Clinical Exams

Question 1

Head + neck exam

Answer 1

C spine
- Pain at rest? Tenderness? ROM
Inspect anteriorly
- Face - Battle’s sign, raccoon eyes
- Teeth + oral cavity
- Nose - check both nostrils are patent
Inspect laterally
- Ears + TM
Inspect posteriorly
- Posterior head
- Trapezius
Palpation
- Nasal bones, zygoma and orbital rims, mandible and maxilla
Eyes
- Pupillary size + response
- EOM
- Visual acuity
- Visual fields
- Sclera, iris, pupil
- Fundoscopy to assess retina
- Red reflex
- Cornea (fluorescein stain, cobalt blue light)
- IOP
- Accommodation reflex
Special tests
- Cerebellum
- Cranial nerve exam
- Concussion testing
- Peripheral nerve exam

Question 2

How to examine cerebellum

Answer 2

Finger to nose
Pronate/ supinate clap
Gait
Pronator Drift - close eyes, arms extended out straight palms up
Romberg – Stand with feet together, Eyes open, lose balance = cerebellar, Eyes closed, lose balance = proprioception

Question 3

Cranial nerve exam

Answer 3

1: Olfactory - any changes to sense of smell?
2: Optic - pupil size, shape, symmetry, visual acuity using snellen chart, pupillary reflexes (direct + consensual), accommodation reflex, color vision using Ishihara plates, visual fields + neglect, fundoscopy
3, 4 + 6: Oculomotor, trochlear + abducens - H movement
5: Trigeminal - sensory (ophthalmic, maxillary, mandibular), masseter palpation, open jaw against resistance, jaw jerk and corneal reflex
7: Facial - change to taste? change to hearing? Raise eyebrows, close eyes, blow out cheeks, big smile, pursed lips
8: Vestibulocochlear - whisper test, Rinne’s (tuning fork on mandible, when no longer able to hear, move in front of ear - air should be louder than bone), Weber’s (tuning fork midline of forehead, sound should be equal - sound louder on affected ear = conductive, sound louder on intact ear = sensorineural), turning test (march on spot w/ arms outstretched in front + eyes closed - vestibular lesion pt turns towards side of lesion)
9 +10: Glossopharyngeal + vagus - problems with swallowing? Inspect uvula, ask pt to cough, ask pt to swallow
11. Accessory - inspect trap + SCM, shrug shoulders against resistance, turn head against resistance
12: Hypoglossal - inspect tongue, protrude tongue, push tongue against resistance in cheek

Question 4

How to examine for ?concussion

Answer 4

Compare to baseline
Orientation - where are we, what happened, who am I, what year is it
Vestibulo-ocular testing
Move eyes from side to side (finger to finger) + up and down
Keep eyes focused on examiner then turn head side to side and up and down

Question 5

Peripheral nerve exam

Answer 5

Sensation to upper deltoid (C4), lateral elbow (C5), tip of thumb (C6), tip of middle finger (C7), tip of little finger (C8), medial elbow (T1), medial side of knee (L3), medial malleolus (L4), 1st webspace (L5), lateral heel (S1)
Power - deltoid (C5), biceps (C5/6), wrist extension (C6/7), triceps (C7), middle finger flexion (C8), fingers splayed (T1), test quads (L3/4) by squatting, tibialis anterior (L4) by heel walking, Trendelenburg test for hip adductors (L5), test gastrocnemius with toe walk (S1/2)
Reflexes - biceps jerk (C5/6), brachioradialis (C6), triceps (C7), patella tendon (L3/4), achilles tendon (S1/S2), abdo reflexes (upper muscles = T7-T10, lower T10-L1)

Question 6

How to do C spine exam

Answer 6

Gait - cervical stenosis
Inspection posteriorly
- Scars? Erythema? Wasting?
- Alignment
Shoulders + iliac crests should be symmetrical
Head should be straight and directly above sacrum
Touch toes and look for symmetry of ribs (rib hump = scoliosis)

Inspection laterally
- Cervical + lumbar lordosis
- Thoracic kyphosis

Inspection anteriorly
- Shoulder alignment
- Cervical AROM - flexion, extension, rotation left + right, lateral flexion left + right
- Hold hips stable then ask pt to laterally rotate left and right

Movement
Flexion, extension
Rotation left + right, rotation + extension together
Lateral flexion left + right (pain = brachial plexus injury)

Palpation
Soft tissue of neck for masses
Prominent vertebrae = C7
Spinous processes - irregularities, steps, tenderness
Mastoid
Occipital region
Trapezius
Levator scapulae

Neurological assessment
Sensation to upper deltoid (C4), lateral elbow (C5), tip of thumb (C6), tip of middle finger (C7), tip of little finger (C8), medial elbow (T1)
Power - deltoid (C5), biceps (C5/6), wrist extension (C6/7), triceps (C7), middle finger flexion (C8), fingers splayed (T1)
Reflexes - biceps jerk (C5/6), brachioradialis (C6), triceps (C7)
Check radial pulses
Check shoulder ROM

Special Tests
Spurlings test (nerve root compression/ radicular pain) - rotate neck towards side of pain, move neck into extension + then apply axial load

Question 7

How to do lumbar spine exam

Answer 7

Gait - lumbar stenosis causes pts to lean forward

Inspection posteriorly
Scars? Erythema? Wasting? Patch of hair (spina bifida)? cafe au lait spots (neurofibromatosis)?
Alignment
Shoulders + iliac crests should be symmetrical
Head should be straight and directly above sacrum
Touch toes and look for symmetry of ribs (rib hump = scoliosis)

Inspection laterally
Cervical + lumbar lordosis
Thoracic kyphosis

Inspection anteriorly
Shoulder alignment
Movement
Forward flexion (pain = discogenic pain)
Extension (pain = pars defect)
Extension to right and left
Hold hips stable then ask pt to laterally rotate left and right
Lateral flexion - note how far down leg hand can go

Schober’s test
Mark level of iliac crest/ find dimples of venus (landmark for L4 spinous process)
Measure 10cm above + 5cm below, keep tape measure still at these marks
Ask athlete to forward flex, if <5cm change = lumbar stiffness

Palpation
Iliac crest, SI joint, paravertebral tenderness
Spinous processes - irregularities, steps, tenderness

Neurological assessment
Power - check standing - test quads (L3/4) by squatting, tibialis anterior (L4) by heel walking, Trendelenburg test for hip adductors (L5), test gastrocnemius with toe walk (S1/2)
Get pt sitting, then flex hip against resistance and test iliopsoas muscle (L2)
Then lift foot up so foot + leg is at 90 degrees to hip - truly positive straight leg will cause pt to lean back in tripod position
Lie pt supine for dermatomes - medial side of knee (L3), medial malleolus (L4), 1st webspace (L5), lateral heel (S1)
Test power extensor hallucis longus (L5)
Reflexes - patella tendon (L3/4), achilles tendon (S1/S2), abdo reflexes (upper muscles = T7-T10, lower T10-L1)
Check pulses in feet

Special tests
Slump test - chin on chest, flex forward and slump - ankle in dorsiflexion, straighten leg - then lift head up - if pain improves = radicular pain
Straight leg raise - with pt lying supine, lift heel up - pain should only start at 30 degrees
If pain occurs, lessen off and then dorsiflexing ankle - if this reproduces pain, it is positive (Lasegue’s test)
Ankylosing spondylitis
Chest expansion <2.5cm
Schober’s: identify level of PSIS (approx at level of L5), mark midline at 5 cm below iliac spine and 10 cm above iliac spine. Patient bends at waist to full forward flexion. Measure distance between 2 lines (started 15 cm apart).
Normal: distance between 2 lines increases to >20 cm.
Abnormal: distance does not increase to >20 cm.
Check ROM in hip (pt supine, flex hip and knee and rotate from side to side)
FABER - ?SIJ pathology, pars stress #
Mennell’s test = lying prone, leg straight and hip extended with hand on lumbar spine = if pain, ?pars defect
Femoral nerve stretch test

If ?cauda equina
Sensation in perineum
DRE for anal tone
Cremesteric reflex

Question 8

Shoulder exam

Answer 8

Inspection anteriorly
Scars, erythema, swelling, muscle wasting (deltoid, pectoral)
Bony lumps, callouses - (AC joint more prominent?)
Sulcus sign (pull down on arm, if depression appears - ?instability)

Inspection laterally
Deltoid (atrophy = C5 plexus injury)
Inspect + palpate axilla

Inspect posteriorly
Supraspinatus, infraspinatus
Trapezius, latissimus dorsi
Abduct arms to assess movement of scapular (winging = long thoracic nerve palsy or CN 11 palsy)

ROM
C spine flexion, extension, rotation, lateral flexion
Abduction (180 degrees), adduction (50 degrees), forward flexion (180), horizontal flexion (130), extension (90), external rotation (60), internal rotation (thumb up back)
Hands behind head = abduction + external rotation
Hands behind back = adduction + internal rotation

Palpation
Sternoclavicular joint, clavicle, AC joint, acromion, subacromial bursa, greater tuberosity of humerus (insertion of supraspinatus tendon), externally rotate arm with finger there to palpate long head biceps tendon, humeral head, GH joint, coracoid process
Posterolateral corner of acromion, scapular spine, inferior angle of scapula, supraspinatus, infraspinatus, trapezius, rhomboids

Special tests
Spurling’s test
Painful arc
Drop arm test
Speed test
Empty can test
Hawkins’ test
Cross arm adduction
Resisted external rotation
Gerber’s lift off
Apprehension test
Yergason’s
Neers test
Sulcus sign
Impingement test
Compression rotation test
O’Brien test

Question 9

What is Spurlings test for?

Answer 9

cervical radiculopathy

Question 10

Painful arc test

Answer 10

Impingement
pain at 30-60 degrees, dissipates at 120 degrees

Question 11

Drop arm test

Answer 11

hold arm at 90 degrees to body, remove support and ask pt to keep arm there (supraspinatus)

Question 12

Speed test

Answer 12

arm straight, forward flexion to 90 degrees, palm up, resisted downwards pressure + palpate bicipital tendon
pain = bicipital tendonitis, labral tear

Question 13

Empty can test

Answer 13

push at deltoids (supraspinatus)

Question 14

Hawkins’ test

Answer 14

bend elbow to 90 degrees, internally rotate humerus (causing greater tuberosity to bump against acromion)
pain = impingement, AC or rotator cuff pathology

Question 15

Cross arm adduction

Answer 15

compresses AC joint

Question 16

Resisted external rotation

Answer 16

infraspinatus

Question 17

Gerber’s lift off

Answer 17

subscapularis

Question 18

Apprehension test

Answer 18

lying supine, abduct arm to 90 degrees w/ elbow flexed then slowly externally rotate - place hand over proximal humerus
if apprehension improves - test = positive

Question 19

Yergason’s

Answer 19

Resisted supination + palpate biceps tendon
biceps tendonitis/ labrum

Question 20

Neers test

Answer 20

The examiner should stabilize the patient’s scapula with one hand, while passively flexing the arm while it is internally rotated. If the patient reports pain in this position, then the result of the test is considered to be positive
subacromial nerve impingement

Question 21

Sulcus sign

Answer 21

apply downwards traction, sulcus sign = inferior instability

Question 22

Impingement test w/ LA

Answer 22

inject subacromial bursa w/ lidocaine = sx improvement = impingement not tear

Question 23

Compression rotation test

Answer 23

patient supine, pts arm abducted to 90 degrees + elbow flexed to 90 degrees, examiner applies axial force to humerus
positive = pain/ clicking = labral tear?)

Question 24

O’Brien test

Answer 24

pt standing, arm forward flexed to 90 degrees w/ elbow in full extension. With adducted arm to 10 degrees and internally rotated humerus, examiner applies downward force to arm as pt resists. Pt then supinates arm and repeats resistance.
Positive = pain w/ internal rotation, reduced w/ external rotation
SLAP or AC lesions

Question 25

Upper cut test

Answer 25

forearm supinated, elbow flexed to 90 degrees, hand in fist. Pt brings first towards chin against resistance.
Pain = biceps tendinopathy

Question 26

Elbow exam

Answer 26

Neck + shoulder
Inspect
C spine ROM
Shoulder ROM

Inspection
Scars, erythema, swelling, muscle wastimh
Carrying angle (normally 5 degrees in males, 10-15 degrees in females)

Palpation
Anteriorly: medial epicondyle, common flexor origin, ulnar nerve, biceps tendon, brachial pulse
Posteriorly: medial + lateral epicondyle, olecranon
Laterally: lateral epicondyle, radial head, common extensor origin

Movement
Arms abducted to 90 degrees then flex elbows (touch hands to shoulders)
Supination + pronation

Special tests
Passively flex wrist + extend elbow (pain over common extensor origin - lateral epicondylitis)
Passively extend wrist + extend elbow (pain over common flexor origin - medial epicondylitis)
Tinel’s test - tap along the line of the ulnar nerve
Valgus instability - with elbow extended, brace lateral side of elbow, apply valgus force (elbow will open if MCL is insufficient)
Valgus stress test = flexes elbow to 30 degrees, apply valgus stress. Positive if pain or instability (UCL sprain). Moving valgus test - apply valgus force as elbow is moved through flexion + extension. Pain between 70-120 degrees flexion is positive for UCL injury
Neuro - make a fist (median nerve), thumbs up (radial nerve), make circle with thumb + forefinger (anterior interosseous branch of medial nerve), starfish (ulnar nerve)
Check radial + ulnar pulses

Question 27

Hand + wrist exam

Answer 27

Screen neck, shoulder + elbow
Cervical, shoulder + elbow ROM

Inspection
Palmar aspect: alignment (fingers should be slightly flexed in rest), scars, erythema, palmar creases, swelling, wasting, thenar + hypothenar eminence
Radial surface: alignment of thumb
Dorsal aspect: scars, erythema, nails
Ulnar aspect: scars, swelling

Palpation
Dorsal aspect: radius to lister’s tubercle, scapholunate interval, radial styloid, ulnar styloid, extensor carpi ulnaris tendon, triangular fibrocartilage, anatomical snuffbox (pain = scaphoid injury), abductor pollicis longus tendons (pain = de Quervain’s tenosynovitis), extensor pollicis longus (hooks around pulley of lister’s tubercle), ulnar head, ulnar styloid
Palmar aspect: pisiform, flexor carpi ulnaris tendon, hook of hamate, transverse carpal ligament (base of thenar eminence - carpal tunnel lies under), tubercle of scaphoid, carpal-metacarpal joint, MCP joints, phalanges, PIP, DIP

Movement
Make a fist (flexion), flatten hand onto table (extension), spread fingers apart (abduction), fingertips to thumb (thumb flexion + opposition), wrist extension + flexion, supination, pronation, wrist ulnar + radial deviation

Neurological
Sensation: radial edge of palmar aspect 2nd digit (median), ulnar edge of palmar aspect 5th digit (ulnar), 1st webspace dorsal aspect (radial), C6 - thumb, C7 - middle finger, C8- little finger
Power:
Median nerve: make fist + make circle w/ thumb + forefinger, resisted thumb abduction + palpate muscle bellies
Ulnar nerve: starfish, palpate hypothenar eminence w/ resisted starfish, Froment’s test (adductor pollicis test): grip paper in 1st webspace, pull paper out - IP joint should not flex - if they flex, adductor pollicis is weak
Radial nerve: wrist + thumb extension
Palpate radial + ulnar pulses
Median nerve: radial half of palmar surface
Ulnar nerve: ulnar side of palmar + dorsal surface
Radial nerve: radial side of dorsal surface

Special tests

Question 28

Hand + wrist special tests

Answer 28

Flexor pollicis longus - flex thumb IP joint with thumb MCP joint immobilised
Flexor digitorum profundus - flex each finger DIP with PIP immobilised
Flexor digitorum superficialis tendon - flex each PIP with each MCP immobilised
Distal radial ulnar joint - make like an arm wrestle, compress distal radial ulnar joint and rotate
Grind test (TFCC) - arm wrestle position, ulnar deviation, rotate - pain in ulnar aspect of wrist = TFCC injury
Supination test (TFCC) - extent of supination, flexion against resistance
Watsons test - thumb over scaphoid tubercle, fingers over dorsum of wrist, wrist into slight extension, move from ulnar to radial deviation - pain or clunk = injury to scapholunate ligament
UCL test - stabilise metacarpal and apply stress to UCL (pain or laxity?)
Extension of DIP against resistance - if not present, ?mallet finger
Carpal tunnel test = tinels sign (tap over carpal tunnel), phalens (backs of hands together in forced flexion)
Functional tests: writing, picking up small objects, grip strength
Finkelstein test - grasp thumb of pt, sharply ulnar deviate hand - pain along distal radius = de Quervain tenosynovitis)

Question 29

Hip exam

Answer 29

Gait
Trendelenburg - weakness of hip abductor muscles causes pt to put weight on affected side and opposite pelvis drops. Pt may compensate by swinging shoulders towards affected side
Antalgic gait - pt spends less time on affected limb, shortening stance
Drop foot gait - ankle can’t dorsiflex

Neurological
Tip toe walking (gastrocsoleus - S1)
Heel walking (tibialis anterior - L4)
Squat (quadriceps - L3)
Trendelenburg test (L5)
Lift opposite leg (stand on one leg) - pelvis should not drop and shoulders should not sway over

Inspect posteriorly
Scars, glutes + hamstrings for wasting
Screen for lumbar flexibility w/ finger + thumb apart on lumbar spine + pt flexing forward
Leg length assessment - knees extended, feet aligned - palpate iliac crests - level? If not, put blocks under shorter leg until they are

Inspect anteriorly, supine
Scars, swelling

Palpation (supine)
ASIS, AIIS, pubic symphisis, hip joint, greater trochanter, gluteal tendons, lumbar, SI joint

Movement
Flexion - place hand under lumbar spine - flex hip until lumbar flattens out - this is limit of flexion, measure angle
Internal + external rotation - legs extended (hold from ankles) and knees bent
Abduction + adduction with examiners arm across iliac crest to stop pelvis from tilting

Sensation: medial side of knee (L3), medial malleolus (L4), 1st webspace (L5), lateral heel (S1)

Special tests

Question 30

Hip special tests

Answer 30

Thomas test (fixed flexion deformity of hip) - flex knee + hips, pt holds one knee in place, then extend other leg back onto bed
Leg length measurement
Apparent - umbilicus to lower part of medial malleolus
True - ASIS to medial malleolus
Abductor tests - lie on side, palpate gluteal muscles with leg in abduction, resisted abduction
Adductor tests
external rotation and palpate adductor longis to bone
squeeze test (pt squeezes legs together while in extension)
Psoas
hip flexion against resistance
palpate medial and deep to ASIS
Thomas test (hung one knee, leg hanging off bed)
Inguinal
palpate lower rectus + conjoint tendon + superficial ring
resisted sit up
Femoral stretch test - flex knee and passively extend hip
Straight leg raise
FABER - pain = ?hip or SI joint pathology
Ober’s test - lying on side, knees flexed, superior leg abducted + moved posteriorly, then dropped - if not touching bed = tight IT band
Groin - FADIR, adductor tests

Question 31

Knee exam

Answer 31

Gait
Use of walking aids

Inspection anteriorly
Shoes + orthotics
Scars, rashes, erythema
Swelling around suprapatellar pouch + prepatellar bursa
Valgus (knock kneed)
Varus (bow legs)
Normal alignment - slight valgus (5 degrees men, 7 degrees women)
Feet - hemosiderin deposition, loss of hair, nail atrophy

Inspection laterally
Scars
Quadriceps wasting
Check extension of knee

Inspection posteriorly
Scars, swelling
Wasting of hamstrings or calves

Gait
Trendenlenburg gait?
Knee should be fully extended at heel strike + flexed otherwise
Thrust - lateral or medial deviation of knee at heel strike

Neurological assessment
Tip toe walking (S1)
Heel walking (L4)
Trendelenburg test (L5)
Squat (L3)

Palpation
Tibial tubercle, joint line, meniscus medial + lateral condyle
Medial epicondyle, MCL, pes anserine bursa
Lateral tibial condyle, lateral epicondyle, LCL, fibular head, biceps femoris tendon
Prepatellar bursa, patella edges + movement, assess for effusion (swipe or patella tap)
Popliteal fossa, popliteal pulse

Movement
Extension
Flexion (active + passive)

Special tests
Quadriceps wasting - measure circumference of thigh about a hand breath above patella
MCL + LCL - apply valgus and varus force to knee (in extension + at 30 degrees flexion)
PCL + ACL
PCL sag sign
Anterior + posterior drawer
Lachman
Meniscus
Hold thigh down onto bed, lift heel off bed - if painful ?meniscus injury
Fully flex hips and knees and apply pressure - if painful ?meniscus injury
Hip
Check passive hip flexion + internal + external rotation

Neurological
Straight leg raise
Sensation: medial side of knee (L3), medial malleolus (L4), 1st webspace (L5), lateral heel (S1)
Pulses

Question 32

Ankle + foot exam

Answer 32

Gait

Inspection
Shoes - wear pattern (normal wear pattern is from lateral heel along the lateral border of foot to big toe)
Orthotics

Inspection anteriorly
Alignment - patella should be pointing forward, ankle under knee
Feet should be angled 10-15 degrees laterally and symmetrical
Check toe alignment + hallux valgus
Scars, swelling, erythema

Inspection laterally
Lateral border is flush along floor
Smooth longitudinal arch medially - should be able to put a finger between arch and floor
If flat - dorsiflex great toe - if arch appears, this is a flexible flat foot
Tip toe (activate tibialis posterior) - recreates arch if foot is flexible

Inspection posteriorly
Scars, swelling, wasting
Heel should be in slight valgus when standing, should move to varus when on tip toes (requires tibialis posterior + mobile hindfoot)
If heel does not move from valgus to varus, indicates issue w/ tibialis posterior dysfunction or issue w/ subtalar joint

Neurological
Tip toe walking (S1) (pain on tip toes could indicate posterior impingement)
Heel walking (L4)
Trendelenburg test (L5)
Squat (L3) - knee flexion

ROM standing
Stand on outside and inside of feet - assessing subtalar joint ROM + pain
Deep squat - pain or loss of ROM ?anterior impingement or dorsal spurs

Closer Inspection (sitting)
Skin, nails, hair follicles (loss of hair, atrophic nails + dry skin = possible peripheral vascular disease)

Palpation
Medial: Tibialis posterior tendon, medial malleolus, navicular, deltoid ligament, move anteriorly to feel ankle joint, tibialis anterior (most medial + largest), move over extensor tendons to extensor tendons to soft belly of extensor digitorum brevis, syndesmosis (AITFL)
Lateral: distal fibula, lateral malleolus, ATFL (anterior from lateral malleolus about 2cm to talus), CFL (inferior from lateral malleolus to calcaneus), PTFL (posterior from lateral malleolus to posterior talus), peroneal tendons (posterior to lateral malleolus), down lateral side to peroneus brevis tendon (inserts at base of 5th metatarsal), base of 5th, talar dome, base of 1st metatarsal, 1st MTP joint (PROM - dorsiflexion should be 60 degrees), forefoot
Compress forefoot (pain = ?inflammatory)
Compress calcaneus (?calcaneal stress #)
Plantar aspect: medial + lateral sesamoid, plantar fascia
Vascular (pulses, temperature)

PROM
Dorsiflexion + plantarflexion of ankle
Subtalar joint eversion + inversion
Anterior drawer test
Pronation + supination of midfoot
Flexion of toes
ROM: 45° PF, 20° DF, 30° inversion, 20° eversion, 20° internal rotation, and 10° external

Hip + Knee
Lying supine, check ROM + tenderness in hip + knee

Neurological
Sensation - dorsum of foot (superficial peroneal nerve), 1st webspace (deep peroneal nerve), lateral border of heel (sural nerve), medial hallux (saphenous nerves), sole of foot (medial + lateral plantar nerves)
Power - resisted dorsiflexion + plantarflexion, inversion (tibialis posterior inversion strength)
+ eversion (peroneal strength), great toe extension

Prone/ kneeling
Observe calcaneus, achilles tendon + gastrocsoleus muscle
Palpate achilles tendon, calcaneus
Thompson test
Ankle reflex

Question 33

Foot + ankle special tests

Answer 33

Tests for syndesmosis - point test for tenderness over syndesmosis, squeeze test mid calf, external rotation (pain medially = deltoid ligament injury, pain at syndesmosis = syndesmosis injury)
Posterior impingement test - lying prone: bring knee + ankle to 90 degrees, posterior impingement test = plantar flexion causing posterior ankle pain
Anterior impingement = forced dorsiflexion causing pain anteriorly
Functional testing = proprioception, single leg stance with eyes closed, single knee bend, single leg hop, lunge test
Talar tilt test
Hopping (apprehension or pain - ?stress #)