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<p>Orthopedic Physical</p><p>Examination Tests</p><p>An Evidence-Based</p><p>Approach</p><p>Second Edition</p><p>Chad E. Cook, PT, PhD, MBA, OCS, FAAOMPT</p><p>Professor and Chair</p><p>Walsh University</p><p>North Canton, Ohio</p><p>Eric J. Hegedus, PT, DPT, MHSc, OCS, CSCS</p><p>Professor and Founding Chair</p><p>High Point University</p><p>High Point, North Carolina</p><p>Boston Columbus Indianapolis New York San Francisco Upper Saddle River</p><p>Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montreal Toronto</p><p>Delhi Mexico City Sao Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo</p><p>Copyright © 2013, 2008 by Pearson Education, Inc., Upper Saddle River, New Jersey 07458. All rights reserved. Printed in</p><p>the United States of America. This publication is protected by Copyright and permission should be obtained from the publisher prior to</p><p>any prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopy-</p><p>ing, recording, or likewise. To obtain permission(s) to use material from this work, please submit a written request to Pearson Education,</p><p>Inc., Permissions Department, One Lake Street, Upper Saddle River, New Jersey 07458 or you may fax your request to 201-236-3290.</p><p>Notice: The authors and publisher of this volume have taken care that the information and technical recommendations contained</p><p>herein are based on research and expert consultation, and are accurate and compatible with the standards generally accepted at</p><p>the time of publication. Nevertheless, as new information becomes available, changes in clinical and technical practices become</p><p>necessary. The reader is advised to carefully consult manufacturers’ instructions and information material for all supplies and</p><p>equipment before use, and to consult with a healthcare professional as necessary. This advice is especially important when using</p><p>new supplies or equipment for clinical purposes. The authors and publisher disclaim all responsibility for any liability, loss, injury,</p><p>or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this volume.</p><p>Library of Congress Cataloging-in-Publication Data</p><p>Cook, Chad.</p><p>Orthopedic physical examination tests : an evidence-based approach / Chad</p><p>E. Cook, Eric J. Hegedus. — 2nd ed.</p><p>p. ; cm.</p><p>Includes bibliographical references and index.</p><p>ISBN-13: 978-0-13-254478-8</p><p>ISBN-10: 0-13-254478-4</p><p>I. Hegedus, Eric J. II. Title.</p><p>[DNLM: 1. Musculoskeletal Diseases—diagnosis—Handbooks. 2. Evidence-Based</p><p>Medicine—methods—Handbooks. 3. Physical Examination—methods—Handbooks. WE 39]</p><p>616.7’075—dc23</p><p>2011043053</p><p>10 9 8 7 6 5 4 3 2 1</p><p>ISBN-10: 0-13-254478-4</p><p>ISBN-13: 978-0-13-254478-8</p><p>Operations Specialist: Lisa McDowell</p><p>Photographer: Patrick J. Watson</p><p>Senior Art Director: Jayne Conte</p><p>Cover Designer: Suzanne Behnke</p><p>Media Editor: Amy Peltier</p><p>Lead Media Project Manager: Lorena Cerisano</p><p>Full-Service Project Management: Patty Donovan</p><p>Composition: Laserwords</p><p>Printer/Binder: Quebecor Printing/Dubuque</p><p>Cover Printer: Lehigh-Phoenix/Hagerstown</p><p>Text Font: 10/12 Gill Sans</p><p>Publisher: Julie Levin Alexander</p><p>Publisher’s Assistant: Regina Bruno</p><p>Editor-in-Chief: Mark Cohen</p><p>Executive Editor: John Goucher</p><p>Development Editor: Melissa Kerian</p><p>Director of Marketing: David Gesell</p><p>Executive Marketing Manager: Katrin Beacom</p><p>Marketing Coordinator: Michael Sirinides</p><p>Senior Managing Editor: Patrick Walsh</p><p>Project Manager: Christina Zingone-Luethje</p><p>Senior Operations Supervisor: Ilene Sanford</p><p>Contents</p><p>Foreword by Claude T. Moorman III v</p><p>Foreword by Kevin E. Wilk vi</p><p>Preface vii</p><p>Contributors viii</p><p>Reviewers ix</p><p>CHAPTER 1 Introduction to Diagnostic Accuracy 1</p><p>Eric J. Hegedus, PT, DPT, MHSc, OCS, CSCS</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 8</p><p>Chad E. Cook, PT, PhD, MBA, OCS, FAAOMPT and Mark Wilhelm</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 66</p><p>Ken Learman, PT, PhD, OCS, FAAOMPT</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 113</p><p>Chad E. Cook, PT, PhD, MBA, OCS, FAAOMPT</p><p>CHAPTER 5 Physical Examination Tests for the Temporomandibular Joint 142</p><p>Jennifer Reneker, PT, MS, NCS and Chad E. Cook, PT, PhD, MBA, OCS, FAAOMPT</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 155</p><p>Eric J. Hegedus, PT, DPT, MHSc, OCS, CSCS</p><p>CHAPTER 7 Physical Examination Tests for the Elbow and Forearm 222</p><p>Adam Goode, PT, DPT, CSCS and Chad E. Cook, PT, PhD, MBA, OCS, FAAOMPT</p><p>CHAPTER 8 Physical Examination Tests for the Wrist and Hand 236</p><p>Adam Goode, PT, DPT, CSCS, Alyson Cadman, and</p><p>Chad E. Cook, PT, PhD, MBA, OCS, FAAOMPT</p><p>CHAPTER 9 Physical Examination Tests for the Thoracic Spine 281</p><p>Chad E. Cook, PT, PhD, MBA, OCS, FAAOMPT</p><p>CHAPTER 10 Physical Examination Tests for the Lumbar Spine 295</p><p>Chad E. Cook, PT, PhD, MBA, OCS, FAAOMPT and</p><p>Eric J. Hegedus, PT, DPT, MHSc, OCS, CSCS</p><p>CHAPTER 11 Physical Examination Tests for the Sacroiliac Joint and Pelvis 325</p><p>Chad E. Cook, PT, PhD, MBA, OCS, FAAOMPT</p><p>CHAPTER 12 Physical Examination Tests for the Hip 373</p><p>Michael Reiman, PT, DPT, OCS, FAAOMPT and</p><p>Chad E. Cook, PT, PhD, MBA, OCS, FAAOMPT</p><p>iii</p><p>iv Contents</p><p>CHAPTER 13 Physical Examination Tests for the Knee 421</p><p>Ben Stern, PT, DPT, Eric J. Hegedus, PT, DPT, MHSc, OCS, CSCS,</p><p>and Dawn Driesner, PT, DPT</p><p>CHAPTER 14 Physical Examination Tests for the Lower Leg, Ankle, and Foot 503</p><p>Chad E. Cook, PT, PhD, MBA, OCS, FAAOMPT</p><p>Index 533</p><p>Foreword</p><p>“If you pour molten iron ore out on the ground you get</p><p>‘pig iron’ but if you beat it a lot you get steel.”</p><p>Lenox D. Baker, MD, Chairman,</p><p>Orthopaedic Surgery, Duke University, 1937–1967</p><p>Such was the traditional philosophy of teaching residents</p><p>at Duke during the Baker, Stead, and Sabiston (Chairman</p><p>respectively of Orthopaedics, Medicine, and Surgery) era.</p><p>The essence of this “beating” was a grounding in anatomy</p><p>and physical examination which has been lost to a large</p><p>extent and overshadowed by newer technologies. These</p><p>technologies, while tremendous in sum, do not replace the</p><p>foundation of a good history and physical examination. We</p><p>would do well to return to these basics. In this light, it is my</p><p>distinct pleasure to introduce the first edition of Orthope-</p><p>dic Physical Examination Tests: An Evidence-Based Approach by</p><p>Chad E. Cook and Eric J. Hegedus, which forms a tremen-</p><p>dous link between the ancient art of physical examination</p><p>and current technology in statistical analysis and outcomes</p><p>research. I believe that the authors have provided informa-</p><p>tion in this text which will result in a paradigm shift in our</p><p>understanding of physical findings.</p><p>There is no shortage of information on physical exami-</p><p>nation of the spine and extremities. The unusual and per-</p><p>haps disappointing reality is that very little has been added</p><p>to the armamentarium of the health care professional in</p><p>this area since the work of Hoppenfeld,1 originally published</p><p>nearly 40 years ago. It is not surprising with the advent of</p><p>the PET scan, 3D CT scan, functional MRI, MRA, and other</p><p>advanced imaging studies that there has been a movement</p><p>away from the basics. We currently operate in a high-tech,</p><p>low-touch world where time constraints and financial issues</p><p>occupy the mind of the busy practitioner. At Duke we have</p><p>no shortage of decorum-laden tradition and the icons of the</p><p>past—Baker, Stead, and Sabiston—call out to us to remain</p><p>proficient in the most basic of the healing arts, the physical</p><p>examination. Dr. Stead, addressing the house staff who had</p><p>unsuccessfully attempted to diagnose a patient’s disease,</p><p>made his famous and acerbic comment, “What this patient</p><p>needs is a doctor.”2 Perhaps in our day and time when</p><p>we are facing a challenging clinical problem where special-</p><p>ized x-ray views, MRI, and neurologic studies have been</p><p>unrevealing, we should suggest “maybe we should order a</p><p>physical examination.”</p><p>It is clear that the work presented in this text by Cook</p><p>and Hegedus addresses this situation in spades. They have</p><p>been tremendously thorough in covering the basic tests for</p><p>all areas of the</p><p>2+ = normal (visual, brief movement of the extrem-</p><p>ity), 3+ = exaggerated (full movement of the extremities), 4+ = abnormal (compulsory and sustained movement, lasting for more</p><p>than 30 seconds).</p><p>30 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Infrapatellar Tendon Reflex</p><p>1 The patient is positioned in sitting with the leg to be tested not touching the ground.</p><p>2 Using a reflex hammer, strike the patellar tendon inferior to the patella.</p><p>3 A positive test is indicated by hyperreflexia of the patellar tendon reflex.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Chikuda et al.8 NT 94 NT NA NA 6</p><p>Rhee et al.42 NT 33 76 1.37 0.88 4</p><p>Comments: Reflex testing is commonly scored as 0+ = absent (no visible or palpable muscle contraction with reinforcement), 1+ =</p><p>tone change (slight, transitory impulse, with no movement of the extremities), 2+ = normal (visual, brief movement of the extremity),</p><p>3+ = exaggerated (full movement of the extremities), 4+ = abnormal (compulsory and sustained movement, lasting for more than 30</p><p>seconds).</p><p>1 The patient is positioned in either sitting or standing.</p><p>2 The clinician grasps the patient’s palm and strikes the dor-</p><p>sum of the patient’s hand with a reflex hammer.</p><p>3 A positive test is indicated by an abnormal flexor response.</p><p>Hand Withdrawal Reflex</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cook et al.10 80% agreement 41 63 1.1 0.9 11</p><p>Comments: This test has questionable value.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 31</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kiely et al.27 (sample consisted</p><p>of asymptomatic patients)</p><p>NT NT 100 NA NA 2</p><p>Comments: The use of this test for assessment of myelopathic symptoms requires additional investigation.</p><p>Gait Deviation</p><p>1 The patient is asked to ambulate as the clinician observes the patient’s gait.</p><p>2 A positive sign is the presence of abnormally wide based gait, ataxia, or spastic gait.</p><p>1 The patient is in a standing position.</p><p>2 The patient’s feet are together, eyes are closed after the patient demonstrates</p><p>stability, and hands are by his or her side.</p><p>3 A positive sign is obvious swaying or falling.</p><p>4 The Dynamic Romberg sign is performed similarly to the static test; however,</p><p>a light external moment is applied to the patient.</p><p>5 A positive sign is still indicated by obvious swaying or falling.</p><p>Static and Dynamic Romberg’s Sign</p><p>UTILITY SCORE ?</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cook et al.9 NT 19 94 3.4 0.85 7</p><p>Comments: Promising finding but requires a better operational definition than the one described in the study.</p><p>32 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Cook’s Clinical Prediction Rule for Myelopathy</p><p>Tests Included in Clinical Prediction Rule</p><p>1 Gait Deviation</p><p>2 Positive Hoffmann’s Test</p><p>3 Inverted Supinator Sign</p><p>4 Positive Babinski Test</p><p>5 Patient age >45 years old</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cook et al. 9</p><p>1 of 5 Positive Tests</p><p>NT 94 31 1.4 0.18 7</p><p>Cook et al.9</p><p>2 of 5 Positive Tests</p><p>NT 39 88 3.3 0.63 7</p><p>Cook et al. 9</p><p>3 of 5 Positive Tests</p><p>NT 19 99 30.9 0.81 7</p><p>Cook et al.9</p><p>4 of 5 Positive Tests</p><p>NT 9 100 Inf 0.91 7</p><p>Comments: This is the first study which is known to show a high sensitivity rather than just high specificity for cervical myelopathy.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 33</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Gotkine et al.18 98.9% agreement 24 NT NA NA 9</p><p>August & Miller2 NT 95 98 38 .21 4</p><p>Isakov et al.23 NT 78 58 1.8 .22 11</p><p>Comments: This test is associated with a high degree of false positives. There is a higher prevalence of positive findings in Parkin-</p><p>son’s and other neurological diseases.</p><p>TEST FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX</p><p>1 The patient is positioned in sitting or supine.</p><p>2 A number of methods to elicit this reflex have been advo-</p><p>cated. The examiner may stroke the thenar eminence of</p><p>the hand in a proximal to distal direction with a reflex</p><p>hammer or may stroke the hypothenar eminence in a simi-</p><p>lar fashion.</p><p>Palmomental Reflex</p><p>3 The process can be repeated up to five times to detect a</p><p>continuous response. If the response diminishes the test is</p><p>considered negative.</p><p>4 A positive test is contraction of the mentalis and orbicularis</p><p>oris muscles causing wrinkling of the skin of the chin and</p><p>slight retraction (and occasionally elevation of the mouth).</p><p>UTILITY SCORE 2</p><p>34 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Maranhao et al.31 NT 51 70 1.7 0.7 11</p><p>Comments: Well done study but less than promising results.</p><p>TESTS FOR FOCAL OR MONOHEMISPHERIC BRAIN TUMORS/LESIONS</p><p>1 The patient is instructed to horizontally extend the arms</p><p>and fingers forward with palms down.</p><p>2 If the fifth finger adducts on one side, that side is con-</p><p>sidered to test positive. If the fifth digit on both sides is</p><p>abducted symmetrically, there is no clinical significance.</p><p>Digit Quinti Sign</p><p>UTILITY SCORE 3</p><p>1 The patient is asked to hold the upper extremities out-</p><p>stretched in front with 90° of shoulder flexion, palms up</p><p>and elbows and wrists extended.</p><p>2 Positive test is indicated by the inability of the patient to</p><p>maintain this position for 20–30 seconds and asymmetric</p><p>pronation or downward drifting of the arm.</p><p>Pronator Drift Test</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 35</p><p>TESTS FOR FOCAL OR MONOHEMISPHERIC BRAIN TUMORS/LESIONS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Maranhao et al.31 NT 41 96 10.25 0.61 11</p><p>Anderson et al.1 NT 22 100 Inf 0.78 8</p><p>Teitelbaum et al.50 81.6 92.2 90 9.2 0.09 9</p><p>Comments: Anderson et al.1 only required the patients to hold their arms supinated for 10 seconds instead of 20–30 seconds.</p><p>UTILITY SCORE 1</p><p>1 Patient is instructed to extend both index fingers and point</p><p>them towards each other in front of the torso approxi-</p><p>mately 1 finger length apart with each index finger point-</p><p>ing at the metacarpophalangeal joint of the flexed fingers</p><p>on the opposite hand.</p><p>2 The patient is instructed to roll the fingers around each</p><p>other.</p><p>3 A positive sign is one finger orbiting around the other (the</p><p>affected side moves less than the unaffected side).</p><p>Finger Rolling Test</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Maranhao et al.31 NT 41 93 5.86 0.63 11</p><p>Anderson et al.1 NT 33 100 Inf 0.67 8</p><p>Comments: This is a modified version of the forearm rolling test.</p><p>36 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR FOCAL OR MONOHEMISPHERIC BRAIN TUMORS/LESIONS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Maranhao et al.31 NT 16 100 Inf 0.84 11</p><p>Anderson et al.1 NT 24 100 Inf 0.76 8</p><p>Teitelbaum et al.50 77.6 45.6 97.5 18.2 0.56 9</p><p>Comments: The forearm rolling test demonstrates very promising results.</p><p>1 The patient is placed in either sitting or standing position.</p><p>2 Patient is instructed to make a fist with both hands.</p><p>3 Patient then flexes both shoulders and both elbows to</p><p>approximately 90° so that the fists and forearms overlap</p><p>by approximately 15 cm in front of the patient and hori-</p><p>zontal to the ground.</p><p>4 The patient is then instructed to rotate both fists around</p><p>each other in this position for 5 to 10 seconds in each</p><p>direction of rotation.</p><p>5 The examiner observes the movement of both</p><p>forearms</p><p>for symmetry of movement.</p><p>6 A positive sign is indicated by one side orbiting around the</p><p>other (the involved side will move less than the uninvolved</p><p>side).</p><p>Forearm Rolling Test</p><p>UTILITY SCORE 1</p><p>1 The patient is placed in sitting or standing.</p><p>2 The patient is instructed to tap the tip of the index finger</p><p>to the interphalangeal joint of the thumb as many times</p><p>as possible in 10 seconds.</p><p>3 A positive sign is a difference of 5 or more taps between</p><p>the right and left index fingers. The movement will be</p><p>slower on the affected side.</p><p>Finger Tap</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 37</p><p>TESTS FOR FOCAL OR MONOHEMISPHERIC BRAIN TUMORS/LESIONS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Maranhao et al.31 NT 18 90 1.8 0.91 11</p><p>Anderson et al.1 NT 15 100 Inf 0.85 8</p><p>Teitelbaum et al.50 80.6 73.3 87.5 5.9 0.31 9</p><p>Comments: It is unknown whether both fingers should be tested at the same time or one after the other. Interpretation of this test</p><p>can be difficult due to the fact that the non-dominant hand may have a slower performance of the test.</p><p>UTILITY SCORE 2</p><p>1 The patient is placed in supine.</p><p>2 Patient is instructed to flex both hips to 75–80° with the</p><p>knees flexed to approximately 100° so the lower legs are</p><p>parallel to the bed.</p><p>3 The ankles are dorsiflexed to 90°.</p><p>4 The patient is then instructed to hold this position for as</p><p>long as possible up to 30 seconds.</p><p>5 A positive sign occurs if the leg or hip begins to fall or if</p><p>the foot begins to lose dorsiflexion.</p><p>Modified Mingazzini’s Maneuver</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Teitelbaum et al.50 NT 55.3 91 6.1 0.49 9</p><p>Comments: Originally this test was performed with the knees in full extension with the hips flexed only to 45°. This was then</p><p>changed by Barre to 90° of flexion at the knees and hips. Teitelbaum et al.51 performed a variant of this version.</p><p>38 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR FOCAL OR MONOHEMISPHERIC BRAIN TUMORS/LESIONS</p><p>Rapid Alternating Movements of the Hands</p><p>1 The patient is placed in a seated position.</p><p>2 Patient is instructed to place his or her hands on his or her</p><p>thighs.</p><p>3 The patient is then instructed to pat the thighs alter-</p><p>nately with the dorsum or palm of his or her hands for 10</p><p>seconds.</p><p>4 This test can also be performed using rapidly extending</p><p>and flexing the fingers of each hand for 10 seconds.</p><p>5 A positive test is indicated by an asymmetry of movement</p><p>between the two upper extremities.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Anderson et al.1 NT 15 100 Inf 0.85 8</p><p>Comments: Somewhat flawed study but the test results appear promising.</p><p>Barre Test</p><p>1 The patient is placed in a seated position.</p><p>2 The patient’s arms are held at 90° of shoulder flexion</p><p>with elbows fully extended, forearms pronated, wrists in</p><p>full extension, and finger extended and abducted. If the</p><p>patient is not able to sit, this can be done in supine with</p><p>shoulders flexed to 45° instead of 90°.</p><p>3 The patient is instructed to hold this position for as long</p><p>as possible up to 1 minute.</p><p>4 A test is considered positive if the patient’s fingers, wrist, or</p><p>arm start to fall, or if the fingers are not able to maintain</p><p>abduction. If the problem is due to an upper motor neu-</p><p>ron lesion, the fingers will adduct or the fingers and wrist</p><p>will begin to drop before the arms drop.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 39</p><p>TESTS FOR FOCAL OR MONOHEMISPHERIC BRAIN TUMORS/LESIONS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Teitelbaum et al.50</p><p>+ = all 3 pos – = >1 neg</p><p>NT 75.5 97.5 30.2 0.25 9</p><p>Teitelbaum et al.50</p><p>+ = >1 pos – = all three neg</p><p>NT 97.8 86.3 7.25 0.03 9</p><p>Comments: Deep tendon reflexes tested were biceps, triceps, brachioradialis, infrapatellar, Achilles and plantar. Positive reflex test</p><p>included abnormal increase of two or more reflexes on the same side or the presence of a positive Babinski’s sign.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Teitelbaum et al.50 79.6 86.7 90.0 8.7 0.15 9</p><p>Comments: When the Barre Test was originally described the wrist was positioned in flexion, but Teitelbaum et al.50 tested with</p><p>the wrist in dorsiflexion.</p><p>Teitelbaum’s Clinical Prediction Rule for Unilateral Cerebral Lesions</p><p>1 This CPR is a combination of three maneuvers.</p><p>2 Pronator Drift</p><p>3 Finger Tap</p><p>4 Deep Tendon Reflexes</p><p>UTILITY SCORE 2</p><p>UTILITY SCORE 1</p><p>40 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR PERIPHERAL NEUROPATHY</p><p>Superficial Pain</p><p>1 The patient is placed in sitting or standing.</p><p>2 The examiner applies a superficial painful stimuli and que-</p><p>ries the patient regarding pain level. The patient’s eyes are</p><p>closed during the testing.</p><p>3 A positive response is a lack of report of pain during appli-</p><p>cation of painful stimuli.</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Olaleye et al.37</p><p>(2 correct responses)</p><p>NT 47 89 4.27 0.59 7</p><p>Olaleye et al.37</p><p>(3 correct responses)</p><p>NT 42 90 4.2 0.64 7</p><p>Olaleye et al.37</p><p>(4 correct responses)</p><p>NT 25 97 8.33 0.77 7</p><p>Olaleye et al.37</p><p>(5 correct responses)</p><p>NT 23 98 11.5 0.78 7</p><p>Perkins et al.40</p><p>(>5 out of 8 attempts)</p><p>NT 59 97 19.7 0.42 9</p><p>Comments: To stimulate superficial pain, a sharp–dull response was used. Anesthesia is considered a positive finding.</p><p>Vibration Testing</p><p>1 The patient is placed in sitting or supine position.</p><p>2 The examiner applies the tuning fork over the selected</p><p>bony prominence. The patient is instructed to close his or</p><p>her eyes and to indicate when the vibration begins and</p><p>when the vibration is complete.</p><p>3 The examiner applies a series of five trials to determine the</p><p>cumulative ability of correct responses.</p><p>4 A positive test is decreased ability to report when the vibra-</p><p>tion was applied and when the vibration dampened while</p><p>still applied.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 41</p><p>TESTS FOR PERIPHERAL NEUROPATHY</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Olaleye et al.37</p><p>(2 correct responses)</p><p>NT 46 94 7.66 0.57 7</p><p>Olaleye et al.37</p><p>(3 correct responses)</p><p>NT 42 97 14 0.59 7</p><p>Olaleye et al.37</p><p>(4 correct responses)</p><p>NT 25 99 25 0.75 7</p><p>Olaleye et al.37</p><p>(5 correct responses)</p><p>NT 22 99 22 0.78 7</p><p>Perkins et al.40</p><p>(>5 out of 8 attempts)</p><p>(On–Off method)</p><p>NT 53 99 53 0.47 9</p><p>Perkins et al.40</p><p>(>5 out of 8 attempts)</p><p>(Timed Method)</p><p>NT 80 98 40 0.20 9</p><p>Jepsen et al.24 (Median</p><p>Nerve)</p><p>.70 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Ulnar</p><p>Nerve)</p><p>.45 kappa NT NT NA NA NA</p><p>Comments: Although primarily tested in this population, the test is not specific for peripheral neuropathy.</p><p>Monofilament Testing</p><p>UTILITY SCORE 1</p><p>1 The patient is placed in sitting.</p><p>2 The examiner applies a Semmes-Weinstein 10-g monofila-</p><p>ment to the selected noncalloused areas of the foot. With</p><p>eyes closed, the patient is queried as to whether he or she</p><p>feels the application.</p><p>3 A positive response is the inability to feel the applied stim-</p><p>ulus. If no stimulus is felt at the palmar aspect of the foot,</p><p>this reflects the lack of a protective sensation from the</p><p>patient.</p><p>(continued)</p><p>42 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR PERIPHERAL NEUROPATHY</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Olaleye et al.37</p><p>(2 correct responses)</p><p>NT 70 75 2.8 0.4 7</p><p>Olaleye et al.37</p><p>(3 correct responses)</p><p>NT 63 82 3.5 0.45 7</p><p>Olaleye et al.37</p><p>(4 correct responses)</p><p>NT 39 96 9.8 0.63 7</p><p>Olaleye et al.37</p><p>(5 correct responses)</p><p>NT 31 97 10.3 0.71 7</p><p>Perkins et al.40</p><p>(>5 out of 8 attempts)</p><p>NT 77 96 19.3 0.24 9</p><p>Mythili et al.36</p><p>(> or = 1 incorrect</p><p>out of 6 attempts)</p><p>NT 98.5 55 2.19 0.027 7</p><p>Comments: The articles addressed the protective sensation secondary</p><p>to peripheral neuropathy of the diabetic foot. Each article</p><p>used a 10-g monofilament to test protective sensation. This procedure is different from a standard assessment of monofilament</p><p>testing, which has not undergone diagnostic accuracy analysis. The test is frequently performed as a component of the upper quar-</p><p>ter screen. Mythili et al.36 performed six trials using a 10-g monofilament with enough pressure to buckle the monofilament. Test</p><p>sites were the plantar surface of the hallux and centrally on the plantar surface of the heel.</p><p>Position Sense of the Great Toe</p><p>UTILITY SCORE 1</p><p>1 Position sense is tested with the patient in supine.</p><p>2 The dominant toe is grasped on the medial and lateral</p><p>sides by the examiner’s thumb and index finger.</p><p>3 Up and down movements are first performed with the</p><p>subject’s eyes open. Then with the subjects eyes closed, a</p><p>series of 10 small amplitude movements are performed.</p><p>The amplitude should be approximately 1 cm over a time</p><p>of 1 second each and the movement should be performed</p><p>smoothly.</p><p>4 The patient is asked to identify if there was any movement</p><p>as well as the direction if it was sensed.</p><p>5 A positive test is the inability of the patient to give correct</p><p>responses on 8 or fewer of the 10 movements.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 43</p><p>TESTS FOR PERIPHERAL NEUROPATHY</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Richardson43 NT 72.1 90.6 7.67 0.31 9</p><p>Comments: Some studies show that the Achilles reflex decreases normally with aging.</p><p>Phalen’s Test</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Richardson43 NT 88.2 68.8 2.83 0.17 9</p><p>Comments: No verbal cues were given to the patient, so an incorrect response was marked if the patient failed to recognize move-</p><p>ment and respond (no response) as well as incorrect identification of the direction of movement.</p><p>Achilles Reflex</p><p>1 The patient is placed in sitting with the foot to be tested not touching the ground.</p><p>2 Using a reflex hammer, either strike the tendon itself or use the plantar strike technique to elicit</p><p>a reflex.</p><p>3 If the reflex is absent, ask the patient to gently plantarflex the foot, tightly close the eyes, and</p><p>pull their clasped hands apart just prior to striking.</p><p>4 A positive test is the inability to elicit a reflex even with facilitation.</p><p>UTILILTY SCORE 2</p><p>UTILILTY SCORE 2</p><p>1 The patient is placed in sitting or standing position.</p><p>2 The patient is asked to hold the forearms vertically and</p><p>maximally flex both wrists for a period of 60 seconds.</p><p>3 A positive test is indicated by the reproduction of symp-</p><p>toms along the distribution of the median nerve’s cutane-</p><p>ous distribution.</p><p>UTILILTY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Onde et al.38 NT 85.7 50 1.71 0.29 6</p><p>Comments: Carpal tunnel syndrome is the most common entrapment neuropathy in diabetes.</p><p>44 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR PERIPHERAL NEUROPATHY</p><p>Tinel’s Sign</p><p>1 The patient is placed in a sitting position.</p><p>2 The patient’s wrist is placed in a neutral position.</p><p>3 The examiner uses his or her finger or a reflex hammer to</p><p>tap on the median nerve where it enters the carpal tunnel.</p><p>4 A positive sign is the presence of pain or parasthesia radiat-</p><p>ing into the hand.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Onde et al.38 NT 72.7 83.3 4.35 0.33 6</p><p>Comments: Carpal tunnel syndrome is the most common entrapment neuropathy in diabetes. A positive Tinel’s sign indicates axo-</p><p>nal regeneration.</p><p>Richardson’s Clinical Prediction Rule for Peripheral Neuropathy Criteria</p><p>1 Absence of the Achilles reflex even with facilitation.</p><p>2 Vibration Sense using a 128-Hz tuning fork. A positive test is the ability of the patient to detect</p><p>vibration for less than 8 seconds at a site proximal to the nail bed of the first digit of the lower</p><p>extremities.</p><p>3 Position Sense of the dominant side great toe.</p><p>4 Positive CPR is presence of 2 or 3 positive tests.</p><p>UTILITY SCORE 2</p><p>UTILILTY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Richardson43 .83 kappa 94.1 84.4 6.03 0.07 9</p><p>Comments: In patients with known diabetes, the sensitivity increased to 97.2 and specificity increased to 90. This changes the LR+</p><p>to 9.72 and the LR− to 0.03.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 45</p><p>TESTS FOR PERIPHERAL NERVE PATHOLOGY</p><p>Long Thoracic Nerve Injury</p><p>1 The patient is positioned in standing facing a wall.</p><p>2 Instruct the patient to complete a wall push-up.</p><p>3 Observe the patient’s scapula for signs of winging.</p><p>4 A positive test is indicated by scapular winging on the</p><p>involved side.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Scifers46 NT NT NT NT NT NA</p><p>Comments: Patient may also have difficulty performing active glenohumeral flexion or abduction due to altered scapulohumeral rhythm.</p><p>Pronator Teres Syndrome Test</p><p>UTILITY SCORE ?</p><p>1 The patient is positioned in sitting.</p><p>2 Instruct the patient to flex his or her elbows to 90° with</p><p>the forearm in supination.</p><p>3 The clinician resists pronation of the patient’s forearm</p><p>while allowing active elbow extension.</p><p>4 A positive test is indicated by parasthesia in the median</p><p>nerve distribution of the involved hand.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Scifers46 NT NT NT NT NT NA</p><p>Comments: This test indicates compression of the median nerve by the pronator teres.</p><p>46 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR PERIPHERAL NERVE PATHOLOGY</p><p>Common Fibular Nerve Injury</p><p>1 The patient is positioned in sitting or supine.</p><p>2 Instruct the patient to provide maximal resistance as the</p><p>examiner performs manual muscle tests for ankle dorsiflex-</p><p>ion and eversion.</p><p>3 A positive test is indicated by significantly decreased ability</p><p>to resist the examiner’s force.</p><p>UTILITY SCORE ?</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Scifers46 NT NT NT NT NT NA</p><p>Comments: The patient may also have a loss of sensation in the common fibular nerve distribution.</p><p>Pencil Test</p><p>1 The patient is positioned in supine, long sitting, or sitting.</p><p>2 Using the blunt end of a pen or the eraser end of a pencil,</p><p>the clinician applies a compressive force to the inter-</p><p>metatarsal space between the third and fourth metatarsals.</p><p>3 A positive sign is indicated by pain or reproduction of the</p><p>patient’s concordant sign indicating a Morton’s Neuroma.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Scifers46 NT NT NT NT NT NA</p><p>Comments: In most cases Morton’s Neuromas are present between the 3rd and 4th metatarsals, but can also occur between the</p><p>2nd and 3rd metatarsals as well.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 47</p><p>TEST FOR FACIOSCAPULOHUMERAL DYSTROPHY</p><p>Beevor’s Sign</p><p>1 The patient lies supine.</p><p>2 The examiner directs the patient to actively move their</p><p>head into flexion.</p><p>3 The examiner watches for upward movement of the umbi-</p><p>licus during neck flexion.</p><p>4 The test is considered positive if there is marked upward</p><p>movement of the umbilicus following neck flexion.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Eger et al. 14 NT 46.4 96.9 15.1 0.55 6</p><p>Shahrizaila &</p><p>Wills47</p><p>NT 95 96 23.8 0.05 5</p><p>Awerbuch et al.3 NT 90 100 Inf 0.1 5</p><p>Comments: The test is similar to the Hyperabduction Test but adds rotation away from the affected side.</p><p>UTILITY SCORE 2</p><p>48 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>Biceps Deep Tendon Reflex</p><p>1 The patient assumes a sitting position.</p><p>2 The examiner places the patient’s forearm on his or her</p><p>forearm to ensure relaxation. The patient’s forearm is held</p><p>in slight supination. The examiner’s thumb is placed</p><p>on</p><p>the biceps tendon of the patient.</p><p>3 The examiner applies a series of quick strikes to his or</p><p>her own thumb. The quick strikes should elicit a reflex</p><p>response of elbow flexion.</p><p>4 A positive test is a depression of reflex when compared to</p><p>the opposite side or “normal.”</p><p>5 The patient may be instructed to perform the lower</p><p>extremity Jendrassik’s maneuver to improve the response</p><p>of the reflex.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Bertilson et al.6 94% agreement NT NT NA NA NA</p><p>Wainner et al.54 .73 kappa 24 95 4.8 0.8 10</p><p>Matsumoto et al.33</p><p>(C4–5)</p><p>NT 65 95 13 0.37 6</p><p>Matsumoto et al.33</p><p>(C5–6)</p><p>NT 65 94 10.8 0.37 6</p><p>Lauder et al.30</p><p>(C5–6)</p><p>NT 14 90 1.4 0.95 9</p><p>Comments: Reflex testing is commonly scored as 0+ = absent (no visible or palpable muscle contraction with reinforcement), 1+ =</p><p>tone change (slight, transitory impulse, with no movement of the extremities), 2+ = normal (visual, brief movement of the extrem-</p><p>ity), 3+ = exaggerated (full movement of the extremities), 4+ = abnormal (compulsory and sustained movement, lasting for more</p><p>than 30 seconds). The test is frequently performed as a component of the upper quarter screen. The test is purported to target C6.</p><p>UTILITY SCORE 2</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 49</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>Triceps Deep Tendon Reflex</p><p>1 The patient assumes a sitting position.</p><p>2 The examiner flexes the patient’s elbow and lifts the shoul-</p><p>der to 90 degrees. The examiner places his or her thumb</p><p>over the distal aspect of the triceps tendon.</p><p>3 The examiner applies a series of strikes to his or her</p><p>thumb. The strikes should elicit a reflex response of elbow</p><p>extension.</p><p>4 A positive test is a depression of reflex when compared to</p><p>the opposite side or “normal.”</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Bertilson et al.6 88% agreement NT NT NA NA NA</p><p>Wainner et al.54 NT 3 93 0.42 1.04 10</p><p>Matsumoto et al.33 NT 38 98 19 0.63 6</p><p>Lauder et al.30 (C7) NT 14 92 1.75 0.93 9</p><p>Comments: Reflex testing is commonly scored as 0+ = absent (no visible or palpable muscle contraction with reinforcement), 1+ =</p><p>tone change (slight, transitory impulse, with no movement of the extremities), 2+ = normal (visual, brief movement of the extrem-</p><p>ity), 3+ = exaggerated (full movement of the extremities), 4+ = abnormal (compulsory and sustained movement, lasting for more</p><p>than 30 seconds). The test is frequently performed as a component of the upper quarter screen. The test is purported to target C7.</p><p>Brachioradialis Deep Tendon Reflex</p><p>1 The patient assumes a sitting position.</p><p>2 The examiner places the patient’s forearm on his or her</p><p>forearm to ensure relaxation. The patient’s forearm is held</p><p>in slight pronation.</p><p>3 The examiner applies a series of quick strikes to the inter-</p><p>section point of the brachioradialis and the tendon. The</p><p>quick strikes should elicit a reflex response of pronation</p><p>and elbow flexion.</p><p>4 A positive test is a depression of reflex when compared to</p><p>the opposite side or “normal.”</p><p>(continued)</p><p>50 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Bertilson et al.6 92% agreement NT NT NA NA NA</p><p>Wainner et al.54 NT 6 95 1.2 0.98 10</p><p>Lauder et al.30</p><p>(C6–7)</p><p>NT 17 94 2.8 0.88 9</p><p>Comments: Reflex testing is commonly scored as 0+ = absent (no visible or palpable muscle contraction with reinforcement), 1+ =</p><p>tone change (slight, transitory impulse, with no movement of the extremities), 2+ = normal (visual, brief movement of the extrem-</p><p>ity), 3+ = exaggerated (full movement of the extremities), 4+ = abnormal (compulsory and sustained movement, lasting for more</p><p>than 30 seconds). The test is frequently performed as a component of the upper quarter screen. The test is purported to target C6.</p><p>Muscle Power Testing</p><p>UTILITY SCORE 3</p><p>1 The patient is placed in sitting.</p><p>2 To test C1–3, cervical rotation is resisted.</p><p>3 The patient is placed in sitting.</p><p>4 To test C4, shoulder shrug is resisted.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 51</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>5 The patient is placed in sitting.</p><p>6 To test C5, shoulder abduction is resisted.</p><p>7 The patient is placed in sitting.</p><p>8 To test C6, the biceps are resisted.</p><p>9 The patient is placed in sitting.</p><p>10 To test C7, wrist flexion is resisted.</p><p>11 The patient is placed in sitting.</p><p>12 To test C8, thumb extension is resisted.</p><p>(continued)</p><p>52 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>13 The patient is placed in sitting.</p><p>14 To test T1, finger abduction is resisted.</p><p>15 With all areas, a positive test is noticeable weakness when</p><p>compared to the opposite side or versus expectations if</p><p>bilateral symptoms are present.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Wainner et al.54 (Deltoid) .62 kappa 24 89 2.18 0.85 10</p><p>Wainner et al.54 (Biceps) .69 kappa 24 94 4 0.8 10</p><p>Wainner et al.54 (Extensor</p><p>Carpi Radialis)</p><p>.63 kappa 12 90 1.2 0.97 10</p><p>Wainner et al.54 (Triceps</p><p>Brachii)</p><p>.29 kappa 12 94 2 0.93 10</p><p>Wainner et al.54 (Flexor</p><p>Carpi Radialis)</p><p>.23 kappa 6 89 0.54 1.05 10</p><p>Wainner et al.54 (Abductor</p><p>Pollicis Brevis)</p><p>.39 kappa 6 84 0.37 1.12 10</p><p>Wainner et al.54 (First Dor-</p><p>sal Interosseus)</p><p>.37 kappa 3 93 0.42 1.04 10</p><p>Matsumoto et al.33 (C4–5)</p><p>(Deltoid Weakness)</p><p>NT 35 98 17.5 0.66 6</p><p>Matsumoto et al.33 (C7 or</p><p>below) (Wrist Extensor</p><p>Weakness)</p><p>NT 28 74 1.07 0.97 6</p><p>Comments: Note that the test tends to exhibit strong specificity and low sensitivity, suggesting it may lack practicality as a screen.</p><p>The test is frequently performed as a component of the upper quarter screen.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 53</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>Sensibility Testing</p><p>1 The patient is placed in sitting or supine.</p><p>2 The examiner applies a series of concurrent sensibility</p><p>tests to both sides (light touch, sharp/dull). The exam-</p><p>iner makes careful effort to apply sensation testing along</p><p>known dermatomes.</p><p>3 Sharp/dull is assessed using pin prick.</p><p>4 A positive test is considered impaired sensation when</p><p>tested against the opposite side.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Jepsen et al.24 (Axillary Nerve) (Light</p><p>Touch)</p><p>.69 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Medial Cutaneous of</p><p>Arm) (Light Touch)</p><p>.90 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Medial Cutaneous of</p><p>Forearm) (Light Touch)</p><p>.75 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Musculocutaneous)</p><p>(Light Touch)</p><p>.67 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Radial Nerve) (Light</p><p>Touch)</p><p>.31 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Median Nerve) (Light</p><p>Touch)</p><p>.73 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Ulnar Nerve) (Light</p><p>Touch)</p><p>.59 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Axillary Nerve) (Pain) .54 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Medial Cutaneous of</p><p>Arm) (Pain)</p><p>.42 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Medial Cutaneous of</p><p>Forearm) (Pain)</p><p>.69 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Musculocutaneous) (Pain) .48 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Radial Nerve) (Pain) .48 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Median Nerve) (Pain) .43 kappa NT NT NA NA NA</p><p>Jepsen et al.24 (Ulnar Nerve) (Pain) .48 kappa NT NT NA NA NA</p><p>Wainner et al.54 (C5) (Pin Prick) .67 kappa 29 86 2.07 0.82 10</p><p>Wainner et al.54 (C6) (Pin Prick) .28 kappa 24 66 0.70 1.15 10</p><p>Wainner et al.54 (C7) (Pin Prick) .40 kappa 28 77 1.21 0.93 10</p><p>Wainner et al.54 (C8) (Pin Prick) .16 kappa 12 81 0.63 1.08 10</p><p>(continued)</p><p>54 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Wainner et al.54 (T1) (Pin Prick) .46 kappa 18 79 0.85 1.03 10</p><p>Matsumoto et al.33 (C3, 4, 5) NT 56 82 3.11 0.53 6</p><p>Matsumoto et al.33 (6 and below) NT 45 81 2.36 0.68 6</p><p>Comments: Results suggest that bilateral stimulus with the patient’s eyes closed generates the most valid findings. Unless indicated, results</p><p>were associated with light touch sensibility testing. The test is frequently performed as a component of the upper quarter screen.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Matsumoto et al.34 (All Deep</p><p>Tendon Reflexes)</p><p>63% agreement 52 NT NA NA 7</p><p>Matsumoto et al.34 (All Muscle</p><p>Weakness)</p><p>63% agreement 23 NT NA NA 7</p><p>Matsumoto et al.34 (All</p><p>Dermatomes)</p><p>63% agreement 62 NT NA NA 7</p><p>Lauder et al.30 (Weakness Any</p><p>Muscle)</p><p>NT 73 61 1.87 0.44 9</p><p>Lauder et al.30 (Sensory and</p><p>Reflexes)</p><p>NT 9 97 3 0.93 9</p><p>Lauder et al.30 (Sensory and</p><p>Weakness)</p><p>NT 27 74 1.04 0.98 9</p><p>Lauder et al.30 (Weakness and</p><p>Reflexes)</p><p>NT 18 98 9 0.83 9</p><p>Lauder et al.30 (Weakness, Sen-</p><p>sory, and Reflex Abnormalities)</p><p>NT 7 98 3.5 0.94 9</p><p>Lauder et al.30 (Any Compo-</p><p>nent-Weakness or Sensory or</p><p>Reflex Abnormalities)</p><p>NT 84 31 1.2 0.51 9</p><p>Lauder et al.30 (Sensation Loss-</p><p>Vibration or Pin Prick)</p><p>NT 38 46 0.70 1.35 9</p><p>Davidson et al.11 (Loss or</p><p>Depression of Reflexes)</p><p>NT 50 NT NA NA 8</p><p>Davidson et al.11 (Any Muscle</p><p>Strength Loss)</p><p>NT 91 NT NA NA 8</p><p>Spurling & Scoville48 (Any Muscle</p><p>Strength Loss)</p><p>NT 58 NT NA NA 4</p><p>Spurling & Scoville48 (Any Loss</p><p>or Depression of Reflexes)</p><p>NT 33 NT NA NA 4</p><p>Comments: For diagnostic purposes, combined values exceeded the findings of single neurological screening testing.</p><p>Combined Tests Upper Extremity</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 55</p><p>Quadriceps Deep Tendon Reflex</p><p>TESTS FOR LUMBAR RADICULOPATHY</p><p>1 The patient assumes a sitting position.</p><p>2 The examiner strikes the infrapatellar tendon just above</p><p>the tibial tuberosity. Three to five strikes are necessary to</p><p>examine fatigue.</p><p>3 A positive test is a depression of knee extension directly</p><p>after the tendon strike in comparison to the opposite side.</p><p>4 The Jendrassik’s maneuver is often used to improve reflex</p><p>response.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Knuttson28 (L3–L4) NT 100 65 2.86 0 3</p><p>Knuttson28 (L5–S1) NT 14 65 0.41 1.32 3</p><p>Knuttson28 (L4–L5) NT 12 65 0.34 1.36 3</p><p>Hakelius & Hindmarsh20 (All Levels</p><p>Included)</p><p>NT 75 NT NA NA 3</p><p>Lauder et al.30 (All Levels Included) NT 12 96 3 0.92 6</p><p>Comments: Reflex testing is commonly scored as 0+ = absent (no visible or palpable muscle contraction with reinforcement), 1+ =</p><p>tone change (slight, transitory impulse, with no movement of the extremities), 2+ = normal (visual, brief movement of the extrem-</p><p>ity), 3+ = exaggerated (full movement of the extremities), 4+ = abnormal (compulsory and sustained movement, lasting for more</p><p>than 30 seconds). Please note that the majority of the studies were very poorly performed and this predicament likely biases find-</p><p>ings. The test is frequently performed as a component of the lower quarter screen. The test is purported to target L2–3.</p><p>56 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR LUMBAR RADICULOPATHY</p><p>Achilles Deep Tendon Reflex (Lumbar Radiculopathy Secondary</p><p>to Disk Herniation or Protrusion)</p><p>1 The patient assumes a sitting or supine position.</p><p>2 The examiner places the ankle in slight dorsiflexion by pull-</p><p>ing the palmar aspect of the forefoot into dorsiflexion.</p><p>3 The examiner applies 3 to 5 quick strikes to the Achilles</p><p>tendon. The examiner observes plantarflexion immediately</p><p>after each strike.</p><p>4 A positive test is depression of the reflex in comparison to</p><p>the opposite side.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Knuttson28 (L5–S1) NT 80 76 3.36 0.26 3</p><p>Knuttson28 (L4–L5) NT 36.5 76 1.53 0.83 3</p><p>Kerr et al.26 (L5–S1) NT 87 89 7.91 0.15 7</p><p>Kerr et al.26 (L4–L5) NT 12 89 1.1 0.99 7</p><p>Hakelius & Hindmarsh20 (All Levels</p><p>Included)</p><p>NT 80 NT NA NA 3</p><p>Lauder et al.30 (All Levels Included) NT 15 92 1.88 0.9 6</p><p>Rico & Jonkman44 (S1) NT 85 89 7.9 0.2 6</p><p>Comments: Reflex testing is commonly scored as 0+ = absent (no visible or palpable muscle contraction with reinforcement), 1+ =</p><p>tone change (slight, transitory impulse, with no movement of the extremities), 2+ = normal (visual, brief movement of the extrem-</p><p>ity), 3+ = exaggerated (full movement of the extremities), 4+ = abnormal (compulsory and sustained movement, lasting for more</p><p>than 30 seconds). Studies were poorly done. The test is frequently performed as a component of the lower quarter screen. The</p><p>test is purported to target L5–S1.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 57</p><p>TESTS FOR LUMBAR RADICULOPATHY</p><p>Extensor Digitorum Brevis Deep Tendon Reflex Test</p><p>(Radiculopathy of L5–S1)</p><p>1 The patient assumes a sitting position.</p><p>2 The examiner prepositions the foot into slight inversion and</p><p>plantarflexion. The great toe is placed in plantarflexion.</p><p>3 The examiner taps the EDB tendons distal to the muscle</p><p>belly near the metatarsalphalangeal joints.</p><p>4 The examiner repeats the process six times in an effort to</p><p>elicit a reflex response.</p><p>5 A positive test is absence of a reflex (L5 with small contri-</p><p>bution of S1) and is indicative of radiculopathy.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Marin et al.32 (L5) NT 18 91 2 .90 8</p><p>Marin et al.32 (S1) NT 11 91 1.22 .98 8</p><p>Marin et al.32 (L5 and S1) NT 14 91 1.56 .95 8</p><p>Comments: Although not acknowledged by Marin et al.32, eliciting any reflex response with this test has shown to be very difficult.</p><p>The test is purported to target L4–L5.</p><p>Muscle Power Testing (Lumbar Radiculopathy Secondary</p><p>to Disk Herniation or Protrusion)</p><p>1 The patient is placed in sitting.</p><p>2 To test L1–L2, hip flexion is resisted.</p><p>(continued)</p><p>58 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR LUMBAR RADICULOPATHY</p><p>3 The patient is placed in sitting.</p><p>4 To test L3–L4, knee extension is resisted.</p><p>5 The patient is placed in sitting.</p><p>6 To test L5, great toe extension is resisted.</p><p>7 The patient is placed in standing.</p><p>8 To test L4–L5 (dorsiflexion), the patient is requested to</p><p>walk on his or her heels.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 59</p><p>TESTS FOR LUMBAR RADICULOPATHY</p><p>12 The patient is placed in standing.</p><p>13 To test S1, the patient is requested to walk on his or her</p><p>toes.</p><p>14 With all areas, a positive test is noticeable weakness when</p><p>compared to the opposite side or versus expectations if</p><p>bilateral symptoms are present.</p><p>9 The patient is placed in standing.</p><p>10 To test L5–S1, the patient is requested to unilaterally stand.</p><p>11 The examiner observes pelvic drop on the opposite side</p><p>for weakness in the hip abductors.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Knuttson28 (L5–S1) (Great Toe</p><p>Weakness)</p><p>NT 48 50 0.95 1.1 3</p><p>Knuttson28 (L4–L5) (Great Toe</p><p>Weakness)</p><p>NT 74 50 1.5 0.52 3</p><p>Knuttson28 (L3–L4) (Great Toe</p><p>Weakness)</p><p>NT 100 50 NA NA 3</p><p>Knuttson28 (L4–L5) (Great Toe</p><p>Weakness)</p><p>NT 36 50 0.72 1.3 3</p><p>(continued)</p><p>60 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR LUMBAR RADICULOPATHY</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Gurdjian et al.19 (Great Toe Weakness) NT 16 50 0.32 1.7 4</p><p>Gurdjian et al.19 (Foot Drop-Dorsiflexion) NT 1 50 0.02 1.98 4</p><p>Kerr et al.26 (L4–L5) (Hip Extension</p><p>Weakness)</p><p>NT 12 96 3 0.92 7</p><p>Kerr et al.26 (L5–S1) (Hip Extension</p><p>Weakness)</p><p>NT 9 89 0.77 1.03 7</p><p>Kerr et al.26 (L3–L4) (Ankle Dorsiflexion) NT 33 89 3.03 0.75 7</p><p>Kerr et al.26 (L4–L5) (Ankle Dorsiflexion) NT 60 89 5.45 0.45 7</p><p>Kerr et al.26 (L5–S1) (Ankle Dorsiflexion) NT 49 89 4.45 0.6 7</p><p>Kerr et al.26 (L3–L4) (Ankle Plantarflexion) NT 0 100 NA NA 7</p><p>Kerr et al.26 (L4–L5) (Ankle Plantarflexion) NT 0 100 NA NA 7</p><p>Kerr</p><p>et al.26 (L5–S1) (Ankle Plantarflexion) NT 28 100 NA NA 7</p><p>Hakelius & Hindmarsh20 (Great Toe</p><p>Extension, All Levels)</p><p>NT 79 NT NA NA 3</p><p>Hakelius & Hindmarsh20 (Dorsiflexion, All</p><p>Levels)</p><p>NT 75 NT NA NA 3</p><p>Hakelius & Hindmarsh20 (Quadriceps, All</p><p>Levels)</p><p>NT 79 NT NA NA 3</p><p>Comments: Note that the study results are highly variable and depend on the population examined. In addition, positive findings are</p><p>affected by the prevalence of conditions represented in the study. Most patients in the studies demonstrated L4–L5 or L5–S1 disor-</p><p>ders, thus it’s expected to see better diagnostic value with muscle groups that reflect this innervation pattern. The test is frequently</p><p>performed as a component of the lower quarter screen.</p><p>Sensibility Testing (Lumbar Radiculopathy from Disk Herniation</p><p>or Protrusion)</p><p>1 The patient is placed in sitting or supine.</p><p>2 The examiner applies a series of concurrent sensibility tests</p><p>(light touch) to both sides. The examiner makes careful</p><p>effort to apply sensation testing along known dermatomes.</p><p>3 Sharp/dull is assessed using pin prick.</p><p>4 A positive test is considered impaired sensation when</p><p>tested against the opposite side.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 61</p><p>TESTS FOR LUMBAR RADICULOPATHY</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Porchet et al.41 NT 57 NT NA NA 5</p><p>Kerr et al.26 (L5 Dermatome) NT 16 86 1.14 0.98 7</p><p>Kerr et al.26 (S1 Dermatome) NT 28 86 2 0.84 7</p><p>Lauder et al.30 (Any Level, Vibra-</p><p>tion and Pinprick)</p><p>NT 55 77 2.4 0.6 6</p><p>Vroomen et al.53 (Any Form, Any</p><p>Level—Sensory Loss)</p><p>NT 45 50 0.9 1.1 10</p><p>Knuttson28 (L3–L4) NT 67 65 1.9 0.5 3</p><p>Knuttson28 (L4–L5) NT 30 65 0.87 1.1 3</p><p>Knuttson28 (L5–S1) NT 27 65 .8 1.1 3</p><p>Gurdjian et al.19 (Hyperesthesia,</p><p>Anesthesia, or Paresthesia)</p><p>NT 40 NT NA NA 4</p><p>Peeters et al.39 (L4) (L3–L4 Disk</p><p>Herniation)</p><p>NT 50 87.5 4 0.6 8</p><p>Peeters et al.39 (L5) (L3–L4 Disk</p><p>Herniation)</p><p>NT 50 100 NA NA 8</p><p>Peeters et al.39 (S1) (L3–L4 Disk</p><p>Herniation)</p><p>NT 0 87.5 0 0 8</p><p>Peeters et al.39 (L4) (L4–L5 Disk</p><p>Herniation)</p><p>NT 59 87.5 4.7 0.5 8</p><p>Peeters et al.39 (L5) (L4–L5 Disk</p><p>Herniation)</p><p>NT 50 100 NA NA 8</p><p>Peeters et al.39 (S1) (L4–L5 Disk</p><p>Herniation)</p><p>NT 23 87.5 1.8 0.9 8</p><p>Peeters et al.39 (L4) (L5–S1 Disk</p><p>Herniation)</p><p>NT 16 87.5 1.3 0.96 8</p><p>Peeters et al.39 (L5) (L5–S1 Disk</p><p>Herniation)</p><p>NT 42 100 NA NA 8</p><p>Peeters et al.39 (S1) (L5–S1 Disk</p><p>Herniation)</p><p>NT 74 87.5 5.9 0.3 8</p><p>Tokuhashi et al.51 (L4, L5, S1)</p><p>(Light Touch)</p><p>NT 62 NT NA NA 4</p><p>Tokuhashi et al.51 (L4, L5, S1)</p><p>(Tuning Fork)</p><p>NT 53 NT NA NA 4</p><p>Tokuhashi et al.51 (L4, L5, S1)</p><p>(Pressure)</p><p>NT 52 NT NA NA 4</p><p>Bertilson et al.5 (L4) .50 kappa NT NT NA NA NA</p><p>Bertilson et al.5 (L5) .71 kappa NT NT NA NA NA</p><p>Bertilson et al.5 (S1) .68 kappa NT NT NA NA NA</p><p>Comments: Results suggest that bilateral stimulus with the patient’s eyes closed generates the most valid findings. Unless indicated, results</p><p>were associated with light touch sensibility testing. The test is frequently performed as a component of the lower quarter screen.</p><p>62 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR LUMBAR RADICULOPATHY</p><p>1 The patient is positioned in supine.</p><p>2 The patient is instructed to place his or her hands behind</p><p>his or her head and passively flex his or her cervical spine.</p><p>3 The patient is instructed to then flex the hip on the tested</p><p>side to end range or to the point of pain. The patient’s</p><p>knee should remain fully extended.</p><p>4 The patient should then be instructed to actively flex the</p><p>knee to 90° on the tested side while maintaining full exten-</p><p>sion on the opposite side.</p><p>5 A positive test is indicated by spine pain or lower extremity</p><p>symptoms which increase with neck and hip flexion but</p><p>are relieved with knee flexion.</p><p>Combined Tests Lower Extremity</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Porchet et al.41 (All LE Reflexes,</p><p>Lateral Disk Herniation)</p><p>NT 82 NT NA NA 5</p><p>Porchet et al.41 (Any Sensory</p><p>Deficit, Lateral Disk Herniation)</p><p>NT 57 NT NA NA 5</p><p>Porchet et al.41 (Any Strength</p><p>Loss, Lateral Disk Herniation)</p><p>NT 79 NT NT NT 5</p><p>Lauder et al.30 (Weakness, Any</p><p>Muscle)</p><p>NT 69 61 1.77 0.51 6</p><p>Lauder et al.30 (Sensory Loss</p><p>and Weakness)</p><p>NT 41 88 3.41 0.67 6</p><p>Lauder et al.30 (Sensory Loss</p><p>and Reflexes)</p><p>NT 14 96 3.5 8.9 6</p><p>Lauder et al.30 (Weakness and</p><p>Reflexes)</p><p>NT 19 96 4.75 0.84 6</p><p>Lauder et al.30 (Sensory,</p><p>Reflexes, and Weakness)</p><p>NT 12 100 NA NA 6</p><p>Vroomen et al.53 (Ankle and</p><p>Knee Loss)</p><p>NT 14 93 2.2 0.92 10</p><p>Comments: For diagnostic purposes, combined values exceed the findings of single neurological screening testing.</p><p>Brudzinski’s Sign</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 63</p><p>TESTS FOR LUMBAR RADICULOPATHY</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Scifers46 NT NT NT NT NT NA</p><p>Comments: The patient should maintain the same degree of hip flexion throughout the test.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Scifers46 NT NT NT NT NT NA</p><p>Comments: A positive test indicates a nerve root impingement, irritation of the dura, and meningeal irritation. This test is also used</p><p>to test for bacterial or viral meningitis.</p><p>Bowstring Test</p><p>1 The patient is positioned in supine.</p><p>2 The clinician performs a passive straight leg raise of the</p><p>involved side. If the patient reports radiating pain during the</p><p>straight leg raise, the clinician should flex the patient’s leg</p><p>approximately 20° in order to relieve the patient’s symptoms.</p><p>3 The clinician should then palpate the sciatic nerve in the</p><p>popliteal fossa in an attempt to reproduce the patient’s</p><p>familiar symptoms.</p><p>4 A positive sign is the presence of radicular symptoms dur-</p><p>ing straight leg raise which is relieved by flexion of the</p><p>knee but exacerbated with palpation of the popliteal fossa.</p><p>UTILITY SCORE ?</p><p>Key Points</p><p>1. Nearly all of the neurological clinical special tests</p><p>exhibit high levels of procedural bias.</p><p>2. Despite the fact that many of the neurological</p><p>clinical special tests are purported to function as</p><p>screens, the majority demonstrate poor sensitivity</p><p>and fair to strong specificity, the opposite diagnos-</p><p>tic values expected in a screening examination.</p><p>3. Hoffmann’s test, a test for upper motor neu-</p><p>ron assessment, is frequently included as a gold</p><p>standard in most studies, but demonstrates only</p><p>poor to fair diagnostic value when examined</p><p>independently.</p><p>4. Those studies with higher QUADAS values rou-</p><p>tinely demonstrate that many of the neurological</p><p>screen tests have less accuracy than studies with</p><p>lower QUADAS scores.</p><p>5. The Babinski sign and offshoots of this test (Allen-</p><p>Cleckley and Gonda-Allen) demonstrate good sen-</p><p>sitivity for testing upper motor neuron disorders.</p><p>6. 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Correlation between</p><p>magnetic resonance imaging and radiographic meas-</p><p>urement of cervical spine in cervical myelopathic</p><p>patients. J Orthop Surg. 2004;12:239–242.</p><p>Use this address to access the Companion Website created for this textbook. Simply select “Physical Therapy” from the</p><p>choice of disciplines. Find this book and log in using your username and password to access video clips of selected tests.</p><p>PEARSON</p><p>66</p><p>Physical Examination</p><p>Tests for Medical</p><p>Screening</p><p>CHAPTER</p><p>3</p><p>Ken Learman</p><p>Index of Tests</p><p>Visceral Screening 68</p><p>Tests for Splenomegaly 68</p><p>Nixon’s Percussion 68</p><p>Castell’s Percussion 69</p><p>Percussion Test in Traube’s Space 70</p><p>Bimanual Palpation of Spleen 70</p><p>Ballottement of Spleen 71</p><p>Middleton’s Maneuver for Splenomegaly</p><p>(Palpation from above the Patient) 72</p><p>Percussion and Palpation of the Spleen 73</p><p>Tests for Hepatomegaly 74</p><p>Palpation of the Liver 74 Percussion of the Liver 75</p><p>Test for Cholecystitis 76</p><p>Murphy’s Sign 76</p><p>Tests for Kidney Size 77</p><p>Palpation of Kidney 77 Percussion of the Kidney (Murphy’s</p><p>Percussion Test or Test for</p><p>Costovertebral Tenderness) 77</p><p>Test for Acute Appendicitis 78</p><p>Palpation of McBurney’s Point 78 Alvarado’s Score to Predict Acute</p><p>Appendicitis 79</p><p>Test for Bladder Size 80</p><p>Palpation of Bladder Volume 80</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 67</p><p>Test for Cardiopulmonary, Vascular Disease, and Abdominal Aortic Aneurysm 81</p><p>Palpation of Abdominal Aorta 81</p><p>Tests for Deep Vein Thrombosis 82</p><p>Wells Criteria for Deep Vein Thrombosis 82 Tests for Upper Extremity Deep Vein</p><p>Thrombosis 84</p><p>Tests for Pulmonary Embolism 85</p><p>Wells Criteria for Pulmonary Embolism 85 Geneva Criteria 86</p><p>Tests to Predict Future Cardiopulmonary Events 87</p><p>San Francisco Syncope Rule for Predicting</p><p>Serious Short-term Outcome 87</p><p>Framingham Criteria for Heart Failure 88</p><p>Thrombolysis in Myocardial Infarction</p><p>(TIMI) Score for Acute Coronary</p><p>Syndromes 88</p><p>Risk Score for Acute Coronary Syndromes 90</p><p>Duke Treadmill Score for Identifying Risk</p><p>of Ischaemic Heart Disease 90</p><p>Clinical Prediction Rule to Identify</p><p>Individuals with Low Risk of Stroke from</p><p>Atrial Fibrillation while Taking Aspirin 91</p><p>Ankle-Brachial Index for Predicting</p><p>Coronary Artery Disease 92</p><p>Ankle Brachial Index for Predicting Stroke 93</p><p>Ankle-Brachial Index for Predicting any</p><p>Cardiovascular Event 94</p><p>Ankle-Brachial Index for Predicting</p><p>Peripheral Artery Disease 95</p><p>Ankle-Brachial Index for Predicting</p><p>Cardiovascular Mortality 96</p><p>Ankle-Brachial Index for Predicting</p><p>Total Mortality 97</p><p>Ankle-Brachial Index for Predicting</p><p>Functional Deficits 98</p><p>Tests to Determine Need for Bone Mineral Densitometry 100</p><p>Male Osteoporosis Risk Estimation Score</p><p>(MORES) Criteria for Bone Densitometry</p><p>in Men 100</p><p>Osteoporosis Self-Assessment Tool (OST)</p><p>Criteria for Bone Densitometry</p><p>in Women 101</p><p>Osteoporosis Risk Assessment Instrument</p><p>(ORAI) Criteria for Bone Densitometry 101</p><p>Simple Calculated Osteoporosis Risk</p><p>Estimation (SCORE) for Bone</p><p>Densitometry 102</p><p>National Osteoporosis Foundation (NOF)</p><p>Criteria for Bone Densitometry 103</p><p>Age, Body Size, No Estrogen (ABONE) for</p><p>Osteoporosis Prediction 104</p><p>Weight Criterion for Osteoporosis</p><p>Prediction 105</p><p>Osteoporosis Index of Risk (OSIRIS) 105</p><p>Study of Osteoporotic Fractures Risk</p><p>Index (SOFSURE) 106</p><p>Tests for Fracture Assessment 107</p><p>Barford Test for Fracture Assessment 107 Tuning Fork Test for Fracture Assessment 108</p><p>68 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>VISCERAL SCREENING</p><p>TESTS FOR SPLENOMEGALY</p><p>Nixon’s Percussion</p><p>1 Patient is placed on right side lying with arms resting at</p><p>shoulder level to allow full access of the spleen.</p><p>2 The distal end of lung resonance is found at the posterior</p><p>axillary line.</p><p>3 Percussion is begun at the point found in step 2 and is</p><p>continued in an anterior and inferior direction toward the</p><p>midanterior costal margin.</p><p>4 A positive test is indicated when dullness extends over 8cm</p><p>above the costal margin (normal is considered 6–8cm).</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Nixon56 NT NT NT NT NT NA</p><p>Sullivan & Williams76 NT 59 94 9.83 0.44 8</p><p>Tamayo et al.77 0.31 37 79 1.76 0.80 11</p><p>Comments: Nixon56 used successful splenic aspiration biopsies of 60 cases as the reference standard of splenomegaly confirmation;</p><p>however, the study is not a true diagnostic accuracy study as very little description of methods and results were provided, making</p><p>QUADAS assessment inappropriate. Sullivan & Williams76 studied 65 subjects with suspected enlarged spleens who were scheduled</p><p>to undergo 99mTc-sulfur colloid scans. Tamayo et al. calculated an overall reliability coefficient for 8 examiners with a Kendall’s W</p><p>(coefficient of concordance). Tamayo et al.’s77 sensitivity and specificity values are data pooled for the 8 examiners and the likeli-</p><p>hood ratios differ slightly from the Mantel-Haenszel estimates provided in the article.</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 69</p><p>TESTS FOR SPLENOMEGALY</p><p>1 The patient is placed in supine with the examiner placing</p><p>his or her fingers over the lowest intercostal space in line</p><p>with the anterior axillary line (usually the 8th or 9th space).</p><p>2 Using a dummy finger technique, the examiner percusses</p><p>the space at rest and with full inspiration.</p><p>Castell’s Percussion</p><p>3 A positive test is perceived dullness of sound during per-</p><p>cussion on full inspiration because the spleen descends</p><p>during this condition. However, a grossly enlarged spleen</p><p>could produce dullness in sound in both conditions, obfus-</p><p>cating the typical resonant sound at rest.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Castell12 NT NA NA NA NA 8</p><p>Sullivan &</p><p>Williams76</p><p>NT 82 83 4.82 0.22 8</p><p>Tamayo et al.77 0.31 39 80 1.95 0.76 11</p><p>Barkun et al.5 NT 79 46 1.46 0.46 9</p><p>Comments: Castell’s12 study included 10 subjects with a positive test and 10 subjects that were not expected to have splenomegaly.</p><p>It is not a true diagnostic accuracy study; therefore, the results are not presented. Tamayo et al.77 calculated an overall reliability</p><p>coefficient for 8 examiners with a Kendall’s W. Tamayo et al.’s77 sensitivity and specificity values are data pooled for the 8 examiners</p><p>and the likelihood ratios differ from the Mantel-Haenszel estimates provided in the article. Barkun et al.5 called this test the splenic</p><p>percussion sign. They performed the Castell maneuver but used the following grading criteria: 1) definitely tympanitic, 2) probably</p><p>tympanitic, 3) uncertain, 4) probably dull, and 5) definitely dull. If the grade of the resonant sound progresses at least one level</p><p>closer to definitely dull on full inspiration, it was considered positive. This criteria operationally defines a positive test more objec-</p><p>tively than Castell’s original description.</p><p>70 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TESTS FOR SPLENOMEGALY</p><p>1 The patient is instructed to lie on right side.</p><p>2 Traube’s space,</p><p>defined by the 6th rib superiorly, the</p><p>midaxillary line laterally, and the costal margin anteriorly,</p><p>is percussed at one or more levels from lateral to medial</p><p>margin while the subject breathes normally.</p><p>3 The quality of sound is graded on a five-point scale</p><p>including 1) definitely tympanitic, 2) probably tympa-</p><p>nitic, 3) uncertain, 4) probably dull, and 5) definitely dull.</p><p>4 A positive test is determined by the responses 3) uncertain,</p><p>4) probably dull, and 5) definitely dull.</p><p>Percussion Test in Traube’s Space</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Barkun et al.6 0.41, 0.22, 0.19 62 72 2.21 0.53 11</p><p>Barkun et al.5 NT 62 72 2.21 0.53 9</p><p>Tamayo et al.77 0.31 22 87 1.69 0.90 11</p><p>Comments: Barkun et al.6 had 3 physicians clinically examine each patient resulting in 3 sets of paired reliability (kappa) coefficients.</p><p>Barkun et al.6 compared subjects known to have splenomegaly by ultrasonography with control subjects. Barkun et al.5 used the</p><p>same data set as Barkun 19896. Tamayo et al.77 calculated an overall reliability coefficient for 8 examiners with a Kendall’s W.</p><p>Tamayo et al.’s77 sensitivity and specificity values are data pooled for the 8 examiners and the likelihood ratios differ from the</p><p>Mantel-Haenszel estimates provided in the article.</p><p>1 Patient is instructed to lie supine and breathe normally.</p><p>2 Standing at the patient’s right side, the examiner reaches</p><p>across the patient’s body and, with the left hand, elevates</p><p>the left rib cage and simultaneously creates skin slack on</p><p>the costal margin.</p><p>3 With the right hand, the examiner palpates at the costal</p><p>margin allowing the fingers to probe underneath the ribs</p><p>attempting to feel the spleen’s decent during inspiration.</p><p>This palpation is performed along the whole costal mar-</p><p>gin. If needed, the patient can roll part way to the right</p><p>allowing greater access to the lateral aspect of the costal</p><p>margin.</p><p>4 A positive test is the ability to palpate the enlarged spleen.</p><p>Bimanual Palpation of Spleen</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 71</p><p>TESTS FOR SPLENOMEGALY</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Tamayo et al.77 0.31 38 83 2.24 0.75 11</p><p>Comments: Tamayo et al.’s77 sensitivity and specificity values are data pooled for 8 examiners and the likelihood ratios differ from</p><p>the Mantel-Haenszel estimates provided in the article.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Tamayo et al.77 0.31 31 82 1.72 0.84 11</p><p>Barkun et al.5 0.7, 0.56, 0.57 56 93 8.00 0.57 9</p><p>Holzbach et al.30 NT 63 100 NA 0.37 6</p><p>Zhang & Lewis91 NT 56 69 1.81 0.64 7</p><p>Halpern et al.28 NT 28 98 14.0 0.73 6</p><p>Blendis et al.7 88% 79 100 NA 0.21 6</p><p>Sullivan & Williams76 NT 71 90 7.1 0.32 7</p><p>Comments: Tamayo et al.’s77 sensitivity and specificity values are data pooled for 8 examiners and the likelihood ratios differ from the</p><p>Mantel-Haenszel estimates provided in the article. Barkun et al.5 combined the Bimanual and Middleton’s maneuver techniques statisti-</p><p>cally and called the combination “Palpation.” Holzbach et al.30 do not describe which palpation technique was implemented in their study.</p><p>In addition, the data set described in their narrative does not appear to match the sample size identified in the appropriate figure in the</p><p>article. Zhang & Lewis91 did not report which palpation technique was performed in the study. Blendis et al.7 used a relatively small sample</p><p>size and the methodology had many potential flaws, but did report that there was 88% agreement for all 4 clinical examiners and 97%</p><p>agreement for 3 of 4 examiners. Halpern et al.28 performed a retrospective chart review that may have verification bias since clinical vs.</p><p>reference standards testing occurred up to 2 months apart. Sullivan & Williams76 did not report which palpation technique was incorpo-</p><p>rated in the study resulting in a lower QUADAS score than in the percussion techniques study.</p><p>Ballottement of Spleen</p><p>1 Patient is instructed to lie supine and breathe normally.</p><p>2 Standing at the patient’s right side, the examiner reaches</p><p>across the patient’s body and, with the left hand, elevates</p><p>the left rib cage and simultaneously creates skin slack on</p><p>the costal margin.</p><p>3 With the right hand, the examiner palpates at the costal</p><p>margin allowing the fingers to probe underneath the ribs.</p><p>4 A positive test is the ability to feel impulses from the spleen</p><p>indicating an enlargement.</p><p>UTILITY SCORE 2</p><p>72 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TESTS FOR SPLENOMEGALY</p><p>Middleton’s Maneuver for Splenomegaly</p><p>(Palpation from above the Patient)</p><p>1 Patient is instructed to lie supine, place his or her own left</p><p>fist under the left lower rib cage and breathe normally.</p><p>2 The examiner stands above the patient at their left shoul-</p><p>der and with both hands, curls the fingertips over the left</p><p>costal margin and palpates for the spleen while the patient</p><p>takes deep breaths.</p><p>3 A positive test is a palpable spleen at any point during the</p><p>examination.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Tamayo et al.77 0.31 35 87 2.69 0.75 11</p><p>Barkun et al.5 0.7, 0.56, 0.57 56 93 8.00 0.57 9</p><p>Comments: Tamayo et al.’s77 sensitivity and specificity values are data pooled for 8 examiners and the likelihood ratios differ from</p><p>the Mantel-Haenszel estimates provided in the article. Barkun et al.5 combined the Bimanual and Middleton’s maneuver techniques</p><p>statistically and called the combination “Palpation.”</p><p>UTILITY SCORE 3</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 73</p><p>TESTS FOR SPLENOMEGALY</p><p>Percussion and Palpation of the Spleen</p><p>1 Perform either bimanual or Middleton’s palpation as described above.</p><p>2 Perform a splenic percussion as described by Castell, Nixon, or in Traube's space.</p><p>3 A positive test is indicated when either the percussion test or the palpation test is positive.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Sullivan & Williams76 NT 88 83 5.18 0.14 7</p><p>Barkun et al.5 [both tests</p><p>concurrently (+)]</p><p>NT 46 97 15.33 0.56 9</p><p>Barkun et al.5 [either test</p><p>(+) or both tests ( – )]</p><p>NT 72 68 2.25 0.41 9</p><p>Comments: Sullivan & Williams76 did not make it clear whether or not both percussion techniques were combined with palpation</p><p>in the combined condition nor did they describe which palpation maneuver was employed. Barkun et al.5 used a combination of</p><p>bimanual palpation and Middleton’s maneuver for palpation and Traube’s space percussion test.</p><p>74 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Halpern et al.28 NT 71 62 1.87 0.47 6</p><p>Joshi et al.32 0.44, 0.49, 0.53 39–42 82–86 2.17–3.0 0.68–0.74 9</p><p>Blendis et al.7 54% 50 47 0.94 1.06 6</p><p>Ralphs et al.64 NT 36 83 2.18 0.76 10</p><p>Comments: Neither Halpern et al.28 nor Joshi et al.32 described the exact technique used to palpate the liver; therefore, a common</p><p>technique for liver palpation was provided above. Joshi et al.32 described the diagnostic accuracy of 3 independent examiners but did</p><p>not provide sufficient data to pool; therefore, ranges were provided for all values. Blendis et al.7 did not provide diagnostic accuracy</p><p>information for the entire sample of subjects tested nor was the reference standard used to diagnose hepatomegaly consistent with</p><p>other reports, bringing into question the validity of the reported values. Ralphs et al.64 examined normal subjects only and compared</p><p>investigator’s ability to determine the liver that extends below the costal margin and performed the palpation and percussion exams</p><p>together.</p><p>UTILITY SCORE 3</p><p>TESTS FOR HEPATOMEGALY</p><p>1 Patient lies supine and is asked to fully relax the abdomen.</p><p>2 The examiner’s left hand is placed under the patient’s</p><p>inferior costovertebral region with the hand parallel to</p><p>the lower ribs.</p><p>3 The examiner places one hand over the patient’s right</p><p>upper</p><p>quadrant of the abdomen in line with the midcla-</p><p>vicular line.</p><p>4 The examiner then palpates deeply in a posterior and</p><p>superior direction while the patient takes a deep breath</p><p>that causes the liver to descend toward the fingers.</p><p>5 A positive test is a readily palpable liver that may be pain-</p><p>ful. Please note, in certain circumstances, COPD and</p><p>young children, the liver is more readily palpable, up to</p><p>3cm below the costal margin.</p><p>Palpation of the Liver</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 75</p><p>TESTS FOR HEPATOMEGALY</p><p>1 Patient lies supine and is asked to fully relax the abdomen.</p><p>2 The examiner locates the right midclavicular region and</p><p>mentally draws a line down from this point through the</p><p>right lower quadrant.</p><p>3 The examiner places the non-dominant third digit on the</p><p>midclavicular line well below the expected point of liver</p><p>dullness (in line with the umbilicus should be far enough</p><p>in most cases).</p><p>4 The examiner then percusses the non-dominant finger</p><p>with the dominant hand to create a sound of tympani</p><p>or dullness. This procedure is continued every couple of</p><p>centimeters in a proximal direction until the tympanitic</p><p>sound of the abdomen gives way to a dull sound at the</p><p>liver’s border. This point is marked.</p><p>5 This technique is repeated from a point on the midcla-</p><p>vicular line well proximal to the expected superior border</p><p>of the liver in a distal direction until the superior border</p><p>of the liver is perceived. This point is also marked and the</p><p>distance between the marks is measured.</p><p>6 A positive test is a superior to inferior liver span of > 10cm.</p><p>This may indicate hepatomegaly.</p><p>Percussion of the Liver</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Joshi et al.32 0.33, 0.31, 0.17 39–61 43–64 1.07–1.15 0.89–0.96 9</p><p>Ralphs et al.64 NT 36 83 2.18 0.76 10</p><p>Comments: Joshi et al.32 did not describe the procedure used in liver percussion. Joshi et al.32 described the diagnostic accuracy of</p><p>3 independent examiners but did not provide sufficient data to pool; therefore, ranges were provided for all values. Ralphs et al.64</p><p>examined normal subjects only and compared investigator’s ability to determine the liver that extends below the costal margin and</p><p>performed the palpation and percussion exams together.</p><p>76 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TEST FOR CHOLECYSTITIS</p><p>1 The patient is directed to lie supine and relax the abdomen.</p><p>2 The examiner places one hand on the right, posterior infe-</p><p>rior costal margin.</p><p>3 The examiner places the other hand on the right upper</p><p>quarter subcostal region.</p><p>4 The patient then draws in a deep breath while the exam-</p><p>iner simultaneously palpates the subcostal region deeply.</p><p>5 A positive test is pain during inspiration and/or an associ-</p><p>ated inspiratory arrest.</p><p>Murphy’s Sign</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Bree8 NT 86 35 1.32 0.40 9</p><p>Ralls et al.63 NT 63 94 9.84 0.40 9</p><p>Singer et al.74 NT 97 48 1.88 0.06 10</p><p>Comments: Bree8 used a sonogram assisted Murphy’s sign to ensure that the point of maximal tenderness was directly over the</p><p>gallbladder which may increase the diagnostic accuracy of the test. Singer et al.74 performed a retrospective chart analysis of subjects</p><p>presenting to an emergency room with abdominal pain.</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 77</p><p>Percussion of the Kidney (Murphy’s Percussion Test or Test</p><p>for Costovertebral Tenderness)</p><p>TESTS FOR KIDNEY SIZE</p><p>1 The patient lies supine and relaxes the abdomen.</p><p>2 The examiner places one hand on the posterior inferior</p><p>costal margin.</p><p>3 The examiner places the other hand on the abdomen lat-</p><p>eral to the rectus abdominus, proximal to the umbilicus,</p><p>and distal to the ribs.</p><p>4 The examiner then draws the trunk anteriorly with the</p><p>posterior hand while palpating deeply into the abdomen.</p><p>5 A positive test is pain during palpation or an appreciable</p><p>difference in the size or texture of the kidneys.</p><p>Palpation of Kidney</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>NT NT NT NT NT NT NT</p><p>Comments: The diagnostic accuracy of kidney palpation does not appear to have been studied.</p><p>1 The patient lies prone or assumes a seated position with-</p><p>out a chair back.</p><p>2 The examiner places one hand over the 12th rib at the</p><p>costovertebral angle.</p><p>3 The examiner then raps the back of the palpatory hand</p><p>with the other fist.</p><p>4 The normal patient will feel a firm thud but should feel no</p><p>pain from the test. A positive test is pain in the back (sub-</p><p>costal region) and/or into the flank and lateral abdomen.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>NT NT NT NT NT NT NT</p><p>Comments: The diagnostic accuracy of kidney percussion does not appear to have been studied.</p><p>78 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Campbell & McPhail11 NT 76 NT NT NT 8</p><p>Alvarado1 (tenderness) NT 100 12 1.14 0.00 8</p><p>Alvarado1 (Blumberg’s sign) NT 55 78 2.5 0.58 8</p><p>Tzanakis et al.79 (tenderness) NT 90 59 2.19 0.17 9</p><p>Tzanakis et al.79</p><p>(Blumberg’s sign)</p><p>NT 66 75 2.61 0.45 9</p><p>Soda et al.75 NT 87 90 8.42 0.15 9</p><p>Comments: Campbell & McPhail11 only reported on cases confirmed as having appendicitis. Both Alvarado1 and Tzanakis et al.79</p><p>found tenderness to be more sensitive and Blumberg’s sign (rebound pain) to be more specific.</p><p>TESTS FOR ACUTE APPENDICITIS</p><p>1 The patient lies supine and is asked to fully relax the</p><p>abdomen.</p><p>2 The examiner gently and deeply palpates the right lower</p><p>quadrant of the abdomen (midway between the umbilicus</p><p>and the ASIS) looking for tenderness.</p><p>3 The examiner then palpates the tenderness deeply and</p><p>releases the palpation quickly to see if rebound tenderness</p><p>is present.</p><p>4 A positive test is greater tenderness with the rebound tech-</p><p>nique (Blumberg’s sign) over McBurney’s point.</p><p>Palpation of McBurney’s Point</p><p>UTILITY SCORE 2</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 79</p><p>TESTS FOR ACUTE APPENDICITIS</p><p>Alvarado’s Score to Predict Acute Appendicitis</p><p>1 The patient reports that pain migrated from epigastric region to right lower quadrant.</p><p>2 The patient reports anorexia.</p><p>3 The patient reports nausea and vomiting.</p><p>4 The patient has tenderness in the right lower quadrant.</p><p>5 Positive Blumberg’s sign (rebound tenderness) over McBurney’s point.</p><p>6 Fever.</p><p>7 Leucocytosis.</p><p>8 Shift to left (white count shifts to left).</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Alvarado1 NT 97</p><p>81</p><p>38</p><p>74</p><p>1.56</p><p>3.12</p><p>0.09</p><p>0.26</p><p>8</p><p>Tzanakis et al.79 NT 90</p><p>66</p><p>59</p><p>75</p><p>2.19</p><p>2.61</p><p>0.17</p><p>0.45</p><p>9</p><p>Memon et al.49</p><p>(cutoff 6 rule in AA)</p><p>NT 58 89 5.24 0.47 7</p><p>Memon et al.49</p><p>(cutoff > 7 rule in AA)</p><p>NT 45 100 NA 0.55 7</p><p>Comments: Alvarado1 assessed components of a physical examination for acute appendicitis. The study concluded that scoring</p><p>the probability of having acute appendicitis (AA) based on 6 clinical examinations and 2 laboratory tests was helpful in determining</p><p>who could be conservatively managed and who required immediate surgery. Alvarado1 developed the Alvarado score and discussed</p><p>the use of stratification of score for diagnostic purposes. Scores 6</p><p>were more likely. Tzanakis et al.79 suggested a cutoff of > 7 for diagnostic purposes in identifying a high probability of AA. Memon</p><p>et al.49 examined two diagnostic cutoffs of > 6, as recommended by Alvarado, and > 7 as recommended by the author.</p><p>80 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TEST FOR BLADDER SIZE</p><p>Palpation of Bladder Volume</p><p>1 The patient lies supine.</p><p>2 The examiner places both hands on the patient’s abdomen</p><p>just distal to the umbilicus.</p><p>3 The examiner then palpates into the abdomen and pro-</p><p>ceeds to</p><p>musculoskeletal system and have gone one</p><p>step further in subjecting each of these tests to scientific</p><p>scrutiny with modern statistical analysis and outcomes mea-</p><p>sures. This will allow for the appropriate placement of each</p><p>of these tests in our armamentarium as we face a difficult</p><p>diagnostic dilemma. I have no doubt that for years to come</p><p>trainees, and ultimately patients, will thank the authors for</p><p>this contribution to our knowledge base.</p><p>Claude T. Moorman III, MD</p><p>Director, Sports Medicine</p><p>Duke University Medical Center</p><p>References</p><p>1. Stanley Hoppenfeld, Physical Examination of the Spine Extremities,</p><p>Upper Saddle River, NJ: Prentice Hall, 1976.</p><p>2. Eugene A. Stead, Jr., What This Patient Needs Is a Doctor,</p><p>Durham, NC: Carolina Academic Press, 1978.</p><p>v</p><p>Foreword</p><p>“It’s what you learn after you know it all that counts.”</p><p>Coach John Wooden</p><p>The key to finding a remedy to a problem is the accurate</p><p>recognition of the problem. In medicine, the recognition of</p><p>the problem is based on the examination process. One of the</p><p>keys to a successful examination is the selection of appropri-</p><p>ate tests. The question the clinician must ask him- or herself</p><p>when examining a patient is, “Which test is best?” for identi-</p><p>fying this specific patient’s problem. The selected examination</p><p>tests can assist the clinician in ruling out specific lesions and</p><p>aid in ruling in others. The appropriate test should render</p><p>true positive results, while minimizing false positive results.</p><p>Thus, the selection of the best examination tests must exhibit</p><p>a high degree of sensitivity and specificity.</p><p>Numerous textbooks and articles have been written</p><p>describing the examination of specific body regions or ana-</p><p>tomical structures. Often authors describe traditional tests</p><p>or explain new tests or modification of existing ones. There</p><p>are hundreds of examination tests available to the clinician,</p><p>but which tests are the best for the specific patient’s lesion?</p><p>The question the practitioner must ask is whether the test</p><p>is a “good test” for this case.</p><p>This textbook is unique. Not only have the authors of</p><p>this textbook described a plethora of examination tests,</p><p>but they have also reviewed the literature extensively to</p><p>analyze the foundation of the described tests. The authors</p><p>have discussed the scientific evidence for all the tests</p><p>described. In this era of evidence-based treatment, the</p><p>authors have provided to the reader the reliability, valid-</p><p>ity, diagnostic values, and perhaps most importantly the</p><p>clinical utility.</p><p>This textbook is a valuable tool to all practitioners</p><p>(physicians, physical therapists, athletic trainers, etc.) when</p><p>evaluating and treating musculoskeletal disorders. This</p><p>textbook assists the clinician in selecting the “best avail-</p><p>able examination test” for his or her patients. Because, as</p><p>the authors have stated in Chapter 1, “clearly all physical</p><p>examination tests are not created equal.”</p><p>Cook and Hegedus should be commended for their</p><p>work. It appears to me that their efforts were a labor of</p><p>love. The authors have put forth an enormous effort com-</p><p>piling this information from the current literature. Over</p><p>600 references have been utilized to write this textbook.</p><p>This textbook is an excellent addition to any practitioner’s</p><p>library. Thank you to Cook and Hegedus for helping us</p><p>practitioners to select the best available physical exami-</p><p>nation tests for our patients. Furthermore, thank you for</p><p>guiding us through the often difficult and curvy road of the</p><p>clinical examination.</p><p>Kevin E. Wilk, PT, DPT</p><p>vi</p><p>Preface</p><p>An old Georgian phrase states, “If it ain’t broke, don’t fix</p><p>it.” We think our first edition of the physical examination</p><p>textbook addressed a significant need with regard to clini-</p><p>cal tests and evidence for their use. There is another saying</p><p>that says, “If it feels good, do it.” Keeping both statements</p><p>in mind, we adhered to the successful format but enhanced</p><p>the content.</p><p>We’ve kept the focus on measures of diagnostic accu-</p><p>racy. We still provide a diagnostic value (Sensitivity, Specificity,</p><p>Positive Likelihood Ratio [LR+], and Negative Likelihood Ratio</p><p>[LR–-]) for each of the tests (if they exist). Diagnostic accuracy</p><p>scores for a given pathoanatomical diagnosis provide clinicians</p><p>with quick information for appropriate test selection. We still</p><p>review each study for quality (using the Quality Assessment</p><p>of Diagnostic Accuracy Studies [QUADAS] instrument) which</p><p>reduces risk that sampling bias, operator bias, or poor study</p><p>design could significantly influence the findings. We’ve kept the</p><p>Utility for the body of research surrounding each test. Our</p><p>Utility Score takes into account the reliability, the diagnostic</p><p>accuracy, the study quality, and the usefulness of the test in</p><p>clinical practice. The Utility Score is unabashedly homegrown</p><p>and is based on our empirical and clinical expertise. The mea-</p><p>sure is our educated opinion as to the use of the test in the</p><p>clinical environment.</p><p>We have kept the foundation, but the enhancements</p><p>are exciting! Based on an updated literature search, we have</p><p>added 200 new tests, valuable clusters of tests, and two</p><p>new chapters on medical screening and temporomandibular</p><p>examination. Further, we have divided the elbow, wrist,</p><p>and hand chapter into two distinct sections. These changes</p><p>have resulted in what we understand to be the most com-</p><p>prehensive, evidence-based textbook on clinical tests in the</p><p>marketplace today.</p><p>In the preface of the first edition we stated that “we</p><p>hope that the information presented in this book adds to a</p><p>growing pool of evidence for orthopedic testing and stimu-</p><p>lates meaningful thought and discussion.” We have noticed</p><p>a decisive trend toward careful consideration of the value</p><p>of clinical tests and will endeavor to continue to add to this</p><p>critical trend.</p><p>Chad E. Cook PT, PhD, MBA, OCS, FAAOMPT</p><p>Walsh University</p><p>Eric J. Hegedus PT, DPT, MHSc, OCS, CSCS</p><p>High Point University</p><p>vii</p><p>Contributors</p><p>Alyson Cadman</p><p>Honors Student</p><p>Youngstown State University</p><p>Youngstown, Ohio</p><p>Chapter 8: Physical Examination Tests for the Wrist and Hand</p><p>Dawn Driesner, PT, DPT</p><p>Physical Therapist</p><p>Duke University Hospitals</p><p>Durham, North Carolina</p><p>Chapter 13: Physical Examination Tests for the Knee</p><p>Adam Goode, PT, DPT, CSCS</p><p>Assistant Professor</p><p>Division of Physical Therapy</p><p>Department of Community and Family Medicine</p><p>School of Medicine</p><p>Duke University</p><p>Durham, North Carolina</p><p>Chapter 7: Physical Examination Tests for the Elbow</p><p>and Forearm, and Chapter 8: Physical Examination Tests</p><p>for the Wrist and Hand</p><p>Ken Learman, PT, PhD, OCS, FAAOMPT</p><p>Associate Professor</p><p>Division of Physical Therapy</p><p>Youngstown State University</p><p>Youngstown, Ohio</p><p>Chapter 3: Physical Examination Tests for Medical Screening</p><p>Michael Reiman, PT, DPT, OCS, FAAOMPT</p><p>Assistant Professor</p><p>Division of Physical Therapy</p><p>Department of Community and Family Medicine</p><p>School of Medicine</p><p>Duke University</p><p>Durham, North Carolina</p><p>Chapter 12: Physical Examination Tests for the Hip</p><p>Jennifer Reneker, PT, MS, NCS</p><p>Assistant Professor</p><p>Division of Physical Therapy</p><p>Walsh University</p><p>North Canton, Ohio</p><p>Chapter 5: Physical Examination Tests</p><p>for the Temporomandibular Joint</p><p>Ben Stern, PT, DPT</p><p>Physical Therapist</p><p>360 Physical Therapy</p><p>Tempe, Arizona</p><p>Chapter 13: Physical Examination Tests for the Knee</p><p>Mark Wilhelm</p><p>Graduate Student in Physical Therapy</p><p>Walsh University</p><p>North Canton, Ohio</p><p>Chapter 2: Physical Examination Tests</p><p>for Neurological Testing and Screening</p><p>viii</p><p>ix</p><p>Reviewers</p><p>SECOND EDITION</p><p>Barbara C Belyea, PT, DPT, CSCS</p><p>Ithaca College</p><p>Ithaca, New York</p><p>Mary Jo Blaschak, PT, Ph.D.</p><p>Northern Illinois University</p><p>DeKalb, Illinois</p><p>Misha Bradford, PT, DPT, OCS</p><p>University of Utah</p><p>Salt Lake City, Utah</p><p>Ray Castle, PhD, ATC, LAT</p><p>Louisiana State University</p><p>Baton Rouge, Louisiana</p><p>Karen S. Jones, PT, DPT</p><p>Herkimer County Community College</p><p>Herkimer, New York</p><p>Joseph P. Kelly, PT, MSPT, OCS</p><p>Bradley University</p><p>Peoria, Illinois</p><p>Jeff Kittelson, PT, M.A., OCS</p><p>College of St. Scholastica</p><p>Duluth,</p><p>move distally until just proximal to the pubic</p><p>symphysis.</p><p>4 The examiner assesses for a palpable bladder (sign of dis-</p><p>tention) and attempts to determine the size of the bladder.</p><p>5 A positive test is a palpable bladder that is either painful</p><p>or difficult for the patient to empty appropriately.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Weatherall &</p><p>Harwood81</p><p>NT 200cc: 72</p><p>400cc: 82</p><p>600cc: 81</p><p>800cc: 63</p><p>Pooled: 76</p><p>200cc: 65</p><p>400cc: 56</p><p>600cc: 50</p><p>800cc: 45</p><p>Pooled: 53</p><p>2.06</p><p>1.86</p><p>1.62</p><p>1.15</p><p>1.62</p><p>.43</p><p>.32</p><p>.38</p><p>.82</p><p>.45</p><p>10</p><p>Nygaard57 NT 14 68 0.44 1.27 10</p><p>Comments: Weatherall & Harwood’s81 study was performed on 16 healthy subjects by 8 examiners. The application of the tech-</p><p>nique to specific patient populations is unknown. Nygaard57 found anecdotal evidence that BMI may alter results secondary to dif-</p><p>ficulty estimating bladder volume size in obese subjects.</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 81</p><p>TEST FOR CARDIOPULMONARY, VASCULAR DISEASE,</p><p>AND ABDOMINAL AORTIC ANEURYSM</p><p>Palpation of Abdominal Aorta</p><p>1 The patient lies supine with legs and abdomen relaxed.</p><p>2 The examiner places the fingertips over the epigastrium to</p><p>determine if an epigastric pulse is present.</p><p>3 Both hands are placed on the abdomen with palms down</p><p>and the index fingers placed on either side of the aorta</p><p>to determine the width of the aortic pulse and thereby</p><p>estimate the width of the aorta.</p><p>4 A positive test is the determination that the abdominal</p><p>aorta is greater than 3cm in width (although some inves-</p><p>tigators feel 4cm is a better cutoff point for AAA).</p><p>(continued)</p><p>82 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TESTS FOR CARDIOPULMONARY, VASCULAR DISEASE, AND ABDOMINAL AORTIC ANEURYSM</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Fink et al.23 0.66 68 75 2.70 0.43 9</p><p>Lederle et al.38 NT 50 NT NT NT</p><p>Chervu et al.15 NT 38</p><p>77</p><p>NT</p><p>NT</p><p>NT</p><p>NT</p><p>NT</p><p>NT</p><p>7</p><p>Collin et al.16 NT 44 91 5.00 0.62 8</p><p>Karkos et al.33 NT 48 NT NT NT 4</p><p>Kiev et al.34 NT 31 NT NT NT 7</p><p>Lederle & Simel37 NT 39 96 12.0 0.72 NA</p><p>Comments: Fink et al.23 designed their study using 99 subjects with known AAA and 101 subjects known to be without AAA. The</p><p>investigators also found that the sensitivity of the palpation examination increased with increasing size of the known aneurysm.</p><p>Lederle et al.38 found that the sensitivity increased to 100% in subjects with waist size 3 days or major surgery within 4 weeks 1</p><p>4 Localized tenderness along the distribution of the deep venous system 1</p><p>5 Entire leg is swollen 1</p><p>6 Calf swelling of > 3 cm when compared with asymptomatic leg 1</p><p>7 Pitting edema that is worse in the symptomatic leg 1</p><p>8 Collateral superficial veins (nonvaricose) 1</p><p>9 Alternative diagnosis that is likely or more probable than DVT – 2</p><p>Scoring risk on a scale of – 2 to 8 is the original Wells rule.</p><p>It has since been categorized into three groups: score ≤ 0 = low probability; score between 1 and 2 =</p><p>intermediate probability; and score ≥ 3 = high probability.</p><p>UTILITY SCORE 3</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 83</p><p>TESTS FOR DEEP VEIN THROMBOSIS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Wells et al.87 0.85 91</p><p>61</p><p>67</p><p>78</p><p>100</p><p>99</p><p>98</p><p>98</p><p>NA</p><p>61</p><p>33.5</p><p>39</p><p>0.09</p><p>0.39</p><p>0.34</p><p>0.22</p><p>11</p><p>Wells et al.83 0.75 90</p><p>56</p><p>64</p><p>96</p><p>2.49</p><p>15.5</p><p>0.16</p><p>0.46</p><p>11</p><p>Wells et al.82 NT 86</p><p>54</p><p>41</p><p>94</p><p>1.46</p><p>8.39</p><p>0.35</p><p>0.49</p><p>9</p><p>Wells et al.84 (Wells score alone) NT 90 64 2.49 0.16 8</p><p>Wells et al.84 (Wells score with</p><p>D-dimer testing)</p><p>NT 98 46 1.79 0.05 8</p><p>Kraaijenhagen et al.36</p><p>(Wells score alone)</p><p>NT 83 63 2.23 0.27 10</p><p>Kraaijenhagen et al.36</p><p>(Wells score with D-dimer testing)</p><p>NT 98 42 1.68 0.06 10</p><p>Oudega et al.59 (Score ≤ 0) NT 79 44 1.42 0.48 13</p><p>Oudega et al.59(score ≤ 0</p><p>with – D-dimer test)</p><p>NT 98 22 1.25 0.08 13</p><p>Oudega et al.59(score ≤ 1</p><p>with – D-dimer test)</p><p>NT 97 26 1.32 0.11 13</p><p>Riddle et al.67 NT 71</p><p>48</p><p>71</p><p>92</p><p>2.49</p><p>6.17</p><p>0.40</p><p>0.57</p><p>11</p><p>Shields et al.73 NT 94 47 1.78 0.13 10</p><p>Anderson et al.2 NT 90 49 1.75 0.21 8</p><p>Miron et al.50 0.32 93</p><p>60</p><p>57</p><p>94</p><p>2.18</p><p>9.93</p><p>0.12</p><p>0.43</p><p>10</p><p>Cornuz et al.20 0.31 83</p><p>39</p><p>48</p><p>92</p><p>1.61</p><p>4.76</p><p>0.35</p><p>0.66</p><p>13</p><p>Dryjski et al.22 NT 100 50 2.00 0.00 11</p><p>Comments: Wells et al.87 provided diagnostic accuracy values for subjects clinically considered at high, moderate, low, and com-</p><p>bined risk values. Wells et al.87 used a version of criteria that stratifies predictor variables as major and minor risks and served as a</p><p>starting point for the currently used Wells criteria of later studies. Wells et al.83 stratified data into low, medium, and high probabil-</p><p>ity of DVT and the first set of numbers is calculated at low probability to rule out DVT and the second set is based on high prob-</p><p>ability to rule in DVT. Wells et al.82 used a diagnostic algorithm to determine risk of DVT. This clinically more relevant procedure</p><p>reduces the QUADAS score as there was variability in the implementation of reference standards. Oudega et al.59 used the Wells</p><p>rule in primary care rather than secondary care as historically tested. Diagnostic accuracy values were based on the ability to dis-</p><p>criminate the low risk category. The article went on to add D-dimer testing to enhance diagnostic accuracy of the Wells rule. For</p><p>Riddle et al.67 the first values identify the low-risk patient and serve to rule out the condition. The second values identify the high-</p><p>risk patient and serve to rule in the pathology. Miron et al.50 was a comparative study assessing the Wells rule against an empirical</p><p>clinical assessment. The values provided here were extrapolated from data tables in the manuscript with the first values represent-</p><p>ing low risk to rule out DVT and the second values high risk to rule in DVT. The kappa statistic reported was the reliability of</p><p>both tools used to classify the subjects in the same category. Cornuz et al.20 measured a kappa statistic for agreement between the</p><p>Wells criteria and the physician’s assessment. Cornuz et al.20 allowed subjects with a previous history of DVT to be included in the</p><p>study which differs from most other studies examining the Wells criteria. Dryjski et al.22 combined the Wells criteria with D-dimer</p><p>results in a particularly small sample of subjects (N = 66); therefore, generalizability of these results may be questionable.</p><p>UTILITY SCORE 1</p><p>84 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TESTS FOR DEEP VEIN THROMBOSIS</p><p>Tests for Upper Extremity Deep Vein Thrombosis</p><p>The following criteria are taken from the history or clinical examination:</p><p>1 The presence of venous material (catheter, venous access, or pacemaker) 1</p><p>2 Upper extremity, unilateral pitting edema 1</p><p>3 Localized upper extremity pain 1</p><p>4 Another diagnosis is reasonably plausible −1</p><p>Scoring is as follows: score ≤ 0 low risk for DVT; score = 1 intermediate risk; and score ≥ 2 = higher risk for UEDVT</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Constans et al.18 NT 79 64 2.21</p><p>0.33 9</p><p>Constans et al.18 NT 96 37 1.51 0.12 10</p><p>Comments: The sensitivity, specificity, and likelihood ratios were calculated from the data provided by the authors using ≤ 0 as the</p><p>cutoff score for ruling out UEDVT. Both internal and external validation samples were reported on in the same article with minor</p><p>differences in methodology accounting for the QUADAS score differences.</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 85</p><p>TESTS FOR PULMONARY EMBOLISM</p><p>Wells Criteria for Pulmonary Embolism</p><p>1 Clinical signs and symptoms of DVT (pain with palpation of the deep veins</p><p>and leg swelling at a minimum) +3.0</p><p>2 Pulmonary embolism is as likely or more likely than an alternative diagnosis +3.0</p><p>3 Pulse greater than 100 +1.5</p><p>4 Previous history of DVT or PE +1.5</p><p>5 Immobilization or major surgery in the past 4 weeks +1.5</p><p>6 Hemoptysis +1</p><p>7 Active cancer with ongoing treatment or within the past 6 months +1</p><p>Wells criteria for pulmonary embolism scoring: Score 4 = high probability</p><p>Dichotomized Wells criteria: score ≤ 4 = PE unlikely; score > 4 PE likely</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Penaloza et al.60 (low pretest</p><p>probability to rule out)</p><p>0.66 93 65 2.62 0.11 12</p><p>Penaloza et al.60 (high pretest</p><p>probability to rule in)</p><p>0.66 66 87 5.13 0.39 12</p><p>Wells et al.86 NT 89</p><p>37</p><p>69</p><p>98</p><p>2.89</p><p>16.77</p><p>0.17</p><p>0.65</p><p>10</p><p>Wells et al.85 NT 92 57 2.12 0.14 10</p><p>Wolf et al.90 0.54</p><p>0.72</p><p>94</p><p>81</p><p>49</p><p>72</p><p>1.85</p><p>2.90</p><p>0.13</p><p>0.26</p><p>10</p><p>Moores et al.53 NT 83</p><p>19</p><p>40</p><p>91</p><p>1.38</p><p>2.1</p><p>0.43</p><p>0.89</p><p>8</p><p>Chagnon et al.13 0.43 73</p><p>14</p><p>69</p><p>99.5</p><p>2.39</p><p>28.2</p><p>0.39</p><p>0.86</p><p>7</p><p>Comment: Penaloza et al.60 provided a kappa statistic comparing reliability between physicians in training with supervising physicians.</p><p>Wolf et al.90 provided kappa statistics for trichotomized and dichotomized Wells criteria scoring respectively.The Moores et al.53</p><p>study was based on a retrospective chart analysis and provides two sets of numbers to rule out PE and to rule in PE respectively.</p><p>Chagnon et al.13 provided a kappa reliability statistic for a Geneva score vs. Wells criteria.</p><p>86 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TESTS FOR PULMONARY EMBOLISM</p><p>Geneva Criteria</p><p>1 Previous pulmonary embolism or deep vein thrombosis +2.0</p><p>2 Pulse greater than 100 +1.0</p><p>3 Recent surgery +3.0</p><p>4 Age (years)</p><p>60–79 +1.0</p><p>≥ 80 +2.0</p><p>5 PaCO2</p><p>65 +1</p><p>2 Known CAD with stenosis ≥ 50% +1</p><p>3 ASA use in past week +1</p><p>4 Severe angina with ≥ 2 episodes in 24 hours +1</p><p>5 ST changes ≥ 0.5mm +1</p><p>6 Have cardiac marker +1</p><p>7 ≥ 3 known cardiac risk factors +1</p><p>TIMI score is based on a 0–7 scale and can be risk stratified as 0–2 low risk, 3–4 intermediate risk, and 5–7 high</p><p>risk.</p><p>UTILITY SCORE 2</p><p>Major Criteria</p><p>1 Paroxysmal nocturnal dyspnea or orthopnea</p><p>2 Neck vein distention</p><p>3 Rales</p><p>4 Cardiomegaly</p><p>5 Acute pulmonary edema</p><p>6 S3 gallop</p><p>7 Hepatojugular reflex</p><p>Minor Criteria</p><p>1 Ankle edema</p><p>2 Nocturnal cough</p><p>3 Dyspnea on exertion</p><p>4 Hepatomegaly</p><p>5 Pleural effusion</p><p>6 Tachycardia (>120 bpm)</p><p>Diagnosis of heart failure is made by the presence of 2 major criteria or 1 major criteria with 2 minor criteria. The minor</p><p>criteria should not be able to be explained by an alternative diagnosis.</p><p>Framingham Criteria for Heart Failure</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 89</p><p>TESTS TO PREDICT FUTURE CARDIOPULMONARY EVENTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Antman et al.3</p><p>(outcome of all CV events)</p><p>NT 69</p><p>15</p><p>47</p><p>95</p><p>1.31</p><p>2.83</p><p>0.66</p><p>0.90</p><p>10</p><p>Antman et al.3</p><p>(outcome of mortality)</p><p>NT 85</p><p>33</p><p>32</p><p>88</p><p>1.25</p><p>2.78</p><p>0.48</p><p>0.76</p><p>10</p><p>Antman et al.3</p><p>(outcome of acute MI)</p><p>NT 84</p><p>29</p><p>33</p><p>88</p><p>1.25</p><p>2.47</p><p>0.48</p><p>0.81</p><p>10</p><p>Antman et al.3 (outcome of</p><p>revascularization)</p><p>NT 85</p><p>21</p><p>34</p><p>88</p><p>1.27</p><p>1.78</p><p>0.46</p><p>0.90</p><p>10</p><p>Antman et al.3 (outcome of</p><p>mortality & MI combined)</p><p>NT 83</p><p>29</p><p>33</p><p>89</p><p>1.24</p><p>2.49</p><p>0.50</p><p>0.81</p><p>10</p><p>Garcia et al.25 NT 76</p><p>27</p><p>71</p><p>99</p><p>2.62</p><p>30.0</p><p>0.33</p><p>0.74</p><p>10</p><p>Morrow et al.54 NT 94</p><p>46</p><p>16</p><p>72</p><p>1.12</p><p>1.65</p><p>0.36</p><p>0.75</p><p>9</p><p>Scirica et al.70</p><p>(6 week outcomes)</p><p>NT 69</p><p>23</p><p>44</p><p>90</p><p>1.23</p><p>2.31</p><p>0.70</p><p>0.85</p><p>8</p><p>Scirica et al.70</p><p>(1 year outcomes)</p><p>NT 71</p><p>24</p><p>45</p><p>91</p><p>1.29</p><p>2.67</p><p>0.64</p><p>0.84</p><p>8</p><p>Chase et al.14</p><p>(outcome is death)</p><p>NT 43</p><p>0</p><p>77</p><p>97</p><p>1.89</p><p>0.00</p><p>0.74</p><p>1.03</p><p>11</p><p>Chase et al.14 (outcome is</p><p>total serious event)</p><p>NT 54</p><p>12</p><p>80</p><p>98</p><p>2.76</p><p>5.90</p><p>0.57</p><p>0.90</p><p>11</p><p>Chase et al.14</p><p>(outcome is MI)</p><p>NT 49</p><p>2</p><p>79</p><p>97</p><p>2.29</p><p>0.67</p><p>0.65</p><p>1.01</p><p>11</p><p>Conway et al.19</p><p>(modified TIMI)</p><p>NT 55</p><p>15</p><p>73</p><p>97</p><p>2.02</p><p>5.21</p><p>0.62</p><p>0.88</p><p>10</p><p>Conway et al.19</p><p>(standard TIMI)</p><p>NT 72</p><p>26</p><p>72</p><p>97</p><p>2.58</p><p>7.97</p><p>0.39</p><p>0.77</p><p>10</p><p>Tong et al.78</p><p>(modified TIMI)</p><p>NT 62</p><p>6</p><p>63</p><p>95</p><p>1.67</p><p>1.30</p><p>0.61</p><p>0.99</p><p>12</p><p>Tong et al.78</p><p>(standard TIMI)</p><p>NT 83</p><p>37</p><p>61</p><p>92</p><p>2.14</p><p>4.74</p><p>0.29</p><p>0.69</p><p>12</p><p>Comments: Antman et al.3 provided data on two sets of subjects and they are combined in this table. The rows correspond to 14</p><p>day outcomes and, within each cell, calculations based on low-risk to rule-out and high-risk to rule-in events are provided respec-</p><p>tively.Garcia et al.25 stratified results by low, intermediate, and high risk categories and diagnostic accuracy values listed are for low</p><p>risk (ruling out) and high risk (ruling in) the conditions in question. Morrow et al.54 included the TIMI risk stratification to a group</p><p>of subjects receiving tirofiban and heparin therapy to reduce the risk of future coronary events. The first set of numbers are based</p><p>on the low risk category for ruling out potential future events and the second set are based on the high risk category for</p><p>ruling in</p><p>future coronary events. Scirica et al.70 data are for low risk (0–2) for ruling out CV events and high risk (5–7) for ruling in CV events</p><p>respectively. Scirica et al.70 did not provide raw data but these diagnostic accuracy values are estimates constructed from data on</p><p>bar charts in the text. Within each cell, Chase et al.14 based calculations on low-risk to rule-out and high-risk to rule-in events</p><p>respectively. Both Conway et al.19 and Tong et al.78 used two versions of the TIMI score including a modified version (mTIMI) that</p><p>did not include the cardiac marker (Troponin I: because it takes time to get back the lab results). Within each cell, calculations</p><p>based on low-risk to rule-out and high-risk to rule-in events are provided respectively.</p><p>UTILITY SCORE 1</p><p>90 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TESTS TO PREDICT FUTURE CARDIOPULMONARY EVENTS</p><p>1 Age: > 67 +1</p><p>2 IDDM +2</p><p>3 Chest pain score ≥ 10 points +1</p><p>4 ≥ 2 chest pain episodes in past 24 hours +1</p><p>5 Prior PTCA +1</p><p>Risk Score is based on a 0–6 scale and can be risk stratified as very low risk 0, low risk 1, intermediate risk 2,</p><p>high risk 3, and very high risk ≥ 4.</p><p>Risk Score for Acute Coronary Syndromes</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Sanchis et al.69 (risk score ≤ 1 to rule out) NT 86 50 1.72 0.28 8</p><p>Sanchis et al.69 (risk score ≥ 3 to rule in) NT 19 97 5.64 0.84 8</p><p>Sanchis et al.69 (risk score ≥ 4 to rule in) NT 61 83 3.48 0.48 8</p><p>Comments: Sanchis et al.69 provided data on risk of death and MI at 12 month follow-up for each risk level. It can be seen that diag-</p><p>nostic accuracy has a higher LR+ for ruling in at the higher risk cutoff.</p><p>1 Treadmill exercise protocol involves minute recordings of heart rate and blood pressure. ST</p><p>depression during exercise was recorded to the nearest 25 mm. Angina was recorded as</p><p>0 = none, 1 = nonlimiting, and 2 = exercise limiting.</p><p>2 Exercise is stopped if exertional hypotension, malignant ventricular arrhythmias, ST depression</p><p>of ≥ 3mm, or exercise limiting chest pain is present.</p><p>3 Exercise time (min) − (5 × ST segment deviation) − (4 × exercise angina)</p><p>4 Scores of ≥ 5 are considered low risk, +4 to −10 are moderate risk, and ≤ −11 are high risk. The</p><p>usual range is between −25 to +15.</p><p>Duke Treadmill Score for Identifying Risk of Ischaemic Heart Disease</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 91</p><p>TESTS TO PREDICT FUTURE CARDIOPULMONARY EVENTS</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Shaw et al.71 outcome = death NT 88</p><p>34</p><p>39</p><p>93</p><p>1.44</p><p>5.11</p><p>0.30</p><p>0.71</p><p>12</p><p>Shaw et al.71 [severe CAD (3 vessels ≥</p><p>75% blockage)]</p><p>NT 87</p><p>25</p><p>45</p><p>97</p><p>1.57</p><p>7.35</p><p>0.29</p><p>0.78</p><p>12</p><p>Shaw et al.71 [significant CAD (at least</p><p>1 vessel ≥ 75% blockage)]</p><p>NT 67</p><p>7</p><p>38</p><p>90</p><p>1.08</p><p>0.68</p><p>0.87</p><p>1.04</p><p>12</p><p>Shaw et al.71 [no significant CAD(no</p><p>vessel ≥ 75% blocked)]</p><p>NT 76</p><p>15</p><p>55</p><p>99.9</p><p>1.67</p><p>152.0</p><p>0.44</p><p>0.85</p><p>12</p><p>Mark et al.42 NT 89</p><p>32</p><p>45</p><p>94</p><p>1.61</p><p>5.44</p><p>0.24</p><p>0.72</p><p>10</p><p>Marwick et al.44 NT 64</p><p>5</p><p>62</p><p>98</p><p>1.67</p><p>2.94</p><p>0.58</p><p>0.97</p><p>10</p><p>Comments: Shaw et al.’s71 results are presented as ruling out the condition with low risk and ruling in the condition with high risk</p><p>scores respectively. Mark et al.42 measured mortality at 4 years post treadmill testing. Marwick et al.44 reported total mortality at</p><p>5 years post treadmill testing. The authors acknowledge that increasing age alters relative risk of death (they should be credited for</p><p>this); however, they do no not report how many subjects in the study were elderly, making independent assessment of the possible</p><p>effects on the results impossible.</p><p>Clinical Prediction Rule to Identify Individuals with Low Risk of Stroke</p><p>from Atrial Fibrillation while Taking Aspirin</p><p>1 If the patient has nonvalvular atrial fibrillation and:</p><p>2 Has no previous history of stroke or transient ischemic attack,</p><p>3 Has no history of treated hypertension or systolic blood pressure ≥ 140 mmHg,</p><p>4 Has no history of myocardial infarction or angina,</p><p>5 Does not have Diabetes;</p><p>6 If all conditions are met, the patient can use daily aspirin rather than oral anticoagulants to</p><p>minimize potential cerebral events.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>van Walraven et al.80 NT 91 NT NT NT NT</p><p>Comments: van Walraven et al.80 did not provide sufficient detail to determine all diagnostic accuracy values. The authors did report</p><p>that in the low risk group, observed event rate was 1.1 per 100 patient years vs. 4.2 per 100 patient years for the moderate to high</p><p>risk groups.</p><p>92 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TESTS TO PREDICT FUTURE CARDIOPULMONARY EVENTS</p><p>Ankle-Brachial Index for Predicting Coronary Artery Disease</p><p>1 The patient lies supine for at least 5–10 minutes to achieve a resting state.</p><p>2 The systolic blood pressure is taken in each arm and each leg. The lower extremity pressures</p><p>may be taken at either the dorsalispedis or posterior tibial arteries.</p><p>3 The patient should have no history of treated hypertension or systolic blood pressure ≥ 140 mmHg.</p><p>4 The ABI calculation is the ratio of the lower extremity systolic pressure divided by the brachial</p><p>systolic pressure.</p><p>5 The method of determining the systolic pressures used has some variability depending on the</p><p>source referenced. Some use the higher value of each arm and each leg, others have used the</p><p>mean values of the arms and legs. Others have calculated the ratio of one side compared with</p><p>the other to determine if asymmetrical disease processes may exist.</p><p>6 An ABI cutoff value may be used to predict future cardiovascular event including mortality, or</p><p>stratified values may be employed to determine the severity of the disease process. The most</p><p>frequent value cited is ≥ 0.90 for predictive purposes. Values between ≥ 1.2 and ≥ 1.5 have</p><p>been used to exclude patients from a diagnostic accuracy study based on the belief that these</p><p>are non-compressible veins due to atherosclerotic disease and represent false negatives. This</p><p>strategy has been inconsistently done and may alter the values calculated.</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Doobay & Anand21 NT 17 93 2.26 0.90 NA</p><p>Resnick et al.65 NT 18 96 4.21 0.86 10</p><p>Leng et al.39 NT 27 82 1.51 0.89 9</p><p>Otah et al.58 (no CAD) NT 62 94 10.28 0.41 12</p><p>Otah et al.58 (significant</p><p>CAD)</p><p>NT 86 81 4.39 0.18 12</p><p>Comments: Doobay & Anand21 is a systematic review of diagnostic accuracy studies; therefore, the QUADAS assessment is not</p><p>applicable to this study. Otah et al.58 studied African-Americans exclusively, limiting generalizability of results to other populations.</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 93</p><p>TESTS TO PREDICT FUTURE CARDIOPULMONARY EVENTS</p><p>Ankle-Brachial Index for Predicting Stroke</p><p>1 The patient lies supine for at least 5–10 minutes to achieve a resting state.</p><p>2 The systolic blood pressure is taken in each arm and each leg. The lower extremity pressures</p><p>may be taken at either the dorsalispedis or posterior tibial arteries.</p><p>3 The patient should have no history of treated hypertension or systolic blood pressure ≥ 140 mmHg.</p><p>4 The ABI calculation is the ratio of the lower extremity systolic pressure divided by the brachial</p><p>systolic pressure.</p><p>5 The method of determining the systolic pressures used has some variability depending on the</p><p>source referenced. Some use the higher value of each arm and each leg, others have used the</p><p>mean values of the arms and legs. Others have calculated the ratio of one side compared with</p><p>the other to determine if asymmetrical disease processes may exist.</p><p>6 An ABI cutoff value may be used to predict future cardiovascular event including mortality, or</p><p>stratified values may be employed to determine the severity of the disease process. The most</p><p>frequent value cited is ≥ 0.90 for predictive purposes. Values between ≥ 1.2 and ≥ 1.5 have</p><p>been used to exclude patients from a</p><p>diagnostic accuracy study based on the belief that these</p><p>are non-compressible veins due to atherosclerotic disease and represent false negatives. This</p><p>strategy has been inconsistently done and may alter the values calculated.</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Doobay & Anand21 NT 16 92 2.05 0.91 NA</p><p>Leng et al.39 NT 29 82 1.59 0.87 9</p><p>Koh et al.35 NT 10 97 3.64 0.92 9</p><p>Newman et al.55</p><p>(history of CAD)</p><p>NT 29 76 1.19 0.94 8</p><p>Newman et al.55</p><p>(no history of CAD)</p><p>NT 17 91 1.85 0.91 8</p><p>Newman et al.55</p><p>(all subjects combined)</p><p>NT 21 87 1.63 0.91 8</p><p>Comments: Doobay & Anand21 is a systematic review of diagnostic accuracy studies; therefore, the QUADAS assessment is not</p><p>applicable to this study.</p><p>94 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TESTS TO PREDICT FUTURE CARDIOPULMONARY EVENTS</p><p>1 The patient lies supine for at least 5–10 minutes to achieve</p><p>a resting state.</p><p>2 The systolic blood pressure is taken in each arm and each</p><p>leg. The lower extremity pressures may be taken at either</p><p>the dorsalispedis or posterior tibial arteries.</p><p>3 The patient should have no history of treated hypertension</p><p>or systolic blood pressure ≥ 140 mmHg.</p><p>4 The ABI calculation is the ratio of the lower extremity sys-</p><p>tolic pressure divided by the brachial systolic pressure.</p><p>5 The method of determining the systolic pressures used has</p><p>some variability depending on the source referenced. Some</p><p>use the higher value of each arm and each leg, others have</p><p>used the mean values of the arms and legs. Others have</p><p>calculated the ratio of one side compared with the other to</p><p>determine if asymmetrical disease processes may exist.</p><p>6 An ABI cutoff value may be used to predict future cardio-</p><p>vascular event including mortality, or stratified values may</p><p>be employed to determine the severity of the disease pro-</p><p>cess. The most frequent value cited is ≥ 0.90 for predictive</p><p>purposes. Values between ≥ 1.2 and ≥ 1.5 have been used</p><p>to exclude patients from a diagnostic accuracy study based</p><p>on the belief that these are non-compressible veins due to</p><p>atherosclerotic disease and represent false negatives. This</p><p>strategy has been inconsistently done and may alter the</p><p>values calculated.</p><p>Ankle-Brachial Index for Predicting any Cardiovascular Event</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Doobay et al.21 NT 17 93 2.26 0.90 NA</p><p>Wild et al.88 NT 24 88 1.89 0.81 9</p><p>Leng et al.39 NT 32 84 1.99 0.81 9</p><p>Newman et al.55 (history of CAD) NT 35 88 2.88 0.74 9</p><p>Newman et al.55 (no history of CAD) NT 15 93 2.23 0.91 9</p><p>Newman et al.55 (all subjects combined) NT 21 92 2.83 0.85 9</p><p>Hooi et al.31 NT 24 91 2.53 0.84 9</p><p>Comments: Doobay et al.21 is a systematic review of diagnostic accuracy studies; therefore, the QUADAS assessment is not appli-</p><p>cable to this study.</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 95</p><p>TESTS TO PREDICT FUTURE CARDIOPULMONARY EVENTS</p><p>Ankle-Brachial Index for Predicting Peripheral Artery Disease</p><p>1 The patient lies supine for at least 5–10 minutes to achieve</p><p>a resting state.</p><p>2 The systolic blood pressure is taken in each arm and each</p><p>leg. The lower extremity pressures may be taken at either</p><p>the dorsalispedis or posterior tibial arteries.</p><p>3 The patient should have no history of treated hypertension</p><p>or systolic blood pressure ≥ 140 mmHg.</p><p>4 The ABI calculation is the ratio of the lower extrem-</p><p>ity systolic pressure divided by the brachial systolic</p><p>pressure.</p><p>5 The method of determining the systolic pressures used</p><p>has some variability depending on the source referenced.</p><p>Some use the higher value of each arm and each leg, oth-</p><p>ers have used the mean values of the arms and legs. Others</p><p>have calculated the ratio of one side compared with the</p><p>other to determine if asymmetrical disease processes may</p><p>exist.</p><p>6 An ABI cutoff value may be used to predict future cardio-</p><p>vascular event including mortality, or stratified values may</p><p>be employed to determine the severity of the disease pro-</p><p>cess. The most frequent value cited is ≥ 0.90 for predictive</p><p>purposes. Values between ≥ 1.2 and ≥ 1.5 have been used</p><p>to exclude patients from a diagnostic accuracy study based</p><p>on the belief that these are non-compressible veins due to</p><p>atherosclerotic disease and represent false negatives. This</p><p>strategy has been inconsistently done and may alter the</p><p>values calculated.</p><p>(continued)</p><p>96 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TESTS TO PREDICT FUTURE CARDIOPULMONARY EVENTS</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Newman et al.55(history of CAD) NT 56 76 2.39 0.57 9</p><p>Newman et al.55(no history of CAD) NT 43 91 4.71 0.63 9</p><p>Newman et al.55(all subjects combined) NT 49 87 3.87 0.58 9</p><p>Hooi et al.31 NT 52 89 4.53 0.55 9</p><p>Guo et al.27 (ABI cutoff = 1.12) NT 100 40 1.67 0.0 12</p><p>Guo et al.27 (ABI cutoff = 0.95) NT 91 86 6.50 0.1 12</p><p>Guo et al.27 (ABI cutoff = 0.90) NT 76 90 7.60 0.27 12</p><p>Guo et al.27 (ABI cutoff = 0.53) NT 14 100 0.14 0.86 12</p><p>Holland-Letz et al.29 0.42 NT NT NT NT NA</p><p>Mätzke et al.45 0.02</p><p>16% > 0.15</p><p>NT NT NT NT NA</p><p>Comments: Guo et al.27 excluded patients with non-compressible vessels (ABI ≥ 1.40). Holland-Letz et al.29 calculated a total</p><p>variance intraclass correlation coefficient (ICC) based on measurements taken by vascular experts, family physicians, and nurses.</p><p>Mätzke et al.45 only examined the reproducibility of ABI and found a median difference of 0.02 when two experienced vascular</p><p>nurses performed ABI testing. They also found that overall 16% of ABI measurements differed by > 0.15 (accepted critical value</p><p>of measurement error).</p><p>1 The patient lies supine for at least 5–10 minutes to achieve a resting state.</p><p>2 The systolic blood pressure is taken in each arm and each leg. The lower extremity pressures</p><p>may be taken at either the dorsalispedis or posterior tibial arteries.</p><p>3 The patient should have no history of treated hypertension or systolic blood pressure ≥ 140 mmHg.</p><p>4 The ABI calculation is the ratio of the lower extremity systolic pressure divided by the brachial</p><p>systolic pressure.</p><p>5 The method of determining the systolic pressures used has some variability depending on the</p><p>source referenced. Some use the higher value of each arm and each leg, others have used the</p><p>mean values of the arms and legs. Others have calculated the ratio of one side compared with</p><p>the other to determine if asymmetrical disease processes may exist.</p><p>6 An ABI cutoff value may be used to predict future cardiovascular event including mortality, or</p><p>stratified values may be employed to determine the severity of the disease process. The most</p><p>frequent value cited is ≥ 0.90 for predictive purposes. Values between ≥ 1.2 and ≥ 1.5 have</p><p>been used to exclude patients from a diagnostic accuracy study based on the belief that these</p><p>are non-compressible veins due to atherosclerotic disease and represent false negatives. This</p><p>strategy has been inconsistently performed and may alter the values calculated.</p><p>Ankle-Brachial Index for Predicting Cardiovascular Mortality</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 97</p><p>TESTS TO PREDICT FUTURE CARDIOPULMONARY EVENTS</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Doobay & Anand21 NT 41 88 3.39 0.67 NA</p><p>Leng et al.39 NT 38 83 2.25 0.74 9</p><p>Wild et al.88 NT 31 85 2.08 0.81 9</p><p>Newman et al.55 (history of CAD) NT 64 77 2.78 0.47 9</p><p>Newman et al.55 (no history of CAD) NT 30 91 3.24 0.78 9</p><p>Newman et al.55 (all subjects</p><p>combined)</p><p>NT 36 88 3.00 0.73 9</p><p>Hooi et al.31 NT 32 89 2.79 0.77 9</p><p>Resnick et al.65 (ABI cutoff 1.40)</p><p>NT 34 87 2.62 0.76 10</p><p>Comments: Doobay & Anand21 is a systematic review of diagnostic accuracy studies; therefore, the QUADAS assessment is not</p><p>applicable to this study. Hooi et al.31 used an ABI value of ≤ 0.95 as their cutoff for measuring disease. Most</p><p>studies exclude subjects</p><p>with ABI > 1.40 but Resnick et al.65 included them for analysis.</p><p>Ankle-Brachial Index for Predicting Total Mortality</p><p>1 The patient lies supine for at least 5–10 minutes to achieve a resting state.</p><p>2 The systolic blood pressure is taken in each arm and each leg. The lower extremity pressures</p><p>may be taken at either the dorsalispedis or posterior tibial arteries.</p><p>3 The patient should have no history of treated hypertension or systolic blood pressure ≥ 140 mmHg.</p><p>4 The ABI calculation is the ratio of the lower extremity systolic pressure divided by the brachial</p><p>systolic pressure.</p><p>5 The method of determining the systolic pressures used has some variability depending on the</p><p>source referenced. Some use the higher value of each arm and each leg, others have used the</p><p>mean values of the arms and legs. Others have calculated the ratio of one side compared with</p><p>the other to determine if asymmetrical disease processes may exist.</p><p>6 An ABI cutoff value may be used to predict future cardiovascular event including mortality, or</p><p>stratified values may be employed to determine the severity of the disease process. The most</p><p>frequent value cited is ≥ 0.90 for predictive purposes. Values between ≥ 1.2 and ≥ 1.5 have</p><p>been used to exclude patients from a diagnostic accuracy study based on the belief that these</p><p>are non-compressible veins due to atherosclerotic disease and represent false negatives. This</p><p>strategy has been inconsistently done and may alter the values calculated.</p><p>(continued)</p><p>98 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>TESTS TO PREDICT FUTURE CARDIOPULMONARY EVENTS</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Doobay & Anand21 NT 31 89 2.81 0.77 NA</p><p>Leng et al.39 NT 31 84 1.92 0.82 9</p><p>Wild et al.88 NT 26 87 2.05 0.85 9</p><p>Newman et al.55 (history of CAD) NT 44 77 1.91 0.73 9</p><p>Newman et al.55 (no history of CAD) NT 24 92 3.00 0.83 9</p><p>Newman et al.55 (all subjects combined) NT 28 89 2.52 0.81 9</p><p>Hooi et al.31 NT 27 90 2.52 0.82 9</p><p>Resnick et al.65 (ABI cutoff 1.40)</p><p>NT 51 91 5.60 0.54 10</p><p>Comments: Doobay & Anand21 is a systematic review of diagnostic accuracy studies; therefore, the QUADAS assessment is not</p><p>applicable to this study. Hooi et al.31 used an ABI value of ≤ 0.95 as their cutoff for measuring disease. Most studies exclude subjects</p><p>with ABI > 1.40 but Resnick et al.65 included them for analysis.</p><p>1 The patient lies supine for at least 5–10 minutes to achieve a resting state.</p><p>2 The systolic blood pressure is taken in each arm and each leg. The lower extremity pressures</p><p>may be taken at either the dorsalispedis or posterior tibial arteries.</p><p>3 The patient should have no history of treated hypertension or systolic blood pressure ≥ 140 mmHg.</p><p>4 The ABI calculation is the ratio of the lower extremity systolic pressure divided by the brachial</p><p>systolic pressure.</p><p>5 The method of determining the systolic pressures used has some variability depending on the</p><p>source referenced. Some use the higher value of each arm and each leg, others have used the</p><p>mean values of the arms and legs. Others have calculated the ratio of one side compared with</p><p>the other to determine if asymmetrical disease processes may exist.</p><p>6 An ABI cutoff value may be used to predict future cardiovascular event including mortality, or</p><p>stratified values may be employed to determine the severity of the disease process. The most</p><p>frequent value cited is ≥ 0.90 for predictive purposes. Values between ≥ 1.2 and ≥ 1.5 have</p><p>been used to exclude patients from a diagnostic accuracy study based on the belief that these</p><p>are non-compressible veins due to atherosclerotic disease and represent false negatives. This</p><p>strategy has been inconsistently done and may alter the values calculated.</p><p>Ankle-Brachial Index for Predicting Functional Deficits</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 99</p><p>TESTS TO PREDICT FUTURE CARDIOPULMONARY EVENTS</p><p>Key Points</p><p>1. Screening tools used for identifying cardiopulmo-</p><p>nary disease processes have variable levels of diag-</p><p>nostic accuracy. Depending on the study, most</p><p>of the values calculated would provide small to</p><p>moderate shifts in posttest probability.</p><p>2. It would appear that most of the tools have cutoff</p><p>scores that can be adjusted to enhance ruling out</p><p>or ruling in potential disease.</p><p>3. Confounding variables (such as age) may reduce</p><p>the diagnostic accuracy of some of the screening</p><p>tools.</p><p>4. Physical examination techniques, such as the ABI,</p><p>may have diagnostic accuracy compromised by</p><p>variability of experience of the examiner.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>McDermott et al.47 (exertional leg pain) NT 36 66 1.04 0.98 9</p><p>McDermott et al.47 (difficulty walking</p><p>¼ mile)</p><p>NT 35 83 2.00 0.79 9</p><p>McDermott et al.47 (difficulty climbing</p><p>10 steps)</p><p>NT 35 75 1.37 0.87 9</p><p>McDermott et al.48 NT 29 92 3.49 0.77 9</p><p>Comments: The diagnostic accuracy values found by McDermott et al.47suggest that the ABI does not predict functional deficits</p><p>particularly well, indicating that other co-morbidities may play a role in this relationship as confounder variables. McDermott et al.48</p><p>provided a bar chart, which served as estimates for the calculations presented.</p><p>100 CHAPTER 3 Physical Examination Tests for Medical Screening</p><p>Male Osteoporosis Risk Estimation Score (MORES)</p><p>Criteria for Bone Densitometry in Men</p><p>1 Age:</p><p>≥ 75 +4</p><p>56–74 +3</p><p>≤ 55 +0</p><p>2 Weight:</p><p>> 80 kg +0</p><p>70−80 kg +4</p><p>≤ 70 kg +6</p><p>3 Chronic obstructive pulmonary disease +3</p><p>MORES scoring: score ≥ 6, DEXA scanning is recommended.</p><p>TESTS TO DETERMINE NEED FOR BONE MINERAL DENSITOMETRY</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Shepherd et al.72 NT 91</p><p>95</p><p>93</p><p>58</p><p>61</p><p>59</p><p>2.17</p><p>2.44</p><p>2.27</p><p>0.16</p><p>0.08</p><p>0.12</p><p>10</p><p>Comments: Shepherd et al.72 used National Health and Nutrition Examination Survey III data and separated these data (as reported</p><p>above) into developmental, validation, and overall data sets respectively.</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 101</p><p>TESTS TO DETERMINE NEED FOR BONE MINERAL DENSITOMETRY</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Koh et al.35 NT 90 29 2.44 0.08 11</p><p>Rud et al.68 NT 92 71 3.17 0.11 9</p><p>Geusens et al.26 NT 88 52 1.83 0.30 9</p><p>Fujiwara et al.24 NT 87 43 1.53 0.23 9</p><p>Martinez-Aguila et al.43 NT 69 59 1.68 0.52 9</p><p>Richy et al.66 NT 97 34 1.47 0.09 10</p><p>Comments: Rud et al.68, Geusens et al.26, and Richy et al.66 used ≤ 2 as their cut-off score. Fujiwara et al.24 refers to this test as</p><p>FOSTA.</p><p>Osteoporosis Risk Assessment Instrument (ORAI)</p><p>Criteria for Bone Densitometry</p><p>1 Age:</p><p>≥ 75 +15</p><p>65−74 +9</p><p>55−64 +5</p><p>2 Weight:</p><p>et al.24 NT 89 39 1.46 0.28 9</p><p>Comments: Mauck et al.46 calculated diagnostic accuracy under three separate conditions in the order presented above: overall,</p><p>ages 45–64 years, and ages 65 years and older. Cadarette et al.9 calculated diagnostic accuracy off two separate samples including: *</p><p>a developmental cohort of 924 women and ** a validation cohort of 450 women. Fujiwara et al.24 used 65 +1</p><p>2 Patient weight is</p><p>the greatest tenderness from the</p><p>physical examination.</p><p>2 The examiner then queries the patient for change in per-</p><p>ceived pain level.</p><p>3 A positive test is determined when the perceived pain level</p><p>increases from application of the tuning fork.</p><p>Tuning Fork Test for Fracture Assessment</p><p>UTILITY SCORE 2</p><p>CHAPTER 3 Physical Examination Tests for Medical Screening 109</p><p>References</p><p>1. Alvarado A. A practical score for the early diagnosis of</p><p>acute appendicitis. Ann Emerg Med. 1986;15:557–564.</p><p>2. Anderson DR, Kovacs MJ, Kovacs G, et al. Combined</p><p>use of clinical assessment and D-dimer to improve</p><p>the management of patients presenting to the</p><p>emergency department with suspected deep vein</p><p>thrombosis (the edited study). J Thromb Haemost.</p><p>2003;1:645–651.</p><p>3. Antman EM, Cohen M, Bernink PJ, et al. 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Many of the studies available are fairly old and are</p><p>not well designed (or at least lack the description</p><p>necessary to evaluate them as being well done).</p><p>3. Reliability of these techniques and variation in</p><p>their description (or a lack of sufficient descrip-</p><p>tion) make it difficult to strongly recommend their</p><p>use. The pretest probability of visceral involve-</p><p>ment should be high based on other clinical fea-</p><p>tures in order to enhance the posttest probability</p><p>of visceral diagnosis.</p><p>4. The use of the tuning fork to assist in clinical</p><p>assessment of potential fractures has not been</p><p>well studied to date.</p><p>5. 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Ann Emerg Med.</p><p>2004;44:503–510.</p><p>91. Zhang B, Lewis SM. A study of the reliability of</p><p>clinical palpation of the spleen. Clin Lab Haematol.</p><p>1989;11:7–10.</p><p>Use this address to access the Companion Website created for this textbook. Simply select “Physical Therapy” from the</p><p>choice of disciplines. Find this book and log in using your username and password to access video clips of selected tests.</p><p>PEARSON</p><p>113</p><p>Physical Examination</p><p>Tests for the Cervical</p><p>Spine</p><p>Chad E. Cook</p><p>Index of Tests</p><p>Tests for Cervical Radiculopathy 115</p><p>Spurling’s Compression Test 115</p><p>Valsalva Maneuver 116</p><p>Brachial Plexus Compression Test 116</p><p>Cervical Hyperflexion Test 117</p><p>Cervical Distraction Test 117</p><p>Upper Limb Tension Test (ULTT) 118</p><p>Cervical Hyperextension (Jackson’s Test) 119</p><p>Shoulder Abduction Test 119</p><p>Quadrant Test 120</p><p>Cervical Compression Test 120</p><p>Wainner’s Clinical Prediction Rule</p><p>for Cervical Radiculopathy 121</p><p>Tests for Upper Cervical Instability 122</p><p>Modified Sharp Purser Test 122</p><p>Alar Ligament Stability Test 123</p><p>Upper Cervical Flexion Test 124</p><p>Original Sharp Purser Test 125</p><p>Anterior Stability Test</p><p>of the Atlanto-Occipital Joint 125</p><p>Direct Anterior Translation Stress Test 126</p><p>Lateral Shear Test of the Atlanto-Axial</p><p>Articulation 126</p><p>Tectorial Membrane Test 127</p><p>Posterior Atlanto-Occipital</p><p>Membrane Test 127</p><p>Tests for Mid-Cervical Instability 128</p><p>AP and PA Stress Testing of the</p><p>Mid-Cervical Spine 128</p><p>Lateral Stress Testing of the Mid-Cervical</p><p>Spine 128</p><p>Tests for Potential Vertebral Artery Dysfunction 129</p><p>Vertebral Basilar Insufficiency</p><p>(VBI) Test 129</p><p>Wallenberg’s Position</p><p>(Extension and Rotation) 130</p><p>Tests for Cervicogenic Headache 131</p><p>Cervical-Flexion Rotation Test 131 C0–1, C1–2, C2–3 Joint Mobility</p><p>Assessment 132</p><p>CHAPTER</p><p>4</p><p>114 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>Tests for Postural Dysfunction 133</p><p>Neck Flexor Muscle Endurance Test 133</p><p>Scapular Muscle Endurance Test 134</p><p>Posterior Extensors Endurance Test 134</p><p>Tests for Level of Dysfunction or Linear Stability 135</p><p>Posterior-Anterior Mobilization Test 135 Palpation of Physiological Movement 136</p><p>Tests to Identify Neck Pain from Asymptomatic Conditions 137</p><p>Manual Examination of Rotation 137 Combined Manual Rotation</p><p>and a Visual Analog Scale 137</p><p>Tests to Determine if a Radiograph Is Required 138</p><p>Canadian C-Spine Rules 138 Nexus (National Emergency</p><p>X-Radiography Utilization Study) 138</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 115</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>1 The patient assumes a neutral cervical posture while in</p><p>sitting position. Assess resting symptoms.</p><p>2 The patient is instructed to side flex his or her head to the</p><p>side of his or her referred symptoms. If radicular pain is</p><p>present, the test is positive.</p><p>3 If no symptoms up to this point, the examiner then applies</p><p>a combined compression and side flexion force in the</p><p>direction of side flexion. If radicular pain is present, the</p><p>test is positive.</p><p>Spurling’s Compression Test</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Bertilson et al.2 .14 to .28</p><p>kappa</p><p>NT NT NA NA NA</p><p>Spurling & Scoville25 NT 100 NT NA NA 4</p><p>Uchihara et al.29 NT 11 100 NA NA 8</p><p>Tong et al.28 NT 30 93 4.3 .75 9</p><p>Shah & Rajshekhar22 NT 93 95 18.6 0.07 9</p><p>Wainner et al.33 .60 kappa 50 86 3.57 0.58 10</p><p>Wainner et al.33 (included side flexion</p><p>toward the rotation and extension)</p><p>.62 kappa 50 74 1.92 0.67 10</p><p>Viikari-Juntura et al.32 (right side) NT 36 92 4.5 0.69 11</p><p>Viikari-Juntura et al.32 (left side) NT 39 92 4.87 0.66 11</p><p>Sandmark & Nisell21 (not for</p><p>radiculopathy)</p><p>NT 77 92 9.62 0.25 9</p><p>DeHertogh et al.6 NT 77.8 77.3 3.4 0.28 9</p><p>Comments: The Spurling’s maneuver appears to be specific but not sensitive and would not function well as a screen. Some have</p><p>described the test by including ipsilateral rotation with side flexion while others have included extension. DeHertogh et al. used a</p><p>case control design to identify neck pain versus no neck pain. The description provided is the original description from Spurling &</p><p>Scoville.25</p><p>UTILITY SCORE 2</p><p>116 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>Valsalva Maneuver</p><p>1 The patient assumes a sitting position.</p><p>2 The patient is instructed to hold his or her breath then</p><p>“bear down” as in performing a toileting procedure.</p><p>3 Reproduction of concordant pain during bearing down is</p><p>considered a positive response.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Wainner et al.33 .69 kappa 22 94 3.67 0.82 10</p><p>Comments: The test appears to be moderately reliable and specific for patients with cervical radiculopathy. The test should not be</p><p>used as a screen.</p><p>Brachial Plexus Compression Test</p><p>UTILITY SCORE 2</p><p>1 The patient assumes a sitting position.</p><p>2 The examiner applies a compressive force with his or her</p><p>hand, just above the clavicle on the symptomatic side.</p><p>3 Special effort to apply compression lateral to the scalenes</p><p>is made to apply traction to the nerve bundle.</p><p>4 A positive test is reproduction of radicular symptoms.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Uchihara et al.29 NT 69 83 4.1 0.37 8</p><p>Comments: The test mimics those of thoracic outlet syndrome. It is doubtful that the test could discriminate between cervical</p><p>radiculopathy and thoracic outlet syndrome, and may demonstrate false positives if localized pain only is queried.</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 117</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>Cervical Hyperflexion Test</p><p>1 The patient assumes a sitting position.</p><p>2 The patient is instructed to flex his or her neck to the first</p><p>point of pain. If no pain, the patient is instructed to flex</p><p>toward end range.</p><p>3 Reproduction of radicular symptoms during hyperflexion</p><p>is considered a positive response.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Uchihara et al.29 NT 8 100 NA NA 8</p><p>Wainner et al.33</p><p>(limited</p><p>0.27 10</p><p>Comments: The dramatic differences in values are unexplained. Wainner et al.33 provided better methodology for their study and</p><p>the results are likely more transferable to a population with cervical radiculopathy.</p><p>Cervical Distraction Test</p><p>UTILITY SCORE 2</p><p>1 The patient assumes a supine position. The patient’s symp-</p><p>toms require assessment prior to the examination.</p><p>2 The examiner uses a chin cradle grip around the head of the</p><p>patient, specifically targeting the occipital shelf of the neck.</p><p>3 A traction force is applied and the patient’s symptoms</p><p>are reassessed. Pain is respected and the same pattern of</p><p>movement to pain, movement beyond pain, and repeated</p><p>movement should be implemented.</p><p>4 A positive test is reduction of symptoms during traction.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Bertilson et al.2 .63 to .43 kappa NT NT NA NA NA</p><p>Wainner et al.33 .88 kappa 44 90 4.4 0.62 10</p><p>Viikari-Juntura et al.32 NT 40 100 NA NA 11</p><p>Comments: Though only moderate, this test provides one of the best diagnostic scores of the tests for cervical radiculopathy. The</p><p>test is highly specific for cervical radiculopathy.</p><p>118 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>Upper Limb Tension Test (ULTT)</p><p>1 The patient assumes a supine position. The examiner</p><p>assesses resting symptoms.</p><p>2 The examiner blocks the shoulder girdle to stabilize the</p><p>scapulae. Symptoms are again assessed.</p><p>3 If no reproduction of symptoms has occurred, the gle-</p><p>nohumeral joint is abducted to 110 degrees with slight</p><p>coronal plane extension. Symptoms are again assessed.</p><p>4 If no reproduction of symptoms has occurred, the fore-</p><p>arm is supinated completely and the wrist and fingers are</p><p>extended. Ulnar deviation is implemented. Symptoms are</p><p>again assessed.</p><p>5 If no reproduction of symptoms has occurred, elbow</p><p>extension is applied. Symptoms are again assessed. One</p><p>may measure the degree of elbow extension if range of</p><p>motion is an objective.</p><p>6 Lateral flexion of the neck is used to sensitize the proce-</p><p>dure. A positive test is reproduction of symptoms during</p><p>distal movement.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Wainner et al.33</p><p>(median nerve bias)</p><p>.76 kappa 97 22 1.24 .14 10</p><p>Wainner et al.33</p><p>(radial nerve bias)</p><p>.83 kappa 72 33 1.07 .84 10</p><p>Bertilson et al.2</p><p>(median nerve bias)</p><p>.03 kappa NT NT NA NA NA</p><p>Bertilson et al.2</p><p>(radial nerve bias)</p><p>.11 kappa NT NT NA NA NA</p><p>Bertilson et al.2</p><p>(ulnar nerve bias)</p><p>NT NT NT NA NA NA</p><p>Sandmark &</p><p>Nisell21 (not for</p><p>radiculopathy)</p><p>NT 77 94 12.8 .24 9</p><p>Comments: This sensitive test is most likely associated with a number of dysfunctions. Studies have supported that a positive ULTT</p><p>is not specific to a selected disorder secondary to anatomical considerations. To increase the specificity of the test, one should look</p><p>for concordant symptoms, sensitization, and asymmetry from side to side. The test should be considered an excellent screen for</p><p>radiculopathy as a negative finding is compelling toward the lack of existence of radiculopathy.</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 119</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>Cervical Hyperextension (Jackson’s Test)</p><p>1 The patient assumes a sitting position.</p><p>2 The patient is instructed to extend his or her neck to the</p><p>first point of pain. If no pain, the patient is instructed to</p><p>extend toward end range.</p><p>3 Reproduction of symptoms is considered a positive</p><p>response.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Uchihara et al.29 NT 25 90 2.5 0.83 8</p><p>Sandmark & Nisell21</p><p>(not for radiculopathy)</p><p>NT 27 90 2.7 0.81 9</p><p>Comments: Although the test is specific, the examiner would be best served to differentiate localized pain compared to radicular</p><p>symptoms.</p><p>Shoulder Abduction Test</p><p>1 The patient assumes a sitting position. The examiner</p><p>assesses resting symptoms.</p><p>2 The patient actively places his or her hand on top of his or</p><p>her head. The examiner then determines the presence or</p><p>absence of the symptoms. It is unlikely that causative level of</p><p>the cervical radiculopathy can be discriminated with this test.</p><p>3 A positive test is identified by reduction of the patient’s</p><p>concordant pain.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Davidson et al.5 NT 68 NT NA NA 8</p><p>Wainner et al.33 .20 kappa 17 92 2.12 0.90 10</p><p>Viikari-Juntura et al.32 (right side) NT 38 80 1.9 0.77 11</p><p>Viikari-Juntura et al.32 (left side) NT 43 80 2.2 0.71 11</p><p>Comments: The test is not considered a good screen but is moderately specific. Overall, the diagnostic value is not compelling for</p><p>diagnosis.</p><p>120 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>Quadrant Test</p><p>1 The patient assumes a sitting position.</p><p>2 The examiner instructs the patient to side flex, rotate, and</p><p>extend his or her neck toward the side of pain.</p><p>3 The examiner gently provides overpressure to the zygo-</p><p>matic process toward side flexion, rotation, and extension.</p><p>4 Reproduction of arm symptoms is considered a positive</p><p>finding.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Uchihara et al.29 NT NT NT NA NA NT</p><p>Comments: This test is commonly used to “rule out” cervical dysfunction but at present is untested.</p><p>Cervical Compression Test</p><p>UTILITY SCORE ?</p><p>1 The patient assumes a sitting position.</p><p>2 The examiner stands behind the patient. With the elbows</p><p>on each shoulder, the examiner applies a downward force</p><p>to the head.</p><p>3 Reproduction of symptoms is considered a positive</p><p>response.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Bertilson et al.2 .44 kappa NT NT NA NA NA</p><p>Comments: The kappa value suggests the test has only fair agreement. The diagnostic value remains untested.</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 121</p><p>TESTS FOR CERVICAL RADICULOPATHY</p><p>Wainner’s Clinical Prediction Rule for Cervical Radiculopathy</p><p>The study includes four criteria: Cervical rotation less than 60 degrees, a positive Spurling’s test, a positive distraction test,</p><p>and a positive upper limb tension sign.</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Wainner et al.33</p><p>(2 of 4 positive tests)</p><p>NT 39 56 0.88 1.08 10</p><p>Wainner et al.33</p><p>(3 of 4 positive tests)</p><p>NT 39 94 6.1 0.64 10</p><p>Wainner et al.33</p><p>(4 of 4 positive tests)</p><p>NT 24 99 30.3 0.76 10</p><p>Comments: A well done study that demonstrates a useful combination for diagnosis.</p><p>122 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS FOR UPPER CERVICAL INSTABILITY</p><p>Modified Sharp Purser Test</p><p>1 The patient assumes a sitting position. The patient’s head</p><p>should be slightly flexed. The examiner assesses resting</p><p>symptoms.</p><p>2 The examiner stands to the side of the patient and stabi-</p><p>lizes the C2 spinous process using a pincer grasp.</p><p>3 Gently at first, the examiner applies a posterior translation</p><p>force from the palm of the hand on the patient’s forehead</p><p>toward a posterior direction.</p><p>4 Symptoms are assessed for both degree of linear displace-</p><p>ment (palpated) or symptom provocation.</p><p>5 Collectively, a positive test is identified either by reproduc-</p><p>tion of myelopathic symptoms during forward flexion or</p><p>decrease in symptoms during an anterior to posterior move-</p><p>ment or excess displacement during the AP movement.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cattrysse et al.3</p><p>(includes only those</p><p>that were significantly</p><p>related)</p><p>.67 kappa NT NT NA NA NA</p><p>Uitvlugt & Indenbaum30 NT 69 96 17.3 0.32 8</p><p>Comments: Uitvlugt & Indenbaum30 found high specificity with the Sharp Purser and described the test as “symptom reduction</p><p>upon posterior force through the head.” The test differs from the original Sharp Purser, which was poorly defined and only con-</p><p>sisted of upper cervical flexion. Precautions should</p><p>Minnesota</p><p>David A. Krause, PT, DSc, MBA, OCS</p><p>Mayo Clinic</p><p>Rochester, Minnesota</p><p>B. J. Lehecka, DPT</p><p>Wichita State University</p><p>Wichita, Kansas</p><p>Eric R. Miller, PT, DSc, FAAOMPT, OCS, Cert MDT</p><p>D’Youville College</p><p>Buffalo, New York</p><p>Patrick Pabian PT, DPT, SCS, OCS, CSCS</p><p>University of Central Florida</p><p>Orlando, Florida</p><p>Jennifer Reneker, MSPT, NCS</p><p>Walsh University</p><p>North Canton, Ohio</p><p>Carey Rothschild, PT, DPT, OCS, CSCS</p><p>University of Central Florida</p><p>Orlando, Florida</p><p>Daniel Sedory, MS, ATC, N.H.LAT</p><p>University of New Hampshire</p><p>Durham, New Hampshire</p><p>Cheryl Sparks, PT, DPT, OCS</p><p>Bradley University</p><p>Peoria, Illinois</p><p>Jacob N. Thorp, PT, DHS, MTC</p><p>East Carolina University</p><p>Greenville, North Carolina</p><p>Arie J. van Duijn, EdD, PT, OCS</p><p>Florida Gulf Coast University</p><p>Fort Myers, Florida</p><p>Nancy H. Wofford, PT, DPT, OCS, Cert MDT</p><p>Armstrong Atlantic State University</p><p>Savannah, Georgia</p><p>FIRST EDITION</p><p>Aimie F. Kachingwe, PT, EdD, OCS, MTC</p><p>California State University–Northridge</p><p>Northridge, California</p><p>Morey J. Kolber, PT, PhD(c), MDT, CSCS</p><p>Nova Southeastern University</p><p>Fort Lauderdale, Florida</p><p>Eric R. Miller, PT, DSc, OCS</p><p>D’Youville College</p><p>Buffalo, New York</p><p>This page intentionally left blank</p><p>1</p><p>Introduction</p><p>to Diagnostic</p><p>Accuracy</p><p>CHAPTER</p><p>1</p><p>Introduction</p><p>Diagnosis of patients with orthopedic problems is a com-</p><p>plex cognitive and psychomotor task that primarily consists</p><p>of patient interview and physical examination. The patient</p><p>interview produces the patient history and the range of</p><p>possible diagnoses. A well-performed history also begins</p><p>to narrow the range of possible diagnoses.3,22,35 The physi-</p><p>cal examination is the next step in the patient encounter</p><p>and a cornerstone of the diagnostic process. During the</p><p>physical examination, the clinician uses findings to further</p><p>modify the probability of the range of diagnoses,3,30 retain-</p><p>ing some, ruling out others, creating a list of impairments,</p><p>and ultimately arriving at a hypothesis as to the pathology</p><p>that produced functional limitation and disability.1,42 We use</p><p>the term “Physical Examination Tests” to capture diagnostic</p><p>elements of observation, motion testing, strength testing,</p><p>accessory motions, palpation, and special tests.</p><p>Physical Examination Tests have historically been an</p><p>integral part of the clinical examination and have great allure</p><p>for the clinician who may want to simplify the complex</p><p>diagnostic process or save the patient from expensive, and</p><p>often painful, imaging and lab tests. Evidence of the mag-</p><p>netism of Physical Examination Tests is obvious in that the</p><p>rate of publication of these tests continues to accelerate25</p><p>and musculoskeletal textbooks are rife with descriptions</p><p>of tests.9,26,33 Unfortunately, many published articles lack</p><p>sound methodology.12,23,32 Further, many of the current</p><p>textbooks26,33 offer no guidance as to the clinical utility of</p><p>the test, the reliability with which the test is performed, or</p><p>the quality of the research evaluating the test, leading the</p><p>reader to the conclusion that “all Physical Examination Tests</p><p>are created equal.” Clearly, all Physical Examination Tests</p><p>are not created equal.31</p><p>Purpose of Physical Examination Tests</p><p>Physical Examination Tests exist as part of the overall</p><p>scheme for the physical examination of the patient. These</p><p>tests are typically performed at two different time peri-</p><p>ods: (1) at the beginning of the physical examination as a</p><p>screening test and (2) toward the end of an orderly exami-</p><p>nation as a diagnostic test.42 The purpose of the Physical</p><p>Examination Test as a screen is to help the clinician rule out</p><p>some of the many possible diagnoses.34 As a diagnostic test,</p><p>the purpose of the Physical Examination Test is to validly</p><p>differentiate among the few remaining competing diagnoses.</p><p>These diagnoses are close to each other with regard to</p><p>nature and severity so the clinician uses the Physical Exami-</p><p>nation Test to ease any remaining confusion with regard to</p><p>the condition or disorder.19</p><p>Regardless of whether the Physical Examination Test is</p><p>used for screening or diagnostic purposes, the test must be</p><p>performed reliably by the practitioner or practitioners in</p><p>order for that test to be a valuable guide during the clinical</p><p>diagnostic process.9,40,41 Reliability captures the extent to</p><p>which a test or measurement is free from error. In refer-</p><p>ence to Physical Examination Tests, reliability is often used</p><p>to capture agreement and is subdivided into intra-rater</p><p>reliability and inter-rater reliability.38 Intra-rater reliability</p><p>examines whether the same single examiner can repeat</p><p>the test consistently while inter-rater reliability captures</p><p>whether two or more examiners can repeat the test.</p><p>Both intra- and inter-rater reliability can be represented</p><p>by a statistic called the intra-class correlation coefficient</p><p>(ICC). Many Physical Examination Tests have dichotomous</p><p>outcomes, meaning that the result of the test is either</p><p>positive (the patient has the pathology) or negative (the</p><p>patient does not have the pathology). When the Physical</p><p>Examination Test has a dichotomous outcome, there is a</p><p>high possibility that two or more examiners will agree by</p><p>chance alone. The statistic frequently used to adjust for</p><p>this chance agreement in dichotomous outcome tests is</p><p>called kappa (�). Kappa measures the amount of agreement</p><p>beyond what would be expected by chance alone. Values</p><p>for � were categorized and value-labeled in 1976 by Landis</p><p>and Koch24 and this categorization remains prevalent today</p><p>despite its arbitrary nature (Table 1-1). In order to deter-</p><p>mine if the Physical Examination Test serves the purpose</p><p>of being both a reliable and valid screen or diagnostic tool,</p><p>the test must be examined in a research study and prefer-</p><p>ably, multiple studies.</p><p>Eric J. Hegedus</p><p>2 CHAPTER 1 Introduction to Diagnostic Accuracy</p><p>TABLE 1-1 The Value of Kappa (�)</p><p>(Adapted from Landis and Koch24)</p><p>Kappa (�)</p><p>Value Explanation</p><p>be taken prior to use on patients who may have a dens fracture.</p><p>UTILITY SCORE 2</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 123</p><p>TESTS FOR UPPER CERVICAL INSTABILITY</p><p>Alar Ligament Stability Test</p><p>1 The patient assumes a sitting or supine position. The head</p><p>is slightly flexed to further engage the Alar ligament. The</p><p>examiner assesses resting symptoms.</p><p>2 The examiner stabilizes the C2 spinous process using a</p><p>pincer grasp. A firm grip ensures appropriate assessment</p><p>of movement.</p><p>UTILITY SCORE 2</p><p>3 Either side flexion or rotation is passively initiated by the</p><p>examiner. During these passive movements, the examiner</p><p>attempts to feel movement of C2.</p><p>4 A positive test is the failure to “feel” movement of the C2</p><p>process during side flexion and rotation.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kaale et al. 16 (right) 0.71 kappa 69 100 Inf 0.31 7</p><p>Kaale et al. 16 (left) 0.69 kappa 72 96 18 0.29 7</p><p>Comments: Precautions should be taken prior to use on patients who may have a dens fracture. There are several considerations</p><p>associated with the Alar ligament test. First, any movement of C2 during side flexion or rotation should be considered normal.</p><p>Second, the patient may experience some discomfort during the procedure, specifically post-trauma, and this finding should be con-</p><p>sidered a “red flag” for high-velocity techniques. Finally, some individuals have recommended using the coupling pattern of C0–1 or</p><p>C1–2 to identify pathology; however, because the coupling pattern is inconsistent, this is not advised. Others suggest that selected</p><p>range of motion loss is indicative of capsular restrictions or hypermobility but this line of thought has not been tested. Kaale et al.16</p><p>used a slight variation of the traditional Alar ligament test which involved palpation of the C1 transverse process to feel for move-</p><p>ment between C1 and C2.</p><p>124 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS FOR UPPER CERVICAL INSTABILITY</p><p>Upper Cervical Flexion Test</p><p>1 The patient assumes a supine position. The examiner</p><p>assesses resting symptoms.</p><p>2 Using a friction massage grip (digits 2 and 3 are held tightly</p><p>together) the examiner contacts the posterior aspect of</p><p>the bilateral C1 transverse processes. The palms of the</p><p>examiner are placed under the occiput of the patient.</p><p>3 The examiner then applies an anterior force to the C1</p><p>transverse processes, lifting the head as the force is applied.</p><p>This position is held for 15 to 20 seconds.</p><p>4 If no symptoms occur, the examiner can apply a down-</p><p>ward force on the patient’s forehead using the anterior</p><p>aspect of the shoulder. This position is held for 15 to 20</p><p>seconds.</p><p>5 A positive test is identified by excessive translation or</p><p>reproduction of instability-related symptoms.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cattrysse et al.3</p><p>(includes only those</p><p>that were significantly</p><p>related among raters)</p><p>.64 to 1.00</p><p>kappa</p><p>NT NT NA NA NA</p><p>Comments: This test exhibits moderate to strong reliability but has not been tested for validity. The test is similar in construct to</p><p>the Sharp Purser test. Precautions should be taken prior to use on patients who may have a dens fracture.</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 125</p><p>TESTS FOR UPPER CERVICAL INSTABILITY</p><p>Original Sharp Purser Test</p><p>1 The patient assumes a sitting position.</p><p>2 The patient is instructed to nod the head into flexion.</p><p>Reproduction of myelopathic symptoms is considered a</p><p>positive test.</p><p>3 If no symptoms are encountered, the examiner can apply</p><p>very gentle flexion to the forehead of the patient.</p><p>4 A positive test is identified by reproduction of myelopathic</p><p>symptoms during flexion movements.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Sharp et al.23 NT NT NT NA NA NA</p><p>Comments: Sharp et al.23 provided a very poor description of the procedure in the seminal paper. The manner in which this test is</p><p>commonly taught is not the description provided by the original authors.</p><p>Anterior Stability Test of the Atlanto-Occipital Joint</p><p>UTILITY SCORE ?</p><p>1 The patient assumes a supine position.</p><p>2 The cranium of the patient is supported with the exam-</p><p>iner’s finger under the occiput. The thumbs of the exam-</p><p>iner are placed medially on the anterior aspect of the</p><p>patient’s C1–2 transverse processes.</p><p>3 The examiner lifts the occiput while simultaneously apply-</p><p>ing pressure to the anterior aspect of C1–2 transverse</p><p>processes.</p><p>4 A positive test is identified either by reproduction of mye-</p><p>lopathic symptoms during anterior translation or excess</p><p>displacement during the PA movement.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kaale et al. 16 0.69 kappa 65 99 65 0.35 7</p><p>Comments: Precautions should be taken prior to use on patients who may have a dens fracture. This is another of the many</p><p>cervical spine instability tests that remain uninvestigated.</p><p>126 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS FOR UPPER CERVICAL INSTABILITY</p><p>Direct Anterior Translation Stress Test</p><p>1 The patient assumes a supine position.</p><p>2 The examiner’s thumbs are placed medially and anteriorly</p><p>over the anterolateral aspect of the axis. The examiner’s fin-</p><p>gers are placed posteriorly over the posterior arch of the atlas.</p><p>3 The examiner applies a stress between the fingers and the</p><p>thumbs.</p><p>4 A positive test is identified either by reproduction of mye-</p><p>lopathic symptoms during translation or excess displace-</p><p>ment during the movement.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Dobbs8 NT NT NT NA NA NA</p><p>Comments: This is another poorly investigated cervical spine instability test. Precautions should be taken prior to use on patients</p><p>who may have a dens fracture. This technique is difficult to perform and may not provide information beyond the modified Sharp</p><p>Purser test.</p><p>Lateral Shear Test of the Atlanto-Axial Articulation</p><p>UTILITY SCORE ?</p><p>1 The patient assumes a supine position.</p><p>2 The examiner uses a “key fob” grip and stabilizes/contacts</p><p>the C1 transverse process on one side. Using a key fob</p><p>grip, the examiner applies the same form of grip on the</p><p>opposite side of the neck at the transverse aspect of C2.</p><p>3 The examiner applies a stress between the two grips incor-</p><p>porating a transverse shear force.</p><p>4 A positive test is identified either by reproduction of mye-</p><p>lopathic symptoms during translation or excess displace-</p><p>ment during the movement.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Dobbs8 NT NT NT NA NA NA</p><p>Comments: Precautions should be taken prior to use on patients who may have a dens or a Jefferson’s fracture. This is another</p><p>poorly studied cervical spine instability test.</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 127</p><p>TESTS FOR UPPER CERVICAL INSTABILITY</p><p>Tectorial Membrane Test</p><p>1 The patient assumes a sitting position.</p><p>2 The examiner places one hand in the suboccipital region</p><p>using the thumb and the first finger against the lower</p><p>aspect of the occiput. The bottom three fingers (while</p><p>flexed) are placed against the spinous processes of the</p><p>cervical spine and block the spine.</p><p>3 Using the other hand the examiner provides a posterior</p><p>and upward force on the mastoid processes of the patient,</p><p>to translate the head posteriorly. The thumb and first fin-</p><p>ger of the first hand provide a traction force.</p><p>4 A positive test is identified as excessive translation between</p><p>the occiput and C1and C2.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kaale et al.16 0.93 kappa 94 99 94 0.06 7</p><p>Comments: This is a difficult technique to master. The study comparative group was MRI findings in patients with whiplash associ-</p><p>ated disorders.</p><p>Posterior Atlanto-Occipital Membrane Test</p><p>1 The patient assumes a sitting position.</p><p>2 The examiner uses one hand to pull downward</p><p>on the</p><p>lateral aspects of C1.</p><p>3 The examiner uses the other hand to pull upward on the</p><p>occiput.</p><p>4 A positive test is identified as excessive motion during the</p><p>traction assessment.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kaale et al. 16 0.97 kappa 96 100 Inf 0.04 7</p><p>Comments: Precautions should be taken prior to use on patients who may have a dens or a Jefferson’s fracture. This is another</p><p>poorly studied cervical spine instability test.</p><p>128 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS FOR MID-CERVICAL INSTABILITY</p><p>AP and PA Stress Testing of the Mid-Cervical Spine</p><p>1 The patient assumes a supine position.</p><p>2 The examiner’s thumbs are placed medially and anteri-</p><p>orly over the anterolateral aspect of the mid-cervical seg-</p><p>ments. The examiner’s fingers are placed posteriorly over</p><p>the posterior arch of segment above or below the tested</p><p>mid-cervical segment.</p><p>3 The examiner applies a stress between the fingers and the</p><p>thumbs.</p><p>4 A positive test is identified either by reproduction of mye-</p><p>lopathic symptoms during translation or excess displace-</p><p>ment during the movement.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Dobbs8 NT NT NT NA NA NA</p><p>Comments: This is an untested stress test of the mid-cervical spine.</p><p>Lateral Stress Testing of the Mid-Cervical Spine</p><p>1 The patient assumes a supine position.</p><p>2 The examiner’s lateral border of his or her metacarpalphalan-</p><p>geal joint is placed against the transverse process of a selected</p><p>mid-cervical level. On the opposite side of the cervical spine,</p><p>the opposite hand of the examiner provides a similar MCP</p><p>grip on a mid-cervical level above or below the previous level.</p><p>3 The examiner applies a medial force to the patient’s neck</p><p>with each hand.</p><p>4 A positive test is identified either by reproduction of mye-</p><p>lopathic symptoms during translation or excess displace-</p><p>ment during the movement.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Dobbs8 NT NT NT NA NA NA</p><p>Comments: This is an untested stress test of the mid-cervical spine.</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 129</p><p>TESTS FOR POTENTIAL VERTEBRAL ARTERY DYSFUNCTION</p><p>Vertebral Basilar Insufficiency (VBI) Test</p><p>1 The patient is interviewed to extract signs and symptoms of VBI. If remarkable, the patient is</p><p>referred out for appropriate medical consult.</p><p>2 Prior to a comprehensive clinical examination, the examiner performs end-range cervical rota-</p><p>tion tests on the patient in a sitting or supine position. The position is held for 10 seconds with</p><p>observation for signs and symptoms of VBI.</p><p>3 The head is returned to a neutral position and held for a minimum of 10 seconds.</p><p>4 Rotation is repeated to the opposite side and the position is held for 10 seconds. The examiner</p><p>observes for signs and symptoms of VBI. If remarkable, the patient is referred for appropriate</p><p>medical consult.</p><p>5 A positive test is identified by initiation of symptoms such as dizziness, diplopia, dysphasia,</p><p>dysarthria, drop attacks, nausea, and nystagmus.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Not tested NT NT NT NA NA NA</p><p>Comments: Much debate exists on the safety and applicability of the VBI tests. We recommend that it is inappropriate to perform</p><p>the VBI if significant signs are present during the patient history. The test may reproduce symptoms and can be dangerous if applied</p><p>injudiciously. In addition to the patient complaints listed above, numbness around the mouth, anxiety, and other neurological sensa-</p><p>tions should be investigated. The protocol selected is associated with literature that promotes end-range rotation. Others have</p><p>described tests that include extension, rotation and extension, and traction. All are likely beneficial. Although VBI testing has been</p><p>associated with measured reductions in blood flow, patients rarely demonstrate clinical symptoms, leading to potential finding of</p><p>false positives.</p><p>130 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS FOR POTENTIAL VERTEBRAL ARTERY DYSFUNCTION</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cote et al.4 (left side</p><p>2.78 velocity)</p><p>NT 0 67 0 1.5 5</p><p>Cote et al.4 (left side</p><p>3.49 velocity)</p><p>NT 0 71 0 1.4 5</p><p>Cote et al.4 (right</p><p>side 2.78 velocity)</p><p>NT 0 86 0 1.2 5</p><p>Cote et al.4 (right</p><p>side 3.49 velocity)</p><p>NT 0 90 0 1.1 5</p><p>Comments: Cote et al.’s4 study used blood velocity measures (upper confidence intervals) when determining symptoms. It is</p><p>unlikely that this could be replicated in the clinic. Not a well done study.</p><p>UTILITY SCORE 3</p><p>1 The patient is placed in a sitting position.</p><p>2 The head is rotated to one side and extension is added.</p><p>This position is held for 30 seconds.</p><p>3 The process is repeated on the opposite side.</p><p>4 A positive test is identified by initiation of symptoms such</p><p>as dizziness, diplopia, dysphasia, dysarthria, drop attacks,</p><p>nausea, and nystagmus.</p><p>Wallenberg’s Position (Extension and Rotation)</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 131</p><p>1 The patient assumes a supine position. The examiner</p><p>stands at the head of the patient. Resting symptoms are</p><p>assessed.</p><p>2 The patient actively moves his or her neck into maximum</p><p>flexion.</p><p>TESTS FOR CERVICOGENIC HEADACHE</p><p>Cervical-Flexion Rotation Test</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Hall & Robinson10 NT 86 100 NA NA 12</p><p>Ogince et al.18 0.81 kappa 91 90 9.1 0.10 10</p><p>Hall et al.11 0.93 kappa 90 88 7.5 0.11 8</p><p>Comments: The test likely isolates C1–C2, and most likely does not assess the presence of cervicogenic headache at other levels.</p><p>All studies used a case control or a modified case control design, thus there is a risk for bias.</p><p>3 The examiner then applies a full rotational force to both</p><p>sides. Symptoms are queried to determine if concordant.</p><p>4 The test is both a pain provocation test and a test for range</p><p>of motion loss. If a loss of 10 degrees or greater is noted,</p><p>the test is considered positive.</p><p>132 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS FOR CERVICOGENIC HEADACHE</p><p>C0–1, C1–2, C2–3 Joint Mobility Assessment</p><p>1 The patient assumes a prone position. The examiner stands</p><p>at the head of the patient. Resting symptoms are assessed.</p><p>2 The examiner applies a downward force with his or her</p><p>thumbs on the C1 transverse process (right and left), the</p><p>C2–3 facet (right and left) (pictured) and the C2–3 facet with</p><p>the head rotated toward the targeted side (right and left).</p><p>3 The test is both a pain provocation test and a test for</p><p>hypomobility.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Zito et al.34 (C0–C1) NT 59 82 3.3 0.49 10</p><p>Zito et al.34 (C1–C2) NT 62 87 4.9 0.43 10</p><p>Zito et al.34 (C2–C3) NT 65 78 2.9 0.44 10</p><p>Comments: This “test” is often used during normal spine differentiation. Some of the subjects were asymptomatic, which can</p><p>amplify the diagnostic accuracy. Seems to be especially beneficial for C1–2.</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 133</p><p>TESTS FOR POSTURAL DYSFUNCTION</p><p>Neck Flexor Muscle Endurance Test</p><p>1 The patient lies in a supine position.</p><p>2 The examiner positions the patient so that the head is</p><p>actively retracted and held approximately 2.5 cm off the</p><p>plinth (the examiner places his or her hand under the head</p><p>for knowledge of position). Visually a skin fold is present in</p><p>the anterior lateral neck. A line is drawn on this skin fold.</p><p>3 The patient is instructed to hold this position. If the</p><p>patient’s head touches the examiner’s hand or he or she</p><p>loses the skin folds, he or she is instructed to hold the head</p><p>or tuck the chin.</p><p>4 A positive test is undefined but the test is terminated if the</p><p>patient cannot hold the lines of the skin fold or cannot</p><p>hold his or her head up for over a second.</p><p>UTILITY SCORE ?</p><p>Study Reliability</p><p>Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Harris et al.12 (with-</p><p>out neck pain)</p><p>.82 – 91 ICC NT NT NA NA NA</p><p>Harris et al.12 (with</p><p>neck pain)</p><p>.67 ICC NT NT NA NA NA</p><p>Olsen et al.19 (with</p><p>neck pain)</p><p>.83, .85, .88</p><p>ICC</p><p>NT NT NA NA NA</p><p>Edmondston et al.9 0.93 NT NT NA NA NA</p><p>Comments: This test would benefit from a validity investigation for patients with cervicogenic headaches. It is likely that this test</p><p>reflects lower cervical flexor strength, not upper cervical. The test is also used for assessment of postural dysfunction.</p><p>134 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS FOR POSTURAL DYSFUNCTION</p><p>Scapular Muscle Endurance Test</p><p>1 The patient stands near a wall and places their shoulders</p><p>in 90 degrees of flexion and the elbows in 90° of flexion.</p><p>2 A ruler is placed between the elbows and the patient is</p><p>requested to externally rotate their shoulders with a 1 kg</p><p>force between the hands.</p><p>3 The end of the test occurs when the patient is unable to</p><p>maintain the set resistance of 1 kg, or drops the ruler-</p><p>spacer, or drops their shoulder below 90 degrees.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Edmondston et al.9 0.67 NT NT NA NA NA</p><p>Comments: Also used as an outcome measure.</p><p>Posterior Extensors Endurance Test</p><p>1 The patient lies in a prone position, with the head off the</p><p>end of the plinth.</p><p>2 A belt is placed around the thoracic spine to reduce the</p><p>chance of thoracic extension. A 2 kg weight can be placed</p><p>on the patients head for loading.</p><p>3 The patient is instructed to chin retract and hold this posi-</p><p>tion as long as possible.</p><p>4 A positive test when the patients head moves 5 degrees</p><p>from the horizontal.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Edmondston et al. 9 0.88 NT NT NA NA NA</p><p>Comments: Also used as an outcome measure.</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 135</p><p>TESTS FOR LEVEL OF DYSFUNCTION OR LINEAR STABILITY</p><p>Posterior-Anterior Mobilization Test</p><p>1 The patient may lie in prone or side lying. The neck is</p><p>positioned in neutral and resting symptoms are assessed.</p><p>2 The examiner palpates the C2 spinous process using the</p><p>tips of the thumb. Using a thumb-to-thumb application,</p><p>the examiner applies a gentle downward force up to the</p><p>first point of the patient’s complaint of pain and the pain</p><p>response is assessed.</p><p>3 The examiner then pushes beyond the first point of pain,</p><p>toward end range, and reassesses pain and quality of move-</p><p>ment. Additionally, splinting or muscle spasm should be</p><p>assessed. The clinician should assess if pain is concordant.</p><p>4 The examiner repeats the movements toward end range</p><p>while assessing pain. One should use caution if the patient</p><p>reports significant pain that is unrelenting.</p><p>5 The process is repeated on each spinous process to T4 to</p><p>identify the concordant segment.</p><p>6 A positive test is identified by reproduction of the patient’s</p><p>concordant pain.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Jull, et al.15 NT 100 100 NA NA 9</p><p>Van Suijlekom</p><p>et al.31 (upper cervical</p><p>tenderness)</p><p>.14 kappa NT NT NA NA 8</p><p>Van Suijlekom</p><p>et al.31 (mid-cervical</p><p>tenderness)</p><p>.37 kappa NT NT NA NA 8</p><p>Van Suijlekom</p><p>et al.31 (lower cervical</p><p>tenderness)</p><p>.31 kappa NT NT NA NA 8</p><p>King et al.17 (C2–C3) NT 88 39 1.4 0.30 5</p><p>King et al.17 (C5–C6) NT 89 50 1.8 0.22 5</p><p>Comments: The test results may vary based on application force, determination of what is considered a positive finding, and the</p><p>examiner’s conception of stiffness. It is likely that this test is highly sensitive at implicating the level of a disorder, but is not specific</p><p>for a pathological process.</p><p>136 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS FOR LEVEL OF DYSFUNCTION OR LINEAR STABILITY</p><p>Palpation of Physiological Movement</p><p>1 The patient is placed in a sitting position.</p><p>2 The examiner palpates the lateral aspect of C2–3 (articular</p><p>pillars) with his or her fingers. The opposite hand stabilizes</p><p>the head in order to apply a lateral/extension movement.</p><p>3 The examiner applies a series of lateral/extension move-</p><p>ments to feel the amount of motion at that segment. The</p><p>same procedure can be used for lower segments.</p><p>4 Increased movement at one level versus another is consid-</p><p>ered positive.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Smedmark et al.24 (C1–2</p><p>rotation)</p><p>.28 kappa NT NT NA NA NA</p><p>Smedmark et al.24 (C2–3</p><p>rotation)</p><p>.43 kappa NT NT NA NA NA</p><p>Smedmark et al.24 (C7</p><p>flex-extension)</p><p>.36 kappa NT NT NA NA NA</p><p>Humphreys et al.14 (C2–3</p><p>block)</p><p>.76 kappa 98 91 10.9 0.02 11</p><p>Humphreys et al.14 (C5–6</p><p>block)</p><p>.46 kappa 78 55 1.7 0.4 11</p><p>Sandmark & Nisell21 (not</p><p>for radiculopathy)</p><p>NT 82 79 3.9 0.23 9</p><p>Rey-Einz et al.20 (C3–C4) 0.75 kappa 83.3 76.3 3.5 0.21 11</p><p>Rey-Einz et al.20 (C4–C5) 0.65 100 79.5 4.9 0.00 11</p><p>Rey-Einz et al.20 (C5–C6) 0.60 100 34.8 1.5 0.00 11</p><p>Comments: The testing procedure appears to be sensitive in identifying fused joint levels or degenerative levels identified during a</p><p>radiograph. Sensitivity may decline in lower joints.</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 137</p><p>TESTS TO IDENTIFY NECK PAIN FROM ASYMPTOMATIC CONDITIONS</p><p>Manual Examination of Rotation</p><p>1 The patient is placed in a sitting position.</p><p>2 The examiner palpates the spinous processes of C0, C2,</p><p>and C7 and uses these locations as landmarks.</p><p>3 The examiner applies a passive rotation to the neck (left</p><p>and right) and scores the passive movement as hyper-</p><p>mobile, normal, and hypomobile).</p><p>4 A positive finding is hyper/hypomobility and/or a hard or</p><p>empty end feel.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>DeHertogh et al.6 NT 77.2 90.0 7.7 025 9</p><p>Comments: It was a nicely done study but there were patients with no symptoms (case control design).</p><p>Combined Manual Rotation and a Visual Analog Scale</p><p>The clustered findings included a standard 100 mm visual analog scale (using 20 mm or greater as a positive finding) and the</p><p>manual rotation described above.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>DeHertogh et al.6 NT 88.9 86.5 6.6 0.21 9</p><p>Comments: It was a nicely done study but there were patients with no symptoms (case control design). It’s very likely that one can</p><p>tell who has neck pain versus who doesn’t and that’s probably why the results are pretty high.</p><p>138 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>TESTS TO DETERMINE IF A RADIOGRAPH IS REQUIRED</p><p>Canadian C-Spine Rules</p><p>1 Patients who are cognitively intact and have no neurological symptoms; or</p><p>2 Patients who are under the age of 65; or</p><p>3 Patients who are not fearful of moving the head upon command; or</p><p>4 Patients who were not involved in a distraction-based injury; or</p><p>5 Patients who demonstrate no midline pain do not need a radiograph.</p><p>6 Any positive finding in any of the above five categories should result in a radiographic test.</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Stiell et al.26 (not includ-</p><p>ing indeterminate cases)</p><p>NT 99 45 1.81 0.01 12</p><p>Stiell et al.26 (not includ-</p><p>ing indeterminate cases)</p><p>NT 99 45 1.81 0.01 12</p><p>Stiell et al.26 (including</p><p>indeterminant cases)</p><p>NT 99 91 10.7 0.01 12</p><p>Stiell et al.27 .6 kappa 100 43 NT NT 12</p><p>Bandiera et al.1 .6 kappa 100 43 NT NT 9</p><p>Comments: Because the test is designed as a screen it is imperative that the findings exhibit high sensitivity. In order to rule out the</p><p>need for an x-ray, all five categories should be negative. The decision rules are designed to be used in the acute stage of the injury.</p><p>NEXUS (National Emergency X-Radiography Utilization Study)</p><p>1 Patients who do not have tenderness at posterior midline of the cervical spine.</p><p>2 Patients who have no focal neurological deficit.</p><p>3 Patients who have a normal level of alertness.</p><p>4 Patients</p><p>who have no evidence of intoxication.</p><p>5 Patients who do not have a clinically apparent, painful injury that may distract them from a</p><p>cervical injury.</p><p>6 Any positive finding in any of the above five categories should result in a radiographic test.</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 139</p><p>TESTS TO DETERMINE IF A RADIOGRAPH IS REQUIRED</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Stiell et al.26 .52 to .72</p><p>kappa</p><p>91 37 1.43 0.25 12</p><p>Dickinson et al.7 .23 to .78</p><p>kappa</p><p>93 38 1.49 0.19 9</p><p>Hoffman et al.13 NT 99 13 1.14 0.08 11</p><p>Comments: Note the lower sensitivity values, suggesting this “screen” is less effective than the Canadian C-Spine rules. Nonethe-</p><p>less, the test still demonstrates value. The rules are designed to be used in the acute stage of the injury.</p><p>UTILITY SCORE 1</p><p>sensitive but a specific test, albeit of high risk if</p><p>findings are noted.</p><p>6. Prior to administration of cervical spine instability</p><p>tests, specifically after trauma, one should perform</p><p>the Canadian C-Spine rules.</p><p>7. The Canadian C-Spine rules, used to detect who</p><p>would benefit from a radiograph, are highly sen-</p><p>sitive and function very well as a screen in the</p><p>acutely injured patient.</p><p>8. The flexion-rotation test for cervicogenic head-</p><p>aches detection is likely diagnostic because the</p><p>criteria included for patients with cervicogenic</p><p>headaches was very specific.</p><p>Key Points</p><p>1. The majority of clinical special tests for cervical</p><p>radiculopathy have been investigated within the</p><p>literature.</p><p>2. Many of the clinical special tests for cervical insta-</p><p>bility have not been investigated for diagnostic</p><p>accuracy. Those that have been studied may be</p><p>influenced by bias.</p><p>3. Tests such as the ULTT and Brachial Plexus Com-</p><p>pression have high sensitivity for detection of cer-</p><p>vical radiculopathy.</p><p>4. The Spurling’s compression test demonstrates</p><p>variable findings, depending on the studies cited.</p><p>5. Although untested for diagnostic accuracy, the</p><p>vertebral basilar insufficiency test is likely not</p><p>References</p><p>1. Bandiera G, Stiell IG, Wells GA, Clement C, De Maio V,</p><p>Vandemheen KL, Greenberg GH, Lesiuk H, Brison R,</p><p>Cass D, Dreyer J, Eisenhauer MA, Macphail I, McKnight RD,</p><p>Morrison L, Reardon M, Schull M, Worthington J;</p><p>Canadian C-Spine and CT Head Study Group.</p><p>The Canadian C-spine rule performs better than</p><p>unstructured physician judgment. Ann Emerg Med.</p><p>2003;42(3):395–402.</p><p>2. Bertilson B, Grunnesjo M, Strender LE. Reliability of</p><p>clinical tests in the assessment of patient with neck/</p><p>shoulder problems—impact of history. Spine.</p><p>2003;19:2222–2231.</p><p>3. Cattrysse E, Swinkels RA, Oostendorp RA, Duquet W.</p><p>Upper cervical instability: Are clinical tests reliable? Man</p><p>Ther. 1997;2(2):91–97.</p><p>4. Cote P, Krietz BG, Cassidy JD, Thiel H. The validity of the</p><p>extension-rotation test as a clinical screening procedure</p><p>before neck manipulation: A secondary analysis. J Manip</p><p>Physiol Therapeutics. 1996;19:159–164.</p><p>5. Davidson R, Dunn E, Metzmaker J. The shoulder abduc-</p><p>tion test in the diagnosis of radicular pain in cervical</p><p>extradural compression monoradiculopathies. Spine.</p><p>1981;6:441–445.</p><p>140 CHAPTER 4 Physical Examination Tests for the Cervical Spine</p><p>6. DeHertogh WJ, Vaes PH, Vijverman V, DeCordt A,</p><p>Duquet W. The clinical examination of neck pain</p><p>patients: The validity of a group of tests. Man Ther.</p><p>2007;12:50–55.</p><p>7. Dickinson G, Stiell IG, Schull M, Brison R, Clement CM,</p><p>Vandemheen KL, Cass D, McKnight D, Greenberg G,</p><p>Worthington JR, Reardon M, Morrison L, Eisenhauer MA,</p><p>Dreyer J, Wells GA. Retrospective application of the</p><p>NEXUS low-risk criteria for cervical spine radiography</p><p>in Canadian emergency departments. Ann Emerg Med.</p><p>2004;43(4):507–514.</p><p>8. Dobbs A. Manual therapy assessment of cervical insta-</p><p>bility. Orthopaedic Physical Therapy Clinics of North Amer-</p><p>ica. 2001;10:431–454.</p><p>9. Edmondston SJ, Wallumrod M, MacLeid F, Kvamme L,</p><p>Joebges S, Brabham GC. Reliability of isometric mus-</p><p>cle endurance tests in subjects with postural neck pain.</p><p>J Manipulative Physiol Ther. 2008;31:348–354.</p><p>10. Hall T, Robinson K. The flexion-rotation test and</p><p>active cervical mobility—a comparative measurement</p><p>study in cervicogenic headache. Man Ther. 2004;9(4):</p><p>197–202.</p><p>11. Hall T, Robinson K, Fujinawa O, Alkaska K, Pyne E.</p><p>Interester reliability and diagnostic validity of the cer-</p><p>vical flexion-rotation test. J Manipulative Physiol Ther.</p><p>2008;31:293–300.</p><p>12. Harris KD, Heer DM, Roy TC, Santos DM, Whitman JM,</p><p>Wainner RS. Reliability of a measurement of neck</p><p>flexor muscle endurance. Phys Ther. 2005;85(12):</p><p>1349–1355.</p><p>13. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI.</p><p>Validity of a set of clinical criteria to rule out injury to the</p><p>cervical spine in patients with blunt trauma. National</p><p>Emergency X-Radiography Utilization Study Group.</p><p>N Engl J Med. 2000;343(2):94–99.</p><p>14. Humphreys BK, Delahaye M, Peterson CK. An inves-</p><p>tigation into the validity of cervical spine motion</p><p>palpation using patients with congenital block verte-</p><p>brae as a “gold standard.” BMC Musculoskelet Disord.</p><p>2004;5:19.</p><p>15. Jull G, Bogduk N, Marsland A. The accuracy of manual</p><p>diagnosis for cervical zygapophyseal joint pain syn-</p><p>dromes. Med J Aust. 1988;148(5):233–236.</p><p>16. Kaale BR, Krakenes J, Albrektsen G, Wester K. Clinical</p><p>assessment techniques for detecting ligament and</p><p>membrane injuries in the upper cervical spine region—</p><p>A comparison with MRI results. Man Ther. 2008;13:</p><p>397–403.</p><p>17. King W, Lau P, Lees R, Bogduk N. The validity of manual</p><p>examination in assessing patients with neck pain. Spine J.</p><p>2005;7:22–26.</p><p>18. Ogince M, Hall T, Robinson K, Blackmore AM. The</p><p>diagnostic validity of the cervical flexion-rotation test</p><p>in C1–2 related cervicogenic headache. Man Ther.</p><p>2007;12:256–262.</p><p>19. Olsen L, Millar L, Dunker J, Hicks J, Glanz D. Reliabil-</p><p>ity of a clinical test for deep cervical flexor endurance.</p><p>J Manipulative Physiol Therapeutics. 2006;29:134–138.</p><p>20. Rey-Einz G, Alburquerque-Sendin F, Barrera-Mellado I,</p><p>Martin-Vallejo F, Fenandez-de-las-Penas C. Validity of</p><p>the posterior-anterior middle cervical spine gliding test</p><p>for the examination of intervertebral joint hypermobil-</p><p>ity in mechanical neck pain. J Manipulative Physiol Ther.</p><p>2010;33:279–285.</p><p>21. Sandmark H, Nisell R. Validity of five common man-</p><p>ual neck pain provoking tests. Scand J Rehabil Med.</p><p>1995;27(3):131–136.</p><p>22. Shah KC, Rajshekhar V. Reliability of diagnosis of soft</p><p>cervical disc prolapse using Spurling’s test. Br J Neuro-</p><p>surg. 2004;18(5):480–483.</p><p>23. Sharp J, Purser DW, Lawrence JS. Rheumatoid arthri-</p><p>tis of the cervical spine in the adult. Ann Rheum Dis.</p><p>1958;17(3):303–313.</p><p>24. Smedmark V, Wallin M, Arvidsson I. Inter-examiner reli-</p><p>ability in assessing passive intervertebral motion of the</p><p>cervical spine. Man Ther. 2000;5(2):97–101.</p><p>25. Spurling RG, Scoville WB. Lateral rupture of the cervi-</p><p>cal intervertebral disc. Surg Gynecol Obstet. 1944;78:</p><p>350–358.</p><p>26. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ,</p><p>Rowe BH, Worthington JR, Eisenhauer MA, Cass D,</p><p>Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G,</p><p>Reardon M, Holroyd B, Lesiuk H, Wells GA. The Cana-</p><p>dian C-spine rule versus the NEXUS low-risk criteria</p><p>in patients with trauma. N Engl J Med. 2003;349(26):</p><p>2510–2518.</p><p>27. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H,</p><p>De Maio VJ, Laupacis A, Schull M, McKnight RD,</p><p>Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA,</p><p>Greenberg GH, MacPhail I, Morrison L, Reardon M,</p><p>Worthington J. The Canadian C-spine rule for radi-</p><p>ography in alert and stable trauma patients. JAMA.</p><p>2001;286(15):1841–1848.</p><p>28. Tong HC, Haig AJ, Yamakawa K. The Spurling test and</p><p>cervical radiculopathy. Spine. 2002;27(2):156–159.</p><p>29. Uchihara T, Furukawa T, Tsukagoshi H. Compression</p><p>of brachial plexus as a diagnostic test of cervical cord</p><p>lesion. Spine. 1994;19(19):2170–2173.</p><p>30. Uitvlugt G, Indenbaum S. Clinical assessment of atlan-</p><p>toaxial instability using the Sharp-Purser test. Arthritis</p><p>Rheum.</p><p>1988;31(7): 918–922.</p><p>31. Van Suijlekom HA, De Vet HC, Van Den Berg SG, Weber WE.</p><p>Interobserver reliability in physical examination of the</p><p>cervical spine in patients with headache. Headache.</p><p>2000;40 (7):581–586.</p><p>32. Viikari-Juntura E, Porras M, Laasonen EM. Validity of</p><p>clinical tests in the diagnosis of root compression in</p><p>cervical disc disease. Spine. 1989;14(3):253–257.</p><p>CHAPTER 4 Physical Examination Tests for the Cervical Spine 141</p><p>33. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A,</p><p>Allison S. Reliability and diagnostic accuracy of the clini-</p><p>cal examination and patient self-report measures for</p><p>cervical radiculopathy. Spine 2003;28(1):52–62.</p><p>34. Zito G, Jull G, Story I. Clinical tests of musculoskeletal</p><p>dysfunction in the diagnosis of cervicogenic headache.</p><p>Man Ther. 2006;11:118–129.</p><p>PEARSON</p><p>Use this address to access the Companion Website created for this textbook. Simply select “Physical Therapy” from the</p><p>choice of disciplines. Find this book and log in using your username and password to access video clips of selected tests.</p><p>142</p><p>Physical</p><p>Examination Tests for</p><p>the Temporomandibular</p><p>Joint</p><p>CHAPTER</p><p>5</p><p>Jennifer Reneker and Chad E. Cook</p><p>Index of Tests</p><p>Tests for Temporomandibular Joint Dysfunction 143</p><p>Pain During Active Movements 143</p><p>Pain During Active-Assistive Opening 143</p><p>Pain During Palpatory Testing 144</p><p>Pain During Resistive Testing 145</p><p>Limitations of Mouth Opening (Active) 146</p><p>Limitations in Protrusion 146</p><p>Limitations in Lateral Condylar Translation 147</p><p>Limitations in Contralateral Movement 148</p><p>Limitations on Mouth Opening (Passive) 148</p><p>Deviation from Symmetrical during</p><p>Mouth Opening 149</p><p>Maximal Mouth Opening 150</p><p>Audible Sounds During Temporomandibular</p><p>Joint Movement (Crepitus) 150</p><p>Audible Sounds During Temporomandibular</p><p>Joint Movement (Presence of a Click) 151</p><p>Audible Sounds During Temporomandibular</p><p>Joint Movement (Presence of a Grating) 152</p><p>Pain During Joint Play 153</p><p>Composite Examination Results</p><p>for Classifications 153</p><p>CHAPTER 5 Physical Examination Tests for the Temporomandibular Joint 143</p><p>Pain During Active-Assistive Opening</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Manfredini et al.5 (effusion) NT 81.9 60.6 2.08 0.30 10</p><p>Stegenga et al.9 (DDR) NT 44 31 0.64 1.81 8</p><p>Stegenga et al.9 (DDNR) NT 74 57 1.72 0.46 8</p><p>Yatani et al.12 (DDR) NT 17 69.9 0.56 1.19 8</p><p>Yatani et al.12 (DDNR) NT 59.1 87.9 4.90 0.47 8</p><p>Comments: DDR = disc displacement with reduction; DDNR = disc displacement without reduction. Note that in all instances the</p><p>movements are used to differentiate one form of TMD classification from another.</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The patient is instructed to open his or her mouth and</p><p>report if the concordant pain is present during the opening</p><p>process or near the end range.</p><p>3 The clinician furthers the opening movement with an</p><p>active-assistive facilitation.</p><p>4 A positive test finding is concordant (familiar) pain during</p><p>any of the active movements.</p><p>UTILITY SCORE 2</p><p>TESTS FOR TEMPOROMANDIBULAR JOINT DYSFUNCTION</p><p>Pain During Active Movements</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The patient is instructed to open his or her mouth and</p><p>report if the concordant pain is present during the opening</p><p>process or near the end range.</p><p>3 A positive test finding is concordant (familiar) pain during</p><p>any of the active movements.</p><p>(continued)</p><p>144 CHAPTER 5 Physical Examination Tests for the Temporomandibular Joint</p><p>TESTS FOR TEMPOROMANDIBULAR JOINT DYSFUNCTION</p><p>Pain During Palpatory Testing</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The clinician instructs the patient to bite down and initi-</p><p>ates the palpation sequence by palpating the temporalis</p><p>and masseter muscles.</p><p>3 The clinician instructs the patient to fully open his or her</p><p>mouth and initiates the palpation sequence by palpating</p><p>the submandibular muscles.</p><p>4 The clinician then instructs the patient to relax.</p><p>5 The clinician palpates the joints of the TMJ externally, both</p><p>laterally and posteriorly.</p><p>6 A positive test finding is concordant (familiar) pain during</p><p>any of the palpatory tests.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Manfredini et al.5 (effusion) NT 93.4 1.6 0.95 4.13 10</p><p>Orsini et al.7 (DDNR) NT 55.4 90.8 6.02 0.49 10</p><p>Stegenga et al.9 (DDR) NT 47 29 0.66 1.83 8</p><p>Stegenga et al.9 (DDNR) NT 78 57 1.81 0.39 8</p><p>Comments: DDR = disc displacement with reduction; DDNR = disc displacement without reduction. Note that in all instances the</p><p>movements are used to differentiate one form of TMD classification from another. Appears to only have value during identification</p><p>of DDNR.</p><p>UTILITY SCORE 2</p><p>CHAPTER 5 Physical Examination Tests for the Temporomandibular Joint 145</p><p>TESTS FOR TEMPOROMANDIBULAR JOINT DYSFUNCTION</p><p>Pain During Resistive Testing</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Holmlund & Axelsson2 (synovitis) NT 88 36 1.38 0.33 7</p><p>Manfredini et al.5 (effusion) NT (P)85.2</p><p>(L)83.6</p><p>62.2</p><p>68.8</p><p>2.25</p><p>2.68</p><p>0.24</p><p>0.24</p><p>10</p><p>Stegenga et al.9 (DDR) NT 38 41 0.64 1.51 8</p><p>Stegenga et al.9 (DDNR) NT 66 67 2.00 0.51 8</p><p>Usumez et al.10 (DDR) NT 100 11.9 1.14 0 7</p><p>Usumez et al.10 (DDNR) NT 100 7.9 1.09 0 7</p><p>Visscher et al.11 (full region) NT 75 67 2.3 0.4 6</p><p>Lobbezoo-Scholte et al.4 (full region) NT 86 64 2.4 0.2 8</p><p>Comments: P = posterior; L = lateral; DDR = disc displacement with reduction; DDNR = disc displacement without reduction.</p><p>Note that in all instances the movements are used to differentiate one form of TMD classification from another. Appears to only</p><p>have value during identification of DDNR. The finding may be very useful to rule out TMD when differentiating the disorder</p><p>from a competing problem.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Manfredini et al.5 (effusion) NT 73.7 44.2 1.32 0.60 10</p><p>Comments: Resistive testing was only used to differentiate effusion from other forms of TMD.</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The clinician instructs the patient to bite down, open, lat-</p><p>erally deviate, protrude, and to perform retrusion, all with</p><p>resistance.</p><p>3 A positive test finding is concordant (familiar) pain during</p><p>any of the resistive testing.</p><p>UTILITY SCORE 3</p><p>146 CHAPTER 5 Physical Examination Tests for the Temporomandibular Joint</p><p>TESTS FOR TEMPOROMANDIBULAR JOINT DYSFUNCTION</p><p>Limitations of Mouth Opening (Active)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Orsini et al.7 (DDNR) NT 32.4 83.2 1.93 0.81 10</p><p>Stegenga et al.9 (DDR) NT 38 21 0.48 2.95 8</p><p>Stegenga et al.9 (DDNR) NT 86 62 2.26 0.23 8</p><p>Usumez et al.10 (DDR) NT 10.5 59.5 0.26 1.50 7</p><p>Usumez et al.10 (DDNR) NT 76.5 87.3 6.02 0.27 7</p><p>Yatani et al.12 (DDR) NT 5.4 69.8 0.18 1.36 8</p><p>Yatani et al.12 (DDNR) NT 43.3 83.6 2.64 0.68 8</p><p>Comments: DDR = disc displacement with reduction; DDNR = disc displacement without reduction. It's very difficult to determine</p><p>the value of restricted mouth opening. It does appear to slightly differentiate DDNR from DDR, in the one study of higher quality.</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The patient is instructed to open his or her mouth to its</p><p>limit.</p><p>3 A positive test is a reduction in full mouth opening.</p><p>UTILITY SCORE 2</p><p>Limitations in Protrusion</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The patient is instructed to protrude his or her mouth to</p><p>its limit.</p><p>3 A positive test is a reduction in full protrusion.</p><p>CHAPTER 5 Physical Examination Tests for the Temporomandibular Joint 147</p><p>TESTS FOR TEMPOROMANDIBULAR JOINT DYSFUNCTION</p><p>Limitations in Lateral Condylar Translation</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Holmlund & Axelsson2</p><p>(any disc dysfunction)</p><p>NT 90 40 1.5 0.25 6</p><p>Stegenga et al.9 (DDR) NT 29 38 0.47 1.87 8</p><p>Stegenga et al.9 (DDNR) NT 62 64 1.7 0.59 8</p><p>Comments: DDR = disc displacement with reduction; DDNR = disc displacement without reduction. Low quality studies reduce</p><p>the likelihood of truly knowing the value of this clinical finding.</p><p>UTILITY SCORE 3</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The patient is instructed to laterally transfer his or her</p><p>mandible to its limit.</p><p>3 A positive test is a reduction of lateral transfer.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Orsini et al.7 (DDNR) NT 68.9 80.7 3.57 0.39 10</p><p>Stegenga et al.9 (DDR) NT 15 38 2.4 2.24 8</p><p>Stegenga et al.9 (DDNR) NT 66 81 3.47 0.42 8</p><p>Yatani et al.12 (DDR) NT 10.7 56.1 0.24 1.59 8</p><p>Yatani et al.12 (DDNR) NT 77.8 82.5 4.44 0.27 8</p><p>Comments: DDR = disc displacement with reduction; DDNR = disc displacement without reduction. There appears to be value in</p><p>detecting a DDNR and differentiating this from a DDR or other classification.</p><p>148 CHAPTER 5 Physical Examination Tests for the Temporomandibular Joint</p><p>TESTS FOR TEMPOROMANDIBULAR JOINT DYSFUNCTION</p><p>Limitations in Contralateral Movement</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The patient is instructed to laterally transfer the jaw, com-</p><p>paring one side to the other.</p><p>3 A positive test is a reduction of movement of one side of</p><p>the jaw in comparison to the other.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Holmlund & Axelsson2 (ID) NT 60 54 1.3 0.74 6</p><p>Stegenga et al.9 (DDR) NT 15 34 0.22 2.5 8</p><p>Stegenga et al.9 (DDNR) NT 66 76 2.75 0.45 8</p><p>Comments: ID = internal dysfunction; DDR = disc displacement with reduction; DDNR = disc displacement without reduction.</p><p>Poorly designed studies reduce the assumptions of this finding. There appears to be marginal value in differentiating classifications.</p><p>UTILITY SCORE 3</p><p>Limitations on Mouth Opening (Passive)</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The clinician passively opens the patient's mouth to its</p><p>limit.</p><p>3 A positive finding is a reduction of mouth opening.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Stegenga et al.9 DDR NT 29 29 0.41 2.4 8</p><p>Stegenga et al.9 DDNR NT 76 69 2.45 0.35 8</p><p>Comments: DDR = disc displacement with reduction; DDNR = disc displacement without reduction. It is certainly not useful in</p><p>discriminating DDR.</p><p>UTILITY SCORE 3</p><p>CHAPTER 5 Physical Examination Tests for the Temporomandibular Joint 149</p><p>TESTS FOR TEMPOROMANDIBULAR JOINT DYSFUNCTION</p><p>Deviation from Symmetrical during Mouth Opening</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The patient is instructed to open their mouth near end</p><p>range.</p><p>3 The patient is instructed to deviate laterally their mouth</p><p>(left and right) near end range.</p><p>4 The patient is instructed to close their mouth to end</p><p>range.</p><p>5 A positive finding is any deviation from midline or a varia-</p><p>tion in lateral excursion from right to left.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Orsini et al.7 (DDNR) NT 32.4 87 2.49 0.78 10</p><p>Stegenga et al.9 (DDR</p><p>with correction)</p><p>NT 44 83 2.59 0.67 8</p><p>Stegenga et al.9 (DDNR</p><p>with correction)</p><p>NT 14 57 0.33 1.51 8</p><p>Stegenga et al.9 (DDR</p><p>without correction)</p><p>NT 18 41 0.30 2.0 8</p><p>Stegenga et al.9 (DDNR</p><p>without correction)</p><p>NT 66 83 3.88 0.41 8</p><p>Usumez et al.10 (DDR) NT 92.1 31 1.33 0.25 7</p><p>Usumez et al.10 (DDNR) NT 35.3 7.9 0.38 8.19 7</p><p>Lobbezoo-Scholte et al.4</p><p>(any deviation)</p><p>NT 56 83 3.3 0.5 8</p><p>Lobbezoo-Scholte et al.4</p><p>(any deviation)</p><p>NT 95 45 1.7 0.1 8</p><p>Comments: DDR = disc displacement with reduction; DDNR = disc displacement without reduction. Several studies have looked</p><p>at this and there does appear to be value in looking at deviation during movement.</p><p>UTILITY SCORE 2</p><p>150 CHAPTER 5 Physical Examination Tests for the Temporomandibular Joint</p><p>TESTS FOR TEMPOROMANDIBULAR JOINT DYSFUNCTION</p><p>Maximal Mouth Opening</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The patient is instructed to open his or her mouth to the</p><p>widest possible tolerated level.</p><p>3 The clinician measures the height of the opening by mea-</p><p>suring the space between the bottom of the top teeth and</p><p>the top of the bottom teeth.</p><p>4 A positive test finding is concordant (familiar) pain dur-</p><p>ing maximal mouth opening or measured limitations in</p><p>opening.</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Visscher et al.11 (overpressure</p><p>during maximal mouth opening)</p><p>NT 80 64 2.2 0.3 6</p><p>Dworkin et al.1 (maximal mouth</p><p>opening of</p><p>his</p><p>or her mouth, with an effort toward going through full</p><p>range.</p><p>4 A positive test finding is the sound of grating during the</p><p>movements.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Dworkin et al.1 (presence of grating) NT 6 99 6 0.9 8</p><p>Comments: Grating is a very specific finding. How grating differs from crepitus is less known.</p><p>UTILITY SCORE</p><p>CHAPTER 5 Physical Examination Tests for the Temporomandibular Joint 153</p><p>TESTS FOR TEMPOROMANDIBULAR JOINT DYSFUNCTION</p><p>Pain During Joint Play</p><p>1 The patient is seated with the mouth partially closed, near</p><p>its resting position.</p><p>2 The clinician places his or her thumb on top of the molars</p><p>and grasps the jaw with the fingers.</p><p>3 The clinician applies a downward and slight anterior glide</p><p>to the TMJ.</p><p>4 A positive test finding is a reduction of joint play during</p><p>this passive assessment.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Manfredini et al.5 (effusion) NT 80.3 39.3 1.3 0.50 10</p><p>Comments: No apparent benefit of joint play to detect effusion.</p><p>UTILITY SCORE 3</p><p>Composite Examination Results for Classifications</p><p>1 A composite examination includes combined findings that represent pre-set criteria for diagnosis.</p><p>2 The composite examination includes palpation, pain during movement, maximal mouth opening</p><p>deficits, and/or asymmetrical movements.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Paesani et al.8 (combined</p><p>examination for arthrosis)</p><p>NT 42 90 4.2 0.6 8</p><p>Paesani et al.8 (combined</p><p>examination for internal</p><p>derangement)</p><p>NT 78 52 1.6 0.4 8</p><p>Israel et al.3 (combined</p><p>examination for osteoarthritis)</p><p>NT 98 71 3.4 0.3 6</p><p>Israel et al.3 (combined</p><p>examination for synovitis)</p><p>NT 92 21 1.2 0.4 6</p><p>Lobbezoo-Scholte et al.4</p><p>(full region for myositis)</p><p>NT 56 83 3.3 0.5 8</p><p>Comments: As with most composite findings, the full examination tends to provide somewhat better diagnostics than individual</p><p>clinical tests and measures. Unfortunately, most articles were not descriptive in their explanation of total tests needed or distinct</p><p>combinations.</p><p>UTILITY SCORE 1</p><p>154 CHAPTER 5 Physical Examination Tests for the Temporomandibular Joint</p><p>Key Points</p><p>1. The majority of tests differentiate subclassifications</p><p>of TMD and not whether one has TMD.</p><p>2. The majority of tests for TMD provide little value</p><p>in differentiation.</p><p>References</p><p>1. Dworkin S, LeResche L, DeRouen T. Assessing clinical</p><p>signs of temporomandibular disorders: reliability of</p><p>clinical examiners. J Prosthet Dent. 1990; 63:574–579.</p><p>2. Holmlund AB, Axelsson S. Temporomandibular arthrop-</p><p>athy: correlation between clinical signs and symptoms</p><p>and arthroscopic findings. Int J Oral Maxillofac. 1996;</p><p>25:178–181.</p><p>3. Israel HA, Diamond B, Saed-Nejad F, Ratcliffe A. Osteo-</p><p>arthritis and synovitis as major pathoses of the tem-</p><p>poromandibular joint: comparison of clinical diagnosis</p><p>with arthroscopic morphology. J Oral Maxillo Surg.</p><p>1998;56:1023–1028.</p><p>4. Lobbezoo-Scholte AM, Steenks MH, Faber JA, Bos-</p><p>man F. Diagnostic value of orthopedic tests in patients</p><p>with temporomandibular disorders. J Dent Res.</p><p>1993;72:1443–1453.</p><p>5. Manfredini D, Tognini F, Zampa V, Bosco M. Predic-</p><p>tive value of clinical findings for temporomandibular</p><p>joint effusion. Oral Surg Oral Med Oral Pathol Oral Radiol</p><p>Endod. 2003;96:521–526.</p><p>6. Manfredini D, Basso D, Salmaso L, Guarda-Nardini L.</p><p>Temporomandibular joint click sound and magnetic</p><p>resonance-depicted disk position: which relationship?</p><p>J Dentistry. 2008;36:256–260.</p><p>7. Orsini MG, Kuboki T, Terada S, Matsuka Y, Yatani</p><p>H, Yamachita A. Clinical predictability of tempo-</p><p>romandibular joint disc displacement. J Dent Res.</p><p>1999;78:650–660.</p><p>8. Paesani D, Westesson PL, Hatala MP, Tallents RH, Brooks</p><p>SL. Accuracy of clinical diagnosis for TMJ internal</p><p>derangement and arthrosis. Oral Surg Oral Med Oral</p><p>Pathol. 1992;73:360–363.</p><p>9. Stegenga B, de Bont LGM, van der Kuijl B, Boering G.</p><p>Classification of temporomandibular joint osteoarthri-</p><p>tis and internal derangement. Part I Diagnostic signifi-</p><p>cance of clinical and radiographic symptoms and signs.</p><p>J Craniomandibular Pract. 1992;10:96–117.</p><p>10. Usumez S, Oz F, Guray E. Comparison of clinical and</p><p>magnetic resonance imaging diagnoses in patients with</p><p>TMD history. J Oral Rehab. 2004; 31:52–56.</p><p>11. Visscher CM, Naeije M, De Laat A, et al. Diagnostic</p><p>accuracy of temporomandibular disorder pain tests: a</p><p>multicenter study. J Orofacial Pain. 2009;23:108–114.</p><p>12. Yatani H, Suzuki K, Kuboki T, Matsuka Y, Maekawa K,</p><p>Yamashita A. The validity of clinical examination for</p><p>diagnosing anterior disk displacement without reduc-</p><p>tion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.</p><p>1998;85:654–660.</p><p>Use this address to access the Companion Website created for this textbook. Simply select “Physical Therapy” from the</p><p>choice of disciplines. Find this book and log in using your username and password to access video clips of selected tests.</p><p>PEARSON</p><p>155</p><p>Physical Examination</p><p>Tests for the Shoulder</p><p>Complex</p><p>CHAPTER</p><p>6</p><p>Eric J. Hegedus</p><p>Index of Tests</p><p>Screening for Bony Abnormality 158</p><p>Olecranon-Manubrium Percussion Test</p><p>(Fracture or Dislocation between</p><p>the Elbow and Manubrium) 158</p><p>The Bony Apprehension Test</p><p>(A Bony Lesion Causing Anterior</p><p>Instability of the Shoulder) 159</p><p>Torn Rotator Cuff/Impingement 160</p><p>External Rotation Lag Sign</p><p>(Supraspinatus/Infraspinatus Tear) 160</p><p>Rent Test [Rotator Cuff (RC) Tear] 161</p><p>Supine Impingement Test (RC Tear) 162</p><p>Lift-Off Test (Subscapularis Tear) 163</p><p>Internal Rotation Lag Sign</p><p>(Subscapularis Tear) 164</p><p>Drop Sign (Infraspinatus Tear,</p><p>Irreparable Fatty Degeneration</p><p>of Infraspinatus) 165</p><p>Empty Can Test/Supraspinatus Test</p><p>(Rotator Cuff Tear, All Stages</p><p>of Impingement Syndrome from</p><p>Bursitis through a Rotator Cuff Tear) 166</p><p>Belly Press/Napoleon Test</p><p>(Subscapularis Tear) 167</p><p>Bear-Hug Test (Subscapularis Tear) 168</p><p>Lateral Jobe Test (RC Tear) 169</p><p>Drop Arm Test (Supraspinatus Tear,</p><p>Subacromial Impingement) 170</p><p>Full Can/Supraspinatus Test</p><p>(Supraspinatus Tear) 171</p><p>Posterior Impingement Sign (Rotator Cuff</p><p>Tear and/or Posterior Labral Tear) 172</p><p>Hornblower’s Sign (Irreparable Fatty</p><p>Degeneration of Teres Minor) 172</p><p>Whipple Test (Supraspinatus Tear) 173</p><p>Diagnostic Clusters—Rotator Cuff Tear 174</p><p>Impingement Tests 175</p><p>Internal Rotation Resisted Strength Test</p><p>(Internal/Intraarticular vs.</p><p>External/Subacromial Impingement) 175</p><p>Infraspinatus/External Rotation</p><p>Resistance Test (All Stages</p><p>of Subacromial Impingement) 176</p><p>Neer Test (Subacromial Impingement,</p><p>Subacromial Bursitis (SAB), Rotator</p><p>Cuff Tear, Superior Labral Tear) 177</p><p>Hawkins-Kennedy Test (Subacromial</p><p>Impingement, Subacromial Bursitis,</p><p>Rotator Cuff Tear, Superior Labral Tear) 178</p><p>Painful Arc Test (All Stages</p><p>of Subacromial Impingement) 179</p><p>Cross-Body Adduction Test</p><p>[Subacromial Impingement,</p><p>Acromioclavicular (AC) Joint Damage] 180</p><p>Diagnostic Clusters—Impingement 180</p><p>156 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>Torn Labrum/Instability Tests 181</p><p>Biceps Load Test II (SLAP Lesion) 181</p><p>Yergason’s Test (Subacromial</p><p>Impingement, Superior Labral</p><p>Anterior to Posterior (SLAP) Lesion,</p><p>Any Labral Lesion, Long Head</p><p>of Biceps Pathology) 182</p><p>Crank Test (Labral Tear, SLAP Lesion) 183</p><p>Kim Test (Posteroinferior Labral Lesion) 184</p><p>Jerk Test (Posteroinferior Labral Lesion) 185</p><p>Anterior Release/Surprise Test</p><p>(Anterior Instability) 186</p><p>Pain Provocation Test (SLAP Lesion) 187</p><p>Passive Compression Test (SLAP Lesion) 188</p><p>Apprehension Test (Anterior Instability,</p><p>All Instabilities of the Glenohumeral</p><p>Joint, Labral Tear, SLAP Lesion) 189</p><p>Modified Dynamic Labral Shear Test</p><p>(Labral Tear) 190</p><p>Modified Relocation/Modified Jobe</p><p>Relocation Test (Labral Pathology,</p><p>Traumatic Anterior Instability) 191</p><p>Apprehension-Relocation/Jobe</p><p>Relocation Test (Anterior Instability,</p><p>Labral Tear, SLAP Lesion) 192</p><p>Supine Flexion Resistance Test</p><p>(Type II SLAP Lesion) 193</p><p>Speed’s Test [All Stages of Subacromial Impinge-</p><p>ment, Superior Labral Anterior</p><p>to Posterior (SLAP) Lesion, Any Labral</p><p>Lesion, Biceps Pathology] 194</p><p>Forced Shoulder Abduction and Elbow</p><p>Flexion Test (Superior Labral Tear) 195</p><p>Sulcus Sign (Inferior Laxity, Superior</p><p>Labral Tear) 196</p><p>Active Compression Test/O’Brien’s Test</p><p>[Labral Tear, SLAP Lesion, Labral</p><p>Abnormality, Acromioclavicular</p><p>(AC) Joint Pathology] 197</p><p>Resisted Supination External Rotation Test</p><p>(RSERT) (SLAP Lesion) 198</p><p>Compression-Rotation Test (SLAP Lesion) 199</p><p>Anterior Slide Test (SLAP Lesion) 200</p><p>Biceps Load Test (SLAP Lesion</p><p>with Anterior Shoulder Dislocation) 201</p><p>Clunk Test (Labral Tear, Superior</p><p>Labral Tear) 202</p><p>Anterior Drawer Test (Anterior Laxity,</p><p>Anterior Instability) 203</p><p>Biceps Tension Test (Unstable Superior</p><p>Labrum—Lesions/SLAP Lesions) 203</p><p>Hyperabduction Test (Inferior Laxity) 204</p><p>Posterior Drawer Test (Posterior Laxity) 205</p><p>Load and Shift Test (Anterior, Posterior,</p><p>Inferior Laxity) 206</p><p>Diagnostic Clusters—Instability 207</p><p>Diagnostic Clusters—Labral Tears 208</p><p>Acromioclavicular (AC) Dysfunction Tests 209</p><p>AC Resisted Extension Test</p><p>(AC Joint Abnormality) 209</p><p>AC Joint Palpation (AC Joint Pain) 210</p><p>Paxinos Sign (AC Joint Pain) 210</p><p>Diagnostic Clusters—AC Joint Pathology 211</p><p>Nerve Palsies 211</p><p>Active Elevation Lag Sign</p><p>(Spinal Accessory Nerve Palsy) 211</p><p>The Triangle Sign</p><p>(Spinal Accessory Nerve Palsy) 212</p><p>Deltoid Extension Lag Sign</p><p>(Axillary Nerve Palsy) 213</p><p>Stiffness-Related Disorders [Osteoarthritis (OA) & Adhesive Capsulitis] 214</p><p>Shrug Sign (OA & Adhesive Capsulitis) 214</p><p>Coracoid Pain Test (Adhesive Capsulitis) 214</p><p>Diagnostic Clusters—Adhesive Capsulitis 215</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 157</p><p>Test For Scapular Dysfunction 215</p><p>Lateral Scapular Slide Test</p><p>(Shoulder Dysfunction) 215</p><p>Tests For Biceps Tendinopathy 217</p><p>Upper Cut Test (Biceps Tendinopathy) 217</p><p>Biceps Palpation</p><p>(Biceps Tear, Type II SLAP) 217</p><p>Diagnostic Clusters—Biceps</p><p>Tendinopathy 218</p><p>158 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Adams et al.1 NT 84 99 84.0 0.27 13</p><p>Comments: According to Adams et al., when the Olecranon-Manubrium Percussion Test1 is positive, the clinician should order an</p><p>x-ray. More research needs to be done to raise the Utility Score to a “1.”</p><p>SCREENING FOR BONY ABNORMALITY</p><p>1 The patient is seated or standing with arms crossed.</p><p>2 The examiner taps on the involved side olecranon while</p><p>using a stethoscope placed on the patient’s manubrium.</p><p>3 Repeat step 2 but on the uninvolved side.</p><p>4 A positive test for fracture or dislocation is indicated by a</p><p>difference in the quality of sound on the involved vs. the</p><p>uninvolved side.</p><p>Olecranon-Manubrium Percussion Test (Fracture or Dislocation</p><p>between the Elbow and Manubrium)</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 159</p><p>SCREENING FOR BONY ABNORMALITY</p><p>1 The patient is seated or standing.</p><p>2 The examiner stands behind the patient and grasps the</p><p>suprascapular/supraclavicular region with one hand and</p><p>the patient’s proximal forearm with the other hand.</p><p>3 With the elbow flexed to 90 degrees, the examiner abducts</p><p>the shoulder to 45 degrees or less and externally rotates</p><p>the shoulder to 45 degrees or less.</p><p>4 A positive test for anterior instability due to a bony lesion</p><p>is indicated by the patient registering apprehension with</p><p>the test.</p><p>The Bony Apprehension Test (A Bony Lesion</p><p>Causing Anterior Instability of the Shoulder)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Bushnell et al.7 NT 94 84 5.88 0.07 9</p><p>Comments: The Bony Apprehension Test7 appears to be a screen for instability due to a Bankart or Hill-Sachs lesion but also has</p><p>moderate diagnostic ability. More research needs to be done to raise the Utility Score to a “1.”</p><p>UTILITY SCORE 2</p><p>160 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>1 The patient is seated with the examiner standing to the</p><p>rear.</p><p>2 The examiner grasps the patient’s elbow with one hand</p><p>and the wrist with the other.</p><p>3 The examiner places the elbow in 90 degrees of flexion</p><p>and the shoulder in 20 degrees of elevation in the scapular</p><p>plane.</p><p>4 The examiner passively externally rotates the shoulder to</p><p>near end-range.</p><p>External Rotation Lag Sign (Supraspinatus/Infraspinatus Tear)</p><p>5 The examiner asks the patient to maintain this position as</p><p>the patient’s wrist is released.</p><p>6 A positive test for supraspinatus/infraspinatus tear is indi-</p><p>cated by a lag that occurs with the inability of the patient</p><p>to maintain his or her arm near full external rotation.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Hertel et al.27 (Infraspinatus) NT 70 100 NA NA 8</p><p>Walch et al.82 (Teres Minor) NT 100 100 NA NA 6</p><p>Jia et al.34 (Massive RC Tear</p><p>Biceps Tendinopathy)</p><p>NT</p><p>NT</p><p>35</p><p>20</p><p>89</p><p>88</p><p>3.18</p><p>1.67</p><p>0.73</p><p>0.91 6</p><p>Miller et al.60 (Full Thickness Tear) NT 46 94 7.2 0.60 11</p><p>Bak et al.4</p><p>(Full Thickness Supraspinatus Tear)</p><p>NT 45 91 5.00 0.61 13</p><p>Castoldi et al.10</p><p>(Full Thickness-Supraspinatus</p><p>Full Thickness Rotator Cuff Tears</p><p>Teres Minor Tear)</p><p>NT</p><p>56</p><p>97</p><p>100</p><p>98</p><p>93</p><p>93</p><p>28.0</p><p>13.86</p><p>14.29</p><p>0.45</p><p>0.03</p><p>0.00</p><p>10</p><p>Comments: The External Rotation Lag Sign appears to be specific for more severe rotator cuff tears.</p><p>UTILITY SCORE 1</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 161</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Wolf & Agrawal85 NT 96 97 32 0.04 9</p><p>Lyons & Tomlinson53 NT 91 75 3.64 0.12 6</p><p>Comments: The Rent Test12 should not be used to judge the size of a rotator cuff tear but rather the absence or presence of a</p><p>rotator cuff tear. The quality of the studies keeps this Utility Score from being a 1.</p><p>1 The patient is seated with arm relaxed and the examiner</p><p>stands to the rear.</p><p>2 The examiner palpates anterior to the anterior edge of</p><p>the acromion with one hand while grasping the patient’s</p><p>flexed elbow with the other.</p><p>Rent Test [Rotator Cuff (RC) Tear]</p><p>3 The examiner extends the patient’s arm and then slowly</p><p>internally and externally rotates the shoulder.</p><p>4 An eminence (prominent greater tuberosity) and a rent</p><p>(depression of about 1 finger width) will be felt in the</p><p>presence of a rotator cuff tear.</p><p>UTILITY SCORE 2</p><p>162 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Litaker et al.49 NT 97 9 1.07 0.33 11</p><p>Comments: This study was done well but retrospectively. The supine impingement test does not appear diagnostic but may have</p><p>value as a screen because a negative finding may rule out a rotator cuff tear. Further research needs to be performed.</p><p>1 The patient assumes a supine position. The examiner</p><p>stands to the side of the patient’s involved shoulder.</p><p>2 The examiner grasps the patient’s wrist and distal humerus</p><p>and elevates the patients arm to end-range (170 degrees</p><p>or greater).</p><p>3 The examiner next moves the patient’s arm into external</p><p>rotation then adducts the arm to the patient’s ear.</p><p>4 The examiner now internally rotates the patient’s arm.</p><p>5 The supine impingement test is positive if the patient</p><p>reports a significant increase in shoulder pain.</p><p>Supine Impingement Test49 (RC Tear)</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 163</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Gerber & Krushell20 NT 89 98 44.5 0.11 8</p><p>Hertel et al.27 NT 62 100 NA NA 8</p><p>Ostor et al.69 κ = .28–.32 NT NT NT NT NA</p><p>Jia et al.34 (Massive RC</p><p>Tear,Glenohumeral OA</p><p>Biceps Tendinopathy)</p><p>NT</p><p>NT</p><p>NT</p><p>28</p><p>29</p><p>28</p><p>86</p><p>89</p><p>90</p><p>2.0</p><p>2.7</p><p>2.8</p><p>0.84</p><p>0.80</p><p>0.80</p><p>6</p><p>Barth et al.5 NT 18 100 NA NA 11</p><p>Gill et al.21 (Partial Biceps Tear) NT 28 89 2.61 0.90 12</p><p>Itoi et al.31 (Pain</p><p>Weakness)</p><p>NT</p><p>NT</p><p>46</p><p>79</p><p>69</p><p>59</p><p>1.48</p><p>1.93</p><p>0.78</p><p>0.36</p><p>8</p><p>Comments: The study by Gerber and Krushell20 had only 16 patients,</p><p>all of whom were male. Two studies show high specificity,</p><p>meaning this test has value, when positive, of ruling in a subscapularis tear or biceps pathology but more research needs to be</p><p>performed incorporating larger sample sizes. Of some concern is fair interobserver agreement.</p><p>1 The patient is seated with affected arm behind his or her</p><p>back.</p><p>2 The patient is asked to lift the arm off the back.</p><p>3 A positive test for subscapularis tear is indicated by inability</p><p>of the patient to lift the arm off the back.</p><p>Lift-Off Test20 (Subscapularis Tear)</p><p>UTILITY SCORE 2</p><p>164 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Hertel et al.27 NT 97 96 24.25 0.03 8</p><p>Scheibel et al.75 NT 75 NT NT NT 6</p><p>Miller et al.60 (Full Thickness Tear) NT 100 84 6.2 0.00 11</p><p>Bak et al.4 (Full Thickness</p><p>Supraspinatus Tear)</p><p>NT 31 87 2.38 0.79 13</p><p>Comments: Despite the solid statistical numbers, the Utility Score is only a 2 due to potential for bias in the conducting of the</p><p>Hertel et al.27 study or incomplete reporting of the study findings. More research still needs to be performed as the Miller et al.60</p><p>study used diagnostic ultrasound as the criterion standard on a small sample size and Bak et al.4 did not use the test to detect</p><p>subscapularis tears.</p><p>1 The patient is seated with affected arm behind his or her</p><p>back.</p><p>2 The examiner grasps the patient’s elbow with one hand</p><p>and the wrist with the other.</p><p>3 The examiner lifts the patient’s arm off the back.</p><p>4 The examiner asks the patient to maintain this position as</p><p>the patient’s wrist is released.</p><p>5 A positive test for subscapularis tear is indicated by a lag</p><p>that occurs with the inability of the patient to maintain the</p><p>arm off the back.</p><p>Internal Rotation Lag Sign27 (Subscapularis Tear)</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 165</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Hertel et al.27 NT 20 100 NA NA 8</p><p>Walch et al.82 NT 100 100 NA NA 6</p><p>Miller et al.60(Full ThicknessTear) NT 73 77 3.2 0.30 11</p><p>Bak et al.4 (Full Thickness</p><p>Supraspinatus Tear)</p><p>NT 45 70 1.50 0.79 13</p><p>Comments: More research needs to be performed, especially in light of the quality of the first two studies and because the Miller</p><p>et al.60 study used diagnostic ultrasound as the criterion standard on a small sample size. Further, the two stronger studies did not</p><p>report the test value in patients with infraspinatus tears as was the original design.</p><p>1 The patient is seated with the examiner standing to the</p><p>rear.</p><p>2 The examiner grasps the patient’s elbow with one hand</p><p>and the wrist with the other.</p><p>3 The examiner places the elbow in 90 degrees of flexion</p><p>and the shoulder in 90 degrees of elevation in the scapular</p><p>plane.</p><p>4 The examiner passively externally rotates the shoulder to</p><p>near end-range</p><p>5 The examiner asks the patient to maintain this position as</p><p>the patient’s wrist is released.</p><p>6 A positive test for infraspinatus tear is indicated by a lag</p><p>that occurs with the inability of the patient to maintain the</p><p>arm near full external rotation.</p><p>Drop Sign27 (Infraspinatus Tear, Irreparable Fatty</p><p>Degeneration of Infraspinatus)</p><p>UTILITY SCORE 2</p><p>166 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Itoi et al.30(Supraspinatus Tear) NT 89 50 1.78 0.22 9</p><p>Park et al.72 (Impingement or Rotator</p><p>Cuff Disease)</p><p>NT 44 90 4.2 0.63 10</p><p>Ostor et al.69 (Supraspinatus Tear) κ =.44−.49 NT NT NA NA NA</p><p>Michener et al.59 (Impingement) κ = .47 50 87 3.90 0.57 11</p><p>Kim et al.42</p><p>Full Thickness Tear (Pain or Weak)</p><p>Full Thickness Tear (Pain & Weak)</p><p>Any Tear (Pain or Weak)</p><p>Any Tear (Pain & Weak)</p><p>NT</p><p>84</p><p>60</p><p>99</p><p>71</p><p>59</p><p>91</p><p>43</p><p>74</p><p>2.05</p><p>6.67</p><p>1.74</p><p>2.73</p><p>0.27</p><p>0.44</p><p>0.02</p><p>0.39</p><p>9</p><p>Kelly et al.38 (Impingement, Weakness,</p><p>Pain)</p><p>NT 52</p><p>52</p><p>67</p><p>33</p><p>1.58</p><p>0.78</p><p>0.63</p><p>1.45</p><p>11</p><p>Itoi et al.31 (Pain</p><p>Weakness)</p><p>NT</p><p>NT</p><p>78</p><p>87</p><p>40</p><p>43</p><p>1.30</p><p>1.53</p><p>0.55</p><p>0.30</p><p>8</p><p>Bak et al.4 (Full Thickness Supraspinatus Tear) NT 76 39 1.25 0.62 13</p><p>Comments: This test was originally described by Jobe & Moynes36 as a supraspinatus strength test only, without a provocation component.</p><p>Itoi et al.30 used weakness, pain, or both as a positive sign and looked at the ability of the test to detect damage in any of the rotator cuff</p><p>muscles. Kim et al.42 gave different estimates of diagnostic accuracy depending on the definition of a tear and of a positive test. The Empty</p><p>Can is sensitive for a rotator cuff tear when the definition of a positive test is broad and specific as the definition of a positive test narrows.</p><p>1 The patient elevates the arms to 90 degrees with thumbs</p><p>up (full can position).</p><p>2 The examiner provides downward pressure on the arms</p><p>and notes the patient’s strength.</p><p>3 The patient elevates the arms to 90 degrees and horizon-</p><p>tally adducts 30 degrees (scapular plane) with thumbs</p><p>pointed down as if “emptying a can.”</p><p>4 The examiner provides downward pressure on the arms</p><p>and notes the patient’s strength.</p><p>5 A positive test for rotator cuff tear is examiner assessment</p><p>of more weakness in the empty can position vs. the full can</p><p>position, patient complaint of pain, or both.</p><p>Empty Can Test/Supraspinatus Test36 (Rotator Cuff Tear, All Stages</p><p>of Impingement Syndrome from Bursitis through a Rotator Cuff Tear)</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 167</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Gerber et al.19 NT NT NT NA NA NA</p><p>Scheibel et al.75 NT 69 NR NA NA 6</p><p>Barth et al.5</p><p>(Belly Press Subscapularis Tear)</p><p>NT 40 98 20.0 0.61 11</p><p>Barth et al.5</p><p>(Napoleon Subscapularis Tear)</p><p>NT 25 98 12.50 0.77 11</p><p>Gill et al.21</p><p>(Belly Press Partial Biceps Tear)</p><p>NT 17 92 2.01 0.90 12</p><p>Comments: The Belly Press Test19 was originally described as an alternative to the Lift-off Test in those patients without adequate</p><p>internal shoulder rotation but still with a suspected subscapularis tear. The Napoleon Test is performed in the same fashion as the</p><p>Belly Press except the definition of a positive Napoleon Test is wrist flexion substituting for humeral internal rotation. In addition to</p><p>a subscapularis tear, pain in the anterior shoulder with the Napoleon Test may be specific for a partial biceps tear.</p><p>1 The patient can sit or stand with elbow flexed to 90</p><p>degrees.</p><p>2 The patient internally rotates the shoulder, causing the</p><p>palm of the hand to be pressed into the stomach.</p><p>3 A positive test is indicated by the elbow dropping behind</p><p>the body into extension.</p><p>Belly Press/Napoleon Test19 (Subscapularis Tear)</p><p>UTILITY SCORE 2</p><p>168 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Barth et al.5 (Subscapularis Tear) NT 60 92 7.23 0.44 11</p><p>Kibler et al.41 (Biceps Pathology</p><p>Labral Tear)</p><p>NT 79</p><p>37</p><p>60</p><p>32</p><p>1.94</p><p>0.54</p><p>0.74</p><p>1.98</p><p>9</p><p>Comment: The Bear Hug Test5 appears to be specific for a torn subscapularis tear but one study does not a special test make.</p><p>Further, the test is of no use in detecting biceps pathology or a labral tear but that is not the purpose of the test anyway.</p><p>1 The patient places the palm of the involved side on the</p><p>opposite shoulder, elbow flexed and pointing straight</p><p>ahead, fingers extended.</p><p>2 The examiner attempts to pull the hand upward and off</p><p>the opposite shoulder.</p><p>3 A positive test for subscapularis tear is if the patient cannot</p><p>hold the hand against the shoulder.</p><p>Bear-Hug Test62 (Subscapularis Tear)</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 169</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Gillooly et al.22 NT 81 89 7.36 0.10 10</p><p>Comments: Based on this one well-performed study, the</p><p>Lateral Jobe Test22 modifies the posttest probability of diagnosing a rota-</p><p>tor cuff tear a moderate to large amount and could be used as a diagnostic tool. More research needs to be performed to confirm</p><p>these statistical numbers.</p><p>1 The patient is standing with arms abducted to 90 degrees.</p><p>2 The patient internally rotates to end-range humeral</p><p>motion.</p><p>3 The examiner applies an inferior force to the patient’s</p><p>elbows as the patient resists.</p><p>4 A positive test is indicated by pain reproduction or weak-</p><p>ness or inability to perform the test.</p><p>Lateral Jobe Test (RC Tear)</p><p>UTILITY SCORE 2</p><p>170 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Calis et al.8 (Supraspinatus Tear</p><p>Impingement)</p><p>NT</p><p>NT</p><p>15</p><p>8</p><p>100</p><p>97</p><p>NA</p><p>2.66</p><p>NA</p><p>.94</p><p>8</p><p>8</p><p>Murrell & Walton63 (Rotator Cuff Tear) NT 10 98 5.00 .92 5</p><p>Park et al.72 (Impingement or Rotator</p><p>Cuff Disease)</p><p>NT 27 88 2.25 .83 10</p><p>Ostor et al.69 (Supraspinatus Tear) κ = .28−.66 NT NT NA NA NA</p><p>Jia et al.34 (RC Tendinopathy</p><p>Full Thickness Tear</p><p>Massive Tear)</p><p>NT 74</p><p>35</p><p>44</p><p>66</p><p>88</p><p>82</p><p>2.15</p><p>2.79</p><p>2.48</p><p>0.39</p><p>0.74</p><p>0.68</p><p>6</p><p>Bak et al.4 Full Thickness Supraspinatus</p><p>Tear</p><p>NT 41 83 2.41 0.71 13</p><p>Comments: Calis et al.8 used subacromial injection as the criterion standard when surgery is the better choice. Park et al.72 used</p><p>this as an active test where the patient moved the arm through “elevation” and looked for a “drop” as the patient lowered the arm.</p><p>If this test has value, it is in a positive finding to rule in either a rotator cuff tear or impingement. The likelihood ratios indicate this</p><p>is only a modest diagnostic test at best despite fair to significant interobserver agreement.</p><p>UTILITY SCORE 3</p><p>1 The patient is standing with the examiner, standing to the</p><p>front.</p><p>2 The examiner grasps the patient’s wrist and passively</p><p>abducts the patient’s shoulder to 90 degrees.</p><p>3 The examiner releases the patient’s arm with instructions</p><p>to slowly lower the arm.</p><p>4 A positive test for supraspinatus tear is the inability by the</p><p>patient to lower the arm.</p><p>Drop Arm Test (Supraspinatus Tear, Subacromial Impingement)</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 171</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>1 The patient elevates the arms to 90 degrees with thumbs</p><p>up (full can position).</p><p>2 The examiner provides downward pressure on the arms</p><p>and notes the patient’s strength.</p><p>3 A positive test for rotator cuff tear is examiner assessment</p><p>of more weakness in the involved shoulder, patient com-</p><p>plaint of pain, or both.</p><p>Full Can/Supraspinatus Test (Supraspinatus Tear)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Itoi et al.30 NT 86 57 2.00 0.25 9</p><p>Kim et al.42</p><p>Full Thickness Tear (Pain or Weak)</p><p>Full Thickness Tear (Pain & Weak)</p><p>Any Tear (Pain or Weak)</p><p>Any Tear (Pain & Weak)</p><p>NT</p><p>74</p><p>42</p><p>90</p><p>59</p><p>68</p><p>91</p><p>54</p><p>82</p><p>2.31</p><p>4.67</p><p>1.96</p><p>3.28</p><p>0.38</p><p>0.64</p><p>0.19</p><p>0.50</p><p>9</p><p>Kelly et al.38 (Impingement</p><p>Weakness</p><p>Pain)</p><p>NT</p><p>45</p><p>35</p><p>75</p><p>25</p><p>1.8</p><p>0.45</p><p>0.73</p><p>2.60</p><p>11</p><p>Itoi et al.31 Pain</p><p>Weakness</p><p>NT</p><p>NT</p><p>80</p><p>83</p><p>50</p><p>53</p><p>2.67</p><p>1.77</p><p>0.40</p><p>0.32</p><p>8</p><p>Comments: Kelly et al.37 first described this test as a less painful alternative test to the Empty Can Test. Like the Empty Can Test,</p><p>this test was originally designed as a supraspinatus strength test only, but as the definition of a positive test broadens, the test</p><p>becomes more sensitive and as the definition narrows, the test becomes more specific. The Full Can has limited ability to modify</p><p>the probability of diagnosing or ruling out a rotator cuff tear.</p><p>UTILITY SCORE 3</p><p>172 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>1 With the patient in supine, the shoulder is placed in</p><p>90–110 degrees of abduction, 10–15 degrees of exten-</p><p>sion, and maximum external rotation.</p><p>2 A positive test is indicated by complaints of pain in the</p><p>deep posterior shoulder.</p><p>Posterior Impingement Sign (Rotator Cuff Tear</p><p>and/or Posterior Labral Tear)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Meister et al.58 NT 76 85 5.06 0.28 6</p><p>Comments: Despite good statistical numbers, the gender of the patients in this study was not specified and other design flaws leave</p><p>a great potential for bias. More research needs to be performed, especially in light of the quality of this study.</p><p>UTILITY SCORE 3</p><p>1 The patient is seated and the examiner supports the</p><p>patients shoulder in 90 degrees of abduction in the scapu-</p><p>lar plane.</p><p>2 The elbow is flexed to 90 degrees and the patient is asked</p><p>to forcefully externally rotate the shoulder against the</p><p>examiner’s resistance.</p><p>3 A positive test is indicated by the inability of the patient to</p><p>externally rotate in this position.</p><p>Hornblower’s Sign (Irreparable Fatty Degeneration of Teres Minor )</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 173</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Walch et al.82 NT 100 93 NA NA 6</p><p>Comments: Despite the solid statistical numbers, the Utility Score is only a 3 due to potential for bias in the conduct of this study</p><p>or incomplete reporting of the study findings. More research needs to be performed, especially in light of the quality of this study.</p><p>UTILITY SCORE 3</p><p>1 The patient is seated, arm flexed 90 degrees and adducted</p><p>until hand is opposite the contralateral shoulder.</p><p>2 The examiner places downward pressure on the forearm</p><p>of the involved side.</p><p>3 A positive test is indicated by reproduction of shoulder</p><p>pain.</p><p>Whipple Test74 (Supraspinatus Tear)</p><p>(continued)</p><p>174 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN ROTATOR CUFF/IMPINGEMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Jia et al.34 (Massive Rotator Cuff Tear,</p><p>Glenohumeral OA,</p><p>AC Joint OA)</p><p>NT</p><p>NT</p><p>NT</p><p>100</p><p>88</p><p>88</p><p>26</p><p>25</p><p>25</p><p>NA</p><p>1.17</p><p>1.17</p><p>NA</p><p>0.48</p><p>0.48</p><p>6</p><p>Oh et al.68 (Type II SLAP) NT 65 42 1.12 0.83 11</p><p>Comments: The Whipple Test74 was originally described as detecting a supraspinatus tear as part of a superior labral, anterior cuff</p><p>(SLAC) lesion. The Whipple Test appears to be a good screen for a massiverotator cuff tear, but this conclusion should be viewed</p><p>with caution due to the potential for bias in the one study to investigate this test.</p><p>UTILITY SCORE 3</p><p>Diagnostic Clusters—Rotator Cuff Tear</p><p>Study Cluster Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Malhi & Khan55 Supraspinatus weak-</p><p>ness or impairment of</p><p>abduction</p><p>NT 100 99 NA NA 5</p><p>Litaker et al.49 Age ≥ 65 and weakness in</p><p>external rotation (Infraspi-</p><p>natus test) and night pain</p><p>NT 49 95 9.84 0.54 10</p><p>MacDonald et al.54</p><p>(Rotator Cuff</p><p>Tendinopathy)</p><p>Hawkins or Neer</p><p>Hawkins and Neer</p><p>NT 88</p><p>83</p><p>38</p><p>56</p><p>1.42</p><p>1.89</p><p>0.32</p><p>0.31</p><p>7</p><p>Ardic et al.2 Hawkins or Neer NT 78 50 1.56 0.44 12</p><p>Park et al.72 Painful Arc, Drop Arm,</p><p>and Infraspinatus test</p><p>NT NT NT 15.57 0.16 10</p><p>Park et al.72 Age ≥ 60, Painful Arc,</p><p>Drop Arm, and Infraspi-</p><p>natus test</p><p>NT NT NT 28.00 0.09 10</p><p>Bak et al.4</p><p>(Full Thickness,</p><p>Supraspinatus Tear)</p><p>Active abduction</p><p>cian on all counts.5,6,27,40 Figure 1-1 shows a tool developed by</p><p>Whiting et al.40 called the Quality Assessment of Diagnostic</p><p>Accuracy Studies (QUADAS). The QUADAS tool helps the</p><p>evidence-based researcher detect error and bias in diagnostic</p><p>accuracy studies, factors which negatively impact study qual-</p><p>ity.40 In research terms, the QUADAS tool provides an orga-</p><p>nized format in which a reader can examine the internal validity</p><p>and external validity of a study. Internal validity is improved</p><p>when the research design minimizes bias. External validity is</p><p>judged by whether the estimates of diagnostic accuracy can be</p><p>applied to the clinical practice setting. QUADAS involves indi-</p><p>vidualized scoring of 14 components. Each of the 14 questions</p><p>is scored as “yes,” “no,” or “unclear.” Individual procedures for</p><p>scoring each of the 14 items, including operational standards</p><p>Research Studies Assessing Physical</p><p>Examination Tests</p><p>Research examining the reliability and diagnostic accuracy</p><p>of a Physical Examination Test should be of high quality.</p><p>CHAPTER 1 Introduction to Diagnostic Accuracy 3</p><p>Truth about the Pathology</p><p>Present Absent</p><p>Test Result + True Positives (TP)</p><p>a</p><p>False Positives (FP)</p><p>b</p><p>− False Negatives (FN)</p><p>c</p><p>True Negatives (TN)</p><p>d</p><p>FIGURE 1-2 A 2 × 2 contingency table.</p><p>for each question, have been published, although a cumulative</p><p>methodological score is not advocated.39 Past studies11,36,37</p><p>have used a score of 7 of 14 or greater “yeses” to indicate a</p><p>high quality diagnostic accuracy study whereas scores below 7</p><p>were indicative of low quality. Based on our experience in the</p><p>use of the QUADAS tool, the consensus is that higher quality</p><p>articles are associated with 10 or greater unequivocal “yeses,”</p><p>whereas those articles with less than 10 unequivocal “yeses”</p><p>are associated with poorly designed studies.10,17–18</p><p>Estimates of diagnostic accuracy are captured using vari-</p><p>ous statistical terms. The simplest way to examine these sta-</p><p>tistical terms is via the 2 × 2 table (Figure 1-2). The 2 × 2 table</p><p>is an epidemiologist’s way of showing the results of the perfor-</p><p>mance of the special test when that special test is compared to</p><p>a “gold” standard, or a criterion standard. The criterion stan-</p><p>dard can be a laboratory test or an imaging test but, in the area</p><p>of musculoskeletal practice, the criterion standard is often</p><p>confirmation of the pathology via surgery.7,8,13,28,29 Regardless</p><p>of which criterion standard is chosen, the assumption in a 2 × 2</p><p>table is that the truth about the presence or absence of the</p><p>pathology under investigation is known. Common information</p><p>gleaned from the 2 × 2 table is as follows:</p><p>True positive (TP)—The special test is positive and the</p><p>patient truly has the pathology. Traditionally represented</p><p>by a.</p><p>False positive (FP)—The special test is positive but the</p><p>patient does not have the pathology. Traditionally repre-</p><p>sented by b.</p><p>False negative (FN)—The special test is negative but</p><p>the patient truly has the pathology. Traditionally repre-</p><p>sented by c.</p><p>True negative (TN)—The special test was negative and</p><p>the patient truly does not have the pathology. Tradition-</p><p>ally represented by d.</p><p>Sensitivity (SN)—The probability of a positive test</p><p>result in someone with the pathology. Formula: a/(a+c)</p><p>Specificity (SP)—The probability of a negative test result</p><p>in someone without the pathology. Formula: d/(b+d)</p><p>Positive Likelihood Ratio (LR+)—The ratio of a posi-</p><p>tive test result in people with the pathology to a positive</p><p>test result in people without the pathology. The LR+ is</p><p>a multiplier in Bayes’ Theorem and is used to modify the</p><p>posttest probability. Formula: SN/(1–SP)</p><p>Negative Likelihood Ratio (LR–)—The ratio of a</p><p>negative test result in people with the pathology to a</p><p>negative test result in people without the pathology.</p><p>Formula: (1–SN/SP)</p><p>Bayes’ Theorem—Pretest probability of a pathology</p><p>× LR+ = Posttest probability of a pathology. Please see</p><p>Fagan’s nomogram13 (Figure 1-3) for an example of</p><p>the clinical application of likelihood ratios and Bayes’</p><p>Theorem.</p><p>Positive Predictive Value (PPV)—The proportion</p><p>of people with the disease of those with a positive test</p><p>result. Formula: a/(a+b)</p><p>Baseline</p><p>Probability</p><p>Odds Ratio Post-exposure</p><p>Probability</p><p>0.01</p><p>0.02</p><p>0.03</p><p>0.05</p><p>0.07</p><p>0.1</p><p>0.2</p><p>0.3</p><p>0.4</p><p>0.5</p><p>0.6</p><p>0.7</p><p>0.8</p><p>0.9</p><p>0.93</p><p>0.95</p><p>0.97</p><p>0.98</p><p>0.99</p><p>(A) (B)</p><p>1000</p><p>500</p><p>100</p><p>50</p><p>10</p><p>5</p><p>1</p><p>0.5</p><p>0.1</p><p>0.05</p><p>0.01</p><p>0.005</p><p>0.001</p><p>(C)</p><p>0.01</p><p>0.02</p><p>0.03</p><p>0.05</p><p>0.07</p><p>0.1</p><p>0.2</p><p>0.3</p><p>0.4</p><p>0.5</p><p>0.6</p><p>0.7</p><p>0.8</p><p>0.9</p><p>0.93</p><p>0.95</p><p>0.97</p><p>0.98</p><p>0.99</p><p>FIGURE 1-3 Fagan’s nomogram for using a likeli-</p><p>hood ratio (LR) to modify pretest probability into an</p><p>estimate of posttest probability accuracy.</p><p>4 CHAPTER 1 Introduction to Diagnostic Accuracy</p><p>Negative Predictive Value (NPV)—The proportion</p><p>of people without the disease who had a negative test</p><p>result. Formula: d/(c+d)</p><p>Accuracy—The proportion of subjects correctly identi-</p><p>fied by the test results. Formula: (a+d)/(a+b+c+d)</p><p>True positives, true negatives, false positives, and false</p><p>negatives are terms to capture the raw data from a study</p><p>examining the accuracy of special tests. All four of these mea-</p><p>sures contribute to sensitivity (SN) and specificity (SP). Tests</p><p>with a high SN are valued as screening tests to rule out pathol-</p><p>ogy when they are negative.34,42 In studies that examine the</p><p>diagnostic ability of a test, SN and SP are arguably the most</p><p>popular measures of test performance. While SN and SP are</p><p>popular, they are, nonetheless, incomplete measures of test</p><p>performance. As SN increases, SP often decreases.15 Further,</p><p>paired indicators like SN/SP, PPV/NPV, and LR+/LR− cannot</p><p>be used to easily rank special tests so that a clinician may eas-</p><p>ily pick the best test15 despite the fact that, in 1994, Jaeschke</p><p>et al.20 attempted to make likelihood ratios more clinician-</p><p>friendly by producing an outline of acceptable likelihood ratios</p><p>(Table 1-2). Accuracy is a single, easily understood measure</p><p>of test performance, but accuracy is greatly affected by the</p><p>prevalence of a pathology.15 The prevalence of a pathology</p><p>can change from clinic to clinic. For example, a sports clinic is</p><p>more likely to see patients with a torn anterior cruciate liga-</p><p>ment than a primary care practice and thus, a special test that</p><p>detects a torn anterior cruciate ligament is likely to appear to</p><p>have greater accuracy when used in the sports clinic.</p><p>All of these measures, while capturing the performance</p><p>of a special test in a research study, lack the ability to com-</p><p>ment on the consistency/reliability with which the diagnostic</p><p>test was performed and the overall quality of that study. If</p><p>examiners are performing the same special test in a different</p><p>fashion then they will have difficulty making valid decisions</p><p>about patients.2 Further, if the overall quality of a study is</p><p>poor and full of bias, the accuracy of the special test will be</p><p>over-estimated in that study and the measures from that</p><p>study should be used with caution.31,41</p><p>How to Use This Book</p><p>The purposes of this textbook are to: (1) produce a com-</p><p>prehensive current list of Physical Examination Tests and,</p><p>when possible, their original descriptions and (2) aid the</p><p>musculoskeletal practitioner in the choosing of the best avail-</p><p>able Physical Examination Tests for his or her practice. With</p><p>these goals in mind, we have attempted to make this book</p><p>as clinician-friendly as possible. The book will be divided into</p><p>broad anatomical areas and subdivided into Physical Exami-</p><p>nation Tests that detect pathologies within those anatomical</p><p>areas. Further, within each pathoanatomic category, the studies</p><p>are ordered so that the clinician will find the best tests first</p><p>and the tests with little or no research to back them last. We</p><p>do realize that this will cause some consternation when some</p><p>clinical favorite Physical Examination Tests are not listed first.</p><p>A detailed description (original if possible) and photograph will</p><p>accompany each Physical Examination Test. All relevant</p><p>Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Zaslav87 NT 88 96 22 0.12 8</p><p>Comments: Despite the great statistical numbers, the Utility Score is only a two because of potential for bias in the conduct of this study</p><p>and/or incomplete reporting of the study findings. More research needs to be performed, especially in light of the quality of this study.</p><p>IMPINGEMENT TESTS</p><p>1 The patient is instructed to stand. The examiner stands</p><p>behind the patient.</p><p>2 The examiner places the patient’s shoulder in 90 degrees</p><p>of abduction and 80 degrees of external rotation with the</p><p>elbow at 90 degrees flexion.</p><p>3 The examiner applies manual resistance to the wrist; first</p><p>to test isometric external rotation.</p><p>4 The examiner applies manual resistance to the wrist next</p><p>to test isometric internal rotation.</p><p>5 The examiner compares the results of this isometric test.</p><p>If internal rotation strength is weaker than external rota-</p><p>tion, the IRRST test is considered positive and the patient</p><p>purportedly has internal impingement.</p><p>Internal Rotation Resisted Strength Test87 (Internal/Intraarticular</p><p>vs. External/Subacromial Impingement)</p><p>UTILITY SCORE 2</p><p>176 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>IMPINGEMENT TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Park et al.72 NT 42 90 4.20 0.65 10</p><p>Ostor et al.69 κ = 0.18−0.45 NT NT NA NA NA</p><p>Michener et al.59 κ = 0.67 56 87 4.39 0.50 11</p><p>Kelly et al.38 (Weakness</p><p>Pain)</p><p>NT 55</p><p>35</p><p>25</p><p>100</p><p>0.73</p><p>NA</p><p>1.80</p><p>NA</p><p>11</p><p>Itoi et al.31 (Infraspinatus Tear</p><p>Pain, Weakness)</p><p>NT</p><p>NT</p><p>54</p><p>84</p><p>54</p><p>53</p><p>1.17</p><p>1.79</p><p>0.85</p><p>0.30</p><p>8</p><p>Comments: Park et al.72 incorporated the External Rotation Lag Sign as part of the assessment of the infraspinatus, in effect combin-</p><p>ing two tests. Unfortunately, the test has only a small effect on posttest probability when trying to find any stage of impingement</p><p>(bursitis through full-thickness rotator cuff tear). Pain may be a more specific sign than weakness.</p><p>1 The patient is standing with elbow in 90 degrees flexion,</p><p>neutral forearm rotation, and elbow adducted against the</p><p>body.</p><p>2 The examiner stands to the side of the patient and pro-</p><p>vides an internal rotation force while the patient resists.</p><p>3 A positive test is indicated by patient giving way due to</p><p>either pain or weakness.</p><p>Infraspinatus/External Rotation Resistance Test72</p><p>(All Stages of Subacromial Impingement)</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 177</p><p>IMPINGEMENT TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>MacDonald et al.54 (SAB,</p><p>Rotator Cuff Tear)</p><p>NT</p><p>NT</p><p>75</p><p>83</p><p>48</p><p>51</p><p>1.40</p><p>1.69</p><p>0.52</p><p>0.33</p><p>7</p><p>7</p><p>Park et al.72 NT 68 69 2.20 0.46 10</p><p>Calis et al.8 NT 89 31 1.28 0.35 8</p><p>Parentis et al.71 (Superior Labral Tear) NT 48 51 0.98 1.02 5</p><p>Bak & Fauno3 (Impingement) NT 0 100 NA NA 6</p><p>Nakagawa et al.65</p><p>(Superior Labral Tear)</p><p>NT 33 60 0.83 1.11 10</p><p>Jia et al.34 (Stage I Impingement</p><p>All Stages of RC Tendinopathy)</p><p>NT</p><p>NT</p><p>86</p><p>64</p><p>49</p><p>43</p><p>1.69</p><p>1.12</p><p>0.29</p><p>0.84</p><p>6</p><p>Michener et al.59(Impingement) κ = .40 81 54 1.76 0.35 11</p><p>Kelly et al.38 (Impingement) NT 62 0 NA NA 11</p><p>Gill et al.21 (Biceps Partial Tear) NT 64 41 1.08 0.88 12</p><p>Bak et al.4 (Full Thickness</p><p>Supraspinatus Tear)</p><p>NT 60 35 0.92 1.14 13</p><p>Silva et al.78 (Impingement) NT 68 30 0.98 1.07 11</p><p>Comments: The test was originally described by Neer in 1983 and a positive test was confirmed by injecting 10 ml of xylocaine into</p><p>the subacromial space and repeating steps 1–4 above in a pain free fashion. Newer and better designed studies show this test is of</p><p>little to no use in diagnosing impingement syndrome. The ability of this test to detect a superior labral tear is worse than chance.</p><p>1 The patient is seated while the examiner stands to the side</p><p>of the involved shoulder.</p><p>2 The examiner raises the patient’s arm into flexion with one</p><p>hand while the other hand stabilizes the scapula.</p><p>3 The examiner applies forced flexion toward end-range in</p><p>an attempt to reproduce the shoulder pain.</p><p>4 If concordant shoulder pain is present, the test is positive.</p><p>Neer Test (Subacromial Impingement, Subacromial Bursitis (SAB),</p><p>Rotator Cuff Tear, Superior Labral Tear)</p><p>UTILITY SCORE 3</p><p>178 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>IMPINGEMENT TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>MacDonald et al.54 (Bursitis</p><p>Rotator Cuff Tear)</p><p>NT</p><p>NT</p><p>92</p><p>88</p><p>44</p><p>43</p><p>1.64</p><p>1.54</p><p>0.18</p><p>0.27</p><p>7</p><p>7</p><p>Park et al.72 (Impingement) NT 72 66 2.11 0.42 10</p><p>Calis et al.8 (Impingement</p><p>Rotator Cuff Tear)</p><p>NT</p><p>NT</p><p>92</p><p>100</p><p>25</p><p>36</p><p>1.22</p><p>NA</p><p>0.32</p><p>NA</p><p>8</p><p>8</p><p>Parentis et al.71 (Superior Labral Tear) NT 65 30 0.94 1.15 5</p><p>Bak & Fauno3 (Impingement) NT 80 76 3.33 0.26 6</p><p>Ostor et al.69 (Impingement) κ = .18–.43 NT NT NA NA NA</p><p>Nakagawa et al.65 (Superior Labral Tear) NT 50 67 1.52 0.75 10</p><p>Jia et al.33 (Stage I Impingement</p><p>All Stages of RC Tendinopathy)</p><p>NT</p><p>NT</p><p>76</p><p>71</p><p>45</p><p>42</p><p>1.38</p><p>1.22</p><p>0.53</p><p>0.69</p><p>6</p><p>Michener et al.59 κ = .39 63 62 1.63 0.61 11</p><p>Kelly et al.38 (Impingement) NT 74 50 1.48 0.52 11</p><p>Gill et al.21 (Biceps Partial Tear) NT 55 38 0.89 1.18 12</p><p>Bak et al.4 (Full Thickness</p><p>Supraspinatus Tear)</p><p>NT 77 26 1.04 0.88 13</p><p>Comments: The Hawkins-Kennedy Test26 is probably a more sensitive test suitable for screening for either impingement or rotator</p><p>cuff tear than it is a specific test suitable for diagnosis. Further, in the four best performed/reported studies, the test has mediocre</p><p>value and may not be a good screening or diagnostic test for impingement.</p><p>1 The patient is seated while the examiner stands anteriorly</p><p>to the involved shoulder.</p><p>2 The examiner first raises the patient’s arm into approxi-</p><p>mately 90 degrees of shoulder flexion or abduction with</p><p>one hand while the other hand stabilizes the scapula (typi-</p><p>cally superiorly).</p><p>3 The examiner applies forced humeral internal rotation in</p><p>an attempt to reproduce the concordant shoulder pain. If</p><p>concordant shoulder pain is present, the test is positive.</p><p>Hawkins-Kennedy Test26 (Subacromial Impingement, Subacromial</p><p>Bursitis, Rotator Cuff Tear, Superior Labral Tear)</p><p>UTILITY SCORE 3</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 179</p><p>IMPINGEMENT TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Park et al.72 Impingement NT 74 81 3.89 0.32 10</p><p>Calis et al.8 (Impingement</p><p>Rotator Cuff Tear)</p><p>NT</p><p>NT</p><p>33</p><p>45</p><p>81</p><p>79</p><p>1.73</p><p>2.14</p><p>0.82</p><p>0.70</p><p>8</p><p>8</p><p>Litaker et al.49 (Rotator Cuff Tear) NT 98 10 1.09 0.20 11</p><p>Jia et al.34 (Rotator Cuff</p><p>Tendinopathy)</p><p>NT 67 50 1.34 0.66 6</p><p>Michener et al59 κ = .45 75 67 2.25 0.38 11</p><p>Kelly et al.38 (Impingement) NT 30 50 0.60 1.40 11</p><p>Bak et al.4 (Full Thickness</p><p>Supraspinatus Tear)</p><p>NT 96 4 1.00 1.00 13</p><p>Silva et al.78 (Impingement) NT 74 40 1.23 0.65 11</p><p>Comments: This test modifies posttest probability very little. Further, the broad cluster of diagnoses captured under “impingement”</p><p>may not aid the examiner with prognosis or intervention.</p><p>1 The patient is standing. The examiner faces the patient to</p><p>observe shoulder motion.</p><p>2 The patient is instructed to actively abduct the involved</p><p>shoulder.</p><p>3 A positive test is indicated by patient report of concor-</p><p>dant pain in the 60–120 degree range. Pain outside of this</p><p>range is considered a negative test. Pain that increases in</p><p>severity as the arm reaches 180 degrees is indicative of “a</p><p>disorder of the acromioclavicular joint.”</p><p>Painful ARC Test39 (All Stages of Subacromial Impingement)</p><p>UTILITY SCORE 3</p><p>180 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>IMPINGEMENT TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Park et al.72 (Impingement) NT 23 82 1.27 0.93 10</p><p>Calis et al.8 (Impingement,</p><p>Rotator Cuff Tear)</p><p>NT</p><p>NT</p><p>82</p><p>90</p><p>28</p><p>29</p><p>1.13</p><p>1.27</p><p>0.64</p><p>0.35</p><p>8</p><p>8</p><p>Chronopoulos et al.11 (AC Joint Pathology) NT 77 79 3.66 0.29 10</p><p>Ostor et al.69 (AC Joint Pathology) κ = .08–.29 NT NT NT NT NA</p><p>Jia et al.34 (AC Joint OA) NT 77 79 3.67 0.29 6</p><p>Comments: The Cross-Body Test57 appears to be a stronger indicator</p><p>of AC joint pathology than impingement but the inter–</p><p>observer agreement for this test may negatively affect clinical application.</p><p>Diagnostic Clusters—Impingement</p><p>1 The patient assumes a sitting position. The patient is</p><p>instructed to elevate the arm to 90 degrees of shoulder</p><p>flexion.</p><p>2 The examiner stands in front of the patient and horizon-</p><p>tally adducts the patient’s arm to end range, maintaining</p><p>the flexion at the shoulder.</p><p>3 If shoulder pain is present, the test is positive.</p><p>Cross-Body Adduction Test57 [Subacromial Impingement,</p><p>Acromioclavicular (AC) Joint Damage]</p><p>UTILITY SCORE 3</p><p>Study Cluster Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Malhi &</p><p>Khan55</p><p>Hawkins or Neer or Painful Arc</p><p>or Subacromial Crepitus</p><p>NT 84 76 3.5 0.21 5</p><p>Calis</p><p>et al.8</p><p>At least 3 of 6: Hawkins, Neer,</p><p>Horizontal Adduction, Speed,</p><p>Yergason, Painful Arc, Drop Arm</p><p>NT 84 44 1.5 0.36 8</p><p>Park</p><p>et al.72</p><p>Hawkins, Painful Arc, and</p><p>Infraspinatus test</p><p>NT NT NT 10.56 0.17 10</p><p>Michener</p><p>et al.59</p><p>3 or more positive of: Hawkins,</p><p>Neer, Painful Arc, Empty Can,</p><p>External Rotation Weakness</p><p>NT 75 74 2.93 0.34 11</p><p>Comments: Despite the strong numbers in the Park et al.46 study, the impingement tests themselves are not strong diagnostic tools</p><p>and the diagnosis of impingement is not helpful in prognosis nor treatment.</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 181</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>1 The patient assumes a supine position. The examiner sits</p><p>on the side of the patient’s involved extremity.</p><p>2 The examiner places the patient’s shoulder in 120 degrees</p><p>of abduction, the elbow in 90 degrees of flexion, and the</p><p>forearm in supination.</p><p>3 The examiner moves the patient’s shoulder to end-range</p><p>external rotation (apprehension position).</p><p>4 At end-range external rotation, the examiner asks the</p><p>patient to flex his or her elbow while the examiner resists</p><p>this movement.</p><p>5 A positive test is indicated as a reproduction of concordant</p><p>pain during resisted elbow flexion.</p><p>Biceps Load Test II44 (SLAP Lesion)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kim et al.44 (SLAP) κ = .82 90 97 26.38 0.11 10</p><p>Oh et al.68 (Type II SLAP) NT 30 78 1.36 0.90 11</p><p>Comments: This sequel to the Biceps Load Test45 was performed in a broader spectrum of patients with blinding of the testers.</p><p>Newest research casts at least some doubt on the original numbers.</p><p>UTILITY SCORE 2</p><p>182 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Calis et al.8 (Impingement</p><p>Rotator Cuff Tear)</p><p>NT</p><p>NT</p><p>37</p><p>50</p><p>86</p><p>86</p><p>2.64</p><p>3.57</p><p>0.73</p><p>0.58</p><p>8</p><p>8</p><p>Holtby & Razmjou29 (SLAP) NT 43 79 2.05 0.72 12</p><p>Guanche & Jones24 (SLAP</p><p>Any Labral Lesion)</p><p>NT</p><p>NT</p><p>12</p><p>9</p><p>96</p><p>93</p><p>3.00</p><p>1.29</p><p>0.92</p><p>0.98</p><p>12</p><p>12</p><p>Parentis et al.71 (SLAP) NT 13 93 1.78 0.94 5</p><p>Parentis et al.70 (SLAP) NT 13 94 1.9 0.9 9</p><p>Kibler et al.41 (Biceps Tendinopathy,</p><p>Labral Tear)</p><p>NT 41</p><p>26</p><p>79</p><p>70</p><p>1.94</p><p>0.88</p><p>0.74</p><p>1.05</p><p>9</p><p>Oh et al.68 (Type II SLAP) NT 12 87 0.92 1.01 11</p><p>Ostor et al.69</p><p>(Long Head of Biceps Pathology)</p><p>κ = .28 NT NT NA NA NA</p><p>Comments: The better studies show Yergason’s Test86 to have high specificity and therefore, a positive test may help rule in a</p><p>labral tear but the likelihood ratios indicate that overall, the test is minimally helpful in diagnosis of a SLAP lesion. The interobserver</p><p>agreement of this test is fair when detecting pathology of the long head of the biceps.</p><p>1 The patient may sit or stand. The examiner stands in front</p><p>of the patient.</p><p>2 The patient’s elbow is flexed to 90 degrees and the fore-</p><p>arm is in a pronated position while maintaining the upper</p><p>arm at the side.</p><p>3 The patient is instructed to supinate his or her forearm,</p><p>while the examiner concurrently resists forearm supination</p><p>at the wrist.</p><p>4 If the patient localizes concordant pain to the bicipital</p><p>groove, the test is positive.</p><p>Yergason’s Test86 (Subacromial Impingement, Superior Labral Anterior</p><p>to Posterior (SLAP) Lesion, Any Labral Lesion, Long Head of Biceps Pathology)</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 183</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Parentis et al.71 SLAP NT 9 83 0.50 1.10 5</p><p>Stetson & Templin81 (Labral Tear) NT 46 56 1.04 0.96 10</p><p>Myers et al.64 (SLAP) NT 35 70 0.87 2 8</p><p>Liu et al.51 (Labral Tear) NT 91 93 7.0 0.10 9</p><p>Nakagawa et al.65</p><p>(Superior Labral Tear)</p><p>NT 58 72 2.1 0.58 10</p><p>Gill et al.21 (Biceps Partial Tear) NT 34 77 1.49 0.86 12</p><p>Walsworth et al.83 (Any Labral Tear) κ = 0.20 61 55 1.35 0.71 11</p><p>Comments: There is uncertainty in use for the Crank Test51 in diagnosing SLAP lesions according to available research and its use</p><p>to detect any labral tear is mixed according to two stronger studies. More well-designed research is needed.</p><p>1 The patient assumes either a sitting or supine position.</p><p>The examiner typically stands at the side of the involved</p><p>extremity.</p><p>2 The examiner places the patient’s shoulder in 160 degrees</p><p>of abduction and elbow in 90 degrees of flexion.</p><p>3 The examiner first applies a compression force to the</p><p>humerus and then rotates the humerus repeatedly into</p><p>internal rotation and external rotation in an attempt to</p><p>pinch the torn labrum.</p><p>4 A positive test is indicated by the production of pain either</p><p>with or without a click in the shoulder or by reproduc-</p><p>tion of the patient’s concordant complaint (usually pain</p><p>or catching).</p><p>Crank Test51 (Labral Tear, SLAP Lesion)</p><p>UTILITY SCORE 2</p><p>184 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ −LR</p><p>QUADAS</p><p>Score (0–14)</p><p>Kim et al46 NT 80 94 13.33 0.21 9</p><p>Comments: More research with more strict methodology needs to be done to corroborate these statistics, but as of now, the Kim</p><p>Test is a significant indicator of a posteroinferior labral lesion. However, the Jerk Test46 is easier to perform and performs better</p><p>statistically.</p><p>1 The patient is seated in a chair with his or her back</p><p>supported.</p><p>2 The examiner stands to the side of the involved shoulder</p><p>and faces the patient. The examiner grasps the elbow with</p><p>one hand and the mid-humeral region with the other and</p><p>elevates the patient’s arm to 90 degrees abduction.</p><p>3 Simultaneously the examiner provides an axial load to the</p><p>humerus and a 45-degree diagonal elevation to the distal</p><p>humerus concurrent with a posteroinferior glide to the</p><p>proximal humerus.</p><p>4 A positive test is indicated by a sudden onset of posterior</p><p>shoulder pain.</p><p>Kim Test46 (Posteroinferior Labral Lesion)</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 185</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>1 The patient assumes a sitting position. The examiner</p><p>stands behind the patient.</p><p>2 The examiner grasps the elbow with one hand and the</p><p>scapula with the other and elevates the patient’s arm to</p><p>90 degrees abduction and internal rotation.</p><p>3 The examiner provides an axial compression-based load to</p><p>the humerus through the elbow maintaining the horizon-</p><p>tally abducted arm.</p><p>4 The axial compression is maintained as the patient’s arm</p><p>is moved into horizontal adduction.</p><p>5 A positive test is indicated by a sharp shoulder pain with</p><p>or without a clunk or click.</p><p>Jerk Test46 (Posteroinferior Labral Lesion)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kim et al.43 NT 73 98 36.5 0.27 9</p><p>Nakagawa et al.65</p><p>(Superior Labral Tear) NT 25 80 1.25 0.94 10</p><p>Comments: More research with more strict methodology needs to be done to corroborate these statistics, but as of now, the Jerk</p><p>Test43 is a significant indicator of a posteroinferior labral lesion and a nondescript test for superior labral tear (not the original pur-</p><p>pose of the test).</p><p>UTILITY SCORE 2</p><p>186 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study</p><p>Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Gross & Distefano23 NT 92 89 8.36 0.08 9</p><p>Lo et al.52 NT 64 99 64 0.36 7</p><p>Comments: Despite the apparently good statistics, the quality of these two studies is poor so the examiner should be guarded</p><p>about the results.</p><p>1 The patient assumes a supine position. The examiner</p><p>stands beside the patient.</p><p>2 The examiner grasps the forearm with one hand and pro-</p><p>vides a posterior force on the humerus with the other.</p><p>3 The posterior force on the proximal humerus is maintained</p><p>while the examiner moves the patient’s shoulder into the</p><p>apprehension position of 90 degrees abduction and end-</p><p>range external rotation.</p><p>4 The posterior force on the humerus is then released.</p><p>5 A positive test is indicated if the patient reports sudden</p><p>pain, an increase in pain, or by reproduction of the patient’s</p><p>concordant symptoms.</p><p>Anterior Release/Surprise Test23 (Anterior Instability)</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 187</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Mimori et al.61 SLAP NT 100 90 NA NA 7</p><p>Parentis et al.71 SLAP NT 17 90 1.72 0.92 5</p><p>Parentis et al.70 SLAP NT 15 90 1.5 0.9 9</p><p>Comments: Despite the great numbers reported by Mimori et al.61, their study had many design faults including a criterion standard</p><p>(arthroscopy) which was given to only 11 of 32 patients. The newer work by Parentis et al.70 in 2006 shows that the Pain Provoca-</p><p>tion test may be a specific test for a SLAP lesion with application to a wider population.</p><p>1 The patient assumes a sitting position. The examiner</p><p>stands behind the patient.</p><p>2 The examiner places the patient’s shoulder in 90 degrees</p><p>of abduction and toward end-range external rotation. The</p><p>elbow is placed at 90 degrees of flexion and the forearm</p><p>in maximum pronation.</p><p>3 The examiner asks the patient to rate his or her pain in this</p><p>position.</p><p>4 The examiner then fully pronates the patient’s forearm and</p><p>asks the patient to, again, rate his or her pain.</p><p>5 A positive test is indicated by production of the patient’s</p><p>concordant pain in the forearm-pronated position or when</p><p>the patient’s pain is worse in pronation than in supination.</p><p>Pain Provocation Test61 (SLAP Lesion)</p><p>UTILITY SCORE 2</p><p>188 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kim et al.47 κ = .77 82 86 5.72 0.21 8</p><p>Comments: Based on this one study of moderate quality, the Passive Compression Test47 appears to be both an accurate and reli-</p><p>able clinical diagnostic tool. However, a sample size of 61 subjects means that more research needs to be done.</p><p>1 The patient lies on the uninvolved side. The examiner</p><p>stands behind the patient.</p><p>2 The examiner stabilizes the superior aspect of the scapula</p><p>with one hand while using the other hand to grasp the</p><p>elbow.</p><p>3 The examiner externally rotates the arm and abducts the</p><p>arm 30 degrees.</p><p>4 The examiner applies a superior compressive force while</p><p>extending the arm.</p><p>5 A positive test is indicated by pain reproduction or a</p><p>painful click.</p><p>Passive Compression Test58 (SLAP Lesion)</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 189</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Guanche & Jones24 (SLAP</p><p>Any Labral Lesion)</p><p>NT</p><p>NT</p><p>30</p><p>40</p><p>63</p><p>87</p><p>0.81</p><p>3.08</p><p>1.11</p><p>0.69</p><p>12</p><p>12</p><p>Lo et al.52 NT 53 99 53 0.47 7</p><p>Jia et al.34 (Any Instability</p><p>Anterior Instability</p><p>Posterior Instability</p><p>Multidirectional Instability)</p><p>NT</p><p>NT</p><p>NT</p><p>NT</p><p>58</p><p>72</p><p>20</p><p>43</p><p>96</p><p>96</p><p>85</p><p>85</p><p>14.5</p><p>18.0</p><p>1.33</p><p>2.87</p><p>0.65</p><p>0.29</p><p>0.94</p><p>0.67</p><p>6</p><p>Farber et al.15 (Pain</p><p>Apprehension)</p><p>NT</p><p>NT</p><p>50</p><p>72</p><p>56</p><p>96</p><p>1.14</p><p>18.0</p><p>0.89</p><p>0.29</p><p>11</p><p>Oh et al.68 (Type II SLAP) NT 62 42 1.07 0.90 11</p><p>Comments: The Apprehension Test was originally described in 1981 by Rowe and Zarins73 to detect anterior instability. The test</p><p>appears to be specific for that pathology when apprehension (not pain) is used as the definition of a positive test.</p><p>1 The patient is either standing or supine. The examiner</p><p>stands either behind or at the involved side of the patient.</p><p>2 The examiner grasps the wrist with one hand and maxi-</p><p>mally externally rotates the humerus with the shoulder in</p><p>90 degrees of abduction.</p><p>3 Forward pressure is then applied to the posterior aspect</p><p>of the humeral head by either the examiner (if patient</p><p>is standing) or the examination table (if the patient is in</p><p>supine).</p><p>4 A positive test for anterior instability is indicated by a show</p><p>of apprehension by the patient or a report of pain.</p><p>Apprehension Test73 (Anterior Instability, All Instabilities</p><p>of the Glenohumeral Joint, Labral Tear, SLAP Lesion)</p><p>UTILITY SCORE 2</p><p>190 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kibler et al.41 NT 72 98 31.57 0.29 9</p><p>Comments: This test appears to be specific for a labral tear but more research needs to be done by other than the inventor of the</p><p>test.</p><p>1 The patient is standing with the involved elbow flexed</p><p>90 degrees and the shoulder abducted in the scapular</p><p>plane to above 120 degrees and externally rotated to</p><p>end-range.</p><p>2 The examiner moves the involved shoulder into maximum</p><p>horizontal abduction.</p><p>3 The examiner applies a posterior-to-anterior force to the</p><p>posterior humeral head while lowering the arm from</p><p>120 degrees to 60 degrees abduction.</p><p>4 A positive test is indicated by reproduction of the pain</p><p>and/or a painful click or catch in the posterior joint line</p><p>between 120 degrees and 90 degrees abduction.</p><p>Modified Dynamic Labral Shear Test80 (Labral Tear)</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 191</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Hamner et al.25 NT 92 100 92 0.08 7</p><p>Farber et al.15 (Pain</p><p>Apprehension)</p><p>NT 30</p><p>81</p><p>90</p><p>92</p><p>3.0</p><p>10.13</p><p>0.78</p><p>0.10</p><p>11</p><p>Comments: There were only 14 subjects in the Hamner et al.25 study—all overhead throwing athletes between the ages of 21 and 31,</p><p>and there were many other design faults that lead to potential bias. The Farber et al.15 study is a nice addition with a sample size of 363</p><p>but the group in their study with traumatic anterior instability was younger and more athletic which may have a great deal to do with</p><p>the numbers. Nevertheless, when apprehension is used as a positive sign, the Relocation Test25 may be a strong diagnostic tool.</p><p>1 The patient assumes a supine position. The examiner</p><p>stands beside the patient.</p><p>2 The examiner pre-positions the shoulder at 120 degrees</p><p>of abduction then grasps the patient’s forearm and maxi-</p><p>mally externally rotates the humerus.</p><p>3 A posterior to anterior force is then applied to the posterior</p><p>aspect of the humeral head by the examiner.</p><p>4 If the patient reports pain, a posterior force is then applied</p><p>to the proximal humerus.</p><p>5 A positive test for labral pathology is indicated by a report</p><p>of pain with the anterior-directed force and relief of pain</p><p>with the posterior-directed force.</p><p>Modified Relocation/Modified Jobe Relocation Test25</p><p>(Labral Pathology, Traumatic Anterior Instability)</p><p>UTILITY SCORE 2</p><p>192 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ −LR</p><p>QUADAS</p><p>Score (0–14)</p><p>Guanche & Jones24 (SLAP</p><p>Any Labral Lesion)</p><p>NT</p><p>NT</p><p>36</p><p>44</p><p>63</p><p>87</p><p>.97</p><p>3.38</p><p>1.02</p><p>.64</p><p>12</p><p>12</p><p>Morgan et al.62 Anterior Labral Tear</p><p>Posterior Labral Tear</p><p>Combined (SLAP)</p><p>NT</p><p>NT</p><p>NT</p><p>4</p><p>85</p><p>59</p><p>27</p><p>68</p><p>54</p><p>.05</p><p>2.67</p><p>1.28</p><p>3.52</p><p>.21</p><p>.76</p><p>11</p><p>11</p><p>11</p><p>Parentis et al.71 (SLAP) NT 44 51 .90 1.10 5</p><p>Nakagawa et al.65 (Superior Labral Tear) NT 75 40 1.25 .63 10</p><p>Lo et al.52 NT 46 54 1.0 1.0 7</p><p>Speer et al.80 (Pain</p><p>Apprehension)</p><p>NT</p><p>NT</p><p>54</p><p>68</p><p>44</p><p>100</p><p>.96</p><p>NA</p><p>1.05</p><p>NA</p><p>9</p><p>9</p><p>Parentis et al.70 NT 50 53 1.1</p><p>0.9 9</p><p>Comments: Originally described by Jobe et al. in 198921, the Relocation Test was supposed to differentiate between impingement</p><p>and anterior instability. The Speer et al.50 study would seem to indicate that the Relocation Test has value as a positive test in rul-</p><p>ing in anterior instability when the patient emotes “apprehension.” However, the Speer et al.50 study had significant limitations with</p><p>regard to blinding and description of the spectrum of patients so the numbers are to be taken with caution. Research does not sup-</p><p>port the use of this test to differentiate impingement from instability or to diagnose any type of labral tear.</p><p>1 The patient assumes a supine position. The examiner</p><p>stands beside the patient.</p><p>2 The examiner pre-positions the shoulder at 90 degrees of</p><p>abduction then grasps the patient’s forearm and maxi-</p><p>mally externally rotates the humerus.</p><p>3 A posterior to anterior force is then applied to the posterior</p><p>aspect of the humeral head by the examiner</p><p>4 If the patient displays apprehension or reports pain, a pos-</p><p>terior force is then applied to the proximal humerus.</p><p>5 A positive test for anterior instability is indicated by a</p><p>decrease in the pain or apprehension whereas no change</p><p>in pain symptoms indicates impingement.</p><p>Apprehension-Relocation/Jobe Relocation Test35 (Anterior Instability,</p><p>Labral Tear, SLAP Lesion)</p><p>UTILITY SCORE 3</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 193</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>1 The patient is supine with arms above head in full elevation</p><p>and palms facing up.</p><p>2 The examiner, standing on the involved side, grasps the</p><p>patient’s arm just distal to the elbow.</p><p>3 The examiner provides resistance as the patient tries to flex</p><p>the arm/raise the arm off the table.</p><p>4 A positive test for a Type II SLAP lesion is indicated by</p><p>reproduction of pain deep inside the shoulder or the dorsal</p><p>aspect of the glenohumeral joint line.</p><p>Supine Flexion Resistance Test (Type II SLAP Lesion)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Ebinger et al.14 NT 80 69 2.58 0.29 12</p><p>Comments: An important note is that the Supine Flexion Resistance Test14 was tested for Type II SLAP lesions only as Type I</p><p>lesions were eliminated from final analysis; perhaps an unrealistic situation for most clinicians.</p><p>UTILITY SCORE 3</p><p>194 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Park et al.72 (Impingement) NT 38 83 2.23 0.74 10</p><p>Calis et al.8 (Impingement</p><p>Rotator Cuff Tear)</p><p>NT</p><p>NT</p><p>69</p><p>85</p><p>56</p><p>57</p><p>1.56</p><p>1.98</p><p>0.55</p><p>0.26</p><p>8</p><p>8</p><p>Holtby & Razmjou29 (SLAP) NT 32 75 1.28 0.91 12</p><p>Bennett6 (SLAP and Biceps Pathology) NT 90 14 1.04 0.72 9</p><p>Guanche & Jones24 (SLAP</p><p>Any Labral Lesion)</p><p>NT</p><p>NT</p><p>9</p><p>18</p><p>74</p><p>87</p><p>0.35</p><p>1.38</p><p>1.23</p><p>0.94</p><p>12</p><p>12</p><p>Morgan et al.62 (Anterior Labrum</p><p>Posterior Labrum</p><p>SLAP)</p><p>NT</p><p>NT</p><p>NT</p><p>100</p><p>29</p><p>78</p><p>70</p><p>11</p><p>37</p><p>NA</p><p>0.32</p><p>1.23</p><p>NA</p><p>6.32</p><p>0.60</p><p>11</p><p>11</p><p>11</p><p>Parentis et al.71 (SLAP) NT 48 68 1.49 0.77 5</p><p>Ostor et al.69 (Long Head</p><p>of Biceps Pathology)</p><p>κ = .17−.32 NT NT NT NT NA</p><p>Nakagawa et al.65 (Superior Labral Tear) NT 4 100 NA NA 10</p><p>Parentis et al.70 (SLAP) NT 48 67 1.5 0.8 9</p><p>Jia et al.34 (Biceps Tendinopathy) NT 50 67 1.51 0.75 6</p><p>Ebinger et al.14 (SLAP) NT 60 38 0.97 1.05 12</p><p>Gill et al.21 (Biceps Partial Tear) NT 50 67 1.51 0.75 12</p><p>Ardic et al.2 (Biceps Tendinopathy) NT 69 60 1.73 0.52 12</p><p>Kibler et al.41 (Biceps Tendinopathy</p><p>Labral Tear)</p><p>NT 54</p><p>29</p><p>81</p><p>69</p><p>2.77</p><p>0.93</p><p>0.58</p><p>1.03</p><p>9</p><p>Oh et al.68 (Type II SLAP) NT 32 66 0.94 1.03 11</p><p>Comments: Speed’s Test was originally used to test for long head bicipital tenosynovitis but the use of the test expanded to many</p><p>pathologies. Unfortunately, in the well-performed studies this test seems a poor test for any of those pathologies with the excep-</p><p>tion of an anterior labral tear, where one study showed it may be used as a screening tool due to high sensitivity.</p><p>UTILITY SCORE 3</p><p>1 The patient assumes a standing position. The patient is</p><p>instructed to extend his/her elbow and fully supinate the</p><p>forearm.</p><p>2 The examiner, standing in front of the patient, resists</p><p>shoulder flexion from zero to 60 degrees.</p><p>3 If the patient localizes concordant pain to the bicipital</p><p>groove, the test is positive.</p><p>Speed’s Test13 [All Stages of Subacromial Impingement, Superior Labral</p><p>Anterior to Posterior (SLAP) Lesion, Any Labral Lesion, Biceps Pathology]</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 195</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>1 The patient assumes a sitting position. The examiner typi-</p><p>cally stands at the side of the involved extremity.</p><p>2 The examiner places the patient’s shoulder in maximum</p><p>abduction with full elbow extension and notes pain in the</p><p>posterior-superior aspect of the shoulder.</p><p>3 The examiner then flexes the patient’s elbow.</p><p>4 A positive test is indicated by the production of pain in</p><p>the posterior-superior aspect of the shoulder during shoul-</p><p>der abduction with elbow extension that is diminished or</p><p>relieved by elbow flexion.</p><p>Forced Shoulder Abduction and Elbow Flexion Test65</p><p>(Superior Labral Tear)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Nakagawa et al.65 NT 67 67 2.0 0.49 10</p><p>Comments: The one study to examine the Forced Shoulder Abduction and Elbow Flexion Test65 had some design /reporting</p><p>flaws. Most notably, all subjects were young throwing athletes and only 2 of 54 subjects were female leading to spectrum bias.</p><p>More well-designed research is needed.</p><p>UTILITY SCORE 3</p><p>196 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Silliman & Hawkins77 ND ND ND ND ND NA</p><p>Nakagawa et al.65 (Superior Labral Tear) NT 17 93 2.43 0.89 10</p><p>Comments: The Sulcus Sign is often used clinically but amazingly, has been researched in only one study.65 The use of this sign to</p><p>detect inferior instability is not supported but the Sulcus Sign may be a specific test that rules in a superior labral tear when positive.</p><p>1 The patient assumes a sitting position. The examiner</p><p>stands behind the patient.</p><p>2 The examiner grasps the elbow and pulls down causing an</p><p>inferior traction force.</p><p>3 The examiner notes, in centimeters, the distance between</p><p>the inferior surface of the acromion and the superior por-</p><p>tion of the humeral head.</p><p>4 The examiner repeats the test in supine with the shoulder</p><p>in 20 degrees of abduction and in forward flexion while</p><p>maintaining a neutral rotation.</p><p>Sulcus Sign77 (Inferior Laxity, Superior Labral Tear)</p><p>UTILITY SCORE 3</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 197</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>O’Brien et al.66 (Labral Abnormality</p><p>AC Joint Pathology)</p><p>NT</p><p>NT</p><p>100</p><p>100</p><p>99</p><p>97</p><p>NA</p><p>NA</p><p>NA</p><p>NA</p><p>3</p><p>3</p><p>Guanche & Jones24 (SLAP</p><p>Any Labral Lesion)</p><p>NT</p><p>NT</p><p>54</p><p>63</p><p>47</p><p>73</p><p>1.01</p><p>2.33</p><p>0.98</p><p>0.51</p><p>12</p><p>12</p><p>Morgan et al.62 [Anterior Labral</p><p>Posterior Labral Tear</p><p>Combined (SLAP)]</p><p>NT 88</p><p>32</p><p>85</p><p>42</p><p>13</p><p>41</p><p>1.52</p><p>0.37</p><p>1.44</p><p>0.28</p><p>5.14</p><p>0.36</p><p>11</p><p>11</p><p>11</p><p>Parentis et al.71 (SLAP) NT 65 49 1.27 0.72 5</p><p>McFarland et al.56 (SLAP) NT 47 55 1.04 0.96 11</p><p>Stetson & Templin81 (Labral Tear) NT 54 31 0.78 1.48 10</p><p>Myers et al.64 (SLAP) NT 78 11 0.88 2 8</p><p>Walton et al.84 (AC Joint) NT 16 90 1.6 0.93 13</p><p>1 The patient is instructed to stand with his or her involved</p><p>shoulder at 90 degrees of flexion, 10 degrees of horizontal</p><p>adduction, and maximum internal rotation with the elbow</p><p>in full extension. The examiner stands directly behind the</p><p>patient’s involved shoulder.</p><p>2 The examiner applies a downward force at the wrist of the</p><p>involved extremity. The patient is instructed to resist the</p><p>force.</p><p>3 The patient resists the downward force and reports any</p><p>pain as either “on top of the shoulder” (acromioclavicular</p><p>joint) or “inside the shoulder” (SLAP lesion).</p><p>4 The patient’s shoulder is then moved to a position of</p><p>maximum external</p><p>rotation, and the downward force is</p><p>repeated.</p><p>5 A positive test is indicated by pain or painful clicking in</p><p>shoulder internal rotation and less or no pain in external</p><p>rotation.</p><p>Active Compression Test/O’Brien’s Test66 [Labral Tear, SLAP Lesion,</p><p>Labral Abnormality, Acromioclavicular (AC) Joint Pathology]</p><p>UTILITY SCORE 3</p><p>(continued)</p><p>198 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Nakagawa et al.65 (Superior Labral Tear) NT 54 60 1.35 0.77 10</p><p>Parentis et al.70 (SLAP) NT 63 50 1.3 0.7 9</p><p>Jia et al.34 (SLAP</p><p>AC Joint)</p><p>NT</p><p>NT</p><p>47</p><p>41</p><p>55</p><p>95</p><p>1.04</p><p>8.2</p><p>0.96</p><p>0.62</p><p>6</p><p>Ebinger et al.14 (Type II SLAP) NT 94 28 1.30 0.21 13</p><p>Kibler et al.41 (Labral Tear) NT 61 84 3.83 0.84 9</p><p>Oh et al.68 (Type II SLAP) NT 63 53 1.34 0.70 11</p><p>Walsworth et al.83 (Any Labral Tear) κ = 0.24 55 18 0.67 2.5 11</p><p>Comments: The original optimistic statistical numbers presented by O’Brien et al.66 were most likely the result of poor study</p><p>design. Better conducted studies may be showing that the Active Compression Test is sensitive for SLAP tears and specific for an</p><p>AC joint problem or that the test may be of no clinical utility.</p><p>1 The patient assumes a supine position. The examiner</p><p>stands beside the patient’s involved extremity.</p><p>2 The examiner grasps the patient’s hand and supports the</p><p>elbow. The examiner then places the patient’s shoulder in</p><p>90 degrees of abduction and neutral rotation, the elbow</p><p>in 65–70 degrees of flexion, and the forearm in neutral</p><p>pronation/supination.</p><p>3 The examiner instructs the patient to attempt to supinate</p><p>his or her arm.</p><p>4 The examiner resists supination while gradually moving</p><p>the patient’s shoulder to end-range of external rotation.</p><p>5 A positive test is indicated by the production of pain in</p><p>the anterior or deep shoulder, clicking or catching in the</p><p>shoulder, or by reproduction of the patient’s concordant</p><p>symptoms.</p><p>Resisted Supination External Rotation Test (RSERT)64 (SLAP Lesion)</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 199</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>McFarland et al.56 (SLAP) NT 24 76 1.0 1.0 11</p><p>Oh et al.68 (Type II SLAP) NT 61 54 1.33 0.72 11</p><p>Comments: The Compression-Rotation Test was originally reported by Snyder et al.79 Both studies to examine the Compression-</p><p>Rotation Test were performed well. There appears to be little use for this test in the clinic to detect SLAP lesions.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Myers et al.64 SLAP NT 83 82 4.61 .20 8</p><p>Comments: The RSERT has only a small to moderate effect on the posttest probability of having a SLAP lesion. Additionally, there is</p><p>only one study, with numerous design/reporting limitations, which looked at this test. More research needs to be performed, espe-</p><p>cially in light of the quality of this study.</p><p>UTILITY SCORE 3</p><p>1 The patient assumes a supine position. The examiner</p><p>stands to the side of the involved extremity.</p><p>2 The examiner passively places the patient’s shoulder in</p><p>90 degrees of abduction and the elbow in 90 degrees of</p><p>flexion.</p><p>3 The examiner first applies a compression force to the</p><p>humerus and rotates the humerus back and forth from</p><p>internal rotation to external rotation in an attempt to</p><p>pinch the torn labrum.</p><p>4 A positive test is indicated by the production of a catching</p><p>or snapping in the shoulder.</p><p>Compression-Rotation Test79 (SLAP Lesion)</p><p>UTILITY SCORE 3</p><p>200 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>McFarland et al.56 (SLAP) NT 8 84 0.50 1.10 11</p><p>Kibler40 (SLAP) NT 78 92 9.75 0.24 6</p><p>Parentis et al.71 (SLAP) NT 13 84 0.79 1.04 5</p><p>Nakagawa et al.65 (Superior Labral Tear) NT 5 93 0.71 1.0 10</p><p>Parentis et al.70 (SLAP) NT 10 82 0.56 1.1 9</p><p>Jia et al.34 (SLAP</p><p>Biceps Tendinopathy)</p><p>NT</p><p>NT</p><p>19</p><p>50</p><p>81</p><p>81</p><p>1.03</p><p>2.68</p><p>1.0</p><p>0.62</p><p>6</p><p>Gill et al.21 (Belly Press,</p><p>Partial Biceps Tear)</p><p>NT 23 84 1.40 0.92 12</p><p>Kibler et al.41 (Labral Tear) NT 48 82 2.63 0.64 9</p><p>Oh et al.68 (Type II SLAP) NT 21 70 0.70 1.13 11</p><p>Walsworth et al.83 (Any Labral Tear) κ = 0.21 43 82 2.38 0.69 11</p><p>Comments: The original author’s solid statistical numbers may be the result of poor study design/reporting. The well-performed</p><p>studies seem to indicate that there is little use for this test in the clinic to detect SLAP lesions, partial biceps tears, or labral tears in</p><p>general.</p><p>1 The patient is in either standing or sitting with his or her</p><p>hands on his or her hips so that the thumb is positioned</p><p>posteriorly. The examiner stands behind the patient.</p><p>2 The examiner places one hand superior on the shoulder to</p><p>stabilize the scapula and clavicle.</p><p>3 The examiner places his or her opposite hand on the</p><p>patient’s elbow with the palm of the hand cupping the</p><p>olecranon.</p><p>4 The examiner provides an anterior-superior force through</p><p>the elbow to the glenohumeral joint while the patient</p><p>resists this movement.</p><p>5 A positive test is indicated by the production of pain in the</p><p>anterior shoulder, by the production of a pop or click in</p><p>the shoulder, or by reproduction of the patient’s concor-</p><p>dant symptoms.</p><p>Anterior Slide Test40 (SLAP Lesion)</p><p>UTILITY SCORE 3</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 201</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kim et al.45 (SLAP) κ = .85 91 97 29.32 .09 9</p><p>Comments: The great numbers reported by Kim et al45 would seem to warrant a better “Utility Score,” but their study had many</p><p>design faults including the fact that only patients with repeated anterior dislocations were studied. The fact that all patients had</p><p>repetitive dislocations may have been a more important predictor of a SLAP lesion than the Biceps Load Test.45 The authors may</p><p>have recognized these shortcomings because they developed the Biceps Load Test II.44</p><p>1 The patient assumes a supine position. The examiner sits</p><p>on the side of the patient’s involved extremity.</p><p>2 The examiner places the patient’s shoulder in 90 degrees</p><p>of abduction, the elbow in 90 degrees of flexion, and the</p><p>forearm in supination.</p><p>3 The examiner moves the patient’s shoulder to end-range</p><p>external rotation (apprehension position).</p><p>4 At end-range external rotation, the examiner asks the</p><p>patient to flex his or her elbow while the examiner resists</p><p>this movement.</p><p>5 The examiner queries the patient if and how his or her</p><p>apprehension has changed after flexion of the elbow.</p><p>6 A positive test is indicated by either no change in apprehen-</p><p>sion or pain that is worsened with resisted elbow flexion.</p><p>Biceps Load Test45 (SLAP Lesion with Anterior Shoulder Dislocation)</p><p>UTILITY SCORE 3</p><p>202 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>1 The patient is supine. The examiner stands to the involved</p><p>side of the patient with one hand on the posterior humeral</p><p>head and the other on the medial distal humerus.</p><p>2 The examiner abducts the patient’s shoulder to end-range.</p><p>3 A posterior to anterior force is then applied to the posterior</p><p>aspect of the humeral head by the examiner’s one hand</p><p>while the hand at the elbow provides a lateral rotation of</p><p>the humerus.</p><p>4 A positive test is indicated by a “clunk” or a grinding.</p><p>Clunk Test (Labral Tear, Superior Labral Tear)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Nakagawa et al.65 (Superior Labral Tear) NT 44 68 1.38 .82 10</p><p>Comments: Based on this one study with a limited patient population (52 male, 2 female throwing athletes), this often-used clinical</p><p>test for labral tear has little merit.</p><p>UTILITY SCORE 3</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 203</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>1 The patient assumes a supine position. The examiner</p><p>stands behind the patient.</p><p>2 The examiner</p><p>secures the distal arm of the patient in his/</p><p>her axillary region.</p><p>3 The examiner’s hands are placed so that one hand stabilizes</p><p>the scapula and the other grasps the proximal humerus.</p><p>4 The examiner abducts the patient’s arm to between 80</p><p>and 100 degrees, and then applies a posterior-to-anterior</p><p>force to the humerus. The examiner carefully notes the</p><p>amount of translation of the glenohumeral joint compared</p><p>to the uninvolved shoulder.</p><p>Anterior Drawer Test18 (Anterior Laxity, Anterior Instability)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Gerber & Ganz18 NT NT NT NA NA NA</p><p>Farber et al.15 (Pain</p><p>Reproduction of Instability Symptoms)</p><p>NT</p><p>NT</p><p>28</p><p>53</p><p>71</p><p>85</p><p>0.97</p><p>3.53</p><p>1.01</p><p>0.55</p><p>11</p><p>Comments: The Anterior Drawer18 is often used clinically but one study of high quality shows this test to be of limited clinical value.</p><p>UTILITY SCORE 3</p><p>1 The patient assumes a sitting or standing position. The</p><p>examiner stands in front of the patient.</p><p>2 The patient places their arm in 90 degrees of shoulder</p><p>abduction, with a fully extended elbow and forearm</p><p>supinated.</p><p>3 The examiner applies a downward-directed force to the</p><p>distal forearm.</p><p>4 A positive test is indicated by patient report of pain.</p><p>Biceps Tension Test16 (Unstable Superior Labrum—Lesions/SLAP Lesions)</p><p>Study Reliability Sensitivity Specificity LR+ LR− DOR</p><p>QUADAS</p><p>Score (0–14)</p><p>Field & Savoie16 NT NT NT NA NA NA NA</p><p>Comments: Research needs to be performed to validate this test. The original description of the test is very limited.</p><p>UTILITY SCORE ?</p><p>204 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>1 The patient assumes a sitting position. The examiner</p><p>stands behind the patient.</p><p>2 The examiner stabilizes the scapula with a downward force</p><p>on the supraclavicular region and passively places the</p><p>patient’s elbow in 90 degrees of flexion and the patient’s</p><p>forearm in pronation.</p><p>3 The examiner moves the patient’s arm to maximum</p><p>abduction stabilizing the scapula to reduce rotation.</p><p>4 A positive test is indicated by passive abduction greater</p><p>than 105 degrees.</p><p>Hyperabduction Test17 (Inferior Laxity)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Gagey & Gagey17 NT NT NT NA NA NA</p><p>Comments: This is a very interesting test studied in cadavers, normal volunteers, and patients undergoing surgery for instability but</p><p>neither diagnostic accuracy nor reliability was established.</p><p>UTILITY SCORE ?</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 205</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>1 The patient assumes a supine position. The examiner</p><p>stands beside the patient to the side of the involved</p><p>shoulder.</p><p>2 The examiner secures the distal arm of the patient in his/</p><p>her axillary region.</p><p>3 The examiner’s hands are placed so that the upper arm is</p><p>stabilized.</p><p>4 The examiner abducts the patient’s arm to between 80</p><p>and 100 degrees, and then applies an anterior-to-posterior</p><p>force to the humerus. The examiner carefully notes the</p><p>amount of translation of the glenohumeral joint compared</p><p>to the uninvolved shoulder.</p><p>Posterior Drawer Test18 (Posterior Laxity)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Gerber & Ganz18 NT NT NT NA NA NA</p><p>Comments: The Posterior Drawer is often used clinically but, amazingly, has never been researched, perhaps because of the diffi-</p><p>culty of establishing a criterion standard for “instability.”</p><p>UTILITY SCORE ?</p><p>206 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Silliman & Hawkins77 NT NT NT NA NA NA</p><p>Comments: Uh . . . Happy twentieth birthday to the Load and Shift?77</p><p>1 The patient assumes a supine position. The examiner</p><p>stands to the side of the patient’s involved shoulder.</p><p>2 The examiner grasps the proximal humerus with one hand</p><p>providing a compression force and “loading” the humerus</p><p>into the glenoid fossa. The examiner’s other hand stabi-</p><p>lizes the scapula.</p><p>3 The examiner applies an anterior-to-posterior force noting</p><p>the amount of translation as either (1) to the posterior rim</p><p>of the glenoid, or (2) beyond the rim of the glenoid.</p><p>4 The examiner applies a posterior-to-anterior force noting</p><p>the amount of translation as either (1) to the anterior rim</p><p>of the glenoid, or (2) beyond the rim of the glenoid.</p><p>5 A Sulcus Sign (see Figure 6.64 is then performed to assess</p><p>the full excursion of the humeral head in the glenoid fossa.</p><p>Load and Shift Test77 (Anterior, Posterior, Inferior Laxity)</p><p>UTILITY SCORE ?</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 207</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Diagnostic Clusters—Instability</p><p>Study Cluster Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Malhi &</p><p>Khan55</p><p>Apprehension or</p><p>Relocation</p><p>NT 81 100 NA 19.0 5</p><p>Lo et al.52 Apprehension and</p><p>Relocation and Surprise</p><p>NT 40 100 NA NA 7</p><p>Farber</p><p>et al.15</p><p>Apprehension and</p><p>Relocation</p><p>NT 81 98 36.98 0.19 11</p><p>Comments: Clearly the combination of Apprehension followed by Relocation is a winning combination but may not be as good as</p><p>the Surprise test by itself, based on the statistics.</p><p>UTILITY SCORE 1</p><p>208 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TORN LABRUM/INSTABILITY TESTS</p><p>Diagnostic Clusters—Labral Tears</p><p>Study Cluster Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Malhi & Khan55 Apprehension or</p><p>Relocation</p><p>NT 81 1.0 NA 19.0 5</p><p>Liu et al.50 Apprehension or</p><p>Relocation or</p><p>Clicking with Load</p><p>and Shift or Sulcus</p><p>NT 90 85 6.00 0.12 9</p><p>Liu et al.50 Age</p><p>her</p><p>side. The examiner stands behind the patient and palpates</p><p>the AC joint.</p><p>AC Joint Palpation84 (AC Joint Pain)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Walton et al.84 NT 96 10 1.07 .40 13</p><p>Comments: Based on this one well-performed study, AC joint palpation should not be used as a diagnostic tool but may be a valu-</p><p>able screen as negative test to rule out the AC joint. More research needs to be performed.</p><p>UTILITY SCORE 2</p><p>1 The patient is seated with the involved arm at his or her</p><p>side. The examiner stands behind the patient.</p><p>2 The examiner places his or her thumb under the postero-</p><p>lateral aspect of the acromion and the index and middle</p><p>fingers of the same hand on the distal clavicle.</p><p>3 The examiner applies an anterosuperior force with the</p><p>thumb while concurrently applying an inferior force with</p><p>the index and middle fingers.</p><p>4 A positive test is indicated by pain reproduction or an</p><p>increase in pain at the AC joint.</p><p>Paxinos Sign84 (AC Joint Pain)</p><p>UTILITY SCORE 3</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 211</p><p>NERVE PALSIESACROMIOCLAVICULAR (AC) DYSFUNCTION TESTS</p><p>Diagnostic Clusters—AC Joint Pathology</p><p>Study Cluster Reliability Sensitivity Specificity LR+ LR− QUADAS</p><p>Chronopoulos</p><p>et al.11</p><p>2 or more of: Cross-</p><p>body Adduction,</p><p>AC Resisted</p><p>Extension, and</p><p>Active Compression</p><p>NT 81 89 7.36 0.21 10</p><p>Comments: There is only a small improvement in diagnostic ability of a cluster of AC joint tests when compared to the AC</p><p>Resisted Extension test alone</p><p>UTILITY SCORE 2</p><p>NERVE PALSIES</p><p>1 The patient is standing. The examiner takes each of the</p><p>patient’s arms into full flexion passively to make sure stiff-</p><p>ness is not an issue. If stiffness is the reason for limited flex-</p><p>ion, the Active Elevation Lag Sign cannot be performed.</p><p>Active Elevation Lag Sign (Spinal Accessory Nerve Palsy)</p><p>2 The examiner stands beside the patient on the unaffected</p><p>side palpating the lumbar spine for hyperextension</p><p>3 The examiner asks the patient to flex their arm to end-</p><p>range which is defined as the maximum elevation of the</p><p>shoulder until the lumbar spine hyperextends</p><p>4 Steps two and three are repeated on the affected side</p><p>5 A positive test is indicated by decreased flexion on the</p><p>involved vs. the uninvolved side.</p><p>212 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>NERVE PALSIES</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Levy et al.48 NT 100 95 NA NA 7</p><p>Comments: This study was performed on only 10 patients (demographics unknown) but the authors derived their numbers</p><p>by having 8 assessors look at video of the test. The quality and methodology of this study are questionable.</p><p>UTILITY SCORE 3</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Levy et al.48 NT 100 95 NA NA 7</p><p>Comments: This study was performed on only 10 patients (demographics unknown) but the authors derived their numbers by hav-</p><p>ing 8 assessors look at video of the test. The quality and methodology of this study are questionable.</p><p>1 The patient is standing. The examiner takes each of the</p><p>patient’s arms into full flexion passively to make sure stiff-</p><p>ness is not an issue. If stiffness is the reason for limited</p><p>flexion, the Triangle Sign cannot be performed.</p><p>2 The examiner stands beside the patient who is lying prone</p><p>with arms overhead.</p><p>3 The examiner asks the patient to flex their arm to end-</p><p>range which is defined as the maximum elevation of the</p><p>shoulder until the lumbar spine hyperextends.</p><p>4 A positive sign is indicated by the compensatory strategy</p><p>of lumbar extension to lift the affected arm from the table.</p><p>The Triangle Sign (Spinal Accessory Nerve Palsy)</p><p>UTILITY SCORE 3</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 213</p><p>NERVE PALSIES</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Hertel et al.28 NT NT NT NA NA NA</p><p>Comments: This study was performed with only five male patients after acute traumatic anterior dislocation of the shoulder to</p><p>track recovery of the axillary nerve.</p><p>1 The patient assumes a supine position. The examiner</p><p>stands behind the patient.</p><p>2 The examiner grasps the patient’s wrist and pulls the arm</p><p>into near full extension.</p><p>3 The examiner then releases the wrists.</p><p>4 A positive test is indicated by an angular drop or lag. The</p><p>inability to maintain the shoulder extension is considered</p><p>a positive test.</p><p>5 The examiner records any lag to the nearest five degrees.</p><p>Deltoid Extension Lag Sign28 (Axillary Nerve Palsy)</p><p>UTILITY SCORE ?</p><p>214 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>Shrug Sign (OA & Adhesive Capsulitis)</p><p>1 The patient is asked to elevate the involved arm overhead or as high as possible</p><p>2 A positive test is indicated when the patient elevates the entire shoulder girdle as if “shrugging”</p><p>the shoulder.</p><p>STIFFNESS-RELATED DISORDERS [OSTEOARTHRITIS (OA) & ADHESIVE CAPSULITIS]</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Jia et al.33 (Glenohumeral OA</p><p>Adhesive Capsulitis</p><p>Rotator Cuff Tendinopathy)</p><p>NT</p><p>NT</p><p>NT</p><p>91</p><p>95</p><p>96</p><p>57</p><p>50</p><p>53</p><p>2.12</p><p>1.90</p><p>2.04</p><p>0.16</p><p>0.10</p><p>0.08</p><p>10</p><p>Comments: Based on this one study of high quality and a sample size of 982 patients, the Shrug Sign84 is a screen for pathologies</p><p>that create stiffness and weakness. More research is needed.</p><p>UTILITY SCORE 2</p><p>1 The examiner palpates the coracoid, the AC joint, and the</p><p>anterolateral subacromial region all on the involved side.</p><p>2 The patient is asked to rate their pain on a 0 (no pain) to</p><p>10 (most severe pain) scale.</p><p>3 A positive test is indicated when the coracoids pain is three</p><p>points or greater above the other two palpated areas.</p><p>Coracoid Pain Test (Adhesive Capsulitis)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Carbone et al.9 (Adhesive Capsulitis) NT 96 89 8.73 0.04 6</p><p>Comments: Statistical gymnastics in this article required recalculation of sensitivity and specificity. Based on this one study</p><p>of moderate quality but with a sample size of 680 patients, the Coracoid Pain Test9 is diagnostic for adhesive capsulitis. More</p><p>research is needed.</p><p>UTILITY SCORE 2</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 215</p><p>TEST FOR SCAPULAR DYSFUNCTION</p><p>Diagnostic Clusters—Adhesive Capsulitis</p><p>Study Cluster Reliability Sensitivity Specificity LR+ LR− QUADAS</p><p>Malhi &</p><p>Khan55</p><p>Global reduction of motion NT 100 95 NA NA 5</p><p>Comments: Clinically, this cluster would seem most appropriate, especially in Stage 2 and 3 but the quality of the research to back</p><p>this clinical assumption is poor.</p><p>UTILITY SCORE 3</p><p>TEST FOR SCAPULAR DYSFUNCTION</p><p>1 The patient is asked to abduct the involved arm to 0, 45</p><p>(with medial rotation), then 90 (with maximal medial rota-</p><p>tion) degrees.</p><p>2 The examiner measures the distance from the inferior</p><p>angle of the scapula to the thoracic spinous process at the</p><p>same level.</p><p>3 The examiner repeats steps one and two on the unin-</p><p>volved side.</p><p>4 A positive test is indicated when a side-to-side difference</p><p>of 1–1.5 cm is detected.</p><p>Lateral Scapular Slide Test (Shoulder Dysfunction)</p><p>(continued)</p><p>216 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TESTS FOR SCAPULAR DYSFUNCTION</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Odom et al.67 1 cm Threshold</p><p>0°Abduction</p><p>45° Abduction</p><p>90° Abduction</p><p>1.5 cm Threshold</p><p>0° Abduction</p><p>45°Abduction</p><p>90° Abduction</p><p>Inter-rater</p><p>ICC = .79</p><p>ICC = .45</p><p>ICC = .57</p><p>Intra-rater</p><p>ICC = .52</p><p>ICC = .66</p><p>ICC = .62</p><p>35</p><p>41</p><p>43</p><p>28</p><p>50</p><p>34</p><p>48</p><p>54</p><p>56</p><p>53</p><p>58</p><p>52</p><p>0.67</p><p>0.89</p><p>0.98</p><p>0.60</p><p>1.19</p><p>0.71</p><p>1.35</p><p>1.09</p><p>1.02</p><p>1.36</p><p>0.86</p><p>1.27</p><p>11</p><p>Shadmehr et al.76 1 cm Threshold</p><p>0° Abduction</p><p>45° Abduction</p><p>90° Abduction</p><p>1.5 cm Threshold</p><p>0° Abduction</p><p>45° Abduction</p><p>90° Abduction</p><p>Inter-rater</p><p>ICC = .79</p><p>ICC = .70</p><p>ICC = .63</p><p>Intra-rater</p><p>ICC = .88</p><p>ICC = .96</p><p>ICC = .90</p><p>93–100</p><p>90–93</p><p>86–96</p><p>90–96</p><p>83–90</p><p>80–90</p><p>8–23</p><p>4–23</p><p>4–15</p><p>12–26</p><p>15–26</p><p>4–19</p><p>1.01–1.21</p><p>0.97–1.17</p><p>0.98–1.13</p><p>1.02–1.22</p><p>1.02–1.22</p><p>0.94–0.99</p><p>0–0.88</p><p>0.43–1.75</p><p>0.27–1.17</p><p>0.21–0.83</p><p>0.38–0.89</p><p>1.05–2.5</p><p>6</p><p>Comments: The Odom et al.67 study used a case-control design which artificially elevates sensitivity and specificity—a sobering</p><p>thought considering how poor those statistics show the Lateral Scapular Slide Test to be. The Shadmehr et al.76 study was not well</p><p>done.</p><p>UTILITY SCORE 3</p><p>CHAPTER 6 Physical Examination Tests for the Shoulder Complex 217</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kibler et al.41 NT 73 78 3.38 0.34 9</p><p>TESTS FOR BICEPS TENDINOPATHY</p><p>1 The patient is standing with the involved shoulder in a</p><p>neutral position, the elbow flexed to 90 degrees, the fore-</p><p>arm supinated, and the patient making a fist.</p><p>2 The examiner stands on the involved side with one hand</p><p>on the patient’s elbow and one hand covering the patient’s</p><p>fist.</p><p>3 The examiner asks the patient to rapidly bring the hand up</p><p>and toward the chin—a boxing “upper cut” punch—while</p><p>resisting this motion</p><p>4 A positive test is indicated by pain or a painful pop over</p><p>the anterior shoulder.</p><p>Upper Cut Test (Biceps Tendinopathy)</p><p>UTILITY SCORE 2</p><p>1 The examiner palpates the proximal long head of the</p><p>biceps over the anterior shoulder region.</p><p>2 A positive test is indicated by pain.</p><p>Biceps Palpation (Biceps Tear, Type II SLAP)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Oh et al.68 (Type II SLAP) NT 27 66 0.79 1.11 11</p><p>Gill et al.21 (Biceps Tear) NT 53 54 1.13 0.87 12</p><p>Comments: Biceps palpation does not appear to be a useful clinical tool.</p><p>UTILITY SCORE 3</p><p>218 CHAPTER 6 Physical Examination Tests for the Shoulder Complex</p><p>TESTS FOR BICEPS TENDINOPATHY</p><p>Diagnostic Clusters—Biceps Tendinopathy</p><p>Study Cluster Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kibler et al.41 Upper Cut and Speed’s NT NT NT NT NT 9</p><p>Gill et al.21</p><p>(Biceps Tear)</p><p>Speed’s and Biceps</p><p>Palpation</p><p>NT 68 49 1.31 0.65 12</p><p>Comments: Kibler et al.41 performed a binary logistic regression to discover that the Upper Cut and Speed’s explained 40% of the</p><p>variance (R2) in detecting biceps tendinopathy.</p><p>UTILITY SCORE 3</p><p>Key Points</p><p>1. Screening and diagnosis for bony abnormality</p><p>and bony instability can be accomplished with</p><p>the Olecranon-Manubrium Percussion test and</p><p>the Bony Apprehension test, respectively.</p><p>2. For rotator cuff tears:</p><p>• The Rent Test and the Lateral Jobe test appear</p><p>to be the best tests for a rotator cuff tear gener-</p><p>ally.</p><p>• The Supine Impingement Test has promise as</p><p>a screening examination technique where a</p><p>negative test would rule out a rotator cuff tear.</p><p>• The External Rotation Lag sign may have value</p><p>as a positive test to rule in a full thickness rota-</p><p>tor cuff tear.</p><p>• The Lift-Off, Internal Rotation Lag, Belly Press,</p><p>and Bear Hug tests may all be appropriate</p><p>when trying to detect a subscapularis tear.</p><p>3. Impingement is a broad diagnosis that captures</p><p>a range of pathologies from subacromial bursitis,</p><p>to partial rotator cuff tear, to a full thickness rota-</p><p>tor cuff tear making its value as a diagnostic label</p><p>questionable.</p><p>4. There are no clinical examination tests of diagnos-</p><p>tic value in cases of impingement.</p><p>5. For detecting laxity/instability, the Anterior</p><p>Release/Surprise Test shows some promise. Also,</p><p>the Apprehension, Relocation, and Modified</p><p>Dynamic Labral Shear tests are specific for insta-</p><p>bility, especially when apprehension is used as a</p><p>positive sign over pain.</p><p>6. For SLAP lesions, the Biceps Load Test II and</p><p>the Passive Compression may be appropri-</p><p>ate diagnostic tools and the Pain Provocation</p><p>test appears to have value in ruling in the SLAP</p><p>when positive.</p><p>7. 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Internal rotation resistance strength test:</p><p>a new diagnostic test to differentiate intra-articular</p><p>pathology from outlet (Neer) impingement syn-</p><p>drome in the shoulder. J Shoulder Elbow Surg. Jan–Feb</p><p>2001;10(1):23–27.</p><p>PEARSON</p><p>Use this address to access the Companion Website created for this textbook. Simply select “Physical Therapy” from the</p><p>choice of disciplines. Find this book and log in using your username and password to access video clips of selected tests.</p><p>222</p><p>Physical Examination</p><p>Tests for the Elbow</p><p>and Forearm</p><p>CHAPTER</p><p>7</p><p>Adam Goode and Chad E.Cook</p><p>Index of Tests</p><p>Tests for Ulnar Nerve Entrapment 223</p><p>Elbow Flexion Test</p><p>(Cubital Tunnel Syndrome) 223</p><p>Pressure Provocation Test</p><p>(Cubital Tunnel Syndrome) 223</p><p>Elbow Flexion Test</p><p>(Ulnar Nerve Neuropathy) 224</p><p>Tinel’s Sign (Cubital Tunnel Syndrome) 225</p><p>Elbow Scratch Collapse Test 225</p><p>Tests for Elbow Fracture 226</p><p>Elbow Extension Test 226</p><p>Elbow Flexion Test 226</p><p>Elbow Pronation Test 227</p><p>Elbow Supination Test 227</p><p>Tests for Elbow Instability 228</p><p>Moving Valgus Stress Test</p><p>(Chronic Medial Collateral Ligament</p><p>Tear of the Elbow) 228</p><p>Posterior Lateral Rotary Instability</p><p>(Posterior Lateral Instability</p><p>of the Radius) 228</p><p>Varus Stress Test (Integrity of the</p><p>Lateral Collateral Complex) 229</p><p>Valgus Stress Test 230</p><p>Tests for Biceps Tear 231</p><p>Biceps Squeeze Test</p><p>(Distal Bicep Tendon Rupture) 231</p><p>Biceps Crease Index</p><p>(Distal Bicep Tendon Rupture) 231</p><p>Hook Test (Distal Bicep Tendon Rupture) 232</p><p>Tests for Lateral Epicondylitis 233</p><p>Cozen’s Test 233</p><p>Resisted Tennis Elbow Test 233</p><p>Passive Tennis Elbow Test 234</p><p>Lateral Epicondylitis/Maudsley’s Test 234</p><p>CHAPTER 7 Physical Examination Tests for the Elbow and Forearm 223</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Buehler & Thayer2 NT 93 NT NA NA NT</p><p>Novak et al.8 NT 75 99 75 0.25 7</p><p>Comments: Buehler & Thayer2 studied 15 subjects with suspected cubital tunnel syndrome confirmed by NCS without a control</p><p>group. Novak et al.8 performed the elbow flexion test without wrist extension and with wrist supination held for 60 seconds.</p><p>1 Patient is sitting with both arms and shoulders in the</p><p>anatomic position. Both elbows are fully but not forcibly</p><p>flexed with full wrist extension.</p><p>2 Patients are asked to describe any symptoms following</p><p>holding this position for 3 minutes.</p><p>3 A positive test is the reproduction of pain, tingling, or</p><p>numbness along the ulnar nerve distribution.</p><p>Elbow Flexion Test (Cubital Tunnel Syndrome)</p><p>TESTS FOR ULNAR NERVE ENTRAPMENT</p><p>1 The examiner places his or her first and second fingers</p><p>over the patient’s ulnar nerve proximal to the cubital</p><p>tunnel with the elbow in 20 degrees flexion and forearm</p><p>supination.</p><p>2 The test is held for 60 seconds.</p><p>3 A positive test is the reproduction of symptoms along the</p><p>ulnar nerve.</p><p>Pressure Provocation Test (Cubital Tunnel Syndrome)</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Novak et al.8 NT 89 98 45 0.11 7</p><p>Cheng et al.4 NT 46 99 46 0.54 6</p><p>Comments: This test should be used with caution secondary to potential bias of the two studies.</p><p>224 CHAPTER 7 Physical Examination Tests for the Elbow and Forearm</p><p>TESTS FOR ULNAR NERVE ENTRAPMENT</p><p>1 Patient is instructed to fully flex the elbows with the</p><p>wrists and shoulders in neutral. This position is held for 60</p><p>seconds.</p><p>2 Full elbow flexion is maintained for 60 seconds with the</p><p>shoulders in neutral and wrists in full extension.</p><p>Elbow Flexion Test (Ulnar Nerve Neuropathy)</p><p>3 The patient is asked to abduct the shoulders to 90 degrees</p><p>with the elbows in full flexion and wrist in full extension</p><p>for 90 seconds.</p><p>4 A positive test is reproduction of ulnar nerve symptoms</p><p>(paresthesia) along the ulnar nerve distribution.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Rayan et al.12 NT NT 13 NA NA NT</p><p>Comments: Rayan et al.12 studied this test in a population of 204 elbows of patients without an upper extremity-related diagnosis.</p><p>The study used a combination of four movements: (1) full elbow flexion passively with wrist in neutral was positive in 10%; (2) same</p><p>test with the wrist in full extension was positive in 7%; (3) same test with the shoulder in 90 degrees of abduction was positive in</p><p>11%; (4) same test with the shoulder in 90 degrees of abduction and wrist in full extension was positive in 13%.</p><p>UTILITY SCORE ?</p><p>CHAPTER 7 Physical Examination Tests for the Elbow and Forearm 225</p><p>TESTS FOR ULNAR NERVE ENTRAPMENT</p><p>1 The examiner applies four to six taps to the patient’s ulnar</p><p>nerve just proximal to the cubital tunnel.</p><p>2 A positive test is the reproduction of symptoms along the</p><p>ulnar nerve.</p><p>Tinel’s Sign (Cubital Tunnel Syndrome)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Novak et al.8 NT 70 98 35 0.31 7</p><p>Rayan et al.12 NT NT 24 NA NA NT</p><p>Cheng et al.4 NT 54 99 54 0.46</p><p>litera-</p><p>ture studying the test’s descriminatory ability and reliability will</p><p>be summarized in a table format along with the epidemiological</p><p>statistics gathered from that material (Figure 1-4). Finally, the</p><p>number of “yeses” on the QUADAS tool will be recorded for</p><p>each article and we will give the test a summary “Utility Score”</p><p>which is our opinion of the clinical use of that special test after</p><p>gathering and critically evaluating all of the literature. Please see</p><p>Figure 1-4 for an example of the textbook’s format. We feel it</p><p>is important for the reader to know that, because the quality</p><p>of research literature in the area of special tests is medio-</p><p>cre, some would say that providing a quality score for Physical</p><p>Examination Tests is unwise.39 Be that as it may, our goal is to</p><p>create a handbook that is as clinician-friendly as possible and</p><p>the “Utility Score” is our expert opinion, as clinicians, teachers,</p><p>and researchers, as to the clinical import of each special test.</p><p>Our scale for the “Utility Score” is as follows:</p><p>TABLE 1-2 The Use of Likelihood Ratios (Adapted from Jaeschke et al.19)</p><p>+ LR Explanation −LR</p><p>1 to 2 Alters posttest probability of a diagnosis to a very small degree .5 to 1</p><p>2 to 5 Alters posttest probability of a diagnosis to a small degree .2 to .5</p><p>5 to 10 Alters posttest probability of a diagnosis to a moderate degree .1 to .2</p><p>More than 10 Alters posttest probability of a diagnosis to a moderate degree Less than .1</p><p>Evidence strongly supports the use of this test1</p><p>Evidence moderately supports the use of this</p><p>test2</p><p>Evidence minimally supports or does not support</p><p>the use of this test3</p><p>The test has not been researched sufficiently so</p><p>we are unsure of its value?</p><p>We hope that you find this textbook of use and that we</p><p>contribute, in some small way, to the value of your clinical</p><p>practice.</p><p>CHAPTER 1 Introduction to Diagnostic Accuracy 5</p><p>ANTERIOR DRAWER TEST [Anterior Cruciate Ligament (ACL) Tear]</p><p>1 The patient is supine with the knee flexed to 90 degrees so</p><p>that the foot is flat.</p><p>2 The examiner sits on the patient's foot and grasps behind</p><p>the proximal tibia with thumbs palpating the tibial plateau</p><p>and index fingers palpating the tendons of the hamstring</p><p>muscle group medially and laterally.</p><p>3 An anterior tibial force is applied by the examiner.</p><p>4 A positive test for a torn ACL is indicated by greater anterior</p><p>tibial displacement on the affected side when compared to</p><p>the unaffected side.</p><p>UTILITY SCORE 2</p><p>QUADAS</p><p>Score</p><p>Study Reliability Sensitivity Specificity LR+ LR– (0–14)</p><p>Hardaker16 NT 18 NT NA NA 8</p><p>Bomberg4 NT 41 100 NA NA 9</p><p>Jonsson21 Acute (A) NT 33 NT NA NA 8</p><p>Chronic (C) NT 95 NT NA NA 8</p><p>Comments: The Anterior Drawer Test appears to be a specific test helpful at ruling in a torn ACL when the test is positive. The</p><p>Anterior Drawer Test may become more sensitive in non-acute patients.</p><p>NT = Not Tested. This designation is used when the statistic was not reported in the study for whatever reason. Also, if a study</p><p>reported only one of either sensitivity or specificity, then the rest of the statistics for that study are reported as NA.</p><p>NA = Not Applicable. This designation, in addition to being used when only one of either sensitivity or specificity are reported,</p><p>is used for the likelihood ratios (LR+/LR−) when either sensitivity or specificity is reported as perfect (100) for a study. Also, if the</p><p>study was not one of diagnostic accuracy then NA was used to indicate that QUADAS cannot be used to critique study quality.</p><p>Inf = Infinity, a value that cannot be truly calculated because the sensitivity or specificity is 100%.</p><p>FIGURE 1-4 Example of Textbook format.</p><p>6 CHAPTER 1 Introduction to Diagnostic Accuracy</p><p>References</p><p>1. Guide to Physical Therapist Practice. 2d ed. American</p><p>Physical Therapy Association. Phys Ther. 2001;81:9–746.</p><p>2. Bartko JJ, Carpenter WT, Jr. On the methods and theory</p><p>of reliability. J Nerv Ment Dis. 1976;163:307–317.</p><p>3. Benbassat J, Baumal R, Heyman SN, Brezis M. View-</p><p>point: suggestions for a shift in teaching clinical skills</p><p>to medical students: the reflective clinical examination.</p><p>Acad Med. 2005;80:1121–1126.</p><p>4. Bomberg BC, McGinty JB. Acute hemarthrosis of the</p><p>knee: indications for diagnostic arthroscopy. Arthros-</p><p>copy. 1990;6:221–225.</p><p>5. Bossuyt PM, Reitsma JB, Bruns DE, et al. Towards</p><p>complete and accurate reporting of studies of diag-</p><p>nostic accuracy: The STARD Initiative. Ann Intern Med.</p><p>2003;138:40–44.</p><p>6. Bossuyt PM, Reitsma JB, Bruns DE, et al. The STARD</p><p>statement for reporting studies of diagnostic accu-</p><p>racy: explanation and elaboration. Ann Intern Med.</p><p>2003;138:W1–12.</p><p>7. Chan YS, Lien LC, Hsu HL, et al. Evaluating hip labral</p><p>tears using magnetic resonance arthrography: a pro-</p><p>spective study comparing hip arthroscopy and mag-</p><p>netic resonance arthrography diagnosis. Arthroscopy.</p><p>2005;21:1250.</p><p>8. Charnley J. Orthopaedic signs in the diagnosis of disc</p><p>protrusion. With special reference to the straight-leg-</p><p>raising test. Lancet. 1951;1:186–192.</p><p>9. Cleland J. Orthopaedic Clinical Examination: An Evidence-</p><p>Based Approach for Physical Therapists. 1st ed. Carlstadt,</p><p>NJ: Icon Learning Systems; 2005.</p><p>10. Cook C, Hegedus E. Diagnostic utility of clinical tests for</p><p>spinal dysfunction. Man Ther. 2011;16:21–25.</p><p>11. de Graaf I, Prak A, Bierma-Zeinstra S, Thomas S, Peul W,</p><p>Koes B. Diagnosis of lumbar spinal stenosis: a system-</p><p>atic review of the accuracy of diagnostic tests. Spine.</p><p>2006;31:1168–1176.</p><p>12. Deeks JJ. Systematic reviews in health care: Systematic</p><p>reviews of evaluations of diagnostic and screening tests.</p><p>BMJ. 2001;323:157–162.</p><p>13. Eren OT. The accuracy of joint line tenderness by physi-</p><p>cal examination in the diagnosis of meniscal tears.</p><p>Arthroscopy. 2003;19:850–854.</p><p>14. Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl</p><p>J Med. 1975;293:257.</p><p>15. Glas AS, Lijmer JG, Prins MH, Bonsel GJ, Bossuyt PM.</p><p>The diagnostic odds ratio: a single indicator of test per-</p><p>formance. J Clin Epidemiol. 2003;56:1129–1135.</p><p>16. Hardaker WT, Jr., Garrett WE, Jr., Bassett FH, 3rd. Evalu-</p><p>ation of acute traumatic hemarthrosis of the knee joint.</p><p>South Med J. 1990;83:640–644.</p><p>17. Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC.</p><p>Physical examination tests for assessing a torn menis-</p><p>cus in the knee: a systematic review with meta-analysis.</p><p>J Orthop Sports Phys Ther. 2007;37:541–550.</p><p>18. Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni</p><p>M, Moorman CT 3rd, Cook C. Physical examination tests</p><p>of the shoulder: a systematic review with meta-analysis</p><p>of individual tests. Br J Sports Med. 2008;42:80–92.</p><p>19. Jaeschke R, Guyatt G, Lijmer JG. User’s Guide to the</p><p>Medical Literature: Essentials of Evidence-Based Practice.</p><p>Chicago, IL: AMA Press; 2002.</p><p>20. Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to the</p><p>medical literature. III. How to use an article about a</p><p>diagnostic test. B. What are the results and will they</p><p>help me in caring for my patients? The Evidence-Based</p><p>Medicine Working Group. JAMA. 1994;271:703–707.</p><p>21. Jonsson T, Althoff B, Peterson L, Renstrom P. Clinical</p><p>diagnosis of ruptures of the anterior cruciate ligament: a</p><p>comparative study of the Lachman test and the anterior</p><p>drawer sign. Am J Sports Med. 1982;10:100–102.</p><p>22. Kassirer JP. Teaching clinical medicine by iterative</p><p>hypothesis testing. Let’s preach what we practice.</p><p>N Engl J Med. 1983;309:921–923.</p><p>23. Knottnerus JA, van Weel C, Muris JW. Evaluation of diag-</p><p>nostic procedures. BMJ. 2002;324:477–480.</p><p>24. Landis JR, Koch GG. The measurement of observer agree-</p><p>ment for categorical data. Biometrics. 1977;33:159–174.</p><p>25. Lijmer JG, Mol BW, Heisterkamp S, et al. Empirical evi-</p><p>dence of design-related bias in studies of diagnostic</p><p>tests. JAMA. 1999;282:1061–1066.</p><p>26. Magee DJ. Orthopedic Physical Assessment. Third ed.</p><p>Philadelphia, PA: W.B. Saunders Company; 1997.</p><p>27. Mulrow CD, Linn WD, Gaul MK, Pugh JA. Assessing</p><p>quality of a diagnostic test evaluation. J Gen Intern Med.</p><p>1989;4:288–295.</p><p>28. Murrell GA,</p><p>6</p><p>Comments: Rayan et al.12 observed the presence of a positive elbow percussion test in 48 of 204 asymptomatic elbows. The Cheng</p><p>et al.4 study was poorly performed.</p><p>UTILITY SCORE 2</p><p>1 The examiner sits directly in front of the patient.</p><p>2 The patient resists bilateral shoulder external rotation</p><p>movement (internal rotation force provided by the</p><p>clinician).</p><p>3 The examiner scratches or swipes the fingertips over the</p><p>area of the compressed ulnar nerve.</p><p>4 The patient again resists bilateral shoulder external (same</p><p>as step 2).</p><p>5 A positive finding is weakness (unilaterally) in the affected</p><p>area.</p><p>Elbow Scratch Collapse Test</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cheng et al.4 NT 69 99 69 0.31 6</p><p>Comments: The finding is doubtful and the bias is very high.</p><p>UTILITY SCORE 3</p><p>226 CHAPTER 7 Physical Examination Tests for the Elbow and Forearm</p><p>TESTS FOR ELBOW FRACTURE</p><p>1 Patient lies supine and is asked to fully extend the elbow.</p><p>2 A positive test is indicated by the patient’s inability to fully</p><p>extend the elbow.</p><p>Elbow Extension Test</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Docherty et al.6 NT 97 69 3.1 0.04 10</p><p>Appelboam et al.1 NT 96.8 48.5 1.88 0.06 8</p><p>Darracq et al.5 NT 100 100 NA NA 11</p><p>Comments: This test was designed as a clinical screening test for radiographic evaluation of elbow fractures. A single false positive</p><p>was present in the Docherty et al.6 study with the patient being able to fully extend the elbow with radiographic evidence of a non-</p><p>displaced radial head fracture.</p><p>1 Patient lies supine and is asked to fully flex the elbow.</p><p>2 A positive test is indicated by the patient’s inability to fully</p><p>flex the elbow in comparison to the opposite side.</p><p>Elbow Flexion Test</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Darracq et al. 5 NT 64 100 Inf 0.36 11</p><p>Comments: This was a well designed study. Comparative assessment using the opposite, unaffected limb was used. A wide variety</p><p>of ages were included in the very large sample size.</p><p>CHAPTER 7 Physical Examination Tests for the Elbow and Forearm 227</p><p>TESTS FOR ELBOW FRACTURE</p><p>1 Patient lies supine and is asked to fully pronate the elbow.</p><p>2 A positive test is indicated by the patient’s inability to fully</p><p>pronate the elbow in comparison to the opposite side.</p><p>Elbow Pronation Test</p><p>1 Patient lies supine and is asked to fully supinate the elbow.</p><p>2 A positive test is indicated by the patient’s inability to fully</p><p>supinate the elbow in comparison to the opposite side.</p><p>Elbow Supination Test</p><p>UTILITY SCORE 1</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Darracq et al. 5 NT 34 100 Inf 0.66 11</p><p>Comments: This was a well designed study. Comparative assessment using the opposite, unaffected limb was used. A wide variety of</p><p>ages were included in the very large sample size.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Darracq et al. 5 NT 43 97 14.3 0.58 11</p><p>Comments: This was a well designed study. Comparative assessment using the opposite, unaffected limb was used. A wide variety of</p><p>ages were included in the very large sample size.</p><p>228 CHAPTER 7 Physical Examination Tests for the Elbow and Forearm</p><p>TESTS FOR ELBOW INSTABILITY</p><p>1 The patient is in an upright position and the shoulder is</p><p>abducted to 90 degrees. With the elbow in full flexion of</p><p>120 degrees, modest valgus torque is applied to the elbow</p><p>until the shoulder reaches full external rotation.</p><p>2 With a constant valgus torque the elbow is quickly</p><p>extended to 30 degrees.</p><p>3 A positive test is reproduction of medial elbow pain</p><p>when forcibly extending the elbow from a flexed position</p><p>between 120 to 70 degrees.</p><p>Moving Valgus Stress Test (Chronic Medial</p><p>Collateral Ligament Tear of the Elbow)</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>O’Driscoll et al.10 NT 100 75 4 0 10</p><p>Comments: Spectrum bias exists within this study: low study population with 19 of 21 patients being male.</p><p>1 The patient lies supine.</p><p>2 The examiner flexes the shoulder until the arm is above the</p><p>patient’s head with the elbow in full extension. One hand</p><p>of the examiner prevents external rotation of the humerus.</p><p>Posterior Lateral Rotary Instability (Posterior Lateral</p><p>Instability of the Radius)</p><p>3 The examiner’s other hand grasps the patient’s forearm</p><p>into full supination.</p><p>4 The examiner brings the patient’s elbow into flexion while</p><p>applying a supinatory force at the forearm and a valgus</p><p>stress and axial compression at the elbow.</p><p>5 A positive test is posterior lateral displacement or appre-</p><p>hension of the radius followed by reduction of the radius</p><p>as the elbow approaches 90 degrees.</p><p>CHAPTER 7 Physical Examination Tests for the Elbow and Forearm 229</p><p>TESTS FOR ELBOW INSTABILITY</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>O’Driscoll et al.9 NT NT NT NA NA NT</p><p>Comments: O’Driscoll et al.9 performed this test on a case series of five patients who demonstrated apprehension with testing and</p><p>posterolateral dislocation of the radial head under anesthesia. All five patients underwent operative restoration to improve func-</p><p>tional integrity of the ulnar part of the lateral collateral ligament. Four of the five patients returned to normal function.</p><p>1 With the patient seated or standing, the examiner places</p><p>one hand at the elbow and the other hand is placed over</p><p>the patient’s wrist. With the patient’s elbow in a fully</p><p>extended position, an adduction or varus force is applied</p><p>while palpating the lateral collateral ligament of the elbow.</p><p>Varus Stress Test (Integrity of the Lateral Collateral Complex)</p><p>2 The examiner places one hand at the elbow and the other</p><p>hand is placed over the patient’s wrist. With the patient’s</p><p>elbow in 20–30 degrees of flexion, an adduction or varus</p><p>force is applied while palpating the lateral collateral liga-</p><p>ment of the elbow.</p><p>3 A positive test is reproduction of distraction pain laterally</p><p>and compression pain medially at the joint line and laxity</p><p>with stress.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>NA NT NT NT NA NA NT</p><p>Comments: No diagnostic accuracy studies have been performed to determine the sensitivity or specificity of the Varus Stress Test</p><p>of the elbow. Authors have suggested that placing the elbow in a slight degree of flexion will assist in differentiating ligamentous</p><p>versus bony joint involvement.</p><p>230 CHAPTER 7 Physical Examination Tests for the Elbow and Forearm</p><p>TESTS FOR ELBOW INSTABILITY</p><p>2 The examiner places one hand at the elbow and the other</p><p>hand is placed over the patient’s wrist. With the patient’s</p><p>elbow in 20–30 degrees of flexion, an abduction or valgus</p><p>force is applied while palpating the medial collateral liga-</p><p>ment of the elbow.</p><p>3 A positive test is reproduction of distraction pain medially</p><p>and compression pain laterally at the elbow joint line with</p><p>stress.</p><p>1 With the patient seated or standing, the examiner places</p><p>one hand at the elbow and the other hand is placed over</p><p>the patient’s wrist. With the patient’s elbow in a fully</p><p>extended position, an abduction or valgus force is applied</p><p>while palpating the medial collateral ligament of the</p><p>elbow.</p><p>Valgus Stress Test</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>None NT NT NT NA NA NT</p><p>Comments: No diagnostic accuracy studies have been performed to determine the sensitivity or specificity of the Valgus Stress Test</p><p>of the elbow. It is suggested that placing the elbow in a slight degree of flexion will assist in differentiating ligamentous versus bony</p><p>joint involvement.</p><p>CHAPTER 7 Physical Examination Tests for the Elbow and Forearm 231</p><p>TESTS FOR BICEPS TEAR</p><p>1 Patient is seated with the forearm resting comfortably in</p><p>the patient’s lap with the elbow flexed to approximately</p><p>60–80 degrees and forearm</p><p>Walton JR. Diagnosis of rotator cuff tears.</p><p>Lancet. 2001;357:769–770.</p><p>29. Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG.</p><p>Diagnostic accuracy of clinical tests for the different</p><p>degrees of subacromial impingement syndrome. J Bone</p><p>Joint Surg Am. 2005;87:1446–1455.</p><p>30. Pauker SG, Kassirer JP. The threshold approach to clinical</p><p>decision making. N Engl J Med. 1980;302:1109–1117.</p><p>31. Pewsner D, Battaglia M, Minder C, Marx A, Bucher HC,</p><p>Egger M. Ruling a diagnosis in or out with ”SpPIn” and</p><p>”SnNOut”: a note of caution. BMJ. 2004;329:209–213.</p><p>32. Reid MC, Lachs MS, Feinstein AR. Use of methodologi-</p><p>cal standards in diagnostic test research. Getting better</p><p>but still not good. JAMA. 1995;274:645–651.</p><p>33. Richardson J, Iglarsh Z. Clinical Orthopaedic Physical</p><p>Therapy. Philadelphia: W.B. Saunders Company; 1994.</p><p>34. Sackett D, Strauss S, Richardson W, Rosenberg W,</p><p>Haynes R. Evidence-Based Medicine: How to Practice and</p><p>Teach EBM. 2d ed. Churchill Livingstone; 2000.</p><p>35. Schmitt BP, Kushner MS, Wiener SL. The diagnostic use-</p><p>fulness of the history of the patient with dyspnea. J Gen</p><p>Intern Med. 1986;1:386–393.</p><p>CHAPTER 1 Introduction to Diagnostic Accuracy 7</p><p>36. Sehgal N, Shah RV, McKenzie-Brown AM, Everett CR.</p><p>Diagnostic utility of facet (zygapophysial) joint injec-</p><p>tions in chronic spinal pain: a systematic review of evi-</p><p>dence. Pain Physician. 2005;8:211–224.</p><p>37. Shah RV, Everett CR, McKenzie-Brown AM, Sehgal</p><p>N. Discography as a diagnostic test for spinal pain:</p><p>a systematic and narrative review. Pain Physician.</p><p>2005;8:187–209.</p><p>38. Sim J, Wright CC. The kappa statistic in reliability stud-</p><p>ies: use, interpretation, and sample size requirements.</p><p>Phys Ther. 2005;85:257–268.</p><p>39. Whiting P, Harbord R, Kleijnen J. No role for quality</p><p>scores in systematic reviews of diagnostic accuracy</p><p>studies. BMC Med Res Methodol. 2005;5:19.</p><p>40. Whiting P, Rutjes AW, Dinnes J, Reitsma J, Bossuyt PM,</p><p>Kleijnen J. Development and validation of methods for</p><p>assessing the quality of diagnostic accuracy studies.</p><p>Health Technol Assess. 2004;8:iii, 1–234.</p><p>41. Whiting P, Rutjes AW, Reitsma JB, Glas AS, Bossuyt PM,</p><p>Kleijnen J. Sources of variation and bias in studies of</p><p>diagnostic accuracy: a systematic review. Ann Intern</p><p>Med. 2004;140:189–202.</p><p>42. Woolf AD. How to assess musculoskeletal conditions.</p><p>History and physical examination. Best Pract Res Clin</p><p>Rheumatol. 2003;17:381–402.</p><p>Use this address to access the Companion Website created for this textbook. Simply select “Physical Therapy” from the</p><p>choice of disciplines. Find this book and log in using your username and password to access video clips of selected tests.</p><p>PEARSON</p><p>8</p><p>Physical Examination</p><p>Tests for Neurological</p><p>Testing and Screening</p><p>Tests for Concussion or Postconcussion Syndrome 16</p><p>Cranial Nerve I: Olfactory Nerve 10</p><p>Cranial Nerve II: Optic Nerve 10</p><p>Cranial Nerve III: Oculomotor Nerve 11</p><p>Cranial Nerve IV: Trochlear Nerve 11</p><p>Cranial Nerve V: Trigeminal Nerve 12</p><p>Cranial Nerve VI: Abducens Nerve 12</p><p>Cranial Nerve VII: Facial Nerve 13</p><p>Cranial Nerve VIII: Vestibulocochlear Nerve 13</p><p>Cranial Nerve IX: Glossopharyngeal Nerve 14</p><p>Cranial Nerve X: Vagus Nerve 15</p><p>Cranial Nerve XI: Spinal Accessory Nerve 15</p><p>Cranial Nerve XII: Hypoglossal Nerve 16</p><p>CHAPTER</p><p>2</p><p>Chad E. Cook and Mark Wilhelm</p><p>Index of Tests</p><p>Tests for Cranial Nerve Assessment 10</p><p>Single Limb Stance 16</p><p>Tandem Walk Test 17</p><p>Finger to Nose Test 18</p><p>ICD-10 Criteria 18</p><p>Tests for Pathological Upper Motor Neuron Reflex</p><p>or Spinal Cord Compression (Myelopathy) 20</p><p>Hoffmann’s Reflex 20</p><p>Babinski Sign 21</p><p>Lhermitte’s Sign 22</p><p>Gonda-Allen Sign 23</p><p>Allen-Cleckley Sign 23</p><p>Inverted Supinator Sign 24</p><p>Finger Escape Sign 24</p><p>Crossed Upgoing Toe Sign (Cut) 25</p><p>Mendel-Bechterew Sign 25</p><p>Schaefer’s Sign 26</p><p>Oppenheim Sign 26</p><p>Chaddock’s Sign 27</p><p>Clonus 27</p><p>Deep Tendon Reflex Tests 28</p><p>Biceps Tendon 28</p><p>Triceps Tendon 28</p><p>Suprapatellar Quadriceps Test 29</p><p>Achilles Tendon Reflex Test 29</p><p>Infrapatellar Tendon Reflex 30</p><p>Hand Withdrawal Reflex 30</p><p>Static and Dynamic Romberg’s Sign 31</p><p>Gait Deviation 31</p><p>Cook’s Clinical Prediction Rule</p><p>for Myelopathy 32</p><p>Test for Pathological Upper Motor Neuron Reflex 33</p><p>Palmomental Reflex 33</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 9</p><p>Tests for Peripheral Neuropathy 40</p><p>Superficial Pain 40</p><p>Vibration Testing 40</p><p>Monofilament Testing 41</p><p>Position Sense of the Great Toe 42</p><p>Achilles Reflex 43</p><p>Phalen’s Test 43</p><p>Tinel’s Sign 44</p><p>Richardson’s Clinical Prediction Rule</p><p>for Peripheral Neuropathy Criteria 44</p><p>Tests for Focal or Monohemispheric Brain Tumors/Lesions 34</p><p>Digit Quinti Sign 34</p><p>Pronator Drift Test 34</p><p>Finger Rolling Test 35</p><p>Forearm Rolling Test 36</p><p>Finger Tap 36</p><p>Modified Mingazzini’s Maneuver 37</p><p>Rapid Alternating Movements of the Hands 38</p><p>Barre Test 38</p><p>Teitelbaum’s Clinical Prediction Rule</p><p>for Unilateral Cerebral Lesions 39</p><p>Tests for Peripheral Nerve Pathology 45</p><p>Long Thoracic Nerve Injury 45</p><p>Pronator Teres Syndrome Test 45</p><p>Common Fibular Nerve Injury 46</p><p>Pencil Test 46</p><p>Test for Facioscapulohumeral Dystrophy 47</p><p>Beevor’s Sign 47</p><p>Biceps Deep Tendon Reflex 48</p><p>Triceps Deep Tendon Reflex 49</p><p>Brachioradialis Deep Tendon Reflex 49</p><p>Muscle Power Testing 50</p><p>Sensibility Testing 53</p><p>Combined Tests Upper Extremity 54</p><p>Tests for Lumbar Radiculopathy 55</p><p>Quadriceps Deep Tendon Reflex 55</p><p>Achilles Deep Tendon Reflex 56</p><p>Extensor Digitorum Brevis Deep</p><p>Tendon Reflex Test 57</p><p>Muscle Power Testing 57</p><p>Sensibility Testing 60</p><p>Combined Tests Lower Extremity 62</p><p>Brudzinski’s Sign 62</p><p>Bowstring Test 63</p><p>Tests for Cervical Radiculopathy 48</p><p>10 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR CRANIAL NERVE ASSESSMENT</p><p>Cranial Nerve I: Olfactory Nerve</p><p>1 The patient is placed in a sitting or standing position.</p><p>2 Can the patient recognize common scents, such as coffee</p><p>or vanilla?</p><p>3 Test each nostril separately.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: Choose commonly used scents that are accessible at the clinic.</p><p>Cranial Nerve II: Optic Nerve</p><p>1 The patient is placed in a sitting or standing position.</p><p>2 Patient may have history of vision loss.</p><p>3 Test visual acuity using an eye chart.</p><p>4 Test each eye separately.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: A standard Snellen chart is useful for testing the optic nerve.</p><p>UTILITY SCORE ?</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 11</p><p>TESTS FOR CRANIAL NERVE ASSESSMENT</p><p>Cranial Nerve III: Oculomotor Nerve</p><p>1 The patient is placed in a sitting or standing position.</p><p>2 Patient may have a history of double or blurred vision.</p><p>3 Ask the patient to follow the clinician’s finger in the vertical</p><p>and horizontal directions with the eyes without moving</p><p>the head.</p><p>4 Look for the ability of the patient to follow movements</p><p>without report of double vision.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: Look for asymmetry of movement or lagging during eye movements.</p><p>Cranial Nerve IV: Trochlear Nerve</p><p>1 The patient is placed in a sitting or standing position.</p><p>2 Patient may have a history of double vision.</p><p>3 Ask the patient to follow the clinician’s finger in the vertical</p><p>and horizontal directions with the eyes without moving</p><p>the head.</p><p>4 A positive sign is the inability of the eye to move down and</p><p>in. The eye may also be held up and out when impaired.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: Look for asymmetry of movement or lagging during eye movements.</p><p>12 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR CRANIAL NERVE ASSESSMENT</p><p>Cranial Nerve V: Trigeminal Nerve</p><p>1 The patient is placed in a sitting or standing</p><p>position.</p><p>2 Patient may have a history of facial numbness or difficulty</p><p>chewing.</p><p>3 Lightly touch the upper, middle, and lower face on each</p><p>side.</p><p>4 Check strength of jaw clenching and the masseter muscles.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: Test both sides. Look for atrophy of the masseter muscles as well.</p><p>Cranial Nerve VI: Abducens Nerve</p><p>1 The patient is placed in a sitting or standing position.</p><p>2 Patient may have a history of double vision.</p><p>3 Ask the patient to follow the clinician’s finger in the vertical</p><p>and horizontal directions with the eyes without moving</p><p>the head.</p><p>4 A positive sign is the inability of the eye to move laterally.</p><p>The eye may also be medially deviated.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: Look for asymmetry of movement or lagging during eye movements.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 13</p><p>TESTS FOR CRANIAL NERVE ASSESSMENT</p><p>Cranial Nerve VII: Facial Nerve</p><p>1 The patient is placed in a sitting or standing position.</p><p>2 The patient may have a history of facial droop.</p><p>3 The examiner asks the patient to smile.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: Look for symmetry of facial structures during face muscle movements.</p><p>Cranial Nerve VIII: Vestibulocochlear Nerve</p><p>1 The patient is placed in a sitting or standing position.</p><p>2 The patient may have a history of dizziness, imbalance, and hearing</p><p>loss.</p><p>3 To test vestibular portion, the examiner asks the patient to look as</p><p>far as possible in each direction without moving his or her head.</p><p>4 The examiner observes the patient’s eyes.</p><p>(continued)</p><p>14 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR CRANIAL NERVE ASSESSMENT</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: Nystagmus involves involuntary eye movements.</p><p>Cranial Nerve IX: Glossopharyngeal Nerve</p><p>5 A positive sign for the vestibular portion is nystagmus when</p><p>the patient looks in each direction.</p><p>6 To test the cochlear portion, the examiner will rub his fin-</p><p>gers together next to each of the patient’s ears.</p><p>UTILITY SCORE ?</p><p>UTILITY SCORE ?</p><p>1 The patient is placed in a sitting or standing position.</p><p>2 The patient may have a history of difficulty swallowing.</p><p>3 Check that the patient can elevate the palate when saying</p><p>“ahh.”</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: Look at the uvula during mouth opening and saying “ahh” to see if it elevates symmetrically.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 15</p><p>TESTS FOR CRANIAL NERVE ASSESSMENT</p><p>Cranial Nerve X: Vagus Nerve</p><p>1 The patient is placed in a sitting or standing position.</p><p>2 The patient may have a history of a hoarse voice or dif-</p><p>ficulty swallowing.</p><p>3 The examiner will listen to the patient’s speech.</p><p>4 Check that the patient gags when a cotton swab touches</p><p>the soft palate.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: Explain to the patient the procedure you are using.</p><p>Cranial Nerve XI: Spinal Accessory Nerve</p><p>1 The patient is placed in a sitting or standing position.</p><p>2 The patient may have a history of neck weakness.</p><p>3 Ask the patient to rotate his or her neck against the resis-</p><p>tance of the examiner’s hand.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: Typically, the patient (unless very acute) will also demonstrate significant atrophy of the neck muscles if the spinal</p><p>accessory nerve is affected.</p><p>16 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR CRANIAL NERVE ASSESSMENT</p><p>Cranial Nerve XII: Hypoglossal Nerve</p><p>1 The patient is placed in a sitting or standing position.</p><p>2 The patient may have a history of tongue weakness (rarely</p><p>complains of this).</p><p>3 Ask the patient to stick out his or her tongue and observe</p><p>for deviation to either side.</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cameron & Klein7 NT NT NT NA NA NA</p><p>Comments: Another method one can use is having the patient poke their tongue in the side of their cheek on both sides.</p><p>TEST FOR CONCUSSION OR POSTCONCUSSION SYNDROME</p><p>Single Limb Stance</p><p>1 The patient is placed in a standing position.</p><p>2 Instruct the patient to place his or her hands on his or her hips (pictured). Once</p><p>the patient has exhibited stability request that they close both eyes.</p><p>3 The patient then stands on one foot.</p><p>4 A positive test is the inability of the patient to maintain standing balance with-</p><p>out opening his or her eyes; touching the floor with the non-test leg, breaking</p><p>contact with the floor and the standing limb; or removal of the hands from the</p><p>hips.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 17</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Schneiders et al.45 NT NT NT NT NT NA</p><p>Comments: The utilization of tandem gait for assessment of sports related concussion is relatively new despite the fact that it has a</p><p>long history of being used for neuromotor function. Schneiders et al.45 described normative values for tandem gait and did not study</p><p>the utility of the test. With multiple trials, there may be a slight learning effect which may increase performance on subsequent</p><p>trials.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Schneiders et al.45 NT NT NT NT NT NA</p><p>Comments: Some studies have shown an age-related deterioration in balance starting in the 4th decade of life. With multiple trials,</p><p>there may be a slight learning effect which may increase performance on subsequent trials.</p><p>Tandem Walk Test</p><p>UTILITY SCORE ?</p><p>TEST FOR CONCUSSION OR POSTCONCUSSION SYNDROME</p><p>1 Prior to testing the patient, the clinician should set up a</p><p>line that is approximately 38 mm wide and 3 meters long.</p><p>2 The patient is placed in a standing position.</p><p>3 Instruct the patient to walk from one end of the line to the</p><p>other using a tandem gait maintaining approximation of</p><p>the heel and toes.</p><p>4 Once the patient reaches the end, he or she should turn</p><p>180° and return to the starting point.</p><p>5 A positive test is the inability of the patient to maintain</p><p>approximation between his or her heel and toes or devia-</p><p>tion from the track.</p><p>UTILITY SCORE ?</p><p>TEST FOR CONCUSSION OR POSTCONCUSSION SYNDROME</p><p>18 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>Finger to Nose Test</p><p>1 The patient is placed in a seated position in a chair with a</p><p>back rest.</p><p>2 Instruct the patient to flex the shoulder to 90° with the</p><p>test arm outstretched and the elbow and index finger</p><p>extended.</p><p>3 The patient’s head is to remain stationary and eyes should</p><p>be open.</p><p>4 The patient is instructed to touch his or her nose with the</p><p>tip of the index finger and return to starting position five</p><p>times.</p><p>5 A positive sign is the inability of the patient to repetitively</p><p>touch the tip of his or her nose using a smooth motion.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Schneiders et al.45 NT NT NT NT NT NA</p><p>Scifers46 NT NT NT NT NT NA</p><p>Comments: Finger to nose assesses upper limb coordination and speed. To increase the difficulty of the test, instruct the patient to</p><p>increase the speed. With multiple trials, there may be a slight learning effect which may increase performance on subsequent trials.</p><p>ICD-10 Criteria</p><p>Criteria consisted of the following 9 self report symptoms:</p><p>1 Headaches</p><p>2 Dizziness/Vertigo</p><p>3 Fatiguing quickly/Getting tired quickly</p><p>4 Irritability</p><p>5 Poor concentration for extended periods of time</p><p>6 Being forgetful/Difficulty remembering things</p><p>7 Sleep disturbances</p><p>8 Depression</p><p>9 Anxiety/Tension</p><p>UTILITY SCORE ?</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 19</p><p>TEST FOR CONCUSSION OR POSTCONCUSSION SYNDROME</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kashluba et al.25 NT See Below See Below See Below See Below 6</p><p>Number of</p><p>symptoms present</p><p>9 NT 21.8 96.6 6.4 0.81 6</p><p>8 NT 30.0 94.9 5.88 0.74 6</p><p>7 NT 46.4 83.9 2.88 0.64 6</p><p>6 NT 57.3 78.0 2.60 0.55 6</p><p>5 NT 72.7 61.0 1.86 0.45 6</p><p>4 NT 9.1 86.4 0.67 1.05 6</p><p>3 NT 10.9 85.6 0.76 1.04 6</p><p>2 NT 3.6 85.6 0.25 1.13 6</p><p>1 NT 2.7 86.4 0.2 1.13 6</p><p>0 NT 0.9 94.9 0.18 1.04 6</p><p>Comments: Assessment of symptoms was performed at 1 month and again at 3 months post MTBI. This data was taken from the</p><p>assessment 1 month post mild traumatic brain injury.</p><p>UTILITY SCORE 2</p><p>20 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL</p><p>CORD COMPRESSION (MYELOPATHY)</p><p>Hoffmann’s Reflex</p><p>1 The patient is placed in sitting or standing.</p><p>2 The examiner stabilizes the middle finger proximally to</p><p>the distal interphalangeal joint and cradles the hand of the</p><p>patient.</p><p>3 The examiner applies a stimulus to the middle finger by</p><p>nipping the fingernail of the patient between his or her</p><p>thumb and index finger or by flicking the middle finger</p><p>with the examiner’s fingernail.</p><p>4 A positive test is adduction and opposition of thumb and</p><p>slight flexion of the fingers.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Denno & Meadows13 (sample</p><p>was biased, negative Hoffmann’s</p><p>was selected)</p><p>NT 0 0 0 0 6</p><p>Sung & Wang49 (sample con-</p><p>sisted of those with positive</p><p>tests only)</p><p>NT 94 NT NA NA 7</p><p>Wong et al.55 (sample con-</p><p>sisted of patients with cervical</p><p>myelopathy)</p><p>NT 82 NT NA NA 3</p><p>Glaser et al.17 (unblinded tester) NT 58 74 2.23 0.57 8</p><p>Glaser et al.17 (blinded tester) NT 28 71 0.96 1.01 8</p><p>Cook et al.10 89%</p><p>agreement</p><p>44 75 1.8 0.7 11</p><p>Rhee et al.42 NT 59 84 3.69 0.49 4</p><p>UTILITY SCORE 2</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 21</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cook et al.9 NT 31 73 4.9 0.74 7</p><p>Kiely et al.27 (sample consisted</p><p>of asymptomatic patients)</p><p>NT NT 90 NA NA 2</p><p>Houten & Noce22 (bilateral or</p><p>unilateral)</p><p>NT 68 NT NA NA 7</p><p>Chikuda et al.8 NT 81 NT NA NA 6</p><p>Comments: Positive findings are typically very subtle. False positives may occur in patients with a history of head injury or concus-</p><p>sion. Note that the only blinded reference involves the Glaser et al.17 study. The values associated with blinding and unblinding are</p><p>significantly affected. We feel that the Hoffmann’s is not a good screening test.</p><p>Babinski Sign</p><p>1 The patient is placed in supine. The foot is held in relative</p><p>neutral by the examiner.</p><p>2 The examiner applies stimulation with the blunt end of a</p><p>reflex hammer to the plantar aspect of the foot (typically</p><p>laterally to medial from heel to metatarsal).</p><p>3 A negative finding is slight toe flexion, smaller digits</p><p>greater than great toe.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Bertilson et al.6 98%</p><p>agreement</p><p>NT NT NA NA NA</p><p>De Freitas & Andre12</p><p>(tested to determine</p><p>brain death)</p><p>NT 0 NT NA NA 6</p><p>Berger et al.4 (tested</p><p>concurrently with sock</p><p>off and sheet removal)</p><p>NT 80 90 8 0.05 7</p><p>Ghosh16 NT 76 NT NA NA 11</p><p>Hindfelt et al.21 NT 18 NT NA NA 6</p><p>Miller & Johnston35 .73 kappa 35 77 1.5 0.8 9</p><p>Cook et al.10 89%</p><p>agreement</p><p>33 92 4.0 0.7 11</p><p>Rhee et al.42 NT 13 100 Inf 0.87 4</p><p>Cook et al.9 NT 7 100 Inf 0.93 7</p><p>UTILITY SCORE 2</p><p>(continued)</p><p>22 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kiely et al.27 (sample con-</p><p>sisted of asymptomatic</p><p>patients)</p><p>NT NT 100 NA NA 2</p><p>Houten & Noce22 NT 33 NT NA NA 7</p><p>Chikuda et al.8 NT 53 NT NA NA 6</p><p>Comments: A positive finding is generally associated with a pyramidal defect. Response changes after 1 year of birth. There are a</p><p>number of ways to perform the stroking of the foot, and it is doubtful if technique or location affects findings.</p><p>1 The patient is placed in standing or supine.</p><p>2 The patient is instructed to flex the neck with emphasis on</p><p>lower cervical flexion.</p><p>3 Some examiners have advocated use of hyperextension to</p><p>produce a Lhermitte’s response.</p><p>Lhermitte’s Sign</p><p>4 The patient is queried for “electrical-type” responses dur-</p><p>ing the flexion or if used, extension. A positive test is an</p><p>“electrical-type” sensation in the midline and occasionally</p><p>to the extremities during flexion.</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Uchihara et al.52 NT 3 97 1 1 8</p><p>Comments: A positive finding is associated with focal lesions of the spinal cord, multiple sclerosis, or other degenerative processes</p><p>causing stenosis (cord compression).</p><p>UTILITY SCORE 3</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 23</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Denno & Meadows13 NT 90 NT NA NA 11</p><p>Comments: The sample was biased because only patients with a negative Hoffmann’s were selected.</p><p>1 The patient is placed in a supine position.</p><p>2 The examiner provides a forceful downward stretch or</p><p>snaps the distal phalanx of the 2nd or 4th toe. The exam-</p><p>iner may also press on the toe nail, twist the toe, and hold</p><p>for a few seconds.</p><p>3 A positive response is the extensor toe sign (great toe</p><p>extension), a similar response to a positive Babinski sign.</p><p>Gonda-Allen Sign</p><p>UTILITY SCORE ?</p><p>1 The patient is placed in a supine position.</p><p>2 The examiner provides a sharp upward flick of the 2nd toe</p><p>or pressure over the distal aspect or ball of the toe.</p><p>3 A positive response is the extensor toe sign.</p><p>Allen-Cleckley Sign</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Denno & Meadows13 NT 82 NT NA NA 11</p><p>Comments: The diagnostic value of this test suggests high sensitivity but caution must be taken. The sample was biased, only</p><p>patients with a negative Hoffmann’s were selected.</p><p>24 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Estanol & Marin15 NT NT NT NA NA NA</p><p>Cook et al.10 78% agreement 61 78 2.8 0.5 11</p><p>Rhee et al.42 NT 51 81 2.68 0.60 4</p><p>Cook et al.9 NT 18 99 29.1 0.82 7</p><p>Kiely et al.27 (sample consisted</p><p>of asymptomatic patients)</p><p>NT NT 72.4 NA NA 2</p><p>Wong et al.55 (sample</p><p>consisted of patients with</p><p>cervical myelopathy)</p><p>NT 53 NT NA NA 3</p><p>Comments: A positive finding is likely related to increased alpha motor neurons below the level of the lesion.</p><p>1 The patient assumes a sitting position.</p><p>2 The examiner places the patient’s forearm on his or her</p><p>forearm to ensure relaxation. The patient’s forearm is held</p><p>in slight pronation.</p><p>3 The examiner applies a series of quick strikes near the sty-</p><p>loid process of the radius at the attachment of the brachio-</p><p>radialis and the tendon.</p><p>4 A positive test is finger flexion or slight elbow extension.</p><p>Inverted Supinator Sign</p><p>UTILITY SCORE ?</p><p>1 The patient is placed in a seated position.</p><p>2 The patient is asked to flex both elbows to 90° and keep</p><p>them at his or her side.</p><p>3 The forearms are then pronated and all fingers are</p><p>adducted.</p><p>4 A positive sign is the inability of the patient to maintain</p><p>adduction of the 5th digit. The 5th digit will start to drift</p><p>in an ulnar and volar</p><p>direction.</p><p>Finger Escape Sign</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 25</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kiely et al.27 (sample consisted</p><p>of asymptomatic patients)</p><p>NT NT 100 NA NA 2</p><p>Wong et al.55 (sample</p><p>consisted of patients with</p><p>cervical myelopathy)</p><p>NT 55 NT NA NA 3</p><p>Comments: The studies are so poorly performed that it is difficult to extract a value from this test.</p><p>UTILITY SCORE ?</p><p>1 The patient is placed in a supine position.</p><p>2 The examiner passively raises the opposite limb into hip</p><p>flexion. The examiner then instructs the patient to hold</p><p>the leg in flexion.</p><p>3 The examiner applies a downward force against the leg.</p><p>4 Visual inspection of the opposite great toe is required to</p><p>observe great toe extension.</p><p>5 A positive test is associated with great toe extension of the</p><p>opposite leg during resistance of hip flexion.</p><p>Crossed Upgoing Toe Sign (Cut)</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Hindfelt et al.21 NT 31 96 7.8 0.72 6</p><p>Comments: Bias limits the true assessment of diagnostic value.</p><p>1 The patient is placed in a supine or sitting position.</p><p>2 The examiner taps on the cuboid bone (on the dorsal</p><p>aspect) using the sharp end of the reflex hammer.</p><p>3 A positive response is flexion of the four lateral toes.</p><p>Mendel-Bechterew Sign</p><p>(continued)</p><p>26 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kumar & Ramasubramanian29 NT NT NT NA NA NT</p><p>Comments: The diagnostic value of this test is unknown.</p><p>UTILITY SCORE</p><p>1 The patient is placed in a supine or sitting position.</p><p>2 The examiner provides a sharp, quick squeeze of the Achil-</p><p>les tendon.</p><p>3 A positive response is the extensor toe sign.</p><p>Schaefer’s Sign</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kumar & Ramasubramanian29 NT NT NT NA NA NT</p><p>Comments: The diagnostic value of this test is unknown.</p><p>1 The patient is placed in a supine or sitting position.</p><p>2 The examiner provides pressure along the shin of the tibia,</p><p>while sliding downward toward the foot.</p><p>3 A positive response is the extensor toe sign.</p><p>Oppenheim Sign</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 27</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kumar & Ramasubramanian29 NT NT NT NA NA NT</p><p>Comments: The diagnostic value of this test is unknown.</p><p>UTILITY SCORE ?</p><p>1 The patient is placed in a supine or sitting position.</p><p>2 The examiner strokes the lateral malleolus from proximal</p><p>to distal with a solid, relatively sharp object.</p><p>3 A positive response is the extensor toe sign.</p><p>Chaddock’s Sign</p><p>UTILITY SCORE ?</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Kumar & Ramasubramanian29 NT NT NT NA NA NT</p><p>Comments: The diagnostic value of this test is unknown.</p><p>Clonus</p><p>1 The patient is placed in a supine or sitting position.</p><p>2 The technique can be applied to the wrist or to the ankle.</p><p>3 The examiner takes up the slack of the wrist (into exten-</p><p>sion; not pictured). The examiner then applies a quick</p><p>overpressure with maintained pressure to the wrist.</p><p>4 The examiner takes up the slack of the ankle (into dorsi-</p><p>flexion; pictured). The examiner then applies a quick over-</p><p>pressure with maintained pressure to the ankle.</p><p>5 A positive response is more than three involuntary beats</p><p>of the ankle or wrist.</p><p>(continued)</p><p>28 CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Rhee et al.42 NT 13 100 Inf 0.87 4</p><p>Cook et al.10 98% agreement 11 96 2.7 0.9 11</p><p>Cook et al.9 NT 7 99 5.4 0.94 7</p><p>Chikuda et al.8 (sustained</p><p>ankle clonus)</p><p>NT 35 NT NA NA 6</p><p>Comments: One or two beats is relatively normal and is not indicative of pathology. Three beats or more is considered abnormal.</p><p>One may see a positive for patients with a history of concussion.</p><p>Deep Tendon Reflex Tests</p><p>UTILITY SCORE 2</p><p>Biceps Tendon</p><p>1 In biceps tendon testing, the patient is positioned in sitting.</p><p>2 The clinician slightly supinates the patient’s forearm and places it on his own forearm assuring</p><p>relaxation.</p><p>3 The clinician’s thumb is placed on the patient’s biceps tendon and he strikes his own thumb</p><p>with quick strikes of a reflex hammer.</p><p>4 A positive test is indicated by hyperreflexia of the biceps deep tendon reflex.</p><p>Triceps Tendon</p><p>1 In triceps tendon testing, the patient is positioned in sitting.</p><p>2 The patient’s shoulder is elevated to 90° with the elbow passively flexed to 90°.</p><p>3 The clinician places his thumb over the distal aspect of the patient’s triceps tendon and applies</p><p>a series of quick strikes with the reflex hammer to the back of his thumb.</p><p>4 A positive test is indicated by hyperreflexia of the triceps deep tendon reflex.</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cook et al.10 89% agreement 44 71 1.5 0.8 11</p><p>Cook et al.9 NT 18 96 4.8 0.85 7</p><p>Comments: Cook et al.9 tested only for biceps tendon hyperreflexia. Reflex testing is commonly scored as 0+ = absent (no visible</p><p>or palpable muscle contraction with reinforcement), 1+ = tone change (slight, transitory impulse, with no movement of the extrem-</p><p>ities), 2+ = normal (visual, brief movement of the extremity), 3+ = exaggerated (full movement of the extremities), 4+ = abnormal</p><p>(compulsory and sustained movement, lasting for more than 30 seconds). The test is frequently performed as a component of the</p><p>upper quarter screen. The biceps reflex test is purported to target C6, and the triceps reflex test is purported to target C7.</p><p>CHAPTER 2 Physical Examination Tests for Neurological Testing and Screening 29</p><p>TESTS FOR PATHOLOGICAL UPPER MOTOR NEURON REFLEX OR SPINAL CORD COMPRESSION (MYELOPATHY)</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cook et al.10 84% agreement 56 33 0.8 1.3 11</p><p>Cook et al.9 NT 22 97 6.9 0.81 7</p><p>Comments: Reflex testing is commonly scored as 0+ = absent (no visible or palpable muscle contraction with reinforcement), 1+ =</p><p>tone change (slight, transitory impulse, with no movement of the extremities), 2+ = normal (visual, brief movement of the extrem-</p><p>ity), 3+ = exaggerated (full movement of the extremities), 4+ = abnormal (compulsory and sustained movement, lasting for more</p><p>than 30 seconds). The test is frequently performed as a component of the upper quarter screen.</p><p>Achilles Tendon Reflex Test</p><p>1 The patient is placed in with the foot to be tested not touching the ground.</p><p>2 Using a reflex hammer, either strike the tendon itself or use the plantar strike technique to elicit</p><p>a reflex.</p><p>3 If the reflex is absent, ask the patient to gently plantarflex the foot, tightly close the eyes, and</p><p>pull their clasped hands apart just prior to striking.</p><p>4 A positive test is indicated by hyperreflexia of the Achilles tendon reflex.</p><p>1 The patient is positioned in seated with his or her feet off</p><p>the ground.</p><p>2 The clinician applies quick strikes of the reflex hammer to</p><p>the suprapatellar tendon.</p><p>3 A positive test is indicated by hyperreflexive knee extension.</p><p>Suprapatellar Quadriceps Test</p><p>UTILITY SCORE 3</p><p>UTILITY SCORE 2</p><p>Study Reliability Sensitivity Specificity LR+ LR−</p><p>QUADAS</p><p>Score (0–14)</p><p>Cook et al.9 NT 15 98 7.8 0.87 7</p><p>Rhee et al.42 NT 26 81 1.37 0.91 4</p><p>Comments: Reflex testing is commonly scored as 0+ = absent (no visible or palpable muscle contraction with reinforcement), 1+ =</p><p>tone change (slight, transitory impulse, with no movement of the extremities),</p>
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