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Chapter 3:
Orthopedic and Neurologic Procedures in Chiropractic
From R. C. Schafer, DC, PhD, FICC's best-selling book:
“Basic Chiropractic Procedural Manual”
The following materials are provided as a service to our profession. There is no charge for individuals to copy and file these materials. However, they cannot be sold or used in any group or commercial venture without written permission from ACAPress.
All of Dr. Schafer's books are now available on CDs, with all proceeds being donated
to chiropractic research. Please review the complete list of available books.Selected Neurologic Problems Overview Types of Neuritides Peripheral Neuritis Local Neuritis Disassociated Anesthesias in Cord Lesions Cervical Lesions and Cerebral Vasomotor Disturbances The Pyramidal System The Extrapyramidal System Cerebellar Lesions Localizing Symptoms and Signs of Intracranial Lesions Examination of Cranial Nerves Additional Signs of Intracranial Lesions Principles of Neurologic Examination Sensory Disturbances Motor Disturbances Differentiation of Upper and Lower Motor Neuron Lesions Superficial and Deep Reflexes Neurologic Aspects of Subluxation Syndromes Nerve Root Insults Reflex Irritations Other Causes Closing Remarks Orthopedic and Neurologic Tests and Signs A PhysicaI Examination Routine Geriatric Considerations Pediatric Considerations Cranial and Thoracic Measurements Developmental Progress Height Estimation During Development Percent of Mature Height Anticipated
Upper Motor Lower Motor
Consideration Neuron Lesion Neuron Lesion
Site Cerebral cortex or Anterior horn or peripheral
pyramidal tract motor neuron
Distribution Diffuse or patchy Segmental (number)
Paralysis type Spastic and rigid Flaccid
Superficial reflex Absent Absent
Deep reflex Exaggerated Absent
Atrophy Disuse Rapid extension, trophic
Trophic lesions Minimal Intense and extensive
Pathologic signs Present Absent
Afferent Center Efferent Superficial Reflexes Corneal V Pons VII Uvular IX Medulla X Upper Abdominal T7–T9 Cord T7–T9 Lower Abdominal T10–T12 Cord T10–T12 Cremasteric Femoral L1 Genitofemoral Plantar Tibial S1–S2 Tibial Anal Pudendal S4–S5 Prudential Consensual II Midbrain III Accommodation II Occipital III Ciliospinal Sensory nerve T1–T2 Cervical sympathetics Oculocardiac V Medulla X Carotic Sinus IX Medulla X Deep Reflexes Biceps Musculocutaneous C5–C6 C5–C6 Triceps Radial C6–C7 C6–C7 Radial Radial C6–C8 C6–C8 Patellar Femoral L2–L4 L2–L4 Achilles Tibial S1–S2 S1–S2 Jaw jerk Trigeminal Pons Trigeminal
Neurologic Aspects of Subluxation Syndromes
As previously described, the disturbances of neurologic function
associated with subluxation syndromes are manifested as abnormalities in
sensory interpretations and/or motor activities. These disturbances may be
through one of two primary mechanisms: direct nerve or root disorders, or of a
reflex nature.
Nerve Root Insults
When direct involvement occurs on the posterior root of a specific
neuromere, it manifests as an increase or decrease in awareness over the
dermatome; ie, the superficial skin area supplied by this segment. Such a
manifestation is often tested by a cotton wisp and sterile pinwheel. Typical
examples might include foraminal occlusion or irritating factors manifesting
hyperesthesia, particularly on the:
Dorsal and lateral aspects of the thumb and radial side of the hand when involvement occurs between C5 and C6.
Dorsum of the hand, the index and middle fingers, and the ventral-radial side of the forearm, thumb, index and middle fingers when involvement occurs between C6 and C7.
Anterolateral aspect of the leg, medial foot, and great toe when involvement occurs between L4 and L5.
Posterolateral aspect of the lower leg, lateral foot and toes when involvement occurs between L5 and S1.
In other instances, nerve root involvement may cause hypertonicity and the sensation of deep pain in the muscles supplied by this neuromere. For example:
(1) C6 involvement — deep pain in the biceps;
(2) C7 involvement — deep pain in the triceps and supinators of forearm; and
(3) L4 and L5 involvements — deep pain or cramping sensations in the buttock, posterior thigh and calf, and/or anterior tibial muscles. In addition, pressure against the nerve root and/or its distribution may be particularly painful.
Nerve root insults from subluxations also may be evident as disturbances in motor reflexes and/or muscular strength. Examples include the deep tendon reflexes such as:
(1) reduced biceps reflex when involvement occurs between C5 and C6;
(2) reduced triceps reflex when involvement occurs between C6 and C7; and
(3) reduced patellar and Achilles reflexes when involvement occurs between L4 and L5. These reflexes must always be compared, one side to the other, to judge whether a hyporeflexia is unilaterally present. And, of course, unilateral hyperreflexia is pathognomonic of an upper motor neuron lesion.
Muscle strength may be tested in various manners, depending on which muscles are involved. The common procedure is to compare the isometric strength of resistance against counterpressure. For example:
(1) weakness in the biceps when involvement occurs between C5 and C6;
(2) weakness in triceps when involvement occurs between C6 and C7;
(3) weakness in the anterior tibialis when involvement occurs between L4 and L5;
(4) weakness in the posterior calf when involvement occurs between L5 and S1.
Prolonged and/or severe nerve root irritation may also produce evidence of
trophic changes in the tissues supplied. This may be characterized by obvious
atrophy, but such a sign is particularly objective when the circumference of
an involved limb is measured at the greatest girth in the initial stage and
this value is compared to measurements taken in later stages. The calf, thigh,
forearm, and upper arm are therefore measured and recorded in many routine
examinations.
Reflex Irritations
In addition to nerve root involvement and/or peripheral irritations, many
sensory disturbances can be caused by reflex irritation to somatic
musculoskeletal tissues. These symptoms lack the typical features of nerve
root involvement such as seen with cervical compression tests, and they
usually do not create significant motor changes. They often arise from
inflammatory tissues or fibrotic muscles, tendons, or ligaments, which
characteristically act as "trigger" areas. That is, their stimulation such as
with deep pressure initiates reflex pain. Injured musculoskeletal tissues may
be an effect of a subluxation syndrome or they may exist as a primary injury
that will cause and/or perpetuate abnormal articular position and motion.
Some typical reflex neuralgias are:
The marked hypertonicity and tenderness of the occipital musculature and the consequent C1 or C2 neuralgia associated with upper cervical subluxations.
The hypertonicity and tenderness of the muscles and tendons of the rotator cuff consequent to rotator-cuff tendinitis and associated with referred pain into the posterolateral arm and often encouraged by cervical subluxations and spondyloarthrosis.
The hypertonicity and tenderness of muscles about the scapula are common to the scapulocostal syndrome. These areas often cause reflex pain along the ulnar side of the upper extremity and are frequently encouraged by a regional thoracic scoliosis with thoracocostal subluxations.
The hypertonicity and tenderness of the gluteal muscles and sacroiliac ligaments, which may reflect pain over the sciatic trajectory and are often causing or being effected by sacroiliac subluxations.
The hypertonicity and tenderness of the piriformis (which may cause a posterior sciatic reflex neuralgia) and peripheral nerve pressure, which is common to many sacral subluxations.
The hypertonicity and tenderness of the tensor fascia latae and the consequent reflex pain along the lateral thigh, associated with iliofemoral tendinitis and innominate subluxation.
There are many other examples of this type of referred pain from
irritations in musculoskeletal tissue, and the relationships of these
supporting tissues to the subluxation syndrome must always be appraised. That
is, are they an effect or are they due to primary injury? Will they create a
subluxation syndrome that may now perpetuate these neuropathic processes?
Consequently, the proper treatment of sprain and strain injuries,
tendinitides, myositides, fibrositides, and so forth, becomes important to the
prevention and/or correction of a subluxation syndrome.
Glossary of Common Orthopedic and Neurologic Tests, Signs, Maneuvers,
Abadie's sign. A lack of deep pain during strong pinching of the Achilles
tendon. It is an early sign of tabes dorsalis.
(1) The patient (sitting or
standing) is asked to raise the arm on the involved side overhead, flex
the elbow, and then place the fingers as far down on the opposite shoulder
blade as possible.
Argyll Robertson sign. This is an abnormally small pupil that fails to respond
to the light reflex but does constrict with accommodation and convergence
a well-established sign of CNS syphilis. The pupils are irregular and
unequal in diameter, fail to change in size in reaction to light both
directly and consensually, and exhibit a normal near response.
Babinski's plantar reflex. The foot should always be warm before testing. With
the patient prone or supine, stroking the sole of the relaxed foot with a
moderately sharp instrument will usually result in rapid plantar flexion
of the toes. Normally, all the toes plantar flex. When the small toes fan
in plantar flexion and the great toe simultaneously moves upward in strong
dorsiflexion, a positive Babinski sign is elicited. A positive sign is
normal in children up to 5 years; in adults, it is indicative of pyramidal
tract involvement in cerebral edema, brain injuries, meningitis, and after
the use of morphine. Depending on the cause, the sign may be bilateral or
unilateral as in the case of hemiplegia. If the plantar reflex is in any
way abnormal, it should be recorded even if a typical Babinski sign is not
present. A Babinski plantar response is the most constant of all
pathologic reflexes.
(1) the skin of the
foot blanches and the superficial veins collapse when the leg is in the
raised position and/or
Bunnel-Littler test. Hold the patient's metacarpophalangeal joint in slight
extension and try to flex the proximal interphalangeal joint of any finger
being tested. If the joint cannot be flexed in this position, it is a
positive sign that the intrinsic muscles are tight or capsule contractures
exist. To distinguish between intrinsic muscle tightness and capsule
contractures, let the involved metacarpophalangeal joint flex slightly,
relaxing intrinsics, and move the proximal interphalangeal joint into
flexion. Full flexion of the joint shows tight intrinsics; limited flexion
suggests probable contracture of the interphalangeal joint capsule. This
is sometimes called the retinacular test or finger contracture test.
Caloric test. Alternately douche warm and cold water into an ear, after
determining that the eardrum is not perforated. The patient should be
seated with the head tilted backward about 60° to bring the horizontal
semicircular canal into a vertical plane. Normally, warm water (not
exceeding 120°F) produces rotary nystagmus, first away and then toward the
irrigated ear. Cold water produces an opposite effect nystagmus first
toward and then away from the ear irrigated. The final response normally
appears within 30–40 seconds. Lack of response shows decreased or absent
vestibular nerve function; ie, no nystagmus results if the labyrinth is
diseased. The test should be discontinued if there is no reaction within 3
minutes. This procedure is also called Barany's test or the thermal test.
(1) The patient is asked to stand
with the feet separated 12–18 inches apart, assume a "knock-kneed"
position by rotating the thighs inward, and then attempt to squat as low
as possible. Pain, joint restriction, or a clicking sensation suggests a
lesion of the medial meniscus.
Chvostek's sign. In cases of tetany, percussion over the masseter muscle (just
below and in front of the ear) when the mouth is partly open produces
spasmotic contraction of the ipsilateral facial muscles due to facial
nerve hyperexcitability.
Dalrymple's sign. This sign is exhibited by widening of the eyelid slits, thus
producing the expression of fright. The phenomenon is due to a
sympathicotonia of the autonomic fibers of the oculomotor nerve that
supply the levator palpebrae.
(1) move the eyeball sharply
medial while the contralateral abducting eye exhibits nystagmus (bilateral
internal rectus ophthalmoplegia) as the result of an oculomotor lesion or
Double-leg raise test. This is a two-phase test:
(1) The patient is placed
supine, and a straight-leg-raising (SLR) test is performed on each limb:
first on one side, and then on the other.
Draw Sign. Tears of the anterior talofibular ligament produce joint
instability, allowing the talus to slide forward (subluxate) on the tibia.
To test for instability and subluxation of the tibia and talus, place one
hand on the anterior aspect of the sitting patient's lower tibia and grip
the heel within your other palm. When the calcaneus and talus are pulled
anteriorly and the tibia is simultaneously pushed posteriorly, the
anterior talofibular ligament should allow no forward movement of the
talus on the tibia. The test is positive if the talus slides anteriorly
from under the cover of the ankle mortise. Sometimes the abnormal bone
movement can be heard as well as felt during the maneuver.
Eden's test. With the patient seated, the examiner palpates the radial pulse
and instructs the patient to pull the shoulders backward, throw the chest outward in a "military posture," and hold a deep inspiration as the pulse
is examined. The test is positive if weakening or loss of the pulse
occurs, indicating pressure on the neurovascular bundle as it passes
between the clavicle and the 1st rib, and thus a costoclavicular syndrome.
(1) push medially with your active hand and laterally with your
stabilizing hand, then
Elbow extension/flexion stress test. The patient's elbow is passively extended
and flexed. Painful instability indicates sprain or destructive joint
pathology, while discomfort with limited motion suggests contractures or
degenerative arthritis.
Facial motor function signs. Weakness of the muscles supplied by the facial
nerve may be evidenced by the presence of drooping of the corner of the
mouth, smoothing out of the nasolabial fold, drooping of the lower lid, or
the inability to close the eye such as seen in Bell's palsy where the
signs are unilateral. If the frontalis muscle is involved, the forehead is
smoothed on the affected side. Note presence or absence of atrophy,
abnormal movements, contractures, etc.
(1) If when
clenching the fist firmly the normal prominence of the middle knuckle is
not produced, the test is initially positive.
Flexor digitorum profundus test. This sign is based on the fact that flexor
digitorum profundus tendons work only in unison. The examiner stabilizes
the metacarpophalangeal and interphalangeal joints in extension. The
patient then flexes the finger being tested at the distal interphalangeal
joint. If the patient cannot do this, the sign is positive and indicates a
cut tendon or denervated muscle.
Gaenslen's test. In this test, the patient is placed supine with knees and
hips acutely flexed by the patient who clasps the knees with both hands
and pulls them toward the abdomen. This brings the lumbar spine firmly in
contact with the table and fixes both the pelvis and lumbar spine. With
the examiner standing at right angles to the patient, the patient is
brought well to the side of the table and the examiner slowly hyperextends
the opposite thigh by gradually increasing force by pressure of one hand
on top of the patient's knee while the examiner's other hand is on the
patient's flexed knee for support in fixing the lumbar spine and pelvis.
Some examiners allow the hyperextended limb to fall from the table edge.
The hyperextension of the hip exerts a rotating force on the corresponding
half of the pelvis. The pull is made on the ilium through the Y ligament
and the muscles attached to the AIISs. The test is positive if the thigh
is hyperextended and pain is felt in the sacroiliac area or referred down
the thigh, providing that the opposite sacroiliac joint is normal and the
sacrum moves as a unit with the side of the pelvis opposite to that being
tested. The test should be conducted bilaterally. A positive sign may be
elicited in a sacroiliac, hip, or lower lumbar nerve root lesion. If the
L4 nerve is involved, pain is usually referred anteriorly to the groin or
upper thigh. If the sign is negative, a lumbosacral lesion should be the
first suspicion. This test is usually contraindicated in the elderly.
Hamilton's sign. Normally, a straight edge (eg, a yardstick) held against the
lateral aspect of the arm cannot be placed simultaneously on the tip of
the acromion process and the lateral epicondyle of the elbow. If these two
points do touch the straight edge, it signifies a dislocated shoulder.
(1) that which is due to irritation of the psoas alone, and
Hirschberg's sign. A pathologic sign exhibited by internal rotation and
adduction of the foot when friction is applied to the lateral aspect of
the plantar surface. It indicates motor tract involvement.
(1) the Achilles tendon is lax,
Hoffman's reflex. The examiner holds the wrist of a patient, suspected of
having pyramidal tract disease, in one hand, and allows the hand to relax.
The examiner then grasps the patient's middle finger between his thumb and
forefinger and snaps the terminal phalanx sharply without dorsiflexing the
finger. If Hoffman's sign is present, the thumb is seen to flex slightly.
Often, a brisk apposition of the thumb and forefinger occurs. It may
occasionally occur in exalted nervous states or in hysteria, but it's
then apt to be bilateral. This reflex is also known as Trommer's sign. The
sign is positive with upper motor neuron lesions and often found in
hemiplegia, but it is not as reliable as Babinski's plantar reflex.
Iliac compression test. The patient is placed on the side with the affected
side up. The examiner places his forearm over the iliac crest and leans
pressure downward for about 30 seconds. This tends to compress the
sacroiliac and pubic joints. A positive sign of joint inflammation or
sprain is seen with an increase in pain; however, absence of pain does not
necessarily rule out sacroiliac involvement. This test is usually
contraindicated in geriatrics and pediatrics or with any sign of a hip
lesion or osseous pelvic pathology.
Jaw jack. This is a pathologic trigeminal reflex exhibited by clonic
contraction of the muscles of mastication and inferior maxilla when a
finger placed on the center of the relaxed and open jaw is percussed. It
is prominent in impaired cortical innervation (eg, dementia) and multiple
sclerosis when upper motor neurons are involved. In unilateral frontal
lobe lesions, the reflex will be increased only on the opposite side of
the lesion. Some authorities state that the reflex is present in many
normal individuals.
Kaplan's test. This is a two-phase test:
(1) The sitting patient is given a
hand dynamometer and instructed to extend the involved upper limb straight
forward and squeeze the instrument as hard as possible. Induced pain and
grip strength are noted.
Kemp's test. While in a seated position, the patient is supported by the
examiner who reaches around the patient's shoulders and upper chest from
behind. The patient is directed to lean forward to one side and then around to eventually bend obliquely backward by placing the palm on the
buttock and sliding it down the back of the thigh and leg as far as
possible. The maneuver is similar to that used in oblique cervical
compression tests. If this compression causes or aggravates a pattern of
radicular pain in the thigh and leg, the sign is positive and suggests
nerve root compression. It may also indicate a strain or sprain and thus
be present when the patient leans obliquely forward or at any point in
motion. Not to be dismissed lightly would be the possibility of shortened
contralateral perispinal ligaments and tendons forcing erratic motion on
the side of lateral flexion.
Lachman's test. With the patient supine, the examiner slightly flexes the
involved knee (about 20°), cups a palm against the proximal calf, and
attempts to pull the tibia forward. Excessive anterior translation of
tibia from the femur (anterior drawer sign) and lack of a definite end
point suggest a rupture of the anterior cruciate ligament.
Maigne's test. The examiner places a seated patient's head in extension and
rotation, and this position is held 15 40 seconds on each side. A
positive sign is indicated by nystagmus or symptoms of vertebrobasilar
ischemia.
Nachlas' test. The patient is placed in the prone position. The examiner
flexes the patient's knee to a right angle, then, with pressure against
the anterior surface of the ankle, the heel is slowly directed straight
toward the ipsilateral buttock. The contralateral ilium should be
stabilized by the examiner's other hand. If a sharp pain is elicited in
the ipsilateral buttock or sacral area, a sacroiliac disorder should be
suspected. If pain occurs in the lower back area or is sciatic-like in
nature, a lower lumbar disorder (especially L3 or L4) is indicated. If
pain occurs in the upper lumbar area, groin, or anterior thigh, quadriceps
spasticity/contracture or a femoral nerve lesion should be suspected.
Ober's test. This is a common test for iliotibial band contractures. The
patient is placed directly on his side with the unaffected side next to
the table. The examiner places one hand on the pelvis or under the thigh
to steady it and grasps the patient's ankle with the other hand, holding
the knee flexed at a right angle. The thigh is abducted and extended in
the coronal plane of the body. In the presence of iliotibial band
contracture, the leg will remain abducted the degree of abduction
depending upon the amount of contracture present.
Palatal reflex. The normal swallowing response induced by stimulating the soft
palate.
(1) If the varicosities increase in their distention (become more
prominent) and possibly become painful, it is an indication that the deep
veins are obstructed and the valves of the communicating veins are
incompetent.
Phalen's test. The patient places both flexed wrists into apposition and
applies moderate pressure for 30–45 seconds. A positive sign of carpal
tunnel syndrome is the production of symptoms (eg, pain, tingling).
Q-angle sign. The patient is placed in the supine position with the knees
extended in a relaxed position, and the quadriceps (Q) angle of the knee
is measured. The Q-angle is formed by a line drawn along the long axis of
the femur that is intersected by a line drawn through the center of the
patella and the tibial tubercle. To make a recording, a goniometer is
centered on its side over the patella with one arm aimed at the
ipsilateral ASIS and the other arm placed in line with the center of the
patellar tendon. This angle is normally 10° in men and 15° in women. In
external tibial rotation and/or genu varus, however, the Q-angle can be
markedly increased; ie, the angle increases as the tibial tubercle is
displaced laterally or when the distal femur and proximal tibia are angled
toward the midline.
Radial reflex. With the patient's arm relaxed, flexed, and well supported,
tapping the relaxed forearm over the lower radius results in flexion of
the elbow. The response, a periosteal rather than a tendon reflex, tests
the C5 C6 segments and has the same significance as the biceps tendon
reflex. This periosteal reflex, absent in many healthy individuals, is
frequently referred to as the brachioradialis reflex. In C5 C6 segment
lesions, an inverted radial reflex may be seen where the fingers flex but
the forearm remains relaxed.
(1) Radial nerve: have the patient extend the wrist. Nerve pathology
causes wrist drop.
Sacroiliac-lumbosacral differentiation test. To differentiate these two common
disorders, the patient is placed supine on a firm flat table. A folded
towel is placed transversely under the small of the patient's back. The
doctor stabilizes the patient's pelvis by cupping the hands over the ASISs
and exerting moderate pressure. The patient is instructed to raise both
extremities simultaneously with the legs held straight. If the patient
senses discomfort or an increase of discomfort in the low back or over the
sacrum and gluteal area at about 25°–50° leg raise and before the small
of the back wedges against the towel, sacroiliac involvement is suspected.
If, on the other hand, discomfort is experienced or augmented only after
the legs have been raised beyond 50° and the small of the back wedges
firmly against the towel, lumbosacral involvement should be the first
suspicion.
(1) The patient is placed prone. With one hand
the doctor stabilizes the contralateral ilium, and the other hand is used to extend the patient's thigh on the hip with the knee slightly flexed. If
pain radiates down the front of the thigh during this extension, inflamed
L3–L4 nerve roots should be suspected if acute spasm of the quadriceps or
hip pathology have been ruled out.
Spinal percussion test. With the patient prone or in a sitting forward-flexed
position, the examiner percusses the spinous process of the involved area.
Induced pain suggests intervertebral sprain, fracture, acute subluxation,
IVD lesion, or dislocation. If negative, the perivertebral soft tissues
(about 1–2 inches lateral) are percussed. Induced pain suggests strain,
radiculitis, transverse process fracture, or a costovertebral lesion. A
variation of this test is to place a c–128 tuning fork on suspected
segments to see if symptoms are aggravated. A positive sign is often
present during the acute phase.
Talar slide test. This test evaluates ankle joint play (translation) in the
horizontal plane. With the patient in either the prone or supine position,
the doctor stands to the side and faces the ankle to be tested. The
examiner's cephalad hand grasps the patient's lower leg just above the
malleoli and the caudad hand grasps the heel just below the malleoli. A
pull is made with the upper hand on the lower leg while the lower hand
pushes the heel horizontally. Then a push is made with the upper hand
while the lower hand pulls the heel horizontally. Excessive lateral or
medial motion with pain indicates ligament instability.
Ulnar reflex. Tapping the styloid process of the ulnar resulting in pronation
of the hand. This is a highly unreliable normal reflex.
Valsalva's maneuver. The sitting patient is asked to bear down firmly
(abdominal push), as if straining at the stool. This act increases
intrathecal pressure, which tends to elicit localized pain in the presence
of a space-occupying lesion (eg, IVD protrusion, cord tumor, bony
encroachment) or of an acute inflammatory disorder of the cord (eg,
arachnoiditis). Deep coughing will produce the same effect under like
circumstances.
(1) With the patient seated and the head
placed in the neutral position, the carotid and subclavian arteries are
palpated for abnormal pulsations and auscultated for bruits. If pulse
abnormalities or bruits are found, the test is positive for carotid,
vertebral, or basilar artery obstruction (stenosis or compression), and
the second maneuver should not be conducted.
Viet's test. See Naffziger's test.
Wartenberg's sign. The patient is instructed to spread the hands out so that the
palms face downward, the fingers are extended, and the thumbs are
adducted; then raise the hands toward the face so that the palms appose.
If the index fingers touch but the thumbs do not meet, paralysis of the
abductor pollicis brevis is indicated.
(1) The knee of the involved
side is flexed to a right angle, the leg is firmly rotated internally, and
then the knee is slowly extended while maintaining the leg in internal
rotation. If osteochondritis of the knee is present, the patient will
complain of pain in front of the medial condyle of the distal femur.
Wright's test. With the patient sitting, the radial pulse is palpated from the
posterior in the downward position and as the arm is passively moved
through an 180° arc. If the pulse diminishes or disappears in this arc or
if neurologic symptoms develop, it may indicate pressure on the axillary
artery and vein under the pectoralis minor tendon and coracoid process or
compression in the retroclavicular spaces between the clavicle and 1st
rib, and thus be a hyperabduction syndrome.
Yeoman's test. The patient is placed prone. With one hand, firm pressure is
applied by the examiner over the suspected sacroiliac joint, fixing the
patient's anterior pelvis to the table. With the other hand, the patient's
leg is flexed on the affected side to the limit, and the thigh is
hyperextended by the examiner lifting the knee off the examining table. If
pain is increased in the sacroiliac area, it is significant of a ventral
sacroiliac or hip lesion because of the stress on the anterior sacroiliac
ligaments. Normally, no pain should be felt on this maneuver.
The geriatric case history and physical examination are an office-oriented
sequence of procedures with the following primary objectives:
(1) To evaluate
the patient's general health status.
It is emphasized that the examination is not intended as a total
diagnostic workup in itself. It is the "mechanics" by which information is
gathered to enable such judgments to be made. That is, the basis of this
examination should be correlated with roentgenographic, clinical laboratory,
and other special studies when indicated. Thus, the procedures incorporated in
the physical examination should be selected with the specific patient in mind;
ie, with concern for obtaining the greatest amount of information without
subjecting the patient to excessive and/or unnecessary strain. In this
respect, the geriatric patient in the seventies, eighties, nineties, etc,
cannot be handled in the same manner as younger patients. Geriatric joints do
not bend with the same ease, geriatric bones are much more prone to fracture,
geriatric skin and subcutaneous tissues are more sensitive, and geriatric
stamina is severely limited as compared to younger patients. Inequality in muscular balance, which may be initiated by trauma,
postural compensations, intrinsic biochemical alterations, psychologic stress,
primary neuromuscular disease processes, and secondary reactions of the
muscular system to somatovisceral sensory irritations.
Structural errors in position or motion due to mechanical alterations
common to developmental abnormalities, acquired disease processes, and/or
residual effects from past major- or micro-traumas. The immediate local effects of tissue irritation, degeneration, or other
disease processes.
The structural effects of mechanical errors in position or motion to
biomechanical function.
Neurologic effects of subluxation such as:
(1) Physical nerve pressure
that may be responsible for motor or sensory alterations.
Note that an abnormal orthopedic finding may suggest a possible neurologic
insult at a specific spinal motor unit, or a positive neurologic test may
suggest a possible biomechanical disorder. Thus, the examination of the
patient should be a systematic but not exhaustive survey of the patient's
general health status. However, one should be constantly alert to signs that a
problem exists that might require other procedures. The typical examination
should include a systems review with spinal examination and orthopedic and
neurologic evaluation. Tests should be conducted in a sequence that expedites
the procedures. The most efficient method is to conduct the examination
according to patient position; ie, standing, sitting, supine, and prone.
Cranial and Thoracic Measurements
Other Causes
There are other causes of abnormalities of sensation or pain such as
direct traumatic injury, nerve inflammations or degenerations of a peripheral
or central nature, local peripheral nerve injury or causalgia, vascular
disease and occlusions, and reflex pains from diseased internal viscera. Thus,
a complete case history and clinical examination are often required to rule
out these possible conditions or determine their relationship with a
subluxation syndrome.
There are still many other clinical features associated with or
pathognomonic of a subluxation syndrome, but the features developed here are
those which are the more commonly appraised and evaluated. The necessary
factor is that a correlation and evaluation of all pertinent signs and
symptoms be made, not only a few isolated findings.
Closing Remarks
Favorable response to chiropractic spinal adjustments is witnessed when
symptoms are due to angiospastic and other vasomotor disorders. When signs and
symptoms suggest an etiology such as tumor, grave cerebral vascular accidents,
and intracranial infectious diseases, the case should have immediate
consultation with possible referral for specialized care.
ORTHOPEDIC AND NEUROLOGIC TESTS AND SIGNS
Reflexes, Syndromes, and Related Clinical Phenomena
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Abarognosis test. The blindfolded patient is asked to estimate the weight of
several objects.
Abbott-Saunders test. A modification of Yergason's test that forces the biceps
tendon against the lesser tuberosity which will stress an instable tendon. The arm of the sitting patient is brought into full abduction, rotated externally, and then lowered to the patient's side. A "click" felt or heard, frequently accompanied by pain and a reproduction of symptoms, indicates subluxation or dislocation of the biceps tendon.
Abdominal reflexes. Skin reflexes tested by light stroking with a blunt
instrument such as a tongue blade toward the middle of the abdomen from
the lateral border, at the level of the umbilicus, and above and below it.
Some authorities recommend that a sterile pinwheel be used. The upper
abdominals are supplied by T8 T10; lower, T10 T12. Contraction of the
abdominal muscles of the same side causes a pulling of the umbilicus
toward the stimulus. This test of superficial reflexes is unreliable in
the obese, pregnant, or those with lax abdominal walls. Similar
contraction effects elicited by tapping neighboring bony structures are
called deep abdominal reflexes.
Accommodation reflex. The normal dilation and contraction of the pupil for far
and near vision. It is progressively weakened and may be lost in the
presbyopic and development of cataract but is persistent with the Argyll
Robertson pupil sign of tabes.
Accommodation test. The patient is instructed to face the light and look at
some object about 2 feet from the eyes and then look toward a distant
object. When looking at a near object, accommodation should accompany
convergence and pupil constriction. A pupil acting better to accommodation
than to light indicates an Argyll Robertson pupil (eg, in syphilis). A
normally dilated pupil in room light that reacts sluggishly to both
accommodation and light but constricts with prolonged stimulation is an
Adie's pupil (eg, in ciliary ganglion disease).
Achilles reflex. The ankle jerk is obtained best by having the patient kneel
in a padded chair with the feet projecting. The patient is asked to relax
the feet, then the Achilles tendon is tapped just below the level of the
malleoli, comparing the two sides. Ankle jerks are absent bilaterally in
tabes dorsalis and frequently in normal old age. The response is increased
in lesions of the pyramidal tract. A reduced or absent reflex may point
toward an IVD herniation between L5 and S1 or L4 and L5. If the patient is
in bed, flex and externally rotate the thigh and leg to about 45° until
the knee rests on the bed or pillow. Grasp the foot with one hand and hold
it easily at right angles to the leg. Then tap the Achilles tendon as
previously described.
Achilles tap test. With the patient prone, the patient's knee is flexed to a
right angle. With a reflex hammer, the Achilles tendon is tapped about an
inch above its insertion at the calcaneus. If pain is induced or the
normal plantar flexion reflex of the foot is absent, a rupture of the
Achilles tendon should be suspected.
Acromial reflex. A short, sharp percussion blow is made on the acromion or
coracoid process, evoking reflex flexion of the forearm with external
rotation of the hand. This pathologic reflex is often seen in hyperkinetic
states such as tetany and sometimes in disseminated and lateral sclerosis.
Adams' sign. If the patient has a S or C scoliosis, note if the scoliosis
straightens when the spine is flexed forward. If it does, it is a negative
sign and evidence of functional scoliosis. A positive sign is noted when
the scoliosis is not improved, thus evidence of a structural scoliosis.
Adaptive constriction test. Along with convergence and accommodation, the
pupils should normally contract on looking at a near object. The pupils
are narrowed as an optical aid to regulate the depth of focus. This type
of near-object pupil constriction does not depend on changes in
illumination and is separate from direct and consensual light reflexes.
Adductor magnus reflex. With the patient supine and the thigh moderately
abducted, a normal response is seen when the tendon of the adductor magnus
is tapped and a contraction of the muscle occurs. This reflex reaction
tests the integrity of the obturator nerve and L2–L4 segments of the
spinal cord, as does the patellar reflex.
Adiadochokinesia test. The patient is asked to perform rapid alternating
movements of a limb (eg, wide hand clapping).
Adie's sign. A benign disorder of the pupil featuring a very weak light
reflex, which is delayed for several seconds, and near-point impairment.
The pupil does react to light, but it is slow or delayed in its response.
It can be confused with the Argyll Robertson pupil. Adie's pupil is larger
than normal and often found in young women with decreased or absent tendon
reflexes. It is sometimes called the tonic pupil sign.
Adson's test. With the patient sitting or standing, the examiner palpates the
radial pulse and advises the patient to bend the head obliquely backward
toward the side being examined, take a deep breath, and tighten the neck
and chest muscles on the side tested. The maneuver decreases the
interscalene space (anterior and middle scalene muscles) and increases any
existing compression of the subclavian artery and lower components (C8 and
T1) of the brachial plexus against the 1st rib. Marked weakening of the
pulse or increased paresthesias indicate a positive sign of pressure on
the neurovascular bundle, particularly of the subclavian artery as it
passes between or through the scaleni musculature, thus indicating a
probable cervical rib or scalenus anticus syndrome. This test is sometimes
called the scalene maneuver.
Alarm points. Eighteen specific sites located on the anterior thorax and the
abdomen offer diagnostic clues to meridian malfunction in Oriental
medicine. All alarm (mo) points are located on the ventral surface of the
thorax and the abdomen, and each point is associated with one of the 12
main meridians and its function. Six of the meridian alarm points are
located on the central conception vessel meridian, thus they are
unilateral. The other six alarm points are bilateral, giving a total of 18
alarm points in all. It is thought by Oriental physicians that tenderness
or pain elicited by light pressure on or spontaneous pain at any of these
points indicates that the meridian has excessive energy (Chi). Tenderness
only on heavy pressure suggests that there is a deficiency of Chi.
Increased or decreased electropermeability is thought to have the same
significance as light or deep tenderness. Generally, the alarm points are
associated with the Yin types of diseases; viz, those diseases associated
with cold, depression, and weakness.
Allen's-test. The sitting patient elevates the arm and is instructed to make a
tight fist to express blood from the palm. The examiner occludes the
radial and ulnar arteries by finger pressure. The patient then lowers the hand and relaxes fist, and the examiner releases the arteries one at a
time. Some examiners prefer to test the radial and ulnar arteries
individually in two tests. The sign is negative if the pale skin of the
palm flushes immediately when the artery is released. The patient should
be instructed not to hyperextend the palm as this will constrict skin
capillaries and render a false positive sign. The sign is positive if the
skin of the palm remains blanched for more than 3 seconds. This test,
which should be performed before Wright's test, is significant in vascular
occlusion of the artery tested.
Allis' hip sign. Relaxation of the fascia between the crest of the ilium and
the greater trochanter. It suggests a fracture of the neck of the femur.
Allis' knee sign. With the patient supine, knees flexed, and soles of feet
flat on the table, the examiner observes the heights of knees superiorly
from the foot of the table. If the top of one knee is lower than the
other, it is indicative of a unilateral hip dislocation, a severe coxa
disorder, or a short femur.
Anal reflex. Normal contraction of the anal sphincter induced on light
stimulation of the anal skin. This reflex is also initiated when a gloved
finger is inserted into the rectum, as during a prostate examination. It
is absent in posterior column diseases such as tabes dorsalis and advanced
pernicious anemia, and in lesions of the cauda equina or conus medullaris.
In such conditions, extreme anal dilation is not painful. The anal reflex
becomes highly sensitive and causes a painful sphincter spasm with such
conditions as anal fissures and inflamed crypts.
Andre-Thomas signs. This sign occurs in cerebellar disease and consists of a
rebound when the finger-to-nose test is conducted; ie, the patient will
touch the nose several times. When asked to raise the arm above the head
and suddenly told to let it drop upon the head, it will rebound. A sign
such as this is also called the spring-like phenomenon.
Ankle clonus. The examiner flexes the patient's leg and thigh to a 45° angle
with one hand, while the other hand brings the foot smartly up to acute
flexion. Ankle clonus exhibits as pathologic rapid contractions and
relaxations of the foot, but a rapidly exhaustible ankle clonus may be
normal. Note if the clonus is sustained. Ankle clonus has the same
clinical significance as patella clonus and is often associated with it.
Ankle dorsiflexion test. Limitation of the gastrocnemius or soleus muscle
restricting ankle dorsiflexion can be differentiated by this test. Have
the patient sit on the examining table with the knees flexed and relaxed.
Grasp the foot and flex the knee to slacken the gastrocnemius, then
dorsiflex the ankle. If this can be achieved, the gastrocnemius is the
cause of the restriction. If the soleus is at fault, it will not be
affected by knee flexion; ie, it will be the same in either knee flexion
or extension.
Ankle lateral-medial (eversion-inversion) stability tests. Gross lateral
instability results when both the anterior talofibular and calcaneofibular
ligaments are torn. To test lateral stability, stabilize the patient's leg and invert the heel back and forth, noting if the talus rocks loosely in
the ankle mortise. Medial instability is the result of a tear or stretch
of the deltoid ligament. To test medial stability, stabilize the patient's
leg and evert the heel back and forth, noting any gap at the ankle
mortise.
Ankle tourniquet test. A sphygmomanometer cuff is wrapped around the suspected
ankle, inflated to a point slightly above the patient's systolic blood
pressure, and maintained for 1 2 minutes. An increase in foot pain
signifies tarsal tunnel syndrome or a similar circulatory deficit.
Anterior doorbell sign. The examiner faces the sitting patient. A slight
pressure is exerted over the emerging ventral roots of the cervical spine.
Contact is made with the thumbs held horizontally. A positive sign is the
reproduction or exaggeration of patient symptoms (eg, upper-extremity
pain, paresthesia).
Anterior drawer sign. The anterior and posterior cruciate ligaments provide
A-P stability to the knee joint. These intracapsular ligaments arise
from the tibia and insert onto the inner aspects of the femoral condyles.
To evaluate anterior stability, place the patient supine and flex the
knees to 90° so that the feet are flat on the table. The examiner should
sit sideways so that his hip can stabilize the patient's feet from moving
during the tests. The examiner positions his hands around the knee being
examined, similar to but lower than the bony palpation starting position;
ie, thumbs pointing superiorly over the lateral and medial joint lines
with fingers wrapped around the lateral and medial insertions of the
hamstrings. In this position, the examiner pulls the tibia forward. When a
distinct sliding forward of the tibia from under the femur is noted, it
indicates a torn anterior cruciate ligament. Slight anterior sliding,
however, is often normal. A positive sign should be confirmed by repeating
the maneuver with the patient's leg internally rotated 30° and externally
rotated 15°. The reason for this is that even if the anterior cruciate
ligament is torn, external rotation should reduce forward movement of the
tibia; if it does not, both the anterior cruciate and the anteromedial
joint capsule may be torn. Likewise, even if the anterior cruciate
ligament is torn, internal rotation should reduce forward movement of the
tibia. If it does not, both the anterior cruciate and the anterolateral
joint capsule may be torn. The medial collateral ligaments may also be
involved in loss of A-P stability. Also see posterior drawer sign.
Apley's compression test. The patient is placed prone with one leg flexed at
90°. The examiner stabilizes the patient's thigh with a knee and grasps
the patient's foot. Downward pressure is applied to the foot to compress
the medial and lateral menisci between the tibia and femur. The examiner
then rotates the tibia internally and externally on the femur, holding
downward pressure. Pain during this maneuver indicates probable meniscal
or collateral damage. Medial knee pain suggests medial meniscus damage;
lateral pain, lateral meniscus injury.
Apley's distraction test. Apley designed this test to follow his compression
test as an aid in differentiating meniscal from ligamentous knee problems.
With the patient and the examiner in the same position as in the
compression test, the examiner applies traction (rather than compression) while the leg is rotated internally and externally. This maneuver reduces
pressure upon the menisci but stretches the medial and lateral ligaments
of the knee.
Apley's scratch test. This is a two-phase test:
(2) The patient is then asked to relax his arm at the
side, then place the hand behind his back and attempt to touch as far up
on the opposite scapula as possible. If either of these maneuvers
increases shoulder pain, inflammation of one of the rotator cuff's tendons
should be suspected. The supraspinatus tendon is most commonly involved.
Restricted motion without sharp pain points to osteoarthritis or shortened
soft tissues.
Arm drop test. Hold the patient's arm horizontally at 90° abduction and then
ask the patient to hold that position without assistance. If this cannot
be done actively for a few moments without pain, it suggests a torn
rotator cuff. In lesser tears, the patient may be able to hold the
abduction (a slight tap on the forearm will make it drop) and slowly lower
it against the side, but the motion will not be smooth.
Arm extension tests. Have the patient in the erect position with the eyes
closed extend the arms straight forward with the hands parallel. This
position is held for 20 30 seconds; then the arms are extended straight
upward over the head with the palms facing forward and held for 20 30
seconds. Note if there is any drooping of an arm or for a tendency of an
arm and hand to flex and rotate internally because this is one of the
earliest signs of CNS paresis. A drift of the upper extremity down and out
suggests a cerebellar disorder. Senile and familial tremors appear in the
outstretched hands. They disappear at rest and are aggravated by stress.
Babinski's sciatica sign. A lessening or lack of the patellar tendon reflex in
sciatica.
Babinski-Weil sign. The patient is instructed to walk several steps straight
forward and then backward with the eyes closed. In cases of internal ear
disease (eg, labyrinthitis), the patient will bend to one side while
walking forward and then to the other side when walking backward. If the
patient leans to only one side when walking either forward or backward, it
signifies an ipsilateral cerebellar lesion.
Bakody's test. The sitting patient is asked to raise the arm laterally to a
horizontal position, flex the elbow, and then place the open palm on the
top of the head. This maneuver should relieve traction on the ipsilateral
lower cervical roots and offer relief of nerve root irritation in cases of
a brachial plexus syndrome.
Baron's sign. The patient is placed supine, relaxed, and instructed to breath
deeply. The examiner's fingers are placed on Poupart's ligament and
pressure is made in the direction of the psoas muscle. The patient is then
told to elevate the leg of the same side with the knee extended, forming
about a 45° angle at the hip. In this position, the examiner's fingers can
readily palpate the now tensed psoas muscle. Similar palpation should be
made bilaterally for comparison. In suspected cases of chronic
appendicitis, Baron found that the right psoas muscle was frequently
hypersensitive to pressure. Even in the healthy individual, a tensed psoas
may be tender, but when the appendix or right ovary is involved, the
tenderness is more marked on the right side. It is also important to
realize that because the psoas is covered by peritoneum it can be painful
in the presence of sacrospinal and gluteal myalgias; in lumbar,
lumbosacral, and iliosacral arthrosis; and sometimes in sciatica.
Barre-Lieou test. The sitting patient is asked to slowly but firmly rotate the
head first to one side and then to the other. Transient mechanical
occlusion of the vertebral artery may be precipitated by simply turning
the head, and this phenomenon is attributed to the compressive action of
the longus colli and scalene muscles on the vertebral artery, just before
its course through the IVF of C6. A positive sign is exhibited if
dizziness, faintness, nausea, nystagmus, vertigo, and/or visual blurring
result, indicative of buckling or compression of the vertebral artery.
Battle sign. An area of ecchymosis occurring over the course of the posterior
auricular artery that develops first near the tip of the mastoid process:
an important sign of basilar fracture.
Bechterew's test. The patient in the sitting position attempts to extend each
leg one at a time followed by an attempt to extend both legs. The sign is
positive if backache or sciatic pain is increased or the maneuver is
impossible. In disc involvements, extending both legs will usually
increase spinal and sciatic discomfort.
Beery's sign. This sign is positive if a patient with a history of lower trunk
discomfort and fatigue is fairly comfortable when sitting with the knees
flexed but experiences discomfort in the standing position. It is
typically seen in spasticity or contractures of the posterior thigh and/or
calf muscles.
Beevor's sign. The examiner notes the position of the umbilicus when the
patient tenses the abdominal muscles as in trying to rise from a recumbent
position with the hands behind the head. Movement of the umbilicus upward
signifies paralysis or weakness of the lower abdominal muscles. If the
umbilicus moves right, weakness of left abdominal muscles is indicated. If
the umbilicus moves left, weakness of the right abdominal muscles is
indicated. A positive sign points to segments T6 T10 such as in spinal
cord or vertebral injury, disease, or tumor; eg, vertebral tumor, anterior
poliomyelitis, transverse myelitis, compression fracture, multiple
sclerosis, or disc protrusions.
Belt test. The standing male patient, with feet about 12–15 inches apart,
flexes forward with the examiner holding the patient's belt at the back.
If bending over without support is more painful than with support, it
suggests a sacroiliac lesion. Conversely, if bending over with support is
more painful than without support, it suggests a lumbosacral or lumbar
involvement. A variation of this test is to stand behind the patient and
place your hands so that they firmly support the patient's innominates.
Some examiners brace a hip against the patient's sacrum when the patient
flexes forward to stabilize the pelvis.
Bent-knee pull test. This maneuver attempts to duplicate the pain pattern in
patients with an upper lumbar root lesion. The examiner pulls the prone
patient's bent knee upward (posterior) while putting downward (anterior)
pressure on the ipsilateral buttock. This test may prove positive even if
Lasegue's SLR test is negative.
Biceps reflex. The muscles of the patient's arm are bared and relaxed, and
then the arm is flexed at the elbow. The examiner places a thumb over the
biceps tendon and makes a light blow with a percussion hammer. Note if the
biceps muscle contracts, how quickly it contracts, and with what force.
The biceps reflex, a normal response, tests C5–C6 segments in terms of
integrity of the musculocutaneous nerve. It is hyperactive in the same
disorders that cause a hyperactive knee jerk.
Bikele's test. The sitting patient is asked to raise the arm laterally to a
horizontal and slightly backward position, flex the elbow, and laterally
flex the neck to the opposite side. If active extension of the elbow,
which stretches the brachial plexus, produces resistance and increased
cervicothoracic radicular pain, the test is said to be positive for a
nerve root or spinal cord inflammatory process (eg, brachial neuritis,
meningitis).
Bing's test. A tuning fork is placed on the vertex of the patient's head and
one ear is covered. Because of bone conduction, the covered ear normally
hears the tuning fork better than the uncovered ear. If no sound is heard
in the covered ear (a positive sign), nerve deafness is indicated.
Bladder reflex. Normal sphincter control of the bladder is under the control
of the pelvic autonomic nerves. If motor fibers to the sphincter are
impaired, incontinency results. If sensory fibers are impaired, distention
and dribbling result because the urge to urinate has been diminished (eg,
tabes dorsalis).
Bonnet's sign. The lower limb of the supine patient is internally rotated and
adducted, and then a Lasegue's SLR test is conducted. A positive sign
occurs when pain occurs sooner than during a normal SLR test, indicative
of sciatic radiculopathy.
Booth-Marvel test. The examiner abducts the patient's arm laterally to the
horizontal position, flexes the elbow to a right angle, and deeply
palpates the bicipital groove as the humerus is passively rotated
internally and externally. If the transverse humeral ligament has been
stretched, a painful and palpable snap will be felt and sometimes heard as
the tendon of the long head displaces from the bicipital groove.
Bounce-home test. The patient is placed supine. The examiner cups one hand
under the patient's heel and slightly flexes the patient's knee with the
other hand. While the patient's heel is held, the patient's knee is
allowed to passively drop gently toward the top of the table in full
extension, normally with an abrupt stop. If this full extension is not
achieved and passive pressure elicits a "rubbery" resistance to extension,
a motion block is likely. This lack of full extension points to a torn
meniscus, intracapsular swelling, or a loose fragment within the knee
joint.
Bowstring sign. If pain occurs during Lasegue's SLR test, the knee is slightly
flexed and the patient's foot is allowed to rest on the examiner's
shoulder. When the pain subsides, manual pressure is applied against the
hamstrings. If this does not increase pain, manual pressure is quickly
applied to the popliteal fossa while holding the knee as straight as
patient comfort will allow. Although local pain in the popliteal fossa is
of minor consequence, a reproduction of leg or back pain is highly
significant of an IVD rupture producing nerve root compression.
Bracelet test. In rheumatoid arthritis, compression of the distal ends of the
radius and ulnar initiates acute pain in the forearm, wrist, and/or hand.
Bradburne's sign. During the acute stage of cervical cord contusion or
compression (with or without vertebral fracture), a sign of spinal cord
damage in the area of C5 and C6 is exhibited by bilateral abduction of the
arms and then flexion with external rotation of the forearms.
Bragard's test. If Lasegue's SLR test is positive at a given point, the leg is
lowered below this point and dorsiflexion of the foot is induced. The sign
is negative if pain is not increased. A positive sign is a finding in
sciatic neuritis, spinal cord tumors, IVD lesions, and spinal nerve
irritations. A negative sign points to muscular involvement such as tight
hamstrings. Bragard's test does not stress the sacroiliac or lumbosacral
articulations.
Brudzinski's hip sign. When one lower limb of a supine patient is passively
flexed at the hip, the opposite leg flexes. This sign, also known as the
contralateral reflex, occurs in acute cerebroleptomeningitis.
Brudzinski's neck sign. A positive sign is elicited when the patient's head is
passively flexed toward the chest which is followed by involuntary flexion
of the lower limbs. Such a reaction is indicative of meningeal irritation.
In such cases, the neck is rigid and painful to flexion and, in most
cases, also to rotation. This test is unreliable in children to 2 years.
Bryant's sign. A posttraumatic ipsilateral lowering of the axillary folds
(anterior and posterior pillars of the armpit) with level shoulders
suggests dislocation of the glenohumeral articulation.
Buckling sign. Automatic flexion of the knee to relieve traction on the
sciatic nerve when Lasegue's SLR test is conducted: significant of sciatic
radiculopathy.
Buerger's test. The patient is placed supine with the knees extended in a
relaxed position, and the examiner lifts a leg with the knee extended so
that the lower limb is flexed on the hip to about a 45° angle. The patient
is then instructed to move the ankle up and down (dorsiflex and plantar
flex the foot) for a minimum of 2 minutes. The limb is then lowered, the
patient is asked to sit up, the legs are allowed to hang down loosely over
the edge of the table, and the color of the exercised foot is noted.
Positive signs of arterial insufficiency are found if
(2) it takes more than a minute for the veins of
the foot to fill and for the foot to turn a reddish cyanotic color when
the limb is lowered.
Buttock sign. A lower extremity of a supine patient is passively flexed at the
hip with the knee extended as in an SLR test. If the flexion of the limb
on the trunk is restricted by local or radiating buttock pain (rather than
pain in the hip or lower back), it is significant of an inflammatory
pelvic lesion such as ischiorectal abscess, osteomyelitis of or near the
hip joint, coxa bursitis, sacroiliac septic arthritis, or an advanced
pelvic neoplasm.
Carnett's maneuver. This is used by some to differentiate tenderness of
visceral origin to that of the parietes. The abdominals are tightened by
having the supine patient raise the head or ballooning the abdomen outward
and fixing it in that position to prevent the examiner from making
pressure on an underlying viscus. If tenderness still remains, it points
to hypersensitive parietes, resulting from a visceroparietal reflex or
transference of pain to the parietes supplied by a spinal nerve in the
same spinal segment as that innervating the diseased organ. Superficial
tenderness is often of parietal origin, frequently due to spinal arthritis
or curvatures.
Carotid sinus reflex. Pressure applied to the carotid area slows the heart
rate and produces a fall in blood pressure. The reflex originates in the
wall of the sinus of the internal carotid artery. If heavy, prolonged
pressure is applied, dizziness or fainting may result. This normal reflex
becomes hyperactive during attacks of vasomotor instability and hypoactive
in lesions of Cranial IX (afferent portion) and Cranial X (efferent
portion).
Cervical active rotary compression test. With the patient sitting, observe
while the patient voluntarily laterally flexes the head toward the side
being examined. With the neck flexed, the patient is then instructed to
rotate the chin toward the same side, which narrows the IVF diameters on
the side of concavity. Pain or reduplication of other symptoms suggests a
physiologic narrowing of one or more IVFs.
Cervical distraction test. With the patient sitting, the examiner stands to
the side of the patient and places one hand under the patient's chin and
the other hand under the base of the occiput. Slowly and gradually the
patient's head is lifted to remove weight from the cervical spine. This
maneuver elongates the IVFs, decreases the pressure on the joint capsules
around the facets, and stretches the perivertebral muscles. If the
maneuver decreases pain and relieves other symptoms, it suggests narrowing
of one or more IVFs, cervical facet syndrome, or spastic perivertebral
muscles.
Cervical compression tests. Two tests are involved. First, with the patient
sitting, the examiner stands behind the patient and the patient's head is
laterally flexed and rotated about 45° toward the side being examined.
Interlocked fingers are placed on the patient's scalp and gently pressed
caudally. If an IVF is physiologically narrowed, this maneuver will
further insult the foramen by compressing the disc and narrowing the
foramen, causing pain and reduplication of other symptoms. In the second
test, the patient's neck is extended by the examiner placing interlocked
hands on the patient's scalp and gently pressing caudally. If an IVF is
physiologically narrowed, this maneuver mechanically compromises the
foraminal diameters bilaterally and causes pain and reduplication of
related symptoms.
Cervical percussion test. The neck of a sitting patient is flexed to about 45°
while the examiner percusses each of the cervical spinous processes and adjacent superficial soft tissues with a rubber-tipped reflex hammer.
Evidence of point tenderness suggests a fractured or acutely subluxated
vertebra or localized sprain or strain, while symptoms of radicular pain
suggest radiculitis or an IVD lesion.
Chaddock's ankle reflex. Stroking the lower leg just behind and under the
external malleolus with the handle of a reflex hammer elicits a
Babinski-like sign. It is positive in conditions involving the pyramidal
tract.
Chapman's test. With the patient in the supine position, the examiner
stabilizes the patient's legs and asks the patient to attempt to flex the
trunk to the sitting position without using the hands. This test, which
requires strong contraction of the abdominals, is positive for abdominal
weakness if the patient is unable to sit upright but abdominal pain is not
produced. If abdominal pain occurs during the attempt, an inflammatory
abdominal lesion should be suspected.
Chest expansion test. With the patient standing, chest measurements are taken
around the circumference of the thorax near the nipple level: first after
the patient inhales and then after the patient exhales completely. A
2-inch difference (possibly less in females) is a negative sign. A
positive sign is indicated by no or very little difference in measurements
a suspicion of osteoarthritic ankylosis or ankylosing spondylitis.
Childress' test. This is a two-phase test:
(2) The test is then conducted with the
patient assuming a "bowed-leg" position by rotating the thighs outward
before squatting. Pain, joint restriction, or a clicking sensation when
attempting to squat suggests a lesion of the lateral meniscus.
Ciliary reflex. The normal actions of the pupil during accommodation to light
or distance.
Ciliospinal reflex. This normal reflex is produced by pinching the skin,
particularly at the neck, which results in dilation of the pupils. The
reaction depends on the integrity of the cervical sympathetic nerves (eg,
interrupted in Horner's syndrome). It should be noted, however, that a
painful stimulus applied to any part of the body will normally produce
pupil dilation.
Clarke's sign. The supine patient extends the knee and relaxes the quadriceps.
The examiner places the web of a hand against the superior aspect of the
patella and depresses it distally. The patient then actively contracts the
quadriceps as the examiner compresses the patella against the condyles of
the distal femur. The sign is positive if the patient cannot maintain
contraction without producing sharp pain.
Claudication test. If lower extremity claudication is suspected, the patient
is instructed to walk on a treadmill at a rate of 120 steps/minute. If
cramping, and sometimes a skin color change, occurs, the approximate level
of the local lesion can be identified. The time span between the beginning
of the test and the occurrence of symptoms is used to record the
"claudication time," which is usually recorded in seconds.
Cochleopapillary reflex. The normal blinking reaction of the eyelids and pupil
contraction followed by dilation after hearing an unexpected loud noise.
It is absent in labyrinthine disease.
Codman's sign. This is a variation of the shoulder abduction stress test and
the arm drop test. If the patient's arm can be passively abducted
laterally to about 100° without pain, the examiner removes support so the
position is held actively by the patient. This produces sudden deltoid
contraction. When a rupture of the supraspinatus tendon or strain of the
rotator cuff exists, the pain produced causes the patient to hunch the
shoulder and lower the arm.
Cogwheel sign. This sign consists of irregular jerky movements when a
hypertonic muscle is passively stretched. Often called Negro's sign, it is
characteristic of paralysis agitans and other disorders of the
extrapyramidal system of the basal ganglia.
Cold test. This test is used to determine the vasospastic gradient in cases of
essential hypertension. It is done by immersing the patient's hand and
wrist in ice water with salt added to produce a temperature of
approximately 4°C. Blood pressure readings are determined before and at
intervals during and after the hand has been immersed from 15 to 30
seconds. Where there is no great element of vasospasm or vasomotor
activity present, namely, in the normal individual, a rise of
approximately 8–10 mm Hg takes place. Where vasospastic phenomena play a
part in the elevation of blood pressure, a marked rise, often as high as
50 mm Hg takes place promptly, and, if this occurs, a large vasomotor
element is undoubtedly present.
Consensual reflex. Contraction of both pupils normally occurs when light
stimulates one eye. It is sometimes called the crossed ocular reflex.
Convergence test. A finger or another object held several feet away from the
patient is moved toward the patient's eyes, midway between them. When the
patient's eyes follow the object, the eyes should move inward, and the
pupils should contract. The medial recti muscles normally contract to move
the eyes into alignment so that images in each eye focus on the same part
of the retina to avoid diplopia. An inability to converge the eyes
commonly occurs in encephalitis and vascular diseases of the midbrain.
Corneal reflex. Forceful rapid contraction of the eyelids when the cornea of
one eye is stimulated with a wisp of cotton. This normal reflex is usually
diminished unilaterally from either a central or peripheral lesion.
Positive signs will be seen in such disorders as tic douloureux,
alcoholism, neuritis, cerebellopontine angle tumors, and lock jaw.
Costoclavicular-maneuver. With the patient sitting, the examiner monitors the
radial pulse of the patient from the posterior on the side being examined. The examiner brings the patient's shoulder and arm posterior and then
depresses the shoulder on the side being examined. This maneuver narrows
the costoclavicular space by approximating the clavicle to the first rib,
tending to compress the neurovascular structures between. When the
shoulder is retracted, the clavicle moves backward on the sternoclavicular
joint and rotates in a counterclockwise direction. An alteration or
obliteration of the radial pulse or a reduplication of other symptoms
suggests compression of the neurovascular bundle passing between the
clavicle and the first rib (costoclavicular syndrome).
Cover test. When there is a tendency for one eye to turn medially, it is
called esophoria; laterally, exophoria. If compensated, these conditions
can be appreciated through the cover test: Have the patient focus on a
light source and alternately cover one eye. The covered eye will normally
return to its position of rest. Thus, the eye will turn nasally in
esophoria; and in exophoria, it will turn laterally. This will be noticed
when the uncovered eye quickly moves medial-central in esophoria and
lateral-central in exophoria.
Cozen's test. With the patient's forearm stabilized, the patient is instructed
to make a fist and extend the wrist. The examiner then grips the patient's
elbow with the stabilizing hand and the top of the patient's fist with the
active hand and attempts to force the wrist into flexion against patient
resistance. A sign of tennis elbow is a severe sudden pain at the lateral
epicondyle area.
Cremasteric reflex. The cremasteric reflex (L1–L2) is especially active in
young men by stroking the upper-inner aspect of the thigh. Observe the
contraction of the cremasteric muscle of the same side, which causes the
testicle to be drawn upward. An absent or diminished response indicates
lesions of the corticospinal tract and lesions of the femoral and
genitofemoral nerves.
Cunningham's sign. This is a vasopressor sign of potential hypertension.
Systolic pressure is noted as the mercury column of the manometer is
rising at a moderate rate. The column is then raised quickly 30 mm higher
and allowed to fall slowly. If the systolic reading on falling is 20 mm or
more higher than on rising, the patient is believed to be a candidate for
hypertension. This appears to be due to a hyperirritability of the
vasocardiac reflex because it is not found in hypertensive heart disease.
In the normal individual, the second reading is the same or no more than
12 mm higher.
Dawbarn's test. With the patient sitting, the examiner stands behind the
patient and deeply palpates the area just below the acromion process to
determine symptoms of focal tenderness or referred pain. Then, while still
maintaining this palpatory pressure to patient tolerance, the examiner
grasps the wrist of the patient with the other hand and brings the arm to
the lateral extended position so that it is abducted to about 100°. If
subacromial bursitis exists, the pain produced on initial palpation should decrease substantially when the arm is raised because the deltoid will
cover the spot below the acromion during abduction. If the pain remains
unaltered or is increased by this abduction maneuver, subacromial bursitis
can usually be ruled out.
Dejerine's sign. This sign constitutes aggravated symptoms of radiculitis,
resulting from a space-occupying lesion within the spinal cord, during any
Valsalva maneuver (eg, coughing, sneezing, abdominal straining) that would
increase intrathecal pressure.
DeKleyn's test. The patient is placed supine on an adjusting table, and the
head rest is lowered. The examiner extends and rotates the patient's head,
and this position is held for about 15–40 seconds on each side. A
positive sign suggests vertebrobasilar ischemia.
Deltoid reflex. Abduct the arm and percuss the insertion of the deltoid muscle
at the junction of the upper and middle third of the lateral aspect of the
humerus. This reflex is carried by the axillary nerve (C5–C6).
Demianoff's test. This is a variant of Lasegue's SLR test used by many in
lumbago and IVF funiculitis with the intent of differentiating between
lumbago and sciatica. When the affected limb is first extended and then
flexed at the hip, the corresponding half of the body becomes lowered and
with it the muscle fibers fixed to the lumbosacral segment. This act,
which stretches the muscles, can induce sharp lumbar pain. Lasegue's sign
is thus negative as the pain is caused by stretching the affected muscles
at the posterior portion of the pelvis rather than stretching the sciatic
nerve. To accomplish this test with the patient supine, the pelvis is
fixed by the examiner's hand firmly placed on the ASIS, and the other hand
elevates the leg on the same side. No pain results when the leg is raised
to an 80° angle. When lumbago and sciatica coexist, Demianoff's sign is
negative on the affected side but positive on the opposite side unless the
pelvis is stabilized. The sign is also negative in bilateral sciatica with
lumbago. The stabilization of the pelvis prevents stretching the sciatic
nerve, and any undue pain experienced is usually associated with
ischiotrochanteric groove adhesions or soft-tissue shortening.
Deyelle-May test. This test may be helpful in differentiating the various
etiologies of sciatic pain and is particularly designed to differentiate
between pain from pressure on the nerve or its roots and pain due to other
mechanisms in the lower back. Compression or traction on muscles,
ligaments, tendons, or bursae may cause reflex pain that often mimics
actual direct nerve irritation. Reflex pain does not usually follow the
pattern of a specific nerve root, is more vague, does not cause sensory
disturbances in the skin, comes and goes, but may be a very intense ache.
The procedure in the sitting position is to instruct the patient to sit
very still and braced by the hands in a chair. The painful leg is
passively extended until it causes pain, then lowered just below this
point. The leg is then held by the examiner's knees and deep palpation is
applied to the sciatic nerve high in the popliteal space that has been
made taut (bow string) by the maneuver. Severe pain on palpation indicates
a definite sciatic syndrome as opposed to other causes of back and leg
pain such as the stretching of strained muscles and tendons or the
movements of sprained sublumbar articulations.
Disconjugate gaze. The is the inability to either
(2) move the eyeball sharply lateral while the contralateral adducting eye
exhibits nystagmus (bilateral external rectus ophthalmoplegia) as the
result of an abducens lesion. In either case, the nystagmus indicates
associated cerebellar involvement and the sign strongly points to multiple
sclerosis.
(2) The SLR test is then
performed on both limbs simultaneously; ie, a bilateral SLR test. If pain
occurs at a lower angle when both legs are raised together than when
performing the monolateral SLR maneuver, the test is considered positive
for a lumbosacral area lesion.
Dreyer's sign. The patient is placed supine with the legs extended in the
relaxed position and asked to raise the involved thigh while keeping the
knee extended. If the patient is unable to do this, the examiner grasps
the large quadriceps tendon just above the knee to anchor it against the
femur and the patient is asked to try to lift the limb again. If the
patient is then able to lift the limb when the quadriceps tendon is
stabilized, a fractured patella should be suspected. The reason for this
is the rectus femoris (a primary hip flexor) attaches to the patella by
way of the quadriceps tendon.
Duchenne's test. The patient is placed supine with the lower limbs extended in
a relaxed position. The examiner's thumb is placed on the plantar aspect
of the head of the 1st metatarsal on the involved side, and the patient is
instructed to plantar flex the foot. If during this action the head of the
1st metatarsal offers little or no pressure against the examiner's thumb,
the medial border of the foot dorsiflexes while the lateral border plantar
flexes, and the arch disappears, the test is positive for peroneus longus
paralysis (L4–S1).
Dugas' test. The patient places the hand on the opposite shoulder and attempts
to touch the chest wall with the elbow and then raise the elbow to chin
level. If it is impossible to touch the chest with the elbow or to raise
the elbow to chin level, it is a positive sign of a dislocated shoulder.
Elbow abduction/adduction stress test. To roughly judge the stability of the
medial and lateral collateral ligaments of the elbow, hold the patient's
wrist with one hand and cup your stabilizing hand under the patient's
distal humerus. As the patient is directed to slightly flex his elbow,
(2) push laterally with your active hand and
medially with your stabilizing hand. With the fingers of your stabilizing
hand, note any joint gap felt during either the valgus or varus stress
maneuver. Painful instability indicates torn ligaments.
Ely's test. To support iliopsoas spasm suspicions, the patient is placed prone
with the toes hanging over the edge of the table, legs relaxed. Either
heel is approximated to the opposite buttock. After flexion of the knee,
pain in the hip will make it impossible to carry out the test if there is
any irritation of the psoas muscle or its sheath. The buttock will tend to
rise on the involved side. However, a positive Ely's test also can be an
indication of rectus femoris contraction, a lumbar lesion, a contracture
of the tensor fascia lata, or an osseous hip lesion.
Epigastric reflex. Contraction of the abdominal muscles caused by stimulating
the skin of the epigastrium or over the 5th and 6th intercostal spaces
near the axilla. See abdominal reflexes.
Erb's sign. Tetanizing contraction rather than the normal "make and break"
contraction of a muscle when a galvanic current is applied, significant of
peripheral hyperexcitability (eg, tetany).
Erben's-reflex. A slowing of the pulse when the head is bent strongly forward.
It is marked in those who are distinctly vagotonic.
Erichsen's test. With the patient supine, the examiner places the hands on the
patient's iliac crests. The examiner's thumbs are placed on the patient's
ASISs and forcibly compress the pelvis toward the midline. This tends to
separate the sacroiliac joints. If conducted carefully, this test can be
quite specific. Pain experienced in the sacroiliac joint suggests a joint
lesion (postural, traumatic, or infectious).
Extensor digitorum communis test. The patient is instructed to flex and then
extend a finger. The inability to extend any finger indicates a lesion of
that extensor digitorum communis tendon.
External tibial torsion sign. A markedly posterior position of the lateral
malleolus relative to the medial malleolus in weight-bearing and supine
positions. An everted heel and flat arch is commonly associated.
Facial motor function tests. The patient is asked to raise the eyebrows,
frown, tightly close both eyes, close each eye separately, show the teeth,
open the mouth wide, retract the lips, whistle, and smile. The inability
to perform such tests normally indicates a weakness or paralysis of the
facial nerve. All facial movements should be equal bilaterally, but some
patients habitually talk, smile, and chew more on one side than the other.
Fajersztajn's test. When straight-leg raising and dorsiflexion of the foot are
performed on the asymptomatic side of a sciatic patient and this causes
pain on the symptomatic side, there is a positive Fajersztajn's sign,
which is said to be particularly indicative of a sciatic nerve root
involvement such as a disc syndrome, dural root sleeve adhesions, or some
other space-occupying lesion. This is sometimes called the well-leg or
cross-leg straight-leg-raising test. From a biomechanical viewpoint, this
test would be suggestive but not indicative.
Femoral retroversion sign. When the femur is retroverted, external rotation of
the femur will be much greater (20°–30°) than internal rotation.
Finger-to-finger test. The patient abducts both arms horizontally and extends
the elbows so that the limbs are outstretched, then attempts to
approximate the tips of the index fingers. This test has the same clinical
significance as the finger-to-nose test.
Finger-to-nose tests. If the patient is supine, have the arms outstretched at
the sides; if sitting, have the hands rest on the knees; if standing, have
the arms relaxed at the sides. Direct the patient to touch the tip of the
nose with the tip of the forefinger, first with the eyes open, then
closed. Note the line between the starting point and the nose to determine
if it is straight, curved, or if there is a jerking, irregular motion.
Observe whether the finger becomes coarsely tremulous as the nose is
touched (intention tremor). If a tremor is present, it indicates a
proprioceptive (sensory) defect when the defect is noted primarily when
the eyes are closed. Note if the finger goes beyond the nose
(hypermetria), or fails to reach the nose (hypometria). The term dysmetria
is used to denote if the finger goes beyond the nose or fails to reach it.
The action should be smooth, rapid, and the arms should remain in the same
plane. Note whether there is a difference when the eyes are closed or if
the same degree of incoordination is present with them open. If there is a
defect, it is technically called dysdiadochokinesis and is a part of
cerebellar dyssynergia. Failure to perform these tests normally indicates
a lesion of the posterior columns or polyneuritis.
Finger winkle test. The functioning of upper extremity sympathetic nerves is
tested by placing the patient's hands in warm water for 30 minutes and
observing if the skin of the fingers wrinkles after the soaking. The skin will normally wrinkle after such soaking, but it will not in diseases of
the sympathetic nervous system. Thus, the test is indicated when there is
a suspicion of diabetes mellitus, Guillain-Barre syndrome, Raynaud's
disease, and other disorders associated with autonomic imbalance.
Finkelstein's test. The patient is asked to make a fist with the thumb tucked
inside the palm. The examiner stabilizes the patient's distal forearm with
one hand and ulnar deviates the wrist with his other hand. Sharp pain in
the area of the first wrist tunnel (radial side) strongly points toward
stenosing tenosynovitis (De Quervain's disease) wherein inflammation of
the synovial lining of the tunnel narrows the tunnel opening and causes
pain on tendon movement.
Finsterer's test. This is a two-phase test for Kienbock's disease:
(2) If percussion of the 3rd
metacarpal just distal to the dorsal aspect of the midpoint of the wrist
elicits abnormal tenderness, the test is confirmed.
Flexor digitorum superficialis test. To test the integrity of the flexor
digitorum superficialis tendon, the examiner holds all of the patient's
fingers in extension except for the finger being tested. The patient then
flexes the finger being tested at the proximal interphalangeal joint. If
the patient cannot do this, the sign is positive for a cut or absent
tendon.
Foot-to-buttock test. The prone patient is asked to flex the thigh and leg,
bringing the foot up near the buttock. Note any swaying of the knee from
side to side (dyssynergia). Many examiners also perform this test with the
patient standing.
Forearm pronation/supination stress test. The patient's forearm is passively
pronated and supinated. Painful instability indicates sprain or
destructive joint pathology, while discomfort with limited motion suggests
contractures or degenerative arthritis.
Forestier's sign. The patient in the upright position is asked to bend
laterally, first to one side and then to the other. Normally, the
contralateral perivertebral muscles will bulge because of the normal
coupling rotation of the lumbar spine (exhibited by the spinous processes
pointing to the ipsilateral side of lateral flexion). However, in
ankylosing spondylitis (Marie-Strumpell's disease) or a state of extensive
spinal fixation, the musculature will appear to bulge greater on the side
of the curve's concavity.
Fouchet's test. The patient is placed supine with the limbs extended in the
relaxed position. If firm pressure on the patella produces pain and focal tenderness at the margin of the patella, chondromalacia of the patella
should be suspected.
Froment's (cone) sign. In paralysis of the ulnar nerve, there is an inability
to approximate the tips of fingers to the thumb to form a cone or make an
"O" with the thumb and index finger. Likewise, early palsy weakness is
exhibited by the inability to firmly hold a piece of paper between the
thumb and fingertips against resistance.
Gag reflex. The gagging normally induced by irritating the posterior
pharyngeal wall. Absence of the reflex signifies a lesion of cranial nerve
IX (sensory component) or cranial nerve X (motor component).
Gauvain's sign. With the patient in the sidelying position, the examiner
stabilizes the patient's uppermost iliac crest with the heel of the hand
and the fingerpads are fixed against the patient's lower abdomen. With the
patient's uppermost knee extended, the examiner grasps the patient's upper
ankle with the other hand, moderately abducts the limb, and firmly rotates
it internally and externally. With the patient's knee locked in extension,
these rotary maneuvers will affect the entire limb, as far superiorly as
the head of the femur. A positive sign is seen when a strong abdominal
contraction occurs, indicating a somatosomatic reflex spasm that is
usually attributed to hip pathology (eg, coxa tuberculosis).
Gelle's test. The examiner applies a vibrating tuning fork over the patient's
mastoid process. If it is heard, the air in the external auditory canal is
compressed by a rubber tube inserted into the auditory canal and a hand
bulb. This fixates the stapes in the oval window, and the sound no longer
is heard. However, it is again perceived if the air pressure is released,
thus testing the mobility of the ossicles.
George's tests. With the patient sitting, blood pressure and the radial pulse
rate are taken bilaterally and recorded. Stenosis or occlusion of the subclavian artery is suggested when a difference of 10 mm Hg between the
two systolic blood pressures and a feeble or absent pulse is found on the
involved side. Even if these signs are absent, a subclavian deficit may be
exhibited by finding auscultated bruits in the supraclavicular fossa.
Giegel's reflex. With the patient supine, the skin of the upper thigh is
stimulated from the midline toward the groin. A normal response is an
abdominal contraction at the upper edge of Poupart's ligament. This reflex
(L1–L2) is essentially the female counterpart of the cremasteric reflex
in the male. It is often referred to as the inguinal reflex.
Gilcrest's sign. The patient is instructed to lift a 5-lb weight (eg,
dumbbell) overhead and then to externally rotate the arm and slowly lower
it to the lateral horizontal position. Pain and/or reduplication of
symptoms during this maneuver (with or without tendon displacement from
the groove) is said to indicate instability of the long head of the biceps
and probable tenosynovitis.
Gillis' test. With the patient prone and the examiner standing on the side of
involvement, the examiner reaches over and stabilizes the uninvolved
sacroiliac joint while the thigh on the involved side is extended at the
hip. Pain initiated by this maneuver in the sacroiliac area of the
involved side is a positive sign of acute sacroiliac sprain/subluxation or
sacroiliac disease.
Goldthwait's test. The patient is placed supine. The examiner places one hand
under the lumbar spine with each fingerpad pressed firmly against the
interspinous spaces. The other hand of the examiner is used to slowly
conduct an SLR test. If pain occurs or is aggravated before the lumbar
processes open (1°–30°), a sacroiliac lesion should be suspected. In
general, Goldthwait believed that if pain occurred while the processes
were opening at 30°–60°, a lumbosacral lesion was suggested; at 60°–90°,
an L1–L4 disc lesion. When pain is brought on before the lumbar spine
begins to move, a lesion, either arthritic or a sprain involving the
sacroiliac joint, is probably present. If pain does not come on until
after the lumbar spine begins to move, the disorder is more likely to have
its site in the lumbosacral area or less commonly in the sacroiliac areas.
The test should be repeated with the unaffected limb. A positive sign of a
lumbosacral lesion is elicited if pain occurs at about the same height as
it did with the first limb. When the unaffected limb can be raised higher
than the affected limb, it is thought to be significant of sacroiliac
involvement of the affected side.
Gonda's sign. This Babinski-like reflex response is elicited by pressing
downward on the third toe and suddenly releasing it with a snap, causing
an upward movement of the great toe.
Gordon's toe sign. A Babinski-like dorsiflexion of the great toe, and possibly
others, occurs when sudden kneading pressure is made upon the deep flexor
muscles of the calf when the pyramidal tracts are involved.
Gower's sign. The patient uses the hands on the thighs in progressive short
steps upward to extend the trunk to the erect position when arising from a
sitting or forward flexed position. This sign is positive in cases of severe degeneration (eg, muscular dystrophy) of the lumbopelvic extensors
or a low back disorder with bilateral implications (eg,
spondylolisthesis).
Graphesthesia test. This refers to the ability to recognize figures written on
the skin. This faculty becomes impaired (graphanesthesia) in some forms of
organic brain disease.
Grasp reflex. Light radialward stroking the palm of the patient's hand elicits
a grasp response (finger flexion) and reluctance to let go. A variation is
to hold the patient's relaxed hand with one hand while the other hand
lightly pulls the patient's fingers from the hypothenar eminence to the
thumb and forefinger. A positive response is seen when the patient
involuntarily squeezes the examiner's fingers, and the reflex is broken by
stroking the back of the patient's fingers. The reflex is normal in
infants up to 10 months of age, but pathologic in adults and usually
signifies toxic or anoxic dementia. When firm stroking is required to
produce this sign, it is called a positive forced grasping sign.
Hamstring reflex. The patient is placed supine with the knees flexed and the
thighs moderately abducted. The tendons of the semitendinosus and
semimembranosus are hooked by the examiner's index finger and the finger
is percussed. Normally, a palpable contraction of the hamstrings occurs.
An exaggerated response indicates an upper motor neuron lesion above L4,
and it may be associated with a reflex flexion of the knee (Stookey
response). An absent response signifies a lower motor neuron lesion
affecting the L4–S1 segments, as do absent Achilles and plantar reflexes.
Hautant's test. The examiner places a sitting patient's upper limbs so that
they are abducted forward with the palms turned upward. The patient is
instructed to close the eyes, and the examiner extends and rotates the
patient's head. This position is held for 15–40 seconds on each side. A
positive sign of vertebrobasilar insufficiency is for one or both arms to
drop into a pronated position.
Heel-to-knee test. The supine patient touches a knee (or shin) with the heel
of the opposite foot, and the examiner makes bilateral comparison. Signs
of a curve in the line of motion, irregular movement, hypermetria, or
hypometria should be noted. The test should be conducted with the
patient's eyes opened and closed. In cerebellar lesions, the patient will
overhit or underhit the mark, and then finally get there. Also observe for
a last-minute intention tremor. The patient may also have difficulty from
a proprioceptive loss, but this would indicate a defect due to loss of
joint sensation rather than a loss of cerebellar coordination. Many
examiners find it advisable to also perform such tests with the patient in
the standing position.
Heel-to-toe test. This is a variant of the heel-to-knee test that has the same
general significance.
Heel walk test. A patient should normally be able to walk several steps on the
heels with the forefoot dorsiflexed. With the exception of a localized
heel disorder (eg, calcaneal spur) or contracted calf muscles, an
inability to do this because of low back pain or weakness can suggest a L5
lesion.
Helfet's test. This test is designed to detect the presence of an
intra-articular "loose body" that disturbs the normal biomechanics of the
joint. To test normal knee locking, a dot is made with a skin pencil in
the center of the patella and another is made over the tibial tubercle
when the knee is flexed. The knee is then passively extended and the
motion of the dot relative to the patella is observed. A positive Helfet
test occurs when there is lack of full lateral movement of the dot.
Palpation of the tibial tubercle during this passive test allows for more
subtle determination of disturbed joint mechanics. Aside from
intra-articular bodies, both a lack of rotational joint play at the
tibiofemoral articulation and imbalance in the tone of the internal and
external rotators of the tibia could promote the pathomechanics observed
during the test. It should also be noted that all but two of these muscles
find their origin in the pelvis.
Hibb's test. The patient is placed in the prone position, and the examiner
stands next to the patient on the side of involvement. The examiner
stabilizes the patient's contralateral uninvolved hip, flexes the
patient's knee on the involved side toward the buttock, and then slowly
adducts the leg, which externally rotates the femur. Pain initiated in the
hip joint indicates a hip lesion; pain rising in the sacroiliac joint, but
not the hip, points to a sacroiliac lesion.
Hip abduction stress test. The patient is placed in the sidelying position
with the underneath lower limb flexed acutely at the hip and knee. With
the upper limb held straight and extended at the knee, the patient is
instructed to attempt to abduct the upper limb while the examiner applies
resistance. Pain initiated in the area of the uppermost sacroiliac joint
or the hip joint suggests an inflammatory process of the respective joint.
Hip adduction deformity sign. When a patient with hip disease walks or stands,
it may be noted that the iliac crest is elevated on the affected side, the
heel is elevated, and the patient walks on the toes of affected side. The
sign is positive if measurement from umbilicus to each medial malleolus
shows one leg short but measurements from the right ASIS to the right
medial malleolus and from the left ASIS to the left medial malleolus shows
limbs to be the same length. This is significant of adduction deformity of
the hip of the apparently short limb and suspicious of tuberculosis. This
stage often precedes the actual shortening of the involved limb by
destruction of the femur head or coxa.
Hip spasm differentiation tests. In the hip joint, two forms of spasm are
common:
(2) that in which all the muscles moving the joint are more or less
contracted. The normal range of hip flexion is 120°. In isolated psoas
spasm, motions of the hip (rotation, adduction, abduction, and flexion)
are not impeded. General spasm of the hip muscles is tested with the
patient supine up a table or bed and the leg flexed at a right angle, both at the knee and at the hip. A child may be tested on its parent's
lap. Using the sound leg as a standard of comparison, the examiner then
draws the knee away from the midline (abduction), toward and past the
midline (adduction), and toward the patient's chest (flexion). Rotation is
tested by holding the knee still and moving the foot away from the median
line of the body or toward and across it.
Hoffa's signs. The patient is placed prone with the relaxed feet and ankles
hanging over the edge of the table. A positive sign of an avulsion
fracture of the calcaneus is found if the examiner by deep palpation finds
that
(2) relaxed dorsiflexion is greater,
and, possibly,
(3) a bone fragment is felt behind either malleolus on the
involved side.
Holmes' rebound phenomenon. A positive sign is noted when the patient flexes
his arm against the resistance of the examiner, and when the arm is
suddenly released, it strikes the patient's chest. This is a significant
finding in ipsilateral cerebellar disease.
Homan's sign. The patient is placed supine with the knees extended in a
relaxed position. The examiner, facing the patient from the involved side,
raises the involved leg, sharply dorsiflexes the ankle with one hand, and
firmly squeezes the calf with the other hand. If this induces a
deep-seated pain in the calf, a strong indication of thrombophlebitis is
found.
Hoover's test. This is a test for malingering associated with an active
straight-leg-raising test. When the patient attempts to raise his leg, the
examiner cups one hand under the heel of the opposite foot. When the
typical patient tries to raise his affected limb, he normally applies
pressure on the heel of the opposite limb for leverage and a downward
pressure can be felt. If this pressure is not felt, the patient is
probably not really trying.
Hughston's jerk sign. This is a modification of McIntosh's test. With the
patient supine, the foot is grasped with one hand while the other hand
rests over the proximal lateral aspect of the leg just distal to the
patella. The knee is flexed to 90°, and valgus stress is applied as the
tibia is rotated internally. The knee is then gradually extended. The lateral tibial plateau is initially in a reduced position to the femoral
condyle; however, as the knee is extended to about 35° of flexion, the
lateral tibial plateau suddenly subluxates forward in relation to the
femoral condyle with a jerking sensation. The lateral plateau slowly
obtains its reduced position, which completes on full extension as the
knee is extended.
Iliopsoas contracture test. Bilateral iliopsoas shortening results in lumbar
rigidity, anterior pelvic tilt, and hip flexion. When associated with
acute back pain, the patient tends to flex the knees and the hip to help
decrease the degree of pelvic tilt and lordosis. When the hip flexors are
short, the lumbar region does not flatten in the supine position unless
the knees and hips are flexed.
Iliopsoas spasm sign. Increased tone tends to pull the lumbar spine into
anterior and inferior flexion, and externally rotate and flex the thigh.
The thigh is usually somewhat flexed on the trunk, although this is
usually concealed by forward bending of the trunk.
Iliopsoas spasm test. Iliopsoas hypertonicity can be confirmed by tension and
pain during deep palpation of the abdomen below the umbilicus, lateral to
the linea alba, medial to and slightly inferior to the ASIS. It will feel
as a taut longitudinal bundle. It is also palpable in the upper sulcus of
the pubic arch.
Impingement syndrome test. The patient is placed supine with the arms resting
loosely at the sides. The elbow on the involved side is then flexed to a
right angle and the arm is rotated internally so that it rests comfortably
on the patient's upper abdomen. The examiner places one hand on the
patient's shoulder and the other hand on the patient's elbow. A
compressive force is then applied, which pushes the humerus against the
inferior aspect of the acromion process and the glenohumeral fossa. Pain
and/or a reduplication of symptoms indicates an impingement syndrome of
the supraspinatus and/or bicipital tendon.
Infraspinatus reflex. This normal reflex (C5 C6) is exhibited by external
rotation of the arm and simultaneous extension of the elbow when the
medial border of the scapula is lightly stimulated.
Internal femoral torsion signs. Internal femoral torsion can be observed if
the patellae are marked with a skin pencil and these points are observed
during gait. There will be toe-in, the patellae will face medially, an
internal contracture of the hips will usually be found, and there will be
excessive anteversion of the femur. If there is toe-in and the patellae face forward (as is normal), the cause of the toe-in will be distal to the
knee. An internal rotation deformity likely exists at the hip when
internal rotation exceeds external rotation by more than 30°.
Internal tibial torsion test. To confirm a suspicion of internal tibial
torsion, have the patient sit on a table with the knee flexed at 90°. The
tibial tubercle will palpate as if it faces straight anterior. The
examiner grasps the malleoli by the thumb and index finger to determine
the position of the ankle joint. In normal adults, about 20°–30° of
external tibial torsion is present and the lateral malleolus will be
posterior to the medial malleolus. If internal tibial torsion exists, the
lateral malleolus will be anterior to its medial mate.
Inverted radial reflex. The normal radial reflex produces forearm flexion.
This pathologic reflex exhibits hand and finger flexion rather than
forearm flexion, indicating a C5 lesion.
Jendrassik's maneuver. When it is impossible to obtain a patellar reflex by
usual methods, re-enforcement may be tried. Ask the patient to clasp the
hands and pull strongly. While the patient's attention is on the pull and
the thigh muscles are relaxed, the examiner taps the patellar tendon.
Joint position and motion sense tests. With the patient's eyes closed and
extremities relaxed, ask the patient to tell in what position a particular
joint has been placed or what joint is being moved. Try each part being
examined several times, and note the findings. The patient should be able
to perceive joint motion with the eyes closed. The examiner should be
cautious that the patient completely relaxes the joints being manipulated.
The best joints to test for position and motion senses are those of the
great toe and thumb. The joint sensation or perception of articular motion
is arthresthesia. The prefixes hyper and hypo are used to indicate
exaggerated or diminished findings.
(2) The test is then repeated except that this
time the examiner firmly encircles the patient's forearm with both hands
(placed about 1–2 inches below the antecubital crease). Induced pain and
grip strength are noted. If the second phase of the test shows reduced
pain and increased grip strength when the muscles of the proximal forearm
are compressed, lateral epicondylitis is indicated.
Kernig's neck test. Biomechanically, this test is the cephalad representation
of Lasegue's SLR test. The supine patient is asked to place both hands
behind his head and forcibly flex his head toward his chest. Pain in
either the neck, lower back, or down the lower extremities indicates
meningeal irritation, nerve root involvement, or irritation of the dural
coverings of the nerve root. That is, some hypersensitive tissue is being
aggravated by the tensile forces. When the examiner passively flexes the
patient's neck and trunk, it is called the Soto-Hall test or Lindner's
test, depending on the examiner's position.
Knee anterolateral rotary instability test. The leg of the supine patient is
grasped with one hand and secured under the examiner's arm. The examiner's
other hand is placed over the lateral proximal aspect of the patient's
leg, and the leg is extended. A valgus stress is applied and the leg
internally rotated as the knee is flexed. During flexion of the knee, the
lateral tibial plateau can be felt to subluxate anteriorly in relation to
the lateral condyle. The iliotibial tract tightens, lateral crepitation
may be felt, and a slight resistance to flexion may be perceived. When the
knee is in about 35° of flexion, the iliotibial band tightens, passes
behind the transverse axis of rotation, and the tibial plateau is suddenly
reduced, often with a "clunk-like" sensation both felt and heard.
Knee effusion test. If a joint is greatly swollen from a major effusion, the
patient is placed in a relaxed supine position. The limb is relaxed, and
the knee is slowly extended. The patella is then pushed into the trochlear
groove and released quickly. This will force fluid under the patella to
the sides of the joint and then to return under the patella. This rebound
is referred to as a ballottable patella. Minimal effusion, however, will
not ballot the patella. In cases of minor effusion, it is necessary to
"milk" the fluid from the suprapatellar pouch and lateral side to the
medial side of the joint. Once the fluid has been moved medially, tapping
over the fluid will return it to the lateral side.
Knee external rotation-recurvatum test. The patient is placed supine, and the
examiner grasps the patient's heel with one hand and supports the calf
with the other hand. The knee is allowed to pass from about 10° flexion
into full extension. A positive test occurs when the knee assumes a
position of slight recurvatum, the tibia rotates externally, and there is
increased tibia vara. Such a sign indicates injury to the arcuate
complex, lateral half of the posterior capsule, and a degree of injury to
the posterior cruciate ligament.
Knee hyperextension stress test. The patient is placed prone with the knees
extended in the relaxed position. The examiner places a fist under the
distal thigh of the involved side, flexes the patient's knee to about 30° with the other hand, and then allows the leg to drop without assistance
when the muscles are relaxed. Most knee lesions limit extension to some
degree. Thus, if extension is limited or the rebound is abnormal during
this "knee drop" test (as compared to the contralateral knee), some type
of knee disorder should be suspected and may possibly be localized.
Knee hyperflexion stress test. With the patient in the supine position, the
examiner places one hand on the involved knee and the other on the
ipsilateral ankle. The patient's knee is moderately flexed, the thigh is
brought towards the patient's abdomen, and the patient's heel is slowly
pushed toward the patient's buttock. Unless the patient is considerably
obese, the normal knee can be flexed without pain so that it touches the
buttock. If knee pain or severe discomfort is induced by this maneuver, a
subtle localized knee lesion may be brought out.
Knee lateral stability stress tests. The collateral ligaments provide medial
and lateral stability to the knee joint. To examine sideways stability,
the patient is placed supine and the knee is flexed just enough to free it
from extension. To test the integrity of the medial collateral ligament,
valgus stress is applied to open the knee joint on the medial side. The
lateral collateral ligament is tested by applying stress to open the knee
joint on the lateral side. In these maneuvers, the ankle is secured with
one hand, the other hand is placed on the opposite side of the knee of the
ligaments being tested, and pressure is applied toward the ligaments being
tested. More knowledge can be gained, however, if the examiner locks the
patient's ankle between his arm and chest and uses this hand to palpate
the ligaments in question and the underlying joint gap during the test.
Knee posterolateral rotary instability test. Posterolateral rotary instability
arises from a posterior subluxation of the lateral tibial plateau in
relation to the lateral femoral condyle, accompanied by abnormal external
tibial rotation. To test for posterolateral rotary instability, the
external rotation-recurvatum and a posterior drawer test are performed.
Excessive posterior sag of the lateral tibial plateau with external tibial
rotation should be noted. This type of instability results from laxity of
the arcuate complex, the lateral half of the posterior capsule, and a
degree of failure of the posterior cruciate ligament.
Laguere's test. With the patient supine, the thigh and knee are flexed and
the thigh is abducted and rotated outward. This forces the head of the
femur against the anterior portion of the coxa capsule. Increased groin
pain and spasm are usually positive signs of a lesion of the hip joint,
iliopsoas muscle spasm, or a sacroiliac lesion. It can help to
differentiate from a lumbar disorder.
Lasegue's differential sign. This test is used to rule out hip disease. A
patient with sciatic symptoms is placed supine. If pain is elicited on
flexing the thigh on the trunk with the knee extended but not produced when the thigh is flexed on the trunk with the knee relaxed (flexed), coxa
pathology can usually be ruled out.
Lasegue's rebound test. At the conclusion of a positive sign during Lasegue's
supine SLR test, the examiner allows the limb to drop to a pillow without
warning. If this rebound test causes a marked increase in pain and muscle
spasm, then a disc involvement is said to be suspect. However, it would
appear that any site of irritation in the lower back and pelvis would be
aggravated by such a maneuver.
Lasegue's standing test. The patient attempts to touch the floor with the
fingers while the knees are held in extension during the standing
position. Under these conditions, the knee of the affected side will
flex, the heel will slightly elevate, and the body will elevate more or
less to the painful side. It should be noted that this would also be true
with shortened posterior thigh and calf muscles.
Lasegue's straight-leg-raising (SLR) test. The patient lies supine with legs
extended. The examiner places one hand under the heel of the affected side
and the other hand is placed on the knee to prevent the knee from bending.
With the limb extended, the examiner most cautiously flexes the thigh on
the pelvis to the point of pain, keeping the knee straight. The patient
will normally be able to have the limb extended to almost 90° without
pain. If this maneuver is markedly limited by pain, the test is positive
and suggests sciatica from a disc lesion, lumbosacral or sacroiliac
lesion, subluxation syndrome, tight hamstring, spondylolisthetic adhesion,
IVF occlusion, or a similar disorder.
Lax shoulder capsule test. To determine a lax capsule, the patient clasps the
fingers behind the head and laterally abducts the elbows. The axilla is
palpated high over the glenohumeral capsule while posterior force is
applied on the patient's flexed elbow. While laxity of the anterior
capsule can always be demonstrated by this maneuver, care must be taken
not to dislocate the humerus within a loose capsule.
Leotta's maneuvers. When intestinal adhesions are suspected, the fingers of
the examiner are placed on the upper right abdominal quadrant of the
patient and pressed inward while the patient exhales completely. If
adhesions exist between the colon and gallbladder or liver, this pressure
will pull on the colon and increase patient distress. To determine the
possible existence of adhesions between the parietal peritoneum and
ascending colon, traction and pressure are made transversely from the
lateral abdominal line toward the median line and from the median line
outward. The direction of stretching and pressure necessary to elicit pain
suggests the site of adhesions. A positive sign may be seen in
cholecystitis, gastric ulcers, duodenal ulcers, or as the result of past
abdominal surgery.
Lewin-Gaenslen test. The patient is placed in the sidelying position with the
underneath lower limb flexed acutely at the hip and knee. The examiner
stabilizes the uppermost hip with one hand. With the other hand, the
uppermost leg is grasped near the knee and the thigh is extended on the
hip. Initiated or aggravated pain suggests a sacroiliac lesion.
Lewin's knee sign. If quick extension of a knee in the standing position
produces pain and a sharp flexion response, hamstring spasm should be
suspected.
Lewin's standing test. With the patient standing with the back to the
examiner, the examiner cautiously forces first the right and then the left
knee into complete extension. Then both knees are straightened at the same
time. In lumbosacral, lower lumbar, sacroiliac, and gluteal disturbances,
these movements will be accompanied by increased pain and the knee will
snap back into flexion.
Lewin's supine test. This test is almost identical to Chapman's test, except
that Lewin believes a positive sign is especially indicative of an
ankylosing dorsolumbar lesion. With the patient supine, the examiner
places his arms or a strap across the patient's thighs just above the
knees. The patient is directed to sit up straight without using the hands.
The sign is positive if the patient is unable to do this maneuver, and
during the attempt, the patient is frequently able to localize the site of
pain. It is frequently associated with lumbar arthritis, lumbar fibrosis,
degenerative disc thinning with protrusion, sacroiliac or lumbosacral
arthritis, or sciatica.
Lhermitte's test. With the patient seated, flexing of the patient's neck and
hips simultaneously with the patient's knees in full extension may produce
sharp pain or shock-like sensations radiating down the spine and/or into
the upper extremities. When this is elicited, it is a sign of cervical
pathology suggesting spinal cord myelopathy by a protruded cervical disc,
tumor, fracture, or multiple sclerosis.
Libman's test. This refers to pressing the mastoid processes to evaluate a
patient's sensitivity to pressure pain.
Lindner's test. The patient is placed supine, and the examiner slowly flexes
the patient's head forward so that the neck and thoracic spine curve
forward. This test often helps to localize diffuse spinal pain.
Essentially, it is the passive form of Kernig's neck test and quite
similar to the Soto-Hall test except for the examiner's position.
Lippman's test. In the relaxed seated position, the sitting patient is asked
to flex the elbow on the involved side and rest the forearm in the lap.
The examiner palpates for the tendon of the long head of the biceps about
3 inches distal from the glenohumeral joint. An attempt is made to
displace the tendon laterally or medially from its groove. Pain,
reduplication of other symptoms, and a palpable displacement of the tendon
from its groove signifies tenosynovitis with instability.
Losee's test. With the patient supine and the knee flexed, the examiner
applies valgus stress to the tibia with one hand while the head of the
fibula is pushed anterior with the other hand. If an anterior subluxation
occurs at the lateral tibial plateau when the knee approaches full
extension, anterolateral rotatory instability is indicated.
Loven's reflex. When an afferent nerve of an organ is sufficiently stimulated,
vasodilation results that produces a corresponding increase in the size of
the organ.
Lucid interval. The classic sign of middle meningeal (extradural) hemorrhage
is a lucid interval: the patient regains consciousness and shortly
thereafter lapses into unconsciousness again.
Magnan's sign. Paresthesia of cocaine addicts that is perceived as if foreign
bodies were under the skin.
Maisonneuve's sign. Excessive dorsiflexion of the wrist as seen in Colles'
fracture.
Mannkopf's test. This is an old, but reliable, objective test for pain, and it
is not restricted to musculoskeletal complaints. The patient is placed in
a relaxed position and the pulse is taken. The examiner then precipitates
the pain (eg, by probing, applying heat or electrostimulation, etc). The
pulse rate is then re-evaluated. In situations of true pain, the pulse
rate will increase a minimum of 10%. Also see Robertson's test.
McBride's test. The patient is asked to stand on the limb opposite the side of
a low back complaint and raise the knee of the other leg upward with the
help of his hands. According to McBride, this maneuver usually relieves
most low back complaints or at least is done with relative ease. The
examiner should stand nearby in the event that the patient might lose
balance. While often contraindicated in geriatrics, if the younger patient
refuses this maneuver or complains of undue pain, one may suspect the
possibility of malingering.
McIntosh's test. The patient is placed supine, the lower extremity is
supported at the heel with one hand, and the other hand is placed
laterally over the proximal tibia just distal to the patella. The
examiner's caudad hand applies valgus stress and internally rotates the
tibia as the knee is gradually moved from full extension into flexion.
During flexion of the knee, the lateral tibial plateau can be felt to
subluxate anteriorly in relation to the lateral condyle. Lateral
crepitation may be felt, and a slight resistance to flexion may be
perceived. When the knee is at about 35° flexion, the iliotibial band
tightens, passes behind the transverse axis of rotation, and the tibial
plateau is suddenly reduced, often with a "clunking" sensation that can
often be both felt and heard.
McMurray's test. In this two-part test, the patient is placed supine with the
thigh and leg flexed until the heel approaches the buttock. One hand of
the examiner is placed on the patient's knee, the other hand on the
patient's ankle. The examiner internally rotates the patient's leg, then
slowly extends the leg. Then the examiner externally rotates the leg and
slowly extends the leg. The test is positive if at some point in the arc a
painful click or snap is heard. This sign can be significant of meniscus
injury. The point in the arc where the snap is heard locates the site of
injury of the meniscus; eg, if noted with internal rotation, the lateral
meniscus will be involved. The higher the leg is raised when the snap is heard, the more posterior the lesion is in the meniscus. If noted with
external rotation, the medial meniscus will usually be involved.
Unfortunately, false positive and false negative signs are not uncommon.
Medial epicondyle test. On the side of involvement, the patient is instructed
to flex the elbow about 90° and supinate the hand. If severe pain arises
over the medial epicondyle when the patient in this position attempts to
extend the elbow against resistance, medial epicondylitis (golfer's elbow)
is suggested.
Mendel-Bechterew sign. In organic hemiplegia or cerebellar tract disease,
plantar flexion of the lateral toes results from percussing the dorsum of
the foot in the area of the cuboid. Under normal conditions, dorsiflexion
of the lateral four toes occurs. In pathologic states, plantar flexion is
produced.
Mennell's tests. The patient is placed prone, and one hand of the examiner is
used to stabilize the contralateral pelvis. With the palpating hand, the
examiner places a thumb over the patient's PSIS and exerts pressure, then
slides his thumb outward and then inward. The sign is positive if
tenderness is increased. When sliding outward, trigger deposits in
structures on the gluteal aspect of the PSIS may be noted. If when sliding
inward tenderness is increased, it suggests sprain of the superior
sacroiliac ligaments. Confirmation is positive when tenderness is
increased when the examiner pulls the ASIS posterior while standing behind
the patient or when the examiner pulls the PSIS forward while standing in
front of the supine patient. These tests are helpful in determining that
sacroiliac tenderness is due to overstressed superior sacroiliac
ligaments.
Milgram's test. The supine patient is asked to keep the knees straight and
lift both legs off the table about 2 inches and to hold this position for
as long as possible. The test stretches the anterior abdominal and
iliopsoas muscles and increases intrathecal pressure. Intrathecal pressure
can be ruled out if the patient can hold this position for 20 seconds
without pain. If this position cannot be held or if pain is experienced
early during the test, a positive sign is offered that indicates pressure
upon the cord from some source (eg, cord pathology, IVD lesion).
Mills' test. The patient makes a fist; flexes the forearm, wrist, and fingers;
pronates the forearm, and then attempts to extend the forearm against the
examiner's resistance. This stretches the extensors and supinators
attached to the lateral epicondyle. Pain at the elbow during this maneuver
is an indication of radiohumeral epicondylitis (tennis elbow).
Minor's sign. Sciatic radiculitis is suggested by the manner in which the
patient with this condition rises from a sitting position. The weight is
supported on the uninvolved side by holding on to the chair for firm
support in arising or the patient places the hands on the knees or thighs
while working into the upright position, balances on the healthy leg,
places one hand on the back, and flexes the leg and extends the thigh of
the affected limb. The sign is often positive in sacroiliac lesions,
lumbosacral strains and sprains, fractures, disc syndromes, dystrophies
and myotonias.
Mittlemeyer's sign. The situation in which the patient is instructed to march
in place and there is automatic turning toward one side. This pathologic
sign indicates vestibular disease.
Morton's test. This test is positive when deep transverse pressure across the
heads of the metatarsals, especially between the 2nd and 3rd metatarsal,
causes a sharp pain in metatarsalgia.
Naffziger's test. This test essentially offers a suspicion of an abnormal
space-occupying mass such as a spinal tumor or disc protrusion. It is
performed by having the patient sit or recline while the examiner holds
digital pressure over the jugular veins for 30–45 seconds. The patient is
then instructed to cough deeply. Pain following the distribution of a
nerve suggests nerve root compression. Though more commonly used for low
back involvements, thoracic and cervical root compression may also be
aggravated. Local pain in the spine does not positively indicate nerve
compression; it may indicate the site of a strain, sprain, or another
lesion. The sign is almost always positive in the presence of cord tumors,
particularly spinal meningiomas. The resulting increased intrathecal
pressure above the tumor or disc protrusion causes the mass to compress or
pull upon sensory structures to produce radicular pain. The test is
contraindicated in geriatrics and extreme care should be taken with anyone
suspected of having atherosclerosis. In all cases, the patient should be
alerted that jugular pressure may result in vertigo.
Neri's bowing sign. This sign is positive when a standing patient can flex the
trunk further without low back discomfort when the ipsilateral leg is
flexed than when both knees are held in extension. A positive sign
suggests hamstring spasm, contractures of the posterior thigh and/or leg
muscles, sciatic neuritis, a lumbar IVD lesion, or a sacroiliac
subluxation syndrome.
Neuroma squeeze test. If needle-like shooting pains occur when the forefoot is
gripped and slowly squeezed, the probability of neuroma should be
considered.
O'Connell's test. This test is conducted in a manner similar to that of the
double leg raise test except that both limbs are flexed on the trunk to an
angle just below the patient's pain threshold. Then the limb on the
opposite side of involvement is lowered. If this exacerbates the pain, the
test is positive for sciatic neuritis.
Oculocardiac reflex. Compression of the eyeball upon closed lids for about 30
seconds and without producing pain, while the patient is in the recumbent
position, may produce slowing of the heart by 5–10 beats. In people who
are distinctly vagotonic, it has been found that this slowing may amount
to 12 beats or more. Under conditions of excessive pressure, in marked
parasympathicotonics, the heart has often been temporarily inhibited. In
people of stable nerve balance, neither inclined to sympathicotonia or
parasympathicotonia, the slowing is usually less than 10 beats; in fact,
in those who are markedly sympathicotonic, no slowing may occur. The
reflex is caused by stimulating the ocular fibers of the trigeminus,
through which the impulse is transmitted to the cardiac inhibitory fibers
of the vagus. In individuals who are distinctly vagotonic, the reflex may
show itself in the gastrointestinal tract as well as in the heart.
Pressure over the vagus in the neck will result in a similar
manifestation.
O'Donoghue's maneuvers. The cervical spine of a sitting patient is passively
flexed, extended, laterally flexed to both sides, and rotated in both
directions against patient resistance. Pain precipitated by such isometric
contraction indicates cervical strain. The test is then repeated without
patient resistance. Pain precipitated by passive unrestricted motion
suggests cervical sprain.
Oppenheim's reflex. This response is met with in spastic conditions of the
legs. The sign is elicited by striking the median surface of the leg
posteriorly from the upper posterior portion of the tibia downward. This
causes contraction of the tibialis anticus, extensor hallucis longus,
extensor digitorum communis, and, in some instances, also the peroneal
muscle. It has Babinski implications and is a variant of Gordon's reflex.
Pallesthesia test. A vibrating tuning fork is placed over bony prominences
(eg, the lower ends of the radius and ulna, the ASISs, and the external
and internal malleoli), then the patient is asked to state when he feels a
vibration or humming sensation. When the vibratory sense is lost, the
patient cannot differentiate between a vibrating fork and a silent one.
Testing begins at the patient's head and proceeds to the feet, with the
examiner comparing with his own hand or other bony prominences. A
nonvibrating fork is alternately placed over a point to determine if the
patient is guessing. Definite findings should be noted. The normal
perception of vibration from the fork when placed against any subcutaneous
bony prominence is called pallesthesia. Decreased sensation is recorded as
pallhypesthesia; loss of sensation, pallanesthesia. If the patient fails
to feel the vibration, it is indicative of an impairment of the tracts of
the posterior columns of the spinal cord that convey the vibratory
impulses. Normal vibratory perception is commonly impaired in tabes dorsalis, subacute sclerosis of the cord following pernicious anemia, and
in generalized arteriosclerosis. It is first detected with a c-268 tuning
fork and later by a c-128.
Parkinson's sign. The immobile mask-like expression of individuals with
postencephalitic disorders, with or without paralysis agitans.
Patella apprehension sign. The patella displaces laterally with vigorous
quadriceps contraction. When a person strongly extends the flexed knee
with the leg externally rotated, the patella may dislocate if its
attachments are weakened. If a patella is prone to dislocation, any
attempt by the examiner to produce such a dislocation will be met with by
sharp patient resistance. In testing, the patient is placed in the relaxed
neutral supine position, and the examiner applies increasing pressure
against the patella. If a chronic weakness exists, the patient will become
increasing apprehensive as the patella begins to dislocate.
Patella clonus. Patellar clonus (or trepidation sign) is a rapid up-and-down
movement when the leg is in extension and relaxed while the patient is
supine. With the lower extremities completely at rest on a bed or padded
table, the examiner pushes down quickly on the patella (use discretion)
and maintains the pressure. This will bring out any tendency to patellar
clonus, which is indicative of lateral tract disease, disseminated
sclerosis, or hysteria.
Patella reflex. A rolled hard pillow is placed beneath the knees of a supine
patient. With the muscles completely relaxed, the patellar tendon is
tapped, and the contraction of the quadriceps muscles (L2–L4) is noted.
Do not rely on the movement of the foot in response to the tapping. Place
one hand on the quadriceps muscle of the thigh, using the other hand for
the percussion hammer. Test bilaterally, and compare the force of
contraction and quickness of response of the two sides. Absence of the
reflex is Westphal's sign. Normal reflex response depends upon the
integrity of the femoral nerve and the lumbar segments. Other positions
for obtaining the knee reflexes are with the patient sitting on the edge
of a bed with muscles relaxed or sitting on a chair with the feet resting
on the floor in parallel position. The thighs should be bared and the same
methods employed as stated previously. Absent or diminished knee jerks are
found in peripheral nerve lesions, anterior horn cell disease, and
posterior column lesions. IVD herniation at the level of L2–L4 will
diminish the response. Hyperactive responses will be seen in tense
patients, corticospinal tract lesions, general pareses, cord tumor
compression or bone compression above L3, multiple sclerosis, and early
hemiplegia. The knee jerk is often wanting or feeble in young infants. It
varies a great deal in persons of different temperament. In high-strung or
overly sensitive people, and often in the Jewish race, lively knee jerks
are often seen without disease.
Patella wobble sign. A patient in the sitting position is instructed to extend
a knee while the examiner cups a palm over the patella. If erratic
patellar motion is felt during the last phase of extension, an irregular
retropatellar growth or some type of incomplete obstruction is indicated
(eg, hypertrophied infrapatellar synovial folds, hardened fat pad).
Patrick's F-AB-ER-E test. This test helps to confirm a suspicion of hip joint
pathology. The patient lies supine, and the examiner grasps the ankle and
the flexed knee. The thigh is flexed (F), abducted (AB), externally
rotated (ER), and extended (E). Pain in the hip during the maneuvers,
particularly on abduction and external rotation, is a positive sign of
coxa pathology.
Payr's sign. The patient is asked to sit flat on the floor with the legs
crossed and folded in so that the femurs are internally rotated, the knees
are flexed and abducted, and the feet are plantar-flexed. If pain occurs
on the medial side of a knee when the examiner applies downward (valgus)
pressure on the knee, a lesion at the posterior horn of the medial
meniscus is suggested.
Pectoralis flexibility test. With the patient placed supine and the hands
clasped behind the head, the elbows are allowed to slowly lower laterally
toward the table. If the elbows do not approximate the tabletop,
shortening (eg, spasm, inflexibility, contracture) of the pectoralis group
is indicated.
Pectoral reflex. With the patient's arm placed halfway between adduction and
abduction, the examiner's finger is placed in the pectoral tendon near the
humerus. A sharp blow on the finger elicits adduction and slight internal
rotation of the patient's arm.
Pende's reflex. In subjects who are distinctly sympathicotonic, stroking of
the skin (especially of the abdomen) may produce a "goose flesh" response;
ie, a pilomotor reflex.
Perkin's tests. The patient is placed in a relaxed supine position. The
examiner locks the top of the patella between the thumb and first finger
and applies pressure towards the patient's foot while the patient is asked
to tighten the quadriceps by hyperextending the knee. As the patella moves
proximally, its movement should be smooth and gliding. An alternative
method is for the examiner to place a firm double hand contact over the
anterior knee, lean over the limb, and displace the patella from side to
side while simultaneously applying pressure from the anterior to the
posterior. Induced pain, grating, or crepitation (palpable or audible)
during this maneuver is a positive sign, suggesting roughening as in
chondromalacia patellae, osteochondral defects, or when degenerative
changes within the trochlear groove occur (eg, retropatellar arthritis).
Perthe's tourniquet test. An elastic bandage is applied to the upper thigh of
a standing patient sufficient to compress the long saphenous vein, and the
patient is instructed to walk briskly around the room for approximately 2
minutes. The varicosities are then examined. This exercise with the thigh
under pressure should cause the blood in the superficial (long saphenous)
system to empty into the deep system via the communicating veins. Thus:
(2) If the superficial varicosities remain unchanged, the
valves of both the long saphenous and communicating veins are incompetent.
(3) If the superficial varicosities disappear, the valves of the long
saphenous and the communicating veins are normal.
Pharyngeal reflex. The response from stimulating the palate, fauces, or
posterior pharyngeal wall that normally results in swallowing.
Phelp's test. The patient is placed in the prone position with both lower
limbs extended in the relaxed position. In this position, the patient's
thighs are abducted just short of the patient's threshold of pain, and
then the examiner flexes the patient's knees to 90° angles with the
thighs. If this flexion allows greater abduction of a thigh on the hip
without undue discomfort, a contracture of the gracilis muscle is
suggested.
Piedallu's sign. When a sacral base is subluxated unilaterally anteroinferior
and lateral so that the adjacent ilium is displaced posteroinferior and
medial, the ipsilateral PSIS on the side of inferiority will be low in the
standing and sitting positions. If this PSIS becomes higher than the
contralateral PSIS during forward flexion, the phenomenon is called a
positive Piedallu's sign. Such a sign signifies either ipsilateral
sacroiliac locking where the sacrum and ilium move as a whole or muscular
contraction that prevents motion of the sacrum on the ilium. Regardless,
it shows that sacral dysfunction is probably present.
Piriformis myofascitis tests. The patient is seated on a table with the hips
and knees flexed. Resistance is applied by the examiner as the patient
attempts to separate the knees. In piriformis myofascitis, pain and
weakness will be noted on resisted abduction and external rotation of the
thigh. Inflammation will be confirmed by rectal examination exhibiting
acute tenderness over the lateral pelvic wall proximal to the ischial
spine.
Piriformis spasm signs. If the patient has deep gluteal pain, sciatic
neuralgia, and walks with the foot noticeably everted on the side of
involvement, involvement of the piriformis should be suspected. Increased
piriformis tone tends to subluxate the sacrum anteriorly and externally
rotate the thigh.
Piriformis spasm test. The patient is placed supine on a firm flat table. The
heels are grasped and firmly inverted and abducted, and the feet are
externally rotated. If one foot resists this effort and the act is
attended by pain in the gluteal area, piriformis spasm should be
suspected. Differentiation of piriformis spasm from other causes can
often be elicited by reproducing the pain on internal rotation of the
femur when it is at a lower level than the original point of pain.
Plantar tension test. The patient is placed supine and the involved foot and
toes are dorsiflexed so that the plantar fascia is tensed. If pain occurs
or if bead-like swellings and irregularities are found as the examiner
deeply runs his thumb vertically along the plantar surface, plantar
fascitis is suggested.
Pollicis longus tests. The examiner stabilizes the proximal phalanx of the
patient's thumb, and the patient is instructed to flex and extend the distal phalanx. Inability to flex the phalanx indicates an injury to the
tendon of the flexor pollicis longus. Inability to extend the phalanx
indicates an injury to the tendon of the extensor pollicis longus.
Posterior drawer sign. With the patient supine and the knees flexed, the
stability of the posterior cruciate ligament is tested in the same manner
as the anterior cruciate except the tibia of the flexed knee is pushed
backward rather than pulled forward. Thus, it can be done in one
continuous movement with the anterior drawer test. When a distinct sliding
backward of the tibia from under the femur is noted, it indicates a torn
posterior cruciate ligament. A positive drawer sign is less common than
the anterior counterpart. Also see anterior drawer sign.
Pupillary reflex. When light is quickly shined on the retina of one eye of a
patient staring at a distant object, both pupils normally contract with
the contralateral eye contracting to a lesser degree. Failure to do so
indicates a lesion of the optic afferents or the contralateral oculomotor
efferents.
Quadriceps flexion test. Scar tissue within muscle invariably limit the
working length of all muscles in the group. Quadriceps contracture is
exhibited by placing the patient prone, flexing the leg toward the
buttocks to tolerance, and measuring the distance from heel to buttock.
Once the point of tolerance is measured, the lumbosacral spine will arch
and the buttocks will rise to prevent further stretch. This test may prove
a lesion too deep to palpate as well as evaluate progress during therapy.
Radial stress sign. Pain over the medial aspect of the wrist is produced when
the examiner forces the wrist into radial deviation. The sign is positive
in posttraumatic disorders or pathology of the medial wrist.
Rebound tenderness sign. Release of palpating pressure by quickly removing the
examining hand(s) causes rebound pain in the abdomen if visceral or
peritoneal irritation exists. The pain is often referred to that abdominal
quadrant where the involved viscus exists.
Red reflex. This is the normal diffusely red-orange appearance of the retina
as seen with an ophthalmoscope from a distance of about 20 inches or more
from the patient. The examiner looks through the window of an
ophthalmoscope and shines a beam of light into the patient's line of
sight. The ocular media (aqueous humor, lens, and vitreous) are normally
transparent and allow the fundus to reflect a red-orange glow from the
beamed light. This is the red reflex. If the ocular media contains any
opacities, they will appear as dark shadows within this red glow.
Repetitive heel raise test. The standing patient is asked to raise the heels
(ie, toe stand) repetitively several times. If this induces ankle pain,
instability, a posterior compartment syndrome or a subluxation complex
should be suspected. If this exercise is unable to be performed because of
weakness and ankle pain is absent, a gastrocnemius weakness or neurologic
deficit should be suspected.
Rinne's test. To test for deafness, a tuning fork is vibrated and placed next
to each ear opening (for air conduction) and then against the mastoid bone
(for bone conduction) to see which tone is heard longer. Normally, the
tone will be heard longer through the otic canal via air conduction.
Robertson's test. Pressure on any painful tissue will invariably produce
dilation of the pupils. This reaction will not occur in the malingerer
with alleged pain. To this author's knowledge, Robertson's test and
Mannkopf's test (which see) are the only objective tests in physical
diagnosis for pain.
Romberg's station test. During this test, the examiner must stand close to the
patient in the event the patient loses balance. The patient is asked to
stand in a relaxed position and to close the eyes. If this cannot be
accomplished without falling or severe swaying that requires the feet to
be moved to regain balance, a positive sign is established that rules out
cerebellar or labyrinthine disease. A positive sign is seen in locomotor
ataxia associated with marked alcoholic neuritis, spinocerebellar tract
disease, and in pernicious anemia when the columns of Goll and Burdach are
affected and is highly indicative of a neurologic lesion interrupting the
proprioceptive pathways between the lower limbs and the cerebellum. While
a patient with cerebellar or labyrinthine disease may have difficulty
standing, the position is usually taken equally well with or without
visual support.
Rossolimo's sign. A pathologic plantar reflex (Babinski variant) that
occurring in lesions of the pyramidal tract, as in organic hemiplegia.
When the great toe of the paralyzed side is lightly percussed, or stroked
upon its plantar surface, extension or abduction of the toe results.
RUM tests. Three quick RUM (radial, ulnar, medial nerve) tests are as follows:
(2) Ulnar nerve: have the patient hold a piece of paper by opposing the thumb and index finger (Froman's cone sign). The
examiner tries to pull the piece of paper away while the patient resists.
If the patient cannot hold the slip, the weakness suggests ulnar nerve
pathology.
(3) Median nerve: the median nerve is tested by asking the
patient to touch each finger with the thumb. Remember that the median
nerve is under the transverse carpal ligament. If carpal tunnel syndrome
is suspected, test by holding the patient's wrist in flexion for 30
seconds. Induced pain is a positive sign.
Sacroiliac stretch test. The patient is placed supine. The examiner, standing
to face the patient, crosses his arms and places a hand on the
contralateral ASIS and the other hand on the ipsilateral ASIS. Oblique
(posterolateral) pressure is then applied to spread the anterior aspects
of the ilia laterally. A positive sign of sacroiliac sprain is a
deep-seated pelvic pain that may radiate into the buttock or groin. While
the iliac compression test is designed to stretch the posterior sacroiliac
ligaments, this test stretches the ligaments on the anterior aspect of the
joints.
Salivation response. This is a normal reflex of the vagal system. When a drop
of weak acid such as vinegar is placed on the tongue, the salivary glands
will normally increase their output of saliva, which can be observed. The
sensation is carried by the facial nerve with action by the
parasympathetics to the salivary glands.
Sargent's sign. This sign is produced by a light stroke drawn in the median
line from above downward over the abdominal wall. When a white line
appears, it indicates increased sympathetic tonus or hyperadrenia.
Scapular reflex. A mild stimulus applied between the scapulae normally
contracts the scapular muscles. It is often called the interscapular
reflex.
Scapulohumeral reflex. Normal adduction with outward rotation of the humerus
produced by percussing along the medial edge of the scapula.
Schaeffer's sign. This reflex occurs in organic hemiplegia. When the middle
portion of the Achilles tendon is firmly pinched, plantar flexion of the
foot and dorsiflexion of the toes, especially the great toe, results in a
Babinski-like fashion.
Schultz's test. Standing behind the sitting patient with acromioclavicular
separation, face the affected side. Place one hand under the flexed elbow
and push up while the other hand placed over the acromioclavicular joint
applies firm pressure. The more "give" that is felt in the joint, the
greater the separation.
Schwabach's test. To screen deafness, the physician with good hearing vibrates
a tuning fork and compares his perception of tone with that of the
patient. A series of several tuning forks of different tones is used and
the number of seconds is noted in which the patient can hear each by air
and bone conduction.
Serial sevens subtraction test. Attention span can be tested clinically simply
by serial subtraction with a patient with an IQ over that of an average
third-grade student. For example, the patient can be asked to begin with
the number 100, subtract 7, then subtract 7 from the answer, and continue
this process and give a verbal answer until zero nears. An occasional
mistake can be attributed to carelessness.
Shober's sign. This procedure is an excellent method for grossly evaluating
the extent of lumbar flexion. One mark is placed over the L5 spinous
process when the patient is standing erect and a second mark is made on
the spine exactly 10 cm above. The patient is then asked to flex forward
in the Adams position, and the distance between the two marks is measured.
A difference of less than 4–5 cm is a positive sign of ankylosing
spondylitis or some irritation producing severe lumbar spasm.
Shoulder abduction stress test. The sitting patient is asked to abduct the arm
laterally to the horizontal position with the elbow extended while the
examiner applies resistance. If this causes pain in the area of the
insertion of the supraspinatus tendon, acute or degenerative shoulder
tendinitis is suggested.
Shoulder apprehension test. If chronic shoulder dislocation is suspected,
slowly and gently abduct and externally rotate the patient's arm with the
elbow flexed toward a point where the shoulder might easily dislocate. If
shoulder dislocation exists, the patient will become quite apprehensive,
symptoms may be reproduced, and the maneuver is resisted as further motion
is attempted.
Shoulder depression test. With the patient sitting, the examiner stands behind
the subject and the patient's head is laterally flexed away from the side
being examined. The doctor stabilizes the patient's shoulder with one hand
and applies pressure alongside the patient's head with the palm of the
other hand; stretching the dural root sleeves and nerve roots or
aggravating radicular pain if the nerve roots adhere to the foramina.
Extravasations, edema, encroachments, and conversion of fibrinogen into
fibrin may result in interfascicular, foraminal, and articular adhesions
and inflammations that will restrict fascicular glide and the ingress and
egress of the foraminal contents. Thus, pain and reduplication of other
symptoms during the test suggest adhesions between the nerve's dura sleeve
and other structures around the IVF.
Sicard's sign. During Lasegue's SLR test, the limb is lowered slightly to a
point just below the level of pain, the examiner then dorsiflexes the big toe to induce traction on the sciatic nerve. Pain arising in the
posterior thigh or calf indicates sciatic radiculopathy.
Simmond's test. The patient is placed prone and the knee is flexed to a right
angle. The examiner grasps the center of the leg with both hands and
applies strong pressure so that the calf muscles are squeezed against the
tibia and fibula. Normally, the foot will plantarflex slightly; if not, a
ruptured Achilles tendon is indicated. This test is a common variant of
Thompson's test.
Slocum's test. This is a modification of McIntosh's test. The patient is
placed in the lateral recumbent position with the involved knee uppermost.
The under extremity is flexed at 90° at both the hip and knee. The pelvis
is rotated slightly posterior about 30°, and the weight of the extremity
is supported by the inner aspect of the foot and heel. This position
causes valgus stress at the knee and a slight internal rotation of the
leg. The examiner then grips the distal thigh with one hand and the
proximal leg with the other hand and presses back of the fibula and
femoral condyle with the thumbs. The knee is then gently pushed from
extension into flexion and, as the iliotibial tract passes behind the
transverse axis of rotation at about 35°, the lateral tibial plateau,
which has subluxated forward, is reduced with a palpable "clunk" or
"giving way" sensation.
Smith-Peterson test. If it is possible during Goldthwait's test to raise the
limb on the unaffected side to a greater level without pain than the
involved side, a positive Smith-Peterson sign is found, which confirms a
sacroiliac lesion; ie, pain usually occurs at the same level for either
leg when a lumbosacral lesion is present.
Snellen's test. The common visual acuity test in which the patient attempts to
read a chart composed of rows of letters of decreasing size that is placed
at a specific distance from the subject.
Soto-Hall test. This test is primarily employed when fracture of a vertebra is
suspected. The patient is placed supine without pillows. One hand of the
examiner is placed on the sternum of the patient, and a slight pressure is
exerted to prevent flexion at either the lumbar or thoracic regions of the
spine. The other hand of the examiner is placed under the patient's
occiput, and the head is slowly flexed toward the chest. Flexion of the
head and neck upon the chest progressively produces a pull on the
posterior spinous ligaments from above, and when the spinous process of
the injured vertebra is reached, an acute local pain is experienced by the
patient.
Speech test. Articulation is a complex coordinated function involving the
cooperation of muscles supplied by the cranial V, VII, IX, and XII nerves.
Note whether the speech is clear, distinct, slurring, scanning, or
tremulous. Test phrases are used such as "truly rural" or "Methodist
Episcopal." The dysarthrias should be differentiated from the aphasias.
Spinal hyperextension tests. These two screening tests help in localizing the
origin of low back pain.
(2) With the patient remaining in the
relaxed prone position, the examiner stabilizes the patient's lower legs
and instructs the patient to attempt to extend the spine by lifting the
head and shoulders as high as possible from the table by extending the
elbows bilaterally. If localized pain occurs, the patient is then asked to
place a finger on the focal point.
Spurling's tests. With the patient in the seated position and the examiner
standing behind, the patient's head is rotated and laterally flexed to one
side. With the patient actively holding the head and neck in this
position, the examiner places a palm on the patient's scalp and vertically
strikes it moderately with the other fist. The patient's head is then
rotated and laterally flexed to the opposite side, and the test is
repeated. If these tests can be tolerated by the patient without undue
discomfort, the procedure is repeated with hyperextension added. In
radiculitis, sensitive spondylosis, IVD syndromes, and other inflammatory
or space-occupying conditions in or near the IVF or posterior facets, pain
will be increased by the induced compression.
Steinmann's sign. In meniscus disorders, tenderness moves posteriorly when the
knee is flexed and anteriorly when the knee is extended. This displaced
tenderness is said not to occur in degenerative osteoarthrosis.
Stenger's test. With the patient blindfolded, two tuning forks of the same
tone are simultaneously vibrated and placed about an inch from each ear.
The forks are then moved away from the ears. The tone is normally heard
equally in each ear from similar distances. If one ear is impaired, the
healthy ear will hear the tone at a greater distance.
Stereognosis test. This refers to the ability to sense form, nature, and
solidity of objects through the sense of touch; eg, familiar objects as
keys, coins, marbles, pencils, etc. Place different objects in either hand
when the patient's eyes are closed. Ask the patient to handle them and to
name them. Loss of the ability to recognize familiar objects occurs in
contralateral brain lesions in the parietal area.
Sternal compression test. Downward pressure is slowly applied against the
sternum of a supine patient. Sharp, localized pain arising laterally
suggests a fractured rib.
Strabismus Test. In testing for strabismus, the examiner stands about 2 feet
in front of the patient and shines a pen light at the patient's supranasal notch (between the eyebrows). The light will normally be reflected in each
eye nearly centered in each pupil. If the light is reflected at a
different point on each eye, it indicates strabismus.
Strunsky's test. This test is designed essentially for the recognition of
lesions of the metatarsal arch. Under normal conditions when the toes are
grasped and quickly flexed, the procedure is painless. Pain results if
there is any inflammatory lesion of the metatarsal arch. This test is
often positive in tendinitis of toe extensors.
Subacromial button sign. The examiner stands behind the sitting patient, cups
a palm over the involved shoulder, and applies finger pressure over the
subacromial bursa. If this produces pain or unusual tenderness,
subacromial bursitis is indicated.
Suprapatellar reflex. With the leg extended and the index finger of the
examiner crooked above the patella, a tap results in a kick-back of the
patella. Jendrassik's reinforcement maneuver may be necessary.
Supraspinatus press test. With the patient in the relaxed seated position, the
examiner applies strong thumb pressure directed toward the midline in the
soft tissues located superior to the midpoint of the scapular spine. The
production of pain signifies an inflammatory process in the supraspinatus
muscle (eg, strain, rupture, tendinitis).
Swallowing test. The sitting patient is asked to drink some water. If a
pharyngeal lesion is ruled out (eg, tonsillitis), painfully difficult
swallowing may suggest a space-occupying lesion at the anterior aspect of
the cervical spine (eg, abscess, tumor, osteophytes, etc).
Taste tests. Taste perception is tested by means of solutions of sour
(vinegar), sweet (sugar), and salty (salt) substances. It is good
procedure to arrange certain signals with the patient before the test is
made. For instance, holding up two fingers may mean that no taste is
recognized and three fingers may mean that a taste is recognized. Then the
applicator is dipped in the solution, and the patient is told to protrude
his tongue. Keep it protruded with the aid of a sterile pad, and apply a
solution to one side of the tongue. After the patient has signaled tasting
or not tasting, request that the flavor be named. The taste buds of the
anterior two-thirds of the tongue are supplied by the facial nerve, those
of the posterior third are supplied by the glossopharyngeal nerve. Thus,
the front, back, and each side of the tongue should be tested separately.
It is best to have the patient rinse his mouth with warm water after each
solution is used to avoid confusion between the solutions.
Teres spasm sign. When the relaxed standing patient is viewed from behind, the
arms normally rest so that the palms face the thighs. If a palm faces
distinctly backward (toward the examiner) on the involved side, a spastic
contraction of the teres major muscle is suggested.
Thermesthesia test. Thermesthesia (thermoesthesia) refers to the capability of
sensing and differentiating degrees of heat and cold. Areas of impaired
temperature differentiation follow a cutaneous pattern that is identical
to areas of impaired pain sensations. Fibers and cells serving the sensory
path for temperature perception follow the same course as those of the
pain pathway. The two systems are so closely associated in the CNS that
they can scarcely be distinguished anatomically, and an injury to one
affects the other to a similar degree. Thus, for most practical clinical
purposes, testing either pain or temperature sensibility accomplishes the
same result.
Thomas' test. This test is used to determine excessive iliopsoas tension. The
supine patient holds one flexed knee against his abdomen with his hands
while the other limb is allowed to fully extend. The patient's lumbar
spine should normally flatten. If the extended limb does not extend fully
(ie, the knee flexes from the table) or if the patient rocks his chest
forward or arches his back, a fixed flexion contracture of the hip is
indicated, as from a shortened iliopsoas muscle. This should always be
tested bilaterally. Some examiners use the degree of pain elicited on
forceful extension of the flexed knee as their criterion of iliopsoas
tension.
Thompson's test. To detect a rupture of the Achilles tendon, the patient
kneels on a chair with the feet extended over the edge. The middle third
of the calf is squeezed. If the Achilles tendon is ruptured, especially
the soleus portion, the squeeze will not cause the normal plantar flexion
response.
Tinel's elbow test. The groove between the olecranon process and the medial
epicondyle is percussed. A hyperactive response indicates an irritable
lesion of the ulnar nerve (eg, neuritis, neuroma).
Tinel's foot test. With the patient prone and the knee flexed to a right
angle, the posterior tibial nerve is percussed as it passes behind the
lateral malleolus. If this induces paresthesias in the foot, tarsal tunnel
syndrome is suggested.
Tinel's sign. Normally, percussion of a nerve above or below a point of
complete severance elicits no subjective sensations. In cases of partial
severance or in cases of compression of this given peripheral nerve where
some conduction is preserved, percussion distal to the involvement will
elicit a tingling paresthesia below the point of tapping. This represents
a positive Tinel's sign. This sign, if positive, is also indicative of
nerve regeneration if it is elicited over a nerve that had previously been
negative on percussion. In this respect, it may have prognostic as well as
diagnostic value.
Tinel's wrist test. The hand of a sitting patient is supinated, and the volar
surface of the wrist is percussed. If this induces pain in all fingers
except the first digit, carpal tunnel syndrome is indicated.
Toe-in sign. Excessive toe-in, especially in children, may be the result of
excessive internal rotation of the tibia caused by a fixed point at either
end of the tibia. Common points of fixation are at the malleoli in the
ankle or the tibial tubercle below the knee. The ankle mortise normally
faces 15° externally; in internal tibial torsion, the ankle mortise faces
anteriorly or internally.
Toe-to-finger test. The supine patient attempts to touch the examiner's finger
with the great toe as the examiner moves the finger to different
stationary positions that can easily be reached. Inability or severe
awkwardness in performing this test indicates a proprioceptive defect from
either a posterior column or cerebellar lesion.
Toe walk test. Walking for several steps on the base of the toes with the
heels raised will normally produce no discomfort to the patient. With the
exception of a localized forefoot disorder (eg, plantar wart, neuroma) or
an anterior leg syndrome (eg, shin splints), an inability to do this
because of low back pain or weakness can suggest an S1–S2 lesion.
Toynbee maneuver. The patient swallows while the nose and lips are firmly
closed. It is a mild test compared to the Valsalva maneuver in seeking
signs of eustachian tube obstruction.
Traction test. With the patient sitting and the arm held in the anatomical
position, the radial pulse is determined while traction is firmly applied
to the patient's wrist. If a decreased pulse is found on one side but not
the other, a thoracic outlet disorder may be suspected on the side of the
decreased pulse.
Trendelenburg's hip test. If the hip and its muscles are normal, the iliac
crest and sacral dimple will be slightly low on the weight-bearing side
and high on the leg-elevated side when one leg is lifted. To test, have
the patient with a suspected hip involvement stand on one foot, on the
side of involvement, and raise the other foot and leg in hip and knee
flexion. If there is hip joint involvement and muscle weakness, the iliac
crest and sacral dimple will be markedly high on the standing side and low
on the side the leg is elevated. A positive sign suggests that the gluteus
medius and minimus muscles on the supported side are weak. The gait will
exhibit a characteristic lurch to counteract the imbalance caused by the
descended hip. The sign is also commonly positive in a developing
Legg-Calve-Perthe's disease, poliomyelitis, muscular dystrophy, coxa vara,
Otto's pelvis, epiphyseal separation, pathology of the superior gluteal
nerve, coxa ankylosis, hip dislocation, fracture, or chronic subluxation
of L4, L5, or the sacral base.
Triceps reflex. The patient's arm should be relaxed and flexed at the elbow.
Support the elbow and tap the triceps tendon where it crosses the
olecranon fossa, observing the same phenomena as in the biceps reflex. The
triceps reflex tests C6 C8 segments and the radial nerve. Upper extremity
reflexes are often diminished in healthy patients.
Tripod sign. The patient is placed prone with the knees flexed over the edge
of the table as in Huntington's test, and active and passive muscle
strength and range of motion of knee extension are evaluated. If the patient must lean back (extend the trunk on the pelvis) and grasp the
table to support body weight on the arms when the knees are bilaterally
extended, hamstring spasm is indicated. This may be the result of any
lower motor irritation located between the midthoracic area and the lower
sacrum.
Trousseau's line sign. The production of a bright red line where the finger is
drawn across the trunk or forehead. It commonly occurs in meningitis.
Turgor test. This is a screening test to judge tissue hydration/collagen
content. First, the examiner lightly pinches and lifts the skin on the
back of the patient's hand with the thumb and forefinger. The suspended
skin is held taut for 30 seconds, released, and the area is observed. It
should quickly begin to flatten and be complete within 3–5 seconds (a
negative sign). If the area that has been pinched very gradually creeps
back to its normal state, the test is considered positive for probable
collagen deficiency and/or an associated sign of osteoporosis.
Two-point discrimination test. In impairment of the proprioceptive pathway,
there is loss of the normal ability to recognize two points simultaneously
applied to the skin as distinct from one single point. Normally, a patient
will be able to distinguish two points that are 2–3 mm apart on the
fingertips. If a lesion is located peripherally, the patient will not be
able to distinguish two points that are less than 5 mm apart. If a
cortical lesion is present, the patient will be unable to consistently
distinguish two points from one.
Ulnar stress sign. Pain arises over the lateral aspect of the wrist when the
examiner forces the patient's wrist into ulnar deviation, indicating
posttraumatic or pathology of the lateral wrist.
Ulnar tunnel triad. Hypothenar wasting, tenderness of the ulnar tunnel, and
flexion contracture of the ring finger are the three classic signs of
entrapment compression of the ulnar nerve in the tunnel of Guyon.
Unterberger's test. The patient is asked to stand with his upper limbs
outstretched, his eyes closed, and then to march in place about 50 times.
The examiner should stand close to the patient during the test because a
positive sign is a loss of balance. In vestibular lesions, the patient
will tend to slowly but continuously rotate towards the side of the
lesion. Many normal people can be expected to rotate once during the test,
and mostly to the left, but not more than 45° total. Some examiners add
additional stress during the test by having the patient extend and rotate
the neck 45°. If this procedure is used, 30 steps in place is usually
sufficient for evaluation.
Uvular reflex. The patient is asked to open his mouth and say "Ah." Raising of
the uvula (uvular reflex) in phonation or from irritation is absent in
disorders of the cranial IX or X nerves. It is important to make this test
with the patient's head in the midline and not turned to the side.
Vanzetti's sign. In sciatica, the pelvis tends to maintain a horizontal
position despite any induced degree of scoliosis, unlike other conditions
in which scoliosis occurs where the pelvis is tilted.
Vertebrobasilar artery maneuvers.
(2) If palpatory and
auscultory signs are negative in the neutral position, the patient is
asked to slowly rotate and hyperextend the neck first in one direction and
then the other to place a motion-induced compression on the vertebral
arteries. Positive signs include faintness, nausea, nystagmus, vertigo,
and/or visual blurring. Also see Maigne's test, DeKleyn's test, Hautant's
test, and Unterberger's test.
Vincent's sign. See Argyll Robertson sign.
Visual-fixation reflex. This normal reflex is demonstrated by an auto passenger
looking out a side window at the passing scenery. The head and eyes turn
slowly in the direction of apparent movement and then jump ahead quickly
to fix the gaze on a new approaching site. This is done without conscious
effort or awareness that the eyes are moving: a true optokinetic reflex.
This reflex is also demonstrated and tested as in reading from line to
line, which normally presents a combination of jerky eye movements
interspaced with pauses.
Von Graefer's sign. This pathologic sign is seen when the upper lids do not
readily follow the cornea when the eyes are lowered, and the upper
movement occurs in a jerky manner. It is caused by the same etiology as
Dalrymple's sign, hypertonia of the levator muscles.
Walking test. The patient is instructed to close the eyes and take two steps
forward and two steps backward several times. If a labyrinthine
disturbance exists, the patient will turn gradually to the involved side.
Weber's test. To test for deafness and lateralization, the base of a vibrating
tuning fork is placed in the center of the forehead at the hairline and
the patient is asked if the tone is heard better in one ear than the
other. Normally, the tone is heard equally in both ears.
Westphal's sign. This term has been used to represent loss of any deep reflex,
thus indicative of lower motor neuron involvement. It is especially
applied to loss of the patellar-quadriceps reflex.
Williamson's sign. Definite lessening of blood pressure in the leg as compared
with the pressure of the ipsilateral arm in pneumothorax.
Wilson's sign. The patient is placed supine with the legs in an extended,
relaxed position. This is a two-phase test:
(2) However, if the leg is then externally rotated, the pain will subside.
Wrist clonus. This refers to a spasmotic contraction of the muscles of the hand
induced by forcibly bending the hand backwards.
Wrist drop sign. The two opposing palms are placed together with the hands in
dorsiflexion. On separation, failure to maintain dorsiflexion indicates a
positive test and is significant of radial nerve impairment.
Wrist flexion/extension stress tests. The examiner moves the wrist firmly into
flexion and extension. If pain is induced, wrist fracture, subluxation,
sprain, acute tendinitis, or pathology are suggested. If negative, the
movements are repeated against patient resistance. Induced pain then
indicates wrist strain, rupture, acute or chronic tendinitis, or
pathology.
Wrist tourniquet test. A sphygmomanometer cuff is wrapped around the suspected
wrist, inflated to a point slightly above the patient's systolic blood
pressure, and maintained for 1–2 minutes. An increase in forearm, wrist,
or hand pain indicates carpal tunnel syndrome.
Yergason's test. The patient flexes the elbow, pronates the forearm, and
attempts elbow flexion, forearm supination, and humeral external rotation
against the resistance of the examiner. The doctor stabilizes the
patient's elbow with one hand while offering resistance to the patient's
distal forearm with his other hand during the maneuver. Severe pain in the
shoulder during this test is usually a positive indication of a bicipital
tendon lesion, a tear of the transverse humeral ligament, or bicipital
tendinitis.
Note: The descriptions within the preceding glossary of clinical signs and
tests have been reproduced with permission for this edition; (C) 1985, R.C.
Schafer, D.C.
A Physical Examination Routine
Table 3.3 offers an outline of examination procedures carried out in
clinical practice. (see Table 3.3 at the end of the Chapter) While vital signs, color blindness examination, and visual acuity tests can be conducted by a trained assistant, other procedures are
usually performed by the examining chiropractic physician. On first observation, the listing appears time consuming; however, in actual practice the full examination seldom exceeds 30 minutes because most tests require only a few seconds and the positions smoothly evolve through standing, sitting, supine, side-lying, prone, Sims', knee-chest, and lithotomy positions, and then conclude with final upright and sitting examinations.
During the examination, it is important to consider the general physical and mental condition of the patient. Care should be given not to create anxiety and to hold orthopedic maneuvers within the tolerance of the individual being examined, ever keeping in mind the possibility of underlying pathologic conditions such as fracture, osteoporosis, atherosclerosis, and
other degenerative changes associated with the aging process.
GERIATRIC CONSIDERATIONS
(2) To collect clinical data by which
judgments may be made that a health problem exists.
(3) To establish etiologic
possibilities; particularly as they relate to chiropractic management and as a
prerequisite to roentgenographic evaluation.
Rather than being a separate clinical specialty, as the term might imply,
chiropractic clinical geriatrics is an integral part of chiropractic general
practice dealing with the elderly patient; the evaluation of the general
health status to advise on proper adaptation to the aging process, and the
evaluation of any specific health problems that may be evident and in need of
attention —either by routine chiropractic methods or by referral to other
health-care practitioners.
With respect to these clinical objectives, it is necessary that a routine
office-oriented case history and examination be conducted on all older
patients at the time of their initial visit and at periodic intervals of no
longer than a year thereafter, regardless of the specific entrance complaint.
This routine case history and physical examination should also be supplemented
by laboratory, roentgenographic, and other special studies when indicated.
With special concern for those aspects of chiropractic clinical geriatrics
that deal with the Medicare patient, it is emphasized that present
chiropractic services are confined to ascertaining spinal subluxations and
their manual correction. Since it is judged to be an imprudent practice to
expose patients to the harmful effects of ionizing radiations, unless such
procedures are clinically justified beforehand, then the case history and
physical examination must be considered the appropriate means by which this
justification is accomplished. Therefore, in regards to the objectives of
chiropractic clinical geriatrics, the determination that a subluxation is
clinically evident is a paramount concern of the case history and physical
examination, particularly as these objectives relate to Medicare procedure.
For purposes of further clarification, the chiropractic subluxation is a
"biomechanical-pathophysiologic cause-and-effect syndrome" that has profound
and far-reaching clinical implications. From the causative viewpoint, two
major categories should be considered:
From the effect (the result of the cause) standpoint, the subluxation may
be clinically manifested in one or more of three major categories:
(2) Local
circulatory changes that may result in edema, hyperemia, or ischemia.
(3)
Meningeal irritations or mechanical pressure on the dural-root sleeve that may
result in abnormal motor or sensory disturbances.
(4) Mechanical alterations
in the circulation of cerebrospinal fluid.
(5) Proprioceptive stimulation as a
result of stress on the interosseous soft tissues, which may initiate motor
responses in the muscles of the spinal column, somatovisceral reflexes, or
sensory interpretation of pain.
No single test or procedure can be taken at face value as a positive
indication of a specific disease entity; but when a "pattern" of signs
develops on the basis of "overlapping" positive signs, clinical judgments of a
particular health problem requiring roentgenographic or other evaluation may
be made. Most neurologic tests are indicative; most orthopedic tests are
suggestive.
PEDIATRIC CONSIDERATIONS
The following list shows normal cranial and thoracic circumference
measurements in inches from birth to 5 years: Age Head Thorax
Birth 13.7 13.7
2 mo. 15.8 15.3
4 mo. 16.8 16.7
6 mo. 17.4 17.2
1 yr. 18.4 18.3
2 yr. 19.2 19.4
3 yr. 19.6 20.3
4 yr. 20.0 21.0
5 yr. 20.3 21.7
Developmental Progress
The following list shows selected normals for motor, language, and social skills related to an average age from 1 to 6 years:
Skill Avg. Age
Regards face 1.0 mo.
Visually follows finger to midline 1.3 mo.
Responds to bell 1.6 mo.
Head up, prone 3.2 mo.
Laughs 3.3 mo.
Puts hands together 3.7 mo.
Visually follows finger 180~ 4.0 mo.
Grasps small objects 4.2 mo.
Sits, head steady 4.2 mo.
Arm support 4.3 mo.
Squeals 4.5 mo.
Rolls over 4.7 mo.
Smiles spontaneously 5.0 mo.
Reaches for objects 5.0 mo.
Bears some weight on legs 6.3 mo.
Learns to chew 6.5 mo.
Looks for familiar objects 7.5 mo.
Accepts objects in hands 7.5 mo.
Pulls to sitting position 7.7 mo,
Sits without support 7.8 mo.
Feeds self a cracker, cookie 8.0 mo.
Turns toward spoken voice 8.3 mo.
Plays "peek-a-boo" 9.7 mo.
Says "dada" and "mama" 10.0 mo.
Resists toy pull 10.0 mo.
Pulls to standing position 10.0 mo.
Thumb-finger grasp 10.6 mo.
Stands briefly, no support 13.0 mo.
Plays "pat-a-cake" 13.0 mo.
Walks forward 13.3 mo.
Indicates desires without crying 14.3 mo.
Drinks from cup 14.3 mo.
Imitates housework 19.5 mo.
Towers two blocks 20.0 mo.
Speaks three words 20.5 mo.
Walks backward 21.5 mo.
Removes garment without help 21.9 mo.
Combines two words 23.0 mo,
Helps with simple tasks 23.5 mo.
Uses spoon 23.5 mo.
Kicks ball 2.0 yr.
Scribbles 2.1 yr.
Towers four blocks 2.2 yr.
Names a picture 2.5 yr.
Throws a ball 2.6 yr.
Puts on shoes, untied 3.0 yr.
Rides tricycle 3.0 yr.
Washes and dries hands 3.2 yr.
Uses plurals in speech 3.2 yr,
Towers eight blocks 3.4 yr.
Dresses self with help 3.5 yr.
Plays tag 3.5 yr.
Gives first and last name 3.8 yr.
Buttons-up clothing 4.2 yr.
Copies letters "O" and "X" 4.4 yr.
Recognizes three colors 4.9 yr.
Hops on one foot 4.9 yr.
Dresses without help 5.0 yr.
Draws a square 5.0 yr.
Draws three-part person 5.2 yr.
Catches ball 5.5 yr.
Defines six words 6.3 yr.
Height Estimation During Development
The following list shows a means to estimate probable height at maturity
during development. Multiply child's height in inches by 100 and divide by the
percentage figure listed at the right.
Percent of Mature Height Anticipated
Age Males Females
1.0 mo. 32.4 30.2
2.0 mo. 34.5 32.4
3.0 mo. 36.0 33.9
4.0 mo. 37.5 35.2
5.0 mo. 38.8 36.5
6.0 mo. 39.8 37.7
7.0 mo. 40.7 38.4
8.0 mo. 39.2 41.8
9.0 mo. 40.1 42.2
10.0 mo. 40.8 43.1
11.0 mo. 41.5 44.1
1.0 yr. 42.2 44.7
1.3 yr. 44.0 46.9
1.5 yr. 45.6 48.8
2.0 yr. 48.6 52.2
2.5 yr. 51.1 54.8
3.0 yr. 53.5 57.2
3.5 yr. 55.6 59.5
4.0 yr. 57.7 61.8
5.5 yr. 59.8 64.0
5.0 yr. 61.6 66.2
5.5 yr. 63.4 68.2
6.0 yr. 65.3 70.3
6.5 yr. 67.1 72.0
7.0 yr. 69.1 74.3
7.5 yr. 70.7 75.9
8.0 yr. 72.4 77.6
8.5 yr. 74.0 79.4
9.0 yr. 75.6 81.2
9.5 yr. 77.2 83.1
10.0 yr. 78.4 84.8
10.5 yr. 79.8 86.9
11.0 yr. 81.3 88.7
11.5 yr. 82.5 90.8
12.0 yr. 84.0 92.6
12.5 yr. 85.4 94.7
13.0 yr. 87.3 96.0
13.5 yr. 89.2 97.2
14.0 yr. 91.0 98.3
14.5 yr. 92.6 98.7
15.0 yr. 94.6 99.3
15.5 yr. 96.0 99.4
16.0 yr. 97.1 99.5
16.5 yr. 98.0 99.6
17.0 yr. 98.8 99.7
17.5 yr. 99.3 99.8
18.0 yr. 99.6 99.9
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I. Vital Signs
1. Temperature 4. Blood pressure
2. Height 5. Pulse
3. Weight 6. Respiration
II. Standing Examination
7. Gait test 23. Tandem Romberg (eyes open)
8. General appearance 24. Tandem Romberg (eyes closed)
9. Minor's sign 25. Heel-to-knee
10. Position-holding test 26. Heel-to-shin
11. Adiachokinesia test 27. Heel walk
12. Patting with hands 28. Toe walk
13. Finger-to-finger (eyes open) 29. Adams position, anterior
14. Finger-to-nose (eyes open) 30. Adams position, posterior
15. Finger-to-finger (eyes closed) 31. Trendelenburg's hip test
16. Finger-to-nose (eyes closed) 32. Neri's bowing test
17. Romberg's position (eyes closed) 33. Lewin's standing test
18. Romberg's position (eyes open) 34. Kemp's test
19. Finger-to-doctor's finger (eyes 35. Quadratus lumborum muscle test
open) 36. Thoracic spine range of motion
20. Finger-to-doctor's finger (eyes 37. Lumbar spine range of motion
closed) 38. Serratus anterior muscle test
21. Pat doctor's hand (hands together) 39. Longissimus dorsi muscle test
22. Pat doctor's hand (right, left) 40. Spinous process percussion test
III. Sitting Examination
41. Cervical spine palpation 60. Gag reflex
42. Cervical range of motion 61. Tongue against tongue depressor
43. Libman's test 62. Pharyngeal reflex
44. Olfactory examination 63. Bite on tongue depressor
45. Otoscopic examination 64. Wink
46. Rhinoscopic examination 65. Smile
47. Ophthalmoscopic examination 66. Whistle
48. Ciliary reflex 67. Close eyelids
49. Accommodation to light (direct 68. Blow out cheeks
and indirect) 69. Weber's test
50. Accommodation to distance 70. Rinne's test
51. Ocular motion test 71. Pallesthesia test
52. Nystagmus check 72. Jaw (jack) jerk
53. Field of vision 73. Chvostek's test
54. Ciliospinal reflex 74. Jaw clonus test
55. Carotid sinus reflex 75. Pectoral reflex
56. Corneal reflex 76. Deltoid reflex
57. Thumb pressure on eyeballs 77. Scapulohumeral reflex
(oculocardiac reflex) 78. Scapular reflex
58. Tongue extension test 79. Biceps reflex
59. "Ah" reflex 80. Triceps reflex
Table 3.3, continued
81. Radial (periosteal) reflex 111. Radial nerve test — ability to
82. Ulnar (periosteal) reflex grasp objects
83. Hoffman's reflex 112. Radial nerve test — make a fist
84. Patellar reflex 113. Radial nerve test — ability to
85. Suprapatellar reflex oppose or flex thumb
86. Achilles reflex 114. Ulnar nerve test — claw hand
87. Bechterew's test 115. Ulnar nerve test — ability to
88. Quadriceps muscle test separate fingers
89. Piriformis muscle test 116. Dorsiflex hand (at wrist):
90. Popliteus muscle test No resistance
91. Cervical compression test Against resistance
92. Shoulder shrug test: 117. Palmarflex hand (at wrist):
No resistance No resistance
Against resistance Against resistance
93. Upper trapezius muscle test 118. Radial deviation of hand (wrist):
94. Adson's test No resistance
95. Allen's test Against resistance
96. Wright's test 119. Ulnar deviation of hand (wrist):
97. Shoulder depression (costoclavic- No resistance
ular syndrome) Against resistance
98. Shoulder depression (neurologic 120. Individual finger range motion
test) 121. Individual finger stretch
99. Dugas' test 122. Hoffman's reflex recheck
100. Yergason's test 123. Pinwheel examination
101. Mills' test 124. Cotton ball (sensory examination)
102. Hand-patting recheck 125. Two-point discrimination
103. Biceps muscle strength test 126. Stereognosis test
104. Triceps muscle strength test 127. Barognosis test
105. Holmes' rebound test 128. Trousseau's test
106. Froment's sign 129. Naffziger's test (Valsalva stress)
107. Finkelstein's test 130. Naffziger's test (patient coughing)
108. Wrist clonus 131. Spinal percussion
109. Radial nerve test — ability to 132. Spinal motion palpation
extend thumb 133. Cardiopulmonary systems exam.
110. Radial nerve test — wrist drop 134. Cervical range of motion
IV. Supine Examination
135. Lindner's test 146. Heel-to-knee test
136. Beevor's test 147. Heel-to-shin test
137. Soto-Hall test 148. Toe-to-doctor's hand test
138. Teres minor muscle test 149. Lasegue's test (S-L-R)
139. Pectoralis major muscle test, 150. Bragard's test
sternal division 151. Fajersztajn's test
140. Pectoralis major muscle test, 152. Lasegue's rebound test
clavicular division 153. Goldthwait's test
141. Serratus anterior muscle test 154. Kernig's test
142. Pectoralis minor muscle test 155. Thomas' test
143. Anterior neck flexors muscle test 156. Patrick's test
144. Sternocleidomastoideus muscle test 157. Gauvain's test
145. Lewin's supine test 158. Laguere's test
Table 3.3, continued
159. Allis' knee test 186. Epigastric reflex
160. Anterior drawer test 187. Abdominal reflex, superficial
161. Posterior drawer test 188. Abdominal reflex, deep
162. McMurray's test 189. Graphesthesia test
163. Psoas muscle test 190. Sensory neurologic examination:
164. Sartorius muscle test Pinwheel
165. Tensor fascia lata test Pin
166. Hoover's test Ring reflex (variant)
167. Homan's test Two-point discrimination
168. Ankle clonus Brush
169. Schaeffer's test Thermesthesia
170. Gordon's test 191. Cardiopulmonary system recheck
171. Patellar clonus 192. Check circulatory system:
172. Dorsiflexion of foot: Carotids
No resistance Abdominal aorta
Against resistance Femoral artery pulse
173. Plantar flex foot: Popliteal artery pulse
No resistance Dorsal pedis artery pulse
Against resistance Posterior tibial artery pulse
174. Dorsiflex great toe: Compare popliteal to posterior
No resistance tibial pulse
Against resistance Compare popliteal to dorsal pedis
175. Plantar flex great toe: pulse
No resistance 193. Auscultate abdomen
Against resistance 194. Palpate abdomen, knees straight
176. Babinski's plantar reflex 195. Palpate abdomen, knees flexed
177. Rossolimo's reflex 196. Check general strength of lower
178. Oppenheim's reflex extremities
179. Chaddock's ankle reflex 197. Anterior abdominal muscle tests
180. Hirschberg's test 198. Gaenslen's test
181. Mendel-Bechterew's test 199. Mensuration
182. Achilles reflex 200. Range of motion examination
183. Patellar reflex 201. Oscilometer examination
184. Hamstring reflex 202. Laryngoscopic examination
185. Gonda reflex
V. Lateral Recumbent Examination
203. Ober's test 206. Gluteus medius muscle test
204. Compression of iliac crests 207. Adductor muscle test
205. Gluteus minimus muscle test
VI. Prone Examination
208. Mennell's test 216. Gracilis muscle test
209. Hibb's test 217. Inner hamstring muscle test
210. Nachlas' test 218. Outer hamstring muscle test
211. Yeoman's test 219. Gluteus maximus muscle test
212. Ely's heel-to-buttock test 220. Hyperextension muscle test
213. Quadratus lumborum muscle test 221. Posterior neck extensors muscle
214. Gastrocnemius muscle test test: posterior, right, left
215. Soleus muscle test
Table 3.3, continued
222. Lower trapezius muscle test 230. Sensory examination of the back:
223. Middle trapezius muscle test Pinwheel
224. Rhomboid major and minor muscle Two-point discrimination
test Sharp
225. Levator scapulae muscle test Dull
226. Teres major muscle test Cotton ball
227. Palpation Thermesthesia
228. Spinous process percussion Pallesthesia
229. Achilles' reflex recheck Graphesthesia
VII. Sims' Position Examination
231. Rectal examination: 232. Rectal examination: anoscopic (if
Rectal surface patient is prepared)
Prostate or uterus 233. Anal reflex
VIII. Knee-Chest Position Examination
234. Babinski's reflex recheck 236. Sigmoidoscopic examination (if
235. Achilles' reflex recheck patient is prepared)
IX. Lithotomy Position Examination
237. Gynecologic pelvic examination
X. Upright Examination
238. Rupture check 242. Cremasteric reflex
239. Testis, epididymis, vas check 243. Mensuration
240. Scrotum palpation 244. Color blindness examination
241. Penis inspection 245. Snellen eye chart examination
XI. Sitting Examination
246. Spirometer examination 247. Tonometer examination (if legal)
XII. Other Clinical Examinations
248. Electrocardiography 251. Laboratory
249. Roentgenography 252. Electromyography
250. Thermography