OSCE Flashcards
spurlings
Therapist passively extends, laterally flexes and ipsilaterally rotates patients head and
neck.
- Therapist provides a direct axial (coronal) pressure on the head
Positive sign
• Pain radiating into the arm toward which the head is side flexed during
compression
Implications
• Test positions narrow the intervertebral foramen so may lead to symptoms:
stenosis, cervical spondylosis, osteophytes, trophic, arthritic, or inflamed facet
joints, herniated disc, or vertebral fractures
foraminal compression
Therapist passively extends, laterally flexes and ipsilaterally rotates patients head and
neck.
- Therapist provides a direct axial (coronal) pressure on the head
Positive sign
• Pain radiating into the arm toward which the head is side flexed during
compression
Implications
• Test positions narrow the intervertebral foramen so may lead to symptoms:
stenosis, cervical spondylosis, osteophytes, trophic, arthritic, or inflamed facet
joints, herniated disc, or vertebral fractures
modified thomas
Thigh remains slightly flexed and does not come parallel with the table/plinth top. This
indicates a tight iliopsoas or rectus femoris. Extend the knee passively to see if the thigh drops to
the table top. If it does the tightness is coming from the rectus femoris.
• If it doesn’t then the tightness is coming from the iliopsoas
• Knee does not flex to 90 degrees. May indicate a tight rectus femoris
• Leg is abducted. May indicate hip abductors including tensor fascia latae, gluteus medius, or
iliotibial band.
• Hip appears laterally rotated. May indicate tight lateral rotators especially piriformis.
• Occasionally unilateral hamstring tightness may cause rotation of the tibia.
piriformis test
Patient is side lying. The upper hip and knee are flexed to 90 degrees. Therapist places one
hand on the pelvis for stability while the other hand pushes the knee towards the floor. If
positive, pain will be felt in the buttock or may also radiate down the leg if the sciatic nerve is
being impinged, indicating piriformis syndrome. If pain is felt locally in the muscle belly it
indicates a tight piriformis muscle.
piriformis length test
Patient is lying prone. The knees are flexed to 90 degrees. Cue the patient to allow their feet to fall to the
side while maintaining knee flexion. This will achieve hip internal rotation. About 45 degrees is “normal”.
A positive is anything less than 45 degrees and indicates a short piriformis.
cervical compression test
Patients head and neck are in neutral
- Apply an axial (coronal) pressure on patient’s head
Positive sign
• Pain radiating into the arm/arms
Implications
• Intervertebral foramen closes maximally during the test
talar tilts
ATFL
TEST: Passive PF and INV
POSITIVE= Pain along the ligament and at its attachments or excessive ROM
CFL
TEST: Passive INV from a neutral position
POSITIVE= Pain along the ligament and at its attachments or excessive ROM (Its rupture is only likely to occur if the anterior talofibular ligament is already ruptured)
Deltoid Ligament
EVR + DF PF NEUTRAL to test all fibers
thompsons test
Tests for a ruptured Achilles’ tendon
Test: Patient prone, therapist squeezes the calf muscles.
POSITIVE= Absence of plantar flexion. It may or not be painful depending on severity.
mortons
Tests for the presence of a neuroma (tumour or new growth of nerve cells) between the 3rd and
4th (sometimes 2nd and 3rd) metatarsal heads. Condition commonly called Morton’s Neuroma.
Test: Long seated, therapist encircles both hands around the metatarsal heads and squeezes them
together.
POSITIVE= Sharp pain between the 3rd and 4th (or 2nd and 3rd) metatarsal heads.
squeeze test (foot)
Tests for the presence of a neuroma (tumour or new growth of nerve cells) between the 3rd and
4th (sometimes 2nd and 3rd) metatarsal heads. Condition commonly called Morton’s Neuroma.
Test: Long seated, therapist encircles both hands around the metatarsal heads and squeezes them
together.
POSITIVE= Sharp pain between the 3rd and 4th (or 2nd and 3rd) metatarsal heads.
Sharp Pursor
Purpose of the test
• To determine subluxation of the atlas on the axis (transverse ligament tear
Test application
- therapist places one hand over patient’s forehead
while the thumb of the other hand is placed over
the spinous process of the axis to stabilitze
- patient asked to slowly flex the head
- therapist presses backward with the palm which
patient flexes the head
Positive sign
• Therapist feels the head slide backward
during the movement
• May hear a “clunk”
Implications
• Transverse ligament maintains the
positive of the odontoid process relative to
the anterior arch of C1, with a subluxation,
patient may be apprehensive to do
forward flexion during functional testing
Trans ligament stress
Purpose of the test
• Evaluate transverse ligament integrity between C1-C2
Test application
- patient lies supine
- therapist support the occiput with the palms and 3rd,
4th, 5th fingers
- therapist places index fingers in the space between
patient’s occiput and C2 SP so that the fingertips are
overlying the neural arch of C1
- the head and C1 carefully lifted anteriorly together,
allowing no flexion or extension
- hold for 10-20 seconds
Positive sign
• Soft end feel
• Muscle spasm, dizziness, nausea, paresthesia of the lip, face, or limb, nystagmus, or a
lump sensation in the throat
Implications
• Transverse ligament prevents the anterior shear of C1
• Positive indicated hypermobility at the A-A articulation
slump
This test will affect the dural sheath of the spine. This combination of movements will put a tension though the entire spine and if positive will reproduce signs and symptoms that the patient originally presented with.
Procedure: Patient is high seated with the upper limbs clasped behind the back; the therapist instructs the patient to “slump” forward through the trunk. The therapist then applies an over pressure through the shoulders to the slumped trunk. Next, the therapist instructs the patient to again bend forward this time through the neck and again applies an over pressure. With this overpressure maintained, the patient then extends the knee actively and the therapist passively dorsiflexes the ankle. Finally, the subject’s head and neck are released and returned to a neutral posture (some texts say to allow the patient to extend the neck).
A positive for this test is a reproduction of signs and symptoms that are then relieved when the head is returned to (at least) a neutral posture.
lasegues test
(S1-S3) provides innervations to the skin of the posterior surface of the thigh and leg as well as the perineum.
*Stage One: patient is lying supine and relaxed as possible, lift the straight leg slowly (some books say to also medially rotate the leg) until the patient reports pain or tightness in the back of the leg. Now lower the leg until the symptoms are no longer present (but no further)
*Stage Two: the patient’s foot is then passively dorsiflexed, also placing a stretch along the nerve (via the tibial nerve). If the patient’s symptoms return the test is then positive. The dorsiflexion of the foot is called “Bragard’s Test”
*Stage Three: if Bragard’s test does not provoke the symptoms then you will have to ask the patient to actively forward flex their neck (still maintaining the passive dorsiflexion from step 2). The forward flexion increases tension through the meninges, especially the dura mater, down through the sciatic nerve. The third stage is referred to as Brudzinski’s sign or Sotto-Hall test (sometimes even called Hyndman’s)
A positive for the SLR usually points to a posterolateral disc herniation due to the dural tension pulling the nerve towards the space-occupying lesion (or herniation) lateral to the nerve(s).
The later 2 stages of the test (DF and forward flexion) may also be positive for meningeal irritation if the patient reports pain or restrictions in the neck or back. Remember always ask where the patient is having the pain! If the patient can’t flex the neck at all they may be suffering from meningitis.
CA!: Kernig’s sign is a similar test done by attempting to extend a partially flexed knee. The difference is that Kernig’s is a test for Meningitis not a disc herniation. It is also worth noting that Kernig’s may incorrectly give a negative result in the case of viral meningitis.
The SLR can also be done in side lying or seated (Slump Test) for patients that cannot lay supine.
upper quadrant
Purpose of the test
• Evaluate facet joint irritation C0-C2
Test application (Done in Supine)
- patient’s head passively extended
- therapist then (ipsilateral) laterally flex the head
- followed by contralateral rotation
Positive sign
• Local pin-point pain at the cervical vertebra(e) in the upper cervical region
• Referral pain that follows the apophyseal joint referred pain patterns (Magee pg.
141 Figure 3-11)
Implications
• Testing action maximally closes the intervertebral foramen which can lead to
radicular symptoms
• Test is highly dependent on patient’s reported symptoms
• At any point of the test, stop if pain is reported
lower quadrant
Purpose of the test
• Evaluate facet joint irritation C2-C7
Test application
- Patient’s neck passively extended
- Therapist then (ipsilateral) laterally flex the neck
- Followed by ipsilateral rotation
Positive sign
• Local pin-point pain at the cervical vertebra(e) in the lower cervical region
• Referral pain that follows the apophyseal joint referred pain patterns (Magee pg.
141 Figure 3-11)
Implications
• Testing action maximally closes the intervertebral foramen which can lead to
radicular symptoms
• Test is highly dependent on patient’s reported symptoms
• At any point of the test, stop if pain is reported
femoral nerve stretch
This test puts the femoral nerve on stretch and unilateral pain may be positive for L2 or L3 or L4 dermatomes (mostly L2 and L3) if there is no lesion or contracture to the quadriceps muscle.
Procedure: Client is prone; therapist passively extends the hip (15 degrees) with the knee extended. If no reproduction of signs and symptoms is present the therapist then slowly passively flexes the clients heel to the buttocks.
Reproduction of pain or paresthesia over the L2 and/or L3 and/or L4 dermatome area may indicate a lesion or irritation to the femoral nerve. This feeling of paresthesia is known as formication.
valsalva
By increasing the intrathecal pressure in the spinal column the positive sign of pain or paresthesia will be felt locally in the spine and may travel down the leg(s) if there is a space-occupying lesion such as a herniated disc, an osteophyte, or a tumor.
Procedure: Ask a high-seated patient to take a breath, hold it (at least 6 seconds), and then bear down as if evacuating the bowels. Alternatively, have them blow into their thumb.
bowstring
If the SLR is positive or if irritation and inflammation of the sciatic nerve is suspected, the sciatic nerve may be directly palpated in the popliteal fossa of the knee. Pressure (or a strumming motion) on
Magee 596
the nerve will cause symptoms to be felt locally and down the leg from the part of the nerve being palpated.
Procedure: Client is supine; passively raise the client’s leg with the knee extended until pain or paresthesia is felt down the leg. Now flex the knee and place it on your shoulder to support it. With your thumb palpate just medial to the biceps femoris tendon in the popliteal fossa.
A positive is a reoccurrence of the symptoms the client originally presented with. If the inflammation is severe and chronic you may be able to feel the nerve, which will feel like a braided cord.
cram test
If the SLR is positive or if irritation and inflammation of the sciatic nerve is suspected, the sciatic nerve may be directly palpated in the popliteal fossa of the knee. Pressure (or a strumming motion) on
Magee 596
the nerve will cause symptoms to be felt locally and down the leg from the part of the nerve being palpated.
Procedure: Client is supine; passively raise the client’s leg with the knee extended until pain or paresthesia is felt down the leg. Now flex the knee and place it on your shoulder to support it. With your thumb palpate just medial to the biceps femoris tendon in the popliteal fossa.
A positive is a reoccurrence of the symptoms the client originally presented with. If the inflammation is severe and chronic you may be able to feel the nerve, which will feel like a braided cord.
segmental instability
Like Pheasant’s test, this will allow you to determine if there is any lumbar spine instability.
Procedure: Patient is prone on the table with their legs hanging off and toes on the ground; the therapist will apply an over pressure segmentally over the lumbar spine while the patient remains relaxed. The therapist then instructs the patient to lift the legs up off the floor by contracting the hip and spinal extensors. While in this position, the therapist again applies pressure over the lumbar spine segmentally.
A positive test will result in low back pain with pressure when the patient is relaxed and no pain when pressure is applied while active muscle contraction. This lack of pain is attributed to the area of instability being protected (and masked) by the muscular contraction.
kemps
Procedure: Client is standing; have them rotate and extend their trunk while running their hand down the back of their thigh. The movement provides greater provocation by decreasing the intervertebersl foramen of the lumbar spine on the side to which the client bends.
This test puts ultimate pressure on the facet joints by placing them in their closed pack position. Facet joint pain may be site specific to the facet that is provoked, or may radiate several centimeters around the joint.
Localized pain on the same side may also come from: an injured muscle being placed in a shortened position and then spasming, pressure placed on inflamed iliolumbar ligaments or from compression of the joint surfaces of the sacroiliac joint. The latter can mimic neurological pain in the Gluteal-hip region. Pain from the side not being tested usually comes from tissue being stretched.
pheasants
Procedure: Client is prone; place one hand on the patient’s lumbar spine and gently compress. With your other hand, pick up the client’s ankles and passively bring their ankles to their buttocks.
This will have the effect of lightly hyper-extending the lumbar spine. If a spinal segment is unstable it may produce pain in the lower limb. (Some versions of this test suggest an Achilles Tendon Reflex text at the beginning and end of the test)
milgrams
Procedure: Patient is supine; have the patient raise both extended legs about 2 inches off the table and hold for 30 seconds.
A positive is pain and/or an inability to raise or hold the legs of the table. This may indicate an intrathecal or extrathecal pathology. **This test may be a little over optimistic as many people have trouble holding their ankles off the table.
hoovers
This test is designed to see if the client is malingering or exaggerating their complaint of low back pain.
Procedure: Client is supine; the therapist takes each of the client’s heels in the palm of a hand. Ask the client to raise each of their legs, one at a time. When the client tries to raise one leg, you should feel a downward pressure in the palm of your hand holding the opposite leg.
If you do not feel such a pressure, then the test is positive and the client is not actually trying to lift their leg.
well leg raise
This test is performed on the leg that does not have any symptoms traveling down the back of the leg (i.e the unaffected or well leg). A positive sign is the reproduction of signs and symptoms in the patient’s affected leg. This points to a space-occupying lesion pressing on the nerve root(s) that govern the affected limb.
Procedure: Client is supine, slowly raise their well leg until either it reaches the end range or you reproduce their chief complaint of neurological symptoms down the leg on the table. A positive for the well leg raise usually points to a posteromedial disc herniation due to the dural tension pulling the nerve towards the space-occupying lesion (or herniation) medial to the nerve(s).
trendelenbergs
Tests the strength and/ or innervation of the hip
abductors (specifically gluteus medius, L5 of the stance
leg) used when stabilizing the ipsilateral pelvis on the
femur during the stance phase of ambulation. The
patient is asked to stand on one foot, if the pelvis drops
on the opposite side the test is positive. Perform on
the opposite side first so the patient understands what
to do.
rocking /Squish
Patient is lying supine. Therapist places his/her
hands over the patient’s anterior superior iliac
spines with the elbow slightly bent. Take up the
slack and initiate a “down and in” rocking motion
at a 45-degree angle on one of the ASIS’s at a
time. A positive is pain felt in the region of the
sacroiliac joint, meaning that the posterior
sacroiliac ligaments are injured. An immediate
translation of the pressure on one ASIS into the
other implies the ASIS being pressured is locked.
gapping
Patient is lying supine. Therapist crosses arms and places hands over the patient’s anterior
superior iliac spines and applies pressure down and out so the anterior superior iliac spines move
apart. A positive is unilateral gluteal or posterior leg pain, indicating anterior sacroiliac ligaments
injury. Be aware of the amount of pressure you’re applying on the anterior hips since the anterior muscles
are commonly tight.
anterior transverse stress test
Patient is lying supine. Therapist crosses arms and places hands over the patient’s anterior
superior iliac spines and applies pressure down and out so the anterior superior iliac spines move
apart. A positive is unilateral gluteal or posterior leg pain, indicating anterior sacroiliac ligaments
injury. Be aware of the amount of pressure you’re applying on the anterior hips since the anterior muscles
are commonly tight.
posterior transverse stress test
Patient is side lying. The therapist places their hands over the iliac
crest and pushes toward the table/plinth. The test is designed to
increase the pressure in the sacroiliac joint and may indicate a
possible sacroiliac lesion of the posterior ligaments. Note only
needs to be done on one side because both SI’s are being
tested at the same time.
approximation
Patient is side lying. The therapist places their hands over the iliac
crest and pushes toward the table/plinth. The test is designed to
increase the pressure in the sacroiliac joint and may indicate a
possible sacroiliac lesion of the posterior ligaments. Note only
needs to be done on one side because both SI’s are being
tested at the same time.
gaenslens sign
Patient is lying supine at the edge of the table/plinth. Both knees are
flexed to their chest, the outer leg is allowed to drop over the edge
of the table, while the inner knee is kept held to the chest. This forces
the ipsilateral innominate to anteriorly rotate (sagittal plane) while
the contra-lateral sacroiliac joint is stabilized by the flexed hip.
Indicates a sacroiliac joint dysfunction on the ipsilateral side, hip
pathology or a L4 nerve root lesion.
supine to sit
The patient is lying supine with the knee flexed to 90 degrees. Instruct the patient to lift their buttocks off
the table then drop back to the table. (This allows the musculature to relax around the pelvis). The
therapist passively extends the legs and palpates the apex of the medial malleoli to determine which leg
lies longer on the table. The patient then rises to a long sitting position, while the therapist watches the
movement of the malleoli carefully and then rechecks the relative position of the malleoli in the long
sitting position. Note if one leg appears to shoot back and forth during the movement of sitting up. Using
the right side as the affected side: If the ilium is posteriorly rotated (sagittally), the leg will appear to
lengthen when the patient sits up, from the shortened position it appeared to be in when they were lying
supine. If the ilium is anteriorly rotated (sagittally), the leg will appear to shorten when the patient sits up,
from the lengthened (or same length) position it appeared to be in when they were lying supine. This may
be caused by iliosacral dysfunction/anterior-posterior sagittal rotation or lumbar muscle spasm in the
presence of lumbar pathology.
Starts short and finishes long = posterior sagittal rotation
Starts long and finishes short = anterior sagittal rotation
Gillet’s
To perform this test, the patient stands while the examiner palpates the posterior superior iliac spine (PSIS) with one thumb and palpates the base of the sacrum with the other thumb medial to the PSIS. The patient is then instructed to stand on one leg while pulling the hip of the side being palpated into 90° or more of hip flexion. The test is then repeated on the other side and compared bilaterally[4][5]. The examiner should compare each side for quality and amplitude of movement[6].
In a normally functioning pelvis, the pelvis of the side being palpated should rotate posteriorly, causing the PSIS to drop or move inferiorly. There should also be symmetry in amount of movement between both the left and right SIJ. The test is positive when the PSIS on the ipsilateral side (same side of the body) of the knee flexion moves minimally in the inferior direction, doesn’t move or is associated with pain. A positive test is an indication of sacroiliac joint hypomobility
patrick
The patient is lying supine. The leg being tested is flexed
and the foot is placed on the knee of the opposite leg so
the patient is in a figure 4 position. (Avoid the
malleolus being directly on the patella.) The leg being
tested is then abducted toward the table and allowed
to relax. This primarily tests the flexibility of the
adductor muscles but pain in the inguinal region can
indicate a hip joint pathology and pain the in region of the
sacroiliac joint can indicated a SI joint lesion.
Faber = F Ab ER = Flexion, abduction, external rotation
roos
patient is seated or standing
• both arms are at 90 degrees of shoulder abduction and
externally rotated
• patient actively brings both elbows to 90 degrees of
flexion
• patient slowly opens and closes the hand for 3 minutes
Positive sign: the inability to maintain the upper limb position,
ischemic pain, numbness or paresthesia of the limb, or
heaviness of the arm.
wrights
palpate the radial pulse on the side being tested
§ ask your patient to take a deep breath and hold it
§ passively fully abduct the patient’s arm (do not allow elevation)
costoclavicular TOS test
palpate the radial pulse on the side being tested
§ ask your patient to stand with the shoulders down and
back in an exaggerated military stance
§ get your patient to take a deep breath
Positive sign: a diminishment of pulse and reproduction of signs
and symptoms.
adson
palpate the radial pulse on the side being tested
§ slightly extend the shoulder and apply a downward
traction
§ ask your patient to take a deep breath and hold, while
actively extending and ipsilaterally rotating the neck
Positive sign: a diminishment of pulse and reproduction of signs
and symptoms.
halstead
§ palpate the radial pulse on the side being tested
§ slightly extend the shoulder and apply a downward
traction
§ ask your patient to take a deep breath and hold, while
actively extending and contralaterally rotating the
neck
Positive sign: a diminishment of pulse and reproduction of
signs and symptoms
