
Paresthesias (medial side of
B: venous arm)1 Correction of movement
Supraclavicular impairment Mobilization
C: arterial Aggravated by overhead
tenderness1,7
positioning of the arms1 PROM for cervical muscles2
True N-TOS very Slight weakness
low incidence, Intrinsic muscle Exercise: Stretching muscles
of affected
mainly affects deficit/atrophy of hand1 that close the space (levator
limb1,5
females8 scapulae, scalenes, pec
Easy fatigability,1 paleness, A: minor)2,7
Disputed N-TOS or coldness of hand1
represents Paresthesias to Strengthening muscles that
1 5 6 7 open the space (stabilizers of
Pain with activity , , , ulnar aspect of
85% of diagnosed hand and inf. scapula)2,7
TOS cases9 Deep, boring, toothache-
forearm1,5,6,7
like pain6 Provocation:
Vascular TOS 5- B:
10% of all TOS Cold intolerance1,5 ROOS /Elevated arm stress
cases8,9 1 5 7
Edema UE , , test (EAST)1,2,6,7
Loss of dexterity1,2
Arterial TOS is 1- Adson,
 5% of vascular Waking from sleep with Cyanosis UE1,2,7 Costoclavicular (military
TOS8,9 pain and numbness1,7 brace),
C:
Venous TOS 2-3% C: Hyperabduction
of all forms of Pallor,
TOS8,9 Feeling of heaviness2,6 pulselessness1,2 Cervical rotation lateral
flexion test
Males most Neck spasms2
affected8,9 1st rib spring test
Fatigue5,6,7

1
Cooke RA. Thoracic outlet syndrome: Aspects of diagnosis in the differential diagnosis of hand-arm
vibration syndrome. Occup Med (Lond). 2003;53(5):331-6.

2
Vanti C, Natalini L, Romeo A, Tosarelli D, Pillastrini P. Conservative treatment of thoracic outlet
syndrome. Eura Medicophys. 2007;43(1):55-70. Epub 2006 Sep 24.

3
Hurley W, Comina S, Green R, Canizzaro J. A traumatic subclavian vein thrombosis in a collegiate
baseball player: A case report. J Athl Train, 2006;41(2):198-200.

4
Lee AD, Agarwal S, Sadhu D. Doppler Adson's test: Predictor of outcome of surgery in non-specific
thoracic outlet syndrome. World J Surg. 2006;20:291-292.

5
Ozcakar L, Inanici F, Kaymak B, Abali G, Cetin A, and Hascelik Z. Quantification of the weakness
and fatigue in thoracic outlet syndrome with isokinetic measurements. Br J Sports Med.
2005;39:178-181.

6
Magee DJ. Orthopedic Physical Assessment. 4th ed. St. Louis, MO: Elsevier Sciences. 2006;126,161.

7
Saunders HD, Saunders R. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders.
4th ed. MN: Saunders Group. 2004; 64,120-121.

8
Wilbourn AJ, et al. Thoracic outlet syndrome is overdiagnosed. Arch Neurol. 1990;47:328-330.

9
Fechter JD, et al. The thoracic outlet syndrome. Orthopedics. 1993;16:1243-1251.

Ruling in Thoracic Outlet Syndrome

Roos Test
1. Patient sits straight with the arms at the side of his or her body.
2. Patient is instructed to abduct his or her arms and externally rotate to 90°.
The patient is then instructed to rapidly open and close his or her hands.
3. Activity is performed for a full minute.
4. (+) test is reproduction of concordant symptoms during opening and closing
the fists.

Reliability Sensitivity Specificity (+) LR (−) LR

NT 82 100 ? ?

Howard M, et al. Documentation of brachial plexus compression (in the thoracic inlet) utilizing
provocative neurosensory and muscular testing. J Reconstr Microsurg. 2003;19(5):303-312.

FIGURE 7-2 Roos Test

FIGURE 7-3 Roos Test

 Supraclavicular Pressure Test
1. Patient sits straight with the arms at the side.
2. Examiner places his or her fingers on the upper trapezius and the thumbs
contacting the lowest portion of the anterior scalene muscle near the first ribs.
3. Examiner squeezes the fingers and thumbs together for 30 seconds.
4. Patient is queried for changes in paresthesia.
5. (+) test is a report of paresthesia by the patient.

Reliability Sensitivity Specificity (+) LR (−) LR

NT NT 79 (vascular changes) NT NT

NT NT 98 (pain) NT NT

NT NT 85 (paresthesia) NT NT

Plewa MC, et al. The false-positive rate of thoracic outlet syndrome shoulder maneuvers in healthy
patients. Acad Emerg Med. 1998;5(4):337-342.

Adson's Test
1. Patient sits straight with the arms placed at 15° abduction.
2. Examiner palpates radial pulse.
3. Patient is instructed to inhale deeply, hold his or her breath, tilt the head
back, and rotate the head so that the chin is elevated and pointed toward the
examined side.
4. Examiner records the radial pusle as diminished or occluded and queries the
patient for paresthesia.
5. (+) test is a change in radial pulse and patient report of paresthesia.
 FIGURE 7-4 Adson's Test

Reliability Sensitivity Specificity (+) LR (−) LR

NT NT 89 (vascular changes) NT NT

NT NT 100 (pain) NT NT

NT NT 89 (paresthesia) NT NT

Plewa MC, et al. The false-positive rate of thoracic outlet syndrome shoulder maneuvers in healthy
patients. Acad Emerg Med. 1998;5(4):337-342.

Costoclavicular Maneuver
1. Patient sits straight (exaggerated military position).
2. Both arms are placed at the sides.
3. Examiner assesses the radial pulse in this position.
4. Patient is instructed to retract and depress the shoulders while protruding
the chest.
5. Position is held for one full minute.
6. Examiner records the radial pusle as diminished or occluded and queries the
patient for paresthesia.
7. (+) test is a change in radial pulse and patient report of paresthesia.

FIGURE 7-5 Costoclavicular Maneuver

Reliability Sensitivity Specificity (+) LR (−) LR

NT NT 89 (vascular changes) NT NT

NT NT 100 (pain) NT NT

NT NT 85 (paresthesia) NT NT

Hyperabduction Test
1. The patient sits very straight.
2. Both arms are placed at the sides.
3. Examiner asseses radial pulse in this position.
4. Patient is instructed to place arms above 90° of abduction and in full
external rotation.
5. The head maintains a neutral position.
6. The arms are held in this position for a full minute.
7. Examiner palpates radial pusle in the hyper abducted position.
8. Radial pulse is recorded as no change, diminished, or occluded.
9. Patient is also queried for paresthesia.
10. (+) test is change in radial pulse and patient report of paresthesia.

FIGURE 7-6 Hyperabduction Test

Reliability Sensitivity Specificity (+) LR (−) LR

NT NT 38 (vascular changes) NT NT

NT NT 79 (pain) NT NT

NT NT 64 (paresthesia) NT NT

Plewa MC, et al. The false-positive rate of thoracic outlet syndrome shoulder maneuvers in healthy
patients. Acad Emerg Med. 1998;5(4):337-342.

Cervical Rotation Lateral Flexion Test (Associated with

Brachialgia)
1. Patient is in a sitting position.
2. Examiner passively rotates the patient's head away from the affected side.
3. Examiner gently side flexes the head (ear to chest) passively. Side flexion
should be opposite of rotation.
4. (+) if a bony restriction blocks the lateral flexion.

Reliability κ Sensitivity Specificity (+) LR (−) LR

1.0 NT NT NA NA

Lindgren KA, et al. Cervical rotation lateral flexion test in brachialgia. Arch
Phys Med Rehabil. 1992;73(8):735-737.

First Rib Spring Test

1. Patient lies in a supine position.
2. Examiner passivley rotates the patient's head toward the rib that is assessed.
3. Examiner places his or her hand posterior to the first rib.
4. Examiner presses downward in a ventral and caudal direction (toward the
opposite hip or opposite shoulder).
5. Opposite side is assessed for comparison.
6. (+) test if the rib is considered stiff or hypomobile as compared with other
side.

Reliability κ Sensitivity Specificity (+) LR (−) LR

0.43 NT NT NA NA

Smedmark V, et al. Inter-examiner reliability in assessing passive intervertbral

motion of the cervical spine. Man Ther. 2000;5:97-101.
 FIGURE 7-7 Cervical Rotation Lateral Flexion Test

FIGURE 7-8 First Rib Spring Test

Costochondritis

Prevalence Symptoms Signs TBC/Special Tests

30% of people Intermittent chest

complaining of
pain1,3 Anterior chest Stabilize Mobilize
chest pain have
pain, usually unilateral2
costochondritis1 GPM V6
Insidious onset or after
> 40 years old5 Pain upon
unaccustomed Exercise Educate
palpation1
movements/repetitive
2nd-5th No palpable Joint play assessment: Assess
trauma1,2,3
junctions are edema2 thoracic spine, costovertebral,
most costosternal and sternoclavicular
Pain w/ trunk
common1,2 If trauma,
movement, deep mobility, as well as rib mobility.2,5
may have
inspiration; sharp,
F > M1, 2, 5 asymmetrical
Hispanics2 nagging, aching, chest wall2 Breathing pattern: Measure chest
localized; may wax and expansion at the level of the 4th rib
4% of cases are wane1,2,3 space. Normal expansion is greater
children and than 5 cm. Less than 2.5 cm is
adolescents2 Pain may radiate to chest, abnormal.
upper abdomen, back2

1
Disla E, Rhim HR, Reddy A, Karten I, Taranta A.
Costochondritis: A prospective analysis in an emergency
department setting. Arch Intern Med. 1994;154(21):2466-
2469.

2
Fam AG, Smythe H. Musculoskeletal chest wall pain. Can
Med Assoc J. 1985;133:379-389.

3
Udermann, et al. Slipping rib syndrome in a collegiate
swimmer: A case report. J Athl Train. 2005;40(2):120-122.

4
Fam AG. Approach to musculoskeletal chest wall pain. Prim
Care.1988;15(4):767-781.

5
Yelland MJ. Back, chest, and abdominal pain. How good are
spinal signs at identifying musculoskeletal causes of back,
chest, or abdominal pain? Australian Family Physician.
2001;30(9):908-912.

6
Aspegren D, et al. Conservative treatment of a female
collegiate volleyball player with costochondritis. J
Manipulative Physiol Thera. 2007;30(4):321-325.

Scheuermann's Kyphosis (Juvenile Kyphosis Dorsalis)

Prevalence Symptoms DSM/Signs TBC/ Special Tests

Exercise

Decrease lumbar lordosis by

tilting of the pelvis, stretching
of hamstrings and correct
kyphosis by hyperextension of
Rigid
hyperkyphosis the thoracic spine (foam roll)5
1-8% general Flexion
in mid- Mobilize
Population1,2,3,4 thoracic/lower Hamstring
thoracic spine Educate
Adolscents2,3 (round tightness3,4 Correction of movement
back)3,4,5,6 impairment
Age: 13-164,6 Decreased
Compensatory flexibility Lateral radiograph3,4
Males to females 2:1 and 7:11,3 lumber of the
hyperloradosis3,4 spine4 Stabilize
Criteria: more than 5° of
wedging of least 3 adjacent Decreased pelvic Tenderness Bradford series with
vertebrae at the apex of the inclination5 above and
kyphosis, endplate irregularities, below the Milwaukee brace3,4
thoracic kyphosis of more than Thoracic pain3,6 apex of the
45° DuPont kyphosis brace4
kyphosis4
Stiffness6
Casting3

Surgery3,4

Recumbent on a rigid bed4

1
Damborg F, Engell V, Anderson M, Kyvik Ohm K, Thomsen K. Prevalence, concordance, and
hereditability of Scheuermann kyphosis based on a study of twins. J Bone Joint Surg. 2006;88:2133-
2136.

2
Kapetanos G, Hantzidis P, Anagnostidis K, Kirkos J. Thoracic cord compression caused by disk
herniation in scheuermann disease. Eur Spine J. 2006;15:553-558.

3
Arlet V, Schlenzka D. Scheuermann's kyphosis; surgical management. Eur Spine J. 2005;14:817-827.

4
Nowak J. Scheuermann disease. eMedicine. Jan. 26,2007

5
Sachs B, Bradford D, Winter R, Lonestein J, Moe J, Willson S. Scheuermann kyphosis: Follow-up of
Milwaukee brace treatment. J Bone Joint Surg. 1987;69:50-57.

6
Magee DJ. Orthopedic Physical Assessment. 4th ed. St. Louis, MO: Elsevier Sciences;
2006:428,429,477.

Scoliosis

Prevalence Symptoms DSM/Signs TBC/Special Tests

Stabilize
Lateral flexion
Bracing for curves 25°-
4.5%8 Rib hump on side of 40°2,3,4
Progression observed in 6.8% of convexity1,2,3,4,5,6 Exercise
the students8
“C” or “S” shaped Educate
Highest prevalence in 12-14 year curve1,2,3,4
olds (1.2%) Correction of
Back Uneven shoulders or movement impairment
Based on Cobb angle > 10°, point pain1,2 hips2
prevalence of 0.5% (76 of 15,799 Promote motions
English patients) Leaning to Cobb angle > 10°2,3,4 opposite to the lateral
one side2 curvature of the spine
1-1.4:1 F:M8 (curves 6 20°) One shoulder blade that
5.4:1 F:M8 (curves 21° or appears more X-ray2
more) prominent than the
Postural evaluation
other2
Right thoracic curve most
Spine ROM
common7 Lateral shift5
Adams Forward Bending
Uneven waist2 Test

1
Negrini S, et al. Why do we treat adolescent idiopathic scoliosis? What we want to obtain and avoid
for our patients. Scoliosis. 2006;1:4.

2
Stirling AJ, Howel D, Millner PA, et al. Late-onset idiopathic scoliosis in children six to fourteen
years old: A cross-sectional prevalence study. J Bone Joint Surg Am. 1996;78(9):1330-1336.
Spelhaug N, et al. Scoliosis. December 15, 2005. Accessed February 10, 2007.
http://www.mayoclinic.com/health/scoliosis/DS00194

3
Weiss, HR. Indications for conservative management of scoliosis (guidelines). Scoliosis. 2006;1:5.

4
Katz, DE. The etiology and natural history of idiopathic scoliosis. JPO. 2003;15:3-10.

5
Saunders HD, Ryan RS. Evaluation, Treatment and Prevention of Musculoskeletal Disorders. 4th
ed. Chaska, MN: The Saunders Group Inc.; 2004.

6
Magee DJ. Orthopaedic Physical Assessment. 4th ed. Canada: Elsevier Sciences; 2006.

7
Robinson CM, McMaster MJ. Juvenile idiopathic scoliosis. Curve patterns and prognosis in one
hundred and nine patients. J Bone Joint Surg Am. 1996;78(8):1140-1148.

8
Rogala EJ, Drummond DS, Gurr J. Scoliosis: Incidence and natural history. A prospective
epidemiological study. J Bone Joint Surg Am. 1978;60(2):173-176.
FIGURE 7-9 Rib Hump in Forward Bending Test, Posterior View.
Source: Reprinted from JH Moe, et al. Scoliosis and Other Spinal Deformities, p. 17, ©
1978, with permisssion from Elsevier.
Chapter 8
The Shoulder and Shoulder Girdle

Shoulder Resting Position Closed Pack Capsular Pattern

GH 55°Abd, 30° H-Add Abd, ER ER, Abd, IR

AC Arm by side 90°Abd Extreme ROM

SC Arm by side Full rotation Extreme ROM

Outcome Tools

DASH—Disabilities of the Arm, Shoulder and Hand Outcome Questionnaire

SPADI—Shoulder Pain and Disability Index

GROC—Global Rating of Change

PSFS—Patient-Specific Functional Scale

FIGURE 8-1 Bones of the Pectoral Girdle and Arm Clark, RK. Anatomy and Physiology:
Understanding the Human Body. © 2005 Jones & Bartlett Publishers, LLC
 FIGURE 8-2 The Pectoral Girdle Including Features of the Scapula Clark, RK. Anatomy
and Physiology: Understanding the Human Body. © 2005 Jones & Bartlett Publishers,
LLC

Movement Impairments of the Shoulder and Shoulder Girdle:

DSM (Directional Susceptibility to Movement)

Scapular Humeral

Downward rotation (most common) Anterior glide (most common)

Depression Superior glide

Abduction Shoulder medial rotation

Winging and tilting GH hypomobility

Internal rotation and anterior tilt Multidirectional glenohumeral accessory hypermobility

Winging

Elevation
Key Tests for Movement Impairments of the Shoulder

Static Examination of the Shoulder Key Observations/Actions

Position on thoracic spine

Vertebral border parallel to and 3 inches from spine

 Superior angle @ T2

Inferior angle @ T7

Flat against thorax and rotated 30° anterior to frontal plane

Normal position of the scapula

Scapular Position

< 1/3 of humeral head protrudes in front of acromion

Antecubital crease faces anteriorly

Normal position of humerus
Olecranon faces posteriorly

Proximal and distal ends of humerus in same vertical plane

Dynamic Examination of the Shoulder Key Observations/Actions

Motion: 2:1 GH joint and scapula

Scapula stops moving by 140° of flexion

Scapular angle at end of range (EOR): 60° upward

Standing shoulder elevation: Scapular rotation
motion and position
Scapular position at EOR: 1/2 inch lateral to midaxillary
line

Scapular motion at end of range: Depressed, adducted,

and posterior tilted?
Standing Key Observations/Actions

Correction of downward rotation

Correction of abducted scapula

Shoulder flexion
Correction of scapular depression

Correction of anterior humeral head

Observe for rhomboid dominance

Shoulder lateral
rotation Observe for lack of adduction of scapulae at first 35° of scapular adduction at
the end of lateral rotation

Scapulothoracic
Serratus Anterior MMT
stability

Supine Key Observations/Actions

Pectoralis Minor length test

Scapular hypomobility Pectoralis Major length test

Teres major length test

Lateral rotation test (position of instantaneous center of rotation

Glenohumeral mobility “PICR”)
precision
Medial rotation test (PICR)

Prone Key Observations/Actions

Lateral rotation test

Glenohumeral mobility precision
Medial rotation test
 Scapulothoracic stability Middle Trapezius MMT

Lower Trapezius MMT

FIGURE 8-3 Treatment-Based Classification: Shoulder Region

Shoulder Treatment-Based Classificaton References

Pain Control
Singh H. The efficacy of continuous cryotherapy on the postoperative shoulder:
A prospective, randomized investigation. J Shoulder Elbow Surg.
2001;10(6):522-525.
Ebenbichler GR, Erdogmus CB, Resch KL, et al. Ultrasound therapy for calcific
tendinitis of the shoulder. N Engl J Med. 1999;340:1533-1538.

Mobilization
Nicholson GJ. The effects of passive joint mobilization on pain and hypomobility
associated with adhesive capsulitis of the shoulder. Orthop Sports Phys Ther.
1985;6(4):238-246.
Vermeulen HM, Obermann WR, Burger BJ, Kok GJ, Rozing PM, van den Ende,
CHM. End-range mobilization techniques in adhesive capsulitis of the shoulder
joint: A multiple-subject case report. Phys Ther. 2000;80(12):1204-1213.
Conroy DE, Hayes KW. The effect of joint mobilization as a component of
comprehensive treatment for primary shoulder impingement syndrome. J
Orthop Sports Phys Ther. 1998;28(1):3-14.

Hsu A, Ho L, Ho S, Hedman T. Joint position during anterior-posterior glide

mobilization: Its effect on glenohumeral abduction range of motion. Arch Phys
Med Rehabil. 2000;81(2):210-214.
Bang MD, Deyle GD. Comparison of supervised exercise with and without
manual physical therapy for patients with shoulder impingement syndrome. J
Orthop Sports Phys Ther. 2000;30:126-137.

Exercise Muscle Length/Strength

Kamkar A, Irrgang JJ, Whitney SL. Nonoperative management of secondary
shoulder impingement syndrome. Orthop Sports Phys Ther. 1993;17(5):212-224.
Kebaetse M, McClure P, Pratt NA. Thoracic position effect on shoulder range of
motion, strength, and three-dimensional scapular kinematics. Arch Phys Med
Rehabil. 1999;80:945-950.
Warner JJ, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R. Patterns of
flexibility, laxity, and strength in normal shoulders and shoulders with
instability and impingement. J Shoulder Elbow Surg. 2000;9:6-11.
Tate AR, et al. Effect of the scapula reposition test on shoulder impingement
symptoms and elevation strength in overhead athletes. J Orthop Sports Phys
Ther. 2008;38(1):4-11.
Endo K, Ikata T, Katoh S, Takeda Y. Radiographic assessment of scapular
rotational tilt in chronic shoulder impingement syndrome. J Orthop Sci.
2001;6:3-10.
Page PA. Posterior rotator cuff strengthening using Theraband® in a functional
diagonal pattern in collegiate baseball pitchers. J Athl Train. 1993;28(4):346,
348-350, 352-354.
Paterson C, Sparkes V. The effects of a six-week scapular muscle exercise
programme on the muscle activity of the scapular rotators in tennis players with
shoulder impingement: A pilot study. Phys Ther Sport. 2006;7(4):172.
Borstad JD, Ludewig PM. The effect of long versus short pectoralis minor resting
length on scapular kinematics in healthy individuals. J Orthop Sports Phys Ther.
2005;35(4):227-238.
Malliou PC, Giannakopoulos K, Beneka AG, Gioftsidou A, Godolias G. Effective
ways of restoring muscular imbalances of the rotator cuff muscle group: A
comparative study of various training methods. Br J Sports Med. 2004;38(6):766-
772.

Correction of Movement Impairment

Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle
activity in people with symptoms of shoulder impingement. Phys Ther.
2000;80:276-291.
Solem-Bertoft E, Thuomas KA, Westerberg CE. The influence of scapular
retraction and protraction on the width of the subacromial space: An MRI study.
Clin Orthop Relat Res. 1993;99-103. Am J Sports Med. 2000;28:668-673.
Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and
treatment of impingement syndrome. J Orthop Sports Phys Ther. 1999;29:31-
38.
Yamaguchi K, et al. Glenohumeral motion in patients with rotator cuff tears: A
comparison of asymptomatic and symptomatic shoulders. J Shoulder Elbow Surg.
2000;9:6-11.
Warner JJ, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R. Scapulothoracic
motion in normal shoulders and shoulders with glenohumeral instability and
impingement syndrome: A study using Moire topographic analysis. Clin Orthop
Relat Res. 1992;191-199.

Stabilization/Immobilization
Lewis JS, Wright C, Green A. Subacromial impingement syndrome: The effect
of changing posture on shoulder range of movement. J Orthop Sports Phys
Ther. 2005;35(2):72-87.
Deyle GD, Nagel KL. Prolonged immobilization in abduction and neutral
rotation for a first-episode anterior shoulder dislocation. J Orthop Sports Phys
Ther. 2007;37(4):192-198.
Selkowitz DM, Chaney C, Stuckey SJ, Vlad G. The effects of scapular taping on
the surface electromyographic signal amplitude of shoulder girdle muscles
during upper extremity elevation in individuals with suspected shoulder
impingement syndrome. J Orthop Sports Phys Ther. 2007;37(11):694-702.
Shamus JL, Shamus EC. A taping technique for the treatment of
acromioclavicular joint sprains: A case study. J Orthop Sports Phys Ther.
1997;25(6):390-394.
Host HH. Scapular taping in the treatment of anterior shoulder impingement.
Phys Ther. 1995;75:803-812.
Peterson C. The use of electrical stimulation and taping to address shoulder
subluxation for a patient with central cord syndrome. Phys Ther.
2004;84(7):634-643.
Thelen MD, Dauber JA, Stoneman PD. The clinical efficacy of kinesio tape for
shoulder pain: A randomized, double-blinded, clinical trial. J Orthop Sports
Phys Ther. 2008;38(7):389-395.
Smith J, Kotajarvi BR, Padgett DJ, Eischen JJ. Effect of scapular protraction and
retraction on isometric shoulder elevation strength. Arch Phys Med Rehabil.
2002;83:367-370. J Orthop Sports Phys Ther. 2007;37:A25.
Griffin A, Bernhardt J. Strapping the hemiplegic shoulder prevents
development of pain during rehabilitation: A randomized controlled trial. Clin
Rehabil. 2006;20(4):287-295.
Itoi E, Hatakeyama Y, Kido T, Sato T, Minagawa H, Wakabayashi I, Koboyashi M.
A new method of immobilization after traumatic anterior dislocation of the
shoulder: A preliminary study. J Shoulder Elbow Surg. 2003;12(5):413-415.
McConnell J. A novel approach to pain relief pre-therapeutic exercise. Clin
Sports Med. 2002;21(3):363-387.
Lewis JS, et al. Subacromial impingement syndrome: The effect of changing
posture on shoulder range of movement. J Orthop Sport Phys Ther. 2005;35:72-
87.

Post-OP Pearls—Shoulder

Immobilize at all times except for exercise

No AROM or resistance for 6 weeks

Rotator cuff repair precautions
No lifting, hand behind back

No weight bearing through hands

PROM and AAROM only

 Type 2 and 4 lesions:

No active shoulder or elbow flexion

SLAP lesion repair
No active GH ER, extension, abduction

Sling and sleep with immobilizer 4 weeks

NO AROM

Bankart lesion repair NO AROM IR if Subscapularis reflected in open repair

Avoid GH Horizontal Abd/ ER/ Extension

Impingement/Rotator Cuff Pathology

Prevalence Symptoms DSM/Signs TBC/Special tests

Shoulder
problems in
general
medical
practice

11.1/1000
women/year5 Scapular mobility impairments:
Pain control
8.4/1000 Night pain3 Decreased scapular posterior
tipping Immobilization
men/year5
Pain with shoulder
Decreased scapular upward Correction of
Peak age for abduction, flexion &
rotation movement
high rotation1
impairment/taping
incidence 45- Humeral mobility impairments:
Infraspinatus—ant.lat.
64 years old5 Mobilization
shoulder & scapula
Increased humeral anterior
Rotator cuff medial Border1 Exercise
translation
tendinitis
Subscaspularis—post. Education
most frequent Increased humeral superior
Shoulder & scapula,
diagnosis5 translation
down med arm to Ultrasonography
Primary elbow1 Increased superior translations with
Rent test (RC
impingement: muscle fatigue
Supraspinatus—sup. tear)
Cumulative Shoulder & over spine Decreased cross body adduction
Supine
microtrauma of scapula 1 Primary impingement: impingement test
(Sn)11
Anatomical Protective shoulder Posterior capsule tightness8
contributions hike1 Internal Rotation
Weak shoulder abduction, rotation lag sign
Decreased Secondary & flexion1,9
subacromial impingement: External Rotation
space 11
Painful arc (Sn) lag sign
Excessive range of
Hooked motion (ROM) into Weakness of greater than 50% Drop arm
acromion6,7 external rotation, relative to the contralateral side in
shoulder abduction at 10° of Hornblowers Sign
Mechanism of Weakness of the abduction was indicative of a large
injury: internal rotators IR vs ER
or massive rotator cuff tear2
Insidious Decreased endurance Hawkins-Kennedy
Painful palpations of RC tendons1
onset3 ratios of the shoulder
abductors and external 4 Painful arc (Sn)11
Limited AROM
Repetitive rotator8,10 Scapular
activities3 Full PROM4 Reposition Test
Fall on
outstretched
hand3

Traumatic
abduction3

1
Wilson, E. Physical Therapy Case Reports. 2001 March; 4(2): 90-97. Differential diagnosis and
treatment of shoulder impairment for a patient referred with a diagnosis of cervical spondylosis with
radiculopathy.

2
Finneran, J.J., McCabe, R. A., McHugh, M. P., Montgomery, K. D., Nicholas, S. J. Journal of
Orthopedic Sports Physical Therapy. 2005 March; 35(3): 130-135. The effects of rotator cuff tear size
on shoulder strength and range of motion.

3
Holtby, R., Razmjou, H. Journal of Orthopedic Sports Physical Therapy. 2004 April; 34 (4): 194-200.
Validity of supraspinatus test as a single clinical test for diagnosing patients with rotator cuff tears.

4
Brotzman S. B., Wilk K. E. Clinical Orthopedic Rehabilitation. 2003: 170-178. Mosby, PA.

5
van der Windt DA, Koes BW, de jong BA, Bouter LM. Shoulder disorders in general practice:
incidence, patient characteristics, and management. Ann Rheum Dis. 1995;54:959-964.

6
Hawkins RJ, Abrams JS. Impingement syndrome in the absence of rotator cuff tear (stages 1 and 2).
Orthop Clin North Am. 1987;18:373-381.

7
Jobe FW, Kvitne RS. Shoulder pain in the overhand or throwing athlete. Orthop Rev. 1989;18:963-
975.
 8
Warner JJP, Micheli L, Arslanian L, Kennedy J, Kennedy R. Patterns of flexibility, laxity, and
strength in normal shoulders with instability and impingement. Am J Sports Med. 1990;18:366-374.

9
Leroux JL, Codine P, Thomas El Pocholle M, Mailhe Dl Blotman F. Isokinetic evaluation of rotational
strength in normal shoulders and shoulders with impingement syndrome. Clin Orthop. 1994;304:108-
115.

10
Beach ML. Whitnev SL, Dickhoff-Hoffman SA. Relationship of flexibility, strength and endurance
to shoulder pain in competitive swimmers. J Orthop Sports Phys Ther. 1992;16:262-268.

11
Litaker D, et al. Returning to the bedside: using the history and physical examination to identify
rotator cuff tears. J Am Geriatr Soc. 2000, Volume 48. Pp. 1633-1637.

FIGURE 8-4 (A) Rotator Cuff (Anterior View); (B) The Muscles of the Rotator Cuff
(Posterior View) Souza, TA. Differential Diagnosis and Management for the
Chiropractor: Protocols and Algorithms. © 2009 Jones & Bartlett Publishers, LLC

Does Your Patient Have a Rotator Cuff Tear?

Screening out rotator cuff tears (Litaker, et al.)
No night pain (Sn-87.7)
No arc of pain (Sn-97.5)
No impingement signs (Sn-97.2)
No weakness

Ruling in Rotator Cuff Tears

3 key findings:
1. Supraspinatus weakness
2. Weakness in external rotation
3. Positive impingement sign or signs

(+) Findings Age (years) Probability of Rotator Cuff Tear (95% CI)

All 3 Any 98% (89-100)

Any 2 ≥ 60 98% (89-100)

Any 2 < 60 64% (47-79)

Any 1 ≥ 70 76% (56-90)

None Any 5% (2-11)

Murrell GA, Walton JR. Diagnosis of rotator cuff tears. Lancet. 2001;357:769.
[Published correction appears in Lancet 2001;357:1452].

Patient Characteristics Points

Age ≥ 65 years 2

Presence of night pain (awoken by pain) 1

Weakness on external rotation 2

Score Likelihood Ratio Probability of Rotator Cuff Tear (95% CI)

 0 to 1 0.2 42%

2 to 3 1.4 68%

4 to 5 9.8 to 14.3 91%

Adapted from Litaker D, Pioro M, El Bilbeisi H, Brems J. Returning to the

bedside: Using the history and physical examination to identify rotator cuff
tears. J Am Geriatr Soc. 2000;48:1636.

Screening Out/Ruling in Rotator Cuff Tears

Rent Test
1. Patient is seated with arm relaxed while examiner stands to the rear.
2. Examiner palpates anterior to the anterior edge of the acromion with one
hand while grasping the patient's flexed elbow with the other.
3. Examiner extends the patient's arm and then slowly internally and externally
rotates the shoulder.
4. (+) test = An eminence (prominent greater tuberosity) and a rent (depression
of about 1 finger width) will be felt in the presence of a rotator cuff tear.

Reliability Sensitivity Specificity +LR -LR

NT 96 97 32 0.04

Wolf EM, et al. Transdeltoid palpation (the rent test) in the diagnosis of rotator
cuff tears. J Shoulder Elbow Surg. 2001;10:470-473.
FIGURE 8-5 Rent Test 1

FIGURE 8-6 Rent Test 2

Screening Out Shoulder Impingement
Supine Impingement Test
1. Patient is in a supine position, with examiner at side of involved arm.
2. Examiner grasps the patient's wrist and distal humerus and elevates the
patient's arm to end range (170° or greater).
3. Examiner next moves the patient's arm into external rotation and adducts
the arm to the patient's ear.
4. Examiner now internally rotates the patient's arm.
5. (+) if the patient reports significant increase in shoulder pain.

Reliability Sensitivity Specificity +LR -LR

Unknown 97 9 1.07 0.33

Litaker D, et al. Returning to the bedside: Using the history and physical
examination to identify rotator cuff tears. J Am Geriatr Soc. 2000;48:1633-
1637.

FIGURE 8-7 Supine Impingement Test 1

 FIGURE 8-8 Supine Impingement Test 2

FIGURE 8-9 Supine Impingement Test 3

Screening out Impingement or Rotator Cuff Pathology

Hawkins-Kennedy Test
1. Patient is in a seated position.
2. Examiner stands in front of involved shoulder.
3. Examiner first raises the patient's arm into approximately 90° of shoulder
flexion with one hand while the other hand stabilizes the scapula (typically
superiorly).
4. Examiner applies forced humeral internal rotation.
5. (+) patient's shoulder pain is reproduced.

Reliability Sensitivity Specificity +LR -LR

 κ = .18-.432 721 661 2.111 0.421

1
Park HB, et al. Diagnostic accuracy of clinical tests for different degrees of subacromial
impingement syndrome. J Bone Joint Surg Am. 2005;87:1446-1455.

2
Ostor AJ, et al. Interrater reproducibility of clinical tests for rotator cuff lesions. Ann Rheum Dis.
2004;63:288-1292.

FIGURE 8-10 Hawkins-Kennedy Test

Screening out/ruling In Subscapularis Tear

Internal Rotation Lag Sign
1. Patient is seated with affected arm behind the back.
2. Examiner grasps the patient's elbow with one hand and the wrist with the
other.
3. Examiner lifts the patient's arm off of the back.
4. Examiner asks the patient to maintain this position as the patient's wrist is
released.
5. (+) test for Subscapularis tear is indicated by a lag that occurs with the
inability of the patient to maintain his or her arm off of the back.
Reliability Sensitivity Specificity +LR -LR

κ = .28-.322 97 96 24.251 0.031

1
Hertel, et al. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg. 1996;5:307-
313.

2
Ostor AJ, et al. Interrater reproducibility of clinical tests for rotator cuff lesions. Ann Rheum Dis.
2004;63:1288-1292.

FIGURE 8-11 Internal Rotation Lag Sign 1

 FIGURE 8-12 Internal Rotation Lag Sign 2

Ruling in Supraspinatus Tears

Drop Arm Test
1. Patient is seated with examiner standing to the front.
2. Examiner grasps the patient's wrist and passively abducts the patient's
shoulder to 90°.
3. Examiner releases the patient's arm with instructions to slowly lower the
arm.
4. (+) if patient demonstrates inability to lower his or her arm in a smooth,
controlled fashion.

Reliability Sensitivity Specificity +LR -LR

κ = .28-.662 271 881 2.251 0.831

1
Park HB, et al. Diagnostic accuracy of clinical tests for different degrees of subacromial
impingement syndrome. J Bone Joint Surg Am. 2005;87:1446-1455.
 2
Ostor AJ, et al. Interrater reproducibility of clinical tests for rotator cuff lesions. Ann Rheum Dis.
2004;63:1288-1292.

FIGURE 8-13 Drop Arm Test

Assessing Posterior Capsular Restriction

Glenohumeral Horizontal Adduction Measurement
1. Patient is in a supine position with both shoulders flush against a standard
examination table.
2. Examiner stands at the head of the table toward the head of the subject.
3. Examiner positions the test shoulder and elbow in 90° of abduction and
flexion, respectively.
4. Examiner stabilizes the lateral border of the scapula by providing a
posteriorly directed force (toward the examination table).
5. Examiner's opposite hand then holds the proximal portion of the subject's
forearm, slightly distal to the elbow, and passively moves the humerus into
horizontal adduction.
6. At the end range of horizontal adduction, a second tester records the
amount of motion present.
7. To measure GH horizontal adduction, the digital inclinometer is aligned with
the ventral midline of the humerus. The angle created by the end position of
the humerus with respect to 0° of horizontal adduction (perpendicular plane to
the examination table, as determined by the digital inclinometer) is then
recorded as the total amount of GH horizontal adduction motion.

FIGURE 8-14 Glenohumeral Horizontal Adduction Measurement

Intratester Reliability Intertester Reliability

ICC = 0.93 ICC = 0.91

[circled white star] This measurement was found to have a moderate to good
relationship with lost internal shoulder rotational motion (r _ .72, P _ .001) of
the dominant arm among the baseball pitchers and (r _ .68) when examining
the non-throwing shoulder. This method of assessment may be suitable for
both athletic and non-athletic populations.
Laudner KG, et al. Assessing posterior shoulder contracture: The reliability and
validity of measuring glenohumeral joint horizontal adduction. J Athl Train.
2006;41(4):375ñ380.

Supraspinatus Calcific Tendinitis

Prevalence Symptoms DSM/Signs TBC/Special Tests

Scapular mobility
impairments:

Decreased scapular
posterior tipping

Decreased scapular
upward rotation
Pain control
40-50 y/o2,4
Pain at Humeral mobility
impairments: Ultrasound5
Hypovascularization, night2
degeneration, and 24 15-minute sessions Pulsed 1:4
Pain in Increased humeral
proliferative changes2 anterior translation US 0.89 MHz 2.5W/cm2, 5 cm2
shoulder and transducer head
Can be asymptomatic and arm1 Increased humeral
dissolve over time4 superior translation Exercise
Difficulty
W > M3 raising arm Increased superior Correction of movement
overhead1 translations with impairment
Bilateral 25% of time3 muscle fatigue
Drop arm test
Decreased cross-
body adduction

Decreased ROM2

Rotator cuff
weakness4

1
Bhargav D, Murrell G. Shoulder stiffness diagnosis. Aust Fam Physician. 2004;33(3):143-47.

2
Brotzman S. Clin Orthop Rehabil. Memphis, TN: Mosby. 2003.

3
Leduc B, et al. Treatment of calcifying tendinitis of the shoulder by acetic acid iontophoresis: A
double-blind randomized controlled trial. Arch Phys Med Rehabil. October 2003;84:1523-1527.

4
Halverson P. Crystal deposition disease of the shoulder (including calcific tenodnitis and Milwaukee
Shoulder syndrome). Curr Rheumatol Rep. 2003;5:244-247.

5
Ebenbichler GR, et al. Ultrasound therapy for calcific tendinitis of the shoulder. N Engl J Med.
1999;340(20):1533-1538.

Biceps Tendonitis (a)/Biceps Rupture (b)

Prevalence Symptoms DSM/Signs TBC/Special Tests

Humeral anterior
glide
95% of biceps tendonitis
Shoulder
patients have
instability,
impingement syndrome as Achy anterior
subluxation6,7,8,9
primary diagnosis3 shoulder pain6,7,8,9 Pain control
Tenderness in Correction of
47-55 years old5 Pain with lifting or bicipital movement
elevated impairment Exercise
Athletes who have groove6,7,8,9
pushing/pulling6,7,8,9 (eccentric when
repetitive overhead PROM—shoulder appropriate)
motions: swimmers and Audible abduction, painful Mobilization
baseball pitchers6,7,8 “pop/snap”6,7,8,9 arc6,7,8,9 Education

Tennis and racquetball Acute, sharp pain in Weakness in Speed's Test2,3

players, rowers/kayakers, anterior
shoulder flexion,
golfers6,7,8 shoulder6,7,8,9 elbow flexion, and Yergason's Test2,3
forearm supination,
Biceps tears: associated Anterior shoulder MMT—elbow flexion,
and possible grip
with Subscapularis (47.1%), soreness may be painful3
strength6,7,8,9
Infraspinatus (34.6%) and worse at night6,7,8,9
Supraspinatous (96.2%)
Visible palpable
tendon tears1 mass between the
shoulder and
elbow6,7,8,9

1
Beall D, et al. Association of biceps tendon tears with rotator cuff
abnormalities: Degree of correlation with tears of the anterior and
superior portions of the rotator cuff AJR. 2003;180:633-639.

2
Calis M, Akgun K, Birtane M, Karacan I, Calis H, Tuzun, F. Diagnostic
values of clinical diagnostic tests in subacromial impingement syndrome.
Ann Rheum Dis. 2000;59:44-47.

3
Curtis AS, Snyder SJ. Evaluation and treatment of biceps tendon
pathology. Orthop Clin North Am. 1993;24(1):33-43.

4
Moore KL, Dalley AF. Clinically Oriented Anatomy. 5th ed. Baltimore,
MD: Lippincott Williams & Wilkins. 2006;789.

5
Murthi A, Vosburgh C, Neviaser T. The incidence of pathologic changes of
the long head of the biceps. J Shoulder Elbow Surg. 2000;9:382-385.

6
Ouellette H, Labis J, Bredella M, et al. Spectrum of shoulder injuries in
 the baseball pitcher. Skeletal Radiol. 2008;37(6):491-498.

7
Park SS, Loebenberg ML, Rokito AS, Zuckerman JD. The shoulder in
baseball pitching: Biomechanics and related injuries: Part 1. Bull Hosp Jt
Dis. 2002-2003;61(1-2):68-79.

8
Patton WC, McCluskey GM 3rd. Biceps tendinitis and subluxation. Clin
Sports Med. 2001;20(3):505-529.

9
Eakin CL, Faber KJ, Hawkins RJ, Hovis WD. Biceps tendon disorders in
athletes. J Am Acad Orthop Surg. 1999;7:300.

Screening out Biceps Tendinopathy

Speed Test
1. Patient is seated with arm flexed to 90°, elbow extended, and forearm fully
supinated.
2. Patient is asked to resist downward force applied by examiner.
3. (+) if patient experiences pain in proximal shoulder during application of
force.

Reliability Sensitivity Specificity +LR -LR

NT 90 14 1.0 0.71

Bennet WF. Specificity of the Speed's Test: Arthroscopic technique for

evaluating the biceps tendon at the level of the bicipital groove. Arthroscopy.
1998;14:789-796.

Screening out Biceps tendinopathy

Yergason's Test
1. Patient may sit or stand.
2. Examiner stands in front of the patient.
3. The patient's elbow is flexed to 90°, and the forearm is in a pronated
position while maintaining the upper arm at the side.
4. Patient is instructed to supinate arm while examiner concurrently resists
forearm supination at the wrist.
5. (+) If the patient localizes concordant pain to the bicipital groove.

Reliability Sensitivity Specificity +LR -LR

NT 74 58 1.76 0.45

Naredo, et al. Painful shoulder: Comparison of physical examination and

ultrasonographic findings. Ann Rheum Dis. 2001;61:132-136.

FIGURE 8-15 Speed's Test

FIGURE 8-16 Yergason's Test

SLAP Lesion

TBC/Special
Diagnosis Prevalence Symptoms DSM/Signs
Tests

MC in males—
91% 1

Avg age: 381 Pain control

Stabilize
Dominant arm Multidirectional GH Exercise
2 times more Accessory Correction of
likely to be hypermobility movement
involved1 impairment
SLAP lesion Associated with
Mobilize
(superior labral, Can be due to glenohumeral
Deep shoulder
anteriorposterior superior instability1,2,7 or Biceps Load
pain in the
lesion) compression or impingement-like Test II8
superior
Classifications inferior syndromes1,2
shoulder, in the
traction1 sup shoulder in Anterior
Type I: Superior Pain with passive ER at Apprehension
an ant-post 90° shoulder
labrum markedly Often occurs Test (Crank
frayed but direction1 abduction, esp. with
from falling on Test)1,3,5,6,7
attachments an OP7
Pain with
intact outstretched overhead Crank
Pain with active arm Test1,3,4,5,7
hand1,2,3 activity1,2,7
Type II: Superior elevation7
labrum has a small Complaints of
Occurs in Clunk
tear and there is clicking, Rotator cuff pathology
throwing Test1,3,7
instability of the popping, and/or (40%)1,2,7
athletes,
labral-biceps locking of Anterior Slide
associated
complex (MC) with the shoulder1,2,7 or Test1,3,4,5,7
follow- Feeling of 22% have Bankart
Type III: Bucket- Active
through1,2,3,7 uneasiness at lesions1,7
handle tear of Compression
common in the shoulder7
labrum that may O'Brien's
displace into Type II7 May have Type I associated with
Test1,3,4,5,6,7
joint; labral nonspecific rotator cuff pathology;
Repetitive Types III and IV
biceps attachment complaints7 Biceps
overhead associated with
intact
activities7 Tension Test3
No pain at rest; traumatic instability7
Type IV: Bucket- intermittent7 Biceps Load
Commonly a Older: rotator cuff
handle tear of Test3,5,7
direct blow to Inability to pathology
labrum that
the perform sporting
extends to biceps SLAP
tendon, allowing shoulder1,2,4 activities at a Younger: instability7 Prehension
high level7 Types I and III more
tendon to sublux
Higher Test3,5
symptomatic with
into joint2 incidence in compression; Types II Pain
occupations and IV more symptomatic Provocation
requiring when simulate Test3,5,7
heavy lifting2 mechanism of injury7
Speed's
No specific Test3,7
cause with
insidious onset
22%1

1
Alessandro DF, Fleischli JE, Connor PM. Superior labral lesions: Diagnosis and management. J
Athletic Training. 2000;35(5):286-292.

2
Donatelli RA, Wooden MJ. Orthopaedic Physical Therapy. 3rd ed. Philadephia, PA: Churchill
Livingstone, Harcourt Health Sciences Company; 2001.

3
Magee DJ. Orthopedic Physical Assessment. 4th ed. Philadelphia, PA: W. B. Saunders Company;
1997.

4
McFarland EG, Kim TK, Savino RM. Clinical assessment of three common tests for superior labral
anterior-posterior lesions. Am J Sports Med. 2002;30(6):810-815.

5
Mirkovic M, Green R, Taylor N, Perrott M. Accuracy of clinical tests to diagnose superior labral
anterior and posterior (SLAP) lesions. Phys Ther Rev. 2005;10:5-14.

6
Stetson WB, Templin K. The Crank Test, the O'Brien Test, and routine magnetic resonance imaging
scans in the diagnosis of labral tears. Am J Sports Med. 2002;30(6):806-809.

7
Wilk KE, Reinold MM, Dugas JF, Arrigo CA, Moser MW, Andrews JR. Current concepts in the
recognition and treatment of superior labral (SLAP) lesions. J Orthop Sports Phys Ther.
2005;35(5):273-291.

8
Kim SH, et al. Biceps Load Test II: A clinical test for SLAP lesions of the shoulder. Arthroscopy.
2001;17:160-164.
 FIGURE 8-17 The Coracoacromial Arch and Glenohumeral Joint (Lateral View) Souza,
TA. Differential Diagnosis and Management for the Chiropractor: Protocols and
Algorithms. © 2009 Jones & Bartlett Publishers, LLC

Screening out/Ruling in SLAP Lesion

Biceps Load Test II
1. Patient is in a supine position.
2. Examiner sits at side of patient's involved extremity.
3. Examiner places patient's shoulder in 120° of abduction.
4. Elbow bent to 90° of flexion, forearm in supination.
5. Examiner moves the arm to end range external rotation.
6. At end range external rotation, the examiner asks the patient to flex his or
her elbow while the examiner resists the movement.
7. (+) reproduction of pain during resisted elbow flexion.

Reliability Sensitivity Specificity +LR -LR

κ = 0.82 90 97 26.38 0.11

Kim SH, et al. Biceps Load Test II: A clinical test for SLAP lesions of the
shoulder. Arthroscopy. 2001;17:160-164.

FIGURE 8-18 Biceps Load Test II

Bankart Lesion (Avulsion of Anteroinferior Capsulolabral

complex)

Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control

Stabilize If
necessary
immobilize with
shoulder in

ER, abduction,
extension2

Early
mobilization8

Exercise

Sense of Isometrics 3-5

instability9 Humeral seconds
Most common in second decade and sixth anterior glide
decade2
Throwing athletes5 Repeat Multidirectional 30x/day
dislocations9 GH accessory
Most commonly occur with a traumatic hypermobility Correction of
anterior dislocation 98% leading to Shoulder movement
anterior instability2,4,5 “goes dead” Possible impairment
proprioceptive
85% of traumatic instability cases requiring Shoulder deficits2 Mobilize
surgery2 “slips in and
out”6 Hill-Sachs Education
70% redislocation rate within 2 years9 deformity often
6-8 weeks of
Decreased occurs2,4 activity restriction
strength6
Surgery7

Jerk Test

Yergason's Test

Anterior Release
Test

Comprehension
Rotation Test

Clunk Test

Sulcus Sign

1
Donatelli RA, Wooden MJ. Orthopaedic Physical Therapy. 3rd ed. Philadelphia, PA: Churchill
Livingstone, Harcourt Health Sciences Company; 2001.

2
Hayes K, Callanan M, Walton J, Paxinos A, Murrell GAC. Shoulder instability: Management and
rehabilitation. J Orthop Sports Phys Ther. 2002;32(10):1-13.

3
Itoi E, Lee SB, Amrami KK, Wenger DE, An KN. Quantitative assessment of classic anteroinferior
bony Bankart lesions by radiography and computed tomography. Am J Sports Med. 2003;31(1):112-
118.

4
Ly JQ, Beall DP, Sanders TG. MR imaging of glenohumeral instability. AJR. 2003;181:203-213.

5
Magee DJ. Orthopedic Physical Assessment, 4th ed. Philadelphia, PA:W. B. Saunders Company;
1997.

6
Simonet WT, Cofield RH. Prognosis in anterior shoulder dislocation. Am J Sports Med. 1984;12:19-
24.

7
Yamashita T, Okamura K, Hotta T, Aoka M, Ishii S. Good clinical outcome of combined Bankart-
Bristow Procedure for recurrent shoulder instability. Acta Orthop Scand. 2002;73(5):553-557.

8
Kim S, et al. Accelerated rehabilitation after arthroscopic Bankart Repair for selected cases: A
 prospective randomized clinical study. Arthroscopy. 2003;19(7):722-731.

9
Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg. 1956;38A:957-977.

Ruling in Labral Tears

Yergason's Test [See Figure 8-16 on page 133]

Reliability Sensitivity Specificity +LR -LR

NT 9 93 1.29 0.98

Guanche CA, Jones DC. Clinical testing for tears of the glenoid labrum.
Arthroscopy. 2003;19:517-523.

Ruling in Posteroinferior Labral Lesion

Jerk Test
1. Patient is in a seated position.
2. Examiner stands behind the patient.
3. Examiner grasps the elbow with one hand and the scapula with the other and
elevates the patient's arm to 90° abduction and internal rotation.
4. Examiner provides an axial compression-based load to the humerus through
the elbow maintaining the horizontally abducted arm.
5. Axial compression is maintained as the patient's arm is moved into horizontal
adduction.
6. (+) if sharp shoulder pain with or without a clunk or click.

Reliability Sensitivity Specificity +LR -LR

NT 73 98 36.5 0.27

Kim KH, et al. Usefulness of physical maneuvers for prevention of vasovagal

syncope. Circ J. 2005;69:1084-1088.
 FIGURE 8-19 Jerk Test

Ruling in Superior Labral Tears

Sulcus Sign
1. Patient is in a seated position.
2. Examiner stands behind the patient.
3. Examiner grasps the elbow and pulls down, causing an inferior traction force.
4. Examiner notes, in centimeters, the distance between the inferior surface of
the acromion and the superior portion of the humeral head.
5. Examiner repeats the test in a supine position, with the shoulder in 20° of
abduction and in forward flexion while maintaining a neutral rotation.

Reliability Sensitivity Specificity +LR -LR

NT 17 93 2.43 0.89

Nakagawa S, et al. Forced shoulder abduction and elbow flexion test: A new
simple clinical test to detect superior labral injury in the throwing shoulder.
Arthroscopy. 2005;21:1290-1295.
 FIGURE 8-20 Sulcus Sign

Adhesive Capsulitis

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

GH hypomobility
Pain
Effects sleep1,2,3,5 Decreased AROM control
and PROM in
3-5% in general public Interferes w/ ADLs Correction
capsular
(fixing hair, fastening of
pattern1,3,4,6
Up to 20% in diabetic population7,8 bra, putting on movement
shirt)1,3,5,6 Loss of passive impairment
40-60 y/o1,2,3,4,5
ER1,2
Lateral upper arm Mobilization
Insidious onset, trauma or after pain at rest1 (Grade III-
Shoulder hike4
surgery2,4 IV)9,10
Pain with lifting or
5 Tight capsule5
Women > Men reaching overheads5 Exercise
Muscle
Associated with insulin-dependent Cannot reach behind AROM same
diabetes, heart disease, weakness3,5 Arm
back into back as PROM
hyperthyroidism, arthritis, cervical postured in
pockets5 adduction and
limitations
spondylosis2,5
Radiating pain to IR1,2 Capsular
elbow1 glide
Joint line assessment
tenderness at GH2

1
Brotzman S. Clinical Orthopaedic Rehabilitation. Memphis, TN: Mosby. 2003.

2
Dias R. Frozen shoulder. BMJ. 2005; 331:1453-1456.
3
Jürgel J, Rannama L, Gapeyeua H, Ereline J, Kolts I, Pääsuke M. Shoulder function in patients with
frozen shoulder before and after 4-week rehabilitation. Medicina(Kaunas). 2005;41(1):30-38.

4
Magee D. Orthopedic Physical Assessment. 5th ed. Philadelphia, PA: Elsevier. 2006.

5
Saunders H. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders. Vol. 2.
Chaska, MN: The Saunders Group. 1994.

6
Vermeulen H. End range mobilization techniques in adhesive capsulitis of the shoulder joint: A
multiple-subject case report. Phys Ther. 2000;80(12):1204-1214.

7
Bridgman JF. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis. 1972;31:69-71.

8
Pal B, Anderson J, Dick WC, Griffiths ID. Limitation of joint mobility and shoulder capsulitis in
insulin- and noninsulin-dependent diabetes mellitus. Br J Rheumatol. 1986;25:147-151.

9
Van den Hout W, et al. Impact of adhesive capsulitis and economic evaluation of high-grade and
low-grade mobilization techniques. Aust J Physiother. 51:141-149.

10
Guler-Uysal F, et al. Comparison of the early response to two methods of rehabilitation in
adhesive capsulitis. Swiss Med Wkly. 2004;134:353-358.

Scapular Dyskinesia

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Downward rotation (most

common)

Depression

Abduction Correction
Throwing of
athletes2 Winging and tilting movement
impairment
Shoulder Internal rotation and anterior tilt
impingement Mobilization
syndrome2,3,5 Shoulder impingement-type Winging
symptoms Exercise
Labral Elevation
pathology, Shoulder pain, stiffness6 Measure
rotator cuff Increased prominence of the bilateral
tears2 Difficulty doing ADLs: superior border and spine of vertical
scapula2 height
 Frozen getting dressed, completing Greater external rotation of difference2
shoulder3 personal hygiene, performing scapula5
tasks requiring overhead Scapular
Idiopathic reaching6 Decreased muscle force and Reposition
shoulder ROM shoulder ROM3,5 Test
loss6
Greater posterior tipping, upward Lateral
Females 6 rotation, and clavicular Scapular
retraction during scapular plane Glide Test
elevation2,3,5,6

Increased scapular protraction

with overhead lifting2,3

1
Tate A, et al. Effect of the Scapula Reposition Test on the shoulder impingement symptoms and
elevation strength in overhead athletes. J Orthop Sports Phys The.r 2008;38(1):4-11.

2
Launder KG, Myers JB, Pasquale MR, Bradley JP, Lephart SM. Scapular dysfunction in throwers with
pathologic internal impingement. J Orthop Sports Phys Ther. 2006;36 (7):485-494.

3
Lin JJ, Hanten WP, Olson SL, Roddey TS, Soto-quijano DA, Lim HK, Sherwood AM. Shoulder
dysfunction assessment: Self-report and impaired scapular movements. Phys Ther. 2006;86(8):1065-
1074.

4
Magee DJ. Orthopedic Physical Assessment. 4th ed. Philadelphia, PA: Elsevier Sciences; 2006.

5
McClure P, Michener LA, Karduna AR. Shoulder function and 3-dimensional scapular kinematics in
people with and without shoulder impingement syndrome. Phys Ther. 2006;86(8):1075-1088.

6
Rundquist PJ. Alterations in scapular kinematics in subjects with idiopathic loss of shoulder range
of motion. J Orthop Sports Phys Ther. 2007;37(1):19-25.

Assessing for Scapular Dysfunction

Scapular Reposition Test
1. Patient is sitting or standing at edge of plinth.
2. Examiner grasps scapula with fingers contacting the AC joint anteriorly.
3. Examiner's palm and thenar eminence contact the spine of the scapula
posteriorly, with the forearm obliquely angled toward the inferior angle of the
scapula for additional support on the medial border.
4. Examiner applies a moderate force to the scapula to encourage scapular
posterior tilting and external rotation, and to approximate the scapula to a mid
position on the thorax. Avoid bringing scapula to end range retraction.
5. (+) test if there is relief of pain based on a verbal numeric rating scale of 0-
10 with provocation testing.
[circled white star] Though unvalidated this test may help to identify a subset
of patients with shoulder pathology that may benefit from interventions
designed to improve scapular muscular function.
Tate A, et al. Effect of the Scapula Reposition Test on the shoulder
impingement symptoms and elevation strength in overhead athletes. J Orthop
Sports Phys The.r 2008;38(1):4-11.

FIGURE 8-21 Scapular Reposition Sign

Suprascapular Neuropathy

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Downward rotation
(most common)

Depression
 Abduction Pain control

Winging and tilting Exercise

Internal rotation and Mobilization

Athletes, particularly
overhead athletes2 anterior tilt Correction
of
10 in 2520 shoulder Winging movement
Aching, burning pain at the
patients (possibly impairment
posterolateral aspect of the Elevation
because often shoulder in the region of the
misdiagnosed in 8/10 EMG2
scapula1 Atrophy of scapular
times)1 muscles, supraspinatus Hawkins-
and infraspinatus, impingement
Repetetive overhead
rhomboids2 sign1
activities
Weakness1 Kennedy-
impingement
Tenderness to
sign1
palpation2
2 Neer's Test1
Winging of scap

Painful arc1

1
Walsworth MK, Mills JT, Michener LA. The differential diagnosis of patients with suprascapular
neuropathy is presented and illustrated using 5 patients with this condition. Phys Ther. 2004;84(4).

2
Ravindran M. Two cases of suprascapular neuropathy in a family. Br J Sports Med. 2003;37:539-541.

Brachial Plexus Neuropathy

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Scapular
depression

Paresthesias4 Exercise
Burning sensation that Correction
Athletes, particularly contact Dysestesias4
radiates down upper of
sports1
extremity4 movement
Weakness4
Axillary, musculocutaneous, impairment
Radicular symptoms abate in
suprascapular and thoracodorsal Tenderness
5-10 minutes with local Mobilization
nerve most commonly involved4 over Erb's
35% of 79 breast cancer patients3 tenderness remaining4 point1,4 ULTT3
(radiation induced)
“Dead arm” or transient Dropped Spurling's
paresis4 shoulder4 Test2

Shoulder
muscle
atrophy4

1
Cramer C. A reconditioning program to lower the reoccurrence rate of brachial plexus neuropraxia
in collegiate football players. J Athl Train. 1999;34(4).

2
Saunders H, Tomberline J. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders:
Volume 2, Extremities. 4th ed. Chaska, MN: The Saunders Group; 2004.

3
Olsen NK, Pfeiffer P, Mondrup K, Rose C. Radiation-induced brachial plexus neuropathy in breast
cancer patients. Acta Oncologica. 1990;29(7):885-890.

4
Markey KL, Di Benedetto M, Curl WW. Upper trunk brachial plexopathy. Am J Sports Med. 1993;
(21):650.

Acromioclavicular Joint Sprain

Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control
Scapular Immobilization
Fall on the tip of the shoulder depression
(that depresses the acromion Exercise
1
inferiorly)1,5 Crepitus
Mobilize
Fall on an outstretched arm (that Palpable step-
MC in transfers the forces superiorly on off of the AC resisted extension
athletes2 the acromion)1,3 clavicle1,3,4
AC palpation
Men > Repetitive overhead activities1 Swelling2,4
Women Acromioclavicular shear
(5:1)6 Pain when moving arm overhead Tenderness2,3,4 test1,4
or across the body in horizontal
Pain4 Acromioclavicular crossover,
adduction1,4
cross body, or horizontal
Pain when sleeping on the injured Decreased adduction test1
shoulder1 shoulder
function4 Cross-body test2,3,5
 O'Brien test3

1
Saunders HD, Saunders RR. Evaluation, Treatment and Prevention of Musculoskeletal Disorders:
Volume 2, Extremities. 4th ed. Chaska, MN: The Saunders Group; 2004.

2
Mouhsine E, Garofalo R, Crevoisier X, Farron A. Grade I and II acromioclavicular dislocations:
Results of conservative treatment. J Shoulder Elbow Surg. 2003;12:599-602.

3
Deitch J. Acromioclavicular joint injuries. Curr Opin Orthop. 2004;15:261-266.

4
Shamus J, Shamus E. A taping technique for the treatment of acromioclavicular joint sprains: A
case study. J Orthop Sports Phys Ther. 1997;25:390-394.

5
Johnson RJ, Harmon K, Rubin A. Acromioclavicular joint injuries: Identifying and treating
“separated shoulder” and other conditions. Phys Sportsmed. 2001;29.

6
Rockwood CA Jr, Williams GR, Young CD. Injuries of the acromioclavicular joint. In Fractures in
Adults. Philadelphia, PA: Lippincott. 1996;1341-1431.

FIGURE 8-22 Ligaments of the Acromioclavicular and Glenohumeral Joints Souza, TA.
Differential Diagnosis and Management for the Chiropractor: Protocols and Algorithms.
© 2009 Jones & Bartlett Publishers, LLC
Screening out/AC Joint Pathology
AC Joint Palpation
1. Patient is seated with involved arm at side of body.
2. Examiner stands behind body and palpates the AC joint.
3. (+) with reproduction of pain.

Reliability Sensitivity Specificity +LR −LR

NT 96 10 1.07 0.40

Walton J, et al. Diagnostic values of tests for acromioclavicular joint pain. J Bone Joint Surg AM.
2004;86-A:807-812.

FIGURE 8-23 AC Joint Palpation

Ruling in AC Joint Pathology

 AC Resisted Extension Test
1. Patient is seated with shoulder in 90° of flexion and internal rotation.
2. Elbow is in 90° of flexion.
3. Examiner stands behind patient.
4. Instruct patient to horizontally abduct arm while examiner blocks movement.
5. (+) pain at AC joint.

Reliability Sensitivity Specificity +LR −LR

NT 72 85 4.8 0.32

Chronopoulos E, et al. Diagnostic value of physical tests for isolated chonic acromioclavicular
lesions. Am J Sports Med. 2004;32:655-661.

FIGURE 8-24 AC Resisted Extension Test

Chapter 9
The Elbow

FIGURE 9-1 Bones of the Arm and Hand Clark, RK. Anatomy and Physiology:
Understanding the Human Body. © 2005 Jones & Bartlett Publishers, LLC
FIGURE 9-2 (A) The Elbow Joint (Medial View) (B) The Elbow Joint (Lateral View)
Souza, TA. Differential Diagnosis and Management for the Chiropractor: Protocols and
Algorithms. © 2009 Jones & Bartlett Publishers, LLC

Elbow Resting Position Closed Pack Capsular Pattern

Humeroulnar 70° Flexion, 10° Sup. Full Ext. Flex > Ext

Humeroradial Full Ext. 90° Flex., 5° sup. Flex > Ext

Prox. Radioulnar 70° Flex., 35° Sup. 5° Sup. Sup = Pron

Dist. Radioulnar 10° Sup. 5° Sup. Sup = Pron

Middle Radioulnar NA Tense in neutral pro/sup NA

Outcome Tools

DASH—Disabilities of the Arm, Shoulder, and Hand Outcome Questionnaire

GROC—Global Rating of Change Scale

PSFS—Patient-Specific Functional Scale

Red Flags for Potential Serious Conditions in Patients with

Elbow Problems

Red Flag
Red Flag
Condition Data Obtained During
Data Obtained During Physical Exam
Interview/History

History of trauma, surgery, Palpable tenderness and tension of involved

or extreme unaccustomed compartment
activity
Compartment Pain intensified with stretch to involved muscles
syndrome1,2 Persistent forearm pain and
“tightness” Tingling, Paresthesia, paresis, and sensory deficits
 burning, or numbness Diminished pulse and prolonged capillary refill

Radial head Elbow joint effusion—arm held in loose packed

History of fall on
position Restricted/painful supination and pronation
fracture3 outstretched hand
AROM Tenderness over radial head

1
Harvey C. Compartment syndrome: When it is least expected. Orthop Nurs. 2001;20(3):15-23.

2
Jawed S, Jawad AS, Padhiar N, Perry JD. Chronic exertional compartment syndrome of the
forearms secondary to weight training. Rheumatology. 2001;40:344-345.

3
Major N, Crawford S. Elbow effusion in trauma in adults and children: is there an occult fracture?
Am J Radiology. 2002;178:413-418.

FIGURE 9-3 Treatment-Based Classification for Elbow Region

Elbow TBC References
Pain Control
Davidson J, et al. The effect of acupuncture versus ultrasound on pain level,
grip strength, and disability in individuals with lateral epicondylitis: A pilot
study. Physiother Can. 2001;53:195-202, 211.
Fink M, Wolkenstein E, Karst M, et al. Acupuncture in chronic epicondylitis: A
randomized controlled trial. Rheumatology. 2002;41:205-209.
Lundeberg T, Abrahamsson P, Haker E. A comparative study of continuous
ultrasound, placebo ultrasound, and rest in epicondylalgia. Scand J Rehabil
Med. 1988;20:99-101.

Mobilization
Abbott JH, Patla CE, Jensen RH. The initial effects of an elbow mobilization
with movement technique on grip strength in subjects with lateral
epicondylalgia. Man Ther. 2001;6(3):163-169.
Bain GI, Ashwood N, Baird R, Unni R. Management of Mason Type-III radial head
fractures with a titanium prosthesis, ligament repair, and early mobilization. J
Bone Joint Surg Am. 2004;86:274-280.
Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-
analysis of clinical trials on physical interventions for lateral epicondylalgia. Br
J Sports Med. 2005;39:411-422.
Ekstrom RA, Holden K. Examination of and intervention for a patient with
chronic lateral elbow pain with signs of nerve entrapment. Phys Ther.
82(11):1077-1086.
Millet PJ, Rushton HN. Early mobilization in the treatment of Colles' fracture: A
3-year prospective study. Injury. 1995;26(10):671-675.
Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Hypoalgesic and
sympathoexcitatory effects of mobilization with movement for lateral
epicondylalgia. Phys Ther. 2003;83(4):374-383.
Seradge MD. Cubital tunnel release and medial epicondylectomy: effect of
timing of mobilization. J Hand Surg. 1997;22(5):863-866.
Struijs PAA, et al. Manipulation of the wrist for management of lateral
epicondylitis: A randomized pilot study. Phys Ther. 2003;83(7):608-616.
Vicenzino B. Lateral epicondylalgia: a musculoskeletal physiotherapy
perspective. Man Ther. 2003;8(2):66.
Vicenzinoa B, Paungmalia A, Buratowskib S, Wright A. Specific manipulative
therapy treatment for chronic lateral epicondylalgia produces uniquely
characteristic hypoalgesia. Man Ther. 2001;6(4):205-212.

Stabilization
Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-
analysis of clinical trials on physical interventions for lateral epicondylalgia. Br
J Sports Med. 2005;39:411-422.
Struijs PAA, et al. Conservative treatment of lateral epicondylitis brace versus
physical therapy or a combination of both: A randomized clinical trial. Am J
Sports Med. 2004;32:462-469.
Vicenzio B, et al. Initial effects of elbow taping on pain-free grip strength and
pressure pain threshold. J Orthop Sports Phys Ther. 2003;33(7):400-407.

Exercise
Croisier J, et al. An isokinetic eccentric programme for the management of
chronic lateral epicondylar tendinopathy. Br J Sports Med. 2007;41:269-275.
Manias P, Stasinopoulos D. A controlled clinical pilot trial to study the
effectiveness of ice as a supplement to the exercise programme for the
management of lateral elbow tendinopathy. Br J Sports Med. 2006;40:81-85.
Martinez-Silvestrin JA, Newcomer KL, Gay RE, Schaefer MP, Kortebein P, Arendt
KW. Chronic lateral epicondylitis: comparative effectiveness of a home exercise
program Including stretching alone versus stretching supplemented with
eccentric or concentric strengthening. J Hand Ther. 2005;18(4):411-420.

Pienimaki T, et al. Progressive strengthening and stretching exercises and

ultrasound for chronic lateral epicondylitis. Physiotherapy. 1996;82:522.
Stasinopoulos D, Stasinopoulou K, Johnson MI. An exercise programme for the
management of lateral elbow tendinopathy. Br J Sports Med. 2005;39:944-947.

Lateral Epicondylalgia
 TBC/Special
Prevalence Symptoms DSM/Signs
Tests

95% dominant
arm2,9,10

1-3% population2,3

30-60 y/o2,10

Equal gender
percentage, but Wrist extension
longer duration and Wrist radial
severity of symptoms deviation Flexibility
in women2,4,9 Gripping exercises
(ECRB)1,2,5,8,10
Large Valgus force Inflammation at
with medial Painful Lateral origin of wrist Varus stress
extensor Pain control (to rule out
distraction and lateral Epicondyle1,2,3,5,6,10
muscles, esp. (acute)1,2,5,8,10 radiate lig.)1
compression5
Decrease function ECRB1,10
Mobilization There are no
Microtrauma with in ADLs2 Friction
wrist flexion, ulnar (+) ULTT radial1 validated
Some pain to massage tests
deviation, forearm
pronation, and elbow forearm1,10 Pain with (healing)1,5,8,10 available
extension1,3,5,10 resisted
supination and GPM V PA to Palpation1,2
Dull ache pain at
Poor lifting rest that increases radial deviation1 scaphoid7
MRI
technique, especially with gripping1,2 Exercise
weight unaccustomed Pain with passive
Stiffness in the stretch into Tomsen Test2
to1,9,10 Strength wrist
morning1 pronation and
extensors Resisted
Motorcycle riders8 ulnar deviation
(eccentric, middle finger
Pain shaking hands and elbow
4,9
high rep, low
Poor work posture and twisting door extension1 test2
load)1,2,5,8,11
knobs10
50% are frequent Less pain with Handgrip test2
tennis players (grip to resisted
small)1,5,10 supination at 90 Chair lifting
degrees elbow test10
Increased glutamate flexion verses
levels with decreased full extension2
prostaglandin E210

Can be from Radial

Carpal Syndrome
(nerve entrapment)1,5

Or from radial head

subluxation1,5
1
Saunders HD, et al. Evaluation, Treatment, and Prevention of Musculoskeletal
Disorders, vol 2. 3rd ed. Chaska, MN: The Saunders Group; 2004.

2
Manias P, Stasinopoulos D. A controlled clinical pilot trial to study the
effectiveness of ice as a supplement to the exercise programme for the
management of lateral elbow tendinopathy. Br J Sports Med. 2006;40(1):81-85.

3
Faes M, et al. A dynamic extensor brace reduces electromyographic activity of
wrist extensor muscles in patients with lateral epicondylalgia. J Orthop Sport Phys
Ther. 2006;36:3.

4
Waugh E, et al. Computer use associated with poor long-term prognosis of
conservatively managed lateral epicondylalgia. J Orthop Sport Phys Ther. 2004;Vol
34:16.

5
Hume P, et al. Epicondylar injury and sport. Sports Med. 2006;36:2.

6
Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local
anesthesia for chronic lateral epicondylitis. J Bone Joint Surg. 2005;87:1297-1304.

7
Struijs PA, et al. Manipulation of the wrist for management of lateral
epicondylitis: A randomized pilot study. Orthopaedic Research Center.
Amsterdam, the Netherlands: Amsterdam Medical Center; 2005.

8
Hoppenrath T, Ciccotte CD. Evidence in practice. Phys Ther. 2006;86:1.

9
Haahr JP, Andersen JH. (2002). Physical and psychosocial risk factors for lateral
epicondylitis: A population-based case-referent study. Department of
Occupational Medicine, Herning, Denmark: Herning Hospital, DK-7400; 2002.

10
Soto-Quijano DA, Rivera-Tavarez CE. Work-related musculoskeletal disorders of
the upper extremity. Critical Reviews in Physical and Rehabilitation Medicine.
2005;17(l):65-82.

11
Svernlov B, Adolfsson L. Non-operative treatment regime including eccentric
training for lateral humeral epicondylalgia. Scand J Med Sci Sports. 2001;11(6):328-
334.

Medial Epicondylalgia

Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control Physical

agents1,2,4
Golfers1,2 Stabilize (acute)
Wrist flexion Bracing1,2
0.4% population3
Wrist ulnar deviation Mobilization
MC found ages 45-544
Pain with Friction massage
Gripping
3 resisted wrist
No gender preference (healing)1,2
flexion1,3 Inflammation over medial
4
Forceful work epicondyle4 STM (mobility)1
Pain at medial
Smokers3,4 elbow and Pain with resisted wrist Exercise
forearm1,2,3 flexion and ulnar
DM3 deviation1,3,4 Strengthen (eccentric,
Dull ache at high rep, low load)1,2,4
Obesity 3 rest1,3 Pain with PROM into wrist
extension and radial Flexibility exercises
Repetitive wrist flexion Increase pain (wrist and finger
deviation and supination1
and pronation and elbow with leaning on extension and radial
extension movements1,3 desk or Tender palpation to deviation)1,2,4
armrest1 medial epicondyle,
MC gradual, but can be pronator teres, or Education
traumatic1 Unable to grip
FCR1,2,3
as much due to Activity modification1,2,4
Overhead throwers2 pain1,3 Decreased grip
strength1,3 Passive test1
Work/play in non-neutral
postures3,4 Decreased ADLs3 Resistive test1

Palpation1,2

MMT1

1
Saunders HD, et al. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders, vol 2.
3rd ed. Chaska, MN: The Saunders Group; 2004.

2
Hume PA, et al. Epicondylar injury and sport. Sports Medicine. 2006;36:2.

3
Shiri R, et al. Prevalence and determinants of lateral and medial epicondylitis: A population study.
Am J Epidemiol. 2006;164 :11.

4
Soto-Quijano DA, Rivera-Tavarez, CE. Work-related musculoskeletal disorders of the upper
extremity. Critical Reviews in Physical and Rehabilitation Medicine. 2005;17(l):65-82.

Occult Elbow Fractures

TBC/Special
Prevalence Symptoms Signs
Tests
 1998 in USA: 1,465,874 estimated cases of
hand/forearm fractures1

1.5% of all emergency department cases1

Radius and/or ulna fractures comprised the largest Posterior fat Stabilize
proportion of fractures (44%)1 Trauma1,2,3 pad sign on Refer out
radiograph3 Elbow
The most affected age group was 5-14 years of age Fall on
(26%)1 outstretched Inability to Extension
hand1,2,3 fully extend
49% of the cases: Most of the fractures occurred at elbow. Test2
home (30%)1

Street/highway was the second most likely fracture

location (14%). Accidental falls caused the majority
(47%) of fractures1

1
Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the
United States. J Hand Surg. 2001;26(5):908-915.

2
Lennon R, et al. Can a normal range of elbow movement predict a normal elbow x-ray? Emergency
Medicine Journal. 2007;24:86-88.

3
Skaggs DL, et al. The posterior fat pad sign in association with occult fracture of the elbow in
children. J Bone Joint Surg. 1999;81:1429-1433.

Screening out Occult Elbow Fracture

Elbow Extension Test
1. Patient lies in a supine position and is asked to fully extend the elbow.
2. (+) test is indicated by the patient's inability to fully extend the elbow.

Reliability Sensitivity Specificity +LR −LR

NT 97 69 3.1 0.04

Docherty MA, Schwab RA, Ma OJ. Can elbow extension be used as a test of clinically significant
injury? South Med J. 2002;95:539-541.
 FIGURE 9-4 Elbow Extension Test 1

FIGURE 9-5 Elbow Extension Test 2

Ulnar Collateral Ligament Sprain

TBC/Special
Prevalence Symptoms Signs
Tests

Sudden onset w/
1 trauma May hear
Repetitive movements Pain
“pop”2 control
Throwing/overhead motions
athlete (baseball, volleyball, Apprehension when Stabilize
Medial (ulnar)
javelin, water polo, tennis.)1 throwing or leaning on
collateral ligament
outstretched arm1 Exercise
Age: 16-56; mean age 262 laxity1,2,3
Decreased functional Educate
 Trauma: Valgus stress or falls1 activities1 Tenderness to Valgus
palpation: Medial Stress Test1
Arthritis2 Possible ulnar nerve epicondyle1,2 Wrist
involvement1 flexors Moving
Posteromedial osteophytes2 Valgus
Painful “clicking”2 Stress Test2
2
Flexion contracture
Loss of velocity3

1
Saunders HD, et al. Evaluation, Treatment and Prevention of Musculoskeletal Disorders, vol. 2.
3rd ed. Chaska, MN: The Saunders Group; 2004.

2
O'Driscoll MR, et al. The “moving valgus stress test” for medial collateral ligament tears of the
elbow. Am J Sports Med. 2005; 33(2):231-239.

3
Safran M, et al. Effects of elbow flexion and forearm rotation on valgus laxity of the elbow. J Bone
Joint Surg Am. 2005;87: 2065-2074.

Screening out/Ruling in Medial Collateral Ligament Pathology

Moving Valgus Stress Test
1. Patient is in an upright position and the shoulder is abducted to 90°. With
the elbow in full flexion of 120°, modest valgus torque is applied to the elbow
until the shoulder reaches full external rotation.
2. With a constant valgus torque, the elbow is quickly extended to 30°.
3. (+) test is reproduction of medial elbow pain when forcibly extending the
elbow from a flexed position between 120-70°.

Reliability Sensitivity Specificity +LR −LR

NT 100 75 4 0

O'Driscoll, et al, The "moving valgus stress test" for medial collateral ligament tears of the elbow. Am
J Sports Med. 2005; 33:231-239.
 FIGURE 9-6 Moving Valgus Stress Test 1

FIGURE 9-7 Moving Valgus Stress Test 2

Supinator Syndrome—Radial Nerve Entrapment

Prevalence Symptoms Signs TBC/Special Tests

Pain control

Ultrasound (3 MHz
at 0.5W/cm2 for 8
min.)2

Repetitive manual Mobilization

Masquerades as lateral Increased pain with
(neural)6
tasks involving rotation epicondylitis2 pronation1
of the forearm1,2 Exercise
Pain and tenderness on No pain with
(progressive
Sports involving palpation over resisted supination5
resistive exercises
repetitive pronation brachioradialis1
supination: golfers, Pain over radial and stretching)2
swimmers, Frisbee Pain aggravated by work tunnel when
Education
players, tennis and present at rest5 resistance is applied
players, violinists, to extension of Avoid aggravating
orchestra Deep, aching, burning middle finger with
positions/activities2
conductors1,2 sensation, diffusely elbow extended and
localized pain around the neutral wrist1,2 Palpation over
Extensive keyboard lateral side of the elbow
radial tunnel2
work at a computer, and dorsal side of the Weak supinator,
repeated gripping, use forearm; sometimes radiates wrist and finger Radial nerve neural
of scissors, stirring2 to the hand1,2,3,4 extensors2,3 tension test

Grip strength2

Nerve conduction
test and needle-
electromyographic
studies5

1
Dickerman RD, Stevens QEJ, Cohen AJ, Jaikumar S. Radial tunnel syndrome in an elite power
athlete: A case of direct compressive neuropathy. J Peripher Nerv Syst. 2002;7:229-232.

2
Ekstrom RA, Holden K. Examination of and intervention for a patient with chronic lateral elbow
pain with signs of nerve entrapment. Phys Ther. 2002;82(11):1077-1086.

3
Magee DJ. Orthopedic Physical Assessment. 4th ed. Philadelphia, PA: Elsevier Sciences; 2006.

4
Saunders HD, Saunders RR. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders,
vol. 2: Spine. 3rd ed. Chaska, MN: The Saunders Group; 2004.

5
Verhaar J, Spaans F. Radial tunnel syndrome: An investigation of compression neuropathy as a
possible cause. J Bone Joint Surg. 1991;73-A(4).

6
Coppieters MW, Butler DS. Do 'sliders' slide and 'tensioners' tension? An analysis of neurodynamic
techniques and considerations regarding their application. Man Ther. 2008;13(3):213-221.

Cubital Tunnel Syndrome

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Gradual onset1
Throwing athlete
Increased pain with use1 Pain control
High school, college (acute)
Medial elbow pain may refer Elbow flexion
and amateur baseball
distally to forearm and hand1 Stabilization
players4 Muscle weakness (C8- (acute)
Dull ache at rest after T1) distribution1,4
Common in ages 30-60
Education
y/o6 activity1 ↑ strain at
acceleration phase of Workspace
Manual laborers1,2 Intermittent compression:
“Muscle cramping” throwing1,3 ergonomics and
posture4
Forearm hypertrophy1 (hypertrophy)1
Hypertrophy triceps4
Mobilization
Frequent computer Tender to palpation in tunnel 4
↑ pain w/ traction
users4 —may radiate to Flexor Carpi neural
Ulnaris1 ↑ pain w/ elbow flex, mobilization-
Repeated gripping,
windup and cocking slider6
supination, pronation, Advanced stages: N/T or pain
phase3
throwing1 4th-5th digits1,2 Tinel's Sign1,2,5
↓ function due to
Prolonged posture Resting medial elbow pain2 ULTT ulnar
pain1
(elbows on work desk)1 nerve bias
Sleeping w/ elbow hypertext.
2 ↓ sensation1,5
Medial elbow ganglia provokes symptoms1 Elbow flexion
test2,5
Osteoarthritis2 “Creptitus or popping” w/ flex
and ext. (subluxation)1

1
Saunders HD, Tomberlin JP. Evaluation, Treatment, and Prevention of Musculoskeletal
Disorders, Vol. 2. 3rd ed. Chaska, MN: The Saunders Group. 2004; 134-135.

2
Kato H, et al. Cubital tunnel syndrome associated with medial elbow ganglia and osteoarthritis of
the elbow. J Bone Joint Surg Am. 2002;84:1413-1419.

3
Aoki M, et al. Strain on the ulnar nerve at the elbow and wrist during throwing motion. J Bone
Joint Surg Am. 2005;87:2508-2514.

4
Ruess L, et al. Carpal tunnel syndrome and cubital tunnel syndrome: Musculoskeletal disorders in
 four symptomatic radiologists. Am J Radiology. July 2003;181:37-42.

5
Magee D. Orthopedic Physical Assessment 4th ed. Philadelphia, PA: Elsevier Sciences. 2006; 337-
341.

6
Coppieters MW, Butler DS. Do 'sliders' slide and 'tensioners' tension? An analysis of neurodynamic
techniques and considerations regarding their application. Man Ther. 2008;13(3):213-221.

Ruling in Ulnar Neuropathy at the Elbow

Elbow Flexion Test
1. Patient is sitting with both arms and shoulders in the anatomic position. Both
elbows are fully but not forcibly flexed.
2. Patient is asked to describe the symptoms following holding this position for
3 minutes.
3. (+) test is reproduction of pain, tingling, or numbness along the ulnar nerve.

Reliability Sensitivity Specificity +LR −LR

NT 75 99 75 0.25
 FIGURE 9-8 Elbow Flexion Test

Percussion Test/Tinel's Sign

1. Examiner applies four to six taps to the patient's ulnar nerve, just proximal
to the cubital tunnel.
2. (+) test if reproduction of symptoms along the ulnar nerve occurs.

Reliability Sensitivity Specificity +LR −LR

NT 70 98 35 0.31

Novak CB, Lee GW, Mackinnon SE, Lay L. Provocation testing for cubital tunnel syndrome. J Hand
Surg Am. 1994;19:817-820.

FIGURE 9-9 Percussion Test/Tinel's Sign

Nursemaid's Elbow

Prevalence Symptoms DSM/Signs TBC/Special Tests

 Mobilize (relocation)

Thumb gives firm, direct pressure over

proximal radial head—forearm is supinated,
then flexed. An audible click may be heard
Humeral- or felt on lateral elbow1,3,4,5
radial
distraction Hyperpronating forearm more successful4
Most common in 1-4
year olds2,3 Pain with Stabilize
Child presents palpation to
Seen in infants as Splint or sling is indicated w/repeated
young as 6 months
with pain in radial head3
elbow; arm is dislocations or if Tx was delayed > 12 hrs3
and adolescents as Loss of elbow
held at side
old as 15 years3 ROM3 Exercise
Slightly flexes
MC in girls5 15°-20° and No edema, Educate—especially parents and
caregivers/siblings
Accounts for 20% of pronated1,3,8 ecchymosis3,5
upper extremity History or mechanism of injury is critical to
Shoulder,
injuries in children3 wrist, and diagnosis1,3,4,5
finger ROM
Check vital signs3
unaffected3,5
Neurovascular assessment ROM shoulder and
wrist3

X-rays not diagnostic unless abuse is

suspected3

1
Brotzman B, Wilk K. Clinical Orthopaedic Rehabilitation, 2nd ed. St. Louis, MO: Mosby; 2003.

2
Kaplan R, et al. Recurrent nursemaid's elbow (annular ligament displacement): Treatment via
telephone. Pediatrics. 2002;110 (1).

3
Kunkler CE. Did you check your nursemaid's elbow? Orthop Nurs. 2000;19(4):49-56.

4
Marcias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the
reduction of radial head subluxations. Pedriatrics. 1998;102(1).

5
Moore K, Dalley A. Clinically Oriented Anatomy. 4th ed. Philadelphia, PA: Lippincott Williams
&Wilkins; 1999.

Myositis Ossificans

Prevalence Symptoms Signs TBC/Special Tests

 Pain control

2% acetic acid iontophoresis6

followed by 1.5 W/cm2 50% pulsed

ultrasound for 8 minutes6

RICE

NSAIDs1,2,4

*No heat2

Ice and compression with elbow

extended as much as possible4

Exercise
Swelling,
warmth, Gentle AROM
ecchymosis4 ˜extension2,4
Initial severe Palpable mass in No resistance exercises2,4
Athletes in their 20-30s4 pain, brachialis2,4
Extreme blow/trauma swelling, Refer out
redness, loss Calcification
causes compression of
soft tissue; muscle is of motion4 usually occurs at Surgical excision if pain, muscle
2-3 weeks5 athrophy, decreased ROM cont.
crushed against bone4 General post 12 months2,4
decrease in Ossification of
Increased incidence w/
symptoms as heterotopic “Therapist may be the first to
aggressive mobilizationss
pathology bone occurs by recognize the condition by
or stretching4
matures4 about 4-8 detecting subtle difference in feel
weeks5 of motion or mass in muscle”2
Decreased use MRI
and ROM4
Soft tissue radiographs (may not
show until 3 wks)2,4

MO vs. benign/malignant tumors:

myositis ossificans are dense at
periphery; tumor dense in center4

MO vs. traumatic arthritis

MO˜passive extension

limited > flexion,

˜resisted flexion = pain

˜palpation of brachialis muscle =

 tender3

1
Brotzman B, Wilk K. Clinical Orthopaedic Rehabilitation. 2nd ed. St. Louis, MO: Mosby; 2003.

2
Donatelli R, Wooden MJ. Orthopaedic Physical Therapy. 3rd ed. Philadelphia: Churchill Livingtone;
2001.

3
Kisner C, Colby L. Therapuetic Exercise: Foundation and Techniques. 4th ed. Philadelphia: F. A.
Davis Company; 2002.

4
Larson C. et al. Evaluating and managing muscle contusions and myositis ossificans. Phys
Sportsmed. 2002;30(2):41-47.

5
Tyler JL, Derbekyan V, Lisbona R. Early diagnosis of myositis ossificans with T099m diphosphonate
imaging. Clin Nucl Med. 1984;9:460-462.

6
Weider D. Treatment of traumatic myositis ossificans with acetic acid iontophoresis. Phys Ther.
1992;72:133-137.
Chapter 10
The Wrist and Hand

FIGURE 10-1 Bones of the Wrist and Hand

Clark, RK. Anatomy and Physiology: Understanding the Human Body. © 2005 Jones &
Bartlett Publishers, LLC
FIGURE 10-2 The Three Layers of the Flexor Muscles of the Forearm
Souza, TA. Differential Diagnosis and Management for the Chiropractor: Protocols and
Algorithms. © 2009 Jones & Bartlett Publishers, LLC
FIGURE 10-3 Extensor Muscles of the Forearm
Souza, TA. Differential Diagnosis and Management for the Chiropractor: Protocols and
Algorithms. © 2009 Jones & Bartlett Publishers, LLC

Capsular
Wrist Resting Position Closed Pack
Pattern
Radiocarpal Neutral, slight ulnar dev. Ext. Flex = Ext

Intercarpal Neutral or slight ulnar dev. Ext. None

Ext. with ulnar

Midcarpal Neutral or slight flex with ulnar dev. Flex = Ext
dev.

Carpometacarpal Midway between abd. add., between

Full opposition Abd > Ext
(Thumb) flex/ext

Carpometacarpal = in all
Midway between flex./ext. Full flexion
(Fingers) directions

Thumb: Full
Metacarpo- opposition
Slight flexion Flex > Ext
phalangeal Finger: Full
flexion

Interphalangeal Slight flexion Full ext. Flex > Ext

Outcome Tools

DASH—Disabilities of the Arm, Shoulder, and Hand Outcome Questionnaire

SSS—Symptoms Severity Scale

GROC—Global Rating of Change

PSFS—Patient Specific Functional Scale

Red Flags for Potential Serious Conditions in Patients with
Elbow, Wrist, or Hand Problems

Red Flag
Red Flag
Condition Data Obtained During
Data Obtained During Physical Exam
Interview/History

History of trauma, surgery, Palpable tenderness and tension of involved

or extreme unaccustomed compartment
Compartment activity Persistent forearm
pain and “tightness” Pain intensified with stretch to involved muscles
syndrome1,2
Tingling, burning, or Paresthesia, paresis, and sensory deficits
numbness Diminished pulse and prolonged capillary refill

Recent cut, scrape, or Kanavel cardinal signs: 1) flexed posture of the

puncture wound, such as a digit, 2) uniform swelling of the digit, 3)
Space infection human or animal bite tenderness over the length of the involved
of the hand3 tendon sheath, 4) severe pain on attempted
Typical symptoms of
hyperextension of the digit
infection and inflammation

Long flexor Laceration in area of tendon Loss of isolated DIP or PIP active flexion
tendon rupture4 Forceful flexor contraction Possible palpable defect in involved muscle

History of fall on hand or Pain at end ranges of wrist extension

Lunate fracture strain
or dislocation4 Decreased grip strength/increased pain with
Generalized wrist pain grasping objects

History of fall on Swelling, bruising around wrist

outstretched hand
Scaphoid Tenderness over anatomical snuff box/scaphoid
fracture5,6 Prevalent in males aged 15- tubercle
30 and females with
osteoporosis Increased pain with gripping

Fall onto outstretched arm Wrist swelling

Distal radius with forceful wrist extension Wrist held in neutral resting position
(Colles')
fracture Young male or older female Movements into wrist extension are painful

Elbow joint effusion—arm held in loose packed

position
Radial head History of fall on
Restricted/painful supination and pronation
fracture7 outstretched hand
AROM

Tenderness over radial head

Positive family history

Skin pallor, cyanosis, and/or hyperemic
Women on estrogen therapy
erythema of the fingers
Raynaud's
Cold exposure/frostbite
phenomenon8 injury
Taking medication promoting vasoconstriction
such as β-blockers, amphetamines,
Underlying collagen vascular decongestants, and caffeine
disease

History of trauma or surgery

Severe
Complex burning/boring/aching pain
regional pain Area swollen (pitting edema), warm, and
out of proportion to the
syndrome erythmatous
inciting event
(reflex
Temperature difference between involved and
sympathetic Pain not responsive to
uninvolved extremity, hot or cold
dystrophy)9,10 typical analgesics

Secondary
hyperalgesia/hypersensitivity

Asymmetric or irregular shape lesion

History of cancer
Borders are notched, scalloped, or vaguely
Female < 40 years of age
defined
Melanoma11
Male > 40 years of age
Color uneven, distributed, or defined
Fair skin, history of sunburns
Diameter > 6 mm

1
Harvey C. Compartment syndrome: When it is least expected. Orthop Nurs. 2001;20(3):15-23.
2
Jawed S, Jawad AS, Padhiar N, Perry JD. Chronic exertional compartment syndrome of the
forearms secondary to weight training. Rheumatology. 2001;40:344-345.

3
Weinzweig N, Gonzalez M. Surgical infections of the hand and upper extremity: A county hospital
experience. Ann Plast Surg. 2002;49:621-627.

4
Hunter JM, Mackin EJ, Callahan AD. Rehabilitation of the Hand and Upper Extremity. 5th ed. St.
Louis, MO: Mosby; 2002.

5
Phillips TG, Reibach AM, Slomiany WP. Diagnosis and management of scaphoid fractures. Am Fam
Physician. 2004;70:879-884.

6
Bhowal B, Dias JJ, Wildin CJ. The incidence of simultaneous fractures of the scaphoid and radial
head. J Hand Surg. 2001;26B:25-27.

7
Major N, Crawford S. Elbow effusion in trauma in adults and children: Is there an occult fracture?
Am J Radiology. 2002;178:413-418.

8
Bloack J, Sequeira W. Raynaud's phenomenon. Lancet. 2001;357:9237.

9
Ciccone DS, Bandilla EB, WU. Psychological dysfunction in patients with RSD. Pain. 1997;71:323-
333.

10
Veldman HJM, Reynen HM, Arnitz IE, Goris RJA. Signs and symptoms of reflex sympathetic
dystrophy: Prospective study of 829 patients. Lancet. 1993;343:1012-1016.

11
American Cancer Society, What are the key statistics for melanoma? Revised April 2004.
http://www.cancer.org/docroot/CRI-2-4-1X Courtesy of Joe Godges.
 FIGURE 10-4 Treatment-Based Classification for Wrist and Hand Region

Wrist and Hand Treatment-Based Classification References

Pain Control
Baysal O, Altay Z, Ozcan C, Ertem K, Yologlu S, Kayhan A. Comparison of three
conservative treatment protocols in carpal tunnel syndrome. Int J Clin Pract.
2006;60(7):820-828.
Piravej K, Boonhong J. Effect of ultrasound thermotherapy in mild to moderate
carpal tunnel syndrome. J Med Assoc Thai. 2004;87(S2):S100-S106.
Dakowicz A, Latosiewicz R. The value of iontophoresis combined with
ultrasound in patients with the carpal tunnel syndrome. Rocz Akad Med
Bialymst. 2005; 50(S1):196-198.
Gokoglu F, Findikoglu G, Yorgancioglu ZR, Okumus M, Ceceli E, Kocaoglu S.
Evaluation of iontophoresis and local corticosteroid injection in the treatment
of carpal tunnel syndrome. Am J Phys Med Rehabil. 2005;84(2):92-96.
Graham RG, Hudson DA, Solomons M, Singer M. A prospective study to assess the
outcome of steroid injections and wrist splinting for the treatment of carpal
tunnel syndrome. Plast Reconstr Surg. 2004;113(2):550-556.
Werner RA, Franzblau A, Gell N. Randomized controlled trial of nocturnal
splinting for active workers with symptoms of carpal tunnel syndrome. Arch
Phys Med Rehabil. 2005;86(1):1-7.
Stralka SW, Jackson JA, Lewis AR. Treatment of hand and wrist pain: A
randomized clinical trial of high voltage pulsed, direct current built into a wrist
splint. AAOHN J. 1998;46(5):233-236.
Cheing GL, Luk ML. Transcutaneous electrical nerve stimulation for neuropathic
pain. J Hand Surg Br. 2005;30(1):50-55.

Stabilize
Walker WC, Metzler M, Cifu DX, Swartz Z. Neutral wrist splinting in carpal
tunnel syndrome: A comparison of night-only versus fulltime wear instructions.
Arch Phys Med Rehabil. 2000;81(4):424-429.
Gerritsen AA, de Vet HC, Scholten RJ, Bertelsmann FW, de Krom MC, Bouter
LM. Splinting vs. surgery in the treatment of carpal tunnel syndrome: A
randomized controlled trial. JAMA. 2002;288(10):1245-1251.

Mobilize
Struijs PA, Damen PJ, Bakker EW, Blankevoort L, Assendelft WJ, Van Dijk CN.
Manipulation of the wrist for management of lateral epicondylitis: A
randomized pilot study. Phys Ther. 2003;83(7):608-616.
Burke J, Buchberger DJ, Carey-Loghmani MT, Dougherty PE, Greco DS, Dishman
JD. A pilot study comparing two manual therapy interventions for carpal tunnel
syndrome. J Manipulative Physiol Ther. 2007;30(1):50-61.
Tal-Akabi A, Rushton A. An investigation to compare the effectiveness of carpal
bone mobilisation and neurodynamic mobilisation as methods of treatment for
carpal tunnel syndrome. Man Ther. 2000;5(4):214-222.
Thomes LJ, Thomes BJ. Early mobilization method for surgically repaired zone
III extensor tendons. J Hand Ther. 1995;8(3):195-198.
Sucher BM. Palpatory diagnosis and manipulative management of carpal tunnel
syndrome. JAOA. 1994;94(8):647-663.
Sucher BM, et al. Manipulative treatment of carpal tunnel syndrome:
Biomechanical and osteopathic intervention to increase the length of the
transverse carpal ligament, Part 2: Effect of sex differences and manipulative
“priming.” JAOA. 2005;105(3):135-143.

Exercise
Akalin E, El Ö, Peker Ö, Senocak Ö, Tamci S, Gülbahar S, Çakmur R, Öncel S.
Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises.
Am J Phys Med Rehabil. 2002;81(2):108-113.

Correction of Movement Impairment

O'Brien AV, Jones P, Mullis R, Mulherin D, Dziedzic K. Conservative hand
therapy treatments in rheumatoid arthritis: A randomized controlled trial.
Rheumatology (Oxford). 2006;45(5):577-583.
Ranganathan VK, Siemionow V, Sahgal V, Liu JZ, Yue GH. Skilled finger
movement exercise improves hand function. J Gerontol A Biol Sci Med Sci.
2001;56(8):M518-M522.
Yavuzer G, Selles R, Sezer N, Sutbeyaz S, Bussmann JB, Koseoglu F, Atay MB,
Stam HJ. Mirror therapy improves hand function in subacute stroke: A
randomized controlled trial. Arch Phys Med Rehabil. 2008;89(3):393-398.
Buljina AI, Taljanovic MS, Avdic DM, Hunter TB. Physical and exercise therapy
for treatment of the rheumatoid hand. Arthritis Rheum. 2001;45(4):392-397.

Scaphoid Fracture

Prevalence Symptoms Signs TBC/Special Tests

Stabilize

Splint—if acute and diagnosis unclear:

minimum of 2 weeks,1 then refer back
Fall on outstretched for further workup If fracture clearly
90% of all hand with wrist diagnosed—12 weeks of splinting
carpal bone hyperextension > 95°
Swelling may Pain control
fractures2 on radial side of the
be absent if
palm4 injury is < 4
MC in men 15- Refer out: Usually 2 weeks after
 30 years old3 Fall backward with hours or > 4 trauma is a good time to refer out to
hand facing days old5 get another radiograph1
16% of anteriorly4
scaphoid Local Exercise
fractures are Hand impact on tenderness
missed on steering wheel2 over scaphoid Limit exercise due to instability
initial tubercle6
Crank-handle Educate
radiograph1
kickback2
Tenderness at scaphoid tubercle5,6,7
(intersection of distal wrist crease and
tendon of flexor carpi radialis)

Anatomical snuff box palpation5

1
Hunter JC. MR Imaging of clinically suspected scaphoid fractures. AJR. 1997;168:1287-1293.

2
Leslie IJ, Dickson RA. The fractured carpal scaphoid. J Bone Joint Surg Br. 1981;63B(2):225-230.

3
Gumucio CA, Fernando B, Young VL, Gilula LA, Kramer BA. Management of scaphoid fractures: A
review and update. South Med J. 1989;82(11):1377-1388.

4
Weber ER, Chao EY. An experimental approach to the mechanism of scaphoid waist fractures. J
Hand Surg Am. 1978;3(2):142-148. The scaphoid bone. Radiology. 1989;171:870-871.

5
Schubert HE. Scaphoid fracture: Review of diagnostic tests and treatment. Can Fam Physician.
2000;46:1825-1832.

6
Freeland P. Scaphoid tubercle tenderness: A better indicator of scaphoid fractures? Arch Emerg
Med. 1989;6(1):46-50.

7
Hankin FM, Smith PA, Braunstein EM. Evaluation of the carpal scaphoid. Am Fam Pract.
1986;34(2):129-132.

Screening out/Ruling in Scaphoid Fracture

Scaphoid Compression Tenderness
1. Examiner holds patient's thumb of the involved side.
2. Examiner applies long axis compression through metacarpal bone into
scaphoid.
3. (+) test is production of pain.

Reliability Sensitivity Specificity +LR −LR

 NT1 100 80 5.0 0

FIGURE 10-5 Scaphoid Compression Tenderness

Scaphoid Tubercle Tenderness

1. Examiner applies pressure to the scaphoid tubercle located at the
intersection of the distal palmer crease and the flexor carpi radialis tendon.
2. (+) test is production of pain.

Reliability Sensitivity Specificity +LR −LR

NT1 83 51 1.69 0.33

[circled white star] This test is better for ruling in scaphoid fracture than
anatomical snuff box tenderness due to higher specificity.
 FIGURE 10-6 Scaphoid Tubercle Tenderness

Screening out Scaphoid Fracture

Anatomical Snuff Box Tenderness
1. Examiner palpates anatomical snuff box.
2. (+) test is production of pain.

Reliability Sensitivity Specificity +LR −LR

NT1 100 29 1.41 0.0

1
Grover R. Clinical assessment of scaphoid injuries and the detection of fractures. J Hand Surg Br.
1996;21:341-343.
 FIGURE 10-7 Anatomical Snuff Box Tenderness

Carpal Instability

Prevalence Symptoms Signs TBC/Special Tests

10% of all wrist

injuries result in
instability1
Stabilize
30% of 134 Colles
fractures had wrist Splint
instability4 Pain control
28% of 36 acute Fall on outstretched hand with wrist
*Limit exercise due to
scaphoid wrist hyperextension8 Swelling8 instability
fractures had DISI or
dorsal intercalated “Fall on thenar eminence”—Wrist Local Educate
segmental extension, ulnar deviation and tenderness8
instability5 intercarpal supination. Scapholunate Refer out
instability: radial-sided wrist pain Loss of grip
19% of 100 wrist strength8 Watson's scaphoid
sprains had “Fall on hypothenar eminence”— shift10
increased intercarpal pronation resulting in Loss of
scapholunate gap2 triquetrolunate IO ligament disruption wrist range Ulnomeniscotriquetral
and dorsal ulna-triquetrial complex of motion8 dorsal glide
19 of 52 wrists with disruption: ulnar-sided wrist pain
rheumatoid Pseudoinstability
arthritis6,7 test9—loss of normal
anteroposterior
 16 of 63 patients translation of the
with scapho- carpus
trapezio-trapezoid
osteoarthritis3

1
Dobyns JH, Linschied RL, Chao EYS. Traumatic instability of the wrist. American Academy of
Orthopaedic Surgeons Instructional Course Lectures. 1975;182-199.

2
Jones WA. Beware the sprained wrist. The incidence and diagnosis of scapholunate instability. J
Bone Joint Surg Br. 1988;70(2):293-297.

3
Ferris BD, Dunnett W, Lavelle JR. An association between scapho-trapezio-trapezoid osteoarthritis
and static dorsal intercalated segment instability. J Hand Surg. 1994;19B:338-339.

4
Tang JB. Carpal instability associated with fracture of the distal radius: Incidence, influencing
factors, and pathomechanics. Chin Med J (Engl). 1992;105(9):758-765.

5
Weber ER. Biomechanical implications of scaphoid wrist fractures. Clin Orthop. Jun 1980;83-89.

6
Kushner I, Dawson NV. Changing perspectives in the treatment of rheumatoid arthritis. J
Rheumatology. 1992;19:1831-1834.

7
Kushner DM, Braunstein EM, Buckwalter KA, Krohn K, White HA. Carpal instability in rheumatoid
arthritis. Can Assoc Radiol J. 1993;44:291-295.

8
Trail IA, Stanley JK, Hayton MJ. Twenty questions on carpal instability. J Hand Surg (European
Volume). 2007;32:240-255.

9
Kelly EP, Stanley JK (1990). Arthroscopy of the wrist. J Hand Surg. 15B:236-242.

10
Watson HK, Rye J, Akelman E. Limited triscaphoid intercarpal arthrodesis for rotatory subluxation
of the scaphoid. J Bone Joint Surg. 1986;68A:345-349.

Ruling in Carpal Instability

Watson Scaphoid Instability Test
1. Patient's arm is slightly pronated.
2. Examiner grasps the wrist from the radial side with thumb over the scaphoid
tubercle.
FIGURE 10-8 Watson Scaphoid Instability Test 1

FIGURE 10-9 Watson Scaphoid Instability Test 2

FIGURE 10-10 Watson Scaphoid Instability Test 3

 FIGURE 10-11 Watson Scaphoid Instability Test 4

3. Examiner's other hand grasps the metacarpals. Starting in ulnar deviation

and slight extension, the wrist is moved into radial deviation and slight flexion.
4. Examiner's thumb presses the scaphoid out of normal alignment when laxity
exists and when the thumb is released, there is a “thunk” as the scaphoid
moves back in place.
5. (+) test is identified by subluxation or clunk over the examiner's thumb and
patient's report of pain.

Reliability Sensitivity Specificity +LR −LR

NT 69 66 2.0 0.47

LaStayo P, et al. Clincal provocative tests used in evaluating wrist pain: a descriptive study. J Hand
Ther. 1995;8:10-17.

Testing for Lunotriquetral Ligament Integrity

Ballottement (Reagan's) Test
1. Examiner grasps the triquetrum between the thumb and second finger of
one hand and the lunate with the thumb and second finger of the other hand.
2. Examiner moves the lunate palmar and dorsal with respect to the
triquetrum.
3. (+) test is laxity, crepitus, or reproduction of the patient's pain during
anterior posterior movement.

Reliability Sensitivity Specificity +LR −LR

NT 64 44 1.14 0.82

LaStayo P, et al. Clincal provocative tests used in evaluating wrist pain: A descriptive study. J Hand
Ther. 1995;8:10-17.

FIGURE 10-12 Ballottement (Reagan's) Test

Carpal Tunnel Syndrome

Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control PRICE6

Mobilize
1% to 3% of general
public Carpal tunnel spreading
maneuver Active and
20% pregnant passive range of motion
women4 for the wrist, elbow,
and shoulder1
MC in women 40-60 Worse at night with Stabilize
years old4,6 burning, tingling, pins Wrist flexion Wrist
and needles, and extension Gripping Wrist splint in neutral
Dominant hand4 numbness into the position for night wear
median nerve Atrophy and weakness 4-6 weeks1,7
Young patients that distribution1,4 of the thenar muscles
use their wrists a (flexor and abductor Day splint 3-4 weeks1
lot in repetitive Relief by shaking hand pollicis brevis and the
manual labor or back and forth lateral 2 lumbricals)4 Ideal for patients with
vibration4 CTS < 1 year and < 6/10
In severe cases, pain is Decreased: pinch rating for nocturnal
High incidence of referred to the forearm strength, grip strength, paresthesia
bilateral CTS > 50% and there is weakness1 light touch sensation1
indicates systemic Exercise
or physiologic Aggravated by wrist Clumsiness in holding
movements4 Flexor tendon gliding1,6
disorders6 small objects1

Diminished hand Educate

Women have Paresthesias over skin of
smaller wrists but sensation in the thumb, thenar eminence may Decreasing repetitive
not smaller index, and long fingers indicate lesion proximal
wrist motion1,6
tendons, so they and radial aspect of the to carpal tunnel1
are more ring finger1 History and physical
susceptible to CTS6
Intermittent1 Wrist-ratio index
6
Obesity
Median nerve
Colles fracture and compression
other trauma to
wrist1 Phalens4

Tinels4

1
Michlovitch SL. Conservative intervention for carpal tunnel syndrome. J Orthop Sports Phys Ther.
2004;34:589-600.

2
Lakey E, Sutton R. Clinical: Investigating Carpal Tunnel Syndrome. Health Source:
Nursing/Academic Edition. GP: General Practitioner; 2006.

3
Ly-Pen D, Andreu J, de Blas G, Sanchez-Olaso A, Millan I. Surgical decompression versus local
steroid injection in carpal tunnel syndrome: A one-year, prospective, randomized, open, controlled
clinical trial. Arth Rheum. 2005;52(2):612-619.

4
Magee DJ. Orthopedic Physical Therapy Assessment. 3rd ed. Philadelphia: W. B. Saunders; 1997.

5
Nalamachu S, Crockett RS, Mathur D. Lidocaine Patch 5 for carpal tunnel syndrome: How it
compares with injections: A pilot study. J Fam Prac. 2006;55(3):209-214.

6
Saunders HD, Tomberlin JP. Evaluation, Treatment, and Prevention of Musculskeletal Disorders,
vol. 2. 3rd ed. Chaska, MN: The Saunders Group; 1995.
 7
Werner RA, Franzblau A, Gell N. Randomized controlled trial of nocturnal splinting for active
workers with symptoms of carpal tunnel syndrome. Arch Phys Med Rehabil. 2005;86(1):1-7.

8
Sucher BM. Palpatory diagnosis and manipulative management of carpal tunnel syndrome. JAOA.
1994;94(8):647-663.

9
Sucher BM, et al. Manipulative treatment of carpal tunnel syndrome: Biomechanical and
osteopathic intervention to increase the length of the transverse carpal ligament. Part 2: Effect of
sex differences and manipulative “priming.” JAOA. 2005;105(3):135-143.

10
Coppieters MW, Butler DS. Do 'sliders' slide and 'tensioners' tension? An analysis of neurodynamic
techniques and considerations regarding their application. Man Ther. 2008;13(3):213-221.

Screening out Carpal Tunnel Syndrome

Wrist Ratio Index
1. Sliding calipers are used to measure the mediolateral (ML) wrist width in
centimeters.
2. Next, sliding calipers are used to measure the anteroposterior height (AP) in
centimeters. Caliper jaws are aligned with the distal wrist crease for both
measurements.
3. Wrist ratio index is computed by dividing the AP wrist width by the ML wrist
width (AP/ML).
4. (+) test is a wrist ratio index of greater than 0.67

Reliability Sensitivity Specificity +LR −LR

ICC 0.77 (AP)

93 26 1.3 0.3
ICC 0.86 (ML)

Wainner RS, et al Development of a clinical prediction rule for the diagnosis of carpal tunnel
syndrome. Arch Phys Med Rehabil. 2005;86:609-618.

[circled white star] The wrist ratio index is suggesting that perhaps wrists that
are wider than they are thick may place a person at a lower risk for carpal
tunnel syndrome.
 FIGURE 10-13 Wrist Ratio Index 1

FIGURE 10-14 Wrist Ratio Index 2

Screening out/Ruling in Median Nerve Neuropathy

Wrist Flexion and Median Nerve Compression
1. Patient sits with elbow fully extended, forearm in supination and wrist
flexed to 60°. Even, constant pressure is applied by the examiner over the
median nerve at the carpal tunnel.
2. (+) test is the reproduction of symptoms along the median nerve distribution
within 30 seconds.

Reliability Sensitivity Specificity +LR −LR

 Unknown 86 95 17 0.1

Tetro, et al. A new provocative test for carpal tunnel syndrome: Assessment of wrist flexion and
nerve compression. J Bone Joint Surg Br. 1998;80:493-498.

FIGURE 10-15 Wrist Flexion and Median Nerve Compression

Flick Maneuver
1. Patient vigorously shakes his or her hand(s)
2. (+) test is the resolution of paresthesia symptoms associated with carpal
tunnel syndrome during or following administration of “flicking the wrist.”

Reliability Sensitivity Specificity +LR −LR

NT1 93 96 23 0.1

NT2 90 30 1.3 0.3

1
Pryse-Phillips WE. Validation of a diagnostic sign in carpal tunnel syndrome. J Neurol Neurosurg
Psychiatry. 1984;47:870-872.
 2
Gunnarson LG, et al The diagnosis of carpal tunnel syndrome: Sensivity and specificity of some
clinical and electrophysiological tests. J Hand Surg Br. 1997;22:34-37.

FIGURE 10-16 Flick Maneuver

Median Nerve Compression Test

1. Examiner sits opposite the patient and holds the patient's hands with the
examiner's thumbs directly over the course of the median nerve as it passes
under the flexor retinaculum between the flexor carpi radialis and palmaris
longus. Examiner places gentle sustained pressure with the thumbs for 15
seconds to 2 minutes.
2. The pressure of the examiner's thumbs is removed, and the examiner
questions the patient on the relief of symptoms, which may take a few
minutes.
3. (+) test is the reproduction of pain, paresthesia, or numbness distal to the
site of compression in the distribution of the median nerve.

Reliability Sensitivity Specificity +LR −LR

0.921 100 97 35 0

NT2 42 99 42 0.6
 NT3 81 100 NA 0.2

1
Williams TM, et al. Verification of the pressure provocation
test in carpal tunnel syndrome. Ann Plast Surg. 1992;29:8-
11.

2
Mondelli M, et al. Provocative tests in different stages of
carpal tunnel syndrome. Clin Neurol Neurosurg.
2001;103:178-183.

3
Yii NW, et al. A study of the dynamic relationship of the
lumbrical muscles and the carpal tunnel. J Hand Surg BR.
1994;19:439-443.

FIGURE 10-17 Median Nerve Compression Test

Phalens Test
1. Patient is asked to hold the forearms vertically and allow both hands to drop
into complete flexion at the wrist for approximately 60 seconds.
2. (+) test is the reproduction of symptoms along the distribution of the median
nerve.

Reliability Sensitivity Specificity +LR −LR

NT1 34 74 1.3 0.9

NT2 87 90 8.7 0.1

NT3 79 92 9.9 0.2

NT4 86 48 1.7 0.3

0.795 77 40 1.29 0.58

1
Hansen PA, et al. Clinical utility of the flick maneuver in diagnosing carpal tunnel syndrome. Am J
Phys Med Rehabil. 2004;83:363-367.

2
Gonzalez del Pino, et al. Value of the carpal compression test in the diagnosis of carpal tunnel
syndrome. J Hand Surg Br. 1997;22:38-41.

3
Fertl E, et al. The serial use of two provocative tests in the clinical diagnosis carpal tunnel
syndrome. Acta Neurol Scand. 1998;98:328-332.

4
Gunnarson LG, et al. The diagnosis of carpal tunnel syndrome: Sensitivity and specificity of some
clinical and electrophysiological tests. J Hand Surg Br. 1997;22:34-37.

5
Wainner RS, et al. Development of a clinical prediction rule for the diagnosis of carpal tunnel
syndrome. Arch Phys Med Rehabil. 2005;86:609-618.
 FIGURE 10-18 Phalens Test

Closed Fist/Lumbrical Provocation Test (Carpal Tunnel

Syndrome from Lumbrical Excursion)
1. Patient is asked to make a fist for 1 minute.
2. (+) test is the reproduction of symptoms along the distribution of the median
nerve.

Reliability Sensitivity Specificity +LR −LR

NT1 37 71 1.3 0.9

NT2 97 93 14 0.03

1
Karl AI, et al. The lumbrical provocation test in subjects with median inclusive paresthesia. Arch
Phys Med Rehabil. 2000;81:348-350.

2
Yii NW, et al. A study of the dynamic relationship of the lumbrical muscles and the carpal tunnel. J
Hand Surg BR. 1994;19:439-443.
 FIGURE 10-19 Patient Is Asked to Make a Fist for 1 Minute

Ruling in Median Nerve Neuropathy

Tinels
1. Patient's wrist is placed in a neutral position. Examiner uses his or her finger
or a reflex hammer to tap on the median nerve where it enters the carpal
tunnel.
2. (+) test reproduces symptoms of paresthesia along the median nerve
distribution.

Reliability Sensitivity Specificity +LR −LR

NT 27 91 3.0 0.8

NT 33 97 11 0.7

Hansen PA, et al. Clinical utility of the flick maneuver in diagnosing carpal tunnel syndrome. Am J
Phys Med Rehabil. 2004;83:363-367. Gonzalez del Pino, et al. Value of the carpal compression test in
the diagnosis of carpal tunnel syndrome. J Hand Surg Br. 1997;22:38-41.

FIGURE 10-20 Tinels

 Atrophy and Weakness
1. Examiner observes the patient's thenar eminence in comparison to the
contralateral thenar eminence for signs of atrophy
2. (+) test is the presence of observable atrophy in the thenar eminence.

Reliability Sensitivity Specificity +LR −LR

NT 70 98 35 0.31

Katz JN, et al. The carpal tunnel syndrome: Diagnostic utility of the history and physical examination
findings. Ann Intern Med. 1990;112:321-327.

FIGURE 10-21 Atrophy and Weakness

Clinical Prediction Rule for Ruling In Carpal Tunnel

Syndrome

Individual Tests Sensitivity Specificity +LR −LR

Question: Does shaking your hands provide symptom relief? 81 57 1.9 0.34

Wrist Ratio Index > 0.67 93 26 1.3 0.29

SSS Score > 1.9 89 36 1.4 0.31

Diminished sensation in the median nerve distribution 65 70 2.2 0.49

Age > 45 64 59 1.58 0.6

# of Variables Present Sensitivity Specificity +LR −LR

≥2 98 14 1.1 0.001

≥3 98 54 2.1 0.04

≥4 77 83 4.6 0.28

All 5 18 99 18.3 0.83

Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML. Development of a clinical
prediction rule for the diagnosis of carpal tunnel syndrome. Arch Phys Med Rehabil. 2005;86:609-
618.

Wrist Sprain

TBC/Special
Prevalence Symptoms DSM/Signs
Tests
 Recreational or work-
related trauma4

Wrist hyperextension Wrist extension

injury2,3,4 Gradual increase in wrist
Limited ROM2,4
problems without a specific
Caused by collision3 injury4 Palpation of anatomical
Pain control
Hyperflexed or 2,4 snuff box painful2,4
Sudden pain Stabilize
forceful twisting less
Tenderness, particularly (splint)1,2,4
common4 Weakness4
the scaphoid bone2,4
Exercise4
Loud pop or snap3,4 Swelling1
Fracture of scaphoid
common4 Educate4
Most common Snapping/clicking or
ligament is clinking with movement or
scapholunate Pain with palpation to the
forceful grip3,4 hook of the hamate is
ligament3,4
fractured4
Less common
lunotriquetral
injuries3

1
Houglum P. Therapeutic Exercise for Musculoskeletal Injuries. 2nd ed. Champaign, IL: Human
Kinetics; 2005.

2
Krimmer H. Wrist: Current diagnosis and treatment of scaphoid. Europ Surg J. 2005;35:4.

3
Rettig A. Athletic injuries of the wrist and hand. Part I: Traumatic injuries of the wrist. Am J
Sports Med. 2003;31:6.

4
Saunders HD, Saunders RS. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders,
vol.1. 4th ed. Chaska, MN: The Saunders Group; 1994.

5
Schmid R, et al. Interosseous ligament tears of the wrist: Comparison of multidetector row CT
arthrography and MR imaging. Radiology. 2005; 237.

Assessing Wrist/Hand Swelling

Figure-of-Eight Method
1. Examiner places zero mark on distal aspect of ulnar styloid process.
2. Tape measure is then brought across ventral surface of wrist to most distal
aspect of radial styloid process.
3. Tape is brought diagonally across dorsum of hand and over 5th MCP joint
line.
4. Tape is then brought over ventral surface of MCP joints.
5. Tape is wrapped diagonally across dorsum to meet start of tape.

Intra-Examiner Reliability ICC Inter-Examiner Reliability ICC

0.99 0.99

Leard J, et al. Reliability and concurrent validity of the figure-of-eight method of measuring hand
size in patients with hand pathology. J Orthop Sports Phys Ther. 2004;24:335-340.

FIGURE 10-22 Figure-of-Eight 1

FIGURE 10-23 Figure-of-Eight 2

 FIGURE 10-24 Figure-of-Eight 3

Colles Fracture—Dorsal Displacement Distal Radius

Prevalence Symptoms Signs TBC/Special Tests

Pain control
Stabilize Educate

Colles fracture
predictor of future
associated hip
fracture, so
reeducation of home
ergonomics is
indicated4

Exercise

Most ROM limitations after Early AROM after

Traumatic fall after slipping or immobilization to
common immobilization in
tripping on outstretched hand achieve optimal
fracture in multitude of directions,
people over with forearm pronated3,4 especially wrist extension function and
age of and forearm supination1 increase wrist
Swelling and stiffness in the extension and grip
403,4,5
elbow, wrist, and hand1 Loss of incongruency of strength1,3,5
Gender distal radial ulnar joint
Decreased functional use of AROM of ipsilateral
bias: women due to excessive dorsal
hand in ADLs and apprehension1 proximal (shoulder,
more than inclination, loss of radial
men1,3,4 inclination, and/or elbow) and distal
Intermittent N/T and pain with
supination deformity2 joints (digit
activity in later stages may
Contributing signify developing neural Decreased dynamometry mobility)2
factors: complications such as carpal grip strength and
osteoporosis tunnel syndrome and/or difficulty with prehension Mobilization
and complex regional pain syndrome1 tasks5
osteopenia4 Grade III oscillations
during early phases
of rehabilitation6

Sustained stretches
during later phases
of rehabilitation6

Figure 8 and
volumetric testing1

Dynamometry1

Joint play1

1
Saunders H, Tomberlin J. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders,
vol. 2: Extremities. Chaska, MN: The Saunders Group. 1995; 174-175.

2
Brotzman S, Wilk K. Clinical Orthopaedic Rehabilitation, 2nd ed. St. Louis, MO: Mosby. 2003; 55-
65.

3
Moore K, Dalley A. Clinically Oriented Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins.
2006; 736.

4
Musad T, Jordan D, Hosking D. Distal forearm fracture in an older community dwelling population:
The Nottingham community osteoporosis study. Age Ageing. 2001;30:255-258.

5
Watt C, Taylor N, Baskus K. Do Colles Fracture patients benefit from routine referral to
physiotherapy following cast removal? Arch Orthop Trauma Surg. 2000;120:413-415.

6
Coyle JA, Robertson CJ. Comparison of two passive mobilizing techniques following Colles'
fracture: A multi-element design. Man Ther. 1998;3(1):34-41.

Triangular Fibrocartilage (TFCC) Disc Injury

Prevalence Symptoms DSM/Signs TBC/Special Tests

By fifth decade
Ulnar-sided wrist pain1
of life,
symptomatic Traumatic fall after slipping or Ulnar deviation
 perforations are tripping on outstretched hand Gripping Pain control Stabilize
identified in 40% with forearm pronated1 Educate Exercise
of TFCC studies Weakness in grip
Tenderness and clicking with strength2,3,4,5 Press Test
By sixth decade, wrist movement1 Ulnomensicotriquetral
the numbers Tenderness over dorsal glide
increase to 50%1 Decreased functional use of hand the ballottable
in ADLs and apprehension1 in area of the Figure 8 and
Common with limited work or sport activity ulna2,3,4,5 volumetric testing1
Colles' fracture9
Intermittent N/T and pain with Tenderness at the Dynamometry1
Wrist pain is activity in later stages may distal passive ulnar
common, signify developing neural deviation and Joint play1
affecting 46% (23 complications such as carpal dorsal ulnar head
of 50) to 79% (30 tunnel syndrome and/or complex subluxation2,3,4,5
of 38) of regional pain syndrome1
gymnasts8

1
Albastaki U, et al. Magnetic resonance imaging of the triangular fibrocartilage complex lesions: A
comprehensive clinicoradiologic approach and review of the literature. JMPT. 2007;30(7):522-526.

2
Fornalski S, Lee TQ, Gupta R. Chronic instability of the distal radioulnar joint: A review. Univ Pa
Orthop J. 2000;13:1-9.

3
Bowers WH. Instability of the distal radioulnar articulation. Hand Clin.1991;7:311-327.

4
Green DP, Hotchkiss RN, Pederson WC. Green's Operative Hand Surgery. New York: Churchill
Livingstone; 1999.

5
Litchman DM, Alexander AH. The Wrist and Its Disorders. Philadelphia: Saunders; 1997.

6
Mandelbaum BR, Bartolozzi AR, Davis CA, et al. Wrist pain syndrome in the gymnast: Pathogenetic,
diagnostic, and therapeutic considerations. Am J Sports Med. 1989;17:305-317.

7
Richards RS, et al. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal
radial fractures. J Hand Surg. 1997;22(5):772-776.

Screening out Triangular Fibrocartilage Complex Tears

Press Test
1. Patient places both hands on the arms of a stable chair and pushes off to
suspend the body using only hands.
2. (+) test is the reproduction of wrist pain while pressing up the patient's body
weight
 Reliability Sensitivity Specificity +LR −LR

NT 100 NT NA NA

Lester B, et al. “Press test” for office diagnosis of triangular fibrocartilage complex tears of the
wrist. Ann Plast Surg. 1995;35:41-45.

FIGURE 10-25 Press Test

Ulnomeniscotriquetral dorsal glide

1. Patient is seated with elbow on table, the forearm is in neutral.
2. Examiner places thumb over head of distal ulna.
3. Examiner then places radial side of index proximal interphalangeal (PIP)
joint over palmar surface of patient's pisotriquetral complex. Examiner
squeezes thumb and index finger together, creating dorsal glide of the
pisotriquetral complex.
4. (+) test if patient's symptoms are reproduced or excessive joint laxity is
perceived compared to the other side.
Reliability Sensitivity Specificity +LR −LR

NT 66 64 1.69 0.56

LaStayo P, et al. Clincal provocative tests used in evaluating wrist pain: A descriptive study. J Hand
Ther. 1995;8:10-17.

FIGURE 10-26 Ulnomeniscotriquetral Dorsal Glide

De Quervain's Tenosynovitis (APL and EPB)

Prevalence Symptoms DSM/Signs TBC/Special Tests

Gripping Ulnar and Stabilize

radial deviation
Splint for the
Localized tenderness minimally affected
New computer users1 Wrist pain
radiating into and swelling in the
region of the styloid Mobilization
Hand/arm symptoms: 39%1 the forearm
Hand/arm disorders: 21%1 and thumb2 process of the Mobilization with
radius2 movements3
47% had Dequervain's1 H/A—Hand or
arm Decreased 1rst CMC Cervical central PAs
Risk factors abduction2 and unilateral PAs1
MSS—
Gender, prior history of H/A Musculoskeletal Palpable thickening Carpal mobilization1
pain, prior computer use, and symptoms of the extensor
children at home were sheath and tendons Neural mobilization1
associated with either H/A MSS MSD— distal to the
or MSD1 Musculoskeletal extensor tunnel2 Extensor pollicis
disorders brevis resistance >
Crepitus of tendons Abductor pollicis
moving through the longus resistance
extensor sheath2 Finkelstein's Test

1
Gerr F, et al. A prospective study of computer users: I. Study design and incidence of
musculoskeletal symptoms and disorders. Am J Ind Med. 2002;41:221-235.

2
Anderson M, Tichenor CJ. A patient with de Quervain's tenosynovitis: A case report using an
Australian approach to manual therapy. Phys Ther. 1994;74:314-326.

3
Backstrom KM. Mobilization with movement as an adjunct intervention in a patient with
complicated de Quervain's tenosynovitis: A case report. J Orthop Sports Phys Ther. 2002;32:86-94;
discussion 94-97.

4
Walker MJ. Manual physical therapy examination and intervention of a patient with radial wrist
pain: A case report. J Orthop Sports Phys Ther. 2004;34(12):761-769.

FIGURE 10-27 (A) Tendons of the Thumb; (B) Tendons of the Finger
Souza, TA. Differential Diagnosis and Management for the Chiropractor: Protocols and
Algorithms. © 2009 Jones & Bartlett Publishers, LLC
Screening out APL/EPB Tenosynovitis
Extensor Pollicis Brevis Test
1. Examiner resists thumb metacarpalphalangeal joint extension.
2. Examiner resists thumb palmer abduction.
3. (+) Test is indicated by.

Reliability Sensitivity Specificity +LR −LR

NT 81 50 1.62 0.38

Alexander RD, et al The extensor pollicis brevis entrapment test in the treatment of de Quervain's
disease. J Hand Surg Am. 2002;27:813-816.

FIGURE 10-28 Extensor Pollicis Brevis Test 1

 FIGURE 10-29 Extensor Pollicis Brevis Test 2

Finkelstein's Test
1. Patient makes a fist with the thumb inside the fingers.
2. Examiner stabilizes the forearm and deviates the wrist toward the ulnar
side.
3. (+) test is indicated by pain over the abductor pollicis longus and extensor
pollicis brevis tendons at the wrist, and is indicative of paratendonitis.

Reliability Sensitivity Specificity +LR −LR

NT NT NT NA NA

Finkelstein H. Stenosing tenovaginitis at the radial styloid process. J Bone Joint Surg. 1930;12:509-
540.
 FIGURE 10-30 Finkelstein's Test

Gamekeeper's or Skier's Thumb

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

3% of all skiing1
injuries

50% of the
above need
surgery1 1st MCP Abduction
Pain on the ulnar side of the
Basketball5 1rst MCP joint3 1st MCP Extension Pain
control
Soccer5 Inability to hold large Swelling3 Stabilize
objects3
Wrestling5 Hematoma3 Thumb
Falling with thumb getting spica splint3
Hockey5 Palpable and tender proximal
stuck on ski poles by straps2
stump on the ulnar side of MCP3 Exercise
5
Cycling Impact of a moving object or
Increased MCP ulnar deviation in Educate
Scottish box2
full flexion3
gamekeepers4

“Skier's thumb”3

“Gamekeeper's
thumb”3

1
Massart P, et al. L'entorse grave metacarpo-phalangienne du pouce au cours des accidents de ski.
Ann Chir Main. 1984;3:101-112.

2
Smith RJ. Post-traumatic instability of the metacarpophalangeal joint of the thumb. J Bone Joint
Surg Am. 1977;59:14-21.

3
Heim D. The skier's thumb. Acta Orthopaedica Belgica. 1999;65(4):440-446.

4
Campell CS. Gamekeeper's thumb. J Bone Joint Surg. 1955;37-B:148-149.

5
Husband JB, et al. Bony skier's thumb injuries. Clin Orthop. 1996;327:79-84.
Screening out Thumb instability
Ulnar Collateral Ligament Test
1. Patient sits while the examiner stabilizes the patient's hand with one hand
and takes the patient's thumb into extension with the other hand.
2. While holding the thumb into extension, the examiner applies a valgus stress
to the metacarpalphalageal joint of thumb to stress the ulnar collateral
ligament.
3. (+) test if the valgus movement is greater than 30°-35°, indicating a
complete tear of the ulnar collateral ligament and accessory collateral
ligaments.

Reliability Sensitivity Specificity (+) LR (-) LR

Valgus > 30°-35° NT 94 NT NA NA

Palpable mass proximal to MCP joint NT 100 46 1.85 0

Heyman P, et al. Injuries of the ulnar collateral ligament of the thumb metacarpalphalangeal joint.
Biomechanical and prospective clinical studies on the usefulness of valgus stress testing. Clin Orthop
Relat Res. 1993:165-171.
FIGURE 10-31 Ulnar Collateral Ligament Test
Chapter 11
The Lumbar Region

FIGURE 11-1 Vertebral Column (Lateral View) Clark, RK. Anatomy and Physiology:
Understanding the Human Body. © 2005 Jones & Bartlett Publishers, LLC

Neuroscreen

Spinal
Myotome Dermatome Reflexes
Levels
L1-2 Resisted hip flexion L1 Inguinal crease
(seated)

Resisted knee Proximal thigh at the level of

L3-4 L2
extension greater trochanter

Pateller
L4-5 Heel walking L3 Medial knee
(L3)

Resisted great toe

L5 L4 Medial ankle
extension

L5-S1 Single leg stance L5 Web space of great toe and 2nd toe

Achilles
S1 Toe walking S1 Lateral foot
(S1)

S2 Toe flexion S2 Posterior medial knee

FIGURE 11-2 Sensory Innervation of the Lower Extremity. (A) Peripheral Nerve
Innervation (B) Dermatomal (Root) Innervation Source: Reprinted from Practical
Strategies in Outpatient Medicine, 2nd Edition, B.B. Reilly, p. 927, © 1991, with
permission from Elsevier.
Outcome Tools

ODI—Oswestry/Modified Oswestry Disability Index

FABQPA—Fear-Avoidance Back Questionnaire Physical Activity

FABQW—Fear-Avoidance Back Questionnaire Work

GROC—Global Rating of Change

PSFS—Patient-Specific Functional Scale

Red Flags for the Low Back Region

Red Flag Data Obtained During Red Flag Data Obtained During
Condition
Interview/History Physical Exam

Age over 50 years (axial skeleton pain)

Ambiguous presentation in early
Age < 20-25 years (pain in long bones of stages. Constant pain not
extremities) affected by position or activity;
Back-related worse with weight bearing, worse
History of cancer
tumor1,2 at night.
Unexplained weight loss (5-10% over 4 weeks
Neurological signs in lower
to 6 months)
extremities
Failure of conservative therapy

Deep, constant pain, increases

Back-related
Recent infection (e.g., urinary tract or skin with weight bearing; may radiate
infection
infection) Intravenous drug user/abuser Fever, malaise, and swelling
(Spinal
Concurrent immunosuppressive disorder Spine rigidity; accessory mobility
osteomyelitis)3
may be limited

Sensory deficits in the feet (L4,

Urine retention or incontinence Fecal
Cauda equina L5, S1 areas) Ankle dorsiflexion,
incontinence Saddle anesthesia Global or
syndrome toe extension, and ankle plantar
progressive weakness in the lower extermities
flexion weakness
 Point tenderness over site of
History of trauma (including minor falls or
fracture Exquisitely tender with
Spinal heavy lifts for osteoporotic or elderly
palpation over fracture site
fracture1,5 individuals) Prolonged use of steroids Age over
Increased pain with weight
70 Loss of function or mobility
bearing Edema in local area

Back, abdominal, or groin pain Presence of Abnormal width of aortic or iliac

peripheral vascular disease or coronary artery arterial pulses Presence of a bruit
Abdominal disease and associated risk factors (> 50, in the central epigastric area
aneurysm6,7 smoker, HTN, DM) Symptoms not related to upon auscultation (specific)
movement Stresses associated with somatic Absence of palpable pulse
LBP (sensitive)

Kidney
disorders8 Unilateral flank or low back pain Difficulty
Pyelonephritis with initiating urination, painful urination, or Positive fist percussion test over
Nephrolithiasis blood in the urine Recent or coexisting urinary the kidney
Renal cell tract infection Past episodes of kidney stone
carcinoma

Adapted from Boissonnault WG. Chapter by Joe Godges. Primary Care for the Physical Therapist:
Examination and Triage. Saunders; 2004 (with permission Godges, J).

1
Bigos S, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR
Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health
Service, U.S. Department of Health and Human Services; December 1994.

2
Deyo RA, Diehl AK. Cancer as a cause of back pain: Frequency, clinical presentation, and diagnostic
strategies. J Gen Intern Med. 1988;3:230-238.

3
Lew DP, Waldvogel FA. Osteomyelitis. N Engl J Med. 1997;336:999-1007.

4
Hakelius A, Hindmarsh J. The comparative reliability of preoperative diagnostic methods in lumbar
disc surgery. Acta Orthop Scand. 1972;43:234-238.

5
Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back
pain? JAMA. 1992;268:760-765.

6
Halperin JL. Evaluation of patients with peripheral vascular disease. Thromb Res. 2002;106:V303-
V311.

7
Krajewski LP, Olin JW. Atherosclerosis of the aorta and lower extremities arteries. In: Young JR,
Olin JW, Bartholomew JR, ed. Peripheral Vascular Diseases. 2nd ed. St. Louis: Yearbook Medical
Publishing; 1996.

8
Bajwa ZH. Pain patterns in patients with polycystic kidney disease. Kidney Int. 2004;66:1561-1569.

Red Flags for the Pelvis, Hip, and Thigh Regions

Red Flag Data Obtained During Red Flag Data Obtained

Condition
Interview/History During Physical Exam

Later stages: may have hypo-

or hyperactive bowel sounds
Age > 50 years old Bowel disturbances (e.g., from obstruction
rectal bleeding, black stools)
Possible tenderness to
Unexplained weight loss (5-10% over 4 weeks palpation of abdomen in area
Colon cancer1
to 6 months) History of colon cancer in of cancer
immediate family
May have ascites
Pain unchanged by positions or movement
First sign may be of metastases
to liver, lung, bone, or brain

Severe, constant pain; worse

Pathological Older females (> 70 years) with hip, groin,
with movement
fractures of the thigh, or knee pain
femoral neck2,3 History of a fall from a standing position
A shortened and externally
rotated lower extremity

Gradual onset of pain; may

refer to groin, thigh, or medial
Osteonecrosis of History of long-term corticosteroid use (e.g.,
knee; worse with weight
in patients with RA, SLE, asthma)
the femoral head4 bearing
(aka avascular History of AVN of the contralateral hip
necrosis) Stiff hip joint; restrictions
Trauma
primarily in IR, flexion,
adduction

Antalgic gait

Legg-Calve- Pain complaints aggravated

5-8 year old boys with groin/thigh pain with hip movement, especially
Perthes Disease5
 hip abduction and internal
rotation

Groin aching exacerbated with

weight bearing
Slipped capital
femoral Overweight adolescent History of a recent Involved leg held in external
growth spurt or trauma rotation
epiphysis6
ROM limitations of hip internal
rotation

Septic hip Child or older adult with vague hip aching who Unwillingness to weight bear
arthritis7 had a recent bacterial infection on or move the involved hip

Symptoms exacerbated by
Pain in groin and/or scrotum in males coughing, sneezing, or
Consider “sports hernia” (internal disruption resisted sit-up
Inguinal hernia8
of the inguinal canal) in an athlete with
unresolving groin pain Tenderness in area of inguinal
canal

Abdominal rigidity, rebound

RLQ pain, then nausea and vomiting
tenderness Positive McBurney's
Appendicitis9 Retroceccal appendix may refer pain to right
Point Positive psoas and
thigh or testicle
obturator sign

Female of childbearing age Sudden, severe

10 abdominal or pelvic pain Menstrual
Ovarian cyst
irregularities and pain

1
Suadicani P, et al. Height, weight, and risk of colorectal cancer. An 18-year follow-up in a cohort
of 5249 men. Scand J Gastroenterol. 1993;28:285-288.

2
Tronzo RG. Femoral neck fractures. In Steinburg ME, ed. The Hip and Its Disorders. Philadelphia:
Saunders. 1991; 247-279.

3
Guss DA. Hip fracture presenting as isolated knee pain. Ann Emerg Med. 1997;29:418-420.

4
Stulberg BN, et al. A diagnostic algorithm for osteonecrosis of the femoral head. Clin Ortho.
1989;249:176-182.
5
Wenger DR, et al. Current concepts review: Legg-Calve-Perthes disease. J Bone Joint Surg Am.
1991;73:778-788.

6
Busch MT, Morrissy RT. Slipped capital femoral epiphysis. Orthop Clin North Am. 1987;18:637-647.

7
Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis
of the hip in children: An evidence-based clinical prediction algorithm. J Bone Joint Surg Am.
1999;81:1662-1670.

8
Kesek P, Ekberg O. Herniographic findings in athletes with unclear groin pain. Acta Radiol.
2002;43:603-608.

9
Graff L, Russell J, Seashore J, et al. False-negative and false-positive errors in abdominal pain
evaluation: Failure to diagnose acute appendicitis and unnecessary surgery. Acad Emerg Med.
2000;7:1244-1255.

10
Kumar S. Right-sided low inguinal pain in young women. R Coll Surg Edinb. 1996;41:93-94.
Courtesy of Joe Godges OPT.

General Prevalence for Low Back Pain

Mechanical low back or leg pain 97%

Lumbar sprain/strain 70%

DDD and/or DJD (facet or z-joint) 10%

HNP (bulge, protrusion, extrusion, sequestration) 4%

Osteoporotic compression fracture 4%

Spinal stenosis 3%

Spondylolisthesis (includes pars defect) 2%

 Spondylolysis, discogenic, instability 2%

Traumatic fracture < 1%

Congenital (severe kyphosis and scoliosis, transitional vert.) < 1%

[circled white star] This information is helpful in two ways:

1. It helps a patient to know that the research shows that almost everyone at
some point in their lives will have some form of back pain. Thus they are not
the only one suffering. (reducing pain catastrophizing and fear avoidance
behaviors)
2. It is valuable to know that the vast majority of instances of back pain is of
the sprain/strain variety.
Deyo RA, Weinstein JN. Low back pain. New Eng J Med. 2001;344(5):363-70.

Education Modifications for Patients Presenting With Yellow

Flags.

Category Principle

“Abnormal” imaging findings “Disc

Very rarely a sign of serious disease Commonly found in people
bulge or degenerative disc
without low back pain
disease”

No suggestion of permanent damage The spine is strong, even

Implications of low back pain when it is painful Pain does not mean your back has serious
damage

A number of treatments can help control the pain

Lasting relief depends on your effort

Treatment of low back pain
Concentrate on maintaining and improving activity to restore
normal function and fitness

Utilize positive attitude and adaptive coping skills

Movement Science
Movement Impairments of the Lumbar Spine: DSM (Directional
Susceptibility to Movement)
Lumbar Extension Syndrome
Lumbar Flexion Syndrome
Lumbar Rotation Syndrome
Lumbar Rotation with Flexion Syndrome
Lumbar Rotation with Extension Syndrome

Key Tests for Lumbar Movement Impairments

Forward bending: corrected forward bending

Return from forward bending: corrected return from

forward bending
Standing
Sidebending: corrected sidebending

Rotation

Back bending

Sitting alignment: (corrected vs. flexed or extended)

Sitting
Knee extension

Resting position of hips and knees extended vs. hips and

knees flexed

Bilateral hip and knee flexion (passive)

Supine
Hip abduction/lateral rotation from flexion

Lower abdominal performance

 Position (pillow vs. no pillow)

Knee flexion
Prone
Hip rotation

Hip extension with knee extended

Rocking backward

Quadruped Rocking forward

Shoulder flexion

Standing with back

Flatten back
to wall
 FIGURE 11-3 Treatment-Based Classification for Lumbar and Sacroiliac Region

Lumbar Spine Treatment-Based Classification References

Fritz JM, George S. The use of a classification approach to identify subgroups of
patients with acute low back pain: Interrater reliability and short-term
treatment outcomes. Spine. 2000;25:106-114.
Fritz JM, George SZ. Identifying psychosocial variables in patients with acute
work-related low back pain: The importance of fear-avoidance beliefs. Phys
Ther. 2002;82:973-983.
Childs JD, et al. A clinical prediction rule to identify patients with low back
pain most likely to benefit from spinal manipulation: A validation study. Ann
Intern Med. 2004;141:920-928.

Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical
prediction rule for determining which patients with low back pain will respond
to a stabilization exercise program. Arch Phys Med Rehabil. 2005;86:1753-1762.
Fritz JM, Brennan GP, Clifford SN, Hunter SJ, Thackeray A. An examination of
the reliability of a classification algorithm for subgrouping patients with low
back pain. Spine. 2006;31:77-82.
Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain:
Evolution of a classification approach to physical therapy. J Orthop Sports Phys
Ther. 2007;37:290-302.
George SZ, et al.The Effect of a fear-avoidance-based physical therapy
intervention for patients with acute low back pain: Results of a randomized
clinical trial. Spine. 2003;28(23):2551-2560.

Lumbar Facet Syndrome

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Rotation extension Rotation

Mobilization
Pain with extension rotation
Nonspecific LBP with a (quadrant)6 Correction of
deep and achy quality movement
Associated
usually localized to Back pain worsened with extension
with post- impairment
unilateral5 or bilateral from a flexed position2
traumatic
facet vertebral area3 Pain control
Absence of pain with sit to stand4
synovitis1 Pain exacerbated w/ L/S Exercise
hyperextension, Pain radiates across back and often
Facet joint into proximal thigh, groin, and upper Flexion biased
twisting, stretching,
as source
lateral bending, and lumbar region1
of chronic Education
torsional load3
LBP 31%2 3
Prior history of LBP Absence of
Quadrant
Pain worse in the symptoms with Valsalva maneuver3
≥ 50 years Palpation for
morning, aggravated Patient may present with normal gait,
old3,6 asymmetries in
with rest, and relieved absence of leg pain, and absence of
flexion/extension
with repeated motions4 muscle spasm3
Prone PA
However, may have hyperreactive palpation
muscle spasms

Dworkin G. Advanced concepts in interventional spine care. JAOA. 2002;102(9):58-61.

 Manchikanti, et al. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and
lumbar regions. BMC Musculoskeletal Disorders. 2004;5(15):1-7.

Jackson RP, Jacobs RR, Montesano PX. Facet joint injection in low back pain. A prospective
statistical study. Spine. 1988;13(9):966-71.

Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of
chronic low back pain. The Spine Journal. 2003;3:460-465.

Wilde VE, Ford JJ, McMeeken JM. Indicators of lumbar zygapophyseal joint pain: Survey of an expert
panel with the Delphi technique. Phys Ther. 2007;87(10):1348-1361.

Laslett M, McDonald B, Aprill C, Tropp H, Öberg B. Clinical predictors of screening lumbar

zygapophyseal joint blocks: Development of clinical prediction rules. The Spine Journal.
2006;6(4):370-379.

Lumbar Zygapophyseal Joint Pain Referral

Fukui S, et al. Distribution of referred pain from the lumbar zygapohpyseal
joints and dorsal rami. Clin J Pain. 1997;13:303-307.
 FIGURE 11-4 Fukui Lumbar Facet

Clinical Prediction Rule: for Screening out/Ruling in

Zygoapophyseal Joint Syndrome

Age ≥ 50y
Symptoms best walking
Symptoms best sitting
Onset pain is paraspinal
(+) lumbar extension/rotation test (quadrant).

Sensitivity Specificity +LR −LR

 ≥3 85 91 9.7 0.17

≥2 100 50 2.0 0.0

[circled white star] If there are ≥ 3 variables present. patient is about 10 times
more likely to have a facet syndrome.
[circled white star] If there are < 2 variables present, the high sensitivity most
likely rules out the presence of the facet syndrome.
Laslett M, McDonald B, Aprill C, Tropp H, Öberg B. Clinical predictors of
screening lumbar zygapophyseal joint blocks: Development of clinical prediction
rules. Spine. 2006;6(4):370-379.

FIGURE 11-5 Neutral Gap 1

FIGURE 11-6 Neutral Gap 2

 FIGURE 11-7 Neutral Gap 3

Lumbar Local Rotation GPM V Lumbar Prone PA Palpation

FIGURE 11-8 Lumbar Central PA 1

FIGURE 11-9 Lumbar Central PA 2

FIGURE 11-10 Lumbar Unilateral PA

 FIGURE 11-11 Lumbar Unilateral PA 2

Lumbar Hypermobility/Lumbar Motor Control Impairment

Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control
Lumbar
rotation- Stabilization Exercise
extension
Abdominal bracing3
Rotation
Strengthen transverse
Low back pain with or without Rotation- abdominis and multifidi4
referred pain3 flexion
More Educate
common in Palpation of
“Recurrent,” “constant,”
females malalignment3 Correction of movement
“locking,” “giving way,” and/or
impairment
Males have accompanied by a feeling of
“instability”7 Excessive
more lumbar passive Posterior Shear Test3 Prone
flexion5 Catching with return from flexed intervertebral Instability Test3,4 Beighton
motion1,2,3 Ligamentous Laxity Scale3
Females posture6
have more Retrolisthesis— Posteroanterior mobility CPR
“Worsening condition” patient self-
lumbar Instability for success with
report6
extension5 catch3 stabilization4
Frequent need to self-manipulate6
“Gower's 1. (+) prone instability test
 sign”3 2. Aberrant movements
present
Pain with
sustained 3. SLR > 91 degrees
postures6
4. Age < 40

1
Abbott JH, McCane B, Herbison P, Moginie G, Chapple C, Hogarthy T. Lumbar segmental instability:
A criterion-related validity study of manual therapy assessment. BMC Musculoskel Disord. 2005;6:56.

2
Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: An examination of
validity for determining intervention strategies in patients with low back pain. Arch Phys Med
Rehabil. 2005;86:1745-1752.

3
Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of clinical examination measures for
identification of lumbar segmental instability. Arch Phys Med Rehabil. 2003;84:1858-1864.

4
Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for
determining which patients with low back pain will respond to a stabilization exercise program. Arch
Phys Med Rehabil. 2005;86:1753-1762.

5
Fritz JM, Piva SR, Childs JD. Accuracy of the clinical examination to predict radiographic instability
of the lumbar spine. Eur Spine J. 2005;14:743-750.

6
Cook C, et al. Subjective and objective descriptors of clinical lumbar spine instability: A Delphi
study. Man Ther. 2006;11(1):11-21.

7
Taylor J, O'Sullivan P. Lumbar “segmental” instability: Pathology, diagnosis, and conservative
management. In: Twomey L, Taylor J, eds. Physical Therapy of the Low Back. 3rd ed. Philadelphia:
W. B. Saunders. 2000;201-247.

CPR for Success with Lumbar Stabilization/Neuromuscular Re-

education (Unvalidated)

CPR for Success with Stabilization4

1. (+) prone instability test
2. Aberrant movements present
3. SLR > 91 degrees
4. Age < 40
 Variables Present Reliability Sensitivity Specificity +LR -LR

3 or more NT 56 86 4.0 0.52

CPR for Failure with Lumbar Stabilization/Neuromuscular Re-

education (Unvalidated)
1. (-) prone instability test
2. Aberrant movement absent
3. Lack of hypermobility with lumbar spring testing
4. FABQ physical activity subscale > 8

Variables Present Reliability Sensitivity Specificity +LR -LR

2 or more NT 85 87 6.3 0.18

Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for
determining which patients with low back pain will respond to a stabilization exercise program. Arch
Phys Med Rehabil. 2005; 86:1753-1762.

Ruling in Lumbar Instability

Passive Physiological Intervertebral Movements (PPIVMs)
Extension
1. Patient is placed in sidelying position. Patient's elbows are locked in
extension, and his or her hands are placed on the ASIS of the assessing
examiner.
2. Examiner applies a posterior to anterior (PA) force at the caudal level (i.e.,
at L5 when assessing L4-L5 mobility).
3. The cephalic segment is palpated just inferior at the interspinous space (i.e.,
during L4-L5 assessment, the interspinous space is palpated to assess
movement). One may repeat on the other side, although most likely results are
similar.
4. (+) test is identified by detection of excessive movement during
examination.

Reliability Sensitivity Specificity +LR -LR

Extension Rotational PPIVMs NT 22 97 7.3 0.8

Extension Translational PPIVMs NT 16 98 8 0.85

Abbott JH, McCane B, Herbison P, Moginie G, Chapple C, Hogarthy T. Lumbar segmental instability:
A criterion-related validity study of manual therapy assessment. BMC Musculoskeletal Disorders.
2005;6:56.

FIGURE 11-12 Passive Physiological Intervertebral Movements (PPIVMs) Extension 1

FIGURE 11-13 Passive Physiological Intervertebral Movements (PPIVMs) Extension 2

 Passive Physiological Intervertebral Movements (PPIVMs)
Flexion
1. Patient is placed in a sidelying position. The hips of the patient are flexed to
90°, and the patient's knees are placed against the ASIS of the examiner.
2. Examiner stabilizes the superior segments by pulling posterior to anterior on
the patient's spine. Examiner applies an anterior to posterior force at the
caudal level (i.e., at L5 when assessing L4-L5 mobility) by applying a force
through the flexed femurs.
3. The cephalic segment is palpated just inferior at the interspinous space (i.e.,
during L4-L5 assessment, the interspinous space is palpated to assess
movement).
4. One may repeat on the other side, although most likely results are similar.
5. (+) test is identified by detection of excessive movement during
examination.

FIGURE 11-14 Passive Physiological Intervertebral Movements (PPIVMs) Flexion 1

 FIGURE 11-15 Passive Physiological Intervertebral Movements (PPIVMs) Flexion 2

FIGURE 11-16 Passive Physiological Intervertebral Movements (PPIVMs) Flexion 3

Reliability Sensitivity Specificity +LR -LR

Flexion Rotational PPIVMs NT 05 99 5 0.96

Flexion Translational PPIVMs NT 05 99 10 0.95

Abbott JH, McCane B, Herbison P, Moginie G, Chapple C, Hogarthy T. Lumbar segmental instability:
A criterion-related validity study of manual therapy assessment. BMC Musculoskeletal Disorders.
2005;6:56.

[circled white star] Flexion and extension PPIVMs are predictive of measurable
excessive movement on flexion-extension radiographs in patients with
recurrent chronic low back pain compared to an asymptomatic control group.
Motion beyond two standard deviations from the reference mean was
considered diagnostic of rotational lumbar segmental instability (LSI) and
translational LSI.
Beighton Ligamentous Laxity Test
1 point per side (9 total)
1. Hyperextension of elbow > 10°
2. Passive hyperextension of 5th finger > 90°
3. Passive abduction of thumb to forearm
4. Passive hyperextension of knees > 10°
5. Flex trunk with hands flat on floor

FIGURE 11-17 Beighton Elbow Hyperextension

FIGURE 11-18 Beighton Fifth Finger Extension

FIGURE 11-19 Beighton Knee Hyperextension

FIGURE 11-20 Beighton Lumbar Flexion

 FIGURE 11-21 Beighton Thumb Abduction

Reliability ICC = 0.79 (Good reliability)

Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of clinical examination measures for
identification of lumbar segmental instability. Arch Phys Med Rehabil. 2003;84:1858-1864.

[circled white star] Use of the Beighton Ligamentous Laxity Test gives me a
clue about the inherent flexibility of the patient, and though not validated,
helps me reason about the potential for injury or the source of injury in my
patients.

Prone Instability Test

1. Patient is prone with the torso on the examining table, the legs over the
edge of the plinth, and the feet resting on the floor.
2. Examiner performs a PA spring on the low back to elicit back pain using the
pisiform grip.
3. Patient is requested to lift his or her legs off the floor by using a back
contraction.
4. Examiner maintains the PA force to the low back.
5. (+) test is reduction of painful symptoms (as applied during the PA) during
raising of the patient's legs.
 FIGURE 11-22 Prone Instability Test 1

FIGURE 11-23 Prone Instability Test 2

Reliability Sensitivity Specificity +LR -LR

 0.69 61 57 1.41 0.69

[circled white star] This test is of limited value when used on its own outside a
cluster of findings.
Fritz JM, et al. Accuracy of the clinical examination to predict radiographic
instability of the lumbar spine. Eur Spine J. 2005;14(8)743-750.

Abdominal Bracing
1. Position in supine or quadruped.
2. Instruct patient: “Draw navel up toward the head and in toward the spine so
that the stomach flattens but spine remains neutral.”
3. Palpate for contraction medial to ASIS.
4. Integrate into functional activity.

Abdominal Hollowing
1. Position: Supine/neutral spine.
2. Biofeedback unit under small of back.
3. Pump up to 40 mm Hg.
4. Instruct patient: “Draw in belly button towards spine.”
5. Spine or pelvis remains stable.
6. Palpate for contraction just medial to ASIS.
7. Rectus abdominis should not flex spine.
8. Proceed with lumbar stabilization sequence.
9. Patient should be able to maintain 40 mm Hg for 10 seconds at a time.
10. *No Valsalva.
[circled white star] Without biofeedback equipment available to most
clinicians, Grenier and McGill demonstrate that abdominal bracing is very
effective for improving relative “stiffness” of the spine. This will make
educating and successful reproduction for patients much easier.8

Neuromuscular Re-education3,4,5,6
Muscle Exercises

Abdominal hollowing7

Transversus abdominis7 Abdominal bracing8

Horizontal side support9

Low-Moderate Intensity 35%±13% to 44%±12% MVIC2

Bridging to a neutral spine position with feet on gym ball

Supine bridging with spine and hips in neutral

Low-Moderate Intensity (co-contractions) 32%±11%

MVIC to 58%±16% MVIC2

Erector spinae and multifidus (in order of Horizontal side support

lowest to highest EMG amplitude)
Moderate Intensity 29%± 11% to 45%±16% MVIC2
Intensity: 15-18 repetition max1
Quadruped upper and lower extremity lifts
Duration: 5 sec. isometric hold at end
range1 Prone upper and lower extremity lifts

Frequency: 3x/week1 High Intensity 92%±14% MVIC2

Prone extensions to end range with resistance

Slow active sitting trunk extension against elastic tubing

resistance

with the pelvis stabilized

Side bridging9

Curl ups9

Oblique abdominals

Rectus abdominis
 Side bridging9
Quadratus lumborum
54% MVIC

1
Danneels LA, et al. Effects of three different training modalities on the cross sectional area of the
lumbar multifidus muscle in patients with chronic low back pain. Br J Sports Med. 2001;35:186-191.

2
Ekstrom RA, et al. Surface electromyographic analysis of the low back muscles during rehabilitation
exercises. J Orthop Sports Phys Ther. 2008;38(12):736-745.

3
Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of
acute, first-episode low back pain. Spine. 1996;21:2763-2769.

4
Hides JA, Stanton WR, McMahon S, Sims K, Richardson CA. Effect of stabilization training on
multifidus muscle cross-sectional area among young elite cricketers with low back pain. J Orthop
Sports Phys Ther. 2008;38:101-108.

5
Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting
ipsilateral to symptoms in patients with acute/subacute low back pain. Spine. 1994;19:165-172.

6
Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-
episode low back pain. Spine. 2001;26:E243-E248.

7
Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first
episode low back pain. Spine 2001; 26: E243-8

8
Grenier SG, McGill SM. Quantification of lumbar stability by using two different abdominal
activation strategies. Arch Phys Med Rehabil. Jan 2007; 88:54-62.

9
McGill SM. Low back exercises: Evidence for improving exercise regimens. Phys Ther. 1998;78:754-
765.
 FIGURE 11-24 Horizontal Side Support for Transverse Abdomens

FIGURE 11-25 Horizontal Side Support for Transverse Abdomens

Lumbar Strain

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Lumbar rotation-
flexion Lumbar
flexion
Pain control
Bent over (flexed
position)4 Mobilization

Unable to straighten Education

up (move into
Correction of
Broad area of extension)4
movement
7-13% of all sports injuries in pain1,2,3
Unable to maintain impairment
intercollegiate athletes are low back Pain increases a normal posture4 Stabilization
injuries Muscle strains (60%)5 with activity or
while sleeping4 Trunk and hip Exercise
Athletes are more likely to sustain muscle weakness2
injuries in practice (80%) than during History of Muscle
competition (6%)5 trauma to Lifting with length/strength
area3,4 flexion, lateral
American football (17%) and flexion, and Mobility
gymnastics (11%) highest incidence5 Movement is rotation4 tests3,4
restricted1,3,4
—machine that Schober Test4
vibrates4
Palpations4
—prolonged sitting4
L/S ROM and
—motor vehicle MMT2,3,4
collision4

—falls4

1
Leinonen V, et al. Back and hip extensor activities during trunk flexion/extension: effects of low
back pain and rehabilitation. Arch Phys Med Rehabil. 2000;81(1):32-39.

2
Nourbakhsh MR. Relationship between mechanical factors and incidence of low back pain. J Orthop
Sports Phys Ther. 2002;32(9):447-457.

3
O'Sullivan PB, et al. The relationship between posture and back muscle endurance in industrial
workers with flexion-related low back pain. Man Ther. June 2006;11(4):264-271.

4
Saunders HD. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders. Chaska, MN:
Saunders. 2004;101-117.

5
Keene JS, Albert MJ, Springer SL, Drummond DS, Clancy WG Jr. Back injuries in college athletes. J
Spinal Disord. 1989;2(3):190-195.

Discogenic Low Back Pain

Prevalence Symptoms DSM/Signs TBC/Special Tests

Lumbar Pain control

rotation-
extension Specific exercise:
Lateral shift
Lumbar
extension Specific exercise:
 Cumulative—History of ↑ Lumbar Extension
flexion position3,4 Initial rotation-flexion
low back pain Traction8
No noted gender (centralized)1,3 Lumbar flexion
difference3,4 20-50 Educate
years of age 98% of Progressive Sitting: slumped
posture3,4 Maintain lordosis at all
herniated discs occur peripheralization
times
at L4-L5 and L5-S13 (peripheral neurologic
Use of hands to
symptoms indicate Correction of
Pain usually starts take weight off
impingement or irritation movement impairment
centrally and may low back
of nerve root)3
progress down the leg, SLR (Sn)
Standing: lateral
usually below the Hypomobility (extension shift (50% of
knee5 most common)3 patients)/lumbar Crossed SLR (Sp)
scoliosis3
Pain in rising from sitting3 Observe for
centralization Lack of
Decreased lumbar
Pain in sitting3,4 centralization useful for
lordosis/posterior
ruling out discogenic
pelvic tilt2,3
involvement7 and
Decreased lumbar prediciting poor
extension ROM3,4 prognosis6

1
Lyle MA, Manes S, McGuinness Michael, Iverson, MD. Relationship of physical examination findings
and self-reported symptom severity and physical function in patients with degenerative lumbar
conditions. Phys Ther. 2005;85:120-133.

2
Magee D. J Orthopedic Physical Assessment. 4th ed. Philadelphia: Saunders for Elsevier; 2002.

3
Saunders HD. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders: Spine.
Chaska, MN: Saunders. 2004; 101-117.

4
Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources
of chronic low back pain. Spine J. 2003;3(6):460-465.

5
Ohnmeiss DD, Vanharanta H, Ekholm J. Relation between pain location and disc pathology: A study
of pain drawings and CT/discography. Clin J Pain. 1999;15(3):210-217.

6
Wernecke M. Centralization phenomenon as a prognostic factor for chronic low back pain and
disability. Spine. 2001;26(7):758-764.

7
Bogduk N. Commentary on a prospective study of centralization and lumbar and referred pain: A
predictor of symptomatic discs and anular competence. Pain Med J Club J. 1997;3:246-248.

8
Fritz JM, et al. Is there a subgroup of patients with low back pain likely to benefit from mechanical
traction? Results of a randomized clinical trial and subgrouping analysis. Spine. 2007;32(26):E793-
E800.
[circled white star] Absence of centralization or peripheralization (Sn = 92-95)
and absence of sciatica (Sn = 95) greatly reduce the likelihood of discogenic
pain.

FIGURE 11-26 Common Disc Syndromes: Neurologic Findings

Source: Reprinted from Practical Strategies in Outpatient Medicine, 2nd Edition, B.B.
Reilly, p. 915, © 1991, with permission from Elsevier.

Sciatica
 Prevalence Symptoms DSM/Signs TBC/Special
Tests

Pain control
5 per 1000 persons Exercise
per year in
Netherlands Radiating pain in the leg below the knee in Correction of
one or more lumbar or sacral movement
22% among male Nerve root
impairment
dermatomes3,4,5,6 tension3,4,5,6
machine operators1
Refer out
24% among male Psychological distress in women2 Neurologic
carpenters1 deficits3,4,5,6 Educate
Hysteria significantly associated with sciatic
14% among male pain among blue-collar workers1 Neuroscreen
office workers1
SLR

Crossed SLR

1
Pietri-Taleb F, et al. The role of psychological distress and personality in the incidence of sciatic
pain among working men. Am J Public Health. 1995;85(4):541-545.

2
Heliövaara M, Knekt P, Aromaa A. Incidence and risk factors of herniated lumbar intervertebral disc
or sciatica leading to hospitalization. J Chronic Dis. 1987;40(3):251-258.

3
Stam J. Consensus in diagnosing and treatment of the lumbosacral radicular syndrome [in Dutch].
Ned Tijdschr Geneeskd. 1996;140(262):1-7.

4
Ostelo RWJG, et al. Rehabilitation following first-time lumbar disc surgery: A systematic review
within the framework of the Cochrane collaboration. Spine. 2003;28:209-218.

5
Weber H, Holme I, Amlie E. The natural course of acute sciatica with nerve root symptoms in a
double-blind placebo-controlled trial evaluating the effect of piroxicam. Spine. 1993;18:1433-1438.

6
Mens JMA, Chavannes AW, Koes BW, et al. NHG-guideline lumbosacral radicular syndrome [in
Dutch]. Huisarts-Wetenschap. 2005;48:171-178.

Screening out Disc Herniation

Straight Leg Raise (SLR)
1. Patient should lie on a firm but comfortable surface, the neck and head in
neutral position.
2. Examiner supports the patient's leg at the heel, maintaining knee extension
and neutral dorsiflexion at the ankle. Clinician raises the leg to the point of
symptom reproduction.
3. Patient's trunk and hips should remain neutral, avoiding internal or external
rotation of the leg or adduction or abduction of the hip.
4. (+) test is concordant reproduction of symptoms, sensitization, and
asymmetry findings.

Reliability Sensitivity Specificity +LR -LR

NT 97 57 2.23 0.05

Vroomen PC, et al. Diagnostic value of history and physical examination in patients suspected of
lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry. 2002;72(5):630-634.

FIGURE 11-27 Straight Leg Raise

Screening out Far Lateral Disc Herniation

Femoral Nerve Tension Test
1. Patient lies prone in a symmetric, pain-free posture.
2. Examiner places one hand on the PSIS, on the same side of the knee that the
examiner will bend into flexion.
3. Examiner then gently moves the lower extremity into knee flexion, bending
the knee until the onset of symptoms.
4. Once the symptoms are engaged, examiner slightly backs the leg out of the
painful position.
5. At this point, examiner may use plantarflexion, dorsiflexion, or head
movements to sensitize the findings.
6. Further sensitization can be elicited by implementing hip extension.
Examiner can repeat on the opposite side if desired.
7. (+) test is reproduction of pain in the affected extremity.

Reliability Sensitivity Specificity +LR -LR

NT 97 NT NA NA

Porchet F, et al. Extreme lateral lumbar disc herniation: Clinical presentation in 178 patients. Acta
Neurochir (Wien). 1994;127(3-4):203-209.

FIGURE 11-28 Femoral Nerve Tension Test

Ruling in Disc Herniation
Well Leg Raise (Crossed Straight-Leg Raise)
1. Patient should lie on a firm but comfortable suface, the neck and head in
the neutral position.
2. Patient's trunk and hips should remain neutral and avoid internal or external
rotation and excessive adduction or abduction.
3. Examiner supports the patient's non-involved leg at the heel, maintaining
knee extension and neutral dorsiflexion at the ankle.
4. Examiner raises to the point of symptom reproduction of the opposite,
comparable leg.
5. (+) test is identified by reproduction of the patient's concordant pain during
the raising of the opposite extremity.

Reliability Sensitivity Specificity +LR -LR

NT 43 97 14.3 0.59

Kerr RSC, et al. The value of accurate clinical assessment in the surgical management of the lumbar
disc protrusion. J Neurol Neurosurg Psychiatr. 1988;51:169-173.

FIGURE 11-29 Well Leg Raise

 Straight Leg Raise
1. [circled white star] Unilateral passive straight-leg raising may produce leg
pain, back pain, or a combination of both but, especially in persons under 30
years of age, has no specific value in the diagnosis of disc protrusion.
2. Negative straight-leg raising, especially in persons under 30 years of age,
usually excludes the diagnosis of disc protrusion.
3. The degree of limitation of straight-leg raising is inversely proportional to
positive disc protrusion.
4. After age 30, unilateral straight-leg raising is seen less often, but its
diagnostic value increases.
5. After age 30, negative straight-leg raising no longer excludes disc protrusion.
6. The crossed straight-leg-raising test is a much more reliable clinical sign of
disc protrusion.
7. In cases of proven disc protrusion:

a. Centrally located protrusions produce mainly back pain during straightleg

raising, probably due to tension on sensitive dura;
b. Intermediately located protrusions produce back and leg pain during straight-
leg raising;
c. Laterally located protrusions usually produce leg pain only during straight-leg
raising, probably due to tension on sensitive nerve roots.
d. Pain patterns observed during straight leg raising are not an accurate
predictor of the level of disc protrusion;
e. A positive crossed straight-leg-raising test usually indicates a more centrally
located prolapse.

1. Urban LM. The straight-leg-raising test: A review. J Orthop Sports Phys Ther.
1981;2(3):117-133

Slump Sit Test

1. Patient sits straight with the arms behind the back, the legs together, and
the posterior aspect of the knees against the edge of the treatment table.
2. Patient slumps as far as possible, producing full trunk flexion; examiner
applies firm overpressure into flexion to the patient's back, being careful to
keep the sacrum vertical.
3. While maintaining full spinal flexion with overpressure, examiner asks the
patient to extend the knee, or passively extends the knee.
4. Examiner then moves the foot into dorsiflexion while maintaining knee
extension.
5. Neck flexion is added to assess symptoms. Neck flexion is released to see if
symptoms abate.
6. (+) test is concordant reproduction of symptoms, sensitization, and
asymmetry findings.

Reliability Sensitivity Specificity +LR -LR

NT 83 55 1.82 0.32

Stankovic R, et al. Use of lumbar extension, slump test, physical and neurological examination in the
evaluation of patients with suspected herniated nucleus pulposus: A prospective clinical study. Man
Ther. 1999;4(1)25-32.

FIGURE 11-30 Slump Sit Test 1

FIGURE 11-31 Slump Sit Test 2

FIGURE 11-32 Slump Sit Test 3

 FIGURE 11-33 Slump Sit Test 4

Centralization
1. Patient either stands or lies prone, depending on the intent of a loaded or
unloaded assessment.
2. Multiple directions of repeated end-range lumbar testing are targeted.
Movements may include extension, flexion, or side flexion (lateral shift).
3. Movements are repeated up to 5 to 20 attempts until a definite
centralization or peripheralization occurs.
4. (+) finding is centralization of symptoms and is generally considered a low
back dysfunction.

Reliability Sensitivity Specificity +LR -LR

NT 9 79 4.2 1.2

Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of
chronic low back pain. Spine. 2003; 3(6)460-465.

[circled white star] Browder, et al. found that people with LBP who centralized
and were placed in an extension-biased exercise treatment classification had
improved disability scores (ODI) at 1 week, 4 weeks, and at 6 months over a
matched group that was instructed in trunk-strengthening exercises.
FIGURE 11-34 Prone on Pillows

FIGURE 11-35 Prone Lying

FIGURE 11-36 Prone on Elbows

FIGURE 11-37 Prone Press Ups

 FIGURE 11-38 Extension in Standing

FIGURE 11-39 Lateral Shift Correction

[circled white star] Werneke, et al. also found that individuals who do not
centralize via the McKenzie testing protocol during the evaluation may be at
higher risk for chronicity, delayed recovery, and possible greater health costs.
Patients with leg pain at intake were 4 times more likely to have sick or down
time at work.
Browder DA, Childs JD, Cleland JA, Fritz JM. Effectiveness of an extension-
oriented treatment approach in a subgroup of subjects with low back pain: A
randomized clinical trial. Phys Ther. 2007;87:1608-1618.
Werneke M, Hart DL. Centralization phenomenon as a prognostic factor for
chronic low back pain and disability. Spine. 2001;26:758-765.

Traction
[circled white star] A subgroup of patients with LBP who may benefit from
traction exhibit:
1. peripheralization with extension
2. (+) crossed straight-leg raise
These patients may be too irritable to achieve centralization with repeated
extension movements though they may fit the extension-biased exercise
treatment category. They may benefit from the following protocol utilizing
traction along with progressing them into extension-biased exercises.
1. Extension-biased exercise treatment with the addition of traction for the
first 2 weeks.
2. Patient is positioned in a prone position.
3. Table is adjusted to maximize centralization, with adjustment of the table
(after 3 minutes) to place patient in neutral to extended spine.
4. Static traction for a maximum of 12 minutes (10-minute treatment with 1
minute ramp up and ramp down).
5. Set at 40-60% of the patient's BW.
6. After traction, patient continues to lay prone for 2 minutes, then performs
prone press ups before resuming weight bearing.
7. Maximum of 12 sessions.
Fritz JM. Is there a subgroup of patients with low back pain likely to benefit
from mechanical traction? Results of a randomized clinical trial and
subgrouping analysis. Spine. 2007;32(26):E793-E800.

Spondylolisthesis

Prevalence Symptoms DSM/Signs TBC/Special Tests

Onset: childhood- Pain control

adulthood
Stabilization
Increased risk: Exercise
adolescents with
genetic Strengthening abdomen
predisposition, young Lumbar rotation-extension and back muscles
athletes (lumbar stabilization)1,3
LBP1,5 Lumbar extension
(hyperextension-type Hamstring stretches3
movements), anyone Tenderness Lumbar rotation Pelvic tilt exercises
diagnosed with to palpation (biofeedback)3 Aerobic
spondylolysis2 over level of Lumbosacral kyphosis at level of exercises (walking and
involvement4 slip resulting in lumbar lordosis swimming)3 Bracing3,5
Type I: dysplastic above that level5 Tight
(congenital) hamstrings1 Cauda equina Correction of
Back spasms4
syndrome (emergent)1 Restricted movement impairment
Type II: isthmic (fx Educate
Pain with ROM in L/S (special note in
of pars)
activity4 children)1,5 Pain with extension1 Historically advised to
Type III: Pain with flexion1 Step-off avoid L/S extension
degenerative; deformity L/S ROM1 L/S
secondary to OA
palpations1,4 SLR1
(adults > 40 y/o)
Neurological tests
Type IV: traumatic (myotomes,
dermotomes, reflexes)1
Type V: pathologic2 MMT trunk1

1
Brotzman SB, Wilk KE. Clinical Orthopedic Rehabilitation. 2nd ed. Philadelphia, PA: Mosby; 2003.

2
Mac-Thiong JM, Labelle H. A proposal for a surgical classification of pediatric lumbosacral
spondylolisthesis based on current literature. Eur Spine J. 2006;5:1425-1435.

3
O'Sullivan PB, Phyty DM, Twomey LT, Allison, GT. Evaluation of specific stabilizing exercise in the
treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis.
Spine. 1997;22(24):2959-2967.

4
Oatis CA. Kinesiology: The Mechanics & Pathomechanics of Human Movement. Philadelphia, PA:
Lippincott Williams & Wilkins; 2004.

5
Seitsalo S, Schlenzka D, Poussa M, Osterman K. Disc degeneration in young patients with isthmic
spondylolisthesis treated operatively or conservatively: A long-term follow-up. Eur Spine J.
1997;6:393-397.

Lumbar Compression Fractures

History Sensitivity Specificity

Age > 50 0.84 0.61

Age > 70 0.22 0.96

Trauma 0.30 0.85

Corticosteroid 0.06 0.995

Deyo RA, Jarvik JG. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern
Med. 2002;137:586-597.

Spinal Stenosis

Prevalence Symptoms DSM/Signs TBC/Special Tests

Lumbar rotation-
extension Specific exercise—
Flexion
Lumbar extension
Mobilization
6
Wide-based gait
Stabilization
Thigh pain with 30
Educate
seconds of lumbar
extension6 Correction of movement
impairment
Decreased muscle
Lumbar back pain with stretch reflexes4 Exercise/stretching
progression of lower
extremity pain (unilateral Decrease LE Muscle
Most common in strength,
or bilateral)3 stretching/strengthening1
people over 50 specifically ext.
years old2 hallucis longus3 Aerobic training:
Posture dependent,
increased pain in lumbar stationary bike,
Effects 1 in 1000 Decreased lumbar
ext.2 harnessed treadmill
people to the ext; decreased walking, aquatic
extent that they lumbar lordosis2
LE numbness or tingling3 therapy2,5
need surgery2
LE muscle cramping No Pain relieved with MMT/ROM, Reflex tests2
pain when seated6 flexion3
LE myotome/dermatome
 Decreased LE testing2,4
sensation
(dermatomal Neural Tension Test
pattern)2 (SLR)4

Diminished pedal Quadrant Test4

pulse3
Two-Stage Treadmill
Neurogenic/vascular Test2
claudication with
ambulation3 Lasegue Test4

1
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd ed. Philadelphia, PA: Mosby;
2003.

2
Fritz J, Erhard R, Vignovic M. A non-surgical treatment approach for patients with lumbar stenosis.
Phys Ther. 1997;77(9): 962-973.

3
Iverson MD, Katz JN. Examination findings and self-reported walking capacity in patients with
lumbar spinal stenosis. Phys Ther. 2001;81(7):1296-1306.

4
Lyle MA, et al. Relationship of physical examination findings and self-reported symptom severity
and physical function impairments in patients with degenerative lumbar conditions. Phys Ther.
2005;85(2):120-133.

5
Saunders HD, Saunders RR. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders.
vol. 1: Spine. 4th ed. Chaska, MN: The Saunders Group; 2004.

6
Katz JN, et al. Degenerative lumbar spinal stenosis: Diagnostic value of the history and physical
examination. Arthritis Rheum. 1995;38(9):1236-1241.

Ruling out Stenosis

Findings Sensitivity

Age > 65 years1,2,3 77%

Pain below buttocks1,2 88%

Leg symptoms worse with walking, better with sitting1,2 81%

Best posture for symptoms is sitting1,2 89%

Worst posture for symptoms is walking or standing1,2 89%

Severe lower extremity pain3 65%

Symptoms worsen when walking3 71%

Numbness3 63%

[circled white star] The above findings, when absent, are useful for ruling out stenosis.

1
Katz JN, et al. Degenerative lumbar spinal stenosis: Diagnostic value of the history and physical
examination. Arthritis Rheum. 1995;38(9):1236-1241.

2
Fritz JM, Erhard RE, Delitto A, Welch WC, Nowakowski PE. Preliminary results of the use of a two-
stage treadmill test as a clinical diagnostic tool in the differential diagnosis of lumbar spinal stenosis.
J Spinal Disord. 1997;10(5):410-416.

3
Deyo RA, Jarvik JG. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern
Med. 2002;137:586-597.

Spondylosis (DDD/DJD, Osteochondrosis, Spinal Arthritis)

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Pain control

Correction of
movement
impairment
Lumbar rotation- Stabilization
extension
Mobilization
 Low back pain,4 Lumbar extension Exercise
especially with
carrying heavy loads Lumbar rotation Muscle
or repetitive length/strength
Usually people over 40 y/o, but Lumbar rotation-
can start as early as 203, twisting5 flexion Educate
especially in those who work with
or carry heavy loads often5 Lumbar stiffness4 Segmental hypo or Extension
hypermobility2 Quadrant
Prevalence of (+) imaging finding Possible sciatic pain5
Segmental
0-86% but not necessarily Reversed lumbopelvic Mobility Test4
Feeling of
predictive of low back pain.1 rhythm4
“catching” or
Lumbar/LE
“clunking” in lumbar Radiating pain with ROM/MMT
spine with forward
SLR if disc herniation2 Shear Stability
flex/ext4
Test4
Increased LBP with
lifting/carrying heavy Active/Passive
loads or extreme Mobility Test4
forward bending.5
SLR2

Anterior Spring
Test4

1
Battie ML, et al. Lumbar disc degneration: Epidemiology and genetic influence. Spine.
2004;29(23):2679-2690.

2
Lyle MA, et al. Relationship of physical examination findings and self-reported symptom severity
and physical function impairments in patients with degenerative lumbar conditions. Phys Ther.
2005;85(2);120-133.

3
Rothschild BM. Lumbar Spondylosis. eMedicine; WebMD. www.emedicine.com.

4
Saunders HD, Saunders RR. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders.
vol. 1: Spine. 4th ed. Chaska, MN: The Saunders Group; 2004.

5
Seidler A, et al. The role of cumulative physical work load in lumbar spine disease: Risk factors for
lumbar osteochondrosis and spondylosis associated with chronic complaints. Occup. Environ Med.
2001;58;735-746.

Ruling out Degenerative Changes in the Spine

Extension Quadrant Test
1. Patient stands with equal dispersion of weight on both legs.
2. Patient is instructed to lean back, rotate, and side-flex toward one side.
3. Movement is a combined motion of extension, rotation, and side flexion.
4. Movement is repeated on the opposite side.
5. (+) test is identified by reproduction of the patient's concordant pain.

Reliability Sensitivity Specificity +LR −LR

NT 70 NT NA NA

FIGURE 11-40 Quadrant

 FIGURE 11-41 Quadrant Overpressure

Ankylosing spondylitis

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Pain control
Exercise
1st symptoms in late
adolescence or early Promote
Lumbar hypomobility
adulthood6 spinal
Loss of spinal mobility extension
Initially it is a dull pain that is
with restriction in
insidious in onset6 flexion, extension of the
Prone lying
lumbar spine, and Passive and
Pain is felt in the deep buttock
expansion of the active spinal
and/or in the lumbar regions
and is accompanied by morning chest1,4,6 extension
stiffness in the same area that
Muscle spasms Mobilization
lasts for a few hours3
Education
Pain in SI joint with
Pain intermittent, may last for direct pressure or Measurement
Rare in North weeks to months5 movement of chest wall
America, in Germany
It improves with activity and expansion2
1%3 2nd or 3rd Inflammation in
decade5,6 Male > returns with inactivity5 peripheral joints3,6 Schober Test2
females6 2-3x
greater in males6 Pain usually worst at night Bone Mild stiffness to total Decreased
tenderness may be primary fused spine4 lumbar
complaint5 lordosis2
Decreased lumbar
Arthritis in the hip and lordosis3,5 Direct
shoulders, often early in the tenderness
course of the disease5 Atrophy of gluteus over
muscles sacroiliac
Asymmetric arthritis of lower joint2
limbs at the stage of the disease Increased thoracic
kyphosis3,5 L3-S1 midline
Neck pain and stiffness is pressure2
characteristic of advanced Cervical spine
disease hyperextension3 Lumbar spine
pressure2
Fatigue4
SASSS1

1
Averns HL, et al. Radiological outcome in ankylosing spondylitis: Use of the stroke ankylosing
spondylitis spine score (ASSS). Br J Rheumatol. 1996;35:373-376.

2
Cleland J. Orthopaedic Clinical Examination: An Evidence-Based Approach for Physical
Therapists. Carlstadt, NJ: Learning Systems. 2005;195.

3
Dougados M. Ankylosing spondylitis. Orphanet. Nov 2001.

4
Ince G, et al. Effects of a multimodal exercise program for people with ankylosing spondylitis. Phys
Ther. 2006;86:7.

5
Saunders HD, Saunders RS. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders.
vol. 1. 4th ed. Chaska, MN: The Saunders Group. 2004; 124.

6
Sieper J, et al. Ankylosing spondylitis: an overview. Ann Rheum Dis. 2002;61:8-18.

Screening out Ankylosing Spondylitis Through the History

(Gran)

Symptoms Sensitivity Specificity +LR −LR

Pain not relieved by lying down 80 49 1.57 0.41

Back pain at night 71 53 1.51 0.55

 Morning stiffness > 30 minutes 64 59 1.56 0.68

Pain or stiffness relieved by exercise 74 43 1.3 0.6

Age of onset ≤ 40 years 1.0 0.07 1.07 0

Gran JT. An epidemiological survey of the signs and symptoms of ankylosing spondylitis. Clin
Rheumatol. 1985;4:161-169.

[circled white star] The symptoms above tend to indicate an atypical pain
presentation that would perhaps indicate systemic disease and referral for
assistance with the management of the disease.

Screening out/Ruling in Ankylosing Spondylitis

Chest Expansion
1. Use tape measure at nipple line.
2. Ask patient to take a deep breath.
3. (+) test is a change of < 2.5 cm.

Reliability Sensitivity Specificity +LR -LR

NT 91 99 91 0.09

Gran JT. An epidemiological survey of the signs and symptoms of ankylosing spondylitis. Clin
Rheumatol. 1985;4:161-169.
FIGURE 11-42 Chest Expansion
Chapter 12
The Pelvic Region

Sacroiliac Joint

FIGURE 12-1 The Pelvic Girdle

Clark, RK. Anatomy and Physiology: Understanding the Human Body. © 2005 Jones &
Bartlett Publishers, LLC

Outcome Tools
ODI—Oswestry/Modified Oswestry Disability Index
FABQPA—Fear-Avoidance Back Questionnaire Physical Activity
FABQW—Fear-Avoidance Back Questionnaire Work
GROC—Global Rating of Change
PSFS—Patient-Specific Functional Scale
Where Does It Refer?

FIGURE 12-2 Insert Sacroiliac Joint Pain Referral Pattern

Anatomic Region of Referred Pain from SIJ Percentage of Patients with SIJ Pain Slipman, et al.

Upper back 6

Low back 72
Buttock 94

Groin 14

Abdomen 2

Thigh 48

Lower leg 28

Ankle 14

Foot 12

Patient Report of Pain Location Dreyfuss, et al. Sensitivity Specificity +LR -LR

Groin 0.19 0.63 0.51 1.29

Buttock 0.80 0.14 0.9 1.42

PSIS 0.76 0.47 1.4 0.51

Pain with sitting 0.03 0.90 0.3 1.07

Slipman C, et al. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil. 2000;81:334-338.

Dreyfuss P, et al. The value of medical history and physical examination in diagnosing sacroiliac joint
pain. Spine. 1996;21:2594-2602.
Screening out Pelvic Fractures
Trauma +
Posterior inflammation (like a little ball)
Pain with hip ROM
Pain during rectal examination
Pain during compression
Sauerland, et al. Reliability of clinical examination in detecting pelvic fractures
in blunt trauma patients: A meta-analysis. Arch Orthop Trauma Surg.
2004;124:123-128.
[circled white star] Presence of pain in Fortin area (PSIS and 3 cm × 10 cm area
below) and absence of pain in ischial tuberosity area more specific to SIJ pain.
1. Van der Wurff P, et al. Intensity mapping of pain referral areas in sacroiliac
joint pain patients. J Manipulative Physiol Ther. 2006;29(3):190-195.
 FIGURE 12-3 Sacroiliac Joint Provocation Cluster Flow Chart
Adapted from Laslett M., et al. Diagnosis of sacroiliac joint pain: Validity of individual
provocation tests and composites of tests. Man Ther. 2005;10:207-218.

Is the Sacroiliac Joint (SIJ) the Source Structure?

Ruling in SIJ Involvement
 Provocation Cluster
1. SI Compression Test
2. SI Distraction Test
3. Gaenslen's Test
4. Posterior Pelvic Pain Provocation (P4) Test
5. Sacral Spring Test
6. 3(+) out of 5 indicates SIJ as the source of the pain.
Laslett M, et al. Diagnosing painful sacroiliac joints: A validity study of a
McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother.
2003;49:89-97.

Provocation Test
SI Compression Test
1. Patient assumes a sidelying position with his or her painful side up superior
to the plinth. Resting symptoms are assessed.

FIGURE 12-4 SI Compression Test

2. Examiner cups the iliac crest of the painful side and applies a downward
force through the ilium. This position is held for 30 seconds. As with the other
sacroiliac, considerable vigor is required to reproduce the symptoms; in some
cases, repeated force is necessary.
3. (+) test is reproduction of the concordant sign of the patient.

Reliability Sensitivity Specificity +LR -LR

NT 69 69 2.2 0.4

Laslett, et al. Diagnosis of sacroiliac pain: Validity of individual provocation

tests and composites of tests. Man Ther. 2005;10:207-218.

Provocation Test
SI Distraction Test
1. Patient assumes a supine position. Resting symptoms are assessed.
2. The medial aspect of both anterior superior iliac spines are palpated by the
examiner. The examiner crosses his or her arms, creating an X at the forearms,
and a force is applied in a lateral-posterior direction. For comfort, it is often
required that the examiner relocate his or her hand on the anterior superior
iliac spine (ASIS) several times.

FIGURE 12-5 SI Distraction Test

3. Examiner holds the position for 30 seconds, then applies a vigorous force
repeatedly in an attempt to reproduce the concordant sign of the patient.
4. (+) test is reproduction of concordant symptoms.
 Reliability Sensitivity Specificity +LR −LR

NT 60 81 3.2 0.5

Laslett, et al. Diagnosis of sacroiliac pain: Validity of individual provocation tests and composites of
tests. Man Ther. 2005;10:207-218.

Provocation Test
4P Test or Thigh Thrust Test
1. Patient is positioned in a supine position. Resting symptoms are assessed.
2. Examiner stands opposite the painful side of the patient.
3. The hip on the painful side is flexed to 90°.
4. Examiner places his or her hand under the sacrum to form a stable “bridge”
for the sacrum.
5. A downward pressure is applied through the femur to force a posterior
translation of the innominate. The patient's symptoms are assessed to
determine if they are concordant.

FIGURE 12-6 4P Test or Thigh Thrust Test

6. (+) test is concordant pain that is posterior to the hip or near the sacroiliac
joint. A (+) test requires reproduction of pain on the thrust side (the side of the
loaded femur).

Reliability Sensitivity Specificity +LR −LR

NT 88 69 2.8 0.17

Laslett, et al. Diagnosis of sacroiliac pain: Validity of individual provocation tests and composites of
tests. Man Ther. 2005;10:207-218.

Provocation Test
Sacral Thrust Test
1. Patient lies in a prone position. Resting symptoms are assessed.
2. Examiner palpates the second or third spinous process of the sacrum. Using
the pisiform, the examiner places a downward pressure on the sacrum at S3. By
targeting the midpoint of the sacrum, the examiner is less likely to force the
lumbar spine into hyperextension.
3. Vigorously and repeatedly (up to six thrusts), examiner applies a strong
downward force to the sacrum in an attempt to reproduce the concordant sign
of the patient.
4. (+) test is a reproduction of the concordant sign during downward pressure.

FIGURE 12-7 Sacral Thrust Test

 Reliability Sensitivity Specificity +LR −LR

NT 63 75 2.5 0.49

Laslett, et al. Diagnosis of sacroiliac pain: Validity of individual provocation tests and composites of
tests. Man Ther. 2005;10:207-218.

Provocation Test
Gaenslen's Test
1. Patient is positioned in a supine position with the painful leg resting very
near the end of the treatment table. Resting symptoms are assessed.
2. Examiner sagitally raises the nonpainful side of the hip (with the knee bent)
up to 90°. Examiner tests both sides if the patient complains of pain bilaterally.
3. A downward force (up to six bouts) is applied to the lower leg (painful side)
while a flexion-based counterforce is applied to the flexed leg (pushing the leg
in the opposite direction). The effect causes a torque to the pelvis. Concordant
symptoms are assessed.
4. (+) test if the torque reproduces pain of the concordant sign.

FIGURE 12-8 Gaenslen's Test

 Reliability Sensitivity Specificity +LR −LR

Right NT 53 71 1.8 0.66

Left NT 50 77 2.2 0.65

Laslett, et al. Diagnosis of sacroiliac pain: Validity of individual provocation tests and composites of
tests. Man Ther. 2005;10:207-218.

[circled white star] Moderately useful for ruling out SIJ if negative in cluster.
[circled white star] Small but occasionally important shift in probability for
patients having SIJ dysfunction if 3/5 tests (+).

The McKenzie Exam Combined with the Provocation Cluster

[circled white star] In the absence of peripheralisation or centralisation of
symptoms, with at least three positive SIJ tests one can hypothesize that a
probable source could be a symptomatic SIJ.

Test Cluster Sensitivity Specificity

(−) McKenzie Exam + 3/6 provocation test present 91 83

Laslett M, et al. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and
sacroiliac provocation tests. Aust J Physiother. 2003;49:89-97.

Validity: Yes as a Cluster, for Identifying Patients with Low

Back Pain

SIJ Motion Asymmetry Cluster Reliability

Standing flexion, prone knee flexion, supine Long Sitting Test, Sitting PSIS Test 0.11-0.231,2,3
 1
Riddle D, et al. Evaluation of the presence of sacroiliac joint dysfunction using a combination of
tests: A multicenter intertester reliability study. Phys Ther. 2002;82:772-781.

2
Potter N, et al. Intertester reliability for selected clinical tests of the sacroiliac joint. Phys Ther.
1985;65:1671-1675.

3
Flynn T, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate
short-term improvement with spinal manipulation. Spine. 2002;27:2835-2843.

[circled white star] Though the reliability of the motion testing cluster above
(Cibulka, et al.) is quite dismal, when a patient is highly irritable, it is worth
considering as a cluster to help guide your reasoning towards the SIJ as the
source of symptoms or dysfunction.

SIJ Motion Asymmetry Cluster

1. Standing Flexion Test
2. Seated PSIS Test
3. Supine to Long Sit Test
4. Prone Knee Bend Test
5. 3 (+) out of 4 indicates SIJ involvement.

Reliability Sensitivity Specificity +LR −LR

NT 82 88 6.83 0.20

Cibulka MT, Koldehoff R. Clinical usefulness of a cluster of sacroiliac joint tests in patients with and
without low back pain. J Orthop Sports Phys Ther. 1999;29(2):83-92.

SIJ Motion Asymmetry Cluster

Prone Knee Bend Test
1. Patient is in a prone position.
2. Examiner assesses leg length, looking at heels.
3. Knees passively bent to 90°.
4. Leg length is reassessed.
5. (+) if leg length changes between positions.

FIGURE 12-9 Prone Knee Bend Test 1

FIGURE 12-10 Prone Knee Bend Test 2

SIJ Motion Asymmetry Cluster

Sitting PSIS Test
1. Patient is in a seated position.
2. Examiner palpates inferior aspect of each PSIS.
3. (+) if PSIS not level.
 FIGURE 12-11 Sitting PSIS Test

Reliability Sensitivity Specificity +LR −LR

0.63 69 22 0.88 1.4

Levangie PK. The association between static pelvic asymmetry and low back pain. Spine.
1999;24(12):1234-1242.

SIJ Motion Asymmetry Cluster

Standing Flexion Test
1. Patient assumes a standing position.
2. Examiner palpates both PSIS of the patient.
3. Patient is instructed to bend forward toward the midline. Midline movement
ensures equity of movement of the left and right.
4. Examiner palpates both PSIS and evaluates whether the movements are
symmetrical (a normal response) or asymmetrical.
5. (+) test if one PSIS moves early or further than the other.
6. The test is repeated during the palpation of the inferior lateral angle of the
sacrum.

Reliability Sensitivity Specificity +LR −LR

 NT 17 79 0.81 1.05

Levangie PK. Four clinical tests of sacroiliac joint dysfunction: The association of test results with
innominate torsion among patients with and without low back pain. Phys Ther. 1999;79(11):1043-
1057.

FIGURE 12-12 Standing Flexion Test 1

FIGURE 12-13 Standing Flexion Test 2

SIJ Motion Asymmetry Cluster

Supine to Long Sit
1. Patient is supine in hooklying position.
2. Patient is instructed to bridge and return to hooklying. Examiner passively
moves the knees into extension.
3. Examiner assesses lengths of legs by comparing medial malleoli.
4. Patient is then asked to long sit.
5. Medial malleoli are compared again.
6. (+) test if one leg appears shorter in supine and lengthens in long sitting.

Reliability Sensitivity Specificity +LR −LR

NT 44 64 1.37 0.88

FIGURE 12-14 Supine to Long Sit 1

FIGURE 12-15 Supine to Long Sit 2

Sacroiliac Joint Strain

TBC/Special
Prevalence Symptoms Signs
Tests

Mobilization2,4
Stabilization
Exercise2,3,5:
Muscle
length/strength5
Educate
Limited standing Distraction and
flexion4 Tenderness thigh thrust SI
in SI joint and compression
buttock or in the Sacral thrust4,7,9
19.3% to 47.9%, post/sup iliac spine4
Unilateral pain11 Pain referred
depending on the Gaenslen's
to buttocks3,5,7 Pain over SI
population studied1 Pain produced or Extension
15% of joint4,5,7,8 Pain referred to increased on rising
groin, posterior thigh, and less Test2,4,7,9
population2,5,6 from sitting11
often to the leg4,5
Pregnancy10 Posterior pelvic
Absence of midline thigh thrust test9
pain11 Rarely has SLR2
pain at or above the
level of L511 Knee to chest
maneuver4 Leg
length
inequality2,3

Gillete test2,5,7

Patrick test2,5,7

1
Knutson G. Sacroiliac sprain: neuromuscular reactions, diagnosis, and treatment with pelvic
blocking. J Am Chiroprac Assoc. 2004;41(8):38-49.

2
Dreyfuss P, Dreyer S, Cole A, Mayo, K. Sacroiliac joint pain. J Am Acad Orthop Surg.
2004;12(4):255-265.

3
Cohen S. Sacroiliac joint pain: A comprehensive review of anatomy, diagnosis, and treatment.
Anesth Analg. 2005;101:1440-1453.

4
LeBlanc KE. Sacroiliac sprain: An overlooked cause of back pain. Am Fam Physician.
1992;46(5):1459-1463.
5
Hansen H, Helm S. Sacroiliac joint pain and dysfunction. Pain Physician. 2003;6:179-189.

6
Haufe S, Mork A. Sacroiliac joint debridement: A novel technique for the treatment of sacroiliac
joint pain. Photomed Laser Surg. 2005;23(6):596-598.

7
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd ed. Philadelphia, PA: Mosby;
2003.

8
Laslett M, et al. Diagnosis of sacroiliac joint pain: Validity of individual provocation tests and
composites of tests. Man Ther. 2005;10:207-218.

9
Laslett M, et al. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and
sacroiliac provocation tests. Aust J Physiother. 2003;49:89-97.

10
Stuge B, et al. The efficacy of a treatment program focusing on specific stabilizing exercises for
pelvic girdle pain after pregnancy. Spine. 2004;29(4):351-359.

11
Young S, et al. Correlation of clinical examination characteristics with three sources of chronic
low back pain. Spine J. 2003;3:460-465.

Piriformis Syndrome

Prevalence Symptoms DSM/Signs TBC/Special Tests

Hip extension with

knee extension Pain control

Hip adduction with US3,4

medial rotation
TENS4
Hip extension with
> 5% adult Correction of movement
Burning pain and medial rotation
population has impairment Mobilization
hyperesthesia in
sciatic (35% of Piriformis
sacral and/or
patients have muscle/gluteal region is Exercise: Muscle strength and
gluteal region1,2
PS)7 tender1,4, length Piriformis stretch3,4
Buttock and leg Strengthen abductors4
Lifetime Hip abd/lateral rotation
pain2 Transrectal massage3,4 Refer for
prevalence 40%8 are weak1,4 injection5
Hypertrophy of Educate
piriformis2 Acute
exacerbation of pain FAIR (flex, add, IR)10 Leg length
caused by stooping or inequality6 SLR9
lifting4
 1
Magee DJ. Orthopedic Physical Assessment. 4th ed. St. Louis,
MO: Elsevier Sciences; 2006.

2
Filler A, et al. Sciatica of nondisc origin and piriformis
syndrome: Diagnosis by magnetic resonance neurography and
interventional magnetic resonance imaging with outcome study
of resulting treatment. J Neurosurg Spine. 2005;2(2):99-115.

3
Beauchesne R, Schutzer S. Myositis ossificans of the piriformis
muscle: An unusual cause of piriformis syndrome. A case report.
J Bone Joint Surg. 1997;79:906-910.

4
Benson E, Schutzer S. Posttraumatic piriformis syndrome:
Diagnosis and results of operative treatment. J Bone Joint Surg.
1999;81:941-949.

5
Raza H, et al. Treatment of piriformis syndrome with botulinum
toxin-a, using V-sNCT to aid diagnosis. Internet J Anesthesiol.
2003;7:1.

6
Danchik J. Pronation, posture, and piriformis syndrome: Putting
the foot down on sciatica. J Am Chiroprac Assoc. 2001;38(3):18-
20.

7
Heliovaara M, et al. Determinants of sciatica and low back pain.
Spine. 1991;6:608-614.

8
Frymoyer JW. Lumbar disk disease: Epidemiology. Instr Course
Lect. 1992;41:217-223.

9
Saunders HD, Saunders R. Evaluation, Treatment, and
Prevention of Musculoskeletal Disorders. 4th ed. Chaska, MN:
Saunders Group; 2004.

10
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation.
2nd ed. Philadelphia, PA; 2003.

Screening out/Ruling in Piriformis Syndrome

Fair Test
1. Patient is sidelying with the involved extremity up.
2. Patient's involved extremity is brought into a position of flexion, adduction,
and internal rotation.
3. (+) test if pain is elicited at the intersection of the sciatic nerve and the
piriformis.

Sensitivity Specificity +LR −LR

88 83 5.2 0.14

Fishman L, et al. Piriformis syndrome: Diagnosis, treatment, and outcome: A 10-year study. Arch
Phys Med Rehabil. 2002;83:296-301.

Fishman L, et al. Electrophysiologic evidence of piriformis syndrome. Arch Phys Med Rehabil.
1992;73:359-364.

FIGURE 12-16 Fair Test

Sacroiliac Joint/Pubic Symphisis Hypermobility

Prevalence Symptoms Signs TBC/Special Tests

Pain control Stabilize

Exercise7: Muscle
 length and strength
1,2,3,4,5,11 Adductors/glut medius
Pregnant Women Pelvic
10
girdle syndrome—6% Symphysiolysis— LBP, pelvic pain2 Latissimus/glut max
2.3%10 One-sided SI pain—5.5%10 Internal/external
Abnormalities
Double-sided SI pain—6.3%10 Groin pain3 oblique ASLR1
on CT3
Miscellaneous category—1.6%10 Pain in medial Distraction and thigh
3 (+) SIJ
buttock, inferior thrust5,6 SI
About 50% of pregnant females or provocation
to PSIS, greater compression Sacral
females that have just conceived7,8,9 trochanter, and tests3
thrust6
Trauma, muscular atrophy, LMN upper thigh3
diseases, multiparity3 Patrick's Test and
Gaenslen's Test3

Posterior Pain
Provocation Tests5

1
Mens JM, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ. The active straight leg raising test and
mobility of the pelvic joints. Eur Spine J. 1999;8(6):468-474.

2
Mens JM, Snijders CJ, Stam HJ. Diagonal trunk muscle exercises in peripartum pelvic pain: A
randomized clinical trial. Phys Ther. 2000;80(12):1164-1173.

3
Cohen SP. Sacroiliac joint pain: A comprehensive review of anatomy, diagnosis, and treatment.
Anesth Analg. 2005;101:1440-1453.4 Depledge J, McNair PJ, Keal-Smith K, Williams M. Management
of symphysis pubis dysfunction during pregnancy using exercise and pelvic support belts. Phys Ther.
2005;85(12):1290.

5
Keer R, Grahame R. Hypermobility Syndrome: Recognition and Management for Physiotherapists.
Burlington, MA: Elsevier Butterworth-Heinemann. 2003;94.

6
Laslett M, et al. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and
sacroiliac provocation tests. Aust J Physiother. 2003;49:89-97.

7
Stuge B, et al. The efficacy of a treatment program focusing on specific stabilizing exercises for
pelvic girdle pain after pregnancy: A randomized controlled trial. Spine. 2004;29(4):351-359.

8
Rost CC, et al. Pelvic Pain during pregnancy: A descriptive study of signs and symptoms of 870
patients in primary care. Spine. 2004;29(22):2567-2572.

9
Sturesson B, et al. Pain pattern in pregnancy and “catching” of the leg in pregnant women with
posterior pelvic pain. Spine. 1997;22(16):1880-1883.

10
Berg G, et al. Low back pain during pregnancy. Obstet Gynecol. 1998;1:71-75.

11
Albert HB, et al. Incidence of four syndromes of pregnancy-related pelvic joint pain. Spine.
2002;27(24):2831-2834.
Assessing Pelvic Mobility and Symmetry
Standing ASIS
1. Patient is placed in a standing position.
2. Using the iliac crests as a guide, examiner measures the symmetry of the
iliac crests, then the ASIS.
3. (+) test is characterized by asymmetry.

Reliability Sensitivity Specificity +LR −LR

NT 74 21 0.94 1.24

Levangie PK. The association between static pelvic asymmetry and low back pain. Spine.
1999;24(12):1234-1242.

FIGURE 12-17 Standing ASIS

Standing PSIS Symmetry
1. Patient is placed in a standing position.
2. Using the iliac crests as a guide, examiner measures the symmetry of the
iliac crests, then the PSIS.
3. (+) test is characterized by asymmetry.

Reliability Sensitivity Specificity +LR −LR

0.70 70 29 1.11 0.72

Levangie PK. Four clinical tests of sacroiliac joint dysfunction: The association of test results with
innominate torsion among patients with and without low back pain. Phys Ther. 1999;79(11):1043-
1057.

FIGURE 12-18 Standing PSIS Symmetry

Screening out/Ruling in Pelvic Instability

 Active Straight Leg Raise
1. Patient is placed in a supine position. Resting symptoms are assessed.
2. Patient is asked to raise the affected leg approximately 6 inches. Pain is
queried.
3. If the previous request was painful, examiner stabilizes the pelvis by
compressing the ASIS medially or by placing a sacroiliac belt around the pelvis.
4. Patient is again asked to raise the affected leg approximately 6 inches.
5. (+) test if the movement is no longer painful.

Reliability Sensitivity Specificity +LR −LR

0.82 ICC 87 94 14.5 0.13

Mens JM, et al. Validity of the active straight leg raise test for measuring disease severity in patients
with posterior pelvic pain after pregnancy. Spine. 2002;27(2):196-200.

FIGURE 12-19 Active Straight Leg Raise 1

 FIGURE 12-20 Active Straight Leg Raise 2

Pubic Symphysis Palpation

1. Patient is placed in a supine position.
2. Examiner palpates the pubic symphysis near the midline.
3. An alternative involves a pubic shear force to the superior and inferior pubis
bones.
4. (+) test is identified by reproduction of the patient's concordant pain.

Reliability Sensitivity Specificity +LR −LR

0.89 81 99 4.68 0.19

Albert H, et al. Evaluation of clinical tests used in classification procedures in pregnancy-related

pelvic joint pain. Eur Spine J. 2000;9(2):161-166.
 FIGURE 12-21 Pubic Symphysis Palpation

Posterior Pelvic Palpation

1. Patient is placed in a sitting or prone position.
2. Examiner carefully palpates the sacrum and bilateral sacroiliac joints.
3. (+) test is associated with local tenderness with moderately deep palpation.

Reliability Sensitivity Specificity +LR −LR

NT 98 94 16.3 0.02

McCormick JP, et al. Clinical effectiveness of the physical examination in diagnosis of

posterior pelvic ring injuries. J Orthop Trauma. 2003;17(4):257-261.
 FIGURE 12-22 Fortin

FIGURE 12-23 Posterior Pelvic Palpation

Resisted Hip Abduction for Total Knee or Total Hip

Replacement Patients
1. Patient is placed in a supine position.
2. Patient's leg is fully extended.
3. Patient's leg is abducted to 30°.
4. Therapist resists abduction.
5. (+) test is reproduction of pain.
 Reliability Sensitivity Specificity +LR −LR

NT 87 100 NA 0.13

Broadhurst NA, et al. Pain provocation tests for the assessment of sacroiliac joint dysfunction. J
Spinal Disord. 1998;11(4):341-345.

FIGURE 12-24 Resisted Hip Abduction

Sign of the Buttock

1. Patient lies in a supine position.
2. Examiner passively performs a straight leg raise to the point of pain or
restriction.
3. Examiner flexes the knee while holding the thigh in the same angle at the
hip.
4. Examiner then applies further flexion to the hip.
5. (+) test if hip flexion is still restricted or results in the same pain as with the
SLR.

Reliability Sensitivity Specificity +LR −LR

 NT NT NT NA NA

Greenwood MJ, et al. Differential diagnosis of the hip vs. lumbar spine: Five case reports. J Orthop
Sports Phys Ther. 1998;27(4):308-315.

[circled white star] A (+) finding is a red flag and requires immediate referral
to the primary care physician.

CPR for patients who do not respond well to manipulation

Longer symptom duration

Presence of symptoms distal to the low back (buttock or leg symptoms)
Lack of hypomobility in the lumbar spine
Little discrepancy in hip MR ROM side-to-side

Fritz JM, WHitman JM, Flynn TW, et al. Factors related to the inability of
individuals with low back pain to improve with a spinal manipulation. Phys
Ther. 2004;84:173-190.

FIGURE 12-25 Sign of the Buttock 1

 FIGURE 12-26 Sign of the Buttock 2

CPR for Spinal Manipulation (Validated)

1 2 3 4 5

Symptoms FABQW < 19 (Fear At least At least 1 hypomobile No symptoms

duration < 16 avoidance back 1 hip > segment in L/S on distal to the
days questionaire work) 35° palpation knee

Number of Variables Present Sensitivity Specificity +LR

3+ 94 64 2.61

4+ 63 97 24.38

Flynn T, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate
short-term improvement with spinal manipulation. Spine. 2002;27:2835-43.

Childs JD, et al. A clinical prediction rule to identify patients with low back pain most likely to
benefit from spinal manipulation: A validation study. Ann Intern Med. 2004;141:920-928.

[circled white star] Any 3 or more variables below, use the technique below for
SIJ or LBP especially acute patients as long as I do not suspect the patient
would respond better to repeated movements or be aggravated by rotational
forces.
[circled white star] 4 variables present, 24.38 +LR that patient will respond well
to this technique.

Sacroiliac Directed Graded Passive Movement V (GPM V)

1. Patient is in a supine position.
2. Passively sidebend patient toward the side to be manipulated (away from the
therapist).
3. Rotate the patient away from the side to be manipulated (toward the
therapist).
4. Deliver a quick thrust through the anterior superior iliac spine in a posterior
inferior direction.
5. If there is no audible cavitation, thrust the same side again.
6. If there is again no audible cavitation, set up and thrust the contralateral
side up to two times.

FIGURE 12-27 Sacroiliac Directed Graded Passsive Movement V (GPM V) 1

 FIGURE 12-28 Sacroiliac Directed Graded Passsive Movement V (GPM V) 2

FIGURE 12-29 Sacroiliac Directed Graded Passsive Movement V (GPM V) 3

Muscles That May Contribute to Force Closure Stability of SI

Joint
Lumbodorsal fascia and contralateral gluteus maximus
Erector spinae and multifidi
External oblique and contralateral internal oblique
Abdominals
Gluteus medius and minimus, TFL, and adductors
U272A; Consider weakness or muscle imbalance during your evaluation of these
muscles.
Stuge B. The efficacy of a treatment program focusing on specific stabilizing
exercises for pelvic girdle pain after pregnancy: A randomized controlled trial.
Spine. 2004;29(4):351-359.
Chapter 13
The Hip

Hip Resting Position Closed Pack Capsular Pattern

Acetabular femoral 30° Flex, 30° Abd, slight ER Full ext, IR, abduction Flex, Abd, IR

Lower Extremity Angles Normal Values

Q-angle Male—13°, Female—18°

Tibial Torsion 12°-18°

Anteversion 8°-15°

Coxa Vara < 120°

Coxa Valga > 135°

FIGURE 13-1 The Ligamentous Support of the Hip. Anterior View Showing Main
Ligaments; Coronal Section Showing Articular Cavity and Capsule.
Source: Reprinted with permission from J.E. Crouch, Functional Human Anatomy, 4th
Ed., p. 164, © 1985, Lea & Febiger

FIGURE 13-2 (A) Quadriceps Mucles (Anterior View); (B) Hamstrings and Gluteal
Muscles (Posterior View)
Souza, TA. Differential Diagnosis and Mangagement for the Chiropractor: Protocols and
Algorithms. © 2009 Jones & Bartlett Publishers, LLC
 FIGURE 13-3 Torsion Angles of the Hip. (A) Positions of the Femoral Neck. (B) Different
Foot Positions with Anteversion and Retroversion at the Hip (Coronal Views)
Adapted from: Physical Therapy of the Hip, J. Echternach, ed. p. 25, © 1990.

Post-OP Pearls—Hip

No flexion beyond 90°/Add/IR past neutral

Total Hip Replacement
Weight bearing as tolerated

Outcome Tools

LEFS—Lower Extremity Functional Scale

Harris Hip Score

WOMAC—Western Ontario and McMaster Universities Index of Osteoarthritis

GROC—Global Rating of Change Scale

PSFS—Patient-Specific Functional Scale

Movement Impairments of the Hip: DSM (Directional

Susceptibility to Movement)

Femoral: Accessory Motion Impairments

Anterior Glide

with medial rotation

with lateral rotation

Posterior Glide

with medial rotation

Accessory Hypermobility

Hypomobility with Superior Glide

Hip: Physiological Motion Impairments

Hip Adduction Syndrome

Hip Adduction Syndrome with Medial Rotation

Hip Extension with Knee Extension

Hip Extension with Medial Rotation Syndrome

Hip Lateral Rotation Syndrome

Key Tests for Movement Impairments of the Hip

Standing Single Leg Stance

Sitting Knee Extension with DF

Hip Flexion (iliopsoas) muscle performance test

Hip Rotation (muscle performance and ROM)

Supine Hip PROM Test

Hip Flexor Length Test

SLR (passive and active) Test

Hip and Knee Flexion Test

Sidelying Position

Hip Abduction/LR/Ext (Posterior Gluteus Medius) muscle performance

Prone Active/Passive Hip Rotation

Hip Extension with Knee Extended

Hip Extension with Knee Flexed (Gluteus Maximus) muscle performance

Quadruped Rocking backward

 FIGURE 13-4 Treatment-Based Categories for the Hip Region

[circled white star] Hip vs Spine Differential Diagnosis

Patient Presentation Hip vs Spine

Limp 7x more likely to have hip OR hip + spine problem vs spine

Groin pain 7x more likely to have hip OR hip + spine problem vs spine

Limited hip internal 14x more likely to have hip disorder only OR combined hip + spine problem
rotation vs spine only

Brown MD, Gomez-Marin O, Brookfield KF, Li PS. Differential diagnosis of hip disease versus spine
disease. Clin Orthop Rel Res. Feb 2008;419:280-284.
Hip Treatment-Based Classification References
Pain Control
Gerber JM, Herrin SO. Conservative treatment of calcific trochanteric bursitis.
J Manipulative Physiol Ther. 1994;17(4):250-252.

Stabilize
Kilbreath SL, Perkins S, Crosbie J, McConnell J. Gluteal taping improves hip
extension during stance phase of walking following stroke. Aust J Physiother.
2006;52(1):53-56.

Mobilize
Crow JB, et al. Use of joint mobilization in a patient with severely restricted
hip motion following bilateral hip resurfacing arthroplasty. Phys Ther.
2008;88(12):1591-1600.
Hoeksma HL, et al. Comparison of manual therapy and exercise therapy in
osteoarthritis of the hip: A randomized clinical trial. Arthritis Rheum.
2004;51(5):722ñ729.
MacDonald CW, et al. Clinical outcomes following manual physical therapy and
exercise for hip osteoarthritis: A case series. J Orthop Sports Phys Ther.
2006;36(8):588ñ599.
Levitsky B. Manual therapy intervention for a patient with a total hip
arthroplasty revision. J Orthop Sports Phys Ther. 2007;37(12):763-768.

Exercise
Van Baar M, et al. The effectiveness of exercise therapy in patients with
osteoarthritis of the hip or knee: A randomized clinical trial. J Rheum.
1998;25(12):2432-2439.
Stanton P, et al. Hamstring injuries in sprinting: The role of eccentric exercise.
J Orthop Sports Phys Ther. 1989;10(9):343-349.
Hoeksma HL, et al. Comparison of manual therapy and exercise therapy in
osteoarthritis of the hip: A randomized clinical trial. Arthritis Rheum.
2004;51(5):722-729.
MacDonald CW, et al. Clinical outcomes following manual physical therapy and
exercise for hip osteoarthritis: A case series. J Orthop Sports Phys Ther.
2006;36(8):588ñ599.
Godges JJ, et al. The effects of two stretching procedures on hip range of
motion and gait economy. J Orthop Sports Phys Ther. 1989;10(9):350-357.
Mascal CL, Landel R, Powers C. Management of patellofemoral pain targeting
hip, pelvis, and trunk muscle function: 2 case reports. J Orthop Sports Phys
Ther. 2003;33:647-660.
Minor MA, Hewett JE, Webel RR, Anderson SK, Kay OR. Efficiency of physical
conditioning exercises in patients with rheumatoid arthritis and osteoarthritis.
Arthritis Rheum. 1989;32:1369-1405.
Johnston CAM, et al. Treatment of iliopsoas syndrome with a hip rotation
strengthening program: A retrospective case series. J Orthop Sports Phys Ther.
1999;29(4):218-224.
Rana S, et al. Aquatic physical therapy for hip and knee osteoarthritis: Results
of a single-blind randomized controlled trial. Phys Ther. 2007;87:32-43.

Correction of Movement Impairment

Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N,
Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band
syndrome. Clin J Sport Med. 2000;10:169-175.
Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip strength in females with
and without patellofemoral pain. J Orthop Sports Phys Ther. 2003;33:671-676.
Lewis CL. Acetabular Labral Tears. Phys Ther. 2006;86:110-121.

Occult Hip Fracture

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

200,000 hip fractures per year in

United States5,6,7 Case-fatality rate 1
year after fracture as high as 50%5,6,7

2-9% delayed diagnosis of hip Decreased

fracture1,2,3,4 weight
Deep, aching pain in the bearing12 Refer out
Risk for fracture doubles every 5 years hip or groin region,11
after 50 years old radiating into the knee11 Antalgic gait Patellar-
Pubic
Caucasian females 1.5-4 times more
Worse with activity11 Decreased
likely than African-American females Better with rest11 Night step length12 Percussion
after age 40 pain is not uncommon11 Test
Trendelenburg
Caucasian females 2 times more likely Gait12
than Caucasian males after age 50

5% of all stress fractures involve the

femoral neck, with another 5%
involving the femoral head8,9,10

1
Pandy R, McNally E, Ali A, Bulstrode C. The role of MRI in the diagnosis of occult hip fractures.
Injury. 1998;29(1):61-63.

2
Pool FJ, Crabbe JP. Occult femoral neck fracture in the elderly: Optimisation of investigation. N Z
Med J. 1996;109(1024):235-237.

3
Guanche CA, Kozin SH, Levy AS, Brody LA. The use of MRI in the diagnosis of occult hip fractures in
the elderly: A preliminary review. Orthopaedics. 1994;17(4):327-330.

4
Mohan Tiru M, et al. Use of percussion as a screening tool in the diagnosis of occult hip fractures.
Singapore Med J. 2002;43(9):467-469.

5
Evans JG, Prudham D, Wandless I: a prospective study of fractured proximal femur: Factors
predisposing to survival. Age Ageing. 1979;8:246-250.

6
Beals RK. Survival following hip fracture: Long follow-up of 607 patients. J Chronic Dis.
1972;25:235-244.

7
Jensen JS, Tondevold E. Mortality after hip fractures. Acta Orthop Scand. 1979;50:161-167.

8
Clough TM. Femoral neck stress fracture: The importance of clinical suspicion and early review. Br
J Sports Med. 2002;36:308-309.

9
Soubrier M, Dubost JJ, Boisgard S, et al. Insufficiency Fracture: A survey of 60 cases and review of
the literature. Joint Bone Spine. 2003;70:209-218.

10
Weistroffer JK, Muldoon MP, Duncan DD, Fletcher EH, Padgett DE. Femoral neck stress fractures:
Outcome analysis at minimum five-year follow-up. J Orthop Trauma. 2003;17:334-337.

11
Egol KA, Koval KJ, Kummer F, Frankel VH. Stress fractures of the femoral neck. Clin Orthop Relat
Res. 1998;(348):72-78.

12
Gurney B, et al. Differential diagnosis of a femoral neck/head stress fracture J Orthop Sports Phys
Ther. 2006;36:80-88.

Screening out/Ruling in Occult Fracture of the Hip or Femur

 Patellar-Pubic Percussion Test
1. Patient is in a supine position.
2. Examiner places a stethoscope over the pubic symphisis of the patient.
3. Examiner taps the patella of the patient's affected side and qualitatively
reports the sound.
4. Examiner repeats the process on the opposite side to determine a difference
in auscultation.
5. (+) test is a diminished percussion note on the side of pain; (-) test is no
difference in percussion note. A tuning fork can be used in place of tapping.

Reliability Sensitivity Specificity +LR −LR

89.2% agreement 94 95 20.4 0.06

Adams, et al. Clinical use of the patellar-pubic percussion sign in hip trauma. Am J Emerg Med.
1997;15:173-175.

FIGURE 13-5 Patellar-Pubic Percussion Test

Hip Osteoarthritis
Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control
0.4% to 27%6 Mobilization9,10
Correction of
Femoral hypomobility with movement impairment
Increased age9 superior glide
Morning stiffness Exercise5,8
Women > men9 ≤ 60 minutes7
(+)LR 1.54 Decreased flexibility7
Flexion-adduction test3
Obese4 Reduced muscle strength7
Pain in the Range of motion
Previous hip lateral thigh,
groin, radiates Decreased walking distance7
injury/joint Long Sitting Test3
damage2,9 to the knee
(+)LR 1.02, 0.72, Loss of function3 Evaluate lumbar
Hip operation3 0.76 extensors and hip
Tear-drop sign4
adductors3
Developmental Pain with
Hip flexion ≤ 115°
disorders (genu prolonged Walk tests7
varum/valgum)3 ambulation (+)LR IR < 15°
1.10 Reports of Timed “up and go”
Physically reduced LE Hip pain test7
demanding function (+)LR
physical 1.19 +LR 3.40, -LR0.19 for cluster above. 6 min. walk test7
activity or If all (+), small but sometimes
occupation Family history of important shift in probability that Restricted motion in 2
(agricultural OA (+)LR 2.94 hip OA present; if all 3 absent, or more planes—small
moderate probability OA absent1 but sometimes
work)3
significant shift in
probability that hip
OA present

1
Altman R, et al. The American College of Rheumatology criteria for the classification and reporting
of the osteoarthritis of the hip. Arthritis Rheum. 1991;34:505-514.

2
Birrell F, Croft P, Cooper C, Hosie G, Macfarlane G, Silman A. Predicting radiographic hip
osteoarthritis from range of movement. Rheum. 2001;40:506-512.

3
Cleland, J. Orthopaedic Clinical Examination: An Evidence-Based Approach for Physical
Therapists. Carlstadt, NJ: Learning Systems. 2005; 261.

4
Cooper C, Inskip H, Croft P, Campbell L, Smith G, McLaren M, Coggon D. Individual risk factors for
hip osteoarthritis: Obesity, hip injury, and physical activity. Am J Epidemiol. 1998;147(6):516-522.

5
Heuts P, de Bie R, Drietelaar M, Aretz K, Hopman-Rock M, Bastiaenen C, Metsemakers J, van Weel
C, van Schayck O. Self-management in osteoarthritis of hip or knee: A Randomized clinical trial in
primary healthcare setting. J Rheum. 2005;32(3):543-549.

6
Ciblha MT, et al. Hip pain and mobility deficits—hip osteoarthritis. J Orthop Sports Phys Ther.
 2009;39(4):A1-A25.

7
Stratford P, Kennedy D, Woodhouse L. Performance measures provide assessments of pain and
function in people with advanced osteoarthritis of the hip or knee. Phys Ther. 2006;86(11):1489-
1500.

8
Van Baar M, Dekker J, Oostendorp R, Bijl D, Voorn T, Lemmens J, Bijlsma J. The effectiveness of
exercise therapy in patients with osteoarthritis of the hip or knee: a randomized clinical trial. J
Rheum. 1998;25(12):2432-2439.

9
Hoeksma HL, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip:
a randomized clinical trial. Arthritis Rheum. 2004;51(5):722ñ729.

10
MacDonald CW, et al. Clinical outcomes following manual physical therapy and exercise for hip
osteoarthritis: A case series. J Orthop Sports Phys Ther. 2006;36(8):588ñ599.

Ruling in Hip Osteoarthritis

CPR for Hip OA
1. Self-reported squatting as an aggravating factor
2. Scour Test with adduction causing groin or lateral pain
3. Active hip flexion causing lateral pain
4. Active hip extension causing hip pain
5. Passive hip internal rotation less than or equal to 25 degrees

Number of Predictors Present Reliability Sensitivity Specificity +LR −LR

5 NT 14 98 7.3 0.87

≥4 NT 48 98 24.3 0.53

≥3 NT 71 86 5.2 0.33

≥2 NT 81 61 2.1 0.31
 ≥1 NT 95 18 1.2 0.27

[circled white star] If at least 4 of 5 variables were present, the positive LR was
equal to 24.3 (95% confidence interval: 4.4-142.1), increasing the probability of
hip OA to 91%.
Sutlive TG, et al. Development of a clinical prediction rule for diagnosing hip
osteoarthritis in inviduals with unilateral hip pain. J Orthop Sports Phys Ther.
2008;38(9):542-550.

Ruling in Hip Osteoarthritis

Assessment of Restricted Planes of Motion: Sagittal, Frontal,
and Transverse Planes

Reliability Sensitivity Specificity +LR −LR

0 planes restricted NT 100 0 NA NA

1 plane restricted NT 100 42 NA NA

2 planes restricted NT 81 69 2.61 0.28

3 planes restricted NT 54 88 4.5 0.52

Birrell F, et al. Predicting radiographic hip osteoarthritis from range of movement. Rheum.
2001;40:506-512.
FIGURE 13-6 Hip Flexion Overpressure

FIGURE 13-7 Hip Internal Rotation Overpressure

FIGURE 13-8 Hip External Rotation Overpressure

 FIGURE 13-9 Hip Abduction Overpressure

FIGURE 13-10 Hip Posterior-Anterior (PA) Pressure

Screening Out/Ruling In Hip Osteoarthritis

Use of an index involving the following:
1. Hip pain
2. IR < 15 degrees
3. Pain with Internal Rotation (IR)
4. Morning stiffness up to 60 minutes
5. Age > 50 years

Reliability Sensitivity Specificity +LR −LR

 NT 86 75 3.4 0.19

Altman R, Alarcon G, Applerouth D, et al. The American College of Rheumatology criteria for the
classification and reporting of the osteoarthritis of the hip. Arthritis Rheum. 1991;34:505-514.

Detecting Hip Joint Mobility Impairments

Flexion Abduction External Rotation (FABER) Test (Patrick
Test)
1. Patient is in a supine position.
2. Resting symptoms are assessed.
3. The painful side leg is placed in a “figure four” position. The ankle is placed
just above the knee of the other leg.
4. Examiner provides a gently downward pressure on both the knee of the
painful side and the ASIS of the non-painful side. Concordant pain is assessed,
specifically the location and type of pain.
5. (+) test is concordant pain near the anterior or lateral capsule of the hip

Reliability Sensitivity Specificity +LR −LR

NT 88 NT NA NA

Mitchell B, et al. Hip joint pathology: clinical presentation and correlation between magnetic
resonance arthrography, ultrasound, and arthroscopic findings. Clin J Sports Med. 2003;13:152-156.
 FIGURE 13-11 Flexion Abduction External Rotation (FABER) Test (Patrick Test)

Anterior Glide
1. Patient is in a prone position.
2. Examiner fully extends hip.
3. Examiner applies anterior force over head of femur.
4. Judged as:

Hypomobile
Normal
Hypermobile

Technique Reliability

Anterior mobility κ = 0.45

Anterior mobility with pain provocation κ = 0.85

 Browder D, Enseki K, Fritz J. Intertester reliability of hip range of motion measurements and special
tests. J Orthop Sports Phys Ther. 2004;34:A1.

FIGURE 13-12 Anterior Glide

Posterior Glide
1. Patient is in a supine position.
2. Examiner passively flexes hip to 90°, IR, and adduction.
3. Examiner applies posterior directed force through femur.
4. Judged as:

Hypomobile
Normal
Hypermobile

Technique Reliability

Posterior mobility κ = 0.37

Posterior mobility with pain κ = 0.65

Browder D, Enseki K, Fritz J. Intertester reliability of hip range of motion measurements and special
tests. J Orthop Sports Phys Ther. 2004;34:A1.

FIGURE 13-13 Posterior Glide

Hip PROM Measurement with Goniometer in Pathological Hips

Hip ROM
Reliability
Measurements

Intrarater
Moderate to generally good: 0.50-0.94 in patients with and without hip OA1,2,3
reliability

Interrater Poor-moderate in involved hip: unilateral hip pain and suspected intraarticular
reliability pathology4

Interrater
Uninvolved hip moderate to good: 0.61-0.79
reliability
 [circled white star] In hips with pathology, your measurements may be less reliable
between raters but tend to be fairly reliable within the rater him/herself; in
asymptomatic hips, inter- and intrarater reliability tends to be quite good.

1
Holm I, et al. Reliability of goniometric measurements and visual estimates of hip ROM in patients
with osteoarthritis. Physiother Res Int. 2000;5:241-248.

2
Klassabo M, et al. Examination of passive ROM and capsular patterns in the hip. Physiother Res Int.
2000;5:241-248.

3
Lin Y-C, et al. Tests for physical function of the elderly with knee and hip osteoarthritis. Scand J
Med Sci Sports. 2001;11:280-286.

4
Browder D, Enseki K, Fritz J. Intertester reliability of hip range of motion measurements and
special tests. J Orthop Sports Phys Ther. 2004;34:A1.

Predictors of Patients Who May Benefit from Total Hip

Replacement

Resting pain2 Night pain2

Symptoms Worsening global rating
of change2

Decrease in exercise
Coping response
tolerance2

Atrophic bone response2

Radiographic markers Kellgren Grade
changes2,3

2
Ledingham J, Dawson S, Preston B, Milligan G, Doherty M. Radiographic
progression of hospital-referred osteoarthritis of the hip. Ann Rheum
Dis. 1993;52(4):263-267.

3
Dougados M, et al. Requirement for total hip arthroplasty: An outcome
measure of hip osteoarthritis? J Rheumatol. 1999;26(4):855-861.

Predictors of Total Hip Replacement Complications

Age (older is worse)1

SF-36 BP (lower scores are worse)1

Low back pain1

Type I or Type II uncontrolled diabetes4

1
Nilsdotter A, Petersson IF, Roos EM, Lohmander LS. Predictors of patient relevant outcome after
total hip replacement for osteoarthritis: A prospective study. Ann Rheum Dis. 2003;62(10):923-930.

4
Bolognesi MP, Marchant MH, Viens NA, Cook C, Pietrobon R, Vail TP. The impact of diabetes on
perioperative patient outcomes after total hip and total knee arthroplasty in the United States. J
Arthroplasty. 2008;23(6 Suppl 1):92-98.

Muscle Length Description

Patient supine

Palpate PSIS

Short hip extensors Flex hip

PSIS moves posteriorly

Take measurement of hip flexion

Patient supine

Lower limbs over plinth

Short hip flexors Both hips flexed

Examiner lowers side being tested

When limb stops moving, measurement taken

Patient prone
 Examiner flexes knee to 90°

External rotators Palpate contralateral PSIS

Passively internal rotate limb

When pelvic rotation occurs, measurement taken

Internal rotators Same as above except for passive external rotation of limb

Assessing Hip Muscles Lengths

Bullock-Saxton and Bullock

Muscle Length Measurements Intra-Examiner Reliability ICC

Short hip extensors (supine hip flexion) 0.87

Short hip flexors (thomas test position) 0.98

External rotators of the hip (prone knee flexed to 90 degrees) 0.99

Internal rotators of the hip (prone knee flexed to 90 degrees) 0.98

Bullock-Saxton J, Bullock M. Repeatability of muscle length measures around the hip. Physiother
Can. 1994;46:105-109.

Hip Labral Tears

Prevalence Symptoms DSM/Signs TBC/Special Tests

> 20% of athletes Femoral

presenting with groin anterior glide
pain11
Athletic activities8 Femoral
involving repetitive anterior glide Mobilization Correction of
pivoting movements or with lateral movement impairment
“Clicking” in the hip11
repetitive hip flexion14 rotation Exercise Education
Sensitivity 1.011
Young adult-middle Specificity 0.8511 (+) LR Femoral Hip ROM
aged patients2,3,10 6.67 (−) LR 0 accessory
hypermobility Hip MMT
14
55% of general Insidious onset
population with Moderate-severe pain14 May have a mild Assess gait for
Groin pain limp14 Trendelenburg Gait
chronic hip pain9
predominating14 Assess for gluteus medius
Trendelenburg
Usually associated Activity-related pain14 weakness
with: Gait14
May complain of sharp or Internal rotation-flexion-
1. Acute hip dull pain14 (+) Impingement
sign14 axial compression
dislocation
maneuver11 Sensitivity 0.75
May have night pain14 Specificity 0.43
2. Dysplastic (+) Internal
hips4,6,12,15 May have seen multiple rotation-
flexion-axial Impingement sign Hip
health care providers
3. Perthes Disease compression flexion to 90°, adduction
previously without
and internal rotation (+)
success14 maneuver11
4. Osteoarthritis Reproduction of groin
Active vs pain14
5. Slipped capital passive SLR
epiphysis5,7 Observe for
excess anterior
6. Hip trauma1,13 femoral glide

1
Dameron TB Jr. Bucket-handle tear of acetabular labrum accompanying posterior dislocation of the
hip. J Bone Joint Surg Am. 1959;41:131-134.

2
Fitzgerald RH Jr. Acetabular labrum tears: Diagnosis and treatment. Clin Orthop Relat Res.
1995;311:60-68.

3
Farjo LA, Glick JM, Sampson TG. Hip arthroscopy for acetabular labral tears. Arthroscopy.
1999;15:132-137.

4
Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: A
cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;417:112-120.

5
Goodman DA, Feighan JE, Smith AD, Latimer B, Buly RL, Cooperman DR. Subclinical slipped capital
femoral epiphysis: Relationship to osteoarthrosis of the hip. J Bone Joint Surg Am. 1997;79:1489-
1497. Erratum in: J Bone Joint Surg Am. 1999;81:592.

6
Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-
effect: An MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint
Surg Br. 2001;83:171-176.
 7
Leunig M, et al. Slipped capital femoral epiphysis: Early mechanical damage to the acetabular
cartilage by a prominent femoral metaphysis. Acta Orthop Scand. 2000;71:370-375.

8
Mason JB. Acetabular labral tears in the athlete. Clin Sports Med. 2001;20:779-790.

9
McCarthy JC, Busconi B. The role of hip arthroscopy in the diagnosis and treatment of hip disease.
Can J Surg. 1995; 38:S13-S17.

10
McCarthy J, Noble P, Aluisio FV, Schuck M, Wright J, Lee JA. Anatomy, pathologic features, and
treatment of acetabular labral tears. Clin Orthop Relat Res. 2003;406:38-47.

11
Narvani AA, et al. Prevalence of acetabular labrum tears in sports patients with groin pain. Knee
Surg Sports Traumatol Arthrosc. 2003;11(6):403-408.

12
Notzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral
head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br.
2002;84:556-560.

13
Paterson I. The torn acetabular labrum: A block to reduction of a dislocated hip. J Bone Joint
Surg Br. 1957;39:306-309.

14
Burnett RS, Della Rocca GJ, Prather H, Curry M, Maloney WJ, Clohisy JC. Clinical presentation of
patients with tears of the acetabular labrum. J. Bone Joint Surg. Am. 2006;88:1448-1457.

15
Siebenrock KA, Wahab KH, Werlen S, Kalhor M, Leunig M, Ganz R. Abnormal extension of the
femoral head epiphysis as a cause of cam impingement. Clin Orthop Relat Res. 2004;418:54-60.

Screening out Hip Labrum Tears or Degeneration

Patient History—Clicking or Locking
1. Patient is asked regarding pain during sitting.
2. Patient is queried regarding clicking or popping during gait, squatting, or
other activities.
3. (+) test if a click is present during active or passive motion of the hip.

Reliability Sensitivity Specificity +LR −LR

NT 100 85 6.67 0

Narvani AA, et al. Prevalence of acetabular labrum tears in sports patients with groin pain. Knee
 Surg Sports Traumatol Arthrosc. 2003;11(6):403-408.

Internal Rotation-Flexion-Axial Compression Maneuver

1. Patient is in a supine position.
2. Therapist flexes and internally rotates the hip.
3. Apply axial compression through the femur.
4. (+) test provocation of pain.

FIGURE 13-14 Internal Rotation-Flexion-Axial Compression Maneuver

Reliability Sensitivity Specificity +LR −LR

NT 75 43 1.32 0.58

Narvani A, Tsirdis E, Kendall S, Chaudhuri R, Thomas P. A preliminary report on prevalence of

acetabular labral tears in sports patients with groin pain. Knee Surg Sports Traumatol Arthrosc.
2003;11(6):403-408.

Hip Scour
1. Patient is in a supine position.
2. Examiner flexes the patient's knee and provides an axial load through the
femur.
3. Examiner performs a sweeping compression and rotation movement from
external rotation to internal rotation.
4. (+) test is pain or apprehension at a given point during the exam.

Reliability Sensitivity Specificity +LR −LR

Narvani, et al. NT 75 43 1.32 0.58

Leuning, et al. NT 91 NT NA NA

Narvani A, Tsirdis E, Kendall S, Chaudhuri R, Thomas P. A preliminary report on prevalence of

acetabular labral tears in sports patients with groin pain. Knee Surg Sports Traumatol Arthrosc.
2003;11(6):403-408.

Leuning M, Werlen S, Ungersbock A, Ito K, Ganz R. Evaluation of the acetabular labrum by MR

arthrography. J Bone Joint Surg Br. 1997;79(2):230-234.

FIGURE 13-15 Hip Scour

Flexion-Adduction-Internal Rotation Test (Click test)

1. Patient is in a sidelying position.
2. Examiner stabilizes pelvis.
3. Examiner passively moves patient's hip through 50-100° of hip flexion and
adduction while internally rotating the hip.
4. (+) presence of a click or reproduction or symptoms.

Validity Reliability

NT κ = 0.48 Poor reliability

Browder D, Enseki K, Fritz J. Intertester reliability of hip range of motion measurements and special
tests. J Orthop Sports Phys Ther. 2004;34:A1.

FIGURE 13-16 Flexion-Adduction-Internal Rotation Test (Click Test) 1

FIGURE 13-17 Flexion-Adduction-linternal Rotation Test (Click Test) 2

Hamstring Strain

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Pain control

Correction of
movement
Hip extension with impairment
**
Athletes—(MC) knee extension
running/sprints6 and Mobilization
jumping, i.e.: Hip extension with (neural)5
soccer, football, medial rotation
track, dancers, Exercise
waterskiers1 Pain (immediate) Hemorrhage Low
hamstring/quadriceps Muscle
Inflammation Pain in gluteal
* strength ratio length/strength
Elderly—secondary region* Occasional radiation into
to falls or muscle posterior thigh and calf History of Overdominance
weakness. Possible Muscle fatigue
insufficient warmup Previous of hamstrings
underlying history of posterior thigh injury2,4 Hamstring tightness over gluteus
pathology 29% of Overuse/repetitive motion maximus
injuries among Insufficient warmup
sprinters3 injury Palpation

12-16% of injuries in Adverse neural Active

soccer players7 tension in slump test5 contraction
painful

Passive
elongation
painful

1
Petersen J, Hölmich P. Evidence-based prevention of hamstring injuries in sport. Br J Sports Med.
Jun 2005;39:319-323.

2
Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring
strains. J Orthop Sports Phys Ther. 2004;34(3):116-125.

3
Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med. 1987;15:168-171.

4
Verrall G, et al. Clinical risk factors for hamstring muscle strain injury: A prospective study with
correlation of injury by magnetic resonance imaging. Br J Sports Med. 2001;35;435-439.
5
George KP, Turlj SE. Adverse neural tension: A factor in repetitive hamstring strain? J Orthop
Sports Phys Ther. 1998;27(1):16-21.

6
Stanton P, et al. Hamstring injuries in sprinting: The role of eccentric exercise. J Orthop Sports
Phys Ther. 1989;10(9):343-349.

7
Woods C, et al. The Football Association Medical Research Programme: An audit of injuries in
professional football—analysis of hamstring injuries. Br J Sports Med. 2004;38;36-41.

Bursitis

Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control:
Femoral anterior glide
Rest3
Femoral anterior glide
with lateral rotation
Iliopsoas Ultrasound3
Femoral anterior glide
RA7 Ant. hip pain with Correction of movement
with medial rotation
impairment Exercise:
activity3
OA7 Restricted hip extension
Muscle length/strength Theraband:
Tenderness in flexibility3
Trauma3 femoral triangle3 Hip IR/ER3 and sidelying abduction3
Positive hip snapping (clam)
Overuse3 Deep snapping sign3
sensation Single involved leg minisquats with
Athletes3 Hip rotation Weakness
hip ER3
when hip flexed to 90°
and hip flexor Education
tightness3
Palpation3

Pain over greater

Trochanteric trochanter,1
Athletes: especially with Femoral posterior glide
young and resisted hip with medial rotation
old7 flexion7 Hip adduction Hip Pain control1,2 Correction of
lateral rotation movement impairment Exercise
Runners7 Pain during
Pain reproduction with Stretch-It band1 Educate Protect
transitions from
Falls 7
standing to lying rotation, abduction, from direct trauma1 Ober's Test4
down to standing1 and adduction of the
Overuse hip5
syndrome1 Paresthesia in
legs5

Hip adduction Hip Pain control2

extension with knee
Ischiogluteal Correction of movement
extension Hip
Falling on Pain with sitting impairment
extension with medial
buttocks2 and walking,
rotation
tenderness over Foam pad or air-filled “doughnut”2
Sedentary ischial tuberosity2 Limited passive flexion
occupations2 and extension of the
Educate
hip2 Sign of the buttock4

1
Adkins SB, Figler RA. Hip pain in athletes. Am Fam Physician. 2000;61(7):2109-2118.

2
Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician.
1996;53(7):2317-2324.

3
Johnston CA, Lindsay DM, Wiley JP. Treatment of iliopsoas syndrome with a hip rotation
strengthening program: A retrospective case series. J Orthop Sports Phy Ther. 1999;29(4):218-224.

4
Magee D. Orthopedic Physical Assessment. Philadelphia, PA: Elsevier. 2006; 630, 632.

5
Sayegh F, Potoupnis M, Kapetanos G. Greater trochanter bursitis pain syndrome in females with
chronic low back pain and sciatica. Acta Orthop Belg. 2004;70(5):423-428.

6
Yamamoto T, Marui T, Akisue T, Yoshiya S, Hitora T, Kurosaka M. Dumbbell-shaped iliopsoas bursitis
penetrating the pelvic wall: A rare complication of hip arthrodesis: A case report. J Bone Joint Surg
Am. 2003;85:343-345.

Myositis Ossificans (MO)

Prevalence Symptoms Signs TBC/Special Tests

History: Fall, blunt trauma (Quadriceps MO) Pain control

to anterior thigh2,5 Decreasesd knee flexion
—pain restricted Acute: Flex to
Pain with contraction of tolerance; ice and
Athletes in 2nd
muscle involved in trauma Pain—quadriceps compress4
or 3rd decade
(75%)2 Isometric contraction
of life4
Cold laser therapy
Increased pain and Subacute presentation:
Most common
sites: quads, inflammation in lateral Palpable mass (−) Acetic acid iontophoresis
brachialis, anterior thigh 1 week post radiograph 2% Acetic acid with
deltoid4 injury2 PROM 3x week, 3 weeks2
3-6 weeks (+)
Traumatic progressive5 radiographs2 Full PROM Stabilize4
knee extension Full hip
Painless enlarged mass3 flexion1 Exercise (subacute)

1
Shih WJ, Hackett MT, Stipp V, Gross K, Pulmano C. Myositis ossificans demonstrated by positive
gallium-67 and technetium-99m-HMDP bone imaging but negative technetium-99m-MIBI imaging. J
Nucl Med Technol. Mar 999; 7:48.

2
Wieder DL. Treatment of traumatic myositis ossificans with acetic acid iontophoresis. Phys Ther.
Feb 1992;72:133-137.

3
Ragunanthan N, Sugavanam C. Pseudomalignant myositis ossificans mimicking osteosarcoma: A case
report. J Orthop Surg (Hong Kong). 2006;14(2):219-221.

4
Larson C, et al. Evaluating and managing muscle contusions and myositis ossificans. Phys
Sportsmed. 2002;30(2):41-47.

Slipped Capital Femoral Epiphysis

TBC/Special
Prevalence Symptoms Signs
Tests

Acute: usually
trauma-related with
symptoms lasting < 3 Limited hip ROM in capsular
Approx. 1-3.5 per 100,000
wks pattern; decreased hip
Age 8-17 yrs
flexion, abduction, and IR9 Stabilize
Chronic: gradual
About 1-2 yrs earlier in *
females
onset of symptoms Weak hip abductors9 Remove
lasting > 3 wks3 from weight
Males more than females Difficulty bearing weight on bearing9
Left > Right (male) Vague thigh or knee externally rotated limb1,9 Refer out4
pain9
African American more than Possible quadriceps atrophy7 Hip ROM
Caucasian1,3,6 88% had a Hip and groin
second slip within 18 pain1,2,3,5 Atypical: signs of endocrine Hip MMT
disorder, metabolic disorder,
months8
May have more or previous radiation therapy5
distal thigh and
knee pain3
 1
Diwan A, Diamond T, Clarke R, Patel MK, Murrell GAC, Sekel R. Familial slipped capital femoral
epiphysis: A report and considerations in management. Aust NZ J Surg. 1998;68:647-649.

2
Fallath S, Letts M. Slipped capital femoral epiphysis: An analysis of treatment outcome according to
physeal stability. Can J Surg. 2004;47(4):284-289.

3
Kelsey JL. Epidemiology of slipped capital femoral epiphysis: A review of the literature. Pediatrics.
1973;51(6):1042-1050.

4
Kocher MS, Bishop JA, Hresko MT, Millis MB, Kim YJ, Kasser JR. Prophylactic pinning of the
contralateral hip after unilateral slipped capital femoral epiphysis. J Bone Joint Surg.
2004;86(12):2658-2665.

5
Loder RT, Starnes T, Dikos G. Atypical and typical (idiopathic) slipped capital epiphysis. J Bone
Joint Surg. 2006;88(7):1574-1581.

6
Loder RT, Starnes T, Dikos G, Aronsson DD. Demographic predictors of severity of stable slipped
capital femoral epiphysis. J Bone Joint Surg. 2006:88(7):97-105.

7
Robben SGF, Lequin MH, Meradji M, Diepstraten AFM, Hop WCJ. Atrophy of the quadriceps muscle
in children with a painful hip. Clin Physiol. 1999:19(5):385-393.

8
Loder RT, et al. The epidemiology of bilateral slipped capital femoral epiphysis. A study of children
in Michigan. J Bone Joint Surg. 1993;75(8):1141-1147.

9
Pellecchia GL, et al. Differential diagnosis in physical therapy evaluation of thigh pain in an
adolescent boy. JOSPT. 1996;26(1):51-55.

Screening out Early Hip Disease

Flexion-Adduction Test
1. Patient is placed in a supine position.
2. Patient's hip flexed to 90°.
3. Hip is placed in neutral rotation.
4. Hip is allowed to passively adduct.
5. Zone 1: Normal joint
6. Zone 2 or 3: Pathological joint
 FIGURE 13-18 Flexion-Adduction Test

Reliability Sensitivity Specificity +LR −LR

NT 100 NT NA NA

Woods D, Macnicol M. The flexion-adduction test: An early sign of hip disease. J Pediatr Orthop.
2001;10:180-185.

Ruling in Early Hip Dysplasia

Passive Hip Abduction Test
1. The patient is in a supine position.
2. Examiner passively moves the hip into abduction.
3. (+) test is a restriction of abduction as compared to the opposite side.

Reliability Sensitivity Specificity +LR −LR

NT 70 90 7.0 0.33

Jari S, et al. Unilateral limitation of abduction of the hip: A valuable clinical sign for DDH? J Bone
Jnt Surg. 2002;84:104-107.
 FIGURE 13-19 Passive Hip Abduction Test

Iliopsoas Tendinopathy

Prevalence Symptoms DSM/Signs TBC/Special Tests

Groin or
trochanteric
pain1

Pain in the lower

abdominal
quadrant1 Femoral anterior glide

4.3% of 206 THA Femoral anterior glide with Pain control

Unilateral or Mobilization
patients8 bilateral1
medial rotation
Correction of
Frequent Femoral anterior glide with movement impairment
Kicking sports1
radiation to groin lateral rotation Exercise
Complication of total region1
hip Anterior thigh mass or Muscle length/strength
Denied direct ecchymosis may be present
arthroplasty2,3,4,5,6,7,8 Thomas Test Palpation
trauma1 Painful hip flexion1 Palpation
tenderness1
Pain disappears
with rest1

Pain reappears
with activity1
 1
Mozes M, et al. Iliopsoas injury in soccer players. BJSM. 1985;19(3):168-170.

2
Trousdale RT, Cabanela ME, Berry DJ. Anterior Iliopsoas impingement after total hip arthroplasty. J
Arthroplasty. 1995;10:546-549.

3
Della Valle CJ, Rafii M, Jaffe WL. Iliopsoas tendinitis after total hip arthroplasty. J Arthroplasty.
2001;16:923-926.

4
Heaton K, Dorr LD. Technical Note: Surgical release of iliopsoas tendon for groin pain after total
hip arthroplasty. J Arthroplasty. 2002;17:779-781.

5
Taher RT, Power RA. Case report: Iliopsoas tendon dysfunction as a cause of pain after total hip
arthroplasty relieved by surgical release. J Arthroplasty. 2003;18:387-388.

6
Wank R, Miller TT, Shapiro JF. Sonographically guided injection of anesthetic for iliopsoas
tendinopathy after total hip arthroplasty. J Clin Ultrasound. 2004;32:354-357.

7
Cheung YM, Gupte CM, Beverly MJ. Iliopsoas bursitis following total hip replacement. Arch Orthop
Trauma Surg. 2004;124:720-723.

8
Ala ET, Remy F, Chantelot C, Giraud F, Migaud H, Duquennoy A. Anterior iliopsoas impingement
after total hip arthroplasty: Diagnosis and conservative treatment in 9 cases. Rev Chir Orthop
Reparatrice Appar Mot. 2001;87(8):815-819.

Assessing iliopsoas/Rectus Femoris Length

Thomas Test (Unvalidated)
1. Patient sits at the edge of the plinth. The patient is then instructed to lie
back, pulling both knees to his or her chest.
2. One knee (asymptomatic side) is held to the chest, and the other is slowly
lowered into extension of the hip. The knee is allowed to extend.
3. Patient is instructed to pull his or her pelvis into posterior rotation.
4. Examiner then uses a goniometer to measure the extension angle of the hip
and/or the knee.
5. (+) test is significant tightness of the hip flexors of the extended leg.
 FIGURE 13-20 Thomas Test 1

FIGURE 13-21 Thomas Test 2

Reliability Sensitivity Specificity +LR −LR

Mobility κ = poor
NT NT NA NA
Mobility with pain provocation κ = 0.55 moderate reliability

[circled white star] The Thomas Test is also considered useful for
differentiating shortness of rectus femoris vs. iliopsoas vs. IT band/TFL.
Browder D, Enseki K, Fritz J. Intertester reliability of hip range of motion
measurements and special tests. J Orthop Sports Phys Ther. 2004;34:A1.
 FIGURE 13-22 Thomas Test IT band

Hip Adductor Strain

Prevalence Symptoms DSM/Signs TBC/Special Tests

10% of all injuries in

elite Swedish ice Pain control Correction
hocky players Femoral anterior glide with lateral of movement impairment
rotation Hip adduction Exercise
43% of all muscle
strains in elite Adductor strength < 80% of Increase adductor
Finnish ice hockey Groin abductor strength9 strength to > 80% of
players pain4,5 abductor strength
Pain on palpation of adductor Eccentric adductor
10-18% per year tendons or insertion on pubic bone training9
incidence of groin with or without pain during resisted
pain in soccer adduction6,7,8 Palpation Resistance
players1,2,3 testing

1
Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: A prospective study. Med Sci Sports
Exerc. 1983;15:267-270.

2
Nielsen AB, Yde J. Epidemiology and traumatology of injuries in soccer. Am J Sports Med.
1989;17:803-807.

3
Engström B, Forssblad M, Johansson C, Törnkvist H. Does a major knee injury definitely sideline an
elite soccer player? Am J Sports Med. 1990;18:101-105 (approach). Scand J Med Sci Sports.
1998;8:332 (abstr).
4
Renström P, Peterson L. Groin injuries in athletes. Br J Sports Med. 1980; 14:30-36.

5
Lovell G. The diagnosis of chronic groin pain in athletes: A review of 189 cases. Aust J Sci Med
Sport. 1995;27:76-79.

6
Holmich P, et al: Effectiveness of active physical training as treatment for long-standing adductor-
related groin pain in athletes: randomised trial. Lancet. 1999;353:439-443.

7
Lynch SA, Renstrom PA. Groin injuries in sport: Treatment strategies. Sports Med. 1999;28:137-
144.

8
Meyers WC, et al. Adductor pain in athletes. In: Arendt EA, ed. Orthopaedic Knowledge Update,
Sports Medicine 2. Rosemont, IL: American Academy of Orthopaedic Surgeons. 1999;281-289.

9
Tyler TF, et al. The association of hip strength and flexibility with the incidence of adductor
muscle strains in professional ice hockey players. Am J Sports Med. 2001;29(2):124-128.

Snapping Hip Syndrome

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Pain
control1,2,4

Ultrasound
Audible snap located
around greater Rest
External—IT band
catching on greater trochanter with hip
Exercise
trochanter1,2,3,4 adducted, flexed, and
rotated9 Femoral anterior glide with Stretching
Intraarticular—labral medial rotation Femoral in extension
tears, loose bodies, Or
posterior glide with medial 6-8 weeks6
articular cartilage rotation Hip lateral rotation
Snapping when hip is
flaps1,2,3,4 Correction
brought from flexion to 9
Coxa Vara of
Internal—iliopsoas tendon extension1,2,3,4
movement
catching on iliopectineal impairment
Variable disability and
eminence5,7 or snapping pain; often snapping is
across femoral head6 ROM
not of subjective
significance8 Ober Test

Thomas
Test
1
Allen WC, Cope R. Coxa saltans: The snapping hip revisited. J Am Acad OrthopSurg. 1995;3:303-
308.

2
Brignall CG, Stainby GD. The snapping hip: Treatment by Z-plasty. J BoneJoint Surg Br.
1991;73:253-254.

3
Dobbs MB, Gordon E, Luhmann SJ, Szymanski DA, Schoenecker PL. Surgical correction of the
snapping iliopsoas tendon in adolescents. J Bone Joint Surg Am. 2002;84:420-424.

4
Hoskins JS, Burd TA, Allen WC. Surgical correction of internal coxa saltans: A 20-year consecutive
study. Am J Sports Med. 2004;32:998-1001.

5
Lyons JC, Peterson LF. The snapping iliopsoas tendon. Mayo Clin Proc. 984;59:327-329.

6
Jacobson T, Allen WC. Surgical correction of the snapping iliopsoas tendon. AmJ Sports Med.
1990;18:470-474.

7
Rotini R, Spinozzi C, Ferrari A. Snapping hip: A rare form of internal etiology. Ital J Orthop
Traumatol. 1991;17:283-288.

8
Edmonson AS, Crenshaw AH. Snapping syndromes. In: Campbell's Operative Orthopaedics, vol 2.
St. Louis, Toronto, London: C.V. Mosby Company. 1980; 1403.

9
Larsen E, Johansen J. Snapping hip. Acta Orthopaedica. 1986;57(2):168-170.

Gluteus Medius Tears

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Pain control
20% of 176 patients after THA had
Weakness of hip Exercise
degenerative pathology of hip abductors1 abduction3 Correction of
movement
16% had isolated gluteus minimus or
Trendelenburg Gait3 impairment
medius tendons involvment1 Trochanteric Refer out
bursae-like Radiological evidence Educate
22% of 50 neck of the femur fracture
pain of sclerotic reaction of
patients Mean age was 83.4 years
bone underlying tear in Hip abduction
Tendon defects and fatty atrophy are 55% of all tears, 100% MMT
more common in symptomatic patients in patients with large Trendelenburg
after THA4 tears2 Gait View
radiograph
 1
Howell GE, Biggs RE, Bourne RB.
Prevalence of abductor mechanism tears
of the hips in patients with
osteoarthritis. Journal Arthroplasty.
2001;16(1):121-123.

2
Bunker TD, Esler CNA, Leach WJ.
Rotator-cuff tear of the hip. J Bone
Joint Surg Br. 1997;79-B:618-620.

3
Bain GI, et al. Abduction strength
following intramedullary nailing of the
femur. J Orthop Trauma. 1997;11(2):93-
97.

4
Pfirrmann CWA, et al. Abductor
tendons and muscles assessed at MR
imaging after total hip arthroplasty in
asymptomatic and symptomatic Patients.
Radiology. 2005;235:969.

Screening out/Ruling in Gluteus Medius Tears/Weakness

Trendelenburg's sign
1. Patient stands in front of the examiner.
2. Examiner instructs the patient to stand on one leg.
3. Examiner evaluates the degree of drop of the contralateral pelvis once the
leg is lifted.
4. Confirmation of abnormal pelvic drop is required during gait.
5. (+) test is identified by an asymmetric drop of one hip compared to the other
during a single stance.

Reliability Sensitivity Specificity +LR −LR

0.676 kappa 73 77 3.15 0.335

Bird PA, et al. Prospective evaluation of magnetic resonance imaging and physical examination
findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001;44:2138-2145.
 FIGURE 13-23 Trendelenburg's Sign

Resisted Hip Abduction

1. Patient is placed in a sidelying position with suspected side up.
2. Examiner instructs the patient to abduct the leg to 45°.
3. Examiner applies a force, resisting hip abduction against the leg.
4. (+) test is replication of symptoms during the testing

Reliability Sensitivity Specificity +LR −LR

0.625 kappa 73 46 1.35 0.59

Bird PA, et al. Prospective evaluation of magnetic resonance imaging and physical examination
findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001;44:2138-2145.
FIGURE 13-24 Resisted Hip Abduction
Chapter 14
The Knee

FIGURE 14-1 Major Ligaments of the Knee Joint

Souza, TA. Differential Diagnosis and Management for the Chiropractor: Protocols and
Algorithms. © 2009 Jones & Bartlett Publishers, LLC

Resting
Knee Closed Pack Capsular Pattern
Position

Flexion Full extension, external rotation of Flexion >

Tibiofemoral 25°
tibia Extension

Knee Motion Range of Motion

Extension-Flexion 0-140°
Outcome Tools
LEFS—Lower Extremity Functional Scale
WOMAC—Western Ontario and McMaster Universities Index of Osteoarthritis
GROC—Global Rating of Change
PSFS—Patient-Specific Functional Scale

Medical Screening for the Knee, Leg, ankle, or Foot Region

Red Flag Data Obtained During Red Flag Data Obtained During Physical
Condition
interview/history exam

Joint effusion and hemarthorsis Bruising,

History of recent trauma: crush swelling, throbbing pain, and point
injury, MVA, falls from heights, or tenderness over involved tissues
Fractures1234
sports injuries Osteoporosis in the
elderly Unwillingness to bear weight on involved
leg

Age > 55 years old Unilaterally cool extremity (may be

History of type II diabetes bilateral if aorta is site of occlusion)

Peripheral Prolonged capillary refill time ( > 2 sec)

History of ischemic heart disease
Arterial
Decreased pulses in arteries below the
Occlusive Smoking history
level of the occlusion
Disease56789
Sedentary lifestyle
Prolonged vascular filling time
Co-occurring intermittent
Ankle brachial index < 0.90
claudication

Calf pain, edema, tenderness, warmth

Calf pain that is intensified with standing

Recent surgery, malignancy,
Deep Vein or walking and relieved by rest and
pregnancy, trauma, or leg
Thrombosis10,11 elevation
immobilization
Possible pallor and loss of dorsalis pedis
pulse

Severe, persistent leg pain that is

 History of blunt trauma, crush intensified with stretch applied to involved
injury or muscles
Compartment
Recent participation in a rigorous, Swelling, exquisite tenderness and
Syndrome121314
unaccustomed exercise or training palpable tension/hardness of involved
activity compartment

Paresthesia, paresis, and pulselessness

History of recent infection, surgery, Constant aching and/or throbbing pain,

Septic joint swelling, tenderness, warmth
or injection Coexisting
Arthritis15 immunosuppressive disorder
May have an elevated body temperature

History of recent skin ulceration or Pain, skin swelling, warmth, and an

abrasion, venous insufficiency, CHF, advancing, irregular margin of
Cellulitis16 or cirrhosis erythema/reddish streaks Fever, chills,
History of diabetes mellitus malaise and weakness

1
Judd DB, Kim DH. Foot fractures misdiagnosed as ankle sprains. Am Fam Physician. 2002;68:785-
794.

2
Hatch RL, Hacking S. Evaluation and management of toe fractures. Am Fam Physician.
2002;68:2413-2418.

3
Hasselman CT, et al. Foot and ankle fractures in elderly white women. J of Bone Joint Surg.
2003;85:820-824.

4
Rammelt S, Zwipp H. Calcaneus fractures: Facts, controversies, and recent developments. Injury.
2004;35:443-461.

5
Boyko EJ, et al. Diagnostic utility of the history and physical examination for peripheral vascular
disease among patients with diabetes mellitus. J Clin Epidemiol. 1997;50:659-668.

6
McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: A critical review.
Arch Intern Med. 1998;158:1357-1364.

7
Halperin JL. Evaluation of patients with peripheral vascular disease. Thromb Res. 2002;106:V303-
V311.

8
Hooi JD, et al. Risk factors and cardiovascular diseases associated with asymptomatic peripheral
occlusive vascular disease. Scand J Prim Health Care. 1998;16:177-182.

9
Leng, GC, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: A
cohort study. BMJ. 1996;313:1440-1479.
10
Constans J, et al. Comparison of four clinical prediction scores for the diagnosis of lower limb
deep venous thrombosis in outpatients. Amer J Med. 2003;115:436-440.

11
Bustamante S, Houlton PG. Swelling of the leg, deep venous thrombosis, and the piriformis
syndrome. Pain Res Manag. 2001;6:200-203.

12
Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop. 1989;240:97-
104.

13
Swain R. Lower extremity compartment syndrome: When to suspect pressure buildup. Postgrad
Med. 1999;105(3):159-162, 165, 168.

14
Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: Are clinical findings
predictive of the disorder? Orthop Trauma. 2002;16:572-577.

15
Gupta MN, et al. A prospective 2-year study of 75 patients with adult-onset septic arthritis.
Rheum. 2001;40:24-30.

16
Stulberg D, Penrod M, Blatny R. Common bacterial skin infections. Am Fam Physician. 2002;
66:119-124. Courtesy of Joe Godges OPT.

Movement Science

Key Muscles to Consider Clinical implications

Strength of posterior gluteus

Weakness found in patellar pain patients
medius

Stiffness of Tensor Fascia Lata Increase in tibial lateral rotation

Quadriceps hypertrophy Increase in tibiofemoral or patellofemoral joint compression

Hamstring dominance Subtitutes for poor quadriceps function

Weak gluteus maxiumus may cause overuse of hamstring

Strength of gluteus maximus
muscles
Lee TQ, et al. The influence of tibial and femoral rotation on patellofemoral contact area and
pressure. JOSPT. 2003;33:686-693. Sahrmann SA. Diagnosis and Treatment of Movement
Impairment Syndromes. St. Louis: Mosby; 2002.

Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD. The role of knee alignment in disease
progression and functional decline in knee osteoarthritis. JAMA. 2001;286:188-195. [Erratum appears
in JAMA Aug 15 2001;286(7):792.]

Movement Impairments of the Knee: DSM (Directional

Susceptibility to Movement)

Tibiofemoral rotation (most common)

Tibiofemoral hypomobility

Knee extension

Knee hyperextension

Patellar tracking

Tibiofemoral accessory hypermobility

Key Kests for Movement Impairments of the Knee

Posture

Single leg stance

Stand
Step up and down test

Hip and knee flexion (squat)

Alignment

Knee extension with dorsiflexion

McConnell Test
Sit
Hip rotation

Long sitting quad contraction

Palpation
 ROM test

Supine Hip flexor length test

SLR (active) test

MMT hip abduction

Sidelying
MMT hip abduction/Lateral rotation/Extension (posterior glut med)

Knee flexion

Active/passive hip rotation

Prone
Hip extension with knee extended (glut max/ hamstrings)

Hip extension with knee flexed (glut max)

Post-Op Pearls—Knee

No open-chain terminal knee extension (quad sets, straight leg

raises are okay in brace only)

Avoid closed chain extension between 60° and 90° flexion

ACL repair precautions (prevent anterior shear forces)

Special care first 2-3 weeks as graft goes through necrotization

process

0-2 weeks achieve full knee ext and 90° flex

Weight bearing as tolerated with brace and crutches

Avoid full squat and lunges for at least 6 months

Meniscal Repair
Avoid twisting, turning, and pivoting for 4 months
Precautions (early phase)
Maximum flexion first 4 weeks 50-90°, depending on tear size

Try to gain full active knee extension by 4 weeks

Weight bearing as tolerated—cemented

 Total Knee arthroplasty Touch down wieght bearing 4-8 weks or weight bearing as tolerated a
(TKA) few days after surgery with walker

Do not use pillow under knee (prevent flexion contracture)

Ankle pumps to prevent DVT

FIGURE 14-2 Treatment-Based Categories for the Knee Region

Knee TBC References

Mobilization
Deyle GD, et al. Effectiveness of manual physical therapy and exercise in
osteoarthritis of the knee: A randomized, controlled trial. Ann Intern Med.
2000;132:173-181.
Currier LL, et al. Development of a clinical prediction rule to identify patients
with knee pain and clinical evidence of knee osteoarthritis who demonstrate a
favorable short-term response to hip mobilization. Phys Ther. 2007;87(9):1-14.
Deyle GD, et al. Physical therapy treatment effectiveness for osteoarthritis of
the knee: A randomized comparison of supervised clinical exercise and manual
therapy procedures versus a home exercise program. Phys Ther. 2005;85:1301-
1317.
Hoeksma HL, et al. Comparison of manual therapy and exercise therapy in
osteoarthritis of the hip: A randomized clinical trial. Arthritis Rheum.
2004;51:722-729.

Exercise
Ettinger WH Jr, Afable RF. Physical disability from knee osteoarthritis: The role
of exercise as an intervention. Med Sci Sports Exerc. 1994;26:1435-1440.
Kovar PA, et al. Supervised fitness walking in patients with osteoarthritis of the
knee: A randomized, controlled trial. Ann Intern Med. 1992;116:529-534.
Purdam CR, et al. A pilot study of the eccentric decline squat in the
management of painful chronic patellar tendinopathy. Br J Sports Med.
2004;38:395-397.
Young MA, et al. Eccentric decline squat protocol offers superior results at 12
months compared with traditional eccentric protocol for patellar tendinopathy
in volleyball players. Br J Sports Med. 2005;39:102-105.
O'Reilly SC, Jones A, Muir KR, Doherty M. Effectiveness of home exercise on
pain and disability from osteoarthritis of the knee: A randomised controlled
trial. Ann Rheum Dis. 1999;58:15-19.

Stabilize
Sathe VM, Ireland ML, Ballantyne BT, Quick NE, McClay IS. Acute effects of the
Protonics system on patellofemoral alignment: An MRI study. Knee Surg Sports
Traumatol Arthrosc. 2002;10:44-48.
Sutlive TG, et al. Identification of individuals with patellofemoral pain whose
symptoms improved after a combined program of foot orthosis use and modified
activity: A preliminary investigation. Phys Ther. 2004;84:49-61.
Pfeiffer RP, et al. Kinematic MRI assessment of McConnell Taping before and
after exercise. Am J Sports Med. 2004;32(3):621-628.
McConnell J. The management of chondromalacia patellae: A long-term
solution. Aust J Physiother. 1986;32:215-223.
McConnell J. The physical therapist's approach to patellofemoral disorders. Clin
Sports Med. 2002;21:363-387.
Wilson T, Carter N, Thomas G. A multicenter, singlemasked study of medial,
neutral, and lateral patellar taping in individuals with patellofemoral pain
syndrome. J Orthop Sports Phys Ther. 2003;33:437-448.
Whittingham M, Palmer S, Macmillan F. Effects of taping on pain and function
in patellofemoral pain syndrome: A randomized Controlled Trial. J Orthop
Sports Phys Ther. 2004;34:504-510.

Correction of Movement impairment

Powers CM. The influence of altered lower-extremity kinematics on
patellofemoral joint dysfunction: A theoretical perspective. J Orthop Sports
Phys Ther. 2003;33:639-646.
Reischl SF, Powers CM, Rao S, Perry J. Relationship between foot pronation and
rotation of the tibia and femur during walking. Foot Ankle Int. 1999;20:513-
520.
Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral
joint mechanics: a theoretical model. J Orthop Sports Phys Ther. 1987;9:160-
169.
Mascal CL, Landel R, Powers C. Management of patellofemoral pain targeting
hip, pelvis, and trunk muscle function: 2 case reports. J Orthop Sports Phys
Ther. 2003; 33:639-646.

Ireland LM, et al. Hip strength in females with and without patellofemoral pain.
J Orthop Sports Phys Ther. 2003;33:671-676.
Caylor D, Fites R, Worrell TW. The relationship between quadriceps angle and
anterior knee pain syndrome. J Orthop Sports Phys Ther. 1993;17:11-16.
Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N,
Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band
syndrome. Clin J Sport Med. 2000;10(3):169-175.
Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of
neuromuscular training on the incidence of knee injury in female athletes: a
prospective study. Am J Sports Med. 1999;27:699-706.
Hewett TE, Stroupe AL, Nance TA, Noyes FR. Plyometric training in female
athletes: Decreased impact forces and increased hamstring torques. Am J
Sports Med. 1996;24:765-773.
Sutlive TG, et al. Quadriceps weakness in knee osteoarthritis: The effect on
pain and disability. Ann Rheum Dis. 1998;57:588-594.

Pain control
Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue
injury? J Athl Train. 2004;39(3):278-279.
Cohn BT, Draeger RI, Jackson DW. The effects of cold therapy in the
postoperative management of pain in patients undergoing anterior cruciate
ligament reconstruction. Am J Sports Med. 1989;17:344-349.
Yurtkuran M, Kocagil T. TENS, electroacupuncture, and ice massage:
Comparison of treatment for osteoarthritis of the knee. Am J Acupunct.
1999;27(3-4):133-140.

Screening out Fracture at the Knee

Ottawa Knee Decision Rule

FIGURE 14-3 Ottawa Knee Decision Rule

Criteria:
1. Age ≥ 55 years
2. Tenderness at the head of the fibula
3. Isolated tenderness of the patella
4. Inability to flex the knee to at least 90°
5. Inability of the patient to bear weight both immediately and in the
emergency department for four steps
6. (+) test is the presence of any one of the five characteristics above, and
should be referred for a radiograph to confirm fracture.

Reliability Sensitivity Specificity +LR −LR

NT 100 49 1.9 0.11

Jackson JL, et al. Evaluation of acute knee pain in primary care. Ann Intern Med. 2003;139:575-588.

Algorithmic Approach for Acute Knee Pain

Appropriate Physical Therapy

Question
Action

Has there been a recent injury and at least one of the following
predictors of fracture?

Age > 55 years old

Refer out for fracture risk. Do
Tenderness at head of the fibula or isolated to the patella not treat.

Inability to bear weight for at least four steps of walking

Inability to flex knee > 90°

Consider possibility of infection

or active rheumatological
pathology

Immediate effusion related to

Is there an effusion?
injury—cruciate ligament injury

Delayed effusion related to

 injury—perhaps meniscal
pathology

Does the physical examination suggest meniscal or ligamentous

Orthopaedic referral
injury or history of locking or give-way sensation?

Are there clinical criteria suggesting osteoarthritis?

At least three of the following:

History: Symptomatic treatment (pain

control treatment category)
Age > 50 years old
Mobilization treatment-based
Morning stiffness lasting > 30 minutes
category
Physical examination:
Exercise treatment-based
Crepitus category

Bony enlargement

No palpable warmth

Refer out

Is there evidence of a systemic rheumatologic disorder (such as Consider serum rheumatologic

RA, seronegative inflammatory arthropathy, or reactive assays
arthropathy)?
Rheumatoid arthritis:
Polyarticular involvement, especially the hands? Morning rheumatoid factor
stiffness lasting > 30 minutes?
Systemic lupus erythematosus:
antinuclear antibody

Does the pain persist or remain undiagnosed despite symptomatic Refer out to rheumatology or
treatment and clinical follow-up? orthopaedic referral

[circled white star] Physical exam is almost as good as imaging for diagnosing ligament tears, but
imaging is best for meniscal injuries. (Jackson 2003)

Knee Osteoarthritis
Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control

Ultrasound4

Mobilization:

Knee joint8

Hip joint9
Tibiofemoral Exercise:
hypomobility
Quadriceps
Swelling5 strengthening
Women > Men5
Pain with weight Bone spurs5,6 Hip strengthening
> 50 y/o6 bearing5
Warmth6 Correction of
Women over 65 are 2x more than Morning movement impairment
men3 stiffness < 30 Redness6
min5 Educate/Wellness
10 million Americans6 Catching or
Diffuse clicking7 Diagnostic Cluster:7
33% Americans > 63 y/o live with tenderness7
knee osteoarthritis2 < ROM6 1. > 50 y/o

WOMAC1,7 2. < 30 minutes of

morning stiffness
SF-36 GHS1,7
3. Crepitus or bony
enlargement

Performance Cluster:1

1. Self-paced walk test

2. Timed “Up & Go”

3. Six-minute walk test

1
Stratford PW, Kennedy DM, Woodhouse LJ. Performance measures provide assessments of pain and
function in people with advanced osteoarthritis of the hip or knee. Phys Ther. 2006; 86:1489-1496.

2
Maly MR, Costigan PA, Olney SJ. Contribution of psychosocial and mechanical variables to physical
performance measures in knee osteoarthritis. Phys Ther. 2005;85:1318-1328.

3
Foy CG, Penninx BW, Shumaker SA, Messier SP, Pahor M. Long-term therapy resolves ethnic
differences in baseline health status in older adults with knee osteoarthritis. J Am Geriatr Soc.
 2005;53:1469-1475.

4
Huang MH, Lin YS, Lee CL, Yang RC. Use of ultrasound to increase effectiveness of isokinetic
exercises for knee osteoarthritis. Arch Phys Med Rehabil. 2005;86:1545-1551.

5
Copstead LC, Banasik JL. Pathophysiology. 3rd ed. New York: Lippincott. 2005; 1276-1278.

6
Parmet S, Lynm C, Glass RM. Osteoarthritis of the knee. JAMA. 2003;289:1068.

7
Oatis CA, Wolff EF, Lennon SK. Knee joint stiffness in individuals with and without knee
osteoarthritis: A preliminary study. J Orthop Sports Phys Ther. 2006;36:935-941.

8
Deyle GD, et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: A
randomized comparison of supervised clinical exercise and manual therapy procedures versus a home
exercise program. Phys Ther. 2005;85(12):1301-1317.

9
Currier LL, et al. Development of a clinical prediction rule to identify patients with knee pain and
clinical evidence of knee osteoarthritis who demonstrate a favorable short-term response to hip
mobilization. Phys Ther. 2007;87(9):1-14.

Criteria for Classification of Osteoarthritis of the Knee

1. Age > 50 years
2. Knee crepitus
3. Palpable bony enlargement
4. Bony tenderness to palpation
5. Morning stiffness that improves in less than 30 minutes
6. No palpable warmth of the synovium

Variables Present Reliability Sensitivity Specificity +LR −LR

>3 NT 95 69 3.06 0.07

Altman R, et al, for the Diagnostic and Therapeutic Criteria Committee of the American Rheumatism
Association. Development of criteria for the classification and reporting of osteoarthritis:
classification of osteoarthritis of the knee. Arthritis Rheum. 1986;29: 1039-1049.

CPR for Knee OA Patients Who Will Benefit from Hip

Mobilization (Unvalidated)
Predictive Variable Reliability Sensitivity Specificity +LR −LR

Hip or groin pain or paresthesia NT 20 98 8.1 0.82

Anterior thigh pain ICC = 0.87 27 95 5.1 0.77

Ipsilateral passive knee flexion less than 122° ICC = 0.76 32 95 6.02 0.72

Ipsilateral passive hip medial (internal)

NT 32 95 6.02 0.72
rotation less than 17° in prone

Pain with ipsilateral hip distraction NT 13 98 5.24 0.89

[circled white star] > 1 variable present → hip mobilization

Mobilizations used in the Currier et al. Study

FIGURE 14-4 Caudal Glide

 FIGURE 14-5 Anterior-Posterior Glide

FIGURE 14-6 Posterior-Anterior Glide

FIGURE 14-7 Posterior-Anterior Glide with Flexion, Abduction and Lateral Rotation
(Prone Glide Faber)

[circled white star] I have found these techniques to be very beneficial for my
patients with hip mobility impairments.
Currier LL, et al. Development of a clinical prediction rule to identify patients
with knee pain and clinical evidence of knee osteoarthritis who demonstrate a
favorable short-term response to hip mobilization. Phys Ther. 2007;87(9):1-14.
[circled white star] Manual Therapy to the osteoarthritic knee is beneficial.
Deyle 2005 showed a clear benefit of manual therapy to the osteoarthritic knee
in function, pain, stiffness, and 6-minute walk test compared to home exercise.
Moss 2007 showed a clear benefit in pressure pain threshold and timed “Up &
Go” test with 9 minute, pain-free large amplitude anterior-posterior glide of
tibia on femur.
[circled white star] Farquhar 2008 demonstrated that 1 year post total knee
arthroplasty, patients were using more hip flexion to get from sit to stand,
using more hip extensor musculature, and avoiding quadriceps activation. Focus
on quadriceps strengthening!

FIGURE 14-8 AP Mobilization of Fem Joint

Meniscal Injury

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Pain control
Presence of medial
Tibiofemoral
joint line Mobilization
Accessory
tenderness14
Hypermobility
9% of patients with knee pain Correction of
presenting to primary care Knee ‘locking’14 Decreased ROM in movement
physician13 when the leg is flexion and impairment
almost straight2 extension15
Common in asymptomatic (76%) and Exercise
symptomatic (91%) osteoarthritic Daily pain14 Joint line pain1,12
knees11 Education
Continuing pain < 1 Spongy end feel1
Thessaly
Non-trauma-related in elderly due month15
to cartilage weakness1 Part of unhappy Test1,10,12
2 15
Effusion , triad4,5:
Recent literature suggests lateral Ege's Test1
meniscus more commonly Locking15 ACL
McMurray's
injured6,7,8,9
Instability15 Medial meniscus Test1,12

Joint line MCL Joint line

tenderness15 pain1,12

1
Cleland J. Orthopedic Clinical Examination: An Evidence-Based Approach for Physical Therapist.
Carlstadt, NJ: Learning System. 2005.

2
Muellner T, Weinstabl R, Schabus R, Vecsei V, Kainberger F. The diagnosis of meniscal tears in
athletes: A comparison of clinical and magnetic resonance imaging investigations. Am J Sports Med.
1997; 25:7-12.

3
Stocker B, Nyland J, Caborn D, Sternes R, Ray JM. Results of Kentucky high school football knee
injury survey. J Ky Med Assoc. 1997;95:458-464.

4
O'Donoghue DH. Surgical treatment of fresh injuries to the major ligaments of the knee, 1950. Clin
Orthop. 1991;271:3-8.

5
O'Donoghue D. An analysis of end results of surgical treatment of major injuries to the ligaments of
the knee. J Bone Joint Surg Am. 1955;37:19-22.

6
Barber F. Accelerated rehabilitation for meniscus repairs. Arthroscopy. 1994;10:206-210.

7
Barber F. Snow skiing combined anterior cruciate ligament/medial collateral ligament disruptions.
Arthroscopy. 1994;10:85-89.

8
Shelbourne KD, Nitz PA. The O'Donoghue triad revisited: Combined knee injuries involving anterior
cruciate and medial collateral ligament tears. Am J Sports Med. 1991;19:474-477.

9
Duncan JB, Hunter R, Purnell M, Freeman J. Meniscal injuries associated with acute anterior
cruciate ligament tears in alpine skiers. Am J Sports Med. 1995;23:170-172.

10
Karachalios T. Diagnostic accuracy of a new clinical test (the Thessaly Test) for early detection of
meniscal tears. J Bone Joint Surg Am. 2005;87:995-962.

11
Bhattacharyya T. The clinical importance of meniscal tears demonstrated by magnetic resonance
imaging in osteoathritis of the knee. J Bone Joint Surg Am. 2003;85:4-9.
 12
Meserve BB, Cleland JA. A meta-analysis examining clinical test utilities for assessing meniscal
injury. Clin Rehabil. 2008;22:143-161.

13
National Ambulatory Medical Care Survey, 1996. Accessed 18 August 2003, from
ftp://ftp.cdc.gov/pub/health_Statistics/NCHS?datasets?Namcs?

14
Abdon P, Lindstrand A, Thorngren KG. Statistical evaluation of the diagnostic criteria for meniscal
tears. Int Orthop. 1990;14:341-345.

15
Noble J, Erat K. In defense of the meniscus: A prospective study of 200 meniscectomy patients. J
Bone Joint Surg Br. 1980;62:7-11.

Screening Out/Ruling in Meniscal Pathology

Thessaly Test
1. Therapist supports patient by holding patient's outstretched hand.
2. Patient stands flat footed on the floor.
3. Patient is asked to rotate his or her knee and body internally and externally,
three times.
4. Knee stays in 20°.
5. (+) Test is Medial or lateral joint line discomfort. May have a sense of locking
or catching.

FIGURE 14-9 Thessaly Test 1

 FIGURE 14-10 Thessaly Test 2

FIGURE 14-11 Thessaly Test 3

Medial Meniscus

Reliability Sensitivity Specificity +LR −LR

NT 89 97 29.67 0.11

Lateral Meniscus

Reliability Sensitivity Specificity +LR −LR

 NT 92 96 23 0.083

Karachalios T, et al. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection
of meniscal tears. J Bone Joint Surg Am. 2005;87:955-962.

McMurray Test
1. Patient is in a supine position.
2. Examiner stands to the side of the patient's involved knee.
3. Examiner grasps the patient's heel and flexes the knee to end range with
one hand while using the thumb and index finger of the other hand to palpate
the medial and lateral tibiofemoral joint line.

FIGURE 14-12 McMurray Test 1

FIGURE 14-13 McMurray Test 2

 FIGURE 14-14 McMurray Test 3

FIGURE 14-15 McMurray Test 4

4. To test medial meniscus, examiner rotates the tibia into external rotation
and then slowly extends the knee.
5. To test the lateral meniscus, examiner flexes the knee again, internally
rotates the tibia, and slowly extends the knee.
6. (+) test is indicated by an audible or palpable “thud” or “click.”

Test Finding Reliability Sensitivity Specificity +LR −LR

Medial “thud” 0.35 16 98 8.0 0.86

Pain NT 50 94 8.33 0.53

Evans PJ, et al. Prospective evaluation of the McMurray Test. Am J Sports Med. 1993;21(4):604-608.

ACL—Anterior Cruciate Ligament Injury

Prevalence Symptoms DSM/Signs TBC/Special Tests

Stabilize

Tibiofemoral Pain control

70% of knee
Relative risk
injuries with: Mobilize
women:men Accessory
3.96:1.49 1) acute blow or Exercise:
Hypermobile
twisting or
Common in sports No open-chain terminal knee
cutting injury Swelling that
requiring cutting, extension initially post op.2
with foot planted occurs within 2
pivoting, sudden
stops, or landing hours post
2) immediate No closed-chain deep squats initially
from a jump15 injury5
effusion/swelling5 post op.2

3.24 per 100 men10 Excessive

3) inability to Early WB and ROM (regain extension
anterior
continue to to minimize cost of proper gait).
3.51 per 100 translation of the
play3,4,9 Initiation of co-contraction of
women10 tibia on the
hams/quad in closed-chain,
Knee feels like it's femur ≥ 3 mm1,6 neuromuscular, and proprioception
Pts. with ACL or
“locking up” or
Joint training2,12
meniscus injury
“giving out”2,9
have a > avg. risk of instability1,6
Improve quad: hamstring strength14
developing OA14 Pt. may
Decrease in
commonly feel a Perturbation training7,8
50% have proprioception1,6
pop or snap when
radiological signs of PNF6,9
the injury Altered gait
OA14
occurs2,9 pattern1 Lachman Test13

Anterior Drawer Test13

1
Barrack RL, et al. Proprioception in the ACL-deficient knee. Am J Sports Med. 1989;17:1-6.

2
Brotzman BS, Wilk KE. Clinical Orthopedic Rehabilitation. 2nd ed. Philadelphia: Mosby Inc; 2003.
3
Daniel DM, et al. Instrumented measurement of anterior knee of the laxity of the knees. J Bone
Joint Surg Am. 1985;67:720-726.

4
Daniel DM, et al. Instrumented measurement of anterior knee laxity in patients with ACL
disruption. Am J Sports Med. 1985;13:401.

5
DeHaven KE. Diagnosis of acute knee injuries with hemarthrosis. Am J Sports Med. 1980;8(1):9-14.

6
Engle RP. Non-operative ACL rehabilitation. In: Engle RP, ed. Knee Ligament Rehabilitation. New
York: Churchill-Livingstone; 1991.

7
Engle RP, Canner GC. Proprioceptive neuromuscular facilitation (PNF) and modified procedures for
ACL instability. J Orthop Sports Phys Ther. 1989;11:230-236.

8
Fitzgerald GK, Axe MJ, Snyder-Mackler L. Proposed practice guidelines for nonoperative anterior
cruciate ligament rehabilitation of physically active individuals. J Orthop Sports Phys Ther.
2000;30:194-203.

9
Gwinn DE, et al. The relative incidence of anterior cruciate ligament injury in men and women at
the United States Naval Academy. Am J Sports Med. 2000;28(1):98-102.

10
Mountcastle, SB, et al. Gender differences in anterior cruciate ligament injury vary with activity.
Am J Sports Med. 2007;35:1634-1642.

11
Hartley A. Practical Joint Assessment. St. Louis: Mosby; 1995.

12
Hewett T, Zazulak B, Myer G, Ford K. A review of electromyographic activation levels, timing
differences, and increased anterior cruciate ligament injury incidence in female athletes. Br J
Sports Med. 2005;39:347-350.

13
Katz J, Fingeroth R. The diagnostic accuracy of ruptures of the anterior cruciate ligament
comparing the Lachman Test, the anterior drawer test, and the pivot shift test in acute and chronic
knee injuries. Am J Sports Med. 1986;14:88-91.

14
Nakamura N, Shino K. Review article: The clinical problems of ligament healing of the knee. Sports
Med Arthrosc. 2005;118-126.

15
Roos EM, Roos HP, Lohmander LS, Ekdahl CE, Beynnon BD. Knee injury and osteoarthritis outcome
score (Koos): Development of a self-administered outcome measure. J Orthop Sports Phys Ther.
1998;28(2):88-96.

Screening out/Ruling in Anterior Cruciate Ligament Tears

Lachman's Test
1. Patient is in a supine position.
2. Knee joint is flexed to 30 degrees.
3. Examiner stabilizes the distal femur with one hand and grasps behind the
proximal tibia with the other hand.
4. Examiner then applies an anterior tibial force to the proximal tibia.
5. (+) test is indicated by greater anterior tibial displacement on the affected
side when compared to the unaffected side.

Reliability Sensitivity Specificity +LR −LR

κ = 0.35 between two physical therapists1 771 501 NA1 NA1

NT 682 942 11.32 0.382

Cooperman JM, et al. Reliability and validity of judgments of the integrity of the anterior cruciate
ligament of the knee using Lachman's Test. Phys Ther. 1990;70:225-233.

Learmonth DJ. Incidence and diagnosis of anterior cruciate injuries in the accident and emergency
department. Injury. 1991;22:287-290.

FIGURE 14-16 Lachman's Test

 Anterior Drawer Test
1. Knee is flexed between 60° and 90° with foot on examination table.
2. Examiner draws tibia anteriorly.
3. (+) test is indicated by greater anterior tibial displacement on the affected
side when compared to the unaffected side.

Reliability Sensitivity Specificity +LR −LR

NT 25 96 6.2 0.78

Noyes FR, et al. Knee sprains and acute knee hemarthrosis: Misdiagnosis of anterior cruciate
ligament tears. Phys Ther. 1980;60:1596-1601.

FIGURE 14-17 Anterior Drawer Test

PCL Injury (Posterior Cruciate Ligament)

Symptoms Prevalence Signs/DSM TBC/Special Test

Pain control

PRICE12

Electric
stimulation
Tibiofemoral Accessory Stabilize
1%-44% of all Hypermobility
Exercise:
knee injuries11 Mechanism of Apparent excessive anterior
injury:3,8 translation of the tibia on the femur or Especially
Isolated PCL
injury about posterior tibial laxity3,8
Direct blow to quadriceps
44%11 anterior tibia in 3 8 strength
Joint instability—posterior sag ,
flexed position Perturbation
ACL often torn
Secondary patellofemoral joint pain12 training12
in conjunction Hyperextension
with PCL3,8 Secondary degenerative joint disease Educate
in medial joint compartment12
Activity
modifications12

Posterior drawer
test13

Posterior sag sign

1
Axe MJ, Snyder-Mackler L. Operative and postoperative management of the knee. In: Wilmarth MA,
ed. Orthopaedic Section Independent Study Course 15.3, Postoperative Management of
Orthopaedic Surgeries. La Crosse, WI: Orthopaedic Section, APTA Inc; 2005.

2
Barrett CR, Savoie FH. Operative management of acute PCL injuries with associated pathology:
Long-term results. Orthopedics. 1991;14:687-692.

3
Berger RS, Larson RL. Posterior cruciate and posterolateral injuries. In: Larson RL, Grana WA, eds.
The knee: Form, Function, Pathology, and Treatment. Philadelphia: Saunders. 1993; 565-583.

4
Dandy DJ, Pusey RJ. The long-term results of unrepaired tears of the posterior cruciate ligament. J
Bone Joint Surg Br. 1992;64:92-94.

5
Daniel DM, et al. Instrumented measurement of the anterior laxity of the knee. J Bone Joint Surg
Am. 1985;67:720-726.

6
Grover JS, Bassett LW, Gross ML, Seeger LL, Finerman GAM. Posterior cruciate ligament: MR
imaging. Radiology. 1990;174:527-530.
 7
Hughston JC, Bowden JA, Andrews JR, Norwood LA. Acute tears of the PCL: Results of operative
treatment. J Bone Joint Surg Am. 1980;62:438-450.

8
Loos WC, Fox JM, Blazina ME, Del Pizzo W, Friedman MJ. Acute PCL injuries. Am Sports Med.
1981;9:86-92.

9
Manal TJ, Sturgill L. Current Concepts of Orthopaedic Physical Therapy. 2nd ed. Independent
Study Course 16.2.10. LaCrosse, WI: Orthopaedic Section, APTA Inc; 2006.

10
Rubinstein RA, et al. The accuracy of the clinical examination in the setting of posterior cruciate
ligament injuries. Am J Sports Med. 1994;22:550-557.

11
Shelbourne KD, Jennings RW, Vahey TN. The natural history of acute, isolated, nonoperatively
treated posterior cruciate ligament injuries. Am J Sports Med. 1999;27:276-283.

12
Snyder-Mackler L, Delitto A, Bailey S, Stralka SW. Strength of the quadriceps femoris muscle and
functional recovery after reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am.
1995;77:1166-1173.

13
Torg JS, Barton TM, Pavlov H, Stine R. Natural history of the posterior cruciate ligament deficient
knee. Clin Orthop Rd Res. 1989;246:208-216.

Screening 0ut/Ruling in Posterior Cruciate Ligament Tears

Posterior Drawer Test
1. Patient is supine, knee bent to 90° knee flexion.
2. Examiner sits on patient's toes to help stabilize the lower extremity.
3. Examiner grasps proximal leg as shown and translates leg posteriorly.
4. Examiner also palpates over joint line with thumbs to assess translation.
5. (+) test is a lack of end point for tibial translation, or excessive tibial
translation.

Reliability Sensitivity Specificity +LR −LR

NT 901 991 901 0.101

NT 1002 NT NA NA
 1
Rubinstein, et al. The accuracy of the clinical examination in the setting of posterior cruciate
ligament injuries. Am J Sports Med. 1994;22:550-557.

2
Fowler PJ, et al. Isolated posterior cruciate ligament injuries. Curr Opin Rheumatol. 2002;14:142-
149.

FIGURE 14-18 Posterior Drawer Test

Posterior Sag Sign or godfrey's Test

1. Patient is supine with the knee flexed to 90° and the hip placed in 90° of
flexion.
2. Examiner supports the leg under the lower calf/heel, suspending the leg in
the air.
3. (+) test for a PCL tear is posterior sagging of the tibia secondary to
gravitational pull.

Reliability Sensitivity Specificity +LR −LR

NT 100 NT NA NA
 Fowler PJ, et al. Isolated posterior cruciate ligament injuries in athletes. Am J Sports Med.
1987;15:553-557.

FIGURE 14-19 Posterior Sag Sign or Godfrey's Test

Identifying Copers
1. Eastlack, et al. Laxity, instability, and functional outcome after anterior
cruciate ligament injury: Copers versus non-copers. Med Sci Sports Exerc.
1999;31:210-215.
Screening is usually done within 2 months of injury.
Patient must meet the following four criteria to be considered for screening:
1. No knee effusion
2. Ability to hop on injured leg without pain
3. Full knee range of motion
4. ≥ 70 involved/uninvolved quadriceps ratio
[circled white star] Start quadriceps setting early!
Shaw, et al. mentions that it is very important to start activating the quadriceps
with quadsets and straightleg raises immediately after surgery. Patients had
faster recovery of knee flexion/extension ROM, improved disability at 6
months, and lower incidence of abnormal knee laxity, even though they may
have had higher pain scores first day post-op.

FIGURE 14-20 Screening Guidelines

 FIGURE 14-21 Noyes Hop Test

Medial and Lateral Collateral Ligaments (MCL and LCL)

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

6% of patients in
primary care clinic
with physical Traumatic injury with Tibiofemoral Accessory
symptoms have knee varus or valgus force at Stabilize
knee1 Hypermobility
pain2
Pain
MCL Swelling that occurs 12-24 control
Collateral ligaments hours post injury5
7% of acute knee
Medial-sided knee pain3 Educate:
pain2 Localized edema/tenderness of
Direct valgus blow on medial joint line, valgus laxity1 Rest and
Football6 lateral aspect of knee in a activity
planted, semiflexed, and Grade I—10.6 days to return to modification
Basketball6 play5
rotated foot1,3
Exercise
Baseball6 Grade II—19.5 days to return to
LCL
play5 Valgus stress
Associated femoral (20° flex)5
Lateral sided knee pain
bone bruise in 24% of Extra-articular localized
MCL-injured patients7 Direct varus stress on swelling of lateral epicondyle, Varus stress
medial aspect of knee in varus laxity, palpation (20° flex)5
Rarely isolated,
semiflexed position1,4 tenderness lateral joint line
usually in conjunction
with ACL/PCL injury7

1
Brotzman S, Wilk, K. Clinical Orthopaedic Rehabilitation. 2nd ed. St. Louis, MO: Mosby. 2003;
252-300.

2
Jackson JL, et al. Evaluation of acute knee pain in primary care. Ann Intern Med. 2003;139:575-
588.

3
Gianooti B, Rudy T, Granzino J. The non-surgical management of isolated medial collateral
ligament injuries of the knee (review article). Sports Med Arthrosc. 2006;74-77.

4
Bahk M, Cosgarea A. Physical examination and imaging of the lateral collateral ligament and
posterolateral corner of the knee (review article). Sports Med Arthrosc. 2006;12-19.
 5
Derscheid GL, Garrick JG. Medial collateral ligament injuries in football. Nonoperative management
of grade I and grade II sprains. Am J Sports Med. 1981;9(6):365-368.

6
Noyes FR, et al. Arthroscopy in acute traumatic hemarthrosis of the knee: incidence of anterior
cruciate tears and other injuries. J Bone Joint Surg Am. 1980;62:687-695.

7
Schweitzer ME, et al. Medial collateral ligament injuries: Evaluation of multiple signs, prevalence,
and location of associated bone bruises, and assessment with MR imaging. Radiology. 1995;194:825-
829.

Screening out Lateral Collateral Ligament Laxity or Tears

Varus Stress Test (LCL)
1. Patient is in a supine position.
2. Patient's knee flexed to 20°.
3. Varus stress applied to knee.
4. (+) if pain or laxity present.

Reliability Sensitivity Specificity +LR −LR

NT 01-252 NT NA NA

1
Harilainen A, et al. Diagnosis of acute knee ligament injuries: The value of stress radiography
compared with clinical examination, stability, under anaesthesia and arthroscopic or operative
findings Ann Chir Gynaecol. 1986;75:37-43.

2
Harilainen A. Evaluation of knee instability in acute ligamentous injuries. Ann Chir Gynaecol.
1987;76:269-273.
 FIGURE 14-22 Varus Stress Test (LCL)

Screening out Medial Collateral Ligament Laxity or Tears

Valgus Stress Test (MCL)
1. Patient is in a supine position.
2. Patient's knee is flexed to 20°.
3. Valgus stress applied to knee.
4. (+) if pain or laxity is present.

Reliability Sensitivity Specificity +LR −LR

k = 0.163 862-1001 NT NA NA

1
Harilainen A et al. Diagnosis of acute knee ligament injuries: The value of stress radiography
compared with clinical examination, stability, under anesthesia and arthroscopic or operative
findings. Ann Chir Gynaecol. 1986;75:37-43.

2
Harilainen A. Evaluation of knee instability in acute ligamentous injuries. Ann Chir Gynaecol.
1987;76:269-273.

3
McClure P,W et al. Intertester reliability of clinical judgments of medial knee ligament integrity.
Phys Ther. 1989;69:268-275.
 FIGURE 14-23 Valgus Stress Test (MCL)

Patellofemoral Joint Pain

Prevalence Symptoms DSM/Signs TBC/Special Tests

Tibiofemoral Pain control

rotation
Stabilize:
Insidious Knee
onset Can be hyperextension Foot and knee orthotics7
bilateral15
Patellar tracking Resistive brace
Diffuse
retropatellar Weakness of quads, Patella taping5,7
knee pain18 hip abd, ER6,18
Correction of movement
Patellar Increased Q-angle impairment exercise:
creptitus
Faulty lower Muscle length/strength
17 Locking (hip, knee, ankle)
Active individuals extremity mechanics

Young adults and Knee joint Overuse Quadriceps strengthening

adolescents 25% of their stiffness
Lateral retinaculum Biofeedback
orthopaedic complaints18
Decreased tightness8,9
activity Weight-bearing and non-
25-40% of all knee problems
levels1011121314 Instability3 weight-bearing quadriceps
in sports medicine clinics17
strengthening16
Females > Males18 Pain with: Crepitus3
Runners7 Prolonged Decreased flexibility Vastus medialis4
sitting in quads, hams, IT coordination test
band3,6
Stair descent Patellar apprehension test4
Ligamentous laxity6
Squatting1,15 Eccentric step down test4
Tenderness to
Ant. knee palpation2 McConnell Test
pain1,3
Leg length Lateral tilt test2,3,5
Knee discrepancy2,7
buckling3 Ober's, Thomas, SLR
Forefoot valgus and Test2,3,6,7
decreased great toe
extension1,7 Patellar mobility Test6

Patellar compression test6

1
Cleland J. Orthopaedic Clinical Examination: An Evidence-Based Approach for Physical Therapy.
Carlstadt, NJ: Learning Systems. 2005; 285.

2
Magee D. Orthopedic Physical Assessment. Philadelphia, PA: Elsevier. 2006; 727-728.

3
Brotzman S, Wilk KE. Clinical Orthopaedic Rehabilitation. Pliladelphia, PA: Mosby. 2003; 319-326.

4
Nijs J, et al. Diagnostic value of five clinical tests in patellofemoral pain syndrome. Man Ther.
2006;11(1):69-77.

5
Gabriel NG, et al. The effects of patellar taping on pain and neuromuscular performance in
subjects with patellofemoral pain syndrome. Clin Rehabil. 2002;16:821-827.

6
Fredericson M. Physical examination and patellofemoral pain syndrome. Am J Phys Med Rehabil.
2006;85:234-243.

7
Sutlive, T. Identification of individuals with patellofemoral pain whose symptoms improved after a
combined program of foot orthosis use and modified activity: A preliminary investigation. Phys Ther.
Jan 2004;84:50-61.

8
Mariani PP, Caruso I. An electromyographic investigation of subluxation of the patella. J Bone
Joint Surg Br. 1979;61:169-171.

9
Westfall DC, Worrell TW. Anterior knee pain syndrome: Role of the vastus medialis oblique. J Sport
Rehabil. 1992;1:317-325.

10
Ficat RP. Lateral fascia release and lateral hyperpressure syndrome. In: Pickett JC, Radin EL, eds.
Chondromalacia of the Patella. Baltimore, MD: Williams & Wilkins. 1983; 95-112.

11
Greenfield MA, Scott WN. Arthroscopic evaluation and treatment of the patellofemoral joint.
Orthop Clin North Am. 1992;23:587-600.

12
James SL. Chondromalacia of the patella in the adolescent. In: Kennedy JC, ed. The Injured
 Adolescent Knee. Baltimore, MD: Williams & Wilkins. 1979; 205-251.

13
Kannus P, Nittymaki S. Which factors predict outcome in the nonoperative treatment of
patellofemoral pain syndrome? A prospective follow-up study. Med Sci Sports Exerc. 1994;26:289-
296.

14
Radin EL. Does chondromalacia patella exist? In: Pickett JC, Radin EL, eds. Chondromalacia of the
Patella. Baltimore, MD: Williams & Wilkins; 1983:68-82.

15
Post MD, Fulkerson MD. Knee pain diagrams: Correlation with physical examination findings in
patients with anterior knee pain. Arthroscopy. 1994;10:618-623.

16
Harrington L, Al-Sherhi A. A controlled trial of weight-bearing versus non-weight-bearing
exercises for patellofemoral pain. J Orthop Sports Phys Ther. 2007;37(4):155-160.

17
Bizzini M, Childs CJD, Piva SR, Delitto A. Systematic review of the quality of randomized
controlled trials for patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2003;33:4-20.

18
Ireland ML et al. Hip strength in females with and without patellofemoral pain. J Orthop Sports
Phys Ther. 2003;33:671-676.

Ruling in Patellofemoral Pain Syndrome

Vastus Medialis Coordination Test (Nijs, 2005)
1. Patient lays in a supine position.
2. Examiner places his/her fist under the subject's knee.
3. Patient is asked to extend the knee slowly without pressing down or lifting
away from the examiner's fist.
4. Patient is instructed to achieve full extension.
 FIGURE 14-24 Vastus Medialis Coordination Test (Nijs, 2005)

5. (+) test when a lack of coordinated full extension was evident; extension
motion not smooth/inappropriate use of hip flexors or extensors.

+LR −LR

2.26 0.9

Nijs J et al. Diagnostic value of five clinical tests in patellofemoral pain syndrome Man Ther.
2006;11(1):69-77.

Patellar apprehension Test

1. Patient is in a supine position and relaxed.
2. Examiner uses hand to push patient's patella to as lateral as possible.
3. Start with knee flexed to 30°.
4. Examiner grasps leg at ankle/heel with other hand.
5. Examiner performs a slow, combined flexion in the knee and hip.
6. Lateral glide is sustained through the test.
7. (+) test if pain or apprehension is present.
 FIGURE 14-25 Patellar Apprehension Test

+LR −LR

2.26 0.79

Nijs J, et al. Diagnostic value of five clinical tests in patellofemoral pain syndrome Man Ther.
2006;11(1):69-77.

Eccentric Step Test

Unilateral Test
1. Patient stands on top of 8-inch platform or step (20.32 cm).
2. Subject is asked to step forward and down toward the floor.
3. The descending limb brushes the floor with the heel and then is brought
back up to the step.
4. This is one repetition.
5. Make sure each repetition is done such that the step limb is not used to
accelerate back onto the step.
 FIGURE 14-26 Ecceentric Step Test

6. The number of repetitions the subject performs in 30 seconds is recorded.

Both limbs are tested.
7. (+) test is pain reproduction.

Study Reliability Sensitivity Specificity +LR −LR

Nijs, et al. NT 42 82 2.34 0.71

Loudon, et al. ICC = 0.94 NT NT NA NA

Nijs J, et al. Diagnostic value of five clinical tests in patellofemoral pain syndrome Man Ther.
2006;11(1):69-77.

Loudon JK et al. Intrarater reliability of functional performance tests for subjects with
patellofemoral pain syndrome. J Athl Train. 2002; 37(3):256-261

McConnell Test
1. Patient is seated at edge of table.
2. Repeat isometric testing of quadriceps at 0°, 30°, 60°, 90°, 120° of knee
flexion.
3. Take note of painful ranges and retest while stabilizing patella laterally.
4. (+) test when lateral stabilization eliminates pain.
[circled white star] I like to use the range in which the test is positive as a start
position for taping.

FIGURE 14-27 McConnell Test

Reliability Sensitivity Specificity +LR −LR

NT NT NT NA NA

McConnell J. The management of chondromalacia patellae: A long-term

solution. Austr J Physiother. 1986;32:215-223.

[circled white star] Useful as a quick functional test:

Measure angle of knee flexion at which you find pain is reproduced, and use as
objective measure for documentation.

Patellar Taping
 CPR for Patellofemoral pain patients whom you should tape with a medial glide

(+) patellar tilt test

or

Tibial varum > 5 degrees

Presence of either of the two variables +LR (4.4)

Lesher JD, et al. Development of a clinical prediction rule for classifying patients with
patellofemoral pain syndrome who respond to patellar taping. J Orthop Sports Phys Ther.
2006;36(11):854-866.

FIGURE 14-28 Patellar Taping

Patellar Position Assessment

[circled white star] Studies show that intra- and interexaminer reliability is
essentially poor.
[circled white star] Fitzgerald et al suggests that the taping that provides the
most relief is the taping that should be used, regardless of assessment during
evaluation.

Suggestions for use of Patellar Taping

1. Use symptom response for determining appropriate taping direction.
2. Multiple applications may be necessary.
3. Taping has been shown to be useful for decreasing complaints of pain in
patients with patellofemoral pain.
Fitzgerald GK, McClure PW. Reliability of measurements obtained with four
tests of patellofemoral alignment. Phys Ther. 1995;75(2):84-90.
Bockrath K, Wooden C, Worrell T, Ingesoll C, Farr J. Effects of patellar taping
on patella position and perceived pain. Med Sci Sports Exerc. 1993;25:989-992.
Powers C, et al. The effects of patellar taping on stride characteristics and
joint motion in subjects with patellofemoral pain. J Orthop Sports Phys Ther.
1997;26:286-291.
Watson CJ, Propps M, Galt W, Redding A, Dobbs D. Reliabiilty of McConnell's
classification of patellar orientation in symptomatic and asymptomatic subjects.
J Orthop Sports Phys Ther. 1999;29:378-393.
Tomsich DA, Nitz AJ, Threlkeld AJ, Shapiro R. Patellofemoral alignment:
Reliability. J Orthop Sports Phys Ther. 1996;23:200-208.

CPR for Orthotics and Patellofemoral Pain (Unvalidated)

[circled white star] For whom should I use “off the shelf” orthotics and activity
modification as an intervention for patellofemoral pain?
Patients who present with the following:

Forefoot valgus ≥ 2 degrees +LR = 4.0 95% confidence interval 0.7-21.9

Great toe extension ≤ 78 degrees +LR = 4.0 95% confidence interval 0.7-21.9

Navicular drop of ≤ 3 mm +LR = 2.4 95% confidence interval CI = 1.3-4.3

Sutlive TG, et al. Identification of individuals with patellofemoral pain whose symptoms improved
after a combined program of foot orthosis use and modified activity: A preliminary investigation.
Phys Ther. 2004;84(1):49-61.
Patellar Tendonosis (Jumper's Knee)

TBC/Special
Prevalence Symptoms Signs/DSM
Tests

Pain
control

Correction
Knee extension of
movement
> 7mm thick and wider impairment
Teenage boys, esp. during patellar tendon3
growth spurt2 Educate:
Pain reproduced by Quadriceps atrophy, patellar
40% in high-level volleyball resisted knee hypermobility, edema on Activity
players3 extension2 infrapatellar tendon, nodules modification
and crepitus3
Frequency of playing Anterior knee pain2 Exercise:
athletes who practiced 5x Decreased quadriceps and
Sharp or aching Eccentric
per week 41.8% incidence3 hamstring flexibility6
pain3 exercises3,4
Surface played on—37.5% Phase 1—Pain after
Feeling of “giving Stretch
from playing on cement3 participation quadriceps
way” with the
Insidious onset of ant. knee absence of true Phase 2—Pain during and
pain; comes on during or locking or catching1 participation that doesn't limit hamstring5,6
soon after repetitive running performance
Pain near insertion Muscle
or jumping1
of tendon at inferior Phase 3—Pain during length and
Most often basketball, pole1 participation that limits strength
volleyball, and track1 performance
Palpate
Phase 4—Complete tendon tendon
disruption1 Pain with
active
contraction
of
quadriceps

1
Brotzman BS, Wilk KE. Clinical Orthopedic Rehabilitation. 2nd ed. Philadelphia, PA: Mosby Inc;
2003.

2
Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: Part II. Differential
diagnosis. Am Fam Phys. 2003;68(5):917-922.
3
Hale S. Etiology of patellar tendinopathy in athletes. J Sports Rehab. 2005;14:258-272.

4
Jensen K, Difabio RP. Evaluation of eccentric exercise in treatment of patellar tendonitis. Phys
Ther. 1989;69:211-216.

5
Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendonitis. Clin Orthop.
1986;208:65-68.

6
Witvrouw E, Bellemans J, Roeland L, Lieven D, Cambier D. Intrinsic risk factors for the
development of patellar tendinitis in an athletic population. Am J Sports Med. 2001;29:190-195.

Iliotibial Band Friction (ITB) Syndrome

Prevalence Symptoms DSM/Signs TBC/Special Tests

History of pain on the lateral aspect Pain control

of the knee during running5,8
Correction of
Distance runners 4- Tenderness over lateral femoral movement
Tibiofemoral
7% of lower condyle with repetitive flexion and impairment
rotation
extremity injuries5,8 extension of the knee5,8
Exercise:
Training
Runners4 Worse running down hill Running long errors3 Strengthen gluteus
distances or with long strides
maximus and
Cyclists9 Genu varus2
Grade 1: Pain after the run and not posterior gluteus
Dancers10 restricting the distance or the speed medius11
Cavus foot1
of running
Military recruits6,7 Leg length Stretching ITB,
Grade 2: Pain during the run but not iliopsoas, rectus
discrepancy2
Weight lifters 5 restricting the distance or the speed femoris,
of running Road gastrocnemiussoleuss
Downhill skiers5 camber2
Grade 3: Pain during the run and Educate:
Athletes engaged in severe enough to restrict distance or Hard running
speed Rest
circuit training5 shoes7
Grade 4: Pain so severe that it Ober Test
prevents running
Modified Ober Test

1
Krissof WB, Ferris WD. Runners' injuries. Phys Sportsmed. 1979;7:53-71.

2
Lindenburg G, Rinshaw R, Noakes TD. Iliotibial band friction syndrome in runners. Phys Sportsmed.
1984;12:118-130.
 3
Nobel CA. The treatment of iliotibial band friction syndrome. Br J Sports Med. 1979;13:51-54.

4
Noble HB, Hajek R, Porter M. Diagnosis and treatment of iliotibial band tightness in runners. Phys
Sportsmed. 1982;19:67-74.

5
Orava S. Iliotibial tract friction syndrome in athletes: An uncommon exertion syndrome of the
lateral side of the knee. Br J Sports Med. 1978;12:69-73.

6
Renne JW. The iliotibial band friction syndrome. J of Bone Joint Surg. 1975;57A:1110-1111.

7
Fredericson M, et al. Quick solutions for iliotibial band syndrome. Phys Sportsmed. 2000;28(2):52-
68.

8
Sutker AN, Brarber FA, Jackson DE, Pagliano JW. Iliotibial band syndrome in distance runners.
Sports Med. 1985;2:447-451.

9
Holmes JC, Pruitt AL, Whalen NJ. Iliotibial band syndrome in cyclists. Am J Sports Med.
1993;21(3):419-424.

10
Winslow J, Yoder E. Patellofemoral pain in female ballet dancers: Correlation with iliotibial band
tightness and tibial external rotation. J Orthop Sports Phys Ther. 1995;22(1):18-21.

11
Powers CM. The influence of altered lower-extremity kinematics on patellofemoral point
dysfunction: A theoretical perspective. J Orthop Sports Phys Ther. 2003;33:639-646.

Assessing the Length of the Iliotibial Band

Ober Test (Unvalidated)
1. Patient lies sidelying with the symptomatic leg placed upward.
2. Examiner prepositions the knee into flexion.
3. Examiner stabilizes the pelvis at the iliac crest.
4. Examiner guides the lower extremity into extension and slight abduction.
5. Using a inclinometer, examiner measures the degree of abduction or
adduction.
6. A comparison of both sides is warranted.
7. (+) test is failure of the knee to drop to the plinth (hip adduction).
 FIGURE 14-29 Ober Test (Unvalidated)

Reliability Sensitivity Specificity +LR −LR

Melchione, et al. (goniometer) 0.94 ICC NT NT NA NA

Reese, et al. Obers (inclinometer) 0.90 ICC NT NT NA NA

Reese, et al. Modified Obers (inclinometer) 0.91 ICC NT NT NA NA

Melchione W, Sullivan S. Reliability of measurements obtained by use of an instrument designed to

measure iliotibial band length indirectly. J Orthop Sports Phys Ther. 1993;18:511-515.

Reese NB, Bandy WD. Use of an inclinometer to measure flexibility of the iliotibial band using the
Ober Test and the Modified Ober Test: Differences in magnitude and reliability of measurements. J
Orthop Sports Phys Ther. 2003;33(6):326-330.

[circled white star] Modified Ober (knee straight) has proven to have very good
reliability as well. I do the Modified Ober exclusively to improve reliability and
because much of the IT band friction problems take place closer to knee
extension.
 FIGURE 14-30 Modified Ober

Pes anserine Bursitis

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Tibiofemoral
hypo/hypermobility
Knee
hyperextension
Pain
2.5% of patients Pain climbing stairs and with OA (93%)2,6 control
suspected of having exercise1,3,4 Swelling on the Correction
pain from internal medial aspect of the
Pain along the medial joint line of
derangement9
knee3,6 movement
mimicking a medial meniscal tear1
Runners1 impairment
Pain localized to anteromedial DM6
Degenerative joint Exercise
aspect of knee, 4 to 5 cm below
Decreased Rom
disease or rheumatoid joint line, often exacerbated by
(esp. extension)1,6 Educate
arthritis7,8 knee flexion6
Decreased Palpation5
hamstring
strength,1,4,6, tight
hamstrings1
1
Rennie WJ, Saifuddin A. Pes anserine bursitis: incidence in symptomatic knees and clinical
presentation. Skeletal Radiol. 2005;34(7):395-398.

2
Yoon HS, et al. Correlations between ultrasonographic findings and the response to corticosteroid
injection in pes anserinus tendinobursitis syndrome in knee osteoarthritis patients. J Korean Med
Sci. 2005;20(1):109-112.

3
Koh WL, et al. Clinics in diagnostic imaging: Pes anserine bursitis. Singapore Med J. 2002;43:9:485-
491.

4
American Academy of Orthopaedic Surgeons. Pes Anserine Bursitis. 2002.

5
Sports Medicine Advisor. Pes Anserine Bursitis. University of Michigan. UMHS. 2005.

6
Alzner S, Jerome E, Casby J. Standard of Care: Pes Anserine Bursitis. Brigham & Women's
Hospital. Department of Rehabilitation Services. 2005.

7
Larsson LG, Baum J. The syndrome of anserine bursitis: An overlooked diagnosis. Arthritis Rheum.
1985;28(1):1062-1065.

8
Brookler MI, Mongan ES. Anserine bursitis: A treatable cause of knee pain in patients with
degenerative arthritis. Calif Med. 1973;119:8-10.

9
Rennie WJ, Saifuddin A. Pes anserine bursitis: Incidence in symptomatic knees and clinical
presentation. Skeletal Radiol. 2005;34(7):395-398.
 FIGURE 14-31 Commonly Irritated Bursae of the Knee Souza, TA. Differential Diagnosis
and Management for the Chiropractor: Protocols and Algorithms. © 2009 Jones &
Bartlett Publishers, LLC

Osteochondritis Dessicans

Prevalence Symptoms DSM/Signs TBC/Special Tests

6 per 10,000
men2

3 per 10,000
women2

2:1 Male to Pain control

female
Stabilize
males 10- 20
Tibiofemoral rotation Correction of
y/o1,3 Pain medial femoral
condyle2,3,4 movement impairment
2 Lack knee extension1
20-45 y/o
Pain at end Exercise
Mild osteoporosis2
Athletes1,5 ranges2,3 Knee pain that fails to Refer out
improve with treatment5
Trauma2,3,4 Limping2 X-ray1,2,5

Ischemia2,5 MRI1,2

Repetitive CT scan2
microtrauma2,3,4

Knee MC2,3,4,5

Hereditary4

1
Peterson L. Treatment of osteochondritis dissecans of the knee with autologous chondrocyte
transplantation. J of Bone Joint Surg. 2003;85:17-24.

2
Bui-Mansfield, LT. Osteochondritis dissecans. American Radiology. Thesis, Wake Forrest. 2003.

3
Aichroth P. Osteochondritis dissecans of the knee. J of Bone Joint Surg. 2006;14(2):90-100.

4
Green JP. Osteochondritis dissecans of the knee. J of Bone Joint Surg. 2006;14(2):101-110.

5
Tomberlin JP, Saunders HD. Evaluation, Treatment, and Prevention of Musculoskeletal
Disorders, vol 2. Philadelphia, PA: The Saunders Group. 1995; 65.

Osgood Schlatter Disease

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Pain
control:

Ice9

10% of painful knees6 Education:9

Age: Athletic, skeletally Knee extension Eliminate

immature 8-16 y/o4 aggravating
Traction apophysitis of tibial factors for
Gender bias: Previously Pain tuberosity 3.2
male, but with increased months7,8
female participation, gap is Swelling/Tenderness 5 cardinal signs of
narrowed2 over tibial inflammation, difference in 7.3 months
tuberosity girth measurements of activity
72% of Osgood Schlatte found Worsens with Deep ache (bone limitation/
in males6 activity such as microtrauma), pain with modification8
running, jumping, quadriceps contraction,
Bilateral involvement in 32% and climbing stairs3 possibly gait deviations and Wearing
of cases6 functional step padding—
down/up/lateral infrapatellar
Contributing factors: Sports discrepancies1,3,4,5 strap5
with powerful quadriceps
contractions (microtrauma), Correction
mechanical (insertion of of
tendon), growth, traumatic1 movement
impairment

Palpation

US imaging10

1
Demirag B, Ozturk C, Yazici Z, Sarisozen, B. The pathophysiology of Osgood-Schlatter disease: A
magnetic resonance investigation. J Pediatr Orthop B. 2004;13(6):379-382.

2
Ross M, Villard D. Disability levels of college-aged men with a history of Osgood-Schlatter disease. J
Strength Cond Res. 2003; 17(4):659-663.

3
Roye, B. Osgood-Schlatter disease. U.S. National Library of Medicine and National Institutes of
Health; 2004.

4
Saunders H, Tomberlin J. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders,
vol. 2: Extremities. Philadelphia, PA: The Saunders Group. 1995; 217-260.

5
Brotzman S, Wilk K. Clinical Orthopaedic Rehabilitation. 2nd ed. St. Loius, MO: Mosby. 2003; 252-
300.

6
Antich TJ, et al. Clinical presentation of Osgood-Schlatter disease in the adolescent population. J
Orthop Sports Phys Ther. 1985;7(1):1-4.

7
Antich TJ, et al. Osgood-Schlatter disease: Reivew of literaly and physical therapy management. J
Orthop Sports Phys Ther. 1985;7(1):5-10.

8
Kujala UM, Kvist M, Heinonen O. Osgood-Schlatter's disease in adolescent athletes: Retrospective
study of incidence and duration. Am J Sports Med. 1985;13:236-241.

9
Beovich R, Fricker PA. Osgood-Schlatter's disease: A review of the literature and an Australian
series. Aust J Sci Med Sport. 1988;20:11-13.

10
Blankstein A. Ultrasonography as a diagnostic modality in Osgood-Schlatter disease: A clinical
study and review of the literature. Arch Orthop Trauma Surg. 2001;121(9):536-539.
Chapter 15
The Ankle and Foot

Hindfoot Resting Position Closed Pack Capsular Pattern

Tibiofibular P-Flex Max. D-Flex Pain on stress

Talocrural 10° P-Flex midway between inv. and ever. Max. D-Flex P-Flex > D-Flex

Subtalar Midway between extreme ROM Supination Varus > Valgus

Midfoot Resting Position Closed Pack Capsular Pattern

Midtarsal Midway between extreme ROM Supination D-flex > P-Flex > Add. > IR

Closed
Forefoot Resting Position Capsular Pattern
Pack

Tarsometatarsal Midway between extreme ROM Supination None

Midway between extreme ROM Big toe: Ext > Flex Toes 2-5:
Metatarsophalangeal Full ext.
(10° ext.) Variable

Interphalangeal Slight flex. Full ext. Flex > Ext

Ankle Motion Range of Motion

Dorsiflexion 0-20°
Plantarflexion 0-50°/60°

Inversion 35°

Eversion 20°
 FIGURE 15-1 (A) Major Bones and Joints of the Foot (Lateral View); (B) Major Bones
and Joints of the Foot (Medial View); (C) Major Ligaments of the Ankle Joint (Lateral
View)
Souza, TA. Differential Diagnosis and Management for the Chiropractor: Protocols and
Algorithms. © 2009 Jones & Bartlett Publishers, LLC

FIGURE 15-2 Treatment-Based Classification for the Lower Leg, Ankle, and Foot
Regions

Outcome Tools
LEFS—Lower Extremity Functional Scale
GROC—Global Rating of Change
PSFS—Patient-Specific Functional Scale
Ankle TBC References
Exercise
Shamus J, Shamus E, Gugel RN, Brucker BS, Skaruppa C. The effect of sesamoid
mobilization, flexor hallicus strengthening, and gait training on reducing pain
and restoring function in individuals with hallux limitus: A clinical trial. J
Orthop Sports Phys Ther. 2004;34:368-376.
Bullock-Saxton JE. Local sensation changes and altered hip muscle function
following severe ankle sprain. Phys Ther. 94;74:17-31.
Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6
weeks of eccentric exercise inpatients with mid-portion Achilles tendinopathy:
A randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;14: 286-
295.
Wester JU, Jespersen SM, Nielsen KD, Neumann L. Wobble board training after
partial sprains of the lateral ligaments of the ankle: a prospective randomized
study. J Orthop Sports Phys Ther. 1996;23:332-336.
Digiovanni BF, et al. Plantar fascia-specific stretching exercise improves
outcomes in patients with chronic plantar fasciitis: A prospective clinical trial
with 2-year follow-up. JBJS. 2006;88-A(8):1775-1781.

Stabilization
Hals TM, Sitler MR, Mattacola CG. Effect of a semirigid ankle stabilizer on
performance in persons with functional ankle instability. J Orthop Sports Phys
Ther. 2000;30:552-556.
Ator R, Gunn K, McPoil TG, Knecht HG. The effect of adhesive strapping on
medial longitudinal arch support before and after exercise. J Orthop Sports
Phys Ther. 1991;14:18-23.
Daniels TR, Lau JT-C, Hearn TC. The effects of foot position and load on tibial
nerve tension. Foot Ankle Int. 1998;19:73-78.
Vicenzio B. Foot orthotics in the treatment of lower limb conditions: A
musculoskeletal physiotherapy perspective. Man Ther. 2004;9:185-196.

Mobilization
Collins N, Teys P, Vicenzio B. The initial effects of a Mulligan's mobilization
with movement technique on dorsiflexion and pain in subacute ankle sprains.
Man Ther. 2004;9:77-82.
Mooney M. Cuboid plantar and dorsal subluxations: Assessment and treatment.
JOSPT. 1994;20(4):220-226.
Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a
passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther.
2001;81(4):984-94.

Pain Control
Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue
injury? J Athl Train. 2004;39(3):278-279.

Achilles Tendinopathy

Prevalence Symptoms DSM/Signs TBC/Special Tests

Feeling of Plantarflexion
being kicked in Swelling6
the posterior Achilles tendon repair NWB 2 wk
Achilles Tendon ankle6 Inability to palpate plantarflexion
Rupture Achilles tendon or
Feeling or palpable defect6,8 Stabilize Orthotic11 Pain control
Commonly men aged hearing a
30-505,6 “pop”6 Small knot or bulge Mobilize Exercise ROM2
at the proximal
Strenuous physical Mild to portion of Achilles6 Strengthening2 Proprioceptive
activity6 moderate pain training2
in the Loss of true
*20-30% are not posterior gastrocnemius and Thompson Test/Calf squeeze
diagnosed in the ankle6 soleus resisted test4,6,8 Volumetric
initial visit6 plantar flexion8 displacement9 “Figure 8” girth
Inability to measurement9
continue Weak or absent
activity6 Achilles reflex8

Plantarflexion

Pain with weight

Achilles Tendonitis bearing9

Any age6 Pain over Tenderness to Educate

Achilles palpation of Achilles
Males > females tendon6,9 Rest6,9
tendon6,9
High mileage runners Pain with Crepitus on Pain control
and jumpers3 activity9 palpation9
Ice6,9
Ballet dancers3 Heel pain6 Edema3,9
Non-steroidal anti-inflammatory
General population, Stiffness6
Tendon thickened , 6 9 drugs6,9
elderly, and
sedentary and obese Pain with ROM3,6,9 Corticosteroid injections3
individuals3
Marked weakness
and decrease in
push-off strength3

Pain control1
Achilles tendinosis > May produce Stabilize
35 years6 no clinical
Heel lifts6 Correction of
Recreational male symptoms3,6 Plantarflexion
Painless, palpable malalignments1
runners aged 35-45
Pain during nodule on Achilles
years1 Exercise
loading of tendon6
Achilles
Patients with Eccentric gastroc-soleus
tendon1
sedentary lifestyle1 strengthening7,9 Stretching6,9

Mobilize

1
Alfredson H, Lorentzon R. Chronic Achilles tendinosis: Recommendations for treatment and
prevention. Sports Med. 2000;29(2):135-146.

2
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd ed. K. Daugherty, ed.
Philadelphia, PA: Mosby; 2003.

3
Canton D, Marks R. Corticosteroid injections and the treatment of Achilles tendonitis: A narrative
review. Res Sports Med. 2003;11:79-97.

4
Cleland J. Orthopaedic Clinical Examination: An Evidence-Based Approach for Physical
Therapists. Carlstadt, NJ: Icon Learning Systems; 2005.

5
Khan RJK, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon
ruptures: A meta-analysis of randomized, controlled trials. J Bone Joint Surg. 2005;87-A(10), 2202-
2210.

6
Mazzone MF, McCue T. Common conditions of the Achilles tendon. Am Fam Physician.
2002;65(9),1805-1810.

7
Ohnberg L, et al. Eccentric training in patients with chronic Achilles teninosis: Normalised tendon
structure anddecreased thickness with followup. Br J Sports Med. 2004;38:8-11.
 8
Ramelli FD. Diagnosis, management, and post-surgical rehabilitation of an Achilles tendon rupture:
a case Report. J Canadian Chiro Assoc. 200;47(4):261-268.

9
Saunders HD, Tomberlin JP. In: Evaluation, Treatment, and Prevention of Musculoskeletal
Disorders, vol. 2. 3rd ed. Beissner KL, Saunders R, eds. Chaska, MN: The Saunders Group; 1994.

10
Wallace RGH, Traynor IER, Kernohan WG, Eames MHA. Combined conservative and orthotic
management of acute ruptures of the Achilles tendon. J Bone Joint Surg. 2004;86-A(6):1198-1202.

Screening out Achilles Tendon Tears

Thompson Test
1. Patient lies in a supine position.
2. Examiner applies a squeeze to the calf of the patient's affected leg.
3. (+) test is a nonresponse during the squeeze test.

FIGURE 15-3 Thompson Test

Reliability Sensitivity Specificity +LR −LR

NT 96 NT NA NA
Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon. A
prospective study in 174 patients. Am J Sports Med. 1998;26(2):266-270.

Ankle Sprain

Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control

Cryotherapy2,4,5,6,7
Vasopneumatic
devices/compressive
sleeves2,4,5,7 Elevation2,4
Inversion (MC)
Eversion Stabilize
Difficulty with Early joint protection with
weight crutches and ankle
2 million injuries per year2,4 7
injuries per 1000 people 23,000 bearing2,6,7 supports2,4,7
injuries per day in the United States5 Post-traumatic Mobilize
edema2,5,6,7
14-33% of all sports-related injuries4 Thrust or nonthrust
2 6
Grade I Ecchymosis , manipulation3
Pain in
- Usually partial tear of ATFL Diminished Exercise
the
(anterior talofibular ligament) proprioception5
ankle2,5 Proprioceptive
Grade II
2 7
ROM limited , exercises4,6,7 ROM4,7 Muscle
Stiffness5
strengthening4,7
Complete tear of ATFL and partial Instability or
calcaneofibular “giving way” of Ottawa ankle and foot
joint2,4,5,7 rules1,2
Grade III
Tenderness to Anterior drawer1,2,7
Complete tear of ATFL and palpation of
calcaneofibular injured Inversion stress/Medial
ligaments7 subtalar glide1,2,7

Bone Talar tilt1,2,7

tenderness2,6
Crossed-leg test2

Volumetric displacement7

“Figure 8” girth
measurements7
 1
Cleland J. Orthopaedic Clinical Examination: An Evidence-Based Approach for Physical
Therapists. Carlstadt, NJ: Icon Learning Systems; 2005.

2
Ivins D. Acute ankle sprain: An update. Am Fam Physician. 2006;74:1714-1720, 1723-1724, 1725-
1726.

3
Whitman JM, et al. Predicting short-term response to thrust and nonthrust manipulation and
exercise in patients post inversion ankle sprain. J Orthop Sports Phys Ther. 2009;39(3):188-200.

4
Osborne MD, Rizzo TD Jr. Prevention and treatment of ankle sprain in athletes. Sports Med.
2003;33(15):1145-1150.

5
Paige NM, Nouvong A. Top 10 things foot and ankle specialists wish every primary care physician
knew. Mayo Clin Proc. 2006;81(6):818-822.

6
Smith M. Ankle sprain: A literature search. Emerg Nurse. 2003;11(3):12-16.

7
Tomberlin JP, Saunders HD. In: Evaluation, Treatment, and Prevention of Musculoskeletal
Disorders, vol. 2. 3rd ed. Beissner KL, Saunders R, eds. Chaska, MN: The Saunders Group; 1994.

*CPR for patients who respond well to Manual Therapy and

Exercise post inversion ankle sprain

Symptoms worse when standing

Symptoms worse in evening
Navicular drop > 5.0 mm
Distal tibiofibular joint hypomobility 3 of 4 variables tLR(5.5)

Whitman JM, et al. Predicting short-term response to thrust and nonthrust

manipulation and exercise in patients post inversion ankle sprain. J Orthop
Sports Phys Ther. 2009;39(3):188-200.

Screening out ankle and Foot Fractures

[circled white star] If 3 variables present LR 5.90, 95°1, probability of success
with manual therapy.

Ottawa Ankle Rules

Refer out for ankle radiographs if any one of the following are present:
Bone tenderness at posterior aspects of the medial malleolus
Bone tenderness at the lateral malleolus
Bone tenderness at the base of the fifth metatarsal
Bone tenderness at the navicular
Inability to weight-bear immediately after the injury and in the emergency
room

FIGURE 15-4 Ottawa Ankle Rules A

FIGURE 15-5 Ottawa Ankle Rules B

Sensitivity -LR

97.6 0.1

Bachmann LM, et al. Accuracy of Ottawa ankle rules to exclude fractures of the
ankle and mid-foot: Systematic review. BMJ. 2003;326(7386):417.

Screening out/Ruling in Damage to the Syndesmosis

Fibular Translation Test
1. Patient lies in a sidelying position.
2. Examiner applies anterior and posterior forces on the fibula at the level of
the syndesmosis.
3. (+) test is pain during translation and more displacement to the fibula than
on the compared side.

Reliability Sensitivity Specificity +LR -LR

NT 82 88 6.8 0.2

Beumer A, et al. Clinical diagnosis of syndesmotic ankle instability: Evaluation

of stess tests behind the curtains. Acta Orthop Scand. 2002;73(6):667-669.

FIGURE 15-6 Fibular Translation Test

External Rotation Test

1. Patient lies in a supine position.
2. Knee is flexed to 90°.
3. Examiner holds the ankle in neutral position then applies an externally
rotated movement to the ankle.
4. (+) test is reproduction of concordant symptoms during movement.

Study Reliability Sensitivity Specificity +LR -LR

Alonso 0.75 kappa NT NT NA NA

Beumer NT NT 95 NA NA

Alonso A. et al. Clinical tests for ankle syndesmosis injury: Reliability and
prediction of return to function. J Orthop Sports Phys Ther. 1998;27(4):276-284.
Beumer A. et al. Clinical diagnosis of syndesmotic ankle instability: Evaluation
of stess tests behind the curtains. Acta Orthop Scand. 2002;73(6):667-669.

FIGURE 15-7 External Rotation Test

Squeeze Test (Unvalidated)

1. Patient lies in a supine or sidelying position.
2. Examiner applies manual squeeze, pushing the fibula into the tibia and
applying force at the midpoint of the calf.
3. (+) test if the proximal force causes distal pain near the syndesmosis.

Reliability Sensitivity Specificity +LR -LR

0.5 kappa NT NT NA NA

Alonso A, et al. Clinical tests for ankle syndesmosis injury: Reliability and
prediction of return to function. J Orthop Sports Phys Ther. 1998;27(4):276-284.

FIGURE 15-8 Squeeze Test (Unvalidated)

Screening out/Ruling in Damage to the Anterior Talofibular

Ligament
Anterior Drawer Test
1. Patient lies in a supine position.
2. Ankle is prepositioned into slight plantar flexion.
3. Examiner provides an anterior glide of the calcaneus and talus on the
stabilized tibia.
4. (+) test is excessive translation of one side in comparison to the opposite
extremity.
 Reliability Sensitivity Specificity +LR -LR

NT 78 75 3.1 0.29

Hertel J, et al. Talocrural and subtalar joint instabililty after lateral ankle
sprain. Med Sci Sports Exerc. 1999;31(11):1501-1508.

FIGURE 15-9 Anterior Drawer Test

Screening out/Ruling in Lateral Ligament Integrity

Medial Talar Tilt Stress Test
1. Patient is placed in a sitting or supine position.
2. Examiner grasps the ankle of the patient at the malleoli.
3. Examiner applies a quick medial thrust to the calcaneus.
4. (+) test is excessive laxity when compared to the opposite side.

Reliability Sensitivity Specificity +LR -LR

NT 67 75 2.7 0.44
Hertel J, et al. Talocrural and subtalar joint instabililty after lateral ankle
sprain. Med Sci Sports Exerc. 1999;31(11):1501-1508.

FIGURE 15-10 Medial Talar Tilt Stress Test (Subtalar Glide)

Test for Ankle Swelling

Figure 8 Test
1. Patient is in a supine or sitting position.
2. Examine using flexible tape measure.
3. Start at mid-point of the anterior aspect of the ankle.
4. Wrap tape distal to medial malleolus.
5. Distal to lateral malleolus.
6. Under the foot.
7. Return tape to starting point.
8. Read measurement.
9. (+) test is substantial difference in girth of one side compared to the other.
 FIGURE 15-11 Figure 8 Test

Reliability

0.98 ICC

Petersen EJ et al. Reliability of water volumetry and the figure eight method
on patients with ankle joint swelling. J Orthop Sports Phys Ther.
1999;29(10):609-615.

Ankle Impingement Syndrome (anterolateral, anterior,

posterior)

Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control
Mobilize Stabilize

Exercise
a,b) Dorsiflexion
Plantarflexion Lateral ankle
Inversion muscle
Prior history of inversion strengthening
32-76% of people
following ankle sprains ankle sprains4 c) Plantarflexion (fibularis group)14
report persistent
a) Subacute or chronic pain a,b,c) Limitation Proprioceptive
problems1,2,3,4,5,6
a) Anterolateral2,5 after inversion sprain Pain in of full ankle training with
the anterolateral ankle2,5 range13 balance board14
b) Anterior4,6
b) Injury or chronic traction a,b) Pain with Plantar flexion
c) Posterior3 on the anterior capsule dorsiflexion12 eversion MMT for
fibularis group
c) Dancers8,10 c) History of forced plantar c) Pain with en
flexion pointe (full a,b) forced
plantar dorsiflexion test
flexion)7,8,9,11
c) Posterior
impingement test
(forced
plantarflexion)

1
Smith RW, Reischl SF. Treatment of ankle sprains in young athletes. Am J Sports Med. 1986;14:465-
471.

2
Bassett FH III, Gates HS, Billys JB, Morris HB, Nikolaou PK. Talar impingement by the anteroinferior
tibiofibular ligament. J Bone Joint Surg Am. 1990;72:55-59.

3
Bureau NJ, Cardinal E, Hobden R, Aubin B. Posterior ankle impingement syndrome: MR imaging
findings in seven patients. Radiology. 2000;215:497-503.

4
Parkes JC II, Hamilton WG, Patterson AH, Rawles JG Jr. The anterior impingement syndrome of the
ankle. J Trauma. 1980;20:895-898.

5
Ferkel RD, Fasulo GJ. Arthroscopic treatment of ankle injuries. Orthop Clin North Am. 1994;25:17-
32.

6
Berberian WS, Hecht PJ, Wapner KL, DiVerniero R. Morphology of tibiotalar osteophytes in anterior
ankle impingement. Foot Ankle Int. 2001;22:313-317.

7
Brodsky AE, Khalil MA. Talar compression syndrome. Am J Sports Med. 1986;14:472-476.

8
Hamilton WG. Foot and ankle injuries in dancers. Clin Sports Med. 1988;7:143-173.

9
Quirk R. Talar compression syndrome in dancers. Foot Ankle. 1982; 3:65-68.

10
Quirk R. Common foot and ankle injuries in dance. Orthop Clin North Am. 1994;25:123-133.

11
Best A, et al. Posterior impingement of the ankle caused by anomalous muscles. J Bone Joint Surg
Am. Sep 2005;87:2075-2079.

12
Liu SH, et al. Diagnosis of anterolateral ankle impingement: Comparison between magnetic
resonance imaging and clinical examination. Am J Sports Med. 1997;25(3):389-393.

13
Robinson P, et al. Anteromedial impingement of the ankle: Using MR arthrography to assess the
anteromedial recess. AJR. 2002;178:601-604.
 14
Reischl SF, Noceti-Dewit LM. Current Concepts of Orthopaedic Physical Therapy. 2nd ed. The
foot and ankle: Physical therapy patient management utilizing current evidence. APTA Independent
Study Course 16.2.11.

Screening Out/Ruling in Ankle Impingement

Clinical Prediction Rule of Impingement
Five of six symptoms below considered (+) for ankle impingement
Anterolateral ankle joint tenderness
Anterolateral ankle joint swelling
Pain with forced dorsiflexion
Pain with single-leg squat on the affected side
Pain with activities
Absence of ankle instability

Reliability Sensitivity Specificity +LR -LR

NT 94 75 3.8 0.08

Liu SH, et al. Diagnosis of anterolateral ankle impingement: Comparison

between magnetic resonance imaging and clinical examination. Am J Sports
Med. 1997; 25(3):389-393.

Forced Dorsiflexion Test

1. Patient assumes a sitting position.
2. Examiner stabilizes the distal aspect of the tibia and places his or her thumb
on the anterloateral aspect of the talus near the lateral gutter.
3. Pressure is applied.
4. The examiner applies a forceful dorsiflexion movement.
5. (+) test is a reproduction of pain at the anterolateral aspect of the foot
during forced dorsiflexion.
 Reliability Sensitivity Specificity +LR -LR

0.36 κ 95 88 7.9 0.06

Alonso A, et al. Clinical tests for ankle syndesmosis injury: Reliability and
prediction of return to function. J Orthop Sports Phys Ther. 1998;27(4):276-284
Molloy S, et al. Synovial impingement in the ankle: A new physical sign. J Bone
Joint Surg Br. 2003;85(3):330-333.

FIGURE 15-12 Forced Dorsiflexion Test

Lateral Ankle Instability (Functional or Mechanical)

Prevalence Symptoms Signs TBC/Special Tests

Fibularis muscle Stabilize Exercise

weakness/delayed
Prior history activity2 Lateral ankle muscle strengthening
of inversion (fibularis group)3
ankle sprains4 Pain and swelling3
30% of people following Proprioceptive training with
ankle sprains report History of Palpable balance board3
persistent problems4 giving way1 tenderness at
specific ligaments Closed-chain proximal hip
Insecurity in involved3 strengthening3 Plantar flexion
the limb4 eversion MMT for fibularis group
 Decreased Palpation of ligaments
balance3

1
Freeman MA. Instability of the foot after injuries to the lateral ligament of the ankle. J Bone Joint
Surg Br. 1965;47:669-677.

2
Hubbard TJ, Kaminski TW, Van der Griend RA, Kovaleski JE. Quantitative assessment of mechanical
laxity in the functionally unstable ankle. Med Sci Sports Exerc. 2004;36:760-766.

3
Reischl SF, Noceti-Dewit LM. Current Concepts of Orthopaedic Physical Therapy. 2nd ed. The foot
and ankle: Physical therapy patient management utilizing current evidence. APTA Independent
Study Course 16.2.11.

4
Smith RW, Reischl SF. Treatment of ankle sprains in young athletes. Am J Sports Med. 1986;14:465-
471.

Medial Tibial Stress Syndrome (Exercise-Related Lower Leg

Pain)

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Pain control
Educate

Rest1

Gradually
3 3 build up
Athletes Runners
Repetitive stress4 Excessive activity
Diffuse pain along the Pronation9 intensity,
subtalar pronation2 posteromedial tibia
frequency,
with activity—in later Tenderness over the
Incidence of exercise-
stages pain can be posteriormedial border of duration1
induced lower leg pain in
constant3 the tibia; absence of
Exercise
athlete accounts for roughly neurovascular
10-20% of all injuries in Correction of
Dull aching to intense abnormalities2,5 movement
runners6,7 pain that is alleviated
impairment
by rest5 Normal radiographs3
60% of all overuse injuries in
the leg6,7 Use of
orthotics for
pronation2

Use of shock
absorbing
 insoles8

1
Robertson J. Exercise-induced shin pain. Human Kinetics. 2005;10(5):72-73.

2
Couture CJ, Karlson KA. Tibial stress injuries: Decisive diagnosis and treatment of “shin splints.”
Physician Sports Med. 2002;30(6):29-36, 51-52.

3
Metzl J. A case-based look at shin splints. Patient Care. 2005;39(11):39-46.

4
Korkola M, Amendola A. Exercise-induced leg pain: Sifting through a broad differential. Physician
Sports Med. 2001;29(6):35-38, 43-46, 49-50.

5
Michael RH, Holder LE. The soleus syndrome: A cause of medial tibial stress (shin splints). Am J
Sports Med. 1985;13(2):87.

6
Batt ME. Shin splints: a review of terminology. Clin J Sport Med. 1995;5(1):53.

7
Bates P. Shin splints: a literature review. Br J Sports Med. 1985;19(3):132.

8
Craig DI. Medial tibial stress syndrome: Evidence-based prevention. J Athl Train. 2008;43(3):316-
318.

9
Willems TM, Witvrouw E, De Cock A, De Clercq D. Gait-related risk factors for exercise-related
lower-leg pain during shod running. Med Science Sports Exerc. 2007;39(2):330-339.

Ruling in Deep Vein Thrombosis

CPR for Deep Vein Thrombosis
Query or assess the patient of the following major criteria:
1. Active cancer within the last 6 months
2. Paralysis
3. Recently bedridden localized tenderness
4. Thigh and calf are swollen
5. Strong family history of DVT
Query or assess the patient for the following minor criteria:
1. History of recent trauma
2. Pitting edema
3. Dilated superficial veins
4. Hospitalized within last 6 months
5. Erythema
6. (+) test is > 3 of the major criteria and > 2 of the minor criteria

Reliability Sensitivity Specificity +LR -LR

NT 78 98 39 0.22

Wells PS, et al. Accuracy of clinical assessment of deep-vein thrombosis.

Lancet. 1995;345(8961):1326-1330.

Posterior Tibial Tendon Dysfunction

Prevalence Symptoms DSM/Signs TBC/Special Tests

Chronic
ache/occasional
swelling along Pain control
medial foot and Stabilize
Frequent in middle-aged to ankle2 Taping/foot
elderly women3
Pain may orthoses2
May be influenced by systemic traverse to
Stage I: short
inflammatory disorders1,3 medial plantar
Pronation walking cast4
arch
Stage I: Pain localized along Dorsiflexion-
Stage II: ankle foot
post. tibial tendon; normal May have hypomobility
orthosis4
alignment of fore/hindfoot2 radiation of Progressive collapse of
pain to proximal arch2 Abnormal shoe Walking or
Stage II: Enlarged and medial calf2 wear pattern2 removable cast for
elongated tendon; poor
function Gradual acute cases2
˜Calcaneal valgus
worsening of
Foot deformity present: pes Exercise
symptoms2 ˜Forefoot abductus
planus, collapse of medial
Calf stretching2
longitudinal arch, hind foot Perception of ˜Too-many-toes sign2
valgus, subtalar eversion, walking on Posterior tibialis
forefoot abduction medial aspect of Excessive pronation
strengthening2,4
foot2 into terminal stance2
Flexible deformity except for
Disruption of collagen Eccentric training2
calf tightness. Walking hurts
Loss of fiber structure and
Single limb heel
*Talonavicular joint reducible
when ankle is in equinus2 endurance orientation2 raise (+) (No
Quick to inversion of
Stage III: Same as above except fatigue2 calcaneus or unable
pes planus fixed, navicular to rise onto
cannot be reduced2 Pain may shift forefoot)2
laterally with
time due to Resisted testing of
lateral subtalar posterior tibialis
impingement2

1
Holmes GB Jr, Mann RA. Possible epidemiological factors associated with rupture of the posterior
tibial tendon dysfunction. Clin Orthop. 1999;365:12-22.

2
Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop. 1989;239:196-206.

3
Mosier SM MD, Pomeroy G MD, Manoli A II MD. Pathoanatomy and etiology of posterior tibial tendon
dysfunction. Clin Orthop Relat Res. Aug 1999;365:12-22.

4
Geidenman WM. Posterior tibial tendon dysfunction. J Orthop Sports Phys Ther. 2000;30(2):68-77.

Plantar Fasciitis

TBC/Special
Prevalence Symptoms DSM/Signs
Tests

Pain control

Iontophoresis
with 5% acetic
acid4
Dorsiflexion first MTP
3 6 hypomobility
Gradual, insidious onset , Stabilize
Acute onset or “strain” of Antalgic gait pattern— Taping4,6
arch during vigorous prolonged eversion at
activities6 midstance of gait6 Orthotics1,3,6

Up to 10% of United Pain in the heel with the Limited ROM first MTP Night Splints1,3
States population has first step in the morning, joint6
heel pain—˜600,000 decreased throughout Exercise
people3 day1,3,6 PROM of first MTP
increased symptoms Gastroc-soleus
< 10° dorsiflexion5 Pain that radiates distally along plantar fascia6 complex
from heel6
Obese3,6 Tenderness to deep stretched1,3,6
BMI > 30 kg/m25 Non-radiating pain in the palpation of medial Educate
arch1 tubercle of the
Sedentary3,6 calcaneus3,6 Cessation of
Pain with excessive WB barefoot
High arch activities3,6 Tenderness to ambulation1
palpation on plantar
Standing jobs1,3,5 Acute pain with walking after aspect of foot1,4 Shock-
prolonged sitting/standing: absorption
Pregnant women “physiological creep”6 Excessively rigid foot shoe inserts,
or mobile foot6 for ridged feet6
DM Pain after long periods of
standing1 Swelling on the plantar TDT
Runners6 (treatment
surface of the heel
Walking upstairs3 direction
X-rays to detect heel test)7
Increased pain when spurs6
barefoot1,3 SLR2
Ultrasound detecting
Increased pain when walking thicker heel Windlass test2
on toes3 aponeurosis3
Calf length2

Hamstring
length2

1
Barry LD, Barry AN, Chen Y. A retrospective study of standing gastrocnemius-soleus stretching
versus night splinting in the treatment of plantar fasciitis. J Foot Ankle Surg. 2002;41(4):221-227.

2
Cleland J. Orthopaedic Clinical Examination: An Evidence-Based Approach for Physical
Therapists. Carlstadt, NJ: Learning Systems; 2005.

3
Cole C, Seto C, Gazewood J. Plantar fasciitis: Evidence-based review of diagnosis and therapy. Am
Fam Physician. 2005;72(11):2237-2242.

4
Osborne HR, Allison GT. Treatment of plantar fasciitis by low dye taping and iontophoresis: Short-
term results of a double blinded, randomized, placebo controlled clinical trail of dexamethasone and
acetic acid. Br J Sports Med. 2006;40(6):545-549.

5
Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: A matched case-
control study. Am J Bone Joint Surg. 2003;85:872-877.

6
Tomberlin JP, Saunders HD. Evaluation, Treatment, and Prevention of Musculoskeletal
Disorders, vol. 2. 3rd ed. Chaska, MN: The Saunders Group; 1994.

7
McPoil TG, et al. Heel pain—plantar fasciitis: Clinical practice guidelines linked to the international
classification of function, disability, and health from the Orthopaedic section of the American
Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(4):A1-A18.
Ruling In Plantar Fasciitis
Windlass Test (Non-Weight Bearing)
1. Patient's knee is flexed to 90° while in a non-weight-bearing position.
2. Examiner stabilizes the ankle and extends the MTP joint while allowing the
IP joint to flex (preventing motion limitations due to short hallucis longus).
3. Patient is standing on a step stool with toes over the stool's edge.
4. MTP joint is extended while allowing IP joint to flex.
5. (+) test if pain was reproduced at the end range of MTP extension.

Reliability Sensitivity Specificity +LR -LR

Non-weight-bearing NT 14 100 NA 0.86

Weight-bearing NT 32 100 NA 0.68

De Garceau, et al. The association between diagnosis of plantar fasciitis and

windlass test results. Foot Ankle Int. 2003;24:251-255.

FIGURE 15-13 Windlass Weight Bearing

 FIGURE 15-14 Windlass Non-Weight Bearing

Plantar Nerve Entrapment: Medial Plantar Nerve (L4,L5)/

Lateral Plantar Nerve (S1,S2)

Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control

Ice massage4

Stabilize

Taping/immobilization2,4

Foot orthotics2,3,4

Treatment direction test

Mobilize

STM gastrocnemius and

soleus4
Insidious onset4 Pronation Dorsiflexion
Neural mobilization in
Pain with first Palpation over the proximal the slump position4
steps in the aspect of the abductor hallucis
morning4 and/or the origin of the Educate Correction of
plantar fascia at the medial movement impairment
30 to 70 y/o.4 Difficulty standing4 Exercise
tubercle of the calcaneus4
Runners/joggers2 Pain with Toe curls4
Tenderness to palpation of
walking3,4 gastrocnemius and soleus4
People with hard Stretching4
Constant pain on
foot orthotics
the plantar Antalgic gait4
surface, off and on SLR, with dorsiflexion
People with and eversion: With
recent, sudden WB4 Decreased PROM pronation = lateral
weight loss2 dorsiflexion2,4 plantar branch;
Burning,
DM 2 numbness, tingling Weak posterior tibialis 4/54 With supination =
of 1st-3rd and medial plantar
Trauma2 medial side of 4th Muscle weakness2 branch4,5
toes and plantar
Inappropriate
surface3,5
Varus deformity of the heel Tinel's Sign1,2,4
foot wear2 with pronated forefoot and
Burning, valgus heel with abducted Impingement sign1
numbness, tingling forefoot in flatfoot
of lateral side of deformities2 Windlass1,4
4th toe and 5th Prone midfoot mobility
Pes planus and pes cavus2
toe3,5 testing4

Calcaneus-cuboid
accessory mobility4

Oblique mid-
tarsaljJoint axis with
calcaneal eversion/
inversion4

Foot talo-navicular
accessory mobility4

Subtalar
(talocalcaneal) medial
and lateral tilt4

1
Cleland J. Orthopaedic Clinical Examination: An Evidence-Based Approach for Physical
Therapists. Carlstadt, NJ: Learning Systems, 2005.

2
Delfaut EM, Demondion X, Bieganski A, Thiron M-C, Mestdagh H, Cotton A. Imagining of foot and
ankle nerve entrapment syndromes: from well-domonstrated to unfamiliar sites. Radiographics.
2003;23:613-623.

3
Lau J T-C. The effects of tarsal tunnel release and stabilization procedures on tibial nerve tension
in a surgically created pes planus foot. Masters thesis, University of Toronto, 1998.

4
Meyer J, Kulig K, Landel R. Differential diagnosis and treatment of subcalcaneal heel pain: a case
report. J Orthop Sports Phys Ther. 2002;32(3):114-124.

5
Tomberlin JP, Saunders HD. Evaluation, Treatment, and Prevention of Musculoskeletal
Disorders, vol. 2. 3rd ed. Chaska, MN: The Saunders Group; 1994.
Tibial Neuritis (Medial Tarsal Tunnel Syndrome)

Prevalence Symptoms DSM/Signs Interventions TBC/Special Tests

Local Pain control Stabilize

anesthetics and Mobilization
steroid
Medial ankle Tinel sign1,2,7,9
burning pain and injections7
paresthesias Orthotics and Dorsiflexion-eversion
Obesity7 radiating distally
Pronation night splints test5,10
7 (occasionally (held in
Hypothyroidism Dorsiflexion-
proximally known Local nerve tenderness
hypomobility plantarflexion
as Valleix on palpation5
Diabetes1 and varus)7
phenomenon)7,8 Hindfoot
No statistical valgus Surgical Electromyography2,3,4,6,7
Posterior tibial
correlation has deformity2,7 intervention
nerve Nerve conduction6
been found7 (removal of
distribution9 spaceoccupying
Needle examination of S7
masses and
Back pain8 external Palpation of the sole over
neurolysis for the heel and proximal
scar tissue)7,9 midfoot2,9

1
A Patient's Guide to Tarsal Tunnel Syndrome. Spine and Extremities
Rehabilitation Center. 2003

2
Aldrige T. Diagnosing heel pain in adults. Am Fam Physician.
2004;70(2):332-338.

3
Fu R, DeLisa JA, Kraft GH. Motor nerve latencies through the tarsal
tunnel in normal adult subjects: Standard determinations corrected for
temperature and distance. Arch Phys Med Rehabil. 1980;61(6):243-248.

4
Kaplan PE, Kernahan WT. Tarsal unnel syndrome: An electrodiagnostic
and surgical correlation. Am J Bone Joint Surg. 1981;63(1):96-99.

5
Kinoshita M, et al. The dorsiflexion-eversion test for diagnosis of tarsal
tunnel syndrome. Am J Bone Joint Surg. 2001;83-A(12):1835-1839.

6
Mondelli M, Giannini F, Reale F. Clinical and electrophysiological
findings and follow-up in tarsal tunnel syndrome. Electroencephalogr
Clin Neurophysiol. 1998;109(5):418-425.

7
Daniels TR, Lau JT, Hearn TC. The effects of foot position and load on
 tibial nerve tension. Foot Ankle Int. 1998;19(2):73-78.

8
Singh SK, Wilson MG, Chiodo CP. Tarsal tunnel syndrome and its
surgical treatment. The Orthopaedic Journal at Harvard Medical
School Online.
http://www.orthojournalhms.org/volume7/manuscripts/ms11.htm

9
Takakura Y, et al. Tarsal tunnel syndrome: Causes and results of
operative treatment. J Bone Joint Surg. 1991;73-B(1):125-128.

10
Alshami AM, Babri AS, Souvlis T, Coppieters MW. Biomechanical
evaluation of two clinical tests for plantar heel pain: The dorsiflexion-
eversion test for tarsal tunnel syndrome and the windlass test for
plantar fasciitis. Foot Ankle Int. 2007;28(4):499-505.

Screening out Tarsal Tunnel Syndrome

The Dorsiflexion-Eversion Test
1. Patient is in a sitting position.
2. Ankle is placed in dorsiflexion, eversion of the foot, and dorsiflexion of all
the toes.
3. Position is held for 5-10 seconds.
4. Patient is queried about any change in symptoms.
5. (+) test is a reproduction or intensification of the patient's symptoms.

Reliability Sensitivity Specificity +LR -LR

NT NA NA NA NA

[circled white star] Even though this study did not report sensitivity numbers,
none of the asymptomatic subjects had any symptoms, whereas there were
significant changes in subjects who had tarsal tunnel syndrome. This may be
useful as a screen for patients with tarsal tunnel syndrome-like symptoms.
Kinoshita M, et al. The dorsiflexion-eversion test for diagnosis of tarsal tunnel
syndrome. Am J Bone Joint Surg. 2001;83-A(12):1835-1839.
 FIGURE 15-15 The Dorsiflexion-Eversion Test

Screening out Tarsal Tunnel Syndrome

Tinel's Sign
1. Patient is in a sidelying position.
2. Examiner applies a tapping force to the posteromedial aspect of the ankle.
3. (+) test is reproduction of tingling during the test.

Reliability Sensitivity Specificity +LR -LR

NT 58 NT NA NA

Oloff, et al. Flexor hallucis longus dysfunction. J Foot Ankle Surg.

1998;37(2):101-109.
 FIGURE 15-16 Tinel's Sign

Screening Out/Ruling in Peripheral Neuropathy

Monofilament Testing of the Diabetic Foot
1. Patient is placed in a sitting position.
2. Examiner applies a Semmes-Weinstein 10-g monofilament to the selected
noncalloused areas of the body. With eyes closed, the patient is queried as to
whether he or she feels the application.
3. (+) response is the inability to feel the applied stimulus. If no stimulus is felt
at the palmar aspect of the foot, this reflects a lack of a protective sensation
from the patient.

Reliability Sensitivity Specificity +LR -LR

NT 77 96 19.3 0.24

Perkins BA, et al. Simple screening tests for peripheral neuropathy in the
diabetes clinic. Diabetes Care. 2001;24(2):250-256.
 FIGURE 15-17 Monofilament Testing of the Diabetic Foot

Assessing Subtalar Joint Stability

Medial Subtalar Glide Test
1. Patient lies in a supine position.
2. Examiner stabilizes the talus superiorly while gripping the calcaneus at the
plantar aspect of the foot.
3. Examiner applies a medial glide of the calcaneus on the fixed talus.
4. (+) test is gross laxity during the procedure.

Reliability Sensitivity Specificity +LR -LR

NT 78 75 3.1 0.29

Hertel J, et al. Talocrural and subtalar joint instability after lateral ankle
sprain. Med Sci Sports Exerc. 1999;31(11):1501-1508.
 FIGURE 15-18 Medial Subtalar Glide Test (Subtalar Glide)

Assessing Midtarsal Joint Pronation and Treating Decreased

Arch Height
Assess Dynamic Angle and Base of Gait
1. Have patient walk while observing distance between malleoli and the medial
aspect of both knees to determine the dynamic base.
2. Observe from behind for the number of toes that are visible from the lateral
aspect of the lower leg while walking.
3. Patient is then placed on paper in his or her dynamic angle and base of gait.
4. Trace outline of foot. (Save template to improve reliability of future
measurements.)
5. Patient steps off and a line is drawn from the most posterior part of the
calcaneus through the second toe.
6. This line is measured and the 50% length is marked with a perpendicular line
towards the medial side of the foot.
FIGURE 15-19 Dynamic Base

FIGURE 15-20 Assessing 50% Foot Length

 FIGURE 15-21 Dorsal Arch Height

7. Have patient return to standing on the template in resting standing foot

posture.
8. Place 12-inch combination square at 50% mark.
9. Measure dorsal arch height.
10. Calculate arch height ratio.
Arch Height Ratio (AHR)
(i) obtained in bilateral standing
(ii) AHR = dorsal arch height (measured at 50% of total foot length) divided by
either total foot or truncated (ball) length

AHR based on
Normative values based on 850 normal, healthy subjects AHR based on
truncated foot
Williams & McClay, Phys Ther, 2000 total foot length
length

Right 0.253 + 0.02 0.345 + 0.03

Length 0.249 + 0.02 0.341 + 0.03

[circled white star] If significant hallux valgus is present, you must use
truncated foot length (posterior calcaneus to first MTP joint) to calculate AHR.
[circled white star] Static AHR appears to be predictive of the posture of the
foot at midstance during walking (Franettovich 2007).
11. Apply Treatment Direction Test (TDT)

Treatment Direction Test (TDT)

1. Establish baseline level.

(i) Painful activity such as stair climbing, running, squatting, etc.

(ii) Use VAS pain scale or Outcome Tool.
2. Start treatment (NAU Reverse 6's taping) after screening for taping allergies
and giving instructions and precautions about using tape.
3. Have patient perform painful activity to assess how much arch height needs
to be increased (the minimal amount of arch height increase needed to be used
to minimize symptoms is ideal).
4. Place patient back on template with tape, and remeasure dorsal arch height.

FIGURE 15-22 Reassess Reverse 6

5. Either leave the tape on or build a semi-custom orthotic for the patient.
Semi-custom orthotic may also accommodate hindfoot and forefoot posting,
which can be measured.
6. Repeat baseline measures after trial period. Should see at least 50 to 75%
reduction in pain after 3 days of use.
7. Remove treatment and reassess baseline measures.

NAU Reverse 6's

(a) Use pre-wrap to prevent skin irritation.
(b) Change path of tape to prevent covering malleoli.
(c) Use Elastikon elastic tape (Johnson & Johnson)—2-inch width.
1. Vicenzino B. Foot orthotics in the treatment of lower limb conditions: A
musculoskeletal physiotherapy perspective. Man Ther. 2004;9(4):185-196.
2. Williams DS, et al. Measurements used to characterize the foot and the
medial longitudinal arch: Reliability and validity research. Phys Ther.
2000;80:864-871.
3. Franettovich M, et al. The ability to predict dynamic foot posture from static
measurements. JAPMA. 2007;97:115-120.
4. Adapted from McPoil T. Examination and conservative management of
chronic foot disorders. CPTA 2008 Annual Conference Oakland, CA: September
26, 2008.

FIGURE 15-23 Reverse 6

FIGURE 15-24 Reverse 6

FIGURE 15-25 Reverse 6

FIGURE 15-26 Reverse 6

FIGURE 15-27 Reverse 6

 FIGURE 15-28 Reverse 6

Testing for Rearfoot Varus and Valgus

Calcaneal Position Technique
1. Patient lies in a prone position with both legs hanging over the plinth.
2. Calcaneus is palpated medially and laterally and bisected by placing dots in
the inferior aspect and middle aspect of the calcaneus.
3. A line is drawn to connect the dots.
4. Examiner finds subtalar neutral by palpating the patient's tali in which both
medial and lateral aspects are felt equally by the examiner.
5. A goniometer is used to measure the varus or valgus of the calcanei.
6. (+) test is substantial rearfoot inversion or eversion during subtalar neutral.

Reliability

Neutral 0.85 ICC

Resting 0.85 ICC

Sell KE et al. Two measurement techniques for assessing subtalar joint position:
A reliability study. J Orthop Sports Phys Ther. 1994;19(3):162-167.
 FIGURE 15-29 Calcaneal Inversion

FIGURE 15-30 Calcaneal Inversion

Testing for Forefoot Posturing

Forefoot Varus and Valgus
1. Patient is in a prone position with foot over edge of table.
2. Examiner palpated medial and lateral talar head, and then grasps 4th and 5th
metatarsals and takes up slack in midtarsal joints. Subtalar neutral is the
position in which medial and lateral talar head is palpated equally.

Intra-Examiner Reliability
Inter-Examiner Reliability ICC
ICC
 Forefoot varus 0.95-0.99 0.61

Forefoot varus/valgus
0.08-0.78 0.38-0.42
goniometric

Forefoot varus/valgus visual 0.51-0.76 0.72-0.81

Van Gheluwe B, et al. Reliability and accuracy of biomechanical measurement

of the lower extremities. J Am Podiatr Med Assoc. 2002;92:317-326.
Somers DL, et al. The influence of experience on the reliability of goniometric
and visual measurement of forefoot position. J Orthop Sports Phys Ther.
1995;22:161-163.

FIGURE 15-31 Forefoot Varus

Metatarsalgia

Prevalence Symptoms DSM/Signs TBC/Special Tests

Pain control
Stabilize
 Metatarsal pad10

Loss of Orthotics1,5
sensation
Athletes who Correction of
Pain at one or more metatarsal of
participate in high- movement
heads—most commonly 3-4 and 2-3 adjacent
impact sports involving impairment Mobilize
(typically during midstance and toes2,3
the lower extremities2 Educate
propulsion)2,7,8,9,10
Painful
High arch, Morton toe, 2 3 Morton's Test
Toe numbness , click2,6
and hammertoe2,3 Metatarsal squeeze
Callus2 test2,3,6

Mulder sign2,6

Electrophysiological4

1
Bedinghaus JM, Niedfeldt MW. Over-the-counter foot remedies. Am Fam Physician.
2001;64(5):791-796.

2
Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. 1999;31(7 supp):S448-S458.

3
Fuhrmann RA, et al. Metatarsalgia: Differential diagnosis and therapeutic algorithm. Orthopade.
2005;34(8):767-768, 769-772, 774-775.

4
Guiloff RJ, Scadding JW, Klenerman L. Morton's metatarsalgia: Clinical, electrophysiological, and
histological observations. J Bone Joint Surg. 1984;66-B(4):586-591.

5
Hassouna H, Singh D. Morton's metatarsalgia: Pathogenesis, aetiology and current management.
Acta Orthop Belg. 2005;71(6):646-655.

6
Mulder JD. The causative mechanism in Morton's metatarsalgia. J Bone Joint Surg. 1951;33-B(1):94-
95.

7
McPoil TG, McGarvey T. The foot in athletics. In: Hunt GC, McPoil TG, eds. Clinics in Physical
Therapy: Physical Therapy for the Foot and Ankle.2nd ed. New York: Churchill Livingstone. 1995;
207-235.

8
Quirk R. Metatarsalgia. Aust Fam Physician. 1996;25(6):863-865; 867-869.

9
Steinberg GG, Akins CM, Baran DT, eds. Metatarsalgia. In Orthopedics in Primary Care.
Philadelphia: Lippincott Williams & Wilkins. 1999; 284-287.

10
Kang JH, Chen MD, Chen SC, Hsi WL. Correlations between subjective treatment responses and
plantar pressure parameters of metatarsal pad treatment in metatarsalgia patients: A prospective
study. BMC Musculoskelet Disord. 2006;7:95.
Test for Stress Fracture or Interdigital Neuroma
Morton's Test (Unvalidated)
1. Patient is positioned in a supine or sitting position.
2. Examiner applies a squeeze to the metatarsal heads from lateral to medial
toward midline.
3. (+) test is reproduction of patient symptoms.

Reliability Sensitivity Specificity +LR -LR

NT NT NT NA NA

FIGURE 15-32 Morton's Test

Hallux Rigidus

TBC/Special
Diagnosis Prevalence Symptoms DSM/Signs
Tests

Pain control

US and
 First MTP contrast bath4
hypomobility
Ankle Mobilize
dorsiflexion Stabilize
Pain and stiffness that Tenderness to Orthotics2,3
Unknown cause , , 1 4 5 comes on quickly and palpation at
increases with cold Shoe
MTP1,6
Association between weather1,5 modifications:
hallux rigidus, hallux Swelling and
valgus, family history, Pain: constant, burning, inflammation if large toe
and trauma5 throbbing, or aching1 acute1,6 box2,3,4

Adolescents1 Persistent pain1 Bone spur4 Correction of

Hallux movement
Rigidus Boys > girls1 Gradual onset of Dosiflexion or impairment
stiffness1 extension is
Acute Second most common limited due to: Gait
disorder of the first MTP Pt. c/o pain at base of analysis1,3
Chronic joint big toe when walking: OA
toe off/preswing1,6 Palpation1
1 4
More common , Abnormally long
Pain with squatting and first MT bone ROM3
1 4
Adults , running1,3 Pronated feet
trauma1,4 Weight-
1 4 6
Men > women , Pain improves with rest bearing
Oblique forefoot patterns1
Bilaterally1,4 May have stiffness with creases in shoe1
rest6 Test joint's
Limping during integrity
gait4
Resting
Limited calcaneal
dorsiflexion1 standing
position3

Radiograph3

1
Magee D. Orthopedic Physical Assessment. 4th ed. Philadelphia, PA: Elsevier Sciences; 2006.

2
Nawoczenski D. Nonoperative and operative intervention for hallux rigidus. JOSPT.
1999;29(12):727-735.

3
Shrader JA, Lohmann K. Nonoperative management of functional hallux limitus in a patient with
rheumatoid arthritis. Phys Ther. 2003;83(9):831-843.

4
Coughlin MJ, Shurnas PS. Hallux rigidus: Demographics, etiology, and radiographic assessment.
Foot Ankle Int. 2003;24(10):731-743.

5
Nilsonne H. Hallux rigidus and its treatment. Acta Orthop Scand. 1930;1:295-302.
 6
McMaster MJ. The pathogenesis of hallux rigidus. J Bone Joint Surg Br. 1978;60(1):82-87.

Screening out/Ruling in Abnormal Excessive Midtarsal Function

During Gait
Functional Hallux Limitus Test
1. Patient is non-weight-bearing.
2. Examiner uses one hand to maintain subtalar joint neutral while dorsiflexing
the first ray.
3. Examiner uses the other hand to dorsiflex the proximal phalanx of the
hallux.
4. (+) test if examiner notes immediate plantarflexion of the first metatarsal
upon dorsiflexion of the proximal phalanx.

Reliability Sensitivity Specificity +LR -LR

NT 72 66 2.12 0.42

Payne C et al. Sensitivity and specificity of the functional hallux limitus test to
predict foot function. J Am Podiatr Med Assoc. 2002;92:269-271.

FIGURE 15-33 Great Toe Extension

Hallux Valgus

Prevalence Symptoms DSM/Signs TBC/Special Tests

1% of Americans7

Women > Men 2:1 to

4:11,2,4 Pain control
Incidence increases Mobilization
Stabilization
with age6
Padding, taping,
3% 15-30 yrs
night splints,
9% 31-60 yrs Bowstringing of long flexor orthotic
Callus on medial side and extensors laterally2 devices1,4,5
16% > 60 yrs of MT bone = bunion
MTP angle > 20°2,4 Education
development1,2
Cause varies:
hereditary2 Wider toe box
Tenderness to touch1 Callus, thickened and
inflamed bursa, and exostosis2 MTP angle4,5
Two types2: Lateral deflection of
congruous (not phalanx at MTP Joint capsule is contracted on Intermetatarsal
progressive) joint1,2 lateral side and lengthened
angle2
on the medial side2
Pathological
(potentially Palpation1
progressive)
Gait analysis2
80% caused by
Test joints
metatarsal primus
integrity4
varus2 Ballet
dancers3

Bilateral2

1
Ayub A, et al. Common foot disorders. Clin Med Res. 2005;3(2):116-119.

2
Magee D. Orthopedic Physical Assesment. 4th ed. Philadelphia, PA: Elsevier Sciences; 2006.

3
Niek van Dijk C, et al. Degenerative joint disease in female ballet dancers. Am J Sports Med.
1995;23(3):295-300.

4
Terrari J, et al. Interventions for treating hallux valgus (abductovalgus) and bunions (review). The
Cochrane Library 2006; 4.
5
Torkki M, et al. Surgery vs. orthosis vs. watchful waiting for hallux valgus: A randomized controlled
trial (abstract). JAMA. 2001;285(19):2474-2480.

6
Gould N, Schneider W, Ashikaga T. Epidemiological survey of foot problems in the continental
United States: 1978-1979. Foot and Ankle. 1980;1:8-10.

7
Greenberg L, Davis H. Foot problems in the United States: The 1990 National Health Interview
survey. J Am Podiatr Med Assoc. 1993;83:475-483.
Chapter 16
Origins, Insertions, Innervations, and Actions

Key for Origin/Insertion/Innervation/Action

SP Spinous process

TP Transverse process

C/S Cervical spine

T/S Thoracic spine

L/S Lumbar spine

Lat Lateral

Med Medial
FIGURE 16-1 The Human Skeleton Chiras, DC. Human Biology, Sixth Edition. © 2008
Jones & Bartlett Publishers, LLC
FIGURE 16-2 The Skeletal Muscles Chiras, DC. Human Biology, Sixth Edition. © 2008
Jones & Bartlett Publishers, LLC
FIGURE 16-3 Posterior View of Superficial Muscles of the Back and Those Connecting
the Axial Skeleton to the Shoulder Girdle Souza, TA. Differential Diagnosis and
Management for the Chiropractor: Protocols and Algorithms. © 2009 Jones & Bartlett
Publishers, LLC

Neck and Back

Origin Insertion Innervation Action
Extensors

Bilaterally,
they extend
the head
Common origin ant. and part or
surface of broad tendon all of the
Erector Spinae attached to medial crest of By tendons into Dorsal rami vertebral
(superficial) sacrum, SP of L/S and inferior borders of of the column.
Iliocostalis: 11+12 T/S vertebrae, Post. angles of lower 6 or cervical Unilaterally,
spinal
Lumborum Med. Lip iliac crest, 7 ribs. nerves they
supraspinous ligt., and lat. laterally flex
crest of sacrum the head or
the
vertebral
column.

Cranial borders of
Dorsal rami
angles of upper 6
By tendons from upper of the
ribs, and dorsum of
Thoracis borders of angles of lower cervical See above
transverse process
6 ribs spinal
of 7th cervical nerves
vertebra

Post. tubercles of
TPs of all T/S
Dorsal rami
vertebrae, and by
of the
fleshy digitations
Cervicis Angles 3rd, 4th, 5th, 6th ribs cervical See above
into lower 9 or 10
spinal
ribs between
nerves
tubercles and
angles

In lumbar region, it is By tendons into tips

blended with iliocostalis of TPs of all T/S
Dorsal rami
lumborum, post. surfaces vertebrae, and by
of the
Longissimus: of transverse and fleshy digitations
cervical See above
Thoracis accessory processes of into lower 9 or 10
spinal
lumbar vertebrae, and ant. ribs between
nerves
layer of thoracolumbar tubercles and
fascia angles

By tendons into
Dorsal rami
post. tubercles of
of the
By tendons from TPs of transverse
Cervicis cervical See above
upper 4 or 5 T/S vertebrae processes of 2nd
spinal
through 6th C/S nerves
vertebrae

Dorsal rami See above

By tendons from TPs of of the Also rotates
upper 4 or 5 T/S vertebrae Post. margin of cervical the head to
Capitis
and articular processes of mastoid process spinal the same
 lower 3 or 4 C/S vertebrae nerves side

Dorsal rami
Spinous processes
By tendons from SPs of of the See Erector
of upper 4-8
Spinalis:Thoracis first 2 lumbar and last 2 cervical Spinae
(variable) T/S
T/S vertabrae spinal above
vertebrae
nerves

Dorsal rami
Ligamentum nuchae, lower SP of axis (C1), and of the See Erector
Cervicis occasionally into cervical Spinae
part; SP of 7th vertebrae
SPs of C3 and C4 spinal above
nerves

Dorsal rami
of the See Erector
Inseparably connected See Semispinalis
Capitis cervical Spinae
with Semispinalis Capitis Capitis
spinal above
nerves

Bilaterally,
Thoracis and
Cervicis
extend the
SPs of upper Dorsal rami cervical and
Transversospinalis
(deep) thoracic 4-8 of the thoracic
TP of lower T/S vertebrae (variable) and cervical spine.
Semispinalis: (1st
lower 2 C/S spinal Unilaterally,
layer) Thoracis
vertebrae nerves they rotate
these
regions to
the opposite
side.

TPs of upper 5 or 6 T/S C/S SPs 2nd through

Cervicis See above See above
vertebrae 5th

Tips of TPs of upper 6 or 7 Dorsal rami

T/S and 7th C/S vertebrae, Between superior of the Bilaterally,
and articular processes of and inferior nuchal cervical
Capitis extends the
lines of occipital
 cervical 4th, 5th, 6th bone spinal head
vertebrae nerves

Unilaterally,
they flex the
trunk
Sacral region: Post. laterally and
surface of sacrum, med. Dorsal rami rotate it to
Spanning 2 to 4
surface of post. Sup. Iliac of the the opposite
Multifidi (2nd vertebrae, inserted
spine, and post. Sacroiliac cervical side.
layer) into SP of a
ligts. L/S: TP of L5 thru C4 spinal Bilaterally,
vertebra above
T/S: TP of L5 thru C4 C/S: nerves they extend
TP of L5 thru C4 the trunk
and stabilize
vertebral
column.

Rotate
rd Lamina of superior
Rotatores (3
TP of vertebrae See above
layer) vertebrae above vertebrae to
opp. side

Placed in pairs between

SPs of contiguous Dorsal rami
vertebrae C/S: 6 pairs T/S: of the Extend the
Interspinales Spinous process cervical vertebral
2 or 3 pairs; between 1st
spinal column
and 2nd, (2nd and 3rd), and
nerves
11th and 12th L/S: 4 pairs

Unilaterally,
Dorsal rami laterally
Post. tubercle of of the flexes and
SPs of 3rd through 6th T/S
Splenius: Cervicis TPs of first 2 or 3 cervical rotates the
vertebrae
C/S vertebrae spinal head and
nerves neck to the
same side

Unilaterally,
Lat. aspect of Dorsal rami laterally
Caudal ½ of ligamentum mastoid process of the flexes and
nuchae; spinous processes and lat. 1/3 of the cervical rotates the
Capitis of first 3 or 4 thoracic sup. nuchal line of spinal head and
vertebrae occiput nerves neck to the
 same side

Bilaterally,
Mastoid process of extend the
Ventral
Small muscles placed temporal bone, and vertebral
rami of the
between TPs of contiguous on occipital bone column.
Intertransversarii cervical
vertebrae in C/S, T/S, and inferior to lateral Unilaterally,
spinal
L/S regions 1/3 of superior laterally flex
nerves
nuchal line the superior
vertebrae.

Superior oblique portion:

ant. tubercles of TP of 3rd,
4th, 5th C/S vertebrae Tubercle on
anterior arch or
Ventral Flex the
Inf. oblique portion: ant. atlas Ant. tubercles
primary neck and
surface of bodies of first 2 of TPs of 5th and 6th
Longus Coli rami of the flex the
or 3 T/S vertebrae C/S vertebrae Ant.
cervical head on the
surface of bodies of
nerves neck
Vertical portion: ant. 2nd, 3rd, 4th cervical
surface of bodies of first 3 vertebrae
T/S and last 3 C/S
vertebrae

Ventral Flexes the

Inf. surface of primary neck and
Ant. tubercles of TPs of 3rd
Longus Capitis basilar part of rami of the flexes the
through 6th C/S vertebrae occipital bone cervical head on the
nerves neck

Ventral
Inf. surface of primary
Rectus Capitis Root of TP and ant. Same as
basilar part of rami of the
Anterior surface of atlas (C2) above
occipital bone cervical
nerves

Ventral
Inf. surface of primary
Rectus Capitis Superior surface of TP of Same as
jugular process of rami of the
Lateralis atlas (C1) above
occipital bone cervical
nerves
 Tenses the
skin of the
Inf. margin of Cervical neck, draws
Fascia covering superior mandible, and skin branch of corner of
Platysma parts of pectoralis minor of lower part of the fascial mouth inf.,
and deltoid face and corner of nerve CN and assists in
mouth VII depressing
the
mandible

Unilaterally,
rotates head
to same
side.
Lat. part of inf. Dorsal
Rectus Captis Bilaterally,
SP of axis (C2) nuchal line of ramus of C1
Posterior Major extends
occipital bone nerve
head at
atlanto-
occipital
joint

Medial part of Dorsal

Rectus Capitis Tubercle on post. arch of Same as
inferior nuchal line ramus of C1
Posterior Minor atlas (C1) above
of occipital bone nerve

Extends and
Inf. and post. part
Dorsal laterally
Obliquus Capitis Apex of spinous process of of transverse
ramus of C1 flexes head
Inferior axis (C2) process of atlas
nerve to the same
(C1)
side

Extends and
Between superior
Dorsal laterally
Obliquus Capitis Sup. surface of TP of atlas and inf. nuchal
ramus of C1 flexes head
Superior (C1) lines of occipital
nerve to the same
bone
side

Scapular
Origin Insertion Innervation Action
Muscles
 Arm ER, holds
Greater tuberosity
Infraspinatus fossa, medial Suprascapular head of
Infraspinatus of humerus,
2/3 N. C5, C6 humerus in
middle facet
glenoid fossa

Greater tuberosity Holds head of

Suprispinatus fossa, medial Suprascapular
Supraspinatus of humerus, humerus in
2/3 N. C5, C6
superior facet glenoid fossa

Scapular
Medial border of
Dorsal elevation,
Rhomboideus Spinous process of T2-T5 scapula below
scapular N. retraction, and
Major and supraspinous ligt. triangular space to
C5 downward
inferior angle
rotation

Scapular
Medial border of
Spinous process of C7 and Dorsal elevation,
Rhomboideus scapula opposite
T1 Low portion of scapular N. retraction, and
Minor the smooth
ligamentum nuchae C5 downward
triangular space
rotation

Laterally
rotates the
Lower facet of
shoulder jt. and
greater tubercle
Upper 2/3 dorsal surface Axiliary N. stabilizes head
Teres Major of humerus and
of lat. border of scapula C5, C6 of humerus in
shoulder joint
the glenoid
capsule
fossa during
movement

Medial rotation,
Dorsal surface of inf. angle Crest of lesser Lower
adducts and
Teres Minor and lower 1/3 of lateral tubercle of Subscapular
extends the
border of scapula humerus N. C5, C6, C7
shoulder joint

Medial border of Scapular

Dorsal
scapula from elevation,
Levator Transverse process of C1- scapular N.
superior angle to retraction, and
Scapulae C4 C5 Spinal N.
smooth triangular downward
C3, C4
space rotation
 Scapula
elevation,
Lateral 1/3 post.
depression,
Medial 1/3 superior nuchal border clavicle,
upward
line of occiput, external med. margin of
rotation,
occiptital protuberence acromion process, Cranial N. XI
retraction,
Trapezius (inion process), sup. lip of spine of Spinal N. C3,
head lateral
ligamentum nuchae, scapula to the C4
flexion,
spinous process C7-T12 apex of the
rotation to the
and supraspinous ligt. smooth triangular
opposite side,
space
extension, and
hyperextension

Arm extension,
T6-T12 spinous processes
hyperextension,
and supraspinous ligt, SP
adduction and
of lumbar and sacral
IR, pull trunk up
vertebra via Floor of
Latissimus Thoracodorsal if arms are
thoracolumbar fascia, intertubercular
Dorsi N. C6, C7, C8 stabilized.
external lip iliac crest, low groove of humerus
Exhalation—
3-4 ribs by fleshy
splints
attachments, may attach
abdominals
to inferior angle of scapula
posteriorly

Scapular
abduction,
upward rotation
Outer surfaces and sup. by lower fibers,
border of ribs 1-9 midway stabilizes
Anterior surface of
Serratus between angles and costal Long thoracic scapula for
entire medial
Anterior cartilage. Low 3 digitations N. other shoulder
border of scapula
interdigitate and origin of girdle muscles
external oblique muscle. (weakness may
appear as
scapular
winging)

Arm IR (primary
IR of arm),
holds head of
humerus in
Upper and
glenoid cavity.
lower
Subscapular fossa, medial Lesser tuberosity
Subscapularis subscapular
2/3 of humerus (Trigger points
N. C5, C6 here may limit
 humeral ER,
thus possibly
causing
impingement.)

Arm abduction,
Lat. 1/3 clavicle, ant. flexion, IR,
border, lat. border of extension,
Deltoid tuberosity Axillary N.
Deltoideus acromion process inf. lip, hyperextension,
of humerus C5, C6
spine of scapula to smooth ER, horizontal
triangular space abduction and
adduction

Anterior
Chest and
Origin Insertion Innervation Action
Trunk
Muscles

Arm adduction,
IR, flexion,
Clavicular head: medial ½, sup. extension,
surface and ant. border of clavicle horizontal
adduction,
Sternal head: lateral ½ ant. Lateral lip of Lateral and
pulls trunk up
the medial
Pectoralis surface of manubrium and body of with arms
intertubercular pectoral N.
Major sternum to rib 7, costal cartilage of stabilized.
groove of (C5, C6, C7)
all true ribs, sponeurosis of external Accessory
humerus (C8, T1)
abdominal oblique muscles, muscle of
sometimes a small slip from rectus inspiration by
abdominus helping to
expand
thoracic cage.

Scapular
abduction,
Lateral and depresses tip
Medial border
Anterior surface and upper margin medial of the shoulder
Pectoralis of coracoid
of ribs 3, 4, 5 near costal cartilages pectoral N. joint
Minor process of
and fascia of intercostal spaces (C5, C6, C7) (downward
scapula
(C8, T1) rotation), cups
the shoulder
forward
 Depresses
clavicle (lateral
end), assist in
Inferior scapular
surface of Nerve to depression and
Junction of costal cartilage with
Subclavius clavicle Subclavius abduction. It
first rib
(subclavian C5 also stabilizes
groove) the clavicle
during shoulder
joint
movements.

Trunk flexion;
Rectus Cartilage of Intercostal
Crest of pubis forced
Abdominus ribs 5, 6, and 7 N. T7-12
exhalation

Sternal portion: dorsum of xiphoid

Costal portion: inner portion of

Central tendon
cartilages of lower six ribs. Phrenic N.
Diaphragm of the Inspiration
C3-C5
Lumbar portion: lumbosacral diaphragm
arches and two crura from lumbar
vertebrae

Elbow Muscles Origin Insertion Innervation Action

Arm flexion,
arm IR, arm
Long head: Radial
abduction,
supraglenoid tubercle tuberosity + Musculocutaneous
Biceps Brachii forearm
of scapula Short head: bicipital N. C5, C6
flexion,
tip of coracoid process aponeurosis
forearm
supination

Distal ½ anterior Ulnar

border; antero-medial tuberosity + Musculocutaneous
Brachialis Forearm flexion
and antero-lateral coronoid N. C5, C6
intermuscular septa process
 Arm flexion,
Medial surface arm IR, arm
of humerus, Musculocutaneous adduction, arm
Coracobrachialis Tip of coracoid process
middle ½ of N. C6, C7
horizontal
shaft adduction

Long head:
infraglenoid tubercle of
scapula

Lateral head: post.

surface and lat. border
of humerus proximal to Arm extension,
Upper surface
the radial groove of the hyperextension,
post. part of
Triceps Brachii humerus (proximal 1/3 Radial N. C7, C8 arm adduction
olecranon
of post. surface of by long head,
process of ulna
humerus) elbow extension

Medial head: post.

surface of humerus
distal to radial groove
(dist. 2/3) and medial
intermuscular septum

Lateral side of
olecranon
Lateral epicondyle of process and Forearm
Anconeus Radial N. C7, C8
humerus upper post. extension
surface of ulna
to oblique line

Forearm
Origin Insertion Innervation Action
Flexors

Med. supracondylar ridge, med. Lateral-side Elbow flexion,

Pronator Median N.
epicondyle via CFT, med. margin radius ½ way forearm
Teres C6, C7
coronoid process down pronation

Wrist flexion,
forearm
Palmaris Palmar Median N. pronation,
Med. epicondyle via CFT
Longus aponeurosis C6, C7 tenses palmar
 fascia

Forearm
pronation,
Flexor Carpi Median N.
Med. epicondyle via CFT Base of 2,3 MC wrist flexion,
Radialis C7, C8
elbow flexion,
radial deviation

Humeral head: med. epicondyle

by CFT
Forearm
Flexor Distal
Ulnar head: med. margin flexion, wrist
Digitorum phalanges, side Median N.
coronoid process of ulna + ulnar flexion, flexion
Superficialis of shaft via split C7, C8
collateral ligt. at PIP and MP
(FDS) tendons
fingers 2-5
Radial head: upper ½ anterior
border radius

Humeral head: med. epicondyle

via CFT Forearm
Pisiform + hook
Flexor Carpi Ulnar head: med. margin of flexion, wrist
of hamate and Ulnar N. C8
Ulnaris flexion, ulnar
olecranon process and post. base of 5th MC
surface ulna by common deviation
aponeurosis

Deep
Forearm Origin Insertion Innervation Action
Extensors

Supinator-crest + fossa/ulna, Lat. ant. PIN, Deep

Supinator lateral epicodyle via CET Lat. radius Radial N. Supination of forearm
collateral ligt. proximal 1/3 C5, C6

Base of
Extensor PIN, Deep
Mid 1/3 radius and IO proximal Thumb MP extension,
Pollicis Radial N.
membrane phalanx of radial deviation
Brevis C7, C8
thumb

Base of distal PIN, Deep Thumb extension IP

Extensor Longus Mid 1/3 ulna IO phalanx of Radial N. and MP, rotates
Pollicis membrane thumb C7, C8 thumb laterally

Wrist extension,
DDE of index PIN, Deep
Extensor hyperextension,
Mid 1/3 ulna IO membrane finger, Radial N.
Indicis index finger
medial side C7, C8
extension

Thenar
Origin Insertion Nerve Action
Muscles

Brevis Flexor retinaculum and Median N. by

Lateral side, base
Abductor lateral pillars of carpal tunnel motor Thumb
of prox. phalanx
Pollicis (scaphoid and trapezium) recurrent abduction
of thumb
Flexor retinaculum branch

Thumb
Abductor extension and
Post. surface of ulna and Base, MC#1 Deep Radial N.,
Pollicis abduction,
radius and IO membrane lateral side PIN C7-C8
Longus wrist radial
deviation

Superficial
head: Median
By common N. by motor
Superficial head: trapezium
Flexor tendon lat. side, recurrent Flexion of
Pollicis Deep head: capitate and base proximal branch thumb, IP
Brevis trapezoid Flexor retinaculum phalange of extension
thumb Deep head:
Deep br. of
Ulnar N.

Median N. by Thumb
Opponens Whole length motor opposition,
Trapezium, flexor retinaculum
Pollicis MC#1, lateral ½ recurrent rotates first MC
branch medially

Oblique head: base MC#2,3;

Adductor capitate and trapezoid Base prox. Deep br. of Adduction of
Pollicis phalanx, medial Ulnar N. thumb
Transverse head: ant. surface side of thumb
of shaft of MC#3

Hypothenar
Origin Insertion Innervation Action
Muscles

Pisiform, tendon Med. side, base of Ulnar N., Little finger

Abductor
FCU and proximal phalanx, little deep abduction, and flex
Digiti Minimi
pisohamate ligt. finger and DDE branch MP of 5th finger

Flexor Ulnar N.,

Flexor Digiti Medial side, base of prox. 5th finger flexion at
retinaculum, hook deep
Minimi phalanx, 5th finger, DDE MP joint
of the hamate branch

Flexor Ulnar N., Draw 5th finger

Opponens Medial side, shaft of 5th
retinaculum, hook deep forward and
Digiti Minimi finger
of the hamate branch laterally rotate

Deep
Forearm Origin Insertion Innervation Action
Extensors

Flexor retinaculum Medial Superficial

Palmaris Deepens hollow of hand, tenses
Palmar side, skin branch of
Brevis skin over hypothenar eminence
aponeurosis of palm Ulnar N.

Gluteal
Origin Insertion Innervation Action
Muscles

External surface of Anterior

Superior
Gluteus ilium, anterior and surface of IR of femur, femoral abduction,
Gluteal N.
Minimus inferior gluteal greater steadies pelvis in gait
L4, L5, S1
lines trochanter
 External surface of Lateral
ilium, anterior and surface of Superior
Gluteus IR of femur, femoral abduction,
posterior gluteal greater Gluteal N.
Medius steadies pelvis in gait
lines trochanter L4, L5, S1

¾ fibers
Post. gluteal line
iliotibial tract
Iliac crest Dorsal Inferior ER of femur, hip extension,
Gluteus post. border
surface of sacrum + Gluteal N. stabilizes knee in ER through the
Maximus Gluteal
coccyx, L5, S1, S2 IT band
tuberosity of
sacrotuberous ligt.
femur

Hip flexion, abduction, IR,

Tensor Lat. surface iliac Iliotibial tract Superior straightens pull of Glut. Max. on
Fascia crest Iliac tubercle below greater Gluteal N. IT band, steadies pelvis on thighs,
Lata to ASIS trochanter L4, L5, S1 and helps keep knee extended in
erect position

S1, S2
Ant. sacrum Lat. to Upper border Hip ER, horizontal abduction,
ventral
Piriformis sacral foramina greater holds head of femur in
primary
Sacrotuberous ligt. trochanter acetabulum
ramus

N. to
Pelvic surface of
Medial obturator
obturator Hip ER, horizontal abduction,
Obturator surface of internus
membrane, margin holds head of femur in
Internus greater and sup.
of obturator acetabulum
trochanter gemellus
foramen
L5, S1, S2

External surface of
obturator Post.
Obturator membrane and Trochanteric division of
Hip ER
Externus adjacent margins fossa of femur obturator
of obturator N. L3, L4
foramen

N. to inf.
Inferior gemellus Hip ER, horizontal abduction,
Inferior border and holds head of femur in
Ischial tuberosity
Gemellus obturator quadratus acetabulum
 internus femoris, L4,
L5, S1

N. to
Superior obturator
Hip ER, horizontal abduction,
Superior Ischial spine, outer border internus
holds head of femur in
Gemellus surface obturator and sup.
acetabulum
internus gemellus
L5, S1, S2

N. to inf.
gemellus
Quadratus Lateral border Quadratus and
Hip ER
Femoris ischial tuberosity tubercle quadratus
femoris, L4,
L5, S1

Anterior
Femoral Origin Insertion Innervation Action
Muscles

Hip
Medial surface of flexion,
Sartorius ASIS + ½ notch below tibia, upper ¼ Pes Femoral N. abduction,
Anserinus ER Knee
flexion, IR

Base of patella
Vastus Upper 2/3 anterior surface, lateral Knee
Tibial tuberosity Femoral N.
Intermedius surface to linea aspera of femur extension
via patella tendon

Lat. lip linea aspera Lat. surface

Vastus Intertrochanteric line Lat. margin patella Tibial Knee
Femoral N.
Lateralis gluteal tuberosity Lat. inferior tuberosity via extension
aspect greater trochanter patella tendon

Med. surface
Vastus Medial lip linea aspera, spiral line, patella Tibial Knee
Medialis intertrochanteric line tuberosity via Femoral N. extension
 patella tendon

Straight head: ant. inf. iliac spine Base of patella Knee

Rectus
Tibial tuberosity Femoral N. extension,
Femoris Reflected head: groove above
via patella tendon hip flexion
acetabulum

Post.
Femoral Origin Insertion Innervation Action
Muscles

Hip
Medial condyle of Tibial division extension,
Semi- Ischial tuberosity, upper
tibia, posteromedial of sciatic nerve knee
membranosus lateral aspect
aspect L5, S1,2 flexion,
knee IR

Hip
Ischial tuberosity Lower Medial surface of
Tibial division extension,
Semi- media aspect by common tibia, upper ¼ into
of sciatic nerve knee
tendinosus tendon with long head of lower post. pes
L5, S1,2 flexion,
biceps femoris anserinus
knee IR

Long head:
Long head: upper medial tibial division
aspect ischial tuberosity, of sciatic N. Hip
Common tendon S1-3 extension,
Biceps Lateral surface
knee
Femoris Short head: lat. lip linea head of fibula Short head: flexion,
aspera Lat. supracondylar fibular division knee IR
ridge of sciatic N.
L5, S1,2

Medial
Femoral Origin Insertion Innervation Action
Muscles

Inferior ramus of Obturator Nerve Hip

Adductor pubis between Upper ½ medial lip linea aspera (ant. or post.
Brevis gracilis and and pectineal line of femur division, or adduction,
obturator externus both) hip flexion

Hip
By a cordlike tendon
Ant. division of adduction,
Adductor from symphisis pubis Middle 1/3 of medial lip of linea
Obturator N. L3- hip
Longus just inf. to pubic aspera of femur
L4 flexion,
tubercle and crest
hip IR

Post. division of
Med. margin gluteal tuberosity, Hip
Ischiopubic ramus + Obturator N.
Adductor intermediate margin of linea adduction
inferior ischial and tibial
Magnus aspera Medial supracondylar Hip
tuberosity division of
ridge Adductor tubercle extension
Sciatic N.

Hip
adduction
Inferior margin of Medial surface tibia Upper ½ Ant. division of
Gracilis Knee
ischiopubic ramus pes anserinus Obturator N.
flexion
Knee IR

Hip
Femoral N. +
flexion
Pectineus Pecten pubis Pectineal line ant. division of
Hip
Obturator N.
Adduction

Hip
Origin Insertion Innervation Action
Muscles

Lesser
trochanter Femoral N.
Iliacus Upper 2/3 of iliac fossa Hip flexion
Pectineal L2, L3
line

Hip flexion,
Transverse processes of L1-5; upper and Lesser trunk
Psoas
lower borders of their bodies; sides of trochanter VPR L2, L3 flexion,
Major
intervertebral discs T12-L5 of femur lateral trunk
flexion
Medial
Femoral Origin Insertion Innervation Action
Muscles

Sides of the bodies of

Pecten pubis
Psoas T12 and L1 and
and iliopubic VPR L1 Weak flexion of the pelvis
Minor intervertebral discs
eminence
between them

Post. lamina:
Posterior lamina:
transverse
iliolumbar ligt. Medial
processes of L1- Fixes 12th rib for
¼ of the inner lip of
4 inspiration; lateral trunk
Quadratus iliac crest VPR T12 and
flexion; trunk flexion,
Lumborum Ant. lamina: L1
Ant. lamina: extension, and
medial ½ of the hyperextension; hip hiker
Transverse processes of
inf. border of
L2-L4
rib #12

Foot and
Origin Insertion Innervation Action
Ankle Muscles

Medial and lateral Lateral side, base, Lateral

Abductor Abduction and
tuberosity of calcaneus proximal phalange Plantar N.
Digiti Minimi flexion of 5th toe
and plantar aponeurosis great toe S1,S2

Medial side of the

Medial tuberosity of Medial Great toe
Abductor base of the prox.
calcaneus and plantar Plantar N. abduction and
Hallucis Phalanx of the
aponeurosis L4,L5 flexion
great toe

Oblique head: bases of Adduction of

metatarsals 2, 3, and 4 great toe;
and fibrous sheath of Lateral side of the Lateral transverse head
Adductor fibularis longus base of the Plantar N. helps maintain
Hallucis proximal phalanx of transverse arch;
 Transverse head: great toe S1,S2 oblique head
capsules of lat. 4 MTP flexes great toe at
joints MP joint

#1—medial side of
the base of the
proximal phalanx of MP flexion; IP
Adjacent side of the toe 2 and the DDE Lateral
Dorsal extension;
shafts of metatarsal Plantar N.
Interossei #2-#4—lateral sides abduction of toes
bones S1, S2
of the bases of the 3 and 4
proximal phalanges
of toes 2-4, DDE

Base of prox.
phalanx of great
Extensor Deep
Dorsal surface of toe and tendons of Toe extension at
Digitorum Fibular N.
calcaneus EDL to toes 2, 3, MP and IP joints
Brevis L5, S1
and 4 on lateral
side

Base of the middle

Lateral condyle of the Foot dorsiflexion;
Extensor and distal Deep
tibia, prox. 2/3 ant. toe extension at
Digitorum phalanges of toes Fibular N.
surface of the fibula and MP and IP and foot
Longus 2-5 on the dorsal L4, L5, S1
IO membrane eversion
surface via DDE

Base of prox. Deep Great toe

Extensor Dorsal surface of
phalanx of great Fibular N. extension at MP
Hallucis Brevis calcaneus
toe L5, S1 joint

Base of 5th metatarsal Lateral side of the Lateral Flexion of the 5th
Flexor Digiti
bone and sheath of base of the prox. Plantar N. toe at the MP
Minimi Quinti
fibularis longus phalanx of 5th toe S1, S2 joint

Via 4 split tendons

Flexor Medial tuberosity of into the sides of Medial
Toe flexion at MP
Digitorum calcaneus and plantar the middle Plantar N.
and PIP joints
Brevis aponeurosis phalanges of toes L4, L5
2-5
 Distal to the soleal line Plantar surface of
Flexor on the post. surface of the distal phalange Toe flexion; foot
tibia and intermuscular of toes 2, 3, 4, and Tibial N. L5,
Digitorum plantar flexion;
septum 5 S1
Longus foot inversion

Medial belly:
medial side of the
base of the
proximal phalanx of
the great toe Medial
Flexor Hallucis Cuboid bone and lateral Great toe flexion
Plantar N.
Brevis cuneiform bones Lateral belly: at MP joint
L4, L5, S1
lateral side of the
base of the
proximal phalanx of
the great toe

Inf. 2/3 of the post. Plantar surface of Great toe flexion;

Flexor Hallucis surface of fibula distal the base of the Tibial N. L5, foot plantar
Longus to origin of soleus on the distal phalanx of S1, S2 flexion; foot
fibula and IO membrane the great toe inversion

Dorsal aspect of Foot dorsiflexion;

Extensor Middle ½ of ant. surface Deep
the base of the great toe
Hallucis of fibula and IO Fibular N.
distal phalanx of extension and
Longus membrane L4, L5, S1
the great toe foot inversion

Tuberosity and Superficial Foot plantar

Fibularis Distal 2/3 lateral surface
dorsal surface of Fibular N. flexion; foot
Brevis of fibula
5th MT L4, L5, S1 eversion

Lateral aspect of
Head and prox. 2/3 Superficial Foot plantar
Fibularis the medial
lateral surface of the Fibular N. flexion; foot
Longus cuneiform and base
fibula L4, L5, S1 eversion
of the 1st MT

Distal 1/3 ant. surface of Dorsal aspect of Deep

Fibularis Foot dorsiflexion;
the fibula and IO the base of the 5th Fibular N.
Tertius foot eversion
membrane MT L4, L5, S1
 Medial head: med.
condyle of femur on the
post. surface just
proximal to articular
area of medial condyle
Posterior surface
Tibial N. S1, Knee flexion; foot
Gastrocnemius Lateral head: lateral of the calcaneus
S2 plantar flexion
condyle of femur on the via tendocalcaneus
post. surface just prox.
to articualr area of lat.
condyle

#1—Medial
Medial side of DDE Plantar N.
#1—medial side of FDL to toes 2-5 and the L4-5 MP flexion; IP
tendon to toe 2 medial side of the
Lumbricales extension of toes
bases of the #2-#4—
#2-#4—adjacent sides of 2-5
proximal phalanges Lateral
FDL tendons to toes 2-5
of toes 2-5 plantar N.
S1, S2

Base of proximal MP flexion; IP

Medial sides of the Lateral
Plantar phalanges on the extension;
shafts of metatarsals 3, Plantar N.
Interossei medial sides of toes adduction of toes
4, and 5 S1,S2
3, 4, and 5; DDE 3, 4, and 5

Inf. aspect of the lat.

supracondylar ridge of
the femur and popliteal Medial border of Tibial N. L4, Knee flexion; foot
Plantaris
surface of femur tendocalcaneus L5, S1 plantar flexion
proximal to lat. head of
gastrocnemius

Knee flexion;
medial rotation of
Lat. surface of the lat. Upper 1/3 of the the leg (lateral
condyle of the femur by post. surface of Tibial N. L4, rotation of the
Popliteus
a cordlike tendon within the tibia prox. to L5, S1 femur in closed
the knee joint soleal line chain); unlocks
the knee joint as
it begins to flex

Medial head: medial side

 of the body of the
calcaneus and plantar Lateral Straighten pull of
Quadratus aponeurosis Tendons of FDL on
Plantar N. the FDL on the
Plantae lateral side
S1,S2 toes
Lateral head: lateral
margin on the plantar
surface of the calcaneus

Upper ¼ post. surface

and post. aspect of the Posterior surface
Tibial N. S1, Knee flexion; foot
Soleus head of fibula, soleal of calcaneus via
S2 plantar flexion
line of tibia, and mid 1/3 tendocalcaueus
medial border of tibia

Medial surface of
Lateral condyle, prox. the medial Deep
Tibialis Foot dorsiflexion;
2/3 lat. surface of tibia, cuneiform bone Fibular N.
Anterior foot inversion
and IO membrane and base of 1st L4, L5, S1
metatarsal bone

Tuberosity of Foot plantar

Upper ½ of post. surface navicular bone with flexion; foot
Tibialis of tibia, IO membrane, slips to all Tibial N. L5, inversion; primary
Posterior and upper 2/3 of post. cuneiorm, cuboid, S1 supinator of the
surface of fibula and bases of MT 2, foot: med. arch
3, and 4 supporter

Legend
C/S = cervical spine, T/S = thoracic spine, L/S = lumbar spine, SP = spinous
process, TP = transverse process, CFT = common flexor tendon, CET = common
extensor tendon, IO = interosseous, DDE = dorsal digital expansion, IP =
interphalangeal, PIP = proximal interphalangeal, MP = metacarpophalangeal, N.
= nerve, br. = branch, MT = metatarsal

Special Testing at a Glance

Cervical
Assessing for Upper Cervical Mobility Impairment
Flexion-Rotation Test Neck Flexor Muscle Endurance Test
Cervical Radiculopathy
 Spurling B Test
Neck Distraction Test
Upper limb Neurodynamic Tension Test A—Median Nerve Bias
Upper Limb Neurodynamic Tension Test B—Radial Nerve Bias
Screening out Upper Motor Neuron Pathology
Hoffman's Reflex
Gonda-Allen Sign
Ruling in Upper Motor Neuron Pathology
Lhermitte's Sign
Babinski Sign Ruling in Upper Cervical Instability
Sharp-Purser Test
Alar Ligament Test
Functional Positional Testing of the Veterbral Artery (rotation)

Thoracic
Ruling in Thoracic Outlet Syndrome
Roos Test
Supraclavicular Pressure Test
Adson's Test
Costoclavicular Maneuver
Hyperabduction Test
Cervical Rotation Lateral Flexion Test
First Rib Spring Test
Shoulder
Screening out/Ruling in Rotator Cuff Tears
Rent Test
Screening out Shoulder Impingement
Supine Impingement Test
Screening out Impingement or Rotator Cuff Pathology
 Hawkins-Kennedy Test
Screening out/Ruling in Subscapularis Tear
Internal Rotation Lag Sign
Ruling in Supraspinatus Tears
Drop Arm Test
Screening out Biceps Tendinopathy
Speed Test
Screening out Biceps Tendinopathy
Yergason's Test
Screening out/Ruling in SLAP Lesion
Biceps Load Test II
Ruling in Labral Tears
Yergason's Test
Ruling in Posteroinferior Labral Lesion
Jerk Test
Ruling in Superior Labral Tears
Sulcus Sign
Assessing for Scapular Dysfunction
Scapular Reposition Test
Screening out/Ruling in AC Joint Pathology
AC Joint Palpation
Ruling in AC Joint Pathology
AC Resisted Extension Test
Elbow
Screening out Occult Elbow Fracture
Elbow Extension Test
Screening out Medial Collateral Ligament Pathology
Moving Valgus Stress Test
Ruling in Ulnar Neuropathy at the Elbow
 Elbow Flexion Test
Percussion Test/Tinel's Sign
Wrist and Hand
Assessing Wrist/Hand Swelling
Figure-of-Eight Method

Screening out/Ruling in Scaphoid Fracture

Scaphoid Compression Tenderness
Scaphoid Tubercle Tenderness
Screening out Scaphoid Fracture
Anatomical Snuff Box Tenderness
Ruling in Carpal Instability
Watson Scaphoid Instability Test
Testing for Lunotriquetral Ligament Integrity
Ballottement (Reagan's) Test
Screening out Carpal Tunnel Syndrome
Wrist Ratio Index
Screening out/Ruling in Median Nerve Neuropathy
Wrist Flexion and Median Nerve Compression
Flick Maneuver
Median Nerve Compression Test
Phalens Test
Closed Fist/Lumbrical Provocation Test
Ruling in Median Nerve Neuropathy
Tinels
Atrophy and Weakness
Clinical Prediction Rule for Ruling in Carpal Tunnel Syndrome
Screening out Triangular Fibrocartilage Complex Tears
Press Test
Screening out APL/EPB Tenosynovitis
Extensor Pollicis Brevis Test Finkelstein's Test
Screening out Thumb Instability
Ulnar Collateral Ligament Test
Lumbar
Clinical Prediction Rule: for Screening out/Ruling in Zygoapophyseal Joint
Syndrome
CPR for Success with Lumbar Stabilization/Neuromuscular Reeducation
(unvalidated)
CPR for Failure with Lumbar Stabilization/Neuromuscular Reeducation
(unvalidated)
Ruling in Lumbar Instability
Passive Physiological Intervertebral Movements (PPIVMs) Extension
Passive Physiological Intervertebral Movements (PPIVMs) Flexion
Beighton Ligamentous Laxity Test
Prone Instability Test
Screening out Disc Herniation
Straight Leg Raise
Screening out Far Lateral Disc Herniation
Femoral Nerve Tension Test
Ruling in Disc Herniation
Well Leg Raise (crossed straight leg raise)
Slump Sit Test

Ruling out Degenerative Changes in the Spine

Extension Quadrant Test
Screening out/Ruling in Ankylosing Spondylitis
Chest Expansion
Sacroiliac Joint
Ruling in SIJ Involvement
 SIJ Motion Asymmetry Cluster
Provocation Cluster SI Compression Test
SI Distraction Test Gaenslen's Test
Posterior Pelvic Thigh Thrust Test Sacral Spring Test

FIGURE 16-4 Patellar-Pubic Percussion Test

Screening out/Ruling in Piriformis Syndrome

Fair Test
Assessing Pelvic Mobility and Symmetry
Standing ASIS
Standing PSIS Symmetry
Screening out/Ruling in Pelvic Instability
Active Straight Leg Raise
Pubic Symphysis Palpation
Posterior Pelvic Palpation
Resisted Hip Abduction for Total Knee or Total Hip Replacement Patients
Sign of the Buttock
CPR for Spinal Manipulation (validated)

Hip
Screening out/Ruling in Occult Fracture of the Hip or Femur
Patellar-Pubic Percussion Test
Ruling in hip osteoarthritis
CPR for Hip OA
Ruling in Hip Osteoarthritis
Assessment of Restricted Planes of Motion: Saggital, Frontal, Transverse
Planes
Screening out/Ruling in hip osteoarthritis
Use of an index involving the following:
1. Hip pain
2. IR < 15°
3. Pain with IR
4. Morning stiffness up to 60 minutes
5. Age > 50 years
Detecting Hip Joint Mobility Impairments
Flexion Abduction External Rotation (FABER) Test (Patrick Test)
Anterior Glide
Screening Out Hip Labrum Tears or Degeneration
Patient History—Clicking or Locking
Internal Rotation-Flexion-Axial Compression Maneuver
Hip Scour
Flexion-Adduction-Internal Rotation Test (Click Test)
Screening out Early Hip Disease
Flexion-Adduction Test
Ruling in Early Hip Dysplasia
Passive Hip Abduction Test
Assessing Iliopsoas/Rectus Femoris Length
Thomas Test (unvalidated)
Ruling in Gluteus Medius Tears/Weakness
 Trendelenburg's Sign Resisted Hip Abduction
Knee
Screening out Fracture at the Knee
Ottawa Knee Decision Rule
Criteria for classification of osteoarthritis of the knee > 3 variables present
1. Age > 50 years
2. Knee crepitus
3. Palpable bony enlargement
4. Bony tenderness to palpation
5. Morning stiffness that improves in < 30 minutes
6. No palpable warmth of the synovium
CPR for Knee OA Patients Who Will Benefit from Hip Mobilization
(unvalidated)
Screening out/ruling in Meniscal Pathology
Thessaly Test
McMurray Test

Screening out/Ruling in Anterior Cruciate Ligament Tears

Lachman's Test
Anterior Drawer Test
Screening out/Ruling in Posterior Cruciate Ligament Tears
Posterior Drawer Test
Posterior Sag Sign or Godfrey's Test
Screening out Lateral Collateral Ligament Laxity or Tears
Varus Stress Test (LCL)
Screening out Medial Collateral Ligament Laxity or Tears
Valgus Stress Test (MCL)
Ruling in Patellofemoral Pain Syndrome
Vastus Medialis Coordination Test
Patellar Apprehension Test
 Eccentric Step Test McConnell Test
CPR for Orthotics and Patellofemoral Pain (unvalidated)
Assessing the Length of the Iliotibial Band
Ober Test (unvalidated) modified Ober Test
Ankle and Foot
Screening out Achilles Tendon Tears
Thompson Test
Screening out Ankle and Foot Fractures
Ottawa Ankle Rules
Screening out/Ruling in Damage to the Syndesmosis
Fibular Translation Test
External Rotation Test Squeeze Test
Screening out/Ruling in Damage to the Anterior Talofibular Ligament
Anterior Drawer Test
Screening out/Ruling in Lateral Ligament Integrity
Medial Talar Tilt Stress Test
Test for Ankle Swelling
Figure-8 Test
Screening out/Ruling in Ankle Impingement
Clinical Prediction Rule of Impingement
Forced Dorsiflexion Test
CPR for Deep Vein Thrombosis
Ruling in Plantar Fasciitis
Windlass Test
Screening out/Ruling in Peripheral Neuropathy
Monofilament Testing of the Diabetic Foot
Screening out Tarsal Tunnel Syndrome
Tinel's Sign
Dorsiflexion Eversion Test
Assessing Subtalar Joint Stability
Medial Subtalar Glide Test
Arch Height Ratio (AHR)
Treatment Direction Test (TDT)
Testing for Rearfoot Varus and Valgus
Calcaneal Position Technique
Testing for Forefoot Posturing
Forefoot Varus and Valgus
Test for Stress Fracture or Interdigital Neuroma
Morton's Test (unvalidated)
Screening out/Ruling in Abnormal Excessive Midtarsal Function During Gait
Functional Hallux Limitus Test
A
Abdominal aorta, 26 27
Abdominal bracing and hollowing, 217 218
Achilles tendon injuries, 345 346 347
AC resisted extension test, 146
Acromioclavicular joint, 144 145 146
Adhesive capsulitis, 140
Adson's test, 106
Alar ligament test, 94
Anatomical snuff box tenderness, 174
Ankle and foot, 341 342 343 344 345 346 347 348 349 350 351 352 353 354
355 356 357 358 359 See also specific injuries/impairments
Ankylosing spondylitis, 236 237 238
Anterior cruciate ligament injury, 303 316 317 318 322
Anterior drawer test, 318 352
Anterior glide, 279
Anterior-posterior glide, 310
Anterior talofibular ligament damage, 352
AP mobilization of femoral joint, 311
Arch height ratio, foot, 369
B
Babinski sign, 91
Back, 199 383 See also Low back pain
Ballottement test, 177
Bankart lesion, 121 137
Beighton ligamentous laxity test, 214 215
Biceps load test II, 136
Biceps tendon injuries, 132 133
Brachial plexus neuropathy, 143
Bursae, knee, 338 339
Bursitis, 288 338
C
Calcaneal position technique, 373
Canadian C-spine rules, 67
Carpal instability, 175 176 177
Carpal tunnel syndrome, 178 179 180 181 182 183 184 185 186 187
Caudal glide, 310
Cervical facet syndrome, 75 76 77 78 79
Cervical instability, 92 93 94 95
Cervical myelopathy, 88 89 90 91
Cervical radiculopathy, 81 82
Cervical rotation lateral flexion test, 108
Cervical spine, 59 60 61 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73
74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96
97 98 63 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93
94 95 96 97 98 See also specific injuries/impairments
Cervical spondylosis, 74
Click test, 286
Clinical reasoning, steps in, 5
Closed fist/lumbrical provocation test, 184
Cognitive reinforcement, 50 51
Colles' fracture, 189
Complex regional pain syndrome, 47
Costochondritis, 109
Costoclavicular maneuver, 107
Craniovertebral sidebending test, 94
Cubital tunnel syndrome, 158
D
DASH, 41 42
Deep forearm flexors, 391 392 393
Deep neck flexor endurance training, 72
Deep vein thrombosis, 358 359
Delome regimen, 4
DeQuervain's tenosynovitis, 193 194 195
Dermatomes, 61 62 198
Diabetic foot, testing for, 366
Diagnostic imaging, advanced, 37
Disability index, 39 40 41 42
Disc herniation, 224 225 226
Distal radius fracture, 189
Dorsal displacement distal radius, 189
Dorsiflexion-eversion test, 364
Drop arm test, 129
Drugs, 2 21 22 24 27 28 29
E
Eccentric step test, 330 331
Elbow, 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161
162 See also specific injuries/impairments
Electrical stimulation, 3
Extension quadrant test, 235
Extensor pollicis brevis test, 194
External rotation test, 350
F
FABER test, 278
Fair test, 254
Fear-Avoidance Back Questionnaires, 20 40 42
Femoral anterior glide, 269
Femoral joint, AP mobilization of, 311
Femoral nerve tension test, 225
Fibular translation test, 349
Figure-of-eight method, for swelling assessment, 188 354
Finkelstein's test, 194 195
First rib spring test, 108
Flexion-abduction tests, 278
Flexion-adduction tests, 286 290 291
Flexion-rotation tests, 78
Flick maneuver, 181
Forced dorsiflexion test, 356 357 358
Forearm, 164 165 391 392
Functional hallux limitus test, 378
G
Gaenslen's test, 247 248
Gait assessment, 368 369 370 371 372 378
Glenohumeral horizontal adduction measurement, 130 131
Gluteus medius tears/weakness, 295 296 297
Godfrey's test, 321
Gonda-Allen sign, 89
Goniometer measurement, of pathological hips, 281
GROC, 40 41
H
Hallux rigidus, 377 378
Hallux valgus, 379
Hamstring muscle, 266 287
Harris Hip Score, 40 42
Hawkins-Kennedy test, 127
Headaches, 73 77 80
Heel drop test, 103
Hip, 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280
281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297
See also specific injuries/impairments
Hip adductor strain, 294
Hip mobilization, 309 310 311
Hip scour, 285
Hoffman's reflex, 88
Hyperabduction test, 107
I
Iliopsoas tendinopathy, 292 293
Iliotibial band friction syndrome, 335 336 337
Intake forms, for medical screening, 11 14 15
Interdigital neuroma, 376
Internal rotation-flexion-axial compression maneuver, 284 285
Internal rotation lag sign, 128
J
Jerk test, 138
Jumper's knee, 334
Juvenile kyphosis dorsalis, 110
K
Kidney, 26
Knee, 299 300 301 299 300 301 302 303 304 305 306 307 308 309 310 311
312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328
329 330 331 332 333 334 335 336 337 338 339 340 308 309 310 311 312
313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329
330 331 332 333 334 335 336 337 338 339 340 See also specific knee
injuries/impairments
Labral tears, 138 139
L
Labrum tears/degeneration, hip, 283 284 285 286
Lachman's test, 317
Lateral collateral ligament, 324 325
Lateral epicondylalgia, 152 153
Lateral ligament integrity, 353
Lateral plantar nerve entrapment, 362
LEFS, 40
Lhermitte's sign, 90
Likelihood ratios, 1
Liver, 26
Low back pain (backache), 31 49 50 51 52 53 202 221 222 229 230 231
Lumbar facet syndrome, 205
Lumbar hypermobility lumbar motor control impairment, 210 211 212 213 214
Lumbar local rotation GPM V, 208
Lumbar prone PA palpation, 208 209
Lumbar spine, 197 198 199 200 201 202 203 204 205 206 207 208 209 210
211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227
228 229 230 231 232 233 234 235 236 237 238 See also specific
injuries/impairments
Lunotriquetral ligament integrity, 177
M
Manual therapists, characteristics of, 4
McBurney's point, 26
McConnell test, 331 332
MCID, 39
McKenzie exam, with provocation cluster, 248
McMurray test, 314 315
Medial collateral ligament, 156 324 326
Medial epicondylalgia, 153 154
Medial plantar nerve entrapment, 362
Medial subtalar glide test, 367
Medial talar tilt stress test, 353
Medial tarsal tunnel syndrome (tibial neuritis), 363 364 365
Medial tibial stress syndrome, 358
Median nerve compression test, 182
Median nerve neuropathy, 180 181 182 183 184 185 186
Medical screening, 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
30 31 32 33 34 35 36 37 38 See also Review of systems
Meniscus injury, 303 312 313 314 315
Metatarsalgia, 375
Midtarsal joint pronation assessment, 368 369
Mini-mental exam, 19
Monofilament testing, of diabetic foot, 365
Morton's test, 376
Movement analysis and rehabilitation, 8
Moving valgus stress test, 156
MRI, 37 38
Muscles, 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394
395 396 397 398 399 400 401 402 403 404 405 383
Myositis ossificans, 162 289
N
NAU Reverse 6's taping, 370 371 372
NDI, 40 41
Neck, 18 68 69 70 71 72 73 76 See also Cervical spine
Neck distraction test, 83
Neck flexor muscle endurance test, 79
Neuromuscular re-education, lumbar, 218
Neutral gap, 207 208
Noyes hop test, 323
Numeric Pain Scale, 41 42
Nursemaid's elbow, 161
O
Ober test, 336 337
ODI, 40 41
Osgood Schlatter disease, 340
Osteoarthritis, 274 275 276 277 308 309 310
Osteochondritis dessicans, 339
Osteochondrosis, 234 235
Ottawa decision rules, 306 307 348
Outcome tools, 39 40 41 42
Oxford regimen, 4
P
Pain, 14 47 48 49 50 51 52 53 54 See also specific types of pain
Pain referral patterns, 25 28 29 30 31 32 75 206 240 241
PAIVM, 65
Passive hip abduction test, 291
Patellar-pubic percussion test, 273
Patellar tendonosis, 334
Patellofemoral joint pain syndrome, 327 328 329 330 331 332 333
Patrick test, 278
Pelvis, 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254
255 256 257 258 259 260 261 262 263 264
Percussion tests, 103 160 273
Peripheral neuropathy, 366
Pes anserine bursitis, 338 339
Phalens test, 183
Physical therapy interventions, 11 12 13 See under specific disorder
Piriformis syndrome, 253 254
Plantar fasciitis, 360 361
Plantar nerve entrapment, 362
Posterior-anterior glide, 310 311
Posterior capsular restriction, 130 131
Posterior cruciate ligament tears, 319 320 321 322 323
Posterior drawer test, 320
Posterior glide, 280
Posterior pelvic palpation, 260
Posterior sag sign, 321
Posterior tibial tendon dysfunction, 359
PPIVM, 64
Press test, 191
Prone instability test, 216 217
Prone knee bend test, 249
Provocation tests, for sacroiliac joint involvement, 243 244 245 246 247 248
PSFS, 39 41
4P test or thigh thrust test, 245 246
Pubic symphysis, 255 259
Q
Quadriceps muscles, 266
R
Radial nerve entrapment, 157
Radiological screening, 34 35 36 37 38
Reagan's test, 177
Rearfoot varsus and valgus, 373
Rebound tenderness, 26
Reflex testing, 62
Rent test, 125
Resistance training, 4
Resisted hip abduction, 261 297
Review of systems, 14 17 18 19 20 21 22 23 24 25 26 27 28
Ribs/ribcage, 99 100 101
RMQ, 40 42
Roos test, 105
Rotator cuff impingement/tears, 121 122 123 124 125 126 127 128 129
S
Sacral thrust test, 246 247
Sacroiliac directed graded passive movement V, 264
Sacroiliac joint, 239 242 243 244 245 246 247 248 249 250 251 252 255 264
Scaphoid injuries, 171 172 173 174
Scapula, 115 116 117 118 117 141 142 143 387 388 389
Scapular reposition test, 142
Scheuermann's kyphosis, 110
Sciatica, 223
Scoliosis, 111 112
Sharp-Purser test, 93
Shoulder abduction test, 87
Shoulder and shoulder girdle, 113 114 115 116 117 118 119 120 121 122 123
124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140
141 142 143 144 145 146 See also specific injuries/impairments
SI compression test, 243 244
SI distraction test, 244 245
Sign of the buttock, 262
SINSS, 43
Sinusitis, 21
Sitting PSIS test, 250
Skeleton, human, 381
SLAP lesions, 121 134 135 136
Slipped capital femoral epiphysis, 289 290
Slump sit test, 228 229
Snapping hip syndrome, 294 295
Soft tissue examination, 35
SPADI, 41 42
Speed test, 132
Spinal arthritis, 234 235
Spinal manipulation, 263 264
Spinal stenosis, 233 234
Spine manipulation, 77
Spondylolisthesis, 232
Spondylosis, 234 235
Spurling B test, 82
Squeeze test, 351
SSS, 41 42
Standing ASIS, 256
Standing flexion test, 250
Standing PSIS symmetry, 257
Straight leg raise tests, 224 226 227 258
Stress fracture, foot, 376
Subclavicular pressure test, 106
Subjective exam, 43 44 45 46
Subscapularis tears, 128 129
Subtalar glide, 353
Subtalar joint stability assessment, 367
Sulcus sign, 139
Superior labral lesions. See SLAP lesions
Supinator syndrome, 157
Supine impingement test, 126
Supine to long sit, 251
Suprascapular neuropathy, 143
Supraspinatus calcific tendinitis, 131
Supraspinatus tears, 129
Syndesmosis injury, 349 350 351
T
Tarsal tunnel syndrome, 364 365
Temperomandibular joint (TMJ), 55 56 57 58
Tests, 1 400 401 402 403 404 405 See also specific tests
Thera-band® elastic band resistance, 4
Thessaly test, 313
Thomas test, 292 293
Thompson test, 346 347
Thoracic outlet syndrome, 104 105 106 107 108 400
Thoracic spine, 99 100 101 102 103 104 105 106 107 108 109 110 111 112
See also specific injuries/impairments
Thumb injuries, 193 195 196
Tibial neuritis (medial tarsal tunnel syndrome), 363 364 365
Tinel's sign, 160 185 365
Tissue healing, 6 7 52
Total hip replacement, 268 281 282
Total knee arthroplasty, 303
Treatment-based classification (TBC), 9 10
Treatment direction test (TDT), 370
Trendelenburg's sign, 296
Triangular fibrocartilage disc injury, 190 191 192
U
Ulnar collateral ligament sprain, 155
Ulnar collateral ligament test, 196
Ulnar neuropathy, 159 160
Ulnomeniscotriquetral dorsal glide, 192
Ultrasound, indications for, 3
Upper limb neurodynamic tension tests, 84 85 86
Upper motor neuron pathology, 88 89 90 91 399
V
Varus stress test, 325 326
Vastus medialis coordination test, 328 329
Vertebral fractures, thoracic, 102 103
Vertebrobasilar artery insufficiency, 98
Vital signs, basic, 33
W
Watson scaphoid instability test, 176 177
Whiplash-associated disorders, 96 97
Windlass test, 361
WOMAC, 40 42
Wrist and hand, 163 164 165 166 167 168 169 170 171 172 173 174 175
176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192
193 194 195 196 See also specific injuries/impairments
Y
Yergason's test, 133 138
Z
Zygoapophyseal joint syndrome, 206 207 208