Many musculoskeletal abnormalities can be evaluated and diagnosed by special testing. History and physical examination are the corner stones of a proper diagnosis. History will contribute up to 80% to the diagnosis, followed by physical examination (6%) and tests (14%). Many musculoskeletal abnormalities can be evaluated and diagnosed by special testing.
Adson’s Test is used for for detecting Thoracic Outlet Syndrome.
Adson’s maneuver is a test looking for the reduction or obliteration of the radial artery pulse with compression at the interscalene triangle. The examiner extends and rotates the patient’s shoulder with the arm at the patient’s side. The cervical spine is then rotated so that the patient’s chin faces the hand on the examined side. The patient is then asked to inspire deeply and hold her breath. With deep inspiration, the subclavian artery may be compressed between the pectoralis minor muscle and the chest wall.
Anterior Drawer Sign
The Anterior Drawer Sign is used to detect cruciate ligament injury in flexion.
The knee is flexed to 90 degrees and the foot rested on the table. The femur is grasped with one hand while the tibia is pulled forward and the amount of excursion noted. In normal subjects no forward movement is elicited.
Apley’s Tests are helpful in the diagnosis of a torn meniscus.
The patient will lie prone on the examining table with one leg flexed to 90 degrees. While pushing down on the foot rotate the knee medially or laterally. Pain on either side will indicate a meniscal tear.
Finkelstein’s Test is used to diagnose tenosynovitis of the abductor pollicis longus and extensor pollicis brevis.
Instruct the patient to make a fist, with the thumb tucked inside of the other fingers. Stabilize the forearm with one hand and deviated the wrist to the ulnar side. If there is sharp pain in the area of the tendons, there is strong evidence for tenosynovitis.
Froment’s Sign is used for testing median nerve dysfunction.
To perform the test, a patient is asked to hold an object, usually a flat object such as a piece of paper, between their thumb and index finger (pinch grip). The examiner then attempts to pull the object out of the subject’s hands.
Gaenslen’s Test is used for detection of sacroiliac joint abnormalities.
The patient will lie supine on the examining table with both legs drawn to the chest. Then shift the patient to the side of the table so that one buttock extends over the edge while the other remains on it. Allow the unsupported leg to drop over the edge while the other leg remains flexed. SI joint abnormalities will elicit pain of the stressed joint.
Godfrey’s test is used for evaluation of posterior cruciate ligament (PCL) injury.
The examiner raises the patient’s foot (hips and knees flexed 90 degrees) and views the tibial tubercle from the side. Posterior sagging of the tibia relative to the femur indicates significant PCL injury and the need for orthopedic evaluation.
Hawkins Test is used to evaluate rotator cuff injury.
In the test for the Hawkins sign, the patient flexes the humerus forward to 90 degrees. The examiner places the shoulder in horizontal adduction and internal rotation. Pain is caused by cuff abrasion on the coracoacromial ligament and indicates impingement.
Ischemic Forearm Testing
Metabolic myopathies are rare disorders. Before considering an EMG and muscle biopsy ischemic forearm testing will help in establishing the correct diagnosis.
Ischemic forearm testing is an extremely valuable tool in the diagnosis of metabolic myopathies. These include:
- Glycogen storage diseases
- Myodenylate deaminase deficiency
- Clinical muscle examination may be un-revealing
- Muscle strength is often normal
- Muscle enzymes may only be elevated during symptomatic periods
- Electromyograms are frequently normal or demonstrate unspecific changes
- Immunohistochemistry, biochemical assays, and molecular analysis will allow a definitive diagnosis
The test is performed by contracting the forearm to fatigue with a blood pressure cuff inflated to greater than systolic pressure. Antecubital blood samples for lactate and ammonia are collected before and following exercise at 0, 1, 2, 5, and 10 minutes. Ischemia blocks oxidative phosphorylation and ensures dependence on anaerobic glycogenolysis lactate normally rises at least fourfold within 1 to 2 minutes of exercise ammonia rises fivefold within 2 to 3 minutes.
Lactate Concentration Testing
Lactate concentration will rise several-fold under ischemic conditions in normal subjects (o-o-o). There will be no or minimal rise in patients with myophosphorylase deficiency (McArdle’s disease)
In myoadenylate deaminase deficiency, ammonia (NH3) levels will show a delayed rise with lower maximal concentrations compared to normal controls.
Lachman test is used to evaluate cruciate ligament injury in extension.
The Lachman Test should be performed if the knee, after an acute injury, cannot flex to 90 degrees.
The femur is grasped with one hand while the tibia is pulled forward and the amount of excursion noted. In normal subjects, no forward movement is elicited.
31P Magnetic Resonance Spectroscopy
Metabolic myopathies can be detected by this non-invasive method.
McMurray Test is used to evaluate knee meniscal injuries.
The knee is flexed to 90 degrees; then foot is grasped and rotated internally or externally. The leg is then slowly extended while applying valgus stress. If an audible or palpable click is noted there is probably a tear of the medial meniscus present. This finding can be supported by pain of the medial knee joint line.
Neer Sign is used to assess rotator cuff injury.
To test for the Neer impingement sign, the examiner elevates the humerus with one hand while depressing the scapula to restrict movement with the other. Pain at greater than 120 degrees of forward flexion constitutes a positive result.
Patrick’s Test (aka Fabere test)
Patrick’s test is used to detect pathology in the hip as well as the sacroiliac joint.
The patient will lie supine on the examining table. Place the foot of his involved side on the opposite knee. Pain in the inguinal area indicates hip disease. To stress the sacroileac joint, extend the range of motion by pushing on the flexed knee as well as on the superior ileac spine of the opposite side. Pain in the sacroileac joint line indicates abnormalities.
Spurling Sign is used for evaluation of cervical spine radiculopathy.
The patient laterally bends the neck to each side while maintaining a posture of cervical extension. Pain intesified with ipsilateral bending strongly suggests a diagnosis of radiculopathy. Pain with contralateral bending suggests a musculo-ligamentous origin.
Steinberg Test is used for the clinical evaluation of Marfan patients.
Instruct the patient to fold his thumb into the closed fist. This test is positive if the thumb tip extends from palm of hand.
Walker-Murdoch Sign is used for the evaluation of patients with Marfan syndrome.
Instruct the patient to grip his wrist with his opposite hand. If thumb and fifth finger of the hand overlap with each other, this represents a positive Walker-Murdoch sign.
Wartenberg’s Sign is used for evaluation of median nerve dysfunction.
This test is a neurological sign consisting of abduction of the fifth finger, caused by unopposed ulnar insertion of the extensor digiti quinti
Wright’s Test is used for evaluation of Thoracic Outlet Syndrome.
Wright’s maneuver is carried out by abducting the shoulder of the patient and externally rotating the humerus with the head and chin in neutral position. The Wright’s test is positive if there is a reproduction of the patient’s symptoms with ablation of the radial pulse. It has been estimated, however, that in up to 30% of normal controls there is a decreased pulse in this position.
Yergason Test is used for testing of biceps tendon stability in bicipital groove in evaluation of a biceps tendon injury.
The elbow is flexed to 90 degrees, the patient is asked to resists while externally rotating the arm. A positive test result is indicated by a snap and pain when the biceps tendon slips over the lesser tubercle.