Ext CLET

Question 1

O’Brien sign

Answer 1

The patients shoulder is placed in flexion to 90 degrees and then into full internal rotation and 10 to 15 degrees of horizontal adduction (cross chest). Examiner exerts a downward force against the patient’s upward resistance. Repeat the test with the arm supinated.

P: 1) Pain felt either deeply or 2) Superficially

I: 1) Labrum tear if felt deeply or 2) AC joint problem if felt superficially

Question 2

Anterior Slide test

Answer 2

Patient seated and the examiner instructs patient to place hands on the waist with the thumbs pointing posterior. With one hand stabilize the scapula and clavicle and with the opposite hand, grasp the humerus and place an anterior to superior force into the shoulder. The patient will then push back against the examiner.

P: Popping, cracking and crepitus is noticed with pain on the antero-superior aspect of the shoulder.

I: Superior or anterior glenoid labrum tear.

Question 3

Anterior apprehension with Relocation (Jobe relocation test)

Answer 3

The patient lies supine on an examination table. The shoulder is placed into the apprehension position. The examiner attempts to reproduce a sense of instability/ apprehension by externally rotating the shoulder in a controlled manner. If apprehension is reproduced, the examiner then places the heel of their hand on the proximal anterior gleno-humeral joint and gently pushes in an anterior to posterior direction (relocation)

P: The patient senses relief upon relocation

I: Confirms anterior instability of the GH joint (rules out tendinitis as false positive for anterior apprehension test.)

Question 4

Painful arc test

Answer 4

Palm facing down, the patient is instructed to elevate their arm from their side slowly (ACTIVELY) up to 180 degrees of full abduction.

P: 1) Pain worse between 70 degrees and 110 degrees of shoulder abduction
2) Pain worse at 160 degrees or above of shoulder abduction

I: 1) Impingement syndrome with supraspinatus pathology
2) A/C joint involvement

Question 5

Neer test

Answer 5

The patients shoulder is placed into passive forward flexion to end range.

P: End range pain as the greater tuberosity jams up against the anterior-inferior border of the acromion.

I: Impingement with overuse injury of the supraspinatus muscle or biceps tendon.

Question 6

Hawkin Kennedy test

Answer 6

Passive internal rotation of the shoulder in 90 degrees of forward flexion with the elbow flexed to 90 degrees while the scapula is stabilized posteriorly.

P: The supraspinatus tendon is jammed up against the anterior surface of the Coraco-acromial ligament due to narrowing of the subacromial space. Posterior pain implicates stretch of the Teres Minor and Infraspinatus tendons.

I: Local pain indicates supraspinatus tendinitis and impingement. Anterior pain is anterior impingement syndrome posterior pain is posterior impingement syndrome.

Question 7

Patte test (Hornblower sign)

Answer 7

The patient will place the shoulder of the affected side in forward flexion to 90 degrees. The shoulder is then slightly abducted (15-20 degrees). The Elbow is bent to 90 degrees with the palm facing the patient (Hornblower position). The examiner will place their hand at the distal forearm on the dorsal surface. The patient is then instructed to externally rotate against the examiners resistance.

P: Pain or inability to actively externally rotate against resistance due to weakness.

I: Infraspinatus or Teres minor tendinopathy

Question 8

Empty can test

Answer 8

Shoulder abducted 90 degrees in the scaption plane (scapular plane elevation)with forearm extended and in 40 degrees forward flexion. The shoulder is placed in maximal internal rotation with the thumb pointing downward. The examiner instructs the patient to push back and out while the examiner pushes down and in.

P: Resistance to the abduction and downward pressure stresses the supraspinatus muscle and tendon insertion.

I: Tear, rupture to the supraspinatus muscle or tendon with possible suprascapular neuropathy.

Question 9

Lift Off test

Answer 9

The patient will place the back of their hand in the small of their back and attempt to lift the hand off the back

P: Inability to actively lift the hand off or away from the back

I: Subscapularis tendinopathy

Question 10

Sulcus sign with Load & Shift

Answer 10

Patient seated with the elbow flexed to 90 degrees and the shoulder in the neutral position for rotation. Grasp the wrist with one hand and with the other, place a downward force on the forearm.

P: This motion attempts to dislocate the shoulder inferiorly. A sulcus that appears on the antero-lateral will indicate shoulder instability and is graded.

I: Inferior shoulder instability (MDI) and possible inferior dislocation. A +1 sulcus indicates less than 1cm, +2 indicates 1-2 cm’s and +3 indicates more than 3cm’s.

Question 11

Mazion shoulder maneuver

Answer 11

The examiner asks the patient to place the hand of the affected shoulder on the unaffected shoulder and bring the elbow toward the chest (like a Dugas position). The patient will then actively raise the elbow toward the forehead.

P: Inability to actively raise the elbow to the forehead due to pain and/or stiffness

I: Early stage adhesive capsulitis or non inflammatory capsular adhesions

Question 12

Maximum elbow flexion test/compression test

Answer 12

The patient is asked to place their elbows in maximum elbow flexion for up to 3 minutes to close down the cubital tunnel.

P: Reproduction of parasthesia’s into the ulnar nerve distribution with possible weakness on handshake (power grip).

I: Cubital tunnel syndrome (ulnar nerve entrapment at the cubital tunnel).

Question 13

Valgus overload test of the elbow

Answer 13

The elbow is placed into 90 degrees of flexion. The examiner then places a valgus stress into the elbow while passively extending the elbow fully (dynamic extension).

P: Pain in the posterior elbow with a reproduction of a locking or catching sensation or an inability to fully extend the elbow due to pain.

I: Posterior elbow impingement syndrome

Question 14

Reverse Mills test

Answer 14

The elbow is extended and the forearm is supinated. The wrist is then fully passively extended. The test is designed to confirm the golfers elbow test.

P: Reproduction of pain in the medial elbow

I: Medial epicondylitis or Golfers elbow

Question 15

Froments paper sign (alternate)

Answer 15

The examiner asks a patient to hold a piece of paper in their hand between the thumb and index finger with the thumb adducted. The examiner then attempts to pull the paper from the patient’s grasp while they attempt to resist.

P: The patient is seen to flex the thumb thereby recruiting the median nerve to compensate for apparent weakness.

I: Weakness or palsy of the adductor pollicus muscle – innervated by the ulnar nerve. Look for wasting of the dorsal thumb web.

Question 16

Craig test for Anteversion

Answer 16

The patient lies prone with the involved side’s knee flexed to 90 degrees. With the examiners hand grasping the distal tib/fib, the hip is internally rotated until the greater trochanter comes parallel to the table.

P: If the hip is internally rotated in excess of 30 degrees in order for the greater trochanter to attain a parallel position, the patient is considered to have a structural anteversion.

Question 17

Hip impingement sign

Answer 17

The patient is supine with hip flexed to 90 degrees. The hip is then adducted across the midline of the body and the examiner forcefully internally rotates the hip.

P: Sharp anterior catching hip pain

I: Hip impingement syndrome

Question 18

Modified Ober test

Answer 18

The patient is side lying with the involved side up. The bottom leg is flexed to allow stability. The patient is moved to the edge of the table and uses their thigh to stabilize the patient’s sacrum and pelvis. The involved legs knee is extended completely and the hip is extended slightly. The examiner then lowers the involved leg off the side of the table.

P: The hip and lateral thigh remains in abduction (does not angle down towards the floor). The patient experiences lateral thigh pain upon this maneuver.

I: Tight TFL (possible contracture) with possible IT band syndrome.

Question 19

Test for synovial knee Plica (Patellar bowstring)

Answer 19

The patient is side lying with the involved side up. The knee is placed in 30 degrees flexion. The examiner grasps the lateral aspect of the patella with the superior hand and pushes it medially. The inferior hand internally rotates the tibia. The knee is then extended fully and flexed again to 30 degrees. The test can be repeated with a lateral pull on the patella and lateral tibial rotation.

P: Popping, snapping, clunking, grinding or stuttering of the patella

I: Medial patella pain is medial knee synovial plica syndrome. Lateral patella pain is lateral knee synovial plica syndrome.

Question 20

Noble test

Answer 20

The patient sits on the table with feet on table, the involved knee flexed to approximately 60 degrees. The examiner places their superior thumb over the lateral femoral condyle with firm pressure where the IT band runs past the knee. The examiner then passively extends the knee to full extension and then flexes the knee back to 60 degrees while maintaining firm pressure with the thumb over the lateral femoral condyle. This can be repeated a few times

P: Worse pain through 30/40 degrees of flexion/extension (painful arc of the knee) of the knee.

I: IT band syndrome or lateral knee impingement syndrome

Question 21

Godfrey “Sag” sign

Answer 21

The patient lies supine with the involved knee flexed to 90 degrees and the hip flexed to 90 degrees. The examiner grasps the distal tib/fib and asks the patient to perform a gentle hamstring contraction (bring heel to buttock). The examiner then observes the proximal anterior tibio-femoral joint.

P: The proximal tibia “sags” posteriorly due to lack of a static posterior constraint

I: ar or sprain of the posterior cruciate ligament. This test is done to confirm injury to this ligament if Drawer test proves inconclusive.

Question 22

Dreyer Sign

Answer 22

Instruct: Patient supine with knee extended. The patient is instructed to raise and then lower the leg. The examiner then applies circumferential pressure around the distal thigh to give anchorage to the quadriceps and instructs the patient to raise the leg again. With the force removed the patient is again asked to raise the leg.

P: Inability to raise the leg, peripatellar pain (without compression) Able to raise the leg, reduction in peripatellar pain when thigh pressure is applied.

I: Patella fracture

Question 23

Wilson Sign

Answer 23

Instruct: The patient is supine. The knee is flexed to 90 degrees by the examiner. The knee is extended with the tibia medially rotated. The knee is again flexed to 90 degrees and the tibia is laterally rotated and extended.

P: knee pain increases near 30 degrees of knee flexion with the tibia internally rotated. Pain disappears when the tibia is eternally rotated.

I: osteochondritis dessicans

Question 24

Fat pad squeeze test of the heel

Answer 24

The examiner depresses the patient’s fad pad forcefully and elicits a painful localized response. The examiner then squeezes the heel and fat pad together thereby creating a cushioning effect of the fat pad. Then the forcefull depression is repeated while maintaining the squeeze.

P: Pain diminishes during this procedure or feels less tender.

I: Lessening of pain rules in fat pad syndrome. If pain remains the same or is worse consider plantar fasciitis, heel spur or calcaneal stress fracture.

Question 25

Test for Plantar fasciitis

Answer 25

The examiner forcefully dorsiflexes the patient’s ankle and then forcefully extends the great toe creating a stretch effect. The examiner then palpates along the medial longitudinal arch while maintaining the passive stretch.

P: Sharp pain along the medial longitudinal arch

I: Plantar fasciitis

Question 26

Distal Tibio-Fibular squeeze test

Answer 26

The examiner squeezes the distal third of the tibio-fibular joint for 3-5 seconds.

P: Pain is reproduced while squeezing or pain is worse when releasing the tib/fib distally as it springs back

I: High ankle sprain of the tibio-femoral ligament and/or the interosseous syndesmosis

Question 27

Navicular drop test

Answer 27

The examiner uses a cloth measuring tape (an index card can also be used) and measures the distance between the navicular tubercle and the ground in a non-weight bearing patient. The patient is the instructed to stand and bear weight and the same distance is measured again. It’s normal for the navicular to drop into the medial arch to some degree.

P: The navicular drops more that 5/8” or 1.6cm’s on the cloth tape

I: Functional pronation – consider adjusting tarsals or recommending orthotics.