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The following tests and their explanations are among those that may be performed by Dr. Pisarek at Advanced Healthcare. Understanding the meaning of the tests is helpful for patients, insurance companies, lawyers, paralegals, and other doctors not familiar with neuro-musculo-skeletal examinations.
Adams' sign. If the patient has an S or a C scoliosis, note if the scoliosis straightens when the spine is flexed forward. If it does, it is a negative sign and evidence of functional scoliosis. A positive sign is noted when the scoliosis is not improved, thus evidence of a structural scoliosis.
Adson's test. With the patient sitting or standing, the examiner palpates the radial pulse and advises the patient to bend the head obliquely backward toward the side being examined, to take a deep breath, and to tighten the neck and chest muscles on the side tested. The maneuver decreases the interscalene space (anterior and middle scalene muscles) and increases any existing compression of the subclavian artery and lower components (C8 and T1) of the brachial plexus against the 1st rib. Marked weakening of the pulse or increased paresthesias indicate a positive sign of pressure on the neurovascular bundle, particularly of the subclavian artery as it passes between or through the scaleni musculature, thus indicating a probable cervical rib or scalenus anticus syndrome. This test is sometimes called the scalene maneuver.
Allen's test. The sitting patient elevates the arm and is instructed to make a tight fist to express blood from the palm. The examiner occludes the radial and ulnar arteries by finger pressure. The patient then lowers the hand and relaxes fist, and the examiner releases the arteries one at a time. Some examiners prefer to test the radial and ulnar arteries individually in two tests. The sign is negative if the pale skin of the palm flushes immediately when the artery is released. The patient should be instructed not to hyperextend the palm as this will constrict skin capillaries and render a false positive sign. The sign is positive if the skin of the palm remains blanched for more than 3 seconds. This test, which should be performed before Wright's test, is significant in vascular occlusion of the artery tested.
Apley's compression test. The patient is placed prone with the involved leg flexed at 90º. The examiner stabilizes the patient's thigh with a knee and grasps the patient's foot. Downward pressure is applied to the foot to compress the medial and lateral menisci between the tibia and femur. The examiner then rotates the tibia internally and externally on the femur, holding downward pressure. Pain during this maneuver indicates probable meniscus or collateral ligament damage. Medial knee pain suggests medial meniscus damage; lateral pain, lateral meniscus injury.
Bechterew's test. The patient in the sitting position attempts to extend each leg one at a time followed by an attempt to extend both legs. The sign is positive if backache or sciatic pain is increased or the maneuver is impossible. In disc involvements, extending both legs will usually increase spinal and sciatic discomfort.
Beery's sign. This sign is positive if a patient with a history of lower trunk discomfort and fatigue is fairly comfortable when sitting with the knees flexed but experiences discomfort in the standing position. It is typically seen in spasticity or contractures of the posterior thigh and/or calf muscles.
Bowstring sign. If pain occurs during Lasegue's SLR test, the knee is slightly flexed and the patient's foot is allowed to rest on the examiner's shoulder. When pain subsides, manual pressure is applied against the hamstrings. If this does not increase pain, manual pressure is then quickly applied to the popliteal fossa while holding the knee as straight as patient comfort will allow. Although local pain in the popliteal fossa is of minor consequence, a reproduction of leg or low-back pain is highly significant of an IVD rupture producing nerve root compression.
Bragard's test. If Lasegue's SLR test is positive at a given point, the examined leg is lowered below this point and dorsiflexion of the foot induced. The test is negative if pain is not increased. A positive sign is a finding in sciatic neuritis, spinal cord tumors, IVD lesions, and spinal nerve irritations. A negative sign points to muscular involvement such as tight hamstrings. Bragard's test does not stress the sacroiliac or lumbosacral articulations.
Buerger's test. The patient is placed supine with the knees extended in a relaxed position, and the examiner lifts a leg with the knee extended so that the lower limb is flexed on the hip to about a 45º angle. The patient is then instructed to move the ankle up and down (dorsiflex and plantarflex the foot) for a minimum of 2 minutes. The limb is then lowered, the patient is asked to sit up, the legs are allowed to hang down loosely over the edge of the table, and the color of the exercised foot is noted. Positive signs of arterial insufficiency are found if (1) the skin of the foot blanches and the superficial veins collapse when the leg is in the raised position and/or (2) it takes more than a minute for the veins of the foot to fill and for the foot to turn a reddish cyanotic color when the limb is lowered.
Cervical active rotary compression test. With the patient sitting, observe while the patient voluntarily laterally flexes the head toward the side being examined. With the neck flexed, the patient is then instructed to rotate the chin toward the same side, which narrows the IVF diameters on the side of scoliotic concavity. Pain or reduplication of other symptoms suggests a physiologic narrowing of one or more IVFs.
Cervical distraction test. With the patient sitting, the examiner stands to the side of the patient and places one hand under the patient's chin and the other hand under the base of the occiput. Slowly and gradually the patient's head is lifted to remove weight from the cervical spine. This maneuver elongates the IVFs, decreases the pressure on the joint capsules around the facets, and stretches perivertebral soft tissues. If the maneuver decreases pain and relieves other symptoms, it suggests narrowing of one or more IVFs, cervical facet syndrome, or spastic perivertebral muscles.
Cervical compression tests. Two tests are involved. First, with the patient sitting, the examiner stands behind the patient and the patient's head is laterally flexed and rotated about 45º toward the side being examined. Interlocked fingers are placed on the patient's scalp and gently pressed caudally. If an IVF is physiologically narrowed, this maneuver will further insult the foramen by compressing the disc and narrowing the channel, causing pain and reduplication of other symptoms. In the second test, the patient's neck is extended by the examiner placing interlocked hands on the patient's scalp and gently pressing caudally. If an IVF is physiologically narrowed, this maneuver mechanically compromises foraminal diameters bilaterally and causes pain and reduplication of related symptoms.
Cervical percussion test. The neck of a sitting patient is flexed to about 45º while the examiner percusses each of the cervical spinous processes and adjacent superficial soft tissues with a rubber-tipped reflex hammer. Evidence of point tenderness suggests a fractured or acutely subluxated vertebral motion unit or a localized sprain or strain, while symptoms of radicular pain suggest radiculitis or an IVD lesion.
Codman's sign. This is a variation of the shoulder abduction stress test and the arm drop test. If the patient's arm can be passively abducted laterally to about 100º without pain, the examiner removes support so the position is held actively by the patient. This produces sudden deltoid contraction. When a rupture of the supraspinatus tendon or strain of the rotator cuff exists, the pain produced causes the patient to hunch the shoulder and lower the arm.
Costo-clavicular maneuver. With the patient sitting, the examiner monitors the radial pulse of the patient from the posterior on the side being examined. The examiner brings the patient's shoulder and arm posterior and then depresses the shoulder on the side being examined. This maneuver narrows the ipsilateral costoclavicular space by approximating the clavicle to the first rib, tending to compress the neurovascular structures between. When the shoulder is retracted, the clavicle moves backward on the sternoclavicular joint and rotates counterclockwise. An alteration or obliteration of the radial pulse or a reduplication of other symptoms suggests compression of the neurovascular bundle passing between the clavicle and the first rib (costoclavicular syndrome).
Cozen's test. With the patient's forearm stabilized, the patient is instructed to make a fist and extend the wrist. The examiner grips the patient's elbow with the stabilizing hand and the top of the patient's fist with the active hand and attempts to force the wrist into flexion against patient resistance. A sign of tennis elbow is a severe sudden pain at the lateral epicondyle area.
Demianoff's test. This variant of Lasegue's SLR test is used in lumbago and IVF funiculitis with the intent of differentiating between lumbago and sciatica. When the affected limb is first extended and then flexed at the hip, the corresponding half of the body becomes lowered and with it the muscle fibers fixed to the lumbosacral segment. This act, which stretches the involved muscles, can induce sharp lumbar pain. Lasegue's sign is thus negative as the pain is caused by stretching the affected muscles at the posterior portion of the pelvis rather than stretching the sciatic nerve. To accomplish this test with the patient supine, the pelvis is fixed by the examiner's hand firmly placed on the ASIS while the other hand elevates the ipsilateral leg. No pain results when the leg is raised to an 80 angle. When lumbago and sciatica coexist, Demianoff's sign is negative on the affected side but positive on the opposite side unless the pelvis is stabilized. This sign is also negative in bilateral sciatica with lumbago. The stabilization of the pelvis prevents stretching the sciatic nerve, and any undue pain experienced is usually associated with ischiotrochanteric groove adhesions or soft-tissue shortening.
Double-leg raise test. This is a two-phase test: (1) The patient is placed supine, and a straight-leg-raising (SLR) test is performed on each limb: first on one side, and then on the other. (2) The SLR test is then performed on both limbs simultaneously; ie, a bilateral SLR test. If pain occurs at a lower angle when both legs are raised together than when performing the monolateral SLR maneuver, the test is considered positive for a lumbosacral area lesion.
Ely's test. To support iliopsoas spasm suspicions, the patient is placed prone with the toes hanging over the edge of the table, legs relaxed. Either heel is approximated to the opposite buttock. After flexion of the knee, hip pain makes it impossible to carry out the test if there is any irritation of the psoas muscle or its sheath. The buttock will tend to rise on the involved side. However, a positive Ely's test also can be an indication of rectus femoris contraction, a lumbar lesion, a contracture of the tensor fascia lata, or an osseous hip lesion.
Fajersztajn's test. When straight-leg raising and dorsiflexion of the foot are performed on the asymptomatic side of a sciatic patient and this causes pain on the symptomatic side, there is a positive Fajersztajn's sign, which is said to be particularly indicative of a sciatic nerve root involvement such as a disc syndrome, dural root sleeve adhesions, or some other space-occupying lesion. This is sometimes called the well-leg or cross-leg straight-leg-raising test. From a biomechanical viewpoint, this test would be suggestive but not indicative.
Forestier's sign. The patient in the upright position is asked to bend laterally, first to one side and then to the other. Normally, the contralateral perivertebral muscles will bulge because of the normal coupling rotation of the lumbar spine (exhibited by the spinous processes pointing to the ipsilateral side of lateral flexion). However, in ankylosing spondylitis (Marie-Strumpell's disease) or a state of extensive spinal fixation, the muscles will appear to bulge greater on the side of the curve's concavity.
Gaenslen's test. In this test, the patient is placed supine with knees and hips acutely flexed by the patient who clasps the knees with both hands and pulls them toward the abdomen. This brings the lumbar spine firmly in contact with the table and fixes both the pelvis and lumbar spine. With the examiner standing at right angles to the patient, the patient is brought well to the side of the table and the examiner slowly hyperextends the opposite thigh by gradually increasing force by pressure of one hand on top of the patient's knee while the examiner's other hand is on the patient's flexed knee for support in fixing the lumbar spine and pelvis. Some examiners allow the hyperextended limb to fall from the table edge. The hyperextension of the hip exerts a rotating force on the corresponding half of the pelvis. The pull is made on the ilium through the Y ligament and the muscles attached to the AIISs. The test is positive if the thigh is hyperextended and pain is felt in the sacroiliac area or referred down the thigh, providing that the opposite sacroiliac joint is normal and the sacrum moves as a unit with the side of the pelvis opposite to that being tested. The test should be conducted bilaterally. A positive sign may be elicited in a sacroiliac, hip, or lower lumbar nerve root lesion. If the L4 nerve is involved, pain is usually referred anteriorly to the groin or upper thigh. If the sign is negative, a lumbosacral lesion should be the first suspicion. This test is usually contraindicated in the elderly.
Gillis' test. With the patient prone and the examiner standing on the side of involvement, the examiner reaches over and stabilizes the uninvolved sacroiliac joint while the thigh on the involved side is extended at the hip. Pain initiated by this maneuver in the sacroiliac area of the involved side is a positive sign of acute sacroiliac sprain/subluxation or sacroiliac disease.
Goldthwait's test. The patient is placed supine. The examiner places one hand under the lumbar spine with each fingerpad pressed firmly against the interspinous spaces. The other hand of the examiner is used to slowly conduct an SLR test. If pain occurs or is aggravated before the lumbar processes open (1º--30º, a sacroiliac lesion should be suspected. In general, Goldthwait believed if pain occurred while the processes were opening at 30º--60º, a lumbosacral lesion was suggested; at 60º--90º, an L1–L4 disc lesion. When pain is brought on before the lumbar spine begins to move, a lesion, either arthritic or a sprain involving the sacroiliac joint, is probably present. If pain does not arise until after the lumbar spine begins to move, the disorder is likely to be in the lumbosacral area or less commonly in the sacroiliac area(s). The test should be repeated with the unaffected limb. A positive sign of a lumbosacral lesion is elicited if pain occurs at about the same height as it did with the first limb. When the unaffected limb can be raised higher than the affected limb, it is thought to be significant of sacroiliac involvement of the affected side.
Heel walk test. A patient should normally be able to walk several steps on the heels with the forefoot dorsiflexed. Except for a localized heel disorder (eg, a calcaneal spur) or contracted calf muscles, an inability to do this because of low-back pain or weakness can suggest an L5 lesion.
Hibb's test. The patient is placed in the prone position, and the examiner stands next to the patient on the side of involvement. The examiner stabilizes the patient's contralateral uninvolved hip, flexes the patient's knee on the involved side toward the buttock, and then slowly adducts the leg, which externally rotates the femur. Pain initiated in the hip joint indicates a hip lesion; pain rising in the sacroiliac joint but not the hip points to a sacroiliac lesion.
Hip abduction stress test. The patient is placed in the sidelying position with the underneath lower limb flexed acutely at the hip and knee. With the upper limb held straight and extended at the knee, the patient is instructed to attempt to abduct the upper limb while the examiner applies resistance. Pain initiated in the area of the upper aspect of the sacroiliac joint or the hip joint suggests an inflammatory process of the respective joint.
Hoover's test. This is a test for malingering associated with an active straight-leg-raising test. When the patient attempts to raise his leg, the examiner cups one hand under the heel of the opposite foot. When the typical patient tries to raise his affected limb, he normally applies pressure on the heel of the opposite limb for leverage and a downward pressure can be felt. If this pressure is not felt, the patient is probably not really trying.
Iliac compression test. The patient is placed on the side with the affected side upward. The examiner places his forearm over the iliac crest and leans pressure downward for about 30º seconds. This tends to compress the sacroiliac and pubic joints. A positive sign of joint inflammation or sprain is seen with an increase in pain; however, absence of pain does not necessarily rule out sacroiliac involvement. This test is usually contraindicated in geriatrics and pediatrics or with any sign of a hip lesion or osseous pelvic pathology.
Kemp's test. While in a seated position, the patient is supported by the examiner who reaches around the patient's shoulders and upper chest from behind. The patient is directed to lean forward to one side and then around to eventually bend obliquely backward by placing the palm on the buttock and sliding it down the back of the thigh and leg as far as possible. The maneuver is similar to that used in oblique cervical compression tests. If this compression causes or aggravates a pattern of radicular pain in the thigh and leg, the sign is positive and suggests nerve root compression. It may also indicate a strain or sprain and thus be present when the patient leans obliquely forward or at any point in motion. Not to be dismissed lightly would be the possibility of shortened contralateral perispinal ligaments and tendons forcing erratic motion on the side of lateral flexion.
Kernig's neck test. Biomechanically, this test is the cephalad representation of Lasegue's SLR test. The supine patient is asked to place both hands behind his head and forcibly flex his head toward his chest. Pain in either the neck, lower back, or down the lower extremities indicates meningeal irritation, nerve root involvement, or irritation of the dural coverings of the nerve root. That is, some hypersensitive tissue is being aggravated by tensile forces. When the examiner passively flexes the patient's neck and trunk, it is called the Soto-Hall test or Lindner's test, depending on the examiner's position.
Lasegue's differential sign. This test is used to rule out hip disease. A patient with sciatic symptoms is placed supine. If pain is elicited on flexing the thigh on the trunk with the knee extended but not produced when the thigh is flexed on the trunk with the knee relaxed (flexed), hip pathology can usually be ruled out.
Lasegue's rebound test. At the conclusion of a positive sign during Lasegue's supine SLR test, the examiner allows the limb to drop to a pillow without warning. If this rebound test causes a marked increase in pain and muscle spasm, then a disc involvement is said to be suspect. However, it would appear that any site of irritation in the lower back or pelvis would be aggravated by such a maneuver.
Lasegue's standing test. The patient attempts to touch the floor with the fingers while the knees are held in extension during the standing position. Under these conditions, the knee of the affected side will flex, the heel will slightly elevate, and the body will elevate more or less to the painful side. It should be noted that this would also be true with shortened posterior thigh and calf muscles.
Lasegue's straight-leg-raising (SLR) test. The patient lies supine with legs extended. The examiner places one hand under the heel of the affected side and the other hand is placed on the knee to prevent the knee from bending. With the limb extended, the examiner most cautiously flexes the thigh on the pelvis to the point of pain, keeping the knee straight. The patient will normally be able to have the limb extended to almost 90º without pain. If this maneuver is markedly limited by pain, the test is positive and suggests sciatica from a disc lesion, lumbosacral or sacroiliac lesion, subluxation syndrome, tight hamstring, spondylolisthetic adhesion, IVF occlusion, or a similar disorder.
Lewin-Gaenslen test. The patient is placed in the sidelying position with the underneath lower limb flexed acutely at the hip and knee. The examiner stabilizes the uppermost hip with one hand. With the other hand, the uppermost leg is grasped near the knee and the thigh is extended on the hip. Initiated or aggravated pain suggests a sacroiliac lesion.
Minor's sign. Sciatic radiculitis is suggested by the manner in which the patient with this condition rises from a sitting position. Body weight is supported on the uninvolved side by holding on to the chair for firm support in arising or the patient places the hands on the knees or thighs while working into the upright position, balances on the healthy leg, places one hand on the back, and flexes the leg and extends the thigh of the affected limb. The sign is often positive in sacroiliac lesions, lumbosacral strains and sprains, fractures, disc syndromes, and dystrophies and myotonias.
Nachlas' test. The patient is placed in the prone position. The examiner flexes the patient's knee to a right angle; then, with pressure against the anterior surface of the ankle, the heel is slowly directed straight toward the ipsilateral buttock. The contralateral ilium should be stabilized by the examiner's other hand. If a sharp pain is elicited in the ipsilateral buttock or sacral area, a sacroiliac disorder should be suspected. If pain occurs in the lower back area or is sciatic-like, a lower lumbar disorder (especially L3 or L4) is indicated. If pain occurs in the upper lumbar area, groin, or anterior thigh, quadriceps spasticity/contracture or a femoral nerve lesion should be suspected.
Patrick's F-AB-ER-E test. This test helps to confirm a suspicion of hip joint pathology. The patient lies supine, and the examiner grasps the ankle and flexed knee. The thigh is flexed (F), abducted (AB), externally rotated (ER), and extended (E). Pain in the hip during the maneuvers, particularly on abduction and external rotation, is a positive sign of coxa pathology.
Sicard's sign. During Lasegue's SLR test, the limb is lowered slightly to a point just below the level of pain, the examiner then dorsiflexes the big toe to induce traction on the sciatic nerve. Pain arising in the posterior thigh or calf indicates sciatic radiculopathy.
Soto-Hall test. This test is primarily employed when fracture of a vertebra is suspected. The patient is placed supine without pillows. One hand of the examiner is placed on the sternum of the patient, and mild pressure is exerted to prevent flexion at either the lumbar or thoracic regions of the spine. The other hand of the examiner is placed under the patient's occiput, and the head is slowly flexed toward the chest. Flexion of the head and neck on the chest progressively produces a pull on the posterior spinous ligaments from above, and when the spinous process of the injured vertebra is reached, an acute local pain is experienced by the patient.
Thomas' test. This test is used to determine excessive iliopsoas tension. The supine patient holds one flexed knee against his abdomen with his hands while the other limb is allowed to fully extend. The patient's lumbar spine should normally flatten. If the extended limb does not extend fully (ie, the knee flexes from the table) or if the patient rocks his chest forward or arches his back, a fixed flexion contracture of the hip is indicated, as from a shortened iliopsoas muscle. This should always be tested bilaterally. Some examiners use the degree of pain elicited on forced extension of the flexed knee as their criterion of iliopsoas tension.
Toe walk test. Walking for several steps on the base of the toes with the heels raised will normally produce no discomfort to the patient. Except for a localized forefoot disorder (eg, plantar wart, neuroma) or an anterior leg syndrome (eg, shin splints), an inability to do this because of low-back pain or weakness can suggest an S1–S2 lesion.
Valsalva's maneuver. The sitting patient is asked to bear down firmly (abdominal push), as if straining at the stool. This act increases intrathecal pressure, which tends to elicit localized pain in the presence of a space-occupying lesion (eg, IVD protrusion, cord tumor, bony encroachment) or of an acute inflammatory disorder of the cord (eg, arachnoiditis). Deep coughing produces the same effect under like circumstances.
Yeoman's test. The patient is placed prone. With one hand, firm pressure is applied by the examiner over the suspected sacroiliac joint, fixing the patient's anterior pelvis to the table. With the other hand, the patient's leg is flexed on the affected side to the physiologic limit, and the thigh is hyperextended by the examiner lifting the knee from the examining table. If pain is increased in the sacroiliac area, it is significant of a ventral sacroiliac or hip lesion because of the stress on the anterior sacroiliac ligaments. Normally, no pain should be felt on this maneuver.
Source: ACAPress Knowledge on Disks Program - Copyright 1995 R. C. Schafer, DC, PhD, FICC
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I have been a patient of Dr. Pisarek for a few years now. Every morning I have to say "thank you Dr. P.!". Your care and your treatment renew my energy... no more pains in my lower back, knee and foot. With your help I lost 20 pounds and I am keeping it off. I am really grateful to you and your wife Hilda for taking care of me. My retirement got a new meaning, thanks to you.