Musculoskeletal Testing

Look for areas of hypersensitivity and tenderness that are likely to have a direct relationship to a somatic dysfunction of a nearby area. They are primarily based on the neuromuscular basis of somatic dysfunction in general. They come from an imbalance in the proprioceptive activity leading to a reflex tenderpoint and a secondary somatic dysfunction.

Most of these are specifically located in a muscle body or near to the area of the body affected. There are several of them located along the sternocleidomastoid muscle that correspond to C2 to C6 spinal segments. Look also for tenderpoints linked to the supraspinatus muscle, the subscapularis muscle, the biceps brachii muscle, the rectus femoris muscle, and the gastrocnemius muscle, usually within the muscle belly or along one of the tendons.

In looking for Jones CS tenderpoints, seek out dime-sized, tense, and fibrotic tender areas with much more tenderness perceived by the patient than can be explained by the pressure actually applied to the site. These tenderpoints will be consistent from one person to the next and are much like CRPs because the pain will not radiate.

In treating these areas, place the patient in the position of greatest comfort. Use counterstrain in order to reduce the degree of tenderness by about two-thirds of the original tenderness. The patient is entirely passive during this treatment and is then returned to a neutral position.

MUSCULOSKELETAL TESTING

You should know about the different musculoskeletal testing done in osteopathic manipulative medicine because these are commonly referred to during the Comlex-USA Level 3 examination. Some of these involve the upper extremities, while others involve the lower extremities. These are listed as follows:

• Adson Test—In the test, the radial pulse is palpated while the patient is asked to rotate and extend their head away from the side of their complaint. The patient then inhales and holds his breath. The test is repeated with the patient rotating and extending his head toward the side of the complaint. A positive finding

involves the decrease or disappearance of the radial pulse on the side where thoracic outlet syndrome. • Spurling Test—in the test, a compressive force is transmitted by the provider down the axial spine through the top of the head. This compression is given with the neck in either the neutral, sidebent left, and sidebent right directions. The test is considered positive if there are radiating symptoms down the arms and into the hands, indicating a possible cervical nerve root impingement. • In the Apley Scratch Test of the Shoulder—the patient is asked to reach behind their back in order to touch the opposite shoulder blade. The patient will then reach above and behind their head toward the shoulder blades. This test determines the ranges of motion of the internal rotation, adduction, and abduction of the shoulder. If there are limitations, there will be asymmetry from one side to the other. • Apprehension/Relocation Test—with the patient’s elbow flexed to 90 degrees and the humerus abducted to 90 degrees, the glenohumeral joint is brought into passive external rotation. Pain will be elicited with apprehension of the patient when there is increased external rotation. When relocated by the stabilization of the humeral head, the patient will feel relief. This positive sign often indicates glenohumeral joint laxity. • Empty can test—this assesses the glenohumeral joint by abducting it to 90 degrees, horizontally flexing it to 30 degrees, and internally rotating it to 90 degrees so that the thumb points in the downward direction. The patient can resist a downward force exerted at the forearm by the examiner, while the examiner also stabilizes the glenohumeral joint. A positive test demonstrates an inability to resist the downward force applied and may drop more quickly compared to the other arm. Pain will be elicited at the greater tuberosity of the humerus, which indicates tendonitis or tear of the supraspinatus muscle. • Hawkins-Kennedy Impingement Test—in the test, the glenohumeral joint is set at 90 degrees of abduction and at 30 degrees of forward flexion. The elbow is flexed to 90 degrees and then the humerus is internally rotated. A positive test will be

seen as pain indicating impingement of the rotator cuff tendons, often the supraspinatus tendons. • Neer sign—this is also a shoulder test in which the elbow is extended and the glenohumeral joint is internally rotated. The glenohumeral joint is passively brought into full forward flexion. If there is pain, this is a positive test often indicating impingement of the rotator cuff tendons, often meaning the supraspinatus tendons. • Speed test—in the test, the elbow is extended with the palm facing upward. The patient is asked to resist the flexion of the glenohumeral joint. A positive test leads to pain with resistance to flexion, which often indicates tendonitis of the long head of the biceps or sometimes a labral injury. • Sulcus sign—in the test, the patient’s arm is held at the elbow and downward traction is applied by the physician. A sulcus or depression is seen below the glenoid fossa, indicating inferior glenohumeral laxity. • Yergason test—this is a shoulder test in which the elbow is flexed to 90 degrees, while the patient resists as the examiner brings the glenohumeral joint into external rotation, pulling the elbow inferiorly. A positive test is seen as a pop or snap in the bicipital groove, indicating laxity of the transverse humeral ligament.

If there is pain without a popping sensation, this could indicate bicipital tendonitis. • Finkelstein test—this is a test of the forearm by having the patient making a fist and tucking the thumb inside the fingers, while the wrist is actively moved into ulnar deviation. A positive test involves pain on the radial side of the forearm, indicating tenosynovitis of the extensor pollicis brevis and abductor pollicis longus tendons, also referred to as de Quervain tenosynovitis. • Phalen test—this is a test for carpal tunnel syndrome done by placing the dorsal aspect of both wrists together so the wrist is hyperflexed for a minute. A positive test involves tingling of the median nerve areas of the hand from carpal tunnel syndrome. The reverse Phalen test involves placing the palms together in order to alleviate symptoms.

• Tinel sign—this is another test for carpal tunnel syndrome in which the median nerve is tapped on at the level of the transverse carpal ligament. A positive test shows tingling that radiates along the median nerve distribution as would be seen in carpal tunnel syndrome. • Patrick test or the FABERE sign—this is a test of the SI joint by having the patient lie supine, resting the affected foot on the opposite thigh to bring the hip into flexion, internal rotation, abduction, and extension. The opposite ASIS is stabilized while the examiner pushes downward on the affected knee. A positive test is seen when there is sacroiliac pain, although pain in the anterior femur indicates pathology of the hip. • Iliac compression/distraction test—this is a test for SI joint pathology by having the patient lie supine with force applied laterally at the ASIS bilaterally. This compresses the SI joints. Then the examiner exerts a medial force at the ilium bilaterally, which gapes the SI joints. A positive test involves pain with compression of the SI joints plus relief of pain when spreading these joints, which mean there is SI joint pathology. • Backward bending test—the patient stands and lifts one leg, while extending at the waist. This is repeated on the opposite side. Pain in the lumbar spine will indicate some type of pathology of the posterior elements of the spine, such as degenerative joint disease, spondylolisthesis, or spondylolysis. • Straight leg raising—the patient lies supine with the affected leg extended. The heel is grasped and the leg is raised with the knee completely extended. The hip is then flexed. A positive test indicates pain and paresthesias down the leg with moderate flexion and indicates some type of irritation in the sciatic nerve or other lumbar nerve root. This can be from disc disease or pyriformis syndrome. • Thomas test—this involves the supine patient with buttocks at the end of the table. One knee is drawn toward the chest, while the other leg is passive. The knee of the tested leg cannot flex to 90 degrees, indicating a tight rectus femoris muscle. If the thigh of the tested leg raises off the table, there is likely a tight iliopsoas muscle.

• Trendelenburg test—the patient stands and raises the opposite leg to the side being examined. A positive test involves the iliac crest of the non-weight-bearing test falling below the level of the iliac crest of the standing leg, which is seen in weakness of the gluteus medius of the standing leg. • The Valsalva test—this involves the seated patient bearing down with the glottis closed in order to increase intrathecal pressure. A positive test involves spinal pain usually from a herniated disc at the level of the perceived pain. • Anterior drawer test—this is a test of the knee. The patient lies supine with the knee flexed at 90 degrees and hip flexed at 45 degrees. The examiner will sit at the foot and will pull forward at the knee by grasping it behind the leg just below the joint line. Increased anterior tibial displacement compared to the opposite side is a positive sign of an ACL tear. • Apley Compression test—the patient lies prone with the knee flexed to 90 degrees. The examiner presses downward on the calcaneus with pressure extending through the tibia while also internally and then externally rotating the knee. A positive sign is pain with compression, which indicates a tear of the meniscus or the collateral ligaments. • Apley distraction test—the patient lies prone with the knee flexed at 90 degrees.

The examiner grabs the ankle with one hand while also stabilizing the femur with the other hand. A distraction force is applied through the ankle, while also externally and internally rotates the knee. A positive test involves pain with distraction seen in a collateral ligament tear. The alleviation of pain with the

Apply compression test indicates some type of meniscal injury. • Lachman test—the patient lies supine with passive flexion of the knee at 20 degrees. The examiner grabs the tibia with one hand and stabilizes the femur with the other. The tibia is translated anteriorly while the femur is pushed in the posterior direction. Increased anterior tibial translation indicates a positive test when this is compared to the opposite side and indicates an ACL tear. • McMurray test—the patient lies supine while the examiner monitors the joint line with one hand while holding the distal tibia with the other hand. Passive flexion of the knee happens with internal and external rotation of the tibia. A valgus

stress is placed on the knee while externally rotating the tibia during slow but passive knee extension. Popping or clicking of the knee along with pain along the joint line is a positive test, indicating a meniscus tear of some kind—usually a medial meniscus tear. • Ober test—this involves the side-lying patient with the affected side up and both the knees and hips flexed at 90 degrees. The examiner maintains pelvic stability with one hand while lifting and extending the top hip and then returning it to neutral. The hip is allowed to then drop to the table. A positive test involves an inability of the knee to drop to the table in an iliotibial band tightening problem. • Posterior drawer test—this involves the same setup as the anterior drawer test but the tibia is pushed posteriorly rather than anteriorly. Increased posterior tibial translation during this maneuver indicates a PCL tear. • Valgus stress test—the patient lies supine and the examiner grabs the tibia with one hand, exerting a valgus stress on the knee with the other hand. It is performed at complete extension and when the knee is flexed at 20 to 30 degrees.

Increased laxity at the medial knee is a positive test indicating an MCL tear. • Varus stress test—the patient lies supine with the examiner grabbing the distal tibia and exerting a varus or lateral stress on the joint line of the knee at complete knee extension and at about 20 to 30 degrees of knee flexion. A positive test is increased laxity of the lateral knee at the joint line, indicating an LCL tear. • Anterior drawer test of the ankle—this assesses the lower leg. The lower leg dangles off the table and the foot is kept at slight plantar flexion. The examiner pulls the talus and calcaneus forward while stabilizing the distal tibia. A positive test is indicated as increased laxity of the joint, which could mean a tear of the anterior talofibular ligament, a common ligament involved in an ankle sprain. • Bump test—the patient is seated with the foot off the examining table. The examiner takes the palm of the hand and bumps the calcaneus with increasing force. Pain in the talus, calcaneus, tibia or fibula can indicate an advanced stress fracture of this area. • Kleiger test—the lower leg dangles from the table and the foot is rotated laterally but not everted or inverted, while the tibia is kept still. A positive test means a

sprain of the deltoid ligament, while pain above the medial malleolus indicates a sprain of the syndesmosis. • Squeeze test—the examiner takes the proximal tibia and fibula and squeezes them together. Pain distally in the leg indicates a tibia or fibular fracture or a sprain of the syndesmosis. • Thompson or Simmonds test—the patient is prone or sitting with the foot off the table. The examiner squeezes the calf. A positive test involves no plantar flexion of the foot, which indicates an Achilles tendon tear. • Talar tilt test—the lower leg dangles from the table, while the examiner grabs the calcaneus in order to invert and evert it. A positive test involves increased tilting and indicates sprains of the calcaneofibular ligament and the deltoid ligaments, respectively.