13.3 Orthopedic Examination: Range of Motion, Strength, and Special Tests

13.3 Orthopedic Examination: Range of Motion, Strength, and Special Tests

Quick Answer: The 2026 BIOM outline asks you to identify orthopedic examination techniques (range of motion, muscle strength testing, and special tests), know how they are performed, and interpret the findings. A systematic exam moves from inspection and palpation to active range of motion (what the patient can do), passive range of motion (what the examiner can achieve), resisted testing (graded 0-5), and finally special tests that stress a specific structure. Pain or weakness on resisted testing points to a contractile tissue (muscle or tendon). Pain at the end of passive range points to an inert tissue (capsule, ligament, joint).

Range of Motion and Strength

The neurological examination (cranial nerves, sensation, reflexes, and upper versus lower motor neuron signs) is covered in Section 13.2.

Essential Orthopedic Provocative Tests

Orthopedic provocative maneuvers apply targeted mechanical stress to specific anatomical tissues (tendons, ligaments, cartilage, nerve roots) to reproduce characteristic symptoms, verify structural tears, or evaluate joint stability.

Cervical Spine Provocative Maneuvers

1. Spurling's Test (Foraminal Compression Test):
   • Procedure: The seated patient extends the neck, laterally flexes the cervical spine toward the symptomatic side, and rotates the head toward that side. The examiner applies a gentle, controlled downward compressive axial load on top of the patient's head.
   • Positive Finding: Reproduction of sharp, electric, shooting pain radiating into the ipsilateral upper extremity following a specific dermatomal distribution.
   • Clinical Implication: High specificity for cervical radiculopathy secondary to lateral disc herniation or foraminal osteophyte encroachment.
2. Cervical Distraction Test:
   • Procedure: The patient lies supine. The examiner places one hand under the patient's occiput and the other under the mandible, applying a steady cephalad axial traction force (approximately 10–15 kg) to separate cervical vertebrae.
   • Positive Finding: Alleviation or substantial reduction of the patient's radicular neck and arm symptoms.
   • Clinical Implication: Confirms cervical radiculopathy by widening the neural foramina and relieving nerve root compression.
3. Lhermitte's Sign:
   • Procedure: The patient is instructed to actively flex the neck forward, bringing the chin toward the sternum.
   • Positive Finding: A sudden, electric shock-like sensation shooting down the center of the spine and into the extremities.
   • Clinical Implication: Indicates posterior cervical spinal cord pathology, demyelination (Multiple Sclerosis), severe cervical spondylotic myelopathy, or subacute combined degeneration.

Shoulder Complex Provocative Maneuvers

1. Empty Can (Jobe's) Test:
   • Procedure: The patient elevates the arms to 90° in the scapular plane (approximately 30° anterior to the coronal plane) with elbows extended and forearms fully pronated so that the thumbs point toward the floor ("emptying a can"). The examiner applies a downward force to the forearms while the patient resists.
   • Positive Finding: Pain and/or marked weakness during downward resistance.
   • Clinical Implication: Isolates pathology, tendinitis, or tearing of the supraspinatus tendon.
2. Neer Impingement Test:
   • Procedure: The examiner stabilizes the patient's scapula with one hand and passively flexes the internally rotated arm fully forward into overhead elevation.
   • Positive Finding: Pain in the anterolateral subacromial region as the greater tuberosity jams against the anteroinferior acromion.
   • Clinical Implication: Subacromial impingement syndrome (supraspinatus or long head of biceps tendon impingement).
3. Hawkins-Kennedy Impingement Test:
   • Procedure: The patient's shoulder and elbow are flexed to 90°. The examiner forcefully internally rotates the shoulder, driving the greater tuberosity under the coracoacromial ligament.
   • Positive Finding: Reproduction of subacromial pain.
   • Clinical Implication: Highly sensitive for subacromial impingement.
4. Speed's Test and Yergason's Test:
   • Speed's Test: Shoulder flexed to 90°, elbow extended, forearm supinated. The patient resists downward pressure applied to the forearm. Pain localized to the bicipital groove indicates bicipital tendinitis.
   • Yergason's Test: Elbow flexed to 90° with forearm pronated. The patient attempts active forearm supination and external rotation against the examiner's firm resistance while the examiner palpates the bicipital groove. Pain or snapping indicates bicipital tendinitis or instability of the biceps tendon within the bicipital groove (transverse humeral ligament tear).
5. Drop Arm Test:
   • Procedure: The examiner passively abducts the patient's arm to 90° and instructs the patient to slowly and smoothly lower the arm back to the side.
   • Positive Finding: Inability to lower the arm slowly with control; the arm drops suddenly to the side once it descends below 90° abduction, often accompanied by severe pain.
   • Clinical Implication: Highly specific for a full-thickness tear of the rotator cuff (specifically the supraspinatus).
6. Apprehension and Relocation Test:
   • Procedure: The supine patient's arm is abducted to 90° and passively externally rotated to 90°. A positive apprehension test is marked by the patient's sudden facial alarm, guarding, or verbalized fear that the shoulder will dislocate anteriorly. The relocation test is performed by applying an immediate posterior stabilizing force on the anterior humeral head; if pain and apprehension vanish, anterior glenohumeral instability is confirmed.

Elbow, Forearm, and Wrist Provocative Maneuvers

1. Cozen's Test and Mill's Test (Lateral Epicondylitis / "Tennis Elbow"):
   • Cozen's Test: The patient makes a fist, pronates the forearm, and actively extends and radially deviates the wrist against the examiner's strong downward resistance. Severe pain elicited over the lateral epicondyle confirms lateral epicondylitis involving the origin of the extensor carpi radialis brevis (ECRB).
   • Mill's Test: The examiner passively pronates the forearm, fully flexes the wrist, and extends the elbow. Reproduction of pain over the lateral epicondyle is positive.
2. Golfer's Elbow Test (Medial Epicondylitis):
   • The patient supinates the forearm and actively flexes the wrist against examiner resistance. Sharp pain localized to the medial epicondyle implicates the common flexor-pronator muscle tendon origin.
3. Phalen's Maneuver and Tinel's Sign (Carpal Tunnel Syndrome):
   • Phalen's Maneuver: The patient places the dorsal surfaces of both hands together, maintaining complete unforced wrist hyperflexion (90°) for 60 seconds. A positive test is reproduction of numbness, tingling, burning, or paresthesias in the median nerve distribution (palmar aspect of thumb, index, middle finger, and radial half of ring finger).
   • Tinel's Sign at the Wrist: Percussing lightly over the volar carpal ligament (transverse carpal ligament) at the wrist crease with a reflex hammer. Elicitation of an electric shock or tingling radiating into the radial three and a half digits indicates median nerve compression within the carpal tunnel.
4. Finkelstein's Test:
   • Procedure: The patient folds their thumb into the palm and closes the fingers tightly over the thumb to form a fist. The examiner passively and sharply deviates the wrist toward the ulnar border.
   • Positive Finding: Intense, lancinating pain along the radial styloid process.
   • Clinical Implication: Pathognomonic for De Quervain's tenosynovitis, representing stenosing tenosynovitis of the first dorsal extensor compartment enclosing the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons.

Lumbar Spine, Sacroiliac Joint, and Hip Provocative Maneuvers

1. Straight Leg Raise (SLR / Lasegue's Test):
   • Procedure: The patient lies supine. The examiner slowly lifts the relaxed, extended symptomatic lower extremity by the ankle with the knee locked in extension.
   • Interpretation: Reproduction of true radicular, lancinating pain shooting below the knee along a dermatomal distribution between 30° and 70° of hip flexion is positive for L4, L5, or S1 nerve root irritation / herniated disc. Pain prior to 30° suggests non-neurological pathology, sacroiliac pathology, or acute hip pathology. Pain beyond 70° typically represents benign hamstring tightness.
   • Bragard's Sign: Lowering the leg by 5° from the point of radicular onset and applying sudden passive ankle dorsiflexion; exacerbation of radicular pain confirms dural nerve root tension.
2. Crossed (Well-Leg) Straight Leg Raise Test:
   • Procedure: The examiner passively raises the asymptomatic (unaffected) leg to 45°–60°.
   • Positive Finding: Reproduction of radicular shooting pain down the affected (symptomatic) contralateral lower extremity.
   • Clinical Implication: Exceptionally high specificity (>90%) for structural lumbar intervertebral disc herniation (usually a large paracentral or extruded disc fragment compressing the axilla of the nerve root).
3. Slump Test:
   • A sensitive dynamic neurodynamic tension test performed seated: patient slumps thoracic and lumbar spine, flexes neck (chin to chest), extends knee, and dorsiflexes ankle. Reproduction of radicular symptoms relieved upon releasing neck flexion confirms neuromeningeal tension.
4. Patrick's / FABER Test:
   • Procedure: Acronym for Flexion, ABduction, and External Rotation. The supine patient's foot of the tested leg is placed atop the contralateral knee (forming a "figure 4"). The examiner stabilizes the opposite anterior superior iliac spine (ASIS) and presses downward gently on the medial aspect of the flexed knee.
   • Interpretation: Pain elicited anteriorly in the groin indicates intra-articular hip joint pathology (osteoarthritis, femoral acetabular impingement, labral tear). Pain elicited posteriorly in the sacroiliac or buttock region indicates sacroiliac joint dysfunction.
5. Trendelenburg Test:
   • The patient stands on one leg. If the pelvis on the unsupported (non-weight-bearing) side drops downward below the horizontal plane, the test is positive. Indicates weakness of the weight-bearing gluteus medius muscle or injury to the superior gluteal nerve.

Knee Joint Stability and Meniscal Provocative Maneuvers

1. Lachman's Test:
   • Procedure: The supine patient's knee is flexed to 20°–30°. The examiner stabilizes the distal anterior femur with one hand and grasps the proximal posterior tibia with the other, applying a sudden anterior translational force to the tibia.
   • Positive Finding: Increased anterior tibial translation (>3 mm compared to uninjured knee) and a soft, "mushy" or absent end-feel.
   • Clinical Implication: The single most sensitive and specific clinical test for an acute Anterior Cruciate Ligament (ACL) tear.
2. Anterior and Posterior Drawer Tests:
   • Knee flexed to 90°, foot flat on the table. The examiner sits on the foot and applies anterior pull (Anterior Drawer: ACL tear) or posterior push (Posterior Drawer: Posterior Cruciate Ligament [PCL] tear).
3. McMurray's Test:
   • The supine patient's knee is fully flexed. The examiner externally rotates the tibia and applies valgus stress while extending the knee to evaluate the medial meniscus; internal rotation and varus stress evaluates the lateral meniscus. A palpable click, pop, or sharp pain along the joint line indicates a meniscal tear.
4. Apley's Grind and Distraction Test:
   • Patient prone with knee flexed to 90°. The examiner applies axial downward compression while rotating the tibia internally and externally (Apley's Compression/Grind: pain confirms meniscal tear). The examiner then applies upward axial traction/distraction with rotation (Apley's Distraction: pain confirms collateral ligament strain, whereas meniscal pain is relieved).
5. Valgus and Varus Stress Tests:
   • Applied at 0° (full extension) and 30° knee flexion. Medial joint gapping under lateral-to-medial force indicates Medial Collateral Ligament (MCL) injury; lateral joint gapping under medial-to-lateral force indicates Lateral Collateral Ligament (LCL) injury.
6. Patellar Apprehension Test:
   • With knee flexed 20°–30°, examiner gently displaces the patella laterally. Sudden anxiety, muscular contraction of the quadriceps, and patient resistance indicate patellar instability or recurrent lateral subluxation.