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# Netter's Orthopaedic Clinical Examination

## An Evidence-Based Approach

THIRD EDITION

Joshua A. Cleland, PT, DPT, PhD

Professor, Physical Therapy Program

Franklin Pierce University

Manchester, New Hampshire

Shane Koppenhaver, PT, PhD

Lieutenant Colonel, Army Medical Specialist Corps

Associate Professor, U.S. Army–Baylor University

Doctoral Physical Therapy Program

Fort Sam Houston, Texas

Jonathan Su, PT, DPT, LMT

Captain, Army Medical Specialist Corps

Brigade Physical Therapist

2nd Stryker Brigade Combat Team, 25th Infantry Division

Schofield Barracks, Hawaii

Illustrations by Frank H. Netter, MD

Contributing Illustrators

Carlos A. G. Machado, MD

John A. Craig, MD

# Table of Contents

Cover image

Title Page

Copyright

Dedication

About the Authors

About the Artists

Foreword

Preface

Video Contents

1 The Reliability and Diagnostic Utility of the Orthopaedic Clinical Examination

Reliability

Diagnostic Accuracy

Confidence Intervals

Pretest and Posttest Probability

Calculating Posttest Probability

Assessment of Study Quality

Summary

References

2 Temporomandibular Joint

Clinical Summary and Recommendations

Anatomy

Patient History

Diagnostic Criteria for TMD

Physical Examination Tests

Outcome Measures

Appendix

References

3 Cervical Spine

Clinical Summary and Recommendations

Anatomy

Patient History

Physical Examination Tests

Outcome Measures

Appendix

References

4 Thoracolumbar Spine

Clinical Summary and Recommendations

Anatomy

Patient History

Physical Examination Tests

Outcome Measures

Appendix

References

5 Sacroiliac Region

Clinical Summary and Recommendations

Anatomy

Patient History

Physical Examination Tests

Outcome Measures

Appendix

References

6 Hip and Pelvis

Clinical Summary and Recommendations

Anatomy

Patient History

Physical Examination Tests

Outcome Measures

Appendix

References

7 Knee

Clinical Summary and Recommendations

Anatomy

Patient History

Physical Examination Tests

Outcome Measures

Appendix

References

8 Foot and Ankle

Clinical Summary and Recommendations

Anatomy

Patient History

Physical Examination Tests

Outcome Measures

Appendix

References

9 Shoulder

Clinical Summary and Recommendations

Anatomy

Patient History

Physical Examination Tests

Outcome Measures

Appendix

References

10 Elbow and Forearm

Clinical Summary and Recommendations

Anatomy

Patient History

Physical Examination Tests

Outcome Measures

Appendix

References

11 Hand

Clinical Summary and Recommendations

Anatomy

Patient History

Physical Examination Tests

Outcome Measures

Appendix

References

Index

Diagnostic and Reliability Interpretation Keys

# Copyright

1600 John F. Kennedy Blvd.

Ste. 1800

Philadelphia, PA 19103-2899

NETTER'S ORTHOPAEDIC CLINICAL EXAMINATION: AN EVIDENCE-BASED APPROACH, THIRD EDITION ISBN: 978-0-323-34063-2

Copyright © 2016, 2011, 2005 by Elsevier Inc.

Previous editions copyrighted 2011, 2005 Saunders, an imprint of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Permission for Netter Art figures may be sought directly from Elsevier's Health Science Licensing Department in Philadelphia, PA: phone 1-800-523-1649, ext. 3276, or (215) 239-3276; or email H.Licensing@elsevier.com.

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

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Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

# Dedication

To our incredible mentors and colleagues who have fostered our passion for evidence-based practice and orthopaedics.

To our photography models (Jessica Palmer, Nicole Koppenhaver, and Farah Faize) and photographers (Sara Randall, Lindsey Browne, Jeff Hebert, and Patrick Moon) for spending more hours and retakes than we'd like to admit.

To Dr. Frank Netter and the Elsevier editorial staff who turned our ideas into a fantastic literary guide.

And, most important, to our wonderful families, whose sacrifices and support made this considerable endeavor possible.

# About the Authors

Joshua A. Cleland PT, DPT, PhD

Dr. Cleland earned a Master of Physical Therapy degree from Notre Dame College in 2000 and a Doctor of Physical Therapy degree from Creighton University in 2001. In February of 2006 he received a PhD from Nova Southeastern University. He received board certification from the American Physical Therapy Association as an Orthopaedic Clinical Specialist in 2002 and completed a fellowship in manual therapy through Regis University in Denver in 2005. Josh is presently a Professor in the Doctor of Physical Therapy Program at Franklin Pierce University. He practices clinically in outpatient orthopaedics at Rehabilitation Services of Concord Hospital, Concord, New Hampshire. Dr. Cleland is actively involved in numerous clinical research studies investigating the effectiveness of manual physical therapy and exercise in the management of spine and extremities disorders. He has published over 170 manuscripts in peer-reviewed journals and is an Editorial Review Board Member for the Journal of Orthopaedic and Sports Physical Therapy. He is currently an author/editor on 4 textbooks. Dr. Cleland is a well-known speaker both nationally and internationally. He is the recipient of the 2015 Rothstein Golden Pen Award for Scientific Writing, the 2011 Chattanooga Research Award, the 2009 Eugene Michels New Investigator Award, and the 2008 Jack Walker Award, all from the American Physical Therapy Association. In addition, he received the Rose Excellence in Research Award from the Orthopaedic Section of the American Physical Therapy Association in 2013, 2014, and 2015.

Shane Koppenhaver PT, PhD

Dr. Koppenhaver received his Master of Physical Therapy degree from the U.S. Army–Baylor University Graduate Program in 1998 and a PhD in Exercise Physiology from the University of Utah in 2009. He became board certified in Orthopedic Physical Therapy in 2001 and completed a fellowship in manual therapy through Regis University in 2009. Dr. Koppenhaver is a Lieutenant Colonel in the U.S. Army and an Associate Professor and Research Director in the U.S. Army–Baylor University Doctoral Program in Physical Therapy. He has published numerous studies on low back pain, spinal manipulation, and the use of ultrasound imaging in the measurement of muscle function. His primary research interests concern mechanistic and clinical outcomes associated with manual therapy and dry needling, especially as they apply to clinical reasoning and management of patients with neuromusculoskeletal conditions.

Jonathan Su PT, DPT, LMT

Dr. Su earned a Doctor of Physical Therapy degree from U.S. Army–Baylor University in 2013 and received board certification as a Sports Clinical Specialist from the American Physical Therapy Association in 2015. Dr. Su is a Captain in the U.S. Army embedded with the 2nd Stryker Brigade Combat Team, 25th Infantry Division, and serves as the unit's subject matter expert on human performance optimization, rehabilitation/reconditioning, and injury prevention. He operates a direct access sports/orthopaedic physical therapy clinic and advises key leaders on the design and implementation of physical training programs to maximize combat readiness for the unit's 4,400 soldiers. Dr. Su was inducted as an Honorary Member of the U.S. Army's 14th Infantry Regiment in 2015 for his contributions to soldier wellness and performance. His primary interest is in translating research into clinical practice to ensure the highest quality care.

# About the Artists

Frank H. Netter MD

Frank H. Netter was born in 1906 in New York City. He studied art at the Art Students League and the National Academy of Design before entering medical school at New York University, where he received his medical degree in 1931. During his student years, Dr. Netter's notebook sketches attracted the attention of the medical faculty and other physicians, allowing him to augment his income by illustrating articles and textbooks. He continued illustrating as a sideline after establishing a surgical practice in 1933, but he ultimately opted to give up his practice in favor of a full-time commitment to art. After service in the United States Army during World War II, Dr. Netter began his long collaboration with the CIBA Pharmaceutical Company (now Novartis Pharmaceuticals). This 45-year partnership resulted in the production of the extraordinary collection of medical art so familiar to physicians and other medical professionals worldwide.

In 2005, Elsevier, Inc. purchased the Netter Collection and all publications from Icon Learning Systems. More than 50 publications feature the art of Dr. Netter and are available through Elsevier, Inc. (in the US: www.us.elsevierhealth.com/Netter and outside the US: www.elsevierhealth.com).

Dr. Netter's works are among the finest examples of the use of illustration in the teaching of medical concepts. The 13-book Netter Collection of Medical Illustrations, which includes the greater part of the more than 20,000 paintings created by Dr. Netter, became and remains one of the most famous medical works ever published. The Netter Atlas of Human Anatomy, first published in 1989, presents the anatomical paintings from the Netter Collection. Now translated into 16 languages, it is the anatomy atlas of choice among medical and health professions students the world over.

The Netter illustrations are appreciated not only for their aesthetic qualities, but, more important, for their intellectual content. As Dr. Netter wrote in 1949, ". . . clarification of a subject is the aim and goal of illustration. No matter how beautifully painted, how delicately and subtly rendered a subject may be, it is of little value as a medical illustration if it does not serve to make clear some medical point." Dr. Netter's planning, conception, point of view, and approach are what inform his paintings and what makes them so intellectually valuable.

Frank H. Netter, MD, physician and artist, died in 1991.

Learn more about the physician-artist whose work has inspired the Netter Reference collection: <http://www.netterimages.com/artist/netter.htm>.

Carlos A.G. Machado MD

Carlos Machado was chosen by Novartis to be Dr. Netter's successor. He continues to be the main artist who contributes to the Netter collection of medical illustrations.

Self-taught in medical illustration, cardiologist Carlos Machado has contributed meticulous updates to some of Dr. Netter's original plates and has created many paintings of his own in the style of Netter as an extension of the Netter collection. Dr. Machado's photorealistic expertise and his keen insight into the physician/patient relationship inform his vivid and unforgettable visual style. His dedication to researching each topic and subject he paints places him among the premier medical illustrators at work today.

Learn more about his background and see more of his art at: <http://www.netterimages.com/artist/machado.htm>.

# Foreword

Appropriate treatment decisions depend on an in-depth understanding of anatomy and an accurate diagnosis. This book is unique in that it combines the extensive library of classic Netter anatomical drawings with high-quality photos and now even video in this edition demonstrating special tests. The authors should be applauded for including quality ratings for 269 studies investigating a test's reliability using the 11-item "Quality Appraisal of Diagnostic Reliability Checklist." This edition includes 84 new studies, 34 new photos, and 25 new videos demonstrating special tests. As a PT/ATC and director of a PT sports medicine doctoral program, I see great utility for this reference from the entry level student athletic trainer and physical therapist to ortho/sports residency and fellowship training PTs and MDs. The book is extremely user-friendly and well organized as it walks the reader through the anatomy, clinical exam, and then critically reviews all literature for given diagnostic tests. As we constantly strive for better evidence-based medicine, new and old clinicians would be well served by such a powerful book detailing the utility of diagnostic tests and even evaluating evidence for treatment modalities when available.

Thank you for this extremely helpful tool.

Don Goss PT, PHD Program Director PT Sports Medicine Doctoral Program U.S. Army–Baylor University

If we can make the correct diagnosis, the healing can begin.

—A. Weil

As an occupational therapist and certified hand therapist, I naturally gravitate toward the chapters on the upper limb. These chapters are exceptional! This is a must-have text for therapists at all levels of experience. The up-to-date tables that provide quality ratings on research facilitate evidence-based practice. The photos demonstrating special tests are invaluable for new learners, as are the supplemental videos included in this third edition. This book signifies a clear intent of the authors to provide a critical resource for therapists. It also shows commitment to education, a desire to translate research into advanced clinical practice, and a vision to advance rehabilitation science through accurate diagnostic evaluation. As I staff upper limb orthopedic cases of my students in training, this book is in my hands and on my clinic exam table as an open-book, go-to reference. It's an educator's dream to have all this valuable information in one text!

Kathleen Yancosek PHD LTC, SP, US Army Program Director Doctor of Science in Occupational Therapy U.S. Army–Baylor University

# Preface

Over the past several years evidence-based practice has become the standard in the medical and healthcare professions. As described by Sackett and colleagues (Evidence-Based Medicine: How to Practice and Teach EBM, 2nd ed, London, 2000, Harcourt Publishers Limited), evidence-based practice is a combination of three elements: the best available evidence, clinical experience, and patient values. Sackett has further reported that "when these three elements are integrated, clinicians and patients form a diagnostic and therapeutic alliance which optimizes clinical outcomes and quality of life." Each element contributes significantly to the clinical reasoning process by helping to identify a diagnosis or prognosis or establish an effective and efficient plan of care. Unfortunately, the evidence-based approach confronts a number of barriers that may limit the clinician's ability to use the best available evidence to guide decisions about patient care, most significantly a lack of time and resources. Given the increasing prevalence of new clinical tests in the orthopaedic setting and the frequent omission from textbooks of information about their diagnostic utility, the need was clear for a quick reference guide for students and busy clinicians that would enhance their ability to incorporate evidence into clinical decision making.

The purpose of Netter's Orthopaedic Clinical Examination: An Evidence-Based Approach is twofold: to serve as a textbook for musculoskeletal evaluation courses in an academic setting and to provide a quick, user-friendly guide and reference for clinicians who want to locate the evidence related to the diagnostic utility of commonly utilized tests and measures.

The first chapter is intended to introduce the reader to the essential concepts underlying evidence-based practice, including the statistical methods it employs and the critical analysis of research articles. The remainder of the book consists of chapters devoted to individual body regions. Each chapter begins with a review of the relevant osteology, arthrology, myology, and neurology and is liberally illustrated with images by the well-known medical artist Frank H. Netter, MD. The second portion of each chapter provides information related to patient complaints and physical examination findings. Reliability and diagnostic utility estimates (sensitivity, specificity, and likelihood ratios) are presented for each patient complaint and physical examination finding and are accompanied by quick access interpretation guides. Test descriptions and definitions of positive test findings are included as reported by the original study authors, both to minimize any alteration of information and to provide readers insight into difference values reported by different studies. At the end of each chapter are tables listing information on commonly used outcome measures and quality ratings for all the studies investigating tests' diagnostic utility. For this new edition, we've also included quality ratings for all the studies investigating tests' reliability. Additionally, new video content demonstrating select tests from each body region can be accessed online.

We hope that clinicians will find Netter's Orthopaedic Clinical Examination a user-friendly clinical resource for determining the relevance of findings from the orthopaedic examination. We also hope that students and educators will find this a valuable guide to incorporate into courses related to musculoskeletal evaluation and treatment.

Joshua A. Cleland

Shane Koppenhaver

Jonathan Su

# Video Contents

 Temporomandibular Joint

Video 2-1 Reciprocal Clicking

Video 2-2 TMJ Pain During Assisted Opening

 Cervical Spine

Video 3-1 Spurling's Test

Video 3-2 Sharp-Purser Test

Video 3-3 Arm Squeeze Test

 Thoracolumbar Spine

Video 4-1 Slump Knee Bend Test

Video 4-2 Passive Lumbar Extension Test

 Sacroiliac Region

Video 5-1 Gaenslen Test

Video 5-2 PSIS Distraction Test

 Hip and Pelvis

Video 6-1 Patrick's Test

Video 6-2 FADIR Impingement Test

 Knee

Video 7-1 Prone Lachman Test

Video 7-2 Loss of Extension Test

 Foot and Ankle

Video 8-1 Impingement Sign

Video 8-2 Anterior Drawer Test

Video 8-3 Medial Talar Tilt Stress Test

Video 8-4 Triple Compression Stress Test

 Shoulder

Video 9-1 Lateral Jobe Test

Video 9-2 Bear-Hug Test

Video 9-3 Belly-Press Test

 Elbow and Forearm

Video 10-1 Shoulder Internal Rotation Test

Video 10-2 Moving Valgus Stress Test

 Hand

Video 11-1 Upper Limb Tension Test A

Video 11-2 Upper Limb Tension Test B

Video 11-3 Wrist Hyperflexion and Abduction of the Thumb Test
1

# The Reliability and Diagnostic Utility of the Orthopaedic Clinical Examination

Reliability, 2

Diagnostic Accuracy, 3

2×2 Contingency Table, 3

Overall Accuracy, 4

Positive and Negative Predictive Values, 4

Sensitivity, 4

Specificity, 5

Likelihood Ratios, 6

Confidence Intervals, 8

Pretest and Posttest Probability, 8

Calculating Posttest Probability, 8

Assessment of Study Quality, 9

Summary, 11

References, 12

The health sciences and medical professions are undergoing a paradigm shift toward evidence-based practice defined as the integration of the best available research evidence and clinical expertise with the patient's values.1,2 Evidence should be incorporated into all aspects of physical therapy patient and client management, including the examination, evaluation, diagnosis, prognosis, and intervention. Perhaps the most crucial component is a careful, succinct clinical examination that can lead to an accurate diagnosis, the selection of appropriate interventions, and the determination of a prognosis. Thus, it is of utmost importance to incorporate evidence of how well clinical tests and measures can distinguish between patients who present with specific musculoskeletal disorders and patients who do not.1,2

The diagnostic process entails obtaining a patient history, developing a working hypothesis, and selecting specific tests and measures to confirm or refute the formulated hypothesis. The clinician must determine the pretest (before the evaluation) probability that the patient has a particular disorder. Based on this information the clinician selects appropriate tests and measures that will help determine the posttest (after the evaluation) probability of the patient having the disorder, until a degree of certainty has been reached such that patient management can begin (the treatment threshold). The purpose of clinical tests is not to obtain diagnostic certainty but rather to reduce the level of uncertainty until the treatment threshold is reached.2 The concepts of pretest and posttest probability and treatment threshold are elaborated later in this chapter.

As the number of reported clinical tests and measures continues to grow, it is essential to thoroughly evaluate a test's diagnostic properties before incorporating the test into clinical practice.3 Integrating the best evidence available for the diagnostic utility of each clinical test is essential in determining an accurate diagnosis and implementing effective, efficient treatment. It seems only sensible for clinicians and students to be aware of the diagnostic properties of tests and measures and to know which have clinical utility. This text assists clinicians and students in selecting tests and measures to ensure the appropriate classification of patients and to allow for quick implementation of effective management strategies.

The assessment of diagnostic tests involves examining a number of properties, including reliability and diagnostic accuracy. A test is considered reliable if it produces precise and reproducible information. A test is considered to have diagnostic accuracy if it has the ability to discriminate between patients who have a specific disorder and patients who do not have it.4 Scientific evaluation of the clinical utility of physical therapy tests and measures involves comparing the examination results with reference standards such as radiographic studies (which represent the closest measure of the truth). Using statistical methods from the field of epidemiology, the diagnostic accuracy of the test, that is, its ability to determine which patients have a disorder and which do not, is then calculated. This chapter focuses on the characteristics that define the reliability and diagnostic accuracy of specific tests and measures. The chapter concludes with a discussion of the quality assessment of studies investigating diagnostic utility.

## Reliability

For a clinical test to provide information that can be used to guide clinical decision making, it must be reliable. Reliability is the degree of consistency with which an instrument or rater measures a particular attribute.5 When we investigate the reliability of a measurement, we are determining the proportion of that measurement that is a true representation and the proportion that is the result of measurement error.6

When discussing the clinical examination process, it is important to consider two forms of reliability: intraexaminer and interexaminer reliability. Intraexaminer reliability is the ability of a single rater to obtain identical measurements during separate performances of the same test. Interexaminer reliability is a measure of the ability of two or more raters to obtain identical results with the same test.

The kappa coefficient (κ) is a measure of the proportion of potential agreement after chance is removed1,5,7; it is the reliability coefficient most often used for categorical data (positive or negative).5 The correlation coefficient commonly used to determine the reliability of data that are continuous in nature (e.g., range-of-motion data) is the intra-class correlation coefficient (ICC).7 Although interpretations of reliability vary, coefficients are often evaluated by the criteria described by Shrout,8 with values less than 0.10 indicating no reliability, values between 0.11 and 0.40 indicating slight reliability, values between 0.41 and 0.60 indicating fair reliability, values between 0.61 and 0.80 indicating moderate reliability, and values greater than 0.81 indicating substantial reliability. "Acceptable reliability" must be decided by the clinician using the specific test or measure9 and should be based on the variable being tested, the reason a particular test is important, and the patient on whom the test will be used.6 For example, a 5% measurement error may be very acceptable when measuring joint range of motion but is not nearly as acceptable when measuring pediatric core body temperature.

## Diagnostic Accuracy

Clinical tests and measures can never absolutely confirm or exclude the presence of a specific disease.10 However, clinical tests can be used to alter the clinician's estimate of the probability that a patient has a specific musculoskeletal disorder. The accuracy of a test is determined by the measure of agreement between the clinical test and a reference standard.11,12 A reference standard is the criterion considered the closest representation of the truth of a disorder being present.1 The results obtained with the reference standard are compared with the results obtained with the test under investigation to determine the percentage of people correctly diagnosed, or the diagnostic accuracy.13 Because the diagnostic utility statistics are completely dependent on both the reference standard used and the population studied, we have specifically listed these within this text to provide information to consider when selecting the tests and measures reported. Diagnostic accuracy is often expressed in terms of positive and negative predictive values (PPVs and NPVs), sensitivity and specificity, and likelihood ratios (LRs).1,14

### 2×2 Contingency Table

To determine the clinical utility of a test or measure, the results of the reference standard are compared with the results of the test under investigation in a 2×2 contingency table, which provides a direct comparison between the reference standard and the test under investigation.15 It allows for the calculation of the values associated with diagnostic accuracy to assist with determining the utility of the clinical test under investigation (Table 1-1).

Table 1-1

2×2 Contingency Table Used to Compare the Results of the Reference Standard with Those of the Test under Investigation

| Reference Standard Positive| Reference Standard Negative
---|---|---
Clinical Test Positive| True-positive results
a| False-positive results
b
Clinical Test Negative| False-negative results
c| True-negative results
d

The 2×2 contingency table is divided into four cells (a, b, c, d) for the determination of the test's ability to correctly identify true positives (cell a) and rule out true negatives (cell d). Cell b represents the false-positive findings wherein the diagnostic test was found to be positive yet the reference standard obtained a negative result. Cell c represents the false-negative findings wherein the diagnostic test was found to be negative yet the reference standard obtained a positive result.

Once a study investigating the diagnostic utility of a clinical test has been completed and the comparison with the reference standard has been performed in the 2×2 contingency table, determination of the clinical utility in terms of overall accuracy, PPVs and NPVs, sensitivity and specificity, and LRs can be calculated. These statistics are useful in determining whether a diagnostic test is useful for either ruling in or ruling out a disorder.

#### Overall Accuracy

The overall accuracy of a diagnostic test is determined by dividing the correct responses (true positives and true negatives) by the total number of patients.16 Using the 2×2 contingency table, the overall accuracy is determined by the following equation:

Overall accuracy=100%×(a+d)/(a+b+c+d)

  (1-1)

A perfect test would exhibit an overall accuracy of 100%. This is most likely unobtainable in that no clinical test is perfect and each will always exhibit at least a small degree of uncertainty. The accuracy of a diagnostic test should not be used to determine the clinical utility of the test, because the overall accuracy can be a bit misleading. The accuracy of a test can be significantly influenced by the prevalence of a disease, or the total instances of the disease in the population at a given time.5,6

#### Positive and Negative Predictive Values

PPVs estimate the likelihood that a patient with a positive test actually has a disease.5,6,17 PPVs are calculated horizontally in the 2×2 contingency table (Table 1-2) and indicate the percentage of patients accurately identified as having the disorder (true positive) divided by all the positive results of the test under investigation. A high PPV indicates that a positive result is a strong predictor that the patient has the disorder.5,6 The formula for the PPV is:

PPV=100%×a/(a+b)

  (1-2)

Table 1-2

2×2 Contingency Table Showing the Calculation of Positive Predictive Values (PPVs) and Negative Predictive Values (NPVs) Horizontally and Sensitivity and Specificity Vertically

| Reference Standard Positive| Reference Standard Negative|
---|---|---|---
Clinical Test Positive| True positives
a| False positives
b| PPV = a/(a + b)
Clinical Test Negative| c
False negatives| d
True negatives| NPV = d/(c + d)
| Sensitivity = a/(a + c)| Specificity = d/(b + d)|

NPVs estimate the likelihood that a patient with a negative test does not have the disorder.5,6 NPVs are also calculated horizontally in the 2×2 contingency table (see Table 1-2) and indicate the percentage of patients accurately identified as not having the disorder (true negative) divided by all the negative results of the test under investigation.11 The formula for the NPV is as follows:

NPV=100%×d/(c+d)

  (1-3)

The predictive values are significantly influenced by the prevalence of the condition.11 Hence, we have not specifically reported these in this text.

#### Sensitivity

The sensitivity of a diagnostic test indicates the test's ability to detect those patients who actually have a disorder as indicated by the reference standard. This is also referred to as the true-positive rate.1 Tests with high sensitivity are good for ruling out a particular disorder. The acronym SnNout can be used to remember that a test with high Sensitivity and a Negative result is good for ruling out the disorder.1

Consider, for example, a clinical test that, compared with the reference standard, exhibits a high sensitivity for detecting lumbar spinal stenosis. Considering the rule above, if the test is negative it reliably rules out lumbar spinal stenosis. If the test is positive, it is likely to accurately identify a high percentage of patients presenting with stenosis. However, it also may identify as positive many of those without the disorder (false positives). Thus, although a negative result can be relied on, a positive test result does not allow us to draw any conclusions (Figs. 1-1 and 1-2).

Figure 1-1 Sensitivity and specificity example. Twenty patients with and 20 patients without the disorder.

Figure 1-2 100% Sensitivity. One hundred percent sensitivity infers that if the test is positive, all those with the disease will be captured. However, although this test captured all those with the disease, it also captured many without it. Yet if the test result is negative, we are confident that the disorder can be ruled out (SnNout).

The sensitivity of a test also can be calculated from the 2×2 contingency tables. However, it is calculated vertically (see Table 1-2). The formula for calculating a test's sensitivity is as follows:

Sensitivity=100%×a/(a+c)

  (1-4)

#### Specificity

The specificity of a diagnostic test simply indicates the test's ability to detect those patients who actually do not have the disorder as indicated by the reference standard. This is also referred to as the true-negative rate.1 Tests with high specificity are good for ruling in a disorder. The acronym SpPin can be used to remember that a test with high Specificity and a Positive result is good for ruling in the disorder.16,18,19

Consider a test with high specificity. It would demonstrate a strong ability to accurately identify all patients who do not have a disorder. If a highly specific clinical test is negative, it is likely to identify a high percentage of those patients who do not have the disorder. However, it is also possible that the highly specific test with a negative result will identify a number of patients who actually have the disease as being negative (false negative). Therefore, we can be fairly confident that a highly specific test with a positive finding indicates that the disorder is present (Fig. 1-3).

Figure 1-3 100% Specificity. One hundred percent specificity infers that if the test is negative, all those without the disease will be captured. However, although this test captured all those without the disease, it also captured many with it. Yet if the test is positive, we are confident that the patient has the disorder (SpPin).

The formula for calculating test specificity is as follows:

Specificity=100%×d/(b+d)

  (1-5)

Sensitivity and specificity have been used for decades to determine a test's diagnostic utility; however, they possess a few clinical limitations.11 Although sensitivity and specificity can be useful in assisting clinicians in selecting tests that are good for ruling in or out a particular disorder, few clinical tests demonstrate both high sensitivity and high specificity.11 Also the sensitivity and specificity do not provide information regarding a change in the probability of a patient having a disorder if the test results are positive or negative.18,20 Instead, LRs have been advocated as the optimal statistics for determining a shift in pretest probability that a patient has a specific disorder.

#### Likelihood Ratios

A test's result is valuable only if it alters the pretest probability of a patient having a disorder.21 LRs combine a test's sensitivity and specificity to develop an indication in the shift of probability given the specific test result and are valuable in guiding clinical decision making.20 LRs are a powerful measure that can significantly increase or reduce the probability of a patient having a disease.22

LRs can be either positive or negative. A positive LR indicates a shift in probability favoring the existence of a disorder, whereas a negative LR indicates a shift in probability favoring the absence of a disorder. Although LRs are often not reported in studies investigating the diagnostic utility of the clinical examination, they can be calculated easily if a test's sensitivity and specificity are available. Throughout this text, for studies that did not report LRs but did document a test's sensitivity and specificity, the LRs were calculated by the authors.

The formula used to determine a positive LR is as follows:

LR=Sensitivity/(1−Specificity)

  (1-6)

The formula used to determine a negative LR is as follows:

LR=(1−Sensitivity)/Specificity

  (1-7)

A guide to interpreting test results can be found in Table 1-3. Positive LRs higher than 1 increase the odds of the disorder given a positive test, and negative LRs less than 1 decrease the odds of the disorder given a negative test.22 However, it is the magnitude of the shifts in probability that determines the usefulness of a clinical test. Positive LRs higher than 10 and negative LRs close to zero often represent large and conclusive shifts in probability. An LR of 1 (either positive or negative) does not alter the probability that the patient does or does not have the particular disorder and is of little clinical value.22 Once the LRs have been calculated, they can be applied to the nomogram (Fig. 1-4)23 or a mathematical equation24 can be used to determine more precisely the shifts in probability given a specific test result. Both methods are described in further detail later in the chapter.

Figure 1-4 Fagan's nomogram. (Adapted with permission from Fagan TJ. Letter: nomogram for Bayes theorem. N Engl J Med. 1975;293:257. Copyright 2005, Massachusetts Medical Society. All rights reserved.)

Table 1-3

Interpretation of Likelihood Ratios

Positive Likelihood Ratio| Negative Likelihood Ratio| Interpretation
---|---|---
>10| <0.1| Generate large and often conclusive shifts in probability
5 to 10| 0.1 to 0.2| Generate moderate shifts in probability
2 to 5| 0.2 to 0.5| Generate small but sometimes important shifts in probability
1 to 2| 0.5 to 1.0| Alter probability to a small and rarely important degree

Adapted from Jaeschke R, Guyatt GH, Sackett DL III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? JAMA. 1994;271:703-707.

If a diagnostic test exhibits a specificity of 1, the positive LR cannot be calculated because the equation will result in a zero for the denominator. In these circumstances, a suggestion has been made to modify the 2×2 contingency table by adding 0.5 to each cell in the table to allow for the calculation of LRs.25

Consider, for example, the diagnostic utility of the Crank test5,26 in detecting labral tears compared with arthroscopic examination, the reference standard. This is revealed in a 2×2 contingency table (Table 1-4). The inability to calculate a positive LR becomes obvious in the following:

Positive LR=Sensitivity/(1−Specificity)=1/(1−1)=1/0

  (1-8)

Table 1-4

Results of the Crank Test in Detecting Labral Tears When Compared with the Reference Standard of Arthroscopic Examination

| Arthroscopic Examination Positive (n = 12)| Arthroscopic Examination Negative (n = 3)|
---|---|---|---
Crank Test Positive| 10
a| 0
b| PPV = 100 × 10/10 = 100%
Crank Test Negative| c
2| d
3| NPV = 100 × 3/5 = 60%
| Sensitivity = 100% × 10/12 = 83%| Specificity = 100% × 3/3 = 100%|

Because zero cannot be the denominator in a fraction, the 2×2 contingency table is modified by adding 0.5 to each cell.

Although the addition of 0.5 to each cell is the only reported method of modifying the contingency table to prevent zero in the denominator of an LR calculation, considering the changes that occur with the diagnostic properties of sensitivity, specificity, and predictive values, this technique has not been used in this text. In circumstances in which the specificity is zero and the positive LR cannot be calculated, it is documented as "undefined" (UD). In these cases, although we are not calculating the positive LR, the test is indicative of a large shift in probability.

## Confidence Intervals

Calculations of sensitivity, specificity, and LRs are known as point estimates. That is, they are the single best estimates of the population values.5 However, because point estimates are based on small subsets of people (samples), it is unlikely that they are a perfect representation of the larger population. It is more accurate, therefore, to include a range of values (interval estimate) in which the population value is likely to fall. A confidence interval (CI) is a range of scores around the point estimate that likely contains the population value.27 Commonly, the 95% CI is calculated for studies investigating the diagnostic utility of the clinical examination. A 95% CI indicates the spread of scores in which we can be 95% confident that they contain the population value.5 In this text, the 95% CI is reported for all studies that provided this information.

## Pretest and Posttest Probability

Pretest probability is the likelihood that a patient exhibits a specific disorder before the clinical examination. Often prevalence rates are used as an indication of pretest probability, but when prevalence rates are unknown, the pretest probability is based on a combination of the patient's medical history, the results of previous tests, and the clinician's experience.16 Determining the pretest probability is the first step in the decision-making process for clinicians. Pretest probability is an estimate by the clinician and can be expressed as a percentage (e.g., 75%, 80%) or as a qualitative measure (e.g., somewhat likely, very likely).11,16 Once the pretest probability of a patient having a particular disorder is identified, tests and measures that have the potential to alter the probability should be selected for the physical examination. Posttest probability is the likelihood that a patient has a specific disorder after the clinical examination procedures have been performed.

## Calculating Posttest Probability

As previously mentioned, LRs can assist with determining the shifts in probability that would occur following a given test result and depend on the respective LR ratios of that given test. The quickest method to use to determine the shifts in probability once an LR is known for a specific test is the nomogram (Fig. 1-5).23 The nomogram is a diagram that illustrates the pretest probability on the left and the posttest probability on the right, with the LRs in the middle. To determine the shift in probability, a mark is placed on the nomogram representing the pretest probability. Then a mark is made on the nomogram at the level of the LR (either negative or positive). The two lines are connected with a straight line and the line is carried through the right of the diagram. The point at which the line crosses the posttest probability scale indicates the shift in probability.

Figure 1-5 Nomogram representing the change in pretest probability from 42% if the test was positive (positive likelihood ratio = 4.2) to a posttest probability of 71%. (Adapted with permission from Fagan TJ. Letter: nomogram for Bayes theorem. N Engl J Med. 1975;293:257. Copyright 2005, Massachusetts Medical Society. All rights reserved.)

A more precise determination of the shift in probability can be calculated algebraically with the following formula16:

Step 1. Pretest odds=Pretest probability/1−Pretest probability

  (1-9)

Step 2. Pretest odds×LR=Posttest odds

  (1-10)

Step 3. Posttest odds/Posttest odds+1=Posttest probability

  (1-11)

The clinician must make a determination of when the posttest probability is either low enough to rule out the presence of a certain disease or when the posttest probability is high enough that the clinician feels confident in having established the presence of a disorder. The level at which evaluation ceases and treatment begins is known as the treatment threshold (Fig. 1-6).16

Figure 1-6 Treatment threshold. Clinicians must use the pretest probability and likelihood ratios to determine the treatment threshold as indicated in this illustration.

## Assessment of Study Quality

Once relevant articles are retrieved, the next step is critical analysis of their content for adequate methodologic rigor. It has been reported that the methodologic quality of studies investigating the diagnostic utility of the clinical examination is generally inferior to that of studies investigating the effectiveness of therapies.28,29 Unfortunately, studies with significant methodologic flaws reporting the usefulness of specific tests and measures can lead to premature incorporation of ineffective tests. This can result in inaccurate diagnoses and poor patient management. Alternatively, identification and use of rigorously appraised clinical tests can improve patient care and outcomes.29

The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) was developed to assess the quality of diagnostic accuracy studies.30 A four-round Delphi panel identified 14 criteria that are used to assess a study's methodologic quality (see tables at the end of Chapters 2 through ). Each item is scored as "yes," "no," or "unclear." The QUADAS is not intended to quantify a score for each study but rather provides a qualitative assessment of the study with the identification of weaknesses.30 The QUADAS has demonstrated adequate agreement for the individual items in the checklist.31 We have used the QUADAS to evaluate each study referenced in this text and have included details of the quality assessments in the appendix of each chapter. Studies deemed to be of poor methodologic quality (represented by red symbols) have not been included in the diagnostic utility tables throughout the chapters unless they are the only studies that examine the diagnostic test in question. Green symbols indicate a high level of methodologic quality and imply that readers can be confident in study results. Yellow symbols indicate fair methodologic quality and imply that readers should interpret such study results with caution. Red symbols indicate poor methodologic quality and imply that readers should interpret such study results with strong caution.

The Quality Appraisal for Reliability Studies (QAREL) was developed to assess the quality of diagnostic reliability studies.32 The QAREL is an 11-item checklist developed in consultation with a reference group of experts in diagnostic research and quality appraisal that is used to assess a study's methodologic quality (see tables at the end of Chapters 2 through ). Each item is scored as "yes," "no," "unclear," or "N/A." The QAREL has been found to be a reliable assessment tool when reviewers are given the opportunity to discuss the criteria by which to interpret each item.33 Reliability of 9 of the 11 items was identified as good reliability, whereas reliability of only 2 of the 11 items was identified as fair reliability.33 We have used the QAREL to evaluate each study related to reliability referenced in this text and have included details of the quality assessments in the appendix of each chapter. Studies deemed to be of poor methodologic quality (represented by red symbols) have not been included in the diagnostic utility tables throughout the chapters unless they are the only studies that examine the diagnostic test in question. Green symbols indicate a high level of methodologic quality and imply that readers can be confident in study results. Yellow symbols indicate fair methodologic quality and imply that readers should interpret such study results with caution. Red symbols indicate poor methodologic quality and imply that readers should interpret such study results with strong caution.

## Summary

It is important to consider the reliability and diagnostic utility of tests and measures before including them as components of the clinical examination. Tests and measures should demonstrate adequate reliability before they are used to guide clinical decision making. Throughout this text, the reliability of many tests and measures is reported. It is essential that clinicians consider these reported levels of reliability in the context of their own practice.

Before implementing tests and measures into the orthopaedic examination, it is first essential to consider each test's diagnostic utility. Table 1-5 summarizes the statistics related to diagnostic accuracy as well as the mathematical equations and operational definitions for each. The usefulness of a test or measure is most commonly considered in terms of the respective test's diagnostic properties. These can be described in terms of sensitivity, specificity, PPVs, and NPVs. However, perhaps the most useful diagnostic property is the LR, which can assist in altering the probability that a patient has a specific disorder.

Table 1-5

2×2 Contingency Table and Statistics Used to Determine the Diagnostic Utility of a Test or Measure

| Reference Standard Positive| Reference Standard Negative
---|---|---
Diagnostic Test Positive| True-positive results
a| False-positive results
b
Diagnostic Test Negative| c
False-negative results| d
True-negative results

Statistic| Formula| Description
Overall accuracy| (a + d)/(a + b + c + d)| The percentage of individuals who are correctly diagnosed
Sensitivity| a /(a + c)| The proportion of patients with the condition who have a positive test result
Specificity| d/(b + d)| The proportion of patients without the condition who have a negative test result
Positive predictive value| a/(a + b)| The proportion of individuals with a positive test result who have the condition
Negative predictive value| d/(c + d)| The proportion of individuals with a negative test result who do not have the condition
Positive likelihood ratio| Sensitivity/(1 − Specificity)| If the test is positive, the increase in odds favoring the condition
Negative likelihood ratio| (1 − Sensitivity)/Specificity| If the test is positive, the decrease in odds favoring the condition

No clinical test or measure provides absolute certainty as to the presence or absence of disease. However, clinicians can determine when enough data have been collected to alter the probability beyond the treatment threshold where the evaluation can cease and therapeutic management can begin. Furthermore, careful methodologic assessment provides greater insight into the scientific rigor of each study and its performance, applicability, reliability, and reproducibility within a given clinical practice.

## References

1. Sackett DL, Straws SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Harcourt Publishers Limited: London; 2000.

2. Kassirer JP. Our stubborn quest for diagnostic certainty: a cause of excessive testing. N Engl J Med. 1989;320:1489–1491.

3. Lijmer JG, Mol BW, Heisterkamp S, et al. Empirical evidence of design-related bias in studies of diagnostic tests. JAMA. 1999;282:1061–1066.

4. Schwartz JS. Evaluating diagnostic tests: what is done−what needs to be done. J G Intern Med. 1986;1:266–267.

5. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. 2nd ed. Prentice Hall Health: Upper Saddle River, NJ; 2000.

6. Rothstein JM, Echternach JL. Primer on Measurement: An Introductory Guide to Measurement Issues. American Physical Therapy Association: Alexandria, VA; 1999.

7. Domholdt E. Physical Therapy Research. 2nd ed. WB Saunders: Philadelphia; 2000.

8. Shrout PE. Measurement reliability and agreement in psychiatry. Stat Methods Med Res. 1998;7:301–317.

9. Van Genderen F, De Bie R, Helders P, Van Meeteren N. Reliability research: towards a more clinically relevant approach. Physical Therapy Reviews. 2003;8:169–176.

10. Bossuyt PMM, Reitsma JB, Bruns DE, et al. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Clin Chem. 2003;49:1–6.

11. Fritz JM, Wainner RS. Examining diagnostic tests: an evidence-based perspective. Phys Ther. 2001;81:1546–1564.

12. Jaeschke R, Guyatt GH, Sackett DL III. How to use an article about a diagnostic test. A. Are the results of the study valid? JAMA. 1994;271:389–391.

13. Bossuyt PMM, Reitsma JB, Bruns DE, et al. The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Clin Chem. 2003;49:7–18.

14. McGinn T, Guyatt G, Wyer P, et al. Users' guides to the medical literature XXII: how to use articles about clinical decision rules. JAMA. 2000;284:79–84.

15. Greenhalgh T. Papers that report diagnostic or screening tests. BMJ. 1997;315:540–543.

16. Bernstein J. Decision analysis (current concepts review). J Bone Joint Surg. 1997;79:1404–1414.

17. Potter NA, Rothstein JM. Intertester reliability for selected clinical tests of the sacroiliac joint. Phys Ther. 1985;65:1671–1675.

18. Boyko EJ. Ruling out or ruling in disease with the most sensitive or specific diagnostic test: short cut or wrong turn? Med Decis Making. 1994;14:175–180.

19. Riddle DL, Stratford PW. Interpreting validity indexes for diagnostic tests: an illustration using the Berg balance test. Phys Ther. 1999;79:939–948.

20. Hayden SR, Brown MD. Likelihood ratio: a powerful tool for incorporating the results of a diagnostic test into clinical decision making. Ann Emerg Med. 1999;33:575–580.

21. Simel DL, Samsa GP, Matchar DB. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol. 1991;44:763–770.

22. Jaeschke R, Guyatt GH, Sackett DL. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? JAMA. 1994;271:703–707.

23. Fagan TJ. Letter: nomogram for Bayes theorem. N Engl J Med. 1975;293:257.

24. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine. Little, Brown: Boston; 1991.

25. Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28:52–62.

26. Mimori K, Muneta T, Nakagawa T, Shinomiya K. A new pain provocation test for superior labral tears of the shoulder. Am J Sports Med. 1999;27:137–142.

27. Fidler F, Thomason N, Cumming G, et al. Editors can lead researchers to confidence intervals, but can't make them think. Psychol Sci. 2004;15:119–126.

28. Moons KGM, Biesheuvel CJ, Grobbee DE. Test research versus diagnostic research. Clin Chem. 2004;50:473–476.

29. Reid MC, Lachs MS, Feinstein AR. Use of methodological standards in diagnostic test research. JAMA. 1995;274:645–651.

30. Whiting P, Harbord R, Kleijnen J. No role for quality scores in systematic reviews of diagnostic accuracy studies. BMC Med Res Methodol. 2005;5:19.

31. Whiting PF, Weswood ME, Rutjes AW, et al. Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies. BMC Med Res Methodol. 2006;6:9.

32. Lucas NP, Macaskill P, Irwig L, Bogduk N. The development of a quality appraisal tool for studies of diagnostic reliability (QAREL). J Clin Epidemiol. 2010;63(8):854–861.

33. Lucas N, Macaskill P, Irwig L, et al. The reliability of a quality appraisal tool for studies of diagnostic reliability (QAREL). BMC Med Res Methodol. 2013;13:111.
2

# Temporomandibular Joint

CLINICAL SUMMARY AND RECOMMENDATIONS, 14

Anatomy, 15

Osteology, 15

Arthrology, 18

Ligaments, 19

Muscles, 20

Nerves, 24

Patient History, 25

Initial Hypotheses Based on Patient History, 25

Reliability of Patient's Reports of Pain in Temporomandibular Dysfunction, 26

Diagnostic Utility of Patient History in Identifying Anterior Disc Displacement, 27

Self-Reported Temporomandibular Pain, 29

Diagnostic Criteria for TMD, 31

Reliability and Diagnostic Criteria for Pain-Related TMD, 31

Reliability and Diagnostic Criteria for Intraarticular TMD, 33

Physical Examination Tests, 35

Palpation, 35

Joint Sounds, 40

Range-of-Motion Measurements, 43

Dynamic Movement Measurements, 48

Other Tests, 54

Combinations of Tests, 56

Outcome Measures, 62

Appendix, 63

References, 67

## Clinical Summary and Recommendations

Patient History
---
Questions|

• Screening instruments have been shown to be very good at identifying temporomandibular disorder (TMD) pain (+LR [likelihood ratio] of 33).

• A subject complaint of "periodic restriction" (the inability to open the mouth as wide as was previously possible) has been found to be the best single history item to identify anterior disc displacement, both in patients with reducing discs and in those with nonreducing discs.

Physical Examination
Palpation|

• Reproducing pain during palpation of the temporomandibular joint (TMJ) and related muscles has been found to be moderately reliable and appears to demonstrate good diagnostic utility for identifying TMJ effusion by magnetic resonance imaging (MRI) and TMD when compared with a comprehensive physical examination. We recommend that palpation at least include the TMJ (+LR = 4.87 to 5.67), the temporalis muscle (+LR = 2.73 to 4.12), and the masseter muscle (+LR = 3.65 to 4.87).

• If clinically feasible, pressure pain threshold (PPT) testing is helpful because it demonstrates superior diagnostic utility in identifying TMD when compared with a comprehensive physical examination.

Joint Sounds|

• Detecting joint sounds (clicking and crepitus) during jaw motion is a generally unreliable sign demonstrating poor diagnostic utility except in attempts to detect moderate to severe osteoarthritis (+LR = 4.79) and nonreducing anterior disc displacement (+LR = 7.1 to 15.2).

Range-of-Motion and Dynamic Movement Measurements|

• Measuring mouth range of motion appears to be a highly reliable test, and when the range of motion is restricted or deviated from the midline, the measurement has moderate diagnostic utility in identifying nonreducing anterior disc displacement.

• Detecting pain during motion is a less reliable sign, but it also demonstrates moderate to good diagnostic utility in identifying nonreducing anterior disc displacement and self-reported TMJ pain.

• The combination of motion restriction and pain during assisted opening has been found to be the best combination for identifying nonreducing anterior disc displacement (+LR = 7.71).

• Consistent with assessment of other body regions, assessment of "joint play" and "end feel" is highly unreliable and has unknown diagnostic utility.

Interventions|

• Patients with TMD who report (1) symptoms ≥4/10 (10 being severe pain) and (2) pain for 10 months' duration or less may benefit from nightly wearing of an occlusal stabilization splint, especially if they have (3) nonreducing anterior disc displacement and (4) show improvement after 2 months (+LR = 10.8 if all four factors are present).

## Anatomy

### Osteology

Figure 2-1 Bony framework of head and neck.

Figure 2-2 Mandible.

Figure 2-3 Lateral skull.

### Arthrology

Figure 2-4 Temporomandibular joint.

The temporomandibular joint (TMJ) is divided by an intraarticular biconcave disc that separates the joint cavity into two distinct functional components. The upper joint is a plane, or gliding, joint that permits translation of the mandibular condyles. The lower joint is a hinge joint that permits rotation of the condyles. The closed pack position of the TMJ is full occlusion. A unilateral restriction pattern primarily limits contralateral excursion but also affects mouth opening and protrusion.

Figure 2-5 Temporomandibular joint mechanics.

During mandibular depression from a closed mouth position, the initial movement occurs at the lower joint as the condyles pivot on the intraarticular disc. This motion continues to approximately 11 mm of depression. With further mandibular depression, motion begins to occur at the upper joint and causes anterior translation of the disc on the articular eminence. Normal mandibular depression is between 40 and 50 mm.

### Ligaments

Figure 2-6 Temporomandibular joint ligaments.

Ligaments| Attachments| Function
---|---|---
Temporomandibular| Thickening of anterior joint capsule extending from neck of mandible to zygomatic arch| Strengthen the TMJ laterally
Sphenomandibular| Sphenoid bone to mandible| Serve as a fulcrum for and reinforcer of TMJ motion
Stylomandibular| Styloid process to angle of mandible| Provide minimal support for joint

### Muscles

#### Muscles Involved in Mastication

Figure 2-7 Muscles involved in mastication, lateral views.

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Temporalis| Temporal fossa| Coronoid process and anterior ramus of mandible| Deep temporal branches of mandibular nerve| Elevate mandible
Masseter| Inferior and medial aspects of zygomatic arch| Coronoid process and lateral ramus of mandible| Mandibular nerve via masseteric nerve| Elevate and protrude mandible

Figure 2-8 Muscles involved in mastication, lateral and posterior views.

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Medial pterygoid| Medial surface of lateral pterygoid plate, pyramidal process of palatine bone, and tuberosity of maxilla| Medial aspect of mandibular ramus| Mandibular nerve via medial pterygoid nerve| Elevate and protrude mandible
Lateral pterygoid (superior head)| Lateral surface of greater wing of sphenoid bone| Neck of mandible, articular disc, and TMJ capsule| Mandibular nerve via lateral pterygoid nerve| Acting bilaterally: protrude and depress mandible
Lateral pterygoid (inferior head)| Lateral surface of lateral pterygoid plate| Acting unilaterally: laterally deviate mandible

#### Muscles of the Floor of the Mouth

Figure 2-9 Floor of mouth, inferior view.

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Mylohyoid| Mylohyoid line of mandible| Hyoid bone| Mylohyoid nerve (branch of cranial nerve [CN] V3)| Elevates hyoid bone
Stylohyoid| Styloid process of temporal bone| Hyoid bone| Cervical branch of facial nerve| Elevates and retracts hyoid bone
Geniohyoid| Inferior mental spine of mandible| Hyoid bone| C1 via hypoglossal nerve| Elevates hyoid bone anterosuperiorly
Digastric (anterior belly)| Digastric fossa of mandible| Intermediate tendon to hyoid bone| Mylohyoid nerve| Depresses mandible; raises and stabilizes hyoid bone
Digastric (posterior belly)| Mastoid notch of temporal bone| Facial nerve

Figure 2-10 Floor of mouth, anteroinferior and posterosuperior views.

### Nerves

#### Mandibular Nerve

Figure 2-11 Mandibular nerve, medial and lateral views.

Nerves| Segmental Levels| Sensory| Motor
---|---|---|---
Mandibular| CN V3| Skin of inferior third of face| Temporalis, masseter, lateral pterygoid, medial pterygoid, digastric, mylohyoid
Nerve to mylohyoid| CN V3| No sensory| Mylohyoid
Buccal| CN V3| Cheek lining and gingiva| No motor
Lingual| CN V3| Anterior tongue and floor of mouth| No motor
Maxillary| CN V2| Skin of middle third of face| No motor
Ophthalmic| CN V1| Skin of superior third of face| No motor

CN V, trigeminal nerve.

## Patient History

### Initial Hypotheses Based on Patient History

Patient Reports| Initial Hypothesis
---|---
Patient reports jaw crepitus and pain during mouth opening and closing. Might also report limited opening with translation of the jaw to the affected side at the end range of opening| Possible osteoarthrosis
Possible capsulitis
Possible internal derangement consisting of an anterior disc displacement that does not reduce1-3
Patient reports jaw clicking and pain during opening and closing of the mouth| Possible internal derangement consisting of anterior disc displacement with reduction1,4,5
Patient reports limited motion to about 20 mm with no joint noise| Possible capsulitis
Possible internal derangement consisting of an anterior disc displacement that does not reduce1

#### The Association of Oral Habits with Temporomandibular Disorders

Figure 2-12 Frequent leaning of head on the palm.

Gavish and colleagues6 investigated the association of oral habits with signs and symptoms of TMDs in 248 randomly selected female high school students. Although sensitivity and specificity were not reported, the results demonstrated that chewing gum, jaw play (nonfunctional jaw movements), chewing ice, and frequent leaning of the head on the palm were associated with the presence of TMJ disorders.

### Reliability of Patient's Reports of Pain in Temporomandibular Dysfunction

Figure 2-13 Temporomandibular joint pain.

Historical Finding and Study Quality| Description and Positive Findings| Population| Test-Retest Reliability
---|---|---|---
Visual analog scale (VAS)7  | A 100-mm line, with ends defined as "no pain" and "worst pain imaginable"| 38 consecutive patients referred with TMD| κ = .38
Numerical scale7  | An 11-point scale, with 0 indicating "no pain" and 10 representing "worst pain"| κ = .36
Behavior rating scale7  | A 6-point scale ranging from "minor discomfort" to "very strong discomfort"| κ = .68
Verbal scale7  | A 5-point scale ranging from "no pain" to "very severe pain"| κ = .44

### Diagnostic Utility of Patient History in Identifying Anterior Disc Displacement

Figure 2-14 Anterior disc displacement.

Historical Finding and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Clicking8  | Momentary snapping sound during opening or functioning| 70 patients (90 TMJs) referred with complaints of craniomandibular pain| Anterior disc displacement via MRI| In presence of reducing disc
.82| .19| 1.01| .95
In presence of nonreducing disc
.86| .24| 1.13| .58
Locking8  | Sudden onset of restricted movement during opening or closing| In presence of reducing disc
.53| .22| .68| 2.14
In presence of nonreducing disc
.86| .52| 1.79| .27
Restriction after clicking8  | Inability to open as wide as was previously possible after clicking| In presence of reducing disc
.26| .40| .43| 1.85
In presence of nonreducing disc
.66| .74| 2.54| .46
Periodic restriction8  | Periodic inability to open as wide as was previously possible| | | In presence of reducing disc
.60| .90| 6.0| .44
In presence of nonreducing disc
.12| .95| 2.4| .93
Continuous restriction8  | Continuous inability to open as wide as was previously possible| In presence of reducing disc
.35| .26| .47| 2.5
In presence of nonreducing disc
.78| .62| 2.05| .35
Function related to joint pain8  | Not reported| In presence of reducing disc
.82| .10| .91| 1.8
In presence of nonreducing disc
.96| .24| 1.26| .17
Complaint of clicking8  | In presence of reducing disc
.28| .24| .37| 3.00
In presence of nonreducing disc
.82| .69| 2.65| .26
Complaint of movement-related pain8  | In presence of reducing disc
.71| .31| 1.03| .94
In presence of nonreducing disc
.74| .36| 1.16| .72
Complaint of severe restriction8  | In presence of reducing disc
.60| .65| 1.71| .62
In presence of nonreducing disc
.38| .93| 5.43| .67

### Self-Reported Temporomandibular Pain

#### Reliability of Self-Reported Temporomandibular Pain

Figure 2-15 Temporomandibular arthrosis.

Historical Finding and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Self-report of TMJ pain9  | See diagnostic table on following page. Participants were asked same questions 2 weeks apart| 120 adolescents: 60 with self-reported TMJ pain and 60 age- and sex-matched controls| Test-retest κ = .83 (.74, .93)
TMD pain screening questionnaire10  | See diagnostic table on following page. Participants were asked same questions 2 to 7 days apart| 549 participants: 212 with pain-related TMD, 116 with TMD, 80 with odontalgia, 45 with headache without TMD pain, and 96 healthy controls| ICC = .83

#### Diagnostic Utility of Self-Reported Temporomandibular Pain

Historical Finding and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Self-report of TMJ pain9  | Participants were asked:

(1) "Do you have pain in your temple, face, TMJ, or jaw once a week or more?"

(2) "Do you have pain when you open your mouth wide or chew once a week or more?"

If answer was "yes" to either question, test was positive| 120 adolescents: 60 with self-reported TMJ pain and 60 age- and sex-matched controls| RDC/TMD diagnosis of myofascial pain or arthralgia, arthritis, and arthrosis| .98| .90| 9.8 (4.8, 20.0)| .02 (.00, .16)
TMD pain screening questionnaire10  | Participants were asked:

(1) "In the last 30 days, on average, how long did any pain in your jaw or temple area on either side last?"

(a) There was no pain

(b) Pain lasted from a very brief time to more than a week, but it did stop

(c) Pain was continuous

(2) "In the last 30 days, have you had pain or stiffness in your jaw on awakening?"

(a) No

(b) Yes

(3) "In the last 30 days, did [...] chewing hard or tough food [...] change any pain (i.e., make it better or make it worse) in your jaw or temple area on either side?"

(a) No

(b) Yes

An (a) response received 0 points, a (b) response received 1 point, and a (c) response received 2 points.
The test was positive for scores of 2 or higher| 549 participants: 212 with pain-related TMD, 116 with TMJ disorder, 80 with odontalgia, 45 with headache without TMD pain, and 96 healthy controls| RDC/TMD assessment protocol| .99| .97| 33.0| .01

RDC/TMD, Research Diagnostic Criteria for Temporomandibular Disorders

diagnostic accuracy statistics reported for participants with pain-related TMD versus healthy controls.

## Diagnostic Criteria for TMD

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) provides evidence-based criteria for assessing patients with TMD. It superseded the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) as of 2014 and is intended for immediate implementation in both clinical and research settings.11 All tools required for clinical implementation are available at the International RDC-TMD Consortium website (www.rdc-tmdinternational.org/, accessed February 2015). A summary of the DC/TMD is presented here along with the associated reliability and diagnostic utility statistics. However, because the sources of the statistical estimates were not always clear, we were unable to assess the quality of the studies that provided the reliability and diagnostic utility values. The previous version of RDC/TMD showed fair to moderate agreement for most diagnoses and no to slight agreement for some diagnoses.

### Reliability and Diagnostic Criteria for Pain-Related TMD

Diagnosis| History| Examination| Interexaminer Reliability| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Myalgia| Positive for both:

1. Pain in jaw, temple, ear, front of ear

2. Pain modified with jaw movement, function, or parafunction

| Positive for both:

1. Confirmation of pain in temporalis or masseter muscle

2. Report of familiar pain with one or more of following:

(a) Palpation of temporalis muscle;

(b) Palpation of masseter muscle;

(c) Maximum unassisted or assisted opening movement

| κ = .94 (.83, 1.00)| .90| .99| 90.0| .10
Local myalgia| Positive for both:

1. Pain in jaw, temple, ear, or front of ear

2. Pain modified with jaw movement, function, or parafunction

| Positive for all:

1. Confirmation of pain in temporalis or masseter muscle

2. Report of familiar pain with palpation of temporalis or masseter muscle

3. Report of pain localized to site of palpation

| Not reported| Not established| Not established| Not established| Not established
Myofascial pain| Positive for both:

1. Pain in jaw, temple, ear, or front of ear

2. Pain modified with jaw movement, function, or parafunction

| Positive for all:

1. Confirmation of pain in temporalis or masseter muscle

2. Report of familiar pain with palpation of temporalis or masseter muscle

3. Report of pain spreading beyond site of palpation but within boundary of muscle

| Not reported| Not established| Not established| Not established| Not established
Myofascial pain with referral| Positive for both:

1. Pain in jaw, temple, ear, or front of ear

2. Pain modified with jaw movement, function, or parafunction

| Positive for all:

1. Confirmation of pain in temporalis or masseter muscle

2. Report of familiar pain with palpation of temporalis or masseter muscle

3. Report of pain at site beyond boundary of muscle palpated

| κ = .85 (.55, 1.00)| .86| .98| 43.0| .14
Arthralgia| Positive for both:

1. Pain in jaw, temple, ear, or front of ear

2. Pain modified with jaw movement, function, or parafunction

| Positive for both:

1. Confirmation of pain in area of TMJ

2. Report of familiar pain in TMJ with at least one of the following provocation tests:

(a) Palpation of lateral pole or around lateral pole

(b) Maximum unassisted or assisted opening, right or left lateral, or protrusive movement

| κ = .86 (.75, .97)| .89| .98| 44.5| .11
Headache attributed to TMD| Positive for both:

1. Headache of any type in temple

2. Headache modified with jaw movement, function, or parafunction

| Positive for both:

1. Confirmation of headache in area of temporalis muscle

2. Report of familiar headache in temple with at least one of the following provocation tests:

(a) Palpation of temporalis muscle

(b) Maximum unassisted or assisted opening, right or left lateral, or protrusive movement

| Not reported| .89| .87| 6.85| .13

Note: Reliability and validity are derived from the datasets of the Validation Project and TMJ Impact Project Finalization of DC/TMD.11

### Reliability and Diagnostic Criteria for Intraarticular TMD

Diagnosis| History| Examination| Interexaminer Reliability| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Disc displacement with reduction| Positive for at least one:

1. In last 30 days, any TMJ noise present with jaw movement or function

2. Patient reports any noise present during examination

| Positive for at least one:

1. Clicking, popping, and/or snapping noise during both opening and closing movements, detected with palpation during at least one of three repetitions of jaw opening and closing movements

2. Clicking, popping, and/or snapping noise detected with palpation during at least one of three repetitions of opening or closing movements AND right or left lateral or protrusive movement(s)

| κ = .58 (.33, .84)| .34| .92| 4.25| .72
Disc displacement with reduction with intermittent locking| Positive for both:

1. In last 30 days, any TMJ noise with jaw movement or function or patient reports any noise present during examination

2. In last 30 days, jaw locks with limited mouth opening and then unlocks

| Positive for at least one:

1. Clicking, popping, and/or snapping noise during both opening and closing movements, detected with palpation during at least one of three repetitions of jaw opening and closing movements

2. Clicking, popping, and/or snapping noise detected with palpation during at least one of three repetitions of opening or closing movements AND right or left lateral or protrusive movement

| Not reported| .38| .98| 19.0| .63
Disc displacement without reduction with limited opening| Positive for both:

1. Jaw locked so that mouth would not open all the way

2. Limitation in jaw opening severe enough to limit jaw opening and interfere with ability to eat

| Positive for the following:

1. Maximum assisted opening (passive stretch) movement, including vertical incisal overlap less than 40 mm

| Not reported| .80| .97| 26.7| .21
Disc displacement without reduction without limited opening| Positive for both of the following in the past:

1. Jaw locked so that mouth would not open all the way

2. Limitation in jaw opening severe enough to limit jaw opening and interfere with ability to eat

| Positive for the following:

1. Maximum assisted opening (passive stretch) movement, including vertical incisal overlap of 40 mm or more

| κ = .84 (.38, 1.00)| .54| .79| 2.57| .58
Degenerative joint disease| Positive for at least one:

1. In last 30 days, any TMJ noise present with jaw movement or function

2. Patient reports any noise present during examination

| Positive for the following:

1. Crepitus detected with palpation during at least one of the following: opening, closing, right or left lateral movement, or protrusive movement

| κ = .33 (.01, .65)| .55| .61| 1.41| .74
Subluxation| Positive for both:

1. In last 30 days, jaw locking or catching in a wide-open mouth position so could not close from wide-open position

2. Inability to close mouth from wide-open position without a self-maneuver

| No examination findings required| Not reported| .98| 1.00| Undefined| .02

Note: Reliability and validity are derived from the datasets of the Validation Project and TMJ Impact Project Finalization of DC/TMD.11

## Physical Examination Tests

### Palpation

#### Reliability in Determining the Presence of Pain during Muscle Palpation

Finding and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Extraoral12  | Examiner palpates the temporalis, masseter, posterior cervical, and sternocleidomastoid muscles| 64 healthy volunteers| κ = .91
Intraoral12  | Examiner palpates tendon of the temporalis, lateral pterygoid, and masseter muscles and body of the tongue| κ = .90
Masseter13  | Examiner palpates the midbelly of the masseter muscle| 79 randomly selected patients referred to craniomandibular disorder department| κ = .33
Temporalis13  | Examiner palpates the midbelly of the temporalis muscle| κ = .42
Medial pterygoid13  | Examiner palpates the insertion of the medial pterygoid muscle| κ = .23
Masseter14  | Examiner palpates the superficial and deep portions of the masseter muscle| 79 patients referred to TMD and orofacial pain department| κ = .33
Temporalis14  | Examiner palpates the anterior and posterior aspects of the temporalis muscle| κ = .42
Medial pterygoid14 attachment  | Examiner palpates the medial pterygoid muscles extraorally| κ = .23
Masseter15  | Examiner palpates the origin, body, and insertion of the masseter muscle| 27 TMD patients| κ (Right) = .78
(Left) = .56
Temporalis15  | Examiner palpates the origin, body, and insertion of the temporalis muscle| κ (Right) = .87
(Left) = .91
Tendon of temporalis15  | Examiner palpates the tendon of the temporalis muscle| κ (Right) = .53
(Left) = .48

#### Reliability in Determining the Presence of Pain during Temporomandibular Joint Regional Palpation

Figure 2-16 Musculature of the temporomandibular joint.

Finding and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Lateral palpation16  | Examiner palpates anterior to the ear over the TMJ| 61 patients with TMJ pain| Intraexaminer κ = .53
Posterior palpation16  | Examiner palpates TMJ through external meatus| 61 patients with TMJ pain| Intraexaminer κ = .48
Palpation of TMJ13  | Examiner palpates the lateral and dorsal aspects of the condyle| 79 randomly selected patients referred to craniomandibular disorder department| Interexaminer κ = .33
Masseter14  | Examiner palpates the superficial and deep portions of the masseter muscle| 79 patients referred to TMD and orofacial pain department| Interexaminer κ = .33
Palpation of TMJ14  | Examiner palpates the lateral pole of the condyle in open and closed mouth positions. The dorsal pole is palpated posteriorly through the external auditory meatus| Interexaminer κ = .33
Retromandibular region15  | Examiner palpation consistent with RDC/TMD guidelines| 27 TMD patients| Interexaminer κ (Right) = .56 (Left) = .50
Submandibular region15  | Interexaminer κ (Right) = .73 (Left) = .68
Lateral pterygoid area15  | Interexaminer κ (Right) = .50 (Left) = .37
Lateral pole and posterior attachment of TMJ15  | Interexaminer κ (Right) = .43 (Left) = .46

Figure 2-17 Palpation tests.

#### Diagnostic Utility of Palpation in Identifying Temporomandibular Conditions

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Lateral palpation16  | Examiner palpates the lateral pole of the condyle with the index finger. Positive if pain is present| 61 patients with TMJ pain| Presence of TMJ effusion via MRI| .83| .69| 2.68| .25
Posterior palpation16  | Examiner palpates the posterior portion of the condyle with the little finger in the patient's ear. Positive if pain is present| .85| .62| 2.24| .24
Palpation17  | Palpation of lateral and posterior aspects of the TMJ and assessment of pain response with active movements. Positive if patient reports pain| 84 patients with symptoms of TMJ pain| TMJ synovitis via arthroscopic investigation| .92| .21| 1.16| .38
Palpation18  | Examiner palpates lateral and posterior aspects of the TMJ with one finger and determines the presence of tenderness| 200 consecutive patients with TMJ disease| TMJ synovitis via arthroscopic investigation| .88| .36| 1.38| .33
Tender joint on palpation8  | Examiner palpates the lateral and posterior aspects of the joint. Positive if pain is present| 70 patients (90 TMJs) referred with complaints of craniomandibular pain| Detecting anterior disc displacement via MRI| In presence of reducing disc
.38| .41| .64| 1.51
In presence of nonreducing disc
.66| .67| 2.0| .51
Palpation19  | Examiner palpates the TMJ laterally and posteriorly, the temporalis muscle, and the masseter muscle. Pain recorded via VAS using a cutoff value to maximize sensitivity and specificity| 147 patients referred for craniomandibular complaints and 103 asymptomatic individuals| Patient report of tenderness in masticatory muscles, preauricular area, or TMJ in past month| .75| .67| 2.27| .37
Palpation of temporalis muscle20  | Performed with index and middle fingers for 2 to 4 seconds with approximately 3 pounds of pressure on the muscle and 2 pounds of pressure on the joint. Pain recorded via VAS with cutoff values at 1 standard deviation from the mean*| 40 patients diagnosed with TMD and 40 asymptomatic patients| TMD diagnosis from RCD/TMD evaluation| Right side*
.60| .78| 2.73| .51
Left side*
.70| .83| 4.12| .36
Palpation of TMJ20  | Right side*
.68| .88| 5.67| .36
Left side*
.73| .85| 4.87| .32
Palpation of masseter muscle20  | Right side*
.73| .85| 4.87| .32
Left side*
.73| .80| 3.65| .34

*Gomes and colleagues20 also calculated sensitivity and specificity for cutoff values of 1.5 and 2 standard deviations. Values showed almost perfect specificity but poor sensitivity.

#### Diagnostic Utility of Pressure Pain Thresholds in Identifying Temporomandibular Disorder

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
PPT of temporalis muscle20  | Used pressure algometer fitted with a rubber tip. PPT defined as lightest pressure to cause pain. Cutoff values represent 1 standard deviation from the mean*| 40 patients diagnosed with TMD and 40 asymptomatic patients| TMD diagnosis from RCD/TMD evaluation| Right side
.68| .88| 5.67| .36
Left side
.63| .90| 6.30| .41
PPT of TMJ20  | Right side
.56| .95| 11.20| .46
Left side
.75| .95| 15.00| .26
PPT of masseter muscle20  | Right side
.75| .90| 7.50| .28
Left side
.78| .90| 7.80| .24
PPT of anterior temporalis muscle21  | Used pressure algometer pressed into relaxed muscle belly. PPT defined as lightest pressure to cause pain. Cutoff values chosen from receiver operator curve when specificity was .91| 99 women with dental or intraarticular TMJ pain| .77| .91| 8.37| .25
PPT of middle temporalis muscle21  | .73| .91| 7.93| .30
PPT of posterior temporalis muscle21  | .67| .91| 7.28| .36
PPT of masseter muscle21  | .55| .91| 5.98| .50

*Gomes and colleagues20 also calculated sensitivity and specificity for cutoff values of 1.5 and 2 standard deviations. Values showed almost perfect specificity but poor sensitivity.

PPT, pressure pain threshold.

### Joint Sounds

#### Reliability of Detecting Joint Sounds during Active Motion

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Click sounds during mouth opening16  | During mouth opening, examiner records the presence of a click sound| 61 patients with TMJ pain| Intraexaminer κ = .12
Crepitus sounds during mouth opening16  | During mouth opening, examiner records the presence of a grating or grinding sound| Intraexaminer κ = .15
Clicking during active maximal mouth opening13  | Intensity of clicking and crepitation is graded on a scale of 0 to 2 from "none" to "clearly audible"| 79 randomly selected patients referred to craniomandibular disorder department| Interexaminer κ = .70
Crepitation during active maximal mouth opening13  | Interexaminer κ = .29
Joint noise13  | Presence of joint noises is recorded by examiner| Interexaminer κ = .24
Opening14  | Examiner records the presence of joint sounds during mandibular opening, lateral excursion to right and left, and protrusion| 79 patients referred to TMD and orofacial pain department| Interexaminer κ = .59
Lateral excursion, right14  | Interexaminer κ = .57
Lateral excursion, left14  | Interexaminer κ = .50
Protrusion14  | Interexaminer κ = .47
TMJ sounds15  | Presence of joint noises is recorded by examiner during mouth opening| 27 TMD patients| Interexaminer κ (Right) = .52 (Left) = .25

#### Reliability of Detecting Joint Sounds during Joint Play

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Joint noise during joint play13  | Examiner records presence of joint noise during traction and translation| 79 randomly selected patients referred to craniomandibular disorder department| Interexaminer κ = −.01
Traction, right14  | Examiner moves the mandibular condyle in an inferior direction for traction and in a mediolateral direction for translation. Examiner records presence of joint sound during translation and traction| 79 patients referred to TMD and orofacial pain department| Interexaminer κ = −.02
Traction, left14  | Interexaminer κ = .66
Translation, right14  | Interexaminer κ = .07
Translation, left14  | Interexaminer κ = −.02

#### Diagnostic Utility of Clicking in Identifying Temporomandibular Conditions

Figure 2-18 Auscultation performed with a stethoscope.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Clicking3  | Examiner palpates the lateral aspect of the TMJ during opening and closing. Examiner records audible, palpable clicking| 146 patients attending TMJ and craniofacial pain clinic| Anterior disc displacement with reduction via MRI| .51| .83| 3.0| .59
Clicking16  | Examiner auscultates for sounds during joint movement. Presence of a click sound is considered positive| 61 patients with TMJ pain| Presence of TMJ effusion via MRI| .69| .51| 1.41| .61
Reproducible clicking8  | Auscultation with a stethoscope. Considered positive if observed at least four times during five repetitions of mouth opening| 70 patients (90 TMJs) referred with complaints of craniomandibular pain| Detecting anterior disc displacement via MRI| In presence of reducing disc
.10| .40| .17| 2.25
In presence of nonreducing disc
.71| .90| 7.10| .32
Reciprocal clicking8   (see Video 2-1)| Auscultation with a stethoscope. Considered positive if a click on opening is followed by a click on closing| In presence of reducing disc
.40| .52| .83| 1.15
In presence of nonreducing disc
.76| .95| 15.2| .25

#### Diagnostic Utility of Crepitus in Identifying Temporomandibular Conditions

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Presence of crepitus16  | Examiner auscultates for sounds during joint movement. Presence of grating or grinding noise is considered positive| 61 patients with TMJ pain| Presence of TMJ effusion via MRI| .85| .30| 1.21| .50
Presence of crepitus17  | Osteoarthritis based on presence of crepitus during auscultation. Presence of crepitus is considered positive| 84 patients with symptoms of TMJ pain| TMJ osteoarthritis via arthroscopic investigation| .70| .43| 1.23| .70
Presence of crepitus18  | Auscultation performed with stethoscope. Presence of crepitus is considered positive| 200 consecutive patients with TMJ disease| TMJ osteoarthritis via arthroscopic investigation| Minor osteoarthritis*
.45| .84| 2.81| .65
Severe osteoarthritis*
.67| .86| 4.79| .38

*Minor osteoarthritis is defined as the presence of smooth, glossy white surfaces of the disc and fibrocartilage. Severe osteoarthritis is defined as the presence of one or more of the following features: (1) pronounced fibrillation of the articular cartilage and disc; (2) exposure of subchondral bone; and (3) disc perforation.

### Range-of-Motion Measurements

#### Reliability of Range-of-Motion Measurements of the Temporomandibular Joint during Mouth Opening

Figure 2-19 Measurement of mouth opening active range of motion.

Figure 2-20 Plastic vernier caliper used to measure mandibular position.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Opening22  | Without TMJ disorder| Patient is instructed to open mouth as much as possible without causing pain. Interincisal distance is measured to the nearest millimeter with a plastic ruler| 15 subjects with TMJ disorder and 15 subjects without this disorder| Interexaminer ICC = .98
Intraexaminer ICC = .77 to .89
With TMJ disorder| Interexaminer ICC = .99
Intraexaminer ICC = .94
Unassisted opening without pain23  | In older adults| Measured in millimeters with ruler consistent with RMC/TMD guidelines| 43 asymptomatic older adults (age 68 to 96 years) and 44 asymptomatic young adults (age 18 to 45 years)| Interexaminer ICC = .88 (.78, .94)
In young adults| Interexaminer ICC = .91 (.83, .95)
Maximum unassisted opening23  | In older adults| Interexaminer ICC = .95 (.91, .97)
In young adults| Interexaminer ICC = .98 (.96, .99)
Maximum assisted opening23  | In older adults| Interexaminer ICC = .96 (.92, .98)
In young adults| Interexaminer ICC = .98 (.96, .99)
Unassisted opening without pain15  | 27 TMD patients| Interexaminer ICC = .83
Maximum unassisted opening15  | Interexaminer ICC = .89
Maximum assisted opening15  | Interexaminer ICC = .93

#### Reliability of Range-of-Motion Measurements of the Temporomandibular Joint

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Overbite22  | Without TMJ disorder| A horizontal line is made on the lower incisor at the level of the upper incisor with the TMJ closed. The vertical distance between the line, and the superior aspect of the lower incisor is measured| 15 subjects with TMJ disorder and 15 subjects without TMJ disorder| Interexaminer ICC = .98
Intraexaminer ICC = .90 to .96
With TMJ disorder| Interexaminer ICC = .95
Intraexaminer ICC = .90 to .97
Excursion, left22  | Without TMJ disorder| Vertical marks are made in the median plane on the anterior surface of the lower central incisors in relationship to the upper central incisors. Patient is instructed to move the jaw as far lateral as possible, and the measurement is recorded| Interexaminer ICC = .95
Intraexaminer ICC = .91 to .92
With TMJ disorder| Interexaminer ICC = .94
Intraexaminer ICC = .85 to .92
Excursion, right22  | Without TMJ disorder| Interexaminer ICC = .90
Intraexaminer ICC = .70 to .87
With TMJ disorder| Interexaminer ICC = .96
Intraexaminer ICC = .75 to .82
Protrusion22  | Without TMJ disorder| Two vertical lines are made on the first upper and lower canine incisors. Subject is instructed to move the jaw as far forward as possible, and a measurement is made between the two marks| Interexaminer ICC = .95
Intraexaminer ICC = .85 to .93
With TMJ disorder| Interexaminer ICC = .98
Intraexaminer ICC = .89 to .93
Overjet22  | Without TMJ disorder| The horizontal distance between the upper and lower incisors is measured when the mouth is closed| Interexaminer ICC = 1.0
Intraexaminer ICC = .98
With TMJ disorder| Interexaminer ICC = .99
Intraexaminer ICC = .98 to .99
Maximum laterotrusion23  | In older adults| Measured in millimeters with ruler consistent with RMC/TMD guidelines| 43 older asymptomatic adults (age 68 to 96 years) and 44 young asymptomatic adults (age 18 to 45 years)| Interexaminer ICC = .71 (.45, .84)
In young adults| Interexaminer ICC = .77 (.57, .88)
Maximum protrusion23  | In older adults| Interexaminer ICC = .78 (.59, .88)
In young adults| Interexaminer ICC = .90 (.81, .95)
Lateral excursion, right15  | 27 TMD patients| Interexaminer ICC = .41
Lateral excursion, left15  | Interexaminer ICC = .40
Horizontal overbite15  | Interexaminer ICC = .79
Vertical overlap15  | Interexaminer ICC = .70
Opening24  | A plastic vernier caliper was used to measure mandibular position| 30 healthy subjects| Interexaminer ICC = .95
Intraexaminer ICC = .97
Protrusion24  | Interexaminer ICC = .77
Intraexaminer ICC = .95
Laterotrusion right24  | Interexaminer ICC = .50
Intraexaminer ICC = .90
Laterotrusion left24  | Interexaminer ICC = .42
Intraexaminer ICC = .92
Overbite24  | Interexaminer ICC = .70
Intraexaminer ICC = .93
Overjet24  | Interexaminer ICC = .70
Intraexaminer ICC = .96

#### Reliability of Joint Play and End-Feel Assessment of the Temporomandibular Joint

Figure 2-21 Translation of mandible, left.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Traction and translation13  | Restriction of movement| Examiner records the presence of restriction of movement at end feel during traction and translation of the TMJ| 79 randomly selected patients referred to craniomandibular disorder department| Interexaminer κ = .08
End feel| Interexaminer κ = .07
Traction, right14  | Joint play| Examiner moves the mandibular condyle in an inferior direction for traction and a mediolateral direction for translation. The extent of joint play and end feel is graded as "normal" or "abnormal"| 79 patients referred to TMD and orofacial pain department| Interexaminer κ = −.03
End feel| Interexaminer κ = −.05
Traction, left14  | Joint play| Interexaminer κ = .08
End feel| Interexaminer κ = .20
Translation, right14  | Joint play| Interexaminer κ = −.05
End feel| Interexaminer κ = −.05
Translation, left14  | Joint play| Interexaminer κ = −.10
End feel| Interexaminer κ = −.13

#### Reliability of Measuring Mandibular Opening with Different Head Positions

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Forward head position25  | Patient is instructed to slide the jaw forward as far as possible, and a measurement of vertical mandibular opening is recorded| 40 healthy subjects| Interexaminer ICC = .92
Intraexaminer ICC = .97
Neutral head position25  | Patient is placed in a position where a plumb line bisects the ear, and a measurement of vertical mandibular opening is recorded| Interexaminer ICC = .93
Intraexaminer ICC = .93
Retracted head position25  | Patient is instructed to slide the jaw backward as far as possible, and a measurement of vertical mandibular opening is recorded| Interexaminer ICC = .92
Intraexaminer ICC = .92

#### Diagnostic Utility of Limited Range of Motion in Identifying Anterior Disc Displacement

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Restriction of condylar translation3  | Examiner asks patient to maximally open mouth while palpating condylar movement. Examiner records any limitation of condylar translation| 146 patients attending TMJ and craniofacial pain clinic| Anterior disc displacement without reduction via MRI| .69| .81| 3.63| .38
Restriction of range of functional opening3  | Examiner asks patient to maximally open mouth and measures the distance in millimeters. Less than 40 mm is considered a restriction| .32| .83| 1.88| .82
Restriction of range of functional opening8  | Measurement is taken at the end range of active mouth opening. Definition of positive not reported| 70 patients (90 TMJs) referred with complaints of craniomandibular pain| Anterior disc displacement via MRI| In presence of reducing disc
.38| .21| .48| 2.95
In presence of nonreducing disc
.86| .62| 2.26| .23
Restriction of range of passive opening8  | Measurement is taken at the end range of passive mouth opening after 15 seconds. Definition of positive not reported| In presence of reducing disc
.29| .29| .41| 2.45
In presence of nonreducing disc
.76| .69| 2.45| .35
Restricted translation8  | Not reported| In presence of reducing disc
.15| .38| .24| 2.24
In presence of nonreducing disc
.66| .81| 3.47| .42
Restricted protrusion8  | Measurement is taken at the end range of active mandibular protrusion. Definition of positive not reported| In presence of reducing disc
.29| .38| .47| 1.87
In presence of nonreducing disc
.62| .64| 1.72| .59
Restricted contralateral movement8  | Measurement is taken at the end of contralateral movement from the midline. Definition of positive not reported| In presence of reducing disc
.15| .34| .23| 2.50
In presence of nonreducing disc
.66| .76| 2.75| .45

### Dynamic Movement Measurements

#### Diagnostic Utility of Deviations in Movement in Identifying Anterior Disc Displacement

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Deviation of mandible3  | Patient is asked to maximally open the mouth. If the midline of the upper and lower incisors does not line up, then the test is considered positive| 146 patients attending TMJ and craniofacial pain clinic| Anterior disc displacement without reduction via MRI| .32| .87| 2.46| .78
Deviation of mandible with correction8  | Examiner observes active mouth opening. Test is considered positive if a deviation occurs and the mandible returns to midline| 70 patients (90 TMJs) referred with complaints of craniomandibular pain| Anterior disc displacement via MRI| In presence of reducing disc
.14| .57| .33| 1.51
In presence of nonreducing disc
.44| .83| 2.59| .67
Deviation of mandible without correction8  | Examiner observes active mouth opening. Test is considered positive if the mandible does not return to midline after deviation| In presence of reducing disc
.18| .41| .31| 2.0
In presence of nonreducing disc
.66| .83| 3.88| .41

#### Reliability of Determining the Presence of Pain during Dynamic Movements

Figure 2-22 Assessment of pain during passive opening.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Mandibular movements16  | Patient is asked if pain is felt during opening, closing, lateral excursion, protrusion, and retrusion| 61 patients with TMJ pain| Intraexaminer κ = .43
Maximum assisted opening16  | Examiner applies overpressure to the end range of mandibular depression| Intraexaminer κ = −.05
Pain on opening14  | Patient is asked to maximally open mouth| 79 patients referred to TMD and orofacial pain department| Interexaminer κ = .28
Pain on lateral excursion, right14  | Patient is asked to move the mandible in a lateral direction as far as possible| Interexaminer κ = .28
Pain on lateral excursion, left14  | Interexaminer κ = .28
Pain on protrusion14  | Patient is asked to actively protrude the jaw| Interexaminer κ = .36
Passive opening13  | At the end of active opening the examiner applies a passive stretch to increase mouth opening| 79 randomly selected patients referred to craniomandibular disorder department| Interexaminer κ = .34
Active opening13  | Patient is asked to open mouth as wide as possible| Interexaminer κ = .32

#### Reliability of Detecting Pain during Resistance Tests

Figure 2-23 Manual resistance applied during lateral deviation.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Dynamic tests16  | Patient performs opening, closing, lateral excursion, protrusion, and retrusion movements while examiner applies resistance| 61 patients with TMJ pain| Intraexaminer κ = .20
Opening14  | Examiner applies isometric resistance during opening, closing, and lateral excursions to the right and left of the TMJ. The presence of pain is recorded| 79 patients referred to TMD and orofacial pain department| Interexaminer κ = .24
Closing14  | Interexaminer κ = .30
Lateral excursion, right14  | Interexaminer κ = .28
Lateral excursion, left14  | Interexaminer κ = .26
Static pain test13  | The examiner applies resistance against the patient's mandible in upward, downward, and lateral directions| 79 randomly selected patients referred to craniomandibular disorder department| Interexaminer κ = .15

#### Reliability of Determining the Presence of Pain during Joint Play

Figure 2-24 Temporomandibular traction.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Joint play test12  | Examiner performs passive traction and translation movements| 61 patients with TMJ pain| Intraexaminer ICC = .20
Joint play test14  | Examiner applies a traction and a translation (mediolateral) force through the TMJ| 79 randomly selected patients referred to craniomandibular disorder department| Interexaminer ICC = .46
Traction, right15  | Examiner moves the mandibular condyle in an inferior direction for traction and a mediolateral direction for translation. The presence of pain is recorded| 79 patients referred to TMD and orofacial pain department| Interexaminer ICC = −.08
Traction, left15  | Interexaminer ICC = .25
Translation, right  | Interexaminer ICC = .50
Translation, left15  | Interexaminer ICC = .28

#### Diagnostic Utility of Pain in Identifying Temporomandibular Conditions

Figure 2-25 Manual resistance applied during mouth opening and closing.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Pain during mandibular movements16  | Patient is asked to open, close, protrude, retrude, and perform lateral excursion of the mandible. Positive if pain present| 61 patients with TMJ pain| Presence of TMJ effusion via MRI| .82| .61| 2.10| .30
Pain during maximum opening and overpressure16  | Patient is asked to perform the movements above while examiner applies resistance. Positive if pain present| .93| .16| .95| 4.38
Pain during dynamic tests16  | Patient is instructed to open the mouth as wide as possible, and examiner applies overpressure. Positive if pain present| .74| .44| 1.32| .59
Pain during joint play16  | Examiner passively performs translation and traction of the TMJ. Positive if pain present| .80| .39| 1.31| .51
TMJ pain during assisted opening3
(see Video 2-2)| At the end of maximal mouth opening, examiner applies 2 to 3 pounds of overpressure. The presence or absence of pain is recorded| 146 patients attending TMJ and craniofacial pain clinic| Anterior disc displacement without reduction via MRI| .55| .91| 6.11| .49
Joint pain on opening8  | Patient is asked to open mouth as wide as possible. Positive if pain present| 70 patients (90 TMJs) referred with complaints of craniomandibular pain| Anterior disc displacement via MRI| In presence of reducing disc
.44| .31| .64| 1.81
In presence of nonreducing disc
.74| .57| 1.72| .46
Pain with contralateral motion8  | Patient is asked to perform lateral excursion contralateral to the side of joint involvement. Positive if pain present| In presence of reducing disc
.60| .69| 1.94| .58
In presence of nonreducing disc
.34| .93| 4.86| .71
Dynamic/static19  | Manual resistance was applied during mouth opening, closing, protrusion, and lateral deviation. Pain was recorded via VAS using a cutoff value to maximize sensitivity and specificity| 147 patients referred for craniomandibular complaints and 103 asymptomatic individuals| Patient report of tenderness in masticatory muscles, preauricular area, or temporomandibular area in past month| .63| .93| .90| .40
Active movements19  | Patient was asked to maximally depress mandible, protrude it, and deviate it right and left. Pain was recorded via VAS using a cutoff value to maximize sensitivity and specificity| .87| .67| 2.64| .19
Passive movements19  | At the end of maximal mouth opening, examiner gently applied overpressure. Pain was recorded via VAS using a cutoff value to maximize sensitivity and specificity| .80| .64| 2.22| .31

### Other Tests

#### Reliability of the Compression Test

Figure 2-26 Bilateral temporomandibular compression.

Test and Study Quality| | Description and Positive Findings| Population| Reliability
---|---|---|---|---
Compression, right14  | Pain| The examiner loads the intraarticular structures by moving the mandible in a dorsocranial direction. The presence of pain and joint sounds are recorded| 79 patients referred to TMD and orofacial pain department| Interexaminer κ = .19
Sounds| Not reported
Compression, left14  | Pain| Interexaminer κ = .47
Sounds| Interexaminer κ = 1.0
Compression12  | Pain| 79 randomly selected patients referred to craniomandibular disorder department| Interexaminer κ = .40
Joint noises| Interexaminer κ = .66

#### Diagnostic Utility of Lower Extremity Measurements

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Leg length inequality26  | With patient supine, examiner visually compares the position of the medial malleoli. Considered positive if leg length inequality is .5 cm or more| 41 dental students| Interexaminer κ = .33 to .39
Internal foot rotation test26  | With patient supine, examiner exerts forced internal rotation of the foot and assesses the amount of end play. Considered positive if difference in rotation is 15 degrees or more| Interexaminer κ = .15 to .27

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Leg length inequality26  | With patient supine, examiner visually compares the position of the medial malleoli. Considered positive if leg length inequality is .5 cm or more| 41 dental students| Jaw muscle myofascial pain from RCD/TMD evaluation| .43| .41| .73| 1.39
Anterior TMJ disc displacement from RCD/TMD evaluation| .50| .41| .85| 1.22
Internal foot rotation test26  | With patient supine, examiner exerts forced internal rotation of the foot and assesses the amount of end play. Considered positive if difference in rotation is 15 degrees or more| Jaw muscle myofascial pain from RCD/TMD evaluation| .43| .47| .81| 1.21
Anterior TMJ disc displacement from RCD/TMD evaluation| .57| .52| 1.19| .83

### Combinations of Tests

#### Diagnostic Utility of Combined Tests for Detecting Anterior Disc Displacement with Reduction

Figure 2-27 Anterior disc displacement with reduction.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
No deviation of mandible; no pain during assisted opening3  | See previous descriptions under single test items| 146 patients attending TMJ and craniofacial pain clinic| Anterior disc displacement with reduction via MRI| .76| .30| 1.09| .80
No deviation of mandible; no limitation of opening3  | .76| .27| 1.04| .89
No deviation of mandible; no restriction of condylar translation3  | .75| .37| 1.19| .68
No deviation of mandible; clicking3  | .51| .85| 3.40| .58
No deviation of mandible; no pain during opening; no limitation of opening3  | .71| .35| 1.09| .83
No deviation of mandible; no pain during opening; no limitation of opening; no restriction of condylar translation3  | .68| .37| 1.08| .86
No deviation of mandible; no pain during opening; no limitation of opening; no restriction of condylar translation; clicking3  | .44| .86| 3.14| .65

#### Diagnostic Utility of Combined Tests for Detecting Anterior Disc Displacement without Reduction

Figure 2-28 Anterior disc displacement without reduction.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Motion restriction; no clicking3  | See previous descriptions under single test items| 146 patients attending TMJ and craniofacial pain clinic| Anterior disc displacement without reduction via MRI| .61| .82| 3.39| .48
Motion restriction; pain during assisted opening3  | .54| .93| 7.71| .49
Motion restriction; limitation of maximal mouth opening3  | .31| .87| 2.38| .79
Motion restriction; deviation of mandible3  | .30| .90| 3.0| .78
Motion restriction; no clicking, TMJ pain with assistive opening3  | .46| .94| 7.67| .59
Motion restriction; no clicking; TMJ pain with assistive opening; limitation of maximum mouth opening3  | .22| .96| 5.50| .81
Motion restriction; no clicking; TMJ pain with assistive opening; limitation of maximum mouth opening; deviation of mandible3  | .11| .98| 5.5| .91
Clinical diagnosis using history and combined tests27  | Examination using Clinical Diagnostic Criteria for Temporomandibular Disorders (CDC/TMD)| 69 patients referred with TMD| Anterior disc displacement without reduction via MRI| .75| .83| 4.41| .3

#### Predicting Treatment Success with Nightly Wear of Occlusal Stabilization Splint

Figure 2-29 Occlusal stabilization splint.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR*
---|---|---|---|---|---|---|---
Time since pain28  | 42 weeks or less| 119 consecutive patients referred to TMD clinic diagnosed with unilateral TMJ arthralgia| Treatment success (more than 70% reduction in VAS) after 6 months with nightly wear of occlusal stabilization splint| .62 (.49, .73)| .69 (.54, .80)| 2.0 (1.3, 3.0)| .55
Baseline pain level28  | 40 mm or more on VAS| .48 (.35, .60)| .72 (.57, .83)| 1.7 (1.0, 2.7)| .72
Change in VAS level at 2 months28  | 15 mm or more on VAS| .72 (.75, .93)| .91, (.64, .88)| 3.9 (2.3, 6.5)| .31
Disc displacement without reduction28  | As observed on MRI| .25 (.15, .37)| .91 (.79, .97)| 2.7 (1.0, 6.8)| .82
Four positive tests28  | Four of the four findings listed above| .10 (.04, .20)| .99 (.90, 1.00)| 10.8 (.62, 188.1)| .91
Three or more positive tests28  | Three or four of the four findings listed above| .23, (.14, .36)| .91 (.79, .97)| 2.5 (.97, 6.4)| .85
Two or more positive tests28  | Two to four of the four findings listed above| .49 (.37, .62)| .85 (.72, .93)| 3.3 (1.7, 6.6)| .60

*−LRs were not reported in the study and, therefore, were calculated by the authors of this book.

VAS, visual analog scale.

#### Predicting Treatment Failure with Nightly Wear of Occlusal Stabilization Splint

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR*
---|---|---|---|---|---|---|---
Time since pain28  | More than 43 weeks| 119 consecutive patients referred to TMD clinic diagnosed with unilateral TMJ arthralgia| Treatment failure after 6 months with nightly wear of occlusal stabilization splint| .56 (.45, .67)| .65 (.47, .79)| 1.68| .68 (.52, .89)
Baseline pain level28  | Less than 40 mm on VAS| .76 (.65, .84)| .68 (.50, .82)| 2.38| .36 (.24, .54)
Change in VAS level at 2 months28  | 9 mm or less on VAS| .82 (.71, .89)| .97 (.84, .99)| 27.33| .19 (.12, .30)
Disc displacement with reduction28  | As observed on MRI| .10 (.05, .19)| .57 (.40, .73)| .23| 1.59 (1.42, 1.78)
Four positive tests28  | Four of the four findings listed above| .96 (.67, 1.0)| .76 (.67, .84)| 4.00| .05 (.00, .77)
Three or more positive tests28  | Three or four of the four findings listed above| .19 (.09, .36)| .96 (.89, .99)| 4.75| .84 (.72, .98)
Two or more positive tests28  | Two to four of the four findings listed above| .38 (.23, .55)| .78 (.67, .86)| 1.73| .80 (.62, 1.0)

*−LRs were not reported in the study and, therefore, were calculated by the authors of this book.

VAS, visual analog scale.

## Outcome Measures

Outcome Measure| Scoring and Interpretation| Test-Retest Reliability| MCID
---|---|---|---
Mandibular Function Impairment Questionnaire (MFIQ)| Users rate perceived level of difficulty on a Likert scale ranging from 0 (no difficulty) to 4 (very great difficulty or impossible without help) on a series of 17 questions about jaw function. The sum item score for function impairment ranges from 0 to 68, with higher scores representing more disability| Spearman's r = .69 to .9629,30  | 1429
Numeric Pain Rating Scale (NPRS)| Users rate their level of pain on an 11-point scale ranging from 0 to 10, with high scores representing more pain. Often asked as current pain or least, worst, and average pain in the past 24 hours| ICC = .7231  | 232,33

MCID, minimum clinically important difference.

## Appendix

#### Quality Appraisal of Reliability Studies for Temporomandibular Disorders Using QAREL

| Magnusson 19957| Nilsson 20069| John 200534| Dworkin 199012| Lobbezoo-Scholte 199413| de Wijer 199514| Leher 200515| Manfredini 200316| Walker 200022| Hassel 200623
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| U| Y| Y| U| U| U| Y| Y| Y| U

4. Were raters blinded to their own prior findings of the test under evaluation?

| U| N/A| N/A| N/A| N/A| N/A| N/A| N/A| Y| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| Y| N/A| N/A| N/A| N/A| Y| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| U| U| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| U

8. Was the order of examination varied?

| U| U| Y| U| U| U| Y| U| Y| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, U = unclear, N/A = not applicable.   Good quality (Y to N = 9 to 11)   Fair quality (Y to N = 6 to 8)   Poor quality (Y to N ≤5).

| Higbie 199925| Farella 200526| Kropmans 199929| Undt 200630| Li 200731| Gonzalez 201110| Best 201324
---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| U| Y| U| U| U| U| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| U| N/A| U| U| U| N/A| N

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| U| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U

8. Was the order of examination varied?

| Y| N| U| U| U| N/A| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y to N = 9 to 11)   Fair quality (Y to N = 6 to 8)   Poor quality (Y to N ≤5).

#### Quality Assessment of Diagnostic Studies for Temporomandibular Disorders Using QUADAS

| Stegenga 19928| Paesani 199235| Holmlund 199618| Israel 199817| Orsini 19993| Visscher 200019| Emshoff 200227
---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| N| Y| Y| Y| N| Y

2. Were selection criteria clearly described?

| Y| N| N| Y| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| U| Y| Y| Y| U| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| U| U| U| U| U| Y

5. Did the whole sample, or a random selection of the sample, receive verification using a reference standard of diagnosis?

| Y| N| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| U| Y| Y| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| Y| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| U| Y| U| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| U| U| U| U| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| U| U| U| Y| Y| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| U| U| Y| U| U| U

13. Were uninterpretable/intermediate test results reported?

| U| U| Y| Y| Y| U| Y

14. Were withdrawals from the study explained?

| U| U| Y| Y| U| U| Y
Quality Summary Rating:|  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y to N = 9 to 11)   Fair quality (Y to N = 6 to 8)   Poor quality (Y to N ≤5).

| Manfredini 200316| Schmitter 200436| Farella 200526| Silva 200521| Nilsson 20069| Emshoff 200828| Gomes 200820| Gonzalez 201110
---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| N| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| U| Y| Y| Y| N| Y| U| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| Y| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| Y| N| U| U| Y| Y| U| Y

5. Did the whole sample, or a random selection of the sample, receive verification using a reference standard of diagnosis?

| Y| Y| U| Y| Y| Y| U| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| Y| Y| Y| Y| Y| U| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| U| Y| Y| N| U

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| Y| Y| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| Y| Y| Y| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| Y| U| U| U| Y| Y| U

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| Y| Y| U| U| U| Y| Y| U

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| Y| U| U| U| U| Y| U| Y

13. Were uninterpretable/intermediate test results reported?

| U| Y| U| U| Y| Y| U| Y

14. Were withdrawals from the study explained?

| Y| Y| U| U| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y to N = 10 to 14)   Fair quality (Y to N = 5 to 9)   Poor quality (Y to N ≤4).

## References

1. Barclay P, Hollender LG, Maravilla KR, Truelove EL. Comparison of clinical and magnetic resonance imaging diagnosis in patients with disc displacement in the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88:37–43.

2. Cholitgul W, Nishiyama H, Sasai T, et al. Clinical and magnetic resonance imaging findings in temporomandibular joint disc displacement. Dentomaxillofac Radiol. 1997;26:183–188.

3. Orsini MG, Kuboki T, Terada S, et al. Clinical predictability of temporomandibular joint disc displacement. J Dent Res. 1999;78:650–660.

4. Gross AR, Haines T, Thomson MA, et al. Diagnostic tests for temporomandibular disorders: an assessment of the methodologic quality of research reviews. Man Ther. 1996;1:250–257.

5. Haley DP, Schiffman EL, Lindgren BR, et al. The relationship between clinical and MRI findings in patients with unilateral temporomandibular joint pain. J Am Dent Assoc. 2001;132:476–481.

6. Gavish A, Halachmi M, Winocur E, Gazit E. Oral habits and their association with signs and symptoms of temporomandibular disorders in adolescent girls. J Oral Rehabil. 2000;27:22–32.

7. Magnusson T, List T, Helkimo M. Self-assessment of pain and discomfort in patients with temporomandibular disorders: a comparison of five different scales with respect to their precision and sensitivity as well as their capacity to register memory of pain and discomfort. J Oral Rehabil. 1995;22:549–556.

8. Stegenga B, de Bont LG, van der Kuijl B, Boering G. Classification of temporomandibular joint osteoarthrosis and internal derangement. 1. Diagnostic significance of clinical and radiographic symptoms and signs. Cranio. 1992;10:96–106 [discussion 116-117].

9. Nilsson IM, List T, Drangsholt M. The reliability and validity of self-reported temporomandibular disorder pain in adolescents. J Orofac Pain. 2006;20:138–144.

10. Gonzalez YM, Schiffman E, Gordon SM, et al. Development of a brief and effective temporomandibular disorder pain screening questionnaire: reliability and validity. J Am Dent Assoc. 2011;142(10):1183–1191.

11. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache. 2014;28(1):6–27.

12. Dworkin SF, LeResche L, DeRouen T, et al. Assessing clinical signs of temporomandibular disorders: reliability of clinical examiners. J Prosthet Dent. 1990;63:574–579.

13. Lobbezoo-Scholte AM, de Wijer A, Steenks MH, Bosman F. Interexaminer reliability of six orthopaedic tests in diagnostic subgroups of craniomandibular disorders. J Oral Rehabil. 1994;21:273–285.

14. de Wijer A, Lobbezoo-Scholte AM, Steenks MH, Bosman F. Reliability of clinical findings in temporomandibular disorders. J Orofac Pain. 1995;9:181–191.

15. Leher A, Graf K, PhoDuc JM, Rammelsberg P. Is there a difference in the reliable measurement of temporomandibular disorder signs between experienced and inexperienced examiners? J Orofac Pain. 2005;19:58–64.

16. Manfredini D, Tognini F, Zampa V, Bosco M. Predictive value of clinical findings for temporomandibular joint effusion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:521–526.

17. Israel HA, Diamond B, Saed-Nejad F, Ratcliffe A. Osteoarthritis and synovitis as major pathoses of the temporomandibular joint: comparison of clinical diagnosis with arthroscopic morphology. J Oral Maxillofac Surg. 1998;56:1023–1027 [discussion 1028].

18. Holmlund AB, Axelsson S. Temporomandibular arthropathy: correlation between clinical signs and symptoms and arthroscopic findings. Int J Oral Maxillofac Surg. 1996;25:178–181.

19. Visscher CM, Lobbezoo F, de Boer W, et al. Clinical tests in distinguishing between persons with or without craniomandibular or cervical spinal pain complaints. Eur J Oral Sci. 2000;108:475–483.

20. Gomes MB, Guimaraes JP, Guimaraes FC, Neves AC. Palpation and pressure pain threshold: reliability and validity in patients with temporomandibular disorders. Cranio. 2008;26:202–210.

21. Silva RS, Conti PC, Lauris JR, et al. Pressure pain threshold in the detection of masticatory myofascial pain: an algometer-based study. J Orofac Pain. 2005;19:318–324.

22. Walker N, Bohannon RW, Cameron D. Discriminant validity of temporomandibular joint range of motion measurements obtained with a ruler. J Orthop Sports Phys Ther. 2000;30:484–492.

23. Hassel AJ, Rammelsberg P, Schmitter M. Inter-examiner reliability in the clinical examination of temporomandibular disorders: influence of age. Community Dent Oral Epidemiol. 2006;34:41–46.

24. Best N, Best S, Loudovici-Krug D, Smolenski UC. Measurement of mandible movements using a vernier caliper: an evaluation of the intrasession, intersession and interobserver reliability. Cranio. 2013;31(3):176–180.

25. Higbie EJ, Seidel-Cobb D, Taylor LF, Cummings GS. Effect of head position on vertical mandibular opening. J Orthop Sports Phys Ther. 1999;29:127–130.

26. Farella M, Michelotti A, Pellegrino G, et al. Interexaminer reliability and validity for diagnosis of temporomandibular disorders of visual leg measurements used in dental kinesiology. J Orofac Pain. 2005;19:285–290.

27. Emshoff R, Innerhofer K, Rudisch A, Bertram S. Clinical versus magnetic resonance imaging findings with internal derangement of the temporomandibular joint: an evaluation of anterior disc displacement without reduction. J Oral Maxillofac Surg. 2002;60(1):36–41.

28. Emshoff R, Rudisch A. Likelihood ratio methodology to identify predictors of treatment outcome in temporomandibular joint arthralgia patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106:525–533.

29. Kropmans TJ, Dijkstra PU, van Veen A, et al. The smallest detectable difference of mandibular function impairment in patients with a painfully restricted temporomandibular joint. J Dent Res. 1999;78:1445–1449.

30. Undt G, Murakami K, Clark GT, et al. Cross-cultural adaptation of the JPF-Questionnaire for German-speaking patients with functional temporomandibular joint disorders. J Craniomaxillofac Surg. 2006;34:226–233.

31. Li L, Liu X, Herr K. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Pain Med. 2007;8:223–234.

32. Farrar JT, Berlin JA, Strom BL. Clinically important changes in acute pain outcome measures: a validation study. J Pain Symptom Manage. 2003;25:406–411.

33. Farrar JT, Portenoy RK, Berlin JA, et al. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287–294.

34. John MT, Dworkin SF, Mancl LA. Reliability of clinical temporomandibular disorder diagnoses. Pain. 2005;118:61–69.

35. Paesani D, Westesson PL, Hatala MP, et al. Accuracy of clinical diagnosis for TMJ internal derangement and arthrosis. Oral Surg Oral Med Oral Pathol. 1992;73:360–363.

36. Schmitter M, Kress B, Rammelsberg P. Temporomandibular joint pathosis in patients with myofascial pain: a comparative analysis of magnetic resonance imaging and a clinical examination based on a specific set of criteria. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97:318–324.
3

# Cervical Spine

CLINICAL SUMMARY AND RECOMMENDATIONS, 70

Anatomy, 71

Osteology, 71

Arthrology, 73

Ligaments, 74

Muscles, 76

Nerves, 82

Patient History, 84

Initial Hypotheses Based on Patient History, 84

Cervical Zygapophyseal Pain Syndromes, 84

Reliability of the Cervical Spine Historical Examination, 86

Diagnostic Utility of Patient Complaints for Cervical Radiculopathy, 87

Physical Examination Tests, 89

Neurologic Examination, 89

Screening for Cervical Spine Injury, 94

Range-of-Motion Measurements, 97

Cervical Strength and Endurance, 102

Passive Intervertebral Motion, 103

Palpation, 108

Postural and Muscle Length Assessment, 110

Spurling's and Neck Compression Tests, 112

Neck Distraction and Traction Tests, 115

Cervical Flexion-Rotation Test, 116

Shoulder Abduction Test, 117

Neural Tension Tests, 118

Sharp-Purser Test, 121

Arm Squeeze Test, 122

Compression of Brachial Plexus, 123

Cervical Myelopathy Tests, 124

Combinations of Tests, 128

Interventions, 130

Outcome Measures, 138

Appendix, 139

References, 145

## Clinical Summary and Recommendations

Patient History
---
Complaints|

• The utility of the patient history has been studied only in the context of identifying cervical radiculopathy. Subjective reports of symptoms were generally not helpful, with diagnoses including complaints of "weakness," "numbness," "tingling," "burning," or "arm pain."

• The patient complaints most useful in diagnosing cervical radiculopathy were (1) a report of symptoms most bothersome in the scapular area (+LR [likelihood ratio] = 2.30) and (2) a report that symptoms improve with moving the neck (+LR = 2.23).

Physical Examination
Screening|

• Traditional neurologic screening (sensation, reflex, and manual muscle testing [MMT]) is of moderate utility in identifying cervical radiculopathy. Sensation testing (pinprick at any location) and MMT of the muscles in the lower arm and hand are unhelpful. Muscle stretch reflex (MSR) and MMT of the muscles in the upper arm (especially the biceps brachii muscle) exhibit good diagnostic utility and are recommended.

• A 2012 systematic review evaluating the accuracy of the Canadian C-Spine Rule (CCR) and the NEXUS Low-Risk Criteria in screening for clinically important cervical spine injury in patients following blunt trauma concluded that the CCR appears to have better diagnostic accuracy than the NEXUS Criteria at ruling out clinically important cervical spine injuries that require diagnostic imaging. We recommend use of the CCR because it has been consistently shown to have perfect sensitivity (−LR = .00).

Range-of-Motion and Manual Assessment|

• Measuring the cervical range of motion is consistently reliable but is of unknown diagnostic utility.

• The results of studies assessing the reliability of passive intervertebral motion are highly variable, but generally, the results show that this maneuver has poor reliability as an assessment for limitations of movement and moderate reliability as an assessment for pain.

• Assessing for both pain and limited movement during manual assessment is highly sensitive for zygapophyseal joint pain and is recommended to rule out zygapophyseal involvement (−LR = .00 to .23).

Special Tests|

• Multiple studies demonstrate the high diagnostic utility of Spurling's test in identifying cervical radiculopathy, cervical disc prolapse, and neck pain (+LR = 1.9 to 18.6).

• Using a combination of Spurling's A test, the upper limb tension test A, a distraction test, and assessment for cervical rotation of less than 60 degrees to the ipsilateral side is very good for identifying cervical radiculopathy and is recommended (+LR = 30.3 if all four factors are present).

• Using a combination of gait deviation, the Hoffmann test, the inverted supinator sign, the Babinski test, and age more than 45 years is very good at identifying cervical myelopathy and is recommended (+LR = 30.9 if three of five factors are present).

Interventions|

• Factors associated with improvement from cervical thrust manipulation in patients with neck pain include symptom duration of less than 38 days, a positive expectation that manipulation will help, a side-to-side difference in cervical rotation range of motion of 10 degrees or greater, and pain with posteroanterior spring testing of the middle cervical spine (+LR 13.5 if three or more of the four factors are present).

• Patients with neck pain for less than 30 days have a high probability of rapid improvement if treated with thoracic manipulation (+LR = 6.4). Other factors associated with improved thoracic manipulation, especially in combination, are (1) no symptoms distal to the shoulder, (2) low fear-avoidance behavior, (3) patient reports that looking up does not aggravate symptoms, (4) a cervical extension range of motion of less than 30 degrees, and (5) decreased upper thoracic spine kyphosis (+LR = 12 if any four of six factors are present).

• Because the risks of thoracic manipulation are minimal, we recommend such treatment be considered a first-line intervention for patients with neck pain (and no contraindications).

## Anatomy

### Osteology

Figure 3-1 Bony framework of the head and neck.

Figure 3-2 Cervical vertebrae.

### Arthrology

Figure 3-3 Joints of the cervical spine.

Joint| Type and Classification| Closed Packed Position| Capsular Pattern
---|---|---|---
Atlantooccipital| Synovial: plane| Not reported| Not reported
Atlantoodontoid/dens| Synovial: trochoid| Extension| Not reported
Atlantoaxial
apophyseal joints| Synovial: plane| Extension| Not reported
C3-C7 Apophyseal joints| Synovial: plane| Full extension| Limitation in side-bending = rotation = extension
C3-C7 Intervertebral joints| Amphiarthrodial| Not applicable| Not applicable

### Ligaments

Figure 3-4 Ligaments of the atlantooccipital joint.

Ligaments| Attachments| Function
---|---|---
Alar| Sides of dens to lateral aspects of foramen magnum| Limits ipsilateral head rotation and contralateral side-bending
Apical| Dens to posterior aspect of foramen magnum| Limits separation of dens from occiput
Tectorial membrane| Body of C2 to occiput| Limits forward flexion
Cruciform ligament (superior longitudinal)| Transverse ligament to occiput| Maintains contact between dens and anterior arch of atlas
Cruciform ligament (transverse)| Extends between lateral tubercles of C1
Cruciform ligament (inferior)| Transverse ligament to body of C2

Figure 3-5 Spinal ligaments.

Ligaments| Attachments| Function
---|---|---
Anterior longitudinal| Extends from anterior sacrum to anterior tubercle of C1. Connects anterolateral vertebral bodies and discs| Maintains stability of vertebral body joints and prevents hyperextension of vertebral column
Posterior longitudinal| Extends from sacrum to C2. Runs within vertebral canal attaching posterior vertebral bodies| Prevents hyperflexion of vertebral column and posterior disc protrusion
Ligamentum nuchae| An extension of supraspinous ligament (occipital protuberance to C7)| Prevents cervical hyperflexion
Ligamenta flava| Attaches lamina above each vertebra to lamina below| Prevents separation of vertebral lamina
Supraspinous| Connects apices of spinous processes C7-S1| Limits separation of spinous processes
Interspinous| Connects adjoining spinous processes C1-S1| Limits separation of spinous processes
Intertransverse| Connects adjacent transverse processes of vertebrae| Limits separation of transverse processes

### Muscles

#### Anterior Muscles of the Neck

Figure 3-6 Anterior muscles of the neck.

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Sternocleidomastoid| Lateral aspect of mastoid process and lateral superior nuchal line| Sternal head: anterior aspect of manubrium Clavicular head: superomedial aspect of clavicle| Spinal root of accessory nerve| Neck flexion, ipsilateral side-bending, and contralateral rotation
Scalene (anterior)| Transverse processes of vertebrae C4-C6| First rib| C4, C5, C6| Elevates first rib, ipsilateral side-bending, and contralateral rotation
Scalene (middle)| Transverse processes of vertebrae C1-C4| Superior aspect of first rib| Ventral rami of cervical spinal nerves| Elevates first rib, ipsilateral side-bending, contralateral rotation
Scalene (posterior)| External aspect of second rib| Ventral rami of cervical spinal nerves C3, C4| Elevates second rib, ipsilateral side-bending, contralateral rotation
Platysma| Inferior mandible| Fascia of pectoralis major and deltoid| Cervical branch of facial nerve| Draws skin of neck superiorly with clenched jaw, draws corners of mouth inferiorly

#### Suprahyoid and Infrahyoid Muscles

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Suprahyoids
Mylohyoid| Mandibular mylohyoid line| Hyoid bone| Mylohyoid nerve| Elevates hyoid bone, floor of mouth, and tongue
Geniohyoid| Mental spine of mandible| Body of hyoid bone| Hypoglossal nerve| Elevates hyoid bone anterosuperiorly, widens pharynx
Stylohyoid| Styloid process of temporal bone| Body of hyoid bone| Cervical branch of facial nerve| Elevates and retracts hyoid bone
Digastric| Anterior belly: digastric fossa of mandible
Posterior belly: mastoid notch of temporal bone| Greater horn of hyoid bone| Anterior belly: mylohyoid nerve
Posterior belly: facial nerve| Depresses mandible and raises hyoid
Infrahyoids
Sternohyoid| Manubrium and medial clavicle| Body of hyoid bone| Branch of ansa cervicalis
(C1, C2, C3)| Depresses hyoid bone after it has been elevated
Omohyoid| Superior border of scapula| Inferior aspect of hyoid bone| Branch of ansa cervicalis
(C1, C2, C3)| Depresses and retracts hyoid bone
Sternothyroid| Posterior aspect of manubrium| Thyroid cartilage| Branch of ansa cervicalis
(C2, C3)| Depresses hyoid bone and larynx
Thyrohyoid| Thyroid cartilage| Body and greater horn of hyoid bone| Hypoglossal nerve
(C1)| Depresses hyoid bone, elevates larynx

Figure 3-7 Suprahyoid and infrahyoid muscles.

#### Scalene and Prevertebral Muscles

Figure 3-8 Scalene and prevertebral muscles.

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Longus capitis| Basilar aspect of occipital bone| Anterior tubercles of transverse processes C3-C6| Ventral rami of C1-C3 spinal nerves| Flexes head on neck
Longus colli| Anterior tubercle of C1, bodies of C1-C3, and transverse processes of C3-C6| Bodies of C3-T3 and transverse processes of C3-C5| Ventral rami of C2-C6 spinal nerves| Neck flexion, ipsilateral side-bending, and rotation
Rectus capitis anterior| Base of skull anterior to occipital condyle| Anterior aspect of lateral mass of C1| Branches from loop between C1 and C2 spinal nerves| Flexes head on neck
Rectus capitis lateralis| Jugular process of occipital bone| Transverse process of C1| Flexes head and assists in stabilizing head on neck

#### Posterior Muscles of the Neck

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Upper trapezius| Superior nuchal line, occipital protuberance, nuchal ligament, spinous processes C7-T12| Lateral clavicle, acromion, and spine of scapula| Spinal root of accessory nerve| Elevates scapula
Levator scapulae| Transverse processes of C1-C4| Superomedial border of scapula| Dorsal scapular nerve (C3, C4, C5)| Elevates scapula and inferiorly rotates glenoid fossa
Semispinalis capitis and cervicis| Cervical and thoracic spinous processes| Superior spinous processes and occipital bone| Dorsal rami of spinal nerves| Bilaterally: extends neck
Unilaterally: ipsilateral side-bending
Splenius capitis and cervicis| Spinous processes T1-T6 and ligamentum nuchae| Mastoid process and lateral superior nuchal line| Dorsal rami of middle cervical spinal nerves| Bilaterally: head and neck extension
Unilaterally: ipsilateral rotation
Longissimus capitis and cervicis| Superior thoracic transverse processes and cervical transverse processes| Mastoid process of temporal bone and cervical transverse processes| Dorsal rami of cervical spinal nerves| Head extension, ipsilateral side-bending, and rotation of head and neck
Spinalis cervicis| Lower cervical spinous processes of vertebrae| Upper cervical spinous processes of vertebrae| Dorsal rami of spinal nerves| Bilaterally: extends neck
Unilaterally: ipsilateral side-bending of neck
Suboccipital Muscles
Rectus capitis posterior major| Spinous process of C2| Lateral inferior nuchal line of occipital bone| Suboccipital nerve (C1)| Head extension and ipsilateral rotation
Rectus capitis posterior minor| Posterior arch of C1| Medial inferior nuchal line| Suboccipital nerve (C1)| Head extension and ipsilateral rotation
Obliquus capitis superior| Transverse process of C1| Occipital bone| Suboccipital nerve (C1)| Head extension and side-bending
Obliquus capitis inferior| Spinous process of C2| Transverse process of C1| Suboccipital nerve (C1)| Ipsilateral neck rotation

Figure 3-9 Posterior muscles of the neck.

### Nerves

Nerves| Segmental Levels| Sensory| Motor
---|---|---|---
Dorsal scapular| C4, C5| No sensory| Rhomboids, levator scapulae
Suprascapular| C4, C5, C6| No sensory| Supraspinatus, infraspinatus
Nerve to subclavius| C5, C6| No sensory| Subclavius
Lateral pectoral| C5, C6, C7| No sensory| Pectoralis major
Medial pectoral| C8, T1| No sensory| Pectoralis major
Pectoralis minor
Long thoracic| C5, C6, C7| No sensory| Serratus anterior
Medial cutaneous of arm| C8, T1| Medial aspect of arm| No motor
Medial cutaneous of forearm| C8, T1| Medial aspect of forearm| No motor
Upper subscapular| C5, C6| No sensory| Subscapularis
Lower subscapular| C5, C6, C7| No sensory| Subscapularis, teres major
Thoracodorsal| C6, C7, C8| No sensory| Latissimus dorsi
Axillary| C5, C6| Lateral shoulder| Deltoid, teres minor
Radial| C5, C6, C7, C8, T1| Dorsal lateral aspect of hand, including the thumb and up to the base of digits 2 and 3| Triceps brachii, brachioradialis, anconeus, extensor carpi radialis longus, extensor carpi radialis brevis
Median| C5, C6, C7, C8, T1| Palmar aspect of lateral hand, including lateral half of digit 4, dorsal distal half of digits 1-3, and lateral border of digit 4| Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor pollicis longus, flexor digitorum profundus (lateral half), pronator quadratus, lumbricals to digits 2 and 3, thenar muscles
Ulnar| C8, T1| Medial border of both palmar and dorsal hand, including medial half of digit 4| Flexor carpi ulnaris, flexor digitorum profundus (medial half), palmar interossei, adductor pollicis, palmaris brevis, dorsal interossei, lumbricals to digits 4 and 5, hypothenar muscles
Musculocutaneous| C5, C6, C7| Lateral forearm| Coracobrachialis, biceps brachii, brachialis

Figure 3-10 Nerves of the neck.

## Patient History

### Initial Hypotheses Based on Patient History

History| Initial Hypotheses
---|---
Patient reports diffuse nonspecific neck pain that is exacerbated by neck movements| Mechanical neck pain
Cervical facet syndrome
Cervical muscle strain or sprain
Patient reports pain in certain postures that is alleviated by positional changes| Upper crossed postural syndrome
Traumatic mechanism of injury with complaint of nonspecific cervical symptoms that are exacerbated in the vertical positions and relieved with the head supported in the supine position| Cervical instability, especially if patient reports dysesthesias of the face occurring with neck movement
Reports of nonspecific neck pain with numbness and tingling into one upper extremity| Cervical radiculopathy
Reports of neck pain with bilateral upper extremity symptoms with occasional reports of loss of balance or lack of coordination of the lower extremities| Cervical myelopathy

### Cervical Zygapophyseal Pain Syndromes

Figure 3-11 Pain referral patterns. Distribution of zygapophyseal pain referral patterns as described by Dwyer and colleagues. (Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine. 1990;15:453-457.)

Figure 3-12 Pain referral patterns. Probability of zygapophyseal joints at the segments indicated being the source of pain, as described by Cooper and colleagues. (Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med. 2007;8:344-353.)

### Reliability of the Cervical Spine Historical Examination

Historical Question and Study Quality| Possible Responses| Population| Interexaminer Reliability
---|---|---|---
Mode of onset  | Gradual, sudden, or traumatic| 22 patients with mechanical neck pain| κ = .72 (.47, .96)
Nature of neck symptoms  | Constant or intermittent| κ = .81 (.56, 1.0)
Prior episode of neck pain  | Yes or No| κ = .90 (.70, 1.0)
Turning the head aggravates symptoms  | Yes or No| (Right) κ = −.04 (2.11, .02)*
(Left) κ = 1.0 (1.0, 1.0)
Looking up and down aggravates symptoms  | Yes or No| (Down) κ = .79 (.51, 1.0)
(Up) κ = .80 (.55, 1.0)
Driving aggravates symptoms  | Yes or No| κ = −.06 (−.39, .26)*
Sleeping aggravates symptoms  | Yes or No| κ = .90 (.72, 1.0)
Which of the following symptoms are most bothersome for you?  |

• Pain

• Numbness and tingling

• Loss of feeling

| 50 patients with suspected cervical radiculopathy or carpal tunnel syndrome| κ = .74 (.55, .93)
Where are your symptoms most bothersome?  |

• Neck

• Shoulder or shoulder blade

• Arm above elbow

• Arm below elbow

• Hands and/or fingers

| κ = .83 (.68, .96)
Which of the following best describes the behavior of your symptoms?  |

• Constant

• Intermittent

• Variable

| κ = .57 (.35, .79)
Does your entire affected limb and/or hand feel numb?  | Yes or No| κ = .53 (.26, .81)
Do your symptoms keep you from falling asleep?  | Yes or No| κ = .70 (.48, .92)
Do your symptoms improve with moving your neck?  | Yes or No| κ = .67 (.44, .90)

*Question had a high percentage of agreement but a low κ because 95% of participants answered "yes."

### Diagnostic Utility of Patient Complaints for Cervical Radiculopathy

Figure 3-13 Cervical radiculopathy.

Complaint and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Weakness  | Not specifically described| 183 patients referred to electrodiagnostic laboratories| Cervical radiculopathy via electrodiagnostics| .65| .39| 1.07| .90
Numbness  | .79| .25| 1.05| .84
Arm pain  | .65| .26| .88| 1.35
Neck pain  | .62| .35| .95| 1.09
Tingling  | .72| .25| .96| 1.92
Burning  | .33| .63| .89| 1.06

Complaint and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR*
---|---|---|---|---|---|---|---
Which of the following symptoms are most bothersome for you?  | Pain| 82 consecutive patients referred to electrophysiologic laboratory with suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome| Cervical radiculopathy via needle electromyography and nerve conduction studies| .47 (.23, .71)| .52 (.41, .65)| .99 (.56, 1.7)| 1.02
Numbness and tingling| .47 (.23, .71)| .56 (.42, .68)| 1.1 (.6, 1.9)| .95
Loss of feeling| .06 (.00, .17)| .92 (.85, .99)| .74 (.09, 5.9)| 1.02
Where are your symptoms most bothersome?  | Neck| .19 (.00, .35)| .90 (.83, .98)| 1.9 (.54, 6.9)| .90
Shoulder or scapula| .38 (.19, .73)| .84 (.75, .93)| 2.3 (1.0, 5.4)| .74
Arm above elbow| .03 (.14, .61)| .93 (.86, .99)| .41 (.02, 7.3)| 1.04
Arm below elbow| .06 (.00, .11)| .84 (.75, .93)| .39 (.05, 2.8)| 1.12
Hands and/or fingers| .38 (.14, .48)| .48 (.36, .61)| .73 (.37, 1.4)| 1.29
Which of the following best describes the behavior of your symptoms?  | Constant| .12 (.00, .27)| .84 (.75, .93)| .74 (.18, 3.1)| 1.05
Intermittent| .35 (.13, .58)| .62 (.50, .74)| .93 (.45, 1.9)| 1.05
Variable| .53 (.29, .77)| .54 (.42, .66)| 1.2 (.68, 1.9)| .87
Does your entire affected limb and/or hand feel numb?  | Yes or No| | | .24 (.03, .44)| .73 (.62, .84)| .87 (.34, 2.3)| 1.04
Do your symptoms keep you from falling asleep?  | | | .47 (.23, .71)| .60 (.48, .72)| 1.19 (.66, 2.1)| .88
Do your symptoms improve with moving your neck?  | | | .65 (.42, .87)| .71 (.60, .82)| 2.23 (1.3, 3.8)| .49

*−LR in this table has been calculated by the authors.

## Physical Examination Tests

### Neurologic Examination

#### Reliability of Sensation Testing

Figure 3-14 Dermatomes of the upper limb.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Identifying sensory deficits in extremities  | No details given| 8924 adult patients who presented to emergency department after blunt trauma to head/neck and had Glasgow Coma Score of 15| Interexaminer κ = .60

#### Diagnostic Utility of Pinprick Sensation Testing for Cervical Radiculopathy

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
C5 Dermatome  | Pinprick sensation testing. Graded as "normal" or "abnormal"| 82 consecutive patients referred to electrophysiologic laboratory with suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome| Cervical radiculopathy via needle electromyography and nerve conduction studies| .29 (.08, .51)| .86 (.77, .94)| 2.1 (.79, 5.3)| .82 (.60, 1.1)
C6 Dermatome  | .24 (.03, .44)| .66 (.54, .78)| .69 (.28, 1.8)| 1.16 (.84, 1.6)
C7 Dermatome  | .18 (.00, .36)| .77 (.66, .87)| .76 (.25, 2.3)| 1.07 (.83, 1.4)
C8 Dermatome  | .12 (.00, .27)| .81 (.71, .90)| .61 (.15, 2.5)| 1.09 (.88, 1.4)
T1 Dermatome  | .18 (.00, .36)| .79 (.68, .89)| .83 (.27, 2.6)| 1.05 (.81, 1.4)
Decreased sensation to pinprick  | Not specifically described| 183 patients referred to electrodiagnostic laboratories| Cervical radiculopathy via electrodiagnostics| .49| .64| 1.36| .80

#### Reliability of Manual Muscle Testing

Figure 3-15 Manual muscle testing of the upper limb.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Identifying motor deficits in the extremities  | No details given| 8924 adult patients who presented to emergency department after blunt trauma to head/neck and had Glasgow Coma Score of 15| Interexaminer κ = .93

#### Diagnostic Utility of Manual Muscle Testing for Cervical Radiculopathy

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
MMT deltoid  | Standard strength testing using methods of Kendall and McCreary. Graded as "normal" or "abnormal"| 82 consecutive patients referred to electrophysiologic laboratory with suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome| Cervical radiculopathy via needle electromyography and nerve conduction studies| .24 (.03, .44)| .89 (.81, .97)| 2.1 (.70, 6.4)| .86 (.65, 1.1)
MMT biceps brachii  | .24 (.03, .44)| .94 (.88, 1.0)| 3.7 (1.0, 13.3)| .82 (.62, 1.1)
MMT extensor carpi radialis longus/brevis  | .12 (.00, .27)| .90 (.83, .98)| 1.2 (.27, 5.6)| .98 (.81, 1.2)
MMT triceps brachii  | .12 (.00, .27)| .94 (.88, 1.0)| 1.9 (.37, 9.3)| .94 (.78, 1.1)
MMT flexor carpi radialis  | .06 (.00, .17)| .89 (.82, .97)| .55 (.07, 4.2)| 1.05 (.91, 1.2)
MMT abductor pollicis brevis  | .06 (.00, .17)| .84 (.75, .93)| .37 (.05, 2.7)| 1.12 (.95, 1.3)
MMT first dorsal interosseus  | .03 (.00, .10)| .93 (.87, .99)| .40 (.02, 7.0)| 1.05 (.94, 1.2)

#### Diagnostic Utility of Muscle Stretch Reflex Testing for Cervical Radiculopathy

Figure 3-16 Reflex testing.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Biceps brachii MSR  | Tested bilaterally using standard reflex hammer. Graded as "normal" or "abnormal"| 82 consecutive patients referred to electrophysiologic laboratory with suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome| Cervical radiculopathy via needle electromyography and nerve conduction studies| .24 (.3, .44)| .95 (.90, 1.0)| 4.9 (1.2, 20.0)| .80 (.61, 1.1)
Brachioradialis MSR  | .06 (.00, .17)| .95 (.90, 1.9)| 1.2 (.14, 11.1)| .99 (.87, 1.1)
Triceps MSR  | .03 (.00, .10)| .93 (.87, .99)| .40 (.02, 7.0)| 1.05 (.94, 1.2)
Biceps  | Not specifically described| 183 patients referred to electrodiagnostic laboratories| Cervical radiculopathy via electrodiagnostics| .10| .99| 10.0| .91
Triceps  | .10| .95| 2.0| .95
Brachioradialis  | .08| .99| 8.0| .93

### Screening for Cervical Spine Injury

Figure 3-17 Compression fracture of the cervical spine.

NEXUS Low-Risk Criteria

Cervical spine radiography is indicated for patients with trauma unless they meet all of the following criteria:|

1. No posterior midline cervical spine tenderness

---|---

2. No evidence of intoxication

3. Normal level of alertness

4. No focal neurologic deficit

5. No painful distracting injuries

#### Diagnostic Utility of the Clinical Examination for Identifying Cervical Spine Injury

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
NEXUS Low-Risk Criteria  | See Figure 3-18| 34,069 patients who presented to emergency department after blunt trauma and had cervical spine radiography| Clinically important cervical spine injury demonstrated by radiography, computed tomography (CT), or magnetic resonance imaging (MRI)| .99 (.98, 1.0)| .13 (.13, .13)| 1.14| .08
NEXUS Low-Risk Criteria  | 320 elderly patients (65 years or older) who presented to emergency department after blunt trauma| Clinically important cervical spine injury demonstrated by CT| .66| .60| 1.65| .57
NEXUS Low-Risk Criteria  | See Figure 3-18| 8924 alert adult patients who presented to emergency department after blunt trauma to head/neck| Clinically important cervical spine injury defined as any fracture, dislocation, or ligamentous instability demonstrated by radiography, CT, and/or a telephone follow-up| .93 (.87, .96)| .38 (.37, .39)| 1.50| .18
NEXUS Low-Risk Criteria  | 7438 alert adult patients who presented to emergency department after blunt trauma to head/neck| .91 (.85, .94)| .37 (.36, .38)| 1.44| .24
Canadian C-Spine Rule  | See Figure 3-18| .99 (.96, 1.0)| .45 (.44, .46)| 1.80| .02
Canadian C-Spine Rule  | 8924 alert adult patients who presented to emergency department after blunt trauma to head/neck| 1.0 (.98, 1.0)| .43 (.40, .44)| 1.75| .00
Canadian C-Spine Rule  | 1.0 (.94, 1.0)| .44 (.43, .45)| 1.79| .00
Physician judgment  | Physicians were asked to estimate the probability that the patient would have a clinically important cervical spine injury by circling one of the following: 0%, 1%, 2%, 3%, 4%, 5%, 10%, 20%, 30%, 40%, 50%, 75%, or 100%| 6265 alert adult patients who presented to emergency department after trauma to head/neck| Clinically important cervical spine injury demonstrated by radiography, CT, and/or a telephone follow-up| .92 (.82, .96)| .54 (.53, .55)| 2.00| .15

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Clinical examination  | Patient history, including mechanism of injury and subjective complaints of neck pain and/or neurologic deficits, followed by physical examination of tenderness to palpation, abnormalities to palpation, and neurologic deficits| 534 patients consulting a level I trauma center after blunt trauma to head/neck| Cervical fracture via CT| .77| .55| 1.70| .42
Among subset of patients with a Glasgow Coma Score of 15 (i.e., alert), who were not intoxicated, and who did not have a distracting injury| .67| .62| 1.76| .54

Figure 3-18 Canadian C-Spine Rule. (See Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349:2510-2518.)

### Range-of-Motion Measurements

Figure 3-19 Range of motion.

#### Reliability of Measuring Range of Motion

Test and Study Quality| Instrumentation| Population| Interexaminer Reliability
---|---|---|---
Extension  | Inclinometer| 30 patients with neck pain| ICC = .86 (.73, .93)
Flexion  | ICC = .78 (.59, .89)
Rotation in flexion  | (Right) ICC = .78 (.60, .89)
(Left) ICC = .89 (.78, .95)
Lateral bending  | (Right) ICC = .87 (.75, .94)
(Left) ICC = .85 (.70, .92)
Rotation  | (Right) ICC = .86 (.74, .93)
(Left) ICC = .91 (.82, .96)
Flexion  | Inclinometer| 22 patients with mechanical neck pain| ICC = .75 (.50, .89)
Extension  | ICC = .74 (.48, .88)
Side-bending  | (Right) ICC = .66 (.33, .84)
(Left) ICC = .69 (.40, .86)
Rotation  | Goniometer| (Right) ICC = .78 (.55, .90)
(Left) ICC = .77 (.52, .90)
Flexion-extension  | Digital inclinometer| 32 patients with neck pain referred to physical therapy| Single measurement ICC = .89 (.77, .94)
Mean of 2 measurements ICC = .95 (.90, .98)
Lateral flexion  | Single measurement ICC = .77 (.58, .88)
Mean of 2 measurements ICC = .89 (.77, .94)
Rotation  | Single measurement ICC = .88 (.78, .94)
Mean of 2 measurements ICC = .95 (.90, .98)
Flexion  | Inclinometer| 50 patients with suspected cervical radiculopathy or carpal tunnel syndrome| ICC = .79 (.65, .88)
Extension  | ICC = .84 (.70, .95)
Left rotation  | Goniometer| ICC = .75 (.59, .85)
Right rotation  | ICC = .63 (.22, .82)
Left side-bending  | Inclinometer| ICC = .63 (.40, .78)
Right side-bending  | ICC = .68 (.62, .87)

ICC, intraclass correlation coefficient.

Test and Study Quality| Instrumentation| Population| Interexaminer Reliability
---|---|---|---
Flexion  | Cervical range-of-motion (CROM) instrument| 60 patients with neck pain| ICC = .58
Extension  | ICC = .97
Right side-bending  | ICC = .96
Left side-bending  | ICC = .94
Right rotation  | ICC = .96
Left rotation  | ICC = .98
Protraction  | ICC = .49
Retraction  | ICC = .35
Flexion-extension  | Inclinometer and CROM| 30 asymptomatic subjects| Inclinometer ICC = .84
CROM ICC = .88
Side-bending  | Inclinometer ICC = .82
CROM ICC = .84
Rotation  | Inclinometer ICC = .81
CROM ICC = .92
Flexion  | CROM, universal goniometer, and visual estimation| 60 patients in whom the assessment of CROM testing would be appropriate during the physical therapy evaluation| CROM ICC = .86
Goniometer ICC = .57
Visual estimation ICC = .42
Extension  | CROM ICC = .86
Goniometer ICC = .79
Visual estimation ICC = .42
Left side-bending  | CROM ICC = .73
Goniometer ICC = .79
Visual estimation ICC = .63
Right side-bending  | CROM ICC = .73
Goniometer ICC = .79
Visual estimation ICC = .63
Left rotation  | CROM ICC = .82
Goniometer ICC = .54
Visual estimation ICC = .70
Right rotation  | CROM ICC = .92
Goniometer ICC = .62
Visual estimation ICC = .82
Identifying ability to actively rotate neck 45 degrees left and right  | No details given| 8924 adult patients who presented to emergency department after blunt trauma to head/neck and had Glasgow Coma Score of 15| κ = .67
Identifying ability to actively flex neck  | κ = .63

#### Reliability of Pain Responses during Active Physiologic Range of Motion

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Extension  | Symptom response recorded as "no effect," "increases symptoms," "decreases symptoms," "centralizes symptoms," or "peripheralizes symptoms"| 30 patients with neck pain| κ = .65 (.54, .76)
Flexion  | κ = .87 (.81, .94)
Rotation in flexion  | (Right) κ = .25 (.12, .39)
(Left) κ = .69 (.59, .78)
Lateral bending  | (Right) κ = .75 (.66, .84)
(Left) κ = .28 (.15, .41)
Rotation  | (Right) κ = .76 (.67, .84)
(Left) κ = .74 (.64, .84)
Flexion  | Patient asked about change in symptoms during active range of motion (AROM). Answers were "no change," "increased pain," or "decreased pain"| 22 patients with mechanical neck pain| κ = .55 (.23, .87)
Extension  | κ = .23 (.09, .37)
Side-bending  | (Right) κ = .81 (.57, 1.0)
(Left) κ = .00 (−.22, .23)
Rotation  | (Right) κ = .40 (−.07, .87)
(Left) κ = .73 (.46, 1.0)
Flexion  | The effect of each movement on centralization (the movement caused the pain and/or paresthesias to move proximally) or peripheralization of symptoms (the movement caused the pain and/or paresthesias to move more distally) was recorded| 22 patients with mechanical neck pain| κ = 1.0 (1.0, 1.0)
Extension  | κ = .44 (.17, .71)
Side-bending  | (Right) κ = −.06 (−.15, .03)
(Left) κ = .02 (−.25, .66)
Rotation  | (Right) κ = −.05 (−.15, .03)
(Left) κ = −.10 (−.21, .00)
Flexion  | Patient seated with back supported. Patient is asked to perform full flexion, and pressure is applied by examiner. Pain responses are recorded on an 11-point numeric pain rating scale (NPRS)| 32 patients with neck pain| κ = .63
Extension  | κ = .71
Rotation, right  | κ = .70
Rotation, left  | κ = .66
Side-bending, right  | κ = .65
Side-bending, left  | κ = .45
Flexion C0-C1  | Patient is asked to perform high cervical flexion/extension by nodding. Pain responses are recorded on an 11-point NPRS| κ = .36
Extension C0-C1  | κ = .56
Flexion  | Patient performs AROM, and pain is determined to be either present or not present| 24 patients with headaches| κ = .53 (.17, .89)
Extension  | κ = .67 (.34, .99)
Rotation, right  | κ = .65 (.31, .99)
Rotation, left  | κ = .46 (.10, .79)

#### Diagnostic Utility of Pain Responses during Active Physiologic Range of Motion

Figure 3-20 Overpressure testing.

Test and Measure Quality| Test Procedure and Determination of Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Active flexion and extension of the neck  | Active flexion and extension performed to the extremes of the range. Positive if subject reported pain with procedure| 75 males (22 with neck pain)| Patient reports of neck pain| .27| .90| 2.70| .81

### Cervical Strength and Endurance

#### Reliability of Cervical Strength and Endurance Testing

Figure 3-21 Cervical flexor endurance.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Neck flexor muscle endurance test  | With patient supine with knees flexed, examiner's hand is placed behind occiput and the subject gently flexes the upper neck and lifts the head off the examiner's hand while retaining the upper neck flexion. The test was timed and terminated when the subject was unable to maintain the position of the head off the examiner's hand| 21 patients with postural neck pain| Interexaminer ICC = .93 (.86, .97)
Chin tuck neck flexion test  | With patient supine, subject tucks the chin and lifts the head approximately 1 inch. The test was timed with a stopwatch and terminated when the patient's position deviated| 22 patients with mechanical neck pain| Interexaminer ICC = .57 (.14, .81)
Cervical flexor endurance  | With patient supine, knees flexed, and chin maximally retracted, subject lifts the head slightly. The test was timed with a stopwatch and terminated when the subject lost maximal retraction, flexed the neck, or could not continue| 27 asymptomatic subjects| Intraexaminer ICC = 0.74 (.50, .87)
Interexaminer
Test #1 ICC = .54 (.31, .73)
Test #2 ICC = .66 (.46, .81)
Cervical flexor endurance  | With patient supine with knees flexed and chin maximally retracted, subject lifts the head approximately 1 inch. The test was timed with a stopwatch and terminated when the subject lost maximal retraction| 20 asymptomatic subjects| Intraexaminer ICC = .82−.91
Interexaminer ICC = .67−.78
20 patients with neck pain| Interexaminer ICC = .67
Craniocervical flexion test  | With patient supine with a pressure biofeedback unit placed suboccipitally, subject performs a gentle head-nodding action of craniocervical flexion for five 10-second incremental stages of increasing range (22, 24, 26, 28, and 30 mm Hg). Performance was measured by the highest level of pressure the individual could hold for 10 seconds| 10 asymptomatic subjects| Intraexaminer κ = .72
Cervical flexor endurance  | With patient supine with knees flexed, subject holds the tongue on the roof of the mouth and breathes normally. Subject then lifts his or her head off the table and holds it as long as possible with the neck in a neutral position. The test was timed with a stopwatch and terminated when the head moved more than 5 degrees either forward or backward| 30 patients with grade II whiplash-associated disorders| Interexaminer ICC = .96

### Passive Intervertebral Motion

#### Reliability of Assessing Limited Passive Intervertebral Motion

Figure 3-22 Assessing limited passive intervertebral motion.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Rotation of C1-C2  | With patient seated, C2 is stabilized while C1 is rotated on C2 until the end of passive range of motion. Positive if decreased rotation is seen on one side compared with the contralateral side| 61 patients with nonspecific neck problems| κ = .28
Lateral flexion of C2-C3  | With patient supine, examiner's left hand stabilizes the patient's head while the right hand performs side-bending flexion of C2-C3 until the end of passive range of motion. This is repeated in the contralateral direction. Positive if lateral flexion on one side is reduced compared with contralateral side| κ = .43
Flexion and extension  | With patient side-lying, examiner stabilizes the patient's neck with one hand while palpating the movement at C7-T1 with the other. Positive if flexion and extension are "stiff" compared with the vertebrae superior and inferior| κ = .36
First rib  | With patient supine, the cervical spine is rotated toward the side being tested. The first rib is pressed in a ventral and caudal direction. Positive if the rib is more "stiff" than the contralateral side| κ = .35
Identification of hypomobile segment  | With subject sitting, examiner palpates passive physiologic intervertebral motion at each cervical vertebra in rotation and lateral flexion and determines the most hypomobile segment| Three asymptomatic patients with single-level congenital fusions in the cervical spine (two at C2-C3 and one at C5-C6)| κ = .68

#### Reliability of Assessing Limited and Painful Passive Intervertebral Motion

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Limited Movements| Pain
Right| Left| Right| Left
C0-C1  | With patient supine, examiner cradles the occiput with both hands and rotates the head 30 degrees toward the side to be tested; an anterior-to-posterior glide is performed to assess the amount of available motion compared with the contralateral side| 22 patients with mechanical neck pain| κ = −.26 (−.57, .07)| κ = .46 (.06, .86)| κ = −.52 (−.09, −.14)| κ = .08 (−.37, .54)
C1-C2  | With patient supine, examiner passively and maximally flexes the neck and then performs passive cervical rotation to one side and then to the other. The amount of motion to each side is compared, and if one side is determined to have less motion, it is considered to be "hypomobile"| κ = .72 (.43, .91)| κ = .74 (.40, 1.0)| κ = .15 (−.05, .36)| κ = −.16 (−.56, .22)
C0-C1  | With patient supine, passive flexion is performed. Motion is classified as "limited" or "not limited" and patient pain response is assessed on 11-point numeric pain rating (NPR) scale| 32 patients with neck pain| κ = .29| Not reported| ICC = .73| Not reported
C1-C2  | With patient supine, rotation is performed and classified as "limited" or "not limited." Patient pain response is assessed on 11-point NPR scale| κ = .20| κ = .37| ICC = .56| ICC = .35
C2-C3  | With patient supine, fixation of lower segment with side-bending to the right and left. Motion classified as "limited" or "not limited" and patient pain response assessed on 11-point NPR scale| κ = .34| κ = .63| ICC = .50| ICC = .78
C3-C4  | κ = .20| κ = .26| ICC = .62| ICC = .75
C4-C5  | κ = .16| κ = −.09| ICC = .62| ICC = .55
C5-C6  | κ = .17| κ = .09| ICC = .66| ICC = .65
C6-C7  | κ = .34| κ = .03| ICC = .59| ICC = .22
C7-T1  | κ = .08| κ = .14| ICC = .45| ICC = .34
T1-T2  | κ = .33| κ = .46| ICC = .80| ICC = .54

Figure 3-23 Assessing limited and painful passive intervertebral motion.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Limited Movements| Pain
C2  | Posterior-to-anterior spring testing centrally over the spinous process of the vertebrae. Mobility judged as "normal," "hypomobile," or "hypermobile" and as "painful" or "not painful"| 22 patients with mechanical neck pain| κ = .01 (−.35, .38)| κ = .13 (−.04, .31)
C3  | κ = .10 (−.25, .44)| κ = .13 (−.21, .47)
C4  | κ = .10 (−.22, .40)| κ = .27 (−.12, .67)
C5  | κ = .10 (−.15, .35)| κ = .12 (−.09, .42)
C6  | κ = .01 (−.21, .24)| κ = .55 (.22, .88)
C7  | κ = .54 (0.2, .88)| κ = .90 (.72, 1.0)
C0-C1 lateral glide  | Mobility was recorded as "normal" or "hypomobile" when compared with the contralateral side. Pain reproduction recorded as "pain" or "no pain"| 30 patients with neck pain| κ = .81 (.72, .91)| κ =32 (.15, .49)
C0-C1 lateral bend  | κ = .35 (.08, .62)| κ = .35 (.15, .55)
C1-C2 rotation in full flexion  | κ = .21 (.08, .34)| κ = .36 (.24, .49)
C1-C2 full lateral flexion  | κ = .30 (.17, .43)| κ = .61 (.50, .72)
C2 lateral glide  | κ = .46 (.33, .59)| κ = .42 (.28, .56)
C3 lateral glide  | κ = .25 (.12, .38)| κ = .29 (.16, .43)
C4 lateral glide  | κ = .27 (.13, .40)| κ = .65 (.54, .76)
C5 lateral glide  | κ = .18 (.03, .33)| κ = .55 (.43, .67)
C6 lateral glide  | κ = −.07 (−.34, .20)| κ = .76 (.64, .87)

#### Reliability of Assessing Passive Mobility in the Upper Cervical Spine for Detecting Ligament and Membrane Injuries

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Alar ligament, right  | Passive stretching of the ligament or membrane by the examiner with the patient sitting in a chair is compared with MRI findings. Positive for examination if subjectively rated to have moderate or extensively increased motion by examiner. Positive for MRI when more than one third of structure showed increased signal intensity| 92 subjects with chronic whiplash-associated disorder and 30 healthy individuals| Interexaminer
κ = .71 (.58, .83)
Alar ligament, left  | κ = .69 (.57, .82)
Transverse ligament  | κ = .69 (.55, .83)
Tectorial membrane  | κ = .93 (.83, 1.03)
Atlantooccipital membrane  | κ = .97 (.92, 1.03)

#### Diagnostic Utility of Assessing Passive Mobility in the Upper Cervical Spine for Detecting Ligament and Membrane Injuries

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Alar ligament, right  | Passive stretching of the ligament or membrane by examiner with the patient sitting in a chair is compared with MRI findings. Positive for examination if subjectively rated to have moderate or extensively increased motion by examiner. Positive for MRI when more than one third of structure showed increased signal intensity| 92 subjects with chronic whiplash-associated disorder and 30 healthy individuals| MRI| .69 (.56, .81)| 1.00 (1.00, 1.00)| Undefined| .31
Alar ligament, left  | .72 (.60, .84)| .96 (.91, 1.00)| 18| .29
Transverse ligament  | .65 (.51, .79)| .99 (.96, 1.01)| 65| .35
Tectorial membrane  | .94 (.82, 1.06)| .99 (.97, 1.01)| 94| .06
Atlantooccipital membrane  | .96 (.87, 1.04)| 1.00 (1.00, 1.00)| Undefined| .04

#### Diagnostic Utility of Assessing Limited and Painful Passive Intervertebral Motion

Figure 3-24 Assessing limited and painful passive intervertebral motion.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Manual examination  | Subjective examination, followed by central posterior-to-anterior glides, followed by passive physiologic intervertebral movements of flexion, extension, side-bending, and rotation. Joint dysfunction is diagnosed if the examiner concludes that the joint demonstrates an abnormal end feel and abnormal quality of resistance to motion and there is reproduction of pain| 173 patients with cervical pain| Level of zygapophyseal pain via radiologically controlled diagnostic nerve block| .89 (.82, .96)| .47 (.37, .57)| 1.7 (1.2, 2.5)| .23
Manual examination  | 20 patients with cervical pain| 1.0 (.81, 1.0)*| 1.0 (.51, 1.0)*| Undefined| .00
Identification of hypomobile segment  | With subject sitting, examiner palpates passive physiologic intervertebral motion at each cervical vertebra in rotation and lateral flexion and determines the most hypomobile segment| Three asymptomatic patients with single-level congenital fusions in cervical spine (two at C2-C3 and one at C5-C6)| Level of congenital cervical fusion| .98| .74| 3.77| .03

*Confidence intervals were not originally reported by Jull and colleagues but were later calculated and presented by King and colleagues.

### Palpation

#### Reliability of Assessing Pain with Palpation

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Upper cervical spinous process  | Patient supine. Graded as "no tenderness," "moderate tenderness," or "marked tenderness"| 52 patients referred for cervical myelography| κ = .47
Lower cervical spinous process  | κ = .52
Right side of neck  | κ = .24
Suprascapular area  | (Right) κ = .42
(Left) κ = .44
Scapular area  | (Right) κ = .34
(Left) κ = .56
Zygapophyseal joint pressure  | High cervical| Method of classification for high, middle, and low not described| 24 patients with headaches| κ = .14 (−.12, .39)
Middle cervical| κ = .37 (.12, .85)
Low cervical| κ = .31 (.28, .90)
Occiput  | No details| (Right) κ = .00 (−1.00, .77)
(Left) κ = .16 (−.31, .61)
Mastoid process  | κ = .77 (.34, 1.00)
Sternocleidomastoid muscle  | Insertion| Sternocleidomastoid insertion on occiput (minor occipital nerve)| (Right) κ = .68 (.29, 1.00)
(Left) κ = .35 (−.17, .86)
Anterior| Just anterior to sternocleidomastoid muscle border| (Right) κ = .35 (−.17, .86)
(Left) κ = .55 (.10, .99)
Middle| At sternocleidomastoid muscle border| (Right) κ = .52 (.12, .92)
(Left) κ = .42 (.01, .82)
Posterior| Just posterior to sternocleidomastoid muscle border| (Right) κ = .60 (.19, 1.00)
(Left) κ = .87 (.62, 1.00)
Midline neck tenderness  | No details given| 8924 adult patients who presented to emergency department after blunt trauma to head/neck and had Glasgow Coma Score of 15| κ = .78
Posterolateral neck tenderness  | κ = .32
Maximal tenderness at midline  | κ = .72

#### Reliability of Assessing Pain with Palpation with and without a Patient History

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Without Knowledge of History| With Knowledge of History
Spinous processes C2-C3  | No details given| 100 patients with neck and/or shoulder problems with or without radiating pain| κ = .60| κ = .49
Spinous processes C4-C7  | κ = .42| κ = .50
Spinous processes T1-T3  | κ = .55| κ = .79
Paraspinal joints C1-C3  | κ = .32| κ = .22
Paraspinal joints C4-C7  | κ = .34| κ = .55
Paraspinal joints T1-T3  | κ = .41| κ = .51
Neck muscles  | κ = .32| κ = .46
Brachial plexus  | κ = .27| κ = .22
Paraspinal muscles  | κ = −.04| κ = .46

#### Reliability of Assessing Pain with Palpation in Patients with Cervicogenic Headache

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Articular pillars C0-C1  | Patient prone with neck in neutral position. Examiner applies progressive unilateral posteroanterior pressure over articular pillars. Positive if patient's headache symptoms are reproduced| 60 patients with cervicogenic headache based on criteria developed by International Headache Society| κ = .64 (.40, .88)
Articular pillars C1-C2  | κ = .71 (.51, .91)
Articular pillars C2-C3  | κ = .70 (.52, .88)
Articular pillars C3-C4  | κ = .61 (.37, .85)

#### Diagnostic Utility of Assessing Pain with Palpation

Test and Measure Quality| Test Procedure and Determination of Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Palpation over the facet joints in the cervical spine  | Articulations were palpated 2 cm lateral to the spinous process. Positive if patient reported pain with procedure| 75 males (22 with neck pain)| Patient reports of neck pain| .82| .79| 3.90| .23

### Postural and Muscle Length Assessment

#### Reliability of Postural Assessment

Figure 3-25 Thoracic kyphosis.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Forward head6  | Answered "yes" if the patient's external auditory meatus was anteriorly deviated (anterior to the lumbar spine)| 22 patients with mechanical neck pain| κ = −.10 (−.20, −.00)
Excessive shoulder protraction6  | Answered "yes" if the patient's acromions were anteriorly deviated (anterior to the lumbar spine)| κ = .83 (.51, 1.0)
C7-T2 excessive kyphosis6  | Recorded as "normal" (no deviation), "excessive kyphosis," or "diminished kyphosis." Excessive kyphosis was defined as an increase in the convexity, and diminished kyphosis was defined as a flattening of the convexity of the thoracic spine (at each segmental group)| κ = .79 (.51, 1.0)
T3-5 excessive kyphosis6  | κ = .69 (.30, 1.0)
T3-5 decreased kyphosis6  | κ = .58 (.22, .95)
T6-10 excessive kyphosis6  | κ = .90 (.74, 1.0)
T6-10 decreased kyphosis6  | κ = .90 (.73, 1.0)

#### Reliability of Muscle Length Assessment

Figure 3-26 Muscle length assessment.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Latissimus dorsi6  | Each muscle was recorded as "normal" or "restricted length"| 22 patients with mechanical neck pain| (Right) κ = .80 (.53, 1.0)
(Left) κ = .69 (.30, 1.0)
Pectoralis minor6  | (Right) κ = .81 (.57, 1.0)
(Left) κ = .71 (.43, 1.0)
Pectoralis major6  | (Right) κ = .90 (.72, 1.0)
(Left) κ = .50 (.01, 1.0)
Levator scapulae6  | (Right) κ = .61 (.26, .95)
(Left) κ = .54 (.19, .90)
Upper trapezius6  | (Right) κ = .79 (.52, 1.0)
(Left) κ = .63 (.31, .96)
Anterior and middle scalenes6  | (Right) κ = .81 (.57, 1.0)
(Left) κ = .62 (.29, .96)
Suboccipitals6  | (Right) κ = .63 (.26, 1.0)
(Left) κ = .58 (.15, 1.0)

### Spurling's and Neck Compression Tests

#### Reliability of Spurling's and Neck Compression Tests

Figure 3-27 Cervical compression test.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Straight compression35  | Patient seated with examiner standing behind patient. Examiner exerts pressure on head. Positive if pain is provoked| 100 patients with neck and/or shoulder problems with or without radiating pain| κ = .34 without knowledge of patient history
κ = .44 with knowledge of patient history
Neck compression with34:  | Right shoulder/arm pain| Cervical compression performed with patient sitting. Examiner passively rotates and side-bends the head to the right and/or left. A compression force of 7 kg is applied. Presence and location of pain, paresthesias, or numbness are recorded| 52 patients referred for cervical myelography| (Right) κ = .61
(Left) Not available
Left shoulder/arm pain| (Right) Not available
(Left) κ = .40
Right forearm/hand pain| (Right) κ = .77
(Left) κ = .54
Left forearm/hand pain| (Right) Not available
(Left) κ = .62
Spurling's A7  | Patient seated with neck side-bent toward ipsilateral side; 7 kg of overpressure is applied| 50 patients with suspected cervical radiculopathy or carpal tunnel syndrome| κ = .60 (.32, .87)
Spurling's B7  | Patient seated with extension and side-bending/rotation to ipsilateral side; 7 kg of overpressure is applied| κ = .62 (.25, .99)
Spurling's to the right35  | Cervical compression performed with patient seated. Examiner passively rotates and side-bends head to right or left and applies compression force of 7 kg. Presence and location of pain, paresthesias, or numbness are recorded| 100 patients with neck and/or shoulder problems with or without radiating pain| κ = .37 without knowledge of patient history
κ = .28 with knowledge of patient history
Spurling's to the left35  | κ = .37 without knowledge of patient history
κ = .46 with knowledge of patient history

#### Diagnostic Utility of Spurling's Test

Figure 3-28 Spurling's test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Spurling's A7  | Patient is seated, the neck is side-bent toward the ipsilateral side, and 7 kg of overpressure is applied (see Fig. 3-28). Positive if symptoms are reproduced| 82 consecutive patients referred to electrophysiologic laboratory with suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome| Cervical radiculopathy via needle electromyography and nerve conduction studies| .50 (.27, .73)| .86 (.77, .94)| 3.5 (1.6, 7.5)| .58 (.36, .94)
Spurling's B7  | Patient seated. Extension and side-bending/rotation to the ipsilateral side and then 7 kg of overpressure is applied (see Fig. 3-28). Positive if symptoms are reproduced| .50 (.27, .73)| .74 (.63, .85)| 1.9 (1.0, 3.6)| .67 (.42, 1.1)
Spurling's test37   (see Video 3-1)| The patient's neck is extended and rotated for the suspected involved side prior to axial compression. Positive with radicular pain that radiates into the upper extremity| 257 patients who had symptoms of unilateral cervical radiculopathy lasting for at least 4 weeks| Cervical radiculopathy via CT scanning| .95| .94| 15.8| .05
Spurling's test38 | The patient's neck is extended and laterally flexed toward the involved side, and downward axial pressure is applied on the head. Positive if radicular pain or tingling in the upper limb is reproduced or aggravated| 50 patients presenting to neurosurgery with neck and arm pain suggestive of radicular pain| Soft lateral cervical disc prolapse via MRI| .93 (.84, 1.0)| .95 (.86, 1.0)| 18.6| .07
Spurling's test39  | Patient side-bends and extends the neck, and examiner applies compression. Positive if pain or tingling that starts in the shoulder radiates distally to the elbow| 255 consecutive patients referred to physiatrist for upper extremity nerve disorders| Cervical radiculopathy via electrodiagnostic testing| .30| .93| 4.29| .75
Spurling's test23  | Extension of the neck with rotation and side-bending to the same side. Positive if subject reports pain with procedure| 75 males (22 with neck pain)| Patient reports of neck pain| .77| .92| 9.63| .25

### Neck Distraction and Traction Tests

#### Reliability of Neck Distraction and Traction Tests

Figure 3-29 Neck distraction and traction tests.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Axial manual traction34  | With patient supine, examiner applies axial distraction force of 10-15 kg. Positive if radicular symptoms decrease| 52 patients referred for cervical myelography| κ = .50
Neck distraction test7  | With patient supine, examiner grasps patient under chin and occiput while slightly flexing patient's neck while applying distraction force of 14 pounds. Positive if symptoms are reduced| 50 patients with suspected cervical radiculopathy or carpal tunnel syndrome| κ = .88 (.64, 1.0)
Traction35  | With patient seated, examiner stands behind patient with hands underneath each maxilla and thumbs on the back of the head. Positive if symptoms are reduced during traction| 100 patients with neck and/or shoulder problems with or without radiating pain| κ = .56 without knowledge of history
κ = .41 with knowledge of history

### Cervical Flexion-Rotation Test

#### Reliability of Cervical Flexion-Rotation Test

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Cervical flexion-rotation test40  | With patient supine and the cervical spine passively maximally flexed, the examiner passively rotates head left and right. Positive if subject reports onset of pain or if examiner encounters firm resistance at an estimated range of motion that is reduced by more than 10 degrees from normal of 44 degrees| 15 subjects with cervicogenic headache evaluated on headache-free days and 10 asymptomatic subjects| κ = .50

### Shoulder Abduction Test

Figure 3-30 Shoulder abduction test.

#### Reliability of Shoulder Abduction Test

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Shoulder abduction test7  | Patient is seated and asked to place the symptomatic extremity on head. Positive if symptoms are reduced| 50 patients with suspected cervical radiculopathy or carpal tunnel syndrome| κ = .20 (.00, .59)
Shoulder abduction test34  | Patient is seated and asked to raise the symptomatic extremity above the head. Positive if symptoms are reduced| 52 patients referred for cervical myelography| (Right) κ = .21
(Left) κ = .40

### Neural Tension Tests

#### Reliability of Neural Tension Tests

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Upper limb tension test A7  | With patient supine, examiner performs the following movements:| 50 patients with suspected cervical radiculopathy or carpal tunnel syndrome| κ = .76 (.51, 1.0)

1. Scapular depression

|

2. Shoulder abduction

|

3. Forearm supination

|

4. Wrist and finger extension

|

5. Shoulder lateral rotation

|

6. Elbow extension

|

7. Contralateral/ipsilateral cervical side-bending

|
Positive response defined by any of the following:|

1. Patient symptoms reproduced

|

2. Side-to-side differences in elbow extension of more than 10 degrees

|

3. Contralateral cervical side-bending increases symptoms or ipsilateral side-bending decreases symptoms

|
Upper limb tension test B7  | With patient supine and shoulder abducted 30 degrees, examiner performs the following movements:| κ = .83 (.65, 1.0)

1. Scapular depression

|

2. Shoulder medial rotation

|

3. Full elbow extension

|

4. Wrist and finger flexion

|

5. Contralateral/ipsilateral cervical side-bending

|
Positive response defined by any of the following:|

1. Patient symptoms reproduced

|

2. Side-to-side differences in wrist flexion of more than 10 degrees

|

3. Contralateral cervical side-bending increases symptoms or ipsilateral side-bending decreases symptoms

|
Brachial plexus test34  | With patient supine, examiner abducts the humerus to the limit of pain-free motion and then adds lateral rotation of the arm and elbow flexion. If no limitation of motion is noted, the humerus is abducted to 90 degrees. The appearance of symptoms is recorded| 52 patients referred for cervical myelography| (Right) κ = .35
Left was not calculated because prevalence of positive findings was less than 10%

#### Reliability of Neural Tension Tests

Figure 3-31 Upper limb tension tests.

#### Diagnostic Utility of Neural Tension Tests for Cervical Radiculopathy

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Upper limb tension test A7  | With patient supine, examiner performs the following movements:

1. Scapular depression

2. Shoulder abduction

3. Forearm supination

4. Wrist and finger extension

5. Shoulder lateral rotation

6. Elbow extension

7. Contralateral and ipsilateral cervical side-bending

Positive response defined by any of the following:

1. Patient symptoms reproduced

2. Side-to-side differences in elbow extension of more than 10 degrees

3. Contralateral cervical side-bending increases symptoms or ipsilateral side-bending decreases symptoms

| 82 consecutive patients referred to electrophysiologic laboratory with suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome| Cervical radiculopathy via needle electromyography and nerve conduction studies| .97 (.90, 1.0)| .22 (.12, .33)| 1.3 (1.1, 1.5)| .12 (.01, 1.9)
Upper limb tension test B7  | With patient supine and patient's shoulder abducted 30 degrees, examiner performs the following movements:

1. Scapular depression

2. Shoulder medial rotation

3. Full elbow extension

4. Wrist and finger flexion

5. Contralateral and ipsilateral cervical side-bending

| .72 (.52, .93)| .33 (.21, .45)| 1.1 (.77, 1.5)| .85, (.37, 1.9)
| Positive response defined by any of the following:| | | |
|

1. Patient symptoms reproduced

| | | |
|

2. Side-to-side differences in wrist flexion of more than 10 degrees

| | | |
|

3. Contralateral cervical side-bending increases symptoms or ipsilateral side-bending decreases symptoms

| | | |
Upper limb tension test23  | With patient seated and arm in extension, abduction and external rotation of the glenohumeral joint, extension of the elbow, the forearm in supination, and the wrist and fingers in extension. Contralateral flexion of the neck is added. Positive if patient reported pain with procedure| 75 males (22 with neck pain)| Patient reports of neck pain| .77| .94| 12.83| .25

### Sharp-Purser Test

#### Diagnostic Utility of the Sharp-Purser Test for Cervical Instability

Figure 3-32 Sharp-Purser test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Sharp-Purser test41   (see Video 3-2)| Patient sits with neck in a semiflexed position. Examiner places palm of one hand on patient's forehead and index finger of the other hand on the spinous process of axis. When posterior pressure is applied through the forehead, a sliding motion of the head posteriorly in relation to axis indicates a positive test for atlantoaxial instability| 123 consecutive outpatients with rheumatoid arthritis| Full flexion and extension lateral radiographs. Atlantodens interval greater than 3 mm was considered abnormal| .69| .96| 17.25| .32

### Arm Squeeze Test

#### Reliability of the Arm Squeeze Test in Distinguishing Cervical Nerve Root Compression from Shoulder Pain

Figure 3-33 Arm squeeze test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Arm squeeze test42   (see Video 3-3)| Examiner squeezes the middle third of the patient's upper arm with thumb on patient's triceps and fingers on patient's biceps with moderate compression (5.9 to 8.1 kg). Positive if patient reports 3 points or higher on visual analog scale (VAS) with pressure on middle third of upper arm compared with acromioclavicular joint and subacromial area| 305 patients with cervical nerve root compression, 903 patients with rotator cuff tear, and 350 healthy volunteers| Intraexaminer
κ = .87 (.85, .89)
Interexaminer
κ = .81 (.79, .82)

#### Diagnostic Utility of the Arm Squeeze Test in Distinguishing Cervical Nerve Root Compression from Shoulder Pain

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Arm squeeze test42  | Examiner squeezes the middle third of the patient's upper arm with thumb on patient's triceps and fingers on patient's biceps with moderate compression (5.9 to 8.1 kg). Positive if patient reports 3 points or higher on VAS with pressure on middle third of upper arm compared with acromioclavicular joint and subacromial area| 305 patients with cervical nerve root compression, 903 patients with rotator cuff tear, and 350 healthy volunteers| Diagnosis of cervical nerve root compression (C5-T1) based on clinical examination, electromyography, x-rays, and MRI| .96 (.85, .99)| .96 (.86, .98)| 24| .04

### Compression of Brachial Plexus

#### Diagnostic Utility of Brachial Plexus Compression for Cervical Cord Compression

Figure 3-34 Cervical disc herniation causing cord compression.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Compression of brachial plexus43  | Firm compression and squeezing of the brachial plexus with the thumb. Positive only when pain radiates to the shoulder or upper extremity| 65 patients who had undergone MRI of cervical spine as result of radiating pain| Cervical cord compression via MRI| .69| .83| 4.06| .37

### Cervical Myelopathy Tests

#### Reliability of Tests for Cervical Myelopathy

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Hoffmann sign44  | With the patient standing or sitting, the clinician stabilizes the proximal interphalangeal joint of the middle finger and applies a stimulus to the middle finger by "flicking" the fingernail between his thumb and index finger into a flexed position. Positive with adduction of the thumb and flexion of the fingers| 51 patients with cervical pain as primary complaint| κ = .76 (.56, .96)
Deep tendon reflex test44  | In biceps tendon testing, the patient assumes a sitting position while the clinician places the patient's slightly supinated forearm on the clinician's own forearm, ensuring relaxation. The clinician's thumb is placed on the patient's biceps tendon, and the clinician strikes his own thumb with quick strikes of a reflex hammer. In triceps tendon testing, the sitting patient's elbow is flexed passively via shoulder elevation to approximately 90 degrees. The clinician then places his thumb over the distal aspect of the triceps tendon and applies a series of quick strikes of the reflex hammer to his own thumb. Positive with hyperreflexia| κ = .73 (.50, .95)
Inverted supinator sign44  | With the patient in a seated position, the clinician places the patient's slightly pronated forearm on his forearm to ensure relaxation. The clinician applies a series of quick strikes near the styloid process of the radius at the attachment of the brachioradialis tendon. The test is performed in the same manner as a brachioradialis tendon reflex test. Positive with finger flexion or slight elbow extension| κ = .52 (.26, .78)
Suprapatellar quadriceps test44  | With the patient sitting with his or her feet off the ground, the clinician applies quick strikes of the reflex hammer to the suprapatellar tendon. Positive with hyperreflexive knee extension| κ = .68 (.46, .89)
Hand withdrawal reflex44  | With the patient sitting or standing, the clinician grasps the patient's palm and strikes the dorsum of the patient's hand with a reflex hammer. Positive with abnormal flexor response| κ = .55 (.34, .82)
Babinski sign44  | With the patient supine, the clinician supports the patient's foot in neutral and applies stimulation to the plantar aspect of the foot (typically from lateral to medial from heel to metatarsal) with the blunt end of a reflex hammer. Positive with great toe extension and fanning of the second through fifth toes| κ = .56 (.24, .89)
Clonus44  | With the patient sitting with his or her feet off the ground, the clinician applies a quick stretch to the Achilles tendon via rapid passive dorsiflexion of the ankle. Positive when ankle "beats" in and out of dorsiflexion for at least three beats| κ = .66 (.03, .99)

#### Diagnostic Utility of Tests for Cervical Myelopathy

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Hoffmann sign44  | With the patient standing or sitting, the clinician stabilizes the proximal interphalangeal joint of the middle finger and applies a stimulus to the middle finger by "flicking" the fingernail between his thumb and index finger into a flexed position. Positive with adduction of the thumb and flexion of the fingers| 51 patients with cervical pain as primary complaint| Cervical myelopathy via MRI| .44 (.28, .58)| .75 (.63, .86)| 1.8 (.80, 4.1)| .70 (.50, 1.1)
Deep tendon reflex test44  | In biceps tendon testing, clinician places the patient's slightly supinated forearm on his own forearm, ensuring relaxation. The clinician's thumb is placed on the patient's biceps tendon, and the clinician strikes his own thumb with quick strikes of a reflex hammer. In triceps tendon testing, the patient's elbow is flexed passively via shoulder elevation to approximately 90 degrees. The clinician then places his thumb over the distal aspect of the triceps tendon and applies a series of quick strikes of the reflex hammer to his own thumb. Positive with hyperreflexia| .44 (.28, .59)| .71 (.59, .82)| 1.5 (.70, 3.4)| .80 (.50, 1.2)
Inverted supinator sign44  | With the patient in a seated position, the clinician places the patient's slightly pronated forearm on his forearm to ensure relaxation. The clinician applies a series of quick strikes near the styloid process of the radius at the attachment of the brachioradialis tendon. The test is performed in the same manner as a brachioradialis tendon reflex test. Positive with finger flexion or slight elbow extension| .61 (.44, .74)| .78 (.65, .88)| 2.8 (1.2, 6.4)| .50 (.30, .90)
Suprapatellar quadriceps test44  | With the patient sitting with his or her feet off the ground, the clinician applies quick strikes of the reflex hammer to the suprapatellar tendon. Positive with hyperreflexive knee extension| .56 (.39, .72)| .33 (.22, .46)| .80 (.50, 1.3)| 1.3 (.60, 2.8)

Figure 3-35 Inverted supinator sign.

Figure 3-36 Hand withdrawal reflex.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Hand withdrawal reflex44  | With the patient sitting or standing, the clinician grasps the patient's palm and strikes the dorsum of the patient's hand with a reflex hammer. Positive with abnormal flexor response| 82 consecutively referred patients with suspected cervical radiculopathy or CTS| Electrophysiologic examination| .41 (.25, .58)| .63 (.51, .75)| 1.1 (.50, 2.3)| .90 (.60, 1.5)
Babinski sign44  | With the patient supine, the clinician supports the patient's foot in neutral and applies stimulation to the plantar aspect of the foot (typically from lateral to medial from heel to metatarsal) with the blunt end of a reflex hammer. Positive with great toe extension and fanning of the second through fifth toes| .33 (.19, .41)| .92 (.81, .98)| 4.0 (1.1, 16.6)| .70 (.60, .90)
Clonus44  | With the patient sitting with his or her feet off the ground, the clinician applies a quick stretch to the Achilles tendon via rapid passive dorsiflexion of the ankle. Positive when ankle "beats" in and out of dorsiflexion for at least three beats| .11 (.30, .16)| .96 (.90, .99)| 2.7 (.40, 20.1)| .90 (.80, 1.1)

### Combinations of Tests

#### Diagnostic Utility of Clusters of Tests for Cervical Myelopathy

Cook and colleagues45 identified a test item cluster, or an optimal combination of clinical examination tests, that may be useful in identifying patients with cervical myelopathy. The five clinical findings listed below demonstrated the capacity to rule out cervical myelopathy when clustered into one of five positive findings and rule in cervical myelopathy when clustered into three of five positive findings.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Gait deviation
+
Positive Hoffmann test
+
Inverted supinator sign
+
Positive Babinski test
+
Age over 45 years45  | One of five positive tests| 249 consecutive patients with primary complaint of cervical pain or dysfunction seen at university spine surgery center| Diagnosis of cervical myelopathy was confirmed or ruled out using MRI| .94 (.89, .97)| .31 (.27, .32)| 1.4 (1.2, 1.4)| .18 (.12, .42)
Three of five positive tests| .19 (.15, .20)| .99 (.97, .99)| 30.9 (5.5, 181.8)| .81 (.79, .87)

#### Diagnostic Utility of Clusters of Tests for Cervical Radiculopathy

Wainner and colleagues7 identified a test item cluster, or an optimal combination of clinical examination tests, that can determine the likelihood that a patient is presenting with cervical radiculopathy. The four predictor variables most likely to identify patients presenting with cervical radiculopathy are the upper limb tension test A, the Spurling's A test, the distraction test, and cervical rotation of less than 60 degrees to the ipsilateral side.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Upper limb tension test A
+
Spurling's A test
+
Distraction test
+
Cervical rotation of less than 60 degrees to the ipsilateral side7  | All four tests positive| 82 consecutive patients referred to electrophysiologic laboratory with suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome| Cervical radiculopathy via needle electromyography and nerve conduction studies| .24 (.05, .43)| .99 (.97, 1.0)| 30.3 (1.7, 38.2)| Not reported
Any three tests positive| .39 (.16, .61)| .94 (.88, 1.0)| 6.1 (2.0, 18.6)
Any two tests positive| .39 (.16, .61)| .56 (.43, .68)| .88 (1.5, 2.5)

Figure 3-37 Fagan's nomogram. Considering the 20% prevalence or pretest probability of cervical radiculopathy in the study by Wainner and colleagues, the nomogram demonstrates the major shifts in probability that occur when all four tests from the cluster are positive (see Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28:52-62). (Reprinted with permission from Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975;293:257. Copyright 2005, Massachusetts Medical Society. All rights reserved.)

### Interventions

#### Clinical Prediction Rule to Identify Patients with Neck Pain Who Are Likely to Benefit from Cervical Thrust Manipulation

Puentedura and colleagues46 developed a clinical prediction rule for identifying patients with neck pain who are likely to benefit from cervical thrust manipulation. The result of their study demonstrated that if three or more of the four attributes (symptom duration less than 38 days, positive expectation that manipulation will help, side-to-side difference in cervical rotation range of motion of 10 degrees or more, and pain with posteroanterior spring testing of the middle cervical spine) were present, the +LR was 13.5 (95% CI 1.0, 328.3) and the probability of experiencing a successful outcome improved from 39% to 90%.

#### Diagnostic Utility of Single Factors and Combinations of Factors for Identifying a Positive Short-Term Clinical Outcome for Cervical Radiculopathy

We used the baseline examination and physical therapy interventions received to investigate predictors for short-term improvement in patients with cervical radiculopathy.47 Patients were treated at the discretion of their physical therapist for a mean of 6.4 visits over an average of 28 days. In addition to identifying the single factors most strongly associated with improvement, we used logistic regression to identify the combination of factors most predictive of short-term improvement.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Age less than 54 years47  | Self-report| 96 patients referred to physical therapy with cervical radiculopathy as defined by being positive on all four items in Wainner's diagnostic test item cluster7 (see previous section on Diagnostic Utility of Clusters of Tests for Cervical Radiculopathy)| Improvement at physical therapy discharge as defined by surpassing the minimal detectable change in all outcome measures| .76 (.64, .89)| .52 (.38, .67)| 1.5 (1.2, 2.1)| Not reported
Dominant arm is not affected47  | Self-report| .74 (.62, .86)| .52 (.38, .67)| 1.5 (1.1, 2.2)
Looking down does not worsen symptoms47  | Self-report| .68 (.55, .81)| .48 (.34, .62)| 1.3 (.93, 1.8)
More than 30 degrees of cervical flexion47  | Patient sitting. Used an inclinometer after two warm-up repetitions| .56 (.42, .70)| .59 (.44, .73)| 1.4 (.89, 2.1)
Age less than 54 years
+
Dominant arm is not affected
+
Looking down does not worsen symptoms
+
Provided with multimodal treatment, including manual therapy, cervical traction, and deep neck flexor muscle strengthening for 50% or more of visits47  | All four tests positive| .18 (.07, .29)| .98 (.94, 1.0)| 8.3 (1.9, 63.9)
Any three tests positive| .68 (.55, .81)| .87 (.77, .97)| 5.2 (2.4, 11.3)
Any two tests positive| .94 (.87, 1.0)| .37 (.23, .51)| 1.5 (1.2, 1.9)
Any one test positive| 1.0 (1.0, 1.0)| .08 (.01, .20)| 1.1 (1.0, 2.0)

#### Diagnostic Utility of Historical and Physical Examination Findings for Immediate Improvement with Cervical Manipulation

Figure 3-38 Cervical manipulation. Delivered by Tseng and colleagues at the discretion of the therapist to the most hypomobile segments. "Once a hypomobile segment was localized, the manipulator carefully flexed and sidebent the patient's neck to lock the facet joints of other spinal segments until the barrier was reached. A specific cervical manipulation with a high-velocity, low-amplitude thrust force was then exerted on the specific, manipulable lesion to gap the facet." (See Tseng YL, Wang WT, Chen WY, et al. Predictors for the immediate responders to cervical manipulation in patients with neck pain. Man Ther. 2006;11:306-315.)

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Initial Neck Disability Index score over 11.5
+
Bilateral involvement pattern
+
Not performing sedentary work for longer than 5 hours/day
+
Feeling better while moving the neck
+
Without feeling worse while extending the neck
+
Diagnosis of spondylosis without radiculopathy48  | Five or six tests positive| 100 patients referred to physical therapy for neck pain| Immediate improvement after cervical manipulation as determined by any of the following:

1. Decrease of 50% or more in score on NPRS

2. Score of 4 or higher (much improved) on Global Rating of Change (GROC) scale

3. Patient satisfaction rating of "very satisfied" after manipulation

| .07 (.00, .13)| 1.00 (1.00, 1.00)| Undefined| Not reported
Any four tests positive| .40 (.28, .52)| .93 (.84, 1.00)| 5.33 (1.72, 16.54)
Any three tests positive| .43 (.31, .56)| .78 (.65, .90)| 1.93 (1.01, 3.67)
Any two tests positive| .08 (.01, .15)| .57 (.42, .73)| .20 (.08, .49)
Any one test positive| .02 (−.02, .05)| .75 (.62, .88)| .07 (.01, .50)

#### Diagnostic Utility of Historical and Physical Examination Findings for Immediate Improvement with Thoracic Manipulation

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR
---|---|---|---|---|---|---
Symptom duration for less than 30 days49  | Self-report| 78 patients referred to physical therapy with mechanical neck pain| Improvement after several standardized thoracic manipulations and cervical range-of-motion exercise as determined by a score of 5 or higher ("quite a bit better") on the GROC scale on the second or third visit| .36 (.22, .52)| .94 (.80, .99)| 6.4 (1.60, 26.3)
No symptoms distal to the shoulder49  | .67 (.50, .80)| .53 (.36, .69)| 1.4 (.94, 2.2)
FABQPA score of less than 1249  | Questionnaire to quantify a person's beliefs about the influence of work and activity on person's own neck pain| .28 (.16, .45)| .91 (.76, .98)| 3.4 (1.05, 11.20)
FABQW score of less than 1049  | .55 (.39, .70)| .69 (.52, .83)| 1.8 (1.02, 3.15)
Three or more prior episodes of neck pain49  | Self-report| .23 (.15, .35)| .83 (.54, .96)| 1.9 (1.3, 2.7)
Patient reports that looking up does not aggravate symptoms49  | .67 (.50, .80)| .86 (.70, .95)| 4.8 (2.07, 11.03)
Exercises more than three times/week49  | .65 (.50, .76)| .67 (.46, .83)| 1.9 (1.1, 3.4)
Cervical extension range of motion of less than 30 degrees49  | Measured with inclinometer| .62 (.46, .76)| .75 (.57, .87)| 2.5 (1.34, 4.57)
Decreased upper thoracic spine kyphosis49  | Increased convexity at T3-T5| .54 (.42, .65)| .64 (.48, .78)| 1.1 (.77, 1.60)
Shoulders protracted49  | Positive if acromion was noted to be anterior to the lumbar spine| .65 (.51, .77)| .76 (.52, .90)| 2.7 (1.6, 3.0)

FABQPA, Fear-Avoidance Beliefs Questionnaire physical activity subscale; FABQW: Fear-Avoidance Beliefs Questionnaire work subscale. –LR not reported. GROC scale, Global Rating of Change scale.

#### Diagnostic Utility of a Cluster of Historical and Physical Examination Findings for Immediate Improvement with Thoracic Manipulation

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR
---|---|---|---|---|---|---
Symptom duration for less than 30 days
+
No symptoms distal to the shoulder
+
FABQPA score of less than 12
+
Patient reports that looking up does not aggravate symptoms
+
Cervical extension range of motion of less than 30 degrees
+
Decreased upper thoracic spine kyphosis (T3-T5)49  | All six tests positive| 78 patients referred to physical therapy with mechanical neck pain| Improvement after several standardized thoracic manipulations and cervical range-of-motion exercise as determined by a score of 5 or higher ("quite a bit better") on the GROC scale on the second or third visit| .05 (.00, .17)| 1.0 (.97, 1.00)| Undefined
At least five tests positive| .12 (.04, .25)| 1.0 (.94, 1.00)| Undefined
At least four tests positive| .33 (.26, .35)| .97 (.89, 1.00)| 12 (2.28, 70.8)
At least three tests positive| .76 (.67, .82)| .86 (.75, .93)| 5.49 (2.72, 12.0)
At least two tests positive| .93 (.84, .97)| .56 (.46, .61)| 2.09 (1.54, 2.49)
At least one test positive| 1.00 (.95, 1.00)| .17 (.11, .24)| 1.2 (1.06, 1.2)

FABQPA, Fear-Avoidance Beliefs Questionnaire physical activity subscale; FABQW, Fear-Avoidance Beliefs Questionnaire work subscale. –LR not reported. GROC scale, Global Rating of Change scale.

Figure 3-39 Thoracic spine manipulation and active range of motion.

#### Diagnostic Utility of Historical and Physical Examination Findings for Improvement with Three Weeks of Mechanical Cervical Traction

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Neck distraction test50  | Patient lies supine and the neck is comfortably positioned. Examiner securely grasps the patient's head under the occiput and chin and gradually applies an axial traction force of up to approximately 30 pounds. Positive response defined by reduction of symptoms| 68 patients referred to physical therapy with neck pain with or without upper extremity symptoms| Improvement after six treatments over 3 weeks of mechanical cervical traction and postural/deep neck flexor strengthening exercise as determined by a score of +7 or higher ("a very great deal better") on GROC scale| .83 (.66, .93)| .50 (.35, .65)| 1.67 (1.18, 2.45)| .33 (.14, .73)
Shoulder abduction test50  | While sitting, the patient is instructed to place the hand of the affected extremity on the head in order to support the extremity in the scapular plane. Positive response defined by alleviation of symptoms| .33 (.19, .51)| .87 (.73, .94)| 2.53 (1.01, 6.50)| .77 (.55, 1.00)
Positive ULTT A50  | With patient supine, examiner performs the following movements:

1. Scapular depression

2. Shoulder abduction

3. Forearm supination

4. Wrist and finger extension

5. Shoulder lateral rotation

6. Elbow extension

7. Contralateral and ipsilateral cervical side-bending

Positive response defined by reproduction of symptoms| .80 (.63, .90)| .37 (.23, .53)| 1.27 (.93, 1.75)| .54 (.23, 1.18)

ULTT, upper limb tension test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Pain with manual muscle testing50  | No details given| 68 patients referred to physical therapy with neck pain with or without upper extremity symptoms| Improvement after six treatments over 3 weeks of mechanical cervical traction and postural/deep neck flexor strengthening exercise as determined by a score of +7 or higher ("a very great deal better") on the GROC scale| .63 (.46, .78)| .71 (.55, .83)| 2.19 (1.27, 3.92)| .52 (.30, .82)
Body mass index score of 28.4 or higher50  | .67 (.49, .81)| .68 (.53, .81)| 2.11 (1.26, 3.66)| .49 (.27, .81)
Frequency of past episodes50  | .70 (.48, .85)| .67 (.47, .82)| 2.10 (1.15, 4.08)| .45 (.21, .87)
Symptoms distal to the shoulder41  | .67 (.49, .81)| .58 (.42, .72)| 1.58 (1.01, 2.53)| .58 (.32, .99)
Headaches50  | .43 (.27, .61)| .55 (.40, .70)| .97 (.56, 1.65)| 1.02 (.65, 1.57)
Diminished strength50  | .43 (.27, .61)| .76 (.61, .87)| 1.83 (.92, 3.69)| .74 (.50, 1.04)
Peripheralization with central posteroanterior motion testing at lower cervical C4-C7 spine50  | .37 (.22, .54)| .82 (.67, .91)| 1.99 (.90, 4.47)| .78 (.54, 1.04)
Ipsilateral rotation of less than 60 degrees50  | .43 (.27, .61)| .66 (.50, .79)| 1.27 (.69, 2.31)| .86 (.57, 1.26)
Patient-reported neck stiffness50  | .43 (.27, .61)| .34 (.21, .50)| .66 (.40, 1.02)| 1.65 (.97, 2.88)
Flexion active range of motion of less than 55 degrees50  | .60 (.42, .75)| .55 (.40, .70)| 1.34 (.84, 2.14)| .72 (.42, 1.19)
Age of 55 years or older50  | .47 (.30, .64)| .89 (.76, .96)| 4.43 (1.74, 11.89)| .60 (.40, .81)
Ipsilateral side-bending of less than 40 degrees50  | .73 (.56, .86)| .45 (.30, .60)| 1.33 (.92, 1.93)| .60 (.29, 1.14)

GROC scale, Global Rating of Change scale.

#### Diagnostic Utility of a Cluster of Historical and Physical Examination Findings for Improvement with Three Weeks of Mechanical Cervical Traction

Figure 3-40 Cervical traction. The cervical traction in this study was performed with the patient supine and the legs supported on a stool. The neck was flexed to 24 degrees for patients with full cervical range of motion and to 15 degrees otherwise. The traction force was set at 10 to 12 pounds initially and adjusted upward during the first treatment session to optimally relieve symptoms. Each traction session lasted approximately 15 minutes and alternated between 60 seconds of pull and 20 seconds of release at 50% force. (See Raney NH, Petersen EJ, Smith TA, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J. 2009;18(3):382-391.)

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Age 55 years or older
+
Positive shoulder abduction test
+
Positive ULTT A
+
Symptom peripheralization with central posteroanterior motion testing at lower cervical (C4-C7) spine
+
Positive neck distraction test50  | At least four tests positive| 68 patients referred to physical therapy with neck pain with or without upper extremity symptoms| Improvement after six treatments over 3 weeks of mechanical cervical traction and postural/deep neck flexor strengthening exercise as determined by a score of +7 or higher ("a very great deal better") on the GROC scale| .30 (.17, .48)| 1.0 (.91, 1.0)| 23.1 (2.50, 227.9)| .71 (.53, .85)
At least three tests positive| .63 (.46, .78)| .87 (.73, .94)| 4.81 (2.17, 11.4)| .42 (.25, .65)
At least two tests positive| .30 (.17, .48)| .97 (.87, 1.00)| 1.44 (1.05, 2.03)| .40 (.16, .90)
At least one test positive| .07 (.02, .21)| .97 (.87, 1.00)| 1.15 (.97, 1.4)| .21 (.03, 1.23)

GROC scale, Global Rating of Change scale; ULTT, upper limb tension test.

## Outcome Measures

Outcome Measure| Scoring and Interpretation| Test-Retest Reliability| MCID
---|---|---|---
Neck Disability Index (NDI)| Users are asked to rate the difficulty of performing 10 functional tasks on a scale of 0 to 5 with different descriptors for each task. A total score out of 100 is calculated by summing each score and doubling the total. The answers provide a score between 0 and 100, with higher scores representing more disability| ICC = .6451  | 10.251
Fear-Avoidance Beliefs Questionnaire (FABQ)| Users are asked to rate their level of agreement with statements concerning beliefs about the relationship between physical activity, work, and their back pain ("neck" can be substituted for "back"). Level of agreement is answered on a Likert-type scale ranging from 0 (completely disagree) to 7 (completely agree). The FABQ is composed of two parts: a seven-item work subscale (FABQW) and a four-item physical activity subscale (FABQPA). Each scale is scored separately, with higher scores representing higher levels of fear avoidance| FABQW: ICC = .82
FABQPA: ICC = .6652  | Not available
Numeric Pain Rating Scale (NPRS)| Users rate their level of pain on an 11-point scale ranging from 0 to 10, with high scores representing more pain. Often asked as "current pain" and "least," "worst," and "average pain" in the past 24 hours| ICC = .7653  | 1.353

MCID, minimum clinically important difference.

## Appendix

#### Quality Appraisal of Reliability Studies Using QAREL

| Cleland 20066| Wainner 20037| Stiell 20019| Piva 200616| Hoving 200517| Olson 200018| Hole 199519| Youdas 199120| Pool 200421| Van Suijlekom 200022
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| Y| Y| Y| U| U| U| Y| U

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| N/A| N/A| N/A| Y| N| U| U| N/A| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| Y| Y| N/A| N/A| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| Y| U| U| U| U| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| U

8. Was the order of examination varied?

| N/A| U| N/A| Y| Y| Y| Y| Y| Y| Y

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Edmondston 200824| Olson 200625| Harris 200526| Chiu 200527| Kumbhare 200528| Smedmark 200029| Humphreys 200430| Viikari-Juntura 198734| Bertilson 200335| Cleland 200853
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| N/A| U| Y| Y| U| Y| Y| U| Y| U

4. Were raters blinded to their own prior findings of the test under evaluation?

| Y| U| U| U| N/A| N/A| N/A| N/A| N/A| U

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| U| U| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| Y| U| Y| U| U

8. Was the order of examination varied?

| Y| Y| N| U| Y| Y| U| U| Y| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Grotle 200652| Hall 201036| Hall 2010 (2)40| Young 200951| Kaale 200831| Gumina 201342| Cook 200944
---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| U| Y| N/A| Y| Y| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| U| N/A| N| U| N/A| N| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| Y| N| N/A| Y| Y| Y

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| Y| Y| Y| U| U| Y

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U

8. Was the order of examination varied?

| U| N/A| N/A| Y| U| U| Y

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

#### Quality Assessment of Diagnostic Studies Using QUADAS

| Jull 198833| Uitvlugt 198841| Viikari-Juntura 198954| Uchihara 199443| Sandmark 199523| Lauder 20008| Hoffman 200011| Stiell 20019| Tong 200239| Wainner 20037
---|---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| N| U| N| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| Y| N| N| N| Y| Y| Y| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| U| Y| N| Y| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| N| U| Y| U| U| Y| Y| U| U| U

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| U| Y| Y| Y| Y| Y| U| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| Y| U| Y| Y| Y| Y| N| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| N| Y| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| N| Y| Y| Y| Y| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| U| N| Y| Y| Y| Y| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| U| N| Y| Y| U| Y| Y| U| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| Y| Y| Y| N| Y| Y| Y| Y| Y

13. Were uninterpretable/intermediate test results reported?

| Y| Y| U| Y| Y| U| Y| Y| U| U

14. Were withdrawals from the study explained?

| Y| Y| U| Y| Y| U| Y| Y| U| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y - N = 10 to 14)   Fair quality (Y - N = 5 to 9)   Poor quality (Y - N ≤ 4).

| Bandiera 200314| Stiell 200310| Dickinson 200413| Humphreys 200430| Shah 200438| Tseng 200648| Duane 200715| Cleland 200747| King 200732| Raney 200950
---|---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| Y| N| Y| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| Y| Y| Y| Y| Y| Y| U| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| N| Y| U| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| U| U| U| U| Y| U| Y| U| Y

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| Y| Y| Y| Y| N| Y

6. Did patients receive the same reference standard regardless of the index test result?

| N| N| N| Y| Y| Y| Y| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| U| Y| Y| Y| Y| U| N| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| Y| Y| Y| Y| U| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| U| Y| Y| Y| U| Y| U| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| Y| Y| Y| Y| Y| U| Y| U| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| Y| Y| Y| N| Y| Y| U| Y| Y| Y

13. Were uninterpretable/intermediate test results reported?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| U

14. Were withdrawals from the study explained?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| U
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y - N = 10 to 14)   Fair quality (Y - N = 5 to 9)   Poor quality (Y - N ≤ 4).

| Goode 201412| Kaale 200831| Gumina 201342| Cook 201045| Shabat 201237| Cook 200944
---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| Y| Y| Y| Y| N| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| Y| U| Y| Y| Y

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| Y| Y| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| N| Y| N| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| Y| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| Y| Y| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| Y| Y| U| U| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| Y| Y| U| Y| Y| Y

13. Were uninterpretable/intermediate test results reported?

| U| Y| Y| N| Y| Y

14. Were withdrawals from the study explained?

| Y| Y| Y| N| Y| Y
Quality Summary Rating:|  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y - N = 10 to 14)   Fair quality (Y - N = 5 to 9)   Poor quality (Y - N ≤ 4).

## References

1. Michaleff ZA, Maher CG, Verhagen AP, et al. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012;184(16):E867–E876.

2. Bogduk N. Neck pain. Aust Fam Physician. 1984;13:26–30.

3. Lord SM, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine. 1996;21:1737–1744 [discussion 1744-1745].

4. Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine. 1990;15:453–457.

5. Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med. 2007;8:344–353.

6. Cleland JA, Childs JD, Fritz JM, Whitman JM. Interrater reliability of the history and physical examination in patients with mechanical neck pain. Arch Phys Med Rehabil. 2006;87:1388–1395.

7. Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28:52–62.

8. Lauder TD, Dillingham TR, Andary M, et al. Predicting electrodiagnostic outcome in patients with upper limb symptoms: are the history and physical examination helpful? Arch Phys Med Rehabil. 2000;81:436–441.

9. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286:1841–1848.

10. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349:2510–2518.

11. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343:94–99.

12. Goode T, Young A, Wilson SP, et al. Evaluation of cervical spine fracture in the elderly: can we trust our physical examination? Am Surg. 2014;80(2):182–184.

13. Dickinson G, Stiell IG, Schull M, et al. Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments. Ann Emerg Med. 2004;43:507–514.

14. Bandiera G, Stiell IG, Wells GA, et al. The Canadian C-spine rule performs better than unstructured physician judgment. Ann Emerg Med. 2003;42:395–402.

15. Duane TM, Dechert T, Wolfe LG, et al. Clinical examination and its reliability in identifying cervical spine fractures. J Trauma. 2007;62:1405–1410.

16. Piva SR, Erhard RE, Childs JD, Browder DA. Intertester reliability of passive intervertebral and active movements of the cervical spine. Man Ther. 2006;11:321–330.

17. Hoving JL, Pool JJ, van Mameren H, et al. Reproducibility of cervical range of motion in patients with neck pain. BMC Musculoskelet Disord. 2005;6:59.

18. Olson SL, O'Connor DP, Birmingham G, et al. Tender point sensitivity, range of motion, and perceived disability in subjects with neck pain. J Orthop Sports Phys Ther. 2000;30:13–20.

19. Hole DE, Cook JM, Bolton JE. Reliability and concurrent validity of two instruments for measuring cervical range of motion: effects of age and gender. Man Ther. 1995;1:36–42.

20. Youdas JW, Carey JR, Garrett TR. Reliability of measurements of cervical spine range of motion: comparison of three methods. Phys Ther. 1991;71:98–104 [discussion 105-106].

21. Pool JJ, Hoving JL, de Vet HC, et al. The interexaminer reproducibility of physical examination of the cervical spine. J Manipulative Physiol Ther. 2004;27:84–90.

22. Van Suijlekom HA, De Vet HC, Van Den Berg SG, Weber WE. Interobserver reliability in physical examination of the cervical spine in patients with headache. Headache. 2000;40:581–586.

23. Sandmark H, Nisell R. Validity of five common manual neck pain provoking tests. Scand J Rehabil Med. 1995;27:131–136.

24. Edmondston SJ, Wallumrod ME, Macleid F, et al. Reliability of isometric muscle endurance tests in subjects with postural neck pain. J Manipulative Physiol Ther. 2008;31:348–354.

25. Olson LE, Millar AL, Dunker J, et al. Reliability of a clinical test for deep cervical flexor endurance. J Manipulative Physiol Ther. 2006;29:134–138.

26. Harris KD, Heer DM, Roy TC, et al. Reliability of a measurement of neck flexor muscle endurance. Phys Ther. 2005;85:1349–1355.

27. Chiu TT, Law EY, Chiu TH. Performance of the craniocervical flexion test in subjects with and without chronic neck pain. J Orthop Sports Phys Ther. 2005;35:567–571.

28. Kumbhare DA, Balsor B, Parkinson WL, et al. Measurement of cervical flexor endurance following whiplash. Disabil Rehabil. 2005;27:801–807.

29. Smedmark V, Wallin M, Arvidsson I. Inter-examiner reliability in assessing passive intervertebral motion of the cervical spine. Man Ther. 2000;5:97–101.

30. Humphreys BK, Delahaye M, Peterson CK. An investigation into the validity of cervical spine motion palpation using subjects with congenital block vertebrae as a "gold standard.". BMC Musculoskelet Disord. 2004;5:19.

31. Kaale BR, Krakenes J, Albrektsen G, Wester K. Clinical assessment techniques for detecting ligament and membrane injuries in the upper cervical spine region: a comparison with MRI results. Man Ther. 2008;13(5):397–403.

32. King W, Lau P, Lees R, Bogduk N. The validity of manual examination in assessing patients with neck pain. Spine J. 2007;7:22–26.

33. Jull G, Bogduk N, Marsland A. The accuracy of manual diagnosis for cervical zygapophysial joint pain syndromes. Med J Aust. 1988;148:233–236.

34. Viikari-Juntura E. Interexaminer reliability of observations in physical examinations of the neck. Phys Ther. 1987;67:1526–1532.

35. Bertilson BC, Grunnesjo M, Strender LE. Reliability of clinical tests in the assessment of patients with neck/shoulder problems: impact of history. Spine. 2003;28:2222–2231.

36. Hall T, Briffa K, Hopper D, Robinson K. Reliability of manual examination and frequency of symptomatic cervical motion segment dysfunction in cervicogenic headache. Man Ther. 2010;15(6):542–546.

37. Shabat S, Leitner Y, David R, Folman Y. The correlation between Spurling test and imaging studies in detecting cervical radiculopathy. J Neuroimaging. 2012;22(4):375–378.

38. Shah KC, Rajshekhar V. Reliability of diagnosis of soft cervical disc prolapse using Spurling's test. Br J Neurosurg. 2004;18:480–483.

39. Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine. 2002;27:156–159.

40. Hall T, Briffa K, Hopper D, Robinson K. Long-term stability and minimal detectable change of the cervical flexion-rotation test. J Orthop Sports Phys Ther. 2010;40(4):225–229.

41. Uitvlugt G, Indenbaum S. Clinical assessment of atlantoaxial instability using the Sharp-Purser test. Arthritis Rheum. 1988;31:918–922.

42. Gumina S, Carbone S, Albino P, et al. Arm squeeze test: a new clinical test to distinguish neck from shoulder pain. Eur Spine J. 2013;22(7):1558–1563.

43. Uchihara T, Furukawa T, Tsukagoshi H. Compression of brachial plexus as a diagnostic test of cervical cord lesion. Spine. 1994;19:2170–2173.

44. Cook C, Roman M, Stewart KM, et al. Reliability and diagnostic accuracy of clinical special tests for myelopathy in patients seen for cervical dysfunction. J Orthop Sports Phys Ther. 2009;39(3):172–178.

45. Cook C, Brown C, Isaacs R, et al. Clustered clinical findings for diagnosis of cervical spine myelopathy. J Man Manip Ther. 2010;18(4):175–180.

46. Puentedura EJ, Cleland JA, Landers MR, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine. J Orthop Sports Phys Ther. 2012;42(7):577–592.

47. Cleland JA, Fritz JM, Whitman JM, Heath R. Predictors of short-term outcome in people with a clinical diagnosis of cervical radiculopathy. Phys Ther. 2007;87:1619–1632.

48. Tseng YL, Wang WT, Chen WY, et al. Predictors for the immediate responders to cervical manipulation in patients with neck pain. Man Ther. 2006;11:306–315.

49. Cleland JA, Childs JD, Fritz JM, et al. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys Ther. 2007;87:9–23.

50. Raney NH, Petersen EJ, Smith TA, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J. 2009;18(3):382–391.

51. Young BA, Walker MJ, Strunce JB, et al. Responsiveness of the Neck Disability Index in patients with mechanical neck disorders. Spine J. 2009;9(10):802–808.

52. Grotle M, Brox JI, Vollestad NK. Reliability, validity and responsiveness of the fear-avoidance beliefs questionnaire: methodological aspects of the Norwegian version. J Rehabil Med. 2006;38:346–353.

53. Cleland JA, Childs JD, Whitman JM. Psychometric properties of the Neck Disability Index and Numeric Pain Rating Scale in patients with mechanical neck pain. Arch Phys Med Rehabil. 2008;89:69–74.

54. Viikari-Juntura E, Porras M, Laasonen EM. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine. 1989;14:253–257.
4

# Thoracolumbar Spine

CLINICAL SUMMARY AND RECOMMENDATIONS, 148

Anatomy, 149

Osteology, 149

Arthrology, 150

Ligaments, 153

Muscles, 155

Fascia, 159

Nerves, 160

Patient History, 163

Initial Hypotheses Based on the Patient History, 163

Lumbar Zygapophyseal Joint Referral Patterns, 164

Thoracic Zygapophyseal Joint Referral Patterns, 165

Reliability of the Historical Examination, 166

Diagnostic Utility of Patient History in Identifying Lumbar Spinal Stenosis, 167

Diagnostic Utility of Patient History in Identifying Lumbar Radiculopathy, 168

Diagnostic Utility of Patient History in Identifying Ankylosing Spondylitis, 169

Physical Examination Tests, 170

Neurologic Examination, 170

Range-of-Motion Measurements, 173

Thoracolumbar Strength and Endurance Tests, 177

Postural Assessment, 178

Motor Control Assessment, 180

Passive Intervertebral Motion Assessment, 181

Palpation, 187

Centralization Phenomenon, 189

Straight-Leg Raise Test, 191

Crossed Straight-Leg Raise Test, 193

Slump Test, 194

Slump Knee Bend Test, 197

Tests for Lumbar Segmental Instability, 198

Tests for Lumbar Spinal Stenosis, 200

Tests for Radiographic Lumbar Instability, 201

Tests for Ankylosing Spondylitis, 204

Classification Methods, 205

Interventions, 207

Outcome Measures, 210

Appendix, 211

References, 218

## Clinical Summary and Recommendations

Patient History
---
Complaints|

• A few subjective complaints appear to be useful in identifying specific spinal pathologic conditions. A report of "no pain when seated" is the answer to the single question with the best diagnostic utility for lumbar spinal stenosis (+LR [likelihood ratio] = 6.6). "Pain not relieved by lying down," "back pain at night," and "morning stiffness for longer than 1/2 hour" are all somewhat helpful in identifying ankylosing spondylitis (+LR = 1.51 to 1.57). Subjective complaints of weakness, numbness, tingling, and/or burning do not appear to be especially helpful, at least in identifying lumbar radiculopathy.

Physical Examination
Neurologic Screening|

• Traditional neurologic screening (sensation, reflex, and manual muscle testing) is reasonably useful in identifying lumbar radiculopathy. When tested in isolation, weakness with manual muscle testing and, even more so, reduced reflexes are suggestive of lumbar radiculopathy, especially at the L3-L4 spinal levels. Sensation testing (vibration and pinprick) alone does not seem to be especially useful. However, when changes in reflexes, muscular strength, and sensation are found in conjunction with a positive straight-leg raise test, lumbar radiculopathy is highly likely (+LR = 6.0).

• In addition, a finding of decreased sensation (vibration and pinprick), muscle weakness, or reflex changes is modestly helpful in identifying lumbar spinal stenosis (+LR = 2.1 to 2.8).

Range-of-Motion, Strength, and Manual Assessment|

• Measuring both thoracolumbar range of motion and motor control, as well as trunk strength, has consistently been shown to be reliable, but the findings are of unknown diagnostic utility.

• The results of studies assessing the reliability of passive intervertebral motion (PIVM) are highly variable, but generally, the reports are of poor reliability when assessing for limited or excessive movement and of moderate reliability when assessing for pain.

• Diagnostic studies assessing PIVM suggest that abnormal segmental motion is moderately useful both in identifying radiographic hypomobility/hypermobility and in predicting the responses to certain conservative treatments. However, restricted PIVM may have little or no association with low back pain.

Special Tests|

• The centralization phenomenon (movement of symptoms from distal/lateral regions to more central regions) has been shown to be both highly reliable and decidedly useful in identifying painful lumbar discs (+LR = 6.9).

• The straight-leg raise test, crossed straight-leg raise test, and slump test have all been shown to be moderately useful in identifying disc pathologic conditions, including bulges, herniations, and extrusions.

• A 2011 systematic review identified the passive lumbar extension test as a useful clinical test in identifying lumbar segmental instability (+LR = 8.8).

• Both the Romberg test and a two-stage treadmill test have been found to be moderately useful in identifying lumbar spinal stenosis.

Interventions|

• Patients with low back pain of less than 16 days' duration and no symptoms distal to the knees and/or patients who meet at least four out of the five criteria proposed by Flynn and colleagues should be treated with lumbosacral manipulation.

• Patients with low back pain who meet at least three out of the five criteria proposed by Hicks should be treated with lumbar stabilization exercises.

## Anatomy

### Osteology

Figure 4-1 Thoracic vertebrae.

Figure 4-2 Lumbar vertebrae.

### Arthrology

#### Joints of the Thoracic Spine

Figure 4-3 T7, T8, and T9 vertebrae, posterior view.

Figure 4-4 Sternocostal articulations, anterior view.

Figure 4-5 Costovertebral joints.

#### Joints of the Lumbar Spine

Figure 4-6 Lumbar spine.

Thoracolumbar Joints| Type and Classification| Closed Packed Position| Capsular Pattern
---|---|---|---
Zygapophyseal joints| Synovial: plane| Extension| Lumbar: significant limitation of side-bending bilaterally and limitations of flexion and extension
Thoracic: limitation of extension, side-bending, and rotation; less limitation of flexion
Intervertebral joints| Amphiarthrodial| Not applicable| Not applicable

Thoracic Spine| Type and Classification| Closed Packed Position| Capsular Pattern
---|---|---|---
Costotransverse| Synovial| Not reported| Not reported
Costovertebral| Synovial| Not reported| Not reported
Costochondral| Synchondroses| Not reported| Not reported
Interchondral| Synovial| Not reported| Not reported
Sternocostal (first joint)| Amphiarthrodial| Not applicable| Not applicable
Sternocostal (second to seventh joints)| Synovial| Not reported| Not reported

### Ligaments

#### Costovertebral Ligaments

Figure 4-7 Costovertebral ligaments.

Ligaments| Attachments| Function
---|---|---
Radiate sternocostal| Costal cartilage to the anterior and posterior aspects of the sternum| Reinforces joint capsule
Interchondral| Connect adjacent borders of articulations between costal cartilages 6 and 7, 7 and 8, and 8 and 9| Reinforces joint capsule
Radiate ligament of head of rib| Lateral vertebral body to head of rib| Prevents separation of rib head from vertebra
Costotransverse| Posterior aspect of rib to anterior aspect of transverse process of vertebra| Prevents separation of rib from transverse process
Intraarticular| Crest of the rib head to intervertebral disc| Divides joint into two cavities

#### Thoracolumbar Ligaments

Figure 4-8 Thoracolumbar ligaments.

Ligaments| Attachments| Function
---|---|---
Anterior longitudinal| Extends from anterior sacrum to anterior tubercle of C1. Connects anterolateral vertebral bodies and discs| Maintains stability and prevents excessive extension of spinal column
Posterior longitudinal| Extends from the sacrum to C2. Runs within the vertebral canal attaching the posterior vertebral bodies| Prevents excessive flexion of spinal column and posterior disc protrusion
Ligamenta flava| Binds the lamina above each vertebra to the lamina below| Prevents separation of the vertebral laminae
Supraspinous| Connect spinous processes of C7-S1| Limits separation of spinous processes
Interspinous| Connect spinous processes of C1-S1| Limits separation of spinous processes
Intertransverse| Connect adjacent transverse processes of vertebrae| Limits separation of transverse processes
Iliolumbar| Transverse processes of L5 to posterior aspect of iliac crest| Stabilizes L5 and prevents anterior shear

### Muscles

#### Thoracolumbar Muscles: Superficial Layers

Figure 4-9 Muscles of the back, superficial layers.

Muscles| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Latissimus dorsi| Spinous processes of T6-T12, thoracolumbar fascia, iliac crest, inferior four ribs| Intertubercular groove of humerus| Thoracodorsal nerve (C6, C7, C8)| Humerus extension, adduction, and internal rotation
Trapezius (middle)| Superior nuchal line, occipital protuberance, nuchal ligament, spinous processes of T1-T12| Lateral clavicle, acromion, and spine of scapula| Accessory nerve (CN XI)| Retracts scapula
Trapezius (lower)| Depresses scapula
Rhomboid major| Spinous processes of T2-T5| Inferior medial border of scapula| Dorsal scapular nerve (C4, C5)| Retracts scapula, inferiorly rotates glenoid fossa, stabilizes scapula to thoracic wall
Rhomboid minor| Spinous processes of C7-T1 and nuchal ligament| Superior medial border of scapula
Serratus posterior superior| Spinous processes of C7-T3, ligamentum nuchae| Superior surface of ribs 2-4| Intercostal nerves 2-5| Elevates ribs
Serratus posterior inferior| Spinous processes of T11-L2| Inferior surface of ribs 8-12| Ventral rami of thoracic spinal nerves 9-12| Depresses ribs

CN, cranial nerve.

#### Thoracolumbar Muscles: Intermediate Layer

Figure 4-10 Muscles of the back, intermediate layer.

Muscles| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Iliocostalis thoracis| Iliac crest, posterior sacrum, spinous processes of sacrum and inferior lumbar vertebrae, supraspinous ligament| Cervical transverse processes and superior angles of lower ribs| Dorsal rami of spinal nerves| Bilaterally: extend spinal column
Unilaterally: side-bend spinal column
Iliocostalis lumborum| Inferior surface of ribs 4-12
Longissimus thoracis| Thoracic transverse processes and superior surface of ribs
Longissimus lumborum| Transverse process of lumbar vertebrae
Spinalis thoracis| Upper thoracic spinous processes

#### Thoracolumbar Muscles: Deep Layer

Figure 4-11 Muscles of the back, deep layer.

Muscles| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Rotatores| Transverse processes of vertebrae| Spinous process of vertebra one to two segments above origin| Dorsal rami of spinal nerves| Vertebral stabilization, assists with rotation and extension
Interspinalis| Superior aspect of cervical and lumbar spinous processes| Inferior aspect of spinous process superior to vertebrae of origin| Dorsal rami of spinal nerves| Extension and rotation of vertebral column
Intertransversarius| Cervical and lumbar transverse processes| Transverse process of adjacent vertebrae| Dorsal and ventral rami of spinal nerves| Bilaterally stabilizes vertebral column. Ipsilaterally side-bends vertebral column
Multifidi| Sacrum, ilium, transverse processes of T1-T3, articular processes of C4-C7| Spinous process of vertebra two to four segments above origin| Dorsal rami of spinal nerves| Stabilizes vertebrae

#### Anterior Abdominal Wall

Figure 4-12 Dynamic "corset" concept of lumbar stability.

Muscles| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Rectus abdominis| Pubic symphysis and pubic crest| Costal cartilages 5-7 and xiphoid process| Ventral rami of T6-T12| Flexes trunk
Internal oblique| Thoracolumbar fascia, anterior iliac crest, and lateral inguinal ligament| Inferior border of ribs 10-12, linea alba, and pecten pubis| Ventral rami of T6-L1| Flexes and rotates trunk
External oblique| External aspects of ribs 5-12| Anterior iliac crest, linea alba, and pubic tubercle| Ventral rami of T6-T12 and subcostal nerve| Flexes and rotates trunk
Transversus abdominis| Internal aspects of costal cartilages 7-12, thoracolumbar fascia, iliac crest, and lateral inguinal ligament| Linea alba, pecten pubis, and pubic crest| Ventral rami of T6-L1| Supports abdominal viscera and increases intraabdominal pressure

### Fascia

Figure 4-13 Transverse abdominis. The transverse abdominis exerts a force through the thoracolumbar fascia, creating a stabilizing force through the lumbar spine. (From Kay AG. An extensive literature review of the lumbar multifidus: biomechanics. J Man Manip Ther. 2001;9:17-39.)

The thoracolumbar fascia is a dense layer of connective tissue running from the thoracic region to the sacrum. It is composed of three separate and distinct layers: anterior, middle, and posterior. The middle and posterior layers blend together to form a dense fascia referred to as the lateral raphe. The posterior layer consists of two distinctly separate laminae. The superficial lamina fibers are angled downward and the deep lamina fibers are angled upward. Bergmark has reported that the thoracolumbar fascia serves three purposes: (1) to transfer forces from muscles to the spine, (2) to transfer forces between spinal segments, and (3) to transfer forces from the thoracolumbar spine to the retinaculum of the erector spinae muscles. The transverse abdominis attaches to the middle layer of the thoracolumbar fascia and exerts a force through the lateral raphe, resulting in a cephalad tension through the deep layer and a caudal tension through the superficial layer of the posterior lamina.,, The result is a stabilizing force exerted through the lumbar spine, which has been reported to provide stability and assist with controlling intersegmental motion of the lumbar spine.-

### Nerves

Figure 4-14 Nerves of the thoracic spine.

Nerve
Ventral Rami| Segmental Level| Sensory| Motor
---|---|---|---
Intercostals| T1-T11| Anterior and lateral aspect of the thorax and abdomen| Intercostals, serratus posterior, levator costarum, transversus thoracis
Subcostals| T12| Part of external oblique
Dorsal rami| T1- T12| Posterior thorax and back| Splenius, iliocostalis, longissimus, spinalis, interspinales, intertransversarii, multifidi, semispinalis, rotatores
Subcostal nerve| T12| Lateral hip| External oblique
Iliohypogastric nerve| T12, L1| Posterolateral gluteal region| Internal oblique, transverse abdominis
Ilioinguinal| L1| Superior medial thigh| Internal oblique, transverse abdominis
Genitofemoral| L1, L2| Superior anterior thigh| No motor
Lateral cutaneous| L2, L3| Lateral thigh| No motor
Branch to iliacus| L2, L3, L4| No sensory| Iliacus
Femoral nerve| L2, L3, L4| Thigh via cutaneous nerves| Iliacus, sartorius, quadriceps femoris, articularis genu, pectineus
Obturator nerve| L2, L3, L4| Medial thigh| Adductor longus, adductor brevis, adductor magnus (adductor part), gracilis, obturator externus
Sciatic| L4, L5, S1, S2, S3| Hip joint| Knee flexors and all muscles of the lower leg and foot

Figure 4-15 Nerves of the lumbar spine.

Figure 4-16 Nerves of the lumbar spine.

## Patient History

### Initial Hypotheses Based on the Patient History

History| Initial Hypothesis
---|---
Reports of restricted motion of the lumbar spine associated with low back or buttock pain exacerbated by a pattern of movement that indicates possible opening or closing joint restriction (i.e., decreased extension, right side-bending, and right rotation)| Zygapophyseal joint pain syndromes-
Reports of centralization or peripheralization of symptoms during repetitive movements or prolonged periods in certain positions| Possible discogenic pain
Reports of lower extremity pain/paresthesia that is worse than the low back pain. May report experiencing episodes of lower extremity weakness| Possible sciatica or lumbar radiculopathy
Pain in the lower extremities that is exacerbated by extension and quickly relieved by flexion of the spine| Possible spinal stenosis
Reports of recurrent locking, catching, or giving way of the low back during active motion| Possible lumbar instability,
Reports of low back pain that is exacerbated by stretching of either the ligaments or muscles. Might also report pain with contraction of muscular tissues| Muscle/ligamentous sprain/strain

### Lumbar Zygapophyseal Joint Referral Patterns

Figure 4-17 Lumbar zygapophyseal joint pain referral patterns. Zygapophyseal pain patterns of the lumbar spine as described by Fukui and colleagues. Lumbar zygapophyseal joints L1-L2, L2-L3, and L4-L5 always referred pain to the lumbar spine region. Primary referral to the gluteal region was from L5-S1 (68% of the time). Levels L2-L3, L3-L4, L4-L5, and L5-S1 occasionally referred pain to the trochanteric region (10% to 16% of the time). Primary referral to the lateral thigh, posterior thigh, and groin regions was most often from L3-L4, L4-L5, and L5-S1 (5% to 30% of the time). (From Fukui S, Ohseto K, Shiotani M, et al. Distribution of referred pain from the lumbar zygapophyseal joints and dorsal rami. Clin J Pain. 1997;13:303-307.)

Area of Pain Referral| Percentage of Patients Presenting with Pain (n = 176 Patients with Low Back Pain)*
---|---
Left groin| 15%
Right groin| 3%
Left buttock| 42%
Right buttock| 15%
Left thigh| 38%
Right thigh| 38%
Left calf| 27%
Right calf| 15%
Left foot| 31%
Right foot| 8%

*Prevalence of pain referral patterns in patients with zygapophyseal joint pain syndromes as confirmed by diagnostic blocks. In a subsequent study, it was determined that in a cohort of 63 patients with chronic low back pain, the prevalence of zygapophyseal joint pain was 40%.

### Thoracic Zygapophyseal Joint Referral Patterns

Figure 4-18 Zygapophyseal pain patterns of the thoracic spine.

### Reliability of the Historical Examination

Historical Question and Study Quality| Population| Reliability
---|---|---
Patient report of   :| Foot pain| Two separate groups of patients with low back pain (n1 = 50, n2 = 33).| Interexaminer κ = .12 to .73
Leg pain| Interexaminer κ = .53 to .96
Thigh pain| Interexaminer κ = .39 to .78
Buttock pain| Interexaminer κ = .33 to .44
Back pain| Interexaminer κ = −.19 to .16
Increased pain with  :| Sitting| 53 subjects with a primary complaint of low back pain| Test-retest κ = .46
Standing| Test-retest κ = .70
Walking| Test-retest κ = .67
Increased pain with  :| Sitting| A random selection of 91 patients with low back pain| Interexaminer κ = .49
Standing| Interexaminer κ = 1.0
Walking| Interexaminer κ = .56
Lying down| Interexaminer κ = .41
Pain with sitting  | 95 patients with low back pain| Interexaminer κ = .99 to 1.0
Pain with bending  | Interexaminer κ = .98 to .99
Pain with bending  | 53 subjects with a primary complaint of low back pain| Test-retest κ = .65
Pain with bending  | Two separate groups of patients with low back pain (n1 = 50, n2 = 33).| Interexaminer κ = .51 to .56
Increased pain with coughing/sneezing  | A random selection of 91 patients with low back pain| Interexaminer κ = .64
Increased pain with coughing  | 53 subjects with a primary complaint of low back pain| Test-retest κ = .75
Pain with pushing/lifting/carrying  | Test-retest κ = .77 to .89

### Diagnostic Utility of Patient History in Identifying Lumbar Spinal Stenosis

Historical Question and Study Quality| Patient Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Age over 65 years  | 93 patients with low back pain 40 years old or older| Lumbar spinal stenosis per attending physician's impression; 88% also supported by computed tomography (CT) or magnetic resonance imaging (MRI)| .77 (.64, .90)| .69 (.53, .85)| 2.5| .33
Pain below knees?  | .56 (.41, .71)| .63 (.46, .80)| 1.5| .70
Pain below buttocks?  | .88 (.78, .98)| .34 (.18, .50)| 1.3| .35
No pain when seated?  | .46 (.30, .62)| .93 (.84, 1.0)| 6.6| .58
Severe lower extremity pain?  | .65 (.51, .79)| .67 (.51, .83)| 2.0| .52
Symptoms improved while seated?  | .52 (.37, .67)| .83 (.70, .96)| 3.1| .58
Worse when walking?  | .71 (.57, .85)| .30 (.14, .46)| 1.0| .97
Numbness  | .63 (.49, .74)| .59 (.42, .76)| 1.5| .63
Poor balance  | .70 (.56, .84)| .53 (.36, .70)| 1.5| .57
Do you get pain in your legs with walking that is relieved by sitting?  | 45 patients with low back and leg pain and self-reported limitations in walking tolerance| Lumbar spinal stenosis per MRI or CT imaging| .81 (.66, .96)| .16 (.00, .32)| .82 (.63, 1.1)| 1.27
Are you able to walk better when holding onto a shopping cart?  | .63 (.42, .85)| .67 (.40, .93)| 1.9 (.80, 4.5)| .55
Sitting reported as best posture with regard to symptoms  | .89 (.76, 1.0)| .39 (.16, .61)| 1.5 (.90, 2.4)| .28
Walking/standing reported as worst posture with regard to symptoms  | .89 (.76, 1.0)| .33 (.12, .55)| 1.3 (.80, 2.2)| .33

### Diagnostic Utility of Patient History in Identifying Lumbar Radiculopathy

Historical Question and Study Quality| Patient Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Patient reports of:| 170 patients with low back and leg symptoms| Lumbosacral radiculopathy per electrodiagnostics| | | |
Weakness  | .70| .41| 1.19| .73
Numbness  | .68| .34| 1.03| .94
Tingling  | .67| .31| .97| 1.06
Burning  | .40| .60| 1.0| 1.0

### Diagnostic Utility of Patient History in Identifying Ankylosing Spondylitis

Figure 4-19 Ankylosing spondylitis.

Clinical Symptom and Study Quality| Patient Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Pain not relieved by lying down  | 449 randomly selected patients with low back pain| The New York criteria and radiographic confirmation of ankylosing spondylitis| .80| .49| 1.57| .41
Back pain at night  | .71| .53| 1.51| .55
Morning stiffness for longer than   hour  | .64| .59| 1.56| .68
Pain or stiffness relieved by exercise  | .74| .43| 1.30| .60
Age of onset 40 years or less  | | 1.0| .07| 1.07| .00

## Physical Examination Tests

### Neurologic Examination

#### Diagnostic Utility of Sensation Testing, Manual Muscle Testing, and Reflex Testing for Lumbosacral Radiculopathy

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Sensation (vibration and pinprick)  | Considered abnormal when either vibration or pinprick was reduced on the side of the lesion| 170 patients with low back and lower extremity symptoms| Electrodiagnostic testing. Radiculopathy defined as the presence of positive sharp waves; fibrillation potentials; complex repetitive discharges; high-amplitude, long-duration motor unit potentials; reduced recruitment; or increased polyphasic motor unit potentials (of more than 30%) in two or more muscles innervated by the same nerve root level but different peripheral nerves| .50| .62| 1.32| .81
Weakness  | Gastrocnemius and soleus| Weakness was defined as any grade of less than 5/5| S1 = .47| S1 = .76| 1.96| .70
Extensor hallucis longus| L5 = .61| L5 = .55| 1.36| .71
Hip flexors| L3-L4 = .70| L3-L4 = .84| 4.38| .36
Quadriceps| L3-L4 = .40| L3-L4 = .89| 3.64| .67
Reflexes  | Achilles| Considered abnormal when the reflex on the side of the lesion was reduced compared with the opposite side| S1 = .47| S1 = .9| 4.70| .59
Patellar| L3-L4 = .50| L3-L4 = .93| 7.14| .54
Reflexes  | Achilles| Test is positive if reflex is absent| 100 patients with lumbar disc herniation diagnosed by MRI| Lumbar disc herniation diagnosed by MRI with level of herniation intraoperatively confirmed| S1 = .83| S1 = .57| 1.93| .30
Medial hamstring| L5 = .76| L5 = .85| 5.07| .28
Patellar| L3-L4 = .88| L3-L4 = .86| 6.29| .14
Reflexes
+
Weakness
+
Sensory  | All three abnormal| 170 patients with low back and lower extremity symptoms| Electrodiagnostic testing. Radiculopathy defined as the presence of positive sharp waves; fibrillation potentials; complex repetitive discharges; high-amplitude, long-duration motor unit potentials; reduced recruitment; or increased polyphasic motor unit potentials (of more than 30%) in two or more muscles innervated by the same nerve root level but different peripheral nerves| .12| .97| 4.00| .91
Reflexes
+
Weakness
+
Sensory
+
Straight-leg raise test  | All four abnormal| .06| .99| 6.00| .95
Any of four abnormal| .87| .35| 1.34| .37

Figure 4-20 Clinical features of herniated lumbar nucleus pulposus.

#### Diagnostic Utility of Sensation Testing, Manual Muscle Testing, and Reflex Testing for Lumbar Spinal Stenosis

Figure 4-21 Lumbar spinal stenosis testing.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Vibration deficit  | Assessed at the first metatarsal head with a 128-Hz tuning fork. Considered abnormal if patient did not perceive any vibration| 93 patients with back pain with or without radiation to the lower extremities| Diagnosis of spinal stenosis by retrospective chart review and confirmed by MRI or CT| .53 (.38, .68)| .81 (.67, .95)| 2.8| .58
Pinprick deficit  | Sensation tested at the dorsomedial foot, dorsolateral foot, and medial and lateral calf. Graded as "decreased" or "normal"| .47 (.32, .62)| .81 (.67, .95)| 2.5| .65
Weakness  | Strength of knee flexors, knee extensors, and hallucis longus muscles was tested. Graded from 0 (no movement) to 5 (normal)| .47 (.32, .62)| .78 (.64, .92)| 2.1| .68
Absent Achilles reflex  | Reflex testing of the Achilles tendon. Graded from 0 (no response) to 4 (clonus)| .46 (.31, .61)| .78 (.64, .92)| 2.1| .69

### Range-of-Motion Measurements

#### Reliability of Range-of-Motion Measurements

Measurement and Study Quality| Instrumentation| Population| Reliability
---|---|---|---
Intraexaminer*| Interexaminer
Forward bending  | Measured distance from fingertips to floor| Heterogeneous group (n = 98) including participants with low back pain and/or pelvic girdle pain and participants with no pain| Not tested| ICC = .93 (.90, .95)
Forward bending  | 30 patients with back pain and 20 asymptomatic subjects (only asymptomatic subjects were used for intraexaminer comparisons)| Intraclass correlation coefficient (ICC) = .95 (.89, .99)| ICC = .99 (.98, .10)
Lateral bending  | Measured distance that fingertip slid down lateral thigh| ICC (right) = .99 (.95, 1.0)
ICC (left) = .94 (.82, .98)| ICC (right) = .93 (.89, .96)
ICC (left) = .95 (.91, .97)
Trunk rotation  | Patients sat with horizontal bar on sternum. Plumb weight hung down to floor, and angle was measured with a protractor| ICC (right) = .92 (.76, .97)
ICC (left) = .96 (.87, .99)| ICC (right) = .82 (.70, .89)
ICC (left) = .85 (.75, .91)
Modified Schober test  | Distances between lumbosacral junction, 5 cm below, and 10 cm above, were measured with patient in erect standing position and while maximally bending forward| ICC = .87 (.68, .96)| ICC = .79 (.67, .88)
Modified Schober test  | Heterogeneous group (n = 98) including participants with low back pain and/or pelvic girdle pain and participants with no pain| Not tested| ICC = .77 (.67, .84)
Flexion
Extension
Left rotation
Right rotation
Left side-bending
Right side-bending  | Back range-of-motion instrument| 47 asymptomatic students| ICC = .91
ICC = .63
ICC = .56
ICC = .57
ICC = .92
ICC = .89| ICC = .77
ICC = .35
ICC = .37
ICC = .35
ICC = .81
ICC = .89
Active rotation in standing  | Patients stood with a horizontal bar resting on their shoulders. A plumb weight hung from the end of the bar to the floor| 24 asymptomatic golfers| ICC (right) = .86 (.70, .94)
ICC (left) = .80 (.58, .92)| ICC (right) = .74 (.49, .88)
ICC (left) = .78 (.56, .90)
Thoracolumbar flexion  | iPhone inclinometer application| 30 asymptomatic adult participants| ICC = .97 (.93, .98)| ICC = .98 (.95, .99)
Thoracolumbar extension  | ICC = .80 (.58, .90)| ICC = .81 (.60, .91)
Thoracolumbar lateral flexion  | ICC (right) = .82 (.61, .91)
ICC (left) = .84 (.67, .92)| ICC (right) = .93 (.86, .97)
ICC (left) = .90 (.77, .96)
Lumbar flexion  | Single inclinometer| 49 patients with low back pain referred for flexion-extension radiographs| Interexaminer ICC = .60 (.33, .79)
Lumbar extension  | Interexaminer ICC = .61 (.37, .78)
Lumbar flexion  | 123 patients with low back pain of less than 90 days' duration| Interexaminer ICC = .74 (.60, .84)
Lumbar extension  | Interexaminer ICC = .61 (.42, .75)

*In the case of multiple examiners, intraexaminer estimates are presented for the first examiner only.

Figure 4-22 Range-of-motion measurement.

#### Reliability of Pain Provocation during Range-of-Motion Measurements

Figure 4-23 Pain provocation during active movements.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Side-bending  | Patient stands with arms at sides. Patient slides hand down the outside of the thigh| 35 patients with low back pain| κ = .60 (.40, .79)
Rotation  | Patient stands with arms at sides. Patient rotates the trunk| κ =.17 (−.08, .42)
Side-bend rotation  | Patient stands with arms at sides. Patient moves the pelvis to one side, creating a side-bend rotation to the opposite side| κ = .29 (.06, .51)
Flexion, side-bending, and rotation  | Patient stands and the therapist guides the patient into lumbar flexion, then side-bending, then rotation| κ = .39 (.18, .61)
Extension, side-bending, and rotation  | Patient stands and the therapist guides the patient into lumbar extension, then side-bending, then rotation| κ = .29 (.06, .52)
Thoracic rotation, right  | Patient places hands on the opposite shoulders and rotates the trunk as far as possible in each direction. Examiner then determines the effect of each movement on the patient's symptoms as "no effect," "increases symptoms," or "decreases symptoms"| 22 patients with mechanical neck pain| κ = −.03 (−.11, .04)
Thoracic rotation, left  | κ = 0.7 (.40, 1.0)

### Thoracolumbar Strength and Endurance Tests

#### Reliability of Assessing Thoracolumbar Strength and Endurance

Figure 4-24 Modified Biering-Sorensen test.

Measurement and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Abdominal endurance  | From a supine hook-lying position, the patient curls up to touch fingertips to the superior patellae and holds the position for as long as possible. Time in seconds is measured with a stopwatch| 30 patients with back pain and 20 asymptomatic subjects (only asymptomatic subjects were used for intraexaminer comparisons)| Intraexaminer ICC = .90 (.75, .97)
Interexaminer ICC = .92 (.87, .96)
Modified Biering-Sorensen test  | Patient starts prone with pelvis and legs supported on couch and trunk hanging off the edge supported by a chair. The patient then extends the trunk and holds a neutral position for as long as possible. Time in seconds is measured with a stopwatch| Intraexaminer ICC = .92 (.75, .97)
Interexaminer ICC = .91 (.85, .95)

### Postural Assessment

#### Reliability of Postural Assessment

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Forward head  | "Yes" if the patient's external auditory meatus was anteriorly deviated (anterior to the lumbar spine)| 22 patients with mechanical neck pain| κ = −.10 (−.20, .00)
Excessive shoulder protraction  | "Yes" if the patient's acromions were anteriorly deviated (anterior to the lumbar spine)| κ = .83 (.51, 1.0)
C7-T2 excessive kyphosis  | Recorded as "normal" (no deviation), "excessive kyphosis," or "diminished kyphosis." Excessive kyphosis was defined as an increase in the convexity, and diminished kyphosis was defined as a flattening of the convexity of the thoracic spine (at each segmental group)| κ = .79 (.51, 1.0)
T3-T5 excessive kyphosis  | κ = .69 (.30, 1.0)
T3-T5 decreased kyphosis  | κ = .58 (.22, .95)
T6-T10 excessive kyphosis  | κ = .90 (.74, 1.0)
T6-T10 decreased kyphosis  | κ = .90 (.73, 1.0)
Kyphosis  | With patient standing, examiner inspects posture from the side. Graded as "present" or "absent"| 111 adults age 60 years of age or older with chronic low back pain and 20 asymptomatic patients| κ = .21
Scoliosis  | With patient standing, examiner runs finger along spinous processes. Patient bends over and examiner assesses height of paraspinal musculature. Graded as "present" or "absent"| κ = .33
Functional leg length discrepancy  | Compared height of bilateral iliac crests with patient standing. Graded as "symmetric" or "asymmetric"| κ = .00

Figure 4-25 Pathologic anatomy of scoliosis.

### Motor Control Assessment

#### Reliability of Tests for Lumbar Motor Control

Figure 4-26 Sitting forward lean.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Repositioning  | Subject seated with feet supported and with low back in neutral. A 5-cm tape measure is taped at S1 (0 cm) and marked by a laser pointer. The subject is instructed to actively move the pelvis twice from maximum anterior tilt to maximum posterior tilt. Subject then repositions the pelvis back to neutral, and the distance is measured between S1 (0 cm) and the laser pointer| 25 subjects with nonspecific low back pain and 15 subjects without it| ICC = .90 (.81, .94)
Sitting forward lean  | Subject seated with feet supported and low back in neutral. S1 and a point 10 cm above S1 are marked. Subject instructed to maintain distance between the two points while performing 5 repetitions of hip flexion to a maximum of 120 degrees. The distance between marks (0 cm and 10 cm) is measured| ICC = .96 (.92, .98)
Sitting knee extension  | Same setup as for the repositioning test but with feet unsupported. The low back is in neutral with a 5-cm tape measure taped at S1 (0 cm) and marked by a laser pointer. Five repetitions of active knee extension to −10 degrees are performed while maintaining the pelvis in neutral. The distance is measured between S1 (0 cm) and the laser pointer| ICC = .95 (.90, .97)
Bent knee fall-out  | Subject supine with one knee flexed 120 degrees and pelvis in neutral. A 5-cm tape measure is placed between the right and left anterior superior iliac spines, with a 0-cm mark and laser pointer placed lateral to the anterior superior iliac spine opposite the bent leg (with the laser pointing medially to the 0-cm mark). Five repetitions of abduction/external hip rotation of the bent leg to 45 degrees are performed. Movement of the pelvis is measured between 0 cm on the tape measure and the laser pointer| ICC = .94 (.88, .97)
Leg lowering  | Subject supine with hips at 90 degrees of flexion, knees in maximum relaxed flexion, and low back in neutral. A pressure biofeedback unit is placed under the low back and inflated to 40 mm Hg. The subject is asked to actively push the low back downward, increasing the pressure to 45 mm Hg. Then the subject is instructed to lower the feet to just above the surface of the plinth. Five repetitions are performed while attempting to maintain 45 mm Hg. Pressure is recorded when the feet are as close as possible to the plinth| ICC = .98 (.96, .99)

### Passive Intervertebral Motion Assessment

#### Reliability of Assessing Limited or Excessive Passive Intervertebral Motion

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Upper lumbar segmental mobility  | With patient prone, examiner applies a posteroanterior force to the spinous process and lumbar facets of each lumbar vertebra. Mobility of each segment is judged as "normal" or "restricted"| 39 patients with low back pain| (Spinous) Interexaminer κ =.02 (−.27, .32)
(Left facet) Interexaminer κ =.17 (−.14, .48)
(Right facet) Interexaminer κ = −.01 (−.33, .30)
Lower lumbar segmental mobility  | (Spinous) Interexaminer κ = −.05 (−.36, .27)
(Left facet) Interexaminer κ = −.17 (−.41, .06)
(Right facet) Interexaminer κ = −.12 (−.41, .18)
Identifying the least mobile segment  | With patient prone, examiner applies a posteroanterior force to the spinous process of each lumbar vertebra| 29 patients with central low back pain| Interexaminer κ = .71 (.48, .94)
Identifying the most mobile segment  | Interexaminer κ = .29 (−.13, .71)
Posterior-to-anterior stiffness  | Each level of the lumbar spine was evaluated for segmental dysfunction. With patient prone, examiner assessed posterior-to-anterior stiffness and multifidus hypertonicity. With patient side-lying, side flexion and ventral flexion were assessed by moving the patient's legs. After performing all four examination procedures, examiners identified the level of maximal dysfunction| 60 patients with low back pain| Intraexaminer κ = .54
Intraexaminer (±1 level) κ = .64
Interexaminer κ = .23
Interexaminer (±1 level) κ = .52
Segmental side flexion  | Intraexaminer κ = .57
Intraexaminer (±1 level) κ = .69
Interexaminer κ = .22
Interexaminer (±1 level) κ = .45
Segmental ventral flexion  | Intraexaminer κ = .31
Intraexaminer (±1 level) κ = .45
Interexaminer κ = .22
Interexaminer (±1 level) κ = .44
Multifidus hypertonicity  | Intraexaminer κ = .51
Intraexaminer (±1 level) κ = .60
Interexaminer κ = .12
Interexaminer (±1 level) κ = .57
Maximal level of segmental dysfunction  | Intraexaminer κ = .60
Intraexaminer (±1 level) κ = .70
Interexaminer κ = .21
Interexaminer (±1 level) κ = .57
Segmental mobility  | With patient side-lying, examiner palpates adjacent spinous processes while moving the patient's legs to produce passive flexion and extension of the lumbar spine. Segmental mobility was graded on a 5-point scale| 20 patients with low back pain| Interexaminer κ ranged from −.25 to .53 depending on examiners and vertebral level

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Determination of segmental fixations  | Passive motion palpation is performed, and the segment is considered fixated if a hard end feel is noted during the assessment| 60 asymptomatic volunteers| Intraexaminer κ ranged from −.09 to .39
Interexaminer κ ranged from −.06 to .17
Passive motion palpation  | 21 symptomatic and 25 asymptomatic subjects| Interexaminer κ = ranged from −.03 to .23, with a mean of .07
Segmental mobility testing  | With patient side-lying with hips and knees flexed, examiner assesses mobility while passively moving the patient. Examiner determines whether mobility of the segment is "decreased," "normal," or "increased"| 71 patients with low back pain| Interexaminer κ = .54
Hypermobility at any level  | With patient prone, examiner applies a posteroanterior force to the spinous process of each lumbar vertebra. Mobility of each segment is judged as "normal," "hypermobile," or "hypomobile"| 49 patients with low back pain referred for flexion-extension radiographs| Interexaminer κ = .48 (.35, .61)
Hypomobility at any level  | Interexaminer κ = .38 (.22, .54)
Determination of posteroanterior spinal stiffness  | Five raters tested lumbar spinal levels for posteroanterior mobility and graded each on an 11-point scale ranging from "markedly reduced stiffness" to "markedly increased stiffness"| 40 asymptomatic individuals| Interexaminer ICC in the first study = .55 (.32, .79)
Interexaminer ICC in the second study = .77 (.57, .89)
Posteroanterior mobility testing  | With the patient prone, examiner evaluates posteroanterior motion mobility. Mobility is scored on a 9-point scale ranging from "severe excess motion" to "no motion," and the presence of pain is recorded| 18 patients with low back pain| Interexaminer ICC = .25 (.00, .39)
Segmental mobility testing  | With patient prone, examiner applies an anteriorly directed force over the spinous process of the segment to be tested. Examiner grades the mobility as "hypermobile," "normal," or "hypomobile"| 63 patients with current low back pain| Interexaminer κ ranged from −.20 to .26 depending on level tested
Identification of a misaligned vertebra  | Static palpation is used to determine the relationship of one vertebra to the vertebra below| 21 symptomatic and 25 asymptomatic subjects| Interexaminer κ ranged from −.04 to .03, with a mean of .00
Detection of a segmental lesion at T11-L5/S1  | Two clinicians used visual postural analysis, pain descriptions, leg length discrepancy, neurologic examination, motion palpation, static palpation, and any special orthopaedic tests to determine the level of segmental lesion| 19 patients with chronic mechanical low back pain| Intraexaminer κ = −.08 to .43
Interexaminer κ = −.16 to .25

#### Reliability of Assessing Painful Passive Intervertebral Motion

Figure 4-27 Assessment of posteroanterior segmental mobility.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Spring test T10-T7  | With patients in the prone position the therapist applies a posteroanterior force to the spinous processes of T7-L5. The pressure of each force is held for 20 seconds. Considered positive if the force produces pain| 84 subjects, of whom 53% reported experiencing low back symptoms within the last 12 months| κ = .73 (.39 to 1.0)| κ =.12 (−.18 to .41)
Spring test L2-T11  | κ = .78 (.49 to 1.0)| κ = .36 (.07 to .66)
Spring test L5-L3  | κ = .56 (.18 to .94)| κ = .41 (.12 to .70)
Pain with upper lumbar mobility testing  | With patient prone, examiner applies a posteroanterior force to the spinous processes and lumbar facets of each lumbar vertebra. Response at each segment is judged as "painful" or "not painful"| 39 patients with low back pain| (Spinous) Interexaminer κ =.21 (−.10, .53)
(Left facet) Interexaminer κ = .46 (.17, .75)
(Right facet) Interexaminer κ = .38 (.06, .69)
Pain with lower lumbar mobility testing  | (Spinous) Interexaminer κ = .57 (.32, .83)
(Left facet) Interexaminer κ = .73 (.51, .95)
(Right facet) Interexaminer κ = .52 (.25, .79)
Pain provocation  | With patient prone, examiner applies an anteriorly directed force over the spinous processes of the segment to be tested. Considered positive if pain is reproduced| 63 patients with current low back pain| Interexaminer κ ranged from .25 to .55 depending on the segmental level tested
Pain during mobility testing  | 49 patients with low back pain referred for flexion-extension radiographs| Interexaminer κ = .57 (.43, .71)

#### Diagnostic Utility of Assessing Limited and Painful Passive Intervertebral Motion

Figure 4-28 Segmental mobility examination.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Active range of motion  | Quantity of forward-bending active range of motion. Rated as "hypomobile," "normal," or "hypermobile"| 9 patients with low back pain| Flexion and extension lateral radiographs. Segments were considered hypomobile if motion was more than 2 standard deviations from the mean of a normal population| .75 (.36, .94)| .60 (.27, .86)| 1.88 (.57, 6.80)| .42 (.07, 1.90)
Abnormality of segmental motion (AbnROM)  | Examiner judged presence of abnormal segmental motion during active range of motion. Rated as "hypomobile," "normal," or "hypermobile| .43 (.19, .71)| .88 (.70, .96)| 3.60 (.84, 15.38)| .65 (.28, 1.06)
Passive accessory intervertebral motion (PAIVM)  | Examiner applies central posteroanterior pressure. Passive accessory intervertebral motion was rated as "hypomobile," "normal," or "hypermobile"| .75 (.36, .94)| .35 (.20, .55)| 1.16 (.44, 3.03)| .71 (.12, 2.75)
Passive physiologic intervertebral motion (PPIVM)  | With patient side-lying, examiner palpates amount of PPIVM during forward bending. Rated as "hypomobile," "normal," or "hypermobile"| .42 (.19, .71)| .89 (.71, .96)| 3.86 (.89, 16.31)| .64 (.28, 1.04)
Motion palpation  | Palpation of a motion segment during either passive or active motion. Examiners evaluated for limited motion (i.e., "fixation"). Patient's pain reaction was noted after motion palpation of each segment| 184 twins| Self-reported low back pain| .42| .57| .98| 1.02
Pain reaction  | .54| .77| 2.35| .60

#### Association of Limited Passive Intervertebral Motion with Low Back Pain

As part of a larger epidemiologic study, Leboeuf-Yde and associates evaluated 184 twins as to the prevalence of restricted intervertebral motion and its relation to low back pain. As can be seen in the figure, motion restrictions were no more prevalent in people with current or recent back pain than in those who had never experienced back pain.

Figure 4-29 Prevalence rates of "fixations" detected during motion palpation. (From Leboeuf-Yde C, van Dijk J, Franz C, et al. Motion palpation findings and self-reported low back pain in a population-based study sample. J Manipulative Physiol Ther. 2002;25:80-87.)

#### Diagnostic Utility of Assessing Excessive Passive Intervertebral Motion

Figure 4-30 Assessing lumbar passive physiologic intervertebral motion (PPIVM).

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Passive accessory intervertebral motion (PAIVM)  | Examiner applies central posteroanterior pressure. PAIVM was rated as "hypomobile," "normal," or "hypermobile"| Patients with a new episode of recurrent or chronic low back pain| Flexion and extension lateral radiographs. Segments were considered hypermobile if motion was more than 2 standard deviations from the mean of a normal population| Rotational Lumbar Segmental Instability
.33 (.12, .65)| .88 (.83, .92)| 2.74 (1.01, 7.42)| .76 (.48, 1.21)
Translational Lumbar Segmental Instability
.29 (.14, .50)| .89 (.83, .93)| 2.52 (1.15, 5.53)| .81 (.61, 1.06)
Flexion passive physiologic intervertebral motion (PPIVM)  | With patient side-lying, examiner palpates amount of PPIVM during forward bending. Rated as "hypomobile," "normal," or "hypermobile"| Rotational Lumbar Segmental Instability
.05 (.01, .36)| .99 (.96, 1.00)| .12 (.21, 80.3)| .96 (.83, 1.11)
Translational Lumbar Segmental Instability
.05 (.01, .22)| .99 (.97, 1.00)| 8.73 (.57, 134.7)| .96 (.88, 1.05)
Extension PPIVM  | With patient side-lying, examiner palpates amount of PPIVM during backward bending. Rated as "hypomobile," "normal," or "hypermobile"| Rotational Lumbar Segmental Instability
.22 (.06, .55)| .97 (.94, .99)| 8.40 (1.88, 37.55)| .80 (.56, 1.13)
Translational Lumbar Segmental Instability
.16 (.06, .38)| .98 (.94, .99)| 7.07 (1.71, 29.2)| .86 (.71, 1.05)

### Palpation

#### Reliability of Identifying Segmental Levels

Procedure Performed and Quality| Description of Procedure| Patient Population| Interexaminer Reliability
---|---|---|---
Detection of segmental levels in the lumbar spine  | With patient prone, examiner identifies nominated levels of the lumbar spine. Examiner marks the specific level with a pen containing ink that can only be seen under ultraviolet light| 20 patients with low back pain| κ = .69
Examiner judgment of marked segmental level  | With the patient prone, one spinous process is arbitrarily marked on each patient. Examiners identify the level of the marked segment| 18 patients with low back pain| ICC = .69 (.53, .82)
Identification of lumbar spinous process using multiple bony landmarks  | With the patient prone, each examiner used all of the following landmarks to determine the location of the spinous processes for L1-L4:

1. Identification of T12 by the smaller size of its spinous process compared with that of L1 to determine the location of L1.

2. Identification of 12th ribs and their attachment site at T12 to determine the location of T12 and its spinous process and, subsequently, the location of L1.

3. Identification of iliac crests to approximately determine the location of the vertebral body of L4.

4. Identification of sacral base to determine the location of L5.

5. Identification of L5 spinous process by the smaller size of its spinous process to determine the location of L4.

Accuracy of the skin marker placement over the corresponding spinous process determined by radiograph| 60 subjects age 20 to 60 years| κ = .81 (.79, .83)

#### Reliability of Identifying Tenderness to Palpation

Procedure Performed and Quality| Description of Procedure| Patient Population| Interexaminer Reliability
---|---|---|---
Lumbar paravertebral myofascial pain37  | Reports of pain with deep thumb pressure (4 kg)| 111 adults age 60 years with chronic low back pain and 20 asymptomatic subjects| κ = .34
Piriformis myofascial pain37  | κ = .66
Tensor fasciae latae myofascial pain37  | κ = .75
Fibromyalgia tender points37  | Reports of pain with enough pressure to blanch thumbnail at:

1. Occiput at suboccipital muscle insertions

2. Low cervical region at the anterior aspects of the intertransverse spaces at C5-C7

3. Trapezius, midpoint of upper border

4. Supraspinatus at origin

5. Rib 2 at the second costochondral junction

6. 2 cm distal to the epicondyle

7. Medial fat pad of the knee

8. Greater trochanter

9. Gluteal at upper outer quadrant of buttocks

| κ = .87
Osseous pain of each joint T11/L1-L5/S144  | With the subject prone, examiner applies pressure over the bony structures of each joint| 21 symptomatic and 25 asymptomatic subjects| Mean κ for all levels = .48
Intersegmental tenderness45  | With patient prone, examiner palpates the area between the spinous processes. Increased tenderness is considered positive| 71 patients with low back pain| κ = .55

#### Reliability of Assessing Lumbar Multifidus Muscle Function via Palpation

Procedure Performed and Quality| Description of Procedure| Patient Population| Interexaminer Reliability
---|---|---|---
Multifidus lift test L4-L556  | Participant prone with arms flexed to approximately 120 degrees and elbows flexed to approximately 90 degrees, the patient is instructed to raise contralateral arm toward the ceiling approximately 5 cm. Test is positive when little or no palpable contraction of the muscle is identified during the arm lift| 32 adults with current low back pain| κ = .75 (.52, .97)
Multifidus lift test L5-S156  | κ = .81 (.62, 1.00)

### Centralization Phenomenon

#### Reliability of Identifying the Centralization Phenomenon

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Centralization and directional preference57  | Two examiners with more than 5 years of training in the McKenzie method evaluated all patients and determined whether centralization occurred during repeated movements. If centralization occurred, the clinician recorded the directional preference| 39 patients with low back pain| κ if centralization occurred = .70
κ related to centralization and directional preference = .90
Judgments of centralization58  | Therapists (without formal training in McKenzie methods) and students viewed videotapes of patients undergoing a thorough examination by one therapist. All therapists and students watching the videos were asked to make an assessment regarding the change in symptoms based on movement status| 12 patients receiving physical therapy for low back pain| Between physical therapists κ = .82 (.81, .84)
Between physical therapy students κ = .76 (.76, .77)
Status change with flexion in sitting35  | 10 different examiners assessed symptom change (centralization, peripheralization, or no change) with single or repeated movements| 123 patients with low back pain of less than 90 days' duration| κ = .55 (.28, .81)
Status change with repeated flexion in sitting35  | κ = .46 (.23, .69)
Status change with extension35  | κ = .51 (.29, .72)
Status change with repeated extension35  | κ =.15 (.06, .36)
Status change with sustained prone extension35  | κ = .28 (.10, .47)

#### Diagnostic Utility of the Centralization Phenomenon

Figure 4-31 Centralization of pain.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Centralization59  | Centralization present if pain in the furthermost region from midline was abolished or reduced with a McKenzie-styled repeated motion examination| 69 patients with persistent low back pain with or without referred leg pain| At least one painful disc adjacent to a nonpainful disc with discography| .40 (.28, .54)| .94 (.73, .99)| 6.9 (1.0, 47.3)| .63 (.49, .82)

### Straight-Leg Raise Test

#### Reliability of the Straight-Leg Raise Test

Figure 4-32 Straight-leg raise test.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Passive straight-leg raise test22  | With patient supine, examiner passively flexes the hip and extends the knee. Examiner measures the angle of straight-leg raising and determines if symptoms occurred in a dermatomal fashion| 91 patients with low back pain randomly selected| For typical dermatomal pain, κ = .68
For any pain in the leg, κ = .36
For straight-leg raising of less than 45 degrees, κ = .43
Passive straight-leg raise test60  | With patient supine, examiner maintains the knee in extension while passively flexing the hip. The hip is flexed until examiner feels resistance. A range-of-motion measurement is recorded| 18 physiotherapy students| ICC Right = .86, Left = .83
Passive straight-leg raise test61  | Passive elevation of the leg with knee extended. Considered positive if pain in the low back or buttock is experienced| 27 patients with low back pain| κ = .32

#### Diagnostic Utility of the Straight-Leg Raise Test for Detecting Disc Bulge or Herniation

Deville and colleagues62 compiled the results of 15 studies investigating the accuracy of the straight-leg raise test for detecting disc herniation. Ten of the studies included information about both the sensitivity and specificity of the straight-leg raise test and were used for statistical pooling of estimates. However, numerous variations of the straight-leg raise maneuver have been reported, and no consistency was noted among the studies selected for the Deville and colleagues review. Similarly, a 2011 Cochrane Review63 investigating the accuracy of the straight-leg raise test for detecting disc herniation used nine studies for statistical pooling of estimates; all nine were the same as those used by the Deville and colleagues study, reported above. The results of each study, as well as the pooled estimates, are listed here.

Straight-Leg Raise Study and Quality| Description and Positive Findings| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Albeck et al64  | With the patient supine, the knee fully extended, and the ankle in neutral dorsiflexion, examiner then passively flexes the hip while maintaining the knee in extension. Positive test defined by reproduction of sciatic pain between 30 degrees and 60 to 75 degrees| Herniated lumbar disc observed during surgery. Herniation was defined as an extruded, protruded, and bulging disc or a sequestrated disc in most studies| .82 (.70, .90)| .21 (.07, .46)| 1.0| .86
Charnley et al65  | .85 (.75, .92)| .57 (.30, .81)| 1.98| .26
Gurdjian et al66  | .81 (.78, .83)| .52 (.32, .72)| 1.69| .37
Hakelius et al67  | .96 (.95, .97)| .14 (.11, .18)| 1.12| .29
Hirsch et al68  | .91 (.85, .94)| .32 (.20, .46)| 1.34| 2.8
Jonsson et al69  | .87 (.81, .91)| .22 (.07, .48)| 1.12| .59
Kosteljanetz et al70  | .89 (.75, .96)| .14 (.01, .58)| 1.03| .79
Kosteljanetz et al71  | .78 (.64, .87)| .48 (.32, .63)| 1.5| .49
Knutsson et al72  | .95 (.91, .98)| .10 (.02, .33)| 1.05| .50
Spangfort et al73  | .97 (.96, .97)| .11 (.08, .15)| 1.09| .27
Pooled estimate of the above listed 10 studies as calculated by Deville et al62  | .91 (.82, .94)| .26 (.16, .38)| 1.23| .35
Pooled estimate of 9 studies from 2011 Cochrane Review63  | As above| As above| .92 (.87, .95)| .28 (.18, .40)| 1.3| .29
Straight-leg raise test74  | With patient supine, examiner slowly lifts the symptomatic straight leg until maximal hip flexion is reached or the patient asks to stop. The angle between the leg and the table is measured. Positive if reproduction of familiar radicular pain occurs| MRI findings of disc bulges, herniations, and/ or extrusions in 75 patients with complaints of acute or recurrent low back and/or leg pain of 12 weeks' duration or less| .52 (.42, .58)| .89 (.79, .95)| 4.73| .54

### Crossed Straight-Leg Raise Test

#### Diagnostic Utility of the Crossed Straight-Leg Raise Test for Detecting Disc Bulging or Herniation

Deville and colleagues62 also compiled the results of eight studies investigating the accuracy of the crossed straight-leg raise test for detecting disc herniation. Five of the studies included information about both the sensitivity and specificity of the crossed straight-leg raise test and were used for statistical pooling of estimates. Similarly, a 2011 Cochrane Review63 investigating the accuracy of the crossed straight-leg raise test for detecting disc herniation used five studies for statistical pooling of estimates. Four of the five studies used for the pooled estimate were the same as those used by the Deville and colleagues62 study, reported above. The results of each study, as well as the pooled estimates, are listed here.

Crossed Straight-Leg Raise Study and Quality| Description and Positive Findings| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Hakelius et al67  | Performed identically to the straight-leg raise test except the uninvolved lower extremity is lifted. A positive test is defined as reproducing pain in the involved lower extremity| Herniated lumbar disc observed during surgery. Herniation was defined as extruded, protruded, and bulging disc or sequestrated disc in most studies| .28 (.25, .30)| .88 (.84, .90)| 2.33| .82
Jonsson et al69  | .22 (.16, .30)| .93 (.64, 1.0)| 3.14| .84
Kosteljanetz et al70  | .57 (.34, .79)| 1.0 (.03, 1.0)| Undefined| .43
Knutsson et al72  | .25 (.18, .32)| .93 (.73, 1.0)| 3.57| .81
Spangfort et al73  | .23 (.21, .25)| .88 (.84, .91)| 1.92| .88
Pooled estimate for the five studies listed above as calculated by Deville and colleagues62  | .29 (.24, .34)| .88 (.86, .90)| 2.42| .81
Pooled estimate of five studies from 2011 Cochrane Review63  | As above| As above| .28 (.22, .35)| .90 (.85, .94)| 2.8| .80

### Slump Test

#### Reliability of the Slump Test

Figure 4-33 Slump test.

Test and Study Quality| Description and Positive Findings| Population| Intraexaminer Reliability
---|---|---|---
Knee extension range of motion during the slump test75  | Subject sitting maximally slumped with one thigh flexed 25 degrees to the horizontal plane. Starting with the knee at 90 degrees and maximal ankle dorsiflexion, the knee was slowly extended to maximal discomfort and measured with an electrogoniometer| 20 asymptomatic subjects| With cervical flexion: ICC = .95
With cervical extension: ICC = .95

#### Diagnostic Utility of the Slump Test for Detecting Disc Bulging or Herniation

Figure 4-34 Role of inflammation in lumbar pain.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Slump test74  | Sitting with the back straight, the patient is encouraged to slump into lumbar and thoracic flexion while looking straight ahead. Then the patient fully flexes the neck and extends one knee. Last, the patient dorsiflexes the ipsilateral foot. Positive if reproduction of familiar radicular pain occurs| 75 patients with complaints of acute or recurrent low back pain and/or leg pain of 12 weeks' duration or less| MRI findings of disc bulges, herniations, and/or extrusions| .84 (.74, .90)| .83 (.73, .90)| 4.94| .19

### Slump Knee Bend Test

#### Reliability of the Slump Knee Bend Test

Figure 4-35 Slump knee bend test.

Test and Study Quality| Description and Positive Findings| Population| Intraexaminer Reliability
---|---|---|---
Slump knee bend test76   (see Video 4-1)| Subject side-lying with no pillow, slightly "cuddling" underside leg with cervical and thoracic spines flexed. Clinician stands behind subject supporting upper leg in neutral (no adduction/abduction). With the subject's upper knee flexed, clinician extends the hip until symptom is evoked. The subject is asked to extend the neck. Positive if symptom diminishes with neck extension| Sixteen patients with radicular leg pain| κ = .71 (.33, 1.00)

#### Diagnostic Utility of the Slump Knee Bend Test in Detecting Nerve Root Compression

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Slump knee bend test76  | As above in reliability section| As above in reliability section| MRI findings of nerve root compression| 1.00 (.40, 1.00)| .83 (.52, .98)| 6.00 (1.58, 19.4)| 0.0 (0.0, .60)

### Tests for Lumbar Segmental Instability

#### Reliability of Tests for Lumbar Segmental Instability

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Hip extension test77  | Prone patient extends one hip at a time. Positive if lateral shift, rotation, or hyperextension of the lumbar spine occurs| 42 patients with chronic low back pain| κ = .72 (left)
κ = .76 (right)
Painful arc in flexion48  | Patient reports symptoms at a particular point in the movement but the symptoms are not present before or after the movement| 63 patients with current low back pain| κ = .69 (.54, .84)
Painful arc on return from flexion48  | Patient experiences symptoms when returning from the flexed position| κ = .61 (.44, .78)
Instability catch48  | Patient experiences a sudden acclimation of deceleration of trunk movements outside the primary plane of movement| κ =.25 (−.10, .60)
Gower sign48  | Patient pushes up from thighs with the hands when returning to upright from a flexed position| κ =.00 (−1.09, 1.09)
Reversal of lumbopelvic rhythm48  | On attempting to return from the flexed position, the patient bends the knees and shifts the pelvis anteriorly| κ =.16 (−.15, .46)
Aberrant movement pattern48  | If the patient demonstrates any of the above five possible movement patterns, the patient is considered to be positive for an aberrant movement pattern| κ = .60 (.47, .73)
Aberrant movement pattern35  | 123 patients with low back pain of less than 90 days' duration| κ =.18 (−.07, .43)
Aberrant movement pattern78  | 30 patients with low back pain| κ =.64 (.32, .90)
Posterior shear test48  | With patient standing with arms crossed over the abdomen, examiner places one hand over the patient's crossed arms while the other stabilizes the pelvis. Examiner uses the index finger to palpate the L5-S1 interspace. Examiner then applies a posterior force through the patient's crossed arms. This procedure is performed at each level. A positive test is indicated by provocation of symptoms| 63 patients with current low back pain| κ = .35 (.20, .51)
Prone instability test48  | The patient is prone with the edge of the torso on the plinth while the legs are over the edge and feet are resting on the floor. Examiner performs a posteroanterior pressure maneuver and notes the provocation of any symptoms. The patient then lifts the feet off the floor, and examiner again performs the posteroanterior pressure maneuver. Provocation of symptoms is reported. Test is considered positive if the patient experiences symptoms while feet are on the floor but symptoms disappear when the feet are lifted off the floor| κ = .87 (.80, .94)
Prone instability test35  | 123 patients with low back pain of less than 90 days' duration| κ = .28 (.10, .47)
Prone instability test39  | 39 patients with low back pain| κ = .46 (.15, .77)
Prone instability test78  | 30 patients with low back pain| κ = .67 (.29, 1.00)
Trendelenburg79  | While standing, the patient flexes one hip to 30 degrees and lifts the ipsilateral pelvis above the transiliac line. The test is positive if the patient cannot hold the position for 30 seconds or needs more than one finger for balance| 36 patients with chronic low back pain| κ = .83 (left)
κ = .75 (right)
Active straight-leg raise test80  | The patient is supine with straight legs and feet 20 cm apart. The patient is instructed to "try to raise your legs, one after the other, above the couch without bending the knee." The patient is asked to score the maneuver on a 6-point scale ranging from "not difficult at all" to "unable to do"| κ = .70 (left)
κ = .71 (right)
Active straight-leg raise test80  | 50 females with lumbopelvic pain| Test-retest ICC = .83
Active straight-leg raise test78  | 30 patients with low back pain| κ = .53 (.20, .84)

Figure 4-36 Prone instability test.

### Tests for Lumbar Spinal Stenosis

#### Diagnostic Utility of Tests for Lumbar Spinal Stenosis

Figure 4-37 Degenerative disc disease and lumbar spinal stenosis.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Abnormal Romberg test24  | Patient stands with feet together and eyes closed for 10 seconds. Considered abnormal if compensatory movements were required to keep feet planted| 93 patients with back pain with or without radiation to the lower extremities| Diagnosis of spinal stenosis by retrospective chart review and confirmed by MRI or CT| .39 (.24, .54)| .91 (.81, 1.0)| 4.3| .67
Thigh pain with 30 seconds of extension24  | Patient performs hip extension for 30 seconds. Positive if patient has pain in the thigh following or during extension| .51 (.36, .66)| .69 (.53, .85)| 1.6| .71
Two-stage treadmill test16  | Subjects ambulate on a level and inclined (15 degrees) treadmill for 10 minutes. The patient rests for 10 minutes while sitting upright in a chair after each treadmill test| 45 subjects with low back and lower extremity pain| Diagnosis of spinal stenosis by MRI or CT scanning| Time to onset of symptoms
.68 (.50, .86)| .83 (.66, 1.0)| 4.07 (1.40, 11.8)| .39
Longer total walking time during the inclined test
.50 (.38, .63)| .92 (.78, 1.0)| 6.46 (3.1, 13.5)| .54
Prolonged recovery after level walking
.82 (.66 to .98)| .68 (.48, .90)| 2.59 (1.3, 5.2)| .26

### Tests for Radiographic Lumbar Instability

#### Diagnostic Utility of Tests for Radiographic Lumbar Instability

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Passive lumbar extension test1
2011 Systematic Review (see Video 4-2)| With subject in the prone position, both lower extremities are passively elevated, concurrently, to a height of about 30 cm while maintaining the knees extended and gently pulling the legs. Positive with low back pain or discomfort during test| 122 patients with low back pain with mean age of 68.9 years| Flexion-extension radiograph with translation motion of 5 mm| .84 (.68, .93)| .90 (.82, .96)| 8.8 (4.5, 17.3)| .20 (.10, .40)
Age younger than 37 years34  | History collected prior to physical examination| 49 patients with low back pain referred for flexion-extension radiographs| Radiologic findings revealed either two segments with rotational/translational instability or one segment with both rotational and translational instability| .57 (.39, .74)| .81 (.60, .92)| 3.0 (1.2, 7.7)| .53 (.33, .85)
Lumbar flexion greater than 53 degrees34  | Range of motion demonstrated by single inclinometer| .68 (.49, .82)| .86 (.65, .94)| 4.8 (1.6, 14.0)| .38 (.21, .66)
Total extension greater than 26 degrees34  | Range of motion demonstrated by single inclinometer| .50 (.33, .67)| .76 (.55, .89)| 2.1 (.90, 4.9)| .66 (.42, 1.0)
Lack of hypomobility during intervertebral testing34  | With patient prone, examiner applies a posteroanterior force to the spinous process of each lumbar vertebra. Mobility of each segment was judged as "normal," "hypermobile," or "hypomobile"| .43 (.27, .61)| .95 (.77, .99)| 9.0 (1.3, 63.9)| .60 (.43, .84)
Any hypermobility during intervertebral motion testing34  | .46 (.30, .64)| .81 (.60, .92)| 2.4 (.93, 6.4)| .66 (.44, .99)
Lumbar flexion greater than 53 degrees + Lack of hypomobility during intervertebral testing34  | Combination of both factors above| .29 (.13, .46)| .98 (.91, 1.0)| 12.8 (.79, 211.6)| .72 (.55, .94)

Figure 4-38 Passive lumbar extension test.

Fritz and colleagues81 investigated the accuracy of the clinical examination in 49 patients with radiographically determined lumbar instability. Results revealed that two predictor variables, including lack of hypomobility of the lumbar spine and lumbar flexion greater than 53 degrees, demonstrated a +LR of 12.8 (.79, 211.6). The nomogram below represents the change in pretest probability (57% in this study) to a posttest probability of 94.3%.

Figure 4-39 Nomogram representing the posttest probability of lumbar instability given the presence of hypomobility in the lumbar spine and lumbar flexion greater than 53 degrees. (Adapted with permission from Fagan TJ. Nomogram for Baye's theorem. N Engl J Med. 1975;293-257. Copyright 2005, Massachusetts Medical Society. All rights reserved.)

### Tests for Ankylosing Spondylitis

#### Diagnostic Utility of Tests for Ankylosing Spondylitis

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Measurements of chest expansion26  | Less than 7 cm (procedure not reported)| 449 randomly selected patients with low back pain| The New York criteria and radiographic confirmation of ankylosing spondylitis| .63| .53| 1.34| .70
Less than 2.5 cm (procedure not reported)| .91| .99| .91| .09
Schober test less than 4 cm26  | With patient standing, examiner marks a point 5 cm below and 10 cm above S2. This distance is then measured in the upright position and then in full flexion. The difference between the two measurements is calculated and recorded to the closest centimeter| .30| .86| 2.14| .81
Decreased lumbar lordosis26  | Visual observation individually judged by each examiner| .36| .80| 1.8| .80
Direct tenderness over sacroiliac joint26  | Direct pressure over the joint with the patient in an upright position. Positive if patient reports pain| .27| .68| .84| 1.07

### Classification Methods

#### Reliability of Low Back Pain Classification Systems

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
McKenzie classification for low back pain82  | Therapists (of which only 32% had ever taken any form of McKenzie training) completed a McKenzie evaluation form and classified the patient as exhibiting a postural, dysfunction, or derangement syndrome. Therapists also determined if the patient presented with a lateral shift| 363 patients referred to physical therapists for the treatment of low back pain| κ for classification = .26
κ for lateral shift = .26
McKenzie classification for low back pain57  | Two examiners with more than 5 years of training in the McKenzie method evaluated all patients. Therapists completed a McKenzie evaluation form and classified the patient as exhibiting a postural, dysfunction, or derangement syndrome. Therapists also determined if the patient presented with a lateral shift| 39 patients with low back pain| κ for classification = .70
κ for lateral shift = .20
McKenzie evaluation83  | Examination consisted of history taking, evaluation of spinal range of motion, and specified test movements| 46 consecutive patients presenting with low back pain| Classification of syndrome κ = .70
Derangement subsyndrome κ = .96
Presence of lateral shift κ = .52
Deformity of sagittal plane κ = 1.0
Movement impairment–based classification system for lumbar spine syndromes84  | Examiners used a standardized history and physical examination to assess patients and classify them into one of five lumbar spine categories| 24 patients with chronic low back pain| κ for classification = .61
Treatment-based classification35  | 30 examiners used a standardized history and physical examination to assess patients and classify them into one of three treatment-based categories| 123 patients with low back pain for less than 90 days' duration| κ for classification = .61 (.56, .64)
Treatment-based classification81  | Examiners used a standardized history and physical examination to assess patients and classify them into one of four treatment-based categories| 120 patients with low back pain| κ for classification = .56
Treatment-based classification85  | Examiners used a standardized history and physical examination to assess patients and classify them into one of four treatment-based categories after a 1-day training session| 45 patients with low back pain| κ for classification = .45
Stabilization subgroup from treatment-based classification78  | Each examiner rated the subject's status on the stabilization subgroup based on age and the rating of aberrant movement, straight-leg raise, and prone instability test scores. If a subject presented with three or more positive tests, his or her status was considered positive| 30 patients with low back pain| κ for subgroup = .86 (.65, 1.00)

#### Treatment-Based Classification Method86

| Subgroup Criteria| Treatment Approach
---|---|---
Specific Exercise Subgroup| Extension

• Symptoms distal to the buttock

• Symptoms centralize with lumbar extension

• Symptoms peripheralize with lumbar flexion

• Directional preference for extension | • End-range extension exercises

• Mobilization to promote extension

• Avoidance of flexion activities

Flexion

• Older age (over 50 years)

• Directional preference for flexion

• Imaging evidence of lumbar spine stenosis | • End-range flexion exercises

• Mobilization or manipulation of the spine and/or lower extremities

• Exercise to address impairments of strength or flexibility

• Body weight−supported ambulation

Stabilization Subgroup|

• Age (under 40 years)

• Average straight-leg raise (more than 91 degrees)

• Aberrant movement present

• Positive prone instability test | • Exercises to strengthen large spinal muscles (erector spinae, oblique abdominals)

• Exercises to promote contraction of deep spinal muscles (multifidus, transversus abdominis)

Manipulation Subgroup|

• No symptoms distal to knee

• Duration of symptoms less than 16 days

• Lumbar hypomobility

• FABQW less than 19

• Hip internal rotation range of motion of more than 35 degrees | • Manipulation techniques for the lumbopelvic region

• Active lumbar range-of-motion exercises

Traction Subgroup|

• Symptoms extend distal to the buttock(s)

• Signs of nerve root compression are present

• Peripheralization occurs with extension movement or positive findings on contralateral straight-leg raise test | • Prone mechanical traction

• Extension-specific exercise activities

Rather than attempt to classify low back pain based on pathologic anatomy, the Treatment-Based Classification (TBC) system identifies subgroups of patients thought to respond to specific conservative treatment interventions. Although its initial proposal was based on experience and clinical reasoning,87 researchers have since systematically identified many of the historical and clinical examination factors associated with each subgroup using clinical prediction rule research methodology.2,3,88

### Interventions

#### Diagnostic Utility of Single Factors for Identifying Patients Likely to Benefit from Spinal Manipulation

Test and Study Quality| Description and Criteria| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Symptoms for less than 16 days' duration2  | Self-report| 71 patients with low back pain| Reduction of 50% or more in back pain− related disability within 1 week as measured by the Oswestry questionnaire| .56 (.39, .72)| .87 (.73, .94)| 4.39 (1.83, 10.51)| Not reported
FABQ work subscale score less than 192  | .84 (.68, .93)| .49 (.34, .64)| 1.65 (1.17, 2.31)
No symptoms distal to the knee2  | .88 (.72, .95)| .36 (.23, .52)| 1.36 (1.04, 1.79)
At least one hip with more than 35 degrees of internal rotation range of motion2  | With patient prone, measured with standard goniometer| .50 (.34, .66)| .85 (.70, .93)| 3.25 (1.44, 7.33)
Hypomobility in the lumbar spine2  | With patient prone, examiner applies a posteroanterior force to the spinous process of each lumbar vertebra. Mobility of each segment was judged as "normal," "hypermobile," or "hypomobile"| .97 (.84, .99)| .23 (.13, .38)| 1.26 (1.05, 1.51)

#### Diagnostic Utility of Combinations of Factors for Identifying Patients Likely to Benefit from Spinal Manipulation

Figure 4-40 Spinal manipulation technique used by Flynn and colleagues. The patient is passively side-bent toward the side to be manipulated (away from the therapist). The therapist then rotates the patient away from the side to be manipulated (toward the therapist) and delivers a quick thrust through the anterior superior iliac spine in a posteroinferior direction. (From Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835-2843.)

Test and Study Quality| Description and Criteria| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Symptoms of less than 16 days' duration
+
No symptoms distal to the knee
+
Hypomobility in the lumbar spine
+
FABQ work subscale score less than 19
+
At least one hip with more than 35 degrees of internal rotation range of motion2  | All five tests positive| 71 patients with low back pain| Reduction of 50% or more in back pain−related disability within 1 week as measured by the Oswestry questionnaire| .19 (.09, .35)| 1.00 (.91, 1.00)| Undefined| Not reported
Four or more tests positive| .63 (.45 to .77)| .97 (.87 to 1.0)| 24.38 (4.63 to 139.41)
Three or more tests positive| .94 (.80, .98)| .64 (.48, .77)| 2.61 (1.78, 4.15)
Two or more tests positive| 1.00 (.89, 1.0)| .15 (.07, .30)| 1.18 (1.09, 1.42)
One or more tests positive| 1.00 (.89, 1.0)| .03 (.005, .13)| 1.03 (1.01, 1.15)
Symptoms of less than 16 days' duration + No symptoms distal to the knee88  | Must meet both criteria| 141 patients with low back pain| .56 (.43, .67)| .92 (.84, .96)| 7.2 (3.2, 16.1)

#### Diagnostic Utility of Single Factors and Combinations of Factors in Identifying Patients Likely to Benefit from Lumbar Stabilization Exercises

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Age younger than 40 years3  | Self-report| 54 patients with low back pain with or without leg pain| Reduction of 50% or more in back pain−related disability after 8 weeks of lumbar stabilization exercises as measured by the Oswestry questionnaire| .61 (.39, .80)| .83 (.68, .92)| 3.7 (1.6, 8.3)| .47 (.26, .85)
Average straight-leg raise test of more than 91 degrees3  | Measured with an inclinometer| .28 (.13, .51)| .92 (.78, .97)| 3.3 (.90, 12.4)| .79 (.58, 1.1)
Aberrant movement present3  | Presence of any of the following during flexion range of motion:

• Instability catch

• Painful arc of motion

• "Thigh climbing" (Gower sign)

• Reversal of lumbopelvic rhythm

| .78 (.55, .91)| .50 (.35, .66)| 1.6 (1.0, 2.3)| .44 (.18, 1.1)
Positive prone instability test3  | See description under Tests for Lumbar Segmental Instability| .72 (.49, .88)| .58 (.42, .73)| 1.7 (1.1, 2.8)| .48 (.22, 1.1)
Combination of any four factors above3  | Three or more tests positive| .56 (.34, .75)| .86 (.71, .94)| 4.0 (1.6, 10.0)| .52 (.30, .88)
Two or more tests positive| .83 (.61, .94)| .56 (.40, .71)| 1.9 (1.2, 2.9)| .30 (.10, .88)
One or more 1 tests positive| .94 (.74, .99)| .28 (.16, .44)| 1.3 (1.0, 1.6)| .20 (.03, 1.4)

#### Clinical Prediction Rule to Identify Patients with Low Back Pain Likely to Benefit from Pilates-Based Exercise

Stolze and colleagues89 developed a clinical prediction rule for identifying patients with low back pain who are likely to benefit from Pilates-based exercise. The result of their study demonstrated that if three or more of the five attributes (total trunk flexion range of motion of 70 degrees or less, duration of current symptoms of 6 months or less, no leg symptoms in the last week, body mass index of 25 kg/m2 or greater, and left or right hip average rotation range of motion of 25 degrees or greater) were present, the +LR was 10.64 (95% CI 3.52, 32.14) and the probability of experiencing a successful outcome improved from 54% to 93%.

## Outcome Measures

Outcome Measure| Scoring and Interpretation| Test-Retest Reliability| MCID
---|---|---|---
Oswestry Disability Index (ODI)| Users are asked to rate the difficulty of performing 10 functional tasks on a scale of 0 to 5 with different descriptors for each task. A total score out of 100 is calculated by summing each score and doubling the total. The answers provide a score between 0 and 100, with higher scores representing more disability| ICC = .9190  | 1191
Modified Oswestry Disability Index (modified ODI)| As above, except the modified ODI replaces the sex life question with an employment/homemaking question| ICC = .9092  | 692
Roland-Morris Disability Questionnaire (RMDQ)| Users are asked to answer 23 or 24 questions (depending on the version) about their back pain and related disability. The RMDQ is scored by adding the number of items checked by the patient, with higher numbers indicating more disability| ICC = .9193  | 591
Fear-Avoidance Beliefs Questionnaire (FABQ)| Users are asked to rate their level of agreement with statements concerning beliefs about the relationship between physical activity, work, and their back pain. Level of agreement is answered on a Likert-type scale ranging from 0 (completely disagree) to 7 (completely agree). The FABQ has two parts: a seven-item work subscale (FABQW) and a four-item physical activity subscale (FABQPA). Each scale is scored separately, with higher scores representing greater fear avoidance| FABQW: ICC = .82
FABQPA: ICC = .6694  | Not available
Numeric Pain Rating Scale (NPRS)| Users rate their level of pain on an 11-point scale ranging from 0 to 10, with high scores representing more pain. Often asked as "current pain" and "least," "worst," and "average" pain in the past 24 hours| ICC = .7295  | 296,97

MCID, Minimum clinically important difference.

## Appendix

#### Quality Appraisal of Reliability Studies for Thoracolumbar Spine Disorders Using QAREL

| McCombe 198920| Roach 199721| Vroomen 200022| Van Dillen 199823| Lindell 200730| Breum 199531| Evans 200632| Fritz 200534| Fritz 200635| Haswell 200427
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| U| N/A| Y| Y| Y| Y| Y| Y| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| U| N/A| N/A| U| U| Y| Y| N/A| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| N/A| N/A| Y| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| U| U| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| U

8. Was the order of examination varied?

| U| N/A| Y| Y| Y| Y| Y| Y| Y| Y

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Cleland 200636| Weiner 200637| Schneider 200839| Landel 200840| Qvistgaard 200741| Johansson 200642| Mootz 198943| Keating 199044| Strender 199745| Maher 199846
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| U| Y| Y| Y| Y| Y| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| N/A| N/A| N/A| Y| N/A| U| N/A| N/A| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| Y| N/A| N/A| N/A| N/A| N/A| Y

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| Y| U| U| U| Y| Y| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| Y| U| U| U| U| U

8. Was the order of examination varied?

| N| N| N| N| N| Y| Y| Y| Y| N

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Binkley 199547| Hicks 200348| French 200049| Horneij 200250| Downey 199954| Kilpikoski 200257| Fritz 200058| Rose 199160| Viikari-Juntura 199861| Tucker 200775
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| U| Y| Y| Y| Y| Y| U| N/A| Y| U

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| N/A| N| U| N/A| N/A| N/A| N| N/A| U

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| U| Y| Y| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| Y| U| U| U

8. Was the order of examination varied?

| Y| N| Y| Y| Y| Y| N/A| N| N| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| U| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Murphy 200677| Roussel 200779| Mens 200180| Fritz 200081| Riddle 199382| Razmjou 200083| Trudelle-Jackson 200884| Heiss 200485| Lauridsen 200690| Fritz 200192
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| Y| Y| Y| Y| Y| Y| N/A| N/A

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| N/A| N| N/A| N/A| N/A| N/A| N/A| N| N

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| Y| Y| Y| Y| U| Y| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| U

8. Was the order of examination varied?

| N/A| Y| U| N| Y| Y| Y| Y| U| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Brouwer 200493| Grotle 200694| Li 200795| Rabin 201378| Enoch 201138| Snider 201155| Kolber 201333| Robinson 201429| Hebert 201356| Trainor 201176
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| N/A| N/A| N/A| Y| Y| Y| Y| Y| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| N| N| N| N/A| N/A| N/A| Y| N/A| N/A| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| Y| N/A| N/A| Y| Y

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| U| U| Y| Y| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| Y| U| Y| U| U

8. Was the order of examination varied?

| U| U| U| N| Y| U| N| Y| Y| Y

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

#### Quality Assessment of Diagnostic Studies for Thoracolumbar Spine Disorders Using QUADAS

| Russel 1981100| Blower 1984101| Gran 198526| Kerr 198898| Katz 199524| Phillips 1996102| Fritz 199716| Lauder 200025| Leboeuf-Yde 200252
---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| U| Y| Y| U| Y| Y| Y| Y| N

2. Were selection criteria clearly described?

| N| N| Y| N| Y| N| N| N| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| U| N| U| Y| Y| U

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| U| U| U| U| N| U| U| Y

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| U| Y| N| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| U| U| Y| N| Y| Y| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| N| Y| N| Y| U| U| Y| N

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| N| U| Y| N| Y| N| U| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| U| N| Y| U| Y| N| U| Y| U

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| U| Y| U| Y| Y| Y| U| U

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| Y| Y| U| Y| U| U| Y| U

13. Were uninterpretable/intermediate test results reported?

| N| U| Y| U| Y| Y| Y| Y| Y

14. Were withdrawals from the study explained?

| U| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Trainor 201176| Esene 201228| Abbott 200351| Laslett 200559| Abbott 200553| Fritz 200534| Hicks 20053| Majlesi 200874
---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| Y| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| Y| Y| Y| Y| Y| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| U| Y| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| Y| Y| U| Y| U| Y| N| U

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| Y| Y| Y| Y| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| U| Y| Y| Y| Y| Y| U

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| Y| Y| Y| Y| Y| U

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| Y| Y| Y| Y| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| Y| U| Y| Y| Y| Y| Y| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| Y| Y| Y| Y| Y| Y| Y| Y

13. Were uninterpretable/intermediate test results reported?

| Y| Y| Y| Y| Y| Y| Y| U

14. Were withdrawals from the study explained?

| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

## References

1. Alqarni AM, Schneiders AG, Hendrick PA. Clinical tests to diagnose lumbar segmental instability: a systematic review. J Orthop Sports Phys Ther. 2011;41(3):130–140.

2. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835–2843.

3. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005;86:1753–1762.

4. Vleeming A, Pool-Goudzwaard AL, Stoeckart R, et al. The posterior layer of the thoracolumbar fascia. Its function in load transfer from spine to legs. Spine. 1995;20:753–758.

5. Bogduk N. The applied anatomy of the lumbar fascia. Spine. 1984;9:164–170.

6. Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl. 1989;230:1–54.

7. Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum. Churchill Livingstone: London; 1997.

8. Evans C, Oldreive W. A study to investigate whether golfers with a history of low back pain show a reduced endurance of transversus abdominis. J Man Manip Ther. 2000;8:162–174.

9. Kay AG. An extensive literature review of the lumbar multifidus: biomechanics. J Man Manip Ther. 2001;9:17–39.

10. Norris CM. Spinal stabilisation. 1. Active lumbar stabilisation—concepts. Physiotherapy. 1995;81:61–78.

11. Bogduk N. Neck pain. Aust Fam Physician. 1984;13:26–30.

12. Schwarzer AC, Aprill CN, Derby R, et al. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine. 1994;19:801–806.

13. Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine. 1994;19:1132–1137.

14. McKenzie RA. Mechanical diagnosis and therapy for disorders of the low back. Twomey LT, Taylor JR. Physical Therapy of the Low Back (5). 3rd ed. Churchill Livingstone: Philadelphia; 2000:141–165.

15. Morris EW, Di Paola M, Vallance R, Waddell G. Diagnosis and decision making in lumbar disc prolapse and nerve entrapment. Spine. 1986;11:436–439.

16. Fritz JM, Erhard RE, Delitto A, et al. Preliminary results of the use of a two-stage treadmill test as a clinical diagnostic tool in the differential diagnosis of lumbar spinal stenosis. J Spinal Disord. 1997;10:410–416.

17. Fritz JM, Erhard RE, Hagen BF. Segmental instability of the lumbar spine. Phys Ther. 1998;78:889–896.

18. O'Sullivan PB. Lumbar segmental "instability": clinical presentation and specific stabilizing exercise management. Man Ther. 2000;5:2–12.

19. Schwarzer AC, Wang SC, Bogduk N, et al. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis. 1995;54:100–106.

20. McCombe PF, Fairbank JC, Cockersole BC, Pynsent PB. 1989 Volvo Award in clinical sciences. Reproducibility of physical signs in low-back pain. Spine. 1989;14:908–918.

21. Roach KE, Brown MD, Dunigan KM, et al. Test-retest reliability of patient reports of low back pain. J Orthop Sports Phys Ther. 1997;26:253–259.

22. Vroomen PC, de Krom MC, Knottnerus JA. Consistency of history taking and physical examination in patients with suspected lumbar nerve root involvement. Spine. 2000;25:91–97.

23. Van Dillen LR, Sahrmann SA, Norton BJ, et al. Reliability of physical examination items used for classification of patients with low back pain. Phys Ther. 1998;78:979–988.

24. Katz JN, Dalgas M, Stucki G, et al. Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination. Arthritis Rheum. 1995;38:1236–1241.

25. Lauder TD, Dillingham TR, Andary M, et al. Effect of history and exam in predicting electrodiagnostic outcome among patients with suspected lumbosacral radiculopathy. Am J Phys Med Rehabil. 2000;79:60–68 [quiz 75-76].

26. Gran JT. An epidemiological survey of the signs and symptoms of ankylosing spondylitis. Clin Rheumatol. 1985;4:161–169.

27. Haswell K, Williams M, Hing W. Interexaminer reliability of symptom-provoking active sidebend, rotation and combined movement assessments of patients with low back pain. J Man Manip Ther. 2004;12:11–20.

28. Esene IN, Meher A, Elzoghby MA, et al. Diagnostic performance of the medial hamstring reflex in L5 radiculopathy. Surg Neurol Int. 2012;3:104.

29. Robinson HS, Mengshoel AM. Assessments of lumbar flexion range of motion: intertester reliability and concurrent validity of 2 commonly used clinical tests. Spine. 2014;39(4):E270–E275.

30. Lindell O, Eriksson L, Strender LE. The reliability of a 10-test package for patients with prolonged back and neck pain: could an examiner without formal medical education be used without loss of quality? A methodological study. BMC Musculoskelet Disord. 2007;8:31.

31. Breum J, Wiberg J, Bolton JE. Reliability and concurrent validity of the BROM II for measuring lumbar mobility. J Manipulative Physiol Ther. 1995;18:497–502.

32. Evans K, Refshauge KM, Adams R. Measurement of active rotation in standing: reliability of a simple test protocol. Percept Mot Skills. 2006;103:619–628.

33. Kolber MJ, Pizzini M, Robinson A, et al. The reliability and concurrent validity of measurements used to quantify lumbar spine mobility: an analysis of an iphone® application and gravity based inclinometry. Int J Sports Phys Ther. 2013;8(2):129–137.

34. Fritz JM, Piva SR, Childs JD. Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. Eur Spine J. 2005;14:743–750.

35. Fritz JM, Brennan GP, Clifford SN, et al. An examination of the reliability of a classification algorithm for subgrouping patients with low back pain. Spine. 2006;31:77–82.

36. Cleland JA, Childs JD, Fritz JM, Whitman JM. Interrater reliability of the history and physical examination in patients with mechanical neck pain. Arch Phys Med Rehabil. 2006;87:1388–1395.

37. Weiner DK, Sakamoto S, Perera S, Breuer P. Chronic low back pain in older adults: prevalence, reliability, and validity of physical examination findings. J Am Geriatr Soc. 2006;54:11–20.

38. Enoch F, Kjaer P, Elkjaer A, et al. Inter-examiner reproducibility of tests for lumbar motor control. BMC Musculoskelet Disord. 2011;12:114.

39. Schneider M, Erhard R, Brach J, et al. Spinal palpation for lumbar segmental mobility and pain provocation: an interexaminer reliability study. J Manipulative Physiol Ther. 2008;31:465–473.

40. Landel R, Kulig K, Fredericson M, et al. Intertester reliability and validity of motion assessments during lumbar spine accessory motion testing. Phys Ther. 2008;88:43–49.

41. Qvistgaard E, Rasmussen J, Laetgaard J, et al. Intra-observer and inter-observer agreement of the manual examination of the lumbar spine in chronic low-back pain. Eur Spine J. 2007;16:277–282.

42. Johansson F. Interexaminer reliability of lumbar segmental mobility tests. Man Ther. 2006;11:331–336.

43. Mootz RD, Keating JCJ, Kontz HP, et al. Intra- and interobserver reliability of passive motion palpation of the lumbar spine. J Manipulative Physiol Ther. 1989;12:440–445.

44. Keating JCJ, Bergmann TF, Jacobs GE, et al. Interexaminer reliability of eight evaluative dimensions of lumbar segmental abnormality. J Manipulative Physiol Ther. 1990;13:463–470.

45. Strender LE, Sjoblom A, Sundell K, et al. Interexaminer reliability in physical examination of patients with low back pain. Spine. 1997;22:814–820.

46. Maher CG, Latimer J, Adams R. An investigation of the reliability and validity of posteroanterior spinal stiffness judgments made using a reference-based protocol. Phys Ther. 1998;78:829–837.

47. Binkley J, Stratford PW, Gill C. Interrater reliability of lumbar accessory motion mobility testing. Phys Ther. 1995;75:786–795.

48. Hicks GE, Fritz JM, Delitto A, Mishock J. The reliability of clinical examination measures used for patients with suspected lumbar segmental instability. Arch Phys Med Rehabil. 2003;84:1858–1864.

49. French SD, Green S, Forbes A. Reliability of chiropractic methods commonly used to detect manipulable lesions in patients with chronic low-back pain. J Manipulative Physiol Ther. 2000;23:231–238.

50. Horneij E, Hemborg B, Johnsson B, Ekdahl C. Clinical tests on impairment level related to low back pain: a study of test reliability. J Rehabil Med. 2002;34:176–182.

51. Abbott J, Mercer S. Lumbar segmental hypomobility: criterion-related validity of clinical examination items (a pilot study). N Z J Physiother. 2003;31:3–9.

52. Leboeuf-Yde C, van Dijk J, Franz C, et al. Motion palpation findings and self-reported low back pain in a population-based study sample. J Manipulative Physiol Ther. 2002;25:80–87.

53. Abbott JH, McCane B, Herbison P, et al. Lumbar segmental instability: a criterion-related validity study of manual therapy assessment. BMC Musculoskelet Disord. 2005;6:56.

54. Downey BJ, Taylor NF, Niere KR. Manipulative physiotherapists can reliably palpate nominated lumbar spinal levels. Man Ther. 1999;4:151–156.

55. Snider KT, Snider EJ, Degenhardt BF, et al. Palpatory accuracy of lumbar spinous processes using multiple bony landmarks. J Manipulative Physiol Ther. 2011;34(5):306–313.

56. Hebert JJ, Koppenhaver SL, Teyhen DS, et al. The evaluation of lumbar multifidus muscle function via palpation: reliability and validity of a new clinical test. Spine J. 2013 [Oct 4; Epub ahead of print].

57. Kilpikoski S, Airaksinen O, Kankaanpaa M, et al. Interexaminer reliability of low back pain assessment using the McKenzie method. Spine. 2002;27:E207–E214.

58. Fritz JM, Delitto A, Vignovic M, Busse RG. Interrater reliability of judgments of the centralization phenomenon and status change during movement testing in patients with low back pain. Arch Phys Med Rehabil. 2000;81:57–61.

59. Laslett M, Oberg B, Aprill CN, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J. 2005;5:370–380.

60. Rose MJ. The statistical analysis of the intra-observer repeatability of four clinical measurement techniques. Physiotherapy. 1991;77:89–91.

61. Viikari-Juntura E, Takala EP, Riihimaki H, et al. Standardized physical examination protocol for low back disorders: feasibility of use and validity of symptoms and signs. J Clin Epidemiol. 1998;51:245–255.

62. Deville WL, van der Windt DA, Dzaferagic A, et al. The test of Lasegue: systematic review of the accuracy in diagnosing herniated discs. Spine. 2000;25:1140–1147.

63. Van der Windt DA, Simons E, Riphagen II, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev. 2010;(2) [CD007431].

64. Albeck MJ. A critical assessment of clinical diagnosis of disc herniation in patients with monoradicular sciatica. Acta Neurochir (Wien). 1996;138:40–44.

65. Charnley J. Orthopaedic signs in the diagnosis of disc protrusion. With special reference to the straight-leg-raising test. Lancet. 1951;1:186–192.

66. Gurdjian ES, Webster JE, Ostrowski AZ, et al. Herniated lumbar intervertebral discs—an analysis of 1176 operated cases. J Trauma. 1961;1:158–176.

67. Hakelius A, Hindmarsh J. The significance of neurological signs and myelographic findings in the diagnosis of lumbar root compression. Acta Orthop Scand. 1972;43:239–246.

68. Hirsch C, Nachemson A. The reliability of lumbar disc surgery. Clin Orthop. 1963;29:189–195.

69. Jonsson B, Stromqvist B. The straight leg raising test and the severity of symptoms in lumbar disc herniation. A preoperative evaluation. Spine. 1995;20:27–30.

70. Kosteljanetz M, Bang F, Schmidt-Olsen S. The clinical significance of straight-leg raising (Lasegue's sign) in the diagnosis of prolapsed lumbar disc. Interobserver variation and correlation with surgical finding. Spine. 1988;13:393–395.

71. Kosteljanetz M, Espersen JO, Halaburt H, Miletic T. Predictive value of clinical and surgical findings in patients with lumbago-sciatica. A prospective study (Part I). Acta Neurochir (Wien). 1984;73:67–76.

72. Knutsson B. Comparative value of electromyographic, myelographic and clinical-neurological examinations in diagnosis of lumbar root compression syndrome. Acta Orthop Scand Suppl. 1961;49:1–135.

73. Spangfort EV. The lumbar disc herniation: a computer aided analysis of 2504 operations. Acta Orthop Scand. 1972;142:5–79.

74. Majlesi J, Togay H, Unalan H, Toprak S. The sensitivity and specificity of the slump and the straight leg raising tests in patients with lumbar disc herniation. J Clin Rheumatol. 2008;14:87–91.

75. Tucker N, Reid D, McNair P. Reliability and measurement error of active knee extension range of motion in a modified slump test position: a pilot study. J Man Manip Ther. 2007;15:E85–E91.

76. Trainor K, Pinnington MA. Reliability and diagnostic validity of the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression: a pilot study. Physiotherapy. 2011;97(1):59–64.

77. Murphy DR, Byfield D, McCarthy P, et al. Interexaminer reliability of the hip extension test for suspected impaired motor control of the lumbar spine. J Manipulative Physiol Ther. 2006;29:374–377.

78. Rabin A, Shashua A, Pizem K, Dar G. The interrater reliability of physical examination tests that may predict the outcome or suggest the need for lumbar stabilization exercises. J Orthop Sports Phys Ther. 2013;43(2):83–90.

79. Roussel NA, Nijs J, Truijen S, et al. Low back pain: clinimetric properties of the Trendelenburg test, active straight leg raise test, and breathing pattern during active straight leg raising. J Manipulative Physiol Ther. 2007;30:270–278.

80. Mens JM, Vleeming A, Snijders CJ, et al. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine. 2001;26:1167–1171.

81. Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain. Interrater reliability and short-term treatment outcomes. Spine. 2000;25:106–114.

82. Riddle DL, Rothstein JM. Intertester reliability of McKenzie's classifications of the syndrome types present in patients with low back pain. Spine. 1993;18:1333–1344.

83. Razmjou H, Kramer JF, Yamada R. Intertester reliability of the McKenzie evaluation in assessing patients with mechanical low-back pain. J Orthop Sports Phys Ther. 2000;30:368–389.

84. Trudelle-Jackson E, Sarvaiya-Shah SA, Wang SS. Interrater reliability of a movement impairment-based classification system for lumbar spine syndromes in patients with chronic low back pain. J Orthop Sports Phys Ther. 2008;38:371–376.

85. Heiss DG, Fitch DS, Fritz JM, et al. The interrater reliability among physical therapists newly trained in a classification system for acute low back pain. J Orthop Sports Phys Ther. 2004;34:430–439.

86. Hebert J, Koppenhaver S, Fritz J, Parent E. Clinical prediction for success of interventions for managing low back pain. Clin Sports Med. 2008;27:463–479.

87. Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative management. Phys Ther. 1995;75:470–489.

88. Fritz JM, Childs JD, Flynn TW. Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention. BMC Fam Pract. 2005;6:29.

89. Stolze LR, Allison SC, Childs JD. Derivation of a preliminary clinical prediction rule for identifying a subgroup of patients with low back pain likely to benefit from Pilates-based exercise. J Orthop Sports Phys Ther. 2012;42(5):425–436.

90. Lauridsen HH, Hartvigsen J, Manniche C, et al. Danish version of the Oswestry Disability Index for patients with low back pain. Part 1: Cross-cultural adaptation, reliability and validity in two different populations. Eur Spine J. 2006;15:1705–1716.

91. Lauridsen HH, Hartvigsen J, Manniche C, et al. Responsiveness and minimal clinically important difference for pain and disability instruments in low back pain patients. BMC Musculoskelet Disord. 2006;7:82.

92. Fritz JM, Irrgang JJ. A comparison of a Modified Oswestry Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther. 2001;81:776–788.

93. Brouwer S, Kuijer W, Dijkstra PU, et al. Reliability and stability of the Roland Morris Disability Questionnaire: intraclass correlation and limits of agreement. Disabil Rehabil. 2004;26:162–165.

94. Grotle M, Brox JI, Vollestad NK. Reliability, validity and responsiveness of the Fear-Avoidance Beliefs Questionnaire: methodological aspects of the Norwegian version. J Rehabil Med. 2006;38:346–353.

95. Li L, Liu X, Herr K. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Pain Med. 2007;8:223–234.

96. Farrar JT, Berlin JA, Strom BL. Clinically important changes in acute pain outcome measures: a validation study. J Pain Symptom Manage. 2003;25:406–411.

97. Farrar JT, Portenoy RK, Berlin JA, et al. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287–294.

98. Kerr RS, Cadoux-Hudson TA, Adams CB. The value of accurate clinical assessment in the surgical management of the lumbar disc protrusion. J Neurol Neurosurg Psychiatry. 1988;51:169–173.

99. Fukui S, Ohseto K, Shiotani M, et al. Distribution of referred pain from the lumbar zygapophyseal joints and dorsal rami. Clin J Pain. 1997;13:303–307.

100. Russel AS, Maksymowych W, LeClercq S. Clinical examination of the sacroiliac joints: a prospective study. Arthritis Rheum. 1981;24:1575–1577.

101. Blower PW, Griffin AJ. Clinical sacroiliac tests in ankylosing spondylitis and other causes of low back pain—2 studies. Ann Rheum Dis. 1984;43:192–195.

102. Phillips DR, Twomey LT. A comparison of manual diagnosis with a diagnosis established by a uni-level lumbar spinal block procedure. Man Ther. 1996;1:82–87.
5

# Sacroiliac Region

CLINICAL SUMMARY AND RECOMMENDATIONS, 224

Anatomy, 225

Osteology, 225

Arthrology, 229

Ligaments, 230

Muscles, 232

Nerves, 233

Patient History, 235

Sacroiliac Pain and Sacroiliac Dysfunction, 235

Pain Location and Aggravating Factors, 236

Sacroiliac Joint Pain Referral Patterns, 237

Physical Examination Tests, 238

Palpation, 238

Pain Provocation, 241

Motion Assessment, 254

Combinations of Tests, 261

Interventions, 265

Outcome Measures, 267

Appendix, 268

References, 273

## Clinical Summary and Recommendations

Patient History
---
Questions|

• The question "Is pain relieved by standing?" is the only question studied to demonstrate some diagnostic utility (+LR [likelihood ratio] of 3.5) for sacroiliac joint pain.

Pain Location|

• Recent evidence suggests that patients with sacroiliac joint pain commonly experience the most intense pain around one or both sacroiliac joints, with or without referral into the lateral thigh.

Physical Examination
Pain Provocation Tests|

• Pain provocation tests generally demonstrate fair to moderate reliability and some exhibit moderate diagnostic utility for detecting sacroiliac joint pain.

• Clusters of pain provocation tests consistently demonstrate good diagnostic utility for detecting sacroiliac joint pain. Using a cluster of four to five tests, including the distraction test, thigh thrust test, sacral thrust test, and compression test after a McKenzie-type repeated motion examination, seems to exhibit the best diagnostic utility (+LR of 6.97) and is recommended.

Motion Assessment and Static Palpation|

• Motion assessment and static palpation tests generally demonstrate very poor reliability and almost no diagnostic utility for either sacroiliac joint pain or innominate torsion and, therefore, are not recommended for use in clinical practice.

• Lumbar hypomobility is the one exception that, although exhibiting questionable reliability, demonstrates some diagnostic utility when used as part of a cluster to determine which patients will respond to spinal manipulation.

Interventions|

• Patients with low back pain of less than 16 days' duration and no symptoms distal to the knees, and/or who meet four out of five of the Flynn and colleagues1 criteria, should be treated with a lumbosacral manipulation.

## Anatomy

### Osteology

Figure 5-1 Bony framework of abdomen.

Figure 5-2 Sacrum and coccyx.

Figure 5-3 Hip (coxal) bone.

Figure 5-4 Sex differences of pelvis.

### Arthrology

Figure 5-5 Sacroiliac joint.

Region| Joint| Type and Classification| Closed Packed Position| Capsular Pattern
---|---|---|---|---
Sacroiliac region| Sacroiliac joint| Plane synovial| Has not been described| Considered a capsular pattern if pain is provoked when joints are stressed
Lumbosacral region| Apophyseal joints| Plane synovial| Extension| Equal limitations of side-bending, flexion, and extension
Intervertebral joints| Amphiarthrodial| Not applicable| Not applicable

### Ligaments

Figure 5-6 Sacroiliac region ligaments.

Sacroiliac Region Ligaments| Attachment| Function
---|---|---
Posterior sacroiliac| Iliac crest to tubercles of S1-S4| Limits movement of sacrum on iliac bones
Anterior sacroiliac| Anterosuperior aspect of sacrum to anterior ala of ilium| Limits movement of sacrum on iliac bones
Sacrospinous| Inferior lateral border of sacrum to ischial spine| Limits gliding and rotary movement of sacrum on iliac bones
Sacrotuberous| Middle lateral border of sacrum to ischial tuberosity| Limits gliding and rotary movement of sacrum on iliac bones
Posterior sacrococcygeal| Posterior aspect of inferior sacrum to posterior aspect of coccyx| Reinforces sacrococcygeal joint
Anterior sacrococcygeal| Anterior aspect of inferior sacrum to anterior aspect of coccyx| Reinforces sacrococcygeal joint
Lateral sacrococcygeal| Lateral aspect of inferior sacrum to lateral aspect of coccyx| Reinforces sacrococcygeal joint
Anterior longitudinal| Extends from anterior sacrum to anterior tubercle of C1. Connects anterolateral vertebral bodies and discs| Maintains stability of vertebral body joints and prevents hyperextension of vertebral column

### Muscles

Figure 5-7 Sacroiliac region muscles. Posterior view of spine and associated musculature.

Sacroiliac Region Muscles| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Gluteus maximus| Posterior border of ilium, dorsal aspect of sacrum and coccyx, and sacrotuberous ligament| Iliotibial tract of fascia lata and gluteal tuberosity of femur| Inferior gluteal nerve (L5, S1, S1)| Extension, external rotation, and some abduction of the hip joint
Piriformis| Anterior aspect of sacrum and sacrotuberous ligament| Superior greater trochanter of femur| Ventral rami of S1, S2| External rotation of extended hip, abduction of flexed hip
Multifidi| Sacrum, ilium, transverse processes of T1-T3, articular processes of C4-C7| Spinous processes of vertebrae two to four segments above origin| Dorsal rami of spinal nerves| Stabilizes vertebrae
Longissimus| Iliac crest, posterior sacrum, spinous processes of sacrum and inferior lumbar vertebrae, supraspinous ligament| Transverse processes of lumbar vertebrae| Dorsal rami of spinal nerves| Bilaterally extends vertebral column Unilaterally side-bends spinal column
Iliocostalis| Inferior surface of ribs 4-12

### Nerves

Nerve| Segmental Level| Sensory| Motor
---|---|---|---
Superior gluteal| L4, L5, S1| No sensory| Tensor fasciae latae, gluteus medius, gluteus minimus
Inferior gluteal| L5, S1, S2| No sensory| Gluteus maximus
Nerve to piriformis| S1, S2| No sensory| Piriformis
Sciatic| L4, L5, S1, S2, S3| Hip joint| Knee flexors and all muscles of leg and foot
Nerve to quadratus femoris| L5, S1, S2| No sensory| Quadratus femoris, inferior gemellus
Nerve to obturator internus| L5, S1, S2| No sensory| Obturator internus, superior gemellus
Posterior cutaneous| S2, S3| Posterior thigh| No motor
Perforating cutaneous| S2, S3| Inferior gluteal region| No motor
Pudendal| S2, S3, S4| Genitals| Perineal muscles, external urethral sphincter, external anal sphincter
Nerve to levator ani| S3, S4| No sensory| Levator ani
Perineal branch| S1, S2, S3| Genitals| No motor
Anococcygeal| S4, S5, C0| Skin in the coccygeal region| No motor
Coccygeal| S3, S4| No sensory| Coccygeus
Pelvic splanchnic| S2, S3, S4| No sensory| Pelvic viscera

Figure 5-8 Sacroiliac region nerves.

## Patient History

### Sacroiliac Pain and Sacroiliac Dysfunction

There has been considerable controversy surrounding the contribution of the sacroiliac joint in low back pain syndromes. Recent research suggests that the sacroiliac joint can be a contributor to low back pain and disability and can certainly be a primary source of pain.2-7 The concept of "sacroiliac joint dysfunction" is distinct from "sacroiliac joint pain" and is hypothetical at best.3 Sacroiliac joint dysfunction is usually defined as altered joint mobility and/or malalignment,8-10 neither of which have been consistently linked to low back or sacroiliac joint pain.

Figure 5-9 Common cause of sacroiliac injury. Falling and landing on the buttock.

### Pain Location and Aggravating Factors

Dreyfuss and colleagues2 performed a prospective study to determine the diagnostic utility of both the history and physical examination in determining pain of sacroiliac origin. The diagnostic properties for the aggravating and easing factors and patient-reported location of pain are below.

Question and Study Quality| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Pain relieved by standing?2  | 85 consecutive patients with low back pain referred for sacroiliac joint blocks| 90% pain relief with injection of local anesthetics into sacroiliac joint| .07| .98| 3.5| .95
Pain relieved by walking?2  | .13| .77| .57| 1.13
Pain relieved by sitting?2  | .07| .80| .35| 1.16
Pain relieved by lying down?2  | .53| .49| 1.04| .96
Coughing/sneezing aggravates symptoms?2  | .45| .47| .85| 1.17
Bowel movements aggravate symptoms?2  | .38| .63| 1.03| .98
Wearing heels/boots aggravates symptoms?2  | .26| .56| .59| 1.32
Job activities aggravate symptoms?2  | .20| .74| .77| 1.08

Patient Report of Pain Location and Study Quality| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Sacroiliac joint pain2  | 85 consecutive patients with low back pain referred for sacroiliac joint blocks| 90% pain relief with injection of local anesthetics into sacroiliac joint| .82*| .12*| .93| 1.50
Groin pain2  | .26*| .63*| .70| 1.17
Buttock pain2  | .78*| .18*| .95| 1.22
Points to posterior superior iliac spine (PSIS) as main area of pain2  | .71*| .47*| 1.34| .62

*Mean of chiropractor and physician sensitivity and specificity scores.

### Sacroiliac Joint Pain Referral Patterns

Figure 5-10 Jung and associates11 determined the most common pain distribution patterns in patients with sacroiliac joint pain. They then prospectively tested the ability of the pain distribution patterns to diagnose the response to sacroiliac joint radiofrequency neurotomies in 160 patients with presumed sacroiliac joint pain. The pain distribution patterns with the best diagnostic utility are depicted, with colors representing pain intensity (scale, 1-5). Left, red = 4; right, blue = 5, purple = 4. (From Jung JH, Kim HI, Shin DA, et al. Usefulness of pain distribution pattern assessment in decision-making for the patients with lumbar zygapophyseal and sacroiliac joint arthropathy. J Korean Med Sci. 2007;22:1048-1054.)

Figure 5-11 In a study similar to the one in Fig. 5-10, van der Wurff and colleagues12 compared pain distribution maps compiled from patients who responded to double-block sacroiliac joint injections with maps from patients who did not respond. The researchers found no differences in the locations of pain distribution but did find differences in the pain intensity locations. Patients with sacroiliac joint pain reported the highest-intensity pain overlying the sacroiliac joint, as depicted, with colors representing pain intensity (scale, 1-5). Left, pink = 5, purple = 4, green = 3, orange = 2, red = 1; right, blue = 2, purple = 1. (From van der Wurff P, Buijs EJ, Groen GJ. Intensity mapping of pain referral areas in sacroiliac joint pain patients. J Manipulative Physiol Ther. 2006;29:190-195.)

## Physical Examination Tests

### Palpation

#### Pain Provocation and Patient Identification of Location of Pain

Measurement and Study Quality| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Sacral sulcus tenderness only2  | 85 consecutive patients with low back pain referred for sacroiliac joint blocks| 90% pain relief with injection of local anesthetics into sacroiliac joint| .89*| .14| 1.03*| .79*
Sacral sulcus tenderness
+
Patient points to the PSIS as the main site of pain2  | .63*| .50*| 1.26*| .74*
Sacral sulcus tenderness
+
Groin pain2  | .25*| .68*| .78*| 1.10*
Patient points to PSIS as main site of pain
+
Patient complains of groin pain2  | .16| .85| 1.07| .99
Sacral sulcus tenderness
+
Patient identifies PSIS as main site of pain
+
Groin pain2  | .13| .86| .93| 1.01

*Mean of chiropractor and physician sensitivity and specificity scores.

#### Assessment of Symmetry of Bony Landmarks

Landmark and Study Quality| Description and Positive Findings| Population| Reliability*
---|---|---|---
Sitting PSIS13  | With patient sitting, examiner palpates right and left PSISs. Positive if one PSIS is higher than the other| 62 women who were recruited from obstetrics; 42 were pregnant and had pelvic girdle pain and 20 were not pregnant and were asymptomatic| Interexaminer κ = .26
Sitting PSIS9  | 65 patients with low back pain| Interexaminer κ = .37
Sitting PSIS1  | 71 patients with low back pain| Interexaminer κ = .23
Standing PSIS1  | Same as above with patient standing| Interexaminer κ = .13
Iliac crest symmetry1  | With patient standing, examiner palpates right and left iliac crests. Positive if one crest is higher than the other| Interexaminer κ = .23
Prone PSIS14  | With patient prone and examiner's fingers or thumbs on landmark and dominant eye over the patient's midsagittal plane, examiner determines if the landmarks are:

• Right higher than left

• Left higher than right

• Equal right to left

| 10 asymptomatic female volunteers| Intraexaminer κ = .33
Interexaminer κ = .04
Sacral inferior lateral angle14  | Intraexaminer κ = .69
Interexaminer κ = .08
Sacral sulcus14  | As above, determining if the landmarks are:

• Right deeper than left

• Left deeper than right

• Equal right to left

| 25 patients with low back or sacroiliac pain| Intraexaminer κ = .24
Interexaminer κ = .07
Sacral sulcus15  | Interexaminer κ = .11 (−.14, .36)
Sacral inferior lateral angle15  | As above, determining if the landmarks are:

• Right more posterior than left

• Left more posterior than right

• Equal right to left

| Interexaminer κ = .11 (−.12, .34)
Interexaminer κ = .17 (−.03, .37)
L5 transverse process15
Medial malleoli15  | As above, determining if the landmarks are:

• Right more superior than left

• Left more superior than right

• Equal right to left

| Interexaminer κ = .28 (−.01, .57)
Medial malleoli16  | 24 patients with low back pain| Interexaminer κ = .21
Anterior superior iliac spine (ASIS)16  | With patient supine, evaluator palpates inferior slope of ASIS. Recorded as above| Interexaminer κ = .15
Sacral base16  | With patient sitting, evaluator palpates the sacral base with the patient's trunk flexed and extended. Recorded as symmetric, left-base anterior or posterior, or right-base anterior or posterior| Interexaminer κ = [Trunk flexion] .37
[Trunk extension] .05

*Potter and Rothstein17 also studied static palpation, but their study was excluded because they only reported the percentage of agreement.

Figure 5-12 Assessment of iliac crest symmetry in standing.

### Pain Provocation

#### Patrick Test (FABER Test)

Figure 5-13 Patrick test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Patrick test18  | With patient supine, examiner brings ipsilateral knee into flexion with lateral malleolus placed over the contralateral knee, fixates the contralateral ASIS, and applies a light pressure over the ipsilateral knee. Positive if familiar pain is increased or reproduced| 15 patients with ankylosing spondylitis, 30 women with postpartum pelvic pain, and 16 asymptomatic subjects| Interexaminer κ = [Right] .60 (.39, .81) [Left] .48 (.27, .69)
Patrick test19  | 25 patients with asymmetric low back pain| Intraexaminer* κ = [Right] .41 (.07, .78)
[Left] .40 (.03, .78)
Interexaminer κ = [Right] .44 (.06, .83)
[Left] .49 (.09, .89)
Patrick test20  | 40 patients with chronic low back pain| Interexaminer κ = [Right] .60 (.35, .85)
[Left] .43 (.15, .71)
Patrick test1  | 71 patients with low back pain| Interexaminer κ = .60
Patrick test21  | 59 patients with low back pain| Interexaminer κ = .61 (.31, −.91)
Patrick test2  | See diagnostic table| Interexaminer κ = .62

*Intraexaminer reliability reported for examiner #1 only.

Test* and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Patrick test20  | With patient supine, examiner brings ipsilateral knee into flexion with lateral malleolus placed over the contralateral knee, fixates the contralateral ASIS, applying a light pressure over the ipsilateral knee. Positive if familiar pain is increased or reproduced| 40 patients with chronic low back pain| Sacroiliitis apparent on magnetic resonance imaging (MRI)| Right side
.66 (.30, .90)| .51 (.33, .69)| 1.37 (.76, 2.48)| .64 (.24, 1.72)
Left side
.54 (.24, .81)| .62 (.42, .78)| 1.43 (.70, 2.93)| .73 (.36, 1.45)
Patrick test2  | 85 consecutive patients with low back pain referred for sacroiliac joint blocks| 90% pain relief with injection of local anesthetics into sacroiliac joint| .68†| .29†| .96†| 1.1†

*Broadhurst and Bond22 also investigated this test, but the study was excluded because results for all participants were positive on the test (making sensitivity = 1 and specificity = 0).

†Mean of chiropractor and physician sensitivity and specificity scores.

#### Thigh Thrust (or Posterior Shear Test or Posterior Pelvic Provocation Test)

Figure 5-14 Thigh thrust test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Thigh thrust20  | Patient supine with hip flexed to 90 degrees. The examiner applies posteriorly directed force through the femur. Positive if familiar pain is increased or reproduced| See diagnostic table| Interexaminer κ = [Right] .46 (.15, .76)
Thigh thrust18  | 15 patients with ankylosing spondylitis, 30 women with postpartum pelvic pain, and 16 asymptomatic subjects| Interexaminer κ = [Right] .76 (.48, .86)
[Left] .74 (.57, .91)
Thigh thrust19  | Patient supine with hip flexed to 90 degrees and slightly adducted. One of the examiner's hands cups the sacrum and the other applies posteriorly directed force through the femur. Positive test is the production or increase of familiar symptoms| 25 patients with asymmetric low back pain| Intraexaminer* κ = [Right] .44 (.06, .83)
[Left] .40 (.00, .82)
Interexaminer κ = [Right] .60 (.24, .96)
[Left] .40 (.00, .82)
Thigh thrust1  | 71 patients with low back pain| Interexaminer κ = .70
Thigh thrust23  | 51 patients with low back pain| Interexaminer κ = .88
Thigh thrust21  | 59 patients with low back pain| Interexaminer κ = .67 (.46, .88)
Thigh thrust2  | See diagnostic table| Interexaminer κ = .64

*Intraexaminer reliability reported for examiner #1 only.

Test* and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Thigh thrust20  | With patient supine with hip flexed to 90 degrees, examiner applies posteriorly directed force through the femur. Positive if familiar pain is increased or reproduced| 40 patients with chronic low back pain| Sacroiliitis apparent on MRI| Right side
.55 (.22, .84)| .70 (.51, .85)| 1.91 (.85, 4.27)| .62 (.29, 1.33)
Left side
.45 (.18, .75)| .86 (.67, .95)| 3.29 (1.07, 10.06)| .63 (.36, 1.09)
Thigh thrust4  | With patient supine with hip flexed to 90 degrees and slightly adducted, one of the examiner's hands cups the sacrum and the other applies posteriorly directed force through the femur. Positive if familiar symptoms are produced or increased| 48 patients with chronic lumbopelvic pain referred for sacroiliac joint injection| 80% pain relief with injection of local anesthetics into sacroiliac joint| .88 (.64, .97)| .69 (NR, .82)| 2.8 (1.66, 4.98)| .18 (.05, 1.09)
Thigh thrust2  | 85 consecutive patients with low back pain referred for sacroiliac joint blocks| 90% pain relief with injection of local anesthetics into sacroiliac joint| .39†| .50†| .78†| 1.22†
Thigh thrust24  | 60 patients with chronic low back pain referred to pain clinic| 50% pain relief with injection of local anesthetics into sacroiliac joint| .93 (.76, .99)| .64 (.45, .80)| 2.58| .11
Pooled estimate of 2 studies4,24 from 2009 Systematic Review25  | Same as above| Pooled from two studies4,33 above| Pooled from two studies4,33 above| .91 (.78, .97)| .66 (.53, .77)| 2.68| .14
Thigh thrust26  | Participants in supine position with 90 degrees of flexion in the hip and knee on the side being tested. The examiner stabilized the contralateral side of the pelvis over the ASIS and applied a light manual pressure to the participant's flexed knee along the longitudinal axis of the femur. The test was positive when the patient felt a familiar well-localized pain deep in the gluteal area on the provoked side.| 110 participants (57 with pelvic girdle pain and 53 with disc herniations determined by computed tomography [CT])| Participants with pelvic girdle pain determined by characteristics included in the European guidelines for pelvic girdle pain, along with pain markings in the posterior pelvic area on a pain drawing. Participants with disc herniations determined by computed tomography.| .88‡| .89‡| 8.00‡| .13‡

*Broadhurst and Bond22 also investigated this test, but the study was excluded because results for all participants were positive on the test (making sensitivity = 1 and specificity = 0).

†Mean of chiropractor and physician sensitivity and specificity scores.

‡This study shows that the posterior pelvic pain provocation test is negative in patients with a well-defined lumbar diagnosis.

NR = not reported.

#### Compression Test

Figure 5-15 Compression test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Compression test18  | With patient side-lying, affected side up, with hips flexed approximately 45 degrees and knees flexed approximately 90 degrees, examiner applies a force vertically downward on the anterior superior iliac crest. Positive test is the production or increase of familiar symptoms| 15 patients with ankylosing spondylitis, 30 women with postpartum pelvic pain, and 16 asymptomatic subjects| Interexaminer κ = [Right] .48 (.18, .78)
[Left] .67 (.43, .91)
Compression test20  | 40 patients with chronic low back pain| Interexaminer κ = [Right] .48 (.14, .81)
[Left] .44 (.08, .79)
Compression test23  | 51 patients with low back pain| Interexaminer κ = .73
Compression test21  | 59 patients with low back pain| Interexaminer κ = .57 (.21, .93)
Compression test1  | 71 patients with low back pain| Interexaminer κ = .26

Test* and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Compression test20  | With patient side-lying, affected side up, with hips flexed approximately 45 degrees and knees flexed approximately 90 degrees, examiner applies a force vertically downward on the anterior superior iliac crest. Positive test is the production or increase of familiar symptoms| 40 patients with chronic low back pain| Sacroiliitis apparent on MRI| Right side
.22 (.03, .59)| .83 (.65, .93)| 1.37 (.31, 5.94)| .92 (.64, 1.33)
Left side
.27 (.07, .60)| .93 (.75, .98)| 3.95 (.76, 20.57)| .78 (.54, 1.12)
Compression test4  | 48 patients with chronic lumbopelvic pain referred for sacroiliac joint injection| 80% pain relief with injection of local anesthetics into sacroiliac joint| .69 (.44, .86)| .69 (.51, NR)| 2.20 (1.18, 4.09)| .46 (.20, .87)
Compression test24  | 60 patients with chronic low back pain referred to pain clinic| 50% pain relief with injection of local anesthetics into sacroiliac joint| .60 (.39, .78)| .70 (.51, .84)| 2.00| .57
Pooled estimate of two studies4,24 from 2009 Systematic Review25  | Same as above| Pooled from two studies4,33 above| Pooled from two studies4,33 above| .63 (.47, .77)| .63 (.57, .80)| 1.70| .59

*Russel and associates27 and Blower and Griffin28 also investigated this test, but their study was excluded due to poor study quality.

#### Sacral Thrust Test

Figure 5-16 Sacral thrust test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Sacral thrust test20  | With patient prone, examiner applies a force vertically downward to the center of the sacrum. Positive test is the production or increase of familiar symptoms| 40 patients with chronic low back pain| Interexaminer κ = [Right] .87 (.70, 1.0)
[Left] .69 (.40, .97)
Sacral thrust test6  | 71 patients with low back pain| Interexaminer κ = .41
Sacral thrust test23  | 51 patients with low back pain| Interexaminer κ = .56
Sacral thrust test2  | 85 patients with low back pain referred for sacroiliac joint blocks| Interexaminer κ = .30

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Sacral thrust test20  | With patient prone, examiner applies a force vertically downward to the center of the sacrum. Positive test is the production or increase of familiar symptoms| 40 patients with chronic low back pain| Sacroiliitis apparent on MRI| Right side
.33 (.09, .69)| .74 (.55, .87)| 1.29 (.42, 3.88)| .89 (.55, 1.45)
Left side
.45 (.18, .75)| .89 (.71, .97)| 4.39 (1.25, 15.36)| .60 (.35, 1.05)
Sacral thrust test4  | 48 patients with chronic lumbopelvic pain referred for sacroiliac joint injection| 80% pain relief with injection of local anesthetics into sacroiliac joint| .63 (.39, .82)| .75 (.58, .87)| 2.5 (1.23, 5.09)| .50 (.24, .87)
Sacral thrust test2  | 85 consecutive patients with low back pain referred for sacroiliac joint blocks| 90% pain relief with injection of local anesthetics into sacroiliac joint| .52*| .38*| .84*| 1.26*

*Mean of chiropractor and physician sensitivity and specificity scores.

#### Gaenslen Test

Figure 5-17 Gaenslen test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Gaenslen test20   (see Video 5-1)| With patient supine near the edge of the table and one leg hanging over the edge of the table and the other flexed toward the patient's chest, examiner applies firm pressure to both the hanging leg and the leg flexed toward the chest. Positive test is the production or increase of familiar symptoms| 40 patients with chronic low back pain| Interexaminer κ = [Right] .37 (.05, .68)
[Left] .28 (0.0, .60)
Gaenslen test1  | 71 patients referred to physical therapy with a diagnosis related to the lumbosacral spine| Interexaminer κ = .54
Gaenslen test23  | 51 patients with low back pain with or without radiation into the lower limb| Interexaminer κ = .76
Gaenslen test21  | 59 patients with low back pain| Interexaminer κ = .60 (.33, .88)

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Gaenslen test20  | With patient supine near the edge of the table and one leg hanging over the edge of the table and the other flexed toward the patient's chest, examiner applies firm pressure to both the hanging leg and the leg flexed toward the chest. Positive test is the production or increase of familiar symptoms| 40 patients with chronic low back pain| Sacroiliitis apparent on MRI| Right side
.44 (.15, .77)| .80 (.61, .91)| 2.29 (.82, 6.39)| .68 (.37, 1.25)
Left side
.36 (.12, .68)| .75 (.56, .88)| 1.5 (.54, 4.15)| .83 (.52, 1.33)
Gaenslen test4  | 48 patients with chronic lumbopelvic pain referred for sacroiliac joint injection| 80% pain relief with injection of local anesthetics into sacroiliac joint| Right side
.53 (.30, .75)| .71 (.53, .84)| 1.84 (.87, 3.74)| .66 (.34, 1.09)
Left side
.50 (.27, .73)| .77 (.60, .89)| 2.21 (.95, 5.0)| .65 (.34, 1.03)
Gaenslen test2  | 85 consecutive patients with low back pain referred for sacroiliac joint blocks| 90% pain relief with injection of local anesthetics into sacroiliac joint| .68*| .29*| .96*| 1.1*

*Mean of chiropractor and physician sensitivity and specificity scores.

#### Distraction Test

Figure 5-18 Distraction test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Distraction test20  | With patient supine, examiner applies cross-arm pressure to both anterior superior iliac spines (ASISs). Positive test is the production or increase of familiar symptoms| 40 patients with chronic low back pain| Interexaminer κ = .50
Distraction test23  | With patient supine, examiner applies a posteriorly directed force to both ASISs. Positive test is the production or increase of familiar symptoms| 51 patients with low back pain, with or without radiation into the lower limb| Interexaminer κ = .69
Distraction test21  | 59 patients with low back pain| Interexaminer κ = .45 (.10, .78)
Distraction test1  | 71 patients referred to physical therapy with a diagnosis related to the lumbosacral spine| Interexaminer κ = .26

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Distraction test20  | With patient supine, examiner applies cross-arm pressure to both ASISs. Positive test is the production or increase of familiar symptoms| 40 patients with chronic low back pain| Sacroiliitis apparent on MRI| .23 (.06, .54)| .81 (.61, .92)| 1.24 (.35, 4.4)| .94 (.68, 1.29)
Distraction test4  | With patient supine, examiner applies a posteriorly directed force to both ASISs. Positive test is the production or increase of familiar symptoms| 48 patients with chronic lumbopelvic pain referred for sacroiliac joint injection| 80% pain relief with injection of local anesthetics into sacroiliac joint| .60 (.36, .80)| .81 (.65, .91)| 3.20 (1.42, 7.31)| .49 (.24, .83)

#### Mennell Test

Figure 5-19 Mennell test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Mennell test20  | With patient side-lying, affected side down, with hip and knee on affected side flexed toward the abdomen, examiner puts one hand over the ipsilateral buttock and iliac crest and with the other hand grasps the semiflexed ipsilateral knee and lightly forces the leg into extension. Positive test is the production or increase of familiar symptoms| 40 patients with chronic low back pain| Interexaminer κ = [Right] .54 (.26, .82)
[Left] .50 (.20, .80)

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Mennell test20  | As above| 40 patients with chronic low back pain| Sacroiliitis apparent on MRI| Right side
.66 (.30, .90)| .80 (.61, .91)| 3.44 (1.49, 8.09)| .41 (.16, 1.05)
Left side
.45 (.18, .75)| .86 (.67, .95)| 3.29 (1.07, 10.06)| .63 (.36, 1.09)

#### Other Pain Provocation Tests

Figure 5-20 Resisted abduction of the hip.

Test* and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Resisted abduction test19  | With patient supine with legs extended and abducted 30 degrees, examiner holds the ankle and pushes medially while the patient pushes laterally. Positive test is the production or increase of familiar symptoms| 25 patients with asymmetric low back pain| Intraexaminer† κ = [Right] .48 (.07, .88)
[Left] .50 (.06, .95)
Interexaminer κ = [Right] .78 (.49, 1.07)
[Left] .50 (−.02, 1.03)
Resisted abduction test1  | 71 patients with low back pain| Interexaminer κ = .41
Internal rotation of the hip18  | With patient prone, examiner maximally internally rotates one or both femurs. Positive test is the production or increase of familiar symptoms| 15 patients with ankylosing spondylitis, 30 women with postpartum pelvic pain, and 16 asymptomatic subjects| Interexaminer κ = [Right] .78 (.60, .94)
[Left] .88 (.75, 1.01)
[Bilateral] .56 (.33, .79)
Drop test18  | With patient standing on one foot, patient lifts the heel from the floor and drops down on the heel again. Positive test is the production or increase of familiar symptoms| Interexaminer κ = [Right] .84 (.61, 1.06)
[Left] .47 (.11, .83)

*Broadhurst and Bond22 investigated the diagnostic properties of the resisted abduction test, but the study was excluded because all participants were positive on the test (making sensitivity = 1 and specificity = 0).

†Intraexaminer reliability reported for examiner #1 only.

Figure 5-21 PSIS distraction test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
PSIS distraction test29   (see Video 5-2)| The examiner applies a distraction force with thumbs on each PSIS in a medial-to-lateral direction with the patient either standing or lying prone. Positive test is the reproduction of patient's symptoms| 46 patients with 61 symptomatic sacroiliac joints| 50% pain relief with injection of local anesthetics into sacroiliac joint| 1.00| .89| 9.10| 0.00

### Motion Assessment

#### Gillet Test (Stork Test)

Test* and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Gillet test30  | With patient standing, examiner palpates the following landmarks:

• L5 spinous process and PSIS

• S1 tubercle and PSIS

• S3 tubercle and PSIS

• Sacral apex and posteromedial margin of the ischium

Patient is instructed to raise the ipsilateral leg of the side of palpation. Positive if the lateral landmark fails to move posteroinferiorly with respect to medial landmark| 54 asymptomatic college students| Intraexaminer mean value for all tests κ = .31
Interexaminer mean value for all tests κ = .02
Gillet test31  | As above except using the following landmarks:

• L5 spinous process and PSIS

• S1 spinous process and PSIS

• S3 spinous process and PSIS

• Sacral hiatus and caudolateral just below the ischial spine

| 38 male students; 9 during the first testing procedure and 12 during the second had low back pain| Intraexaminer† κ = .08 (.01, .14)
Interexaminer κ = −.05 (−.06, −.12)
Gillet test19  | With patient standing, examiner palpates the PSIS and asks patient to flex the hip and knee on the side being tested. Positive if the PSIS fails to move posteroinferiorly| 25 patients with asymmetric low back pain| Intraexaminer† κ = [Right] .42 (−.01, .87)
[Left] .49 (.09, .89)
Interexaminer κ = [Right] .41 (.03, .87)
[Left] .34 (−.06, .70)
Gillet test32  | With patient standing, examiner palpates the S2 spinous process with one thumb and the PSIS with the other and asks patient to flex the hip and knee on the side being tested. Rated intrapelvic motion as "cephalad," "neutral," or "caudad"| 33 volunteers; 15 had pelvic girdle pain| Interexaminer κ = [Right] .59
[Left] .59
Gillet test16  | With patient standing, examiner palpates the S2 spinous process with one thumb and the PSIS with the other and asks patient to flex the hip and knee on the side being tested. Positive if the PSIS fails to move posteroinferiorly with respect to S2| 24 patients with low back pain| Interexaminer κ = .27
Gillet test2  | See diagnostic table| Interexaminer κ = .22
Gillet test6  | 71 patients with low back pain| Interexaminer κ = .59

*Potter and Rothstein17 and Herzog and colleagues33 also studied this test, but their studies were excluded because they only reported the percentage of agreement.

†Intraexaminer reliability reported for examiner #1 only.

Figure 5-22 Gillet test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Gillet test2  | With patient standing with feet spread 12 inches apart, examiner palpates the S2 spinous process with one thumb and the PSIS with the other. The patient then flexes the hip and knee on the side being tested. The test is considered positive if the PSIS fails to move in a posteroinferior direction relative to S2| 85 consecutive patients with low back pain referred for sacroiliac joint blocks| 90% pain relief with injection of local anesthetics into sacroiliac joint| .47*| .64*| 1.31*| .83*
Gillet test34  | 274 patients being treated for low back pain or another condition not related to the low back| Innominate torsion calculated by measured differences in pelvic landmarks| .08| .93| 1.14| .99

*Mean of chiropractor and physician sensitivity and specificity scores.

#### Spring Test (Joint Play Assessment)

Figure 5-23 Spring test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Spring test18  | With patient prone, examiner uses one hand to lift the ilium while using the other hand to stabilize the sacrum and palpate the movement between the sacrum and ilium with the index finger. The test is positive if motion is different between the two sides.| 15 patients with ankylosing spondylitis, 30 women with postpartum pelvic pain, and 16 asymptomatic subjects| Interexaminer κ = −.06

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Spring test2  | Therapist's hands are placed over the superior sacrum, and a posteroanterior thrust is applied while the therapist monitors the spring at the end range of motion. The asymptomatic side is compared with the symptomatic side| 85 consecutive patients with low back pain referred for sacroiliac joint blocks| 90% pain relief with injection of local anesthetics into sacroiliac joint| .66*| .42*| 1.14*| .81*

*Mean of chiropractor and physician sensitivity and specificity scores.

#### Long-Sit Test (Supine-to-Sit Test)

Figure 5-24 Long-sit test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Long-sit test1  | With patient supine, the lengths of the medial malleoli are compared. Patient is asked to long-sit, and the lengths of the medial malleoli are again compared. Positive if one leg appears shorter when patient is supine and then lengthens when the patient comes into the long-sitting position| 71 patients with low back pain| Interexaminer κ = .21
Long-sit test9  | 65 patients with low back pain| Interexaminer κ = .19

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Long-sit test34  | With patient supine, the lengths of the medial malleoli are compared. Patient is asked to long-sit, and the lengths of the medial malleoli are again compared. Positive if one leg appears shorter when patient is supine and then lengthens when the patient comes into the long-sitting position| 274 patients being treated for low back pain or another condition not related to the low back| Innominate torsion calculated by measured differences in pelvic landmarks| .44| .64| 1.22| .88

#### Standing Flexion Test

Figure 5-25 Standing flexion test.

Test* and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Standing flexion test19  | With patient standing, examiner palpates inferior slope of PSIS. Patient is asked to forward bend completely. Positive for sacroiliac hypomobility if one PSIS moves more cranially than the PSIS on the contralateral side| 25 patients with asymmetric low back pain| Intraexaminer† κ = [Right] .68 (.35, 1.01)
[Left] .61 (.27, .96)
Interexaminer κ = [Right] .51 (.08, .95)
[Left] .55 (.20, .90)
Standing flexion test16  | 24 patients with low back pain| Interexaminer κ = .06
Standing flexion test9  | 65 patients currently receiving treatment for low back pain| Interexaminer κ = .32
Standing flexion test35  | 14 asymptomatic graduate students| Interexaminer κ = .52
Standing flexion test,10,36  | 480 male construction workers; 50 had low back pain the day of the examination; 236 reported experiencing low back pain within the past 12 months| Interexaminer κ values ranged from .31 to .67
Standing flexion test1  | 71 patients with low back pain| Interexaminer κ = .08

*Potter and Rothstein17 also studied this test, but their study was excluded because they only reported the percentage of agreement.

†Intraexaminer reliability reported for examiner #1 only.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Standing flexion test34  | With patient standing, examiner palpates inferior slope of PSIS. Patient is asked to forward bend completely. Positive for sacroiliac hypomobility if one PSIS moves more cranially than the PSIS on the contralateral side| 274 patients being treated for low back pain or another condition not related to the low back| Innominate torsion calculated by measured differences in pelvic landmarks| .17| .79| .81| 1.05

#### Sitting Flexion Test

Figure 5-26 Sitting flexion test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Sitting flexion test19  | With patient sitting, examiner palpates inferior slope of PSIS. Patient is asked to forward bend completely. Positive for sacroiliac hypomobility if one PSIS moves more cranially than the PSIS on the contralateral side| 25 patients with asymmetric low back pain| Intraexaminer* κ = [Right] .73 (.45, 1.01)
[Left] .65 (.34, .96)
Interexaminer κ = [Right] .75 (.42, 1.08)
[Left] .64 (.32, .96)
Sitting flexion test1  | 71 patients with low back pain| Interexaminer κ = .21
Sitting flexion test16  | 24 patients with low back pain| Interexaminer κ = .06

*Intraexaminer reliability reported for examiner #1 only.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Sitting flexion test34  | With patient seated, examiner palpates inferior aspect of each PSIS. Positive for sacroiliac joint dysfunction if inequality of the PSISs is found| 274 patients being treated for low back pain or another condition not related to the low back| Innominate torsion calculated by measured differences in pelvic landmarks| .09| .93| 1.29| .98

#### Prone Knee Bend Test

Figure 5-27 Prone knee bend test.

Test* and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Prone knee bend test19  | With patient prone, examiner, looking at heels, assesses leg lengths. Knees are passively flexed to 90 degrees and leg lengths are again assessed. Considered positive if a change in leg lengths occurs between positions| 25 patients with asymmetric low back pain| Intraexaminer† κ = [Right] .41 (.07, .78)
[Left] .27 (−.22, .78)
Interexaminer κ = [Right] .58 (.25, .91)
[Left] .33 (−.18, .85)
Prone knee bend test1  | 71 patients with low back pain| Interexaminer κ = .21
Prone knee bend test9  | 65 patients with low back pain| Interexaminer κ = .26

*Potter and Rothstein17 also studied this test, but their study was excluded because they only reported the percentage of agreement.

†Intraexaminer reliability reported for examiner #1 only.

#### Other Motion Assessment Tests

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Click-clack test13  | With patient sitting and examiner's thumbs on caudal PSIS, the patient rocks the pelvis forward and backward. Test is positive if one PSIS moves more slowly from cranial to caudal than the other| 62 women recruited from obstetrics: 42 were pregnant and had pelvic girdle pain and 20 were not pregnant and were asymptomatic| Interexaminer κ = .03
Heel-bank test13  | With patient sitting and examiner's thumbs on caudal PSIS, the patient raises one leg at a time and places the heel on the bench without using hands. Considered positive if the test required any effort| Interexaminer κ = [Right] .32 [Left] .16
Abduction test13  | With patient side-lying with hips flexed 70 degrees and knees flexed 90 degrees, the patient is asked to lift the top leg about 20 cm. Considered positive if the test required any effort| Interexaminer κ = [Right] .61 [Left] .41

### Combinations of Tests

#### Pregnancy-Related Pelvic Girdle Pain Classification37

Inclusion Criteria| Classification Subgroup
---|---
All four of the following criteria must be met for subjects to be evaluated for classification:

• Currently pregnant or recently pregnant (within 2 years)

• Daily pain at the time of the examination (week 33 of gestation or beyond)

• The ability to point out the exact area of one or more of the pelvic girdle joints as the painful area

• Pain during one or more of the five selected clinical tests: active straight-leg raise test, compression test, distraction test, Gaenslen test, thigh thrust test

| Pelvic girdle syndrome: Daily pain in all three pelvic joints confirmed by objective findings.
Symphysiolysis: Daily pain in the pubic symphysis confirmed by objective findings.
One-sided sacroiliac syndrome: Daily pain from one sacroiliac joint alone, confirmed by objective findings.
Double-sided sacroiliac syndrome: Daily pain from both sacroiliac joints, confirmed by objective findings.
Miscellaneous: Daily pain from one or more pelvic joints but inconsistent objective findings from the pelvic joints.

#### Reliability of Pregnancy-Related Pelvic Girdle Pain Classification

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Pregnancy-related pelvic girdle pain classification37  | As described in the pregnancy-related pelvic girdle pain classification above| 13 female patients with pelvic girdle pain| Interexaminer κ = .78 (.64, .92)

#### Sacroiliac Joint Pain

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Mennell test
+
Gaenslen test
+
Thigh thrust20  | Procedures all previously described in this chapter.
At least two of three tests need to be positive to indicate sacroiliitis| 40 patients with chronic low back pain| Sacroiliitis apparent on MRI| Right side
.55 (.22, .84)| .83 (.65, .93)| 3.44 (1.27, 9.29)| .52 (.25, 1.11)
Left side
.45 (.18, .75)| .86 (.67, .95)| 3.29 (1.07, 10.0)| .63 (.36, 1.09)
Distraction test
+
Thigh thrust
+
Gaenslen test
+
Patrick sign
+
Compression test24  | Procedures all previously described in this chapter.
At least three of five tests need to be positive to indicate sacroiliac joint pain| 60 patients with chronic low back pain referred to pain clinic| 50% pain relief with injection of local anesthetics into sacroiliac joint| .85 (.72, .99)| .79 (.65, .93)| 4.02 (2.04, 7.89)| .19 (.07, .47)
Distraction test
+
Thigh thrust
+
Sacral thrust
+
Compression test4  | Procedures all previously described in this chapter.
At least two of four tests need to be positive to indicate sacroiliac joint pain| 48 patients with chronic lumbopelvic pain referred for sacroiliac joint injection| 80% pain relief with injection of local anesthetics into sacroiliac joint| .88 (.64, .97)| .78 (.61, .89)| 4.0 (2.13, 8.08)| .16 (.04, .47)
Distraction test
+
Thigh thrust
+
Gaenslen test
+
Sacral thrust
+
Compression test5  | Procedures all previously described in this chapter.
At least three of five tests need to be positive to indicate sacroiliac joint pain| 48 patients with chronic lumbopelvic pain referred for diagnostic spinal injection| 80% pain relief with injection of local anesthetics into sacroiliac joint| .91 (.62, –.98)| .78 (.61, .89)| 4.16 (2.16, 8.39)| .12 (.02, .49)
Distraction test
+
Thigh thrust
+
Gaenslen test
+
Sacral thrust
+
Compression test38  | Procedures all previously described in this chapter.
At least three of five tests need to be positive to indicate sacroiliac joint pain| 81 patients with chronic lumbopelvic pain referred for diagnostic spinal injection| 80% pain relief with injection of local anesthetics into sacroiliac joint| .77 (.56, .91)| .70 (.51, .85)| 2.57| .33
Pooled estimate of four studies4,5,24,38 from 2009 Systematic Review25  | Same as above| Pooled from four studies4,5,24,38 above| Pooled from four studies4,5,24,38 above| .85 (.75, .92)| .76 (.68, .84)| 3.54| .20

Figure 5-28 Nomogram representing the changes from pretest to posttest probability using the cluster of tests for detecting sacroiliac dysfunction. Considering a 33% pretest probability and a +LR of 4.16, the posttest probability that the patient presents with sacroiliac dysfunction is 67%. (Adapted with permission from Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975;293-257. Massachusetts Medical Society, 2005.)

#### Following the McKenzie Evaluation to Rule Out Discogenic Pain

Figure 5-29 (Adapted from Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975;293-257. Massachusetts Medical Society, 2005.)

Laslett and associates5 assessed the diagnostic utility of the McKenzie method of mechanical assessment combined with the following sacroiliac tests: distraction test, thigh thrust test, Gaenslen test, sacral thrust test, and compression test. The McKenzie assessment consisted of flexion in standing, extension in standing, right and left side gliding, flexion in lying, and extension in lying. The movements were repeated in sets of 10, and centralization and peripheralization were recorded. If it was determined that repeated movements resulted in centralization, the patient was considered to have pain of discogenic origin. Following the use of the McKenzie method to rule out individuals presenting with discogenic pain, in terms of diagnostic utility, the cluster of these tests exhibited a sensitivity of .91 (95% CI .62, .98), specificity .87 (95% CI .68, .96), +LR of 6.97 (95% CI 2.16, 8.39), −LR .11 (95% CI .02, .44).

### Interventions

#### Identifying Patients Likely to Benefit from Spinal Manipulation

Figure 5-30 Spinal manipulation technique used by Flynn and colleagues. The patient is passively side-bent toward the side to be manipulated (away from the therapist). The therapist then rotates the patient away from the side to be manipulated (toward the therapist) and delivers a quick thrust through the ASIS in a posteroinferior direction. (From Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835-2843.)

Flynn and colleagues1 investigated the effects of the spinal manipulation technique in a heterogeneous population of patients with low back pain. They identified a number of variables that were associated with a successful outcome following the manipulation. A logistics regression equation was used to identify a cluster of signs and symptoms leading to a clinical prediction rule that could significantly enhance the likelihood of identifying patients who would achieve a successful outcome with spinal manipulation. Five variables form the clinical prediction rule: (1) symptoms for fewer than 16 days, (2) no symptoms distal to the knee, (3) hypomobility in the lumbar spine, (4) FABQ work subscale score of less than 19, and (5) at least one hip with more than 35 degrees of internal rotation range of motion.

Childs and colleagues39 tested the validity of the clinical prediction rule when applied in a separate patient population and by a variety of clinicians with varying levels of clinical experience and practicing in different settings. Consecutive patients with low back pain were randomized to receive either spinal manipulation or a lumbar stabilization program. The results of the study demonstrated that patients who satisfied the clinical prediction rule and received spinal manipulation had significantly better outcomes than patients who did not meet the clinical prediction rule but still received spinal manipulation and the group who met the clinical prediction rule but received lumbar stabilization exercises.

To make use of the clinical prediction rule more practical in a primary care environment, Fritz and colleagues40 tested an abbreviated version consisting of only the acuity and symptom location factors. Ninety-two percent of patients with low back pain who met both criteria had successful outcomes. The results of the Childs and colleagues39 and Fritz and associates40 studies support the findings of Flynn and colleagues1 and significantly increase clinician confidence in using the clinical prediction rule in decision making regarding individual patients with low back pain.

Figure 5-31 Nomogram representing the changes from pretest to posttest likelihood that a patient with low back pain who satisfies four of five criteria for the rule will have a successful outcome following spinal manipulation. The pretest likelihood that any patient with low back pain would respond favorably to sacroiliac manipulation was determined to be 45%. However, if the patient presents with four of the five predictor variables identified by Flynn and colleagues1 (+LR 24), then the posttest probability that the patient will respond positively to spinal manipulation increases dramatically to 95%. (Adapted from Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975;293-257. Massachusetts Medical Society, 2005.)

Test and Study Quality| Description and Criteria| Population| Reference Standard| Sens| Spec| +LR
---|---|---|---|---|---|---
Symptoms for less than 16 days
+
No symptoms distal to the knee
+
Hypomobility in the lumbar spine
+
FABQ work subscale score of less than 19
+
At least one hip with more than 35 degrees of internal rotation range of motion1  | At least four of five tests needed to be positive| 71 patients with low back pain| Reduction of 50% or more in back pain−related disability within 1 week as measured by the Oswestry questionnaire| .63 (.45 to .77)| .97 (.87 to 1.0)| 24.38 (4.63 to 139.41)
Symptoms for less than 16 days
+
No symptoms distal to the knee40  | Must meet both criteria| 141 patients with low back pain| .56 (.43, .67)| .92 (.84, .96)| 7.2 (3.2, 16.1)

## Outcome Measures

Outcome Measure| Scoring and Interpretation| Test-Retest Reliability| MCID
---|---|---|---
Oswestry Disability Index (ODI)| Users are asked to rate the difficulty of performing 10 functional tasks on a scale of 0 to 5 with different descriptors for each task. A total score out of 100 is calculated by summing each score and doubling the total. The answers provide a score between 0 and 100, with higher scores representing more disability| ICC = .9141  | 1142
Modified Oswestry Disability Index (modified ODI)| As above except replaces the sex life question with an employment/homemaking question| ICC = .9043  | 643
Roland-Morris Disability Questionnaire (RMDQ)| Users are asked to answer 23 or 24 questions (depending on the version) about their back pain and related disability. The RMDQ is scored by adding up the number of items checked by the patient, with higher numbers indicating more disability| ICC = .9144  | 542
Fear-Avoidance Beliefs Questionnaire (FABQ)| Users are asked to rate their level of agreement with statements concerning beliefs about the relationship between physical activity, work, and their back pain. Level of agreement is answered on a Likert-type scale ranging from 0 (completely disagree) to 7 (completely agree). The FABQ has two parts: a seven-item work subscale (FABQW) and a four-item physical activity subscale (FABQPA). Each scale is scored separately, with higher scores representing higher levels of fear avoidance| FABQW: ICC = .82
FABQPA: ICC = .6645  | Not available
Numeric Pain Rating Scale (NPRS)| Users rate their level of pain on an 11-point scale ranging from 0 to 10, with high scores representing more pain. Often asked as current pain and least, worst, and average pain in the past 24 hours| ICCs = .7246  | 247,48

MCID, Minimum clinically important difference.

## Appendix

#### Quality Appraisal of Reliability Studies for the Sacroiliac Region Using QAREL

| Flynn 20021| Dreyfuss 19962| Maigne 19966| Riddle 20029| Toussaint 199910| Van Kessel-Cobelens 200813| O'Haire 200014| Holmgren 200815| Tong 200616| Robinson 200718
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| U| Y| Y| Y| Y| Y| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| N/A| N/A| N/A| N/A| N/A| Y| N/A| N/A| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| U| N/A| N/A| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| U| Y| U| U| U| Y

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| Y| U| Y| U| U

8. Was the order of examination varied?

| U| N| U| Y| U| Y| Y| Y| U| Y

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| U| Y| Y| Y| U| Y| Y| Y| U| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Arab 200919| Ozgocmen 200820| Kokmeyer 200221| Laslett 199423| Carmichael 198730| Meijne 199931| Hungerford 200732| Vincent-Smith 199935| Toussaint 1999 (2)36| Lauridsen 200641
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| Y| Y| Y| Y| U| Y| Y| N/A

4. Were raters blinded to their own prior findings of the test under evaluation?

| U| N/A| N/A| N/A| U| U| N/A| U| N/A| N

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| Y| Y| Y| Y| Y| Y| U| Y| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| Y| U| U

8. Was the order of examination varied?

| Y| U| Y| Y| N| N| Y| Y| U| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| U| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Fritz 200143| Brouwer 200444| Grotle 200645| Li 200746| Cook 200737| | | | |
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| | | | |

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| | | | |

3. Were raters blinded to the findings of other raters during the study?

| N/A| N/A| N/A| N/A| Y| | | | |

4. Were raters blinded to their own prior findings of the test under evaluation?

| N| N| N| N| N/A| | | | |

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| | | | |

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| Y| | | | |

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| | | | |

8. Was the order of examination varied?

| U| U| U| U| U| | | | |

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| | | | |

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| | | | |

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| | | | |
Quality Summary Rating:|  |  |  |  |  | | | | |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

#### Quality Assessment of Diagnostic Studies for the Sacroiliac Region Using QUADAS

| Russel 198127| Blower 198428| Dreyfuss 19962| Broadhurst 199822| Levangie 199934| Laslett 20035| Laslett 20054| van der Wurff 200624| Jung 200711| Ozgocmen 200820| Flynn 20021| Fritz 200540
---|---|---|---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| U| Y| Y| Y| Y| Y| Y| Y| N| Y| Y| Y

2. Were selection criteria clearly described?

| N| N| N| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| Y| Y| Y| Y| Y| U| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| U| U| Y| U| Y| Y| Y| U| Y| Y| Y

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| U| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| U| U| Y| N| Y| Y| Y| Y| Y| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| N| Y| Y| Y| Y| Y| Y| N| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| N| U| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| U| N| Y| Y| N| Y| Y| Y| U| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| U| U| N| Y| Y| Y| Y| U| U| Y| U

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| Y| U| N| N| Y| Y| N| U| N| Y| Y

13. Were uninterpretable/intermediate test results reported?

| N| U| Y| Y| Y| Y| Y| Y| N| Y| Y| Y

14. Were withdrawals from the study explained?

| U| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| U
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y - N = 10 to 14)   Fair quality (Y - N = 5 to 9)   Poor quality (Y - N ≤ 4).

| Gutke 200926| Young 200338| Werner 201329| | | | | | | | |
---|---|---|---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| Y| | | | | | | | |

2. Were selection criteria clearly described?

| Y| N| Y| | | | | | | | |

3. Is the reference standard likely to correctly classify the target condition?

| U| Y| Y| | | | | | | | |

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| Y| U| U| | | | | | | | |

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| N| N| N| | | | | | | | |

6. Did patients receive the same reference standard regardless of the index test result?

| N| N| Y| | | | | | | | |

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| | | | | | | | |

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| | | | | | | | |

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| Y| | | | | | | | |

10. Were the index test results interpreted without knowledge of the results of the reference test?

| U| Y| Y| | | | | | | | |

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| Y| U| | | | | | | | |

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| U| U| | | | | | | | |

13. Were uninterpretable/intermediate test results reported?

| Y| N| N| | | | | | | | |

14. Were withdrawals from the study explained?

| Y| U| Y| | | | | | | | |
Quality Summary Rating:|  |  |  | | | | | | | | |

Y = yes, N = no, U = unclear.   Good quality (Y - N = 10 to 14)   Fair quality (Y - N = 5 to 9)   Poor quality (Y - N ≤ 4).

## References

1. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835–2843.

2. Dreyfuss P, Michaelsen M, Pauza K, et al. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996;21:2594–2602.

3. Laslett M. Pain provocation tests for diagnosis of sacroiliac joint pain. Aust J Physiother. 2006;52:229.

4. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005;10:207–218.

5. Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother. 2003;49:89–97.

6. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine. 1996;21:1889–1892.

7. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine. 1995;20:31–37.

8. Cibulka MT, Delitto A, Koldehoff RM. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain. An experimental study. Phys Ther. 1988;68:1359–1363.

9. Riddle DL, Freburger JK. Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter intertester reliability study. Phys Ther. 2002;82:772–781.

10. Toussaint R, Gawlik CS, Rehder U, Ruther W. Sacroiliac dysfunction in construction workers. J Manipulative Physiol Ther. 1999;22:134–138.

11. Jung JH, Kim HI, Shin DA, et al. Usefulness of pain distribution pattern assessment in decision-making for the patients with lumbar zygapophyseal and sacroiliac joint arthropathy. J Korean Med Sci. 2007;22:1048–1054.

12. van der Wurff P, Buijs EJ, Groen GJ. Intensity mapping of pain referral areas in sacroiliac joint pain patients. J Manipulative Physiol Ther. 2006;29:190–195.

13. van Kessel-Cobelens AM, Verhagen AP, Mens JM, et al. Pregnancy-related pelvic girdle pain: intertester reliability of 3 tests to determine asymmetric mobility of the sacroiliac joints. J Manipulative Physiol Ther. 2008;31:130–136.

14. O'Haire C, Gibbons P. Interexaminer and intra-examiner agreement for assessing sacroiliac anatomical landmarks using palpation and observation: pilot study. Man Ther. 2000;5:13–20.

15. Holmgren U, Waling K. Inter-examiner reliability of four static palpation tests used for assessing pelvic dysfunction. Man Ther. 2008;13:50–56.

16. Tong HC, Heyman OG, Lado DA, Isser MM. Interexaminer reliability of three methods of combining test results to determine side of sacral restriction, sacral base position, and innominate bone position. J Am Osteopath Assoc. 2006;106:464–468.

17. Potter NA, Rothstein JM. Intertester reliability for selected clinical tests of the sacroiliac joint. Phys Ther. 1985;65:1671–1675.

18. Robinson HS, Brox JI, Robinson R, et al. The reliability of selected motion and pain provocation tests for the sacroiliac joint. Man Ther. 2007;12:72–79.

19. Arab AM, Abdollahi I, Joghataei MT, et al. Inter- and intra-examiner reliability of single and composites of selected motion palpation and pain provocation tests for sacroiliac joint. Man Ther. 2009;14:213–221.

20. Ozgocmen S, Bozgeyik Z, Kalcik M, Yildirim A. The value of sacroiliac pain provocation tests in early active sacroiliitis. Clin Rheumatol. 2008;10:1275–1282.

21. Kokmeyer DJ, van der Wurff P, Aufdemkampe G, Fickenscher TC. The reliability of multitest regimens with sacroiliac pain provocation tests. J Manipulative Physiol Ther. 2002;25:42–48.

22. Broadhurst NA, Bond MJ. Pain provocation tests for the assessment of sacroiliac joint dysfunction. J Spinal Disord. 1998;11:341–345.

23. Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine. 1994;19:1243–1249.

24. van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil. 2006;87:10–14.

25. Szadek KM, van der Wurff P, van Tulder MW, et al. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. J Pain. 2009;10(4):354–368.

26. Gutke A, Hansson ER, Zetherström G, Ostgaard HC. Posterior pelvic pain provocation test is negative in patients with lumbar herniated discs. Eur Spine J. 2009;18(7):1008–1012.

27. Russel AS, Maksymowych W, LeClercq S. Clinical examination of the sacroiliac joints: a prospective study. Arthritis Rheum. 1981;24:1575–1577.

28. Blower PW, Griffin AJ. Clinical sacroiliac tests in ankylosing spondylitis and other causes of low back pain—2 studies. Ann Rheum Dis. 1984;43:192–195.

29. Werner CML, Hoch A, Gautier L, et al. Distraction test of the posterior superior iliac spine (PSIS) in the diagnosis of sacroiliac joint arthropathy. BMC Surg. 2013;13:52.

30. Carmichael JP. Inter- and intra-examiner reliability of palpation for sacroiliac joint dysfunction. J Manipulative Physiol Ther. 1987;10:164–171.

31. Meijne W, van Neerbos K, Aufdemkampe G, van der Wurff P. Intraexaminer and interexaminer reliability of the Gillet test. J Manipulative Physiol Ther. 1999;22:4–9.

32. Hungerford BA, Gilleard W, Moran M, Emmerson C. Evaluation of the ability of physical therapists to palpate intrapelvic motion with the Stork test on the support side. Phys Ther. 2007;87:879–887.

33. Herzog W, Read LJ, Conway PJ, et al. Reliability of motion palpation procedures to detect sacroiliac joint fixations. J Manipulative Physiol Ther. 1989;12:86–92.

34. Levangie PK. Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Phys Ther. 1999;79:1043–1057.

35. Vincent-Smith B, Gibbons P. Inter-examiner and intra-examiner reliability of the standing flexion test. Man Ther. 1999;4:87–93.

36. Toussaint R, Gawlik CS, Rehder U, Ruther W. Sacroiliac joint diagnostics in the Hamburg Construction Workers Study. J Manipulative Physiol Ther. 1999;22:139–143.

37. Cook C, Massa L, Harm-Ernandes I, et al. Interrater reliability and diagnostic accuracy of pelvic girdle pain classification. J Manipulative Physiol Ther. 2007;30(4):252–258.

38. Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J. 2003;3:460–465.

39. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004;141:920–928.

40. Fritz JM, Childs JD, Flynn TW. Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention. BMC Fam Pract. 2005;6:29.

41. Lauridsen HH, Hartvigsen J, Manniche C, et al. Danish version of the Oswestry Disability Index for patients with low back pain. Part 1: Cross-cultural adaptation, reliability and validity in two different populations. Eur Spine J. 2006;15:1705–1716.

42. Lauridsen HH, Hartvigsen J, Manniche C, et al. Responsiveness and minimal clinically important difference for pain and disability instruments in low back pain patients. BMC Musculoskelet Disord. 2006;7:82.

43. Fritz JM, Irrgang JJ. A comparison of a Modified Oswestry Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther. 2001;81:776–788.

44. Brouwer S, Kuijer W, Dijkstra PU, et al. Reliability and stability of the Roland Morris Disability Questionnaire: intra class correlation and limits of agreement. Disabil Rehabil. 2004;26:162–165.

45. Grotle M, Brox JI, Vollestad NK. Reliability, validity and responsiveness of the fear-avoidance beliefs questionnaire: methodological aspects of the Norwegian version. J Rehabil Med. 2006;38:346–353.

46. Li L, Liu X, Herr K. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Pain Med. 2007;8:223–234.

47. Farrar JT, Berlin JA, Strom BL. Clinically important changes in acute pain outcome measures: a validation study. J Pain Symptom Manage. 2003;25:406–411.

48. Farrar JT, Portenoy RK, Berlin JA, et al. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287–294.
6

# Hip and Pelvis

CLINICAL SUMMARY AND RECOMMENDATIONS, 276

Anatomy, 277

Osteology, 277

Arthrology, 278

Ligaments, 279

Muscles, 280

Nerves, 284

Patient History, 286

Initial Hypotheses Based on Historical Findings, 286

Diagnostic Utility: Hip Pain, Osteoarthritis, and Acetabular Labral Tears, 287

Physical Examination Tests, 288

Range-of-Motion Measurements, 288

Assessing Muscle Strength, 295

Assessing Muscle Length, 301

Functional Movement Assessments, 305

Palpation, 308

Special Tests, 309

Combinations of Tests, 315

Interventions, 315

Outcome Measures, 316

Appendix, 317

References, 320

## Clinical Summary and Recommendations

Patient History
---
Complaints|

• Several complaints appear to be useful in identifying specific hip pathologic conditions. A subjective complaint of "clicking in the hip" is strongly associated with acetabular labral tears.

• Reports of "constant low back/buttock pain" and "ipsilateral groin pain" are moderately helpful in diagnosing osteoarthritis (OA) of the hip.

Physical Examination
Range-of-Motion Measurements|

• Measuring hip range of motion has consistently been shown to be highly reliable and when limited in three planes can be fairly useful in identifying hip OA (+LR [likelihood ratio] = 4.5 to 4.7).

• Assessing pain during range-of-motion measurements can be helpful in identifying both OA and lateral tendon pathologic conditions. Lateral hip pain during passive abduction is strongly suggestive of lateral tendon pathologic disorders (+LR = 8.3), whereas groin pain during active hip abduction or adduction is moderately suggestive of OA (+LR = 5.7).

• Limited hip abduction in infants can also be very helpful in identifying hip dysplasia or instability.

Strength Assessment|

• Assessment of hip muscle strength has been shown to be fairly reliable, but it appears to be less helpful in identifying lateral tendon pathologic conditions than reports of pain during resisted tests, especially of the gluteus minimus and medius muscles (+LR = 3.27).

• Similarly, a report of posterior pain with a squat is also fairly useful in identifying hip OA (+LR = 6.1).

• Although less reliable than strength tests, the Trendelenburg test is also moderately useful in identifying both lateral tendon pathologic conditions and gluteus medius tears (+LR = 3.2 to 3.6).

Special Tests|

• Generally, special tests of the hip have not been demonstrated to be especially helpful in identifying specific hip pathologic conditions. The Patrick (FABER) test, the flexion−internal rotation−adduction (FADIR) test, and the scour test appear to have little diagnostic utility.

• One exception is the patellar-pubic-percussion test, which is very good at detecting and ruling out hip fractures (+LR = 6.7 to 21.6, −LR = .07 to .14).

Combinations of Findings|

• Patients with at least four of five signs and symptoms (squatting aggravates symptoms, lateral pain with active hip flexion, scour test with adduction causes lateral hip or groin pain, pain with active hip extension, and passive internal rotation of 25 degrees or less) are highly likely to have hip OA.

## Anatomy

### Osteology

Figure 6-1 Hip (coxal) bone.

Figure 6-2 Femur.

### Arthrology

Figure 6-3 Hip and pelvis joints.

Joint| Type and Classification| Closed Packed Position| Capsular Pattern
---|---|---|---
Femoroacetabular| Synovial: Spheroidal| Full extension, some internal rotation, and abduction| Internal rotation and abduction greater than flexion and extension
Pubic symphysis| Amphiarthrodial| Not applicable| Not applicable
Sacroiliac| Synovial: Plane| Not documented| Not documented

### Ligaments

Figure 6-4 Ligaments of the hip and pelvis.

Hip Ligaments| Attachments| Function
---|---|---
Iliofemoral| Anterior inferior iliac spine to intertrochanteric line of femur| Limits hip extension
Ischiofemoral| Posterior inferior acetabulum to apex of greater tubercle| Limits internal rotation, external rotation, and extension
Pubofemoral| Obturator crest of pubic bone to blend with capsule of hip and iliofemoral ligament| Limits hip hyperabduction
Ligament of head of femur| Margin of acetabular notch and transverse acetabular ligament to head of femur| Carries blood supply to head of femur
Pubic Symphysis Ligaments| Attachments| Function
Superior pubic ligament| Connects superior aspects of right and left pubic crests| Reinforces superior aspect of joint
Inferior pubic ligament| Connects inferior aspects of right and left pubic crests| Reinforces inferior aspect of joint
Posterior pubic ligament| Connects posterior aspects of right and left pubic crests| Reinforces inferior aspect of joint

### Muscles

#### Posterior Muscles of Hip and Thigh

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Gluteus maximus| Posterior border of ilium, dorsal aspect of sacrum and coccyx, and sacrotuberous ligament| Iliotibial tract of fascia lata and gluteal tuberosity of femur| Inferior gluteal nerve (L5, S1, S2)| Extension, external rotation, and some abduction of the hip joint
Gluteus medius| External superior border of ilium and gluteal aponeurosis| Lateral aspect of greater trochanter of femur| Superior gluteal nerve (L5, S1)| Hip abduction and internal rotation; maintains level pelvis in single-limb stance
Gluteus minimus| External surface of ilium and margin of greater sciatic notch| Anterior aspect of greater trochanter of femur
Piriformis| Anterior aspect of sacrum and sacrotuberous ligament| Superior greater trochanter of femur| Ventral rami of S1, S2| External rotation of extended hip, abduction of flexed hip; steadies femoral head in acetabulum
Superior gemellus| Ischial spine| Trochanteric fossa of femur| Nerve to obturator internus (L5, S1)
Inferior gemellus| Ischial tuberosity| Nerve to quadratus femoris (L5, S1)
Obturator internus| Internal surface of obturator membrane, border of obturator foramen| Nerve to obturator internus (L5, S1)
Quadratus femoris| Lateral border of ischial tuberosity| Quadrate tubercle of femur| Nerve to quadratus femoris (L5, S1)| Lateral rotation of hip; steadies femoral head in acetabulum
Semitendinosus (hamstring)| Ischial tuberosity| Superomedial aspect of tibia| Tibial division of sciatic nerve (L5, S1, S2)| Hip extension, knee flexion, medial rotation of knee in knee flexion
Semimembranosus (hamstring)| Posterior aspect of medial condyle of tibia
Biceps femoris (hamstring)| Long head: ischial tuberosity
Short head: linea aspera and lateral supracondylar line of femur| Lateral aspect of head of fibula, lateral condyle of tibia| Long head: tibial division of sciatic nerve (L5, S1, S2)
Short head: common fibular division of sciatic nerve (L5, S1, S2)| Knee flexion, hip extension, and knee external rotation when knee is flexed

Figure 6-5 Muscles of hip and thigh: posterior views.

#### Anterior Muscles of Hip and Thigh

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Obturator externus| Margin of obturator foramen and obturator membrane| Trochanteric fossa of femur| Obturator nerve (L3, L4)| Hip external rotation; steadies head of femur in acetabulum
Hip Flexors
Psoas major| Lumbar transverse processes| Lesser trochanter of femur| L1-L4| Flexes the hip, assists with external rotation and abduction
Psoas minor| Lateral bodies of T12-L1| Iliopectineal eminence and arcuate line of ileum| L1-L2| Flexion of pelvis on lumbar spine
Iliacus| Superior iliac fossa, iliac crest and ala of sacrum| Lateral tendon of psoas major and distal to lesser trochanter| Femoral nerve (L1-L4)| Flexes the hip, assists with external rotation and abduction
Tensor fasciae latae| Anterior superior iliac spine and anterior aspect of iliac crest| Iliotibial tract that attaches to lateral condyle of tibia| Superior gluteal nerve (L4, L5)| Hip abduction, internal rotation and flexion; aids in maintaining knee extension
Rectus femoris| Anterior inferior iliac spine| Base of patella and through patellar ligament to tibial tuberosity| Femoral nerve (L2, L3, L4)| Hip flexion and knee extension
Sartorius| Anterior superior iliac spine and notch just inferior| Superomedial aspect of tibia| Femoral nerve (L2, L3)| Flexes, abducts, and externally rotates hip; flexes knee
Adductors
Longus| Inferior to pubic crest| Middle third of linea aspera of femur| Obturator nerve (L2, L3, L4)| Hip adduction
Brevis| Inferior ramus of pubis| Pectineal line and proximal linea aspera of femur| Obturator nerve (L2, L3, L4)| Hip adduction and assists with hip extension
Magnus| Adductor part: inferior pubic ramus, ramus of ischium
Hamstring part: ischial tuberosity| Adductor part: gluteal tuberosity, linea aspera, medial supracondylar line
Hamstring part: adductor tubercle of femur| Adductor part: obturator nerve (L2, L3, L4)
Hamstring part: tibial part of sciatic nerve (L4)| Hip adduction
Adductor part: hip flexion
Hamstring part: hip extension
Gracilis| Inferior ramus of pubis| Superomedial aspect of tibia| Obturator nerve (L2, L3)| Hip adduction and flexion; assists with hip internal rotation
Pectineus| Superior ramus of pubis| Pectineal line of femur| Femoral nerve and obturator nerve (L2, L3, L4)| Hip adduction and flexion; assists with hip internal rotation

Figure 6-6 Muscles of thigh: anterior view.

### Nerves

Figure 6-7 Nerves of the hips and buttocks.

Nerve| Segmental Level| Sensory| Motor
---|---|---|---
Obturator| L2, L3, L4| Medial thigh| Adductor longus, adductor brevis, adductor magnus (adductor part), gracilis, obturator externus
Saphenous| Femoral nerve| Medial leg and foot| No motor
Femoral| L2, L3, L4| Thigh via cutaneous nerves| Iliacus, sartorius, quadriceps femoris, articularis genu, pectineus
Lateral cutaneous of thigh| L2, L3| Lateral thigh| No motor
Posterior cutaneous of thigh| S2, S3| Posterior thigh| No motor
Inferior cluneal| Dorsal rami L1, L2, L3| Buttock region| No motor
Sciatic| L4, L5, S1, S2, S3| Hip joint| Knee flexors and all muscles of lower leg and foot
Superior gluteal| L4, L5, S1| No sensory| Tensor fasciae latae, gluteus medius, gluteus minimus
Inferior gluteal| L5, S1, S2| No sensory| Gluteus maximus
Nerve to quadratus femoris| L5, S1, S2| No sensory| Quadratus femoris, inferior gemellus
Pudendal| S2, S3, S4| Genitals| Perineal muscles, external urethral sphincter, external anal sphincter

Figure 6-8 Nerves and arteries of thigh: anterior views.

## Patient History

### Initial Hypotheses Based on Historical Findings

History| Initial Hypothesis
---|---
Reports of pain at the lateral thigh. Pain exacerbated when transferring from sitting to standing| Greater trochanteric bursitis1
Muscle strain2
Age over 60 years. Reports of pain and stiffness in the hip with possible radiation into the groin| OA3
Reports of clicking or catching in the hip joint. Pain exacerbated by full flexion or extension| Labral tear4
Reports of a repetitive or an overuse injury| Muscle sprain/strain2
Deep aching throb in the hip or groin. Possible history of prolonged steroid use| Avascular necrosis4
Sharp pain in groin. Often misdiagnosed by multiple providers| Femoroacetabular (anterior) impingement5
Pain in the gluteal region with occasional radiation into the posterior thigh and calf| Piriformis syndrome6
Hamstring strain2,4
Ischial bursitis2

### Diagnostic Utility: Hip Pain, Osteoarthritis, and Acetabular Labral Tears

Patient Complaint and Study Quality| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Groin pain7  | 49 potential surgical patients with hip pain| Intraarticular hip pain as defined by relief of more than 50% with intraarticular anesthetic-steroid injection| .59 (.41, .75)| .14 (.05, .33)| .67 (.48, .98)| 3.0 (.95, 9.4)
Catching7  | .63 (.44, .78)| .54 (.35, .73)| 1.39 (.81, 2.4)| .68 (.36, 1.3)
Pinching pain when sitting7  | .48 (.31, .66)| .54 (.35, .73)| 1.1 (.58, 1.9)| .95 (.56, 1.6)
No lateral thigh pain7  | .78 (.59, .89)| .36 (.2, .57)| 1.2 (.84, 1.8)| .61 (.25, 1.5)
Constant low back/buttock pain8  | 78 patients with unilateral pain in the buttock, groin, or anterior thigh| Hip OA on radiographs using the Kellgren and Lawrence grading scale| .52 (.30, .74)| .92 (.80, .97)| 6.4 (2.4, 17.4)| .52 (.33, .81)
Ipsilateral groin pain8  | .29 (.12, .52)| .92 (.80, .97)| 3.6 (1.2, 11.0)| .78 (.59, 1.00)
Squatting aggravates symptoms8  | .76 (.52, .91)| .57 (.42, .70)| 1.8 (1.2, 2.6)| .42 (.19, .93)
Patient complains of clicking in the hip9  | 18 patients with hip pain| Acetabular labral tear as determined by magnetic resonance arthrography| 1.0 (.48, 1.0)| .85 (.55, .98)| 6.7| .00

## Physical Examination Tests

### Range-of-Motion Measurements

#### Reliability of Range-of-Motion Measurements

Measurements and Study Quality| Instrumentation| Population| Interexaminer Reliability
---|---|---|---
External rotation (sitting)
Internal rotation (sitting)
External rotation (supine)
Internal rotation (supine)
Flexion
Abduction
Adduction
Extension10  | Goniometer| 6 patients with hip OA| Prestandardization/poststandardization:
ICC = .55/.80
ICC = .95/.94
ICC = .87/.80
ICC = .87/.94
ICC = .91/.91
ICC = .91/.88
ICC = .72/.56
ICC = NA/.66
Internal rotation
External rotation
Flexion
Abduction
Extension (knee flexed)
Extension (knee unconstrained)11  | Goniometer (except rotation with inclinometer)| 22 patients with hip OA| ICC = .93 (.83, .97)
ICC = .96 (.91, .99)
ICC = .97 (.93, .99)
ICC = .94 (.86, .98)
ICC = .86 (.67, .94)
ICC = .89 (.72, .95)
Flexion
Abduction
Adduction
External rotation
Internal rotation
Extension8  | Inclinometer| 78 patients with unilateral pain in the buttock, groin, or anterior thigh| ICC = .85 (.64 to .93)
ICC = .85 (.68 to .93)
ICC = .54 (−.19 to .81)
ICC = .77 (.53 to .89)
ICC = .88 (.74 to .94)
ICC = .68 (.32 to .85)
Passive hip flexion12  | Gravity inclinometer| 22 patients with knee OA and 17 asymptomatic subjects| ICC = .94 (.89 to .97)
Flexion
Extension
Abduction
Adduction
External rotation
Internal rotation
Total hip motion13  | Goniometer| 25 subjects with radiologically verified OA of the hip| ICC = .82
ICC = .94
ICC = .86
ICC = .50
ICC = .90
ICC = .90
ICC = .85
Flexion
Internal rotation
External rotation
Abduction
Extension
Adduction14  | Goniometer| 167 patients, 50 with no hip OA, 77 with unilateral hip OA, 40 with bilateral hip OA based on radiologic reports| ICC = .92
ICC = .90
ICC = .58
ICC = .78
ICC = .56
ICC = .62
Hip flexion, right
Hip flexion, left15  | Goniometer| 106 patients with OA of the hip or knee confirmed by a rheumatologist or an orthopaedic surgeon| ICC = .82 (.26, .95)
ICC = .83 (.33, .96)
Internal rotation16  | Digital inclinometer| 25 healthy subjects| ICC = .93 (.84, .97)

ICC, Intraclass correlation coefficient; NA, not applicable.

Figure 6-9 Measurement of passive range of motion.

#### Reliability of Determining Capsular and Noncapsular End Feels

Measurements and Study Quality| Description and Positive Finding| Population| Intraexaminer Reliability
---|---|---|---
Flexion test8  | Maximal passive range of motion was assessed. End feels were dichotomized into "capsular" (early capsular, spasm, bone-to-bone) and "noncapsular" (soft tissue approximation, springy block, and empty) as defined by Cyriax| 78 patients with unilateral pain in the buttock, groin, or anterior thigh| κ =.21 (−.22, .64)
Internal rotation test8  | κ = .51 (.19, .83)
Scour test8  | κ = .52 (.08, .96)
Patrick (FABER) test8  | κ = .47 (.12, .81)
Hip flexion test8  | κ = .52 (.09, .96)

#### Diagnostic Utility of Cyriax's Capsular Pattern for Detecting Osteoarthritis

A few studies14,17 have investigated the diagnostic utility of Cyriax's capsular pattern (greater limitation of flexion and internal rotation than of abduction, little if any limitation of adduction and external rotation) in detecting the presence of OA of the hip. Bijl and associates17 demonstrated that hip joints with OA had significantly lower range-of-motion values in all planes when compared with hip joints without OA. However, the magnitude of the range limitations did not follow Cyriax's capsular pattern. Similarly, Klässbo and colleagues14 did not detect a correlation between hip OA and Cyriax's capsular pattern. In fact, they identified 138 patterns of passive range-of-motion restrictions depending on the established norms used (either the mean for symptom-free hips or Kaltenborn's published norms).

Figure 6-10 Hip joint involvement in osteoarthritis.

#### Diagnostic Utility of Pain and Limited Range of Motion

Test and Study Quality| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Lateral pain with active hip flexion8  | 78 patients with unilateral pain in the buttock, groin, or anterior thigh| Hip OA on radiographs using the Kellgren and Lawrence grading scale| .43 (.23, .66)| .88 (.75, .95)| 3.6 (1.5, 8.7)| .65 (.44, .94)
Passive internal rotation of 25 degrees or less8  | .76 (.52, .91)| .61 (.46, .74)| 1.9 (1.3, 3.0)| .39 (.18, .86)
Pain with active hip extension8  | .52 (.30, .74)| .80 (.66, .90)| 2.7 (1.3, 5.3)| .59 (.37, .94)
Groin pain with active abduction or adduction8  | .33 (.15, .57)| .94 (.83, .98)| 5.7 (1.7, 18.6)| .71 (.52, .96)
Decreased passive hip internal rotation range of motion18  | 40 patients with unilateral lateral hip pain| Lateral hip tendon pathologic condition as seen with MRI| .43 (.19, .70)| .86 (.42, .99)| 3.00 (.44, 20.31)| .67 (.40, 1.10)
Pain with active hip internal rotation18  | .31 (.10, .61)| .86 (.42, .99)| 2.15 (.29, 15.75)| .81 (.54, 1.22)
Pain with passive hip abduction18  | .59 (.33, .82)| .93 (.49, 1.00)| 8.31 (.56, 123.88)| .44 (.24, .81)
Pain with passive hip internal rotation18  | .53 (.27, .78)| .86 (.42, .99)| 3.73 (.57, 24.35)| .54 (.30, .98)
Number of planes with restricted movement19  | 0| 195 patients presenting with first-time episodes of hip pain| Radiographic evidence of mild to moderate OA| 1.0| .00| 1.0| NA
1| .86| .54| 1.87| .26
2| .57| .77| 2.48| .56
3| .33| .93| 4.71| .72
Number of planes with restricted movement19  | 0| Radiographic evidence of severe OA| 1.0| .00| 1.0| NA
1| 1.0| .42| 1.72| NA
2| .81| .69| 2.61| .28
3| .54| .88| 4.5| .52
Pain with hip passive range of motion20  | 21 women diagnosed with pelvic girdle pain| Pelvic girdle pain as defined by:

• Current or recent pregnancy

• Daily pain

• Points to the pelvic girdle joints as the painful area

• Pain during one or more of the five selected clinical tests (active straight-leg raise test, Gaenslen test, sacroiliac compression test, sacroiliac distraction test, thigh thrust test)

| .55| 1.0| Undefined| .45

Figure 6-11 Passive range-of-motion measurement.

#### Diagnostic Utility of Limited Range of Motion for Detecting Avascular Necrosis

Figure 6-12 Osteonecrosis.

Motion and Finding and Study Quality| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Passive range-of-motion extension of less than 15 degrees21  | 176 asymptomatic HIV-infected patients| MRI confirmation of avascular necrosis of the hip. Ten had avascular necrosis| .19 (.00, .38)| .92 (.89, .95)| 2.38| .88
Passive range-of-motion abduction of less than 45 degrees21  | .31 (.09, .54)| .85 (.82, .89)| 2.07| .81
Passive range-of-motion internal rotation of less than 15 degrees21  | .50 (.26, .75)| .67 (.62, .72)| 1.52| .75
Passive range-of-motion external rotation of less than 60 degrees21  | .38 (.14, .61)| .73 (.68, .77)| .48| .85
Pain with internal rotation21  | .13 (.00, .29)| .86 (.83, .89)| .93| 1.01

HIV, human immunodeficiency virus; MRI, magnetic resonance imaging.

#### Diagnostic Utility of Limited Hip Abduction for Detecting Developmental Dysplasia in Infants

Figure 6-13 Recognition of congenital dislocation of the hip.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Limited hip abduction test22  | Unilateral limitation| Passive abduction of the hips performed with both hips flexed 90 degrees. Considered positive if abduction is more than 20 degrees greater than on the contralateral side| 1107 infants| Ultrasound verification of clinical instability of the hip| .70 (.60, .69)| .90 (.88, .92)| 7.0| .33
Bilateral limitation| .43 (.50, .64)| .90 (.88, .92)| 4.3| .63
Limited hip abduction23  | As above, except considered positive if either (1) abduction is less than 60 degrees or (2) there is asymmetry in abduction of 20 degrees compared to contralateral side| 683 infants| Hip dysplasia as detected by ultrasound| .69| .54| 1.5| .57

### Assessing Muscle Strength

#### Reliability of Detecting Pain or Weakness during Resisted Tests

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Abduction strength24  | With patient supine, the patient exerts maximal isometric hip abduction force into a handheld dynamometer placed just proximal to the knee| 29 football players| ICC (right/left) = .81/.84| ICC (right/left) = .73/.58
Abduction strength25  | With patient sitting, the patient exerts maximal isometric hip abduction force into a handheld dynamometer placed 5 cm above the lateral malleolus| 37 patients with hip OA| ICC (most symptomatic limb) = .85| Not tested
Adduction strength24  | With patient supine, the patient exerts maximal isometric hip adduction force into a sphygmomanometer placed between the knees| 29 football players| ICC = .81 to .94 (depending on knee angle)| ICC = .80 to .83 (depending on knee angle)
Adduction strength25  | With patient sitting, the patient exerts maximal isometric hip abduction force into a handheld dynamometer placed 5 cm above the medial malleolus| 37 patients with hip OA| ICC (most symptomatic limb) = .86| Not tested
Internal rotation24  | With subject supine and tested knee flexed to 90 degrees, patient exerts maximal isometric rotational force into a handheld dynamometer placed just proximal to the lateral malleolus| 29 football players| ICC (right/left) = .67/.57| ICC (right/left) = .40/.54
Internal rotation25  | With patient sitting, the patient exerts maximal isometric hip abduction force into a handheld dynamometer placed 5 cm above the lateral malleolus| 37 patients with hip OA| ICC (most symptomatic limb) = .83| Not tested
External rotation24  | With patient supine and the tested knee flexed to 90 degrees, the patient exerts maximal isometric rotational force into a handheld dynamometer placed just proximal to the medial malleolus| 29 football players| ICC (right/left) = .55/.64| ICC (right/left) = .60/.63
External rotation25  | With patient sitting, the patient exerts maximal isometric hip abduction force into a handheld dynamometer placed 5 cm above the medial malleolus| 37 patients with hip OA| ICC (most symptomatic limb) = .78| Not tested
Abduction strength10  | With patient sitting, the patient abducts bilateral hips into examiner's hands. Strength graded on scale of 0 to 2| 6 patients with hip OA| Interexaminer prestandardization/poststandardization: κ = .90/.86
Adduction strength10  | As above, except the patient adducts bilateral hips| 6 patients with hip OA| Interexaminer prestandardization/poststandardization: κ = .87/.86
Flexion strength (sitting)10  | With patient sitting, the patient lifts one knee against examiner's hand. Strength graded on scale of 0 to 2| 6 patients with hip OA| Interexaminer prestandardization/poststandardization: κ = .83/.95
Flexion strength (supine)10  | As above, except the patient is supine with knees bent 90 degrees| 6 patients with hip OA| Interexaminer prestandardization/poststandardization: κ = NA/.90
Flexion strength (sitting)25  | With patient sitting, the patient exerts maximal isometric hip abduction force into a handheld dynamometer placed 5 cm above the patella| 37 patients with hip OA| ICC (most symptomatic limb) = .85
Extension strength10  | Patient side-lying with tested leg up. Bottom leg with hip flexed 45 degrees and knee flexed 90 degrees. Patient pushes top leg posteriorly into examiner with knee extended. Strength graded on scale of 0 to 2| 6 patients with hip OA| Interexaminer prestandardization/poststandardization: κ = .85/.86

Figure 6-14 Assessing hip strength.

#### Diagnostic Utility of Pain or Weakness for Identifying Lateral Hip Tendon Pathologic Conditions

Figure 6-15 Gluteus minimus and medius manual muscle test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Pain with resisted gluteus minimus18  | Tested isometrically as described by Kendal and colleagues. Positive if there is reproduction of pain| 40 patients with unilateral lateral hip pain| Lateral hip tendon pathologic condition as seen with MRI| .47 (.22, .73)| .86 (.42, .99)| 3.27 (.49, 21.70)| .62 (.37, 1.05)
Pain with resisted gluteus minimus and medius18  | .47 (.22, .73)| .86 (.42, .99)| 3.27 (.49, 21.70)| .62 (.37, 1.05)
Gluteus minimus and medius weakness18  | Tested isometrically as described by Kendal and colleagues. Positive if five or fewer signs or symptoms are seen| .80 (.51, .95)| .71 (.30, .95)| 2.80 (.85, 9.28)| .28 (.09, .86)
Gluteus minimus weakness18  | .80 (.51, .95)| .57 (.20, .88)| 1.87 (.76, 4.55)| .35 (.10, 1.19)
Pain with resisted abduction26  | With patient supine and affected hip at 45 degrees, positive if symptoms over the greater trochanter are reproduced on resisted abduction| 24 patients with lateral hip pain and tenderness over the greater trochanter| Gluteus medius tendon tear via MRI| .73| .46| 1.35| .59
Pain with resisted internal rotation26  | With patient supine and affected hip at 45 degrees and maximal external rotation, positive if symptoms over the greater trochanter are replicated on internal rotation| .55| .69| 1.77| .65

#### Reliability of the Trendelenburg Test

Figure 6-16 Trendelenburg test.

Test and Study Quality| Description and Positive Findings| Population| Intraexaminer Reliability
---|---|---|---
Positive Trendelenburg test10  | Standing patient raises one foot 10 cm off the ground while examiner inspects for change in level of pelvis. Positive if pelvis drops on the unsupported side or trunk shifts to the stance side| 6 patients with hip OA| κ = .36 (prestandardization)
κ = .06 (poststandardization)
Positive Trendelenburg test26  | Assessed in two ways. Pelvic tilt was assessed in single-leg stance on the affected leg. Pelvic movement was assessed during gait. A positive test was defined as clearly abnormal pelvic tilt during both stance and gait| 24 patients with lateral hip pain and tenderness over the greater trochanter| κ = .67 (.27, 1.08)

#### Diagnostic Utility of the Trendelenburg Test for Identifying Lateral Hip Tendon Pathology

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Positive Trendelenburg test18  | Patient lifts one foot off the ground at a time while standing. Positive if the patient is unable to elevate his or her pelvis on the nonstance side and hold the position for at least 30 seconds| 40 patients with unilateral lateral hip pain| Lateral hip tendon pathologic condition as seen with MRI| .23 (.05, .57)| .94 (.53, 1.00)| 3.64 (.20, 65.86)| .82 (.59, 1.15)
Positive Trendelenburg test26  | Assessed in two ways. Pelvic tilt was assessed in single-leg stance on the affected leg. Pelvic movement was assessed during gait. A positive test was defined as clearly abnormal pelvic tilt during both stance and gait| 24 patients with lateral hip pain and tenderness over the greater trochanter| Gluteus medius tendon tear via MRI| .73| .77| 3.17| .35

### Assessing Muscle Length

#### Reliability of Tests for Iliotibial Band Length

Figure 6-17 Tests for iliotibial band length.

Measurements and Study Quality| Test Procedure| Population| Reliability
---|---|---|---
Ober test10  | With patient side-lying with examined leg up, examiner flexes patient's knee to 90 degrees and abducts and extends the hip until the hip is in line with the trunk. Examiner allows gravity to adduct hip as much as possible. Positive if unable to adduct to horizontal position| 6 patients with hip OA| κ = .38 (prestandardization)
κ = .80 (poststandardization)
Ober test27  | As above, except an inclinometer is used on the distal lateral thigh to measure hip adduction angle| 30 patients with patellofemoral pain syndrome| Interexaminer ICC = .97 (.93, .98)
Ober test28  | 61 asymptomatic individuals| Intraexaminer ICC = .90
Modified Ober test29  | As above, but with test knee fully extended| 10 patients experiencing anterior knee pain| Interexaminer ICC = .73
Intraexaminer ICC = .94
Modified Ober test29  | 61 asymptomatic individuals| Intraexaminer ICC = .91

#### Reliability of the Thomas Test for Hip Flexor Contracture

Figure 6-18 Thomas test.

Measurements and Study Quality| Test Procedure| Population| Reliability
---|---|---|---
Modified Thomas test30  | With the patient sitting as close to the edge of the table as possible and holding the nontested thigh, the patient rolls back into supine position and flexes the untested hip until the lumbar lordosis is flattened. The tested limb is allowed to hang into extension and is measured with an inclinometer or goniometer| 42 asymptomatic individuals| ICC = .92 (goniometer)
ICC = .89 (inclinometer)
Thomas test10  | With patient supine with both hips flexed and maintaining one hip in flexion, the tested hip is extended. Positive if unable to touch posterior thigh with examination table| 6 patients with hip OA| κ = .60 (prestandardization)
κ = .88 (poststandardization)

#### Reliability of Assessing Muscle Length

Test and Study Quality| Description and Positive Findings| Population| Reliability|
---|---|---|---|---
Intraexaminer| Interexaminer
Bent knee fall-out (adductors)24  | With patient supine and knees flexed to 90 degrees, the patient lets knees fall out while keeping feet together. The distance from the fibular head to the table is measured with a tape measure| 29 football players| ICC (right/left) = .90/.89| ICC (right/left) = .93/.91
External rotators of the hip24  | With patient prone and knees flexed to 90 degrees, the patient lets feet fall outward while keeping knees together. Examiner passively flexes knee 90 degrees. Internal rotation measurement is taken with an inclinometer| ICC (right/left) = .97/.96| ICC (right/left) = .89/.93
Internal rotators of the hip24  | With patient supine with nontested hip flexed and the test leg hanging over the end of the table, passive external rotation is measured with an inclinometer| ICC (right/left) = .82/.80| ICC (right/left) = .64/.77
Short hip extensors31  | With patient supine, examiner brings hip passively into flexion while palpating posterior superior iliac spine on ipsilateral side. As soon as the posterior superior iliac spine moves posteriorly, the movement is ceased and the measurement is recorded with an inclinometer| 11 asymptomatic individuals| Intraexaminer ICC = .87
Short hip flexors31  | With patient supine, lower limbs over the plinth, and both hips flexed, examiner slowly lowers the side being tested. When limb ceases to move, measurement is recorded with an inclinometer| Intraexaminer ICC = .98
External rotators of the hip31  | With patient prone, examiner passively flexes knee 90 degrees. Examiner palpates contralateral posterior superior iliac spine and passively internally rotates limb. When rotation of pelvis occurs, measurement is taken with an inclinometer| Intraexaminer ICC = .99
Internal rotators of the hip31  | Same as above, except examiner takes hip into external rotation| Intraexaminer ICC = .98

Figure 6-19 Measurement of muscle length with a bubble inclinometer.

### Functional Movement Assessments

#### Forward Step-Down Test

The forward step-down test32 is a functional task used to assess lower extremity movement quality involving weight-bearing stress as well as dynamic muscular control. Subjects with moderate movement quality have been shown to have significantly less strength of the hip abductors, less hip adduction range of motion, and less knee flexion range of motion compared with those with good movement quality.

The subject stands on a 20-cm step, with the foot of the tested limb close to the edge of the step and the nontested limb positioned in front of the step, with the knee straight and the ankle at maximum dorsiflexion. The subject is asked to keep the trunk straight and the hands on the waist and to bend the knee on the tested side until the heel of the nontested limb touches the floor. The subject is asked not to apply any weight on the heel of the nontested limb once it reaches the floor and to immediately reextend the knee of the tested limb to return to the starting position. The examiner rates the performance of the subject across five repetitions. A total score of 0 or 1 is classified as good movement quality, a total score of 2 or 3 is classified as moderate movement quality, and a total score of 4 or more is classified as poor movement quality.

Criteria| Description| Scoring
---|---|---
Arm strategy| Patient removes the hands from the waist (interpreted as a strategy to recover balance)| 1 point is given
Trunk movement| Patient leans the trunk to either side (interpreted as a strategy to recover balance)| 1 point is given
Pelvic plane| If one side of the pelvis is rotated in the transverse plane or elevated in the frontal plane compared with the other side| 1 point is given
Knee position
(only one score is given from this category)| If the knee of the tested limb moves medially in the frontal plane and the tibial tuberosity crossed an imaginary vertical line positioned directly over the second toe of the tested foot, 1 point was given| 1 point is given
If the knee moves medially and the tibial tuberosity crossed an imaginary vertical line positioned directly over the medial border of the tested foot, 2 points were given| 2 points are given
Maintenance of a steady unilateral stance| Subject has to support body weight on the nontested limb, or the foot of the tested limb moved during testing| 1 point is given

#### Reliability of the Forward Step-Down Test

Figure 6-20 Forward step-down test.

Test and Study Quality| Description and Positive Findings| Population| Intraexaminer Reliability
---|---|---|---
Forward step-down test32  | As described on previous page| 26 asymptomatic female subjects| κ = .80 (.57, 1.00)

#### Diagnostic Utility of Pain with Functional Movement Assessments

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Posterior pain with squat8  | Patient squats as low as possible with feet 20 cm apart, trunk upright, and hands on hips| 78 patients with unilateral pain in the buttock, groin, or anterior thigh| Hip OA on x-rays using the Kellgren and Lawrence grading scale| .24 (.09, .48)| .96 (.85, .99)| 6.1 (1.5, 25.6)| .79 (.62, 1.00)
Step-up test20  | No details given| 21 women with pelvic girdle pain| Pelvic girdle pain defined by:

• Current or recent pregnancy

| .29| 1.0| Undefined| .71
Single-leg stance20  |

• Daily pain

| .35| .67| 1.1| .97
Lunge20  |

• Points to the pelvic girdle joints as the painful area

| .44| .83| 2.6| .68
Sit to stand20  |

• Pain during one or more of the six selected clinical tests (active straight-leg raise test, Gaenslen test, sacroiliac compression test, sacroiliac distraction test, thigh thrust test, palpation of pubic symphysis)

| .13| 1.0| Undefined| .88
Deep squat20  | .24| 1.0| Undefined| .88

### Palpation

#### Reliability of Pain with Palpation

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Trochanteric tenderness10  | With patient supine, firm pressure is applied to the greater trochanter. Test positive if patient's symptoms are reproduced| 6 patients with hip OA| κ = .40 (prestandardization)
κ = .68 (poststandardization)
Trochanteric tenderness33  | 70 patients with hip pain| κ = .66 (.48, .84)

#### Diagnostic Utility of Pain with Palpation for Intraarticular Hip Pain

Patient Complaint and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Trochanteric tenderness7  | With patient supine, firm pressure is applied to the greater trochanter. Test positive if patient's symptoms are reproduced| 49 potential surgical patients with hip pain| Intraarticular hip pain as defined by relief of more than 50% with intraarticular anesthetic-steroid injection| .57 (.39, .74)| .45 (.27, .65)| 1.1 (.36, 3.6)| .93 (.49, 1.8)

### Special Tests

#### Reliability of the Patrick (FABER) Test

Figure 6-21 Patrick test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Patrick test33  | With patient supine, examiner flexes, abducts, and externally rotates the involved hip so that the lateral ankle is placed just proximal to the contralateral knee. While stabilizing the anterior superior iliac spine, the involved leg is lowered toward the table to end range. Test is positive if it reproduces the patient's symptoms| 70 patients with hip pain| Intraexaminer κ = .63 (.43, .83)
Patrick test10  | As above, except test is considered positive if the patient has inguinal pain| 6 patients with hip OA| Interexaminer κ = .78 (prestandardization)
κ = .75 (poststandardization)
Patrick test8  | As above, except inclinometer is used 2.5 cm proximal to the patient's flexed knee| 78 patients with unilateral pain in the buttock, groin, or anterior thigh| Intraexaminer ICC = .90 (.78 to .96)

#### Diagnostic Utility of the Patrick (FABER) Test

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Patrick test7   (see Video 6-1)| With patient supine, examiner flexes, abducts, and externally rotates the involved hip so that the lateral ankle is placed just proximal to the contralateral knee. While stabilizing the anterior superior iliac spine, the involved leg is lowered toward the table to end range. Test is positive if it reproduces the patient's symptoms| 49 potential surgical patients with hip pain| Intraarticular hip pain as defined by relief of more than 50% with intraarticular anesthetic-steroid injection| .60 (.41, .77)| .18 (.07, .39)| .73 (.50, 1.1)| 2.2 (.80, 6.0)
Patrick test less than 60 degrees8  | As above, but also uses inclinometer 2.5 cm proximal to the patient's flexed knee| 78 patients with unilateral pain in the buttock, groin, or anterior thigh| Hip OA on radiographs using the Kellgren and Lawrence grading scale| .57 (.34, .77)| .71 (.56, .82)| 1.9 (1.1, 3.4)| .61 (.36, 1.00)

#### Reliability of Special Tests for Detecting Intraarticular Pathologic Conditions

Figure 6-22 Internal rotation−flexion−axial compression maneuver.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Flexion−internal rotation−adduction (FADIR) impingement test33  | With patient supine, examiner flexes, adducts, and internally rotates the involved hip to end range. Test is positive if it reproduces the patient's symptoms| 70 patients with hip pain| κ = .58 (.29, .87)
Log roll33  | With patient supine with greater trochanters in the maximally prominent position, examiner places both hands on the patient's midthigh and passively externally rotates each hip maximally. Test is positive if greater external rotation is noted on the symptomatic side| κ = .61 (.41, .81)

#### Diagnostic Utility of Special Tests for Detecting Intraarticular Pathologic Conditions

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Scour test with adduction causes lateral hip or groin pain8  | With patient supine, examiner passively flexes the symptomatic hip to 90 degrees and then moves the knee toward the opposite shoulder and applies an axial load to the femur| 78 patients with unilateral pain in the buttock, groin, or anterior thigh| Hip OA on radiographs using the Kellgren and Lawrence grading scale| .62 (.39, .81)| .75 (.60, .85)| 2.4 (1.4, 4.3)| .51 (.29, .89)
FADIR impingement test7   (see Video 6-2)| With patient supine, examiner flexes, adducts, and internally rotates the involved hip to end range. Test is positive if it reproduces the patient's symptoms| 49 potential surgical patients with hip pain| Intraarticular hip pain as defined by relief of more than 50% with intraarticular anesthetic-steroid injection| .78 (.59, .89)| .10 (.03, .29)| .86 (.67, 1.1)| 2.3 (.52, 10.4)
Internal rotation−flexion−axial compression maneuver9  | With patient supine, examiner flexes and internally rotates the hip and then applies an axial compression force through the femur. Provocation of pain is considered positive| 18 patients with hip pain| Acetabular labral tear as determined by magnetic resonance arthrography| .75 (.19, .99)| .43 (.18, .72)| 1.32| .58

#### Diagnostic Utility of the Patellar-Pubic-Percussion Test for Detecting Hip Fractures

Figure 6-23 Percussion test and hip fractures.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Patellar-pubic-percussion test34  | With patient supine, examiner percusses (taps) one patella at a time while auscultating the pubic symphysis with a stethoscope. A positive test is a diminution of the percussion note on the affected side| 290 patients with suspected radiologically occult hip fractures| Hip fracture seen on repeat radiographs, bone scintigraphy, MRI, or computed tomography (CT)| .96 (.87, .99)| .86 (.49, .98)| 6.73| .14
Patellar-pubic-percussion test35  | 41 patients in the emergency department with a chief complaint of hip trauma| Hip fracture seen on radiograph| .94| .96| 21.6| .07

#### Reliability of Balance Tests

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Four-square step test36  | Four walking sticks are placed on the floor at right angles to each other with handles outward so that they form four squares. The participant starts in square 1, facing square 2, and remains facing in this direction for the duration of the test. The participant steps forward with both feet as quickly as possible into square 2, then sideways to the right into square 3, then backward into square 4, and finally sideways to the left back into square 1. The participant then reverses the sequence back to the starting position. The trial is recorded to the nearest 10th of a second| 30 patients with hip OA| ICC = .83 (.57, .93)| ICC = .86 (.72, .93)
Step test36  | A step that is 15 cm high is used with a cardboard template 5 cm wide positioned on the floor along the edge of the step to provide a standardized starting position. As the test is performed, the participant remains on the stance leg the entire time while moving the other leg back and forth from the step to the floor (i.e., the participant places the stepping foot flat up onto the step and then back down flat onto the ground) as many times as possible in 15 seconds without moving the stance leg from the starting position. The number of whole steps (up onto the step and back down to a flat position on the floor) performed in 15 seconds is recorded for each stance leg. If the participant overbalances, the test is concluded and the number of completed steps and the time taken are recorded| ICC = .81 (.42, .93)| ICC = .85 (.71, .93)
Timed single-leg stance test36  | The participant starts with hands on hips and stands on one leg for as long as possible up to a maximum of 30 seconds. The nonstance hip remains in a neutral position with the knee flexed so that the foot is positioned behind and is not permitted to touch the stance leg. The participant is encouraged to look at a nonmoving target 1 to 3 meters ahead. The test is stopped if the participant moves his or her hands off the hips, touches the nonstance foot down on the floor, or touches the stance leg with the nonstance leg. The longest time, up to a maximum of 30 seconds, is recorded| ICC = .82 (.64, .91)| ICC = .89 (.78, .95)
Forward reach test36  | The participant starts in a normal relaxed stance with the dominant arm facing side-on, but not touching, a wall. A leveled measuring tape is mounted on the wall at acromion height. The participant makes a fist with the dominant hand and elevates the arm to shoulder level. The position of the third knuckle along the tape is recorded as the starting point. Keeping the contralateral arm by the side and both heels on the floor, the participant reaches as far forward as possible to maintain a maximal reach position for 3 seconds without losing balance. The final reach position of the third knuckle along the tape is recorded as the finishing point. The mean difference between the starting point and the finishing point across three trials is recorded to the nearest millimeter as the test score| ICC = .68 (.42, .84)| ICC = .68 (.29, .85)

### Combinations of Tests

#### Diagnostic Utility of Combinations of Tests for Osteoarthritis

Test and Study Quality| Number of Variables Present| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Squatting aggravates symptoms
+
Lateral pain with active hip flexion
+
Scour test with adduction causes lateral hip or groin pain
+
Pain with active hip extension
+
Passive internal rotation of 25 degrees or less8  | Five of five| 78 patients with unilateral pain in the buttock, groin, or anterior thigh| Hip OA on radiograph using the Kellgren and Lawrence grading scale| .14 (.04, .37)| .98 (.88, 1.0)| 7.3 (1.1, 49.1)| .87 (.73, 1.1)
Four or more of five| .48 (.26, .70)| .98 (.88, 1.0)| 24.3 (4.4, 142.1)| .53 (.35, .80)
Three or more of five| .71 (.48, .88)| .86 (.73, .94)| 5.2 (2.6, 10.9)| .33 (.17, .66)
Two or more of five| .81 (.57, .94)| .61 (.46, .74)| 2.1 (1.4, 3.1)| .31 (.13, .78)
One or more of five| .95 (.74, 1.0)| .18 (.09, .31)| 1.2 (.99, 1.4)| .27 (.04, 2.0)

### Interventions

#### Clinical Prediction Rule to Identify Patients with Primary Hip Osteoarthritis Likely to Benefit from Physical Therapy Intervention

Wright and colleagues37 developed a clinical prediction rule for identifying patients with primary hip OA who are likely to benefit from physical therapy interventions. The result of their study demonstrated that if two or more of the five attributes (unilateral hip pain, age 58 years or younger, score of 6/10 or higher on the numeric pain rating scale, 40-meter self-paced walk test score of 25.9 seconds or less, and duration of symptoms 1 year or less) were present, the +LR was 3.99 (95% CI 2.66, 4.48) and the probability of experiencing a successful outcome improved from 22% to 65%.

## Outcome Measures

Outcome Measure| Scoring and Interpretation| Test-Retest Reliability and Study Quality| MCID
---|---|---|---
Lower Extremity Functional Scale (LEFS)| Users are asked to rate the difficulty of performing 20 functional tasks on a Likert-type scale ranging from 0 (extremely difficult or unable to perform activity) to 4 (no difficulty). A total score out of 80 is calculated by summing each score. The answers provide a score between 0 and 80, with lower scores representing more disability| ICC = .9238  | 939
Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)| The WOMAC consists of three subscales: pain (5 items), stiffness (2 items), and physical function (17 items). Users answer the 24 condition-specific questions on a numeric rating scale ranging from 0 (no symptoms) to 10 (extreme symptoms), or alternatively on a Likert-type scale from 0 to 4. Scores from each subscale are summed, with higher scores indicating more pain, stiffness, and disability| ICC = .9038  | 6.7% for improvement and 12.9% for worsening40
Numeric Pain Rating Scale (NPRS)| Users rate their level of pain on an 11-point scale ranging from 0 to 10, with high scores representing more pain. Often asked as "current pain" and "least," "worst," and "average pain" in the past 24 hours| ICC = .7241  | 242,43

MCID, Minimum clinically important difference.

## Appendix

#### Quality Appraisal of Reliability Studies for the Hip and Pelvis Using QAREL

| Martin 2008 (2)33| Sutlive 20088| Cibere 200810| Pua 200811| Cliborne 200412| Holm 200013| Klässbo 200314| Lin 200115| Malliaras 200924| Bird 200126
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| U

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| Y| N/A| N/A| N/A| N/A| N/A| Y| N/A

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| N/A| N/A| U| Y| U| U| U| U| Y

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| Y| N/A| N/A| N/A| N/A| Y| N/A| N/A| U

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| Y| U| U| U| U| U| U| U| U| Y

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| U

8. Was the order of examination varied?

| N| U| Y| U| Y| Y| U| U| Y| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| U| Y| Y| Y| N

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Piva 200627| Reese 200328| Melchione 199329| Clapis 200830| Bullock-Saxton 199431| Pua 200938| Li 200741| Bieler 201425| Krause 201416| Choi 201436| Park 201332
---|---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| N/A| Y| Y| N/A| N/A| N/A| N/A| Y| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| Y| Y| N/A| U| Y| N| Y| Y| Y| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| U| U| U| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| U| U

8. Was the order of examination varied?

| N| Y| U| Y| N| U| U| N| Y| Y| N/A

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

#### Quality Assessment of Diagnostic Studies for the Hip and Pelvis Using QUADAS

| Altman 19913| Adams 199735| Birrell 200119| Bird 200126| Castelein 200123| Joe 200221| Jari 200222| Fishman 20026| Tiru 200234| Narvani 20039| Cook 200720| Martin 20087| Sutlive 20088| Woodley 200818
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| U| U| Y| Y| Y| N| Y| U| Y| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| N| N| Y| Y| Y| N| Y| U| Y| U| Y| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| U| Y| Y| Y| Y| Y| Y| U| Y| Y| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| U| Y| U| U| U| U| Y| U| N| U| U| Y| Y

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| U| Y| Y| Y| Y| Y| Y| U| Y| Y| N| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| N| Y| Y| Y| N| U| Y| Y| Y| U| N| Y| Y| N

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| N| U| Y| Y| Y| Y| Y| Y| U| Y| Y| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| U| Y| Y| Y| U| Y| U| U| U| U| U| U| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| Y| U| U| Y| U| U| U| U| U| U| U| U| Y| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| U| Y| Y| Y| Y| U| Y| U| U| U| U| Y| Y

13. Were uninterpretable/intermediate test results reported?

| Y| U| U| Y| U| Y| Y| U| Y| Y| Y| Y| Y| Y

14. Were withdrawals from the study explained?

| Y| U| U| Y| Y| Y| Y| U| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear. Good quality (Y - N = 10 to 14)   Fair quality (Y - N = 5 to 9)   Poor quality (Y - N ≤ 4)  .

## References

1. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. 3rd ed. Lippincott: Philadelphia; 1996.

2. Pecina MM, Bojanic I. Overuse Injuries of the Musculoskeletal System. CRC Press: Boca Raton, Florida; 1993.

3. Altman R, Alarcon G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum. 1991;34:505–514.

4. Hartley A. Practical Joint Assessment. Mosby: St Louis; 1995.

5. Clohisy JC, Knaus ER, Hunt DM, et al. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res. 2009;467:638–644.

6. Fishman LM, Dombi GW, Michaelsen C, et al. Piriformis syndrome: diagnosis, treatment, and outcome—a 10-year study. Arch Phys Med Rehabil. 2002;83:295–301.

7. Martin RL, Irrgang JJ, Sekiya JK. The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates. Arthroscopy. 2008;24:1013–1018.

8. Sutlive TG, Lopez HP, Schnitker DE, et al. Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip pain. J Orthop Sports Phys Ther. 2008;38:542–550.

9. Narvani AA, Tsiridis E, Kendall S, et al. A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain. Knee Surg Sports Traumatol Arthrosc. 2003;11:403–408.

10. Cibere J, Thorne A, Bellamy N, et al. Reliability of the hip examination in osteoarthritis: effect of standardization. Arthritis Rheum. 2008;59:373–381.

11. Pua YH, Wrigley TV, Cowan SM, Bennell KL. Intrarater test-retest reliability of hip range of motion and hip muscle strength measurements in persons with hip osteoarthritis. Arch Phys Med Rehabil. 2008;89:1146–1154.

12. Cliborne AV, Wainner RS, Rhon DI, et al. Clinical hip tests and a functional squat test in patients with knee osteoarthritis: reliability, prevalence of positive test findings, and short-term response to hip mobilization. J Orthop Sports Phys Ther. 2004;34:676–685.

13. Holm I, Bolstad B, Lutken T, et al. Reliability of goniometric measurements and visual estimates of hip ROM in patients with osteoarthrosis. Physiother Res Int. 2000;5:241–248.

14. Klässbo M, Harms-Ringdahl K, Larsson G. Examination of passive ROM and capsular patterns in the hip. Physiother Res Int. 2003;8:1–12.

15. Lin YC, Davey RC, Cochrane T. Tests for physical function of the elderly with knee and hip osteoarthritis. Scand J Med Sci Sports. 2001;11:280–286.

16. Krause DA, Hollman JH, Krych AJ, et al. Reliability of hip internal rotation range of motion measurement using a digital inclinometer. Knee Surg Sports Traumatol Arthrosc. 2014 [Epub ahead of print].

17. Bijl D, Dekker J, van Baar ME, et al. Validity of Cyriax's concept capsular pattern for the diagnosis of osteoarthritis of hip and/or knee. Scand J Rheumatol. 1998;27:347–351.

18. Woodley SJ, Nicholson HD, Livingstone V, et al. Lateral hip pain: findings from magnetic resonance imaging and clinical examination. J Orthop Sports Phys Ther. 2008;38:313–328.

19. Birrell F, Croft P, Cooper C, et al. Predicting radiographic hip osteoarthritis from range of movement. Rheumatology (Oxford). 2001;40:506–512.

20. Cook C, Massa L, Harm-Ernandes I, et al. Interrater reliability and diagnostic accuracy of pelvic girdle pain classification. J Manipulative Physiol Ther. 2007;30:252–258.

21. Joe G, Kovacs J, Miller K, et al. Diagnosis of avascular necrosis of the hip in asymptomatic HIV-infected patients: clinical correlation of physical examination with magnetic resonance imaging. J Back Musculoskeletal Rehabil. 2002;16:135–139.

22. Jari S, Paton RW, Srinivasan MS. Unilateral limitation of abduction of the hip. A valuable clinical sign for DDH? J Bone Joint Surg Br. 2002;84:104–107.

23. Castelein RM, Korte J. Limited hip abduction in the infant. J Pediatr Orthop. 2001;21:668–670.

24. Malliaras P, Hogan A, Nawrocki A, et al. Hip flexibility and strength measures: reliability and association with athletic groin pain. Br J Sports Med. 2009;43(10):739–744.

25. Bieler T, Magnusson SP, Kjaer M, Beyer N. Intra-rater reliability and agreement of muscle strength, power and functional performance measures in patients with hip osteoarthritis. J Rehabil Med. 2014;46(10):997–1005.

26. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001;44:2138–2145.

27. Piva SR, Fitzgerald K, Irrgang JJ, et al. Reliability of measures of impairments associated with patellofemoral pain syndrome. BMC Musculoskelet Disord. 2006;7:33.

28. Reese NB, Bandy WD. Use of an inclinometer to measure flexibility of the iliotibial band using the Ober test and the modified Ober test: differences in magnitude and reliability of measurements. J Orthop Sports Phys Ther. 2003;33:326–330.

29. Melchione WE, Sullivan MS. Reliability of measurements obtained by use of an instrument designed to indirectly measure iliotibial band length. J Orthop Sports Phys Ther. 1993;18:511–515.

30. Clapis PA, Davis SM, Davis RO. Reliability of inclinometer and goniometric measurements of hip extension flexibility using the modified Thomas test. Physiother Theory Pract. 2008;24:135–141.

31. Bullock-Saxton JE, Bullock MI. Repeatability of muscle length measures around the hip. Physiother Can. 1994;46:105–109.

32. Park K-M, Cynn H-S, Choung S-D. Musculoskeletal predictors of movement quality for the forward step-down test in asymptomatic women. J Orthop Sports Phys Ther. 2013;43(7):504–510.

33. Martin RL, Sekiya JK. The interrater reliability of 4 clinical tests used to assess individuals with musculoskeletal hip pain. J Orthop Sports Phys Ther. 2008;38(2):71–77.

34. Tiru M, Goh SH, Low BY. Use of percussion as a screening tool in the diagnosis of occult hip fractures. Singapore Med J. 2002;43:467–469.

35. Adams SL, Yarnold PR. Clinical use of the patellar-pubic percussion sign in hip trauma. Am J Emerg Med. 1997;15:173–175.

36. Choi YM, Dobson F, Martin J, et al. Interrater and intrarater reliability of common clinical standing balance tests for people with hip osteoarthritis. Phys Ther. 2014;94(5):696–704.

37. Wright AA, Cook CE, Flynn TW, et al. Predictors of response to physical therapy intervention in patients with primary hip osteoarthritis. Phys Ther. 2011;91(4):510–524.

38. Pua YH, Cowan SM, Wrigley TV, Bennell KL. The Lower Extremity Functional Scale could be an alternative to the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale. J Clin Epidemiol. 2009;62(10):1103–1111.

39. Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther. 1999;79:371–383.

40. Angst F, Aeschlimann A, Stucki G. Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with osteoarthritis of the lower extremities. Arthritis Rheum. 2001;45:384–391.

41. Li L, Liu X, Herr K. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Pain Med. 2007;8:223–234.

42. Farrar JT, Berlin JA, Strom BL. Clinically important changes in acute pain outcome measures: a validation study. J Pain Symptom Manage. 2003;25:406–411.

43. Farrar JT, Portenoy RK, Berlin JA, et al. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287–294.
7

# Knee

CLINICAL SUMMARY AND RECOMMENDATIONS, 324

Anatomy, 325

Osteology, 325

Arthrology, 326

Ligaments, 327

Muscles, 330

Nerves, 333

Patient History, 336

Initial Hypotheses Based on Historical Findings, 336

Assessing Subjective Questions in Patients with Osteoarthritis, 337

Reliability of the Meniscal Symptom Index in Patients with Meniscal Tears, 338

Diagnostic Utility of Meniscal Symptom Index in Patients with Meniscal Tears, 339

Diagnostic Utility of Patient History: Meniscal and MCL Tears and Effusion, 340

Physical Examination Tests, 341

Screening, 341

Range-of-Motion Measurements, 346

Assessing Strength, 350

Assessing Muscle Length, 351

Assessing Bony Alignment, 352

Palpation, 360

Special Tests, 362

Combinations of Tests, 376

Interventions, 380

Outcome Measures, 384

Appendix, 385

References, 393

## Clinical Summary and Recommendations

Patient History
---
Complaints|

• Little is known about the utility of subjective complaints with knee pain. The lack of self-noticed swelling seems moderately helpful in ruling out knee joint effusion. Similarly, the absence of "weight bearing during trauma" may help rule out a meniscal tear (both –LRs [likelihood ratios] = .40).

Physical Examination
Screening|

• The Ottawa Knee Rule for Radiography is highly sensitive for knee fractures in both adults and children. When patients are younger than 55 years, can bear weight and flex the knee to 90 degrees, and have no tenderness on the patella or fibular head, providers can confidently rule out a knee fracture (−LR = .05 to .07).

Range-of-Motion and Strength Assessment|

• Measuring knee range of motion has consistently been shown to be highly reliable but is of unknown diagnostic utility. The assessment of "end feel" during range-of-motion measurements, however, is unreliable, especially between different examiners.

• Assessing strength with manual muscle testing has been shown to accurately detect side-to-side knee extension strength deficits, at least in patients in an acute rehabilitation hospital setting.

Special Tests|

• Several systematic reviews with metaanalysis have examined special tests of the knee.

• Both "joint line tenderness" and the McMurray test consistently show moderate utility in detecting and ruling out meniscal tears. The Thessaly test has been shown to be excellent at both detecting and ruling out meniscal tears (+LR = 1.79 to 39.3, −LR = .08 to .73).

• Although the anterior drawer test and pivot shift test are good at identifying anterior cruciate ligament (ACL) tears (+LR = 1.5 to 36.5), the Lachman test is best at ruling them out (−LR = .10 to .24).

• Varus and valgus testing, while not particularly reliable, is fairly good at ruling out medial collateral ligament (MCL) tears (−LR = .20 to .30).

• The "moving patellar apprehension test" seems to show very good diagnostic utility in both identifying and ruling out patellar instability (+LR = 8.3, −LR = .00).

Combinations of Findings|

• Generally, the clinical examination and/or combinations of findings seem to be very good at identifying and ruling out various knee pathologic conditions, including meniscal tears, ACL tears, and symptomatic plica.

• Presence of joint line tenderness and a positive McMurray test seems to show good diagnostic utility in both identifying and ruling out meniscal tears (+LR = 10.1 to 75, −LR = .10 to .25).

• Presence of joint line tenderness and a positive Thessaly test also seems to show good diagnostic utility in both identifying and ruling out meniscal tears (+LR = 11.6 to 78, −LR = .08 to .22).

Interventions|

• In patients with patellofemoral pain syndrome, a combination of factors (age over 25 years, height less than 65 inches, worst pain visual analog scale less than 53 mm, and a difference in midfoot width from non−weight bearing to weight bearing of more than 11 mm) seems to predict a favorable response to foot orthoses (+LR = 8.8 if three of four factors present).

• Similarly, several factors have been identified that predict which patients with knee osteoarthritis (OA) may benefit from hip mobilizations.

## Anatomy

### Osteology

Figure 7-1 Femur.

Figure 7-2 Tibia and fibula.

### Arthrology

Figure 7-3 Sagittal knee.

Joints| Type and Classification| Closed Packed Position| Capsular Pattern
---|---|---|---
Tibiofemoral| Double condyloid| Full extension| Flexion restricted greater than extension
Proximal tibiofibular| Synovial: plane| Not reported| Not reported
Patellofemoral| Synovial: plane| Full flexion| Not reported

### Ligaments

Figure 7-4 Posterior ligaments of knee.

Ligaments| Attachments| Function
---|---|---
Posterior meniscofemoral| Lateral meniscus to posterior cruciate ligament (PCL) and medial femoral condyle| Reinforces posterior lateral meniscal attachment
Oblique popliteal| Posterior aspect of medial tibial condyle to posterior aspect of fibrous capsule| Strengthens posterior portion of joint capsule
Arcuate popliteal| Posterior fibular head over tendon of popliteus to posterior capsule| Strengthens posterior portion of joint capsule
Posterior ligament of fibular head| Posterior fibular head to inferior lateral tibial condyle| Reinforces posterior joint capsule
Anterior cruciate| Anterior intracondylar aspect of tibial plateau to posteromedial side of lateral femoral condyle| Prevents posterior translation of femur on tibia and anterior translation of tibia on femur
Posterior cruciate| Posterior intracondylar aspect of tibial plateau to anterolateral side of medial femoral condyle| Prevents anterior translation of femur on tibia and posterior translation of tibia on femur
Fibular collateral| Lateral epicondyle of femur to lateral aspect of fibular head| Protects joint from varus stress
Tibial collateral| Femoral medial epicondyle to medial condyle of tibia| Protects the joint from valgus stress
Transverse ligament of knee| Anterior edges of menisci| Allows menisci to move together during knee movement

Figure 7-5 Posterior ligaments of knee (continued).

Figure 7-6 Inferior, anterior, and superior views of ligaments of knee.

### Muscles

Muscles| Proximal Attachments| Distal Attachments| Nerve and Segmental Level| Action
---|---|---|---|---
Quadriceps
Rectus femoris| Anterior inferior iliac spine and ileum just superior to acetabulum| Base of patella and by patellar ligament to tibial tuberosity| Femoral nerve (L2, L3, L4)| Extends knee; rectus femoris also flexes hip and stabilizes head of femur in acetabulum
Vastus lateralis| Greater trochanter and linea aspera of femur
Vastus medialis| Intertrochanteric line and linea aspera
Vastus intermedius| Anterolateral aspect of shaft of femur
Articularis genu| Anteroinferior aspect of femur| Synovial membrane of knee joint| Femoral nerve (L3, L4)| Pulls synovial membrane superiorly during knee extension to prevent pinching of membrane
Hamstrings
Semimembranosus| Ischial tuberosity| Medial aspect of superior tibia| Tibial branch of sciatic nerve (L4, L5, S1, S2)| Flexes and medially rotates knee, extends and medially rotates hip
Semitendinosus| Ischial tuberosity| Posterior aspect of medial condyle of tibia
Biceps femoris
Short head| Lateral linea aspera and proximal two thirds of supracondylar line of femur| Lateral head of fibula and lateral tibial condyle| Fibular branch of sciatic nerve (L5, S1, S2)| Flexes and laterally rotates knee
Long head| Ischial tuberosity| Tibial branch of sciatic nerve (L5, S1-S3)| Flexes and laterally rotates knee, extends and laterally rotates hip
Gracilis| Body and inferior ramus of pubis| Medial aspect of superior tibia| Obturator nerve (L2, L3)| Adducts hip, flexes and medially rotates knee
Sartorius| Anterior superior iliac spine and anterior iliac crest| Superomedial aspect of tibia| Femoral nerve (L2, L3)| Flexes, abducts, and externally rotates hip, flexes knee
Gastrocnemius
Lateral head
Medial head| Lateral femoral condyle
Superior aspect of medial femoral condyle| Posterior calcaneus| Tibial nerve (S1, S2)| Plantarflexes ankle and flexes knee
Popliteus| Lateral femoral condyle and lateral meniscus| Superior to soleal line on posterior tibia| Tibial nerve (L4, L5, S1)| Weak knee flexion and unlocking of knee joint
Plantaris| Lateral supracondylar line of femur and oblique popliteal ligament| Posterior calcaneus| Tibial nerve (S1, S2)| Weak assist in knee flexion and ankle plantarflexion

Figure 7-7 Anterior and posterior muscles of knee.

Figure 7-8 Lateral and medial muscles of knee.

### Nerves

Figure 7-9 Obturator nerve.

Nerves| Segmental Level| Sensory| Motor
---|---|---|---
Femoral| L2, L3, L4| Thigh via cutaneous nerves| Iliacus, sartorius, quadriceps femoris, articularis genu, pectineus
Obturator| L2, L3, L4| Medial thigh| Adductor longus, adductor brevis, adductor magnus (adductor part), gracilis, obturator externus
Saphenous| L2, L3, L4| Medial leg and foot| No motor
Tibial nerve| L4, L5, S1, S2, S3| Posterior heel and plantar surface of foot| Semitendinosus, semimembranosus, biceps femoris, adductor magnus, gastrocnemius, soleus, plantaris, flexor hallucis longus, flexor digitorum longus, tibialis posterior
Common fibular nerve| L4, L5, S1, S2| Lateral posterior leg| Biceps femoris

Figure 7-10 Femoral nerve and lateral femoral cutaneous nerves.

Figure 7-11 Sciatic nerve and posterior femoral cutaneous nerve.

## Patient History

### Initial Hypotheses Based on Historical Findings

Figure 7-12 Anterior cruciate ligament ruptures.

Patient Reports| Initial Hypothesis
---|---
Patient reports a traumatic onset of knee pain that occurred during jumping, twisting, or changing directions with foot planted| Possible ligamentous injury (ACL)1,2
Possible patellar subluxation2
Possible quadriceps rupture
Possible meniscal tear
Patient reports traumatic injury that resulted in a posteriorly directed force to tibia with knee flexed| Possible PCL injury3
Patient reports traumatic injury that resulted in a varus or valgus force exerted on knee| Possible collateral ligament injury (lateral collateral ligament [LCL] or MCL)3
Patient reports anterior knee pain with jumping and full knee flexion| Possible patellar tendinitis2,4
Possible patellofemoral pain syndrome5,6
Patient reports swelling in knee with occasional locking and clicking| Possible meniscal tear7
Possible loose body within knee joint
Patient reports pain with prolonged knee flexion, during squats, and while going up and down stairs| Possible patellofemoral pain syndrome5,6
Patient reports pain and stiffness in morning that diminishes after a few hours| Possible OA8,9

### Assessing Subjective Questions in Patients with Osteoarthritis

Figure 7-13 Osteoarthritis of the knee.

History and Study Quality| Population| Interexaminer Reliability
---|---|---
Acute injury10  | 152 patients with OA of knee| κ = .21 (.03, .39)
Swelling10  | κ = .33 (.17, .49)
Giving way10  | κ = .12 (−.04, .28)
Locking10  | κ = .44 (.26, .62)
Pain, generalized10  | κ = −.03 (.15, .21)
Pain at rest10  | κ = .16 (.00, 32)
Pain rising from chair10  | κ = .25 (.05, .45)
Pain climbing stairs10  | κ = .21 (.06, .48)

### Reliability of the Meniscal Symptom Index in Patients with Meniscal Tear

History and Study Quality| Population| Interexaminer Reliability
---|---|---
Clicking: "Do you feel a clicking sensation or hear a clicking noise when you move your knee?"11  | 30 patients with meniscal tear| κ = .80 (.58, 1.0)
Catching: "Do you feel that sometimes something is caught in your knee that momentarily prevents movement?"11  | κ = .65 (.37, .93)
Giving way: "Do you sometimes feel that your knee will give out and not support your weight?"11  | κ = .80 (.58, 1.0)
Localized pain: "Is your knee pain centered to one spot on the knee that you can point to with your finger?"11  | κ = .84 (.63, 1.0)

### Diagnostic Utility of Meniscal Symptom Index in Patients with Meniscal Tears

Patient Report and Study Quality*| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Clicking: "Do you feel a clicking sensation or hear a clicking noise when you move your knee?"11  | 300 patients with knee pain| Physician's impression, supported by magnetic resonance imaging (MRI) findings| .65 (.56, .73)| .50 (.43, .58)| 1.3| 7.0
Catching: "Do you feel that sometimes something is caught in your knee that momentarily prevents movement?"11  | .59 (.50, .67)| .75 (.68, .80)| 2.4| 5.5
Giving way: "Do you sometimes feel that your knee will give out and not support your weight?"11  | .69 (.60, .77)| .53 (.45, .60)| 1.5| 5.9
Localized pain: "Is your knee pain centered to one spot on the knee that you can point to with your finger?"11  | .74 (.65, .81)| .49 (.31, .56)| 1.5| 5.3

*Among patients with none of these symptoms, 16% (95% CI: 2% to 30%) had symptomatic meniscal tear, while among those with all four symptoms, 76% (95% CI: 63% to 88%) had symptomatic meniscal tear.

### Diagnostic Utility of Patient History: Meniscal and MCL Tears and Effusion

Figure 7-14 Medial collateral ligament rupture.

Patient Report and Study Quality| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Self-noticed swelling12  | 134 patients with traumatic knee complaints| Knee joint effusion per MRI| .80 (.68, .92)| .45 (.35, .39)| 1.5 (1.1, 1.9)| .40 (.20, .90)
Trauma by external force to the leg13  | MCL tear per MRI| .21 (.07, .35)| .89 (.83, .96)| 2.0 (.80, 4.8)| .90 (.70, 1.1)
Rotational trauma13  | .62 (.41, .83)| .63 (.51, .74)| 1.7 (1.1, 2.6)| .60 (.30, 1.1)
Age over 40 years14  | Meniscal tear per MRI| .70 (.57, .83)| .64 (.54, .74)| 2.0 (1.4, 2.8)| .50 (.30, .70)
Continuation of activity impossible1  | .64 (.49, .78)| .55 (.45, .66)| 1.4 (1.0, 2.0)| .70 (.40, 1.0)
Weight bearing during trauma14  | .85 (.75, .96)| .35 (.24, .46)| 1.3 (1.1, 1.6)| .40 (.20, .90)

## Physical Examination Tests

### Screening

Figure 7-15 Identifying the need to order radiographs following acute knee trauma.

#### Reliability of the Ottawa Knee Rule for Radiography

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Ottawa Knee Rule for Radiography in Adults15  | Knee x-rays ordered when patients exhibited any of the following:

(1) Age 55 years or older

(2) Isolated patellar tenderness without other bone tenderness

(3) Tenderness of the fibular head

(4) Inability to flex knee to 90 degrees

(5) Inability to bear weight immediately after injury and in the emergency department

| 90 patients 18 to 79 years old visiting the emergency department of a general hospital with a knee injury that had occurred within the prior 7 days| κ = .51 (.32, .71)

#### Diagnostic Utility of the Ottawa Knee Rule for Radiography

Figure 7-16 Nomogram. Assuming a fracture prevalence of 7% (statistically pooled from Bachmann and colleagues), an adult seen in the emergency department with an acute injury whose finding was negative on the Ottawa Knee Rule would have a 0.37% (95% CI: 0.15% to 1.48%) chance of having a knee fracture. (Adapted from Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975;293:257. Copyright 2005, Massachusetts Medical Society. See also Bachmann LM, Haberzeth S, Steurer J, ter Riet G. The accuracy of the Ottawa Knee Rule to rule out knee fractures: a systematic review. Ann Intern Med. 2004;140:121-124.)

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Ottawa Knee Rule for Radiography in Adults16
2004 Metaanalysis| As above| Statistically pooled data from six high-quality studies involving 4249 adults| X-rays| .99 (.93, 1.0)| .49 (.43, .51)| 1.9| .05 (.02, .23)
Ottawa Knee Rule for Radiography in Children17
2009 Metaanalysis| Statistically pooled data from three high-quality studies involving 1130 children| .99 (.94, 1.0)| .46 (.43, .49)| 1.9 (1.6, 2.4)| .07 (.02, .29)
Ottawa Knee Rule for Radiography in Adults15  | 90 patients 18 to 79 years old visiting the emergency department of a general hospital with a knee injury that had occurred within the prior 7 days| .86 (.57, .96)| .27 (.21, .35)| 1.18| .52

#### Reliability of the Pittsburgh Decision Rule for Radiography

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Pittsburgh Rule for Radiography15  | Knee x-rays ordered when patients exhibited any of the following:

(1) Fall or blunt trauma mechanism

(2) Age older than 12 years or younger than 50 years

or

(1) Fall or blunt trauma mechanism

(2) Age between 12 and 50 years

(3) Inability to walk four weight-bearing steps in emergency department

| 90 patients 18 to 79 years old visiting the emergency department of a general hospital with a knee injury that had occurred within the prior 7 days| κ = .71 (.57, .86)

#### Diagnostic Utility of the Pittsburgh Decision Rule for Radiography

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Pittsburgh Rule for Radiography15  | As above| As above| X-rays| .86 (.57, .96)| .51 (.44, .59)| 1.76| .28

#### Reliability of Detecting Inflammation

Figure 7-17 Fluctuation test.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Observation of swelling18  | Not described| 53 patients with knee pain| κ = −.02 to .65
Palpation for warmth18  | κ = −.18
Palpation for swelling18  | κ = −.11 to .11
Fluctuation test19  | With patient supine, examiner places thumb and finger around patella while pushing any fluid from suprapatellar pouch with other hand. Positive if finger and thumb are pushed apart| 152 patients with unilateral knee dysfunction| κ = .37
Patellar tap test19  | With patient supine, examiner presses suprapatellar pouch and then taps on patella. Patella remains in contact with femur if no swelling is present| κ = .21
Palpation for warmth19  | Examiner palpates anterior aspect of knee. Results compared with uninvolved knee| κ = .66
Visual inspection for redness19  | Examiner visually inspects involved knee for redness and compares it with uninvolved side| κ = .21

#### Reliability of the Stroke Test for Identifying Knee Joint Effusion

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Stroke test20  | Patient is supine and has knee in full extension. Starting at the medial tibiofemoral joint line, the examiner strokes upward two or three times toward the suprapatellar pouch in an attempt to move the swelling within the joint capsule to the suprapatellar pouch. The examiner then strokes downward on the distal lateral thigh, just superior to the suprapatellar pouch, toward the lateral joint line. Positive if fluid is observed on the medial side of the knee and quantified using a 5-point scale| 75 patients referred to an outpatient physical therapy clinic for treatment of knee dysfunction for which effusion testing was deemed appropriate by the treating therapist| κ = .64 (.54, .81)

Stroke Test Grading Scale20

Grade| Test Result
---|---
Zero| No wave produced on downstroke
Trace| Small wave on medial side with downstroke
1+| Larger bulge on medial side with downstroke
2+| Effusion spontaneously returns to medial side after upstroke (no downstroke necessary)
3+| So much fluid that it is not possible to move the effusion out of the medial aspect of the knee

#### Diagnostic Utility of the Ballottement Test for Identifying Knee Joint Effusion

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Ballottement test12  | Examiner quickly pushes the patient's patella posteriorly with two or three fingers. Positive if patella bounces off trochlea with a distinct impact| 134 patients with traumatic knee complaints| Knee joint effusion per MRI| .83 (.71, .94)| .49 (.39, .59)| 1.6 (1.3, 2.1)| .30 (.20, .70)
Self-noticed knee swelling + Ballottement test12  | Combination of two findings| .67 (.52, .81)| .82 (.73, .90)| 3.6 (2.2, 5.9)| .40 (.30, .60)

### Range-of-Motion Measurements

#### Reliability of Range-of-Motion Measurements

Figure 7-18 Measurement of active knee flexion range of motion.

Measurements and Study Quality| Instrumentation| Population| Reliability
---|---|---|---
Active flexion sitting21  | Standard goniometer| 30 patients 3 days after total knee arthroplasty| Interexaminer ICC = .86 (.64, .94)
Passive flexion sitting21  | Interexaminer ICC = .88 (.69, .95)
Active flexion supine21  | Interexaminer ICC = .89 (.78, .95)
Passive flexion supine21  | Interexaminer ICC = .88 (.77, .94)
Active extension21  | Interexaminer ICC = .64 (.38, .81)
Passive extension21  | Interexaminer ICC = .62 (.28, .80)
Passive flexion18  | Standard goniometer| 53 patients with knee pain| Intraexaminer ICC = .82
Interexaminer ICC = .68
Passive flexion
Passive extension22  | Standard goniometer| 25 patients with knee OA| Interexaminer ICC = .87 (.73, .94)
Interexaminer ICC = .69 (.41, .85)
Passive flexion and extension23  | Three standard goniometers (metal, large plastic, and small plastic)| 24 patients referred for physical therapy| Intraexaminer ICC
| Flexion| Extension
Metal| .97| .96
Large| .99| .91
Small| .99| .97
Passive flexion24  | Standard goniometer| 30 asymptomatic subjects| Interexaminer ICC = .99
Passive flexion
Passive extension25  | Standard goniometer| 43 patients referred for physical therapy where examination would normally include passive range-of-motion measurements of knee| Intraexaminer ICC| Interexaminer ICC
Flexion| .99| Flexion| .90
Extension| .98| Extension| .86
Passive flexion
Passive extension25  | Visual estimation| Interexaminer ICC = .83
Interexaminer ICC = .82
Active flexion
Active extension26  | Standard goniometer| 20 asymptomatic subjects| Intraexaminer ICC = .95
Intraexaminer ICC = .85
Active flexion27  | Universal goniometer| 60 healthy university students| Intraexaminer ICC = .86 to .97
Interexaminer ICC = .62 to 1.0
Passive flexion
Passive extension28  | Universal goniometer| 79 patients with OA of knee| Intraexaminer ICC = .95 to .96
Intraexaminer ICC = .71 to .86
Passive flexion
Passive extension19  | Standard goniometer| 152 patients with unilateral knee dysfunction| Interexaminer ICC
Involved knee| Uninvolved knee
Flexion| .97| Flexion| .80
Extension| .94| Extension| .72

ICC, Intraclass correlation coefficient.

#### Reliability of Determining Capsular and Noncapsular End Feels

Figure 7-19 Assessment of end feel for knee flexion.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Flexion end feel
Extension end feel22  | End feel is assessed at end of passive range of motion and categorized as "normal," "empty," "stiff," or "loose"| 25 patients with knee OA| Interexaminer ICC = .31
(−.53, 1.15)
Interexaminer ICC = .25 (−.18, .68)
Flexion end feel
Extension end feel28  | End feel is assessed at end of passive range of motion and categorized as "capsular," "tissue approximation," "springy block," "bony," "spasm," "empty"| 79 patients with OA of knee| Intraexaminer κ = .48
Intraexaminer κ = .17
Flexion end feel
Extension end feel29  | End feel is assessed at end of passive range of motion and graded on an 11-point scale with "capsular at end of normal range," "capsular early in range," "capsular," "tissue approximation," "springy block," "bony," "spasm," "empty"| 40 patients with unilateral knee pain| Intraexaminer κ = .76 (.55, .97)
Interexaminer κ = −.01 (−.36, .35)
Intraexaminer κ = 1.0 (1.0, 1.0)
Interexaminer κ = .43 (−.06, .92)
End-feel assessment during Lachman test30  | Examiners asked to grade end feel during Lachman test. End feel graded as "hard" or "soft"| 35 patients referred to physical therapy clinics for rehabilitation of knee joint| Intraexaminer κ = .33
End feel of adduction stress applied to knee31  | Examiner places knee in 0 degrees and 30 degrees of flexion and applies valgus force through knee. End feel graded as "soft" or "firm"| 50 patients referred to an outpatient orthopaedic clinic who would normally undergo valgus stress tests directed at knee| Interexaminer 0 degrees of flexion κ = .00 30 degrees of flexion κ = .33

#### Reliability of Assessing Pain during Range-of-Motion Movements

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Pain resistance sequence:
Passive flexion
Passive extension28  | Pain sequence is assessed during passive range of motion of knee. Pain is graded on a 4-point scale as "no pain," "pain occurs after resistance is felt," "pain occurs at the same time as resistance is felt," or "pain occurs before resistance is felt"| 79 patients with OA of knee| Intraexaminer κ = .34
Intraexaminer κ = .36
Pain resistance sequence:
Passive flexion29  | 40 patients with unilateral knee pain| Intraexaminer κ = .78 (.68, .87)
Interexaminer κ = .51
Pain resistance sequence:
Passive extension29  | Intraexaminer κ = .85 (.75, .95)
Interexaminer κ = .42
Pain resistance sequence:
Passive flexion19  | Examiner passively flexes knee. Subject is directed to report when pain is above baseline levels. Examiner reports if pain occurs before, during, or after passive range-of-motion limitation has occurred| 152 patients with unilateral knee dysfunction| Interexaminer κ = .28
Assessment of pain during adduction stress applied to knee31  | Examiner places knee in 0 degrees and 30 degrees of flexion and applies valgus force through knee. Pain responses recorded| 50 patients referred to outpatient orthopaedic clinic who would normally undergo valgus stress tests directed at knee| Interexaminer 0 degrees of flexion κ = .40
30 degrees of flexion κ = .33

### Assessing Strength

#### Reliability of Strength Assessment

Measurements and Study Quality| Instrumentation| Population| Reliability
---|---|---|---
Determination of one repetition maximum (1RM) knee extension32  | With patient sitting in leg extension machine, patient performs slow knee extension from 100 degrees to 0 degrees. Amount of weight is systematically increased until patient can no longer complete lift. 1RM defined as the heaviest resistance that could be lifted once| 27 asymptomatic adults| Interday (same examiner) ICC = .90
Interexaminer ICC = .96
Isometric extensor strength18  | Against inflated sphygmomanometer cuff| 53 patients with knee pain| Intraexaminer ICC = .85
Interexaminer ICC = .83
Isometric flexor strength18  | Intraexaminer ICC = .89
Interexaminer ICC = .70

#### Diagnostic Utility of Manual Muscle Testing for Detecting Strength Deficits

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Manual muscle testing of knee extension strength33  | Patient extends knee as forcefully as possible into examiner's hand. Strength graded on a scale of 0 to 5| 107 patients from an acute rehabilitation hospital| Side-to-side difference with a handheld dynamometer of:
15%
20%
25%
30%| .63| .89| 5.7| .42
.68| .88| 5.7| .36
.72| .83| 4.2| .34
.72| .77| 3.1| .36

### Assessing Muscle Length

#### Reliability of Assessing Muscle Length

Figure 7-20 Quadriceps length.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Quadriceps length22  | Assessed with Thomas test| 25 patients with knee OA| Result: κ = .18 (−.17, .53)
Pain: κ = .39 (.14, .64)
Quadriceps length34  | Passive knee flexion test with inclinometer| 14 asymptomatic participants| Intraexaminer ICC = .73 to .90
Interexaminer ICC = .81 to .95
Hamstring length34  | Passive knee extension test with inclinometer| 14 asymptomatic participants| Intraexaminer ICC = .88 to .97
Interexaminer ICC = .88 to .97
Hamstring length35  | Active knee extension test with goniometer| 16 asymptomatic participants| ICC = .81 (.41, .94)
Hamstring length36  | Straight-leg raise test with inclinometer| 30 patients with patellofemoral pain syndrome| ICC = .92 (.82, .96)
Iliotibial band/tensor fasciae latae complex length36  | Ober test with inclinometer| ICC = .97 (.93, .98)
Quadriceps length36  | Quadriceps femoris muscle angle with inclinometer| ICC = .91 (.80, .96)
Gastrocnemius length36  | Dorsiflexion with knee extended and inclinometer| ICC = .92 (.83, .96)
Soleus length36  | Dorsiflexion with knee flexed 90 degrees and inclinometer| ICC = .86 (.71, .94)

### Assessing Bony Alignment

#### Reliability of Assessment of Mediolateral Patellar Tilt

Figure 7-21 Examination of mediolateral patellar tilt.

Test and Measure Quality| Procedure| Determination of Positive Finding| Population| Reliability
---|---|---|---|---
Mediolateral tilt37  | Examiner estimates patellar alignment while palpating medial and lateral aspects of patella| Patellar orientation graded using an ordinal scale extending from –2 to +2, with –2 representing a lateral tilt, 0 no appreciable tilt, and +2 a medial tilt| 27 asymptomatic subjects| Intraexaminer κ = .57
Interexaminer κ = .18
Mediolateral tilt38  | Examiner palpates medial and lateral borders of patella with thumb and index finger| If digit palpating the medial border is higher than the lateral border, then patella is considered laterally tilted. If digit palpating the lateral border is higher than the patella, then patella is medially tilted| 66 patients referred for physical therapy who would normally undergo an evaluation of patellofemoral alignment| Interexaminer κ = .21
Mediolateral tilt39  | Examiner attempts to palpate posterior surface of medial and lateral patellar borders| Scored 0, 1, or 2. Score is 0 if examiner palpates posterior border on both medial and lateral sides. Score is 1 if more than 50% of lateral border can be palpated but posterior surface cannot. Score is 2 if less than 50% of lateral border can be palpated| 56 subjects, 25 of whom had symptomatic knees| Intraexaminer κ = .28 to .33
Interexaminer κ = .19
Patellar tilt test39  | Examiner lifts lateral edge of patella from lateral femoral epicondyle| Graded as having positive, neutral, or negative angle with respect to horizontal plane| 99 knees, of which 26 were symptomatic| Intraexaminer κ = .44 to .50
Interexaminer κ = .20 to .35

#### Reliability of Assessment of Patellar Orientation

Figure 7-22 Examination of mediolateral patellar orientation.

Test and Measure Quality| Procedure| Determination of Positive Finding| Population| Reliability
---|---|---|---|---
Mediolateral position37  | Examiner visually estimates patellar alignment while palpating sides of lateral epicondyles with index fingers and patella midline with thumbs| Patellar orientation graded using an ordinal scale extending from −2 to +2, with −2 representing a lateral displacement and +2 a medial displacement| 27 asymptomatic subjects| Intraexaminer κ = .40
Interexaminer κ = .03
Mediolateral orientation40  | With patient's knee supported in 20 degrees of flexion, examiner identifies medial and lateral epicondyle of femur and midline of patella. Examiner then marks medial and lateral epicondyle and patella midline with tape| Distances between patella midline and medial and lateral condyles are measured| 20 healthy physiotherapy students| Interexaminer
Medial distance: ICC = .91
Lateral distance: ICC = .94
Mediolateral orientation41  | As described above| As described above| 15 asymptomatic subjects| Interexaminer ICC = .60 to .75
Mediolateral displacement38  | Examiner palpates medial and lateral epicondyles with index fingers while simultaneously palpating midline of patella with thumbs| Distance between index fingers and thumbs should be same. When distance between index finger palpating lateral epicondyle is less, patella is laterally displaced. When distance between index finger palpating medial epicondyle is less, patella is medially displaced| 66 patients referred for physical therapy who would normally undergo evaluation of patellofemoral alignment| Interexaminer κ = .10
Mediolateral glide39  | Examiner uses a tape measure to record distance from medial and lateral femoral condyles to midpatella| Scored 0 or 1. Score is 0 if the distance from medial epicondyle to midpatella equals distance from lateral epicondyle to midpatella. Score is 1 if the distance from medial epicondyle to midpatella is 0.5 cm greater than from lateral condyle to midpatella| 56 subjects, 25 of whom had symptomatic knees| Intraexaminer κ = .11 to .35
Interexaminer κ = .02

#### Reliability of Assessing Superoinferior Patellar Tilt

Figure 7-23 Examination of anteroposterior patellar tilt.

Test and Measure Quality| Procedure| Determination of Positive Finding| Population| Reliability
---|---|---|---|---
Superoinferior tilt37  | Examiner visually estimates patellar alignment while palpating superior and inferior patellar poles| Patellar orientation graded using an ordinal scale extending from −2 to +2, with −2 representing inferior patellar pole below superior pole and +2 representing inferior patellar pole above superior pole| 27 asymptomatic subjects| Intraexaminer κ = .50
Interexaminer κ = .30
Anterior tilt38  | Examiner palpates inferior patellar pole| If examiner easily palpates inferior pole, no anterior tilt exists. If downward pressure on superior pole is required to palpate inferior pole, it is considered to have an anterior tilt| 66 patients referred for physical therapy who would normally undergo evaluation of patellofemoral alignment| Interexaminer κ = .24
Anteroposterior tilt component39  | Examiner palpates inferior and superior patellar poles| Scored 0, 1, or 2. Score is 0 if inferior patellar pole is as easily palpable as superior pole. Score is 1 if inferior patellar pole is not as easily palpable as superior pole. Score is 2 if inferior pole is not clearly palpable compared with superior pole| 56 subjects, 25 of whom had symptomatic knees| Intraexaminer κ = .03 to .23
Interexaminer κ = .04

#### Reliability of Assessing Patellar Rotation

Figure 7-24 Examination of patellar rotation.

Test and Measure Quality| Procedure| Determination of Positive Finding| Population| Reliability
---|---|---|---|---
Rotation37  | Examiner positions index fingers along longitudinal axes of patella and estimates acute angle formed| Graded using ordinal scale extending from −2 to +2. −2 represents longitudinal axis of patella being more lateral than axis of femur. +2 represents patella being more medial than axis of femur| 27 asymptomatic subjects| Intraexaminer κ = .41
Interexaminer κ = −.03
Patellar rotation38  | Examiner determines relationship between longitudinal axis of patella and femur| Longitudinal axis of patella should be in line with anterior superior iliac spine. If distal end of patella is medial, it is considered to be medially rotated. If distal end is lateral, it is considered to be laterally rotated| 66 patients referred for physical therapy who would normally undergo evaluation of patellofemoral alignment| Interexaminer κ = .36
Patellar rotation component39  | Scored as −1, 0, or +1. Score is 0 when patellar long axis is parallel to long axis of femur. Score is 1 when inferior patellar pole is lateral to axis of femur and classified as a lateral patellar rotation. Score is −1 when inferior pole is medial to axis of femur and classified as medial patellar rotation| 56 subjects, 25 of whom had symptomatic knees| Intraexaminer κ = −.06 to .00Interexaminer κ = −.03

#### Reliability of Patellar Mobility in Patients with Patellofemoral Pain Syndrome

Test and Measure Quality| Procedure| Determination of Positive Finding| Population| Reliability
---|---|---|---|---
Superior-inferior mobility42  | Examiner translates patella inferiorly| Patellar mobility graded as diminished or nondiminished| 82 patients with anterior knee pain of more than 4 weeks' duration| Interexaminer κ = .55 (−.37, .69)
Medial-lateral mobility42  | Examiner translates patella laterally| Interexaminer κ = .59 (.42, .72)
Inferior pole tilt42  | Examiner applies a posterior force with index finger on superior pole of patella and observes for tilting of inferior pole of patella| Interexaminer κ = .48 (−.28, .61)
Patellar tendon mobility42  | Examiner stabilizes the patella with one hand while translating the patellar tendon medially with the other hand| Interexaminer κ = .45 (−.27, .56)

#### Diagnostic Utility of Patellar Mobility in Identifying Patients with Patellofemoral Pain Syndrome

Test and Study Quality| Description and Positive Findings| Population| Reference Standard*| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Superior-inferior mobility42  | Examiner translates patella inferiorly. Patellar mobility graded as diminished or nondiminished| 82 patients with anterior knee pain of more than 4 weeks' duration| Physician diagnosis of patellofemoral pain syndrome| .63 (.56, .69)| .56 (.39, .72)| 1.4 (.90, 2.5)| .70 (.40, 1.1)
Medial-lateral mobility42  | Examiner translates patella laterally. Patellar mobility graded as diminished or nondiminished| .54 (.47, .59)| .69 (.52, .83)| 1.8 (.90, 3.6)| .70 (.50, 1.0)
Inferior pole tilt42  | Examiner applies a posterior force with index finger on superior pole of patella and observes for tilting of inferior pole of patella. Patellar mobility graded as diminished or nondiminished| .19 (.13, .22)| .83 (.68, .93)| 1.1 (.40, 3.0)| .90 (.80, 1.3)
Patellar tendon mobility42  | Examiner stabilizes the patella with one hand while translating the patellar tendon medially with the other hand. Patellar mobility graded as diminished or nondiminished| .49 (.43, .53)| .83 (.66, .93)| 2.8 (1.3, 7.3)| .60 (.50, .90)

*Note: There is currently no definitive reference standard for patellofemoral pain syndrome. The disorder is a clinical diagnosis often made by ruling out other potential disorders.

#### Reliability of Assessing Quadriceps Angle Measurements

Figure 7-25 Quadriceps angle.

Test and Measure Quality| Procedure| Population| Reliability ICC
---|---|---|---
Q angle36  | Proximal arm of goniometer is aligned with anterior superior iliac spine, distal arm is aligned with tibial tubercle, and fulcrum is positioned over patellar midpoint| 30 patients with patellofemoral pain syndrome| Interexaminer ICC = .70 (.46, .85)
Q angle37  | 27 asymptomatic subjects| Intraexaminer ICC = .63
Interexaminer ICC = .23
Q angle43  | As above. Measure with knee fully extended and in 20 degrees of flexion| 50 asymptomatic knees| Interexaminer at full extension
Right ICC = .14 to .21| Left ICC = .08 to .11
Interexaminer at 20 degrees of knee flexion
Right ICC = .04 to .08| Left ICC = .13 to .16
Q angle44  | Proximal arm of goniometer is aligned with anterior superior iliac spine, distal arm is aligned with tibial tubercle, and fulcrum is positioned over patellar midpoint| 52 asymptomatic subjects| Intraexaminer ICC = .88 (.81, .92)
Q angle45  | As above. Measure with knee in 10 degrees of flexion| 18 asymptomatic subjects| Short-arm goniometer
Intraexaminer ICC = .78 (.67, .86)| Interexaminer ICC = .56 (.28, .75)
Long-arm goniometer
Intraexaminer ICC = .92 (.88, .95)| Interexaminer ICC = .88 (.77, .93)

#### Reliability of Assessing the Angle between the Longitudinal Axis of the Patella and the Patellar Tendon (A Angle)

Figure 7-26 The A angle.

Test and Measure Quality| Procedure| Population| Reliability
---|---|---|---
A angle37  | Proximal and distal goniometer arms are aligned with middle of superior patellar pole and tibial tubercle. Fulcrum is positioned over midpoint of inferior patellar pole. Angle recorded in degrees| 27 asymptomatic subjects| Intraexaminer ICC = .61
Interexaminer ICC = .49
A angle46  | Superior patellar pole, superior patellar width, inferior patellar width, inferior patellar pole, and tibial tuberosity are identified. The A angle is then measured with a goniometer. Angle recorded in degrees| 36 asymptomatic subjects| Intraexaminer ICC = .20 to .32
Interexaminer ICC = −.01

#### Reliability of the Lateral Pull Test to Assess Patellar Alignment

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Lateral pull test47  | With patient supine and knee extended, examiner asks patient to perform isometric quadriceps contraction. Examiner observes patellar tracking during contraction. Positive if patella tracks more laterally than superiorly. Negative if superior displacement is equal to lateral displacement| 99 knees, 26 of which were symptomatic| Intraexaminer κ = .39 to .47
Interexaminer κ = .31

### Palpation

#### Reliability of Pain during Palpation

Figure 7-27 Palpation of joint lines.

Physical Finding and Study Quality| Population| Reliability
---|---|---
Palpation for tenderness18  | 53 patients with knee pain| Interexaminer κ = .10 to .30
Posterior joint line tenderness48  | 71 patients with knee pain| Interexaminer κ = .48
Tenderness at medial joint line10  | 152 patients with OA of knee| Interexaminer κ = .21 (.01, .41)
Tenderness at lateral joint line10  | Interexaminer κ = .25 (.07, .43)

#### Diagnostic Utility of Joint Line Tenderness

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Joint line tenderness49   2010 Metaanalysis| Depended on study, but generally: Examiner palpates joint line with patient's knee in 90 degrees of flexion. Positive if test reproduces pain| Pooled estimates from 13 studies*| Meniscal tears via arthroscopy, arthrotomy, or MRI| .64 (.62, .66)| .61 (.59, .63)| 1.6 (1.5, 1.8)| .59 (.54, .65)
Joint line tenderness50   2008 Metaanalysis| Pooled, quality-adjusted estimates from eight studies*| Meniscal tears via arthroscopy or arthrotomy| .76 (.73, .80)| .77 (.64, .87)| 3.3| .31
Joint line tenderness51   2007 Metaanalysis| Pooled estimates from 14 studies*| Meniscal tears via arthroscopy, arthrotomy, or MRI| .63 (.61, .66)| .77 (.76, .79)| 2.7| .48
Joint line tenderness52  | Same as above| 109 patients with history or symptoms suggestive of meniscal tear| Meniscal tears via arthroscopy| Medial meniscus
.83 (.71, .90)| .76 (.55, .89)| 3.50| .22
Lateral meniscus
.68 (.46, .85)| .97 (.89, .99)| 22.7| .33

*Some of the included studies would not have met our QUADAS quality criterion for inclusion.

#### Diagnostic Utility of Joint Line Fullness

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Joint line fullness53  | With patient supine, the examiner palpates along the joint line to identify palpable fullness in comparison with the normal knee. The lateral compartment of the knee was examined at 30 to 45 degrees of knee flexion to relax the iliotibial band and the medial compartment, at 70 to 90 degrees of flexion to relax the medial collateral ligament. Any joint line fullness causing a loss of normal joint compression was a positive result| 100 patients undergoing routine knee arthroscopy (18 for lateral compartment pathologic condition, 70 for medial compartment pathologic condition, 12 for unknown intraarticular knee pathologic condition)| Meniscal tears via arthroscopy| .70| .82| 3.89| .37

### Special Tests

#### Reliability of the Lachman Test

Figure 7-28 Lachman test (see Fig. 7-29 for prone Lachman test).

Test and Measure Quality| Procedure| Determination of Positive Finding| Population| Reliability
---|---|---|---|---
Lachman test30  | Examiners perform Lachman test as they would in practice| Results are graded as "positive" or "negative." Examiners also grade amount of anterior tibial translation as 0, 1+, 2+, or 3+. Score of 0 represents no difference in tibial translation between unaffected and affected knees| 35 patients referred to physical therapy clinics for rehabilitation of knee joint| For positive or negative findings
Intraexaminer κ = .51
Interexaminer κ = .19
For grading of tibial translation
Intraexaminer κ = .44 to .60
Interexaminer κ = .02 to .61
Lachman test10  | Not specified| Not specified| 152 patients with OA of knee| Interexaminer κ = −.08 (−.12, .04)
Prone Lachman test54   (see Video 7-1)| Patient in prone position with lower extremity fully relaxed and small towel roll placed under distal end of the involved thigh. The examiner places the distal hand on the anterior proximal tibia, with the index finger and long finger positioned on each side of the patellar tendon, resting on the anterior joint line. The examiner's thigh is placed under the patient's shin to support the patient's knee in 10 to 30 degrees of flexion. The heel of the examiner's proximal hand is placed over the posterocentral aspect of the proximal tibia, with the fingers lightly resting on the medial gastrocnemius, and is used to direct an anterior force on the posterior tibia, while the fingers of the distal hand apply slight pressure directed posteriorly and simultaneously palpate the amount of anterior tibial translation relative to the femur| The test is positive if there is absence of end feel or a perception of greater than 3 mm anterior translation on the injured side as compared with the uninvolved side| 52 patients referred from the emergency room of a hospital to orthopaedic surgery for definitive evaluation of a painful knee| Interexaminer κ = .60

#### Diagnostic Utility of the Lachman Test in Identifying Anterior Cruciate Ligament Tears

Figure 7-29 Prone Lachman test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Lachman test (without anesthesia)55
2013 Metaanalysis| Depended on study, but generally: With patient supine and knee joint flexed between 10 and 20 degrees, examiner stabilizes femur with one hand. With other hand, examiner translates tibia anteriorly. Positive if lack of end point for tibial translation or subluxation is positive| Pooled estimates from 1579 patients from17 studies*| ACL tears via arthroscopy, arthrotomy, or MRI| .81| .81| 4.26| .24
Lachman test (with anesthesia)55   2013 Metaanalysis| Pooled estimates from 1189 patients from 12 studies*| .91| .78| 4.14| .12
Lachman test (without anesthesia)56
2006 Metaanalysis| Pooled estimates from 2276 patients from 21 studies*| .85 (.83, .87)| .94 (.92, .95)| 1.2 (4.6, 22.7)| .20 (.10, .30)
Lachman test (with anesthesia)56   2006 Metaanalysis| Pooled estimates from 1174 patients from 15 studies*| .97 (.96, .98)| .93 (.89, .96)| 12.9 (1.5, 108.5)| .10 (.00, .30)
Prone Lachman test54  | As described for the prone Lachman test above| 52 patients referred from the emergency room of a hospital to orthopaedic surgery for definitive evaluation of a painful knee| ACL tears via arthroscopy or MRI| .70 (.40, .89)| .80 (.38, .96)| 3.5 (5.8, 21.2)| .57 (.32, .69)

*Some of the included studies would not have met our QUADAS quality criterion for inclusion.

#### Reliability of the Anterior Drawer Test

Figure 7-30 Anterior drawer test.

Test and Study Quality| Description and Positive Finding| Population| Interexaminer Reliability
---|---|---|---
Anterior drawer test18  | Not specified| 53 patients with knee pain| κ = .34

#### Diagnostic Utility of the Anterior Drawer Test in Identifying Anterior Cruciate Ligament Tears

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Anterior drawer test (without anesthesia)55
2013 Metaanalysis| Depended on study, but generally: With patient's knee flexed between 60 and 90 degrees with foot on examination table, examiner draws tibia anteriorly. Positive if there is anterior subluxation of more than 5 mm| Pooled estimates from 934 patients from 13 studies*| ACL tears via arthroscopy, arthrotomy, or MRI| .38| .81| 2| .77
Anterior drawer test (without anesthesia)55
2013 Metaanalysis| Pooled estimates from 826 patients from 10 studies*| .63| .91| 7| .41
Anterior drawer test (without anesthesia)56
2006 Metaanalysis| Pooled estimates from 1809 patients from 20 studies*| .55 (.52, .58)| .92 (.90, .94)| 7.3 (3.5, 15.2)| .50 (.40, .60)
Anterior drawer test (with anesthesia)56
2006 Metaanalysis| Pooled estimates from 1306 patients from 15 studies*| .77 (.82, .91)| .87 (.82, .91)| 5.9 (.90, 38.2)| .40 (.20, .80)
Anterior drawer test (without anesthesia)57  | Patient in supine position with hip flexed to 45 degrees and knee flexed to 90 degrees. With the foot stabilized on the examination table and the hamstrings relaxed, frequent manual gentle anteroposterior forces are applied to the proximal tibia, and tibia anteroposterior displacement in flexed knee is measured. The degree of displacement is compared with normal side. Positive if displacement is more than 6 mm comparing the opposite side with a soft end point| 428 patients with suspected ACL rupture| ACL tears via arthroscopy| .94| Not tested| Not tested| Not tested
Anterior drawer test (with anesthesia)57  | .96| Not tested| Not tested| Not tested

*Some of the included studies would not have met our QUADAS quality criterion for inclusion.

#### Diagnostic Utility of the Pivot Shift Test in Identifying Anterior Cruciate Ligament Tears

Figure 7-31 Pivot shift test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Pivot shift test (without anesthesia)55
2013 Metaanalysis| Depended on study, but generally: Patient's knee is placed in 10 to 20 degrees of flexion, and tibia is rotated internally while examiner applies valgus force. Positive if lateral tibial plateau subluxes anteriorly| Pooled estimates from 1192 patients from 12 studies*| ACL tears via arthroscopy, arthrotomy, or MRI| .28| .81| 1.47| .89
Pivot shift test (with anesthesia)55
2013 Metaanalysis| Pooled estimates from 1094 patients from 10 studies*| .73| .98| 36.5| .28
Pivot shift test (without anesthesia)56
2006 Metaanalysis| Pooled estimates from 1431 patients from 15 studies*| .24 (.21, .27)| .98 (.96, .99)| 8.5 (4.7, 15.5)| .90 (.80, 1.0)
Pivot shift test (with anesthesia)56
2006 Metaanalysis| Pooled estimates from 1077 patients from 13 studies*| .74 (.71, .77)| .99 (.96, 1.0)| 2.9 (2.8, 156.2)| .30 (.10, .70)

*Some of the included studies would not have met our QUADAS quality criterion for inclusion.

#### Diagnostic Utility of the Loss-of-Extension Test in Identifying Anterior Cruciate Ligament Tears

Figure 7-32 Loss-of-extension test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Loss-of-extension test58   (see Video 7-2)| The examiner stabilizes the thigh of the affected knee with one hand with the patella facing forward, while the other hand extends the knee into maximum passive extension. A second examiner measures the distance between the patient's heel and the bed. The test is positive when the affected knee extends less than the healthy knee| 196 patients with unilateral knee pathologic findings| ACL tears via MRI or surgical findings| .78| .95| 15.6| .23

#### Reliability of Varus and Valgus Stress Tests

Figure 7-33 Varus and valgus stress tests.

Test and Study Quality| Description and Positive Finding| Population| Interexaminer Reliability
---|---|---|---
Varus test18  | Not specified| 53 patients with knee pain| (Laxity) κ = .24
(Pain) κ = .18
Valgus test18  | (Laxity) κ = .48
(Pain) κ = .37
Varus test10  | 152 patients with OA of knee| κ = 0 (−.18, .18)
Valgus test10  | κ = .05 (−.13, 2.3)

#### Diagnostic Utility of Valgus Stress for Identifying Medial Collateral Ligament Tears

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Pain with valgus stress at 30 degrees of knee flexion13  | Not specifically described| 134 patients with traumatic knee complaint| MCL tears per MRI| .78 (.64, .92)| .67 (.57, .76)| 2.3 (1.7, .3.3)| .30 (.20, .60)
Laxity with valgus stress at 30 degrees of knee flexion13  | .91 (.81, 1.0)| .49 (.39, .59)| 1.8 (1.4, 2.2)| .20 (.10, .60)

#### Reliability of the McMurray Test

Figure 7-34 McMurray test.

Test and Study Quality| Description and Positive Finding| Population| Reliability
---|---|---|---
McMurray test10  | Knee is passively flexed, externally rotated, and axially loaded while brought into extension. Test is repeated in internal rotation. Positive if a palpable or audible click or pain occurs during rotation| 152 patients with osteoarthritis of knee| Interexaminer κ = .16
(−.01, .33)

#### Diagnostic Utility of the McMurray Test

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
McMurray test49   2010 Metaanalysis| Depended on study, but generally same as above| Pooled estimates from 13 studies*| Arthroscopy, arthrotomy, or MRI| .51 (.48, .53)| .78 (.77, .80)| 2.3 (2.1, 2.6)| .63 (.59, .68)
McMurray test50   2008 Metaanalysis| Pooled, quality-adjusted estimates from eight studies*| Arthroscopy or arthrotomy| .55 (.50, .60)| .77 (.62, .87)| 2.4| .58
McMurray test51   2007 Metaanalysis| Pooled estimates from 14 studies*| Arthroscopy, arthrotomy, or MRI| .71 (.67, .73)| .71 (.69, .73)| 2.5| .41
McMurray test52  | Same as above| 109 patients with history or symptoms suggestive of meniscal tear| Meniscal tears via arthroscopy| Medial meniscus
.50 (.38, .62)| .77 (.57, .90)| 2.17| .65
Lateral meniscus
.21 (.09, .43)| .94 (.85, .98)| 3.5| .84

*Some of the included studies would not have met our QUADAS quality criterion for inclusion.

#### Diagnostic Utility of the Apley Test

Figure 7-35 Apley grinding test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Apley test49   2010 Metaanalysis| Depended on study, but generally: Patient is prone with knee flexed to 90 degrees. Examiner places downward pressure on foot, compressing knee, while internally and externally rotating tibia| Pooled estimates from seven studies*| Arthroscopy| .38 (.36, .41)| .84 (.82, .86)| 2.4 (2.0, 3.0)| .73 (.68, .78)
Apley test50
2008 Metaanalysis| Pooled, quality-adjusted estimates from three studies*| Arthroscopy or arthrotomy| .22 (.17, .28)| .88 (.72, .96)| 1.8| .89
Apley test51
2007 Metaanalysis| Pooled estimates from seven studies*| Arthroscopy, arthrotomy, or MRI| .61 (.56, .66)| .70 (.68, .72)| 2.0| .56

*Some of the included studies would not have met our QUADAS quality criterion for inclusion.

#### Diagnostic Utility of Other Tests for Identifying Meniscal Tears

Figure 7-36 Ege test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Pain with passive knee flexion14  | Not described| 134 patients with traumatic knee complaint| Meniscal tear per MRI| .77 (.64, .89)| .41 (.31, .52)| 1.3 (1.0, 1.7)| .60 (.30, 1.0)
Ege test59  | Patient stands with feet 30 to 40 cm apart. To detect medial meniscal tears, the patient performs a full squat with legs maximally externally rotated. To detect lateral meniscal tears, the patient performs a full squat with legs maximally internally rotated. Positive when the patient feels pain and/or a click in the joint line| 150 consecutive patients with knee symptoms related to intraarticular knee pathologic conditions| Knee arthroscopy| Medial
.67| .81| 3.5| .41
Lateral
.64| .90| 6.4| .40

#### Diagnostic Utility of the Thessaly Test for Identifying Meniscal Tears

Figure 7-37 Thessaly test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Thessaly test60  | Patient stands on the symptomatic leg while holding the examiner's hands. The patient then rotates the body and leg internally and externally with the knee bent 5 degrees and then 20 degrees. Positive when the patient feels pain and/or a click in the joint line| 213 knee injury patients and 197 asymptomatic volunteers| Meniscal tear per MRI| With knee at 5 degrees of flexion
.66 MMT| .96 MMT| 16.5 MMT| .35 MMT
.81 LMT| .91 LMT| 9.0 LMT| .21 LMT
With knee at 20 degrees of flexion
.89 MMT| .97 MMT| 29.7 MMT| .11 MMT
.92 LMT| .96 LMT| 23.0 LMT| .08 LMT
Thessaly test61  | As above, except only at 20 degrees of knee flexion| 116 consecutive patients who had knee arthroscopy for suspected meniscal pathologic conditions| Meniscal tear via arthroscopy| .90| .98| 39.3| .09
Thessaly test52  | As above, with 20 degrees of knee flexion| 109 patients with history or symptoms suggestive of meniscal tear| Meniscal tears via arthroscopy| Medial meniscus
.59 (.47, .71)| .67 (.45, .83)| 1.79| .61
Lateral meniscus
.31 (.15, .54)| .95 (.87, .98)| 6.2| .73

LMT, lateral meniscal tear; MMT, medial meniscal tear.

#### Diagnostic Utility of the Moving Patellar Apprehension Test for Identifying Patellar Instability

Figure 7-38 Moving patellar apprehension test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Moving patellar apprehension test62  | With patient supine with ankle off examination table and knee fully extended, examiner flexes the knee to 90 degrees and back to extension while holding the patella in lateral translation. The procedure is then repeated with medial translation. Positive if patient exhibits apprehension and/or quadriceps contraction during lateral glide and no apprehension during medial glide| 51 patients who had had knee surgery and in whom patellar instability was suspected| Ability to dislocate the patella when examined under anesthesia| 1.0| .88| 8.3| .00

### Combinations of Tests

#### Diagnostic Utility of Combinations of Tests for Diagnosing Meniscal Tears

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Both pain and laxity with valgus stress at 30 degrees
+
Trauma by external force to the leg or rotational trauma13  | Self-reported trauma and physical examination of valgus stress| 134 patients with traumatic knee complaint| MRI| .56 (.33, .79)| .91 (.85, .98)| 6.4 (2.7, 15.2)| .50 (.30, .80)
Age older than 40 years
+
Continuation of activity impossible
+
Weight bearing during trauma
+
Pain with passive knee flexion14  | All four factors positive| 134 patients with traumatic knee complaint| MRI| .15 (.05, .25)| .97 (.94, 1.0)| 5.8 (1.3, 26.8)| .90 (.80, 1.0)
Tenderness to palpation of joint line
+
Bohler test
+
Steinmann test
+
Apley grinding test
+
Payr test
+
McMurray test7  | If two tests are positive, then patient is considered to have meniscal lesion| 36 patients scheduled to undergo arthroscopic surgery| Arthroscopic visualization| .97| .87| 7.5| .03
Combined historical and physical examination63  | Physical examination includes assessment of joint effusion and joint line tenderness, McMurray test, hyperflexion test, and squat test. Exact procedures of each test not defined| 100 consecutive patients who underwent arthroscopic surgery of knee| Arthroscopic visualization| .86| .83| 5.06| .17
Patient history
+
Joint line tenderness
+
McMurray test
+
Steinmann test
+
Modified Apley test64  | Conclusion of examiner| 50 patients with clinical diagnosis of meniscal tears and/or ACL rupture| Knee arthroscopy| Medial
.87| .68| 2.7| .19
Lateral
.75| .95| 15.0| .26
Joint line tenderness
+
McMurray test52  | Both tests positive| 109 patients with history or symptoms suggestive of meniscal tear| Meniscal tears via arthroscopy| Medial meniscus
.91| .91| 10.1| .10
Lateral meniscus
.75| .99| 75| .25
Joint line tenderness
+
Thessaly test (20 degrees of knee flexion)52  | Medial meniscus
.93| .92| 11.6| .08
Lateral meniscus
.78| .99| 78| .22

Figure 7-39 Types of meniscal tears.

#### Diagnostic Utility of Combinations of Tests for Diagnosing Pathologic Conditions of the Knee Other Than Meniscal Tears

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Clinical examination65  | Retrospective review of clinical examination and clinical diagnosis| 698 patients who had undergone knee arthroscopy| Medial meniscal tear via arthroscopy| .92| .79| 4.4| .10
OA via arthroscopy| .75| .97| 25.0| .26
ACL tear via arthroscopy| .86| .98| 43.0| .14
Lateral meniscal tear via arthroscopy| .54| .96| 13.5| .48
Loose body via arthroscopy| .94| .98| 47.0| .06
Tight lateral retinaculum via arthroscopy| 1.0| 1.0| UD| .00
Synovitis via arthroscopy| .57| 1.0| UD| .43
Lateral meniscal cyst via arthroscopy| 1.0| .99| 100.0| .00
Patient history
+
Anterior drawer test
+
Lachman test
+
Pivot shift test64  | Conclusion of examiner| 50 patients with clinical diagnosis of meniscal tears and/or ACL rupture| ACL rupture via arthroscopy| 1.0| 1.0| UD| .00
History of anteromedial knee pain
+
Pain primarily over the medial femoral condyle
+
Visible or palpable plica
+
Exclusion of other causes of anteromedial knee pain66  | Meet all four criteria| 48 patients with anteromedial knee pain that was clinically suspected of being caused by pathologic medial plica| Pathologic medial plica via arthroscopy| 1.0 (.92, 1.0)| .00| 1.0| UD

UD, Undefined.

### Interventions

#### Diagnostic Utility of History and Physical Examination Findings for Predicting a Favorable Response to Foot Orthoses and Activity Modification

Figure 7-40 Nomogram. Considering a pretest probability of success of 60% (as determined in the Sutlive et al study), 2 degrees or more of forefoot valgus or 78 degrees or less of great toe extension results in a posttest probability of 85%. This means that if a patient presented with one of the two aforementioned variables, the likelihood of achieving a successful outcome with off-the-shelf orthotics and activity modification would be 85%. (Adapted from Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975;293:257. Copyright 2005, Massachusetts Medical Society. See also Sutlive TG, Mitchell SD, Maxfield SN, et al. Identification of individuals with patellofemoral pain whose symptoms improved after a combined program of foot orthosis use and modified activity: a preliminary investigation. Phys Ther. 2004;84:49-61.)

Sutlive and colleagues67 have developed a clinical prediction rule that identifies individuals with patellofemoral pain who are likely to improve with an off-the-shelf foot orthosis and modified activity. The study identified a number of predictor variables.

Test and Study Quality| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
2 degrees or more of forefoot valgus67  | 50 patients with patellofemoral pain syndrome| Decrease in pain of more than 50% after 3 weeks of wearing off-the-shelf foot orthoses and activity modification| .13 (.04, .24)| .97 (.90, 1.0)| 4.0 (.70, 21.9)| .90
78 degrees or less of great toe extension67  | .13 (.04, .24)| .97 (.90, 1.0)| 4.0 (.70, 21.9)| .90
3 mm or less of navicular drop67  | .47 (.32, .61)| .80 (.67, .93)| 2.4 (1.3, 4.3)| .66
5 degrees or less of valgus and any varus of relaxed calcaneal stance67  | .36 (.17, .55)| .81 (.71, .92)| 1.9 (1.0, 3.6)| .79
Tight hamstring muscles as measured by 90/90 straight-leg raise test67  | .68 (.55, .80)| .56 (.37, .75)| 1.5 (1.0, 2.3)| .57
Reports of difficulty walking67  | .71 (.55, .86)| .48 (.33, .62)| 1.4 (1.0, 1.8)| .60

#### Diagnostic Utility of History and Physical Examination Findings for Predicting a Favorable Short-Term Response to Hip Mobilizations

Test and Study Quality| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Ipsilateral anterior thigh pain22  | 60 patients with knee OA| Decrease in pain of more than 30% or Global Rating of Change scale rated as "moderately better" 2 days after hip mobilizations| .27 (.13, .40)| .95 (.85, 1.05)| 5.1 (.71, 36.7)| .77 (.62, .96)
Intermittent hip or groin pain22  | .15 (.05, .26)| .98 (.91, 1.04)| 6.2 (.40, 104.7)| .87 (.75, 1.00)
Strengthening exercises aggravate knee pain22  | .20 (.04, .37)| .96 (.85, 1.07)| 4.9 (.30, 83.7)| .83 (.65, 1.06)
Location of hip or groin pain bilaterally22  | .18 (.06, .29)| .98 (.91, 1.04)| 7.1 (.40, 119.0)| .84 (.72, .99)
Side-to-side difference in hip internal rotation range of motion22  | .98 (.93, 1.02)| .11 (−.03, .24)| 1.1 (.90, 1.3)| .23 (.02, 2.40)
Empty end feel on ipsilateral hip flexion range of motion22  | .13 (.03, .23)| .98 (.91, 1.04)| 5.2 (.30, 9.2)| .89 (.78, 1.02)
Pain with ipsilateral hip distraction22  | .13 (.03, .23)| .98 (.91, 1.04)| 5.2 (.30, 9.2)| .89 (.78, 1.02)
Pain at knee on ipsilateral hip extension range of motion22  | .11 (.01, .20)| .98 (.91, 1.04)| 4.3 (.20, 75.8)| .92 (.81, 1.04)
Ipsilateral knee flexion passive range of motion of less than 122 degrees22  | .32 (.17, .46)| .95 (.85, 1.05)| 6.0 (.90, 42.8)| .72 (.57, .91)
Ipsilateral hip internal rotation passive range of motion of less than 17 degrees22  | .32 (.17, .45)| .95 (.85, 1.05)| 6.0 (.90, 42.8)| .72 (.57, .91)
Pain or paresthesia in ipsilateral hip or groin22  | .20 (.08, .32)| .98 (.91, 1.04)| 8.1 (.50, 133.4)| .82 (.69, .97)

Figure 7-41 Hip mobilization technique used in the management of patients with knee OA. Patients were treated with one session of four different hip mobilizations, including (1) posteroanterior glide with flexion, abduction, and lateral rotation (depicted left), (2) caudal glide, (3) anteroposterior glide (depicted right), and (4) posteroanterior glide.

#### Clinical Prediction Rule to Identify Patients with Patellofemoral Pain Likely to Benefit from Foot Orthoses

Vicenzino and colleagues68 developed a clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthoses. The result of their study demonstrated that if three or more of the four attributes (age older than 25 years, height less than 65 inches, worst pain visual analog scale of less than 53 mm, and a difference in midfoot width from non−weight bearing to weight bearing of more than 11 mm) were present, the +LR was 8.8 (95% CI: 1.2 to 66.9) and the probability of experiencing a successful outcome improved from 40% to 86%.

## Outcome Measures

Outcome Measure| Scoring and Interpretation| Test-Retest Reliability and Study Quality| MCID
---|---|---|---
Lower Extremity Functional Scale (LEFS)| Users rate the difficulty of performing 20 functional tasks on a Likert-type scale ranging from 0 (extremely difficult or unable to perform activity) to 4 (no difficulty). A total score out of 80 is calculated by summing each score. The answers provide a score between 0 and 80, with lower scores representing more disability| ICC = .9269  | 970
Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)| The WOMAC consists of three subscales: pain (5 items), stiffness (2 items), and physical function (17 items). Users answer the 24 condition-specific questions on a numeric rating scale ranging from 0 (no symptoms) to 10 (extreme symptoms), or alternatively on a Likert-type scale from 0 to 4. Scores from each subscale are summed, with higher scores indicating more pain, stiffness, and disability| ICC = .9069  | 6.7% for improvement
12.9% for worsening71
Knee Outcome Survey (KOS) Activity of Daily Living Scale (ADLS)| The KOS ADLS consists of one section on symptoms and one section on functional disability. Users rate the eight symptom items on a Likert-type scale from 5 (never have) to 0 (prevent me from all daily activity) and the eight functional items from 5 (not difficult at all) to 0 (unable to do). Scores are summed and divided by 80 to get a percentage. Higher scores represent fewer symptoms and higher function| ICC = .9372  | 7.1%73
Numeric Pain Rating Scale (NPRS)| Users rate their level of pain on an 11-point scale ranging from 0 to 10, with high scores representing more pain. Often asked as "current pain" and "least," "worst," and "average" pain in the past 24 hours| ICC = .7274  | 275,76

MCID, Minimum clinically important difference.

## Appendix

#### Quality Appraisal of Reliability Studies for the Knee Using QAREL

| Dervin 200110| Jones 19929| Wood 200618| Fritz 199819| Lenssen 200721| Currier 200722| Rothstein 198323| Gogia 198724| Watkins 199125| Clapper 198826
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| U| U| Y| Y| Y| Y| Y| Y| Y| N/A

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| U| U| N/A| N/A| N/A| Y| N/A| Y| N

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| U| N/A| N/A| N/A| N/A| N/A| N/A| U| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| Y| U| U| U| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| U

8. Was the order of examination varied?

| U| U| Y| U| Y| Y| Y| U| Y| Y

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| U| U| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality summary rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y − N = 9 to 11)   Fair quality (Y − N = 6 to 8)   Poor quality (Y − N ≤ 5).

| Brosseau 199727| Hayes 199428| Hayes 200129| Cooperman 199030| McClure 198931| Tagesson 200732| Piva 200636| Tomsich 199637| Fitzgerald 199538| Watson 199939
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| N/A| Y| Y| Y| Y| Y| Y| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| Y| U| U| Y| N/A| U| N/A| Y| N/A| U

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| U| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| Y| Y| Y| U| U| Y| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| Y| U| U| U| Y| U| U

8. Was the order of examination varied?

| N| N| Y| Y| Y| Y| N| Y| N| N

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| N| Y| Y| Y| Y| Y| Y| Y| U

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality summary rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y − N = 9 to 11)   Fair quality (Y − N = 6 to 8)   Poor quality (Y − N ≤ 5).

| Herrington 200240| Greene 200143| Ehrat 199446| Watson 200147| Wadey 200748| Pua 200969| Marx 200172| Li 200774| Mulligan 201154| Sturgill 200920
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| U| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| Y| Y| Y| N/A| N/A| N/A| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| N/A| Y| U| N/A| Y| N| N| N/A| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| U| N/A| N/A| N/A| N/A| N/A| N/A| N/A| Y| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| Y| U| U| U| Y| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| U

8. Was the order of examination varied?

| U| N| U| Y| U| U| U| U| Y| N

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| U

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality summary rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y − N = 9 to 11)   Fair quality (Y − N = 6 to 8)   Poor quality (Y − N ≤ 5).

| Sacco 201041| Hamid 201335| Weiss 201344| Draper 201145| Gnat 201034| Sweitzer 201042| Cheung 201315| Niu 201111| |
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| |

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| U| Y| Y| Y| Y| U| |

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| N/A| Y| Y| Y| Y| Y| |

4. Were raters blinded to their own prior findings of the test under evaluation?

| Y| U| N| N| Y| N/A| N/A| N/A| |

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| U| N/A| N/A| Y| Y| |

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| Y| U| U| U| U| |

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| Y| U| U| U| U| |

8. Was the order of examination varied?

| U| N| U| Y| Y| U| Y| Y| |

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| U| Y| Y| Y| Y| Y| Y| Y| |

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| |

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| |
Quality summary rating:|  |  |  |  |  |  |  |  | |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y − N = 9 to 11)   Fair quality (Y − N = 6 to 8)   Poor quality (Y − N ≤ 5).

#### Quality Assessment of Diagnostic Studies for the Knee Using QUADAS

| Braunstein 198282| Katz 198683| Bonamo 198863| Lee 198884| Cooperman 199030| Boeree 199185| Evans 199386| Rubinstein 199487| Shelbourne 199588| Stiell 199577| Stiell 199778| Muellner 19977| Khine 200181| Emparanza 200179| Ketelslegers 200280
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| N| U| U| N| Y| Y| N| Y| Y| Y| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| N| N| N| N| Y| N| N| N| N| Y| Y| Y| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| U| U| Y| U| U| U| U| U| Y| Y| U| Y| U| Y

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| N| Y| N| N| Y| N| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| U| U| Y| N| U| Y| N| Y| N| N| Y| Y| Y| N

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| U| Y| Y| N| N| Y| Y| Y| Y| Y| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| N| Y| Y| Y| N| Y| Y| N| Y| Y| Y| Y| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| U| U| U| Y| U| U| U| Y| Y| Y| Y| Y| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| U| U| U| U| U| U| U| U| Y| N| Y| Y| Y| U

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| U| Y| U| U| U| U| N| U| Y| U| U| Y| Y| U

13. Were uninterpretable/intermediate test results reported?

| Y| U| Y| Y| U| U| Y| Y| Y| Y| U| Y| Y| Y| Y

14. Were withdrawals from the study explained?

| U| Y| Y| U| Y| Y| Y| Y| Y| Y| U| Y| Y| Y| Y
Quality summary rating:|  |  |  |  |  |  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y − N = 9 to 11)   Fair quality (Y − N = 6 to 8)   Poor quality (Y − N ≤ 5).

| Bulloch 200390| Eren 200389| Sutlive 200467| Akseki 200459| Kocabey 200464| Bohannon 200533| Karachalios 200560| Haim 200691| Shetty 200766| Currier 200722| Doberstein 200892| Wagemakers 200814| Kastelein 200813| Kastelein 200912| Ahmad 200962| Nickinson 201065| Harrison 200961
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| Y| U| U| Y| Y| U| Y| Y| N| Y| Y| Y| Y| Y| U

2. Were selection criteria clearly described?

| Y| Y| Y| N| N| Y| Y| Y| U| Y| N| Y| Y| Y| U| N| N

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| Y| Y| Y| U| N| Y| Y| Y| U| Y| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| Y| U| Y| U| U| U| U| U| U| Y| U| Y| Y| Y| U| U| U

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| Y| Y| Y| U| Y| Y| Y| Y| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| N| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| U| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| Y| U| Y| Y| Y| N| Y| Y| Y| Y| Y| Y| N| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| U| Y| U| U| Y| Y| U| Y| Y| N| Y| Y| Y| N| N| U

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| Y| Y| Y| Y| U| Y| N| U| Y| U| Y| Y| Y| U| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| Y| U| Y| U| U| U| Y| N| U| Y| U| Y| Y| Y| U| U| U

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| Y| Y| Y| Y| Y| U| Y| Y| Y| Y| U| Y| Y| Y| Y| Y| U

13. Were uninterpretable/intermediate test results reported?

| Y| Y| Y| U| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| U| U

14. Were withdrawals from the study explained?

| Y| Y| Y| U| U| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| U
Quality summary rating:|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear. Good quality (Y − N = 10 to 14).   Fair quality (Y − N = 5 to 9).   Poor quality (Y − N ≤ 4).  .

| Mulligan 201154| Sweitzer 201042| Salvi 201358| Cheung 201315| Niu 201111| Couture 201253| Konan 200952| Makhmalbaf 201357
---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| Y| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| Y| Y| Y| Y| Y| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| U| Y| Y| U| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| Y| Y| U| Y| U| Y| Y| Y

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| N| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| N| Y| Y| Y| N| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| U| U| Y| Y| Y| Y| Y| U

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| N| Y| Y| Y| Y| N| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| N| U| N| Y| N| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| U| Y| Y| Y| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| Y| U| U| U| Y| U| U| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| Y| Y| Y| U| U| U| U

13. Were uninterpretable/intermediate test results reported?

| Y| N| N| Y| Y| Y| U| N

14. Were withdrawals from the study explained?

| Y| N| Y| Y| Y| Y| Y| Y
Quality summary rating:|  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear. Good quality (Y − N = 10 to 14).   Fair quality (Y − N = 5 to 9).   Poor quality (Y − N ≤ 4).  .

## References

1. Greenfield B, Tovin BJ. Knee. Current Concepts of Orthopedic Physical Therapy (11.2.11). Orthopaedic Section, American Physical Therapy Association: La Crosse, Wisconsin; 2001.

2. Hartley A. Practical Joint Assessment. Mosby: St Louis; 1995.

3. DeHaven KE. Diagnosis of acute knee injuries with hemarthrosis. Am J Sports Med. 1980;8:9–14.

4. Cook JL, Khan KM, Kiss ZS, et al. Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players. Victorian Institute of Sport tendon study group. Br J Sports Med. 2001;35:65–69.

5. Cleland JA, McRae M. Patellofemoral pain syndrome: a critical analysis of current concepts. Phys Ther Rev. 2002;7:153–161.

6. Grelsamer RP, McConnell J. The Patella: A Team Approach. Aspen Publishers: Gaithersburg, Maryland; 1998.

7. Muellner T, Weinstabl R, Schabus R, et al. The diagnosis of meniscal tears in athletes. A comparison of clinical and magnetic resonance imaging investigations. Am J Sports Med. 1997;25:7–12.

8. Cibere J, Bellamy N, Thorne A, et al. Reliability of the knee examination in osteoarthritis: effect of standardization. Arthritis Rheum. 2004;50:458–468.

9. Jones A, Hopkinson N, Pattrick M, et al. Evaluation of a method for clinically assessing osteoarthritis of the knee. Ann Rheum Dis. 1992;51:243–245.

10. Dervin GF, Stiell IG, Wells GA, et al. Physicians' accuracy and interrator reliability for the diagnosis of unstable meniscal tears in patients having osteoarthritis of the knee. Can J Surg. 2001;44:267–274.

11. Niu NN, Losina E, Martin SD, et al. Development and preliminary validation of a meniscal symptom index. Arthritis Care Res (Hoboken). 2011;63(2):208–215.

12. Kastelein M, Luijsterburg PA, Wagemakers HP, et al. Diagnostic value of history taking and physical examination to assess effusion of the knee in traumatic knee patients in general practice. Arch Phys Med Rehabil. 2009;90:82–86.

13. Kastelein M, Wagemakers HP, Luijsterburg PA, et al. Assessing medial collateral ligament knee lesions in general practice. Am J Med. 2008;121:982–988.

14. Wagemakers HP, Heintjes EM, Boks SS, et al. Diagnostic value of history-taking and physical examination for assessing meniscal tears of the knee in general practice. Clin J Sport Med. 2008;18:24–30.

15. Cheung TC, Tank Y, Breederveld RS, et al. Diagnostic accuracy and reproducibility of the Ottawa Knee Rule vs the Pittsburgh Decision Rule. Am J Emerg Med. 2013;31(4):641–645.

16. Bachmann LM, Haberzeth S, Steurer J, ter Riet G. The accuracy of the Ottawa Knee Rule to rule out knee fractures: a systematic review. Ann Intern Med. 2004;140:121–124.

17. Vijayasankar D, Boyle AA, Atkinson P. Can the Ottawa Knee Rule be applied to children? A systematic review and meta-analysis of observational studies. Emerg Med J. 2009;26:250–253.

18. Wood L, Peat G, Wilkie R, et al. A study of the noninstrumented physical examination of the knee found high observer variability. J Clin Epidemiol. 2006;59:512–520.

19. Fritz JM, Delitto A, Erhard RE, Roman M. An examination of the selective tissue tension scheme, with evidence for the concept of a capsular pattern of the knee. Phys Ther. 1998;78:1046–1056 [discussion 1057-1061].

20. Sturgill LP, Snyder-Mackler L, Manal TJ, Axe MJ. Interrater reliability of a clinical scale to assess knee joint effusion. J Orthop Sports Phys Ther. 2009;39(12):845–849.

21. Lenssen AF, van Dam EM, Crijns YH, et al. Reproducibility of goniometric measurement of the knee in the in-hospital phase following total knee arthroplasty. BMC Musculoskelet Disord. 2007;8:83.

22. Currier LL, Froehlich PJ, Carow SD, et al. Development of a clinical prediction rule to identify patients with knee pain and clinical evidence of knee osteoarthritis who demonstrate a favorable short-term response to hip mobilization. Phys Ther. 2007;87:1106–1119.

23. Rothstein JM, Miller PJ, Roettger RF. Goniometric reliability in a clinical setting. Elbow and knee measurements. Phys Ther. 1983;63:1611–1615.

24. Gogia PP, Braatz JH, Rose SJ, Norton BJ. Reliability and validity of goniometric measurements at the knee. Phys Ther. 1987;67:192–195.

25. Watkins MA, Riddle DL, Lamb RL, Personius WJ. Reliability of goniometric measurements and visual estimates of knee range of motion obtained in a clinical setting. Phys Ther. 1991;71:90–97.

26. Clapper MP, Wolf SL. Comparison of the reliability of the Orthoranger and the standard goniometer for assessing active lower extremity range of motion. Phys Ther. 1988;68:214–218.

27. Brosseau L, Tousignant M, Budd J, et al. Intratester and intertester reliability and criterion validity of the parallelogram and universal goniometers for active knee flexion in healthy subjects. Physiother Res Int. 1997;2:150–166.

28. Hayes KW, Petersen C, Falconer J. An examination of Cyriax's passive motion tests with patients having osteoarthritis of the knee. Phys Ther. 1994;74:697–709.

29. Hayes KW, Petersen CM. Reliability of assessing endfeel and pain and resistance sequence in subjects with painful shoulders and knees. J Orthop Sports Phys Ther. 2001;31:432–445.

30. Cooperman JM, Riddle DL, Rothstein JM. Reliability and validity of judgments of the integrity of the anterior cruciate ligament of the knee using the Lachman's test. Phys Ther. 1990;70:225–233.

31. McClure PW, Rothstein JM, Riddle DL. Intertester reliability of clinical judgments of medial knee ligament integrity. Phys Ther. 1989;69:268–275.

32. Tagesson SK, Kvist J. Intra- and interrater reliability of the establishment of one repetition maximum on squat and seated knee extension. J Strength Cond Res. 2007;21:801–807.

33. Bohannon RW. Manual muscle testing: does it meet the standards of an adequate screening test? Clin Rehabil. 2005;19:662–667.

34. Gnat R, Kuszewski M, Koczar R, Dziewońska A. Reliability of the passive knee flexion and extension tests in healthy subjects. J Manipulative Physiol Ther. 2010;33(9):659–665.

35. Hamid MS, Ali MR, Yusof A. Interrater and intrarater reliability of the active knee extension (AKE) test among healthy adults. J Phys Ther Sci. 2013;25:957–961.

36. Piva SR, Fitzgerald K, Irrgang JJ, et al. Reliability of measures of impairments associated with patellofemoral pain syndrome. BMC Musculoskelet Disord. 2006;7:33.

37. Tomsich DA, Nitz AJ, Threlkeld AJ, Shapiro R. Patellofemoral alignment: reliability. J Orthop Sports Phys Ther. 1996;23:200–208.

38. Fitzgerald GK, McClure PW. Reliability of measurements obtained with four tests for patellofemoral alignment. Phys Ther. 1995;75:84–92.

39. Watson CJ, Propps M, Galt W, et al. Reliability of McConnell's classification of patellar orientation in symptomatic and asymptomatic subjects. J Orthop Sports Phys Ther. 1999;29:378–393.

40. Herrington LC. The inter-tester reliability of a clinical measurement used to determine the medial-lateral orientation of the patella. Man Ther. 2002;7:163–167.

41. Sacco ICN, Onodera AN, Butugan MK, et al. Inter- and intra-tester reliability of clinical measurement to determine medio-lateral patellar position using a pachymeter or visual assessment. Knee. 2010;17(1):92–95.

42. Sweitzer BA, Cook C, Steadman JR, et al. The inter-rater reliability and diagnostic accuracy of patellar mobility tests in patients with anterior knee pain. Phys Sportsmed. 2010;38(3):90–96.

43. Greene CC, Edwards TB, Wade MR, Carson EW. Reliability of the quadriceps angle measurement. Am J Knee Surg. 2001;14:97–103.

44. Weiss L, DeForest B, Hammond K, et al. Reliability of goniometry-based Q-angle. PM R. 2013;5(9):763–768.

45. Draper CE, Chew KTL, Wang R, et al. Comparison of quadriceps angle measurements using short-arm and long-arm goniometers: correlation with MRI. PM R. 2011;3(2):111–116.

46. Ehrat M, Edwards J, Hastings D, Worrell T. Reliability of assessing patellar alignment: the A angle. J Orthop Sports Phys Ther. 1994;19:22–27.

47. Watson CJ, Leddy HM, Dynjan TD, Parham JL. Reliability of the lateral pull test and tilt test to assess patellar alignment in subjects with symptomatic knees: student raters. J Orthop Sports Phys Ther. 2001;31:368–374.

48. Wadey VM, Mohtadi NG, Bray RC, Frank CB. Positive predictive value of maximal posterior joint-line tenderness in diagnosing meniscal pathology: a pilot study. Can J Surg. 2007;50:96–100.

49. Ockert B, Haasters F, Polzer H, et al. [Value of the clinical examination in suspected meniscal injuries. A meta-analysis]. Unfallchirurg. 2010;113(4):293–299.

50. Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test utilities for assessing meniscal injury. Clin Rehabil. 2008;22:143–161.

51. Hegedus EJ, Cook C, Hasselblad V, et al. Physical examination tests for assessing a torn meniscus in the knee: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2007;37:541–550.

52. Konan S, Rayan F, Haddad FS. Do physical diagnostic tests accurately detect meniscal tears? Knee Surg Sports Traumatol Arthrosc. 2009;17(7):806–811.

53. Couture J-F, Al-Juhani W, Forsythe ME, et al. Joint line fullness and meniscal pathology. Sports Health. 2012;4(1):47–50.

54. Mulligan EP, Harwell JL, Robertson WJ. Reliability and diagnostic accuracy of the Lachman test performed in a prone position. J Orthop Sports Phys Ther. 2011;41(10):749–757.

55. Van Eck CF, van den Bekerom MPJ, Fu FH, et al. Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia. Knee Surg Sports Traumatol Arthrosc. 2013;21(8):1895–1903.

56. Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther. 2006;36:267–288.

57. Makhmalbaf H, Moradi A, Ganji S, Omidi-Kashani F. Accuracy of Lachman and anterior drawer tests for anterior cruciate ligament injuries. Arch Bone Jt Surg. 2013;1(2):94–97.

58. Salvi M, Caputo F, Piu G, et al. The loss of extension test (LOE test): a new clinical sign for the anterior cruciate ligament insufficient knee. J Orthop Traumatol. 2013;14(3):185–191.

59. Akseki D, Ozcan O, Boya H, Pinar H. A new weightbearing meniscal test and a comparison with McMurray's test and joint line tenderness. Arthroscopy. 2004;20:951–958.

60. Karachalios T, Hantes M, Zibis AH, et al. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am. 2005;87:955–962.

61. Harrison BK, Abell BE, Gibson TW. The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. Clin J Sport Med. 2009;19:9–12.

62. Ahmad CS, McCarthy M, Gomez JA, et al. The moving patellar apprehension test for lateral patellar instability. Am J Sports Med. 2009;37:791–796.

63. Bonamo JJ, Shulman G. Double contrast arthrography of the knee. A comparison to clinical diagnosis and arthroscopic findings. Orthopedics. 1988;11:1041–1046.

64. Kocabey Y, Tetik O, Isbell WM, et al. The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy. 2004;20:696–700.

65. Nickinson R, Darrah C, Donell S. Accuracy of clinical diagnosis in patients undergoing knee arthroscopy. Int Orthop. 2010;34(1):39–44.

66. Shetty VD, Vowler SL, Krishnamurthy S, Halliday AE. Clinical diagnosis of medial plica syndrome of the knee: a prospective study. J Knee Surg. 2007;20:277–280.

67. Sutlive TG, Mitchell SD, Maxfield SN, et al. Identification of individuals with patellofemoral pain whose symptoms improved after a combined program of foot orthosis use and modified activity: a preliminary investigation. Phys Ther. 2004;84:49–61.

68. Vicenzino B, Collins N, Cleland J, McPoil T. A clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthoses: a preliminary determination. Br J Sports Med. 2010;44(12):862–866.

69. Pua YH, Cowan SM, Wrigley TV, Bennell KL. The Lower Extremity Functional Scale could be an alternative to the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale. J Clin Epidemiol. 2009;62(10):1103–1111.

70. Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther. 1999;79:371–383.

71. Angst F, Aeschlimann A, Stucki G. Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with osteoarthritis of the lower extremities. Arthritis Rheum. 2001;45:384–391.

72. Marx RG, Jones EC, Allen AA, et al. Reliability, validity, and responsiveness of four knee outcome scales for athletic patients. J Bone Joint Surg Am. 2001;83A:1459–1469.

73. Piva SR, Gil AB, Moore CG, Fitzgerald GK. Responsiveness of the activities of daily living scale of the knee outcome survey and numeric pain rating scale in patients with patellofemoral pain. J Rehabil Med. 2009;41:129–135.

74. Li L, Liu X, Herr K. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Pain Med. 2007;8:223–234.

75. Farrar JT, Berlin JA, Strom BL. Clinically important changes in acute pain outcome measures: a validation study. J Pain Symptom Manage. 2003;25:406–411.

76. Farrar JT, Portenoy RK, Berlin JA, et al. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287–294.

77. Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med. 1995;26:405–413.

78. Stiell IG, Wells GA, Hoag RH, et al. Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries. JAMA. 1997;278:2075–2079.

79. Emparanza JI, Aginaga JR. Validation of the Ottawa Knee Rules. Ann Emerg Med. 2001;38:364–368.

80. Ketelslegers E, Collard X, Vande Berg B, et al. Validation of the Ottawa Knee Rules in an emergency teaching centre. Eur Radiol. 2002;12:1218–1220.

81. Khine H, Dorfman DH, Avner JR. Applicability of Ottawa Knee Rule for knee injury in children. Pediatr Emerg Care. 2001;17:401–404.

82. Braunstein EM. Anterior cruciate ligament injuries: a comparison of arthrographic and physical diagnosis. AJR Am J Roentgenol. 1982;138:423–425.

83. Katz JW, Fingeroth RJ. The diagnostic accuracy of ruptures of the anterior cruciate ligament comparing the Lachman test, the anterior drawer sign, and the pivot shift test in acute and chronic knee injuries. Am J Sports Med. 1986;14:88–91.

84. Lee JK, Yao L, Phelps CT, et al. Anterior cruciate ligament tears: MR imaging compared with arthroscopy and clinical tests. Radiology. 1988;166:861–864.

85. Boeree NR, Ackroyd CE. Assessment of the menisci and cruciate ligaments: an audit of clinical practice. Injury. 1991;22:291–294.

86. Evans PJ, Bell GD, Frank C. Prospective evaluation of the McMurray test. Am J Sports Med. 1993;21:604–608.

87. Rubinstein RAJ, Shelbourne KD, McCarroll JR, et al. The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries. Am J Sports Med. 1994;22:550–557.

88. Shelbourne KD, Martini DJ, McCarroll JR, VanMeter CD. Correlation of joint line tenderness and meniscal lesions in patients with acute anterior cruciate ligament tears. Am J Sports Med. 1995;23:166–169.

89. Eren OT. The accuracy of joint line tenderness by physical examination in the diagnosis of meniscal tears. Arthroscopy. 2003;19:850–854.

90. Bulloch B, Neto G, Plint A, et al. Validation of the Ottawa Knee Rule in children: a multicenter study. Ann Emerg Med. 2003;42:48–55.

91. Haim A, Yaniv M, Dekel S, Amir H. Patellofemoral pain syndrome: validity of clinical and radiological features. Clin Orthop Relat Res. 2006;451:223–228.

92. Doberstein ST, Romeyn RL, Reineke DM. The diagnostic value of the Clarke sign in assessing chondromalacia patella. J Athl Train. 2008;43:190–196.
8

# Foot and Ankle

CLINICAL SUMMARY AND RECOMMENDATIONS, 398

Anatomy, 399

Osteology, 399

Arthrology, 401

Ligaments, 402

Muscles, 407

Nerves, 416

Patient History, 418

Initial Hypotheses Based on Historical Findings, 418

Physical Examination Tests, 419

Screening, 419

Range-of-Motion Measurements, 422

Assessing Strength, 424

Assessing Bony Alignment, 425

Assessing Balance and Dynamic Performance, 428

Assessing Foot Motion during Gait, 430

Assessing Swelling, 431

Assessing Sensation, 432

Special Tests, 433

Outcome Measures, 441

Appendix, 442

References, 447

## Clinical Summary and Recommendations

Patient History
---
Complaints|

• No studies of acceptable quality have assessed either the reliability or diagnostic utility of items from the subjective history in patients with foot and ankle problems.

Physical Examination
Screening|

• The Ottawa Ankle Rule for Radiography is highly sensitive for ankle and midfoot fractures in both adults and children. When patients can bear weight and have no tenderness on the malleoli, navicular bone, or base of the fifth metatarsal, providers can confidently rule out foot and ankle fractures (−LR [likelihood ratio] = .10). The addition of a tuning fork may increase the specificity of the rules, especially when it is placed on the distal fibula.

Range-of-Motion and Strength Assessment|

• Measuring ankle range of motion has consistently been shown to be highly reliable when one person does the measuring, but it is much less reliable when different people do the measuring.

• Calf strength can be reliably assessed using repeated calf raises. The paper grip test is a simple yet accurate method to measure toe plantarflexion strength.

Other Assessments|

• Assessments of static foot alignment, sensation, swelling, proprioception, and dynamic performance have all been shown to be adequately reliable but are of unknown diagnostic utility. Dynamic assessments of hindfoot motion during gait are likely too unreliable to be clinically useful.

Special Tests|

• The Thompson test seems to show very good diagnostic utility in both identifying and ruling out subcutaneous tears of the Achilles tendon (+LR = 13.47, −LR = .04).

• The impingement sign seems to show very good diagnostic utility in both identifying and ruling out anterolateral ankle impingement (+LR = 7.9, −LR = .06).

• The triple compression test seems to show good diagnostic utility in ruling out tarsal tunnel syndrome (−LR = .14).

• The windlass test appears highly reliable but is of unknown diagnostic utility in identifying plantar fasciitis.

## Anatomy

### Osteology

Figure 8-1 Bones of the foot.

Figure 8-2 Bones of the foot.

### Arthrology

Figure 8-3 Talocrural (hinge) joint.

Joint| Type and Classification| Closed Packed Position| Capsular Pattern
---|---|---|---
Talocrural| Synovial: hinge| Dorsiflexion| Plantarflexion slightly more limited than dorsiflexion
Distal tibiofibular| Syndesmosis| Not available| Not available
Subtalar| Synovial: plane| Supination| Inversion greatly restricted; eversion not restricted
Talocalcaneonavicular| Synovial: plane| Supination| Supination more limited than pronation
Calcaneocuboid| Synovial: plane| Supination
Transverse tarsal| Synovial: plane| Supination
Tarsometatarsal| Synovial: plane| Supination| Not available
Metatarsophalangeal (MTP)| Synovial: condyloid| Extension| Great toe: extension more limited than flexion
MTP joints 2 to 5: variable
Interphalangeal (IP)| Synovial: hinge| Extension| Extension more limited than flexion

### Ligaments

#### Posterior Ankle Ligaments

Figure 8-4 Calcaneus: posterior view with ligaments.

Ligaments| Attachments| Function
---|---|---
Posterior talocalcaneal| Superior body of calcaneus to posterior process of talus| Limits posterior separation of talus from calcaneus
Posterior tibiofibular| Distal posterior tibia to distal posterior fibula| Maintains distal tibiofibular joint
Posterior talofibular| Posterior talus to posterior lateral malleolus| Limits separation of fibula from talus
Interosseous membrane| Continuous connection between tibia and fibula| Reinforces approximation between tibia and fibula

#### Lateral Ankle Ligaments

Figure 8-5 Ligaments of ankle: lateral view of right foot.

Ligaments| Attachments| Function
---|---|---
Anterior tibiofibular| Anterior aspect of lateral malleolus to inferior border of medial tibia| Reinforces anterior tibiofibular joint
Lateral collateral
Posterior talofibular
Calcaneofibular
Anterior talofibular| Lateral malleolus to lateral talus
Lateral malleolus to lateral calcaneus
Lateral malleolus to talus| Limits ankle inversion
Interosseous talocalcaneal| Inferior aspect of talus to superior aspect of calcaneus| Limits separation of talus from calcaneus
Dorsal talonavicular| Dorsal aspect of talus to dorsal aspect of navicular| Limits separation of navicular from talus
Bifurcate
Calcaneonavicular
Calcaneocuboid| Distal calcaneus to proximal navicular
Distal calcaneus to proximal cuboid| Limits separation of navicular and cuboid from calcaneus
Dorsal cubonavicular| Lateral aspect of cuboid to dorsal aspect of navicular| Limits separation of navicular from cuboid
Dorsal cuneonavicular| Navicular to three cuneiforms| Limits separation of cuneiforms from navicular
Dorsal intercuneiform| Joining of three cuneiforms| Limits separation of cuneiforms
Dorsal tarsometatarsal| Dorsal tarsal bones to corresponding metatarsal bones| Reinforces tarsometatarsal joints

#### Medial Ankle Ligaments

Figure 8-6 Ligaments of ankle: medial view of right foot.

Ligaments| Attachments| Function
---|---|---
Medial (deltoid)
Posterior tibiotalar| Medial malleolus to medial talus| Limits ankle eversion
Tibiocalcaneal| Anterior distal medial malleolus to sustentaculum tali
Tibionavicular| Medial malleolus to proximal aspect of navicular
Anterior tibiotalar| Medial malleolus to talus
Medial talocalcaneal| Sustentaculum tali to talus| Limits posterior separation of talus on calcaneus
Plantar calcaneonavicular (spring)| Sustentaculum tali to posteroinferior navicular| Maintains longitudinal arch of foot

#### Plantar Foot Ligaments

Figure 8-7 Capsules and ligaments of metatarsophalangeal and interphalangeal joints: lateral view.

Ligaments| Attachments| Function
---|---|---
Long plantar| Plantar of calcaneus to cuboid| Maintains arches of foot
Plantar calcaneocuboid (short plantar)| Anteroinferior aspect of calcaneus to inferior aspect of cuboid| Maintains arches of foot
Plantar calcaneonavicular (spring)| Sustentaculum tali to posteroinferior aspect of talus| Maintains longitudinal arch of foot
Plantar cubonavicular| Inferior navicular to inferomedial cuboid| Limits separation of cuboid from navicular and supports arch
Plantar tarsometatarsal| Connects metatarsals 1 to 5 to corresponding tarsal on plantar aspect| Limits separation of metatarsals from corresponding tarsal bones
Collateral| Distal aspect of proximal phalanx to proximal aspect of distal phalanx| Reinforces capsule of IP joints
Plantar plate| Thickening of plantar aspect of joint capsule| Reinforces plantar aspect of IP joint
Deep transverse metatarsal| MTP joints on plantar aspect| Limits separation of MTP joints

Figure 8-8 Ligaments and tendons of foot: plantar view.

### Muscles

#### Lateral Muscles of Leg

Muscles| Proximal Attachments| Distal Attachments| Nerve and Segmental Level| Action
---|---|---|---|---
Gastrocnemius| Lateral head: lateral femoral condyle
Medial head: popliteal surface of femur| Posterior aspect of calcaneus| Tibial nerve (S1, S2)| Plantarflexes ankle and flexes knee
Soleus| Posterior aspect of head of fibula, fibular soleal line, and medial aspect of tibia| Posterior aspect of calcaneus| Tibial nerve (S1, S2)| Plantarflexes ankle
Fibularis longus| Superolateral surface of fibula| Base of first metatarsal and medial cuneiform| Superficial fibular nerve (L5, S1, S2)| Everts foot and assists in plantarflexion
Fibularis brevis| Distal aspect of fibula| Tuberosity of base of fifth metatarsal| Superficial fibular nerve (L5, S1, S2)| Everts foot and assists in plantarflexion
Fibularis tertius| Anteroinferior aspect of fibula and interosseus membrane| Base of fifth metatarsal| Deep fibular nerve (L5, S1)| Dorsiflexes ankle and everts foot
Extensor digitorum longus| Lateral condyle of tibia, medial surface of fibula| Middle and distal phalanges of digits 2 to 5| Deep fibular nerve (L5, S1)| Extends digits 2 to 5 and assists with ankle dorsiflexion
Extensor hallucis longus| Anterior fibula and interosseous membrane| Dorsal base of distal phalanx of great toe| Deep fibular nerve (L5, S1)| Extends great toe and assists with ankle dorsiflexion
Extensor digitorum brevis| Superolateral aspect of calcaneus, extensor retinaculum| Dorsal base of middle phalanx of digits 2 to 5| Deep fibular nerve (L5, S1)| Extends digits 2 to 4 at MTP joints
Tibialis anterior| Lateral condyle and anterior surface of tibia| Inferomedial aspect of medial cuneiform and base of first metatarsal| Deep fibular nerve (L4, L5)| Ankle dorsiflexion and foot inversion

#### Lateral Muscles of Leg

Figure 8-9 Muscles of foot and ankle: lateral view.

#### Posterior Muscles of Leg

Figure 8-10 Muscles of leg: posterior view.

Muscles| Proximal Attachments| Distal Attachments| Nerve and Segmental Level| Action
---|---|---|---|---
Tibialis posterior| Interosseous membrane, posteroinferior aspect of tibia, and posterior fibula| Navicular tuberosity, cuneiform, cuboid, and bases of metatarsals 2 to 4| Tibial nerve (L4, L5)| Plantarflexes ankle and inverts foot
Flexor hallucis longus| Posteroinferior fibula and interosseous membrane| Base of distal phalanx of great toe| Tibial nerve (S2, S3)| Flexes great toe and assists with ankle plantarflexion
Flexor digitorum longus| Posteroinferior tibia| Bases of distal phalanges 2 to 5| Tibial nerve (S2, S3)| Flexes lateral four digits, plantarflexes ankle, supports longitudinal arch of foot

#### Muscles of Dorsum of Foot

Figure 8-11 Muscles, arteries, and nerves of front of ankle and dorsum of foot: deeper dissection.

Muscles| Proximal Attachments| Distal Attachments| Nerve and Segmental Level| Action
---|---|---|---|---
Extensor digitorum brevis| Superolateral aspect of calcaneus and extensor retinaculum| Dorsal base of middle phalanx of digits 2 to 5| Deep fibular nerve (L5, S1)| Extends digits 2 to 4 at MTP joints
Extensor hallucis brevis| Superolateral aspect of calcaneus and extensor retinaculum| Dorsal base of proximal phalanx of great toe| Deep fibular nerve (L5, S1)| Extends great toe at MTP joints
Dorsal interossei| Sides of metatarsals 1 to 5| First: medial aspect of proximal phalanx of second digit
Second to fourth: lateral aspect of digits 2 to 4| Lateral plantar nerve (S2, S3)| Abducts digits 2 to 4 and flexes
MTP joints

#### First Layer of Muscles: Sole of Foot

Figure 8-12 Muscles of sole of foot: first layer.

Muscles| Proximal Attachments| Distal Attachments| Nerve and Segmental Level| Action
---|---|---|---|---
Abductor hallucis longus| Medial calcaneal tuberosity, flexor retinaculum, and plantar aponeurosis| Base of proximal phalanx of first digit| Medial plantar nerve (S2, S3)| Abducts and flexes great toe
Flexor digitorum brevis| Medial calcaneal tuberosity and plantar aponeurosis| Sides of middle phalanges of digits 2 to 5| Medial plantar nerve (S2, S3)| Flexes digits 2 to 5
Abductor digiti minimi| Medial and lateral calcaneal tuberosities| Lateral aspect of base of proximal phalanx of fifth metatarsal| Lateral plantar nerve (S2, S3)| Abducts and flexes fifth digit

#### Second Layer of Muscles: Sole of Foot

Figure 8-13 Muscles of sole of foot: second layer.

Muscles| Proximal Attachments| Distal Attachments| Nerve and Segmental Level| Action
---|---|---|---|---
Lumbricals| Tendons of flexor digitorum longus| Medial aspect of expansion over lateral four digits| Lateral three: lateral plantar nerve (S2, S3)
Medial one: medial plantar nerve (S2, S3)| Flexes proximal phalanges and extends middle and distal phalanges of digits 2 to 5
Quadratus plantae| Medial and plantar aspect of calcaneus| Posterolateral aspect of tendon of flexor digitorum longus| Lateral plantar nerve (S2, S3)| Assists in flexing digits 2 to 5

#### Third Layer of Muscles: Sole of Foot

Figure 8-14 Muscles of sole of foot: third layer.

Muscles| Proximal Attachments| Distal Attachments| Nerve and Segmental Level| Action
---|---|---|---|---
Flexor digiti minimi brevis| Base of fifth metatarsal| Base of proximal phalanx of fifth metatarsal| Superficial branch of lateral plantar nerve| Flexes proximal phalanx of fifth digit
Adductor hallucis (transverse head)| Plantar ligaments of MTP joints| Lateral base of proximal phalanx of great toe| Deep branch of lateral plantar nerve (S2, S3)| Adducts great toe
Adductor hallucis (oblique head)| Bases of metatarsals 2 to 4
Flexor hallucis brevis| Plantar cuboid and lateral cuneiforms| Sides of proximal phalanx of great toe| Medial plantar nerve (S2, S3)| Flexes proximal phalanx of great toe

#### Deep Interosseous Muscles: Sole of Foot

Figure 8-15 Interosseous muscles and plantar arterial arch.

Muscles| Proximal Attachments| Distal Attachments| Nerve and Segmental Level| Action
---|---|---|---|---
Plantar interosseous| Bases of metatarsals 3 to 5| Medial bases of proximal phalanges 3 to 5| Lateral plantar nerve (S2, S3)| Adducts digits 2 to 4 and flexes MTP joints
Dorsal interosseous| Sides of metatarsals 1 to 5| First: medial aspect of proximal phalanx of second digit
Second to fourth: Lateral aspect of digits 2 to 4| Lateral plantar nerve (S2, S3)| Abducts digits 2 to 4 and flexes MTP joints

### Nerves

Figure 8-16 Tibial and fibular nerves: anterior view.

Nerves| Segmental Levels| Sensory| Motor
---|---|---|---
Sural| S1, S2| Posterior and lateral leg and lateral foot| No motor
Tibial| L4, L5, S1, S2, S3| Posterior heel and plantar surface of foot| Semitendinosus, semimembranosus, biceps femoris, adductor magnus, gastrocnemius, soleus, plantaris, flexor hallucis longus, flexor digitorum longus, tibialis posterior
Medial plantar| S2, S3| Medial   digits| Flexor hallucis brevis, abductor hallucis, flexor digitorum brevis, lumbricales
Lateral plantar| S2, S3| Lateral   digits| Adductor hallucis, abductor digiti minimi, quadratus plantae, lumbricales, flexor digiti minimi brevis, interossei
Saphenous| L2, L3, L4| Medial leg and foot| No motor
Deep fibular| L4, L5, S1| First interdigital cleft| Tibialis anterior, extensor digitorum longus, extensor hallucis longus, fibularis tertius, extensor digitorum brevis, extensor hallucis brevis
Superficial fibular| L5, S1, S2| Distal anterior leg and dorsum of foot| Fibularis longus, fibularis brevis

Figure 8-17 Tibial and fibular nerves: posterior view.

## Patient History

### Initial Hypotheses Based on Historical Findings

Patient Reports| Initial Hypothesis
---|---
Patient reports a traumatic incident resulting in either forced inversion or eversion| Possible ankle sprain1,2
Possible fracture
Possible peroneal nerve involvement (if mechanism of injury is inversion)3-5
Patient reports trauma to ankle that included tibial rotation on a planted foot| Possible syndesmotic sprain1
Patient notes tenderness of anterior shin and may exhibit excessive pronation. Symptoms may be exacerbated by repetitive weight-bearing activities| Possible medial tibial stress syndrome6
Patient reports traumatic event resulting in inability to plantarflex ankle| Possible Achilles tendon rupture
Patient reports pain with stretch of calf muscles and during gait (toe push off)| Possible Achilles tendonitis7
Possible Sever disease1
Patient reports pain at heel with first few steps out of bed after prolonged periods of walking| Possible plantar fasciitis
Patient reports pain or paresthesias in plantar surface of foot| Possible tarsal tunnel syndrome1
Possible sciatica
Possible lumbar radiculopathy
Patient reports pain on plantar surface of foot between third and fourth metatarsals. Might also state that pain is worse when walking with shoes compared with barefoot| Possible Morton neuroma7
Possible metatarsalgia

## Physical Examination Tests

### Screening

#### Evaluation Following Acute Ankle Trauma

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Ability to bear weight8| Tenderness calculated as tender or not. Swelling and range-of-motion limitations dichotomized as "none-minimal" or "moderate-marked"| 100 patients having sustained acute ankle trauma| κ = .83
Bone tenderness at base of fifth metatarsal8| κ = .78
Bone tenderness at posterior edge of lateral malleolus8| κ = .75
Bone tenderness at tip of medial malleolus8| κ = .66
Bone tenderness at proximal fibula8| κ = −.01
Combinations of bone tenderness8| κ = .76
Soft tissue tenderness8| κ = .41
Degree of swelling in area of anterior talofibular ligament8| κ = .18
Ecchymosis8| κ = .39
Range-of-motion restrictions present8| κ = .33
Palpation test1| Examiner palpates over anterior talofibular ligament. Positive if pain is reproduced| 53 patients presenting for treatment of ankle injury| κ = .36
External rotation test1| Patient sitting over edge of plinth. Passive external rotation stress is applied to foot and ankle. Positive if pain is reproduced over syndesmotic ligaments| κ = .75
Squeeze test1| Patient sitting over edge of plinth. Examiner manually compresses fibula and tibia over calf midpoint. Positive if pain is reproduced over syndesmotic ligaments| κ = .50
Dorsiflexion-compression test1| Patient is standing. Patient actively dorsiflexes ankle while bearing weight. Examiner applies manual compression around malleoli while in dorsiflexed position. Positive if significant increase in ankle dorsiflexion or reduction in pain with compression| κ = .36

#### Diagnostic Utility of the Ottawa Ankle Rule for Radiography

Figure 8-18 Ottawa ankle rules.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Ottawa Ankle Rule for Radiography3
2003 Metaanalysis  | Ankle x-ray series ordered when a patient had bone tenderness (exhibited at A, B, C, or D in Fig. 8-18) or if the patient could not bear weight immediately after the injury or during the examination (four steps regardless of limping)| Statistically pooled data from 27 high-quality studies involving 15,581 adults and children| Ankle or midfoot fracture on x-rays| .98 (.97, .99)| .20| 1.23| .10 (.06, .16)
Bernese Ankle Rules9  | Ankle x-ray series ordered when patients had pain with any of the following:

(1) indirect fibular stress applied by compressing the tibia and fibula proximal to the malleoli

(2) direct medial malleolar stress with examiner's thumb

(3) compression stress of the midfoot and hindfoot applied simultaneously

| 354 patients reporting to the emergency department after a low-energy, supination-type ankle or foot injury| 1.0| .91| 11.11| .00
Adding tuning fork to Ottawa Ankle Rule for Radiography10  | Base of a vibrating tuning fork placed on tip of lateral malleolus. Positive if report of discomfort or pain| 49 patients reporting to emergency department after inversion ankle injury| 1.0| .61| 2.59| .00
As above, but placed on distal fibular shaft| 1.0| .95| 22.00| .00

Figure 8-19 Nomogram. Assuming a fracture prevalence of 15% (statistically pooled from Bachmann et al10), an adult seen in the emergency department with an acute injury whose findings were negative on the Ottawa Ankle Rule would have a 1.4% (95% CI: 0.15% to 1.48%) chance of having an ankle and/or midfoot fracture. (From Fagan TJ. Nomogram for Bayes' theorem. N Engl J Med. 1975;293-257. Copyright 2005, Massachusetts Medical Society. See also Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326:417.)

### Range-of-Motion Measurements

#### Reliability of Range-of-Motion Measurements

Measurements and Study Quality| Instrumentation| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Active range of motion (sitting)
Subtalar joint inversion
Subtalar joint eversion11  | Plastic goniometer| 31 asymptomatic subjects| ICC = .91 to .96
ICC = .82 to .93| ICC = .73 (.61, .82)
ICC = .62 (.49, .74)
Active range of motion (prone)
Subtalar joint inversion
Subtalar joint eversion11  | Plastic goniometer| 31 asymptomatic subjects| ICC = .94 (.91, .96)
ICC = .83 to .94| ICC = .54 (.33, .70)
ICC = .41 (.25, .56)
Active range of motion
Ankle dorsiflexion
Ankle plantarflexion12  | Plastic goniometer| 38 patients with orthopaedic disorders of ankle or knee| ICC = .89
ICC = .91| ICC = .28
ICC = .25
Passive range of motion
Subtalar joint neutral
Subtalar joint inversion
Subtalar joint eversion
Plantarflexion
Dorsiflexion13  | Plastic goniometer| 43 patients with orthopaedic or neurologic disorders where measurements of foot and ankle would be appropriate in a clinical setting| ICC = .77
ICC = .62
ICC = .59
ICC = .86
ICC = .90| ICC = .25
ICC = .15
ICC = .12
ICC = .72
ICC = .50
Passive range of motion
Pronation
Supination
Ankle dorsiflexion
First-ray plantarflexion
First-ray dorsiflexion14  | Inclinometer| 30 healthy subjects| ICC = .89 to .97
ICC = .90 to .95
ICC = .86 to .97
ICC = .72 to .97
ICC = .90 to .98| ICC = .46 to .49
ICC = .28 to .40
ICC = .26 to .31
ICC = .21 to .91
ICC = .14 to .16
First-ray mobility7  | Manual assessment. Graded as hypomobile, normal, or hypermobile| 30 asymptomatic subjects| Not tested| κ = .08 to .20
Dorsiflexion in a calf stretch position15  | Digital inclinometer used to measure angle of tibia between vertical position and calf stretch position with knee extended| 30 healthy subjects| ICC = .77 to .91| ICC = .92 to .95
Dorsiflexion in a modified lunge test16  | During lunge, inclinometer used to take measurements of angle formed by fibular head and lateral malleolus| 31 subjects 76 to 87 years of age recruited from general population| ICC = .87 (.74, .94)| Not tested
Open kinetic chain:
Resting subtalar joint
Subtalar joint neutral17  | Inclinometer| 30 asymptomatic subjects| ICC = .85
ICC = .85| ICC = .68
ICC = .79
Passive dorsiflexion18  | Standard goniometer| 63 healthy naval reserve officers| ICC = .74| ICC = .65

Figure 8-20 Lunge measurements.

#### Reliability of Range-of-Motion Measurements of Calcaneal Position

Figure 8-21 Measurement of relaxed calcaneal stance.

Measurements and Study Quality| Instrumentation| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Relaxed calcaneal stance position19  | Standard goniometer| 212 healthy subjects: 88 adults and 124 children| ICC = .61 to .90| Not tested
Relaxed calcaneal stance
Neutral calcaneal stance14  | Gravity goniometer| 30 healthy subjects| ICC = .95 to.97
ICC = .87 to .93| ICC = .61 to .62
ICC = .21 to .31
Rearfoot angle18  | Standard goniometer| 63 healthy naval reserve officers| ICC = .88| ICC = .86

### Assessing Strength

#### Reliability of Strength Assessment

Test or Measure and Study Quality| Description| Population| Interexaminer Reliability
---|---|---|---
Ankle plantarflexion strength and endurance20  | Children asked to perform as many single-leg heel rises as possible at a rate of one every 2 seconds while the examiner counts the repetitions| 95 children 7 to 9 years old| ICC = .99

#### Diagnostic Utility of the Paper Grip Test for Detecting Toe Plantarflexion Strength Deficits

Figure 8-22 Paper grip test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Paper grip test21  | Patient is sitting with hips, knees, and ankles at 90 degrees and toes on a piece of cardboard. While stabilizing the feet, the examiner attempts to slide cardboard away from the patient's toes. Positive if patient cannot maintain cardboard under toes| 80 asymptomatic adults| Toe plantarflexion strength as measured by a force plate system| .80| .79| 3.8| .25

### Assessing Bony Alignment

#### Measurement of Navicular Height

Figure 8-23 Measurement of navicular height.

Test or Measure and Study Quality| Description| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Navicular height16  | Navicular tuberosity is marked while patient is in weight-bearing position. Distance from ground to navicular tuberosity is measured| 31 subjects 76 to 87 years of age recruited from general population| ICC = .64
(.38, .81)| Not tested
Navicular drop test22  | Navicular tuberosity is marked. Examiner measures height of navicular tuberosity

(1) as patient's foot rests on the ground, weight bearing is mostly on contralateral lower extremity, and examiner maintains the subtalar joint in neutral position
and

(2) as the patient's foot is in relaxed bilateral stance with full weight bearing.

The two measurements are recorded| 30 patients with patellofemoral pain syndrome| Not tested| ICC = .93 (.84, .97)
Navicular height technique17  | 30 asymptomatic subjects| ICC = .83| ICC = .73
Navicular height23  | Height of navicular tuberosity is calculated with a digital caliper| 100 consecutive patients presenting to an orthopaedic foot and ankle clinic| ICC = .90| ICC = .74

#### Assessment of Medial Arch Height

Figure 8-24 Measurement of arch angle.

Test or Measure and Study Quality| Description| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Arch angle18  | Patient is in weight-bearing position. Examiner measures angle formed by line connecting medial malleolus and navicular tuberosity and angle from tuberosity to medial aspect of first metatarsal head with standard goniometer| 63 healthy naval reserve officers| ICC = .90| ICC = .81
Arch height test23  | Highest point of soft tissue margin along medial longitudinal arch is recorded with a digital caliper| 100 consecutive patients presenting to an orthopaedic foot and ankle clinic| ICC = .91| ICC = .76

#### Measuring Forefoot Position

Figure 8-25 Determination of forefoot varus/valgus.

Test or Measure and Study Quality| Description| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Forefoot varus14  | Patient is prone with foot over edge of table. Examiner palpates medial and lateral talar head and then grasps fourth and fifth metatarsals and takes up slack in midtarsal joints. Subtalar neutral is position in which medial and lateral talar head is palpated equally24| 30 healthy subjects| ICC = .95 to .99| ICC = .61

### Assessing Balance and Dynamic Performance

#### Reliability of Assessing Balance and Proprioception

Test and Study Quality| Description| Population| Reliability
---|---|---|---
Single-leg balance test25  | Participant is asked to stand on one foot, without shoes on, on a polyfoam mat with the eyes closed and the contralateral leg bent for 1 minute. Number of errors (e.g., surface contact with contralateral foot or movement of the test foot) is counted by the examiner| 24 male recreational athletes with functional ankle instability| Test-retest ICC = .94
Single-leg balance test26  | Participant is asked to stand on one foot, without shoes on, and with the contralateral leg bent and not touching the tested limb. Test is positive if participant is unable to remain balanced or if participant reports a sense of imbalance| 240 healthy athletes| Interexaminer κ = .90
Threshold for perception of passive movement27  | Examiner collects measurements with potentiometer| 24 healthy adult subjects| Test-retest ICC = .95
Active-to-active reproduction of joint position27  | Test-retest ICC = .83
Reproduction of movement velocity27  | Test-retest ICC = .79
Reproduction of torque27  | Test-retest ICC = (Dorsiflexion) .86
(Plantarflexion) .72

#### Reliability of Assessing Dynamic Performance

Figure 8-26 Single-leg hop test.

Test or Measure and Study Quality| Description| Population| Reliability
---|---|---|---
Single-leg hopping course25  | Course consists of eight squares, some of which are inclined, declined, or have a lateral inclination. Patient is asked to jump on each square on one leg as quickly as possible. Performance is indicated by the number of seconds taken| 24 male recreational athletes with functional ankle instability| Test-retest ICC = .97
Single-leg hop for distance25  | Patient is asked to hop once or three times as far as possible on one leg. Performance is indicated by distance covered| Test-retest ICC = .97
Triple hop for distance25  | Test-retest ICC = .98
6-meter hop for time25  | Patient is asked to hop, in a straight line or crosswise over a line, for 6 meters on one leg as quickly as possible. Performance is indicated by the number of seconds taken| Test-retest ICC = .95
Cross 6-meter hop for time25  | Test-retest ICC = .94

### Assessing Foot Motion during Gait

#### Reliability of Assessing Hindfoot Motion during Gait

Test or Measure and Study Quality| Description| Population| Interexaminer Reliability
---|---|---|---
5-Point Scale| 2-Point Scale
Duration of hindfoot motion28  | Each aspect of dynamic hindfoot motion is graded on a 2-point or 5-point scale while observing participant walking barefoot on a treadmill.
5-point scale:

(1) Less than normal

(2) Normal

(3) Mildly abnormal

(4) Moderately abnormal

(5) Severely abnormal

2-point scale:

(1) Normal or less than normal

(2) Greater than normal

| 24 healthy participants| κ = −.03 to .01| κ = .14 to .24
Velocity of hindfoot motion28  | κ = −.04 to .01| κ = .02 to .20
Timing of hindfoot motion28  | κ = .15 to .20| κ = .19 to .20
Maximum degree of hindfoot motion28  | κ = .13 to .18| κ = .27 to .48
Range of hindfoot motion28  | κ = .06 to .19| κ = .15 to .28

#### Accuracy of the Functional Hallux Limitus Test to Predict Abnormal Excessive Midtarsal Function during Gait

Figure 8-27 Functional hallux limitus test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Functional hallux limitus test29  | With the patient in a non−weight-bearing position, the examiner uses one hand to maintain the subtalar joint in a neutral position while maintaining the first ray in dorsiflexion. The other hand is used to dorsiflex the proximal phalanx of the hallux. The test is considered positive if the examiner notes immediate plantarflexion of the first metatarsal upon dorsiflexion of the proximal phalanx| 46 asymptomatic students (86 feet) with no significant orthopaedic or structural deformities of the foot| Abnormal midtarsal motion by observing if the navicular moved in a plantar direction or was adducted when the heel began to lift off the ground| .72| .66| 2.1| .42

### Assessing Swelling

#### Reliability of Measuring Ankle Joint Swelling

Figure 8-28 Figure-of-eight measurement.

Test and Study Quality| Description| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Figure-of-eight method30  | In open kinetic chain, examiner places tape measure midway between tibialis anterior tendon and lateral malleolus. Tape is then drawn medially and placed just distal to navicular tuberosity. Tape is then pulled across arch and just proximal to base of fifth metatarsal. Tape is then pulled across anterior tibialis tendon and around ankle joint just distal to medial malleolus. Tape is finally pulled across Achilles tendon and placed just distal to lateral malleolus and across start of tape| 30 postoperative patients with ankle edema| ICC = .99 to 1.0| ICC = .99 to 1.0
Figure-of-eight method32  | 50 healthy subjects| ICC = .99| ICC = .99
Figure-of-eight method32  | 29 individuals with ankle swelling| ICC = .98| ICC = .98
Water volumetrics32  | Water displacement is measured with patient's foot in a volumeter with toe tips touching front wall| ICC = .99| ICC = .99

### Assessing Sensation

#### Reliability of Assessing Protective Sensation

Figure 8-29 Foot involvement in rheumatoid arthritis.

Test and Study Quality| Description| Population| Reliability
---|---|---|---
Sensation testing33  | 3-gram and 10-gram Semmes-Weinstein monofilaments were used to assess protective sensation. Monofilaments were applied perpendicular to the skin for approximately 1.5 seconds at six sites (plantar hallux and first to fifth MTP joints). Participants had their eyes closed and were asked to respond if they perceived pressure| 51 patients with rheumatoid arthritis and 20 controls| (3-gram monofilament) test-retest κ = .73 (.64, .83)
(10-gram monofilament) test-retest κ = .75 (.65, .85)

### Special Tests

#### Detecting Subcutaneous Tears of the Achilles Tendon

Figure 8-30 Thompson test.

Test and Study Quality| Description| Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---|---
Thompson test34  | Patient positioned prone while examiner gently squeezes the patient's calf muscles with the palm of his or her hand| If the Achilles tendon is intact, plantarflexion occurs in the ankle. If the Achilles tendon is torn, the ankle either remains still or only minimal plantarflexion occurs| 174 patients with suspected Achilles tendon tear referred to orthopaedic clinic| Surgical confirmation for subjects with the diagnosis; magnetic resonance imaging (MRI) and ultrasound for subjects without the diagnosis| .96 (.91, .99)| .93 (.75, .99)| 13.47 (3.54, 51.25)| .04 (.02, .10)
Achilles palpation34  | Patient positioned prone while examiner gently palpates the course of the tendon| The gap is classified as present or absent| .73 (.64, .80)| .89 (.71, .97)| 6.81 (2.32, 19.93)| .30 (.23, .40)

#### Detecting Syndesmotic Injury

Test and Study Quality| Description| Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---|---
External rotation test35  | Clinician applies external rotation of patient's foot with leg stabilized and ankle in neutral position| Pain elicited at anterolateral ankle| 56 patients with lateral ankle sprain referred to orthopaedic clinic| MRI| .20 (.04, .56)| .85 (.71, .93)| 1.31 (.32, 5.41)| .94 (.69, 1.30)
Dorsiflexion−external rotation test36  | Leg is stabilized in 90 degrees of knee flexion, and the ankle is in maximal dorsiflexion; an external rotation stress is applied to the injured foot and ankle| Reproduction of anterolateral pain over the syndesmosis area| 87 patients with an acute ankle injury| MRI| .71 (.55, .83)| .63 (.49, .75)| 1.93 (1.28, 2.94)| .46 (.27, .79)
Dorsiflexion lunge with compression test36  | Patient lunges forward on the injured leg as far as possible. The lunge is repeated with manual compression provided by the examiner across the ankle syndesmosis| Increase in the ankle range of motion or decreased pain when compression added| .69 (.53, .82)| .41 (.28, .56)| 1.18 (.86, 1.64)| .74 (.41, 1.35)
Syndesmosis squeeze test35  | Clinician applies lateromedial compression at the transition between the middle and distal third of the patient's leg| Pain elicited at distal syndesmosis| 56 patients with lateral ankle sprain referred to orthopaedic clinic| MRI| .30 (.08, .65)| .93 (.81, .98)| 4.60 (1.08, 19.55)| .75 (.50, 1.13)
Syndesmosis squeeze test36  | Patient sitting over the side of the bed. Compression of the fibula to the tibia about the midpoint of the calf using one or both hands| Replication of pain in the area of the ankle syndesmosis| 87 patients with an acute ankle injury| MRI| .26 (.15, .42)| .88 (.76, .94)| 2.15 (.86, 5.39)| .84 (.68, 1.04)
Syndesmosis ligament palpation36  | Palpation of anterior and posterior inferior tibiofibular ligament. Palpation between the tibia and fibula| Report of pain after pressing the ligament or membrane| MRI| .92 (.79, .97)| .29 (.18, .42)| 1.29 (1.06, 1.58)| .28 (.09, .89)

Figure 8-31 Squeeze test.

Figure 8-32 Dorsiflexion-compression test.

Figure 8-33 External rotation test.

#### Detecting Anterolateral Ankle Impingement

Figure 8-34 Impingement sign.

Test and Study Quality| Description| Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---|---
Impingement sign37 (see Video 8-1)  | Patient is seated. Examiner grasps calcaneus with one hand and uses other hand to grasp forefoot and bring it into plantarflexion. Examiner uses thumb to place pressure over anterolateral ankle. Foot is then brought from plantarflexion to dorsiflexion while thumb pressure is maintained| Positive if pain provoked with pressure from examiner's thumb is greater in dorsiflexion than plantarflexion| 73 patients with ankle pain| Arthroscopic visualization| .95| .88| 7.91| .06
History and clinical examination38  | Examiner records aggravating factors and reports loss of motion. Examination includes observation of swelling, passive forced ankle dorsiflexion and eversion, active range of motion and double-leg and single-leg squats| Positive if five or more findings are positive:

(1) Anterolateral ankle joint tenderness

(2) Anterolateral ankle joint swelling

(3) Pain with forced dorsiflexion and eversion

(4) Pain with single-leg squat

(5) Pain with activities

(6) Ankle instability

| 22 patients undergoing arthroscopic surgery for complaints of chronic ankle pain| Arthroscopic visualization| .94| .75| 3.76| .08

#### Detecting Joint Instability after Lateral Ankle Sprain

Figure 8-35 Medial talar tilt stress test.

Figure 8-36 Medial subtalar glide test.

Test and Study Quality| Description| Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---|---
Anterior drawer test12  | Clinician stabilizes patient's distal leg and grasps the calcaneus to impart an anteriorly directed force in an attempt to move the talus; patient is seated with ankle in 10 to 20 degrees of plantarflexion| Clinician-assessed grades of 3 and above on a 4-point laxity scale| 66 patients with history of lateral ankle sprain and 20 healthy controls| Ultrasound| .33 (.18, .53)| .73 (.59, .85)| 1.27 (.59, 2.72)| .90 (.64, 1.26)
Anterior drawer test39 (see Video 8-2)  | Manual examination for anterior displacement of the talus within the mortise| Anterior displacement of the talus within the mortise graded on a 4-point laxity scale| 12 subjects with history of lateral ankle sprain and 8 healthy controls| Stress fluoroscopy| .58 (.29, .84)| 1.00 (.60, 1.00)| Undefined| .42 (.21, .81)
Medial talar tilt stress test39 (see Video 8-3)  | Manual examination for excessive inversion of the talus within the mortise| Inversion of the talus within the mortise graded on a 4-point laxity scale| .50 (.22, .78)| .88 (.47, .99)| 4.00 (.59, 27.25)| .57 (.31, 1.04)
Medial subtalar glide test39  | Examiner holds the talus in subtalar neutral position with one hand and glides the calcaneus medially on the fixed talus with the other hand| Examiner assesses the end feel of the glide graded on a 4-point laxity scale| .58 (.29, .84)| .88 (.47, .99)| 4.67 (.70, 31.04)| .48 (.24, .96)

Figure 8-37 Anterior drawer test.

#### Detecting Tarsal Tunnel Syndrome

Figure 8-38 Triple compression test.

Test and Study Quality| Description| Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---|---
Triple compression stress test40 (see Video 8-4)  | Clinician positions patient's ankle in full plantarflexion and inversion while simultaneously applying direct digital pressure for 30 seconds over posterior tibial nerve behind the medial malleolus| Reproduction or intensified clinical symptoms and signs of tarsal tunnel syndrome| 50 subjects with symptoms suggestive of tarsal tunnel syndrome and 40 healthy controls| Basic motor nerve conduction for tibial nerve| .86 (.76, .92)| 1.00 (.93, 1.00)| Undefined| .14 (.08, .24)

#### Reliability of the Windlass Test

Figure 8-39 Windlass test.

Test and Study Quality| Description| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Windlass test41  | Two methods of performing the Windlass test were used. In the first version, the patient's knee was flexed to 90 degrees while in a non−weight-bearing position. The examiner stabilized the ankle and extended the MTP joint while allowing the IP joint to flex, thus preventing motion limitations due to a shortened hallucis longus muscle. In the second method, the patient was standing on a step stool with toes over the stool's edge. Again the MTP joint was extended while the IP joint was allowed to flex| 22 patients with plantar fasciitis, 23 patients with other types of foot pain, and 30 controls| ICC = .99| ICC = .96

## Outcome Measures

Outcome Measure| Scoring and Interpretation| Test-Retest Reliability and Study Quality| MCID
---|---|---|---
Lower Extremity Functional Scale (LEFS)| Users are asked to rate the difficulty of performing 20 functional tasks on a Likert-type scale ranging from 0 (extremely difficult or unable to perform activity) to 4 (no difficulty). A total score out of 80 is calculated by summing each score. The answers provide a score between 0 and 80, with lower scores representing more disability| ICC = .9226| 96
Foot Function Index (FFI)| A self-administered questionnaire consisting of 23 items divided into pain, disability, and activity restriction subscales. A score between 0 and 100 is derived by dividing the visual analog scale into 10 segments. Higher scores indicate more impairment| ICC = .854| Unknown
American Orthopaedic Foot and Ankle Society (AOFAS) scales| Ankle-Hindfoot| Each scale is administered by a clinician and has subjective and objective criteria, including range-of-motion, gait abnormalities, stability, alignment, and callus assessment. The answers provide a score between 0 and 100, with lower scores representing more disability| Unknown| 943
Midfoot| Unknown| 1243
Hallux| ICC = .954| 2543
MTP-IP joints| ICC = .804| 1143
Numeric Pain Rating Scale (NPRS)| Users rate their level of pain on an 11-point scale ranging from 0 to 10, with high scores representing more pain. Often asked as "current pain" and "least," "worst," and "average pain" in the past 24 hours| ICC = .7244| 245,46

ICC: Intraclass correlation coefficient; MCID: minimum clinically important difference.

## Appendix

#### Quality Appraisal of Reliability Studies for the Foot and Ankle Using QAREL

| Elveru 198813| Stiell 19928| Youdas 199347| Sell 199417| Saltzman 199523| Tatro-Adams 199531| Jonson 199718| Alonso 19981| Sobel 199919| Petersen 199932
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| U| Y| Y| Y| U| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| Y| U| Y| Y| U| Y| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| N/A| Y| U| U| U| U| N/A| Y| N

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| Y| N/A| N/A| U| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| Y| U| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| Y| Y| U| U| U| U| U

8. Was the order of examination varied?

| Y| U| Y| Y| U| Y| U| N| Y| Y

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality summary rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y − N = 9 to 11)   Fair quality (Y − N = 6 to 8)   Poor quality (Y − N ≤ 5).

| Van Gheluwe 200214| De Garceau 200341| Deshpande 200327| Menz 200316| Cornwall 20047| Piva 200622| Wilson 200633| Menadue 200611| Trojian 200626
---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| U| Y| N| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| U| U| U| U| Y| Y| N/A| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| N| U| N/A| U| N/A| N/A| N/A| Y| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| U| N/A| N/A| N/A| N/A| N/A| Y| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| Y| U| U| U| U| Y

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| Y

8. Was the order of examination varied?

| U| U| U| U| U| N| N/A| Y| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| U| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality summary rating:|  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y − N = 10 to 14)   Fair quality (Y − N = 5 to 9)   Poor quality (Y − N ≤ 4).

| Baumhauer 20064| Li 200744| Rohner-Spengler 200730| Keenan 200628| Maurer 200720| Sekir 200825| Munteanu 200915| Pua 200942
---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| U| Y| Y| Y| U| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| N/A| N/A| Y| Y| U| N/A| Y| U

4. Were raters blinded to their own prior findings of the test under evaluation?

| U| N| U| U| N/A| U| Y| U

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| Y| U| U| U

8. Was the order of examination varied?

| U| U| Y| Y| N/A| U| Y| Y

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y
Quality summary rating:|  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y − N = 10 to 14)   Fair quality (Y − N = 5 to 9)   Poor quality (Y − N ≤ 4).

#### Quality Assessment of Diagnostic Accuracy Studies for the Foot and Ankle Using QUADAS

| Liu 199738| Maffulli 199834| Hertel 199939| Payne 200229| De Garceau 200341| Molloy 200337| Eggli 20059| Dissmann 200610
---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| N| N| U| Y| Y| Y

2. Were selection criteria clearly described?

| N| Y| Y| Y| N| N| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| U| U| U| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| Y| U| U| U| U| Y| U

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| U| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| N| Y| Y| U| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| U| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| N| Y| Y| Y| U| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| Y| N| N| Y| Y| U

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| U| Y| Y| U| Y| Y| U

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| U| Y| U| U| U| U| U

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| Y| U| Y| U| U| U| U| U

13. Were uninterpretable/intermediate test results reported?

| U| Y| N| U| U| U| U| U

14. Were withdrawals from the study explained?

| U| Y| N| Y| U| U| Y| U
Quality summary rating:|  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y − N = 10 to 14)   Fair quality (Y − N = 5 to 9)   Poor quality (Y − N ≤ 4).

| Menz 200621| Wilson 200633| de César 201135| Abouelela 201240| Croy 201312| Sman 201536
---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| Y| Y| U| U

2. Were selection criteria clearly described?

| Y| U| Y| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| U| Y| U| U| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| Y| U| Y| Y| Y| Y

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| Y| Y| Y| Y| N

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| U| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| N| Y| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| U| U| Y| U| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| U| Y| U| N| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| Y| U| Y| Y| Y

13. Were uninterpretable/intermediate test results reported?

| U| U| Y| Y| Y| U

14. Were withdrawals from the study explained?

| Y| U| Y| Y| Y| Y
Quality summary rating:|  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y − N = 10 to 14)   Fair quality (Y − N = 5 to 9)   Poor quality (Y − N ≤ 4).

## References

1. Alonso A, Khoury L, Adams R. Clinical tests for ankle syndesmosis injury: reliability and prediction of return to function. J Orthop Sports Phys Ther. 1998;27:276–284.

2. Reischl SF, Noceti-DeWit LM. Foot and Ankle. Current Concepts of Orthopedic Physical Therapy. Orthopaedic Section, American Physical Therapy Association: La Crosse, Wisconsin; 2001.

3. Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326:417.

4. Baumhauer JF, Nawoczenski DA, DiGiovanni BF, Wilding GE. Reliability and validity of the American Orthopaedic Foot and Ankle Society Clinical Rating Scale: a pilot study for the hallux and lesser toes. Foot Ankle Int. 2006;27:1014–1019.

5. Bennett JE, Reinking MF, Pluemer B, et al. Factors contributing to the development of medial tibial stress syndrome in high school runners. J Orthop Sports Phys Ther. 2001;31:504–510.

6. Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther. 1999;79:371–383.

7. Cornwall MW, Fishco WD, McPoil TG, et al. Reliability and validity of clinically assessing first-ray mobility of the foot. J Am Podiatr Med Assoc. 2004;94:470–476.

8. Stiell IG, McKnight RD, Greenberg GH, et al. Interobserver agreement in the examination of acute ankle injury patients. Am J Emerg Med. 1992;10:14–17.

9. Eggli S, Sclabas GM, Eggli S, et al. The Bernese ankle rules: a fast, reliable test after low-energy, supination-type malleolar and midfoot trauma. J Trauma. 2005;59:1268–1271.

10. Dissmann PD, Han KH. The tuning fork test–a useful tool for improving specificity in "Ottawa positive" patients after ankle inversion injury. Emerg Med J. 2006;23:788–790.

11. Menadue C, Raymond J, Kilbreath SL, et al. Reliability of two goniometric methods of measuring active inversion and eversion range of motion at the ankle. BMC Musculoskelet Disord. 2006;7:60.

12. Croy T, Koppenhaver S, Saliba S, Hertel J. Anterior talocrural joint laxity: diagnostic accuracy of the anterior drawer test of the ankle. J Orthop Sports Phys Ther. 2013;43(12):911–919.

13. Elveru RA, Rothstein JM, Lamb RL. Goniometric reliability in a clinical setting. Subtalar and ankle joint measurements. Phys Ther. 1988;68:672–677.

14. Van Gheluwe B, Kirby KA, Roosen P, Phillips RD. Reliability and accuracy of biomechanical measurements of the lower extremities. J Am Podiatr Med Assoc. 2002;92:317–326.

15. Munteanu SE, Strawhorn AB, Landorf KB, et al. A weightbearing technique for the measurement of ankle joint dorsiflexion with the knee extended is reliable. J Sci Med Sport. 2009;12:54–59.

16. Menz HB, Tiedemann A, Kwan MM, et al. Reliability of clinical tests of foot and ankle characteristics in older people. J Am Podiatr Med Assoc. 2003;93:380–387.

17. Sell KE, Verity TM, Worrell TW, et al. Two measurement techniques for assessing subtalar joint position: a reliability study. J Orthop Sports Phys Ther. 1994;19:162–167.

18. Jonson SR, Gross MT. Intraexaminer reliability, interexaminer reliability, and mean values for nine lower extremity skeletal measures in healthy naval midshipmen. J Orthop Sports Phys Ther. 1997;25:253–263.

19. Sobel E, Levitz SJ, Caselli MA, et al. Reevaluation of the relaxed calcaneal stance position. Reliability and normal values in children and adults. J Am Podiatr Med Assoc. 1999;89:258–264.

20. Maurer C, Finley A, Martel J, et al. Ankle plantarflexor strength and endurance in 7-9 year old children as measured by the standing single leg heel-rise test. Phys Occup Ther Pediatr. 2007;27:37–54.

21. Menz HB, Zammit GV, Munteanu SE, Scott G. Plantarflexion strength of the toes: age and gender differences and evaluation of a clinical screening test. Foot Ankle Int. 2006;27:1103–1108.

22. Piva SR, Fitzgerald K, Irrgang JJ, et al. Reliability of measures of impairments associated with patellofemoral pain syndrome. BMC Musculoskelet Disord. 2006;7:33.

23. Saltzman CL, Nawoczenski DA, Talbot KD. Measurement of the medial longitudinal arch. Arch Phys Med Rehabil. 1995;76:45–49.

24. Root ML, Orien WP, Weed JH. Biomechanical examination of the foot. Clinical Biomechanics Corp: Los Angeles; 1971.

25. Sekir U, Yildiz Y, Hazneci B, et al. Reliability of a functional test battery evaluating functionality, proprioception, and strength in recreational athletes with functional ankle instability. Eur J Phys Rehabil Med. 2008;44:407–415.

26. Trojian TH, McKeag DB. Single leg balance test to identify risk of ankle sprains. Br J Sports Med. 2006;40:610–613 [discussion 613].

27. Deshpande N, Connelly DM, Culham EG, Costigan PA. Reliability and validity of ankle proprioceptive measures. Arch Phys Med Rehabil. 2003;84:883–889.

28. Keenan AM, Bach TM. Clinicians' assessment of the hindfoot: a study of reliability. Foot Ankle Int. 2006;27:451–460.

29. Payne C, Chuter V, Miller K. Sensitivity and specificity of the functional hallux limitus test to predict foot function. J Am Podiatr Med Assoc. 2002;92:269–271.

30. Rohner-Spengler M, Mannion AF, Babst R. Reliability and minimal detectable change for the figure-of-eight-20 method of, measurement of ankle edema. J Orthop Sports Phys Ther. 2007;37:199–205.

31. Tatro-Adams D, McGann SF, Carbone W. Reliability of the figure-of-eight method of ankle measurement. J Orthop Sports Phys Ther. 1995;22:161–163.

32. Petersen EJ, Irish SM, Lyons CL, et al. Reliability of water volumetry and the figure of eight method on subjects with ankle joint swelling. J Orthop Sports Phys Ther. 1999;29:609–615.

33. Wilson O, Kirwan JR. Measuring sensation in the feet of patients with rheumatoid arthritis. Musculoskeletal Care. 2006;4:12–23.

34. Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients. Am J Sports Med. 1998;26(2):266–270.

35. De César PC, Avila EM, de Abreu MR. Comparison of magnetic resonance imaging to physical examination for syndesmotic injury after lateral ankle sprain. Foot Ankle Int. 2011;32(12):1110–1114.

36. Sman AD, Hiller CE, Rae K, et al. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. Br J Sports Med. 2015;49(5):323–329.

37. Molloy S, Solan MC, Bendall SP. Synovial impingement in the ankle: a new physical sign. J Bone Joint Surg B. 2003;85:330–333.

38. Liu SH, Nuccion SL, Finerman G. Diagnosis of anterolateral ankle impingement. Comparison between magnetic resonance imaging and clinical examination. Am J Sports Med. 1997;25:389–393.

39. Hertel J, Denegar CR, Monroe MM, Stokes WL. Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc. 1999;31(11):1501–1508.

40. Abouelela AA, Zohiery AK. The triple compression stress test for diagnosis of tarsal tunnel syndrome. Foot (Edinb). 2012;22(3):146–149.

41. De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int. 2003;24:251–255.

42. Pua YH, Cowan SM, Wrigley TV, Bennell KL. The Lower Extremity Functional Scale could be an alternative to the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale. J Clin Epidemiol. 2009;62(10):1103–1111.

43. Dawson J, Doll H, Coffey J, Jenkinson C. Responsiveness and minimally important change for the Manchester-Oxford foot questionnaire (MOXFQ) compared with AOFAS and SF-36 assessments following surgery for hallux valgus. Osteoarthritis Cartilage. 2007;15:918–931.

44. Li L, Liu X, Herr K. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Pain Med. 2007;8:223–234.

45. Farrar JT, Berlin JA, Strom BL. Clinically important changes in acute pain outcome measures: a validation study. J Pain Symptom Manage. 2003;25:406–411.

46. Farrar JT, Portenoy RK, Berlin JA, et al. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287–294.

47. Youdas JW, Bogard CL, Suman VJ. Reliability of goniometric measurements and visual estimates of ankle joint active range of motion obtained in a clinical setting. Arch Phys Med Rehabil. 1993;74:1113–1118.
9

# Shoulder

CLINICAL SUMMARY AND RECOMMENDATIONS, 450

Anatomy, 451

Osteology, 451

Arthrology, 452

Scapulohumeral Rhythm, 453

Ligaments, 454

Muscles, 456

Nerves, 459

Patient History, 461

Initial Hypotheses Based on Historical Findings, 461

Physical Examination Tests, 463

Range-of-Motion Measurements, 463

Assessing Strength and Proprioception, 465

Assessing Muscle Length, 466

Palpation, 468

Assessing Alignment, 470

Classifying Shoulder Disorders, 472

Special Tests—Instability, 473

Special Tests—Labral Tears, 477

Special Tests—Subacromial Impingement, 490

Special Tests—Rotator Cuff Tears, 500

Special Tests—Brachial Plexus Palsy, 509

Special Tests—Acromioclavicular Lesions, 510

Special Tests—Adhesive Capsulitis, 511

Combinations of Tests, 512

Outcome Measures, 515

Appendix, 516

References, 523

## Clinical Summary and Recommendations

Patient History
---
Complaints|

• Little is known about the utility of subjective complaints with shoulder pain. Although a report of trauma does not seem clinically useful, a history of popping, clicking, or catching may be minimally helpful in diagnosing a labral tear (+LRs [likelihood ratios] = 2.0).

Physical Examination
Range-of-Motion, Strength, and Muscle Length Assessment|

• Measuring shoulder range of motion has consistently been shown to be highly reliable but is of unknown diagnostic utility. Visual assessments and functional tests of range of motion are more variable and may be adequately reliable in some instances.

• Assessing strength with manual muscle testing appears to be reliable. Weak abduction and/or external rotation may be fairly useful in identifying subacromial impingement and/or full-thickness rotator cuff tears. Weak internal rotation appears to be very helpful in identifying subscapularis tears (+LR = 7.5 to 20.0).

• Assessments of shoulder muscle tightness are moderately reliable. However, the single study done to test associated diagnostic utility found tight pectoralis minor muscles in all 90 participants regardless of whether they had shoulder problems or not (100% sensitivity, 0% specificity).

Special Tests|

• The apprehension test appears to be the most useful test in identifying shoulder instability, especially when defining a positive test by an "apprehensive response" (+LR = 7.1 to 20.2, −LR = .00 to .29) as opposed to "pain" (+LR = 1.1 to 3.1, −LR = .69 to .90). To a lesser extent, it may also be helpful in diagnosing labral tears.

• Results of studies examining the diagnostic utility of tests to identify labral tears are highly variable. Even though most single tests do not appear very useful, one study found both the Kim test and the jerk test to be very good at identifying labral tears (+LRs of 13.3 and 36.5, respectively). The same author also found the biceps load tests I and II to be very effective at identifying superior labrum anterior and posterior (SLAP) lesions (+LR = 30 for both).

• A 2012 metaanalysis found the lift-off test to be very effective at identifying subacromial impingement (+LR = 14).

• The same 2012 metaanalysis found both the Hawkins-Kennedy test and Neer test to be minimally helpful for ruling in or ruling out subacromial impingement. The presence of a "painful arc" during elevation was also found to have minimal value in identifying the condition (+LR = 2.3, −LR = .62).

• In addition to rotator cuff muscle weakness (above), the external and internal rotation lag signs appear to be very helpful at identifying infraspinatus and subscapularis tears, respectively. Several other tests (the bear-hug, belly-press, and Napoleon tests) appear to be also very useful in diagnosing subscapularis tears.

• Whereas several signs and symptoms are helpful in identifying brachial plexus nerve root avulsions, the shoulder protraction test appears to be the most useful (+LR = 4.8, −LR = .05).

• One study showed that the coracoid pain test was moderately helpful in identifying adhesive capsulitis (+LR = 7.4).

Combinations of Findings|

• Even though combinations of tests are generally better than single tests, combinations of tests are only moderately helpful in identifying labral tears. The most efficient pair seems to be the anterior apprehension and Jobe relocation tests (+LR = 5.4).

• One study showed that a combined history of popping, clicking, or catching in addition to a positive anterior slide test was moderately helpful in identifying a type II to IV SLAP lesion (+LR = 6.0).

• Another study reported even better diagnostic utility when specific combinations of three tests were used. By selecting two highly sensitive tests (compression rotation test, anterior apprehension test, and O'Brien test) and one highly specific test (Yergason test, biceps load II test, or Speed tests), users can be fairly confident in both ruling out and ruling in SLAP lesions.

## Anatomy

### Osteology

Figure 9-1 Anterior humerus and scapula.

Figure 9-2 Superior and inferior surfaces of clavicle.

### Arthrology

Figure 9-3 Sternoclavicular joint.

Joint| Type and Classification| Closed Packed Position| Capsular Pattern
---|---|---|---
Glenohumeral| Spheroidal| Full abduction and external rotation| External rotation limited more than abduction, limited more than internal rotation and flexion
Sternoclavicular| Saddle| Arm abducted to 90 degrees| Not reported
Acromioclavicular| Plane synovial| Arm abducted to 90 degrees
Scapulothoracic| Not a true articulation| Not available| Not available

### Scapulohumeral Rhythm

Figure 9-4 Scapulohumeral rhythm.

Scapulohumeral rhythm consists of integrated movements of the glenohumeral, scapulothoracic, acromioclavicular, and sternoclavicular joints occurring in sequential fashion to allow full functional motion of the shoulder complex. Scapulohumeral rhythm serves three functional purposes: It allows for greater overall shoulder range of motion; it maintains optimal contact between the humeral head and glenoid fossa; and it assists with maintaining an optimal length-tension relationship of the glenohumeral muscles. To complete 180 degrees of abduction, the overall ratio of glenohumeral to scapulothoracic, acromioclavicular, and sternoclavicular motion is 2 : 1.

Inman and colleagues were the first to explain scapulohumeral rhythm and described it as two phases that the shoulder complex completes to move through full abduction. During the first phase (0 degrees to 90 degrees), the scapula is set against the thorax to provide initial stability as the humerus abducts to 30 degrees., From 30 degrees to 90 degrees of abduction, the glenohumeral joint contributes another 30 degrees of range of motion while the scapula rotates upward 30 degrees. The upward rotation results from clavicular elevation through the sternoclavicular and acromioclavicular joints. The second phase (90 degrees to −180 degrees) entails 60 degrees of glenohumeral abduction and 30 degrees of scapular upward rotation. The scapular rotation is associated with 5 degrees of elevation at the sternoclavicular joint and 25 degrees of rotation at the acromioclavicular joint.,

### Ligaments

Figure 9-5 Shoulder ligaments: anterior view.

Ligaments| Attachments| Function
---|---|---
Glenohumeral| Glenoid labrum to neck of humerus| Reinforces anterior glenohumeral joint capsule
Coracohumeral| Coracoid process to greater tubercle of humerus| Strengthens superior glenohumeral joint capsule
Coracoclavicular
(trapezoid)| Superior aspect of coracoid process to inferior aspect of clavicle| Anchors clavicle to coracoid process
Coracoclavicular
(conoid)| Coracoid process to conoid tubercle on inferior clavicle
Acromioclavicular| Acromion to clavicle| Strengthens acromioclavicular joint superiorly
Coracoacromial| Coracoid process to acromion| Prevents superior displacement of humeral head
Sternoclavicular| Clavicular notch of manubrium to medial base of clavicle anteriorly and posteriorly| Reinforces sternoclavicular joint anteriorly and posteriorly
Interclavicular| Medial end of one clavicle to medial end of other clavicle| Strengthens superior sternoclavicular joint capsule
Costoclavicular| Superior aspect of costal cartilage of first rib to inferior border of medial clavicle| Anchors medial end of clavicle to first rib

Figure 9-6 Shoulder (glenohumeral) joint.

### Muscles

#### Posterior Muscles of Shoulder

Figure 9-7 Muscles of the shoulder: posterior view.

Muscles| Origin| Insertion| Nerve and Segmental Level| Action
---|---|---|---|---
Upper trapezius| Occipital protuberance, nuchal line, ligamentum nuchae| Lateral clavicle and acromion| Cranial nerve XI; C2 to C4| Rotates glenoid fossa upwardly, elevates scapula
Middle trapezius| Spinous processes of T1 to T5| Acromion and spine of scapula| Cranial nerve XI; C2 to C4| Retracts scapula
Lower trapezius| Spinous processes of T6 to T12| Apex of spine of scapula| Cranial nerve XI; C2 to C4| Upward rotation of glenoid fossa, scapular depression
Levator scapulae| Transverse processes of C1 to C4| Superior medial scapula| Dorsal scapular nerve; C3 to C5| Elevates and adducts scapula
Rhomboids| Ligamentum nuchae and spinous processes of C7 to T5| Medial scapular border| Dorsal scapular nerve; C4 to C5| Retracts scapula
Latissimus dorsi| Inferior thoracic vertebrae, thoracolumbar fascia, iliac crest, and inferior ribs 3 and 4| Intertubercular groove of humerus| Thoracodorsal nerve; C6 to C8| Internally rotates, adducts, and extends humerus
Serratus anterior| Ribs 1 to 8| Anterior medial scapula| Long thoracic nerve; C5 to C8| Protracts and upwardly rotates scapula

#### Anterior Muscles of Shoulder

Figure 9-8 Muscles of the shoulder: anterior view.

Muscles| Origin| Insertion| Nerve and Segmental Level| Action
---|---|---|---|---
Deltoid| Clavicle, acromion, spine of scapula| Deltoid tuberosity of humerus| Axillary nerve; C5 to C6| Abducts arm
Pectoralis major (clavicular head)| Anterior medial clavicle| Intertubercular groove of humerus| Lateral and medial pectoral nerves; C5, C6, C7, C8, T1| Adducts and internally rotates humerus
Pectoralis major
(sternocostal head)| Lateral border of sternum, superior six costal cartilages, and fascia of external oblique muscle
Pectoralis minor| Just lateral to costal cartilage of ribs 3 to 5| Coracoid process| Medial pectoral nerve; C8, T1| Stabilizes scapula

#### Rotator Cuff Muscles

Figure 9-9 Muscles of the shoulder: rotator cuff.

Muscles| Origin| Insertion| Nerve and Segmental Level| Action
---|---|---|---|---
Supraspinatus| Supraspinous fossa of scapula| Greater tubercle of humerus| Suprascapular nerve; C4 to C6| Assists deltoid in abduction of humerus
Infraspinatus| Infraspinous fossa of scapula| Greater tubercle of humerus| Suprascapular nerve; C5 to C6| Externally rotates humerus
Teres minor| Lateral border of scapula| Greater tubercle of humerus| Axillary nerve; C5 to C6| Externally rotates humerus
Subscapularis| Subscapular fossa of scapula| Lesser tubercle of humerus| Upper and lower subscapular nerves; C5 to C6| Internally rotates humerus
Teres major| Inferior angle of scapula| Intertubercular groove of humerus| Lower subscapular nerve; C5 to C6| Internally rotates and adducts humerus

### Nerves

Nerves| Segmental Levels| Sensory| Motor
---|---|---|---
Radial| C5, C6, C7, C8, T1| Posterior aspect of forearm| Triceps brachii, anconeus, brachioradialis, extensor muscles of forearm
Ulnar| C7, C8, T1| Medial hand, including medial half of digit 4| Flexor carpi ulnaris, medial half of flexor digitorum profundus, most small muscles in hand
Musculocutaneous| C5, C6, C7| Becomes lateral antebrachial cutaneous nerve| Coracobrachialis, biceps brachii, brachialis
Axillary| C5, C6| Lateral shoulder| Teres minor, deltoid
Suprascapular| C4, C5, C6| No sensory| Supraspinatus, infraspinatus
Dorsal scapular| Ventral rami of C4, C5| No sensory| Rhomboids, levator scapulae
Lateral pectoral| C5, C6, C7| No sensory| Pectoralis major, pectoralis minor
Medial pectoral| C8, T1| No sensory| Pectoralis minor
Long thoracic| Ventral rami of C5, C6, C7| No sensory| Serratus anterior
Upper subscapular| C5, C6| No sensory| Subscapularis
Lower subscapular| C5, C6| No sensory| Teres major, subscapularis
Medial cutaneous of arm| C8, T1| Medial arm| No motor

Figure 9-10 Anterior axilla.

## Patient History

### Initial Hypotheses Based on Historical Findings

History| Initial Hypothesis
---|---
Patient reports lateral/anterior shoulder pain with overhead activities or exhibits a painful arc| Possible subacromial impingement,
Possible tendonitis
Possible bursitis
Patient reports instability, apprehension, and pain with activities, most often when shoulder is abducted and externally rotated| Shoulder instability
Possible labral tear if clicking is present,
Decreased range of motion and pain with resistance| Possible rotator cuff or long head of the biceps tendonitis
Patient reports pain and weakness with muscle loading, night pain. Age over 60 years| Possible rotator cuff tear
Patient reports poorly located shoulder pain with occasional radiation into elbow. Pain is usually aggravated by movement and relieved by rest. Age over 45 years. Females more often affected than males| Possible adhesive capsulitis
Patient reports fall on shoulder followed by pain over acromioclavicular joint| Possible acromioclavicular sprain
Patient reports upper extremity heaviness or numbness with prolonged postures and when lying on involved side| Possible thoracic outlet syndrome,
Possible cervical radiculopathy

#### Diagnostic Utility of the Patient History for Identifying Labrum and Rotator Cuff Tears

Patient Report and Study Quality| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
History of trauma  | 55 patients with shoulder pain scheduled for arthroscopy| Glenoid labral tear observed during arthroscopy| .50 (.35, .65)| .36 (.08, .65)| .79 (.46, 1.34)| 1.38 (.60, 3.17)
History of popping, clicking, or catching  | .55 (.40, .69)| .73 (.46, .99)| 2.0 (.73, 5.45)| .63 (.38, 1.02)
History of trauma  | 448 patients with shoulder pain scheduled for arthroscopy| Rotator cuff tear observed during arthroscopy| .36| .73| 1.33| .88
Reports of night pain  | .88| .20| 1.10| .60

## Physical Examination Tests

### Range-of-Motion Measurements

#### Reliability of Range-of-Motion Measurements

Figure 9-11 Range-of-motion measurements.

Test Procedure and Study Quality| Instrumentation| Population| Reliability
---|---|---|---
Passive flexion  | Universal goniometer| 100 patients referred for physical therapy for shoulder impairments| Intraexaminer: ICC = .98
Interexaminer: ICC = .89
Passive extension  | Intraexaminer: ICC = .94
Interexaminer: ICC = .27
Passive abduction  | Intraexaminer: ICC = .98
Interexaminer: ICC = .87
Active elevation  | Visual estimation of range of motion| 201 patients with shoulder pain| Affected side: ICC = .88 (.84, .91)*
Unaffected side: ICC = .76 (.67, .82)*
Passive elevation  | Affected side: ICC = .87 (.83, .90)*
Unaffected side: ICC = .73 (.66, .79)*
Passive external rotation  | Affected side: ICC = .73 (.22, .88)*
Unaffected side: ICC = .34 (.00, .65)*
Passive horizontal adduction  | Affected side: ICC = .36 (.22, .48)*
Unaffected side: ICC = .18 (.04, .32)*
Active scaption (scapular plane shoulder elevation)  | Goniometer| 30 asymptomatic subjects| Intraexaminer: ICC = .87 (.74, .94)
Interexaminer: ICC = .92 (.83, .96)
Digital inclinometer| Intraexaminer: ICC = .88 (.75, .94)
Interexaminer: ICC = .89 (.77, .95)

*Interexaminer only.

ICC, Intraclass correlation coefficient.

#### Reliability of Functional Range-of-Motion Tests

Figure 9-12 Hand behind back (functional internal rotation of shoulder test).

Test and Measure and Study Quality| Description| Population| Reliability
---|---|---|---
Hand to neck  | Visual estimation of range of motion graded on a scale of 0 to 3 or 4| 46 patients with shoulder pain| Intraexaminer: ICC = .80 (.63, .93)
Interexaminer: ICC = .90 (.69, .96)
Hand to scapula  | Intraexaminer: ICC = .90 (.72, .92)
Interexaminer: ICC = .90 (.69, .94)
Hand to opposite scapula  | Intraexaminer: ICC = .86 (.65, .90)
Interexaminer: ICC = .83 (.75, .96)
Active abduction  | Range of motion assessed visually to nearest 5 degrees. Pain assessed as "no pain," "little pain," "much pain," or "excruciating pain"| 91 patients with shoulder pain| Range of motion (ROM): ICC = .96
Pain: κ = .65
Passive abduction  | ROM: ICC = .96
Pain: κ = .69
Painful arc with active abduction  | Presence of: κ = .46
Starting ROM: ICC = .72
Ending ROM: ICC = .57
Painful arc with passive abduction  | Presence of: κ = .52
Starting ROM: ICC = .54
Ending ROM: ICC = .72
Passive external rotation  | ROM: ICC = .70
Pain: κ = .50
Hand behind back  | As above, except range of motion graded on a scale of 0 to 7| ROM: κ = .73
Pain: κ = .35
Hand on neck  | ROM: κ = .52
Pain: κ = .52
Spring test for first rib  | Examiner exerts force with the second metacarpophalangeal joint on the first rib of the patient, assessing range of motion (normal or restricted), pain (present or absent), and joint stiffness (present or absent)| ROM: κ = .26
Stiffness: κ = .09
Pain: κ = .66

### Assessing Strength and Proprioception

#### Reliability of Assessing Strength

Test and Measure and Study Quality| Description| Population| Test-Retest Reliability
---|---|---|---
Within-Day| Between-Days
Serratus anterior strength  | With subject supine with arm at 90 degrees of shoulder flexion and 105 degrees of shoulder horizontal adduction, subject presses toward ceiling while holding weighted apparatus| 30 asymptomatic students| Interexaminer ICC = .90 to .93| ICC = .83 to .89
Serratus anterior endurance  | As above, with patient holding weight equal to 15% of body weight| Interexaminer ICC = .71 to .76| ICC = .44 to .62
Lower trapezius strength  | With patient prone and using a handheld dynamometer on the spine of the scapula, resistance is applied to scapular adduction and depression| 40 patients with shoulder pain| ICC = .93 (.89, .96)| ICC = .89 (.68, .95)
Serratus anterior strength  | With patient supine with shoulder and elbow at 90 degrees and using a handheld dynamometer on the elbow, resistance is applied to scapular protraction| ICC = .93 (.88, .96)| ICC = .94 (.88, .97)
Middle trapezius strength  | With patient prone and using a handheld dynamometer on the spine of the scapula, resistance is applied to scapular retraction| ICC = .94 (.90, .97)| ICC = .94 (.82, .97)
Upper trapezius strength  | With patient sitting and using a handheld dynamometer on the superior scapula, resistance is applied to scapular elevation| ICC = .95 (.92, .97)| ICC = .96 (.91, .98)

#### Reliability of Assessing Proprioception

Test and Measure and Study Quality| Description| Population| Test-Retest Reliability
---|---|---|---
Joint position sense  | With patient standing, examiner measures full external rotation and internal rotation of shoulder with inclinometer. Target angles are determined as 90% of internal rotation and 90% of external rotation. With patient blindfolded, examiner guides patient's arm into target angle position and holds it for 3 seconds. The patient's arm is returned to neutral. The patient is instructed to return the arm to the target angle. Examiner takes measurement with inclinometer| 31 asymptomatic subjects| Internal rotation ICC = .98
External rotation ICC = .98

### Assessing Muscle Length

#### Reliability of Determining Length of Pectoralis Minor Muscle

Test and Measure and Study Quality| Description| Population| Test-Retest Reliability
---|---|---|---
Posterior shoulder tightness  | Side-lying horizontal adduction| The humerus is passively taken into horizontal adduction. The limit of posterior shoulder flexibility is considered the onset of scapula movement or humerus rotation out of neutral. An assistant using a carpenter's square measures the distance from the top of the plinth to the medial epicondyle| 37 patients with shoulder impingement syndrome and 22 control subjects (measurements taken 8 to 12 weeks apart)| Patients: ICC = .40 (.09, .64)
Controls: ICC = .63 (.29, .83)
Supine horizontal adduction| Degree of rotation is recorded at the palpable onset of scapular motion away from the plinth| Patients: ICC = .79 (.63, .89)
Controls: ICC = .74 (.47, .88)
Supine internal rotation| With an assistant preventing scapular movement, degrees of rotation are recorded at the end of passive motion| Patients: ICC = .67 (.45, .82)
Controls: ICC = .79 (.55, .91)
Pectoralis minor muscle length  | With the participant supine with hands resting on the abdomen, examiner measures the linear distance from the treatment table to the posterior aspect of the acromion using a plastic right angle| 45 patients with shoulder pain and 45 asymptomatic persons| Single measure: ICC = .90 to .93
Mean of 3 measures: ICC = .92 to .97
Pectoralis minor muscle length  | Patient is in supine position, with the elbows extended alongside the body and both palms placed on the examining table. The distance between the inferomedial aspect of the coracoid process and the caudal edge of the fourth rib at the sternum is measured with a vernier caliper during exhalation by the patient| 25 patients with shoulder impingement symptoms and 25 controls| Patients:
Intraexaminer ICC = .87 to .93
Interexaminer ICC = .65 to .72
Controls:
Intraexaminer ICC = .76 to .87
Interexaminer ICC = .64 to .67
Latissimus dorsi muscle length  | With the subject supine with hips and knees flexed and feet flat on the treatment table in posterior pelvic tilt, the examiner passively flexes the subject's shoulder until a firm flexion end feel is noted or until the humerus begins to medially rotate. One arm of a goniometer is aligned with the humerus, the other arm of the goniometer is aligned parallel with the treatment table, and the axis of the goniometer is aligned with the center of the glenohumeral joint| 30 asymptomatic subjects| Intraexaminer: ICC = .19

#### Diagnostic Utility of a Tight Pectoralis Minor Muscle in Identifying Shoulder Pain

Figure 9-13 Measuring pectoralis minor muscle length.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Tight pectoralis minor muscle  | As above, with a positive test being a measurement of less than 2.6 cm (1 inch)| 45 patients with shoulder pain and 45 asymptomatic persons| Self-report of shoulder pain and/or restriction of shoulder movement| 1.0*| 0.0*| 1.0| Undefined

*These results are due to the fact that all 90 symptomatic and asymptomatic participants were classified as "tight" using this definition.

### Palpation

#### Reliability of Palpating the Subacromial Space

Figure 9-14 Palpation of subacromial space.

Test and Measure and Study Quality| Description| Population| Reliability
---|---|---|---
Palpation of subacromial space  | Examiner palpates subacromial space and estimates distance as  ,  ,  , or whole finger's breadth| 36 patients with shoulder subluxation| Intraexaminer ICC = .90 to .94
Interexaminer ICC = .77 to .89

#### Diagnostic Utility of Palpation in Identifying Subacromial Impingement

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Supraspinatus palpation test  | The examiner performs deep palpation of the tendon at the shoulder joint. Positive if tenderness is present with palpation| 69 patients with shoulder pain| Evidence of subacromial impingement via sonographic examination| .92 (.78, .95)| .41 (.18, .64)| 1.6| .20
Infraspinatus palpation test  | .33 (.06, .79)| .66 (.54, .76)| .97| 1.0
Subscapularis palpation test  | .60 (.23, .88)| 0 (0, .13)| .60| Undefined
Biceps palpation test  | .85 (.67, .94)| .48 (.33, .62)| 1.63| .31

#### Diagnostic Utility of Palpation in Identifying Labral Tears

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Bicipital groove tenderness  | Examiner gently presses the biceps groove with the patient's shoulder adducted 10 degrees. Positive if pain occurs| 68 patients with type II SLAP lesions and 78 age-matched controls who underwent shoulder arthroscopy| Type II SLAP lesion visualized during arthroscopy| .27| .66| .80| 1.11
Biceps palpation  | Point tenderness of the biceps tendon in the biceps groove 3 to 6 cm below anterior acromion| 847 patients who underwent diagnostic arthroscopy of the shoulder| Partial biceps tendon tear visualized during arthroscopy| .53| .54| 1.2| .87
Bicipital groove tenderness  | Not reported| 62 shoulders scheduled to undergo arthroscopy| SLAP lesion visualized during arthroscopy| .44| .40| .73| 1.40
Bicipital groove tenderness  | Not described| 54 throwing athletes with shoulder pain| .25| .80| 1.3| .94

### Assessing Alignment

#### Reliability of Assessing Scapular Asymmetry during Static and Dynamic Activity

Test and Measure and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Lateral scapular slide test  | Position 1| With patient standing, examiner records measurement between inferior angle of scapula and spinous process of thoracic vertebra at same horizontal level in three positions.
Position 1: With glenohumeral joint in neutral
Position 2: At 45 degrees of shoulder abduction and internal rotation
Position 3: With upper extremity in 90 degrees of abduction and full internal rotation
A difference between sides of more than 1 cm is considered scapular asymmetry| 29 patients with shoulder pain| Not reported| ICC = .82 (left)
ICC = .96 (right)
Position 2| Not reported| ICC = .85 (left)
ICC = .95 (right)
Position 3| Not reported| ICC = .70 (left)
ICC = .85 (right)
Lateral scapular slide test  | Position 1| 46 subjects with shoulder dysfunction and 26 subjects without shoulder dysfunction| With dysfunction ICC = .52 (.10, .74)
Without dysfunction ICC = .75 (.56, .85)| With dysfunction ICC = .79 (.46, .91)
Without dysfunction ICC = .67 (.25, .85)
Position 2| With dysfunction ICC = .66 (.36, .82)
Without dysfunction ICC = .58 (.60, .86)| With dysfunction ICC = .45 (−.38, .78)
Without dysfunction ICC = .43 (−.29, .75)
Position 3| With dysfunction ICC = .62 (.27, .79)
Without dysfunction ICC = .80 (.65, .88)| With dysfunction ICC = .57 (−.23, .85)
Without dysfunction ICC = .74 (.41, .88)
Position of posterior acromion  | Measured from the posterior border of the acromion and the table surface with the patient supine| 29 patients with shoulder pain| Not reported| ICC = .88 to .94
Position of medial scapular border  | Measured from the medial scapular border to T4 spinous process| Not reported| ICC = .50 to .80
Movement evaluation during abduction  | Examiner classifies scapular movement during shoulder abduction into categories 1 to 4:
Category 1: Inferior angle tilts dorsally compared with contralateral side
Category 2: Medial border tilts dorsally compared with contralateral side
Category 3: Shoulder shrug initiates movement
Category 4: Scapulae move symmetrically| 20 subjects with shoulder injuries and 6 asymptomatic subjects| κ = .42| Not reported

Figure 9-15 Detecting scapular asymmetry.

#### Reliability of Assessing Clavicular Tilt Angle

Test and Measure and Study Quality| Description| Population| Reliability
---|---|---|---
Clavicular tilt angle  | With patient standing, the stationary arm of goniometer is aligned vertically between the jugular notch and xiphoid process, the movable arm of goniometer is aligned along long axis of the clavicle, and the axis of goniometer is placed at the intersection of the vertical line and the long axis of the clavicle| 18 healthy subjects| Interexaminer ICC = .85 (.72, .92)| Intraexaminer ICC = .80 (.64, .89)

#### Reliability of Assessing Thoracic Kyphosis

Test and Measure and Study Quality| Description| Population| Reliability
---|---|---|---
Thoracic kyphosis  | With patient standing, first inclinometer is placed over T1 to T2 spinal level and second inclinometer is placed over T12 to L1 spinal level. Thoracic kyphosis angle is calculated by the summation of the angles recorded by the two inclinometers| 45 subjects with shoulder symptoms and 45 controls| Patients:
Intraexaminer ICC = .92 to .97| Controls:
Intraexaminer ICC = .94 to .97

### Classifying Shoulder Disorders

#### Reliability of Classifying Shoulder Disorders

Figure 9-16 Adhesive capsulitis of the shoulder.

Classification and Study Quality| Description| Population| Interexaminer Reliability
---|---|---|---
Bursitis  | Examiner uses patient history combined with "selective tissue tension" examination during active movements, passive movements, and isometric strength assessments| 56 painful shoulders| κ = .35 to.58
Capsulitis  | κ = .63 to .82
Rotator cuff lesion  | κ = .71 to .79
Other diagnosis  | κ = .69 to .78
Capsular syndrome  | Examiner obtains patient history. Physical examination consists of active, passive, and resistive movements. The range of motion, presence of painful arc or capsular pattern, and degree of muscle weakness are identified| 201 patients with shoulder pain| κ = .63 (.50, .76)
Acute bursitis  | κ = .50 (−.10, 1.0)
Acromioclavicular syndrome  | κ = .24 (−.06, .53)
Subacromial syndrome  | κ = .56 (.45, .68)
Rest group (does not fit any category above)  | κ = .39 (.24, .54)
Mixed group (patient presents with two or more of above classifications)  | κ = .14 (−.03, .30)

### Special Tests—Instability

#### Reliability of Tests to Identify Shoulder Instability

Figure 9-17 Shoulder instability.

Test and Measure and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Sulcus sign  | With patient supine, examiner applies inferior distraction to shoulder. Amount of laxity is graded on a 0 to 3+ scale. 0 represents no laxity; 3+ represents maximum laxity| 43 healthy college athletes| Interexaminer κ = .03 to .06| Intraexaminer κ = .01 to .20

#### Diagnostic Utility of the Apprehension Test in Identifying Shoulder Instability

Figure 9-18 Apprehension test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Bony apprehension test  | With patient standing, examiner places the patient's arm in a position of 45 degrees or less of abduction and 45 degrees or less of external rotation. Positive if patient appears apprehensive| 29 patients with symptoms of instability undergoing shoulder surgery| Arthroscopic evidence of significant bony lesion causing instability of the shoulder| 1.0| .86| 7.1| .00
Anterior apprehension test  | With patient supine, examiner passively abducts and externally rotates humerus. Positive if patient complains of pain or instability| 68 patients with type II SLAP lesions and 78 age-matched controls who underwent shoulder arthroscopy| Type II SLAP lesion visualized during arthroscopy| .62| .42| 1.1| .90
Anterior apprehension test  | As above. Positive if pain is produced with external rotation| 62 shoulders scheduled to undergo arthroscopy| Labral tear via arthroscopic visualization| .40| .87| 3.08| .69
Apprehension test (pain)  | With patient standing, examiner places both of the patient's arms in 90 degrees of abduction and 90 degrees of external rotation. Positive if patient appears apprehensive and/or reports pain| 363 patients undergoing shoulder surgery| Either radiographic documentation of an anterior shoulder dislocation after trauma or demonstration of a Hill-Sachs lesion, a Bankart lesion, or a humeral avulsion of the glenohumeral ligament at the time of arthroscopy| .50| .56| 1.1| .90
Apprehension test (apprehension)  | .72| .96| 20.2| .29

#### Diagnostic Utility of the Apprehension and Relocation Tests in Identifying Shoulder Instability

Figure 9-19 Relocation test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Relocation test  | With patient supine with glenohumeral joint at edge of table, examiner places arm in 90 degrees of abduction, full external rotation, and 90 degrees of elbow flexion. Examiner then applies a posterior force on head of humerus. Positive if patient's pain or apprehension diminishes with applied force| 68 patients with type II SLAP lesions and 78 age-matched controls who underwent shoulder arthroscopy| Type II SLAP lesion visualized during arthroscopy| .44| .54| 1.0| 1.04
Relocation test (pain)  | 363 patients undergoing shoulder surgery| Either radiographic documentation of an anterior shoulder dislocation after trauma or demonstration of a Hill-Sachs lesion, a Bankart lesion, or a humeral avulsion of the glenohumeral ligament at the time of arthroscopy| .30| .90| 3.0| .77
Relocation test (apprehension)  | .81| .92| 10.4| .20
Jobe relocation test (pain)  | 62 shoulders scheduled to undergo arthroscopy| Arthroscopic visualization| .44| .87| 3.38| .64
Relocation test (pain)  | Relocation test performed as above. Following relocation test, examiner applies anteriorly directed force to proximal humerus| 100 patients undergoing shoulder surgery| Surgical observation| .30| .58| .71| 1.21
Relocation test (apprehension)  | .57| 1.0| Undefined| .43
Anterior relocation test (pain)  | .54| .44| .96| 1.05
Anterior relocation test (apprehension)  | .68| 1.0| Undefined| .32

#### Diagnostic Utility of the Anterior Drawer Test in Identifying Shoulder Instability

Figure 9-20 Anterior drawer test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Anterior drawer test (pain)  | With patient supine with glenohumeral joint at edge of table, examiner places arm in 60 degrees to 80 degrees of abduction and neutral rotation and then translates the humeral head anteriorly. Positive if patient reports pain or reproduction of instability symptoms| 363 patients scheduled to undergo shoulder surgery| Either radiographic documentation of an anterior shoulder dislocation after trauma or demonstration of a Hill-Sachs lesion, a Bankart lesion, or a humeral avulsion of the glenohumeral ligament at the time of arthroscopy| .28| .71| 1.0| 1.01
Anterior drawer test (instability symptoms)  | .53| .85| 3.6| .56

### Special Tests—Labral Tears

#### Reliability of the Crank Test

Figure 9-21 Crank test.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Crank test  | Patient is supine with shoulder in 160 degrees of abduction and elbow in 90 degrees of flexion. The examiner applies a compressive force to the humerus while repeatedly rotating it into internal and external rotation. Positive if click is produced during the test| 40 subjects with shoulder pain| κ = .36 (−.07, .59)
Crank test  | As above| 55 patients with shoulder pain scheduled for arthroscopic surgery| κ = .20 (−.05, .46)

#### Diagnostic Utility of the Crank Test in Identifying Labral Tears

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Crank test   2012 Metaanalysis| Not described| Pooled estimates from four studies (n = 282)| Labral tear diagnosed by arthroscopy| .34 (.19, .53)| .75 (.65, .83)| 1.4 (.84, 2.2)| .88 (.69, 1.1)
Crank test  | 847 patients who underwent diagnostic arthroscopy of the shoulder| Partial biceps tendon tear visualized during arthroscopy| .34| .77| 1.5| .86
Crank test  | Patient is supine while examiner elevates humerus 160 degrees in scapular plane. Axial load is applied to humerus while shoulder is internally and externally rotated. Positive if pain is elicited| 55 patients with shoulder pain scheduled for arthroscopic surgery| Glenoid labral tear observed during arthroscopy| .61 (.47, .76)| .55 (.25, .84)| 1.35 (.68, 2.69)| .71 (.37, 1.36)
Crank test  | 132 patients scheduled to undergo shoulder arthroscopy| .13| .83| .80| 1.05
Crank test  | 40 athletes with shoulder pain| .35| .70| 1.2| .93
Crank test  | Not described| 54 throwing athletes with shoulder pain| .58| .72| 2.1| .58
Crank test  | Patient is supine while examiner elevates humerus 160 degrees in scapular plane. Axial load is applied to humerus while shoulder is internally and externally rotated. Positive if pain is elicited| 65 patients with symptoms of shoulder pain| .46| .56| 1.1| .96
Crank test  | Patient is supine while examiner elevates humerus 160 degrees in scapular plane. Axial load is applied to humerus while shoulder is internally and externally rotated. Positive if pain is elicited.| 62 patients scheduled to undergo arthroscopic shoulder surgery| .91| .93| 13.0| .10
Crank test  | Patient is supine. Examiner fully abducts humerus and internally and externally rotates arm while applying axial force through glenohumeral joint. Positive if pain or clicking is elicited| 62 shoulders undergoing arthroscopy| .40| .73| 1.5| .82

#### Diagnostic Utility of the Compression Rotation Test in Identifying Labral Tears

Figure 9-22 Compression rotation test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Compression rotation test  | With patient supine with arm abducted to 90 degrees and elbow flexed to 90 degrees, examiner applies axial force to humerus. Humerus is circumducted and rotated. Positive if pain or clicking is elicited| 68 patients with type II SLAP lesions and 78 age-matched controls who underwent shoulder arthroscopy| Type II SLAP lesion visualized during arthroscopy| .61| .54| 1.3| .72
Compression rotation test  | 426 patients who had undergone shoulder arthroscopy| Labral tear visualized during arthroscopy| .24| .76| 1.0| 1.0
Compression rotation test  | Not described| 54 throwing athletes with shoulder pain| .25| 1.0| Undefined| .75

#### Diagnostic Utility of the Speed Test in Identifying Superior Labrum Anterior and Posterior Lesions

Figure 9-23 Speed test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Speed test   2012 Metaanalysis| Not described| Pooled estimates from four studies (n = 327)| SLAP lesion diagnosed by arthroscopy| .20 (.05, .53)| .78 (.58, .90)| .90 (.43, 1.9)| 1.0 (.86, 1.2)
Speed test   2008 Metaanalysis| Patient elevates humerus to 90 degrees with elbow extended and forearm in supination. Patient holds this position while examiner applies resistance against elevation. Positive if pain is elicited in the bicipital groove area| Pooled estimates from four high-quality studies| SLAP lesion visualized during arthroscopy| .32 (.24, .42)| .61 (.54, .68)| .80| 1.11
Speed test  | 133 patients who underwent diagnostic arthroscopy of the shoulder| .60| .38| 1.0| 1.05
Speed test  | 68 patients with type II SLAP lesions and 78 age-matched controls who underwent shoulder arthroscopy| .32| .66| .90| 1.03
Speed test  | 847 patients who underwent diagnostic arthroscopy of the shoulder| Partial biceps tendon tear visualized during arthroscopy| .50| .67| 1.5| .75
Speed test  | With patient seated, elbow extended, and forearm in full supination, the clinician resists active forward flexion from 0 to 60 degrees. Positive if pain is increased in the shoulder and the patient localizes pain to the bicipital groove| 87 individuals with variable shoulder pathologic conditions| SLAP lesion diagnosed by arthroscopy| .50 (.21, .79)| .54 (.49, .58)| 1.1 (.41, 1.8)| .93 (.40, 1.6)

#### Reliability of the Active Compression/O'Brien Test

Figure 9-24 Active compression test.

Test and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Active compression test  | Patient is standing with involved shoulder flexed 90 degrees, horizontally adducted 10 degrees, and in maximum internal rotation and the elbow in full extension. Patient resists a downward force applied to the wrist of the involved extremity. The same procedure is repeated with the shoulder in maximum external rotation. Positive with shoulder pain that is worse in the position of internal rotation and relieved in the position of external rotation| 40 subjects with shoulder pain| Acromioclavicular joint:
κ = .22 (−.24, .68)
Labral pathologic condition:
κ = .38 (.10, .65)
Active compression test  | See next table| 55 patients with shoulder pain scheduled for arthroscopic surgery| κ = .24 (−.02, .50)

#### Diagnostic Utility of the Active Compression/O'Brien Test

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Active compression test   2012 Metaanalysis| Not described| Pooled estimates from six studies (n = 782)| Labral tear diagnosed by arthroscopy| .67 (.51, .80)| .37 (.22, .54)| 1.1 (.90, 1.3)| .89 (.67, 1.2)
Active compression test  | Patient stands and flexes arm to 90 degrees with elbow in full extension. Patient then adducts arm 10 degrees internally and rotates humerus. Examiner applies downward force to arm as patient resists. Patient then fully supinates arm and repeats procedure. Positive if pain is elicited with first maneuver and reduced with second maneuver| 55 patients with shoulder pain scheduled for arthroscopic surgery| Glenoid labral tear observed during arthroscopy| .55 (.40, .69)| .18 (–.05, .41)| .67 (.45, .98)| 2.5 (.68, 9.13)
O'Brien test  | 133 patients who underwent diagnostic arthroscopy of the shoulder| SLAP lesion visualized during arthroscopy| .94| .28| 1.3| .21
O'Brien test  | 68 patients with SLAP lesions and 78 age-matched controls| .63| .53| 1.3| .70
Active compression test  | 132 patients scheduled to undergo shoulder arthroscopy| .63| .50| 1.3| .74
Active compression test  | 40 athletes with shoulder pain| .78| .11| .10| 2.00
Active compression test  | 426 patients who had undergone shoulder arthroscopy| .47| .55| 1.0| .96
Active compression test (palm down)  | As above, except positive if pain is elicited in tested position| 847 patients who underwent diagnostic arthroscopy of the shoulder| Partial biceps tendon tear visualized during arthroscopy| .68| .46| 1.3| .70
Active compression test (palm up)  | .40| .57| .90| 1.1
O'Brien test  | As above, except patient is seated| 65 patients with symptoms of shoulder pain| .54| .31| .78| 1.48
O'Brien test  | 62 shoulders undergoing arthroscopy| .63| .73| 2.3| .51
O'Brien test  | Not described| 54 throwing athletes with shoulder pain| .54| .60| 1.4| .77
Active compression test  | Patient stands with involved shoulder at 90 degrees of flexion, 10 degrees of horizontal adduction, and in maximum internal rotation, with the elbow in full extension. Examiner applies a downward force at the wrist of the involved arm. The patient resists the downward force and reports any pain as ''on top of the shoulder'' (acromioclavicular joint) or ''inside the shoulder'' (SLAP lesion). The patient's shoulder is then moved to a position of maximum external rotation, and the downward force is repeated. A positive test is indicated by pain or painful clicking when shoulder is in internal rotation and less or no pain when shoulder is in external rotation| 87 individuals with variable shoulder pathologic conditions| SLAP lesion diagnosed by arthroscopy| .85 (.61, .97)| .10 (.05, .12)| .94 (.65, 1.1)| 1.5 (.22, 6.8)

#### Diagnostic Utility of the Yergason Test in Identifying Labral Tears

Figure 9-25 Yergason test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Yergason test   2012 Metaanalysis| Not described| Pooled estimates from four studies (n = 246)| Labral tear diagnosed by arthroscopy| .12| .95| 2.5| .91
Yergason test  | With patient standing or sitting with elbow at 90 degrees of flexion, patient supinates forearm against examiner's resistance. During procedure, examiner palpates long head of biceps tendon. Positive if pain at biceps tendon| 68 patients with type II SLAP lesions and 78 age-matched controls who underwent shoulder arthroscopy| SLAP lesion visualized during arthroscopy| .12| .87| .90| 1.01
Yergason test  | 132 patients scheduled to undergo shoulder arthroscopy| .13| .94| 2.2| .93
Yergason test  | 62 shoulders scheduled to undergo arthroscopy| .09| .93| 1.29| .98
Yergason test  | 54 throwing athletes with shoulder pain| .13| 1.0| Undefined| .87
Yergason test  | 152 subjects with shoulder pain scheduled to undergo surgery| Biceps tendon and/or labral tear visualized during arthroscopy| .43| .79| 2.05| .72

#### Reliability of the Anterior Slide Test/Kibler Test

Test and Study Quality| Description| Population| Interexaminer Reliability
---|---|---|---
Anterior slide test  | See next table| 55 patients with shoulder pain scheduled for arthroscopic surgery| κ = .21 (−.05, .46)

#### Diagnostic Utility of the Anterior Slide Test/Kibler Test in Identifying Labral Tears

Figure 9-26 Anterior slide test/Kibler test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Anterior slide test   2012 Metaanalysis| Not described| Pooled estimates from four studies (n = 831)| Labral tear diagnosed by arthroscopy| .17 (.03, .55)| .86 (.81, .89)| 1.2 (.22, 6.5)| .97 (.96, 1.4)
Anterior slide test  | With patient standing or sitting with hands on hips and thumbs facing posteriorly, examiner stabilizes scapula with one hand and, with other hand on elbow, applies anteriorly and superiorly directed force through humerus. Patient pushes back against force. Positive if pain or click is elicited in anterior shoulder| 55 patients with shoulder pain scheduled for arthroscopic surgery| Glenoid labral tear observed during arthroscopy| .43 (.29, .58)| .82 (.59, 1.05)| 2.38 (.65, 8.7)| .69 (.48, 1.01)
Anterior slide test (Kibler test)  | 68 patients with type II SLAP lesions and 78 age-matched controls who underwent shoulder arthroscopy| Type II SLAP lesion visualized during arthroscopy| .21| .70| .70| 1.13
Anterior slide test (Kibler test)  | 847 patients who underwent diagnostic arthroscopy of the shoulder| Partial biceps tendon tear visualized during arthroscopy| .23| .84| 1.4| .92
Anterior slide test  | 426 patients who had undergone shoulder arthroscopy| SLAP lesion visualized during arthroscopy| .08| .84| .56| 1.1

#### Reliability of Various Tests in Identifying Labral Tears

Figure 9-27 Jerk test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Passive compression test  | Patient is side-lying with the affected shoulder up and the examiner standing behind the patient. The examiner stabilizes the patient's affected shoulder by holding the acromioclavicular joint with one hand and the patient's elbow with the other hand. The examiner rotates the patient's shoulder externally with 30 degrees of abduction and then pushes the arm proximally while extending the arm. The test is positive if pain or a painful click is elicited in the glenohumeral joint.| 61 patients undergoing arthroscopy for shoulder pain| Interexaminer κ = .77
Kim test  | With patient sitting with arm abducted 90 degrees, examiner holds the elbow and lateral aspect of the proximal arm and applies a strong axial loading force. Examiner then elevates the arm to 135 degrees and adds a posterior/inferior force. Positive if sudden onset of posterior shoulder pain| 172 painful shoulders| Interexaminer κ = .91
Kim test  | Patient is seated with back supported. The examiner holds the patient's elbow and midhumerus with arm abducted 90 degrees. The examiner then elevates the arm to 135 degrees while simultaneously adding a posterior/inferior glide and axial load to the humerus. Positive with production of posterior shoulder pain| 40 subjects with shoulder pain| κ = −.04 (−.12, .03)

#### Diagnostic Utility of the Kim Test in Identifying Labral Tears

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Kim test  | With patient sitting with arm abducted 90 degrees, examiner holds the elbow and lateral aspect of the proximal arm and applies a strong axial loading force. Examiner then elevates the arm to 135 degrees and adds a posterior/inferior force. Positive if sudden onset of posterior shoulder pain| 172 painful shoulders| Labral tear visualized during arthroscopy| .80| .94| 13.3| .21

#### Diagnostic Utility of the Biceps Load Test in Identifying Labral Tears

Figure 9-28 Biceps load test II.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Biceps load test II  | With patient supine, examiner grasps patient's wrist and elbow. Arm is elevated 120 degrees and fully externally rotated, with elbow held in 90 degrees of flexion and forearm supinated. Examiner then resists elbow flexion by patient. Positive if resisted elbow flexion causes pain| 68 patients with type II SLAP lesions and 78 age-matched controls who underwent shoulder arthroscopy| Type II SLAP lesion visualized during arthroscopy| .30| .78| 1.4| .90
Biceps load test II  | 127 patients experiencing shoulder pain scheduled to undergo arthroscopy| .90| .97| 30| .10
Biceps load test II  | With patient supine, the examiner places the patient's shoulder in 120 degrees of abduction, the elbow in 90 degrees of flexion, and the forearm in supination. The examiner moves the patient's shoulder to end-range external rotation and asks the patient to flex his or her elbow while the examiner resists this movement. A positive test is indicated as reproduction of pain during resisted elbow flexion| 87 individuals with variable shoulder pathologic conditions| SLAP lesion diagnosed by arthroscopy| .55 (.46, .64)| .53 (.38, .68)| 1.2 (.73, 2.0)| .85 (.53, 1.4)
Biceps load test  | With patient supine, examiner grasps wrist and elbow. Arm is abducted to 90 degrees, with elbow flexed to 90 degrees and forearm supinated. Examiner externally rotates arm until patient becomes apprehensive, at which time external rotation is stopped. Patient flexes elbow against examiner's resistance. Positive if patient's apprehension remains or pain is produced| 75 patients with unilateral recurrent anterior shoulder dislocations| SLAP lesion diagnosed by arthroscopy| .90| .97| 30| .10

#### Diagnostic Utility of Various Tests in Identifying Labral Tears

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Passive compression test  | With patient side-lying with affected side up, examiner places one hand over the acromioclavicular joint to stabilize the shoulder and places the other hand on the elbow. Examiner then externally rotates the shoulder in 30 degrees of abduction and gives axial compression while extending the arm. Positive if pain occurs| 61 patients undergoing arthroscopy for shoulder pain| SLAP lesion visualized during arthroscopy| .82| .86| 5.90| .21
Jerk test  | With patient sitting, examiner holds scapula with one hand and internally rotates and abducts the patient's arm to 90 degrees with the other hand. Examiner then horizontally adducts the arm while applying an axial loading force. Sharp pain indicates a positive test| 172 painful shoulders| Labral tear visualized during arthroscopy| .73| .98| 36.5| .28
Supine flexion resistance test  | With patient supine with arm resting in full flexion and palm up, examiner grasps patient's arm just distal to the elbow and asks the patient to lift the arm as if throwing. Positive if pain is felt deep inside the shoulder joint| 133 patients who underwent diagnostic arthroscopy of the shoulder| SLAP lesion visualized during arthroscopy| .80| .69| 2.6| .29
Resisted supination external rotation test  | With patient supine with arm abducted 90 degrees and elbow flexed 70 degrees, examiner supports the arm by the elbow. Examiner resists supination and gently maximally externally rotates the shoulder. Positive if shoulder pain, clicking, or catching is elicited| 40 athletes with shoulder pain| .83| .82| 4.6| .21
Whipple test  | The arm is flexed 90 degrees and adducted until the hand is opposite the other shoulder. The patient resists while examiner pushes downward on the arm. Positive if pain occurs| 68 patients with type II SLAP lesions and 78 age-matched controls who underwent shoulder arthroscopy| Type II SLAP lesion visualized during arthroscopy| .65| .42| 1.1| .83
Posterior jerk test  | Not described| 54 throwing athletes with shoulder pain| .25| .80| 1.3| .72
Dynamic labral shear test (O'Driscoll test)  | Patient is sitting with the arm at the side and the elbow flexed 90 degrees. Examiner externally rotates patient's arm 90 degrees and brings the arm into 90 degrees of abduction. With the elbow flexed, the arm is abducted from 90 degrees to 120 degrees. Test is positive if pain is reproduced in the abduction range of 90 to 120 degrees| 87 individuals with variable shoulder pathologic conditions| SLAP lesion diagnosed by arthroscopy| .89 (.81, .95)| .30 (.17, .41)| 1.3 (.98, 1.6)| .40 (.10, 1.1)
Labral tension test  | Patient is supine with arm placed in 120 degrees of abduction and neutral forearm rotation. The shoulder is then taken to end-range external rotation. At end-range rotation, the examiner grasps the patient's hand and asks him or her to supinate the forearm, against resistance, from the neutral position. Positive if patient reports increased pain with resisted supination| .28 (.20, .36)| .76 (.61, .88)| 1.2 (.50, 2.9)| .94 (.73, 1.3)

### Special Tests—Subacromial Impingement

#### Reliability of the Hawkins-Kennedy Test

Figure 9-29 Hawkins-Kennedy test.

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Hawkins-Kennedy test60  | Examiner flexes the humerus and elbow to 90 degrees and then maximally internally rotates the shoulder and applies overpressure. Positive with reproduction of pain of the superior shoulder| 55 patients with shoulder pain| Interexaminer κ = .39 (.12, .65)
Hawkins-Kennedy test46  | 40 subjects with shoulder pain| κ = .38 (.10, .63)
Hawkins-Kennedy test61  | 33 patients with shoulder pain| Test-retest κ = 1.0
Interexaminer κ = .91

#### Diagnostic Utility of the Hawkins-Kennedy Test in Identifying Subacromial Impingement

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Hawkins-Kennedy test62   2012 Metaanalysis| The examiner places the patient's arm in 90 degrees of forward flexion and then gently internally rotates the arm. The end point for internal rotation is either when the patient feels pain or when the rotation of the scapula is felt or observed by the examiner. The test is positive when the patient experiences pain during the maneuver| Pooled estimates from six studies (n = 1029)| Impingement syndrome diagnosed by arthroscopy| .74 (.57, .85)| .57 (.46, .67)| 1.7| .46
Hawkins-Kennedy test47   2012 Metaanalysis| Not described| Pooled estimates from seven studies (n = 944)| Impingement syndrome diagnosed by arthroscopy, magnetic resonance imaging (MRI), or ultrasound| .80 (.72, 086)| .56 (.45, .67)| 1.8 (1.5, 2.3)| 0.35 (0.27, 0.46)
Hawkins-Kennedy test6   2008 Metaanalysis| Patient is standing. The affected arm is forward flexed 90 degrees and then forcibly medially rotated.
Positive if the patient complains of pain| Pooled estimates from four high-quality studies| Impingement syndrome diagnosed from subacromial injection or surgery| .79 (.75, .82)| .59 (.53, .64)| 1.9| .36
Hawkins-Kennedy test63  | 30 patients with new onset of shoulder pain| Subacromial impingement confirmed by MRI| .74| .40| 1.2 (.70, 2.3)| .65
Hawkins- Kennedy test63  | Subacromial bursitis confirmed by MRI| .80| .43| 1.4 (.80, 2.4)| .47
Hawkins-Kennedy test32  | 847 patients who underwent diagnostic arthroscopy of the shoulder| Partial biceps tendon tear visualized during arthroscopy| .55| .38| .90| 1.18
Hawkins-Kennedy test60  | Examiner flexes the humerus and elbow to 90 degrees and then maximally internally rotates the shoulder and applies overpressure. Positive with reproduction of pain of the superior shoulder| 55 patients with shoulder pain| Impingement diagnosed via arthroscopy| .63 (.39, .86)| .62 (.46, .77)| 1.6 (.94, 2.8)| .61 (.31, 1.2)
Hawkins-Kennedy test31  | The arm of the patient is flexed up to 90 degrees and then forced into internal rotation. Test is considered positive if pain occurs| 69 patients with shoulder pain| Evidence of subacromial impingement via sonographic examination| .67 (.53, .78)| .47 (.26, .69)| 1.3| .70

#### Reliability of the Neer Test

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Neer test60  | Examiner stabilizes the scapula with a downward force while fully flexing the humerus overhead while applying overpressure. Positive with reproduction of pain of the superior shoulder| 55 patients with shoulder pain| Interexaminer κ = .40 (.13, .67)
Neer test61  | Examiner stabilizes the scapula with a downward force while fully flexing the humerus overhead while applying overpressure. Positive with reproduction of pain of the superior shoulder| 33 patients with shoulder pain| Test-retest κ = 1.0
Interexaminer κ = 1.0

#### Diagnostic Utility of the Neer Test in Identifying Subacromial Impingement

Figure 9-30 Neer test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Neer test62   2012 Metaanalysis| The examiner stabilizes the scapula and asks the patient to forward flex the arm until he or she reports pain or until full elevation is reached. Positive if pain is produced| Pooled estimates from five studies (n = 1127)| Impingement syndrome diagnosed by arthroscopy| .78 (.68, .87)| .58 (.47, .68)| 1.9| .38
Neer test47   2012 Metaanalysis| Not described| Pooled estimates from seven studies (n = 946)| Impingement syndrome diagnosed by arthroscopy, MRI, or ultrasound| .72 (.60, .81)| .60 (.40, .77)| 1.8 (1.2, 2.6)| .47 (.39, .56)
Neer test52   2008 Metaanalysis| Examiner forces patient's internally rotated arm into maximal elevation. Positive if pain is produced| Pooled estimates from four high-quality studies| Impingement syndrome diagnosed from subacromial injection or surgery| .79 (.75, .82)| .53 (.48, .58)| 1.7| .40
Neer test63  | 30 patients with new onset of shoulder pain| Subacromial impingement confirmed by MRI| .68| .30| 1.0 (.60, 1.6)| 1.07
Subacromial bursitis confirmed by MRI| .80| .43| 1.4 (.80, 2.4)| .47
Neer test32  | 847 patients who underwent diagnostic arthroscopy of the shoulder| Partial biceps tendon tear visualized during arthroscopy| .64| .41| 1.1| .88
Neer test60  | Examiner stabilizes the scapula with a downward force while fully flexing the humerus overhead while applying overpressure. Positive with reproduction of pain of the superior shoulder| 55 patients with shoulder pain| Impingement diagnosed via arthroscopy| .81 (.62, 1.0)| .54 (.38, .69)| 1.8 (1.2, 2.7)| .35 (.12, .97)
Neer test31  | The examiner performs maximal passive abduction of the patient's arm on the scapular plane, with internal rotation, while stabilizing the scapula. Test is considered positive if pain occurs| 69 patients with shoulder pain| Evidence of subacromial impingement via sonographic examination| .80 (.67, .89)| .52 (.30, .73)| 1.7| .39

#### Reliability of the Painful Arc Test in Identifying Subacromial Impingement

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Painful arc test60  | Patient asked to actively abduct shoulder and report any pain during abduction. If pain of the superior shoulder is noted between 60 degrees and 120 degrees of abduction, the test is considered positive| 55 patients with shoulder pain| Interexaminer κ = .45 (.18, .72)

#### Diagnostic Utility of the Painful Arc Test in Identifying Subacromial Impingement

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Painful arc test47   2012 Metaanalysis| Not described| Pooled estimates from four studies (n = 756)| Impingement syndrome diagnosed by arthroscopy and ultrasound| .53 (.31, .74)| .76 (.68, .84)| 2.3 (1.2, 4.1)| .62 (.37, 1.0)
Painful arc sign64  | Patient actively elevates arm in scapular plane to full elevation. Positive if patient experiences pain between 60 degrees and 120 degrees| 552 patients with shoulder pain| Arthroscopic visualization| | | |

• All impingement

| .74| .81| 3.9| .32

• Bursitis

| .71| .47| 1.3| .62

• Partial thickness rotator cuff tear

| .67| .47| 1.3| .70

• Full-thickness rotator cuff tear

| .76| .72| 2.7| .33
Painful arc test65  | Patient is instructed to perform straight plane abduction throughout full range of motion. Positive if pain occurs between 60 degrees and 100 degrees of abduction| 125 painful shoulders| Subacromial impingement diagnosed via subacromial injection| .33| .81| 1.74| .83
Painful arc test60  | Patient is asked to actively abduct shoulder and report any pain during abduction. If pain of the superior shoulder is noted between 60 degrees and 120 degrees of abduction, the test is considered positive| 55 patients with shoulder pain| Impingement diagnosed via arthroscopy| .75 (.54, .96)| .67 (.52, .81)| 2.3 (1.3, 3.8)| .38 (.16, .90)

#### Reliability of the Drop-Arm Test in Identifying Subacromial Impingement

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Drop-arm test46  | The examiner passively abducts the patient's arm to 90 degrees. The examiner releases the patient's arm with instructions to hold the arm in the same position. Positive with inability to hold the arm at 90 degrees of abduction or with a sudden drop of the arm| 40 subjects with shoulder pain| κ = .57 (−.14, .57)

#### Diagnostic Utility of the Drop-Arm Test in Identifying Subacromial Impingement

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Drop-arm test62   2012 Metaanalysis| The patient fully elevates the arm and then slowly reverses the motion in the same arc. If the arm is dropped suddenly or the patient has severe pain, the test is considered to be positive| Pooled estimates from five studies (n = 1213)| Impingement syndrome diagnosed by arthroscopy| .21 (.14, .30)| .92 (.86, .96)| 2.6| .86
Drop-arm test65  | Patient is instructed to abduct shoulder to 90 degrees and then lower it slowly to neutral position. Positive if patient is unable to do this because of pain| 125 painful shoulders| Subacromial impingement diagnosed via subacromial injection| .08| .97| 2.67| .95

#### Reliability of the Empty Can Test in Identifying Subacromial Impingement

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Empty can test (Jobe test)60  | Examiner elevates patient's shoulder to 90 degrees in the scapular plane and then places the shoulder in internal rotation by asking the patient to rotate the shoulder so that his or her thumb is pointing toward the floor. The examiner then applies a downward directed force at the wrist while the patient attempts to resist. Test is considered positive if weakness is detected of the involved shoulder as compared bilaterally| 55 patients with shoulder pain| Interexaminer κ = .47 (.22, .72)

#### Diagnostic Utility of the Empty Can Test in Identifying Subacromial Impingement

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Empty can test62   2012 Metaanalysis| The examiner asks the patient to elevate and internally rotate the arm with thumbs pointing downward in the scapular plane. The elbow should be fully extended. In this position the examiner applies downward pressure on the upper surface of the arm. Test is positive with weakness| Pooled estimates from six studies (n = 695)| Impingement syndrome diagnosed by arthroscopy| .69 (.54, .81)| .62 (.38, .81)| 1.8| .50
Empty can test (Jobe test)60  | Examiner elevates patient's shoulder to 90 degrees in the scapular plane and then places the shoulder in internal rotation by asking the patient to rotate the shoulder so that his or her thumb is pointing toward the floor. The examiner then applies a downward directed force at the wrist while the patient attempts to resist. Test is considered positive if weakness is detected of the involved shoulder as compared bilaterally| 55 patients with shoulder pain| Impingement diagnosed via arthroscopy| .50 (.26, .75)| .87 (.77, .98)| 3.9 (1.5, 10.1)| .57 (.35, .95)

#### Diagnostic Utility of the Lift-Off Test in Identifying Subacromial Impingement

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Lift-off test62   2012 Metaanalysis| The patient internally rotates the shoulder, placing the hand on the ipsilateral buttock. Patient is then asked to lift the hand off the buttock against resistance. Test is positive with weakness of this action| Pooled estimates from four studies (n = 267)| Impingement syndrome diagnosed by arthroscopy| .42 (.19, .69)| .97 (.79, 1.0)| 14| .60
Lift-off test (Gerber test)63  | Patient attempts to lift the affected arm off the back. Positive if unable to lift off back| 30 patients with new onset of shoulder pain| Subacromial impingement confirmed by MRI| .68| .50| 1.4 (.70, 2.7)| .64
Subacromial bursitis confirmed by MRI| .93| .71| 3.3 (1.4, 7.6)| .10
Lift-off test (Gerber test)32  | 847 patients who underwent diagnostic arthroscopy of the shoulder| Partial biceps tendon tear visualized during arthroscopy| .28| .89| 2.5| .81

#### Reliability of Various Tests in Identifying Subacromial Impingement

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
External rotation resistance test60  | With patient's arm at the side and elbow flexed to 90 degrees, a medially directed force is exerted on the distal forearm to resist shoulder external rotation. Test is considered positive if weakness is detected on the involved shoulder as compared bilaterally| 55 patients with shoulder pain| Interexaminer κ = .67 (.40, .94)

#### Diagnostic Utility of Various Tests in Identifying Subacromial Impingement

Figure 9-31 Horizontal adduction test.

Figure 9-32 Yocum test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Cross-body adduction test64  | With patient's arm at 90 degrees of flexion, examiner adducts arm across the patient's body. Positive if shoulder pain is produced| 552 patients with shoulder pain| Arthroscopic visualization| | | |

• All impingement

| .23| .82| 1.3| .94

• Bursitis

| .25| .80| 1.3| .94

• Partial thickness RCT

| .17| .79| .80| 1.05

• Full-thickness RCT

| .23| .81| 1.2| .95
Yocum test63  | With patient seated or standing, patient places hand of involved shoulder on contralateral shoulder and raises elbow. Positive if pain is elicited| 30 patients with new onset of shoulder pain| Subacromial impingement confirmed by MRI| .79| .40| 1.3 (.80, 2.3)| .53
Subacromial bursitis confirmed by MRI| .80| .36| 1.2 (.08, 2.0)| .56
Horizontal adduction test65  | Examiner forces patient's arm into horizontal adduction while elbow is flexed. Positive if pain is elicited| 125 painful shoulders| Subacromial impingement via subacromial injection| .82| .28| 1.14| .64
External rotation resistance test60  | With patient's arm at the side and elbow flexed to 90 degrees, a medially directed force is exerted on the distal forearm to resist shoulder external rotation. Test is considered positive if weakness of the involved shoulder is detected as compared bilaterally| 55 patients with shoulder pain| Impingement diagnosed via arthroscopy| .56 (.32, .81)| .87 (.77, .98)| 4.4 (1.7, 11.1)| .50 (.28, .89)

#### Diagnostic Utility of the Internal Rotation Resistance Strength Test in Differentiating Subacromial Impingement from Intraarticular Pathologic Conditions

Figure 9-33 Internal rotation resistance strength test.

Zaslav66 investigated the usefulness of the internal rotation resistance strength (IRRS) test in distinguishing intraarticular pathologic conditions from impingement syndrome in a group of 115 patients who underwent arthroscopic shoulder surgery. The IRRS test is performed with the patient standing. The examiner positions the patient's arm in 90 degrees of abduction and 80 degrees of external rotation. The examiner applies resistance against external rotation and then internal rotation of the arm in this position. The test is considered positive for an intraarticular pathologic condition if the patient exhibits greater weakness in internal rotation than in external rotation. If the patient demonstrates greater weakness with external rotation, the test is considered positive for impingement syndrome. The IRRS test had a sensitivity of .88, a specificity of .96, a +LR of 22.0, and a −LR of .13.

### Special Tests—Rotator Cuff Tears

#### Reliability of Special Tests for Identifying Supraspinatus and/or Infraspinatus Tears

Figure 9-34 Superior rotator cuff tear.

Figure 9-35 Supraspinatus muscle test (empty can test).

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Supraspinatus muscle test (empty can test)61  | Shoulder and elbow at 90 degrees with arm internally rotated. Examiner then resists internal rotation force. Positive if patient gives way| 33 patients with shoulder pain| Test-retest κ = 1.0
Interexaminer κ = .94
Patte maneuver61  | Test-retest κ = 1.0
Interexaminer κ = 1.0

#### Diagnostic Utility of Special Tests for Identifying Supraspinatus and/or Infraspinatus Tears

Figure 9-36 Lateral Jobe test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Lateral Jobe test67   (see Video 9-1)| Patient's shoulder is abducted 90 degrees in the coronal plane and internally rotated so that with the elbow flexed 90 degrees the fingers point inferiorly and thumb medially. Test is positive with pain or weakness on resisting an inferiorly directed force applied to the distal arm or an inability to perform the test| 175 patients undergoing arthrography| Arthrographic confirmation of complete or partial rotator cuff tear| .81| .89| 7.36| .21
Weakness with elevation (empty can test)13  | With patient standing with arms elevated to shoulder level in scapular plane and thumbs pointing down, examiner applies downward force and patient resists. Positive if weakness is present| 448 patients undergoing arthrography| .64| .65| 1.83| .55
Weakness with elevation (empty can test)63  | 30 patients with new onset of shoulder pain| MRI has confirmed| | | |

• Subacromial impingement

| .74| .30| 1.1| .87

• Subacromial bursitis

| .73| .29| 1.0| .93
Supraspinatus muscle test63  | Examiner resists abduction of the arm at 90 degrees with patient's arm neutral or internally rotated. Positive if patient gives way| 30 patients with new onset of shoulder pain| MRI has confirmed| | | |

• Subacromial impingement

| .58| .20| .70| 2.10

• Subacromial bursitis

| .73| .43| 1.3| .63
Supraspinatus muscle test64  | 552 patients with shoulder pain| Arthroscopic visualization of| | | |

• All impingement

| .44| .90| 4.4| .62

• Bursitis

| .25| .67| .80| 1.12

• Partial thickness RCT

| .32| .68| 1.0| 1.00

• Full-thickness RCT

| .53| .82| 2.9| .57
Drop-arm test64  | Patient elevates arm fully and then slowly lowers arm. Positive if the arm suddenly drops or patient has severe pain| 552 patients with shoulder pain| Arthroscopic visualization of| | | |

• All impingement

| .27| .88| 2.3| .83

• Bursitis

| .14| .77| .60| 1.12

• Partial thickness RCT

| .14| .78| .60| 1.10

• Full-thickness RCT

| .35| .88| 2.9| .74
Infraspinatus muscle test (Patte test)63  | Elbow at 90 degrees with arm neutrally rotated and adducted to the trunk. Examiner then resists internal rotation force. Positive if patient gives way| 30 patients with new onset of shoulder pain| MRI has confirmed| | | |

• Subacromial impingement

| .58| .60| 1.5| .70

• Subacromial bursitis

| .73| .71| 2.5| .38
Infraspinatus muscle test64  | 552 patients with shoulder pain| Arthroscopic visualization of| | | |

• All impingement

| .42| .90| 4.2| .64

• Bursitis

| .25| .69| .80| 1.09

• Partial thickness RCT

| .19| .69| .60| 1.17

• Full-thickness RCT

| .51| .84| 3.2| .58
External rotation lag sign68  | With patient sitting, examiner holds the patient's arm in 20 degrees of shoulder elevation (in the scapular plane), 5 degrees from full external rotation, and 90 degrees of elbow extension. Patient maintains the position when examiner releases arm. Positive if unable to hold position| 37 patients with shoulder pain| Supraspinatus or infraspinatus tear diagnosed via ultrasound| .46| .94| 7.2 (1.7, 31.0)| .60 (.40, .90)
Drop sign68  | With patient sitting, examiner holds the arm in 90 degrees of abduction and full external rotation. Patient is asked to maintain the position when examiner releases arm. Positive if unable to hold position| .73| .77| 3.2 (1.5, 6.7)| .30 (.20, .80)
Supraspinatus test69  | Tendonitis or partial thickness tear*| With patient standing and shoulders abducted to 90 degrees in scapular plane and internal rotation of humerus, examiner applies isometric resistance. Strength of involved side is compared with uninvolved side Positive if weakness or pain is elicited| 50 patients with shoulder pain scheduled to undergo surgery| Supraspinatus tear diagnosed via arthroscopic visualization| .62 (.49, .75)| .54 (.40, .68)| 1.35| .70
Full-thickness tear†| .41 (.27, .55)| .70 (.57, .83)| 1.37| .84
Large or massive full-thickness tear†| .88 (.79, .97)| .70 (.58, .82)| 2.93| .17

*Tendonitis is defined as inflammation or fraying of the supraspinatus tendon. Partial thickness is defined as partial tear of the supraspinatus tendon.

†Full-thickness tears are categorized as small, moderate, large, or massive. Small indicates a tear of less than 1 cm; moderate indicates a tear of 1 to 3 cm that includes the infraspinatus muscle; large indicates a tear of 3 to 5 cm that includes the infraspinatus and teres minor muscles; and massive indicates a tear of more than 5 cm that includes the infraspinatus, teres minor, and subscapularis muscles.

Figure 9-37 Hornblower sign.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Passive elevation of less than 170 degrees13  | With patient supine, examiner maximally elevates shoulder| 448 patients undergoing arthrography| Arthrographic confirmation of complete or partial rotator cuff tear| .30| .78| 1.36| .90
Passive external rotation of less than 70 degrees13  | With patient supine with arm at side, examiner externally rotates arm| .19| .84| 1.19| .96
Arc of pain sign13  | With patient standing, examiner passively abducts arm to 170 degrees. Patient then slowly lowers arm to side. Positive if patient reports pain at 120 degrees to 70 degrees of abduction| .98| .10| 1.09| .20
Atrophy of the supraspinatus muscle13  | Examiner determines atrophy through visual inspection| .56| .73| 2.07| .60
Atrophy of the infraspinatus muscle13  | .56| .73| 2.07| .60
Hornblower sign (teres minor muscle)70  | With patient seated, examiner places patient's arm in 90 degrees of scaption and patient attempts to externally rotate arm against resistance. Positive if patient is unable to externally rotate shoulder| 54 patients who underwent shoulder surgery to repair rotator cuff| Stage of fatty degeneration of infraspinatus muscle as determined by computed tomography (CT) scan| 1.0| .93| 14.29| .00
Dropping sign (infraspinatus muscle)70  | With patient seated, examiner places patient's shoulder in 0 degrees of abduction and 45 degrees of external rotation, with elbow flexed to 90 degrees. Patient holds position when examiner releases forearm. Positive if patient is unable to hold position and arm returns to 0 degrees of external rotation| 1.0| 1.0| Undefined| .00

#### Reliability of Special Tests for Identifying Subscapularis Tears

Test and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Belly-press test46  | With elbow at 90 degrees and hand on belly, patient forcefully presses into a tensiometer on the belly. Positive if weak compared with other side or if patient uses elbow or shoulder extension to push. Positive with weakness of 30% or more compared with the opposite shoulder measured with a handheld dynamometer| 40 subjects with shoulder pain| κ = .65 (.33, .96)

#### Diagnostic Utility of Special Tests for Identifying Subscapularis Tears

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Internal rotation lag sign68  | With patient sitting, examiner holds patient's hand behind the lumbar region in full internal rotation. Patient maintains the position when examiner releases arm. Positive if patient is unable to hold position| 37 patients with shoulder pain| Subscapularis tear diagnosed via ultrasound| 1.0| .84| 6.2 (1.9, 12.0)| .00 (.00, 2.50)
Internal rotation lag sign71  | Examiner places the hand of the patient's affected arm on the back at the midlumbar region; it is held by the examiner at almost maximum internal rotation. The back of the hand is passively lifted away from the body until almost full internal rotation is reached. The patient is then asked to actively maintain this position. The test is considered positive if the patient is unable to maintain this position and the hand has dropped back to the lumbar region| 55 patients suffering from subacromial and/or glenohumeral impingement syndrome scheduled for an arthroscopic procedure| Subscapularis tear diagnosed via arthroscopic visualization| .71| .60| 1.8| .48
Internal rotation lag sign72  | The patient's affected arm is placed on the back in the middle lumbar region. The dorsum of the hand is then passively lifted away from the body until almost full internal rotation is reached, and the patient is asked to actively maintain this position. The sign is considered positive if lag occurs| 312 patients scheduled to undergo arthroscopic shoulder surgery| Subscapularis tear diagnosed via arthroscopic visualization| .20| .97| 6.7| .83

Figure 9-38 Bear-hug test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Bear-hug test72   (see Video 9-2)| The palm of the hand on the patient's involved side is placed on the opposite shoulder with fingers extended, and the elbow is positioned anterior to the body. The patient is then asked to hold that position as the examiner tries to pull the patient's hand from the shoulder with an external rotation force applied perpendicular to the forearm. The test is considered positive if the patient is unable to resist the examiner's external rotation power and if the affected arm exhibits weakness compared with the contralateral side| 165 patients scheduled to undergo arthroscopic shoulder surgery| Subscapularis tear diagnosed via arthroscopic visualization| .19| .99| 19| .82
Bear-hug test73  | Patient places palm of hand on involved side on the opposite shoulder, and fingers are extended. Examiner attempts to pull the hand off the shoulder into external rotation while the patient resists. Positive if patient is unable to maintain hand on shoulder or there is weakness at more than 20 degrees compared with the other side| 68 shoulders scheduled to undergo arthroscopic shoulder surgery| Subscapularis tear diagnosed via arthroscopic visualization| .60| .92| 7.5| .43
Belly-press test73  | With elbow at 90 degrees and hand on belly, patient forcefully presses into a tensiometer on the belly. Positive if weak compared with other side or if patient uses elbow or shoulder extension to push| .40| .98| 20.0| .61

Figure 9-39 Belly-press test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Belly-press test72   (see Video 9-3)| The patient's arm is at the side and the elbow is flexed. The patient is asked to press the palm into his or her abdomen by internally rotating the shoulder. The test is considered positive if the patient pushes the hand against the belly by wrist flexion, despite instruction to the contrary| 312 patients scheduled to undergo arthroscopic shoulder surgery| Subscapularis tear diagnosed via arthroscopic visualization| .28| .99| 28| .73
Modified belly-press test71  | With the hand flat on the abdomen and the elbow close to the body, the patient is asked to bring the elbow forward and straighten the wrist. The final wrist flexion position or belly-press angle of the wrist is then measured by a goniometer. The test is considered positive if the measured belly-press angle at the wrist shows a side-to-side difference of at least 10 degrees| 55 patients suffering from subacromial and/or glenohumeral impingement syndrome scheduled for an arthroscopic procedure| Subscapularis tear diagnosed via arthroscopic visualization| .80| .88| 6.7| .23
Belly-off sign71  | The arm of the patient is passively brought into flexion and maximum internal rotation with the elbow flexed at 90 degrees. The elbow is supported by one hand of the examiner while the examiner's other hand brings the arm into maximum internal rotation, placing the palm of the patient's hand on the abdomen. The patient is asked to keep the wrist straight and actively maintain the position of internal rotation as the examiner releases the wrist. Test is positive if the patient cannot maintain that position, if the wrist is flexed or lag occurs, and if the hand is lifted off the abdomen| .86| .91| 9.6| .15
Lift-off test71  | Examiner places the hand of the patient's affected arm on the back at the midlumbar region and asks the patient to rotate the arm internally and lift the hand posteriorly off the back. The test is considered positive if the patient is unable to do so| .40| .79| 1.9| .76

Figure 9-40 Lift-off test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Lift-off test72  | Hand of the affected arm is placed on the back and patient is asked to internally rotate the arm so as to lift the hand off the back. The test is considered positive if the patient is unable to lift the hand off or if the patient performs the lifting maneuver by extending the elbow or shoulder| 312 patients scheduled to undergo arthroscopic shoulder surgery| Subscapularis tear diagnosed via arthroscopic visualization| .12| 1.0| Undefined| .88
Lift-off test73  | Patient places the hand of the affected arm on the back (at the position of the midlumbar spine) and then attempts to internally rotate the arm to lift the hand posteriorly off the back. Test is positive if patient is unable to lift the arm off the back or if patient performs the lifting maneuver by extending the elbow or the shoulder| 68 shoulders scheduled to undergo arthroscopic surgery| Subscapularis tear diagnosed via arthroscopic visualization| .18| 1.0| Undefined| .82
Napoleon test73  | Same as the belly-press test except without a tensiometer. Positive if patient uses wrist flexion of more than 30 degrees to press into belly| .25| .98| 12.5| .77

### Special Tests—Brachial Plexus Palsy

#### Diagnostic Utility of Special Tests for Identifying Nerve Root Avulsion in People with Brachial Plexus Palsy

Figure 9-41 Brachial plexus: schema.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Tinel sign C574  | Gentle percussion on the supraclavicular region. Positive if painful paresthesias radiate into forearm| 32 patients with complete brachial plexus palsy| CT myelography agreement with surgical findings| .85| .67| 2.6| .22
Tinel sign C674  | As above, except painful paresthesias radiate into hand| .50| .81| 2.6| .62
Shoulder protraction test74  | From supine position, patient protracts the shoulder against resistance of the examiner's hand placed on the patient's anterior shoulder. Test is positive if the shoulder is weaker than the opposite shoulder| .96| .80| 4.8| .05
Hand pain74  | Positive if reported as severe burning or crushing sensation| .86| .75| 3.4| .19

### Special Tests—Acromioclavicular Lesions

#### Diagnostic Utility of Special Tests for Identifying Acromioclavicular Lesions

Figure 9-42 Common mechanism of injury for acromioclavicular tears.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
O'Brien sign75  | Patient is standing. Examiner asks patient to flex arm to 90 degrees with elbow in full extension. Patient then adducts arm 10 degrees and internally rotates humerus. Examiner applies downward force to arm as patient resists. Patient fully supinates arm and repeats procedure. Positive if pain is localized to acromioclavicular joint| 1013 patients with pain between midclavicle and deltoid| Acromioclavicular joint infiltration test: Acromioclavicular joint was injected with lidocaine. Patients who experienced a reduction in symptoms of at least 50% within 10 minutes were considered to have an acromioclavicular pathologic condition| .16| .90| 1.6| .93
Paxinos sign75  | Patient sits with arm by side. With one hand, examiner places thumb over posterolateral aspect of acromion and index finger superior to midportion of clavicle. Examiner then applies compressive force. Positive if pain is reported in area of acromioclavicular joint| .79| .50| 1.58| .42
Palpation of acromioclavicular joint75  | Not reported| .96| .10| 1.07| .40

### Special Tests—Adhesive Capsulitis

#### Diagnostic Utility of Special Tests for Identifying Adhesive Capsulitis

Figure 9-43 Coracoid pain test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Coracoid pain test2  | Digital pressure is applied on the area of the coracoid process, the acromioclavicular joint, and the anterolateral subacromial area. The test is positive if the severity of pain in the coracoid area is 3 points or higher on the visual analog scale (VAS) and pain in the coracoid area is more severe than pain in the other two areas| 830 patients (85 with adhesive capsulitis, 595 with other shoulder pain, 150 asymptomatic)| Codman criteria, shoulder stiffness, MRI, and x-ray| .96 (.90, .99)| .87 (.76, .96)| 7.4| .05

### Combinations of Tests

#### Diagnostic Utility of Combinations of Tests for Identifying Glenoid Labral Tears

Test* and Study Quality| Patient Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Popping
+
Crank test18  | 55 patients with shoulder pain scheduled for arthroscopic surgery| Glenoid labral tear observed during arthroscopy| .27 (.14, .40)| .91 (.74, 1.08)| 3.0 (.44, 20.67)| .80 (.62, 1.04)
Popping
+
Anterior slide test18  | .16 (.05, .27)| 1.0 (1.0, 1.0)| Undefined| .84 (.74, .96)
Active compression test
+
Anterior slide test18  | .25 (.12, .38)| .91 (.74, 1.08)| 2.75 (.40, 19.09)| .83 (.64, 1.06)
Anterior slide test
+
Crank test18  | .34 (.20, .48)| .91 (.74, 1.08)| 3.75 (.55, 25.41)| .73 (.55, .96)
Crank test
+
Apprehension test
+
Relocation test
+
Load and shift test
+
Inferior sulcus sign12  | 54 patients with shoulder pain| Arthroscopic visualization| .90| .85| 6.0| .12
Jobe relocation test
+
O'Brien test33  | 62 shoulders scheduled to undergo arthroscopy| As above| .41| .91| 4.56| .65
Jobe relocation test +
Anterior apprehension test33  | .38| .93| 5.43| .67
O'Brien test
+
Anterior apprehension test33  | .38| .82| 2.11| .76
Jobe test
+
O'Brien test
+
Apprehension test33  | .34| .91| 3.78| .73

*See test descriptions under single tests.

#### Diagnostic Utility of Combinations of Tests for Identifying SLAP Lesions

Oh and colleagues4 studied the usefulness of combinations of two and three special tests in identifying type II SLAP lesions. Although combinations of two tests were not useful in substantially increasing the overall diagnostic utility, several combinations of three tests were. When two tests were chosen from the group with relatively high sensitivities and one from the group with relatively high specificities, the sensitivities of the three "or" combinations were approximately 75% and the specificities of the three "and" combinations were approximately 90%.

High Sensitivity (choose 2)| High Specificity (choose 1)
---|---
Compression rotation test + Anterior apprehension test + O'Brien test| Yergason test + Biceps load test II + Speed test

#### Diagnostic Utility of Combinations of Tests for Identifying Type II to IV SLAP Lesions

Test and Study Quality| Test Combination| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
History of popping, clicking, or catching
+
Anterior slide test3  | History and test positive| 55 patients with shoulder pain| Arthroscopic visualization| .40 (.10, .70)| .93 (.86, 1.0)| 6.0 (1.6, 22.7)| .64 (.39, 1.1)

#### Diagnostic Utility of Combinations of Tests for Identifying Subacromial Impingement

Test* and Study Quality| Test Combination| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Hawkins-Kennedy impingement test
+
Painful arc sign
+
Infraspinatus muscle test64  | All three tests positive| 552 patients with shoulder pain| Arthroscopic visualization of| | | |

• Any impingement

| .26| .98| 10.6| .75

• Full-thickness RCT

| .33| .98| 15.9| .69
Two of three tests positive| Arthroscopic visualization of| | | |

• Any impingement

| .26| .98| 10.6| .75

• Full-thickness RCT

| .35| .90| 3.6| .72
Neer test
+
Hawkins test
+
Horizontal adduction test
+
Painful arc test
+
Drop-arm test
+
Yergason test
+
Speed test65  | All seven tests positive| 125 painful shoulders| Impingement diagnosed via subacromial injection test| .04| .97| 1.33| .99
At least six tests positive| .30| .89| 2.73| .79
At least five tests positive| .38| .86| 2.71| .72
At least four tests positive| .70| .67| 2.12| .45
At least three tests positive| .84| .44| 1.95| .28
Hawkins test
+
Jobe test
+
Patte test
+
Gerber test
+
Speed test76  | A scale of elicited pain ranging from 0 to 2 (0 = none, 1 = moderate, 2 = severe) is scored for each clinical test. Positive if total score is more than 4| 203 patients with shoulder pain| Impingement diagnosed via ultrasonography assessment| .37 (.29, .44)| .98 (.87, 1.0)| 11| .70

*See test descriptions under single tests.

## Outcome Measures

Outcome Measure| Scoring and Interpretation| Test-Retest Reliability| MCID
---|---|---|---
Upper Extremity Functional Index| Users are asked to rate the difficulty of performing 20 functional tasks on a Likert-type scale ranging from 0 (extremely difficult or unable to perform activity) to 4 (no difficulty). A total score out of 80 is calculated by summing each score. The answers provide a score between 0 and 80, with lower scores representing more disability| ICC = .9577  | Unknown (MDC = 9.1)77
Disabilities of the Arm, Shoulder, and Hand (DASH)| Users are asked to rate the difficulty of performing 30 functional tasks on a Likert-type scale. Twenty-one items relate to physical function, 5 items relate to pain symptoms, and 4 items relate to emotional and social functioning. A total score out of 100 is calculated, with higher scores representing more disability| ICC = .9078  | 10.278
Shortened Version of Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH)| Users are asked to rate questions on an 11-item questionnaire that addresses symptoms and physical function. A total score out of 100 is calculated, with higher scores representing more disability| ICC = .9079  | 8.079
Shoulder Pain and Disability Index (SPADI)| Users are asked to rate their shoulder pain and disability on 13 items, each on a VAS from 0 (no pain/difficulty) to 100 (worst pain imaginable/so difficult requires help). Eight items relate to physical function, and 5 items relate to pain symptoms. A total score out of 100 is calculated, with higher scores representing more disability| ICC = .8978  | 13.178
Penn Shoulder Score (PSS)| Users are asked to rate their level of pain, satisfaction, and function on three subscales. The pain subscale is based on a 10-point numeric rating scale with "no pain" and "worst pain possible" as end points. The satisfaction subscale is also based on a 10-point numeric rating scale with "not satisfied" and "very satisfied" as end points. The function subscale is based on a 4-point Likert scale with "can't do at all," "much difficulty," "with some difficulty," and "no difficulty" as response options. A maximum score of 100 indicates low pain, high satisfaction, and high function| ICC = .9480  | 11.480
American Shoulder and Elbow Surgeons (ASES) score| Users are asked to rate their shoulder pain on a 1-item scale and VAS and functional ability on 10 items on a Likert-type scale ranging from 0 to 4. Pain and function are equally weighted to create a total score out of 100. Lower scores represent more pain and disability| ICC = .9178  | 6.478
Numeric Pain Rating Scale (NPRS)| Users rate their level of pain on an 11-point scale ranging from 0 to 10, with high scores representing more pain. Often asked as "current pain" and "least," "worst," and "average" pain in the past 24 hours| ICC = .7281  | 282,83

ICC, Intraclass correlation coefficient; MDC, minimal detectable change; MCID, minimum clinically important difference.

## Appendix

#### Quality Appraisal of Reliability Studies for the Shoulder Using QAREL

| Riddle 198719| Terwee 200520| Yang 200622| Nomden 200923| Wang 200624| Michener 200525| Dover 200326| Borstad 200727| Lewis 20071| Boyd 199230
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| U| Y| U| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| Y| Y| U| N/A| U| N/A| N/A| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| Y| N/A| U| N/A| N/A| N| U| U| N| U

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| Y| Y| U| Y| U| U| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| U

8. Was the order of examination varied?

| Y| Y| Y| Y| Y| N| Y| U| Y| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| U| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Nijs 200535| Odom 200136| Kibler 200237| Hanchard 200540| De Winter 199941| Levy 199942| Walsworth 200818| Kim 200756| Kim 200557| Johansson 200961
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| Y| N| N/A| N/A| U| N/A| N/A| N/A| U

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| N/A| Y| Y| Y| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| Y| U| Y| Y| Y| U| Y| Y| Y| Y

7. Were raters blinded to additional cues that were not part of the test?

| Y| Y| U| U| U| U| U| U| U| U

8. Was the order of examination varied?

| N| N| U| Y| Y| U| U| U| U| Y

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| U| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Stratford 200177| Mintken 200979| Li 200781| Ha 201338| Kolber 201221| Borstad 201029| Michener 200960| Struyf 201428| Lewis 201039| Cadogan 201146
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| U| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| N/A| N/A| N/A| Y| Y| N/A| Y| Y| N/A| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| N/A| N/A| N| U| Y| Y| N/A| Y| N/A| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| Y| N/A| N/A| Y| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| Y| U| U| U| Y| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| U

8. Was the order of examination varied?

| U| U| U| Y| U| N| U| Y| U| Y

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| U| U| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

#### Quality Assessment of Diagnostic Studies for the Shoulder Using QUADAS

| Speer 199445| Liu 199612| Walch 199870| Kim 199959| Calis 200065| Litaker 200013| Kim 200158
---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| U| Y| U| U| Y| Y| U

2. Were selection criteria clearly described?

| N| N| Y| N| Y| Y| U

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| U| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| Y| U| U| U| U| U| U

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| Y| Y| Y| U| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| Y| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| U| N| U| N| Y| U| N

10. Were the index test results interpreted without knowledge of the results of the reference test?

| U| U| U| Y| U| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| U| U| Y| U| U| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| Y| U| U| U| Y| N

13. Were uninterpretable/intermediate test results reported?

| U| U| U| U| U| Y| U

14. Were withdrawals from the study explained?

| U| U| U| U| U| Y| U
Quality Summary Rating:|  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Zaslav 200166| McFarland 200251| Stetson 200250| Guanche 200333| Holtby 200455| Holtby 200469| Walton 200475| Kim 200557| Park 200564| Myers 200549| Nakagawa 200534
---|---|---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| U| U| U| U| Y| Y| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| N| U| N| U| Y| Y| Y| Y| Y| U| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| Y| U| Y| U| U| U| U| Y| U| U

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| U| Y| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| Y| Y| Y| U| Y| Y| Y| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| U| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| N| N| N| Y| Y| Y| Y| N

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| N

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| Y| Y| U| Y| Y| Y| Y| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| U| U| U| U| Y| Y| Y| U| Y| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| Y| Y| Y| Y| Y| U| Y| U| Y| Y| U

13. Were uninterpretable/intermediate test results reported?

| U| U| U| U| U| U| U| U| Y| U| U

14. Were withdrawals from the study explained?

| U| Y| U| Y| U| U| Y| U| Y| Y| U
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Barth 200673| Bertelli 200674| Parentis 200648| Farber 200644| Gill 200732| Kim 200756| Miller 200868| Bushnell 200843| Oh 20084| Silva 200863| Ebinger 200853| Walsworth 200818
---|---|---|---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| U| Y| Y| U| Y| Y| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| U| U| Y| N| Y| Y| Y| Y| Y| Y| U| U

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| U| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| U| U| U| U| U| Y| U| Y| Y| Y| U

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| U| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| U| U| U| U| U| Y| U| U| Y| U| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| U| Y| Y| Y| N| Y| Y| Y| Y| Y| Y

13. Were uninterpretable/intermediate test results reported?

| U| U| Y| U| Y| Y| U| U| U| U| U| Y

14. Were withdrawals from the study explained?

| U| U| U| U| Y| Y| Y| U| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

| Michener 200960| Carbone 20102| Gillooly 201067| Cook 201254| Michener 20113| Toprak 201331| Salaffi 201076| Bartsch 201071| Yoon 201372
---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| Y| Y| U| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| U| Y| Y| Y| Y| U| Y| Y

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| N| Y| U| Y| Y| Y| Y| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| U| Y| Y| Y| Y| Y| Y| U

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| Y| Y| Y| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| U| Y| Y| Y| Y| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| Y| U| U| N| Y| Y| Y| U| U

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| Y| Y| Y| Y| Y| Y| U| Y

13. Were uninterpretable/intermediate test results reported?

| Y| Y| Y| Y| Y| Y| N| Y| Y

14. Were withdrawals from the study explained?

| Y| Y| Y| Y| Y| Y| N| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y - N = 9 to 11)   Fair quality (Y - N = 6 to 8)   Poor quality (Y - N ≤ 5).

## References

1. Lewis JS, Valentine RE. The pectoralis minor length test: a study of the intra-rater reliability and diagnostic accuracy in subjects with and without shoulder symptoms. BMC Musculoskelet Disord. 2007;8:64.

2. Carbone S, Gumina S, Vestri AR, Postacchini R. Coracoid pain test: a new clinical sign of shoulder adhesive capsulitis. Int Orthop. 2010;34(3):385–388.

3. Michener LA, Doukas WC, Murphy KP, Walsworth MK. Diagnostic accuracy of history and physical examination of superior labrum anterior-posterior lesions. J Athl Train. 2011;46(4):343–348.

4. Oh JH, Kim JY, Kim WS, et al. The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion. Am J Sports Med. 2008;36:353–359.

5. Norkin CC, Levangie PK. The shoulder complex. Joint Structure and Function: A Comprehensive Analysis. 2nd ed. FA Davis: Philadelphia; 1992:240–261.

6. Inman VT, Saunders SJB, Abbott LC. Observations on the function of the shoulder joint. 1944. Clin Orthop. 1996;330:3–12.

7. Neumann DA. Shoulder complex. Kinesiology of Musculoskeletal System: Foundations for Physical Rehabilitation. Mosby: St. Louis; 2002:189–248.

8. Brody LT. Shoulder. Current Concepts of Orthopaedic Physical Therapy (11.2.6). Orthopaedic Section, American Physical Therapy Association: La Crosse, Wisconsin; 2001.

9. Michener LA, Walsworth MK, Burnet EN. Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. J Hand Ther. 2004;17:152–164.

10. Hartley A. Practical Joint Assessment. Mosby: St Louis; 1995.

11. Berg EE, Ciullo JV. A clinical test for superior glenoid labral or "SLAP" lesions. Clin J Sport Med. 1998;8:121–123.

12. Liu SH, Henry MH, Nuccion SL. A prospective evaluation of a new physical examination in predicting glenoid labral tears. Am J Sports Med. 1996;24:721–725.

13. Litaker D, Pioro M, El Bilbeisi H, et al. Returning to the bedside: using the history and physical examination to identify rotator cuff tears. J Am Geriatr Soc. 2000;48:1633–1637.

14. Cleland J, Durall CJ. Physical therapy for adhesive capsulitis. Physiotherapy. 2002;88:450–457.

15. Rayan GM, Jensen C. Thoracic outlet syndrome: provocative examination maneuvers in a typical population. J Shoulder Elbow Surg. 1995;4:113–117.

16. Winsor T, Brow R. Costoclavicular syndrome: its diagnosis and treatment. JAMA. 2004;196:109–111.

17. Wainner RS, Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J Orthop Sports Phys Ther. 2000;30:728–744.

18. Walsworth MK, Doukas WC, Murphy KP, et al. Reliability and diagnostic accuracy of history and physical examination for diagnosing glenoid labral tears. Am J Sports Med. 2008;36:162–168.

19. Riddle DL, Rothstein JM, Lamb RL. Goniometric reliability in a clinical setting. Shoulder measurements. Phys Ther. 1987;67:668–673.

20. Terwee CB, de Winter AF, Scholten RJ, et al. Interobserver reproducibility of the visual estimation of range of motion of the shoulder. Arch Phys Med Rehabil. 2005;86:1356–1361.

21. Kolber MJ, Fuller C, Marshall J, et al. The reliability and concurrent validity of scapular plane shoulder elevation measurements using a digital inclinometer and goniometer. Physiother Theory Pract. 2012;28(2):161–168.

22. Yang JL, Lin JJ. Reliability of function-related tests in patients with shoulder pathologies. J Orthop Sports Phys Ther. 2006;36:572–576.

23. Nomden JG, Slagers AJ, Bergman GJ, et al. Interobserver reliability of physical examination of shoulder girdle. Man Ther. 2009;14:152–159.

24. Wang SS, Normile SO, Lawshe BT. Reliability and smallest detectable change determination for serratus anterior muscle strength and endurance tests. Physiother Theory Pract. 2006;22:33–42.

25. Michener LA, Boardman ND, Pidcoe PE, Frith AM. Scapular muscle tests in subjects with shoulder pain and functional loss: reliability and construct validity. Phys Ther. 2005;85:1128–1138.

26. Dover G, Powers ME. Reliability of joint position sense and force-reproduction measures during internal and external rotation of the shoulder. J Athl Train. 2003;38:304–310.

27. Borstad JD, Mathiowetz KM, Minday LE, et al. Clinical measurement of posterior shoulder flexibility. Man Ther. 2007;12:386–389.

28. Struyf F, Meeus M, Fransen E, et al. Interrater and intrarater reliability of the pectoralis minor muscle length measurement in subjects with and without shoulder impingement symptoms. Man Ther. 2014;19(4):294–298.

29. Borstad JD, Briggs MS. Reproducibility of a measurement for latissimus dorsi muscle length. Physiother Theory Pract. 2010;26(3):195–203.

30. Boyd EA, Torrance GM. Clinical measures of shoulder subluxation: their reliability. Can J Public Health. 1992;83(suppl 2):S24–S28.

31. Toprak U, Ustuner E, Ozer D, et al. Palpation tests versus impingement tests in Neer stage I and II subacromial impingement syndrome. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):424–429.

32. Gill HS, El Rassi G, Bahk MS, et al. Physical examination for partial tears of the biceps tendon. Am J Sports Med. 2007;35:1334–1340.

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

34. Nakagawa S, Yoneda M, Hayashida K, et al. Forced shoulder abduction and elbow flexion test: a new simple clinical test to detect superior labral injury in the throwing shoulder. Arthroscopy. 2005;21:1290–1295A.

35. Nijs J, Roussel N, Vermeulen K, et al. Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests. Arch Phys Med Rehabil. 2005;86:1349–1355.

36. Odom CJ, Taylor AB, Hurd CE, et al. Measurement of scapular asymmetry and assessment of shoulder dysfunction using the Lateral Scapular Slide Test: a reliability and validity study. Phys Ther. 2001;81:799–809.

37. Kibler WB, Uhl TL, Maddux JW, et al. Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg. 2002;11:550–556.

38. Ha S, Kwon O, Weon J, et al. Reliability and validity of goniometric and photographic measurements of clavicular tilt angle. Man Ther. 2013;18(5):367–371.

39. Lewis JS, Valentine RE. Clinical measurement of the thoracic kyphosis. A study of the intra-rater reliability in subjects with and without shoulder pain. BMC Musculoskelet Disord. 2010;11:39.

40. Hanchard NC, Howe TE, Gilbert MM. Diagnosis of shoulder pain by history and selective tissue tension: agreement between assessors. J Orthop Sports Phys Ther. 2005;35:147–153.

41. de Winter AF, Jans MP, Scholten RJ, et al. Diagnostic classification of shoulder disorders: interobserver agreement and determinants of disagreement. Ann Rheum Dis. 1999;58:272–277.

42. Levy AS, Lintner S, Kenter K, et al. Intra- and interobserver reproducibility of the shoulder laxity examination. Am J Sports Med. 1999;27:460–463.

43. Bushnell BD, Creighton RA, Herring MM. The bony apprehension test for instability of the shoulder: a prospective pilot analysis. Arthroscopy. 2008;24:974–982.

44. Farber AJ, Castillo R, Clough M, et al. Clinical assessment of three common tests for traumatic anterior shoulder instability. J Bone Joint Surg Am. 2006;88:1467–1474.

45. Speer KP, Hannafin JA, Altchek DW, Warren RF. An evaluation of the shoulder relocation test. Am J Sports Med. 1994;22:177–183.

46. Cadogan A, Laslett M, Hing W, et al. Interexaminer reliability of orthopaedic special tests used in the assessment of shoulder pain. Man Ther. 2011;16(2):131–135.

47. Hegedus EJ, Goode AP, Cook CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012;46(14):964–978.

48. Parentis MA, Glousman RE, Mohr KS, et al. An evaluation of the provocative tests for superior labral anterior posterior lesions. Am J Sports Med. 2006;34:265–268.

49. Myers TH, Zemanovic JR, Andrews JR. The resisted supination external rotation test: a new test for the diagnosis of superior labral anterior posterior lesions. Am J Sports Med. 2005;33:1315–1320.

50. Stetson WB, Templin K. The crank test, the O'Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. Am J Sports Med. 2002;30:806–809.

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

52. Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008;42:80–92 [discussion 92].

53. Ebinger N, Magosch P, Lichtenberg S, Habermeyer P. A new SLAP test: the supine flexion resistance test. Arthroscopy. 2008;24:500–505.

54. Cook C, Beaty S, Kissenberth MJ, et al. Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. J Shoulder Elbow Surg. 2012;21(1):13–22.

55. Holtby R, Razmjou H. Accuracy of the Speed's and Yergason's tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy. 2004;20:231–236.

56. Kim YS, Kim JM, Ha KY, et al. The passive compression test: a new clinical test for superior labral tears of the shoulder. Am J Sports Med. 2007;35:1489–1494.

57. Kim SH, Park JS, Jeong WK, et al. The Kim test: a novel test for posteroinferior labral lesion of the shoulder—a comparison to the jerk test. Am J Sports Med. 2005;33:1188–1192.

58. Kim SH, Ha KI, Ahn JH, et al. Biceps load test II: a clinical test for SLAP lesions of the shoulder. Arthroscopy. 2001;17:160–164.

59. Kim SH, Ha KI, Han KY. Biceps load test: a clinical test for superior labrum anterior and posterior lesions in shoulders with recurrent anterior dislocations. Am J Sports Med. 1999;27:300–303.

60. Michener LA, Walsworth MK, Doukas WC, Murphy KP. Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Arch Phys Med Rehabil. 2009;90(11):1898–1903.

61. Johansson K, Ivarson S. Intra- and interexaminer reliability of four manual shoulder maneuvers used to identify subacromial pain. Man Ther. 2009;14:231–239.

62. Alqunaee M, Galvin R, Fahey T. Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2012;93(2):229–236.

63. Silva L, Andreu JL, Munoz P, et al. Accuracy of physical examination in subacromial impingement syndrome. Rheumatology (Oxford). 2008;47:679–683.

64. Park HB, Yokota A, Gill HS, et al. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am. 2005;87:1446–1455.

65. Calis M, Akgun K, Birtane M, et al. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis. 2000;59:44–47.

66. Zaslav KR. Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. J Shoulder Elbow Surg. 2001;10:23–27.

67. Gillooly JJ, Chidambaram R, Mok D. The lateral Jobe test: A more reliable method of diagnosing rotator cuff tears. Int J Shoulder Surg. 2010;4(2):41–43.

68. Miller CA, Forrester GA, Lewis JS. The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation. Arch Phys Med Rehabil. 2008;89:1162–1168.

69. Holtby R, Razmjou H. Validity of the supraspinatus test as a single clinical test in diagnosing patients with rotator cuff pathology. J Orthop Sports Phys Ther. 2004;34:194–200.

70. Walch G, Boulahia A, Calderone S, et al. The "dropping" and "hornblower's" signs in evaluation of rotator-cuff tears. J Bone Joint Surg Br. 1998;80:624–628.

71. Bartsch M, Greiner S, Haas NP, Scheibel M. Diagnostic values of clinical tests for subscapularis lesions. Knee Surg Sports Traumatol Arthrosc. 2010;18(12):1712–1717.

72. Yoon JP, Chung SW, Kim SH, Oh JH. Diagnostic value of four clinical tests for the evaluation of subscapularis integrity. J Shoulder Elbow Surg. 2013;22(9):1186–1192.

73. Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006;22:1076–1084.

74. Bertelli JA, Ghizoni MF. Use of clinical signs and computed tomography myelography findings in detecting and excluding nerve root avulsion in complete brachial plexus palsy. J Neurosurg. 2006;105:835–842.

75. Walton J, Mahajan S, Paxinos A, et al. Diagnostic values of tests for acromioclavicular joint pain. J Bone Joint Surg Am. 2004;86A:807–812.

76. Salaffi F, Ciapetti A, Carotti M, et al. Clinical value of single versus composite provocative clinical tests in the assessment of painful shoulder. J Clin Rheumatol. 2010;16(3):105–108.

77. Stratford PW, Binkley JM, Stratford DM. Development and initial validation of the upper extremity functional index. Physiotherapy Canada. 2001;53:259–263.

78. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum. 2009;61:623–632.

79. Mintken PE, Glynn P, Cleland JA. Psychometric properties of the shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain. J Shoulder Elbow Surg. 2009;18(6):920–926.

80. Leggin BG, Michener LA, Shaffer MA, et al. The Penn shoulder score: reliability and validity. J Orthop Sports Phys Ther. 2006;36(3):138–151.

81. Li L, Liu X, Herr K. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Pain Med. 2007;8:223–234.

82. Farrar JT, Berlin JA, Strom BL. Clinically important changes in acute pain outcome measures: a validation study. J Pain Symptom Manage. 2003;25:406–411.

83. Farrar JT, Portenoy RK, Berlin JA, et al. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287–294.
10

# Elbow and Forearm

CLINICAL SUMMARY AND RECOMMENDATIONS, 528

Anatomy, 529

Osteology, 529

Arthrology, 530

Ligaments, 531

Muscles, 533

Nerves, 536

Patient History, 537

Initial Hypotheses Based on Historical Findings, 537

Physical Examination Tests, 538

Range-of-Motion Measurements, 538

End-Feel Classification, 540

Assessing Strength, 540

Special Tests, 541

Interventions, 548

Outcome Measures, 549

Appendix, 550

References, 552

## Clinical Summary and Recommendations

Patient History
---
Complaints|

• Little is known about the utility of subjective complaints with elbow pain.

Physical Examination
Range-of-Motion Measurements|

• Measuring elbow range of motion has consistently exhibited good to high reliability for assessing flexion, extension, supination, and pronation.

Strength Assessment|

• Grip strength testing in patients with lateral epicondylalgia exhibits high interrater reliability.

Special Tests|

• In general, few studies have examined the diagnostic utility of special tests of the elbow.

• The elbow extension test has consistently been shown to be an excellent test for ruling out the presence of bony or joint injury (sensitivity values between .91 and .97 and −LR values between .04 and .13).

• The pressure provocation test, the flexion test, the shoulder internal rotation test, and the Tinel sign at the elbow have been found to be useful tests for identifying the presence of cubital tunnel syndrome.

• The moving valgus stress test has been shown to exhibit superior diagnostic accuracy when compared with the valgus stress test for identifying a medial collateral tear.

• No studies to date have examined the utility of the varus stress test for identifying the presence of a lateral collateral tear.

• The hook test, the passive forearm pronation test, and the biceps crease interval test have been shown to have 100% sensitivity and specificity for identifying distal biceps tendon rupture when the outcomes on all three tests are positive.

## Anatomy

### Osteology

Figure 10-1 Bones of elbow.

### Arthrology

Figure 10-2 Anterior and posterior opened elbow joint.

Joint| Type and Classification| Closed Packed Position| Capsular Pattern
---|---|---|---
Humeroulnar| Synovial: hinge| Elbow extension| Flexion is limited more than extension
Humeroradial| Synovial: condyloid| 0 degrees of flexion, 5 degrees of supination| Flexion is limited more than extension
Proximal radioulnar| Synovial: trochoid| 5 degrees of supination| Pronation = supination
Distal radioulnar| Synovial: trochoid| 5 degrees of supination| Pronation = supination

### Ligaments

#### Elbow

Figure 10-3 Ligaments of the elbow.

Ligaments| Attachments| Function
---|---|---
Radial collateral| Lateral epicondyle of humerus to annular ligament of radius| Resists varus stress
Annular ligament of radius| Coronoid process of ulna, around radial head to lateral border of radial notch of ulna| Holds head of radius in radial notch of ulna and allows forearm supination and pronation
Ulnar collateral| Medial epicondyle of humerus to coronoid process and olecranon of ulna| Resists valgus stress

#### Forearm

Figure 10-4 Ligaments of the forearm.

Ligaments| Attachments| Function
---|---|---
Oblique cord| Tuberosity of ulna to just distal to tuberosity of radius| Transfers forces from radius to ulna and reinforces proximity of ulna to radius
Interosseous membrane| Lateral border of ulna to medial border of radius| Transfers force from radius to ulna and reinforces proximity of ulna to radius

### Muscles

#### Anterior and Posterior Muscles of Arm

Figure 10-5 Muscles of forearm: posterior view.

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Triceps brachii (long head)| Infraglenoid tubercle of scapula| Olecranon process of ulna| Radial nerve (C6, C7, C8)| Extends elbow
Triceps brachii (lateral head)| Superior to radial groove of humerus
Triceps brachii (medial head)| Inferior to radial groove of humerus
Anconeus| Lateral epicondyle of humerus| Superoposterior aspect of ulna| Radial nerve (C7, C8, T1)| Assists in elbow extension, stabilizes elbow joint

#### Anterior and Posterior Muscles of Arm

Figure 10-6 Muscles of forearm: anterior view.

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Biceps brachii (short head)| Coronoid process of scapula| Radial tuberosity and fascia of forearm| Musculocutaneous nerve (C5, C6)| Supinates forearm and flexes elbow
Biceps brachii (long head)| Supraglenoid tubercle of scapula| Flexes and abducts shoulder, supinates forearm, and flexes elbow
Brachialis| Distal aspect of humerus| Coronoid process and tuberosity of ulna| Musculocutaneous nerve (C5, C6)| Flexes elbow

#### Supinators and Pronators of the Forearm

Figure 10-7 Individual muscles of forearm: rotators of radius.

Muscle| Proximal Attachment| Distal Attachment| Nerve and Segmental Level| Action
---|---|---|---|---
Supinator| Lateral epicondyle of humerus, supinator fossa, and crest of ulna| Proximal aspect of radius| Deep branch of radial nerve (C5, C6)| Supinates forearm
Pronator teres| Medial epicondyle of humerus and coronoid process of ulna| Lateral aspect of radius| Median nerve (C6, C7)| Pronates forearm and flexes elbow
Pronator quadratus| Distal anterior aspect of ulna| Distal anterior aspect of radius| Anterior interosseous nerve (C8, T1)| Pronates forearm

### Nerves

Figure 10-8 Nerves of forearm: anterior view.

Nerves| Segmental Levels| Sensory| Motor
---|---|---|---
Musculocutaneous| C5, C6, C7| Lateral antebrachial cutaneous nerve| Coracobrachialis, biceps brachii, brachialis
Lateral cutaneous of forearm| C5, C6, C7| Lateral forearm| No motor
Median| C6, C7, C8, T1| Palmar and distal dorsal aspects of lateral   digits and lateral palm| Flexor carpi radialis, flexor digitorum superficialis, lateral   of flexor digitorum profundus, flexor pollicis longus, pronator quadratus, pronator teres, most thenar muscles, and lateral lumbricales
Anterior interosseous| C6, C7, C8, T1| No sensory| Flexor digitorum profundus, flexor pollicis longus, pronator quadratus
Ulnar| C7, C8, T1| Medial hand, including medial   of digit 4| Flexor carpi ulnaris, medial   of flexor digitorum profundus, and most small muscles in hand
Radial| C5, C6, C7, C8, T1| Posterior aspect of forearm| Triceps brachii, anconeus, brachioradialis, extensor muscles of forearm
Posterior interosseous| C5, C6, C7, C8, T1| None| Abductor pollicis longus, extensor pollicis brevis and longus, extensor digitorum communis, extensor indicis, extensor digiti minimi

## Patient History

### Initial Hypotheses Based on Historical Findings

Figure 10-9 Palpation of lateral epicondyle.

History| Initial Hypothesis
---|---
Pain over lateral elbow during gripping activities| Possible lateral epicondylitis1-4
Possible radial tunnel syndrome5-7
Pain over medial elbow during wrist flexion and pronation| Possible medial epicondylitis8,9
Reports of numbness and tingling in ulnar nerve distribution distal to elbow| Possible cubital tunnel syndrome9,10
Pain in anterior aspect of elbow and forearm that is exacerbated by wrist flexion combined with elbow flexion and forearm pronation| Possible pronator syndrome11
Reports of pain during movement with sensations of catching or instability| Possible rotatory instability11
Reports of posterior elbow pain during elbow hyperextension| Possible valgus extension overload syndrome11

## Physical Examination Tests

### Range-of-Motion Measurements

#### Reliability of Elbow Flexion and Extension Measurements

Figure 10-10 Measurement of elbow flexion.

Test and Measure and Study Quality| Instrumentation| Population| Reliability ICC
---|---|---|---
Intraexaminer| Interexaminer
Active range of motion (AROM) elbow flexion12  | 12-inch metal goniometer| 24 patients referred to physical therapy in whom range-of-motion measurements of elbow were appropriate| .94| .89
10-inch plastic goniometer| .97| .96
6-inch plastic goniometer| .96| .90
AROM elbow extension12  | 12-inch metal goniometer| .86| .96
10-inch plastic goniometer| .96| .94
6-inch plastic goniometer| .99| .93
AROM elbow flexion13  | Universal standard goniometer| 38 patients who had undergone a surgical procedure for injury at elbow, forearm, or wrist| .55 to .98| .58 to .62
AROM elbow extension13  | .45 to .98| .58 to .87
AROM elbow flexion14  | Universal plastic goniometer| 30 healthy subjects| Not reported| .53
Fluid-filled bubble inclinometer| Not reported| .92

#### Reliability of Forearm Supination and Pronation Measurements

Figure 10-11 Forearm supination and pronation measurements.

Test and Measure and Study Quality| Instrumentation| Population| Reliability ICC
---|---|---|---
Intraexaminer| Interexaminer
Active range of motion (AROM)13  | Supination| Universal standard goniometer| 38 patients who had undergone a surgical procedure for elbow, forearm, or wrist injury| .96 to .99| .90 to .93
Pronation| .96 to .99| .83 to .86
AROM15  | Supination| 14.5-cm plastic goniometer| 40 subjects, 20 injured and 20 not injured| Injured| .98| .96
Not injured| .96| .94
Pronation| Injured| .95 to .97| .95
Not injured| .86 to .98| .92
Supination| Plumb line goniometer: a 14.5-cm single-arm plastic goniometer with a plumb line attached to the center of its 360 degrees.The plumb line is used as the second arm to take measurement.| Injured| .98| .96
Not injured| .94 to .98| .96
Pronation| Injured| .96 to .98| .92
Not injured| .95 to .97| .91
AROM supination/pronation16  | 8-inch steel goniometer| 31 asymptomatic subjects| .81 to .97| Not reported
Passive range of motion (PROM)17  | Supination| Plumb line goniometer| 30 hand therapy patients| .95| Not reported
Pronation| .87| Not reported
Supination| Standard goniometer| .95| Not reported
Pronation| .79| Not reported

ICC, Intraclass correlation coefficient.

### End-Feel Classification

#### Reliability of Classification According to End Feel for Elbow Flexion and Extension

Figure 10-12 End feel for elbow flexion and extension assessment.

Test and Measure and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Flexion/extension18  | With patient standing, examiner stabilizes humerus with one hand and maintains forearm in neutral with the other hand. Examiner extends or flexes elbow and assesses end feel. End feel is graded as "soft tissue approximation," "muscular," "cartilage," "capsule," or "ligament"| 20 asymptomatic subjects| Flexion κ = .40
Extension κ = .73

### Assessing Strength

#### Reliability of Grip Strength Testing in Patients with Lateral Epicondylalgia

Test and Study Quality| Description| Population| Interexaminer Reliability
---|---|---|---
Pain-free grip strength test19  | With patient standing with elbow extended and forearm in neutral, patient squeezes dynamometer until discomfort is felt| 50 patients diagnosed with lateral epicondylalgia on clinical examination| ICC = .97
Maximum grip strength test19  | As above, except patient is instructed to squeeze dynamometer as hard as possible| ICC = .98

### Special Tests

#### Indication of Bony or Joint Injury

Test and Study Quality| Description| Positive Findings| Population| Reference Standard| Sens (95% CI)| Spec (95% CI)| +LR| −LR
---|---|---|---|---|---|---|---|---
Elbow extension test20  | With patient seated with arms supinated, patient flexes shoulders to 90 degrees and then extends both elbows| Positive if the involved elbow has less extension than the contralateral side| 2127 adults and children presenting to the emergency department| Radiographic evaluation and/or a 7- to 10-day phone call follow-up| 96.8 (95.0, 98.2)| 48.5 (45.6, 51.4)| 1.88 (1.78, 1.99)| .06 (.04, .10)
Elbow extension test21  | Supine patient fully extends elbow| Positive if patient is unable to fully extend elbow| 114 patients with acute elbow injuries| Radiographic evaluation| .97| .69| 3.13| .04
Elbow extension test22  | As above, except patient is standing| As above| 100 patients presenting to an emergency department with elbow injury| As above| .91 (.81, 1.0)| .70 (.61, .78)| 3.03| .13
Elbow extension test23  | Active elbow extension to fully locked position with patient in supine or sitting position| Positive if patient is unable to fully extend elbow| 113 patients presenting to an emergency department with elbow injury| Radiographic evaluation| 1.0 (.93, 1.0)| 1.0 (.94, 1.0)| Undefined| 0.0
Elbow flexion test23  | Active elbow flexion to at least 90 degrees with patient in supine or sitting position| .64 (.50, .69)| 1.0 (.94, 1.0)| Undefined| .36
Elbow pronation test23  | Full active elbow pronation from anatomic position with patient in supine or sitting position| .34 (.22, .48)| 1.0 (.94, 1.0)| Undefined| .66
Elbow supination test23  | Full active elbow supination from anatomic position with patient in supine or sitting position| .43 (.30, .58)| .97 (.89, 1.0)| 14.3| .59

CI, Confidence interval.

#### Detecting Cubital Tunnel Syndrome

Test and Measure and Study Quality| Description| Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---|---
Shoulder internal rotation test24   (see Video 10-1)| Patient holds shoulder at 90 degrees of abduction, maximal internal rotation, and 10 degrees of flexion; elbow at 90 degrees of flexion; forearm and wrist in neutral position; and fingers fully extended. Position is held for 10 seconds| Positive if patient reports symptoms in distribution of ulnar nerve| 93 subjects, 25 with cubital tunnel syndrome, 14 with cervical or upper extremity neuropathy other than cubital tunnel syndrome, and 54 asymptomatic subjects| Electrodiagnostically proven cubital tunnel syndrome| .80| 1.00| Undefined| .20
Flexion test25  | Patient's shoulder is in anatomic position; elbow is placed in maximum flexion; forearm is in full supination; and wrist is in extension. Position is held for 10 seconds| .60| 1.00| Undefined| .40
Flexion test26  | Patient's elbow is placed in maximum flexion with full supination of forearm and wrist in neutral. Position is held for 60 seconds| Positive if patient reports symptoms in distribution of ulnar nerve| 55 subjects, 32 with cubital tunnel syndrome and 33 asymptomatic subjects| Electrodiagnostically proven cubital tunnel syndrome| .75| .99| 75| .25
Pressure provocative test26  | With patient's elbow in 20 degrees of flexion and forearm supination, examiner applies pressure to ulnar nerve just proximal to cubital tunnel for 60 seconds| As above| .89| .98| 44.5| .11
Combined pressure and flexion provocative test26  | Patient's arm is in maximum elbow flexion and forearm supination. Examiner applies pressure on ulnar nerve just proximal to cubital tunnel. Pressure is held for 60 seconds| As above| .98| .95| 19.6| .02
Tinel sign26  | Examiner applies four to six taps to patient's ulnar nerve just proximal to cubital tunnel| Positive if tingling sensation in distribution of ulnar nerve| .70| .98| 35| .31

Figure 10-13 Shoulder internal rotation test.

Figure 10-14 Tinel sign.

#### Detecting Medial Collateral Tears

Figure 10-15 Moving valgus stress test.

Test and Measure and Study Quality| Description| Positive Findings| Patient Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---|---
Moving valgus stress test27   (see Video 10-2)| Patient's shoulder is abducted to 90 degrees with maximal external rotation. Clinician maximally flexes the elbow and applies a valgus stress. The clinician quickly extends the elbow to 30 degrees| If patient experiences maximal medial elbow pain between 120 and 70 degrees of elbow flexion, test is considered positive| 21 patients referred with chronic medial collateral ligament injuries| Surgical visualization| 1.0 (.81, 1.0)| .75 (.19, .99)| 4.0 (.73, 21.8)| .04 (.00, .72)
Valgus stress test at 30, 60, 70, or 90 degrees of elbow flexion27  | Valgus stress is applied to the elbow at 30, 60, 70, and 90 degrees of elbow flexion| If the clinician identifies laxity or the patient reports pain, the test is considered positive| 21 patients referred with chronic medial collateral ligament injuries| Surgical visualization| Pain: .65 (.38, .86) Laxity: .19 (.04, .46)| Pain: .50 (.70, .93) Laxity: 1.0 (.40, 1.0)| Pain: 1.3 Laxity: Undefined| Pain: .70 Laxity: .81

#### Detecting Complete Distal Biceps Tendon Rupture

Test and Measure and Study Quality| Description| Positive Findings| Patient Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---|---
Biceps squeeze test28  | Patient seated with forearm resting in patient's lap, elbow flexed 60 to 80 degrees, and forearm in slight pronation. Examiner squeezes the biceps firmly with both hands (one hand around the muscle belly and one hand at the distal myotendinous junction)| Lack of forearm supination as the biceps is squeezed| 25 patients with suspected distal biceps tendon injuries| Surgical visualization or magnetic resonance imaging (MRI) studies| .96| 1.0| Undefined| .04
Bicipital aponeurosis flex test25  | Patient is asked to make a fist and actively flex the wrist with a supinated forearm. While maintaining the flexed wrist and hand, the patient is asked to flex the elbow and maintain it in 75 degrees of flexion. The examiner palpates the medial part of the antecubital fossa for the sharp, thin edge of the aponeurosis| Absence of palpable sharp thin edge of the aponeurosis on the medial part of the antecubital fossa| 17 patients with suspected distal biceps tendon injuries| Surgical visualization| 1.0| .90| 10| .00
Hook test29  | Examiner uses index finger to palpate patient's flexed elbow from the lateral side of the antecubital fossa in an attempt to "hook" the distal biceps tendon| No cord-like structure under which the examiner can hook the finger| 48 patients with suspected distal biceps tendon injuries| Surgical visualization and/or MRI studies| .81| 1.0| Undefined| .19
Passive forearm pronation test29  | Examiner passively moves the patient's forearm from a supinated position to pronation| Loss of visible and palpable proximal-to-distal movement of the biceps muscle belly| .09| 1.0| Undefined| .91
Biceps crease interval test29  | The distance is measured between the antecubital crease and the cusp of the distal descent of the biceps muscle| Biceps crease interval greater than 6 cm| .88| .50| 1.76| .24
Hook test
+
Passive forearm pronation test
+
Biceps crease interval test29  | As described for each test above| As described for each test above| 1.0| 1.0| Undefined| 0.0

Figure 10-16 Bicipital aponeurosis flex test.

Figure 10-17 Biceps crease interval test.

### Interventions

#### Diagnostic Utility of History and Physical Examination Findings for Predicting a Favorable Short-Term Response to Mobilization with Movement and Exercise in Patients with Lateral Epicondylalgia

Vicenzino and colleagues30 have developed a preliminary clinical prediction rule to identify individuals with lateral epicondylalgia who are likely to benefit from mobilization with movement and exercise. The study identified a number of predictor variables.

Test and Study Quality| Population| Reference Standard| Sens| Spec| +LR
---|---|---|---|---|---
Age less than 49 years30  | 62 patients with lateral epicondylalgia| A global perceived effect of improved, much improved, or completely recovered| .61 (.46, .74)| .77 (.46, .94)| 2.6 (.96, 7.3)
Affected pain-free grip more than 112 newton (N)30  | .53 (.38, .67)| .77 (.46, .93)| 2.3 (.82, 6.4)
Unaffected pain-free grip less than 336 N30  | .49 (.35, .63)| .77 (.46, .94)| 2.1 (.76, 6.0)
Change in pain-free grip following the mobilization with movement of more than 25%30  | .75 (.58, .87)| .5 (.78, 2.9)| 1.5 (.78, 2.9)

The following three variables formed the clinical prediction rule:

1. Age younger than 49 years

2. Affected pain-free grip more than 112 N

3. Unaffected pain-free grip less than 336 N

Diagnostic Accuracy for the Clinical Prediction Rule
---
Number of Variables Present| Sens| Spec| +LR
3| .01 (.03, .20)| 1.0 (.70, 1.0)| Undefined
2| .57 (.42, .71)| .85 (.54, .97)| 3.7 (1.0, 13.6)
1| .98 (.88, .99)| .46 (.20, .74)| 1.8 (1.1, 3.0)

## Outcome Measures

Outcome Measure| Scoring and Interpretation| Test-Retest Reliability and Study Quality| MCID
---|---|---|---
Upper Extremity Functional Index| Users are asked to rate the difficulty of performing 20 functional tasks on a Likert-type scale ranging from 0 (extremely difficult or unable to perform activity) to 4 (no difficulty). A total score out of 80 is calculated by summing each score. The answers provide a score between 0 and 80, with lower scores representing more disability| ICC = .9531  | Not reported; however, the MDC has been determined: MDC = 9.1 points31
Patient-Rated Tennis Elbow Evaluation| Users are asked to rate their levels of pain and function on two subscales. The pain subscale includes five questions and each is scored from 0 to 10 (0 = no pain, 10 = worst pain imaginable). The sum of the score on the five items is recorded as the pain score with a maximum of 50, with higher scores indicating greater levels of pain. The function subscale has 10 items and each is scored from 0 to 10 (0 = no difficulty, 10 = unable to do). The sum of the 10 items is divided by 2 and the patient can score a maximum of 50 on the functional scale, with higher scores representing greater disability. To compute a total score (out of 100), the sum of the pain and functional scales is computed| Pain ICC = .89 to .9932-34
Function ICC = .83 to .9932-34
Total ICC = .89 to .9932-34  | Not reported
Numeric Pain Rating Scale (NPRS)| Users rate their level of pain on an 11-point scale ranging from 0 to 10, with high scores representing more pain. Often asked as "current pain" and, "least," "worst," and "average" pain in the past 24 hours| ICC = .7235  | 236,37

ICC, intraclass correlation coefficient; MCID, minimum clinically important difference; MDC, minimal detectable change.

## Appendix

#### Quality Appraisal of Reliability Studies for the Elbow and Forearm Using QAREL

| Rothstein 198312| Armstrong 199813| Petherick 199814| Karagiannopoulos 200315| Gajdosik 200116| Flowers 200117| Patla 199318| Smidt 200219| Stratford 200131| Newcomer 200533| Overend 199934| Li 200735| Leung 200432
---|---|---|---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| Y| Y| Y| Y| N/A| N/A| Y| Y| U| U| U| N/A| U

4. Were raters blinded to their own prior findings of the test under evaluation?

| Y| N| Y| N| Y| Y| Y| N| U| U| U| N| U

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| U| U| U| U| U| U| U| U| U

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| Y| U| U| U| U| U| U

8. Was the order of examination varied?

| Y| Y| Y| Y| U| Y| Y| Y| U| U| U| U| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality summary rating:|  |  |  |  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.  Good quality (Y − N = 9 to 11)   Fair quality (Y − N = 6 to 8)   Poor quality (Y − N ≤ 5).

#### Quality Assessment of Diagnostic Studies for the Elbow and Forearm Using QUADAS

| Hawksworth 199122| Novak 199426| O'Driscoll 200527| Docherty 200221| Ochi 201124| Darracq 200823| Devereaux 201329| El Maraghy 201325| Ruland 200528| Appelboam 200820
---|---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| U| Y| Y| Y| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| N| N| Y| Y| Y| Y| Y| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| U| U| Y| Y| U| Y| Y| Y| Y| Y

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| N| N| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| U| Y| Y| N| N| Y| N| Y| N| N

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y| Y| N| U| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| N| Y| Y| N| Y| Y| Y| Y| Y| N

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| U| U| Y| U| Y| Y| U| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| Y| U| U| Y| U| Y| N| U| U| Y

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| Y| Y| Y| Y| Y| U| U| Y| Y| Y

13. Were uninterpretable/intermediate test results reported?

| Y| U| Y| Y| Y| N| Y| Y| Y| Y

14. Were withdrawals from the study explained?

| Y| U| Y| Y| Y| Y| Y| Y| Y| Y
Quality summary rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y − N = 10 to 14)   Fair quality (Y − N = 5 to 9)   Poor quality (Y − N ≤ 4).

## References

1. Baquie P. Tennis elbow. Principles of ongoing management. Aust Fam Physician. 1999;28:724–725.

2. Borkholder CD, Hill VA, Fess EE. The efficacy of splinting for lateral epicondylitis: a systematic review. J Hand Ther. 2004;17:181–199.

3. Vicenzino B. Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Man Ther. 2003;8:66–79.

4. Vicenzino B, Wright A. Lateral epicondylalgia I: epidemiology, pathophysiology, aetiology and natural history. Phys Ther Rev. 1996;1:23–34.

5. Pecina MM, Bojanic I. Overuse Injuries of the Musculoskeletal System. CRC Press.: Boca Raton, Florida; 1993.

6. Ellenbecker TS, Mattalino AJ. The Elbow in Sport. Human Kinetics: Champaign, Illinois; 1997.

7. Ekstrom R, Holden K. Examination of and intervention for a patient with chronic lateral elbow pain with signs of nerve entrapment. Phys Ther. 2002;82:1077–1086.

8. Pienimäki TT, Siira PT, Vanharanta H. Chronic medial and lateral epicondylitis: a comparison of pain, disability, and function. Arch Phys Med Rehabil. 2002;83:317–321.

9. Hertling D, Kessler RM. The elbow and forearm. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. 3rd ed. Lippincott; 1990:217–242.

10. Kingery WS, Park KS, Wu PB, Date ES. Electromyographic motor Tinel's sign in ulnar mononeuropathies at the elbow. Am J Phys Med Rehabil. 1995;74:419–426.

11. Ryan J. Elbow. Current Concepts of Orthopaedic Physical Therapy, Orthopaedic Section, American Physical Therapy Association. 2001.

12. Rothstein JM, Miller PJ, Roettger RF. Goniometric reliability in a clinical setting. Elbow and knee measurements. Phys Ther. 1983;63:1611–1615.

13. Armstrong AD, MacDermid JC, Chinchalkar S, et al. Reliability of range-of-motion measurement in the elbow. J Elbow Shoulder Surg. 1998;7:573–580.

14. Petherick M, Rheault W, Kimble S, et al. Concurrent validity and intertester reliability of universal and fluid-based goniometers for active elbow range of motion. Phys Ther. 1988;68:966–969.

15. Karagiannopoulos C, Sitler M, Michlovitz S. Reliability of 2 functional goniometric methods for measuring forearm pronation and supination active range of motion. J Orthop Sports Phys Ther. 2003;33:523–531.

16. Gajdosik RL. Comparison and reliability of three goniometric methods for measuring forearm supination and pronation. Percept Mot Skills. 2001;93:353–355.

17. Flowers KR, Stephens-Chisar J, LaStayo P, Galante BL. Intrarater reliability of a new method and instrumentation for measuring passive supination and pronation. J Hand Ther. 2001;14:30–35.

18. Patla C, Paris S. Reliability of interpretation of the Paris classification of normal end feel for elbow flexion and extension. J Man Manipulative Ther. 1993;1:60–66.

19. Smidt N, van der Windt DA, Assendelft WJ, et al. Interobserver reproducibility of the assessment of severity of complaints, grip strength, and pain pressure threshold in patients with lateral epicondylitis. Arch Phys Med Rehabil. 2002;83:1145–1150.

20. Appelboam A, Reuben AD, Benger JR, et al. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. Br Med J. 2008;337:a2428.

21. Docherty MA, Schwab RA, Ma OJ. Can elbow extension be used as a test of clinically significant injury? South Med J. 2002;95:539–541.

22. Hawksworth CR, Freeland P. Inability to fully extend the injured elbow: an indicator of significant injury. Arch Emerg Med. 1991;8:253–256.

23. Darracq MA, Vinson DR, Panacek EA. Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture. Am J Emerg Med. 2008;26(7):779–782.

24. Ochi K, Horiuchi Y, Tanabe A, et al. Comparison of shoulder internal rotation test with the elbow flexion test in the diagnosis of cubital tunnel syndrome. J Hand Surg [Am]. 2011;36(5):782–787.

25. El Maraghy A, Devereaux M. The "bicipital aponeurosis flex test": evaluating the integrity of the bicipital aponeurosis and its implications for treatment of distal biceps tendon ruptures. J Shoulder Elbow Surg. 2013;22(7):908–914.

26. Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. J Hand Surg [Am]. 1994;19:817–820.

27. O'Driscoll SW, Lawton RL, Smith AM. The "moving valgus stress test" for medial collateral ligament tears of the elbow. Am J Sports Med. 2005;33:231–239.

28. Ruland RT, Dunbar RP, Bowen JD. The biceps squeeze test for diagnosis of distal biceps tendon ruptures. Clin Orthop Relat Res. 2005;437:128–131.

29. Devereaux MW, El Maraghy AW. Improving the rapid and reliable diagnosis of complete distal biceps tendon rupture: a nuanced approach to the clinical examination. Am J Sports Med. 2013;41(9):1998–2004.

30. Vicenzino B, Smith D, Cleland J, Bisset L. Development of a clinical prediction rule to identify initial responders to mobilisation with movement and exercise for lateral epicondylalgia. Man Ther. 2009;14:550–554.

31. Stratford PW, Binkley JM, Stratford DM. Development and initial validation of the upper extremity functional index. Physiotherapy Canada. 2001;53:259–267.

32. Leung HB, Yen CH, Tse PY. Reliability of Hong Kong Chinese version of the Patient-rated Forearm Evaluation Questionnaire for lateral epicondylitis. Hong Kong Med J. 2004;10:172–177.

33. Newcomer KL, Martinez-Silvestrini JA, Schaefer MP, et al. Sensitivity of the Patient-Rated Forearm Evaluation Questionnaire in lateral epicondylitis. J Hand Ther. 2005;18:400–406.

34. Overend TJ, Wuori-Fearn JL, Kramer JF, MacDermid JC. Reliability of a patient-rated forearm evaluation questionnaire for patients with lateral epicondylitis. J Hand Ther. 1999;12:31–37.

35. Li L, Liu X, Herr K, et al. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Pain Med. 2007;8:223–234.

36. Farrar JT, Young JP Jr, LaMoreaux L, et al. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149–158.

37. Farrar JT, Portenoy RK, Berlin JA, et al. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287–294.
11

# Hand

CLINICAL SUMMARY AND RECOMMENDATIONS, 556

Anatomy, 557

Osteology, 557

Arthrology, 559

Ligaments, 560

Muscles, 563

Nerves, 569

Patient History, 572

Initial Hypotheses Based on the Patient History, 572

Diagnostic Utility of Patient History in Identifying Carpal Tunnel Syndrome, 573

Physical Examination Test, 575

Screening, 575

Range-of-Motion Measurements, 579

Assessing Strength, 582

Assessing Wrist Anthropometry, 585

Assessing Swelling, 586

Testing Sensation, 587

Special Tests, 589

Combinations of Tests, 603

Outcome Measures, 604

Appendix, 605

References, 609

## Clinical Summary and Recommendations

Patient History
---
Complaints|

• Overall subjective complaints do not appear useful in identifying carpal tunnel syndrome. Only reports of "dropping objects" and "shaking hand improves symptoms" statistically altered the probability of the diagnosis and then only minimally (+LR [likelihood ratio] = 1.7 to 1.9, −LR = .34 to .47).

Physical Examination
Screening|

• Scaphoid fractures can effectively be ruled in or ruled out by testing for snuffbox tenderness, pain with resisted supination, and pain with longitudinal compression after an injury; these signs and symptoms suggest a possible fracture (for each test, approximate +LR = 50, −LR = 0.0).

• The physical examination appears less effective at identifying other wrist fractures, at least in children.

Range-of-Motion, Strength, and Sensation Assessments|

• Measuring wrist range of motion appears to be highly reliable but is of unknown diagnostic utility. Measuring finger and thumb range of motion is less reliable, even when it is performed by the same examiner.

• Assessing strength with dynamometry has consistently been shown to be highly reliable but, again, is of unknown diagnostic utility. Manual muscle testing of the abductor pollicis brevis muscle does not appear to be very helpful in identifying carpal tunnel syndrome.

• Sensory testing of the hand is of poor to moderate reliability. Only sensory loss at the pad of the thumb appears helpful in identifying carpal tunnel syndrome, and then only minimally (+LR = 2.2, −LR = .49).

Special Tests|

• Evidence for the diagnostic utility of the Tinel sign, Phalen test, and carpal tunnel compression test is highly variable. The highest-quality studies of each suggest that none of the three tests is particularly helpful in identifying carpal tunnel syndrome. Additionally, one study1 found all three tests to be both more sensitive and more specific in identifying tenosynovitis than carpal tunnel syndrome.

• The ulnar fovea sign appears to be very useful at ruling in or ruling out foveal disruption of the distal radioulnar ligaments and ulnotriquetral ligament injuries (+LR = 7.1, −LR =.06).

Combinations of Findings|

• Although not yet validated, a clinical prediction rule appears to be very effective at identifying carpal tunnel syndrome. The presence of five variables (a Hand Severity Scale score of more than 1.9, a wrist ratio index higher than .67, a patient report of shaking the hand for symptom relief, diminished sensation on the thumb pad, and age over 45 years) was found to be associated with a +LR of 18.3.

## Anatomy

### Osteology

Figure 11-1 Carpal bones.

Figure 11-2 Bones of wrist and hand.

### Arthrology

Figure 11-3 Wrist joint.

Joints| Type and Classification| Closed Packed Position| Capsular Pattern
---|---|---|---
Radiocarpal| Synovial: condyloid| Full extension| Limitation equal in all directions
Intercarpal| Synovial: plane| Extension| Limitation equal in all directions
Carpometacarpal (CMC)| Synovial: plane, except for first CMC, which is sellar| Full opposition| Limitation equal in all directions
Metacarpophalangeal (MCP)| Synovial: condyloid| Extension except for first digit| Limitation equal in all directions
Interphalangeal (IP)| Synovial: hinge| Extension| Flexion greater than extension

### Ligaments

#### Palmar Ligaments of the Wrist

Figure 11-4 Palmar ligaments of wrist.

Ligaments| Attachments| Function
---|---|---
Transverse carpal| Hamate and pisiform medially, and scaphoid and trapezium laterally| Prevents bowstringing of finger flexor tendons
Palmar radiocarpal (radioscapholunate and radiocapitate portions)| Distal radius to both rows of carpal bones| Reinforces fibrous capsule of wrist volarly
Palmar ulnocarpal (ulnolunate and ulnotriquetral portions)| Distal ulna to both rows of carpal bones| Reinforces fibrous capsule of wrist volarly
Palmar radioulnar| Distal radius to distal ulna| Reinforces volar aspect of distal radioulnar joint
Radial collateral| Radial styloid process to scaphoid| Reinforces fibrous capsule of wrist laterally
Ulnar collateral| Ulnar styloid process to triquetrum| Reinforces fibrous capsule of wrist medially
Pisometacarpal| Pisiform to base of fifth metacarpal| Reinforces fifth CMC joint
Pisohamate| Pisiform to hook of hamate| Maintains proximity of pisiform and hamate
Capitotriquetral| Capitate to triquetrum| Maintains proximity of capitates and triquetrum
Palmar CMC| Palmar aspect of carpals to bases of metacarpals 2 to 5| Reinforces volar aspect of CMC joints 2 to 5
Palmar metacarpal| Attaches bases of metacarpals 2 to 5| Maintains proximity between metacarpals

#### Posterior Ligaments of the Wrist

Figure 11-5 Posterior ligaments of wrist.

Ligaments| Attachments| Function
---|---|---
Dorsal radioulnar| Distal radius to distal ulnar| Reinforces dorsal aspect of distal radioulnar joint
Dorsal radiocarpal| Distal radius to both rows of carpal bones| Reinforces fibrous capsule of wrist dorsally
Dorsal CMC| Dorsal aspect of carpals to bases of metacarpals 2 to 5| Reinforces dorsal aspect of CMC joints 2 to 5
Dorsal metacarpal| Attaches bases of metacarpals 2 to 5| Maintains proximity between metacarpals

#### Metacarpophalangeal and Interphalangeal Ligaments

Figure 11-6 Metacarpophalangeal and interphalangeal ligaments.

Ligaments| Attachments| Function
---|---|---
Collateral ligaments of IP joints| Sides of distal aspect of proximal phalanx to proximal aspect of distal phalanx| Reinforces medial and lateral capsules of IP joints
Deep transverse metacarpal ligaments| Connects adjacent MCP joints| Reinforces MCP joints
Palmar ligament (volar plate)| Individual plates attach to palmar aspect of MCP and IP joints| Reinforces palmar aspect of MCP and IP joints

### Muscles

#### Extensor Muscles of the Wrist and Digits

Figure 11-7 Extensors of wrist and digits.

Muscles| Proximal Attachments| Distal Attachments| Nerve and Segmental Level| Action
---|---|---|---|---
Extensor carpi radialis longus| Lateral supracondylar ridge of humerus| Base of second metacarpal| Radial nerve (C6, C7)| Extends and radially deviates wrist
Extensor carpi radialis brevis| Lateral epicondyle of humerus| Base of third metacarpal| Deep branch of radial nerve (C7, C8)| Extends and radially deviates wrist
Extensor carpi ulnaris| Lateral epicondyle of humerus| Base of fifth metacarpal| Radial nerve (C6, C7, C8)| Extends and ulnarly deviates wrist
Extensor digitorum| Lateral epicondyle of humerus| Extensor expansions of digits 2 to 5| Posterior interosseous nerve (C7, C8)| Extends digits 2 to 5 at MCP and IP joints
Extensor digiti minimi| Lateral epicondyle of humerus| Extensor expansion of fifth digit| Posterior interosseous nerve (C7, C8)| Extends fifth digit at MCP and IP joints
Extensor indicis| Posterior aspect of ulna and interosseous membrane| Extensor expansion of second digit| Posterior interosseous nerve (C7, C8)| Extends second digit and assists with wrist extension
Abductor pollicis longus| Posterior aspect of ulnar, radius, and interosseous membrane| Base of first metacarpal| Posterior interosseous nerve (C7, C8)| Abducts and extends thumb
Extensor pollicis brevis| Posterior aspect of radius and interosseous membrane| Base of proximal phalanx of thumb| Posterior interosseous nerve (C7, C8)| Extends thumb
Extensor pollicis longus| Posterior aspect of ulnar and interosseous membrane| Base of distal phalanx of thumb| Posterior interosseous nerve (C7, C8)| Extends distal phalanx of thumb at MCP and IP joints

#### Flexor Muscles of the Wrist and Digits

Figure 11-8 Flexors of wrist and digits.

Muscles| Proximal Attachments| Distal Attachments| Nerve and Segmental Level| Action
---|---|---|---|---
Flexor carpi radialis| Medial epicondyle of humerus| Base of second metacarpal bone| Median nerve (C6, C7)| Flexes and radially deviates hand
Flexor carpi ulnaris| Medial epicondyle of humerus and olecranon and posterior border of ulna| Pisiform, hook of hamate, and fifth metacarpal| Ulnar nerve (C7, C8)| Flexes and ulnarly deviates hand
Palmaris longus| Medial epicondyle of humerus| Distal aspect of flexor retinaculum and palmar aponeurosis| Median nerve (C7, C8)| Flexes hand and tightens palmar aponeurosis
Flexor digitorum superficialis (humeroulnar head)| Medial epicondyle of humerus, ulnar collateral ligament, coronoid process of ulna| Bodes of middle phalanges of digits 2 to 5| Median nerve (C7, C8, T1)| Flexes digits at proximal IP joints 2 to 5 and at MCP joints 2 to 5
Flexor digitorum superficialis (radial head)| Superoanterior border of radius
Flexor digitorum profundus (median portion)| Proximal anteromedial aspect of ulnar and interosseous membrane| Bases of distal phalanges of digits 2 to 5| Ulnar nerve (C8, T1)| Flexes digits at distal IP joints 2 to 5 and assists with flexion of hand
Flexor digitorum profundus (lateral portion)| Median nerve (C8, T1)
Flexor pollicis longus| Anterior aspect of radius and interosseous membrane| Base of distal phalanx of thumb| Anterior interosseous nerve (C8, T1)| Flexes phalanges of first digit

#### Intrinsic Muscles of the Hand

Figure 11-9 Intrinsic muscles of hand.

Muscles| Proximal Attachments| Distal Attachments| Nerve and Segmental Level| Action
---|---|---|---|---
Opponens pollicis| Flexor retinaculum, scaphoid, and trapezium| Lateral aspect of first metacarpal| Median nerve (C8, T1)| Opposes and medially rotates thumb
Abductor pollicis brevis| Lateral aspect of base of proximal phalanx of thumb| Abducts thumb and assists in thumb opposition
Flexor pollicis brevis| Flexes thumb
Adductor pollicis (oblique head)| Bases of metacarpals 2 and 3 and capitates| Medial aspect of base of proximal phalanx of thumb| Deep branch of ulnar nerve (C8, T1)| Adducts thumb
Adductor pollicis (transverse head)| Anterior aspect of third metacarpal
Abductor digiti minimi| Pisiform| Medial aspect of base of proximal phalanx of fifth digit| Abducts fifth digit
Flexor digiti minimi| Hook of hamate and flexor retinaculum| Flexes proximal phalanx of fifth digit
Opponens digiti minimi| Medial aspect of fifth metacarpal| Draws fifth digit at MCP joints and extends IP joints
Lumbricals (lateral)| Tendons of flexor digitorum profundus| Lateral sides of extensor expansions 2 to 5| Median nerve (C8, T1)| Flexes digits at MCP joints and extends IP joints
Lumbricals (medial)| Deep branch of ulnar nerve (C8, T1)
Dorsal interosseous| Adjacent sides of two metacarpals| Bases of proximal phalanges 2 to 4 and extensor expansion| Deep branch of ulnar nerve (C8, T1)| Abducts digits and assists with action of lumbricals
Palmar interosseous| Palmar aspect of metacarpals 2, 4, and 5| Bases of proximal phalanges 2, 4, and 5 and extensor expansion| Adducts digits and assists with action of lumbricals

Figure 11-10 Intrinsic muscles of hand (continued).

### Nerves

#### Median Nerve

Figure 11-11 Median nerve.

Nerve| Segmental Level| Sensory| Motor
---|---|---|---
Median nerve| C6, C7, C8, T1| Palmar and distal dorsal aspects of lateral   digits and lateral palm| Abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, lateral lumbricals

#### Ulnar Nerve

Figure 11-12 Ulnar nerve.

Nerve| Segmental Level| Sensory| Motor
---|---|---|---
Ulnar nerve| C7, C8, T1| Palmar and distal dorsal aspects of medial   digits and medial palm| Interosseous, adductor pollicis, flexor pollicis brevis, medial lumbricals, abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi

#### Radial Nerve

Figure 11-13 Radial nerve.

Nerve| Segmental Level| Sensory| Motor
---|---|---|---
Radial nerve| C5, C6, C7, C8, T1| Dorsal aspect of lateral hand, excluding digits| No motor in hand

## Patient History

### Initial Hypotheses Based on the Patient History

#### Reliability of the Historical Examination

History| Initial Hypothesis
---|---
Pain over radial styloid process with gripping activities| Possible de Quervain syndrome2
Reports of an insidious onset of numbness and tingling in first three fingers; may complain that pain is worse at night| Possible carpal tunnel syndrome3-5
Reports of paresthesias over dorsal aspect of ulnar border of hand and fingers 4 to 5| Possible ulnar nerve compression at canal of Guyon1,6,7
Patient reports inability to extend MCP or IP joints| Possible Dupuytren contracture1
Possible trigger finger8
Reports of falling on hand with wrist hyperextended; complains of pain with loading of wrist| Possible scaphoid fracture9,10
Possible carpal instability8

History and Study Quality| Population| Interexaminer Reliability
---|---|---
Most bothersome symptom is pain, numbness, tingling, or loss of sensation?11  | 82 patients presenting to primary care clinic, orthopaedic department, or electrophysiology laboratory with suspected cervical radiculopathy or carpal tunnel syndrome| κ = .74 (.55, .93)
Location of most bothersome symptom?11  | κ = .82 (.68, .96)
Symptoms intermittent, variable, or constant?11  | κ = .57 (.35, .79)
Hand swollen?11  | κ = .85 (.68, 1.0)
Dropping objects?11  | κ = .95 (.85, 1.0)
Entire limb goes numb?11  | κ = .53 (.26, .81)
Nocturnal symptoms wake patient?11  | κ = .83 (.60, 1.0)
Shaking the hand improves symptoms?11  | κ = .90 (.75, 1.0)
Symptoms exacerbated with activities that require gripping?11  | κ = .72 (.49, .95)

### Diagnostic Utility of Patient History in Identifying Carpal Tunnel Syndrome

History and Study Quality| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---
Age over 45 years 11  | 82 patients presenting to a primary care clinic, orthopaedic department, or electrophysiology laboratory with suspected cervical radiculopathy or carpal tunnel syndrome| Needle electromyography and nerve conduction studies| .64 (.47, .82)| .59 (.47, .72)| 1.58 (.46, 2.4)| .60 (.35, 1.0)
Most bothersome symptom is pain, numbness, tingling, or loss of sensation11  | .04 (−.04, .11)| .91 (.83, .98)| .42 (.05, 3.4)| 1.1 (.94, 1.2)
Location of most bothersome symptom11  | .35 (.16, .53)| .40 (.27, .54)| .58 (.33, 1.0)| 1.6 (1.1, 2.5)
Symptoms intermittent, variable, or constant11  | .23 (.07, .39)| .89 (.81, .97)| 2.1 (.74, 5.8)| .87 (.69, 1.4)
Reports of hand becoming swollen11  | .38 (.20, .57)| .63 (.50, .76)| 1.0 (.57, 1.9)| .98 (.68, 1.4)
Dropping objects11  | .73 (.56, .90)| .57 (.44, .71)| 1.7 (1.2, 2.5)| .47 (.24, .92)
Entire limb goes numb11  | .38 (.20, .57)| .80 (.69, .90)| 1.9 (.92, 3.9)| .77 (.55, 1.1)
Nocturnal symptoms wake patient11  | .73 (.56, .90)| .31 (.19, .44)| 1.1 (.79, 1.4)| .86 (.41, 1.8)
Shaking hand improves symptoms11  | .81 (.66, .96)| .57 (.43, .70)| 1.9 (1.3, 2.7)| .34 (.15, .77)
Symptoms exacerbated with activities that require gripping11  | .77 (.61, .93)| .37 (.24, .50)| 1.2 (.91, 1.6)| .62 (.28, 1.4)
Age 40 years or older12  | 110 patients referred to laboratory for electrophysiologic examination| Nerve conduction tests| .80| .42| 1.38| .48
Nocturnal symptoms12  | .77| .28| 1.07| .82
Bilateral symptoms12  | .61| .58| 1.45| .67

Figure 11-14 Carpal tunnel syndrome.

## Physical Examination Tests

### Screening

#### Diagnostic Utility of Tests in Identifying Scaphoid Fractures (see Fig. 11-15)

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Snuffbox tenderness13  | Examiner palpates anatomic snuffbox. Positive if pain is elicited| 85 patients presenting to emergency department with mechanism of injury suggesting possible scaphoid fracture| Radiographic confirmation of scaphoid fracture| 1.0| .98| 50.0| 0.0
Pain with supination against resistance13  | Examiner holds patient's hand in handshake position and directs patient to resist supination of forearm. Positive if pain is elicited| 1.0| .98| 50.0| 0.0
Pain with longitudinal compression of thumb13  | Examiner holds patient's thumb and applies long-axis compression through metacarpal bone into scaphoid. Positive if pain is elicited| .98| .98| 49.0| .02
Anatomic snuffbox tenderness14  | Examiner palpates anatomic snuffbox. Positive if pain is elicited| 221 patients with a suspected scaphoid injury| 1.0| .29 (.23, .35)| 1.41| 0.0
Scaphoid tubercle tenderness14  | Examiner applies pressure to scaphoid tubercle. Positive if pain is elicited| .83 (.70, .96)| .51 (.44, .58)| 1.69| .33
Scaphoid compression tenderness14  | Examiner holds patient's thumb and applies long axis compression through metacarpal bone into scaphoid. Positive if pain is elicited| 1.0| .80 (.74, .86)| 5.0| 0.0

#### Diagnostic Utility of Hand Symptom Diagrams in Identifying Carpal Tunnel Syndrome

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Katz score15  | Subjects shaded in hand diagrams based on where they have experienced numbness, tingling, burning, or pain. Diagrams were scored based on the modified Katz system.12 A diagram scored as "classic" or "probable" was considered positive| 110 subjects who reported symptoms of burning, pain, tingling, or numbness in the hand| Nerve conduction studies| .38 (.28, .50)| .81 (.73, .87)| 2.0| .77
Median nerve digit score15  | Subjects shaded in hand diagrams based on where they have experienced numbness, tingling, burning, or pain. Diagrams were scored based on the number of digits innervated by the median nerve with distal volar shading. A score of 2 or more digits was considered positive| .54 (.43, .65)| .76 (.68, .83)| 2.25| .61

#### Diagnostic Utility of Tests in Identifying Scaphoid Fractures

Figure 11-15 Testing for tenderness of anatomic snuffbox.

#### Reliability of Hand Symptom Diagrams in Identifying Carpal Tunnel Syndrome

Test and Measure and Study Quality| Description| Population| Reliability
---|---|---|---
Intraexaminer| Interexaminer
Katz score15  | Subjects shaded in hand diagrams based on where they have experienced numbness, tingling, burning, or pain| 110 subjects who reported symptoms of burning, pain, tingling, or numbness in the hand| κ = .86 (.49, .95)| ICC = .87 (.84, .90)
Median nerve digit score15  | κ = .97 (.49, .95)| ICC = .96 (.95, .97)

#### Acute Pediatric Wrist Fractures: Clinical Prediction Rule

Figure 11-16 Fracture of forearm bones in children.

Pershad and colleagues44 developed a clinical prediction rule for identifying acute pediatric wrist injuries. Predictor variables included reduction in grip strength of 20% or more compared with the opposite side and distal radius point tenderness. The rule exhibited a sensitivity of 79%, a specificity of 63%, a +LR of 2.14, and a −LR of .33.

### Range-of-Motion Measurements

#### Reliability of Wrist Range-of-Motion Measurements

Figure 11-17 Wrist range of motion.

Test and Measure and Study Quality| Instrumentation| Population| Reliability
---|---|---|---
Intraexaminer| ICC| Interexaminer| ICC
Active range of motion (AROM)17  | 8 in plastic goniometer| 48 patients where measurements of the wrist would normally be included in examination| Wrist flexion| .96| Wrist flexion| .90
Wrist extension| .96| Wrist extension| .85
Radial deviation| .90| Radial deviation| .86
Ulnar deviation| .92| Ulnar deviation| .78
Passive range of motion (PROM)17  | Wrist flexion| .96| Wrist flexion| .86
Wrist extension| .96| Wrist extension| .84
Radial deviation| .91| Radial deviation| .66
Ulnar deviation| .94| Ulnar deviation| .83
PROM18  | Alignment of plastic 6 in goniometer| 140 patients where PROM of wrist would be included in standard evaluation| Radial flexion| .86| Radial flexion| .88
Ulnar flexion| .87| Ulnar flexion| .89
Dorsal flexion| .92| Dorsal flexion| .93
Radial extension| .80| Radial extension| .80
Ulnar extension| .80| Ulnar extension| .80
Dorsal extension| .84| Dorsal extension| .84

Figure 11-18 Wrist range of motion.

#### Reliability of Finger and Thumb Range-of-Motion Measurements

Figure 11-19 Measurement of proximal interphalangeal joint flexion.

Test and Measure and Study Quality| Instrumentation| Population| Test-Retest Reliability ICC
---|---|---|---
Total active range of motion (AROM) of IP flexion and extension3  | Finger goniometer| 30 patients with hand injuries| Intraexaminer = .97 to .98
Interexaminer = .97
Palmar abduction7  | | | Intraexaminer| Interexaminer
| | Active| Passive| Active| Passive

• Goniometer

| 25 healthy subjects| .55 (.34, .87)| .76 (.69, .94)| .31 (−.18, .77)| .37 (−.42, .79)

• Pollexograph-thumb

| .71 (.62, .93)| .82 (.78, .96)| .66 (.53, .91)| .59 (.42, .89)

• Pollexograph-metacarpal

| .82 (.78, .96)| .81 (.76, .95)| .57 (.38, .88)| .61 (.45, .89)

• American Medical Association method

| .72 (.63, .92)| .65 (.51, .90)| .24 (−.40, .73)| .52 (.28, .86)

• American Society of Hand Therapists method

| .78 (.72, .94)| .72 (.63, .93)| .55 (.34, .87)| .52 (.29, .86)

• Intermetacarpal distance

| .95 (.95, .99)| .92 (.90, .98)| .82 (.79, .96)| .79 (.78, .96)

### Assessing Strength

#### Intraexaminer Reliability of Assessing Strength

Test and Study Quality| Instrumentation| Population| Test-Retest Reliability (ICC)
---|---|---|---
Wrist extensors (mean of two efforts)20  | Dynamometer| 40 patients with suspected myopathy| Dominant side = .88 (.79, .94)
Nondominant side = .94 (.90, .97)
Wrist extensors (maximum of two efforts)20  | 40 patients with suspected myopathy| Dominant side = .87 (.76, .93)
Nondominant side = .94 (.88, .97)
Grip2  | 21 healthy elder volunteers| Left = .95 (.89, .98)
Right = .91 (.78, .96)
Grip4  | 22 asymptomatic subjects| One trial: .95 (.89, .98)
Mean of three trials: .85 (.67, .94)
Highest of three trials: .95 (.89, .98)
22 patients after carpal tunnel decompression| One trial: .97 (.94, .99)
Mean of three trials: .94 (.80, .98)
Highest of three trials: .97 (.92, .99)
22 patients after carpal tunnel decompression| One trial: .96 (.91, .98)
Mean of three trials: .98 (.96, .99)
Highest of three trials: .97 (.90, .99)
Grip21  | 104 healthy primary school children| Dominant side = .97 (.95, .98)
Nondominant side = .95 (.92, .96)
Vigorimeter| Dominant side = .84 (.77, .89)
Nondominant side = .86 (.80, .90)
Grip
Palmar pinch
Key pinch
Tip pinch22  | Pinch gauge| 27 healthy volunteers| Right
.99
.98
.99
.99| Left
.99
.99
.98
.99
Grip
Tip pinch
Key pinch23  | Hand and pinch grip dynamometers| 33 patients with a unilateral hand injury| Injured
.93 to .97
.89
.94| Noninjured
.92 to .94
.84
.86
Grip
Tip pinch
Jaw pinch3  | Grip dynamometer and pinch gauge| 30 patients with hand injuries| Intraexaminer
.96
.86 to .94
.88 to .93| Interexaminer
.95
.91
.89
Grip
Tripod
Key pinch24  | Dynamometer and pinch gauge| 38 patients receiving physical therapy for hand impairments| Symptomatic
.93 (.86, .96)
.88 (.78, .96)
.94 (.88, .97)| Asymptomatic
.94 (.89, .97)
.87 (.74, .93)
.93 (.86, .96)
Abductor pollicis muscle strength11  | Examiner performs manual muscle testing of abductor pollicis muscle. Graded as markedly reduced, reduced, or normal compared with contralateral extremity| 82 patients with suspected cervical radiculopathy or carpal tunnel syndrome| κ = .39 (.00, .80)
Wrist extensors25  | Dynamometer| 30 patients presenting to a physical therapy clinic| .94
Wrist flexion
Wrist extension26  | Dynamometer| 20 healthy subjects| Wrist flexion .85
Wrist extension .91

#### Intraexaminer Reliability of Assessing Strength

Figure 11-20 Measurement of grip strength.

Figure 11-21 Measurement of pinch strength.

#### Diagnostic Utility of Weakness in Identifying Carpal Tunnel Syndrome

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Abductor pollicis brevis muscle strength11  | Strength is tested by placing thumb in a position of abduction and applying a force in direction of adduction at proximal phalanx. Positive if strength is reduced or markedly reduced compared with contralateral extremity| 82 patients with suspected cervical radiculopathy or carpal tunnel syndrome| Needle electromyography and nerve conduction studies| .19 (.04, .34)| .89 (.81, .90)| 1.7 (.58, 5.2)| .91 (.74, 1.1)
Abductor pollicis brevis muscle weakness27  | Patient is instructed to touch pad of thumb and pad of fifth digit together. Examiner applies posteriorly directed force over thumb IP joint toward palm. Positive if weakness is detected| 228 hands referred for electrodiagnostic consultation with suspected carpal tunnel syndrome| Nerve conduction studies| .66| .66| 1.94| .52

### Assessing Wrist Anthropometry

#### Reliability of Measuring Wrist Anthropometry

Test and Measure and Study Quality| Description| Population| Interexaminer Reliability
---|---|---|---
Wrist anteroposterior width11  | Width of wrist is measured in centimeters with pair of calipers| 82 patients with suspected cervical radiculopathy or carpal tunnel syndrome| ICC = .77 (.62, .87)
Wrist mediolateral width11  | ICC = .86 (.75, .92)

#### Diagnostic Utility of Wrist Anthropometry in Identifying Carpal Tunnel Syndrome

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Wrist ratio index greater than .6711  | Anteroposterior width of wrist is measured and divided by mediolateral width. Positive if ratio is greater than .67| 82 patients with suspected cervical radiculopathy or carpal tunnel syndrome| Needle electromyography and nerve conduction studies| .93 (.83, 1.0)| .26 (.14, .38)| 1.3 (1.0, 1.5)| .29 (.07, 1.2)
T-square-shaped wrist test27  | Anteroposterior and mediolateral dimensions of wrist are measured at distal flexor wrist crease using pair of standard calipers. Positive if wrist ratio (anteroposterior dimension divided by mediolateral dimension) is .70 or more| 228 hands referred for electrodiagnostic consultation with suspected carpal tunnel syndrome| Nerve conduction studies| .69| .73| 2.56| .42

### Assessing Swelling

#### Reliability of Assessing Swelling

Figure 11-22 Figure-of-eight measurement.

Test and Measure and Study Quality| Description| Population| Reliability ICC
---|---|---|---
Intraexaminer| Interexaminer
Figure-of-eight test28  | Examiner places zero mark on distal aspect of ulnar styloid process. Tape measure is then brought across ventral surface of wrist to most distal aspect of radial styloid process. Next, tape is brought diagonally across dorsum of hand and over fifth MCP joint line, brought over ventral surface of MCP joints, and wrapped diagonally across dorsum to meet start of tape measure| 24 individuals (33 hands) with pathologic conditions affecting hand| ICC = .99| ICC =.99
Volumetric test28  | Hand is placed vertically in standard volumeter| ICC = .99| Not reported

### Testing Sensation

#### Reliability of Sensory Testing

Test and Measure and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Semmes-Weinstein monofilament test24  | Sensory test is performed on pulp of thumb, index finger, and long and small fingertips| 36 hands with carpal tunnel syndrome| κ = .22 (.26, .42)
Median sensory field deficit of thumb pad11  | Sensation is tested with straight end of paper clip. Graded as absent, reduced, or normal sensation or hyperesthetic condition| 82 patients presenting to a primary care clinic, orthopaedic department, or electrophysiology laboratory with suspected cervical radiculopathy or carpal tunnel syndrome| κ = .48 (.23, .73)
Median sensory field deficit of index finger pad11  | κ = .50 (.25, .75)
Median sensory field deficit11  | κ = .40 (.12, .68)

#### Diagnostic Utility of Diminished Sensation in Identifying Carpal Tunnel Syndrome

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Sensory loss at pad of thumb11  | Sensation is tested with straight end of paper clip. Positive if sensation is absent or reduced| 82 patients presenting to a primary care clinic, orthopaedic department, or electrophysiology laboratory with suspected cervical radiculopathy or carpal tunnel syndrome| Needle electromyography and
nerve conduction studies| .65 (.47, .84)| .70 (.47, .84)| 2.2 (1.3, 3.6)| .49 (.28, .46)
Sensory loss at pad of index finger11  | .52 (.32, .72)| .67 (.32, .72)| 1.6 (.92, 2.7)| .72 (.86, 1.1)
Sensory loss at pad of medial finger11  | .44 (.26, .63)| .74 (.26, .63)| 1.7 (.58, .52)| .75 (.86, 1.1)
Moving two-point discrimination test12  | Examiner strokes the tip of the index finger, fifth finger, or both fingers five times with either one or two caliper tips. Positive if patient is unable to identify number of fingertips that have been stroked at least one of the five times| 110 patients referred to laboratory for electrophysiologic examination| Nerve conduction tests| .32| .81| 1.68| .84

#### Diagnostic Utility of Diminished Sensation in Identifying Carpal Tunnel Syndrome

Figure 11-23 Testing sensation.

### Special Tests

#### Reliability of the Tinel Sign

Figure 11-24 Tinel sign.

Test and Measure and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Tinel A sign11  | Patient is seated with elbow flexed 30 degrees, forearm supinated, and wrist in neutral position. Examiner allows a reflex hammer to fall from a height of 6 inches along median nerve between the tendons at proximal wrist crease. Positive if patient reports a nonpainful tingling sensation along course of median nerve| 82 patients with suspected cervical radiculopathy or carpal tunnel syndrome| κ = .47 (.21, .72)
Tinel B sign11  | Performed as the Tinel A sign test, above, except examiner attempts to elicit symptoms using mild-to-moderate force with reflex hammer. Positive if pain is exacerbated along course of median nerve| κ = .35 (.10, .60)
Tinel sign24  | Examiner percusses over palm from proximal palmar crease to distal wrist crease. Positive if symptoms are elicited in distribution of median nerve| 36 hands with carpal tunnel syndrome| κ = .81 (.66, .98)

#### Diagnostic Utility of the Tinel Sign in Identifying Carpal Tunnel Syndrome

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Tinel sign 29  | Examiner taps median nerve at wrist with fingers. Positive if patient reports pain or paresthesias in distribution of median nerve| 142 patients referred for electrodiagnostic testing| Electrodiagnostic testing| .27 (.18, .36)| .91 (.84, 1.0)| 3.0| .80
Tinel sign 27  | 228 hands referred for electrodiagnostic consultation regarding suspected carpal tunnel syndrome| Nerve conduction studies| .23| .87| 1.77| .89
Tinel A test 11  | Patient seated with elbow flexed 30 degrees, forearm supinated, and wrist in neutral position. Examiner allows reflex hammer to fall from height of 6 inches along median nerve between tendons at proximal wrist crease. Positive if patient reports nonpainful tingling sensation along course of median nerve| 82 patients with suspected cervical radiculopathy or carpal tunnel syndrome| Needle electromyography and nerve conduction studies| .41 (.22, .59)| .58 (.45, .72)| .98 (.56, 1.7)| 1.0 (.69, 1.5)
Tinel B test11  | Performed as the Tinel A sign test, above, except examiner attempts to elicit symptoms using mild-to-moderate force with reflex hammer. Positive if pain is exacerbated along course of median nerve| .48 (.29, .67)| .67 (.54, .79)| 1.4 (.84, 2.5)| .78 (.52, 1.2)
Tinel test30  | Positive if percussion of the median nerve at the wrist causes tingling in the median nerve distribution| 162 hands from 81 patients seeking treatment for carpal tunnel syndrome| Electrodiagnostic testing*| .90| .81| 4.7| .12
Tinel test1  | Percussion of the median nerve at the wrist (no other details)| 232 patients with carpal tunnel syndrome manifestations and 182 controls| Carpal tunnel syndrome diagnosed via clinical examination| .30 (.24, .36)| .65 (.58, .71)| 0.9| 1.10
Tenosynovitis via ultrasonography| .46 (.41, .53)| .85 (.80, .89)| 3.1| .64
Tinel sign12  | Examiner drops square end of reflex hammer on distal wrist crease from height of 12 cm. Positive if patient reports pain or paresthesias in at least one finger innervated by median nerve| 110 patients referred to laboratory for electrophysiologic examination| Nerve conduction tests| .60| .67| 1.82| .60

*Also used latent class analysis to define reference standard diagnosis of carpal tunnel syndrome, but doing so resulted in study being excluded for poor quality because the reference standard was then not independent of index tests.

#### Reliability of the Phalen Test

Figure 11-25 Phalen test.

Test and Measure and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Phalen test24  | Patient places dorsal aspects of hands together, maintaining maximal wrist flexion for 60 seconds. Positive if symptoms are elicited in distribution of median nerve| 36 hands with carpal tunnel syndrome| κ = .88 (.77, .98)
Phalen test11  | With patient seated with elbow flexed 30 degrees and forearm supinated, examiner places the wrist in maximal flexion for 60 seconds. Positive if patient experiences exacerbation of symptoms in median nerve distribution| 82 patients with suspected cervical radiculopathy or carpal tunnel syndrome| κ = .79 (.59, 1.0)
Wrist extension test24  | Patient places palmar aspects of hands together, maintaining maximal wrist extension for 60 seconds. Positive if symptoms are elicited in distribution of median nerve| 36 hands with carpal tunnel syndrome| κ = .72 (.55, .88)

#### Diagnostic Utility of the Phalen Test in Identifying Carpal Tunnel Syndrome

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Phalen test11  | With patient seated with elbow flexed 30 degrees and forearm supinated, examiner places wrist in maximal flexion for 60 seconds. Positive if patient experiences an exacerbation of symptoms in median nerve distribution| 82 patients with suspected cervical radiculopathy or carpal tunnel syndrome| Needle electromyography and nerve conduction studies| .77 (.61, .93)| .40 (.26, .53)| 1.3 (.94, 1.7)| .58 (.27, 1.3)
Phalen test29  | Patient is instructed to maximally flex wrist and hold position for 60 seconds. Positive if symptoms are produced| 142 patients referred for electrodiagnostic testing| Electrodiagnostic testing| .34 (.24, .43)| .74 (.62, .87)| 1.31| .89
Phalen test27  | 228 hands referred for electrodiagnostic consultation regarding suspected carpal tunnel syndrome| Nerve conduction studies| .51| .76| 2.13| .64
Phalen test30  | 162 hands from 81 patients seeking treatment for carpal tunnel syndrome| Electrodiagnostic testing*| .85| .79| 4.0| .19
Phalen test1  | Complete wrist flexion for 60 seconds (no other details)| 232 patients with carpal tunnel syndrome manifestations and 182 controls| Carpal tunnel syndrome diagnosed via clinical examination| .47 (.41, .54)| .17 (.13, .23)| 0.6| 3.12
Tenosynovitis diagnosed via ultrasonography| .92 (.36, .49)| .87 (.82, .91)| 7.1| .09
Reverse Phalen test1  | Complete wrist extension for 60 seconds (no other details)| Carpal tunnel syndrome diagnosed via clinical examination| .42 (.36, .49)| .35 (.29, .42)| 0.6| 1.66
Tenosynovitis diagnosed via ultrasonography| .75 (.69, .80)| .85 (.80, .89)| 5.0| .29
Phalen test12  | Examiner instructs patient to flex both wrists to 90 degrees with dorsal aspects of hands held in opposition for 60 seconds. Positive if patient reports pain or paresthesias in at least one finger innervated by median nerve| 110 patients referred to laboratory for electrophysiologic examination| Nerve conduction tests| .74| .47| 1.4| .55
Phalen's test10  | Patient holds forearms in pronation with elbows resting on examination table, forearms vertical and wrists in gravity-assisted flexion. Positive if symptoms are produced| 132 patients with pain of upper limb| Electro-physiological confirmation| .79| .92| 9.88| .23

*Also used latent class analysis to define reference standard diagnosis of carpal tunnel syndrome, but doing so resulted in study being excluded for poor quality because the reference standard was then not independent of index tests.

#### Reliability of the Carpal Compression Test

Test and Measure and Study Quality| Description and Positive Findings| Population| Reliability
---|---|---|---
Carpal compression test11  | With patient seated with elbow flexed 30 degrees, forearm supinated, and wrist in neutral position, examiner places both thumbs over transverse carpal ligament and applies 6 pounds of pressure for 30 seconds maximum. Positive if patient experiences exacerbation of symptoms in median nerve distribution| 36 hands with carpal tunnel syndrome| κ = .77 (.58, .96)

#### Diagnostic Utility of the Carpal Compression Test in Identifying Carpal Tunnel Syndrome

Figure 11-26 Carpal compression test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Carpal compression test11  | With patient seated with elbow flexed 30 degrees, forearm supinated, and wrist in neutral position, examiner places both thumbs over transverse carpal ligament and applies 6 pounds of pressure for 30 seconds maximum. Positive if patient experiences exacerbation of symptoms in median nerve distribution| 82 patients presenting to a primary care clinic, orthopaedic department, or electrophysiology laboratory with suspected cervical radiculopathy or carpal tunnel syndrome| Needle electromyography and nerve conduction studies| .64 (.45, .83)| .30 (.17, .42)| .91 (.65, 1.3)| 1.2 (.62, 2.4)
Carpal compression test27  | Examiner applies moderate pressure over median nerve just distal to distal flexor wrist crease for 5 seconds. Considered positive if pain, paresthesia, or numbness is reproduced| 228 hands referred for electrodiagnostic consultation regarding suspected carpal tunnel syndrome| Nerve conduction studies| .28| .74| 1.08| .97
Carpal tunnel compression test1  | Examiner exerts even pressure on the space between thenar eminence and the hypothenar eminence for 30 seconds while arm is supinated. Patient is questioned regarding symptoms every 15 seconds| 232 patients with carpal tunnel syndrome manifestations and 182 controls| Carpal tunnel syndrome diagnosed via clinical examination| .46 (.40, .53)| .25 (.20, .31)| 0.6| 2.16
Carpal compression test10  | The examiner applies moderate pressure with thumbs over transverse carpal ligament with wrist in neutral for 30 sec. Considered positive if pain, paresthesia or numbness is reproduced| 132 patients with pain of upper limb| Electrophysiological confirmation| .83| .92| 10.38| .18

#### Diagnostic Utility of the Hand Elevation Test in Identifying Carpal Tunnel Syndrome

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Hand elevation test 31  | Patient is asked to elevate both hands above the head for
1 minute. Positive if symptoms are reproduced| 70 patients with symptoms of carpal tunnel syndrome and positive nerve conduction studies| Electrodiagnostic testing| .99| .91| 11.0| .01

Figure 11-27 Infraspinatus test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Infraspinatus test 32  | 2.5 kg of pressure is exerted for 30 seconds on the lateral edge of the infraspinatus muscle between
the tip of the inferior angle of the scapula and the dorsal tip of the acromial angle. Positive if carpal tunnel syndrome symptoms appear or disagreeable local pressure is felt| 34 patients with symptoms of carpal tunnel syndrome| Electrodiagnostic testing| .70| .87| 5.4| .34

#### Diagnostic Utility of Using a Questionnaire in Predicting the Results of Nerve Conduction Tests for Carpal Tunnel Syndrome

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Kamath and Stothard questionnaire 33  | Patients who scored higher than 6 on the questionnaire can be classified as having abnormal nerve conduction tests| 211 patients with symptoms of carpal tunnel syndrome| Electrodiagnostic testing| N/A| .87 (.80 to .93)| N/A| N/A
Patients who scored below 3 on the questionnaire can be classified as having normal nerve conduction tests| .87 (.80 to .94)| N/A

N/A, Not applicable.

#### Reliability of Upper Limb Tension Tests

Test and Measure and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Upper limb tension test A11  | See below| 82 patients with suspected cervical radiculopathy or carpal tunnel syndrome| κ = .76 (.51, 1.0)
Upper limb tension test B11  | κ = .83 (.65, 1.0)

#### Diagnostic Utility of Upper Limb Tension Tests in Identifying Carpal Tunnel Syndrome

Figure 11-28 Upper limb tension test A.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Upper limb tension test A11   (see Video 11-1)| With patient supine, examiner performs scapular depression, shoulder abduction, forearm supination, wrist and finger extension, shoulder lateral rotation, elbow extension, and contralateral/ipsilateral cervical side-bending. Positive if symptoms are reproduced, side-to-side difference in elbow extension is greater than 10 degrees, contralateral neck side-bending increases symptoms, or ipsilateral side-bending decreases symptoms| 82 patients with suspected cervical radiculopathy or carpal tunnel syndrome| Needle electromyography and nerve conduction studies| .75 (.58, .92)| .13 (.04, .22)| .86 (.67, 1.1)| 1.9 (.72, 5.1)
Upper limb tension test B11   (see Video 11-2)| With patient supine with shoulder abducted 30 degrees, examiner performs scapular depression, shoulder medial rotation, full elbow extension, wrist and finger flexion, and contralateral/ipsilateral cervical side-bending. Positive if symptoms are reproduced, side-to-side difference in wrist flexion is more than 10 degrees, contralateral neck side-bending increases symptoms, or ipsilateral side-bending decreases symptoms| .64 (.45, .83)| .30 (.17, .42)| .91 (.65, 1.3)| 1.2 (.62, 2.4)

#### Diagnostic Utility of Special Tests in Identifying Carpal Instability

Figure 11-29 Scaphoid shift test.

Figure 11-30 Ballottement test.

Test and Measure and Study Quality| Description| Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---|---
Scaphoid shift test34  | Patient's elbow is stabilized on table with forearm in slight pronation. With one hand, examiner grasps radial side of patient's wrist with thumb on the palmar prominence of scaphoid. With the other hand, examiner grasps patient's hand at metacarpal level to stabilize wrist. Examiner maintains pressure on scaphoid tubercle and moves patient's wrist into ulnar deviation with slight extension and then radial deviation with slight flexion. Examiner releases pressure on scaphoid while wrist is in radial deviation and flexion| Positive for instability of scaphoid if scaphoid shifts, test elicits a "thunk," or symptoms are reproduced when scaphoid is released| 50 painful wrists undergoing arthroscopy| Arthroscopic visualization| .69| .66| 2.03| .47
Ballottement test34  | Examiner stabilizes patient's lunate bone between thumb and index finger of one hand while other hand moves pisotriquetral complex in a palmar and dorsal direction| Positive for instability of lunotriquetral joint if patient's symptoms are reproduced or excessive laxity of joint is revealed| | | .64| .44| 1.14| .82
Ulnomeniscotriquetral dorsal glide34  | With patient seated with elbow on table and forearm in neutral, examiner places thumb over head of distal ulna. Examiner then places radial side of index proximal IP joint over palmar surface of patient's pisotriquetral complex. Examiner squeezes thumb and index finger together, creating a dorsal glide of pisotriquetral complex| Considered positive for ulnomeniscotriquetral complex instability if the patient's symptoms are reproduced or excessive laxity of the joint is revealed| .66| .64| 1.69| .56

#### Diagnostic Utility of Special Tests in Identifying de Quervain Tenosynovitis

Figure 11-31 Wrist hyperflexion and abduction of the thumb test.

Figure 11-32 Eichhoff test.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Wrist hyperflexion and abduction of the thumb test35   (see Video 11-3)| Patient's wrist is hyperflexed with thumb abducted in
full MCP and IP extension, resisted against the examiner's index
finger. Positive with symptom exacerbation| 104 patients who presented clinically with the symptoms
of de Quervain disease| X-ray and ultrasonography confirmation| .99 (.96, 1.02)| .29 (−.14, .71)| 1.39| .04
Eichhoff test35  | Patient performs ulnar deviation
of the clenched wrist while holding the opposed thumb. Positive with symptom exacerbation| .89 (.81, .97)| .14 (−.19, .47)| 1.04| .75

#### Reliability of Miscellaneous Special Tests

Test and Measure and Study Quality| Description and Positive Findings| Population| Interexaminer Reliability
---|---|---|---
Tethered median nerve test24  | Examiner passively extends patient's index finger while forearm is in supination and wrist is in full extension. Position is maintained for 15 seconds. Positive if symptoms are elicited in distribution of median nerve| 36 hands with carpal tunnel syndrome| κ = .49 (.26, .71)
Pinch test24  | Patient actively pinches a piece of paper between the tip of the thumb, the index finger, and the long fingers using MCP flexion and IP extension. Positive if symptoms are elicited in distribution of median nerve| 36 hands with carpal tunnel syndrome| κ = .76 (.62, .91)

#### Diagnostic Utility of Miscellaneous Special Tests

Figure 11-33 Ulnar fovea sign.

Test and Study Quality| Description and Positive Findings| Population| Reference Standard| Sens| Spec| +LR| −LR
---|---|---|---|---|---|---|---
Flick maneuver29  | Patient is instructed to demonstrate hand motions or positions the patient uses when pain is most severe. Positive if patient demonstrates a flicking down of hands similar to shaking a thermometer| 142 patients referred for electrodiagnostic testing| Carpal tunnel syndrome diagnosed via electrodiagnostic testing| .37 (.27, .46)| .74 (.62, .87)| 1.42| .85
Lumbrical provocation test16  | Patient is instructed to make a fist for 60 seconds. Considered positive if the patient reports paresthesia in the distribution of the median nerve| 96 consecutive patients referred for electrodiagnostic testing| .37| .71| 1.28| .89
Ulnar fovea sign36  | Examiner presses thumb distally and deep into the "soft spot" between the patient's ulnar styloid process and flexor carpi ulnaris tendon. Positive if patient feels exquisite tenderness similar to experienced wrist pain| 272 consecutive patients undergoing wrist arthroscopy| Foveal disruption of the distal radioulnar ligaments and ulnotriquetral ligament injuries observed during arthroscopy| .95 (.90, .98)| .87 (.79, .92)| 7.1 (4.5, 11.0)| .06 (.03, .11)

### Combinations of Tests

#### Carpal Tunnel Syndrome: Clinical Prediction Rule

Wainner and colleagues11 developed a clinical prediction rule for detecting carpal tunnel syndrome. The result of their study demonstrated that if five variables (a Brigham and Women's Hospital Hand Severity Scale score of more than 1.9, a wrist ratio index of more than .67, a patient report of shaking the hand for symptom relief, diminished sensation on the thumb pad, and age over 45 years) were present, the +LR was 18.3 (95% CI: 1.0, 328.3). This clinical prediction rule results in a posttest probability of 90% that the patient has carpal tunnel syndrome.

Figure 11-34 Nomogram representing the change in pretest (34% in this study) to posttest probability given the clinical prediction rule. (From Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975;293:257. Copyright 2005, Massachusetts Medical Society.)

#### Scaphoid Fracture: Clinical Prediction Rule

Duckworth and colleagues37 developed a clinical prediction rule that incorporates demographic and clinical factors predictive of a scaphoid fracture. In the study, 260 patients with a clinically suspected or radiologically confirmed scaphoid fracture were evaluated within 72 hours of injury and at approximately 2 and 6 weeks after injury using clinical assessment and standard radiographs. A logistic regression model identified four variables (male gender, sports injury, anatomic snuffbox pain on ulnar deviation of the wrist within 72 hours of injury, scaphoid tubercle tenderness at 2 weeks) as independent predictors of fracture. The risk of fracture was 91% with these four positive factors. All patients who did not have pain at the anatomic snuffbox on ulnar deviation of the wrist within 72 hours of injury did not have a fracture.

## Outcome Measures

Outcome Measure| Scoring and Interpretation| Test-Retest Reliability and Study Quality| MCID
---|---|---|---
Upper Extremity Functional Index| Users are asked to rate the difficulty of performing 20 functional tasks on a Likert-type scale ranging from 0 (extremely difficult or unable to perform activity) to 4 (no difficulty). A total score out of 80 is calculated by summing each score. The answers provide a score between 0 and 80, with lower scores representing more disability| ICC = .9538  | Unknown (MDC = 9.1)38
Disabilities of the Arm, Shoulder, and Hand (DASH)
2009 Metaanalysis| Users are asked to rate the difficulty of performing 30 functional tasks on a Likert-type scale. Of the items, 21 items relate to physical function, 5 items relate to pain symptoms, and 4 items relate to emotional and social functioning. A total score out of 100 is calculated, with higher scores representing more disability| ICC = .9039| 10.239
Michigan Hand Outcomes Questionnaire (MHQ)| Consists of 37 items on 6 scales: (1) overall hand function, (2) activities of daily living (ADLs), (3) work performance, (4) pain, (5) aesthetics, and (6) satisfaction with hand function. Users rate each item on a 5-point Likert-type scale. Answers provide a total score between 0 and 100, with higher scores indicating better hand performance| ICC = .9540  | Pain = 23
Function = 13
ADL = 11
Work = 841
Numeric Pain Rating Scale (NPRS)| Users rate their level of pain on an 11-point scale ranging from 0 to 10, with high scores representing more pain. Often asked as "current pain" and "least," "worst," and "average pain" in the past 24 hours| ICC = .7242  | 28,9

ICC, Intraclass correlation coefficient; MCID, minimum clinically important difference; MDC, minimal detectable change.

## Appendix

#### Quality Appraisal of Reliability Studies for the Hand Using QAREL

| Mathiowetz 198422| Bohannon 198725| Rheault 198926| Horger 199017| LaStayo 199418| MacDermid 199424| Brown 20003| Stratford 200138| Schreuders 200323| Leard 200428
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| U| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| U| Y| N| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| U| U| U| U| U| Y| Y| N/A| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| U| N| U| N/A| U| N/A| N/A| N/A| Y| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| U| N/A| N/A| N/A| N/A| N/A| Y| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| Y| U| U| U| U| Y

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| Y

8. Was the order of examination varied?

| U| U| U| U| U| U| N| N/A| Y| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| U| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y − N = 9 to 11)   Fair quality (Y − N = 6 to 8)   Poor quality (Y − N ≤ 5).

| Massy-Westropp 200440| Bohannon 20052| Wainner 200511| Coldham 20064| Stam 200619| van den Beld 200620| Li 200742| Molenaar 200821| de Kraker 20097| Calfee 201215
---|---|---|---|---|---|---|---|---|---|---

1. Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied?

| U| Y| Y| Y| Y| Y| Y| Y| Y| Y

2. Was the test performed by raters who were representative of those to whom the authors intended the results to be applied?

| Y| Y| U| Y| N| Y| Y| Y| Y| Y

3. Were raters blinded to the findings of other raters during the study?

| U| U| U| U| U| Y| Y| N/A| Y| Y

4. Were raters blinded to their own prior findings of the test under evaluation?

| U| N| U| N/A| U| N/A| N/A| N/A| Y| N/A

5. Were raters blinded to the results of the reference standard for the target disorder (or variable) being evaluated?

| N/A| N/A| U| N/A| N/A| N/A| N/A| N/A| Y| N/A

6. Were raters blinded to clinical information that was not intended to be provided as part of the testing procedure or study design?

| U| U| U| U| Y| U| U| U| U| Y

7. Were raters blinded to additional cues that were not part of the test?

| U| U| U| U| U| U| U| U| U| Y

8. Was the order of examination varied?

| U| U| U| U| U| U| N| N/A| Y| U

9. Was the time interval between repeated measurements compatible with the stability (or theoretical stability) of the variable being measured?

| Y| Y| U| Y| Y| Y| Y| Y| Y| Y

10. Was the test applied correctly and interpreted appropriately?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

11. Were appropriate statistical measures of agreement used?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear, N/A = not applicable.   Good quality (Y − N = 9 to 11)   Fair quality (Y − N = 6 to 8)   Poor quality (Y − N ≤ 5).

#### Quality Assessment of Diagnostic Studies for the Hand Using QUADAS

| Waeckerle 198713| Katz 199012| LaStayo 199534| Grover 199614| Kuhlman 199727| Fertl 199810| Szabo 199943| Pershad 200044| Karl 200116| Hansen 200429| LaJoie 200530| Wainner 200511| Tay 200736| El Miedany 20081
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| Y| Y| Y| N| N| Y| Y| Y| Y| Y| Y| N

2. Were selection criteria clearly described?

| Y| N| Y| Y| Y| N| N| Y| Y| Y| U| Y| U| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| U| Y| Y| U| Y| Y| Y| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| Y| U| U| Y| Y| U| U| Y| U| Y| Y| Y| U| U

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| Y| Y| Y| N| Y| Y| Y| Y| Y| Y| Y

6. Did patients receive the same reference standard regardless of the index test result?

| Y| Y| Y| Y| Y| Y| N| Y| Y| Y| Y| Y| U| Y

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| N| Y| Y| U| Y| Y| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| Y| Y| Y| Y| Y| Y| Y| Y| N| Y| N| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| Y| Y| U| Y| Y| Y| U| Y| Y| Y| U| U| Y| U

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| N| Y| U| Y| U| U| U| U| U| U| U| Y| U| U

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| Y| Y| U| U| Y| Y| Y| U| U| U| Y| Y| Y

13. Were uninterpretable/ intermediate test results reported?

| U| U| U| U| Y| Y| U| Y| U| U| U| Y| U| U

14. Were withdrawals from the study explained?

| Y| U| U| U| Y| Y| U| Y| U| Y| U| Y| U| U
Quality Summary Rating:|  |  |  |  |  |  |  |  |  |  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y − N = 10 to 14)   Fair quality (Y − N = 5 to 9)   Poor quality (Y − N ≤ 4).

| Amirfeyz 201131| Bridges 201133| Calfee 201215| Meder 201232| Goubau 201435
---|---|---|---|---|---

1. Was the spectrum of patients representative of the patients who will receive the test in practice?

| Y| Y| Y| Y| Y

2. Were selection criteria clearly described?

| Y| Y| Y| Y| Y

3. Is the reference standard likely to correctly classify the target condition?

| Y| Y| Y| Y| Y

4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

| Y| Y| Y| Y| U

5. Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

| Y| Y| Y| U| N

6. Did patients receive the same reference standard regardless of the index test result?

| U| Y| Y| U| N

7. Was the reference standard independent of the index test (i.e., the index test did not form part of the reference standard)?

| Y| Y| Y| Y| Y

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

| Y| Y| Y| Y| Y

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

| Y| Y| Y| Y| Y

10. Were the index test results interpreted without knowledge of the results of the reference test?

| N| Y| Y| Y| Y

11. Were the reference standard results interpreted without knowledge of the results of the index test?

| U| N| U| U| U

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

| U| Y| Y| Y| Y

13. Were uninterpretable/ intermediate test results reported?

| N| U| U| U| N

14. Were withdrawals from the study explained?

| N| U| U| Y| N
Quality Summary Rating:|  |  |  |  |

Y = yes, N = no, U = unclear.   Good quality (Y − N = 10 to 14)   Fair quality (Y − N = 5 to 9)   Poor quality (Y − N ≤ 4).

## References

1. El Miedany Y, Ashour S, Youssef S, et al. Clinical diagnosis of carpal tunnel syndrome: old tests—new concepts. Joint Bone Spine. 2008;75:451–457.

2. Bohannon RW, Schaubert KL. Test-retest reliability of grip-strength measures obtained over a 12-week interval from community-dwelling elders. J Hand Ther. 2005;18:426–427 [quiz 428].

3. Brown A, Cramer LD, Eckhaus D, et al. Validity and reliability of the Dexter hand evaluation and therapy system in hand-injured patients. J Hand Ther. 2000;13:37–45.

4. Coldham F, Lewis J, Lee H. The reliability of one vs. three grip trials in symptomatic and asymptomatic subjects. J Hand Ther. 2006;19:318–326 [quiz 327].

5. Cole IC. Fractures and ligament injuries of the wrist and hand. The Wrist and Hand. Orthopaedic Section, American Physical Therapy Association: La Crosse, Wisconsin; 1995.

6. D'Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome? JAMA. 2000;283:3110–3117.

7. de Kraker M, Selles RW, Schreuders TA, et al. Palmar abduction: reliability of 6 measurement methods in healthy adults. J Hand Surg [Am]. 2009;34:523–530.

8. Farrar JT, Berlin JA, Strom BL. Clinically important changes in acute pain outcome measures: a validation study. J Pain Symptom Manage. 2003;25:406–411.

9. Farrar JT, Portenoy RK, Berlin JA, et al. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287–294.

10. Fertl E, Wober C, Zeitlhofer J. The serial use of two provocative tests in the clinical diagnosis of carpal tunnel syndrome. Acta Neurol Scand. 1998;98:328–332.

11. Wainner RS, Fritz JM, Irrgang JJ, et al. Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Arch Phys Med Rehabil. 2005;86:609–618.

12. Katz JN, Larson MG, Sabra A, et al. The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings. Ann Intern Med. 1990;112:321–327.

13. Waeckerle JF. A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures. Ann Emerg Med. 1987;16:733–737.

14. Grover R. Clinical assessment of scaphoid injuries and the detection of fractures. J Hand Surg [Br]. 1996;21:341–343.

15. Calfee RP, Dale AM, Ryan D, et al. Performance of simplified scoring systems for hand diagrams in carpal tunnel syndrome screening. J Hand Surg [Am]. 2012;37(1):10–17.

16. Karl AI, Carney ML, Kaul MP. The lumbrical provocation test in subjects with median inclusive paresthesia. Arch Phys Med Rehabil. 2001;82:935–937.

17. Horger MM. The reliability of goniometric measurements of active and passive wrist motions. Am J Occup Ther. 1990;44:342–348.

18. LaStayo PC, Wheeler DL. Reliability of passive wrist flexion and extension goniometric measurements: a multicenter study. Phys Ther. 1994;74:162–174 [discussion 174-176].

19. Stam HJ, Ardon MS, den Ouden AC, et al. The compangle: a new goniometer for joint angle measurements of the hand. A technical note. Eura Medicophys. 2006;42:37–40.

20. van den Beld WA, van der Sanden GA, Sengers RC, et al. Validity and reproducibility of hand-held dynamometry in children aged 4-11 years. J Rehabil Med. 2006;38:57–64.

21. Molenaar HM, Zuidam JM, Selles RW, et al. Age-specific reliability of two grip-strength dynamometers when used by children. J Bone Joint Surg Am. 2008;90:1053–1059.

22. Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations. J Hand Surg [Am]. 1984;9:222–226.

23. Schreuders TA, Roebroeck ME, Goumans J, et al. Measurement error in grip and pinch force measurements in patients with hand injuries. Phys Ther. 2003;83:806–815.

24. MacDermid JC, Kramer JF, Woodbury MG, et al. Interrater reliability of pinch and grip strength measurements in patients with cumulative trauma disorders. J Hand Ther. 1994;7:10–14.

25. Bohannon RW, Andrews AW. Interrater reliability of hand-held dynamometry. Phys Ther. 1987;67:931–933.

26. Rheault W, Beal JL, Kubik KR, et al. Intertester reliability of the hand-held dynamometer for wrist flexion and extension. Arch Phys Med Rehabil. 1989;70:907–910.

27. Kuhlman KA, Hennessey WJ. Sensitivity and specificity of carpal tunnel syndrome signs. Am J Phys Med Rehabil. 1997;76:451–457.

28. Leard JS, Breglio L, Fraga L, et al. Reliability and concurrent validity of the figure-of-eight method of measuring hand size in patients with hand pathology. J Orthop Sports Phys Ther. 2004;34:335–340.

29. Hansen PA, Micklesen P, Robinson LR. Clinical utility of the flick maneuver in diagnosing carpal tunnel syndrome. Am J Phys Med Rehabil. 2004;83:363–367.

30. LaJoie AS, McCabe SJ, Thomas B, Edgell SE. Determining the sensitivity and specificity of common diagnostic tests for carpal tunnel syndrome using latent class analysis. Plast Reconstr Surg. 2005;116:502–507.

31. Amirfeyz R, Clark D, Parsons B, et al. Clinical tests for carpal tunnel syndrome in contemporary practice. Arch Orthop Trauma Surg. 2011;131(4):471–474.

32. Meder MA, Lange R, Amtage F, Rijntjes M. Proximal stimulus confirms carpal tunnel syndrome—a new test? A clinical and electrophysiologic, multiple-blind, controlled study. J Clin Neurophysiol. 2012;29(1):89–95.

33. Bridges MJ, Robertson DC, Chuck AJ. Predicting the result of nerve conduction tests in carpal tunnel syndrome using a questionnaire. Hand Surg. 2011;16(1):39–42.

34. LaStayo P, Howell J. Clinical provocative tests used in evaluating wrist pain: a descriptive study. J Hand Ther. 1995;8:10–17.

35. Goubau JF, Goubau L, Van Tongel A, et al. The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff's test. J Hand Surg Eur Vol.2014;39(3):286–292.

36. Tay SC, Tomita K, Berger RA. The "ulnar fovea sign" for defining ulnar wrist pain: an analysis of sensitivity and specificity. J Hand Surg [Am]. 2007;32:438–444.

37. Duckworth AD, Buijze GA, Moran M, et al. Predictors of fracture following suspected injury to the scaphoid. J Bone Joint Surg Br. 2012;94(7):961–968.

38. Stratford PW, Binkley JM, Stratford DM. Development and initial validation of the upper extremity functional index. Physiotherapy Canada.2001;53(4):259–267.

39. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum. 2009;61:623–632.

40. Massy-Westropp N, Krishnan J, Ahern M. Comparing the AUSCAN Osteoarthritis Hand Index, Michigan Hand Outcomes Questionnaire, and Sequential Occupational Dexterity Assessment for patients with rheumatoid arthritis. J Rheumatol. 2004;31:1996–2001.

41. Shauver MJ, Chung KC. The minimal clinically important difference of the Michigan hand outcomes questionnaire. J Hand Surg [Am]. 2009;34:509–514.

42. Li L, Liu X, Herr K. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Pain Med. 2007;8:223–234.

43. Szabo RM, Slater RRJ, Farver TB, et al. The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg [Am]. 1999;24:704–714.

44. Pershad J, Monroe K, King W, et al. Can clinical parameters predict fractures in acute pediatric wrist injuries? Acad Emerg Med.2000;7:1152–1155.

# Index

Page numbers followed by "f" indicate figures, and "t" indicate tables.

A

A angle, in knee, , 359f, 359t

Abdomen, bony framework of, 225f

Abdominal endurance test, 177t

Abdominal wall muscles, anterior,

Abduction strength, of hip and pelvis, length assessment with, 295t-296t

Abduction/abduction test

of hand, 581t

of hip. _See_ Hip abduction

of palm, 581t

of sacroiliac joint, 260t

of shoulder. _See_ Shoulder abduction/abduction tests

of thumb, for carpal tunnel syndrome, 584t

Abductor digiti minimi brevis tendon, 406f

Abductor digiti minimi muscle

in foot, 410f, 412f-415f, 412t, 417f

nerve to, 413f, 417f

in hand, 567t, 568f

innervation of, 570f

Abductor hallucis brevis tendon, 406f

Abductor hallucis longus muscle, 412t

Abductor hallucis muscle, 410f, 413f-414f, 417f

insertion of, 415f

Abductor hallucis nerve, 417f

Abductor hallucis tendon, 413f

Abductor pollicis brevis muscle, 567t, 568f

innervation of, 569f

manual muscle testing of,

manual testing of, for cervical radiculopathy, 92t

Abductor pollicis longus muscle, 533f, 563f, 563t-564t

area on radius for, 532f

innervation of, 571f

Abductor pollicis longus tendon, 536f

insertion of, 559f

AC joint. _See_ Acromioclavicular (AC) joint

Accuracy, of diagnostic test, 2-8, 11t

Acetabular fossa, fat in, 279f

Acetabular labrum, 279f

Acetabular ligament, transverse, 279f

Acetabular notch, 227f, 277f

Acetabulum, 227f, 277f

advanced degenerative changes in, 290f

lunate surface of, 227f, 277f

margin (limbus) of, 227f, 230f, 277f

Achilles reflex, with lumbar spinal stenosis, 172t

Achilles tendon

calcaneal, 403f-404f, 408f-409f

neurological examination of, 170t

palpation of, 433t

in physical examination, 431t

subcutaneous tears of, , 433f, 433t

rheumatoid arthritis involvement of, 432f

rupture of, 418t

Achilles tendonitis, 418t

ACL. _See_ Anterior cruciate ligament (ACL)

Acromial angle, of scapula, 451f-452f

Acromial branch, of thoracoacromial artery, 460f

Acromial end, of clavicle, 451f

Acromial facet, of clavicle, 451f

Acromioclavicular (AC) joint, 452t, 455f, 458f

capsule of, 454f, 454t

integrated movements of, , 453f

lesions of, tests for, , 510f, 510t

palpation of, 510t

sprains of, 461t

Acromioclavicular ligament, 454f

Acromioclavicular syndrome, 472t

Acromion, 451f-452f, 454f-458f, 460f

in physical examination, 466t, 470t

Acronyms

SnNout, , 5f

SpPin, , 6f

Activity modification, 380-381, 380f, 381t

Activity of Daily Living Scale (ADLS), in knee outcomes, 384t

Adduction angle, of hip, 301t

Adduction stress, of knee

end feel with, 348t

pain during, 349t

Adductor brevis muscle, 333f

Adductor hallucis brevis tendon, 406f

Adductor hallucis muscle, 417f

insertion of, 415f

oblique head of, 414f, 414t

transverse head of, 414f, 414t

Adductor hiatus, 285f, 333f

Adductor longus muscle, 283f, 285f, 333f

Adductor magnus muscle, 281f, 285f, 333f

obturator nerve to, 335f

Adductor magnus tendon, 285f, 328f, 332f

Adductor minimus muscle, 281f

Adductor pollicis muscle, 567t, 568f

innervation of, 570f

oblique head of, 567t

transverse head of, 567t

Adductor tubercle, of femur, 325f

on medial epicondyle, 285f, 327f

Adhesions

in shoulder joint, 472f

in temporomandibular joint arthrosis, 29f

Adhesive capsulitis, of shoulder, 461t, 472f, 472t, , 511f, 511t

ADLS. _See_ Activity of Daily Living Scale (ADLS)

Afferent nerves, somatic, lumbar disc herniation and, 195f

Ala (wing)

of ilium, 225f-226f, 277f-278f

gluteal surface of, 227f

iliac fossa, 227f, 277f

of sphenoid bone, greater, 17f

Alar ligament, 74f, 74t

Algometer, for TMJ pressure pain thresholds, 39t

Alignment assessment

of bones. _See_ Bony alignment assessment

dynamic. _See_ Dynamic movements

static. _See_ Static alignment

Alveolar artery, inferior, 23f

Alveolar nerve, inferior, 19f, 21f, 23f-24f

entering mandibular foramen, 24f

Alveolar process, of maxilla, 17f, 71f

American Orthopaedic Foot and Ankle Society (AOFAS) scales, 441t

American Shoulder and Elbow Surgeons (ASES) score, for shoulder outcomes, 515t

Anal (rectal) nerve, inferior, 162f, 284f

Anconeus muscle, 533f, 533t

innervation of, 571f

Anesthetic injection, for sacroiliac pain, 236t, 238t

double-block, referral patterns, 237f

motion assessment and, 254t-256t

provocation test and, 242t, 244t-246t, 248t-250t

Anesthetic-steroid injection, for intraarticular hip pain, 308t, 310t

Angle between longitudinal axis of patella and patellar tendon (A angle), , 359f, 359t

Ankle, 397-448. _See also_ Foot and ankle

anterolateral impingement in,

detection of, , 436f, 436t

pain in. _See_ Foot and ankle pain

trauma to

fractures as, 420t

patient report of, 418t

screening for, 419-440

x-rays of. _See_ Ottawa Ankle Rule for Radiography.

Ankle flexibility angle, 423f

Ankle-hindfoot, AOFAS scale for, 441t

Ankylosing spondylitis

pain provocation and, 241t, 243t, 245t, 252t

of thoracolumbar spine, 204t

patient history in, , 169f

tests for, diagnostic utility of, , 204t

Annular ligament, of radius, 531f, 531t

Annulus fibrosus, of lumbar intervertebral disc, 149f

fissure in, 195f

nociceptors in, disc herniation and, 195f

ossification of, in ankylosing spondylitis, 169f

Anococcygeal nerve, 162f, 233t, 234f

Anserine bursa, 331f-332f

Anterior apprehension test, of shoulder, 474t

combined with other tests, 512t-513t

Anterior cruciate ligament (ACL), 327f, 327t, 329f

degrees of sprain of, 367f

ruptures of, 336f, 336t

tears of, , 364t-366t

combinations of tests for, 379t

pivot shift test for, , 367f, 367t

Anterior disc displacement, in TMJ disorders

deviations of, , 48t, 50f

diagnostic criteria for, 47t

patient history, 27-28, 27f, 47-48, 56-57

range of motion in, , 47t

with reduction, 56-57, 56f

without reduction, 58-59, 58f

Anterior drawer test

of ankle, 437t, 438f

of knee, , , 365f, 365t-366t

of shoulder, , 476f, 476t

Anterior relocation test, of shoulder, 475t

Anterior slide test, for glenoid labral tears, , 485f, 485t

combined with other tests, 512t

Anterior superior iliac spine (ASIS)

as sacroiliac bony landmark, 239t

in sacroiliac pain provocation, 242t, 250t

Anterior temporalis muscle, pressure pain thresholds of, 39t

Anterior view

of axis, 72f

of carpal bones, 557f

of cervical spine arthrology, 73f

of cervical spine ligaments, 75f

of elbow bones, in extension, 529f

of elbow joint, opened, 530f

of elbow ligaments, 531f

of female pelvic inlet, 228f

of female pelvis, 228f

of femur, 277f

of fibular nerves, 416f, 416t

of forearm ligaments, 532f

of forearm nerves, 536f

of hand nerves, 569f-570f

of hip and pelvis ligaments, 279f

of humerus, 451f

of knee muscles, 331f

of male pelvic inlet, 228f

of male pelvis, 228f

of metacarpophalangeal and interphalangeal ligaments, 562f, 562t

of muscles of thigh, 283f

of nerves and arteries of thigh, 285f

of rotator cuff muscles, 458f

of sacroiliac region ligaments, 230f

of scapula, 451f

of shoulder ligaments, 454f

of shoulder muscles, , 457f, 457t

of sternocostal articulations, 150f

of tibia and fibula, 325f

of tibial nerves, 416f, 416t

of wrist and digit muscles, 565f, 567f-568f

of wrist and hand bones, 558f

Anteroinferior view, of mouth floor muscles, 23f

Anteroposterior diameter, of pelvic outlet, 228f

Anteroposterior glide, for hip mobilization, 383f

Anteroposterior width, of wrist, 585t

in carpal tunnel syndrome, 585t

Anthropometry, of wrist, , 585t

carpal tunnel syndrome identification with, , 585t

AOFAS (American Orthopaedic Foot and Ankle Society) scales, 441t

Apical ligament, 74f, 74t

Apley grinding test, of knee, , 371f, 371t

combined with other tests, 376t-377t

Aponeuroses

epicranial, 81f

gluteal, 155f

gluteus, 281f

palmar, 565f

plantar, 412f-414f

Apophyseal joints

of cervical spine,

lumbar, ossification of, 169f

lumbosacral, 229t

Apprehension test

moving patellar, , , 375f, 375t

of shoulder, , 474f, 474t

anterior, 474t

combined with other tests, , 512t

bony, 474t

relocation, 475t

Arc of pain sign, 504t

Arch angle, measurement of, 426f, 426t

Arch drop, longitudinal, 432f

Arch height test, medial, 426t

Arcuate artery, 410f, 415f

posterior perforating branches of, 415f

Arcuate line, 225f, 227f, 230f, 277f-278f

Arteries. _See also_ specific arteries

of hand, 568f

of hip and pelvis, 285f

of neck, 75f-76f, 78f-79f, 81f

of sacroiliac region, 234f

of shoulder, 457f, 460f

of sole of foot, 415f

of thigh, 285f

Arthralgia, in TMJ disorders,

Arthrology

of cervical spine,

of elbow,

of foot and ankle,

of hand,

of hip and pelvis,

of knee,

of lumbar spine,

of sacroiliac region, , 229f, 229t

of shoulder,

of temporomandibular joint,

jaws closed, 18f

jaws slightly opened, 18f

jaws widely opened, 18f

of thoracic spine, 150-152

first, 152t

joint classifications, 152t

second to seventh, 152t

Arthroscopic view, of anterior cruciate ligament rupture, 336f

Arthroscopy

physical examination vs., 474t-475t

of shoulder

combined with other tests, 512t-513t

IRRS test following,

physical examination vs., 469t, 478t

Articular cartilage

in elbow,

of hip and pelvis, 279f

erosion, 290f

in knee, 326f

erosion of, 337f

Articular cavities

of knee, 326f

of sternoclavicular joint, 452f

sternocostal, 150f

Articular discs

of mandible, 18f

of sternoclavicular joint, 452f

of temporomandibular joint, 20f

Articular facets

of atlas

for dens, 72f

posterior, 73f

of axis

anterior, for atlas, 72f

inferior, for C3, 72f

posterior, for atlas, 72f

superior, for atlas, 72f

of dens, posterior, 74f

of lumbar vertebrae

inferior, 154f

in physical examination, 183t

superior, 154f

of rib head, superior, 151f, 153f

for sacrum, 152f, 226f

of thoracic vertebrae

inferior, 149f, 154f

superior, 149f-150f

Articular nerve, recurrent, 416f

articular branches of, 417f

Articular pillar, of cervical vertebrae, 73f

Articular process

of axis, inferior, 72f

of cervical vertebrae, 73f

of lumbar vertebrae

inferior, 152f

superior, 149f, 152f

of sacrum, 226f

facets of, 226f

of T9 vertebra, inferior, 150f

of thoracic vertebrae, inferior vs. superior, 149f-150f, 154f

Articular surfaces

of acetabulum, 279f

of atlas

inferior, lateral mass of, 72f

superior, for occipital condyle, 73f

of femur, medial and lateral, 327f, 329f

of sacrum, 226f

of tibia, superior, 325f, 329f

Articular tubercles

of mandible, 21f

of temporal bone, 17f

of temporomandibular joint, 18f

Articularis genus muscle, 326f, 330t, 334f

Articulations. _See_ Joints; specific articulations

ASES (American Shoulder and Elbow Surgeons) score, for shoulder outcomes, 515t

ASIS. _See_ Anterior superior iliac spine (ASIS)

Atlantoaxial joints,

instability of, 121t

lateral, capsule of, 74f-75f

Atlanto-occipital joint

arthrology of,

capsule of, 74f-75f

ligaments of, 74f, 74t

Atlanto-occipital membrane, anterior and posterior, 75f

Atlantoodontoid/dens joint,

Atlas (C1)

anterior arch of, 72f

arthrology of, 73f

groove for vertebral artery on, 72f

ligaments of, 74f-75f, 74t

nerves of, dorsal ramus of, 75f, 81f

osteology of

articular facet of axis for

anterior, 72f

posterior, 72f

superior, 72f

in head and neck, 71f

inferior view of, 72f

in relation to head and neck, 15f

superior view of, 72f

palpation of, 109t

posterior arch of, 72f, 81f

rotation testing of, 103f, 103t

limited and painful passive, 104t

transverse process of, 72f, 75f, 79f, 157f

tubercles of

anterior, 72f

posterior, 72f, 156f-157f

for transverse ligament, 72f

in zygapophyseal pain referral pattern, 85f

Atrophy. _See_ Muscle atrophy

Auditory (pharyngotympanic) tube, cartilaginous part of, 21f

Auricular artery, posterior, 81f

Auricular nerve

great, 81f

posterior, 24f

Auricular surface, of hip bone, for sacrum, 227f, 277f

Auriculotemporal nerve, 19f, 21f, 24f

Auscultation

performed with stethoscope, 41f

triangle of, in shoulder, 456t

Avascular necrosis, of hip and pelvis

detection with limited ROM, , 293f, 293t

patient history in, 286t

Avulsions

humeral, of glenohumeral ligaments, , 474t-476t

nerve root, of brachial plexus,

Axillary nerve, 82t, 83f, 458f, 458t, 569f

anterior, 459t, 460f

to arm, 571f

in brachial plexus schema, 509f

Axillary recess, 455f

Axis (C2)

arthrology of, 73f

congenital fusion of, 107t

interarticular part of, 72f

ligaments of, 74f-75f

limited and painful passive motion of, 104t-105t

nerves of, 456t

dorsal ramus of, 81f

osteology of

anterior view of, 72f

posterosuperior view of, 72f

in relation to head and neck, 15f, 71f

palpation of, 109t

rotation testing of, 103f, 103t

spinous process of, 72f, 155f, 157f

transverse process of, 72f

posterior tubercle of, 79f

in upper limb dermatomes, 89f

in zygapophyseal pain referral pattern, 84f-85f

B

Babinski sign, cervical myelopathy and, 124t-125t

Back muscles

deep layer of, , 157f, 157t

intermediate layer of, , 156f, 156t

superficial layer of, , 155f, 155t

Back pain

cervical. _See_ Cervical (neck) pain

lumbar. _See_ Low back pain

patient history in, 287t

sacral. _See_ Sacroiliac pain

thoracic. _See_ Thoracolumbar pain

Balance assessment/tests

foot and ankle in, , 428t

reliability of, , 314t

single leg, 428t

for pelvic pain, 307t

Ballottement test, 599f, 599t-600t

for knee joint effusion, 345t

Bankart lesion, of shoulder, 474t

Basilic vein, 460f

Bear-hug test, for subscapularis tears, , 506f, 506t

Belly-off sign, for subscapularis tears, 507t

Belly-press test, for subscapularis tears, , 505t-506t, 506f

modified, 507t

Bend/bending tests. _See also_ Lateral bending; Side bending

of cervical spine, 98t-100t

of knee, prone, , 260f, 260t

of thoracolumbar spine, 166t

forward vs. lateral, 173t-174t

Bent knee fall-out test, 180t, 303t

Bernese ankle rules, 420t

Biceps brachii muscle, 460f, 534f

long head of, 457f-458f, 534t

manual testing of, 91f

for cervical radiculopathy, 92t

muscle stretch reflex testing of, 93f

for cervical radiculopathy, 93t

palpation, 469t

short head of, 457f, 534t

tendonitis of, 461t

Biceps brachii tendon, 531f, 534f, 536f

long head of, 454f-455f

oblique cord of, 531f

tears of, 478t

Biceps crease interval test, 545t-546t, 547f

Biceps femoris muscle, 408f, 416f

long head of, 280t, 281f, 284f, 330t, 332f, 335f, 408f

tendon of, 230f

short head of, 280t, 281f, 330t, 332f, 335f, 408f

Biceps femoris tendon, 408f-409f, 416f

and bursa beneath it, 328f

and inferior subtendinous bursa, 332f

Biceps load test I/II, for glenoid labral tears, , , 487f, 487t

combined with other tests, , 512t-513t

Biceps squeeze test, 545t-546t

Bicipital aponeurosis flex test, 545t-546t, 547f

Bicipital groove, tenderness of, 469t, 480t

Biering-Sorensen test, modified, of thoracolumbar spine, 177f, 177t

Bifurcate ligaments, 403f, 403t

Bigelow, Y ligament of, 279f

Blunt trauma

clinical examination for, 95t

to head/neck, Glasgow Coma Score with, , 91t, 99t, 108t

Bohler test, for meniscal tears, 376t-377t

Bone anatomy. _See_ Osteology

Bone spurs

on acetabulum margins, 290f

on metatarsals, 432f

Bone tenderness

in foot and ankle

impingement sign with, 436t

patient report of, 418t

with trauma screening, 419t-420t

in knee, with trauma screening, 341f, 341t

Bony alignment assessment

in foot and ankle

forefoot position, , 427f, 427t

medial arch height, , 426f, 426t

navicular height, , 425f, 425t

in knee, 352-359

A angle measurement, , 359f, 359t

lateral pull test, , 359t

mediolateral patellar tilt, , 352f, 352t

patellar orientation, 353-354, 353f, 353t-354t

patellar rotation, , 356f, 356t

quadriceps angle measurements, , 358f, 358t

superoinferior patellar tilt, , 355f, 355t

Bony apprehension test, of shoulder, 474t

Bony injury, elbow, indication of, , 541t

Bony landmark symmetry, in sacroiliac region

motion assessment and, 254t

palpation for, , 239t, 240f

Boots, sacroiliac pain aggravated by, 236t

Bowel movements, sacroiliac pain aggravated by, 236t

Brachial artery, 460f, 534f, 536f

branches of, 533f

Brachial plexus, 79f, 460f

compression of, for cervical cord compression diagnosis, , 123f, 123t

medial, posterior, and lateral cords of, 569f

nerve root avulsions of,

palpation of, 109t

schema of, 509f

Brachial plexus palsy, , 509t

Brachial veins, 460f

Brachialis muscle, 460f, 534f, 534t, 536f

insertion of, 531f

Brachioradialis muscle, 533f-534f

innervation of, 571f

muscle stretch reflex testing of, 93t

Brachioradialis tendon, 536f

Brevis muscle, 282t

Buccal nerve, , 24f

Buccinator muscle, 20f-21f, 24f, 36f

Bucket handle tear, of meniscus, 378f

Bunions, 432f

Bursa

beneath biceps femoris tendon, 328f

iliopectineal, 279f

of olecranon, subcutaneous, 531f

radial, in carpal tunnel syndrome, 574f

subdeltoid, 455f

subtendinous. _See_ Subtendinous (deep) bursa

ulnar, in carpal tunnel syndrome, 574f

Bursitis

ischial, 286t

in shoulder, 461t, 472t

"Burst" fracture, of cervical spine, 94f

Buttocks

falling and landing on, 235f

nerves of, 284f

pain in. _See_ Gluteal (buttock) pain

C

C0 vertebra, limited and painful passive intervertebral motion, 104t-105t

C1 vertebra. _See_ Atlas (C1)

C2 vertebra. _See_ Axis (C2)

C3 vertebra

arthrology of, 73f

congenital fusion of, 107t

nerves of, 456t

dorsal ramus of, 81f

osteology of, in relation to head and neck, 15f, 71f

palpation of, 109t

passive intervertebral motion of, 103t-105t

transverse process of, tubercles of, anterior and posterior, 79f

in upper limb dermatomes, 89f

in zygapophyseal pain referral pattern, 84f-85f

C4 vertebra

arthrology of, 73f

groove for spinal nerve on, 72f

limited and painful passive intervertebral motion of, 104t-105t

nerves of, 82t, 83f, 456t, 458t

dorsal rami of, posterior cutaneous branches of, 81f

osteology of, superior view of, 72f

palpation of, 109t

transverse process of, 72f

tubercle of, anterior and posterior, 72f

in upper limb dermatomes, 89f

in zygapophyseal pain referral pattern, 84f-85f

C5 vertebra

arthrology of, 73f

congenital fusion of, 107t

limited and painful passive intervertebral motion of, 104t-105t

nerves of, 82t, 83f, 456t, 458t, 534t-536t, 571t

brachial plexus schema, 509f

dorsal rami of, posterior cutaneous branches of, 81f

palpation of, 109t

type III fracture of, 94f

in upper limb dermatomes, 89f, 90t

in zygapophyseal pain referral pattern, 84f-85f

C6 vertebra

arthrology of, 73f

congenital fusion of, 107t

limited and painful passive intervertebral motion of, 104t-105t

nerves of, 82t, 83f, 456t, 458t, 533t-536t, 563t-566t, 571t

brachial plexus schema, 509f

dorsal rami of, posterior cutaneous branches of, 81f

palpation of, 109t

tubercle of, anterior, 75f

type IV fracture of, 94f

in upper limb dermatomes, 89f, 90t

in zygapophyseal pain referral pattern, 84f-85f

C7 vertebra

arthrology of, 73f

groove for spinal nerve on, 72f

limited and painful passive intervertebral motion of, 104t-105t

nerves of, 82t, 83f, 456t, 533t, 535t-536t, 563t-566t, 570t-571t

brachial plexus schema, 509f

osteology of

in relation to head and neck, 15f, 71f

superior view of, 72f

palpation of, 109t

spinous process of, 75f, 155f-157f, 456f

in thoracic kyphosis, 110t, 178t

transverse process of, 72f, 79f

tubercle of, anterior and posterior, 72f

in upper limb dermatomes, 89f, 90t

in zygapophyseal pain referral pattern, 84f-85f

C8 vertebra

nerves of, 82t, 83f, 456t, 533t, 535t, 563t-566t, 570t-571t

brachial plexus schema, 509f

in thoracic kyphosis, 178t

in upper limb dermatomes, 89f, 90t

Calcaneal artery, lateral vs. medial, 413f-414f

Calcaneal nerve, lateral vs. medial, 413f-414f

Calcaneal stance, relaxed vs. neutral measurement of, 423f, 423t

Calcaneal tendon, 403f-404f, 409f

nodules over, 432f

rheumatoid arthritis involvement of, 432f

Calcaneocuboid joint, 401f, 401t

Calcaneocuboid ligament, 403f, 403t, 415f

dorsal, 403f

plantar, 405t, 406f

Calcaneofibular ligament

in ankle joint, 402f-403f

anterior, tears of, 438f

Calcaneonavicular ligament

in ankle joint, 403f, 403t

plantar, 404f, 404t, 406f, 415f

Calcaneus, 399f, 406f

body of, 399f-400f

erosion of, 432f

fibular trochlea of, 399f

groove for fibularis longus tendon on, 399f

groove for flexor hallucis longus tendon on, 399f

lateral process of, 400f, 406f, 412f

medial process of, 400f, 406f, 412f

tuberosity of, 399f-400f, 406f, 412f-414f

Calcar, of femur, 277f

Calf pain, 164t, 171f

Calf strength,

Calf stretch position, for ankle dorsiflexion measurement, 422t

Calipers, wrist anthropometry, 585t

Callouses, on metatarsals, 432f

Canadian C-Spine Rule (CCR), , 95t, 96f

Canal of Guyon, ulnar nerve compression at, 572t

Capitate, 557f-561f

in carpal tunnel syndrome, 574f

in scaphoid fractures, 577f

Capitotriquetral ligament, 560f, 560t

Capitulum, of humerus, 451f, 529f

Capsular ligaments

of knee, rupture of, 340f

of shoulder, 455f

Capsular syndrome, of shoulder, 472t

Capsule. _See_ Joint capsule(s)

Capsulitis, adhesive, of shoulder, 461t, 472f, 472t

Carotid artery

common, 79f

external, 76f, 78f

Carotid sheath, 76f

Carotid tubercle, 75f

Carpal arterial arch, palmar, 568f

Carpal bones

in carpal tunnel syndrome, 574f

of hand, 557f-558f

instability of, patient history in, 572t

Carpal compression test, , 595t

in carpal tunnel syndrome, 595-596, 595f, 595t-596t

Carpal instability, 599-600, 599f, 599t-600t

Carpal ligaments

instability of. _See_ Carpal bones

palmar, 534f

transverse, 534f, 560t, 568f

Carpal tunnel syndrome

carpal bones in, 574f

clinical prediction rule for,

clusters of tests for, 129t

diminished sensation in, 587t, 588f

hand symptom diagrams in identifying, 576t-577t

neck distraction test for, 115t

neurologic examination for, 92t

patient history in, 86t, 88t, 572t-573t

physical examination for, hand in,

shoulder abduction test for, 117t

Spurling's test for, 113t-114t

thumb pad sensation testing for,

weakness with, testing for, 584t

Carpometacarpal (CMC) joint, 559f, 559t

1st, capsule of, 561f

articular capsule of, 560f

Carpometacarpal ligament

dorsal, 561f, 561t

palmar, 560f, 560t, 562f

Cartilage. _See_ specific cartilages

Catching, in shoulder, 462t

Caudal glide, for hip mobilization, 383f

CCR (Canadian C-Spine Rule), , 95t, 96f

Centralization phenomenon, 148t

cervical pain and, 100t

in lumbar pain

diagnostic utility of, , 190f, 190t

patient history in, 163t

reliability of, , 189t

Cephalic vein, 457f, 460f

Cervical artery, transverse, 460f

Cervical curvature, 73f

Cervical fascia, deep

investing layer of, 76f

pretracheal layer of, 76f

Cervical flexor endurance test, 102f, 102t

Cervical fusion, congenital, 107t

Cervical manipulation, for cervical radiculopathy, , 131f, 131t

Cervical myelography, 108t, 115t, 117t,

Cervical (neck) pain,

during active physiologic range of motion, , 101f, 101t

interventions for, 131t

during limited passive intervertebral motion, 104-105, 104t-105t, 105f

mechanical, 84t, 86t, 98t, 100t, 110t-111t

postural assessment for, 178t

patient reports of, 84t

physical examination for, 98t-100t

radiculopathy and, 84t, 86t-88t, 87f

thoracic manipulation for,

zygapophyseal referral patterns of

Cooper description of, 85f

diagnostic nerve block for, 107t

Dwyer description of, 84f

Cervical plexus, 81f

Cervical radiculopathy,

interventions for, 130-137

cervical manipulation for immediate improvement, , 131f, 131t

identifying factors of positive short-term clinical outcome, , 130t

mechanical traction as, 135-136, 135t-137t, 137f

thoracic manipulation for immediate improvement, , 132t-133t, 134f

patient history in, , 572t

physical examination for, 70t, , 90t-93t, 91f, 93f

clusters of tests for, , 129f, 129t
tension tests in. _See_ Upper limb tension tests (ULTTs)

of wrist, 585t

range of motion measurements for, 98t

screening for,

Cervical range-of-motion (CROM) instrument, 99t

Cervical spine, 69-146

arthrology of,

clinical summary and recommendations for,

diagnostic utility of examination of

arm squeeze test, , 122t

brachial plexus compression, , 123f, 123t

for cervical myelopathy, 125-127, 125t, 126f

clusters of tests, , 128t-129t, 129f

limited and painful passive intervertebral motion, , 107f, 107t

manual muscle testing, , 92t

muscle stretch reflex testing, , 93f, 93t

neural tension tests, , 120t

pain during active physiologic range of motion, , 101f, 101t

palpation assessment of pain, , 109t

passive mobility, , 106t

patient history, 87-88, 87t-88t

pinprick sensation testing, , 90t

radiography, 95t, 96f

Sharp-Purser test, , 121f, 121t

Spurling's test, 113-114, 113f, 113t-114t

fractures of, 94f, 95t

injury screening for, 94-96

interarticular parts of, 73f

interventions for, , 130-137. _See also_ Cervical (neck) pain; Cervical radiculopathy

ligaments of, 72f-73f

atlantooccipital joint, 74-75, 74f, 74t

spinal, 75f, 75t

muscles of, 76-80, 76f

anterior,

posterior,

scalene and prevertebral,

suprahyoid and infrahyoid,

nerves of, , 82t, 83f

anterior vs. posterior divisions of, 83f

brachial plexus schema, 509f

cords of, 83f

terminal branches of, 83f

neurologic examination of, 89-93

osteology of,

in head and neck, 71f

vertebral, 72f

outcome measures of, , 138t

patient history and, ,

initial hypotheses based on, , 84t

report of pain in, 84t

physical examination of, 70t, 89-137

radiography for trauma in,

quality appraisal of reliability studies for, 139-141, 139t-141t

quality assessment of diagnostic studies for, 142-144, 142t-144t

range-of-motion of,

limited passive intervertebral, , 103f, 103t-104t

measurements of, 97-101, 97f, 98t-100t

pain during, , 101f, 101t

reliability of examination for

arm squeeze test, , 122f, 122t

cervical myelopathy, , 124t

compression tests, , 112f, 112t

flexion-rotation test, , 116t

limited and painful passive intervertebral motion, 104-105, 104t-105t, 105f

limited passive intervertebral motion, , 103f, 103t

manual muscle testing, , 91f, 91t

muscle length assessment, , 111f, 111t

neck distraction test, , 115f, 115t

neural tension tests, , 119f

pain during active physiologic range of motion in,

palpation assessment of pain, , 108t-109t

passive mobility, , 106t

patient history in, , 86t

postural assessment, , 110f, 110t

range of motion measurements, 98-99, 98t

sensation testing, , 89f

shoulder abduction test, , 117f, 117t

Spurling's A and B tests, 112t

Spurling's to the right and left tests, 112t

strength and endurance testing, , 102f, 102t

traction test, , 115f, 115t

Cervical thrust manipulation, clinical prediction rule for,

Cervical traction, for cervical radiculopathy

after three weeks, 135-136, 135t-136t

cluster of findings in, , 137f, 137t

Cervical vertebrae. _See also_ specific vertebra

articular facet of, 72f

anterior, 72f

inferior, 72f

posterior, 72f-73f

superior, 72f

articular process of, 73f

inferior, 72f

spinous process of, 72f-73f, 75f, 155f-157f

palpation of, 108t-109t

tubercles of

anterior, 72f, 75f

posterior, 72f, 156f-157f

Cervical zygapophyseal pain syndromes, , 84f

Chemical factors, of lumbar pain, 195f

Chest expansion, in ankylosing spondylitis, 169f, 204t

Children, wrist fractures in, , 578f

Chin, neck distraction test and, 115t

Chin tuck neck flexion test, 102t

Choanae, 21f, 71f

Chorda tympani nerve, 24f

CI (confidence interval),

Circumflex artery(ies)

deep, iliac, 285f

femoral

lateral, 285f

ascending, transverse, and descending branches of, 285f

medial, 285f

humeral, anterior vs. posterior, 460f

scapular, 460f

groove on scapula for, 452f

Clavicle, 76f, 78f, 150f

acromial end of, 451f

acromial facet of, 451f

conoid tubercle of, 451f

impression for costoclavicular ligament on, 451f

ligaments of, 454f

muscles of, 457f-458f

in shoulder joint, 451f-452f, 460f

sternal end of, 451f

sternal facet of, 451f

subclavian groove of, 451f

surfaces of

inferior vs. superior, 451f

posterior and anterior, 451f

trapezoid line of, 451f

Clavicular branch, of thoracoacromial artery, 460f

Clavicular tilt angle, , 471t

Click-clack test, of sacroiliac joint, 260t

Clicking, in shoulder, 462t

Clinical examination

history in. _See_ Patient history

physical. _See_ Physical examination

reliability and diagnostic utility of, 1-12. _See also_ specific anatomy or test

assessment of study quality, 9-11

diagnostic accuracy, 2-8, 11t

2×2 contingency table, 3-8, 3t, 11t

likelihood ratios in, 7f, 7t, 8-9, 11t

overall accuracy in,

positive and negative predictive values in, , 4t, 11t

pretest and posttest probability,

reliability, 2-3

sensitivity in, 4-5, 5f, 11t

specificity, 5-6, 5f-6f, 11t

statistics related to, , 11t

summary of, , 11t

Clinical prediction rule

for carpal tunnel syndrome, , , 603f

for cervical thrust manipulation,

for epicondylalgia, , 548t

for scaphoid fracture,

of spinal manipulation, , 266f

for wrist fractures, in children,

Clivus, of basilar part of occipital bone, 74f

Clonus, cervical myelopathy and, 124t-125t

Cluneal nerve, inferior, 284f, 284t, 335f

CMC. _See_ Carpometacarpal (CMC) joint

Coccygeal cornu (horn), 226f

Coccygeal nerve, 233t, 234f

herniated lumbar nucleus pulposus and, 171f

Coccygeal plexus, 162f

Coccygeus muscle

(ischio-), 234f

nerve to, 162f, 233t, 234f

Coccyx

nerves of, 162f, 233t, 234f

osteology of, 225f-226f, 278f

superior articular process of, 226f

surfaces of, dorsal vs. pelvic, 226f

tip of, in female, 228f

transverse process of, 226f

Collateral ligaments

of elbow, 531f, 531t

tear of,

fibular. _See_ Fibular collateral ligament

of knee, tears of, , 336t

patient history in, 336t, 340f, 340t

valgus stress test for, 369t

lateral, 403f, 403t, 405f

medial, tears of, detection of, , 544f, 544t

metacarpophalangeal and interphalangeal, 562f, 562t

plantar foot, 405t

of radius, 531f, 531t, 560f, 560t

tibial. _See_ Tibial collateral ligament

of ulna, 531f, 531t, 560f-561f, 560t

Comminuted fracture, of femur, 313f

into shaft, 341f

Common extensor tendon

of forearm, 533f

of hand, 563f

Common flexor tendon, of hand, 565f

Complete distal biceps tendon rupture, detection of, 545-546, 545t-546t, 547f

Compression

of cervical cord, , 123f, 123t

of hand, longitudinal, for scaphoid fractures, 575t

of nerve root, with herniated disc, 87f

of spinal cord, with cervical fracture, 94f

of spinal nerve roots

degenerative disc disease, 200f

detection of, with slump knee bend test, , 197t

with lumbar disc herniation, 195f

Compression fracture, of cervical spine, 94f

Compression tests

of brachial plexus, for cervical cord compression, , 123f, 123t

of cervical spine, , 112f, 112t

of foot and ankle, for trauma screening, 419t

direct vs. indirect, 420t

for glenoid labral tears

active, 481-483, 481f, 481t-483t

rotation with, 481f, 482t-483t

combined with other tests, 513t

combinations of tests, 512t

passive, 486t

rotation, , 479f, 479t

for pelvic pain, 291t

of sacroiliac region, , 245-246, 245f, 245t-246t

combined with other tests, 262t,

of temporomandibular joint, bilateral, 54f

Computed tomography (CT)

of cervical fracture, 95t

of lumbar spinal stenosis, 167t, 172t, 200t

Computed tomography (CT) myelography, of brachial plexus palsy, 509t

Condylar process, of mandible, 15f-17f, 71f

Condyles

in anterior disc displacement, 27f

of femur

lateral vs. medial, 325f, 327f, 329f

in trauma screening, 341f

of humerus, lateral vs. medial, 451f

occipital. _See_ Occipital condyle

of tibia

lateral, 325f

medial, 325f, 327f, 329f, 331f

in trauma screening, 341f

Confidence interval (CI),

Conjugate diameter, of pelvic inlet, 228f

Conoid ligament, 454f, 454t, 458f

Conoid tubercle, of clavicle, 451f

Contingency table, 2×2, 3-8, 3t, 11t

likelihood ratios in, 7f, 7t, 8-9, 11t

Contractures, hip flexor, Thomas test for, , 302f, 302t

Coracoacromial ligament, 454f-455f, 454t, 458f

Coracobrachialis muscle, 460f

Coracoclavicular ligaments, 454f, 454t, 458f

Coracohumeral ligament, 454f-455f

Coracoid pain test, 511f, 511t

Coracoid process, of scapula, 451f-452f, 455f, 458f, 460f

Corns, on metatarsals, 432f

Coronal section/view

of shoulder joint capsule, 472f

of shoulder ligaments, 455f

through S2 foramina, 226f

of wrist joint, 559f

Coronal suture, of mandible, 17f

Coronoid fossa, of humerus, 451f, 529f

Coronoid process

of mandible, 15f, 17f, 71f

temporalis muscle insertion into, 20f

of ulna, 529f, 532f

Correlation coefficient, 2-3

"Corset" concept, dynamic, of lumbar stability, 158f

Costal cartilage, 150f, 160f, 225f, 452f

6th, 457f

Costal facets

for 1st rib, 73f, 151f, 153f

costovertebral

inferior vs. superior, 151f

transverse, 151f, 153f

of thoracic vertebrae, 149f

inferior vs. superior, 149f

transverse, 149f

Costochondral joints, of thoracic spine, 150f, 152t

Costoclavicular ligament, 150f, 452f, 454t

impression on clavicle for, 451f

Costotransverse joint, of thoracic spine, 152t

Costotransverse ligaments, 151f, 153f, 153t

lateral, 151f, 153f

ossification of, 169f

superior, 151f, 153f, 160f

Costovertebral joints, of thoracic spine, 151f, 152t

Costovertebral ligaments, , 153f, 153t

Costoxiphoid ligament, 150f

Coughing

sacroiliac pain aggravated by, 236t

thoracolumbar pain with, 166t

Coxal bone. _See_ Hip (coxal) bone

Cranial nerve(s)

V1,

V2,

V3,

XI, 456t

Craniocervical flexion test, 102t

Crank test

diagnostic utility of, , 8t

for glenoid labral tears, 477-478, 477f, 477t-478t

combined with other tests, 512t

Crepitus, in TMJ conditions, , 42t

Cricoid cartilage, 15f, 71f, 76f, 78f

Cricothyroid ligament, 78f

Cricothyroid muscle, 78f

CROM (cervical range-of-motion) instrument, 99t

Cross 6-meter hop for time, 428t

Cross-body adduction test, for subacromial impingement identification, 498t

Crossed straight-leg raise (CSLR) test, for lumbar radiculopathy, 148t, , 193t

Cruciate/cruciform ligament, 74f, 74t

anterior. _See_ Anterior cruciate ligament (ACL)

longitudinal band of, 74f

posterior. _See_ Posterior cruciate ligament (PCL)

CT. _See_ Computed tomography (CT)

Cubital tunnel syndrome, 537t, , 542t, 543f

tests for,

Cuboid bone, 399f-400f, 403f, 406f, 415f

groove for fibularis longus tendon on, 400f

tuberosity of, 400f, 406f, 415f

Cuboideonavicular ligament

dorsal, 403f

plantar, 406f

Cubonavicular ligament

dorsal, 403t

plantar, 405t, 406f

Cuneiform bones, 399f-400f

intermediate, 399f-400f, 415f

lateral, 400f, 415f

medial, 399f-400f, 404f, 406f, 415f

Cuneocuboid ligament, dorsal, 403f

Cuneonavicular ligament, dorsal, 403f-404f

Cutaneous branches

of C4-C6 dorsal rami, posterior, 81f

of obturator nerve, 285f

of saphenous nerve, medial, 334f

of thoracic spine nerve

anterior, 160f

lateral, 160f

Cutaneous innervation

of median nerve, 569f

of ulnar nerve, 570f

Cutaneous nerves

of arm, medial, 82t, 83f

dorsal, lateral, 335f

femoral, lateral, 334f

lateral, 534f, 536f, 536t, 571f

inferior and superior, 571f

of lower extremity

dorsal

intermediate, 416f

lateral, 416f-417f

sural cutaneous nerve via, 416f

medial, 416f

in foot and ankle, 416f-417f

medial, 569f

of muscles. _See_ Musculocutaneous nerve

perforating, 162f, 233t, 234f, 284f

perineal branches of, 335f

posterior, 571f

superficial, 571f

sural. _See_ Sural cutaneous nerve

of thigh. _See also_ Thigh

lateral, 160t, 161f-162f, 284t, 285f, 333f-334f

posterior, 162f, 233t, 234f, 284f, 284t, 335f

perineal branches, 284f

of upper extremity, medial, 459t, 460f

in brachial plexus schema, 509f

Cyriax's capsular pattern, for detecting osteoarthritis,

in hip and pelvis, , 290f

Cyst, meniscal, 379t

D

DASH. _See_ Disabilities of the Arm, Shoulder, and Hand (DASH)

de Quervain syndrome, 572t

de Quervain tenosynovitis, , 601f, 601t

Deep artery

of forearm, 460f

middle collateral branch of, 533f

of thigh, 285f

perforating branches of, 285f

Deep dissection

of thigh nerves and arteries, 285f

of wrist and digit muscles, 563f

Deep temporal branches, from mandibular nerve,

Deep tendon reflex test, cervical myelopathy and, 124t-125t

Degenerative disc disease, in thoracolumbar spine, 200f

Degenerative disease, of acetabulum, advanced, 290f

Deltoid branch, of thoracoacromial artery, 460f

Deltoid ligament, of ankle, 402t, 404f, 404t

tibiocalcaneal part of, 404f, 404t

tibionavicular part of, 404f, 404t

tibiotalar part of, anterior vs. posterior, 404f, 404t

Deltoid muscle, 76f, 155f, 455f-457f, 457t, 460f

manual testing of, 91f

for cervical radiculopathy, 92t

Deltoid tuberosity, of humerus, 451f-452f

Deltopectoral triangle, 457f

Dens, 72f-73f

articular facet for, 72f

articular facet of, posterior, 74f

ligaments of, 74f, 74t

Depressor anguli oris muscle, 20f

Depressor labii inferioris muscle, 20f

Derangement syndrome, in low back pain, 205t

Dermatomes

in cervical radiculopathy testing, 90t

of upper limb, anterior vs. posterior view of, 89f

Developmental hip dysplasia, in infants, , 294f, 294t

Deviation/deviation tests

of radius and ulna, 579t, 580f

of temporomandibular joint

anterior disc displacement and, , 48t, 50f

lateral, , 50f

of toes, lateral, 432f

Diagnostic accuracy, 2-8, 11t

Diagnostic utility, of orthopaedic clinical examination, 1-12. _See also_ Clinical examination; specific anatomy or test

Diaphragm, 161f

slip of costal part of, 160f

Digastric fossa, of mandible, 16f

Digastric muscle

anterior belly of, 22f-24f, 22t, 36f, 76f, 77t, 78f

posterior belly of, 22f-24f, 22t, 76f, 77t, 78f

Digastric tendon, intermediate, fibrous loop for, 22f-23f, 76f, 78f

Digital arteries

of foot and toes

common plantar, 413f, 415f

from plantar metatarsal artery, 412f

dorsal, 410f, 415f

proper plantar, 412f, 415f

dorsal branches of, 410f

superficial branch from medial plantar artery, 414f

of hand

common palmar, 568f

deep palmar arch, 568f

palmar metacarpal, 568f

Digital fibrous sheaths, 562f

Digital nerves/branches

palmar

common, 569f-570f

dorsal, 570f-571f

proper, 569f-570f

plantar

common, 413f, 417f

communicating branches of, 412f

dorsal, 416f

proper, 417f

dorsal branches of, 410f

lateral vs. medial branches of, 412f-414f

Digits. _See also_ Finger; Toes

muscles of

extensor, 563-564, 563f, 563t-564t

flexor, 565-566, 565f, 565t-566t

Disabilities of the Arm, Shoulder, and Hand (DASH)

in hand outcomes, 604t

for shoulder outcomes, 515t

Disc(s)

articular. _See_ Articular discs

degenerative disease of, in thoracolumbar spine, 200f

displacement of, in temporomandibular joint. _See_ Anterior disc displacement, in TMJ disorders

intervertebral. _See_ Intervertebral discs.

Disc herniation

lumbar

clinical features of, 171f, 194t

inflammation with, 195f

nerve root compression with, 171f

straight-leg raise test detection of, , 192t

crossed, , 193t

nerve root compression with, 87f

Discogenic pain

McKenzie evaluation to rule out, , 264f

thoracolumbar, 163t, 195f

Dislocations. _See also_ Subluxations

of shoulder, 473f, 474t

Displacement

of discs, in temporomandibular joint, with reduction, 33t-34t

with intermittent locking, 33t-34t

of patella

lateral pull test for, 359t

mediolateral, 353t-354t

of wrist fractures, 578f

Distraction test, , 250f, 250t

combined with other tests, 262t,

of hip, with knee interventions, 382t

of neck, , , 115f, 115t, 137t

combined with other tests, 129t

PSIS, 253f, 253t

of sacroiliac joint/region, for pelvic pain, 291t

for sacroiliac region,

Dorsal nerve, of penis/clitoris, 162f, 284f

Dorsal view

of carpal bones, 557f

of deep interosseous muscles of sole, 415f

of foot and ankle, 400f

of hand muscles, 568f

of hand nerves, 569f-570f

of wrist and hand bones, 558f

of wrist ligaments, , 561f, 561t

Dorsalis pedis artery, 410f

deep plantar artery from, 415f

Dorsiflexion

of ankle, 422t, 423f

impingement sign with, 436f, 436t

in slump test, 194f, 194t

of knee, 351t

Dorsiflexion lunge with compression test, 434t

Dorsiflexion-compression test

for ankle trauma, 419t

for syndesmotic injury, 435f

Dorsiflexion-external rotation test, 434t

Double-sided sacroiliac syndrome, 261t

Drawer test, of ankle. _See_ Anterior drawer test

Drop test, heel, of sacroiliac joint, 252t

Drop-arm test

for subacromial impingement, 494-495, 494t-495t

combined with other tests, 514t

for supraspinatus and/or infraspinatus tears, 501t-503t

Drop/dropping sign, 501t-503t

supraspinatus and/or infraspinatus tears, 504t

Dropping objects, 572t

Dupuytren contracture, in hand, 572t

Dynamic activity, of shoulder, scapular asymmetry during, , 470t, 471f

Dynamic labral shear test (O'Driscoll test), 488t-489t

Dynamic movements. _See also_ Functional movements

aberrant, in lumbar segmental instability, 198t-199t, 209t

for lumbar stability, "corset" concept of, 158f

of temporomandibular joint

anterior disc displacement and, , 49f

pain during, , 49f

conditions identified by, 52-53, 52f

joint play,

resistance tests and, , 50f

Dynamic performance, of foot and ankle, assessment of, , , 429f, 429t-430t

Dynamometry, for strength testing, , 582t

Dysplasia, hip, developmental, in infants, , 294f, 294t

E

Ecchymosis, foot and ankle, in trauma screening, 419t

Ege test, for meniscal tears, 372f, 372t

Elbow and forearm, 527-553

arthrology of,

clinical summary and recommendations for,

ligaments of, 531-532, 531f-532f, 531t

mobilization of, , 548t

muscles of, , 533t-534t

nerves of, , 536f, 536t

osteology of, , 529f

outcome measures of,

patient history and,

initial hypotheses based on, , 537t

physical examination of, , 528t, 538-548

complete distal biceps tendon rupture detection in, 545-546, 545t-546t, 547f

cubital tunnel syndrome detection in, , 542t, 543f

extension test for, , 541t

interventions in,

medial collateral tears detection in, , 544f, 544t

quality appraisal of reliability studies for, , 550t

quality assessment of diagnostic studies for, , 551t

range-of-motion of, measurement of, , 538-539, 538f-539f

reliability of examination for

end-feel classification in, , 540f, 540t

flexion and extension measurements in, , 538f, 538t

grip strength testing in, , 540t

supination and pronation measurements in, , 539f, 539t

Elbow pain

epicondylar. _See_ Tennis elbow

history in, 537t

neuropathic. _See_ Cubital tunnel syndrome

Electrodiagnostics

for cervical radiculopathy, 87t, 90t, 93t, 113t-114t

for lumbar radiculopathy, 168t, 170t

Elevation tests, of shoulder, 463t

Empty can test (Jobe test)

for subacromial impingement, 495-496, 495t-496t

for supraspinatus tears, 500t-503t

End feel assessment

of knee, capsular and noncapsular, ,

extension vs. flexion, 348f, 348t, 382t

of temporomandibular joint, , 46f

of thoracolumbar spine, 182t

End feel classification, for elbow, , 540f, 540t

Endurance testing

of cervical spine, , 102f, 102t

of serratus anterior muscle, 465t

of thoracolumbar spine, , 177f, 177t

Epicondylalgia, 537f. _See also_ Tennis elbow

grip strength testing in, , 540t

movement and exercise for, , 548t

Epicondyle

of femur

lateral, 325f, 331f

medial, 325f, 331f-332f

adductor tubercle on, 285f, 327f

in physical examination, 352t-354t

of hand, lateral and medial, 563f, 565f, 570f-571f

of humerus

lateral vs. medial, 451f-452f, 529f, 531f, 533f-536f

palpation of, 537f

tenderness over. _See_ Tennis elbow

Epicondylitis, lateral and medial, 537t

Epicranial aponeurosis, 81f

Epiglottis, 15f, 71f

Erector spinae muscle, 155f-157f, 160f

Ethmoid bone, 17f

Eversion, subtalar joint, 422t

Evidence-based practice,

Excursions, of temporomandibular joint, 44t-45t

Exercise, for epicondylalgia, , 548t

Extension view

of anterior knee muscles, 331f

of posterior knee ligaments, 327f

Extension/extension tests

of cervical spine, 97f, 98t-99t

limited passive, 103t

pain during, 100t-101t

in slump test, 194f, 194t

of elbow, , 541t

end-feel classification in, , 540f, 540t

ROM measurements and, , 538f, 538t

of great toe, 380f, 381t

of hip, 292f

in flexor contracture test, 302f, 302t

length assessment with, 303t

for lumbar segmental instability, 198t-199t

for lumbar spinal stenosis, 200t

mobilizations effect on, 382t

strength assessment with, 297f

of knee

measurements of

active and passive, 346t-347t

end feel, 348t

pain during, 349t

for strength, 350t

in pivot shift test, 367f

in slump test, 194f, 194t

of lumbar spine, 173t-174t

centralization phenomena and, 189t

lying, 186f, 186t

radiography with, for instability, 201t

of sacroiliac joint

lying,

standing,

of shoulder, 463t

of thoracolumbar spine, 173t-174t

in low back pain classifications, 206t

pain during, 176f, 176t

of wrist, 579t, 580f, 582t

Extensor carpi radialis brevis muscle, 533f, 563f, 563t-564t

groove on radius for, 532f

innervation of, 571f

manual testing of, for cervical radiculopathy, 92t

Extensor carpi radialis brevis tendon, 533f, 559f

Extensor carpi radialis longus muscle, 563f, 563t-564t

groove on radius for, 532f

innervation of, 571f

manual testing of, for cervical radiculopathy, 92t

Extensor carpi radialis longus tendon, 533f, 559f

Extensor carpi ulnaris muscle, 563f, 563t-564t

innervation of, 571f

Extensor carpi ulnaris tendon, 533f

Extensor digiti minimi muscle, 563f, 563t-564t

innervation of, 571f

Extensor digiti minimi tendon, 533f, 563f

Extensor digitorum brevis muscle, 407t, 408f, 410f, 411t, 416f

Extensor digitorum brevis tendon, 410f, 415f

Extensor digitorum longus muscle, 331f, 407t, 408f, 416f

Extensor digitorum longus tendon, 408f, 410f, 415f

Extensor digitorum muscle, 563f, 563t-564t

groove on radius for, 532f

innervation of, 571f

Extensor digitorum tendon, 533f, 563f

Extensor expansions

of foot and ankle, 410f, 415f

of hand, tendinous slips to, 567f

Extensor hallucis brevis muscle, 410f, 411t, 416f

Extensor hallucis brevis tendon, 415f

Extensor hallucis longus muscle, 407t, 408f, 410f, 416f

neurological examination of, 170t, 172f

Extensor hallucis longus tendon, 408f, 410f, 415f

Extensor indicis muscle, 533f, 563f, 563t-564t

groove on radius for, 532f

innervation of, 571f

Extensor indicis tendon, 563f

Extensor muscles

of anterior abdominal wall, 158f, 158t

of hip and thigh, length assessment of, 303t

of wrist and digits, 563-564, 563f, 563t-564t

Extensor pollicis brevis muscle, 533f, 563f, 563t-564t

area on radius for, 532f

innervation of, 571f

Extensor pollicis brevis tendon, 536f

insertion of, 559f

Extensor pollicis longus muscle, 533f, 563f, 563t-564t

groove on radius for, 532f

innervation of, 571f

Extensor pollicis longus tendon, insertion of, 559f

Extensor retinaculum

of foot

inferior, 408f, 416f

superior, 408f

of forearm, 533f-534f

of wrist, 559f

Extensor tendon, of forearm, common, 533f, 563f

External acoustic meatus, 15f, 17f, 71f

posterior TMJ palpation through, 37f

External rotation (ER) lag sign, in shoulder, , 501t-503t

External rotation (ER) test, 434t, 435f

for ankle trauma, 419t

of hip and pelvis, length assessment with, 295t-296t

F

FABER test. _See_ Patrick test

FABQ. _See_ Fear-Avoidance Beliefs Questionnaire (FABQ)

Facets

articular. _See_ Articular facets

of clavicle

acromial, 451f

sternal, 451f

costal. _See_ Costal facets

of tibia, lateral and medial, 325f, 329f

Facial nerve, 24f

FADIR. _See_ Flexion-internal rotation-adduction (FADIR) impingement test

Fagan's nomogram, 7f, 129f

False-negative findings, , 3t-4t, 11t

False-positive findings, , 3t-4t, 11t

Fascia. _See_ specific anatomy

Fasciitis, plantar, , 418t

Fat, in acetabular fossa, 279f

Fat body, suprapatellar, 326f

Fat pads

in elbow joint, 530f

infrapatellar, 326f, 329f

Fear-Avoidance Beliefs Questionnaire (FABQ)

for cervical spine outcomes, 138t

for sacroiliac region outcomes, 267t

for thoracolumbar spine outcomes, 210t

Female pelvic inlet, anterior view of, 228f

Female pelvic outlet, inferior view of, 228f

Female pelvis

anterior view of, 228f

inferior view of, 228f

sagittal section of, 228f

Femoral artery, 285f

circumflex

lateral, 285f

ascending, transverse, and descending branches of, 285f

medial, 285f

Femoral nerves, 160t, 161f-162f, 284t, 285f, 330t, 333f-334f, 333t

articular branch of, 334f

cutaneous branches of
anterior, 334f

lateral, 334f

Femoral vein, 285f

Femoroacetabular (anterior) impingement, 286t

Femoroacetabular joint, 278t

Femur

adductor tubercle of, 325f

on medial epicondyle, 285f, 327f

anterior vs. posterior view of, 277f

articular cartilages of, erosion of, 290f, 337f

body (shaft) of, 277f, 325f

bursitis of, in greater trochanter, 286t

condyle of, lateral vs. medial, 325f, 327f, 329f

epicondyle of

lateral, 325f, 331f

medial, 325f, 331f-332f

adductor tubercle on, 285f, 327f

in physical examination, 352t-354t

fibrous capsule of

line of attachment of, 277f, 325f

line of reflection of, 277f, 325f

unattached, 325f

fractures of

distal, 341f

intertrochanteric, 313f

shaft, 313f, 341f

head of, 277f, 279f

erosion of cartilage and deformity of, 290f

ligament, 279f, 279t

osteonecrosis of, 293f

posterior ligament of, fovea for, 277f

intercondylar fossa of, 325f

intercondylar fracture, 341f

in knee, 326f, 328f, 331f

neck of, 277f, 279f

osteology of, 325f

in physical examination, of knee, 353t-354t, 356t

trochanters of. _See_ Trochanters, of femur

FFI (Foot Function Index), 441t

Fibromyalgia, tenderness to palpation and, 188t

Fibula

in ankle joint, 402f-403f, 408f, 410f

anterior border of, 325f

apex of, 325f

head of, 283f, 325f, 327f, 329f, 331f-332f, 408f-409f, 416f

posterior ligament of, 327t, 328f

lateral surface of, 325f

neck of, 325f

osteology of, 325f

in physical examination, 341f

of foot and ankle, 419t-420t, 423f

of knee, 341f, 367f

Fibular artery, 409f

communicating branch of, 409f

lateral calcaneal artery from, 413f

lateral calcaneal branch of, 409f

perforating branch of, 409f-410f

posterior lateral malleolar branch of, 409f

Fibular collateral ligament, 327f, 327t, 329f, 408f-409f

and bursa, 331f-332f

inferior subtendinous bursa of, 328f

Fibular nerve

deep, 407t, 410f, 416f, 416t

superficial, 407t, 416f, 416t

Fibular retinaculum

inferior, 408f-409f

fibular tendons in, 402f

superior, 408f

Fibular tendon, in inferior fibular retinaculum, 402f

Fibular trochlea, of calcaneus, 399f-400f

Fibularis brevis muscle, 407t, 410f, 416f

Fibularis brevis tendon, 408f-410f

Fibularis longus muscle, 407t

Fibularis longus tendon, 409f-410f

Fibularis tertius muscle, 407t, 410f

Figure-of-eight measurement

of ankle joint swelling, 431f, 431t

of hand, 586f, 586t

Finger, range of motion measurements of, , , 581f, 581t

Fixations, segmental, of lumbar spine, 182t, 185f

Flap tear, of meniscus, 378f

Flatfoot, 432f

Flexion strength, of hip and pelvis, length assessment with, 295t-296t, 297f

Flexion view, of anterior knee ligaments, 329f

Flexion/flexion tests

of cervical spine, 97f, 98t-99t

limited passive, 103t-104t

pain during, 100t-101t, 101f

in slump test, 194f, 194t

in straight-leg raise test, 191f

strength and endurance testing of, 102f, 102t

of elbow,

for cubital tunnel syndrome, 542t

pressure provocative test combined with, 542t

end-feel classification in, , 540f, 540t

ROM measurements and, , 538f, 538t

of hip and pelvis, 289t, 292f

in flexor contracture test, 302f

of interphalangeal joint, 581f

of knee

hip mobilization effect in, 382t

measurements of

active and passive, 346t-347t

end feel, 348t

pain during, 349t, 372t-374t, 376t-377t

in pivot shift test, 367f

in slump test, 194f, 194t

of lumbar spine, 173t-174t

centralization phenomena and, 189t

excessive, 186f, 186t

for instability

radiography with, 201-203, 201t, 202f-203f

segmental, 198t-199t

segmental side vs. ventral, 181t

of sacroiliac joint

lying,

sitting, , 259f, 259t

standing, , 258f, 258t,

of shoulder, 463t

for labral tears, supine resistance with, 488t-489t

for muscle assessments, 465t-466t

of thoracolumbar spine, 173t-174t, 175f

in low back pain classifications, 206t

pain during, 176f, 176t

of wrist, 579f, 579t

Flexion-internal rotation-adduction (FADIR) impingement test, for hip and pelvis, diagnostic utility of, 311t-312t

Flexion-rotation test, cervical, , 116t

Flexor carpi radialis muscle, 536f, 565f, 565t-566t

innervation of, 569f

manual testing of, for cervical radiculopathy, 92t

Flexor carpi radialis tendon, 534f, 536f

in carpal tunnel syndrome, 574f

Flexor carpi ulnaris muscle, 533f-534f, 536f, 565f, 565t-566t

innervation of, 570f

Flexor carpi ulnaris tendon, 536f, 560f, 568f

Flexor digiti minimi brevis muscle

in foot, 412f-415f, 414t

in hand, 568f

innervation of, 570f

Flexor digiti minimi brevis tendon, 406f

Flexor digiti minimi muscle, 567t

Flexor digitorum brevis muscle, 412f-414f, 412t, 417f

Flexor digitorum brevis nerve, 417f

Flexor digitorum brevis tendon, 412f-413f

to 2nd toe, 406f

fibrous sheaths of, 413f

Flexor digitorum longus muscle, 409f, 409t, 417f

Flexor digitorum longus tendon, 406f, 409f, 412f-414f

to 2nd toe, 406f

Flexor digitorum profundus muscle, 536f, 565f

median vs. lateral portion of, 565t-566t

Flexor digitorum profundus tendons, 562f

in carpal tunnel syndrome, 574f

Flexor digitorum superficialis muscle, 534f, 565f, 565t-566t

humeroulnar head of, 534f, 536f, 565t-566t

innervation of, 569f

medial and lateral, innervation of, 570f

radial head of, 534f, 536f, 565t-566t

Flexor digitorum superficialis tendons, 562f

in carpal tunnel syndrome, 574f

Flexor hallucis brevis muscle, 414f, 414t, 417f

lateral vs. medial head of, 412f-415f

Flexor hallucis brevis nerve, 417f

Flexor hallucis brevis tendon

lateral vs. medial head of, 406f

lateral vs. medial origin of, 415f

Flexor hallucis longus muscle, 409f, 409t, 417f

Flexor hallucis longus tendon, 406f, 412f-415f

groove for

on calcaneus, 399f-400f

on talus, 400f

Flexor muscles, 158f, 158t

of hip

contractures of, , 302f, 302t

neurological examination of, 170t

of wrist and digits, 565-566, 565f, 565t-566t

Flexor pollicis brevis muscle, 567t, 568f

superficial vs. deep head of, innervation of, 569f-570f

Flexor pollicis longus muscle, 534f, 536f, 565f, 565t-566t

innervation of, 569f

Flexor pollicis longus tendon, 536f

in carpal tunnel syndrome, 574f

Flexor retinaculum, 409f

of foot and ankle, 413f-414f, 417f

of hand, 568f

in carpal tunnel syndrome, 574f

Flexor tendons

common, 565f

of sole of foot, fibrous sheaths of, 412f

Flick maneuver, 602t

Fluctuation test, for knee inflammation, 344f, 344t

Flynn technique, for spinal manipulation, 208f, , 265f

Foot and ankle, 397-448

arthrology of,

clinical summary and recommendations,

diagnostic utility of examination,

anterior drawer test, 437t, 438f

anterolateral ankle impingement detection, , 436f, 436t

functional hallux limitus test, , 430f, 430t

strength assessment, , 424f, 424t

talar tilt test, 437f-438f, 437t

trauma screening, , 420f, 420t

Windlass test, , 440f, 440t

fractures of, 418t

screening for, , 420t

ligaments of, 402-405

lateral, , 403f, 403t

medial, , 404f, 404t

plantar, , 405f-406f, 405t

posterior, , 402f, 402t

of sole, 415f

sprain injuries of, 418t

lumbar zygapophyseal joint pain referral to, 164t

muscles of

dorsum, 410-411, 410f, 411t

leg vs.,

in sole

deep interosseous, , 415f, 415t

first layer of, , 412f, 412t

second layer of, , 413f, 413t

third layer of, , 414f, 414t

nerves of, , 416f, 416t

in sole of foot, 412f

osteology of, 399-416

dorsal vs. plantar view of, 400f

lateral vs. medial view of, 399f

Ottawa rules for, 420f-421f

outcome measures of, , 441t

paresthesias in, 418t

patient history and, 398t

initial hypotheses based on, 398t,

report of pain, 398t

report of trauma, 398t

physical examination of, 398t, 419-440

subcutaneous tears of Achilles tendon, , 433f, 433t

syndesmotic injury, , 434t

tarsal tunnel syndrome, , 439f, 439t

range-of-motion measurements, , 418t-419t

calcaneal position, , 423t

passive vs. active, 422t

reliability of examination

balance and proprioception assessment, , 428t

bony alignment assessment

forefoot position, , 427f, 427t

medial arch height, , 426f, 426t

navicular height, , 425f, 425t

dynamic performance assessment, , 429f, 429t

hindfoot motion during gait,

joint swelling measurements, , 431f, 431t

ligamentous injury detection after sprains, , 437t, 438f

protective sensation assessment, , 432f, 432t

trauma screening, 419-440, 419t, 420f

rheumatoid arthritis involvement of, 432f, 432t

strength assessment,

weakness in, with herniated lumbar nucleus pulposus, 171f

Foot and ankle pain

impingement detection with, 436t

as lumbar zygapophyseal joint pain referral, 164t

patient report of, 418t

in trauma screening, 419t

Foot Function Index (FFI), 441t

Foot orthoses, 380-381, 380f, 381t

for patellofemoral pain syndrome, ,

Foot rotation test, internal, for TMJ disorders, diagnostic utility of, 55t

Foramen. _See_ specific anatomy

Foramen ovale, 24f, 71f

Foramen spinosum, 24f, 71f

Force

high-velocity thrust, for cervical manipulation, 131f

in knee injuries, 340f, 340t

mechanical, in lumbar pain, 195f

posteroanterior, for lumbar pain provocation, 183t

in shoulder tests

for instability, 475t

for labral tears, 478t-479t

transfer of, by thoracolumbar fascia, , 159f

Forearm, 527-553. _See also_ Elbow and forearm

bones of. _See_ Humerus; Radius; Ulna

fracture of, in children, 578f

ligaments of, , 532f, 532t

muscles of, 533-535

anterior and posterior, , 533f

anterior view of, 534f, 534t

posterior view of, 533f, 533t

nerves of, , 536f, 536t

pain in, with cervical compression test, 112t

supinators and pronators of, , 535f, 535t

Forefoot position, measurement of, , 427f, 427t

Forward bending, of thoracolumbar spine, 173t-174t

Forward step-down test, of hip and pelvis, , 305t-306t, 306f

Fossa. _See_ specific anatomy

Foveal disruption, of radioulnar ligaments,

Fractures

of cervical spine

compression, 94f

screening for, 95t

of femur

distal, 341f

intertrochanteric, 313f

shaft, 313f, 341f

of foot and ankle, 418t

of forearm, in children, , 578f

of hip, patellar-pubic percussion test for, , 313f, 313t

of knee,

distal femur and, 341f

of wrist, screening for, , , 575t, 577f

Frontal bone, 17f

Functional hallux limitus test, during gait, , 430f, 430t

Functional movements. _See also_ Dynamic movements

of shoulder, assessment tests for, 464t

Functional outcomes. _See_ Outcome measures

G

Gaenslen test

for pelvic pain, 291t

of sacroiliac joint, , 249f, 249t

combined with other tests, 262t,

Gait

characteristic, with hip osteoarthritis, 290f

functional hallux limitus test during, , 430f, 430t

hindfoot motion during, dynamic assessment of, , 430f, 430t

Galea aponeurotica, 81f

Ganglion

otic, 19f, 21f, 24f

semilunar (trigeminal), 24f

sensory

of lumbar spine nerves, 195f

of thoracic spine nerves, 160f

submandibular, 24f

Gastrocnemius muscle, 331f-332f, 335f, 407t, 408f, 417f

atrophy of, with herniated lumbar nucleus pulposus, 171f

lateral head of, 281f, 328f, 330t, 409f

length assessment of, 351t

medial head of, 281f, 328f, 330t, 409f

neurological examination of, 170t

subtendinous bursa of

lateral, 326f, 328f

medial, 328f

Gastroc-soleus complex, neurological examination of, 170t

Gemellus muscle, inferior vs. superior, 280t, 281f, 284f

nerves to, 162f, 234f

Genicular arteries

articular branch of, 285f

descending, 285f

inferior lateral vs. superior lateral, 408f-409f

inferior medial vs. superior medial, 285f, 409f

Genioglossus muscle, superior mental spine for, 23f

Geniohyoid muscle, 22t, 23f, 36f, 77t, 78f

Genitofemoral nerve, 160t, 161f-162f, 333f

femoral branch of, 161f-162f

genital branch of, 162f

Gerber test, for subacromial impingement, 497t

combined with other tests, 514t

Gerdy's tubercle, 325f, 329f

iliotibial tract insertion to, 331f

Gillet test, 254-255, 254t-255t, 255f

Glabella, of frontal bone, 17f

Glasgow Coma Score, with blunt trauma to head/neck, , 91t, 99t, 108t

Glenohumeral joint, 452t

avulsions of, 476t

integrated movements of, , 453f

in physical examination, 470t, 475t-476t

Glenohumeral ligaments, 454f, 454t

avulsions of, 474t-475t

inferior vs. middle vs. superior, 455f

Glenohumeral muscles, length-tension relationship of,

Glenoid cavity, of scapula, 451f, 455f

Glenoid fossa, in scapulohumeral rhythm,

Glenoid labral tears. _See also_ Superior labrum anterior posterior (SLAP) lesions

active compression/O'Brien test for, 481-483, 481f, 481t-483t

combined with other tests, 512t

anterior slide/Kibler test for, , 485f, 485t

combined with other tests, 512t

combination of tests for, , 512t

compression rotation test for, , 479f, 479t

Crank test for, 477-478, 477f, 477t-478t

patient history in, 461-462, 461t

various tests for, , 488-489, 488t-489t

Yergason test for, , 484f, 484t

Glenoid labrum, 455f

Glide test/technique

anteroposterior, for hip mobilization, 383f

caudal, for hip mobilization, 383f

of cervical spine, lateral, 105t

mediolateral, of patella, 353t-354t

of sacroiliac joint,

Gluteal lines, of hip bone, 227f, 277f

anterior vs. posterior, 227f, 277f

inferior, 227f, 277f

Gluteal nerve

inferior, 162f, 233t, 234f, 284f, 284t

superior, 162f, 233t, 234f, 284f, 284t

Gluteal (buttock) pain

as lumbar zygapophyseal joint pain referral, 163t-164t, 164f

sacroiliac pain and, 236t

Gluteal tuberosity, 277f

Gluteus maximus muscle, 155f, 232f, 232t, 280t, 281f, 284f

Gluteus medius muscle, 155f, 280t, 283f-285f, 298f

resisted, pain during, 298t

weakness, 298t

Gluteus medius tendon, tears of, 298t, 300t

Gluteus minimus muscle, 280t, 281f, 284f, 298f

Goniometer

in cervical spine assessment, 98t

in elbow flexion and extension measurement, 538t-539t

in foot and ankle assessment, 422t-423t, 423f

in hand assessment, 579t, 581t

in hip and pelvis assessment, 288t

in knee assessment, 346t-347t, 358t-359t

in lumbar spine assessment, 207t

in shoulder assessment, 463t

Gower sign, of lumbar segmental instability, 198t-199t, 209t

Gracilis muscle, 281f, 282t, 283f, 330t, 332f-333f

Gracilis tendon, 283f, 331f-332f

Great toe. _See also_ Hallux

distal vs. proximal phalanx of, 406f

extension, 380f, 381t

Grip/gripping, 572t

strength testing of

forearm in, , , 540t

with fractures,

wrist in, 582t, 583f

Groin pain. _See_ Inguinal (groin) pain

H

Habitus, characteristic, with hip osteoarthritis, 290f

Hallux. _See also_ Great toe

AOFAS scale for, 441t

Hallux limitus test, functional, during gait, , 430f, 430t

Hamate, 557f-559f, 561f

in carpal tunnel syndrome, 574f

hook of, 557f-558f, 560f, 562f, 565f

in scaphoid fractures, 577f

Hammertoes, 432t

Hamstrings, 280t

length assessment of, 351t

sciatic nerve supply to, 333f

strains, 286t

Hamulus (hook)

of hamate, 557f-558f, 560f, 562f, 565f

in scaphoid fractures, 577f

of medial pterygoid plate, 15f, 21f, 24f, 71f

of pterygoid process, 71f

Hand, 555-610

abduction of, 581t

arthrology of,

carpal bones, 557f

clinical summary and recommendations of,

fascia of, 559f

fracture screening, , 575t, 577f

ligaments of, metacarpophalangeal and interphalangeal, , 562f, 562t

muscles of, 563-567

intrinsic, , 567f, 567t

nerves of, 569-571

median, , 569f, 569t

radial, , 571f, 571t

ulnar, , 570f, 570t

osteology of, 557-571, 558f

outcome measures of, 604t

pain in, with cervical compression test, 112t

paresthesias of, patient history of, 572t

patient history and,

initial hypotheses based on, , 572t

physical examination of, 556t, 575-603

quality appraisal of reliability studies for, 605t-608t

reliability of examination

patient history, , 572t

sensory testing, , 587t

screening for, , 575-578, 575t

strength assessment, , 582t, 583f

Hand behind back test, 464f, 464t

Hand elevation test, in carpal tunnel syndrome, 596-597, 596t

Hand in neck test, 464t

Hand pain

brachial plexus palsy causing, 509t

patient history of, 572t

Hand Severity Scale, for carpal tunnel syndrome,

Hand to neck test, 464t

Hand to scapula tests, 464t

opposite, 464t

Hand withdrawal reflex, cervical myelopathy and, 124t-125t, 126f

Handshake position, for scaphoid fracture identification, 575t

Hawkins-Kennedy test, , , 490f, 490t

combined with other tests, 514t

for subacromial impingement, , 491t

combined with other tests, 514t

Head

forward test of, in postural assessment, 110t

leaning on palm, and TMJ disorders, 25f

Head and neck. _See also_ Neck

bony framework of

cervical spine and, 71f

in relation to TMJ, 15f

Headaches

attributed to TMD,

cervical spine and, 100t, 108t,

Heel-bank test, of sacroiliac joint, 260t

Heels, sacroiliac pain aggravated by, 236t

Herniation, of intervertebral discs. _See_ Disc herniation

Hill-Sachs lesion, of shoulder, 474t-476t

Hindfoot, in physical examination, 420t

Hindfoot motion, during gait, dynamic assessment of, , 430t

Hinge joints, temporomandibular,

Hip abduction,

limited, developmental dysplasia in infants, , 294f, 294t

osteonecrosis detection with, 293f

resisted, for sacroiliac pain provocation, 252f, 252t

strength, 297f

Hip and pelvis, 275-321

arthritis of. _See_ Osteoarthritis (OA)

arthrology of,

clinical summary and recommendations,

diagnostic utility of examination

avascular necrosis detection with limited ROM, , 293f, 293t

combinations of tests for osteoarthritis, , 315t

developmental dysplasia detection in infants, , 294f, 294t

functional movement assessments, , 307t

hip fracture detection, , 313f, 313t

intraarticular pathology detection, , 312t

lateral tendon pathology identification, , 300t

pain and limited range of motion, , 291t

pain with palpation, , 308t

patellar-pubic percussion test, , 313f, 313t

Patrick (FABER) test, , 310t

Trendelenburg test, , 299f, 299t

forward step-down test, , 305t

fractures, patellar-pubic-percussion test for, , 313f, 313t

functional movement assessments, 305-307, 305t, 306f

ligaments of, 279f, 279t

mobilizations for, for knee osteoarthritis, , , 382t, 383f

muscles of, 280-282

anterior, , 282t, 283f

posterior, , 280t, 281f

nerves of,

of buttocks, 284f

of thigh, 285f

osteology of,

femur, 277f

hip (coxal) bone, 277f

outcome measures, , 316t

palpation of,

patient history and, 286-287

initial hypotheses based on, , 286t

physical examination and, 276t, 288-294

quality appraisal of reliability studies for, 317-318, 317t-318t

quality assessment of diagnostic studies, , 319t

range of motion of

passive measurements of, 289f

physical examination of, 288-294, 288t

reliability of examination

capsular and noncapsular end-feels, , 289t

forward step-down test, , 306f, 306t

intraarticular pathology detection, , 311f, 311t

muscle length assessment, 301-303

flexor contracture in, , 302f, 302t

iliotibial band length in, , 301f, 301t

Ober test, 301f, 301t

pain with palpation, , 308t

Patrick (FABER) test, , 309f, 309t

Thomas test, , 302f, 302t

in straight-leg raise test, 192t

Hip (coxal) bone, 227f

auricular surface of, for sacrum, 227f

osteology of, 277f

Hip flexion test, of hip and pelvis, 289t

Hip pain. _See also_ Sacroiliac pain

combined tests for,

during functional movements, 305-307

intraarticular

anesthetic-steroid injection, 308t, 310t

palpation for, , 308t

patient examination of, , 308t

special tests, 309-314, 309t

diagnostic utility,

reliability of, , 311f, 311t

patient history in,

History, in clinical examination. _See_ Patient history

Hoffmann sign, cervical myelopathy and, 124t-125t

Hook (tool), in thoracolumbar muscles, 156f

Hook of hamate, 536f

Hook test, for complete distal biceps tendon rupture detection, 545t-546t

Horizontal adduction test, for subacromial impingement, 498f, 498t

combined with other tests, 514t

Horizontal tear, of meniscus, 378f

Hornblower's sign

with rotator cuff tears, 503f

supraspinatus and/or infraspinatus tears, 504t

Humeral artery, circumflex, anterior vs. posterior, 460f

Humeroradial joint, 530t

Humeroulnar joint, 530t

Humerus

capitulum of, 451f, 529f

condyles of, lateral vs. medial, 451f

deltoid tuberosity of, 451f-452f

in elbow joint, 530f

end-feel classification and, 540t

epicondyles of

lateral vs. medial, 451f-452f, 529f, 531f, 533f, 535f-536f

palpation of, 537f

tenderness over. _See_ Tennis elbow

fossa of, 451f, 529f

groove for ulnar nerve on, 452f, 529f

head of, 451f-452f

in scapulohumeral rhythm,

intertubercular sulcus of, 451f

ligaments of, 531f

neck of, anatomical vs. surgical, 451f-452f

olecranon fossa of, 452f, 529f

radial fossa of, 451f, 529f

radial groove of, 452f

in shoulder examination, 466t, 472f, 474t

in shoulder joint, 452f

anterior view of, 451f

supracondylar ridge of, 529f

medial vs. lateral, 451f-452f

trochlea of, 451f-452f, 529f

tubercles of

greater vs. lesser, 451f-452f, 454f

crests of, 451f

infraglenoid, 452f

Hyaline cartilage, in knee, osteoarthritis of, 337f

Hyoglossus muscle, 78f

Hyoid bone, 76f, 78f

body, lesser horn, and greater horn of, 15f, 22f-23f, 71f

Hyperflexion test, for meniscal tears, 376t-377t

Hypermobile segments, of lumbar spine, 182t, 201t, 203f

spinal manipulation for, 207t

Hypertonicity, of multifidus muscle, in lumbar spine, 181t

Hypogastric (pelvic) plexus, inferior, 234f

Hypoglossal nerve, 24f

Hypomobile segments

of cervical spine, 103t-105t, 107t

manipulation and, 131f

of lumbar spine, 182t, 201t, 203f

spinal manipulation for, 207t

Hypothenar muscles, innervation of, 570f

Hypotheses, based on patient history

of cervical spine conditions, , 84t

in diagnostic process,

of elbow and forearm conditions, , 537t

of foot and ankle conditions, , 418t

of hand conditions, , 572t

of hip and pelvis, , 286t

of shoulder conditions, 461-462, 461t-462t

of temporomandibular joint conditions, , 25t

of thoracolumbar spine conditions, , 163t

I

ICC (intra-class correlation coefficient), 2-3

Iliac artery

circumflex, deep, 285f

external, 285f

Iliac crest, 155f-157f, 225f, 227f, 230f, 277f-278f, 281f, 284f

inner vs. outer lip of, 225f, 227f, 230f, 278f

intermediate zone of, 225f, 227f, 230f, 277f-278f

symmetry of

in postural assessment, 178t

as sacroiliac bony landmark, 239t, 240f

tuberculum of, 225f, 227f, 230f, 277f-278f

Iliac fossa, 230f

ala of ilium and, 227f, 277f

Iliac spine

anterior, inferior vs. superior, 225f, 230f, 277f-279f

in physical examination. _See_ Anterior superior iliac spine (ASIS); Posterior superior iliac spine (PSIS)

posterior, inferior vs. superior, 227f, 230f, 277f-279f

sacroiliac pain and

anterior superior, 241t

posterior superior, 236t, 238t

Iliac vein, external, 285f

Iliacus muscle, 161f, 234f, 282t, 283f, 334f

nerve branch to, 160t, 161f-162f

Iliocostalis cervicis muscle, 156f

Iliocostalis extensor muscle, 158f

Iliocostalis lumborum muscle, 156f, 156t

Iliocostalis muscles

sacroiliac, 232f, 232t

thoracic, 156f, 156t

Iliofemoral ligament, 279f, 279t

Iliohypogastric nerve, 160t, 161f-162f, 333f

lateral branch of, 162f

Ilioinguinal nerve, 160t, 161f-162f, 333f

Iliolumbar ligament, 154t, 230f

Iliopectineal bursa, 279f

Iliopsoas muscle, 283f, 285f

Iliopubic eminence, 225f, 227f, 230f, 277f-279f

female, 228f

Iliotibial band (ITB), length assessment of, , 301f, 301t

tensor fasciae latae complex and, 351t

Iliotibial tract, 283f, 331f-332f, 408f

blended into lateral patellar retinaculum, 329f

bursa deep to, 331f-332f

insertion of, to Gerdy tubercle, 331f

Ilium

body of, 227f, 277f

crest of. _See_ Iliac crest

spine of. _See_ Iliac spine

tuberosity of, 227f

wing of. _See_ Ala (wing)

Impingement sign, in ankle, , 436f, 436t

Impingement tests

compressive. _See_ Compression tests

FADIR. _See_ Flexion-internal rotation-adduction (FADIR) impingement test

Inclinometer

in cervical spine assessment, 97f, 98t-99t, 130t

in elbow flexion and extension measurement, 538t

in foot and ankle assessment, 422t

in hip and pelvis assessment, 288t

in muscle length assessment

of hip, 301t, 304f

of knee, 351t

in shoulder assessment, 463t,

in thoracolumbar spine assessment, 173t-174t, 175f, 201t, 209t

Infants, limited hip abduction in, with developmental dysplasia, , 294f, 294t

Inferior view

of atlas, 72f

of female pelvic outlet, 228f

floor of mouth, 22f

Inflammation. _See also_ Swelling

of knee, , 344t

lumbar pain and, 195f

Infraglenoid tubercle

of humerus, 452f

of scapula, 451f

Infrahyoid muscle, fascia of, 76f

Infrapatellar bursa

deep (subtendinous), 326f

subcutaneous, 326f

Infrapatellar fat pad, 326f, 329f

Infrapatellar synovial fold, 329f

Infraspinatus fascia, 155f, 456t

Infraspinatus muscle, 155f, 456f, 458f, 458t

atrophy, 504t

palpation test, 469t

tears of, 500-504, 500f-501f, 500t-503t

Infraspinatus tendon, 455f, 458f

Infraspinatus test, 597f, 597t

for rotator cuff tears, combined with other tests, 514t

Infraspinous fossae, 452f

notch connecting, 452f

Infratemporal fossa, 71f

Inguinal ligament, 161f, 283f, 285f

Inguinal (groin) pain

ipsilateral, 287t

knee interventions and, 382t

as lumbar zygapophyseal joint pain referral, 164f, 164t

patient history in, 287t

sacroiliac pain and, 236t, 238t

Injuries. _See_ Trauma; specific injuries
Innominate torsion, of sacroiliac region, , 254t-255t, 257t-259t

Instability. _See_ Stability/instability

Interalveolar septa, of mandible, 16f

Interarticular ligament, of rib head, 151f, 153f

Intercarpal joint, 559t

Intercarpal ligaments, interosseous, 559f

Interchondral joints, of thoracic spine, 150f, 152t

Interchondral ligaments, 153t

Interclavicular ligament, 150f, 452f, 454t

Intercondylar area, of tibia, anterior and posterior, 325f

Intercondylar eminence, of tibia, 325f

Intercondylar fossa, of femur, 325f

Intercondylar (T or Y) fracture, of femur, 341f

Intercondylar tubercle, of tibia, lateral and medial, 325f

Intercostal muscle, external, 157f

Intercostal nerves

1st, 83f

of thoracic spine, 160f, 160t, 162f

external, 160f

innermost, 160f

window cut in, 160f

internal, 160f

anterior to external, 160f

as ventral (anterior) ramus of spinal nerve, 160f

Intercostobrachial nerve, 460f

Intercuneiform ligaments, dorsal, 403f-404f, 403t

Intermetacarpal joints, 559f

Intermuscular septum

of hip and pelvis, anteromedial, 283f, 285f

of muscle, 533f, 536f

Internal rotation, of hip and pelvis, length assessment with, 295t-296t

Internal rotation (IR) lag sign, in shoulder, , 505t

Internal rotation resistance strength (IRRS) test, of shoulder, , 499f

Internal rotation test

of foot, for TMJ disorders, diagnostic utility, 55t

of hip and pelvis, 289t

Internal rotation-flexion-axial compression maneuver, for intraarticular hip pathology, 311f, 312t

Interosseous artery

anterior and posterior, 533f, 536f

common, 534f, 536f

Interosseous border, of forearm, 532f

Interosseous ligaments, intercarpal, 559f

Interosseous membrane, 563f, 565f

of ankle joint, 402f, 402t

dorsal, 410f

of forearm, 532f, 532t

1st dorsal, 533f

of knee, 328f

of wrist joint, 560f-561f

1st dorsal, 559f

Interosseous muscles, 406f, 409f

of foot and ankle

4th, superficial branch of tibial nerve to, 417f

deep branch of tibial nerve to, 417f

dorsal, 411t, 415f, 415t

plantar, 414f, 415t

of hand

1st dorsal, 568f

deep branch of ulnar nerve to, 568f

dorsal (bipennate), 567t, 568f

innervation of, 570f

palmar, 567t

innervation of, 570f

manual testing of, 91f

for cervical radiculopathy, 92t

Interosseous nerve

anterior, 565t-566t, 569f

of forearm

anterior, 536f, 536t

posterior, 536t

of leg, 417f

posterior, 563t-564t, 571f

Interphalangeal (IP) joints, 401t, 406f, 559t

AOFAS scale for, 441t

capsules and ligaments of, 405f, 405t

distal, 562f

ligaments of, , 562f, 562t

nodules over, 432f

proximal, 562f

measurement of, 581f

Intersegmental tenderness, of thoracolumbar spine, 188t

Interspinalis lumborum muscle, 157f, 157t

Interspinalis muscle, 157f, 157t

Interspinous ligaments, 154f, 154t

of cervical spine, 75t

of thoracolumbar spine, in ankylosing spondylitis, 169f

Intertransversarius muscle, lateral, 157f, 157t

Intertransverse ligaments

of cervical spine, 75t

of thoracolumbar spine, 151f, 153f, 154t

Intertrochanteric crest, 277f, 279f, 284f

Intertrochanteric fracture, of femur, 313f

Intertrochanteric line, 277f, 279f

Intertubercular sulcus, of humerus, 451f

Intertubercular tendon sheath, 454f

Interval estimate,

Intervertebral discs

cervical, 75f

herniation. _See_ Disc herniation

lumbar, 149f, 152f, 154f

neovascularization of, 195f

ossification of, in ankylosing spondylitis, 169f

in scoliosis pathology, 179f

Intervertebral foramen

of lumbar vertebrae, 152f, 154f

impact of degenerative disc disease on, 200f

of sacrum, 226f

for spinal nerve, 73f

of thoracic vertebrae, 154f

lower margin of, 149f

Intervertebral joints

cervical, , 73f

lumbosacral, 229t

thoracolumbar, 152t

Intervertebral motion. _See_ Passive intervertebral motion (PIVM)

Intervertebral spaces, thoracolumbar, in degenerative disc disease, 200f

Intra-articular ligament

costovertebral, 153f, 153t

of thoracic spine, 151f

Intra-class correlation coefficient (ICC), 2-3

Inversion, subtalar joint, 422t

Inverted supinator sign, cervical myelopathy and, 124t-125t, 126f

IP joints. _See_ Interphalangeal (IP) joints

Ischial spine, 225f, 227f, 230f, 277f-279f, 284f

female, 228f

(Ischio-)coccygeus muscle, 234f

Ischiofemoral ligaments, 279f, 279t

Ischium

body of, 227f, 277f

bursitis of, 286t

ramus of, 227f, 277f

spine of. _See_ Ischial spine

tuberosity of, 225f, 227f, 230f, 277f

male vs. female, 228f

Isometric strength, of knee, extensor vs. flexor, 350t

J

Jerk test

for glenoid labral tears, , 488t-489t

posterior, 488t-489t

for supraspinatus and/or infraspinatus tears, lateral, 501t-503t

Job activities, sacroiliac pain aggravated by, 236t

Jobe relocation test, of shoulder, 475t

combined with other tests, , 512t, 514t

Joint anatomy. _See_ Arthrology

Joint capsule(s)

acromioclavicular, 454f

in anterior disc displacement, 27f

atlantoaxial, lateral, 74f-75f

atlanto-occipital, 74f-75f

of elbow, 530f-531f

interphalangeal, 405f, 405t

of knee, 329f, 332f

attachment of, 328f

edge arching over popliteus muscle, 328f

iliotibial tract blended into, 329f

medial patellar retinaculum blended into, 329f

of mandible, 18f-19f, 27f

metacarpophalangeal and interphalangeal ligaments, 562f

metatarsophalangeal, 405f, 405t

of shoulder, pain in, 461t

zygapophyseal

cervical, 74f-75f

thoracolumbar, 154f

Joint injury, elbow, indication of, , 541t

Joint line fullness, , 361t

Joint line tenderness, of knee, ,

with meniscal tears, 376t-377t

palpation for, 361t

Joint play, in temporomandibular joint

joint sounds during, , 40t

pain during, , 51f

ROM with,

Joint play test, of temporomandibular joint,

Joint position sense test, of shoulder, 465t

Joint sounds, in temporomandibular joint, 40-42, 40t

during active motion, , 40t

during joint play, , 40t

Joints. _See also_ specific joints

of cervical spine, , 73f

of elbow, 530f, 530t

of foot and ankle, 401f, 401t

of hip and pelvis, 278f, 278t

of knee, 326t

of lumbar spine, , 152t

paraspinal, palpation of, 109t

of sacroiliac region, 229f, 229t

of shoulder, 452t

integrated movements of, , 453f

temporomandibular, 18f

of thoracic spine, , 150f-151f, 152t

of wrist, 559f, 559t

Jugular notch, 76f

Jugular process, of occipital bone, 79f

Jugular vein, internal, 76f, 78f-79f

K

Kappa coefficient (κ), 2-3

Kellgren grading scale, for hip osteoarthritis, 287t

Kendall grades, of muscle strength, 92t

Key pinch strength, 583f

Kibler test, for glenoid labral tears, , 485f, 485t

Kim test, for glenoid labral tears, , , 486f, 486t

Knee, 323-395

arthritis of. _See_ Osteoarthritis (OA)

arthrology of,

clinical summary and recommendations,

diagnostic utility of examination

anterior drawer test, 365-366, 365t-366t

Apley test, , 371f, 371t

combinations of tests, 376-379

for meniscal tears, 376-377, 376t-377t, 378f

for other pathology, , 379t

Ege test, 372f, 372t

Lachman test, , 364f, 364t

McMurray test, , 370t

meniscal tears identification, , 372f-373f

combinations of tests, 376-377, 376t-377t, 378f

moving patellar apprehension test, , 375f, 375t

patient history, 339-340, 339t-340t, 379t

Pittsburgh Decision Rule for Radiography, , 343t

pivot shift test, , 367f, 367t

predicting response to foot orthoses and activity modification, 380-381, 380f, 381t

predicting response to hip mobilizations, , 382t, 383f

radiography rule for fracture, , 342f, 342t

strength assessment, 350t

Thessaly test, 373f

valgus stress, , 369t

fractures of,

distal femur and, 341f

interventions for,

groin pain and, 382t

hip distraction with, 382t

hip mobilization as, , 382t, 383f

orthoses and activity modification as, 380-381, 380f, 381t

thigh pain and, 382t

ligaments of,

anterior, 329f

inferior, 329f

posterior, 327f-328f, 327t

meniscus of. _See_ Meniscus

"moving patellar apprehension test",

muscles of,

anterior, 331f

lateral and medial, 332f

nerves of,

femoral and lateral femoral cutaneous, 333t, 334f

obturator, 333f, 333t

sciatic and posterior femoral cutaneous, 335f

osteology of,

femur, 325f

fibula, 325f

tibia, 325f

outcome measures of, 384t

patient history and, ,

initial hypotheses based on, , 336t

with osteoarthritis, 336t-337t, , 337f

report of pain, 336t-337t

report of swelling, 336t-337t, 340t, 344t

report of trauma, 336t, 340t

physical examination of, 324t, 341-383

to identify radiographic needs following trauma, 341f

quality appraisal of reliability studies, 385-388, 385t-392t

range of motion measurements of,

active and passive, 346-347, 346f, 346t-347t

physical examination of, 346-349

in slump test, 194f, 194t

reliability of examination

anterior drawer test, , 365f, 365t

bony alignment assessment, 352-359

A angle measurement, , 359f, 359t

lateral pull test, , 359t

mediolateral patellar tilt, , 352f, 352t

patellar orientation, 353-354, 353f, 353t-354t

patellar rotation, , 356f, 356t

quadriceps angle measurements, , 358f, 358t

superoinferior patellar tilt, , 355f, 355t

capsular and noncapsular end feel determination, , 348f, 348t

inflammation detection, , 344f, 344t

Lachman test, 348t, 362-363, 362f, 362t-363t

McMurray test, , 370f, 370t

muscle length assessment, , 351f, 351t

pain during palpation, , 360f, 360t

pain during range of motion movements, , 349t

patient history, , 337f, 337t

range of motion measurements, , 346-347, 346f, 346t-347t

strength assessment, , , 350t

varus and valgus stress tests, , 369f, 369t

in straight-leg raise test, 192t

x-rays of. _See_ Ottawa Knee Rule for Radiography.

Knee bend test, prone, , 260f, 260t

Knee jerk reflex, with herniated lumbar nucleus pulposus, 171f

Knee Outcome Survey (KOS), 384t

Knee pain

anteromedial, history of, in diagnosing pathology, 379t

hip mobilizations and, 382t

during palpation, , 360f, 360t

in patellofemoral syndrome. _See_ Patellofemoral pain syndrome

patient reports of, 336t-337t

during range of motion, , 349t

during varus and valgus stress tests, 369t, 376t-377t

Kyphosis, of thoracic spine, 132t

postural assessment and, 110f, 110t

L

L1 vertebra

nerves of, 160t, 161f-162f, 333f-334f

osteology of, 225f

in zygapophyseal pain referral pattern, 164f

L2 vertebra

nerves of, 160t, 161f-162f, 330t, 333f-334f, 333t, 416t

osteology of, 225f

in zygapophyseal pain referral pattern, 164f

L3 vertebra

disc herniation at level of, 171f

nerves of, 160t, 161f-162f, 284t, 330t, 333f-334f, 333t, 416t, 417f

osteology of, 225f

posterior view of, 152f

in zygapophyseal pain referral pattern, 164f

L4 vertebra

disc herniation at level of, 171f

nerves of, 160t, 161f-162f, 233t, 234f, 284t, 330t, 333f-335f, 333t, 407t, 416t, 417f

osteology of, 225f

posterior view of, 152f

in zygapophyseal pain referral pattern, 164f

L5 vertebra

disc herniation at level of, 171f

nerves of, 160t, 161f-162f, 233t, 234f, 330t, 333f, 333t, 335f, 407t, 416t, 417f

osteology of, 225f

as sacroiliac bony landmark, 239t

motion assessment and, 254t

in zygapophyseal pain referral pattern, 164f

Labia, perineal nerve of, posterior branch of, 162f

Labral tears

acetabular, , 287t

palpation of, , 469t

patient history in, diagnostic utility of, , 462t

of shoulder. _See_ Glenoid labral tears

Lachman test, of knee, , 362f

diagnostic utility of, , 364f, 364t

end-feel assessment during, 348t

reliability of, 362-363, 362f, 362t-363t

Lacrimal bone, 17f

Lacrimal sac, fossa for, 17f

Lag signs, in shoulder external rotation,

Lambdoid suture, 17f

Lamina

of cervical vertebrae, 72f

of lumbar vertebrae, 149f, 152f, 154f

in scoliosis pathology, 179f

of thoracic vertebrae, 149f, 154f

Lateral bending

of cervical spine, 98t

pain during, 100t, 105t

of thoracolumbar spine, 173t-174t

Lateral collateral ligament (LCL), injury of, 336t

Lateral glide test, of cervical spine, 105t

Lateral hip tendon, identifying pathology of, , 298f, 298t

Lateral ligaments. _See_ Collateral ligaments

Lateral mass, of atlas, 72f

Lateral pull test, for patellar alignment, , 359t

Lateral raphe,

Lateral slide test, for scapular asymmetry, 470t

Lateral view

of ankle ligaments, , 403f

of elbow bones, in extension vs. flexion, 529f

of elbow ligaments, in flexion, 531f

of foot and ankle, 399f

Ottawa rules in, 420f

of hip and pelvis ligaments, joint opened, 279f

of hip bone, 227f

of knee muscles, 332f

left

of costovertebral joints, 151f

of costovertebral ligaments, 153f

of lumbar vertebrae, 152f

of thoracolumbar ligaments, 154f

of leg muscles, 408f

of mandibular nerve, 24f

of muscles involved in mastication, 21f

of pelvis, 277f

right

of cervical spine arthrology, 73f

of cervical spine ligaments, 75f

of shoulder ligaments, 455f

of T6 vertebra, 149f

of T12 vertebra, 149f

Latissimus dorsi muscle, 155f, 155t, 160f, 456f-457f, 456t, 460f

length assessment of, 111t, 466t

Lawrence grading scale, for hip osteoarthritis, 287t

LCL. _See_ Lateral collateral ligament (LCL)

Leaning head on palm, and TMJ disorders, , 25t

LEFS. _See_ Lower Extremity Functional Scale (LEFS)

Leg. _See also_ Lower extremity

bones of. _See_ Femur; Fibula; Tibia

muscles of, lateral, , 407t, 408f

nerves of, , 416f-417f, 416t. _See also_ Thigh

Leg length discrepancy/inequality

in postural assessment, 178t

in TMJ disorders, diagnostic utility of, 55t

Leg lowering, 180t

Leg raise test. _See_ Straight-leg raise (SLR) test

Levator anguli oris muscle, 20f

Levator ani muscle, nerves to, 162f, 233t, 234f

Levator costae muscle, 157f

Levator labii superioris alaeque nasi muscle, 20f

Levator labii superioris muscle, 20f

Levator scapulae muscle, 80t, 155f, 456f, 456t

length assessment of, 111t

Levator veli palatini muscle, 21f

Levatores costarum brevis muscle, 157f

Levatores costarum longus muscle, 157f

Lift test, of multifidus muscle, , 188t

Lifting/carrying, thoracolumbar pain with, 166t

Lift-off test

for subacromial impingement, , 497t

for subscapularis tears, 507t-508t, 508f

Ligamenta flava

of cervical spine, 75f, 75t

of thoracolumbar spine, 154t

Ligaments. _See also_ Collateral ligaments

of cervical spine, 72f-73f

atlantooccipital joint, 74-75, 74f, 74t

spinal, 75f, 75t

of elbow, 531-532, 531f, 531t

of foot and ankle, 402-405

lateral, , 403f, 403t

medial, , 404f, 404t

plantar, , 405f-406f, 405t

posterior, , 402f, 402t

sprain injuries of, 418t

of forearm, , 532f, 532t

of hip and pelvis, 279f

of knee,

anterior, 329f

inferior, 329f

posterior, 327f-328f, 327t

of sacroiliac region, 230-231, 230f, 231t

of shoulder, 452f, 454t

anterior view of, 454f-455f

coronal section, 455f

lateral view of, 455f

temporomandibular, , 19f

of thoracolumbar spine, 153-154, 154f, 154t

costovertebral, 151f, , 153f, 153t

sternocostal, 150f

of wrist, 560-562

metacarpophalangeal and interphalangeal, , 562f, 562t

palmar, , 560f, 560t

posterior, , 561f, 561t

Ligamentum nuchae, of cervical spine, 75f, 75t

Likelihood ratios, 6-8

application of. _See_ Clinical prediction rule

positive or negative, 7f, 7t, 11t

interpretation of, 8-9, 9f, 11t

Limbs. _See_ Lower extremity; Upper extremity

Linea alba, 160f

Linea aspera, medial vs. lateral lip of, 277f

Linea terminalis, 226f

Lingual nerve, 19f, 21f, 23f-24f,

Lingula, 16f

Lips

of iliac crest, inner vs. outer, 225f, 227f, 230f, 278f

of linea aspera, medial vs. lateral, 277f

Load, in biceps test(s) I/II, for labral tears, , , 487f, 487t

combined with other tests, , 512t

Log roll, for intraarticular hip pathology, 311t

Longissimus capitis muscle, 80t, 81f, 156f

Longissimus cervicis muscle, 80t

Longissimus extensor muscle, 158f

Longissimus lumborum muscle, 156f, 156t

Longissimus muscles

sacroiliac, 232f, 232t

thoracic, 156f, 156t

Longitudinal ligaments

of cervical spine

anterior, 75f, 75t

posterior, 74f, 75t

costovertebral, anterior, , 153f, 153t

of sacroiliac region, anterior, 230f, 231t

of thoracolumbar spine

anterior, 151f, 154f, 154t

ossification of, 169f

posterior, 154f, 154t

nociceptors in, 195f

Longitudinal (vertical) tear, of meniscus, 378f

Long-sit test, of sacroiliac joint, , 257f, 257t

Longus capitis muscle, , 79f

Longus colli muscle, , 79f

nerve to, 83f

Longus muscle, 282t

Loose body, within knee joint, 336t

Lordosis, lumbar, in ankylosing spondylitis, 204t

Loss-of-extension test, in anterior cruciate ligament tears, , 368f, 368t

Low back pain. _See also_ Thoracolumbar pain

ankylosing spondylitis causing, 204t

centralization phenomenon in, 148t

vs. peripheralization phenomenon, , 189t-190t, 190f

classification systems for, , 205t

treatment-based, , 206t

clinical prediction rule for,

inflammation role in, 195f

and limited passive intervertebral motion,

lumbosacral manipulation for,

motion assessment for, 256t-260t, 262t

neurological examination for, 170t, 171f, 172t

palpation identification of, 187t

passive intervertebral motion assessment for, 181-184, 181t, 184f, 184t,

patient report of, 163t, 166t-168t

physical examination for, 198t-200t

provocative test for, 241t, 243t-252t

radiographic examination for, 201t

referral patterns of, zygapophyseal, 163t, 164f

sacroiliac joint in, , 236t

bony landmark symmetry and, 239t

spinal manipulation for, 265f-266f, 266t

classification system based on, , 206t

clinical prediction rule for, 265-266

Flynn technique for, 208f

lumbosacral, 148t, 206t-207t, , 208f

stabilization exercise programs for, 148t, , 209t

classifications based on, 206t

straight-leg raise tests for, 191t-193t

Lower extremity. _See also_ specific anatomy

measurements of, in TMJ disorders, diagnostic utility of, , 55t

pain in, with lumbar spine pathology, 171f, 200t, 209t

paresthesias of, with lumbar pain, 163t

Lower Extremity Functional Scale (LEFS)

in foot and ankle outcomes, 441t

in hip and pelvis outcomes, 316t

in knee outcomes, 384t

Lumbar lordosis, in ankylosing spondylitis, 204t

Lumbar nucleus pulposus, herniated, clinical features of, 171f

Lumbar paravertebral myofascial pain, 188t

Lumbar plexus, 162f, 333f-334f

Lumbar radiculopathy

neurological examination for, 170-172, 170t

patient history in, 163t, , 168t, 418t

slump test for, 148t, 194f, 194t

straight-leg raise test for, 148t, 191f

crossed, 148t, , 193t

diagnostic utility of, , 192t

reliability of, , 191f, 191t

Lumbar spinal stenosis

clinical summary and recommendations for, 148t

neurological examination for, , 172f, 172t

patient history in, 163t, , 167t

physical examination tests for, 148t, , 200f, 200t

Lumbar spine

arthrology of,

clinical summary and recommendations, 148t

diagnostic utility of examination

centralization phenomena, , 190f, 190t

crossed straight-leg raise test, , 193t

neurological examination, 170-172, 170t, 171f-172f, 172t

passive intervertebral motion assessment

excessive, , 186f, 186t

limited and painful, 184-185, 184f-185f, 184t

spinal manipulation factors, , 207t, 208f

stabilization exercise factors, , 209t

stenosis tests, , 200f, 200t

straight-leg raise test, , 192t

fascia of, 155f-156f,

hypermobile segments of, 182t, 201t, 203f

hypomobile segments of, 182t, 201t, 203f

hypomobility of,

instability of, 163t

dynamic "corset" concept of, 158f

radiographic tests for, 201-203, 201t, 202f-203f

segmental tests for, 198-199, 198t-199t

muscles of, , 155f, 155t

nerves of, 161f-162f

anterior vs. posterior divisions of, 161f

lumbosacral trunks of, 161f

osteology of, 149f

pain in. _See_ Low back pain

reliability of examination

assessing lumbar multifidus muscle function via palpation, , 188t

centralization phenomena identification, , 189t

identifying segmental levels, , 187t

instability tests

radiographic, 201-203, 201t, 202f-203f

segmental, 198-199, 198t-199t, 199f

palpation of tenderness, , 188t

passive intervertebral motion assessment, 181-182, 181t-182t

pain during, , 183f, 183t

straight-leg raise test, , 191f, 191t

Lumbar stabilization program, for low back pain, 148t, , 209t,

classifications based on, 206t

Lumbar triangle, internal oblique muscle in, 155f

Lumbar vertebrae. _See also_ specific vertebra

accessory process of, 149f, 152f

articular processes of

inferior, 152f, 154f

superior, 149f, 152f, 154f

segmental mobility of. _See_ Segmental mobility testing

spinous process of, 149f, 152f, 154f

in palpation examination, 188t

transverse processes of, 149f, 152f, 154f, 225f, 278f

Lumbopelvic pain, 244t-246t, 249t, 262t

in lumbar segmental instability, 198t-199t

Lumbopelvic rhythm, in lumbar segmental instability, 198t-199t, 209t

Lumbosacral articular surface, 226f

Lumbosacral radiculopathy, neurological examination for, 170-172, 170t

Lumbosacral region, joints in, 229t

Lumbosacral spine, pain diagnoses related to, 249t

Lumbosacral/pelvic manipulation,

classification based on, 206t-207t

combined factors of likely benefits, , 208f, 208t

for low back pain, 148t

single factors of likely benefits, , 207t

Lumbrical muscles, 412f-413f, 413t, 415f

1st, 417f

2nd, 417f

3rd, 417f

4th, 417f

innervation of, 569f-570f

lateral and medial, 567t

tendons of, 414f

Lumbrical nerve, 417f

Lumbrical provocation test, 602t

Lumbrical tendon, 4th, 406f

Lunate, 557f-561f

in scaphoid fractures, 577f

Lunge test

for ankle ROM measurements, 422t, 423f

for pelvic pain, 307t

Lying down

sacroiliac pain relieved by, 236t

thoracolumbar pain with, 166t, 169t, 184f, 184t

Lying flexion test, of lumbar spine, 186f, 188t

M

Magnetic resonance imaging (MRI)

of cervical spine injury, 95t

of lumbar spinal stenosis, 167t, 172t, 200t

of lumbar spine herniations, 192t, 196t

sacroiliac pain and, 242t, 244t-246t, 248t-251t

Magnus muscle, 282t

Male pelvic inlet, anterior view of, 228f

Male pelvis, anterior view of, 228f

Malleolar artery, anterior, lateral vs. medial, 410f

Malleolar zone, in physical examination, 420f

Malleolus/malleoli

lateral, 408f-410f

tuning fork test of, 420t

medial, 409f-410f

direct compression stress test, 420t

as sacroiliac bony landmark, 239t

in physical examination, 419t-420t, 420f, 423f, 431t

in sacroiliac motion assessment, 257t

Mammillary process, of lumbar vertebrae, 149f, 152f

Mandible

alveolar part (crest), 16f

in anterior disc displacement, 27f

base of, 16f

body of, 15f, 17f, 71f

condylar process of, 71f

coronoid process of, 71f

digastric fossa of, 16f

head of, 16f

mental tubercle of, 16f

neck of, 16f

oblique line of, 16f-17f

opening of, measuring with different head positions, , 46t

osteology of

in relation to head and neck, 15f

in relation to lateral skull, 17f

ramus of, 15f, 17f, 71f

translation of, 46f

Mandible angle, 15f, 17f, 71f

Mandibular foramen, 16f, 24f

inferior alveolar nerve entering, 24f

Mandibular fossa, 18f

Mandibular Function Impairment Questionnaire (MFIQ), 62t

Mandibular nerve,

anterior vs. posterior division of, 24f

deep temporal branches of,

meningeal branch of, 24f

via masseteric nerve,

Mandibular notch, 15f-17f, 71f

Manual muscle testing (MMT)

of hand,

of knee, , , 350t

of lumbar spine, 148t

for radiculopathy, , 170t, 172f

for spinal stenosis, 172f, 172t

of shoulder,

of upper limb, 91f, 91t

for cervical radiculopathy, , , 92t

Manubriosternal joint, 150f

Manubriosternal synchondrosis, 452f

Manubrium, 150f, 452f

of sternum, 76f

Masseter muscle, , 20f, 76f

deep vs. superficial part of, 20f

insertion of, 20f

palpation of, 37f

in physical examination, 36f

pressure pain thresholds of, 39t

Masseteric artery, 20f-21f

Masseteric nerve, 20f-21f, 24f

mandibular nerve via,

Mastication, muscles involved in, , 20f-21f

Mastoid process, 15f, 17f, 22f, 71f, 76f, 78f-79f, 157f

palpation of, 108t

Maxilla, 17f

alveolar process of, 71f

frontal process of, 17f

traction test and, 115t

tuberosity of, 71f

Maxillary artery, 19f-21f, 24f

Maxillary nerve, , 24f

McCreary grades, of muscle strength, 92t

McKenzie evaluation/classification

of discogenic pain, , 264f

of low back pain, 205t

of lumbar spine motion, 189t-190t

MCL. _See_ Medial collateral ligament (MCL)

McMurray test, of knee,

diagnostic utility of, , 370t

combinations of tests, 376t-377t

with internal and external rotation, 370f

reliability of, , 370f, 370t

MCP joint. _See_ Metacarpophalangeal (MCP) joint

Measurement error,

determination of acceptable, 2-3

Mechanical cervical traction, for cervical radiculopathy

after three weeks, 135-136, 135t-136t

cluster of findings in, , 137f, 137t

Medial collateral ligament (MCL),

tears

in elbow, , , 544f, 544t

in knee, 369t

patient history in, 336t, 340f, 340t

Medial ligament, of ankle, 402f, , 404f, 404t

tibiocalcaneal part of, 404f, 404t

tibionavicular part of, 404f, 404t

tibiotalar part of, anterior vs. posterior, 404f, 404t

Medial tibial stress syndrome, 418t

Medial view

of elbow bones, extension vs. flexion, 529f

of elbow ligaments, in flexion, 531f

of foot and ankle, 399f

of ankle ligaments, , 404f, 404t

Ottawa rules in, 420f

of hip bone, 227f

of knee muscles, 332f

of mandibular nerve, 24f

of metacarpophalangeal and interphalangeal ligaments, in extension vs. flexion, 562f

of pelvis, 277f

of sacroiliac region nerves, 234f

Median nerve, 460f, 565t-567t, , 569f, 569t
anterior vs. posterior view of, 569f

articular branch of, 569f

branches to hand muscles, 568f

branches to phalanges, dorsal, 569f

in carpal tunnel syndrome, 574f

of cervical spine, 82t, 83f

in brachial plexus schema, 509f

communicating branch of, 569f

compression of, 574f

of forearm, 534f, 536f, 536t

palmar branch of, 534f

inconstant contribution to, 569f

palmar branch of, 569f

Median raphe between mylohyoid muscle, 22f

Mediolateral displacement, of patella, 353t-354t

Mediolateral glide, of patella, 353t-354t

Mediolateral orientation/position, of patella, 353f, 353t-354t

Meningeal artery, middle, 19f, 21f, 24f

Meningeal nerve, recurrent, lumbar disc herniation and, 195f

Meniscal tears, of knee,

Ege test for, 372f, 372t

joint line tenderness with, 361t

patient history in, 336t, , 338t

Thessaly test for, 373f, 373t-374t

types of, 378f

Meniscofemoral ligament, posterior, 327f, 327t, 329f

Meniscus

in anterior disc displacement, 27f

of knee

cyst of, 379t

lateral, 326f-327f, 329f

medial, 327f, 329f

of wrist, 559f

Mennell test, , 251f, 251t

combined with other tests, 262t

Mental foramen, of mandible, 16f-17f

Mental nerve, 24f

Mental protuberance, of mandible, 16f

Mental spine, superior, for genioglossus muscle, 23f

Mentalis muscle, 20f

Metacarpal arteries, palmar, 568f

Metacarpal bones, 558f-562f

1st, 533f, 536f, 558f-561f

2nd, 533f, 558f-561f

3rd, 558f-561f

4th, 558f-561f

5th, 533f, 536f, 558f-561f

base of, 558f

compression of, for scaphoid fractures, 575t

head of, 558f

palmar vs. dorsal view of, 557f, 562f

shafts of, 558f

Metacarpal ligaments

deep transverse, 562f, 562t, 567f-568f

dorsal, 561f, 561t

palmar, 560f, 560t, 562f

Metacarpophalangeal (MCP) joint, 559t

ligaments of, 562f

Metalloproteinases, in lumbar pain, 195f

Metatarsal arteries

anterior perforating branches of, 415f

common plantar digital arteries from, 412f

dorsal, 410f, 415f

anterior perforating arteries to, 414f-415f

posterior perforating branches of, 415f

plantar, 414f-415f

anterior perforating branches from, 410f

Metatarsal bones, 399f-400f, 405f, 410f, 415f

1st, 399f-400f, 404f, 406f

in physical examination, 430t

tuberosity of, 399f, 404f

2nd, 400f

3rd, 400f

4th, 400f

5th, 400f, 406f, 408f

in physical examination, 420f, 431t

tuberosity of, 399f-400f, 406f, 414f-415f

base of, 400f

head of, 400f

erosion of, 432f

plantar metatarsal ligaments between bases of, 415f

shaft (body) of, 400f

Metatarsal drift, 432f

Metatarsal ligaments

deep transverse, 405t, 415f

dorsal, 403f, 415f

plantar, 406f

between bases of metatarsal bones, 415f

Metatarsalgia, 418t

Metatarsophalangeal (MTP) joints, 401f, 401t, 406f

AOFAS scale for, 441t

capsules and ligaments of, 405f, 405t

in physical examination, 432t

MFIQ (Mandibular Function Impairment Questionnaire), 62t

Michigan Hand Outcomes Questionnaire (MHQ), 604t

Midcarpal joint, 559f

Middle temporalis muscle, pressure pain thresholds of, 39t

Midfoot

AOFAS scale for, 441t

fractures of, , 420t

Midfoot zone, in physical examination, 420f, 420t

MMT. _See_ Manual muscle testing (MMT)

Mobilizations, of hip, for knee osteoarthritis, , , 382t, 383f

Morton neuroma, 418t

Motion assessment, 254-260

active. _See_ Dynamic movements; Functional movements

McKenzie-type repeated, 190t

passive. _See_ Passive intervertebral motion (PIVM)

for range. _See_ Range of motion (ROM)

Motor control assessment, 180f, 180t

Motor innervation

of cervical spine, 82t

of foot and ankle, 416t

of hand, 569t-571t

of lumbar spine, 160t

of sacroiliac region, 233t

of thoracic spine, 160t

Mouth floor, muscles of,

Movement, for epicondylalgia, , 548t

Movement velocity, in balance assessment, 428t

MRI. _See_ Magnetic resonance imaging (MRI)

MSR (muscle stretch reflex), for cervical radiculopathy, , 93f, 93t

MTP joints. _See_ Metatarsophalangeal (MTP) joints

Multifidus extensor muscle, 158f

Multifidus muscle, 157f, 157t

in lumbar spine, hypertonicity of, 181t

sacroiliac, 232f, 232t

Muscle atrophy

in hand, 574f

with herniated lumbar nucleus pulposus, 171f

in shoulder, 472f

Muscle length, assessment of

in cervical spine, , 111f, 111t

of hip and pelvis, 301-303

flexor contracture, , 302f, 302t

iliotibial band length, , 301f, 301t

reliability of, , 303t, 304f

in knee, , 351f, 351t

Muscle strength

in foot and ankle, , 424f

in hip and pelvis

during resisted tests, 295-296, , 298f, 298t

Trendelenburg test for, , 299f, 299t

in lower extremity

with herniated lumbar nucleus pulposus, 171f

with lumbar spinal stenosis, 172f, 172t

manual. _See_ Manual muscle testing (MMT)

in shoulder, , , 465t

in thoracolumbar spine, 148t, , 177f, 177t

Muscle stretch reflex (MSR), for cervical radiculopathy, , 93f, 93t

Muscle tightness, in shoulder, , 466t

Muscles

of elbow, 533-535

of foot and ankle

dorsum, 410-411, 410f, 411t

leg vs.,

in sole

deep interosseous, , 415f, 415t

first layer of, , 412f, 412t

second layer of, , 413f, 413t

third layer of, , 414f, 414t

of forearm, 533-535

anterior and posterior, , 533f

anterior view of, 534f, 534t

posterior view of, 533f, 533t

supinators and pronators, , 535f, 535t

of hand, 563-567

extensor, 563-564, 563f, 563t-564t

flexor, 565-566, 565f, 565t-566t

intrinsic, , 567f-568f, 567t

of hip and pelvis, 280-282

anterior, , 282t, 283f

posterior, , 280t, 281f

of knee,

anterior, 331f

lateral and medial, 332f

of leg, lateral, 407-408, 407t, 408f

manual testing of, for radiculopathy, 91f, 91t-92t

of neck, 76-80

anterior, , 76f

posterior,

scalene and prevertebral,

suprahyoid and infrahyoid,

paraspinal, palpation of, 109t

ruptures and tears of. _See_ specific muscle

of sacroiliac region, , 232f, 232t

of shoulder, 456-458

anterior, , 457f, 457t

posterior, , 456f, 456t

of rotator cuff, , 458f, 458t

stress injuries of. _See_ Sprains; Strains, muscle

of temporomandibular joint, 20-22

floor of mouth,

involved in mastication, , 20f-21f

tendons of. _See_ Tendons

of thoracolumbar spine, , 155f, 155t

anterior abdominal wall, 158f

deep layer of, , 157f, 157t

intermediate layer of, , 156f, 156t

superficial layers of, , 155f, 155t

Musculocutaneous nerve

of cervical spine, 82t, 83f

in brachial plexus schema, 509f

in forearm, 534f, 536f, 536t

innervation of, 569f

in shoulder, 459t, 460f

Myalgia, in TMJ disorders, diagnostic criteria for,

Myelography

cervical, 108t, 115t, 117t,

CT, for brachial plexus palsy, 509t

Mylohyoid artery, 23f

Mylohyoid groove, 16f

Mylohyoid line, 16f

Mylohyoid muscle, 22f-24f, 22t, 36f, 76f, 77t, 78f

median raphe between, 22f

Myofascial pain

lumbar paravertebral, 188t

piriformis, 188t

tensor fasciae latae, 188t

in thoracolumbar spine, palpation identification of, 188t

in TMJ disorders, diagnostic criteria for,

N

Napoleon test, for subscapularis tears, , 508t

Nares, posterior, 71f

Nasal bone, 17f

Nasal spine, anterior, of maxilla, 17f

Navicular bone, 399f-400f, 404f, 415f

in physical examination, 420f, 425t, 431t

tuberosity of, 399f-400f, 406f, 410f, 415f

Navicular drop test, 425t

Navicular height, measurement of, , 425f, 425t

Neck

bony framework of

cervical spine and, 71f

in relation to TMJ, 15f

muscles of,

anterior, , 76f

palpation of, 109t

posterior,

scalene and prevertebral,

suprahyoid and infrahyoid,

nerves of, , 82t, 83f

pain during flexion and extension of, 101t

posterior triangle of, 155f

range of motion of, in slump test, 194f, 196t

tenderness in, 108t

veins of, 76f, 79f

Neck Disability Index (NDI), 131t

for cervical spine outcomes, 138t

Neck flexor muscle endurance test, 102t

Neck pain. _See_ Cervical (neck) pain

Necrosis

avascular, of hip and pelvis

detection with limited ROM, , 293f, 293t

patient history in, 286t

osteonecrosis, of hip and pelvis, 293f, 293t

Needle electromyography, for cervical radiculopathy, 88t, 90t, 92t-93t, 113t-114t, 129t

Neer test, , 492t

combined with other tests, 514t

for subacromial impingement, , 492-493, 492f, 493t

Negative predictive values (NPV), , 4t, 11t

Nerve conduction studies

for carpal tunnel syndrome, , 597t

for cervical radiculopathy, 88t, 90t, 92t-93t, 113t-114t, 129t

Nerve fibers, unmyelinated, in lumbar spine, 195f

Nerve root-dura interface, in lumbar pain, 195f

Nerve roots. _See also_ Spinal nerve roots

avulsions of, in brachial plexus,

compression of, with herniated disc, 87f

Nerve to abductor digiti minimi muscle, 413f, 417f

Nerve to coccygeus, 162f

Nerve to inferior gemellus muscle, 162f, 233t, 234f, 284f

Nerve to levator ani muscle, 162f, 233t, 234f

Nerve to mylohyoid, 21f, , 24f

Nerve to obturator internus muscle, 162f, 233t, 234f, 284f

Nerve to piriformis muscle, 162f, 233t, 234f

Nerve to popliteus muscle, 417f

Nerve to quadratus femoris muscle, 162f, 233t, 234f, 284f

Nerve to subclavius, 82t, 83f

Nerve to superior gemellus muscle, 162f, 233t, 234f, 284f

Nerves

of cervical spine, in brachial plexus schema, 509f

costal. _See_ Intercostal nerves; Subcostal nerves

cranial. _See_ Cranial nerve(s)

digital. _See_ Digital nerves/branches

of elbow, , 536f, 536t

of foot and ankle, , 416f, 416t. _See also_ Plantar nerves

in sole, 412f

of forearm, 533f-534f, 536t

of hand, 569-571

median, , 569f, 569t

radial, , 571f, 571t

ulnar, , 570f, 570t

of hip, , 284f

and buttocks, 284f, 284t

of knee,

femoral and lateral femoral cutaneous, 333t, 334f

obturator, 333f, 333t

sciatic and posterior femoral cutaneous, 335f

motor. _See_ Motor innervation

of neck, , 82t, 83f

of sacroiliac region, , 233t, 234f

sensory. _See_ Sensory innervation

of shoulder, 82t

anterior axilla, 459t, 460f

of skin. _See_ Cutaneous nerves

spinal. _See_ Spinal nerves

of temporomandibular joint,

mandibular, , 24f

of thigh, 284t, 285f

lateral cutaneous, 160t, 161f-162f, 285f, 333f-334f

posterior cutaneous, 162f, 284f, 335f

Neural tension tests

of cervical spine, , 119f

of upper limb. _See_ Upper limb tension tests (ULTTs)

Neurologic examination/screening

for cervical radiculopathy,

of cervical spine, 89-93

of lumbar spine, 170-172

for radiculopathy, 148t, , 170t, 171f

for spinal stenosis, , 172f, 172t

Neurotomies, radiofrequency, for sacroiliac joint pain, 237f

New York criteria, for ankylosing spondylitis, 169t, 204t

NEXUS Low-Risk Criteria, for cervical spine injury, , , 95t

Nipple line measurement, in ankylosing spondylitis, 169f

Nitric oxide, in lumbar pain, 195f

Nociceptors, in annulus fibrosus, 195f

Nodding

endurance test of, 102t

pain during, 100t

Nomograms

for cervical radiculopathy, 129f

of discogenic pain, 264f

of lumbar instability, , 203f

of Ottawa Knee Rule for Radiography, 342f

of probability, , 7f, 8-9, 9f

of sacroiliac dysfunction, 263f

Notches. _See_ specific anatomy

NPRS. _See_ Numeric Pain Rating Scale (NPRS)

NPV (negative predictive values), , 4t, 11t

Nuchal line, superior, of skull, 155f-157f

Nucleus pulposus, of lumbar intervertebral disc, 149f

herniated, 171f, 195f

Numbness. _See_ Paresthesias

Numeric Pain Rating Scale (NPRS)

for cervical spine, 104t, 131t, 138t

for elbow and forearm, 549t

for foot and ankle, 441t

for hand outcomes, 604t

for hip and pelvis, 316t

for knee, 384t

for sacroiliac region, 267t

for shoulder outcomes, 515t

for thoracolumbar spine, 210t

for TMJ pain, 62t

Nutrient foramen, of tibia, 325f

O

OA. _See_ Osteoarthritis (OA)

Ober test, of muscle length, 301f, 301t, 351t

modified, 301f, 301t

Oblique cord, 532t

Oblique diameter, of pelvic inlet, 228f

Oblique fracture, of femur, 313f

Oblique line

of mandible, 16f-17f

of thyroid cartilage, 78f

of tibia, 325f, 331f

Oblique muscles, 160f

external, 155f-156f, 158f, 158t, 457f

internal, 155f-156f, 158f, 158t

Obliquus capitis inferior muscle, 80t, 81f, 156f-157f

Obliquus capitis superior muscle, 80t, 81f, 156f-157f

O'Brien test

for acromioclavicular lesions, 510t

for glenoid labral tears, 481-483, 481f, 481t-483t

combined with other tests, , 512t-513t

Obturator artery, 279f

acetabular branch, 279f

anterior vs. posterior branch of, 279f

Obturator canal, 285f

Obturator crest, 227f, 277f, 279f

Obturator externus muscle, 282t, 285f, 333f

Obturator foramen, 225f, 227f, 230f, 277f-278f

Obturator groove, 227f, 277f

Obturator internus muscle, 280t, 281f, 284f

nerves to, 162f, 233t, 234f, 284f

Obturator membrane, 279f

Obturator nerve, 160t, 161f-162f, 234f, 284t, 330t, 333f-334f, 333t

accessory, 161f-162f

to adductor magnus muscle, 335f

anterior branch of, 285f, 333f

articular branch of, 333f

to knee joint, 333f

cutaneous branch of, 333f

posterior branch of, 285f, 333f

branches of, 285f

Occipital artery, 81f

Occipital bone, 17f

basilar part of, 75f, 79f

clivus of, 74f

jugular process of, 79f

Occipital condyle, 79f

lateral mass articular surface for, superior, 72f-73f

Occipital nerve

3rd (least), 81f

greater and lesser, 81f

Occipital protuberance, external, 17f

Occipitofrontalis muscle, occipital belly of, 81f

Occiput

neck distraction test and, 115t

palpation of, 108t

Occlusal stabilization splint, nightly wear of, for TMJ disorders, 60f

predicting treatment failure with, , 61t

predicting treatment success with, , 60f

ODI. _See_ Oswestry Disability Index (ODI)

Olecranon, 529f, 532f-533f, 563f

Olecranon bursa, subcutaneous, 531f

Olecranon fossa, 452f, 529f

Omohyoid muscle, 22f, 77t, 457f, 460f

inferior belly of, 76f, 78f

investing layer of deep cervical fascia, 457f

superior belly of, 76f, 78f

One repetition maximum (1RM), in knee assessment, 350t

One-sided sacroiliac syndrome, 261t

Open kinetic chain, in foot and ankle assessments, 431t

Ophthalmic nerve, , 24f

Opponens digiti minimi muscle, 567t, 568f

innervation of, 570f

Opponens pollicis muscle, 567t, 568f

innervation of, 569f

Oral habits, association with TMJ disorders,

Orbicularis orb muscle, 36f

Orbicularis oris muscle, 20f

Orbital plate, of ethmoid bone, 17f

Orthopaedic clinical examination, reliability and diagnostic utility of, 1-12

Orthoses, foot, 380-381, 380f, 381t

for patellofemoral pain syndrome, ,

Ossification, of thoracolumbar spine, in ankylosing spondylitis, 169f

Osteoarthritis (OA)

of hip and pelvis

clinical prediction rule for,

clinical summary and recommendations, 276t

combinations of tests for, , 315t

Cyriax's capsular pattern for detecting,

patient history in, , 287t

radiograph, 290f

testing for, , 315t

of knee

hip mobilizations for, , 382t

outcome measures of, 384t

progressive stages of, 337f

subjective questions for assessing, , 337f, 337t

testing for, 360t, 369t-370t, 379t

in TMJ disorders, 42t

Osteology

of cervical spine,

in head and neck, 71f

in relation to TMJ, 15f

vertebrae, 72f

of elbow, , 529f

of foot and ankle, 399-416, 400f

dorsal vs. plantar view of, 400f

lateral vs. medial view of, 399f

Ottawa rules for, 420f-421f

of hand, 557-571

carpal bones, 557f

of hip and pelvis,

femur, 277f

hip (coxal) bone, 277f

of knee,

femur, 325f

fibula, 325f

tibia, 325f

of sacroiliac region

abdominal framework in, , 225f

coccyx, 226f

hip (coxal), 227f

sacrum, 226f

sex differences in, 228f

of shoulder,

anterior humerus and scapula, 451f

superior and inferior clavicle surface, 451f

of temporomandibular joint, 15-24

head and neck, 15f

mandible, 16f

skull, 17f

of thoracolumbar spine,

lumbar vertebrae, 149f

thoracic vertebrae, 149f

of wrist and hand, 558f

Osteonecrosis, of hip and pelvis, 293f, 293t

Oswestry Disability Index (ODI)

for sacroiliac region outcomes, 266t-267t

Modified, 267t

for thoracolumbar spine outcomes, 207t-210t

Modified, 210t

Otic ganglion, 19f, 21f, 24f

Ottawa Ankle Rule for Radiography, , 420f

diagnostic utility of, , 420t, 421f

Ottawa Knee Rule for Radiography,

diagnostic utility of, , 342f, 342t

reliability of, , 341t

Outcome measures

of cervical spine, , 138t

of elbow and forearm,

of foot and ankle, , 441t

of hip and pelvis, , 316t

of knee, 384t

of sacroiliac region, , 267t

of shoulder, , 515t

of temporomandibular joint, , 62t

of thoracolumbar spine, , 210t

Overbite, 44t-45t

Overpressure testing, of cervical spine, 101f

Overuse injury, of hip and pelvis, 286t

P

Pain

ankle. _See_ Foot and ankle pain

back (spinal)

cervical. _See_ Cervical (neck) pain

lumbar. _See_ Low back pain

sacral. _See_ Sacroiliac pain

thoracic. _See_ Thoracolumbar pain

buttock. _See_ Gluteal (buttock) pain

calf, 164t, 171f

discogenic

McKenzie evaluation to rule out, , 264f

thoracolumbar, 195f

elbow. _See_ Elbow pain

extremity. _See_ Lower extremity; Upper extremity

foot. _See_ Foot and ankle pain

in forearm, with cervical compression test, 112t

groin. _See_ Inguinal (groin) pain

hand. _See_ Hand pain

hip. _See_ Hip pain

knee. _See_ Knee pain

lumbopelvic, 244t-246t, 249t, 262t

myofascial. _See_ Myofascial pain

neck. _See_ Cervical (neck) pain

patellar syndrome. _See_ Patellofemoral pain syndrome

pelvic. _See_ Pelvic pain

sciatic, 163t, 192t

shoulder. _See_ Shoulder pain

snuffbox, with scaphoid fractures, 575t, 577f

thigh. _See_ Thigh pain

thoracolumbar, 163t

with TMJ disorders. _See_ Temporomandibular pain

Pain provocation tests. _See_ specific anatomy or test

Pain referral patterns

in cervical spine, zygapophyseal

Cooper description of, 85f

diagnostic nerve block for, 107t

Dwyer description of, 84f

in lumbar spine, zygapophyseal, 163t, 164f

in sacroiliac joint,

with double-block injections, 237f

with radiofrequency neurotomies, 237f

in thoracic spine, zygapophyseal, 163t, , 165f

Painful arc sign, in shoulder, , 461t, 464t, 472t

combined with other tests, 514t

Painful arc test, for subacromial impingement, , 494t

combined with other tests, 514t

Palatine bone, pyramidal process of, 71f

Palmar abduction, 581t

Palmar (arterial) arch, deep, 568f

Palmar ligament (volar plate), 562f, 562t

Palmar view

of carpal bones, 557f

of wrist and digit muscles, 565f, 567f-568f

of wrist and hand bones, 558f

of wrist ligaments, flexor retinaculum removed, 560f

Palmaris brevis, innervation of, 570f

Palmaris longus muscle, 536f, 565f, 565t-566t

innervation of, 569f

Palmaris longus tendon, 534f

in carpal tunnel syndrome, 574f

Palpation

of cervical spine, for pain assessment, , 108t

with cervicogenic headache, , 109t

with and without patient history, , 109t

of foot and ankle, for trauma screening, 419t

of hip, , 308t

diagnostic utility for intraarticular pain, , 308t

of humerus, lateral epicondyle, 537f

of knee

for inflammation detection, 344f, 344t

lateral and medial, 360f, 360t

pain during, , 360t, 376t-377t

pain with, reliability of,

of sacroiliac region, 238-239

for bony landmark symmetry assessment, , 239t, 240f

pain location identification with, , 238t

of shoulder

labral tears, , 469t

subacromial impingement, , 469t

static,

of temporomandibular joint, 35-61

conditions identified by, , 38t

lateral, 37f

muscle, , 35t

posterior, , 36f-37f

pressure pain thresholds, , 39t

regional, , 36f

test, 37f

of thoracolumbar spine, 187-188

lumbar multifidus muscle function assessment, , 188t

segmental level identification with, , 187t

segmental mobility identification with, 182t, 184f-186f, 184t, 186t

tenderness identification with, , 188t

Paper grip test, for toe strength, , , 424f, 424t

Paraspinal joints, palpation of, 109t

Paraspinal muscles, palpation of, 109t

Parasympathetic nerve, of sacroiliac region, 234f

Paresthesias. _See also_ Radiculopathy

in foot and ankle, 418t

in hand, patient history of, 572t

in lower extremity, with lumbar pain, 163t

with neck pain, during ROM, 100t

Parietal bone, 17f

temporal lines of, inferior vs. superior, 17f

Parotid duct, 20f-21f

Parotid gland, 76f

Parrot beak tear, of meniscus, 378f

Passive forearm pronation test, 545t-546t

Passive intervertebral motion (PIVM)

of cervical spine, limited, , 103f, 103t

pain during, 104-105, 104t-105t, 105f

of lumbar spine

accessory, 184t, 186t

limited vs. excessive, 181-182, 181t-182t, , 186t

association of, and low back pain,

diagnostic utility of, , 184f, 184t

pain with, 148t, , 183f, 183t-184t, 185f

physiologic, 184t

flexion vs. extension, 186t

radiography with, for instability, 201t

Patella, 285f, 326f, 331f-332f, 408f

alignment of, lateral pull test for, , 359t

angle between longitudinal axis of, and patellar tendon, , 359f, 359t

articular cartilages of, erosion of, 337f

bony assessment of, 352t

displacement of

lateral pull test for, 359t

mediolateral, 353t-354t

instability of,

in physical examination, 341f, 341t, 344t

quadriceps angle in, 358f, 358t

subluxation of, 336t, 358f

tenderness of, in trauma screening, 341f, 341t

Patella poles, inferior and superior, in alignment assessment, 355t-356t, 359f, 359t

Patellar anastomosis, 285f

Patellar apprehension test, moving, , , 375f, 375t

Patellar ligament, 283f, 285f, 326f, 329f, 331f-332f, 408f

Patellar orientation

assessment of, 353-354, 353f, 353t-354t

mediolateral, 353f, 353t-354t

Patellar retinaculum

lateral, 283f, 285f, 331f-332f, 408f

iliotibial tract blended into, 329f

tight, 379t

medial, 283f, 285f, 331f-332f

blended into joint capsule, 329f

Patellar rotation, , 356f, 356t

Patellar surface, of femur, 325f

Patellar tap test, for knee inflammation, 344t

Patellar tendon, angle between longitudinal axis of patella and, , 359f, 359t

Patellar tendonitis, 336t

Patellar tilt, 352t

anterior, 355t

anteroposterior, 355f, 355t

mediolateral, , 352f, 352t

superoinferior, , 355t

Patellar-pubic percussion test, for hip fractures, , 313f, 313t

Patellofemoral joint, 326t

Patellofemoral pain syndrome, , 336t, 357t

foot orthoses for, ,

iliotibial band length in, 301t

Patient history

cervical spine and, ,

elbow and forearm and,

foot and ankle and, 398t

hand and, , , 572t

hip and pelvis and, , 286t

knee and, ,

combined with tests, in diagnosing pathology, 379t

in meniscal tear diagnosis, 379t

lumbar zygapophyseal joint referral patterns in, , 164f, 164t

reliability and diagnostic utility of, . _See also_ specific anatomy or physiology

reliability of historical examination, , 166t

sacroiliac region and, , 235-237

shoulder and,

temporomandibular joint and, 14t,

thoracolumbar spine and, 148t, , 163t

in diagnosing pathology, 167-168, 167t-168t, 201t

in low back pain classifications, 205t

Patient-Rated Tennis Elbow Evaluation, 549t

Patrick test

of hip and pelvis, 289t, , 309f

diagnostic utility of, , 310t

reliability of, , 309f, 309t

of sacroiliac region, 241-242, 241f, 241t-242t

combined with other tests, 262t

Patte maneuver

combined with other tests, 514t

for infraspinatus tears, 501t-503t

for supraspinatus tears, 500t-503t

Paxinos sign, for acromioclavicular lesions, 510t

Payr test, for meniscal tears, 376t-377t

PCL. _See_ Posterior cruciate ligament (PCL)

Pecten pubis, 225f, 227f, 230f, 277f-278f

Pectineal line, , 227f, 230f, 277f-278f

Pectineus muscle, 282t, 283f, 285f, 334f

Pectoral branch, of thoracoacromial artery, 460f

Pectoral nerve, lateral vs. medial, 82t, 83f, 459t, 460f

in brachial plexus schema, 509f

Pectoralis major muscle, 76f, 457f, 457t, 460f

abdominal part of, 457f

clavicular head of, 457f, 457t

length assessment of, 111t

sternocostal head of, 457f, 457t

Pectoralis minor muscle, 457t, 460f

identifying shoulder pain, , 467f, 467t

length assessment of, 111t, 466-467, 466t

Pectoralis minor tendon, 460f

Pedicles

of cervical vertebrae, 72f

of lumbar vertebrae, 149f, 152f, 154f

of thoracic vertebrae, 149f, 154f

Pelvic brim, sacral part of, 226f

Pelvic girdle syndrome, 261t

Pelvic inlet

diameters of, in male and female, 228f

female

anterior view of, 228f

plane of, 228f

male, anterior view of, 228f

Pelvic outlet, female

anteroposterior diameter of, 228f

inferior view of, 228f

plane of, 228f

Pelvic pain. _See also_ Sacroiliac pain

girdle, 239t, 291t

motion assessment for, 254t, 260t

postpartum, 241t, 243t, 245t, 252t, 256t

Pelvic (hypogastric) plexus, inferior, 234f
Pelvic provocation test, posterior, 243-244, 243t-244t

Pelvic tilt, in Trendelenburg test, 299t

Pelvis. _See also_ Hip and pelvis

lateral vs. medial view of, 277f

sex differences in, 228f

Penis, dorsal nerve of, 162f, 284f

Penn Shoulder Score (PSS), for shoulder outcomes, 515t

Percussion test, patellar-pubic, for hip fractures, , 313f, 313t

Perforating branches

anterior

to dorsal metatarsal artery, 414f-415f

of plantar metatarsal arteries, 415f

of arcuate artery, posterior, 415f

of deep artery, of thigh, 285f

posterior, to dorsal metatarsal artery, 415f

Perineal branch, nerve to, 233t, 234f

Perineal nerve, 162f, 284f

posterior scrotal/labial branches of, 162f

Peripheralization

cervical pain and, 100t

in lumbar pain, 163t, 189t

Peroneal artery, lateral calcaneal branch of, 413f

Peroneal nerve, 234f

common, 162f, 281f, 331f-332f, 335f, 408f-409f, 416f-417f

articular branch of, 335f, 417f

division of sciatic nerve, 335f

phantom, 416f

deep, 416f

dorsal digital branches of, 410f

lateral branch of, 410f, 416f

medial branch of, 410f, 416f

in foot and ankle injury, 418t

phantom, 416f

superficial, 408f, 410f, 416f

dorsal digital branches of, 410f

superficial, division of sciatic nerve, 335f

Peroneal retinaculum

inferior, 403f, 408f

fibular tendons in, 402f

superior, 403f, 408f-409f

Peroneal tendons, in inferior fibular retinaculum, 402f

Peroneal trochlea, of calcaneus, 399f-400f

Peroneus brevis muscle, 416f

Peroneus brevis tendon, 403f, 414f-415f

Peroneus longus muscle, 331f-332f, 416f

groove for, on cuboid, 399f

passing to sole, 408f, 416f

Peroneus longus tendon, 403f, 406f, 414f-415f

fibrous sheath of, 414f

groove for

on calcaneus, 399f

on cuboid, 399f-400f

Peroneus tertius tendon, 408f, 415f

Pes anserinus, 283f, 331f-332f

Petrosal nerve, lesser, 24f

Phalanx (phalanges), 399f-400f

base of, 400f

body of, 400f

distal, 400f, 405f, 558f, 562f

4th, 406f

base of, 558f

head of, 558f

median nerve branches to, 569f

shafts of, 558f

ulnar nerve branches to, 570f

great toe, distal vs. proximal, 406f

middle, 400f, 405f, 558f, 562f

4th, 406f

base of, 558f

head of, 558f

median nerve branches to, 569f

shafts of, 558f

ulnar nerve branches to, 570f

proximal, 400f, 405f, 558f, 562f

5th, 406f

base of, 558f

head of, 558f

shafts of, 558f

tuberosity of, 400f

Phalen test, , , 592f, 592t

in carpal tunnel syndrome, 593t-594t

reverse, 592f

Pharyngeal tubercle, 75f

Pharyngotympanic (auditory) tube, cartilaginous part of, 21f

Phospholipase A2, in lumbar pain, 195f

Phrenic nerve, 79f, 83f, 460f

Physical examination

of cervical spine, 70t, 89-137

radiography for trauma in,

of elbow and forearm, , 528t, 538-548

of foot and ankle, 398t, 419-440

subcutaneous tears of Achilles tendon, , 433f, 433t

syndesmotic injury, , 434t

of hand, 556t, 575t

of hip and pelvis, 276t, 288-294

of knee, 324t, 341-383

to identify radiographic needs following trauma, 341f

of sacroiliac region, , 238-239

of shoulder, 450t, 463-514

of temporomandibular joint, 35-39

of thoracolumbar spine, 170-172

Physical therapy referral, for shoulder impairments, 463t

Physician judgment, on cervical spine injury, 95t

Pilates-based exercise, for low back pain,

Pinch strength, measurement of, 583f

Pinch test, 601t

Pinprick testing

for cervical radiculopathy, , , 90t

for lumbar spinal stenosis, 172f, 172t

for radiculopathy, lumbar, 148t, 170t

Piriformis muscle, 280t, 281f, 284f

nerves to, 162f, 233t, 234f

sacroiliac, 232f, 232t

Piriformis myofascial pain, 188t

Piriformis syndrome, 286t

Pisiform, 534f, 536f, 557f-560f, 562f, 565f, 568f

in scaphoid fractures, 577f

Pisometacarpal ligament, 560f, 560t

Pittsburgh Decision Rule for Radiography

diagnostic utility of, , 343t

reliability of, , 343t

PIVM. _See_ Passive intervertebral motion (PIVM)

Pivot shift test, for anterior cruciate ligament tears, , , 367f, 367t

Plantar (arterial) arch, deep, 415f

deep plantar artery to, 410f, 415f

posterior perforating branches of arcuate artery to, 415f

Plantar arteries, 413f

deep

to deep plantar arch, 410f, 415f

from dorsalis pedis artery, 415f

digital. _See_ Digital arteries

lateral, 410f, 413f-415f

medial, 413f-414f

deep branch of, 413f-414f

proper plantar digital branch of, 414f

superficial branch of, 412f-414f

metatarsal, 414f-415f

Plantar fasciitis, , 418t

Plantar foot, ROM measurements of, 422t

Plantar ligaments, 405f, 415f

long, 403f-404f, 405t, 406f, 415f

metatarsal, between bases of metatarsal bones, 415f

plate of, 405f-406f, 405t

short, 404f, 405t, 406f, 415f

tarsometatarsal, 405t

Plantar nerves

digital. _See_ Digital nerves/branches

lateral, 335f, 413f-414f, 415t-416t, 417f

deep branch of, 413f-414f

deep plantar arterial branch of, 414f

plantar metatarsal branch of, 412f

proper plantar digital branches of, 412f-414f

superficial branch of, 413f-414f

from tibial nerve, 417f

medial, 335f, 413f-414f, 416t, 417f

deep branch of, 414f

proper plantar digital branches of, 412f-414f

superficial branch of, 414f

from tibial nerve, 417f

Plantar view

of deep interosseous muscles of sole, 415f

of foot and ankle, 400f

Plantarflexion, ankle, 422t, , 424t

impingement sign with, 436f, 436t

Plantaris muscle, 281f, 328f, 332f, 335f, 409f, 417f

Plantaris tendon, 281f

Plastic vernier caliper, 43f

Plate. _See_ specific anatomy

Platysma muscle, , 76f

Plica, medial, in knee pathology, 379t

Point estimates,

Popliteal artery, 285f, 409f

Popliteal ligaments

arcuate, 327t, 328f-329f

oblique, 327t, 328f-329f

Popliteal surface, of femur, 325f, 328f

Popliteus muscle, 281f, 328f, 409f, 417f

capsule edge arching over, 328f

nerve to, 417f

Popliteus tendon, 327f, 329f

Popping, in shoulder, 462t

Positive predictive values (PPV), , 4t, 11t

Posterior cruciate ligament (PCL), 327f, 327t, 329f, 336f

ruptures of, 336t

Posterior shear test

for lumbar segmental instability, 198t-199t

of sacroiliac region, 243-244, 243t-244t

Posterior superior iliac spine (PSIS)

distraction test, 253f, 253t

in hip muscle length assessment, 303t

as sacroiliac bony landmark

prone, 239t

sitting, 239t

standing, 239t

in sacroiliac motion assessment, 254t, 258t-259t

sacroiliac pain and, 236t, 238t

Posterior temporalis muscle, pressure pain thresholds of, 39t

Posterior tibial reflex, with herniated lumbar nucleus pulposus, 171f

Posterior triangle of neck, 155f

Posterior view

of ankle ligaments, , 402f

of carpal bones, 557f

of cervical spine ligaments, 74f-75f

of elbow bones, in extension, 529f

of elbow joint, opened, 530f

of femur, 277f

of fibular nerves, 417f

of hand muscles, 568f

of hand nerves, 569f-571f

of hip and pelvis ligaments, 279f

of lumbar vertebrae, 152f

of mandible osteology, left, 16f

of muscles involved in mastication, 21f

of rotator cuff muscles, 458f

of sacroiliac region ligaments, 230f

of shoulder muscles, , 456f, 456t

of T7 vertebra, 150f

of T8 vertebra, 150f

of T9 vertebrae, 150f

of thoracic vertebrae, 150f

of tibia and fibula, 325f

of tibial nerves, 417f

of wrist and hand bones, 558f

of wrist ligaments, , 561f, 561t

Posteroanterior central glides, to cervical spine, 107f, 107t

Posteroanterior glide, for hip mobilization, 383f

with flexion, abduction, and lateral rotation, 383f

Posterolateral view, of costovertebral ligaments, right, 153f

Posterosuperior view

of axis, 72f

of mouth floor muscles, 23f

Posttest probability,

calculating, 8-9

Postural assessment

of cervical spine

in head and shoulder, 110t

muscle length, 111f, 111t

thoracic kyphosis in, 110f, 110t

of thoracolumbar spine, , 178t, 179f

for ankylosing spondylitis, 169f

in low back pain classification, 205t

Potentiometer, in foot and ankle assessment, 428t

Poupart ligament, 161f, 285f

PPV (positive predictive values), , 4t, 11t

Predictive values, positive and negative, , 4t, 11t

likelihood ratios and, 3-4, 8t

Pregnancy

pelvic girdle pain related to, classification of, , 261t

sacroiliac bony landmarks and, 239t

sacroiliac motion assessment and, 260t

Prepatellar bursa, subcutaneous, 326f

Pressure pain threshold (PPT), in TMJ disorders, , 39t

Pressure provocation test, of elbow, , 542t

flexion test combined with, 542t

Pretest probability,

Prevalence rates,

Probability

determination of shifts in, 8-9, 9f

posttest calculation of, 8-9, 9f

pretest and posttest,

Processes. _See_ specific anatomy

articular. _See_ Articular process

spinous. _See_ Spinous processes

transverse. _See_ Transverse process(es)

Pronation measurements, of forearm, , 539f, 539t

Pronator muscles, of forearm, , 535f, 535t

Pronator quadratus muscle, 535f-536f, 535t

of hand, 568f

innervation of, 569f

Pronator syndrome, 537t

Pronator teres muscle, 533f-536f, 535t

humeral head of, 534f

innervation of, 569f

ulnar head of, 534f, 536f

innervation of, 569f

Prone instability test, of lumbar spine, 198t-199t, 199f, 209t

Prone knee bend test, , 260f, 260t

Proprioception assessment

foot and ankle in, , , 428t

shoulder in, , 465t

Prostaglandins, in lumbar pain, 195f

Protraction test

of cervical spine, 99t

in postural assessment, 110t

shoulder, for brachial plexus palsy, 509t

Protractor, for ROM measurements, of thoracolumbar spine, 173t-174t

PSIS. _See_ Posterior superior iliac spine (PSIS)

Psoas major muscle, 161f-162f, 234f, 282t, 283f

lower part of, 334f

Psoas minor muscle, 162f, 282t

Psoas muscles, 158f

nerve branch to, 161f-162f

Pterion, 17f

Pterygoid fovea, 16f

Pterygoid muscle

in anterior disc displacement, 27f

internal vs. external, 36f

lateral, 20f-21f, 21t, 24f

medial, 21f, 21t, 24f

palpation of, 37f

Pterygoid nerve, lateral, 24f

Pterygoid plate

lateral, 15f, 21f, 71f

medial, 21f

hamulus of, 15f, 21f, 24f, 71f

Pterygoid process

hamulus of, 71f

lateral and medial plate of, 71f

Pterygomandibular raphe, 15f, 21f, 71f

Pterygopalatine fossa, 71f

Pubic arch, 225f, 278f

male vs. female, 228f

Pubic ligaments

inferior, 278f

superior, 279t

Pubic ramus

inferior, 225f, 227f, 230f, 277f-278f, 279t

superior, 225f, 227f, 230f, 234f, 277f-279f

Pubic symphysis, 225f, 230f, 278f

as joint, 278t

male vs. female, 228f

Pubic tubercle, 225f, 227f, 230f, 277f-278f, 283f

Pubofemoral ligament, 279f, 279t

Pudendal artery, internal, 234f

Pudendal nerve, 162f, 233t, 234f, 284f, 284t

Pushing, thoracolumbar pain with, 166t

Pyramidal process, of palatine bone, 71f

Q

Q angle, , 358f, 358t

QAREL. _See_ Quality Appraisal for Reliability Studies (QAREL)

QUADAS. _See_ Quality Assessment of Diagnostic Accuracy Studies (QUADAS)

Quadratus femoris muscle, 281f, 284f-285f

nerves to, 233t, 234f, 284f, 284t

posterior view of, 280t

nerve to, 162f

Quadratus lumborum muscle, 157f, 161f

Quadratus plantae muscle, 413f-414f, 413t, 417f

Quadratus plantae nerve, 417f

Quadriceps angle, , 358f, 358t

Quadriceps femoris muscles/tendons, 283f, 285f, 326f, 332f, 408f

atrophy of, with herniated lumbar nucleus pulposus, 171f

isometric contraction of, for patellar alignment, 359t

length assessment of, 351f, 351t

nerves to, 334f

neurological examination of, 170t

rectus femoris tendon becoming, 331f

rupture of, 336t

Quality Appraisal for Reliability Studies (QAREL), 10-11

for cervical spine, 139-141, 139t-141t

for elbow and forearm, , 550t

for foot and ankle, 442-444, 442t-444t

for sacroiliac region, 268-270, 268t-270t

for shoulder, 516-518, 516t-518t

for temporomandibular disorders, 63-66, 63t-64t

for thoracolumbar spine disorders, 212t-215t

Quality Assessment of Diagnostic Accuracy Studies (QUADAS),

for cervical spine, 142-144, 142t-144t

for elbow and forearm, , 551t

for foot and ankle, 445-446, 445t-446t

for hip and pelvis, , 319t

for sacroiliac region, 271-272, 271t-272t

for shoulder, 519-522, 519t-522t

for temporomandibular joint, 65-66, 65t-66t

for thoracolumbar spine, 211-215, 211t, 216t

disorders of, 216-217, 217t

QuickDASH (Shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire), for shoulder outcomes, 515t

R

Radial artery, 533f-534f, 536f, 568f

dorsal carpal branch of, 559f

palmar carpal branch of, 536f, 568f

recurrent, 534f, 536f

in snuffbox, 559f

superficial palmar branch of, 534f, 568f

Radial bursa, in carpal tunnel syndrome, 574f

Radial collateral ligament, 531f, 531t, 560f, 560t

Radial fossa, 451f, 529f

Radial nerve, 82t, 83f, 460f, 533f-534f, 533t, 536f, 536t, 563t-564t, , 571f, 571t

in brachial plexus schema, 509f

deep branch of, 533f-534f, 563t-564t

dorsal digital branches of, 559f, 571f

inconstant contributions to, 571f

innervation of, 569f

posterior view of, 571f

in shoulder, 459t

superficial branch of, 534f, 559f, 571f

Radial notch, of ulna, 529f, 532f

Radial tear, of meniscus, 378f

Radial tunnel syndrome, 537t

Radiate ligament, of rib head, 151f, 153f, 153t

ossification of, 169f

Radiculopathy. _See also_ Paresthesias

cervical. _See_ Cervical radiculopathy

lumbar. _See_ Lumbar radiculopathy

thoracolumbar, 148t

screening for, 148t

Radiocapitate portion, of palmar radiocarpal ligament, 560f, 560t

Radiocarpal joint, 559f, 559t

Radiocarpal ligament

dorsal, 561f, 561t

palmar, 560f, 560t

radiocapitate portion of, 560f, 560t

radioscapholunate portion of, 560f, 560t

Radiography

of ankle, Ottawa Rule for, , 420f

diagnostic utility of, 420t, 421f

of cervical spine, for injury screening, , 95t, 96f

of elbow injury, 541t

of hand, for fractures, 575t

of hip joint, for osteoarthritis, 290f

of knee, Ottawa Rule for, , 341-342, 341t-342t, 342f

of shoulder, for instability identification, 474t-476t

of thoracolumbar spine

for degenerative disc disease, 200f

flexion-extension, 173t-174t, 183t-184t, 186t, 201t

for instability, 201-203, 201t, 202f-203f

Radioscapholunate portion, of palmar radiocarpal ligament, 560f, 560t

Radioulnar joint

distal, 530t, 559f

proximal, 530t

Radioulnar ligament

dorsal, 561f, 561t

foveal disruption of,

palmar, 560f, 560t

Radius

anterior and posterior border of, 532f

area for abductor pollicis longus muscle on, 532f

area for extensor pollicis brevis muscle on, 532f

deviation of, 579t, 580f

distal, fractures of, in children, 578f

dorsal tubercle of, 557f

in elbow, 529f-531f

groove for extensor carpi radialis brevis muscle on, 532f

groove for extensor carpi radialis longus muscle on, 532f

groove for extensor digitorum muscle on, 532f

groove for extensor indicis muscle on, 532f

groove for extensor pollicis longus muscle on, 532f

in hand, 557f

head of, 529f, 532f

interosseous border of, 532f

ligaments of, 531f, 531t

muscles of, 533f, 563f, 565f, 567f-568f

supinator and pronator, 535f

neck of, 529f, 532f

nerves of, 536f, 536t

styloid process of, 532f, 557f

surface of, 532f

tuberosity of, 529f, 532f

in wrist joint, 559f-561f

Rami communicantes

of cervical nerves

dorsal, in brachial plexus schema, 509f

ventral, in brachial plexus schema, 509f

gray, 234f

of thoracolumbar nerves, 162f

dorsal, 156t-157t, 160f, 160t

lateral vs. medial branch of, 160f

posterior, 160f

gray vs. white, 160f-161f

ventral, 155t, 158t, 160f-161f

Ramus

dorsal, 83f

inferior pubic, 277f

of ischium, 227f, 277f

of mandible, 15f, 17f, 71f

of pubis. _See_ Pubic ramus

superior pubic, 277f

ventral, 83f

Range of motion (ROM)

of cervical spine,

limited passive intervertebral, , 103f, 103t

pain during, 104-105, 104t-105t, 105f

measurements of, 97f, 98t-100t

pain during, , 101f, 101t

of elbow and forearm, measurement of, , 538-539, 538f-539f

of finger and thumb, , 581f, 581t

of foot and ankle,

calcaneal position, , 423f

passive vs. active, 422t

patient history in, 418t, 436t

in trauma screening, 419t

of hand,

of hip and pelvis, , 291t

capsular and noncapsular end-feels, , 289f, 289t

limited, abduction, developmental dysplasia in infants with, , 294f, 294t

measurements, , 288t, 292f

passive, 289f

intervertebral. _See_ Passive intervertebral motion (PIVM)

of knee,

active and passive, 346-347, 346f, 346t-347t

capsular and noncapsular end feels, , 348f, 348t

pain during, , 349t

of shoulder

disorders classification based on, 472f, 472t

functional tests of, , 464f, 464t

integrated movements of, , 453f

measurements of, , , 463f, 463t

pain during, 463t

of temporomandibular joint

anterior disc displacement and, , 47t

joint play and end-feel assessment in,

mandibular opening in, , 46t

measurements of, 43-47, 44t-45t

during mouth opening, , 43f

of thoracolumbar spine, 148t

in low back pain classifications, 205t

in lumbar instability tests, 201t, 209t

measurements of, 173-176, 173t-174t, 175f

pain during, , 176f, 176t

of wrist, measurements of, , 579f-580f, 579t

Rays. _See_ Metatarsal bones

RDC (Research Diagnostic Criteria), for TMJ disorders,

Rearfoot angle, 423f, 423t

Rectal (anal) nerve, inferior, 162f, 284f

Rectus abdominis muscle, 158f, 158t, 160f

Rectus capitis anterior muscle, , 79f

Rectus capitis lateralis muscle, , 79f

Rectus capitis posterior major muscle, 80t, 81f, 156f-157f

Rectus capitis posterior minor muscle, 80t, 81f, 156f-157f

Rectus femoris muscle, 282t, 283f, 285f, 330t, 334f

Rectus femoris tendon, 283f

becoming quadriceps femoris tendon, 331f

Rectus sheath, anterior layer of, 457f

Reference standard,

test results compared to, 4-5

Reflex tests

for cervical radiculopathy, , 93f, 93t

of lumbar spine

for radiculopathy, , 170t, 171f

for spinal stenosis, , 172f, 172t

Reliability, of orthopaedic clinical examination, 2-3. _See also_ Clinical examination

definition of,

intra-examiner vs. inter-examiner,

Relocation tests, of shoulder, 475t

anterior, 475t

apprehension, 475t

combined with other tests, , 512t

Jobe, 475t

pain, 475t

Repositioning, 180t

Research Diagnostic Criteria (RDC), for TMJ disorders,

Resistance tests

of hand, for fractures, 575t

of knee, pain during, 349t

pain or weakness during, 295-296, 295t-296t

of shoulder

for subacromial impingement

external rotation with, 497t-498t, 499f

internal rotation with, , 499f

supine flexion with, 488t-489t

of temporomandibular joint, pain during

diagnostic utility of, 52-53, 52f

mouth opening and closing, 52f

reliability of, , 50f

Rheumatoid arthritis

cervical spine and, 121t

foot involvement in, 432f, 432t

Rhomboid major muscle, 155f, 155t, 456f, 456t

Rhomboid minor muscle, 155f, 155t, 456f, 456t

Rib head

in ankylosing spondylitis, 169f

articular facets of, superior, 151f, 153f

ligaments of, 151f, 153f, 153t

Ribs

1st, 15f, 71f, 79f, 452f, 460f

in brachial plexus schema, 509f

costal facets for, 73f

spring test for, 464t

synchondrosis of, 452f

testing stiffness of, 103f

2nd, 452f

7th, 150f

12th, 155f, 225f

in ankylosing spondylitis, of the thoracolumbar spine, 169f

costal facets for, 151f, 153f

in scoliosis pathology, 179f

sternocostal articulation, 150f

tubercle of, transverse costal facet for, 153f

RMDQ. _See_ Roland-Morris Disability Questionnaire (RMDQ)

Roland-Morris Disability Questionnaire (RMDQ)

for sacroiliac region outcomes, 267t

for thoracolumbar spine outcome, 210t

ROM. _See_ Range of motion (ROM)

Romberg test, for lumbar spinal stenosis, 148t, 200t

Rotation lag signs, in shoulder

external,

internal,

Rotation tests

of cervical spine, 98t-100t

C1-C2, 103f, 103t

combined with other tests, 129t

pain during, 100t

of foot, for TMJ disorders, diagnostic utility of, 55t

of hip and pelvis

muscle length assessment, , 304f

muscle strength assessment, 295-300, 295t-296t

for sacroiliac pain provocation, 252t

strength assessment, 295-300

of knee

with internal and external rotation, 370f

patellar, , 356f, 356t

of shoulder

functional, 464f, 464t

for instability, 474t-476t

for labral tears

active compression with, , 479f, 479t

passive compression with, 488t-489t

resisted supination with, 488t-489t

measurement of, 463f, 463t

in proprioception testing, 465t

of thoracolumbar spine, 173t-174t, 201t

pain during, , 176f, 176t

Rotator cuff

lesions of, 472t

of shoulder, muscles of, , 458f, 458t

tears of

patient history in, 461-462, 461t

diagnostic utility of, , 462t

retracted, 500f

subscapularis tests for, 505-508

superior, 500f

supraspinatus/infraspinatus tests for, 500-504, 500f-501f, 500t-503t

Rotatores cervicis brevis muscle, 157f

Rotatores cervicis longus muscle, 157f

Rotatores thoracis brevis muscle, 157f, 157t

Rotatores thoracis longus muscle, 157f, 157t

Rotators, of radius, 535f

Rotatory instability, 537t

Ruptures. _See_ specific anatomy

S

S1 vertebra

disc herniation at level of, 171f

nerves of, 160t, 162f, 233t, 234f, 284t, 330t, 333t, 335f, 407t, 416t, 417f

in sacroiliac motion assessment, 254t

in zygapophyseal pain referral pattern, 164f

S2 vertebra

foramina of, coronal section through, 226f

nerves of, 160t, 162f, 233t, 234f, 284t, 330t, 333t, 335f, 407t, 415t-416t, 417f

in sacroiliac motion assessment, 254t

S3 vertebra

nerves of, 160t, 162f, 233t, 234f, 284t, 330t, 333t, 335f, 415t-416t, 417f

in sacroiliac motion assessment, 254t

S4 vertebra, nerves of, 162f, 233t, 234f, 284t

perineal branch of, 162f, 234f

S5 vertebra, nerves of, 162f, 233t, 234f

Sacral canal, 226f

Sacral cornu (horn), 226f

Sacral crest, 226f

Sacral foramen

anterior (pelvic), 226f, 230f

posterior, 226f, 230f

Sacral hiatus, 226f

Sacral plexus, 162f

Sacral promontory, 225f-226f, 230f, 278f

female, 228f

Sacral sulcus

as sacroiliac bony landmark, 239t

tenderness of, 238t

Sacral thrust test, , 247-248, 247f, 247t-248t

combined with other tests, 262t,

Sacrococcygeal ligaments

anterior and posterior, 230f, 231t

lateral, 230f, 231t

Sacroiliac joint, 229f, 229t, 278t

tenderness over, with ankylosing spondylitis, 204t

Sacroiliac pain. _See also_ Hip pain; Pelvic pain

aggravating factors of, , 236t

anesthetic injection for, 236t, 238t

double-block, 237f

discogenic, McKenzie evaluation to rule out, , 264f

dysfunction vs.,

with herniated lumbar nucleus pulposus, 171f

intensity locations of, 237f

interventions for, , 265-266

spinal manipulation as, 265-266, 265f-266f, 266t

location of, 236t

palpation for identification of location of, , 238t

patient report of, , 236t

physical examination for, , 238-239

combination of tests for,

provocative test for, , 241-253

anesthetic injection with, 242t, 244t-246t, 248t-250t

reliability of, 241t, 243t, 245t, 247t, 249t-252t

radiofrequency neurotomies for, 237f

referral patterns of,

with double-block injections, 237f

with radiofrequency neurotomies, 237f

Sacroiliac region, 223-274

arthrology of, , 229f, 229t

clinical summary and recommendations for, , 224t

dysfunction of

pain vs.,

tests for detecting, 263f

injury, common cause of, 235f

ligaments of, 230-231, 230f, 231t

male vs. female, 228f

muscles of, , 232f, 232t

nerves of, , 233t, 234f

osteology of

abdominal framework, , 225f

coccyx, 226f

hip (coxal), 227f

sacrum, 226f

sex differences in, 228f

outcome measures of, , 267t

patient history and, , 235-237

location and aggravating factors in, , 236t

referral patterns in, , 237f

physical examination of,

bony landmark symmetry in, palpation for, , 239t, 240f

combinations of tests for, 261-264, 262t

compression test for, , 245-246, 245f, 245t-246t

distraction test for, , 250f, 250t

drop test for, heel, 252t

Gaenslen test for, , 249f, 249t

Gillet test for, 254-255, 254t-255t, 255f

internal rotation of hip in, 252t

long-sit test for, , 257f, 257t

Mennell test for, , 251f, 251t

motion assessment for, , 254-260

pain location identification in, palpation for, , 238t

pain provocation tests for, , 241-253, 241f, 243f, 245f, 247f, 249f-252f

Patrick test for, 241-242, 241t-242t

prone knee bend test for, , 260f, 260t

PSIS distraction test for, 253f

resisted abduction test for, 252t

sacral thrust test for, 247-248, 247f, 247t-248t

sitting flexion test for, , 259f, 259t

spring test for, , 256f, 256t

standing flexion test for, , 258f, 258t

static palpation for,

thigh thrust test for, 243-244, 243f, 243t-244t

Sacroiliitis, 242t, 244t-246t, 248t-251t, 262t

bilateral, 169f

lower spine involvement in, 169f

Sacrospinous ligament, 230f, 231t, 281f, 284f

Sacrotuberous ligament, 230f, 231t, 281f

Sacrum. _See also_ Sacral entries

apex of, 226f

articular facets for, 152f, 226f

articular surface of, 226f

auricular surface of, 226f-227f

auricular surface of hip bone for, 277f

base of, 226f

as sacroiliac bony landmark, 239t

inferior lateral angle of, 239t

nerve roots of, in herniated lumbar nucleus pulposus, 171f

osteology of, 225f-226f, 278f
surfaces of, 226f

transverse ridges of, 226f

tuberosity of, 226f

Sagittal section

of female pelvis, 228f

of knee, 326f

of sacrum and coccyx, 226f

of wrist joint, 559f

Saphenous nerve, 284t, 334f, 416t, 417f

infrapatellar branch of, 285f, 334f

medial cutaneous branches to leg, 334f

Sartorius muscle, 281f, 282t, 283f, 285f, 330t, 332f, 334f

Sartorius tendon, 283f, 331f-332f

Scalene muscles, 76f, 78f,

anterior, , 79f, 460f

length assessment of, 111t

slips of origin of, 79f

middle, , 79f

length assessment of, 111t

nerve to, 83f

posterior, , 79f

slips of origin of, 79f

Scaphoid, 557f-559f, 561f

compression of, 575t

fractures of, , 572t

common, 577f

screening for, , 575t

tubercle of, 557f-558f, 560f

Scaphoid shift test, 599f, 599t-600t

Scapula, 78f

acromion of, 451f-452f, 454f-458f, 460f

in physical examination, 466t, 470t

angles of

acromial, 451f-452f

inferior vs. superior, 451f-452f

asymmetry of, during static and dynamic activity, , 470t, 471f

borders of

lateral vs. medial, 451f-452f

superior, 451f-452f, 458f

coracoid process of, 451f-452f, 455f, 458f, 460f

fossae of

infraspinous vs. supraspinous, 452f

notch connecting, 452f

subscapular, 451f

glenoid cavity of, 451f, 455f

groove for circumflex scapular vessels on, 452f

ligaments of, 454f

neck of, 451f-452f

osteology of, 451f

in physical examination, 465t-466t, 472f

spine of, 155f, 452f, 456f, 458f

suprascapular notch of, 451f-452f, 454f, 458f

tubercles of, infraglenoid vs. supraglenoid, 451f

Scapular area, palpation of, 108t

Scapular circumflex artery, 460f

groove on scapula for, 452f

Scapular ligament, superior transverse, 454f, 458f

Scapular nerve, dorsal, 82t, 456t, 459t, 460f

in brachial plexus schema, 509f

Scapular slide test, lateral, 470t, 471f

Scapulohumeral rhythm, , 453f

Scapulothoracic joint, 452t

integrated movements, , 453f

Scheuermann's disease, 110f

Schober test, of thoracolumbar spine

for ankylosing spondylitis, 204t

modified, 173t-174t

Sciatic foramen

greater, 230f, 335f

lesser, 230f

Sciatic nerve, 160t, 162f, 233t, 234f, 335f

fibular branch of, 330t

common (peroneal), 335f

superficial, 335f

to hamstrings, 333f

medial sural cutaneous nerve from, 335f

tibial branch of, 330t, 335f

Sciatic notches, lesser vs. greater, 225f, 227f, 277f-278f

Sciatic pain, 163t, 192t

Sciatica, 418t

SCM. _See_ Sternocleidomastoid (SCM) muscle

Scoliosis, 178t, 179f

Scour test, of hip and pelvis, 289t

for intraarticular pathology, , 312t

Screening

for ankle trauma, , 419-440

for cervical spine injury, 94-96

fracture, 94f

radiography in, , 95t

of hand fractures, , 575-578, 575t

for knee

fractures, , 341-345

inflammation,

neurologic. _See_ Neurologic examination/screening

Scrotal nerve, posterior, 162f, 284f

Segmental fixations, of lumbar spine, 182t, 185f

Segmental fracture, of femur, 313f

Segmental instability test, of lumbar spine, 198-199, 198t-199t

Segmental lesion, in thoracolumbar spine, 182t

Segmental mobility testing, of lumbar vertebrae, 184f, 184t, 186t

pain during, 183t

posteroanterior, 182t-183t, 183f

radiographic findings vs, 201t, , 203f

spinal manipulation as, 207t-208t

Semilunar (trigeminal) ganglion, 24f

Semimembranosus bursa, 332f

deep to tendon, 328f

Semimembranosus muscle, 280t, 330t, 332f, 335f

tendinous expansion of, 328f

Semimembranosus tendon, 328f-329f, 332f, 409f

groove for insertion of, on tibia, 325f

Semispinalis capitis muscle, 80t, 81f, 155f-157f, 456f

Semispinalis cervicis muscle, 80t, 81f

Semispinalis thoracis muscle, 157f

Semitendinosus muscle, 280t, 281f, 283f-284f, 330t, 335f

Semitendinosus tendon, 283f

Semmes-Weinstein monofilament test, 587t, 588f

Semmes-Weinstein monofilaments, in sensation testing, of foot and ankle, 432t

Sensation testing

of cervical spine, , 89f

pinprick, for radiculopathy, , , 90t

of foot and ankle,

anterolateral ankle impingement detection, , 436f, 436t

protective, , 432f, 432t

of hand,

of lumbosacral spine

for radiculopathy, , 170t

for spinal stenosis, , 172f, 172t

of thoracolumbar spine, 148t

Sensitivity, of diagnostic tests, 4-5, 5f, 11t

likelihood ratios and, , 8t

limitation of,

Sensory ganglion

of lumbar spine nerves, 195f

of thoracic spine nerves, 160f

Sensory innervation

of cervical spine, 82t

of hand, 569t-571t

of lumbar spine, 160t

of sacroiliac region, 233t

of thoracic spine, 160f, 160t

Serratus anterior muscle, 160f, 456t, 457f, 460f

endurance testing of, 465t

strength testing of, 465t

Serratus posterior anterior muscle, 155f

Serratus posterior inferior muscle, 155f, 155t

Serratus posterior superior muscle, 155f, 155t

Sesamoid bones, 399f-400f, 406f, 413f-415f, 558f

lateral, 400f

medial, 400f

Sever disease, 418t

Shaking, in hand,

patient history of, 572t

Sharp-Purser test, of cervical spine, , 121f, 121t

Shear test. _See_ Posterior shear test

Shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH), for shoulder outcomes, 515t

Shoulder, 449-525

arthrology of, integrated movements in, , 453f

brachial plexus palsy identification, , 509f, 509t

bursitis in, 461t, 472t

clinical summary and recommendations,

diagnostic utility of examination

acromioclavicular lesion tests, , 510f, 510t

active compression/O'Brien test, 482-483, 482t-483t

combined with other tests, 512t

anterior drawer test, , 476f, 476t

anterior slide/Kibler test, , 485f, 485t

apprehension tests, 474-475, 474f, 474t

combined with other tests,

combination of tests

for labral tears, , 512t

for SLAP lesions, , 513t

for subacromial impingement, , 514t

compression rotation test, , 479f, 479t

Crank test, , 478t

drop-arm test, , 495t

empty can test, , 496t

Hawkins-Kennedy test, , 491t

labral tear palpation, , 469t

lift-off test, , 497t

Neer test, 492-493, 492f, 493t

painful arc test, , 494t

relocation test, , 475f, 475t

Speed test, , 480f, 480t

subscapularis tear tests, 505-508

supraspinatus/infraspinatus muscle tear tests, 501-504, 501f, 501t-503t

Yergason test, , 484f, 484t

dislocations of, 474t

disorders of, classification of, , 472f, 472t

impingement syndrome of, 466t

intra-articular pathology of, subacromial impingement vs., , 499f

ligaments of, 452f, 454t

anterior view of, 454f-455f

coronal section, 455f

lateral view of, 455f

muscle tightness in, , 466t

muscles of, 456-458

anterior, , 457f, 457t

posterior, , 456f, 456t

nerves of

anterior axilla, 459t, 460f

in brachial plexus schema, 509f

osteology of,

anterior humerus and scapula, 451f

superior and inferior clavicle surface, 451f

outcome measures of, , 515t

pain in, with cervical compression test, 112t

patient history and, , 461-462, 461t

initial hypotheses based on, 461-462, 461t-462t

physical examination of, 450t

posterior tightness, 466t

protraction of, in postural assessment, 110t

quality appraisal of reliability studies for, 516-518, 516t-518t

quality assessment of diagnostic accuracy studies, 519-522, 519t-522t

range of motion of

disorders of, classification based on, 472f, 472t

functional tests of, , 464f, 464t

integrated movements of, , 453f

measurements of, , , 463f, 463t

pain during, 463t-464t

reliability of examination

active compression/O'Brien test, , 481f, 481t

anterior slide/Kibler test, , 485t

classifying disorders of, , 472f, 472t

clavicular tilt angle, , 471t

Crank test, , 477f, 477t

drop-arm test, , 494t

empty can test, , 495t

Hawkins-Kennedy test, , 490f, 490t

instability tests, , 473f, 473t

labral tear tests,

Neer test, 492-493, 492f, 492t-493t

painful arc test, , 494t

proprioception assessment, , 465t

ROM functional tests, , 464f, 464t

ROM measurements, , 463f, 463t

scapular asymmetry during activity, , 470t, 471f

strength assessment, , 465t

subacromial space palpation, , 468f, 468t

supraspinatus/infraspinatus tests, , 500f, 500t

thoracic kyphosis, , 471t

scapulohumeral rhythm of, , 453f

Shoulder abduction/abduction tests

for asymmetry assessment, 470t, 471f

of cervical spine, , 117f, 117t

cervical traction and, 137t

functional assessment of, 464t

for instability, 474t-476t,

for labral tear identification, , 469t, 478t-479t

measurement with, 463f, 463t

for muscle assessments, 465t-466t

in scapulohumeral rhythm, , 453f

Shoulder adduction/adduction tests, horizontal, for subacromial impingement identification, 498f, 498t

Shoulder pain

disorders classification based on, 472f, 472t

with impingement. _See_ Subacromial impingement

with instability, 474t-475t

during muscle length determination, 466t-467t, , 467f

patient history in, , 461t-462t

during range of motion, 463t-464t

with scapular asymmetry, 470t

during strength assessment, 465t

with tears. _See_ Glenoid labral tears; Rotator cuff

Shoulder Pain and Disability Index (SPADI), for shoulder outcomes, 515t

Shoulder protraction test, for brachial plexus palsy, 509t

Side bending

of cervical spine

left vs. right

measurements of, 97f, 98t-99t

pain during, 100t, 101f

testing of, 105f

of thoracolumbar spine, 173t-174t, 184f

pain during, , 176f, 176t

Single leg hop for distance, 429f, 429t

Single-leg hopping course, 429t

Sinuvertebral nerve, lumbar disc herniation and, 195f

Sit to stand test, for pelvic pain, 307t

Sitting

forward lean, 180t

knee extension, 180t

motion palpation, 184f

sacroiliac bony landmarks with, 239t

sacroiliac pain relieved by, 236t

for slump test, 194f, 194t

thoracolumbar pain with, 166t-167t

thoracolumbar spine ROM with, 173t-174t

Sitting flexion test, for sacroiliac joint, , 259f, 259t

6-Meter hop for time, 429t

Skull

lateral, osteology of, 17f

posterior, ligaments of, 75f

superior nuchal line of, 155f-157f

temporal lines of, inferior vs. superior, 17f

SLAP lesions. _See_ Superior labrum anterior posterior (SLAP) lesions

Slide tests

anterior, for glenoid labral tears, , 485f, 485t

combined with other tests, 512t-513t

lateral, for scapular asymmetry, 470t, 471f

SLR test. _See_ Straight-leg raise (SLR) test

Slump test, 194-196, 194f, 194t

knee bend, , 197f, 197t

radicular pain with, 148t, 195f, 196t

Sneezing

sacroiliac pain aggravated by, 236t

thoracolumbar pain with, 166t

Snuffbox, tenderness of, 575t, 577f

Soft tissue tenderness, in foot and ankle trauma, 419t

Sole

cutaneous innervation of, 417f

fibularis longus tendon passing to, 408f

muscles of

deep interosseous, , 415f, 415t

first layer of, , 412f, 412t

second layer of, , 413f, 413t

third layer of, , 414f, 414t

Soleal line, of tibia, 325f

Soleus muscle, 332f, 335f, 407t, 408f-410f, 417f

atrophy of, with herniated lumbar nucleus pulposus, 171f

length assessment of, 351t

neurological examination of, 170t

tendinous arch of, 281f, 409f

Space of Poirier, 560f

SPADI (Shoulder Pain and Disability Index), for shoulder outcomes, 515t

Specificity, of diagnostic tests, 5-6, 5f-6f, 11t

likelihood ratios and, , 8t

limitation of,

Speed test

for SLAP lesions, , 480f, 480t

for subacromial impingement, combined with other tests, , 513t-514t

Sphenoid bone, 15f, 17f, 71f

spine of, 71f

Sphenomandibular ligament, , 19f, 21f

Sphenopalatine foramen, 71f

Sphygmomanometer cuff, in knee assessment, 350t

Spinal artery, compression of, with cervical fracture, 94f

Spinal canal. _See_ Vertebral canal

Spinal column. _See also_ Vertebrae

nerves of. _See_ Spinal nerves

pain in. _See_ specific location

posterior view of, with associated musculature, 232f

Spinal cord, compression of

with cervical fracture, 94f

with disc herniation, 123f

Spinal manipulation

cervical, for cervical radiculopathy, , 131f, 131t

for low back pain, , 265f-266f, 266t

clinical prediction rule for,

Flynn technique for, 208f, , 265f

lumbosacral, 148t, 206t-207t, , 208f

lumbosacral/pelvic, for low back pain, 148t,

classification based on, 206t-207t

combined factors of likely benefits, , 208f, 208t

single factors of likely benefits, , 207t

of sacroiliac region, as pain intervention, 265-266, 265f

thoracic

for cervical radiculopathy, , 132t-133t, 134f

for neck pain,

Spinal nerve roots

avulsions of, in brachial plexus, , 509t

compression of

detection of, with slump knee bend test, , 197t

with lumbar disc herniation, 171f

with degenerative disc disease, 200f

with lumbar disc herniation, dorsal ganglion and, 195f

rami of. _See_ Rami communicantes

thoracic, dorsal vs. ventral, 160f

Spinal nerve trunks

in brachial plexus schema, 509f

lumbar, 161f-162f

lumbosacral, 161f-162f

thoracic, 160f, 160t

Spinal nerves

cervical, anterior vs. posterior divisions of, in brachial plexus schema, 509f

cranial. _See_ Cranial nerve(s)

groove for

on C4, 72f

on C7, 72f

intervertebral foramina for, 73f

lumbar, 161f-162f

anterior vs. posterior divisions of, 161f-162f

motor. _See_ Motor innervation

sensory. _See_ Sensory innervation

thoracic, . _See also_ Thoracic nerve

Spinal stenosis. _See_ Lumbar spinal stenosis

Spinalis cervicis muscle, 80t, 156f

Spinalis thoracis muscle, 156f, 156t

Spine. _See_ specific anatomy

Spinous processes

of cervical vertebrae, 73f

axis, 72f, 155f, 157f

C4, 72f

C7, 72f, 75f, 155f-157f, 456f

palpation of, 108t-109t

of lumbar vertebrae, 149f, 152f, 154f

in sacroiliac motion assessment, 254t

in scoliosis pathology, 179f

of thoracic vertebrae, 149f, 154f

in shoulder asymmetry assessment, 470t

T7, 150f

T9, 150f

T12, 155f-156f, 456f

in ROM assessment, 175f

of thoracolumbar vertebrae

in palpation examination, 188t

in passive intervertebral motion examination, 181t-183t

Spiral fracture, of femur, 313f

Splanchnic nerve

greater vs. lesser, 160f

pelvic, 162f, 233t, 234f

sacral, 234f

Splenius capitis muscle, 80t, 81f, 155f-156f, 456f

Splenius cervicis muscle, 80t, 81f, 155f-156f

Spondylosis, of cervical spine, 131t

Sprains

acromioclavicular joint, 461t

of anterior cruciate ligament, degrees of, 367f

foot and ankle, 418t

syndesmotic, 418t

hip and pelvis, 286t

Spring ligament, 404f, 404t-405t, 406f, 415f

Spring test

for 1st rib, for shoulder ROM, 464t

of cervical spine, 105t

of sacroiliac joint, , 256f, 256t

of thoracolumbar spine, 183t

Spur formation, in degenerative disc disease, 200f

Spurling's test,

combined with other tests, 129t

diagnostic utility of, 113-114, 113f, 113t-114t

reliability of, 112t

Squat test

double leg, 436t

for hip and pelvis, pain, 307t

deep, 307t

for meniscal tears, 376t-377t

single leg, 436t

Squeeze test

for ankle trauma, 419t

syndesmosis, 434t, 435f

Stability/instability

of cervical spine,

of elbow and forearm, 537t

of foot and ankle, , 428t

after sprains, 418t, , 438f

of hand, patient history in, 572t

of lumbar spine, 163t

dynamic "corset" concept of, 158f

radiographic tests for, 201-203, 201t, 202f-203f

segmental tests for, 198-199, 198t-199t

of patella, , , 375f, 375t

scapulohumeral rhythm of, , 453f

of shoulder, 461t

testing for, , 473-476, 476t

Stabilization exercises, lumbar, for low back pain, 148t, , 209t

classifications based on, 206t

Stabilization program, lumbar, for low back pain,

Stance

calcaneal, relaxed vs. neutral measurement of, 423f, 423t

single-leg, pain in, 307t

Standing

sacroiliac bony landmarks with, 239t, 240f

sacroiliac pain relieved by, 236t

thoracolumbar pain with, 166t-167t, 176f, 176t

thoracolumbar spine ROM with, 173t-174t, 175f

Standing flexion test, of sacroiliac joint, , 258f, 258t,

Static alignment

of foot and ankle,

of shoulder, , 470t, 471f

Static pain test, of temporomandibular joint,

Static palpation, of thoracolumbar spine, 182t

Statistics, related to diagnostic accuracy,

Steinmann test, for meniscal tears, 376t-377t

Stenosis, spinal. _See_ Lumbar spinal stenosis

Step up test, for pelvic pain, 307t

Sternal end, of clavicle, 451f

Sternal facet, of clavicle, 451f

Sternoclavicular joint, 452f, 452t

articular cavities of, 452f

articular discs of, 452f

integrated movements of, , 453f

Sternoclavicular ligament, 454t

anterior, 452f

Sternocleidomastoid (SCM) muscle, , 76f, 81f, 155f, 457f, 460f

clavicular head of, 76f

palpation of, 108t

sternal head of, 76f

Sternocostal articulations, anterior view of, 150f

Sternocostal joint, 452f

Sternocostal ligaments

intraclavicular, 150f

radiate, 150f, 153t, 452f

Sternohyoid muscle, 22f, 76f, 77t, 78f

Sternothyroid muscle, 76f, 77t, 78f

Sternum, 78f, 457f

body of, 225f

manubrium of, 76f

Stethoscope, for auscultation, of TMJ, 41f

Stork test. _See_ Gillet test

Straight-leg raise (SLR) test, 148t

for lumbar radiculopathy, 148t, 191f

cervical flexion for sensitizing, 191f

crossed, 148t, , 193t

diagnostic utility of, , 192t

reliability of, , 191f

for lumbar segmental instability, 198t-199t, 209t

for muscle length assessment, 351t

for pelvic pain assessment, 291t

for sciatic pain, 192t

Strains, muscle

hamstring, 286t

in hip and pelvis, 286t

Strength

cervical, and endurance testing, , 102f, 102t

in elbow and forearm, , 540t

in hand, ,

in knee, , , 350t

Strengthening exercises, and knee pain, 382t

Stress, adduction, of knee

end feel with, 348t

pain during, 349t

Stress test, compression, of foot and ankle, 420t

Stroke test

grading scale of, 345t

for knee joint effusion, , 345t

Study quality, assessment of, 9-11

Stylohyoid ligament, 71f

Stylohyoid muscle, 22f-24f, 22t, 76f, 77t, 78f

Styloid process, 15f, 19f, 22f, 71f, 79f

of radius, 532f, 557f

of ulna, 532f, 557f

Stylomandibular ligament, 15f, 19f, 71f

Subacromial bursa, 455f

Subacromial impingement

combination of tests for, , 514t

drop-arm test for, 494-495, 494t-495t

empty can test (Jobe test) for, 495-496, 495t-496t

Hawkins-Kennedy test for, , , 491t

intra-articular pathology vs., , 499f

lift-off test for, , 497t

Neer test for, , 492-493, 492f, 493t

patient history in, 461t

testing for,

various tests, 497-498, 497t-498t

Subacromial space, palpation of, , 468f, 468t

Subacromial syndrome, 472t

Subclavian artery, 79f, 460f

Subclavian groove, of clavicle, 451f

Subclavian muscle, groove on clavicle for, 451f

Subclavian vein, 79f, 460f

Subclavicular dislocation, of shoulder, 473f

Subclavius muscle, 452f, 460f

nerve to, 82t, 83f

Subcoracoid dislocation, of shoulder, 473f

Subcostal nerves

of lumbar spine, lateral branch of, 162f

of thoracic spine, 160f-162f, 160t

Subcutaneous bursa

infrapatellar, 326f

prepatellar, 326f

Subdeltoid bursa, 455f

Subglenoid dislocation, of shoulder, 473f

Sublingual fossa, 16f

Sublingual gland, 23f-24f

Sublingual nerve, 24f

Subluxations

of patella, 336t, 358f

of talus, anterior, 438f

Submandibular fossa, 16f

Submandibular ganglion, 24f

Submandibular gland, 76f

and duct, 23f

Suboccipital muscle, length assessment of, 111t

Suboccipital nerve, 75f, 81f

Subpopliteal recess, 329f

Subscapular artery, 460f

Subscapular fossa, 451f

Subscapular nerve

lower vs. upper, 459t, 460f

in brachial plexus schema, 509f

middle, 83f, 460f

in brachial plexus schema, 509f

upper and lower, 82t, 83f, 458t

Subscapularis muscle, 455f, 458f, 458t

palpation test, 469t

tears of, , 505-508, 505t-508t

Subscapularis tendon, 454f-455f, 458f

subtendinous bursa of, openings of, 455f

Subtalar glide test, medial, 437f, 437t

Subtalar joint, 401f, 401t

in alignment assessment, 427t

in motion assessment, 430t

ROM measurements of, 422t

Subtendinous (deep) bursa

of gastrocnemius muscle

lateral, 326f, 328f

medial, 328f

inferior, 331f

biceps femoris tendon and, 332f

infrapatellar, 326f

medial head of, 328f

of subscapularis tendon, 455f

openings of, 455f

of supraspinatus tendon, communications of, 454f

of tendocalcaneus, 408f

Sulcus sign, of shoulder instability, 473t

combined with other tests, 512t

Superficial dissection

of hip and thigh muscles, 281f

of wrist and digit muscles, 563f

Superior labrum anterior posterior (SLAP) lesions

active compression/O'Brien test for, 481-483, 481f, 481t-483t

combined with other tests, 512t

anterior slide/Kibler test for, 485t

combination of tests for, , 513t

compression rotation test for, 479t

palpation of, 469t

Speed test for, , 480f, 480t

various tests for, , 488-489, 488t-489t

Yergason test for, , 484f, 484t

Superior view

of atlas, 72f

of C4, 72f

of C7, 72f

of cervical spine ligaments, 74f

of costovertebral joints, transverse, 151f

of costovertebral ligaments, transverse section, 153f

of mandible, anterolateral, 16f

of rotator cuff muscles, 458f

of T6 vertebra, 149f

Supination, of hand, for scaphoid fractures, 575t

Supination measurements, of forearm, , 539f, 539t

for cubital tunnel syndrome, 542t

Supinator muscle, 533f-536f, , 535t

innervation of, 571f

Supine-to-sit test. _See_ Long-sit test

Supracondylar fracture, of femur, transverse, 341f

Supracondylar ridge, of humerus, 529f

medial vs. lateral, 451f

Supraglenoid tubercle, of scapula, 451f

Supraorbital notch (foramen), of frontal bone, 17f

Suprapatellar fat body, 326f

Suprapatellar quadriceps test, cervical myelopathy and, 124t-125t

Suprapatellar synovial bursa, 326f, 329f

Suprascapular area, palpation of, 108t

Suprascapular nerve, 82t, 83f, 458t-459t, 460f

Suprascapular notch, 451f-452f, 454f, 458f

Supraspinatus muscle, 155f, 455f-456f, 458f, 458t

atrophy, 504t

tears of, 500-504, 500f-501f, 500t-503t

Supraspinatus tendon, 454f-455f, 458f

subtendinous bursa of, 454f

communications of, 454f

Supraspinous fossa, 452f

notch connecting, 452f

Supraspinous ligament, 230f

of cervical spine, 75t

of thoracolumbar spine, 154f, 154t

Suprasternal space, 76f

Sural cutaneous nerve

lateral, 335f, 416f-417f

branches of, 416f-417f

phantom, 416f

lateral calcaneal nerve from, 413f

medial, 335f, 417f

from sciatic nerve, 335f

via lateral dorsal cutaneous branch, 410f, 416f

Sural nerve, 335f, 416t, 417f

communicating branch of, 335f

lateral calcaneal branches of, 335f, 409f, 417f

muscular branches of, 409f

Sustentaculum tali, 400f, 404f, 406f

on calcaneus, 399f

Swelling

in foot and ankle

impingement sign with, 436t

measurement of, , 431f, 431t

in trauma screening, 419t

in hand, in fracture screening, 577f, , 586f, 586t

in knee, patient reports of, 336t-337t, 340t, 344t

Sympathetic nerves

of lumbar spine, 161f-162f

of sacroiliac region, 234f

of thoracic spine, 160f

Symphyseal surface, of hip bone, 227f, 277f

Symphysiolysis, 261t

Synchondrosis

of 1st rib, 452f

manubriosternal, 452f

Syndesmosis ligament palpation, 434t

Syndesmotic injury,

Syndesmotic ligaments, 419t

Syndesmotic sprain, 418t

Synovial bursa, suprapatellar, 326f, 329f

Synovial cavities

costovertebral, 153f, 452f

of thoracic vertebrae, 151f

Synovial fold, infrapatellar, 329f

Synovial joint, of sternum, 452f

Synovial membrane

of acetabular fossa, 279f

of elbow, 530f

of femur

line of attachment of, 277f, 325f

line of reflection of, 277f, 325f

of knee, 326f, 329f

protrusion of, in hip, 279f

of shoulder, 455f

Synovitis, of knee, 379t

T

T1 vertebra

arthrology of, 73f

in kyphosis, 178t

ligaments of, 75f

limited and painful passive intervertebral motion of, 104t

nerves of, 82t, 83f, 533t, 535t-536t, 565t-567t, 570t-571t

in brachial plexus schema, 509f

osteology of, 15f, 71f

palpation of, 109t

in upper limb dermatomes, 89f, 90t

T2 vertebra

in kyphosis, 110t, 178t

limited and painful passive intervertebral motion of, 104t

nerves of, 83f

palpation of, 109t

in zygapophyseal pain referral pattern, 165f

T3 vertebra

in kyphosis, 110t, 178t

palpation of, 109t

in zygapophyseal pain referral pattern, 165f

T4 vertebra

in kyphosis, 110t, 178t

in zygapophyseal pain referral pattern, 165f

T5 vertebra

in kyphosis, 110t, 178t

in zygapophyseal pain referral pattern, 165f

T6 vertebra

in kyphosis, 110t, 178t

osteology of

lateral view of, 149f

superior view of, 149f

in zygapophyseal pain referral pattern, 165f

T7 vertebra

arthrology of, 150f

in kyphosis, 110t, 178t
spinous process of, 150f

in zygapophyseal pain referral pattern, 165f

T8 vertebra

arthrology of, 150f

in kyphosis, 110t, 178t

in zygapophyseal pain referral pattern, 165f

T9 vertebra

arthrology of, 150f

in kyphosis, 110t, 178t

transverse process of, 150f

in zygapophyseal pain referral pattern, 165f

T10 vertebra

in kyphosis, 110t, 178t

in zygapophyseal pain referral pattern, 165f

T11 vertebra

osteology of, 225f

in zygapophyseal pain referral pattern, 165f

T12 vertebra

nerves of, 160t, 161f-162f, 334f

osteology of, 225f

lateral view of, 149f

spinous process of, 155f-156f, 456f

in ROM assessment, 175f

Talar tilt test, for ankle instability, 437f-438f, 437t

Talocalcaneal ligament

interosseous, 403f, 403t

lateral, 403f

medial, 404f, 404t

posterior, 402f, 402t, 404f

Talocalcaneonavicular joint, 401f, 401t

Talocrural joint, 401f, 401t

Talofibular ligaments

anterior, 403f, 403t

in physical examination, 419t

tears of, 438f

posterior, 402f-403f, 402t-403t

Talonavicular ligament, dorsal, 403f-404f, 403t-404t

Talus, 399f-400f, 402f

anterior subluxation of, 438f

groove for flexor hallucis longus tendon on, 400f

head of, 399f-400f

lateral process of, 399f

neck of, 399f-400f

in physical examination, 427t, 438f

posterior process of, 399f-400f, 404f, 406f

trochlea of, 399f-400f

tubercles of, lateral vs. medial, 399f-400f, 406f

Tarsal arteries, lateral vs. medial, 410f, 415f

Tarsal joint, transverse, 399f-401f, 401t

Tarsal sinus, 399f-400f

Tarsal tunnel syndrome, 418t

detecting,

Tarsometatarsal joint, 399f-401f, 401t

plantar, 406f

Tarsometatarsal ligaments

dorsal, 403f-404f, 403t, 415f

plantar, 405t

Tears. _See_ specific anatomy

Tectorial membrane, 74f, 74t

deeper (accessory) part of, 74f

Temporal bone, 15f, 17f, 27f, 71f

squamous part, 17f

Temporal fascia, 20f, 24f

deep vs. superficial layer of, 20f

Temporal fossa, 15f, 71f

of parietal bone, 17f

Temporal nerve, deep, anterior vs. posterior, 24f

Temporalis muscle, , 20f, 24f, 36f

insertion into coronoid process of mandible, 20f

palpation of, 37f

in physical examination, 36f

pressure pain threshold of, 39t

Temporomandibular joint (TMJ), 13-68

arthrology,

jaws closed, 18f

jaws slightly opened, 18f

jaws widely opened, 18f

arthrosis, 29f

clinical summary and recommendations,

conditions with crepitus, , 42t

diagnostic criteria for, 31-34

intraarticular, 33-34, 33t-34t

diagnostic utility of examination

anterior disc displacement

with reduction, 56-57, 56f

without reduction, 58-59, 58f

conditions with clicking,

conditions with crepitus, , 42t

conditions with pain during dynamic movements, 52-53, 52f

of lower extremity measurements, , 55t

patient history, , 25t

pressure pain thresholds, , 39t

disorder, reliability and diagnostic criteria for pain-related, 31-34

dynamic movements and, , 49f

pain during joint play, , 51f

interventions for, 14t

occlusal stabilization splint as, , 60f

joint sounds in, 40-42, 40t

in physical examination, 40-42

ligaments, , 19f

mechanics, 18f

muscles of, 20-22

floor of mouth,

involved in mastication, , 20f-21f

nerves of,

mandibular, , 24f

night occlusal stabilization splint for, , 60f

predicting treatment failure with, , 61t

predicting treatment success with, , 60f

osteology of, 15-24

head and neck, 15f

mandible, 16f

skull, 17f

outcome measures of, , 62t

palpation of, 35-39, 35t, 37f

conditions identified by, , 38t

lateral, 37f

muscle, , 35t

posterior, , 36f-37f

pressure pain thresholds, , 39t

regional,

test, 37f

patient history and, 14t,

anterior disc displacement, 27-28

initial hypotheses based on, , 25t

oral habits,

report of pain, 26f, 26t

physical examination of, 35-39

quality assessment of diagnostic studies for, 65-66, 65t-66t

range-of-motion measurements, 43f, 44-45, 44t-45t

physical examination, 43-47

reliability of examination

compression test, , 54f

joint play and end-feel assessment, , 46f

joint sounds during active motion, , 40t

joint sounds during joint play, , 40t

lower extremity measurements, , 55t

mandibular opening with different head positions, , 46t

mouth opening measurements, , 43f

pain during dynamic movements, , 49f

pain during joint play, , 51f

pain during muscle palpation, , 35t

pain during regional palpation, , 36f

pain during resistance tests, , 50f

range-of-motion measurements, , 44t-45t

self-reported,

Research Diagnostic Criteria for,

anterior disc displacement, 27f

reliability of, 31-34

Temporomandibular ligament, , 19f

Temporomandibular pain

diagnostic criteria for, 31-34

during dynamic movements, , 49f

conditions identified by, 52-53, 52f

resistance tests, , 50f

during muscle palpation, , 35t

myofascial, 31t-32t

patient history, 29-30

self-reported,

diagnostic utility of, , 30t

Tenderness. _See_ Pain

Tendonitis, of shoulder, 461t

Tendons

of foot and ankle, 399f

ruptures of, 418t

of knee, 325f-329f, 331f-332f

of lateral hip, identifying pathology of, , 298f, 298t

of neck, 78f

of sacroiliac region, 230f

of shoulder, 454f-455f

of thoracolumbar spine, 156f-157f

of wrist, 559f-560f, 562f-563f, 565f

Tennis elbow

patient history in, 537f

patient-rated evaluation of, 549t

Tenosynovitis, in hand,

Tension test, for glenoid labral tears, 488t-489t

Tensor fasciae latae muscle, 282t, 283f-285f

Tensor fasciae latae myofascial pain, 188t

Tensor tympani muscle, 24f

Tensor tympani nerve, 24f

Tensor veli palatini muscle, 21f, 24f

Tensor veli palatini nerve, 24f

Teres major muscle, 155f, 456f, 458t, 460f

Teres minor muscle, 155f, 456f, 458f

Teres minor tendon, 455f, 458f, 458t

Test(s)/testing. _See_ specific test or under specific anatomy, disorder or component

Tethered median nerve test, 601t

Thenar eminence, impact of fall in, 577f

Thenar muscles, 568f

innervation of, 569f-570f

Thessaly test, of knee,

for meniscal tears, 373-374, 373f

Thigh

muscles of,

anterior, , 282t, 283f

posterior, , 280t

nerves of, 233t, 285f

lateral cutaneous, 160t, 161f-162f, 284t, 285f, 333f-334f

posterior cutaneous, 162f, 335f

Thigh pain

with herniated lumbar nucleus pulposus, 171f

knee interventions and, 382t

as lumbar zygapophyseal joint pain referral, 164f, 164t

patient report of, 286t-287t

Thigh thrust test, , 243-244, 243f, 243t-244t

combined with other tests, 262t,

for pelvic pain, 291t

Thomas test, 351t

for hip flexor contracture, , 302f, 302t

modified, 302t

Thompson test, 433f, 433t

Thoracic artery, superior, 460f

Thoracic kyphosis, , 471t

Thoracic manipulation, for cervical radiculopathy, , 132t

cluster of findings, , 133t, 134f

for neck pain,

Thoracic nerve

collateral branch of, 160f

rejoining intercostal nerve, 160f

communicating branch of, 160f

cutaneous branches of

anterior, 160f

dorsal vs. ventral root of, 160f

lateral, 160f

meningeal branch of, 160f

sensory ganglion of, 160f

subcostal branch of, 160f-161f, 160t

long, 82t, 83f, 459t, 460f

in brachial plexus schema, 509f

subcostal branches of, 160t, 162f

Thoracic outlet syndrome, 461t

Thoracic spine

arthrology of, 150-152

first, 152t

joint classifications, 152t

second to seventh, 152t

fascia of, 155f,

joints of, , 152t

kyphosis of, 178t

postural assessment for, 110f, 110t, 178t

ligaments of, 150f-151f, 153-154

costovertebral, , 153f, 153t

thoracolumbar, , 154f, 154t

muscles of, , 155f, 155t

superficial layers of, , 155f, 155t

nerves of, . _See also_ Thoracic nerve

osteology of, 149f

pain in. _See_ Thoracolumbar pain

scoliosis of, 178t

Thoracic vertebrae. _See also_ specific vertebra

articular facets of

inferior, 149f, 154f

superior, 149f-150f

articular processes of, inferior vs. superior, 149f-150f, 154f

spinous processes of, 149f, 154f

in palpation examination, 188t

in shoulder asymmetry assessment, 470t

T7, 150f

T9, 150f

T12, 155f-156f

transverse process of, 149f-150f, 153f-154f

Thoracoacromial artery, 460f

acromial branch of, 460f

clavicular branch of, 460f

deltoid branch of, 457f, 460f

pectoral branch of, 460f

Thoracodorsal artery, 460f

Thoracodorsal nerve, 82t, 83f, 460f

in brachial plexus schema, 509f

Thoracolumbar fascia, 155f-156f,

anterior layer of, 157f,

middle layer of,

pain in, palpation identification of, 188t

posterior layer of, 157f, , 159f

stabilizing force of, , 159f

superficial, , 159f

Thoracolumbar joints, 152t

zygapophyseal syndromes of,

Dreyfuss description of, 165f

Fukui description of, 165f

Thoracolumbar pain

discogenic, 163t, 195f

interventions for, 148t

during motion/mobility assessments, , 176f, 176t, 183t

patient report of, 163t, 164f-165f, 166t-167t

physical examination of, 148t, , 176f, 176t

provocative tests for, , 176f, 176t, 183t

zygapophyseal syndromes of, 163t

Fukui description of, 164f

Thoracolumbar spine, 147-221

arthrology of, 150-152

clinical summary and recommendations,

degenerative disc disease in, 200f

diagnostic utility of examination

for ankylosing spondylitis, , 204t

instability tests, 201-203, 201t, 202f-203f

neurological examination, 170-172, 170t, 171f-172f, 172t

passive intervertebral motion assessment, , 184f, 184t, , 186f

patient history, 167-168, 167t-168t, 202f

slump knee bend test, , 197t

slump test, 194-196, 194f-195f, 194t

stenosis test, , 200f, 200t

fascia of. _See_ Thoracolumbar fascia

interventions for, 148t

low back pain classification based on, , 206t

spinal manipulation as, , 207t

stabilization exercises as, 148t, 206t, , 209t

joints of, 152t

ligaments of, 153-154, 154f, 154t

costovertebral, 151f, , 153f, 153t

sternocostal, 150f

muscles of

anterior abdominal wall, 158f

deep layer of, , 157f, 157t

intermediate layer of, , 156f, 156t

superficial layer of, , 155f, 155t

nerves of

anterior vs. posterior divisions of, 162f

lumbar, 161f-162f

lumbosacral trunks of, 162f

thoracic, . _See also_ Thoracic nerve

ossification of, in ankylosing spondylitis, 169f

osteology of,

lumbar vertebrae, 149f

thoracic vertebrae, 149f

outcome measures of, , 210t

patient history and, 148t, , 163t, 202f

ankylosing spondylitis identification with, , 169f, 169t

initial hypotheses based on, , 163t

radiculopathy identification with, , 168t

report of pain, 163t, 164f-165f

spinal stenosis identification with, , 167t

physical examination of, 148t, 170-172

quality appraisal of reliability studies, for disorders of, 212t-215t

quality assessment of diagnostic studies, 211-217, 211t, 216t-217t

range of motion of, 148t

in low back pain classifications, 205t

measurement of, 173-176, 173t-174t, 175f

pain during, , 176f, 176t

reliability of examination

identifying segmental levels and, , 187t

instability tests, 198-199, 198t-199t, 199f

low back pain classification, , 205t

lumbar motor control, , 180f, 180t

lumbar multifidus muscle function assessment via palpation, , 188t

pain provocation, , 176f, 176t

palpation of tenderness, , 188t

passive intervertebral motion assessment, 181-183, 181t, 183f

patient history, , 166t

postural assessment, , 178t

ROM measurements, 173-176, 173t-174t, 175f

slump test, , 194f, 194t

knee bend, , 197f, 197t

strength and endurance assessment, , 177f, 177t

Thoracolumbar vertebrae. _See also_ Lumbar vertebrae; Thoracic vertebrae

anterior segments of, posterior view of, 154f

posterior segments of, posterior view of, 154f

segmental level identification in, palpation for, , 187t

segmental mobility identification in, palpation for, 182t, 184f-186f, 184t, 186t

Thrust test. _See_ Sacral thrust test; Thigh thrust test

Thumb

articular capsule of, 560f

compression of, for scaphoid fractures, 575t

extensor muscles of, 563f

range of motion measurements of, , , 581f, 581t

Thumb pad, sensation testing of, carpal tunnel syndrome identification with,

Thyrohyoid membrane, 78f

Thyrohyoid muscle, 22f, 76f, 77t, 78f

Thyroid cartilage, 15f, 71f, 76f, 78f

oblique line of, 78f

Thyroid gland, 76f, 78f

Tibia

of ankle joint, 402f-404f, 410f

anterior border of, 325f

condyle of

lateral, 325f

medial, 325f, 327f, 329f, 331f

groove for insertion of semimembranosus tendon on, 325f

intercondylar area of, anterior and posterior, 325f

intercondylar eminence of, 325f

intercondylar tubercle of, lateral and medial, 325f

in knee, 326f, 328f

lateral condyle of, 408f

lateral surface of, 325f

oblique line of, 325f, 331f

osteology of, 325f

in physical examination

of foot and ankle, 419t-420t, 438f

of knee, 358f-359f, 358t-359t, 367f, 370f, 371t

tuberosity of, 283f, 325f-326f, 329f, 331f-332f, 408f

Tibial arteries

anterior, 409f-410f

posterior, 409f

medial calcaneal branches of, 409f, 412f

posterior medial malleolar branch of, 409f

Tibial collateral ligament, 327f-329f, 327t, 331f, 409f

deep part bound to medial meniscus, 329f

oblique fibers, 332f

parallel fibers, 332f

rupture of, 340f

superficial and deep parts, 329f

Tibial nerve, 162f, 234f, 281f, 330t, 335f, 407t, 409f, 417f

anterior view of, 416f, 416t

articular branch of, 335f

deep branch to interosseous muscles, 417f

dividing, 413f

lateral plantar nerve from, 417f

medial calcaneal branches of, 335f, 409f, 412f, 417f

medial plantar nerve from, 417f

posterior view of, 417f

superficial branch to 4th interosseous muscle, 417f

Tibialis anterior muscle, 331f-332f, 407t, 408f, 410f, 416f

Tibialis anterior tendon, 404f, 406f, 410f, 415f

in physical examination, 431t

Tibialis posterior muscle, 409f, 409t, 417f

Tibialis posterior tendon, 404f, 406f, 409f, 413f-415f

Tibiofemoral joint, 326t

Tibiofibular joint

distal, 401t

proximal, 326t

Tibiofibular ligament

anterior, 403f, 403t

posterior, 402f-403f, 402t

Tinel sign

in carpal tunnel syndrome, 590t-591t

in elbow and forearm, , 542t, 543f

in hand, , , 589f, 589t

in shoulder, 509t

Tingling. _See_ Paresthesias

Tip pinch strength, 583f

TMJ. _See_ Temporomandibular joint (TMJ)

Toe strength, plantarflexion, , 424t

Toes

lateral deviation of, 432f

ulcer on, 432f

Tongue, 36f

Torque, reproduction of, in balance assessment, 428t

Torsion, innominate, of sacroiliac region, , 254t-255t, 257t-259t

Trachea, 15f, 71f, 76f, 78f

Traction, mechanical

for cervical radiculopathy. _See_ Cervical traction, for cervical radiculopathy

for low back pain, classifications based on, 206t

Traction test

of cervical spine, , 115f, 115t

of temporomandibular joint, 51f

Translation test, of mandible, 46f

Transverse diameter, of pelvic inlet, 228f

Transverse fracture, of femur, 313f

Transverse ligaments

of acetabulum, 279f

of atlas, 72f, 74f, 74t

posterior articular facet for, 73f

posterior articular facet of axis for, 72f

of knee, 327t, 329f

of metatarsal, deep, 405t, 415f

Transverse process(es)

of cervical vertebrae, 72f, 75f, 79f, 157f

of coccyx, 226f

of lumbar vertebrae, 149f, 152f, 225f, 278f

L5, as sacroiliac bony landmark, 239t

of thoracic vertebrae, 149f, 152t, 153f-154f

Transverse section

of costovertebral joints, superior view of, 151f

of costovertebral ligaments, superior view of, 153f

Transverse tarsal joint, 399f, 401f, 401t

Transversus abdominis muscle, 158f, 158t, 160f-161f

tendon of origin of, 156f-157f

thoracolumbar fascia attachment to, , 159f

Trapezium, 557f-559f, 561f-562f

in carpal tunnel syndrome, 574f

in scaphoid fractures, 577f

tubercle of, 557f-558f, 560f

Trapezius muscles, 76f, 78f, 81f, 160f, 456f-457f, 456t, 460f

lower, 155f, 155t, 456f, 456t

middle, 155f, 155t, 456f, 456t

strength testing of, 465t

upper, 80t, 456f-457f, 456t

length assessment of, 111t

Trapezoid, 557f-559f, 561f

in carpal tunnel syndrome, 574f

in scaphoid fractures, 577f

Trapezoid ligament, 454f, 454t, 458f

Trapezoid line, of clavicle, 451f

Trauma. _See also_ specific injury

foot and ankle

ligament sprains as, 418t

patient report of, 418t

screening for, 419-440

to head/neck, Glasgow Coma Score with,

knee

patient reports of, 336t, 340t

screening for, 341f, 376t-377t

shoulder, 461t-462t

Treadmill test, two-stage, for lumbar spinal stenosis, 200t

Treatment threshold, , , 10f

Trendelenburg test

for lumbar segmental instability, 198t-199t

reliability of, , 299f, 299t

Triangle of auscultation, in shoulder, 456t

Triceps brachii muscle, 460f

lateral head of, 456f-457f, 533t

long head of, 456f, 533t

manual testing of, 91f

for cervical radiculopathy, 92t

medial head of, 533t

muscle stretch reflex testing of, 93f

for cervical radiculopathy, 93t

Triceps brachii tendon, 531f, 533f

Trigeminal (semilunar) ganglion, 24f

Trigger finger, 572t

Triple compression stress test, 439f, 439t

Triple hop for distance, 429t

Tripod pinch strength, 583f

Triquetrum, 557f-559f, 561f

in scaphoid fractures, 577f

Trochanteric fossa, 277f

Trochanteric region, lumbar zygapophyseal joint pain and, 164f

Trochanters, of femur

greater, 225f, 277f-279f, 281f, 283f-284f

bursitis, 286t

tenderness over, 298t

lesser, 225f, 277f-279f

tenderness with palpation, 308t

Trochlea

of humerus, 451f-452f, 529f

of talus, 399f-400f

Trochlear notch, 529f, 532f

True-negative rate, 3t-4t, , 11t

True-positive rate, 3t-4t, , 11t

Trunk

alignment of, in scoliosis, 179f

neural. _See_ Spinal nerve trunks

Tubercles. _See also_ specific anatomy

articular. _See_ Articular tubercles

of cervical vertebrae, 72f. _See also_ specific vertebra

anterior, 72f, 75f

posterior, 72f, 156f-157f

Tuberosity. _See also_ specific anatomy

on calcaneus, 399f

of maxilla, 71f

Tuning fork test, for foot and ankle injury, , 420t

2×2 contingency table, 3-8, 3t, 11t

likelihood ratios in, 7f, 7t, 8-9, 11t

Tympanic cavity, 24f

U

Ulcers/ulcerations

due to vasculitis, 432f

on toes, 432f

Ulna

anterior border of, 532f

anterior surface of, 532f

coronoid process of, 529f, 532f

deviation of, 579t, 580f

distal, fractures of, in children, 578f

in elbow, 529f-531f

in hand, 557f

interosseous border of, 532f

ligaments of, 531f, 531t

muscles of, 533f, 535f, 563f, 565f, 567f-568f

nerves of, 536f, 536t

olecranon of, 529f, 533f

subcutaneous bursa of, 531f

radial notch of, 529f

styloid process of, 532f, 557f

trochlear notch of, 529f

tuberosity of, 529f, 532f

in wrist joint, 559f-561f

Ulnar artery, 534f, 536f, 568f

anterior recurrent, 534f, 536f

in carpal tunnel syndrome, 574f

deep palmar branch of, 534f, 536f, 568f

palmar carpal branch of, 536f, 568f

posterior recurrent, 533f, 536f

Ulnar bursa, in carpal tunnel syndrome, 574f

Ulnar collateral branches, of brachial artery, 533f

Ulnar collateral ligament, 531f, 531t, 560f-561f, 560t

Ulnar fovea sign, , 602f, 602t

Ulnar nerve, 82t, 83f, 459t, 460f, 533f, 536f, 536t, 565t-566t, 568f, , 570f, 570t

anterior vs. posterior view of, 570f

articular branch of, 570f

in carpal tunnel syndrome, 574f

communicating branch of, 569f-570f

compression at canal of Guyon, 572t

in cubital tunnel syndrome, 542t

deep branch of, 534f, 536f, 567t, 570f

palmar, 568f

dorsal branch of, 534f, 536f, 570f

to flexor digitorum profundus muscle, 569f

groove on humerus for, 452f, 529f

inconstant contribution to, 570f

innervation of, 569f

palmar branch of, 534f, 570f

in shoulder, 459t

superficial branch of, 534f, 570f

Ulnocarpal ligament

dorsal, 561f

palmar, 560f, 560t

ulnolunate and ulnotriquetral portions of, 560f, 560t

Ulnolunate portion, of palmar radiocarpal ligament, 560f, 560t

Ulnomeniscotriquetral dorsal glide test, 599t-600t

Ulnotriquetral ligament, foveal disruption of,

Ulnotriquetral portion, of palmar radiocarpal ligament, 560f, 560t

ULTTs. _See_ Upper limb tension tests (ULTTs)

Uncus (uncinate process), 73f

Upper arm, MMT of, for cervical radiculopathy,

Upper Extremity Functional Index, 604t

in elbow and forearm outcomes, 549t

for shoulder outcomes, 515t

Upper limb

dermatomes of, anterior vs. posterior view of, 89f

manual muscle testing of, 91f, 91t

for cervical radiculopathy, 92t

Upper limb tension tests (ULTTs), , 597t, 598f

for carpal tunnel syndrome, , 598t

for cervical radiculopathy

A, , , 119f

cervical traction and, 137t

combined with other tests, 129t

B, , 119f

diagnostic utility of, 120t

reliability of, , 119f

V

Valgus extension overload syndrome, 537t

Valgus stress test

diagnostic utility of, , 369t, 376t-377t

of elbow and forearm, moving, , 544f, 544t

in knee joint, 340f, 369f

medial collateral ligament tears and, 369t

reliability of, , 369t

Varus stress test

of elbow and forearm,

of forefoot, 427f, 427t

of knee, 369f

reliability of,

Vasculitis, foot ulcerations due to, 432f

Vastus intermedius muscle, 283f, 285f, 330t, 331f, 334f

Vastus lateralis muscle, 283f, 285f, 330t, 331f-332f, 334f, 408f

Vastus medialis muscle, 283f, 285f, 330t, 331f-332f, 334f

Veins. _See also_ specific veins

of neck, 76f, 79f

of shoulder, 457f

Vertebra prominens, 75f

Vertebrae. _See also_ specific segment

bony framework of

head and neck, 15f

lumbar, 149f

facets of. _See_ Articular facets; Costal facets

in kyphosis pathology, 178t

processes of. _See_ Articular process; Spinous processes; Transverse process

in scoliosis pathology, 179f

Vertebral artery, 75f

atlantic part of, 81f

groove on atlas for, 72f

Vertebral body(ies)

cervical, 72f

fracture of, 94f

lumbar, 149f, 152f, 154f

in scoliosis pathology, 179f

thoracic, 149f

posterior surface of, 154f

Vertebral canal

lumbar, 152f

in scoliosis pathology, 179f

thoracic, 152t

Vertebral foramen

of cervical vertebrae, 72f

of lumbar vertebrae, 149f

of thoracic vertebrae, 149f

Vertebral notch

of lumbar vertebrae, inferior vs. superior, 152f

of thoracic vertebrae, inferior vs. superior, 149f

Vibration testing

of lumbar spine, 170t, 172t

of thoracolumbar spine, 148t

Vigorimeter, for grip, 582t

Visual analog scale, for rating pain, 26t

Visual estimation

of cervical spine, 99t

of knee range of motion, 346t-347t

of shoulder ROM, 463t

Visual inspection, of knee, for inflammation, 344t

Visual observation, of lumbar lordosis, 204t

Volar plate, of palmar ligament, 562f, 562t

W

Wainner's diagnostic test item cluster, for cervical radiculopathy, 130t

Walking. _See also_ Gait

sacroiliac pain relieved by, 236t

thoracolumbar pain with, 166t-167t

Water volumetrics, ankle joint swelling, 431t

Weakness. _See_ Muscle strength

Weight-bearing activities, 425t

foot and ankle disorders with

alignment measurements for, 425t

patient report of, 418t

ROM measurements for, 423f

trauma screening of, 419t-420t

Windlass test, , 440f, 440t

knee, during trauma, 341f, 341t, 376t-377t

patient report of, 340t

in Windlass test, vs. non-weight bearing, , 440f, 440t

Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 384t

in hip and pelvis outcomes, 316t

Whipple test, for glenoid labral tears, 488t-489t

Windlass test, weight bearing vs. non-weight bearing, , 440f, 440t

Wing. _See_ Ala (wing)

Wrist

arthrology of,

in children, , 578f

ligaments of, 560-562

palmar, , 560f, 560t

posterior, , 561f, 561t

muscles of

extensor, 563-564, 563f, 563t-564t

flexor, 565-566, 565f, 565t-566t

osteology of, 558f

reliability of examination, range of motion measurements, , , 579f, 579t

Wrist joint, 559f, 559t

articular disc of, 559f

Wrist ratio index, in carpal tunnel syndrome, 585t

X

Xiphoid process, 153t, 225f

X-rays. _See_ Radiography

Y

Y ligament of Bigelow, 279f

Yergason test, for shoulder pain, , 484f, 484t

combined with other tests, , 513t-514t

Yocum test, for subacromial impingement, 498f, 498t

Z

Zona orbicularis, 279f

Zygapophyseal joints

capsule of

cervical, 74f-75f, 154f

thoracolumbar, 154f

of cervical spine, 73f, 75f

limited movement in,

palpation of, 108t

thoracolumbar, 152t

Zygapophyseal pain referral pattern/syndrome

in cervical spine,

Cooper description of, 85f

diagnostic nerve block for, 107t

Dwyer description of, 84f

in thoracolumbar spine, 163t,

Dreyfuss description of, 165f

Fukui description of, 164f-165f

Zygomatic arch, 15f, 17f, 20f, 71f

Zygomatic bone, 17f

Zygomatic process, of temporal bone, 17f

Zygomaticus major muscle, 20f

Zygomaticus minor muscle, 20f

# Diagnostic and Reliability Interpretation Keys

Diagnostic Interpretation Key

\+ LR| Interpretation| –LR
---|---|---
≥10| Large| <.1
5.0-10.0| Moderate| .1-.2
2.0-5.0| Small| .2-.5
1.0-2.0| Rarely important| .5-1.0

Reliability Interpretation Key

ICC or κ| Interpretation
---|---
.81-1.0| Substantial agreement
.61-.80| Moderate agreement
.41-.60| Fair agreement
.11-.40| Slight agreement
.0-.10| No agreement

# Table of Contents

  1. Cover image
  2. Title Page
  3. Table of Contents
  4. Copyright
  5. Dedication
  6. About the Authors
  7. About the Artists
  8. Foreword
  9. Preface
  10. Video Contents
  11. 1 The Reliability and Diagnostic Utility of the Orthopaedic Clinical Examination
    1. Reliability
    2. Diagnostic Accuracy
    3. Confidence Intervals
    4. Pretest and Posttest Probability
    5. Calculating Posttest Probability
    6. Assessment of Study Quality
    7. Summary
    8. References
  12. 2 Temporomandibular Joint
    1. Clinical Summary and Recommendations
    2. Anatomy
    3. Patient History
    4. Diagnostic Criteria for TMD
    5. Physical Examination Tests
    6. Outcome Measures
    7. Appendix
    8. References
  13. 3 Cervical Spine
    1. Clinical Summary and Recommendations
    2. Anatomy
    3. Patient History
    4. Physical Examination Tests
    5. Outcome Measures
    6. Appendix
    7. References
  14. 4 Thoracolumbar Spine
    1. Clinical Summary and Recommendations
    2. Anatomy
    3. Patient History
    4. Physical Examination Tests
    5. Outcome Measures
    6. Appendix
    7. References
  15. 5 Sacroiliac Region
    1. Clinical Summary and Recommendations
    2. Anatomy
    3. Patient History
    4. Physical Examination Tests
    5. Outcome Measures
    6. Appendix
    7. References
  16. 6 Hip and Pelvis
    1. Clinical Summary and Recommendations
    2. Anatomy
    3. Patient History
    4. Physical Examination Tests
    5. Outcome Measures
    6. Appendix
    7. References
  17. 7 Knee
    1. Clinical Summary and Recommendations
    2. Anatomy
    3. Patient History
    4. Physical Examination Tests
    5. Outcome Measures
    6. Appendix
    7. References
  18. 8 Foot and Ankle
    1. Clinical Summary and Recommendations
    2. Anatomy
    3. Patient History
    4. Physical Examination Tests
    5. Outcome Measures
    6. Appendix
    7. References
  19. 9 Shoulder
    1. Clinical Summary and Recommendations
    2. Anatomy
    3. Patient History
    4. Physical Examination Tests
    5. Outcome Measures
    6. Appendix
    7. References
  20. 10 Elbow and Forearm
    1. Clinical Summary and Recommendations
    2. Anatomy
    3. Patient History
    4. Physical Examination Tests
    5. Outcome Measures
    6. Appendix
    7. References
  21. 11 Hand
    1. Clinical Summary and Recommendations
    2. Anatomy
    3. Patient History
    4. Physical Examination Tests
    5. Outcome Measures
    6. Appendix
    7. References
  22. Index
  23. Diagnostic and Reliability Interpretation Keys

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    39. Figure 7-39
    40. Figure 7-40
    41. Figure 7-41
  8. Figures in 8
    1. Figure 8-1
    2. Figure 8-2
    3. Figure 8-3
    4. Figure 8-4
    5. Figure 8-5
    6. Figure 8-6
    7. Figure 8-7
    8. Figure 8-8
    9. Figure 8-9
    10. Figure 8-10
    11. Figure 8-11
    12. Figure 8-12
    13. Figure 8-13
    14. Figure 8-14
    15. Figure 8-15
    16. Figure 8-16
    17. Figure 8-17
    18. Figure 8-18
    19. Figure 8-19
    20. Figure 8-20
    21. Figure 8-21
    22. Figure 8-22
    23. Figure 8-23
    24. Figure 8-24
    25. Figure 8-25
    26. Figure 8-26
    27. Figure 8-27
    28. Figure 8-28
    29. Figure 8-29
    30. Figure 8-30
    31. Figure 8-31
    32. Figure 8-32
    33. Figure 8-33
    34. Figure 8-34
    35. Figure 8-35
    36. Figure 8-36
    37. Figure 8-37
    38. Figure 8-38
    39. Figure 8-39
  9. Figures in 9
    1. Figure 9-1
    2. Figure 9-2
    3. Figure 9-3
    4. Figure 9-4
    5. Figure 9-5
    6. Figure 9-6
    7. Figure 9-7
    8. Figure 9-8
    9. Figure 9-9
    10. Figure 9-10
    11. Figure 9-11
    12. Figure 9-12
    13. Figure 9-13
    14. Figure 9-14
    15. Figure 9-15
    16. Figure 9-16
    17. Figure 9-17
    18. Figure 9-18
    19. Figure 9-19
    20. Figure 9-20
    21. Figure 9-21
    22. Figure 9-22
    23. Figure 9-23
    24. Figure 9-24
    25. Figure 9-25
    26. Figure 9-26
    27. Figure 9-27
    28. Figure 9-28
    29. Figure 9-29
    30. Figure 9-30
    31. Figure 9-31
    32. Figure 9-32
    33. Figure 9-33
    34. Figure 9-34
    35. Figure 9-35
    36. Figure 9-36
    37. Figure 9-37
    38. Figure 9-38
    39. Figure 9-39
    40. Figure 9-40
    41. Figure 9-41
    42. Figure 9-42
    43. Figure 9-43
  10. Figures in 10
    1. Figure 10-1
    2. Figure 10-2
    3. Figure 10-3
    4. Figure 10-4
    5. Figure 10-5
    6. Figure 10-6
    7. Figure 10-7
    8. Figure 10-8
    9. Figure 10-9
    10. Figure 10-10
    11. Figure 10-11
    12. Figure 10-12
    13. Figure 10-13
    14. Figure 10-14
    15. Figure 10-15
    16. Figure 10-16
    17. Figure 10-17
  11. Figures in 11
    1. Figure 11-1
    2. Figure 11-2
    3. Figure 11-3
    4. Figure 11-4
    5. Figure 11-5
    6. Figure 11-6
    7. Figure 11-7
    8. Figure 11-8
    9. Figure 11-9
    10. Figure 11-10
    11. Figure 11-11
    12. Figure 11-12
    13. Figure 11-13
    14. Figure 11-14
    15. Figure 11-15
    16. Figure 11-16
    17. Figure 11-17
    18. Figure 11-18
    19. Figure 11-19
    20. Figure 11-20
    21. Figure 11-21
    22. Figure 11-22
    23. Figure 11-23
    24. Figure 11-24
    25. Figure 11-25
    26. Figure 11-26
    27. Figure 11-27
    28. Figure 11-28
    29. Figure 11-29
    30. Figure 11-30
    31. Figure 11-31
    32. Figure 11-32
    33. Figure 11-33
    34. Figure 11-34

## Landmarks

  1. Cover Image
  2. Title Page
  3. Table of Contents

  1. iii
  2. iv
  3. v
  4. vii
  5. viii
  6. ix
  7. x
  8. xii
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  654. IBC1

redpajama_set_name: RedPajamaBook