Special Tests and Diagnostic Signs

Question 1

Kiloh-Nevin sign

Answer 1

Inability to form the OK sign from AIN palsy (weakness of FPL and radial FDP).

Question 2

Scapular flip sign.

Answer 2

The medial border of the scapula “flips away” from the thoracic wall during resisted ER. This occurs from weak middle and lower trapezius being unable to oppose external rotators and is indicative of spinal accessory nerve palsy.

Question 3

Elson Test (Classic and modified)

Answer 3

The Elson test and modified Elson test are used to identify a disruption of the central slip after an acute closed boutonnire injury. This test requires full flexion of the PIP off the edge of a table. The patient is asked to extend the PIP joint and is observed for extension at the DIP joint. If the central slip is disrupted, PIP joint extension will be weaker and there will be increased extensor tone present in the DIP (compared to the uninvolved side). If the central slip is intact, flexion of the PIP advances the extensor mechanism, resulting in distal slack in the lateral bands and an inability to extend the DIP. With the modified Elson test, the patients fingers (involved and uninvolved) are flexed to 90 degrees at the PIP joint and the patient is asked to extend the DIP joints. The finger with the central slip injury will be able to extend at the DIP joint more than the uninvolved digit. References: 1. Elson R. A. (1986). Rupture of the central slip of the extensor hood of the finger. A test for early diagnosis. The Journal of Bone and Joint Surgery. British Volume, 68(2), 229231. https://doi.org/10.1302/0301-620X.68B2.3958008

Question 4

What are some often used shoulder special tests of questionable or no value?

Answer 4

Internal rotation lag sign for subscapularis (one study of moderate quality). Full can supraspinatus test. Empty can test. Belly press test for subscapularis (diagnostics unknown). Neer impingement test. Hawkins-Kennedy Test. Drop arm test. Active Compression Test. Speed Test.

Question 5

Lateral Jobe Test

Answer 5

For Impingement / RC tear: Abduct shoulder to 90 deg and full IR. Press downward on the elbow. Positive = weakness, pain, or inability to perform the test. It is moderately dependable for ruling pathology in or out

Question 6

External Rotation Lag Sign

Answer 6

For full-thickness RC tear: Shoulder is placed by examiner in 20-30 deg abduction and full ER and elbow flexed to 90. A positive test is inability to hold position. Moderately dependable for ruling pathology in.

Question 7

Infraspinatus Test

Answer 7

Patient stands with shoulder slightly abducted and ER. Examiner provides IR force while patient resists. Positive sign is inability to resist. Small to moderate value ruling in pathology.

Question 8

The Shrug Sign

Answer 8

For massive RC tear. Pt is asked to abduct shoulder to 90 degrees. Positive sign is need to shrug to achieve this. Small value for ruling in and large value for ruling out.

Question 9

Best Cluster for Rotator Cuff Tear

Answer 9

Positive if 1) age is or greater than 65 2) weakness in ER (+ infraspinatus test) 3) pain at night. Moderate to strong when ruling in

Question 10

Belly-Off Test

Answer 10

For subscapularis pathology. Examiner stands in front of Pt while passively moving affected UE into flexion and IR with elbow flexed to 90 (put Pt’s palm on her belly). Examiner supports Pt’s elbow while bringing shoulder into maximal IR. Examiner also has his on patient’s wrist, maintaining palm against her belly. The patient is asked to keep wrist straight and maintain position while examiner removes his hand from her wrist. Positive sign is inability to maintain position, including wrist flexing. Moderate for ruling in or out.

Question 11

Modified Belly Press Test

Answer 11

For subscapularis pathology. Place Pt’s hands on her belly with elbows at sides. Examiner instructs Pt to bring elbow forward while straightening the rest, then measures the angle at the wrist. Positive test is a difference greater than 10 deg on contralateral side. Moderate for ruling in and out.

Question 12

Bear Hug Test

Answer 12

For subscapularis pathology. Pt places hand of affected arm on opposite shoulder. Examiner supports the elbow while attempting to lift hand up and off, positive result being Pt being unable to keep hand on shoulder. Moderate value ruling in, small value for ruling out.

Question 13

Subacromial Grind Test

Answer 13

For RC tears. Examiner places the patient’s arm in 90 deg scaption and puts other hand on GH joint to feel for crepitus. Examiner internally and externally rotates Pt’s shoulder, feeling for crepitus, which is positive indication. Strong when ruling in and small when ruling out any tear.

Question 14

A ‘clunk’ with radial and ulnar deviation of the wrist is characteristic of what injury?

Answer 14

SL injury.

Question 15

Cozen’s Test

Answer 15

For lateral epicondylitis, particularly involvement of ECRB. There are variations of this test, but the purple book describes resisted wrist extension in elbow flexion and then extension.

Question 16

Bouvier’s Test

Answer 16

Used to deterine if the PIP joint capsules and extensor mechanisms are functioning properly in cases of claw hand. A positive test (functioning properly) occurs when blocking hyperextension of the MPs results in IP extension (indicative of intrinsic paralysis instead of mechanical deficit).