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Page 1: Musculoskeletal examination
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BLBK145-Gross February 13, 2009 21:2

MusculoskeletalExamination3rd Edition

Jeffrey M. Gross, MDClinical Associate Professor of Rehabilitation MedicineNew York University School of MedicineMedical DirectorUnion Square Rehabilitation and Sports MedicineNew York, New York

Joseph Fetto, MDAssociate Professor of Orthopedic SurgeryNew York University School of MedicineAssociate Professor and ConsultantManhattan V.A. Medical CenterNew York, New York

Elaine Rosen, PT, DHSc, OCSAssociate Professor of Physical TherapyHunter CollegeCity University of New YorkPartnerQueens Physical Therapy AssociatesForest Hills, New York

A John Wiley & Sons, Ltd., Publication

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MusculoskeletalExamination3rd Edition

Jeffrey M. Gross, MDClinical Associate Professor of Rehabilitation MedicineNew York University School of MedicineMedical DirectorUnion Square Rehabilitation and Sports MedicineNew York, New York

Joseph Fetto, MDAssociate Professor of Orthopedic SurgeryNew York University School of MedicineAssociate Professor and ConsultantManhattan V.A. Medical CenterNew York, New York

Elaine Rosen, PT, DHSc, OCSAssociate Professor of Physical TherapyHunter CollegeCity University of New YorkPartnerQueens Physical Therapy AssociatesForest Hills, New York

A John Wiley & Sons, Ltd., Publication

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This edition first published 2009 C© 1996, 2002, 2009 by Jeffrey Gross, Joseph Fetto, Elaine Rosen

Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishingprogram has been merged with Wiley’s global Scientific, Technical and Medical business to formWiley-Blackwell.

Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex,PO19 8SQ, UK

Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UKThe Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK111 River Street, Hoboken, NJ 07030-5774, USA

For details of our global editorial offices, for customer services and for information about how to applyfor permission to reuse the copyright material in this book please see our website atwww.wiley.com/wiley-blackwell

The right of the author to be identified as the author of this work has been asserted in accordance withthe Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, ortransmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise,except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permissionof the publisher.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print maynot be available in electronic books.

Designations used by companies to distinguish their products are often claimed as trademarks. All brandnames and product names used in this book are trade names, service marks, trademarks or registeredtrademarks of their respective owners. The publisher is not associated with any product or vendormentioned in this book. This publication is designed to provide accurate and authoritative informationin regard to the subject matter covered. It is sold on the understanding that the publisher is not engagedin rendering professional services. If professional advice or other expert assistance is required, theservices of a competent professional should be sought.

Library of Congress Cataloging-in-Publication Data

Gross, Jeffrey M., 1957–Musculoskeletal examination / Jeffrey M. Gross, Joseph Fetto, Elaine Rosen.—3rd ed.

p. ; cm.Includes bibliographical references and index.ISBN 978-1-4051-8049-81. Musculoskeletal system—Examination. I. Fetto, Joseph. II. Rosen, Elaine. III. Title.[DNLM: 1. Musculoskeletal Diseases—diagnosis. 2. Musculoskeletal Physiology.

3. Musculoskeletal System—anatomy & histology. 4. Physical Examination—methods.WE 141 G878m 2009]

RC925.7.G76 2009616.70076–dc22

2008039510

ISBN: 978-1-4051-8049-8

A catalogue record for this book is available from the British Library.

Set in 10/12pt Sabon by Aptara R© Inc., New Delhi, IndiaPrinted & bound in Singapore

1 2009

Commissioning Editor: Ben TownsendDevelopment Editor: Laura MurphyProduction Editor: Cathryn GatesEditorial Assistant: Madeleine Hurd

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Contents

How to Use This Book, iv

Acknowledgments, v

1 Introduction, 1

2 Basic Concepts of Physical Examination, 14

3 Overview of the Spine and Pelvis, 31

4 The Cervical Spine and Thoracic Spine, 34

5 The Temporomandibular Joint, 82

6 The Lumbosacral Spine, 95

7 Overview of the Upper Extremity, 139

8 The Shoulder, 141

9 The Elbow, 199

10 The Wrist and Hand, 235

11 The Hip, 293

12 The Knee, 335

13 The Ankle and Foot, 379

14 Gait, 432

Appendices, 445

Bibliography, 449

Index, 453

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How to Use This Book

Musculoskeletal Examination is to be used as botha teaching text and a general reference on the tech-niques of physical examination. This volume rep-resents the joint authoring efforts of a physiatrist,an orthopedic surgeon, and a physical therapist andpresents the information in a clear and concise for-mat, free of any professional biases that reflect onespecialty’s preferences. The importance of this willbe seen as we take you through each anatomical re-gion and delineate the basic examination. Includedin each chapter are the abnormalities most frequentlyencountered noted while performing an examination.

The book is organized into regional anatomical sec-tions including the spine and pelvis, the upper extrem-ity, and the lower extremity. The book opens withtwo chapters that define the structures of the muscu-loskeletal system and discuss the basic concepts andparts of the musculoskeletal exam. A final chapterdescribes the examination of gait.

Each main chapter is organized in an identical man-ner:� overview of the anatomical region� observation of the patient� subjective examination� gentle palpation� trigger points (where applicable)� active movement testing� passive movement testing� physiological movements� mobility testing� resistive testing� neurological examination� referred pain patterns� special tests� radiological views

In Chapter 2, Basic Concepts of the Physical Ex-amination, we provide you with a framework for per-forming the examination, beginning with observationand ending with palpation. However, in each regionalanatomy chapter, palpation follows observation andsubjective examination and precedes all other sec-tions. This is deliberate. For reasons of length, wefelt it important to discuss each anatomical regionand its own special anatomical structures as soon aspossible in each chapter. This avoids repetition, givesyou the anatomy early in each chapter, and then al-lows you to visualize each structure as you read thesubsequent sections on testing. Hopefully, this willreinforce the anatomy and help you apply anatomyto function and function to the findings of yourexamination.

Each chapter includes a generous number of origi-nal line drawings, many of which are two color. Theseprovide clear snapshots of how to perform each exam-ination technique. Thirty-two x-rays and MRIs havebeen included to help you with radiological anatomy.Paradigms and tables provide additional informationthat will help you understand the how and why ofeach examination technique.

By using Musculoskeletal Examination as a guideand reference, the reader will be able to performthe complete basic examination and understand com-mon abnormalities and their pathological signifi-cance. We hope that our readers will gain an ap-preciation for the intimate relationship between thestructure and function of the components of themusculoskeletal system. This understanding shouldthen enable any reader to make a correct diag-nosis and a successful treatment plan for eachpatient.

iv

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Acknowledgments

The writing of Musculoskeletal Examination wouldnot have been possible without the overwhelmingsupport and understanding of my wife Elizabeth andmy sons, Tyler and Preston. I also want to thank myparents, Malcolm and Zelda Gross, as well as myteachers Dr. Joseph Goodgold, Dr. Bruce Grynbaum,Dr. Howard Thistle, and Dr. Matthew Lee for theirguidance and efforts on my behalf.

J.G.

Thank you to my wife and family for their under-standing, patience, support, and love.

J.F.

To my husband, Jed, for his unlimited patience, un-derstanding, and encouragement.To my business partner and friend, Sandy, for beingthere whenever I needed her.To my family for their support, and to my many pa-tients, colleagues, and friends who have helped megrow.

E.R.

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vi

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C H A P T E R 1

IntroductionThe intention of this book is to provide the readerwith a thorough knowledge of regional anatomy andthe techniques of physical examination. A second andequally important intention is to describe a methodfor the interpretation and logical application of theknowledge obtained from a physical examination.

What Is a Physical Examination?

The physical examination is the inspection, palpation,measurement, and auscultation of the body and itsparts. It is the step that follows the taking of a patienthistory and precedes the ordering of laboratory testsand radiological evaluation in the process of reachinga diagnosis.

What Is the Purpose of the PhysicalExamination?

The physical examination has two distinct purposes.The first is to localize a complaint, that is, to associatea complaint with a specific region and, if possible, aspecific anatomical structure. The second purpose ofa physical examination is to qualify a patient’s com-plaints. Qualifying a complaint involves describingits character (i.e., dull, sharp, etc.), quantifying itsseverity (i.e., visual analog scale; grade I, II, III), anddefining its relationship to movement and function.

How Is the Physical ExaminationUseful?

By relating a patient’s complaints to an anatomicalstructure, the physical examination brings meaningto a patient’s history and symptoms. This, however,

presupposes that the clinician possesses a thoroughknowledge of anatomy. It also requires a method-ology for the logical analysis and application of theinformation obtained from the patient’s history andphysical examination. This methodology is derivedfrom a clinical philosophy based on specific concepts.These concepts are as follows:1. If one knows the structure of a system and

understands its intended function, it is possible topredict how that system is vulnerable tobreakdown and failure (injury).

2. A biological system is no different from aninorganic system in that it is subject to the samelaws of nature (physics, mechanics, engineering,etc.). However, the biological system, unlike theinorganic system, has the potential not only torespond but also to adapt to changes in itsenvironment.Such concepts lay the foundation for understanding

the information obtained on physical examination.They also lead to a rationale for the treatment andrehabilitation of injuries. A correlation of this typeof analysis is that it becomes possible to anticipateinjuries. This in turn permits proactive planning forthe prevention of injuries.

How Does the MusculoskeletalSystem Work?

The musculoskeletal system, like any biological sys-tem, is not static. It is in a constant state of dynamicequilibrium. This equilibrium is termed homeostasis.

As such, when subjected to an external force orstress, a biological system will respond in a very spe-cific manner. Unlike the inorganic system (i.e., an air-plane wing that is doomed to fail after a predictablenumber of cycles of load), the biological system willattempt to reestablish an equilibrium state in responseto a change that has occurred in its environment. In

1

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2 Introduction Chapter 1

X

Stress

Time

X

Chronic overuse failure

Acu

te fa

ilure

Maximum tolerance limit

Figure 1.1 Biological systems, like inorganic systems, can fail under one of two modes: an acute single supramaximal stress orrepetitive submaximal chronic loading.

doing so, the biological system will experience one ofthree possible scenarios: adaptation (successful estab-lishment of a new equilibrium state without break-down), temporary breakdown (injury), or ultimatebreakdown (death). These scenarios can be expressedgraphically. Any system can be stressed in one of twomodes: acute single supratolerance load or chronicrepetitive submaximal tolerance load (Figure 1.1). Inthe first mode, the system that suffers acute failure isunable to resist the load applied. In the second mode,the system will function until some fatigue limit isreached, at which time failure will occur. In the bi-ological system, either failure mode will initiate aprotective-healing response, termed the inflammatoryreaction. The inflammatory reaction is composed ofcellular and humoral components, each of which ini-tiates a complex series of neurological and cellularresponses to the injury. An important consequence ofthe inflammatory reaction is the production of pain.The sole purpose of pain is to bring one’s attention tothe site of injury. Pain prevents further injury fromoccurring by causing protective guarding and lim-ited use of the injured structure. The inflammatory

response is also characterized by increased vascular-ity and swelling in the area of injury. These are thecauses of the commonly observed physical signs (i.e.,redness and warmth) associated with the site of in-jury.

However, the problem with pain is that although itbrings protection to the area of injury (the consciousor unconscious removal of stress from the injuredarea), and permits healing to take place by remov-ing dynamic stimuli from the biological system, thisremoval of stimuli (rest) promotes deterioration of asystem’s tolerance limit to a lower threshold. In thisway, when the injury has resolved, the entire system,although “healed,” may actually be more vulnerableto reinjury when “normal” stresses are applied to therecently repaired structures. This initiates the “viciouscycle of injury” (Figure 1.2).

Contrary to this scenario is one in which the biolog-ical system successfully adapts to its new environmentbefore failure occurs. This situation represents condi-tioning of a biological system. The result is hypertro-phy, enhanced function, and a consequent increase inthe system’s tolerance limit. The concept acting here is

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3Chapter 1 Introduction

Injury

Acute trauma

Repetitive overuse

Activity

Weakness, stiffness, etc.

Inflammatory response

Pain

Rest

“Vicious Cycle of Injury”

Figure 1.2 The “vicious cycle of injury” results from the reinjuryof a vulnerable, recently traumatized system. This increasedvulnerability occurs due to a diminishing of a system’s tolerancelimit as a result of adaptation to a lower level of demand duringthe period of rest necessitated by pain.

that the biological system’s tolerance limit will adaptto increased demands if the demands are applied at afrequency, intensity, and duration within the system’sability to adapt (Figure 1.3).

Therefore, during the physical examination, asym-metry must be noted and analyzed as representing ei-ther adaptation or deconditioning of a given system.Any of these fundamental principles under which themusculoskeletal system functions makes it possibleto organize the information obtained from a physi-cal examination and history into general categoriesor pathological conditions (traumatic, inflammatory,metabolic, etc.), and the subsets of these conditions(tendinitis, ligamentous injuries, arthritis, infection,etc.). From such an approach, generalizations calledparadigms can be formulated. These paradigms pro-vide a holistic view of a patient’s signs and symptoms.In this way, diagnoses are arrived at based on an anal-ysis of the entire constellation of signs and symptomswith which a given patient presents. This method,relying on a multitude of factors and their interrela-tionships rather than on a single piece of information,

such as the symptom of clicking or swelling, ensures agreater degree of accuracy in formulating a diagnosis.

What Are Paradigms?

Paradigms are snapshots of classic presentations ofvarious disease categories. They are, as nineteenth-century clinicians would say, “augenblick,” a blink-of-the-eye impression of a patient (Table 1.1). Fromsuch an impression, a comparison is made with anidealized patient, to evaluate for congruities or dis-similarities. Here is an example of a paradigm for os-teoarthritis: a male patient who is a laborer, who is atleast 50 years old, whose complaints are asymmetri-cal pain involving larger joints, and whose symptomsare in proportion to his activity. Another examplemight be that of rheumatoid arthritis. This paradigmwould describe a female patient who is 20–40 yearsold, complaining of symmetrical morning stiffness in-volving the smaller joints of the hands, with swelling,possibly fever, and stiffness reducing with activity.

Paradigms may also be created for specific tissues(i.e., joints, tendons, muscles, etc.). The paradigm fora joint condition such as osteoarthritis would be well-localized pain, swelling, stiffness on sedentary postur-ing, and pain increasing in proportion to use, whereasa paradigm for a mild tendon inflammation (tendini-tis) may be painful stiffness after sedentary posturingthat becomes alleviated with activity and gentle use.A paradigm for ligament injury would include a his-tory of a specific traumatic event, together with theresultant loss of joint stability demonstrated on activeand passive tensile loading of a joint.

The reader is encouraged to create his or her ownparadigms for various conditions—paradigms that in-clude the entire portrait of an injury or disease processwith which a given patient or tissue may be com-pared. In this process, it will become obvious that itis not sufficient to limit one’s expertise to the local-ization of complaints to an anatomical region. It isalso necessary to be able to discriminate between theinvolvement of specific structures that may lie in closeproximity within that region (i.e., bursae and tendonsoverlying a joint).

It can be concluded therefore that an accurate phys-ical examination is as critical to the process of diag-nosis as is a complete and accurate history of a pa-tient’s complaints. An accurate physical examinationdemands a thorough knowledge and familiarity withanatomy and function.

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4 Introduction Chapter 1

Time

Tolerance limit 3

Tolerance limit 2

Tolerance limit 1

Figure 1.3 Conditioning is the adaptation of a biological system to the controlled application of increasing stress at a frequency,intensity, and duration within the system’s tolerance limit, with a resultant increase in the system’s tolerance limit.

What Are the Components of theMusculoskeletal System?

The musculoskeletal system is composed of bone, car-tilage, ligaments, muscle, tendons, synovium, bursae,and fascia. This system is derived embryologicallyfrom the mesenchyme and is composed of soft andhard connective tissues. These tissues have evolved

Table 1.1 Paradigms for osteoarthritis and rheumatoidarthritis.

Paradigm for rheumatoidParadigm for osteoarthritis arthritis

Male FemaleLaborer 20–40 years old50+ years old Symmetrical small joint

involvementLarge joint involvement Associated swelling, fever,

rash, morning stiffnessAsymmetrical involvement Abating with usePain in proportion to activity

to serve two basic functions: structural integrity andstable mobility. The tissues are composite materialsmade up of cells lying within the extracellular matrixthey produce.

Collagen, a long linear protein (Figure 1.4a), is themost abundant of the extracellular materials foundin connective tissues. The foundation of collagenis a repetitive sequence of amino acids that formpolypeptide chains. Three such chains are thenbraided together to form a triple helical strand calledtropocollagen. These strands join to make microfib-rils; long linear structures specifically designed toresist tensile loading. The microfibrils are bondedtogether through chemical cross-linking to form col-lagen fibers. The degree of cross-linking determinesthe physical properties of a specific collagen fiber.The more cross-linking that exists, the stiffer the fiberwill be. The degree of collagen cross-linking is in partgenetically and in part metabolically determined. Thisexplains why some people are much more flexiblethan others. Vitamin C is critical for the formationof cross-links. As such, scurvy, a clinical expressionof vitamin deficiency, is characterized by “weak tis-sues.” Hypermobility of joints (i.e., ability to extend

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5Chapter 1 Introduction

(a)

(b)

(c) �1 chains

�2 chain

All �1 chains

Type I collagen

Type II collagen

Figure 1.4 (a) Collagen is a linear protein made of α-chains that wind into a triple helix. (b) Collagen fibrils are formed by thecross-linking of collagen monomer proteins. (c) The different types of collagen are determined by the number of α1 and α2 collagenmonomers that join to form a triple-helix collagen molecule. For example, two α1 chains and one α2 chain that join to form atriple-helix make type I collagen, which is found in bone, tendon, ligament, fascia, skin, arteries, and the uterus. Type II collagen,which is found in articular cartilage, contains three α1 chains. There are at least 12 different collagen types.

the thumbs to the forearms, ability to hyperextend atthe knees and elbows, excessive subtalar pronationwith flat, splayed feet) is a clinical manifestationof genetically determined collagen cross-linking(Figure 1.4b).

Different types of collagen exist for different cate-gories of tissues. These types are defined by the spe-cific composition of the polypeptide chains that formthe strands of the collagen molecules. Type I collagenis found in connective tissue such as bone, tendons,and ligaments. Type II is found uniquely in articularhyaline cartilage. Other collagen types exist as well(Figure 1.4c).

If collagen represents the fiber in the compositestructure of connective tissue, ground substancerepresents the “filler” between the fibers. The maincomponents of ground substance are aggregates ofpolyglycan macromolecules. An example of sucha macromolecule is the proteoglycan hyaluronicacid, found in articular cartilage. Hyaluronic acidis a molecule of more than 1 million daltons. It iscomposed of a long central core from which are pro-jected many protein side chains containing negatively

charged sulfate radicals. It can best be visualized as abristle brush from which many smaller bristle brushesare projected (Figure 1.5). These strongly negativesulfate radicals make the hyaluronic acid moleculehighly hydrophilic (water attracting). This ability toattract and hold water allows the connective tissueground substance to function as an excellent hydro-static bearing surface that resists compression load.

Immobilization reduces the diffusion and migrationof nutrients throughout the connective tissues. Thisin turn compromises cellular activity and upsets thenormal homeostatic balance of collagen and groundsubstance turnover. The result is an atrophy of col-lagen fibers and a diminution of ground substance(Cantu and Grodin, 2001), with subsequent deteri-oration of the connective-tissue macrofunction (i.e.,chondromalacia patellae).

Bone

Bone provides the structure of the body. It is the hard-est of all connective tissues. One-third of bone is com-posed of collagen fibers and two-thirds mineral salts,

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6 Introduction Chapter 1

Hyaluronic acid (HA)

Hyaluronic acidcentral “core”

Linkprotein

Keratansulfate-richregion

Chrondroitin sulfate-richregion

Keratansulfatechain

Chrondroitin sulfatechain

Protein core

Protein sidechain core

Sulfate radicals(chrondroitin and keratan sulfate)

Proteoglycan “bristle brushes”

Figure 1.5 The proteoglycan aggregate is formed on abackbone of hyaluronic acid and has the appearance of a bristlebrush.

primarily calcium hydroxyapatite. Bone is formed inresponse to stress. Although genetically determined,the size and shape of a bone are dependent on environ-mental factors for its full expression. This response ofbone to its loading history has been termed Wolff’slaw. There are two major types of bone: cortical andcancellous. All bones are covered by highly vascular-ized and innervated tissue called periosteum, exceptwhen they are within the synovial cavity of a joint(Figure 1.6).

Cortical bone is very dense, highly calcified, anduniquely constructed to resist compression loads. Itcan also resist tensile bending and torsional loads,but much more poorly. This is a direct function ofcortical bone’s ultrastructure, which is a compositeof flexible collagen fibers and rigid mineral crystals.Cortical bone is usually found within the diaphysisof long bones. It has a hollow central cavity that istermed the medullary canal or marrow cavity.

At the end of long bones and at the sites of tendonand ligament attachments, bones tend to expand andcortical bone gives way to a more porous structure,termed cancellous or trabecular bone. The trabeculaeof cancellous bones lie in the direction of transmitted

Articular cartilage

Line of epiphysealcartilage

Trabeculae ofspongy bone

Compact orcortical bone

Periosteum

Line of epiphysealcartilage

Articular cartilage

Marrow cavity

Figure 1.6 The structure of a typical long bone.

loads. They act as conduits of load from the articularsurface to the underlying diaphyseal cortical bone.Overload of the trabeculae will, on a microscopicscale, duplicate overload of an entire bone (i.e., frac-ture). This overload, because of the innervation thatexists within a bone, will give rise to pain (arthriticdiscomfort due to mechanical overload secondary tojoint deformity or erosion of articular cartilage). Theresultant healing of these microfractures leads to in-creased calcium deposition, hence subchondral scle-rosis noted around articular joints on x-ray films, andhypertrophy of stressed sites such as the midshaft ofthe tibia secondary to stress fractures occurring fromoveruse in distance running.

Cartilage

Cartilage is a connective tissue made of cells (chon-droblasts and chondrocytes) that produce an extra-cellular matrix of proteoglycans and collagen fiberswith a high water content. The tensile strength ofcartilage is due to the collagen component. Its resis-tance to compression is due to the ability of proteogly-can to attract and hold water. Cartilage types include

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7Chapter 1 Introduction

Tidemark

Subchrondral bone

Composition and Structure of CartilageArticular hyaline cartilage

HistologyZone I

Tangential

Orientation of collagen fibers

Zone IIOblique

Zone IIIVertical

Zone IVVertical

End plate

Trabecularbone

Calcified cartilage

Chondrocytesin lacunae

Matrix

Lamina splendens

Groundsubstance

H2O in and out due topressure of joint surfaces

on one another

Figure 1.7 The composition and structure of articular hyaline cartilage. Water moves in and out of the cartilage due to the pressure ofthe joint surfaces on one another and attraction of the water by the ground substance. Note the orientation of the collagen fibers.

articular or hyaline cartilage (Figure 1.7); fibrocarti-lage, which exists at the attachment sites of ligaments,tendons, and bones; fibroelastic cartilage, found inmenisci and intravertebral discs; and growth-platecartilage, located in the physis of immature bones.With age, cartilage tends to decrease in water con-tent and the number of cross-links among collagenmolecules increases. The result is that cartilage tis-sue becomes more brittle, less supple, and less ableto resist tensile, torsional, and compression loading.Hence, cartilage becomes more vulnerable to injurywith age.

Articular cartilage lines the spaces in synovialjoints. It is attached to the underlying bone by a com-plex interdigitation analogous to that of a jigsaw puz-zle. Regeneration of this cartilage is slow and incon-sistent in terms of restoration of articular integrity. Itcan be replaced by a less mechanically efficient fibro-cartilage after injuries have occurred. There are noblood vessels within articular cartilage and nutritionis solely dependent on the loading and unloading ofthe joint, which allows water-soluble nutrients andwaste products to enter and leave the cartilaginousmatrix through a porous surface layer.

The fibroelastic cartilage of the intervertebral discallows for very minimal movement between adjacentvertebrae while providing shock absorption. Becauseof the orientation of the fibers, they are more vulner-able to flexion and rotational forces. Fibroelastic car-tilage is also present in the menisci of the knee. Here,it functions not only to absorb shock but also to in-crease the functional surface area of the joint, therebyproviding additional stability. Because of its elastincontent, fibroelastic cartilage is resilient and able toreturn to its prior shape following deformation.

Ligaments

Ligaments are the static stabilizers of joints. They con-nect bones to bones (Figure 1.8). Ligaments and othercapsular structures of the joint are made of dense, or-ganized connective tissue. Ligaments contain collagenand a variable amount of elastin. The collagen pro-vides tensile strength to the ligaments and elastin pro-vides suppleness. The fibers of collagen are arrangedmore or less parallel to the forces that the ligamentis intended to resist. Most ligaments and capsular tis-sues enter the bone as a progression from collagen

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8 Introduction Chapter 1

Medial collateralligament

Lateralcollateralligament

Posteriorcruciate

ligament

Anteriorcruciateligament

Figure 1.8 The ligaments of the knee. Because of the inherentinstability of the joint, ligaments are necessary to prevent motionin all planes. They act as the primary stabilizers of the joint andare assisted by the muscles and other connective tissues.

fibers to fibrocartilage to calcified cartilage and thenfinally bone. Some ligaments (and tendons) attach tothe periosteum first, which then attaches to the bone.The site of ligament failure is a function of the load itexperiences. Ligaments resist slow loading better thanrapid loading. Therefore, rapid loading may producean intraligamental lesion, whereas a slower patternof loading will create injuries at or near the bone–ligament interface.

Elastin is a protein that permits elastic recoiling tooccur in a tissue. Some ligaments, such as the cruciateligament of the knee, contain almost no elastin. Otherligaments, such as the ligamentum flavum of the spine,contain large amounts of elastin. Figure 1.9 showsthat because it contains more collagen than elastin,the anterior cruciate ligament can resist tensile loadswith little elongation. In this way, the anterior cruci-ate ligament serves the knee well as a stabilizing struc-ture. On the other hand, the ligamentum flavum of thespine, being composed mostly of elastin and little col-lagen, can be stretched a great deal before breaking,but can only resist very weak tensile loading.

Ligaments function to limit joint motion and toguide the bones as they move. Ligaments thereforeusually have a dual internal structure, such that theymay stabilize the joint at either extreme of motion.Ligaments are most lax at midrange of joint motion.The capsule of a synovial joint is in fact a weak lig-amentous structure. Disruption of a ligament can re-sult in severe joint instability and increased frictionalstresses to the articular surfaces of that joint. Thiswill result in premature osteoarthritis. Conversely, aloss of normal capsular laxity from fibrosis follow-ing trauma will result in a severe restriction in jointmotion (i.e., posttraumatic adhesive capsulitis of theshoulder).

Ligaments have very little vascularity; hence theyheal poorly. However, they do have innervation,which may be useful to quantify the severity of a givenligamentous injury. When the structural integrity ofa ligament has been completely compromised (gradeIII sprain), relatively little pain is produced on at-tempts to passively stretch the injured ligament. Thisis because no tension load can be created across acompletely disrupted ligament. However, in a less se-vere partial tear (grade I sprain), severe and exquisitepain will be produced when tension is applied acrossthe damaged structure. This paradoxical pain pattern(less pain equals a more severe sprain) can be a sig-nificant diagnostic clue obtained during the physicalexamination of a recently injured ligament. This alsohas dramatic import in defining a patient’s prognosisand determining a treatment plan.

Muscle

Skeletal muscle is a contractile tissue made up of fibersthat contain specialized proteins (Figures 1.10 and1.11). A loose connective tissue known as endomy-sium fills the space between these fibers. This tissueattaches to a stronger connective tissue that surroundsthe muscle vesiculae, known as perimysium. Perimy-sium is in turn connected to the epimysium, whichencases the entire muscle. This in turn is anchored tothe fascial tissues of the nearby structures. Musclestherefore are composed of two elements: contractiletissues and inert, noncontractile tissues. The forcesgenerated by the muscles are extrinsically applied tothe muscle and will affect both types of tissue.

Muscles exist in many shapes and sizes. Some ofthese are shown in Figure 1.12.

Muscles contain three different fiber types: I, IIa,and IIb. They are defined by the chemical machineryused to generate adenosine triphosphate (ATP).

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9Chapter 1 Introduction

Anteriorlongitudinalligament

Ligamentum flavum

Breaking point

Breaking point

STRAIN (extension/original length)

STR

ESS

(lo

ad/c

ross

-sec

tion

are

a)

Figure 1.9 The mechanical response of stress and strain on the anterior longitudinal ligament and the ligamentum flavum. Theanterior cruciate ligament, having more collagen than elastin, can handle a larger load but will only stretch a short amount beforebreaking. The ligamentum flava, having more elastin than collagen, cannot tolerate a very large load but can stretch a lot beforebreaking.

Genetic makeup, training, and neuromuscular dis-ease can affect the composition of a given musclewith respect to fiber type. Characteristics of thesevarious fiber types are shown in Table 1.2.

Muscles act to move body parts or to stabilize ajoint. As dynamic stabilizers of joints, muscles serveto duplicate the static stabilizing action of ligaments.Muscle fibers are capable of shortening to about50% of their original length. The tension developedby a contracted muscle can be either active or pas-sive. Active tension is due to the contractile compo-nents, namely, actin and myosin. Passive tension re-sults from elastic properties of the contractile tissueswithin the muscle.

The strength of the muscle is proportional to itscross-sectional area and mass. The force of contrac-tion of a muscle is related to many factors, includ-ing the length of the fibers, the velocity of contrac-tion, and the direction in which the fiber is movingat the time of its contraction. Types of muscle con-traction include concentric or shortening, eccentricor lengthening, and isometric, in which the muscle

does not change length. Muscles are characterized bytheir function; agonists are prime movers, antagonistsresist the action of prime movers, and synergists sup-port the function of the agonists. For example, inankle dorsiflexion, the anterior tibialis is the agonist.The extensor hallucis longus and extensor digitorumlongus muscles assist the tibialis anterior muscle andtherefore are synergists. The gastrocnemius and soleusand plantar flexors of the toes are antagonists of thetibialis anterior.

Muscles are described in anatomy texts as havingorigins and insertions. It is very important to recog-nize that this is an arbitrary distinction. A muscle thatis referred to as a hip flexor because it brings the thightoward the torso can function just as well to bring thetorso over the thigh. In order for muscles to functionnormally, they must be both strong and flexible.

With respect to innervation of muscles, except forthe deepest layers of the vertebral muscles, the exactinnervation of the limb and trunk muscles is simi-lar between individuals, with some variability. Tableslisting segmental innervation differ from text to text.

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10 Introduction Chapter 1

I bandA band

A bandSarcomere(from Z line to Z line)

Muscle fiber is a bundleof myofibrils

Muscle consists ofmuscle fibers

Intact muscle

Muscle cell (fiber)

Myofibril

Two sarcomeres

Z lines

Enlarged view

Z lineZ line M line

Stripes or striations

Figure 1.10 A microscopic view of muscle shows the repeated patterns of the sarcomeres and the fibrils.

Injuries to muscles are termed strains. Analogous toligament injuries, they are classified by severity intothree grades: grade I indicates minimal damage;grade II represents an intermediate amount of dam-age to the muscle structure; and grade III, completedisruption.

Tendons

Tendons connect muscles to other structures (see Fig-ure 1.13). Like ligaments, tendons are also composedof collagen, ground substance, and cells. The collagenof tendons is aligned in a very strict linear fashion

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11Chapter 1 Introduction

Muscle fascicles

Muscle fiber

Z Z

H

A

M

Z Z

I

Myofilaments

Sarcomere

Endomysium

Epimysium

Perimysium

Myofibril

SarcolemmaSarcoplasmNuclei

Satellite cell Basement

Muscle

Figure 1.11 The organization of skeletal muscle tissue.

Parallel muscle fibers

Fan-shaped fibers

Unipennate muscle

Bipennate muscle

Fusiform muscle

Figure 1.12 Different types of muscle–fascicle arrangements.

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12 Introduction Chapter 1

Table 1.2 Characteristics of skeletal muscle fibers based on their physical and metabolic properties.

Muscle fiber type

Property Slow-twitch Intermediate Fast-twitch

Speed of contraction Slow Intermediate FastRate of fatigue Slow Intermediate FastOther names used Type I Type II B Type II A

Slow oxidative Fast oxidative/glycolytic Fast glycolyticMuscle fiber diameter Small Intermediate LargeColor Red Red WhiteMyoglobin content High High LowMitochondria Numerous Numerous FewOxidative enzymes High Intermediate LowGlycolytic enzymes Low Intermediate HighGlycogen content Low Intermediate HighMyosin ATPase activity Low High HighMajor source of ATP Oxidative phosphorylation Oxidative phosphorylation Glycolysis

ATP, adenosine triphosphate.

and is always oriented in the line of the pull of themuscle. Tendons have been designed to transmit theforce of the muscular contractile tissues to bone andother connective tissues, such as skin and ligaments,to which they are attached. Tendons are said to beable to withstand at least twice the maximum forcethat muscles can exert on them. The zone wherethe muscle blends into the tendinous tissues is calledthe musculotendinous junction. Muscle–tendon unitsrepresent tensile structures. As such, they may failin the muscle, at the muscle–tendon junction, withinthe tendon, or at the tendon–bone insertion. Mostcommonly, however, failure occurs at the pointof transition between two different materials (i.e.,the musculotendinous junction). Some tendons aresurrounded by a double-walled tubular covering,

referred to as a tendon sheath or a peritendon (i.e.,Achilles tendon or flexor tendons of the hand). Thisis lined with a synovial membrane. The sheath is usedboth to lubricate the tendon and to guide it towardthe bony attachment. Tendon sheaths provide apathway for the gliding movement of the tendonwithin the sheath. An inflamed tendon sheath cancause a locking or restricted movement, as in a triggerfinger. Inflammation of the tendon structure is termedtendinitis.

Synovium and Bursae

Synovial tissue lies in the inner aspect of synovialjoints and bursal sacs. It has two functions: to pro-duce lubricating fluids and to phagocytize (remove)

Muscle

Ligament

Tendon

Figure 1.13 A tendon.

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13Chapter 1 Introduction

Ulna

Humerus

Radius

Olecranon process

Olecranon bursa

Skin

Skin

Figure 1.14 The olecranon bursa is between the skin and theolecranon process at the elbow.

foreign debris. Synovium is highly vascularized andinnervated. As such, when traumatized or inflamed,synovial tissue will rapidly enlarge and produce sig-nificant pain.

Bursal sacs serve to reduce friction. Therefore, theyare located wherever there is need for movement be-tween structures in close proximity. For example, theolecranon bursa lies between the olecranon process ofthe ulna and the skin overlying the posterior part ofthe elbow (see Figure 1.14). The subacromial bursalies between the acromioclavicular arch above and

the rotator cuff tendons below. Inflammation of syn-ovial or bursal tissues due to trauma, inflammatoryprocesses, or foreign materials is termed synovitis orbursitis.

Fascia

There are three kinds of fascial tissues: superficial,deep, and subserous. The fascia is composed of looseto dense connective tissue. Superficial fascia is underthe skin; deep fascia is beneath the superficial and alsoenvelops the head, trunk, and limbs. Subserous fasciasurrounds organs in the thorax, abdomen, and pelvis.

Superficial fascia contains fat, blood vessels, andnerves. It is loose in consistency and very thin. It isattached to the undersurface of the skin.

Deep fascia is dense and tough and has two lay-ers. It wraps around regions of the body and splitsto envelop superficial muscles such as the sartoriusand tensor fasciae latae. Periosteum, perimysium, andperichondrium are all elements of the deepest layer ofthe deep fascia. The deep fascia serves to interconnectthe different muscle groups. By being continuous, itcan provide tension at a distant site when pulled bya contracting muscle. Some muscles take their ori-gin from the deep fascia. The fascia also separatesgroups of muscles with similar function, for exam-ple, the flexor and extensor groups of the leg. Becauseof the relative inelasticity of fascia, abnormally highpressure within a fascial compartment (i.e., due to in-jury or inflammation) can compromise the functionof the nerves and blood vessels that course throughthat compartment. This may result in serious com-promise of the tissues supplied by these nerves andvessels. Fascia may, as other tissues, experience an in-flammatory reaction, fasciitis. This condition can beaccompanied by moderate or even severe discomfortand scarring (fibrosis). Fibrosis can lead to stiffnessand restricted movement.

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C H A P T E R 2

Basic Concepts of PhysicalExaminationIntroduction

The ability to examine a joint completely and accu-rately is a critical part of the diagnostic process forthe clinician evaluating an orthopedic problem. Toaccomplish this, the clinician must possess a thoroughknowledge of anatomy, biomechanics, and kinesi-ology, as well as an understanding of the structure,purpose, and response of the various tissues. Informa-tion is obtained through observation and palpation.The clinician must be able to determine whether thepatient’s pathology is of musculoskeletal origin.

The examination process must be performed in aspecific and logical order. This order will remain thesame regardless of whether the clinician is examiningthe shoulder joint or the spine. It is important forthe examiner to develop the habit of utilizing a setsequence in order to be as organized and efficientas possible and to avoid inadvertently omittinginformation.

Observation

The examination should begin in the waiting roombefore the patient is aware of being observed.Information regarding the degree of the patient’spain, disability, level of functioning, posture, andgait can be observed. The clinician should pay carefulattention to the patient’s facial expressions withregard to the degree of discomfort the patient reportsthat he or she is experiencing. Observing the patientsitting and coming to a standing position will provideinsight into the patient’s ability to tolerate flexion andto then go from flexion to extension. Observation ofthe patient’s gait will provide information regardingthe ability to bear weight, strength of push-off,

balance in relationship to unilateral stance, andcadence. The information gathered in this shortperiod could be very useful in creating a total pictureof the patient’s condition.

Subjective Examination (History)

The patient should be escorted to a private area toenable the clinician to begin the subjective portionof the examination. The patient will be much morecomfortable and relaxed if he or she is allowed to re-main dressed during this part of the examination. Theclinician should pay close attention to the details ofthe present bout and all previous related bouts. Thepatient deserves and will appreciate the examiner’sundivided attention, even if only for a short period. Askilled clinician must be able to listen politely whiledirecting the interview. Concise and direct questionsposed in a logical order will help to provide the ap-propriate information.

The clinician should begin the interview by deter-mining the history of the present bout. Questionsshould include the following: When did the episodebegin? What was the etiology (traumatic vs. insidi-ous)? Are the symptoms the same or are they increas-ing? It is important to determine whether there wereany previous episodes, and if there were, to determinewhen they occurred, what the etiology was, how longthey lasted, and how they resolved (Box 2.1).

It is helpful to elicit whether the pain is constantor intermittent. Symptoms that are brought about bychanging position may be mechanical in nature. If thesymptoms remain unaltered regardless of position oractivity, they may be chemical in nature, secondaryto the release of noxious substances that are at asufficient level to irritate the nerve endings. Constantpain that changes in intensity or quality is considered

14

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15Chapter 2 Basic Concepts of Physical Examination

Box 2.1 Typical Questions for the SubjectiveExamination

Where is the pain located?How long have you had the pain?How did the pain start? Was it traumatic or insidious?Is the pain constant or intermittent?If it is intermittent, what makes it better or worse?How easy is it to bring on the complaint?Describe the pain (nature of pain)?What is the intensity of the pain (0–10)?Does the pain awaken you at night?What position do you sleep in?What are your work and leisure activities?What type of mattress and pillow do you use?How many pillows do you sleep on?Does the pain change as the day progresses?Have you had a previous episode of this problem?If yes, how was it treated?

Past medical history (PMH):Thorough systems reviewSpecific questions are beyond the scope of this text

Medications:Are you taking any medication?For which problem (symptom) is the medication providingrelief?

Special questions:Specific questions and concerns related to each joint arediscussed in the individual chapters.

to be intermittent (Cyriax, 1979). It is also useful todetermine what makes the symptoms better or worseand how long the symptoms remain following theironset. If a patient develops pain very quickly whileperforming an activity and the pain lasts a long time,the clinician would consider the patient’s pain to beirritable (Maitland et al., 2005). It would be beneficialto modify the physical portion of the examinationso as not to exacerbate the symptoms. The pain canalso be followed over a 24-hour period. Is the patientbetter or worse at times throughout the course ofthe day? If the patient is stiffer in the morning onarising, he or she may not be using a firm mattress,may be sleeping in an inappropriate position, or mayhave osteoarthritis, which presents with increasedstiffness following prolonged inactivity. A painscale (McGill Pain Scale; Melzack, 1975) or numeric(visual pain rating, 0–10) may be used to gain a betterunderstanding of the patient’s perception of pain.

To organize the information that is obtained, it ishelpful to use a body chart (Figure 2.1). This chart

allows information to be recorded graphically for ob-servation and comparison. The chart also enables therecording of information concerning areas other thanthe one affected. If an area is examined and foundto be asymptomatical (clear), a check mark can beplaced over that area to indicate that it has been ex-amined and found to be free of symptoms. For ex-ample, if the patient presents with pain in the righthip on the day of the initial examination but returnswith pain in the left hip 2 weeks later, the cliniciancan quickly refer back to the diagram to confirm thehistory.

Information must be gathered regarding the pri-mary area of the complaint and any related area(s).Areas of radiating pain, anesthesia, or paresthesiashould be noted. This allows the clinician to developa better total picture of the problem. It will alsohelp to assess whether there is any relationshipbetween the areas. For example, if the patient’smajor complaint is that of low back pain andpain in the right knee, there may or may not be adirect relationship. Perhaps the patient has radicularpain in an L3 dermatomal pattern, or perhaps thatpatient’s injury was secondary to a fall in which thepatient landed on the right knee at the same timethe back was injured. The quality or description ofthe pain (stabbing, nagging) in the patient’s ownwords must also be noted. If the patient complainsof burning pain, the nerve root might be implicated,whereas a deep ache may be associated with muscledysfunction.

Objective Examination

Dominant Eye

Accuracy in observation requires the use of visual dis-crimination. This can best be accomplished by usingthe dominant eye. Determination of the dominant eyeis done as follows: the clinician extends both armsand uses the thumb and the index finger to make asmall triangle. A distant object is then selected andaligned in the center of the triangle. The clinician thencloses the left eye and checks if the object remainsin the same position or if it moves. If it remains,the clinician is right-eye dominant. The procedure isrepeated for the other eye. The dominant eye shouldbe checked periodically since it may change. Thedominant eye should be placed over the center ofall structures as they are being examined to allow

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16 Basic Concepts of Physical Examination Chapter 2

X

X

Figure 2.1 Body chart.

for more accuracy in visualization (Isaacs andBookhout et al., 1992).

Structural Examination

The posture or structural examination is a staticobservation of the patient. This is an extremely

important part of the total examination process. Youcan obtain a considerable amount of informationregarding the patient on the basis of structurealone. Normal posture is maintained by balanced,strong, and flexible muscles, intact ligaments, freelymoving fascia, healthy, properly functioning joints,a balanced line of gravity and good postural habits.

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17Chapter 2 Basic Concepts of Physical Examination

Changes in postural alignment may be secondary tostructural malformation, joint degeneration, bonedeterioration, joint instability, a change in the centerof gravity, poor postural habits, or pain. Faultyalignment creates unnecessary stress and strain onthe individual, creating either excessive elongation oradaptive shortening of muscles. Muscle elongation orshortening results in decreased efficiency while per-forming even the easiest of activities. The structuralexamination will help you gain a better understandingof the patient’s predisposition to overuse or to injury.

The structural examination allows you to integratethe structure and function of all the joints. Recognizethat when a person develops elongated or shortenedmuscles, he or she may not develop symptoms imme-diately. It may take many years of stress and strainfor problems to reach clinical recognition.

To begin the examination, the patient is asked todisrobe and is provided with an appropriate garment,which allows you to expose the areas that are be-ing examined. It is important that the lighting in theroom is equally distributed so there are not any shad-ows. The patient should be instructed to stand in themiddle of the examining room with their feet approx-imately 6 in. apart so that you can observe him orher from the anterior, posterior, and lateral views.Note whether the patient is distributing the weightequally between both feet. Most examiners prefer tohave the patient remove his or her shoes to observe thefeet. If, however, the patient has a known leg lengthdiscrepancy and uses a lift or wears an orthotic de-vice, have the patient wear the shoes with the liftor orthotic device in place. Observe the patient withand without inserts or lifts. Pay particular attentionto symmetry of structure including bony landmarks,muscle tone, bulk, guarding, atrophy, and alignmentof the joints. The optimal, most efficient posture issymmetrical and balanced. Recognizing that no oneis perfectly symmetrical, minor variations are con-sidered to be functional. Significant differences maybe secondary to anatomical malposition which is ei-ther congenital or acquired; mechanical dysfunctionwhether hypomobile or hypermobile; or dysfunctionof the soft tissue whether hypertrophied, atrophied,taut, or slack.

The examination is approached in a logical fash-ion, proceeding either in a cranial or caudal direction.Here, we describe the examination from the feet firston the basis of the assumption that the weight-bearingstructures will influence the structures that rest onthem. It is helpful to compare any affected jointsto those on the “normal” opposite side. Information

from this examination can be quickly recorded on abody chart for ease of documentation and recall.

Posterior View

Normal

In a normal individual the calcaneus is in neutralalignment with the Achilles tendon vertically aligned.The feet should show 8–10 degrees of toeing out.The medial malleoli should be of equal height onboth sides. The tibias should be straight without anybowing or torsion. The popliteal fossae should be ofequal heights and the knee joints should show 13–18 degrees of valgus. The greater trochanters and thegluteal folds should be of equal heights. The pelvisshould be the same height on both sides, with theposterior superior iliac spines level on the horizontalplane. The spine should be straight without any lat-eral curves. The scapulae should be equidistant fromthe spine and flat against the thoracic cage. The levelsof the inferior angles and the spines of the scapulaeshould be equal in height. The shoulders should be ofequal height. Patients may demonstrate a hand dom-inance pattern where the dominant shoulder is lowerand the corresponding hip higher (Kendall, 1993).The head and neck should be straight without anylateral tilt or rotation (Figure 2.2).

Possible Deviations from the Norm

Start by observing the patient’s feet. Does the patientdemonstrate pes planus or cavus and to what degree?Is the patient able to put the entire foot on the groundwhile not wearing shoes, or does he or she need a shoewith a heel because of an equinus deformity? Whatis the alignment of the calcaneus? Is there an exces-sive degree of varus or valgus (Figure 2.3)? Checkthe alignment of the Achilles tendon. Note the girthand symmetry of the calves. Is any atrophy or edemanoted? Note the length of the leg. Does one tibia ap-pear to be shorter than the other? Is there any bowingof the tibia or tibial torsion?

Check the alignment of the knee joints. From theposterior aspect you can observe genu recurvatum,varum, or valgum (Figure 2.4). Any of these deformi-ties will cause a functional leg length difference unlessthey are symmetrical bilaterally. Note the height ofthe fibular heads. A difference in height may indicatean anatomical leg length difference in the tibia andfibula.

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18 Basic Concepts of Physical Examination Chapter 2

Figure 2.2 Normal posterior view.

Figure 2.3 Calcaneal valgus deformity.

(a)

(b)

Figure 2.4 Genu varum (a) and valgum (b) deformities.

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19Chapter 2 Basic Concepts of Physical Examination

Figure 2.5 Scoliosis.

Note the alignment of the hip joint. Increased flex-ion may be present secondary to a hip flexion con-tracture (see pp. 324, 327, Figure 11.66). To confirmthis, a Thomas test would have to be performed to testfor hip flexor length. Is there excessive medial or lat-eral rotation? Check the relative heights of the greatertrochanters. A difference in height may be secondaryto a structural difference in the length of the femur.

Check the pelvis. Place your hands on the iliac crestsand observe their relative heights. If one is higher thanthe other, it may be secondary to a pelvic torsion,a structural anomaly, or a structural or functionalshort leg. Place your hands on the posterior superioriliac crests and note their relative location. A changein height may be secondary to a pelvic rotation, asacroiliac dysfunction, or a leg length discrepancy.

Observe the spine. First pay attention to the soft tis-sue. Are there any areas of muscle guarding or spasm?These may be secondary to a facilitated segment orsurrounding an area of dysfunction. Note any differ-ences in the skinfolds. This will allow you to bettervisualize lateral curves and spinal rotations. Note thealignment of the spinous processes. Is the back instraight alignment or does the patient present witha scoliosis (Figure 2.5) or kyphosis (Figure 2.6)? If

scoliosis is present, note the rib cage, the degree of ro-tation, and the presence of any lateral humps. Is theresymmetrical rib expansion both anteriorly/posteriorlyand laterally? Is a lateral shift present? Is the patientable to stand in the erect position or is he or she for-ward or laterally flexed?

Observe the scapulae. Are they equidistant fromthe spine? Are they of equal height? Are they overlyabducted or adducted (Figure 2.7)? Is one side winged(Figure 2.8)? This may be secondary to weaknessof the serratus anterior muscle or long thoracicnerve palsy. Is a Sprengel’s deformity present (Figure2.9)? Note the muscle bellies of the infraspinatus,supraspinatus, and teres major and minor musclesover the scapula. Is there an area of atrophy?Disuse atrophy may occur in the supraspinatus orinfraspinatus following a rotator cuff injury. Note therelative shoulder heights and position. Pay attentionto the upper trapezius and note any hypertrophy oratrophy. Note the upper extremities. Does the patientposition both arms in the same manner? Is one armheld farther away from the trunk or in either moreinternal or external rotation? This can be secondaryto muscle shortening and imbalances or fascialrestrictions.

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20 Basic Concepts of Physical Examination Chapter 2

Figure 2.6 Rounded thoracic kyphosis.

X

X is more than two inches

Figure 2.7 Abducted scapula.

Figure 2.8 Winged scapula.

Observe the position of the head and neck. Is thehead in a forward, rotated, or laterally flexed posture?Can the patient hold the head up against gravity?

Anterior View

Normal

The feet should show 8–10 degrees of toeing out.There should be a normal medial longitudinal archthat is symmetrical bilaterally. The navicular tuberos-ity should be located on Feiss’ line (see p. 385, Fig-ures 2.19, 13.7) (from the medial malleolus to thefirst metatarsophalangeal joint). The tibias shouldbe straight without bowing or torsion. The kneesshould show 13–18 degrees of valgus (normal Q an-gle) (see Figures 12.9, 12.12). The patellae shouldpoint straight ahead. The fibular heads should be ofequal height. The pelvis should be of equal height onboth sides. The anterior superior iliac spines shouldbe level bilaterally. The spine should be straight with-out any lateral curves. Although the spine is not di-rectly visible from this view, you can surmise curvesby observing the anterior trunk and the pattern inwhich the hair grows. The rib cage should be sym-metrical without any protrusion or depression of theribs or sternum. The shoulders should be of equal

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21Chapter 2 Basic Concepts of Physical Examination

Figure 2.9 Sprengel’s deformity.

height. The slope and development of the trapezeiishould be symmetrical. The acromioclavicular joints,the clavicles, and the sternoclavicular joints should beat equal heights and symmetrical. The arms shouldhang equally from the trunk with the same degree ofrotation. The elbows should demonstrate equal val-gus (carrying angle) (see p. 201) bilaterally. The headand neck should be straight without any rotation orlateral tilt.

The normal posture of the jaw should be wherethe lips are touching but relaxed and with a smallspace between the upper and lower teeth. The tongueshould be on the hard palate behind the upper teeth(see pp. 92–93, Figure 5.16 and Figure 2.10).

Possible Deviations from the Norm

Starting from the feet, observe the patient’s mediallongitudinal arch. Does the patient have a normalarch or is a pes planus (Figure 2.11) or cavus present?Note whether the patient has hammertoes (Figure2.12), hallux valgus (Figure 2.13), or claw toes. Whatis the appearance of the toenails? Are they discolored,brittle, thickened, or absent? Note the color of the pa-tient’s feet and the pattern of hair growth. This willgive the information regarding the patient’s peripheralvascular status by noting any deviations from normal.

Figure 2.10 Normal anterior view.

Feiss’s line

Figure 2.11 Pes planus deformity.

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22 Basic Concepts of Physical Examination Chapter 2

Figure 2.12 Hammertoe deformity.

Observe the tibia. Note whether any bowing ortibial rotation is present. The patient may have tibialtorsion. Note the relative heights of the fibular heads.Pay attention to the patellae. Do they squint (Figure2.14) or are they bullfrog eyes (see pp. 340–341 and

Figure 2.13 Hallux valgus deformity.

Figure 2.14 Squinting patellae. The patellae face each other.

Figure 12.10)? Are they of equal height? Observethe anterior aspect of the thigh and note whether thepatient presents with quadriceps atrophy. Does thepatient present with genu recurvatum, valgum, orvarum (Figure 2.15)?

Observe the hip joint. Is there excessive medial orlateral rotation? There may be an excessive amountof anteversion or retroversion present. Is a hip flexioncontracture present? Is the patient’s hip postured inan abnormal position? Note the heights of the greatertrochanters. Place your hand over the iliac crest andcheck for leg length discrepancies. Place your fingersover the anterior iliac crests and note whether theyare symmetrical. Changes in relative height may besecondary to pelvic rotation, sacroiliac dysfunction,or structural or functional leg length discrepancies.

Observe the patient’s trunk. If the patient has chesthair, you will more easily be able to determine if a sco-liosis is present by observing changes in the growthpattern. Observe the patient’s chest. Note symmetryof expansion during the breathing cycle. Is there sym-metrical rib expansion both anteriorly/posteriorly andlaterally? If a scoliosis is present, note the rib cage,the degree of rotation, and the presence of any lateralhumps. Is a lateral shift present? Is the patient able to

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23Chapter 2 Basic Concepts of Physical Examination

(a)

(b)

Figure 2.15 Genu varum (a) and valgum (b) deformities.

Figure 2.16 Barrel chest deformity.

stand in the erect position or is he or she forward orlaterally flexed?

Observe the clavicles and sternum. Is one acromio-clavicular or sternoclavicular joint higher than theother? Is a shoulder separation present? Does thepatient demonstrate pectus excavatum, pectus cari-natum, or barrel chest (Figure 2.16)? Check the ster-noclavicular joints for symmetry. Note the acromio-clavicular joints and observe for any separation. Notethe upper extremities. Does the patient position botharms in the same manner? Is one arm held fartheraway from the trunk or held in more medial or lateralrotation? This can be secondary to muscle shorteningand imbalances or fascial restrictions.

Does the patient present with a forward head pos-ture? Is the head tilted to one side? Is torticollispresent, with the head postured in side bending androtation to opposite sides (Figure 2.17)?

Lateral View

Normal

It is important to observe the patient from both theright and left lateral views and compare the findings(Figure 2.18). The feet should show a normal longitu-dinal arch. The navicular tuberosity should be located

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24 Basic Concepts of Physical Examination Chapter 2

sternocleidomastoid

Figure 2.17 Torticollis.

2

Figure 2.18 Normal lateral view.

on Feiss’ line (from the medial malleolus to the firstmetatarsophalangeal joint). The knees should be from0 to 5 degrees of flexion. The hips should be in 0 de-grees of flexion. The pelvis should be aligned so thatthe anterior and posterior superior iliac spines are inthe same plane horizontally, creating a normal lordo-sis. The pelvis should not be rotated. The anterior su-perior iliac spine and pubic symphysis should be in thesame plane vertically. The normal posterior–anteriorpelvic angle is 30 degrees from the posterior supe-rior iliac spine to the pubic ramus. The spine shoulddemonstrate the normal anterior–posterior curves oflumbar lordosis, thoracic kyphosis, and cervical lor-dosis. The chest should have a smooth contour with-out any areas of depression or protrusion. The shoul-ders should be in proper alignment without beingprotracted or rounded. The head should be over theshoulders with the ear lobe on a vertical line withthe acromion process. Rocabado (unpublished data,1982) notes that the apex of the thoracic kyphosisshould not be more than 2 in. posterior to the deepestpoint of the cervical lordosis (Figure 2.18).

Possible Deviations from the Norm

Start by observing the patient’s feet. Note the me-dial longitudinal arch (Figure 2.19). You can observe

Feiss’s line

Figure 2.19 Normal medial longitudinal arch.

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25Chapter 2 Basic Concepts of Physical Examination

Figure 2.20 Genu recurvatum deformity.

Feiss’ line and determine if a pes planus (Figure 2.11)or cavus is present. Note the alignment of the knee.The lateral view gives you the easiest way to note aknee flexion contracture or genu recurvatum (Figure2.20).

Note the relative position of the anterior and poste-rior superior iliac spines. If the anterior superior iliacspine is higher, it could indicate a posterior pelvictilt or a posterior rotation of the innominate bone. Aposterior pelvic tilt will cause a decrease in the lum-bar lordosis or a flat back (Figure 2.21). Is a swayback present (Figure 2.22)? If the posterior superioriliac spine is relatively higher, this could indicate ananterior pelvic tilt or an anterior rotation of the in-nominate bone. An anterior pelvic tilt will cause anincrease in the lumbar lordosis.

Observe the trunk. The lateral view allows you toobserve the anterior and posterior curves. Does thepatient present with a rounded (Figure 2.6) or a flat-tened thoracic kyphosis? Is a Dowager’s hump present(Figure 2.23)?

Note the position of the shoulders. Does the pa-tient present with anteriorly displaced rounded shoul-ders (Figure 2.24)? Where are the upper extremitiesin relation to the trunk? Observe the head and neck.

Figure 2.21 Flat back deformity.

Figure 2.22 Sway back deformity.

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26 Basic Concepts of Physical Examination Chapter 2

Figure 2.23 Dowager’s hump deformity.

Figure 2.24 Rounded shoulders.

Figure 2.25 Forward head posture.

Does the patient present with a forward head posture(Figure 2.25)?

Sitting Posture

Observe the patient in the sitting position while youare standing behind him or her. Note the differencesin the alignment of the head, neck, trunk, and pelvisfrom the posterior view. These differences can be dueto the removal of the influence of the lower extremi-ties. Some patients may have considerably better pos-ture in the sitting position by eliminating deviationsin the lower extremities, which create functional leglength discrepancies or muscle imbalances.

Active Movement Testing

The examiner should proceed by directing the patientto move through all available ranges of motion. It isbeneficial to have the patient move independently be-fore the clinician begins the palpatory examination, asthe degree of movement may be adversely affected ifthe patient’s pain level is increased. Active movementtesting will provide the clinician with information re-garding the status of both contractile (i.e., muscle, ten-don) and noncontractile (ligaments, bones) structuresof the joint (Cyriax, 1979). These tests can be used to

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27Chapter 2 Basic Concepts of Physical Examination

GROSS MOVEMENT

Forwardbending

Backwardbending

Right-sidebending

Rightrotation

Leftrotation

Left-sidebending

Figure 2.26 Movement diagram.

assess the quantity and the quality of movement. Theclinician should observe the degree of movement, theease with which the patient moves, the willingness ofthe patient to move, and the rhythm, symmetry, andrate of movement (Cyriax, 1979). This will providethe clinician with information regarding the degree ofthe patient’s flexibility, mobility, and strength.

If on active movement the patient obtains full pain-free active range of motion with an overpressure, theclinician can continue with the resisted testing portionof the examination. If the patient’s range of motion islimited, the clinician should utilize passive movementtesting to gain a better understanding of the structurescausing the restriction.

Objective measurement of movement in the spinecan be recorded utilizing a movement diagram (Figure2.26). This very simple method allows the clinicianto document the percentage of movement relative tothe total normal anatomical range of motion in alldirections. Deviations from the midline and the pointof the onset of pain can also be noted. The diagramallows the clinician to quickly ascertain symmetry ofmovement.

Formal measurement of range of motion can alsobe documented with a standard goniometer using ei-ther the 180- or 360-degree scale. The specifics of ap-

propriately placing and utilizing the goniometer aremore thoroughly addressed in a textbook on goniom-etry. In addition, bubble goniometers, flexible rulers,inclinometers, and tape measures have all been docu-mented in the literature as appropriate measurementtools. More specific information concerning range-of-motion measurements is included in the individualchapters devoted to the joints.

Passive Movement Testing

Passive testing of the physiological movements (car-dinal plane, gross joint movement) is used to provideinformation regarding the state of the noncontractile(inert) elements (Cyriax, 1979). Cyriax defined in-ert structures as those tissues that lack the inherentability to contract. These structures (ligaments, jointcapsule, fascia, bursa, dura mater, and nerve root)are stretched or stressed when the joint is taken to theend of the available range. It is important, however,to note that even though the muscles are not called onto contract during passive movement, they do exertan influence on the degree of motion. If the muscleis maintained in a shortened state, it will prevent thejoint from achieving its full anatomical range.

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28 Basic Concepts of Physical Examination Chapter 2

When performing passive movement testing, it isnecessary to have the patient relax and place him orher in a secure and comfortable position. This will al-low movement without internal resistance. The move-ment should be carried out smoothly and gently toallow maximal movement with the least discomfort.

If the patient does not achieve full anatomicalrange, the end of the available motion is referred to asthe pathological limit. The examiner should assess thefeel of the limiting tissue at the end of this range. Thissensation is referred to as the end feel (end point).The end feel can be hard (bony), abrupt and firm(ligamentous), soft (tissue approximation), or elastic(tendinous). This end feel will help the clinician un-derstand which tissue may be responsible for the lossof motion. Pain can also be a limiting factor. In thiscase, the clinician will experience the sense that thetissue is not restricting the motion, rather the patientis actively preventing the rest of the movement fromoccurring. This is referred to as an empty end feel(Cyriax, 1979; Paris, 1991; Kaltenborn, 1999).

If pain is present before a sense of structural re-sistance is felt, the condition can be considered to beacute. Because of the pain, the patient will prevent themovement well before the anatomical structures limitthe range. If resistance is noted before the onset ofpain, the condition can be considered to be chronic.The structures being stretched at the end of the rangewill cause the discomfort (Cyriax, 1979).

Resisted Movement Testing

Resisted movement testing involves an isometric con-traction of the muscle that is performed in the neutral(mid) position. The joint must be held still so that theamount of stress placed on the inert (noncontractile)structures is minimized. The patient is instructed toproduce a progressive maximal isometric contrac-tion. This is accomplished by the clinician graduallyincreasing the degree of resistance until a maximalcontraction is achieved. Resisted testing will helpisolate the musculotendinous unit as the cause of thepain. The clinician should consider the results of theresisted movement tests. It is possible that a musclethat is tested as weak has either a musculoskeletalcomponent, such as a strain or inflammation, or aneurological component, such as a peripheral nervecompression. If the patient has a musculoskeletaldysfunction, the resisted movement will be painfulsince the damaged structure is stressed. If the test re-veals a muscle that is weak and painless, it is possiblethat the etiology is neurological (Cyriax, 1979).

The clinician must classify the response as strong,weak, painless, or painful. A muscle is consideredstrong if the patient can maintain a contractionagainst a moderate degree of resistance. If the muscleis unable to generate enough force to match the ap-plied resistance, it is considered to be weak (Cyriax,1979). If the patient’s pain level remains unchangeddespite the examiner’s resistance, the response is clas-sified as painless. If the patient’s degree of pain in-creases or changes with the examiner’s resistance, theresponse is classified as painful. This pain–strengthrelationship will give the clinician better insight intowhich structures are responsible for the problem. In-terpretation using Cyriax’s method indicates the fol-lowing:1. Strong and painful responses may be indicative of

an injury to some part of the muscle or tendon.2. Weak and painless responses may be indicative of

a full rupture of the muscle or may imply aninterruption of the nervous innervation of themuscle.

3. Weak and painful responses may be an indicationof a gross lesion such as a fracture or metastaticlesion.

4. Strong and painless responses are indicative ofnormal structures.

Passive Mobility (Accessory) Movement Testing

Accessory movements (joint play) are movements thatoccur within the joint simultaneously with active orpassive physiological movements. A combination ofroll, spin, and glide allows the joint to move follow-ing the shape of the joint surface. The clinician canalso assess the degree of laxity (slack) that is presentwhen separating or gliding the joint surfaces. Laxityis the degree of looseness or “play” that is allowed bythe capsule and ligaments in a normal joint while themuscles are relaxed. These movements are not underthe volitional control of the patient and are totallyindependent from muscle contraction. To obtain full,pain-free physiological range of motion, the accessorymovements must be present and full. The clinicianshould compare the findings from the symptomaticside with those obtained from the unaffected side.

Neurological Examination

The neurological examination helps the clinician de-termine whether the patient’s symptomatology stemsfrom the musculoskeletal system, the nervous system,or a combination of both. For example, a patient with

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29Chapter 2 Basic Concepts of Physical Examination

complaints of shoulder pain may have a C5 radicu-lopathy or a subdeltoid bursitis. The clinician cannotdifferentiate between the two diagnoses without com-pleting a thorough examination of the cervical spineand shoulder. The specifics of these examinations arediscussed later in this chapter.

Manual Muscle Testing

If the clinician prefers to obtain specific grades ofstrength for each individual muscle as opposed to clas-sifying the strength as strong or weak, a formal man-ual muscle test can be performed. The patient is placedin the appropriate positions with resistance appliedto elicit specific muscle contractions. The strength isthen evaluated and graded using a system from 0 to 5or 0 to normal. Generally accepted definitions of themuscle grades are as follows (Kendall et al., 1993):� Normal (5): The muscle can withstand a strong

degree of resistance against gravity.� Good (4): The muscle can withstand a moderate

degree of resistance against gravity.� Fair (3): The muscle is able to sustain the test

position against gravity.� Poor (2): The muscle is able to complete the range

of motion in a plane that is parallel to gravity(gravity eliminated).

� Trace (1): The muscle can perform a palpablecontraction but without any visible movement.

� Zero (0): No contraction is present.Some clinicians may prefer to use plus and minus

grades with the above definitions or use a scale from 0to 10. A discussion related to functional muscle test-ing is included in each of the chapters on individualjoints. Selected manual muscle tests are included inthe individual chapters later in this book. However,detailed information regarding the specifics of manualmuscle testing is beyond the scope of this book. Someclinicians may want to continue their evaluation withmore extensive equipment, such as that required forisokinetic testing.

Deep Tendon (Stretch) Reflexes

It is important to test the deep tendon (stretch-myotatic) reflexes. Comparison of both sides is veryimportant. A patient may present with symmetricallydecreased reflexes and be perfectly normal. Normalvariations must be taken into account. If the patientpresents with hyperreflexia, a correlation can be madewith upper motor neuron disease secondary to de-creased inhibition by the motor cortex. If the patient

presents with hyporeflexia, lower motor neuron dis-ease may be the causative factor secondary to an inter-ruption in the reflex arc. Jendrassik’s method of rein-forcement, where the patient pulls his or her claspedhands apart, may be needed to determine whethera reflex is present if the patient is very hyporeflexic.Asking the patient to lightly contract the muscle beingtested can also enhance a difficult to elicit reflex.

Sensory Testing

The clinician should proceed with the pinprick test toassess the presence or absence of skin sensation. Theclinician should correlate the findings with eithera dermatomal or peripheral nerve distribution. Ifthe patient appears to have significant neurologicaldeficits, a more detailed sensory examination (includ-ing tests for temperature, position, and vibration sen-sations) would be appropriate. Light touch may alsobe used as a screening test for sensation.

Nerve Stretch Testing

Nerve stretch tests can be used to determine whetherthere is compression of a nerve. The most commontests used are the straight-leg raise (SLR) (Laseue’s)test and the femoral nerve (prone knee bending) test.An increased dural stretch can be added to the SLRtest by flexing the patient’s head and neck, adding dor-siflexion of the ankle. This creates additional stretchon the nerve root and increases the positive findings.Butler (1991) adds a slumping maneuver to the SLRand neck flexion in the sitting position, entitling it the“slump test.” Peripheral nerves can also be tested bystretching them to provoke or worsen symptoms.

Compression and Distraction

Compression and distraction of the spine can be usedto evaluate whether the patient’s symptoms are ei-ther increased or decreased. Distraction can relievepressure in an area that is compressed by separatingthe structures and allowing more space for the nerveroot. Pain can also be increased because of increasedstretch on the nerve root. Compression will increasean already existing pressure by decreasing the spacein the nerve root foramen.

Pathological Reflex Testing

Pathological reflexes should also be tested. The clini-cian should check for the presence of the Babinski or

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30 Basic Concepts of Physical Examination Chapter 2

Hoffmann reflex. If either of these is present, a corre-lation to upper motor neuron disease can be made.

Palpatory Examination

The clinician should start the examination by visuallyinspecting the skin and subcutaneous tissue over theaffected area. Areas of localized swelling, excess fat,abrasion, discoloration, hematoma, and birthmarksshould be noted. The clinician should then palpatethe area and note areas of increased or decreasedmoisture and temperature. If warmth, redness, andincreased moisture are present, a correlation can bemade to an acute lesion. A scratch test can be per-formed to evaluate the degree of histamine reaction.Skin rolling can determine whether there are any ar-eas of adhesion. In a normal patient, the skin shouldroll freely.

The clinician should palpate bony landmarks, not-ing their orientation and areas of tenderness or defor-mity. When examining the spine, the clinician shouldpay attention to the alignment of the spinous andtransverse processes and note if they are appropri-ately positioned. The inexperienced clinician may bemisled into thinking that a faulty alignment existswhen actually a congenital anomaly is present.

The muscles should be palpated and areas of spasm,guarding, knots, and tenderness should be noted. The

clinician should be aware that it is easy to be fooledby listening to the patient’s complaint without com-pleting the actual physical examination. Very oftenthe area of complaint will not correlate to the area ofpalpable tenderness or dysfunction. When palpated,trigger points within muscles may radiate pain to adistant location. Ligaments and tendons should alsobe palpated. Swelling and a sense of bogginess mayindicate an acute lesion, whereas stringiness may befound in chronic injuries. Finally, the clinician shouldpalpate the arterial pulses in the area being exam-ined to determine whether any vascular compromiseis present.

Correlation

On completion of the examination, the clinicianshould correlate the information in a logical fash-ion, so that all the pieces of the puzzle fit togetherto formulate a diagnosis. If one piece of informationdoes not fit, the clinician should re-examine the pa-tient to guarantee that the finding is accurate. If theinformation does not fit together, the clinician shouldconsider that the etiology of the problem is comingfrom another body system and refer the patient ac-cordingly.

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C H A P T E R 3

Overview of the Spineand PelvisThe spine and pelvis represent the central support ofthe body. The pelvis can be thought of as a trape-zoidal structure lying atop two columns (the lowerextremities) upon which the spine sits.

The spine is composed of more than 30 segmentscalled vertebrae. The vertebrae permit rotation, lat-eral bending, and flexion–extension movements. Theyvary in shape and size, but in general have similarstructures (Figure 3.1). Most of the vertebrae havea large central body. Posteriorly, they have a hol-low ring through which the spinal cord passes. Thereare bony projections extending posteriorly from thelateral and posterior aspects of this ring. These bonyprojections are termed the transverse and spinous pro-cesses and serve as points of attachment for spinalligaments and muscular tissues. Stability of the ver-tebrae is dependent on soft tissues (intervertebral lig-aments and paraspinal muscles) and posterior artic-ulations called the facet joints. The vertebrae can bedivided into five subgroups. Each subgroup has a dif-ferent function; hence, vertebrae, although somewhatsimilar within a subgroup, vary significantly in theirgeometry from vertebrae of another subgroup. Thischange in shape and size reflects the different func-tions of these subgroups. The different shapes havesignificant effects on vertebral mobility and stability.

The most superior subgroup is termed the cervicalspine. There are seven vertebrae within the cervicalspine. At the apex is the atlas, or C1 vertebra. It isso named because it carries the “world” (the head)on its shoulders. Its articulation with the base of theskull permits a small amount of front-to-back move-ment (nodding) and side bending. Beneath the atlasis the axis, or C2 vertebra. Its name comes from thefact that it presents a vertical structure (odontoid),much like that of a gatepost to the atlas, about whichthe atlas can rotate. This bony odontoid shares spacewith the spinal cord within the central hollow ring

of the atlas (Figures 3.2 and 3.3). As such, any in-stability, whether traumatic or secondary to anotheretiology (rheumatoid inflammation), can cause ante-rior translation of the atlas on the axis. This can resultin compression of the odontoid onto the spinal cordwithin the spinal canal, with life-threatening conse-quences. Beneath the axis, the remaining five cervicalvertebrae are similar in shape and function. They ac-commodate flexion–extension, lateral (side) bending,and lateral rotation. Below C2, the point of maxi-mum flexion–extension movement is at the C4–C5and C5–C6 levels. Hence, it is at these sites that os-teoarthritic degeneration is most commonly seen. Theconsequence of this frequency of osteoarthritic degen-eration is that radicular symptomatology secondaryto cervical osteoarthritis most commonly affects theC4, C5, and C6 nerve roots. This is due to forami-nal and disc space narrowing (stenosis) caused by de-generative changes and osteophyte formation at theselevels. One additional anatomical curiosity of the cer-vical spine involves the vertebral artery becoming en-tombed within the vertebral processes of C2, C3, C4,and C5 as it travels proximal toward the skull. Thistethering of the vertebral artery within the bony ver-tebrae can create a stress point to the vessel with ex-treme movement of the cervical spine.

The 12 thoracic vertebrae are stabilized by the ribcage into a relatively immobile segment. There arefour localized points of significant stress created atthe proximal and distal ends of the thoracic spine,at the cervicothoracic and thoracolumbar junctions.This is due to the abrupt change in stiffness at thesepoints.

The five segments of the lumbar spine are very largeversions of those found in the cervical spine. This isconsistent with the increased load to which they aresubjected and the fact that their purpose is to permitmotion in all three planes between the rigid pelvis

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32 Overview of the Spine and Pelvis Chapter 3

Spinalcanal

Spinousprocess

Inferiorfacet

Superiorfacet

Transverseprocess

Body

Spinalcord

Figure 3.1 A generalized vertebral segment is composed of alarge, solid cylindrical body. Posteriorly, there is a bony ringthrough which the spinal cord and its coverings pass. Transverseand spinous processes project from the ring.

POSTERIOR

ANTERIOR

C1 (ring of atlas)Spinal cord

Transverse ligamentof odontoid

Transverseprocess

Odontoid processof C2

Foramen forvertebral artery

Lateralmass

Figure 3.2 A transverse view through the ring of C1 (atlas)shows the spinal canal to be divided into thirds. The anteriorthird is occupied by the bony odontoid process of C2; theposterior third is filled by the spinal cord; the transverseligament prevents migration of C1 on C2, not allowing theodontoid to invade the empty central third of the spinal canal.

Skull

C1 (atlas)

Spinal cord

C2 (axis)

C2 (axis)

C1 (atlas)

Odontoidprocess

Figure 3.3 The skull rests on the atlas (C1); the head rotates about the odontoid process as if it were a gatepost.

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33Chapter 3 Overview of the Spine and Pelvis

below and the semirigid thorax above. Like the cervi-cal spine, the lumbar spine is a common site of degen-erative change. It has been said that the human lumbarspine has not yet sufficiently evolved to accommodatethe erect bipedal stance. This is certainly borne out bythe fact that back pain is almost a universal ailmentamong humans at some point during their lives. Ofparticular importance are the L4–L5 and L5–S1 ar-ticulations. A forward-facing convexity called lordo-sis is quite pronounced at these levels. This lordosisaccounts for the slight “hollow” one normally per-ceives at the region of the low back when lying onthe floor with the lower extremities fully extended.This lordosis creates a tremendous forward pressureon the vertically oriented facet joints, which serve tostabilize the lower lumbar segments against forwardtranslation. This constant forward pressure may ex-plain the high frequency of degenerative change seenwithin these particular facet articulations.

The lumbar, thoracic, and cervical spinal segmentsrest on a large triangular structure called the sacrum.The sacrum is formed by the fusion of five vertebralsegments into one large triangular bone. Similar tothe keystone at the top of the arch, the sacrum iskeystoned into the pelvic ring between the ilia (in-nominates). It is held in place by a combination ofextremely strong ligaments and a synchondrosis witheach iliac wing.

Beneath the sacrum are the vertebral segments ofthe coccyx. Seen on lateral x-ray films, the coccyxhas the appearance of a short tail. It actually repre-sents the vestigial remnants of the tails that existedon our ancestors. Occasionally, an infant will beborn with accessory coccygeal segments or an actualtail, which will require surgical removal. The coccyxserves to protect the structures of the lower pelvisand acts as an attachment for some of the lowerpelvic musculature and ligaments.

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C H A P T E R 4

The Cervical Spine andThoracic Spine

F U R T H E R I N F O R M A T I O N

Please refer to Chapter 2 foran overview of the sequence of a

physical examination. For purposes oflength and to avoid having to repeatanatomy more than once, the palpationsection appears directly after the sectionon subjective examination and before any

section on testing, rather than at the endof each chapter. The order in which theexamination is performed should bebased on your experience and personalpreference as well as the presentation ofthe patient.

Observation

The cervical spine is a flexible column that supportsthe weight of the head and provides a protected path-way for the spinal cord as it descends. It protects thevertebral arteries, the internal jugular veins, and thesympathetic chain of the autonomic nervous system.It is imperative that special care be taken to moni-tor these structures during the examination. The dis-tinctive arrangement of the articulations of the up-per cervical spine continuing with the facet joints ofthe lower cervical spine allows for the head to movethrough space. The muscles and ligaments create agreat deal of stability as they counteract the inertia ofthe head. There is also a unique interaction with theshoulder girdle because of the many mutual muscleattachments. In contrast, the thoracic spine is quiterigid because of its attachment to the rib cage. Activemotion is therefore much more restricted (see Figures4.1–4.4).

Note the manner in which the patient is sitting inthe waiting room. Notice how the patient is posturingthe head, neck, and upper extremity. Is the patient’s

head forward or laterally bent? Is the patient support-ing their head with their hands or is he or she wearinga cervical collar? Is the arm relaxed at the side or isit being cradled for protection? How willing is thepatient to turn the head or look up at you as youapproach? Will the patient use the upper extremity?Will he or she extend the arm to you to shake yourhand? Pain may be altered by changes in position, sowatch the patient’s facial expression for indicationsas to their pain level.

Observe the patient as he or she assumes the stand-ing position and note their posture. Pay particular at-tention to the position of the head, cervical spine, andthoracic kyphosis. Note the height of the shouldersand their relative positions. Once the patient startsto ambulate, observe whether he or she is willing toswing their arms. Arm swing can be limited by pain orloss of motion. Once the patient is in the examinationroom, ask him or her to disrobe. Observe his or herwillingness to bend the head to allow for removal ofthe shirt. Note the ease with which upper extremitiesare used and the rhythm of the movements. Observethe posture of the head, neck, and upper back. Ob-serve for symmetry of bony structures. Observe the

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35Chapter 4 The Cervical Spine and Thoracic Spine

Hyoid boneThyroid cartilage

First cricoid ring

Carotid tubercle

Sternum

Trachea

C1C2

C6C7

T4

T2

Mastoid process

Superior nuchal line

Inion

Spinous processes

Mandible

Facet joint

C1 transverseprocess

Figure 4.1 Overview of the neck with anterior–posteriorrelationships.

clavicles and the sternum. An uneven contour may bepresent secondary to a healed fracture. Observe thescapulae and determine whether they are equidistantfrom the spine and are lying flat on the rib cage. Is asubluxation present at the glenohumeral joint and ifso, to what degree? Notice the size and contour of thedeltoid muscle and compare to the opposite deltoid.

Vertebraprominens (C7)

Spinous process of T1

Clavicle

Spine ofscapula

8th rib

7th rib

Rib angle

Inferior angleof scapula(T7 vertebra)

T2

T3

T7

Figure 4.2 Overview of the posterior thorax.

Temporalartery

Vertex of headTemporal bone

Parietal bone

Occipital bone

Mastoid process

Frontalbone

Orbit

Nasalbone

Maxilla

Zygoma

Parotidduct

Mandible

Parotidgland

Figure 4.3 Overview of the skull.

Sternocleidomastoidmuscle

Scalenemuscles

Figure 4.4 The sternocleidomastoid muscle acts both as acervical flexor and lateral rotator of the cervical spine. Thescaleni muscles act to bend the cervical spine laterally and alsoassist in flexion.

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36 The Cervical Spine and Thoracic Spine Chapter 4

Observe for any areas of atrophy in the upper extrem-ities. Pay attention to the rib cage. Does the patienthave a barrel chest? Observe the patient’s breathingpattern. Is he or she a mouth breather? Note the de-gree and symmetry of expansion bilaterally.

Subjective Examination

Since the cervical spine is quite flexible, it is an areavery commonly affected by osteoarthritis, inflamma-tion, and trauma. You should inquire about the na-ture and location of the patient’s complaints and theirduration and intensity. Note if the pain travels up tothe patient’s head or distally to below the elbow. Thebehavior of the pain during the day and night shouldalso be addressed. Is the patient able to sleep or ishe or she awakened during the night? What positiondoes the patient sleep in? How many pillows do theyuse? What type of pillow is used?

You should determine the patient’s functional lim-itations. Can the patient independently support thehead upright? Is he or she able to read, drive, or liftheavy objects? If the patient complains of radicularpain, ask questions regarding use of the upper ex-tremity. Is the patient able to comb their hair, fas-ten a bra, bring their hand to their mouth to eat,or remove their jacket? Is the radicular pain associ-ated with numbness or tingling in the arm or hand?Does the patient regularly participate in any vigoroussports or work-related activity that would stress theneck and upper back? What is the patient’s occupa-tion? Working at a computer or constant use of thetelephone can influence the patient’s symptoms.

If the patient reports a history of trauma, it is im-portant to note the mechanism of injury. The direc-tion of force, the position of the head and neck duringimpact, and the activity the patient was participatingin at the time of the injury all contribute to an under-standing of the resulting problem and help to betterdirect the examination. If the patient was involved ina motor vehicle accident, it is important to determinewhether he or she was the driver or the passenger.Did the patient strike their head during the accident?Did the patient suffer a loss of consciousness and ifso, for how long? Was the patient wearing a seatbeltand if so, what type? The degree of pain, swelling,and disability at the time of the trauma and withinthe next 24 hours should be noted. Does the patienthave a previous history of the same injury?

Is the pain constant or intermittent? The answer tothis question will give you information as to whetherthe pain is chemical or mechanical in nature. Can thepain be altered by position? If the pain is altered byposition, one can assume that there is a mechanicalbasis. Consider the factors that make the patient’scomplaints increase or ease. Does the pain increasewhen the patient takes a deep breath? This may besecondary to a musculoskeletal problem or a space-occupying lesion. Does coughing, sneezing, or bear-ing down increase the symptoms? Increased pain withgreater intra-abdominal pressure may be secondaryto a space-occupying lesion. Does the patient com-plain of gastrointestinal problems? Pain may be re-ferred from the viscera to the thoracic spine. If the pa-tient has a central nervous system disorder including acompression of the spinal cord, he or she may presentwith the following complaints: headaches, dizziness,seizures, nausea, blurred vision, or nystagmus. Thepatient may notice difficulty swallowing secondaryto an anterior disc bulge or a change in the qual-ity of his or her voice. The patient may experiencedifficulty with the lower extremities and gait disor-ders. How easily is the patient’s condition irritatedand how quickly can the symptoms be relieved? Theexamination may need to be modified if the patientreacts adversely with very little activity and requiresa long time for relief.

The patient’s disorder may be related to age, gen-der, ethnic background, body type, static and dy-namic posture, occupation, leisure activities, hobbies,and general activity level. It is important to inquireabout any change in daily routine and any unusualactivities that the patient has participated in.

You should inquire about the nature, location, du-ration, and intensity of the complaints. The locationof the symptoms may provide some insight into theetiology of the complaints. For example, pain that islocated over the lateral aspect of the shoulder mayactually be referred to C5.

(Please refer to Box 2.1, Chapter 2, p. 15 for typicalquestions for the subjective examination.)

Gentle Palpation

The palpatory examination is started with the patientin the standing position. This allows you to see the in-fluence of the lower extremities on the trunk and thelumbar spine in the weight-bearing position. If thepatient has difficulty standing, he or she may sit on

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37Chapter 4 The Cervical Spine and Thoracic Spine

a stool with the back toward you. The patient mustbe sufficiently disrobed so that the thoracic spine andneck are exposed. You should first search for areas oflocalized effusion, discoloration, birthmarks, open si-nuses or drainage, incisional areas, bony contours andalignment, muscle girth, symmetry, and skinfolds. Acafe au lait spot or a “faun’s” beard most commonlyfound in the lumbar spine might be indicative of aspina bifida occulta. Remember to use the dominanteye (see p. 15) (Isaacs and Bookhout 1992) whenchecking for alignment or symmetry. Failure to dothis can alter the findings. You should not have touse deep pressure to determine areas of tenderness ormalalignment. It is important to use firm but gentlepressure, which will enhance your palpatory skills.By having a sound basis of cross-sectional anatomy,you should not have to physically penetrate throughseveral layers of tissue to have a good sense of the un-derlying structures. Remember, if the patient’s painis increased at this point in the examination, the pa-tient will be very reluctant to allow you to continue,or may become more limited in his or her ability tomove.

Palpation is most easily performed with the patientin a relaxed position. Although the initial palpationmay be performed with the patient standing or sitting,

the supine, sidelying, or prone positions allow foreasier access to the bony and soft-tissue structures.

Posterior Aspect

The easiest position for palpation of the posteriorstructures is with the patient supine and the exam-iner sitting behind the patient’s head. You can restyour forearms on the table, which enables you to re-lax your hands during palpation.

Bony Structures

Inion (External Occipital Protuberance)Place your fingers on the middle of the base of theskull and move slightly superiorly into the hairlineand you will feel a rounded prominence, which isthe inion (Figure 4.5). This is often referred to as the“bump of knowledge.”

Superior Nuchal LinePlace your fingers on the inion and move laterally andinferiorly diagonally toward the mastoid process. Youwill feel the ridge of the superior nuchal line underyour fingers (Figure 4.6).

Inion

Inion

Figure 4.5 Palpation of the inion.

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38 The Cervical Spine and Thoracic Spine Chapter 4

Superiornuchal line

Superiornuchal line

Figure 4.6 Palpation of the superior nuchal line.

OcciputPlace your hands under the base of the patient’s headand allow your fingertips to rest on the most inferioraspect. This area is the occiput (Figure 4.7).

Mastoid ProcessesPlace your fingers directly under the patient’s earlobesand you will feel a rounded prominence on each sideunder your fingers. These are the mastoid processes(Figure 4.8).

Transverse Processes of C1Place your fingers anterior to the mastoid processesand in the space between the mastoid processes andthe angle of the mandible, you will find the projectionof the transverse processes of C1 (Figure 4.9). Al-though they can be deep, be careful not to press toofirmly since they are often tender to palpation even inthe normal patient.

Spinous Process of C2Place your finger on the inion and move inferiorly intoan indentation (posterior arch of C1). As you continue

to move inferiorly, the rounded prominence that youfeel is the spinous process of C2 (Figure 4.10).

Spinous ProcessesPlace your middle fingers in the upper portion of themidline of the posterior aspect of the neck. You willfeel blunt prominences under your fingers. These arethe spinous processes (Figure 4.11). The spinous pro-cesses are often bifurcated, which you may be able tosense as you palpate them. You can start countingthe spinous processes from C2 (location describedabove) caudally. You will notice the cervical lor-dosis as you palpate. Notice that the spinous pro-cesses of C3, C4, and C5 are deeper and closer to-gether, making them more difficult to differentiateindividually.

Spinous Process of C7The spinous process of C7 is normally the longestof all the cervical spinous processes (Figure 4.12).It is referred to as the prominens. However, it maybe the same length as the spinous process of T1. Todetermine whether you are palpating C7 or T1, lo-cate the spinous process you assume is C7. Place one

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39Chapter 4 The Cervical Spine and Thoracic Spine

Occiput

Occiput

Figure 4.7 Palpation of the occiput.

Mastoidprocess

Figure 4.8 Palpation of the mastoid process.

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40 The Cervical Spine and Thoracic Spine Chapter 4

Transverse process of C1

Figure 4.9 Palpation of the transverse process of C1.

Spinousprocess of C2

Figure 4.10 Palpation of the spinous process of C2.

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41Chapter 4 The Cervical Spine and Thoracic Spine

Spinousprocess of C4

Spinousprocessesof C3 to C7

Figure 4.11 Palpation of the spinous processes.

Spinousprocess of C7

Figure 4.12 Palpation of the spinous process of C7.

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42 The Cervical Spine and Thoracic Spine Chapter 4

finger on the spinous process that you presume is C7,and one over C6 and T1, and then have the patientextend the head slightly. The C6 vertebra will dropoff slightly at the beginning of the movement, fol-lowed by C7 with a slight increase in extension, andT1 will not drop off at all. The T1 spinous processis immobilized by the first ribs and therefore doesnot move.

Articular Pillar (Facet Joints)Move your fingers laterally approximately 1 in. fromthe spinous processes, over the erector spinae untilyou find a depression. You will be on the articular pil-lar. As you palpate in a caudal direction, you will beable to differentiate the joint lines of the facet joints:they feel like a stick of bamboo (Figure 4.13). If thejoints deteriorate secondary to osteoarthritis, they be-come enlarged and are not as clearly delineated. Notethat the facet joints can be tender to palpation even ina normal individual. Facet joints can become lockedor dislocated. They will alter the patient’s ability tomove and limit the available range of motion in adistinctive pattern.

Transverse Processes of the Cervical SpineMove your fingers to the most lateral aspect ofthe neck and you will feel a series of blunt promi-nences. These are the transverse processes (Figure4.14). The second cervical transverse process can bepalpated through the sternocleidomastoid muscle ap-proximately 1 cm inferior to the mastoid process.These processes are normally tender to palpation.

The following palpations are more easily accom-plished with the patient in either the prone or theseated position.

Spinous Processes of the Thoracic SpineThe spinous processes of the thoracic spine are longerand more slender than those of the cervical spine.Since the direction of the spinous processes changesthroughout the thoracic spine, a method for relat-ing the location of the spinous process to the trans-verse process was developed. This is referred to asthe “rule of 3’s.” T1–T3 vertebrae have spinous pro-cesses that are posteriorly directed as in the cervicalspine. Therefore, the spinous process is at the samelevel as its own transverse process. T4–T6 vertebraehave spinous processes that are angled in a slightlydownward direction. Therefore, the tip of the spinous

ArticularPillar

Figure 4.13 Palpation of the articular pillar.

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43Chapter 4 The Cervical Spine and Thoracic Spine

Transverseprocesses

Figure 4.14 Palpation of the transverse processes of the cervicalspine.

process is located at a point halfway between thetransverse process at the same level and the verte-bra below. T7–T9 vertebrae have spinous processesthat are angled moderately downward. Therefore, thespinous process is located at the same level as thetransverse process of the vertebra below. T10–T12vertebrae have spinous processes that slowly resumethe horizontal direction as in the lumbar spine, wherethe spinous process is at the same level as the trans-verse process (Isaacs and Bookhout 1992) (Figure4.15).

Transverse Processes of the Thoracic SpineIn T1–T3 vertebrae the transverse processes are atthe same level as the spinous processes. The trans-verse processes of T4–T6 vertebrae are halfway be-tween each vertebra’s own spinous process and theone above. The transverse processes of T7–T9 ver-tebrae are at the level of the spinous process of thevertebra above. The transverse processes of T10–T12vertebrae are the reverse of those in the previous threegroups (T10 process resembles T7–T9 processes, T11resembles T4–T6, and T12 resembles T1–T3) as thespinous processes become more horizontal (Figure4.16).

Spine of the ScapulaPalpate the posterior aspect of the acromion andfollow medially along the ridge of the spine of the

Figure 4.15 Palpation of the spinous processes of the thoracicspine.

Figure 4.16 Palpation of the transverse processes of the thoracicspine.

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44 The Cervical Spine and Thoracic Spine Chapter 4

Spinousprocess of

3rd thoracicvertebrae

Spine of scapula

Figure 4.17 Palpation of the spine of the scapula.

scapula as it tapers and ends at the level of the spinousprocess of the third thoracic vertebra (Figure 4.17).

Medial (Vertebral) Border of the ScapulaMove superiorly from the medial aspect of the spineof the scapula until you palpate the superior angle,which is located at the level of the second thoracicvertebra. This area serves as the attachment of thelevator scapulae and is often tender to palpation. Itis frequently an area of referred pain from the cervi-cal spine. Continue inferiorly along the medial borderand note if it lies flat along the rib cage. If the borderwings away from the rib cage, it may be indicative ofa long thoracic nerve injury. Notice the attachmentof the rhomboid major along the length of the medialborder from the spine to the inferior angle. The infe-rior angle is located at the level of the seventh thoracicvertebra (Figure 4.18).

Soft-Tissue Structures

Trapezius MuscleStand behind the seated patient or observe the patientin the prone position. Differences in contour and ex-panse can be easily noted as you observe the patientprior to palpation. To enable you to palpate the fibersof the upper trapezius, allow your fingers to travel lat-erally and inferiorly from the external occipital protu-berance to the lateral third of the clavicle. The muscle

T2—T7

Medialborder of

scapula

Figure 4.18 Palpation of the medial border of the scapula.

is a flat sheet but feels like a cordlike structure becauseof the rotation of the fibers. It is frequently tender topalpation and often very tight secondary to tension ortrauma. You can palpate the muscle using your thumbon the posterior aspect and your index and middle fin-gers anteriorly. The fibers of the lower trapezius canbe traced as they attach from the medial aspect of thespine of the scapula, running medially and inferiorlyto the spinous processes of the lower thoracic verte-brae. The fibers become more prominent by askingthe patient to depress the scapula. The fibers of themiddle trapezius can be palpated from the acromionto the spinous processes of the seventh cervical andupper thoracic vertebrae. The muscle becomes moreprominent by asking the patient to adduct the scapu-lae (Figure 4.19).

Suboccipital MusclesThe suboccipital muscles consist of the rectus capi-tis posterior major and minor and the obliquus capi-tis superior and inferior. The rectus minor and theobliquus superior attach from the atlas to the occiput.The rectus major and the obliquus inferior have theirdistal attachment on the axis. The rectus then travelsto the occiput while the obliquus attaches to the trans-verse processes of atlas (Figure 4.20). This group of

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45Chapter 4 The Cervical Spine and Thoracic Spine

Lowertrapezius

Middletrapezius

Uppertrapezius

Figure 4.19 Palpation of the trapezius muscle.

muscles is designed to allow for independent functionof the suboccipital unit. They can be palpated by plac-ing your fingertips at the base of the occiput while thepatient is in the supine position. It is important to rec-ognize that they are very deep structures and that youare actually palpating the fascia and superficial mus-cles simultaneously (Porterfield and DeRosa, 1995).

These muscles are often in spasm and become ten-der to palpation.

Semispinalis Cervicis and CapitisThe semispinalis cervicis has its attachments to thetransverse processes of the upper thoracic spine andthe spinous process of C2. It functions as a stabilizerof the second cervical vertebra.

The semispinalis capitis has its attachments to thetransverse processes of the upper thoracic and lowercervical vertebrae and to the occiput between the su-perior and inferior nuchal line.

The semispinalis capitis is superficial to thesemispinalis cervicis. The two muscles form a cord-like structure. Place your finger over the spinous pro-cesses from C2–C7 and move laterally until you feelthe rounded cordlike structure (see Figure 4.53).

Rectus capitis posterior minor muscle

Rectus capitisposterior majormuscle

Obliquuscapitis

superiormuscle

Obliquuscapitis inferior muscle

Spinousprocessof axis

Greater occipital nerve

Figure 4.20 Palpation of the suboccipital muscles and the greater occipital nerves.

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46 The Cervical Spine and Thoracic Spine Chapter 4

Greater Occipital NervesThe greater occipital nerves pierce the upper trapeziusnear its attachment to the occiput. Locate the proxi-mal attachment of the trapezius and palpate the baseof the skull on either side of the external occipitalprotuberance (see Figure 4.20). The nerves are onlypalpable if they are inflamed. The nerves pierce thesemispinalis muscle. An entrapment syndrome withpain, numbness, or burning in the scalp may occurwhen the semispinalis capitis muscle is hyperirritable(Porterfield and DeRosa, 1995). They may also be thesource of headaches in patients with acute cervicalstrain.

Ligamentum NuchaeThe superficial part of the ligamentum nuchae hasits attachment on the external occipital protuberanceand the seventh cervical vertebra (Figure 4.21). Itis easily palpated on top of and between the cer-vical spinous processes. It becomes more apparentas the patient flexes the neck. This ligament con-tinues caudally as the supraspinous and interspinousligaments.

Levator ScapulaeThe levator scapulae are attached to the transverseprocesses of C1–C4 and the superior medial aspect ofthe scapula. The muscle can function as a scapula ele-vator and also as a lateral flexor of the neck. However,it also functions as a dynamic check to the anteriorpull of the cervical lordosis. It is therefore often ob-ligated to maintain a state of constant contraction.Tenderness can be palpated over its distal attachmenton the superior medial border of the scapula. You canpalpate the muscle with the patient in either the proneor the seated position (see Figure 8.71). You can facili-tate the palpation by asking the patient to rotate awayfrom the side being examined. This will allow forgreater tension in the levator scapulae by moving thetransverse processes anteriorly while creating laxity inthe trapezius by moving the spinous processes towardthe side being tested (Porterfield and DeRosa, 1995).

Anterior Aspect

To facilitate palpation of the anterior aspect of theneck, the patient should be in the supine position.

Ligamentumnuchae

Ligamentumnuchae

Figure 4.21 Palpation of the ligamentum nuchae.

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47Chapter 4 The Cervical Spine and Thoracic Spine

The head should be supported and the neck relaxed.Make sure that the neck is in neutral alignment.

Bony Structures

Hyoid BoneThe hyoid bone is located at the anterior aspect of theC3–C4 vertebral bodies. It is useful as a landmark forlocating the spinous processes, as you can easily pal-pate the anterior surface and then wrap your fingersposteriorly at the same level. The hyoid is a horseshoe-shaped bone. With your thumb and index finger, sur-round the most superior aspects of the structure andmove it from side to side. It is not easy to palpatebecause it is tucked under the mandible and is sus-pended by many of the anterior neck muscles. Whenthe patient swallows, movement of the hyoid becomesapparent (Figure 4.22). You may notice crepitus whilemoving the hyoid laterally, which indicates a rough-ened cartilage surface.

Thyroid CartilageThe thyroid cartilage (commonly referred to asAdam’s apple) is located at the anterior aspect of the

C4–C5 vertebral bodies. Continuing inferiorly fromthe hyoid bone, you will feel the rounded dome ofthe thyroid cartilage (Figure 4.23). If the neck is fullyextended, the upper part of the thyroid cartilage canbe located at the mid position between the chin andthe sternum. The thyroid cartilage is partially coveredby the thyroid gland. If there is a swollen area notedover the anterior inferior aspect of the cartilage, itmight be an enlargement of the thyroid gland knownas goiter.

First Cricoid RingAs you continue to palpate inferiorly along the ante-rior part of the neck, you reach a tissue that is softerthan the thyroid cartilage at the level of the C6 verte-bral body. This is the first cricoid ring (Figure 4.24).Palpation of this area creates a very unpleasant sen-sation for the patient. This is an area commonly usedfor tracheostomy incisions because of the easy andsafe access into the trachea.

Carotid TubercleThe carotid tubercle is located on the anterior aspectof the transverse process of C6 (Figure 4.25). The

C3

Hyoid bone

Hyoid bone

C3

Figure 4.22 Palpation of the hyoid bone.

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C4-5

Thyroidcartilage

Figure 4.23 Palpation of the thyroid cartilage and gland.

common carotid artery is located superficially nextto the tubercle. The artery can be easily compressedwhen palpating the tubercle. Care must be taken notto palpate both carotid tubercles simultaneously be-cause of the possible consequences of decreased bloodflow in the carotid arteries. The carotid tubercle is auseful landmark to orient you and confirm your loca-tion while examining the anterior cervical spine.

Suprasternal NotchStand facing the patient and use your middle or indexfinger to locate the triangular notch between the twoclavicles. This is the suprasternal notch (Figure 4.26).

Sternal Angle (Angle of Louis)You can locate the sternal angle by findingthe suprasternal notch and moving inferiorly

C6

Figure 4.24 Palpation of the first cricoid ring.

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49Chapter 4 The Cervical Spine and Thoracic Spine

Carotid tubercle

C6

Carotid tubercle

Figure 4.25 Palpation of the carotid tubercle.

approximately 5 cm (Bates, 1983, p. 126) until youlocate a transverse ridge where the manubrium joinsthe body of the sternum. If you move your hand lat-

1st ribClavicle

Gladiolus(of sternum)

2nd ribSuprasternal

notch

Manubrium(of sternum)

Level of sternal angle

(angle ofLouis)

Figure 4.26 Palpation of the suprasternal notch.

erally, you will find the attachment of the second rib(Figure 4.27).

Sternoclavicular JointMove your fingers slightly superiorly and laterallyfrom the center of the suprasternal notch until youfeel the joint line between the sternum and the clavi-cle. The joints should be examined simultaneously toallow for comparison of heights and location. Youcan get a better sense of the exact location of the ster-noclavicular joint by having the patient shrug his orher shoulders while you palpate the movement of thejoint and the upward motion of the clavicles. A supe-rior and medial displacement of the clavicle may beindicative of dislocation of the sternoclavicular joint(Figure 4.28).

Clavicle and Surrounding AreaContinue to move laterally from the sternoclavic-ular joint along the superior and anterior curvedbony surface of the clavicle. The bony surface shouldbe smooth and continuous. Any area of increasedprominence, pain, or sense of motion or crepitus inthe bony shaft may be indicative of a fracture. Theplatysma muscle passes over the clavicle as it coursesup the neck and can be palpated by having the patient

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Sternalangle

Intercostalangle

Infrasternalnotch

Figure 4.27 Palpation of the sternal angle.

strongly pull the corners of the mouth in a downwarddirection (Figure 4.29). The supraclavicular lymphnodes are found on the superior surface of the clavicle,lateral to the sternocleidomastoid in the supraclavicu-lar fossa. If you notice any enlargement or tenderness,

Sternoclavicularjoint

Figure 4.28 Palpation of the sternoclavicular joint.

Clavicle

Figure 4.29 Palpation of the clavicle.

a malignancy or infection should be suspected. Youcan also palpate for the first rib in this space.

First RibThe first rib is a little tricky to find since it is locatedbehind the clavicle. If you elevate the clavicle andmove your fingers posterior and inferior from themiddle one-third of the clavicle, you will locate thefirst rib just anterior to the trapezius muscle (Figure4.30). This rib is often confused by examiners asbeing a muscle spasm of the trapezius. It is normallytender to palpation.

RibsThe second rib is the most superior rib that is eas-ily palpable on the anterior part of the chest. Locatethe sternal angle (described previously) and move lat-erally until you locate the second rib. You can thenproceed inferiorly and count the ribs by placing yourfingers in the intercostal spaces. The fifth rib is locatedat the xiphisternal joint. Note the symmetry of align-ment and movement. Check the rib angles posteriorlyalong the insertion of the iliocostalis muscle approxi-mately 1-in. lateral to the spinous processes. Observefor both the pump-handle elevation and the bucket-handle lateral expansion movements. The eleventhand twelfth ribs are found just above the iliac crests.

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51Chapter 4 The Cervical Spine and Thoracic Spine

First rib

T1

Figure 4.30 Palpation of the first rib.

They are most easily palpated on the lateral aspectalong their free ends (Figure 4.31).

Soft-Tissue Structures

Sternocleidomastoid MuscleTo facilitate palpating the sternocleidomastoid mus-cle, have the patient bend the neck toward the side youare palpating and then simultaneously rotate away.This movement allows the muscle to become moreprominent and therefore easier to locate. Palpate thedistal attachments on the manubrium of the sternumand the medial aspect of the clavicle and follow themuscle superiorly and laterally until it attaches to themastoid process. The upper trapezius and sternoclei-domastoid meet at their attachment at the skull at thesuperior nuchal line. Move just medial to the attach-ment and you will feel the occipital artery (Moore andDalley, 1999). The sternocleidomastoid is the anteriorborder of the anterior triangle of the neck; the uppertrapezius is the posterior border, and the clavicle theinferior border. It is a useful landmark for palpatingenlarged lymph nodes (Figure 4.32).

Scaleni MusclesThe scalenus anterior attaches proximally to the an-terior tubercles of the transverse processes of allthe cervical vertebrae. The scalenus medius attaches

T1Second rib

Sternum

Figure 4.31 Palpation of the ribs.

Sternocleidomastoidmuscle

Scaleni

Figure 4.32 Palpation of the sternocleidomastoid muscle andthe scaleni muscles.

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52 The Cervical Spine and Thoracic Spine Chapter 4

proximally to the posterior tubercles of the transverseprocesses of all the cervical vertebrae. They both havetheir distal attachment to the first rib. The scalenusanterior is clinically significant because of its rela-tionship to the subclavian artery and the brachialplexus. Compression of these structures may lead tothoracic outlet syndrome. Both the scalenus anteriorand medius can assist in elevating the first rib. Thescalenus posterior attaches from the posterior tuber-cles of the transverse processes from C4–C6 into thesecond rib. The scalenus anterior muscles can workbilaterally to flex the neck. Unilaterally, the group canlaterally flex the neck. These muscles work togetheras stabilizers of the neck in the sagittal plane. Theycan be injured in acceleration-type accidents. This oc-curs when the individual is sitting at a standstill andhit from behind. Place your fingers over the lateral as-pect of the neck in the posterior triangle and ask thepatient to laterally flex away from you. This placesthe muscles on stretch and facilitates palpation (seeFigure 4.32). Inhalation will also make the musclesmore distinct.

Lymph Node ChainMultiple lymph nodes are located in the head andneck. There is a long lymph node chain with the ma-jority of the nodes located deep to the sternocleido-mastoid muscle. These are not normally accessible topalpation. If they are enlarged secondary to an infec-tion or a malignancy, they can be palpated by sur-rounding the sternocleidomastoid with your thumband finger (Figure 4.33).

Carotid PulseThe carotid pulse may be visible by inspection. Lo-cate the sternocleidomastoid muscle in the area of thecarotid tubercle (see description, p. 51). Place yourindex and middle fingers medial to the midsection ofthe muscle belly and press toward the transverse pro-cesses of the cervical spine. Ask the patient to rotatethe head toward the side you are palpating. This re-laxes the muscle and makes the pulse more accessible(Figure 4.34). Remember not to press too hard or thepulse will be obliterated.

Parotid GlandThe parotid gland is the largest of the three salivaryglands. It is not normally palpable. If it is enlarged, itcan be found in the space between the sternocleido-mastoid, the anterior mastoid process, and the ramusof the mandible (Figure 4.35). It is enlarged when the

Figure 4.33 Palpation of the lymph node chain.

Palpate wellbelow the

upper borderof the thyroid

cartilage

Carotidsinus

Sternocleidomastoidmuscle

Carotid artery

Figure 4.34 Palpation of the carotid pulse.

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53Chapter 4 The Cervical Spine and Thoracic Spine

Parotidgland

Figure 4.35 Palpation of the parotid gland.

patient has the mumps or a ductal stone. The contourof the mandibular angle will appear more rounded.

Trigger Points of the Cervical Spine

The trapezius muscle contains numerous triggerpoints. Five common trigger points are illustrated inFigures 4.36, 4.37, and 4.38. The sternocleidomastoidmuscle contains trigger points that frequently causesymptoms such as nasal congestion, watery eyes, andheadaches (Figure 4.39). The scalene muscles may re-fer pain down as far as the hand (Figure 4.40). Triggerpoints of the splenius capitis and suboccipital musclesalso commonly cause headaches (Figures 4.41 and4.42).

Active Movement Testing

Have the patient sit on a stool in a well-lit area of theexamination room. Shadows from poor lighting willaffect your perception of the movement. The patientshould be appropriately disrobed so that you can ob-serve the neck and upper thoracic spine. You should

Upper trapezius

Figure 4.36 A trigger point in the upper trapezius muscle maycause headaches. (Adapted with permission from Travell andRinzler, 1952.)

watch the patient’s movements from the anterior, pos-terior, and both lateral aspects. While observing thepatient move, pay particular attention to his or herwillingness to move, the quality of the motion, andthe available range. Lines in the floor may serve asvisual guides to the patient and alter the movementpatterns. It may be helpful to ask the patient to repeatmovements with the eyes closed.

Before your examination of the cervical spine, youshould have the patient perform a quick test to clearthe joints of the upper extremities. Ask the patientto fully elevate the upper extremities; stress a combi-nation of shoulder internal rotation, adduction, andextension at the end of the range; and passively stressthe elbow and wrist. This will check the range of mo-tion of the entire upper extremity. If the movementsare painless, these joints are not implicated and youshould proceed with the examination of the cervicalspine.

You should then have the patient perform the fol-lowing movements: bending the head forward andbackward, lateral (side) bending to the right and left,and rotation to the right and left. You should observethe alignment and symmetry of the spinal curves. You

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54 The Cervical Spine and Thoracic Spine Chapter 4

Middle trapezius

T12

Lower trapezius

Figure 4.37 Trigger points in the middle and lower trapezius may cause pain in the occipital region and along the paraspinal region.(Adapted with permission from Travell and Rinzler, 1952.)

C7

Trapezius

Figure 4.38 Additional trigger points in the left lower and rightmiddle trapezius are shown with their referred pain patterns.(Adapted with permission from Travell and Rinzler, 1952.)

may note a flattening in a particular area as the pa-tient bends to the side or a deviation to one side duringforward bending. These deviations should alert youto more carefully examine the involved area. If themotion is pain free at the end of the range, you canadd an additional overpressure to “clear” the joint(Cyriax, 1979). You can also ask the patient to sus-tain the position for 15 seconds to determine whetherthe symptoms can be reproduced. Sustained move-ments can also be combined to increase the degree ofnerve root compression symptoms. If the patient ex-periences pain in any of these movements, you shouldnote the position that increases or alleviates the symp-toms.

Forward Bending

Instruct the patient to sit on a stool with the feet firmlyon the ground approximately 6 in. apart. Stand be-hind the patient to observe them from the back duringthe movement. Note the patient’s normal resting pos-ture, as changes in the normal thoracic and lumbarcurves can influence the resting position and mobilityof the cervical spine. It is also helpful to observe thepatient from the side to obtain a better view of thecervical lordosis. Instruct the patient to sit in an erect

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55Chapter 4 The Cervical Spine and Thoracic Spine

Sternocleidomastoid

Figure 4.39 Trigger points in the sternocleidomastoid muscle may cause referred pain in the face and head and also symptoms ofwatery eyes and runny nose. (Adapted with permission from Travell and Rinzler, 1952.)

X

X

Scalene

Figure 4.40 Trigger points within the scaleni muscles may refer pain all the way to the hand. (Adapted with permission from Travelland Rinzler, 1952.)

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Suboccipital

Figure 4.41 Trigger points in the suboccipital muscles radiatepain in the region of the greater occipital nerve. (Adapted withpermission from Travell and Rinzler, 1952.)

Splenius capitis muscle

Figure 4.42 A trigger point in the splenius capitis muscle may cause referred pain on the top of the head. (Adapted with permissionfrom Travell and Rinzler, 1952.)

posture before you begin your examination. Ask thepatient to drop the head forward with the chin towardthe chest (Figure 4.43a). Observe the degree of rangeof motion and any deviation to the right or left. Notethe smoothness with which each intervertebral levelopens as the cervical lordosis reverses. Note whetherthe range is limited by pain or the patient’s anticipa-tion of pain. The patient achieves full flexion whenthe chin, with mouth closed, touches the chest. It isaccepted as normal if there is a two-finger space be-tween the chin and chest. The normal range of motionof flexion is 80–90 degrees (Magee, 2002).

The amount of movement can be recorded on amovement diagram. Deviations to the side and theonset of symptoms can also be recorded. A more ob-jective method of measuring the range can be accom-plished in one of a few ways. One method is to use aruler to measure the distance from the patient’s chinto the sternal notch. Another is by using a standardgoniometer or a gravity-assisted bubble goniometerspecifically designed for the cervical spine to give youthe actual degrees of movement.

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57Chapter 4 The Cervical Spine and Thoracic Spine

(a) (b)

(c) (d)

Figure 4.43 Active movement testing. (a) Cervical forward bending. (b) Cervical backward bending. (c) Cervical sidebending.(d) Cervical rotation.

Backward Bending

Instruct the patient to sit on a stool with the feet firmlyon the ground approximately 6 in. apart. Stand be-hind the patient to observe the movement. Instructthe patient to sit in an erect posture before you be-gin your examination. Ask the patient to raise thechin and look toward the ceiling (Figure 4.43b). Nor-

mal range is achieved when the patient’s foreheadand nose are on a horizontal plane. Note the smooth-ness with which each intervertebral level closes. Notewhether the range is limited by pain or the patient’santicipation of pain.

Range of motion is most easily recorded on a move-ment diagram. Another method of recording is to usea ruler to measure the distance from the patient’s

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58 The Cervical Spine and Thoracic Spine Chapter 4

chin to the sternal notch as the neck is extended.A standard goniometer or one specifically designedfor the cervical spine can be used to give you the ac-tual degrees of movement. Normal range of motion is70 degrees (Magee, 2002).

Lateral (Side) Bending

Instruct the patient to sit on a stool with the feet firmlyon the ground approximately 6 in. apart. Stand be-hind the patient to observe the movement. Instruct thepatient to sit in an erect posture before you begin yourexamination. Ask the patient to allow their ear to ap-proach the shoulder on the side to which he or sheis moving (Figure 4.43c). Do not allow the patient tosubstitute by raising the shoulder to meet the ear. Lat-eral bending should be repeated on the right and leftsides. Compare the degree and quality of movementfrom side to side. Note any breaks in the continuityof the curve. An angulation of the curve may indi-cate an area of hypermobility or hypomobility. Notethe smoothness with which each intervertebral levelopens. Note whether pain or the patient’s anticipationof pain limits the range.

Range of motion is most easily recorded on a move-ment diagram. You can also use a ruler to measurethe distance from the mastoid process to the tip of theacromion process and compare one side to the other.A standard goniometer or one specifically designedfor the cervical spine can be used to give you the ac-tual degrees of movement. Normal range of motionis 20–45 degrees (Magee, 2002).

Rotation

Instruct the patient to sit on a stool with the feet firmlyon the ground approximately 6 in. apart. Stand be-hind the patient to observe the movement. Instructthe patient to sit in an erect posture before you beginyour examination. Ask the patient to turn the head inthe horizontal plane so that the chin moves towardthe shoulder (Figure 4.43d). The patient may try tosubstitute by rotating the trunk. Rotation should berepeated on the right and left sides. Compare the de-gree and quality of movement from side to side. Noteany discontinuity of the curve. Note the smoothness inwhich each intervertebral level opens. Note whetherthe range is limited by pain or the patient’s anticipa-tion of pain.

Range of motion is most easily recorded on a move-ment diagram. You can use a ruler to measure thedistance from the chin to the acromion process and

compare one side to the other. A standard goniometeror one specifically designed for the cervical spine canbe used to give you the actual degrees of movement.Normal range of motion is 70–90 degrees (Magee,2002).

Upper Cervical Spine

Tucking the chin in will produce flexion of the up-per cervical spine and extension of the lower cervicalspine. Jutting the chin produces extension of the up-per cervical spine and flexion of the lower cervicalspine.

Thoracic Motion

Active motion of the upper thoracic spine can be eval-uated as an extension of the cervical spine. After thepatient takes up all the motion in each direction ofthe cervical spine, instruct him or her to continuethe flexion, extension, lateral bending, and rotationmovements to a greater degree until you can sensemovement in the middle thoracic vertebrae. The lowerthoracic spine can be evaluated as an extension of thelumbar spine. Recognize that the thoracic spine is themost restricted area of the spine because of the costalattachments.

Passive Movement Testing

Passive movement testing can be divided into twocategories: physiological movements (cardinal plane),which are the same as the active movements, and mo-bility testing of the accessory (joint play, component)movements. Using these tests helps to differentiatethe contractile from the noncontractile (inert) ele-ments. These elements (ligaments, joint capsule, fas-cia, bursa, dura mater, and nerve root) (Cyriax, 1979)are stretched or stressed when the joint is taken to theend of the available range. At the end of each pas-sive physiological movement, you should sense theend feel and determine whether it is normal or patho-logical. Assess the limitation of movement and see ifit fits into a capsular pattern. The capsular patternof the cervical spine is equally limited lateral bendingand rotation, followed by extension that is less limited(Magee, 2002). This pattern is only clearly noticeablewhen multiple segments are involved. Paris describeda capsular pattern for the cervical spine secondary to afacet lesion. With the facet lesion on the right, lateral

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59Chapter 4 The Cervical Spine and Thoracic Spine

bending is limited to the left, rotation is limited to theleft, and forward bending deviates to the right (Paris,1991).

Since the structures of the cervical and thoracicspine can be easily injured, it is imperative that youtake a history and are aware of the radiological find-ings before you initiate the passive movement por-tion of the examination. Patients may have fractures,subluxations, or dislocations that are not easily diag-nosed on the initial clinical evaluation. If these injuriesexist, the patient’s well-being may be jeopardized dur-ing the examination process.

Passive Physiological Movements

Passive testing of the physiological movements is easi-est if they are performed with the patient in the sittingposition. You should place one hand over the top ofthe patient’s head and rest your fingers on the anterioraspect of the skull and your palm over the patient’sforehead. Your other hand should grasp the patient’socciput. This hold will allow you to support the pa-tient’s head and allow him or her to relax while youperform the passive movements.

Mobility Testing of AccessoryMovements

Mobility testing of accessory movements will give youinformation about the degree of laxity present in thejoint and the end feel. The patient must be totally re-laxed and comfortable to allow you to move the jointand obtain the most accurate information. Before be-ginning the mobility testing portion of the examina-tion, you must be sure that the vertebral artery is notcompromised and that the cervical spine is stable.

Intervertebral Mobility of the Cervical Spine

Flexion Intervertebral Mobility TestingPlace the patient in the sitting position either on astool or on a low table, with the head and neck inneutral alignment. Stand beside the patient to observethe movement occurring posteriorly. Support the pa-tient’s head by placing your hand over his or her fore-head onto the skull. Place the middle finger of yourother hand in the interspace between the spinous pro-cesses of C2 and C3. Flex the patient’s head and neckuntil you feel movement at the segment you are pal-pating. Note the opening of the intervertebral space.You can slightly extend the neck to get a better senseof opening and closing. Slightly increase the degree of

Figure 4.44 Mobility testing of cervical spine flexion.

flexion to palpate the next intervertebral segment andcontinue in a caudal direction (Figure 4.44). You canalso palpate over the facet joints during passive flex-ion. The test should be repeated bilaterally to evaluateall of the joints.

Extension Intervertebral Mobility TestingCervical extension is evaluated in the same manneras described above for flexion except that you shouldbe feeling a closing between the spinous processes asyou extend the neck.

Lateral Bending Intervertebral Mobility TestingPlace the patient in the sitting position either on astool or on a low table, with the head and neck inneutral alignment. Stand beside the patient to observethe movement occurring posteriorly. Support the pa-tient’s head by placing your hand over the top of theskull. Place the middle finger of your other hand overthe facet joint on the side that you are testing. Start byplacing your middle finger over the facet joint betweenC2 and C3. Bend the patient’s head and neck towardthe side you are evaluating until you feel movementat the segment being palpated. Note the closing ofthe facet joint. You can laterally bend the head andneck slightly in the opposite direction to get a better

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60 The Cervical Spine and Thoracic Spine Chapter 4

Figure 4.45 Mobility testing of cervical spine lateral (side)bending.

sense of opening and closing. Slightly increase the de-gree of sidebending to palpate the next intervertebralsegment and continue in a caudal direction (Figure4.45). This movement can also be palpated over thefacet joints on the opposite side of the movement. Inthat case, you will palpate an opening of the facetjoint. The test should be repeated on both sides toevaluate all of the joints.

Rotation Intervertebral Mobility TestingPlace the patient in the sitting position either on astool or on a low table, with the head and neck inneutral alignment. Stand beside the patient to observethe movement occurring posteriorly. Support the pa-tient’s head by placing your hand over the foreheadonto the skull. Place the middle finger of your otherhand on the lateral aspect of the spinous process ofC2. Rotate the patient’s head and neck away fromthe side on which you have placed your finger untilyou feel the spinous process pressing into your fin-ger at the segment you are palpating. Slightly increasethe degree of rotation to palpate the next interver-tebral segment and continue in a caudal direction

Figure 4.46 Mobility testing of cervical spine rotation.

(Figure 4.46). You can also palpate by rotating thehead toward your palpating finger. You will then feelthe spinous process moving away from you. The testshould be repeated on both sides to evaluate all thejoints.

Thoracic Spine Movements

Passive motion of the upper thoracic spine can beevaluated as a continuation of the cervical spine. Af-ter you evaluate all the motions in each direction,continue the flexion, extension, lateral bending, androtation movements to a greater degree until you cansense movement down to the middle thoracic verte-brae. The middle thoracic spine can be evaluated withthe patient in the sitting position. Hold the patient byplacing your arm around the patient’s crossed upperextremities and grasping the opposite shoulder. Yourhand placements and the method of palpation are thesame as described above for the cervical spine. Thelower thoracic spine can be evaluated as a continua-tion of the lumbar spine. When evaluating the lumbarspine, you should move the pelvis and lower extremi-ties with a greater amount of range in a cranial direc-tion until you can sense mobility in the lower thoracicvertebrae.

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61Chapter 4 The Cervical Spine and Thoracic Spine

Figure 4.47 Cervical spine traction.

Cervical Traction

Place the patient in the supine position. Stand behindthe patient’s head. Place your hands so that your fin-gertips grasp under the occiput. Use your body weightand lean back, away from the patient, to create thetraction force (Figure 4.47).

Accessory Movements of the Cervical Spine

Posteroanterior Central Pressure (Ventral Glide) onthe Spinous ProcessPlace the patient in the prone position with the neckin neutral rotation midway between flexion and ex-tension. Stand on the side of the patient so that yourdominant eye is centered over the spine, with yourbody turned so that you are facing the patient’s head.Place your overlapping thumbs onto the spinous pro-cess. Press directly over the process in an anteriordirection until all the slack has been taken up (Figure4.48).

Posteroanterior Unilateral Pressure on theArticular PillarPlace the patient in the prone position with the neckin neutral rotation midway between flexion and ex-tension. Stand on the side of the patient so that yourdominant eye is centered over the spine, with yourbody turned so that you are facing the patient’s head.Place your overlapping thumbs onto the articular pil-lar on the side closest to you. Press directly over thepillar in an anterior direction until all the slack hasbeen taken up. This will cause a rotation of the verte-bral body away from the side that you are contacting(Figure 4.49).

Transverse Pressure on the Spinous ProcessPlace the patient in the prone position with the neckin neutral rotation midway between flexion and ex-tension. Stand on the side of the patient so that yourdominant eye is centered over the spine, with your

Spinousprocess

Figure 4.48 Mobility testing of central posteroanterior pressureon the spinous processes.

Figure 4.49 Mobility testing of the posteroanterior pressure onthe articular pillar.

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62 The Cervical Spine and Thoracic Spine Chapter 4

Figure 4.50 Mobility testing of transverse pressure on thespinous process.

body turned so that you are facing the side of thepatient. Place your thumbs on the lateral aspect ofthe spinous process. Push the process away from youuntil you have taken up all the slack. This will causerotation of the vertebral body toward the directionthat you are contacting (Figure 4.50).

First Rib Ventral–Caudal GlidePlace the patient in the sitting position either on astool or on a low table, with the head and neck rotatedto the right. Stand behind the patient. Support thepatient by placing your left hand over the patient’shead and rest your elbow on the shoulder. Place thelateral aspect of your index finger of the right handover the superior dorsal aspect of the first rib. Pressin a ventral and caudal direction until all the slack istaken up (Figure 4.51).

Resistive Testing

Movements of the head and neck are flexion, ex-tension, rotation, and lateral bending. Testing thestrength of the cervical muscles is best performed withthe patient in the seated position. Testing the cervical

Firstrib

Figure 4.51 Mobility testing of first rib ventral–caudal glide.

muscles with gravity eliminated is performed with thepatient lying supine. Significant weakness of cervicalmuscles may be found in neuromuscular diseases suchas myasthenia gravis and polymyositis.

Cervical Flexion

The sternocleidomastoid muscle is the primary cervi-cal flexor. The scaleni anterior, medius, and posterior,as well as the intrinsic neck muscles (see Figure 4.4)assist it.� Position of the patient: Seated.� Resisted test (Figure 4.52): Place one of your hands

on the patient’s sternum to prevent substitution ofneck flexion by flexion of the thorax. Place thepalm of your other hand on the patient’s foreheadand ask the patient to bring the head downwardso as to look at the floor. Resist this movementwith your hand as he or she pushes against you.

Cervical Extension

The primary extensors of the cervical spine are thetrapezius (superior fibers), the semispinalis capitis,splenius capitis, and splenius cervicis (Figure 4.53).

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63Chapter 4 The Cervical Spine and Thoracic Spine

Movement

Resistance

Figure 4.52 Testing cervical flexion.

These muscles are assisted by the levator scapulaeand the intrinsic neck muscles.� Position of patient: Seated. Stand behind the

patient.� Resisted test (Figure 4.54): Place one hand on the

patient’s shoulder over the scapula forstabilization. Place your other hand over theocciput and vertex of the patient’s skull and askthe patient to bring the head backward againstyour resistance as he or she tries to look to theceiling. The patient may attempt to lean backwardand you should resist this movement with yourstabilizing hand.

Rotation (see Figure 4.55)

The sternocleidomastoid muscle is the prime rotatorof the cervical spine. The left sternocleidomastoid ro-tates the head to the right (Figure 4.4).� Position of patient: Seated, with you in front of

the patient.

Trapezius muscle(superior fibers)

Semispinaliscapitis muscle

Spleniuscapitismuscle

Splenius cervicis muscle

Figure 4.53 The cervical extensors.

Movement

Resistance

Figure 4.54 Testing cervical extension.

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64 The Cervical Spine and Thoracic Spine Chapter 4

Movement

Resistance

Figure 4.55 Testing lateral rotation. Resisting rotation of thehead to the left tests the right sternocleidomastoid muscle.

� Resisted test (Figure 4.55): To test the leftsternocleidomastoid muscle, you should resistright rotation of the head as follows. Place yourright hand on the patient’s left shoulder tostabilize the torso. Cup your left hand and place itso that the patient’s chin is in the palm of yourhand and your fingers cover the patient’s cheek.Ask the patient to rotate the head in a horizontalplane against the resistance of your left hand.Weakness of the sternocleidomastoid muscle may

be due to damage to the spinal accessory nerve. Com-pare left and right rotation.

Lateral Bending

The primary muscles of lateral bending are the scalenimuscles, and the intrinsic muscles of the neck assistthem. Lateral bending is not a pure motion and occursin conjunction with rotation of the cervical spine (seeFigure 4.4).� Position of patient: Seated, with you at the side.� Resisted test (Figure 4.56): Test left lateral

bending by placing your left hand on the patient’sleft shoulder to stabilize the torso. Place your righthand over the temporal aspect of the skull abovethe ear and ask the patient to tilt the ear towardthe shoulder as you resist this motion. Compareyour findings with those of the opposite side.

Movement Resistance

Figure 4.56 Testing lateral bending.

Neurological Examination of theCervical Spine and Upper Extremity

The Brachial Plexus

The brachial plexus (Figure 4.57) is composed of theC5, C6, C7, C8, and T1 nerve roots. In some indi-viduals, C4 is included, and this is referred to as aprefixed brachial plexus. In others, T2 is included,and this is called a postfixed brachial plexus.

During embryogenesis, the upper limb bud rotatesso that the upper nerve roots, C5 and C6, becomelateral in the arm, and the lower nerve roots, C8 andT1, become medial in the arm.

The five nerve roots that form the plexus join toform three trunks. C5 and C6 form the upper trunk,C7 forms the middle trunk, and C8 and T1 join toform the lower trunk. The trunks are located at thelevel of the clavicle.

Each trunk splits into an anterior and posteriordivision. The posterior divisions of the three trunksjoin to form the posterior cord. The anterior divisionsof the upper and middle trunks form the lateral cord,and the anterior division of the lower trunk continueson as the medial cord. The names posterior, lateral,

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65Chapter 4 The Cervical Spine and Thoracic Spine

MusculocutaneousLateralUpper

Axillary

Radial

Median

UlnarMedialLower

Middle

Long thoracicnerve

Upper subscapular

Lower subscapular

Thoracodorsal

Medial pectoral

Medial brachial cutaneous

Medial antebrachial cutaneous

Supr

asca

pula

r

C5

C6

C7

C8

T1

Roots Trunks Divisions Cords Branches

Roots Trunks Divisions Cords Branches

Clavicle

Posterior divisions

Anterior divisions

Dor

sal S

capu

lar

Late

ral p

ecto

ral

Second part ofthe axillary artery

Posterior

Figure 4.57 The brachial plexus. The anterior divisions of the upper and middle trunks form the lateral cord and the anterior divisionof the lower trunk forms the medial cord. The three posterior divisions of the trunk form the posterior cord.

and medial cords are based on their relationship tothe second part of the axillary artery and the axilla.

Portions of the lateral and medial cords join to formthe median nerve. The lateral cord continues on as themusculocutaneous nerve, and the medial cord contin-ues on as the ulnar nerve. The posterior cord branchesinto the axillary and radial nerves.

Upper Limb Tension Test (BrachialPlexus Tension Test, Elvey’s Test)

Performing a stretch test can test the componentnerves of the brachial plexus.

Median Nerve

The patient is supine with the scapula unobstructed.Depress the shoulder and maintain the position. Ex-tend the elbow and externally rotate the upper ex-tremity. Then extend the wrist, fingers, and thumb.If nerve root irritation is present, local palpation of

the nerve will increase the symptoms (Butler, 1991)(Figure 4.58).

Radial Nerve

The patient is supine with the scapula unobstructed.Depress the shoulder and maintain the position.Extend the elbow and internally rotate the upper ex-tremity. Then flex the wrist. Adding ulnar deviationand flexion of the thumb can enhance the position.If nerve root irritation is present, local palpation ofthe nerve will increase the symptoms (Butler, 1991)(Figure 4.59).

Adding cervical lateral bending away from the sidebeing tested and some adduction or extension of theshoulder can enhance both tests.

Ulnar Nerve

The starting position is the same as for the mediannerve. Extend the patient’s wrist and supinate the

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66 The Cervical Spine and Thoracic Spine Chapter 4

depression

whole armlateral rotation

shoulderabduction

elbowextension

wrist and fingerextension

Figure 4.58 The median nerve stretch test. (Adapted from Butler, 1991.)

forearm. Then fully flex the elbow and depress theshoulder. Add external rotation and abduct the shoul-der. The neck can be placed in lateral bending (Figure4.60).

The patient will likely complain of numbness orpain in the thumb, index, and middle fingers. This isa normal response. In 70% of normal patients, lat-eral bending away from the test side will exacerbatethe symptoms (Kenneally et al., 1988). The test isabnormal if the patient notes symptoms in the ringand little finger while the head is in neutral. To con-firm that the findings are secondary to root irritation,slacken the position of one of the peripheral joints and

then side bend the neck. If the symptoms return, thenerve root is probably the source (Kaltenborn, 1993).

Note that these maneuvers will be painful if thereis concomitant disease of the joints, ligaments, or ten-dons being mobilized. Refer to other chapters for spe-cific tests of these important structures.

Neurological Testing by Root Level

Neurological examination of the upper extremity isrequired to determine the location of nerve root im-pingement or damage in the cervical spine, as maybe caused by spondylosis or a herniated disc. By

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67Chapter 4 The Cervical Spine and Thoracic Spine

starting position,shoulder depression,elbow extensionas for median nerve

whole arminternal rotation

wrist flexion(gently)

wrist flexion(alternate position)

Figure 4.59 The radial nerve stretch test.

cervical lateral flexion

shoulder lateral rotation

elbow flexionwrist and finger extension, then

pronation orsupination (pronation

more sensitive)

shoulder abduction

Figure 4.60 The ulnar nerve stretch test. (Adapted from Butler, 1991.)

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68 The Cervical Spine and Thoracic Spine Chapter 4

examining the motor strength, sensation, and reflexesin the upper extremities, you can determine the rootlevel that is functioning abnormally. Recall that in thecervical spine, the C1 through C7 nerves exit abovethe vertebrae of the same number. The C8 nerve rootexits between the C7 and T1 vertebral bodies, and theT1 nerve root exits below the T1 vertebral body. Keymuscles, key sensory areas, and reflexes are tested foreach root level.

The C5 Root Level

MotorThe biceps muscle, which flexes the elbow, is inner-vated by the musculocutaneous nerve and representsthe C5 root level (Figure 4.61). Many authors alsoconsider the deltoid muscle, innervated by the axil-lary nerve, to be a key C5 muscle. The patient flexesthe elbow with the forearm fully supinated. Resist thismovement with your hand placed on the anterior as-pect of the mid forearm (see pp. 218–219, Figure 9.33for further information).

SensationThe key sensory area for C5 is the lateral antecubitalfossa.

ReflexThe biceps reflex is tested by placing your thumb onthe biceps tendon as the patient rests his or her fore-arm on yours. Take the reflex hammer and tap yourthumb briskly and observe for contraction of the bi-ceps and flexion of the elbow (see pp. 223–224, Fig-ures 9.43, 9.45 for further information).

The C6 Root Level

MotorThe wrist extensors (extensor carpi radialis longusand brevis) are innervated by the radial nerve andrepresent the C6 root level (Figure 4.62). Test wristextension by having the patient pronate the forearmand raise his or her hand, as if to say “stop.” Re-sist this motion with your hand against the posterioraspect of the metacarpals (see pp. 264, 266, Figure10.55 for further information).

SensationThe key sensory area for C6 is the anterior distalaspect of the thumb.

ReflexThe brachioradialis reflex is used to test the C6 nerveroot level. To test this reflex, have the patient rest the

forearm over yours, with the elbow in slight flexion.Use the flat end of the reflex hammer to tap the distalpart of the radius. The test result is positive whenthe brachioradialis muscle contracts and the forearmjumps up slightly (see pp. 223–224, Figure 9.45 forfurther information). The biceps reflex can also betested to evaluate the C6 root level because both theC5 and C6 roots innervate the biceps nerve roots.

The C7 Root Level

MotorElbow extension (triceps brachii) is examined to testthe C7 root level (Figure 4.63). The triceps is inner-vated by the radial nerve. Testing elbow extension isperformed by having the patient lie supine with theshoulder flexed to 90 degrees and the elbow flexed.Stabilize the arm with one hand placed just proximalto the elbow and apply a downward flexing resistiveforce with your other hand placed on the forearm justproximal to the wrist. Ask the patient to extend thehand upward against your resistance (see pp. 219–220, Figure 9.36 for further information).

SensationThe key sensory area for C7 is located on the anteriordistal aspect of the long finger.

ReflexThe triceps reflex tests the C7 nerve root level. Thistest is performed by having the patient’s forearm rest-ing over yours. Hold the patient’s arm proximal tothe elbow joint with your hand, to stabilize the upperarm. Ask the patient to relax. Tap the triceps tendonwith the reflex hammer just proximal to the olecranonprocess. The test result is positive when a contractionof the triceps muscle is visualized (see pp. 223–225,Figure 9.46 for further information).

The C8 Root Level

MotorThe long flexors of the fingers (flexor digitorum pro-fundus), which are innervated by the median and ul-nar nerves, are tested to evaluate the C8 root level(Figure 4.64). Finger flexion is tested by asking thepatient to curl the second through fifth fingers to-ward the palm as you place your fingers against thepatient’s palmar finger pads to prevent him or herfrom forming a fist (see p. 267, Figure 10.58 for fur-ther information).

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69Chapter 4 The Cervical Spine and Thoracic Spine

C5

Reflex

Motor

Sensation

T2

T1

C5

C6

C8 C7

Key C5sensory area

C5

Resistance

Movement

Anterior view

Figure 4.61 The C5 root level.

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70 The Cervical Spine and Thoracic Spine Chapter 4

C6

Reflex

Motor

Sensation

T2

T1

C5

C6

C8 C7

Key C6sensory area

C6

ResistanceMovement

Anterior view

Wrist extension (extensor carpiradialis longus and brevis)

Brachioradialis reflex

Figure 4.62 The C6 root level.

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71Chapter 4 The Cervical Spine and Thoracic Spine

C7

Reflex

Motor

Sensation

T2

T1

C5

C6

C8 C7

Key C7sensory area

C7

Resistance

Movement

Anterior view

Triceps reflex

Elbow extension (triceps brachii)

Figure 4.63 The C7 root level.

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C7

T1

Reflex

Motor

Sensation

T2

T1

C5

C6

C8 C7

Key C8sensory area

C8

“No Reflex”

Movement

Finger flexion (flexor digitorum profundis)

Anterior view

Figure 4.64 The C8 root level.

SensationThe key sensory area for C8 is located over the ante-rior distal aspect of the fifth finger.

ReflexThe finger flexor jerk is not often tested. The reader isreferred to neurological textbooks for further infor-mation regarding this reflex.

The T1 Root Level

MotorThe small and index finger abductors (abductor digitiquinti, first dorsal interosseous) are tested to eval-uate the T1 root level (Figure 4.65). These musclesare innervated by the ulnar nerve. The patient is ex-amined with the forearm pronated. Ask the patient tospread the fingers apart as you apply resistance to this

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73Chapter 4 The Cervical Spine and Thoracic Spine

T1

Reflex

Motor

Sensation

T2

T1

C5

C6

C8 C7Key T1sensory area

T1

"No Reflex"

(b)(a)

(c) (d)

MovementResistance

Anterior view

Finger abduction (abductor digiti quinti, first dorsal interosseous)

Figure 4.65 The T1 root level.

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74 The Cervical Spine and Thoracic Spine Chapter 4

T3T2

T4

T5

T6

T7

T8

T9

T10

T11

T12

Key sensory areas

Figure 4.66 The thoracic dermatomes and their key sensoryareas.

movement against the outer aspects of the proxi-mal phalanges of the index and little fingers (seepp. 269–272, Figures 10.66, 10.67, 10.70 for furtherinformation).

SensationThe key sensory area for T1 is located on the medialaspect of the arm just proximal to the antecubitalfossa.

ReflexNone.

T2 through T12 Root Levels

The thoracic root levels are tested primarily by sensa-tion, and the key sensory areas are located just to theside of the midline on the trunk as illustrated in Figure4.66. The only exception to this is the T2 key sensoryarea, which is located in the anteromedial aspect ofthe distal axilla.

Special Tests

Compression of the cervical spine from above is per-formed to reproduce or amplify the radicular symp-toms of pain or paresthesias that occur due to com-pression of the cervical nerve roots in the neuralforamina. The neural foramina become narrowed

when the patient extends the neck, rotates the neck, orlaterally bends the head toward the side to be tested.

Spurling Test

The Spurling test (Figure 4.67) is performed with thepatient’s neck in lateral flexion. The patient is sitting.Place your hand on top of the patient’s head and

Figure 4.67 The Spurling test. The patient’s head is flexedlaterally. Compression causes the neural foramina on the sameside to narrow in diameter.

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75Chapter 4 The Cervical Spine and Thoracic Spine

Figure 4.68 The distraction test. Distracting the cervical spineincreases the diameter of the neural foramina.

press down firmly or bang the back of your hand withyour fist. If the patient complains of an increase inradicular symptoms in the extremity, the test findingis positive. The distribution of the pain and abnormalsensation is useful in determining which root levelmay be involved.

Distraction Test

The distraction test (Figure 4.68) is performed in aneffort to reduce the patient’s symptoms by openingthe neural foramina. The patient is sitting. Place oneof your hands under the patient’s chin and the otherhand around the back of the head. Lift the patient’shead slowly to distract the cervical spine. If the pa-tient notes relief or diminished pain, the test finding ispositive for nerve root damage. Be careful to protectthe temporomandibular joint when pulling up on thechin.

Upper Cervical Instability Testing

Sharp-Purser Test

The patient is placed in the sitting position. Ask thepatient to flex their head. Extreme caution should beexercised with upper cervical stability testing since it

is possible to compromise the spinal cord. The initialpositive finding is the reproduction of the patient’scomplaints. The therapist can postulate that the symp-toms are caused by incompetency of the transverseligament allowing for forward translation of C1 onC2. The therapist then stabilizes the spinous processesof C2 using their thumb and index finger and simulta-neously translates the patient’s head posteriorly withtheir forearm anterior to the patient’s forehead. Thepositive finding is the reduction of the patient’s symp-toms. The assumption is that the unstable upper cer-vical spine has been reduced, thus relieving the com-pression on the spinal cord (Figure 4.69) (Aspinall,1990).

Aspinall’s Transverse Ligament Test

If the Sharp-Purser test is negative and you have suspi-cions that the patient has an upper cervical instabilityof the transverse ligament, you can perform this addi-tional test. This test can compromise the spinal cord,therefore extreme caution should be used. The patientis placed in the supine position stabilizing the occiputin flexion. Apply a gradually increasing pressure overthe posterior aspect of C1. Your direction of forceis from posterior to anterior. The patient may per-ceive a feeling of a “lump” in their throat which canincrease during testing. This sensation or movementbetween the atlas and the occiput are considered tobe positive findings. Check for any vertebral arterysymptoms (Figure 4.70) (Aspinall, 1990).

Figure 4.69 Sharp-Purser test. Stabilize at C2 and translate thehead posteriorly.

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76 The Cervical Spine and Thoracic Spine Chapter 4

Figure 4.70 Aspinall’s transverse ligament test. Direct forcegradually from posterior to anterior.

Alar Ligament Stress Tests

Lateral Flexion Alar Ligament StressTest

The patient is in the supine or sitting position. Use onehand to stabilize the spinous process of C2 and thenpassively side bend the patient’s neck in the neutralposition, followed by sidebending in both flexion andextension. The positive finding is movement betweenthe head and neck. If the alar ligament is intact, onlya minimal amount of movement should be present(Figure 4.71) (Aspinall, 1990).

Rotational Alar Ligament Stress Test

The patient is in the supine or sitting position. Useone hand to stabilize the spinous process of C2 andthen passively rotate the patient’s head in both di-rections, starting with the asymptomatic side. Nor-mally, only 20–30 degrees of rotation can occur if theligament is stable. If excessive movement is present,the test is considered positive for increased laxity ofthe contralateral alar ligament (Figure 4.72) (Magee,2002).

Lhermitte’s Sign

Lhermitte’s sign (Figure 4.73) is used to diagnosemeningeal irritation and may also be seen in multi-ple sclerosis. The patient is sitting. Passively flex thepatient’s head forward so that the chin approachesthe chest. If the patient complains of pain or pares-thesias down the spine, the test result is positive. The

Figure 4.71 Lateral flexion alar ligament stress test. Attemptpassive sidebending of the head in neutral, flexion andextension.

Figure 4.72 Rotational alar ligament stress test. Stabilize at C2.Passively rotate the head, first to the asymptomatic side andthen to the other side.

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77Chapter 4 The Cervical Spine and Thoracic Spine

Figure 4.73 Lhermitte’s sign.

patient may also complain of radiating pain into theupper or lower extremities. Flexion of the hips canalso be performed simultaneously with head flexion(i.e., with the patient in the long sitting position).

Vertebral Artery Test

Movement of the cervical spine affects the vertebralarteries because they course through the foramina ofthe cervical vertebrae. These foramina may be stenoticand extension of the cervical spine may cause symp-toms such as dizziness, light-headedness, or nystag-mus. The vertebral artery test is performed prior tomanipulation of the cervical spine, to test the patencyof the vertebral arteries. The patient is most easilytested in a supine position. Place the patient’s headand neck in the following positions passively for atleast 30 seconds, and observe for symptoms or signs aspreviously described: head and neck extension, headand neck rotation to the right and left, head and neckrotation to the right and left with the neck in exten-sion (with or without lateral bending to the oppositeside). Take time between each position to allow thepatient to reequilibrate. In general, turning the head

Figure 4.74 Vertebral artery test. This test should be performedif cervical manipulation is being contemplated.

to the right will affect the left vertebral artery moreso and vice versa (Figure 4.74).

Shoulder Abduction (Relief) Test(Bakody’s Sign)

The patient is in either the sitting or supine position.Ask the patient to abduct their symptomatic arm andbring their hand to the top of their head. The positivefinding is the relief of the symptoms by shortening thelength of the neural tissues and therefore decreasingpressure on the nerve roots. This is usually associatedwith cervical radiculopathy from a C4 to C5 or C5 toC6 disc herniation. The test is usually negative if thecomplaints are caused by spondylosis (Figure 4.75)(Magee, 2002).

Valsalva Maneuver

The patient can be in any position. The Valsalva ma-neuver occurs when the patient exhales with consid-erable force and maintains their mouth in a closedposition. This maneuver increases the intrathoracicpressure. The positive finding is increased symptomsin the upper extremities if the patient has any typeof space-occupying lesion (tumor, disc) creating in-creased pressure on the spinal cord.

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78 The Cervical Spine and Thoracic Spine Chapter 4

Figure 4.75 Shoulder abduction (relief) test (Bakody’s sign).Radicular pain is relieved by this position.

Scalp Ears

Face

Jaw andTeeth

Throat

Figure 4.76 The scalp, ears, face, jaw, teeth, and throat may allrefer pain to the cervical spine.

Figure 4.77 Anteroposterior view of the cervical spine.

Figure 4.78 Lateral view of the cervical spine.

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79Chapter 4 The Cervical Spine and Thoracic Spine

Figure 4.79 Oblique view of the cervical spine.

Referred Pain Patterns

Pain in the cervical spine may result from disease orinfection in the throat, ears, face, scalp, jaw, or teeth(Figure 4.76).

Radiological Views

Radiological views of the cervical spine are providedin Figures 4.77–4.81.

V = Vertebral bodyD = Intervertebral discSc = Spinal cordS = Spinous process

Figure 4.80 Magnetic resonance image of the cervical spine,sagittal view.

N = Neural foramenP = Pedicle of vertebral archI = Intervertebral disc spaceF = Facet jointsT = T1 transverse process

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S A M P L E E X A M I N A T I O N

History: 45-year-oldpatient who presents with pain at

the superomedial border of the rightscapula, aggravated with rotation of thehead to the right. The patient gives ahistory of being evaluated after a motorvehicle accident in which he was thedriver of a car struck from behind,airbags deployed. He recalls looking inthe rear view mirror just as the car wasstruck. There was no loss ofconsciousness reported. He wasevaluated and released from his localemergency room, where x-rays werereported to show no fractures ordislocation, but noted “straightening ofthe cervical lordosis.” The patient has noprior history related to his neck.

Physical Exam: 45-year-old male,ambulatory, wearing a soft collar,sweater, and tied shoes. There was noincrease in symptoms on verticalcompression or distraction of the cervicalspine. There was limitation of 50% of therange of motion of the cervical spine inall planes due to pain. Resistive testingof the upper extremities was withinnormal limits. Sensation was intact inboth upper extremities. Deep tendonreflexes were brisk and symmetrical.

There was no evidence of bowel andbladder dysfunction. Cervical mobilitytesting was not restricted. Flexibilitytesting was restricted in the righttrapezius. The left trapezius and bilateralsternocleidomastoids revealed normalflexibility testing. He had tenderness topalpation over the right paracervical andtrapezius muscles with trigger points.Vascular testing was negative.

Presumptive Diagnosis: Acuteparacervical/trapezial strain.

Physical Examination Clues: (1) Thepatient was ambulatory, indicating nogross myelopathy. (2) He was dressedwith a sweater and tied shoes, and allneurological testing was negativeindicating no compromise of movementor motor function in the upperextremities. (3) He had well-localizedtenderness, identifying injury to specificanatomic structures. (4) He had negativefindings with vertical compression anddistraction and intact mobility testing ofthe cervical spine, indicating no irritationof intervertebral joints or cervical rootsexiting from the spinal foramina. (5) Hehad negative neurologic and vascularsigns in the upper extremities, indicatinga less serious degree of injury.

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Paradigm for a herniated cervical disc

A 45-year-old male presents 2 days after the car he was driving was struck from behind. At the time of the accident, he hadimmediate pain in the posterior aspect of his neck which radiated down the entire right upper extremity into the small finger of hisright hand. He noted weakness in his grip and loss of dexterity in fine motor movements of the digits of his right hand. There wasalso a sensation of “pins and needles” in the ring and small fingers. He gave no history of complaints relative to his head or neckexisting prior to the accident.

On physical examination, the patient is able to ambulate independently without support. He holds his neck in a rigid posture andresists neck rotation in any direction. He has full active movement of his upper extremities, but has weakness in the grip of hisright hand. Biceps and triceps reflexes appear to be equal bilaterally. However, there is diminished light touch on the ulnar aspectof the hand. Pain is produced on vertical compression of the cervical spine and with passive cervical spine extension. The patientcan actively forward flex his neck 20 degrees without causing himself distress. His lower extremity exam is unremarkable. X-raysdemonstrate loss of cervical lordosis and narrowing of the C6–C7 disc space without fracture or displacement of the bony structures.There are signs of mild early osteoarthritis of the facet joints at the mid cervical levels.

This is a paradigm for an acute herniated cervical disc because of:

A history of acute traumaNo prior history of symptomsImmediate onset of pain and neurological symptoms at the time of injuryInability to extend the cervical spineLimited painless active flexion of the cervical spinePain with vertical compressionMotor and sensory deficits in a specific distribution

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C H A P T E R 5

The Temporomandibular Joint

F U R T H E R I N F O R M A T I O N

Please refer to Chapter 2 foran overview of the sequence of a

physical examination. For purposes oflength and to avoid having to repeatanatomy more than once, the palpationsection appears directly after the sectionon subjective examination and before any

section on testing, rather than at the endof each chapter. The order in which theexamination is performed should bebased on your experience and personalpreference as well as the presentation ofthe patient.

Functional Anatomy of theTemporomandibular Joint

The TMJ is a synovial articulation. It is formed by thedomed head of the mandible resting in the shallowmandibular fossa at the inferolateral aspect of theskull beneath the middle cranial fossa. Similar to theacromioclavicular joint of the shoulder, the articularsurfaces of the temporomandibular joint (TMJ) areseparated by a fibrous articular disc. The surface areaof the mandibular head is similar in size to that ofthe tip of the small finger, yet it is subjected to manyhundreds of pounds of compressive load with eachbite of an apple or chew of a piece of meat.

Downward movement of the jaw is accomplishedby a combination of gravity and muscular effort. Themasseter and temporalis muscles perform closing ofthe mouth. The temporalis muscle inserts on the coro-noid process. As such it functions very much like theflexors of the elbow. The masseter is attached to thelateral surface of the mandible along its posterior in-ferior angle. The mandible is stabilized against the in-fratemporal surface of the skull by contraction of thepterygoid muscles. The lateral pterygoid is attacheddirectly onto the medial aspect of the articular disc.

There are numerous neurological structures aboutthe TMJ. Branches of the auricular temporal nerveprovide sensation to the region. The last four cranialnerves (IX, X, XI, and XII) lie deep and in close prox-imity to the medial surface of the TMJ.

Given the great magnitude of repetitive forcestraversing the relatively small articular surfaces of theTMJ, it is remarkable that it normally functions aswell as it does over many years of use. It is equallyunderstandable why when the anatomy of the TMJhas been altered this articulation may become an ex-tremely painful and challenging problem.

Trauma to the face and jaw may cause subluxationor dislocation of the TMJ. Untreated compromise ofligamentous stability will result, just as in the knee,in the rapid development of premature degenerativearthritis of the joint.

Instability of the TMJ may also be the result ofexuberant synovitis secondary to inflammatory dis-ease, such as rheumatoid arthritis, stretching capsularligaments. The resultant instability causes further in-flammation, swelling, pain and compromise of jointfunction.

Damage to the articular disc either by directtrauma, inflammation or simple senescence exposesthe articular surfaces of the TMJ to excessive loads.

82

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83Chapter 5 The Temporomandibular Joint

This is yet another pathway leading to the prematureand rapid onset of a painful osteoarthritic joint.

Given the density of neurological structures in closeproximity to the TMJ, pain referred from the TMJmay be perceived about the face, scalp, neck, andshoulder. Complaints in these areas resulting fromTMJ pathology are often difficult to analyze. Thissituation often leads to incomplete or inaccurate di-agnoses and inappropriate treatment plans. As withother pathological articular conditions, a greater like-lihood of success with treatment requires a thoroughknowledge of local anatomy together with an accu-rate history and a meticulous physical examination ofthe patient.

The TMJ is a synovial joint, lined with fibrocarti-lage and divided in half by an articular disc. The TMJsmust be examined together along with the teeth.

Observation

Note the manner in which the patient is sitting inthe waiting room. Notice how the patient is postur-ing the head, neck, and upper extremities. Refer toChapter 4 (pp. 34–36) for additional questions re-lating to the cervical spine. Is there facial symme-try? Is the jaw in the normal resting position (mouthslightly open but lips in contact)? How is the chinlined up with the nose in the resting position and infull opening? (Iglarsh and Snyder-Mackler, 1994) Isthe patient supporting his or her jaw? Are they havingdifficulty talking and opening their mouth? Are theteeth in contact or slightly apart? Is there a crossbite,underbite, overbite or malocclusion? Patients with acrossbite present with their mandibular teeth later-ally displaced to their maxillary teeth. Patients withan underbite present with their mandibular teeth ante-riorly displaced to their maxillary teeth. Patients withan overbite present with their maxillary teeth extend-ing below the mandibular teeth. Is hypertrophy ofthe masseters present? Is there normal movement ofthe tongue? The patient should be able to move thetongue up to the palate, protrude and click it. Ob-serve the tongue. Is there scalloping on the edges ordoes the patient bite the tongue? This may indicatethat the tongue is too wide or rests between the teeth(Iglarsh and Snyder-Mackler, 1994).

What is the resting position of the tongue and whereis it when the patient swallows? The normal restingposition of the tongue should be on the hard palate.Are all the patient’s teeth intact? Do you notice anyswelling or bleeding around gums?

Observe the patient as he or she assumes the stand-ing position and note their posture. Pay particularattention to the position of the head, cervical and tho-racic spine. Additional information relating to postureof the spine can be found in Chapters 2 and 4 (pp. 16,27 and pp. 34–36). Pain may be altered by changes inposition so watch the patient’s facial expression forindications as to their pain level.

Subjective Examination

The TMJs are extremely well utilized and are openedapproximately 1800 times during the day (Harrison,1997). These joints are essential in our ability to eat,yawn, brush our teeth, and talk. They are intimatelyrelated to the head and cervical spine and should beincluded in their examination. Approximately 12.1%of Americans experience head and neck pain (Iglarshand Snyder-Mackler, 1994). Unfortunately, however,these problems are frequently overlooked in the ex-amination process.

You should inquire about the nature and locationof the patient’s complaints and their duration and in-tensity. Note if the pain travels up to the patient’shead or distally to below the elbow. The behaviorof the pain during the day and night should also beaddressed. Is the patient able to sleep or is he or sheawakened during the night? What position does thepatient sleep in? How many pillows do they use?What type of pillow is used? Additional subjectivequestions relating to the cervical spine can be foundin Chapter 4 (p. 36) and in Box 2.1 (p. 15) for typicalquestions of subjective examination.

Does the patient report trauma to the TMJ? Wasthe patient hit in the jaw or did he or she fall on theirface? Did he or she bite down on something hard?Was the mouth held open excessively for a prolongedperiod of time (at the dentist’s office)? Did the patientoveruse the joint by talking for a prolonged periodof time or chewing on a tough piece of meat? Wastraction applied to the neck, compressing the jaw withpart of the harness?

Does the patient experience pain on opening orclosing of the mouth? Pain in the fully opened po-sition may be from an extra-articular problem, whilepain with biting may be an intra-articular problem(Magee, 2002). Does the patient complain of clickingwith movement? Crepitus may be indicative of degen-erative joint disease. Has the patient ever experiencedlocking of the jaw? This may be due to displacementof the disc. If the jaw locks in the open position, the

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84 The Temporomandibular Joint Chapter 5

TMJ might have dislocated (Magee, 2002). Is therelimited opening of the mouth? Does the patient havepain with yawning, swallowing, speaking, and shout-ing? Is there pain while eating? Does the patient chewequally on both sides of their mouth? Has the patienthad previous dental interventions? Teeth may havebeen pulled or ground down. Does the patient clenchor grind (bruxism) his or her teeth? If the front teethare in contact and the back teeth are not, there isa malocclusion. Has the patient worn braces? Whenand for how long? The braces will have altered the oc-clusion. Has the patient been wearing a dental appli-ance? What type of appliance are they using and howlong have they been wearing it? Has the appliancebeen helpful in alleviating the patient’s symptoms?

Special Questions

Was the patient breast or bottle-fed (Iglarsh andSnyder-Mackler, 1994)? Did the patient suck on apacifier or on their fingers and for how long? Is thepatient a mouth breather? This alters the position ofthe tongue on the palate. Does the patient complainof problems swallowing? This may be due to cranialnerve problems of the CN VII (facial nerve) and CN V(trigeminal nerve). Earaches, dizziness, or headachesmay be due to TMJ, inner ear, or upper cervical spineproblems.

Consider the factors that make the patient’s com-plaints increase or ease. He or she may presentwith the following complaints: headaches, dizziness,seizures, nausea, blurred vision, nystagmus, or stuffi-ness. How easily is the patient’s condition irritatedand how quickly can the symptoms be relieved? Theexamination may need to be modified if the patientreacts adversely with very little activity and requiresa long time for relief.

The patient’s disorder may be related to age, gen-der, ethnic background, body type, static and dy-namic posture, occupation, leisure activities, hobbies,and general activity level. Psychosocial issues, stresslevel, and coping mechanisms should be addressed.It is important to inquire about any change in dailyroutine and any unusual activities that the patient hasparticipated in.

Gentle Palpation

The palpatory examination is started with the patientin the sitting position.

You should first search for areas of localized ef-fusion, discoloration, birthmarks, open sinuses ordrainage, incisional areas, bony contours and align-ment, and muscle girth and symmetry.

Remember to use the dominant eye when checkingfor alignment or symmetry. Failure to do this can alterthe findings. You should not have to use deep pressureto determine areas of tenderness or malalignment. Itis important to use firm but gentle pressure, whichwill enhance your palpatory skills. By having a soundbasis of cross-sectional anatomy, you should not haveto physically penetrate through several layers of tissueto have a good sense of the underlying structures. Re-member, if the patient’s pain is increased at this pointin the examination, the patient will be very reluctantto allow you to continue, or may become more limitedin his or her ability to move.

Palpation is most easily performed with the patientin a relaxed position. Although the initial palpationmay be performed with the patient sitting, the supineand prone positions allow for easier access to the bonyand soft-tissue structures.

The easiest position for palpation of the posteriorstructures is with the patient supine and the examinersitting behind the patient’s head. You can rest yourforearms on the table, which enables you to relax yourhands during palpation.

Posterior Aspect

Bony Structures

Mastoid ProcessesPlease refer to Chapter 4 (pp. 38–39, Figure 4.8).

Transverse Processes of C1Please refer to Chapter 4 (pp. 38, 40, Figure 4.9).

Soft-Tissue Structures

TrapeziusPlease refer to Chapter 4 (pp. 44–45, Figure 4.19).

Suboccipital MusclesPlease refer to Chapter 4 (pp. 44–45, Figure 4.20).

Semispinalis Cervicis and CapitisPlease refer to Chapter 4 (p. 63, Figure 4.53).

Greater Occipital NervesPlease refer to Chapter 4 (pp. 45–46, Figure 4.20).

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85Chapter 5 The Temporomandibular Joint

Ligamentum NuchaePlease refer to Chapter 4 (p. 46, Figure 4.21).

Levator ScapulaePlease refer to Chapter 4 (pp. 46, 176) and Figure8.71.

Anterior Aspect

To facilitate palpation of the anterior aspect of theneck, the patient should be in the supine position.The head should be supported and the neck relaxed.Make sure that the neck is in neutral alignment.

Bony Structures

MandibleRun your fingers along the entire bony border ofthe mandible starting medial and inferior to the ears,move inferiorly to the angle of the mandible and thenanteriorly and medially. Palpate both sides simulta-neously (Figure 5.1).

TeethWearing gloves, the examiner is able to retract themouth and examine the teeth. Note if any teeth aremissing or loose, the type of bite, and any malocclu-sion.

Mandible

Figure 5.1 Palpation of the mandible.

HyoidPlease refer to Chapter 4 (p. 47, Figure 4.22).

ThyroidPlease refer to Chapter 4 (pp. 47–48, Figure 4.23).

Cervical SpinePlease refer to Chapter 4 (pp. 36–53) for a full de-scription of palpation of all bony prominences andsoft-tissue structures.

Soft-Tissue Structures

TemporalisPalpate on the lateral aspect of the skull over thetemporal fossa. Ask the patient to close their mouthand you will be able to feel the muscle contract. Spasmof the muscle may be a cause of headaches (Figure5.2).

Lateral and Medial PterygoidPlace your gloved little or index finger between thecheek and the superior gum. Travel past the molaruntil you reach the neck of the mandible. Ask the pa-tient to open their jaw and you will note tightnessin the muscle. You will not be able to differentiatebetween the lateral and medial portions of the mus-cle (Iglarsh and Snyder-Mackler, 1994). Spasm in the

Temporalismuscle

Figure 5.2 Palpation of the temporalis muscle.

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86 The Temporomandibular Joint Chapter 5

Figure 5.3 Palpation of the pterygoid muscles.

muscle can cause pain in the ear and discomfort whileeating (Figure 5.3).

MasseterPlace your gloved index finger in the patient’s mouthand slide the finger pad along the inside of the cheekapproximately halfway between the zygomatic archand the mandible. Simultaneously, palpate the exter-nal cheek with your index thumb. Ask the patient toclose their mouth and you will feel the muscle contract(Figure 5.4).

Sternocleidomastoid MusclePlease refer to Chapter 4 (p. 51, Figure 4.32).

Scaleni MusclesPlease refer to Chapter 4 (pp. 51–52, Figure 4.32).

The Suprahyoid MuscleCan be palpated externally inferior to the chin, in thearch of the mandible (Rocabado and Iglarsh, 1991).The infrahyoid muscle can be palpated on either sideof the thyroid cartilage. A contraction of the muscle isfelt if you gently resist cervical flexion at the beginningof the range (Rocabado and Iglarsh, 1991). Spasmin the suprahyoid muscle can elevate the hyoid andcreate difficulty swallowing. Pain can also be felt inthe mouth near the muscles’ origin (Figure 5.5).

(a)

(b)

Figure 5.4 Palpation of the masseter muscle.

Trigger Points of the TMJ Region

Myofascial pain of the TMJ region is quite commonand can occur due to dental malocclusion, bruxism,excessive gum chewing, prolonged mouth breathing(while wearing diving gear or a surgical mask), andtrauma. Activation of these trigger points can causeheadaches and can mimic TMJ intrinsic joint disease.

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87Chapter 5 The Temporomandibular Joint

(a)

(b)

Figure 5.5 Palpation of the suprahyoid and infrahyoid muscles.

The masseter and lateral pterygoid are the mostcommonly affected, followed by the temporalis andmedial pterygoid muscles. The location and referredpain zones for trigger points in these muscles areillustrated in Figures 5.6–5.9.

Figure 5.6 Trigger points of the lateral pterygoid, shown withcommon areas of referred pain.

Active Movement Testing

Have the patient sit on a stool in a well-lit area of theexamination room. Shadows from poor lighting willaffect your perception of the movement. The patientshould be appropriately disrobed so that you can ob-serve the neck and upper thoracic spine. You shouldwatch the patient’s movements from the anterior, pos-terior, and both lateral aspects. While observing thepatient move, pay particular attention to his or herwillingness to move, the quality of the motion, andthe available range. Lines in the floor may serve asvisual guides to the patient and alter the movementpatterns. It may be helpful to ask the patient to repeatmovements with the eyes closed. A full assessment ofcervical movement should be performed first. (Referto Chapter 4, pp. 53–54, 56–58 for a full description.)Note the position of the patient’s mouth with all thecervical movements.

Assess the active range of motion of the TMJs.Active movements of the TMJs include: opening ofthe mouth, closing of the mouth, protrusion, and lat-eral mandibular deviation to the right and left. Whileobserving the patient move, pay particular attentionto his or her willingness to move, the quality of themotion, the available range, and any deviations thatmight be present.

Movement can be detected by placing your fourthor fifth fingers in the patient’s ears to palpate thecondyles. The TMJs can also be palpated externally,by placing your index finger anterior to the ear.

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88 The Temporomandibular Joint Chapter 5

(a) (b)

(c) (d)

Figure 5.7 Trigger points of the masseter, shown with common areas of referred pain.

Note any clicking, popping, or grinding with themovement. Pain or tenderness, especially on closing,is indicative of posterior capsulitis (Magee, 2002).During opening of the jaw, the condyle must moveforward. Full opening requires that the condylesrotate and translate equally (Magee, 2002). If thissymmetrical movement does not occur, you will notea deviation. Loss of motion can be secondary torheumatoid arthritis, congenital bone abnormalities,soft tissue or bony ankylosis, osteoarthritis, andmuscle spasm (Hoppenfeld, 1976).

The TMJ is intimately related to both the cervicalspine and the mouth. To be complete in the evalua-tive process, cervical active range of motion shouldbe included in the examination of the TMJ. Details

of cervical spine testing can be found in Chapter 4(pp. 53–54, 56–58, Figure 4.43).

Opening of the Mouth

Ask the patient to open their mouth as far as they can.Both TMJs should be working simultaneously andsynchronously, allowing the mandible to open evenlywithout deviation to one side. The clinician shouldpalpate the opening by placing their fifth fingers intothe patient’s external auditory meatus with the fingerpads facing anteriorly and should feel the condylesmove away from their fingers. If one’s TMJ is hypo-mobile, the jaw will deviate to that side. Normal rangeof motion of opening is between 35 and 55 mm from

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89Chapter 5 The Temporomandibular Joint

(a) (b)

(c) (d)

Figure 5.8 Trigger points of the temporalis, shown with common areas of referred pain.

the rest position to full opening (Magee, 2002). Theopening should be measured between the maxillaryand mandibular incisors. If the jaw opens less than25–33 mm, it is classified as being hypomobile. Ifopening is greater than 50 mm, the joint is classifiedas hypermobile (Iglarsh and Snyder-Mackler, 1994).A quick functional test is performed by asking thepatient to place—two to three flexed fingers, at theirknuckles, between the upper and lower teeth (Figure5.10).

Closing of the Mouth

The patient is instructed to close their mouth from fullopening. The clinician should palpate the opening by

placing their fifth fingers into the patient’s externalauditory meatus with the finger pads facing anteri-orly and should feel the condyles move toward theirfingers.

Protrusion of the Mandible

The patient should be instructed to jut the jaw ante-riorly so that it protrudes out from the upper teeth.The movement should not be difficult for the patientto perform. Measure the distance the lower teeth pro-trude anteriorly past the upper teeth. Normal rangeof motion for this movement should be between 3and 6 mm from the resting position to the protrudedposition (Iglarsh and Snyder-Mackler, 1994; Magee,2002) (Figure 5.11).

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90 The Temporomandibular Joint Chapter 5

(a)

(b)

Medialpterygoidmuscle

Figure 5.9 Trigger points of the medial pterygoid, shown withcommon areas of referred pain.

Lateral Mandibular Deviation

The patient should be instructed to disengage his orher bite and then move the mandible first to oneside, back to the midline, and then to the other side.The clinician should pick points on both the upperand lower teeth to be used as markers for measuringthe amount of lateral deviation. The normal amountof lateral deviation is 10–15 mm (Magee, 2002),approximately one-fourth of the range of opening(Iglarsh and Snyder-Mackler, 1994). Lateral devia-tion to one side from the normal resting position oran abnormal degree of deviation may be caused bymuscle dysfunction of the masseter, temporalis, orlateral pterygoid, or problems with the disc or lat-eral ligament on the opposite side from which the jawdeviates (Magee, 2002) (Figure 5.12).

(a)

(b)

Figure 5.10 Observe as the patient opens their mouth as far asthey can. Both TMJ should be working simultaneously andsynchronously allowing the mandible to open evenly withoutdeviation to one side. A quick functional test is performed byasking the patient to place two to three flexed fingers, at theirknuckles, between the upper and lower teeth.

Measurements of TMJ movements can be made byusing a ruler marked in millimeters, or a Boley gauge(Iglarsh and Snyder-Mackler, 1994).

Assessing the Freeway Space

The freeway space is the point within the openpack position where the soft tissues of the temporo-mandibular joints are the most relaxed. The patientcan achieve this position by leaving their tongue ontheir hard palate and leaving the mandible slightlydepressed. You can assess the freeway position byplacing your fourth finger’s pad facing anteriorly

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91Chapter 5 The Temporomandibular Joint

Figure 5.11 Observe as the patient juts the jaw anteriorly sothat it protrudes out from the upper teeth.

into the patient’s external auditory meatus as thepatient slowly closes their mouth. The freewayspace is achieved when you palpate the mandibularheads touching your finger pads (Iglarsh and Snyder-Mackler, 1994). The normal measurement is 2–4mm (Harrison, 1997) (Figure 5.13).

Measurement of Overbite

Ask the patient to close their mouth. Mark the pointwhere the maxillary teeth overlap the mandibularteeth. Ask the patient to open their mouth and mea-sure from the top of the teeth to the line that youmarked. This measurement is usually 2–3 mm (Iglarshand Snyder-Mackler, 1994; Rocabado, unpublisheddata, 1982) (Figure 5.14).

Measurement of Overjet

Overjet is the distance that the maxillary teeth pro-trude anteriorly over the mandibular teeth. Ask thepatient to close their mouth and measure from un-derneath the maxillary incisors to the anterior sur-face of the mandibular incisors. This measurement isusually 2–3 mm (Iglarsh and Snyder-Mackler, 1994;Rocabado, unpublished data, 1982) (Figure 5.14).

Figure 5.12 Observe as the patient disengages his or her biteand then moves the mandible first to one side, back to themidline, and then to the other side.

Mandibular Measurement

Measure from the back of the TMJ to the notch of thechin. Compare both sides. If one side is asymmetricalfrom the other a structural or developmental defor-mity may be present. Normal measurements should bebetween 10 and 12 cm (Magee, 2002) (Figure 5.15).

Figure 5.13 The freeway space is the point within the openpack position where the soft tissues of the temporomandibularjoints are the most relaxed.

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92 The Temporomandibular Joint Chapter 5

A

B

Overbite

Overjet

Figure 5.14 Overbite is the point where the maxillary teethoverlap the mandibular teeth. Overjet is the distance that themaxillary teeth protrude anteriorly over the mandibular teeth.

Swallowing and Tongue Position

The patient is instructed to swallow with their tonguein the normal relaxed position. The gloved clinicianseparates the patient’s lips and observes the positionof the tongue. The normal position should be at thetop of the palate (Figure 5.16).

Passive Movement Testing

Passive movement testing can be divided into twocategories: physiological movements (cardinal plane),which are the same as the active movements, and mo-bility testing of the accessory (joint play, component)movements. Using these tests helps to differentiate thecontractile from the noncontractile (inert) elements.These elements (ligaments, joint capsule, fascia,bursa, dura mater, and nerve root) (Cyriax, 1979) are

Figure 5.15 Measurement of the mandible is taken from theback of the TMJ to the notch of the chin. Compare themeasurement of both sides.

stretched or stressed when the joint is taken to the endof the available range. At the end of each passive phys-iological movement, you should sense the end feel anddetermine whether it is normal or pathological.

Passive Physiological Movements

Passive testing of the physiological movements areeasiest if they are performed with the patient in thesitting position. Testing of the cervical spine move-ments is described in Chapter 4 on the Cervical Spine(pp. 58–62). Passive movement testing of the TMJ israrely performed unless the clinician is examining theend feel of the movement. The end feel of opening isfirm and ligamentous, while the end feel of closing ishard, teeth to teeth.

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93Chapter 5 The Temporomandibular Joint

Figure 5.16 The normal position of the tongue is at the top ofthe palate.

Mobility Testing of AccessoryMovements

Mobility testing of accessory movements will give youinformation about the degree of laxity or hypomobil-ity present in the joint and the end feel. The patientmust be totally relaxed and comfortable to allow youto move the joint and obtain the most accurate infor-mation.

Distraction of the TMJ

The patient is in the sitting position with the examinerto one side of the patient. The clinician places theirgloved thumb into the patient’s mouth on the superioraspect of the patient’s molars and pushes inferiorly.The examiner’s index finger simultaneously rests onthe exterior surface of the mandible and pulls infe-riorly and anteriorly. The test should be performedunilaterally with one hand testing mobility and theother hand available to stabilize the head. The endfeel should be firm and abrupt (Figure 5.17).

Resistive Testing

Movements of the jaw are complex due to the free-dom of movement allowed by the TMJs. The cervi-cal muscles serve to stabilize the head as the muscles

Figure 5.17 Mobility testing of distraction of thetemporomandibular joint.

of mastication act on the mandible. The temporalisand masseter are the main closing muscles. The in-ferior portion of the lateral pterygoid functions toopen the mouth and protrude the mandible. The su-perior portion of the lateral pterygoid stabilizes themandibular condylar process and disc during closureof the mouth. Extreme weakness of these muscles isunusual except in cases of central nervous system ortrigeminal nerve damage.

Jaw Opening

The primary mouth opener is the lateral pterygoid(inferior portion) (Figure 5.18). The anterior head of

Lateralpterygoidmuscle

Upperhead

Lowerhead

Medial pterygoid muscle

Figure 5.18 Lateral and medial pterygoid muscles.

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94 The Temporomandibular Joint Chapter 5

Masseter muscle(superficial)

Figure 5.19 Masseter.

the digastric muscle assists this muscle.� Position of patient: Sitting, facing you.� Resisted test: Place the palm of your hand under

the patient’s chin and ask them to open theirmouth from the closed position as you resist theireffort. Normally, the patient will be able toovercome maximal resistance.

Jaw Closing

The masseter (Figure 5.19) and temporalis (Figure5.20) are the primary muscles that close the mouth.

Temporalismuscle

Coronoidprocess

Figure 5.20 Temporalis.

Figure 5.21 Jaw jerk. Make sure the patient is relaxed.

The medial pterygoid (Figure 5.18) assists them.� Position of patient: Sitting, facing you.� Resisted test: Ask the patient to close their mouth

tightly and then attempt to open their jaw bypulling down on the mandible.

Reflex Testing

Jaw Jerk

The trigeminal (fifth cranial) nerve mediates the jawreflex. This reflex results from contraction of themasseter and temporalis muscles following a tapon the chin (mandible). To perform the reflex, thepatient should relax the jaw in the resting position,with the mouth slightly open. Place your index andlong fingers under the lip, on the chin, and tap yourfingers with the reflex hammer (Figure 5.21). A nor-mal response is closure of the mouth. An exaggeratedresponse indicates an upper motor neuron lesion.A reduced response indicates a trigeminal nervedisorder.

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C H A P T E R 6

The Lumbosacral Spine

F U R T H E R I N F O R M A T I O N

Please refer to Chapter 2for an overview of the sequence of

a physical examination. For purposes oflength and to avoid having to repeatanatomy more than once, the palpationsection appears directly after the sectionon subjective examination and before any

section on testing, rather than at the endof each chapter. The order in which theexamination is performed should bebased on your experience and personalpreference as well as the presentation ofthe patient.

Observation

The lumbar spine and sacroiliac joints are intimatelyrelated. They function together to support the upperbody and transmit weight through the pelvis to thelower extremities. In addition, they receive groundreaction forces through the lower extremities at thetime of heel strike and through the stance phase ofgait. A disruption of the balance of these forces caninflict an injury to either or both.

Observe the patient in your waiting room. Is thepatient able to sit or is he or she pacing because sit-ting is too uncomfortable? If the patient is sitting, ishe or she symmetrical or leaning to one side? Thismay be due to pain in the ischial tuberosity secondaryto bursitis, sacroiliac dysfunction, or radiating painfrom the low back. Pain may be altered by changes inposition. Watch the patient’s facial expression to giveyou insight into their pain level.

Observe the patient as he or she assumes the stand-ing position. How difficult is it for the patient to gofrom flexion to extension? Can the patient evenly dis-tribute weight between both lower extremities? Ob-serve the patient’s posture. Note any structural de-formities such as kyphosis or scoliosis. Are the spinalcurves normal, diminished, or exaggerated? Observe

the patient’s total spinal posture from the head to thesacral base. It is also important to recognize the influ-ence of the lower extremities. Observe any structuraldeviations in the hips, knees, and feet. Once the pa-tient starts to ambulate, a brief gait analysis shouldbe initiated. Note any gait deviations and whetherthe patient requires or is using an assistive device.Details and implications of deviations are discussedin Chapter 14.

Subjective Examination

Inquire about the etiology of the patient’s symptoms.Was there a traumatic incident or did the pain developinsidiously? Is this the first episode or does the patienthave a prior history of low back pain? Is the patientpregnant or has she recently delivered a baby? Is thepatient’s symptomatology related to her menstrual cy-cle? Pregnancy and menstruation influence the degreeof ligamentous laxity, making the patient more sus-ceptible to injury. Is the pain constant or intermittent?Can the pain be altered by position? What exaggeratesor alleviates the patient’s complaints? Does coughing,sneezing, or bearing down increase the symptoms?

95

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96 The Lumbosacral Spine Chapter 6

Increased pain with increased intra-abdominal pres-sure may be secondary to a space-occupying lesionsuch as a tumor or a herniated disc. How easily is thepatient’s condition irritated and how quickly can thesymptoms be relieved? Your examination may needto be modified if the patient reacts adversely with verylittle activity and requires a long time for relief.

The patient’s disorder may be related to age, gen-der, ethnic background, body type, static and dy-namic posture, occupation, leisure activities, hobbies,and general activity level. It is important to inquireabout any change in daily routine and any unusualactivities in which the patient may have participated.If an incident occurred, the details of the mechanismof injury are important to help direct your examina-tion.

You should inquire about the nature and locationof the complaints as well as the duration and intensityof the symptoms. The course of the pain during theday and night should be addressed. The location ofthe symptoms may give you some insight into the eti-ology of the complaints. Pain, numbness, or tinglingthat is located over the anterior and lateral part of thethigh may be referred from L3 or L4. Pain into theknee may be referred from L4 or L5 or from the hipjoint. The patient may complain about pain over thelateral or posterior aspect of the greater trochanter,which may be indicative of trochanteric bursitis orpiriformis syndrome. Note any pain or numbness inthe saddle (perineal) area. This may be indicative ofradiation from S2 and S3. Inquire about any changesin bowel, bladder, and sexual function. Alterationof these functions may be indicative of sacral plexusproblems. (Please refer to Box 2.1, p. 15 for typicalquestions for the subjective examination.)

Gentle Palpation

The palpatory examination starts with the patientstanding. This allows you to see the influence of thelower extremities on the trunk in the weight-bearingposition. If the patient has difficulty standing, he orshe may sit on a stool with their back toward you. Thepatient must be sufficiently disrobed so that the en-tire back is exposed. You should first search for areasof localized effusion, discoloration, birthmarks, opensinuses or drainage, and incisional areas. Note thebony contours and alignment, muscle girth and sym-metry, and skinfolds. A caf au lait spot or a “faun’s”beard may be indicative of spina bifida occulta or

neurofibromatosis. Remember to use your dominanteye when checking for alignment or symmetry. Fail-ure to do this can alter your findings. You should nothave to use deep pressure to determine areas of ten-derness or malalignment. It is important to use a firmbut gentle pressure, which will enhance your palpa-tory skills. If you have a sound basis of cross-sectionalanatomy, it should not be necessary to physically pen-etrate through several layers of tissue to have a goodsense of the underlying structures. Remember that ifyou increase the patient’s pain at this point in the ex-amination, the patient will be very reluctant to allowyou to continue, or may become more limited in hisor her ability to move.

Palpation is most easily performed with the patientin a relaxed position. Although the initial palpationcan be performed with the patient standing or sitting,the supine, side-lying, and prone positions may alsobe used to allow for easier access to the bony andsoft-tissue structures.

Posterior Aspect

Bony Structures

Iliac CrestThe iliac crest is very prominent since it is so su-perficial and is therefore easy to palpate. Place yourextended hands so that the index fingers are at thewaist. Allow your hands to press medially and reston the superior aspect of the ridge of the crests. Thenplace your thumbs on the lumbar spine in line with thefingers on the crests. The L4–L5 vertebral interspaceis located at this level. This is a useful starting land-mark when palpating the lumbar spinous processes(Figure 6.1).

Iliac crests that are uneven in height may occur sec-ondary to a leg-length difference, a pelvic obliquity,or a sacroiliac dysfunction.

Spinous ProcessesThe spinous processes of the lumbar spine are quad-rangular in shape and are positioned in a horizontalfashion just posterior to the vertebral body. Locatethe posterior superior iliac spine (PSIS) and allowyour finger to drop off in the medial and superiordirection at a 30-degree angle. You will locate thespinous process of L5. Another consistent method tolocate the vertebra is by placing your hands on the il-iac crest and moving medially where you will find thevertebral interspace of L4–L5. You can count up thespinous processes from either of these starting points.

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97Chapter 6 The Lumbosacral Spine

Iliaccrest

Figure 6.1 Palpation of the iliac crest.

You can locate the spinous process of L1 by locat-ing the 12th rib and moving your hand medially anddown one level. If you choose this method, locate theremaining spinous processes by counting down to L5(Figure 6.2).

Spinousprocesses

L5

L1

Figure 6.2 Palpation of the spinous processes.

Tenderness or a palpable depression from one levelto another may indicate the absence of the spinousprocess or a spondylolisthesis.

Transverse ProcessesThe transverse processes of the lumbar spine are longand thin and are positioned in a horizontal fashion.They vary in length, with L3 being the longest andL1 and L5 the shortest. The L5 transverse process ismost easily located by palpating the PSIS and movingmedially and superiorly at a 30- to 45-degree angle.The transverse processes are more difficult to palpatein the lumbar spine because of the thickness of theoverlying tissue. They are most easily identified in thetrough located between the spinalis and the longis-simus muscles (Figure 6.3).

Posterior Superior Iliac SpinesThe PSISs can be found by placing your extendedhands over the superior aspect of the iliac crests andallowing your thumbs to reach diagonally in an in-ferior medial direction until they contact the bonyprominence. Have your thumbs roll so that they areunder the PSISs and are directed cranially to more ac-curately determine their position. Many individualshave dimpling that makes the location more obvious.

Paraspinalmuscles

Transverseprocesses

Figure 6.3 Palpation of the transverse processes.

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98 The Lumbosacral Spine Chapter 6

L5

S2

PSIS

Figure 6.4 Palpation of the posterior superior iliac spine (PSIS).

However, you should be careful because dimpling isnot present in all individuals, and if it is present, it maynot coincide with the PSISs. If you move your thumbsin a medial and superior angle of approximately 30degrees, you will come in contact with the posteriorarch of L5. If you move your thumbs at a caudad andinferior angle of approximately 30 degrees, you willcome in contact with the base of the sacrum. If youare having difficulty, you may also locate the PSISs byfollowing the iliac crests posteriorly and then inferi-orly until you arrive at the spines (Figure 6.4).

Sacroiliac JointThe actual joint line of the sacroiliac joint is not pal-pable because it is covered by the posterior aspect ofthe innominate bone. You can get a sense of its lo-cation by allowing your thumb to drop off mediallyfrom the PSIS. The sacroiliac joint is located deep tothis overhang at approximately the second sacral level(Figure 6.5).

Sacral BaseLocate the PSISs on both sides (described above). Al-low your thumbs to drop off medially and then moveanteriorly until you contact the sacral base. The drop-off between the PSIS and sacral base is referred to

S2 Spinousprocess

PSIS

L5

Figure 6.5 Palpation of the sacroiliac joint.

as the sacral sulcus (Figure 6.6). Palpation of thesacral base is useful in determining the position ofthe sacrum.

Inferior Lateral AnglePlace your fingers on the inferior midline of the pos-terior aspect of the sacrum and locate a small verticaldepression, this is the sacral hiatus. Move your fingerslaterally approximately 3/4 in. and you will be on theinferior lateral angle (Figure 6.7).

Ischial TuberosityYou can place you thumbs under the middle portionof the gluteal folds at approximately the level of thegreater trochanters. Allow your thumb to face supe-riorly and gently probe through the gluteus maximusuntil the thumb is resting on the ischial tuberosity.Some people find it easier to perform this palpationwith the patient lying on the side with the hip flexed,allowing the ischial tuberosity to be more accessiblesince the gluteus maximus is pulled up, reducing themuscular cover (Figure 6.8). If this area is tender topalpation, it may be indicative of an inflammation ofthe ischial bursa or an ischiorectal abscess.

CoccyxThe tip of the coccyx can be found in the gluteal cleft.To palpate the anterior aspect, which is essential todetermine the position, a rectal examination must beperformed (Figure 6.9). Pain in the coccyx is referred

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99Chapter 6 The Lumbosacral Spine

Sacrum

Sacral base

Figure 6.6 Palpation of the sacral base.

Inferiorlateralangle

Sacralhiatus

Figure 6.7 Palpation of the inferior lateral angle.

Ischialtuberosity

Figure 6.8 Palpation of the ischial tuberosity.

Coccyx

Figure 6.9 Palpation of the coccyx.

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100 The Lumbosacral Spine Chapter 6

Supraspinousligament

Interspinousligament

Figure 6.10 Palpation of the supraspinous ligament.

to as coccydynia and is usually secondary to directtrauma to the area.

Soft-Tissue Structures

Supraspinous LigamentThe supraspinous ligament joins the tips of thespinous processes from C7 to the sacrum. This pow-erful fibrous cord that is blended with the fascia isdenser and wider in the lumbar than in the cervicaland thoracic spines. The ligament can be palpated byplacing your fingertip between the spinous processes.The tension of the ligament is more easily noted if thepatient is in a slight degree of flexion (Figure 6.10).

Erector Spinae (Sacrospinalis) MusclesThe erector spinae muscles form a thick fleshy massin the lumbar spine. The intermediate muscles of thegroup are the spinalis (most medial), longissimus,and iliocostalis (most lateral) muscles. They are easilypalpated just lateral to the spinous processes. Theirlateral border appears to be a groove (Figure 6.11).These muscles are often tender and in spasm in pa-tients with an acute low-back pain.

Quadratus Lumborum MusclePlace your hands over the posterior aspect of the il-iac crest. Press medially in the space below the ribcage and you will feel the tension of the quadratuslumborum as it attaches to the iliolumbar ligament

and the iliac crest (Figure 6.12). The muscle can bemade more distinct by asking the patient to lift thepelvis toward the thorax. The quadratus lumborumis important in the evaluation of the lumbar spine.

SpinalisLongissimus

Iliocostalis

Figure 6.11 Palpation of the erector spinae muscles.

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101Chapter 6 The Lumbosacral Spine

Quadratuslumborum

Figure 6.12 Palpation of the quadratus lumborum muscle.

It can adversely affect alignment and muscle balancebecause of its attachment to the iliolumbar ligament.It can also play a role in changing pelvic alignmentbecause of its intimate relationship to the iliac crest.

Sacrotuberous LigamentPlace the patient in the prone position and locate theischial tuberosities as described above. Allow yourthumbs to slide off in a medial and superior direc-tion. You will feel a resistance against your thumbs,which is the attachment of the sacrotuberous ligament(Figure 6.13).

Side-Lying Position

Soft-Tissue Structures

Piriformis MuscleThe piriformis muscle is located between the ante-rior inferior aspect of the sacrum and the greatertrochanter. This muscle is very deep and is normallynot palpable. However, if the muscle is in spasm, acordlike structure can be detected under your fingersas you palpate the length of the muscle (Figure 6.14).Because of its attachment to the sacrum, the piriformis

is able to influence the alignment of the sacrum bypulling it anteriorly. The sciatic nerve runs either un-der, over, or through the muscle belly. Compressionor irritation of the nerve can occur when the muscleis in spasm.

Sciatic NerveThe sciatic nerve is most easily accessed while thepatient is lying on the side, which allows the nerveto have less muscle cover since the gluteus maximusis flattened. Locate the mid position between theischial tuberosity and greater trochanter. The nerveusually travels under the piriformis muscle, but insome patients it pierces the muscle. You may be ableto roll the nerve under your fingers if you take up thesoft-tissue slack. Tenderness in this area can be due toan irritation of the sciatic nerve secondary to lumbardisc disease or a piriformis spasm (Figure 6.15).

Anterior Aspect

Bony Structures

Anterior Superior Iliac SpinePlace your hands on the iliac crests and allow yourthumbs to reach anteriorly and inferiorly, on a

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102 The Lumbosacral Spine Chapter 6

Sacrospinusligament

Sacrotuberousligament

Figure 6.13 Palpation of the sacrotuberous ligament.

diagonal, toward the pubic ramus. The most promi-nent protuberance is the anterior superior iliac spine(ASIS). To determine their position most accurately,roll the pads of your thumbs in a cranial direction

Piriformismuscle

Greatertrochanter

Sciaticnerve

Figure 6.14 Palpation of the piriformis muscle.

so that they can rest under the ASISs. This areais normally superficial but can be obscured in anobese patient. Differences in height from one side tothe other may be due to an iliac rotation or shear(Figure 6.16).

Ischialtuberosity

Piriformismuscle

Greatertrochanter

Sciaticnerve

Figure 6.15 Palpation of the sciatic nerve.

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103Chapter 6 The Lumbosacral Spine

ASIS

Figure 6.16 Palpation of the anterior superior iliac spine (ASIS).

Pubic TuberclesThe patient should be in the supine position. Standso that you face the patient and start the palpationsuperior to the pubic ramus. Place your hands so thatyour middle fingers are on the umbilicus and allowyour palms to rest over the abdomen. The heel of yourhand will be in contact with the superior aspect of thepubic tubercles. Then move your finger pads directlyover the tubercles to determine their relative position.They are located medial to the greater trochanters andthe inguinal crease. Make sure that your dominant eyeis in the midline. The tubercles are normally tenderto palpation. If they are asymmetrical either in heightor in an anterior–posterior dimension, there may be asubluxation or dislocation or a sacroiliac dysfunction(Figure 6.17).

Soft-Tissue Structures

Abdominal MusclesThe abdominal muscles play a major role in support-ing the trunk. They also play a role in influencingthe position of the pubic symphysis and sacroiliacalignment. The group consists of the rectus abdomi-nis, obliquus externus abdominis, and the obliquusinternus abdominis. The rectus abdominis covers the

anterior aspect of the trunk and attaches from thefifth through seventh ribs to the crest of the pubis.The muscles are segmentally innervated. The musclebelly of the rectus abdominis can be made more dis-tinct by asking the patient to place the arms behindthe head and perform a curl-up. Note for symmetry inthe muscle and observe for any deficits (Figure 6.18).

Psoas MuscleThe psoas muscle is extremely important in patientswith a low-back condition because of its attachmentto the lumbar transverse processes and the lateral as-pects of the vertebral bodies of T12 and L1–L5. Themuscle can be palpated at its insertion on the lessertrochanter and medial and deep to the ASIS on themedial aspect of the sartorius (Figure 6.19). The bellyis made more distinct by resisting hip flexion.

Trigger Points of the LumbosacralRegion

Trigger points and myofascial pain are frequentlynoted in the abdominal muscles and in the intrinsicand extrinsic lumbar spinal muscles. Trigger points inthe abdominal muscles may radiate pain posteriorly,and trigger points in the lumbar spinal muscles mayradiate pain anteriorly. Occasionally, trigger pointsin the lumbosacral spine will mimic the symptoms ofa herniated disc. Characteristic locations of referredpain patterns of trigger points in the abdominal andlumbosacral spinal muscles are illustrated in Figures6.20–6.25.

Active Movement Testing

The patient should be appropriately disrobed so thatyou can observe the entire back. Have the patientstand without shoes in a well-lit area of the exam-ination room. Shadows from poor lighting will af-fect your perception of the movement. You shouldobserve the patient’s active movements from the an-terior, posterior, and both lateral aspects. While ob-serving the patient move, pay particular attention tohis or her willingness to move, the quality of the mo-tion, and the available range. Lines in the floor mayserve as visual guides to the patient and alter his orher movement patterns. It may be helpful to ask thepatient to repeat movements with the eyes closed.

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104 The Lumbosacral Spine Chapter 6

Umbilicus

(a)

Pubictubercles

Anteriorsupeior

iliacspine

Umbilicus

(b)

Figure 6.17 Palpation of the pubic tubercles.

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105Chapter 6 The Lumbosacral Spine

Figure 6.18 Palpation of the abdominal muscles.

Before your examination of the lumbar spine move-ments, you should have the patient perform a quicktest to clear the joints of the lower extremities, byasking the patient to perform a full flat-footed squat.This will check the range of motion (ROM) of thehip, knee, ankle, and foot. If the movement is full andpainless, the joints can be cleared.

You should then have the patient perform the fol-lowing movements: forward and backward bending,lateral bending to the right and left, and rotation tothe right and left. You should observe for the amountof available range, smoothness of movement, the will-ingness of the patient to move, and the alignment andsymmetry of the spinal curves. You may note a flat-tening in a particular area as the patient bends to theside or a deviation to one side during forward bend-ing. These deviations should alert you to examine theinvolved area more carefully. The patient may demon-strate a pattern of limitation referred to as the capsu-lar pattern (see section on assive Movement Testing).If the motion is pain free at the end of the range,

Psoasmuscle

Figure 6.19 Palpation of the psoas muscle.

you can add an additional overpressure to lear thejoint (Cyriax, 1979). You can also ask the patientto sustain the position for 15 seconds to determinewhether the symptoms can be reproduced. Sustainedmovements of lateral bending and rotation can alsobe combined with flexion and extension to increasethe degree of compression. If the patient experiencespain during any of these movements, you should notethe position that increases the symptoms and whetherany position alleviates the symptoms.

Forward Bending

Instruct the patient to stand with the feet approxi-mately 6 in. apart. Stand behind the patient to observethe back during the movement. Additionally, observethe patient from the side, to have a better view of thelumbosacral curve contour. To initiate the movement,ask the patient to bend the head forward by tuckingthe chin toward the chest, then drop the arms, andallow the trunk to roll forward with the fingertipsreaching downward. Have the patient go as far as heor she can (Figure 6.26a). Observe the available rangeand deviation to either side if one occurs. If you feelthat the patient is able to compensate for the devia-tion by using visual cues, have the patient close theireyes during the movement. Observe how much move-ment is actually coming from the lumbar spine andnot by substitution from the hip joint and the normallumbar–pelvic rhythm (Cailliet, 1995). To separatethe movements, you can stabilize the pelvis with yourarm to limit the degree of hip flexion. Patients also

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106 The Lumbosacral Spine Chapter 6

Rectus abdominusmuscle

Location ofthe triggerpoints

Area of referred pain

C

Figure 6.20 Trigger points in the rectus abdominis may simulate the pain of dysmenorrhea. (Adapted with permission from Travelland Rinzler, 1952.)

Rectus abdominusmuscle

Areas of radiating

pain

A

X

1

2

Figure 6.21 Trigger points in the rectus abdominis may also radiate pain into the posterior lower part of the thorax and lower back.(Adapted with permission from Travell and Rinzler, 1952.)

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107Chapter 6 The Lumbosacral Spine

MultifidiMultifidi

X

L2

S1

S4

(a) (b)

X

Figure 6.22 Trigger points within the multifidi muscles may cause referred pain in the paraspinal region. Pain may also radiateanteriorly or inferiorly. (Adapted with permission from Travell and Rinzler, 1952.)

Iliocostalisthoracis

T11

X

Figure 6.23 Trigger points in the iliocostalis thoracis muscle may radiate pain superiorly and inferiorly as well as anteriorly. (Adaptedwith permission from Travell and Rinzler, 1952.)

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108 The Lumbosacral Spine Chapter 6

X

L1

Iliocostalislumborum

X

Longissimusthoracis

Figure 6.24 Trigger points in the iliocostalis lumborum and longissimus thoracis muscles radiate pain inferiorly. (Adapted withpermission from Travell and Rinzler, 1952.)

try to substitute by allowing knee flexion. Note thesmoothness of the movement as each intervertebrallevel opens. At the end range, note if the range islimited by pain or the patient’s anticipation of pain.The normal ROM of flexion is 80 degrees (AmericanAcademy of Orthopedic Surgeons, 1965).

McKenzie (1981) also has the patient perform flex-ion in the supine position, asking the patient to bringthe knees up to the chest. The movement is there-fore initiated from below, as opposed to above whenthe patient is standing. Therefore, pain noted at thebeginning of the movement may be originating fromL5–S1.

The amount of movement can be recorded on amovement diagram. Deviations to the side and theonset of symptoms can also be recorded. Objectivemethods of measuring the ROM in flexion are as fol-lows: (1) Use a ruler to measure the distance from thepatient’s middle fingertip to the floor. (2) Measurethe distance from T12 to the S1 spinous processeswhile the patient is in neutral position. Then have thepatient complete a forward bend and measure fromthe same landmarks. The normal excursion observedshould be 7–8 cm. To perform the Schober test, mea-sure the point midway between the PSISs, which is

approximately the level of the second sacral vertebra.Mark 5 cm below and 10 cm above. Measure the dis-tance between the outer landmarks, first in neutraland then in flexion (Magee, 2002). Record the dif-ference in the distance measured. A gravity-assistedbubble goniometer (inclinometer) can be placed onthe patient to give you the actual degrees of move-ment.

Backward Bending

Instruct the patient to stand with the feet approxi-mately 6 in. apart. Stand behind the patient to ob-serve the back during the movement. Ask the patientto place his or her hands behind the back so thatthe palms contact the buttocks. Instruct the patientto allow the neck to extend, but not hyperextend,and then slowly allow the trunk to move backwardtoward their hands (Figure 6.26b). Patients will of-ten substitute by flexing their knees when they havelimited back extension. Observe the smoothness inwhich each intervertebral level closes. Note whetherthe range is limited by pain or the patient’s anticipa-tion of pain.

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109Chapter 6 The Lumbosacral Spine

Figure 6.25 Pelvic, abdominal, and retroperitoneal organs mayradiate pain to the lumbar spine. The hip may also causelow-back pain.

As an alternative method of performing back ex-tension, Isaacs and Bookhout (2002) and colleaguesand Greenman (2003) prefer to have the patient bendbackward by allowing him or her to prop up on theelbows and support the chin on the hands (sphinx po-sition) while in a prone position. This allows for easierpalpation of the bony position since the patient’s mus-cles are relaxed. McKenzie (1981) prefers to have thepatient perform a full push-up with the arms fully ex-tended and the pelvis sagging to the table. This allowsthe patient to passively extend the back by using theupper-extremity muscles (McKenzie, 1981).

ROM should be recorded on a movement diagram.Normal ROM is 30 degrees (American Academy ofOrthopedic Surgeons, 1965).

Lateral Bending

Instruct the patient to stand with the feet approxi-mately 6 in. apart. Stand behind the patient to observethe back during the movement. Instruct the patient toallow their ear to approach the shoulder on the sideto which he or she is moving. Then ask the patientto slide the hand down the lateral aspect of the lowerextremity as he or she bends the trunk to that side(Figure 6.26c). This movement should be repeated tothe right and left and comparison of the degree and

(b)(a) (c) (d)

Figure 6.26 Active movement testing. (a) Lumbar forward bending. (b) Lumbar backward bending. (c) Lumbar side bending. (d)Lumbar rotation.

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110 The Lumbosacral Spine Chapter 6

quality of movement should be noted. Patients maytry to increase the motion by lifting their lower ex-tremity off the floor and hiking their hip. This can beminimized by stabilizing the pelvis with your arm asthe patient performs the movement testing. Note anydiscontinuity of the curve. An angulation of the curvemay indicate an area of hypermobility or hypomo-bility. Note the smoothness in which each interverte-bral level contributes to the overall movement. Notewhether the range is limited by pain or the patient’santicipation of pain. ROM is most easily recorded ona movement diagram. You can measure the distancefrom the tip of the middle finger to the floor and com-pare one side to the other. Normal ROM is 35 degrees(American Academy of Orthopedic Surgeons, 1965).

McKenzie (1981) prefers to have the patient per-form a side-gliding movement while standing insteadof side bending. This movement is accomplished byinstructing the patient to move the pelvis and trunkto the opposite direction while maintaining the shoul-ders level in the horizontal plane. This movementcombines rotation and side bending simultaneously.

If the patient experiences increased symptoms as heor she bends toward the side with the pain, the prob-lem may be caused by an intra-articular dysfunctionor a disc protrusion lateral to the nerve root. If thepatient experiences increased symptoms as he or shebends away from the side with the pain, the problemmay be caused by a muscular or ligamentous lesion,which will cause tightening of the muscle or ligament.The patient may have a disc protrusion medial to thenerve root. A detailed neurological examination willhelp differentiate between the diagnoses.

Rotation

Instruct the patient to stand with the feet approxi-mately 6 in. apart. Stand behind the patient to observethe back during the movement. Instruct the patientto start by turning the head in the direction in whichhe or she is going to move and allowing the trunkto continue to turn (Figure 6.26d). Patients tend tocompensate for limitation of rotation by turning theentire body. This can be minimized by stabilizing thepelvis with your arm or having the patient performthe test while sitting. This movement should be re-peated toward the right and left. Compare the degreeand quality of movement from side to side. Noteany discontinuity of the curve. Note the smoothnessin which each intervertebral level contributes. Notewhether the range is limited by pain or the patient’santicipation of pain. ROM can be recorded on a

movement diagram. Normal ROM is 45 degrees(American Academy of Orthopedic Surgeons, 1965).

Passive Movement Testing

Passive movement testing can be divided into twocategories: physiological movements (cardinal plane),which are the same as the active movements, and mo-bility testing of the accessory (joint play, component)movements. You can determine whether the noncon-tractile (inert) elements can be incriminated by usingthese tests. These elements (ligaments, joint capsule,fascia, bursa, dura mater, and nerve root) (Cyriax,1979) are stretched or stressed when the joint is takento the end of the available range. At the end of eachpassive physiological movement, you should sense theend feel and determine whether it is normal or patho-logical. Assess the limitation of movement and deter-mine whether it fits into a capsular pattern. The cap-sular pattern of the lumbar spine is equally limitedto lateral bending and rotation followed by extension(Magee, 2002). This pattern is only clearly noticeablewhen multiple segments are involved. Paris (1991)described a capsular pattern for the lumbar spine sec-ondary to a facet lesion. With the facet lesion on theright, lateral bending is limited to the left, rotation islimited to the right, and forward bending deviates tothe right.

Physiological Movements

Passive testing of the gross physiological movementsis difficult to accomplish in the lumbar spine becauseof the size and weight of the trunk. Maneuverabil-ity of the trunk is cumbersome and the informationthat can be obtained is of limited value. You can ob-tain a greater sense of movement and understandingof the end feel by performing passive intervertebralmovement testing.

Mobility Testing

Mobility testing of intervertebral joint movementsand accessory movements will give you informationabout the degree of laxity present in the joint and theend feel. The patient must be totally relaxed and com-fortable to allow you to move the joint and obtain themost accurate information.

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111Chapter 6 The Lumbosacral Spine

Intervertebral Mobility of the Lumbar Spine

FlexionPlace the patient in the side-lying position facing you,with the head and neck in neutral alignment. Standso that you are facing the patient. Be careful not toallow the trunk to rotate or else your findings will bedistorted. Place your middle finger in the interspacebetween the spinous process of L5 and S1. Flex thepatient’s hips and knees. Support the patient’s lowerextremities on your hip creating flexion of the lumbarspine to the level that you are palpating by increasingthe degree of hip flexion. Note the opening of the in-tervertebral space. You can slightly extend the spineto get a better sense of opening and closing. Slightlyincrease the degree of flexion to palpate the next in-tervertebral segment and continue in a cranial fashion(Figure 6.27).

Side BendingPlace the patient in the prone position with the neckin neutral rotation. Stand on the side of the patientthat is on the side of your dominant eye, with yourbody turned so that you are facing the patient’s head.Place your middle finger in the interspace betweenthe spinous processes of L5 and S1. Hold the pa-

tient’s lower extremity that is closer to you. Flex thepatient’s knee to shorten the lever arm and supportthe lower extremity with your arm. Move the lowerextremity into abduction until you feel movement atthe interspace that you are palpating. This will createbending to the side on which you are standing andyou will feel a narrowing of the interspace. You canalso palpate on the opposite side and you will feelopening of the interspace. Slightly increase the degreeof side bending by creating additional abduction topalpate the next intervertebral segment and continuein a cranial fashion (Figure 6.28).

RotationPlace the patient in the prone position with the neckin neutral rotation. Stand on the side of the patientthat is on the side of your dominant eye, with yourbody turned so that you are facing the patient’s head.Place your middle finger on the side of the spinousprocess of L5 that is closest to you. Hold the patient’sinnominate bone on the side opposite from which youare standing. Lift the pelvis toward the ceiling. Thiswill create rotation of L5 away from you and you willsense the spinous process moving into your palpatingfinger (Figure 6.29).

Figure 6.27 Mobility testing of lumbar spine flexion.

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112 The Lumbosacral Spine Chapter 6

Figure 6.28 Mobility testing of lumbar spine side bending.

Accessory Movements of the Lumbar Spine

Central Posteroanterior Spring on theSpinous ProcessPlace the patient in the prone position with the neckin neutral rotation. Stand on the side of the patientthat is on the side of your dominant eye, with yourbody turned so that you are facing the patient’s head.Place the central portion of your palm (between the

Figure 6.29 Mobility testing of lumbar spine rotation.

thenar and hypothenar eminences) over the spinousprocess and press directly over the process in an an-terior direction until all the slack has been taken up(Figure 6.30).

Posteroanterior Spring on the Transverse ProcessPlace the patient in the prone position with the neck inneutral rotation. Stand on the side of the patient thatis on the side of your dominant eye, with your bodyturned so that you are facing the patient’s head. Placethe hypothenar eminence, just medial to the pisiform,over the transverse process on the side closest to you.Press on the process in an anterior direction until allthe slack has been taken up. This will cause a rotationof the vertebral body away from the side that you arecontacting (Figure 6.31).

Transverse Pressure on the Spinous ProcessPlace the patient in the prone position with the neckin neutral rotation. Stand on the side of the patientthat is on the side of your dominant eye, with yourbody turned so that you are facing the side of thepatient. Place your thumbs on the lateral aspect ofthe spinous process. Push the process away from youuntil you have taken up all the slack. This will cause

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113Chapter 6 The Lumbosacral Spine

Figure 6.30 Mobility testing of central posteroanterior springon the spinous process.

rotation of the vertebral body toward you (Figure6.32).

Sacroiliac Joint Examination

After concluding the examination of the lumbar in-tervertebral mobility tests and accessory movements,proceed with the examination of the sacroiliac joint.

Standing Flexion TestThis is a mobility test for the ilium moving on thesacrum. Instruct the patient to stand with the feet ap-proximately 6 in. apart. Stand behind the patient toobserve the movement. Remember to use your domi-nant eye. Locate the PSISs and place your thumbs un-der them. Maintain contact with the PSISs throughoutthe movement. Ask the patient to bend as far forwardas he or she can. Observe the movement of the PSISsin relation to each other. They should move equally.If there is a restriction, the side that moves first andfurthest is considered to be hypomobile (Figure 6.33).If the patient presents with tight hamstrings, a false-positive finding can occur (Greenman, 2003; Isaacset al., 2002).

Figure 6.31 Mobility testing of central posteroanterior springon the transverse process.

Figure 6.32 Mobility testing of transverse pressure on thespinous process.

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114 The Lumbosacral Spine Chapter 6

Figure 6.33 Mobility testing of the sacroiliac joint: standing forward-bending test.

Stork (Gillet, Marching) TestThis is a mobility test for the ilium moving on thesacrum. Instruct the patient to stand with the feet ap-proximately 6 in. apart. Stand behind the patient toobserve the movement. Remember to use your dom-inant eye. Locate the PSIS on the side that you aretesting and place one thumb under it. Place your otherthumb just medial to the PSIS, on the sacral base. Askthe patient to raise the lower extremity on the sidebeing tested so that the hip and knee are flexed to90 degrees. Note the movement of the PSIS in rela-tion to the sacrum. This test should be repeated onthe contralateral side. Compare the amount of move-ment from one side to the other. If the PSIS does not

drop down into your thumb on one side, the iliumis considered to be hypomobile (Greenman, 2003)(Figure 6.34).

Backward-Bending TestInstruct the patient to stand with the feet approxi-mately 6 in. apart. Stand behind the patient to observethe movement. Remember to use your dominant eye.Place your thumbs medial to the PSISs bilaterally onthe sacral base. Instruct the patient to bend backward.Observe as your thumbs move in an anterior direc-tion. An inability to move anteriorly demonstrates hy-pomobility of the sacrum moving on the ilium (Green-man, 2003; Isaacs and Bookhout 1992) (Figure 6.35).

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115Chapter 6 The Lumbosacral Spine

Figure 6.34 Mobility testing of the sacroiliac joint: stork test.

Seated Flexion TestThis is a mobility test for the sacrum moving on theilium. This test eliminates the influence of the lowerextremities. Instruct the patient to sit on a stool withthe feet firmly on the ground for support. Stand be-hind the patient to observe the movement. Rememberto use your dominant eye. Locate the PSISs and placeyour thumbs under them. Maintain contact with thePSISs throughout the movement. Ask the patient tobend as far forward as he or she can with their arms

Figure 6.35 Mobility testing of the sacroiliac joint:backward-bending test.

between their knees. Observe the movement of thePSISs in relation to each other. The side that movesfirst and furthest is considered to be hypomobile(Greenman, 2003; Isaacs and Bookhout 1992) (Figure6.36).

Posteroanterior Spring of the SacrumThis a test for posterior to anterior mobility of thesacrum. Place the patient in the prone position withthe neck in neutral rotation. Stand on the side of thepatient that is on the side of your dominant eye, withyour body turned so that you are facing the patient’shead. Place your hands over the central aspect of theposterior sacrum using the palm as the contact point.Press directly over the sacrum in an anterior directionuntil all the slack has been taken up (Paris, 1991)(Figure 6.37).

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116 The Lumbosacral Spine Chapter 6

Figure 6.36 Mobility testing of the sacroiliac joint: sitting forward-bending test.

Resistive Testing

Trunk Flexion

The rectus abdominis is the primary trunk flexor. It isassisted by the obliquus internus and externus muscles(Figure 6.38).� Position of patient (Figure 6.39): Supine with

hands clasped behind the head.� Resisted test: Stabilize the patient’s lower

extremities by pressing down on the anterioraspect of the thighs and ask the patient to performa curl-up, lifting the scapulae off the table.Observe the umbilicus for movement cranially orcaudally. Movement toward the head indicatesstronger contraction of the upper aspect of the

muscle, and movement toward the feet indicatesstronger contraction of the lower segments of therectus abdominis. Observe the umbilical region fora bulging of the abdominal contents through thelinea alba. This represents an umbilical hernia.Trunk flexion is made easier if the patientattempts the test with the arms relaxed at the side.Weakness of trunk flexion results in increased risk

of lower back pain and may cause difficulty in gettingup from a seated position.

Trunk Rotation

The rotators of the trunk are the obliquus inter-nus and externus muscles (Figure 6.40). Accessory

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117Chapter 6 The Lumbosacral Spine

Figure 6.37 Mobility testing of the sacroiliac joint:posteroanterior spring of the sacrum.

muscles include the multifidi, rotatores, rectus abdo-minis, latissimus dorsi, and semispinalis muscles.� Position of patient (Figure 6.41): Supine with the

hands behind the neck.� Resisted test: Stabilize the patient’s lower

extremities by pressing down on the anterior

Rectus abdominusmuscle

Figure 6.38 The trunk flexors.

aspect of the thighs and ask the patient to raise theleft shoulder blade up and twist the body so as tobring the left elbow toward the right hip. Thistests for the left obliquus externus and the rightobliquus internus muscles. Now ask the patient to

Figure 6.39 Testing trunk flexion.

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118 The Lumbosacral Spine Chapter 6

Internaloblique External

oblique

Figure 6.40 The trunk rotators.

repeat the procedure, bringing the right shoulderand scapula off the table and twisting toward theleft to test the right obliquus externus and leftobliquus internus muscles.Weakness of the trunk rotators causes reduced ex-

piratory effort and may result in a functional scoliosis.The risk of lower back pain is also increased.

Trunk Extension

The extensors of the trunk are the erector spinae,which include the iliocostalis thoracis, longissimusthoracis, spinalis thoracis, and iliocostalis lumborum(Figure 6.42).� Position of patient (Figure 6.43): Prone with arms

at the side. Place a pillow beneath the abdomen forpatient comfort and to reverse the lumbar lordosis.

� Resisted test: Stabilize the patient’s pelvis with oneof your forearms and ask the patient to raise theneck and sternum upward as the patient attemptsto raise the trunk against your resistance appliedto the middle of the back.Weakness of the back extensor muscles results in a

loss of the lumbar lordosis and an increase in the tho-racic kyphosis. Weakness on one side results in lateralcurvature with concavity toward the strong side.

Neurological Testing

The Lumbar Plexus

The lumbar plexus is composed of the L1 through L4nerve roots, with some contribution from T12 (Fig-ure 6.44). The nerve roots branch into anterior andposterior divisions near to the spine. The peripheralnerves that are formed from the anterior divisions in-nervate the adductor muscles of the hip. The nervesthat form from the posterior divisions innervate thehip flexors and knee extensors.

Figure 6.41 Testing trunk rotation.

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119Chapter 6 The Lumbosacral Spine

Iliocostalis

Longissimus

Spinalis

Figure 6.42 The trunk extensors.

The Lumbosacral Plexus

The lumbosacral plexus is composed of the nerveroots from L4 through S3 (Figure 6.45).

Because of the rotation of the lower limb thatoccurs during embryogenesis, the anterior divisionsand the peripheral nerves that emanate from them

Figure 6.43 Testing trunk extension.

innervate the posterior aspect of the lower extremityand the plantar surface of the foot. The posterior divi-sions of the lumbosacral nerve roots and the periph-eral nerves derived from them innervate the lateralabductors and an extensor of the hip, the dorsiflexormuscles of the ankle, and the extensor muscles of thetoes.

Testing by Neurological Level

Pathology of the lumbosacral spine is common andneurological testing is necessary to determine wherein the lumbosacral spine the pathology exists. Themuscles of the lower extremity are usually innervatedby specific nerve roots. Muscles that share a commonnerve root innervation are in the same myotome (Ta-ble 6.1).

The skin of the lower extremity is innervated by pe-ripheral nerves that emanate from specific nerve roots.Skin that shares innervation from a particular nerveroot shares a common dermatome (Figure 6.46).

Knowledge of the myotomes, dermatomes, and pe-ripheral nerve innervations (Figure 6.47) of the skinand muscles will assist you in the diagnosis of neuro-logical pathology. Remember that there is significantvariability from patient to patient with respect to pat-terns of innervation. With this in mind, the neurolog-ical examination is organized by root levels.

The L1 and L2 Levels

Muscle TestingThe L1 and L2 nerve roots (Figure 6.48) innervatethe iliopsoas muscle, which is a hip flexor. Test hipflexion by having the patient sit at the edge of the tablewith the knees bent to 90 degrees. Ask the patient toraise the knee upward as you apply resistance to theanterior mid aspect of the thigh (see pp. 313–314 formore information).

Sensation TestingThe L1 dermatome is located over the inguinal liga-ment. The key sensory area is located over the medialthird of the ligament. The L2 dermatome is locatedover the proximal anteromedial aspect of the thigh.The key sensory area is located approximately mid-way from the groin to the knee in the medial aspectof the thigh.

Reflex TestingThere is no specific reflex for the L1 and L2 levels.

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120 The Lumbosacral Spine Chapter 6

T12

L1

L2

L3

L4

L5

L1

T12

L2

L3

L4

IliohypogastricT12L1

IlioinguinalL1

Lateral femoralcutaneous

L2, 3

FemoralL2, 3, 4

ObturatorL2, 3, 4

GenitofemoralL1, 2

Divisions

AnteriorPosterior

Figure 6.44 The lumbar plexus. The lumbar plexus is formed by the ventral primary rami of L1, L2, L3, and L4 and possibly T12. Notethat the peripheral nerves from the anterior divisions innervate the adductor muscles of the hip, and the peripheral nerves from theposterior divisions innervate the hip flexors and knee extensors.

The L3 Level

Muscle TestingThe L3 root level (Figure 6.49) is best tested by exam-ining the quadriceps muscle, which extends the knee.This is performed by having the patient sit on the edgeof the examining table with the knees bent to 90 de-grees. Ask the patient to extend the knee as you applyresistance to the anterior aspect of the lower leg (seepp. 361–362, Figure 12.57 for further information).

Sensation TestingThe L3 dermatome is located on the anteromedialaspect of the thigh. It extends just below the medialaspect of the knee. The key sensory area for L3 islocated just medial to the patella.

Reflex TestingThere is no specific reflex for the L3 level. The L3nerve root does contribute to the quadriceps reflex atthe knee (see below).

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121Chapter 6 The Lumbosacral Spine

Divisions

Anterior

Posterior

S1

L5

L4

S2

S3

S4

Superior glutealL4, 5

S1

Inferior glutealL5

S1, 2

Commonperoneal

L4,5S1, 2

TibialL4, 5

S1, 2, 3

SciaticL4, 5

S1, 2, 3

to Gemellusinferior and Quadratus

femoris L4, 5S1, (2)

toGemellussuperior

andObturatorinternus

L5S1, 2

Posteriorfemoral

cutaneousS1, 2, 3

Perforatingcutaneous

S2, 3

PudendalS2, 3, 4

S1

L5

S3

L4

S2

S4

Nerve to Piriformis S1, 2

Figure 6.45 The lumbosacral plexus. This plexus is formed by the ventral primary rami of L4, L5, S1, S2, and S3.

The L4 Level

Muscle TestingThe L4 nerve root (Figure 6.50) is best examined bytesting dorsiflexion, which is performed by the tibialisanterior muscle. The patient is in a sitting positionor supine. Ask the patient to bring the foot upwardand inward, bending at the ankle, while you applyresistance to the dorsum of the foot (see p. 410, Figure13.69 for further information).

Sensation TestingThe L4 dermatome is located over the medial aspectof the leg and extends beyond the medial malleolus.The key sensory area of L4 is located just proximalto the medial malleolus.

Reflex TestingL4 is tested by examining the quadriceps reflex. Thepatient is sitting with the legs over the edge of the

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122 The Lumbosacral Spine Chapter 6

Table 6.1 The lumbosacral plexus: muscle organization.

Root level Muscle test Muscles innervated at this level

L1–L2 Hip flexion (adduction) Psoas, iliacus, sartorius, adductor longus,pectineus, gracilis, adductor brevis

L3 Knee extension (hip adduction) Quadriceps, adductor magnus, and longus, brevisL4 Ankle dorsiflexion (knee extension) Tibialis anterior, quadriceps, adductor magnus,

obturator externus, tibialis posterior, tensorfascia lata

L5 Toe extension (hip abduction) Extensor hallucis longus, extensor digitorumlongus, gluteus medius and minimus, obturatorinternus, peroneus tertius, semimembranosus,semitendinosus, popliteus

S1 Ankle plantar flexionHip extensionKnee flexionAnkle eversion

Gastrocnemius, soleus, gluteus maximus, bicepsfemoris, semitendinosus, obturator internus,piriformis, peroneus longus and brevis, extensordigitorum brevis

S2 Knee flexion Biceps femoris, piriformis, flexor digitorum longus,flexor hallucis longus, gastrocnemius, soleus,intrinsic foot muscles

table. Tap the patellar tendon with a reflex hammerand observe for quadriceps contraction and extensionof the knee.

L1

L2

L3

L4

L5 L5

L4

L3

L2

S2 S2

L1

S1 S1

S1

S3

L2L2

L3

L4

L4

L3

L5L5S1S1

S 3

S 4

S 5

KeySensoryAreas

Figure 6.46 The dermatomes and key sensory areas of thelower extremity.

The L5 Level

Muscle TestingThe L5 nerve root (Figure 6.51) is best tested by ex-amining the extensor hallucis longus muscle, whichextends the great toe’s distal phalanx. The patient issitting or supine. Ask the patient to raise the great toeas you apply resistance to the distal phalanx.

Sensation TestingThe L5 dermatome is located on the anterolateral re-gion of the leg and extends onto the dorsal aspect ofthe foot. The L5 key sensory area is located just prox-imal to the second web space on the dorsal aspect ofthe foot.

Reflex TestingThe medial hamstring jerk can be used to test the L5nerve root. This is performed with the patient supine.Support the lower leg with your forearm and placeyour thumb over the distal medial hamstring tendonin the popliteal fossa. Tap your thumb with the reflexhammer and observe for knee flexion.

The S1 Level

Muscle TestingThe S1 nerve root (Figure 6.52) is best tested by exam-ining plantar flexion of the foot by the gastrocnemiusand soleus muscles. This is performed by asking thepatient to stand up on the toes (see p. 410, Figure13.66 for further information).

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123Chapter 6 The Lumbosacral Spine

Lateralcutaneousbranch ofsubcostal

nerve T12

Lateral cutaneousbranch ofiliohypogastricnerve

Lateralfemoral

cutaneousnerve,

anteriorbranches

Lateral femoralcutaneous nerve,posteriorbranches

Intermediatefemoral

cutaneousnerves

Infrapatellarbranch of

saphenousnerve

Cutaneousbranches of

commonfibular

or peronealnerve

Superficial fibularor peroneal nerve becoming

dorsal digital nerves

Dorsal lateralcutaneous nerve of foot

Femoralbranch

Genitalbranch

Genitofemoralnerve

Cutaneous branch ofobturator nerve

Cutaneous branches:

Medial femoralcutaneous nerve

Saphenousnerve

Deep fibularor peronealnerve

A. Anterior view B. Posterior view

Ilioinguinalnerve

Branches of posteriorfemoral cutaneousnerve

Lateral femoralcutaneous nerve

Posterior femoralcutaneous nerve,end branch

Lateral sural cutaneous nerve

Medial sural cutaneous nerve

Dorsal lateralcutaneous nerve of foot (sural)

Lateral plantar nerve

Calcaneal nerve

Medialplantarnerve

Performingcutaneous

nerve

Dorsalrami

S1S2S3

Dorsalrami

L1L2L3

Figure 6.47 The cutaneous innervation of a lower limb.

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124 The Lumbosacral Spine Chapter 6

T3

T1

C6

C8

C7

T4

T5T6

L1

L2

L3

L4L5 L5

L4

L3

L2

L1

T7T8T9T10T11T12

Motor

Sensation

L1, L2 dermatomes

Key ( )sensory areas

Reflex

L1

L2

L3

L4

L5

“No reflex”

S3

Hip flexion (iliopsoas)

Figure 6.48 The L1 and L2 root levels.

Sensation TestingThe S1 dermatome is located on the posterior aspectof the calf and extends distally to the heel and thenlaterally along the dorsum of the foot. The key sensoryarea for S1 is located lateral to the insertion of theAchilles tendon on the foot.

Reflex TestingThe S1 nerve root is tested by examining the anklejerk. The patient is sitting with the legs hanging overthe edge of the table. Gently apply light pressure tothe plantar aspect of the foot and ask the patient torelax as you tap the Achilles tendon with the reflex

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125Chapter 6 The Lumbosacral Spine

Motor

Knee extension (quadriceps)

Sensation

L3 dermatome

Key ( )sensory areas

Reflex

L1

L2

L3

L4

L5

L2

L3

L4 L5L4

L3

L2

S1 S1

S1

Quadriceps reflex

Figure 6.49 The L3 root level.

hammer. Observe the patient for plantar flexion ofthe foot and contraction of the calf muscles.

The S2–S5 Levels

Muscle TestingThe S2 through S4 nerve roots supply the urinarybladder and the intrinsic muscles of the foot.

Sensation TestingThe S2 dermatome is located on the posterior as-pect of the thigh and extends distally to the midcalf. The key sensory area is located in the cen-ter of the popliteal fossa. The S3, S4, and S5dermatomes are located concentrically around theanus, with the S3 dermatome forming the outermostring.

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126 The Lumbosacral Spine Chapter 6

Motor

Sensation

L4 dermatome

Reflex

L1

L2

L3

L4

L5

L1

L2

L3

L4L5

L5L4

L3

L2

L1

S1 S1

S1

S3

( ) Key sensoryareas

Dorsiflexion (tibialis anterior)

Quadriceps reflex

Figure 6.50 The L4 root level.

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127Chapter 6 The Lumbosacral Spine

Sensation Reflex

L1

L2

L3

L4

L5

L5 dermatome

Key ( )sensory areas

L2

L3

L4L5 L5L4

L3

L2

S1 S1

S1

Motor

Big toe extension(extensor hallucis longus)

Medial hamstring jerk

Figure 6.51 The L5 root level.

The Superficial Reflexes

The upper, middle, and lower abdominal skin re-flexes, the cremasteric reflex, and Babinski’s reflexare tested to examine the upper motor neurons ofthe pyramidal tract. These reflexes are exaggeratedin upper motor neuron diseases, such as strokes andproximal spinal cord injuries.

Upper Abdominal Skin Reflex (T5–T8) (Figure 6.53)The patient is in a supine position and relaxed withthe arms at the sides and the knees gently flexed. Theskin over the lower part of the rib cage is strokedwith a fingernail or key from laterally to medially.Observe the patient for contraction of the upper ab-dominal muscles on the same side. You may also note

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128 The Lumbosacral Spine Chapter 6

Motor

Sensation

S1 dermatome

Key ( )sensory areas

Reflex

L1

L2

L3

L4

L5

L2 L2

L3

L4

L4

L3

L5L5S1S1

S 3

S 4

S 5

S1

Ankle jerk

Plantar flexion(gastrocnemius, soleus)

Figure 6.52 The S1 root level.

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129Chapter 6 The Lumbosacral Spine

Figure 6.53 The upper abdominal skin reflex (T5–T8).

movement of the umbilicus to the same side as thescratch.

Mid-Abdominal Skin Reflex (T9–T11) (Figure 6.54)Perform the test above, but this time at about the levelof the umbilicus. The response is similar to that forthe upper abdominal skin reflex.

Lower Abdominal Skin Reflex (T11–T12)(Figure 6.55)Perform the test as above, but this time over the levelof the iliac crest to the hypogastric region. Again ob-serve for contraction of the lower abdominal muscleson the same side and movement of the umbilicus inthe direction of the scratch.

Cremasteric Reflex (L1–L2) (Figure 6.56)This test is performed in men only. The inner aspectof the thigh is scratched with the handle of the reflexhammer from the pubis downward. You will note animmediate contraction of the scrotum upward on thesame side. An irregular or slow rise of the testis onthe same side is not a positive response.

Figure 6.54 The mid-abdominal skin reflex (T9–T11).

Figure 6.55 The lower abdominal skin reflex (T11, T12).

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130 The Lumbosacral Spine Chapter 6

Figure 6.56 The cremasteric reflex. Note that immediatemovement of the scrotum upward is a positive test result.

Special Tests

Straight-Leg-Raise Test

This test is performed to stretch the sciatic nerve andits dural covering proximally. In patients who have aherniated disc at L4–L5 or L5–S1 (Figures 6.57 and6.58) that is causing pressure on the L5 or S1 nerveroots, stretching the sciatic nerve will frequently causeworsening of the lower-extremity pain or paresthesiasor both. The test is performed by asking the patientto lie supine (Figure 6.59). With the patient’s kneeextended, take the patient’s foot by the heel and ele-vate the entire leg 35–70 degrees from the examiningtable. As the leg is raised beyond approximately 70degrees, the sciatic nerve is being completely stretchedand causes stress on the lumbar spine. The patient willcomplain of increased lower-extremity pain or pares-thesias on the side that is being examined. This is apositive response on the straight-leg-raising test. If thepatient complains of pain down the opposite leg, thisis called a positive crossed response on the straight-leg-raising test and is very significant for a herniateddisc. The patient may also complain of pain in theposterior part of the thigh, which is due to tightnessof the hamstrings.

You can determine whether the pain is caused bytight hamstrings or is of a neurogenic origin by raising

the leg up to the point where the patient complainsof leg pain, and then lowering the leg slightly (Figure6.60). This should reduce the pain in the leg. Nowpassively dorsiflex the patient’s foot to increase thestretch on the sciatic nerve. If this maneuver causespain, the pain is neurogenic in origin. If this move-ment is painless, the patient’s discomfort is caused byhamstring tightness.

Variations on the Straight-Leg-RaiseTest

The tibial nerve can be stretched by first dorsiflexingthe ankle and everting the foot, and then performinga straight-leg-raise test. The test is abnormal if thepatient complains of pain or numbness in the plantaraspect of the foot that is relieved by returning the footto the neutral position.

The peroneal nerve can be stretched by first plantarflexing the ankle and inverting the foot, and then per-forming a straight-leg-raise test. The test is abnormalif the patient complains of pain or numbness on thedorsum of the foot that is relieved by returning thefoot to the neutral position.

The test can be conducted in two ways: either theankle or the leg can be positioned first. You choosewhat order to perform the test by first positioning thebody part closest to the symptoms. For example, ifthe pain is in the buttock, use the straight-leg-raisetest first and position the ankle afterward. If the painis in the foot, position the ankle first (Butler, 1991).

The Slump Test

The slump test (Figure 6.61) is a neural tension testwhich is indicated when the patient complains ofspinal symptoms. The test is conducted as follows:� Patient’s position: The patient is sitting with both

lower extremities supported with the upperextremities behind the back and the hands clasped.

� Instruct the patient to “sag.” Overpressure can beadded to increase the degree of flexion. Maintainflexion and then ask the patient to bend the necktoward the chest. Overpressure can be added andthe symptoms are reassessed. While maintainingthe position, instruct the patient to extend oneknee and reassess. Then ask the patient to dorsiflexthe ankle and reassess. Release neck flexion andreassess. Ask the patient to flex the neck again andrepeat the process on the other leg. Finally, bothlegs can be extended simultaneously. The test isterminated when the symptoms are produced.Normal responses can include pain at T8–T9 in

approximately 50% of patients, pain on the posterior

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131Chapter 6 The Lumbosacral Spine

L5

L4

L3

L2

L1

L5 nerve root

L4-L5disc

Figure 6.57 A posterolateral herniation of the L4–L5 disc can cause pressure and injury to the L5 nerve root.

S1 nerve rootL5 nerve root

L5,S1 disc

L3

L4

L5

L2

L1

Figure 6.58 A posterolateral herniation of the L5–S1 disc can cause pressure and injury to the L5 and S1 nerve roots.

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132 The Lumbosacral Spine Chapter 6

Figure 6.59 Straight-leg-raising test. Between 35 and 70degrees, the L5 and S1 nerve roots may be stretched against anintervertebral disc. Flexing the hip more than 70 degrees causesstress on the lumbar spine.

aspect of the extended knee, decreased ROM in dor-siflexion, and a release of symptoms and an increasein range when neck flexion is released (Butler, 1991).Worsening of neurological symptoms can be indica-tive of pathology secondary to tension in the nervoussystem.

Femoral Nerve Stretch Test

This test (Figure 6.62) is useful in determiningwhether the patient has a herniated disc in the L2–L4 region. The purpose of the test is to stretch thefemoral nerve and the L2–L4 nerve roots. The patientis lying on the side, with the test side up. The testcan also be performed with the patient lying prone.Support the patient’s lower extremity with your arm,cradling the knee and leg. The test leg is extendedat the hip and flexed at the knee. If this maneuvercauses increased pain or paresthesias in the anteriormedial part of the thigh or medial part of the leg, it islikely that the patient has a compressive lesion of theL2, L3, or L4 nerve roots, such as an L2–L3, L3–L4,or L4–L5 herniated disc. You can determine whetherthe pain is caused by tight rectus femoris or of neuro-genic origin by releasing some of the knee flexion andthen extending the hip. If the pain increases with hipextension, it is neurogenic in origin.

Figure 6.60 By lowering the leg slightly to the point where thepatient stops feeling pain or paresthesias in the leg, and thendorsiflexing the ankle, you can determine whether the pain inthe leg is due to tight hamstrings or has a neurogenic origin. Ifthe pain is reproduced on dorsiflexion of the ankle after thehamstrings have been relaxed by lowering the leg slightly, thepain has a neurogenic origin.

Hoover Test

This test is useful in identifying a malingering patientwho is unable to raise the lower extremity from theexamining table while lying supine. The test is per-formed by taking the patient’s heels in your handswhile the legs are flat on the table. Ask the patient toraise one of the legs off the table while maintainingthe knee in an extended position. Normally, the op-posite leg will press downward into your hand. If thepatient states that he or she is trying to raise the legand there is no downward pressure in your oppositehand, it is likely that the patient is malingering.

Tests to Increase Intrathecal Pressure

These tests are performed in an effort to determinewhether the patient’s back pain is caused by intrathe-cal pathology, such as a tumor. By increasing the vol-ume of the epidural veins, the pressure within theintrathecal compartment is elevated.

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133Chapter 6 The Lumbosacral Spine

Slump stage 1 Slump stage 2

Slump stage 3 Slump stage 4

Slump stage 5

Testing bilateral knee extension in slump

Slump stage 6

The slump test with an assistant

Figure 6.61 The slump test. (Adapted from Butler, 1991.)

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134 The Lumbosacral Spine Chapter 6

Figure 6.62 The femoral stretch test. The test leg is extended at the hip first, and then the knee is flexed.

Valsalva Maneuver

The patient is seated. Ask the patient to take a fullbreath and then bear down as if he or she were tryingto have a bowel movement. This increases intrathecalpressure and may cause the patient to have increasedback pain or increased pain down the legs. This is apositive Valsalva maneuver (Figure 6.63).

Sacroiliac Joint Tests

Gaenslen’s Sign

This test is used to determine ipsilateral sacroiliacjoint disease by stressing the sacroiliac joint. The testis performed with the patient supine on the examiningtable with both knees flexed and drawn toward thechest. Move the patient toward the edge of the exam-ining table so that one buttock (the test side) is off the

table (Figure 6.64). Support the patient carefully andask him or her to lower the free thigh and leg downto the floor (Figure 6.65). This stresses the sacroil-iac joint, and if it is painful, the patient probably hassacroiliac joint dysfunction or pathology.

Patrick’s (Fabere) Test

This test (Figure 6.66) is described in more detail onp. 328. It is useful in determining whether there issacroiliac joint pathology, as well as hip pathology.The patient is supine in a figure-of-four position. Pressdownward on the patient’s bent knee with one handand with your other hand apply pressure over theiliac bone on the opposite side of the pelvis. Thiscompresses the sacroiliac joint, and if it is painful, thepatient has sacroiliac joint pathology. If pressure onthe knee alone is painful, this indicates hip pathologyon the same side.

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135Chapter 6 The Lumbosacral Spine

Figure 6.63 Valsalva maneuver.

Figure 6.65 Allow the patient’s thigh and leg to movedownward to stress the sacroiliac join on that side. Pain on thismaneuver reflects sacroiliac joint pathology.

Figure 6.64 Gaenslen’s sign. Bring the patient to the edge ofthe table with the test-side buttock over the edge.

Figure 6.66 Patrick’s or Fabere test. The hip is flexed, abducted,externally rotated, and extended.

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136 The Lumbosacral Spine Chapter 6

Figure 6.67 The sacroiliac distraction test. By compressing thepelvis medially and distracting the sacroiliac joints, this testdetermines whether sacroiliac pathology is present.

Figure 6.68 Test for spondylolysis (extension in one-legstanding).

Sacroiliac Distraction Test

This test is performed to distract the sacroiliac joints.The patient is lying supine and your thumbs are placedover the anterolateral aspect of the iliac crest bilater-ally. With both hands, compress the pelvis towardthe midline. The test result is positive for sacroiliacjoint pathology if the patient complains of pain in theregion of the sacroiliac joint (Figure 6.67).

Spondylolysis Test (Extension in One-Leg Standing)

This test (Figure 6.68) is performed to identify a stressfracture of the pars interarticularis, which may cause aspondylolisthesis. Ask the patient to stand on one legand extend the lumbar spine. If the patient complainsof pain in the back, the test result is positive andmay represent a stress fracture (spondylolysis). Thisposture stresses the facet joints and will also be painfulif there is pathology of the facet joints.

Figure 6.69 Anteroposterior view of the lumbosacral spine.

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Figure 6.70 Lateral view of the lumbosacral spine.

Figure 6.71 Oblique view of the lumbosacral spine.

Figure 6.72 Magnetic resonance image of the lumbosacralspine, sagittal view.

Figure 6.73 Magnetic resonance image of the lumbosacralspine, transverse view.

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138 The Lumbosacral Spine Chapter 6

Figure 6.74 Magnetic resonance view of the lumbosacral spine,sagittal view. DG, dorsal root ganglion.

Radiological Views

Radiological views are shown in Figures 6.69–6.74.

A = L2 vertebral bodyB = L3/4 disc space

C = Spinous processD = Transverse processDG = Dorsal root ganglion of L2 in intervertebral

foramenE = Sacroiliac (S–I) jointES = Erector spinae muscleF = Articular facetID = Intervertebral discL = Lamina of vertebral archL5 = L5 vertebral bodyN = Nerve rootPI = Pars interarticularisPL = PedicleS = Spinal canal, cauda equina (C)A = L2 vertebral bodySI = Sacroiliac jointV = Vertebral body

Paradigm for a neoplasm of the lumbar spine

A 65-year-old bank executive presents with acute pain in themid low-back region. There has been a slow insidious increas-ing discomfort for the past 3 months, which has becomesevere during the past week. There has been no history oftrauma. He describes his pain as being worse at night and re-lieved with standing. His pain is not made worse by coughing,sneezing, or straining during a bowel movement.

On a physical examination, the patient appears to be in milddiscomfort while seated. He is independent in transfer toand from the exam table and dressing. He has no tensionsigns with straight leg raise, reflexes are equal bilaterally, as isstrength.

There is pain on percussion over the mid lumbar spinous pro-cesses. X-rays suggest an absence of the right pedicle of thethird lumbar vertebrae.

This paradigm is characteristic of a spinal neoplasm becauseof:

No history of a traumaPain at rest, relieved on standingNo evidence of nerve involvement

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C H A P T E R 7

Overview of the UpperExtremityThe usefulness of the human upper extremity is de-fined by its complex end organ, the hand. The solepurpose of the upper extremity is to position andmove the hand in space. The upper extremity is at-tached to the remainder of the body through only onesmall articulation, called the sternoclavicular joint.Otherwise, it is suspended from the neck and held fastto the torso by soft tissues (muscles and fasciae). Theclavicle, or collarbone, acts as a cantilever, projectingthe upper extremity laterally and posteriorly from themidline. The upper extremity gains leverage againstthe posterior aspect of the thorax by virtue of thebroad, flat body of the scapula. The scapula lies flatlyon the posterior aspect of the thorax; as such, it isdirected approximately 45 degrees forward from themidsagittal plane. At the superolateral corner of thescapula is a shallow socket, the glenoid. The glenoidis aligned perpendicularly to the body of the scapula.The socket faces obliquely forward and laterally. Thespherical head of the humerus is normally directedposteromedially (retroverted 40 degrees) so as to becentered within the glenoid socket. The result is thatthe shoulder is a highly mobile, but extremely unsta-ble configuration that permits a tremendous degree offreedom of movement in space (Figure 7.1).

Midway along the upper extremity, there is a com-plex modified hinge articulation called the elbow. Aswill be discussed, the elbow accommodates flexionas well as rotation movements of the forearm. Un-like the shoulder, the elbow has a much more stableconfiguration. The primary purpose of the elbow isto approximate the hand to other parts of the body,particularly the head.

At the terminus of the upper extremity is the hand.It is connected to the upper extremity by a complex

Scapula

Sternum

Humerus

Ulna

Radius

Clavicle Acromion process

Corocoid process

Figure 7.1 Overview of the upper extremity.

139

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140 Overview of the Upper Extremity Chapter 7

hinge articulation termed the wrist. The wrist servesto modify the grosser movements of the elbow andshoulder. The importance of the wrist and complex-ity of the hand can best be appreciated when its func-tion has been compromised. There is no single tool

or appliance that can duplicate the function of thehand. The disproportionate amount of motor cortexthat the brain has allocated to control hand move-ments emphasizes both the hand’s importance and itscomplexity.

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C H A P T E R 8

The Shoulder

F U R T H E R I N F O R M A T I O N

Please refer to Chapter 2 foran overview of the sequence of

a physical examination. For purposes oflength and to avoid having to repeatanatomy more than once, the palpationsection appears directly after the sectionon subjective examination and before any

section on testing, rather than at the endof each chapter. The order in which theexamination is performed should bebased on your experience and personalpreference as well as the presentation ofthe patient.

Functional Anatomy

The shoulder contains four articulations: the ster-noclavicular, the acromioclavicular, the scapulotho-racic, and the glenohumeral.

The shoulder girdle facilitates the placement of thehand in space. It accomplishes this through the com-plementary movements of the scapula on the thoraxand the glenohumeral articulation. This complemen-tary movement is termed the scapulohumeral rhythm.

Historically, movements of the shoulder girdle havebeen subdivided into the specific responsibilities ofeach of the shoulder’s four articulations. However,such an artificial fragmentation of shoulder functionis not an accurate portrayal of reality. In fact, un-der normal circumstances, the articulations work insynchrony, not isolation. The corollary of this fact isthat the pathology of any single articulation will havesignificant adverse consequences on the functioning ofthe other remaining articulations and the entire upperextremity.

The entire upper extremity is attached to the torsothrough the small sternoclavicular articulation. It af-fords limited movement but must withstand signifi-cant loads. Therefore, it is not unusual to observe os-teoarthritic degeneration of this joint, associated with

significant soft-tissue swelling and osteophyte forma-tion.

The acromioclavicular joint, like the sternoclavic-ular, is a small synovial articulation that has lim-ited range of motion and frequently undergoes os-teoarthritic degeneration. More importantly than inthe case of the sternoclavicular joint, enlargement ofthe acromioclavicular articulation has significant ad-verse consequences on shoulder movement and in-tegrity (see below).

The scapulothoracic articulation is a nonsynovialarticulation. It is composed of the broad, flat, trian-gular scapula overlying the thoracic cage and is sep-arated from the thoracic cage by a large bursa. Itsstability is strictly dependent on the soft tissue attach-ments of the scapula to the thorax. The plane of thescapula lies 45 degrees forward from the midcoronalplane of the body. Thus, the scapulothoracic articu-lation serves to supplement the large ball-and-socketarticulation of the true shoulder joint.

The glenohumeral joint, or shoulder joint, is a shal-low ball-and-socket articulation. As such, it enjoystremendous freedom of movement. However, thisfreedom comes at a cost. It is inherently an unstablejoint. The glenoid is so shallow that the ball (humeralhead), if unprotected, can easily slip inferiorly out ofthe socket, creating a shoulder dislocation.

141

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142 The Shoulder Chapter 8

Clavicle Coracoid process

AcromionDeltoidmuscle

Scapula

Glenohumeraljoint

Biceps muscle

Pectoralismajor

Sternum

Trapeziusmuscle

Sternoclavicular joint

Acromioclavicular joint

Figure 8.1 Overview of the shoulder showing the importance ofthe soft tissues in maintaining the round humeral head in theflattened glenoid process of the scapula. The other joints of theshoulder are also shown.

Normally, this is prevented by soft tissues (Figure8.1). Anteriorly, there is the subscapularis tendon.Superiorly, there are the tendons of the supraspina-tus and long head of the biceps. Posteriorly are thetendons of the infraspinatus and teres minor muscles.These tendons surround the humeral head, forming a“cuff,” and the corresponding muscles are responsi-ble for rotating the humeral head within the glenoidsocket. Hence, they are referred to as the rotator cuff.The purpose of the rotator cuff is to stabilize thehumeral head within the glenoid socket, thereby cre-ating a stable pivot point on which the larger shouldermuscles (deltoid and pectoralis major) can efficientlyexert force.

The rotator cuff does not extend to the inferior(axillary) aspect of the glenohumeral articulation.Here, the only soft-tissue connection between the balland socket is the capsular ligaments, the strongestof which is the inferior glenohumeral ligament. Thisligament is important because as the arm moves over-head, abduction and external rotation of the humerusare limited by the acromion process (Figure 8.2).When the shaft of the humerus reaches the acromion,

Acromion

Inferiorglenohumeralligament

Clavicle

Figure 8.2 The inferior glenohumeral ligament prevents furtherinferior movement of the humeral head as the arm abducts.

a fulcrum is created. Further attempts to abduct thearm will force the humeral head out of the glenoidsocket inferiorly against the glenohumeral ligament.If the tolerance of the inferior capsular ligament toresist this movement is exceeded, either due to themagnitude of the acute force being applied or due tothe inherent stretchability of a genetically determinedlax ligament, a classic anterior–inferior shoulder dis-location will result (Figure 8.3). The consequent elon-gation of the inferior glenohumeral ligament is irre-versible. Unless corrected, the glenohumeral joint be-comes vulnerable to repeat episodes of instability withmovement of the arm above the shoulder height (ap-prehension sign).

The superior aspect of the shoulder is protected bythe acromioclavicular bony arch and the coracoacro-mial ligament (Figure 8.4). The latter representsthe fibrous vestigial remnant of the coracoacromial

Acromion

Inferiorglenohumeralligament

Clavicle

Sternum Scapula

Dislocation

Figure 8.3 Inferior dislocation of the glenohumeral articulation,with attenuation of the inferior glenohumeral ligament.

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143Chapter 8 The Shoulder

Acromion

ClavicleHumeralhead

Supraspinatusmuscle

Bicepstendon

Coracoacromialligament

Coracoid

Figure 8.4 Superior view of the shoulder, showing theacromioclavicular joint and the coracoacromial ligamentoverlying the humeral head.

bony arch of quadripeds. Beneath this protective roofpasses the superior portion of the rotator cuff, thesupraspinatus tendon and the long head of the bi-ceps tendon. The biceps is the only part of the rotatorcuff that depresses the humeral head. As the humerusmoves, these tendons slide through a space definedby the bony-ligamentous roof above and the humeralhead below (Figure 8.5). To reduce friction, there is abursal sac, the subacromial bursa, positioned betweenthe tendons below and the roof above.

The subacromial space can be absolutely narrowedby osteophytes extending inferiorly from the clavicle,acromion, or acromioclavicular joint. Swelling of thesoft tissues within the space (i.e., bursitis and ten-dinitis) can also relatively narrow the space. Thesesoft-tissue swellings may arise as the result of acute

Long head ofbicepstendon

Subacromialbursa

Supraspinatusmuscle-tendon

Subacromialspace

Coracoacromialligament

Figure 8.5 The subacromial space is defined superiorly by theacromioclavicular bony arch and the coracoacromial ligament.Inferiorly, it is defined by the humeral head. Within this spacelies the subacromial bursa and the tendons of the supraspinatusand long head of the biceps muscles.

injuries or chronic overuse syndromes. In either case,the result is insufficient space for the free passage ofthe rotator cuff beneath the coracoacromial arch. Thiscreates a painful pinching of the tissues between theroof above and the humeral head below. This con-dition has been termed an impingement syndrome.The resulting pain from this condition can lead notonly to a chronically disabling condition, with ero-sion of the rotator cuff tissues, but also to an attemptto compensate for the loss of glenohumeral motionwith scapulothoracic movement. Excessive stress canbe created on the cervical spine due to the musculareffort of the proximal back and shoulder muscles tocompensate for the lack of glenohumeral movement.

When the biceps tendon has become chronically in-flamed by either frictional wear beneath the acromialarch or chronic tendinitis, it is at risk of rupture. Ifthis occurs, the humeral head depression is compro-mised. The humerus will then ride superiorly withinthe glenoid, increasing pressure between the humeralhead and the acromial arch. This will also preventclearance of the greater tuberosity of the humerus be-neath the acromion during abduction and will resultin limited shoulder motion. The resultant cycle of painand guarded range of motion produces an increasingpattern of upper-extremity dysfunction.

Shoulder movement therefore represents a complexinterplay of multiple articulations and soft tissues,which must be recognized and appreciated for theirdelicate interrelationship.

Observation

Note the manner in which the patient is sitting in thewaiting room. Notice how the patient postures theupper extremity. Is the arm relaxed at the side or isthe patient cradling it for protection? How willingis the patient to use the upper extremity? Will thepatient extend the arm to you to shake your hand?Pain may be altered by changes in position. Therefore,it is important to watch the patient’s facial expression,which may give you insight into the patient’s painlevel.

Observe the patient as he or she assumes the stand-ing position and note their posture. Pay particularattention to the position of the head and cervicaland thoracic spine. Note the height of both shoul-ders and their relative positions. Once the patientstarts to ambulate, observe whether he or she is will-ing to swing the arms, as pain or loss of motion can

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limit arm swing. Once the patient is in the examina-tion room, ask him or her to disrobe. Observe theease with which the patient uses the upper extremi-ties and the rhythm of the movements. Observe forsymmetry of bony structures. From the front, observethe clavicles. An uneven contour may be present sec-ondary to a healed fracture. Follow the clavicle anddetermine whether the acromioclavicular and stern-oclavicular joints are at equal heights. From the back,observe the scapulae and determine whether they areequidistant from the spine and laying flat on the ribcage. Is one scapula structurally higher, as in Spren-gel’s deformity? Is a visible subluxation present at theglenohumeral joint? Notice the size and contour ofthe deltoid and compare both sides for atrophy orhypertrophy.

Subjective Examination

The glenohumeral joint is a flexible joint held bymuscles that allow a wide range of movement. Theshoulder is non-weight-bearing; therefore, problemsare most commonly related to overuse syndromes, in-flammation, and trauma. You should inquire aboutthe nature and location of the patient’s complaintsas well as their duration and intensity. Note if thepain travels below the elbow. This may be an in-dication that the pain is originating from the cervi-cal spine. The behavior of the pain during the dayand night should also be addressed. Is the patientable to sleep on the involved shoulder or is he orshe awakened during the night? Is the patient ableto lie down to sleep or forced to sleep in a recliningchair? This will give you information regarding thepatient’s reaction to changes in position, activity, andswelling.

You want to determine the patient’s functional lim-itations. Question the patient regarding the use of theupper extremity. Is the patient able to comb his hair,fasten her bra, bring his hand to his mouth to eat,or remove her jacket? Can the patient reach for ob-jects that are above shoulder height? Can the patientlift or carry? Does the patient regularly participatein any vigorous sports activity that would stress theshoulder? What is the patient’s occupation? Are therejob-related tasks that involve excessive or impropershoulder use?

If the patient reports a history of trauma, it is im-portant to note the mechanism of injury. The direc-tion of the force and the activity being participated

in at the time of the injury contribute to your un-derstanding of the resulting problem and help you tobetter direct your examination. The degree of pain,swelling, and disability noted at the time of the traumaand within the first 24 hours should be noted. Doesthe patient have a previous history of the same typeof injury or other injury to the same location?

The patient’s disorder may be related to age, gen-der, ethnic background, body type, static and dy-namic posture, occupation, leisure activities, hobbies,and general activity level. Therefore, it is important toinquire about any change in daily routine and any un-usual activities in which the patient has participated.

The location of the symptoms may give you someinsight as to the etiology of the complaints. Pain lo-cated over the lateral part of the shoulder may bereferred from C5. The temporomandibular joint andelbow can also refer pain to the shoulder. In addition,particular attention should be paid to the possibilityof referred pain from the viscera, especially the heart,gallbladder, and pancreas. (Please refer to Box 2.1,p. 15 for typical questions for the subjective exami-nation.)

Gentle Palpation

The palpatory examination is started with the pa-tient in the supine position. You should first examinefor areas of localized effusion, discoloration, birth-marks, open sinuses or drainage, incisions, bony con-tours, muscle girth and symmetry, and skinfolds. Youshould not have to use deep pressure to determine ar-eas of tenderness or malalignment. It is important touse a firm but gentle pressure, this will enhance yourpalpatory skills. If you have a sound basis of cross-sectional anatomy, you will not need to physicallypenetrate through several layers of tissue to have agood sense of the underlying structures. Rememberthat if you increase the patient’s pain at this point inthe examination, the patient will be very reluctant toallow you to continue, and his or her ability to movemay become more limited.

Palpation is best performed with the patient in a re-laxed position. Although palpation may be performedwith the patient standing, the sitting position is pre-ferred for ease of shoulder examination. While lo-cating the bony landmarks, you should pay attentionto areas of increased or decreased temperature andmoisture to identify areas of acute or chronic inflam-mation.

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Anterior View

Bony Structures

Suprasternal NotchStand facing the seated patient and use your middle orindex finger to locate the triangular notch between thetwo clavicles. This is the suprasternal notch (Figure8.6).

Sternoclavicular JointMove your fingers slightly superiorly and laterallyfrom the center of the suprasternal notch until youfeel the joint line between the sternum and the clav-icle (Figure 8.7). The joints should be examined si-multaneously to allow for comparison of heights andlocation. A superior and medial displacement of theclavicle may be indicative of dislocation of the stern-oclavicular joint. You can get a better sense of the ex-act location and stability of the sternoclavicular jointby having the patient shrug the shoulders while youpalpate the joint and the upward motion of the clavi-cles.

ClavicleContinue to move laterally from the sternoclavicu-lar joint along the superiorly and anteriorly curved

Suprasternalnotch

Figure 8.6 Palpation of the suprasternal notch.

Sternoclavicularjoint

Figure 8.7 Palpation of the sternoclavicular joint.

bony surface of the clavicle. The bony surface shouldbe smooth and continuous. Any area of increasedprominence, sense of motion, crepitus, or pain alongthe shaft may be indicative of a fracture. In addi-tion, the platysma muscle passes over the clavicle asit courses up the neck and can be palpated by havingthe patient strongly pull the corners of the mouth in adownward direction (Figure 8.8). The supraclavicu-lar lymph nodes are found on the superior surface ofthe clavicle, lateral to the sternocleidomastoid. If younotice any enlargement or tenderness, an infection ormalignancy should be suspected.

Acromioclavicular JointContinue to palpate laterally along the clavicle fromthe convexity to where it becomes concave to themost lateral aspect of the clavicle, just medial to theacromion. You will be able to palpate the acromio-clavicular joint line where the clavicle is slightly su-perior to the acromion (Figure 8.9). You can get abetter sense of its location by asking the patient toextend the shoulder while you palpate the movementat the acromioclavicular joint. The acromioclavicu-lar joint is susceptible to osteoarthritis, crepitus, andtenderness, which can be noted with palpation. Pain

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146 The Shoulder Chapter 8

Clavicle

Figure 8.8 Palpation of the clavicle.

Acromioclavicularjoint

Figure 8.9 Palpation of the acromioclavicular joint.

Acromion

Figure 8.10 Palpation of the acromion process.

with movement and swelling in the joint may be in-dicative of acromioclavicular joint subluxation. If thejoint is severely traumatized, usually by a fall directlyon the shoulder, a dislocation may occur and the clav-icle may be displaced superiorly and posteriorly. Theacromioclavicular joint is one area in which the painis felt locally and is not referred.

Acromion ProcessPalpate past the lateral aspect of the acromioclavic-ular joint and palpate the broad, flattened surface ofthe acromion between your index finger and thumb(Figure 8.10).

Greater Tuberosity of the HumerusAllow your fingers to follow to the most lateral aspectof the acromion and they will drop off inferiorly ontothe greater tuberosity of the humerus (Figure 8.11).

Coracoid ProcessMove your fingers on a diagonal inferiorly and me-dially from the acromioclavicular joint. Gently placeyour middle finger deep into the deltopectoral triangleuntil you locate the bony prominence of the coracoid

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147Chapter 8 The Shoulder

Greatertuberosity

Figure 8.11 Palpation of the greater tuberosity of the humerus.

process, which is normally tender to palpation (Figure8.12). The coracoid process is the attachment of thepectoralis minor, the coracobrachialis, and the shorthead of the biceps.

Bicipital GrooveHave the patient position the upper extremity at theside so that the arm is in mid position between internaland external rotation, and the forearm is in mid po-sition between pronation and supination. Move yourfingers laterally from the coracoid process, onto thelesser tuberosity of the humerus, and finally into thebicipital groove. The groove can be difficult to palpateif the patient has a hypertrophied deltoid. It may behelpful to locate the medial and lateral epicondyles ofthe humerus, making sure that they are in the frontalplane. Find the midpoint of the humerus and traceproximally to find the bicipital groove. The groovecontains the tendon of the long head of the bicepsand its synovial sheath and can therefore be tenderto palpation. Ask the patient to internally rotate thearm and you will then feel your finger roll out of thegroove and onto the greater tuberosity of the humerus(Figure 8.13).

Coracoidprocess

Figure 8.12 Palpation of the coracoid process.

Lessertuberosity

Bicepstendon

Greatertuberosity

Bicipitalgroove

Figure 8.13 Palpation of the bicipital groove.

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148 The Shoulder Chapter 8

Sternocleidomastoidmuscle

Figure 8.14 Palpation of the sternocleidomastoid muscle.

Soft-Tissue Structures

SternocleidomastoidTo facilitate palpating the sternocleidomastoid mus-cle, have the patient bend the neck toward the sideyou are palpating and simultaneously rotate away.This movement allows the muscle to be more promi-nent and therefore easier to locate. Palpate the distalattachments on the manubrium of the sternum andthe medial aspect of the clavicle and follow the mus-cle superiorly and laterally to its attachment on themastoid process. The sternocleidomastoid is the ante-rior border of the posterior triangle of the neck and isa useful landmark for palpating enlarged lymph nodes(Figure 8.14).

TrapeziusStand behind the seated patient. Differences in con-tour and expanse can be easily noted as you observethe patient prior to palpation. To enable you to pal-pate the fibers of the upper trapezius, allow your fin-gers to travel laterally and inferiorly from the externaloccipital protuberance to the lateral third of the clav-icle. The muscle is a flat sheet but feels like a cordlikestructure because of the rotation of the fibers. It is

Lowertrapezius

Middletrapezius

Upper trapezius

Figure 8.15 Palpation of the trapezius muscle.

frequently tender to palpation and often very tight,secondary to tension or trauma. You can palpate themuscle using your thumb on the posterior aspect andyour index and middle fingers anteriorly. The fibers ofthe lower trapezius can be traced as they attach fromthe medial aspect of the spine of the scapula, runningmedially and inferiorly to the spinous processes ofthe lower thoracic vertebrae. The fibers can be mademore prominent by asking the patient to depress thescapula. The fibers of the middle trapezius can be pal-pated from the acromion to the spinous processes ofthe seventh cervical and upper thoracic vertebrae. Themuscle is made more prominent by asking the patientto adduct the scapulae (Figure 8.15).

Pectoralis MajorThe pectoralis major is located on the anterior surfaceof the shoulder girdle. It is palpated from its attach-ment on the sternal aspect of the clavicle and alongthe sternum to the sixth or seventh rib, to its lateralattachment to the crest of the greater tubercle of thehumerus. It creates the inferior aspect of the deltopec-toral groove where it lies next to the deltoid muscle.The muscle forms the anterior wall of the axilla (Fig-ure 8.16).

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Pectoralismajor

Deltopectoralgroove

Figure 8.16 Palpation of the pectoralis major muscle.

DeltoidThe deltoid has proximal attachments to the lat-eral clavicle, acromion, and spine of the scapula.The fibers then converge and insert onto the deltoidtuberosity of the humerus. The deltoid has a largerounded mass, creating the full contour of the shoul-der (Figure 8.17). Atrophy can be caused by injury tothe upper trunk of the brachial plexus or to the ax-illary nerve, following fracture or dislocation of thehumerus. Start your examination by standing in frontof the patient. Allow your hand to travel from theclavicle inferiorly and laterally as you feel the fullnessof the muscle. Take note that the anterior fibers are su-perficial to the bicipital groove, making it difficult todistinguish whether tenderness in this area is from themuscle itself or the underlying structures. Continue byfollowing the middle fibers from the acromion to thedeltoid tuberosity. Note that the middle fibers over-lie the subdeltoid bursa. If the patient has bursitis,careful examination of the area will help differenti-ate the tender structures. A neoplasm affecting thediaphragm or cardiac ischemia can refer pain to thedeltoid.

Deltoid

Figure 8.17 Palpation of the deltoid muscle.

BicepsStand in front of the seated patient. Palpate the bicip-ital groove as described previously. Trace the longhead of the biceps tendon inferiorly through thegroove as it attaches to the muscle belly. Tenderness ofthe biceps tendon on palpation may indicate tenosyn-ovitis. This is also a site for subluxation or dislocationof the biceps tendon. The tendon of the short head canbe palpated on the coracoid process as previously de-scribed. The muscle belly is more prominent when thepatient is asked to flex the elbow. The distal aspectof the belly and the biceps tendon can be palpatedat its insertion on the bicipital tuberosity of the ra-dius. Palpate for continuity of the belly and tendon(Figure 8.18). If a large muscle bulge is noted on thedistal anterior aspect of the humerus with a concav-ity above it, you should suspect a rupture of the longhead of the biceps. A subluxation of the biceps ten-don secondary to a rupture of the transverse humeralligament is known as a snapping shoulder.

Posterior Aspect

Bony Structures

Spine of the ScapulaPalpate the posterior aspect of the acromion medi-ally along the ridge of the spine of the scapula as it

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Tendon oflong headof the biceps

Tendon ofshort headof the biceps

Bicipitalaponeurosis

Figure 8.18 Palpation of the biceps muscle.

tapers at the medial border. The spine of the scapulais located at the level of the spinous process of thethird thoracic vertebra (Figure 8.19). The spine of thescapula separates the supraspinous and infraspinousfossae and serves as the attachment of the supraspina-tus and infraspinatus muscles.

Medial (Vertebral) Border of the ScapulaMove superiorly from the medial aspect of the spineof the scapula until you palpate the superior angle,which is located at the level of the second thoracicvertebra. This area serves as the attachment of thelevator scapulae and is often tender to palpation. Inaddition, it is frequently an area of referred pain fromthe cervical spine. Continue inferiorly along the me-dial border and note whether it lies flat on the ribcage. If the border wings away from the cage, it maybe indicative of a long thoracic nerve injury. Noticethe attachment of the rhomboideus major along thelength of the medial border from the spine to the infe-rior angle. The inferior angle of the scapula is locatedat the level of the seventh thoracic vertebra and servesas the attachment of the latissimus dorsi and serratusanterior (Figure 8.20).

T3Spine of scapula

Figure 8.19 Palpation of the spine of the scapula.

T2

T7

Figure 8.20 Palpation of the medial border of the scapula.

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151Chapter 8 The Shoulder

Lateral borderof scapula

Inferior angleof scapula

Figure 8.21 Palpation of the lateral border of the scapula.

Lateral Border of the ScapulaContinue superiorly and laterally from the inferior an-gle along the lateral border of the scapula. The lateralborder is less defined than the medial border becauseof the muscle attachments of the subscapularis ante-riorly and the teres major and minor posteriorly. Theattachment of the long head of the triceps can also bepalpated on the infraglenoid tubercle, which is at thesuperior aspect of the lateral border (Figure 8.21).

Soft-Tissue Structures

Rhomboideus Major and MinorThe rhomboideus major originates from the spinousprocesses of T2–T5 and inserts on the medial bor-der of the scapula between the spine and the inferiorangle. The rhomboideus minor attaches from the lig-amentum nuchae and the spinous processes of C7 andT1 to the medial border at the root of the spine of thescapula. Stand behind the seated patient. The musclescan be located at the vertebral border of the scapula.You can more easily distinguish the muscle by hav-ing the patient place the hand behind the waist andadduct the scapula (Figure 8.22).

Rhomboids

Figure 8.22 Palpation of the rhomboideus major and minormuscles.

Latissimus DorsiThe latissimus dorsi attaches distally to the spinousprocesses of T6–T12, inferior three or four ribs, theinferior angle of the scapula, thoracolumbar fascia,iliac crest, and converges proximally to the intertu-bercular groove of the humerus. Palpation of the su-perior portion is discussed in the section on the pos-terior wall of the axilla. Continue to slide your handalong the muscle belly in an inferior and medial di-rection until you reach the iliac crest. The fibers aremuch harder to differentiate as you move inferiorly(Figure 8.23).

Medial Aspect

Soft-Tissue Structures

AxillaThe axilla has been described as a pentagon (Mooreand Dalley, 1999) created by the pectoralis major andminor anteriorly; the subscapularis, latissimus dorsi,and teres major posteriorly; the first four ribs withtheir intercostal muscles covered by the serratus ante-rior medially; and the proximal part of the humeruslaterally. The interval between the outer border of the

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152 The Shoulder Chapter 8

Figure 8.23 Palpation of the latissimus dorsi muscle.

first rib, the superior border of the scapula, and theposterior aspect of the clavicle forms the apex. Theaxillary fascia and skin make up the base. To ex-amine the axilla, face the seated patient. Supportthe patient’s abducted upper extremity by supportingthe forearm with the elbow flexed. Allow your oppo-site hand to gently but firmly palpate. Remember thatthis area is especially ticklish to palpation. The axillais clinically significant because it allows for passageof the brachial plexus and the axillary artery and veinto the upper extremity.

Allow your fingers to palpate the anterior wall andgrasp the pectoralis major between your thumb, indexand middle fingers. Move to the medial aspect of theaxilla and palpate along the ribs and serratus anterior.Move superiorly into the axilla and gently pull thetissue inferiorly, rolling it along the rib cage, to pal-pate the lymph nodes. Normal lymph nodes shouldnot be palpable in an adult. If palpable nodes arefound, they should be noted since they are indicativeof either an inflammation or a malignancy. Continueto palpate laterally and you will note the brachialpulse as you press against the proximal aspect of thehumerus, located between the biceps and triceps mus-

Brachialartery

Axillarylymphnodes

Figure 8.24 Palpation of the axilla.

cles. Continue to palpate the posterior wall and graspthe latissimus dorsi between your thumb, index, andmiddle fingers. While palpating the muscles, pay at-tention to their tone and size. Note whether they aresymmetrical bilaterally (Figure 8.24).

Serratus AnteriorThe description of this palpation is found in the pre-vious section on the axilla. The serratus anterior isimportant since it secures the medial border of thescapula to the rib cage (Figure 8.25). Weakness ordenervation will be observed as a winged scapula (seep. 20 for further information).

Lateral Aspect

Soft-Tissue Structures

Rotator CuffWhen the patient rests the arm at the side, the rotatorcuff tendons are located under the acromial arch atthe point of their attachment to the greater tubercleof the humerus. These tendons are referred to as theSIT muscles by virtue of the order of their attachmentfrom anterior to posterior: supraspinatus, infraspina-tus, and teres minor. The remaining muscle of therotator cuff is the subscapularis and is not palpable inthis position. To gain easier access to the tendons, ask

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153Chapter 8 The Shoulder

Axillarylymph nodes

Serratusanterior

Figure 8.25 Palpation of the serratus anterior muscle.

the patient to bring the arm behind the waist in inter-nal rotation and extension (Figure 8.26). You will beable to distinguish the tendons as a unit over the ante-rior aspect of the greater tubercle. If an inflammationis present, palpation of the tendons will cause pain.

Cyriax (1984) described a more specific methodof palpation of the individual tendons. To locate thesupraspinatus tendon, have the patient bend the el-bow to 90 degrees and place his or her forearm behindthe back. Then ask the patient to lean back onto theelbow in a half-lying position. This fixes the arm inadduction and medial rotation. You can localize thetendon by palpating the coracoid process and movinglaterally to the greater tubercle, under the edge of theacromion (Figure 8.27).

To locate the infraspinatus tendon, have the patientprop himself or herself up on the elbows. Ask the pa-tient to hold onto the edge of the treatment table tomaintain lateral rotation. Instruct the patient to shifthis or her weight over the arm being examined. Theweight of the trunk will help to uncover the greatertubercle. The combination of flexion, adduction, andlateral rotation brings the greater tubercle out later-ally. Palpate along the spine of the scapula laterallyand palpate the infraspinatus tendon on the head ofthe humerus (Figure 8.28).

Rotator

cuff

Subaromial

bursa

Figure 8.26 Palpation of the rotator cuff muscles.

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154 The Shoulder Chapter 8

Supraspinatus

Figure 8.27 Palpation of the supraspinatus tendon.

Subacromial (Subdeltoid) BursaThe subacromial bursa is located between the deltoidand the capsule. It is elongated under the acromionand coracoacromial ligament. This bursa does notcommunicate with the joint. The subacromial bursacan be easily inflamed and become impinged under

Figure 8.28 Palpation of the infraspinatus tendon.

Subacromial bursa

Figure 8.29 Palpation of the subacromial bursa.

the acromion by virtue of its position. It will be verytender to palpation if it is inflamed and a thicken-ing may be noted. It can be more easily palpated if itis brought forward from under the acromion by ex-tending and internally rotating the shoulder (Figure8.29).

Trigger Points of the ShoulderRegion

Myofascial pain of the shoulder girdle is extremelycommon, especially because of the occupationaloveruse that occurs in many patients. Trigger pointsaround the shoulder can mimic the symptoms of cer-vical radiculopathy or angina.

The common locations and referred pain zones fortrigger points for the levator scapulae, supraspinatus,infraspinatus, deltoid, subscapularis, rhomboideusmajor and minor, and pectoralis major are illustratedin Figures 8.30 through 8.36.

Active Movement Testing

Active movement testing can be performed eitherby having the patient perform individual specific

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155Chapter 8 The Shoulder

Levatorscapulae

Figure 8.30 Trigger points in the levator scapulae, shown with common areas of referred pain. (Adapted with permission from Travelland Rinzler, 1952.)

Supraspinatus

Figure 8.31 Trigger points of the supraspinatus muscle, shown with common areas of referred pain. (Adapted with permission fromTravell and Rinzler, 1952.)

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156 The Shoulder Chapter 8

(a)

(b)

Infraspinatus

Figure 8.32 Trigger points of the infraspinatus muscle, shown with common areas of referred pain. (Adapted with permission fromTravell and Rinzler, 1952.)

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157Chapter 8 The Shoulder

(a)

(b)

(c)

Deltoid

Figure 8.33 Trigger points of the deltoid muscle, shown with common areas of referred pain. (Adapted with permission from Travelland Rinzler, 1952.)

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158 The Shoulder Chapter 8

Subscapularis

Figure 8.34 Trigger points of the subscapularis muscle, shown with common areas of referred pain. (Adapted with permission fromTravell and Rinzler, 1952.)

Rhomboids

Figure 8.35 Trigger points of the rhomboid muscles, shown with common areas of referred pain. (Adapted with permission fromTravell and Rinzler, 1952.)

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159Chapter 8 The Shoulder

(c)

(b)

(a) Pectoralisminor

Pectoralismajor

Pectoralisminor

Pectoralismajor

Figure 8.36 Trigger points of the pectoralis major muscle, shown with common areas of referred pain. (Adapted with permission fromTravell and Rinzler, 1952.)

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160 The Shoulder Chapter 8

movements or by functionally combining the move-ments. The patient can perform the following move-ments: flexion and extension on the transverse axis,abduction and adduction on the sagittal axis, andmedial and lateral rotation on the longitudinal axis.These should be quick, functional tests designed toclear the joint. If the motion is pain free at the endof the range, you can add an additional overpres-sure to “clear” the joint. Be aware, however, thatoverpressure in external rotation can cause anteriordislocation of an unstable shoulder. If the patient ex-periences pain in any of these movements, you shouldcontinue to explore whether the etiology of the pain issecondary to contractile or noncontractile structuresby using passive and resistive tests.

Place the patient in either the sitting or standing po-sition. Have the patient repeat the movement so thatyou can observe from both the anterior and posterioraspect. Have the patient place the arms next to thebody. Ask the patient to abduct both arms out to 90degrees with the palms facing the floor. Direct the pa-tient to externally rotate the arms and bring the palmstogether overhead (Figure 8.37), which achieves theend of range for forward flexion and abduction. Ob-

serve the patient for symmetry of movement and theactual available range. Does the patient present witha painful arc (Cyriax, 1979) (pain-free movement ispresent before and after the pain occurs) secondaryto bursitis or tendinitis? Note that the dominant armmay be more limited even in normal activity. Is thepatient willing to move or is the patient apprehensivebecause of instability? From the posterior view, no-tice how the scapulae move. Is winging present? Markthe inferior angle of the scapula with your thumbsand observe them rotate upward. Note the scapulo-humeral rhythm. If a reverse scapulohumeral rhythmis noted, the patient may have a major shoulder dys-function such as an adhesive capsulitis or rotator cufftear. From the anterior view, note the symmetry andmovement of the sternoclavicular and acromioclavic-ular joints. From the lateral view, note whether thepatient is attempting to extend the spine so that itappears that the range is greater than it actually is.

Some clinicians prefer to have patients perform ab-duction in the neutral plane or plane of the scapula.This is located with the arm in approximately 30–45degrees of horizontal adduction from the midcoronalplane. This plane is less painful for the patient and

Abduction

Flexion

Figure 8.37 Active movement testing of shoulder abduction and flexion.

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161Chapter 8 The Shoulder

30°

Figure 8.38 Active movement testing of shoulder flexion in the plane of the scapula.

represents a more functional movement. There is lessstress on the capsule, making the movement easier toperform (Figure 8.38).

Have the patient abduct the shoulder to 90 de-grees with the elbow flexed to 90 degrees. Instructthe patient to reach across and touch the oppositeacromion. This movement will test for horizontal ad-duction (cross flexion). Then instruct the patient tobring the arm into extension while maintaining the90 degrees of abduction. This will test for horizontalabduction (cross extension) (Figure 8.39).

Figure 8.39 Active movement testing of shoulder in horizontaladduction and abduction.

Combined functional movements may save yourtime in the examination process. Be aware, however,that since you are testing several movements simul-taneously, determining the source of the limitation ismore difficult. Using the Apley “scratch” test (Magee,2002) will give you the most information most ef-ficiently. Ask the patient to bring one hand behindthe head and reach for the superior border of thescapula on the opposite side. This movement com-bines abduction and external rotation. Then ask thepatient to bring the opposite hand behind the backand reach up to touch the contralateral inferior angleof the scapula. This movement combines adductionand internal rotation. Then have the patient reversethe movements to observe the combination bilaterally(Figure 8.40).

Figure 8.40 Active movement testing using the Apley “scratch”test.

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Passive Movement Testing

Passive movement testing can be divided into two ar-eas: physiological movements (cardinal plane), whichare the same as the active movements, and mobilitytesting of the accessory (joint play, component) move-ments. You can determine whether the noncontractile(inert) elements are causative of the patient’s problemby using these tests. These structures (ligaments, jointcapsule, fascia, bursa, dura mater, and nerve root)(Cyriax, 1984) are stretched or stressed when the jointis taken to the end of the available range. At the endof each passive physiological movement, you shouldsense the end feel and determine whether it is normalor pathological. Assess the limitation of movementand see whether it fits into a capsular pattern. Thecapsular pattern of the shoulder is lateral rotation,abduction, and medial rotation (Kaltenborn, 1999).

Physiological Movements

You will be assessing the amount of motion availablein all directions. Each motion is measured from theanatomical starting position, which is 0 degrees offlexion–extension, with the upper arm lying parallelto the trunk, the elbow in extension, and the thumbpointing anteriorly (Kaltenborn, 1999). The patientshould be relaxed to enable you to perform the testswith greater ease. Testing can be performed with thepatient in the sitting position, but the supine posi-

tion and the prone position offer more stability bysupporting the patient’s trunk.

Flexion

The patient is placed in the supine position with thehip and knees flexed to 90 degrees to flatten the lum-bar lordosis. The shoulder is placed in the anatomicalstarting position. Place your hand over the lateral bor-der of the scapula to stabilize it and thereby accuratelyassess glenohumeral movement. Place your hand overthe lateral part of the rib cage to stabilize the thoraxand prevent spinal extension when you assess shoul-der complex movement. Face the patient’s side andstabilize either the scapula or the thorax with yourleft hand. Hold the distal part of the patient’s forearm,just proximal to the wrist joint, and move the upperextremity in an upward direction. When you sensemovement in the scapula, you will know that youhave reached the end of the available glenohumeralmovement. Continue to move the upper extremityuntil the end feel is noted for the entire range of mo-tion of the shoulder complex. The normal end feel ofglenohumeral flexion is abrupt and firm (ligamentous)(Magee, 2002; Kaltenborn, 1999) because of the ten-sion in the posterior capsule, muscles, and ligaments.The normal end feel of the shoulder complex is alsoabrupt and firm (ligamentous) due to tension in thelatissimus dorsi. The normal range of motion for flex-ion of the shoulder complex is 0–180 degrees (Figure8.41) (American Academy of Orthopedic Surgeons,1965).

Figure 8.41 Passive movement testing of shoulder flexion.

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Extension

The patient is placed in the prone position with theshoulder in the anatomical position. Do not place apillow under the patient’s head. The elbow shouldbe slightly flexed so that the long head of the bicepsbrachii is slack and does not decrease the availablerange. Place your hand over the superior and poste-rior aspect of the scapula to stabilize it, and therebyaccurately assess glenohumeral movement. Place yourhand over the lateral part of the rib cage to stabilizethe thorax and prevent spinal flexion while you as-sess shoulder complex movement. Face the patient’sside and stabilize either the scapula or the thorax withyour right hand. Place your hand under the distal an-terior aspect of the humerus and lift the upper extrem-ity toward the ceiling. The normal end feel is abruptand firm (ligamentous) due to tension from the an-terior capsule and ligaments. The normal end feel ofthe shoulder complex is also abrupt and firm (liga-mentous) due to tension in the pectoralis major andserratus anterior. Normal range of motion is 0–60degrees (Figure 8.42) (American Academy of Ortho-pedic Surgeons, 1965).

Abduction

The patient is placed in the supine position withthe shoulder in the anatomical starting position. The

Figure 8.42 Passive movement testing of shoulder extension.

elbow should be in extension to prevent limitation ofmotion from tension in the long head of the triceps.Place your hand over the lateral border of the scapula,stabilizing it for accurate assessment of glenohumeralmovement. Place your hand over the lateral part ofthe rib cage to stabilize the thorax and to preventspinal lateral flexion while you assess shoulder com-plex movement. Face the patient’s side and stabilizeeither the scapula or the thorax with your left hand.Hold the distal aspect of the patient’s arm, just proxi-mal to the elbow joint, and move the upper extremityin an outward direction. You must rotate the humeruslaterally before you reach 90 degrees to allow for thegreater tubercle of the humerus to pass more easilyunder the acromion and prevent impingement. Whenyou sense movement in the scapula, you will knowthat you have reached the end of the available gleno-humeral movement. Continue to move the upper ex-tremity until the end feel is noted for the entire rangeof motion of the shoulder complex. The normal endfeel of glenohumeral abduction is abrupt and firm (lig-amentous) (Magee, 2002; Kaltenborn, 1999) becauseof the tension in the inferior capsule and anterior andposterior muscles and ligaments. The normal end feelof the shoulder complex is also abrupt and firm (liga-mentous) due to tension in the posterior muscles. Thenormal range of motion for abduction of the shoul-der complex is 0–180 degrees (Figure 8.43) (AmericanAcademy of Orthopedic Surgeons, 1965).

Medial (Internal) Rotation

The patient is placed in the supine position with thehip and knees flexed to 90 degrees to flatten the

Figure 8.43 Passive movement testing of shoulder abduction.

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lumbar lordosis. The shoulder is placed at 90 degreesof abduction, with neutral position between supina-tion and pronation of the forearm, with the forearmat a right angle to the treatment table, and the pa-tient’s hand facing inferiorly. Support the elbow witha small folded towel so that the shoulder is not ex-tended. Stabilize the elbow to maintain 90 degrees ofabduction during the beginning of the movement. To-ward the end of the movement, you should stabilizethe scapula by placing your hand over the acromionto prevent anterior tilting. Place your hand over theanterior part of the rib cage, just medial to the shoul-der, to stabilize the thorax and prevent spinal flexionwhile you assess shoulder complex movement. Facethe patient’s side and stabilize either the scapula or thethorax with your right hand. Hold the distal aspect ofthe patient’s forearm, just proximal to the wrist joint,and move the upper extremity so that the palm movestoward the table. When you sense movement in thescapula, you will know that you have reached the endof the available glenohumeral movement. Continue tomove the upper extremity until the end feel is notedfor the entire range of motion of the shoulder com-plex. The normal end feel of glenohumeral medial ro-tation is abrupt and firm (ligamentous) (Magee, 2002;Kaltenborn, 1999) because of the tension in the poste-

rior capsule, muscles, and ligaments. The normal endfeel of the shoulder complex is also abrupt and firm(ligamentous) due to tension in the posterior muscles.The normal range of motion for medial rotation ofthe shoulder complex is 0–70 degrees (Figure 8.44)(American Academy of Orthopedic Surgeons, 1965).

Lateral (External) Rotation

Lateral rotation is performed with the body in thesame starting position as for medial rotation. Holdthe distal aspect of the patient’s forearm, just prox-imal to the wrist joint, and move the upper extrem-ity so that the dorsum of the hand moves towardthe table. When you sense movement in the scapula,you will know that you have reached the end of theavailable glenohumeral movement. Continue to movethe upper extremity until the end feel is noted forthe entire range of motion of the shoulder complex.The normal end feel of glenohumeral medial rota-tion is abrupt and firm (ligamentous) (Magee, 2002;Kaltenborn, 1999) because of the tension in the ante-rior capsule, muscles, and ligaments. The normal endfeel of the shoulder complex is also abrupt and firm(ligamentous) due to tension in the anterior muscles.The normal range of motion for lateral rotation of

Figure 8.44 Passive movement testing of shoulder medial rotation.

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Figure 8.45 Passive movement testing of shoulder lateral rotation.

the shoulder complex is 0–90 degrees (Figure 8.45)(American Academy of Orthopedic Surgeons, 1965).

Mobility Testing of AccessoryMovements

Mobility testing of accessory movements will give youinformation about the degree of laxity in the joint.The patient must be totally relaxed and comfortableto allow you to move the joint and obtain the most ac-curate information. The joint should be placed in themaximal loose packed (resting) position to allow forthe greatest degree of joint movement. The resting po-sition of the shoulder is abduction to approximately55 degrees and horizontal adduction to 30 degrees(Kaltenborn, 1999).

Traction (Lateral Distraction)

Place the patient in the supine position with the shoul-der in the resting position and the elbow in flexion.Stand on the side of the table so that your body isturned toward the patient. Place your hand over theacromion and the superior posterior aspect of thescapula for stabilization. Place your hand on the me-dial superior aspect of the humerus and support the

patient’s arm with your forearm. Pull the humerusaway from the patient until all the slack is taken up.This creates a lateral traction force and a separationof the humerus from the glenoid fossa (Figure 8.46).

Figure 8.46 Mobility testing of shoulder lateral distraction.

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Figure 8.47 Mobility testing of shoulder caudal glide.

Caudal Glide (Longitudinal Distraction)

Place the patient in the supine position with the shoul-der in the resting position. Stand on the side of thetable so that your body is turned toward the patient.Cup your hand over the lateral border of the scapulawith your thumb located up to the coracoid processfor stabilization. Place your other hand around thedistal aspect of the humerus, proximal to the elbowjoint. Pull the humerus in a caudal direction until allthe slack is taken up. This creates a caudal glide orlongitudinal traction force and a separation of thehumerus from the glenoid fossa (Figure 8.47).

Ventral Glide of the Humeral Head

Place the patient in the prone position so that thehumerus is just off the table. Place a small foldedtowel under the coracoid process to stabilize thescapula. The shoulder is placed in the resting posi-tion. Stand at the side of the table so that you arebetween the patient’s arm and trunk and your bodyis turned toward the patient’s shoulder. Hold the pa-tient’s humerus with one hand placed over the distalaspect. Place the other hand over the proximal aspectof the humerus, just distal to the glenohumeral joint.

Figure 8.48 Mobility testing of ventral glide of the humeralhead.

Move the humerus as a unit in an anterior directionuntil you take up all the slack. This creates an anteriorglide of the humeral head (Figure 8.48).

Dorsal Glide of the Humeral Head

Place the patient in the supine position so that thehumerus is just off the table. Place a small foldedtowel under the scapula to stabilize it. The shoulderis placed in the resting position. Stand at the side ofthe table so that you are between the patient’s armand trunk and your body is turned toward the pa-tient’s shoulder. Hold the patient’s humerus with onehand over the distal aspect and support the patient’sforearm by holding it between your arm and trunk.Place your other hand at the proximal end of thehumerus just distal to the glenohumeral joint. Movethe humerus as a unit in a posterior direction until youtake up all the slack. This creates a posterior glide ofthe humeral head (Figure 8.49).

Sternoclavicular Joint Mobility

Place the patient in the supine position. Stand at theside of the table so that you are facing the patient’shead. Palpate the joint space of the sternoclavicularjoint with the index finger of one hand. Place yourindex finger and thumb of the other hand aroundthe medial aspect of the clavicle. Move the clavicle

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Figure 8.49 Mobility testing of dorsal glide of the humeral head.

in cranial, caudal, anterior, and posterior directions.Take up the slack in each direction. This creates aglide of the clavicle in the direction of your force(Figure 8.50).

Figure 8.50 Mobility testing of the sternoclavicular joint.

Figure 8.51 Mobility testing of the acromioclavicular joint.

Acromioclavicular Joint Mobility

Place the patient in the supine position. Stand at theside of the table so that you are facing the patient’shead. Palpate the joint space of the acromioclavicularjoint with the index finger of one hand. Place yourindex finger and thumb on the anterior and posteriorsurfaces of the acromion to stabilize it. Place yourindex finger and thumb around the lateral aspect ofthe clavicle. Move the clavicle in an anterior and pos-terior direction. Take up the slack in each direction.This creates a glide of the clavicle in the direction ofyour force (Figure 8.51).

Scapular Mobilization

Place the patient in the side-lying position. Stand sothat you are facing the patient. Place one hand be-tween the patient’s upper extremity and trunk. Holdthe inferior angle of the scapula by placing your handso that your fingers grasp the medial border and yourpalm rests on the lateral border of the scapula. Placeyour other hand so that your thenar eminence is overthe acromion and your fingers surround the superiorposterior aspect of the scapula. Move the scapula incranial, caudal, medial, and lateral directions. Takeup the slack in each direction. This creates a glideof the scapula on the thorax in the direction of yourforce (Figure 8.52).

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Figure 8.52 Mobility testing of the scapula.

Resistive Testing

The muscles of the shoulder joint, in addition to beingresponsible for the movement of the arm, are neces-sary to maintain coaptation of the humeral head tothe glenoid fossa of the scapula. For example, dur-ing heavy lifting with the extremity, the long musclesthat include the triceps, coracobrachialis, and longand short heads of the biceps contract in an effort toraise the humeral head up to the scapula and preventits inferior dislocation.

As with most joints, weakness of a particular move-ment may be compensated for by other muscles. Thisis accomplished by substitution and is generally no-ticeable on examination as irregular or abnormalmovement of the body part. For example, weaknessor restricted abduction of the glenohumeral joint maybe compensated for by greater lateral rotation, eleva-tion, and abduction of the scapulothoracic joint (i.e.,shrugging of the shoulder). To test the strength of theshoulder, you will have to examine flexion, extension,abduction, adduction, internal (medial) rotation, andexternal (lateral) rotation.

The following movements of the scapula shouldalso be tested: elevation, retraction, protraction, andadduction with depression.

Shoulder Flexion

The primary flexors of the shoulder are the anteriorpart of the deltoid and the coracobrachialis (Figure8.53). Secondary flexors include the clavicular head ofthe pectoralis major, the middle fibers of the deltoid,

Deltoid muscle(anterior fibers)

Coracobrachialis

Figure 8.53 The primary flexors of the shoulder are the anteriorfibers of the deltoid and the coracobrachialis muscles.

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Figure 8.54 Testing shoulder flexion.

the biceps brachii, the serratus anterior, and thetrapezius.� Position of patient: Sitting with the arm at the side

and the elbow slightly flexed. The patient shouldthen attempt to flex the shoulder to about 90degrees without rotation or horizontaldisplacement.

� Resisted test: Stand beside the patient and placeone hand on the upper thorax to stabilize thebody, and place your other hand just proximal tothe elbow joint so that you can apply a downwardforce on the lower arm. Ask the patient to attemptto elevate the arm directly upward against yourresistance (Figure 8.54).Testing shoulder flexion with gravity eliminated

can be performed with the patient lying on the sidewith the tested arm upward. The arm is placed ona powdered board and the patient is asked to flexthrough the range of motion in the coronal plane (Fig-ure 8.55).

Painful resisted shoulder flexion may be due to ten-dinitis of the contracting muscles.

Weakness of shoulder flexion results in an inabilityto perform many activities of daily living and self-care.

Shoulder Extension

The primary extensors of the shoulder are the latis-simus dorsi, teres major, and the posterior fibers ofthe deltoid (Figure 8.56). Secondary extensors includethe teres minor and long head of the triceps.� Position of patient: In the prone position with the

shoulder internally rotated and adducted so thatthe palm is facing upward.

� Resisted test: Stabilize the thorax in its upperportion with one hand and hold the patient’s armproximal to the elbow with your other hand whileapplying downward resistance as the patientattempts to elevate the arm from the examiningtable straight upward (Figure 8.57).Testing shoulder extension with gravity eliminated

can be performed with the patient lying on the sidewith the tested arm upward. The arm is placed ona powdered board and the patient attempts to ex-tend the shoulder through the range of motion (Figure8.58).

Painful shoulder extension may be due to tendinitisof the contracting muscles.

Weakness of shoulder extension will limit the pa-tient’s ability to use their arms for climbing, walk withcrutches, swim, or row a boat.

Shoulder Abduction

The abductors of the shoulder are primarily the mid-dle portion of the deltoid and supraspinatus muscles(Figure 8.59). Assisting those muscles are the anteriorand posterior fibers of the deltoid and the serratusanterior by its direct action on the scapula to rotate itoutward and upward.� Position of patient: Sitting with the arm abducted

to 90 degrees and the elbow flexed slightly.� Resisted test: Stand behind the patient and put one

hand over the upper trapezius next to the neck tostabilize the thorax. Take your other hand andplace it over the arm just proximal to the elbowjoint and apply downward resistance as the patientattempts to abduct the arm upward (Figure 8.60).Testing shoulder abduction with gravity eliminated

is performed with the patient in the supine positionwith the arm at the side and the elbow flexed slightly.The patient attempts to abduct the arm with theweight of the arm supported by the examining tablethrough the range of motion (Figure 8.61).

Painful resisted shoulder abduction may be due totendinitis of the contracting muscles.

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Figure 8.55 Testing shoulder flexion with gravity eliminated.

Teresmajor

Latissimusdorsi

Posteriordeltoid

Figure 8.56 The primary extensors of the shoulder are thelatissimus dorsi and teres major muscles.

Weakness of shoulder abduction causes a signifi-cant restriction in the patient’s ability to perform ac-tivities of daily living and self-care.

Shoulder Adduction

The primary adductor of the shoulder is the pectoralismajor muscle (Figure 8.62). Accessory muscles in-clude the latissimus dorsi, the anterior portion of thedeltoid, and the teres major.� Position of patient: Supine with the shoulder

abducted to about 90 degrees. The patienthorizontally adducts the shoulder, bringing thearm across the chest.

� Resisted test: Place one hand behind the patient’sshoulder to stabilize the thorax. Take your otherhand and hold the patient’s arm with your thumbposteriorly so that you can apply a resisting forceaway from the midline of the patient as the patientattempts to adduct the arm against your resistance(Figure 8.63).Testing shoulder adduction with gravity eliminated

is performed with the patient sitting, with the upperextremity on an examining table and the elbow

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Figure 8.57 Testing shoulder extension.

extended. The patient attempts to swing the armforward across the body while the weight of thearm is supported by the examining table (Figure8.64).

Painful resisted shoulder adduction can be causedby tendinitis of the contracting muscles.

Weakness of shoulder adduction can result inrestricted bimanual activities. For example, carrying

a heavy object at the level of the waist would bedifficult.

Shoulder Internal (Medial) Rotation

The primary internal rotators of the shoulder are thelatissimus dorsi, teres major, subscapularis, and pec-toralis major (Figure 8.65).

Figure 8.58 Testing shoulder extension with gravity eliminated.

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Deltoid(middle fibers)

Supraspinatus

Figure 8.59 The primary abductors of the shoulder are themiddle fibers of the deltoid and the supraspinatus muscle.

� Position of patient: Prone with the arm abducted90 degrees and the elbow flexed to 90 degrees.

� Resisted test: Place one hand on the upper arm tostabilize it. Place your other hand above thepatient’s wrist and push downward as the patient

Figure 8.60 Testing shoulder abduction.

attempts to push your hand upward against yourresistance (Figure 8.66).Testing shoulder internal rotation with gravity

eliminated is performed by having the patient lieprone with the tested arm hanging from the tableand in external rotation. The patient attempts to in-ternally rotate the arm from the externally rotatedposition while you support the scapula and thoraxwith your forearm and hand (Figure 8.67).

Painful internal rotation may be due to tendinitisof the working muscles.

Shoulder External (Lateral) Rotation

The external rotators of the shoulder are the in-fraspinatus and teres minor muscles (Figure 8.68).The posterior fibers of the deltoid muscle assist in thismovement.� Position of patient: Prone with the shoulder

abducted to 90 degrees and the elbow bent at90 degrees. The upper arm is supported by theexamining table, with a pillow or folded towelplaced underneath the upper arm.

� Resisted test: While stabilizing the scapula withthe palm and fingers of one hand, take thepatient’s arm just above the wrist with your otherhand and apply downward resistance as thepatient attempts to upwardly rotate the shoulderso that the hand is elevated above the level of theexamining table (Figure 8.69).Testing shoulder external rotation with gravity

eliminated is performed with the patient in the proneposition, with the test arm dangling over the edge ofthe examining table in internal rotation. The patientattempts to externally rotate the arm while you stabi-lize the scapula with your hands (Figure 8.70).

Painful resisted external rotation may be due totendinitis of the working muscles.

Weakness of external rotation will prevent abduc-tion of the shoulder to more than 95 degrees dueto the impingement of the greater tuberosity of thehumerus against the acromion, secondary to inabilityto depress the humeral head.

Scapular Elevation (Shoulder Shrug)

The primary scapular elevators are the upper trapez-ius and levator scapulae muscles (Figure 8.71). Therhomboid muscles assist in this movement.� Position of patient: Standing with arms at the

sides.

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Figure 8.61 Testing shoulder abduction with gravity eliminated.

Pectoralisminor

Pectoralismajor

Figure 8.62 The primary adductor of the shoulder is thepectoralis major muscle.

Figure 8.63 Testing shoulder adduction.

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Figure 8.64 Testing shoulder adduction with gravity eliminated.

� Resisted test: Stand behind the patient, placingeach of your hands over the upper trapeziusmuscles. Ask the patient to shrug his or hershoulders against your resistance (Figure 8.72).Testing scapular elevation with gravity eliminated

is performed with the patient in the supine positionwith the arms at the sides. Ask the patient to shrughis or her shoulders in this position (Figure 8.73).

Painful resisted scapular elevation can be due totendinitis of the working muscles or a sprain of thecervical spine.

Costal view (Anterior)Subscapularis

Figure 8.65 The primary shoulder internal rotators are thesubscapularis, pectoralis major, and latissimus dorsi.

Weakness of scapular elevation may be due to cra-nial nerve damage and other brain stem signs shouldbe searched for. The spinal accessory nerve may becut during a radical neck dissection.

Scapular Retraction

The scapular retractors are the rhomboideus majorand minor muscles, assisted by the middle fibers ofthe trapezius (Figure 8.74).� Position of patient: Standing with the arm

adducted and the elbow slightly bent. Thehumerus is slightly extended.

� Resisted test: Stand beside the patient and placeyour hand so that you are cupping the elbow. Askthe patient to resist as you attempt to abduct thescapula, using his or her arm as leverage (Figure8.75).Testing scapular retraction with gravity eliminated

is performed with the patient in the same position.Painful scapular retraction may be due to tendinitis

of the contracting muscles or disorders of the thoracicspine.

Weakness of scapular fixation by the rhomboidmuscles leads to weakness of humeral adduction andextension.

Scapular Protraction

The serratus anterior muscle is the primary scapularprotractor (Figure 8.76). This muscle maintains theinferior angle of the scapula against the thoracic walland rotates the inferior angle upward.� Position of patient: Standing with the test arm

flexed forward approximately 90 degrees and theelbow bent also about 90 degrees.

� Resisted test: Stand behind the patient and placeone hand over the thoracic spine for stabilization.Take your other hand and hold the proximalaspect of the patient’s forearm and elbow andattempt to pull the arm backward toward youfrom this point while the patient attempts to pushthe arm forward (Figure 8.77).

Testing scapular protraction with gravity eliminatedis performed with the patient in the sitting position(Figure 8.78).

Painful scapular protraction may be due to tendini-tis of the contracting muscles.

Weakness of the serratus anterior muscle is fre-quently caused by damage to the long thoracic nerve.This nerve is comprised of C5, C6, and C7 nerveroots. The result of weakness of this muscle is a me-dial winging of the scapula. This can be elicited by

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Figure 8.66 Testing shoulder internal rotation.

asking the patient to push against the wall, as shownin Figure 8.79. The scapula wings out medially be-cause the trapezius muscle maintains the medialscapular border close to the vertebral column.

Figure 8.67 Testing shoulder internal rotation with gravityeliminated.

The inability to abduct and rotate the scapulaprevents the patient from being able to forwardflex the arm to the complete upright position(Figure 8.80).

Infraspinatus

Teres minor

Figure 8.68 The primary external rotators of the shoulder arethe infraspinatus and teres minor.

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Figure 8.69 Testing external rotation.

Figure 8.70 Testing external rotation with gravity eliminated.

Trapezius(superior fibers)

Levatorscapulae

Figure 8.71 The primary scapular elevators are the superiorfibers of the trapezius and the levator scapulae muscles.

Figure 8.72 Testing scapular elevation.

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Figure 8.73 Testing scapular elevation with gravity eliminated.

Neurological Examination

Motor

The innervation and spinal levels of the muscles thatfunction in the shoulder are listed in Table 8.1.

Reflexes

The pectoralis major jerk test is performed to test theC5 nerve root and pectoralis major muscle (Figure

Rhomboideusmajor

Trapezius middle fibers(Overlay the rhomboids)

Rhomboideusminor

Figure 8.74 The scapular retractors are the rhomboideus major,rhomboideus minor, and the middle fibers of the trapeziusmuscles.

8.81). Perform the reflex test by having the patientlie in the supine position and placing your thumbover the tendon of the pectoralis major muscle justproximal to the shoulder joint. Tap your thumb withthe reflex hammer and observe for contraction ofthe pectoralis major muscle. The shoulder may alsoadduct somewhat during this reflex. Compare yourfindings with those from the opposite side. This reflexwill be absent if there is severe injury to the pectoralismajor muscle, medial and lateral pectoral nerves,upper trunk of the brachial plexus, or C5 nerveroot.

Sensation

Light touch and pinprick sensation should be ex-amined after the motor and reflex examination. Thedermatomes for the shoulder are C4, C5, C6, andC7. The upper thoracic (T2, T3) dermatomes areresponsible for the axilla and medial aspect of the arm(Figure 8.82). Peripheral nerves providing sensationin the shoulder region are shown in Figures 8.83 and8.84.

Damage to the axillary or the musculocutaneousnerves can result from shoulder dislocation, and thesensory areas of these nerves should be examinedcarefully when the patient presents with a dislocation(Figure 8.85).

The suprascapular nerve may be damaged dueto acromioclavicular joint separation or a ganglioncyst and this will result in pain and atrophy of thesupraspinatus and infraspinatus muscles. Forced ad-duction of the arm across the chest worsens the paindue to stretching of the suprascapular nerve (Figure8.86).

Damage to the upper trunk of the brachial plexus,which comprises the C5 and C6 nerve roots, leads toan Erb–Duchenne palsy of the upper extremity. Thismay be caused at birth by trauma due to shoulderdystocia or may be congenital. Characteristic postureand weakness as well as sensory loss result (Figure8.87).

The spinal accessory nerve may be injured duringsurgery, and if the branch to the trapezius muscles isdestroyed, the patient will present with an inabilityto shrug the shoulder and a lateral winging of thescapula. The scapula will move posteriorly awayfrom the thorax, as in medial winging. However, themedial border of the scapula is set laterally awayfrom the spinous processes by the strong serratusanterior.

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Levatorscapulae

Trapezius (superior fibers)

Trapezius (middle fibers)

Trapezius (lower fibers)

Rhomboideus minor

Rhomboideus major

Figure 8.75 Testing scapular retraction.

SerratusAnterior

Figure 8.76 The primary scapular protractor is the serratusanterior muscle.

Figure 8.77 Testing scapular protraction.

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179Chapter 8 The Shoulder

Figure 8.78 Testing scapular protraction with gravity eliminatedis performed with the patient in a sitting position with the armoutstretched on a table in front. Ask the patient to bring theentire extremity forward and watch for movement of thescapula away from the midline.

Special Tests

Tests for Structural Stability andIntegrity

Many tests have been devised to examine the shoul-der for stability in the anterior, posterior, and inferiordirections. There are also tests to examine the pa-tient for multidirectional instability. All the tests areperformed by applying passive forces to the gleno-humeral joint in different directions. A great dealof experience is necessary to evaluate the degree ofshoulder instability correctly.

Anterior Instability Tests

Anterior Instability Test (Rockwood Test)This test is used to evaluate the degree to which thehumeral head can be anteriorly subluxed from theglenoid cavity of the scapula (Figure 8.88a–8.88d).The patient is standing. Stand behind the patient and

Figure 8.79 Medial winging of the scapula is caused byweakness of the serratus anterior muscle. This is frequentlycaused by damage to the long thoracic nerve (C5, C6, and C7nerve roots).

Figure 8.80 Note that with weakness of the right serratusanterior, the patient is unable to fully rotate and abduct thescapula as compared to the left side. The result is an inability toforward flex the arm completely upward.

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180 The Shoulder Chapter 8

Table 8.1 Movements and innervation of shoulder muscles.

Movement Muscles Innervation Root level

Forward flexion 1 Deltoid Axillary C5, C62 Pectoralis major (clavicular fibers) Lateral pectoral C5, C6, C73 Coracobrachialis Musculocutaneous C6, C74 Biceps Musculocutaneous C5, C6

Extension 1 Deltoid (posterior fibers) Axillary C5, C62 Teres major Subscapular C5, C63 Teres minor Axillary C54 Latissimus dorsi Thoracodorsal C6, C7, C85 Pectoralis major (sternocostal fibers) Lateral pectoral C5, C6, C7

Medial pectoral C7, C8, T16 Triceps (long head) Radial C7, C8

Abduction 1 Deltoid Axillary C5, C62 Supraspinatus Suprascapular C53 Infraspinatus Suprascapular C5, C64 Subscapularis Subscapular C5, C65 Teres major Axillary C5

Adduction 1 Pectoralis major Lateral pectoral C5, C6, C72 Latissimus dorsi Thoracodorsal C6, C7, C83 Teres major Subscapular C5, C64 Subscapularis Subscapular C5, C6

Internal (medial) rotation 1 Pectoralis major Lateral pectoral C5, C6, C72 Deltoid (anterior fibers) Axillary C5, C63 Latissimus dorsi Thoracodorsal C6, C7, C84 Teres major Subscapular C5, C65 Subscapularis Subscapular C5, C6

External (lateral) rotation 1 Infraspinatus Suprascapular C5, C62 Deltoid (posterior fibers) Axillary C5, C63 Teres minor Axillary C5

Elevation of scapula 1 Trapezius (upper fibers) Accessory Cranial nerve XIC3, C4 nerve roots C3, C4 roots

2 Levator scapulae C3, C4 nerve roots C3, C4 rootsDorsal scapular C5

3 Rhomboideus major Dorsal scapular C54 Rhomboideus minor Dorsal scapular C5

Retraction (backward movement of scapula) 1 Trapezius Accessory Cranial nerve XI2 Rhomboid major Dorsal scapular C53 Rhomboideus minor Dorsal scapular C5

Protraction (forward movement of scapula) 1 Serratus anterior Long thoracic C5, C6, C72 Pectoralis major Lateral pectoral C5, C6, C73 Pectoralis minor Medial pectoral C7, C8, T14 Latissimus dorsi Thoracodorsal C5, C6, C7

hold his or her arms just proximal to the wrists withyour hands and laterally rotate the shoulders. Thenabduct the arms to 45 degrees and again passivelyrotate the shoulders laterally. This same procedure isrepeated at 90 and 120 degrees. At 0 degree, there israrely any complaint of apprehension or pain. At 45and 120 degrees, the patient may show some signsof apprehension. The test result is positive when thepatient shows marked apprehension and pain pos-

teriorly when the arm is at 90 degrees of abduction.This is due to anterior capsular/labral insufficiency.

Rowe, Volk, Gerber, and Ganz have describedother tests for anterior instability.

Apprehension Test for Anterior Shoulder Dislocation(Crank Test)The result of this test is frequently positive in patientswho have had recent shoulder dislocation or are prone

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181Chapter 8 The Shoulder

Figure 8.81 Testing the pectoralis reflex (C5 nerve root).

to recurrent shoulder dislocation. Ninety-five percentof shoulder dislocations occur anteriorly. The patientwith acute shoulder dislocation shows a characteris-tic posture of the arm held close to the body, witha prominent acromion and a depression below thedeltoid. Any movement of the arm or shoulder is ex-tremely painful.

The apprehension test is performed with the patientin the supine position. Take the patient’s forearm withone hand and support the patient’s upper arm posteri-orly with your other hand. Gently and slowly abductand externally (laterally) rotate the arm. A positivefinding is noted when the patient appears to be afraidthat the arm may dislocate. The patient may resistfurther motion and may state that the shoulder feelsas though it is going to pop out (see Figure 8.89).

As you are performing this test, note the degreeof external rotation at which the patient begins tobecome apprehensive. At this point, put a posteriorstress on the humerus with one of your hands bypressing on the proximal part of the humerus ante-riorly. You may now be able to further externallyrotate the arm with this posterior stress. This is calleda relocation test (Fowler or Jobe relocation test).

Posterior Instability Tests

Posterior Drawer Test of the ShoulderThis test is used to determine whether there is poste-rior shoulder instability. The test is performed withthe patient in the supine position. Stand next to thepatient and grasp the proximal end of the forearmwith one hand while allowing the elbow to flex to

120 degrees. Now position the shoulder so that it isin 30 degrees of forward flexion and approximately100 degrees of abduction. Take your other hand andstabilize the scapula by placing your index and mid-dle fingers on the spine of the scapula and your thumbover the coracoid process. Now flex the shoulder for-ward to 80 degrees and rotate the forearm medially.While doing this with one hand, move your thumboff the coracoid process and push the head of thehumerus posteriorly. You should be able to palpatethe head of the humerus with the index finger of yourhand. If this test causes apprehension in the patient,or if there is greater posterior mobility of the humeralhead than on the opposite side, the test result is posi-tive and indicates posterior instability (Figure 8.90a–8.90d).

Inferior Instability Tests

Feagin TestThe patient sits on the examination table with theirshoulder abducted to 90 degrees, elbow in full exten-sion and arm resting on your shoulder.

This test is used to assess the presence of humeralhead inferior subluxation, caused by damage to theinferior glenohumeral ligament. Place both of yourhands along the proximal humerus over the deltoidwhile interlocking your fingers. Apply an inferiorlydirected force to the humerus and palpate for inferiormovement. Also, observe the patient for apprehen-sion or discomfort. Abnormal inferior motion of thehumerus and/or patient apprehension is indicative ofinferior glenohumeral instability (Figure 8.91).

Sulcus SignInstruct the patient to stand with their arm relaxedat their side. Gently distract the arm inferiorly. Thepresence of a sulcus, space, distal to the acromionmay be indicative of inferior glenohumeral instability(Figure 8.92).

Multidirectional Instability Tests

Multidirectional Instability TestThis test is performed to find multidirectional or in-ferior instability of the shoulder joint. It can be donewith the patient sitting or lying down. Traction alongthe long axis of the humerus is performed by plac-ing one hand on the scapula for stabilization, withyour index finger just below the acromion. Take yourother hand and apply downward traction force on thehumerus by holding the middle part of the patient’s

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182 The Shoulder Chapter 8

C4

T2

C5

C5

C6

C6

T3T4

T6 T5

C7

Key sensoryarea for C4

Key sensoryarea for T2

Figure 8.82 The dermatomes of the shoulder and axilla. Note the key sensory areas for the C4 and T2 dermatomes in this region.

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183Chapter 8 The Shoulder

1

1

2

2

3

3

6

6

8

5

5

Anterior view

Figure 8.83 The nerve supply and distribution of the shoulderin the anterior view. 1 = supraclavicular nerve (C3, C4); 2 =upper lateral cutaneous (axillary) (C5, C6); 3 =intercostobrachial (T2); 4 = posterior cutaneous nerve of thearm (radial) (C5–C8); 5 = lower lateral cutaneous nerve (radial)(C5, C6); 6 = medial cutaneous nerve of the arm (C8, T1); 7 =posterior cutaneous nerve of the forearm (radial) (C5–C8); 8 =medial cutaneous nerve of the forearm (C8, T1).

forearm. Try to appreciate a palpable gap betweenthe acromion and the humerus, which indicates infe-rior instability. The patient may have a notable gap,on observation, below the acromion. This is called asulcus sign. This is very common in stroke patients(Figures 8.91 and 8.92a).

Rowe Multidirectional Instability TestWhile standing, the patient bends forward slightlywith the arm relaxed. Palpate using your thumb andindex finger around the humeral head. Position thearm in 20–30 degrees of extension and push anteri-orly on the proximal humerus to determine whetherthere is anterior instability. Position the arm in 20–30degrees of flexion and push posteriorly to determinewhether there is posterior instability. Distract thearm slightly inferior and pulling on the forearm todetermine if there is inferior instability (Figure 8.93).

1

1

2

2

3

5

7

3

6

4

6

7

5

4

Posterior view

Figure 8.84 The nerve supply and distribution of the shoulderin the posterior view. 1 = supraclavicular nerve (C3, C4); 2 =upper lateral cutaneous (axillary) (C5, C6); 3 =intercostobrachial (T2); 4 = posterior cutaneous nerve of thearm (radial) (C5–C8); 5 = lower lateral cutaneous nerve (radial)(C5, C6); 6 = medial cutaneous nerve of the arm (C8, T1); 7 =posterior cutaneous nerve of the forearm (radial) (C5–C8); 8 =medial cutaneous nerve of the forearm (C8, T1).

Tests for Labral Tears

Clunk Test

This test is performed to confirm a tear of the glenoidlabrum. The patient is in supine. Place one hand onthe arm above the elbow and put your other hand overthe humeral head. Now, bring the arm into full ab-duction. Push the humeral head anteriorly while yourother hand laterally rotates the humerus. A grind-ing sound or “clunk” indicates a labral tear (Figure8.92b).

SLAP Lesions

Biceps Tension Test

Resist forward flexion of the shoulder with the el-bow extended and the wrist supinated. If the patient

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184 The Shoulder Chapter 8

Dislocation

Figure 8.85 Appearance of a dislocated right shoulder. Alwaysassess the patient for neurovascular damage when a dislocationis suspected.

reports pain, the test is considered positive for bicepstendon pathology (Figure 8.94).

Biceps Load Test

Place the patient in supine. Abduct the shoulder to120 degrees, with maximum external rotation. Flexthe elbow to 90 degrees and supinate the forearm. Ifthis test position is painful, ask the patient to flex hiselbow against your resistance. Active elbow flexionwill increase the pain. The test is negative if the painis not increased by elbow flexion. A positive test oc-curs since contraction of the biceps in this shoulderposition places increased tension on the torn supe-rior labral tissue, leading to worsening of the pain(Figure 8.95).

Active Compression Test of O’Brien

Place the patient in the standing position. Ask thepatient to place his arm, with the elbow extended,in 90 degrees of flexion. Adduct the arm 10 degreesfrom the midline and internally rotate (thumb point-ing down). You should stand behind the patient andapply force in a downward direction. Allow the armto return to the starting position and then repeat thetest in full external rotation/supination (palm facingupward). The test is considered to be positive if pain isproduced inside the shoulder during the initial part of

Suprascapular nervecan be compressed

against the spine ofthe scapula

Figure 8.86 The location of the suprascapular nerve close to theskin can cause it to be compressed against the underlying bone.

Figure 8.87 Characteristic position of a patient with anErb–Duchenne palsy of the upper extremity, also referred to as awaiter’s tip posture. The shoulder is internally rotated andadducted, and the wrist is flexed.

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185Chapter 8 The Shoulder

(a) (b)

(c) (d)

Figure 8.88 Anterior instability test (Rockwood test). This test is used to identify weakness or insufficiency of the anterior capsular andlabral structures. (a) With the arms at the sides. (b) With the arm in 45 degrees of abduction. (c) With the arm at 90 degrees ofabduction. Look for apprehension and posterior pain in this position, for a positive test result. (d) With the arm at 120 degrees.

the test and if the pain is decreased while performingthe test in the externally rotated position. If the testis correlated with a positive Speed’s test, an anteriortype II SLAP (superior labrum anterior–posterior)tear can be diagnosed (Figure 8.96).

SLAP Prehension Test

Place the patient in either the sitting or standing po-sition. Ask the patient to place his arm in 90 degrees

of abduction with the elbow extended and the fore-arm pronated (thumb pointing down). This posi-tion puts tension on the long head of the bicepsand traps the torn labral tissue between the glenoidand humeral head. This may cause pain in theregion of the bicipital groove with or without an au-dible or palpable click. The test should then be re-peated with the forearm in supination (thumb point-ing up). The test is positive only if the pain is

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186 The Shoulder Chapter 8

Figure 8.89 The anterior apprehension test.

(a) (b)

(c) (d)

Figure 8.90 Test for posterior drawer of the shoulder. (a and b) How the test is performed. (c and d) The test with a superimposeddrawing of the bones on the skin.

reduced or disappears when the forearm is supinated(Figure 8.97).

Tests for the Acromioclavicular Joint

Cross-Flexion Test

By taking the patient’s arm and abducting it to 90degrees, and flexing the arm across the body, you canexacerbate the pain emanating from the acromioclav-icular joint. Palpate the joint with your thumb whileforcing cross-flexion of the patient’s arm with yourother hand (Figure 8.98).

Acromioclavicular Shear Test

This test is used to determine whether the source ofpain is the acromioclavicular joint. With the patient inthe seated position, cup your hands over the anteriorand posterior aspects of the shoulder. Squeeze theclavicle and scapular spine toward each other withyour palms. This compresses the acromioclavicular

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187Chapter 8 The Shoulder

Figure 8.91 Feagin test.

joint. The result is positive if the patient complains ofpain or if you note any abnormal movement (Figure8.99).

Scapula Stability Tests

Wall Push-up Test

Ask the patient to stand arms length from the wall.Instruct them to perform 10–20 repetitions of wallpush-ups. The test is positive if weakness of thescapula muscles or winging of the scapula is noted(Figure 8.99).

Test for Tendinous Pathology

Yergason’s Test of the Biceps

This test stresses the long head of the biceps tendon inthe bicipital groove to determine if it remains withinthe groove. The patient is in the standing positionwith you at the side. Take the patient’s elbow withone hand and grasp the forearm with the other.The patient’s elbow should be flexed to 90 degreesand the arm should be against the thorax. Ask thepatient to resist external rotation of the arm as youpull the forearm toward you. At the same time, pushdownward as the patient also resists flexion of the el-bow. Resistance of attempted supination can also beincluded. If the biceps tendon is unstable within thebicipital groove, the patient will experience pain andthe tendon may pop out of place (Figures 8.100a and8.100b).

Sulcussign

Acromium

Humeralhead

(a)

(b)

Figure 8.92 (a) The appearance of a gap below the acromion ina patient who has hemiplegia. (b) The clunk test for glenoidlabral tears.

Speed’s Test of the Biceps

This test is used to confirm biceps tendinitis or partialrupture of the tendon. The patient is sitting withthe elbow fully extended and the shoulder forwardflexed to 90 degrees. Resist forward flexion with

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188 The Shoulder Chapter 8

(c)(b)(a)

Figure 8.93 Rowe multidirectional instability test. (a) Test for anterior instability. (b) Test for posterior instability. (C) Test for inferiorinstability.

the forearm in supination. The test is positive whenthe patient feels pain in the bicipital groove (Figure8.100c).

Tests for Impingement of theSupraspinatus Tendon

Hawkins–Kennedy Supraspinatus Impingement Test

This test brings the supraspinatus tendon against theanterior portion of the coracoacromial ligament. Withthe patient standing, take the arm and forward flex

Figure 8.94 Biceps tension test. Resist active flexion of theshoulder.

the shoulder to 90 degrees; then forcibly internallyrotate the shoulder. This will cause pain if the patienthas supraspinatus tendinitis (Figure 8.101).

Yocum Test

This is a variation of the Hawkins–Kennedy test. Askthe patient to abduct the affected arm to 90 degreesand place their hand on the opposite shoulder. In-struct the patient to elevate the elbow without allow-ing them to shrug their shoulder. The test is positiveif the patient reports pain (Figure 8.102).

Figure 8.95 Biceps load test. If the starting position is painful,resist active elbow flexion to determine if pain is increased.

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189Chapter 8 The Shoulder

(b)(a)

Figure 8.96 Active compression test of O’Brien. (a) Apply a downward force with shoulder internally rotated. (b) Apply a downwardforce with shoulder externally rotated.

Neer Impingement Test

Test the patient in either sitting or standing. Place onehand on the posterior aspect of the scapula to stabilizethe shoulder girdle. With your other hand, internallyrotate the patient’s arm by grasping it near the el-

bow and raise it into full forward flexion. The test ispositive if the patient reports pain from 70 to 120 de-grees of forward flexion, as the rotator cuff comesinto contact with the coracoacromial arch (Figure8.103).

(b)(a)

Figure 8.97 SLAP prehension test. (a) If this position is painful, check if pain is reduced by changing to the posture as in (b). The test ispositive if pain is reduced.

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190 The Shoulder Chapter 8

30°

Figure 8.98 The cross-flexion test.

Supraspinatus Test (Empty Can Test)

This test is also performed to examine the supraspina-tus tendon for pathology. The patient can be sittingor in the supine position. Stand in front of the patientand have him or her abduct the shoulder to 90 de-grees and then forward flex the arm approximately

Figure 8.99 Wall push-up test.

30 degrees with the arm internally rotated so thatthe thumb points down to the ground. Place yourhand over the patient’s elbow and apply downwardpressure as the patient attempts to raise the arm up-ward against your resistance. If this is painful, the pa-tient likely has pathology of the supraspinatus muscleor tendon or involvement of the suprascapular nerve(Figure 8.104). A variation of this test is referred toas the full can test. The patient repeats the test asdescribed above with their arm in external rotation.This is thought to allow for a better contraction ofthe supraspinatus muscle.

Tests for Muscle Pathology

Drop Arm Test

This test is performed to determine whether there isa tear of the rotator cuff tendons. The patient canbe standing or sitting. Stand behind the patient andabduct the arm to 90 degrees passively with the elbowextended. Ask the patient to slowly lower the armback to the side. The test result is positive if the patientis unable to lower the arm slowly (i.e., it drops), orif the patient has severe pain while attempting thismaneuver (Figures 8.105a and 8.105b).

Lift-Off Test (Gerber’s Test)

This is a test for the subscapularis muscle. The sub-scapularis muscle internally rotates and extends theshoulder. This test can only be performed if the pa-tient has full active internal rotation of the shoulderso that he may achieve the starting position. Examinethe patient in standing. Ask the patient to place hishand behind his back with the dorsum of the handresting on the mid-lumbar spine. Then, ask the pa-tient to raise the dorsum of his hand away from hisback. The test is normal if the patient can activelylift the dorsum of the hand off the back. If he cannotlift off his hand, there is damage to the subscapularismuscle or tendon (Figure 8.106).

Lateral Rotation Lag Sign (Infraspinatus SpringBack Test)

This is a test for the posterosuperior rotator cuff. Askthe patient to sit on the examination table with hisback to you. Hold the patient’s wrist. Passively abductthe shoulder to 90 degrees in the plane of the scapula,flex the elbow to 90 degrees, and move the shoulder

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191Chapter 8 The Shoulder

(a)Tendon of the

long head of biceps

Transverse humeralligament

Coracoidprocess

Short head ofthe biceps

(b)

(c)

Figure 8.100 (a) The Yergason’s test for integrity of the long head of the biceps tendon in the bicipital groove. (b) If the ligament thatrestrains the long head of the biceps tendon within its groove is damaged, the biceps will sublux, as shown. (c) Speed’s test for bicepstendinitis.

to near maximal external rotation. Ask the patient toactively maintain the position of external rotation inabduction. Continue to support the elbow, but releaseyour hold at the wrist. The degree of movement isestimated and is referred to as the lag. This lag equalsthe difference between passive and active ROM (rangeof motion). For small ruptures of the infraspinatus orteres minor, the lag may be as little as 5 degrees. A

greater lag suggests a larger disruption of the musclesor tendons (Figure 8.107).

Hornblower’s Sign

This test is used to determine whether the teres mi-nor and infraspinatus tendons are damaged. Ask thepatient to either sit or stand. Abduct the shoulder

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192 The Shoulder Chapter 8

Figure 8.101 The supraspinatus impingement test(Hawkins–Kennedy).

Figure 8.102 Yocum test.

Figure 8.103 Neer impingement test. Flex and internally rotatethe patient’s shoulder.

30°

Figure 8.104 The supraspinatus test.

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193Chapter 8 The Shoulder

(a)

(b)

Figure 8.105 (a) The patient’s arm is passively elevated by theexaminer. (b) The patient’s arm drops suddenly due to aninability to hold the arm up as a result of tears in the rotator cuff.

(b)(a)

Figure 8.106 Lift-off test (Gerber’s test). (a) Starting position. (b) Patient attempts to lift “off” his hand and wrist away from his back.

Figure 8.107 Lateral rotation lag sign (infraspinatus spring backtest). This is the starting position. When you release the hand, itwill “spring forward.”

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194 The Shoulder Chapter 8

(b)(a)

Figure 8.108 Hornblower’s sign. (a) Normal result. (b) Patient is unable to abduct the left upper extremity to reach the same level asthe mouth.

to 90 degrees and support the arm in the scapularplane. Ask the patient to flex the elbow to 90 degrees.The patient then tries to externally rotate the armagainst resistance. The sign is positive if the patientis unable to maintain the externally rotated positionand the arm drops back to the neutral position. Analternate method is to ask the patient to bring bothhands to their mouth, as though they were trying toblow a horn. The test is positive if the patient is un-able to reach their mouth without abducting their arm(Figure 8.108).

Checkthe pulse

Subclavianartery and vein

Internal jugularvein

Rightcommoncarotidartery

Brachiocephalictrunk

Rightbrachiocephalic

vein

1st rib

Axillary arteryand vein

Medial brachialcutaneous nerve

Medial antebrachialcutaneous nerve

(a) (b)

Ulnar nerve

Radial nerve

Median nerve

Axillary nerve

Musculocutaneousnerve

Pectoralis minor

Suprascapularnerve

Figure 8.109 (a) The structures of the thoracic outlet. Note the position of the nerves, arteries, and veins as they pass over the first riband beneath the pectoralis minor muscle. (b) Adson’s maneuver for testing for thoracic outlet syndrome.

Tests for Thoracic Outlet Syndrome

The tests used for diagnosis of thoracic outlet syn-drome attempt to narrow the thoracic outlet and re-produce symptoms or signs of neurovascular com-pression (numbness, tingling, pain, loss of palpablepulses) (Figure 8.109a).

Adson’s Maneuver

The patient is sitting and the arm is outstretched.Find the patient’s radial pulse with one hand. While

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195Chapter 8 The Shoulder

(a)

(b)

Figure 8.110 (a) Wright’s maneuver for testing for thoracicoutlet syndrome. (b) Roos test for thoracic outlet syndrome.

palpating the pulse, ask the patient to turn his or herhead so as to face the test shoulder. Then ask the pa-tient to extend the head while you laterally rotate andextend the patient’s shoulder and arm. Now ask thepatient to take a deep breath and hold it (Valsalva’smaneuver). A disappearance of the pulse indicates apositive test result (Figure 8.109b). This occurs be-cause the anterior scalene muscle is being stretchedand it pulls the first rib upward, narrowing the tho-racic outlet.

Wright’s Maneuver

The patient is seated, with you on the side to be tested.Palpate the patient’s radial pulse with one hand. Askthe patient to rotate the head away from you and thetest shoulder. Ask the patient, at the same time, toelevate the chin in a torsional manner, again away

Cervicalspine

Elbow

GallbladderSpleen

Diaphragm

HeartLungs

Figure 8.111 Structures referring pain to the shoulder. Theseorgans have a common embryological origin with themidcervical spine and therefore may radiate pain to theshoulder.

from the side that is being tested. Now ask the pa-tient to take a deep breath and hold it in (Valsalva’smaneuver). The test result is positive if symptoms areaggravated or precipitated, or if the pulse is no longerpalpable (Figure 8.110a).

Figure 8.112 Internal rotation view of the shoulder.

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196 The Shoulder Chapter 8

Figure 8.113 External rotation view of the shoulder.

Figure 8.114 Magnetic resonance image of the shoulder(* = rotator cuff).

Roos Test

The patient stands and abducts and externally rotatestheir arms. The elbows are flexed to 90 degrees. Thepatient then opens and closes their fists for 3 minutes.If they experience ischemic pain in the arm, numbnessor tingling in the hand, or extreme weakness, the testis positive for thoracic outlet syndrome on the affectedside (Figure 8.110b).

Referred Pain Patterns

A painful shoulder may be due to irritation of thediaphragm that can occur with hepatobiliary or pan-creatic disease. An apical lung tumor (Pancoast’s tu-mor) may cause pain in the shoulder as well. A C5or C6 radiculopathy frequently causes shoulder pain.Pain may radiate from the elbow to the shoulder.Cardiac pain is also sometimes felt in the shoulder.Embryologically, there is a common origin of inner-vation of the diaphragm and adjacent internal organs(liver, gallbladder, and heart). This innervation orig-inates near the midcervical spine (Figure 8.111). Forthis reason, inflammation of these organs may be per-ceived as discomfort (referred pain) in the C5 or C6dermatome.

Radiological Views

Radiological views of the shoulder are presented inFigures 8.112–8.114:A = AcromionC = ClavicleCo = Coracoid processD = Acromioclavicular jointG = GlenoidGr = Greater tubercle of the humerusH = HumerusS = Scapula

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197Chapter 8 The Shoulder

S A M P L E E X A M I N A T I O N

History: 50-year-oldright-hand-dominant recreational tennisplayer presents with a chief complaint ofone week of neck pain. He recently wonhis club tournament. There was notrauma. The pain began several daysafter the event. There had been noneurovascular symptoms.

Physical Examination: Well-developed,well-nourished male with full ROM ofthe cervical spine. There was tendernesson palpation of the paramedial rightscapula. DTRs, sensation, and muscletesting of both upper extremities werenormal. He had a negative vascularexam of the upper extremities. He hadnegative compression and distraction ofthe cervical spine. The patient lackedterminal 20 degrees of forward flexionand external rotation of the rightshoulder. The remaining motions werenormal. Scapular dyskinesia was notedwith shoulder flexion and abduction.Special provocation tests for instability,apprehension, SLAP lesions, andimpingement were negative. Mobilitytesting of the right scapulothoracic jointand glenohumeral joint were mildlyrestricted. Popping was perceived withpassive ROM of the right shoulder aboveshoulder height.

Presumptive Diagnosis: Overusesyndrome with resultant strain of thetrapezius and rhomboid muscles of theright shoulder.

Physical Examination Clues: (1) He hadwell-localized tenderness and triggerpoints, identifying injury to a specificanatomic structure. (2) He had negativeneurologic and vascular signs in theupper extremities, indicating that therewas no radicular or vascular componentto his injury. (3) He had negativefindings with vertical compression anddistraction of the cervical spine, fullROM of the cervical spine, and anegative neurovascular examination,indicating no irritation of intervertebraljoints or cervical roots exiting from thespinal foramina. (4) Negative specialprovocation testing of the shoulder ruledout impingement, instability, and labraltears. (5) A popping noise with passiveROM of the right shoulder aboveshoulder height, decreasedscapulothoracic mobility, and scapulardyskinesia indicate scapulothoracicdysfunction. Proper shoulder and neckfunction require normal glenohumeraland scapulothoracic movement.Limitation of either, as noted in therestricted mobility exam of thescapulothoracic and glenohumeraljoints, will expose the remainingarticulation to overuse due tocompensation. The lack of full shoulderROM in the context of a sport such astennis, which requires repetitive and fullROM of the shoulder, exposes the patientto a compensatory overuse of theotherwise unaffected region.

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Paradigm for a chronic impingement syndrome of the shoulder

A 45-year-old man presents with a complaint of right shoulder pain. The pain has been episodic for at least 10 years, but has becomemore severe, constant, and limiting in activities of daily living (ADL) over the past 3 months. There has been no recent trauma to theupper extremity, but the patient had fallen onto the right shoulder skiing 25 years ago. At that time, he had limited use of his rightdominant arm for 4 weeks. Eventually, he recovered “full” use of that limb and has participated in regular athletic activities. Threemonths ago, the patient had been traveling extensively on business. He developed pain in the superior shoulder and lateral aspectof the arm. It is not aggravated by movement of the head and neck, and is not associated with “pins and needles” or “electricshock” sensations in any part of the upper extremity. He has noticed that there is often a sensation or sound of “rubbing” and“popping” in the area of the shoulder when reaching overhead.

On physical exam, the patient lacks the terminal 20 degrees of shoulder external rotation due to pain. He shows full strengthand no evidence of shoulder instability. His right acromioclavicular joint is larger and more tender as compared with that on theopposite side. There are no neurological deficits found and he has a negative cervical spine exam. X-rays show normal glenohumeralalignment; there is hypertrophy of the acromioclavicular joint with elevation of the clavicle. There is slight sclerosis on the superiormargin of the greater tuberosity and minimal narrowing of the subacromial space.This paradigm is most consistent with chronic subacromial impingement because of:

A history of prior injury with apparent full recoveryDelayed onset of symptomsA history of recent aggravating event(s)Crepitus on ROM without instability

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C H A P T E R 9

The Elbow

F U R T H E R I N F O R M A T I O N

Please refer to Chapter 2 foran overview of the sequence of

a physical examination. For purposes oflength and to avoid having to repeatanatomy more than once, the palpationsection appears directly after the sectionon subjective examination and before any

section on testing, rather than at the endof each chapter. The order in which theexamination is performed should bebased on your experience and personalpreference as well as the presentation ofthe patient.

Functional Anatomy

The elbow is a complex hinged joint whose functionis to facilitate the placement of the hand in space.It allows flexion–extension and pronation–supinationof the forearm. It is composed of three bones: thehumerus, radius, and ulna, and three articulations:humeroulnar, humeroradial, and the less importantproximal radioulnar.

The humeroulnar joint is the largest and most sta-ble of the elbow articulations. It is a simple hinge.Its stability is dependent on the medial collateral lig-ament. Dislocation at the elbow is pathognomonic ofmedial collateral ligament compromise. Therefore, af-ter reduction of dislocation, the reduced elbow mustbe recognized as being potentially unstable until me-dial collateral ligament integrity has been restored byhealing or surgical repair or both.

The humeroradial joint lies lateral to the humer-oulnar articulation. It is composed of a shallow disc(radial head) articulating on the spherical humeralcapitellum. As such, proximal migration of the radiusis prevented throughout the entire arc of elbow flexionand extension (Figure 9.1). Pronation and supinationare accomplished by rotation of the radius along itslong axis about the ulna (Figure 9.2a). Rotation to-

ward the palm down is pronation, whereas rotationtoward the palm up is supination. At full supination,the radius and ulna lie parallel within the forearm.At full pronation, the radius crosses the ulna at itsmid shaft. Although it rotates during pronation andsupination, the radial head remains otherwise in afixed position relative to the ulna. The relative posi-tion and movement of the radius about the elbow iscrucial to the diagnosis and treatment of injuries to theelbow–arm–wrist complex. A common mechanism ofinjury of the upper extremity is falling onto the out-stretched hand (Figure 9.2b). In this position, the el-bow is extended and the forearm is usually pronatedby the rotation of the body on the fixed hand. Dur-ing pronation with the radial head fixed proximallyto the ulna by the annular ligament, the shaft of theradius rotates about the long axis of the ulna. Termi-nal pronation is limited by the contact of the shaft ofthe radius on the ulna. At maximum pronation, thecontact point of the crossed radius (increased prona-tion) places enormous stress on the bones and articu-lations of the elbow and forearm. The consequencesof forcibly pronating the forearm beyond this pointwill result in the following spectrum of possible in-juries:1. tear of the annular ligament with dislocation of

the radial head;

199

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200 The Elbow Chapter 9

Proximal ulna(Olecranon process)

Humerus

Capitellum

Radial head

Annular ligament

Figure 9.1 The medial humeroulnar joint is a hinge joint. The lateral humeroradial joint is a shallow ball and socket. The proximalradioulnar joint allows for pronation and supination. The radial head is distal to the ulna and is supported against the ulna by theannular ligament.

2. fracture of the radial shaft;3. fracture of the ulnar shaft;4. fracture of both bones of the mid forearm; or5. combination or permutation of the above (i.e.,

Monteggia fracture, a fracture of the ulna withdislocation of the radial head).Understanding this analysis of the mechanism of

injury provides insight into the treatment of such in-juries. It is crucial to their resolution. For example,treatment of fractures and dislocations usually re-quires a maneuver that reverses the mechanism ofinjury. Therefore, for injuries resulting from hyper-pronation of the forearm, an integral part of themanipulative movements performed for treatment in-volves supination of the forearm.

In addition to bony and articular injuries, the softtissue about the elbow can also be injured, for exam-ple, from excessive movements. As a consequence ofthe enormous range of motion, the elbow must per-form during the course of daily activities; the largeexcursions of bony prominences beneath the overly-ing soft tissues can create irritations. To permit theelbow its large range of excursion (0–150 degreesof flexion), the skin overlying the posterior aspect ofthe elbow is very redundant and loosely attached tothe underlying hard and soft tissues. Interposed be-

tween the skin and underlying tissues is the olecranonbursa. This bursa ensures that the skin will not be-come adherent to the underlying tissues restrictingterminal flexion of the elbow. This function is simi-lar to that which exists on the anterior aspect of theknee and the dorsum of the metacarpophalangeal andinterphalangeal joints of the digits of the hand. Likethese areas, as a consequence of its location, the poste-rior elbow bursa (olecranon bursa) is very vulnerableto blunt trauma, the result of which may be hemor-rhage, swelling, pain, and inflammation characteristicof traumatic injuries. The lining of a bursal sac is sim-ilar to the synovial lining that exists in synovial artic-ulations. As a result, when traumatized and inflamed,it becomes thickened, produces excessive fluid exu-dates, and is characterized by localized swelling andwarmth (bursitis) (Figure 9.2c).

Observation

The examination should begin in the waiting roombefore the patient is aware of the examiner’s observa-tion. Information regarding the degree of the patient’sdisability, level of functioning, posture, and gait can

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be observed. The clinician should pay careful atten-tion to the patient’s facial expressions with regard tothe degree of discomfort the patient is experiencing.The information gathered in this short period can bevery useful in creating a total picture of the patient’scondition

Note the manner in which the patient is sitting inthe waiting room. Notice how the patient is posturingthe upper extremity. Is the arm relaxed at the side oris the patient cradling it for protection? If the elbowis swollen, the patient may posture it at 70 degreesof flexion (the resting position), which allows for themost space for the fluid. Swelling may be easily no-ticed at the triangular space bordered by the lateralepicondyle, radial head, and the olecranon. How will-ing is the patient to use the upper extremity? Will heor she extend their arm to you to shake your hand?Pain may be altered by changes in position, so watchthe patient’s facial expression to give you insight intotheir pain level.

Observe the patient as he or she assumes the stand-ing position. Observe the patient’s posture. Pay par-ticular attention to the position of the head, cervicalspine, and the thoracic kyphosis. Note the height ofthe shoulders and their relative positions. Once thepatient starts to ambulate, observe whether he or sheis willing to swing the arms, which can be limited byeither loss of motion or pain.

Once the patient is in the examination room, askthe patient to disrobe. Observe the ease with whichthe patient uses the upper extremities and the rhythmof the movements. Observe for symmetry of bonystructures. Note the carrying angle with the upperextremity postured in the anatomical position. Doesthe patient present with cubitus valgus or varus (gun-stock deformity). Note whether there is any atrophypresent in the biceps. This may be secondary to C5or C6 myotomal involvement. Note the symmetry ofthe forearms. Atrophy may be secondary to C6, C7,or C8 myotomal involvement.

Subjective Examination

The elbow is a stable joint. Since it is non-weight-bearing, problems are most commonly related tooveruse syndromes, inflammatory processes, andtrauma. You should inquire about the nature andlocation of the patient’s complaints as well as theirduration and intensity. Note whether the pain travelseither above or below the elbow. Inquire about the

behavior of the pain during the day and night to giveyou better insight into the pain pattern secondary tochanges in position, activity level, and swelling.

You want to determine the patient’s functional lim-itations. Question the patient regarding use of theirupper extremity. Is the patient able to comb his hair,fasten her bra, bring his arm to his mouth to eat, orremove her jacket? Does the patient regularly partici-pate in any vigorous sports activity that would stressthe elbow? What is the patient’s occupation?

If the patient reports a history of trauma, it is im-portant to note the mechanism of injury. The direc-tion of the force and the activity in which the patientwas participating at the time of the injury contributeto your understanding of the resulting problem andhelp you to better direct the examination. The degreeof pain, swelling, and disability noted at the time ofthe trauma and within the initial 24 hours should be

Humerus

Pronation

Radius

Ulna

(a)

Figure 9.2 (a) Pronation is the medial rotation of the radiusanterior to the ulna; this results in a palm-down position of thehand. Supination is the reverse movement, palm-up rotation ofthe hand.

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Pronation

Radius

Ulna

Fulcrum

(b)

Olecranonbursa

Triceps

Humerus

Skin

Ulna Radius

(c)

Figure 9.2 (Cont.) (b) Falling onto an outstretched hand with the forearm pronated results in a fracture of the ulnar shaft due to afulcrum effect. (c) The olecranon bursa in a flattened sac with synovial lining. It lies between the skin at the posterior aspect of theelbow and the underlying bony and muscular soft tissues.

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203Chapter 9 The Elbow

noted. Does the patient have a previous history ofthe same injury? Does the patient report any click-ing or locking? This may be due to a loose body inthe joint. Is any grating present? This may be due toosteoarthritis.

The patient’s disorder may be related to age, gen-der, ethnic background, body type, static and dy-namic posture, occupation, leisure activities, hobbies,and general activity level. Therefore, it is important toinquire about any change in daily routine and any un-usual activities in which the patient has participated.

The location of the symptoms may give you someinsight into the etiology of the complaints. The cervi-cal spine and the shoulder can refer pain to the elbow.The most common nerve roots that refer pain are C6and C7. (Please refer to Box 2.1, p. 15 for typicalquestions for the subjective examination.)

Gentle Palpation

The palpatory examination is started with the pa-tient in either the supine or sitting positions. Youshould first search for areas of localized effusion, dis-coloration, birthmarks, open sinuses or drainage, in-cisional areas, bony contours, muscle girth and sym-metry, and skinfolds. You should not have to use deeppressure to determine areas of tenderness or malalign-ment. It is important to use a firm but gentle pressure,which will enhance your palpatory skills. By having asound basis of cross-sectional anatomy, you will notneed to physically penetrate through several layers oftissue to have a good sense of the underlying struc-tures. Remember that if you increase the patient’s painat this point in the examination, the patient will bevery reluctant to allow you to continue and may be-come more limited in his or her ability to move.

Palpation is most easily performed with the patientin a relaxed position. Although palpation may be per-formed with the patient standing, the sitting positionis preferred for ease of examination of the elbow.While locating the bony landmarks, it is also usefulto pay attention to areas of increased or decreasedtemperature and moisture. This will help you identifyareas of acute and chronic inflammation.

Anterior Aspect

Soft-Tissue Structures

Cubital (Antecubital) FossaThe anterior surface of the crook of the elbow is re-ferred to as the cubital fossa. This has been described

as a triangular structure. The base of the triangle isformed by a line between the medial and lateral epi-condyles of the humerus. The medial side is formedby the pronator teres and the lateral side by the bra-chioradialis. The floor is composed of the brachialisand the supinator. The fossa contains the followingstructures: biceps tendon, distal part of the brachialartery and veins, the origins of the radial and ulnararteries, and parts of the median and radial nerves(Figure 9.3).

Trauma in the cubital fossa can lead to compressionof the brachial artery, leading to Volkmann’s ischemiccontracture.

Biceps Muscle and TendonThe anterior surface of the middle two-thirds of thehumerus is composed of the biceps muscle belly. Fol-low the fibers distally and you will feel the taperedropelike structure, which is the biceps tendon justproximal to its distal attachment on the radial

Brachial artery

Median nerve

Biceps

Pronatorteres

Brachioradialis

Figure 9.3 Palpation of the cubital fossa and contents.

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204 The Elbow Chapter 9

Bicepstendon

Figure 9.4 Palpation of the biceps muscle and tendon.

tuberosity (Figure 9.4). The tendon becomes moreprominent if you resist elbow flexion with the fore-arm in the supinated position.

The distal tendon or muscle belly can be rup-tured following forceful flexion of the elbow. Thepatient will demonstrate weakness in elbow flexionand supination, pain on passive pronation, and ten-derness in the cubital fossa. Rupture of the long headis often asymptomatic and may not be evident clin-ically, except for a concavity in the upper arm or abulbous swelling in the anterior lower half of the arm,which is the retracted muscle belly.

Brachial ArteryThe brachial artery is located in the cubital fossa me-dial to the biceps tendon (see Figure 9.3). The brachialpulse can be readily assessed at this point.

Median NerveThe median nerve crosses in front of the brachialartery and travels medial to it in the cubital fossa.Locate the brachial artery and allow your finger tomove slightly medially and you will feel a ropelikestructure, which is the median nerve (see Figure 9.3).It travels between the bicipital aponeurosis and thebrachialis before it enters the forearm between theheads of the pronator teres.

Medial Aspect

Bony Palpation

Medial Epicondyle and Supracondylar RidgeStand next to the patient and make sure the upperextremity is in the anatomical position. Place yourfingers along the medial aspect of the humerus andallow them to move distally along the medial supra-condylar ridge of the humerus until you reach a veryprominent pointed structure. This is the medial epi-condyle of the humerus (Figure 9.5). Tenderness inthis area can be due to inflammation of the commonaponeurosis of the flexor and pronator tendons of theforearm and wrist and is commonly referred to asgolfer’s elbow (medial epicondylitis).

Soft-Tissue Structures

Medial (Ulnar) Collateral LigamentThe medial collateral ligament consists of anteriorand posterior sections that are connected by an inter-mediate section. The anterior portion attaches fromthe medial epicondyle of the humerus to the coro-noid process. The posterior section attaches from themedial epicondyle to the olecranon. It has been de-scribed as a fan-shaped structure (Figure 9.6). Theligament is responsible for the medial stability of theelbow and its integrity can be tested with a valgusstress test (described on pp. 214–216). The ligamentis not distinctly palpable, but the medial joint lineshould be examined for areas of tenderness secondaryto sprains.

Ulnar NerveAsk the patient to flex the elbow to 90 degrees. Pal-pate the medial epicondyle and continue to move pos-teriorly and laterally until you feel a groove betweenthe medial epicondyle and the olecranon. Gently pal-pate in the groove and you will feel a round cordlikestructure under your fingers. This is the ulnar nerve(Figure 9.7). Because the nerve is so superficial, becareful not to press too hard; you may cause pares-thesias radiating down the forearm and into the hand.It is often referred to as the funny bone since when itis accidentally hit, the person experiences tingling. Be-cause of its close proximity to the bony prominences,the nerve can be injured secondary to fractures of themedial epicondyle and the supracondylar ridge. Theulnar nerve can be entrapped in the cubital tunnelformed by the medial collateral ligament and flexorcarpi ulnaris. This can cause a tardy ulnar palsy (seesection on “Neurological Examination”).

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205Chapter 9 The Elbow

MedialSupracondylarline

MedialEpicondyle

Figure 9.5 Palpation of the medial epicondyle and supracondylar ridge.

Wrist Flexor–PronatorThe common origin of the flexor–pronator mus-cle group is found at the medial epicondyle of thehumerus. From lateral to medial, this group is com-posed of the pronator teres, flexor carpi radialis, pal-maris longus, and flexor carpi ulnaris (Figure 9.8).The individual muscles are difficult to differentiate bypalpation. You can get a sense of their location by re-sisting the individual muscle’s function. Resist prona-tion of the forearm and you will feel the pronator terescontract under your fingers. Provide resistance whilethe patient flexes the wrist in radial deviation and youget a sense of the location of the flexor carpi radialis.Provide resistance while the patient flexes the wrist inulnar deviation and you get a sense of the location ofthe flexor carpi ulnaris. The tendons are easily distin-guishable at the wrist (described on pp. 220–221 inChapter 9).

The muscle mass should be examined for tendernessand swelling, which can occur after overuse or strain.Inflammation of this area is commonly involved ingolfer’s elbow. The specific test is described later onp. 231.

Lateral Aspect

Bony Structures

Lateral Epicondyle and Supracondylar RidgeStand next to the patient and make sure the upperextremity is in the anatomical position. Place yourfingers along the lateral aspect of the humerus andallow them to move distally along the lateral supra-condylar ridge of the humerus until you reach a smallrounded structure. This is the lateral epicondyle ofthe humerus (Figure 9.9). Tenderness in this area canbe due to inflammation of the common aponeurosisof the extensor tendons of the wrist and is commonlyreferred to as tennis elbow (lateral epicondylitis).

Radial HeadAsk the patient to flex the elbow to 90 degrees. Placeyour fingers on the lateral epicondyle and move themdistally. You will first palpate a small indentation andthen come to the rounded surface of the radial head(Figure 9.10). If you place your fingers more laterally,the radial head is more difficult to locate because itis covered by the thick bulk of the extensor mass.

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206 The Elbow Chapter 9

Medialcollateralligament

Figure 9.6 Palpation of the medial collateral ligament.

Ulnarnerve

Figure 9.7 Palpation of the ulnar nerve.

Figure 9.8 Palpation of the wrist flexor–pronator muscles.

Lateralepicondyle

Supracondylarridge

Figure 9.9 Palpation of the lateral epicondyle andsupracondylar ridge.

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207Chapter 9 The Elbow

Radialhead

Figure 9.10 Palpation of the radial head.

To confirm your hand placement, ask the patient tosupinate and pronate the forearm and you will feelthe radial head turning under your fingers.

Soft-Tissue Structures

Lateral (Radial) Collateral LigamentThe lateral collateral ligament attaches from the lat-eral epicondyle to the annular ligament. It is a cordlikestructure (Figure 9.11). The ligament is responsiblefor the lateral stability of the elbow and its integritycan be tested with a varus stress test (described onpp. 214–216, Figure 9.28). The ligament is not dis-tinctly palpable, but the lateral joint line should be ex-amined for areas of tenderness secondary to sprains.

Annular LigamentThe annular ligament surrounds the radial head andserves to keep it in contact with the ulna. The lateralcollateral ligament blends with the superficial fibers.The ligament is not palpable (Figure 9.12).

Lateral collateral ligament

Figure 9.11 Palpation of the lateral collateral ligament.

Humeroradial BursaThe humeroradial bursa is located over the radialhead and under the common aponeurosis of the ex-tensor tendons. It is not normally palpable. It can beinflamed secondary to direct trauma or overuse andshould not be confused with lateral epicondylitis. Cal-cification can be visualized in a radiograph.

Wrist Extensor–SupinatorThe common origin of the extensor–supinator mus-cle group is found at the lateral epicondyle and thesupracondylar ridge of the humerus. This group iscomposed of the brachioradialis, extensor carpi radi-alis longus, extensor carpi radialis brevis, and exten-sor digitorum (Figure 9.13). The individual musclesare difficult to differentiate by palpation at the musclebelly. You can get a sense of their location by resistingthe muscle function. Provide resistance while the pa-tient flexes the elbow with the forearm in the neutralposition and you will see the contour of the brachio-radialis on the anterolateral surface of the forearmlateral to the biceps tendon. It forms the lateral bor-der of the cubital fossa. Provide resistance while thepatient extends the wrist in radial deviation and youget a sense of the location of the extensor carpi radi-alis longus and brevis. Resist finger extension and youwill feel the extensor digitorum contract under yourfingers. The tendons are easily distinguishable at thewrist (described in Chapter 10).

The muscle mass should be examined for tendernessand swelling, which can occur after overuse or strain.Inflammation of this area is commonly involved intennis elbow. The specific test is described later inthis chapter (p. 231).

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208 The Elbow Chapter 9

Annular ligament

Figure 9.12 The annular ligament.

Posterior Aspect

Bony Structures

OlecranonMove your fingers to the posterior surface of the el-bow and you will palpate a very prominent process

Figure 9.13 Palpation of the wrist extensor–supinator muscles.

that tapers to a rounded cone. This is the olecranonprocess (Figure 9.14). The olecranon is more distinctwhen the patient flexes the arm, bringing the ole-cranon out of the olecranon fossa. The relationshipbetween the medial and lateral epicondyles and theolecranon can be examined in both the flexed and

Olecranon

Olecranon fossa

Figure 9.14 Palpation of the olecranon and olecranon fossa.

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209Chapter 9 The Elbow

Medial epicondyle

Lateral epicondyle

Olecranon

Figure 9.15 Alignment of the medial and lateral epicondyles and olecranon in flexion and extension.

extended positions. In flexion, as the olecranon movesout of the fossa, it becomes the apex of an isoscelestriangle formed by the three structures. As the armmoves back into extension and the olecranon movesback into the fossa, the three structures form a straightline (Figure 9.15). Disruption of these geometric fig-ures can be caused by a fracture of any of the struc-tures, or dislocation of the olecranon.

Olecranon FossaOnce you have found the olecranon, move your fin-gers proximally and allow them to drop into a smalldepression, which is the olecranon fossa (see Figure9.14). This fossa cannot be palpated when the pa-tient’s elbow is in extension, as it is filled by the ole-cranon process. When the elbow is completely flexed,the fossa is blocked by the tension in the triceps ten-don. Therefore, the optimal position for palpation isat 45 degrees of elbow flexion.

Ulna BorderGo back to the olecranon process and allow yourfingers to move distally along the superficial ridge ofthe ulna. The ulna border is easily followed and can betraced along the length of the bone until you reach theulna styloid process (Figure 9.16). Point tendernessand an irregular surface can be indicative of a fracture. Figure 9.16 Palpation of the ulna border.

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210 The Elbow Chapter 9

Olecranonbursa

Figure 9.17 Palpation of the olecranon bursa.

Soft-Tissue Structures

Olecranon BursaThe olecranon bursa lies over the posterior aspect ofthe olecranon process. It is not normally palpable. Ifthe bursa becomes inflamed, you will feel a thickeningin the area under your fingers. The inflammation canbe so significant that it may appear as a large swellingresembling a golf ball over the posterior olecra-non and is sometimes referred to as student’s elbow(Figure 9.17).

TricepsThe triceps muscle is composed of three portions. Thelong head originates from the infraglenoid tubercleof the scapula, the lateral head originates from theposterior surface of the humerus, and the medial headoriginates from the posterior aspect of the humerusbelow the radial groove. All three heads insert distallyby a common tendon to the olecranon.

The superior portion of the long head can be pal-pated on the proximal posterior aspect of the humerusas it emerges from under the deltoid. The lateralhead can be palpated on the middle posterior as-pect of the humerus. The medial head can be lo-cated on both sides of the triceps tendon just superiorto the olecranon. The contour of the muscle can bemade much more distinct by resisting elbow extension(Figure 9.18).

Figure 9.18 Palpation of the triceps muscle.

Trigger Points

Myofascial pain of the elbow region is relatively un-common. Referred pain patterns from trigger pointsin the biceps and triceps muscles are illustrated inFigures 9.19 and 9.20.

Active Movement Testing

The major movements of the elbow (humeroulnar andhumeroradial) joint are flexion and extension on thetransverse axis. To accomplish the full range of flex-ion and extension, the radius and ulna must be able toabduct and adduct. The major movements of the su-perior radioulnar joint are supination and pronationaround a longitudinal axis. These should be quick,functional tests designed to clear the joint. If the mo-tion is pain free at the end of the range, you can add anadditional overpressure to “clear” the joint. If the pa-tient experiences pain during any of these movements,you should continue to explore whether the etiologyof the pain is secondary to contractile or noncontrac-tile structures by using passive and resistive testing.

A quick screening examination of the movementscan be accomplished by asking the patient to reach forthe back of the neck on the ipsilateral side of the elbow

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211Chapter 9 The Elbow

Biceps

Figure 9.19 Common trigger points and their referred pain patterns within the biceps muscle. (Adapted with permission from Travelland Rinzler, 1952.)

being tested. Then ask the patient to return the arm tothe side in the anatomical position. Symmetrical hy-perextension of 10 degrees can be considered normal.Pronation and supination can be checked functionallyby asking the patient to place the elbow into the an-gle of the waist and turn the forearm as though he orshe is turning a doorknob to the right or left. Observethe patient’s wrist as he or she may try to substitutefor the movement by abducting or adducting the arm.These tests can be performed with the patient in eitherthe sitting or standing position.

Passive Movement Testing

Passive movement testing can be divided into two ar-eas: physiological movements (cardinal plane), whichare the same as the active movements, and mobil-ity testing of the accessory (joint play, component)movements. You can determine whether the noncon-tractile (inert) elements are causative of the patient’sproblem by using these tests. These structures (liga-ments, joint capsule, fascia, bursa, dura mater, andnerve root) (Cyriax, 1979) are stretched or stressedwhen the joint is taken to the end of the availablerange. At the end of each passive physiological move-ment, you should sense the end feel and determinewhether it is normal or pathological. Assess the lim-itation of movement and see whether it fits into a

capsular pattern. The capsular pattern of the elbowis greater restriction of flexion than extension so thatwith 90 degrees of limited flexion there is only 10 de-grees of limited extension (Cyriax, 1979; Kaltenborn,1999). The capsular pattern of the forearm is equal re-striction of pronation and supination, which usuallyonly occurs with significant limitation in the elbowjoint (Kaltenborn, 1999).

Physiological Movements

You will be assessing the amount of motion avail-able in all directions. Each motion is measured fromthe zero starting position. For the elbow, both thearm and the forearm are in the frontal plane, withthe elbow extended and the forearm supinated. Forthe forearm, the elbow should be flexed to 90 de-grees with the forearm midway between supinationand pronation (Kaltenborn, 1999).

Flexion

The best position for measuring flexion is supinewith the patient’s elbow in the zero starting positionwith the shoulder at 0 degree of flexion and abduc-tion. A small towel placed under the distal posterioraspect of the humerus will allow for full extension.Place one hand over the distal end of the humerus

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212 The Elbow Chapter 9

Triceps

Triceps

Figure 9.20 Common trigger points and their referred pain patterns within the triceps muscle. (Adapted with permission from Travelland Rinzler, 1952.)

to stabilize it, but be careful not to obstruct the pa-tient’s range into flexion. Hold the distal aspect ofthe patient’s forearm and bring the hand toward theshoulder. The normal end feel is soft tissue caused bythe muscle bulk of the biceps. If the patient’s mus-

cles are very atrophied, a hard end feel can be notedas the coronoid process meets or compresses into thecoronoid fossa. This motion can also be restricted bytightness in the triceps muscle and the posterior cap-sule, producing an abrupt and firm (ligamentous) end

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Figure 9.21 Passive movement testing of flexion of the elbow.

feel (Magee, 2002; Kaltenborn, 1999). Normal rangeof motion is 0–150 degrees (American Academy ofOrthopedic Surgeons, 1965) (Figure 9.21).

Extension

Full extension is achieved when the patient is placedin the supine position. The hand placement is thesame as for flexion of the elbow. The motion is ac-complished by allowing the patient’s elbow to re-turn to the zero starting position from flexion. Thenormal end feel is hard due to the contact betweenthe olecranon and the olecranon fossa. The motioncan also be restricted by tightness in the biceps andbrachialis muscles and anterior capsule that producesan abrupt and firm (ligamentous) end feel (Magee,2002; Kaltenborn, 1999). The normal range of mo-tion is 0 degree (American Academy of OrthopedicSurgeons, 1965) (Figure 9.22).

Pronation

The best position for measuring pronation is havingthe patient sitting with their forearm in the zero start-ing position and the shoulder at 0 degree of flexionand abduction. Stand so that you face the patient.Stabilize the posterior distal aspect of the humerus bycupping your hand around the olecranon to preventsubstitution by shoulder medial rotation and abduc-tion. Support the distal end of the forearm with yourother hand. Rotate the forearm so that the patient’spalm faces the floor. The normal end feel is hard dueto the contact of the radius rotating over the ulna. Themotion can be restricted by tightness in the supinator

Figure 9.22 Passive movement testing of extension of theelbow.

muscles, the interosseous membrane, and the inferiorradioulnar joint that produces an abrupt and firm(ligamentous) end feel (Magee, 2002; Kaltenborn,1999). Normal range of motion is 0–80–90 degrees(American Academy of Orthopedic Surgeons, 1965)(Figure 9.23).

Supination

Supination is tested with the patient in the same posi-tion as pronation. Substitution can be accomplishedby shoulder lateral rotation and adduction. Rotate thepatient’s forearm so that the palm faces the ceiling.The normal end feel is abrupt and firm (ligamentous)due to tension in the pronator muscles, interosseousmembrane, and the inferior radioulnar joint (Magee,2002; Kaltenborn, 1999). Normal range of motion is0–80–90 degrees (American Academy of OrthopedicSurgeons, 1965) (Figure 9.24).

Mobility Testing of the AccessoryMovements

Mobility testing of accessory movements will give youinformation about the degree of laxity present in thejoint. The patient must be totally relaxed and com-fortable to allow you to move the joint and obtain themost accurate information. The joint should be placedin the maximal loose packed (resting) position to al-low for the greatest degree of joint movement. The

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Radius

Ulna

Figure 9.23 Passive movement testing of pronation of theforearm.

Radius

Ulna

Figure 9.24 Passive movement testing of supination of theforearm.

resting position of the elbow is 70 degrees of flexionand 10 degrees of supination. The resting position ofthe forearm (superior radioulnar joint) is 70 degreesof flexion and 35 degrees of supination (Kaltenborn,1999) and the resting position of the humeroradialjoint is the forearm fully supinated and the elbowfully extended.

Traction of the Elbow (Humeroulnar) Joint

Place the patient in the supine position with the el-bow flexed approximately 70 degrees and the forearmsupinated approximately 10 degrees. Stand to the sideof the patient facing the posterior aspect of the fore-arm to be tested. Stabilize by grasping the posteriordistal aspect of the humerus. Allow the distal partof the forearm to rest against your trunk. Place yourother hand around the anterior proximal portion ofthe ulna as close as possible to the joint line. Pull theulna in a longitudinal direction until you have takenup the slack, producing traction in the humeroulnarjoint (Figure 9.25).

Lateral Glide of the Ulna

Place the patient in the supine position with the el-bow flexed approximately 70 degrees. Stand on theside of the patient with your body facing the patient.Allow the patient’s forearm to rest against your chest.Place one hand around the lateral distal aspect of thehumerus to stabilize it. Place your other hand aroundthe proximal medial aspect of the ulna. Move the ulnain a lateral direction until all the slack has been takenup. This tests the ability of the ulna to glide laterallyon the humerus (Figure 9.26).

Medial Glide of the Ulna

This test is performed with the patient in the same po-sition as the lateral glide of the ulna except that yourhand placement is reversed. Stabilize the humerus byplacing your hand around the proximal medial aspect.Move the ulna medially, until all the slack has beentaken up, by placing your hand around the proximallateral aspect of the forearm over the radius and ulna(Figure 9.27).

Medial and Lateral Gapping (Varus–Valgus Stress)

Place the patient in the supine position with the pa-tient’s elbow in slight flexion and supination. Standon the side of the table and face the patient. Place your

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215Chapter 9 The Elbow

Figure 9.25 Mobility testing of traction of the elbow.

Stabilize

Figure 9.26 Mobility testing of lateral glide of the ulna.

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Stabilize

Figure 9.27 Mobility testing of medial glide of the ulna.

hand around the distal lateral aspect of the humerusto stabilize it. Place your other hand at the distal me-dial aspect of the forearm proximal to the wrist. Movethe ulna laterally, producing a gapping on the medial

aspect of the elbow. This is also referred to as a me-dial (valgus) stress. This tests for the integrity of themedial collateral ligament (Figure 9.28).

To test the integrity of the lateral collateral liga-ment, the same test should be repeated by reversingyour hand placements. This will allow you to createa varus (lateral) force creating gapping on the lateralaspect of the elbow joint (see Figure 9.28).

Traction of the Humeroradial Joint

Place the patient in the supine position with the armresting on the table and the elbow flexed to approxi-mately 70 degrees. Stand on the side of the table andface the patient. Place your hand around the distal an-terior aspect of the humerus to stabilize it. Place yourthumb at the joint space to palpate the movement.Place your other hand at the distal end of the fore-arm just proximal to the wrist joint. Make sure thatyou are holding only the radius. Pull the radius in alongitudinal direction until you take up all the slack.This movement produces traction in the humeroradialjoint (Figure 9.29).

Ventral and Dorsal Glide of the Radial Head

Place the patient in the seated position so that thearm is supported on the treatment table. Position thepatient’s arm in the resting position. Stand so that

Lateral gapping

Figure 9.28 Mobility testing of medial and lateral gapping of the elbow.

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Stabilize

Figure 9.29 Mobility testing of traction of the humeroradial joint.

you are facing the patient. Place one hand under theproximal dorsal aspect of the ulna to stabilize it. Placethe index finger and thumb of your other hand aroundthe radial head. Move the radial head in a ventral andthen a dorsal direction until all the slack is taken upin both directions. This tests for the mobility of theproximal radioulnar joint (Figure 9.30).

Radialhead

Figure 9.30 Mobility testing of ventral and dorsal glide of theradial head.

Ventral and Dorsal Glide of the Radius

Place the patient in the seated position so that the armis supported on the treatment table. Position the pa-tient’s arm in the resting position. Stand so that youare facing the patient. Place one hand under the distaldorsal aspect of the ulna to stabilize it. Place the indexfinger and thumb of your other hand around the dis-tal end of the radius just proximal to the wrist joint.Move the radius in both a ventral and a dorsal direc-tion until all the slack is taken up in both directions.This tests for the mobility of the distal radioulnar joint(Figure 9.31).

Resistive Testing

The muscles of the elbow function to position thehand in space. The motions to be tested are flex-ion, extension, pronation, and supination. The primemovers of the elbow joint are located in the arm.

Although the elbow is analogous to the knee inmany respects, unlike the knee, the elbow usuallyfunctions as part of an open chain with the handand wrist. This may be why most of the flexors and

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Stabilize

Figure 9.31 Mobility testing of ventral and dorsal glide of theradius.

extensors of the wrist and fingers also cross the elbowjoint, affording more precise control of the fingersand hand in space. Note that none of the muscles ofthe toes cross the knee joint. The gastrocnemius is theonly muscle that crosses the knee and ankle joints.

Bicepsbrachii

Brachialis

Brachioradialis

Figure 9.32 The flexors of the elbow.

Elbow Flexion

The flexors of the elbow are the biceps brachii, thebrachialis, and brachioradialis (Figure 9.32).� Position of patient: Sitting with the arm at the

side. The forearm is supinated (Figure 9.33).� Resisted test: Take the patient’s wrist with your

hand and stabilize his or her upper arm with yourother hand. Ask the patient to flex the elbow asyou resist this motion by holding the forearm andpulling downward.Testing elbow flexion with gravity eliminated is

performed with the patient in a supine position andthe shoulder abducted to 90 degrees and externallyrotated (Figure 9.34). Stabilize the upper arm as thepatient attempts to slide the forearm along the ta-ble into elbow flexion through the complete range ofmotion.

Painful resisted elbow flexion accompanied by alarge bulge in the mid arm may be due to rupture ofthe biceps tendon.

Weakness of elbow flexion caused by damage tothe musculocutaneous nerve, which innervates the bi-ceps and brachialis muscles, will cause the patient to

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219Chapter 9 The Elbow

Figure 9.33 Testing elbow flexion.

pronate the forearm and substitute for loss of elbowflexion by using the brachioradialis, extensor carpi ra-dialis longus, wrist flexors, and pronator teres. Weak-ness of elbow flexion causes a substantial restriction

Figure 9.34 Testing elbow flexion with gravity eliminated.

in activities of daily living such as feeding and groom-ing.

Elbow Extension

The elbow extensors are the triceps brachii and an-coneus muscles (Figure 9.35).� Position of patient: Supine with the shoulder flexed

to 90 degrees and the elbow flexed (Figure 9.36).� Resisted test: Stabilize the arm with one hand just

proximal to the elbow and apply a downwardflexing resistive force with your other hand to theforearm just proximal to the wrist. Ask the patientto extend the elbow upward against yourresistance.Testing elbow extension with gravity eliminated is

performed with the patient in the supine position andthe shoulder abducted to 90 degrees and internallyrotated (Figure 9.37).

Painful resisted elbow extension associated with aswelling over the olecranon process is likely due toolecranon bursitis.

Weakness of elbow extension causes difficulty inusing a cane or crutches owing to an inability tobear weight on the extended elbow. Activities suchas throwing, reaching upward toward a high object,and doing push-ups are also restricted.

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220 The Elbow Chapter 9

Longhead of triceps

Lateral head of triceps

Medial head of triceps

Figure 9.35 The elbow extensors.

Forearm Pronation

The pronators of the forearm are the pronator teresand pronator quadratus muscles (Figure 9.38).� Position of patient: Sitting with the arm at the side

and the elbow flexed to 90 degrees to preventrotation at the shoulder. The forearm is initiallysupinated (Figure 9.39).

� Resisted test: Stabilize the upper arm with onehand placed just proximal to the elbow joint. Withyour other hand, take the patient’s forearm justproximal to the wrist and apply a rotational stressinto supination as the patient attempts to pronatethe forearm. Do not allow the patient to internallyrotate the shoulder in an effort to increase themovement of the forearm.Testing forearm pronation with gravity eliminated

is performed with the patient in the same position.The test is performed without resistance (Figure 9.40).

The pronator quadratus muscle can be isolated byperforming the resisted test with the elbow in ex-treme flexion. This puts the pronator teres muscleat a mechanical disadvantage. This is useful in testingfor anterior interosseous nerve syndrome (see p. 227,Figure 9.55).

Figure 9.36 Testing elbow extension.

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221Chapter 9 The Elbow

Figure 9.37 Testing elbow extension with gravity eliminated.

Forearm Supination

The supinators of the forearm are the biceps brachiiand the supinator muscles (Figure 9.41).

Pronator quadratus

Pronator teres

Figure 9.38 The forearm pronators.

� Position of patient: Seated with the arm at the sideand the elbow flexed to 90 degrees to preventexternal rotation of the shoulder, which is used tocompensate for lack of supination range of

Figure 9.39 Testing forearm pronation.

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222 The Elbow Chapter 9

Figure 9.40 Testing forearm pronation with gravity eliminated.

Biceps brachii

Supinator

Figure 9.41 The forearm supinators.

Figure 9.42 Testing forearm supination.

motion. The forearm is in neutral position (Figure9.42).

� Resisted test: Stabilize the upper arm with onehand placed above the elbow and take thepatient’s forearm just proximal to the wrist. Thepatient attempts to supinate the forearm as youapply a rotational force into pronation to resisthim or her.Testing forearm supination with gravity eliminated

is performed with the patient in the same position,but without resistance (Figure 9.43).

Painful resisted supination may be due to bicepstendinitis.

Weakness of forearm supination affects many ac-tivities of daily living, including feeding oneself andpersonal hygiene.

Neurological Examination

Motor

The innervation and spinal levels of the muscles thatfunction across the elbow are listed in Table 9.1.

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223Chapter 9 The Elbow

Figure 9.43 Testing forearm supination with gravity eliminated.

Reflexes

Biceps Reflex

The biceps reflex (Figure 9.44) is used to test the C5,and to a lesser extent, the C6 neurological levels. Thetest is performed by having the patient rest their fore-arm on your forearm as you take the patient’s elbowin your hand with your thumb pressing downward onthe biceps tendon. The tendon becomes more promi-nent as the patient flexes the elbow slightly. Ask thepatient to relax and take the reflex hammer with yourother hand and tap onto your thumbnail. The bicepswill contract and the arm may jump slightly. Absence

of this reflex indicates damage to the C5 nerve rootlevel, the upper trunk or lateral cord of the brachialplexus, musculocutaneous nerve, or biceps musculo-tendinous unit. Always compare the findings to theopposite side.

Brachioradialis Reflex

The brachioradialis reflex (Figure 9.45) is used to testthe C6 nerve root level. Have the patient rest theirforearm over yours with the elbow in slight flexion.Use the flat end of the reflex hammer to tap the dis-tal end of the radius. The test result is positive whenthe brachioradialis muscle contracts and the forearmjumps up slightly. Absence of this reflex signifies dam-age in the C6 nerve root level, the upper trunk or pos-terior cord of the brachial plexus, the radial nerve,or the brachioradialis musculotendinous unit. Alwayscompare the findings to the opposite side.

Triceps Reflex

The triceps reflex (Figure 9.46) tests the C7 nerve rootlevel. The test is performed by having the patient’sforearm resting over yours. Hold the patient’s armproximal to the elbow joint to stabilize the upper arm.Ask the patient to relax, and tap the triceps tendonwith the reflex hammer, just proximal to the olecra-non process. The test result is positive when contrac-tion of the triceps muscle is visualized. Absence of thisreflex signifies damage to the C7 nerve root, middletrunk or posterior cord of the brachial plexus, ra-dial nerve, or triceps musculotendinous unit. Alwayscompare the findings to the opposite side.

Sensation

Light touch and pinprick sensation should be ex-amined after the motor and reflex examination. The

Table 9.1 Muscles, innervation, and root levels of the elbow.

Movement Muscles Innervation Root levels

Flexion of elbow 1 Biceps brachii Musculocutaneous C5, C62 Brachialis Musculocutaneous C5, C63 Brachioradialis Radial C5, C64 Pronator teres Median C6, C75 Flexor carpi ulnaris Ulnar C7, C8, T1

Extension of elbow 1 Triceps Radial C7, C82 Anconeus Radial C7, C8

Pronation of forearm 1 Pronator teres Median C6, C72 Pronator quadratus Anterior interosseous (median) C8, T1

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224 The Elbow Chapter 9

Figure 9.44 Testing the biceps reflex.

dermatomes for the elbow are C5, C6, C7, C8, andT1. Peripheral nerves and their distribution in the el-bow region are shown in Figures 9.47–9.49.

Entrapment Neuropathies

Median Nerve

Median nerve entrapment at the elbow is much lesscommon than at the wrist, as in carpal tunnel syn-

drome. The median nerve may be compressed abovethe elbow by an anomalous structure known as theligament of Struthers. At and below the elbow, themedian nerve may be compressed by the bicipitalaponeurosis (lacertus fibrosus). It may also be com-pressed at the level of the pronator teres and the flexordigitorum superficialis muscles (Figure 9.50).

The anterior interosseous nerve, which is a branchof the median nerve, may be compressed in the prox-imal part of the forearm.

Figure 9.45 Testing the brachioradialis reflex.

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225Chapter 9 The Elbow

Figure 9.46 Testing the triceps reflex.

Anterior

Anterior

Anterior

Posterior

Posterior

C5

C5

C6

C7

T1

Key sensory area for C5

Key sensory area for T1

T2

Figure 9.47 The dermatomes of the upper arm and forearm. Note the key sensory areas for C5 and T1, located laterally and mediallyin the antecubital fossa.

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226 The Elbow Chapter 9

1

2

3

4

5

6

1

2

3

4

5

6

1. Intercostobrachial2. Upper lateral cutaneous3. Medial cutaneous of arm4. Lower lateral cutaneous5. Medial cutaneous of forearm6. Lateral cutaneous of forearm

Figure 9.48 Anterior view of the sensory nerves and their distributions in the upper arm and forearm.

Ligament of StruthersThe ligament of Struthers is a relatively rare com-pression site of the median nerve. The patient usuallycomplains of pain and paresthesias in the index orlong finger. You may exacerbate the pain in this con-dition by having the patient extend the elbow andsupinate the forearm. In addition, you may be ableto palpate a bony spur proximal to the medial epi-condyle of the humerus, which is the attachment siteof this anomalous ligament.

Pronator Teres SyndromeHere, the median nerve is being compressed betweenthe two heads of the pronator teres muscle (Fig-ure 9.51). The other entrapment sites at the bicipi-tal aponeurosis and flexor digitorum superficialis areusually grouped with pronator teres syndrome.

A patient with entrapment of the median nerveat the pronator teres will frequently have tendernessover the proximal portion of the pronator teres mus-cle. Compression of the pronator teres for 30 seconds,resulting in paresthesias in the thumb and index fin-gers, is positive for pronator teres syndrome. Repro-duction of symptoms of pain or paresthesias duringresisted wrist flexion and pronation is also positivefor pronator teres syndrome (Figure 9.52).

Reproduction of symptoms of pain or paresthesiasin the proximal part of the forearm caused by resistedsupination and elbow flexion (biceps muscle) is a pos-itive sign for median nerve compression at the lacertusfibrosus (Figure 9.53).

Reproduction of the symptoms of pain or pares-thesias in the forearm or hand following resisted flex-ion of the long finger is positive for median nerve

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227Chapter 9 The Elbow

1

2

3

4

5

6

7

8

1. Intercostobrachial2. Upper lateral cutaneous3. Medial cutaneous of arm4. Lower lateral cutaneous5. Medial cutaneous of forearm6. Lateral cutaneous of forearm7. Superior lateral cutaneous of forearm8. Posterior cutaneous of arm

2

3

4

5

6

7

8

Figure 9.49 Posterior view of the sensory nerves to the arm and forearm, along with their distributions.

compression at the flexor digitorum superficialis arch(Figure 9.54).

Anterior Interosseous Nerve

This nerve is a motor nerve to the long flexors of thethumb and index and middle fingers, and the prona-tor quadratus muscle. There are no cutaneous sen-sory fibers. However, this nerve does provide somesensation to the joints of the wrist. Examination of

a patient with anterior interosseous nerve syndromecharacteristically reveals weakness of the long flexormuscles. This can be tested for by asking the patient tomake the “OK” sign. An inability to do tip-to-tippinch of the thumb and index finger results from dam-age to the anterior interosseous nerve (Figure 9.55).

Ulnar Nerve

The ulnar nerve is susceptible to compression at threesites in the region of the elbow. These include the

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228 The Elbow Chapter 9

Ligament of Struthers

Lacertus fibrosis

Pronator teres

Flexor digitorumsuperficialis arch

Median nerve

Proximalpronator teres

Figure 9.50 Common sites of entrapment of the median nerve near the elbow include the ligament of Struthers, the lacertus fibrosus,pronator teres muscle, and flexor digitorum superficialis arch.

Median nerve

Ligamentof Struthers

Superficial headof pronator teres

Deep headof pronator teres

Flexor digitorumsuperficialis

Figure 9.51 In pronator teres syndrome, the median nerve iscompressed after its branches are given off to the pronator teresmuscles. This muscle is intact. If the nerve is compressed by theligament of Struthers more proximally, the pronator teres willnot be functional. The median nerve is shown coursing betweenthe two heads of the pronator teres muscle.

Pronatorteres

Mediannerve

Figure 9.52 Pain that results from resistance of pronation of theforearm and flexion of the wrist may be due to median nervecompression at the level of the pronator teres muscle. Thismaneuver squeezes the median nerve within the pronator teresmuscle.

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229Chapter 9 The Elbow

Figure 9.53 The presence of pain in the forearm increased byresistance of forearm supination and elbow flexion is positive forcompression of the median nerve at the lacertus fibrosus.

arcade of Struthers, which is proximal to the elbow;the retrocondylar groove of the humerus at the elbow;and the cubital tunnel just distal to the elbow joint(Figure 9.56). The localization of ulnar neuropathyin the elbow region is best elucidated with electrodi-agnostic studies.

Ulnar neuropathy at the elbow results in weaknessof the intrinsic muscles of the hand. This can be testedfor by having the patient attempt to adduct the littlefinger to the ring finger. An inability to do this is calleda Wartenberg’s sign. Atrophy may also be noted in theintrinsic muscles of the hand.

Tinel’s sign may be elicited at the elbow betweenthe olecranon process and medial epicondyle (Figure9.57). This is obtained by tapping the ulnar nerve inits groove with your finger. The test result is positivewhen a tingling sensation is noted in the forearm andmedial aspect of the hand. As the nerve regenerates,Tinel’s sign is felt more distally by the patient. Bewarethat false-positive Tinel’s signs are common at theelbow.

The patient may have increased symptoms of pares-thesias and tingling in the ulnar nerve distribution

Figure 9.54 Pain in the proximal part of the forearm that ismade worse by resisted flexion of the long finger may be due tocompression of the median nerve at the level of the flexordigitorum superficialis arch.

when asked to flex the elbow for 5 minutes. This iscalled the elbow flexion test.

Radial Nerve

The radial nerve may be compressed within the spiralgroove in the proximal part of the humerus, as inSaturday night palsy (Figure 9.58).

Normal Abnormal

Figure 9.55 The patient with anterior interosseous nervecompression is unable to form the “OK” sign. This is due toweakness of the flexor digitorum profundus to the index fingerand the flexor pollicis longus.

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230 The Elbow Chapter 9

Lower cervical roots

Brachial plexus

Medial cutaneous nerve of forearm

Arcade of Struthers

Retrocondylar groove

Cubital tunnel

Flexor carpi ulnaris

Figure 9.56 Common sites of entrapment of the ulnar nerveinclude the arcade of Struthers, the retrocondylar groove of thehumerus, and the cubital tunnel.

Ulnarnerve

Figure 9.57 Tinel’s sign is produced in the ulnar nerve bytapping in the groove between the medial epicondyle of thehumerus and the ulna. Similarly, pain may be felt in the medialaspects of the hand and forearm.

Spiral grooveof humerus

Radial nerve

Figure 9.58 The radial nerve may be compressed at the spiralgroove of the humerus due to pressure, as in Saturday nightpalsy.

The radial nerve (posterior interosseous branch)may also be compressed at the arcade of Frohse(Figure 9.59), which is the proximal tendinous archof the supinator muscle.

Saturday Night PalsyThe patient will be unable to extend the wrist orfingers. Sensory loss in the distribution of the radialnerve will also be noted. The triceps muscle will benormal because the branch to it arises proximal to thedamage to the radial nerve. Therefore, elbow exten-sion will be strong.

Posterior Interosseous Nerve or Supinator SyndromeThe patient will have weakness of wrist and finger ex-tension (see Figure 9.59). Sensation to the posteriorlateral hand and brachioradialis and supinator mus-cle function will all be normal. On wrist extension,the patient may deviate radially due to some sparingof the extensor carpi radialis longus and brevis mus-cle function, with complete loss of the extensor carpiulnaris muscle. Note that some interphalangeal jointextension will be present due to preservation of themedian and ulnar intrinsic muscles of the hand. A ra-dial nerve lesion should always be ruled out in thepresence of lateral elbow pain (tennis elbow).

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231Chapter 9 The Elbow

Radial nerve

Posteriorinterosseousnerve

Supinator

Superficialradial nerve

Arcadeof Frohse

Medialnerve

Biceps

Figure 9.59 The posterior interosseous branch of the radial nerve may be compressed at the level of the arcade of Frohse, which ispart of the supinator muscle. Note that the superficial radial nerve, which is a sensory nerve to the hand, is not affected by thiscompression.

Special Tests

Tennis Elbow (Lateral Epicondylitis)Test

The various maneuvers used to test for lateral epi-condylitis attempt to stress the tendinous attachmentof the extensor carpi radialis brevis and longus mus-cles at the lateral epicondyle of the humerus (Figure9.60). These muscles can be stretched by having thepatient make a fist, flex the wrist, pronate the fore-arm, and extend the elbow. Resisted extension of thethird metacarpophalangeal joint or of the wrist mayalso be performed to stress this common attachmentsite of the extensor muscles.

Golfer’s Elbow (Medial Epicondylitis)Test

The patient’s forearm is supinated and the elbow andwrist are extended by the examiner (Figure 9.61). Painis felt by the patient in the region of the medial epi-condyle due to overuse of the wrist flexors. Puttingthe patient in this position stretches these overusedmuscles at their tendinous attachment to the medial

epicondyle of the humerus. This test will also causepain in the proximal medial area of the forearm inpatients with overuse syndromes due to typing andplaying instruments (i.e., strings, piano, and wood-winds).

Referred Pain Patterns

Pain in the region of the elbow may be referred fromthe lower cervical spinal segments, the shoulder, andthe wrist (Figure 9.62).

Radiological Views

Radiological views are presented in Figures 9.63–9.65.

H = HumerusO = Olecranon process of ulnaR = RadiusU = UlnaT = Trochlea of humerusM = Medial epicondyle of humerusC = Capitellum of humerus

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232 The Elbow Chapter 9

Examiner

Stabilizer

Patient

Extension

Flexion

(a)

(b)

Figure 9.60 Tennis elbow (lateral epicondylitis) can be tested for by resisting wrist extension, as in (a), or by passively extending theelbow and flexing the wrist to stretch the tendons of the wrist extensors, as in (b).

Site of tenderness

Figure 9.61 Golfer’s elbow (medial epicondylitis) will be noted by palpating at the site of tenderness in the medial epicondylar region.The pain is intensified by resisting wrist flexion and forearm pronation with the elbow extended.

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Figure 9.62 Pain may be referred to the elbow from the neck, shoulder, or wrist.

Figure 9.63 Anteroposterior view of the elbow. Figure 9.64 View of the elbow with the forearm pronated.

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Figure 9.65 Lateral view of the elbow.

Paradigm for inflammatory disease involving the elbow

A 25-year-old woman presents with complaints of swelling, pain, and limited motion in her right elbow. She reports no history ofrecent or prior trauma. She is employed as a secretary and has recently joined a health club. A year ago, her symptoms were initiallyepisodic, but now have become a daily problem.

Upon arising each morning, she notices stiffness in the elbows, wrists, and finger joints of both upper extremities. She has had norecent infections but reports having a low-grade temperature and her face to be “flushed”. Her weight has decreased by 10 pounds,and she has noticed an increase in the frequency of her urination. She has no significant prior medical history, but does rememberan aunt who became an early invalid because of “arthritis.”

Her physical exam demonstrates the patient to be a slender young woman in no acute distress. Her right elbow is slightly swollen,minimally tender, and lacking the terminal 30 degrees of flexion and extension. Her left elbow seems unremarkable, but themetacarpophalangeal and proximal interphalangeal joints of many digits on each hand are moderately enlarged and lack fullextension. Her cheeks have a slightly erythematous rash. Laboratory tests report a mild anemia, an increase in the white cell count,increased protein in the urine, and an elevated sedimentation rate. X-rays of the elbows and hands show only soft-tissue enlargementwith no bony lesions. Aspiration of the elbow produces a cloudy yellowish viscous fluid, which on analysis shows a large number ofinflammatory cells but no organisms.

This is a paradigm of inflammatory disease (rheumatoid arthritis or systemic lupus erythematosus) rather than soft-tissue injury ofthe elbow because of:

No history of traumaAge and sex of the patientPattern of symptom onset and progressionSymmetrical distribution of signs and symptoms to both upper extremities

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C H A P T E R 1 0

The Wrist and Hand

F U R T H E R I N F O R M A T I O N

Please refer to Chapter 2for an overview of the sequence of

a physical examination. For purposes oflength and to avoid having to repeatanatomy more than once, the palpationsection appears directly after the sectionon subjective examination and before any

section on testing, rather than at the endof each chapter. The order in which theexamination is performed should bebased on your experience and personalpreference as well as the presentation ofthe patient.

Functional Anatomy

The hand can be divided into two major parts: thewrist and five digits. The carpus, or wrist, is com-posed of eight small bones. As a unit, the carpus can bethought of as an egg lying on its side, resting in a shal-low cup. In this way, it can accommodate movementin three planes, although in unequal amounts. Thegreatest degree of freedom is in the flexion–extensionplane. Next is ulnar–radial deviation. The least move-ment occurs in rotation about the long axis of theforearm.

The shallow cup is formed by both bony and softtissues. There are laterally, the distal end of the ra-dius and its styloid, and medially, the distal ulnarstyloid and the triangular fibrocartilaginous menis-cus. The meniscal soft tissue is interposed betweenthe distal end of the ulna and the wrist bones. The“egg” of the wrist is composed of two rows of small,irregularly shaped bones called the carpals (Figure10.1). These two rows are linked together by manyinterosseous ligamentous structures and are also con-nected through the navicular bone, which acts as alinkage between the proximal and distal carpal rows.The carpal bones, because of their shape, permit vary-ing amounts of movement. Together, they facilitate

and modify placement of the digits in space. Becauseof its position as linkage between carpal rows, the sc-pahoid (navicular) (meaning “boat shaped”) can bestressed across its midsection or waist, creating a frac-ture of that bone. Because of its vascular supply fol-lowing the unusual distal-to-proximal direction, frac-ture of the scpahoid can lead to avascular necrosisand collapse of the proximal half of that bone. Thisdamage leads to impairment of wrist function andprogressive osteoarthritis of the wrist joint.

The five digits can be divided into three groups.The index and long fingers represent a stable centralcolumn about which the medial ring and small fingers,and lateral thumb wrap.

The basal joint of the thumb is the most mobile ofthe hand articulations. Shaped like a saddle, the basaljoint permits flexion and extension in two planes. Thesaddle shape, however, is quite unstable, and possiblythe reason for the greater propensity for this joint toundergo osteoarthritic degeneration compared to theother joints of the hand.

Each of the digits of the hand has joints that permitflexion and extension. They can each be thought of assimple hinge joints stabilized by collateral ligamentson their medial and lateral aspects.

Movement of the wrist and digits is performed bythe flow of the long, sinewy tendons passing from

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236 The Wrist and Hand Chapter 10

Pisiform

Lunate

Radius

Ulna

Triangularfibrocartilaginous

meniscus

Carpus

CapitateHamate

Triquetrum

Scaphoid(Navicular)

Trapezium

Trapezoid

Styloidprocessof radius

Styloidprocessof ulna

Figure 10.1 The eight small carpal bones of the hand form an“egg,” which rests in a shallow dish formed by the distal radiusand ulnar meniscus.

their origins in the forearm across the palmar anddorsal aspects of the wrist. These tendons, along withthe major neurovascular structures of the hand, passthrough well-defined tunnels or compartments. Twoof these tunnels on the palmar side of the wrist areparticularly rigid in their cross-sectional dimension.As such, neurovascular structures passing throughthem are particularly vulnerable to compression in-juries should any space-occupying lesion invade thespace of this tunnel (i.e., edema from injury or thy-roid dysfunction, or adipose tissue due to obesity).These tunnels are so often involved in clinical syn-dromes that they bear specific mention. They are thecarpal tunnel, which contains the median nerve to-gether with the flexor tendons of the digits, and thetunnel of Guyon, which contains the ulnar nerve. In-jury to the median nerve presents as paresthesias, at-rophy, and loss of sensation to the thenar eminenceof the thumb, the index and long fingers, and theradial half of the ring finger. Compression injury ofthe ulnar nerve will affect the medial aspect of thehand (hypothenar eminence, small finger, and ulnarhalf of the ring finger), together with the ulnar intrin-sic muscles of the hand. This muscular compromisewill lead to classic posturing of the digits called the

benediction hand, referring to the appearance of apriest’s hand when giving a blessing (see p. 282–284,Figure 10.97).

Observation

The examination should begin in the waiting roombefore the patient is aware of the examiner’s observa-tion. Information regarding the degree of the patient’sdisability, level of functioning, posture, and gait canbe observed. The clinician should pay careful atten-tion to the patient’s facial expressions with regard tothe degree of discomfort the patient is experiencing.The information gathered in this short period can bevery useful in creating a total picture of the patient’scondition.

Note the manner in which the patient is sitting andhow he or she is posturing the upper extremity. Isthe arm relaxed at the side or is the patient cradlingit for protection? What is the relaxed posture of thehand itself? Note whether the wrist or hand is edema-tous. Note the shape of the hand and if there are anychanges in contour. The patient may have a protuber-ance secondary to a ganglion, nodule, or bony dislo-cation. Note any bony deformities. The patient mayhave a swan neck, boutonniere deformity, or claw fin-gers. Compare one hand to the other, rememberingthat the dominant hand may be larger in the normalindividual. What is the cosmetic appearance of thehand? Many patients are extremely self-conscious ofhow their hands look.

How willing is the patient to use the upper extrem-ity? Will he or she allow you to shake their hand?Is the patient able to move the hand in an effortlessand coordinated fashion or is he or she stiff and un-coordinated? Is the patient willing to bear weight onan extended wrist? Watch as the patient gets up fromthe chair to see whether he or she pushes down withthe wrist. Pain may be altered by changes in positionso watch the patient’s facial expression to give youinsight into the pain level.

Observe the patient as he or she assumes the stand-ing position. Observe the patient’s posture. Pay par-ticular attention to the position of the head, cervicalspine, and the thoracic kyphosis. Note the height ofthe shoulders and their relative positions. Once thepatient starts to ambulate, observe whether he or sheis willing to swing the arms. Arm swing can be lim-ited by either loss of motion, pain, or neurologicaldamage.

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237Chapter 10 The Wrist and Hand

Once the patient is in the examination room, askhim or her to disrobe. Observe the ease with whichthe patient uses the upper extremities and the rhythmof the movements. Observe for symmetry of bonystructures. Note the carrying angle with the upperextremity postured in the anatomical position. Ob-serve the hand on all surfaces. Observe for areas ofmuscle wasting that may be secondary to peripheralnerve lesions. Inspect for scars, open lesions, abra-sions, calluses, color, hair growth patterns, nails, andthe presence of any trophic changes. Abnormalitiesmay be secondary to reflex sympathetic dystrophy,shoulder hand syndrome, Raynaud’s disease, or pe-ripheral vascular or metabolic disease. Observe theskin. Is the skin smooth with a loss of the creases? Isthere an increase in moisture or a decrease in sensibil-ity? Spindlelike fingers can be secondary to systemiclupus erythematosus, long-standing neuropathy, orrheumatoid arthritis. Clubbing and cyanosis of thenails may be secondary to pulmonary disease.

Subjective Examination

The wrist and hand are extremely active structuresthat are both complicated and delicate. They arevery vulnerable to injury. Since they are non-weight-bearing, problems are most commonly related tooveruse syndromes, inflammation, and trauma. Youshould inquire about the nature and location of thepatient’s complaints as well as their duration and in-tensity. Note whether the pain travels up to the el-bow. The behavior of the pain during the day andnight should also be addressed.

You should determine the patient’s functional lim-itations. How much was the patient able to do beforethe onset of symptoms? Which is the dominant hand?How incapacitated does the patient consider himselfor herself to be? Question the patient regarding actualuse of the upper extremity. Is the patient able to combhis hair, fasten her bra, fasten buttons, handle smallobjects, or feed himself? Is this injury traumatic innature? What was the mechanism of the injury? Doesthe patient regularly participate in any vigorous sportactivity that would stress the wrist or hand? Whatis the patient’s occupation? Does he or she use toolsor spend a great deal of time at a computer terminalstressing the wrist and hand repetitively?

If the patient reports a history of trauma, it is im-portant to note the mechanism of injury. The direc-tion of the force, the position of the upper extrem-

ity, and the activity the patient was participating inat the time of the injury contribute to your under-standing of the resulting problem and help you tobetter direct your examination. The degree of pain,edema, and disability at the time of the trauma andwithin the initial 24 hours should be noted. Does thepatient have a previous history of the same injury?Does the patient report any clicking, grating, or snap-ping? This may be due to a stenosing tenosynovitis orto a loose body. Is any grating present? This may bedue to osteoarthritis.

The patient’s disorder may be related to age, gen-der, ethnic background, body type, static and dy-namic posture, occupation, leisure activities, hobbies,and general activity level. It is important to inquireabout any change in daily routine and any unusualactivities that the patient has participated in. The lo-cation of the symptoms may give you some insightinto the etiology of the complaints. The cervical spineand the shoulder can refer pain to the wrist and handand should be included as part of the examination.The most common nerve roots that refer pain are C6,C7, C8, and T1. (Please refer to Box 2.1, p. 15 fortypical questions for the subjective examination.)

Gentle Palpation

The palpatory examination is started with the patientin the sitting position. You should first examine forareas of localized effusion, discoloration, birthmarks,calluses, open sinuses or drainage, incisional areas,abrasions, bony contours, muscle girth and symme-try, and skin creases. You should not have to use deeppressure to determine areas of tenderness or malalign-ment. It is important to use firm but gentle pressure,which will enhance your palpatory skills. By having asound basis of cross-sectional anatomy, you will notneed to physically penetrate through several layers oftissue to have a good sense of the underlying struc-tures. Remember that if you increase the patient’s painat this point in the examination, the patient will bevery reluctant to allow you to continue and may be-come more limited in his or her ability to move.

Palpation is most easily performed with the patientin a relaxed position. The sitting position with theextremity supported on a table is preferred for ease ofexamination of the wrist and hand. Remember thatfor palpation of all the structures described, the handis in the anatomical position. While locating the bonylandmarks, it is also useful to pay attention to areas

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of increased or decreased temperature and moisture.This will help you identify areas of acute and chronicinflammation.

Anterior (Palmar) Aspect

Bony Structures

Since thick skin and fascia cover the palm, the bonystructures are more difficult to palpate on the anteriorsurface. The carpal bones are more accessible andeasier to identify from the dorsal aspect. Descriptionsof their locations are found later in this chapter.

Soft-Tissue Structures

Start your palpation by observing the superficial pal-mar surface. The skin is thicker than on the dorsalaspect. The skin contains many sweat glands but isfree of hair. Observe the creases in both the longitu-dinal and transverse directions. You will notice thatthe longitudinal creases are more distinct when the pa-tient opposes the thumb. The transverse creases aremore distinct when the patient flexes the metacar-pophalangeal joints. Note the absence of the fibro-fatty tissues and how the skin is securely attachedto the deep fascia in the area of the skeletal jointsforming the creases. They are useful to identify theunderlying anatomical structures. At the level of thewrist, you will notice the proximal and then the distalwrist creases. On the lateral side, notice the thenar(radial longitudinal) crease that surrounds the thenareminence.

Continuing distally, note the proximal palmar (flex-ion) crease, which begins simultaneously with thethenar crease, just proximal to the head of the sec-ond metacarpal. It travels medially across the palmalong the middle of the shafts of the third throughfifth metacarpals.

The distal palmar (transverse) crease is located onthe palmar surface of the heads of the second or thirdthrough fifth metacarpals. It becomes more distinct asthe patient flexes the metacarpophalangeal joints.

As you continue distally, you will notice the prox-imal digital creases located at the level of the fingerwebs. There are no joints under these creases. Themetacarpophalangeal joints are about 2 cm proximalto the proximal digital creases.

The proximal and distal interphalangeal creases liesuperficial to the proximal and distal interphalangealjoints and deepen as the joints are flexed (Figure 10.2).

Proximal wrist crease

Distal wrist crease

Proximal digital creases

Distal palmar crease

Proximal palmar crease

Thenar crease

Proximal interphalangeal crease

Distal interphalangeal crease

Figure 10.2 Palpation of the palmar surface of the hand.

To enable you to more easily organize the palpationof the deeper soft tissues, the anterior surface of thehand can be divided into three areas: the medial, mid-dle, and lateral compartments. Each compartment isdescribed, from proximal to distal.

Medial (Ulnar) CompartmentFlexor Carpi Ulnaris. Move your fingers to the me-dial palmar surface and locate the pisiform bone (seedescription on p. 242, Figure 10.11). The tendon ofthe flexor carpi ulnaris is palpable proximal to its at-tachment on the pisiform (Figure 10.3). The tendonbecomes more distinct when you resist wrist flexionand ulnar deviation.

Ulnar Artery. The ulnar pulse can be palpated onthe medial volar surface of the wrist (Figure 10.4).Press against the distal aspect of the ulna, just proxi-mal to the pisiform, to facilitate palpating the pulse.Remember not to press too hard since the pulse willbe obliterated.

Ulnar Nerve. The ulnar nerve passes into the handlateral to the pisiform, medial and posterior to theulnar artery, and then under the hook of the hamate.It is not readily palpable in the wrist, but it is at themedial elbow (see p. 204, Figure 9.7).

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239Chapter 10 The Wrist and Hand

Flexor carpi ulnaris tendon

Figure 10.3 Palpation of the flexor carpi ulnaris.

UlnarArtery

Figure 10.4 Palpation of the ulnar artery.

Figure 10.5 Palpation of the hypothenar eminence.

Hypothenar Eminence. Place your fingers on thepisiform and move distally until you reach the distalpalmar crease. You will feel the longitudinal bulk ofthe muscle bellies of the hypothenar eminence (Figure10.5). The eminence is composed of the palmaris bre-vis, abductor digiti minimi, flexor digiti minimi bre-vis, and the opponens digiti minimi. It is not possibleto differentiate between these muscles on palpation.Examine the hypothenar eminence and compare it tothe one in the opposite hand for size and symmetry.Atrophy and diminished sensation can be indicativeof compression of the ulnar nerve in the elbow in thecubital tunnel or in the canal of Guyon secondary totrauma or from compression from a ganglion. Powergrip will be significantly impaired.

Middle CompartmentPalmaris Longus. Continue to move laterally alongthe anterior surface of the wrist. The long thin tendonin the middle is the palmaris longus. It can be palpatedjust proximal to its attachment to the anterior dis-tal surface of the flexor retinaculum and the palmaraponeurosis (Figure 10.6). The tendon becomes moredistinct when the patient flexes the wrist and approx-imates the thenar and hypothenar eminences, causinga tensing of the palmar fascia. The palmaris longus is

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240 The Wrist and Hand Chapter 10

Figure 10.6 Palpation of the palmaris longus.

absent in either one or both wrists in approximately13% of the population. However, its absence doesnot alter the patient’s function (Moore and Dalley,1999). When the tendon is present, it may be usefulas a donor site for two-stage tendon reconstructivesurgery. The tendon can be used to help locate themedian nerve, which runs just lateral to it at the wrist.

Flexor Digitorum Profundus and Superficialis. Thetendons of the flexor digitorum profundus and super-ficialis travel in a common sheath passing under theflexor retinaculum and deep to the palmar aponeuro-sis. They then divide, are covered by synovial mem-brane, and enter into individual osseofibrous digitaltunnels. In some individuals, it is possible to pal-pate the individual tendons as they travel along thepalm toward the digits. Ask the patient to flex and ex-tend the fingers and you will feel the tendon becomemore prominent as the fingers contract into flexionand taut as they move toward extension.

If snapping, “clunking,” or grating in the tendonis noted with either flexion or extension, a triggerfinger may be present. This is caused by swelling ofthe tendon, which creates difficulty in gliding underthe pulley at the metacarpal head during movement.

Carpal Tunnel. The carpal tunnel is created by theflexor retinaculum covering the anterior concavity ofthe carpal bones. Its floor is formed medially by thepisiform and the hook of the hamate and laterally bythe tubercle of the scaphoid and the tubercle of thetrapezium (Figure 10.7). The tunnel allows the flexortendons of the digits and the median nerve to travel

through to the hand. It is extremely significant clini-cally because of the frequency of compression of themedian nerve secondary to edema, fracture, arthri-tis, cumulative trauma, or repetitive motion injuries.This is referred to as carpal tunnel syndrome. You canconfirm the diagnosis with electrodiagnostic testing.

Palmar Aponeurosis. The palmar aponeurosis is atriangular shaped fascia found in the palm of the handcovering the long finger flexors. It divides into fourbands, which join with the fibrous finger sheaths. It ispalpable as a resistance to your pressure in the centerof the palm while the fingers are in extension. Markedfinger flexion at the metacarpophalangeal joints withincreased fibrosis of the palmar fascia is indicative ofa Dupuytren-like contracture.

Lateral (Radial) CompartmentFlexor Carpi Radialis. If you continue to move lat-erally from the palmaris longus, the next tendon youwill palpate is the flexor carpi radialis (Figure 10.8).The tendon is palpable at the level of the wrist as itpasses into the hand and attaches at the base of thesecond metacarpal. In some individuals, the musclemay be absent. The tendon is made more distinct byproviding resistance during wrist flexion and radialdeviation.

Radial Artery. The radial pulse can be palpated justlateral to the tendon of the flexor carpi radialis. Pressagainst the radius to facilitate palpating the pulse.Remember not to press too hard or the pulse will beobliterated.

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241Chapter 10 The Wrist and Hand

Scaphoidtuberosity

Tubercle oftrapezium

Pisiform

Hook of hamate

Carpal tunnel

Tubercle oftrapezium

Trapezium

Trapezoid

Pisiform

CapitateTriquetrum

Lunate

Median nerve

Palmarislongus

Flexordigitorumprofundus

Flexordigitorumsuperficialis

Ulnar A & N

Flexorpollicislongus

Transverse carpalligament

Figure 10.7 The carpal tunnel.

Thenar Eminence. The thenar eminence is com-prised of the three short muscles of the thumb: abduc-tor pollicis brevis, flexor pollicis brevis, and opponenspollicis. It is located at the base of the thumb and isa thick, fleshy prominence that is freely movable onpalpation. It is demarcated by the thenar crease.

Flexor carpi radialis

Figure 10.8 Palpation of the flexor carpi radialis.

Compare both hands for symmetry, especially pay-ing attention to the size, shape, and feel of the thenareminence. Note that the dominant side may be notice-ably larger, particularly when the individual engagesin racquet sports or is a manual laborer. Notice anyatrophy. The muscles are innervated by the recurrentbranch of the median nerve and may be affected whenthe individual has carpal tunnel syndrome. The thenareminence may actually become hollow in advancedstages of the pathology.

Fingers. Observe the bony alignment of the pha-langes. They should be symmetrical and straight fromboth the anterior–posterior and medial–lateral views.The patient may present with a swan neck deformitysecondary to a contracture of the intrinsic muscles.This is often seen in patients with rheumatoid arthri-tis. A boutonniere deformity may be present when thepatient ruptures or lacerates the central tendinous slipof the extensor digitorum communis tendon, whichallows the lateral bands to migrate volarly. This canoccur secondary to trauma. In rheumatoid arthritis,the balance between the flexors and extensors is dis-turbed, not allowing the central slip to pull properlyand letting the lateral bands migrate volarly. Clawfingers can also be present secondary to loss of the

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intrinsic muscles and a subsequent overactivity of theextrinsic muscles.

Note the presence of any nodules. Heberden’snodes can be found on the dorsal aspect of the dis-tal interphalangeal joint and are associated with os-teoarthritis. Bouchard’s nodes can be found on thedorsal aspect of the proximal interphalangeal jointand are associated with rheumatoid arthritis.

Examine the finger pads. They are highly inner-vated and vascularized. The pads are especially sus-ceptible to infection because of their location anduse. Note any area of edema, erythema, and warmth.Osler’s nodes may be present secondary to subacutebacterial endocarditis.

Medial (Ulnar) Aspect

Bony Structures

Ulna Styloid ProcessPlace your fingers along the shaft of the ulna (see de-scription on p. 209, Figure 9.16) and follow it distallyuntil you come to the rounded prominence of the ulnastyloid process. It is more defined than the radial sty-loid process. The ulna styloid process is located moreproximal than its radial counterpart and slightly moreposterior (Figure 10.9). The ulna styloid process doesnot have a direct articulation with the carpal bones.

Ulnarstyloid

Figure 10.9 Palpation of the ulna styloid process.

TriquetrumPalpate the ulna styloid process and continue to movedistally on the medial aspect of the wrist. You will firstfind the space for the articular meniscus and then feelthe rounded surface of the triquetrum. Move the pa-tient’s hand into radial deviation and the triquetrumwill move medially into your finger (Figure 10.10).The dorsal aspect can also be palpated and will bemore prominent as the patient’s hand is flexed. Thepalmar aspect is not palpable since it is covered bythe pisiform.

PisiformThe pisiform is located on the anterior surface of thetriquetrum just distal and anterolateral to the ulnastyloid process (Figure 10.11). The pisiform serves asthe attachment for the flexor carpi ulnaris.

HamateThe most palpable portion of the hamate is the hookor the hamulus. It is located proximal to the radialborder of the fourth metacarpal. An easy way to lo-cate the hook is by placing the interphalangeal joint ofyour thumb over the pisiform and direct your thumbdiagonally toward the patient’s web space. The hookwill be located under your thumb pad, approximately2.5 cm distal to the pisiform (Warwick and Williams,

Triquetrium

Figure 10.10 Palpation of the triquetrum.

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243Chapter 10 The Wrist and Hand

Pisiform

Figure 10.11 Palpation of the pisiform.

1998) (Figure 10.12). Because the bony structure isdeep, you must press into the soft tissue to locate it.Be careful because of the proximity of the ulnar nerve.The hook is often tender to touch. You can palpatethe posterior aspect by simultaneously placing yourindex finger over the dorsal aspect of the hand. Thehamate is located proximal to the base of the fourthand fifth metacarpals.

Pisiform

Hook of Hamate

Figure 10.12 Palpation of the hamate.

The hook of the hamate is clinically significant be-cause with the pisiform it forms the canal of Guyon.This is the second most common area of compressionneuropathy of the ulnar nerve (see section on “En-trapment Neuropathies” on p. 280, Figure 10.96).

Soft-Tissue Structures

Triangular Fibrocartilaginous ComplexThe triangular fibrocartilaginous complex is com-prised of the triangular fibrocartilage, the ulnocarpalmeniscus, a small recess containing synovium, and thepalmar ulnocarpal and ulnolunate ligaments. The tri-angular cartilage attaches to the radius. The ligamentsattach from the cartilage itself to the palmar aspect ofthe ulnar carpal bones. Therefore, the triangular fi-brocartilaginous complex serves to suspend the wristfrom the radius (Lichtman, 1988).

To facilitate description, the remainder of the soft-tissue structures is described in the section relating tothe anterior surface of the hand.

Lateral (Radial) Aspect

Bony Structures

Radial Styloid ProcessPlace your fingers along the lateral aspect of the fore-arm and follow the shaft of the radius distally untilyou come to the radial styloid process, which is justproximal to the radiocarpal joint (Figure 10.13).

Scaphoid (Navicular)Allow your fingers to move slightly distal from the ra-dial styloid process and you will notice a small depres-sion. Ask the patient to ulnar deviate the wrist and youwill feel your finger being pushed out of the depressionby a dome-shaped bone. This is the scaphoid (Figure10.14). The scaphoid forms the floor of the anatom-ical snuffbox (see p. 245, Figure 10.17). Tendernessin the area should raise your suspicion. Fractures ofthe scaphoid can be difficult to diagnose and are com-monly overlooked and misdiagnosed as sprains. Sincea retrograde vascular supply exists in the scaphoid,nonunion or avascular necrosis (Preiser’s disease) cansubsequently result.

Trapezium and Trapezoid (Greater and LesserMultangular)Continue to move distally from the scaphoid. In thesmall space between the scaphoid and the base of

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Radial styloid

Figure 10.13 Palpation of the radial styloid process.

the first metatarsal, you will find the trapezium andtrapezoid (Figure 10.15). It is not possible to clini-cally differentiate between these two bones and theyare commonly referred to as the trapezeii. The articu-lation between the trapezeii and the first metacarpal,or the first carpometacarpal joint, is a saddle joint and

Scaphoid

Figure 10.14 Palpation of the scaphoid.

allows for increased dexterity of the thumb. It is verycommonly affected by degenerative arthritis.

First MetacarpalLocate the trapezium and the joint line with thefirst metacarpal. Follow the first metacarpal distally

Trapezium

Trapezoid

Figure 10.15 Palpation of the trapezium and trapezoid.

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245Chapter 10 The Wrist and Hand

First metacarpal

Figure 10.16 Palpation of the first metacarpal.

until you reach the metacarpophalangeal joint (Fig-ure 10.16). It is very superficial and easy to locatealong its lateral and dorsal aspects. Notice that it issmaller and thicker than the other metacarpals. It hasthe most mobility of all five metacarpals, allowingfor prehension of the thumb. A fracture of the prox-imal first metacarpal is known as Bennett’s fractureand may result in an avulsion of the abductor pollicislongus.

Soft-Tissue Structures

Anatomical SnuffboxAllow your fingers to move slightly distally from theradial styloid process and ask the patient to extendthe thumb. You will see a small triangular depres-sion, called the anatomical snuffbox. The depressionis bordered by the extensor pollicis brevis and abduc-tor pollicis longus laterally and the extensor pollicislongus medially. The floor is made up of the scaphoid.The radial pulse can be palpated between the borders(Figure 10.17). If there is tenderness in the snuffbox,you should be suspicious of a fracture of the scaphoid.

Posterior (Dorsal) Aspect

Bony Structures

Dorsal Tubercle of the Radius (Lister’s Tubercle)Find the radial styloid process and move medially ap-proximately one-third of the way along the posterioraspect of the radius until you come to a narrow ridge.This is the dorsal tubercle of the radius (Lister’s tuber-

Anatomical“snuffbox”

Extensorpolicis longus

Figure 10.17 Palpation of the anatomical snuffbox.

cle). It can also be located by finding the indentationbetween the index and middle fingers and followingproximally until you reach the radius (Figure 10.18).It is an important structure since the extensor pollicislongus hooks around it, creating a 45-degree angle asit travels to its attachment at the distal phalanx of thethumb.

LunateKeep the patient’s wrist in a slightly extended posi-tion. Find the dorsal tubercle of the radius and con-tinue slightly distally and medially. You will feel anindentation under your index finger. Flex the patient’swrist and you will feel your finger being pushed out ofthe indentation by the lunate (Figure 10.19). You canpalpate the anterior surface of the lunate by simulta-neously placing your thumb in the area between thethenar and hypothenar eminences. The lunate is themost common carpal to dislocate and at first glanceit can be confused with a ganglion. Tenderness andswelling in the area may be secondary to avascularnecrosis or Keinbock’s disease.

CapitateAfter finding the lunate, you can continue to movedistally and you will find the capitate in the space

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Lister'stubercle

Figure 10.18 Palpation of the dorsal (Lister’s) tubercle of the radius.

between the lunate and the base of the thirdmetacarpal (Figure 10.20). If the patient’s hand is inthe neutral or slightly extended position, you will feela dip under your finger which is the dorsal concav-ity of the crescent-shaped capitate. As you flex thepatient’s wrist, the capitate rolls, coming out fromunder the lunate, filling in the dip, and pushing yourfinger dorsally.

MetacarpalsThe metacarpals are more easily palpated from thedorsal aspect of the hand. Pronate the individual’sforearm, rest the palm on your thumb, and palpatethe metacarpals using your index and third fingers.

Locate the bases of the second through fifthmetacarpals just distal to the distal row of carpals.You will notice a flaring of the bones. Trace them dis-tally until you reach the metacarpophalangeal joints(Figure 10.21). You will notice that the fourth andfifth metacarpals are much more mobile than the sec-ond and third are because of the less rigid attachmentat the carpometacarpal joints. This allows for stabilityon the lateral aspect of the hand and increased mobil-ity on the medial aspect to allow for power grasp.

Metacarpophalangeal JointsContinue to follow the metacarpals distally un-til you reach the metacarpophalangeal joints. The

Lunate

Figure 10.19 Palpation of the lunate.

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Capitate

Figure 10.20 Palpation of the capitate.

“knuckles” are most clearly visualized on the dor-sal surface with the patient’s fingers flexed. In thisposition, you can more easily visualize and palpatethe joint surfaces. The anterior aspect of the metacar-pophalangeal joints is deceiving since it appears to bemore distal than you would expect. Remember that

the joints are located deep to the distal palmar crease(Figure 10.22).

Phalanges and Interphalangeal JointsThe three phalanges of fingers two through fiveand the two phalanges of the thumb are more

Metacarpophalangeal joint

Figure 10.21 Palpation of the metacarpals.

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Head ofsecond metacarpal

Figure 10.22 Palpation of the metacarpophalangeal joints.

easily visualized from the dorsal aspect of the hand.Find the metacarpophalangeal joint and follow thephalanges distally, stopping to palpate the proximalinterphalangeal joints and then the distal interpha-langeal joints. Note the continuity of the bones andthe symmetry of the joints. The interphalangeal jointsare common sites for deformities secondary to os-teoarthritis and rheumatoid arthritis.

NailsThe fingernails should be smooth and with good col-oration. Nail ridges can occur secondary to trauma,avitaminosis, or chronic alcoholism. A direct traumato the nail can cause bleeding, resulting in a subun-gual hematoma. Brittle nails with longitudinal ridgescan occur secondary to exposure to radiation. Spoon-shaped nails can occur due to Plummer–Vinson syn-drome which is secondary to iron deficiency anemia.Psoriasis can cause a scaling deformity of the nails.Congenital absence of the thumbnail may be seen inpatients with patella–nail syndrome. This is charac-terized by a small patella, subluxation of the radialhead, and a bony projection from the ilium.

Soft-Tissue Structures

Observe the skin over the dorsum of the hand. Noticethat it is much looser than the skin over the palm.This allows for greater mobility of the fingers into

flexion. Additional skin is noted over the interpha-langeal joints and forms transverse ridging. The ex-tensor tendons are clearly visible on the dorsum ofthe hand since they are not covered by thick fascia, ason the anterior surface. The individual tendons canbe traced as they continue to their distal attachmentson the bases of the middle phalanges of fingers twothrough five. The tendons can be made more distinctby resisting finger extension.

Extensor RetinaculumThe extensor retinaculum is a strong fibrous band lo-cated on the dorsal aspect of the wrist. It attaches fromthe anterior border of the radius to the triquetrum andpisiform bones. There are six tunnels deep to the ex-tensor retinaculum that allow for the passage of theextensor tendons into the hand (Figure 10.23).

To enable you to more easily organize the palpa-tion of the deeper soft tissues, the posterior surfaceof the hand is divided into six areas. The individualcompartments are described, from the lateral to themedial aspect.

Compartment IThe most lateral compartment allows the abductorpollicis longus and extensor pollicis brevis to travelto the thumb (Figure 10.24). These muscles comprise

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Abductor pollicis longus

Extensor pollicis longus

Extensor indicis

Extensor digititorum tendons

Extensor digitiminimi

Extensor pollicis brevis

Extensor carpi ulnaris

Extensor rectinaculum

Figure 10.23 Palpation of the extensor retinaculum.

Abductorpollicisbrevis

Extensorpollicis longus

Figure 10.24 Palpation of compartment I.

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the radial border of the anatomical snuffbox (seepp. 270–274 for full description). The tendons canbe made more distinct by resisting thumb extensionand abduction.

Tenderness in this area may be indicative of deQuervain’s disease, which is a result of stenosingtenosynovitis of the tendon sheath. Differential diag-nosis can be done by using Finkelstein’s test, which isdescribed in the section on special test of this chapter(p. 285, Figure 10.99).

Compartment IIContinuing into the next most medial compartment,which is located lateral to Lister’s tubercle, you willfind the extensor carpi radialis longus and the exten-sor carpi radialis brevis (Figure 10.25). The tendonscan be made more distinct by resisting wrist extensionand radial deviation.

Compartment IIIOn the medial aspect of Lister’s tubercle, you will findthe tendon of the extensor pollicis longus as it wrapsaround the tubercle (Figure 10.26). This tendon cre-ates the medial border of the anatomical snuffbox (seedescription on pp. 270, 274, Figures 10.76, 10.77).

The tendon travels through a groove on the radiusand passes through the extensor retinaculum aroundthe dorsal tubercle of the radius. The tendon hasa large degree of angulation, which increases withthumb extension. This tendon can be easily irritatedby repetitive use of the thumb. Palpate this tendon forcontinuity to ensure that it has not been disrupted.

Extensor carpiradialis longus

Extensor carpiradialis brevis

Figure 10.25 Palpation of compartment II.

Extensor pollicis longus

Lister’stubercle

Figure 10.26 Palpation of compartment III.

Compartment IVCompartment IV allows the tendons of the exten-sor digitorum communis and the extensor indicis totravel to the hand (Figure 10.27). The individual ten-dons can be traced as they continue to their distalattachments on the bases of the middle and distalphalanges of fingers two through five. It is easiest tolocate them in the area between the carpal bones andthe metacarpophalangeal joints. The tendons can bemade more distinct by resisting finger extension. Arupture or elongation of the terminal portion of theextensor tendon can cause a mallet finger.

Compartment VAs you continue medially, the tendon of the exten-sor digiti minimi is palpable in a small depressionlocated slightly lateral to the ulna styloid process (Fig-ure 10.28). The tendon can be made more distinct byresisting extension of the fifth finger.

Compartment VIThe most medial compartment contains the tendon ofthe extensor carpi ulnaris. The tendon can be palpatedin the groove between the head and the styloid processof the ulna as it passes to its distal attachment at the

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Extensordigitorum

Extensor indicis

Figure 10.27 Palpation of compartment IV.

base of the fifth metacarpal (Figure 10.29). It canbe made more distinct by resisting wrist extensionand ulnar deviation. The tendon can also be palpatedby having the patient ulnar deviate the wrist, whichincreases the tension of the tendon.

Extensor digitiminimi

Figure 10.28 Palpation of compartment V.

Extensor carpiulnaris

Figure 10.29 Palpation of compartment VI.

Active Movement Testing

The major movements of the wrist joint are flexion,extension, and ulnar and radial deviation. Pronationand supination of the forearm also must be consid-ered. Movements of the metacarpophalangeal, proxi-mal interphalangeal, and distal interphalangeal jointsinclude flexion and extension. Abduction and adduc-tion also occur at the metacarpophalangeal joints.The thumb movements include flexion, extension, ab-duction, adduction, and opposition. These should bequick, functional tests designed to clear the joint. Ifthe motion is pain free at the end of the range, you canadd an additional overpressure to “clear” the joint.If the patient experiences pain during any of thesemovements, you should continue to explore whetherthe etiology of the pain is secondary to contractile ornoncontractile structures by using passive and resis-tive testing.

Quick testing of the movements of the wrist andhand should be performed simultaneously by bothupper extremities. The patient should be sitting with

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the forearms resting on a treatment table. You shouldface the patient to observe symmetry of movement.

To examine the wrist–hand complex from proxi-mal to distal, start by asking the patient to supinateand pronate the forearm. A full description of thismovement is described in Chapter 9 (pp. 210–211).Have the patient move the arm so that the wrist ispositioned at the end of the table with the forearmpronated. Ask the patient to raise the dorsum of thehand toward the ceiling as far as he or she can, to com-plete wrist extension. Then ask the patient to allowthe hand to bend toward the floor as far as possi-ble, to complete wrist flexion. Instruct the patient tomove the arm so that the entire hand is supported onthe table in the pronated position. Ask the patient tomove the hand to the side, allowing the thumb to ap-proximate the radius to complete the motion of radialdeviation. Instruct the patient to return to the neutralposition, and then move the hand to the opposite side,with the fifth finger approximating the ulna, to com-plete ulnar deviation. Note that the range of motionshould normally be greater for ulnar deviation sincethere is no direct contact between the carpals and theulna because of the meniscus.

To quickly assess the movement of the fingers, in-struct the patient to make a tight fist. Observe thequality of the movement and whether all of the fin-gers are working symmetrically. Full range of motionof finger flexion is accomplished if the patient’s fin-gertips can contact the proximal palmar crease. Theninstruct the patient to release the grasp and straightenout all the fingers, to accomplish finger extension. Youshould observe that the fingers are either in a straightline (full extension) or slightly hyperextended. Nowask the patient to spread the fingers apart as far as heor she can, starting with the fingers in the extendedposition and the forearm pronated. Have the patientreturn the fingers together and they should all be incontact with each other. This accomplishes finger ab-duction and adduction.

The last movements to be considered are those ofthe thumb. Have the patient supinate the forearm andthen move the thumb diagonally across the palm asfar as he or she can. Full thumb flexion should allowthe patient to contact the distal palmar crease at thedistal aspect of the hypothenar eminence. Then askthe patient to release flexion and move the thumb lat-erally away from the palm, increasing the dimensionof the web space. This is full thumb extension. Nextask the patient to lift the thumb away from the palmtoward the ceiling. This motion is thumb abduction.Ask the patient to release the thumb and return to

the palm in contact with the second metacarpal. Thisis thumb adduction. The last thumb movement to beassessed is opposition. Instruct the patient to contactthe fingertips starting with the thumb meeting the fifthfinger.

Passive Movement Testing

Passive movement testing can be divided into two ar-eas: physiological movements (cardinal plane), whichare the same as the active movements, and mobilitytesting of the accessory (joint play, component) move-ments. You can determine whether the noncontractile(inert) elements are causative of the patient’s prob-lem by using these tests. These structures (ligaments,joint capsule, fascia, bursa, dura mater, and nerveroot) (Cyriax, 1979) are stretched or stressed whenthe joint is taken to the end of the available range.At the end of each passive physiological movement,you should sense the end feel and determine whetherit is normal or pathological. Assess the limitation ofmovement and see if it fits into a capsular pattern.The capsular pattern of the wrist is equal restriction inall directions (Cyriax, 1979; Kaltenborn, 1999). Thecapsular pattern of the forearm is equal restrictionof pronation and supination, which almost alwaysoccurs with significant limitation in the elbow joint(Kaltenborn, 1999). The capsular patterns for the fin-gers are as follows: the thumb carpometacarpal jointis limited in abduction followed by extension; fingerjoints have more limitation of flexion than extension(Cyriax, 1979).

Physiological Movements

You will be assessing the amount of motion availablein all directions. Each motion is measured from thezero starting position. For the wrist, the radius andthe third metacarpal form a straight line with 0 degreeof flexion and extension. For the fingers, the onlyresting position described in the literature is for thefirst carpometacarpal joint. The position is midwaybetween maximal abduction–adduction and flexion–extension (Kaltenborn, 1999).

Supination and Pronation

Supination and pronation are described in Chapter 9(p. 213).

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Wrist Flexion

The best position for measuring wrist flexion iswith the patient sitting, with the arm supported ona treatment table. The forearm should be placedso that the radiocarpal joint is located slightlybeyond the edge of the supporting surface to allowfor freedom of movement at the wrist joint. Theforearm should be pronated, the wrist should be inthe zero starting position, and the fingers should berelaxed. Hold the patient’s forearm to stabilize it.Place your hand under the dorsum of the patient’shand and move the wrist into flexion. The motionmay be restricted by tightness in the wrist and fingerextensor muscles, the posterior capsule, or the dorsalradiocarpal ligament, producing an abrupt and firm(ligamentous) end feel (Magee, 2002; Kaltenborn,1999). Normal range of motion is 0–80 degrees(American Academy of Orthopedic Surgeons, 1965)(Figure 10.30).

Wrist Extension

The best position for measuring wrist extension iswith the patient sitting, with the arm supported ona treatment table. The forearm should be placed so

that the radiocarpal joint is located slightly beyondthe edge of the supporting surface to allow for free-dom of movement at the wrist joint. The forearmshould be pronated, the wrist should be in the zerostarting position, and the fingers should be relaxed.Hold the patient’s forearm to stabilize it. Place yourhand under the palm of the patient’s hand and movethe wrist into extension. The motion may be restrictedby tightness in the wrist and finger flexor muscles, theanterior capsule, or the palmar radiocarpal ligament,producing an abrupt and firm (ligamentous) end feel(Magee, 2002; Kaltenborn, 1999). A hard end feelmay be present secondary to bony contact betweenthe radius and the proximal carpals. Normal range ofmotion is 0–70 degrees (American Academy of Or-thopedic Surgeons, 1965) (Figure 10.31).

Radial Deviation

The best position for measuring wrist radial deviationis with the patient sitting, with the arm supportedon a treatment table. The forearm should be placedso that the radiocarpal joint is located slightly be-yond the edge of the supporting surface to allow forfreedom of movement at the wrist joint. The fore-arm should be pronated, the wrist should be in the

Figure 10.30 Passive movement testing of wrist flexion.

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Figure 10.31 Passive movement testing of wrist extension.

zero starting position, and the fingers should be re-laxed. Hold the patient’s forearm to stabilize it andto prevent the patient from substituting with supina-tion and pronation. Place your hand under the palmof the patient’s hand and move the wrist into radialdeviation. A hard end feel may be present due to bonycontact between the radius and the scaphoid. The mo-tion can be restricted by tension in the ulnar collateralligament or the ulnar side of the capsule, producingan abrupt and firm (ligamentous) end feel (Magee,2002; Kaltenborn, 1999). Normal range of motion is0–20 degrees (American Academy of Orthopedic Sur-geons, 1965) (Figure 10.32).

Ulnar Deviation

The best position for measuring wrist ulnar deviationis with the patient sitting, with the arm supportedon a treatment table. The forearm should be placedso that the radiocarpal joint is located slightly be-yond the edge of the supporting surface to allow forfreedom of movement at the wrist joint. The fore-arm should be pronated, the wrist should be in thezero starting position, and the fingers should be re-laxed. Hold the patient’s forearm to stabilize it andto prevent the patient from substituting with supina-tion and pronation. Place your hand under the palm

of the patient’s hand and move the wrist into ulnardeviation. The motion can be restricted by tension inthe radial collateral ligament or the radial side of thecapsule, producing an abrupt and firm (ligamentous)end feel (Magee, 2002; Kaltenborn, 1999). Normalrange of motion is 0–30 degrees (American Academyof Orthopedic Surgeons, 1965) (Figure 10.33).

Fingers

All tests for passive movements of the fingers shouldbe performed with the patient in the sitting position,with the forearm and hand supported on an adjacenttreatment table. The examiner should be sitting facingthe patient’s hand.

Metacarpophalangeal Joint FlexionThe forearm should be positioned midway betweenpronation and supination with the wrist in the neu-tral position. The metacarpophalangeal joint shouldbe in the mid position between abduction and adduc-tion. The proximal and distal interphalangeal jointsshould be comfortably flexed. Avoid the end rangeof flexion as this will decrease the available rangebecause of tension in the extensor tendons. Placeyour hand on the metacarpal corresponding to the

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Figure 10.32 Passive movement testing of radial deviation.

Figure 10.33 Passive movement testing of ulnar deviation.

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Figure 10.34 Passive movement testing of flexion of the metacarpophalangeal joint.

metacarpophalangeal joint being evaluated. Use yourother index finger and thumb to hold the proximalphalanx and move the metacarpophalangeal joint intoflexion. The motion can be restricted by tension inthe collateral ligaments or the dorsal aspect of thecapsule, producing an abrupt and firm (ligamentous)end feel. A hard end feel is possible if contact occursbetween the proximal phalanx and the metacarpal(Magee, 2002; Kaltenborn, 1999). Normal range ofmotion is 0–90 degrees (American Academy of Or-thopedic Surgeons, 1965) (Figure 10.34).

Metacarpophalangeal Joint ExtensionThe forearm should be positioned midway betweenpronation and supination with the wrist in the neu-tral position. The metacarpophalangeal joint shouldbe in the mid position between abduction and adduc-tion. The proximal and distal interphalangeal jointsshould be comfortably flexed. Place your hand onthe metacarpal corresponding to the metacarpopha-langeal joint being evaluated. Use your other indexfinger and thumb to hold the proximal phalanx andmove the metacarpophalangeal joint into extension.The motion can be restricted by tension in the volaraspect of the capsule, producing an abrupt and firm(ligamentous) end feel (Magee, 2002; Kaltenborn,1999). Normal range of motion is 0–45 degrees(American Academy of Orthopedic Surgeons, 1965)(Figure 10.35).

Metacarpophalangeal Abduction and AdductionThe forearm should be fully pronated with the wrist inthe neutral position. The metacarpophalangeal joint

should be at 0 degree of flexion–extension. Use yourhand to stabilize the metacarpal to prevent substitu-tion by radial or ulnar deviation. Grasp the fingerbeing examined just proximal to the proximal inter-phalangeal joint and move it away from the midlinefor abduction, returning to the midline for adduction.The motion can be restricted by tension in the col-lateral ligaments of the metacarpophalangeal joints,skin, fascia in the finger web spaces, and the interosseimuscles, producing an abrupt and firm (ligamentous)end feel (Magee, 2002; Kaltenborn, 1999). The col-lateral ligaments of the metacarpophalangeal jointsare taut in flexion and relaxed in extension. You willnote that the presence of abduction or adduction ofthe metacarpophalangeal joint in a flexed positionis due to collateral ligament discontinuity or rupture.Normal range of motion is 0–20 degrees (Hoppenfeld,1976) (Figure 10.36).

Proximal and Distal Interphalangeal Joint FlexionThe forearm should be positioned midway betweenpronation and supination with the wrist in the neu-tral position. The metacarpophalangeal joint shouldbe at 0 degree of flexion–extension and abduction–adduction. Place your thumb and index fingers onthe proximal phalanx of the finger being examinedto stabilize it. Use your other index finger and thumbto hold the middle phalanx and move the proximalinterphalangeal joint into flexion. To assess the dis-tal interphalangeal joint, with the hand in the sameposition, stabilize the middle phalanx and move thedistal phalanx into flexion. The motion of the proxi-mal interphalangeal joint can be restricted by contact

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Figure 10.35 Passive movement testing of extension of the metacarpophalangeal joint.

Figure 10.36 Passive movement testing of abduction and adduction of the metacarpophalangeal joint.

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between the middle and proximal phalanges, produc-ing a hard end feel. A soft end feel is possible sec-ondary to compression of soft tissue on the volar as-pect. The motion of the distal interphalangeal jointcan be restricted by tension in the dorsal aspect ofthe capsule or the collateral ligaments, producing anabrupt and firm (ligamentous) end feel (Magee, 2002;Kaltenborn, 1999). Normal range of motion is 0–110degrees for the proximal interphalangeal joint and 0–65 degrees for the distal interphalangeal joint (Amer-ican Society for Surgery of the Hand, 1983) (Figure10.37).

Proximal and Distal Interphalangeal Joint ExtensionThe position and stabilization used for proximal anddistal interphalangeal joint extension are the sameas those listed for flexion. Grasp the middle pha-lanx (proximal interphalangeal joint) or the distalphalanx (distal interphalangeal joint) and return thejoint to extension. The motion of the proximal anddistal interphalangeal joints can be restricted by ten-sion in the volar aspect of the capsule, producing anabrupt and firm (ligamentous) end feel (Magee, 2002;Kaltenborn, 1999). Normal range of motion is 0 de-gree for the proximal interphalangeal joint and 0–20

degrees for the distal interphalangeal joint (Hoppen-feld, 1976) (Figure 10.38).

First Carpometacarpal Abduction and AdductionThe forearm should be positioned midway betweenpronation and supination with the wrist in the neu-tral position. The metacarpophalangeal joint shouldbe at 0 degree of flexion–extension and abduction–adduction. The carpometacarpal, metacarpopha-langeal, and interphalangeal joints of the thumbshould all be at 0 degree. Place your hand aroundthe carpal bones and the second metacarpal to sta-bilize the hand. Using your other thumb and indexfinger, grasp the first metacarpal and move the thumband metacarpal away from the palm, creating abduc-tion. Check adduction by returning the thumb to thepalm. Carpometacarpal abduction is restricted by fas-cial tension in the web space and tension in the in-trinsic muscles, producing an abrupt and firm (liga-mentous) end feel (Magee, 2002; Kaltenborn, 1999).Normal range of motion is 0–70 degrees for abduc-tion and 0 degree for adduction (American Academyof Orthopedic Surgeons, 1965) (Figure 10.39).

Proximalinterphalangealjoint

Figure 10.37 Passive movement testing of flexion of the proximal and distal interphalangeal joints.

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PIP joint

Figure 10.38 Passive movement testing of extension of the proximal and distal interphalangeal joints.

OppositionThe forearm should be positioned in supinationwith the wrist at 0 degree of flexion–extension andabduction–adduction. The interphalangeal joints ofthe thumb and fifth finger should be at 0 degree. Us-ing your thumb and index and middle fingers, graspthe fifth metacarpal. Use the same grasp with your

1st CMCjoint

Figure 10.39 Passive movement testing of abduction andadduction of the first carpometacarpal (CMC) joint.

other hand on the first metacarpal. Approximate thefirst and fifth metacarpals (Figure 10.40). Soft-tissuecontact of the thenar and hypothenar eminences canproduce a soft end feel. Tension in the posterior as-pect of the joint capsules or in the extensor musclescan produce an abrupt and firm (ligamentous) endfeel (Magee, 2002; Kaltenborn, 1999). Loss of rangeof motion is determined by measuring the distancebetween the finger pads of the first and fifth fingers.

Thumb Metacarpophalangeal FlexionThe positions of the patient and examiner for test-ing thumb metacarpophalangeal flexion are the sameas those described in the section on metacarpopha-langeal flexion of fingers two through five. Use yourthumb and index finger to grasp the first metacarpaland carpometacarpal joint to stabilize them. Themovement is accomplished by grasping the proximalphalanx of the thumb and moving it across the palmtoward the hypothenar eminence. The motion can berestricted by tension in the collateral ligaments, thedorsal aspect of the capsule, or the extensor pollicisbrevis tendon, producing an abrupt and firm (liga-mentous) end feel. A hard end feel is possible if con-tact occurs between the proximal phalanx and thefirst metacarpal (Magee, 2002; Kaltenborn, 1999).Normal range of motion is 0–50 degrees (Ameri-can Academy of Orthopedic Surgeons, 1965) (Figure10.41).

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Figure 10.40 Passive movement testing of opposition.

Thumb Metacarpophalangeal ExtensionThe positions of the patient and the examiner forthumb metacarpophalangeal extension are the sameas those described in the section on metacarpopha-langeal extension of fingers two through five. Use yourthumb and index finger to grasp the first metacarpaland carpometacarpal joint to stabilize them. Themovement is accomplished by the examiner grasp-

Thumb MCP joint

Figure 10.41 Passive movement testing of flexion of the thumbmetacarpophalangeal (MCP) joint.

ing the proximal phalanx of the thumb and movingit laterally away from the palm and opening the webspace. The motion can be restricted by tension in thevolar aspect of the capsule or the flexor pollicis brevistendon, producing an abrupt and firm (ligamentous)end feel (Magee, 2002; Kaltenborn, 1999). Normalrange of motion is 0 degree (American Academy ofOrthopedic Surgeons, 1965) (Figure 10.42).

Figure 10.42 Passive movement testing of extension of thethumb metacarpophalangeal joint.

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Thumb Interphalangeal Joint Flexion and ExtensionThe positions of the patient and the examiner andstabilization for thumb interphalangeal flexion andextension are the same as those described in the sec-tion on interphalangeal flexion and extension of fin-gers two through five. The end feels and limiting fac-tors are also the same. The normal range of motionfor interphalangeal flexion is 0–80 degrees and forinterphalangeal extension it is 0–20 degrees (Ameri-can Academy of Orthopedic Surgeons, 1965) (Figure10.43).

Mobility Testing of AccessoryMovements

Mobility testing of accessory movements will giveyou information regarding the degree of laxitypresent in the joint. The patient must be totallyrelaxed and comfortable to allow you to move thejoint and obtain the most accurate information.The joint should be placed in the maximal loosepacked (resting) position to allow for the greatestdegree of joint movement. The resting positionof the wrist is as follows: the longitudinal axesof the radius and the third metacarpal form astraight line with slight ulnar deviation (mid po-sition between ulnar and radial deviation). Theresting position of the first carpometacarpal joint iswith the metacarpal midway between abduction–adduction and flexion–extension. The restingposition of the fingers is slight flexion of all joints(plus slight ulnar deviation of the second throughfifth metacarpophalangeal joints) (Kaltenborn,1999).

Figure 10.43 Passive movement testing of flexion andextension of the thumb interphalangeal joint.

Ventral and Dorsal Glide of the Radiusand Radial Head

Refer to Chapter 9 (pp. 216–217, Figures 9.30, 9.31)for a full description of these mobility tests.

Traction of the Radiocarpal Joint

Place the patient in the sitting position, with the armpronated and supported on the treatment table. Thewrist should be in the neutral position. Stand so thatyou are facing the ulnar aspect of the wrist. Stabilizeby grasping the dorsal distal aspect of the forearmwith your hand. Wrap your other hand around theproximal row of carpals, just distal to the radiocarpaljoint. Pull the carpals in a longitudinal direction untilyou have taken up the slack, producing traction in theradiocarpal joint (Figure 10.44).

Traction of the Midcarpal Joint

Place the patient in the sitting position, with the armpronated and supported on the treatment table. Thewrist should be in the neutral position. Stand so thatyou are facing the ulnar aspect of the wrist. Stabilizeby grasping the dorsal aspect of the proximal carpalrow with your hand. Wrap your other hand aroundthe distal row of carpals. Pull the distal row of carpalsin a longitudinal direction until you have taken upthe slack, producing traction in the midcarpal joint(Figure 10.45).

Figure 10.44 Mobility testing of traction of the radiocarpal joint.

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262 The Wrist and Hand Chapter 10

Figure 10.45 Mobility testing of traction of the midcarpal joint.

Individual Carpal Joints

Each of the individual carpal bones can be moved oneach other at their specific articulations. Descriptionof these techniques is beyond the scope of this book.The reader should consult a text on mobilization forfurther details.

Palmar and Dorsal Glide of the Metacarpals

Place the patient in the sitting position, with the fore-arm pronated and supported on the treatment table.The wrist should be in the neutral position. Standso that you are facing the dorsal aspect of the hand.Grasp the third metacarpal with your thumb and thenwrap your fingers around the palmar surface. Usingthe same hold with your other hand, move the secondmetacarpal first in a dorsal and then a volar directionuntil all the slack is taken up in each direction. Thiscan be repeated for the fourth and fifth metacarpals(Figure 10.46).

Traction of the Metacarpophalangeal and Proximaland Distal Interphalangeal Joints

Place the patient in a sitting position, with the fore-arm pronated. Sit facing the patient so that you canhold the ulnar aspect of the patient’s hand againstyour body. Grasp the metacarpal just proximal tothe metacarpophalangeal joint to stabilize it. Usingyour thumb and index finger, grasp the proximal pha-lanx. Pull in a longitudinal direction until you have

Stabilizinghand

Figure 10.46 Mobility testing of palmar and dorsal glide of themetacarpals.

taken up the slack, producing traction in the metacar-pophalangeal joint. To produce traction in the prox-imal interphalangeal joint, the stabilization is movedto the proximal phalanx and the middle phalanx ismobilized. To produce traction in the distal interpha-langeal joint, the stabilization is moved to the mid-dle phalanx and the distal phalanx is moved (Figure10.47).

Traction of the First Carpometacarpal Joint

Place the patient in a sitting position, with the forearmmidway between supination and pronation. Stand sothat you are facing the dorsal aspect of the hand.Using your thumb and index finger, grasp the trapezeiifor stabilization. Using the thumb and index finger ofyour other hand, grasp the proximal aspect of thefirst metacarpal, just distal to the carpometacarpaljoint. Pull in a longitudinal direction until you havetaken up all the slack, producing traction in the firstcarpometacarpal joint (Figure 10.48).

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263Chapter 10 The Wrist and Hand

MCP joint

Figure 10.47 Mobility testing of traction of themetacarpophalangeal (shown in diagram) and proximal anddistal interphalangeal joints.

Ulnar Glide of the First Metacarpophalangeal Joint

Place the patient in a sitting position, with the forearmmidway between supination and pronation. Stand sothat you are facing the dorsal aspect of the hand.Using your thumb and index finger, grasp the firstmetacarpal for stabilization. Using the thumb and in-dex finger of your other hand, grasp the proximalaspect of the proximal phalanx and glide it in anulnar direction until all of the slack is taken up (Fig-ure 10.49). Rupture of the ulnar collateral ligamentof the first metacarpophalangeal joint is known asgamekeeper’s or skier’s thumb (Figure 10.50).

Resistive Testing

The Wrist

The primary movements of the wrist are flexion andextension. The wrist is also able to deviate in the radialand ulnar directions because of the attachments of theflexor and extensor muscles of the wrist on the radialand ulnar borders of the hand.

Figure 10.48 Mobility testing of traction of the firstcarpometacarpal joint.

Flexion

The flexors of the wrist are the flexor carpi radialis(Figure 10.51) and flexor carpi ulnaris (Figure 10.52).They are assisted by the flexor digitorum superficialisand profundus.� Position of patient: Sitting or supine. The forearm

is supinated.� Resisted test: Support the patient’s forearm with

one hand and ask the patient to flex the wrist sothat the hand moves directly upward,perpendicular to the forearm. If you ask thepatient to flex the wrist radially and applyresistance proximal to the thumb, you will isolatethe flexor carpi radialis (Figure 10.53). Likewise, ifyou ask the patient to flex the wrist in an ulnardirection and you apply resistance to thehypothenar eminence, you will isolate the flexorcarpi ulnaris muscle (Figure 10.54).

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264 The Wrist and Hand Chapter 10

Ulnar collateralligament beingstretched

Figure 10.49 Mobility testing of ulnar glide of the firstmetacarpophalangeal joint.

Testing wrist flexion with gravity eliminated is per-formed by asking the patient to place the hand andforearm on a table with the forearm midway betweenpronation and supination, and to flex the wrist withthe table supporting the weight of the hand and fore-arm.

Weakness of wrist flexion results in difficulty withfeeding oneself and performing personal hygiene.

Extension

The extensors of the wrist on the radial side are theextensor carpi radialis longus and brevis (Figure10.55). The extensor of the wrist on the ulnar side isthe extensor carpi ulnaris (Figure 10.56). These mus-cles are assisted by the extensor digitorum, extensorindicis, and extensor digiti minimi.� Position of patient: Sitting with the elbow slightly

flexed.� Resisted test: Support the patient’s pronated

forearm on the treatment table and ask the patientto extend the wrist in the line of the forearm whileyou apply resistance to the dorsum of the hand(Figure 10.57). You can isolate the extensor carpiradialis longus and brevis by applying resistancealong the second and third metacarpals. Thepatient should try to extend the wrist in a radialdirection. You can isolate the extensor carpiulnaris by having the patient extend the wrist in

Ruptured ulnar collateral ligament

Figure 10.50 Gamekeeper’s (skier’s) thumb.

an ulnar direction while applying resistance to thefourth and fifth metacarpals.Testing wrist extension with gravity eliminated is

performed with the patient’s forearm in a mid posi-tion between pronation and supination and the handresting on the table. The patient attempts to extendthe wrist through the range of motion while the tablesupports the weight of the hand and forearm.

Painful resisted wrist extension may be due to lat-eral epicondylitis (see p. 231).

Weakness of wrist extension results in a weakeningof the grip due to loss of the tenodesis effect. Exten-sion of the wrist is necessary for the finger flexors tobe in a stretched position so that they can functionproperly. Note that your grip strength is very weakwith a fully flexed wrist. Grip strength is maximal atabout 20 degrees of wrist extension.

The Hand

Flexion, extension, abduction, and adduction of thesecond through fifth fingers should be examined. Thesuperficial and deep finger flexors should be tested inisolation.

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Palmaris longus

Flexor carpiradialis

Figure 10.51 The flexor carpi radialis muscle.

Flexor carpiulnaris

Figure 10.52 The flexor carpi ulnaris muscle.

Flexor carpiradialis

Figure 10.53 Testing wrist flexion, isolating the flexor carpi radialis.

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Flexor carpiulnaris

Figure 10.54 Testing wrist flexion while isolating the flexor carpi ulnaris.

Extensor carpiradialis longus

Extensor carpi radialisbrevis

Figure 10.55 The extensor carpi radialis longus and brevis.

Extensor carpiulnaris

Figure 10.56 The extensor carpi ulnaris.

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267Chapter 10 The Wrist and Hand

Figure 10.57 Testing wrist extension.

Special attention should be devoted to the thumband its movements of flexion, extension, abduction,adduction, and opposition.

Distal Interphalangeal Joint Flexion

The long finger flexor muscle is the flexor digitorumprofundus (Figure 10.58). This is the only muscle thatflexes the distal interphalangeal joint. It also can flexthe wrist and the proximal joints of the fingers. Notethat the flexor digitorum profundus to the index andmiddle fingers is innervated by the median nerve. Theflexor digitorum profundus to the ring and fifth fin-gers is innervated by the ulnar nerve.� Position of patient: Sitting.

IV

III

III

I

Flexor digitorumprofundus tendons

Flexor digitorumprofundus

Figure 10.58 The flexor digitorum profundus. Note the innervation to the index and middle fingers is from the median nerve, andthat to the ring and little fingers is from the ulnar nerve.

� Resisted test: Test each finger individually bysupporting it with one hand. Ask the patient toflex the distal phalanx while you apply resistanceon the palmar surface of the finger over the distalfinger pad (Figure 10.59).Pain located in the region of the metacarpopha-

langeal joint associated with a swelling may be dueto tenosynovitis of the flexor tendon, and may causea “triggering” of the finger. A clicking sensation maybe palpated along the flexor tendon where the inflam-mation exists. The patient may be unable to extendthe finger independently due to a ball-and-valve phe-nomenon (Figure 10.60).

Proximal Interphalangeal Joint Flexion

The flexor digitorum superficialis attaches to the mid-dle phalanx of the finger and flexes the proximal in-terphalangeal and metacarpophalangeal joints, andthe wrist (Figure 10.61). It is assisted by the flexordigitorum profundus.� Position of patient: Sitting.� Resisted test: The goal of the test is to isolate the

flexor digitorum superficialis. This can beaccomplished by stabilizing the patient’smetacarpophalangeal joint with one hand andasking the patient to flex the proximalinterphalangeal joint while the distalinterphalangeal joint is maintained in extension.Apply resistance to the palmar aspect of themiddle phalanx (Figure 10.62).

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268 The Wrist and Hand Chapter 10

Figure 10.59 Testing distal interphalangeal joint flexion.

This test can also be performed by hyperextendingall of the patient’s fingers except for the thumb and theone being tested. Due to the mechanical disadvantageof the flexor digitorum profundus in this position,

Tendon sheathsAnnular

ligaments

Nodule

(a)

(b)

(c)

(d)

Figure 10.60 Trigger fingers. (a) The anatomy of the flexor tendons within their sheaths and the annular ligaments is shown. (b) Anodular thickening of the tendon sheath passes underneath the ligament during flexion of the finger. (c) The nodule is shown underthe annular ligament. (d) After flexion of the finger, re-extension is not possible because the nodule is unable to pass under theannular ligament.

only the flexor digitorum superficialis will flex thefinger being tested (Figure 10.63).

Weakness of finger flexion results in the inability togrip or carry objects with the fingers.

Finger Extension

The extensors of the metacarpophalangeal joints arethe extensor digitorum, extensor indicis, and exten-sor digiti minimi (Figure 10.64). The interphalangealjoints are extended with the help of the lumbricals andinterossei. The finger extensors also assist in wrist ex-tension.� Position of patient: Sitting. The pronated forearm

is supported on a table.� Resisted test: Ask the patient to extend the fingers

at the metacarpophalangeal joints. Applyresistance with your fingers to the posterior aspectof the proximal phalanges (Figure 10.65).Weakness of finger extension results in the fingers

remaining in a position of flexion at the metacar-pophalangeal joints. Relative weakness of wrist flex-ion may also be noted.

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269Chapter 10 The Wrist and Hand

Palmar view

Flexor digitorumsuperficialis

Flexor digitorumsuperficialis tendons

Figure 10.61 The flexor digitorum superficialis muscle. This muscle is innervated by the median nerve only.

The Interossei

It is said that the interossei function primarily toabduct and adduct the second through fifth digits. Thepalmar interossei adduct the fingers (Figure 10.66),and the dorsal interossei abduct the fingers (Figure10.67). Mnemonics for these are “PAD” and “DAB.”

Figure 10.62 Testing flexion of the proximal interphalangealjoint.

Abduction and adduction of the digitis provides lit-tle functional advantage other than providing for avariety of handgrip sizes. A very important functionof the interossei is to flex and rotate the proximalphalanx of the finger. Note that when closing yourhand, the four fingers point toward the scaphoid tu-bercle (Figure 10.68). This occurs because of the co-ordinated function of the interossei. Likewise, therotation of the fingers as they extend also requiresprecise function of these muscles. Weakness or con-tracture of the interossei will prevent normal hand

Figure 10.63 Testing flexion of the proximal interphalangealjoint by the flexor digitorum superficialis only.

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270 The Wrist and Hand Chapter 10

Extensorindicis

Extensor digitorum

Extensordigiti

minimi

Figure 10.64 The extensor digitorum, extensor indicis, andextensor digiti minimi.

function. The rotational alignment of the metacarpalsand proximal phalanges following a fracture is ex-tremely important for preservation of normal func-tion of the associated interossei muscles. Malalign-ment due to a fracture can result in overlappingof the fingers as the patient closes his or her fist(Figure 10.69).� Position of patient: Sitting. The forearm is

pronated.� Resisted test: The palmar interossei are tested by

attempting to abduct the fingers as the patientsqueezes the fingers into adduction (Figure10.70a–10.70d). The dorsal interossei are testedby asking the patient to spread the fingers apart asyou attempt to adduct them one on the other(Figure 10.71a–10.71d).

The Thumb

FlexionThe flexors of the thumb are the flexor pollicislongus and flexor pollicis brevis (Figures 10.72 and10.73). The flexor pollicis longus also assists in wristflexion.� Position of patient: Sitting. The forearm is

supinated and the hand is in a relaxed posture.� Resisted test: The flexor pollicis longus is tested by

supporting the patient’s thumb on the palmarsurface as the patient attempts to flex theinterphalangeal joint (Figure 10.74). The flexorpollicis brevis is tested by applying pressure to theproximal phalanx of the thumb on the palmarsurface while the patient attempts to flex thethumb, keeping the interphalangeal joint extended(Figure 10.75).Painful resisted thumb flexion may be due to

tenosynovitis.Weakness of the short thumb flexor will result

in a weakened grip. Weakness of the long thumbflexor will result in difficulty holding a pencil or smallobjects.

ExtensionThe extensors of the thumb are the extensor pollicislongus and extensor pollicis brevis (Figures 10.76 and10.77).� Position of patient: Sitting. The forearm is

supinated and the wrist is in neutral.

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271Chapter 10 The Wrist and Hand

Figure 10.65 Testing metacarpophalangeal joint extension.

Palmarinterossei

Transversemetacarpalligament

Figure 10.66 The palmar interossei.

Dorsalinterossei

Figure 10.67 The dorsal interossei.

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272 The Wrist and Hand Chapter 10

Scaphoidtuberosity

Figure 10.68 The normal hand in a flexed posture shows allfour fingers pointing toward the scaphoid tubercle.

(a) (b)

(c) (d)

Figure 10.70 Testing adduction of the fingers.

Scaphoidtuberosity

Figure 10.69 Malrotation due to a fracture of the fourthproximal phalanx results in overlapping of the fingers withflexion.

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273Chapter 10 The Wrist and Hand

(a) (b)

(c) (d)

Figure 10.71 Testing abduction of the fingers.

Flexor pollicislongus

Figure 10.72 The flexor pollicis longus muscle.

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274 The Wrist and Hand Chapter 10

Flexor pollicisbrevis

Figure 10.73 The flexor pollicis brevis muscle. This muscle hasinnervation to the superficial head from the median nerve andthe deep head from the ulnar nerve.

� Resisted test: The patient’s hand is supported withyour hand and you resist thumb movement awayfrom the index finger in the plane of the palm, firstproximally over the proximal phalanx, to test theextensor pollicis brevis and then distally, over thedistal phalanx to test the extensor pollicis longus(Figures 10.78 and 10.79).Painful extension of the thumb may result from

tenosynovitis at the wrist where the extensor pollicis

Figure 10.74 Testing flexion of the interphalangeal joint of the thumb.

brevis crosses the radial styloid process. This is calledde Quervain’s syndrome. Associated tenosynovitisin the abductor pollicis longus muscle may also benoted (see special test for de Quervain’s syndrome onp. 285, Figure 10.99).

Weakness of thumb extension results in a flexiondeformity of the thumb.

AbductionThe abductors of the thumb are the abductor pollicislongus, innervated by the radial nerve (Figure 10.80),and the abductor pollicis brevis, innervated by themedian nerve (Figure 10.81).� Position of patient: Sitting. The forearm is

supinated and the wrist is in neutral.� Resisted test: The abductor pollicis longus is tested

by resisting first metacarpal abduction with yourhand, putting pressure on the palmar aspect of thefirst metacarpal as the patient attempts to elevatethe thumb in a plane perpendicular to the hand.Support the hand and wrist from underneath withyour other hand (Figure 10.82). Testing theabductor pollicis brevis is accomplished byapplying pressure to the radial aspect of theproximal phalanx of the thumb as the patientattempts to abduct the thumb in a planeperpendicular to the hand (Figure 10.83).

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Figure 10.75 Testing flexion of the metacarpophalangeal joint of the thumb.

Extensor pollicislongus

Figure 10.76 The extensor pollicis longus.

Extensor pollicis brevis

Radialstyloid process

Figure 10.77 The extensor pollicis brevis. Note that the tendon rides over the radial styloid process, and this is a common site oftenosynovitis, also known as de Quervain’s syndrome.

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276 The Wrist and Hand Chapter 10

Figure 10.78 Testing extension of the metacarpophalangealjoint of the thumb.

Painful abduction of the first metacarpal can bedue to de Quervain’s syndrome affecting the tendonof the abductor pollicis longus as it crosses the radialstyloid process (see the special test for de Quervain’ssyndrome on p. 285, Figure 10.99).

Weakness of thumb abduction results in the pa-tient’s inability to grasp a large object, as the thumbcannot be moved away from the hand. Weakness ofthe abductor pollicis brevis is seen in advanced casesof carpal tunnel syndrome.

AdductionThumb adduction is accomplished by the adductorpollicis muscle (Figure 10.84). This muscle is assistedby the deep head of the flexor pollicis brevis. Both ofthese muscles are innervated by the ulnar nerve.� Position of patient: Sitting.� Resisted test: Place your index and long fingers in

the patient’s first web space. Ask the patient to

Figure 10.79 Testing extension of the interphalangeal joint ofthe thumb. The extensor pollicis brevis also extends themetacarpophalangeal and carpometacarpal joints of the thumb.

press your fingers into his or her palm with thethumb. Try to pull the patient’s thumb upwardinto abduction in a plane perpendicular to his orher palm (Figure 10.85).Weakness of thumb adduction prevents the patient

from making a strong clenched fist.To test for Froment’s sign, ask the patient to hold

a piece of paper between the thumb and the radialaspect of the index finger. Try to pull the paper awayfrom the patient and if the adductor pollicis is weak,the patient will flex the thumb interphalangeal jointas a compensatory measure as he or she attempts tocompensate with the flexor pollicis longus for a weakadductor pollicis (Figure 10.86).

Opposition of the Thumb and Fifth FingerThe muscles responsible for opposition are the op-ponens pollicis and opponens digiti minimi (Figure10.87). They are innervated by the median and ulnarnerves, respectively.� Position of patient: Sitting.� Resisted test: The patient attempts to bring the

palmar surfaces of the tips of the thumb and fifthfinger together. Apply resistance against theanterior aspect of the first and fifth metacarpals soas to pry them apart (Figure 10.88). The musclescan be tested separately to note their individualstrengths. Note that the patient can attempt to flexthe thumb with the flexor pollicis longus andbrevis in the plane of the palm. Opposition occurswith the thumb away from the palm.Weakness of opposition of the thumb and fifth fin-

ger results in the inability to hold a pencil and graspobjects firmly.

Neurological Examination

Motor

The innervation and spinal levels of the muscles thatfunction across the wrist and hand are outlined inTable 10.1.

Sensation

Light touch and pinprick sensation should be checkedin the wrist and hand after the motor examina-tion. The dermatomes for the hand are C6, C7,and C8 (Figure 10.89). Peripheral nerves and their

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277Chapter 10 The Wrist and Hand

Abductor pollicis longus

Radial styloid process

Figure 10.80 The abductor pollicis longus. Note that the tendon rides over the radial styloid process and is often affected bytenosynovitis in de Quervain’s syndrome.

distributions in the wrist and hand are shown inFigures 10.90 and 10.91. Note the key sensory ar-eas for the C6, C7, and C8 dermatomes.

Abductor pollicis brevis

Figure 10.81 The abductor pollicis brevis.

Entrapment Neuropathies

Median Nerve

Entrapment of the median nerve within the carpaltunnel is extremely common (Figure 10.92). A varietyof primary conditions are associated with carpal tun-nel syndrome (Table 10.2). The definitive diagnosisof carpal tunnel syndrome is made with electrodiag-nostic studies. Pain or numbness of the thumb, indexand middle fingers, as well as thenar atrophy may benoted in the patient with carpal tunnel syndrome.

Various tests have been used to diagnose carpaltunnel syndrome on physical examination. They in-clude Tinel’s test, the tourniquet test, and Phalen’stest.

Tinel’s TestThis test is performed by tapping over the mediannerve, which is located just medial to the flexor carpiradialis tendon at the most proximal aspect of thepalm (Figure 10.93). The test result is positive whenthe patient reports pain or tingling in the first threedigits.

Tourniquet TestThis test attempts to exacerbate the median neu-ropathy in the carpal tunnel by causing temporary

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278 The Wrist and Hand Chapter 10

Figure 10.82 Testing abduction of the carpometacarpal joint of the thumb.

ischemia. A blood pressure cuff is inflated proximalto the elbow, about where you would take measure-ments for systolic pressure. The test result is positiveif the patient notes numbness or tingling in the distri-bution of the median nerve within 60 seconds. Thistest produces a high rate of false-positive results.

Phalen’s TestThis test makes use of the fact that the carpal tun-nel narrows in a position of increased wrist flexion.

The patient is asked to flex both of the wrists againstone another. The test result is positive if the patientnotes paresthesias or numbness in the thumb, index,or middle fingers after holding this position for 60 sec-onds or less (Figure 10.94). This test has the fewestfalse-negative results.

Ulnar Nerve

The ulnar nerve gives off a dorsal cutaneous branchapproximately 8 cm proximal to the wrist (Figure10.95). This branch has no motor function.

Figure 10.83 Testing abduction of the metacarpophalangeal joint of the thumb. The abductor pollicis brevis is weak in patients withcarpal tunnel syndrome.

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279Chapter 10 The Wrist and Hand

Adductor pollicis

Obliquehead

Transversehead

Transverse head

Figure 10.84 The adductor pollicis.

Figure 10.85 Testing adduction of the thumb.

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280 The Wrist and Hand Chapter 10

normal abnormal

Figure 10.86 Froment’s sign. The patient will flex theinterphalangeal joint of the thumb to compensate for weaknessof the adductor pollicis seen in ulnar nerve injury.

The ulnar nerve continues into the wrist throughGuyon’s canal (Figure 10.96). There are two motorbranches of the ulnar nerve in the hand and one sen-sory branch to the palmar aspect of the medial hand.

Dorsal Cutaneous Ulnar Nerve EntrapmentThis sensory branch of the ulnar nerve may be injuredby a fracture of the ulna, a ganglion cyst, or an ulnarartery aneurysm. Loss of sensation on the dorsal me-dial aspect of the hand will be noted. Hand functionwill otherwise be normal.

Figure 10.88 Testing opposition of the thumb and fifth finger.

Opponens pollicis

Opponensdigitiminimi

Figure 10.87 The opponens pollicis and the opponens digitiminimi muscles.

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281Chapter 10 The Wrist and Hand

Table 10.1 Muscle, innervation, and root levels of the hand and wrist.

Movement Muscles Innervation Root levels

Flexion of wrist 1 Flexor carpi radialis Median C6, C72 Flexor carpi ulnaris Ulnar C8, T1

Extension of wrist 1 Extensor carpi radialis longus Radial C6, C72 Extensor carpi radialis brevis Posterior interosseous (radial) C6, C7 (radial)3 Extensor carpi ulnaris Posterior interosseous (radial) C6, C7, C8

Flexion of fingers 1 Flexor digitorum profundus Anterior interosseous profun-dus (median): lateral twodigits

C8, T1

Ulnar: medial two digits C8, T12 Flexor digitorum sublimis Median C7, C8, T13 Lumbricals First and second: median C7, C8, T1

Third and fourth: ulnar (deepterminal branch)

C8, T1

4 Interossei Ulnar (deep terminal branch) C8, T15 Flexor digiti minimi Ulnar (deep terminal branch)

little fingerC8, T1

Extension of fingers 1 Extensor digitorum communis Posterior interosseous (radial) C6, C7, C82 Extensor indicis (second finger) Posterior interosseous (radial) C7, C83 Extensor digiti minimi (little finger) Posterior interosseous (radial) C6, C7, C8

Abduction of fingers 1 Dorsal interossei Ulnar (deep terminal branch) C8, T1(with fingers extended) 2 Abductor digiti minimi (little finger) Ulnar (deep terminal branch) C8, T1

Adduction of fingers Palmar interossei Ulnar (deep terminal branch) C8, T1(with fingers extended)Flexion of thumb 1 Flexor pollicis brevis Superficial head: median (lat-

eral terminal branch)C8, T1

Deep head: ulnar C8, T12 Flexor pollicis longus Anterior interosseous (median) C8, T13 Opponens pollicis Median (lateral terminal

branch)C8, T1

Extension of thumb 1 Extensor pollicis longus Posterior interosseous (radial) C6, C7, C82 Extensor pollicis brevis Posterior interosseous (radial) C6, C73 Abductor pollicis longus Posterior interosseous (radial) C6, C7

Abduction of thumb 1 Abductor pollicis longus Posterior interosseous (radial) C6, C72 Abductor pollicis brevis Median (lateral terminal

branch)C6, C7, C8

Adduction of thumb Adductor pollicis Ulnar (deep terminal branch) C8, T1

Opposition of thumb 1 Opponens pollicis Median (lateral terminal C8, T1and little finger branch)

2 Flexor pollicis brevis Superficial head: median (lat-eral terminal branch)

C8, T1

3 Abductor pollicis brevis Median (lateral terminalbranch)

C6, C7, C8

4 Opponens digiti minimi Ulnar (deep terminal branch) C8, T1

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282 The Wrist and Hand Chapter 10

AnteriorPosterior

( ) Key sensory areas

C6C6

C7C7 C8C8

Figure 10.89 The dermatomes of the hand and wrist. Note thekey sensory areas for C6, C7, and C8 at the interphalangealjoints of the thumb and the long and fifth fingers, respectively.

Ulnar Nerve Compression at Guyon’s CanalCompression of the ulnar nerve in Guyon’s canal (seeFigure 10.96) most often results from a ganglion, butcan also occur with rheumatoid arthritis or trauma.The findings on examination include weakness of theulnar-innervated intrinsic hand muscles, which in-clude the interossei and the medial two lumbricals. Ifthe superficial sensory branch to the fourth and fifthdigits is involved, decreased sensation will be noted

Ulnar nerve C7, C8

Palmer branch, ulnar nerve

Median nerve C6, C7

Palmar branchmedian nerve

Superficial radial nerve C6, C7, C8

Anterior view

Figure 10.90 The anterior view of the wrist and hand shows theperipheral nerves and their respective territories.

Ulnarnerve

C7, C8

Dorsal cutaneous branch, ulnar nerve

Median nerve C6, C7

Median nerve C6, C7

Superficial radial nerve C6, C7, C8

Superficial radial nerve C6, C7, C8

Posterior view

Figure 10.91 The posterior view of the wrist and hand showsthe peripheral nerves and their respective territories.

on the palmar aspect of these fingers. A characteristicposture of the hand known as a benediction defor-mity (Figure 10.97) results from ulnar nerve damageat Guyon’s canal, affecting both the hypothenar andintrinsic muscles.

Damage to the median and ulnar nerves at the wrist,which occurs most commonly with trauma, results ina deformity known as a claw hand (Figure 10.98).This is also referred to as an intrinsic minus hand.

Table 10.2 Disorders associated with carpal tunnelsyndrome.

TraumaWrist fracture (Colles’ fracture, scaphoid fracture, etc.)Wrist contusion or hematomaEndocrine disordersHypothyroidismPregnancyDiabetes mellitusMenopauseObesityInflammationTenosynovitisOthersGoutGanglion cystsOsteoarthritis of the carpal bonesGeneralized edema from any cause

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283Chapter 10 The Wrist and Hand

Scaphoidtuberosity

Tubercle oftrapezium

Pisiform

Hook of hamate

Carpal tunnel

Tubercle oftrapezium

Trapezium

Trapezoid

Pisiform

CapitateTriquetrum

Lunate

Median nerve

Palmarislongus

Flexordigitorumprofundus

Flexordigitorumsuperficialis

Ulnar A & N

Flexorpollicislongus

Transverse carpalligament

Figure 10.92 The carpal tunnel and its contents. The roof of the tunnel is formed by the transverse carpal ligament. The flexortendons of all five fingers and the flexor carpi radialis are located within the carpal tunnel, along with the median nerve. Note that thetunnel is located at the proximal palm and not under the creases of the wrist.

Figure 10.93 Testing Tinel’s sign at the wrist for carpal tunnel syndrome.

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Figure 10.94 Phalen’s test. This position is held for at least 60seconds.

Dorsal ulnarcutaneous nerve

Deep ulnarmotor branch

Guyon canal

Ulnar nerve

Figure 10.95 The ulnar nerve and its branches.

Pisiform

Ulnar nerve

Pisohamateligament

Hamate

Pisohamate ligament

Pisiform

Hamate

Ulnar nerve

Figure 10.96 The anatomy of Guyon’s canal. The ulnar nerveenters the wrist through this canal. It gives off a superficialsensory branch and a deep motor branch. Three types of lesionsare possible at Guyon’s canal. The trunk may be affected, thesensory branch may be affected, or the deep motor branch maybe affected. These lesions can occur simultaneously. Injury tothe ulnar nerve at Guyon’s canal can result from pressure due tocrutch walking, pressure from bicycle handlebars, or apneumatic drill.

Figure 10.97 The benediction hand deformity results fromdamage to the ulnar nerve. There is wasting of the interosseousmuscles, the hypothenar muscles, and the two medial lumbricalmuscles.

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285Chapter 10 The Wrist and Hand

Figure 10.98 The claw hand deformity results from loss ofintrinsic muscles with overactivity of the extensor digitorum,causing hyperextension of the metacarpophalangeal joints. Thisis most often caused by combined damage to the median andulnar nerves at the wrist.

Special Tests

Finkelstein’s Test (de Quervain’sSyndrome)

This test is used to diagnose tenosynovitis of the firstdorsal compartment of the wrist, which contains thetendons of the abductor pollicis longus and exten-sor pollicis brevis muscles (Figure 10.99). Pain andswelling are usually present over the radial styloidprocess. A ganglion cyst may be noted. Finkelstein’stest is performed by having the patient place thethumb inside the closed fist. Take the patient’s handand deviate the hand and wrist in the ulnar directionto stretch the tendons of the first extensor compart-ment. Pain over the radial styloid process is pathog-nomonic of de Quervain’s syndrome. Arthritis of thefirst carpometacarpal joint will also sometimes causepain with the maneuver.

Tenosynovitis of the hand and wrist is encounteredfrequently. Tenderness to palpation is noted in char-acteristic locations (Figure 10.100). Passively stretch-ing the involved muscle will also produce pain.

Pain here in radial styloid

Abductorpollicislongus

Extensor pollicis brevis

Figure 10.99 Finkelstein’s test is used to diagnose tenosynovitisof the first dorsal compartment of the wrist, which includes theextensor pollicis brevis and abductor pollicis longus muscles.

Tests for Flexibility and Stabilityof the Joint

Bunnel–Littler Test (Intrinsic MusclesVersus Contracture)

This test is useful in determining the cause of restrictedflexion of the proximal interphalangeal joints of thefingers (Figure 10.101). A limitation in flexion at thesejoints may be caused by tightness of the intrinsic mus-cles (interossei and lumbricals) or secondary to con-tracture of the joint capsule. The purpose of the testis to put the finger in a position of relaxation of theintrinsic muscles by flexing the metacarpophalangealjoint. Attempt to flex the proximal interphalangealjoint (Figure 10.102). If the joint can be flexed, the dif-ficulty in flexion with the metacarpophalangeal jointextended is due to tightness of the intrinsic muscles.If a joint contracture is present, relaxing the intrinsicmuscles will have no effect on the restricted mobilityof the proximal interphalangeal joint and you will beunable to flex this joint in any position of the finger(Figure 10.103).

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286 The Wrist and Hand Chapter 10

DeQuervain's disease

EPL tendinitis

Dorsal view Ventral view

Intersection syndrome

Digital flexortendinitis

EIP syndrome

EDQtendinitis

FCRtendinitis

Triggerfinger

Lateralepicondylitis

ECUtendinitis,

subluxationFCU tendinitis,calcification

Medialepicondylitis

Figure 10.100 Common locations for tendinitis of the hand and wrist are shown posteriorly (left) and anteriorly (right).

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287Chapter 10 The Wrist and Hand

Interosseusmuscle

Lumbrical muscle

Figure 10.101 The Bunnel–Littler test. Put the metacarpophalangeal joint in slight extension and attempt to flex the proximalinterphalangeal joint. If you are unable to do so, there is either a joint capsular contracture or tightness of the intrinsic muscles.

Figure 10.102 Placing the metacarpophalangeal joint in flexion relaxes the intrinsic muscles. If you are now able to flex the proximalinterphalangeal joint, the intrinsic muscles are tight.

Figure 10.103 If you are unable to flex the proximal interphalangeal joint, even with the intrinsic muscles in a relaxed position, thereis a joint capsular contracture of the proximal interphalangeal joint.

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288 The Wrist and Hand Chapter 10

Attempt to flex DIP joint with MCP and PIP in neutral

Figure 10.104 Test for retinacular ligament tightness. Attemptto flex the distal interphalangeal joint (DIP) with the proximalinterphalangeal (PIP) and metacarpophalangeal (MCP) joints inneutral.

Able to flex DIP joint

Unable to flex DIP joint

Figure 10.105 Testing for retinacular ligament tightness isperformed by first relaxing the proximal interphalangeal jointinto flexion. If you can now flex the distal interphalangeal joint,the retinacular ligaments are tight. If the proximalinterphalangeal joint is flexed and you still cannot flex the distalinterphalangeal joint (DIP), there is a contracture at the distalinterphalangeal joint.

Retinacular Test

The retinacular test is used to determine the causeof the patient’s inability to flex the distal interpha-langeal joint. This inability may be caused by eitherjoint contracture or tightness of the retinacular liga-ments. Hold the patient’s finger so that the proximalinterphalangeal and metacarpophalangeal joints arein neutral position. Now support the finger and at-tempt to flex the distal interphalangeal joint (Figure10.104). If the distal interphalangeal joint does notflex, perform the retinacular test by initially flexingthe proximal interphalangeal joint to relax the reti-nacular ligaments (Figure 10.105). Now try to flexthe distal interphalangeal joint with the ligaments re-laxed. If the distal interphalangeal joint still does notflex, there is a contracture of the distal interphalangealjoint.

Scaphoid-Lunate Dissociation (Watson’s) Test

This test is used to diagnose abnormal separationof the lunate and scaphoid bones (Figure 10.106).The normal separation should be less than 2 mm.

Scaphoidtubercle

Figure 10.106 Watson’s test for scaphoid-lunate dissociation.The scaphoid tubercle is palpated with the thumb and the wristis passively moved from ulnar to radial deviation with your otherhand. The presence of pain, crepitus, or occasionally an audibleclick reflects a positive test result.

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289Chapter 10 The Wrist and Hand

Increased separation due to a fracture displacementcauses disruption of the wrist and can lead to arthri-tis. This test result is difficult to interpret. Stabilizethe patient’s radius with one hand while your thumbpresses against the scaphoid tubercle. Take the pa-tient’s hand and passively glide the wrist in an ulnar-to-radial direction. The test result is positive if thepatient complains of pain or if you note crepitus oran audible click. Ulnar deviation of the wrist bringsthe tubercle of the scaphoid out from behind the ra-dius.

Allen’s Test

This test is used to check the patency of the radial andulnar arteries at the level of the wrist (Figure 10.107).The patient is first asked to open and close the handfirmly several times. The hand is then squeezed verytightly to prevent any further arterial flow into thehand. Place your thumb and index finger over the ra-

(a)

(b)

(c)

Figure 10.107 Allen’s test is used to evaluate the patency of the radial and ulnar arteries at the wrist. (a) The hand is opened andclosed rapidly and firmly. (b) Both arteries are compressed as the patient maintains a closed fist. (c) Release pressure over one of thearteries as the patient opens the hand and observe for flushing of the hand. Normal color should return to the entire hand.

dial and ulnar arteries at the wrist and press firmly.Now ask the patient to open the hand while you main-tain pressure over both arteries. Remove your fingerfrom one of the arteries and watch for the hand toturn red. This indicates normal circulation of thatartery. Repeat the test, releasing pressure from theother artery. Check both arteries and both hands forcomparison.

Grip and Pinch Evaluation

Different types of power grips and pinches are shownin Figures 10.108 and 10.109. Observe the patient’sability to posture the fingers and hand as illustrated.

Referred Pain Patterns

The patient may complain of wrist and hand painand in fact have pathology in the neck, shoulder, orelbow (Figure 10.110). Any disease process affecting

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Spherical Hook PowerGrip

Cylinder

Figure 10.108 Types of power grips include the spherical, hook, fist, and cylinder grips.

Three-jaw chuck(digital prehension)

Lateral pinch(lateral prehension)

Tip pinch(tip-to-tip prehension)

Pad-to-pad pinch(pad-to-pad prehension)

Figure 10.109 Various types of pinches.Figure 10.110 Pain may be referred to the hand and wrist fromthe neck, shoulder, or elbow.

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291Chapter 10 The Wrist and Hand

Figure 10.111 Anteroposterior view of the wrist and hand.

the sixth, seventh, or eighth cervical nerves or the firstthoracic nerve will affect the function of the hand.Damage to the brachial plexus or peripheral nerveshigher up in the arm will also affect hand function.Shoulder or elbow joint pathology may also refer painto the hand.

Figure 10.112 Lateral view of the wrist and hand.

Radiological Views

Radiological views of the hand and wrist are shownin Figures 10.111 and 10.112.U = UlnaR = RadiusN = NavicularM = MetacarpalsP = PhalangesW = Wrist jointCMC = First carpometacarpal joint

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292 The Wrist and Hand Chapter 10

Paradigm for carpal tunnel syndrome

A 45-year-old female office worker presents with complaintsof “pins and needles” in her dominant right hand. She statesthat she has been having pain in her neck, upper arm, andthumb.

Her symptoms seem to be aggravated by typing for longperiods of time at her word processor. She is often awakenedduring the night by pain in her hand. She can find reliefby shaking her hand or holding it under warm water. Sherecalls no injuries to either her hand or neck; and has nodifficulty rotating her head when driving. She has recentlybeen told that she has an “underactive thyroid” and has hada 20-pound weight gain. The remainder of her medical historyis unremarkable.

On physical examination, the patient is a slightly obesewoman in no apparent distress. She has full range of motionof her cervical spine and upper extremity joints without pain.There are no symptoms produced with vertical compressionapplied to the head and neck. She has diminished light touchin the distal palmar aspects of the thumb, index, and long fin-gers. She has positive Tinel’s and Phalen’s tests. X-rays of thecervical spine and hand are reported as showing no pathol-ogy. Electrodiagnostic studies (electromyography (EMG) andnerve conduction) demonstrate no motor deficits in the upperextremity, but confirm increased latency of the signal acrossthe wrist.

This paradigm is consistent with distal rather than proximalnerve injury because of:

A history of repetitive hand/wrist movementsNo history of trauma to the neckHistory of a possible contributory collateral medical conditionSymptoms suggestive of compromised circulation to thenerve (see Table 10.2)

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C H A P T E R 1 1

The Hip

F U R T H E R I N F O R M A T I O N

Please refer to Chapter 2 foran overview of the sequence of a physicalexamination. For purposes of length andto avoid having to repeat anatomy morethan once, the palpation section appearsdirectly after the section on subjectiveexamination and before any section on

testing, rather than at the end of eachchapter. The order in which theexamination is performed should bebased on your experience and personalpreference as well as the presentation ofthe patient.

Functional Anatomy

The hip is a large, deep ball-and-socket articulation.As such, it is quite stable, while permitting a sig-nificant range of motion. To achieve stability, thehip relies on a combination of ligamentous and ar-ticular (i.e., acetabular, labrum) structures. The pri-mary ligaments of the hips are the capsular Y liga-ment and the intra-articular ligamentum teres. Asidefrom the modest vascular supply to the femoral headthe ligamentum provides, the ligamentum teres pro-vides relatively little stability to the hip joint. Thecapsular Y ligament is, on the other hand, a signif-icant stabilizer for the hip joint. It is important forits ability to shorten and tighten with extension andinternal rotation, a fact found to be useful in the re-duction of certain fractures. Since the hip is offsetlaterally from the midline of the body, unassisted itprovides little stability to the torso during unilateralstance. During gait, the body’s center of gravity isnormally medial to the supporting limb. As such, lig-amentous structures of the hip are insufficient to sta-bilize the body during the unilateral support phaseof gait. For stability during gait, the body is criti-cally dependent upon the muscles proximal to the hipjoint.

The muscles providing medial–lateral stability arethe glutei (minimus, medius, and maximus) and theiliotibial band (with the tensor fasciae latae). Thesemuscles and tissues lie lateral to the hip joint. In gen-eral, the hip can be visualized as a fulcrum on whichthe pelvis and torso are supported (Figure 11.1). Themedial aspect of the fulcrum experiences the down-ward force of the body’s weight (merging at a pointin space 1 cm anterior to the first sacral segment inthe midline of the body). The other side of the ful-crum is counterbalanced by the muscular contractioneffort of the abductor muscles. The ratio of the rel-ative lengths over which these two opposing forceswork is 2:1. Hence, the glutei must be capable ofexerting two times the body weight of contractile ef-fort during unilateral stance in order to maintain thepelvis at equilibrium. A corollary of this is that duringunilateral support, the hip will experience a total ofthree times body weight of compressive load (bodyweight + [2 × body weight] muscular contractileforce across the hip joint). This is a sixfold increaseover the force experienced by the hip during bilateralstance.

The glutei are supplemented by the iliotibial band,which is a broad fibrous sheath extending from theiliac crest of the pelvis to its attachment at the distalend of the femur and on across to the anterolateral

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294 The Hip Chapter 11

(a)

Hip joint

Gluteus medius

and minimus

Fulcrum

Knee

Ankle

Bodyweight

2 1

(b)

Figure 11.1 (a) The classic Koch model depicts the hip as afulcrum of uneven lengths. Stability against the inward rotationof the pelvis during unilateral stance is provided dynamically bythe abductor musculature (gluteus medius, gluteus minimus).(b) During unilateral support, the body’s center of gravitycreates a compression and varus moment deforming force at thehip, knee, and ankle of the supporting limb.

Iliotibialband

Figure 11.2 A more complete model of hip mechanics includesthe iliotibial band. This inelastic structure extends from thelateral iliac crest to the distal part of the femur and on across theknee joint to the tubercle of Gerdy on the anterolateral aspect ofthe tibia. As such, the iliotibial band acts as a static stabilizer ofthe hip during the unilateral stance phase of gait. As a tensionband, it protects the femur from excessive medial bendingdeformation. It therefore converts what would otherwise bepotentially damaging tension loads on the lateral femur intowell-tolerated compression stresses.

aspect of the knee joint. As such, it functions as a ten-sion band and has the important task of convertingwhat would otherwise be a potentially unsustainabletensile load into a moderate and well-tolerated com-pression load along the lateral femoral cortex (Figures11.2 and 11.3). The importance of these soft-tissuestructures for proper hip function can be greatly ap-preciated when they are compromised by either pain,injury, or neurological impairment. The result will bea severely compromised and dysfunctional pattern ofgait. The most dramatic demonstration of the impor-tance of the iliotibial band soft tissues as stabilizersof the hip can be seen when one compares the func-tional capacities of subjects who have had a below-knee amputation with those of subjects who have hadan above-knee amputation. The below-knee amputee,

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295Chapter 11 The Hip

Hip joint

ITB

Bodyweight

Pelvis

Femur

Figure 11.3 This is a mechanical model of the situationdepicted in Figure 11.2.

with the benefit of modern technology, can functionwith as little as 10% energy inefficiency as comparedto a normal, intact individual. In fact, it is possible fora below-knee amputee with a properly fitted prosthe-sis to run 100 m in 11 seconds. The below-knee am-putee also is able to easily sustain unilateral stance onthe amputated extremity. The above-knee amputee,however, experiences at least 40% energy deficiencyin function as compared to normal individuals. Theabove-knee amputee is also unable to stand unilater-ally on the amputated limb without leaning towardthe affected side. This inability to stand erect withoutlisting is termed a positive Trendelenburg sign. In theamputee, this is directly due to the loss of the static sta-bilizing function of the iliotibial band due to compro-mise of the iliotibial band insertion with above-kneeamputation. The loss of the static stabilizing effect ofthe iliotibial band places too great a functional de-mand on the remaining muscular soft tissues (gluteusmedium, gluteus minimus, hip capsule) to efficientlystabilize the pelvis during unilateral support stance.

Observation

The examination should begin in the waiting roombefore the patient is aware of the examiner’s observa-tion. Information regarding the degree of the patient’sdisability, level of functioning, posture, and gait canbe observed. The clinician should pay careful atten-

tion to the patient’s facial expressions with regard tothe degree of discomfort the patient is experiencing.The information gathered in this short period can bevery useful in creating a total picture of the patient’scondition.

Note the manner in which the patient is sitting inthe waiting room. If the patient is sitting reclined pos-teriorly, he or she may have decreased range of motionin hip flexion. If the patient is leaning to one side, thismay be due to pain in the ischial tuberosity secondaryto bursitis, sacroiliac dysfunction, or radiating painfrom the low back. Pain may be altered by changes inposition, so watch the patient’s facial expression togive you insight into their pain level.

Observe the patient as he or she assumes the stand-ing position. How difficult is it to go from flexion toextension? Can the patient evenly distribute weightbetween both lower extremities? Once the patientstarts to ambulate, a brief gait analysis should beinitiated. Note any gait deviations and whether thepatient requires or is using an assistive device. Detailsand implications of gait deviations are discussed inChapter 14.

Subjective Examination

The hip is an extremely stable joint. Therefore, com-plaints and dysfunctions are usually limited to prob-lems relating to trauma or deterioration. You shouldinquire about the nature and location of the com-plaints and their duration and intensity. The courseof the pain during the day and night should be ad-dressed. This will give you information regarding howthe pain responds to changes in position, activity, andswelling.

The patient’s disorder may be related to age, gen-der, ethnic background, body type, static and dy-namic posture, occupation, leisure activities, hobbies,and general activity level. It is important to inquireabout any change in daily routine and any unusualactivities that the patient has participated in. If an in-cident occurred, the details of the mechanism of injuryare important to help direct your examination.

The location of the symptoms may give you someinsight into the etiology of the complaints. Pain thatis located over the anterior and lateral aspects of thethigh may be referred from L1 or L2. Pain into theknee may be referred from L4 or L5 or from the hipjoint. The patient may complain about pain over thelateral or posterior aspect of the greater trochanter,

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296 The Hip Chapter 11

which may be indicative of trochanteric bursitis orpiriformis syndrome. (Please refer to Box 2.1, p. 15for typical questions for the subjective examination.)

Gentle Palpation

The palpatory examination is started with the patientin the supine position. You should first examine forareas of localized effusion, discoloration, birthmarks,open sinuses or drainage, incisional areas, bony con-tours, muscle girth and symmetry, and skinfolds. Youshould not have to use deep pressure to determine ar-eas of tenderness or malalignment. It is important touse firm but gentle pressure, which will enhance yourpalpatory skills. If you have a sound basis of cross-sectional anatomy, you will not need to physicallypenetrate through several layers of tissue to have agood sense of the underlying structures. Rememberthat if you increase the patient’s pain at this point inthe examination, the patient will be very reluctant toallow you to continue, or may become more limitedin his or her ability to move.

Palpation is most easily performed with the patientin a relaxed position. Although palpation can be per-formed standing, the supine, side-lying, or prone po-sitions are preferred for stability and ease of exami-nation.

Anterior Aspect—the Patient isPositioned in Supine

Bony Structures

Iliac CrestThe iliac crest is superficial, very prominent, and easyto palpate. Place your extended hands so that theindex fingers are at the waist. Allow your hands topress medially and rest on the superior aspect of theiliac crests. Iliac crests that are uneven in height maybe due to a leg length difference, a pelvic obliquity,a bony anomaly, or a sacroiliac dysfunction (Figure11.4).

Iliac TubercleThe iliac tubercle is the widest portion of the iliaccrest. After you have located the crest, palpate ante-riorly and medially along the outer lip. You will findthe widest portion approximately 3 in. from the topof the crest (Figure 11.5).

Iliac crest

L4

L5

Figure 11.4 Palpation of the iliac crest.

Anterior Superior Iliac SpinesPlace your hands on the iliac crests and allow yourthumbs to reach anteriorly and inferiorly on a di-agonal toward the pubic ramus. The most prominentprotuberance is the anterior superior iliac spine. Place

Iliactubercle

Figure 11.5 Palpation of the iliac tubercle.

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297Chapter 11 The Hip

Anteriorsuperioriliac spine

Figure 11.6 Palpation of the anterior superior iliac spines.

your thumb pads in a superior orientation so that theycan roll under the anterior superior iliac spines for themost accurate determination of position. This area isnormally superficial but can be obscured in an obesepatient. Differences in height may be due to an iliacrotation or shear (Figure 11.6).

Pubic TuberclesPlace your hands so that your middle fingers are on theumbilicus and allow your palms to rest over the ab-domen. The heel of your hands will be in contact withthe superior aspect of the pubic tubercles. Then moveyour finger pads directly over the tubercles to deter-mine their relative position. They are located medialto the inguinal crease and at the level of the greatertrochanters. The pubic tubercles are normally tenderto palpation. If they are asymmetrical either in heightor in an anterior posterior dimension, there may be asubluxation or dislocation or a sacroiliac dysfunction(Figure 11.7).

Greater TrochantersPlace your hands on the iliac crests and palpate dis-tally along the lateral aspect of the pelvis until youreach a small plateau. Allow your extended hands torest on top of the greater trochanters to determine

Umbilicus

(a)

Anterioriliac spine

Pubictubercle

(b)

Figure 11.7 Palpation of the pubic tubercles.

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298 The Hip Chapter 11

their height. They are located at the same level as thepubic tubercles. The superior and posterior aspectsof the greater trochanters are superficial and easilypalpable. The anterior and lateral aspects are coveredby the attachments of the gluteus medius and tensorfasciae latae, making the bony prominence more diffi-cult to locate. You can confirm your hand placementby having the patient medially and laterally rotate thelower extremity. A difference in height may be sec-ondary to a malalignment following a hip fracture, acongenitally dislocated hip, or a congenital anomaly.If the patient is examined in a weight-bearing posi-tion, a height difference could be secondary to a leglength difference. If tenderness is noted in this area,the patient may have a trochanteric bursitis or a piri-formis syndrome (Figure 11.8).

Soft-Tissue Structures

Femoral TriangleThe femoral triangle is located in the area directlycaudal to the crease of the groin. The base of thetriangle is formed by the inguinal ligament. The lat-eral border is the medial aspect of the sartorius andthe medial border is the adductor longus. The flooris trough-like and is comprised of the iliacus, psoasmajor, adductor longus, and pectineus. The femoral

GreaterTrochanter

Figure 11.8 Palpation of the greater trochanters.

vessels are located superficial to the floor and con-sist of the femoral artery, vein, and nerve and somelymph nodes. The tissues can be most easily accessedby placing the patient’s lower extremity in a po-sition of flexion, abduction, and external rotation(Figure 11.9).

Inguinal LigamentThe inguinal ligament attaches to the anterior supe-rior iliac spines and the pubic tubercles and is foundunder the inguinal crease of the groin. This ligamentfeels cordlike as you run your fingers across it. If abulge is found, the patient may have an inguinal her-nia (Figure 11.10).

Femoral ArteryThe femoral pulse can most easily be detected atthe midway point between the pubic tubercles and theanterior superior iliac spines. This is a valuable pulseto assess and is normally strong, but if a weak pulseis detected, occlusion of the aorta or the iliac arteriesshould be considered (Figure 11.11). If the patient isobese, a hand-over-hand technique may be useful.

Femoral VeinThe femoral vein is located medial to the femoralartery at the base of the femoral triangle. It isnot easily palpable in the normal individual. Thisarea may be inspected for enlarged lymph nodes,which may indicate an infection or systemic disease(Figure 11.12).

Femoral NerveThe femoral nerve is located on the lateral aspect ofthe femoral artery. This very important structure isnot normally palpable.

Sartorius MuscleThe sartorius muscle can be visualized by asking thepatient to flex, abduct, and laterally rotate the hip andto flex the knee. It is most easily palpable at the prox-imal anteromedial aspect of the thigh (Figure 11.13).It is the longest muscle in the body.

Adductor Longus MuscleThe adductor longus muscle can be visualized byasking the patient to abduct the lower extremityand then resist adduction. The tendon is palpableat the proximal medial aspect of the thigh inferiorto the pubic symphysis. The adductor longus musclemay be injured during athletic activities (e.g., soccer)(Figure 11.14).

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299Chapter 11 The Hip

Femoralarteryand vein

Sartorius

Adductor longus

Femoral triangle

Inguinalligament

Figure 11.9 The femoral triangle.

Inguinalligament

Figure 11.10 The inguinal ligament.

Femoralartery

Figure 11.11 Palpation of the femoral pulse.

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300 The Hip Chapter 11

Femoralnerve

Femoralvein

Figure 11.12 Femoral vein and nerve.

Figure 11.13 Palpation of the sartorius muscle.

Adductorlongus

Figure 11.14 Palpation of the adductor longus muscle.

Posterior Aspect—the Patient isPositioned in Prone

Bony Structures

Posterior Superior Iliac SpinesThe posterior superior iliac spines can be found byplacing your extended hands over the superior aspectof the iliac crests and allowing your thumbs to reachon a diagonal in an inferior medial direction until theycontact the bony prominences. Have your thumbs rolltoward a cranial orientation to more accurately deter-mine the position of the posterior superior iliac spines.Many individuals have dimpling, which makes the lo-cation more obvious. However, you should be carefulbecause not everyone has dimpling and if it is present,it may not coincide with the posterior superior iliacspines. With your fingers on the posterior superior il-iac spines, if you move your thumbs at a medial andsuperior angle of approximately 30 degrees, you willcome in contact with the posterior arch of L5. If youmove your thumbs medially in a caudad and inferiorangle of approximately 30 degrees, you will come incontact with the base of the sacrum. If you are havingdifficulty, you can also locate the posterior superior

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301Chapter 11 The Hip

PSIS PSIS

Figure 11.15 Palpation of the posterior superior iliac spines.

iliac spines by following the iliac crests posteriorlyuntil you arrive at the spines (Figure 11.15).

Sacroiliac JointThe actual joint line of the sacroiliac joint is not pal-pable because it is covered by the posterior aspect ofthe innominate bone. You can get a sense of its loca-tion by allowing your thumb to drop medially fromthe posterior superior iliac spine. The sacroiliac jointis located deep to this overhang at approximately thesecond sacral level (Figure 11.16).

Ischial TuberosityYou can place your thumbs under the middle por-tion of the gluteal folds at approximately the level ofthe greater trochanters. Allow your thumbs to facesuperiorly and gently probe through the gluteus max-imus until your thumbs are resting under the ischialtuberosity. Some people find it easier to perform thispalpation with the patient in the side-lying positionwith the hip flexed; with this position, the ischialtuberosity is more accessible because the gluteus max-imus is pulled up, reducing the muscular cover. If thisarea is tender to palpation, it may be indicative of aninflammation of the ischial bursa (Figure 11.17).

L4

L5

S2

Sacroiliacjoint

Figure 11.16 Palpation of the sacroiliac joint.

Ischialtuberosity

Figure 11.17 Palpation of the ischial tuberosity.

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302 The Hip Chapter 11

Side-Lying Position

Soft-Tissue Structures

Piriformis MuscleThe piriformis muscle is located between the ante-rior inferior aspect of the sacrum and the greatertrochanter. This muscle is very deep and is normallynot palpable. However, if the muscle is in spasm, acordlike structure can be detected under your fingersas you palpate the length of the muscle (Figure 11.18).The piriformis is able to influence the alignment of thesacrum by pulling it anteriorly by virtue of its attach-ment. The sciatic nerve runs either under, over, orthrough the muscle belly. Compression of the nervecan occur when the muscle is in spasm.

Sciatic NerveThe sciatic nerve is most easily accessed with the pa-tient in the side-lying position, which allows the nerveto have less muscle cover since the gluteus maximusis flattened. Locate the mid position between the is-chial tuberosity and greater trochanter. The sciaticnerve emerges from the internal pelvis, exiting via thegreater sciatic notch and foramen under the piriformismuscle. You may be able to roll the nerve under yourfingers if you take up the soft-tissue slack. Tendernessin this area can be due to an irritation of the sciaticnerve secondary to lumbar disc disease or piriformisspasm (Figure 11.19).

Greatertrochanter

Sciaticnerve

Piriformismuscle

Figure 11.18 Palpation of the piriformis muscle.

Greatertrochanter

Sciaticnerve

Piriformismuscle

Figure 11.19 Palpation of the sciatic nerve.

Trigger Points

Most muscles about the hip can develop myofas-cial dysfunction and have trigger points within them.Common trigger point locations for the gluteus max-imus, gluteus medius, piriformis, tensor fascia lata,and iliopsoas muscles are illustrated in Figures 11.20through 11.24.

While myofascial dysfunction can result in asciatica-like pain syndrome, it should be noted thattrue sciatic nerve damage is associated with sensoryloss, muscle weakness, or loss of reflexes. These find-ings do not occur in myofascial pain syndromes.

Active Movement Testing

You should have the patient perform the followingmovements: flexion and extension on the frontal axis,abduction and adduction on the sagittal axis, andmedial and lateral rotation on the longitudinal axis.These should be quick, functional tests designed toclear the joint. If the motion is pain free at the end ofthe range, you can add an additional overpressure to“clear” the joint. If the patient experiences pain dur-ing any of these movements, you should continue toexplore whether the etiology of the pain is secondaryto contractile or noncontractile structures by usingpassive and resistive tests.

Flexion

The patient, in the supine position, is instructed tobend the hip and bring the knee toward the chest asfar as he or she can without causing a posterior pelvicrotation (Figure 11.25).

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X1

Gluteusmaximus

X3 X2

X3X2X1

Figure 11.20 Trigger points (X1, X2, X3) in the gluteus maximus muscle. The referred pain patterns are noted by the dark andstippled areas. (Adapted with permission from Travell and Rinzler, 1952.)

X1 X2 X3X1 X2 X3

Gluteusmedius

Figure 11.21 Trigger points (X1, X2, X3) in the gluteus medius muscle. The referred pain patterns are noted by the dark and stippledareas. (Adapted with permission from Travell and Rinzler, 1952.)

X2

X1 Piriformis

Figure 11.22 Trigger points (X1, X2) in the piriformis muscle. The referred pain patterns are noted by the dark and stippled areas.(Adapted with permission from Travell and Rinzler, 1952.)

303

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304 The Hip Chapter 11

X1X1

Figure 11.23 A trigger point, X1, in the tensor fascia latamuscle. The referred pain pattern is noted by the dark andstippled areas. (Adapted with permission from Travell andRinzler, 1952.)

Iliopsoas

Figure 11.24 Trigger points in the iliacus and psoas muscles. The referred pain patterns are noted by the dark and stippled areas.Note that pain can be felt both anteriorly and along the lumbar spine. (Adapted with permission from Travell and Rinzler, 1952.)

Extension

The patient, in the supine position, is instructed toreturn the lower extremity to the table (Figure 11.26).

Abduction

The patient, in the supine position, is instructed tobring the lower extremity out to the side as far aspossible without creating an obliquity of the pelvis(Figure 11.27).

Adduction

The patient, in the supine position, is instructed toreturn the lower extremity to the midline from theabducted position (Figure 11.28).

Medial (Internal) Rotation

The patient, in the supine position, is instructed to rollthe extended lower extremity inward without liftingthe buttock off the table (Figure 11.29).

Lateral (External) Rotation

The patient, in the supine position, is instructed toroll the lower extremity outward (Figure 11.30).

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Figure 11.25 Active movement testing of flexion.

Figure 11.26 Active movement testing of extension.

Figure 11.27 Active movement testing of abduction.

305

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Figure 11.28 Active movement testing of adduction.

Figure 11.29 Active movement testing of medial (internal) rotation.

Figure 11.30 Active movement testing of lateral (external) rotation.

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307Chapter 11 The Hip

Passive Movement Testing

Passive movement testing can be divided into two ar-eas: physiological movements (cardinal plane), whichare the same as the active movements, and mobil-ity testing of the accessory (joint play, component)movements. You can determine whether the noncon-tractile (inert) elements can be incriminated by usingthese tests. These structures (ligaments, joint capsule,fascia, bursa, dura mater, and nerve root) (Cyriax,1979) are stretched or stressed when the joint is takento the end of the available range. At the end of eachpassive physiological movement, you should sense theend feel and determine whether it is normal or patho-logical. Assess the limitation of movement and see ifit fits into a capsular pattern. The capsular pattern ofthe hip is medial rotation, extension from 0 degree,abduction, and lateral rotation (Kaltenborn, 1999). Ifyou find that the patient has limited motion, experi-ences pain during hip flexion with the knee extendedor with the knee flexed, and presents with a noncap-sular pattern, you should consider that the patient hasthe sign of the buttock (Cyriax, 1979). This is indica-tive of a serious lesion such as neoplasm, fracture ofthe sacrum, or ischiorectal abscess.

Physiological Movements

Assess the amount of motion available in all direc-tions. Each motion is measured from the anatomi-

Figure 11.31 Passive movement testing of flexion.

cal starting position which is 0 degree of flexion–extension, abduction–adduction, and medial–lateralrotation. Patients will substitute for tightness in thejoint or surrounding muscles with trunk or pelvicmovement. Therefore, it is important to monitorwhere the movement is taking place while stabilizingthe pelvis.

Flexion

The patient is placed in a supine position with thehip in the anatomical position. Place your hand overthe patient’s knee and ankle and create flexion in thehip and knee joint. Increased motion can be achievedby posteriorly tilting the pelvis; therefore, stabiliza-tion of the pelvis is important for the accurate deter-mination of hip movement. Hip flexion is normallyblocked by the approximation of the anterior part ofthe thigh and the abdomen. If the patient is obese,range of motion can be limited by early contact withthe abdominal area. The normal end feel is consid-ered to be soft (tissue approximation) (Magee, 2002;Kaltenborn, 1999). Normal range of motion is 0–120degrees (Figure 11.31) (American Academy of Ortho-pedic Surgeons, 1965).

Extension

The patient is placed prone with the hip in theanatomical position. The knee must be extended to

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308 The Hip Chapter 11

put the rectus femoris on slack and so that it does notdecrease the available range. Place your hand underthe anterior distal aspect of the thigh and lift the lowerextremity toward the ceiling. Increased motion can becreated by increasing the lumbar lordosis and by an-terior tilting of the pelvis. Stabilization of the pelvisis important to obtain accurate measurements. Thenormal end feel is firm (ligamentous) due to tensionfrom the anterior capsular ligaments (Magee, 2002;Kaltenborn, 1999). Tight anterior muscles can alsocontribute to the limitation of motion. Normal rangeof motion is 0–30 degrees (Figure 11.32) (AmericanAcademy of Orthopedic Surgeons, 1965).

Abduction

The patient is placed supine with the hip in theanatomical position. Place your hand on the medialdistal aspect of the leg and move the lower extremitylaterally. Increased motion can be created by laterallyrotating the lower extremity and hiking the pelvis.Stabilization of the pelvis is important to obtain ac-curate measurements. Normal end feel is firm (lig-amentous) due to tension from the medial capsularligaments (Magee, 2002; Kaltenborn, 1999). Motioncan also be limited by tightness in the adductor mus-

cles. Normal range of motion is 0–45 degrees (Figure11.33) (American Academy of Orthopedic Surgeons,1965).

Adduction

Place the patient supine with the hip in the anatom-ical position. Abduct the contralateral hip to allowenough room for movement. Place your hand on thelateral distal aspect of the leg and move the lower ex-tremity medially. Increased motion can be created bylaterally tilting the pelvis. Stabilization of the pelvis isimportant to obtain accurate measurements. Normalend feel is firm (ligamentous) due to tension from thelateral capsule and superior band of the iliofemoralligament. Motion can also be limited by tightness inthe abductor muscles. Normal range of motion is 0–30 degrees (Magee, 2002; Kaltenborn, 1999) (Figure11.34) (American Academy of Orthopedic Surgeons,1965).

Medial (Internal) Rotation

Medial rotation can be assessed with the hip in ei-ther flexion or extension. To assess movement withthe hip in extension, place the patient prone with the

Figure 11.32 Passive movement testing of extension.

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309Chapter 11 The Hip

Figure 11.33 Passive movement testing of abduction.

hip in the anatomical position and the knee flexed to90 degrees. Place your hand on the medial distal as-pect of the leg and rotate the leg outward. Increasedmotion can be created by rotating the pelvis. Stabi-lization of the pelvis is important for accurate mea-

surement. Motion can also be limited by tightness inthe external rotator muscles. The normal end feel isfirm (ligamentous) due to tension from the posteriorcapsule and the ischiofemoral ligament (Magee, 2002;Kaltenborn, 1999) (Figure 11.35).

Figure 11.34 Passive movement testing of adduction.

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310 The Hip Chapter 11

Figure 11.35 Passive movement testing of medial (internal) rotation with the hip extended.

To assess medial rotation with the hip in flexion,have the patient sit with the hip and knee flexed to90 degrees. Place your hand on the medial distal as-pect of the leg and rotate the leg outward. Increasedmotion can be created by rotating the pelvis and lat-erally flexing the spine. Stabilization of the pelvisis important for accurate measurement. The normalend feel is firm (ligamentous) due to tension fromthe posterior capsule and the ischiofemoral ligament(Magee, 2002; Kaltenborn, 1999). Motion can alsobe limited by tightness in the external rotator mus-cles. Normal range of motion is 0–45 degrees (Figure11.36) (American Academy of Orthopedic Surgeons,1965).

Lateral (External) Rotation

Lateral rotation is performed in flexion and exten-sion using the same positions as for medial rotation.Place your hand on the lateral distal aspect of theleg and rotate the leg inward. Increased motion canbe created by further abducting the hip and laterallyflexing the spine. Stabilization of the pelvis is impor-tant for accurate measurement. The normal end feelis firm (ligamentous) due to tension in the anteriorcapsule and iliofemoral and pubofemoral ligaments.Motion can also be limited by tightness in the me-dial rotator muscles. Normal range of motion is 0–45 degrees (Magee, 2002; Kaltenborn, 1999) (Figure11.37) (American Academy of Orthopedic Surgeons,1965).

Mobility Testing of AccessoryMovements

Mobility testing of accessory movements will give youinformation about the degree of laxity present in the

Figure 11.36 Passive movement testing of medial (internal)rotation with the hip flexed.

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311Chapter 11 The Hip

Figure 11.37 Passive movement testing of lateral (external) rotation with the hip extended.

joint. The patient must be totally relaxed and com-fortable to allow you to move the joint and obtain themost accurate information. The joint should be placedin the maximal loose packed (resting) position to al-low for the greatest degree of joint movement. Theresting position of the hip is 30 degrees of flexion,30 degrees of abduction, and slight lateral rotation(Kaltenborn, 1999).

Traction (Longitudinal Distraction)

Place the patient in the supine position with the hip inthe resting position and the knee in flexion. Stand onthe side of the table so that your body is turned toward

the patient. The pelvis should be stabilized so that allthe movement takes place at the hip joint. Place yourhands on the medial and lateral inferior aspects of thethigh. Pull along the axis of the femur in a longitudinaldirection until the slack is taken up. This techniqueprovides an inferior separation of the femoral headfrom the acetabulum (Figure 11.38). This techniquecan also be performed with the knee in extension.You would place your hands around the patient’smalleoli and pull in the same direction as previouslydescribed. Recognize that additional stress is placedon the knee joint. This technique should not be usedwith patients who have increased laxity in the knee(Figure 11.39).

stabilizingstrap

Figure 11.38 Mobility testing of hip traction (longitudinal distraction).

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312 The Hip Chapter 11

stabilizingstrap

Figure 11.39 Mobility testing of hip distraction through the knee.

Lateral Distraction or Glide

Place the patient in the supine position with the hipin the resting position and the knee in flexion. Standon the side of the table so that your body is turnedtoward the side of the patient. The pelvis should bestabilized so that all the movement takes place at thehip joint. Place your hands on the proximal medialaspect of the thigh as close to the inguinal creaseas possible. Pull laterally at a 90-degree angle fromthe femur until the slack is taken up. This movementwill separate the femoral head from the acetabulum(Figure 11.40).

Ventral Glide of the Femoral Head

Place the patient in the prone position so that thepelvis is resting on the table and the remainder of thelower extremity is unsupported. Stand at the end ofthe table so that your body is turned toward the me-dial side of the patient’s thigh. The pelvis is stabilizedby the treatment table. Place your hands so you sup-port the lower extremity by holding the distal partof the leg and allowing the knee to flex. Your otherhand should be at the proximal posterior aspect of thethigh as close to the gluteal crease as possible. Pushanteriorly with your proximal hand until the slack is

Figure 11.40 Mobility testing of lateral distraction (glide).

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313Chapter 11 The Hip

taken up. This movement will create an anterior glideof the femoral head (Figure 11.41).

Resistive Testing

There are six motions of the hip to be examined: flex-ion, extension, abduction, adduction, external (lat-eral) rotation, and internal (medial) rotation. Al-though a single action is usually ascribed to each mus-cle in the hip region, it should be remembered thatmost of the muscles perform more than one actionsimultaneously. The position of the leg at the time ofmuscle contraction is an important determinant of themuscle’s function. For example, the adductor longusmuscle is a hip flexor up to 50 degrees of hip flex-ion. Beyond 50 degrees of hip flexion, the adductorlongus functions as an extensor. This is an exampleof inversion of muscular action.

Flexion

The most powerful flexors of the hips are the psoasand the iliacus, which share a common tendon (Figure11.42). The iliopsoas is assisted by the rectus femoris,

Psoas major

Iliacus

Figure 11.42 The flexors of the hip.

Figure 11.41 Mobility testing of ventral glide of the femoral head.

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314 The Hip Chapter 11

sartorius, and tensor fascia lata, which cross both thehip and the knee joints.� Position of patient: Sitting upright with knees bent

over the edge of the table, with hands holdingonto the edge of the table for support and toprevent substitution.

� Resisted test: Ask the patient to raise the thigh offthe table while you resist this movement byapplying pressure downward on the thigh justabove the knee (Figure 11.43).Testing hip flexion with gravity eliminated is per-

formed with the patient in a side-lying position (Fig-ure 11.44). The upper part of the leg is elevatedslightly, and the patient is asked to flex the hip.

Inguinal pain during resisted hip flexion may be dueto iliopsoas bursitis or abdominal pathology.

Weakness of hip flexion results in difficulty gettingout of a chair, walking up an incline, and climbingstairs.

Extension

The extensors of the hip are the glutei and hamstrings(Figure 11.45). The gluteal muscles attach to the fe-mur and iliotibial band (gluteus maximus only), and

Figure 11.44 Testing hip flexion with gravity eliminated.

Figure 11.43 Testing hip flexion.

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315Chapter 11 The Hip

Gluteusmaximus

Long head ofBiceps femoris

Semi-tendinosus

Semi-membranosus

Figure 11.45 The extensors of the hip.

the hamstrings attach to the proximal part of the tibia.The gluteus maximus is the strongest of all the hipextensors. The strength of the hamstrings in hip ex-tension is dependent on the position of the knee. Withthe knee flexed, the hamstrings are at a disadvantageand are relatively weaker. As the knee is extended, thehamstrings are stretched more and become strongerextensors of the hip.� Position of patient: Lying prone on the table with

the knee extended. The test can also be performedwith the knee flexed to isolate the gluteusmaximus (Figure 11.46).

� Resisted test: Stabilize the pelvis with one handwith downward pressure, and apply downwardresistance above the knee posteriorly on the thigh.Ask the patient to elevate the leg and thigh off thetable.Testing hip extension with gravity eliminated is per-

formed by having the patient lie on the opposite sidewith the hip flexed and the knee extended (Figure11.47). Elevate the upper part of the leg (test leg),

which is flexed at the hip, and support the weightof the leg as the patient attempts to extend the hiptoward you. The gluteus maximus is isolated by per-forming this test with the patient’s knee flexed (Figure11.46B).

Painful resisted hip extension can be due to spasmof the gluteus maximus or hamstring muscles. Paincan also be caused by ischial bursitis at the ischialtuberosity. Pain may be referred to the hip extensorsfrom spondylolisthesis or a herniated lumbosacraldisc.

Weakness of the hip extensors results in diffi-culty with ambulation and return to erect posture.Stair climbing and walking up an incline are alsorestricted.

Abduction

The main abductor muscle is the gluteus medius. It isassisted by the gluteus maximus and piriformis (Fig-ure 11.48). The efficiency of the gluteus medius mus-cle is increased because of the presence of the femoralneck. The more lateral attachment of the muscle in-creases its resultant torque (Figure 11.49). The pri-mary function of the hip abductors, rather than mov-ing the thigh away from the midline, is to prevent thepelvis from adducting on the thigh (dropping) duringunilateral stance.� Position of patient: Lying on the side with the

lower leg slightly flexed at the hip and the knee.The upper leg is in neutral position at the hip andextended at the knee (Figure 11.50).

� Resisted test: Stabilize the pelvis with one hand toprevent the patient from rolling forward orbackward. As the patient attempts to elevate theleg from the table, put downward pressure on theinferior distal aspect of the leg.Testing abduction with gravity eliminated is per-

formed by having the patient lie supine with the kneesextended (Figure 11.51). The patient tries to move theleg into abduction so as to separate the legs. Be carefulnot to allow the patient to externally rotate the hip(substitution).

Lateral hip pain during resisted abduction canbe due to trochanteric bursitis. This can re-sult from an excessively tight gluteus medius orminimus.

Weakness of hip abduction results in an abnormalgait pattern, known as a Trendelenburg gait.

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316 The Hip Chapter 11

(a)

(b)

Figure 11.46 (a) Testing hip extension. (b) Isolating the gluteus maximus by testing hip extension with the knee flexed.

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317Chapter 11 The Hip

Figure 11.47 Testing hip extension with gravity eliminated.

Gluteus medius

Tensor fasciae latae

Figure 11.48 The abductors of the hip.

Short leverarm of adductors

without femoral neck

Longer leverarm due to presence

of femoral neck

Femoralneck

Figure 11.49 The presence of the femoral neck increases theefficiency of the hip abductors.

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318 The Hip Chapter 11

Figure 11.50 Testing hip abduction.

Figure 11.51 Testing hip abduction with gravity eliminated.

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319Chapter 11 The Hip

Adduction

The strongest hip adductor is the adductor magnus(Figure 11.52). Along with the adductor longus, ad-ductor brevis, and gracilis, the adductor muscles alsofunction to stabilize the pelvis. The hamstrings, glu-teus maximus, pectineus, and some of the short rota-tors also assist in adduction. The hip adductors pre-vent the lower extremity from sliding into abductionduring ambulation (Figure 11.53).� Position of patient: Lying on the side, with the

spine, hip, and knee in neutral position (Figure11.54).

� Resisted test: Lift the upper leg and support it withone hand while pressing down on the lower limbjust above the knee with the other hand. Ask thepatient to raise the lower extremity off theexamining table against your resistance.Testing hip adduction with gravity eliminated is

performed with the patient lying supine (Figure11.55). The hip is passively or actively abducted, andthe patient attempts to bring the limb back towardthe midline.

Adductor brevis

Adductor magnus

Gracilis

Pectineus Adductor longus

Figure 11.52 The adductors of the hip.

Painful resisted adduction can be due to tendinitisor a tear in the adductor longus, which is the mostcommonly “pulled groin muscle.” Pain in the regionof the pubic ramus can be due to osteitis pubis. Painbelow the knee can be due to a pes anserinus bursitisirritated by the contracting gracilis muscle at its distalattachment.

External (Lateral) Rotation

The external rotators of the hip include the piriformis,obturator internus, obturator externus, and the twogemelli. The quadratus femoris and pectineus also as-sist in external rotation (Figure 11.56).� Position of patient: Sitting with both knees flexed

over the edge of the table (Figure 11.57).� Resisted test: Hold the patient’s leg at the medial

aspect above the ankle. The patient then attemptsto rotate the leg upward so as to reach theopposite knee.Testing external rotation with gravity eliminated is

performed with the patient lying supine with the knee

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320 The Hip Chapter 11

Hip adductors

Figure 11.53 During the stance phase of gait, there is a tendency for the weight-bearing limb to slide into abduction. Powerful hipadductors prevent this from occurring, especially during running.

Figure 11.54 Testing hip adduction.

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321Chapter 11 The Hip

Figure 11.55 Testing hip adduction with gravity eliminated.

Piriformis

Gemellus superior

Quadratus femoris

Obturator externus

Obturator internus

Gemellus inferior

Figure 11.56 The lateral (external) rotators of the hip.

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322 The Hip Chapter 11

Figure 11.57 Testing hip lateral (external) rotation.

and hip in neutral position (Figure 11.58). The patientattempts to rotate the lower extremity away from themidline so that the lateral malleolus is in contact withthe table.

Painful resisted external rotation can be caused bydysfunction in the piriformis muscle. This can be con-firmed by performing the piriformis test.

Piriformis Test

This test is used to isolate the piriformis muscle inexternal rotation of the hip (Figure 11.59).� Position of patient: Lying supine with the affected

hip and knee flexed.� Resisted test: Push the patient’s thigh and knee

into adduction and then ask the patient to pushthem back toward your chest.A complaint of pain on attempted external rotation

in this position against resistance is considered a posi-tive finding on the piriformis test. This maneuver mayelicit tingling or pain in the distribution of the sciaticnerve due to its proximity to the piriformis muscle.

Internal (Medial) Rotation

The internal rotators of the hip are less than half asstrong as the external rotators. The gluteus medius,gluteus minimus, and tensor fasciae latae are theprimary internal rotators of the hip (Figure 11.60).Accessory muscles include the semitendinosus andsemimembranosus.� Position of patient: Sitting at the edge of the table

with the knees bent over the table (Figure 11.61).� Resisted test: Place your hand on the distal lateral

aspect of the leg proximal to the ankle. Thepatient attempts to rotate the leg laterally awayfrom the opposite leg.

Figure 11.58 Testing hip lateral (external) rotation with gravity eliminated.

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323Chapter 11 The Hip

Figure 11.59 The piriformis test isolates this muscle as a causeof buttock pain. Reproduction of symptoms of sciatica, such astingling or radiating pain down the posterolateral aspect of thethigh and leg, confirms the diagnosis of piriformis syndrome.

Testing internal rotation with gravity eliminated isperformed with the patient lying supine with the hipand knee in neutral position (Figure 11.62). The pa-tient then attempts to roll the lower extremity inwardso as to bring the medial aspect of the foot in contactwith the table.

Painful resisted internal rotation can be seen inarthritic conditions of the hip.

Neurological Examination

Motor

The innervation and spinal levels of the muscles thatfunction across the hip joint are listed in Table 11.1(p. 325).

Reflexes

There are no reflexes that can be elicited at the hip.

Gluteus minimus

Tensor fasciae latae

Figure 11.60 The medial (internal) rotators of the hip.

Figure 11.61 Testing hip medial (internal) rotation.

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324 The Hip Chapter 11

Figure 11.62 Testing hip medial (internal) rotation with gravity eliminated.

Sensation

Light touch and pinprick sensation should be ex-amined following the motor examination. The der-matomes for the anterolateral aspect of the hip areL1 and L2. Refer to Figure 11.63 for the exact loca-tions of the key sensory areas in these dermatomes.We have intentionally included dermatome drawingsfrom different sources in this text to emphasize thatpatients as well as anatomists vary significantly withrespect to sensory nerve root innervation of the ex-tremities. The peripheral nerves providing sensationin the hip region are shown in Figure 11.64.

The lateral femoral cutaneous nerve (Figure 11.65)is of clinical significance, as it may be compressed atthe waist, where it crosses the inguinal ligament. Pain,numbness, or tingling in the proximal lateral aspectof the thigh may be due to compression of this nerve.This is called meralgia paresthetica.

Many common abnormal gait patterns result fromdysfunction in the muscles about the hip. These ab-normal gait patterns are described in Chapter 14.

Referred Pain Patterns

Pain in the hip and groin region can result from uro-genital or abdominal organ disease. For example, re-sisted hip flexion or external rotation may be painfulin patients with appendicitis.

Dysfunction of the knee or diseases of the distalpart of the femur can also radiate pain to the hip.

An L1 or L2 radiculopathy and sacroiliac joint dys-function can also refer pain to the hip.

Special Tests

Flexibility Tests

Thomas Test

This test is used to rule out a hip flexion contracture(Figure 11.66). The test is performed with the pa-tient lying supine on the examining table. One kneeis brought to the patient’s chest and held there. Makesure the lower region of the lumbar spine remains flaton the table. In the presence of a hip flexion contrac-ture, the extended leg will bend at the knee and thethigh will raise from the table.

Ober’s Test

This test is used to assess tightness of the iliotibialband (Figure 11.67). The patient is placed in a posi-tion so as to stretch the iliotibial band. The patientlies on the unaffected side. The lower leg is flexedat the hip and knee. The upper leg (test leg) is flexed atthe knee and extended at the hip while being lifted inthe air by the examiner. The iliotibial band is tight and

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Table 11.1 Muscle, innervation, and root levels of the hip.

Movement Muscles Innervation Root levels

Flexion of hip 1 Psoas L1–L3 L1–L32 Iliacus Femoral L2, L33 Rectus femoris Femoral L2–L44 Sartorius Femoral L2, L35 Pectineus Femoral L2, L36 Adductor longus Obturator L2, L37 Adductor brevis Obturator L2–L48 Gracilis Obturator L2, L3

Extension of hip 1 Biceps femoris Sciatic L5, S1, S22 Semimembranosus Sciatic L5, S13 Semitendinosus Sciatic L5, S1, S24 Gluteus maximus Inferior gluteal L5, S1, S25 Gluteus medius (posterior) Superior gluteal L4, L5, S16 Adductor magnus Obturator and sciatic L3, L4

Abduction of hip 1 Tensor fascia lata Superior gluteal L4, L5, S12 Gluteus medius Superior gluteal L4, L5, S13 Gluteus minimus Superior gluteal L4, L5, S14 Gluteus maximus Inferior gluteal L5, S1, S25 Sartorius Femoral L2, L3

Adduction of hip 1 Adductor magnus Obturator and sciatic L3, L42 Adductor longus Obturator L2, L33 Adductor brevis Obturator L2–L44 Gracilis Obturator L2, L35 Pectineus Femoral L2, L3

Internal (medial) rotation ofthe hip

1 Adductor longus Obturator L2, L3

2 Adductor brevis Obturator L2–L43 Adductor magnus Obturator and sciatic L3, L44 Gluteus medius (anterior) Superior gluteal L4, L5, S15 Gluteus minimus (anterior) Superior gluteal L4, L5, S16 Tensor fasciae latae Superior gluteal L4, L5, S17 Pectineus Femoral L2, L38 Gracilis Obturator L2, L3

External (lateral) rotation ofhip

1 Gluteus maximus Inferior gluteal L5, S1, S2

2 Obturator internus Nerve (N) to obturator internus L5, S1, S23 Obturator externus Obturator L3, L44 Quadratus femoris N to quadratus femoris L4, L5, S15 Piriformis L5, S1, S2 L5, S1, S26 Gemellus superior N to obturator internus L5, S1, S27 Gemellus inferior N to quadratus femoris L4, L5, S18 Sartorius Femoral L2, L39 Gluteus medius (posterior) Superior gluteal L4, L5, S1

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Key sensoryarea for L1

L1

L3 L2

L2

S4

S3

S3

S4S3

Key sensoryarea for L2

L1

Posterior

Figure 11.63 The dermatomes of the hip. Note the key areas for testing sensation in the L1 and L2 dermatomes.

Subcostal nerve

Genitofermoral

Ilioinguinal nerve

Lateral femoral cutaneousnerve of thigh

Medial intermediate cutaneousnerve of thigh (femoral nerve)

Obturator nerve

Iliohypogastric nerve

Subcostal nerve

L1, L2, L3 nerve roots

S1, S2, S3 nerve roots

Lateral cutaneous nerveof thigh

Posterior femoral cutaneousnerve

Obturator nerve

Medial cutaneous nerveof thigh (femoral nerve)

Anterior view Posterior view

Figure 11.64 The peripheral nerves and their sensory territories.

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327Chapter 11 The Hip

Compression(causing tinglingand numbnessdown thigh)

Lateral femoralcutaneous nerve

Figure 11.65 The lateral femoral cutaneous nerve (L2, L3) is apurely sensory nerve that can be compressed under the inguinalligament at the anterior superior iliac spine, causing meralgiaparesthetica.

the test is abnormal when the knee cannot be loweredto the table. If the test is performed with the knee inextension, you may pick up a less obvious contractureof the iliotibial band.

Ely’s Test

This test is used to assess tightness of the rectusfemoris (Figure 11.68). It is performed with the pa-tient lying supine with the knees hanging over the edgeof the table. The unaffected leg is flexed toward thechest to stabilize the pelvis and back, and you shouldobserve the test leg to see if the knee extends. Exten-sion of the knee on the test side is a sign of rectusfemoris tightness and is due to the fact that flexion ofthe opposite leg rotates the pelvis posteriorly, pullingon the rectus femoris muscle.

Piriformis Test

This test was described previously in the ResistiveTesting section (p. 322–323, Figure 11.59).

Piriformis Flexibility Test

The patient is in the supine position with their hipflexed to 60 degrees. Fully adduct the patient’s hipfollowed by internal then external rotation. The

Normal

Abnormal

Figure 11.66 Thomas test. Note that the patient’s knee elevates from the examination table due to a right hip flexion contracture.

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328 The Hip Chapter 11

Figure 11.67 Ober’s test. The test is performed with the knee in flexion. Extend the hip passively so that the tensor fascia lata (TFL)crosses the greater trochanter of the femur. The test result is positive when the knee fails to drop downward due to excessive tightnessof the iliotibial band.

normal range should be 45 degrees in either direction.Tightness in internal rotation is due to the superiorfibers. Tightness in external rotation is due to tight-ness in the inferior fibers (Figure 11.68a) (Dutton,2004).

Trendelenburg’s Test

This test is used to determine whether pelvic stabilitycan be maintained by the hip abductor muscles (Fig-ure 11.69). The patient stands on the test leg andraises the other leg off the ground. Normally, thepelvis should tilt upward on the non-weight-bearingside. The test finding is abnormal if the pelvis dropson the non-weight-bearing side.

Patrick’s (Fabere) Test

This test is performed to assess possible dysfunctionof the hip and sacroiliac joint (Figure 11.70). Thepatient is supine with the hip flexed, abducted, andexternally rotated. The patient is asked to place thelateral malleolus of the test leg above the knee of theextended, unaffected leg. The test result is positive if

this maneuver causes pain for the patient. The testmay be amplified by your pressing downward on thetest knee. Pain with downward pressure indicates asacroiliac joint problem, as the joint is compressed inthis position.

Sign of the Buttock

This test is performed to determine if there is seriouship pathology (neoplasm, fracture, infection). The pa-tient is in the supine position. Passively assess straightleg raising. If it is limited, assess the range of hip flex-ion with the knee flexed. If this is also restricted andthe patient presents with a non-capsular pattern, thetest is considered to be positive (Cyriax, 1979).

Alignment Tests

Test for True Leg Length

This test should be performed if you think the patienthas unequal leg length, which may be noted on inspec-tion and during observation of gait. A true leg lengthdiscrepancy is always noted when the patient stands

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329Chapter 11 The Hip

(b)

(a)

Figure 11.68 Ely’s test. (a) Negative test result is when the thigh remains in contact with the examination table. (b) Positive findingfor rectus femoris tightness is when the thigh elevates and the hip flexes.

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330 The Hip Chapter 11

Normal Abnormal

Figure 11.69 Trendelenburg’s test. (a) Normally, the pelvis onthe non-weight-bearing side elevates. (b) Positive finding due toleft abductor weakness. Note that the pelvis is dropped on thenon-weight-bearing side.

with both feet on the floor. The knee of the longerleg will be flexed, or the pelvis will be dropped on theshort side. A valgus deformity of the knee or anklemay also be noted. To measure leg length accurately,it is important to make sure that the patient is lyingon a flat, hard surface. Both legs should be placed inthe same position with regard to abduction and ad-duction from the midline. Measurement is taken fromthe anterior superior iliac spine to the distal medialmalleolus on the same side (Figure 11.71). This is thencompared to the opposite side.

The true leg length discrepancy is due to short-ening of either the tibia or the femur. If the pa-tient lies supine with both knees flexed and thefeet flat on the table, you can observe whether theknees are at the same height. If the knee is loweron the short side, the difference in leg length isdue to a shortened tibia. If the knee extends fur-ther on the long side than the other, the shorteningis due to a difference in the femoral length (Figure11.72). More precise measurements can be made fromradiographs.

Figure 11.70 Patrick’s (Fabere) test. By applying pressure to the pelvis and the knee, you can elicit sacroiliac joint dysfunction as youcompress the joint.

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331Chapter 11 The Hip

ASIS

(a) (b)

Medialmalleolus

Figure 11.71 (a) True leg length is measured from the anteriorsuperior iliac spine to the medial malleolus. (b) A leg lengthdiscrepancy is illustrated.

Apparent Leg Length Discrepancy

This test should be performed after true leg lengthdiscrepancy is ruled out. Apparent leg length discrep-ancy may be due to a flexion or adduction deformityof the hip joint, a tilting of the pelvis, or a sacroiliacdysfunction.

The test is performed with the patient supine, ly-ing as flat as possible on the table. Attempt to haveboth legs oriented symmetrically. Measure from theumbilicus to the medial malleolus on both sides. Adifference in measurement signifies a difference of ap-parent leg length (Figure 11.73).

Craig Test

This test is used to measure the degree of femoralanteversion. The femoral head and neck are not per-pendicular to the condyles of the femur. The anglethat the head and neck of the femur make with theperpendicular to the condyles is called the angle ofanteversion (Figure 11.74). This angle decreases fromabout 30 degrees in the infant to about 10 to 15degrees in the adult. A patient with femoral antev-ersion of more than 15 degrees may be noted tohave excessive toeing-in. Freedom of internal rotation

(a)

(b)

Figure 11.72 (a) The tibia is shorter on the patient’s left. (b) Thefemur is shorter on the right.

Umbilicus

Medialmalleolus

Note

(a) (b)

pelvicassymetry

Figure 11.73 (a) Apparent leg length is measured from theumbilicus to the medial malleolus. (b) Here, the difference inapparent leg length is due to an asymmetrical pelvis.

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332 The Hip Chapter 11

15°

80°

(c)

(a)

(b)

Figure 11.74 (a) The angle of femoral anteversion. (b) Normal angle. (c) Excessive angle.

on passive range of motion would also be noted, withrelative restriction of external rotation. Observationof the knees may reveal medially placed patellae, alsoreferred to as squinting patellae.

To perform the test for approximation of antever-sion of the femur, the patient is placed in the proneposition and the test knee is flexed to 90 degrees

Palpate greater trochanterparallel to table

Degree of anteversion

Figure 11.75 Craig test. To measure the angle of femoral anteversion, first palpate the greater trochanter and rotate the leg so thatthe trochanter is parallel to the examination table. Now note the angle formed by the leg and the vertical.

(Figure 11.75). Examine the greater trochanter andpalpate it as you rotate the hip medially andlaterally. With the trochanter being palpated inits most lateral position, the angle of anteversioncan be measured between the leg and the verti-cal. More precise measurements can be made fromradiographs.

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333Chapter 11 The Hip

Radiological Views

Radiological views of the hip are shown in Figures11.76–11.78.

A = Iliac crestB = Lumbar spineC = Symphysis pubisD = Sacroiliac jointE = SacrumF = Femoral headG = Greater trochanter of femurI = IschiumL = Lesser trochanter of femur

Figure 11.76 Anteroposterior view of the pelvis.

Figure 11.77 “Frog-lateral” view of the hip, with the hip in 45degrees of flexion and maximum external rotation.

Figure 11.78 Anteroposterior view of the hip joint.

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334 The Hip Chapter 11

S A M P L E E X A M I N A T I O N

History: 30-year-old femalerecreational hiker returns after a

recent 30-mile trek with a complaint ofleft groin pain, aggravated by weightbearing. No radiology evaluationperformed at this time.

Physical Examination: Well-developed,well-nourished female, limping with acane in the right upper extremity. Shecomplains of pain transitioning from sitto stand. She has full range of motion ofthe hips, except for moderate limitationdue to pain of internal rotation of the lefthip. Muscle strength is 5/5 except for thehip abductors which are 3 + /5. There isslightly less development (atrophy) ofthe left abductor musculature. Mobilitytesting of the hip is normal. Notenderness is noted on soft tissuepalpation. Flexibility testing isinconclusive secondary to pain.

Presumptive Diagnosis: Incompletestress fracture of the left femoral neck.

Physical Examination Clues:1. Painful limp, indicating a protective

mechanism in response to an injury.2. Painful limited internal rotation of the

hip, indicating probable hip jointpathology because the “Y” capsularligament tightens in internal rotationcreating a capsular pattern.

3. Weak or atrophic abductormusculature: the abductor muscles,when contracting during unilateralstance phase of gait, not only assist inthe maintenance of balance but alsoprotects the superior aspect offemoral neck from experiencingexcessive varus bending stress witheach step. This action is termed a“tension band effect,” and is presentin many areas of the body as a meansby which soft tissues reduce oreliminate what would otherwise becatastrophic tensile forces from actingon bony elements of the body. Failureof this muscle action due to relativeweakness resulted in a femoral neckstress fracture.

Paradigm for osteoarthritis of the hip due to congenital hip dysplasia (CDH)

A 40-year-old female patient presents with a complaint of left groin pain. She gives no history of injury now or in the past. Shewas the product of a breech birth and achieved normal developmental milestones. About 1 year ago she began to notice episodicdiscomfort in her left groin which radiated to the inner aspect of her thigh. Pain was in proportion to her level of weight-bearingactivity. She was beginning to notice a slight limp on walking more than 15 minutes or standing for more than 30 minutes. Sheis having difficulty entering and exiting her new sports car and has difficulty in cutting her toenails. She reports no pain at rest,but does report stiffness on arising in the morning and after prolonged periods of sitting. She does not perceive any noises withmovement, and does not report symptoms of “pins and needles” or tingling in the lower extremity. There are no other familymembers so affected, and she has no other significant medical history.

Physical exam demonstrates a well-developed, well-nourished woman who walks with a slight abductor limp. Her stride lengths areequal as are her leg lengths. She uses no assistive devices. She has a positive Trendelenburg sign, with no significant weakness ineither lower extremity. She mounts and dismounts from the examining table easily and independently. Her musculoskeletal examis otherwise unremarkable except for a significant lack of internal and external rotation of the left hip.

X-rays confirm a markedly shallow acetabulum with narrowing of the articular “space” and periarticular osteophyte formation.

This is a paradigm for secondary osteoarthritis of the hip because of:

The patient’s young ageHer being femaleThe involvement of the left hipThe history of breech birthNo history of trauma or excessive loading to the hip

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C H A P T E R 1 2

The Knee

F U R T H E R I N F O R M A T I O N

Please refer to Chapter 2for an overview of the sequence of

a physical examination. For purposes oflength and to avoid having to repeatanatomy more than once, the palpationsection appears directly after the sectionon subjective examination and before any

section on testing, rather than at the endof each chapter. The order in which theexamination is performed should bebased on your experience and personalpreference as well as the presentation ofthe patient.

Functional Anatomy

The knee is the largest synovial joint of the body. It isalso one of the most complex. The knee is composedof three bones (femur, tibia, and patella) and twoarticulations (tibiofemoral and patellofemoral). It liesmidway along the lower extremity and permits flexionto occur within the lower extremity. This ability tobend the lower extremity has obvious implications fordaily functions, as well as assisting in the mechanicalefficiency of the body during locomotion.

The tibiofemoral joint is formed by two large,bulbous femoral condyles resting on a relativelyflat tibial plateau. As a result, it is inherentlyunstable. The tibiofemoral articulation can poten-tially move without limit in four directions: flexion–extension, varus–valgus, external–internal rotation,and anterior–posterior translation (or glide). Theamount of movement that can, in fact, occur differsfrom individual to individual. This movement is sta-bilized and limited by muscles (dynamically) and lig-aments (statically). Accessory soft tissues such as themenisci, by virtue of their concave shape, increasestability of the knee joint by increasing the articularcongruity the tibial plateau presents to the femoralcondyles (Figure 12.1).

The geometry of the articular surfaces also con-tributes to the knee joint’s stability (i.e., the concavefemoral trochlea and convex patellar articular surfaceof the patellofemoral articulation) (Figure 12.2).

There are two pairs of major ligaments (medialand lateral collateral ligaments, anterior and poste-rior cruciate ligaments) and many minor or capsularligaments stabilizing the knee joint. Although it is notpossible to truly injure one ligament alone, an isolatedligament sprain is defined as an injury in which thereis clinically significant injury to only one of the fourmajor knee ligaments.

The medial collateral ligament and lateral collateralligament lie parallel to the longitudinal axis of theknee. As such, they, respectively, prevent excessivevalgus or varus displacement of the tibia relative tothe femur (Figure 12.3).

The anterior cruciate ligament and posterior cruci-ate ligament lie intra-articularly and extrasynoviallyin the midline of the knee (Figure 12.4).

The posterior cruciate ligament is about 50% largerin diameter than the anterior cruciate ligament. It hastwo functions. It acts as a linkage between the poste-rior cortex of the femur and the posterior cortex ofthe tibia about which tibial motion may occur, muchlike a gate hinge (Figure 12.5). It prevents posteriordisplacement of the tibia on the femur.

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336 The Knee Chapter 12

Femoralcondoyles

Menisci

Figure 12.1 The concave surface of the menisci increases thestability of the knee joint by increasing the congruity of thesurface presented to the femoral condyles.

The function of the anterior cruciate ligament canbe deduced from its location within the knee. It is di-rected anterior to posterior and medial to lateral fromnear the anterior tibial spine to the posteromedialintercondylar aspect of the lateral femoral condyle.It prevents anterior displacement of the tibia on the

Patella

Femur

Figure 12.2 The patellofemoral articulation is composed of theconvex patella lying within the trochlear groove of the femur.

Medialcollateralligament

Lateralcollateralligament

Menisci

Posterior view

Figure 12.3 The medial collateral ligament and lateral collateralligament lie parallel to the longitudinal axis of the knee. Theyprovide stability against side-to-side (varus–valgus) deformingforces.

Posteriorcruciate

ligament

Anteriorcruciateligament

Posterior view

Figure 12.4 The anterior cruciate ligament and posteriorcruciate ligament lie within the knee joint (intra-articular), butthey are extrasynovial structures.

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337Chapter 12 The Knee

Posteriorcruciateligament

Figure 12.5 The posterior cruciate ligament is the flexiblelinkage between the posterior cortices of the femur and tibia. Itacts as a pivot point much like a gatepost about which the kneerotates.

femur. It “wraps around” the posterior cruciate liga-ment, becoming tighter with internal rotation of thetibia on the femur (Figure 12.6). As such, it also pre-vents excessive internal rotational movement of thetibia on the femur.

Injuries therefore that occur with excessive anteriordisplacement or internal rotation of the tibia jeopar-dize the integrity of the anterior cruciate ligament.

Once a ligament (or ligaments) is compromised,there will be excessive movement and displacementof the knee in one or more planes of knee movement.This increased laxity creates excessive sheer stress onthe articular structure. This will result in acceleratederosion of the articular and meniscal surfaces and in-creased synovial fluid production due to synovial tis-sue irritation (synovitis).

The frequency of anterior cruciate ligament injuryand the severity of its consequences warrant addi-tional comment.

A balance exists within the knee, maintaining sta-bility against anterior displacement of the tibia onthe femur (anterior drawer). This balance betweenthe forces destabilizing the knee and those designedto resist anterior displacement of the tibia can be de-picted figuratively (Figure 12.7). Anterior stability of

Anteriorcruciateligament

Posteriorcruciateligament

Figure 12.6 The anterior cruciate ligament wraps around theposterior cruciate ligament as it courses anterior to posterior,medial to lateral, from the intraspinous region of the tibia to theposteromedial surface of the lateral femoral condyle.

(A)Femoral geometry

Post horn of meniscus Hamstrings

ACL

(B)Flat distal femoral surface

Momentum of legQuadriceps

Posterior horn of meniscus

ACLHamstrings

Quadriceps

Figure 12.7 A balance exists between the structures thatstabilize the knee against anterior displacement of the tibia onthe femur and the structures and forces attempting to move thetibia anteriorly on the femur (anterior drawer).

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338 The Knee Chapter 12

the knee relies primarily on the anterior cruciate lig-ament. This is supplemented by the dynamic pull ofthe hamstrings, the buttressing effect of the posteriorhorn of the menisci, and improved by the flexion ofthe knee, which enhances the efficiency of the ham-string pull and presents a more convex surface of thefemoral condyles with which the menisci have betterpurchase.

Acting to destabilize the knee are the anteriorly di-rected pull of the quadriceps muscles, the forwardmomentum of extending the leg, and the extendedposition of the knee, which serves to reduce the me-chanical advantage of the hamstrings while present-ing a relatively flat distal femoral surface, which isless conforming to the meniscal surfaces.

As such, if the anterior cruciate ligament is com-promised by injury, it is theoretically possible to re-duce the effects of its absence by increasing hamstringfunction and avoiding knee extension, thereby reduc-ing the possibility of the knee experiencing an ante-rior subluxation event (“giving way” or “buckling”).However, the ability of an individual to accomplishthis compensation will be directly dependent on theneuromuscular status and specific activities. For ex-ample, extension of the knee during jumping has ahigh likelihood of resulting in anterior subluxation ofthe tibia while the individual is in the air. Sudden re-duction of this subluxation with ground contact andknee flexion will give the sensation of the bones slip-ping within the knee as the tibia and posterior horn ofthe menisci (particularly that of the lateral meniscus)return to a normal relationship to the femur. This sud-den reduction usually results in the knee “buckling”or “giving way.” This action has been demonstratedto be accurate by laboratory investigation. It is thesame mechanism as that produced by the clinical testcalled the pivot shift (Fetto and Marshall, 1979). Theultimate results of such repeated events are sheer fa-tigue and tearing of the posterior horns of the menisciand premature osteoarthritic degeneration of the ar-ticular surfaces of the knee.

The patella has the thickest articular cartilage ofany bone in the body. This is a direct result of the sig-nificant loads it experiences during activities such asrunning, jumping, and stair climbing (up to six timesbody weight). The patella is a sesamoid bone withinthe quadriceps mechanism. As such, it displaces thequadriceps tendon anteriorly so as to increase the me-chanical advantage of the quadriceps by 25% (Figure12.8).

Because of the tremendous loads experienced by thepatella, the nutrients of the synovial fluid are forced

BB is 25% greater than AA

Quadriceps

Patella

Figure 12.8 The function of the patella as a sesamoid bone withthe quadriceps–patellar tendon is to displace the quadricepsanteriorly. This effectively increases the mechanical advantage ofthe quadriceps’ ability to extend the knee by 25%.

deeper into its articular cartilage than that of anyother articular surface. This permits the chondrocytesof the patellar articular cartilage to continue multi-plying to a greater depth than would otherwise bepossible. The hips are wider apart than are the knees.This results in a valgus angle between the femur andthe tibia of about 7 degrees. Because the quadricepslies along the axis of the femur, when it contracts,there will be a resultant lateral displacement vectoron the patella. This creates a traction load on themedial peripatellar soft tissues, driving the patella to-ward lateral subluxation out of the femoral trochlea.This displacement or tendency toward lateral trackingis resisted by the oblique fibers of the vastus medialis.

Any imbalance in these forces in favor of lateraldisplacement of the patella will result in several po-tential pathological situations: excessive tensile load-ing of the medial peripatellar soft tissues (capsule,plica), noncontact deterioration of the medial patel-lar articular facet cartilage, and excessive compressionloading of the lateral patellar facet, with secondaryarticular erosion or soft-tissue impingement. The lat-ter two conditions lead to a prearthritic condition

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339Chapter 12 The Knee

Q angle

VMO

Hip joint

Femur

Figure 12.9 The Q angle measures the tendency of the patellato track laterally. It is the angle formed between the mid axis ofthe femur and the line extending from the midpoint of thepatella to the tibial tubercle. Patellofemoral lateral subluxationand related tracking pathologies are associated with Q angles ofmore than 15 degrees. The normal Q angle for females isgenerally a few degrees more than that for males.

termed chondromalacia patellae (chondro means“cartilage,” malacia means “softening”).

The frequency toward these pathologies can bepredicted by measuring magnitude of the angula-tion within the quadriceps-patellar tendon mecha-nism. This angle has been termed the Q angle (Fig-ure 12.9) (see pp. 340, 342, Figure 12.12 for furtherdescription).

Observation

The examination should begin in the waiting roombefore the patient is aware of the examiner’s observa-tion. Information regarding the degree of the patient’sdisability, level of functioning, posture, and gait canbe observed. The clinician should pay careful atten-tion to the patient’s facial expressions with regard tothe degree of discomfort the patient is experiencing.The information gathered in this short period couldbe very useful in creating a total picture of the pa-tient’s condition. Note whether the patient is able tosit with the knees flexed to 90 degrees or whetherthe involved knee is extended. This will help you to

understand the degree of discomfort the patient ex-periences with movement and the amount of rangeavailable.

Observe the patient as he or she goes from sit-ting to standing. How difficult is it for the patientto change the position of the knee? Can the patientachieve full extension? Can he or she evenly distributeweight between both lower extremities? Look at thealignment of the hip. Femoral anteversion can causepatellofemoral malalignment syndromes.

Pay attention to the alignment of the knee fromboth the anterior and lateral views. Does the patientappear to have an excessive degree of genu valgumor varum? Genu valgum creates an increase in the Qangle (explained on pp. 340, 342) and is also a causeof patellofemoral malalignment syndromes. IncreasedQ angles can create a predisposition to patella sub-luxation. The patient will also have increased stressplaced on the medial collateral ligament.

Is genu recurvatum present? Note the position ofthe patella. Is a tibial torsion present? Observe thealignment of the feet with and without shoes. Movearound the patient and check the knee for signs ofedema and muscle wasting.

Observe the swing and stance phases of gait, notic-ing the ability to move quickly and smoothly fromflexion to extension. Note any gait deviations andwhether the patient is using or requires an assistivedevice. The details and implications of gait deviationsare discussed in Chapter 14.

Subjective Examination

The knee joint is much more mobile than the hipjoint. However, under normal conditions it is verystable. It is easily susceptible to trauma and degen-erative changes. It is important to note the mecha-nism of injury if the patient has sustained a trauma.The patient may have noticed tearing, popping, orcatching occurring during the incident. Does the pa-tient report any clicking, buckling, or locking? Thedirection of the force, the activity the patient wasparticipating in at the time of the injury, and thetype of shoes he or she was wearing contribute toyour understanding of the resulting problem. Notethe degree of pain, swelling, and disability reportedat the time of the trauma and during the initial24 hours.

You should determine the patient’s functional lim-itations. Is the patient able to ascend and descendsteps without difficulty? Can he or she walk up or

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downhill? Is the patient able to squat or kneel? Canthe patient sit in one position for a prolonged periodof time? Is the patient stiff when he or she arises inthe morning or after sitting?

The patient’s disorder may be related to age, gen-der, ethnic background, body type, static and dy-namic posture, occupation, leisure activities, and gen-eral activity level.

Location of the symptoms may give you some in-sight into the etiology of the complaints. For example,if the pain is located over the anteromedial aspect ofthe knee, it may be coming from a torn medial menis-cus or from an L4 radiculopathy.

(Please refer to Box 2.1, p. 15 for typical questionsfor the subjective examination.)

Gentle Palpation

It is easiest to begin the palpatory examination withthe patient in the supine position since asymmetryis easier to observe with the knee in the extendedposition. You should examine the knee to see if itis swollen, either locally or generally. Note any ar-eas of ecchymosis, bruising, muscle girth asymmetry,bony incongruities, incisional areas, or open wounds.Generalized edema may be secondary to metabolicor vascular disorders. Hypertrophic bone is a sign ofosteoarthritis.

Observe the skin for any dystrophic changes (loss ofhair, decrease in temperature, thickening of the nails)which may indicate the presence of reflex sympatheticdystrophy. You should not have to use deep pressureto determine areas of tenderness or malalignment. Itis important to use a firm but gentle pressure, whichwill enhance your palpatory skills. If you have a soundbasis of cross-sectional anatomy, you will not need tophysically penetrate through several layers of tissueto have a good sense of the underlying structures.Remember that if you increase the patient’s pain atthis point in the examination, the patient will be veryreluctant to allow you to continue, or may becomemore limited in his or her ability to move.

Palpation is most easily performed with the patientin a relaxed position. Although palpation can be per-formed with the patient standing, non-weight-bearingpositions are preferred. The sitting position with thepatient’s leg hanging over the edge of the examiningtable allows for optimal palpation of the knee region.It provides easy access to all aspects of the joint andexposes the joint lines secondary to the traction force

that is offered by gravity. The examiner should sit ona rolling stool and face the patient.

Anterior Aspect

Bony Structures

PatellaThe patella is very superficial and easily located on theanterior surface of the knee. This large sesamoid bonecan be situated in a superior, inferior, medial, or lat-eral direction, instead of the normal resting position,while the knee is positioned in extension. The patellatracks within the trochlear groove. Its resting positionshould be at the midpoint on a line drawn between thefemoral condyles. The patella and its tendon shouldbe of equal length with the knee in extension, withoutany muscle contraction.

The patella may be superiorly displaced (patellaalta), inferiorly displaced (patella baja), medially dis-placed (squinting patella), and laterally displaced(bullfrog’s, fish, grasshopper eyes) (Figure 12.10).Squinting patella can be caused by medial femoralor lateral tibial torsion.

The patella should lie flat when viewed from thelateral and superior aspects. Medial and lateral tiltscan produce abnormal wear on the posterior aspectof the patella and its cartilage, causing patellofemoralcompression syndrome. With the patient sitting, theinferior pole of the patella should be at the same levelas the tibiofemoral joint line.

Tenderness to palpation can be secondary to a con-tusion or fracture of the patella following a directinsult. Pain, swelling, and tenderness at the inferiorpole of the patella in an adolescent may indicateLarsen–Johansson disease (osteochondritis of the in-ferior pole). Pain with patellar compression may beindicative of chondromalacia patellae.

The trochlear groove is the channel in which thepatella glides. It is partially palpable with the kneein flexion. This causes the patella to be inferiorly dis-placed. Place your thumbs superior to the most cranialportion of the patella between the medial and lateralfemoral condyles and you will palpate an indenta-tion, which is the trochlear groove (Figure 12.11).The patella is stabilized within the trochlea by virtueof the surface geometry and the patellofemoral liga-ments called plicae.

This is an appropriate time to measure the Q(quadriceps) angle. Draw a line between the ante-rior superior iliac spine and the center of the patella.Draw a second line between the center of the patella

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Patella baja Patella altaNormal patella

Squinting patella Bullfrog eyes

Figure 12.10 Patella alta, baja, squinting, and bullfrog eyes.

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MedialcondyleLateral

condyle

Trochleargroove

Figure 12.11 Palpation of the trochlear groove.

and the tibial tubercle. Measure the angle formed bythe intersection of the two lines (Figure 12.12). Nor-mal findings should be between 10 and 15 degrees inmales and 10–19 degrees in females. The tibial tuber-

Q angle

Patella

Tibial tubercle

Figure 12.12 Measurement of the Q angle.

cle should line up with the midline or the lateral halfof the patella in the sitting position. Therefore, the Qangle should be 0 degree when the patient is in thesitting position.

Tibial TuberosityPlace your fingers on the midpoint of the inferior poleof the patella. Approximately 2 in. caudad to thatpoint is a superficial prominence, which is the tib-ial tuberosity. This serves as the attachment for theinfrapatellar ligament (Figure 12.13). If the tibial tu-bercle is excessively prominent, the patient may havehad osteochondrosis of the tibial apophysis (Osgood–Schlatter disease).

Soft-Tissue Structures

Quadriceps MusclePlace your fingers over the anterior aspect of the thighand palpate the large expanse of the quadriceps mus-cle. This four-muscle group attaches to the superioraspect of the patella. The muscle bulk is most obvi-ous with isometric contraction of the knee in exten-sion. The vastus medialis and lateralis are the mostprominent of the muscles, with the medialis extend-ing slightly more inferiorly. Vastus medialis obliquusatrophy is very common following knee trauma,

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Tibial tubercle

Figure 12.13 Palpation of the tibial tubercle.

immobilization, or surgery. It is helpful to observe andthen palpate both knees simultaneously for compar-ison. Both muscles should be symmetrical and with-out any visible defect. You can compare the girthmeasurements using a tape measure. Thigh girth maybe increased secondary to edema or decreased dueto atrophy. Measurements should be taken at regu-lar intervals bilaterally starting approximately 3 in.proximally to the superior pole of the patella (Figure12.14). A focal point of tenderness or a lump in themuscle can be caused by a strain, hematoma or tumor.

Patellar (Infrapatellar) Ligament (Tendon)Place your hands on the medial inferior aspect of thepatella and palpate the bandlike structure runninginferiorly to the tibial tubercle. The infrapatellar fatpad is situated immediately posterior to the ligamentand may be tender to palpation. Inflammation of thefat pad creates a generalized effusion and is readilyvisible (Figure 12.15). Tenderness of the tendon maybe secondary to patellar tendinitis (jumper’s knee),which is related to overuse.

BursaeBursae are not commonly palpable unless they areinflamed and enlarged. However, since bursitis is a

3"

Figure 12.14 Measurement of thigh girth.

Patellarligament

Tibial tubercle

Figure 12.15 Palpation of the patellar ligament.

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Prepatellarbursa

Superficialinfrapatellarbursa

Deep infrapatellarbursa

Pes anserinebursa

Figure 12.16 Location of the bursae of the knee.

common occurrence in the knee, you should familiar-ize yourself with their anatomical locations. Inflam-mation of any of these bursae will create localizedeffusions, which are easily palpable.

The prepatellar bursa is located just anterior to thepatella. This bursa creates greater freedom of move-ment of the skin covering the anterior aspect of thepatella. Inflammation of the prepatellar bursa can becaused by excessive kneeling and is referred to ashousemaid’s/carpenter’s knee.

The superficial infrapatella bursa is located just an-terior to the patella ligament. Inflammation can occursecondary to prolonged kneeling and is referred to asParson’s knee.

The deep infrapatella bursa is located directly be-hind the patellar ligament (Figure 12.16).

Medial Aspect

Bony Structures

Medial Femoral CondylePlace your thumbs on either side of the infrapatellarligament and allow them to drop into the indenta-tion. This places you at the joint line. Allow yourfingers to move medially and superiorly first overthe sharp eminence and then allow your fingers totravel over the smooth rounded surface of the medialfemoral condyle. The medial femoral condyle is widerand protrudes more than the lateral femoral condyle

Medialcondyle

Figure 12.17 Palpation of the medial femoral condyle.

(Figure 12.17). Localized tenderness may be sec-ondary to osteochondritis dissecans.

Adductor TubercleAllow your fingers to move further cranially from themidline of the medial femoral condyle, and at the verytop of the dome you will be on the adductor tubercle.You will know that you are in the correct place ifthe adductors are isometrically contracted and youcan palpate their attachment at the tubercle (Figure12.18). Tenderness can be secondary to an adductormagnus strain.

Medial Tibial PlateauAllow your fingers to rest in the indentation medialto the infrapatellar ligament and press in a poste-rior and inferior direction. You will feel the eminencealong the edge of the medial tibial plateau as your fin-gers move medially along the joint line (Figure 12.19).The coronary ligaments are located along the antero-medial joint line. They are more easily palpated withthe tibia passively internally rotated, which allows themedial border of the tibia to move anteriorly.

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Adductor tubercle

Figure 12.18 Palpation of the adductor tubercle.

Figure 12.19 Palpation of the medial tibial plateau.

Soft-Tissue Structures

Medial MeniscusThe medial meniscus is located between the medialfemoral condyle and the medial tibial plateau. It isanchored by the coronary ligaments and attached tothe medial collateral ligament. The meniscus is pulledanteriorly by the medial femoral condyle as the tibiais internally rotated, making it slightly more accessi-ble to palpation (Figure 12.20). If an injury causes atearing of the medial meniscus, tenderness to palpa-tion will be noted along the joint line. Tears in themedial meniscus are very common. They may be cou-pled with injury to the medial collateral and anteriorcruciate ligaments.

Medial Collateral LigamentThe medial collateral ligament is attached from themedial epicondyle of the femur to the medial condyleand shaft of the tibia. The ligament is not easily pal-pable since it is very flat. You can approximate itsgeneral location by following the joint line with yourfingers moving in an anterior and then posterior di-rection. The ligament will obliterate the midjoint line(Figure 12.21). The medial collateral ligament is re-sponsible for the valgus stability of the knee joint. Itcan be easily injured by a force directed at the lateral

Medialmeniscus

Figure 12.20 Palpation of the medial meniscus.

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Medialcollateralligament

Figure 12.21 Palpation of the medial collateral ligament.

aspect of the knee (valgus strain). A lesion of the up-per border of the ligament with subsequent periostealdamage is known as Pellegrini–Stieda disease.

Sartorius, Gracilis, and Semitendinosus Muscles(Pes Anserinus)The pes anserinus is located on the posteromedial as-pect of the knee, attaching to the inferior portion ofthe medial tibial plateau approximately 5–7 cm belowthe joint line. This common aponeurosis of the ten-dons of gracilis, semitendinosus, and sartorius mus-cles adds additional support to the medial aspect ofthe knee joint and protects the knee during valgusstress. Place your hand medial and slightly posteriorto the tibial tubercle. You will feel a bandlike struc-ture that becomes evident. Stabilize the patient’s legby holding it between your knees. Resist knee flex-ion by using your legs as the resistance to make thetendons more evident (Figure 12.22). The semitendi-nosus tendon is palpated as a cordlike structure, lo-cated at the medial posterior aspect of the knee.

Anserine BursaThe pes anserine bursa is located between the tibiaand the insertion of the pes anserine aponeurosis. Like

Figure 12.22 Palpation of the pes anserinus.

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the other bursae in the knee, it is not readily palpableunless it is inflamed, in which case it will feel swollenand boggy.

Lateral Aspect

Bony Structures

Lateral Femoral CondylePlace your fingers on either side of the infrapatellarligament and allow them to drop into the indentation.This places you at the joint line. Allow your fingersto move in a lateral and superior direction until youreach the eminence of the lateral femoral condyle. Ifyou continue to move laterally along the joint linewith the tibia, you will feel the popliteus tendon andattachment, and then a groove. You will then palpatea flat, almost concave surface of the condyle (Figure12.23).

Lateral Femoral EpicondyleAs you continue to move laterally past the concav-ity of the lateral femoral condyle, you will feel theprominence of the lateral femoral epicondyle (Figure12.24).

Lateral femoralcondyle

Figure 12.23 Palpation of the lateral femoral condyle.

Lateralfemoralepicondyle

Figure 12.24 Palpation of the lateral femoral epicondyle.

Lateral Tibial PlateauAllow your fingers to rest on the lateral aspect ofthe infrapatella ligament and press in a posterior andinferior direction. You will feel the eminence alongthe edge of the lateral tibial plateau as your fingersmove laterally along the joint line (Figure 12.25).

Lateral Tubercle (Gerdy’s Tubercle)Place your fingers on the lateral tibial plateau andmove inferiorly. You will locate a prominence justlateral to the tibial tubercle. This is the lateral tubercle(Figure 12.26). This can be tender at the insertion ofthe iliotibial band.

Fibular HeadPlace your middle finger over the lateral femoral epi-condyle. Allow your finger to move in an inferiordirection crossing the joint line and you will locatethe fibular head and move your fingers in a superiordirection and you will feel a bandlike structure stand-ing away from the joint (Figure 12.27). The popliteusmuscle is located underneath the lateral collateral lig-ament and separates the ligament from the lateralmeniscus (Figure 12.28). The popliteus can be pal-pated, after a groove, slightly posterior to the lateralcollateral ligament along the joint line. The lateral

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Lateral tibialplateau

Figure 12.25 Palpation of the lateral tibial plateau.

Lateral tubercle

Figure 12.26 Palpation of the lateral tibial tubercle.

Fibular head

Figure 12.27 Palpation of the fibular head.

Lateralcollateralligament

Popliteusmuscle

Lateralmeniscus

Figure 12.28 Palpation of the lateral meniscus.

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Lateralcollateral ligament

Figure 12.29 Palpation of the lateral collateral ligament.

collateral ligament is responsible for the varus sta-bility of the knee joint. It can be injured when theindividual sustains a medial force to the knee. If asprain has occurred, the ligament will be tender topalpation (Figure 12.29).

Iliotibial TractThe iliotibial tract is a strong band of fascia that isattached superiorly to the iliac crest. It ensheathes the

Iliotibial tractTensor fascia latae

Gluteusmaximus Gerdy’s tubercle

Figure 12.30 Palpation of the iliotibial band.

tensor fasciae latae and a large part of the gluteusmaximus inserts into it. Inferiorly, it attaches to thelateral condyle of the tibia (Gerdy’s tubercle) where itblends with an aponeurosis from the vastus lateralis.You can locate it by placing your hand on the band,which is visible on the anterolateral aspect of the kneewhen the knee is extended (Figure 12.30). It is tightestwhen the knee is flexed between 15 and 30 degrees.

Common Peroneal NervePlace your fingers along the posterior aspect of thefibular head. Allow your fingers to travel behind thehead, just below the insertion of the biceps femoris.The common peroneal nerve is very superficial andyou can roll it under your fingers. Remember not toapply too much pressure because you can induce aneurapraxia. The nerve can normally be tender topalpation. Enlargement of the nerve is commonlynoted in Charcot–Marie–Tooth disease. Damage tothe common peroneal nerve will cause a foot drop,creating difficulty during the heel strike and swingphases of gait (Figure 12.31).

Posterior Aspect

Bony Structure

There are no bony structures that are best palpatedon the posterior aspect.

Soft-Tissue Structures

Biceps FemorisHave the patient lie in the prone position withthe knee flexed. The biceps femoris will become

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350 The Knee Chapter 12

Figure 12.31 Location of the common peroneal nerve.

a prominent cordlike structure that is easily palpableproximal to its attachment to the fibular head. Youcan increase its prominence by providing resistance toknee flexion (Figure 12.32).

Biceps femoris

Figure 12.32 Palpation of the biceps femoris.

Gastrocnemius

Figure 12.33 Palpation of the gastrocnemius.

GastrocnemiusThe gastrocnemius muscle is palpable on the poste-rior surface of the medial and lateral femoral condyleswith the patient in the prone position and the kneeextended. The muscle can be made more distinct byresisting either knee flexion or ankle plantar flexion.The muscle belly is located further distally over themid portion of the posterior aspect of the tibia. Ten-derness can be indicative of a strain of the muscle.Localized tenderness and effusion can be indicativeof a deep venous thrombosis (Figure 12.33).

Popliteal FossaThe popliteal fossa is formed on the superior aspect bythe biceps femoris on the lateral side, and the tendonsof the semimembranosus and semitendinosus on themedial side. The inferior aspect is defined by the twoheads of the gastrocnemius (Figure 12.34).

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Popliteal fossaBicepsfemoris

Semimembranosus

Semitendinosus

Figure 12.34 The popliteal fossa.

Popliteal Vein, Artery, and NerveThe popliteal nerve is the most superficial structurepassing within the popliteal fossa. This structure is notnormally palpable. Deep to the nerve, the poplitealvein is located and is also not normally palpable. Thepopliteal artery is the deepest of the structures andcan be palpated with deep, firm pressure through thesuperficial fascia. The popliteal pulse is much easierto palpate when the knee is flexed between 60 and 90degrees, relaxing the muscle and connective tissue.

A comparison should be made between the dorsalispedis and tibialis posterior pulses to rule out vascularcompression. If you palpate an irregular lump on theartery, it may be an aneurysm.

Semimembranosus MuscleThe major insertion of the semimembranosus tendonis at the posteromedial aspect of the tibia, 1 cm distalto the joint line of the knee. The tendon is about 6mm in diameter and is surrounded by a large synovialsleeve. Because of its proximity to the medial jointline, inflammation of the tendon and/or its sheath canbe misinterpreted as medial joint line pain. Semimem-branosus inflammation may be the result of repetitiveor excessive stretching of the muscle.

Baker's cyst

Figure 12.35 Baker’s cyst.

Gastrocnemius–Semimembranosus BursaThe gastrocnemius–semimembranosus bursa is lo-cated in the popliteal fossa. It is not normally pal-pable unless it becomes inflamed. It is then known asa Baker’s cyst. It is more easily visible and palpableif the patient’s knee is in extension. The cyst is eas-ily moveable and is normally painless (Figure 12.35).Any type of knee effusion can cause a Baker’s cyst todevelop.

Trigger Points

Trigger points of the quadriceps and hamstring mus-cles can refer pain distally to the knee. Common trig-ger point locations for these muscles are illustrated inFigures 12.36 and 12.37.

Active Movement Testing

The two major movements of the knee joint are flex-ion and extension on the transverse axis. Internaland external rotation on the vertical axis can also be

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Semitendinosus

Biceps femoris(both heads)

Figure 12.36 Trigger points in the right hamstring muscle are represented by the X’s. Referred pain pattern distributions arerepresented by the stippled regions. (Adapted with permission from Travell and Rinzler, 1952.)

Vastus medialis

Figure 12.37 Trigger points in the quadriceps muscle are depicted above. The stippled regions are areas of referred pain from thetrigger points, noted by the X’s. (Adapted with permission from Travell and Rinzler, 1952.)

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performed with the knee in 90 degrees of flexion. Toaccomplish the full range of flexion and extension,the tibia must be able to rotate. These are designed tobe quick, functional tests designed to clear the joint.If the motion is pain free at the end of the range,you can add an additional overpressure to “clear”the joint. If the patient experiences pain during anyof these movements, you should continue to explorewhether the etiology of the pain is secondary to con-tractile or noncontractile structures by using passiveand resistive testing.

A quick screening examination of the movementscan be accomplished by asking the patient to per-form a full, flat-footed squat and then to return tofull extension. Flexion of the knee can also be ac-complished in the prone position, during which thepatient is asked to bend the knee toward the buttockand then return the leg to the table. Internal and ex-ternal rotation can be observed by asking the patientto turn the tibia medially and then laterally while heor she is in the sitting position with the legs danglingoff the edge of the table.

Passive Movement Testing

Passive movement testing can be divided into twocategories: physiological movements (cardinal plane),which are the same as the active movements, and mo-bility testing of the accessory movements (joint play,component). You can determine whether the noncon-tractile (inert) elements are the cause of the patient’sproblem by using these tests. These structures (liga-ments, joint capsule, fascia, bursa, dura mater, andnerve root) (Cyriax, 1979) are stretched or stressedwhen the joint is taken to the end of the availablerange. At the end of each passive physiological move-ment, you should sense the end feel and determinewhether it is normal or pathological. Assess the lim-itation of movement and see if it fits into a capsularpattern. The capsular pattern of the knee is a greaterrestriction of flexion than extension so that with 90degrees of limited flexion there is only 5 degrees oflimited extension. Limitation of rotation is only notedwhen there is significant limitation of flexion and ex-tension (Kaltenborn, 1999).

Physiological Movements

You will be assessing the amount of motion availablein all directions. Each motion is measured from the

anatomical starting position, which is the knee ex-tended with the longitudinal axes of both the femurand tibia in the frontal plane. They normally meet atan angle of 170 degrees (Kaltenborn, 1999).

Flexion

The best position for measuring flexion is the proneposition with the patient’s foot over the edge of the ta-ble. If the rectus femoris appears to be very shortened,you should place the patient in the supine position.Place your hand over the distal anterior aspect of thetibia and bend the leg toward the buttock. The normalend feel for this movement is soft tissue from the con-tact between the gastrocnemius and the hamstrings.If the rectus femoris is the limiting factor, the endfeel is abrupt and firm (ligamentous) (Magee, 2002;Kaltenborn, 1999). Normal range of motion is 0–135degrees (American Academy of Orthopedic Surgeons,1965) (Figure 12.38).

Extension

Full extension is achieved when the patient is placedin either the prone or the supine position. The nor-mal end feel is abrupt and firm (ligamentous) be-cause of tension in the posterior capsule and liga-ments (Magee, 2002; Kaltenborn, 1999). The normalrange of motion is 0 degree (Figure 12.39) (AmericanAcademy of Orthopedic Surgeons, 1965).

Medial and Lateral Rotation

You can measure medial and lateral rotation with thepatient either in the sitting position with the leg dan-gling off the end of the table or in the prone positionwith the knee flexed. Place your hand over the distalpart of the leg, proximal to the ankle joint, and ro-tate the tibia first in a medial direction to the end ofthe available range, back to the midline, and then ina lateral direction to the end of the available range.The normal end feel is abrupt and firm (ligamentous)(Magee, 2002; Kaltenborn, 1999). Normal range ofmotion is 20–30 degrees of medial rotation of thetibia and 30–40 degrees of lateral rotation of the tibia(Magee, 2002) (Figure 12.40).

Mobility Testing of AccessoryMovements

Mobility testing of accessory movements will give youinformation about the degree of laxity present in the

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Figure 12.38 Passive flexion of the knee.

Figure 12.39 Passive extension of the knee.

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Lateralrotation

Medialrotation

Figure 12.40 Passive lateral and medial rotation of the tibia.

joint. The patient must be totally relaxed and com-fortable to allow you to move the joint and obtainthe most accurate information. The joint should beplaced in the maximal loose-packed (resting) positionto allow for the greatest degree of joint movement.The resting position of the knee is 25 degrees of flex-ion (Kaltenborn, 1999).

Traction

Place the patient in the supine position with the hipflexed to approximately 60 degrees and the kneeflexed approximately 25 degrees. Stand to the sideof the patient, facing the lateral aspect of the leg to betested. Stabilize the femur by grasping the distal me-dial aspect of the femur with your index finger at thejoint line, to enable you to palpate. Stabilize the legagainst your trunk. Hold the distal end of the tibia,proximal to the malleoli from the medial aspect. Pullthe tibia in a longitudinal direction producing tractionin the tibiofemoral joint (Figure 12.41).

Figure 12.41 Traction of the tibiofemoral joint—mobilitytesting.

Ventral Glide of the Tibia

Place the patient in the supine position with the kneeflexed to approximately 90 degrees. Stand on the sideof the patient, with your body facing the patient. Youcan rest your buttock on the patient’s foot to stabilizeit. Place your hands around the tibia, allowing yourthumbs to rest on the medial and lateral joint lines,to enable you to palpate the joint line. Pull the tibiain an anterior direction until all the slack has beentaken up. This not only tests for anterior mobility ofthe femoral tibial joint, but also tests for the integrityof the anterior cruciate ligament. The test for the an-terior cruciate ligament is referred to as the anteriordrawer test (Figure 12.42).

Medial and lateral rotation of the tibia can be addedto the anterior drawer test to check for rotationalinstability. Medial rotation increases the tension inthe intact posterolateral structures and decreases thedegree of anterior displacement. Lateral rotation in-creases the tension in the intact posteromedial struc-tures and decreases anterior displacement of the tibiaeven when the anterior cruciate ligament is compro-mised (Figure 12.43) (see pp. 367–368, Figure 12.70).

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Figure 12.42 Anterior drawer test.

Posterior Glide of the Tibia

Place the patient in the supine position with the kneeflexed to approximately 90 degrees. Stand on the sideof the patient, with your body facing the patient. Youcan rest your buttock on the patient’s foot to stabilize

Figure 12.43 Anterior drawer test with medial and lateralrotation.

it. Place your hands around the tibia so that the heelsof your hands are resting on the medial and lateraltibial plateaus and your fingers are wrapped aroundthe medial and lateral joint spaces. Push the tibia in aposterior direction until all the slack has been takenup. This not only tests for posterior mobility of thefemoral tibial joint, but also tests for the integrity ofthe posterior cruciate ligament. The test for the pos-terior cruciate ligament is referred to as the posteriordrawer test or the gravity test (Figure 12.44). Medialand lateral tibial rotation can be added to check forposterior medial and lateral stability and is known asHughston’s Draw sign (Magee, 2006).

Medial and Lateral Gapping (Varus–Valgus Stress)

Place the patient in the supine position, and stand onthe side of the table and face the patient. Hold the pa-tient’s ankle between your elbow and trunk to securethe leg. Extend your arm proximally to the joint spaceon the medial aspect of the knee, allowing you to pal-pate. Place your other hand on the distal lateral aspectof the patient’s femur, as the stabilizing force. Allowthe patient’s knee to flex approximately 30 degrees.Apply a valgus force to the knee by pulling the distalaspect of the tibia in a lateral direction while main-taining your stabilization on the lateral part of thefemur. This will create a gapping on the medial side

Figure 12.44 Posterior drawer test.

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of the knee joint. You should expect to feel a nor-mal abrupt and firm (ligamentous) end feel (Magee,2002; Kaltenborn, 1999). If there is increased gap-ping, a different end feel, or a “clunk” as you re-lease, you should suspect a loss of integrity of themedial collateral ligament. This procedure should berepeated with the patient’s knee in extension. If youhave a positive finding in both the flexed and the ex-tended position, involvement of the posterior cruciateligament in addition to the medial collateral ligamentshould be suspected (Figure 12.45).

To test the integrity of the lateral collateral liga-ment, the same test should be repeated by reversingyour hand placements. This will allow you to createa varus force, creating gapping on the lateral aspectof the knee joint (Figure 12.46).

Medial and Lateral Glide of the Tibia

Place the patient in the supine position so that theknee is at the end of the table. Face the patient andsecure the ankle between your legs. Place your stabi-lizing hand on the distal medial aspect of the femurjust proximal to the joint line. Your mobilizing handshould be on the proximal lateral part of the tibia justdistal to the joint line. Use your mobilizing hand topush in a medial direction until all the slack has beentaken up. You should feel an abrupt and firm (liga-

mentous) end feel (Magee, 2002; Kaltenborn, 1999).This tests for normal mobility of medial glide of thetibia (Figure 12.47).

Testing for normal mobility of lateral glide can beassessed in the same manner by reversing your handplacements (Figure 12.48).

Patellar Mobility

Place the patient in the supine position, with a smalltowel placed underneath the knee to avoid full ex-tension. Stand on the stand of the table, facing thepatient. With both hands, grasp the patella betweenyour thumb and index and middle fingers. Distractthe patella by lifting it away from the femur (Figure12.49).

Stand so that you are facing the lateral aspect ofthe patient’s lower extremity. Place your extendedthumbs on the lateral aspect of the patella. Push yourthumbs simultaneously in a medial direction. This willcreate medial glide of the patella (Figure 12.50). Lat-eral glide can be accomplished by placing your handson the medial aspect of the patella. The patella shouldmove approximately one-half its width in both medialand lateral glides in extension. The lateral glide is eas-ier to perform and has a greater excursion than themedial glide (Figure 12.51). Inferior glide can be ac-complished by turning so that you face the patient’s

Figure 12.45 Valgus strain (medial gapping).

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358 The Knee Chapter 12

(b)

(a)

Figure 12.46 (a) Varus strain (lateral gapping). (b) Varus strain with flexion of the knee.

foot. Place the heel of one hand over the superior poleof the patella, allowing your arm to rest on the pa-tient’s thigh. Place your other hand on top of thefirst hand and push in an inferior (caudad) direc-tion (Figure 12.52). This will test inferior mobilityof the patella. It is important to remember not to cre-ate any compressive forces on the patella during theglide.

Resistive Testing

The primary movements of the knee to be examinedare flexion and extension. Resisted internal and exter-nal rotation of the tibia can also be tested. The abilityto resist rotational forces is especially important whendamage has occurred to the ligamentous stabilizers ofthe knee.

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Figure 12.47 Medial glide of the tibia—mobility testing.

Figure 12.48 Lateral glide of the tibia—mobility testing.

Figure 12.49 Distraction of the patella—mobility testing.

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360 The Knee Chapter 12

Figure 12.50 Medial glide of the patella—mobility testing.

Figure 12.51 Lateral glide of the patella—mobility testing.

Figure 12.52 Inferior glide of the patella—mobility testing.Remember not to compress the patella.

Flexion

The flexors of the knee are the hamstrings—semitendinosus, biceps femoris, and semimembra-nosus (Figure 12.53). The hamstrings are assisted bythe sartorius, gracilis, and popliteus muscles. Exceptfor the popliteus muscle, all the knee flexors cross thehip as well. As the hip is flexed, the strength of thehamstrings as knee flexors increases.� Position of patient: Prone with the hip in neutral

(Figure 12.54).� Resisted test: Ask the patient to bend the knee so

as to bring the heel toward the buttock. Resist themovement by placing one hand posteriorly abovethe ankle. Stabilize the patient’s thigh downwardwith the other hand. Note: Medial and lateralhamstrings may be relatively isolated by rotatingthe thigh and leg medially to test the medialhamstrings and laterally to test the lateralhamstrings.Testing knee flexion with gravity eliminated is per-

formed in the same manner, except that the patient isin the side-lying position (Figure 12.55).

Painful resisted knee flexion may be due to tendini-tis of the hamstring muscles or the muscles of the pesanserinus. A popliteal (Baker’s) cyst may also causepain during knee flexion.

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361Chapter 12 The Knee

Bicepsfemoris

Semitendinosus

Semimembranosus

Figure 12.53 The primary knee flexors. Note that the long headof the biceps is innervated by the tibial portion of the sciaticnerve and the short head of the biceps femoris is innervated bythe peroneal portion of the sciatic nerve.

Figure 12.54 Testing knee flexion.

Figure 12.55 Testing knee flexion with gravity eliminated.

Weakness of knee flexion results in an abnormalgait. A hyperextension deformity of the knee may re-sult from lack of dynamic stability. Isolated weaknessof the medial or lateral hamstrings will result in kneeinstability on the same side of the joint as the weak-ness. For example, weakness of the lateral hamstringscauses a tendency toward varus deformity of the kneeon weight bearing.

Extension

The primary extensor of the knee is the quadricepsfemoris muscle (Figure 12.56). The rectus femoris alsocrosses the hip as well and assists in hip flexion.� Position of patient: Sitting with the legs hanging

over the edge of the table. Place a rolled towel orsmall pillow under the patient’s knee and distalpart of the thigh to act as a cushion(Figure 12.57).

� Resisted test: Ask the patient to extend the kneewhile applying downward pressure with yourhand above the ankle.Testing knee extension with gravity eliminated is

performed with the patient lying on the side and theknee initially bent. The patient attempts to extendthe knee while the leg is resting on the table (Figure12.58).

Painful resisted knee extension may be due to patel-lar tendinitis, also known as jumper’s knee. Disor-ders of the patellofemoral joint may also be painful ifknee extension is tested in a position of extreme kneeflexion. This position increases the force within thepatellofemoral joint.

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362 The Knee Chapter 12

Rectusfemoris

Vastusintermedius

Vastusmedialis

Vastus lateralis

Figure 12.56 The primary extensors of the knee. Note that therectus femoris muscle also crosses the hip joint and acts as a hipflexor as well as a knee extensor.

Weakness of knee extension causes difficulty in get-ting out of a chair, climbing stairs, and walking up anincline. An abnormal gait also results.

Figure 12.57 Testing knee extension.

Figure 12.58 Testing knee extension with gravity eliminated.

Rotation

The medial hamstrings, sartorius, gracilis, and popli-teus muscles are medial rotators of the tibia (Figure12.59). This rotation occurs as the knee is unlockedfrom its extended position during initiation of kneeflexion.

The lateral rotators of the tibia are the bicepsfemoris and tensor fasciae latae muscles (see Figure12.59). All the rotators of the knee act as dynamicstabilizers in conjunction with the ligaments.

Medial hamstrings

Sartorius

Popliteus

Gracilis

Figure 12.59 The medial rotators of the knee.

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363Chapter 12 The Knee

Figure 12.60 Testing medial and lateral rotation of the knee.

� Position of patient: Sitting upright with the kneesbent over the edge of the table (Figure 12.60).

� Resisted test: Take the tibia with both hands andask the patient to attempt to rotate it. Have thepatient twist the tibia medially and then laterallyas you resist this movement.

Neurological Examination

Motor

The innervation and spinal levels of the muscles thatfunction across the knee joint are listed in Table 12.1.

Table 12.1 Movements of the knee: the muscles and their nerve supply, as well as their nerve root derivations are shown.

Movement Muscles Innervation Root levels

Flexion of knee 1 Biceps femoris Sciatic L5, S1, S22 Semitendinosus Sciatic L5, S1, S23 Semimembranosus Sciatic L5, S14 Gracilis Obturator L2, L35 Sartorius Femoral L2, L36 Popliteus Tibial L4, L5, S17 Gastrocnemius Tibial S1, S2

Extension of knee 1 Rectus femoris Femoral L2, L3, L42 Vastus medialis Femoral L2, L3, L43 Vastus intermedius Femoral L2, L3, L44 Vastus lateralis Femoral L2, L3, L4

Medial rotation of flexed leg 1 Popliteus Tibial L4, L5, S12 Semimembranosus Sciatic L5, S13 Sartorius Femoral L2, L34 Gracilis Obturator L2, L35 Semitendinosus Sciatic L5, S1, S2

Lateral rotation of flexed leg 1 Biceps femoris Sciatic L5, S1, S2

Reflexes

Knee Jerk

The knee jerk is performed to test the L3 and L4 nerveroots (Figure 12.61). To test the knee jerk, place thepatient in the supine position. Elevate the leg behindthe knee with one hand so that it is flexed approx-imately 20–30 degrees. Take the reflex hammer andtap the patellar tendon below the patella to observethe response. Look for contraction of the quadricepsmuscle with or without elevation of the foot fromthe table. Perform the test bilaterally for comparison.Loss of this reflex may be due to a radiculopathy ofthe L3 or L4 nerve roots, or damage to the femoralnerve or quadriceps muscle.

Hamstring Jerk

The medial and lateral hamstring reflexes are per-formed to test the L5–S1 (medial hamstring) and S1and S2 (lateral hamstring) root levels (Figure 12.62).The patient is prone with the knee flexed and theleg supported. Place your thumb over the medial orlateral hamstring tendon and tap your thumb withthe reflex hammer. Look for contraction of the ham-string muscle exhibited by knee flexion. Compareboth sides.

Sensation

Light touch and pinprick sensation should be exam-ined after the motor examination. The dermatomes

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364 The Knee Chapter 12

Figure 12.61 The patient is positioned for the patellar reflex.The reflex can also be obtained with the patient seated, bytapping on the patellar tendon with the knee flexed.

for the anterior aspect of the knee are L2 and L3.Please refer to Figure 12.63 for the exact locations ofthe key sensory areas of these dermatomes. We haveincluded dermatome drawings from more than oneanatomy text to emphasize the variability that existsamong patients and anatomists. The peripheral nervesproviding sensation in the knee region are shown inFigure 12.64.

Infrapatellar Nerve Injury

The infrapatellar branch of the saphenous nerve maybe cut during surgery of the knee. Tinel’s sign may beobtained by tapping on the medial aspect of the tibialtubercle (Figure 12.65). A positive response would betingling or tenderness.

Referred Pain Patterns

Pain in the region of the knee may be referred fromthe ankle and hip. Pain in the knee that is referredfrom the hip is usually felt medially. An L3, L4, orL5 radiculopathy can also be perceived as pain in theknee (Figure 12.66).

Figure 12.62 Testing the medial and lateral hamstring reflexes is performed with the patient in this position.

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365Chapter 12 The Knee

Keysensoryareas

S2

S1

L5

L3L2

Medial view

Figure 12.63 The dermatomes in the region of the knee. Note that the key sensory area for L3 is medial to the patella. The keysensory area for S2 is depicted in the popliteal fossa. The key sensory area for S1 is located distal to the lateral malleolus and calcaneus.

Obturatornerve

Medial intermediatecutaneous nerve of

the thigh

Medial cutaneous nerveof the thigh (femoral)

Saphenous nerve (femoral)

Posterior cutaneousnerve of the thigh

Lateral cutaneous nerve of the thigh

Lateral cutaneous nerve of the calf (peroneal)

Superficial peroneal nerve

Figure 12.64 The nerve distributions to the skin of the anteriorand posterior aspects of the thigh and leg.

Special Tests

Flexibility Tests

An estimation of quadriceps flexibility can be per-formed by asking the patient to take the lower legwith one hand and bend the knee and foot behindhim or her so as to bring the heel toward the buttocks(Figure 12.67). The patient may compensate for atight rectus femoris by rotating the pelvis anteriorlyand flexing the hip. Hamstring flexibility is describedin Chapter 11.

Tests for Stability and StructuralIntegrity

There is an abundance of testing procedures with as-sociated eponyms that have been developed in an ef-fort to test the stability of the anterior and posteriorcruciate ligaments in various planes. Some of the morecommonly used tests are described in this section. Aclear understanding of the functional anatomy of thecruciate ligaments is necessary in order to appreciatethe purpose of the various tests. Many of the tests

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366 The Knee Chapter 12

Infrapatellar branch of saphenous nerve

Figure 12.65 The infrapatellar branch of the saphenous nervecan be injured during surgery. This will cause numbness ortingling in the distribution of this nerve medial to the patella.Tapping the region of the nerve with a reflex hammer will causea tingling sensation, known as Tinel’s sign.

Figure 12.66 Pain may be referred to and from the knee.

Figure 12.67 The patient is shown stretching the quadricepsmuscle and displaying normal flexibility of the muscle.

reveal subtle responses and require a great deal ofexperience to interpret (Figure 12.68).

Anterior Stability Tests

In testing the anterior and posterior cruciate liga-ments, you should first examine the patient for ante-rior and posterior instability of the tibia. This can beaccomplished with the anterior drawer and posteriordrawer tests, which are performed with the knee in 90degrees of flexion. These tests were described earlierin this chapter (see pp. 355–356, Figure 12.43).

Lachman Test

This test is used to elicit excessive anterior movementof the tibia that results from damage to the anteriorcruciate ligament. The test is performed with the pa-tient in the supine position and the knee flexed toabout 30 degrees. Use one hand to stabilize the thighwhile trying to displace the tibia anteriorly. A pos-itive test result implies damage to the anterior cru-ciate ligament (Figure 12.69). As with all tests ofstability, you must examine the opposite side forcomparison.

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367Chapter 12 The Knee

Anterior

Anterolateralinstability

ACL

ITB

Lateral

LCL

PT

LG

Posterolateralinstability

PCL

MG

PosteriorPOL

Posteromedialinstability

MedialSG

SMST

Anteromedialinstability MCL

(deep layer)

MCL(superficiallayer)

Figure 12.68 Knee instability. ACL, anterior cruciate ligament;PCL, posterior cruciate ligament; MCL, medial collateralligament; LCL, lateral collateral ligament; G, gracilis; PT,popliteus tendon; ITB, iliotibial band; SM, semimembranosus;ST, semitendinosus; MG, medial head of gastrocnemius; LG,lateral head of gastrocnemius; S, sartorius. This figure wasoriginally published in Magee DJ. Orthopedic PhysicalAssessment, 4th edn. Philadelphia: WB Saunders, 2002Copyright Elsevier.

Anterior Medial and Lateral InstabilityTests

In testing anteromedial and anterolateral instabil-ity, the goal is to reproduce the “giving way” phe-nomenon that the patient recognizes after injury tothe anterior cruciate ligament. The test may be per-formed beginning with the patient’s knee extended orbeginning with the patient’s knee flexed. A sudden

Stabilize

Figure 12.69 The position of the examiner and patient for theLachman test. It is very important that the patient be relaxed forthis test.

jerk, which is the giving way phenomenon, is notedby the patient and the examiner as the knee is movedfrom the extended to a flexed position, or from theflexed to an extended position.

Slocum Test

This test can be used to define damage in the ante-rior cruciate and medial collateral ligaments (Figure12.70). The patient is in the supine position and thehip is flexed to 45 degrees. The knee is flexed to 80–90 degrees. Place the leg and foot in 15 degrees oflateral rotation and sit on the foot to stabilize it inthis position. Take the lower leg with both of yourhands and attempt to pull the tibia anteriorly. Thetest result will be positive when anterior movementoccurs primarily on the medial side of the knee. Thistest can also be performed with the leg and foot in 30degrees of medial rotation. When excessive movementof the lateral part of the tibia is noted, the test result ispositive and indicates anterior cruciate ligament andposterolateral capsular damage.

Additional tests for anteromedial and anterolateralinstability include the Losee test, the crossover test,the Noyes test, and the Nakajima test.

Pivot Shift Test (MacIntosh)

The patient is placed in the supine position with thehip extended. Take the affected foot in one hand andmedially rotate the tibia on the femur. The other handis placed behind the patient’s knee so that a valgusstress and flexion maneuver can be performed simul-taneously. At about 25 to 30 degrees of flexion, thereis a sudden jerk and you will feel and see the lateralfemoral condyle jump anteriorly on the lateral tibialplateau. This is a positive test result and signifies arupture of the anterior cruciate ligament. As the kneeis flexed further, the tibia suddenly reduces (Figure12.71).

Posterior Stability Tests

“Reverse” Lachman Test

This test is used to elicit excessive posterior movementof the tibia that results from damage to the posteriorcruciate ligament. The test is performed with the pa-tient is the prone position with the knee flexed toabout 30 degrees. Use one hand to stabilize the thighwhile trying to displace the tibia posteriorly with theother hand. (Figure 12.72)

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(a)

(b)

Figure 12.70 (a) The Slocum test. Note that the leg is in external rotation. The test result is positive when anterior drawer fails totighten in 25ci cr of external rotation of the leg. This occurs with damage to the anterior cruciate and medial collateral ligaments. (b)This is the same test performed with the foot in internal rotation. The test result is positive when anterior drawer does not decreasewith internal rotation. This results from damage to the anterior cruciate ligament and posterolateral secondary restraints.

(a)

(b)

(c)

Figure 12.71 Position for the lateral pivot shift test. (a) Note that the patient’s knee is fully extended. Internally rotate the leg andapply a valgus stress. (b) As you begin to flex the knee, the lateral tibial plateau subluxes. (c) As tension in the iliotibial band is lessenedat 45˚ of flexion, a pivot shift is felt as the tibia reduces. This test is used to identify a rupture of the anterior cruciate ligament.

368

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369Chapter 12 The Knee

Figure 12.72 The position for performing the reverse Lachmantest. The test result is positive when the tibia is able to besubluxed posteriorly on the femur. The patient should be fullyrelaxed while performing this test.

Hughston (Jerk) Test

This test is performed similarly to the pivot shift test.However, the starting position is with the patient’sknee flexed to 90 degrees. Again, take one hand androtate the tibia medially while using the other handbehind the knee to apply a valgus and extension stress.Here, the lateral femoral condyle starts out in a for-ward subluxed position relative to the tibia. As theknee is extended and at about 20 degrees, a sublux-ation of the tibia occurs. This subluxation reducesin full extension. This is a positive test result andindicates a rupture of the anterior cruciate ligament(Figure 12.73).

Posterior Medial and Lateral Stability

Hughston Posteromedial and PosterolateralDrawer Test

This test is performed similarly to the posteriordrawer test. This test can be used to define damagein the posterior cruciate and medial and lateral col-lateral ligaments (Figure 12.74). The patient is in thesupine position and the hip is flexed to 45 degrees.The knee is flexed to 80–90 degrees. Place the leg andfoot in 15 degrees of lateral rotation and sit on thefoot to stabilize it in this position. Take the lower legwith both of your hands and attempt to push the tibiaposteriorly. When excessive movement of the lateralpart of the tibia is noted, the test result is positive and

indicates posterior cruciate ligament, lateral collateralligament, and posterolateral capsular damage.

This test can also be performed with the leg andfoot in 30 degrees of medial rotation. When excessivemovement of the medial part of the tibia is noted, thetest result is positive and indicates posterior cruciateligament, medial collateral ligament, and posterome-dial capsular damage.

Medial and Lateral Stability Tests

In testing for the stability of the medial and lateralcollateral ligaments, you should first examine the pa-tient for medial and lateral instability of the tibia.This can be accomplished with the varus (adduction)and valgus (abduction) stress tests. These tests weredescribed earlier in this chapter.

Tests for Meniscal Damage

The goal of these tests is to assess the presence ofmeniscal injury. The tests are performed by applyinga stress to the knee that reproduces pain or a click asthe torn meniscus is impinged by the tibia and femur.

McMurray’s Test

This test can be performed to examine the lateral andmedial menisci. The patient is placed in a supine po-sition with the test knee completely flexed, so that theheel approaches the buttock. Put your hand on theknee so that the thumb and index fingers are alongthe joint line of the knee. Take the other hand androtate the tibia internally (medially), while applying avarus stress. A painful click on rotation is significantfor damage to the lateral meniscus (Figure 12.75a).

If the tibia is rotated externally (laterally) whileapplying a valgus stress, the medial meniscus can beexamined (Figure 12.75b).

The test can be performed in a position of less thanfull flexion. With more extension, the further ante-rior portions of the meniscus can be examined. Theresult of McMurray’s test can also be positive in thepresence of osteochondritis dissecans of the medialfemoral condyle.

Bounce Home Test

The purpose of this test is to examine for a blockageto extension that may result from a torn meniscus.The patient is placed in a supine position. Take theheel of the patient’s foot and cup it in your hand and

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370 The Knee Chapter 12

(a)

(b)

(c)

(d)

Figure 12.73 The Hughston jerk test. (a) Note the initial starting position with the knee in 90 degrees of flexion and the leg internallyrotated as a valgus stress is applied. (b) and (c) Note that the patient’s knee is extended while maintaining internal rotation of the legand valgus stress at the knee. (d) At 20 degrees, a subluxation of the tibia occurs, and reduces in full extension.

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371Chapter 12 The Knee

(a) (b)

Figure 12.74 Hughston posterolateral drawer test. (a) Starting position (b) the test is positive as shown.

then flex the patient’s knee fully. Allow the patient’sknee to extend passively. If the patient’s leg does notextend fully, or if the end feel is rubbery, there is ablockage to extension and the test result is positive(Figure 12.76).

Apley (Grinding, Distraction) Test

This test is performed to assess whether medial orlateral joint line pain is due to meniscus or collat-eral ligament damage. The test is performed with thepatient in the prone position. The knee is flexed to90 degrees, and the patient’s thigh is stabilized by theweight of your knee. Grab the patient’s ankle withyour hand and rotate the tibia internally and exter-nally while applying a downward force on the foot.Pain during compression with rotation is significantfor meniscal damage. Perform the same rotation me-dially and laterally, but this time pulling upward onthe foot and ankle so as to distract the tibia fromthe femur. If rotation with distraction is painful, thepatient is more likely to have a ligamentous injury(Figure 12.77).

Patellofemoral Joint Tests

Apprehension (Fairbanks) Test

This test is used to diagnose prior dislocation of thepatella. The patient is placed in a supine position withthe quadriceps muscles as relaxed as possible. Theknee is flexed to approximately 30 degrees while youcarefully and gently push the patella laterally. The testresult is positive if the patient feels like the patella isgoing to dislocate and abruptly contract the quadri-ceps (Figure 12.78).

Clarke’s Sign (Patella Grind Test)

This test is used to diagnose patellofemoral dysfunc-tion. The patient is in supine with the knee in exten-sion. Using your hand as shown in Figure 12.79, holdthe superior border of the patella. Ask the patient tocontract their quadriceps muscle while you continueto push downwards. If the patient is able to com-plete the muscle contraction without pain, the test isconsidered to be negative (Figure 12.79).

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372 The Knee Chapter 12

(a)

(b)

Figure 12.75 (a) McMurray’s test is performed with the leg externally rotated, and applying a valgus stress to test the medialmeniscus. (b) McMurray’s test is performed with the leg internally rotated, and applying a varus stress to test for the lateral meniscus.

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373Chapter 12 The Knee

Figure 12.76 The bounce home test looks for damage to the torn menisci. The patient’s foot is cupped in the hand and the knee isallowed to lower into extension. If the knee does not reach full extension, or if spongy end feel is noted, the test result is positive.

Figure 12.77 The grinding/distraction test of Apley. The tibia is rotated first with a distraction force on the leg and then with acompression force. Distraction with rotation tests the collateral ligaments, while compression with rotation tests the menisci.

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374 The Knee Chapter 12

Figure 12.78 The apprehension test for patellar subluxation anddislocation.

Figure 12.79 Clarke’s sign. Apply downward pressure on theproximal patella as the patient actively contracts the quadriceps.

Patellofemoral Arthritis (Waldron) Test

This test is used to detect the presence of patello-femoral arthritis. The patient is asked to perform sev-eral deep knee bends slowly. Place your hand over thepatella so that you can palpate the patella as the pa-tient bends and straightens. Tell the patient to informyou if there is pain during the bending or straighten-ing. The presence of crepitus during a complaint ofpain is positive for patellofemoral joint disease.

Test for Plica

Medial and lateral plicae are synovial thickenings thatconnect from the femur to the patella. In some indi-viduals, these synovial thickenings are overdevelopedand may be pinched in the patellofemoral joint or maybe painful. The plicae can be examined by having thepatient lie in the supine position with the thigh re-laxed. Test for the medial plica by pushing the patellamedially with one hand. Then attempt to pluck theplica like a guitar string on the medial aspect of thepatella. Check for lateral patellar plica by pushingthe patella laterally with one hand and attempting topluck the plica on the lateral aspect of the patella.

Tests for Joint Effusion

Wipe Test

This test is sensitive to detecting small amounts ofjoint fluid. The patient lies in the supine position withthe knee extended, if possible. Fluid is first massagedacross the suprapatellar pouch from medial to lateral.Next, try to move the fluid from lateral to medial,using a wiping action over the patella. If you see abulge of fluid inferomedially to the patella, a jointeffusion is present (Figure 12.80).

Ballotable Patella

If a large effusion is suspected, you can test for it byhaving the patient lie in the supine position with theknee extended as much as possible. Push down onthe patella. The fluid will flow to either side and thenreturn underneath the patella, causing the patella torebound upward (Figure 12.81).

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375Chapter 12 The Knee

Lateral Medial

Lateral Medial

Wave offluid

Figure 12.80 The wipe test for swelling in the knee. Attempt tomove the fluid from medial to lateral first. Then attempt to wipethe fluid from lateral to medial over the patella. If a bulge offluid is noted inferior and medial to the patella, the test result ispositive for a small joint effusion.

Figure 12.81 Test for large knee effusion showing a ballotablepatella with fluid exiting on either side of the patella withdownward compression.

Radiological Views

Radiological views are shown in Figures 12.82–12.86.F = FemurT = TibiaP = PatellaFi = FibulaMFC = Medial femoral condyleTT = Tibial tubercleFT = Femoral trochlear grooveA = Anterior cruciate ligamentB = Posterior cruciate ligament

Figure 12.82 Anteroposterior view of the knee.

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376 The Knee Chapter 12

Figure 12.83 Lateral view of the knee.

Figure 12.84 ”Skyline” view of the patella.

Figure 12.85 MRI of the patellofemoral joint.

(a)

(b)

Figure 12.86 Sagittal view of the knee.

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377Chapter 12 The Knee

S A M P L E E X A M I N A T I O N

History: 25-year-old snowskier presents with painful swelling anddecreased range of motion of the leftknee and limited weight-bearingtolerance, two days after a fall. He is anintermediate skier who, whileattempting to turn to the right, “caughtan edge.” His ski tips crossed and he fellforward over the skis. He perceivedacute pain in the left knee. He haddifficulty trying to stand up. He wasuncertain as to whether he heard or felt a“pop.” He was able to complete the rundown the hill, although slowly and withsome difficulty. He had swelling of theknee overnight. He had no prior historyof injury to the extremity.

Physical Examination: Moderateswelling and effusion of the left knee.Limited range of motion of 20–70degrees of flexion. Muscle testing wasinconclusive secondary to pain. Therewas pain at the posterolateral knee. Hehad inconclusive anterior drawer,Lachman test, Slocum test and pivot shiftsigns due to pain and limited range ofmotion of the left knee. Negative sagsign, posterior drawer test, reverseLachman test, Hughston’s test, varusand valgus stress, Fairbanks and Clarkesign, McMurray test. Neurovascularexam was normal.

Presumptive Diagnosis: Acute anteriorcruciate ligament (ACL) sprain.

Physical Examination Clues:(1) Historyclearly describes the mechanism ofinjury: indicating potential injury wassustained by the ACL, because the ACLin the static stabilizer (ligament) of theknee which resists internal rotation. (2)Posterolateral knee pain, indicating thatthere was a combined extension, internalrotational stress applied to the knee tocause pain in this area of the joint. Thisfurther raises suspicion of an ACL injurybecause of the ACL’s function in a staticstabilizer of the knee against excessiveinternal rotational movement. When theligament fails under excessive loading,this stress is then translated further tothe posterolateral aspect of the kneejoint. (3) Delayed onset of swelling andeffusion classic for an acute ACL sprain;indicating an accumulating hemarthrosiswhich can be exquisitely painful andrestrictive to movement. (4) The absenceof special testing for the medial collateralligament, lateral collateral ligament,posterior cruciate ligament, meniscus,and patella and the absence of medialjoint line or medial peripatellardiscomfort, indicating no apparent orsignificant injury to the medial collateralligament, medial meniscus, patella, orpatellar retinaculum.

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Paradigm of a knee ligament injury

Medial Collateral Ligament InsufficiencyA young athlete presents with a complaint of “knee instability”and “giving way” when pivoting or changing direction. Thissymptom is followed, not preceded, by medial knee pain andswelling. The patient gives a history of prior injury to theknee. The traumatic event described by the patient impliesthe mechanism of injury to have been one of excessive val-gus stress. At the time of the original injury the patient recallsfeeling a "tearing " sensation emanating from the medial kneejoint. Pain was localized to the medial aspect of the knee andproximal tibia. Swelling, although not evident at the time ofinjury, was apparent and significant over the next 12 hours.The patient’s symptoms seem to resolve completely with 6weeks of rest and protection of the knee. However, on return-ing to sports and vigorous activities, the patient found theknee to be somewhat unstable and painful.

His symptoms became more frequent, even to occur withdaily activities. There have been no episodes of “locking” orlimitation in range of knee motion. On physical examination,the patient had no limp and a full range of knee motion.Patellofemoral and tibiofemoral alignment were unremark-able. There was pain on palpation of the medial collateralligament. Valgus stress on the knee revealed a discernablegap and was mildly painful. Minimal soft-tissue swelling waspresent. There was no increased anterior excursion of the tibiaon the femur during an anterior drawer test. There was a neg-ative pivot shift sign. Meniscal signs were negative; and x-rayswere read as normal.

This is a paradigm of ligament injury because of:

A history of injuryA characteristic mechanism of injuryInstability not precipitated by painNormal bony alignmentUnremarkable x-rays

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C H A P T E R 1 3

The Ankle and Foot

F U R T H E R I N F O R M A T I O N

Please refer to Chapter 2for an overview of the sequence of

a physical examination. For purposes oflength and to avoid having to repeatanatomy more than once, the palpationsection appears directly after the sectionon subjective examination and before any

section on testing, rather than at the endof each chapter. The order in which theexamination is performed should bebased on your experience and personalpreference as well as the presentation ofthe patient.

Functional Anatomy

The Ankle

The ankle is a synovial articulation composed of threebones: the tibia, the fibula, and the talus. Although in-timately interrelated with the foot, the ankle and foothave separate and distinct functions. The ankle is thesimpler of the two structures. It is an extraordinarilystable linkage between the body and its base of sup-port, the foot. Generally, the ankle lies lateral to thebody’s center of gravity. Therefore, the ankle jointis subjected to varus as well as compressive loading(Figure 13.1). The structure of the ankle is that of abony mortise. It is bounded medially by the malleolarprocess at the distal end of the tibia, superiorly bythe flat surface of the distal end of the tibia (the tib-ial plafond), and laterally by the malleolar process ofthe distal end of the fibula. The smaller fibular malle-olus extends distally and posteriorly relative to themedial malleolus. As a result, the transmalleolar axisis externally rotated approximately 15 degrees to thecoronal axis of the leg (Figure 13.2). Anteriorly, themortise is deepened by the anterior tibiofibular liga-ment. Posteriorly, it is buttressed by the bony distalprojection of the tibia (posterior malleolus) and theposterior tibiofibular ligament. Within this mortise is

set the body of the talus. The talus articulates withthe tibial plafond by its large superior convexity (thedome). It also presents an articular surface to each ofthe malleoli. The dome of the talus is wider anteriorlythan it is posteriorly. As such, the talus becomes firmlywedged within the ankle mortise on dorsiflexion. Thiscreates medial–lateral tension across the distaltibiofibular syndesmosis and ligament. The intactankle mortise primarily allows the talus a singleplane of motion (flexion–extension), with only amodest amount of anterior–posterior glide. There-fore, this increased stability of the ankle during dor-siflexion affords the means to isolate and assessmedial–lateral ankle ligament integrity and subtalarinversion–eversion mobility.

The ankle is solely responsible for transmission ofall weight-bearing forces between the body and thefoot. The ankle is remarkably immune to the oth-erwise universally observed degenerative changes ofsenescence, seen in other large synovial articulations.This unusual and unique sparing of the ankle joint isprobably a consequence of a combination of factors,including the ankle’s requirement of limited degrees offreedom and its extreme degree of stability. However,to accommodate the severe stresses of daily activitiesand changes in ground contours, the ankle is comple-mented by a complex of accessory articulations that

379

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380 The Ankle and Foot Chapter 13

X

Varus

Compression

Figure 13.1 The ankle is lateral to the center of gravity andtherefore is subject to a varus stress as well as compression.

Posterior

Anterior

15˚

LateralMedial

Figure 13.2 The transmalleolar axis is externally rotated 15degrees.

comprise the foot. The most significant of these is thesubtalar (talocalcaneal) articulation.

The Foot

The primary functions of the foot are to provide astable platform of support to attenuate impact load-ing of the extremity during locomotion, and to as-sist in the efficient forward propulsion of the body.To accomplish these tasks, the foot is made up ofthree sections. These sections—the hindfoot, the mid-foot, and the forefoot—are in turn composed of mul-tiple mobile and semirigid articulations that affordfoot conformity to varying surface topographies. Thebony elements of the foot are arranged to form alongitudinal and a transverse arch. These arches arespanned across the plantar aspect by soft-tissue ten-sion bands that act as shock absorbers during impact(Figure 13.3a).

The foot has 26 bones distributed among the hind-foot, midfoot, and forefoot (Figure 13.3b). The hind-foot represents one-third of the total length of thefoot. It contains the two largest bones of the foot, thecalcaneus and the talus. The larger is the calcaneus(heel bone). The calcaneus lies beneath and supportsthe body of the second bone, the talus. The talus (an-kle bone) is the only bony link between the leg and thefoot. The tibia articulates with the talus in the middleof the hindfoot.

The midfoot contains the small, angular navicular,cuneiforms (medial, middle, and lateral), and cuboidbone. The midfoot makes up slightly more than one-sixth of the overall length of the foot. Little movementoccurs within the midfoot articulations.

The forefoot represents the remaining one-half ofthe overall length of the foot. It is composed of minia-ture long bones, 5 metatarsals and 14 phalanges.

Structural integrity of the foot is dependent onthe combination of articular geometry and soft-tissuesupport. All articulations of the foot are synovial. Thesoft-tissue support is provided by static (ligamentous)and dynamic (musculotendinous) stabilizers. The fail-ure of either articular or soft-tissue structural integritywill result in ankle dysfunction, foot dysfunction, re-duced efficiency, arthritis, and bony failure (fatiguefractures).

The support of the talus is afforded posteriorlyby the anterior calcaneal facet and distally by thenavicular bone. There is a void of bony support atthe plantar aspect between the calcaneus and