Viva

Question 1

How can we assess ACJ pathology?

Answer 1

• Cross Body Adduction Test
• Patient places hand on opposite shoulder with shoulder at 90 deg flexion. EP passively moves hand posteriorly over shoulder (cross/horizontal adduction).
• Positive test: Localised pain over ACJ.

Question 2

How do we assess impingement of ACJ?

Answer 2

• Hawkins/Kennedy test
• Including supraspinatus tendon
• Pt. Examined seated with arm at 90 deg horizontal flexion and elbow flexed 90 deg, arm supported by EP. Stabilise elbow and wrist. Move arm quickly into int. Rot. Impingement between greater tuberosity of humerus against Coraco-humeral ligament, trapping structures that intervene.
• Positive test: pain located in sub-acromial space.

Question 3

How can we assess integrity of supraspinatus tendon?

Answer 3

• Empty can test
• pt. tested at 90 deg elevation in scapular plane, 30 deg horizontal flexion, and full int. Rot. Pt. resists downward pressure by EP at elbow or wrist.
• Positive test: indicated by pain during pressure or an inability to resist pressure.

Question 4

How can we assess subacromial impingement?

Answer 4

• Neers test
• EP performs maximal passive abduction in scapular plane, with int. rot. Ensure scapula is stabilised from behind. Forced elevation of humerus while holding the other hand on top of shoulder girdle.
• Positive test: pain is reported in the anterior-lateral aspect of the shoulder , subacromial space, or anterior edge of acromion.
• Elevation of arm in ext. or int. rot. causes critical areas to pass under the coracoacromial ligament or anterior acromion.

Question 5

How can we assess subacromial impingement or RC tear?

Answer 5

• Infraspinatus muscle strength test
• pt. Standing, arm in neutral position, elbow flexed 90 deg
• EP applies medial force to arm while pt. resists.
• Positive test: pain or weakness upon resistance.

Question 6

How can we assess full thickness RC tear (integrity of supraspinatus/infraspinatus tendons)?

Answer 6

• External rotation lag sign test
• pt. seated with elbow passively flexed to 90 deg, shoulder abducted to 90 deg, and 5 deg off maximal ext. rot. Pt. actively maintains position when wrist released and elbow supported.
• Positive test: inability to maintain position

Question 7

How can we assess biceps tendon pathology?

Answer 7

• Yergason’s test
• Pt. Elbow flexed to 90 deg and forearm pronated. EP holds wrist to resist active supination.
• Positive test: pain in bicipital groove is positive for bicep injury. Pain local to bicipital groove area suggests pathology in long head of biceps in its sheath.

Question 8

How can we assess for pathology of long head biceps tendon in its groove?

Answer 8

• Speeds test
• pt. elbow extended, forearm supinated and humerus elevated to 60 deg. Forward flex shoulder against EP resistance while maintaining elbow in extension and forearm in supination.
• Positive test: pain or tenderness in the bicipital groove indicates bicipital tendinitis.

Question 9

How to measure shoulder abduction ROM?

Answer 9

Shoulder Abduction AROM

• pt. supine in anatomical position, scapular stabilised to prevent upward rotation and elevation, arm abducted, thorax stabilised to prevent lateral flexion. End feel firm due to tension in middle and inferior GH ligaments, inferior joint capsule, and surrounding muscle.
• Goniometer placed over anterior acromion, proximal parallel to midline of sternum, distal aligned with medial midline of humerus.
• 180 deg

Question 10

How can we assess subacromial bursitis?

Answer 10

• Shoulder abduction to 70-80 deg traps bursa and pain relieved >120 deg.
• need to differentiate between biceps tendinitis/supraspinatus

Question 11

How can we assess supraspinatus bursitis?

Answer 11

• Shoulder abduction- pain and muscle weakness increases between 80-120 deg
• Need to differentiate biceps tendinitis

Question 12

How can we assess passive length pec major and minor?

Answer 12

• Pec minor: (70 deg) arms by side, push down on coracoid process (+ve if stress experienced)
• Pec major:(45 deg) hands under head (+ve inability to bring elbows down)

Question 13

How can we assess limitations in the upper limb?

Answer 13

• Apley’s scratch test —>perform bilaterally to compare
• Touch opposite shoulder with hand:GH adduction, int. rot., horizontal adduction, scapular protraction
• place arm overhead to reach behind neck to touch upper back: GH abduction, ext. rot. and scapular upward rotation and elevation
• place hand on lower back and reach upward as far as possible: GH adduction, int. rot. and scapular retraction with downward rotation.

Question 14

How can we assess for abnormal scapular movement or malposition?

Answer 14

• Lateral slide test
• Measure from inferior medial tip of scapula to nearest spinous process @ arms by side, hands on hips, arms abducted 90 deg and maximally int. rot.
• Abnormal movement can be related to shoulder pathology.

Question 15

How can we assess subscapularis rupture or dysfunction?

Answer 15

• Gerber’s test
• standing, place hand behind back with dorsum resting on mid-lumbar spine. Raise off back by maintaining or increasing int. rot. at the humerus and extension at the shoulder.
• Positive test: inability to move dorsum off back
  IF CANNOT MEDIALLY ROTATE SHOULDER TO PUT HAND BEHIND BACK
• Belly press test (subscapularis lesion)
• EP hand on abdomen. Pt. places hand on stomach and applies pressure. Brings elbow forward into scapula plane (increased med. rot. at shoulder)
• Positive test: pain upon pressure, inability to maintain pressure, extension of shoulder.

Question 16

Shoulder instability

How can we assess anterior/posterior laxity of shoulder?

Answer 16

• Load and shift test
• Movement 25% within normal clinical boundaries
• pt. arms on pillow, seated, arm in 10-15 deg abduction
  . Stabilise scapular and load (push in) humeral head using pinch grip. Test laxity by anteriorly and posteriorly displacing humerus.

Question 17

How can we assess shoulder instability and comfortable ROM?

Answer 17

• Apprehension test
• supine, shoulder abducted 90 deg, elbow flexed 90 deg. Ext. rot. shoulder. Screen for guarding, facial expression, vocal prompts.
  THEN
• Apprehension and relocation test
• (as per apprehension test) . At full range, apply posterior force on shoulder. Checked for reduced apprehension, displacement posteriorly, and clicking in joint.

Question 18

How can we assess for a superior labrum from anterior to posterior (SLAP) lesion?

Answer 18

• Anterior slide test
• seated, hands on hips, thumb posterior. EP hand on shoulder proximal to GH joint in order to stabilise scapula, acromion, and clavicle. Other hand on elbow. Apply superior and anterior force while stabilising shoulder. Pt. resists.
• Positive test: pain reproduced or click or pop is felt local to anterior shoulder. Accurate for determining tear in superior glenoid labrum near origin of long head of biceps.

Question 19

How can we assess latissimus Doris length?

Answer 19

• Latissimus Doris length test
• supine with knees bent, rotate pelvis posteriorly to flatten lumbar spine, rotate palms upwards (shoulder ext. rot.). Extends arm over head.
• Positive test: int. rot. of hands, movement into lumbar lordosis, imbalances between sides

Question 20

How can we assess movements that alter neural tension in the upper limb?

Answer 20

• Upper limb tension test
• Supine, edge on plinth, neck laterally flexed away from testing side. Shoulder depressed with left hand, arm abducted to 110 deg and ext. rot. Forearm supinated and wrist and fingers extended. Elbow extended to point of symptom onset. Neck position returns to neutral and laterally flexed to side of test.
• used to reproduce symptoms and identify differences between sides.

Question 21

How can we assess if a herniated disc, neural tension, or altered neurodynamics are contributing to patient’s symptoms?

Answer 21

• Slump test
• Pt. seated upright with hands held together behind back. Flex spine (slump) then flex neck. Place pressure on top of head. Extend knee. Dorsiflex foot. Alternate knee. Neck back to neutral.
• Positive test: if symptoms are increased in slumped position and decreased as pt. moved out of neck flexion.

Question 22

How can we measure hip abduction ROM?

Answer 22

• Hip abduction AROM
• Active range 45 deg
• Supine, neutral, knee extended, abduct hip while stabilising pelvis to prevent rotation and lateral tilting. Ankle held to prevent lateral rotation of hip. End when pelvis starts to tilt, lat flex of spine. End feel is firm due to tension in joint capsule, adductor muscles, pubofemoral, and medial band of Iliofemoral ligaments.
• Goniometer placed over ASIS, proximal arm aligned with opposite ASIS, distal arm aligned with midline of patella.

Question 23

How can we measure hip external rotation ROM?

Answer 23

• Lateral rotation AROM
• Active range 45 deg
• Femoral shaft moves posteriorly and laterally
• seated with legs hanging, hip 90 deg (towel under thigh to maintain horizontal femur placement). Stabilise distal femur to prevent adduction and further flexion of hip. Rotate hip laterally by moving leg toward midline. End of movement when pelvis lifts off surface. End feel firm due to tension in joint capsule, iliofemoral, pubofemoral ligaments and medial rotators.
• Goniometer placed on patella, arm towards floor, other arm between malleoli.

Question 24

How can we assess adductor muscle length?

Answer 24

• Adductor muscle length test
• Feet together, legs abducted at hip (45 deg). Posterior displacement force applied.
• Resistance to stretch indicative of tight adductor muscles.

Question 25

How can we assess for tight ITB or abductor muscle length?

Answer 25

• Obers test
• on side with 90 deg hip and knee flexion. Passively move top leg backward until 5-10 deg hip extension. Stabilise pelvis to prevent hip flexion and int. rotation. Lower leg to surface.
• Positive test: continued abduction of thigh and/or lateral knee pain indicative of tight ITB.
• Adequate length if thigh displaced below horizontal.

Question 26

How can we assess hamstring length (knee straight)?

Answer 26

• Hamstring length PROM
• supine, passive hip flexion
• Lateral (biceps fem) int. rotate and adduct
• Medial (semi memb and tend) ext. rotate and abduct

Question 27

How can we assess hamstring length (knee bent)?

Answer 27

• Bent knee hamstring length (functional, reduces impact of neural tension through bent knee).
• Supine, neutral spine, testing knee and hip 90 deg, feet neutral. Passive extension of bent knee. End range of muscle - tension or pelvic rotation
  Normal range 45-90 deg

Question 28

How can we assess quadricep muscle length?

Answer 28

• Quad muscle length test

- Passive hip extension with knee straight

Question 29

How can we assess psoas muscle length?

Answer 29

• Psoas muscle length test

- Passive hip extension with flexed knee

Question 30

How can we assess piriformis muscle length (also articulation of sciatic nerve through or under piriformis muscle)?

Answer 30

• Piriformis length test
• side lying 60-90 deg hip flexion and 90 deg knee flexion. Stabilise pelvis, provide pressure on lateral surface of the knee (providing adduction force).
• positive if pain in buttock or radiating to lower back

Question 31

How can we assess psoas muscle strength?

Answer 31

• Resistive hip flexion

- Attempt to manoeuvre pt. into hip extension through placing a posterior force on the knee.

Question 32

How can we assess Gluteus Medius muscle strength?

Answer 32

• Resistive hip extension

- Measure prone, isolate glute med by bending knee.

Question 33

How can we assess Hip Adductor muscle strength?

Answer 33

• Resistive hip adduction
• Side lying, bottom leg in neutral hip and knee position, top leg 90 deg hip and knee flexion. Pt. attempts to adduct bottom leg against resistance.

Question 34

How can we assess Hip Abductor muscle strength?

Answer 34

• Resistive hip abduction

- Side lying, Botton leg 90 deg hip and knee flexion, top leg neutral. Pt. attempts to abduct top leg against resistance

Question 35

Resistive hip internal and external rotation

Question 36

How can we assess anterior-superior impingement syndrome, anterior labral tear, iliopsoas tendinitis/dysfunction?

Answer 36

• FADIR test
• Able to determine contribution of the non-contractile elements to pain
• Supine, passively moved into hip flexion, lat rot. and full abduction as starting position. Passively moved into hip extension while combining int. Rot. with adduction motion.
• positive test: provocation of symptoms with or without click.
• Pain flex. to ext. indicative of iliopsoas dysfunction “snapping sensation”
• Pain upon full flexion and int. and ext. rot. indicative of anterior-superior impingement syndrome.
• Pain upon medial rotation and adduction is indicative of anterior labral tear.

Question 37

How can we assess knee and ankle recruitment?

Answer 37

• Single leg stand
• (or 3x slow single leg knee bend/hopping)
• Things to monitor:
  —>Ant. Pelvic tilt - use of back extensors to stabilise. Not engaging core
  —>Supporting leg pelvis shifts lat. or dips - weak glute med muscle
  —>Pelvis hitching on opposite side-overactive quadratus lumborum and weak glute med in supporting leg
  —>Hip int. rot. (Valgus) -weak hip ext. rotators
  —>Hip ext. rot. (Varus) - poor balance and/or supinated foot
  —>Foot pronation -weak ankle stabilisers and/or past ankle injury
  —>Toe gripping-weak intrinsic muscles of the feet and/or reduced arch stability

Question 38

How can we assess Gastrocnemius and Soleus muscle length?

Answer 38

• Knee to wall test
• Foot placed 5cm from wall, toe of rear foot placed 1 FOOT LENGTH behind heel of front foot> Place hands on wall for balance. Pt. asked to bend knee into lunge position with neutral foot and pelvis position. Knee should track over 2nd toe, both feet flat on floor.
• Soleus restriction: Inability to touch the FRONT kneecap to the wall with heel down indicates lack of soleus length. —>ability to displace knee 8cm from toes indicates elongated soleus
• Gastroc restriction: Inability to keep REAR heel down with knee locked and lunge forward indicates lack of gastroc length.—>isolate gastroc by placing knee against wall, displace foot backwards until heel contact and alignment cannot be maintained.

Question 39

Knee stability

How can we assess MCL stability?

Answer 39

• MCL stability test
• two testing positions: knee full ext. (ACL involvement), 30 deg flex. (MCL primary stabiliser). EP places valgus (int. force)-stabilising leg against femoral rotation
• Assess for onset of pain, extent of valgus movement, and end point

Question 40

Knee stability

How can we assess LCL stability?

Answer 40

• LCL stability test
• Knee in full ext. and 30 deg flex. (MCL primary stabiliser). EP applies a varus (ext. force)- stabilising leg against femoral rotation
• Assess for onset of pain, extent of varus movement, and end point

Question 41

Knee stability

How can we assess ACL laxity and stability/quality of end point?

Answer 41

• Lachman’s test
• knee 15 deg of flex. Ensure hamstrings relaxed, draw tibia forward
• Positive if end feel soft or more translation compared to other side
• in patients with normal ACL, maximally anterior position of tibia can be used as starting point for reverse Lachman.

Question 42

Knee stability

How can we assess PCL integrity?

Answer 42

• Reverse lachman’s test
• knee 15 deg flex., hams relaxed, posterior force on tibia
• positive if end feel is soft of translation larger compared to other leg

Question 43

Knee stability

How can we assess ACL laxity - degree of movement and quality of end point?

Answer 43

• Anterior Draw Test
• Knee 90 deg flex., pt. foot stabilised with hamstring relaxed, index fingers placed on femoral condyles, tibia drawn anteriorly.
• positive if tibia translates anterior more than 6mm or if soft end feel
• can be performed with tibia int and ext rot. to assess anterolateral and anteromedial instability

Question 44

Knee stability

How can we assess anterolateral rotary instability of the knee?

Answer 44

• Pivot Shift Test
• ACL, LCL, posterolateral capsule and ITB
• Hold knee in full ext. with tibia int. rot. Hip 20-30 deg flex. Apply valgus force (Anterior cruciate deficient knee condyles will be subluxated). Knee flexed, listen for ‘clunk’ of reduction (positive shift test). Extend knee, feel for click into subluxation (positive jerk test).
• A positive test is indicated by subluxation of the tibia while the femur rotated externally followed by a reduction of the tibia at 30-40 deg of flex. (Due to ITB involvement)

Question 45

Knee stability

How can we assess for PCL deficiency?

Answer 45

• Posterior Sag Test
• Both knees flexed 90 deg, quads and hams relaxed, assess position of tibia relative to femur.
• Positive test: PCL deficient knee will be displaced posteriorly

Question 46

Knee stability

How can we assess PCL laxity -degree of movement and quality of end point?

Answer 46

• Posterior Draw Test
• Knee 90 deg flex. and pt. foot stabilised with hamstring relaxed. Thumbs placed on tibial tubercle. Tibia displaced posteriorly.
• Positive if tibia displaced more than 6mm or soft end feel
• can be performed with tibia ext. rot. to assess posterolateral capsule integrity.

Question 47

Knee stability

How can we assess for meniscus injury?

Answer 47

• McMurray’s test
• knee and hip flexed 90 deg, hip stabilised.
• Test for medial meniscus injury: tibia ext. rot. and valgus force applied
• Test for lateral meniscus injury:tibia int. Rot. and varus force applied
• Rotational manoeuvre of knee-uses the tibia to trap meniscus between the condyles of the femur
  Positive test: screen for locking, clicking and pain

Question 48

How can we measure ankle eversion (pronation) ROM?

Answer 48

• Ankle Eversion AROM
• 15-20 deg
• seated, tibia and fibula stabilised to prevent lat. rot. and flex. at knee and med. rot and adduction at hip. Foot everted.
• End feel firm due to tension in medial, dorsal and plantar ligaments and tibialis posterior
• Goniometer midway between malleoli, proximal arm towards tibial tuberosity, distal aligned with 2nd metatarsal

Question 49

How can we measure ankle inversion (supination) ROM?

Answer 49

• Ankle inversion AROM
• 30-50 deg
• seated, tibia and fibula stabilised to prevent med rot and extension at knee and lat rot and abduction at hip. Foot inverted. End feel firm due to tension in anterior, posterior, lateral, dorsal and plantar ligaments and peroneus Lingus and breves.
• Goniometer between malleoli, proximal arm toward tibial tuberosity, distal arm aligned with 2nd metatarsal.

Question 50

How can we assess Achilles’ tendon integrity?

Answer 50

• Simmond’s Calf Squeeze Test
• Prone, fleshy part of calf squeezed.
• Test positive if the foot fails to plantarflex
• Common site of tendon rupture is 2-6 cm proximal to calcaneus.

Question 51

How can we assess for sacroiliac joint or hip joint being source of patient’s pain?

Answer 51

• FABER Test
• leg in figure 4 position where knee is flexed and ankle placed on opposite knee. Posterior force applied against medial knee of bent leg.
• Positive test: groin pain or buttock pain produced + due to forces going through hip, Pt. may experience pain if pathology also in hip.
• Sacroiliac joint dysfunction can be assessed with pt. side lying with knees together and hips 45 deg flex. Screen for increase pain when compression force placed on iliac crest (compression test)

Question 52

How can we assess sacroiliac joint dysfunction?

Answer 52

• Compression test
• pt. side lying with knees together and hips 45 deg flex. Screen for increase pain when compression force placed on iliac crest x3

Question 53

How can we assess flexibility of iliopsoas, rectus femoris, tensor fascia latae, and sartorius muscles?

Answer 53

• The Thomas test
• Supine, both knees held, one limb released and lowered to table, length of iliopsoas measured by angle of hip flexion ( With patient supine with both hips flexed and maintaining one hip in flexion, the tested hip is extended. Thomas test Positive if unable to touch posterior thigh with examination table.)
• Negative if pt. lower back and sacrum are able to remain on table, hip can passively move into 10 deg of hip extension and the knee passively moved to 90 deg flex.
  -Positive;
  —> Psoas tight: lower back and sacrum not touching table + hip in posterior tilt or flexed
  —>Psoas dysfunction: Hip extension greater than 15 deg
  —> Rectus Femoris tightness: knee unable to maintain 80 deg flexion
  -Additional clinical indicators:
  —>presence of abducted hip indicative of TFL and ITB tightness
  —>presence of tibial lat. rot. is indicative of biceps femoris tightness
  —> presence of med. rot. of the hip is indicative of sartorius tightness (as knee bent)

Question 54

How can we assess gluteus medius tendon tears or weakness in hip abductors?

Answer 54

• Trendelenburg test
• Stand on one leg
• Positive test: 1. Compensated-> pt. trunk leans ipsilaterally to side of stance leg
  2. Uncompensated->occurs when EP observes contra lateral pelvic drop
• Normal test when able to maintain level pelvis without these substitutions. Hip hike not true trendelenburg.

Question 55

How can we assess order of recruitment of lumbar spine erector spine, gluteus maximum, and hamstrings during hip extension?

Answer 55

• Gluteal firing test
• Prone, finger contact with muscles, extend leg st hip maintaining neutral hip
• Correct pattern glute max -> Hamstrings-> ES
• Additional assessment: side lying, assess deg of glute recruitment to 20 deg abduction. Apply resistance and assess for increased recruitment.

Question 56

How can we assess weakness in hip external rotators?

Answer 56

• Dynamic Hip Ext. Rot
• Clam movement with spine neutral, feet in line with glutes and knees at equal angles. Downward force to assess strength
• Positive test:
  > posterior pelvis rotation
  > recruitment of TFL and hip extensors
  >hip hitching (recruitment of QL)
  > Lifting heels
  > No core muscle activation
  > Excessive tension in upper body and neck for stabilisation (lack of strength)

Question 57

How can we assess lumbar flexion control?

Answer 57

• Waiter bow assessment
• Feet wider than hip, knees unlocked, hands held in front. Bend at hips, maintaining straight back. Note angle hip flexion where loss of neutral spine occurs.
• Positive test: loss of neutral spine prior to 45 deg, compensatory signs in cervical spine, thoracic spine, pelvis rot.
• Less than 50 deg indicates can’t use hip hing exercises (positions that increase flex. forces through lumbar spine.

Question 58

How can we assess presence of disc herniate on or sciatic nerve issues?

Answer 58

• Straight leg raise
• Passively flex hip while maintaining knee in full extension. Note deg where pain reported or reproduction of symptoms
  Positive test:
  ->Disc herniation: pain reproduction at 40 deg hip flex. or less
  ->At 75 deg sciatic nerve on stretch, displace leg in and out of pain range. If pain REDUCES=MUSCULAR. Dorsiflex foot outside painful range, if INCREASE PAIN=SCIATIC NERVE. Pain local to OPPOSITE side is indicative of HERNIATED DISC.

Question 59

How can we assess contribution of neural tension to pt. symptoms?

Answer 59

• Prone knee bend
• Lies prone, flex knee, add hip extension.
• Positive test:
• > pain in anterior thigh indicates tight/strained QUADS or neural tension of FEMORAL NERVE
• > pain on unilateral lumbar area, buttock, or posterior thigh may indicate LUMBAR RADICULOPATHY of L2-L3 nerve roots.

Question 60

How can we assess integrity of anterior talo-fibular ligament (ATFL)?

Answer 60

• Anterior Draw test
• seated, ankle in neutral position, 20 deg plantar flexion, displaced off table. Stabilise tibia anteriorly, hand under heel of foot. Pressure exerted upwards and degree of excursion noted and compared to uninjured side.
  (use pillow under knee to prevent guarding by immobilising gastrocnemius)

Question 61

How can we assess integrity of calcaneofibular ligament?

Answer 61

• Talar tilt test
• Seated, ankle neutral 20 deg plantar flexion, ankle displaced off table. Stabilise tibia to prevent rotation. Hand under heel of foot. Medial and lateral movement of talus and calcaneus assessed in relation to tibia and fibula.