Orthopedic tests are designed to evaluate individuals for musculoskeletal impairment. Orthopedic tests enable the clinician, such as a physician or physical therapist, to identify a specific area of injury and aid in the diagnosis and treatment plan of the injured individual. There is a general plan for physical assessment that includes taking a patient's history; examining how the patient moves and how individual joints move; evaluating sensation and reflexes; and, if necessary, administering diagnostic tests to aid in the diagnosis. These are specific orthopedic tests for the upper and lower extremities as well as the spine. The orthopedic tests, or "special tests," help the clinician in the differential diagnosis of the patient.
Purpose
A medical or health history taken by the clinician is extremely important in evaluating and diagnosing the patient. A patient's description of the pain, weakness, or both will guide the clinician as to what structures to evaluate and which orthopedic tests, if necessary, to complete. After the history has been taken, the clinician may focus on sensory and reflex testing to evaluate the integrity of the nervous system. Depending on where the injury or impairment is on the body, the clinician may opt to evaluate range of motion of the joint(s) of the area of injury or near the injury. For example, if a patient has knee pain, the clinician will more than likely assess how far the patient can bend the knee and straighten the knee. The clinician will compare this movement to the uninvolved side or "good leg." Thus, the clinician has a baseline for the individual and the "good leg" serves as a reference point or goal. It is usually advisable that the "good side" always be evaluated first, so that a true comparison can be made to the affected side. Obviously, if there is bilateral involvement the clinician must use his/her experience with other patients to evaluate and set a plan of care. Also included in an assessment is the evaluation of muscle strength.
Precautions
Most orthopedic tests stress areas to be evaluated in an effort to evaluate pain, joint play, and muscle extensibility. Because of the stress involved during some orthopedic tests, care must be taken to avoid further injury. Before doing any orthopedic tests, an area must be free from fracture or neoplasm (an abnormal growth). Furthermore, any patient with characteristics such as severe spasm, pain with unknown etiology, or pain that awakens the patient at night, should not be evaluated with orthopedic tests until a full medical evaluation can be completed to address these unexplained symptoms.
Description
There are numerous orthopedic tests that help the clinician diagnose impairment. It should be pointed out that these tests alone do not confirm a diagnosis. As stated previously, the medical history and other evaluative tools need to be completed so as to get a total representation of the patient's health and the nature of injury or problem. Furthermore, a positive test does not necessarily indicate a specific problem, and a negative test does not necessarily rule out the problem. Some tests that are frequently used by clinicians to evaluate the spine and extremities will be described below.
Cervical spine
One possible problem associated with the cervical spine could be narrowing of the space occupied by the nerve root. This could be due to many causes, two of which could be injury or osteoarthritis. It is possible that as the space occupied by the nerve root closes, there may be impingement on the nerve root. If this occurs there could be pain, changes in sensation, and weakness in the neck, shoulder, and possibly down the arm. Two tests that may help diagnose an individual with this pathology are the distraction and compression tests. The distraction test for the cervical spine is performed by the clinician to assess if there is pressure on the nerve roots. In a positive test, symptoms will decrease or disappear. The compression test is also performed by the clinician to evaluate if there is pressure on the nerve root. If symptoms are provoked down either arm during the test, it would indicate pressure on the nerve root and thus, a positive test.
Shoulder
In the shoulder there are many muscles that act to stabilize and control the humeral head in the glenoid (shoulder socket). Injury can occur to any of these muscles and cause pain in and around the shoulder. The biceps muscle flexes the elbow but has a tendinous attachment that crosses the shoulder. It is commonly involved in overuse injuries. Yergason's test evaluates muscle tendon pathology of the biceps tendon. In this test, a positive result is evidenced by tenderness or pain over the bicipital groove of the shoulder indicating a possible bicipital tendinitis (inflammation of the biceps tendon). Another common test is the Neer impingement test, which evaluates the integrity of the subacromial space (below the highest point of the shoulder blade) as it relates to the supraspinatus muscle (a muscle in the shoulder area). A positive sign is when pain is elicited in the superior shoulder and is usually an indication of some type of injury to the supraspinatus tendon, that is tendinitis. The cause of tendinitis is usually overuse.
Elbow
Tennis elbow test or Cozen's test is used to assess if there is an injury to the lateral epicondyle of the humerus (a bony prominence at the elbow end of the bone). A positive test is indicated by the patient having increased symptoms over the area of the lateral epicondyle. Pain usually indicates involvement of the wrist extensors at their origin. Pain is usually due to inflammation secondary to overuse. Golfer's elbow test or the medial epicondylitis test assesses the integrity of the medial epicondyle and the muscular attachments. A positive sign is pain over the area of the medial epicondyle and is usually indicative of tendinitis of the wrist flexors, also at their origin.
Wrist and hand
A common problem associated with repetitive strain is that of typists who spend hours at a time with the wrist slightly bent in the upward position. Constant stress on the wrist can eventually lead to pain and abnormal sensations, often tingling, of the wrist and hand. The common term is carpal tunnel syndrome. Phalen's test is a good test to evaluate the presence of pressure on the median nerve, which is the cause of pain. A positive test occurs when tingling is present in the fingers and is usually indicative of carpal tunnel syndrome. Another common test is the Finkelstein test. It is a test to evaluate the presence of tenosynovitis (inflammation of the tendon sheath) in the thumb. A positive sign is pain across the top and base of the thumb.
Hip
Sometimes individuals who are in sitting positions for extended periods of time, such as being in a wheelchair, may present with tightness of the muscles around the hip. There are three tests that are good tools to evaluate muscle flexibility around the hip. The Thomas test assesses fexibility of the hip flexors. It is a good test to evaluate tightness of the muscles that cross the front of the hip. The Ober test is another common flexibility test to assess the tightness of the tensor fasciae latae (connective tissue that covers the muscle and directs its tightening) and the iliotibial band (connects the pelvis to the leg bone). Ely's test is another test for assessing muscle tightness. It is used for evaluating the tightness of the rectus femoris, which crosses the front of the hip joint.
Knee
The knee is a common area that is frequently involved in pathology. One common problem, especially in the athletic population, is the disruption or tearing of the anterior cruciate ligament (ACL) of the knee. A Lachman test is probably the best orthopedic manual test to evaluate the integrity of the ACL. Other tests that assess the stability of the ligaments and the joint capsule are the Slocum test, lateral pivot shift test, and Hughston's test. The tests mentioned here are termed stress tests, and they assess laxity, or the amount of movement, at the knee joint.
Foot and ankle
The foot and ankle is a complex area that allows for both mobility and stability. There are many flexibility and ligamentous stress tests to evaluate the foot and ankle. Some common tests are the Talar tilt test, Thompson's test, and a test to assess blood supply to the lower extremity called Buerger's test.
KEY TERMS
Anatomy—The study of the structural makeup of the human body.
Anterior cruciate ligament—A ligament that attaches the surfaces of the tibia and femur, thus stabilizing the knee joint. This structure prevents anterior translation of the tibia with respect to the femur.
Biomechanics—The study of mechanics pertaining to the human body.
Etiology—The causes of a disease or abnormal condition.
Iliotibial band—A fascial sheath that extends from the upper thigh and traverses down the side of the femur, attaching around the area of the knee joint.
Kinesiology—The study of the principles of biomechanics as it pertains to human movement.
Physiology—The study of the physical and chemical processes as it relates to an organism, i.e. human body.
Rectus femoris—An anterior muscle that, when contracting, can initiate hip flexion, knee extension, or both at the same time.
Spasm—An involuntary and abnormal muscular contraction.
Tensor fasciae latae—A single muscle on the side of the thigh covering the hip joint that, when contracting, aids other muscles in moving the leg away from midline and out to the side.
Preparation
There are many orthopedic tests designed to aid the clinician in better evaluating the patient who has musculoskeletal impairment. Before doing these tests, clinicians must have knowledge of anatomy, biomechanics, kinesiology, and physiology. Furthermore, most of these tests are performed by licensed and experienced clinicians such as physicians, chiropractors, and physical therapists. Before doing these tests, it is important to point out that most of these tests can cause pain and produce symptoms. In fact, some of these tests are termed provocation tests, because they produce or "provoke" onset of symptoms.
Aftercare
Clinicians will focus on specific tests that can best evaluate the joint, limb, or spine. The goal is not to complete as many tests as possible, but to isolate tests that are joint or pathology specific. Clinicians should refrain from over-testing. It is not uncommon that after extensibility tests or stress tests to a joint, the patient may require heat to relax tight tissues or ice to minimize pain and/or inflammation.
Complications
Orthopedic tests are designed to aid the clinician in the determination of a diagnosis. When used sparingly and appropriately, these "special tests" can provide valuable information about the impairment. However, these tests require clinical competencies, and problems can arise when clinicians are not properly trained in certain techniques.
Results
Orthopedic tests will give the clinician some insight into the nature of the patient's complaints, although they may not directly correlate to a specific diagnosis. Imaging studies, such as x rays or an MRI scan, may be done to aid in diagnosis. Once the source of the pain has been determined, a course of treatment will be set. Treatment may include icing and resting the injury and prescribing pain relievers. Surgery is sometimes necessary. Physical therapy is often begun as soon as the patient's level of pain permits.
Health care team roles
It is important for the clinician to utilize as many sources as possible when evaluating an individual who presents with musculoskeletal involvement. For example, a physical therapist doing an evaluation needs to take a sound medical history followed by a complete assessment of all systems, i.e. muscular, skeletal, nervous. Furthermore, the physical therapist must be in complete contact with the referring physician and the nursing staff regarding medication, protocols, and diagnostic tests. Other therapies, such as speech, occupational, and respiratory may also be part of the evaluation. If the patient is in a rehabilitation hospital or nursing home, the nursing staff can provide an up-to-date status on the patient. It is quite clear that the evaluation of a patient requires input from the entire healthcare team, including the patient.
BOOKS
Hertling D., R.M. Kessler. Management of Common Musculoskeletal Disorders. Baltimore: Lippincott, Williams & Wilkins, 1996.
Lehmkuhl L.D., L. K. Smith. Brunnstroms Clinical Kinesiology. Philadelphia: F.A. Davis Co., 1996.
Magee D. J. Orthopedic Physical Assessment. Philadelphia: W.B. Saunders Co., 1997.
Moore K.L., A.F. Dalley. Clinically Oriented Anatomy. Baltimore: Lippincott, Williams & Wilkins, 1999.
