SHOULDER EXAMINATION

INSPECTION: (anterior posterior)

• Scars
• Muscle wasting (infraspinatus, supraspinatus, deltoid)
• Pigmentation
• Anatomical landmarks: (important for muscle
attachments + surgical procedures)
Suprasternal notch
Sternoclavicular joint
Clavicle
Acromioclavicular joint
Shoulder contour (acromion)
Coracoid palpation 2cm inferior to clavicle

REVIEW: important muscles, innervation and action:

• Supraspinatus (subscapular nerve) initiates abduction (0-15°)
• Infraspinatus (suprascapular nerve) external rotation
• Subscapularis (subscapular nerve) internal rotation
• Teres minor (axillary nerve) external rotation
• Biceps brachii (musculocutaneous nerve) flexion, supination

RANGE OF MOTION: (glenohumeral joint)

• Synovial (ball and socket) joint
Flexion + extension
Abduction + adduction
Internal + external rotation
Circumduction

• Active ROM (ask patient to move)

• Passive ROM (you move patient’s arm)
• Against resistance (tests power graded from 1-5)

SPECIAL TESTS:
• Drop arm test
o Assesses supraspinatus
o Patient position:
Full abduction of the shoulder (internally rotated/ thumbs
down)
Start adducting, PAUSE at 90° continue till full adduction
o POSITIVE = sudden drop when adducting below 90 ° (injury to
supraspinatus)
• Tests for bicipital tendonitis:
a) Speed test
Assesses biceps tendon
Patient position: forward flex the shoulder at 90° + elevate against
resistance
POSITIVE = anterior shoulder pain (pathology in long head of biceps)

b) Yergason test
Assesses biceps tendon
Patient position: supinate against hand resistance
POSITIVE = anterior shoulder pain (pathology in long head of
biceps)

c) Obrien’s test
Assesses biceps tendon (long head)
Patient position: abduct shoulder against resistance (internally
rotated)
POSITIVE = anterior shoulder pain (slap tear in biceps long head)

• Tests for impingement syndrome: (tendonitis of rotator cuff muscles as they pass through subacromial
space under acromion)
a) Neers test:
Patient position: passively flex arm forward, internally rotate
POSITIVE = shoulder pain

b) Hawkins test:
Patient position:
– Flex shoulder and elbow 90°
– Passive internal rotation of elbow (quickly &
forcefully)
POSITIVE = anterior shoulder pain

• Tests for dislocation (instability): (anterior, recurrent dislocations)

Apprehension test:
• Patient position: (supine or sitting)
– Abduct shoulder
– Flex elbow at 90°
– Passively/ progressively externally rotate elbow
while pushing patient’s shoulder anteriorly
• POSITIVE => patient is apprehensive/nervous
 ELBOW EXAMINATION

INSPECTION: (anterior, posterior, lateral, medial)

o Muscle wasting, scars
o Deformities – varus (outwards), valgus (inwards)
o Anatomical landmarks:
– Lateral & medial epicondyle (anterior)
– Olecranon (posterior)
– Radial head palpation felt by pronating & supinating (lateral)
– Muscles around the elbow
Common extensor tendon
Flexors
Biceps

RANGE OF MOTION: (elbow joint)

o Synovial (hinge) joint flexion + extension; supination + pronation
o Active ROM
o Passive ROM
o Against resistance

SPECIAL TESTS:
a. Tinel sign test (at elbow)
– Test for CUBITAL tunnel syndrome (ulnar nerve compression in
cubital tunnel)
– Ulnar nerve passes behind medial epicondyle
– Test by tapping on medial epicondyle while arm is lifted
– POSITIVE = numbness along ulnar part of forearm

b. Tennis elbow
– Tests for lateral epicondylitis (inflammation in common extensor origin)
– Patient position: extend wrist against resistance
– POSITIVE = pain in lateral epicondyle

c. Golf elbow
– Tests for medial epicondylitis (inflammation in common flexor origin)
– Patient position: flex wrist against resistance
– POSITIVE = pain in medial epicondyle
d. Stress test (elbow stability)
– Assesses medial + lateral collateral ligaments (hold the elbow joint ensures stability)
– Stress test: adding pressure to collateral ligaments to test if there’s an opening in the joint
Varus stress test:
1. Tests lateral collateral ligament
2. Flex elbow 30°
3. Push elbow inwards
Valgus stress test
1. Tests medial collateral ligament
2. Flex elbow 30°
3. Push elbow outwards

HAND EXAMINATION
INSPECTION:
• Inspect from dorsal palmar surface
• Check for muscle wasting
• Anatomical landmarks:
Tendons (flexor carpi radialis; palmaris longus)
Ulnar head
Lister tubercle
Anatomical snuffbox (in the radial aspect)
Hypothenar & thenar eminence (wasting of thenar
eminence = carpal tunnel syndrome)

REVIEW: joint movement

• Wrist joint: flexion + extension; supination + pronation; circumduction
• Fingers: flexion + extension
• Thumb: adduction + abduction; flexion + extension; opposition, circumduction

RANGE OF MOTION: active ROM passive ROM against resistance

SPECIAL NERVE TESTS:
Median nerve
• Normally supplies flexors of anterior arm
• Compressed in CARPAL tunnel syndrome + interossei muscle wasting
• SENSORY FUNCTIONS: radial side = 3 ½ fingers (volar/ palmar aspect)
 • MOTOR FUNCTION (special tests):
a- Tinel sign test (at the wrist)
Press on median nerve over flexor retinaculum tendon (midpart of
palm)
POSITIVE => tingling over median nerve distribution

b- Phalen maneuver
Flex patient’s wrist
POSITIVE => numbness within 1 min on volar (palm) surface

c- OK sign: POSITIVE = cannot flex thumb and index fingers (become extended)

d- Pointing index sign

Ask patient to make a fist
Cannot flex middle and index fingers

Radial nerve (injury results in wrist drop)

a- Motor function test:
Ask to extend the wrist & thumb
POSITIVE => wris t flexes instead (wrist drop)
b- Sensory function: supplies 3 ½ fingers & thumb (dorsal)

Ulnar nerve
a- Motor function test: supplies intrinsic muscles for fine movements (palmar + dorsal)
Froment's sign:
• Tests adductor pollicis
• Put paper in between thumb & index
• Pull paper (against resistance)
• POSITIVE => patient flexes IP joint (uses
flexor pollicis longus supplied by median)
Interossei function test: ask to extend against resistance
Test for flexor tendon at finger:
a- Includes digitorum profundus + digitorum superficialis
b- Important in cut wound injuries (to check if its deep or superficial)
c- Patient position: hold index finger, palmar surface facing upwards
Test for digitorum profundus: ask to flex at DIP joint
Test for digitorum superficialis: ask to flex at IP joint

HIP EXAMINATION
INSPECTION: (anterior, posterior, medial, lateral)
o Symmetry of thighs, pelvis and abdomen (discoloration, hair distribution)
o Muscle wasting
o Anatomical landmarks:
Anterior superior iliac spine
Iliac crest
Greater trochanter

o Leg length:
Apparent leg length: measure distance between umbilicus + medial malleolus tip
True leg length: measure distance between ASIS + medial malleolus tip

RANGE OF MOTION: active, passive & against resistance

o Synovial (ball and socket) joint flexion + extension; abduction + adduction; internal + external
rotation

SPECIAL TESTS:
1. ADULT TEST:
a. Thomas test: (tests for flexion contraction/ inability to fully extend)
Patient position supine
Place hand under lumbar spine
If examining the left hip:
– Passively flex right hip
– Feel lumbar spine touching palm
– Measure angle of thigh
 POSITIVE => affected thigh is raised (under the lumbar spine)

b. Trendelenburg test: (tests for injury to superior gluteal nerve)

While patient is standing, flex knee + hip
Pelvis tilts bc weight-bearing leg cannot maintain pelvic alignment during hip
abduction
POSITIVE:
– Lesion is contralateral to side of hip that drops
– E.g.: if RIGHT hip drops = injury to LEFT superior gluteal nerve

2. PEDIATRIC TESTS: (< 6 months)

a. Ortolani test: (for hip relocation in DDH)
Done to relocate infant’s dislocated hip (anteriorly)
Flex and ABDuct baby’s hip joint
Push posteriorly (into greater trochanter)
Result: hip inserts anteriorly

b. Barlow test: (for hip dislocation)

Done to dislocate infant w/ unstable hip
Flex and ADDuct baby’s hip joint
Push posteriorly

c. Galeazzi sign: (DDH in infants)

Flex hip and knee at level of the femur
 KNEE EXAMINATION
INSPECTION: thigh muscle wasting, deformities
PALPATION:
o Bony landmarks:
Lateral & medial humeral epicondyle
Lateral & medial tibial epicondyle
Patellar tendon
Tibial tuberosity
o Soft tissue landmarks:
Quadriceps
Calf muscles

RANGE OF MOTION:
o Synovial (modified hinge) joint dorsiflexion +
plantarflexion; adduction + abduction; inversion +
eversion at subtalar joint

SPECIAL TEST:
a) Stabilization test:
Varus stress test:
– Tests lateral collateral ligament
– Bend knees 30° while supporting medial side
– Push INwards
Valgus stress test:
– Tests medial collateral ligament
– Bend knees 30° while supporting lateral side
– Push OUTwards

b) Meniscus:
Palpation:
– Locate lateral meniscus
– Palpate anteriorly to posteriorly
– Check for tenderness or swelling
McMurray test:
– Tests for medial/ lateral collateral ligament injury
– Hold foot and knee with one hand
– Internally rotate flex and extend the knee

c) Anterior & posterior cruciate ligament: (drawer test)

Anterior CL
– Patient lying supine
– Stabilize patient’s foot by sitting on it or w/ your knees
– Place 2 thumbs on posterior knees
– Pull the knee check how far it goes anteriorly
– POSITIVE = significant movement, indicates injury to ACL
Posterior CL (same but for posterior ligament)
d) Patellar tap (effusion test)
Push fluid from lower thigh until reaching superior patella
Push patella using other hand

e) Apprehension test
Tests for lateral patellar dislocation due to rupture of medial patellofemoral ligament
2 ways:
– Stabilize knee while pushing patella laterally
– Push patella upwards while flexing knee
POSITIVE => patient is apprehensive/ tenderness is felt
 ANKLE AND FOOT EXAMINATION

INSPECTION: (anterior, posterior, lateral & medial)

o Swelling, discoloration, hair distribution
o Scarring
o Check between toes
o Landmarks:
– Medial & lateral malleolus
– Calcaneus
– Achilles tendon
– Navicular bone
– Head of talus
– Tarsal bone
o Palpate between each metatarsal throughout tarsal bone
o Check each joint in the toes (MCP, IP, DIP)
o Palpate plantar fascia for tenderness

RANGE OF MOTION:
o Active, passive, against resistance
o Ankle joint synovial (hinge): plantarflexion + dorsiflexion;
inversion + eversion

SPECIAL TESTS:
a) Ankle stability test (medial & lateral collateral ligament)
• Valgus stress test:
i. Tests medial collateral ligament
ii. Stabilize ankle while holding heel ABDuct ankle

• Varus stress test:

i. Tests lateral collateral ligament
ii. Stabilize ankle while holding heel ADDuct ankle

b) Thompson test (achilles tendon injury)

• Palpate posterior calf while patient prone plantarflexion
• POSITIVE => no plantarflexion (indicates rupture in achilles tendon)
 SPINE EXAMINATION
(1) CERVICAL EXAM
INSPECTION:
• Check posture, swelling, discoloration, etc.
• Anterior landmarks:
o Hyoid bone (C4)
o Thyroid cartilage (C4,5)
o Cricoid ring (C6)
• Posterior landmarks: occiput, spinous processes (C1 C7)

PALPATION: feel tips of spinous processes

RANGE OF MOTION: active, passive & against resistance

• Flexion, extension
• Lateral rotation
• Lateral flexion (bending)

EXAMINATION: when examining the spine, we assess:

• Muscle power
o 5 = normal
o 4 = limitation against resistance
o 3 = movement only against gravity
o 2 = movement only with gravity
o 1 = flicker movement
o 0 = no movement

• Reflex
o 0= absent reflex
o 1= hyporeflexia lower motor lesion
o 2= normal
o 3= hyperreflexia without clonus (brisk) upper motor lesion
o 4= hyperreflexia with clonus

1- Dermatomes – skin innervated by single nerve root (picture)

2- Myotomes – muscle innervated by single nerve root
C5 = elbow flexion
C6 = wrist extension’
C7 = wrist flexion; finger extension
C8 = finger flexion
 3- Reflexes – involuntary movement in response to stimulus
C5/C6: biceps reflex
– Place your thumb over biceps tendon
– Hit with hammer
– Normal: elbow flexion

C6/C7: brachioradialis reflex

– Hit hammer over radial styloid process
– Normal: forearm should supinate

C7: triceps
– Place your thumb over triceps tendon
– Hit with hammer
– Normal: elbow extension

(2) LUMBAR SPINE EXAM

INSPECTION: posture, swelling, discoloration, wasting of paravertebral muscles
PALPATION:
Spinous processes palpation
Paraspinal muscles for tenderness

RANGE OF MOTION:
Flexion, extension
Lateral bending
Rotation

EXAMINATION:
Dermatomes (picture)
Myotomes
L1, 2 = hip abduction
L3, 4 = knee extension
L5, S1 = knee flexion
L5 = great toe extension
S1 = great toe flexion
 Reflexes
L3,4: quadriceps (knee jerk) reflex
– Patient lying supine, flex knee
– Hit patellar tendon w/ hammer
– Normal: knee extension

L5, S1: achilles tendon (ankle jerk)

– Hit over tendon w/ hammer
– Normal: plantarflexion

(3) OTHER PERIPHERAL NERVE EXAMINATION

Sciatic stretch test (straight leg raising test)

o Function:
– Motor: hip flexion, knee extension, ankle movement
– Sensory: lateral leg
o Tests for sciatica: radiating pain along course of sciatic nerve (due to
irritation via herniated disc)
o Patient position:
– Passive hip flexion + foot dorsiflexion of UNAFFEECTED LEG (while
supine)
– Flex till 60° look for apprehension
o POSITIVE: apprehensive patient

Femoral stretch test (L2,4)

o Function:
– Motor: hip flexion, knee extension, quadriceps reflex
– Sensory: anterior thigh
o Patient position: (prone) flex knees extend hip
o POSITIVE = pain on anterior thigh

NERVE ROOT INJURIES

Nerve root lesion Cause Sensory loss Affected motor function

C5 Lateral arm Abduction & external rotation of shoulder
Elbow flexion & wrist extension
C6 Lateral forearm
Loss of biceps reflex
Herniated disc
Elbow & finger extension
C7 Middle digit
Loss of triceps reflex
C8 Ulnar digit Finger adduction & abduction
Radiculopathy Plantarflexion
L5, S1 Herniated disc Foot sole Lumbar lordosis
Posterior hip dislocation Loss of ankle jerk