Performing the Examination in a Station
An examination station rewards what the examiner can see and hear: a test performed with the correct hand placement, in the correct position, explained to the patient, and finished with the finding stated aloud. Knowing that Spurling test suggests a cervical radiculopathy earns nothing if you do it with the head in flexion and then say nothing. This chapter turns the vital signs, orthopedic and neurological examinations into performance routines you can run under time, safely, with the reasoning that tells you which tests deserve the minutes you have.
By the end of this chapter you can
- Measure blood pressure, pulse and respiration with correct technique, recognize the common measurement errors, and interpret values against current adult categories.
- Perform an efficient general inspection, posture and gait screen and state findings aloud in plain clinical language.
- Perform the core cervical, thoracic, lumbar and pelvic orthopedic tests correctly and say what a positive finding is and what it suggests.
- Perform the core shoulder, elbow, wrist and hand, hip, knee and ankle tests with correct positioning, and apply the Ottawa rules.
- Run a regional neurological screen of dermatomes, myotomes and deep tendon reflexes, grade the findings, and check for upper motor neuron signs.
- Perform rapid cranial nerve and cerebellar screens and know when they are mandatory.
- Use sensitivity and specificity (SnNout and SpPin) and test clusters to choose a short, hypothesis driven test list.
- Maintain draping, consent, communication and safety throughout, and stop testing when a finding changes the plan.
Section 1Vital signs and general examination performance
Why vital signs are scored
Vital signs are the first screen for systemic illness and the first safety check before manual care. A fever turns back pain into a possible infection, a very high blood pressure turns a neck adjustment into a referral, and a fast irregular pulse may be atrial fibrillation in a patient whose "dizziness" you were about to attribute to the neck. In a station, vitals may be given on the door card or you may be asked to measure them. When you measure them, examiners score technique step by step, so the routine must be exact. When they are given, read them and act on any abnormal value.
Blood pressure technique
Correct technique matters because small errors produce large, predictable distortions. Prepare the patient: seated with the back supported, feet flat, legs uncrossed, quiet for a few minutes, no talking during the reading, ideally no caffeine, exercise or smoking in the previous 30 minutes. Bare the upper arm (a sleeve pushed up can act as a tourniquet). Support the arm so the cuff is at heart level (mid sternum).
- Choose the cuff size. The bladder length should encircle about 80 percent of the arm and its width about 40 percent of the arm circumference. A cuff that is too small overestimates pressure; too large underestimates it.
- Place the cuff snugly with the bladder center (often marked with an arrow) over the brachial artery on the medial arm and the lower edge about 2 to 3 cm above the antecubital crease.
- Estimate systolic pressure by palpation. Palpate the radial (or brachial) pulse, inflate until it disappears, note that value, and deflate fully. This prevents missing an auscultatory gap, a silent interval in some hypertensive patients that can cause systolic pressure to be underestimated.
- Auscultate. Place the stethoscope bell or diaphragm lightly over the brachial artery in the antecubital fossa, not tucked under the cuff. Inflate to 20 to 30 mmHg above the palpated systolic value.
- Deflate at 2 to 3 mmHg per second. Faster deflation underestimates systolic and overestimates diastolic pressure.
- Read the Korotkoff sounds. The first appearance of repetitive tapping sounds (phase I) is systolic; the disappearance of sounds (phase V) is diastolic in adults. Record to the nearest 2 mmHg.
- Deflate fully, wait about a minute before repeating, and average two or more readings. At a first visit, measure both arms and use the higher arm thereafter; a consistent difference over about 10 to 15 mmHg suggests subclavian or aortic disease and is noteworthy in a patient with arm or neck symptoms.
| Error | Effect on reading |
|---|---|
| Cuff too small for the arm | Falsely high |
| Cuff too large | Falsely low |
| Arm below heart level | Falsely high (hydrostatic pressure) |
| Arm above heart level | Falsely low |
| Unsupported arm or back, legs crossed | Falsely high (isometric muscle work) |
| Talking during the reading, full bladder, recent caffeine or nicotine | Falsely high |
| Cuff over clothing | Unreliable, usually high |
| Deflating too fast | Systolic underestimated, diastolic overestimated |
| No palpatory estimate, auscultatory gap present | Systolic underestimated |
| Single reading, no rest period | Often high (white coat effect, anxiety) |
Interpreting blood pressure
The adult categories most commonly taught in the United States are: normal under 120/80; elevated 120 to 129 systolic with diastolic under 80; stage 1 hypertension 130 to 139 systolic or 80 to 89 diastolic; stage 2 hypertension 140 or higher systolic or 90 or higher diastolic. A reading over 180 systolic and/or 120 diastolic is a hypertensive crisis: with signs of target organ damage (chest pain, breathlessness, neurological deficit, visual change, confusion, severe headache) it is an emergency for which you call emergency services; without symptoms it calls for prompt medical evaluation and you should not proceed with manual therapy that day. Recheck any abnormal value after rest before acting, unless the patient is symptomatic. Very low blood pressure with dizziness, fainting or postural change also needs attention; orthostatic hypotension is a fall of 20 mmHg systolic or 10 mmHg diastolic within about three minutes of standing.
Pulse, respiration and temperature
Pulse: palpate the radial artery with the pads of the index and middle fingers (never the thumb, which has its own pulse). If the rhythm is regular, count for 30 seconds and double; if irregular, count a full 60 seconds and note whether it is regularly irregular or irregularly irregular (the latter suggests atrial fibrillation, a stroke risk factor). Normal resting adult rate is 60 to 100 beats per minute; note rate, rhythm and volume. Respiration: count for 30 to 60 seconds while appearing to still take the pulse, because patients change their breathing when they know it is being watched; normal adult rate is 12 to 20 breaths per minute. Note effort, accessory muscle use and pattern. Temperature: normal oral temperature is about 97.8 to 99.1°F (36.5 to 37.3°C), and 100.4°F (38.0°C) or higher is the usual threshold for fever. Pulse oximetry, height, weight and body mass index may also be part of the vitals in some stations.
| Vital sign | Adult reference value | Station action if abnormal |
|---|---|---|
| Blood pressure | Under 120/80 normal | Recheck; over 180/120 do not treat that day; with symptoms call emergency services |
| Pulse | 60 to 100 per minute, regular | Irregularly irregular: suspect atrial fibrillation, ask about palpitations, anticoagulation, refer |
| Respirations | 12 to 20 per minute | Tachypnea with chest pain or breathlessness: consider pulmonary embolus, pneumothorax, cardiac cause |
| Temperature | About 97.8 to 99.1°F | 100.4°F or higher with spine pain: infection screen, no manipulation, refer |
| Oxygen saturation | 95 percent or higher on room air | Under about 92 percent or falling: urgent medical evaluation |
General inspection
Inspection starts when you enter the room: how the patient sits, stands, moves and speaks. Describe what you see in neutral, specific terms. Look at general appearance (distress, pallor, sweating, body habitus), posture in three views (head carriage, shoulder and iliac crest levels, scoliosis, kyphosis, lordosis, antalgic lean), gait (antalgic, Trendelenburg, steppage, ataxic, spastic, shuffling), skin (scars, bruising, rashes such as the dermatomal vesicles of herpes zoster, cafe au lait spots, hair tufts over the spine) and muscle bulk (atrophy of the thenar eminence, quadriceps or calf, fasciculations). An antalgic lean away from the painful side has traditionally been linked to a disc lesion lateral to the nerve root and a lean toward it to a medial (axillary) lesion; treat that rule as a teaching heuristic rather than a reliable localizer.
Then palpate and assess range of motion: active range first (willingness and pattern), then passive range where needed (end feel), and resisted isometric testing to separate contractile from inert tissue. Palpate for midline bony tenderness (a fracture screen after trauma), step offs, muscle spasm, trigger points, temperature and swelling.
Verbalizing findings
Examiners cannot score a finding they do not hear. As you finish each test, state the result in one sentence that names the test, the side and the finding: "Right Kemp test produces local right low back pain without leg radiation, suggesting a facet source." Normal findings are stated too: "Blood pressure 124 over 78, right arm, seated. Pulse 72 and regular. Respirations 14. No midline bony tenderness from T10 to the sacrum." In a station where the SP cannot simulate a sign (an absent reflex, a fever), the examiner may hand you a card or tell you the finding when you perform the test correctly; you then state its significance.
| Step | What you do | What you say aloud |
|---|---|---|
| 1. Explain and consent | Describe the blood pressure check | "I am going to check your blood pressure. The cuff will squeeze your arm for a moment. Is that all right?" |
| 2. Position | Seat, support back and arm, feet flat, bare arm | "Please sit back, keep your feet flat and let your arm rest here." |
| 3. Cuff | Size, place over brachial artery, 2 to 3 cm above crease | "This is the right size cuff for your arm." |
| 4. Palpatory estimate | Inflate until radial pulse disappears, deflate | "First I will feel your pulse as the cuff inflates." |
| 5. Auscultate | Inflate 20 to 30 above estimate, deflate 2 to 3 per second | (Silent while listening) |
| 6. Report | State reading, arm, position | "Your blood pressure is 136 over 84 in the right arm while seated. That is in the stage 1 range, so I would like to recheck it." |
| 7. Pulse and respiration | Radial pulse 30 seconds; count respirations without announcing it | "Pulse 76 and regular. Respirations 16." |
Reasoning: Explain the blood pressure check and get consent. Seat him with back and arm supported, feet flat, bare the arm, choose a large cuff for his muscular arm, palpate the systolic estimate (about 190), inflate to 220, deflate at 2 to 3 mmHg per second: 186/112. Say it aloud. Pulse is 88 and irregularly irregular; respirations 16. Ask about headache, chest pain, breathlessness, visual change, weakness or confusion: he has a mild headache only. After a few minutes of rest the recheck is 182/110. Critical actions: do not proceed to cervical manipulation; explain that the blood pressure is in the crisis range and the pulse is irregular, that both need medical evaluation today, and that if any chest pain, breathlessness, weakness, speech or vision change occurs he should call emergency services; arrange same day medical assessment; document the readings, arm, position and advice. Had he reported a neurological symptom or chest pain, the action would be an immediate emergency call.
Vital signs are both a skill station and a safety screen. Prepare the patient, choose the right cuff, place it over the brachial artery at heart level, estimate systolic by palpation, deflate at 2 to 3 mmHg per second, and read phases I and V. Count pulse and respiration properly, inspect systematically, and say every finding, normal or abnormal, out loud.
Section 2Spinal orthopedic test performance
The performance rules for every orthopedic test
Every test has the same five beats: explain what you will do and that it may reproduce symptoms, position the patient correctly, perform the maneuver with correct hand placement and controlled force, ask a neutral question ("What do you feel, and where?"), and state the result and its meaning. Test the uninvolved side first when practical, so the patient knows what to expect and you have a comparison. Stop immediately if the test produces severe pain, neurological symptoms, dizziness or any sign of vascular compromise. Never force a provocative cervical test in a patient whose history suggests instability, fracture or vascular disease; the safest test is the one you do not need.
Cervical tests
| Test | How to perform it | Positive finding | Suggests |
|---|---|---|---|
| Foraminal compression | Seated, head neutral or laterally flexed toward the symptomatic side; press straight down on the vertex | Radiating arm pain on that side; local pain only is less specific | Foraminal encroachment, nerve root irritation; local pain suggests facet |
| Spurling (maximal foraminal compression variants) | Extend, laterally flex and rotate the head toward the symptomatic side, then apply gentle axial pressure; stop at symptom reproduction | Reproduction of radiating arm pain in a dermatomal pattern | Cervical radiculopathy; high specificity, modest sensitivity |
| Jackson compression | Laterally flex the head to each side and press down | Radiating pain on the side of flexion | Nerve root compression; local pain suggests facet |
| Distraction | One hand under the occiput, one under the chin; lift gently | Relief of arm or neck pain (positive); increased pain suggests muscle or ligament strain | Relief supports foraminal or root compression |
| Shoulder depression | Laterally flex the head away and depress the opposite shoulder | Radiating pain on the stretched side; pain on the compressed side suggests foraminal encroachment | Dural sleeve adhesion, root tension, brachial plexus traction |
| Bakody (shoulder abduction relief) | Patient places the palm of the symptomatic arm on top of the head | Relief of arm pain | Root compression, often around C5 to C6, rather than a shoulder lesion |
| Valsalva | Seated, patient bears down as if straining | Spinal or radiating pain | Space occupying lesion: disc, osteophyte, tumor |
| Upper limb tension test A (median nerve bias) | Supine; scapular depression, shoulder abduction, forearm supination, wrist and finger extension, shoulder external rotation, elbow extension, then contralateral neck side bend | Reproduction of symptoms, side to side difference, change with neck position | Neural tension; high sensitivity for cervical radiculopathy |
| Lhermitte sign | Seated or supine; passively flex the neck (with or without hip flexion) | Electric shock sensation down the spine or into the limbs | Cervical cord lesion: myelopathy, multiple sclerosis |
| Soto Hall | Supine; stabilize the sternum and passively flex the neck | Localized posterior pain | Posterior ligament or vertebral body injury; positive after trauma means stop and image |
The Wainner clinical prediction rule for cervical radiculopathy combines four findings: a positive upper limb tension test A, a positive Spurling test, a positive distraction test, and cervical rotation under 60 degrees toward the involved side. Three positives make radiculopathy considerably more likely, and four positives make it very likely. Use the cluster as the frame for your cervical neurological examination.
Vertebral artery screening. Positional tests that hold the neck in sustained extension and rotation (often called George test, Maigne or DeKleyn variants) have poor diagnostic accuracy and do not reliably predict who will suffer an adverse event; current guidance emphasizes the history (new severe neck pain or headache, brainstem symptoms), vital signs, the cranial nerve and cerebellar screen and clinical reasoning. If your program or the station expects a positional test, perform it gently, in a position you would use for treatment, watching the eyes for nystagmus and asking about dizziness, and stop at the first symptom. Do not present a negative test as clearance for cervical manipulation.
Thoracic tests
| Test | How to perform it | Positive finding and meaning |
|---|---|---|
| Adams forward bend | Standing, feet together, bend forward with arms hanging; view from behind at eye level | Rib hump or paraspinal prominence: structural scoliosis with vertebral rotation; a curve that disappears suggests functional scoliosis |
| Chest expansion | Tape at the fourth intercostal space; measure full exhalation and full inspiration | Expansion under about 2.5 cm (1 inch) suggests costovertebral restriction, as in ankylosing spondylitis; normal adult is roughly 5 cm or more |
| Rib springing (rib motion) | Prone or side lying; spring each rib angle | Localized pain or restriction: rib fracture, costovertebral dysfunction; avoid in suspected fracture or osteoporosis |
| Schepelmann | Seated, arms overhead, bend laterally each way | Pain on the concave side: intercostal neuritis; pain on the convex side: intercostal muscle or fibrous pleural irritation |
| Beevor sign | Supine, partial sit up with arms crossed; watch the umbilicus | Umbilicus moves upward: weak lower abdominals from a lesion around T10 to T12 |
| Adson | Seated; palpate radial pulse, extend and rotate the head toward the tested side, deep breath held | Diminished pulse with symptom reproduction: scalene compression of the subclavian artery (thoracic outlet) |
| Eden (costoclavicular) | Shoulders drawn back and down (military posture), pulse monitored | Diminished pulse and symptoms: costoclavicular compression |
| Wright (hyperabduction) | Arm hyperabducted overhead, pulse monitored | Diminished pulse and symptoms: pectoralis minor compression |
| Roos elevated arm stress test | Arms abducted 90 degrees with elbows flexed 90 degrees; open and close the hands for up to 3 minutes | Early fatigue, heaviness, paresthesia: thoracic outlet syndrome (neurogenic or vascular) |
Pulse diminution alone is common in healthy people during the thoracic outlet tests; the finding that counts is reproduction of the patient's symptoms. In the thoracic region, remember the visceral mimics from Chapter 5: if the examination does not reproduce thoracic pain mechanically, say so and consider a nonmusculoskeletal source.
Lumbar tests
| Test | How to perform it | Positive finding and meaning |
|---|---|---|
| Straight leg raise (Lasegue) | Supine, knee straight, raise the leg passively by the heel | Radiating pain below the knee, usually between about 35 and 70 degrees: L5 or S1 root tension, disc herniation; high sensitivity |
| Braggard | After a positive SLR, lower the leg until pain eases, then dorsiflex the foot | Return of radiating pain: sciatic nerve tension rather than hamstring |
| Crossed (well leg) SLR | Raise the asymptomatic leg | Pain in the symptomatic leg: large or medial (axillary) disc herniation; high specificity |
| Slump | Seated; slump the thoracolumbar spine, flex the neck, extend the knee, dorsiflex the foot; release neck flexion | Symptom reproduction that eases when the neck is extended: neural tension |
| Bechterew | Seated; extend one knee, then the other, then both | Radiating pain or leaning back to avoid it: sciatic tension, disc lesion |
| Kemp | Standing or seated; extend, rotate and laterally bend toward each side, with gentle downward pressure through the shoulders | Local pain: facet; radiating leg pain: foraminal or lateral disc encroachment |
| Milgram | Supine; raise both straight legs about 2 inches and hold up to 30 seconds | Inability to hold or pain: intrathecal or intradiscal pressure lesion (also affected by abdominal strength) |
| Valsalva | Seated, bear down | Low back or leg pain: space occupying lesion |
| Femoral nerve stretch (prone knee bend) | Prone; flex the knee, optionally extend the hip | Anterior thigh pain: L2 to L4 root irritation; distinguish from rectus femoris tightness |
| Schober (modified) | Mark the lumbosacral junction (dimples of Venus line) and points 10 cm above and 5 cm below; measure in full flexion | Increase under about 5 cm: reduced lumbar flexion, as in ankylosing spondylitis |
Pelvic and sacroiliac tests
No single sacroiliac test is reliable, but a cluster is useful. The commonly taught Laslett cluster uses five provocation tests: distraction, thigh thrust, compression, sacral thrust and Gaenslen. Three or more positives of five (or two of the first four, with the thigh thrust included) support the sacroiliac joint as the pain source, particularly when centralization with repeated movements is absent.
| Test | How to perform it | Positive finding and meaning |
|---|---|---|
| Distraction (gapping) | Supine; press posterolaterally on both anterior superior iliac spines | Reproduction of sacroiliac pain |
| Compression | Side lying; press down on the uppermost iliac crest | Reproduction of sacroiliac pain |
| Thigh thrust (posterior shear) | Supine, hip flexed 90 degrees; axial pressure down the femur with the sacrum supported | Reproduction of buttock pain on that side |
| Sacral thrust | Prone; downward pressure on the sacrum | Reproduction of sacroiliac pain |
| Gaenslen | Supine at the table edge; flex one hip to the chest and lower the other leg off the edge into extension | Pain in the sacroiliac joint of the extended side |
| Patrick FABERE | Supine; figure four position, press down on the flexed knee and opposite ASIS | Groin pain: hip joint; posterior pain: sacroiliac joint |
| Yeoman | Prone; flex the knee and extend the hip | Sacroiliac pain: anterior sacroiliac ligament; lumbar pain: lumbar facet; anterior thigh: femoral or rectus |
| Hoover | Supine; hands under both heels while the patient lifts the symptomatic leg | No downward pressure from the opposite heel: incomplete effort; a nonorganic sign, not proof of malingering |
The Waddell signs (nonorganic tenderness, simulation, distraction, regional disturbance, overreaction) suggest a nonorganic contribution when three or more of five categories are present. They indicate that psychosocial factors deserve attention; they do not mean there is no pathology and they are not a lie detector. Say so if you use them.
Reasoning: Hypothesis: left C6 radiculopathy (thumb), with differential of carpal tunnel syndrome, thoracic outlet syndrome and a double crush. Explain and consent. Inspect: head held slightly away from the left. Active range: left rotation about 50 degrees with reproduction of arm symptoms. Perform foraminal compression and Spurling to the left gently, stopping at symptom reproduction: "Left Spurling reproduces pain and tingling into the left lateral forearm and thumb, consistent with left C6 nerve root irritation." Distraction: "Distraction relieves the arm symptoms." Upper limb tension test A: positive on the left with a side to side difference. Bakody: relief with hand on head. State the Wainner cluster: four of four positive, making radiculopathy very likely. Then neurological screen of C5 to T1 (Section 4) and a Phalen and Tinel at the wrist to address the differential. Critical actions: test the uninvolved side first where relevant, stop at symptom reproduction, verbalize each finding, and screen for myelopathy (Hoffmann, gait) before concluding.
Every spinal test is explain, position, perform, ask, and state. Know the correct positioning and what counts as positive, use clusters (Wainner for the neck, Laslett for the sacroiliac joint) rather than single tests, avoid provocative cervical testing when the history suggests instability or vascular disease, and always say where the pain was reproduced.
Section 3Extremity orthopedic test performance
Structure of an extremity examination
Extremity stations follow the same order every time: inspect (swelling, bruising, deformity, atrophy) with both sides exposed for comparison, palpate the specific structures implicated by the history, test active, passive and resisted range of motion, then perform the special tests chosen for your hypotheses, and finish with a neurovascular check distal to the injury (pulses, capillary refill, sensation, strength). Always clear the joint above and below and the relevant spinal region: shoulder pain may come from the cervical spine, knee pain from the hip, and a slipped capital femoral epiphysis in an adolescent classically presents as knee pain. Compare with the uninvolved side throughout.
Shoulder, elbow, wrist and hand
| Test | How to perform it | Positive finding and meaning |
|---|---|---|
| Neer impingement | Stabilize the scapula; passively flex the internally rotated arm fully overhead | Anterolateral shoulder pain: subacromial impingement |
| Hawkins Kennedy | Shoulder and elbow flexed 90 degrees; passively internally rotate the shoulder | Pain: subacromial impingement; sensitive |
| Empty can (Jobe) | Arms in 90 degrees abduction in the scapular plane, thumbs down; resist downward pressure | Weakness or pain: supraspinatus tendinopathy or tear |
| Drop arm | Passively abduct to 90 degrees; patient slowly lowers the arm | Arm drops or cannot be lowered smoothly: full thickness rotator cuff tear; specific |
| External rotation lag | Elbow at side flexed 90 degrees; passively externally rotate near end range and ask the patient to hold | Arm drifts back: infraspinatus or supraspinatus tear |
| Lift off or belly press | Hand behind the back lifted away, or palm pressed into the abdomen with the elbow forward | Inability: subscapularis tear |
| Apprehension and relocation | Supine; abduct 90 degrees and externally rotate; then apply posterior pressure on the humeral head | Apprehension that is relieved by posterior pressure: anterior glenohumeral instability |
| Speed | Elbow extended, forearm supinated; resist forward flexion of the shoulder | Pain in the bicipital groove: biceps tendinopathy |
| Yergason | Elbow flexed 90 degrees, forearm pronated; resist supination and external rotation | Pain or tendon snapping in the groove: biceps tendinopathy or transverse humeral ligament tear |
| O'Brien active compression | Shoulder flexed 90 degrees, adducted 10 to 15 degrees, thumb down; resist downward force, repeat palm up | Deep pain thumb down relieved palm up: labral (SLAP) lesion; pain on top of the shoulder: acromioclavicular joint |
| Cross body adduction | Arm flexed 90 degrees and adducted across the chest | Pain at the acromioclavicular joint |
| Cozen | Elbow extended, forearm pronated, fist radially deviated; resist wrist extension | Lateral epicondyle pain: lateral epicondylopathy |
| Mill | Passively pronate the forearm, flex the wrist and extend the elbow | Lateral epicondyle pain: lateral epicondylopathy |
| Medial epicondylitis test | Resist wrist flexion and pronation, or passively supinate and extend the wrist and elbow | Medial epicondyle pain: medial epicondylopathy |
| Valgus and varus stress (elbow) | Elbow flexed about 20 to 30 degrees; apply valgus then varus force | Pain or laxity: ulnar or radial collateral ligament injury |
| Elbow flexion test and Tinel at the cubital tunnel | Full elbow flexion with wrist extension held; or tap the ulnar groove | Paresthesia in the little and ring fingers: cubital tunnel syndrome |
| Phalen | Hold both wrists in full flexion for up to 60 seconds | Paresthesia in the median distribution: carpal tunnel syndrome |
| Tinel at the wrist and carpal compression (Durkan) | Tap over the carpal tunnel; or press the thumbs over it for up to 30 seconds | Median distribution paresthesia: carpal tunnel syndrome; carpal compression is among the more sensitive |
| Finkelstein (Eichhoff variant) | Thumb tucked in a fist, then ulnar deviate the wrist | Pain over the radial styloid: de Quervain tenosynovitis of abductor pollicis longus and extensor pollicis brevis |
| Allen | Patient makes a fist; occlude radial and ulnar arteries; open hand; release one artery | Slow return of color (over about 5 to 7 seconds): impaired flow in the released artery |
Hip, knee and ankle
| Test | How to perform it | Positive finding and meaning |
|---|---|---|
| Patrick FABER | Figure four; press the knee toward the table and stabilize the opposite ASIS | Groin pain: hip joint; posterior pain: sacroiliac joint |
| FADIR | Supine; flex the hip to 90 degrees, adduct and internally rotate | Anterior groin pain: femoroacetabular impingement or labral tear |
| Thomas | Supine at the table end; hug one knee to the chest | Opposite thigh lifts: hip flexor contracture; knee extends: rectus femoris tightness |
| Ober | Side lying, lower hip and knee flexed; extend and abduct the upper hip, then let it drop | Leg stays abducted: iliotibial band or tensor fasciae latae tightness |
| Trendelenburg | Stand on one leg for about 30 seconds | Pelvis drops on the opposite (unsupported) side: weak gluteus medius of the stance leg (superior gluteal nerve, L5) |
| Log roll | Supine; roll the relaxed leg into internal and external rotation | Groin pain: intra-articular hip pathology; a useful first test in a painful hip |
| Lachman | Supine, knee flexed 20 to 30 degrees; stabilize the distal femur, draw the proximal tibia forward | Increased anterior translation with a soft end point: ACL tear; most sensitive ACL test |
| Anterior and posterior drawer | Knee flexed 90 degrees, foot stabilized; pull the tibia forward, then push it back | Anterior translation: ACL; posterior translation: PCL |
| Posterior sag (Godfrey) | Hips and knees flexed 90 degrees; view from the side | Tibia sags backward: PCL tear |
| Valgus and varus stress | At 0 and 30 degrees of knee flexion | Laxity at 30 degrees only: isolated MCL or LCL; laxity at 0 degrees: collateral plus cruciate or capsular injury |
| McMurray | Fully flex the knee; externally rotate the tibia with valgus stress and extend (medial meniscus), then internally rotate with varus stress and extend (lateral) | Painful click or catch on the joint line: meniscal tear |
| Thessaly | Standing on one leg with the knee flexed 20 degrees, rotate the body three times each way | Joint line pain or catching: meniscal tear |
| Apley compression and distraction | Prone, knee flexed 90 degrees; compress and rotate, then distract and rotate | Pain with compression: meniscus; pain with distraction: ligament |
| Patellar apprehension | Knee slightly flexed; push the patella laterally | Apprehension or quadriceps contraction: lateral patellar instability |
| Bulge (stroke) test and ballottement | Milk fluid from the medial gutter upward then stroke the lateral side; or tap the patella | Fluid wave or patellar tap: knee effusion |
| Ankle anterior drawer | Ankle slightly plantar flexed; stabilize the tibia, draw the heel forward | Excess translation: anterior talofibular ligament tear |
| Talar tilt | Ankle neutral; invert the calcaneus | Excess tilt: calcaneofibular ligament injury |
| Squeeze and external rotation (Kleiger) | Compress the tibia and fibula at mid calf; or externally rotate the foot with the knee flexed | Distal leg or ankle pain: syndesmosis (high ankle) sprain |
| Thompson | Prone, foot off the table; squeeze the calf | No plantar flexion: complete Achilles tendon rupture |
Decision rules for imaging after extremity trauma
Two rules are high yield because they combine examination findings into an imaging decision. The Ottawa ankle rules: ankle radiographs are indicated if there is pain in the malleolar zone and either bone tenderness along the distal 6 cm of the posterior edge or tip of the lateral or medial malleolus, or inability to bear weight for four steps both immediately and at the examination. Foot radiographs are indicated if there is midfoot pain and tenderness at the base of the fifth metatarsal or the navicular, or the same inability to bear weight. The Ottawa knee rule: radiographs if age 55 or older, isolated patellar tenderness, fibular head tenderness, inability to flex to 90 degrees, or inability to bear weight for four steps. Both rules are highly sensitive, so a negative rule makes fracture unlikely (Section 5).
Reasoning: A noncontact pivot with a pop and rapid swelling suggests ACL tear, with meniscal tear and MCL sprain as companions, and fracture to exclude. Explain, consent, and drape with shorts. Inspect both knees: right effusion. Apply the Ottawa knee rule aloud: she can bear weight four steps with a limp, no patellar or fibular head tenderness, flexion past 90 degrees, age under 55, so radiographs are not required by the rule. Bulge test positive. Test the left knee first, then the right: "Right Lachman shows increased anterior translation with a soft end point compared with the left, consistent with ACL tear." Anterior drawer positive; valgus stress at 30 degrees mild pain without laxity; McMurray limited by guarding. Check distal pulses and sensation. Critical actions: compare sides, apply the decision rule, avoid forceful testing on an acutely swollen knee, recommend MRI and orthopedic referral, and protect the knee (crutches as needed) in the meantime.
Run every extremity station as inspect, palpate, range of motion, special tests, neurovascular check, and clear the joint above and below. Know the exact positioning of each test, compare sides, apply the Ottawa rules after trauma, and match tests to their roles: sensitive tests to rule out and specific tests to rule in.
Section 4Neurologic examination performance
The regional neurological screen
For any limb symptom, the neurological screen tests three things for each root level: sensation (the dermatome), strength (the myotome) and the deep tendon reflex. Test both sides, compare, and state the findings by level. Use light touch and sharp versus dull (pinprick with a clean disposable pin) in the center of each dermatome (the autonomous zone, where overlap from adjacent roots is least), and add vibration with a 128 Hz tuning fork and joint position sense at the great toe or index finger when large fiber or dorsal column disease is possible.
| Root | Dermatome (test point) | Myotome (key muscle test) | Reflex |
|---|---|---|---|
| C5 | Lateral arm over the deltoid | Shoulder abduction (deltoid), elbow flexion | Biceps |
| C6 | Lateral forearm, thumb and index finger | Wrist extension, elbow flexion | Brachioradialis |
| C7 | Middle finger | Elbow extension (triceps), wrist flexion, finger extension | Triceps |
| C8 | Little finger and medial forearm | Finger flexion (grip) | None reliable |
| T1 | Medial arm | Finger abduction (interossei) | None |
| L2 and L3 | Anterior and medial thigh to the medial knee | Hip flexion (iliopsoas), hip adduction | None reliable |
| L4 | Medial leg and medial malleolus | Knee extension, ankle dorsiflexion (tibialis anterior) | Patellar |
| L5 | Lateral leg, dorsum of the foot and great toe | Great toe extension (extensor hallucis longus), hip abduction; heel walking | Medial hamstring (less reliable) |
| S1 | Lateral foot, little toe and sole | Ankle plantar flexion and eversion; toe walking | Achilles |
Motor testing and grading
Test strength with the joint in a mid range position, stabilize proximally, and apply resistance gradually ("Don't let me push you down"). Compare sides. Grade on the 0 to 5 Medical Research Council scale: 0 no contraction, 1 flicker or trace contraction, 2 movement with gravity eliminated, 3 movement against gravity only, 4 movement against some resistance, 5 normal strength. Functional tests are fast and sensitive in the lower limb: heel walking (L4 and L5 dorsiflexors), toe walking or repeated single leg heel raises (S1 plantar flexors), and a squat and rise (L3 and L4 quadriceps).
Reflexes and their grading
Position the limb relaxed with the tendon on slight stretch, strike briskly with the hammer swinging freely, and compare sides. Grade on the 0 to 4 scale: 0 absent, 1+ diminished or present only with reinforcement, 2+ normal, 3+ brisker than average, possibly with spread, 4+ very brisk with sustained clonus. If a reflex seems absent, use reinforcement (the Jendrassik maneuver: patient hooks the fingers together and pulls just as you strike for lower limb reflexes; clenching the teeth or a fist for upper limb reflexes) before calling it absent. An isolated reduced reflex with dermatomal and myotomal findings at the same level indicates a lower motor neuron root lesion; generalized hyperreflexia indicates an upper motor neuron problem.
| Feature | Upper motor neuron lesion | Lower motor neuron lesion |
|---|---|---|
| Location | Brain or spinal cord (corticospinal tract) | Anterior horn cell, root, plexus or peripheral nerve |
| Reflexes | Increased (3+ to 4+), clonus | Decreased or absent |
| Tone | Increased (spasticity, velocity dependent) | Decreased (flaccid) |
| Atrophy | Mild, from disuse, late | Marked, early |
| Fasciculations | Absent | May be present |
| Pathological reflexes | Babinski, Hoffmann, clonus present | Absent |
| Distribution | Patterns below a level, often bilateral | Root, plexus or nerve distribution |
Pathological reflexes
- Babinski: stroke the lateral sole firmly with a blunt object from the heel toward the ball of the foot, curving medially. Positive (upgoing plantar response): extension of the great toe with fanning of the other toes, an upper motor neuron sign in anyone past infancy.
- Oppenheim (downward stroke along the tibial crest) and Chaddock (stroke around the lateral malleolus) elicit the same upgoing toe response.
- Hoffmann: hold the middle finger and flick its distal phalanx downward. Positive: flexion of the thumb and index finger, suggesting cervical cord compression (myelopathy) when asymmetric or with other signs.
- Ankle clonus: briskly dorsiflex the foot and hold. More than a few beats, or sustained clonus, indicates an upper motor neuron lesion.
- Superficial abdominal reflexes: stroke each quadrant toward the umbilicus; the umbilicus moves toward the stimulus. Upper quadrants test about T8 to T10, lower about T10 to T12. Loss may accompany upper motor neuron lesions.
Cranial nerve screen
A fast screen is mandatory for headache, dizziness, facial symptoms, neck trauma and any suspected vascular presentation, and useful whenever the cervical spine is examined.
| Nerve | Rapid station test |
|---|---|
| I Olfactory | Identify a familiar scent with each nostril (often omitted unless indicated) |
| II Optic | Visual acuity, visual fields by confrontation, pupillary light reflex (afferent) |
| III, IV, VI | Pupils (III efferent), eye movements in an H pattern, look for diplopia, nystagmus and ptosis |
| V Trigeminal | Light touch on forehead, cheek and jaw; clench the jaw (masseter); corneal reflex if indicated |
| VII Facial | Raise eyebrows, close eyes tightly, smile, puff cheeks |
| VIII Vestibulocochlear | Finger rub or whisper at each ear; Weber and Rinne with a 512 Hz fork if hearing differs |
| IX, X | Say "ah": uvula midline, palate rises symmetrically; gag reflex if indicated; voice and swallowing |
| XI Accessory | Shrug shoulders and turn the head against resistance |
| XII Hypoglossal | Protrude the tongue: deviation toward the weak side |
Cerebellar and coordination screen
Finger to nose (alternating between your finger and the patient's nose, with your target moving): intention tremor and past pointing indicate ipsilateral cerebellar dysfunction. Heel to shin: run the heel down the opposite shin. Rapid alternating movements: pronation and supination of the hand on the thigh; slowness and irregularity is dysdiadochokinesia. Tandem gait (heel to toe) reveals truncal ataxia. The Romberg test (standing with feet together, eyes open and then closed, guarding the patient) is a test of proprioception: a patient who is steady with eyes open but sways or falls with eyes closed has a sensory (dorsal column or peripheral) ataxia, whereas cerebellar ataxia is unsteady even with eyes open. Always stand close enough to catch the patient.
Reasoning: Clumsy hands in a man in his late fifties suggest cervical spondylotic myelopathy until proven otherwise; differential includes bilateral carpal tunnel syndrome, peripheral neuropathy and motor neuron disease. Explain and consent. Inspect for intrinsic hand wasting and fasciculations. Test upper limb dermatomes, myotomes and reflexes: "Biceps and triceps reflexes are 3+ bilaterally." Hoffmann: "Positive on the right and left." Lower limbs: patellar 3+, three beats of ankle clonus on the left, Babinski upgoing on the left. Gait: broad based, unsteady tandem walk; Romberg sway with eyes closed (dorsal column involvement). State the conclusion: upper motor neuron signs in all four limbs with hand clumsiness and gait disturbance, consistent with cervical myelopathy. Critical actions: no cervical manipulation, no provocative compression testing, prompt referral for MRI and spine surgical evaluation, and safety advice about falls and about new bladder change or rapid worsening, which would require emergency care.
Screen each root with a dermatome, a myotome and a reflex, grade strength 0 to 5 and reflexes 0 to 4+, and use reinforcement before calling a reflex absent. Separate lower motor neuron root lesions from upper motor neuron signs (hyperreflexia, clonus, Babinski, Hoffmann), add the cranial nerve and cerebellar screens whenever the head, neck or balance is involved, and say every finding by level and side.
Section 5Choosing which tests to perform
Hypothesis driven examination
A station rarely has time for every test in this chapter, and examiners do not reward a scattershot battery. They reward an examination that follows from the history: each test chosen to confirm or exclude a specific hypothesis, plus the safety screens that the case requires. Before you touch the patient, name your leading diagnosis, the main alternatives and the dangerous possibility. Then select a short sequence: a regional screen (inspection, palpation, range of motion), the two or three special tests that best separate the hypotheses, the neurological screen if any limb symptom or red flag exists, and any safety test the case demands (vital signs, cranial nerves, myelopathy signs, pulses).
Sensitivity, specificity and clusters
Sensitivity is the proportion of people with the condition who test positive; a highly sensitive test that is negative helps rule out (SnNout). Specificity is the proportion of people without the condition who test negative; a highly specific test that is positive helps rule in (SpPin). Likelihood ratios combine both: a positive likelihood ratio above about 5 to 10 meaningfully raises probability, and a negative likelihood ratio below about 0.1 to 0.2 meaningfully lowers it. Single orthopedic tests are often only moderately accurate, which is why validated clusters outperform them.
| Hypothesis | Sensitive test to rule out | Specific test or cluster to rule in |
|---|---|---|
| Lumbar disc herniation with radiculopathy | Straight leg raise | Crossed straight leg raise; matching neurological deficit |
| Cervical radiculopathy | Upper limb tension test A | Spurling; Wainner cluster (3 or 4 of 4) |
| Sacroiliac joint pain | Negative provocation cluster | Laslett cluster (3 or more of 5) |
| ACL tear | Lachman | Pivot shift |
| Full thickness rotator cuff tear | Painful arc and weakness absent | Drop arm, external rotation lag |
| Ankle or midfoot fracture after trauma | Ottawa ankle rules negative | Radiographs |
| Cervical myelopathy | Normal gait, reflexes and Hoffmann (reassuring, not definitive) | Hyperreflexia, Hoffmann, Babinski, clonus, gait ataxia together |
What examiners look for
- Relevance: tests that match the complaint and the hypotheses, including at least one test aimed at the dangerous alternative.
- Correct technique: positioning, hand placement, force and sequence as described in this chapter.
- Bilateral comparison, uninvolved side first where it makes sense.
- Communication: an explanation before each maneuver, a neutral question after it, and the finding stated aloud.
- Safety and dignity: consent, draping, chaperone offer, stopping when symptoms escalate, and no provocative testing when red flags are present.
- Efficiency: grouping tests by position (all standing tests, then seated, supine, side lying, prone) so the patient moves as few times as possible.
| Position | Typical lumbopelvic and lower limb tests grouped there |
|---|---|
| Standing | Inspection, gait, range of motion, Kemp, Trendelenburg, Adams, heel and toe walk, Romberg |
| Seated | Slump, Bechterew, Valsalva, reflexes, upper and lower limb sensation and strength |
| Supine | Straight leg raise, Braggard, crossed SLR, FABER, FADIR, Thomas, Gaenslen, distraction, thigh thrust, Babinski, pulses |
| Side lying | Compression, Ober |
| Prone | Sacral thrust, Yeoman, femoral nerve stretch, palpation of spinous processes and paraspinals |
Safety and draping
Expose only the area being examined and keep the rest covered. Explain why clothing must be moved, offer a gown, step out or turn away while the patient changes, and use a drape to cover the pelvis and breasts during lumbar, pelvic, hip and thoracic examination. Ask before touching sensitive areas, offer a chaperone for any sensitive examination, and never examine the breast, genitalia or perineum in a station unless the task explicitly requires it; for suspected cauda equina, saddle sensation testing and rectal examination belong in the emergency setting. Throughout, set and honor a stop signal. If a test causes severe pain, new neurological symptoms, dizziness, nausea, visual change or a vasovagal reaction, stop, help the patient into a safe position, monitor vital signs, and change the plan.
Reasoning: Hypotheses: sacroiliac joint pain (leading), L5 or S1 radicular pain, lumbar facet pain, hip joint pathology, and the dangerous possibility of a sacral stress fracture or tumor. Choose: standing inspection, lumbar range of motion and Kemp (facet), heel and toe walk; seated reflexes and slump; supine straight leg raise (sensitive for root tension), FABER (hip versus sacroiliac), distraction, thigh thrust and Gaenslen; side lying compression; prone sacral thrust. State: "Straight leg raise to 80 degrees produces only hamstring tightness, slump negative, reflexes 2+ and symmetric, strength 5 of 5: radiculopathy unlikely. Kemp produces no local pain. FABER produces posterior right sacroiliac pain, not groin pain. Thigh thrust, distraction, compression and sacral thrust are positive on the right: four of five provocation tests positive, supporting right sacroiliac joint pain." Critical actions: a sensitive test to rule out radiculopathy, a validated cluster to rule in the sacroiliac joint, grouping by position, draping for pelvic tests, and asking about night pain and trauma so the stress fracture possibility is addressed.
Choose tests from your hypotheses, not from a memorized list: a safety screen, a regional screen, two or three special tests chosen for sensitivity or specificity (or a validated cluster), a neurological screen when indicated, and each finding stated aloud. Group tests by position, drape and communicate throughout, and stop provocative testing as soon as a red flag appears.
The chapter in one breath
- Every test has five beats: explain, position, perform, ask, state; examiners score what they see and hear.
- Blood pressure: right cuff size, bladder over the brachial artery 2 to 3 cm above the crease, arm at heart level, palpatory estimate, deflate 2 to 3 mmHg per second, phase I systolic and phase V diastolic.
- A small cuff or a low arm reads high; over 180/120 means no manual care that day, and with symptoms an emergency call.
- Count the pulse a full minute if irregular and respirations without announcing it; 100.4°F or higher is fever.
- Cervical: Spurling is specific, ULTT A sensitive, and the Wainner cluster combines them with distraction and rotation; positional vertebral artery tests do not clear a patient for manipulation.
- Lumbar: SLR is sensitive, the crossed SLR specific; sacroiliac pain is best supported by the Laslett cluster.
- Extremities: inspect, palpate, range, special tests, neurovascular check, clear the joint above and below; Lachman for the ACL, drop arm and lag signs for full thickness cuff tears, and the Ottawa rules after trauma.
- Neurological screen: dermatome, myotome and reflex per root (biceps C5, brachioradialis C6, triceps C7, patellar L4, Achilles S1); L5 is tested by great toe extension and hip abduction.
- Upper motor neuron signs (hyperreflexia, clonus, Babinski, Hoffmann) mean cord or brain involvement and referral, not manipulation.
- Cranial nerve and cerebellar screens are mandatory for headache, dizziness and neck trauma; Romberg tests proprioception.
- Choose tests by hypothesis: SnNout, SpPin, clusters, grouping by position, draping, consent and a stop signal throughout.
Words worth knowing
| Term | What it means |
|---|---|
| Korotkoff sounds | Sounds heard over the brachial artery as cuff pressure falls; phase I marks systolic and phase V marks diastolic pressure. |
| Auscultatory gap | A silent interval between systolic and diastolic sounds that can cause systolic pressure to be underestimated if the cuff is not inflated high enough. |
| Hypertensive crisis | Blood pressure over 180 systolic and/or 120 diastolic; an emergency when target organ symptoms are present. |
| Orthostatic hypotension | A drop of at least 20 mmHg systolic or 10 mmHg diastolic within about three minutes of standing. |
| Spurling test | Extension, lateral flexion and rotation of the neck toward the symptomatic side with axial pressure; radiating arm pain suggests radiculopathy. |
| Upper limb tension test A | A sequence of shoulder, elbow, wrist and neck positions that tensions the median nerve and roots; sensitive for cervical radiculopathy. |
| Wainner cluster | Four findings (ULTT A, Spurling, distraction, rotation under 60 degrees) whose combination predicts cervical radiculopathy. |
| Lhermitte sign | Electric shock sensation down the spine on neck flexion, suggesting a cervical cord lesion. |
| Straight leg raise | Passive hip flexion with the knee straight; radiating leg pain between about 35 and 70 degrees suggests lumbosacral root tension. |
| Crossed straight leg raise | Raising the asymptomatic leg reproduces pain in the symptomatic leg; specific for disc herniation. |
| Laslett cluster | Five sacroiliac provocation tests; three or more positives support the sacroiliac joint as the pain source. |
| Waddell signs | Five categories of nonorganic findings; three or more suggest psychosocial contribution, not malingering. |
| Lachman test | Anterior translation of the tibia with the knee in 20 to 30 degrees of flexion; the most sensitive office test for ACL tear. |
| McMurray test | Knee flexion with rotation and varus or valgus stress during extension; a painful click suggests meniscal tear. |
| Ottawa ankle rules | Clinical rule using malleolar, navicular and fifth metatarsal tenderness and weight bearing to decide on radiographs. |
| Thompson test | Squeezing the calf of a prone patient; absent plantar flexion indicates Achilles rupture. |
| Dermatome | The area of skin supplied by the sensory fibers of a single spinal nerve root. |
| Myotome | The group of muscles supplied mainly by a single spinal nerve root. |
| Jendrassik maneuver | Reinforcement by having the patient pull hooked fingers apart while a lower limb reflex is tested. |
| Babinski sign | Great toe extension with fanning of the toes on stroking the lateral sole; an upper motor neuron sign. |
| Hoffmann sign | Thumb and index flexion when the distal phalanx of the middle finger is flicked; suggests cervical cord compression. |
| Clonus | Rhythmic involuntary contractions after a sudden sustained stretch, indicating an upper motor neuron lesion. |
| Romberg test | Standing with feet together and eyes closed; increased sway with eyes closed indicates impaired proprioception. |
| Sensitivity | The proportion of people with a condition who test positive; a negative highly sensitive test helps rule out (SnNout). |
| Specificity | The proportion of people without a condition who test negative; a positive highly specific test helps rule in (SpPin). |