4.2 Spinal and Extremity Orthopedic Procedures
Key Takeaways
- Spurling's test reproduces radicular arm pain with cervical extension, rotation, and compression toward the symptomatic side.
- A positive crossed/well leg raise (Fajersztajn's sign) is a strong, specific indicator of a large central or axillary lumbar disc herniation.
- Three or more clustered positive sacroiliac provocation tests carry more diagnostic weight than any single SI test alone.
- Lachman's test is generally more sensitive than the anterior drawer test for detecting an ACL tear, especially acutely.
- Most orthopedic special tests have a known false-positive mechanism the exam expects candidates to rule out before confirming the tested diagnosis.
Why Orthopedic Special Tests Matter
Orthopedic procedures used on Part III are provocative or stress maneuvers that reproduce a patient's pain or reveal mechanical instability by loading, stretching, or compressing a specific structure. No single orthopedic test is perfectly sensitive or specific — most were validated against small samples with imperfect reference standards — so the exam consistently rewards understanding why a test is positive (which tissue is stressed, which nerve root is tensioned, which biomechanical fault is provoked) over rote memorization of names. Equally important is knowing each test's false positive: a mechanism by which the test can reproduce pain from an unrelated structure, which is exactly the kind of distractor built into vignette-style questions. High-yield procedures below are grouped by region.
Cervical Spine
| Test | Procedure | Positive Finding | Indicates | False Positive / Pitfall |
|---|---|---|---|---|
| Spurling's test (foraminal compression) | Extend, laterally flex, and axially compress the head toward the symptomatic side | Reproduction of radicular arm pain | Cervical nerve root compression (foraminal encroachment, disc herniation) | Local facet-joint pain without radiation is a false positive; the pain must radiate in a dermatomal pattern |
| Cervical distraction test | Examiner lifts the head axially, unloading the cervical spine | Relief of radicular symptoms | Confirms nerve root compression (the relieving counterpart to Spurling's) | Relief from simple muscle-guarding unrelated to a nerve root can mimic a true positive |
| Lhermitte's sign | Passive neck flexion | An electric shock-like sensation down the spine or into the limbs | Cervical cord/dural irritation (cervical myelopathy, multiple sclerosis, disc herniation with cord involvement) | Simple neck stiffness pain is not a true positive; the sensation must have the shock-like quality |
| Shoulder depression test | Head laterally flexed away from the tested side while the shoulder on that side is depressed | Radicular pain on the side being stretched | Nerve root adhesion or foraminal pathology | Upper trapezius muscle strain can mimic the finding |
| Adson's test | Extend and rotate the head to the tested side, extend/abduct/externally rotate the arm, then take a deep breath | Loss or diminution of the radial pulse | Thoracic outlet syndrome (compression at the scalene triangle) | Pulse changes occur in some healthy people; the finding must correlate with symptom reproduction |
| Wright (hyperabduction) test | Passively abduct and externally rotate the arm overhead | Diminished or absent radial pulse, or paresthesia | Thoracic outlet syndrome (compression beneath pectoralis minor/coracoid) | Same pulse-variability caveat as Adson's test |
| Roos test (EAST) | Arms abducted 90 degrees and externally rotated; patient opens and closes the hands for three minutes | Reproduction of arm heaviness, paresthesia, or inability to continue | Thoracic outlet syndrome; the most clinically reliable of the TOS provocation tests | Generalized fatigue in deconditioned patients can mimic the finding |
| Valsalva maneuver | Patient bears down as if straining | Reproduction of radicular pain | Increased intrathecal pressure over a space-occupying lesion (disc herniation, tumor) | A non-specific increase in intra-abdominal/thoracic pressure can cause pain unrelated to the spine |
| Soto-Hall test | Passive chin-to-chest flexion with a hand placed on the sternum | Localized pain at a specific spinal level | Ligamentous or vertebral pathology (fracture, disc, or bony lesion) at that level | Generalized flexion-stretch discomfort without focal localization is a false positive |
Thoracic Cage
Two supporting maneuvers assess rib and thoracic mobility. The chest expansion test compares circumferential rib cage measurement at maximal exhalation versus maximal inhalation; less than roughly 2 inches (5 cm) of expansion is a classic screening sign for ankylosing spondylitis and other causes of costovertebral joint restriction. The rib motion (springing) test applies a gentle posterior-to-anterior spring at each costovertebral junction; a positive finding is focal pain or a boggy, restricted end-feel over one rib, suggesting a fixated costovertebral or costotransverse joint rather than a distant visceral source of chest wall pain.
Lumbar Spine
| Test | Procedure | Positive Finding | Indicates | False Positive / Pitfall |
|---|---|---|---|---|
| Straight leg raise (SLR / Lasegue's) | Passively raise the straight leg while the patient is supine | Radicular leg pain reproduced roughly between 30-70 degrees of elevation | Lumbosacral nerve root tension (typically L4-S1 disc herniation) | Pain confined to the low back or posterior thigh only, from hamstring tightness, is a false positive; true positives must radiate below the knee |
| Well leg raise (Fajersztajn's/crossed SLR) | Raise the unaffected leg | Reproduction of pain on the opposite, symptomatic side | Highly specific for a large central or axillary disc herniation | Rarely positive, but a strong confirmatory sign when it is |
| Bowstring sign | From a positive SLR, slightly lower the leg, then compress the popliteal fossa | Reproduction of radicular pain with popliteal pressure | Confirms nerve root tension found on SLR (sciatic nerve origin) | Direct popliteal soft-tissue tenderness without radiation is a false positive |
| Kemp's test (quadrant test) | Patient extends, rotates, and laterally flexes toward the painful side | Localized or radicular pain | Facet joint pathology or foraminal nerve root compression | Purely local paraspinal muscle pain without radiation suggests a myofascial source, not a nerve root or facet cause |
| Milgram's test | Patient lies supine and holds both legs raised about 2 inches off the table for 30 seconds | Reproduction of low back or radicular pain | Increased intrathecal pressure from a space-occupying lesion | Simple hip flexor fatigue or strain, since the test is demanding on the iliopsoas |
| Slump test | Sequential slumped sitting, neck flexion, knee extension, and ankle dorsiflexion | Reproduction of radicular symptoms that ease with cervical extension | Neuromeningeal (dural/nerve root) tension throughout the neuraxis | Generalized hamstring tightness discomfort that lacks the characteristic relief on neck extension |
Sacroiliac Joint
| Test | Procedure | Positive Finding | Indicates |
|---|---|---|---|
| FABER / Patrick's test | Flexion, ABduction, External Rotation of the hip (figure-4 position), with gentle overpressure | Groin pain (hip) or posterior SI pain | Hip joint pathology if pain is groin-based; SI joint pathology if pain is posterior over the SI region |
| Gaenslen's test | Supine near the table edge, one hip hyperextended off the table while the other is flexed to the chest | Unilateral SI pain | SI joint dysfunction (shears the joint via opposing rotational forces) |
| SI compression test | Side-lying, downward pressure applied through the iliac crest | SI joint pain | SI joint dysfunction (compresses the joint surfaces) |
| SI distraction (gapping) test | Supine, posterolateral pressure applied to both ASIS | SI joint pain | SI joint dysfunction (gaps/distracts the anterior joint) |
| Yeoman's test | Prone, examiner extends the hip while stabilizing the sacrum | SI joint pain | SI joint dysfunction (stresses the anterior SI ligaments) |
| Gillet test | Standing, patient flexes one hip/knee toward the chest while the examiner palpates the PSIS bilaterally | Absent or reduced posterior movement of the PSIS on the flexed side | SI joint fixation (motion palpation, not pure pain provocation) |
A well-known exam teaching point: no single SI provocation test is diagnostic alone. A cluster of three or more positive tests (from among Gaenslen's, FABER, compression, distraction, and thigh thrust) meaningfully increases diagnostic confidence for sacroiliac joint pain compared with relying on any single test.
Shoulder
| Test | Procedure | Positive Finding | Indicates | False Positive / Pitfall |
|---|---|---|---|---|
| Neer's impingement test | Passive forward flexion of the internally rotated, pronated arm | Pain in the anterior/lateral shoulder | Subacromial impingement (supraspinatus/bursa compressed under the acromion) | AC joint arthritis pain at end-range can mimic |
| Hawkins-Kennedy test | Arm forward flexed to 90 degrees, elbow flexed 90 degrees, then forcibly internally rotated | Pain in the anterior/lateral shoulder | Subacromial impingement (rotator cuff compressed against the coracoacromial ligament) | Similar AC joint overlap as Neer's test |
| Empty can test (Jobe's) | Arms abducted 90 degrees, forward flexed 30 degrees, internally rotated (thumbs down), resisted elevation | Weakness or pain | Supraspinatus tendinopathy or tear | Deltoid substitution can mask or mimic the weakness pattern |
| Drop arm test | Passively abduct the arm to 90 degrees, then ask the patient to slowly lower it | Inability to smoothly lower the arm; it drops | Full-thickness rotator cuff tear (usually supraspinatus) | Pain-guarding without an actual tear can produce a similar-looking catch |
| Speed's test | Resisted forward flexion with the elbow extended and forearm supinated | Pain in the bicipital groove | Biceps tendinopathy/tendinitis (long head) | A SLAP lesion can present with similar pain |
| Yergason's test | Elbow flexed 90 degrees, resisted forearm supination while the examiner palpates the bicipital groove | Pain or subluxation in the bicipital groove | Biceps tendon instability or tendinopathy | Generalized anterior shoulder pain without groove localization is a false positive |
| Apprehension test | Arm abducted 90 degrees and externally rotated | Patient guards or resists further rotation and shows apprehension | Anterior glenohumeral instability | True pain alone, without apprehension, suggests impingement rather than instability |
| O'Brien's (active compression) test | Arm at 90 degrees flexion, 10-15 degrees adduction, internally rotated (thumb down), resisted downward, then repeated palm up | Pain deep in the joint with palm down that improves with palm up | SLAP lesion/labral tear | AC joint pathology produces pain in both positions rather than only the internally rotated one |
Knee
| Test | Procedure | Positive Finding | Indicates |
|---|---|---|---|
| McMurray's test | Flex the knee fully, rotate the tibia internally/externally while extending | Palpable/audible click or pain along the joint line | Meniscal tear (medial with external rotation, lateral with internal rotation) |
| Apley's compression/distraction test | Prone, knee flexed 90 degrees; compress or distract while rotating the tibia | Pain with compression | Meniscal injury (compression); ligamentous injury is suggested instead if pain occurs with distraction |
| Anterior drawer test | Knee flexed about 90 degrees, tibia pulled anteriorly | Excess anterior translation | Anterior cruciate ligament (ACL) laxity/tear |
| Lachman's test | Knee flexed 20-30 degrees, tibia pulled anteriorly | Excess anterior translation with a soft, mushy end-feel | ACL laxity/tear (more sensitive than the anterior drawer test, especially acutely) |
| Posterior drawer test | Knee flexed about 90 degrees, tibia pushed posteriorly | Excess posterior translation | Posterior cruciate ligament (PCL) laxity/tear |
| Valgus stress test | Knee slightly flexed (20-30 degrees), lateral-to-medial force applied | Excess medial joint gapping | Medial collateral ligament (MCL) sprain |
| Varus stress test | Knee slightly flexed, medial-to-lateral force applied | Excess lateral joint gapping | Lateral collateral ligament (LCL) sprain |
| Patellar grind (Clarke's sign) | Examiner cups the suprapatellar pouch; patient contracts the quadriceps against resistance | Pain or grinding under the patella | Patellofemoral pain syndrome/chondromalacia patellae |
Hip
| Test | Procedure | Positive Finding | Indicates |
|---|---|---|---|
| Thomas test | Supine, one hip fully flexed to flatten the lumbar lordosis; observe the opposite (extended) leg | The extended leg lifts off the table or fails to stay flat | Hip flexor (iliopsoas) contracture on the raised side |
| Ober's test | Side-lying, hip abducted and extended, then allowed to adduct | The leg remains abducted and fails to drop to the table | Iliotibial band tightness/contracture |
| Scour (quadrant) test | Supine, hip flexed and axially compressed through a circular range of motion | Pain, grinding, or catching | Hip labral tear or early osteoarthritis |
| Log roll test | Supine, examiner internally/externally rotates the straight leg at the hip | Pain, or an asymmetric range compared with the other side | Intra-articular hip pathology (highly specific, since it isolates the joint from surrounding soft tissue) |
Test Selection and Clustering on the Exam
Because most orthopedic special tests have only moderate sensitivity and specificity individually, well-constructed exam vignettes often describe two or more positive findings and expect the candidate to identify the single structure or pathology that explains all of them — for example, a positive Spurling's test plus a diminished biceps reflex plus C6 dermatomal numbness all localize to a C5-C6 nerve root problem, rather than being treated as three isolated facts. When a vignette gives a single isolated positive test with no corroborating findings, consider the listed false-positive mechanism before selecting the most obvious diagnosis.
Raising the unaffected leg during a straight leg raise test reproduces pain in the opposite, symptomatic leg. This finding, the well leg raise or Fajersztajn's sign, is most specific for which condition?
Which orthopedic test is performed by flexing the elbow to 90 degrees and resisting forearm supination while palpating the bicipital groove for pain or subluxation?
According to sacroiliac joint provocation testing evidence referenced on the exam, what best supports a diagnosis of SI joint dysfunction?
A patient's arm is passively abducted to 90 degrees and externally rotated. Instead of reporting pain, the patient becomes guarded and apprehensive, resisting further motion. This response is most consistent with: