Herbert Frisch

Systematic
Musculoskeletal
Examination
Including Manual Medicine
Diagnostic Techniques

Translated by Terry C. Telger

With 327 Figures

in 709 Separate Illustrations

Springer-Verlag
Berlin Heidelberg New York
London Paris Tokyo
Hong Kong Barcelona
Budapest
Herbert Frisch, M. D.
Orthopedic Surgeon and Internist
Chairman ofthe Physicians' Seminar Hamm (FAC)
German Society of Manual Medicine
RheinstraBe 30
D-47226 Duisburg

Translator
Terry C. Telger
6112 Waco Way, Ft. Worth, TX 76133, USA

Title of the German Edition

Programrnierte Untersuchung des Bewegungsapparates
5. Auflage
ISBN 3-540-56347-4 Springer-Verlag
Berlin Heidelberg New York London Paris Tokyo
Hong Kong Barcelona Budapest

Library of Congress Cataloging-in-Publication Data

Frisch, Herbert. [programmierte Untersuchung des Bewegungsapparates. English] Systema-
tic musculoskeletal examination: including manual medicine diagnostic techniques 1Herbert
Frisch; translator, Terry C.Telger. p. em.
Translation of: Programrnierte Untersuchung des Bewegnngsapparates 1 Herbert Frisch.
5th Aufl. Includes bibliographical references and index.
ISBN-13: 978-3-642-75153-0 e-ISBN-13: 978-3-642-75151-6
DOl: 10.1007/978-3-642-75151-6
1. Musculoskeletal system-Examination. 2. Manipulation (Therapeutics) I. Title. [DNLM:
1. Musculoskeletal System. 2. Physical Examination. 3. Muscular Diseases-diagnosis. 4. Joint
Diseases-diagnosis. 5. Bone Diseases-diagnosis. WE 141 F917p 1993a]
RC925.7.F7513 1994 616.7' 0754-dc20 DNLMlDLC
for Library of Congress 93-30002

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Preface

This book is a revised, English version of Programmierte Untersuchung

des Bewegungsapparates, my very successful and award-winning book
now in its fifth edition in German. The original publication had a long his-
tory, growing out of an unpublished collection of summaries describing
the most effective and reliable techniques in manual medicine for con-
ducting examinations and treatment.
My experience at courses in manual medicine had convinced me that, in
order for these new methods to be incorporated into daily routine, it
would be necessary to put them in the context of the techniques already
being used to conduct orthopedic and neurologic examinations. Although
the combination of old and new examinations made diagnosis more pre-
cise, it also made it very time-consuming and thus impracticaL It was nec-
essary to develop a comprehensive, logical, and systematic scheme so as to
eliminate redundant and superfluous work. Furthermore, the sequence in
which the tests were conducted had to make it possible to analyze func-
tionally the various factors causing the disturbance. Such a structural
analysis of symptoms associated with the locomotive apparatus is a fun-
damental prerequisite for optimal therapy, and particularly for a specific
application of manual or physical therapies.
The result is the systematic musculoskeletal examination described in this
book. It comprises the components inspection, motion testing, palpation,
neurologic and angiologic tests, and special diagnostic procedures; each
of these has in turn been divided into five subgroups, providing the basis
for the name "5/5 scheme" occasionally used to refer to it. This systemat-
ic musculoskeletal examination combines precision with a shorter exami-
nation time.
This book is the product, first of all, of the knowledge I have gained from
30 years of work as therapist, educator, and head of the Physicians' Semi-
nar in Hamm, part of the German Society of Manual Medicine. It is based,
furthermore, on the experience of colleagues, both in Germany and
abroad, which I both studied in the literature and heard first hand, for ex-
ample through personal contacts with members of the College of Os-
teopathy at Michigan State Universty; this contact always prompted me
to critically reexamine my methods. Several such critical evaluations
based on functional anatomy and neurophysiological function are includ-
ed in the passages on biomechanics.
My gratitude goes to the participants at the Physicians' Seminar in Hamm,
to the staff of Springer-Verlag, and to the translator, Terry Telger, each of
whom has contributed in their own way to preparing an optimal product,
which I hope English-speaking readers will find an interesting enrichment
to the current literature.
H. Frisch
Contents

Examination Program

Introduction . . . . . . . 3
Patient-Oriented Aspects. . 3
Examiner-Oriented Aspects 3
Examination According to the 515 Program 4

Structure of the Systematic Examination

Systematic History . . . . . 6
Basic Physical Examination . 6
Inspection. . . . . . . . . . 7
Conduct of Examination 8
Palpation . . . . . . . . . . 8
Conduct of the Examination and Findings 10
Motion Testing . . . . . . . . . . . . . . . . . 11
Conduct of the Examination . . . . . . . . 12
Rationale for the Basic Physical Examination 13
Adjunctive Neurologic and Angiologic Studies ........ ~. 14
Neurologic Studies . . . . . 14
Conduct of the Examination . . . . . . 14
Angiologic Studies . . . . . . . . . . . 14
Adjunctive Special Diagnostic Procedures . 15
Examination Positions . . 16
Body Regions Examined. . . . . . . . . . . 17
Diagnosis . . . . . . . . . . . . . . . . . . . 18
Disease Groups Involving the Musculoskeletal System. 18

Structural Analysis of Function Using the Diagnostic Program 19

Structural Analysis in the Patient History with Reference to Pain 19
Types of Pain from a Structural Perspective 19
Basic Principles in the Analysis of Pain 20
Analysis of Pain During History Taking 20
Joint Pain . . . 20
Muscle Pain . . . . . . . 21
Ligament Pain 21
Bursitis, Tendovaginitis 22
Nerve Pain 22
Vascular Pain . . . . . . 23
Vertebragenic Pain . . . 23
Structurally Specific Findings in the Arthron 24
Examination of the Joint . . . . . . . . . . 24
VIII Contents

Inspection . . . . . . . . . . . . . . 24
Active and Passive Motion Testing 24
Palpation . . . . . . . . 26
Joint Play . . . . . . . . 26
Examination of the Spine 32
Inspection . . . 32
Motion Testing 32
Palpation . . . . 34
Joint Play . . . . 34
Examination of the Muscles. 35
Muscle Groups. . . . . . . 36
Findings of Muscle Examination. 39
Inspection . . . 39
Motion Testing. . 39
Palpation . . . . . 40
Resistance Tests . 41
Examination of the Nerves 42
Inspection . . . . . . . . 42
Active and Passive Motion Testing. 43
Palpation . . . . . . . . . . . . . . . 43
Muscle Tests . . . . . . . . . . . . . 43
Special Neuropathologic Findings During the Basic Physical
Examination . . , . . . . . . . . 43
Inspection . . . . . . . . . . . . . . . . 43
Complex Motor Sequences. . . . . . 43
Spontaneous Muscular Contractions 43
Trophic Disturbances (Chiefly Involving the Hands and Feet) 44
Active and Passive Motion Testing . 45
Active Motion Testing 45
Passive Motion Testing . . . . . 45
Palpation . . . . . . . . . . . . . . 45
Autonomic Nervous Disorders. 45
Nerve Pressure Points. . . . 46
Thickening of Nerve Trunks . . 46
Muscle Tests . . . . . . . . . . . . 46
Differential Diagnosis of Nerve Lesions 46
Symptoms of Nerve Lesions by Location 46
1. Muscular Nociceptive Symptoms (Nociceptive Reaction
of Wolff) . . . . . . . . . . . . . . . . . . 46
2. Symptoms of Peripheral Nerve Lesions. 47
3. Radicular Symptoms . . . . . . . . . . . 47
4. Symptoms of Plexus Damage . . . . . . 48
5. Symptoms Due to Disturbances Involving
the Neuromuscular Junction or Muscle Fiber. . . . . . . .. 48
6. Symptoms of Lesions ofthe Central Neuron
(Central Paralysis) . . . . . . . . . . . . . . . 48
Practical Relevance of the Structural Analysis of Function . 48
How Does the Control and Warning System Function? 48
Proprioception . . . . . . . . . . . . . . . . . . . . . . 48
 Contents IX

Stability ... 50
Coordination 50
Nociception . 51
Testing of Irritation Zones. 54
Location of the Irritation Zones or Irritation Points 54
Examination Technique. . . . . . . . . . . . . . . . 55
Diagnostic Implications of Irritation Zone Testing. 57

Basic Examination of the Spine and the Joints of the Extremities

Detailed Introduction
Systematic History . . 61
Interpretation of the History. 62
Current Pain . . . . . . . . 62
1 Location of Pain: What Hurts? Where Does it Hurt? . 62
1.1 Localized Pain (Monoarticular, Monosegmental) 62
1.2 Multifocal Pain (Polyarticular, Vertebral Region
or Entire Spine). . . . . . . . . . . . . . . . . . . 62
1.3 Referred Pain (Muscle Chains, Nerve Pathways,
Vessels) . . . . . . . . . . . 63
1.4 Diffuse Pain. . . . . . . . . . . . . . . . 63
1.5 Unilateral or Bilateral Pain . . . . . . . 63
2 Pain Occurrence: When Does It Occur
and When Did It First Occur? . . . . . . 63
2.1 24-Hour Rhythm . . . . . . . . . . . . . 63
2.2 Periodic Pain (Ovarian Cycle, Seasons, Age) 63
2.3 Episodic Pain (With or Without a Change in Pain
Location) . . . . . 63
3 Nature of the Pain 63
3.1 Intensity. 63
3.2 Character . . . . . 64
3.3 Course . . . . . . . 64
4 What Precipitates on Changes the Pain? 64
4.1 Body Posture . . . . . . . . . 64
4.2 Body Movements. . . . . . . 64
4.3 Other Mechanical Influences 64
4.4 Miscellaneous Influences .. 64
5 Associated Phenomena: What Accompanies the Pain? . 64
5.1 Sensory Disturbances . . 64
5.2 Motor Disturbances . . . 64
5.3 Circulatory Disturbances 64
5.4 Trophic Disturbances .. 64
5.5 Psychological Disturbances 64
Previous Course, General State of Health,
Other Current Diseases . . . . . . . . . . . . . . . . . . 64
1 What Treatments Have Been Given in the Past? 64
2 What Improved or Changed the Pain? 65
3 How Are the Vital Functions? . . . . . . . . . . 65
X Contents

4 When Did Previous Pain Occur Involving

the Spine and Joints? . . . . . . . . . . . . 65
5 What Other Diseases or Disorders Does
the Patient Have Now? . . . . . . . . . . 65
The Basic Physical Examination: Preliminary Information. 65
Exceptions . . . . . . . . . . . . . . . . . . . . . . . . . 65
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . 66
Symbols Used in the Figures on Examination Techniques. 66
Checklist for Joint Examinations. . . . . 67
Checklist for Muscle Examinations. . . . 67
Documentation of Findings Using Symbols 68
Ten Standard Symbols 68
General Symbols 68
Inspection . . . 69
Palpation . . . . 69
Motion Testing. 69
Measurements 70
Joints. . 70
Muscles. . . 70

General Inspection in the Standing Position (A) 71

1 Ordinary Movements . . . . . . . . 72
1.1 Gait . . . . . . . . . . . . . . . 72
1.2 Other Ordinary Movements. 74
2 Posture . . . . . . . . . . . . . . 74
3 Body Contours and Proportions 74
4 Skin. . . . . . . . 82
5 Assistive Devices. . . . . . . . . 82

Examination o/the LPH Region in the Standing Position (AlII) .. 83

1 Inspection (see Generallnspection) . . . . . . . . . . . 84
2 Active and Passive Trunk Movements in Three Planes
(Regional Diagnosis). . . . . . . . . . . . . . . . . . . . 84
2.1 Sagittal Plane: Forward and Backward Bending. 84
2.2 Frontal Plane: Sidebending 87
2.3 Transverse Plane: Rotation 87
3 Palpation of the Pelvic Joints . . . 88
Palpation at Rest . . . . . . . . . . 88
3.1 Pelvic Position, Leg Length Discrepancy. 88
Palpation During Movement - Testing Joint Play in Both SIJs 90
3.2 Standing Flexion Test (SIJ) . . . . . . . 90
Unilateral Joint Play Testing . . . . . . . . . . 91
3.3 Recoil Phenomenon (SIJ), "Spine Test" 91
3.4 Hip Drop Test (Lumbar Spine) 92
3.5 Lateral Shift Test (SIJ) . . . . . 94
4 Tests of Joint Translation . . . . . . . 96
4.1 Traction on the Lumbar Spine. 96
4.2 Compression of the Lumbar Spine 97
5 Muscle Test. . . . . . . . . . . . . . . . . 97
 Contents XI

General Examination of the Lower Extremities in the Standing

Position (All) (Supplement to Examination of the LPH Region) . 99
1 Three-Phase Squat. . 100
2 Standing on the Toes. . . . . . . . . . . 100
3 Standing on the Heels . . . . . . . . . . 101
4 Standing on the Outer Edge of the Foot 101
5 Muscle Tests . . . . . . . . . . . . . . . 101

Examination of the LPH Region in the Sitting Position (B/Il) . 103

1 Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 104
1.1 Relaxed and Erect Sitting Posture. . . . . . . . . . . .. 104
1.2 Pelvic Position - Comparison with Findings in Standing 104
2 Active and Passive Trunk Movements in Three Planes
(Regional Diagnosis). . . . . . . . . . . . . . . . . . . . . . . 105
Supplementary SIJ Test for Differentiating Motion Faults
in the SIJ and Lumbar Spine . . . . . . . . . . . . . . . . . 105
Regional Motion Testing ofthe Lumbar (and Thoracic) Spine
in Three Planes with the Pelvis Stationary. . . . . . . . . .. 105
3 Palpation of the SIJ and Lumbar Spine (Segmental Diagnosis) 109
Palpation at Rest. . . . . . . 109
3.1 Pelvic Position. . . . . . . . . . . . . . . . . . . . 109
Palpation During Movement . . . . . . . . . . . . . . . 110
3.2 Seated Flexion Test (for Asymmetric Excursion
ofthe Iliac Spines) . . . . . . . . . . . . . . . . . 110
3.3 Segmental Motion Testing of the Lumbar Spine . 111
4 Tests ofJoint Translation 115
4.1 Traction . . . 115
4.2 Compression . . . 115
5 Muscle Tests . . . . . . . 116
Resistance Tests of the Flexors, Rotators, Abductors,
and Adductors ofthe Hip. . . . . . . . . . . . . . . . . 116

Examination of the LPH Region in the Prone Position (ClIl) . . .. 118

1 Inspection. . . . . . . . . . . . . . . . . . 120
1.1 Pelvic Position and Gluteal Profile 120
1.2 Pelvis-Leg Angle . . . . . . . . 120
1.3 Leg Length Discrepancy . . . . . . 120
1.4 Asymmetric Muscle Contours. . . 120
1.5 Alignment ofthe Vertebral Column. 120
2 Active and Passive Hip and Knee Movements
(Regional Diagnosis . . . . . . . . . . . . .. . . . . . . . . . . 121
2.1 Hyperextension of the Hip Joint
(Extension from the Neutral Position) 121
2.2 Rotation ofthe Hip Joint. . . . . . . . 123
2.3 Flexion, Extension, Rotation of the Knee Joint 123
3 Palpation Field of the Dorsal Pelvis:
Lumbar Joints/Soft-Tissue Diagnosis (Segmental Diagnosis) 124
Palpation at Rest . . . . . . . . . . . . . . . 124
3.1 Palpation Field of the Dorsal Pelvis. . . . . . . . . . . 124
XII Contents

3.2 Test for Functional Leg Length Discrepancy

(Functionally Short Leg) . . . . . . . . . . . . . . . . . .. 130
3.3 Segmental Palpation of the Lumbar Spine (MobilitylPain) 131
3.4 Kibler's Skin Rolling Test . . . . . . . . . . . . . . . . .. 134
3.5 Connective-Tissue Stroke Test . . . . . . . . . . . . . .. 135
4 Tests ofJoint Translation . . . . . . . . . . . . . . . . . . . . .. 135
4.1 Lumbar Spine. . . . . . . . . . . . . . . . . . . . . . . .. 135
4.2 SacroiliacJoints. . . . . . . . . . . . . . . . . . . . . . .. 137
4.3 Hip Joints: Rotation . . . . . . . . . . . . . . . . . . . .. 143
5 Muscle Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 144
5.1 Resistance Tests of the Hip Muscles. . . . . . . . . . . .. 144
5.2 Knee Muscles . . . . . . . . . . . . . . . . . . . . . . . .. 145
5.3 Back Extensors . . . . . . . . . . . . . . . . . . . . . . .. 147
Examination o/the LPH Region in the Lateral Position (D/II) . .. 148
3 Palpation of the Lumbar Spine During Movement
(Segmental Mobility) . . . . . . . . . . . . . . . . . . . . . . .. 149
3.1 Forward and Backward Bending . . . . . . . . . . . . .. 149
3.2 Sidebending. . . . . . . . . . . . . . . . . . . . . . . . .. 149
3.3 Rotation. . . . . . . . . . . . . . . . . . . . . . . . . . .. 152
4 Tests ofJoint Translation . . . . . . . . . . . . . . . . . . . . .. 152
4.1 Hypermobility Test of the SIJ . . . . . . . . . . . . . . .. 152
4.2 Hypermobility Test ofthe Lumbar Spine. . . . . . . . .. 153
5 Muscle Tests (Resistance Tests of Hip Muscles). . . . . . . . .. 153
5.1 Abductors. . . . . . . . . . . . . . . . . . . . . . . . . .. 153
5.2 Adductors . . . . . . . . . . . . . . . . . . . . . . . . . .. 154
Examination o/the LPH Region in the Supine Position (EllI). . .. 155
1 Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 156
1.1 Legs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 156
1.2 Pelvic Position . . . . . . . . . . . . . . . . . . . . . . .. 157
1.3 Vertebral Column . . . . . . . . . . . . . . . . . . . . . . 157
1.4 Abdominal Wall . . . . . . . . . . . . . . . . . . . . . .. 157
2 Active and Passive Motion Testing: Hip and Knee Joints, SIJ,
and Lumbar Spine . . . . . . . . . . . . . . . . . . . . . . . . .. 157
2.1 Hip Flexion . . . . . . . . . . . . . . . . . . . . . . . . .. 157
2.2 Hip Rotation . . . . . . . . . .. . . . . . . . . . . . . .. 160
2.3 Hip Abduction . . . . . . . . . . . . . . . . . . . . . . .. 161
2.4 Knee Joint Screening Tests . . . . . . . . . . . . . . . . . 162
2.5 Differentiation of the LPH Joints: Hip Joint, SIJ,
Lumbar Spine, and Muscles . . . . . . . . . . . . . . . .. 163
3 Palpation Field ofthe Ventral Pelvis . . . . . . . . . . . . . . .. 166
Palpation at Rest. . . . . . . . . . . . . . . . . . . . . . . . . .. 166
4 Tests ofJoint Translation . . . . . . . . . . . . . . . . . . . . .. 169
4.1 Traction and Compression of the Lumbar Spine. . . . .. 169
4.2 Traction and Compression of the Hip Joint. . . . . . . .. 171
4.3 SIJ Springing Test via the Thigh . . . . . . . . . . . . . .. 172
5 Muscle Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 173
5.1 Resistance Tests ofthe Hip and Abdominal Muscles . .. 173
5.2 Shortening Tests . . . . . . . . . . . . . . . . . . . . . .. 176
 Contents XIII

Examination of the Thora."'( (Thoracic Spine and Ribs)

in the Sitting Position (BIlll) . . . . . . . . . . . . . . . . . . . . .. 180
1 Inspection. . . . . . . . . . . . 181
1.1 Thoracic Morphology . . . . . . . . . . . . . . . 181
1.2 Respiratory Movements . . . . . . . . . . . . . . 181
2 Active and Passive Trunk Movements in Three Planes
(Regional Diagnosis) . . . . . . . . . . . . . . . . . . . 183
3 Palpation of the Thoracic Joints (Segmental Diagnosis) 184
Palpation at Rest . . . . . . . . . . . . . . . . . 184
3.1 Sternal and Costal Synchondroses
(Sternocostal Joints 2-7), Floating Ribs 184
3.2 Costotransverse Joints. 184
3.3 Segmental Muscles . . . . . . . . . . . . 186
Palpation During Movement . . . . . . . . . . 186
3.4 Segmental Motion Testing of the Thoracic Spine 186
3.5 Segmental Motion Testing ofthe Ribs ("Harp") . 190
4 Tests ofJoint Translation . . . . . . . . . . . . . . . . . 193
4.1 Bimanual Compression of the Thorax in the Frontal Plane 193
4.2 Bimanual Compression of the Thorax in the Sagittal Plane 193

Examination of the Thorax (Thoracic Spine and Ribs)

in the Prone Position (CIlll) . . . . . . . . . . . . . . . . . . . . .. 194
1 Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 195
2 Active Movements: Respiratory Movements (Deep Breathing)
(Regional Diagnosis) . . . . . . . . . . . . . . . . . . . 195
3 Palpation ofthe ThoracicJoints (Segmental Diagnosis) 195
Palpation at Rest. . . . . . . . . . . . . . . . . 195
3.1 Palpation Field ofthe Posterior Thorax 195
Palpation During Movement . . . . . . . . . . 197
3.2 Rib Movements and Intercostal Spaces. 197
4 Tests of Joint Translation 199
4.1 Thoracic Segments 199
4.2 Scapula 199
5 Muscle Tests . . . . . . . 201

Examination of the Thorax (Thoracic Spine and Ribs)

in the Lateral Position (DIlll) . . . . . . . . . . . . . . . . . . . .. 202
3 Palpation of the Thoracic Joints During Movement
(Segmental Diagnosis). . . . . . . . . . . . . . . . . . . . . . .. 203
3.1 Segmental Mobility Testing of the Thoracic Spine. . . .. 203
3.2 Segmental Mobility Testing of the Cervicothoracic1unction
(C6-T3) . . . . . . . . . . . . . . . . . . . . . . . . . . .. 204
3.3 Segmental Mobility Testing ofthe Lower (6th-12th) Ribs 205

Examination of the Thorax (Ribs) in the Supine Position (E/III) .. 207

1 Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
2 Active Movements: Respiratory Movements (Deep Breathing)
(Regional Diagnosis) . . . . . . . . . . . . . 208
3 Palpation of the Ribs (Segmental Diagnosis) . . . . . . . . . .. 208
XIV Contents

Palpation at Rest . . . . . . . . . . . . . . . . . 208

3.1 Palpation Field of the Anterior Thorax. 208
Palpation During Movement . . . . . . . . . . 209
3.2 Rib Movements and Intercostal Spaces. 209
3.3 Segmental Mobility Testing of the Upper (2nd-6th) Ribs. 210
4 Tests ofJoint Translation . . . . . . . . . . . . . . . . 211
4.1 CostalJoints. . . . . . . . . . . . . . . . . . . . . . 211
4.2 Sternoclavicular and Acromioclavicular Joint . . . 211
5 Muscle Test: Test for Shortening of the Pectoralis Major. 211

Examination of the Cervical Spine in the Sitting Position (BN) .. 213

1 Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 214
2 Active and Passive Movements of the Cervical Spine and Head
in Three Planes (Regional Diagnosis). . . . . . . . . . . 214
2.1 Sagittal Plane: Backward and Forward Bending. 214
2.2 Frontal Plane: Sidebending . . . . . . . . . . . 214
2.3 Transverse Plane: Rotation . . . . . . . . . . . 215
2.4 Provocative Testing of the Vertebral Segments
(Modified from de Kleyn) . . . . . . . . . . . . ...... 215
2.5 Provocative Test for Motion Segment Laxness
(Hypermobility). . . . . . . . . . . . . . . . . . . . . . . 215
3 Palpation of the Cervical Spine During Movement
(Segmental Diagnosis) . . . . . . . . . . . . . . . . . 216
3.1 Mobility Testing of the Occiput/Atlas (CO/C1) . 216
3.2 Mobility Testing of the Atlas/Axis (ClIC2). 220
3.3 Mobility Testing of the C2/C3 Segment .. 225
3.4 Mobility Testing of the C3-C5 Segments . 226
3.5 Mobility Testing of the C5-T3 Segments
(Cervicothoracic Junction). 229
4 Tests ofJoint Translation 231
4.1 Traction . . . . . . . . . . . 231
4.2 Compression . . . . . . . . 232
4.3 Tests of FacetJoint Gliding 233
5 Muscle Tests - Resistance Tests of the Cervical Muscles
(Synergists) . . . . . . . . . . . . . . . . . . . . . . . 235

Examination of the Head (Temporomandibular Joints,

Sensory Organs) in the Sitting Position (BN). . . . . . . . . . . .. 238
1 Inspection. . . . . . . . . . 239
1.1 Facial Asymmetries . 239
1.2 Mimetic Activity . . . 239
1.3 Sensory Organs: Eyes 239
2 Jaw Movements and Swallowing 240
2.1 Opening and Closing of the Jaw. 240
2.2 Protraction and Retraction of the Jaw. 240
2.3 Lateral Jaw Movements (Grinding Movements) . 240
3 Palpation Field ofthe Face . . . . . . . . . . . . . . . . 240
3.1 Trigeminal Pressure Points. . . . . . . . . . . . . 240
3.2 Corneal Reflex (First Division of the Trigeminal Nerve) 240
 Contents XV

3.3 Pressure on the Tragus. . . . . . . . . . . . 241

3.4 Palpation of the Temporomandibular Joints . . . 241
3.5 Percussion of the Frontal and Maxillary Sinuses . 241
4 Passive Testing of Temporomandibular Joint Motion and Play 241
5 Muscle Tests . . . . . . . . 242
5.1 Mimetic Muscles . . 242
5.2 Masticatory Muscles 243
5.3 Lingual Muscles. 243
5.4 Ocular Muscles. . . 243

Examination of the Cervical Spine in the Supine Position (E/V) . 244

1 Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 245
2 Active and Passive Movements of the Cervical Spine and Head
in Three Planes (Regional Diagnosis) . . . . . . . . . . . . 245
2.1 Forward Bending, Backward Bending, Sidebending,
and Rotation. . . . . . . . . . . . . . . . . 245
2.2 Side-to-Side Head Movement. . . . . . . . . . . . . 245
2.3 Provocative Test for the Vertebral Artery
(De Kleyn's Hanging Test) . . . . . . . . . 247
3 Palpation of the Cervical Spine During Movement
(Segmental Diagnosis) .. 248
3.1 Forward Bending .. 248
3.2 Backward Bending . 248
3.3 Sidebending . . . . 248
3.4 Rotation . . . . . . . 248
4 Tests ofJoint Translation . 250
4.1 Three-Dimensional Traction on All Cervical Segments. 250
4.2 COIC1 Segment: Backward and Forward Gliding
of the Occipital Condyles on the Atlas (Forward
and Backward Nodding) . . . . . . . . . . 250
4.3 COICl/CZ Segment: Combined Movements
in the Craniovertebral Joints. . . . . . . . . . . . . . . .. 250
4.4 Cl/CZ Segment: Atlas Traction . . . . . . . . . . . . . .. 252
4.5 Cl/CZ Segment: Lateral Gliding of the Atlas on the Axis
(HypermobilityTest). . . . . . . . . . . . . . . . . 252
4.6 CZ-C7 Segments: ConvergentlDivergent Gliding
in the Facet Joints. . . . . . . . . . . . . . . . . . . 254
5 Muscle Tests - Resistance Testing of the Cervical Muscles. 255

Examination of the Upper Extremities in the Sitting Position (BIIV)

Shoulder Joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 256
1 Inspection. . . . . . . . . 257
1.1 Shoulder Position. . . . . . . . . . . . . . . . . 257
1.2 Shoulder Contours . . . . . . . . . . . . . . . . 258
2 Active and Passive Movements of the Shoulder Joint. 258
2.1 General Active Tests. . . . . . . . . . . . . . . 258
2.2 Frontal Plane: Abduction!Adduction and Rotation
ofthe Arms . . . . . . . . . . . . . . . . . . . . . . . 259
2.3 Sagittal Plane: Raising the Arms Forward and Behind 262
XVI Contents

3 Palpation Field of the Shoulder. . . . . . . . 263

4 Tests of Joint Translation (Humeral Head) . 267
5 Resistance Testing of the Shoulder Muscles . 269
5.1 Synergists (2x4) . . . . . . . 269
5.2 Differentiating Tests (3x5) . . . . . . . 272

Joints o/the Shoulder Girdle. . . . . . . . . . . . . . . . . . . . .. 277

1 Inspection (See B/Shoulder/Sect. 1) . . . . . . . . . . . 278
2.1 Raising and Lowering the Shoulder Girdle. . . 278
2.2 Advancing and Retracting the Shoulder Girdle 278
3 Palpation Field of the Shoulder Girdle. . . . . . . . . 278
3.1 Palpation of the Shoulder Girdle at Rest . . . . 280
3.2 Palpation of the Shoulder Girdle During Movement 283
4 Tests of Joint Translation - Clavicle and Scapula 285
Sternoclavicular Joint . . . . 285
Acromioclavicular Joint. . . . . . . . . . . . . . 288
Alternative Techniques . . . . . . . . . . . . . 288
5 Resistance Testing of the Muscles of the Shoulder Girdle 291
5.1 Synergists . . . . . . . . . . . . 291
5.2 Scapular Rotators. . . . . . . . 291
6 Examination of the Cervical Spine . . 293

Elbow foint, Upper Arm, and Forearm . . . . . . . . . . . . . . .. 296

1 Inspection. . . ... . . 297
1.1 Joint Position . . . . . . . . . . . . . . . . . . . . . . . .. 297
1.2 Joint Contours . . . . . . . . . . . . . . . . . . . . . . .. 297
1.3 Changes in the Muscle Contours of the Upper Extremity. 299
2 Active and Passive Elbow Movements . 299
2.1 FlexionlExtension . . 299
2.2 Pronation/Supination . . . . . . 299
2.3 Abduction/Adduction
(Collateral Ligament Stability Test ) . 300
3 Palpation Field of the Elbow/Arm . . 300
3.1 Extensor Side of the Elbow . . 300
3.2 Lateral (Radial) Epicondyle. 301
3.3 Medial (Ulnar) Epicondyle 302
3.4 Flexor Side of the Elbow . 304
3.5 Upper Arm and Forearm 305
4 Tests of Joint Translation . . . . 305
4.1 Humeroradial Joint ... 305
4.2 Proximal and Distal Radioulnar Joints. 305
4.3 Humeroulnar Joint. . . . . . . . . . . . 309
5 Resistance Testing of the Muscles ofthe Elbow Joint. 310
5.1 Flexors and Extensors . . 310
5.2 Pronators and Supinators 311

Hand and Finger f oints. . . . . . . 314

1 Inspection . . . . . . . . . . 315
1.1 Shape and Position . . 315
1.2 Contour Changes . . . 316
 Contents XVII

1.3 Skin and Nail Changes . . . 317

Skin Changes . . . . . . . . 317
Nail Changes . . . . . . . . 318
2 Active and Passive Wrist and Finger Movements. 318
2.1 Wrist Movements in Two Planes. 318
2.2 Finger Movements in two Planes 319
2.3 Thumb Movements. . . . . 319
3 Palpation Field of the Hand. . . . 320
3.1 Radial Border ofthe Hand. 320
3.2 Ulnar Border of the Hand 322
3.3 Dorsum of the Hand 323
3.4 Palm of the Hand . . 325
3.5 Fingers and Thumb . 327
4 Tests of Joint Translation . 328
4.1 WristJoint (Five Tests) . 328
4.2 IntercarpaiJoints (Ten Tests) . . . . . . 330
4.3 CarpometacarpaiJoint of the Thumb (Five Tests) . 335
4.4 Second to Fifth Carpometacarpal and Intercarpal Joints
(Five Tests) . . . . . . . . . . . . . . . . . . . . 337
4.5 PhalangeaiJoints (Five Tests) . . . . . . . . . . 341
5 Resistance Testing of the Hand and Finger Muscles. . 344
5.1 Wrist Muscles . . 344
5.2 Finger Muscles . 346
5.3 Thumb Muscles. 347

Examination of the Lower Extremities in the Supine Position (Ell)

Hip Joint (LPH Region) . . . . . . . . . . . . . . . . . . . . . . .. 349

Knee Joint, Upper Leg, Lower Leg. . . . . . . . . . . . . . . . . .. 351

1 Inspection: Abnormalities of Shape and Position,
Contours of the Upper and Lower Leg. 352
1.1 Anterior Aspect 352
1.2 Lateral Aspect . . . . . . . . . . 353
1.3 Posterior Aspect . . . . . . . . . 354
2 Active and Passive Motion Testing of the Knee Joint
and Femoropatellar Joint 355
2.1 Knee Joint. . . . . . . . . . . . . . . . . . . . . . 355
2.2 Patellar Tracking . . . . . . . . . . . . . . . . . . 356
3 Palpation Field of the Knee Joint and Lower Extremity 356
Palpable Findings. . . . . . . . . . . . . . . . . . . . 357
3.1 Anterior Side of the Knee (Patellar Region) . . . 357
3.2 Medial Side ofthe Knee (Medial Condyle) . 359
3.3 Lateral Side of the Knee (Lateral Condyle) 361
3.4 Popliteal Fossa . . . . . . . . . . 363
3.5 Upper and Lower Leg Contours . . . . . . 364
4 Tests of Joint Translation . . . . . . . . . . . . . . 364
4.1 Mediolateral and Caudal Gliding Movements
of the Patella. . . . . . . . . . . . . . . . . . . . . . . . .. 364
XVIII Contents

4.2 Traction on the Meniscotibial Joint . 366

4.3 Mediolateral Gliding Movements in the Meniscotibial
Joint (Shear Test) . . . . . . . . . . . . . . . . . . . . . 366
4.4 Anteroposterior Gliding Movements
in the Meniscotibial Joint (Drawer Test) 367
4.5 Mobility in the Superior Tibiofibular Joint. 369
5 Tests of the Menisci and Ligaments. . 369
Testing of the Menisci . . . . . . . . . 370
Testing of the Capsule and Ligaments 371
Examination Technique . . . . . . . . 371
5.1 Test Group: Sagittal Plane (Tests 1-3) 371
Testing of the Menisci . . . . . . . . . 371
Testing of the Capsule and Ligaments. 371
5.2 Test Group: Frontal Plane (Tests 4-7) 372
Testing of the Menisci . . . . . . . . . 372
Testing of the Capsule and Ligaments. 373
5.3 Test Group: Transverse Plane. . . . . 375
Testing of the Menisci .. . . . . . . . 375
Testing of the Capsule and Ligaments 375
5.4 Testing the Posterior Horns of the Menisci
by a Combination of Flexion, Lateroduction,
and Rotation (Test 12) . . . . . . . . 377
5.5 Specific Tests for Rotary Instability. 378

Joints of the Feet and Toes . . . . . . . . . . . 383

1 Inspection. . . . . . . . . . . . . . . . 384
1.1 Shape and Position of the Foot 384
1.2 Contour Changes . . . . . . . . 386
1.3 Skin Changes . . . . . . . . . . 387
2 Active and Passive Motion Testing of the Pedal Joints 387
2.1 Active Movements . 387
2.2 Passive Movements . . . . 388
3 Palpation Field of the Foot . . . . 390
3.1 Medial Border ofthe Foot . 390
3.2 Lateral Border ofthe Foot. 393
3.3 Dorsum of the Foot. 396
3.4 Sole of the Foot. . . . . . 398
4 Tests of Joint Translation . . . . 400
4.1 Inferior Tibiofibular Joint
(Distal Tibiofibular Syndesmosis) . 400
4.2 TarsalJoints (Ten Tests) . . . 400
4.3 MetatarsalJoints (Five Tests) . . . 406
4.4 PhalangealJoints: Five Tests ... 409
5 Resistance Testing ofthe Foot and Toe Muscles. 411
5.1 Foot Muscles 411
5.2 Toe Muscles. . . . . . . . . . . . . . . . . 413
 Contents XIX

Radiography

Special Diagnostic Procedures. 416

Radiography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 417
1 Rules for the Radiographic Examination
ofthe Vertebral Column and the Joints ofthe Extremities. . .. 418
2 Analysis of the X-Ray Image . . . . . . . . . . . . . 418
Practical Approach to the Analysis of X-Ray Films 419
3 Techniques for the Radiographic Examination
ofthe Vertebral Column. . . . . . . . . . . . . . . . 420
3.1 Anteroposterior Projection of the LPH Region
(After Gutmann) . . . . . . . . . . . . . . . 420
3.2 Lateral Projection of the Lumbar Spine .. . . . 426
3.3 Thoracic Spine . . . . . . . . . . . . . . . . . . . 430
3.4 Anteroposterior Projection of the Cervical Spine
(After Sandberg-Gutmann) . . . . . . . . . . . . 431
3.5 Anteroposterior Functional Views of the Cervical Spine
(with Sidebending) . . . . . . . . . . . . . . . . 434
3.6 Lateral Projection ofthe Cervical Spine . . . . 436
3.7 Lateral Functional Views of the Cervical Spine
(Forward and Backward Bending) . . . . . . . 438
3.8 Arlen's Quantitative Technique
for the Functional Evaluation of the Cervical Spine 440

References . . . . . 453

Subject Index . . . 459

Examination
Program
Introduction

The musculoskeletal system - the spine and the gram is required. Such a program may be orient-
joints of the extremities - consists of: ed either toward the patient (complaints,
anatomic structures) or toward the diagnostic
- Mobile sites: joints, intervertebral disks, pubic
tools available to the examiner.
symphysis (material)
- Motivating structures: muscles and tendons
Patient-Oriented Aspects
(force)
- Motion-initiating structures: peripheral and The patient's description of his complaints is the
central nervous system (control) simplest and most commonly used guide helping
the physician make a diagnosis on the basis of his
This functional unit of material, force, and con-
experience and the symptoms associated with
trol is known as the arthron (i.e., total joint).
various pathologic states. These complaints can
Each of its components is subject to distur-
be classified as referring to:
bances of form and function, and careful analysis
is needed to determine which component is the - Pain
cause of a disturbance. It is also important to - Morphologic abnormality
establish the nature of the disturbance, i.e., - Functional disturbance
whether it relates to a pathoanatomic (macro-
A somewhat more precise method is to supple-
scopic or microscopic) change in morphology, or
ment the patient's description with information
whether it involves a purely functional (re-
obtained by performing general inspection and
versible) disturbance. Furthermore, a disorder
palpation and correlating the patient's com-
may be congenital or acquired, and it may have a
plaints to specific anatomic structures. An even
traumatic, degenerative, metabolic, hormonal,
more accurate approach is to analyze the func-
inflammatory, or neoplastic etiology.
tion of the structures by motion testing. The
Three basic questions need to be addressed in
anatomic structures of interest are:
the diagnostic process:
- Skin
1. Which part of the arthron is affected? - ·Muscles and tendons
Anatomic joint, muscles and tendons, tendon - Tendon sheaths and bursae
sheaths and bursae, nerve pathways, blood - Joints
vessels, central nervous system? - Neurovascular pathways
2. What is the nature of the disturbance? Trau-
Another factor to be considered in designing a
matic, degenerative, inflammatory, metabol-
diagnostic program is the need for patient coop-
ic, hormonal, neoplastic?
eration during the examination. This coopera-
3. To what clinical entity can the functional dis-
tion should be direct, limited, clearly defined,
turbance be assigned?
and easily comprehended by the patient.
To answer these questions, it may be necessary
Examiner-Oriented Aspects
to perform a number of individual tests and ex-
aminations on the structures of the arthron. If The basic diagnostic tools available to the exam-
these examinations are to be done efficiently iner are his sensory organs. He gathers informa-
and routinely, a standardized diagnostic pro- tionby
4 Examination According

- Listening Examination According to the

- Seeing 5/5 Program (Fig. 1)
- Touching
1. Systematic History. Thjs stage allows for in-
Usually these channels for gaining information dividual adaptation of the basic physical
function concurrently during the examination. examination that follows.
2. Basic Physical Examination. This examina-
Listening. The exchange of information be- tion consists of djagnostic measures that do
tween patient and physician during history tak- not require special instrumentation: in-
ing and during the examination itself (patient's spection, active and passive motion testing,
reports of pain) represents a subjective interpre- palpation, and joint and muscle tests.
tation of objective reality for both the patient 3. Neurologic and/or Angiologic Tests. These
and the physician. tests are necessary adjuncts when the histo-
ry or basic physical examination shows evi-
Seeing. By comparison, visual inspection is more dence of a neurologic or vascular disorder.
objective because it can be subjectively inter- 4. Special Diagnostic Procedures. The nature
preted only by the examiner. and scope of other, more specialjzed diag-
nostic procedures (e.g., radiologic sludies,
Touch. The same applies to the palpation of vis- laboratory studies, bjopsy) depend on the
ible and invisible alterations of form and func- results of the previous stages.
tion. 5. Diagnosis. The preljminary diagnosis is fi-
nalized to the definitive diagnosis on the
The number of examinations should be just suf- basis of the patient's response to trial ma-
ficient to permit an accurate diagnosis. It can be nipulation and any further investigations
reasonably limited by a synoptic interpretation of that may have been requjred.
the various tests and by the sequence of the ex-
aminations. The sequence of the examinations
should take into account all the above-men-
tioned criteria, should be easy to learn, and
should fit into the accustomed routine of a med-
ical examination. Consideration of these aspects
led us to devise a stepwise diagnostic workup
called the 5/5 program, an apt name for this sys-
tematic examination because it consists of five
parts, each of which in turn have five elements.
 Examination According 5

Patient complaints Diagnostic tools

5/5 Program

Pain

Active and passive

movements

Basic physical
Morphologic examination
disturbance

Functional
disturbance

Fig. I. The 515 diagnostic program

Structure of the Systematic Examination

Systematic History tion testing. It consists of five sets of examina-

tions:

A systematic history in the 5/5 program covers

1. Inspection
the following five items, each consisting of five
2. Active and passive motion testing
individual aspects:
3. Palpation
1. Current complaints 4. Tests of joint play
} Case history 5. Mu cle tests (resistance tests)
2. Previous course
3. Social history
4. Health history } Personal history
Each set of examinations consists of multiple
5. Family history
tests designed to permit a stepwise analysis of the
The first two items furnish basic information on patient's complaints (pain, morphologic change,
the patient's history to provide a guide for the dysfunction). Motion testing, for example, pro-
subsequent basic examination of the spine and ceeds in stages from the complex pattern of com-
the extremity joints. These five items should also bined movements and designated anatomic
be used to update a diagnosis (Gutmann), such joint motions to passive joint play and muscular
as when taking an intermediate history in chron- contraction without articular motion, following
ic cases or performing a follow-up examination the sequence: visible findings, visible and palpa-
after a prolonged period. ble findings, and findings that are palpable
only.
The principal source of information in the basic
physical examination is palpation. Whenever the
Basic Physical Examination examiner touches the patient, he usually gains a
general palpatory impression of skin tem-
perature, moisture, superficial structural chan-
The basic physical examination described below ges, etc. (e.g., with the immobilizing hand during
is a rational approach to performing a basic passive motion testing). Detailed palpation with
functional evaluation of the spine and extremi- the hand or fingertips proceeds systematically
ties. It involves a stepwise analysis of diseases from superficial structures to deeper-lying struc-
and dysfunctions affecting the "arthron," which tures as the examiner attempts not just to differ-
is the complete functional unit consisting of the entiate the skin, subcutaneous tissue, muscles,
anatomic joint with its articulating bones; inter- tendons, tendon sheaths, bursae,joints, and neu-
nal joint structures (menisci); the joint capsule rovascular structures but also to detect abnor-
and reinforcing ligaments; related muscles, ten- malities. Palpatory findings are supplemented
dons, tendon sheaths, and bursae; neuroregula- by the examiner's noting of the visible and audi-
tory mechanisms from the peripheral nerves to ble reactions of the patient. The examiner uti-
the cerebrum (including the psyche); and the lizes his sensation of deeper-lying structures
arterial, venous, and lymphatic vascular sys- when testing joint play and muscle resistance.
tems. The basic physical examination includes a The sequence of the physical examinations is
combination of inspection, palpation, and mo- determined by the following principles:
 Inspection 7

- The stepwise examination of a diminishing

path of motion.
- Inspection comes before palpation.
- Inspection and palpation are always per-
formed first at rest and then during move-
ment.
- Palpation covers all specific palpable findings
that can be perceived with the hand or finger-
tips, including palpable joint movements such
as those in the intervertebral facet joints.

The components of the basic physical examina-

tion can thus be defined as follows:

L Inspection: inspection at rest (except for

the observation of natural, complex move-
ments at the start of the examination)
2. Active motion testing: general inspection
of movements
Passive motion testing: general palpation
of de ignated joint movements in all three
planes of motion
3. Palpation: superficial fingertip palpation
exploring the details of palpable cuta-
neous, subcutaneous, articular, muscular,
and neurovascular structures at rest and
during movement
4. Tests of joint play: deep palpation of joint
movements
5. Muscle tests (resistance tests): deep palpa-
tion of the muscles and tendons

Inspection (Fig. 2)

The examiner notes and records visible morpho-

logic abnormalities at rest and functional distur-
bances during movement.

11 Natural movements. How the patient walks,

sits down, stands up, dresses and undresses,
etc.

12 Posture (position). The patient's posture with Fig. 2

reference to the spine and the joints of the
extremities; favoring or faulty position of
joints.
8 Palpation

13 Body symmetry and contours. Congenital or

acquired alterations in body contours, hyper-
trophy, swelling, effusion, atrophy, deformity.

14 Skin. Color, circulatory disturbances, scars,

calluses, eczema, nevi.

15 Orthopedic aids. Corset, crutch, prosthesis,

harness, brace, cane.

Conduct ofExamination
The observation of natural movements precedes
inspection of the patient at rest. It begins as the
patient enters the office (11) and continues dur-
ing history taking (12) and while the patient is
disrobing for the examination (11). After the pa-
tient has undressed, more specific attention is
given to body symmetry, skin, orthopedic aids
(h-Is), and postural deviations.

Palpation (Fig. 3)

Tactile examination is used to evaluate the tissue

quality and tenderness of palpable morphologic
abnormalities at rest and of functional distur-
bances during movement.

PI Skin and subcutaneous tissue. Temperature,

perfusion, sweat secretion, ease of scar dis-
placement, skin rolling test (consistency of
the skin fold).

P 2 Muscles and tendons. Muscle tone at rest and

during movement, splinting, myegeloses,
ease of displacement of muscle layers, ten-
derness of tendon attachments.

P 3 Tendon sheaths and bursae. Pain, swelling,

crepitus, ease of displacement.

P 4 Bones and joints. Joint space, bony struc-

tures, deformities, attachments of joint cap-
sules, ligaments, menisci, joint play (transla-
tional joint mobility). Fig. 3

Ps Nerves and vessels. Tenderness over nerves

and vessels, sites of induration, pulses.
 Palpation 9

In the following I distinguish between five pal- tenderness of tissues (at trigger points, maximal
patory techniques: points, or segmental irritation points).
Palpation for tenderness is an example of a
1 Touch Palpation at Rest provocative test. The pressure may be applied
With the patient in a relaxed position, the exam- perpendicular to the tissue surface or parallel to
iner lays his hand or fingertip very lightly upon it in a shearing motion. The palpated sites are
the site to be palpated. To palpate deeper tissue basically the same as in touch palpation.
layers, the examiner presses just hard enough on Applying pressure or thrust to a vertebral seg-
the superficial layers to make contact with the ment produces a compressing or distracting
deeper-lying tissue points. Too much pressure force across the intervertebral facet joint, espe-
may elicit pain and can also desensitize the re- cially in hypermobile segments. These provoca-
ceptors in the palpating finger to tactile informa- tive tests are frequently more rewarding than
tion (e.g., on tissue alterations). the tests of joint play.
Touch palpation may be passive or active. In the
passive technique, the examiner keeps his hand 4 Kibler's Skin RoBing Test (Hyperalgesic Skin
or finger stationary and progressively palpates Zone) (Fig.4S)
from the skin surface to deeper layers, as de- A skin fold that includes the subcutaneous tissue
scribed above, while evaluating the consistency layers is formed between the thumb and index
of the individual tissue layers. In the active tech- finger of each hand and is rolled perpendicular
nique, the palpating finger is actively moved to the course of the dermatomes on the trunk
along the tissue layer to explore structural de- (parallel to the spine) or on the extremities. The
tails such as the attachments of soft tissues to examiner notes: (1) the thickness and consisten-
bone (joint capsule, ligaments, tendons). cy of the skin fold, (2) the resistance to raising
and advancing the fold, and (3) tenderness. In
2 Palpation During Movement hyperalgesic zones, the skin fold is thickened
This is used in active, passive, and segmental and has a firm, doughy consistency. It is usually
motion testing, joint play testing, and resistance tender to light pressure and is relatively difficult
tests. In one technique the flat hand is used to to raise and advance. The skin frequently pre-
palpate active movements by the patient, such as sents a coarse "orange peel" texture.
muscular contractions and mobility, the motion
of tendon sheaths and bursae, respiration-de- • Note
pendent rib excursions, or "asymmetric excur- Some authors relate a tender skin fold at the eye-
sion" in an upper rib pair (apparent increase in brow, mandibular angle, side of the neck, and
the mobility of an unaffected rib relative to its lateral scalp to a dysfunction at the C2-C4level.
counterpart that is restricted by a segmental dys-
function). In another technique the palpating 5 Connective Tissue Stroke Test of Leube and
finger is used to examine more circumscribed Dicke (Fig. 46)
areas during active or passive movement, e. g.: This is another palpatory technique for evaluat-
ing the subcutaneous connective tissue and its
- Asymmetric excursions in the sacroiliac joints
ease of displacement. A bulge of skin is raised
- Active/passive mobility and joint play of the
with the middle and ring fingers and pulled
vertebral segments
along on the underlying fascia. As in the skin
- Joint play in the extremities
rolling test, the resistance felt in the subcuta-
neous tissue is recorded. This palpation (just like
3 Pressure Palpation, Thrusting, Percussion connective tissue massage) is performed on pa-
(Palpation for Tenderness) tients primarily in sitting.
These techniques are for detecting local tissue The connective tissue stroke test is suitable not
changes caused by increased muscle tone just for segmental diagnosis but also for detect-
(spasm, hypertonicity) and for evaluating the ing reactions of the connective tissue to toxins or
10 Palpation

to metabolic disturbances and diseases of the - Interpretation of the palpatory information;

connective tissue itself, like those occurring in this requires attentiveness, objectivity, and ex-
rheumatoid or collagen diseases. perience, especially since palpation may be in-
fluenced by other sensory impressions ("One
Segmental Irritation Points ofSeH feels what one wants to feel").
The category of trigger points or "maximal
points" in muscle tissue includes the segmental
Conduct of the Examination and Findings
irritation points of Sell. Sell regards these points
as foci of reflex tissue irritation with myalgic fea- Skin Subcutaneous Tissue (P J
tures which originate from restricted spinal seg- Palpation of the skin and subcutaneous tissue
ments and are palpable as sites of tenderness begins when the immobilizing hand is placed on
and myogelosis. They appear whenever the the skin during passive motion testing. Detailed
stimulation of nociceptors in the various struc- palpation is required if inspection reveals in-
tures of the active (mobile) spinal segment in- flammatory changes or trauma sequelae (scars,
cites hypertonicity of the short, deep, intrinsic altered muscle contours) or there is presumptive
back muscles. evidence of circulatory impairment.
The segmental irritation points are usually locat- The following findings may be noted:
ed near the site of emergence of the segmental Skin temperature: warm - cold (circulatory im-
spinal nerve. In the cervical region, they are lo- pairment, arteriosclerosis) - hot (inflammation)
cated either between the posterior border of the Sweat secretion: moist (autonomic lability) - dry
sternocleidomastoid muscle and the lateral bor- (peripheral nerve lesion, endocrine distur-
der of the nuchal ridge or on the occipital squa- bance)
ma at the nuchal line. They are palpated with the
cervical spine in the neutral position. • Note
The irritation points disappear after (therapeu- Disturbances and defects of sweat secretion usu-
tic) elimination of the joint restriction. They be- ally result from lesions of the nerve plexus and
come more prominent following a therapeutic peripheral nerve. Loss of sweat secretion ac-
maniplulation in the wrong direction (irritation companied by normal sensation implies a lesion
zone testing). of the sympathetic trunk.
Plantar anhidrosis with sensory disturbances
and paralysis of the muscles of the lower leg and
• Note foot is never radicular in origin and most com-
Touch palpation can be used to examine all tis-
monly results from injection trauma to the glu-
sue structures, whereas the skin rolling test and
teus maxim us.
connective tissue stroke test evaluate only the
Trophic status: soft - hard (scar, callus, hyper-
subcutaneous connective tissue, especially in the
keratosis). Thick - thin (e. g., after local corti-
segmental zones. Palpation during movement
sone injections). Rough - smooth.
and pressure palpation are most appropriate for
Subcutaneous tissue: easy to displace - fixed or
the examination of joints, muscles, and segmen-
difficult to displace (connective tissue zones,
tal irritation zones.
segmental zones corresponding to Kibler's fold).
Palpation is the most difficult method of muscu-
loskeletal examination and requires much prac-
Muscles and Tendons (P2 )
tice and experience. Beallists three essential el-
The patient's muscles should be relaxed (posi-
ements of a successful palpatory examination:
tioning). Muscle palpation shouid proceed sys-
- Perception, i. e., the ability to sense tactile im- tematically from origin to insertion, and the di-
pressions, which requires a trained hand rection of palpation should be at right angles to
- Conveyance of the tactile impressions by a the direction of the muscle fibers.
well-functioning proprioceptive system (re- The simultaneous palpation of the muscle ori-
laxation) gins or insertions during muscle function tests
 Motion Testing 11

often permits the first accurate determination of - Fractures

which muscle or tendon attachment is part of the - Osteoporosis
synergy of a muscular dysfunction. The same ap- - Bekhterev's disease
plies to the palpation of bursae and tendon - Hemangioma
sheaths. Tendon attachments are palpated in the
Very marked tenderness to percussion is general-
direction of the tendon fibers.
ly associated with:
Findings - Herniated disk
Firm - hard (reflex splinting, irritation zones, 10- - Spondylitis
eal myegeloses) - lax and soft (hypotonicity, - Tumors
paresis). Elastic - rigid (rigor). Movable - fixed
(tumor, inflammation) Nerves and Vessels (P5)
The palpation of nerves and vessels is indicated
Tendon Sheaths and Bursae (P3) when previous examinations have been unable
Tendon sheaths and bursae are examined for to assign the cause of the disturbance to the
swelling and crepitation. anatomic joint or to musculotendinous struc-
tures including the tendon sheaths and bursae.
Bones and Joints (P4) Because peripheral nerves and vessels tend to
Findings follow common paths, it is prudent to check
The bone may be smooth or rough (exostoses, "neurologic tender points" (e. g., at narrow
periostitis, fracture sequelae). Joints are exam- anatomic passages for nerves and vessels) not
ined for joint-space width, the consistency of the just regionally during detailed palpation but also
joint capsule (thickened, tender), and tender- by a systematic palpation that proceeds in a
ness of the reinforcing ligaments and tendon at- proximal-to-distal (central-to-peripheral) direc-
tachments. After the joint structures have been tion. When palpating blood vessels, the exam-
palpated at rest (palpation zones), they are pal- iner notes whether the vessel wall is elastic or
pated during movement as part of function test- rigid (sclerosis) and checks for equal pulses on
ing. With few exceptions, then, joint palpation is both sides.
useful for evaluating not just the position of the
joint structures but also the mobility of any joint
not covered by an excessive thickness of soft tis-
sues (e. g., the shoulder joint, hip joint, most in-
I Motion Testing (FigA)
tervertebral facet joints).
The stepwise analysis of the affected portion of
Pathologic Findings the joint in articular dysfunctions is central in
In addition to the use of touch palpation and pal- motion testing. Again, the basic diagnostic tech-
pation for tenderness, it may be necessary to eval- niques used here are inspection and palpation.
uate the tenderness of vertebral bodies to percus- The following structures are evaluated by mo-
sion. tion testing:
Moderate tenderness to percussion is character-
istic of: Ml Active movements (functional move-
ments). All the structures of the arthron
- Hypermobile segments (contractile and noncontractile): anatomic
- Scheuermann's disease joint, muscles, tendons, tendon sheaths,
- Degenerative segmental changes bursae, and nervous system including the
Marked tenderness to percussion is noted psyche.
with:
M2 Passive movements (mobility). All struc-
tures except the motor pathway.
12 Motion Testing

Active Passive Muscle tests

movements (8 1 ) movements (82) against a res istance (8 5 )
Joint: Muscles
gliding (8 4 )

1
1
1 Articular surface Articular surface 1 Articular su rface 3

r 1 Joint:
traction (8 3 )

2 Capsule + ligaments 2 Capsule + ligaments 2 Capsule + ligaments

Muscles Muscles

f 1
MJ Distraction and compression of the joint.
Distraction (called simply "traction" in the
test descriptions) and compression of the
joint members without muscular activity
3-----' 3----/ (tests translation of the articular surface ,
Nerve pathways internal structures, joint capsule, and liga-
ments) .

M4 Intraarticular gliding. Parallel gliding of the

joint members without muscular activity
(tests translation of the same structures as in
M3, especially the articular surfaces).

Ms Muscle resistance tests. The muscles and

tendons are tested for strength and tender-
ness without joint motion.

Conduct of the Examination

If active and passive movements (M I, M2) can be
performed without pain or limitation, motion
testing may be concluded. But if a painful or
even nonpainful hypo- or hypermobility is not-
Fig. 4. Motion testing ed, it is necessary to analyze the end-feel at the
absolute limit of the passive range of motion.
The elasticity of the end-feel tells the examiner
whether a motion restriction (hypomobility) is
caused by contractile (muscle) or noncontractile
structures (bone, capsule, ligaments).
 Motion Testing 13

After passive motion testing is completed, fur- Rationale for the Basic Physical
ther differentiation, if needed, is accomplished Examination
by distraction of the joint (M3) perpendicular to
The synoptic assignment of findings to specific
the articular surface. Separating the articular
structures can reduce the number of individual
surfaces usually alleviates pain by lowering the
examinations that are necessary and/or make it
intraarticular pressure, whereas compression of
possible to organize the examinations more ra-
the articular surfaces produces the opposite ef-
tionally. Pathologic findings at any stage are an
fect. Gliding motions (M4) parallel to the articu-
indication for the necessity to conduct further
lar surface can disclose the direction of the
tests. If no pathologic findings are found, the ex-
motion disturbance, whether the articulating
amination may be concluded after passive mo-
surfaces are affected, and what portions of the
tion testing, and the examination of peripheral
capsule and ligaments are chiefly involved.
nerves and blood vessels may conclude with
If tests M3 and M4 are negative, the examination
their palpation. However, if the findings suggest
concludes with function testing of the muscles
damage of the peripheral nerves and vascular
and tendons. This consists of: resistance tests
system, these structures must be examined in
(Ms) of the muscular synergists in an intermedi-
greater detail.
ate position (right-left comparison) and/or the
differential diagnostic testing of individual mus-
cles in an intermediate position and in a position
of muscle stretch that places increased tension
on the tendon attachments. (The significance of
the individual motion tests is described more
fully on p.12f.)
14 Adjunctive Neurologic and Angiologic Studies

Adjunctive Neurologic and

Angiologic Studies

Neurologic Studies (Fig. 5)

Adjunctive neurologic studies are performed
when there is suspicion of damage to a nerve
pathway.

Nt Reflexes and indicator muscles (segment)

N2 Sensory testing (superficial and deep sensa-
tion)
N3 Motor function (peripheral nerve)
N4 Coordination and autonomic regulation
Ns Cranial nerve examination

Conduct of the Examination

The inspection of ordinary patient movements
and motion testing, supplemented by the palpa-
tion of nerve pathways, have already given the
examiner a gross impression of nervous system
function. Thus, these additional tests are neces-
sary only in those circumstances when the na-
ture and extent of the disturbance remain un-
clear and in certain disease states that neces- Coordination
sitate a neurologic workup, e. g., reflex testing
(N1) and testing for sensory disturbances (N2 ) in
the approximately 3%-4% of disorders that are
associated with true radicular disturbances of
varying causes. The specific examination of mo-
tor function (N3) is indicated in all posttraumat-
ic states with peripheral nerve injury.
Coordination testing (N4 ) and the cranial nerve 4
examination (N s) are intended to establish Cranial nerve exam ination
whether the patient has a central neurogenic le-
sion or a disturbance of the sensory organs that
would warrant referral to a neurologist or organ
specialist.

Angiologic Studies
Angiologic evaluation may be indicated on the
5
basis of the history, inspection, and palpation,
e. g., when there is suspicion of damage to blood Fig.S
vessels.
 Adjunctive Special Diagnostic Procedures 15

History
Radiologic stud ies - Vasogenic pain
- Limited walking distance (intermittent clau-
dication)
- Risk factors: advanced age, smoking, exces-
sive body weight, metabolic disorders, lack of
exercise, other vascular diseases (heart, kid-
neys), family history

Inspection
Laboratory stud ies - Alteration of skin color, altered structure of
the superficial blood vessels, edema
- Limited walking distance

Palpation
- Skin temperature
- Tissue turgor
2 - Tender points
Aspiration, biopsy - Pulse status

Adjunctive Special Diagnostic

Procedures (Fig. 6)

3 SI Radiologic studies. Basic morphologic eval-

Electrodiagnostic studies uation, X-ray function studies, motion-con-
trolled tomography. Contrast examinations,
CT, MRI, scintigraphy, isotope scans, and
sonography are not used routinely but are
reserved for selected cases according to set
indications.

S2 Laboratory studies. Basic workup for dis-

4
eases of the musculoskeletal system.

S3 Histologidcytologic studies. Aspiration,

percutaneous or open biopsy, arthroscopy,
arthrotomy.

S4 Electrodiagnostic studies. Peripheral elec-

trodiagnosis, chronaximetry, electromyog-
5 Organ studies raphy (EMG) , electroencephalography
(EEG).
Fig.6. Special diagnostic
procedures S5 Organ studies. Gynecologic, neurologic, an-
giologic, ophthalmologic, and other visceral
disorders, ENT diseases.
Examination Positions

Patient cooperation during the examination is C Prone (relaxation)

facilitated by minimizing the number of time- D Lateral (relaxation)
consuming changes in position. The following E Supine (relaxation)
five positions are employed in the sequence indi-
cated (Fig. 7 a): In each position, the particular spinal segments
and extremity joints are examined that are func-
A Standing (effort) tionally interrelated. The examination of these
B Sitting (effort) segments and joints is conducted by body region.

o
C
O( ;-::

A B 0
c1 =
~
Fig. 7. a Positions of examination E
Body Regions Examined

The following body regions are examined (from III Thorax Examination in Slttzng,
caudal to cranial) (Fig. 7b): prone, lateral, and supine
I Legs positions
II LPH region: lumbar spine, pelvis (SIJ), hip IV CSA region Examination in sitting po-
joints sition (also prone and su-
III Thorax: thoracic spine and ribs pinefor certain tests)
IV CSA region: cervical spine, shoulder girdle, V Cervical spine, Examination in sitting and
arm joints head supine positions
V Cervical spine, head
The data furnished by the history and examina-
The examination plan by body region is as fol- tion must still be correlated with specific patho-
lows: logic states. In my view, the "rheumatoid" classi-
I Legs Examination in all posi- fication of disease groups (Toronto 1957) is
tions inadequate for this purpose, and I therefore pro-
II LPH region Examination in all posi- pose the classification of disease groups given in
tions the next section.

v Cervical spine and head

IV CSA region : cervical spine,

shoulder girdle, arm joints
III Thorax (thoracic spine, ribs)

II l PH region : lumbar spine,

pelvis (sacroiliac joints),
hip joints

Legs

Fig. 7. b Body regions cov-

ered in the examination
Diagnosis

The diagnosis suggested by the findings of the Group 6: Tumors

various examinations is considered to be prelim- Caution: The primary manifestation frequently
inary until it has been confirmed by response to consists of generalized soft-tissue symptoms or
trial therapy. For joint dysfunctions, this trial an inflammatory joint condition.
manipulation usually consists of articular dis-
traction. The diagnosis may not be regarded as It is common for physicians to prescribe medical
definitive until there has been positive response "antirheumatoid" therapy for pain and dysfunc-
to the trial manipulation. tion based on traumatic, degenerative, or symp-
tomatic joint disorders that can be managed
more safely (no side effects) and effectively by
other treatment methods.
Disease Groups Involving the In the six disease groups, the "laboratory line,"
Musculoskeletal System important for differential diagnosis, runs
through the middle of group 4 (articular involve-
The following is a simplified classification of dis- ment by diseases of other organ systems). This
ease groups and is proposed primarily for thera- means that abnormal laboratory findings are ob-
peutic reasons: tained in groups 5 and 6 and in certain diseases of
group 4.
Group 1: Functional disturbances not associated The laboratory line also marks the limit of the
with an objectively demonstrable lesion range of indications for manual and physical
therapeutic procedures. Thus, the relative indi-
Group 2: Trauma cations in this range, such as true rheumatoid
disorders, call for a highly critical approach. This
Group 3: Degenerative processes ("-osis," "-pa- classification of disorders of the musculoskeletal
thy"). Arthroses (osteoarthritides), ligamen- system greatly facilitates programming of the
toses, myoses, tendinopathies, periostoses, neu- treatment plan.
ropathies, venopathies. The above classification was retained with re-
gard to the clinical indications for special exami-
Group 4: Symptomatic disorders. The joint dis- nations of specific joints and the spine.
order is symptomatic of a disease process extrin-
sic to the joint. The articular manifestation may
be degenerative or inflammatory.

Group 5: Inflammatory processes ("-itis").

Arthritis (including activated degenerative dis-
ease!), myositis, tendinitis, periostitis, neuritis,
phlebitis.
Structural Analysis of Function
Using the Diagnostic Program

Structural Analysis in the Patient Referred Receptor Pain. It is not felt at its point
History with Reference to Pain of origin but is referred to a site elsewhere. It is
produced by nociceptor stimulation in response
to tissue irritation inside the body Goints, mus-
Pain is not a reaction to specific environmental cles, viscera, etc.) and also by purely functional
stimuli, like seeing or hearing, but can originate disturbances not associated with a demonstrable
from all nociceptors in the body in response to a pathoanatomic substrate.
stimulus of adequate intensity. Nociception is The site of irritation and the painful site do not
nonspecific. The intensity of pain does not cor- coincide. The density and activation threshold
relate with the degree of tissue irritation or in- of the nociceptors are critical in the occurrence
jury. Also, as in referred pain, the site where pain of receptor pain. The pain itself is accompanied
is felt often does not correspond to the site by a somatic reaction to the pain (motor and
where the pain originates. Pain sensation, more- autonomic response) (H.D. Wolff). Receptor
over, is strongly linked to the central processing pain is associated with an increase in sensitivi-
of pain, i. e., the affective pain response. Thus, ty (hyperesthesia, hyperalgesia) but never with
pain has much in common with general sensa- decreased sensitivity (hypoesthesia, analgesia)
tions such as hunger, thirst, fatigue, and fear, or significant motor or reflex deficits. Most
which cannot be precisely assigned to a particu- vertebral and spondylogenic pain is receptor
lar body structure. Nevertheless, since pain as a pain.
clinical phenomenon is a warning sign of disease Two types of nociceptor have been identified:
or tissue injury, it is important to analyze pain
1. Nociceptors with thin, myelinated A b fibers,
with respect to its causation despite its often
which produce a "bright," sharp, cutting or
vague localization due to referral and subjective
stinging, well-localized pain that is felt imme-
processing.
diately after the painful stimulus and is called
"first pain." These nociceptors are most abun-
dant in the skin.
Types of Pain from a Structural 2. Nociceptors with thin, unmyelinated C fibers,
Perspective which produce a dull, burning, gnawing, or
boring pain of slower onset known as "second
The precise localization of pain and dysesthe- pain." These receptors are most numerous in
sia provides a guide for identifying the site the joints (articular capsules, ligaments), ten-
where the pain originates (tissue irritation). It dons, and internal organs.
programs the examination procedure that fol-
lows. Projected Neuralgic Pain. In this type of pain
The following types of pain are distinguished the irritation of a pain pathway (peripheral
(modified from Janzen): nerve, dorsal root) of the associated ganglion or
of relay points in the spinal cord causes pain to
Local Receptor Pain. It is associated with irrita- project to the related skin area. The site of irrita-
tion of the body surface. The painful site coin- tion can be inferred from the distribution of the
cides with the site of irritation. pain.
20 Analysis of Pain During History Taking

Pain in Circumscribed Portions ofthe Body and

Extremities (meralgia) associated with neuro- Analysis of Pain Dnring History Taking
circulatory or neurodystrophic disturbances.
The site of irritation is located in nerves that Five questions are of key importance in the anal-
transmit sympathetic fibers (plexus, median ysis of pain:
nerve, tibial nerve, C6-C8 roots) or large vessels What hurts (location) ?When, how, and by what
with perivascular plexuses of autonomic fibers. is the pain or dysfunction precipitated and
The autonomic disturbances permit the origin of changed?
the pain to be localized to a particular side. Uni- With what is the pain associated (accompanying
lateral pain that is not localized to a specific features)?
nerve area represents central pain (thalamus).
A delay in nerve conduction velocity is another The pain history may, furthermore, disclose any
sign suggesting an irritation site in the peripher- of seven patterns ofpain that are helpful in iden-
al nerve or plexus. tifying the most likely structural substrate of the
Meralgias (and merodysesthesias) are depen- presenting complaints. These patterns must be
dent on rhythmic processes such as diurnal supplemented and confirmed by corresponding
rhythm, unilateral occupational strains, the findings during the examination.
menstrual cycle, episodic processes (pregnancy,
puerperium), and metabolic disturbances. Joint Pain
Receptor pain arising from the synovial mem-
Bilateral Pain and/or Dysesthesia. They relate brane, joint capsule, or possibly from the sub-
both to a site of irritation and to systemic factors: chondral layers of the articular surface, perios-
- Inflammations . teum, ligaments, and capsular vessels. Joint pain
- Hematologic disorders may be degenerative or inflammatory.
- Metabolic disorders
- Intoxications Degenerative Joint Pain
- Tumors What
Joint or spinal pain radiating to the soft-tissue
Basic Principles in the Analysis structures about the joint (muscles, ligaments,
of Pain tendons).
1. Avoid a hasty diagnosis without a sys-
tematic exploration of complaints and When
a thorough evaluation. The "frequen - "Cold pain" after prolonged rest (morning
cy rule" is valid in looking for patho- pain); exertional and fatigue pain; later there is
logic processes but not in tbe interpre- often rest pain or nocturnal pain.
tation of phenomena (Janzen).
How
2. Any increase or change in pain (or
Dull, gnawing, boring (muscle pain); sharp
dysesthesia) may signify an exacerba-
acute pain with incarceration (meniscus, joint
tion of the disease process.
mouse); pain gradually increases with overuse.
3. Any sudden or unexpected "improve-
ment" in complaints may also signify By What
exacerbation (tissue destruction fol- Mechanical factors such as faulty or excessive
lowing a state of irritation). use, traumatization, fatigue; weather (humidi-
ty), temperature ; relieved by rest.

With What
Inspection: swelling (with activated degenera-
tive disease) , guarding.
 Analysis of Pain During History Taking 21

Function: pain on motion, later motion restric- When

tion; muscle weakness, gait disturbances. Cold pain after prolonged immobility (e. g.,
Palpation: local tenderness to pressure. morning pain) or after prolonged maintenance of
Systemic manifestations are absent. the same posture or load (occupational strain).

Inflammatory Joint Pain How

Diffuse, dull, gnawing, boring, or tearing pain.
What
Myogelotic pain may be bright or sharp on pal-
Joint or spinal pain radiating diffusely to sur-
pation.
rounding tissues. Pain from a bone lesion does
not radiate but stays confined to the bone (pe-
By What
riosteum, medullary cavity).
Local myalgias: muscle splinting about restrict-
ed joints. Stretching of shortened or contracted
When
muscles in pathologic muscle stereotypes (reflex
Severe, persistent pain during rest and especial-
increase in resting tone). Faulty or excessive use
ly at night, worsening in the morning (with
(muscle soreness). Improved by heat (except
morning stiffness).
with an inflammatory cause) and movement.
General myalgias: can accompany viral diseases
How
(influenza), bacterial infections, and collagen
Intense, sharp, burning, boring or pulsating (ef-
diseases (elevated ESR, leukocytosis), especial-
fusion) pain. Bone lesions cause a dull ache; pe-
ly in rheumatoid polymyalgia. Not precipitated
riosteal involvement causes sharp inflammatory
by coughing, sneezing, or straining.
pain.
With What
By What
Function: muscle stiffness (rigor, cogwheel phe-
Inflammatory synovial changes, joint effusions,
nomenon), rapid fatigability, need for posture or
inflammatory bone diseases and tumors.
position change with muscular insufficiency and
hypermobility. Translational joint movements
With What
do not elicit pain.
Inspection: swelling, guarding (resting), possible
Palpation: local tenderness to pressure and
deformity.
more general muscle splinting, possibly with
Function: early, verypainfullimitationofmotion.
hard foci in the muscle (trigger points, maximal
Palpation: heat, marked local tenderness.
points, segmental irritation points, myogeloses)
Systemic manifestations: malaise, fatigue, febrile
that may be knoblike or cordlike.
episodes, weight loss. In the late stages of degen-
Neurologic symptoms: no radicular symptoms,
erative or inflammatory processes, it can be dif-
possible dysesthesias.
ficult to differentiate joint pain (from the cap-
sule and ligaments) and bone pain (from the
Ligament Pain
periosteum and medullary cavity) due to spread
of the process to adjacent structures. Receptor pain arising from tendon and ligament
attachments.
Muscle Pain
What
Receptor pain arising from muscle fibers and Local pain at the attachments of tendons and lig-
tendon attachments. aments, frequently radiating to associated mus-
cles.
What
Pain in individual muscles or synergies, usually When
showing a functional relationship to joints or After prolonged maintenance of the same pos-
segments (chain tendomyoses). ture, especially with muscular insufficiency. In
22 Analysis of Pain During History Taking

segments with incipient intervertebral disk de- How

generation (diskoligamentous tension imbal- Bright stabbing or cutting pain, prickling, lanci-
ance). nating. No tendency to spread within the nerve
area.
How
Same character as muscle pain. By What
Local mechanical irritation at the site of origin:
By What compression or stretching of the nerve or nerve
Overuse, stretch, pressure, and tension. Acute root (Lasegue's sign), e.g., by coughing, sneez-
improvement by rest and immobility; perma- ing, straining, or with latent intervertebral disk
nent improvement by muscular training. Termi- protrusion; peripheral entrapment syndromes;
nal pain on passive movement of hypermobile constant radicular pain with disk prolapse (her-
joints. niation); trauma.

With What With What

Dysesthesia, hyperalgesia; tenderness over liga- Reflex disorders, sensory disturbances (hypes-
ment attachments, often with increased range of thesia, hypalgesia, paresthesia) in the der-
passive joint motion and joint play (hypermobil- matome or the area of the peripheral nerve, mo-
ity). tor deficits in the segmentally related muscles
(indicator muscles) or muscles of the peripheral
Bursitis, Tendovaginitis nerve; abnormal sweat secretion only with a pe-
ripheral nerve lesion. In the spine: antalgic pos-
Receptor pain. ture, restricted mobility, spasticity. No systemic
manifestations.
What
Local pain over bursae or tendon sheaths. Autonomic Pain
Direct stimulation of autonomic nerve fibers or
When receptor pain from inside the body.
Usually after overuse or monotonous work.
What
How Referred pain or meralgia: poorly localized pain
Gnawing, tearing. on the body surface with a tendency toward dif-
fuse spread.
By What
Single blunt trauma or repeated microtrauma, When
rheumatoid and metabolic diseases (gout), dis- Continuous pain, often experienced in waves.
turbances of the hormonal and vitamin balance The pain outlasts the pain stimulus!
(vitamin E). Improved by rest, exacerbated by
pressure or movement. How
Dull, smouldering, burning, cramping.
Nerve Pain
By What
Direct stimulation of the nerve pathway.
Stimulation of peripheral nerves containing
abundant autonomic fibers (e. g., median nerve,
Neuralgic Pain
tibial nerve). Nociception from the body interior
What (Head's zones, Mackenzie's zones) and/or from
Local or projected pain; superficial, sharply cir- the joints.
cumscribed pain in the distribution of a periph-
eral nerve or nerve root.
 Analysis of Pain During History Taking 23

With What sibly from subchondral layers of the articular

Associated with autonomic disturbances: cold surface and from the segmental muscles over the
sensation, swelling sensation, sweating, circula- dorsal rami of the spinal nerves. The functional
tory impairment, trophic disturbances, malaise. interrelationship of all these structures gives rise
to the radicular and pseudoradicular pain pat-
Vascular Pain terns, which may be mixed and superimposed.
What
Pain about the course of a blood vessel. RadicuJarPain
What
When
Sharp local or radiating nerve pain.
Exertional pain (grade II) or constant pain
(grade III, IV) secondary to arterial occlusive
When
disease. Exertional pain is also characteristic of
Sudden and paroxysmal after trauma (micro-
acute thrombophlebitis.
trauma!) or mechanical loading.
How
How
Sudden paroxysmal pain distal to the site of the
Severe, stabbing pain in the dermatome.
vascular lesion (arterial pain), also cold sensa-
tion. Gradually increasing sensation of pressure,
By What
tension, and heaviness, calf pain (venous pain).
Irritation of the nerve root in the intervertebral
foramen by compression. Potential causes: disk
By What
protrusion or prolapse; faulty vertebral position;
Arterial pain is exacerbated by walking (inter-
swelling of the facet joint capsule, usually associ-
mittent claudication) and by cold or heat; ve-
ated with degenerative vertebral and joint
nous pain is exacerbated by standing (approx.
changes (spurring); circulatory impairment, ede-
20-30 min). Arterial pain is improved by placing
ma, or tumors in the region of the nerve root. The
the part in a dependent position; venous pain is
pain is usually initiated and exacerbatedby move-
improved by elevation and ambulation.
ment (coughing, sneezing, straining) and trauma.
With What
With What
Skin changes associated with arterial and venous
Inspection: painful postural deformity (antalgic
lesions: pallor and coldness (arterial), bluish dis-
scoliosis).
coloration and heat (venous). Malaise with
Function: usually severe motion restriction at
thrombophlebitis.
the affected level and within the segment.
Palpation: local tenderness to pressure, unilat-
Vertebragenic Pain
eral muscle spasm.
The two forms of vertebragenic pain can be dif- Neurologic symptoms: nerve stretch pain
ficult to distinguish from each other because (Lasegue's sign), reflex deficits (later), sensory
they may coexist: deficits (paresthesias in the dermatome, hypes-
Direct irritation of the nerve pathway (radicular thesia, hypalgesia), motor deficits (only in se-
pain; see also Neuralgic Pain, p. 22) vere cases).
Receptor pain from the spinal segment ("pseu-
doradicular pain" after Brugger)
Receptor Pain from the Vertebral Segment,
The latter type of pain originates from the dorsal
Pseudoradicular Pain (after Briigger)
part of the anulus fibrosus, the posterior longitu-
dinal ligament, the inner portion of the facet What
joint capsule over the meningeal rami, from the Local or radiating pain in the muscle chain, with
outer portion of the facet joint capsule, and pos- or without autonomic symptoms.
24 Examination of the Joint

When Special Diagnostic Procedures

Usually a gradual onset after trauma (micro- Radiography: morphology of the articulating
trauma) or after faulty or excessive use. bones, pathologic changes in the soft-tissue en-
velope. Function studies: films at the limit of
How motion, stress films.
Diffuse, dull, boring, gnawing, tearing (myalgic Laboratory investigations: synovial fluid, blood
pain). studies.
Biopsy: synovium, bone.
By What The findings of the various examinations are de-
Receptor stimulation in the various structures of tailed below.
the vertebral segment, especially the facet joints,
caused by a diskoligamentous tension imbal- Inspection
ance presenting as a hypomobile dysfunction
Inspection gives evidence of visible congenital
(restriction) or a hypermobile dysfunction (gen-
(dysplasias, aplasias) and acquired morphologic
eral or local hypermobility) following trauma or
changes (trauma, inflammation, tumors).
after faulty or excessive use.
Active and Passive Motion Testing (Fig. 8)
With What
Inspection: usually little or no antalgic scoliosis. During functional movements, all the structures
Function: decreased mobility (restriction) or in- of the arthron are tested together. If active move-
creased mobility (hypermobility) of spinal sec- ment is painless and unrestricted, the examiner
tions or segments, often with positive ligament passively moves the jointfrom the end of its active
tests. range of motion (relative limit) to its absolute mo-
Palpation: positive tenderness in the segment, tion limit and evaluates the end-feel at that posi-
muscle spasm (restriction), occasional weakness tion (Fig. 8 a). If no pain or motion restriction is
of muscle groups, swollen subcutaneous cellular noted, the examination ofthe jointis concluded.
tissue (Kibler'S fold). Testing the end-feel during passive motion testing
Neurologic deficits are absent. (Fig. 8 b) helps determine whether the functional
disturbance is more likely to be located in the
anatomic joint or in musculotendinous structures.
In making this assessment, the examiner must
know whether joint motion is restrained chiefly by
Structurally Specific Findings bone or by soft tissues (muscles, ligaments), ac-
in the Arthron cording to the anatomic structure of the joint. A
springy end-feel is suggestive of incarceration
(e. g., of a meniscus or intraarticular loose body).
It should also be determined whether hypo- or hy-
Examination of the Joint
permobility exists. Hypo- or hypermobile joint
dysfunctions may arise from the joint itself or re-
Among the anatomic structures tested in the flexly from other components ofthe arthron. Hy-
synoptic examination procedure, priority is giv- pomobility arising from the joint itself is known as
en to the joint. The following articular findings restriction. A number of theories have been pro-
may be noted: posed regarding the pathogenesis of joint restric-
Inspection: congenital and acquired deformities. tion, but so far none have been proven. A rule of
Active and passive motion testing: restricted or thumb for motion restriction is that, during active
increased mobility and altered end-feel. and passive motion testing, an arthrogenic cause
Palpation: altered joint-space width and capsu- produces pain and restriction in the same direction
lar attachment, positional faults. of motion, whereas a myogenic cause produces
Joint play: absent, decreased, or increased. pain and restriction in opposite directions.
 Examination ofthe Joint 25

Resting position
(Center, neutral
anatomiC position)

Normal The neutral position during flexion/

mobility extension is variable depending on
the degree of kyphosis or lordosis
Active
movement Treatment position
t
Relative
(physiologic)
motion limit

Passive movement ----t=;:~J._

Manipulation

Absolute Absolute
(anatomic) (anatomic)
motion limit motion limit

Dislocation
Flexion/extension
on sagittal plane

Lateral flex ion

on frontal plane Rotation
a on transverse plane
Biceps

Soft-elastic Firm-elastic Hard-elastic

b (motion checked by muscle) (motion checked by ligaments, (motion checked by bone)
"capsular feel")
Fig. 8. a Normal and pathologic vertebral mobility (modified from Kimberley). b Qualities of end-feel (after Ka-
pandji)
26 Examination orthe Joint

The presence of a motion restriction in only one other (distraction) or one member is shifted on a
or two directions suggests a contracted joint cap- straight path relative to the other, stationary
sule ("capsular pattern" of Cyriax). member (translation). Meanwhile the examiner
With a hypermobile joint, stability is reduced. evaluates the structure-dependent end-feel at
The pain associated with gliding movements in a the limit of the motion. .
hypermobile joint is of ligamentous origin. All active and passive joint movements consist
Further examination of the anatomic joint is ac- of two components, rotation (rolling) and glid-
complished by palpation. ing. Rotation is predominant between articular
surfaces that are incongruent, as in the knee
-Note joint, while gliding is predominant between
Articular dysfunction and/or its reflex effects more congruent surfaces, as in the interverter-
are alternately known as: bral facet joints (Fig. 9 a).
In rotation (rolling), illustrated by a wheel
- Nociceptive somatomotor blocking effect
rolling over a surface, new points on the wheel
(Brugger)
successively come into contact with new points
- Somatic dysfunction
on the opposing surface. As the wheel turns, its
- Spondylogenic reflex syndrome (Sutter)
center, i. e., the axis of the moving body, travels
- Minor intervertebral derangement (Maigne)
from its starting point in the direction of the
rolling movement.
Palpation In gliding, one point on the gliding surface comes
into contact with numerous successive points on
Width of the Joint Space. The joint space may be
the opposing surface. Again, the center of the
narrowed due to degeneration of the articular
moving body (assuming flat or nearly flat sur-
cartilage or contracture of the surrounding soft
faces) travels in the direction of the gliding move-
tissues (e.g., with epicondylopathy in the radio-
ment as long as the linear motion continues.
humeral joint), or it may be widened as a result
These different modes of contact in rolling and
of effusion. Additionally, the cartilage margins
gliding may play a role the proprioceptive and
and menisci (knee joint) are palpated for tender-
nociceptive control of muscular activity from the
ness to pressure.
joint. It is important for the mechanics of joint
motion that the center about which the move-
Capsular Attachment. Tenderness and thicken-
ment occurs (the axis of rotation) remain in a rel-
ing of the capsular attachment are common in
atively fixed position. Otherwise the joint sur-
states of chronic joint irritation. Ligaments and
faces would tend to separate from each other
muscle attachments also may be tender to pres-
and dislocate, as illustrated by the femoral
sure. With synovitis, the consistency of the cap-
condyles rolling on the tibia or the humeral head
sule is soft, spongy, and fluctuant.
rolling on the glenoid (Fig. 9 b). To prevent this
tendency, the moving surface must roll and glide
Positional Faults of the Joint Members. When
simultaneously to maintain the constant, stable
caused by a post-traumatic or functional rela-
apposition that is essential for unimpaired joint
tional disturbance, such faults can sometimes be
function (Fig. 9 c,d). This rolling-gliding motion
detected by palpation.
prevents destabilizing distraction and trauma-
tizing compression of the articulating surfaces
Joint Play (Fig. 9)
(Fig.9c).
Active and passive functional joint movements A basic distinction is drawn between the angular
can be analyzed in greater detail by breaking the gliding that occurs in active and passive rolling-
motions down into separate components. This is gliding (Fig. 9 d) and straight translational gliding
done by testing joint play. (Fig. 9 e). Translational gliding occurs most read-
Joint play refers to the passive mobility of the ily in the neutral resting position of a joint, i. e., the
joint as one joint member is lifted away from the central position of a physiologic path of motion
 Examination ofthe Joint 27

Gliding Rolling

Stationary axis Movement of bone

j \ during traction
/ \
\
\
\
--+--. Movement
of bone in space

Traction

Glidi ng

Compression

Fig. 9 a. Components of
functional movements Rolling-gliding Joint play

Fig.9 b. Dislocation tendency when one joint member rolls without gliding, illustrated for the
knee and shoulder joints
28 Examination of the Joint

Fig.9 c. Nonunifonn separation (and apposition) of the articular surfaces when

angular rolling occurs without gliding

Fig.9 d. Unifonn separation and apposition when the moving member rolls and
glides simultaneously (angular rolling-gliding) during active and passive movements

where the surrounding soft-tissue structures (es- however small, will still be possible within the re-
pecially the capsule and ligaments) are lax and maining limits of motion when the joint is in its
there is little receptor activity. In this situation the displaced (virtual) resting position (Fig. 8 a).
articular surfaces are less firmly in contact with The translation gliding of a convex articular sur-
each other, so gliding can occur more easily. This face occurs in a direction opposite to its direc-
translational gliding, which I defined earlier as tion of rotation, whereas a concave articular sur-
joint play, is the fundamental partial function of face glides in the same direction that it rotates.
the joint. Even with a severe restriction of joint This is because the rotational axis is always lo-
mobility, some amount of translational gliding, cated at the center of the member whose articu-
 Examination of the Joint 29

iUi
:,, ,

!..
, I

, ~~,,---,

Fig.9 e. Uniform separation and apposition during passive translational (straight)

gliding

lar surface is convex (Fig. 9 d). Because all artic- Compression, on the other hand, by raising the
ular surfaces have some degree of curvature and pressure on the intraarticular contact surfaces,
mate with a surface of reciprocal shape, this generally accentuates the pain, just as does any
"convex-concave rule" (Kaltenborn) applies to general increase in pressure caused by joint effu-
all the joints in the body. It is the basic mechani- sion or by the pathological transformation of in-
cal principle of articular motion (Fig. 9 g). ternal structures (such as a meniscal lesion).
Joint play is tested in order to evaluate the par- However, the cartilage gliding surface itself can
tial functions of the joint. Distraction and com- be affected by a traumatic, inflammatory, or de-
pression are performed at right angles to the tan- generative pathology (e. g., an intraarticular
gential plane, while translations are performed loose body). All "meniscal tests" in the knee, for
parallel to the tangential plane, in the plane of example, consist of angular gliding movements
articular contact. The tangential plane ("treat- under pressure. The varying pressure in the con-
ment plane") passes through the outermost dis- tact area between the articular surfaces also
tal borders of the concave articular surface (usu- seems to playa significant role in the proprio-
ally the socket) and thus changes with every ceptive and nociceptive regulation of the joint,
change in position of that member (Fig. 9 f). This although it still has not been determined at
also applies to the actual treatment plane, run- which point the joint sensors detect this in-
ning parallel, in the area of articular contact. creased pressure.

Traction and Compression Translational Gliding (Parallel Gliding)

Traction, considered here to be synonymous Translational gliding movements, the most im-
with distraction, causes the articular surfaces to portant components of joint play, are, unlike the
separate from each other, leading to a decrease angular rolling-gliding of active and passive joint
in pressure within the joint (Fig.9h). This re- movements, short, straight parallel shifts of the
lieves the pain of inflammatory and degenera- moving bone relative to its stationary partner on
tive joint diseases or other lesions of the internal the plane of joint contact, to the degree permit-
structures (incarcerations). Even with a con- ted by the curvature of the joint surface and cap-
tracted joint capsule, traction temporarily low- sular constraints (Fig. ge). The translation can
ers the raised intraarticular pressure and re- be continued only after the position of the mov-
duces pain (trial manipulation). ing bone (joint angle) has been altered. This
30 Examination of the Joint

Stationary member Stationary member

Moving
member

Gliding

-Traction

Tangential plane Tangenlial plane

(treatmenl plane) moving (treatment plane) constant

Fig. 9 f. Direction changes during distraction (traction) and gliding on the tangential gliding plane ("treatment
plane")

Movement
- - - - of bone In space - - - - --

Stationary Stationary

Fig. 9 g. Convex-concave rule (after Kaltenborn)

Stationary
member Moving
member

: }=
~ i:~t Taking up the slack
3 = Stretched

Fig. 9 h. Stages in the stretching of the joint capsule during translational joint movements
 Examination ofthe Joint 31

Fig. 9 i. Separation and apposition of the articular surfaces in the resting

and locked positions

means that the translational gliding path is a por- ther course of cerebrally programmed angular
tion of the angular gliding path, the latter con- motion, the separation and coaptation of the
sisting of a series of short, straight motion seg- joint surfaces are disturbed. At the immobile
ments. Translational gliding movements cannot contact surface there is a sudden and nonphysio-
be actively and selectively performed. logical increase in pressure, and at the side away
The soft-tissue envelope of the joint (capsule from the movement there is an abrupt overex-
and reinforcing ligaments) also plays a major tension of the articular capsule.
role in the movements of the bony elements. The If there were a primary degenerative or inflam-
ligament apparatus acts with the cohesive forces matory change in the gliding surface itself, this
between the articular surfaces to maintain appo- capsuloligamentous contracture and the resul-
sition of the joint. Usually the collateral liga- tant motion restriction would have to be consid-
ments are responsible for keeping the joint sur- ered a nociceptive adaptation to the underlying
faces apposed and guiding their movements. change. This adaptation further increases the in-
Laxness of these guiding ligaments leads to loss traarticular pressure, initiating a vicious circle.
of coaptation and, in tum, to instability, unphys- The treatment of choice in all such cases is to
iologic loading of the joint surfaces, and prema- restore the translational gliding mobility in the
ture joint wear (flail joint, osteoarthritis). At the joint and, thus, restore angular rolling-gliding, in
same time, contractures of the capsule or liga- order to reestablish normal joint function. Trac-
ments and shortening of the muscles can alter tion and parallel gliding are applied therapeuti-
the uniform separation of the joint surfaces and cally to (1) separate the articular surfaces, (2)
hamper intra articular gliding, causing restric- tighten the joint capsule and its reinforcing liga-
tion of mobility. Contraction of portions of the ments, and (3) stretch the contracted portions of
capsule or ligaments shift the rotational axis for the capsule and ligaments of t/;le hypomobile
the gliding movement toward the side of the joint (Fig. 9 h). The starting point for the manip-
shortened or contracted structures (Fig.9j), ulation is not the resting position or the virtual
which prevents angular rolling-gliding corre- resting position in a restricted joint, where glid-
sponding to the axis because parallel gliding is ing is not obstructed. Experience has shown that
obstructed by the shift in the axis of movement increasing the joint play that is always present in
and the thus inadequate length of the ligaments. the resting position is not an adequate treat-
The area of contact that has lost its capacity for ment. Rather, the end point of the residual active
gliding becomes a new rotational axis. In the fur- motion range should form the starting point
32 Examination ofthe Spine

from which the restricted range of translational ed by rotating the spine in the opposite direc-
gliding is extended. I call this starting point the tion.
treatment position. If the translational tests demonstrate normal
joint play, the functionally related muscles must
be examined in greater detail (see p. 35).
Testing Joint Play
Since small translational movements are diffi-
cult to palpate, one of the joint members has to
be fixed manually and functionally. It is also of- Examination of the Spine
ten necessary, just as in treatment, to secure the
adjacent joint in a fixed position to avoid con- Examination of the spine differs from the exami-
comitant movements in that joint. This particu- nation of the extremity joints in that, besides the
larly applies to the closely spaced intervertebral two intervertebral facet joints, there is a third
facet joints. Immobilizing a joint in a locked po- mobile element, the intervertebral disk, that in-
sition (Fig. 9i) maximizes the contact area be- fluences the mechanics of the active segment and
tween the articular surfaces and presses them its susceptibility to dysfunction (J unghanns).
firmly together. The joint can be locked by posi-
tioning the joint capsule and reinforcing liga- Inspection
ments such that they are sufficiently taut to sta-
Congenital deformities such as kyphosis and sco-
bilize the joint and maximally restrain its motion
liosis; acquired deformities based on antalgic
in the direction of treatment.
posture, growth disturbances, and metabolic or
Joints in the vertebral column are locked by re-
inflammatory processes.
versing the physiologic joint mechanics, i. e., the
coupled rotation that accompanies sidebending
Motion Testing (Fig. 10)
of the spine. For example, if sidebending mobil-
ity between two vertebrae requires a conco- Active Motion Testing. The entire spine is tested
mitant rotation toward the side to which the in all three anatomic planes for restriction and
spine is bent, the desired locking can be achiev- deviation in one or more directions of motion.

Stabilizing muscles Normal jOint function

Axis of motion

Joint capsule

Fig. 9 j . Legend see page 33

 Examination of the Spine 33

Pathologic joint function

Shortened
~..,~-- muscle
Pathologic
function

Contracted ca psule

Cartilage d amage

Compression

Fig. 9 j.l-4 Models of restricted mobility joint. 1 Normal joint function. 2 Restricted mobility due to shorten-
ing of muscels, 3to contracture of the capsule, and 4 due to pathologic changes in the gliding surfaces
34 Examination of the Spine

Cervical Thoracic Lumbar

1-2 2-3 :i-4 4-5 5-6 6-7 1-2 2-3 3-4 4-5 5-6 6-77-88-99-10 HI-1111-12 1-2 2-3 3-4 4-5

Occiput- Cervico- Thoraco- Lumbo-

Atlas thoracic lumbar sacral
junction junction junction

Fig.tO. Spinal segmental mobilities during forward and backward bending, side bending, and rotation. Solid line,
Forward and backward bending; dashed line, side bending; dotted line, rotation

Passive Motion Testing. Motion is tested in all pled with a rotation of the vertebral bodies,
directions, proceeding by levels. which rotate toward the concavity of the curve
when the spine is ventrally flexed and toward the
convexity of the curve when the spine is dorsi-
Palpation
flexed ("coupled rotation"). The amount of cou-
At Rest pled rotation depends on the position of the glid-
Superficial Palpation (Touch Palpation). Der- ing plane in the facet joint. Coupled rotation is
matomic changes with signs of a neurologic dis- always palpalted during side bending. The ab-
turbance (Kibler's fold). sence of rotation signifies a segmental dysfunc-
Deep Palpation (Palpation for Tenderness). tion.
Spasticity of the intrinsic muscles and long ex-
tensors; insertional tendinopathies at the
Joint Play (Fig. 11)
spinous processes; faulty position of individual
vertebrae. Tenderness of facet and costoverte- Disk Traction and Compression (Fig. 11 b)
bral joints. Traction involves the segmental decompression
of the intervertebral disks. The gliding apart of
During Movement the articular surfaces increases the craniocaudal
Segmental palpation of the excursions of the ver- diameter of the foramina, which causes a de-
tebra in all directions of passive movement compression of the nerve roots, accompanied by
(Fig.lO). Dorsiflexion (backward bending) a gliding movement in the facet joints. Compres-
causes maximal approximation of the interver- sion involves the loading of intervertebral disks
tebral facets (convergence) and increases the and emerging nerves as a result of the gliding to-
area of articular contact. Ventral flexion (for- gether of the facet joints, which leads to in-
ward bending) causes separation ofthe articular creased pressure on the disks and a restriction of
facets and the palpable spinous processes (diver- the intervertebral foramen.
gence) and reduces the area of articular contact.
Sidebending to the right causes the facet joints Facet Joint Play (Fig. 11 )
to converge on the right side and diverge on the Distraction of the facet joints in the cervical and
left side, while sidebending to the left produces thoracic spine is effected by backward move-
the opposite effect. Sidebending is always cou- ment and in the lumbar spine by rotational
 Examination of the Muscles 35

proven, at least for restriction in the facet joints.

The motion deficit noted in a restricted segment
may well be caused by a hypertonic segmental
muscle response to nociceptive afference from
the vertebral segment. Moreover, the primary
nociceptive afference need not originate from
the facet joint itself but may come from, say, a
disk protrusion, which often cannot be reliably
distinguished from pure facet joint disturbances.
Fixed caudal
Some cases of facet joint hypomobility are due
vertebra to nociceptive afference originating outside the
a
spine (e. g., from the viscera).
H.D. Wolff, who has worked extensively with
the neurophysiologic aspects of hypomobile
joint dysfunction, believes that vertebral restric-
tion is a spinal and supraspinal response to noci-
ceptive afferent flow which, when relayed to the
second neuron in the posterior horn complex,
evokes corresponding motor, sensory, and auto-
nomic reactions.
The motor reactions consist of an increase in
muscle tone due to effects on the gamma loop
Stationary vertebra (the intrinsic control mechanism in muscle for
b
adjusting the stimulus threshold for muscle
Fig. 11 a,b. Translational joint movements in the tone). This leads to myalgias (lowered muscular
spinal segment
pain threshold), splinting, and myogelosis. The
autonomic effects caused by the linkage of the
posterior and lateral horns in the spinal cord in-
movement of the cranial vertebra relative to the volve the vasomotors, smooth muscle, and sweat
fixed adjacent vertebra below. In contrast, glid- glands. The pain sensations, like those arising
ing movements in the cervical and thoracic spine elsewhere (e.g., in the internal organs), are re-
are produced by cranial-caudal movement (di- ferred to the segmentally related skin zones
vergence-convergence) during flexion/exten- (Head's zones) or subcutaneous tissues (Kibler'S
sion or unilaterally by lateral flexion. The rota- zones).
tion that accompanies lateral flexion can be
detected by the lateral movement of the spinous
process relative to the fixed process below it
(Fig. 11 a). Translational gliding is produced in Examination of the Muscles
the lumbar spine by forward movement of the
caudal vertebra relative to the fixed adjacent Examination of the muscles is not entirely sepa-
vertebra above. rate from the examination of the joints and ner-
The purpose of testing translational mobility in vous system (see pp. 24 and 42) because the mus-
the individual segments is to detect vertebral re- cle contains peripheral receptors of the afferent
strictions (hypomobile or absent joint play) or nerve pathway and is also an end-organ of the ef-
hypermobility. The question arises whether ferent pathway. Thus, a question that always
there can in fact be a primary mechanical restric- arises during the examination is whether a dis-
tion in joints, aside from trapped menisci and in- turbance of muscular function is primarily myo-
traarticular loose bodies in the joints of the ex- genic or neurogenic. The muscle examination
tremities. So far no such analogies have been gives information on the condition of:
36 Examination of the Muscles

- the muscle itself Movement patterns arise through the interac-

- the tendon attachments tion of conditioned and unconditioned reflexes.
- the nerve pathway They develop during ontogenesis and include all
repetitive motor sequences that are carried out
Muscle Groups
during the activities of daily living. Because they
From a mechanical standpoint, we can distin- are largely specific for the individual, an individ-
guish the following types of muscle groups in ualized pattern tends to emerge. This pattern,
each direction of joint movement (after Janda): which forms gradually from the innervation of
The agonists (main muscles) are the main effec- individual muscles that is present shortly after
tors of the tested movement. They also perform birth, is controlled initially by the cortex and lat-
an auxiliary function in other directions of er by subcortical centers. The learning of move-
movement. ment patterns is a stringent task which accounts
Synergists (auxiliary muscles) do not effect the for the rapid fatigability of infants and small chil-
tested movement but act in the same direction as dren. In later life as well, the acquisition of new
the agonists and thus perform an auxiliary func- patterns in work and sports is fatiguing until the
tion. These muscles function chiefly in a different new motor sequence has become routine and
direction. They are temporally coordinated with can be performed with less effort (training ef-
the agonist but are anatomically separate from it. fect). Frequently, faulty movement patterns that
They support the main muscle and can partially have developed through environmental influ-
replace its function. Synergy refers to a muscle ences have to be restructured. The rapidity and
group composed of agonists and synergists. skill with which new patterns are acquired and
Antagonists act in opposition to the action of the faulty patterns are restructured depend on the
agonists. When the agonists are active, the an- learning ability of the brain.
tagonists are tense and stretched without limit- An ideal pattern, in which only those muscle
ing the normal range of motion. Restriction oc- groups are activated that can effect the desired
curs only if there is reflex splinting (nociceptive movement efficiently with minimum effort, is
co-contraction) or shortening of the muscles. practically nonexistent. Far more common are
Stabilizing muscles do not participate in the test- faulty movement patterns resulting from an im-
ed movement. They tend to fix the tested body balance of antagonistic muscles. The occurrence
region in a position favorable for exercise. Poor of these imbalances is due largely to the exis-
stabilizing muscles can simulate paresis of the tence of two functionally distinct types of striat-
agonists. During muscle tests, therefore, the ex- edmuscle:
aminer himself should fix (stabilize) the exam-
1. Postural tonic "slow-reacting" muscles, which
ined body part proximal to the tested joint in or-
perform the predominantly static function of
der to deactivate the stabilizing muscles. The
postural maintenance. The neurophysiologic
general rule is: fixation by the examiner is neces-
control of these muscles requires a constant
sary for the testing of polyarticular muscles,
nominal value for muscle length and tension,
weak muscles, and for muscle testing in children.
even when variable extrinsic forces are ap-
Neutralizing muscles are muscles that abolish
plied.
(neutralize) the auxiliary function of the main
2. Phasic "fast-reacting" muscles, which are
muscle but often support the tested movement
needed for the differentiated movements of
effected by the agonist. While the main move-
daily living. Muscle length and tension must
ments add together, the auxiliary movements
be rapidly adjusted by higher centers in re-
cancel out. The auxiliary function of the syner-
sponse to changing demands on the muscles.
gists can be used to differentiate the various
muscles of a synergy. A muscle can function si- All the muscles in the body have both a postural
multaneously as a synergist and a neutralizer. (tonic) and a phasic component, their ratio de-
All these muscles work in a functional relation- termining the definitive function of the muscle
ship called a "movement pattern." in a movement pattern. Every movement pat-
 Examination ofthe Muscles 37

tern can, moreover, vary during the individual's Hip adductors: Pectineus, adductor longus, bre-
lifetime as a result of maturation and changing vis, and magnus, gracilis
demands. External rotators of the hip: Piriformis
The postural "red" muscles (Fig. 12) are phylo- Extensors of the spine: Erector spinae (longis-
genetically older, have a better blood supply and simus dorsi, multifidi, rotators)
lower O 2 demand, are prone to shortening and Elevators of the shoulder girdle: Trapezius (su-
contracture, are less subject to fatigue, have a perior portion), levator scapulae, sternocleido-
lower stimulus threshold, and are slower to atro- mastoid
phy. Muscle shortening, unlike contracture, is Other: Pectoralis major (sternal portion),
reversible because it merely involves a change in quadratus lumborum
elasticity. The principal postural muscles are: The phasic "white" muscles are phylogenetically
Plantar flexors: Triceps surae, gastrocnemius, younger, prone to weakness, fatigue rapidly,
soleus have a higher stimulus threshold, and atrophy
Knee flexors: Hamstrings (biceps femoris, semi- more quickly than the tonic muscles. The phasic
tendinosus, semimembranosus) muscles include:
Hip flexors: Psoas, rectus femoris, tensor fasciae Dorsiflexors of the foot: Tibialis anterior,
latae peronaei

.....-- - - - M. e
l vator scaputae
....._---- M. trapezius

,-+'\-_ _ __ M. pectora lis major

r---HH-+-it--- M. errector spinae

Flexors of the hand

m - ; - ;'\-It+\-- M. Quadratus .I"'ti- - - - and fingers
tumborum

Hamstring group :
.""'t-'P--J'--- - - Adductor group

Ilr .• ft-'H'----- - - M. semitendinosus +-- - - - - M. rectus femoris

+-- - - - - M. bic eps femoriS

/ - - - - M.gastrocnemius

, .- -- - - - M. soleus

Fig. 12 a, b. Tonic muscles prone to shortening (after Janda)

38 Examination of the Muscles

Knee extensors: Vastus medialis and lateralis the apparatus is stimulated by stretch and simul-
Hip extensors: Gluteus maximus, medius, min- taneously facilitates the antagonist.
imus Tho structures playa key role in this control of
Abdominal muscles: Rectus abdominis, obliqu- muscular function, muscle spindles and Golgi
us externus and internus tendon bodies. The muscle spindles, which mon-
Inferior scapular stabilizers: Serratus anterior, itor change in muscle length, are arranged paral-
trapexius (middle and inferior portions), rhom- lel to the working muscle fibers and thus can
boids sense and respond to muscular stretch. The pro-
Superficial and deep neck flexors: Scaleni prioceptive afference from the muscle spindles
Other: Pectoralis major (inferior portion) acts at the spinal level to stimulate the a mo-
Imbalances between these two muscles groups toneurons in the anterior horn. This causes the
arise when the postural muscles, prone to short- muscle to contract until the length change in the
ening, inhibit the phasic antagonists at the spinal muscle spindle is reversed and the correspond-
level (weakening them to grade 4 or 3 in muscle ing proprioceptive input is terminated, thereby
strength tests). This can result in a faulty joint abolishing the contractile stimulus from the a
position that can accentuate the muscle imbal- motoneurons.
ance through proprioceptive feedback, setting The Golgi tendon bodies perform a complemen-
up a vicious cycle. The faulty movement pattern tary function to the muscle spindles. When ten-
can also be aggravated by the recruitment of sion in the muscle becomes excessive, they exert
synergists for the weakened muscle. an inhibitory effect on the a motoneurons, caus-
A position change of a few degrees in a joint fa- ing the muscle to relax. Their function may un-
cilitates (stimulates) the shortening-prone mus- derlie the muscle-relaxing effect of vibratory
cles that are functionally related to the joint and massage over the tendon attachment, for
inhibits (weakens) the antagonistic muscle example.
group. The stimulus threshold within the control sys-
The following reflex mechanisms are useful for tem is adjustable to ensure that the system is
the examination of movement patterns: flexible enough to adapt to changing demands.
Reflex effects originating from the joint: The y loop can raise the muscle tone in the face
of nociceptive afference and can sustain the
- An altered joint position facilitates postural
higher setting as long as the nociceptive inflow
muscles and inhibits phasic muscles.
persists. This process underlies the phenomenon
Reflex effects originating from the muscle: of muscle splinting and, in longer-standing cases,
myogelosis. The influence of psychological and
- Postural muscles inhibit phasic muscles.
autonomic effects on the y system can account
- Agonists inhibit the antagonists, which in turn
for some psychosomatic phenomena.
facilitate the agonists.
- Rapid activation of a muscle facilitates the an-
Examination ofthe Muscles During the Basic
tagonist as a protective mechanism (co-con-
Physical Examination
traction).
Inspection. Individual movement pattern during
- Maximum activation (contraction) of a mus-
ordinary actions (gait, posture, working posi-
cle causes a very brief postfacilitation inhibi-
tions); muscle contour changes due to atrophy,
tion (i. e., relaxation) that can be utilized ther-
hypertrophy, or injury (torn muscle).
apeutically.
- In the muscle: the muscle spindle, when
Active Motion Testing. Paresis, see Isometric
stretched, facilitates contraction of its parent
Resistance Tests, p.4l; Coordination distur-
muscle while simultaneously inhibiting the
bances. Marked general muscular hypotoni-
antagonist.
city in infants and small children is an early
The Golgi apparatus in the tendon attachment sign of neuromuscular disease ("floppy in-
inhibits (relaxes) the associated muscle when fant").
 Examination of the Muscles 39

Passive Motion Testing. Alterations of tone, erative spinal processes, neuritis, poliomyelitis,
muscle shortening, contractures. or tumors. Disuse atrophy can occur after pro-
longed immobilization and sometimes after in-
Palpation. Touch palpation: hypo- or hypertonic jections.
changes. Pressure palpation: tenderness of mus- ' Neurogenic muscular atrophy is never seen in
cles and tendon attachments (tender points; see central paralytic states. Muscular atrophy in the
palpation tables), splinting, myogelosis. setting of myopathies (e. g., progressive muscu-
lar dystrophy, myositis, endocrine myopathies)
Resistance Tests. Pain (tendon attachments) and occurs in the presence of an intact reflex arc and
strength are tested by isometric resistance tests, is not associated with other neurologic symp-
strength (muscular weakness, true paresis) by toms.
isotonic resistance tests. Congenital muscle defects have been described
for the pectoralis, lateral serratus, trapezius,
Special Diagnostic Procedures infraspinatus, sternocleidomastoid, palmaris,
Radiography: sclerosis of the tendon attach- psoas, quadriceps femoris, tibialis anterior, and
ments, calcium deposits peroneus brevis muscles.

Laboratory studies: creatine, creatinine, en- Hypertrophy

zymes (CPK, aldolase, LOR, GOT, GPT) True hypertrophy, such as that in athletes, has a
firm consistency on palpation, whereas pseudo-
Electrodiagnostic studies: peripheral electrodi- hypertrophy feels flaccid.
agnosis, EMG
Occurrence
Muscle biopsy: see one of the relevant guides
Generalized hypertrophy is physiologic in ath-
Findings of Muscle Examination letes, pathologic in myotonia congenita.
Local hypertrophy may involve the calf ("gnome
Inspection calf"), quadriceps femoris, pectoralis, deltoid,
Muscle Contour Changes brachioradialis, or extensor digitorum brevis in
Changes in muscular contours are detected by cases of progressive muscular dystrophy and
comparison with the opposite side. The differ- spinal muscular atrophy.
ence in muscle volume is determined by girth
measurements. Motion Testing
Atrophy Active Motion Testing
Mild degrees of muscular atrophy are demon- Regarding paresis, see Isometric Resistance
strated more clearly by side-illumination. Atro- Tests, pAl. Coordination disturbances involve
phy generally results from paresis of the periph- disturbances of motor control with regard to the
eral neuron, and the site of the causative lesion force and temporal sequence of muscle activa-
(root, plexus, peripheral nerve) must be ascer- tion. Incoordination can occur:
tained. Muscular atrophy may be masked by
overlying subcutaneous fat. Edema and varicose - in an individual muscle
veins can also make it difficult to compare the - in a synergy
muscle girth with the opposite side. - between antagonists
- in completely independent muscle groups
Occurrence
Generalized atrophy in consumptive diseases or Uncoordinated movements lead to:
alimentary, senile, and cancer cachexia. - impaired performance
Local atrophy from lesions of peripheral - premature fatigue
nerves or nerve roots caused by trauma, degen- - faulty (increased) joint loading
40 Examination of the Muscles

Passive Motion Testing (for Muscle Shortening) Tone

Passive motion testing is usually performed im- The muscle tone may be increased or reduced.
mediately after the terminal phase of an active This can be assessed by comparison with the mus-
movement. As noted earlier, if further passive cle when it is tense (during the resistance test).
movement of the joint is not possible, it must be Hypotonicity is noted inweakened, paretic mus-
determined whether the cause lies in the joint cles.
itself (contracted capsule or mechanical block- Sustained hypertonicity is palpable as muscle
age), or whether terminal passive (and active) splinting incited reflexly by disturbances in the
movement are restricted by muscle splinting or related joint or spinal segment. A splinted mus-
shortening. cle is usually very tender to palpation.
If articular function is intact, the problem gener- Myotendinoses are circumscribed hard areas,
ally relates to a shortened muscle participating in oriented parallel to the course of the muscle
a faulty movement pattern. In this case all poten- fibers, which develop after prolonged splinting.
tiallyoffendingmuscles that are prone to shorten- Most common in poorly perfused areas about
ing must be examined. These muscles are listed on the origins and insertions of muscles, they prob-
p. 37. Thepsoasis the premier muscle in the pelvic ably result from the accumulation of fatigue
girdle, the pectoralis major in the shoulder girdle. products (lactic acid) following overuse. Myo-
tendinosis is less painful than splinting. Since
Muscle Stretch Tests both conditions diminish the local pain thresh-
These tests are conducted on the postural mus- old, they are a source of spontaneous pain dur-
cles that are prone to shortening. The muscle is ing exercise.
passively stretched to lengthen it while increas- Maximal points or trigger points (usually in the
ing its internal tension. region of tendon attachments) are most com-
The passive stretch should test the elastic limit of monly found in the following muscles (after Le-
the muscle without exceeding it. A healthy mus- wit):
cle presents a soft elastic end-feel. If motion is
limited due to causal factors unrelated to the - The adductors with disturbances of the hip
joint or CNS (spasticity), muscular shortening joint and sacroiliac joint (symphyseal region)
may be diagnosed. It is not caused by active mus- - The psoas with hip disturbances (lesser
cular contraction, increased activity of the ner- trochanter) and restrictions of the lower tho-
vous system (no increase in EMG activity), or racic segments. Cubis regards the psoas as the
reflex splinting. As noted earlier, shortening is indicator muscle for restricted thoracic verte-
most apt to affect the muscles of postural main- brae.
tenance, such as the leg muscles required for - The iliacus with a sacroiliac lesion (pelvic tor-
one-legged stance (loads in the stance phase of sion) and lumbosacral restrictions
gait are 85% those in one-legged stance) or the - The piriformis with restrictions of the IA/L5
arm muscles that are used for grasp. segment
The examination is conducted basically accord- - The segmental muscles of the erector spinae
ing to the same rules as the isotonic resistance with vertebral restrictions (segmental irrita-
tests described below. tion points)
- The pectoralis and interscapular muscles with
Palpation disturbances of the upper costotransverse
joints
The examiner palpates the fully relaxed muscle
- The deltoid with disturbances in the shoulder
with the flat hand, gently palpating through the
joint (deltoid tuberosity)
superficial layers (skin and connective tissue).
The muscle is palpated over its entire course; -Note
tendinous areas are palpated in the direction of In myositis ossificans, muscle becomes ossified
their fibers, and the muscle belly at right angles due to the retraumatization (e. g., by massage) of
to its fibers. injured muscle tissue that has not completely
 Examination ofthe Muscles 41

healed. The quadriceps femoris and adductors on the tendinous attachment to bone. The find-
are particularly susceptible (e. g., in riders, soc- ings can be interpreted as follows.
cer players, and ice hockey players).
Nonnal Finding
Resistance Tests The muscular contraction is strong and pain-
Up to this point, muscular function has been less.
evaluated by active motion testing (movement
pattern) and passive motion testing (for muscle
Pathologic Findings
shortening). The next step is to test the muscles
1. The contraction is strong and painful = mild
specifically for strength and pain. When testing
musculotendinous damage
muscle strength, several distinctions must be
2. The contraction is weak and painful = severe
made (according to Krejci and Koch):
musculotendinous damage
Maximum strength: the maximum force that a
3. The contraction is weak and painless = neuro-
muscle can develop to overcome a resistance,
logic lesion (paresis)
without regard for speed of movement. It is in-
creased most effectively by isometric exercises.
Isotonic Strength Tests
Power: the "explosive capability" of a muscle to
In these tests, shortening contraction of the
surmount a resistance at high speed. Power is
muscle affects movement. The tendon is
improved by isotonic training.
stretched but remains under constant tension.
Endurance: the length of time a force can be ex-
The patient should first perform the movement
erted until fatiguing occurs.
without correction (individual movement pat-
Strength, power, and endurance are mutually in-
tern). Then the strength of weakened or paretic
terdependent parameters.
muscles is tested according to the following
rules (Janda).
Isometric Resistance Tests for Pain
1. Test the complete range of movement slowly
and Strength
at a constant speed.
The resistance tests ("resisted movement," Cy-
2. Throughout the test, apply a constant resis-
riax) furnish information on muscle strength and
tance acting opposite to the direction of the
the tenderness of tendon attachments due to
movement. Do not apply resistance across
traumatic, degenerative, or inflammatory pro-
two joints.
cesses. The tendon attachments can be palpated
3. Limit the movement to only one joint.
while the resistance test is being performed. The
4. Fix the proximal joint member securely.
synergy is first tested against a maximum resis-
5. Do not press on the tendon or muscle belly
tance, starting either from the intermediate po-
(facilitation).
sition (favorable working position) or from the
position of maximum stretch (unfavorable The test should be performed against maximal
working position), in which case pain may result resistance.
from the increased intraarticular pressure. Pain The test findings, i. e., muscle strength, are grad-
can be differentially assigned to a particular ed from 0 to 5 as follows:
muscle of the synergy by testing other synergies Grade 5 (100%) Moves joint against maximal
in which the muscle of interest is also active as an resistance
agonist or synergist. Grade 4 (75%) Moves joint against strong re-
Very little resistance should be used in testing an sistance
individual muscle to avoid activating the whole Grade 3 (50%) Moves joint against gravity
synergy. The resistance prevents shortening of Grade 2 (25%) Moves joint but not against
the muscle, and thus prevents movement. The gravity
resistance stretches the (elastic) tendinous por- Grade 1 (10%) Palpable contraction only
tion of the muscle and places increased tension Grade 0 (%) No contraction
42 Examination ofthe Nerves

The results can be further differentiated by rat- 5. Weakness

ing the individual grades (especially grade 4) - Reflex (inhibition)
as + or-. - Stretch-related (?)
The antagonists of postural muscles that are - Structural, neurogenic, myogenic
weakened by spinal inhibition usually score no - Disturbed movement pattern
better than grade 4 or (rarely) grade 3. More se-
vere degrees of paresis are generally due to neu- Muscular imbalance is a relational disturbance
rologic disease. affecting muscles with different actions. The dis-
The test cannot evaluate fatigability during pro- turbance may involve tension, activation, or
longed exertion. A gross assessment, without strength.
the formal grading of muscle strength, can be
made by comparing the responses of the right
and left sides to the same test. Examination of the Nerves
The muscle tests are not useful in patients with
central (spastic) paralysis or a primary muscular
Disturbances of joint mobility (material) are
disease (myopathy). The mimic muscles can be
caused chiefly by incipient or overt morphologic
tested only by comparison with the opposite
changes, and muscular dysfunctions (energy)
side.
are usually considered a reflex response to these
The individual tests are described at the appro-
articular changes. But they can also result from a
priate places in the diagnostic program.
primary neurologic disorder (control), since
functional disturbances ofthe muscles and ner-
Pathologic Muscle Findings
vous system produce largely identical symp-
The following pathologic findings may account
toms. Thus, in dealing with purely functional
for a limitation of motion during muscle testing:
disturbances of the joints and muscles, it is
1. Increased resting tone (spasm, hypertonicity) important to establish the origin of the nocicep-
tive afference and the (morphologic) cause of
- Localized, circumscribed
the irritation so that effective causal treatment
• trigger point
can be provided.
• muscular maximal point
Localization of the irritation site is aided by the
• segmental irritation point
symptom complexes typically associated with
• myosis
specific lesion sites. These symptom complexes
- Tension increase in a whole muscle or muscle
are discussed in the section on Differential Diag-
group
nosis of Nerve Lesions (p.46).
- Generalized increase in muscle tone (e. g., fi-
In a synoptic interpretation of the spinal and
bromyalgia)
joint examinations, a general examination of the
2. Muscle shortening nervous system is conducted as part of the basic
physical examination. It consists of:
- Reflex shortening
- Reversible structural shortening
Inspection
- Irreversible structural shortening (contrac-
ture) - Body symmetry and contours: muscular atro-
phy or hypertrophy (see Examination of the
3. Decreased resting tone (hypotonicity) Muscles)
- Reflex hypotonicity (inhibition) - Complex motor sequences, ordinary move-
- Peripheral paresis ments (gait, etc.), innervation, coordination
- Spontaneous muscular contractions (espe-
4. Impaired muscular activation cially with damage to the central neuron and
- Disturbed movement pattern subcortical centers) (see p.43)
- Paresis - Trophic skin changes (see p.44)
 Inspection 43

Active and Passive Motion Testing Special Neuropathologic Findings

- Active: the entire neural pathway (innerva- During the Basic Physical
tion, coordination) Examination
- Passive: sensitivity to nerve stretch (on mus-
cle tone, see also Examination of the Muscles,
p.35ff.)
The neurologic findings described in this section
are limited to those that are noted with some fre-
Palpation
quency during the regional physical examina-
- Autonomic disturbances (impaired blood tion and are characteristic of a joint or a particu-
flow and sweat secretion) lar body region.
- Nerve pressure points (Valleix pressure
points, irrigation points, see Palpation Zones)

Muscle Tests I Inspection

- Motor disturbances involving muscular syner-
Complex Motor Sequences
gies or individual muscles during resistance
testing Gait
Normal findings (see p.72), pathologic findings
(see pp. 73f.).
Neurologic junction testing is always indicat-
ed if the basic physical examination has dis- Ordinary Complex Movements
closed evidence of a primary lesion of the Sitting down - standing up
nerve pathway. Undressing - dressing
Lying down - sitting up
In this case adjunctive neurologic studies (N) are
Pathologic Findings
performed to test the reflexes and indicator
Flaccid pareses and coordination disturbances.
muscles (N1)' sensation (superficial and deep
sensation; N2), motor function (root, plexus, pe-
Spontaneous Muscular Contractions
ripheral nerve; N3), coordination (N4)' and cra-
nial nerves (Ns). Spontaneous muscular contractions can occur in
These studies may have to be supplemented by the calf muscles and the small muscles of the
special diagnostic procedures (S) performed by a hand, even in healthy individuals.
neurologist or radiologist:
Sl Special neuroradiologic investigations
Pathologic Muscnlar Contractions
S2 Laboratory studies: CSF analysis, Ninydrin
test (of Moberg) With Inability to Move
S3 Cerebral angiography Spasms (muscle cramps): painful muscular con-
S4 Electrodiagnostic studies: peripheral elec- tractions accompanied by painful limitation of
trodiagnosis, electromyography (EMG), motion, usually involving the lower extremities.
nerve conduction velocity, electroen- Frequent at night in response to cold or mechan-
cephalography (EEG), echoencephalogra- ical insult.
phy Tetanic muscle spasms in the hands and feet (car-
Ss Special examinations of the sensory organs popedal spasms) or involving the mimic muscles
(by a specialist) (facial tetany).
Obstetrician's hand, Trousseau's phenomenon-
accentuated by hyperventilation or an upper
arm tourniquet (3-5 min). Pronation of the foot
44 Inspection

on percussion of the peroneal nerve at the fibu- Jacksonian seizures: coarse, slow, rhythmic
lar head (peroneal nerve sign). clonic movements that may spread from a cir-
cumscribed area to adjacent muscles or the
Without Movement ofJoints whole body (Jacksonian epilepsy); secondary
Fibrillary and fascicular contractions: lightning- to lesions about the cerebral cortex (trauma,
like contractions of individual muscle fibers or vascular diseases, inflammatory diseases, tu-
fiber bundles secondary to anterior horn lesions mors).
or nerve/root lesions; can be triggered by cold
exposure in healthy individuals. Uncoordinated Movements
Myokymia: slower, irregular, quivering contrac- Torsion dystonia: slow, twisting movements of
tions involving large muscle areas; occurs after the head, neck, and trunk. Usually the head is
cold exposure and rarely in polyneuropathies. maximally rotated and cannot be voluntarily
turned forward, although it can do so against a
With Movement ofJoints resistance; seen with extrapyramidal lesions;
Tic: lightning-like muscular contractions involv- never psychogenic. Etiology is usually obscure.
ing a specific region (e. g., the facial nerve); may Athetoses: slow, writhing movements caused
be due to an organic brain lesion (e. g., posten- by alternating contraction of agonists and an-
cephalitic) or psychogenic. tagonists. Flexion-extension movements are
Myoclonus: individual or repeated, jerky mus- most pronounced in the extremities (fingers,
cular contractions of variable location; occur in toes), less so in the trunk, neck, and face. Bayo-
cerebrovascular sclerosis and postencephalitic nette-like finger positions. Secondary to early
states (midbrain lesion). childhood brain damage or brainstem syn-
dromes.
Rhythmic Oscillatory Movements Chorea: brief, rapid, irregular, uncoordinated
Tremor most commonly affects the distal por- movements of varying intensity and location af-
tions ofthe extremities and the head (nodding or fecting the extremities, trunk, and face (grimac-
head-shaking tremor). ing, Vitus' dance). Accentuated by emotional
Several types can occur: stress. Occurs in chorea minor (rheumatism)
and other organic brain diseases (striatum).
1. Resting tremor, which is accentuated by emo- Hemiballism: rapid, forceful, slinging move-
tional stress and decreased by voluntary ments of the arm or leg on one side of the body,
movement. Fine tremor is seen with nervous- secondary to lesions of the thalamus and sub-
ness and hyperthyroidism, moderate tremor thalamic nucleus. The movements are intensi-
with cold and fatigue, coarse tremor with ex- fied by external stimuli and disappear during
cessive alcohol or drug use (essential tremor). sleep.
2. Intention tremor: coarse, jerky tremors that
are intensified by purposeful movements; due Trophic Disturbances (Chiefly Involving
to cerebellar lesions. the Hands and Feet)
3. Psychogenic tremor: coarse tremor affecting
Vasomotor impairment: initially hyperemia and
the proximal portions of the extremities; dis-
redness, later cyanosis and skin coolness.
appears when the patient is distracted or un-
Sudomotor impairment.
observed.
Skin atrophy: thin, smooth skin with flattened
All types of tremor are relieved by sleep and cutaneous ridges on the bulbs of the fingers.
general anesthesia! Hyperkeratoses.
Myorhythmias: very rapid, fine vibrations, Abnormalities of hair growth.
chiefly affecting the mimic muscles, also the soft Nail changes: increased transverse convexity of
palate; secondary to brainstem lesions. the nails, transverse ridges or pale bands (Mees'
Myorhythmias are not relieved by sleep or gen- stripes), thickened ridge of skin beneath the end
eral anesthesia. of the nail (nail-bed sign of AlfOldi).
 Palpation 45

These include rapid, passive trunk rotations by

Active and Passive Motion Testing passive twisting of the shoulder girdle, and pas-
sive shaking movements of the forearm and
hand (wrist muscles).
Active Motion Testing
1. Hypotonicity (i. e., no resistance). The distal
The complete neural pathway is tested, including
extremities have a "rag doll" limpness. Hypo-
the central nervous system and the psychic will-
tonicity can result from lesions of the periph-
ingness of the patient.
eral nerves or pyramidal tract (acute stage),
cerebellar lesions, extrapyramidal diseases, or
Normal Findings myopathies.
Strong, painless, coordinat d movements. 2. Hypertonicity occurs in two forms:
Spasticity: Springy resistance to normal and
rapid passive movements, diminished at rest.
Pathologic Findings Secondary to cerebral or spinal lesions involv-
1. Painful active and passive limitation of mo- ing the pyramidal system.
tion [radicular irritation, nociceptive somato- Rigor: Firm, increasing resistance to passive
motor blocking effect (Brugger 1962)]. motion, unaffected by rest. Often presents as
2. Painless limitation of motion (paresis, paraly- a series of "catches" during passive motion
sis). (cogwheel phenomenon). Secondary to ex-
3. Coordination disturbances. trapyramidal diseases.
3. Poikilotonia: alternation between hypotonic-
Passive Motion Testing ity and an irregular rigor of varying intensity
and duration, seen in Huntington's chorea and
This tests the sensitivity of the nerve trunks to
athetosis.
stretch and muscle tone.

Normal Findings Palpation

No nerve stretch pain over the physiologic
range of joint motion.
o hypo- or hypertonicity. Autonomic Nervous Disorders

Normal Findings
Pathologic Findings Warm, moist skin of normal hue showing no
Nerve Stretch Pain significant visible or palpable sweat ecretion
at rest. Palpable nerve pathways are not thick-
1. Nerve stretch pain is a neuralgic (sharp, stab- ened or tender to palpation.
bing, or tearing) pain that radiates to the distri-
bution of the nerve or nerve root (dermatome).
It is perceived as superficial and welllocalized. Pathologic Findings
2. Muscle stretch pain is perceived as a dull or Dryness (anhidrotic area) is noted when the skin
gnawing pain that is poorly localized and oc- is stroked with the fingertip or back of the hand.
curs at a deeper level (myalgic pain). It is ag- Anhidrosis occurs with lesions of the peripheral
gravated by increasing muscle stretch. nerves or nerve plexus for all forms of sweat
secretion, whether thermoregulatory or in re-
Dystonias sponse to pharmacologic stimuli (peripheral
If passive joint movements show evidence of ab- dyshidrosis). With a preganglionic lesion (proxi-
normal muscle tone (hypo- or hypertonicity), mal to the sympathetic trunk), only centrogenic
this can be checked by special tonicity tests. (thermoregulatory) sweating is affected, while
46 Symptoms of Nerve Lesions by Location

sweating in response to drug stimuli (e. g., pilo- - monoparesis or monoplegias = partial or com-
carpine) is preserved = central dyshidrosis. This plete paralysis of one extremity.
occurs with intramedullary lesions and the in- By their degree:
traspinal compression of nerve roots by a herni- - paralysis (plegia) = complete paralysis
ated disk or tumor. Lesions above T21T3 and - paresis = incomplete paralysis.
below L3 do not affect sweat secretion due to the By the site of the lesion:
absence of efferent sweat fibers past those levels. - peripheral paralysis (peripheral neuron)
- central paralysis (central neuron).
Nerve Pressure Points
Diffuse sensitivity to nerve percussion is noted
distal to sites of nerve injury (Hoffmann-Tinel
sign). Symptoms of Nerve Lesions
by Location
Thickening of Nerve Trunks
Diffuse thickening of peripheral nerves is a fea- Lesions at different sites give rise to characteris-
ture of "hypertrophic neuritis," a special form of tic findings and frequently produce a character-
neural muscular atrophy. istic clinical picture.
Nodular thickenings are found in neurofibro-
matosis (von Recklinghausen's disease) and 1. Muscular Nociceptive Symptoms
leprosy. (Nociceptive Reaction of Wolff)
Etiology:
I Muscle Tests - Occur reflexly due to stimulation of joint noci-
ceptors by mechanical stresses (increased
Motor disturbances of individual muscles or syn- intraarticular pressure) or inflammatory
ergistic groups usually are already apparent dur- changes about the joint (articular surfaces
ingthe active and passive motion testing of ajoint. and/or capsule and ligaments). The location
Resistance and shortening tests further establish and function of proprioceptors and nocicep-
whether the cause of the disturbance is a faulty tors in the joints are summarized in Table l.
movement pattern or a true nerve paralysis. Nociceptive symptoms are probably also
caused by proprioceptive and especially noci-
ceptive input from pressure changes in the
subchondral layers at the momentary contact
Differential Diagnosis area between the articular surfaces.
of Nerve Lesions - Faulty muscular control (faulty movement
pattern).
Pain and deficits are extremely diverse accord- Complaints: Myalgic pain: dull, boring, tearing,
ing to the location of the lesion. Clinical mani- burning; motion-dependent.
festations depend chiefly on the location and Inspection: Fasciculations to contracture.
severity of the damage. Active Movements: Restriction of terminal joint
Nerve paralyses are distinguished: motion, and rapid fatigability to paresis of seg-
By their location: mentally related muscles.
- tetrapareses or tetraplegias = partial or com- Passive Mobility: Rigor-like hypertonicity (of-
plete paralysis of all four limbs, ten with cogwheel phenomenon) to restriction
- parapareses or paraplegias = partial or com- in the direction of painful motion ("nociceptive
plete paralysis of both arms or legs, somatomotor blocking effect" of Brugger).
- hemipareses or hemiplegias = partial or com- Palpation: Myogeloses, trigger points at tendon
plete paralysis affecting one side of the body, attachments, segmental irritation zones.
 Symptoms of Nerve Lesions by Location 47

Differentiating featores of peripheral and central paralysis:

Peripheral neuron Central neuron

(past anterior horn (in brain or spinal cord)
motor cell)
1. Inspection Muscular atrophy No muscular atrophy
2. Active movements Paresis or paralysis No paresis or paralysis
3. Passive movements Hypotonicity Hypertonicity
4. Reflexes H ypo- or areflexia, no Hyperreflexia, pathologic
pathologic reflexes reflexes
5. Special tests: Degeneration reaction No degeneration reaction
electro diagnostic Lengthening of chronaxy,
studies increase in rheobase

Autonomic Disturbances: Trophic disturbance loint Play: Pain aggravated by compression (im-
(circulatory impairment) may occur. paction, coughing, sneezing).
Neurologic Deficits: None. Neurologic Tests: Radicular neurologic deficits
after hours to days; require differentiation from
2. Symptoms of Peripheral Nerve Lesions peripheral nerve irritation.
Etiology: Exogenous pressure due to trauma Reflexes: Muscle stretch reflexes are not consis-
(including avulsions) or inflammatory changes tent with symptoms of a peripheral nerve lesion.
(e.g., herpes zoster, neuritides), intoxications, Sensation: Disturbance essentially limited to
tumors (entrapment syndromes). pain sensation, since the overlap for the pain
Polyneuropathies are usually caused by meta- zones is smaller than for other sensory modali-
bolic disturbances (e. g., diabetes). ties.
Complaints: Local pain radiating distally and Motor Function: With monoradicular deficit,
proximally along the course of the nerve. paresis of corresponding indicator muscles; with
Inspection: Atrophy (late symptom). polyradicular deficits, again no correlation with
Sensation: Hypo- to anesthesia, paresthesias. a peripheral nerve lesion.
Motor Function: Pareses with corresponding Autonomic Disturbances: No sudomotor or va-
EMG changes. somotor disturbance or impaired piloerection,
Autonomic Disturbances: Diminished sweat se- since autonomic innervation is via the sympa-
cretion. thetic trunk (T21T2 to L2/L3). With a lesion of
multiple adjacent roots, irritative phenomena
3. Radicular Symptoms may be present but do not correspond to the
Etiology: Approximately 90% caused by pro- analgesic areas.
lapsed disk impingement on the spinal root, also
by irritation from osteochondrosis and spondy- Symptoms of a Caudal Lesion
losis (spurring). Caused by medial disk prolapse (acute) or tu-
Complaints: Neuralgic pain radiating to the cor- mors (gradual).
responding dermatomes. Pain: Intractable "sciatica."
Reflexes: Loss of knee jerk, ankle jerk, and ad-
Symptoms of Disk Herniation ductor reflex.
Inspection: Painful postural abnormality. Sensation: "Saddle block anesthesia."
Active and Passive Motion Testing: Severe, Motor Function: Paresis of both triceps surae
painful limitation of motion. and the small muscles of the foot; bladder and
Palpation: Paravertebral muscle splinting. rectal paralysis.
48 Symptoms of Nerve Lesions by Location

4. Symptoms ofPlexus Damage Practical Relevance of the

Etiology: Trauma or tumors. Plexus damage is Structural Analysis of Function
uncommon in the lumbar region owing to the
protected position of the plexus. Entrapment
The uniting of material (joints) and effectors
syndromes do not occur in the lumbar region but
(muscles) by the control system (nerve path-
may occur at the cervical levels.
ways) into a functional unit not only forms the
Motor Function: Paresis or paralysis of entire
basis for the smooth, coordinated function of the
muscle groups. Rapid atrophy of the affected
joints of the locomotor apparatus but also pro-
muscles.
vides a reliable mechanism for the detection of
Sensation: Sensory disturbances in the region of
functional disturbances and structural defects.
the damaged portions of the plexus.
Reflexes: Losses consistent with the location and
extent of the plexus damage.
Autonomic Disturbances: Homer's syndrome How Does the Control and Warning
(cervical) and other autonomic signs (degenera- System Function?
tion reaction).

Proprioception
5. Symptoms Due to Disturbances
Involving the Neuromuscular Junction Proprioception is concerned with the control of
or Muscle Fiber posture and movement and the orientation of
the body in space. It relies on afferent input from
Myasthenia
the mechanoreceptors - the sensory end-organs
Inspection: No atrophy or fasciculations (atro-
of the control system that give information on
phy is present in myopathies).
position and changes of state in the locomotor
Motor Function: Diffuse paralysis of highly vari-
apparatus. This information is utilized to keep
able intensity, according to demand. Excessive
the center of gravity aligned over the area of sup-
fatigability.
port (statics) and to execute coordinated move-
Sensation: Intact.
ments (dynamics). Proprioceptive afference is
Occurrence in true muscular diseases:
transmitted from the entire functional unit of
- Progressive muscular dystrophy (progressive the joints and muscle and also from the skin and
degeneration of the muscle fibers). subcutaneous tissues. The afferents are located
- Myotonias (hyperexcitability of striated mus- in the joint capsule (types I and II), in the capsule
cle). and ligaments (type III), and perhaps in the sub-
- Myositides (inflammatory muscle diseases). chondral layers of the joint surfaces. All three
- Myopathies (metabolic, endocrine, or con- types exert a reflex (tonic or phasic) effect on the
genital muscle diseases). motor neurons of the spine and extremities (see
Table 1).
6. Symptoms ofLesions of the Central Additional afferent input is provided by the
Neuron (Central Paralysis) muscle spindles, which respond to changes in
muscle length. Arranged parallel to the extra-
Motor Function: Spastic pareses affecting one
fusal fibers, the spindles react to muscle stretch
whole extremity, one side of the body, or both
(depending on their threshold) by stimulating a
extremities (paraparesis). Increased muscle
reflex contraction of the working muscle (via al-
tone.
pha motor neurons). At the same time, the mus-
Reflexes: Increased; pyramidal signs; central
cle spindles adapt to the shortening ofthe work-
coordination defects.
ing muscle via the more slowly conducting
gamma motor neurons. A similar adaptation can
be effected by central nervous influences. Be-
 How Does the Control and Warning System Fnnction? 49

Table 1. Function of joint receptors (after Wyke). Four types: mechanical receptors types I-III (proprioceptors),
type IV: nociceptors
Type Location Function Threshold Adaptation
Outer layer of Joint position Low Slow
joint capsule Signal tension in joint
Conduction capsule, inhibit nociception,
velocity: 30-70 rnIs have reflex tonic effect on
muscles (gamma system)
II Inner layer of Joint movement Low Rapid
joint capsule Briefly inhibit nociceptors
Conduction in response to brief
velocity: tension changes and
60-100 rnIs stimuli, have reflex phasic
effect on muscles
(gamma system)
III Ligaments and Alarm/stress situations High Very
tendon attachments (stretch receptors) Slow
Conduction Inhibit motor neurons
velocity 130 rnIs
IV Whole joint capsule Signals damage/pain High None
and ligaments Have reflex tonic effect on
(nociceptors) muscles (gamma system),
(conduction spine, and extremities;
velocity 1 rnIs) pain production;
Unimodal nociceptors have reflex tonic effect on
(mechanical) respiratory and circulatory
Polymodal nociceptors systems
(chemical)

Receptor: Organ that transforms a mechanical or chemical stimulus into electrical impulses that
are relayed along the nerve pathway.
Threshold: Minimum stimulus to which a receptor will respond.
Adaptation: Rate at which a receptor adjusts to a stimulus, the receptor ceasing to fire under conditions of
constant stimulation.

sides the extrafusal muscle, the afferent dis- and the contact area between the articular sur-
charge from the muscle spindles also activates faces.
synergistic muscles and inhibits antagonists. The joint capsule and the ligaments surrounding
The Golgi tendon organs register the tension of the joint undergo varying states of tension and re-
the muscle. If the tension becomes too great, laxation during articular motion. In response to
they exert an inhibitory effect on the surround- the capsular stresses, the joint receptors provide
ing muscle while also inhibiting the synergists information on joint position (type I) and the
and stimulating the antagonists. stress changes that accompany movement (type
The cutaneous receptors act to increase muscle II) while also signaling the danger of excessive
tone (in the related segments) while inhibiting stresses (type III) and the occurrence of those
the tone of the antagonists. stresses (nociception, type IV). Information from
As mentioned, the proprioceptors of the joint the mechanoreceptors is relayed by sensory
capsule and ligaments perform control func- nerves to the posterior horn of the spinal cord,
tions by providing information on joint position, where it is used to initiate the motor reflexes re-
intraarticular pressure, and joint movements. quired for the coordination of stability and move-
This underlies the neurophysiologic feedback ment. Also at this level, endorphins are released at
circuit driven by input from the joint capsule the interneuron to inhibit the transmission of pain
50 How Does the Control and Warning System Function?

signals. The spinothalamic pathways subsequent- tational axis for joint movements should always
1y relay the information to higher centers, culmi- be positioned so that only parallel gliding occurs
nating in an autonomic response to the input and at the point where the surfaces appose. This nat-
possibly a conscious awareness ofthe pain. urally requires a fine control of muscular tension
The joint capsule and the ligaments also perform in the agonists and aritagonists, and this can be
passive mechanical (stabilizing) functions, one accomplished most accurately by signals ema-
of which is to ensure that the rotational axis of nating from the loaded joint surface itself.
the joint remains within physiologic limits. Stability, then, is an active, dynamic process in
The practical importance of the proprioceptive which the tension of the small periarticular mus-
information sources can be summarized as fol- cles must constantly adjust to the movement of
lows: the joint, the accompanying stresses, and the
goal of the movement to ensure optimum
1. The Skin. Any contact with the skin, especial- rolling-gliding of the articular surfaces. In this
lyon the hands and feet, gives us information process the capsule and ligaments not only main-
from the pressure at the contact site and the tain passive mechanical stability by preventing
position of the extremity. We also utilize this subluxation during uncontrolled movements
information source when we have the patient (e.g., trauma) but also function as an organ for
ambulate with a cane or when we wrap the the proprioceptive control of the stabilizing
joint with an elastic bandage (other examples: muscles. This is evidenced by the poor joint sta-
corset, neck brace, taping). bility that follows operations in which torn joint
2. The Muscles and Tendons. These structures ligaments have been replaced by synthetic mate-
contain receptors sensitive to changes in mus- rials. The mechanoreceptors important for pro-
cle length and tension. These parameters prioception cannot be replaced by a prosthesis,
(tension and length) are constantly monitored although therapeutic exercises can indirectly
and adjusted to ensure that balance (statics), compensate for this loss to a degree. This also ap-
movements (dynamics), and stability in the plies to the loss of control afference caused by
joints remain within physiologic bounds. removal of the biological joint surfaces (e. g., in
3. The Capsules and Ligaments. They contain replacement arthroplasties).
mechanoreceptors that give information on
the position and movements of the joints.
Coordination
Rolling-gliding is made possible by continual
adjustments in muscle tension. These tensions The coordinated interaction of different muscles
are controlled reflexly by the mechanorecep- helps to preserve joint stability and ensure that
tors in the capsules and ligaments. There is the execution of movements proceeds in an or-
much evidence that they are also controlled derly, harmonious fashion.
by input from the changing areas of interartic- Muscular activity is coordinated at various lev-
ular contact. els. At the articular level, the tone of the small
4. Other Sources of Information. These are the periarticular muscles should be sufficient to
sense organs, the eyes, and the otovestibular maintain satisfactory apposition of the joint sur-
system. faces. During all movements and under all loads,
the muscles should keep the joint surfaces in a
position in which gliding of the surfaces can oc-
Stability
cur without compression.
The joint stability afforded by the muscles, cap- Slightly farther from the joint, the tension of the
sule, and ligaments ensures that an optimum agonists and antagonists must be controlled in a
pressure is maintained at the contact site be- way that maintains optimum loading and move-
tween the articular surfaces. The pressure on the ment of the joint. At an even greater distance,
joint surface should be low enough to ensure that muscles that pass over the joint must provide for
the gliding surface is not damaged. Also, the ro- harmony of movement and coordinate the ac-
 How Does the Control and Warning System Fnnction? 51

tions of different joints. Finally, in the body as a Nociception

whole, movements of the individual joints must
be coordinated in a way that preserves balance, The coordinated movements of joints are made
avoids pain, and provides for the optimum, har- possible by the sensorimotor mechanisms de-
monious execution of movements. This coordi- scribed above. Under pathologic conditions,
nation is accomplished chiefly in the brain and however, significant disturbances can arise in
the higher segments of the cervical spine. motor sequences and can irritate receptors that

1 Neocortex
2 Thalamus
3 Reticular formation

Afference
A

Efference

A= afferent pathways
Sympathetic E= efferent pathways
trunk

Fig. 13. a Synopsis ofthe theory of the spondylogenic nociceptive reaction leading to vertebral restriction. (Modi-
fied from H. D. Wolff)
52 How Does the Control and Warning System Function?

Table 2. Sites for intervention with medical treatment, manual therapy, physical therapy, or therapeutic exercises

II Skin Medical treatment: stimulation of cutaneous receptors by ointments,

local anesthesia (wheal)

Connective tissue massage

Lymphatic drainage
Reflex zone treatment
Acupuncture (acupressure)

Medical treatment: muscle relaxants, antirheumatic agen ts, local

anesthesia of tendon allachments

Active relaxation
PIR (postisometric relaxa tion)
MET (muscle energy training)
Muscle stretch
Coordination training (PNF, Vojta, Bobath, Brunkow)
Muscular training (stabilization)
Massage (tone, circulation, metabolism)
Thermo-, hydro-, electrotherapy

Medical treatment: antiinflammatory agents (also intraarticular)

Local anesthesia of capsule and ligaments Uoint receptors)

Immobilization: bed rest, stabilizing bandages,

neck brace, corset, other braces
Translational mobilization
Manipulation
Thermo-, hydro-, electrotherapy
Active and passive exe rcises
Automanipulations by the patient

Medical treatment:
Local anesthesia
Peripheral nerve
Spinal nerve (ganglion/sympath. trunk)
Posterior root
Tranquilizers (as needed)
Vasodilators
Elastic wraps

Elect rostimulation (of peripheral nerves) for pareses

are sensitive to noxious or harmful stimuli. These acerbate the disturbance are inhibited to the
nociceptors (Wyke type IV) are present in all point of paralysis, while muscles that can protect
components of the locomotor apparatus (bones, a pathologic focus from further damage become
joints, muscles, tendons, tendon sheaths, bursae, hypertonic in an effort to immobilize the focus
nerves, vessels, skin, and subcutaneous tissue) as (reflex splinting). Initially this occurs without re-
well as in smooth muscle and the internal organs. gard for the cause of the disturbance, which may
Every disturbance signaled by the nociceptors be mechanical (loose body, incarcerated liga-
evokes a reflex change in the execution of a ment, disk prolapse) or inflammatory (arthritis,
movement. All muscles whose activity would ex- bursitis, tendovaginitis).
 How Does the Control and Warning System Function? 53

Brugger calls this neuroautonomic reflex mecha- ceptive reaction can occur in all structures that are
nism for protecting a disease focus the "nocicep- related to the same segment, i. e., not just in the
tive somatomotor blocking effect" (1962). He skin (Head's zone) and muscles (Mackenzie's
applies the term "tendomyosis" to the associat- zone) but also in the vertebrae, leading to sec-
ed change in the functional state of the muscle. ondary restriction. The restriction may persist
Hypotonic muscles cause a painful, fatigued after the primary stimulus (e. g., from an internal
feeling and become more painful when they organ) has passed and in tum can incite a further
contract. Hypertonic muscles cause a painful nociceptive reaction in the muscle and skin
muscular rigidity (rigor) and become more (Fig. 13 a).
painful when they are stretched. Both types Thus, effective causal treatment can be provided
of muscle are prone to rapid fatigue. Hyperton- only if the irritation site is identified and appro-
ic muscles frequently contain sites of myo- priate measures are taken to eliminate the dis-
gelosis, whose nociceptive afferent discharge turbing factor.
can further accentuate the pathologic hyper- Since, in principle, there are only three struc-
tonicity. tures that can be influenced by manual therapy,
Brugger notes, however, that nociceptive hyper- physical therapy, or therapeutic exercises - the
tonicity and hypotonicity are not limited to joints, muscles, and nerves (Table 2) - it is clear
antagonistic muscle groups, but can coexist in the isolated application of portions of the thera-
the same muscle if the irritative focus requires it. peutic spectrum, such as massage, physical ther-
Moreover, the arthromuscular irritative phe- apy, soft-tissue treatments, or therapeutic exer-
nomena described above may be accompanied cises, is not an optimum approach. Optimum
by autonomic, vasomotor, and dystrophic management must include a structurally orient-
changes (e. g., reflex sympathetic dystrophy). ed combination of multiple therapeutic modali-
The nociceptive reactions in joints and muscles
are very similar and sometimes even identical. It
is imperative, then, to determine the site of ori- Table 3. Methods for treatment of musculoskeletal
gin of the nociceptive irritation so that causal disorders
treatment can be planned. This site may be lo- Pain
cated in the afferent or efferent limb of the pe- Medications (injections)
ripheral neuron. The nociceptive afference may Immobilization (bed rest, bandages)
Massage, joint traction, muscular training
emanate from the receptor fields of the arthro- Thermo-, hydro-, electrotherapy
muscular unit, from the skin, or from the inter- Surgical intervention
nal organs (Fig. 13 a). The nerve pathway may be
Functional disturbance
disturbed in the region of the sensory or mixed Decreased motion (hypomobility)
nerve, at the nerve root, or at the motor nerve Massage, active relaxation, muscle stretch
fibers (nerve compression or entrapment, disk Joint (segmental) mobilization, manipulation
prolapse). Automanipulation by the patient
Sensorimotor coordination training
Disturbances of the central neuron, by contrast,
(PNF, Vojta, Bobath)
are easily differentiated by their distinctive signs Electrostimulation (pareses)
(seep.49). Surgical mobilization
According to H.D. Wolff, a steady influx of no-
Excessive motion (hypermobility)
ciceptive impulses from various structures of the Stabilizing muscular training
body can cause a stimulus overload in the poste- Autostabilization by the patient
rior hom with a nociceptive reaction in the ante- Stabilizing bandages and appliances
rior hom, lateral hom, and center. Through con- Surgical stabilization
tinuous depolarization of the gamma motor Morphologic abnormality
neurons, this leads to increased tone in the seg- Medical treatment (joint effusions, swellings)
mental muscles and perhaps to secondary re- Postural and motor training
Surgical correction
striction of the associated vertebra. Thus, a noci-"
54 Testing of Irritation Zones

ties whose precise makeup is determined by terion, for they can be tested below the pain
whether pain, dysfunction, or morphologic ab- threshold. Sachse and Schildt claim that the cor-
normality is the most prominent feature of the relation with mechanical dysfunctions of the
condition requiring treatment (Table 3). spine is closer than that between pain and dys-
function. "For this reason," they write, "these re-
flex algetic signs of disease can be effectively used
as the sole criterion for therapeutic planning."
Testing of Irritation Zones (Figs. 13b-f, They also note,however, that the origin of the pri-
44a--c, 103a-d) mary irritation (internal organ or vertebral seg-
ment) cannot be positively identified. This is pos-
A number of authors (Sell, Caviezel, Maigne, sible only when there are neurologic deficits that
Bischoff, Dvorak) diagnose segmental dysfunc- point to a direct injury ofthe nerve pathway.
tion by testing for "zones of irritation" or similar Dvorak cautions that, in various regions of the
soft-tissue changes in addition to segmental mo- vertebral column, the examiner may confuse the
tion testing. Segmental motion restriction alone, irritation zone (IZ) with trigger points in other
unaccompanied by pain or tenderness, is not muscles. Bischoff further notes that segmental
considered an indication for manual medical irritation points can be found in association with
treatment unless it is associated with an irrita- disk protrusions, activated spinal arthrosis,
tion syndrome involving the soft-tissue enve- arthritis, and tumors, all of which would be a
lope of the affected joints. contraindication for manual therapy.
Thus, Bischoff states that the second diagnostic Bischoff lists the following structural causes:
step, following segmental motion testing, is to - Splinting of the intrinsic segmental muscles
search for the segmental irritation point (IP) or - Swelling of the periarticular connective tissue
irritation zone (IZ). The third step is then to de- - Painful protrusions of the joint capsule due to
termine the response of the IP to movements in extruded synovial fluid
the segment, noting that the increase or decrease
Dvorak believes that the irritation zones are
in pain intensity and the change in consistency of
caused by direct joint or muscle injury, excessive
the IP during designated movements are the es-
loading, or a "functional positional fault."
sential guide to the appropriate direction for
Tilscher believes that trigger points are the result
therapeutic manipulation.
of a nociceptive stimulus processing that can
Sachse and Schildt refer to the palpable tension
originate in various portions of the arthron
changes in the motor and autonomic efference
Goint, ligament, muscle, viscera) and necessi-
as "reflex algetic signs."
tates concomitant treatment of the primary
Synonyms for irritation point include:
source of the irritation.
- Trigger point (myofascial point) The activity of these IPs or muscular trigger
- Maximal point points can be decreased by stretching the mus-
- Myosis/tendinosis cle, administering local anesthesia, or applying a
- Paramedian tender point (Maigne) cooling spray.
The authors agree that a comparison of the me-
The structural changes thus designated are rec-
chanical mobility fault with the segmental irrita-
ognized as a local, circumscribed increase in the
tion is useful for assessing the reactivity (auto-
resting muscle tone (hypertonicity).
nomic lability) of the patient's nervous system.
According to Sachse and Schildt, the examiner
should test the responses of these palpable ten-
Location of the Irritation Zones
sion changes to pressure, traction, displacement,
or Irritation Points (Fig. 13 b)
and elevation and should compare them with the
responses of adjacent or contralateral tissues. There is considerable disagreement among
The authors regard these "reflex algetic signs" in some authors regarding the location ofthe irrita-
the muscle and skin as an objective diagnostic cri- tion points:
 Testing ofirritation Zones 55

Lumbar Spine Thoracic Spine

The IPs for Ll-L4 are said to be located 1 finger- One fingerwidth lateral to the spinous processes
width lateral to the spinous processes (Bischoff (Bischoff and Neumann) or at the end of the
and Neumann) or at the end of the transverse transverse processes (Dvorak) where the longis-
processes (Dvorak). At L5, they are described as simus and semispinalis muscles attach.
occurring 2 fingerwidths lateral and 1-11/2 fin-
gerwidths above the tip of the spinous process of Ribs
L5 (Bischoff and Neumann) or 1 fingerwidth lat- The IPs for costotransverse joints II-IV are lo-
eral to and below the posterior iliac spine (Dvo- cated 2 fingerwidths lateral to the spinous pro-
rak). cesses; for joints V-XI, lateral to the costotrans-
verse joints (Neumann); other authors place
them at the costal angle.

Cervical Spine
The points for C2-C7 are located over the artic-
ular processes of the cervical vertebrae and on
the nuchal line (Sell). The IP for C7 is located lat-
era
ly at the tip of the mastoid process, and the
other points are more medial, spaced at intervals
of 1 fingerwidth along the same line. C2 is on the
midline, with C1 below it (Bischoff and Neu-
mann). Dvorak places the IPs for C1 and C2lat-
erally at the superior end of the mastoid notch,
with an additional IP for C1 at the tip of the
transverse process.

Pelvis
Reports on IP locations show the greatest dis-
crepancy in the pelvic region. Bischoff and Neu-
mann state that the IP for Sl is 3 fingerwidths
lateral to the upper pole of the sacroiliac joint
and 4 fingerwidths caudal to the iliac spine,
while that for S3 is 1 fingerwidth lateral to the
lower joint pole (see also Fig. 34). Dvorak
places these points at the lateral border of the
sacrum between the posterior inferior iliac
spine and inferolateral angle and at the origins
of the erector spinae and gluteus maxim us mus-
cles.

Examination Technique
Thoracic and Lumbar Spine
The authors also describe various routes of ac-
• = Irritation points according to Bischoff and Neumann cess to the IPs: a medial route, a paraspinous
o = Irritation points according to Dvorak route, and a lateral route.
R = Irritation points oflhe ribs
Bischoff and Neumann use the paraspinous ap-
Fig. 13. b Testing of irritation zones (after Bischoff, proach between the spinous processes and the
Neumann, and Dvorak) erector spinae in the thoracic and lumbar re-
 56 Testing of Irritation Zones

c .......;..,,;_

Fig. 13. c,d Provocative testing by rotation of the lumbar spine. e Provocative testing by flexion of the lumbar
spine. fProvocative testing by rotation ofthe thoracic spine

gions, pushing the erector muscle approximate- hooking around the semispinalis capitis. Inter-
ly 1 cm to the side and applying straight, perpen- vertebral joint play can be simultaneously as-
dicular finger pressure. sessed. Sell's bimanual palpation of the inser-
Dvorak, using a bimanual technique, reaches for tions of the splenius capitis and splenius cervicis
the tip of the transverse process from the lateral on the nuchal line and at the mastoid process was
side, parallel to the body surface, with the previously mentioned. A notable feature in this
thumbs placed medially between the iliocostal region is the segmental arrangement at the mas-
and abdominal muscles. The IP is located near toid, which Dvorak assigns to segments CO and
the costotransverse joint. The IPs of the superior Cl, while Bischoffplaces the IPs of C7 and C6 at
articular processes are, for Dvorak, "only of the mastoid and places the higher segments
theoretical importance." along the nuchal line, spaced at l-fingerwidth in-
tervals, so that C2 is adjacent to the midline with
Ribs Cl below. The tip of the transverse process of the
Here the IPs are accessed at the costotransverse atlas also has been reported for Cl.
joint (Bischoff), lateral to it (Neumann), or at
the costal angle (Dvorak) . Findings
The IPs are palpable as sites of increased tissue
Cervical Spine firmness that are tender to pressure and change
There is general agreement regarding access to with rotation, flexion, or extension of the affect-
the IPs in the cervical spine: The finger pushes ed area. A significant abatement of pain and
straight down toward the superior articular pro- firmness during the trial movements indicates
cess of the cervical vertebra or reaches it by the appropriate therapeutic direction.
 Testing of Irritation Zones 57

Provocative Testing (to test for changes in the Maigne refers to the palpable changes in the
IPs) skin, muscle, and at the tendoperiosteal junction
During provocative maneuvers, the examiner as the "segmental cellulo-periosto-myalgic ver-
maintains a constant pressure on the IP with the tebral syndrome." He states that these changes
palpating finger while noting any increase or de- occur at specific paraspiilouS points and relate
crease in pain and firmness. closely to the affected metamere. The tissue
In the cervical region, flexion-extension and ro- changes can cause radicular joint pain or viscer-
tation of the cervical spine are used to test for IP al pain but also may produce no complaints.
changes over the facet joints and on the nuchal They are reversible when the primary causative
line. stimulus is removed but may become self-sus-
In the thoracic region, the thoracic spine is rotat- taining and outlast the primary irritant. During
ed by elevating the shoulder on the test side, or the examination of a painful segment, the tissue
the head is fully retroflexed (neck extension; changes are disclosed by axial (posteroanterior)
Bischoff). or lateral pressure to the spinous process and the
Dvorak tests for change by pressing laterally, up- resultant vertebral movement. They are caused,
ward, or downward on the spinous process using then, by a segmental dysfunction, herniated
a technique like that shown in Fig. 13 c,f. disk, or activated degenerative arthritis.
The ribs: Dvorak does provocative testing by Maigne, unlike Bischoff and Dvorak, gives no
pressing the rib in the sternal direction (placing details on the location of these palpable changes
traction on the costotransverse joint) or in the or their response to specific provocative move-
direction of the transverse process. Bischoff and ments. Nor does he draw therapeutic conclu-
Neumann merely test pain and firmness during sions from the provocative test findings.
inspiratory and exspiratory excursions (to pro-
duce gliding movements in the costovertebral
Diagnostic Implications of Irritation
joints).
Zone Testing
In the lumbar region (Ll-L4) , Bischoff per-
forms rotation testing, as in the thoracic spine, It is well established that reactions in the soft
by elevating the shoulder on the test side, and tissues about the joints and related muscles are
extension testing by elevating the leg on the test consistently evoked by functional disturbances
side to increase the lordotic curvature of the in the joints, analogous to Head zones and
lumbar spine. Mackenzie zones in the skin and muscle. These
The IP at L5 is palpated about 1.5 cm above and reactions are palpable by an examiner applying
2 em lateral to the spinous process, with pressure pressure or thrust to the vertebral segments
directed toward the lower facet joint. Provoca- (Figs. 42, 43). It is also known that these func-
tive testing is performed as described above. tional tissue changes respond to a change or
Dvorak seeks the IP of L5 over the inferior iliac elimination of the primary articular (or viscer-
spine, 1 fingerwidth lateral and caudal to the al) disturbance as a result of the nociceptive
superior iliac spine. His provocative maneuver processing of the disturbance (reaction) in the
consists of applying pressure at the thoracolum- soft-tissue envelope. The question remains,
bar junction, which, he feels, can correct a back- however, whether the investigation of these
ward positional fault in the tested segment. changes can add significant additional diagnos-
We believe that testing for a forward fault by po- tic and therapeutic information beyond that
sitioning the patient on a rubber ball is impracti- furnished by the mechanical testing of angular
cal for routine examinations. and segmental joint play and the evaluation of
Pelvis: Dvorak tests the IPs for S1-S3 at the lat- end-feel.
eral sacral border by pushing forward on the It would appear that the diagnostic implications
sacrum (to reduce pressure in the ISJ, see Fig. 51). of IP testing are inherently limited by the fact
Additional IPs are described at the origins of the that IPs are not pathognomonic for joint dys-
gluteus maximus and erector spinae muscles. function but may emanate from a variety of mor-
58 Testing of Irritation Zones

phologic joint disturbances and visceral abnor- pressure used for rib testing and the sacral pres-
malities. sure used for testing pelvic IPs, can account for
Another potential source of uncertainty is the the reaction of the IPs to the test maneuvers. It
fact that some authors who advocate IP testing is instructive to consider that the associated in-
disagree markedly with regard to the location of crease and decrease of pathologic pressure in
the IPs and their segmental and structural allo- the dysfunctional joint can alter the reactive
cations (Fig. 13 b). This may lead to confusion soft-tissue findings through changes in afferent
with trigger points in other structures. discharge. A similar change of afference is pro-
The same may be said of examination technique. duced by the change in articular contact area
An examiner using the medial paraspinous ap- during flexion testing (Fig. 13 e) and especially
proach described above can easily palpate other during extension testing.
structures. It is essential, then, that the test movements oc-
Another difficulty is that the examiner must cur precisely in the joint to be tested - a require-
apply uniform pressure to the IP during the ment that is often difficult to satisfy when long
provocative movement, which sometimes is lever arms are employed.
applied through distant levers (arm, leg) and This raises the final question of whether irrita-
across multiple joints. This requires consider- tion zone testing performed during the already
able practice and experience, and the desired time-consuming manual therapeutic examina-
force cannot always be exerted precisely on the tion contributes significant new information, not
targeted segment. This is more easily accom- furnished by joint play and end-feel, that will
plished by using short levers at the spinous pro- help establish a diagnosis and determine the ap-
cess of the affected segment (Fig. 13 c,f) or oth- propriate therapeutic direction. If so, the testing
er short levers sUGh as the pelvis for rotation of irritation zones should be an integral part of
testing in the lumbar region (Fig. 13d). The re- every examination. Given current knowledge
SUlting traction and compression effect in the and the discrepancies among published reports,
intervertebral joints, like that produced by however, there appears to be no justification for
Dvorak's traction techniques or the anterior this at the present time.
Basic
Examination of
the Spine and
the Joints of the
Extremities
Detailed Introduction

Systematic History he may be able to offer additional information

that did not occur to him during the initial inter-
view. Another advantage is that the physician
The systematic history covers the following five does not have to record the history himself, but
question areas, each consisting of five individual need only supplement it. Also, this method
questions: avoids the problem of the patient interrupting
the examination later to offer afterthoughts on
1. Current complaints
} Case history his medical history.
2. Previous course
History taking in musculoskeletal diseases
3. Social history
should always cover the following points:
4. Health history } Personal history
5. Family history 1. Current Pain (Part one of case history)
Rather than begin with the family history, it is 1. What hurts and/or functions abnormally?
more pertinent to have the patient first describe (Localization)
the complaints that prompted him to seek medi- 2. When did the pain and/or dysfunction first oc-
cal attention (pain, dysfunction, morphologic cur? (Onset of the disturbance)
abnormality). The patient should be allowed to 3. How are the pain and/or dysfunction? (Na-
spf}ak as freely as possible. The nature of the de- ture ofthe disturbance)
scription often provides clues to the patient's 4. What brings on the pain and/or dysfunction?
personality. Seriously ill patients tend to give (Modalities that initiate or change the com-
more objective reports, whereas a tendency to plaint)
offer vague or multiple complaints often signi- 5. What accompanies the pain and/or dysfunc-
fies a neurotic component. Depressives tend to tion? (Associated symptoms)
give scant information. The examiner should in-
terrupt the spontaneous narrative with questions 2. Previous Course (General condition, other
only in order to: current diseases; part two of case history)
1. Clarify unclear statements 1. What treatments have been given in the
2. Elicit further information where needed past?
3. Prompt a hesitant patient to continue talking 2. What improved or changed the pain?
The patient should also be asked what he be- 3. How are the vital functions? (eating, drinking,
lieves the cause of his pain to be. stool, bladder habits, sleep, sexuality)
The past history, like any other findings, should 4. When did previous pain occur involving the
be recorded. This is often difficult in the outpa- spine and joints?
tient setting, but we have found that time can be 5. What other diseases (including risk factors,
saved by having an assistant take and record the focal lesions ) does the patient have at the pre-
history prior to the examination, following the sent time?
outline shown above. This has the advantage of
3. Social History (Part one of personal history)
letting the patient know what information is im-
portant for the examiner to know. Afterward, 1. Occupation (training, work performed; asso-
when discussing his history with the physician, ciated activities)
62 Current Pain

2. Sports and hobbies 2. Projected pain (from the nerve to the body
3. Injuries (work, household, sports, vehicular) surface)?
that have affected the patient's ability to func- 3. Referred receptor pain (from the body interi-
tion. or to the body surface) ?
4. Operations (on the spine and joints, on other 4. Unilateral circumscribed limb or quadrant
organs) that have affected the patient's ability pain (from involvement of autonomic nerve
to function. fibers)?
5. Home and family life 5. Bilateral pain (from involvement of systemic
factors)?
4. Health History (Previous diseases by organ
systems; part two of personal history) Rule of Thumb. The more vaguely defined the
boundaries of the pain, the deeper or more cen-
1. Lower abdomen (gynecologic, urologic;
tral the location of the somatic irritation.
screening examinations).
The pattern ofjoint involvement often permits an
2. Abdominal organs (stomach and bowel)
immediate differential diagnosis of the problem
3. Thoracic organs (heart and lungs, respiratory
as degenerative, inflammatory, metabolic, or
tract)
hormonal.
4. Head (eyes, ears, teeth, central nervous sys-
tem)
1.1 Localized Pain
5. Mental status
(Monoarticular, Monosegmental)
5. Family History (Part three of personal history) Predominantly large joints:
Degenerative: osteoarthritis, posttraumatic, os-
1. Age of parents and cause of death (if appli-
teonecrosis, chondromatosis.
cable)
Inflammatory: chronic rheumatoid arthritis in
2. Chronic diseases of parents
children, infectious arthritis, psoriasis,
3. Chronic diseases of siblings
Bekhterev's disease.
4. Serious diseases of children
Metabolic: gouty arthritis, chondrocaIcinosis,
5. Congenital and other disorders (especially:
ochronosis, diabetes, tabetic arthropathy, sy-
cancer, rheumatism, diabetes, gout, tubercu-
ringomyelia, hemophilia.
losis); malformations, psychological illness.
Small joints: Gouty arthritis
Spine: Vertebral restriction, fractures, disk
prolapse, spondylolysis, acquired disk loosen-
ing.
Interpretation of the History
1.2 MultifocalPain
(Polyarticular, Vertebral Region or Entire Spine)
Current Pain
Large joints: Osteoarthritis, Reiter's disease (in
the lower extremities)
1 Location ofPain: What Hurts? Where Small joints: Rheumatoid arthritis, polyarthro-
Does it Hurt? sis, Heberden's and Bouchard's disease, psoriat-
ic arthritis, gout.
The patient should indicate the location of the
Proximal joints: Ankylosing spondylitis
pain as precisely as possible. The site can be fur-
Peripheral joints:
ther localized by asking "Where doesn't it
Psoriatic arthritis: Transverse type = all distal in-
hurt?" The maximum extent ofthe pain is criti-
terphalangealjoints; axial type = all joints of one
cal for assigning the pain to a particular struc-
finger or toe ray
ture. Is the patient experiencing:
Gouty arthritis (basal joint of big toe)
1. Localized receptor pain (body surface) ? Spine: Osteochondrosis, spondylosis, ankylos-
 Current Pain 63

ing hyperostosis (Forrestier), hypermobility, Bekhterev's disease, inflammatory joint dis-

osteoporosis eases)
Continuous pain (inflammatory, neoplastic)
1.3 Referred Pain
(Muscle Chains, Nerve Pathways, Vessels) 2.2 Periodic Pain
The involvement of muscle chains is typical of (Ovarian Cycle, Seasons, Age)
nociceptive (pseudoradicular) syndromes. A monthly rhythm is sometimes observed in dis-
Radicular pain radiates to the dermatome, while eases with an autonomic component and in hy-
pain due to peripheral nerve damage radiates to permobile individuals (fluctuating hormone lev-
the area supplied by the nerve. els?). Aseasonalrhythm (warmandcoldperiods)
Pain associated with arterial stenosis is always is seen in rheumatoid diseases. Age is also a factor:
perceived distal to the stenosing lesion. Re- Childhood: inflammatory diseases.
ferred pain radiates to the derma tomes or my- Adolescence: growth disturbances, postural de-
otomes of the segments with which the internal fects.
organ is associated. Young adulthood: disk protrusions, Bekhterev's
disease, incipient joint degeneration.
1.4 Diffuse Pain
Older adulthood: degenerative processes,
Psychosomatic conditions, systemic diseases,
metabolic diseases, hormonal changes, tumors.
depression.
Old age: senile bone changes (osteoporosis, os-
1.5 Unilateral or Bilateral Pain teomalacia), tumors.
Chronic rheumatoid arthritis is usually bilateral. An increase in the duration and intensity of de-
generative, metabolic, hormonal, or inflamma-
tory processes signals a progression of the dis-
2 Pain Occurrence: When Does It Occur ease process. The results of earlier examinations
and When Did It First Occur? (X-ray films) should be taken into account.
Intermittent or episodic pain is characteristic of
all diseases of the locomotor apparatus. Various 2.3 Episodic Pain
rhythms can occur: (With or Without a Change in Pain Location)
Spinal syndromes may take an episodic or peri-
2.1 24-Hour Rhythm odic course.
Cold pain (mechanical pain)
Exertional pain (mechanical, inflammatory, in
3 Nature of the Pain
arterial blood flow disturbances)
Rest pain (ligamentous in hypermobile individu- 3.1 Intensity
als, inflammatory) Mild, moderate, severe, lancinating, excruciat-
Night pain (ligamentous, muscular insufficiency, ing.

Differentiation of degenerative ("-osis") from inflammatory (".itis") pain:

Type ofjoint pain Degenerative Inflammatory
Cold pain Brief, preexertional Severe morning pain
morning pain
Exertional pain During course of day During any exertion
Rest pain Minimal Usually present
Night pain None (except shoulder) Frequent
Continuous pain In late cases Only with severe
inflammation
64 Previous Course, General State of Health, Other Current Diseases

3.2 Character 5 Associated Phenomena:

The character of the pain depends on the affect- What Accompanies the Pain?
ed receptors and conduction pathways.
5.1 Sensory Disturbances
Epicritical ("sharp"): piercing, stabbing, cutting,
Hypoesthesia, anesthesia
pinching, gnawing, twinging. Most common with
Hyperesthesia } with ~ociceptive
lesions of nerves and skin.
Paresthesia, dysesthesia reactIOn
Protopathic ("dull"): gnawing, tearing, boring,
Thermesthesia
burning, cramplike. Characteristic of deeper
Hypalgesia, analgesia (with nerve compression)
structures: muscles, joints, internal organs.
Vascular pains are described as pulsating,
pounding, throbbing, or hammering. 5.2 Motor Disturbances
Feeling of weakness (nociceptive somatomotor
blocking effect).
3.3 Course
Paresis, paralysis.
Acute, subacute, episodic, rhythmic, chronic,
Limitation of motion.
lightning-like, transient, startling, paroxysmal,
Incoordination.
wavelike, persistent, constant, intractable, fre-
Bladder and bowel difficulties.
quent.
It should again be emphasized that the character
5.3 Circulatory Disturbances
of pain often gives only a vague clue to the af-
Pallor, coldness.
fected tissue structure and the site of the irrita-
Congestion, heat, swelling, livid discoloration.
tion due to subjective processing of the pain by
Migraine, headache, vertigo.
the patient. Usually the irritation site can be de-
Tinnitus, hearing loss.
termined only by reference to the overall pain
Syncopal attacks.
pattern and from the findings of the subsequent
examination.
5.4 Trophic Disturbances
Nails.
Cutaneous changes.
4 What Precipitates or Changes
Dermographism.
the Pain ?
Sweating.
Modalities that precipitate, change, exacerbate,
5.5 Psychological Disturbances
improve, or relieve the pain.
Feeling of inadequacy, depletion.
Anxiety, tension.
4.1 Body Posture
Sleep disturbances.
Lying, sitting, kneeling, standing, working pos-
Aggravation, dissimulation.
tures (stressful positions).
Feelings of "Iessness" (powerlessness, hopeless-
ness, etc.) associated with depression (Der-
4.2 Body Movements
bolovsky).
Walking, bending over, sitting down, sitting up,
standing up, turning (stressful positions), lying
down (stress-relieving position).
Previous Course, General State
4.3 Other Mechanical Influences
of Health, Other Current Diseases
Lifting, carrying, work activities, sports activi-
ties, fatigue.
1 What Treatments Have Been Given
4.4 Miscellaneous Influences
in the Past?
Coughing, sneezing, straining. Heat/cold, mois- Pharmacologic (what medications, dosage, how
ture, climatic changes, excitement, stress. long; diet?).
 The Basic Physical Examination: Preliminary Information 65

Physical (radiation, massages, baths, therapeu- Exceptions

tic exercises, how often ?).
1. Examination of the thoracic region in the sitting
Balneologic (spa treatments: where, how long,
position consists of only four test groups, since
most recent?).
muscle tests are not required. The muscles cov-
Orthopedic, surgical (operative).
ering the chest belong to the shoulder region
Manual therapy (by whom, how often, most re-
and are tested when the shoulder is examined.
cent?).
2. Muscle tests are also omitted during exami-
Acupuncture, neurotherapy; other applications.
nation of the knee joint. These biarticular
muscles are examined together with the mus-
2 What Improved or Changed the Pain?
cles of the hip joint during the pelvic phase of
Associated features, intolerances, self-treat- the examination (LPH region). An addition-
ment. al group of meniscus and ligament tests is
added at the end of the knee examination,
3 How Are the Vital Functions? however.
3. The hip joint is examined together with the
Eating and drinking (appetite, diet, smoking, al-
sacroiliac joints and lumbar spine in the LPH
cohol, drugs?).
region.
Bowel and bladder habits.
4. Examination ofthe shoulder girdle does not in-
Respiration.
clude inspection, as this was already done dur-
Sleep.
ing examination of the shoulder; rather, it
Sexuality.
concludes with examination of the cervical
spine owing to its close functional relationship
4 When Did Previous Pain Occur
with the shoulder and arm.
Involving the Spine and Joints?
5. In the lateral position, only four groups of tests
At what age: childhood, puberty, middle age, cli- are performed on the lumbar spine and tho-
macteric, old age (see item 2.2, p. 63)? racic spine (palpation of lumbar segments,
sacroiliac joint play, hip muscle tests, palpa-
5 What Other Diseases or Disorders tion of thoracic segments).
Does the Patient Have Now?
The description of the individual examinations
Could these diseases be associated with joint covers:
problems (arthritides, arthropathies)? - Starting position
- Procedure
- Anticipated normal findings
- Principal pathologic findings
The Basic Physical Examination:
Preliminary Information In many cases special attention is given to exam-
ination criteria and technical points where this is
considered necessary to help the rea~er under-
After the history is taken according to the
stand the examination procedure.
scheme outlined above, all spinal regions and ex-
For conciseness, procedures are described in an
tremity joints are systematically investigated in
abbreviated "telegram" style using a tabular for-
the basic physical examination by means of:
mat and simple medical language. In decriptions
1. Inspection of muscle tests, the word "muscle" is usually
2. Active and passive movements omitted in references to muscle names, and the
3. Palpation at rest and during movement related segment and peripheral nerve are noted
4. Tests of joint play where appropriate.
5. Muscle tests against a resistance (also short- Special diagnostic procedures, except for X-rays
ening tests if needed). and laboratory tests, are mentioned only briefly
66 The Basic Physical Examination: Preliminary Information

in reference to their diagnostic value, since our CAS region Cervical spine/shoulder/arm
main focus is on the comprehensive basic physi- joints
cal examination. SIJ Sacroiliac joints
Because the examinations proceed by body re-
gions, overlaps and repetitions of methods and
findings were unavoidable. Since the book is Symbols Used in the Figures
also intended as a reference work, some items of on Examination Techniques
information or entire passages are repeated in
• = Point used for immobilization, support, or
different places and in different contexts.
counterpressure in muscle tests
Examination positions are designated by capital
letters, and examination regions by roman nu-
t = Arrows indicate the direction of an active
movement performed by the examiner or
merals (both appear in chapter headings):
patient. A small arrow with a "P" on the
A = Standing
examiner's fingers indicates deep contact
B = Sitting
during palpation (e. g., when palpating for
C = Prone
tenderness) .
D = Lateral
T=Traction decompressing the articular
E = Supine
surfaces.
I Lower extremities
II LPH region (lumbar spine/pelvis/hip)
f Arrows with a cross bar indicate active
movement by the patient against a resis-
III Thorax
tance. For technical reasons these symbols
IV CSA region (cervical spine/shoulder/arms)
were sometimes placed on the hand or arm
V Cervical spine and head
of the examiner applying the resistance,
but they still have the same meaning. They
Abbreviations
were then marked with a "P."
The following abbreviations are used:
LPH region = Lumbar spine/pelvis (sacroiliac
joints )/hip joints
 The Basic Physical Examination: Preliminary Information 67

Checklist for Joint Examinations Checklist for Muscle Examinations

1. Patient Position The synergistic muscle group, and in some

The joints to be examined or treated cases the individual muscle, are tested for:
should be held or placed in a relaxed posi-
tion that is as painless as possible. The ex- - Muscle (fiber) length
amined body part is well supported to en- - Muscle tension
sure muscular relaxation. - Coordination
- Pain
~ExanrinerPosition - Endurance cannot be tested during the
The examiner (therapist) starts in a stable, normal examination of the arthromuscu-
ergonomically favorable position close to lar functional unit.
the patient. For examination of the spine,
the patient should be supported in a way Muscle testing during the basic physical ex-
that permits free body movements by the amination:
examiner.
- Active movements: coordination,
3.lmmDobllUingliand strength.
The joint member that is to be immobi- - Passive mobility: muscle length (end-
lized is graspedf/at-handed, directly adja- feel), pain (in stretched
cent to the joint line, in a way that causes no position).
pain (skin is pushed forward opposite the - Palpation: tension/pain on palpation of
direction of mobilization, delicate soft tis- the muscle (origin, insertion,
sues are pushed aside). In the spinal re- muscle belly; especially in
gion, the vertebral segments adjacent to stretched position).
the segment to be tested are immobilized - Resistance tests: strength (in inter-
by reversing the physiologic joint me- mediate position), pain
chanics (locking). The immobilizing hand (especially in stretched
palpates and controls the locked position position).
in the tested segment.
The clinical examination consists of the basic
4. MobllUing lIand physical examination and any adjunctive
The joint member that is to be moved is procedures that are required, including a
grasped in the same way, and the joint- trial manipulation.
play movement is carried out.
S. Execution
Determine the resting position (virtual
resting position or treatment position),
the gliding plane and the direction of
translational movement (traction, com-
pression, gliding). Determine the force
and duration of the movement, record the
end-feel (soft-, firm-, or hard-elastic).
68 Ten Standard Symbols

er can document 80%-90% of all findings in the

Documentation of Findings Using locomotor apparatus. The symbols are entered
Symbols on a skeletal diagram shown from the posterior
(dorsal) aspect; all anterior (ventral) or volar
The use of symbols for recording diagnostic findings are marked with. a v.
findings not only provides for efficient, repro- Blue symbols are used to record findings in
ducible documentation but also permits a more joints, nerves, and skin, and red symbols are used
rapid review of previous findings. By combining for muscles and tendons. All other findings can
the following ten standard symbols, the examin- be documented in words or with special symbols.

Ten Standard Symbols

Last, first name

Birthdate
Left

~W
o Right

Date of
.~m;",~
General Symbols

1. + Form or function increased

c
c 2. - Form or function decreased

~(rt' 3.
4. 0
Form or function painful
Function abolished

t
CJ
(NP No pathologic findings)

~
~~~
~o~

11 JI
Dorsal aspect Dorsal aspect

Skeletal diagram for the documentation of find-

ings
 Ten Standard Symbols 69

Inspection Palpation
5. () Range of change noted in physiologic pa- 8.. Pressure point; tissue resistance
rameters
Example:. ! = Painful resistance
Example: R = Rubor (redness) (blue) (trigger point)
C = Calor (heat) o = Questionable pressure point,
= Dolor (pain) questionable resistance
+ = Tumor (swelling) • = Muscle ortendon attachments,
- = Atrophy (red) myogelosis(triggerpoint)
D = Deformity (bony de-
formities can also be Blue: Sensory disturbance (indicate seg-
indicated by redraw- ment or nerve )Red: Myalgia
ing contour lines in
the skeletal dia- Example: L5 = Paresthesia (in L5 seg-
gram.) ment)
= Hyperesthesia
6. Injury or inflammatory changes in the
= Hypoesthesia
skin or deeper tissue layers
= Hyperalgesia
= Analgesia
Example: W= Wound
A = Abscess
Ph = Phlegmon (cellulitis)
F = Fistula
S = Scar Motion Testing
10. -? Direction of movement
7. - Discontinuity in tissue

Example: -Fr = Fracture Sagittal plane: i = Flexion (forward

Amp = Amputation (indicate stump bending, anteflexion)
length) (anterior-posterior) J.. = Extension (backward

1 20
R = Rupture or tear in muscle or
tendon (indicate length) Frontal plane: =
bending, dorsiflexion)
Adduction (arrow to-

n
f--
cm
(medial-lateral) ward the body)
= Abduction (arrow
away from the body)
Transverse plane: r \ = Internal rotation,
l ~ pronation (arrow
toward the body)
= External rotation,
supination (arrow
away from the body)
70 Measurements

I Measurements Measurement of Spinal Mobility

The position of the vertebrae is documented
verbally.
Joints i = Anteflexion J, = Dorsiflexion
±+ = Side bent to the left or right
Measurement of Joint Mobility
1. 1-3 - or 1-3+: moderate, severe, or very severe
n= Rotation to the left
limitation or increase of joint movement, re- n=Rotation to the right
spectively.
Grades of mobility: 0 = Total restriction (no
2. State amount of limitation, e. g., - 113.
movement)
3. State angular degrees according to the neu-
1 = Severe restriction
tral-O method.
2 = Mild restriction
The neutral-O method (Cave and Roberts, quot- 3 =Normal
ed in Debrunner) measures the range of joint 4 = Hypermobility
motion from the normal anatomic position: up-
right stance with feet parallel, arms hanging Muscles
loosely, thumbs forward, gaze straight ahead.
Measurements are performed in the: Muscle is designated by its initial letters, for ex-
ample: i Bi= biceps muscle
- Sagittal plane (extension/flexion) J, Ext. dig. = extensor digitorum muscle
- Frontal plane (abduction/adduction) Movement against a resistance = i
- Transverse plane (external/internal rotation)
in the sequence: Symbols for changes in the physiologic state
1. Movements away from the body (extension, A shortened muscle is indicated by a crossed ar-
abduction, external rotation) row, e.g.:
2. Return to the neutral position iPs = Shortened psoas muscle
3. Movement past the neutral position in the op- K = Contracture
posite direction S = Spasticity
Example: Normal ranges of motion in the Measurement of muscle strength (after Krendall
shoulder joint
and Kendall)
Extension/flexion 45°-0°-180°
5 = Normal (moves joint aginst maximal resis-
Abduction/adduction 180°-0°- 45°
tance)
External/internal rotation 60°- 0°- 90° 4 = Good (moves joint against moderate resis-
If the neutral position is shifted due to motion
tance)
restriction, the zero point will be either before
3 = Weak (moves joint against gravity)
or behind the angular measurements. 2 = Very weak (moves joint but not against grav-
Example: Motion restriction in the hip joint
ity)
Extension/flexion 0°-1 0°-1 00°
1 = Trace (palpable contraction only)
Abduction/adduction 20°- 0°_ 20°
0= Zero (no contraction)
External/internal rotation 15°- 0°- 10°
General Inspection
in the Standing Position (A)

1 Ordinary Movements
1.1 Gait
1.2 Other Ordinary Movements

12 Posture

13 Body Contonrs and Proportions

14 Skin

Is Assistive Devi«:es
72 Ordinary Movements

In the general inspection, the examiner evalu- Between these two phases is a double-support
ates the overall static and dynamic situation and phase in which the body weight is borne on both
records congenital and acquired morphologic legs (25% of the total movement of the stance
defects. The inspection begins as the patient en- and swing phases). As the gait quickens, the
ters the consultation room. Initial general im- double-support phase becomes more brief until,
pressions are formed with regard to: with jogging, it disappears altogether.
In gait analysis, attention is given successively to
1. Sex
the symmetry of:
2. Age
3. Constitution 1. Leg loading (step length, step width, pace, co-
4. Physiognomy ordination, and directional stability)
5. Conduct 2. Pelvic position
3. Spinal excursions
This is followed by a systematic inspection of or-
4. Arm movements
dinary movements.
5. Head position

Normal Findings
1 Ordinary Movements 1. Leg loading: Equal step lengths, step width
no more than about a 10-cm intermalle-
1.1 Gait olar distance. Rhythmic, symmetrical load-
1.2 Other Ordinary Movements ing of both leg with equal heel-to-toe
rolling on both ides. The patient should
be able to walk a straight line with eyes
1.1 Gait closed.
2. Pelvic position: In stance, the pelvis hould
Owing to its importance, gait is inspected at the
be horizontal on the frontal plane. When
start of the examination to provide the first gen-
the leg is lifted for the wing pha e, the ipsi-
eral dynamic impression of the inspection, which
lateral half of the pelvis should rise (Tren-
otherwise is performed at rest. Gait consists of
delenburg's phenomenon) and there
two phases, the stance phase and the swing phase.
should be a full. rhythmic anterior leg swing
The stance phase (60% of the total cycle) con-
if the mechanics of the pelvic joints, espe-
sists of five events that describe the evolution of
cially the SIJ (nutation), are intact.
the step from heel strike to loading of the trans-
3. Movement of spine: Slight convex bend to-
verse arch and big toe:
ward the supporting leg. Maximum mobili-
1. Heel strike ty in the mid-lumbar region. Slight recipro-
2. Forefoot strike cal curve in the thoracic spine. Right-left
3. Midstance (approximate neutral position of alternation of curvatures synchronous with
all lower extremity joints) gait.
4. Heel takeoff 4. Ann movements: Each arm swings forward
5. Toe takeoff from the shoulder joint opposite the swing-
ing leg (associated movements). Scapulae
During the stance phase of gait, the pelvis un-
fixed. No significant shift in center of body
dergoes a slight abduction and internal rotation
gravity.
relative to the thigh of the supporting leg.
5. Head position: upright, no significant asso-
The swing phase (40% of the total cycle) consists
ciated movement.
of three parts:
1. Acceleration (after takeoff)
2. Midswing
3. Deceleration (until heel strike)
 Ordinary Movements 73

Pathologic Findings - With cerebellar ataxia, the gait abnormality is

not exacerbated by closing the eyes.
Asymmetric Gait (mildest abnormality of gait)
Trailing of one leg due to greater fatigability. Decreased step width: narrow gait (adductor
Occurrence: spasm)
- Incipient diseases of hip joint Occurrence:
- Functional disturbances involving the SIJ or - In patients with spastic limb stiffness (Little's
symphysis disease).

Careful, shuffling gait

Unequal Step Lengths
Occurrence:
Increasedstep length of the affected leg, no ataxia.
- Inflammatory disorders of the lower extremi-
Occurrence:
ties (arthritis, osteomyelitis, inflammatory
- Disturbances involving the toe joints, foot
vertebral diseases)
joints, or knee
- Peroneal paresis: steppage gait (plantar-
Slow, Laborious Gait caused by rapid fatigue
flexed foot is lifted higher than normal)
and general weakness.
- Hamstring paresis: genu recurvatum
Occurrence:
- Quadriceps paresis: anterior swing of lower
- In consumptive diseases, Addison's disease,
leg, genu recurvatum
myasthenia.
Decreased step length of the affected leg.
Biza"e Gait Patterns
Occurrence:
They are usually psychogenic. Often associated
- Contracture or ankylosis of the hip joint in
with trembling, sweating, anxious behavior.
flexion (pendulum limp)
- Psoas contracture, paralysis of trunk or hip
Change in Pelvic Positon (Equilibrating Limp,
muscles
Waddling Gait)
- "Cowtow" limp due to severe hip contracture
Dropping of the pelvis (with equal step lengths)
with trunk bent forward
toward the nonsupporting swing leg side (equili-
brating limp), positive Trendelenburg sign (in
Decreased step length and brief "touch-down "on
milder cases, only truncal deviation toward the
the affected leg to relieve pain.
supporting leg side; see also Duchenne's sign).
Occurrence:
Cause: Insufficiency of the hip abductors of the
- Painful leg disorders, especially involving the
supporting leg due to approximation of the ori-
hip joint and SIJ, such as coxitis, Perthes' dis-
gin and insertion of gluteus medius and minimus.
ease, epiphyseal plate separation, sciatica, in-
Occurrence:
termittent claudication (history)
- Congenital dislocation of the hip (if bilateral:
Ligamentous pain is improved by ambulation. waddling gait), coxa vara
- Osteoarthritis of the hip
- Diseases that flatten the femoral head (e. g.,
Unequal Step Widths
Perthes' disease, avascular necrosis, slipped
Increased step width with a slow, lurching, wide-
capital epiphysis)
based gait.
- Early stages of progressive muscular dystro-
phy (together with lordotic pelvic tilt and ex-
Occurrence:
cessive lumbar lordosis), polyneuritis, po-
- With disturbance of deep position sense and
liomyelitis
cerebellar function (ataxic gait; reeling, stag-
gering; high step, slapping of the forefoot). Gait Elevation of the pelvis due to deficient joint flex-
abnormality is accentuated by closing the eyes. ion, dragging the sole of the foot (scraping
- Proprioceptive ataxia (polyneuropathy) sounds); slow, springy gait (spastic gait).
74 Body Contours and Proportions

Occurrence: 2 Posture (Fig.14a,b)

- Spastic diplegia (tendency of legs to cross in
front of each other)
- Amyotrophic lateral sclerosis In a physical sense, posture involves the dynam-
- Spastic spinal paralysis ic maintenance of an upright body position with
- Multiple sclerosis (with intention tremor of a normally shaped trunk and extremities and un-
legs) restricted joint mobility in the spine and extrem-
- Hemiplegia (circumduction of the extended ities. Little muscular effort is expended in postu-
leg) ral maintenance. Muscular activity is greatest in
the nuchal region and calf, occurring as a tonic
Leading pelvic rotation and forward leg swing
contraction of the triceps surae and phasic con-
with marked elevation of the hemipelvis and an
tractions of the anterolateral leg muscles, mani-
increased step width (stiff-legged limp).
fested by visible tendon movements on the dor-
Occurrence:
sum of the foot.
- Fusion or ankylosis of the hip or knee joint
In a psychosomatic sense, posture is the mental
- Hemiplegia
and physical assertion of the human body in re-
- Prosthesis wearers
sponse to gravitational forces.
Posture is evaluated in the sitting and standing
1.2 Other Ordinary Movements
positions (see alsoBILPH Region/Sect.1,p.104).
Properly coordinated movements permit ac- Criteria for body posture
tions to be executed harmoniously at the lowest
1. Static axes of the spine and extremities
energy cost. The movement is lithe, i. e., esthetic
2. Pelvic position
and coordinated.
3. Spinal curvature in the frontal and sagittal
The following tests have been proposed for the
planes
analysis of faulty movement patterns (after Le-
4. Shape of thorax (see BlThoracic Regionl1.1)
wit and Janda):
5. Position of shoulder girdle and arms
1. For the lumbar spine: Have the standing pa- 6. Shape and position of head and neck
tient pick up an object and place it on a high
shelf. (Bending and straightening the trunk to
full extension)
2. For the thoracic spine: Have the seated pa-
tient shelve an object behind and level with 3 Body Contours and Proportions
the head. (Fig. 14)
3. For the cervical spine: Have the patient turn
the head side to side and move it in circles.
Posture can be examined concurrently with
Also: body contours and proportions owing to the ef-
4. Have the patient dress, undress, sit down, fect of postural deviations on body contours.
stand up, lie down, sit up.
5. Have the patient assume typical working posi- Conduct of the Examination
tions and perform typical working move- The patient wears only a slip or undershorts dur-
ments. ing the examination. Side illumination helps to
disclose asymmetries and changes in muscular
relief. The examiner should stand 2-3 m from
the patient (distant inspection).
The examination proceeds from below upwards.
Based on the postural criteria listed above, the
distant inspection of posture, contours, and pro-
portions should address the following questions:
 Body Contours and Proportions 75

1. Are there any deviations from normal body Normal Findings (Fig. 14)
proportions? I Body Proportio/lS (After Klein- Vogel-
2. Are there asymmetries with respect to the me-
bach)
dian plane caused by The line dividing the body into upper and
- Leg length discrepancy or pelvic obliquity? lower halves is approximately at the level of
- Deviations from the static axes (spinal axes, the pubic symphysis and the tip of the greater
leg axes)? trochanters. The upper body length is mea-
- The rotational position of the legs? sured from the vertex of the skuU to the cau-
- Alterations in the shape of the legs or arms? dal pole of the symphysis, and the lower body
length from that point to the sole of the foot
3. Shape and position of the trunk?
(see Fig. 14b).
4. Shape and position of the shoulder girdle and The upper body length can be ubdivided
arms?
into:
S. Shape and position of the neck and head?

Head:
·t - - - - sy mmetr ical
skull shape

f - - - - - Neck:
length, muscularity
Top of shou lder -----~o--~ ~=:;;;~~-- Shoulders at same level,
Interscapular distance ---j~~=L\--­ equal roundness
Position of scapulae - -+--t:>_
Axillary fold ------1---1 Axillary folds
at same level

Arms:
equal shape
and length --\-_+- Waist triangles
symmet rical
Iliac crests
at same level
Ana l
cleft vertica l -------.:Ir---+l'-:.,I~~ Anterior superior
iliac spines at same level
Tip of coccyx on the midlin,e--+--l--./ Posterior superior
iliac spines at same level
Gluteal folds
Muscularity symmetrica l at same level

Lower limb axes symmetr ica l

Popliteal fol ds
Muscularity symmetrical - - --I- at same level

Malleoli of both legs

1+-- -- symmetrical,
at equal levels
Perpendiculars from head
and base coincide

Fig. 14. a General inspection from behind

76 Body Contours and Proportions

Distance from symphysis to umbilicus = 115 2 Asymmetries with Respect to the Median
Distance from umbilicus to jugular notch = 2/5 Plane
Distance from jugular notch to cranial ver- Position of examination: comfortable stance
tex = 2/5 with the feet parallel and about 20 cm apart
In stance, then. the center of the body is ap- and the weight distributed evenly on both
proximately at the level of the symphysis. The legs.
sit/ing height is approximately half the total
- Equal leg length. Malleoli, knees, and
height (52:48).
gluteal folds at equal levels on both sides.
The greatest frontal chest diameter is roughly
- Static axes
equal to the intertrochanteric distance. The
distance between the right and left hip joints Lower limb axis on the frontal plane: through
is approximately half the distance between the center of the inguinal fold, patella, ankle
the right and left shoulder joints. The length mortise, second toe.
of the foot approximately equals the greatest Lower Limb axis on the sagittal plane: greater
anteroposterior diameter of the chest. trochanter, center of knee joint, navicular
bone.

Harmonious
--------1
-:; No gross
facia l
Proportions

Vertex

215
spinal curvatu res asymmetries

Cervical lordosis - - - - - - - - - Jugular notch

Sternum

ThOracic kyphosis
215

Lumbar lordosis Umbilicus

Pelvic pOSi tion - - ---jfi'- 1/5 Upper body length

Symphisis

Lower body length

Fig. 14. b General inspection

from the side
 Body Contours and Proportions 77

The femora l shaft should form about a 10° an- Sagittal plane: Harmonious pinal curva-
gIe to the frontal leg axis (physiologic genu tures, firm abdominal wall.
valgum, intermalleolar di tance up to 4 cm).
Transverse plane: 0 torsion of trunk or
The angle is larger in women due to their
pelvis, no scoliosis.
greater pelvic width.
Even if the spinous processes align, scoliosis
Phy~iologic genu varum in newborns (often
can still be present. This is recognized by
simulated by flexion of the knee and external
asymmetrical protrusions of the trunk
rotation at the hip).
(bulging of the ribs, lumbar bulge). Forward
Physiologic bilateral genu valgum from 2 to 6
bending of the trunk may be nece sary to dis-
years of age.
close milder curvatures.
Spinal axis on the frontal plane: perpendicu-
lar line through the external occipital protu-
4 Shoulder Girdle and Arms
berance and spinous process of Sl.
Arm are of equal shape and length, hang par-
Spinal axis on the agittal plane: perpendicu-
allel to the trunk.
lar line through the auditory meatu , C7 and
Shoulders and axillary folds are at the same
L5 spinous processes, behind the (ran verse
level , show symmetrical roundness.
hip axis, to the navicular bone.
Clavicles are horizontal, form a 60° angle to
- Legs are rotated 12° relative to the frontal the midsagittal plane.
plane due to physiologic antetorsion of the Scapulae are at the same level, superior bor-
femoral neck. The antetorsion is nullified der level with TI. Medial border and inferior
by maximum internaL rotation oCthe femur. angle are slightly rai ed from the chest wall.
- Joint and muscle contour are equal on Medial borders are equidi tant from the
both ides. spinous processes (about 5 COl) , inferior angle
- Horizontal pelvic position, i.e.: is approximately at T7 level.
Frontal plane: Anterior and posterior superi-
5 Neck and Head
or iliac spines and iliac crests are at equal lev-
Shape of the neck. eck is straight, shows
els on both side .
symmetrical muscularity.
Sagittal plane: Pubic ymphysis is lightly be-
Head position: Head is upright. Perpendicular
low the tip of the coccyx (sacral promontory
lines from the head (external occipital protu-
and symphysis form about a 60° angle to the
berance/S 1spinous process) and from the ba e
horizontal) .
(midline between medial malleoli) coincide.
Tran verse plane: No pelvic rotation. Iliac
Cranial shape is symmetrical, shows no devia-
crests, anterior and posterior iliac spine ,and
tion of size.
sacrum are each in the corresponding frontal
Face. 0 gros facial asymmetries or distur-
plan . Contours (soft-tissue signs): symmetri-
bances of mimic muscles.
cal gluteal prom inence, anal cleft on the mid-
line, gluteal folds at same level. Compare
finding in (he sitting and prone position .
Pathologic Findings
3 Trunk Contours
The trunk contours depend chiefly on pelvic 1 Body Proportions
position and the alignment of the spinal col- Increased trunk growth : pituitary gigantism.
umn in the frontal and sagittal planes. Increased leg growth: eunuchoid gigantism with
genital hypoplasia and atrophy of subcutaneous
Frontal plane: Spine i straight with no colio- fat: Marfan's syndrome (spider fingers).
sis. Symmetrical muscular prominence and Lengthened trunk, shortened extremities, short
waist triangles, symmetrical chest (see Tho- neck, pawlike hands, scaly skin, bristly hair : hy-
rax, B/III, Sect. 1.1, p.lS1). pothyroid dwarfism.
78 Body Contours and Proportions

Lengthened trunk, lordotic pelvis, crura vara, Talipes equinus with functional leg lengthening
short legs: chondrodystrophy (congenital sys- and elevation on the contracted side.
temic disease, e. g., Lilliputians).
Deficient longitudinal growth with normal body Deviations from the Static Axes
proportions: primordial dwarfism. Deviations from the static axes place increased
Deficient longitudinal growth with hypogenital- stresses on the postural muscles and lead to un-
ism. physiologic joint loads.
Enchondral dystoses (genetic damage). Deviations from the static leg axes are present
Dysproportionate form: dorsolumbar kyphosis, with genu varum and valgum, causing static mus-
often with scoliosis and platyspondylisis (Brails- cular pain (standing occupations) and foot de-
ford-Pfaundler-Hurler type). formities
Proportionate form: multiple symmetrical ver- Measurement: Position the feet parallel.
tebral growth disturbances, kyphosis (Rib- Genu valgum: Measure the intermalleolar dis-
bing-Millier type). tance with the knees touching.
Acquired dwarfism due to rickets, osteomalacia, Genu varum: Measure the distance between the
osteoporosis, spondylitis, scoliosis, kyphoscoliosis. femoral condyles with the malleoli touching.
In small children, make an outline drawing (child
2 Asymmetries With Respect to the Median sitting with legs extended and in neutral rota-
Plane tion) and take measurements from the drawing.
Unilateral genu valgum: congenital, epiphyseal
Leg Length Discrepancy plate disturbance, traumatic, to compensate for
a) Leg shortening hip adduction contracture.
Anatomically shotter leg: Unilateral genu varum: epiphyseal plate distur-
bance, rickets, hormonal during menopause.
- Growth disparity
Genu recurvatum: ligamentous laxity, epiphy-
- Unilateral flatfoot or planovalgus (supporting
seal plate injury, compensation for equinus.
leg in standing occupations)
- Trauma (femoral neck fractures, femoral and
Rotational Position of the Legs
tibial fractures)
Increased external rotation of one or both legs:
- Diseases that cause flattening of the femoral
head (Perthes' disease, coxitis, avascular - Posterior rotation of the ilium at the SIJ
necrosis, slipped capital epiphysis) - Psoas muscle shortening and states of psoas ir-
- Pareses (e. g., poliomyelitis) ritation (Moser's sign)
- Flexion contracture of the hip (osteoarthritis)
Functionally shorter leg: with flexion and adduction
- Faulty position of SIJ due to backward rota- - Congenital dislocation of the hip (compare
tion of the ipsilateral ilium or anteroinferior levels of greater trochanters on both sides)
rotation of the sacrum about the "oblique - Retrotorsion of the femoral head
sacral axis"
Increased internal rotation (usually bilateral)
- Muscle shortening (shortening of the ipsilat-
with increased ante torsion angle, accompanied
eral psoas or quadratus lumborum)
by hyperlordosis.
- Joint contractures: flexion contracture of the
Contour changes in lower extremity joints may
knee or hip joint with dropping of the pelvis
signify joint swelling, effusion, or ankle edema.
on the contracted side; abduction contracture
"Thick legs" represent a distal thickening of un-
of the hip joint with ipsilateral pelvic descent
known etiology.
and contralateral pelvic elevation
Changes in muscle contours may signify
b) Leg lengthening (functionally longer leg) Muscular hypertrophy: Congenital muscular hy-
Adduction contracture of the hip with elevation pertrophy or unilateral hypertrophy due to func-
on the contracted side. tion or neoplasia. "Gnome calves."
 Body Contours and Proportions 79

Muscular atrophy: Disuse atrophy following im- Frontal plane:

mobilization for trauma or muscle disease; thigh - Posterior and anterior iliac spines are higher
atrophy secondary to knee disorders, such as on one side with an anatomically short leg.
atrophy of the vastus medialis in meniscopathy. - With a functionally short leg, the anterior and
Can also result from peripheral nerve palsies, posterior iliac spines are at different levels,
e.g., and the iliac crest is low on the displaced side.
- Femoral nerve on the front of the thigh, (See A/LPH Region/Sect. 3.1 (p.88).
L2-L4 (quadriceps femoris, sartorius) - Lateral displacement of the pelvis in congeni-
- Obturator nerve on the medial side of the tal or acquired lumbar scoliosis or due to SIJ
thigh, L2-L4 (adductors) displacement (countemutation) toward the
- Sciatic nerve on the back of the thigh, L4---S3 side of the longer leg when leg length discrep-
(knee flexors) ancy is present.
- In the lower legs and feet (foot flexors and ex-
tensors) Sagittal plane:
- With a "lordotic" pelvis, the sacrum is more
Indentations: horizontal (sacrum acutum), lumbar lordosis
With extensive ruptures of muscles or tendons, is accentuated, and the symphysis is low.
e.g., Greater strain is placed on the trunk exten-
- Rupture ofthe rectus femoris above the patella sors, and the increased hip load predisposes to
- Rupture of the triceps surae above the heel coxalgia and osteoarthritis ("coxarthrosis
pelvis" of Gutmann).
• Note - With a "kyphotic" pelvis, lumbar lordosis is
Increased tendon play with the feet close togeth- decreased or absent, and the sacrum is more
er that increases further with the eyes closed sig- vertical (see also Sect. 3, Trunk Contours).
nifies a coordination disturbance that may range The spine is less springy than normal, result-
to ataxia. Tendon play in a wide-based stance is ing in greater loading of the intervertebral
always indicative of ataxia. disks ("osteochondrosis pelvis" of Gutmann).

Transverse plane:
Pelvic Position - Asymmetry of the inferior lateral angles of
The position of the pelvis in the frontal plane the sacrum in the transverse and frontal
is determined by the length of the legs. A planes due to flexion or rotation of the sacrum
leg length discrepancy (anatomic or functio- about the oblique (diagonal) sacral axis (see
nal) causes pelvic obliquity with associated Fig. 40, p.130).
scoliotic deviation of the spine in the frontal
plane. Usually this assymetry can be detected only by
Pelvic position in the sagittal plane is determined palpation, and its significance is unclear due to
by morphologic changes in the hip joint and by the numerous congenital morphologic varia-
imbalances of the shortening-prone postural tions of the sacrum.
muscles (psoas and erector spinae) and of sec- Contour changes in the glutei (soft-tissue signs):
ondarily weakened phasic muscles (glutei and - Unilateral flattening with an SIJ restriction on
abdominal muscles). Pelvic position is further the same side
influenced by morphologic defects at the - Oblique anal cleft (may indicate faulty sacral
lumbosacral junction (high-assimilation pelvis, position)
sacrum acutum). This in tum affects trunk con- - Lower gluteal folds at different levels with
tours and spinal morphology. faulty hip position (e. g., congenital disloca-
The changes described above often have effects tion) or weakened gluteal muscles
in the transverse plane as well.
Findings associated with pelvic deformity in the: Soft-tissue signs are not reliable.
80 Body Contours and Proportions

3 Trunk Contours a) Muscle shortening (psoas/erector spi-

nae)
Spinal Changes
b) Muscle weakening (glutei/abdominal mus-
Frontal Plane. Scoliosis, i. e., asymmetric waist
cles) associated with general connective tissue
triangles, deepened on the concave side and flat-
weakness
tened on the convex side; bulging of ribs and
In most cases a) and b) coexist.
lumbar spine. Several types of scoliosis can oc-
cur: - Hip contracture secondary to inflammatory
or degenerative disease
- Static scoliosis caused by pelvic obliquity with
an anatomically or functionally short leg A flat back (flattening of all spinal curvatures)
- Antalgic scoliosis secondary to vertebral re- occurs in:
striction, disk protrusion or prolapse
- Vertebral restrictions (prolapses)
- Congenital scoliosis (often associated with
- Constitutional states (often combined with
bulging ribs in the thoracic region), idiopathic
impaired lumbosacral assimilation)
scoliosis
- Scoliosis secondary to pareses or muscular de- Increased thoracic kyphosis is seen with fixed
fects
- hump back, Scheuermann's disease
- Posttraumatic scoliosis following vertebral in-
- Bekhterev's disease, spondylitis, osteoporosis
jury
Transverse Plane. Torsion of the trunk or pelvis
Sagittal Plane. The physiologic curvatures of the (viewed from above) with vertebral or SIJ re-
spine may be accentuated (hollow back, hump striction or with hip contractures caused by in-
back) or decreased (flat back). flammatory or degenerative diseases of the hip
A major postural determinant is the apex of the joint or by paresis. Scoliosis.
spinal curvature. With a normally curved spine,
the apex is at C3/C4 in the cervical spine, TS/T6 Abdominal Wall Changes
in the thoracic spine, and L31L4 in the lumbar General protrusions:
spine. Fat roll overhanging the symphysis like an
Postural changes result from the cranial or cau- apron, often combined with a muscle roll. The
dal shift of these apices, and function testing is protrusion is most prominent about the umbili-
needed to determine whether the shift has a cus. Cannot be corrected by contraction of the
morphologic or functional cause. abdominal muscles. Leads to "lordotic pelvis"
The following apical deviations can occur: with excessive lumbar lordosis.
- Caudal deviation of the cervical apex in hy- Unilateral flank protrusions due to paralysis and
permobility scoliosis, frog belly, ascites.
- Cranial deviation of the thoracic apex in Bekh- Local protrusions:
terev's disease, osteoporosis, osteomalacia - Femoral hernia (DD: lymph nodes, gravita-
- Cranial deviation of the lumbar apex tion abscess)
secondary to restriction at the lumbosacral - Inguinal hernia ("soft groin," palpable only)
junction, lumbar Scheuermann's disease; - Scrotal hernia (DD: hydrocele)
caudal deviation occurs with spondylolisthe- - Umbilical hernia
sis. - Rectus hernia (gastric hernia), rectus diastasis
- Scar hernia
A hollow back with a low symphysis occurs in:
- Spondylolisthesis (with a cross-groove and Test for Postural Weakness
step above the sacrum in pronounced forms) With evidence of postural weakness in children,
- Muscular imbalances in the pelvis region inspection can be immediately followed by a
caused by: function test of the back extensors.
 Body Contours and Proportions 81

In Matthias' arm holding test for postural weak- Changes in Scapular Position and Contours
ness, the patient stands erect and extends the arms Winged scapula (prominent medial border and
straight forward. The examiner measures the inferior angle) due to
length of time the patient can hold the arms in
- Serratus paresis
that position with no change in spinal curvatures.
- Weak scapular fixators (transverse part of
trapezius and rhomboids)
Normal Findings - Contracture of the pectoralis major ("poor
The posture can be maintained for at least posture")
30s.
Increased external rotation (inferior angle shift-
ed laterally) due to paresis of the rhomboids
Pathologic Findings and/or levator scapulae.
A premature change of posture by backward Increased internal rotation (inferior angle
displacement of the thorax, decreased lumbar shifted medially) due to paresis of the trapezius
lordosis, and dropping of the arms signifies pos- (ascending part) and/or serratus anterior.
tural weakness. Prominence of the scapular spine due to paresis
of supra- and/or infraspinatus with muscular at-
4 Shoulder Girdle and Arms rophy.
Arms
Dysmelia, paralysis. 5 Head and Neck
Shape of Neck
Shoulders
A short neck with raised shoulders occurs con-
- Raised position: stitutionally in Klippel-Feil syndrome (multiple
Hypertonicity of levator muscles of scapula, spinal anomalies with block and wedge verte-
trapezius (descending part or levator scapu- brae).
lae). Asymmetries may be caused by "swollen
Paresis of depressor muscles of scapula, trapez- glands," as in goiter (thyroid) or Hodgkin's-re-
ius (ascending part), or serratus anterior. lated lymphadenopathy.
Thoracic scoliosis on the convex side.
Sprengel's deformity (unilateral). Head Position
Torticollis (wryneck) = tilting and rotation of
- Contour changes:
the head toward the same side:
Thickening due to effusion (traumatic, inflam-
matory) or neoplasia. - Vertebral restriction in a divergent position
Flattening due to paresis of the deltoid muscle can cause head twist and rotation toward the
(axillary nerve), disuse atrophy. opposite side
Deformity due to dislocation. - Congenital torticollis, usually with facial
Anterior displacement due to labile posture, asymmetry
Scheuermann's disease, senile kyphosis. - Ocular torticollis due to ocular muscle palsy
- Due to cervical inflammation
Changes in Clavicular Position and Contours - Due to paralysis of the neck muscles
(shoulders forward) due to clavicular fractures - Due to meningeal irritation
and dislocations - In early Parkinson's disease
Deepening of supra- and infraclavicular fossae - Due to muscular dystrophy in children
due to labile posture (displacement of clavicle in
the transverse plane). Head Shape
Effacement of the fossae due to inflammatory or Congenital asymmetries: usually in patients
neoplastic processes. with spinal asymmetries, especially involving
82 Assistive Devices

the skull base and craniovertebral joints; Bluish, smooth, tense, glossy skin is characteris-
aplasias and dysplasias of the craniovertebral tic of remission periods in rheumatoid arthritis
joints; basilar impression, etc. and of reflex sympathetic dystrophy.
Traumatic defects: scars, bony defects. Redness and swelling of the skin is characteristic
Abnormalities of size: microcephalus, macro- of inflammations.
cephalus, external hydrocephalus, oxycephaly, 2. Skin changes that may be associated with joint
square skull (rickets). changes:
Erythema nodosum: painful nodules with color
Facial Asymmetries or Disturbances of the changes like those seen with hematoma. Hyper-
Mimic Muscles sensitivity reaction (streptococci, Tb, drug aller-
Facial palsy: ptosis, corner of mouth sags and is gy) predominantly affecting women and usually
drawn toward affected side, unilateral facial showing symmetrical involvement of the lower
rigidity. legs.
Oculomotor palsy: ptosis, strabismus, unequal Psoriasis: sharply circumscribed hyperemic
pupils. patches with a variable, silvery-white scale,
Parkinsonism: mimic rigidity, infrequent blink- chiefly affecting the extensor surfaces of the ex-
ing, salivation, seborrhea. tremities (knee, elbow), the sacral region, scalp,
Chorea: irregular grimacing. and nails. Psoriatic arthropathy tends to involve
Myasthenia: weak facial expressions due to at- the joints of the fingers and toes and the knee
rophy of facial muscles. joints.
Angioneurotic edema (Quincke's edema): uni- 3. Traumatic changes. Scars (injuries, opera-
lateral swelling of the eye or lip. tions) or healed inflammatory processes, fis-
tulae.
4. Inflammatory changes. Pustules, pimples,
vesicles may signify an irritation of the der-
4 Skin matome, e. g., in herpes zoster.

Pathologic Findings 5 Assistive Devices

Foremost are cutaneous changes that may be as-
sociated with diseases of the locomotor appara-
tus or musculoskeletal pain. Prostheses are used for limb replacement.
Splints and splint apparatus are used to support
1. Circulatory changes or partially immobilize and rest the vertebral
Pale, yellowish, waxy skin (on one side of the ex- column or joints.
tremities) is seen with arterial occlusions. Pale, Bandages and corsets are used to support or to
slightly cyanotic or marbled skin (hands and feet of- partially immobilize and take the strain off the
ten cold and moist) in autonomically labile patients. spine or joints.
Pallor due to local circulatory disturbances, Orthopedic shoes or footwear modifications are
blood deficiency (anemia), shock (vasoconstric- worn to correct for foot deformities or leg length
tion), or chronic inflammatory diseases (nephri- discrepancies.
tis, endocarditis).
Bluish skin (cyanosis) due to circulatory and
respiratory insufficiency.
Examination of the LPH Region
in the Standing Position (AlII)

1 Inspection
(see General Inspection)

2 Active and Passive Trnnk

Movements in Three Planes
(Regional Diagnosis)
2.1 Sagittal Plane: Forward and Backward
Bending
2.2 Frontal Plane: Sidebending
2.3 Transverse Plane: Rotation

3 Palpation of the Pelvic Joints

Palpation at Rest
3.1 Pelvic Position
Palpation During Movement-
Testing Joint Play in Both SIJs
3.2 Standing Flexion Test (SU)
Unilateral Joint Play Testing
3.3 Recoil Phenomenon (SU), "Spine Test"
3.4 Hip Drop Test (Lumbar Spine)
3.5 Lateral Shift Test (SU)

4 Tests of Joint Translation

4.1 Traction on the Lumbar Spine
4.2 Compression of the Lumbar Spine

5 Muscle Test
First Phase: Trendelenburg
Phenomenon (Hip Abductors)
84 Active and Passive Trunk

1 Inspection (see General Inspection) causes an early, increased convergence in the

facet joints of the lumbar spine due to fixation of
the pelvis in anteflexion.
Inspection ofthe overall static and dynamic situ- Sidebending with the legs spread apart tests the
ation was described in the section on General In- range of lateral flexion in the mid- and upper
spection. lumbar spine. To stabilize the pelvis, the body
weight is shifted toward the concave side. As the
stance widens, the axis for the side bending
movement is increasingly shifted to a higher lev-
2 Active and Passive Trunk el. Segment L5/S1 is therefore tested with the
stance closed.
Movements in Three Planes
(Regional Diagnosis) 2.1 Sagittal Plane: Forward
and Backward Bending (Figs. 15, 16)
2.1 Sagittal Plane: Forward and Backward
Bending Normal Findings
2.2 Frontal Plane: Sidebending The spine forms a smooth arc with slight
2.3 Transverse Plane: Rotation residual lordosis over the sacrum during for-
ward bending.
Symmetrical paravertebral muscular con-
Active and passive trunk movements give an im-
tours.
pression of the mobility of the spinal column as a
Apex of the movement should be at L3/L4
whole. They are performed in all three planes of
during forward and backward bending. Maxi-
motion.
mum kyphosis at T2- T6 during forward bend-
ing.
Starting Position. Upright stance, feet parallel
The total range of motion is approximately
and 2 footwidths apart, knees extended.
70°. This can be estimated by measuring the
finger-to-floor distance (FFD) . The greatest
Procedure. The patient's arms hang loosely so
flexion should occur at the hip joints. The po-
that, on forward bending (anteflexion), the dis-
sition of the sacrum should also be noted.
tance from fingertips to floor can be measured.
At the end ofthe active range of motion (relative
limit, see Figs. 15a, 16a), the examiner holds and Schober's Sign. With the patient standing, a tape
steadies the pelvis with one hand, especially if measure is used to measure 10 cm upward from
there is painful motion restriction, and with the the SI spinous process. Then the patient bends
other gently pushes the trunk on to the limit of the trunk forward, and the increase in the dis-
passive flexion (absolute limit, see Figs. 15b, tance between the two reference points is mea-
16b), meanwhile testing the end-feel and record- sured. The normal increase is 4-6 cm. Smaller
ing the type and radiation of any associated pain. increases indicate hypomobility, greater increas-
Duringforward bending with the knees and hips es hypermobility.
flexed (Fig. 15c), a (painful) disability caused by A similar test is used in the thoracic spine. Ott's
shortening of the hamstrings and triceps surae sign is tested by measuring 30 cm down from the
can be largely eliminated. Flexion of the trunk is C7 spinous process. The normal increase on for-
increasingly performed by divergence of the ward bending is 8 cm.
facet joints in the lumbar spine, since the pelvis is Even with a vertebral restriction, the patient
largely fixed by co-contraction of the attached may still be able to touch the floor by flexion of
muscles. the hip joints, so the FFD is not a very reliable in-
During backward bending (dorsiflexion) with dex of spinal mobility.
the knees flexed (Fig. 16c), the rectus femoris End-feel: soft-elastic (muscular).
 Active and Passive Trunk 85

a b

• Note
In a modification of Schober's sign, Erdmann
recommends measuring the distance from S5 to
Tl2, noting that the greater distance reduces
the range of error and that the spinous proces-
ses at L5 and Sl are sometimes difficult to pal-
pate.

Pathologic Findings
Asymmetric paravertebral muscle contours dur-
ing forward bending due to vertebral rotation in
scoliosis.

Decreased Range of Forward Bending

The sacrum remains more or less upright, and an
excessive amount of lumbar lordosis remains.
Causes:
c
- Restriction of divergence in the facet joints or Fig. 15a-c. Forward bending. a Active,
disk prolapse. (With radiating neuralgic pain: b passive, c increased lumbar motion due
test dermatomes and reflexes.) to increased pelvic fixation by co-contrac-
- Shortening of the hamstrings (myalgic pain): tion of the pelvic muscles
posterior thigh pain
- Shortening of the erector spinae: severe para-
vertebral back pain
- Decreased motion in the hip joint: diffuse
pain radiating to the thigh
86 Active and Passive 1hmk

a b c

d e

Fig.16a--c. Backward bending: a active, b passive, c increased lumbar motion due to increased pelvic fixation
by co-contraction of the pelvic muscles. d-fSidebending (d upper lumbar spine, e lower lumbar spine, fpassive)
 Active and Passive Trunk 87

Increased Range of Forward Bending

toward the opposite side (e.g., rotation to the
The entire hand can be placed flat on the floor.
left during sidebending to the right). The spi-
The cause is general hypermobility.
nous processes move toward the concave ide.
The total range of sidebending of the lumbar
Decreased Range of Backward Bending
and tboracic pine is approximately 80°
Cause:
(about 40° to each side).
- Restriction of convergence in the facet joints Mobility can be estimated by recording the
andlor disk protrusions lowest point tbat each middle finger can reach
- Sacrum acutum on the lateral aspect of the leg (compare both
- Baastrup's disease (kissing spines) sides!).
- Restriction of counternutation (posterior nu- End-feel: firm-elastic.
tation) in the SIJ
- Limitation of hip motion (hyperextension,
capsule pattern)
Pathologic Findings
Distorted Movement
Twisting ("painful arc") andlor lateral deviation Decreased Range of Sidebending (Uni- or
of the trunk during forward and backward bend- Bilateral)
ing. May be accompanied by pelvic rotation to-
- On the convex side of scoliosis
ward the same side and flexion of the knee on
- Muscle contractures (erector spinae, quadra-
the side of sciatic stretch pain.
tus lumborum)
Causes:
- Vertebral restrictions or disk protrusions
- Vertebral restrictions - Spondylolisthesis, Bekhterev's disease
- Disk protrusions - SIJ lesions
- Painful arc - Painfullirnitation of ipsilateral side bendingis
also common in patients with hip joint disease.
• Note
In "painful arc" the restricted intervertebral Increased Range of Sidebending
joint or disk protrusion temporarily becomes The perpendicular line from the axillary fold
the center of rotation for the movement due to may move past the anal fissure, often to the lat-
protective fixation . This lateral deviation dur- eral pelvic margin on the opposite side. The
ing forward bending results from either an im- cause is general hypermobility.
pairment of divergence on the side of the de- Sachse notes that during sidebending of the
viation or an impairment of convergence on the trunk, the pelvis not only moves toward the op-
opposite side during backward bending. posite side but also makes a small forward rota-
tion on the concave side at the beginning and
2.2 Frontal Plane: Sidebending end of the sidebending movement. Absence of
this movement on one side may signify a func-
Normal Findings tional disturbance at the thoracolumbar or lum-
Weight borne by the leg on the concave ide bosacral junction or in the SIJ.
(supporting leg). Equal excursion on each
side culminating in a smooth arc' no forward or 2.3 Transverse Plane: Rotation
backward deviations from the frontal plane. A
perpendicular line from tbe axillary fo ld on the Normal Findings
convex side should pass through the anal fis- Equal excur ions on both ides, the spinous
sure. processes forming a flat scoliotic arc. Total
When lumbar lordosis is preserved, idebending range of rotation is approximately 75°.
is coupled with a rotation of the vertebral bodies End-feel: firm-elastic.
88 Palpation of the Pelvic Joints

Pathologic Findings 3 Palpation of the Pelvic Joints

Decreased rotation due to:
Palpation at Rest
- Restrictions or disk protrusions
3.1 Pelvic Position
- Bekhterev's disease
Palpation During Movement-
Local stiffness due to Testing Joint Play in Both SIJs
3.2 Standing Flexion Test (SI1)
- Vertebral position faults
Unilateral Joint Play Testing
- Disk-space narrowing (osteochondrosis)
3.3 Recoil Phenomenon (SI1), "Spine Test"
- End-plate fissures (trauma, Scheuermann's
3.4 Hip Drop Test (Lumbar Spine)
disease)
3.5 Lateral Shift Test (SI1)
- Vertebral body edge separations (persistent
apophyses)
- Block vertebrae
Palpation at Rest
Increased rotation
Common in pathologic hypermobile segments.
3.1 Pelvic Position, Leg Length
• Note Discrepancy (Fig. 17)
Rule of thumb for differentiating vertebral re-
The following landmarks are used:
striction from prolapse: The more directions in
which motion is limited, and the more severe the - Posterior superior iliac spines
limitation, the greater the likelihood of a disk - Iliac crests
protrusion or prolapse. - Greater trochanters
Limitation of motion in all directions is always - Anterior superior iliac spines
caused by a disk prolapse, inflammatory pro-
cess, or tumor. Starting Position
Provocative test for "sciatica" due to root incar- Same as before.
ceration:
The examiner stands behind the patient as in the Procedure
previous examinations, grasps both shoulders The examiner palpates both posterior superior
firmly, and bends the trunk obliquely backward iliac spines with the thumbs from below while
in a direction between backward bending and placing the index fingers or palms over the iliac
sidebending. This maximally reduces the cranio- crests at sites equidistant from the midline.
caudal diameter of the intervertebral foramen, Somewhat greater palpatory pressure will be
which, when compounding a relative crowding needed if the overlying soft tissues are thick
due to disk narrowing and protrusion into the in- (Fig. 17 a). The examiner similarly palpates the
tervertebral foramen, causes absolute crowding tips of the greater trochanters and compare their
with radicular irritation (Kemp's sign). The heights (Fig. 17 c). He then moves to the anterior
examiner notes pain radiation to specific der- side to palpate the anterior superior iliac spines
matornic areas. The test also causes maximum (Fig. 17b).
convergence, and thus compression, of the joint
facets on the concave side.
Normal Findings
Both anterior and posterior iliac spines and
both iliac crests are at the same level on the
frontal plane (no leg length discrepancy) and
transverse plane (no pelvic rotation).
The tips of the trochanters also are at the
same level.
 Palpation at Rest 89

a b c
Fig. 17a--c. Palpation of pelvic position. a Posterior superior iliac spines, b anterior superior iliac spines,
c greater trochanters

Pathologic Findings The result is a functionally short leg. The crest of

the posteriorly rotated ilium also moves back-
Leg Length Discrepancy
ward and, due to the anterior slope of the iliac
With an anatomic leg length discrepancy, the ili-
crests, is lower than on the opposite (nondis-
ac crests (and trochanters) and the iliac spines are
placed) side. Meanwhile the acetabulum of the
at different heights on each side, i. e., all the fore-
posteriorly rotated ilium is shifted slightly for-
going landmarks are lower on the side of an
ward and upward. The result of this "pelvic tor-
anatomically shorter leg.
sion" is a high acetabulum and a functionally
short lower limb.
Faulty Iliac Position Example:
Unequal heights of the posterior and anterior ili- Right posterior iliac spine and right iliac crest
ac spines due to backward or forward rotation of are lower than on the left side.
an iliac wing. Right anterior iliac spine is higher than on
Example: the left side (or possibly at the same level). The
One of the posterior iliac spines is lower than displacement of the acetabulum upward and
on the opposite side. The ipsilateral anterior forward leads to a functionally short right leg.
iliac spine is then higher than the anterior spine This is recognized by noting that the anterior
of the opposite ilium. The cause of this differ- and posterior iliac spines are at different lev-
ence in the heights of the posterior and anterior els on the side of the functionally shortened
iliac spines is a backward rotation of the ilium limb.
on the femoral head with a concomitant poste-
rior displacement with respect to the sacrum in Summary
the SIJ on the side of the lower posterior iliac With an anatomically short leg, both iliac spines,
spine. the iliac crest, and the greater trochanter on
As this occurs, the sacrum makes a relative the same side are lower than on the opposite
countermovement forward and downward (uni- side.
lateral nutation, "sacrum ventralisatum et cau- With a functionally short leg, the anterior
dalisatum" of Sell) and is usually fixed in this ter- and posterior iliac spines are at different lev-
minal position. els.
90 Palpation Dnring Movement - Testing Joint Play in Both SUs

An anatomically short opposite leg can compen-

Palpation Dnring Movement-
sate for the low position of the pelvis on the side
Testing Joint Play in Both SIJs
of the functionally short leg. An anatomically
short leg on the ipsilateral side can aggra-
3.2 Standing Flexion Test (SIJ) (Fig. IS a,b)
vate it.
Asymmetry of the posterior superior iliac spines Following the examination of pelvic position, the
in the transverse plane. If one posterior iliac posterior superior iliac spines are palpated in a
spine is more anterior than the other, it signifies position of maximum trunk flexion. This is a test
pelvic rotation caused, for example, by a distur- for movemen t of the sacrum relative to the ilia in
bance of the hip rotators (weakening of the me- the SIJs Goint play). Since the pelvis is not fixed
dial rotators, as in osteoarthritis of the hip). The by the ischial tuberosities and thighs as it is in the
opposite applies to an iliac spine that is located seated flexion test (see BII, Sect. 3.2, p.lIO),
more posteriorly than the other. Pelvic rotation muscular disturbances in the legs can affect the
can also result from a disk protrusion in the lum- mobility of the ilia at the SIJs owing to the attach-
bar spine. ments ofthose muscles to the iliac wings.
A low posterior iliac spine may be seen in pa-
tients with shortening of the ipsilateral ham- Starting Position
strings. Same as before. Any pelvic obliquity due to
anatomic leg length disparity is first corrected by
Faulty Sacral Position elevating the foot on the short side.
A unilateral positional fault in the SIJ (unilater-
al nutation) may originate from the ilium, as de- Procedure
scribed above, but it may also develop as a pri- The palpation technique is like that used for pal-
mary sacral position fault caused by the body pating the posterior iliac spines at rest. The exam-
weight. Unilateral nutation of the sacrum occurs iner places both hands over the ilia, palpating the
about the oblique axes through the sacrum (see posterior iliac spines with the abducted thumbs.
Fig.40). The patient then slowly bends completely for-
The examination is performed in the prone posi- ward while keeping the knees extended (maxi-
tion and is described in that chapter (see CILPH mum trunk flexion). If the findings are doubtful
Region/Sect. 3, pp.I29f.). or inconclusive, the flexion should be main"-

a b

Fig.1S a, b. Standing flexion test (for asymmetric excursion of the posterior iliac spines)
 Unilateral Joint Play Testing 91

tained for up to 20 s so that an excursion caused

purely by muscular action can subside.
Unilateral Joint Play Testing

3.3 Recoil Phenomenon (SIJ), "Spine

NormaJ Findings Test"
The iliac spines are at the same level both be-
The term "spine test" is misleading, since the in-
fore and at the end of trunk flexion = unre-
tent is to test the joint play between the ilium and
stricted mobility in both sacroiliac joints.
sacrum. The test is actually a variant of the recoil
phenomenon.
Pathologic Findings
One posterior iliac spine moves higher than the Starting Position
other, signifying restriction of the ipsilateral SIJ The patient stands on both legs, as for the stand-
(positive test). Even when flexion is maintained ing flexion test.
for 20 s, however, it cannot always be determined
whether the cause is an arthrogenic dysfunction First Procedure
or a myogenic pelvic torsion, and further tests In the spine test, the patient slightly raises the
may be required. foot on the side to be tested. Motion of the SIJ is
Bilateral limitation of iliac motion due to ham- palpated at the posterior superior iliac spine,
string shortening on both sides can prevent the which should move slightly backward and down-
recognition of a positive test. Similarly, unilater- ward due to posterior rotation of the ilium with
al shortening of the hamstrings can create a respect to the fixed sacrum. The sacrum is fixed
false-positive test on the opposite side, i. e., the by nutation of the SIJ on the weight-bearing side
side where motion is unrestricted. (Fig. 18c-e).

c d e
Fig. 18 c-e. Spine test using the iliac spine of the supporting leg as a landmark (c, e) ; alternative landmark on the
median sacral crest (d, e)
92 UnilateralJoint Play Testing

The usual reference point or landmark on the

Normal Findings
fixed sacrum is a point on the median sacral crest
With free mobility in the hip and knee joints
level with the iliac spine. The contralateral iliac
and unrestricted sacroiliacjointplay, the poste-
spine makes a better reference point, however,
rior iliac spine on the tested free-leg side first
as it allows for the detection of unintended con-
moves superiorly with the hemipelvis as a
comitant motion of the SIJ on the weight-bear-
whole (due to weight shift to the supporting
ingside.
side), but in the terminal phase it "recoils" to a
lower position than on the weight-bearingside.
Normal Findings (Fig. 18 c-e)
Descent of the posterior superior iliac spine
Pathologic Findings
of the tested free leg by 0.5-2 cm.
If the iliac spine does not move lower on the un-
supported side than on the weight-bearing side,
Second Procedure it may signify SIJ restriction due to diminished
To test for the recoil phenomenon, the patient joint play or shortening of the erector spinae
maximally flexes the leg at the hip and knee and and/or quadratus lumborum.
manually holds the knee against the chest
(Fig. 18 f). The examiner, keeping the patient
3.4 Hip Drop Test (Lumbar Spine)
balanced, then inspects or palpates the position
(Fig. 181, m)
of the posterior iliac spines, comparing the right
and left sides (Fig. 18f-h). Starting Position
The posterior-rotating impetus on the ilium is Same as before.
probably produced by the direct pressure of the
maximally flexed thigh and/or the traction of the Procedure
posterior portions of the hip capsule; in the The patient flexes first the left and then the right
"spine test" it is produced by iliposoas tension knee (stands alternately on each leg), allowing
(Fig. 18i,k). the hemipelvis to sag on the side of the flexed
knee. The pelvic obliquity incites a compensato-
ry lumbar scoliosis. The examiner inspects or
palpates the posterior superior iliac spines to de-

9
Fig.1S f-h. Recoil phenomenon with comparison of both sides
 Unilateral Joint Play Testing 93

Psoas

Posterior
iliac spine

Fig. 18 i,k. Joint mechanics in the spine test (i) and recoil test (k). (Modified from Kapandji)

Fig. 18 I,m. Hip drop test (lum-

bar spine) with comparison of
both sides m

termine which half of the pelvis drops more. A Pathologic Findings

valid test requires unrestricted mobility in the Asymmetric hip drop implies that sidebending
hip joints. in the lower lumbar spine is restricted on the side
of greater descent. Slight disparities of hip drop
Normal Findings can also result from SIJ lability on the unsup-
ported side.
Equal descent of each hemipelvis.
Pelvic drop is an indicator of free or restricted
convergence of the facet joints on the side oppo-
site the drop. Example: Greater descent of the
spine on the right side indicates better side bend-
ing to the left in the lower lumbar spine.
94 Unilateral Joint Play Testing

3.5 Lateral Shift Test (SIJ) consideration, a large portion of the SU tests
must be assigned to the group of introductory
Starting Position
tests that are of limited diagnostic value. This is
Same as before. The palpating thumbs are on the
true of all tests of motion used to determine SIJ
iliac spines and in the adjacent sulcus between
play in the context of test movements that in-
the sacrum and ilium.
volve the hip and the symphysis and that might
be caused or affected by the action of muscles at-
Procedure tached to the ilium. These muscles are, for bend-
The examiner pushes the pelvis alternately to ing, the iliopsoas and rectus femoris, for stretch-
each side in the frontal plane, causing a greater ing the gluteus maxim us and hamstrings, and in
nutation movement to occur on the side momen- the frontal plane the adductors and abductors.
tarily bearing the greater weight. Palpating the The transversal portion of the gluteus maximus,
spines and adjacent sulcus, he notes the posteri- which originates on the lateral surface of the ili-
or displacement of the corresponding ilium and um, and the piriform muscle - the only two mus-
compares it with the opposite side. The very cles that originate on the sacrum - probably pri-
small movement is difficult to palpate and is marily increase joint fit but do not initiate any
commonly confused with skin displacements be- significant movement in the SU.
neath the palpating finger. The numerous tests described for examining the
The diagnostic value of this test is minimal. It is SU can be divided into three groups:
likely that the examiner palpates only the chang-
ing tension of the hip adductors during the later- - General test of motion utilizing changes in the
al shift. position of the palpable bony protrusions (an-
terior and posterior spinous processes)
- Palpation of reactive muscle changes
Biomechanical Considerations
- Testing joint play with fixation of the corre-
In view of the clinical consequences of SIJ prob-
spondingjoint member
lems, testing joint play takes on great signifi-
cance. The question is which of the large number In the first group of tests, absence of joint play is
of SU tests enable the diagnostician to reliably checked with regard to a change in position of
ascertain the nature of the disturbance. In recent the spinous processes. These tests include:
years there have been numerous reports of un sat-
- Standing flexion test (see below)
isfactory experiences with individual tests;
- Spine test (recoil phenomenon) (see p. 95)
even experienced diagnosticians have reached
- Hip drop test (see p. 95)
very different results with the same tests. It
- Lateral shift test (see p. 95)
therefore seems appropriate to subject the
procedures for examining the SIJ to a critical re- A common feature of all four tests is that they
view. examine the change noted in the position of the
A relatively reliable evaluation of joint play, par- spinous processes on both sides in connection
ticularly in the case of the SU, is only possible if with bending involving primarily the hip and
one joint member is securely fixed before the only to a small extent the SU. Furthermore, the
motion of the corresponding member is tested motion of the ilium is also affected by the hip
for its translatory movement. In the process, all muscles that originate on it, practically all of
extra-articular factors must be eliminated, re- which tend to shorten.
gardless of whether they contribute to or ob- In the standing flexion test, the ilia are stabilized
struct motion. It must, for example, be deter- against posterior motion both by the upward
mined whether soft-tissue reactions such as pressure of the legs on the acetabula, which are
reactive muscle hardening (for example, in irri- anterior to the rotational axis of the ilia, and by
tation zones) might result from or be affected by the tension-band effect of the hamstring muscles
extra-articular factors. (and the rectus femoris). As the trunk is bent
Taking these criteria for articular function into forward, the initial movement is a segmental di-
 Unilateral Joint Play Testing 95

vergence producing flexion in the lumbar spine manner, i. e., the thigh on the tested side is raised
(approx. 60°), followed by an anterior move- until there is maximum hip flexion, there is much
ment of the pelvis on the femoral heads. Be- more movement in the hip joint on the weight-
tween the movements of the lumbar segments bearing side. First, the rump and pelvis must be
and the movement of the pelvis on the femoral displaced to the weight-bearing side to reestab-
heads, bilateral nutation occurs as a result of lish balance; in the process, the abductive move-
joint play between the ilium and sacrum. This ment of the pelvis on the femoral head raises the
may occur between lumbar flexion and the onset spinous process on the side being tested. During
of hip flexion, driven by the pressure ofthe spine the subsequent complete flexion of the hip joint
on the sacrum, or it may occur at the end of hip on the side being tested, the ilium is displaced
flexion when further flexion of the ilia is checked posteriorly as a result of the tightening of the
by the posterior portions of the hip joint capsule. posterior portions of the joint capsule and the
This remains unclear. hamstrings and of the direct pressure of the
In the standing flexion test, the major part of the thigh against the iliac wing. This too is probably
forward trunk movement takes place in the hip. much more a matter of recoil of the entire pelvis
The forward movement of the spinous process, by means of posterior gliding on the femoral
which is supposed to indicate the blockage, i. e., head of the weight-bearing side. With these two
the absence of joint play on the forward-moving tests, it hardly seems possible to reliably distin-
side, can also be caused by a shortening of the guish the elements of this movement caused by
hamstring muscles or a gliding obstruction in the the hip joint from those by the SIJ. This is true
hip of the side not moving forward. Moreover, even if the fixation of the sacrum is considered
real blockage of the SIJ caused by shortened sufficient because of the nutation on the weight-
hamstrings on the same side can elude de- bearing side.
tection. In addition to these tests of movement in the sag-
In the recoil phenomenon, or spine test, descent ital plane, movements in the frontal plane are
of the posterior superior iliac spine on the un- also used to diagnose disturbances of the SIJ.
supported side relative to the weight-bearing Some authors consider the hip-drop test a means
side is considered proof of the presence of joint to evaluate the SIJ. The ability to let one hip sag
play. Which force might be the cause of the iliac while standing, i. e., the different amounts the
recoil phenomenon that is necessary for this to pelvis drops, is supposed to indicate absence of
occur? The different answers that have been giv- joint play, specifically in the SIJ of the unsup-
en show that opinions differ. ported side. Because the SIJ is fixed on the
If only the knee of the side being tested is pushed weight-bearing side, however, this effect is ques-
forward as far as possible, then the psoas insert- tionable since the test movement consists main-
ing on the lesser trochanter of the femur (as the ly of an adductive movement of the pelvis on the
initial phase of beginning flexion of the hip) can weight-bearing hip joint and sidebending of the
effect upward traction of the head of the femur- lower lumbar spine toward the weight-bearing
as long as it is still vertical under the joint - there- side with convergence of the facet joints. This
by possibly causing the posterior displacement test, then, while specific for convergence-diver-
of the ilium. This force, however, counteracts the gence in the lower lumbar segments when the
tendency of the pelvis to drop somewhat be- sides are compared, is of dubious value for test-
cause of gravity (Trendelenburg effect). This can ing motion in the SIJ.
also lead to a sinking of the iliac spine relative to The lateral shift test appears to be the least re-
the weight-bearing side; such a movement warding test of sacroiliac joint play. In it, the ex-
would, however, be elicited by the adductive aminer shifts the patient's pelvis laterally while
movement of the pelvis in the hip of the weight- the patient is standing on both legs. It is a global
bearing side and would not be proof of move- test that registers, on the one hand, nutation on
ment of the SIJ. the displaced side by means of the increasing
If the spine test is executed in the alternative depth of the sulcus between the posterior sur-
96 Tests of Joint Translation

face of the sacrum and the ilium, and on the oth- - SIl springing test over the upper thigh in a
er hand, the changing tension of the soft tissues supine postion
and any possible restrictions of motion. Here
too, it is impossible to reliably differentiate
the role of two joints in motion and of the
muscles.
A common feature of all these tests is that they 4 Tests of Joint Translation
do not satisfy the requirements of a precise test
of joint play because ofthe absence of a possibil- 4.1 Traction on the Lumbar Spine
ity to fix one of the joint members being tested; 4.2 Compression of the Lumbar Spine
instead they register the very different mobility
of two joints. The same diagnostic limitations
also apply to the palpation of the reactive muscle These translation tests are used to test the play of
changes: the intervertebral disk and intervertebral joints.
Traction on the spine removes pressure from the
- Test of hyperabduction according to Patrick
disks while simultaneously producing a diver-
Kubis
gent gliding movement in both facet joints. Com-
- Palpation of the contracted muscles (the ad-
pression increases disk pressure and produces
ductors, the iliac and piriform muscles) and
convergence of the joint surfaces (see Examina-
the spinal irritation zones
tion ofthe Spine, p. 32f.). Fixation is effected by
the weight of the pelvis and lower limbs.
They cannot serve as specific examinations since
Thus, the entire mobile segment is tested. Com-
the causes of muscle hardening and contraction
pression should be applied sparingly or even
can stem from either the hip joint or the SIl.
withheld if local or radiating pains show marked
All of the above-mentioned tests can thus only
improvement in response to traction. Traction
serve as guides. Yet despite the limitations in in-
and compression in the standing position chiefly
terpreting their results, they nonetheless de-
test the lumbar spine. Traction and compression
serve to retain their position in examinations of
of the other spinal segments are performed in
the SIl since they are easy to include in the se-
the sitting position.
quence of tests and, in part, are a necessary part
of examinations of the hip.
The techniques for testing joint play with fixa- 4.1 Traction on the Lumbar Spine
tion of one part of the joint are probably the only (Fig. 19)
specific tests since they satisfy the condition of
Starting Position
having one fixed and one mobile joint member.
The patient lets the arms hang loosely or crosses
They can be used both as a test of motion to de-
them in front of the chest. The examiner stands
termine the springy nature of displacement of
behind the patient with one leg before the other,
the freely mobile joint, and as a provocative test
places both arms around the chest below the ribs,
registering a hard-elastic end feeling and pain
and holds one of his wrists with the other hand.
that is also indicative of a possible end-position.
The patient stands fully relaxed, leaning back
These tests are:
against the examiner with the spine in slight
- Comparative palpation of the sulcus between kyphosis.
the posterior surface of the sacrum and the
edge of the ilium Procedure
- Four-point springing test (provocative test for Maintaining the lumbar kyphosis, the examiner
the upper pole of the SIl) exerts traction on the spine by shifting his body
- Springing test over the apex of the sacrum weight from the front to the rear leg.
- Springing test over ilium
- Craniocaudal sacral push
 Muscle Test 97

Normal Findings
The traction is not painful.
The traction relieves pain that was present in
an upright weight-bearing po ture. In this
case traction is followed by com pre sion as a
provocative test.

Pathologic Findings
No pain relief with inflammatory or osteolytic
processes or with a disk prolapse if there is asso-
ciated facet joint restriction.

4.2 Compression of the Lumbar Spine

Starting Position
Heels raised.

Procedure
The patient drops onto the heels.

NormaJ Findings
The spinal compression produced by drop-
ping onto the heels is not painful.
Fig.19. Traction on the lumbar spine

Pathologic Findings
Compression pain in the lumbar spine with in-
flammatory and osteolytic processes or with a
disk prolapse (pain may radiate to the corre-
sponding dermatomes).

5 Muscle Test

First Phase: Trendelenburg phenomenon (Hip

abductors)

Starting Position
Usual standing position on both legs.

Procedure
The patient flexes the hip and knee joints at right
angles.
Fig.20. Trendelenburg test
98 Muscle Test

Normal Findings - Congenital dislocation of the hip

The pelvis shouLd remain almost horizontal. - Coxa vara
The perpendicular line from the head should - Flattening of the femoral head (Perthes' dis-
show little shift toward the supporting leg. 0 ease, arthritis, osteoarthritis, epiphyseal plate
increase in lordosis. separation, avascular necrosis)
- Paresis of the hip abductors (L4-LS, superior
gluteal nerve)
Pathologic Findings 2. Marked shifting of the trunk toward the sup-
1. Dropping of the non-weight-bearing side of porting leg due to severe paresis (Duchenne's
the pelvis as a result of abductor insufficiency sign) or congenital dislocation of the hip.
(gluteus medius and minimus) on the weight-
bearing side due to
General Examination of the Lower Extremities
in the Standing Position (All)
(Supplement to Examination ofthe LPH Region)

1 Three-Phase Squat
(General Weight-Bearing Test for All
Lower Extremity Joints and Muscles, In-
nervation, Coordination)

2 Standing on the Toes

(Joint Test: Ankle and Toe Joints, Flexor
Muscles of Foot)

3 Standing on the Heels

(Joint Test: Ankle Joint, Extensor Muscles
of Foot)

4 Standing on the Outer Edge ofthe Foot

(Joint Test: Subtalar Joint, Supinators)

5 Muscle Tests
(Shortening Test: Iliopsoas and Triceps
Surae)
100 General Examination orthe Lower Extremities

The legs are the static and dynamic foundation Pathologic Findings
for the LPH region. A gross evaluation of their
Phase I
functional status during weight bearing is indi-
Painful limitation of hip, knee, or ankle function
cated when the LPH examination shows evi-
due to degenerative or other joint process. Co-
dence of paralysis or lower limb shortening.
ordination defects.

Phase II
Patient experiences calf pain when heel touches
1 Three-Phase Squat floor due to soleus shortening.

Phase III
The three-phase squat test is a general weight-
Limitation due to paresis of the leg muscles:
bearing test for all the lower extremity joints and
muscles, innervation, and coordination. - Iliopsoas (~-L3, femoral nerve)
- Quadriceps (L3-L4, femoral nerve)
Starting Position - Plantar flexors (L4-S3, tibial nerve)
The test begins with the patient standing upright Coordination defects.
with the feet parallal and 1 foot wide apart,
knees extended. Have the younger patient or athlete rise to a
standing position on one leg, using an arm for
Procedure support, to:
- Test the stability of the knee ligaments
Phase I - Increase muscle loading to test for mild pare-
Test for ranges of hip and knee motion. Patient ses (compare both sides)
slowly goes down to a squatting position, allow- - Test the articular cartilage under weight bear-
ing the heels to rise. ing.

Phase II
Test for soleus shortening. Patient places both
heels on the floor.
2 Standing on the Toes
Phase III
Muscle test for foot flexors, knee, and hip exten-
sors. Patient returns to an upright position with Tests the ankle and toe joints and the flexor mus-
the heels raised. cles of the foot.

Procedure
Normal Findings
Patient presses the toes against the floor to test
Phase I
the toe flexors (St, tibial nerve). Patient then ris-
The hips and knees can be maximally flexed
es up on the toes.
without limitation.
Performing the test on one leg also tests coordi-
Phase II
nation. Hopping on one leg brings out latent
The patient can place the heels on the floor
pareses.
(barefoot) without pain.
Phase III
Patient rises smoothly to an upright posture. Normal Findings
Patient can stand on the toes with unrestrict-
ed motion in the ankle, subtalar joint, and toe
joints.
 General Examination ofthe Lower Extremities 101

The longitudinal arch of the foot is deepened; 4 Standing on the Outer Edge
the calcaneus goes into varus. of the Foot

Pathologic Findings Standing on the outer edge of the foot is a test of

Pathologic findings in this test signify functional the subtalar joint and supinator muscles.
disturbances involving the joints of the foot and
toes: Normal Findings
- Paresis of the triceps surae (L4-S 3 , tibial In the test position the longitudinal arch is fIat
nerve) but prominent and there is unrestricted subta-
- Paresis of the foot and toe flexors (L4-S 3 , tib- lar joint motion.
ial nerve). Flexor hallucis longus is considered
an indicator muscle for Sj.
Pathologic Findings
Muscular disturbances in the foot result from Subtalar joint motion fault, paresis of supinators,
paresis of the short'toe flexors due to Sj paresis especially tibialis anterior and posterior (L4-S 3 ,
or a tarsal tunnel lesion. If the toes do not touch common peroneal nerve and tibial nerve).
the floor in standing, a disturbance in the inner-
vation of the small foot muscles should be sus-
pected.
5 Muscle Tests (Fig. 21)

The muscle tests are tests for shortening of the

3 Standing on the Heels iliopsoas and triceps surae.

Standing on the heels is a test of the ankle joint

and foot extensors.

Procedure
The patient raises the forefoot from the floor.

Normal Findings
Patient can raise the forefoot with unrestrict-
ed ankle motion and intact dorsifJexors (ex-
tensors).

Pathologic Findings
Functional disturbance in the ankle joint; pare-
sis of the dorsiflexors of the foot (L4-S Z, com-
mon peroneal nerve); extensor hallucis longus is
an indicator muscle for Ls.
Coordination defects.

Fig. 21. Test for shortening of the iliposoas and triceps

surae
102 General Examination of the Lower Extremities

Starting Position
Normal Findings
The free leg is placed on the examination bench
The movement is painles and unrestricted.
or table. The weight -bearing leg is set as far back
The weight-bearing hip should reach 5°_10°
as possible, with the foot flat on the floor. The foot
of hyperextension.
is in the sagittal plane with no medial or lateral ro-
tation. The weight-bearing knee is extended. The
trunk and supporting leg form a straight line. Pathologic Findings
Limitation of motion with increasing muscle
Procedure pain in the groin area (psoas shortening) and/or
Patient maximally flexes the free leg at the hip calf (shortening of triceps surae) in the weight-
and knee while moving the trunk as far forward as bearing leg.
possible and keeping the lumbar spine straight.
Examination of the LPH Region
in the Sitting Position (Bill)

1 Inspection
1.1 Relaxed and Erect Sitting Posture
1.2 Pelvic Position - Comparison with
Findings in Standing

2 Active and Passive Trunk Movements

in Three Planes
(Regional Diagnosis)
Supplementary SIJ Test

3 Palpation of the SIJ and Lumbar Spine

(Segmental Diagnosis)
Palpation at Rest
3.1 Pelvic Position
Palpation During Movement
3.2 Seated Flexion Test
(For Asymmetric Excursion of the Iliac
Spines)
3.3 Segmental Motion Testing of the Lum-
bar Spine

4 Tests of Joint Translation

4.1 Traction on the Thoracic and Lumbar
Spine
4.2 Compression ofthe Thoracic and Lum-
bar Spine

5 Muscle Tests
Resistance Testing of Hip Muscles
104 Examination ofthe LPH Region

1 Inspection High kyphosis: age-related degenerative

changes (senile kyphosis, osteoporosis, osteo-
malacia), ankylosing spondylitis, postural
1.1 Relaxed and Erect Sitting Posture kyphosis.
1.2 Pelvic Position - Comparison with Find- Low kyphosis: adolescent kyphosis (Scheuer-
ings in Standing mann). In children, kyphosis in sitting.
Apex of curve shifted to higher or lower level:
possible vertebral restriction.
Examiner tests the movement patterns associat- Gibbus formation: osteolytic processes and
ed with relaxed and erect sitting postures and fractures.
evaluates pelvic position. Local flattening of the spinal arch: vertebral re-
striction.
1.1 Relaxed and Erect Sitting Posture High (upper lumbar) lordosis: restriction at the
lumbosacral junction or ankylosis in the thoracic
Starting Position spine.
Patient sits on a stool or the examination table Low lordosis: spondylolisthesis with a palpable
with both feet on the floor. Changing from a re- (and perhaps visible) step.
laxed sitting posture to an erect sitting posture is
accompanied by changes in the pelvic position
and spinal curvatures. 1.2 Pelvic Position - Comparison
with Findings in Standing

Normal Findings Normal Findings

1. Relaxed posture Same as normal findings in the standing posi-
The pelvis is tilted back ("kyphotic" posi- tion.
tion), and there is a smooth, kyphotic spinal Frontal Plane
arch from C7 to L3. The apex of the arch is Anterior and posterior iliac spines and iliac
centrally located, with a normal range ofvari- crests are at equal levels on both sides. 0 lat-
ation from T6 to the upper lumbar spine. The eral deviation of the trunk.
center of body gravity is over the ischial Transverse Plalle (Overhead View)
tuberosities. The muscles are fully relaxed ex- Pelvis and trunk are not rotated.
cept for residual tension in the intrinsic back Sagittal PlmJe
mu cles. The scapulae are shifted laterally, Posterior pelvic tilt and general kyphosis in
and the arms hang loosely. the relaxed posture, anterior pelvic tilt and
2. Erect sitting posture lumbar lordosis in the erect posture.
On active change to an erect sitting posture,
the pelvis tilts forward ("lordotic" position). Pathologic Findings
The spinal arch straightens, leaving residual Pelvic obliquity noted in standing is not present
kypho is in the upper thoracic spine whi le the in the sitting position, i. e., the iliac spines and
lumbar and lower thoracic spine become crests are on equal levels. Sitting also abolishes
slightly lordotic with the apex at L2. The cer- any (static) scoliotic deformity (= anatomically
vical pine also is slightly lordotic. The back short leg).
extensors are tense, and tbe scapulae are Pelvic obliquity in standing is not present, but
shifted medially. the iliac spines are on different levels, i. e., the
contralateral low position of the iliac spines in
standing (possibly with pelvic rotation toward
Pathologic Findings the low side) persists in the sitting position
Marked kyphosis in the relaxed position: mus- (= functionally short leg due to SIJ restriction
cular and ligamentous weakness. with displacement).
 Examination of the LPH Region 105

2 Active and Passive Frontal Plane: Sidebending (Fig. 23 a,b)

Patient bends actively to both sides with the
Trunk Movements in Three Planes
arms crossed over the chest (Fig. 23 a) or the
(Regional Diagnosis)
hands behind the neck (as in Fig. 24a), the el-
bows forward.
For passive testing, the examiner grasps both
Supplementary SIJ Testfor shoulders and continues the movement to its
Differentiating Motion Faults passive limit (Fig. 23 b).
in the SIJ and Lumbar Spine
Transverse Plane: Rotation (Fig. 24 a,b)
Procedure Active: patient rotates to both sides with the
Patient alternately crosses one leg over the other. hands behind the neck, the elbows forward to
serve as "pointers" to aid range-of-motion com-
parison on both sides.
Normal Findings
Passive: examiner continues the movement to
Each leg can be painlessly adducted to an
its passive limit, as in side bending.
equal degree (approximately 45°) and placed
upon the thigh of the opposite leg.
Alternative Technique: Guided Passive
Movements/or the Segmental Examination
Pathologic Findings (Fig. 25 a-d)
Limitation of motion, possibly accompanied by
pain over the SIl if there is restriction (displace- Sagittal Plane: Forward and Backward Bending
ment) in the ipsilatenil SIl. The arms are crossed over the chest or the hands
are placed behind the neck, the elbows forward.
The examiner stands to one side and reaches
Regional Motion Testing of the Lumbar
across the chest beneath the arms, placing the
(and Thoracic) Spine in Three Planes
flat hand against the axilla. From this position he
with the Pelvis Stationary (Figs. 22-25)
alternately guides the chest forward (= fixation
of thoracic spine by ligament tension, Fig. 25 a)
Starting Position (Fig. 22 a)
and backward (= fixation by facet joint conver-
Patient sits erect on the table (or stool) with
gence, Fig. 25 b). Movement in the lumbar spine
weight distributed equally on the buttocks. On
is accomplished by backward and forward tilting
forward bending, the arms hang loosely between
of the pelvis over the ischial tuberosities effected
the legs. During sidebending and rotation, the
by the anterior and posterior displacement of
arms are crossed over the chest or the hands are
the thorax on the transverse plane (Fig. 25a,b).
clasped behind the neck, the elbows pointing
forward.
Frontal Plane: Side bending
The examiner raises one shoulder (by extending
Procedure
his own knee or standing on his toes) and pulls
Sagittal plane:/orward and backward bending the opposite shoulder downward, thereby bend-
(Fig. 22 a-e ) ing the entire thoracic and lumbar spine toward
Active movements are performed with the arms the opposite side (convexity toward the examin-
hanging loosely beside or between the legs. er, see Fig. 25 c). With the patient's hands behind
The examiner imparts an extra passive stretch at the neck and the elbows forward, the examiner
the end of, and in the same direction as, the ac- can place his own shoulder directly into the pa-
tive movement. With backward bending, coun- tient's axilla and thread his arm through the tri-
terpressure is applied to the pelvis (Fig. 22 e). angle formed by the patient's forearm and upper
arm to grasp the opposite shoulder (not shown).
This provides a greater leverage that acts mainly
106 Examination of the LPH Region

a b c

d e
Fig.22. a Starting position. b,c Active and passive forward bending. d,e Active and passive
backward bending
 Examination of the LPH Region 107

a b

Fig. 23 a, b. Active and passive sidebending

a b

Fig. 24 a, b. Active and passive rotation

108 Examination ofthe LPH Region

on the thoracic spine, whereas the previous tech- Transverse Plane: Rotation
nique produces more sidebending at the lumbar Examiner position and hand placement are the
level due to the lower arm placement. Generally same as in the side bending test. Trunk rotation is
the examiner changes sides to test sidebending performed about the longitudinal body axis with
in the opposite direction, or he can stay on the no anteroposterior or mediolateral deviation.
same side and flex his knees. Rotation in the opposite direction may be tested

a b

c d

Fig. 25 a-d. Guided passive movements for segmental motion testing. a Forward bend-
ing, b backward bending, c sidebending, d rotation. (The arrows indicate the direction
of motion of the spinous processes that are palpated for the segmental examination)
 Palpation at Rest 109

from the same position, or the examiner may 3. Gibbus formation occurs with a congenital or
change sides (Fig. 2Sd). acquired wedge-shaped vertebral deformity
Passive motion testing may be done after the ac- due to traumatic, degenerative, metabolic, in-
tive testing of all the above movements is com- flammatory, or neoplastic processes.
pleted, or the examiner can immediately contin- 4. Plateau formation in the uniform spinal arc oc-
ue each active movement to its passive limit. The curs with vertebral restriction or synostosis
first method is recommended if an active motion (block vertebrae).
fault (delayed onset, stiff or uncoordinated 5. Pain
movement, limitation of motion) is noted. In this Myogenic pain accompanying the divergent
case the examiner should test passive motion not movement of a facet joint.
just in the terminal range but over the whole Arthrogenic pain associated with a divergent
range of movement. or convergent movement of the joint.
Radicular pain caused by disk protrusion or
prolapse (dermatomal distribution).
Normal Findings When motion is abruptly restricted by a barri-
1. No limitation of motion and no deviation er, the normal firm-elastic end-feel becomes
from the given plane of motion harder and painful.
2. Smooth, uniform arch of the lumbar spine
in all terminal positions • Note
3. Equal ranges of sidebending and rotation Limitation of motion in a segment with unre-
on both sides stricted joint play is almost always myogenic.
4. No gibbus or plateau formation Limitation of side bending in a whole vertebral
S. Painless movements with a firm-elastic end- region may signify muscular shortening on the
feel opposite (convex) side.

Pathologic Findings
(See also NLPH Region/Sect. 2, pp.1OS)
3 Palpation of the SIJ
1. Forward bending and Lumbar Spine
Limitation in the sitting position but no limita- (Segmental Diagnosis)
tion in the standing position: hamstring short-
ening.
Limitation in the sitting and standing posi- Palpation at Rest
tions: vertebral restriction. 3.1 Pelvic Position
With the same lateral deviation (active) from Palpation During Movement
the plane of motion: vertebral restriction in 3.2 Seated Flexion Test
the convergent position on the side of the de- (For Asymmetric Excursion of the Iliac
viation. Spines)
With slight lateral deviation on backward 3.3 Segmental Motion Testing of the Lum-
bending: vertebral restriction in the divergent bar Spine
position on the side opposite the deviation.
Greater and more painful lateral deviation
(possibly with dermatomal distribution) oc- Palpation at Rest
curs with intervertebral disk protrusion or
prolapse.
2. Sidebending and rotation show a decrease or
3.1 Pelvic Position (Fig. 26 a)
painful limitation on one side: convergent
facet-joint restriction on the concave side Starting Position
and/or divergent restriction on the convex side. The patient sits on a stool or an examination
110 Palpation During Movement

table low enough to permit the feet to rest flat on must be performed to differentiate the lesion.
the floor. The legs are apart. Since both ilia are stabilized in the seated flex-
ion test by the ischial tuberosities and femurs,
Procedure this test evaluates the relative motion of the
The iliac crests and spines are palpated in the sacrum with respect to the ilia. Whereas the ili-
same way as in the standing test previously de- um requires only one rotational axis for its mo-
scribed. tion relative to the sacrum (approximately level
with the posterior iliac spines on the frontal
plane), the sacrum is assumed to have multiple
Normal Findings
frontal axes at various levels for flexion/exten-
The anterior and posterior iliac spines and the
sion during forward and backward bending of
iliac crest are at equal levels on both sides.
the trunk. Additionally there are two diagonal
The sitting position abolishes di parities due
axes for compensatory countermovements of
to anatomic leg length discrepancy.
the sacrum ("sacrum ventralisatum et caudali-
saturn per rotationem" after Sell) and the ilium
Pathologic Findings (see Fig.40).
Different heights of the iliac spines persist in the
sitting position: suspicious for an arthrogenic
SIJ restriction due to iliac rotation on one side or
upward "subluxation" (displacement) of one ili- Palpation During Movement
um (traumatic).
Tilted or rotated pelvis with motion-dependent
3.2 Seated Flexion Test (for Asymmetric
pain: suspicious for a spinal dysfunction, such as a
Excursion of the Iliac Spines) (Fig. 26 a,b)
lumbar prolapse, in which the pelvic position fault
represents a compensatory antalgic posture. Starting Position
With an abnormal pelvic position or positive The starting position for this test is the same as
standing flexion test, the seated flexion test that in Sect. 3.1.

a b

Fig.26a,b. Testing pelvic position and iliac spine excursions on forward bending (seat-
ed flexion test). a Starting position, b final position
 Palpation During Movement 111

Procedure - Forward, producing dorsiflexion of the lum-

Again, the thumbs are placed on the poste- bar spine by anterior tilting of the pelvis on the
rior superior iliac spines from below. With ischial tuberosities (Fig. 27 b)
the arms hanging loosely, the patient slowly - Side bending ofthe lumbar spine (with a slight,
bends forward to the limit of active trunk opposite sidebending of the thoracic spine)
flexion (Fig. 26b). The final degrees of move- (Fig. 27 c)
ment are most critical in terms of palpable find- - Rotation (Fig. 27 d)
ings.
While performing these movements, the exam-
Normal Findings iner palpates two adjacent spinous processes and
The iliac spines move synchronously an equal notes their mobility relative to each other. The
distance forward (upward) and are at the axis of motion is always at the level of the palpat-
same level after the movement as before. ing finger. During forward and backward bend-
Mu c1e contours are symmetric on botb sides ing, the tips of the spinous processes are palpated
of the spinous processes. from the rear (Fig. 27a,b). During sidebending,
they are palpated from the concavity of the curve
(Fig. 27 c), the examiner recording the coupled
Pathologic Findings rotation by the motion of the spinous processes.
One iliac spine is higher than the other at the end During rotation, they are palpated from the side
of the movement: restriction of the SIJ on the opposite the direction of rotation, e. g., from the
"high" side (positive test). right side during rotation to the left (Fig. 27 d).
Determining the position in which the sacrum is
restricted requires additional tests, which are • Note
conducted during palpation of the dorsal pelvic The untested portion of the thoracic spine
field and are described in that section (see should be held in a stabilizing position of oppo-
C/LPH Region/Sect. 3.1, p.124). site curvature or ligament fixation so that mo-
Asymmetric paravertebral muscle contours in- tion occurs only in the lumbar spine.
dicate congenital (scoliosis) or functional distur- Example: When segmental divergence is tested
bances of the vertebral column, as does an irreg- during forward bending, the thoracic spine
ularity of the spinal arch in maximum trunk should be stabilized before the initiation of lum-
flexion. bar kyphosis to confine the divergent movement
to the lumbar segments. Pure kyphosis of the
spine as a whole would only produce a diver-
3.3 Segmental Motion Testing
gence effect in the lower thoracic segments.
of the Lumbar Spine (Fig. 27a-d)
Starting Position Combined Motion Testing (Fig. 28 a-d)
Erect sitting posture with both feet on the floor, The segmental motion testing of side bending
the hands behind the neck, the elbows forward. and rotation can be combined, since sidebend-
The examiner reaches across the front of the ing is consistently accompanied by "coupled ro-
chest and places his hand on the patient's oppo- tation." During sidebending the vertebral bod-
site shoulder. ies of the thoracic and lumbar spine rotate
toward the concavity of the curve when the spine
is ventrally flexed and toward the convexity of the
Procedure
curve when the spine is dorsiflexed.
From this position the thorax is successively
Example: On sidebending to the right in ventral
moved as follows in the transverse plane:
flexion, the vertebral bodies rotate to the right
- Backward, producing ventral flexion of the while the spinous processes behind the rotation-
lumbar spine by posterior angulation of the al axis deviate to the left (Fig. 28a). The verte-
pelvis (Fig. 27 a) bral bodies also rotate to the right in dorsiflexion
112 Palpation During Movement

a b

c d

Fig.27a-d. Segmental motion testing in the anatomic planes. a Forward bending,

b backward bending, c sidebending, d rotation

when the patient side bends to the opposite side of the vertebral bodies, and in dorsiflexion by
(Fig. 28 b). left rotation of the vertebral bodies, the spin-
General vertebral rotation is tested by maintain- ous processes simultaneously deviating to the
ing the same degree of lateral flexion as the pa- right.
tient is moved from ventral flexion to dorsiflex-
ion (Fig.28c,d), since sidebending to the right in Combined Test for Side bending and Rotation
ventral flexion is accompanied by right rotation (Convergence-Divergence Test, Fig. 28 a-c)
 Palpation During Movement 113

a b

c d

Fig.28a-d. Combined motion testing a in ventral flexion, b in dorsiflexion. c,d

Full vertebral rotation is obtained only by maintaining the same degree of
sidebending

Starting Position hand atop the opposite shoulder. Alternatively,

Erect sitting position with the hands behind the thepatientmaycrossthearmsinfrontofthechest.
neck and the elbows forward . The examiner
stands on the patient's right side, for example, Procedure
reaches across the chest with his right arm (below The thorax is side bent toward the examiner and
the patient's arms), and places his hand on the op- also bent forward (and rotated to the right)
posite shoulder; or he may reach through the tri- (Fig. 28 a,c). The lower the level of the palpated
angle formed by the patient's arms and place his segment, the more forward bending and rota-
114 Palpation During Movement

tion are required. An attempt is made to keep Pathologic Findings

the thoracic spine as dorsiflexed as possible to Limited and/or painful motion in one or more
focus the movement on the lumbar region. The segments between adjacent, nonpainful seg-
spinous processes are palpated from the side op- ments of normal mobility may signify vertebral
posite the movement, as in simple rotation. restriction andlor disk protrusion.
Next the thorax is bent backward (and rotated to Hypermobility, usually with only slight terminal
the left) while maintaining the same amount of pain, in one or more segments may signify a
lateral flexion (Fig. 28d). The reversal of right loose intervertebral disk (motion segment lax-
vertebral rotation to left rotation is detected by ness) or bony instability (e. g., spondylolisthe-
palpating the spinous processes [with just the in- sis).
dex finger (illustration) or between the thumb
and index finger]. The rotation associated with Biomechanical Considerations on the Joint
backward bending is less than in forward bend- Mechanics of Combined Movements
ing, so it is more difficult to palpate. The mechanical principle underlying coupled
rotation of the vertebrae is that the joint facets
• Note on the concave side are immobilized by maxi-
If the thorax, sidebent to the right, is moved diag- mum convergence and become the center for ro-
onally from a ventrally flexed to a dorsiflexed po- tation in the spinal segment. Meanwhile, the
sition, i.e., sidebent toward the opposite (left) separation of the facets on the convex side per-
side with a concomitant rotation to the right mits the upper vertebra to rotate relative to its
(Fig. 28 b), there will be no change in the (right) partner below.
rotation of the individual vertebrae, as noted The direction of the coupled vertebral rotation
above. The spinous processes show markedly less depends on whether the side bent vertebra, or
rotation in the lumbar spine than in the lower tho- the plane of its articular surfaces, is inclined for-
racicspine. The combined motion test is less time- ward or backward with respect to the frontal
consuming than individual motion testing but is plane (neutral plane of motion). If the articulat-
technically more demanding as the examiner ing facets are angled forward with respect to the
must manipulate the thorax in three dimensions. frontal plane (range of ventral flexion), the ver-
tebra will rotate toward the concavity of the
Normal Findings curve.
Spinal mobility depends on the height of the Example: Sidebending to the right with the
intervertebral disk and the position of the spine bent forward causes the vertebral bodies
joint surfaces relative to the plane of motion. to rotate to the right.
If the facet joint surfaces in the segment are in-
Ranges of mOlion clined backward with respect to the frontal
Forward bending (ventral flexion): separa- plane (range of extension or dorsiflexion) , the
tion (divergence) of the spinous proces es. vertebrae will rotate toward the convexity of the
Mobility increase from Ll to LS decrea es curve.
markedly at LS/Sl. Example: Sidebending to the right causes the
Backward bending (dorsiflexion): approxima- vertebral bodies to rotate to the left.
tion (convergence) of the pinous processes. This applies to the thoracic as well as the lumbar
Mobility increases from L1 to Sl. vertebrae. The cervical vertebrae always rotate
Sidebending (lateral flexion): toward the concavity during sidebending (ex-
Mobility increases from L1 to L3 (LA) (total cept in the atlantoaxial segment) because these
range approximately 50°), decreases from L3 facets are consistently inclined 20°-70° forward
to LS , is greatly decreased at LS/Sl. in the sagittal plane, so divergence is associated
Rotation: mobility decreases from L1 to LS with a forward movement, and convergence
(see Fig. 10). with a backward movement, which together pro-
duce the vertebral rotation.
 Tests ofJoint Translation 115

Sidebending and Coupled Rotation 4 Tests of Joint Translation

in a Segment
Sidebending is effected by shifting the weight to- 4.1 Traction on the Thoracic and Lumbar
ward one side. As the spine flexes laterally, the Spine
intervertebral disk space becomes asymmetric. 4.2 Compression of the Thoracic and Lum-
Panjabi notes that the pivot point for this move- bar Spine
ment is believed to be located in the facet joint of
the opposite (convex) side. The increased
weight on the concave side cause the facet joints
to converge.
Tests of joint translation are tests of loading and
The accompanying rotation proceeds automati-
unloading of the intervertebral disks and tests
cally as long as the sidebending continues and
for facet joint gliding.
there is associated convergence of the facets in
the ventrally or dorsally inclined gliding plane of
4.1 Traction (Fig.29a)
the joint. When the facets cease to converge, the
joint becomes immobile, and if sidebending con- Traction in the sitting position tests the interme-
tinues, the joint becomes the pivot point for all diate and lower thoracic segments more than the
further lateral movements in the segment, which lumbar segments, while traction in the standing
thereafter can occur only in the anterior or pos- position tests the lumbar segments more. If a pa-
terior direction (third dimension of motion). tient cannot be examined while standing, trac-
These voluntary lateral movements then take tion in the sitting position is acceptable for test-
place in the facet joint of the opposite, convex ing of the lumbar region.
side; the direction of the movement may be for-
ward by divergent gliding or backward by trac- Procedure (see Fig. 29 a)
tion in the joint. Same as for traction in the standing position (see
In forward movements, the pivot point probably p.96).
shifts slightly forward along the margin of the
vertebral body on the concave side. Alternative Technique
Occasionally there may be asymmetric articular The patient crosses the arms over the chest, and
surface orientations in the two facet joints of the the examiner grasps the elbows at the crossing
segment due to different angular positions of the point to keep them from separating laterally
two frontal gliding planes with respect to the ("pharoah grip").
sagittal plane (lumbar spine) or frontal plane
(cervical and thoracic spine). In some circum-
4.2 Compression (Fig.29b)
stances this asymmetry can hamper gliding in
the sagittal plane during flexion/extension as Procedure and Findings
well as optimum adjustment of the gliding plane Like traction, spinal compression by downward
during three-dimensional movements. Conver- pressure on both shoulders acts on the thoracic
gent gliding, which already is hampered by the spine more than the lumbar spine. The findings
increased joint pressure associated with increas- correspond to those for compression in the
ing articular surface contact and possible mor- standing position (see p. 97).
phologic changes in the joint surfaces, can be
markedly impaired by asymmetry of the articu-
lar surfaces.
116 Muscle Tests

a b

Fig.29. a Traction on the thoracic and lumbar spine. b Compression of the thoracic
and lumbar spine

5 Muscle Tests

Resistance Tests of the Flexors, Rotators,

Abductors, and Adductors of the Hip
(Figs. 30-32)
These resistance tests of the synergists with
the hip and knee in 90° flexion are for orien-
tation purposes, since only the final 30° of
the range of motion can be tested. A more dif-
ferentiated examination of the synergists with
the hip in the neutral position is performed in the
prone position (extensors, rotators) or supine
position (flexors, abductors, adductors), see
C/LPH Region/Sect.5, p.144, and E/LPH Re-
gion/Sect. 5, pp.173-178).

Starting Position
The patient sits on the table (or stool) as in the
previous tests, the hip and knee flexed 90°, the
legs slightly apart. The table should support the
thigh as far as the popliteal fossa to permit ade- Fig. 30 a, b. Resistance test of the iliopsoas (a) and
quate stabilization. quadriceps femoris (b)
 Muscle Tests 117

Fig. 31 a, b. Resistance test of the external rotators (a) and internal rotators of the hip (b)

Fig. 32 a-d. Resistance test of the hip adductors (a, b) and abductors (c, d)
118 Muscle Tests

Procedure rotated to test the internal rotators (L4-S2' su-

The examiner applies resistance as follows: perior gluteal nerve) (Fig. 31 b).
4. Lateral resistance is applied to the medial as-
1. Downward pressure on the thigh (against pect ofboth knees with the hands, or by placing
flexion) to test the major hip flexor, the iliop- the legs between the slightly abducted legs of
soas muscle (LrL4, femoral nerve). The the patient, to test the adductor muscles of the
thigh should not rotate during the test hip (Lz-L4, obturator nerve) (Fig. 32 a,b).
(Fig.30a). 5. Medial resistance is applied to the lateral as-
Posterior resistance is applied above the malle- pect of both knees with the hands, or by pla-
olus to test the major knee extensor, the quadri- cing the examiner's legs outside the patient's
cepsfemoris (L3-L4' femoral nerve) (Fig. 30 b). legs, to test the abductor muscles of the hip
2. Lateral resistance is applied at the medial (L4-Sh superior gluteal nerve) (Fig. 32 c,d).
malleolus (against external thigh rotation)
with the thigh gently stabilized and internally The proper conduct of the tests can be checked
rotated to test the external rotators (L4-S2 , by simultaneously palpating the point of the
femoral nerve) (Fig. 31 a). greater trochanter. These orienting tests are suf-
3. Medial resistance is applied at the lateral ficient to test the gross function of all the hip
malleolus (against internal thigh rotation) muscles except for the extensors and tensor fas-
with the thigh gently stabilized and externally ciae latae.
Examination of the LPH Region
in the Prone Position (C/II)

1 Inspection
1.1 Pelvic Position and Gluteal Profile
1.2 Pelvis-Leg Angle
1.3 Leg Length Discrepancy
1.4 Asymmetric Muscle Contours
1.5 Alignment of the Vertebral Column

2 Active and Passive Hip and Knee

Movements
(Regional Diagnosis)
2.1 Hyperextension ofthe Hip Joint
(Extension from the Neutral Position)
2.2 Rotation of the Hip Joint
2.3 Flexion, Extension, Rotation of the
Knee Joint

3 Palpation Field of the Dorsal Pelvis:

Lnmbar Joints/Soft-Tissne
Diagnosis
(Segmental Diagnosis)
Palpation at Rest
3.1 Palpation Field ofthe Dorsal Pelvis
3.2 Test for Functional Leg Length
Discrepancy
3.3 Segmental Palpation of the Lumbar
Spine
(Mobility/Pain)
3.4 Kibler's Skin Rolling Test
3.5 Connective-Tissue Stroke Test
3.6 Segmental Irritation Points of Sell
(Testing of Irritation Zones)

5 Mnscle Tests
4 Tests of Joint Translation 5.1 Resistance Tests of Hip Muscles
4.1 Lumbar Spine (Extensors and Rotators)
4.2 Sacroiliac Joints 5.2 Knee Muscles
4.3 Hip Joints: Rotation 5.3 Back Extensors
120 Inspection

1 Inspection Hyperlordosis of the lumbar spine secondary to

- Psoas shortening (usually with gluteal weak-
1.1 Pelvic Position and Gluteal Profile ness)
1.2 Pelvis-Leg Angle - Flexion contracture of the hip (osteoarthritis)
1.3 Leg Length Discrepancy
When shortened, the psoas accentuates lumbar
1.4 Asymmetric Muscle Contours
lordosis.
1.5 Alignment of the Vertebral Column

1.3 Leg Length Discrepancy

1.1 Pelvic Position and Gluteal Profile Normal Findings
The malleoli, popliteal folds, and gluteal folds
Normal Findings are at equal levels.
1. Pelvis horizontal, iljac crests at equal levels
2. 0 lateral shift of pelvis
3. Posterior superior iliac spines at equal lev- Pathologic Findings
els (rhomboid fossae) Leg length discrepancy due to an anatomically
4. Anal cleft (attachment at sacral apex) on or functionally short leg.
the midline Above- and below-knee disparities due to con-
5. Gluteal symmetry. genital growth discrepancies, trauma, paresis,
etc.

Pathologic Findings 1.4 Asymmetric Muscle Contours

1. Pelvic obliquity or restrictions in the lumbar
Normal Findings
spine or SIJ (with a functionally short leg)
Symmetric contours of the thigh and lower leg
2. Lateral pelvic shift associated with lumbar
muscles and erector trunci.
scoliosis or disk prolapse
3. Unequal heights of the iliac spines due to SIJ
displacement or an anatomically short leg Pathologic Findings
4. Deviation of the anal cleft from the midline, Asymmetric muscle contours, congenital or due
usually toward the site opposite a sacral posi- to paresis.
tion fault (e. g., due to SIJ displacement) Increased prominence of the erector trunci due
5. Decreased gluteal prominence: unilateral to muscle shortening or reflex splinting.
with old SIJ restriction and/or displacement
and with paresis; bilateral with muscular
weakness or paresis
1.5 Alignment of the Vertebral Column
Pathologic Findings
Decrease or accentuation or normal lordosis,
1.2 Pelvis-Leg Angle
scoliotic deformity.
Normal Findings
Hip joints in neutral position, perhaps show-
ing slight abduction and external rotation
(resting position).

Pathologic Findings
Buttock raised on one or both sides, visible an-
gulation between the trunk and thigh.
 Active and Passive Hip and Knee Movements 121

2 Active and Passive Hip Phase I1

and Knee Movements Movement in the SU. While the leg is held in hy-
perextension, the free hand immobilizes the
(Regional Diagnosis)
sacrum parallel to the sacroiliac joint line
(Fig. 33 b) and tests the (very slight) joint play in
2.1 Hyperextension of the Hip Joint
the SU.
(Extension from the Neutral Position)
2.2 Rotation of the Hip Joint
Phaselll
2.3 Flexion, Extension, Rotation of the
Test for convergence of the lumbar facet joints,
Knee Joint
especially at the lumbosacral junction. For this
phase the lumbar spine is immobilized up to and
Movements in the posterior sagittal plane and including LS. Higher segments can also be tested
transverse plane by shifting the immobilizing hand cephalad
("Posterior sagittal plane" is the portion of the (Fig. 33 c).
sagittal plane located behind the neutral posi- The leg is held in hyperextension during all
tion.) phases of the test, and only the immobilizing
hand is repositioned. The leg is moved in the
sagittal plane with no mediolateral deviation.
2.1 Hyperextension of the Hip Joint
(Extension from the Neutral Position) Normal Findings
No abduction, adduction, or rotation of the
Active Hyperextension ofthe Straight Leg tested leg. Motion is painless and unrestricted
in all three phases.
Normal Findings Phase I
Normal movement pattern. Activity se- Range of hyperextension is approximately
quence: gluteus maxim us, hamstrings, erector 20° when slight terminal abduction i allowed
trunci of opposite side. (otherwise 10°_15°).
Motion is checked by tbe joint capsule and
iliofemoral ligament.
Range of motion: approximately 15°-20°.
Phase II
Painless limitation of joint play by the sacroil-
Pathologic Findings
iac ligaments.
Gluteus markedly weakened due to ipsilateral
Phase III
SIJ lesion and/or psoas shortening.
Painless hyperextension of the lumbar spine
at the lumbosacral junction.
Passive Hyperextension ofthe Straight Leg End-feel: firm-elastic changing to hard-ela tic
(Three-Phase Test) (Fig. 33 a-c) in phase III (facet closure at LS/Sl).
Procedure
• Differential Diagnosis
Phase 1 Painful SI] and lumbar segments can be differ-
Hyperextension of the hip joint (stage 3 capsular entiated in phase II and III by lifting both legs
pattern after Cyriax). One hand stabilizes the simultaneously, a maneuver that elicits practi-
ilium on the test side at the level of the greater cally no motion in the SUs. Pain during this ma-
trochanter to keep the anterior iliac spine on the neuver (= hyperlordosis) is almost always refer-
table. The other hand grasps the extended leg able to a disturbance in the lower lumbar
above the knee and raises it into hyperextension vertebrae.
(Fig. 33 a). When the limit is reached, the immo-
bilizing hand is repositioned for phase II.
122 Active and Passive Hip and Knee Movements

a
Fig. 33 a-c. Three-phase test (from bottom to top). a Hip joint,
b sacroiliac joint, c lumbar segments

Pathologic Findings even adduction in the final degrees of hyperex-

Range of motion and painfulness are noted. De- tension.
viation of the leg from the sagittal plane signifies
a muscular imbalance. Phase II
Decreased motion with or without pain due to
Phase I SIJ restriction or other SIJ disorders (e. g., anky-
Pain and decreased motion due to: losing spondylitis).
- Psoas shortening (gradually increasing myal-
Phase III
gic pain at the front of the thigh in the inguinal
Pain and limited motion due to:
fold), soft end point
- Contracture of the joint capsule (iliofemoral - VertebralrestrictionatlA-Sl (slight limitation)
ligament) secondary to arthritis or degenera- - Disk protrusion or prolapse (L4-S1, with sig-
tive joint disease nificant limitation or total loss of motion)
Painless hypermobility permits hyperextension Hypermobility may be accompanied by signifi-
to 40 0 with approximately 20 0 of abduction or cant, nonpainfullordosis.
 Active and Passive Hip and Knee Movements 123

Passive Hyperextension with the Knee Flexed and inferior, quadratus femoris, obturator inter-
90° nus and externus, gluteus medius, adductors).
Active resistance test for the external rotators of
Procedure
the hip from a stretched position (see Fig.58b,
One hand immobilizes the ilium on the test side
p.145).
(as above) while the other hand raises the leg,
flexed at the knee, posteriorly.
Passive medial movement of the lower leg
(= passive external hip rotation) and active in-
Normal Findings ternal rotation of the thigh. Combined joint-
Painless hyp rextension of approximately 20° muscle test for passive external rotation of the
with slight abduction . hip joint and active external rotation.
Passive external rotation stretches the internal
rotators of the hip (gluteus medius and minimus,
Pathologic Findings
tensor fasciae latae).
1. Osteoarthritis of the hip. The hip joint cannot Active resistance test for the internal rotators of
be hyperextended. the hip from a stretched position (see Fig. 58 a,
2. Rectus shortening. The pelvis rises from the p.145).
table at once when the knee is flexed. Myalgic
pain at the front of the thigh.
Normal Findings
3. Psoas and rectus shortening. The pelvis, al-
Rotation is painless and bilaterally equal, ex-
ready raised from the table by psoas shorten-
ternal rotation proceeding until elevation of
ing, rises even further on flexion of the knee.
the ipsilateral iliac spine, internal rotation un-
4. Stretched femoral nerve ("reverse Lasegue's
til elevation of tbe contralateral iliac spine.
sign," inguinal ligament syndrome). Sudden,
End-feel: firm-elastic in both directions.
shooting neuralgic pain in the front of the
thigh due to:
Internal rotation tightens the joint capsule and
- Root syndromes at L3 and L4 ischiocapsular ligament (phase one capsular
- Paresthetic meralgia: pain on the outside of pattern after Cyriax), while external rotation
the thigh due to incarceration and stretching tightens the iliofemoral ligament. Ranges of
of the lateral femoral cutaneous nerve in the motion: 30° internal rotation, 45° external rota-
inguinal ligament or of the fascia lata; also oc- tion.
curs in diabetic neuropathy with femoral
nerve involvement Pathologic Findings
Painful limitation of motion with deficient in-
2.2 Rotation of the Hip Joint traarticular gliding (first in internal rotation)
due to arthritis or degenerative joint disease.
Movements in the transverse plane with the hip
Paresis of the internal or external rotators.
joint in the neutral position and the knee flexed
Contracture of the internal or external rotators.
90°,
2.3 Flexion, Extension, Rotation
Passive lateral movement of the lower leg (= pas-
of the Knee Joint
sive internal hip rotation) and active external ro-
tation of the thigh. Combined joint-muscle test Combined joint-muscle test for gliding of the ar-
for passive internal rotation of the hip (capsular ticu
arsurfaces and menisci of the knee.
pattern) and active external rotation. Active test- Active muscle test for the hamstring group:
ing of the external rotators immediately follows biceps femoris, semitendinosus, semimembra-
passive internal rotation (stretched position). nosus (L4-S 3, tibial nerve, fibular nerve) (= knee
Passive internal rotation stretches the external flexion) and the quadriceps femoris (Lz-L4 ,
rotators of the hip (piriformis, gemellus superior femoral nerve) (= knee extension).
124 Palpation at Rest

Passive stretch test for shortening of the rectus 3 Palpation Field of the
femoris muscle. Dorsal Pelvis: Lumbar Jointsl
Soft-Tissue Diagnosis
Normal Findings
(Segmental Diagnosis)
Painless flexion of the lower leg to approxi-
mately 130° (heel almost touches the but-
Palpation at Rest
tock). Extension to 0°.
3.1 Palpation Field of the Dorsal Pelvis
End-feel: firm-elastic.
3.2 Test for Functional Leg Length Discrep-
ancy
Pathologic Findings 3.3 Segmental Palpation of the Lumbar
Painful limitation of passive motion due to: Spine
(Mobility/Pain)
- Shortening of the rectus femoris (terminal 3.4 Kibler's Skin Rolling Test
stretch pain) at the front of the thigh 3.5 Connective-Tissue Stroke Test
- Internal knee derangement (motion blocked 3.6 Segmental Irritation Points of Sell
by degenerative disease, meniscal pathology, (Testing of Irritation Zones)
intraarticular loose body)
Painless limitation of active motion due to:
- Knee flexor paresis, quadriceps paresis, or re-
flex weakening of these muscles
Palpation at Rest
• Differential Diagnosis
If knee flexion is impaired (meniscal pathology,
3.1 Palpation Field of the Dorsal Pelvis
ligamentous lesion), the Apley test is performed
(Fig. 265 e, f, see p. 367). All palpation (touch palpation, palpation for
tenderness) employs bimanual technique with
Procedure and Findings comparison of the right and left sides.
With the knee flexed 90°, The five landmarks for palpation in this field
(see Fig. 34) are as follows:
- The lower leg is rotated with compression:
painful with meniscallesion. 1. Ischial tuberosity
- The lower leg is rotated with traction: painful 2. Greater trochanter
with ligamentous lesion. 3. Posterior hip muscles
4. Posterior superior iliac spine, sacroiliac joint
line, SIJ irritation points
5. Inferior sacral contour, inferior lateral angle,
coccyx Qoint)

1) Ischial Tuberosity (Fig. 35 a,b)

The tuberosities are palpated with both thumbs.
The origin of the hamstrings is palpable posteri-
orly: semitendinosus, semimembranosus, biceps
femoris, long head (L4-S 3, tibial nerve).
Tendinopathies and bursitis may occur, also
apophyseal avulsions in young athletes (run-
ners, jumpers).
Medial to the muscle attachments: attachment
of the sacrotuberalligament (segment S2).
 Palpation at Rest 125

0)
Sacroiliac joint

®
Posterior hip muscles ®
Erector spinae • IP = irritation pOints at the superior pole (S, )
and inferior pole (8 3 ) of the jOints

-h~H-JR-It------ Latissimus dorsi

S1 - S3 irritation zones

H---~c3j Tensor fasciae latae

Greater trochanter
®

"+-+ 1 + f f l f f l - - -
CD
Ischial tuberosity

H~,f-f+Hf*"H-I----~j i CE)PS femoris

1~~~~~~~rt~~Ttt-----A(jductormagnus

®
Greater trochanter sacral contour
CD (inferior lateral ang le and coccyx)

Ischial tuberosity
Fig.34. Palpation field of the dorsal pelvis (general view)
 126 Palpation at Rest

Findings: Painful hypertonicity may be found

with sacrum acutum.
Anteromedial to the ligament on the ischium:
adductor magnus (Lz-SJ, obturator nerve, sciat-
ic nerve).

-Note
a
Pain and tenderness in this area can also occur
with radicular syndromes of the lumbar spine
and with hamstring shortening. The adductor at-
tachments also may be tender in association with
hip joint lesions and restrictions of the SIJ (mus-
cle shortening).

2) Greater Trochanter (Fig. 36 a,b)

The trochanters are palpated with the index or
middle fingers, followed by the muscle and liga-
ment attachments.
Posteroinferiorly: the gluteus maximus at the
b
gluteal tuberosity (LS-S 2 , inferior gluteal nerve).
Fig. 35 a, b. Bimanual palpation of the ischial tubero- Posterior aspect of the trochanter: deeply, the ex-
sities (1) ternal rotators obturator externus and quadra-
tus femoris (LS-S 2 , inferior gluteal nerve) and
the trochanteric bursa.
Point of the trochanter: gluteus medius and min-
imus (L4-S 1, superior gluteal nerve) and, deep to
the trochanteric fossa, the piriformis (Sl/S2/
sacral plexus).

-Note
The small external rotators cannot be differenti-
ated. If the piriformis is shortened, however, it
can sometimes be felt in the area of the greater
a ischiadic foramen by palpating obliquely from
the posterior superior iliac spine toward the is-
chial tuberosity (Janda). The test for piriformis
shortening is described in E/LPH Region/5.2
(p.176).

Additional Findings
Tenderness to percussion of the greater
trochanter is noted with hip joint lesions (sub-
capital femoral fracture, growth disturbance, in-
flammation, tumor, tendinopathy, bursitis).
Abrupt slippage of the iliotibial tract over the
b greater trochanter occurs in a "snapping hip."
Fig.36a,b. Bimanual palpation of the greater Test by palpating flexion and extension of the
trochanters (2) hip joint with the thigh slightly adducted.
 Palpation at Rest 127

3) Posterior Hip Muscles (Fig. 37 a-c) Erector spinae (iliocostalis) at the superior bor-
The following structures are palpated laterally der of the sacrum.
to medially: Iliac crest muscles and iliolumbar ligament from
Tensor fasciae latae over the greater trochanter medial to lateral (Fig. 37 c).
(Fig. 37 a). Hypertonicity of this muscle (and the
iliposoas) is common with SIJ restriction. Thick- - Iliolumbar ligament (to transverse process of
ening and tenderness are present in a "snapping L4 and LS) is tender to pressure when hyper-
hip." mobility is present.
Gluteus medius and minimus at the lateral supe- - Quadratus lumborum (Tl2 and L 1-L3, femoral
rior border of the ilium (Fig.37b). nerve) is a lateral flexor and is prone to short-
Check for myogeloses in the upper outer quad- ening, in which case its lateral border can be
rant (muscle sign of Sell). palpated on the midscapular line lateral to the
Gluteus maximus medially, parallel to the erector trunci. Lumbar sidebending to the op-
sacroiliac joint line. posite side is limited, and occasionally there is
Sell notes that myogeloses and decreased tone respiratory impairment (attachment to the
are found in the gluteals in association with twelfth rib). Increased paravertebral promi-
chronic restrictions and SIJ displacements on nence is noted during forward bending in the
the ipsilateral side. Usually there is accompany- sitting position. Trigger points are found at the
ing hypertonicity of the contralateral tensor fas- lower end of the muscle over the iliac crest.
ciae latae. Gluteal tenderness is also noted with - Obliquus abdominis externus (Ts-T12' inter-
hypermobility. costal nerves) (Mackenzie point).

4) Posterior Superior Iliac Spine, Sacral Sulcus,

Sacroiliac Joint (Fig. 38 a-e )
Initial palpation is bimanual as both thumbs are
placed over the posterior superior iliac spines,
sliding medially into the sulcus between the iliac
spine and median sacral crest. Then each sacroil-
iac joint line is palpated for its full extent (supe-
a '----'......._ _ • rior and inferior poles, Sl-S3) and compared
with the opposite side, giving attention to sulcus
depth, ligament tension (dorsal sacroiliac liga-
ments), and tenderness to pressure. This exami-
nation, like palpation of the inferior sacral con-
tour (especially the inferior lateral angle), aids in
detecting positional faults of the sacrum relative
to the ilia and the functional disturbances that
may result.
The SIJ irritation points (after Sell and Bischoff)
for Sl are located about 3 fingerwidths lateral to
the superior joint pole and about 4 fingerwidths
caudal to the iliac crest. The S3 points are about
1 fingerwidth lateral to the inferior joint pole.
An irritation point has not been described for S2
(see Fig. 34).
Dvorak places the irritation zones for the SIJ on
c the lateral border of the sacrum from the poste-
Fig.37a~. Bimanual palpation of the posterior hip rior inferior iliac spine (Sl) to the inferior later-
muscles al angle above the sacral cornu (S3). Sl-S3
 128 Palpation at Rest

points are also arranged vertically on the pubic

bone adjacent to the symphysis. The author
claims that the finding of symphyseal irritation
zones signifies a general dysfunction involving
the pelvic ring rather than a disturbance con-
fined to the SU.

5) Inferior Sacral Contour, Inferior Lateral

Angle, and Coccyx (Sacrococcygeal Joint)
(Fig. 39 a-e)
The middle finger of the palpating hand slides
down the median sacral crest to the depression of
the sacral hiatus. The inferior lateral angles are
located by spreading the index and ring fingers to
the side. At this site both thumbs are placed on
the dorsal surface of the inferior sacral angle to
check for asymmetric posterior projection. This
area should be observed from the caudal aspect
to aid in detecting the very slight differences in
height. Finally the palpating thumbs slide to the
inferior border of the sacral angle (Fig. 39 a-c) to
check for craniocaudal asymmetry.
The last structure to be examined is the sacro-
coccygeal joint (Fig. 39 d,e). The tip of the coccyx
c
is tender to pressure in the anterior and lateral
direction in the case of positional faults and fol-
lowing sprains caused, for example, by a fall
onto the buttock. A painful sacrococcygeal joint
requires further transrectal examination of the
joint. The attachments of the gluteus maximus
(posterior), levator ani, and coccygeus muscles
and the sacrospinalligament (anterior, palpable
per rectum) also will show relative tenderness.
An open sacral hiatus is found in spina bifida.
d
Biomechanical Considerations
According to Mitchell et aI., palpation of the
sacral sulcus and inferior lateral angle permits
the diagnosis of sacral positional faults that can
lead to functional disturbances in the SUs (posi-
tive seated flexion test, see B!LPH Region!
Sect. 3.2, p.llO).
The axes for sacral movements are as follows
(Fig.40):

- Left and right diagonal axes for torsional

e movements of the sacrum
Fig. 38 a-e. Bimanual palpation of the sacroiliac - One or two transverse axes for flexion and ex-
joints tension movements of the sacrum
 Palpation at Rest 129

Torsional movement of the sacrum about the left

or right diagonal axis is recognized by noting
that the sacral sulcus is deeper on one side than
on the other. This indicates that the base of the
sacrum has moved forward on the side of the
deeper sulcus. Meanwhile the opposite inferior
lateral angle moves backward, occupying a more
dorsal and caudal position than the ipsilateral in-
ferior angle. This positional fault can be accen-
tuated by pressing on the sacral base, producing
a palpable backward movement of the sacrum at
the opposite SU (in addition to precipitating or
aggravating pain). The fifth (and fourth) lumbar
vertebrae always make a relative countermove-
ment in response to this rotation of the sacral
base, because they are connected by the iliolum-
bar ligament with the ilium, which also under-
goes a relative countermovement ("dorsal rota-
tion") in response to sacral torsion. The result is
a slight rotation ofthe vertebrae toward the side
of the deeper sulcus. This exerts an opposite ro-
tatory stress on the fibrous ring ofthe LS-Sl disk
which, according to Farfan, may tear in its outer
layers if the stress exceeds the elastic limit (the
physiologic range of rotary motion in the lumbar
segments is only about 1°-2°). Subsequent fur-
ther tearing of the more central fibers of the
anulus lamellosus may culminate in prolapse of
the nucleus pulposus.
The sacrum can assume forward and backward
torsional positions by rotating about the diago-
nal axes, forward torsion accentuating lumbar
lordosis and backward torsion decreasing it. The
two torsional positions are differentiated by the
springing test (see Two-Stage Springing Test,
p.131). The test elicits an elastic springiness with
a lordotic lumbar spine and nonelastic rigidity
with lumbar kyphosis. Sacral torsion thus repre-
sents a functional adaptation to the lumbar cur-
vature, and vice-versa.
Flexion/extension movements of the sacrum oc-
cur on transverse axes at the level of the SU. The
movement may be a symmetric nutation ("nod-
ding") of the sacrum with respect to the ilia or a
unilateral nutation on the left or right side. With
unilateral nutation, we again find a deeper sul-
Fig.39a-e. Bimanual palpation of the inferior sacral cus on the side of the movement, but now the in-
contour (a~) and palpation of the sacrococcygeal ferior lateral angle of the sacrum moves down-
joint (d,e) ward and backward on the ipsilateral side. The
130 Palpation at Rest

Flexion Torsion

Iliolumbar
ligament Iliolumbar ligament Diagonal axes

1 Movements of the
sacrum and ilium
during sacral torsion
2 Countermovement of Ls
3 Movements of the sacrum
and ilium during sacral
flexion

Inferior lateral
angle

Fig.40. Movements of the sacrum

effects on the vertebral column are the same, sacrum and ilium can produce a functional leg
i. e., sacral flexion accentuates lumbar lordosis. length discrepancy. This is tested before the joint
translation tests are performed (see Sects. 3.1
Summary Pelvic Position and 3.2 Seated Flexion Test).
The sacral sulcus is deeper on one side and dis-
placed posteroinferiorly relative to the opposite 3.2 Testfor Functional Leg Length
inferior angle: sacral torsion about the diagonal Discrepancy
axis. With forward torsion of the sacrum, the
The test for functional leg length discrepancy is
lumbar spine is lordotic (elastic in the springing
performed in the prone or supine position. The
test); with backward torsion, the lumbar spine is
legs must be parallel to the midline with no ad-
kyphotic (rigid in the springing test). The ipsilat-
duction or abduction. The examiner places his
eral inferior angle is displaced downward and
thumbs at the distal border of the medial malle-
backward: sacral flexion.
oli and determines whether they are at the same
The foregoing models of sacral positional faults
level.
are a useful aid to interpreting the subsequent
tests of joint translation, for they help to show
the appropriate directions for corrective thera- Normal Findings
peutic manipulations on the SUs. These transla- The malleoli are at equal levels.
tion tests are provocative tests based on the ex-
perience that aggravating a positional fault of Pathologic Findings
articulating structures evokes (capsular) pain, A functionally short leg can result from a unilat-
while restoring a neutral fit relieves or reduces eral restriction of sacral nutation on the side of
presenting complaints. Positional faults of the the shorter limb.
 Palpation at Rest 131

3.3 Segmental Palpation of the Lumbar

Spine (Mobility/Pain)
Five different palpatory tests are done to evalu-
ate the elasticity and tenderness of the lumbar
spine (and thoracic spine) and identify the af-
fected segment.

Starting Position
Prone with the spine in slight kyphosis.

1) Two-Stage Springing Test

(To establish the level of the disturbance)
(Fig.41 a-c) .
Test for springiness and tenderness to pressure.
Springing is a palpatory technique for testing the
general mobility ofthe spinal segments and is es-
pecially useful for preprogramming the segmen-
tal palpation for tenderness (the "pain rosette "),
which involves circular palpation about the
spinous process. It is most efficient to examine
the thoracic spine concurrently with the lumbar
spine.

Procedure
The heel of the hand is placed on the spinous
processes of the area to be tested. The wrist is
dorsiflexed 90 0 ; the elbow is straight
(Fig.41 a-c).
Alternatively, the thumb may be placed on the
tip of the spinous process, and the pressure ap-
plied through the pisiform bone of the other
hand, which is placed over the thumb (Fig. 42c).
The two test stages are as follows:
1. Light thrusts are applied to test the springiness
of the segments below the heel of the hand. Fig. 41 a--c. Two-stage springing test
Springiness is usually lowest at the midtho-
racic level.
2. Tenderness is tested by applying greater pres- According to Lewit, a tender point on one side
sure to the spinous or transverse processes ofthe spinous process is always located opposite
(see Fig. 43). to a vertebral restriction. Thus, tenderness on
the right side of the spinous process would indi-
2) Palpating the Tips of the Spinous Processes cate a restriction of the left facet joint. It remains
for Tenderness ("Pain Rosette") (Fig. 42 a) unclear, though, whether the vertebra is restrict-
Moderate pressure is applied from all sides of ed with respect to the higher or lower adjacent
the spinous process to the attachments of the lig- vertebra, and whether the restriction is conver-
aments (supra- and infraspinal ligaments) and gent or divergent in nature. In most cases the
intrinsic muscles (interspinales, multifidus, restriction involves the vertebra above. This is
semispinalis) to test for tenderness. determined by the thrust technique described
132 Palpation at Rest

below, direct palpation of the facet joints (see

under Sect. 4), and tests of joint translation (see
C/LPH RegioniSect.4.1, p.135).

3) Thrusting of the Spinous Processes

(Fig.42 b-d)

Thrusting
The forceful application of an anteriorly direct-
ed (Fig.42 d) or cranially directed (Fig.42 b)
thrust to the spinous processes affects the entire
motion segment. It places tension on the liga-
ments about the vertebral arches and interverte-
bral disks, produces traction or anterior gliding
in the facet joints of the vertebra above and
some compression in the joints of the vertebra
below, and thus constitutes a test of translational
motion Goint play) in the sagittal plane that will
require additional tests of facet joint play if ten-
derness or pathologic motion is elicited (see
C/LPH Region/Sect. 4.1, p.135).

-Note
Increased pain in response to thrusting at L4 and
L5 may also indicate spondylolisthesis.
Pain in a spinous process elicited by shaking of
the process has similar significance as pain elicit-
ed by a thrust.

Keyring Test (ofMaigne)

A thrust applied between the spinous processes
toward the supra- and interspinous ligaments
differentiates ligament pain from joint pain.
Liagment pain is most commonly seen with seg-
mental loosening (motion segment laxness).

Normal Findings
The palpatory tests elicit a firm-elastic
springiness.

Pathologic Findings
Springy resistance, muscular guarding, and ten-
derness due to joint effusion, disk protrusion, or
joint restriction.
Severe pain and boardlike muscular rigidity
occur with osteolytic processes.
Fig.42. a, b Pain rosette. c, d Thrust techniques
 Palpation at Rest 133

4) Palpation ofthe Facet Joints (Springing

Test) and Segmental Muscles (Fig. 43 a-d)
The index and middle fingers, spread in V fash-
ion, are placed onto the articular processes di-
rectly adjacent to the spinous process (Fig. 43 b)
or onto the transverse processes about 2 cm lat-
eral to the spinous process (Fig.43 c). The facet
joints and segmental muscles are tested for ten-
derness by applying light, momentary, anteriorly
directed pressure to the palpating fingertips with
the ulnar border of the free hand. Forceful pres-
sure on the transverse processes has the same ef-
fect in the segment as a thrust applied to the
spinous process. This technique is a useful ad-
junct in cases where thrusting ofthe spinous pro-
cess has yielded equivocal results. This test, to-
gether with unilateral hypertonicity of the
segmental muscles, can accurately identify the
side affected by a restriction (see under 2
above). The LS/Sl segment is approached from
the cranial side (Fig. 43 d).

5) Palpation ofthe Segmental Neural Trigger

Points
Dorsal spinal nerve roots incarcerated at the site
where they pierce the fascia, with or without ac-
companying fat herniation ("entrapment neu-
ropathy"), can be palpated a handswidth lateral
to the spinous processes in the lumbar and lower
thoracic region. Pain in the sacral region is local-
ized to the midline. Clinical differential diagno-
sis: pain is exacerbated by massage, often dra-
matically improved by local anesthesia.
Occurrence: relatively rare.

6) Segmental Irritation Points of SeD (Testing

of Irritation Zones) (Fig. 44 a-c)
Starting Position
Prone with the arms hanging loosely at the sides
to relax the back muscles.

Procedure
The segmental IrrItation point is located by
placing the tip of the middle finger adjacent to
the line of the spinous processes, between the
spinous process and erector trunci, and pressing
in deeply (Fig. 44 a). The palpating finger push- Fig. 43 a-d. Springing test. a Starting position: the fin-
es aside the erector trunci about 1 fingerwidth gers are placed on the articular process (b) or trans-
verse process (c). d Hand placement for testing L5
134 Palpation at Rest

(Fig.44c). Sensitivity to forward bending is test-

ed by active flexion and sensitivity to backward
bending by passive hyperextension of the leg on
the palpated side (Fig. 44b).
The diagnostic criteria are pain and change in
firmness; an increase or decrease in these crite-
ria constitutes an indication for treatment. The
movement that produces a decrease in pain and
firmness indicates the appropriate direction for
therapeutic manipulation.
At the sacroiliac joints, Sell and Bischoff report
that the segmental IPs for Sl are located about 3
fingerwidths lateral to the superior joint pole
and about 4 fingerwidths caudal to the iliac crest,
while the IP for S3 is approximately 1 finger-
width lateral to the inferior joint pole.
Restriction is not described for S2, which is be-
lieved to represent the transverse axis for flex-
ion/extension movements of the sacrum. It ap-
pears, then, that irritation zones for S2 could
exist only with hypermobility of the SIJ (see
Fig. 34, p.125). Sutter and Dvorak state that the
IPs for Sl-S3 are located between the posterior
superior iliac spine and the sacral cornu, which
compromises their usefulness as diagnostic indi-
cators.

3.4 Kibler's Skin Rolling Test (Fig. 45)

This test is used for the evaluation ofhyperalget-
ic zones (Head's zones).

Fig.44a-c. Segmental irritation points of Sell

laterally to reach a tender, sharply circum-

scribed area of increased firmness about
0.5-1 cm in diameter: the irritation point (IP).
Keeping the palpating finger on the IP, the ex-
aminer notes its behavior in response to rota-
tion, forward bending, and backward bending
of the spine.
Sensitivity to rotation is tested by moving the pa-
tient's upper arm posteriorly until the lumbar
spine at the level of the IP begins to rotate Fig. 45. Skin rolling test
 Tests of Joint Translation 135

Procedure 4 Tests of Joint Translation

A skin fold extending laterally from each side
of the midline is formed between the thumb
4.1 Lumbar Spine
and index finger and rolled upward toward
4.2 Sacroiliac Joints
the head, parallel to the spinous processes.
4.3 Hip Joints: Rotation
The examiner notes the thickness and consis-
tency of the fold and its resistance to displace-
ment.
While the palpatory tests at rest begin at the hip
Pathologic Findings
joint and proceed to the SUs and lumbar spine,
Excessive firmness of consistency, excessive re-
this sequence is reversed for the testing of joint
sistance to displacement, pain in the area of hy-
play. Mitchell et al. state, moreover, that func-
peralgetic zones.
tional disturbances in the vertebral column
Similar information is furnished by the connec-
should be treated before disturbances in the
tive-tissue stroke test.
pelvic region.
3.5 Connective-Tissue Stroke Test
4.1 LumbarSpine
(Fig.46).
All segments that exhibit tenderness in re-
The skin and subcutaneous tissue are displaced
sponse to firm palpation or thrusting must be
relative to the deeper layers (muscle, tendon,
tested for joint play (Fig.47 a) to establish the
bone).
location of the motion fault and, if possible,
identify the causative factor (facet joint, inter-
Procedure
vertebral disk, segmental muscle) or detect pos-
The examiner's index finger is placed over the
sible hypermobility caused by destabilizing
middle finger, which is stroked firmly across the
structural changes.
skin to raise a bulge of soft tissue. The angle of
the finger to the body surface determines
Starting Position
whether a deeper or more superficial effect is
Prone with lumbar spine elevated to produce
achieved.
kyphosis.
Pathologically altered zones show signs similar
to those observed in the skin rolling test.
Procedure (Fig.47 a-e )
The spinous processes tender to palpation are
first rotated in one direction and then in the op-
posite direction while the next lower vertebra is
immobilized (Fig. 47 b,c). Spinous processes that
are painful in one direction of motion are rotat-
ed in that direction and held in the terminal posi-
tion. Then the spinous process of the next higher
and lower vertebrae are counterrotated
(Fig.47 d,e).
This maneuver first produces a slight gliding
movement in the frontally oriented joint sur-
faces, followed by compression of the facet joint
on the side of the movement (Fig. 47 d) and trac-
tion (decompression) of the joint on the oppo-
site side (Figs. 47e and 62b, p. 149). In each case
Fig. 46. Connective-tissue stroke of approximately the segmental muscles are tensed on the side op-
0.5-1 cm posite the movement.
136 Tests of Joint Translation

Fig.47a-g. Tests of joint play (rotation) in the lumbar

segments. a Finger placement. b,c Procedure. d,e
Identification of the affected level. f, g Testing the di-
rection oflimited or painful motion in the affected seg-
ment
 Tests of Joint Translation 137

segmental muscles. This mode of testing each

Normal Findings
segment yields further information on the ap-
The rotational movements are painless and
propriate direction for therapeutic manipula-
unlimited.
tion.
According to Brugger's theories, however, (pro-
Pathologic Findings
tective) spasm may occur on the unaffected side
A restriction exists in the segment in which
if this helps to prevent movement of the dam-
counterrotation is painful and/or limited. Oppo-
aged joint that would increase nociception
site rotation in the same segment generally
(pain).
evokes little or no pain. If rotation in both direc-
In any case, the muscles that become hypertonic
tions produces significant pain, more severe disk
are those that help to prevent an increase of
involvement (prolapse or inflammatory change)
pressure within the damaged joint or segment.
should be suspected. Slight terminal pain associ-
ated with normal mobility or hypermobility is
more suggestive of motion segment laxness, 4.2 Sacroiliac Joints
which can be confirmed by the key ring test of
Because motion testing of the SIJ is difficult due
Maigne (see p.132).
to its irregular facetting and the very small am-
For hypermobility testing in the prone position
plitude of its movements, it is best to apply sev-
(Fig.6Sc, p.lS3), the examiner places his flat
eral tests to evaluate SIJ mobility. Provocative
hand above the symphysis below the abdomen
tests are the most rewarding, though care must
and lifts the abdomen slightly. The other hand
be taken to avoid concomitant movements in the
palpates the cranial spinous process to check
LS/Sl segment. Figure 48 illustrates the testing
for dorsal displacement due to pathologic
of passive and translational mobility at the lum-
laxness of the mobile segment. Pathologic mo-
bosacral junction.
tion is usually demonstrated more clearly by
pushing the caudal vertebra of the tested seg-
Four-Point Springing Test (Provocative Test
ment in the opposite direction (toward the
for the Upper Pole ofthe SU)
table) with the thenar eminence of the pal-
Pressure on the sacrum at the level of the poste-
pating hand.
rior superior iliac spine (Fig.49 a,b) exerts trac-
-Note tion on the SIJ, while pressure on the adjacent
Palpation of the segmental muscles and facet portion ofthe ilium (Fig.49c,d) exerts compres-
joint is also necessary for identifying the sion on the SIJ. The examiner notes which
restricted side of the segment. According to pre- movement elicits pain. The same pressure points
vious conceptual models, the restriction is gen- are tested on the contralateral SIJ, and both
erally located on the side opposite the paraver- sides are compared.
tebral muscle spasm, since, as in the extremities, Pressure is then applied to the upper outer
nociceptive muscle spasm occurs in the muscles border of the sacral base on one side to produce
that are functionally related to the joint. The in- sacral torsion (nutation) and on both sides to
trinsic back muscles of the medial tract extend produce sacral flexion. If the sacrum is already in
from spinous process to spinous process (inter- a position of flexion or torsion, so that the
spinal muscles), from transverse process to fibrous ring at LS/Sl is already under a rotary
transverse process (intertransverse muscles), strain produced by the automatic counterrota-
and from transverse process to spinous process tion of LS induced by these sacral positions, any
(short rotator muscles) of adjacent vertebrae. increase in rotation will elicit pain; decreasing
They become painful and hypertonic when the the rotary stress by applying a force in the oppo-
tender spinous process is rotated away from the site direction (pressure on the inferior lateral
spastic side and the spinous process below it is angle = counternutation) will alleviate pain
rotated toward that side (muscle stretch). Op- (Fig. SO a-f). The opposite points are tested at
posite rotation of the same vertebrae relaxes the the sacral base and at the inferior lateral angle
138 Tests of Joint Translation

Fig. 48. Pa sive and translational joint mobility at the

lumbosacral junction

Fig.49a-d. Four-point springing test. a,b Sacrum. c,d Ilium

 Tests ofJoint Translation 139

using the same technique, and the results for

both sides are compared. Marked bilateral ten-
derness to pressure on the sacral base indicates
more severe L5/S1 disk pathology.

Springing Test Over the Sacrum (Test for

Countemutation/ Posterior Motion) (Fig. 51)
As one hand applies a springing pressure to the
sacral apex, the forefinger of the other hand pal-
pates the lower end of the posterior iliac spine
(Fig. 51 b) or the upper pole of the SIJ (Fig. 51 a)
to detect the small springy movement. This
c
movement, which is more traction than gliding,
is imparted chiefly to the inferior joint pole near
the site where the force is applied. The patient
must state whether the test movement is painful.
The pain may arise in a restricted joint or in an
overloaded joint showing compensatory hyper-
mobility. A dearly palpable movement of sub-
stantial amplitude accompanied by pain signifies

Fig.50a-f. Counternutation (nutation in the posterior

direction). a Same side (flexion axis). b Opposite side
(torsion axis). c-fMovements of the sacrum about the
d
diagonal axis (torsion axis). Clinical examination and
demonstration on a skeletal model

b
140 Tests of Joint Translation

a painful hypermobility. To avoid confusing skin where it can be palpated even without touching
tension caused by the sacral movement with the ilium. Absence or painful limitation of mo-
movement of the joint, the springing hand on the tion suggests an iliac positional fault in dorsal ro-
sacrum should push the skin slightly cephalad tation if there is concomitant deepening of the
before applying the springing pressure. adjacent sulcus.

lliac Lift Test (Motion Test in Nutation) Craniocaudal Sacral Push (Provocative Test
(Fig. 52 a,b) for the Lower Pole of the Sacrum)
One hand grasps the ilium at the anterior superi- This is a two-phase test that centers on the infe-
or iliac spine and applies a springing force di- rior pole of the sacrum. Its purpose is to identify
rected back toward the sacrum while the finger the therapeutic direction for manipulation or
of the other hand palpates the sulcus between mobilization of the joint in cases of sacroiliac
the ilium and sacrum, above the posterior supe- displacement (iliac rotation, sacral torsion or
rior iliac spine. The hypothenar of the palpating flexion) where the joint is fixed in a terminal po-
hand stabilizes the sacrum during the test so that sition. Again, the test is based on the concept
iliac motion is more clearly perceived. The and experience that pain is provoked by the at-
movement (posterior movement of the ilium rel- tempt to accentuate a positional fault in a joint,
ative to the sacrum) occurs chiefly at the upper while pain is relieved by moving the joint sur-
pole of the SIJ and is easier to palpate at that lo- faces back to an intermediate position of con-
cation. With a firm restriction of the joint, the il- gruency. This test movement is not accessible to
iac movement will be transmitted to the sacrum, digital palpation.

Fig. 51a,b. Springing test over the sacrum (counter- Fig.52a,b. Springing test over the ilium (lift test)
nutation) with simultaneous palpation of the lower with simultaneous palpation of the upper pole of the
pole ofthe SIJ SIJ
 Tests of Joint Translation 141

Phase 1: Countemutation ("Backward

Nodding") of the Sacrum by an Upward Push
(Figs. 54 a-d, 53a; Fig. 54 a,b shows the
technique for the left SIJ, Fig. 54 c,d for the
right SIJ).
The immobilizing hand is placed so that the hy-
pothenar and little finger are over the iliac crest.
The pushing hand is placed so that the pisiform
bone is at the inferior lateral angle ofthe sacrum
next to the sacral hiatus. The hands and fore-
arms are positioned opposite to each other in the
direction of the push. The caudal hand pushes
upward to elicit a counternutational movement
of the sacrum. Example: Patient presents with
forward torsion or unilateral flexion of the
sacrum or dorsal rotation of the ilium. In this sit-
uation the base of the sacrum has moved down-
ward and forward in relation to the ilium on one
side (the side with the deeper sacral sulcus). It
should be possible to push the sacrum forward
and upward, causing the base to move posterior-
ly, without eliciting pain. If this movement is
painful, the opposite direction (nutation) must

f't--....L..._-'---f\. Iliac crest

immobilized

Direction
a of test movement

Direction
c:::::J of test movement

~l

b
Fig.54a-d. Counternutation test of the left (a, b) and
Fig.53a,b. Craniocaudal sacral push right sacroiliac joints (c, d)
 142 Tests of Joint Translation

be tested by pushing the sacrum forward and ing the joint are twisted posteriorly to release
downward in relation to the ilium. This move- soft-tissue tension, then an anterolateral push is
ment should then be painless. applied deeply to the ilium while the contralat-
eral side of the sacrum is immobilized. The ante-
Phase II: Nutation ("Forward Nodding") of rior superior iliac spine should not rest directly
the Sacrum by a Downward Push (Figs. 55a,b, on the table (padding).
53b; right SIJ).
The pushing hand is placed so that the pisiform -Note
bone is on the base of the sacrum next to L5; the If the initial situation is reversed (backward tor-
immobilizing hand is placed with the hy- sion of the sacrum or forward rotation of the ili-
pothenar on the ischial tUberosity. Lumbar lor- um, the sacrum having moved upward and back-
dosis is eliminated to ensure that the pushing ward relative to the ilium on one side), the
hand has sufficient contact with the sacrum and principle remains the same. In this case an up-
that the lumbar segments, especially L5/Sl, do ward push on the sacrum (counternutation) will
not move. The cranial hand pushes downward to evoke pain by accentuating the positional fault,
elicit a forward and downward nutational move- while a downward push (nutation) will relieve
ment of the sacrum. pain by decompressing the joint.
Both tests are generally performed in succes-
sion. They may be followed by an anterolateral
Normal Findings
iliac push in which the hand is placed flat on the
Pushing in either direction does not elicit
ilium with the thumb and thenar parallel to the
pain.
sacroiliac joint line. First the soft tissues cover-

Pathologic Findings
In most cases the nutational push is painful while
the counternutational push relieves pain, since
the SIJ generally is displaced or restricted in a
position of terminal nutation. This is because in
an upright posture or while walking, the pre-
dominant joint movement is nutation due to the
weight of the torso. Excessive movement can
culminate in a restriction.
While the foregoing tests act on the joint mem-
bers themselves, in the following tests the exam-
iner transmits the motivating force through the
a
adjacent hip joint by using the lower extremity
as a lever arm.

Gapping Test (SIJ Traction) by Internal

Rotation of ihe Femur
As in the testing of internal hip rotation, the ex-
aminer flexes the knee 90° and grasps the ankle
to internally rotate the femur (as in Fig. 56a).
Motion at the hip joint should not be painful.
When the opposite iliac spine begins to lift up,
gapping of the ipsilateral SIJ can be detected
with the palpating finger (not shown in the fig-
b
ure). Similarly, the hyperextended femur (phase
Fig.SSa,b. Nutation test ofthe right sacroiliac joint 2 of the three-phase test) can be used as a lever
 Tests of Joint Translation 143

to induce palpable counternutation of the Internal Rotation (Fig. 56 a)

sacrum in the ipsilateral SIJ (see p.122).
Starting Position
Sell's Traction-Assisted Test The examiner stands on the lateral side of the
In this technique the sites of induration com- tested leg. The thigh is slightly abducted, the
monly associated with SIJ restrictions and dis- knee flexed 90°.
placements are first palpated in the area of the
gluteus maximus, medius, or minimus (segmen- Procedure
tal irritation points, see p.133). Then a counter- The lower leg is moved laterally until the con-
nutation movement of the sacrum is produced at tralateral anterior superior iliac spine rises
the SIJ by pushing on the inferior lateral angle of about 5 em from the table. The examiner stead-
the sacrum in the cranial and/or anterior direc- ies the lower leg in that position against his body.
tion while supportive caudal traction is applied The other hand then presses the ipsilateral ilium
to the leg (gripped between examiner's arm and (with the acetabulum) anteriorly and medially
body). A palpable "softening" of the firm sites (toward the table) to produce a gliding move-
(irritation zones) and the patient's confirmation ment of the acetabulum relative to the fixed fe-
of decreased tenderness to palpation indicate mur, which thus undergoes a relative internal ro-
the therapeutic direction. One disadvantage of tation.
this test is that the anterior pull on the ilium is
transmitted across the intervening hip joint. External Rotation (Fig. 56 b)
Further SIJ tests are performed as needed in the
lateral and supine positions (see D/LPH Re- Starting Position
gion/Sect.4, p.152; E/LPH RegioniSect.4.3, The examiner stands on the side of the untested
p.l72). leg.

4.3 Hip Joints: Rotation (Fig. 56)

Procedure
Internal rotation is the first motion that is re- The lower leg is brought medially toward the ex-
stricted in the presence of a joint lesion. aminer until the anterior superior iliac spine on

a b

Fig.56a,b. Hip joint rotation. a Internal rotation. b External rotation

144 Muscle Tests

the tested side rises about 5 cm from the table. Extensors (Fig. 57)
Again, the examiner steadies the lower leg in
Starting Position
that position against his body. The other hand
Leg is extended or flexed 90° at the knee. Leg
presses the ilium on the test side anteriorly and
position is intermediate between internal and
laterally (toward the table) to produce a relative
external rotation. Pelvis is immobilized.
external rotation of the fixed femur with respect
to the moving pelvis.
Procedure
The examiner applies resistance as follows:
Normal Findings Below the knee with the leg extended: Resis-
Equa l ranges of painJess internal and external tance is applied anteriorly against extension by
rotation on both sides with a firm-elastic end- the gluteus maximus (Ls-S2' inferior gluteal
feel. nerve) and hamstrings (L4-S 3 , inferior gluteal
Ranges of motion: nerve, tibial nerve), Fig. 57 a.
Internal rotation 30°-40°
External rotation 40°-50° eNote
The pelvis should be well immobilized and mon-
itored for movement, e.g., by palpation of the
These tests can also be applied therapeutically in
greater trochanter.
patients with limitation of hip motion.
Above the knee: Resistance is applied anteriorly
against extension with the knee flexed 90° (to
deactivate the hamstrings), Fig.57b. The ten-
don attachment on the gluteal tuberosity (only
5 Muscle Tests gluteus maximus) can be simultaneously pal-
pated.
An even more accurate test for gluteus maximus
5.1 Resistance Tests of Hip Muscles
weakness is to support only the patient's trunk
(Extensors and Rotators)
on the examination table while the patient per-
5.2 Knee Muscles
forms the above tests, raising the leg without ex-
5.3 Back Extensors
ternal resistance. When weakness is present, the
leg cannot be raised past the horizontal and
5.1 Resistance Tests o/the Hip Muscles begins to deviate into abduction and external
(Figs. 57, 58) rotation.

Fig.57a,b. Resistance test of the hip extensors. a Hip extensor group. bGluteus maximus
 Muscle Tests 145

a b

Fig.58a,b. Resistance test ofthe hip rotators. a Internal rotators. b External rotators

Rotators (Fig. 58)

Procedure
With the knee flexed 90°, the internal rotators of
the hip are tested by applying resistance at the
lateral malleolus while the thigh is in neutral ro-
tation or maximum external rotation (Fig. 58 a).
Then, with the knee still flexed 90°, the external
rotators are tested by moving the lower leg later-
ally to a position of neutral or maximum internal
thigh rotation and applying resistance at the me-
dial malleolus (Fig. 58 b).
The pelvis must be immobilized for both tests.

5.2 Knee Muscles (Figs. 59,60)

Starting Position
The knee joint is moderately flexed to 70°-80°.

Procedure
The examiner applies resistance as follows:
On the anterior side of the lower leg: Extension is
resisted to test the quadriceps femoris (Lz-L4 ,
femoral nerve), Fig. 59a. The femur must not ro- ____b
tate during the test.
On the posterior side of the lower leg: Flexion is Fig. 59 a, b. Resistance tests of the knee muscles.
resisted to test the hamstring muscles (L4-S 3, tib- a Knee extensors. b Knee flexors
 146 Muscle Tests

ial and peroneal nerve), Fig. 59 b. The hip should

be slightly flexed during this test.

-Note
If the hip joint is in 0° flexion while the knee is
flexed 90° or more during the hamstring resis-
tance test, spasm may occur in the (weakened)
hamstrings if there is coexisting rectus shorten-
ing. This can be avoided by flexing the hip slight-
1y to relax the rectus.
Substitution by the sartorius tends to produce
a external rotation at the hip.

Differentiation of the Hamstrings

Starting Position
Knee flexed 30°-40°.

Procedure
Flexion with the femur internally rotated, i. e.,
the lower leg swung laterally. Resistance to flex-
ion is applied at the medial malleolus (Fig. 60 a)
to test the semitendinosus, semimembranosus,
b-"'_ _-""_ and gracilis (L4-S 2 , tibial nerve).
Flexion with the femur externally rotated, i. e., the
Fig.60a,b. Differentiation of the flexors. a Semi- lower leg swung toward the median plane. Re-
tendinosus, semimembranosus, gracilis. b Biceps
sistance to flexion is applied at the lateral malle-
femoris
olus (Fig. 60 b) to test the biceps femoris (L4-S 3 ,
sciatic nerve).

Fig.61. Resistance test of the

back extensors
 Muscle Tests 147

5.3 Back Extensors (Fig. 61) the same starting position. In this more difficult
version of the gluteus test, the tested leg is
Starting Position
extended while the other leg is braced against
The patient lies at the end of the table with part
the floor. Resistance to hip extension is ap-
of the pelvis extending past the table edge. The plied to the back of the thigh (see extensor
legs hang over the table edge, flexed at the hips
tests).
and k]1ees. The patient maintains the position by
holding onto the opposite end of the table.
-Note
Tests for shortening of the rectus femoris,
Procedure iliposoas, tensor fasciae latae, short adductors,
Extension of the lumbar spine is resisted by ap- piriformis, and hamstrings are performed in
plying caudally directed pressure to the sacrum. the supine position (see E/LPH Regionl
The gluteus maximus also can be tested from Sect. 5.2, p.176).
Examination of the LPH Region
in the Lateral Position (DIll)

3 Palpation ofthe Lumbar Spine During

Movement
(Segmental Mobility)
3.1 Forward and Backward Bending
3.2 Sidebending
3.3 Rotation

4 Tests of Joint Translation

4.1 Hypermobility Test ofthe S11
4.2 Hypermobility Test of the Lumbar Spine

5 Muscle Tests
Resistance Tests of Hip Musc1es
5.1 Abductors
5.2 Adductors
 Palpation of the Lumbar Spine During Movement 149

3 Palpation of the Lumbar Spine Procedure

During Movement (Segmental Mobility) The patient's flexed knees are immobilized be-
tween the examiner's thighs. The examiner then
grasps the lower legs from the front and moves
3.1 Forward and Backward Bending
both legs cephalad to flex the lumbar spine, si-
3.2 Sidebending
multaneously imparting a slight back-and-forth
3.3 Rotation
action to aid the assessment of segmental mobil-
ity.
The backward bending test is performed in anal-
The movements in the facet joints of the lumbar ogous fashion (Fig. 63 b). Also, a posteriorly di-
spine are illustrated in Fig. 62. rected push is applied to the pelvis via the femo-
ra to increase the segmental motion.
During forward and backward bending of the
3.1 Forward and Backward Bending
spine, the index finger of the examiner's free
(Fig. 63 a,b)
hand palpates the interspaces between two adja-
cent spinous processes to assess their movement
Starting Position
relative to each other (Fig. 63 e).
Stable lateral position on the edge of the exami-
nation table. The hips and knees are flexed; the
head rests on the hand or forearm. Normal Findings
Divergence (separation) of tbe palpated
spinous proce ses during forward bending,
convergence (approximation) of the proces-
ses during backward bending. During forward
bending, the amount of movement at Ll-L5
increase while mobility in the L5-S1 segment
decrease . During backward bending, L5fSl
becomes more mobile (see also Fig. 10).

Pathologic Findings
- Limitation of segmental motion
- Pain on terminal motion that mayor may not
radiate (disk protrusionf nociceptive reaction
from the facet joint)
a

3.2 Sidebending (Fig. 63 c,d)

Starting Position
Same as before. The examiner stands in front of
Tra9tion the patient or at a 90° angle, i. e., facing the foot
( ;/--+
Direction of test movement of the table. The patient's hips and knees are
\: flexed 90°.

Procedure
b
One hand grasps the patient's lower legs above
Fig. 62. a 1, Gliding during distraction, forward the malleoli and moves the legs and pelvis later-
bending, backward bending; 2, translational gliding. ally and superiorly, producing lateral flexion of
b Translational joint motion during rotation the lumbar spine with the concavity upward. The
150 Palpation of the Lumbar Spine During Movement

Fig.63a--e. Segmental exami-

nation during a forward
bending, b backward bend-
ing, c, d sidebending. e Pal-
pation of the spinous proces-
ses and palpable movements
 Palpation ofthe Lumbar Spine During Movement 151

Fig.64a-d. Segmental exami-

nation during rotation: a ro-
tation of the upper vertebra
to the left, b, d rotation of the
lower vertebra to the right.
c Rotation with traction.
d Right rotation of the lower
vertebra on a skeletal model d
152 Tests of Joint Translation

index finger of the free hand palpates the con- left rotation and to the left with right rotation,
comitant rotation of the spinous processes from since the palpated spinous process is located be-
the concave (upper) side (Fig. 63 c) or from the hind the axis of vertebral rotation. If there is
other side if the lumbar spine is in kyphosis. Fig- suspicion of disk involvement (protrusion),
ure 63d illustrates sidebending produced by traction is superimposed upon the rotation
direct tilting of the pelvis. (Fig. 64c).

Normal Findings Normal Findings

Rotation of the spinous processes toward the Slight rotational mobility from Ll to L5 (max-
concavity if the lumbar spine is in lordosis, or imum 3°_7° according to Pulz ). Greatest cou-
away from the concavity if lumbar spine is in pled rotation (according to White and Pan-
kyphosis. Mobility increase from Ll- L3, de- jabi) in the L3/L4 segment. Greatest axial
creases from L3 to S1 (see Fig. 10). Mobility is rotation at the lumbosacral junction.
lowest at the lumbosacral junction.
Pathologic Findings
Decreased or increased mobility in one or more
Pathologic Findings
motion segments compared with the adjacent
- Decreased sidebending mobility segments.
- Pain on terminal motion

3.3 Rotation (Fig. 64 a-c) 4 Tests of Joint Translation

Starting Position
Unstable lateral position with the lower leg al- 4.1 Hypermobility Test ofthe SIJ
most extended and the upper leg flexed at the 4.2 Hypermobility Test of the Lumbar Spine
hip and knee so that the foot rests on the calf or
in the popliteal fossa of the lower leg.

Procedure
4.1 Hypermobility TestoftheSIJ
The examiner either steadies the thorax with Mennell's test ofthe sacroiliac joint and ligaments
one hand and rotates the pelvis anteriorly (dorsal sacroiliac ligaments) (Fig. 65 a)
(Fig. 64 b) or steadies the pelvis and rotates the
thorax posteriorly (Fig.64a). Both maneuvers Starting Position
rotate a given vertebra to the left if the patient is Stable lateral position at the edge of the table.
on the right side, or to the right if the patient is on The knees and hips are both flexed about 90°,
the left side, relative to the vertebra below. Thus, the head resting in the hand.
the rotational movement can be initiated either
from the thigh (pelvic rotation) or from the Procedure
shoulder (thoracic rotation). With rotation of Brief, forceful compression is applied to the an-
the thorax (Fig. 64a), the tested segment should terolateral portion of the uppermost iliac wing
be in the neutral position or in slight kyphosis, and/or sustained pressure to the uppermost iliac
because rotation to full dorsiflexion leads to a wing for 1-2 min using the examiner's full body
facet closure that blocks further motion in the weight.
segment, especially in broad-shouldered pa-
tients.
Normal Findings
Vertebral rotation is assessed by palpating the
Brief compression or sustained pressure does
lateral movement of the spinous process rela-
not elicit pain.
tive to the process below, i. e., to the right with
 Muscle Tests 153

4.2 Hypermobility Test of the Lumbar

Spine (Fig. 65 b,c)

Starting Position
Same as above (Sect. 4.1).

Procedure
The upper leg is flexed past 90° until the liga-
ments in the tested joint begin to tighten (palpa-
tion). The examiner then applies a posteriorly
directed thrust via the flexed thighs and palpates
for a step between two adjacent spinous process-
es in the segment. Then the other hand pushes
back anteriorly and checks for disappearance of
the step. The test in the prone position (Fig. 65 c)
was described on p.137.

Normal Findings
b
No step between adjacent spinous processes,
no pain.

Pathologic Findings
A step signifies motion segment laxness.

c.-
5 Muscle Tests
(Resistance Tests of Hip Muscles)

Fig.65. a Test for SIJ hypennobility (Mennel's test). 5.1 Abducto"

b Test for hypennobility of the lumbar spine, c in the .1 5.2 Adductors
prone position

Pathologic Findings 5.1 Abductors (Fig. 66a)

Brief compression evokes or aggravates pain in
the dependent hip joint if hip disease is present. Starting Position
Pain occurs in one or both SIJs with inflammato- Lateral with the head resting in the hand, as be-
ry disease (sacroiliac arthritis, ankylosing fore. The lower leg is flexed at the hip and knee,
spondylitis). Sustained pressure for about 1-2 the upper leg is extended. The patient holds onto
min evokes stretch pain in the dorsal sacroiliac the front of the table with the upper arm to sta-
ligaments when SIJ hypermobility is present bilize the trunk.
(Fig. 65 a). Turning to a lateral recumbent posi-
tion is painful in the presence of SIJ lesions or Procedure
motion segment laxness in the lumbar spine. Ly- One hand immobilizes the uppermost iliac wing
ing on the side causes pain in the dependent os- from above, exerting caudally directed pres-
teoarthritic hip. Hip pain also occurs with SIJ re- sure, to keep the abdominal muscles or quadra-
striction and/or osteoarthritis on the same side. tus lumborum from supporting the gluteals.
154 Muscle Tests

The other hand applies steady counterpressure

to the lateral side of the extended thigh above
the knee as the patient actively abducts the leg
(with the hip in the neutral position) against the
resistance. The thigh must not deviate in flex-
ion, extension, or rotation to eliminate the re-
cruitment of other muscle groups.

Normal Findings
Painless abduction, equal on both ides, with
a muscular strength of 4-5.

Pathologic Findings
Muscular strength decreased as a result of:
Muscular insufficiency secondary to hip disor-
ders (dysplasia, congenital dislocation, coxa
vara, Perthes' disease, etc.). Evidenced by a de-
crease in the distance between the origin and in-
sertion of the gluteus medius and minimus (with
a positive Trendelenburg test).
Muscular insufficiency due to shortening of the
ipsilateral adductor group.
Paresis of the superior gluteal nerve (L4-S 1). ......_.. b

Fig.66a,b. Hip muscles. a Abductors, b adductors

5.2 Adductors (Fig. 66 b)
Starting Position
Normal Findings
Same as above.
Painless adduction with a muscular strength
of 4-5.
Procedure
The patient's upper leg is steadied against the ex-
aminer's body. Manual resistance to adduction is Pathologic Findings
applied at the medial side of the thigh. Again, Decreased muscular strength with adductor
great care is taken to maintain a neutral hip posi- paralysis due to obturator nerve palsy (Lz-L4 ).
tion to avoid substitution by other flexor or ex- Pain at the symphysis, especially with gracilis
tensor muscles. syndrome, adductor tendopathy, or inflammato-
Usually the abductors and adductors are rou- ry bone lesions at the adductor attachments (pu-
tinely tested in the supine position (Fig. 82 b,c, bic osteitis: traumatic, rheumatoid, tuberculous,
p.173) or sitting position (Fig. 32 a-d, p.118). or from hormonal overdose).
Examination of the LPH Region
in the Supine Position (E/II)

1 Inspection
1.1 Legs
1.2 Pelvic Position
1.3 Vertebral Column
1.4 Abdominal Wall

2 Active and Passive Motion Testing:

Hip and Knee Joints, SIJ, and Lnmbar
Spine
2.1 Hip Flexion
2.2 Hip Rotation
2.3 Hip Abduction
2.4 Knee J oint Screening Tests
2.5 Differentiation of the LPH Joints:
Hip Joint, SIJ, Lumbar Spine, and
Muscles

3 Palpation Field ofthe Ventral Pelvis

(Palpation at Rest)

4 Tests of Joint Translation

4.1 Traction and Compression of the
Lumbar Spine
4.2 Traction and Compression of the
Hip Joint
4.3 SIJ Springing Tests via the Thigh

5 Muscle Tests
5.1 Resistance Tests of the Hip and
Abdominal Muscles
5.2 Shortening Tests
156 Inspection

1 Inspection - Flexion contracture ofthe hip, e. g., secondary

to inflammatory or degenerative hip disease
1.1 Legs 2. Axial limb deformity (in the frontal plane)
1.2 Pelvic Position
- Genu varum or valgum
1.3 Vertebral Column
- Malunited femoral or tibial fracture
1.4 Abdominal Wall
3. increased external rotation of one or both legs

Starting Position - External rotation contracture of the hip joint

Relaxed supine position with the legs parallel (e. g., osteoarthritis)
and the pelvis horizontal. - Growth disturbance (e.g., Perthes' disease),
inflammatory diseases
- Congenital dislocation of the hip (compare
1.1 Legs trochanter levels)
Up to 60° increase of femoral neck antever-
Normal Findings
sion in an anteverted hip
1. Equal length and parallel alignment of the
Flexion, abduction, external rotation defor-
legs. Patellae in the frontal plane.
mity with a pubic (anterior) hip dislocation
2. No axial deformity. The leg axis should pass
Flexion, adduction, internal rotation deformi-
through the center of the femoral heads,
ty with an iliac or ischial hip dislocation
patellae, and ankle mortices. Note the rela-
- Psoas shortening (with a flexed joint posi-
tive positions of the patellae and feet.
tion): Reversible psoas shortening (Moser's
3. Physiologic external rotation of tbe lower
sign) can result from irritation at the psoas
extremity. There is a normal 12° antever-
origins (transverse processes T12-L4) or in
sion of the femoral neck (angle between
proximity to the muscle (appendix, kidneys,
condylar axis and femoral neck axis). Max-
ovaries, gravity abscess, hip joint irritation or
imum internal rotation of the leg nullifies
inflammation) or from restrictions of the SIJ
the physiologic anteversion of the femoral
or midlumbar spine
neck, placing the trochanters on the frontal
- Dorsal rotation of the ilium in the SIJ
plane. The iliotibial tract may run over or
behind the greater trochanter. 4. Leg girth discrepancy (contour changes,
4. Equal muscle girths on both sides, mea- swelling)
sured 20 cm and 10 cm above and 15 cm be- Girth increased:
low the medial joint line of the knee. - Thick legs (distal portions, thigh and lower
keg): etiology unknown
For inspection of the legs in standing (weight - Thrombosis, varicose veins, elephantitis, lym-
bearing), see NGeneral Inspection (p.76 f.). phedema
- Muscular hypertrophy (athletes)
Girth decreased:
Pathologic Findings
- Disuse atrophy (e.g., after prolonged immo-
i. Unequal leg lengths bilization)
- Peripheral nerve palsies (LZ-L4, femoral
- Anatomically short or long leg nerve; Lz-L4, obturator nerve; L4-Sj, sciatic
- Functional leg length discrepancy. Dorsal ro- nerve)
tation of the ipsilateral ilium and/or rotation - Muscle diseases
of the sacrum forward and downward about
its oblique axis produces a functionally short
limb.
- Psoas shortening
 Active and Passive Motion Testing 157

1.2 Pelvic Position 2 Active and Passive Motion

Deviations in the frontal plane. Testing: Hip and Knee Joints, SIJ,
and Lumbar Spine
Normal Findings
Pel vi horizontal with no rotation. Anterior 2.1 Hip Flexion
2.2 Hip Rotation
2.3 Hip Abduction
2.4 Knee Joint Screening Tests
Pathologic Findings 2.5 Differentiation of the LPH Joints: Hip,
Pelvis high on one side due to hip contracture: SIJ, Lumbar Spine, and Muscles
- Adduction contracture: contracted side is
high.
- Abduction contracture: contracted side is low.
2.1 Hip Flexion
Motion testing in the anterior sagittal plane
Lateral pelvic shift due to scoliosis of the lumbar
Tests are performed first with the knee extend-
spine (shifted toward the concavity), anatomic
ed, then flexed.
or functional pelvic torsion.
Starting Position
1.3 Vertebral Column Relaxed supine position.

Viewed from the side. The physiologic curva- a) Active Elevation of the Extended Legs to
tures are dependent on pelvic position. About 20° Flexion
Test for the hip flexors, iliopsoas, and rectus
Pathologic Findings femoris (~-L4' femoral nerve) and lower lum-
Flattening of the curvatures due to hypermobili- bar disk compression.
ty (high assimilation pelvis).
Hyperlordosis secondary to shortening of the
Normal Findings
psoas, rectus femoris, and/or erector trunci; hip
The movement is painless and unrestricted;
flexion contracture; congenital hip dislocation.
lumbar lordosis is increased.

1.4 Abdominal Wall Pathologic Findings

Pain on disk compression in the lower lumbar
Pathologic Findings
segments by psoas tension indicates a disk lesion
1. Scars and striae (motion segment laxness).
2. Hernial openings and swellings about the in-
guinalligament: b) Maximum Passive Elevation ofthe
Swelling above the inguinal ligament: in- Extended Legs and Return to the Neutral
guinal hernia Position
Swellings level with the inguinal ligament: This test, performed immediately after the pre-
usually lymph nodes vious test, involves a passive continuation of the
Swelling below the inguinal ligament: femoral active hip flexion.
hernia, gravity abscess, traumatic anterior hip
dislocation
Normal Findings
Depression below the inguinal ligament: trau-
Painless hip flexion to 90°-120° and painless
matic posterior hip dislocation
extension to the neutral position. Lumbar lor-
See also AlGeneral Inspection/Sects. 1.2 and 3
dosis disappears during hip flexion.
(p.74).
158 Active and Passive Motion Testing

Pathologic Findings (external rotator). This can also be used to de-

Lumbar lordosis persists (and is painful): verte- tect aggravation in Laseque's sign (see Bon-
bral restriction in the lumbar spine or shortening net's sign).
of the erector trunci. Pain in the final motion • flLggard's sig!1 is used to distinguish a true
phase after the elimination of lumbar lordosis Laseque's sign from pseudo-Lasegue. When
indicates a lesion at the lumbosacral junction Lasegue-type pain is first elicited, the leg is
(pelvic rotation pain). Pain on sudden reversal lowered until the pain just disappears. In that
to hip extension signifies lumbosacral ligamen- position the foot is strongly dorsiflexed to
tous insufficiency, pathologic segmental laxness provoke typical sciatic stretch pain. This
(chondrosis, spondylolisthesis), or degenerative maneuver also can test for aggravation
irritation in the L5/S1 segment. tendencies. The sign is usually negative when
aggravation is present.
c) Active Elevation of One Leg • Crossed Lasegue: Sciatic pain is felt on the
involved side even when the leg on the healthy
Normal Filldings side is raised (Lasegue-Moutand-Martin sign)
- Painless active flexion to about 80°_90° due to transmission of the leg movement to
(with 10° additional passive flexion). the affected vertebral segment. This response
- Elimination of lumbar lordosis. is pathognomonic for an intervertebral disk
- Terminal external rotation of the leg by protrusion.
psoas predominance. • Thomsen s sig!1.: palpation of the painful sciat-
- More than 120° hip flexion is considered ic nerve above the popliteal fossa with the foot
hypermobile, 90 0 -120 0 i normal, and Ie s dorsiflexed and the knee flexed 90°-120°.
than 90° is hypomobile. • Kernigll1g!1.: Accentuation of pain on raising
the head or passive dorsiflexion of the big toe
(Turyn's sign) indicates significant sciatic
d) Passive Elevation of One Leg with the Knee irritation.
Extended (Straight Leg Raising Test)
• Note. Some believe that the sciatic pain in this
In patients with radiating leg pain, this test can
test is not caused by nerve stretch but by
differentiate the far more common myalgic pain
venous congestion and a change in the cross
(pseudo-Lasegue's sign) from the less common section of the spinal cord.
neuralgic pain (true Lasegue's sign).
• Bonnets sig!1.: sciatic pain evoked by adduct-
ing and internally rotating the leg flexed at the
Nonnal Filldings knee (piriformis sign).
Same as in previous test. • Brudzinski's sig!1.: Raising of the head (ante-
flexion) is accompanied by a slight flexion of
the knee and hip joints due to meningeal
Pathologic Filldings
irritation.
Pain The same effect can be produced by pressure
• Lasegue's sig[h Sudden shooting neuralgic on the pubic symphysis (Brudzinski II).
pain along the back of the thigh, calf, and foot. • Note. Other symptoms of meningeal irrita-
Examiner notes the angle between the trunk tion are nausea, vomiting, circulatory impair-
and thigh at which pain occurs. ment, hypersensitivity to stimuli, and psychic
• Pseudo-Lasegue's sig!1 refers to a dull muscle changes.
ache of gradual onset due to hamstring
shortening. Decreased Passive Mobility
Lasegue's sign occurs earlier when the test is - With a dull, gradually increasing ache from
performed with the leg adducted and internal- the back of the thigh to the knee from about
ly rotated, which causes additional stretching 40°-50° due to shortening of the hamstrings
of the nerve as it passes below the piriformis (pseudo-Lasegue) and/or erector trunci
 Active and Passive Motion Testing 159

- Due to a unilateral SIJ dysfunction accom- e) Active and Passive Maximum Flexion of the
panied by painless, unrestricted leg raising Hip and Knee Joints (Figs. 67, 68)
on both sides (backward pelvic tilt) Test of knee mobility, hip joints, and sacroiliac
- With sudden, sharp, lancinating ("bright") joints Goint play, stability, ligaments).
pain between about 20° and 50° due to radicu-
lar irritation (Lasegue's sign)
Normal Findillgs
- Motion limited by hip joint disease (stage III
Painless maximum hip flexion while the knee
capsular pattern of Cyriax)
is maximally flexed (eliminating lumbar lor-
- Irreversible external rotation and abduction
dosis) is possible in the following directions:
(Drehmann's sign) due to retroversion of the
I. Toward the patient's ipsilateral shoulder
slipped capital femoral femoral epiphysis rel-
(sacrotuberalligament) (Figs. 67b, 6Sa)
ative to the femoral neck
2. Toward the opposite shoulder (iliosacraJ
- Hip-lumbar extension deformity: The patient
and sacrospinalligament ) (Fig. 68 b)
can be painlessly lifted from the table with the
3. Toward the opposite hip (iliolumbar liga-
knees, hips, and lumbar spine rigidly extended.
ment) (Fig. 68 c)
Etiology is unclear (disk protrusion, tumor?).
When maximum flexion is reached, a painles
force is applied along the longitudinal axis of
Decreased Active Mobility the femur and maintained for several sec-
- Hip flexor paresis (LZ-L4, femoral nerve) dur- onds.
ing active testing
- Progressive muscular dystrophy
Pathologic Findings
Ligament pain in directions 1-3:
Increased Mobility
General hypermobility, indicated by hip flexion 1. Pain radiating along the back ofthe thigh with
past 120° (clasp-knife phenomenon) with the tenderness of the ischial tuberosity
knees extended. 2. Pain radiating to the S1 dermatome

Fig.67a,b. Hip and knee flexion, SIJ mobility (joint play), ligament tests. a Active, b passive
(sacrotuberalligament)
160 Active and Passive Motion Testing

a b c

Fig.68a-c. Hip and knee flexion, ligament tests. a Sacrotuberalligament, b sacrospinal and
sacroiliac ligaments, .c iliolumbar ligament

3. Pain radiating to the groin region (with hip Procedure

joint disease) The lower leg is first swung to its maximum lat-
erallimit (Fig. 69a) and then to its medial limit
Lumbar lordosis is not eliminated:
(Fig.69b) while range of motion and end-feel
- Lumbar vertebral restriction are assessed.
- Shortening of the erector trunci
Normal Findings
The contralateral leg rises from the table: Equal ranges of painless internal rotation
Flexion contracture of the hip of the rising leg or (30°--40°) and external rotation (40°-50°) on
shortening of the psoas muscle. both sides.

Maximum knee flexion is not possible and/or

Pathologic Findings
painful:
Limitation of motion and/or pain may be present:
Possible meniscal lesion (posterior horns), os-
With internal rotation (lower leg turned out-
teoarthritis of the knee.
ward) due to:
- Capsular contracture (stage I capsule pattern
2.2 Hip Rotation (Fig. 69a,b)
of Cyriax) secondary to hip joint disease (e. g.,
Motion testing in the transverse plane of the joint osteoarthritis)
- Shortening of the external rotators (e. g., the
Starting Position piriformis)
Hip and knee in 90° flexion. - Paresis of the internal rotators
 Active and Passive Motion Testing 161

Procedure
The examiner fixes the pelvis on the side oppo-
site the tested leg, then the patient lets the flexed
leg fall into abduction (Fig. 70 b). Tenderness at
the adductor attachments can be additionally
tested by continuing the abduction to its passive
limit (Fig. 70c). The test is done comparatively
on both sides, and the distance of the abducted
knee from the table is measured, or the range of
abduction is measured in angular degrees.

Nonnal Findings
Equal ranges of painless hlp abduction on
both side , bringing the knee to about a
handswidtb from the table surface (approx.
800 ).

Pathologic Findings
Limitation of abduction due to adductor short-
ening. This can occur in patients with:
- Hip joint disorders (e. g., osteoarthritis after
replacement arthroplasty)
- SIJ restrictions (Kubis)

b) Passive Abdnction in Neutral Hip Position

(Fig. 70 d,e)
Fig.69a,b. Hip rotation. a Internal rotation, b exter-
nal rotation Starting Position
Relaxed supine position with the legs extended.
Examiner stands next to the knee on the tested
With external rotation (lower leg turned inward)
side. He grasps the ankle with one hand and stead-
due to:
ies the opposite hip with the other (Fig. 70d).
- Paresis of the external rotators
- End-range pain common with lesions of the
Procedure
SIJ or lower lumbar spine (see Patrick's sign,
The extended leg is abducted until the contralat-
Sect. 2.3.1).
eral anterior superior iliac spine begins to move.
The anterior superior iliac spines must remain in
the frontal plane (no pelvic tilt) and transverse
2.3 Hip Abduction (Fig. 70 a,b)
plane (no pelvic rotation). Then the knee is flexed
a) Active Hip Abduction: Hyperabduction over the edge of the table, and further abduction
Test (Patrick-Kubis Test) is attempted (Fig. 70e;seealsoFig. 86a,b,p.176).
Starting Position
Hip flexed approximately 45°, foot next to the
Normal Findings
knee of the untested leg (Fig.70a).
Equal ranges of painless hip abduction
(30°-40°) on each side, with and without knee
flexion.
162 Active and Passive Motion Testing

8 b c

Pathologic Findings
Abduction limited by shortening of the ham-
strings and/or adductors. Differentiation is ac-
complished by flexing the knee at the end of ab-
duction. If the hip can be abducted slightly
farther after knee flexion, the initial abduction
limit was due to shortening of the hamstrings, es-
pecially the gracilis. If the hip cannot be abduct-
ed farther, the movement was limited by adduc-
tor shortening.
Abduction limited by contracture of the hip
joint capsule in dysplastic or osteoarthritic
hips, coxa valga luxans, coxitis, Perthes' disease,
etc. This limitation is not affected by knee flex-
ion.

2.4 Knee Joint Screening Tests

Given the overlapping symptoms of hip and
knee joint lesions and the predominantly biartic-
ular muscularity of the thigh, these screening
tests are important for differentiation. If an ab-
normal finding is noted, the knee joint is further
investigated according to the knee examination
protocol (see ElExamination of the Lower Ex-
Fig.70a-e. Active and passive hip abduction, hyper-
tremities: Knee Joint, p.351). abduction test (Patrick-Kubis sign). a Starting posi-
tion, b terminal position. c Passive abduction. d, e
Starting Position Passive hip abduction in the neutral position. Differ-
Relaxed supine position. Examiner stands on entiation of adductors and hamstrings from pure ad-
the side of the joint to be examined. ductor shortening and contracture of the joint capsule
 Active and Passive Motion Testing 163

Procedure 2.5 Differentiation of the LPH Joints:

Hyperextension of the knee joint: screens for le- Hip Joint, SIJ, Lumbar Spine, and Muscles
sions of the menisci (anterior horns), posterior
capsule, and posterior cruciate ligament; see Supine Malleolar Excursion Test
Fig. 269 a. Variable Leg Length Discrepancy After Derbo-
Adduction of the lower leg: screens for lesions lowsky, Reverse Three-Phase Test (Figs. 71-73)
of the medial meniscus and lateral ligaments
(compression of the medial compartment and Starting Position
test for lateral compartment stability); see Relaxed supine position.
Fig.271a.
Abduction of the lower leg: screens for lesions
Procedure
of the lateral meniscus and medial ligaments
(compression of the lateral compartment and 1. The examiner notes the relative heights and
test for medial compartment stability); see rotational positions of the medial malleoli
Fig.271b. with the legs parallel and extended (Fig. 71 a).

Fig.71a,b. Testing ofvari-

able leg length discrepancy
(supine leg excursion test).
a Starting position, b termi-
nal position
164 Active and Passive Motion Testing

Fig. 72 a, b. Malleolar posi-

tion in the supine excursion
test. a Starting position,
b pathologic terminal posi-
tion (asymmetric malleolar
excursion)
a b

Fig.73. Differentiating test

for the lumbar spine, SU,
and muscles

The legs must not deviate laterally or medial- the position of the sacrum in the sagittal
ly from the midline, as this would cause an ap- plane.
parent leg length discrepancy (trochanter 3. Finally the patient is told to bend as far for-
phenomenon). The landmark for palpation is ward as possible, bringing the trunk as close
the distal border of the medial malleolus on to the extended knee joints as she can
each side (Fig. 72 a) . (Fig. 73).
2. The patient then moves to an upright sitting
position (assisted as needed) while keeping
Normal Findings
the legs extended. The examiner lifts the legs
1. Patient can sit upright without pain. Sitting
slightly from the table and again checks the
up does not significantly alter the posilion of
relative heights and rotational positions of
the malleoli in term of height or rotation.
the malleoli (Figs. ?lb, 72b). He also notes
 Active and Passive Motion Testing 165

2. When the patient sits up with the leg ex- SIJ displacements are commonly associated
with lumbar scoliosis and external rotation of
tended, the sacrum assumes a vertical posi-
the leg on the side of the dorsally rotated ili-
tion. The knees should not flex as thi oc-
um. A positive {pseudo ) Lasegue's sign is not-
curs.
ed on the side of the SU displacement or re-
3. The trunk can bend forward until (he head
striction during maximum flexion.
is about 15 cm from the knees. The hip joint
is maximally flexed, the sacrum is slightly
BiomechanicaI Considerations
anteflexed, and the spine is smoothly
arcbed. The knees remain extended. Maxi- The phenomenon of variable leg length (with
mum forward bending is painless, although anatomically equal leg lengths) occurs when the
ilium is dorsally rotated at the SU relative to the
there may be sLight muscular tension at tbe
sacrum and is fixed in that position (=unilateral
back of the thigh and lower leg.
nutation of the sacrum) so that the acetabulum
and ischial tuberosity are higher and more ante-
rior than on the opposite side.
Pathologic Findings
The high acetabulum causes the leg to appear
1. Change in malleolar position (asymmetric ex- shortened in both the standing and recumbent
cursion of tbe malleoli, variable leg length dis- positions (functionally short leg), while the
crepancy after Derbolowsky). When the pa- more anterior position of the acetabulum causes
tient sits up, the initially symmetric malleolar the leg lengths to equalize when the patient as-
positions become asymmetric, i. e., the leg sumes a sitting position. Because the ischial
with a restricted SIJ becomes longer, or sitting tuberosity also is more anterior on the restricted
up corrects for a previous shortening due to side, "rolling" of the tuberosity during sitting up
SIJ restriction in nutation. If an anatomically is delayed and prolonged relative to the unaf-
short leg coexists with SIJ restriction in nuta- fected side, so that the leg on the restricted side
tion on the same side, sitting up will accentuate moves farther distally, i. e., appears to lengthen.
the leg length discrepancy. The test is meaningful only if the length discrep-
2. Sacral position ancy or change is at least 1-2 cm.
The sacrum assumes a vertical position, but it P. Wolff (personal communication) offers a dif-
is painful: suggestive of motion segment lax- ferent explanation for the phenomenon: When
ness in the upper lumbar spine. the patient sits up, the upper body rolls upon the
The sacrum does not assume a fully vertical ischii as on the sector of a wheel, so that both legs
position, and there is muscular pain at the undergo equal distal movement in a healthy sub-
back of the thigh : hamstring shortening. ject with freely mobile SUs. With a restricted SIJ,
With a disk protrusion or prolapse, vertical however, one joint is immobile (say, the right)
orientation of the sacrum is severely restrict- while the other is mobile. As the patient sits up,
ed, and there is radicular pain in the sciatic there is a point at which the center of body gravi-
nerve. ty passes over the SU and sacrum. At this point
3. Forward bending with the legs extended the sacrum normally undergoes a nutation ("for-
Marked limitation of maximum trunk flexion ward nodding") at the SUs under the weight of
and approximation of the head to the knees. the trunk. But if this can occur only in the mobile
Posterior thigh pain with normal spinal flexion joint (i. e., the left), forward progession ofthe left
(smooth arch) is usually caused by hamstring ilium is momentarily checked by gliding within
shortening. the joint, while the immobile (restricted) ilium is
Pain above the sacrum with nonuniform spinal still able to move. As a result, the right leg (on the
curvature is caused by shortening of the erec- restricted side) continues to move distally while
tor trunci or by a lumbar restriction or protru- the left leg is momentarily halted.
sion (the latter associated with neuralgic pain This process can be monitored: When the pa-
in the sciatic region) . tient starts to sit up, both legs move distally at an
166 Palpation Field ofthe Ventral Pelvis

equal rate. When the upper body is approxi- - Marked discrepancy (5-6 cm) with neuralgic
mately vertical, the feet are moving at different pain, pelvic rotation, and compensatory knee
rates. As trunk flexion continues past the verti- flexion: disk protrusion or prolapse.
cal, they again move distally at equal rates but
different lengths. The length discrepancy, i. e.,
the "functionally short leg," has been caused by
the brief period in which distal leg movement 3 Palpation Field
was suspended on the unaffected side. of the Ventral Pelvis
The test for variable leg length discrepancy is in-
terpreted as follows:
Palpation at Rest
- Slight discrepancy (1-2 cm): suspicion of SIJ
displacement (muscular) and/or restriction
(arthrogenic). Bimanual palpation is used whenever possible.
- Moderate discrepancy (often more than 2 cm) The examination of muscle attachments can be
with myalgic pain: hamstring shortening. combined with resistance testing.

Lateral femora l
cutaneous nerve

Iliacus muscle ------t-t----1~,.;,--

CD
Anterior superior ---7-,Kr"
iliac spine Femora l nerve
CD Tensor fasciae lalae - -+-+...".

CD Sartorius muscle---f--I'--H+7HI<rt--

® Hip joint - -+MIHnf----IIP.-'l ' Pubic symphysis

and rami
®
Lesse r trochanter+----IW-I+f1I7B+..---+4IIr.
(insertion of iliopsoas)

Adductor longus
CD Rectus femoris --+-+-T-1f7-:--- \~"\

4--/------(,1) GraCilis

Fig.74. a Palpation field of the ventral pelvis (general view)

 Palpation at Rest 167

The five landmarks for palpation in this field

(Fig. 74 a-e) are as follows:
1. Anterior superior iliac spine
2. Hip joint
3. Lesser trochanter
4. Pubic symphysis and pubic rami
5. Inguinal canal

Starting Position
Relaxed supine position.
Procedure
1) Anterior superior iliac spine (Fig. 75)
The position of the iliac spines is examined and
compared with findings in the standing position.
The palpating thumbs are placed on the inferior
border of the spines. A height discrepancy may
be caused by iliac rotation on one side.
Then the muscle attachments are palpated.
Lateral: tensor fasciae latae, which is prone to
shortening. Hypertonicity and myogeloses are
often present with SIJ displacement or restric-
tion on the opposite side (Sell).
Anterior: sartorius stabilizer of the knee joint).
Medial: iliac muscle, painful hypertonicity with
ipsilateral SIJ displacement or restriction or
with L5/S1 segmental dysfunction.
Anterior inferior iliac spine: rectus femoris mus-
cle, which also is commonly shortened.

2) Hip joint (Fig. 76)

The coxofemoral joint is palpable at the inter-
section of the inguinal ligament and the femoral
artery or nerve (midway between the anterior
superior iliac spine and pubic symphysis).
Protrusions above the inguinal ligament signify
inguinal hernia; protrusions below the ligament,
femoral hernia. They occur in the crural triangle
formed by the sartorius, adductor longus, and in-
guinalligament.

3) Lesser trochanter (Fig. 77)

The hip and knee joints are flexed by placing the
foot next to the opposite extended knee. The
Fig.74 b-e. Bony landmarks for palpation of the
thigh is abducted and externally rotated (Lauen- ventral pelvis. b Anterior superior iliac spine (1),
stein position) as in the abduction test (Fig. 70 b). c hip joint (2), d lesser trochanter (3), e pubic sym-
The landmark is reached by palpating upward physis (4)
from the adductors toward the greater
 168 Palpation at Rest

Fig. 75 a, b. Palpation of the anterior superior iliac

Fig.76a,b. Palpation of the hip joint
spine

trochanter. The insertion of the iliopsoas is often the ilium undergoes a rotational movement on
tender to pressure because of bursal pain (in ath- the weight-bearing side that must be compensat-
letes). Dull lumbar pain also can result from ed by rotation about a transverse axis through
shortening of the muscle (origins on the Ll-L4 the symphysis. To correct this symphyseal dis-
transverse processes) or from inflammatory irri- turbance, especially if it recurs frequently, the
tation about the course of the iliopsoas (appen- balance ofthe hip and abdominal muscles must
dicitis, gynecologic disorders; Moser's sign). be assessed and treated. The upper lumbar
nerve roots supplying these muscles also may re-
4. Pubic symphysis (Fig. 78) quire diagnosis and treatment.
The pubic tubercle, giving attachment to the rec- The attachment of the pectineus muscle can be
tus abdominis, is palpable superiorly at the same palpated lateral to the pubic tubercle. Painful
level as the greater trochanters. bursae may be found in athletes.
The height of the (bony!) tubercles is deter- Below the pubic tubercle: attachments of the ad-
mined by palpation with both index fingers and ductor longus and brevis muscles and the sym-
compared. A step at the symphysis may be physeal joint line.
caused by a high or low position of one ramus. A Symphyseal tenderness can result from loosen-
positional fault can be found on the side of a pos- ing of the symphysis (usually hormonal) during
itive malleolar excursion test. pregnancy or the latter half of the menstrual
According to Mitchell, the positional faults de- cycle, from a therapeutic hormonal overdose
velop due to imbalances of the hip and abdomi- (menopausal complaints, osteoporosis prophy-
nal muscles that insert about the symphysis. This laxis), or from general ligamentous laxity in hy-
concept is supported by the fact that, during gait, permobile women. The pains radiate to the
 Tests ofJoint Translation 169

groin, especially after exertion such as prolonged

walking and standing. The loosening effect may
produce a visible step at the pubic symphysis
(pelvic ring loosening described by Kamieth).
At the inferior border and descending ramus: at-
tachments of the gracilis (gracilis syndrome in
athletes, especially soccer players) and adductor
magnus (as far as the tuber ischii).

• Note
With symptoms of meningeal irritation, pressure
a on the symphysis can cause reflex flexion of the
legs (Brudzinski II).

5. Inguinal canal (Fig. 74 a)

Medial: Hernial openings (inguinal hernias).
Lateral: Tender points above the inguinalliga-
ment at the passage of the ilioinguinal nerve and
iliohypogastric nerve (L1-L:!) and of the lateral
femoral cutaneous nerve in the inguinal liga-
ment.

Fig. 77 a, b. Palpation of the lesser trochanter 4 Tests of Joint Translation

4.1 Traction and Compression of the
Lumbar Spine
4.2 Traction and Compression ofthe
Hip Joint
4.3 SIJ Springing Test via the Thigh

A joint-play test in the supine position is avail-

able for each joint ofthe LPH region. These tests
are necessary, however, only if the previous ex-
amination has yielded equivocal pathologic
findings.

4.1 Traction and Compression

of the Lumbar Spine (Fig. 79)

Starting Position
Supine with the legs flexed at the hip and knee to
eliminate lumbar lordosis (Thomas' maneuver).
The feet are positioned on the table so that the
toes can be braced against the examiner's thighs.
The examiner stands at the foot of the table, one
leg back, and grasps the patient's calfs from be-
Fig. 78 a, b. Palpation of the pubic symphysis hind (Fig. 79 a). Or he can support the lower legs
170 Tests of Joint Translation

on his forearms and use his elbows to hold them shows the application ofthree-dimensional trac-
against his body (Fig. 79 b). tion using an antalgic posture.

Procedure Pathologic Findings

From the starting position, the examiner exerts In the presence of a painful lumbar spine dys-
traction on the lower extremities by shifting his function (restriction or posterolateral prolapse),
weight to his back leg. This produces a distract- traction generally alleviates pain while compres-
ing force in the lumbar spine if lordosis has been sion may exacerbate it. With a posteromedial
eliminated and the pelvis lifted so that it can prolapse, traction usually intensifies pain, serv-
slide down the table. Compression is applied ing to distinguish the lesion from a posterolater-
cephalad with the legs extended. Figure 79c al prolapse.

Fig. 79 a-c. Traction on the

lumbar spine
 Tests of Joint Translation 171

4.2 Traction and Compression loose-packed position"). This corresponds to

of the Hip Joint (Fig. SO) approximately 30° flexion and abduction and
15°-20° external rotation at the hip. Both hands
Starting Position grasp the patient's foot at the ankle and dorsum
Relaxed supine position. and immobilize it against the examiner's body. In
this position the examiner exerts longitudinal
Procedure traction by shifting his body weight (Fig. SOa) or
The extended test leg is placed in the resting po- by pulling with the arms extended (Fig. SO b).
sition on both the sagittal and frontal planes (po- Compression is produced in the same position
sition of least muscular tension, or "maximally by applying force in the opposite direction.

Fig. 80 a4:. Traction on

the hip joint. a,b Stan-
dard technique. c Alter-
native technique for pa-
tients with lesions of the
knee joint
172 Tests of Joint Translation

In patients with knee joint lesions, the traction is 4.3 SIJ Springing Test via the Thigh
applied directly to the hip. The leg is flexed at (Fig. 81)
the hip and knee, and the foot rests on the table
or the knee lies relaxed on the examiner's shoul- Starting Position
der (Fig. 80 c). The examiner stands next to the hip on the non-
tested side. The leg, flexed approximately
1000 -1200 at the hip and knee, is adducted until
Normal Findings the side of the pelvis with the tested SIJ lifts up
Traction is painless or aUeviates pain. from the table (Fig. 81 a).

Procedure
Pathologic Findings
The examiner slides his hand beneath the
With a lesion of the hip joint, traction reduces
gluteals of the tested leg, placing the palpating
pain while compression exacerbates it. This oc-
index finger in the sulcus between the ilium and
curs in:
sacrum so that it touches both the posterior iliac
- Osteoarthritis of the hip spine and the sacrum. The pelvis is returned to
- Coxitis the supine position, and the thigh is adducted
- Irritation of the hip joint capsule until slight gapping is felt in the posterior sacroil-

Fig. 81 a, b. SIJ springing test via

the femur. a Starting position,
btechnique
 Muscle Tests 173

iac joint space. Then the examiner uses his body 5.1 Resistance Tests of the Hip
weight to apply light pressure to the acetabulum and Abdominal Muscles (Figs. 82-85)
and ilium via the long axis of the patient's femur.
The following tests are used for the further dif-
This produces springing in the SIJ if the thigh ad-
ferentiation of conditions such as insertion
duction has not made the dorsal ligaments too
tendinopathies and pareses. In many cases pal-
tight (Fig. 81 b).
pation has already shown evidence of a lesion in
This test is a supplement to previous SIJ tests
a particular muscle.
and is done comparatively on both sides. It
requires considerable experience in the differ-
Flexors, Abductors, Adductors (Fig. 82)
entiation of palpable impressions, since the
It is most efficient to perform the tests in two
weight of the pelvis also rests on the palpating
groups, i. e., using two different starting posi-
hand.
tions.

Starting Position I
5 Muscle Tests Leg extended, hip and knee in neutral position.
One side of the pelvis is immobilized as required.
5.1 Resistance Tests ofthe Hip and
Abdominal Muscles Procedure
5.2 Shortening Tests
1. Leg is not rotated. Resistance to hip flexion is
applied above the knee (Fig. 82 a) to test the
The general resistance tests for the flexors, ab- iliopsoas.
ductors, adductors, internal rotators, and exter- 2. Leg is slightly abducted but not rotated. Resis-
nal rotators were described earlier in the section tance to abduction is applied above the lateral
on examinations in the sitting position (see malleolus (Fig. 82 b) to test the abductor
B/LPH Region/Sect. 5, p.116). The extensors group (gluteus minimus and medius and ten-
are tested in the prone position (see C/LPH Re- sor fasciae latae, L4-S 1 , superior gluteal
gion/Sect. 5, p.l44). nerve).

a b c

Fig.82a-c. Resistance tests ofthe hip muscles. a Flexors, b abductors, c adductors

174 Muscle Tests

Slight internal rotation is required for differ- Procedure

entiation of the gluteus medius and slight ex-
1. Abduction resistance is applied to the lateral
ternal rotation for the gluteus minirnus and
aspect of the knee (Fig. 83 a) to test the exter-
tensor fasciae latae.
nal rotators, abductors, and gluteus maxim us.
3. Leg is slightly abducted but not rotated. Resis-
Differentiation is accomplished by palpating
tance to adduction is applied above the medial
the muscle attachments:
malleolus (Fig. 82 c) to test the adductor brevis
Point of trochanter and intertrochanteric
and gracilis muscles (Lz-L4 , obturator nerve).
crest, external rotators ; gluteal tuberosity,
Differentiation is accomplished by palpating
gluteus maximus.
the muscle attachments: Pectineal line:
2. Adduction resistance is applied to the medial
pectineus; pubic tubercle : adductor brevis;
aspect of the knee (Fig. 83 b) to test the long ad-
next to symphysis: gracilis.
duetors (adductor magnus and longus ; Lz-L4,
obturator nerve). Both sides are tested and
Starting Position II
compared.
Hip flexed approximately 50 knee flexed ap-
0 ,

proximately 90 0 , foot flat on the table beside the

opposite knee.

Fig. 83 a, b. Resistance tests of the

hip muscles. a External rotators,
b long adductors (bimanual)
 Muscle Tests 175

Sartorius Test (Fig. 84) Normal Findings

Starting Position Painless muscular tension with a strength of
Hip is abducted, externally rotated, and slightly 4-5.
flexed; knee is flexed approximately 120°. The
foot is held loosely; the opposite side of the
pelvis is immobilized. Abdominal Muscles (Rectus abdominis)
(Fig. 85)
Procedure Starting Position
Resistance to flexion, abduction, and external The legs are flexed at the hips and knees (to de-
rotation of the hip is applied at the knee and activate the iliopsoas). The feet are flat on the
lower leg. table, and the patient actively presses them

Fig.84. Resistance test of

the sartorius

Fig.85. Resistance test of

the abdomin al muscles
176 Muscle Tests

against the table surface. The hands are clasped 5.2 Shortening Tests (Figs. 86-88)
behind the head.
If previous tests have shown evidence of muscle
shortening in the LPH region, these findings can
Procedure
The patient sits up gradually by successively be checked by the following tests, which employ
three different starting positions.
raising the cervical spine, the thoracic spine, and
finally the lumbar spine from the table without
Starting Position I
lifting the feet (Fig. 85). Attention is given to dis-
Relaxed supine position with both legs extend-
tortion of the umbilicus, which is drawn toward
ed.
the strongest muscle quadrant. The movement is
resisted by the weight of the trunk.
Tests

Normal Findings 1. Hamstrings

2. Hamstrings and adductors
Patient sits up lowly without pain.
3. Piriformis

Fig.86a,b. Differentiation of the

adductors and hamstrings. a Ad-
ductors and hamstrings. b Adduc-
tors
 Muscle Tests 177

The hamstrings, gracilis, short adductors, and

piriformis muscles are tested.

Procedure
1. Hamstrings. Straight leg is maximally flexed at
the hip while the non tested leg is held station-
ary on the table. Gradually increasing pain at
the back of the thigh occurs with hamstring
shortening (pseudo-Lasegue sign).
2. Hamstrings and adductors. Straight leg is max-
imally abducted while the nontested leg is
steadied at the ilium or the inside of the thigh.
Pain, decreased motion, and possible slight Fig. 87. Differentiation of Lasegue's sign from pseu-
compensatory hip flexion suggest shortening do-Lasegue
of the (monoarticular) adductors (Fig. 86a) if
abduction cannot be continued after the knee
pain felt before the knee is extended is caused by
has been flexed (Fig. 86 b). Otherwise there is
sciatic nerve irritation (Lasegue's sign).
shortening of the biarticular muscles: gracilis,
biceps, semitendinosus, and semimembra-
Starting Position III
nosus (hamstrings).
The patient sits at the end of the examination
3. Piriformis. The hip and knee are maximally
table.
flexed (Figs. 67b and 68a, pp.159, 160). The
pelvis is immobilized by pressing downward
Procedure (Fig. 88 a-c)
on the knee along the femoral axis (as in
The patient lies back with the examiner's help
Fig. 67 b). While one hand maintains this fixa-
while maximally flexing the hip and knee of the
tion, the other hand moves the knee toward
nontested leg to tilt the pelvis back and straight-
the opposite shoulder in maximum flexion, ad-
en the lumbar spine. The patient holds the flexed
duction (see Fig.68b), and also internal rota-
leg against the chest with both hands.
tion by turning the lower leg outward. Painful
The examiner supports this position (which fixes
limitation of adduction and internal rotation
the sacrum and eliminates lumbar lordosis)
in the terminal position suggest shortening of
while providing lateral support, if needed, to
the piriformis. This test also evaluates the ilio-
keep the flexed leg upright.
sacral ligaments and sacrospinalligament.

Starting Position II NormaJ Findings in the Starting Position

Patient sits at the foot of the table, the knee The thigh of the tested leg hangs freely in a
flexed 90 and the trunk in maximum active an-
0
horizontal or slightly lower position: The
teflexion. psoas is not shortened.
This test differentiates pseudo-Lasegue's sign The lower leg hangs almost perpendicular to
from true Lasegue's sign. the thigh: The rectus is not shortened.
The patella is centered or slightly lateralized.
No significant depression on the lateral side
Procedure
of the thigh: Tensor fasciae latae is not short-
The examiner individually extends the patient's
ened.
legs at the knee joint (Fig. 87). If this evokes mus-
cular pain at the back of the thigh and the patient
is forced to straighten the trunk or even extend it Pathologic Findings
back past the vertical, hamstring shortening is Flexed position of the hip: shortening of the
present. A sudden, sharp, lancinating neuralgic iliopsoas.
178 Muscle Tests

Fig.88a--c. Tests for

shortening of the hip flex-
0rs. a Psoas, b rectus
femoris, c tensor fasciae
latae
 Muscle Tests 179

Lower leg flexed less than 90°: shortening of the ment provokes slight extension of the knee,
rectus femoris. the rectus femoris is shortened.
Lateralized patella with a depression on the lat- 2. Rectus femoris. Passively flex the knee by
eral side of the thigh: shortening of the tensor pressing backward on the tibia (Fig. 88 b).
fasciae latae. Pain and slight hip flexion in response to this
maneuver indicates shortening of the rectus
Tests (After Janda) femoris.
3. Tensor fasciae latae. Passively adduct the
1. Psoas major
flexed knee (Fig. 88c). If this provokes lateral
2. Rectus femoris
thigh pain with the formation or deepening
3. Tensor fasciae latae
of a hollow over the iliotibial tract, the tensor
1. Psoas major. Passively move the thigh an extra fasciae latae is shortened. Often this is asso-
10°-20° posteriorly (Fig. 88a). If this is not ciated with some lateral deviation of the
possible, the psoas is shortened. If the move- patella.
Examination of the Thorax (Thoracic Spine and Ribs)
in the Sitting Position (B/III)

1 Inspection
1.1 Thoracic Morphology
1.2 Respiratory Movements

2 Active and Passive Trunk Movements

in Three Planes
(Regional Diagnosis)

3 Palpation of the Thoracic Joints

(Segmental Diagnosis)
Palpation at Rest
3.1 Sternal and Costal Synchondroses
(Sternocostal Joints 2-7), Floating Ribs
3.2 Costotransverse Joints
3.3 Segmental Muscles
Palpation During Movement
3.4 Segmental Motion Testing of the
Thoracic Spine and Cervicothoracic
Junction
3.5 Segmental Motion Testing of the Ribs

4 Tests of Joint Translation

4.1 Bimanual Compression ofthe Thorax
in the Frontal Plane
4.2 Bimanual Compression of the Thorax
in the Sagittal Plane
 Inspection 181

1 Inspection - Pectus excavatum ("funnel chest") = concavi-

ty of the sternum; cardiovascular complaints
1.1 Thoracic Morphology may develop in severe cases.
1.2 Respiratory Movements
1

3. Ribs
- Parasternal thickening of costal cartilages ( es-
pecially T2-T4) and/or sternoclavicular joints
(Tietze's syndrome)
1.1 Thoracic Morphology - Deepening of the intercostal spaces and
Normal Findings
supra- and infraclavicular fossae due to con-
1. Shape of the thoracic cage stricting lesions of the lungs and pleura
Narrow and slender in ectomorphs, short and - Protrusion ofthe intercostal spaces in emphy-
tocky in pyknics. sema
2. Sternum Clavicles
Slight protrusion of the sternal angle between Position, malposition, and deformity see
the body and manubrium of the sternum. B/Shoulder/Sect.1 (pp. 77,257,258).
3. Ribs
Symmetry of the arches and intercostal 4. Vertebral column
spaces, of the clavicular fossae (superior tho- - Scoliosis with bulging of the ribs (on the con-
racic aperture) , rib position, and inferior tho- vex side of idiopathic scoliosis)
racic aperture. - Apex of kyphosis shifted superiorly or inferi-
4. Vertebral column orly (see BILPH/Sect. 1, p.104), especially
Moderate kyphosis of the lumbar spine with with age-related kyphosis
the apex at T5- T6, no scoliosis.
5. Thoracic organs 5. Thoracic organs
No visible pulsations. Prominent apex beat and epigastric pulsations
due to cardiac disease (usually more obvious in
the supine position).
Pathologic Findings
1. Shape of the thoracic cage
1.2 Respiratory Movements
- Bell-shaped thorax: turned-up costal margins,
Respiratory movements are inspected to deter-
thoracic cage indrawn along the insertion of
mine:
the diaphragm (Harrison'S groove), costal
arch expansions (rickets, osteomalacia) 1. Type of respiration (predominance ofthoracic
- Flat chest: flattening ofthe thoracic arch (con- or abdominal respiration)
genital deformity) 2. Respiratory movements of the ribs (costal
- Piriform thorax: pear-shaped chest that is joints)
large above, small below (with restricted ab- 3. Chest expansion (measurement of chest cir-
dominal respiration) cumference)
- Barrel-shaped thorax: rounded like a barrel
Normal respiration relies on unrestricted mobil-
due to emphysema (with restricted expira-
ity of the costovertebral joints and the joints of
tion)
the lumbar spine. There should be no paresis of
- Phthisic thorax: narrow thoracic inlet
the respiratory muscles or the auxiliary muscles
2. Sternum of respiration. The examination covers sponta-
neous respiration as well as forced inspiration
Deformities:
and expiration (deep breathing).
- Pectus carinatum ("pigeon breast") = con-
vexity of the sternum
182 Inspection

Phases of Respiration tal chest diameter. This increase is slight because

the ribs are tethered by the quadratus lumborum.
Inspiration
Most easily palpable on the anterior axillary line.
The thoracic cage is raised during inspiration by
the external intercostal muscles and the auxil-
Measurement of Chest Expansion
iary respiratory muscles (sternocleidomastoid,
Chest expansion is determined by measuring the
scaleni) when the head and cervical spine are
change in thoracic circumference from full inspi-
fixed, also by the pectoralis major and latissimus
ration to full expiration. Expansion can be mea-
dorsi when the shoulder girdle and arms are
sured at three different levels:
fixed in abduction. Ascent of the thoracic cage is
further aided by the serratus posterior superior 1. Thoracic respiration: measured below the ax-
and intercostal muscles of the neck. illa with the arms hanging loosely. Expansion
The abdominal wall is expanded by contraction at this level is approximately 8 cm.
of the diaphragm (C3, C4 , phrenic nerve), which 2. Upper flank respiration: measured below the
pushes the abdominal viscera downward, in- breasts in women, above the nipple line inmen.
creases the vertical thoracic diameter by descent Expansion is approximately 9 cm (Fig. 89 a,b).
of the centrum tendineum, and increases the 3. Lower flank respiration: measured at the infe-
horizontal thoracic diameter by raising the low- rior border of the thoracic cage. Expansion is
er ribs. The activity of the abdominal muscles approximately 11 cm.
makes the ascent of the lower ribs possible by
raising the intraabdominal pressure. The ab-
dominal muscles thus increase their efficiency Normal Findings
through their antagonistic-synergistic relation- Equal respiratory movements and rib mobili-
ship to the diaphragm. ty on each side , interplay between thoracic
and abdominal respiration.
Expiration
Inspiration
Expiration is a passive process in which the elas-
Ascent of the thoracic cage and enlargement
tic chondro-osseous elements of the thorax and
of the inferior thoracic aperture anteriorly
the lung parenchyma recoil to their resting posi-
and laterally.
tion, assisted by the internal intercostals, the
abdominal muscles, the lumbar intercostals,
Expiration
longissimus, and quadratus lumborum.
Descent of the thoracic cage and flattening of
the abdominal arch by contraction of tbe ab-
Respiratory Movements ofthe Ribs dominal muscles and activation of the mus-
The first and second ribs move by the pump-han- cles that assist in lowering the rib (internal
dle mechanism (increases the sagittal and verti- intercostals and the group of secondary expi-
cal diameter of the chest). Palpable on the ante- ratory muscles). The ribs return to their prein-
rior side of the thorax. spira tory position.
The third through sixth ribs move by a combined Normal chest expansion measures at least
pump-handle and bucket-handle mechanism (in- 5-6 cm. The measurement of upper flank res-
creases the sagittal and horizontal diameter of piration is generally sufficient.
the chest). Palpable on the anterior axillary line.
The sixth through tenth ribs undergo a combined
bucket-handle and lateral movement (mainly in- Pathologic Findings
creases the horizontal chest diameter). Palpable Restricted or painful inspiration
at the side of the thorax. Unilateral or bilateral pain on deep inspiration
The eleventh and twelfth ribs undergo a pure lat- due to:
eral movement (outward, backward, and up- 1. Rib fixation in a position of expiration (prima-
ward) with an associated increase in the horizon- ry rib restriction)
 Active and Passive Trunk 183

_ __ b
a
Fig.89a,b. Measurement of chest expansion. a Inspiration, bexpiration

2. Vertebral restnctlOfl in the thoracic spine may develop, however, in long-standing cases of
(secondary rib restriction) thoracic vertebral restriction. "Intercostal neu-
ralgia" is often not a true neuralgia but is caused
Restricted or painful expiration by a primary or secondary rib restriction.
Unilateral or bilateral pain on deep expiration
due to:
1. Rib fixation in a position of inspiration (pri-
mary rib restriction) 2 Active and Passive Trunk
2. Vertebral restriction in the thoracic spine Movements in Three Planes
(secondary rib restriction)
(Regional Diagnosis)
Painful limitation of inspiration and expiration
Causes:
Staged motion testing of the thoracic spine (and
1. Inflammatory or neoplastic pleural diseases lumbar spine) in three planes with the pelvis sta-
2. Pericarditis tionary.
Starting position, procedure, and findings are
Painless limitation of inspiration and expiration
the same as in the examination of the lumbar
Occurs in ankylosing spondylitis.
spine (see p.1OS).
Painless limitation of expiration
Causes:
1. Bronchial asthma
2. Emphysema

Chest- wall pain with no respiratory impairment

A restrictive positional fault of the thoracic ver-
tebrae can cause chest-wall pain with no associ-
ated respiratory impairment. Rib restrictions
184 Palpation of the Thoracic

3 Palpation of the Thoracic

Joints (Segmental Diagnosis)

Palpation at Rest
3.1 Sternal and Costal Synchondroses
(Sternocostal Joints 2-7), Floating Ribs
3.2 Costotransverse Joints
3.3 Segmental Muscles
Palpation During Movement
3.4 Segmental Motion Testing of the
Thoracic Spine and Cervicothoracic
Junction
3.5 Segmental Motion Testing of the Ribs

Palpation at Rest Fig.90. Palpation of sternocostal joints 2-7

3.1 Sternal and Costal Synchondroses Pathologic Findings

(Sternocostal Joints 2-7), Floating Ribs 1. Tenderness at the rib attachments with rib re-
(Figs. 90,91, 113)
strictions
Palpation for tenderness is performed bimanu- 2. Significant tenderness of the xiphoid process
ally, and both sides are compared. This is an ori- sometimes occurs with malformations, trau-
enting examination. If findings are equivocal, ma, and diseases of the internal organs (re-
the patient should also be examined in the flex: e. g., heart, stomach, duodenum, gall-
supine position (see ErrhoraxiSect.3.1, p.208). bladder) and may accompany restriction of
the seventh rib and seventh thoracic vertebra.
Starting Position
Upright sitting position. The examiner stands 3.2 Costotransverse Joints (Figs. 92a-c, 97,98)
behind the patient, who leans against the exam-
Functionally, it is reasonable to combine palpa-
iner.
tion of the thoracic segments (Fig. 92 a,b) and
costal joints (Fig. 92c). If there are positional
Procedure
faults and/or restrictions of thoracic vertebrae,
The examination proceeds segmentally with pal-
the associated rib may follow the synchronous
pation of the sternal margin, sternocostal joints
movement of the adjacent ribs, leading to ten-
2-7 (Fig.90), costochondral junctions, xiphoid
sion and pain in the associated costovertebral
process (Fig. 91 a), and the tips of the floating
and costotransverse joint, or it may rigidly fol-
ribs (Fig. 91 b).
low the movements of the thoracic vertebral
body, leading to secondary functional distur-
Normal Findings
bances in the rib cage with complaints at the in-
The rib attachments are not tender to palpa-
tercostal connections (secondary rib restric-
tion. Springing palpation of the xiphoid pro-
tion).
cess in the anterior, posterior, and lateral di-
With normal position and mobility of the tho-
rections is painless and unrestricted.
racic vertebra, the rib may occupy a faulty posi-
tion in inspiration or expiration due to a primary
cause such as trauma (primary rib restriction).
 Palpation at Rest 185

Fig.92a-c. Tactile and pressure palpation of the facet

joints and costotransverse joints. a, b Thoracic facet
joints, c costotransverse joints

Procedure
The examiner stands next to the patient on the
unexamined (left) side, which he steadies
Fig.91. a Palpation of the xiphoid process, b of the
against his body. He then reaches around the
floating ribs
front of the patient's chest to immobilize the
right elbow and upper arm. He also pulls the left
Both types of restriction are associated with res- scapula as far forward as possible to place some
piration-dependent pain. primary tension on the capsule and ligaments of
the costovertebral joints. The patient now
a) Palpation of the Costotransverse Joints breathes in deeply, placing additional tension on
(Fig. 92 c) the costotransverse capsule and ligaments and
This examination is illustrated for the right cos- usually producing visible prominence of the
totransverse joints. costal tubercle.
The costotransverse joint is palpated by apply-
Starting Position ing firm, localized pressure with the tip of the
The patient places the arm of the examined thumb or index finger in a slightly lateral direc-
(right) side on the opposite (left) shoulder (not tion. The other hand is free to assist as needed
pictured). with compression or passive motion.
186 Palpation During Movement

Normal Findings The examiner evaluates for:

Palpation i virtually painJess (compare both - right-left symmetry ofthe first rib position
sides). - tenderness and mobility of the joint
See also: Palpation Field of the Shoulder Girdle
Pathologic Findings and Fig. 197, p.279.
Primary Rib Restriction
Tenderness to palpation usually occurs in the Normal Findings
following sequence: Slight, virtually painless springing of the joint.
1. Costotransverse joint
2. Intercostal pain Pathologic Findings
3. Sternocostal pain Fixation of the first rib in a high position is usu-
ally caused by abrupt upward movements of the
The joints of the thoracic spine are unaffected.
clavicle (costoclavicular ligament) or prolonged
overhead work.
Secondary Rib Restriction
Tenderness to palpation occurs in the following
3.3 Segmental Muscles
sequence:
The segmental muscles are palpated for in-
1. Joints of the thoracic spine
creased tone, splinting, myogelosis, and tender-
2. Costotransverse joints
ness (irritation zones).
3. Possible intercostal pain in long-standing cases
Little or no tenderness in the sternocostal joints.
Rib restriction frequently causes chest-wall pain Palpation During Movement
with minimal respiratory impairment.

3.4 Segmental Motion Testing

• Differential Diagnosis
of the Thoracic Spine (Fig. 93a-i)
Pain at the attachments of the pectoralis major
and minor to the humerus, clavicle, sternum, Starting Position
ribs, and coracoid process (see Etrhoraxl Upright sitting position. The patient's hands are
Sect. 3.1, p. 208). clasped behind the neck, the elbows forward.

Procedure
b) Palpation of the First Rib (see Fig. 202)
The examiner reaches in front of the patient's
Procedure thorax, which is successively bent forward,
The superior border of the trapezius is pushed backward, sideways, and rotated. The spinous
backward, and the first costotransverse joint is processes are palpated from behind during for-
palpated from above while the head is slightly ward and backward bending of the thoracic
tilted toward the examined side (to relax the spine (Fig. 93 a,b). During side bending (e. g., to
scalenes). The cervical spine permitting, the the right, Fig. 93 c), the coupled rotation is pal-
head also may be rotated toward the examined pated from the convex side. The same technique
side until there is concomitant movement of the is used for palpating pure rotation of the tho-
T1 spinous process, leading to dorsal rotation of racic spine (e. g., to the left, Fig. 93 d).
the transverse process and thus producing trac- The combined test for sidebending and cou-
tion in the costotransverse joint. The palpatory pled rotation (convergence-divergence test,
force is directed downward toward the con- Fig. 93 e-i) is performed from the same starting
tralateral hip and is synchronized with expira- position. Alternative arm placements and the
tion (Fig. 202). procedure were described in the section on lum-
 Palpation During Movement 187

Fig. 93 a-f. See p.188

for legend

e
 188 Palpation During Movement

9 h
Fig. 93 a-i. Segmental mobility testing. a Forward bending, b backward bending, c sidebending, d rotation,
e combined movement in ventral flexion, f combined movement in dorsiflexion. g Palpation of coupled rotation.
Combined movement (b) forward, (i) backward with palpation of full coupled rotation

Facet joint
convergence

a b

Fig.94. a 1, Movement of vertebral body; 2, gliding of costovertebral joints; 3, gliding of facet joint; 4, traction
on facet joint. bGliding movements during sidebending and rotation

bar spine examination in the sitting position (see left in dorsiflexion. Figures 93h and 93i show
BILPH/Sect.3.3, p.l11). the same sidebending to the right during
Figure 93e shows right rotation due to diver- forward and backward bending. In this case
gence of the left facet joints during sidebending the coupled rotation changes direction from a
to the right in ventral flexion. Figure 93 f shows rotation to the right to a rotation to the left, so
the same right rotation due to convergence of it is most clearly palpable during this move-
the left facet joints during side bending to the ment.
 Palpation During Movement 189

• Note Motion Testing oftbe Cervicotboracic Junction

When lordosis extends to a high level, the cou- (C6-T3) (Fig. 95)
pled rotation of the lower thoracic vertebrae
Starting Position
may occur opposite to the direction of sidebend-
Upright sitting position. The hands are not
ing, as in the lumbar spine itself. This occurs
clasped behind the neck, but hang loosely.
when the articulating facet surfaces are oriented
backward rather than forward with respect to Procedure
the frontal plane. The examiner reaches in front of the patient's
Possible motions in the thoracic facet joints are head, bracing the forehead against his upper arm
illustrated in Fig. 94. and placing his flat hand on the back of the neck

c ....._ _ _ _!'..-_ _~_ _ _ _

Fig.95a-d. Segmental motion testing of the cervicothoracic junction. a Forward

bending, b backward bending, csidebending, d rotation
190 Palpation During Movement

to stabilize it. From this position the head is bent Mobility gradually increases from T9 to Ll.
forward and backward (Fig. 95 a,b), sideways All vertebral movements are painless and unre-
(Fig. 95c), and rotated (Fig. 95 d) while a simul- stricted.
taneous transverse pressure is maintained. The
excursions are palpated as described above. 3.5 Segmental Motion Testing of the Ribs
Active rotation at C6-T4 also can be assessed by ("Harp") (Figs. 96a,b, 97 , 98)
bimanual palpation of the spinous processes
Testing of bucket-ladle and lateral rib movements.
(Fig. 133, p.229). Although the thoracic excur-
Terrier's "harp" tests for widening of the inter-
sions are smaller, the movement is easily palpated
costal spaces during sidebending of the thorax.
by the long spinous processes (lever arms). The
Restrictions of the ribs can be observed and pal-
spinous processes are not approximately level
pated more clearly in this position.
with the associated transverse processes, as in the
lumbar spine, and they must be palpated at a sig- Starting Position (Fig. 96 a)
nificantly higher level than the tip of the spinous Relaxed sitting position. Example: test position
process: for palpation of the left ribs. The examiner stands
Tl-T4: 2 (patient's) fingerwidths higher behind the seated patient and places his right
T5-T9: 3 fingerwidths higher foot next to the patient's right hip on the exami-
TlO-T12: 2 fingerwidths higher nation table. The patient side bends over the ex-
aminer's thigh, causing separation of the ribs on
Normal Findings the left side. The patient's left arm is raised with
The palpable excursions in the thoracic re- the elbow over the temple; it is held in that posi-
gion are markedly mailer than in the lumbar tion by the examiner's right hand.
spine. This is due to the smaller disk height of
the thoracic egments and the relative rigidity Procedure
of the thorax. The rib movement is accentuated by further pas-
sive side bending of the thorax and by respira-
tion. The palpating index finger of the left hand
1. Forward bending (Figs. 93a and 95a) is placed on the anterior or posterior axillary line
The adjacent spinous processes separate. (Fig. 96 a,b), or several intercostal spaces can be
2. Backward bending (Figs. 93b and 95b) palpated at once by spreading the fingers and
The adjacent spinous processes approximate. placing a fingertip in each interspace. The
3. Sidebending (Figs. 93c and 95c) same starting position can be used when the ribs
The upper vertebra rotates toward the side to are immobilized for therapeutic purposes
which the trunk bends (i. e., to the right during (Fig. 96 b,c).
sidebending to the right). As this occurs, the up-
The examiner evaluates for:
per spinous process rotates toward the opposite
side and is palpated there. 1. Equal widths of the intercostal spaces (rib po-
4. Rotation (Figs. 93d and 95d) sition)
The upper spinous process rotates slightly more 2. Palpability and tenderness of the (blunt) su-
than the one below it toward the opposite side perior borders and (sharper) inferior borders
(e. g., to the right during rotation to the left). of the ribs
3. Asynchrony or limitation of rib movement, or
Excursions of the thoracic segments (Fig. 10). pain near the motion limit
Forward and backward bending:
Mobility gradually decreases from Tl to T8ff9.
Normal Findings
Mobility increases markedly from TlO to Ll.
1. Rib position
Side bending and rotation:
Equidistant from the upper and lower adja-
Mobility gradually decreases from Tl to T5ff6.
cent ribs. Interspaces narrowest about the
Mobility increases markedly from T6 to T8.
 Palpation During Movement 191

Fig.96a-c. Palpation of rib mobility. The "harp" (Terrier). a Test

position for palpation of the ribs and intercostal spaces. b,c Fixation
of the lower rib for therapeutic purposes (mobilization)

sixth rib, becom ing wider superiorly and infe-

riorly.
2. Rib tenderness
Tested by palpating the superior and inferior
borders of the rib bodies. Normally the supe-
rior border is more blunt than the relatively
sharp-edged inferior border. Neither is tender
to pressure. c
3. Rib mobility
During respiratory movements and during
blunt border of the rib is more easily palpated
separatjon of the ribs by sidebending, all the
by slight internal rotation in the costotrans-
ribs move in unison, the intercostal spaces
verse joint and is tender to pressure. Its mobili-
widening by equal amounts (Figs. 97, 98).
ty on deep inhalation is decreased and may be
Gliding movements in the costotransverse
painful at full inspiration. The uppermost mo-
joints should be unrestricted.
tion-restricted rib is the key rib (Greenman). It
4. Intercostal muscles
must be treated (mobilized) first.
No spasticity or tenderness to pressure
2. Expiratory restriction (i. e., fixation in a posi-
tion of inspiration). The restricted rib is not
centered between the adjacent ribs, being
Pathologic Findings
closer to the rib above than the rib below. The
1. Inspiratory restriction (i. e., fixation in a posi- lower, sharp border of the rib is more easily
tion ofexpiration). The restricted rib is notcen- palpated by slight external rotation in the cos-
tered between the adjacent ribs, being closer to totransverse joint and is often tender to pres-
the rib below than the rib above. The upper, sure. Its mobility on deep exhalation is de-
 192 Tests of Joint Translation

Costotransverse
joint

Fig. 97. Mobility of the ribs at the costovertebral Fig.98. Bucket-handle motion ofthe ribs
joints

Fig. 99 a, b. Thoracic compression. a Frontal, b sagittal

 Tests oUoint Translation 193

creased and is painful at full expiration. The Procedure

lowermost motion-restricted rib is the key rib Both hands grasp the thorax with the palms flat
and should be treated first. and apply a springing pressure directed toward
Examination of the ribs in a recumbent posi- the midline.
tion is described in D/Ribs/Sect.3.3 (lower
ribs), p.20S, and ElThoraxiSects.3.2 and 3.3 4.2 Bimanual Compression of the
(upper ribs), pp. 208, 208. Thorax in the Sagittal Plane (Fig. 99 b)
This produces compression of the costotrans-
verse joints.
4 Tests of Joint Translation
Procedure
4.1 Bimanual Compression of the Thorax One hand steadies the thorax from behind while
in the Frontal Plane the other hand applies a light springing pressure
4.2 Bimanual Compression of the Thorax to the sternum at the end of expiration. Alterna-
in the Sagittal Plane tively, each hemithorax may be compressed sep-
arately.

4.1 Bimanual Compression of the

Normal Findings
Thorax in the Frontal Plane (Fig. 99 a)
Painless, springy compression in both planes.
Test for pain and limitation of movement in the
costal joints.
Compression on the posterior axillary line ex- Pathologic Findings
erts pressure on the costovertebral joints while Resistance and tenderness are noted in patients
also pushing inward on the costotransverse with:
joints. If the compression is applied more on the
1. Restricted ribs
anterior axillary line (as in Fig. 99a), the greatest
2. Rib fractures (traumatic or spontaneous)
pressure is exerted on the sternocostal joints.
3. Inflammatory disorders of the costal joints
Starting Position
Relaxed sitting posture.
Examination of the Thorax (Thoracic Spine and Ribs)
in the Prone Position (C/III)

/1 Inspection

2 Active Movements: Respiratory

Movements (Deep Breathing)
(Regional Diagnosis)

3 Palpation of the Thoracic Joints

(Segmental Diagnosis)
Palpation at Rest
3.1 Palpation Field of the Posterior Thorax
Palpation During Movement
3.2 Rib Movements and Intercostal Spaces

4 Tests of Joint 'Iranslation

4.1 Thoracic Segments
4.2 Scapula

5 Muscle Tests
Scapular Fixators (Transverse Portion of
Trapezius, Rhomboids)
 Palpation at Rest 195

These tests are indicated for cases that cannot be Pressure palpation in the anterior direction
adequately evaluated by examination in the sit- (Fig. 101 a) causes a tilting of the vertebra in the
ting position. sagittal plane that produces traction in the facet
Palpation and joint-translation testing of the joint above and compression in the facet joint
thoracic spine are usually performed during the below.
analogous examination of the lumbar spine. Upward pressure on the tip of the spinous pro-
Again, the entire vertebral column should be in cess (Fig. 101 b) exerts traction on the interverte-
a position of slight kyphosis. bral disk and causes parallel divergent gliding in
the facet joints.

b) Facet Joints and Transverse Processes

1 Inspection (Fig. 102 a)
These structures are palpated on a line approxi-
See Brrhorax/Sect.1 (p.1S1): Inspection of the mately 1 cm lateral to the spinous processes on
thorax in the sitting position. each side. It should be noted that the tip of a giv-
en spinous process is 2-3 fingerwidths lower
than the transverse processes of the same verte-
bra. Thus, at T1-T4 a tender spinous process is
2 Active Movements: Respiratory located 2 cm (2 fingerwidths) lower than the cor-
Movements (Deep Breathing) responding facet joints and costovertebral
(Regional Diagnosis) joints, at T5-T9 it is 3 cm (3 fingerwidths) lower,
and at TlO-T12 it is 2 cm (2 fingerwidths) lower.
Deep, active respiration can be evaluated by in- The transverse processes are palpated with the
spection and/or palpation. "yoke" formed by the adjacent index and middle
fingers, which are pressed down with the other
hand (Fig. 102 a).
Palpation over restricted facet joints will dis-
close small (1-2 cmZ) zones that are markedly
3 Palpation of the Thoracic Joints tender to pressure. Maigne states that these ar-
(Segmental Diagnosis) eas of trophic alteration and muscle spasm are
based either on a periarticular reaction about
Palpation at Rest the facet joint (irritation zones) or an irritation
3.1 Palpation Field of the Posterior Thorax of the dorsal ramus ofthe spinal nerve. The ten-
Palpation During Movement der zones are easily palpable in the cervical and
3.2 Rib Movements and Intercostal Spaces thoracic regions but are very difficult to detect in
the lumbar region when acute muscle splinting is
present (see also p.196).
I Palpation at Rest c) Costotransverse Joints (Fig. 102 b)
These joints are palpated approximately 3-5 cm
from the spinous processes, just lateral to the
3.1 Palpation Field of the Posterior
erector trunci muscles. Joint tenderness may re-
Thorax (Fig. 100)
sult from a positional fault or restriction involv-
a) Thoracic Segments ("Pain Rosette" About ing the costovertebral joint itself or the facet
the Spinous Processes) (Fig. 101 a,b) joints of the same thoracic segment (primary or
The examination technique, normal findings, secondary rib restriction). Whenever costo-
and pathologic findings are basically the same as transverse joint tenderness is present, even if
in palpation of the lumbar spine (see CILPH Re- respirations are unimpaired, the examiner
gion/Sect. 3.3, p.131), with these differences: should palpate rib movements and the inter-
196 Palpation at Rest

1 Spinous processes ("pain rosette")

2 Facet jOints, transverse processes
3 Costotransverse jOints
4 Segmental muscles
(trigger pOints)
5 Segmental irritation points
of Sell
Multifidus muscle ---:7"""----Hli),l'-<o~

Levator
""",,,, ::O~--7&\---+--+-I- _ _ costae
longus

Fig.too. Palpation field of the posterior thorax

costal spaces and evaluate the translational mo- more painful in response to certain spinal move-
bility of the costovertebral joints in the supine ments and improve in response to others. The
position (see EffhoraxiSect.4.1, p.21O). latter movements signal the appropriate direc-
tion for therapeutic manipUlation.
d) Muscular and Neural Trigger Points The testing of irritation zones in the thoracic
As in the lumbar spine, paravertebral muscle spine follows basically the same technique used
splinting and myotendinoses due to nociceptive in the lumbar spine.
afference from the spinal segments are found
in association with restricted thoracic seg- Procedure
ments. These sites correspond very closely to The palpating finger is pressed in deeply about 1
the segmental irritation zones. Neural trigger fingerwidth lateral to the spinous process. The
points (entrapped dorsal rami of spinal nerves) paraspinous irritation point (IP) is felt as an area
are located about 1 cm from the midline in the of spasticity of the deep back muscles
upper thoracic and cervical region and a (Fig. 103 a). The IPs are tested for sensitivity to
handswidth from the midline in the lower tho- rotation and flexion by corresponding head
racic region. movements (Fig.103b) orrotational movements
of the shoulder girdle (Fig.103c,d).
e) Segmental Irritation Points ofSeU The IPs of the costotransverse joints are palpat-
(Fig. 103 a-d) ed about 2 fingerwidths lateral to the spinous
As described earlier (pp.54 and 127), these are processes; they are located beneath the erector
approximately lentil-sized areas of tissue firm- trunci muscle by proceeding medially along the
ness, tender to pressure, that become firmer and rib. Functional testing of the irritation zones in-
 Palpation During Movement 197

Fig.lOla,b. Thoracic segments (pain rosette). a Pal- Fig. 102. a Palpation of the transverse processes.
pation with forward pressure on the spinous process. b Palpation of the costotransverse joints
b Palpation with upward pressure on the spinous pro-
cess

volves palpating for structural changes in the IPs

Normal Findings
during inspiratory and expiratory rib excursions.
1. Equal width of the intercostal spaces on
both sides. The interspaces are narrowest
at the level of the 6th rib and become wider
Palpation During Movement in the cranial and caudal directions.
2. No tenderness to pressure at the (blunt) su-
perior borders and (sharp) inferior borders
3.2 Rib Movements
of the ribs.
and Intercostal Spaces (Fig. 104 a,b)
3. The amplitude of rib excursions during in-
Procedure spiration and expiration decreases from
The examiner, standing at the head of the table, about the mid-thoracic region upward. The
places both hands over the intercostal spaces so rib excursions are equal on both sides.
that the fingers are in the interspaces and checks 4. The intercostal muscles show equal tone on
for asymmetries of rib movements. Both normal the right and left sides and are nontender.
respiration and active deep respiration are tested.
198 Palpation During Movement

c d

Fig.l03a-d. Examination of irritation points. a Palpation at rest, b during backward bending, c, d during rota-
tion of the thoracic spine

Fig.l04a, b. Palpation of the intercostal spaces and rib movements. Springing of the costotransverse joints
 Tests ofJoint Translation 199

4 Tests of Joint Translation

4.1 Thoracic Segments •

4.2 Scapula
•

4.1 Thoracic Segments (Fig. lOS)

The examination technique (Fig. lOS), normal
findings, and pathologic findings are the same as
in the lumbar region (see CILPH Region!
Sect.4.1, p.13S). Unlike the lumbar spine, how- a
ever, the articular surfaces in the thoracic spine
are oriented such that the facets do not experi- ~
ence compression on the side of rotation or trac-
tion on the side opposite the rotation; rather,
both facet joints undergo a lateral gliding in
translation. As in the lumbar spine, the adjacent
vertebrae above and below the fixed vertebra
are tested. (Figure 10Sa,b illustrates the test
technique, and c shows the test position and ver-
tebral mobility on a skeletal model.)

4.2 Scapula (Figs. 106, 107) b

These are shoulder-girdle tests that cannot

be performed in the sitting position. The scapula
is passively moved on the thorax to test the
following:
1. Ease of scapular gliding on the thorax
2. Mobility of the acromioclavicular joint
3. Stretch sensitivity of muscle insertions on the
scapula

Starting position c
Relaxed prone position with the spine in slight
Fig. IDS a-c. Tests of joint translation in the thoracic
kyphosis. The arms are adjacent to the trunk and
segments
internally rotated.

Procedure
The examiner stands level with the pelvis on the between the scapula and thorax at the inferior
tested side (say, the right side). He places his angle. This lifts the scapula away from the thorax
right hand on the anterosuperior aspect of the so that the muscle attachments and a portion of
right shoulder so that the patient's upper arm the subscapularis can be palpated.
rests on the examiner's forearm. The other hand If necessary, the patient is moved to the lateral
is placed with the thumb at the inferior angle of position to test all movements of the shoulder
the scapula and the index finger at its medial girdle in the scapulothoracic joint (Fig. 107): di-
border (Fig. 106). The upper hand pushes the rections of movement, abduction (lateral) and
scapula caudally while the lower hand presses in adduction (medial) (Fig. 107 a,b), elevation (cra-
200 Tests of Joint Translation

Fig.l06a,b. Scapular mobility. a Caudocranial,

b craniocaudal

8 _ _ _ _ _ _ _ _ _ __ _
e
Fig.l07a--e. Tests of shoulder-girdle movements in the scapulothoracic joint. a,b Abduction and adduction,
c craniocaudal motion, d,e external and internal rotation
 Muscle Tests 201

Fig.IOS. Resistance tests of the scapular fixators

nial) and depression (caudal) (Fig.107 c), exter- Starting Position

nal rotation (of the inferior angle) and internal Same as in Sect.4.2 (scapular motion test,
rotation (Fig. 107 d, e). Fig. 106).

Procedure (Fig.108)
The hands are crossed and placed on the inferior
5 Muscle Tests angles of the scapulae from below, the index fin-
ger at the medial border of the scapula and the
thumb at the lateral border. The palm is placed
Scapular Fixators (Transverse Portion of
flat against the thorax to resist adduction and in-
Trapezius, Rhomboids)
ternal rotation of the scapula.

This supplementary test to the shoulder-girdle

examination is seldom required.
Examination of the Thorax (Thoracic Spine and Ribs)
in the Lateral Position (D/III)

3 Palpation or the Thoracic Joints

During Movement
(Segmental Diagnosis)
3.1 Segmental Mobility Testing of the
Thoracic Spine
3.2 Segmental Mobility Testing of the
Cervicothoracic Junction (C6-T3)
3.3 Segmental Mobility Testing of the
Lower Ribs

Examination steps 1,2,4, and 5 are omitted.

Only the segmental mobility of the thoracic
spine and lower ribs is palpated in the lateral
position.
 Examination of the Thorax 203

3 Palpation of the Thoracic Joints 3.1 Segmental Mobility Testing

During Movement of the Thoracic Spine (Fig. 109)
(Segmental Diagnosis) The segmental mobility of the thoracic spine is
tested almost exclusively in conjunction with ex-
3.1 Segmental Mobility Testing of the amination of the lumbar spine. Generally, exami-
Thoracic Spine nation of the thoracic spine is more easily per-
3.2 Segmental Mobility Testing of the formed in the sitting position. Decubitus exami-
Cervicothoracic Junction (C6-T3) nationmaybenecessaryinbed-confinedpatients.
3.3 Segmental Mobility Testing of the Low-
erRibs Starting Position
The patient clasps the hands behind the neck (to
protect the cervical spine). The trunk is at the
edge of the table or bed and is steadied against
the examiner's body. The hips and knees are
slightly flexed.

Fig. 109 a-e. Segmental mobility testing of the tho-

racic spine. a, b Backward bending, c, d forward bend-
ing, erotation e
204 Examination ofthe Thorax

Procedure
3. Rotation: The upper spinous process ro-
Sagittal Plane: Backward Bending tates to tbe side opposite tbe direction of
(Fig. 109 a,b) rotation, moving somewhat farther than
The patient's head and arms are cradled from be- the process below it. The facet joint on the
low so that they rest on the examiner's forearm. rotation side undergoes decompression
Segmental testing proceeds in a cranial to caudal (traction) at the motion limit.
direction with increasing lordotic curvature (dor-
siflexion) of the thoracic spine. The finger pal- Pathologic Findings
pates the approximation of 2 adjacent spinous Decreased or increased mobility in one or more
processes, the palpating finger serving as the ful- segments compared with the adjacent seg-
crum (pivot point) for the segmental motion. ments.

Sagittal Plane: Forward Bending (Fig. 109 c,d)

Position and hand placement are as before. Seg-
3.2 Segmental Mobility Testing o/the
mental testing proceeds in a cranial to caudal
CervicothoracicJunction (C6-T3)
(Fig. 110 a-d)
direction as the patient's trunk is increasingly
flexed forward, the finger palpating for separa- Starting Position
tion of the adjacent spinous processes. Same as before. The patient's arms are crossed
Sidebending requires elevation of the trunk, so over the chest or clasped behind the neck (to im-
this test is more conveniently done in the sitting mobilize the cervical spine).
position. Only (coupled) rotation is tested in de-
cubitus. Procedure
One hand cradles the back of the patient's
Transverse Plane: Rotation (Fig. 109 e) head and neck, the head resting on the examin-
The patient is in an "unstable" side-lying posi- er's forearm, the forehead on the upper arm
tion, the arms behind the head or crossed ("lipstick" technique). This is the starting
in front ("pharoah position"). The head rests on pOSItIOn from which forward bending
a flat cushion, the hips and knees are slightly (Fig. 110 a), backward bending (Fig. 110 b),
flexed. Palpation proceeds segmentally as the sidebending (Fig. 110 c), and rotation (Fig.
shoulder girdle and thorax are rotated back- 110d) are initiated.
ward. The palpating finger is placed between the As in the analogous tests of the lumbar spine, the
spinous processes or on the lower side (side op- palpating finger is placed between two spinous
posite the rotation) of the spinous processes of processes to assess their mobility relative to ad-
the motion segment (as in Fig. 64 a, p.15l). jacent segments. The findings are accentuated
by applying light cephalad traction to the spine.
With midcervical hypermobility, better control
Normal Findings is achieved by having the patient clasp the hands
Range of motion: Slight mobility should be behind the neck to immobilize the cervical spine.
noted in all vertebral segments. The examiner then cradles the patient's elbows
Forward and backward bending: Mobility de- and proceeds with the test.
creases to T9, increases to T12.
Rotation: Mobili ty decreases to TS, then in- Normal Findings
creases at lower levels. Ranges of motion:
(See also Bffhorax/Sect. 3.4.) Forward and backward bending: Mobility de-
1. Backward bending: The adjacent spinous creases sharply from C6 to Tl and is minimal
proces es converge. from T1 to T3.
2. Forward bending: The adjacent spinous Sidebending and TOtaton: Mobility is marked-
processes separate. ly decreased from C7 to T3 (ribs).
 Examination ofthe Thorax 205

~ ___ _ ______~______ ~ _________ d

Fig.ll0a-d. Segmental mobility testing of the cervicothoracic junction. a Forward bending, b backward bend-
ing, c sidebending, d rotation

Pathologic Findings Procedure

Decreased mobility in one or more segments, The patient's uppermost arm is extended above
with or without pain on motion. the head and slighty flexed at the elbow. One
hand grasps this arm at the shoulder and, at
end-inspiration, pulls the arm cephalad to fur-
3.3 Segmental Mobility Testing of the
ther widen the intercostal spaces, which are pal-
Lower (6th-12th) Ribs (Figs. 111, 112)
pated (Fig. l11a,b). This inspiration is repeated
Bucket-handle and lateral rib movements are for each interspace. The palpating finger is in
tested in the lateral position. the intercostal space on the anterior or posteri-
or axillary line (Fig. 112 a-c).
Starting Position During expiration the finger palpates for nar-
Unstable side-lying position, the head resting on rowing of the intercostal spaces. At end-expira-
the hand and arm. The lower leg is flexed, the up- tion the costal margin is palpated to determine
per leg straight. The ribs to be tested are separat- whether further, passive caudal movement of
ed somewhat by placing a flat pillow beneath the the rib is possible.
thorax. The examiner stands at the head of the
table on the patient's anterior or posterior side.
 206 Examination of the Thorax

a
a
----=---~

Fig.llla,b. Testing the mobility of the lower ribs.

a Palpation of the ribs and intercostal spaces. b Fixa-
tion ofthe lower ribs during therapy (mobilization) b c
Fig. 112a-c. Palpation of the intercostal spaces and
costal margins

Normal Findings Pathologic Findings

1. Painful resistance to rib movements
1. Widening of the intercostal spaces during
inspiration. 2. Unequal intercostal spaces
2. Upward movement of the ribs during in- 3. Limited movement of one or more ribs ("key
rib") during inspiration and arm traction or
spiration.
3. Painless, passive continuation of the up- during expiration
ward rib movement by arm traction
4. Opposite findings during expiration
Examination of the Thorax (Ribs)
in the Supine Position (E/III)

11 Inspection

2 Active Movements: Respiratory

Movements (Deep Breathing)
(Regional Diagnosis)

3 Palpation of the Ribs

(Segmental Diagnosis)
Palpation at Rest
3.1 Palpation Field of the Anterior Thorax
Palpation During Movement
3.2 Rib Movements and Intercostal Spaces
3.3 Segmental Mobility Testing of the Up-
per (2nd-6th) Ribs

4 Tests of Joint Translation

4.1 CostaiJoints
4.2 Sternoclavicular and Acromioclavicular
Joint

5 Muscle Test: Test for Shortening of the

Pectoralis Major
208 Palpation at Rest

This set of examinations is necessary only if the 3 Palpation of the Ribs

examinations in the sitting and prone positions (Segmental Diagnosis)
have not furnished adequate information on rib
mobility and the functional status of the ster-
nocostal joints. Palpation at Rest
3.1 Palpation Field of the Anterior Thorax
Palpation During Movement
3.2 Rib Movements and Intercostal Spaces
1 Inspection
3.3 Segmental Mobility Testing of the Up-
Thoracic asymmetries, posItIon of clavicles, per (2nd-6th) Ribs
shape of sternum, epigastric angle, thoracic or-
gans, and respiration are compared with the
findings in the sitting and prone positions. Palpation at Rest

Normal and Pathologic Findings

See B/Thorax/Sect.1 (pp.181-183). 3.1 Palpation Field
of the Anterior Thorax (Fig. 113 )
1) Sternoclavicular and Acromioclavicular
2 Active Movements: Respiratory Joints (Figs. 198, 199, p.280)
Movements (Deep Breathing) See Palpation Field of the Shoulder Girdle
(Regional Diagnosis) (B/Shoulder Girdle/Sect. 3, p. 278, and Fig. 197).

Normal respiration. and deep respirations are 2) Rib Synchondroses and Sternocostal Joints
evaluated by inspection and palpation. 2-7 (see Fig. 90)
Palpation and findings of the rib synchondroses
(chondrocostal and chondrosternal attach-

1 Clavicular joints
2 Rib synchondroses,
coslal joints
3 Xiphoid process
4 Floating ribs
5 Muscle attachments

Pectoralis - -+--+-- -t-n

minor
o-==:=----t--t-- Pectoralis
major

Serratus - --I----i- +_
anlerior

Fig.113. Palpation field ofthe anterior thorax

 Palpation During Movement 209

ments) were described in the section on exami- costal space, the examiner can assess and com-
nation in the sitting position (see Bffhoraxi pare the widths of the interspaces, the position
Sect. 3.1, p.184). (margins) of the ribs, the symmetry of rib
movements and their synchrony with respira-
3) Xiphoid Process (see Fig. 91 a) tions, and the tension of the intercostal mus-
With tenderness of the xiphoid process, the mo- cles. The hands can also be placed on the up-
bility of the 7th rib and the associated thoracic per or lateral portions of the ribs from the
vertebra should be assessed. caudal side to check for synchrony of rib
movements on both sides. When asymmetry is
4) Floating Ribs (see Fig. 91 b) present, the greater excursion generally repre-
If the free ends ofthe 11th and 12th ribs are ten- sents normal function while the less mobile
der when palpated anteriorly, the associated cos- side signifies an inspiratory restriction that re-
tovertebral joints should be examined along quires further investigation by the segmental
with the 11th and 12th thoracic vertebrae. testing of rib motion. As in the prone examina-
tion, the rib movements and intercostal spaces
5) Muscle Origins (Fig. 113) are individually palpated and assessed (see
Origins of the three great fan-shaped muscles Cffhorax/Sect.3.2, p.197).
connecting the upper limb to the chest wall:
Serratus anterior: 1st-9th ribs on the mid-axil- Normal and Pathologic Findings
lary line. See B/Ribs/Sect.3.5 (p.189) and Cffhoraxl
Pectoralis major: inferior border of the medial Sect. 3.2 (p.197).
third of the clavicle, the lateral sternal border,
and the rectus abdominis sheath. 3.3 Segmental Mobility Testing
Pectoralis minor: 3rd-5th ribs, anterior to the of the Upper (2nd-6th) Ribs
serratus origins.
These muscle origins may be painful due to A sand bag is placed beneath the thoracic spine
strain (overuse, athletic injuries). In these cases to hyperextend it and increase the inspiratory
a rib fracture should always be excluded, and expansion of the thoracic cage.
the thoracic vertebrae and costal joints should
be examined. Starting Position
Relaxed supine position. The examiner stands at
the head of the table and grasps the patient's
I Palpation During Movement arm, extended above the head, proximal to the
slightly flexed elbow. This provides a reasonably
secure hold so that traction can be applied to the
3.2 Rib Movements and Intercostal Spaces arm without causing painful skin irritation. The
The pump-handle movements (upper ribs) and patient's forearm is steadied against the examin-
bucket-handle movements (lower ribs) are pal- er's body (Fig. 114).
pated and assessed.
Procedure
Starting Position At end-inspiration, longitudinal traction is ap-
Relaxed supine position, perhaps using a roll to plied to the arm to increase expansion of the tho-
produce lordosis. The examiner stands at the racic cage and widen the separation of the inter-
head of the table to palpate the intercostal costal spaces. Meanwhile the index finger of the
spaces and rib movements. examiner's free hand is placed in the intercostal
space on the anterior axillary line for the seg-
Procedure mental palpation of individual rib movements
As in Fig. 104. With the hands on the anterolat- (see D/Ribs/Sect. 3.3, p. 205).
eral thorax so that each finger is in an inter-
210 Palpation During Movement

4 Tests of Joint Translation

4.1 Costal Joints

4.2 Sternoclavicular and Acromioclavicular
Joint

4.1 Costal Joints (Figs. l1Sa-c, 116)

Starting Position
Relaxed supine position. The arms are crossed
over the chest.

Procedure
The examiner stands on the non tested side of
the thorax, grasps the shoulder, and turns the pa-
tient toward himself to a side-lying position. He
then places the flat palpating hand, fingers to-
gether, over the tested rib so that the tip of the
thumb touches the transverse process while the
thumb and thenar eminence lie along the tested
rib (Figs. l1Sa, 116).
Then the thorax is returned to the supine posi-
Fig. 114 a, b. Segmental mobility testing of the upper tion and further rotated toward the test side un-
ribs. a Pump-handle motion, bbucket-handle motion til the joint to be treated, and the costal angle,
are almost directly above the examiner's hand
(on the line of gravity). The examiner then
presses his body weight against the table surface
with a gentle springing action (Fig.11S b), the
thumb acting as a fulcrum to impart a springy an-
terior movement to the rib which distracts it
from the transverse process in the costotrans-
Normal and Pathologic Findings verse joint (Fig. 116).
See B/Ribs/Sect.3.5, p.189, and Crrhoraxl
Sect.3.2, p.197. • Note
Restrictions of the costotransverse joint can be
• Note treated using the same technique.
Disturbances of the uppermost ribs are a fre- All the ribs that showed pathologic findings on
quent source of shoulder pain and pain at the general motion testing or palpation are exam-
medial scapular margin. ined by this technique.
P Wolff states that lesions of the third rib can
cause refractory pain on the lateral side of the
4.2 Sternoclavicular and Acromio-
upper arm that radiates to the lateral epicondyle
clavicular Joint (See Figs. 208-211)
and the little finger.
For examination technique, see Palpation Field
of the Shoulder Girdle and Clavicular Joint
Normal Findings Tests, B/IV Shoulder Girdle, Sects.3 and 4
Painless, bilaterally symmetrical movements (pp. 278, 28S-288).
of the ribs during inspiration and expiration.
 Muscle Test 211

Fig. US a-c. Testing of costotrans-

verse joint play. a Starting position.
b,c Technique

5 Muscle Test: Test for Shortening shoulders, humpback), the test is performed at
of the Pectoralis Major that point in the examination.

Starting Position
The test for shortening of the pectoralis major is Relaxed supine position. The patient has raised
the only test of the shoulder-girdle muscles that the arm (palm facing forward and medially) to
is reliably performed only in the supine position about 130 0 of abduction and is told to lower the
(Fig. 117 a,b). Since pectoralis shortening is a arm to the table surface. If the pectoralis is short-
major determinant of thoracic shape (drooping ened' the patient usually cannot lower the arm to
212 Muscle Test

Fig.116. Distraction of the rib from the

transverse process in the costotransverse
joint

the table in this position, and inspection of the Pathologic Findings

muscle shows prominent tension compared with 1. The arm does not reach the table surface. Pas-
the opposite side. sive stretching of the pectoralis provokes a
The examiner stands on the tested side and twinging pain in the muscle = pectoralis short-
steadies the thorax with the free hand to prevent ening.
rolling of the thorax toward that side during 2. The arm can be moved back past the edge of
stretching of the pectoralis (e. g., in patients with the table = hypermobility (hypotonicity) of
fixed kyphosis). the muscle.

Procedure
With the other hand the examiner grasps the pa-
tient's extended, externally rotated arm above
the elbow and attempts to push it closer to the
table, noting the degree to which this is possible
and whether it elicits pain in the pectoralis ma-
jor. The direction of motion is obliquely upward
and outward to test the abdominal portion of the
muscle (Fig. 117 a).
The arm is moved to a horizontal position of ap-
proximately 90° abduction to test the sternal
portion of the pectoralis (Fig. 117b), and to a
slightly lower position to test the clavicular por-
tion. The arm is kept in external rotation for all
three tests.

Normal Findings
From the starting position described, the arm
can be actively lowered to the table surface or
can be brought to that position by passively
continuing the active movement. Fig.117a,b. Test for shortening of the pectoralis ma-
----- jor. a Abdominal portion, b sternal portion
Examination of the Cervical Spine
in the Sitting Position (BN)

11 Inspection

2 Active and Passive Movements of the

Cervical Spine and Head in Three
Planes
(Regional Diagnosis)
2.1 Sagittal Plane: Backward and Forward
Bending
2.2 Frontal Plane: Sidebending
2.3 Transverse Plane: Rotation
2.4 Provocative Testing of the Vertebral
Segments (Modified from de Kleyn)
2.5 Provocative Test for Motion Segment
Laxness (Hypermobility)

3 Palpation of the Cervical Spine During

Movement
(Segmental Diagnosis)
3.1 Mobility Testing of the OcciputlAtlas
(CO/C1)
3.2 Mobility Testing of the AtlaslAxis
(Cl/C2)
3.3 Mobility Testing of the C2/C3 Segment
3.4 Mobility Testing of the C3-C5 Segments
3.5 Mobility Testing of the C5-T3 Segments

4 Tests of Joint fianslation

4.1 Traction
4.2 Compression
4.3 Three Tests of Facet Joint Gliding

5 Muscle Tests: Resistance Tests of the

Cervical Muscles (Synergists)
214 Examination ofthe Cervical Spine

1 Inspection movement) of the facet joints that progresses

segmentally from above downward. Finally,
Shape of the neck, head position, cranial shape, maximum convergence of the articular facets
face. leads to a bony limitation of dorsiflexion, with
fixation of the joints.
Findings From that point the examiner continues the ac-
See A/General Inspection/Sect. 3 (pp. 77,81). tive movement to its passive limit by pressing
lightly on the patient's forehead.
End-feel: hard-elastic.
Rotation of the head in dorsiflexion aids in de-
2 Active and Passive Movements tecting restrictions below the axis (Lewit).
of the Cervical Spine and Head The test can also be done in stages to establish
in Three Planes the level of a lesion by grasping and immobiliz-
(Regional Diagnosis) ing the neck with one hand (yoke grip) at the lev-
el of the middle and lower cervical spine.
2.1 Sagittal Plane: Backward and Forward
Forward Bending
Bending
In this movement the occipital condyles glide
2.2 Frontal Plane: Sidebending
backward upon the atlas. Then the atlas tilts for-
2.3 Transverse Plane: Rotation
ward on the axis, followed by a segmental sepa-
2.4 Provocative Testing of the Vertebral
ration (divergent movement) of the facet joints.
Segments (Modified from de Kleyn)
The joints below the axis are fixed (locked) by
2.5 Provocative Test for Motion Segment
ligamentous tension. The active movement is
Laxness (Hypermobility)
carried to its passive limit by pressing lightly on
the occiput.
Testing the overall mobility of the cervical spine End-feel: firm-elastic. Often the motion limit
(staged testing). Potential sites of irritation in- has a muscular end-feel due to shortening of the
clude the facet joints, nerve roots, and vertebral dorsal neck extensors.
artery. Backward bending should be tested first, Rotation of the head in maximum anteflexion oc-
as it is best for revealing articular disturbances curs chiefly in the craniovertebral joints (at-
and root irritation. lanto-occipital and atlantoaxial). If these joints
are restricted, the anteflexed head cannot be ro-
Starting Position tated, or at the very least this rotation is limited
Upright sitting posture. and/or painful. This test, then, can differentiate a
craniovertebral joint restriction from a vertebral
Procedure restriction at a lower level (Lewit). A severe ro-
The examiner stands behind the patient and im- tation deficit suggests hypomobilityin the Cl/C2
mobilizes the thorax or shoulder, especially dur- segment, while a milder deficit suggests involve-
ing passive movements. During passive rotation, ment at the CO/C1 (atlanto-occipital) level.
the patient leans the head against the examiner's
chest.
2.2 Frontal Plane: Sidebending
2.1 Sagittal Plane: Backward
Side bending is assessed by a comparison of both
and Forward Bending
sides. The joints on the concave side are com-
Backward Bending pressed by a convergent movement, while those
Backward bending is marked initially by a for- on the convex side are decompressed by facet
ward gliding of the occipital condyles upon the separation. Side bending narrows the interverte-
atlas. Then the atlas tilts backward on the axis, bral foramina on the concave side, accompanied
followed by an approximation (convergent by a slight coupled rotation toward that side.
 Examination of the Cervical Spine 215

Side bending can localize a painful limitation of The chin-in movement produces kyphosis at
motion on backward and/or forward bending to C1-C4 and lordosis at CS-C7. Counterpressure
a particular side, i.e., can establish which of the is applied to the upper thoracic spine, and the
two joints is involved in the disturbance. The ac- movement is increased by backward pressure on
tive movement is continued to its passive limit by the forehead. Pain usually occurs when motion
pressing on the temple on the convex side. segment laxness is present.
End-feel: firm-elastic.
Normal Findings 2.1-2.S
2.3 Transverse Plane: Rotation
Rotation, like sidebending, is tested and com- 1. Painless movements in all direction
pared on both sides. The joint facets approxi- 2. Uniform spinal curve at the end of all ex-
mate on the side toward which the neck rotates cursions
and separate on the opposite side. This is accom- 3. Equal excursions in sidebending and rota-
panied by a slight degree of side bending in the tion on both sides
direction of rotation. The active movement is 4. Rallges of malion (age-dependent):
continued to its passive limit by pressing on the - Backward bending approximately 70°
forward temple while the other hand immobi- (chin- forehead line in the horizontal
lizes the shoulder. plane).
End-feel: firm-elastic. - Forward bending approximately SO° (chin
can be placed on the sternum; may measure
2.4 Provocative Testing of the Vertebral distance from chin to sternal notCh).
Segments (Modified from de Kleyn) - Sidebending approximately 40° in both di-
Combined provocative test of the cervical spinal rections.
structures in maximum dorsiflexion and rotation. - Rotation approximately 90° in both direc-
The head is rotated while the cervical spine is in tions (including the upper thoracic spine).
maximum dorsiflexion. - Unrestricted rotation of the head in maxi-
This test causes maximum convergence and com- mum dorsiflexion and anteflexion .
pression of the facet joints on the side of the rota- S. End-feel: finn-elastic (springy) in anteflex-
tion while also provoking the nerve roots by max- ion and ide bending, bard-elastic in dorsi-
imally constricting the intervertebral foramina flexion
(Spurling's test) and partially occluding the verte-
bral artery in the craniovertebral joint region on
the side opposite the rotation (de Kleyn's test).
The test can furnish evidence of impaired blood Pathologic Findings
flow in the vertebral artery on the side to which 1. Painful limitation of motion in one or more di-
the head is rotated. It can also aid in the diagno- rections. The more painful and severe the lim-
sis of disk protrusions and facet joint restrictions itation, and the more directions it involves
or degenerative arthritis. within the segment, the greater the likelihood
of disk involvement (protrusion, prolapse) or
2.5 Provocative Testfor Motion Segment
inflammatory joint disease.
Laxness (Hypermobility)
Radiating neuralgic-type arm pain is sugges-
Chin out/chin in (provocative test in the sagittal tive of radicular irritation.
plane). The patient is told to "stick the chin 2. Limitation offorward bending may be caused
out" and then "tuck the chin in." The chin-out by shortening of the nuchal ligament or neck
position produces maximum lordosis at CI-C4 muscles or by meningeal irritation (Brudzin-
and kyphosis from CS to C7. Counterpressure is ski's sign).
applied at the sternum, and the movement is in- Limitation of backward bending or sidebend-
creased by forward pressure to the occiput. ing is usually caused by segmental restrictions
216 Examination of the Cervical Spine (CO/Cl)

Uoint restriction or disk protrusion). Another 3 Palpation of the Cervical Spine

common cause of decreased sidebending During Movement
is muscle shortening [trapezius, scaleni
(Segmental Diagnosis)
(prevertebral muscles)]. Limitation of head
rotation in dorsiflexion suggests a restriction
below C2, while limitation in anteflexion 3.1 Mobility Testing of the Occiput/Atlas
suggests a restriction in the craniovertebral (CO/C1)
joints (Lewit). 3.2 Mobility Testing of the Atlas/Axis
3. Vasomotor disturbances (worsening of (C1/C2)
headache, vertigo, tinnitus, possible syncope) 3.3 Mobility Testing of the C2/C3 Segment
imply an irritation of the vertebral artery 3.4 Mobility Testing of the C3-CS Segments
(positive de Kleyn test). 3.S Mobility Testing of the CS-T3 Segments
4. Brainstem symptoms (diencephalic symp- (Cervicothoracic Junction)
toms, especially after whiplash injury) are, ac-
cording to H.D. Wolff, strong evidence of a
craniovertebral joint dysfunction. Symptoms Segmental motion testing of the cervical spine in
include headache, vertigo, auditory and visual three planes, with loading imposed by the head
disturbances, tinnitus, autonomic dysfunction weight and the tone of the active neck muscles.
(disturbances of thermoregulation, diurnal The segmental muscles are tested for hypertonic
rhythm, peripheral vasomotor function), im- reactions due to articular disturbances.
paired concentration, rapid fatigability, psy-
chic lability. 3.1 Mobility Testing of the OcciputlAtlas
S. Painless limitation of motion with no associat- (COIC1) (Figs. 118-123)
ed cervical phenomena in older patients usu-
ally signifies age-related stiffness due to Starting Position
degenerative disease (osteochondrosis, spon- Relaxed sitting posture. The examiner stands
dylosis) in the motion segment. Therapeutic behind the patient so that he can provide light
posterior support. (Alternatively, the patient
mobilization is indicated only if the condition
causes painful functional disability. may sit on a chair with a back rest.)
6. Disruption of the uniform spinal curve by an-
gulations, straight sections, or abnormal pro- Examination ofthe Atlas
trusions must be investigated by palpation Procedure (Fig. 118)
and radiography to establish the etiology. The patient's head is grasped with both hands
7. Asymmetric excursions are most often caused from above with the fingers directed downward.
by unilateral restriction of the facet joints but The palpating fingers (index or middle fingers)
can also result from congenital or acquired on each side are placed in the angle between the
dysmorphias. mastoid and ascending mandibular ramus on the
8. End-feel: firm-elastic, usually painful, with in- tips of the transverse processes of the atlas. The
creased ranges of motion when hypermobility examiner first assesses the position of the trans-
is present. verse processes (Fig. 118 a-d) and then the mo~
A soft-to firm-elastic end-feel, with little pain, bility between the mastoid and the mandible,
is found when motion is limited, e. g., by mus- comparing both sides (Figs. 119-123).
cle shortening (upper trapezius, levator
scapulae) or spasm.
An almost hard-elastic end-feel with signifi-
Nonnal Findings
cant pain and limited motion is found with
Position ofthe transverse processes: If the bony
reflex muscle spasms secondary to vertebral
structures are symmetrical, the transverse pro-
restriction or traumatic or inflammatory
cesses, palpable as a point on each side, will be
changes.
 Examination ofthe Cervical Spine (CO/Ct) 217

approximately midway between the mastoid

and mandible at the inferior border of the mas-
toid (Fig.1I8a), usually slightly closer to the
mastoid. Deviations from this position may
have an anatomic or functional cause. A low
position of the transverse processes suggests
prominent occiputal condyles; a high position
is common with basilar impression.

Examination During Movement

The tests below are presented in the order of
their diagnostic value.

Sidebending (Figs.1l9a-d, 124a)

With the thumb and hypothenar of both hands,
the examiner sidebends the patient's head to
each side. The rotational axis for the sidebend-
ing is approximately in the lower third of the cra-
nial cavity (level with the root of the nose).

Normal Findings
Equal lateral gliding of the occipital condyles
on the atlas joint surfaces toward the side op-
posite the movement. The atlas "shifts" to-
ward the side of the movement as a rotational
effect. When this occurs, the transverse pro-
cess is more easily palpated on the side to-
ward which the head is inclined.

Rotation (Figs. 120 a, b, combined movement)

Starting Position
Relaxed sitting posture. The cervical spine is
moderately flexed at C2-C7 for ligament fixa-
tion, and the craniovertebral joints (CO-C2) are
slightly extended.

Procedure
Testing rotation as part of the combined move-
ment: Sidebending and rotation begins with
sidebending that is coupled with a rotation to the
opposite side. The examiner palpates the
springy end-feel between the transverse process
and mastoid, comparing both sides.
Testing rotation of co on Cl with the head maxi-
Fig.11S a-d. Examination of the atlas
mally rotated is illustrated in Fig.12l. The cervi-
cal spine is fixed below C2 by slight sidebending
218 Examination ofthe Cervical Spine (CO/Cl)

Fig. 120. a Combined movement (see also Fig. 127)

toward the palpated side, and the end-feel is as-

sessed.
During rotation testing at COICI with the head
in maximal rotation (Fig. 121), the distance
between the transverse process and mandible in-
creases on the side away from the rotation with a
springy end-feel, while the transverse process
moves palpably closer to the mastoid. The cervi-
cal spine should be fixed below C2 in this test by
sidebending toward the palpated side.
Rotation in the Cl/C2 segment can be similarly
tested (Fig. 127) by employing more head rota-
tion and less sidebending. The examiner pal-
pates the range of motion and end-feel between
c the vertebral arches of Cl and C2 (interarcual
palpation).

Differential Diagnosis
With a disparity of sidebending in the upper cer-
vical spine, the level of the affected segment can
be determined as follows:
a) C2/C3 segment: sidebending and rotation in
the same direction. The C2/C3 facet or C2
spinous process is palpated.
b) Cl/C2 segment: rotation and slight sidebend-
ing in the same direction. The Cl/C2 vertebral
Fig.l19 a-d. Mobility testing: sidebending arches are palpated.
c) COICI segment: sidebending with slight rota-
tion in the opposite direction. The space be-
tween the Cl transverse process and mastoid is
palpated.
 Examination ofthe Cervical Spine (CO/Cl) 219

~ Sidebending
to the left

Fig. 120. b Craniovertebral joint mechanics during a

combined movemen t. (Modified from Kapandji)

BackwardBending (Fig. 122 a) lower cranial third on the frontal plane. The cer-
The head is tilted backward (by anterior gliding vical spine is fixed below C2 by ligament tension
of the condyles on the atlas). The axis of rotation (cervical kyphosis) or facet closure (lordosis).
of this movement is in the lower cranial third on Figure 123 shows a different, "wrap-around"
the frontal plane. There is associated facet clo- hand placement for backward and forward
sure or ligament tightening below C2. bending, which also permits the application of
The palpating finger is on the atlantal transverse some traction.
process or behind the mastoid between the oc-
ciput and the posterior arch of the atlas (see
Fig. 124a), where motion between the arches of
Cl and C2 is usually easier to palpate.

Normal Findings
By the movement of the occiput, the trans-
verse proces of the atlas moves closer to the
mastoid and away from the mandibular ramus
on each side. The range of motion is very
small becau e it i palpated so close to the
motion axi .
End-feel: firm-elastic.

Forward Bending (Fig. 122 b) Fig.12l. Routine test in the terminal position (with
The head is flexed forward, the occiput gliding some sidebending of the cervical spine toward the pal-
backward on the atlas, on an axis located in the pated side to immobilize the segments below C2)
220 Examination of the Cervical Spine (CVC2)

L--L~ __ ~ ____________ ~~~ ____ b

Fig.122. a Backward bending, b forward bending Fig. 123 a, b. Backward and forward bending at COICl
using an alternate hand placement

Normal Findings 3.2 Mobility Testing of the Atlas/Axis

The distance between the mastoid and trans- (Cl/C2) (Figs. 124-128)
verse process increases on each side with for-
ward bending and decreases between the Figure 124 shows the gliding movements that
mandible and transverse process. Again, the occur at the ClIC2 articulation.
range of motion is very small because it is pal-
pated close to the axis of the motion. In pa- Sidebending (Fig.l25)
tients with weak nuchal muscles, the posterior
arch of the atlas will approach the occiput Starting Position
during backward bending and may separate Same as in Sect. 3.1.
from the occiput during forward bending.

Procedure
With a painful limitation of motion, we recom- On the concave side of the neck, the atlas rotates
mend the hand placement in Fig. 123, where one forward (and laterally) on the axis. This rotation
hand is placed around the posterior circumfer- was already palpated at the atlantal transverse
ence of the occiput or the posterior arch of the process during sidebending in the CO/Cl seg-
atlas in the ClICZ segment and passively moves ment (see Fig. 119). Lewit states that sidebend-
the head. Often it is better to perform the for- ing in the atlanto-occipital joint is best palpated
ward and backward bending tests in the supine at the atlantal transverse process with the head
position (Figs. 156, 157) since better muscular in maximum rotation (to fix the lower cervical
relaxation is obtained. spine).
 Examination ofthe Cervical Spine (Cl/C2) 221
Palpation of C1 position
Sidebending at CO/C1/C2
Rotation at CO/C1

Palpation Palpation
of rotation at C1/C2 of backward/forward bending
a Sidebending at C2/C3 and rotation at C 1fC2
•

Pa lpation of rotation at C l/C2

b Sidebending at C2/C3

Fig. 124. a, b Gliding movements and sites for palpation ofthe craniovertebral joints (CO, Cl, C2), rotation at Cl
and C2. c Craniovertebral joint mechanics during backward and forward bending of the cervical spine (c after
Kapandji)
222 Examination or the Cervical Spine (CVC2)

Fig.12S a, b. Sidebending at ClICl

Fig.126. a Rotation ofthe atlas on the stationary axis.

b Rotation in terminal position. c,d Rotation test us-
ing an alternate hand placement
 Examination of the Cervical Spine (Cl/C2) 223

Normal Findings
The atlas is more easily palpated on the side to
which the head is idebent.

Rotation (Figs. 125-127)

Starting Position
The examiner fixes the spine of the axis be-
tween the thumb and index finger, supporting
the hand on the back of the patient's neck
(Fig. 126a,c,d).

Procedure
The examiner grasps the patient's head from
above with the free hand and rotates the head on
the longitudinal axis of the cervical spine Fig. U7. Rotation at ClIC2, combined movement
("twisting a light bulb"). The examiner deter-
mines the point at which the axis spine starts to
follow the movement (Fig. 126a) or palpates as
for rotation testing at the COIC1 segment
(Fig. 120b ). The end-feel is assessed as in the Atlas Rotation
COIC1 segment, but the palpating finger is posi- Atlas rotation can also be palpated as a com-
tioned along the vertebral arches from the joint bined movement, previously described in con-
facet to the spinous process of C2 (Fig. 124a). nection with motion testing at the COIC1 seg-
This palpation is more difficult. The hand place- ment (p.218, Fig. 120a). It is described below for
ment in Fig. 126 c,d is also suitable for therapeu- the ClIC2 segment (Fig. 127 a).
tic manipulation.
Starting Position
Cervical spine flexed for ligament fixation, cra-
Technique of Examination in Maximum Head
niovertebral joints slightly extended.
Rotation (Fig. 126b)
Starting Position Procedure
Maximum rotation and slight flexion of the cer- Rotation of the occiput and atlas with slight
vical spine. The craniovertebral joints are ex- sidebending to the opposite side, palpation of
tended. the springy end-feel between the vertebral
arches of C1 and C2.
Procedure
Same as at COICl. Terminal rotation of the Forward and Backward Bending (Fig. 128 a--c)
occiput and atlas with slight side bending to- This is performed like forward and back-
ward the opposite side, and interarcual palpa- ward bending in the CO/Cl segment (Figs. 122,
tion of movement and end-feel between the two 123), but the palpating finger is between
vertebrae. the arches of C1 and C2, posterior to the
mastoid process (Fig.128c). This test is diffi-
cult and is usually easier to perform in the
Normal Findings
recumbent patient. It is less rewarding than
Motion of the axis spine begins at about
side bending and rotation. Figure 128a,b illus-
20°-25° on each side during movement of the
trates the alternate "wrap-around" hand place-
axis on C3. Springy end-feel.
ment.
224 Examination ofthe Cervical Spine (C2IC3)

Fig. 128a-c. Forward and backward bending at

Cl/C2. a, b Technique. c Palpation site on the verte-
b bral arches

a b

Fig.129a-i. Movements in the C2/C3 segment. a-c Sidebending: a,b Compara-

tive side bending to the left and right. c Coupled rotation in the skeletal model.
d,e Backward and forward bending in the skeletal model. f,g Divergent move-
ment, h,i convergent movement
 Examination ofthe Cervical Spine (C1JC3) 225

Starting Position
Normal Findings
The examiner stands more to the side.
Approximation of the arches on backward
bending, separation on forward bending.
Procedure
• Note Sidebending at C21C3 (Fig. 129a-c)
Craniovertebral joint restrictions can be treated One hand sidebends the patient's head while the
only after any shortening of the deep nuchal other palpates (Fig. 129 a,b). Figure 129 c shows
muscles has been corrected by stretching. the terminal positions from the dorsal aspect
during sidebending at C2/C3. The coupled rota-
3.3 Mobility Testing
tion of C2 on C3 that accompanies side bending
of the C21C3 Segment (Fig. 129 a-g)
is palpated at the C2 spinous process or at the
The C2/C3 segment is prone to dysfunction. The facet, as in Fig. 129 g, i.
gliding movements in this segment are tested dur-
ing sidebending, backward bending, and forward Backward and Forward Bending
bending. Combined movements are also tested. Figure 129d, e shows the combined movements

Fig. 129 c-e. See p. 224

 226 Examination ofthe Cervical Spine (C3-C5)

Fig. 129f-i. See p. 224

of sidebending and rotation in flexion (diver- The lower vertebra is then fixed using the
gence; f, g) and extension (convergence; h, i). thumb-forefinger yoke of the palpating hand.
Divergent and convergent movements are pal-
3.4 Mobility Testing
pated on one side during combined movements
of the C3-CS Segments (Figs. 130, 131) (Fig. 131).
Since spinous and transverse processes are not Moving the head obliquely laterally and for-
available as palpation sites in the C3-C6 seg- ward or backward while rotating it toward the
ments, the divergent and convergent move- side to which it is inclined yields combined
ments are palpable only at the facet joints movements such as side bending, rotation, and
themselves. Both joints can be palpated simulta- forward bending to the left (i. e., divergence in
neously during forward and backward bending the right facet joint, Fig. 131 a,c) or sidebending,
(Fig.130). This technique can also be applied rotation, and backward bending to the right
therapeutically. (i. e., convergence in the right facet joint,
 Examination ofthe Cervical Spine (C3-C5) 227

d e

Fig. 130 a-e. Technique for testing and therapy. a, d Forward bending. c, e Backward bending

Fig. 131 b, d). The little finger of the mobilizing For therapy, the lower vertebra of the segment
hand is positioned over the arch of the vertebra to be mobilized is again fixed with the
that is to be moved. The palpating finger of the thumb-forefinger yoke of the palpating hand.
other hand is placed on the joint facet immedi- Figure 131e illustrates rotation testing in the
ately below and palpates the movement of the terminal position.
joint.
228 Examination of the Cervical Spine (C3-C5)

Fig.131a-e. Combined movements. a,cDivergence, b,dconver-

gence. c,d Joint palpation illustrated on the model (which shows
decreased mobility of the atlas and of C3 and C6 in divergence).
e Rotation in the terminal position
 Examination oftbe Cervical Spine (C5-TJ) 229

3.5 Mobility Testing of the C5-T3 occiput (Fig. 134 c,d). The free hand palpates the
Segments (Cervicothoracic Junction) joint facets. Generally, the spinous processes can
(Figs. 132-134) again be palpated beyond CS, although the
thumb and index finger of the palpating hand
Rotation (Fig. 133) can still palpate the joints on both sides and,
Rotation from C6 to T3 can be accomplished by when a motion fault is noted, differentiate the
active rotatory movements by the patient while sides by lateral flexion.
the spinous processes are simultaneously pal- See also BIIII Thoracic Spine, Sect.3.4, p. 186,
pated on both sides. and DIIII Cervical Spine in the Lateral Position,
Sect. 3.2, p. 204.
Backward and Forward Bending (Fig. 134a-d) Combined movements are tested by a combina-
As before, the patient's head is moved either by tion of sidebending and rotation in flexion or ex-
grasping the forehead with the forearm touching tension and are palpated at the articular surface,
the side of the head (Fig. 134a,b) or by "wrap- as in the higher segments.
ping" the arm around the head and holding the

Stationary
vertebra

Fig. 132 a, b. Gliding movements in the C6/C7 facet joints

a b c

Fig.133a-<. Active rotation at the cervicothoracic junction

 230 Examination ofthe Cervical Spine (C5-T3)

Fig.134a-f. Motility testing at the cervicothoracic junction. a Backward bending,

b forward bending. c,d Same examination with a different hand placement (wrap-
around grip). e,fPalpation site and vertebral mobility (panel fshows hypomobili-
ty at C3/C4 and C617 during forward bending)
 Examination ofthe Cervical Spine (C5-T3) 231

Vertebral Artery
NormaJ Findings
The following findings during the segmental ex-
Normal findings in the craniovertebral joints,
amination of the cervical spine suggest that the
see pp. 220-222.
vertebral artery may be endangered:
Ranges of motion at C2-C7 (see Fig. 10).
Backward and forward bending: increase in 1. Before reaching the end of an active range of
mobility from C2 to C5, marked decrease in movement, the patient experiences com-
mobiLity (rom C5 to T3. plaints or displays reflex resistance. This par-
Sidebending (with coupled rotation to the ticularly applies to examination of the cra-
same side): Moderate decrease in mobility niovertebral joints.
from C2 to C7, marked decrease in mobility 2. The passive movement pattern differs
from C7 toTI. markedly from that ordinarily associated with
a true restriction.
3. There are no signs of mechanical restriction,
Pathologic Findings (for Sects. 3.1-3.3) but clinical signs point to cervical spine in-
volvement.
CO/Cl/C2 Segments
4. Reflex hypertonicity of the segmentally relat-
1. Unequal prominence: ed intrinsic muscles is either absent or atypical
- With tenderness of one transverse process in- in its location, intensity, and extent.
dicates vertebral displacement and possible 5. The segmental neurologic signs of restriction
restriction (function test!) (hyperesthesia and hyperalgia) are absent or
- Without tenderness or function impairment noncharacteristic.
indicates vertebral.asymmetry
Positive findings require further investigation
2. Sidebending: Decreased mobility usually af-
by the vertebral artery tests (de Kleyn's hanging
fects rotation to the opposite side as well.
test, Hautant's test, Unterberger's walking-in-
3. A suspected increase of mobility must be
place test).
checked by hypermobility testing in the
supine position.
4. On head rotation, the axis spine begins to fol-
low the movement after less than 20° rotation.
This indicates a restriction of CIon C2. 4 Tests of Joint Translation
C2-C7 Segments
4.1 Traction
1. The axis spine is not palpable in the median 4.2 Compression
plane with vertebral asymmetry, sidebending, 4.3 Tests of Facet Joint Gliding
or a rotary position fault.
2. Sidebending: The centered or asymmetrically
positioned axis spine does not rotate in the op- These tests are specific for disorders of the cervi-
posite direction from the start of the move- cal disks, facet joints, and nerve exits.
ment. The spine makes unequal excursions to
both sides. 4.1 Traction (Fig. 135 a)
3. There is painful limitation of sidebending in
Starting Position
one or more segments, and of coupled rota-
The examiner grasps the patient's head with
tion as well. Thus, with a restriction of facet
both hands, placing the thenar eminence over
joint convergence on one side, ipsilateral
the mastoid. The palm is placed loosely over the
rotation and backward bending are also re-
ear, the hypothenar below the zygoma.
stricted.
 232 Examination of the Cervical Spine

Slight sidebending and backward bending can be

used to differentiate the right and left facet joints.

Normal Findings
Compression and traction are tolerated with-
out pain.

Pathologic Findings
In patients with neck or arm complaints relating
a
to disk pathology, traction (always applied
first) alleviates pain while light, careful com-
pression may exacerbate pain, with associated
dermatomal projection, or it may aggravate der-
matomal pain (compression of the interverte-
bral foramen).
Exacerbation of pain by traction suggests a
spinal cord lesion (medulla oblongata impinge-
ment in the foramen magnum).

4.3 Tests of Facet Joint Gliding

Fig. 135. a Traction on the cervical spine. b Compres-
(Figs. 136-139)
sion of the cervical spine Principle of Examination
Isolated motion testing of a cervical segment by
immobilization of the lower vertebra and dis-
Procedure traction or gliding of the facet joints induced by
The examiner carefully extends the cervical backward or upward movements of the vertebra
spine on the longitudinal spinal axis by leaning above.
back with his own body. If there is a fault of
head posture, traction is first applied coaxial Starting Position
with the postural fault ("three-dimensional" The examiner stands beside the patient. With
traction), followed by the careful application of one hand he grasps the arch of the lower
traction in other directions, according to pain vertebra and immobilizes it at the level of the
tolerance. facet joint with the proximal phalanx of the
Cervical traction can also be applied segmental- thumb and index finger (thumb-forefinger
ly (see p.233, Fig. 136). yoke). The other hand reaches around and
grasps the next higher vertebra and, using
mainly the little finger and the ulnar edge of the
4.2 Compression (Fig. 135 b)
hand, immobilizes the inferior border of the
Starting Position vertebral arch, the wrist and forearm resting
Both hands are placed flat on the patient's hand, against the side of the patient's head. In accor-
the fingers of one hand slightly overlapping the dance with the orientation of the joint surfaces,
other. the examiner's elbow is placed level with the pa-
tient's forehead for translatory motion testing
Procedure of the upper cervical spine, and it is placed level
The examiner carefully presses downward with the cervicothoracic junction at the pa-
with both hands, directing the pressure along tient's chin or zygoma for testing the lower cer-
the longitudinal axis of the cervical spine. vical spine.
 Examination ofthe Cervical Spine 233

Fig.136. Segmental traction (intervertebral disk) Fig.137. Segmental traction (facet joints)

Procedure - Downward, backward, and laterally with rota-

Longitudinal traction on the cervical spine tion to the same side, producing convergence
(Fig.l36) causes distraction of the intervertebral in the facet joint on the side to which the head
disk and superior gliding of the two upper facet is inclined (Fig.l38 b,c)
joints relative to the fixed lower joint surfaces.
This is particularly true in the lower cervical Normal Findings
spine, where there is less than 45° of forward
Equal, painless excur ion on both sides in the
inclination. In the upper cervical spine, the
individual motion segments.
test also produces some degree of facet joint
distraction.
Backward pressure on the upper vertebra Pathologic Findings
(Fig.l37) relative to the adjacent lower vertebra Painful limitations of motion associated with
exerts a pure distracting force on the facet joints. vertebral restrictions, disk protrusions, or in-
The disk is subject to backward shearing. Poste- flammatory processes.
rior-to-anterior pressure on the atlas can test the Translational movements are increased when
strength of the ligament apparatus (transverse hypermobility is present.
and alar ligaments) in the C1fC2 segment (see
also examination of the cervical spine in the • Note
supine position, Sect. 4.5, p.252). Hypermobility in the ClIC2 segment contraindi-
Lateral pressure with no rotatory component cates therapeutic mobilization of the craniover-
causes a purely lateral gliding movement in the tebral joints.
facet joints. This is a very important test for hy-
permobility in the C1fC2 segment (see Figs.
158-161, pp.252, 253).
In combined movements (Fig. 138) the exam-
iner's cranial hand moves the head, and the test-
ed upper vertebra, as follows:
- Upward, forward, and laterally with rotation
to the same side, producing divergence on the
side away from the movement (Fig.l38 a,b)
234 Examination of the Cervical Spine

c Fig.138a-c. Seep.234

5 Muscle Tests: Resistance Tests Starting Position

of the Cervical Muscles (Synergists) Upright sitting posture.

Procedure
This muscle group is also examined to some ex-
tent during testing of the shoulder girdle eleva- Forward Bending (Fig. 139)
tors (see p.291). From a position of slight ventral flexion, the pa-
tient bends the head in a forward arc toward the
 Examination of the Cervical Spine 235

Fig.138a-e. Translation testing of the C2/C3 segment. a,b Divergent movement,

c convergent movement (here, in the examination of wryneck). d,e. Translatory di-
vergence and convergence in a patient with normal segmental mobility

sternum Uugular fossa) while the examiner ap- Sidebending (Fig. 142)
plies resistance at the forehead or zygomas with The patient bends the head to the side. The
both hands (Fig. 139): test for the superficial examiner applies resistance at the temple
neck flexors, i. e., the scaleni (C3-C8, cervical while placing the elbow on the patient's
plexus) and the sternocleidomastoid (Cz-C 3 , ac- acromion to steady the ipsilateral shoulder:
cessory nerve). test for upper trapezius, rectus capitis poste-
Forward nodding (Fig. 140): Resistance is ap- rior minor (C3-C4, accessory nerve), rectus
plied below the chin. capitis anterior, rectus capitis lateralis, and
Test for the deep neck flexors, i. e., longus capitis, scaleni (Cr C8 , cervical plexus) on the tested
longus colli, rectus capitis anterior, rectus capital side.
lateralis (C1-CS, cervical plexus).
Rotation (Fig. 143)
Backward Bending The patient turns the head to one side while
The patient bends the head backward while the bending it toward the opposite side (Fig. 143).
examiner applies occipital resistance with the The examiner applies resistance to rotation and
hand, his forearm placed between the scapulae sidebending: test for the sternocleidomastoid on
to steady the upper body: test for the upper one side, e. g., rotation to the left and sidebend-
trapezius (C3-C4, accessory nerve), levator ing to the right test the right sternocleidomas-
scapulae (CrCs, dorsal scapular nerve), erector toid muscle.
spinae (C1- T4).
Backward nodding (Fig. 141): Upward resis- Forward Head Movement
tance is applied below the occiput (occipital The patient moves the head straight forward in
squama): test for the deep neck extensors (dor- the sagittal plane with no flexion while the ex-
sal flexors), rectus capitis posterior major and aminer applies resistance to the forehead with
minor, obliquus capitis superior and inferior, both hands: test for both sternocleidomastoids
splenius capitis, semispinalis capitis. (Cz-C 3 , accessory nerve).
236 Examination of the Cervical Spine

Fig.139. Superficial ventral flexors Fig.141. Deep dorsal extensors

Fig.l40. Deep ventral flexors Fig.142. Lateral flexors

 Examination ofthe Cervical Spine 237

Pathologic Findings

1. The deep neck flexors are prone to weakening.

This can be detected by sustained testing in
the supine position (see also E/Cervical
Spine/Sect. 5, p.255). The superficial flexors
(sternocleidomastoid and scalenus anterior)
often assume the function of the weakened
muscles.
2. The neck extensors (trapezius, levator scapu-
lae, erector spinae), as tonic muscles, are
prone to shortening, which can lead to a high
shoulder position and muscular limitation of
forward bending and side bending when the Fig.l43. Sternocleidomastoid muscle
shoulder is fixed. (Test for levator scapulae
shortening in the supine position!)
3. Muscular torticollis (from unilateral stern-
ocleidomastoid contracture): The head is tilt-
ed to the same side and rotated to the opposite
side.
Spastic torticollis ("rheumatic" torticollis): The
head is tilted and rotated to the side opposite the
restriction, i. e., the joint is in a convergent posi-
tion on the concave side and a divergent position
on the convex side. Function is restricted either
on the concave side for divergent movements or
on the convex side for convergent movements.
Examination of the Head (Temporomandibular Joints,
Sensory Organs) in the Sitting Position (BN)

1 Inspection
1.1 Facial Asymmetries
1.2 Mimetic Activity
1.3 Sensory Organs: Eyes

2 Jaw Movements and Swallowing

2.1 Opening and Closing ofthe Jaw
2.2 Protraction and Retraction of the Jaw
2.3 Lateral Jaw Movements
(Grinding Movements)
2.4 Swallowing

3 Palpation Field of the Face

3.1 Trigeminal Pressure Points
3.2 Corneal Reflex (First Division of
the Trigeminal Nerve)
3.3 Pressure on the Tragus
3.4 Palpation of the Temporomandibular
Joints
3.5 Percussion of the Frontal and Maxillary
Sinuses

4 Passive Testing of Temporomandi-

bnlar Joint Motion and Play

5 Muscle Tests
5.1 Mimetic Muscles
5.2 Masticatory Muscles
5.3 Lingual Muscles
5.4 Ocular Muscles
 Inspection 239

1 Inspection Mydriasis
Abnormal bilateral pupillary dilation due to ex-
1.1 Facial Asymmetries citement, fear, pain, glaucoma.
1.2 Mimetic Activity Unilateral mydriasis accompanied by an in-
1.3 Sensory Organs: Eyes creased lid aperture and exophthalmos occurs
with sympathetic irritation ("inverse Horner").
This oculopupillary irritation syndrome may be
the initial stage of a true Horner's syndrome and
Almost all faces have an irregular shape. Asym-
has the same causes (Finke).
metry is the element which animates the face
and gives it character. The face reflects the inter-
Miosis
nalmilieu.
Abnormal bilateral pupillary constriction oc-
curs with vascular sclerosis, neurosyphilis (ter-
1.1 Facial Asymmetries tiary syphilis), and drug use.
Congenital facial asymmetries frequently coex- Unilateral miosis combined with a decreased
ist with congenital deformities of the cervical lid aperture (ptosis, enophthalmos) occurs
spine and especially of the craniovertebral with sympathetic paralysis (Horner's syndro-
joints: "facial scoliosis" due to a congenital fault me).
of metameric segmentation (bony torticollis, Miosis results from root lesions at C8-T2, e. g., in
Klippel-Feil syndrome). radicular plexus paralysis, sympathetic trunk le-
Facial asymmetries can also occur with myo- sions (Pancoast's tumor, cervical ribs, struma),
genic torticollis (contracture of the sternocleido- carotid artery thrombosis (internal carotid
mastoid), an acquired form of wryneck that is artery), tumors or injUlies of the lower cervical
probably caused by obstetric trauma (sternoclei- and upper thoracic cord, and idiopathic causes
domastoid hematoma) and is common following (anomalies).
breech deliveries. They also result from paraly-
sis (facial palsy), marked by decreased promi- Anisocoria
nence of the nasolabial fold, sagging of the cor- (Unilateral pupillary dilation or constriction):
ners of the mouth, and lack of facial expression pupil enlarged in oculomotor paralysis, "inverse
on the affected side. Horner," amaurosis; constricted in sympathetic
paralysis (Horner'S syndrome), carotid occlu-
1.2 Mimetic Activity sion.

A decreased power of facial expression (hy- Ocular Position

pomimia) is seen in Parkinson's disease (loss of Asymmetric ocular position (dysconjugate
skin creases, masklike facies). gaze) due to oculomotor palsy.
Grossly exaggerated mimetic activity (compul- Function testing of the sensory organs.
sive laughing and crying) can occur with lesions
of the cerebral hemispheres.
Choreatic movements of the mimetic muscles
occur with lesions of the neostriatum.
Asymmetric mimetic activity is seen with facial
paralysis.

1.3 Sensory Organs: Eyes

Primary attention is given to the size (drugs?)
and shape ofthe pupils.
240 Palpation Field of the Face

2 Jaw Movements and SwaUowing 3 Palpation Field of the Face

2.1 Opening and Closing of the Jaw 3.1 Trigeminal Pressure Points
2.2 Protraction and Retraction of the Jaw 3.2 Corneal Reflex (First Division of
2.3 Lateral Jaw Movements the Trigeminal Nerve)
(Grinding Movements) 3.3 Pressure on the Tragus
2.4 Swallowing 3.4 Palpation of the Temporomandibular
Joints
2.1 Opening and Closing of the Jaw 3.5 Percussion of the Frontal and Maxillary
Sinuses
As the patient opens and closes the jaw, atten-
tion is given to any deviation of the mandible to
one side. With limitation of motion in one of the 3.1 Trigeminal Pressure Points
temporomandibular joints (TMJs), the jaw will
deviate toward the affected side. Above the eye (eyebrow): Supraorbital nerve
Jaw deviation is also observed in motor trigemi- Below the eye: Infraorbital nerve
nal paresis due to pterygoid dysfunction. The At the chin: Mental nerve
masseter reflex in these cases is diminished. Forcomparison, the area around the nerve exits is
With a TMJ lesion, jaw opening is impaired. also tested to exclude or confirm true nerve pres-
Bilateral flaccid paralysis of the third division of sure pain. Tenderness of the trigeminal nerve
the trigeminal nerve leads to sagging of the low- divisions to pressure can have various causes:
er jaw. With a unilateral lesion, masticatory pres- - Paranasal sinusitis
sure is decreased only on the affected side. - Diseases of the teeth and jaw
2.2 Protraction and Retraction ofthe Jaw - Meningeal irritation
- Increased intracranial pressure
Straight or angular protraction and retraction of - Less commonly, diseases of the trigeminal
the lower jaw require that joint function not be nerve itself (Finke).
restricted.
2.3 Lateral Jaw Movements 3.2 Corneal (First Division
(Grinding Movements) of the Trigeminal Nerve)
With a restriction of one joint, movement to-
ward the opposite side is impaired. In patients Procedure
with trigeminal lesions, lateral jaw movements Touching the cornea with a wisp of cotton elicits
toward the healthy side are impaired due to an immediate bilateral blink response.
pterygoid dysfunction.
eNote Pathologic Findings
Active movements of the TMJ are a richer A diminished corneal reflex on one side, com-
source of diagnostic information than passive bined with normal lid closure (facial nerve), in-
movements because they demonstrate the qual- dicates a lesion of the first division of the trigem-
ity of muscular function. inalnerve.
2.4 Swallowing
eNote
Swallowing difficulties are experienced with Sensory function in the areas supplied by all
vagus nerve lesions. A globus sensation in the three trigeminal nerve divisions is tested with a
pharynx or esophagus, with no objective find- cotton wisp. Motor function (third division) is
ings, can also occur with cervical dysfunction evaluated by testing the masticatory muscles
(restriction of C2/C3/C4). Gaw clenching).
 Passive Testing of Temporomandibular Joint Motion and Play 241

3.3 Pressure on the Tragus patient's neck and steadies the patient's head
against his own body. The border of the little fin-
Pressure on the tragus elicits pain in patients
ger is directly above the TMJ, parallel to the zy-
with TMJ disorders and inflammatory disorders
goma (as in Fig. 147).
of the ear canal. Differential diagnostic pressure
on the cartilaginous ear canal from behind is
Procedure
painful only in the presence of auditory canal
disease.
Downward Movement (Fig. 144)
The other hand (wearing a sterile glove) grasps
3.4 Palpation the mandible between the thumb and index fin-
of the Temporomandibular Joints ger, placing the thumb inside the mouth on the
The examiner sits opposite the patient or stands molars and the index finger below the jaw on the
behind him and bimanually palpates both TMJs outside. With the hand thus positioned, the ex-
while the patient's mouth is open. aminer pulls downward on the lower jaw.
Tenderness of one TMJ to palpation indicates
joint irritation. This is usually accompanied by Forward Movement (Protraction) (Fig. 145)
pain during mastication. There may also be Forward traction can be applied with the same
spontaneous attacks of pain in front of the ear, in hand position by placing the index finger not be-
the temporal region, or affecting the whole side low the jaw but behind the ascending ramus of
of the head (Costen's syndrome). With the the mandible. This, combined with slight down-
mouth open and with the jaw tightly clenched, ward traction on the jaw, produces anterior glid-
the masseter muscle is palpated by pressing on ing in the TMJ. If the patient cannot open the
its insertion at the mandibular angle, and the mouth, the examiner simply grasps the jaw angle
temporalis muscle is palpated at the temporal externally between the thumb and forefinger
bone. and applies forward traction (Fig. 145).
Spontaneous pain, functional pain, and/or ten-
derness to palpation occur with degenerative Medial-Lateral Movement (Figs. 146, 147)
arthritis of the TMJ and especially with TMJ The examiner now stands behind the patient and
dysfunction due to occlusal disturbances: "myo- places the immobilizing hand on the side of the
fascial pain syndrome." patient's head, the edge of the hand directly
above the TMJ and parallel to the zygoma. The
3.5 Percussion of the Frontal other (mobilizing) hand cradles the chin with the
and Maxillary Sinuses thenar eminence directly below the opposite
TMJ and applies transverse, lateral-to-medial
Tenderness to percussion over the frontal and pressure. This moves the mandibular head adja-
maxillary sinus (zygoma) occurs with inflamma- cent to the mobilizing hand in a medial direction
tory disease (sinusitis). while the opposite mandibular head, below the
immobilizing hand, is moved laterally. Figure
147 shows the same test with a different hand
4 Passive Testing of placement.
Temporomandibular Joint Motion
and Play Normal Findings
Painless gliding of the mandible in all three
Downward, forward, medial, and lateral move-
tests.
ment of the head of the mandible.

Starting Position
The patient is seated. The examiner stands to
one side, places one arm around the back of the
242 Muscle Tests

Fig. 144. Downward traction on the head of the Fig. 145. Forward traction (protraction) on the head
mandible of the mandible

Fig.l46. Medial-lateral gliding Fig.147. Medial-lateral gliding (alternate hand place-

ment)

5 Muscle Tests - Knitting the brow (vertical crease over the

nasal root): corrugator glabellae
- Drawing the nostrils together: nasalis
5.1 Mimetic Muscles
- Whistling (puckering the lips): orbicularis
5.2 Masticatory Muscles
oris
5.3 Lingual Muscles
- Laughing (raising the corner of the mouth):
5.4 Ocular Muscles
risorius, zygomaticus major
- Lowering the corner of the mouth: triangu-
laris
5.1 Mimetic Muscles - Raising the corner of the mouth and nose:
caninus (levator anguli oris)
Function testing:
- Drawing the lower lip downward and lateral-
- Wrinkling the forehead: frontalis ly: quadratus labu mandibularis
- Shutting the eyes tightly: orbicularis oculi - Wrinkling the skin of the chin: mentalis
 Muscle Tests 243

- Retracting the angle of the mouth (laugh- 5.4 Ocular Muscles

ing/crying): buccinator
During examination of the functional triad of
- Making a transverse crease between the eye-
nerves that supply the ocular muscles - the ocu-
brows: depressor glabellae
lomotor (third cranial), trochlear (fourth cra-
nial), and abducens (sixth cranial) - attention is
5.2 Masticatory Muscles
given to the following symptoms:
Function testing: Inspection:
Opening the mouth: digastricus, mylohyoideus, Ptosis, inferolateral eye position (pull from the
geniohyoideus. muscles of the fourth and sixth cranial nerves):
Closing the mouth: temporalis, masseter, ptery- ophthalmoplegia externa (oculomotor nerve).
goideus medialis. Large, nonreactive pupil, loss of accommoda-
Protracting the chin: temporalis, suprahyoid tion (functional loss ofthe intraocular muscles):
muscles. ophthalmoplegia interna (oculomotor nerve).
Lateral movements: ipsilateral temporalis, con- Function testing:
tralateral pterygoideus lateralis. Upward deviation of the eye during inferolateral
gaze: paresis of the trochlear nerve. Associated
5.3 Lingual Muscles diplopia. Compensatory inclination and rota-
tion of the head toward the opposite side.
All the muscles of the tongue are innervated by
Failure of lateral eye movement during gaze to
the hypoglossal nerve.
both sides: paresis of the abducens nerve. Severe
Function testing:
associated diplopia. Compensatory rotation of
Intraoral tongue position. With unilateral paral-
the head toward the opposite side.
ysis, there is deviation to the healthy side; with
atrophy, deviation to the affected side.
Extending the tongue. Unilateral paralysis and
atrophy cause deviation to the affected side.
Moving the tongue back andforth. With unilater-
al paralysis, movements toward the affected side
are slowed and of smaller amplitude.
Examination of the Cervical Spine
in the Supine Position (EN)

11 Inspection

2 Active and Passive Movements ofthe

Cervical Spine and Head in Three
Planes (Regional Diagnosis)
2.1 Forward Bending, Backward Bending,
Sidebending, and Rotation
2.2 Side-to-Side Head Movement
2.3 Provocative Test for the Vertebral
Artery (De Kleyn's Hanging Test)

3 Palpation ofthe Cervical Spine Dur-

ing Movement (Segmental Diagnosis)
3.1 Forward Bending
3.2 Backward Bending
3.3 Side bending
3.4 Rotation

4 Tests of Joint Translation

4.1 Three-Dimensional Traction on
All Cervical Segments
4.2 COIC1 Segment: Backward and Forward
Gliding of the Occipital Condyles on the
Atlas (Forward and Backward Nodding)
4.3 COIClIC2 Segment: Combined
Movements in the Craniovertebral
Joints
4.4 ClIC2 Segment: Atlas Traction
4.5 ClIC2 Segment: Lateral Gliding of the
Atlas on the Axis (Hypermobility Test)
4.6 C2-C7 Segments: Convergentl
Divergent Gliding in the Facet Joints

5 Muscle Tests - Resistance Testing of

the Cervical Muscles
 Active and Passive Movements 245

1 Inspection

Findings
Findings are the same as in the sitting position.
Attention is given to any discrepancy of head
position between sitting and lying down. Faults
of head position due to anatomic variations in
the joints (e. g., different left and right facet in-
clinations in the same vertebra) or postural
guarding due to vertebral restrictions or disk
problems may lessen or even disappear in the re-
laxed, supine position.
See AlGeneralInspectioniSect. 3.1.5 (pp. 77,81).

2 Active and Passive Movements

of the Cervical Spine and Head
in Three Planes (Regional Diagnosis)

2.1 Forward Bending, Backward Bending,

Sidebending, and Rotation
2.2 Side-to-Side Head Movement Fig. 148a,b. Forward bending (a) and backward
2.3 Provocative Test for the Vertebral bending (b) of the cervical spine
Artery (De Kleyn's Hanging Test)

2.1 ForwardBending, BackwardBending, 1. Forward bending (Fig. 148a)

Sidebending, and Rotation (Figs. 148, 149) 2. Backward bending (Fig. 148 b)
3. Side bending (Fig. 149 a,b)
Starting Position 4. Rotation (Fig. 149c,d)
Relaxed supine position; the head position is not
adjusted or corrected.
For passive mobility testing, the supine patient Findings
slides upward until the head and cervical spine See B/Cervical Spine/Sect. 2 (p.214).
project past the upper end of the table. The ex-
aminer cradles the patient's head in both hands -Note
so that he can freely move it in flexion, exten- The same hand placement can be used for
sion, sidebending, and rotation. the segmental examination (see Figs. 151, 152,
p.249).
Procedure
The passive movements are supplemented by
2.2 Side-to-Side Head Movement
light traction on the longitudinal axis of the cervi-
(Fig. 150)
cal spine. This usually affords a slightly greater
range of movement than is obtained in the sitting Segmental lateral pressure:
position. The sides are compared and end-feel The passive motion test described below can al-
evaluated as in the seated examination. The low preliminary identification of the affected
sequence of the tests is as follows: segment.
246 Active and Passive Movements

Fig.149. a, b Sidebending, Cod rotation of the cervical spine

Starting Position site the movement, and the end-feel is assessed.

Same as above. The hands are placed so that the The test proceeds segmentally from above
radial sides of the index fingers are on the arches downward.
of the same vertebra.
Normal Findings
Procedure
Painless, equal lateral gliding of the adjacent
The patient's head is moved as far as possible to
upper and lower vertebrae on both sides. The
one side, then to the other, parallel to the exam-
range of motion diminishes in the caudal
ination table (and shoulder girdle) without
direction.
sidebending. The index finger on the transverse End-feel: firm-elastic.
process slightly augments the lateral shift at the
end of the movement, causing sidebending (con-
vergence) of the palpated joint on the side oppo-
 Active and Passive Movements 247

2.3 Provocative Test for the Vertebral

Artery (De Kleyn's Hanging Test)
De Kleyn's hanging test is a test for vertebral
artery insufficiency on the side toward which the
head is rotated, since blood flow on the side op-
posite the movement is normally occluded in the
terminal phase of rotation by stretching and
compression of the vessel.

Starting Position
The examiner initially supports the patient's
head, which projects past the end of the table,
and then lowers it into a freely hanging position.

Procedure
The head is first placed in maximum dorsiflex-
ion, then rotated and held in that position for
about 20-30 s. The patient speak alouds (counts)
continuously during the test.

Normal Findings
The patient can tolerate the test for about
20-30 s with no adverse reaction or discom-
fort.

Pathologic Findings
- Apprehension
- Discontinuation of speech
- Nystagmus (horizontal or rotatory)
- Nausea and vertigo
- Facial paresthesias

Nausea, vertigo, and nystagmus occur

1. Immediately but then decrease in intensity:
Fig.150a-<. Side-to-side movement of the head vertebral restriction.
2. After 15-30 s and increase in intensity: verte-
bral arterial insufficiency.

Pathologic Findings • Note

Painfullirnitation of motion in one or more seg- The examiner should closely supervise the test
ments. due to its somewhat hazardous nature.
248 Palpation ofthe Cervical Spine During Movement

3 Palpation of the Cervical Spine facets. Slight traction applied in the cranial di-
rection will accentuate the movements.
During Movement
(Segmental Diagnosis)
3.2 Backward Bending (Fig. 152)
3.1 Forward Bending As in the forward bending test, both rows of
3.2 Backward Bending facet joints can be tested simultaneously.
3.3 Side bending
3.4 Rotation Starting Position
Same as before.

Segmental mobility testing of the cervical spine

Procedure
The radial sides of the index fingers are placed
and craniovertebral joints (Figs. 151-154)
on the right and left articular facets of the same
The position is the same as for passive motion
segment. Then the neck is segmentally dorsi-
testing. The examiner supports and moves the
flexed, the fingers providing the fulcrum over
patient's head with his palms while using the fin-
gers for palpation. The vertex of the slightly an- which the head falls slightly backward under its
own weight. The examiner palpates the conver-
teflexed head rests against the examiner's body
gent movement of the facets in each segment.
without compressing the cervical spine.
The palpation sites (transverse process of the at-
las, posterior arch of the atlas, and articular 3.3 Sidebending (Fig. 153)
facets of C2 to C7) are the same as in the seated Starting Position
examination. During the segmental palpation of Same as before.
mobility, the range of motion in the individual
segments is usually greater and more easily as- Procedure
sessed in the supine position than in the sitting The head is sidebent by segments, the index fin-
position. gers palpating the convergent movement of the
It should be recalled that mobility can be opti- facets on the concave side and their divergent
mally palpated only if the head is moved such that movement on the convex side (Fig. 153 a). A
the axis of motion is always at the level of the pal- slight rotatory component to the same side dur-
pating finger. During palpation below the atlas, ing convergence and to the opposite side during
the palpating finger should always be placed be- divergence (Fig. 153 b) will make the gliding
hind the sternocleidomastoid. movements easier to palpate.
The movements associated with side bending are
more clearly appreciated if the head is simulta-
3.4 Rotation (Fig. 154)
neously rotated slightly toward the same side.
Starting Position
As before, except that the patient's head rests in
3.1 Forward Bending (Fig. 151)
one hand - the hand toward which the head and
Starting Position cervical spine are rotated (e. g., the right hand
Relaxed supine position. The patient's head pro- during rotation to the right).
jects past the upper end of the table, and the ex-
aminer supports it with both hands. Procedure
The head is slowly rotated with both hands, pro-
Procedure ducing a forward and upward segmental move-
Proceeding segmentally from above downward, ment of the facets on the side opposite the move-
the index fingers palpate the articular facets on ment (e. g., on the left side of the neck during
both sides, without applying pressure of their rotation to the right). The examiner palpates the
own, to assess the divergent movement of the divergence of the facets on the side away from
 Palpation of the Cervical Spine During Movement 249

Fig.15I. Forward bending Fig.152. Backward bending

the rotation and their convergence on the side of

the rotation (as in Fig. 163).
The hand positions are switched for testing rota-
tion to the opposite side.

Normal Findings (for Sects. 3.1-3.4)

Soft, painless, unrestricted movement in all
directions (see Fig. 10).

Pathologic Findings (for Sects. 3.1-3.4)

During forward bending and rotation, the re-
stricted joint facet is palpable as a firm area that
is usually tender to palpation.

Fig.153a,b. Sidebending Fig.154. Rotation

250 Tests of Joint Translation

During sidebending and backward bending, the 4.2 COIC1 Segment: Backward and
hard-elastic end-feel is absent due to lack of Forward Gliding of the Occipital
facet convergence. Condyles on the Atlas (Forward and
The findings in these examinations may provide Backward Nodding) (Fig. 156)
an indication for proceeding with tests of joint
Starting Position
translation.
Relaxed supine position, the patient's head rest-
ing on the table. The thumb-forefinger yoke of
one hand grasps the posterior atlantal arch and
immobilizes it with forward pressure, the ulnar
4 Tests of Joint Translation
border of the hand resting on a small cushion.

4.1 Three-Dimensional Traction on Procedure

All Cervical Segments The other hand first pushes the skin downward,
4.2 CO/Cl Segment: Backward and Forward then grasps the occiput above the immobilizing
Gliding of the Occipital Condyles on the hand with the thumb-forefinger yoke and ap-
Atlas (Forward and Backward Nodding) plies upward and backward traction. With the
4.3 CO/Cl/C2 Segment: Combined atlas well fixed (by anterior pressure), this pro-
Movements in the Craniovertebral duces a small but palpable springing movement
Joints ("forward nodding") of the occiput on the atlas.
4.4 Cl/C2 Segment: Atlas Traction This movement can be accentuated by pressing
4.5 Cl/C2 Segment: Lateral Gliding of the gently downward on the patient's forehead with
Atlas on the Axis (Hypermobility Test) the shoulder. The rotational axis for the move-
4.6 C2-Cl Segments: Convergent/ ment is approximately in the lower third of the
Divergent Gliding in the Facet Joints cranium (Fig. 156 a).
"Backward nodding" of the occiput can be simi-
larly tested by approximating the occiput to the
stationary atlas (Fig. 156 b). The thumb yoke of
4.1 Three-Dimensional Traction the immobilizing hand fixes the atlantal trans-
on All Cervical Segments (Fig. 155) verse process by pressing backward from the an-
Starting Position terior side, while the occiput glides forward and
One hand supports the patient's occiput, the downward. This test is technically demanding
forefinger and thumb forming a yoke that cra- due to the difficulty of immobilizing the atlas
dles the head above the atlas. The other hand from the front, and often it cannot be successful-
grasps the chin. ly performed.

Procedure 4.3 COICl/C2 Segment: Combined

Both hands gently extend the cervical spine by Movements in the Craniovertebral Joints
pulling the head in the cranial direction (Fig. 157)
(Fig. 155 a). This is followed by: Starting Position
- Forward bending (Fig. 155 b) Relaxed supine. The patient's head is cradled in
- Backward bending (Fig. 155 c) both hands, the vertex resting lightly on the ex-
- Side bending (Fig. 155 d) aminer's abdomen to place the lower cervical
- Rotation (Fig. 155 e) spine in moderate flexion (ligament fixation).
The craniovertebral joints are slightly extended.
The examiner notes the directions in which pain
is relieved and/or mobility is increased. Procedure
The head is side bent at the craniovertebraljoints,
accompanied by slight rotation to the opposite
 Tests of Joint Translation (CO/Cl) 251

_ _ _ _..... e

Fig.l55a-e. Three-dimensional traction on the cervi-

cal spine. a Axial, b forward, c backward, d lateral,
c
erotation

Fig.l56 a, b. COICl segment: backward gliding (a), forward gliding of the occipital condyles (b)
252 Tests of Joint Translation (CVC2)

Starting Position
The immobilizing hand supports the patient's
head, the radial side of the index finger fixing the
atlantal arch from the side at the spinous process
and posterior arch. The index finger of the other
hand is on the posterior atlantal arch of the op-
posite side.

Procedure
One hand immobilizes the atlas on one side or
the axis on the opposite side as described above,
while the other hand pushes from posterolater-
ally to anteromedially against the immobilizing
hand, in alternating fashion, to test the ease of
Fig. IS7. Combined motion in the craniovertebral lateral displacement (ligament weakness) of the
joints (CO/ClIC2) atlas or axis.
The following tests are performed:
- With the axis immobilized on the left, the atlas
side. The palpating finger is between the atlantal is pushed to the left (Fig. 158).
transverse process and the mastoid for palpation - With the axis immobilized on the right, the at-
of the COIC1 segment, and between the vertebral las is pushed to the right (Fig. 159).
arches for palpation of the ClIC2 segment (see
Fig.128c, p.224). The examiner palpates the
springiness in the segment at the limit of motion.

4.4 ClIC2 Segment: Atlas Traction

Starting Position
Supine, as before. The hands are placed as in
Fig.156a.

Procedure
As in the examination ofthe ClIC2 segment, the
immobilizing hand grasps the posterior atlantal
arch as described, and the mobilizing hand is
placed on the atlantal arch and occiput. Traction
is exerted on the joints of the ClIC2 segment,
producing an upward gliding of the atlas in the
anterior atlantoaxial joint. The examiner pal-
pates the tension buildup in the segment and the
springiness at the motion limit.

4.5 ClIC2 Segment: Lateral Gliding

of the Atlas on the Axis
(Hypermobility Test) (Figs. 158-161)
Since lateral gliding does not occur in the ClIC2
segment, this is the most important test of joint
play in the cervical spine as it can reveal hyper-
mobility in the ClIC2 segment (ligamentous in- Fig.IS8a,b. Hypermobility test at ClIC2: The atlas is
stability). pushed to the left
 Tests of Joint Translation (CllC2) 253

Fig. 159 a, b. The atlas is pushed to the right Fig. 161 a, b. The axis is pushed to the left

- Or: With the atlas immobilized on the right,

the axis is pushed to the right (Fig. 160).
- With the atlas immobilized on the left, the axis
is pushed to the left (Fig. 161).

Normal Findings
Springy resistance but no lateral displace-
ment.

Pathologic Findings
Marked lateral displacement indicates hyper-
mobility (ligamentous weakness) in the Cl/C2
segment. Hypermobility is severe if the tested
vertebra can be displaced even when the head
is slightly inclined away from the direction
in which the vertebra is pushed (Figs. 158-161).

Fig. 160 a, b. The axis is pushed to the right

254 Tests of Joint Translation (C2-C7)

4.6 C2-C7 Segments: Convergent/ Procedure

Divergent Gliding in the Facet Joints The hand on the upper vertebra moves down-
(Figs. 162, 163) ward, backward, and laterally (toward the test-
ed joint) to test convergence (Fig. 163a) or up-
Starting Position ward, forward, and medially (away from the
Same as in Sect.4.2, i. e., one hand immobilizes tested joint) to test divergence (Fig. 163 b).
the arch of the lower vertebra with the yoke of The examiner's ipsilateral shoulder touches
the thumb and index finger. The volar side ofthe the patient's forehead and assists in the ma-
index finger of the other (mobilizing) hand is neuver (not shown in the photo). Convergence
placed around the upper vertebra (Fig. 162). is always tested first, because it is more fre-

Fig.162. Testing convergence/divergence at C2/C3

Fig. 163a,b. Testing convergence/divergence at C2/C3 on a skeletal

model
 Muscle Tests - Resistance Testing ofthe Cervical Muscles 255

quently impaired and more diagnostically re-

warding.
The test is performed on both sides, proceeding
from above downward by segments.

Normal Findings
Equal mobility in the segments on both sides,
with motion decreasing in the more caudal
segments (see Fig. to).

Pathologic Findings
Decreased or increased mobility in one or more
segments. Pain is felt during the gliding move-
ments and especially during convergence.

5 Muscle Tests - Resistance

Testing of the Cervical Muscles

The technique of the principal muscle tests was c

described previously in the section on cervical
spine examination in the sitting position (see Fig. 164a-i:. Superficial neck flexors (a), deep neck
B/Cervical Spine/Sect. 5, p. 233). flexors (b), deep neck extensors (c)

Starting Position
Relaxed supine position. In patients with weak Normal Findings
abdominal muscles and in children, the thorax Cervical flexor muscle strength is normal if
must be immobilized. The shoulders should not the patient can actively hold the head in the
lift up from the examination table. flexed position for about 30 s without tremor.

Procedure
Forward Nodding (Fig. 164 b)
Forward Bending One hand supports the patient's head while the
other applies resistance below the chin. The pa-
1. The examiner applies resistance to the chin
tient tries to nod the head forward against the re-
and forehead while the patient tries to raise
sistance: test for the deep flexors of the neck.
the head vertically from the table: test for the
sternocleidomastoids.
Backward Nodding (Fig. 164 c)
2. The examiner applies resistance only to the
Resistance is applied at the occiput.
forehead while the patient tries to flex the
head forward and appose the chin to the jugu-
Sidebending
lar fossa: test for the superficial cervical flex-
The head is maximally rotated on the examina-
ors (scaleni, longus capitis, longus colli).
tion table. Resistance is applied to the uppermost
Alternatively, the patient can actively bend the side of the forehead with the flat hand while the
head forward slightly and attempt to hold it in patient tries to sidebend against the resistance:
that position (Fig. 164a). test for the cervical flexors on the concave side.
Examination of the Upper Extremities
in the Sitting Position (B/IV) Shoulder Joint

1 Inspection
1.1 Shoulder Position
1.2 Shoulder Contours

2 Active and Passive Movements ofthe

Shoulder Joint
2.1 General Active Tests
2.2 Frontal Plane: Abduction/Adduction
and Rotation of the Arms
2.3 Sagittal Plane: Raising the Arms
Forward and Behind

I 3 Palpation Field of the Shoulder

4 Tests of Joint Translation
(Humeral Head)

5 Resistance Testing of the Shoulder

Muscles
5.1 Synergists (2 x 4)
5.2 DifferentiatingTests (3 x 5)
 Inspection 257

1 Inspection Levator scapulae spasm due to irritation of the

dorsal scapular nerve in the scalenus medius.
1.1 Shoulder Position
Winged Scapula
1.2 Shoulder Contours
Markedly raised medial margin and inferior an-
gle ("angel wing") due to:
- Paresis of the serratus lateralis (secondary to
1.1 Shoulder Position long thoracic nerve lesion) following unilater-
al blunt trauma (carrying sacks) or strenuous
Normal Findings physical labor
The arms (at rest) hang paralJel to the trunk, - Contracture of the pectoralis major and minor
the shoulder are at equal levels, and there is - Weakened scapular adductors: trapezius
equal shoulder roundnes on both side. (transverse part) and rhomboids
- "Poor posture" (covers both points above)
- The clavicles are approximately in the - Exostoses ofthe scapula or chest wall (scapu-
transverse plane and form about a 600 angle lar crepitation)
to the median plane. - Occasionally in C6 syndrome
- The scapulae are at the same level, the su-
perior angle approximately level with the Scapular Rotation
second rib, the inferior angle level with the Externally rotated position (inferior angle shift-
7th rib. The medial margin is parallel to the ed laterally) with paresis of the rhomboids
vertebral column and is about 5 cm from and/or levator scapula. Occurs bilaterally in
the vertebral spinous processes on both myopathy.
sides. The medial margin and inferior pole Internally rotated position (inferior angle shift-
are u ually slightly elevated from the tho- ed medially) with paresis of the trapezius (de-
rax. scending part) due, say, to an accessory nerve le-
- The vertebral column shows no significant sion and/or serratus anterior paresis.
deviation.
- The head is upright, i.e., "on the plumb Abduction Deformity
line." Swelling (inflammation) in the axilla.
Dislocation of the shoulder:
- Axillary dislocation (downward dislocation of
Pathologic Findings the humeral head into the axilla)
High Shoulder Position - Subcoracoid dislocation (forward beneath the
Hypertonicity of the trapezius (Bettmann's coracoid process)
shoulder-crest syndrome) to relieve tension and - Subarcomial dislocation (backward beneath
protect the shoulder joint (shortening of the the acromion)
trapezius and levator scapulae). - Infraspinous dislocation (backward beneath
Thoracic scoliosis. Bulging of the ribs on the the scapula)
convex side of the scoliosis.
Sprengel's deformity (rare): unilateral elevation All dislocations are associated with correspond-
of the scapula with winging (q. v.) and a supero- ing changes in the shoulder contours.
lateral to inferomedial course of the medial
scapular border due to shortening of the levator
scapulae. The size of the scapula is usually re-
duced, limiting elevation of the arm.
Paresis of the shoulder-girdle depressors (serra-
tus lateralis, trapezius inferior, subclavius).
258 Active and Passive Movements of the Shoulder Joint

1.2 Shoulder Contours 2 Active and Passive Movements

Pathologic Findings of the Shoulder Joint

Thickening of the Contours 2.1 General Active Tests

- Traumatic effusions (hematomas) 2.2 Frontal Plane: Abduction/Adduction
- Subacromial dislocation of the shoulder joint and Rotation of the Arms
- Joint inflammations 2.3 Sagittal Plane: Raising the Arms
- Tumors Forward and Behind

Flattening of the Contours

(Loss ofRoundness) The following criteria are evaluated during mo-
tion testing:
- Angular shoulder; deltoid atrophy due to axil-
lary nerve paresis - Range of motion
- Slight flattening (disuse atrophy) due to pro- - End-feel
longed immobilization of the joint (Desault - Pain
bandage, abduction splint) - Evasive movements
- Coordination (arm-scapula)
Deformities
Starting Position
- Stepoff in the clavicle or acromioclavicular
Upright sitting posture. The examiner stands be-
joint: fracture or dislocation of the clavicle
hind the patient. During passive motion testing,
(acromioclavicular separation)
which follows the corresponding active tests, the
- Depression below the acromion: "empty
scapula on the tested side is immobilized and the
glenoid" following shoulder dislocation (axil-
elbow is extended. This starting position is used
lary); protrusion below the coracoid or next to
for practically all examinations.
the scapula: coracoid or infraspinous disloca-
tion
- Prominence of the medial margin and inferior 2.1 General Active Tests (Fig. 165)
angle with winging of the scapula
- Prominence of the scapular spine with Starting Position
supraspinatus and/or infraspinatus atrophy Arms in the neutral position.
- Deepening of the supraspinous fossa (com-
pared with the opposite side) in "humero- Procedure
scapular periarthritis" (Duplay's disease) or The patient alternately crosses the hands behind
supraspinatus tendon rupture the back. The upper arm is flexed, adducted, and
- Deepening of the supra- and infraclavicular externally rotated while the lower arm is hyper-
fossae due to anterior prominence of the clav- extended, adducted, and internally rotated.
icles in individuals with "poor posture"
- Flattening of the supra- and infraclavicular Normal Findings
fossae due to inflammatory or neoplastic dis- The patient can touch the fingertips of both
ease (e. g., lymph nodes in gastric carcinoma hands together.
patients)
Pathologic Findings
Limitation of motion. The patient cannot touch
the fingertips together.
Hypermobility. The patient can place all or part
of one hand over the other.
 Active and Passive Movements of the Shoulder Joint 259

2.2 Frontal Plane: Abduction/Adduction current dislocation). The movement is limited

and Rotation of the Arms (Figs. 166-169) by the joint capsule, coracohumeral ligament,
and internal rotators.
Starting Position I
Arms extended in neutral position. Forearm in Test 3: Internal Rotation (Fig. 167 b)
semipronation, hand parallel to the body. Performed as in the previous test. Examiner in-
ternally rotates the joint to its passive limit, de-
fined by the joint capsule and external rotators.
Procedure
Test 1: Abduction Starting Position m
The arm is abducted to the vertical position Arm in the neutral position, elbow and forearm
(Fig. 166a). The examiner continues the abduc- as before (90° flexion, semipronation).
tion to its passive limit (frontal plane, Fig. 166 b)
and then flexes to the passive limit (sagittal Procedure
plane, Fig. 166c) while immobilizing the scapu-
la. The movement is limited by the adductors Test 4: External Rotation (Fig. 168 a)
and by the inferior and posterior portions of the The examiner externally rotates the patient's
capsule. upper arm, held at the side of the body, to its pas-
sive limit.
Starting Position II
Arm abducted 90°, elbow flexed 90°, forearm in Normal Findings
semipronation. Movements are painless and coordinated,
with equal ranges of motion on both sides and
Procedure no eva ive movements.
End-feel: firm-e la tic.
Test 2: External Rotation (Fig. 167 a)
------------------~
The examiner holds the patient's upper arm in
the abducted position while externally rotating
the shoulder joint to its passive limit (test for re-
260 Active and Passive Movements of the Shoulder Joint

Fig.166a--c. Abduction.
a Active, b passive,
c passive flexion
a b c

Fig.167a,b. Rotation in
90° abduction. aExter-
nal rotation, binternal
rotation
a b

Pathologic Findings (pain from 70° to 100° abduction, improved or

relieved by externally rotating the arm or raising
Test 1: Abduction it past 100°) is usually caused by rotator cuff
Limitation may be caused by the shoulder joint pathology at the greater tuberosity or by sub-
(stage 2 capsular pattern of Cyriax) or by de- acromial bursitis. The pain is caused by acromial
creased motion in the sternoclavicular or impingement against the irritated tissue. Painful
acromioclavicular joint. Continuation of abduc- arc past 100° is usually due to a functional distur-
tion and flexion to their passive limit tests stabil- bance of the clavicular joints.
ity, with increased motion signifying hypermo- Limited motion can also result from trapezius
bility of the joint. The "painful arc" of Cyriax palsy (accessory nerve) or amyotrophic lateral
 Active and Passive Movements of the Shoulder Joint 261

Fig. 168 a, b. Rotation

in the neutral position.
a External rotation,
b internal rotation
a b

Fig.169a,b. Adduction
a b

sclerosis (early symptom). With tears of the ro- Test 3: Internal Rotation
tator cuff, the arm cannot be held in abduction Often the last direction of motion restriction fol-
(arm drop test). lowing the improvement of shoulder stiffness.
Limitation of motion occurs with subcoracoid or
Test 2: External Rotation subscapular bursitis.
First direction of motion restriction with de-
generative or inflammatory joint disease (stage Tests 4 and 5: Rotation
1 capsular pattern of Cyriax). Limited mo- Same as tests 2 and 3.
tion also occurs with rotator cuff tears and bur-
sitis.
262 Active and Passive Movements ofthe Shoulder Joint

Test 6: Adduction Normal Findings

Adduction is always markedly increased in pa- Painless, coordinated movements with equal
tients with general and local hypermobility. In
ranges on both ides. 0 evasive movements.
this case the forearm or elbow can be placed on End-feel: firm -elastic.
the opposite shoulder. There is associated hy-
perextensibility in other joints (cubitus valgus,
hyperextensible hand, finger, and knee joints).
Pathologic Findings

• Note Test 1: Flexion

Unlike Cyriax, Sachse believes that limitation of Limited with paresis of the external rotators of
abduction occurs earlier in the capsular pattern the scapula.
than limitation of external rotation.
Test 2: Hyperextension
2.3 Sagittal Plane: Raising the Arms Pain during this test may result from lesions of
Forward and Behind (Fig. 170) the long biceps tendon in the intertubercular
groove.
Starting Position Active movements of the shoulder joint are limit-
ed by arthrogenic lesions and by myogenic and
Arms in the neutral position. neurogenic lesions of the shoulder muscles such
as rheumatoid polymyalgia, dermatomyositis,
Procedure polymyositis, menopausal myopathy, and neu-
Test 1: Flexion rologic disorders (plexus lesions, pareses of pe-
The arm is raised forward to the vertical posi- ripheral nerves).
tion. Examiner continues the flexion to its pas- Passive movements are often limited (usually
sive limit (see Sect. 2.2., test 1, Fig. 166c). concentrically) after injuries and operations
(mastectomy), by capsular lesions (peri-
Test 2: Extension (Backward/rom 0°) arthropathy, frozen shoulder), reflexly (after
(Fig. 170 a) Examiner continues the extension myocardial infarction), and by inflammatory
to its passive limit while immobilizing the joint disease (synovitis, arthritis).
scapula.

Fig. 170. a Extension

(from 0°), b internal ro-
tation in extension
a b
 Palpation Field of the Shoulder 263

3 Palpation Field of the Shoulder tween the lesser and greater tuberosities. Patho-
logic changes in the tendon or groove can be
palpated when the externally rotated upper arm
The bony and muscular attachments between is passively moved in an anterolateral to pos-
the humerus and scapula are examined. The five teromedial direction, as this movement causes
palpation sites (Fig. 171 ) on the humeral head extensive biceps tendon gliding within the
and shaft are as follows: groove.
1. Lesser tuberosity
3) Greater Tuberosity (Fig. 175)
2. Bicipital groove
The anterior part of the approximately 2-cm-
3. Greater tuberosity
wide greater tuberosity (the supraspinatus in-
4. Humeral fornix
sertion) is palpable anteriorly, directly below the
5. Deltoid tuberosity
acromion, when the arm is maximally internally
These sites mark the attachments or gliding sur- rotated and extended (anterior point of the
faces of the muscles that connect the humerus to shoulder; Fig. 175 a). The posterior part (inser-
the scapula. Each side is palpated and compared tion of the infraspinatus and teres minor) is pal-
with the opposite side. If muscle attachments are pated below the posterolateral border of the
painful or tender, palpation can be followed im- acromion (posterior point of the shoulder;
mediately by resistance testing of the affected Fig. 175 b) when the patient's arm is maximally
muscle (see B/ShoulderlSect. 5, p. 269). adducted and externally rotated, bringing the
posterior part of the greater tuberosity beneath
1) Lesser Tuberosity (Fig. 173) the lateral (and posterior) border of the
The first palpation site is located most easily by acromion.
standing behind the seated patient and immobi-
lizing the shoulder with one hand while placing 4) Humeral Fornix (Subacromial Space)
the palpating finger on the front of the shoulder (Fig. 176)
(Fig. 172). With the patient's arm abducted With the upper arm abducted approximately
about 70° and the elbow flexed 90°, the exam- 60°, this space is palpable as a groove directly
iner rotates the upper arm approximately 20° in- below the lateral border of the acromion. The
ternally (Fig. 172 a) and externally (Fig. 172b). subacromial bursa and the supraspinatus ten-
The lesser tuberosity is palpable with the index don below it are accessible to palpation in this
finger of the immobilizing hand as a small, ante- area.
rior, subacromial bony prominence that moves
laterally or medially with the rotary movements 5) Deltoid Tuberosity (Fig. 177)
of the arm. Just medial to the lesser tuberosity is Palpable at the visible inferior end of the deltoid
a second prominence of equal size, the coracoid muscle. Below the muscle is the subdeltoid bursa.
process, which remains stationary during arm
rotation.
Normal Findings
The lesser tuberosity (Fig. 173) (and the crest of
All the above site are nontender when pal-
the lesser tuberosity below it) is the site of inser-
pated at re t and during arm movements.
tion ofthe internal rotators: subscapularis, latis-
There are no palpable areas of increased firm-
simus dorsi, teres major. The fourth internal ro-
ness.
tator, the pectoralis major, inserts somewhat
more laterally and inferiorly on the crest of the
greater tuberosity. Pathologic Findings
Insertion tendinopathies are marked by tender-
2) Bicipital Groove (Fig. 174) ness on palpation of the tendon insertions
The bicipital groove is palpable just lateral to the during passive stretch or active contraction from
lesser tuberosity as a conspicuous groove be- a position of maximum stretch. Crepitation
264 Palpation Field of the Shoulder

..::..:..--_~~_-- Brachial plexus

- ---!!I.,------- Subclavian artery

G~r
tuberosity
0
.-- - ' T - - - + - - - - - - Humeral fornix
0 -+---:-----:--. ---~---1---CD Lesser tuberosity
® Bicipital groove
(long biceps tendon)

__-i'==--,.-~-----
®
Deltoid
tuberosity
8

Scalene interval

Brachial plexus

Subclavian artery

o
Hu meral fornix - -i'---T'----'C--'------:-'>---. CD
" ---'t-+...,...-,:...-- + - - - Lesser tuberosity

®
Bicipital groove
(long biceps tendon)

o
Greater tuberosity

® Deltoid
5 tuberosity --t'--:--:-'!lII-:--'--i:'---=-4•. 1

Fig.I71a,b. Palpation field of the shoulder (palpation sites on the humeral head and shaft) (after Lanz-
Wach~mllth)
 Palpation Field ofthe Shoulder 265

c
Fig.l72. a, b Differentiation ofthe greater tuberosity, bicipital groove, lesser tuberosity, and coracoid process by
rotation of the upper arm. cDifferentiation of the palpation sites on the rotator cuff

at site 2 (bicipital groove) during passive arm

motion signifies a lesion of the long biceps ten-
don.

• Note
Sometimes it may be necessary to palpate the
axilla (lymph nodes, axillary artery), as in post-
mastectomy patients.

Fig.l73. Test 1: lesser tuberosity (insertion of the sub-

scapularis)
266 Palpation Field of the Shoulder

b
Fig. 174 a, b. Test 2: bicipital groove (for the long biceps tendon)

a b

Fig.175a,b. Test 3: greater tuberosity (insertion of the external rotators)

Fig.176. Test 4: humeral fornix Fig.177. Test 5: deltoid tuberosity (deltoid resistance
test)
 Tests of Joint Translation 267

4 Tests of Joint Translation Test 3: Forward Pressure on the Humeral Head

(Humeral Head) (Fig.180)
The thumb-forefinger yoke of one hand is
placed over the acromion and glenoid from the
The mobility of the humeral head in response to front to immobilize the scapula. The other hand
inferior, anterior, and posterior pressure and lat- similarly grasps the humeral head near the joint
eral traction is evaluated. from the posterior side. The examiner's fore-
arms are directed toward each other on the same
Starting Position plane. The hand on the back of the shoulder then
Upright sitting posture. The examiner stands on pushes forward on the humeral head without ro-
the side of the tested shoulder joint, which is tating it.
placed in a position of rest (typically about 50°
abduction, 30° horizontal adduction, and slight Test 4: Backward Pressure on the Humeral
internal rotation). The actual resting position of Head (Fig.181)
a given shoulder joint will vary somewhat with The technique is the same as in test 3, except that
the conditon of the soft-tissue envelope. The pa- the hand positions are reversed and a posteriorly
tient's forearm rests on the examiner's forearm, directed pressure is applied.
and the elbow is braced against the examiner's
body.
Normal Findings
Procedure All the tests produce a brief, painless gliding
movement of the humeral head in the direc-
Test 1: Downward Pressure on the Humeral tion tested.
Head (Fig.178)
The arm is placed in the resting position, as de-
scribed. The thumb-forefinger yoke of the mo- Pathologic Findings
bilizing hand is positioned above the humeral Painful limitations of motion are seen in shoul-
head, just lateral to the acromion. The exam- der dysfunctions caused by degenerative or in-
iner's forearm points straight down, in line with flammatory joint disease. The findings are inter-
the applied downward pressure. preted as follows:
Impaired downward gliding: limitation of ab-
Test 2: Lateral Traction on the Humeral Head duction and elevation.
(Fig. 179) Impaired forward gliding: limitation of exten-
The thumb-forefinger yoke is placed over the sion and external rotation.
posterosuperior aspect of the scapula (with the Impaired backward gliding: limitation of flexion
glenoid fossa) and fixes it against the thorax, the and internal rotation.
thumb braced on the acromion. The other hand Impaired lateral movement: concentric limita-
grasps the upper arm just below the humeral tion of motion (increased joint pressure, con-
head from the axillary aspect, placing the fingers tracted capsule).
within the axilla and the thumb on the anterolat- Hypermobility is manifested by excessive trans-
eral side of the humeral head. The patient's fore- lation of the humeral head. Pain with hyper-
arm rests on the examiner's forearm as before. mobility in the first test is caused by pressure
The hand in the axilla pulls the upper humerus of the humeral head against the inferior
laterally to distract the humeral head from the glenoid rim and increased traction on the rotator
glenoid fossa. cuff.
 268 Tests of Joint Translation

a b

Fig. 178 a, b. Test 1: downward pressure on the humeral head

a b

Fig. 179 a, b. Test 2: lateral traction on the humeral head

 Resistance Testing ofthe Shoulder Muscles 269

Fig.ISO. Test 3: forward pressure on the Fig. lSI. Test 4: backward pressure on
humeral head the humeral head

5 Resistance Testing 2. Adduction (pectoralis major, latissimus dorsi,

of the Shoulder Muscles teres major, subscapularis) (Fig. 182 b). Resis-
tance is directed laterally by placing the fists
between the chest and elbow on each side and
5.1 Synergists (2x4)
having the patient "squeeze in" with the arms.
5.2 Differentiating Tests (3xS)
3. Flexion (deltoid, coracobrachialis, biceps)
(Fig. 183 a). Resistance is directed posteriorly
against anteflexion of the shoulder joints. This
5.1 Synergists (2x4)
may be done with both hands as shown, or the
Both sides are examined simultaneously in two examiner may thread his forearms through
sets offour tests. Resistance is applied at the el- the opening between the patient's elbow and
bow (first set) and wrist (second set). back and brace the dorsum of his hands
against the patient's back. The patient then at-
Starting Position tempts to flex the shoulders.
Upright sitting posture. The shoulder joint is in 4. Extension (deltoid, latissimus dorsi, teres ma-
the neutral position, the elbow is flexed 90°, and jor) (Fig. 183b). Resistance is directed anteri-
the hand position is between pronation and orly as shown, or the examiner may clasp both
supination. The examiner stands behind the pa- hands in front of the patient's abdomen and
tient. resist extension with his forearms.
On each side the examiner applies resistance at
Procedure
the wrist to:
On each side the examiner applies resistance at
the elbow to : 1. External rotation (Fig. 184a). Resistance is
directed medially.
1. Abduction (deltoid, supraspinatus) (Fig. 182 a). 2. Internal rotation (Fig. 184 b). Resistance is
Resistance is directed medially. directed laterally.
270 Resistance Testing ofthe Shoulder Muscles

b Fig. 182. a Abductors, b adductors

Fig.183. a Flexors,
bextensors
a b
 Resistance Testing ofthe Shoulder Muscles 271

Fig. 184. a External rotators, binternal rota-

tors

a ___"'-_ _......

Fig.18S. a Elbow flexors, b elbow extensors

272 Resistance Testing of the Shoulder Muscles

Fig.186. a Abductors,
badductors
a b

Fig. 187. a Flexors,

b extensors
a b

3. Elbow flexion (Fig. 185 a). Resistance is (abductors and adductors, Fig. 186; flexors and
directed downward against the supinated extensors, Fig. 187; external and internal rota-
hand. tors, Fig. 188).
4. Elbow extension (Fig. 185 b). Resistance is di-
rected upward. The patient's hand position is
5.2 Differentiating Tests (3 x 5)
the same as before.
If further differentiation ofthe shoulder muscles
The foregoing tests can also be performed sepa- is required, this can be accomplished with three
rately on each side, as shown in the photographs sets offive differentiating tests.
 Resistance Testing ofthe Shoulder Muscles 273

Fig.188. a External ro-

tators, b internal rota-
tors
8 b

Starting Position I extended arms. When the muscle is paretic,

Shoulder joint in various positions of flexion winging of the scapula occurs. The test can
(90°-180°). also be performed against a table or couch
rest.
Procedure
1. Internal rotators (pectoralis major, abdominal 4. Pectoralis major (Cs-TJ, anterior thoracic
part; latissimus dorsi; teres major; subscapu- nerve). The arms are held forward in 90° ante-
laris). The arm is in maximum external rotation flexion. The patient presses the hands of the ex-
(maximum stretch), the upper arm flexed about tended arms together, or resistance is applied at
160° (elevation), the elbow flexed 90°. Resis- the wrist by having the patient squeeze the ex-
tance to internal rotation is applied from the aminer's forearm with both hands. This tests the
front to the flexor surface of the wrist. middle portion of the pectoralis.
When the test is done unilaterally, the opposite
2. Triceps brachii (long head; CrCg, radial shoulder must be immobilized.
nerve) (Fig. 189). The test is performed from a
position of maximum stretch, i. e., the upper arm 5. Coracoid muscles: coracobrachialis and bi-
in maximum elevation (180°) and external rota- ceps brachii, short head (C6-C7 , musculocuta-
tion, the elbow maximally flexed. The upper arm neous nerve) (Figs. 190, 191) in the stretched po-
is placed against the head. Very light resistance sition (Fig.200b,c). The arm is abducted 70°
to extension of the forearm at the elbow is ap- (coracobrachialis) to 90° (short head of biceps),
plied at the wrist. the elbow is flexed, the hand supinated. The
hand is pronated for testing of the short head of
3. Serratus lateralis (anterior) (CS-C7 , long biceps. Resistance to flexion and horizontal ad-
thoracic nerve) , test as stabilizing muscle. The duction at the shoulder joint (coracobrachialis)
patient's arm is raised to approximately 120° is applied above the elbow joint (Fig. 190). For
anteflexion. Resistance to downward movement testing the short head of the biceps brachii, resis-
(extension) is applied at the upper arm. The tance to flexion and supination of the elbow
patient extends the shoulder joint (moves it joint is applied at the pronated forearm
downward) or pushes against a wall with the (Fig. 191).
274 Resistance Testing of the Shoulder Muscles

Fig.189. Triceps brachii, long head Fig.190. Coracobrachialis

• Note
When the short head of biceps is tested with the
muscle maximally stretched while the arm is
nearly extended and abducted 90° at the shoul-
der (Fig. 191), the coracobrachialis can be deac-
tivated by horizontal abduction against the ex-
aminer's body.

Starting Position II
The shoulder joint is abducted 40°-60°, the el-
bow is flexed 90°, and the hand is semipronated.
In all tests of the deltoid, the scapula must be im- Fig.191. Biceps brachii, short head, in stretched posi-
mobilized. tion (see also Fig. 200c)

Procedure
6. Deltoid (central portion; CS-C6 , axillary rotation (forearm down as in Fig. 167b, p.260).
nerve) (Fig. 192b). The examiner applies resis- The upper arm should be held in abduction to
tance to abduction of the nonrotated upper arm. prevent abduction/adduction movements. Re-
sistance to external rotation of the shoulder joint
7. Deltoid (posterior portion) (Fig. 192a). The
is applied to the extensor surface of the forearm.
upper arm is in slight internal rotation. Forward
resistance to abduction and extension of the up- 10. Internal rotators (pectoralis major, latissimus
per arm is applied. dorsi, teres major, subscapularis). The test is per-
formed from maximum external rotation (fore-
8. Deltoid (anterior portion) (Fig. 192c). The up-
arm up) . The upper arm is steadied as in test 9
per arm is in slight external rotation. Resistance
(Fig. 167 a, p.260). Resistance to internal rota-
to abduction and flexion is applied to the flexor
tion of the shoulder joint is applied to the flexor
aspect ofthe upper arm.
surface of the forearm.
9. External rotators (infraspinatus, teres minor).
The test is performed from maximum internal
 Resistance Testing of the Shoulder Muscles 275

?ig.192a-c. Deltoid
nuscle
a b c

Fig.193. Supraspinatus muscle Fig.194. Biceps brachii, long head

276 Resistance Testing of the Shoulder Muscles

Fig.195. Latissimus dorsi Fig.196. Teres major

Tests 1-10 also can be performed in the prone or 13. Latissimus dorsi (C6-Cg , thoracodorsal
supine position. nerve) (Fig. 195). The hand is again pronated.
Resistance is applied from the posteromedial as-
Starting Position m pect of the forearm to resist adduction, internal
Arm is extended with the shoulder and elbow rotation, and extension of the arm at the shoul-
joints in the neutral position. Hand is der joint.
semipronated.
14. Teres minor (CS-C6, thoracodorsal nerve)
Procedure (Fig. 196). The elbow is flexed 90 0 • The patient
11. Supraspinatus (CrCs, suprascapular nerve) may place the dorsum of the hand on the ipsilat-
(Fig. 193). Resistance to abduction of the ex- eral buttock or (if this is painful) support the
tended arm is applied at the dorsal side of the palm on the iliac crest as shown. Resistance is
wrist. Meanwhile the patient should slightly dor- applied posteromedially to resist adduction and
siflex the head and rotate it to the opposite side extension of the upper arm at the shoulder joint.
(to relax the trapezius). If the alternative position is used, the patient
presses the hand inward against the iliac crest.
12. Biceps brachii (long head; CS-C7 , musculo-
cutaneous nerve) (Fig. 194). The test is initiated 15. External rotators (infraspinatus and teres mi-
with the muscle in a stretched position. The pa- nor). These muscles are tested from maximum
tient's hand is pronated. Resistance to elbow internal rotation. With the forearm and dorsum
flexion is applied at the dorsal side of the wrist. of the hand against the back, the patient at-
tempts to rotate the shoulder externally (as in
Fig. 170b).

Tests 11-15 also can be performed in the prone

position.
Joints of the Shoulder Girdle

1 Inspection
(See B/ShoulderISect.1)

2 Active and Passive Movements of

the Shoulder Girdle
2.1 Raising and Lowering the Shoulder
Girdle
2.2 Advancing and Retracting the Shoulder
Girdle

3 Palpation Field of the Shoulder Girdle

3.1 Palpation of the Sboulder Girdle at Rest
3.2 Palpation of the Shoulder Girdle
During Movement

4 Tests of Joint Translation - Clavicle

and Scapula

5 Resistance Testing of the Muscles of

the Shoulder Girdle
5.1 Synergists
5.2 Scapular Rotators

I 6 Examination of the Cervical Spine

278 Palpation Field ofthe Shoulder Girdle

The shoulder region is subdivided into the ening of the descending part of the trapezius
shoulder and the shoulder girdle for purposes of and the levator scapulae.
clarity and to facilitate the systematic implemen- 2. Radiating neuralgic arm pain is caused by
tation of the numerous tests. brachial plexus irritation due to entrapment at
critical sites in the shoulder girdle (e. g., sca-
lene syndrome, costoclavicular syndrome).
1 Inspection
See B/ShoulderlSect.1 2.2 Advancing and Retracting
the Shoulder Girdle
2 Active and Passive Movements Shoulder Girdle Forward
ofthe Shoulder Girdle The patient "slouches" the shoulders forward, and
the examiner continues this movement to its passive
2.1 Raising and Lowering the Shoulder Girdle limit on both sides. The medial scapular border
2.2 Advancing and Retracting the Shoulder moves laterally while thoracic kyphosis is increased.
Girdle
Shoulder Girdle Back
If these tests are indicated, they generally can be The patient "sits erect" with the shoulders back.
combined with palpation of the sternoclavicular The examiner continues the movement to its
and acromioclavicular joints as described below. passive limit on both sides while applying coun-
As before, active movements are followed at terpressure with the knee to the patient's back.
once by passive motion testing. The scapula moves medially.

2.1 Raising and Lowering the Shoulder NormaJ Findings

Girdle AU movements are painless and equal on both
sides. The medial scapular border should
Shoulder Girdle Up move about 5 cm laterally and medially when
Active shoulder elevation is followed by passive the sboulders move forward and back, respec-
bilateral raising of the elbows, which are flexed tively, accompanied by a respective increase
90 0 • Attention is given to the symmetry of shoul- and decrease in thoracic kypbosis.
der height and scapular position.

Shoulder Girdle Down

Pathologic Findings
The patient "drops the shoulders," then the ex-
Same as in Sect. 2.1.
aminer presses the shoulders downward with
both hands.

Normal Findings
All movements arc painless and equal on both
3 Palpation Field of the Shoulder
sides. The scapulae should move 10-12 cm Girdle
when the shoulder girdle is raised and lowered.
3.1 Palpation of the Shoulder Girdle at Rest
3.2 Palpation of the Shoulder Girdle During
Pathologic Findings
Movement
1. Painful limitation of motion due to joint re-
strictions involving the clavicle and first rib.
Increased motion occurs with hypermobility. The bony and muscular attachments between
Lowering of the shoulder is impaired by con- the scapula and thorax are examined. The fol-
tracture of the pectoralis major and by short- lowing sites are palpated (Fig. 197):
 Palpation Field of the Shoulder Girdle 279

f4\ Shoulder girdle

'-:v muscles
Scalene interval Carotid artery

®
First rib - - - , : - : - - - ---e
l..l-.-:.::-::!!V----- Brachial plexus
~----'---,",!!~--- Subclavian artery
Sternoclavicular
joint
Acromioclavicular
jOint

f4\ Shoulder girdle

'-:v muscles
Levator scapulae """::::::---~L*-~~L
Scalenus anterior
Brachial plexus
Scalene interval
Subclavian artery

CD
Sternoclavicular
joint
@ Trapezius @ Subctavius
®
Acromioclavicular
joint

®
Coracoid
process

Fig. 197 a, b. Palpation field of the shoulder girdle (palpation sites about the clavicle and scapula)
(after Lanz-Wachsmuth)
280 Palpation Field of the Shoulder Girdle

1. Sternoclavicular joint 3.1 Palpation of the Shoulder Girdle

2. Acromioclavicular joint at Rest
3. Coracoid process
4. Levator and depressor muscles of the shoul- 1) Sternoclavicular Joint (Fig. 198)
der girdle The sternoclavicular joints are palpated biman-
5. First rib ually from the anterior and inferior aspects. If
tenderness is noted, joint function should be
Palpation of these sites helps to localize the tested. The costoclavicular ligament is palpable
source of complaints to the joints or the muscles at the inferior joint margin.
of the shoulder girdle. If tenderness is noted, the
examiner proceeds with passive joint motion
Nonnal Findings
testing or resistance testing of the inserting mus- A step between the clavicle and sternum, no
cles. Palpation of the coracoid process was de- tenderness to palpation.
scribed earlier in the section on the Palpation
Field of the Shoulder (p.263). All tests except
for the last (first rib) are performed simultane-
ously on both sides.

Fig.198. Sternoclavicular
joints

Fig.199. Acromioclavicular
joints
 Palpation Field of the Shoulder Girdle 281

2) Acromioclavicular Joint (Fig. 199) 3) Coracoid Process (Fig. 200)

The main feature to be noted during bimanual Palpation at the inferior border of the coracoid
palpation is the presence of a step between the process identifies the attachments of the pec-
clavicle and acromion. The superior acromio- toralis minor (Fig.200a), coracobrachialis
clavicular ligament is palpable at the superior (Fig. 200 b), and short head of biceps in the
joint margin. stretched position (Fig.200c). Palpation at the
superior border identifies the stabilizing cora-
co acromial, conoid, and trapezoid ligaments. If
Normal Findings
pain is elicited, the corresponding resistance
Joint is not tender to palpation. The step at
tests (Fig.200) can establish whether the pain
the anterior margin of the acromioclavicular
arises from a muscle attachment and can identi-
joint partiaUy disappears with maximum ex-
fy the muscle involved.
ternal rotation of the arm (abducted 90°) and
reappears with internal rotation.

_ _ ""';'_ _ ...1 8

Fig.200a-c. Coracoid process

with resistance tests of the a pec-
toralis minor, b coracobrachialis,
and c short head of biceps
brachii
c
282 Palpation Field of the Shoulder Girdle

4) Levator and Depressor Muscles ofthe

Shoulder Girdle (Figs. 197b, 201)
The levator muscles of the shoulder girdle are
tested as a synergistic group. To protect the cer-
vical spine from the pressure that is produced in
the vertebral joints by isometric contraction of
the muscles that cross the joints, the examiner
first immobilizes the cervical facet joints by
side bending the neck to the left, for example,
and rotating it to the right. The examiner then
resists active shoulder elevation while evaluat-
ing pain and strength (Fig.201). Spasticity and
tenderness of the muscle attachments warrant
functional examination, especially since the le-
vator muscles of the shoulder girdle are predom-
inantly tonic muscles that are prone to shorten-
ing. These muscles are, from posterior to
anterior:
1. Trapezius (descending part). Inserts on the Fig. 201. Resistance testing of the levator muscles of
clavicle opposite the deltoid. the shoulder girdle

2. Levator scapulae. Evaluated by palpating the

superior angie of the scapula and the origins of
the muscle on the CI-C4 transverse processes.

• Note
The superior portions of the trapezius and leva-
tor scapulae are especially prone to shortening.

3. Scaleni (at the first rib). Tenderness of the

brachial plexus may be noted during palpation in
the scalene interval. Scalene function is tested by
maximum expiration and sidebending the cervi-
cal spine to the opposite side. The subclavian
artery pulse is palpable behind the clavicle.

4. Sternocleidomastoid. Inserts on the sternum

and clavicle. Fig.202. Springing test of the first rib

5. Subclavius (the only "shoulder girdle depres-

sor" of this group). Palpable below the lateral
part of the clavicle. and second cervical vertebrae begin to rotate
(confirm by palpation). Then the radial side of
5) First Rib (Fig. 202) the index finger is placed against the rib from
The palpating hand pushes the trapezius aside above and tests the springiness of the joint by
posteriorly while the other hand tilts the pa- pressing toward the opposite inguinal fold. This
tient's head toward the examined side to relax actually tests the translation of the sternocostal
the scaleni and trapezius muscles. The head is joint and, strictly speaking, counts among the
also rotated toward the same side until the first motion tests described below. Because the ring
 Palpation Field of the Shoulder Girdle 283

formed by both first ribs, the sternum, and the clavicular joints while passively moving the test-
first thoracic vertebra forms the base of the ed shoulder in this sequence:
shoulder girdle, these joints must be examined
- Craniocaudally (Figs. 203, 204)
as welL
- Anteroposteriorly (Fig. 205)
- External and internal rotation (with the upper
arm abducted 90°) (Figs. 206, 207)
3.2 Palpation of the Shoulder Girdle
During Movement (Figs. 203-207)
Normal Findings
Painless, equal ranges of motion on both
Starting Position sides.
Same as before. The examiner palpates the The palpable step between the clavicle and
movements of the sternoclavicular and acromio- acromion is affected most strongly by rota-
tion: It becomes less promjnent during exter-
nal rotation of the arm due to elevation of the
acromion (with external rotation of the
scapula) and becomes more prominent with
internal rotation.

a b

Fig.203a,b. Sternoclavicular joint tested by a upward pressure and b downward

traction on the clavicle
284 Palpation Field of the Shoulder Girdle

a b

Fig.204a,b. Acromioclavicular joint tested by a upward pressure and b downward

traction on the clavicle

Fig. 205 a, b. Sternoclavicular joint. a Protraction : forward pressure on the clavicle;

b retraction: backward pressure on the clavicle
 Tests of Joint Translation - Clavicle and Scapula 285

Fig.206a,b. Sternoclavicular joint. a External rotation, b internal ro-

tation

4 Tests of Joint Translation -

Clavicle and Scapula
I Sternoclavicular Joint (Fig. 208)
Starting Position
The following techniques can be used in either Sitting (Fig. 208 a) or supine (Fig.208b,c).
the sitting or supine position to test sternoclavic-
ular, acromioclavicular, and scapulothoracic Procedure
gliding. The techniques shown in Figs. 210 and The examiner stands behind the patient, grasps
211 can also be applied therapeutically. the clavicle with the thumb and index finger
next to the joint space, and tests craniocaudal
joint play. The examiner's hand and forearm are
placed on the humeral head from the front and
286 Sternoclavicular Joint

Fig. 207 a,b. Acromioclavicular joint. a External rotation, b internal

rotation

apply a posteriorly directed pressure; the re- mobilize the shoulder and/or palpate the arti-
sultant traction effect in the sternoclavicular cular motion. Immobilization is not strictly nec-
joint facilitates the translatory movement, mak- essary owing to the fixed position of the ster-
ing it easier to palpate. The other hand can im- num.
 Sternoclavicular Joint 287

Fig.208a-d. Sternoclavicular joint examined in the sitting position (a)

and examined (or treated) in the supine position (b, c). Gliding plane
(d) ~ __________________ ~~ d
288 Acromioclavicular Joint

I Acromioclavicular Joint (Fig. 209 a)

Procedure
The examiner stands behind the patient. The
thumb of the test hand (the left hand tests the
right joint) slides laterally along the top of the
clavicle to the acromion, the thumb and index
finger grasping the clavicle directly adjacent to
the joint line. The other hand fixes the acromion,
the fingers placed over the humeral head and the
thumb over the lateral end of the acromion. The
thumb and index finger of the test hand now ap-
ply an anteriorly directed force and test the
small gliding movement in the joint. The joint
line is oriented almost in the sagittal plane, run-
ning slightly laterally.

Alternative Techniques
These are particularly appropriate for therapy.

Sternoclavicular Joint (Fig. 20S b-d)

Starting Position
Same as before (or supine). Fig.209. a Acromioclavicular joint examined in the
sitting position and b examined (or treated) in the
Procedure supine position
The examiner stands in front of the patient on
the side of the examined joint. One hand (the
left for examining the right shoulder) immobi-
lizes the shoulder and acromioclavicular joint.
The index finger of the other hand is placed Procedure
against the medial end of the clavicle from be- The examiner stands behind the patient (or at
low, the dorsal side of the distal and middle pha- the head of the table if the patient is supine).
langes covering the sternoclavicular joint space. Again, the thumb (the right thumb for testing
The thumb of the same hand is placed on the in- the right shoulder) is slid laterally along the up-
dex finger and the patient's clavicle to keep the per border of the clavicle to the acromion. The
finger from slipping upward (and injuring the other fingers are placed over the shoulder joint
soft tissues of the neck). Then the examiner from the front so that the index finger is over the
pushes cephalad to test the mobility of the clavi- acromion and can immobilize it. Then the
cle at the joint (traction with cranial gliding). If thumb of the test hand pushes the clavicle for-
this is too painful, the ball of the thumb can be ward from behind to test the mobility of the
used (Fig.20Sc). acromioclavicular joint. The other hand can
steady the patient's thorax from the front
Acromioclavicular Joint (Fig. 209) (Fig. 209 b) or support the test hand by placing
thumb over thumb and fingers over fingers to
Starting Position augment both the mobilizing and immobilizing
Same as before. forces.
 Acromioclavicular Joint 289

Scapulothoracic Joint (Gliding Plane) can be performed in the prone position (see
(Figs. 21Oa--c and 211) CfThorax, Sect.4.2, p.199, Fig. 106). But since
Scapular mobility can usually be assessed on the the treatment of impaired scapular gliding is un-
basis of shoulder movements owing to the dertaken in the lateral position, that is the start-
scapulohumeral component that is present in all ing position used for the tests below.
movements of the shoulder joint. Thus, two-
thirds of shoulder joint motion occurs in the Starting Position
humeral articulation while the remaining third is Stable side-lying position with the lower leg and
accomplished by external or internal rotation of arm flexed and the patient's head resting in the
the scapula. If translatory tests are indicated to lower hand. The arm on the tested side hangs
evaluate scapular tracking on the thorax, they loosely over the examiner's forearm.

b _ _ _ _ _ ____

Fig.210a-e. Gliding movements of the scapula on the

thorax. a lateral, b medial (abduction and adduction);
c cranial-caudal; d, e external-internal rotation
290 Acromioclavicular Joint

Procedure Abduction and adduction of the inferior angle

Both hands grasp the scapula, one hand at the of the scapula should equal about 5° in each
superior margin and scapular spine and one at direction, accompanied by a corresponding
the inferior angle. The examiner then succes- change in the craniocaudal orientation of the
sively tests the passive ranges of motion cranio- glenoid cavity.
caudally (Fig. 210 a), mediolaterally (adduc- About the vertical axis:
tion/abduction) (Fig. 21Ob), and in internal and Abduction and adduction of the medial mar-
external rotation (Fig. 210 c). Concomitant gill of the scapula should equal about 10° in
movement at the glenohumeral joint, which fa- each direction. The medial border is elevated
cilitates scapular motion, is accomplished by fix- from the thorax (winged capula) while the
ation ofthe upper arm (Fig. 211 d). c1aviculoscapular angle increases by about
10° on the horizontal plane; the glenoid as-
Normal Findings sumes a more anterior or posterior orienta-
Painless motion in ali directions, with equal tion.
ranges on both ides. Soft-elastic end-feel. The rhomboids and levator capulae become
With normal mobility in both clavicular joint , stretched near the Limit of abduction.
the scapula should have the following ranges About the longitudinal axis through the clavi-
ofpa sive, painless mobility on the thorax: cle:
External and internal rotation of the scapula
- Approximately 10-12 cm craniocaudally
should equal about 25° in each direction. The
- Approximately 15 cm mediolaterally
rhomboids and levator scapulae are stretched
- Approximately 60° of internal and external at the limit of external rotation, and the
rotation of the inferior angle, the inferior
trapezius (descending part) and serratus an-
angle moving about 10 em mediolateraliy
terior at the limit of internal rotation.
and the superior angle moving about Movements occur about the same axes in the
5-6 cm craniocaudaliy.
sternoclavicular joifll.
Movements in the acromioclavicular joint
abow the sagittal axis:

Fig.211a-il. Scapular movements and angular gliding movements

in the glenohumeral joint with the upper arm supported (therapy) d
 Resistance Testing of the Muscles of the Shoulder Girdle 291

Pathologic Findings Lowering the Shoulders (Fig. 212 b)

The examiner applies upward resistance at the
- Decreased caudal mobility of the scapula due
flexed elbows. The following muscles are tested:
to reactive hypertonicity of the shoulder-gir-
dle levator muscles secondary to shoulder - Trapezius (inferior portion; C2-C4 , accessory
joint disease or levator shortening nerve)
- Decreased abduction due to pectoralis con- - Pectoralis major (C5-TJ, anterior thoracic
tracture or shortening nerves)
- Limitation of motion due to hypomobility in - Pectoralis minor (C6-CS, anterior thoracic
the clavicular joints nerves)

Moving the Shoulders Forward

(Protraction, Fig. 213 a)
5 Resistance Testing ofthe Muscles Backward resistance is applied at the front of
of the Shoulder Girdle both shoulders, the patient's back resting against
the examiner's body. The following muscles are
tested:
5.1 Synergists
5.2 Scapular Rotators - Pectoralis major (C5-TJ, anterior thoracic
nerves)
- Pectoralis minor (C 6-CS, anterior thoracic
nerves)
5.1 Synergists (Figs. 212,213)
- Serratus lateralis (C5-C7 , long thoracic nerve)
Starting Position
Drawing Back the Shoulders
Examiner stands behind the patient, whose arms
(Retraction, Fig. 213 b)
hang loosely at the sides.
Forward resistance is applied at the back of the
shoulder. The opposite shoulder or the thorax is
Procedure
immobilized from the front. The following mus-
cles are tested:
Raising the Shoulders (Fig. 212 a)
The examiner applies downward resistance at - Trapezius (middle portion; C1-C2, accessory
the acromion. For unilateral testing, the head nerve)
is immobilized by sidebending to the opposite - Rhomboids (C4-C5, dorsal scapular nerve)
side and rotation to the tested side (to lock
Only one side at a time can be tested with this
the facet joints). The following muscles are test-
technique.
ed:

- Trapezius (superior portion; C2-C4 , accessory 5.2 Scapular Rotators (See Fig.1D7 d,e, p. 200)
nerve) If necessary, additional tests can be performed
- Levator scapulae (Cr C5), dorsal scapular on the rotator muscles of the scapula.
nerve)
Internal Rotators (Rhomboids, Pectoralis
• Note Minor)
Shortening of the levator scapulae can also be
Procedure
tested and treated in the lateral position by
The examiner's hands are crossed so that the ra-
applying caudally directed pressure to the
dial side of each index finger is on the medial
scapula.
border of the scapula. He pushes the inferior an-
gle of the medial border laterally while the pa-
tient attempts to rotate the scapulae medially.
292 Resistance Testing of the Muscles of the Shoulder Girdle

Fig.212. a Trapezius ( descending part)

and levator scapulae. b Trapezius
(ascending part), serratus lateralis, and
pectoralis minor

Fig.213. a Pectoralis
major and minor.
b Trapezius and rhom-
boids
 Examination of the Cervical Spine 293

External Rotators (Serratus Lateralis, 6 Examination

Descending Part of Trapezius) of the Cervical Spine
Procedure
For this test the examiner's hands are placed so Functional disturbances of the upper extremity
that the radial side of each index finger is on the joints, like pain radiating to the arm, are an indi-
lateral side of the scapula. He tries to push the cation for concurrent examination of the cervi-
scapula medially against active resistance by the cal spine so that segmental disturbances can be
patient. diagnosed and treated.
The examination technique is described in
-Note B/Cervical Spine (p.214).
Shortening of the pectoralis minor leads to im-
paired external rotation of the scapula.
294 Examination of the Cervical Spine

Hyperabduction

/'"
/
I
1I
I
I
I ~ i '

I 3,~~v/.;;
I
I ,
I ....
I Rotation I
,
h Gleno-
h~meral
'" )Olnt
4 ~ I \ _ ' (trans":"'
\ .. ~ lation)

\
\
,,
\
\

,
......... Active!passive!
translation
a

Fig. 166a, p. 260 1) Painful arc: general motion test for the joints of the shoulder and
shoulder girdle
Fig.166b,c,p.260 2) Hyperabductionlhyperflexion: joint stability
Fig. 167 a, b, p. 260 3) Rotation in 90° abduction: joint gliding/capsular tension/end-feel!
rotator cuff
Fig. 168a,b, p.261 4) Rotation in OOposition: joint gliding/capsular tension/end-feel!rotator
cuff in moderate tension
Figs. 178-181, pp. 268, 269 5) Glenohumeraijoint tests: joint play: downward traction on humeral
head; may be supplemented by lateral traction and anterior/posterior
pressure
 Examination ofthe Cervical Spine 295

, O . Cervical spine examination

(+ 1st rib)

+
I
I
9. Clavicular joints

t
I
8. 4Resistance tests
at the wrist

+
•
7. 4Resistance tests
at the elbow

t
I
6. Resistance tests with the arm
in the neutral position

Figs. 193-196,pp.275,276 6) Muscle resistance tests with the arm straight at the side: specif-
ic muscles in the stretched position: supraspinatus, long head
of biceps, latissimus dorsi, teres major
Figs. 182 (186), 7) Four resistance tests at the elbow: synergistic groups : abduc-
183 (187), pp. 270, 272 tors, adductors, shoulder flexors, extensors
Figs. 184 (188), 185 8) Four resistance tests at the wrist: synergistic groups: shoulder
(223 a,c), pp. 271, 273, 311 rotators, elbow flexors and extensors
Figs. 208/209, pp. 287, 288 9) Clavicular joints: gliding tests
Figs. 129-134, 10) Cervical spine examination: segmental mobility, test for shoul-
201. pp.224-230, 282 der girdle levators
Elbow Joint, Upper Arm, and Forearm

1 Inspection
1.1 Joint Position
1.2 Joint Contours
1.3 Changes in the Muscle Contours of the
Upper Extremity

2 Active and Passive Elbow

Movements
2.1 FlexionlExtension
2.2 Pronation/Supination
2.3 Abduction/Adduction (Collateral
Ligament Stability Test)

3 Palpation Field of the ElbowlArm

3.1 Extensor Side of the Elbow
3.2 Lateral (Radial) Epicondyle
3.3 Medial (Ulnar) Epicondyle
3.4 Flexor Side of the Elbow
3.5 Upper Arm and Forearm

4 Tests of Joint Translation

4.1 Humeroradial Joint
4.2 Proximal and Distal Radioulnar Joints
4.3 Humeroulnar Joint

5 Resistance Testing of the Mnscles of

the Elbow Joint
5.1 Flexors and Extensors
5.2 Pronators and Supinators
 Inspection 297

1 Inspection - Degenerative or inflammatory disease (gout,

chondrocalcinosis, infection)
1.1 JointPosition - Contractures
- Dislocations (less common)
1.2 Joint Contours
- Neurogenic flail joint
1.3 Changes in the Muscle Contours of the
- Aseptic necrosis of the radial head in children
Upper Extremity
(Panner's syndrome)

1.2 Joint Contours

1.1 Joint Position
Normal Findings
Volar Aspect Witb tbe elbow flexed 90°, inspection from
behind reveals HUler's triangle (Figs. 214a-c,
215), an equilateral triangle formed by the
Normal Findings
two epicondyles and the olecranon. The trian-
Physiologic valgus of 20° (0°_26°). Changes in
gle is visible only when the elbow is flexed 90°.
normal valgus angulation can be appreciated
With the elbow extended, the three vertices of
only when the elbow joint is in the neutral po-
the triangle lie on a horizontal line.
sition with the forearm supinated.
The skin fold on the flexor surface corre-
sponds to the position of the joint line. Pathologic Findings
Changes in Huter's triangle occur with supra-
condylar fractures of the humerus. T or Y frac-
Pathologic Findings
tures are associated with proximal displacement
Increased valgus angulation due to:
of the olecranon andlor lateral displacement of
- Hypermobility associated with recurvatum the epicondyles (Fig. 214 g, 1-10).
- Supracondylar fractures Asymmetry of Hilter's triangle is seen with dis-
- Growth plate abnormalities locations of the forearm (Fig. 214 g, 1, 2) and
avulsion fractures of the epicondyles (Fig. 214 g,
Increased varus angulation due to: 3-6).
- Intraarticular fractures
- Systemic disorders (chondrodystrophy, en-
chondral dysostosis, rickets)

Lateral Aspect

Normal Findings
The olecranon is behind the humeral shaft
axis when the elbow is extended, in front of
the humeral shaft axis when the elbow is
acutely flexed , and on the humeral shaft axis
when the elbow is flexed 90° (Fig. 214 d-f). Fig. 214. a-c Hiiter's
triangle, when the
elbow is flexed and
Pathologic Findings extended.
Flexion deformity due to: d-f Shaft of the
humerus when the
- Fractures elbow is flexed and
- Effusions extended
298 Inspection

Lateral dislocation
of the forearm 2 Medial dislocation

3 4
Y-fracture of the Avulsion of the
distal humerus lateral epicondyle

Avulsion of the Olecranon fracture

medial epicondyle

Fig.214b-f. (after Lanz-Wachsmuth)

Fig. 214 g. Changes in Huter's triangle with fractures

and dislocations ..
1. Lateral dislocation of the forearm 7 Flexion 8 ExtenSion
2. Medial dislocation of the forearm fracture fracture
3. Y-shaped intraarticular fracture of the distal 10
humerus
4. Avulsion of the lateral epicondyle
5. Avulsion of the medial epicondyle
6. Fracture of the olecranon
7. Supracondylar flexion fracture of the humerus
8. Supracondylar extension fracture of the
humerus Anterior
9. Anterior dislocation of the forearm dislocation Posterior
dislocation
10. Posterior dislocation of the forearm
 Active and Passive Elbow Movements 299

Lateral changes: Supracondylar fractures of 2 Active and Passive Elbow

the humerus shift the axis of the humeral shaft
Movements
in front of or behind the epicondyles (Fig. 214g,
7, 8). Anterior or posterior dislocations of
2.1 FlexionlExtension
the forearm shift the olecranon in front of or
2.2 Pronation/Supination
behind the humeral shaft axis (Fig. 214g, 9,
2.3 Abduction/Adduction (Collateral
10).
Ligament Stability Test)
Joint swelling occurs with fractures and inflam-
mations (arthritis, osteomyelitis, synovitis, Tb).
Fusiform swelling can result from effusions
(fluctuations) and tumors. 2.1 Flexion/Extension
Changes in the radial head contour are caused by
sprains, fractures, or dislocations. Starting Position
Effacement of radial contour: anterior disloca- Upright sitting posture, elbow extended, fore-
tion of the radial head. arm supinated (neutral position).
Accentuation of radial contour: posterior dislo-
cation of the radial head. Procedure
Bayonet position: lateral dislocation. Active and passive flexion, with a passive stretch
Swelling at the olecranon lateral to, above, or on imparted at the end of the movement. The upper
both sides ofthe triceps tendon is seen with bur- arm is fixed above the elbow during passive
sitis. Meynet's nodules occur in chronic rheuma- movements.
toid arthritis. Fibromas, xanthomatosis (choles-
terol deposits). Normal Findings
Flexion to 150°.
1.3 Changes in the Muscle Contours Hyperextension to +10° (from the neutral
of the Upper Extremity position).
Cubitus valgus (with the arm in the neutral
Pathologic Findings position) of 10° (males) to 20° (females).
Atrophy following prolonged immobilization or Equal ranges of motion on both sides.
paresis in tuberculous synovitis. End-feel: In flexion. often soft-elastic muscu-
Tumorlike swellings can result from lar restraint, otherwise firm-elastic ligamen-
tous restraint. In extension, hard-elastic bony
- Muscle ruptures (biceps, triceps) restraint in the olecranon fossa. In muscular
- Herniation of muscle through fascial tears individuals, biceps ten ion may impart a oft-
- Myositis ossificans (brachialis muscle) elastic end-feel to extension.

• Note
2.2 Pronation/Supination
Girth measurements can be taken approximate-
ly 15 cm above and below the flexed elbow and Starting Position
compared with the opposite side. Elbow flexed 90°, forearm and hand in
semipronation (thumb pointing upward), upper
arm against the chest.

Procedure
From this intermediate elbow position with the
forearm between pronation and supination, ac-
tive and passive pronation (palm downward) are
performed while the elbow is held stationary
300 Palpation Field ofthe Elbow/Arm

above the joint. Active and passive supination 3 Palpation Field

follow. of the ElbowlArm
Normal Findings 3.1 Extensor Side ofthe Elbow
Pronation and supination of 80°_90°. 3.2 Lateral (Radial) Epicondyle
Equal ranges of motion on both ides. 3.3 Medial (Ulnar) Epicondyle
End-feeL: Pronation: hard-elastic bony re- 3.4 Flexor Side of the Elbow
straint (radius on ulna). 3.5 Upper Arm and Forearm
Supination: firm-elastic ligamentous re-
straint.
The palpation field about the elbow includes five
Pathologic Findings areas in which various palpable sites are exam-
Painful limitation of motion due to trauma, in- ined. The illustrations are for the right elbow.
cluding radial head subluxation in children
("nursemaid's elbow"). Sudden motion block by 3.1 Extensor Side of the Elbow (Fig.21S)
a "joint mouse" in chondromatosis or osteo- Proceeding distally to proximally, the following
chondritis dissecans. structures are palpated:

• Note 1) Olecranon
Flexion is usually limited earlier and more The position of the tip of the olecranon is assessed
severely than extension. Limitation of prona- in relation to the epicondyles. The equilateral tri-
tion/supination occurs only if flexion and exten- angle formed by these three points (Huter's trian-
sion are also restricted. gle) is easily palpable when the elbow is flexed 90°
Disturbances of flexion/extension involve the (Fig. 21S). When the joint is extended, the three
humeroradial or humeroulnar joint, while dis- points lie on a straight line (see also Sect. 1,Inspec-
turbances of pronation/supination additionally tion). These relations are altered by fractures and
involve the proximal and distal radioulnar joint. dislocations (see p.298, Fig. 214 g). If swelling
or joint effusion is present, the three bony land-
marks can be identified only by palpation.
2.3 Abduction/Adduction
(Collateral Ligament Stability Test) Pathologic Findings
Anterior displacement of the olecranon with a
Starting Position
dislocation.
Extension or slight flexion with the forearm
Lateral displacement with a monocondylar frac-
supinated. One hand immobilizes the patient's
ture.
upper arm.
Proximal displacement with a Y- or T-fracture of
the distal humerus.
Procedure
With the other hand, the examiner abducts or
2) Tip oftbe Olecranon
adducts the forearm to assess collateral ligament
The insertion of the triceps tendon and the ole-
stability (similar to the position in Fig. 221).
cranon bursa are palpable in this area. Bony
spurs are sometimes palpable (and visible on X-
rays) in patients with triceps tendinopathy.

3) Olecranon Fossa
This is palpable only when the elbow is slightly
flexed. The triceps tendon is also palpable in this
position.
 Palpation Field of the Elbow/Ann 301

3/1 Posterior view of the elbow

®
----- Olecranon fossa

® Tip of olecranon
(insertion of triceps brachii)

CD Olecranon
(HOter's triang le)

Fig.215. Palpation field of elbow: Extensor surface of the elbow (after

Lanz-Wachsmuth). "Huter's triangle" appears only when the elbow is
flexed 90 0 (see p. 297)

3.2 Lateral (Radial) Epicondyle (Fig.216b) tion ("nursemaid's elbow"). This lesion is caused
by longitudinal traction on the pronated fore-
It is somewhat smaller and flatter than its medi-
arm, the lax interosseous membrane permitting
al counterpart. Proceeding distally to proximal-
distal movement of the radius with subluxation
ly, the following sites are palpated:
of the deficiently molded radial head into the an-
"
1) Humeroradial Joint Space (Fig. 216 e,f)
nular ligament.
The position of the radial head is palpated at rest
3) Muscle Insertions: Extensors
(Fig. 216c), and the joint capsule is checked for
From distal to proximal:
tenderness. The movements of the radial head in
Common tendon of insertion of the
flexion/extension are palpated with both hands
(Fig. 216 c,d). Pronation and supination are pal- - Extensor carpi radialis brevis
pated with one hand while the other hand pas- - Extensor digitorum
sively pronates and supinates the forearm - Extensor digiti minimi
(Fig. 216e,f). Motion may be limited by joint - Extensor carpi ulnaris
pathology, and supination may be limited by a - Anconeus
contracted interosseous membrane.
Above the lateral epicondyle:
2) Annular Ligament of Radius
- Extensor carpi radialis longus
The annular ligament is palpable at the radial
- Brachioradialis
head just distal to the humeroradial joint space.
It is palpable within the joint space in small chil- Both hand extensors and the brachioradialis
dren who have sustained a radial head disloca- form a mobile, lateral muscular pad on the fore-
302 Palpation Field ofthe Elbow/Ann

3/3 Medial (ulnar) epicondyle 3/2 Lateral (radial) epicondyle

Ulnar nerve - -- - - - - - r - -.....

srachioradialiS]
®
M
muscle

Extensor carpi
® - { ]Iexor tendons:
Pronator teres
rad ialis longus

If'
Flexor carpI radialis ", fA\ Radial collateral
CD Medial olecranon~ J~
sulcus ~ ~I
)
)
( \
... '
~ ligament
Common
® Ulnar COllaterAl ,
tendon
of insertion
ligament ~l ;---+-- Extensor carpi
rad ialis brevis ®
Flexor dlgitorum Extensor digitorum
superlic lalis

®
Extensor digiti minimi
Palmaris longus Extensor carpi ulnaris
Anconeus muscle

Flexor carpi ulnaris

f'1' ~~meroradial
\.V JOint space

® Annular ligament
a b of radius
Fig.216 a, b. Palpation field of elbow. a Medial (ulnar) epicondyle, b lateral (radial) epicondyle (after Lanz-
Wachsmuth)

arm which is easily palpated between the thumb 4) Radial Collateral Ligament
and index finger at the level of the radial head. This ligament is palpable at the distal anterior
margin of the lateral epicondyle above the
• Note humeroradial joint space, where it passes anteri-
The muscles can also be evaluated by resistance orly and posteriorly about the radial head to the
testing. ulna. Stability is tested by ulnar abduction of the
Extensor carpi radialis and ulnaris: elbow extend- slightly flexed and supinated forearm. This test
ed, forearm pronated. Resistance to dorsiflexion is painful following sprains and dislocations.
ofthe hand is applied at the back ofthe hand.
Brachioradialis: elbow flexed 90 0 , forearm in in- 3.3 Medial (Ulnar) Epicondyle (Fig. 216 a)
termediate position. Resistance to elbow flexion
From distal to proximal:
is applied at the radial aspect of the forearm.
1) Medial Olecranon Soleus
Lying between the olecranon and the medial
 Palpation Field of the Elbow/Arm 303

Fig.216 c-f. Palpation of the humerora-

dialjointinmotion. c,d Flexion,exten-
sion; e, f rotation in the radioulnar joint
304 Palpation Field ofthe Elbow/Arm

epicondyle (funny bone), the medial olecranon - Flexor carpi radialis

sulcus contains the ulnar nerve, which is easily - Pronator teres
palpated at that location. Scarring can create a
Again, these muscles can be differentiated by
constricted passage, leading to paresthesias in
appropriate resistance tests.
the fourth and fifth fingers (which are supplied
by the ulnarnerve). The humeroulnar joint space
3.4 Flexor Side of the Elbow (Fig. 217)
and capsule are palpable in the sulcus medial
and lateral to the olecranon. Several structures are contained within a trian-
gular area bounded proximally by the line con-
2) Ulnar CoUaterai Ligament necting the humeral condyles, laterally by the
This ligament is more susceptible to injury than brachioradialis muscle, and medially by the
the radial collateral ligament. The stability test is pronator teres:
like that for the radial ligament but is performed
in the opposite direction, i. e., by radial abduc- 1) Biceps Tendon
tion of the forearm. This tendon is more easily palpated at the medi-
al border of the brachioradialis when the fore-
3) Muscle Insertions: Flexors arm is flexed against a resistance while the fist
From distal to proximal: is clenched (tenderness at the radial tuberosity).
- Flexor carpi ulnaris
2) Bicipitoradial Bursa
- Palmaris longus
Tenderness to palpation is more pronounced
- Flexor digitorum superficialis
with bursitis than with a pure biceps tendinopa-

!i-;--
®
Brachial artery
- ; - - - -----:7"
CD
Tendon of biceps
brachii muscle
BraChioradialis muscle

®
Lateral antebrachial
cutaneous nerve ( -,r--=---l-- -- - - Pronator teres

® ~ r
muscle

Bicipitoradial bursa -+----;;;--'-t--"o+/~_il

I ;, /
1 \ --.J /1
\ 1 / ~---r----'>.0 Median nerve
\ I
\ /
~/

Fig.217. Palpation field of elbow: Flexor aspect of the elbow (after Lanz-Wachsmuth)
 Tests of Joint Translation 305

thy. The bursa lies below the biceps aponeuro- is defined by the flexors of the hand and fingers
sis. Lymph nodes are also found in the cubital and by pronator teres. Pareses cause a flattening
fossa. of the muscle contours.

3) Brachial Artery
Brachial artery pulsations are palpable medial
to the biceps tendon. 4 Tests of Joint Translation
4) Median Nerve 4.1 HumeroradiaUoint
The median nerve descends medial to the 4.2 Proximal and Distal Radioulnar Joints
brachial artery before piercing the pronator 4.3 Humeroulnar Joint
teres muscle. It can be irritated at this site by pas-
sive maximum supination and extension or by
active pronation against a resistance. The following techniques are described for the
right side.
5) Lateral Antebrachial Cutaneous Nerve
This nerve runs lateral to the biceps tendon and
4.1 HumeroradialJoint (Fig. 218)
is not accessible to direct palpation.
Starting Position
The patient sits beside the table with the elbow
3.5 Upper Arm and Forearm
resting on the table surface. The elbow joint is in
a) Upper Arm (Posterior Side) the resting position of approximately 70° flexion
The humerus can be palpated upward from the and 10°supination. The restingposition for the el-
olecranon. Any contour deviation or step defor- bow is a "tradeoff" between the true resting posi-
mity is noted. The radial nerve crosses the bone tions of the humeroradial joint (full extension
at its middle third. The long head of the triceps and supination) and the proximal radioulnar
muscle is palpable posteromedial to the joint (70° flexion and about 30° supination). The
humerus in its distal third. Above it is the medial examiner's right hand grasps the patient's upper
head of the triceps, and posterolateral to the arm from the back of the elbow and steadies it on
humerus is the lateral head. the table. The left hand grasps the patient's radius
(only the radius) from the radial side.
b) Upper Arm (Anterior Side)
The biceps brachii defines the anterior muscular Procedure
relief of the upper arm. An indentation in the The examiner pulls distally on the radius with
muscle belly is observed with a muscle or tendon the left hand while palpating the humeroradial
rupture. Proximal displacement of the muscle joint space with the right index finger
belly signifies a tear in the elbow region, while (Fig. 218 a). The reverse test, applying proximal
distal displacement signifies a tear in the bicipi- compression, is a provocative test for the
tal groove. humeroradial joint (Fig. 218 c). Both tests simul-
taneously produce proximal-distal gliding in the
c) Radial Head radioulnar joint.
The shaft of the radius can be palpated distally
from its head. The lateral muscle contour is
4.2 Proximal and Distal Radioulnar
formed by the brachioradialis and the hand ex-
Joints (Fig.219a,b)
tensors.
Starting Position
d) Ulna The patient's arm lies on the examination table
The ulna is palpable distally from the ulnar bor- with the ulnar side of the forearm in the resting
der of the olecranon. The medial muscle contour position of 70° flexion and about 30° supination.
 306 Tests of Joint Translation

c
Fig.2IS a--c. Humeroradialjoint. a,b Traction, c compression
 Tests of Joint Translation 307

a
• • b

-- -
c

Fig.219a-i!. Radioulnar joints. a,b Proximal, c-e distal. Volar movement of the radius (c), volar movement of
the ulna (= dorsal movement ofthe radius) (d)

The examiner grasps the distal upper arm with Starting Position
the left hand and immobilizes the joint in that Same as before, with a resting position of 10°
position. The thumb of the same hand can simul- supination. The examiner grasps the ulna and
taneously palpate the radioulnar joint space. wrist from the ulnar side and immobilizes the
arm in 10° supination on the examination table.
Procedure
The right hand grasps the radial head between Procedure
the thumb and index finger and moves it in the The right hand grasps the radius from the other
volar and dorsal directions. If pain is elicited, side and tests the dorsovolar play in the distal ra-
the fingers are placed on the intermuscular sep- dioulnar joint. Alternatively, the right hand may
tum from the volar side and the thenar eminence fix the radius while the left hand moves the ulna
is placed broadly on the dorsal side of the radius. (Fig. 219 d).
If pathologic findings are noted, the distal radio-
ulnar jointmust also be examined (Fig. 219 c,e).
 308 Tests of Joint Translation

Fig. 220 a-i:. Humeroulnar joint. a, b Traction, c compression

 Tests of Joint Translation 309

4.3 Humeroulnar Joint (Figs. 220, 221) Medial-Lateral Mobility (Fig. 221)
Starting Position
Traction and Compression (Fig. 220 a,b)
The examiner stands on the radial side ofthe joint
Starting Position to be tested. He grasps the patient's forearm and
The patient's hand is supinated, the back of the wrist with his right hand and steadies it against his
hand and forearm resting on the examiner's right own body. The elbow is slightly flexed (10°-20°).
shoulder. Again the resting position is approxi-
mately 70° flexion and 10° supination. The left Procedure
hand grasps the distal part ofthe upper arm from The left hand grasps the elbow from the radial
the extensor side and steadies it on the examina- side, the thumb on the flexor side and the fingers
tion table. The other hand grasps the forearm on the extensor side. While the wrist is held sta-
from the flexor side just below the joint space. tionary, this hand pushes the elbow medially and
laterally. This produces a slight gliding and rock-
Procedure ing of the ulna on the humeral trochlea (gap-
To apply traction to the joint, the examiner pulls ping), which tests not only the gliding of the artic-
distally (and slightly dorsally) with the right ular surfaces but also the stability of the capsule
hand while his shoulder "gives" slightly back- and ligaments on the side opposite the motion.
ward with the movement (Fig. 220a). If evasive shoulder movements interfere with
For compression of the joint (Fig. 220c), the the test, the arm should be tested in a position of
forearm is pushed toward the elbow, which is im- greater abduction.
mobilized as before. For this test the forearm is
grasped more distally, above the wrist, and forms NQrmal Findings
about a 45°-70° angle with the upper arm. Painless, equal gliding movements on both
sides in all tests.

Fig.221a-c. Humeroulnar joint: medial-lateral mo-

b
bility (gapping)
310 Resistance Testing of the Muscles of the Elbow Joint

5 Resistance Testing of the Muscles Stretched position for the long head: upper arm
extended, adducted, and externally rotated,
of the Elbow Joint
forearm extended and pronated (Fig. 189, p.274).
Stretched position for the short head: upper arm
5.1 Flexors and Extensors extended, abducted 90°, and externally rotated,
5.2 Pronators and Supinators forearm extended and pronated (i. e., like the
long head, but with 90° abduction at the shoul-
der) (Fig.200c, p.281).
5.1 Flexors and Extensors
(Figs. 222, 223) Brachioradialis (Cs-C;, Radial Nerve). Favor-
able working position: forearm intermediate be-
Flexors tween pronation and supination. Resistance is
applied to the radial side of the forearm
General Test (Fig. 222 a) (Fig. 223 b).

Starting Position BrachiaHs (CS-4, Musculocutaneous Nerve).

The patient's upper arm is flexed approximately Strictly a flexor. Favorable working position:
40° and slightly abducted. It is held in that posi- forearm in pronation (also involves pronator
tion with one hand. The forearm is flexed ap- teres). Resistance is applied to the extensor side
proximately 90° and supinated. of the forearm (Fig. 223 c).
The extensor muscles of the hand (extensor
Procedure
carpi radialis and ulnaris, extensor digitorum)
The other hand gt:asps the flexor side of the fore-
should remain inactive during this test if possi-
arm above the wrist and applies resistance to
ble.
flexion.

Differentiating Test for the Flexor Group Extensors (Fig. 222 b)

(Fig. 223) Starting Position
Starting Position Same as in the general flexor test. The upper arm
The shoulder joint is in the neutral position, the is flexed about 40°, the elbow 90°; the forearm is
elbow flexed 90°. The examiner stands behind supinated.
the patient or, for unilateral testing, on the test-
ed side. The upper arm is fixed at the elbow Procedure
against the patient's body to prevent concomi- Triceps Brachii (C6-CS, Radial Nerve). Resis-
tant movements of the shoulder joint. tance to extension of the elbow is applied to the
extensor side of the forearm above the wrist.
Procedure Contracture of the muscle is associated with a
For all three muscles of the flexor group, resis- terminal deficit of elbow flexion.
tance to flexion is applied at the wrist. Strong re- Stretched position for the long head (Fig.189,
sistance activates the entire group, so light resis- p.274): upper arm in maximum elevation (flex-
tance (using moderate finger pressure) is ion), adduction, and external rotation, forearm
needed to differentiate the muscles. in maximum flexion. Light resistance is applied
to the ulnar aspect of the forearm.
Biceps Brachii (Cs-C;, Musculocutaneous
Nerve). This muscle is active in all joint posi- Anconeus (C,4, Radial Nerve). Starting posi-
tions. tion is the same as in the general test, but the
Favorable working position: forearm in supina- forearm is intermediate between pronation and
tion. Resistance is applied to the flexor side of supination. Resistance to extension is applied at
the forearm (Fig. 223 a). the ulnar side of the wrist.
 Resistance Testing of the Muscles of the Elbow Joint 311

Fig.222. a Flexors, b extensors

Fig. 223 a-<. Differentiation of the flexors. a Biceps
brachii, b brachioradialis, cbrachialis

Stretched position: maximum flexion of the el- Starting Position

bow joint. Semipronation as in the previous test. The upper
arm is immobilized to prevent assistance from
• Note the shoulder muscles.
The anconeus stabilizes the ulna during prona-
tion and tightens the capsule during the final de- Procedure
grees of extension. With the forearm pronated, The forearm is grasped just above the wrist (with
the muscle is palpable adjacent to the radial epi- pressure from the dorsal side against the radial
condyle. Loss of anconeus function decreases styloid process or from the volar side against the
the force of extension by 20%. ulnar styloid process), and resistance to external
rotation is applied. When the test is performed
from a position of maximum pronation, the bra-
5.2 Pronators and Supinators (Fig. 224) chioradialis is also active.

Biceps Brachii (Cs-C6 , Musculocutaneous

Supinators (Fig. 224 a)
Nerve). Favorable working position: elbow in
These muscles externally rotate the forearm. 90° flexion.
312 Resistance Testing of the Muscles of the Elbow Joint

flexed with pronated forearm, or arm extended

with forearm pronated.
Pronators (Fig. 224 b)
These muscles internally rotate the forearm.

Starting Position
Same as in the supinator test. The forearm is
again intermediate between pronation and
supination, or it may be supinated (stretched po-
sition). As before, the upper arm is immobilized
above the elbow to eliminate assistance from the
shoulder muscles.

Procedure
The forearm is grasped above the wrist, and re-
sistance to internal rotation is applied at the ra-
dial styloid process from the volar side and/or to
the ulnar styloid process from the dorsal side. If
the test is done from maximum supination, the
brachioradialis contributes to the pronation
movement.

Pronator Teres (CS-C7 , Median Nerve). Favor-

able working position: elbow joint slightly
Fig.224. a Supinators, b pronators flexed.

Pronator Quadratus (C,.C8, Median Nerve).

Favorable working position: elbow maximally
Stretched position: elbow in neutral position,
forearm pronated. flexed, creating an unfavorable working posi-
tion for the pronator teres.
Supinator (CS-C6 , Radial Nerve). The most fa-
vorable working position is the position least fa-
vorable for the biceps brachii: elbow maximally
 Resistance Testing of the Muscles of the Elbow Joint 313

Summary of protocol for examination of the elbow jOints

(The 10 most important
motion tests)

1 Flexion

a Activel pass ive

1) Flexion: angular glidinglend-feelljoint stability

2) Extension (interpreted like flexion)
3) Pronation and supination: range of motion/end-feel
Figs. 247a, 4) Resistance tests ofthe hand and finger extensors
255, pp. 344, 346
Figs. 247b, 5) Resistance tests ofthe hand and finger flexors
254a,b, pp. 344, 346
Fig. 221 a, b, p. 309 6) Joint translation tests: ulnar gapping: ulnar gliding on the trochlea, col-
lateral ligament test
Fig. 218 a, p. 306 7) Traction on the radius (joint traction)
Fig. 220 a, p. 308 8) Traction on the ulna (joint traction)
Fig. 219 a, b, p. 307 9) Proximal radioulnar joint: translatory gliding

Fig. 219 c-e, p. 307 10) Distal radioulnar joint: translatory gliding
Hand and Finger Joints

1 Inspection
1.1 Shape and Position
1.2 Contour Changes
1.3 Skin and Nail Changes

2 Active and Passive Wrist and Finger

Movements
2.1 Wrist Movements in Two Planes
2.2 Finger Movements in Two Planes
2.3 Thumb Movements

3 Palpation Field of the Hand

3.1 Radial Border o,f the Hand
3.2 Ulnar Border of the Hand
3.3 Dorsum ofthe Hand
3.4 Palm of the Hand
3.5 Fingers and Thumb

4 Tests of Joint Translation

4.1 Wrist Joint (Five Tests)
4.2 Intercarpal Joints (Ten Tests)
4.3 Carpometacarpal Joint of the Thumb
(Five Tests)
4.4 Second to Fifth Carpometacarpal and
Intercarpal Joints (Five Tests)
4.5 Phalangeal Joints (Five Tests)

5 Resistance Testing of the Hand and

Finger Mnscles
5.1 Wrist Muscles
5.2 Finger Muscles
5.3 Thumb Muscles
 Inspection 315

1 Inspection Clinodactyly: lateral or medial deviation of the

distal phalanges with mild flexion contracture of
1.1 Shape and Position the PIP joints.
1.2 Contour Changes
1.3 Skin and Nail Changes Flexion Contractures oJthe Fingers
Distal interphalangeal (DIP) joint affected by
extensor tendon avulsion.
1.1 Shape and Position Joints of the fifth finger (unilateral or bilateral)
affected in camptodactyly (congenital, heredi-
tary malformation).
Normal Findings Third to fifth fingers with nodules and scar con-
In resting position: Wrist in slight volar flex- tracture of the volar skin in Dupuytren's con-
ion (approximately 5°-10°) with light ulnar tracture.
abduction (approximately 5°), fingers slight- Clawing of the fourth and fifth fingers due to ul-
ly flexed, thumb extended. nar nerve palsy.
Clawing of all the fingers due to contracture of
the long digital flexors in the forearm caused
Pathologic Findings by:
Congenital Dejects - Ischemic muscle contracture (Volkmann)
following improperly treated forearm frac-
Numerical or Morphologic Abnormalities of the tures
Fingers - Central neurologic disorders such as sy-
Polydactyly: supernumerary fingers, usually in- ringomyelia and amyotrophic lateral sclero-
volving the first ray. sis.
Partial gigantism: elongated and thickened fin- Clawing of the PIP joint with hyperextension
gers. of the metacarpophalangeal (MCP) and DIP
Oligodactyly: fewer fingers than normal. joints due to loosening of the tendon sheaths
Brachydactyly: shortened fingers. (button hole deformity) in rheumatoid arthri-
Arachnodactyly (spider fingers): elongated tis.
fingers, sometimes with atrophy of the subcu- Clawing of the MCP and DIP joints with hyper-
taneous fatty tissue (often associated with extension of the PIP joint due to spasm and con-
funnel chest and scoliosis) in Marfan's syn- tracture ofthe intrinsic muscles (swan's neck de-
drome. formity) in:

Dysmelias - Rheumatoid arthritis

Peromelia: aplasia affecting the distal portion of - Ulnar nerve palsy
an extremity. - Spasticity or parkinsonism
Ectomelia: partial or complete defect in one of Volar and ulnar deviation at the MCP joints with
the three long arm bones. joint swelling in rheumatoid arthritis (classic
Phocomelia: rudimentary fingers or hands at- RA).
taching directly to the shoulder. Flexion contracture of the thumb. Compensable
Amelia: complete absence of the arm. contracture of the flexor pollicis longus muscle.
Congenital flexion contracture of the distal pha-
Deformities of the Fingers lanx of the thumb (pollex rigidus). Both are
Syndactyly (spoon hand): fusion of fingers . caused by a constriction of the flexor pollicis
Camptodactyly: flexion contracture affecting longus tendon sheath.
the proximal interphalangeal (PIP) joint of the Deformities are also seen with fractures and dis-
fifth finger or sometimes the fourth finger. locations.
316 Inspection

Deformities and Position Faults Affecting the Pathologic Findings

Whole Hand
Swellings
1. Elevation of the hand following acute injuries, Swellings in both hands. Acromegaly (pituitary
inflammatory changes, and joint effusions. tumor).
2. Deformities without contracture in flaccid Swelling of the entire hand
paralysis. Traumatic dorsal hand edema (algodystrophic
Drop hand: radial nerve palsy. syndrome). Hard, cool, cyanotic swelling with
Ape hand: hand with the thumb permanently tense skin. Seen with cervical root or nerve irri-
extended: median nerve palsy. tation, trauma, jaundice.
Oath hand: The first three fingers remain ex- Tense, painful edema with bluish-red skin discol-
tended when a fist is made: median nerve pal- oration and increased sweat secretion due to va-
sy. somotor dysfunction or Sudeck's syndrome.
Claw hand: ulnar nerve palsy (fourth and fifth Swelling due to tendovaginitis. Occurs on the
fingers flexed at the IP joints, MCP joint hyper- back of the hand (extensors) or on the wrist and
extended due to intrinsic muscle paralysis). palm (flexors).
3. Deformities with contracture Swelling affecting portions of the hand
- Contracture of the hand in the volar or dorsal Dorsal hand swelling due to local hemorrhagic
direction due to cerebral palsy or stroke effusion after trauma.
- Clubhand: fixed radial deviation of the hand Dorsal hand swelling on the ulnar side due to
due to congenital bone aplasia tendovaginitis involving the second to fifth fin-
- Ulnar deviation of the hand in rheumatoid ger extensors.
arthritis (do not confuse with ulnar deviation Dorsal hand swelling on the radial side in de
of the fingers) Quervain's disease (chronic tendovaginitis due
- Bayonet position of the wrist: volar deviation to tendon sheath stenosis).
of the entire hand due to radial fracture (flex- Fusiform swelling of the tendon sheaths on the
ion fracture), epiphyseolysis, radial growth ulnar or radial border of the hand (flexor side)
disturbance, etc., resulting in an increased due to tendovaginitis of individual finger flexors.
volar-ulnar orientation of the joint surface Tendovaginitis can result from:
and increased prominence of the ulnar head
- Purulent inflammations (severe pain)
(Madelung's deformity). Observed after
- Tuberculosis (less painful)
about 10 years of age.
- Rheumatoid arthritis

Deformities and Position Faults of the Ulna

Dorsal prominence of the ulnar head is common Swelling at the Wrist
in young girls. Arthritis due to gout, chondrocalcinosis, Tb, or
Dorsal subluxation of the ulna with no hand de- bacterial infection.
formity due to radioulnar joint instability, with Hemispheric synovial cysts (ganglia from the
slight volar displaceability of the ulna. joint), tense consistency, on the dorsum of the
Ulnar deviation of the ulna with radial deviation hand, typically located between the scaphoid, lu-
of the hand in patients with a "minus" type of ra- nate, capitate, and trapezoid.
dius or "plus" type of ulna. Tendon sheath hygromas.

Swelling of the Fingers

1.2 Contour Changes
Enlargement of the distal phalanges III acro-
megaly (pituitary tumor).
Normal Findings
Distal phalangeal hypertrophy with hourglass nails
No contour changes due to swelling, atrophy,
(clubbed fingers, "osteoarthropathie hypertrophi-
or deformity.
cante pneumonique"); bony expansion due to:
 Inspection 317

- Lung disease (chronic disorders, carcinoma) palsy (carpal tunnel syndrome, pronator teres
- Cardiac disease (congenital defects, endo- syndrome, C6 syndrome).
carditis) "Pseudo-carpal tunnel": flattened thenar with
- Gastrointestinal disease (colitis, ileitis, carci- no sensory disturbance in persons doing heavy
noma) physical labor.
- Liver disease (cirrhosis) Hypothenar atrophy. Caused by ulnar nerve pal-
- Thyroid disease (myxedema) sy in the ulnar tunnel between the pisiform and
- Idiopathic hamate and in C8 syndrome. Pressure on the
motor branch of the ulnar nerve leads to hy-
Diffuse swelling of the fingers occurs in meno- pothenar atrophy with no sensory dysfunction.
pausal women and in carpal tunnel syndrome Occurs in printers and machinists.
(along with hand swelling).
Isolated swelling of individual phalangeal joints
occurs in gout, chondrocalcinosis, and Reiter's
1.3 Skin and Nail Changes
disease. Skin Changes
Swelling of specific joints:
Distal phalanges: paronychiae. Topography of the skin folds relative to the pha-
DIP joints: Heberden's nodules (usually involve langeal joints:
multiple joints). Flexor side: over the PIP joint line, proximal to
PIP joints: Bouchard's nodules (usually involve the DIP joint line, distal to the MCP joint line.
all the joints, with degenerative arthritis of the Extensor side: all folds are proximal to the asso-
first carpometacarpal joint). ciated joint line.
Callosity of the palms indicates the degree of use
DIP and PIP joints: psoriatic arthropathy, gout
(atypical). ofthe hands.
PIP and MCPjoints (and usually the wrist joint): Blood flow disturbances are most easily detected
generalized osteoarthritis (usually in men over in the fingertips.
40 years of age).
First carpometacarpal (CM) joint: osteoarthritis Normal Findings
of the CM joint of the thumb ("rhizarthrosis"), No changes in the skin or blood flow.
Bennet's fracture (compression fracture of the
thumb metacarpal, boxer's fracture).

Atrophic Changes Pathologic Findings

Flattening of the contours of the palm. Atrophy Smooth, tense, glossy skin in rheumatoid arthri-
of the intrinsic hand muscles due to cervical tis and Sudeck's disease.
myelopathy with diminished arm reflexes (leg Pale, acrocyanotic skin in Raynaud's syndrome.
reflexes may be increased). Redness and swelling due to inflammation of the
Atrophy of the interossei can occur in: distal phalanx (paronychiae).
Other important skin diseases: eczema, psoria-
- Rheumatoid arthritis sis, erythema exudativum multiforme, sclero-
- Ulnar nerve palsy (third to fifth metacarpals) derma.
- Senile hand (with atrophic skin). Other cutaneous signs of systemic disease:
First interosseous space in ulnarnerve palsy (deep - Increased skin temperature in inflammatory
branch) due to paralysis of adductor pollicis. Usu- diseases
ally this finding is associated with hyperextension - Warm, moist skin in hyperthyroidism
of the proximal phalanx of the thumb and claw- - Cold, moist skin due to autonomic dysfunc-
ing of the fourth and fifth fingers (1 eanne'ssign). tion
Thenar atrophy. Usually combined with adduc- - Cool, dry skin in myxedema
tion of the thumb: ape hand due to median nerve - Dry skin with peripheral nerve lesions
318 Active and Passive Wrist and Finger Movements

Nail Changes -Note

Many neurologic diseases produce manifesta-
tions in the hands.
Normal Findings
More arched and elliptical in fema les; flatter,
thicker, and more rectangular in males.

2 Active and Passive Wrist

and Finger Movements
Pathologic Findings
Size 2.1 Wrist Movements in Two Planes
Large nails in acromegaly. 2.2 Finger Movements in Two Planes
2.3 Thumb Movements
Shape
Hourglass nails in patients with pulmonary or
cardiac disease (congestion) or in patients ex-
2.1 Wrist Movements in Two Planes
posed to toxic and trophoneurotic agents (neu-
rologic disorders). Starting Position
Spoon nails or flat nails (platyonychia) due to Wrist in neutral position, fingers slightly flexed.
anemia, eczema, or trauma.
Procedure
Hardness The patient performs active volar flexion, dor-
Soft nails in patients with consumptive diseases. siflexion, radial abduction, and ulnar abduction
Hard nails in patients with myxedema, subun- at the wrist. The examiner continues each
gual hyperkeratosis, eczema, psoriasis, or movement to its passive limit while the other
paronychiae; also congenital. hand immobilizes the forearm above the wrist.
If an abnormality is noted, the wrist should be
Suiface and Color passively tested over its complete range of mo-
Normal color: light pink. tion.
Pale transverse striations (Mees' leukonychia) in
addition to thickenings, irregularities, and Normal Findings
cracks in polyneuritis and metal intoxication. Equal ranges of painless wrist motion on both
Dark discoloration in fungal infections, eczema, sides.
chemical and cosmetic changes. Ranges of motion:
Ridges and furrows (Beau's furrows) in trophic Volar flexion approximately 80°
disturbances due to infectious diseases, meta- Dorsiflexion approximately 70°
bolic disorders or circulatory disturbances, and Ulnar abduction approximately 40°
in certain neurologic diseases (neuritis, tabes, Radial abduction approximately 20°
MS, hemiplegia). End-feel: hard-elastic in extension (bony re-
Hemorrhage due to trauma or blood disorders straint) ; firm-elastic in aJJ other directions
(petechiae) . (ligamentous restraint).
Friability and nail loss occur with various inter- The fingers extend near the limit of passive
nal diseases such as: volar flexion, and they flex during dorsiflex-
- Chronic infections and intoxications ion.
- Metabolic disorders, diabetes, avitaminoses,
iron deficiency
- Neurologic disorders and peripheral nerve
lesions
- Skin diseases (eczema, psoriasis, etc.)
 Active and Passive Wrist and Finger Movements 319

Pathologic Findings PIP joints: flexion 100°, extension to the neu-

- Painful limitation of active and passive mo-
tral position.
tion by inflammatory or degenerative joint DIP joints: flexion 90°, hyperextension
disease 0°_10°.
- Painless limitation of active motion by palsy End-feel: firm -elastic in all joints (capsular re-
- During terminal volar flexion, pain may radi- straint).
ate to the first three or four fingers due to The end-feel in volar flexion and dorsiflexion
compression in the carpal tunnel (Phalen's
is initially soft-elastic due to the tendons of
test). flexor digitoTUm profundus and extensor dig-
- Limitation of terminal dorsiflexion by short-
itorum communis. The end-feel in adduction
ening of the hand flexors
is hard-elastic (bony restraint) due to approx-
- Pain on active or passive ulnar abduction of
imation of the phalangeal bones.
the extended hand (Muckard's test, Fig. 225 c)
When the fingers are individually flexed , the
or the closed fist (Finkelstein's test, Fig. 225 b)
ball of the finger occupies a terminal position
in stenotic tendovaginitis on the thenar eminence over the scaphoid.
Differential diagnosis: radial styloiditis, radial
neuritis.
Pathologic Findings
Extension and flexion are restricted by ten-
2.2 Finger Movements in two Planes dovaginitis and by degenerative and inflamma-
tory joint disease. Extension deficits in the third,
Starting Position fourth, and fifth fingers occur with Dupuytren's
Same as in the wrist tests. contracture.

Procedure
2.3 Thumb Movements
The patient makes a fist without placing the
thumb in the palm, reextends the fingers, spreads Starting Position
the fingers, then returns to a closed-fist position. Same as before. The patient's hand or forearm is
Volar flexion and dorsiflexion are passively in- immobilized between the thumb and index fin-
duced by pressing the heel of the hand against ger.
the proximal and middle phalanges while the
other hand immobilizes the patient's hand by Procedure
placing the thumb in the palm and the four fin- The patient performs the following movements:
gers on the dorsum of the hand, or vice-versa.
- Circumduction
Abduction is tested by moving the fourth and
- Flexion/opposition
fifth fingers ulnarward with one hand and the
- Extension/reposition
second and third fingers radialward with the oth-
- Abduction radialward and abduction volar-
erhand.
ward
For the passive motion testing of individual pha-
- Adduction
langeal joints, the proximal phalanx of the tested
digit is immobilized between the thumb and in- For passive testing, the proximal phalanx is im-
dexfinger. mobilized. For testing the CM joint of the
thumb, the trapezium and scaphoid are immobi-
lized.
Normal Findings
Painless, equal mobility on both sides.
Ranges of m.otion: Normal Findings
MCP joints: flexion 90°, hyperextension MCP joint of the thumb: flexion 50°, exten-
20°-40°, abduction 20°. ion 0°.
320 Palpation Field of the Hand

IP joint of the thumb: flexion 80°, extension Tenderness occurs with:

0°-10° (hyperextension). Brachioradialis tendinopathy (provocative test:
First CM joint (of the thumb): radial and pal- active elbow flexion against a resistance in
mar abduction 70°, adduction to the neutral semipronation).
position. Collateral ligament lesion (provocative test:
passive, maximum ulnar abduction).
Stenotic tendovaginitis (de Quervain's disease);
Pathologic Findings provocation by Muckard's test: ulnar abduction
Painful limitation of motion due to degenerative of the extended hand (Fig. 225c) or Finkelstein's
and inflammatory disease (CM osteoarthritis, test: sharp pain on ulnar abduction of the fist
post-Bennett's-fracture osteoarthritis of the first with the thumb on the palm (Fig. 225 b).
CMjoint).
Congenital hypermobility. -Note
Radial styloiditis may be an early symptom of
rheumatoid arthritis.

3 Palpation Field of the Hand 2) Scaphoid

On the ventral side is the scaphoid tuberosity,
which is easily palpated on dorsal and/or radial
3.1 Radial Border of the Hand
movement of the hand (which tilts the scaphoid)
3.2 Ulnar Border of the Hand
and disappears during the reverse movement (in
3.3 Dorsum ofthe Hand
the ventral and ulnar direction). It is the site of
3.4 Palm ofthe Hand
attachment for the proximal portion of the flex-
3.5 Fingers and Thumb
or retinaculum, the radial collateral ligament,
and the abductor pollicis brevis.
Five areas of the hand are examined by palpa-
Pathologic Findings
tion. Tender points or pressure points can be dif-
Pain or swelling over the scaphoid and impaired
ferentiated to a degree by provocative testing.
dorsiflexion of the hand due to:
The skin of the hand is less displaceable on the
volar side than dorsally. - Fracture or nonunion of the scaphoid
- Aseptic necrosis
- Restriction of the scaphoid
3.1 Radial Border of the Hand (Fig. 225 a)
Snuflbox 3) Trapezium
The "snuffbox" is bounded on the radial side by The tubercle of the trapezium is palpable on the
abductor pollicis longus and extensor pollicis volar side. It marks the attachment of the distal
brevis and on the ulnar side by extensor pollicis portion of the flexor retinaculum, the flexor pol-
longus. It is most conspicuous during extension licis brevis (deep head), which also comes from
and reposition of the thumb. the trapezoid, and the opponens pollicis.
The hand is placed in a position of slight ulnar
abduction. From proximal to distal, the follow- 4) Base of the First Metacarpal
ing structures are palpated in the snuffbox on The flexor pollicis brevis (deep head) inserts on
the radial border of the hand: the volar side, and the abductor pollicis longus
and radial collateral ligament on the dorsal side.
1) Styloid Processof the Radius
The abductor pollicis longus and extensor polli- - Note
cis brevis are palpable on the styloid process in The CMjoint ofthe thumb is more easilypalpated
the first dorsal tendon compartment. during opposition and reposition of the thumb.
 Palpation Field ofthe Hand 321

®
Trapezium
®Scaphoid

CD
Styloid process of radius
Abductor
poliicis longus

Extensor poliicis longus

o
Snuffbox
Brachioradialis
muscle
Radial artery
First metacarpal Rad ius
® Extensor
poliicis brevis Extensor retinacu lum

® Snuffbox tendons
a ® Abductor
pollicis longus

b c
Fig.225. a Radial border of hand with palpation points (after Lanz-Wachsmuth). Tests for stenotic ten-
dovaginitis: bFinkelstein's test and c Muckard's test
322 Palpation Field ofthe Hand

Pathologic Findings At the base of the snuffbox are the deep branch
Tenderness at the first eM joint, i. e., between the of the radial artery and the terminal branch of
trapezium and first metacarpal, due to degenera- the superficial radial nerve (cutaneous branch to
tive arthritis or trauma (Bennett's fracture). the thumb).

5) Snuffbox Tendons 3.2 Ulnar Border of the Hand (Fig. 226)

The tendons of abductor pollicis longus and ex-
The hand should be positioned in slight radial
tensor pollicis brevis are palpated from the radi-
abduction during palpation.
al side with the thumb extended.
The tendon of extensor pollicis longus is palpat-
1) Styloid Process ofthe Ulna
ed from the ulnar side.
This structure is somewhat more proximal than
The tendons of extensor carpi radialis longus
the styloid process of the radius but usually
and brevis are located radial to extensor pollicis
shows greater dorsal prominence. The tendon of
longus and the dorsal radial tubercle (Lister'S tu-
extensor carpi ulnaris occupies a bony groove on
bercle) at the distal border of the radius. They
the ulnar side. The ulnar collateral ligament also
are most easily palpated when the patient makes
attaches at this site. The palpating finger glides
a fist.
distally to the triquetrum, which articulates with
the pisiform on its volar surface.
• Note
The tendon of extensor pollicis longus may be
absent if ruptured, e. g., after a radial fracture.

, I
o Flexor carpi ulnaris

Ulnar artery a ndnerve - - - -----r-.!.----I'1

CD
Styloid process
of ulna
Ulnartunnel - - ---Ir--r- --..
\oR-----{2 Ulnar collateral ligament
A +-- - -----TriQuetrum

12' Transverse
\61 ligament ®
Pisiform star
'----0 Pisohamate ligament
o Pisometacarpalligament

o Abductor
digiti minimi

Fig. 226. Ulnar border of the hand

with palpation points (after Lanz-
Wachsmuth)
 Palpation Field of the Hand 323

2) Pisiform Star (Volar) 3. Radioulnar joint, in line with the fourth

With the hand in a relaxed position of flexion, metacarpal
the pisiform is easily movable on the triquetrum 4. Styloid process of the ulna (ulnar border)
in the radioulnar direction.
The following ligaments and muscles arise from Topography
the pisiform bone in a stellate pattern called the
Radial Duo
"pisiform star":
The first and second tendon compartments lie
• The ulnar collateral ligament runs proximally between the styloid process of the radius and
to the styloid process of the ulna and distally to
Lister's tubercle:
the base of the fifth metacarpal (provocation:
• First tendon compartment. The first two snuff-
maximum passive radial abduction of the hand).
box tendons (of abductor pollicis longus and
• The pisohamate ligament runs distally and radi-
extensor pollicis brevis). De Quervain's ten-
ally to the hamate bone. It is made tense by con-
dovaginitis can be diagnosed by passive ulnar
traction of the flexor carpi ulnaris. Below it is the
abduction of the fist (with the thumb in),
ulnar tunnel which transmits the ulnar nerve.
which evokes pain in the tendon area
• The pisometacarpal ligament courses to the
(Fig. 225 b).
fifth metacarpal.
• Second tendon compartment. The tendons of
• The flexor retinaculum (distal portion) runs
the two radial hand extensors (extensor carpi
radially to the tubercle of the trapezium. It is
radialis longus and brevis), which are palpable
tightened by the flexor carpi ulnaris.
just radial to Lister's tubercle within the snuff-
• The abductor digiti minimi runs distally
box, i. e., radial to the extensor pollicis longus
(provocation by abduction of the fifth finger
tendon, at the distal border of the radius. They
against a resistance).
are palpable only when the fist is closed.
• Flexor carpi ulnaris. The pisiform constitutes
a sesamoid bone embedded in the muscle, Median Duo
which runs proximally and distally but is The third and fourth tendon compartments are
palpable only in its proximal course. Radial to located between Lister's tubercle and the ra-
the tendon are the ulnar artery and nerve, these dioulnar joint:
three structures forming the "ulnar trio" on the • Third tendon compartment. The third snuff-
flexor side of the wrist. box tendon (of extensor pollicis longus) runs
Contraction of the abductor digiti minimi and immediately ulnar to Lister's tubercle, which
flexor carpi ulnaris can fix the pisiform on the therefore acts as a fulcrum for the tendon and
triquestrum while also tightening the ligaments can rupture the tendon through increased fric-
that attach there. tion following a bony injury of the radius.
• Fourth tendon compartment. This contains the
3.3 Dorsum of the Hand (Fig. 227) four tendons of extensor digitorum commu-
Tendon Compartments (Fig. 227 a) nis, which can be palpated just radial to the ra-
Palpation of the dorsal surface of the hand identi- dioulnar joint (along with extensor indicis
fies the tendon compartments in the extensorreti- proprius). The tendons can be individually
naculum, from which the course of the tendons can palpated further distally.
be traced distally and also proximally to a degree.
Ulnar Duo
Four bony landmarks, each separated from the ad-
The fifth and sixth tendon compartments lie be-
jacent landmark by two tendon compartments,
tween the radioulnar joint and the ulnar border
can be identified from the radial to the ulnar side:
ofthe ulna:
1. Styloid process ofthe radius (radial border) • Fifth tendon compartment contains the ten-
2. Dorsal tubercle of the radius (Lister's tuber- don for the fifth finger (extensor digiti mini-
cle), located between the prolongations of the mi), which is immediately ulnar to the radio-
second and third metacarpals ulnar joint.
324 Palpation Field of the Hand

Extensor digitorium communis and First compartment

extensor indicis proprius - - - f T- t-;M:-f' Abductor pollicis
longus
Extensor digiti quinti Extensor pollicis
brevis
Extensor carpi ulnaris

StylOid process 01 ulna Radioulnar joint

..-;:~~;;..;t=== Uster's tubercle
Fourth compartment ~ Styloid process of radius
Extensor digitorum
communis
Extensor indicis Second compartment
proprius Extensor carpi
radialis longus
Fifth compartment Extensor carpi
Extensor digiti quinti radialis brevis

Sixth compartment Third compartment

Extensor carpi Extensor pollicis
ulnaris longus

,,---- -- - - Snuffbox
Attachments
of the
extensor tendons ....>i~-----Abducto r poilicis longus
Extensor carpi ulnaris - - -.. .l
Extensor carpi radialis brevis - +----= Rhizarthrosis
(osteoarthr~is of the
Extensxor carpi radialis longus CM joint of the thumb)

xtensor pollicis brevis

xtensor pollicis longus

Rheumatoid
arthritis
1 - - - --"7 Psoriasis/gouty tophi
Joints:
lateral and
dorsovolar palpation

Bouchard's nodules
(PIP joints)
b .

Fig.227a,b. Dorsum ofthe hand (after Lanz-Wachsmuth). a Tendon compartments. b Attachments

of the extensor tendons and the most frequent pathologic joint changes
 Palpation Field of the Hand 325

• Sixth tendon compartment contains the tendon 3.4 Palm of the Hand (Fig. 228)
of extensor carpi ulnaris on the ulnar side of
Carpal Tunnel and Muscular Relief (Fig. 228)
the ulna. Forced pronation can cause this ten-
The carpal tunnel is formed by the carpal bones
don to dislocate from its shallow bony groove.
and the flexor retinaculum, whose proximal por-
All the tendons can be more easily palpated
tion passes from the scaphoid tubercle on the ra-
when they are actively moved:
dial side to the pisiform on the ulnar side, and
- The three snuffbox tendons by extension and whose distal portion passes from the tubercle of
reposition of the thumb the trapezium (radial) to the hook of the hamate
- The two radial hand extensor tendons by dor- (ulnar). The identification of these attachment
soradial extension of the fist sites was described in connection with the palpa-
- The tendon of extensor digitorum communis tion of the radial and ulnar borders of the hand
by extension of the second-fifth fingers; ten- (Sects. 3.1, 3.2).
don of extensor indicis by isolated extension The carpal tunnel transmits five muscles in addi-
of the index finger while the other fingers are tion to nerves and vessels that are easily located
flexed by reference to their guide muscles (palmaris
- The tendon of extensor digiti minimi by isolat- longus for the median nerve, flexor carpi ulnaris
ed extension of the small finger (during flex- for the ulnar nerve).
ion of the other fingers)
- The tendon of extensor carpi ulnaris by dor- Topography
soulnar extension of the fist
Median Duo
• Note The center of the carpal tunnel is traversed by:
All the extensor tendons may become painful • Palmaris longus, which is made prominent by
with rheumatoid arthritis and may eventually opposing the thumb and small finger against a
rupture. resistance (but is absent in 7% of the popula-
tion) .
Intercarpal and Carpometacarpal Joints • Median nerve, which is radial to palmaris
(Fig. 227 b) longus. Other deep structures are the two
These joints are best palpated in the distal-to- "tendon quartets" of the superficial and deep
proximal direction. The palpating finger slides flexor digitorum muscles.
proximally from the Mep joints to the base of
the metacarpals. Radial Trio
• Palpation of the first metacarpal was described • Flexor carpi radialis, made prominent by radi-
in Sect. 3.1. The abductor pollicis longus in- al flexion of the closed fist.
serts at the base of the first metacarpal. • Radial artery, which is radial to flexor carpi ra-
• Extensor carpi radialis longus inserts at the dialis (pulse).
base of the second metacarpal. The trapezoid • Flexor pollicis longus, which is deeply situat-
and scaphoid are palpable proximal to the sec- ed.
ond metacarpal base (tender with scaphoid
nonunion and restrictions). Ulnar Trio
• Extensor carpi radialis brevis inserts at the • Flexor carpi ulnaris, made palpable by flexion
base of the third metacarpal. The capitate and of the closed fist.
lunate are palpable proximal to it (tender with • Ulnar artery and ulnar nerve, located in the ul-
lunate malacia, fractures, dislocations, and re- nar tunnel radial to the hook of the hamate,
strictions). below the pisohamate ligament.
• The fourth and fifth metacarpals point proxi- The radiating pain and/or paresthesia of carpal
mally to the hamate and triquetrum. Extensor tunnel syndrome are caused by compression of
carpi ulnaris inserts at the base of the fifth the median nerve. The pain radiates distally to
metacarpal. the first three fingers or proximally to the arm.
 Tl
326 Palpation Field ofthe Hand

Superficial and deep Two tendon quartets

flexor digitorum

Median Duo
Palmaris IOngUs- - ------;--:7-r':-to
'
Median nerve--------t----;-;-T-,:.
Ir I

Radial trio /' Ulnar trio

Radial artery~~1 Flexor carpi ulnaris
Flexor carpi rad ialis - - - - -' ------ ~ Ulnar nerve
Flexor pollieis longus , _ _ _ _ _ _ _ -, Ulnar artery
I I Carpal and
L _ _ _ _ _ _ _ ...J ulnar tunnels
Thenar - - - - - - -- --
- - - - Hypothenar

Two tendon quartets - -----1i------;====t===== Superficial and deep

flexor digitorum

Median duo
Radial trio
...!---Iftt---t---- Palmaris longus
Radial artery ----it--i'l
Flexor carpi radialis 14--4--tH---+---- Median nerve
Flexor pollieis longus
Ulnar trio
Flexor carpi ulnaris
Ulnar nerve
Ulnar artery

b Thenar Hypothenar

Fig. 228 a, b. Tendons ofthe hand during flexing (a) and extending ( b)of the w rist. Vessels and
nerves in the carpal and ulnar tunnels
 Palpation Field ofthe Hand 327

Provocative tests: are not palpable. Phlegmons of the tendon

sheaths cause swelling on the dorsum of the
1. Firm pressure with both thumbs on the flexor
hand.
retinaculum
The "web" between the first and second meta-
2. Maximum volar flexion of the wrist (Phalen's
carpals consists of the adductor pollicis and first
test)
interosseous. Atrophy occurs with ulnar nerve
3. Firm pressure with the fingertip proximal to
palsy.
the flexor retinaculum and adjacent to pal-
maris longus, directing the pressure deeply
and distally
3.5 Fingers and Thumb (Fig. 229)
Joints
Palmar Soft TIssues (Fig. 229) The joints are palpated with the thumb and in-
The thenar or hypothenar may exhibit loss of dex finger. The palpable impression on the dor-
tone and atrophy due to palsy of the median or sal and volar aspects is soft (volar more than dor-
ulnar nerve, respectively. sal) due to the overlying tendons. Tenderness is
In palmar aponeurosis hard nodules are seen noted with joint effusions.
with Dupuytren's contracture. The volar soft Palpation of the sides of the joints conveys a
tissues - the tendons of the hand and finger firmer impression due to the joint capsule and
flexors and the palmar nerves and vessels - collateral ligaments. Tenderness occurs with:

Palmar aponeurosis
Thenar: Dupuytren)
~rlr--+------- Tendon sheath
Opponens pollieis
Abductor pollieis brevis Hypothenar:
Flexor pollieis brevis
\O+--=----+- Opponens digiti minimi

Abductor digiti minimi

Adductor pollieis \""""-\--t-- Flexor digiti minimi

Sudeck's atrophy Herberden's nodules

(MP joints) (DIP joints)
Tendon
insertions
Psoriasis
and gouty tophi
(PIP and DIP joints) Rheumatoid arthritis
(MP and PIP joints)
Bouchard's
nodes
(PIP joints)
Fig. 229. Thenar and hypothenar muscles (fingers, thumb) (after Lanz-Wachsmuth). The most
frequent pathological changes to the finger joints
328 Tests ofJoint Translation

- Collateral ligament pathology 4 Tests of Joint Translation

- Joint effusions
- Rheumatoid arthritis
4.1 WristJoint (Five Tests)
- Sudeck's atrophy (MCP joints)
4.2 IntercarpalJoints(Ten Tests)
4.3 Carpometacarpal Joint of the Thumb
• Note (Five Tests)
Palpable, nonbony thickenings are characteris-
4.4 Second to Fifth Carpometacarpal and
tic of Heberden's nodules (DIP joints) and
Intercarpal Joints (Five Tests)
Bouchard's nodules (PIP joints). 4.5 Phalangeal Joints (Five Tests)
An ulnar sesamoid (insertion of adductor polli-
cis) and a radial sesamoid (insertion of abductor
pollicis brevis and flexor pollicis brevis) are pal-
The tests of joint translation in the hand are per-
pable at the M CP joint of the thumb.
formed in the five groups listed above.
Globular masses on the diaphyses of the
metacarpals and phalanges occur with enchon-
4.1 Wrist Joint (Five Tests) (Figs. 230-234)
dromas (enchondromatosis).
These tests are described as they are performed
Tendons and Soft Tissues on the right hand.
Extensor tendon avulsion is marked by tender-
ness and soft swellings at the DIP joints, which Starting Position
are held in a slightly flexed position. The hand is in the resting position, i. e., the neu-
Very painful swellings on the volar side ofthe dis- tral position intermediate between maximum
tal phalanges occur with the various types of radial and ulnar abduction, with slight ulnar de-
paronychia (cutaneous, subcutaneous, tendi- viation.
nous, articular, osseous).
Marked tenderness over the volar side of the Procedure
MCP joints occurs with callous abscesses. The examiner stands or sits on the side of the
A palpable jerk is felt at the level of the MCP tested hand. With the proximal (left) hand he
joint in de Quervain's tendovaginitis as the immobilizes the forearm against his own body or
thickened flexor tendon passes through the on the table, holding the forearm from the dorsal
stenosed tendon sheath. side above the joint line of the wrist. The distal
A flexion contracture of the thumb (e. g., pollex (right) hand grasps the wrist (making firm con-
rigidus in children) is palpable over the MCP tact with the scaphoid and triquetrum) distal to
joint of the thumb. the joint line.
With inflammatory changes of the tendons and 1. Traction and compression on the longitudinal
tendon sheaths, a skin fold cannot be raised from axis of the forearm. Examiner applies traction
underlying tissues on the volar aspect of the fin- by abducting his right upper arm (Fig. 230a). If
gers (Savil's test). this relieves pain, compression is applied as a
provocative maneuver (Fig. 230 c).
2. Volar gliding (Fig. 231). For this test the hands
are positioned more upright and parallel to the
tangential plane (=treatment plane) of the wrist.
The mobilizing distal hand pushes the patient's
hand downward to induce volar gliding at the
wrist.
3. Dorsal gliding (Fig. 232). Using the same hand
placement, the examiner pulls the hand upward
to induce dorsal gliding at the wrist.
 Tests ofJoint Translation 329

8 8

Fig. 231 a, b. Volar gliding ofthe carpus

c
Fig.230. a, b Traction on the wrist. c Compression of Fig.232. Dorsal gliding of the carpus
the wrist

• Note the distal row of carpal bones at a slightly more

It is usually adequate to test volar and dorsal distal level. The test vectors are then applied as
gliding from the same starting position, i. e., with described above.
the hand pronated. For therapeutic application
4. Ulnar gliding (Fig. 233). The hand is
of the same technique, the patient's hand should
semipronated and tested for ulnar gliding using
be turned over, or the forearm can be moved
the same hand placement as before.
while the hand is held stationary.
The carpal and intercarpal joints (between the 5. Radial gliding (Fig. 234). The same technique
proximal and distal rows of carpal bones) can be is used to test gliding in the radial direction.
differentiated to a degree by immobilizing not All test movements except for traction are per-
just the forearm but also the proximal row of formed along the tangential plane (treatment
carpal bones. The mobilizing hand grasps only plane) of the radius. The orientation of this
 330 Tests of Joint Translation

Limitation of ulnar gliding due to impaired radi-

al abduction.
Limitation of radial gliding due to impaired ul-
nar abduction.

4.2 Intercarpal Joints (Ten Tests)

(Figs. 235-238)
Testing of the intercarpal joints provides addi-
tional information on pathologic findings noted
in previous tests. It is also used to investigate
8
painful conditions of the hand that are not asso-
ciated with decreased motion.
The intercarpal joints are tested in three loca-
tions (Fig. 235):
- In a circular arc around the capitate (tests 1-4)
- At the radial border of the hand (tests 5-7)
- At the ulnar border of the hand (tests 8-10)
Again, it is assumed that the tests are performed
on the right hand.

b
Circular Arc Around the Capitate (Fig. 236)
Fig.233a,b. Ulnar gliding ofthe carpus
Starting Position
The hand is in the resting position. The examiner
faces the patient. One hand immobilizes the
patient's hypothenar (the thenar in test 4)
(Fig. 236 a) while the other performs the gliding
movements.
For therapeutic mobilization, the index fingers
immobilize the bone that is to be fixed while the
thumbs perform the mobilization (Fig. 236 b).

Procedure (Fig. 236 a,b)

The examiner grasps the ulnar border of the
hand with his left hand, the fingers on the pa-
Fig.234. Radial gliding of the carpus tient's hypothenar, the examiner's thenar on the
back of the hand over the fourth and fifth
metacarpals. For therapeutic manipulation, the
plane is from distal-dorsal to proximal-volar examiner's right hand grasps the patient's thenar
and from distal-radial to proximal-ulnar. from the radial side, placing the last three fingers
on the volar side and the thenar on the dorsal
Pathologic Findings side.
Limitation of traction due to decreased mobility For testing, the examiner successively grasps the
in the wrist. following structures between the thumb and in-
Limitation of volar gliding due to impaired dor- dex finger of the same hand:
siflexion.
Limitation of dorsal gliding due to impaired Test 1: Trapezium and Trapezoid (Fig. 236 c,d)
volar flexion. These bones are grasped together because they
 Tests oUoint Translation 331

Overview of tests of joint translation

Wrist

Intercarpal joints
("10 test") Carpometacarpal joint
ofthethumb

Metacarpal joints

Fig. 235. a Tests of joint translation in the hand

• '" Fixed joint member
..-=Movingjoint
1 =traction, compression
2/3 = volar, dorsal gliding
4/5 '" ulnar, radial gliding
In the metacarpal region 3+4 signify dorsovolar gliding (at the intermetacarpaljoints), and 5 trans-
verse compression of the intermetacarpal joints
The numbers in the area of the intercarpal joints correspond to the sequence of the examinations in
the "10 tests" (Fig. 235 b)
332 Tests of Joint Translation

10 Tests of joint translation: wrist

Ulna Radius

P =Pisiform
Tl =Triquetrum
L =Lunate
S =Scaphoid
H =Hamate
C =Capitate
T2 =Trapezoid
T3 =Trapezium
0 =Fixed
.... joint member
= Moving
joint member

Fig.235. b Test of joint translation

in the wrist (after Kaltenborn)

a _ _....._ ••

Fig.236. a Hand placement for testing. b Hand placement for therapy (proximal and distal fixation)
 Tests of Joint Translation 333

c .............._ e

c, d Test 1 capitate-trapezoid-trapezium e, f Test 2 capitate-scaphoid

Fig.236a-j. Testing the circumcapitate arc. Test

position (a, b)
Test 1 capitate-trapezoid-trapezium (c, d)
Test 2 capitate-scaphoid (e, f)
Test 3 capitate-lunate (g, h)
Test 4 capitate-hamate (i,j) g, h Test 3 capitate-lunate
334 Tests of Joint Translation

Test 4 capitate-hamate (i, j) Test 5 scaph oid-trapezii (a, b)

Fig. 236. i, j (Legend see page 333) Fig.237. a, b (Legend see page 235)

form a functional unit during excursions of the proximal side and immobilizes the scaphoid be-
scaphoid. tween the thumb and index finger.

Test 2: Scaphoid (Fig. 236 e,f) Procedure

Test 5: Trapezium and Trapezoid (Fig. 237 a,b)

Test 3 Lunate (Fig. 236 g,h)
The right hand grasps the trapezii between the
Dorsovolar gliding of these bones is tested rela-
thumb and index finger from the distal side and
tive to the fixed capitate. tests their dorsovolar play relative to the
scaphoid. Dorsal gliding of the trapezii is impor-
Test 4 Hamate (Fig. 236 i,j)
tant for physiologic excursions of the scaphoid
The mobilizing hand on the radial side now im-
during dorsal and radial wrist movements.
mobilizes the capitate while the previous immo-
bilizing hand on the ulnar side tests dorsovolar
• Note
gliding of the hamate relative to the capitate.
Occasionally it may be necessary to test the
articulation between the trapezium and tra-
Radial Border ofthe Hand (Fig. 237 a-f)
pezoid.
Starting Position
The ulnar border of the patient's pronated hand Tests 6 and 7: Scaphoid and Lunate
is held against the examiner's body. With the left The immobilizing hand is moved proximally to
hand, the examiner grasps the forearm from the the radius, and the same technique is used to test
 Tests of Joint Translation 335

Test 6 rad ius-scaphoid (c, d) Test 7 radius-lunate ( e,f)

Fig.237. a, b Test 5: scaphoid-trapezii. c,d Test 6: radius-scaphoid. e,fTest 7: radius-lunate

the mobility of the scaphoid (Test 6, Fig. 237 c,d) the hamate or, preferably, immobilizes the ha-
and lunate (Test 7, Fig. 237 e,f) . mate while the more mobile triquetrum is moved
relative to it (Fig. 238 c,d).
. Ulnar Border ofthe Hand (Fig. 238 a-f)
Test 10: Pisiform (Fig. 238 e,f)
Starting Position With the wrist flexed and the flexor and abduc-
The radial border of the pronated hand is held tor digiti minimi relaxed, the pisiform is moved
against the examiner's body. The examiner's in the radial and ulnar directions. Again, the tri-
right hand grasps the forearm from the proximal quetrum is immobilized during this test.
side and immobilizes the ulna (and disk) be-
tween the thumb and index finger. Normal Findings
Motion is painles and ea ily palpated in all
Procedure the joint te ted .
Test 8: Triquetrum (Fig. 238 a,b)
The left hand grasps the triquetrum and tests its 4.3 Carpometacarpal Joint of the Thumb
mobility relative to the disk and ulna. (Five Tests) (Figs. 239, 240)
The following tests are performed:
Test 9: H amate-Triquetrum (Fig. 238 c,d)
The right immobilizing hand moves distally to 1. Traction/compression
the triquetrum , and the left hand either moves 2. Dorsal gliding
 336 Tests of Joint Translation

a C

Test 8 ulna-triquetrum (a, b) Test 9 hamate-triquetrum (c, d)

3. Volar gliding
4. Radial gliding
5. Ulnar gliding

Test 1: Traction and Compression (Fig. 239)

Starting Position
The patient's pronated hand is in the resting po-
sition, the ulnar border steadied against the ex-
aminer's body.
e
Procedure
The left hand, placed proximally, immobilizes
the trapezium between the thumb and index fin-
ger (Fig. 239 a). The right hand, placed distally,
grasps the base of the first metacarpal close to
the joint line and applies traction and compres-
sion (Fig. 239b,c).

Tests 2-5: Gliding movements (Fig. 240)

...
Fig.238. a, b Test 8: ulna-triquetrum. Cod Test 9: ha-
Test 10 triquetrum-pisiform (e, f) mate-triquetrum. e, fTest 10: triquetrum-pisiform
 Tests of Joint Translation 337

Carpometacarpal joints: thumb

Fig.2393-(:. Carpometacarpal joint of the thumb (first

CM joint). Test 1: a Fixation, trapezium. b Traction,
first metacarpal. c Traction/compression on the skele-
tal model

Starting Position Normal Findings

Same as before.
Pronounced degree of joint play (large joint
capsule), especially in the radioulnar direc-
Procedure
tion. Ligamentous restraint: firm-elastic.
Painless traction and compression.
Dorsovolar Gliding (Tests 2,3, Fig. 240 a, b)
Hand placement is as in the previous test. Al-
though the dorsovolar gliding movement occurs 4.4 Second to Fifth Carpometacarpal
in the sagittal plane of the first CM joint, the and Intercarpal Joints (Five Tests)
plane is rotated approximately 45° toward the (Figs. 241-244}
palm so that the vector of the volar gliding
Sequence of the tests:
movement is directed toward the ulnar border
of the hand. Gliding movements of the concave 1. Traction/compression
articular surface of the first metacarpal occur in 2. Dorsovolar gliding of the CM joints
the same direction as active and passive move- 3. Dorsovolar gliding of the intermetacarpal
- ments of the first metacarpal, i.e. , in the volar joints
direction (flexion) during volar gliding and in 4. Distal intermetacarpal syndesmoses dorso-
the dorsal direction (extension) during dorsal volar gliding
gliding. 5. Compression of intermetacarpal syndes-
moses (Gaenslen's maneuver)
Radioulnar Gliding (Tests 4, 5, Fig. 240 c-e)
Example: Third CM joint (of the right hand).
The thumb and index finger of the immobili-
zing hand grasp the trapezium as before. The
Test 1: Traction and Compression of the CM
thumb and index finger of the mobilizing
Joints (Fig. 241)
hand move 90° onto the frontal plane of the CM
joint of the thumb. The gliding movements of Starting Position
the convex articular surface consist in radial Like that for the first CM joint (of the thumb).
gliding of the base of the first metacarpal to test The patient's hand is pronated.
adduction in the joint and ulnar gliding to test
abduction, i.e., the gliding movement is oppo- Procedure
site to the active and passive movements of the The left hand, placed proximally, successively
joint. immobilizes
 338 Tests of Joint Translation

a
c

b ~ ____ ~ _ _______________________ ~

Fig.240a-e. Carpometacarpal joint ofthe thumb. a,b

Tests 2, 3: dorsal and volar gliding. c-e Tests 4, 5: radi-
al and ulnar gliding e

- The trapezoid for the second CM joint, makes it easier to grasp and pull than the base of
- The capitate for the third CM joint, and the bone.
- The hamate for the fourth and fifth CM Compression (Fig. 241 b): Compression is ap-
joints. plied to the head of the metacarpal slightly more
distally, from the MCP joint space.
Traction (Fig. 241 a,c,d): With the selected carpal Figure 241c illustrates an alternate placement of
bone held immobile, the right hand applies trac- the immobilizing hand. Figure 241d shows the
tion to the second through fifth metacarpals at traction applied to a skeletal model.
the head of the metacarpal, whose flared shape
 Tests of Joint Translation 339

Carpometacarpal joints: fingers

Fig.242a,b. Test 2: on the eM joints: dorsovolar glid-

ing of the third eM joint

Test 2: Dorsovolar Gliding of the eM Joints

(Fig. 242)
Example: third CM joint.

Starting Position
The carpal bones are selectively immobilized as
in test 1.

Procedure
Dorsovolar forces are successively applied to
the bases of the metacarpals.

Fig.241a-d. Second to fifth carpometacarpal joints. Normal Findings

Test 1: a Traction, bcompression ofthe third eM joint. Very slight, barely perceptible motion of the
c Same test with different fixation of the capitate.
CM joints in response to traction and dorso-
d Metacarpal traction on the skeletal model
volar forces.
 340 Tests of Joint Translation

Test 3: Dorsovolar Gliding Procedure

of the IntermetacarpaJ Joints (Fig. 243) The immobilizing hand grasps the base of one
metacarpal and tests the dorsovolar mobility of
Starting Position the adjacent metacarpal bases. In Fig. 243 a,b,
Both hands grasp the wrist from the proximal the examiner's left hand (on the radial side)
side while steadying the patient's forearm holds the third metacarpal such that the thumb is
against the examiner's body. The patient's on the base of the bone and covers its articula-
hand is pronated and in the resting position; tions with the carpus and fourth metacarpal.
it is held at the radial and ulnar borders. Meanwhile the right, mobilizing hand (on the ul-
nar side) tests the dorsovolar mobility of the
fourth metacarpal relative to the immobilized
third metacarpal.

Fig. 243 a-e. Second to fifth intermetacarpal joints.

Test 3: a, b dorsovolar gliding at the third/fourth inter-
metacarpal joint. c Schematic diagram of the test. d, e
Same test using the thenar eminence (this technique is
c also used for treatment)
 Tests of Joint Translation 341

The same test can be performed with the thenar Pathologic Findings
(Fig. 243d,e) - a technique that can also be ap- Painful limitation of motion due to:
plied therapeutically (trial manipulation). - Trauma
The immobilizing and mobilizing hands are - Excessive loading
moved toward the ulnar side to test the fifth eM - Degenerative joint disease
joint, and toward the radial side to test the sec- - Inflammatory joint disease
ond and third eM joints.
Transverse compression elicits pain (Gaenslen's
test): early sign of rheumatoid arthritis.
Normal Findings
Firm-elastic end-feel with increasing mobili- • Note
ty in the third/fourth and fourth/fifth inter- Testing from the distal side is advantageous be-
metacarpal joints. cause in most other examinations of the hand
and arm joints the examiner stands facing the
patient. For treatment, however, it is better to
Test 4: Dorsovolar Gliding of the Distal
grip the hand from the proximal side as this facil-
Intermetacarpal Syndesmoses (Tests the
itates immobilization.
Dorsal, Interosseous, and Palmar Metacarpal
Ligaments) (Fig. 244)
Example: Second/third/fourth intermetacarpal 4.5 Phalangeal Joints (Five Tests)
syndesmoses of the right hand. (Figs. 245, 246)

Starting Position Starting Position

Same as in the previous test (Fig. 243 a,b), or us- The hand is in the resting position and pronated.
ing the thenar eminence as in Fig. 243 d,e. The ulnar border of the hand is steadied against
the examiner's body or the examination table.
Procedure (Fig. 244 a)
One hand grasps the head of the third metacarpal Procedure
from the side, the thumb on the dorsal surface For each test the bone proximal to the joint is im-
and the index finger on the volar surface. The oth- mobilized directly adjacent to the joint line. The
er hand on the opposite side ofthe patient's hand other hand, placed distally, grasps the bone just
similarly grasps the head of the second distal to the joint line and performs the following
metacarpal and tests dorsovolar mobility in the mobility tests:
intercarpal syndesmoses. The mobilizing and im-
mobilizing hands may be interchanged. Again, 1. Traction (Fig. 245 a) and compression
testing with the thenar (Fig. 244 b,c) is preferred (Fig. 245 b)
for therapeutic manipulation. The hand also may 2. Volar gliding (Fig. 246 a,c)
be grasped from the distal side (Fig. 244 d). 3. Dorsal gliding (Fig. 246b,c)
4. Ulnar gliding (Fig. 246 d)
Test 5: Transverse Compression of the Inter- 5. Radial gliding (Fig. 246 e)
metacarpal Joints with One Hand (Gaenslen's For testing of the fourth and fifth fingers, the ra-
Maneuver) (Fig. 244 f) dial rather than ulnar side of the hand is held
against the examiner's body.
Normal Findings
Significantly greater mobility than in the in- Normal Findings
tercarpal joints. Mobility increases from the Painless motion in the phalangeal joints (DIP,
second to fifth metacarpals. PIP, Mep) of both hands, with equal motion
Ligamentous restraint: firm-elastic. on both sides. Play in the Mep joints should
Transverse compression does not elicit pain. be greater than in the DIP and PIP joints.
 342 Tests of Joint Translation

a
--~- -

c
Test 4

Fig. 244 a-f. Intermetacarpal syndesmoses. a Test 4:

dorsovolar gliding in the secondlthird intermetacarpal
syndesmosis. b,c Same test in joint III/IV using the
therapeutic hand placement. d Same test from the dis-
tal side. e Schematic diagram of the test. f Transverse
compression of the intermetacarpal joints with one
hand (Gaenslen's technique) TestS
 Tests of Joint Translation 343

Fig. 245 a, b. Phalangeal joints: traction. Test 1: a traction/compression of the second !'vIP joint. b Traction/com-
pression on the skeletal model

Fig. 246 a-e. Phalangeal joints: gliding. Tests 2-5: glid-

ing movements in the second !'vIP joint. a Volar glid-
c
ing, b dorsal gliding, c schematic diagram of the test,
TestU3 d ulnar gliding, e radial gliding
344 Resistance Testing of the Hand and Finger Muscles

Pathologic Findings 5.1 Wrist Muscles (Figs. 247-253)

1. Traction is impaired due to concentric limita- Tests of Synergistic Muscle Groups
tion of motion. (Figs. 247,248)
2. Volar gliding is impaired due to limitation of These tests are mainly for the diagnosis of inser-
volar flexion. tion tendinopathies (medial and lateral epi-
3. Dorsal gliding is limited due to decreased dor- condyle disease).
siflexion.
4. Radial gliding is impaired due to limitation of Starting Position
radial abduction. The elbow joint is slightly flexed. For the exten-
5. Ulnar gliding is limited due to decreased ulnar sor test (Fig. 247a) the forearm is pronated and
abduction. slightly dorsiflexed at the wrist; for the flexor test
(Fig. 247 b) the forearm is supinated and slightly
flexed at the wrist. The fingers are completely
5 Resistance Testing of the Hand relaxed. The examiner uses his left hand and
and Finger Muscles forearm to immobilize the patient's forearm.

Procedure
5.1 Wrist Muscles The patient attempts first to dorsiflex the wrist while
5.2 Finger Muscles resistance is applied to the back of the hand (ex-
5.3 Thumb Muscles tensors, Fig. 247a) , then to flex thewristwhileresis-

I Resistance testing of synergistic muscles

8 8

b b

Fig. 247. a Extensor muscles of the hand, b flexor Fig.248. a Radial abductors, bulnar abductors
muscles of the hand
 Resistance Testing ofthe Hand and Finger Muscles 345

I Differential resistance tests

Fig.249. Flexor carpi radialis Fig.252. Extensor carpi ulnaris

Fig.250. Flexor carpi ulnaris Fig.253. Palmaris longus

Specific Muscle Tests (Figs. 249-253)

Starting Positions
The examiner faces the patient and immobilizes
his forearm above the wrist. Then the hand is
successively placed in:
Volar flexion and radial abduction to test the
flexor carpi radialis (C6-Cg, median nerve; see
Fig. 249).
Volar flexion and ulnar abduction to test the
Fig.251. Extensores carpi radialis
flexor carpi ulnaris (C,T 1, ulnar nerve; see
Fig. 250).
Dorsiflexion and radial abduction to test the ex-
tensor carpi radialis (C6-Cg, radial nerve; see
tanceis appliedtothevolarside (flexors, Fig. 147b ). Fig. 251).
The same principle is used to test radial and ul- Dorsiflexion and ulnar abduction to test the ex-
nar abduction starting with the hand in the neu- tensor carpi ulnaris (C,Cg, radial nerve; see
tral position (Fig. 248). Fig. 252).
346 Resistance Testing of the Hand and Finger Muscles

Procedure
Resistance tests: finger mnscles Once the hand has been positioned, the patient
tries to keep it in that position against a resistance,
or to move the hand from the initial position in the
direction of the testedmuscle,i. e., in the volar-ra-
dial direction for the flexors (Fig. 250) and in the
dorsal-radial direction (Fig. 251) or dorsal-ulnar
direction (Fig.252) for the extensors while the
examiner applies the appropriate resistance.
In the rare cases that require testing of the pal-
maris longus (Fig. 253), the patient approxi-
mates the thenar and hypothenar by opposing
the thumb and small finger, and the examiner at-
tempts to separate them while simultaneously
extending the wrist against the resistance of-
fered by the patient. The tightened tendons of
palmaris longus and flexor carpi radialis become
visible over the wrist during the test.

5.2 Finger Muscles (Figs. 254-257)

Starting Position
The hand and finger joints are in the resting po-
sition (approximately 10° flexion), the hand
coaxial with the forearm. For testing of the indi-
vidual fingers, the phalanx proximal to the joint
Fig.254a,b. Finger flexors. a Flexor digitorum pro- is held at the radial and ulnar sides between the
fundus. b Flexor digitorum superficialis thumb and index finger to avoid tendon com-
pression. All the joints proximal to the tested
joint remain extended. For simultaneous testing
of the whole muscle, all the proximal phalanges
are immobilized between the examiner's thumb
and index finger (Figs. 254,255).

Procedure
The examiner applies resistance against the
functional direction of the muscle being tested:

Flexors (Fig. 254)

Resistance at the distal phalanx tests flexor digi-
torum profundus (C/T j , median nerve, ulnar
Fig.255. Extensor digitorum communis nerve; Fig. 254 a).
Resistance at the middle phalanx tests flexor
digitorum superficialis (C/T j , median nerve;
Fig. 254b).
The fingers must be relaxed during the tests and Resistance at the proximal phalanx tests the
should not move independently of the hand lumbricales and interossei palmares (C, Tj, ul-
(substitution by finger flexors or extensors). nar nerve, median nerve).
 Resistance Testing ofthe Hand and Finger Muscles 347

gers and having the patient attempt to close the

fingers together. This tests the interossei pal-
mares (Cs-T j, ulnar nerve).

Abductors (Fig. 257)

The patient attempts to spread the fingers while
the examiner applies resistance to the second
finger from the radial side and to the fourth and
fifth fingers from the ulnar side. This tests the in-
terossei dorsales and abductor digiti minimi
(Cs-Ts, ulnar nerve). Again, this movement oc-
curs on the plane of the palm.
Fig.256. Interossei palmares
5.3 Thumb Muscles (Fig. 258)
Starting Position
The wrist is held stationary from the ulnar or ra-
dial side.

Procedure
First, resistance to flexion is applied at the volar
side of the distal phalanx: flexor pollicis longus
(C7-Tl, median nerve). Resistance to extension
is applied at the dorsal side: extensor pollicis
longus (C6-CS, radial nerve).
Next, resistance to flexion is applied at the volar
side of the proximal phalanx: flexor pollicis bre-

Fig.257. Interossei dorsales

1
vis (C6-TJ, me~ian. nerve: ulna nerve). Resis-
tance to extensIOn IS applied at the dorsal side:
extensor pollicis brevis (C6-Cs, radial nerve).
Resistance to adduction toward the plane of the
palm is applied at the ulnar side of the proximal
phalanx: adductor pollicis (Cs-TJ, ulnar nerve;
Extensors (Fig. 255) Fig. 258 a).
Resistance to palmar abduction is applied at the
Resistance at the distal and middle phalanges
radial side of the proximal phalanx: abductor
tests extensor digitorum communis (C6-CS, radi-
pollicis brevis (C6-Tj, median nerve; Fig. 258b ).
al nerve), interossei palmares and lumbricales.
Finally, resistance is applied at the first
Resistance at the proximal phalanx tests exten-
metacarpal: Resistance to abduction on the
sor digitorum communis.
plane of the palm is applied at the dorsoradial
Attempting extension from a sharply flexed po-
aspect: abductor pollicis longus (C6-Cs, radial
sition predominantly tests extensor digitorum
nerve; Fig. 258 c). Resistance to opposition is
communis; testing from a slightly flexed position
applied at the ulnar, volar aspect of the first
predominantly tests the interossei and lumbri-
metacarpal: opponens (CrT 1, median nerve;
cales.
Fig. 258 d). Resistance to palmar adduction is
applied at the ulnar aspect to test the first in-
Adductors (Fig. 256)
terosseus dorsalis.
This movement occurs on the plane of the palm.
The examiner creates adduction resistance by in-
terlacing his fingers between the patient's fin-
 348 Resistance Testing ofthe Hand and Finger Muscles

Thumb muscles

c ___ ~'-- _ _ __
d

Fig.258. a Adductor pollicis, b abductor pollicis brevis, c abductor pollicis longus,

dopponens
Examination of the Lower Extremities in the Supine Position
(Ell) Hip Joint (LPH Region)

The examination of the hip joint is included in

1 Inspection
the examination of the LPH region because of
NI (General Inspection), p. 72
the overlap of symptoms involving disturbances
C/LPH Regionll, p.120
of the SIJ and lumbar spine. The indications for
E/LPH Region/l, p.155
examination of the hip joint include:
- A history of hip and groin pain
2 Active and Passive Motion Testing - Limitation of internal rotation and abduction
NLower Extremities/I, p. 72 of the hip (capsular pattern)
C/LPH Region/2, p.121 - Pain on percussion of the greater trochanter
EILPH Region/2, p.157
The examination of the hip joint as part of the
LPH region was described in the following chap-
3 Palpation ters:
CILPH Region/3, p.124
EILPH Region/3, p.166

4 Tests of Joint Translation

C/LPH Region/4, p.135
EILPH Regionl4, p.169

5 Muscle Tests
NLPH Regionl5, p.lOl
B/LPH Region/5, p.116
C/LPH Region/5, p.144
D/LPH Regionl5, p.153
E/LPH Region/5, p.173
350 Overview of hip examination

Overview of hip examination

Straight leg raising

Adduction

1) Straight leg raising: Lasegue's test for hamstring shortening

Fig. 67 a, b, p.159 2) Maximum hip and knee flexion: SIJ nutation/sacrotuberal ligament/
lumbar segments: divergence/elimination of lumbar lordosis/ test for
shortening of erector spinae
Fig. 68 a, p.160 3) Flexion and adduction toward the opposite shoulder: test for sacrospinal
ligament
Fig. 68b, p.160 4) Adduction: test for SI ligaments, adduction with internal rotation: piri-
form test
Fig. 69, p.161 5) Internal and external rotation of the hip: capsular pattern/joint gliding,
rotator stretch
Fig. 70 b, p.162 6) Abduction with the hip flexed: hyperabduction test of Patrick-Kubis/
differentiation: shortening of the adductors or hamstringslhip abduction
test
Fig. 80 a, b, p.l71 7) Traction on the hip joint: test of joint translation
8) Extended position: increased lumbar lordosis with flexor shortening!
position of malleoli = leg-length discrepancy
Fig. 86 a, p.176 9) Abduction in 0° position: joint testitest for adductor and hamstring
shortening
Fig. 86 b, p.176 10) Further abduction with the knee flexed: differentiates hamstring and
adductor shortening
Knee Joint, Upper Leg, Lower Leg

1 Inspection: Abnormalities of Shape

and Position, Contours of the Upper
and Lower Leg
1.1 Anterior Aspect
1.2 Lateral Aspect
1.3 Posterior Aspect

2 Active and Passive Motion Testing of

the Knee Joint and Femoropatellar
Joint
2.1 Knee Joint
2.2 Patellar Tracking

3 Palpation Field of the Knee Joint and

Lower Extremity
Palpable Findings
3.1 Anterior Side ofthe Knee (Patellar
Region)
3.2 Medial Side of the Knee (Medial
Condyle)
3.3 Lateral Side ofthe Knee (Lateral
Condyle)
3.4 Popliteal Fossa
3.5 Upper and Lower Leg Contours

4 Tests of Joint Translation

4.1 Mediolateral and Caudal Gliding
Movements of the Patella
4.2 Traction on the Meniscotibial Joint 5 Tests of the Menisci and Ligaments
4.3 Mediolateral Gliding Movements in 5.1 Sagittal Plane
the Meniscotibial Joint (Shear Test) 5.2 Frontal Plane
4.4 Anteroposterior Gliding Movements in 5.3 Transverse Plane
the Meniscotibial Joint (Drawer Test) 5.4 Testing the Posterior Horns of the
4.5 Mobility in the Superior Tibiofibular Menisci
Joint 5.5 Specific Tests for Rotary Instability
352 Inspection

1 Inspection: Abnormalities Pathologic Findings

of Shape and Position, Contours Swellings
ofthe Upper and Lower Leg Prepatellar (patellar effacement): prepatellar
bursitis (in tile setters, cleaning women, nuns).
1.1 Anterior Aspect Infrapatellar (patella and patellar tendon stand
1.2 Lateral Aspect out markedly from the swelling): infrapatellar
1.3 Posterior Aspect bursitis.
Inflammations of the bursa may be caused by
trauma or infection.
During examination of the knee joint, attention Tibial tuberosity: swollen in Osgood-Schlatter
is given not just to the appearance of the joint it- disease or aseptic necrosis in adolescents (11-14
self but to its position in relation to neighboring years).
joints. Thus, the examination must additionally Parapatellar (increased by extension of the
cover the shape and position of the upper and knee): swelling in the infrapateJlar fat pad.
lower legs. As in the examination of the hip joint, Symptoms: pain on weight bearing, unsteady gait.
the gait is also evaluated (limp, weight bearing, A soft to firm, nonfluctuant swelling is usually a
mobility, pain). Findings are discussed on p. 73. result of trauma.
Hydrops: The contours of the knee are indis-
tinct. Flexion of the joint pushes intraarticular
1.1 AnteriorAspect effusion up into the suprapatellar pouch. Copi-
Position of the PateUa ous effusions will even fill the pouch when the
knee is extended ("horseshoe effusion").
Normal Findings Knee effusions can result from:
The patella is on the frontal plane, the inferi- - Trauma (including mild sprains and meniscal
or pole approximately 1 cm above the joint lesions)
space of the knee. When the knee is flexed - Degenerative joint disease
90°, the inferior pole of the patella is level - Osteochondritis dissecans
with the joint space of the knee. - Bacterial infections
- Hydrocortisone injection
- Rheumatoid disorders
Pathologic Findings - Soft-tissue swelling (tumor albus)
High position due to rectus shortening. Lateral - Bone tumors (exostoses)
deviation due to condylar dysplasia or genu val-
gum (danger of recurrent patellar dislocation) . Meniscal cysts disappear or become flatter when
the knee is flexed.
Contour ofthe PateUa
-Note
With the joint in the neutral position, the con-
Normal Findings
tents of the suprapatellar pouch can be manually
The patellar contour is well defined. Distally:
expressed to test the mobility of the patella
patellar tendon, flanked by the bulges of the
("dancing patella," see Sects. 2.2 and 3.2).
infrapatellar fat pad. When the knee is flexed
90°, the bulges disappear and are replaced Atrophy
by small fossae adjacent to the patellar ten- The vastus medialis can become atrophic due
don. to traumatic joint lesions or meniscal pathology.

Deformity
Indentation over the patella due to rupture of
the rectus femoris.
 Inspection 353

Limb Axis
- Approximately 12° external rotation of the
Normal Findings
femoral neck axis (anteversion of the
femoral head)
The Mikulicz limb axis runs through the cen-
- Approximately 24° external rotation of the
ter of the inguinal fold (femoral head) , patel-
malleolar axis (10°-30°), i. e., both feet are
la, and ankle mortise. The joint line of the
externally rotated at about a 45° angle.
knee should be perpendicular to the limb axis
(horizon tal) .

Pathologic Findings
Pathologic Findings With excessive tibial torsion (>45°), the gait
evolves over the medial border of the foot and
Valgus Deformity (Genu Valgum, Pes Valgus) with the knees slightly flexed, because compen-
Effects: satory anteversion at the hip is not sufficient to
achieve a normal foot position. This leads to
- Increased loading of the lateral compartment rapid fatigue.
(lateral meniscus)
- Stretching of the medial ligaments
- Overloading of the medial muscular restraints Contours ofthe Upper and Lower Leg
(pes anserinus group: sartorius, gracilis, semi-
Nonnal Findings
tendinosus)
Upper Leg
Sartorius muscle passes diagonally from the
Varus Deformity (Genu Varum, Crus Varum,
anterior superior iliac spine (lateral) to the
Pes Varus)
pes anserinus (medial). Lateral to artorius
Effects:
are rectus femoris and vast us lateral is. The
- Increased loading of the medial compartment vast us medialis appears farther distally. Medi-
(medial meniscus) al to sartorius are the vastus medialis, which
- Stretching of the lateral ligaments extends distally almost to the patella, and the
- Overloading of the lateral muscular restraints adductor group.
(iliotibial tract, biceps femoris) Lower Leg
The tibialis anterior (below-knee analog to
Occurrence: rickets, fracture of the medial tibial the sartorius) runs obliquely from below the
condyle, chondrodystrophy. tensor fasciae latae tuberosity to the base of
the first metatarsal.
• Note Lateral to the tibialis anterior are the long ex-
All valgus and varus deviations can cause static tensors (extensor digitorum longus and ex-
muscular complaints. Bilateral genu valgum is tensor hallucis longus).
considered normal between the second and Medial to it are, from above downward, the
sixth years. medial head of gastrocnemius, soleus, and
flexor digitorum longus.
Tibial Torsion and Angle of Femoral Neck
Anteversion
1.2 Lateral Aspect
Nonnal Findings Limb Axis
With the patella in the frontal plane, the fol-
lowing relationships apply: Nonnal Findings
The upper leg and lower leg are on a com-
- Knee joint axis is in the frontal plane. mon vertical line and show no curvature.
354 Inspection

Pathologic Findings
- Superolaterally: biceps femoris
Flexion deformities of the knee can result from:
- Superomedially: pes anserinus (sartorius,
- Meniscal pathology. Extension loss is typical gracilis, semitendinosus)
of meniscallesions. - Inferiorly: heads of gastrocnemius
- Flexion contracture of the hip (compensato-
ry)
Pathologic Findings
- Talipes equinus (compensatory)
Swelling may be caused by lipomas, cysts (Bak-
Genu recurvatum due to ligament weakness is er's cyst, popliteal cyst from the knee joint or
common in children under 10 years of age. neighboring bursae), enlarged lymph nodes, in-
Hypermobility (ligament weakness) may be due flammations, or exostoses. These are differenti-
to recurrent joint effusions, general hypermobil- ated by palpation and radiography; some cases
ity (Ehler-Danlos syndrome, Marfan's syn- may require biopsy. Asymmetry due to atrophy
drome), cruciate ligament injuries, or muscle of the adjacent muscles.
palsy about the knee (quadriceps femoris). It
also occurs with a flail joint (tabes, sy- Contours of the Upper and Lower Leg
ringomyelia) and as a compensatory response to
pes equinus deformity. Normal Findings
Contour changes: Platycnemia due to growth The biceps femoris (lateral) and the semi-
disturbances or systemic diseases. Patellar con- tendinosus and semimembranosus (medial)
tours, see Sect. 1.1. form parallel longitudinal prominences on
the back of the upper leg. The adductor field
Contours ofthe Upper and Lower Leg is adjacent medially. In the proximal half of
the lower leg, the two gastrocnemius heads
Normal Findings form th elliptical bulge of the calf.
The iliotibial tract produces a shallow groove
extending from the greater trochanter of the
Pathologic Findings
femur to the lateral femoral epicondyle. An-
terior to it are the tensor fasciae latae proxi- Hypertrophy
mally and the vast us lateralis distally. Posteri-
- Muscular exertion
or to it are the gluteus maximus proximally
- Myositis
and the biceps femoris distally.
- Tumors
- Muscle ruptures (indentation with an accen-
tuated muscle contour above the rupture site)
1.3 Posterior Aspect - Varicose veins
The posterior aspect of the lower extremity is in-
spected while the patient is erect or in the prone Atrophy
position. But since all other examinations of the - Trauma
lower extremity are performed in the supine po- - Degenerative and inflammatory disorders of
sition, it is most convenient to turn the patient the knee joint
and inspect the back of the legs at that time. (See - Muscular diseases
also A, General Inspection, p. 77f.) - Paresis

Popliteal Fossa

Normal Findings
The fossa is slightly convex and bounded by
the following structures:
 Active and Passive Motion Testing ofthe Knee Joint and Femoropatellar Joint 355

2 Active and Passive Motion Extension

Testing of the Knee Joint Slight hyperextensibility is normal. Greater
and Femoropatellar Joint hyperextensibility signifies ligament weak-
ness or trauma.
End-feel: firm-elastic due to restraint by the
2.1 Knee Joint
posterior capsule, the collateral and cruciate
2.2 Patellar Tracking
ligaments. and the anterior horns of the
menisci.

2.1 KneeJoint
Rotation
Flexion and Extension Rotation consists of a pure gliding movement in
the meniscotibial joint. The tibia can rotate only
Starting Position
when the knee is flexed.
Supine with the hips and knees extended (in the
neutral position).
Starting Position
Knee and hip flexed 90°.
Procedure
Every active movement is followed at once Procedure
by a corresponding passive movement in each
plane of motion. Flexion and extension occur
Internal Rotation
predominantly through rolling and gliding Active internal rotation of the lower leg.
in the meniscofemoral joint and to a lesser Passive. Again, the examiner immobilizes the
degree through gliding in the meniscotibial
upper leg above the patella. With the other hand
joint.
he grasps the heel from below so that he can in-
ternally rotate the lower leg.
Flexion
Maximum flexion of the knee joint with the hip
External Rotation
flexed. Concomitant hip flexion prevents pre-
Active and passive external rotation are tested
mature limitation of knee motion due to possi-
using an analogous technique to that described
ble rectus femoris shortening. for internal rotation.
Passive. Flexion of the knee is continued while
the upper leg is held stationary above the
patella. Normal Findings
Range of internal rotation: 10°_15°
Extension End-feel: firm-elastic due to restraint by the
Maximum extension of the knee and hip joint lateral capsular ligament, cruciate ligaments,
back to the neutral position. arcuate popliteal ligament, biceps femoris,
Passive. The lower leg is passively hyperextend- and iliotibial tract (tensor fasciae latae, glu-
ed while the upper leg is held stationary above teus maximus).
the patella. Range of externtJl rotation: 40°
End-feel: firm-elastic due to restraint by the
medial collateral and capsular ligaments, the
Normal Findings posterior oblique Ligament (POL) , the anteri-
Range offlexion: 140° or cruciate ligament (ACL), and the medial
End-feel: soft- to firm-elastic due to restraint muscular stabilizers of the pes anserinus
by the thigh and calf muscles, cruciate liga- group, semimembranosus, and popliteus.
ments, the posterior horns of the menisci, and
the quadriceps femoris.
356 Palpation Field of the Knee Joint and Lower Extremity

2.2 Patellar Tracking - Weakness or injury of the collateral ligaments

- Lateral deviation of the patella during exten-
Gliding movements of the patella in the
sion of the flexed knee in genu valgum (later-
femoropatellar joint are observed during flex-
aJization phenomenon of Outerbridge)
ion/extension of the knee.
"Dancing" patella due to joint effusion.
Normal Findings
The patella changes its relation to the joint The "patellar syndrome" (patellar chondroma-
space during flexion and extension of the lacia) has the following symptoms:
knee. In extension, the inferior pole of the - Spontaneous retropatellar pain during stand-
patella is approximately 1 cm above the joint ing from a squatting position
space, and the patella is in contact only with - Retropatellar tenderness after prolonged sit-
the anterosuperior border of the femoral ting, descending stairs, or walking down-
condyles. As the knee flexes, the anterior sur- hill
face of the femoral condyles glides upward - Limitation of patellar gliding (pseudolocking)
behind the patella, which is equivalent to a - Pain during movement under pressure or on
relative distal gliding of the patella. As this oc- palpation of the articular surface and patellar
curs, patellar tracking is increasingly con- borders
strained by bony structures, and a lateralizing - Associated symptoms: capsular irritation,
pull is increasingly exerted on the patella by crepitation of the patella during movement:
the oblique traction of the quadriceps muscle. fine crepitation with chondromalacia, coarse
Congruity between the articular surfaces is crepitation with degenerative arthritis. If
optimum in 9{)0 of flexion. As the joint is crepitus persists with elevation of the patella,
extended, the reverse process occurs while the cause is in the femorotibial compartment;
quadriceps contraction increases the upward hypertrophy of the infrapatellar fat pad; feel-
movement of the patella. ing of instability while walking downhill; hy-
There should be no crepitus and no lateraliza- potrophy of the vastus medialis
tion of the patella during extension. The
patella should be easier to displace toward the
medial side. The total range of patellar track-
ing is approximately 6 cm. 3 Palpation Field of the Knee Joint
and Lower Extremity
Pathologic Findings
Palpable Findings
Limitation ofpatellar mobility may be caused by
3.1 Anterior Side of the Knee (Patellar
degenerative or inflammatory joint disorders or
Region)
by meniscal pathology. Snapping sounds may be
3.2 Medial Side of the Knee (Medial
due to:
Condyle)
- Intraarticular loose bodies 3.3 Lateral Side of the Knee (Lateral
- A displaced meniscus Condyle)
- Discoid meniscus in children 3.4 Popliteal Fossa
3.5 Upper and Lower Leg Contours
Increased patellar mobility may be caused by lig-
ament weakness, ligament injuries, or paresis.
The range of patellar tracking is decreased by Palpation (except of the popliteal fossa) is usual-
rectus femoris shortening. ly performed with the knee extended.
Recurrent patellar dislocation may result from:
- Dysplasia of the femoral condyles and/or
patella
 Palpable Findings 357

Pain at the patellar border occurs with genu val-

Palpable Findings gum or genu varum as a result of unilateral mus-
cular strain. Usually there is associated femo-
3.1 Anterior Side of the Knee ropatellar osteoarthritis. This type of pain also
(Patellar Region, Fig. 259) occurs with pes planus.
Local warmth occurs with suprapatellar or
1) Superior Patellar Border
prepatellar bursitis. Capsuloligamentous lesions
The superior border of the patella gives attach-
are associated with slight local warmth of the
ment to the muscular stabilizers of the knee: the
joint, and synovitis with a significant local tem-
rectus femoris centrally and the vastus muscles
perature elevation.
medially and laterally.

Palpation field of
knee joint and lower --------;-'+--- Rectus femoris

extremity

Vastus latera lis - - -\ -- --4 ---:-- f - - - - Vastus medialis

G)
Superior
border of patella
Prepatellar
bursitis ®
Inferior
® Infrapatellar
bursitis
.......r _ - border of patella
Joint space - - -.

Infra-
®
-t-i-'-~~--- I nfrapatellar
patellar
fat pad fat pad

0
Tubercle of Gerdy - -- i -- -
+---......",.,.~-- Tibial tuberosity

Peroneus longus ---+- '--- -- - - Pes anserinus

Extensor - - - --+.-- ---4 -':\---- Gastrocnemius muscle

digitorum longus (medial head)

Tibial is anterior - - f - - - --
---+---- - - - Soleus muscle

Fig.259. a Anterior aspect of the knee (patellar region) (after Lanz-Wachsmuth): joint contour, pal-
pation points, and pathologic changes of contour
358 Palpable Findings

Rectus
femoris - - - -- T-'r------""'<:\\t- - Superior border
CD
of patella
Rectus
femoris

Vastus lateralis "",""""---++..s".~

H-i1-H--t-- - --_=_ Vastus

medialis

- -- -- -- - - --++-»-+--\\-_-.
®
Patella

'-';;:::-~-+----J:4-f---- Inferior pole

of patella
® ~~moropatellar Patellar tendon
Jomt space ,,;:-+-:,-~~H'-----

Head of fib ula - -- - -- ....

Infrapatella fat pad

®
Tubercle of Gerdy (corp us adiposum in frapatella re)

' -- - - - P e s anserinus
Peron eus longus

E~te n sor digitorum longus - -t.....\-'--#1o'

Tibialis anterior - -- --t-i:t-:'7t'--tt--

Fig. 259. b Anterior aspect of the knee (patellar region) (after Lanz-Wachsmuth): anatomic structures and
palpation points

2) Inferior Patellar Border sification center with aseptic necrosis). Pain-

(Palpated with the Knee Extended) ful swelling is also seen with infrapatellar bursi-
The soft-tissue envelope is displaceable and tis.
non tender in all planes. The inferior pole of
the patella is 1 cm above the joint space of the 3) Infrapatellar Fat Pad
knee. The patellar borders are nontender and The infra patellar fat pad is located on both sides
show no swelling (patellar contours are well de- of the patellar tendon proper. It can become
fined). painful and swollen due to inflammation or in-
The attachment of the patellar tendon is pain- creased quadriceps tension.
ful in Larsen-Johannson disease (persistent os-
 Palpable Findings 359

4) Tubial Tuberosity Capsular Attachment

Attachment of the patellar tendon proper. Ten- The capsule attaches up to 5 cm above the patel-
derness or quadriceps tendon pain can result la. The attachment runs along the lateral and
from: medial patellar borders and posteriorly along
the femoral condyles. The distal fold of the joint
- Posttraumatic irritation
capsule on the tibia extends to about 1 cm below
- Schlatter's disease (Osgood-Schlatter disease,
the joint space.
i. e., aseptic necrosis of the tibial tuberosity in
Thickening and marked tenderness of the joint
8- to 15-year-olds, predominantly males, due
capsule occur with osteoarthritis and chronic
to overexertion)
arthritis and may be accompanied by crepitus
- Bursitis (subcutaneous bursa at the tibial
and marginal osteophytes.
tuberosity)
As noted earlier, smaller effusions can be extrud-
- Curved tibia with a knobby surface in Paget's
ed from the suprapatellar pouch and palpated in
disease
the inferior recess. The suprapatellar pouch is
firmer and more tender in hemarthrosis than
5) FemoropateUar Joint Space
with synovial effusion.
Patellar mobility is tested in the caudal and
Large effusions cause a "dancing patella" (see
mediolateral directions. With caudal displace-
Sect. 1.1, p.352).
ment of the patella, small effusions can move
Cysts have a firm-elastic consistency.
into the inferior recess where they are palpable
next to the patellar tendon. Even smaller effu-
2) Medial Femoral Epicondyle and Medial
sions can move from one side of the inferior re-
Tibial Condyle
cess to the other and can be palpated there.
These structures are palpated above and below
Passive patellar mobility is tested by palpating
the joint line of the knee. The bony contours are
translatory movement in the femoropatellar
clearly palpable. Adjacent structures include:
joint (procedure: see Sect. 4.1, p.364).
- The attachment of the medial collateralliga-
ment (MCL) and, below it, the medial capsu-
3.2 Medial Side of the Knee lar ligament
(Medial Condyle, Fig. 260) - The medial patellar retinaculum at the superi-
or border of the femoral condyle
1) Medial Joint Space - Posteriorly, the attachment of the medial head
The joint space is palpated at the level of the dis- of the gastrocnemius
tal pole of the patella.
The sprained MCL tends to be more painful for
a longer period due to its attachment with the
Medial Meniscus
medial meniscus. With more serious injuries, a
The medial meniscus is palpable next to the me-
calcium shadow (Stieda shadow) is often visible
dial patellar border with the lower leg internally
on radiographs. The calcium deposit is especial-
rotated. With external rotation, the tibial
ly common after a mild or moderate sprain of the
plateau moves forward and the meniscus re-
collateral ligament.
cedes more deeply into the joint where it is inac-
cessible to palpation. There may be tenderness
3) Adductor Tubercle
at the ligamentous attachment of the anterior
Located slightly proximal to the origin of the
hom of the meniscus. When the knee is flexed,
collateral ligament, the adductor tubercle gives
the pain shifts posteriorly to the collateralliga-
attachment to the adductor magnus tendon (ad-
ment; with extension, the pain moves forward
ductor canal). Provocative testing of this muscle
("wandering tenderness," Steinmann II, see
is accomplished by maximum passive abduction
meniscal tests, p. 371).
of the thigh with the hip flexed 45° or by adduct-
ing the thigh against a resistance from the ab-
360 Palpable Findings

Vastus medialis -----\---~

®
Adductor tubercle -~-I--+-----
(-- - - --4-- - -- 0) Capsu lar attachment
I
I I \
® I - - +-\- -+--+-® Medial collateral ligament
Medial femoral I \ \
epicondyle -------l~---I----\\-__ ))

CD
Medial
joint space
\,........
__
_-- //
,/'/
/
/
- _--:-::- 0-.--------,-+- - Medial tibial condyle
0) Medial meniscus - - - - "
- - -- -- --'-':-:".----® Medial collateral
0) Capsular attachment ligament

~------*-0 Pes anserinus

Fig.260 3. Medial aspect of the knee (medial condyle) (after Lanz-Wachsmuth): joint contour and palpation
points

ducted position. Proximal and anterior to the ad- - Sartorius: from the anterior superior iliac
ductor tubercle is the origin of the vastus medi- spine (anterior).
alis. Atrophy of the vastus medialis can result - Gracilis: from the pubic symphysis (central).
from chronic meniscal pathology. - Semitendinosus: from the ischial tuberosity
(posterior).
4) Pes Anserinus
The pes anserinus is palpable below the joint Due to the divergent course of these muscles,
line of the knee. It is located medial to the tibial abnormal tension can develop as a result of stat-
tuberosity and is frequently tender to pressure. ic deviations involving the pelvis and hips.
It is the site of insertion of the medial muscular A bursa is situated below the pes anserinus.
stabilizers of the knee:
 Palpable Findings 361

® - HH'--- Semitendinosus
Adductor tubercle ---'t--+tT-t, ":,.. muscle

...-----j~-+--- Pes a nserinus group

Vastus medialis ----iH----liit--+-
of---1'-1-+- - Gracilis muscle
-~I...--f-lll-t-- Sartorius muscle
Medial
patellar retina<;ullJm---HY---i""'i"

®
Medial femoral Medial collateral
epicondyle and
® ligament with
media; capsular
medial tibial ligament below
condyle

(DJoint space I ~r...,+-~~.,-I-- Semitendinosus muscle

+ medial meniscus

Sartorius muscle- - - -----"

Pes anserinus
Gracilis muscle - - - --.../

Gastroc nemius muscle

Semitendinosus muscle _ _--' ----i--t+ - - - (media l head)

Fig. 260 b. Medial aspect ofthe knee (medial condyle) (after Lanz-Wachsmuth): anatomic structures
and palpation points

3.3 Lateral Side of the Knee nally rotated (place the lateral malleolus on the
(Lateral Condyle, Fig. 261) opposite thigh).
1) Joint Space (Abb. 260b,261) 2) Lateral Femoral Epicondyle (Abb. 260 b)
The lateral meniscus is not palpable. The lateral The proximal contour of the bone is clearly pal-
collateral ligament (LCL) is palpable and, unlike pable. The LCL and lateral patellar retinaculum
the MCL, is not adherent to the meniscus but attach to the superior border of the condyle. Be-
passes freely over the joint space at the level of hind and parallel to the LCL is the arcuate liga-
the fibular head. The approximately pencil- ment, covered by the lateral head of the gastroc-
thick LCL is most easily palpated when the knee nemius.
is flexed 90° and the hip is abducted and exter-
362 Palpable Findings

Latera l patellar retinaculum

® Lateral femoral
epicondyle
Lateral
collateral ligament _~~:--_ __~
Lateral
capsular ligament -""""":<:=-:----l-'+-'-Ir--m' - - -_r_

--'----=----=-'"7--1---G) Joint space

Arcuate ligament - - ---I

--- ---+-+--- - '4' Tubercle

\0' of Gerdy

Lateral collateral ligament

Common peroneal nerve Anterior ligament

® Head of fibula
of fibular head

Origin
of tibialis anterio r
Insertion of
bleeps femoris _ __ -f

Fig.261. Lateral aspect ofthe knee (lateral condyle) (after Lanz-Wachsmuth): anatomic structures and palpation
points

3) Head of the Fibula (Abb. 261) - Arcuate ligament and retinaculum (posteri-
The biceps femoris muscle inserts on the head of or)
the fibula, which also gives attachment to the fol-
The peroneal nerve is palpable behind the head
lowing ligaments:
of the fibula, where it is susceptible to injury by
- Anterior ligament of the fibular head pressure or fibular head fractures.
- LCL. The LCL is beneath the biceps tendon in
the extended knee and is more easily palpated 4) Tubercle of Gerdy (Abb. 261)
in the flexed knee between the iliotibial tract Situated lateral to the tibial tuberosity, the tu-
and biceps tendon. bercle of Gerdy gives attachment to the distal
 Palpable Findings 363

Gracilis muscle------',.---!,-.

- -- - -- - Iliotibial tract

o-!-..L.;......t~---- Biceps femo ris

Semimembranosus
muscle --:;t:;-f--------- Sciatic nerve
Jof..l,-l.-.....:,..--..:~-+-------- ® Tibial nerve

®
Popliteal fossa , --t-~.!...ft-~,.
\4--.....!.:""":"---+---® Common peroneal nerve
O-lr~-....lr-'f-l------- ® Planta ris m uscle

jOint capsule
CD
---- - - - Attachment of
CD
Attachment - - -- . ,\
lateral head
of gastrocnemius,
of medial head with popliteus
of gastrocnemius below
®
Attachment of semi-
membranosus muscle
®
Attachment of
® Pop liteal artery and vein biceps femoris and
arcuate popliteal
ligament
Long saphenous vein ' - - - - - - - Soleus muscle
(soleus pressure point)
Triceps surae ------~'----'--~

® Common peroneal
nerve

.........- - - - Sural nerve

Fig.262. Popliteal fossa (after Lanz .. Wachsmuth): anatomic structures and palpation points

end of the iliotibial tract. The ligament of the torius), superolaterally by the biceps femoris,
fibular head is palpable below and behind the and inferiorly by the heads of the gastrocnemius.
Gerdy tubercle, and the origin of the tibialis an- The popliteus muscle runs parallel to the lateral
terior is palpable farther distally. head of the gastrocnemius, and the arcuate
popliteal ligament runs along the superior bor-
3.4 Popliteal Fossa (Fig. 262) der of the popliteus.

This region is most easily palpated when the

knee is flexed 90°. The rhomboid-shaped 1) Heads ofthe Gastrocnemius Muscle
popliteal fossa is bounded superomedially by These structures are palpable at the superior
the pes anserinus (semitendinosus, gracilis, sar- border of the femoral condyles and are fre-
364 Tests of Joint Translation

quently tender to pressure, especially when the 4 Tests of Joint Translation

triceps surae is shortened. The more distal soleus
pressure point, located below the popliteus, can 4.1 Mediolateral and Caudal Gliding
be differentiated by a resistance test for the Movements of the Patella
soleus (planar flexion of the foot) with the knee 4.2 Traction on the MeniscotibialJoint
flexed. 4.3 Mediolateral Gliding Movements in
the Meniscotibial Joint (Shear Test)
2) Insertions of the Semimembranosus and
4.4 Anteroposterior Gliding Movements in
Biceps Femoris the Meniscotibial Joint (Drawer Test)
The semimembranosus inserts medially (pes 4.5 Mobility in the Superior Tibiofibular
anserinus profundus), posterior to the insertion Joint
of the pes anserinus. Deep and lateral to the
semimembranosus insertion is the oblique
popliteal ligament. On the lateral side of the The following techniques are illustrated for ex-
popliteal fossa is the insertion of the biceps amination of the right knee joint.
femoris and, medial to it, the arcuate popliteal
ligament.
4.1 Mediolateral and Caudal Gliding
3) Contents of the Popliteal Fossa Movements of the Patella (Figs. 263, 264)
Superficial Structures
Mediolateral Patellar Gliding
Nerves and blood vessels. At the center of the
The examiner stands at the patient's side, level
popliteal fossa are the tibial nerve, the popliteal
with the knees, and grasps the upper and lower
artery (palpable pulsations), and the short
halves of the patella between the thumb and in-
saphenous vein. The common peroneal nerve
dex finger, one hand grasping the proximal half
runs along the biceps femoris to the head of the
from above and the other the distal half from be-
fibula.
low. Medial gliding is tested by pushing the
patella over the medial femoral condyle with
Deep Structures
both thumbs (Fig. 263 a,c). Lateral gliding is test-
The joint space is in the inferior angle of the
ed by pushing in the opposite direction with the
popliteal fossa, level with the site where the
index fingers (Fig. 263 b,d).
heads of gastrocnemius diverge. The lateral
In each case the projecting undersurface of the
head of gastrocnemius is reinforced by the plan-
patella can be palpated with the thumbs or index
taris muscle. A tense, nondisplaceable mass
fingers. If increased lateral mobility is suspected,
(Baker's cyst) is often palpable medially; on
the same test is performed with contraction of
knee flexion the cyst retracts out of palpable
the quadriceps femoris to test stability. The same
range. Other swellings may be caused by in-
hand placement can be used to apply traction to
flamed bursae, lipomas, effusions, or tumors.
the patella by raising it from the condyles.
A bursa is located at each muscular insertion.
Distal PateUar Gliding (Fig. 264)
3.5 Upper and Lower Leg Contours
The examiner lays his forearm flat on the pa-
The long saphenous vein is palpable on the medi- tient's thigh so that pressure is not exerted on
al aspect of the calf. During palpation, attention the patella (Fig. 264 a,d). Pushing the patella dis-
is given to tonicity changes in the muscles and to tally with a thrust motion and holding it in
sites of myogelosis, swelling, or tenderness. that position can elicit clonic contractions of
the quadriceps femoris when reflexes are in-
-Note creased.
The pedal pulses are checked following acute In patients with a high-riding patella due to rec-
knee trauma to exclude arterial injury. tus shortening, a different technique is recom-
 Tests of Joint Translation 365

I Tests ofjoint translation: patella

Fig.263a-d. Patellar gliding movements. a, c Medial Fig.264a-d. Distal gliding of the patella. a, d Without
gliding, b, d lateral gliding compression, b, c with compression
366 Tests of Joint Translation

mended (Fig. 264 c) in which the wrist of the pal- Procedure

pating hand is placed on the superior border of
Sitting Position (Fig. 265 a)
the patella while the forearm is again placed on
When traction is applied to improve mobility in
the thigh. The forearm can be raised from the
extension (0°-60°), the patient sits at the end of
thigh to exert slight compression on the patella
the examination table. The knee is slightly
(Fig. 264 b). The same distal thrust is applied.
flexed to the angle at which the traction will be
These techniques can also be used therapeuti-
applied. The thigh is immobilized on the table.
cally.
The examiner grips the ankle between his legs to
assist traction on the lower leg. The hands grasp
Normal Findings the leg just below the knee while the thumbs are
Patellar gliding is painless and equal on both placed over the joint space on both sides of the
sides. There is no crepitation or proneness to patellar tendon to palpate the effect of the trac-
dislocation. tion. The examiner applies the traction by using
both hands and the leg grip to exert a longitudi-
nal pull on the lower leg.
Pathologic Findings
Altered Displaceability Prone Position (Fig. 265 b,c)
Decreased distal displacement of the patella due One hand immobilizes the thigh against the
to rectus shortening. table. The other hand grasps the lower leg so
Increased lateral displacement in patients with that the foot rests on the inside of the elbow.
lax ligaments and recurrent patellar dislocation. Again, the examiner exerts a longitudinal pull
on the lower leg and may support this maneuver
Crepitation During Patellar Displacement by rotating his body slightly.

- Fine crepitation in chondropathy

Traction-Compression in Rotation
- Coarse crepitation in degenerative arthritis
(Apley Test) (Fig. 265 e, f)
The patient is prone with the knee flexed 90°.
• Note The examiner immobilizes the patient's thigh
Crepitation is increased by moving the patella
with his own knee, grasps the patient's ankle with
while compression is applied and is decreased by
both hands, and rotates it while applying upward
raising the patella from the condyles (traction).
traction. This tests separation of the joint sur-
If crepitation persists despite traction on the
faces as well as the stability of the lateral capsule
patella, it must originate between the femur and
and ligaments (coUateralligaments) (Fig. 264 e).
tibia (see also p.356: symptoms of the patellar
The menisci are tested by applying compression
syndrome).
while rotating the lower leg (Fig. 265 f).

4.2 Traction on the Meniscotibial Joint 4.3 Mediolateral Gliding Movements

(Fig. 265 a,b)
in the Meniscotibial Joint (Shear Test)
(Fig. 266 a-d)
Starting Position The lower leg and slightly flexed knee of the ab-
The sitting position is used in patients with a lim- ducted leg project over the edge of the table. The
itation of extension (0°-60°) or the prone posi- examiner grips the ankle between his own legs
tion when the limitation is more in the flexion and exerts a slight traction during the test. One
range (60°-90°). hand grasps the patient's thigh from the medial
side above the joint line of the knee while the
other hand grasps the lower leg from the lateral
side below the knee and pushes medially
(Fig. 166a). Lateral gliding of the tibia is tested
 Tests of Joint Translation 367

--------
a b

Fig.265a-f. Traction-compression in the meniscotibialjoint. a,b Sitting position, c,d prone position (different
starting positions are also used therapeutically). e,fTraction and compression in the prone position (Apley test)

by reversing the hand positions and applying lat- 4.4 Anteroposterior Gliding Movements
eral pressure (Fig. 266 b). in the Meniscotibial Joint (Drawer Test)
In another technique both hands are placed be- (Fig. 267 a, b)
low the knee joint and alternately apply medial
and lateral pressure to test for medial and lateral For this test the knee is flexed approximately 90°
with the foot resting on the table. The examiner
gapping (ligament stability, Fig. 266 c, d). The ex-
sits on the patient's forefoot to immobilize it,
aminer's legs apply a slight concomitant traction
then grasps the lower leg with both hands just
at the ankle to facilitate the gliding movement.
below the joint space. The thenar eminences are
Both tests can also be applied therapeutically.
placed on the anterior side of the tibia, and the
368 Tests of Joint Translation

Fig.266a-d. Gliding in the meniscotibialjoint. a Medial gliding, b lateral gliding,

c, d gapping (ligament test)

fingers are placed over the heads of the gastroc- rotation (Fig. 267 a) and internal rotation
nemius. The pads of the thumbs are placed light- (Fig. 267 b).
ly over the anterior joint space to palpate rela- The Lachmann test (Fig. 267 c) for a lesion of the
tive anteroposterior translation of the tibia. ACL is used chiefly in the acutely injured knee,
The lower leg is alternately moved forward as it is easier to tolerate than the drawer test in
and backward. This gliding test, like the one 90° flexion.
preceding it, also tests the ligaments of the
knee joint (drawer phenomenon; see also
Sect. 5). As a ligament test, the drawer test is ad-
ditionally performed with the tibia in external
 Tests of the Menisci and Ligaments 369

tibiofibular joint" (distal tibiofibular syndesmo-

sis) should also be tested (Fig. 268 c,d).

Normal Findings
Tibiofibular joint mobility is painles and
equal on both sides.

Pathologic Findings
Limitation of motion due to degenerative, post-
a traumatic, or arthritic changes. Pathologic hy-
perrnobility is seen following capsuloligamen-
tous injuries.

5 Tests of the Menisci

and Ligaments

5.1 Sagittal Plane

5.2 Frontal Plane
b 5.3 Transverse Plane
5.4 Testing the Posterior Horns of the
Menisci
5.5 Specific Tests for Rotary Instability

The muscle resistance and shortening tests ordi-

narily performed at this stage are omitted be-
cause the biarticular muscles of the knee joint are
tested concurrently with the hip muscles (see
A/LPH Region/Sect.5, p.101; B/LPH/Sect.5.1,
c p.l16; C/LPH/Sect.5, p.144; DILPH Region/
Sect.5,p. 153;EILPH/Sect.5,p. 173).
Fig.267a-<. Drawer test (anteroposterior gliding in
The meniscal and ligament tests are performed
the meniscotibial joint). Combined joint and ligament
test. a In external rotation, b in internal rotation, concurrently and in three planes:
c Lachmann test in slight flexion - Sagittal plane [Bohler test, Steinmann II, pos-
terior capsule, anterior extensor apparatus
(quadriceps femoris and retinacula)]
4.5 Mobility in the Superior Tibiofibular - Frontal plane (Bohler-Kromer test, lateral
Joint (Fig. 268 a,b) and medial capsuloligamentous structures)
- Transverse plane (Steinmann I, lateral capsu-
The starting position is the same as in the drawer
loligamentous structures and cruciate liga-
test. The tibia is grasped from the medial side
ments, McMurrey test, Bragard test, medial
and immobilized while the other hand grasps the
capsuloligamentous structures)
head of the fibula between the thumb and index
finger and tests the anterior and posterior mobil- Combined movements are additionally tested in
ity of the tibiofibular joint (Fig. 268 a,b). If pain all three planes to test the integrity of the poste-
and/or limited motion is found, the "inferior rior horns (Payr test).
 370 Testing ofthe Menisci

II

Fig.268. a,b Superior tibiofibular joint. c,d Inferior tibiofibular joint (distal tibiofibular syndesmosis)

The cruciate ligament tests are performed in the - Flexion and extension with internal and exter-
transverse plane with the tibia in the intermedi- nal rotation of the lower leg
ate position and also internally and externally - Posterior horn tests in maximum flexion
rotated (see Sect. 5.3, pp. 375 and 377). - Flexion and rotation with weight bearing
Examination of the menisci and capsuloliga- (standing position)
mentous structures is identical for straight insta-
bilities (involving only one plane of motion: The cardinal signs of meniscal pathology are as
sagittal or frontal), since meniscal pathology follows:
may coexist with any ligamentous lesion. Inspection: atrophy of the thigh muscles, espe-
cially the vastus medialis (late symptom); joint
effusions.

I Testing ofthe Menisci Function testing: locking; snapping sounds dur-

ing movement.
Palpation: joint line tenderness.
The screening test for meniscal pathology is the
The meniscal tests evaluate the gliding ability of deep knee bend (if it can be performed). This
the articular surfaces, especially in the menis- provides a gross impression of the function of all
cotibial joint, under simple (unloaded) condi- the lower extremity joints. Deep knee bending is
tions and with compression of the menisci. Five almost always impaired, at least in its terminal
groups of tests are performed: stage, by meniscal pathology (see A/Lower Ex-
- Simple flexion and extension tremity/Sect.1, p.100).
- Flexion and extension with adduction and ab-
duction of the lower leg
 Examination Technique 371

L...1_'I_e_st_i_n_g_O_f_th_e_c_a_p_SU_I_e_a_n_d_L_ig_a_ID_e_n_t_s__1 I Examination Technique

Systematic testing for ligament damage is gener-
ally indicated only if there is a history of trauma. 5.1 Test Group: Sagittal Plane
For acute injuries, examination under anesthe-
(Tests 1-3) (Figs. 269, 270)
sia is frequently required. Ligamentous instabil- Starting Position
ity is manifested by abnormal displacement of Supine with the knee joint in the neutral posi-
the tibia with respect to the femur. This displace- tion.
ment may be mediolateral or rotational and can
have various axes.
Testing of the Menisci
The cardinal signs ofligamentous injuries are as
follows: Simple Flexion and Extension
History: previous knee injury.
Pain: only with a partial rupture; may be absent Test 1: Bohler's Test (Fig. 269 a-c)
with a complete rupture. Hyperextension ofthe tibia at the knee. Tender-
Inspection: swelling, effusion, later muscular ness in the anterior (medial) joint space is noted
atrophy. with a lesion of the (medial) anterior horn. The
Function: Function is impaired by mechanical tenderness diminishes with flexion.
blockages or by instability that may include
pathologic tibial rotation. The only limitation in Test 2: Steinmann II (Fig. 270 a-c)
milder cases is a feeling of instability during With flexion, the palpable tender point in the
stairclimbing or walking on uneven ground. joint space travels medially and posteriorly to-
Older lesions often produce only a feeling of ward the medial collateral ligament. The oppo-
weakness and rapid fatigue. site occurs with extension. This test evaluates
Palpation: tenderness at the ligament attach- only the medial meniscus.
ments, joint effusions.
Five stages of ligamentous injury can be identi-
Testing of the Capsule and Ligaments
fied (after Muhr and Wagner):
Test 3: Hyperextension Test
- Fresh ligamentous lesions
The passive hyperextensibility of the knee joint
- Injuries unaccompanied by loss of stability
is tested by lifting the extended leg by the toes.
- Injuries accompanied by a straight instability,
This tests the stability of the posterior capsule
i. e., loss of stability in only one plane of mo-
and ligaments and the ACL. The test is re-
tion and about one axis of motion
warding for acute injuries but not for older in-
- Injuries producing a complex instability, i. e., juries that have healed with ligamentous scar-
loss of stability in two or more planes of mo-
ring.
tion and about multiple axes
- Chronic compensated ligament lesions
Pathologic Findings
- Chronic decompensated ligament lesions If lifting the foot produces genu recurvatum
The topography of the ligament attachments is with varus angulation at the knee and marked
shown in Fig. 277a. external rotation of the tibia, this indicates pos-
Lesions of the menisci and ligaments can be terolateral instability due to a rupture of the
differentiated by the Apley test. Performed in LCL, popliteus tendon, and arcuate popli-
the prone position, this test was described in teal ligament (external rotation-hyperextension
the sections dealing with traction in the menis- test).
cotibial joint (Figs. 265e, 267) and LPH exami-
nation in the prone position (see C/LPH/Sect.
2.3).
372 Examination Technique

a
a

........ b

Fig. 269 a-c. Test 1: Bohler's test in the sagittal plane

Migration of
(loading of the menisci by maximum extension and tender pOint
flexion) . bPathologic finding with flexion

c
5.2 Test Group: Frontal Plane (Tests
4-7) (Figs. 271-273) Fig. 270a-c. Test 2: Steinmann II (migrating tender-
ness in the medial joint space). c Pathologic finding
Starting Position
Knee joint is extended (neutral position).

eral meniscus, respectively, while exerting a dis-

Testing of the Menisci
tracting force on the opposite collateral liga-
Adduction and Abduction ofthe Tibia ment and posterior capsule. A lax capsuloliga-
mentous apparatus poses a threat to the menisci
Test 4: Bohler's Test (Fig. 271) (see Fig. 278).
Adduction and abduction of the extended lower
leg produce compression of the medial and lat-
 Examination Technique 373

"':""i~""1 Adduction
\II c

Pain
. . - or
instability
with
ligament injuries

Fig.271a~. Test 4: Bohler's test in the frontal plane; com-

bined meniscal and ligament test by a adduction and b ab-
duction ofthe lower leg (c, d pathologic findings) d

Adduction or Abduction Combined with Testing of the Capsule and Ligaments

Flexion and Extension
Test 6: Abduction Tests (Fig. 273 a,b)
Test 5: Bohler-Kromer Test (Fig.272). Gliding The starting position is the same as before. In
of the menisci is tested by flexing and extending Bohler's meniscal tests on the frontal plane, the
the knee while the lower leg is adducted or knee ligaments on the side away from the move-
abducted to place pressure on the medial or ment are simultaneously tested.
lateral meniscus, respectively. Abduction with the knee extended tests the pos-
teromedial ligaments: the posteromedial cap-
• Note sule and POL, the medial capsular ligament, and
This test can also be applied as a therapeutic ma- the MCL (Fig. 273 a).
nipulation which utilizes gapping of the joint Abduction with the knee flexed 30° (Fig. 273 b)
space. relaxes the posterior capsule and tests only the
medial ligaments: the medial capsular ligament
andMCL.
 374 Examination Technique

a b

Fig. 272 a, b. Test 5: Bohler-Kromer test (flexion-extension of the adducted or abducted leg)

. . . .~~~. ._ __ _~ d

Fig. 273 a-d. Test 6: Comparison of abduction with the knee extended (a) and flexed 30° (b) (medial ligaments
and posterior capsular plate). Test 7: adduction with the knee extended (c) and flexed 30° (d) (lateral ligaments
and posterior capsular plate)

Test 7: Adduction Tests (Fig. 273 c,d) tightens only the lateral ligaments, i. e. , the later-
Adduction with the knee extended tests the al capsular ligament and the LCL.
posterolateral ligaments: the posterolateral In the abduction and adduction tests with the
capsule, the arcuate popliteal ligament, the knee flexed 300 , the tension on the medial and
lateral capsular ligament, and the LCL (Fig. lateral ligaments can be increased by adding
273c). external or internal rotation of the tibia (Fig.
Adduction in 30 flexion (Fig. 273 d) relaxes the
0 277b). The danger posed to the menisci by slack
posterior capsule, and the adduction selectively ligaments is illustrated in Fig. 278, p. 379.
 Examination Technique 375

5.3 Test Group: Transverse Plane

(Figs. 274, 275)
Starting Position
The knee and hip are flexed 90 0 •

Testing of the Menisci

Internal and External Rotation ofthe TIbia

Test 8: Steinmann I (Fig. 274)

Abrupt internal rotation can evoke pain in the a
lateral meniscus by increasing the cruciate liga-
ment pressure on the meniscus. Abrupt external
rotation can evoke pain at the anterior ligamen-
tous attachment of the damaged medial menis-
cus. The test can also be performed in the stand-
ing, weight-bearing position:

Steinmann I (Merke's sign)

While standing with the tibia in maximum ex-
ternal rotation, the patient actively twists the
b
body to internally rotate the femur. Pain or lim-
itation indicate a lesion of the medial meniscus.
The lateral meniscus is tested analogously by
starting with the tibia internally rotated and
fr,'!s1f
(
then twisting the body to externally rotate the Pain
femur. ~~
Rotation Combined with Extension ~
\1 I
Test 9: McMurrey Test (Fig. 275)
With the knee and hip joints maximally flexed,
the examiner strongly rotates the tibia external-
ly (to test the medial meniscus, Fig. 275 a) or in-
ternally (to test the lateral meniscus) and then
extends the knee to a position of 90 0 flexion
(Fig. 275b). c
Bragard's test is performed by continuing the
Fig.274a-<. Test 8: Steinmann I, internal (a) and ex-
movement to the neutral position (Fig. 275 c). ternal rotation (b), leg flexed 90° at the knee (c posi-
Extending the lower leg to the neutral position tive test in the standing positioniMerke's sign)
from a position of 90 0 knee flexion and external
tibial rotation approximates the medial menis-
cus to the anterior joint space, causing pain at
Testing of the Capsule and Ligaments
the anterior ligamentous attachment of the
meniscus or aggravating preexisting pain. In- The states of ligament tension associated
creased firmness is occasionally palpable at the with rotation of the tibia are illustl:ated in
affected site. Fig. 277 b.
 376 Examination Technique

Internal rotation tightens the lateral capsular lig-

ament, the arcuate popliteal ligament, both cru-
ciate ligaments, the iliotibial tract, and the bi-
ceps femoris.
The load on the ligaments can be increased by
additionally moving the tibia in the sagittal
plane - not just in extension as in the McMurrey
or Bragard test but also by producing an antero-
posterior drawer motion in the meniscotibial
joint (Fig. 267, p.369).
8

Rotation Combined with Sagittal Gliding

(Drawer Testing)
Test 11: Drawer Testing in External and
Internal Rotation to Diagnose Rotary
Instabilities, and Drawer Testing in Neutral
Rotation (Fig. 267)

Starting Position
Supine with the knee flexed 90°. The patient's
b
foot is flat on the table, and the examiner sits on
the forefoot to immobilize it in the sagittal plane.
The tibia is in 30° of external rotation or 15° of
internal rotation.

Procedure
The examiner grasps the medial and lateral sides
of the upper tibia with both hands so that the
thumbs are on the joint space, parallel to the
patellar tendon, and the forefingers are over the
knee flexors.
c
Fig.275a-c. Test 9: McMurrey test (knee extension
from maximum flexion with the tibia externally rotat- Normal Findings
ed). a Starting position. bFinal position of McMurrey A " mini-drawer" of 2- 3 mm (translational
test, starting position for Bragard test (further exten- gliding of the tibia) is normally encountered
sion). c Final position of Bragard test in external and neutral rotation.

Test 10: Terminal Phase ofInternal and Pathologic Findings

External Rotation of the Tibia Rotary Drawer. Rotation toward the uninjured
In the Steinmann I meniscal test, the medial andlat- side, occurs with injury to one collateral liga-
eralligaments also are tested in the terminal phase ment and the ACL.
of internal and external rotation, because these
ligaments are tightened on the side away from the Anterior Drawer in 30° External Rotation (see
movement and therefore function as restraints. Figs. 267a, 27Th). Test for the presence of an-
External rotation tightens all the medial liga- teromedial rotary instability. In this position the
ments, the ACL, the pes anserinus muscles, and cruciate ligaments are slack and the collateral
the popliteus. ligaments are taut. A positive test signifies injury
 Examination Technique 377

to the medial ligaments. A plausible sequence of Active Drawer

injury would be: medial capsular ligament, Starting Position. The knee is flexed 20 0 -30°
MCL, ACL, and posteromedial capsule ("un- over a wedge-shaped pad.
happy triad" of O'Donoghue). This instability, Procedure. With active extension of the knee,
which involves an anterior rotation of the medi- quadriceps muscle tension pulls the upper tibia
al tibial plateau, is termed an anteromedial com- anteriorly. When the quadriceps is relaxed, the
plex instability (after Slocum and Nicholas) or an upper tibia falls back to its former position. This
anteromedial rotary drawer. phenomenon represents a muscular compensa-
tion of ligamentous injuries like those men-
Anterior Drawer in 150 Internal Rotation (see tioned in the description of the drawer tests
Fig. 267 b). The collateral ligaments are slack. above.
The cruciate ligaments are taut (Fig. 277 b) be-
cause they are twisted around each other, causing Lachman Test (Fig. 267 c)
them to shorten. A positive test signifies injury to If the drawer test cannot be performed in an
the lateral ligaments. A plausible sequence of in- acutely injured knee due to limitation of flexion
jury would be: lateral capsular ligament, LCL to 90 0 , an alternative is to perform the test in
and iliotibial tract, lateral meniscus, and cruciate 10°_20°flexion.
ligaments. This instability involves an anterior
rotation of the lateral tibial plateau about an axis 5.4 Testing the Posterior Horns of the
through the medial meniscus: anterolateral com- Menisci by a Combination ofFlexion,
plex instability or anterolateral rotary drawer. Lateroduction, and Rotation (Test 12)
(Fig. 276)
Posterior Drawer. The posterior drawer is an Test 12: Payr's Test (Fig. 276)
equivocal sign. The types of ligament injury With the knee in maximum flexion, the exam-
mentioned in connection with the anterior draw- iner externally rotates the tibia as far as possible
er are additionally associated with a rotary insta- and then slightly adducts it while flexing it fur-
bility in which the pivot point is shifted toward ther toward the opposite hip (Fig. 276a). This
the uninjured side. The significance of the test maneuver compresses the posterior horn of the
and the sequence of injured structures is the medial meniscus. During the movement the
same as in the anterior drawer, except that there thumb and index finger of the hand holding the
is involvement of the PCL. knee palpate the lateral and medial joint space,
The posterior drawer in 300 external rotation respectively.
serves to demonstate a posterolateral complex The posterior horn of the lateral meniscus is sim-
instability (posterolateral capsule and PCL). ilarly tested by internal rotation and abduction
The posterior drawer in 15 0 internal rota- of the lower leg (Fig. 276b).
tion serves to demonstate a posteromedial com- The original Payr test is performed in a cross-
plex instability (posteromedial capsule and legged sitting position. In this version intermit-
PCL). tent pressure is applied to the maximally flexed
knee (with the tibia externally rotated), or the
Drawer Test (Sagittal Gliding) in Neutral patient "rocks" the knees to produce a rhythmic
Rotation compression of the medial meniscus.
This corresponds to anteroposterior gliding in
the meniscotibial joint (see Tests of Joint Trans- Pathologic Findings
lation, Sect. 4.4, Fig. 267, p. 369). With a lesion of the posterior horn, a snapping
sound is produced by the meniscus receding into
Anterior Drawer in Neutral Rotation. This test the joint. A tear in the posterior horn blocks the
is markedly positive with injury to both collater- normal excursion of the meniscus within the
alligaments, the medial and lateral capsular lig- joint. A snapping sound in 90 0 flexion indicates a
aments, and the ACL. possible lesion of the middle third of the menis-
378 Examination Technique

-
a
Fig. 276 a, b. Test 12: Payr's test (compression of the posterior horns of the menisci by maximum flexion in rota-
tion). a External rotaton-adduction-flexion. b Internal rotation-abduction-flexion

cus. A snapping in the lateral joint space during capsular ligament and/or the posterolateral cap-
terminal extension occurs in children with a dis- sule, which are functional synergists of the ACL.
coid meniscus. A positive test is signified by a forward subluxa-
tion of the lateral tibial plateau during the final
5.5 Specific Tests/or Rotary Instability degrees of extension (5°_10° flexion) while the
These tests are used in the diagnosis of multiple lower leg is internally rotated and abducted.
ligamentous lesions of the knee, i. e., a lesion of When the knee is flexed, the pull of the iliotibial
the ACL combined with a lesion of the lateral tract reduces the lateral tibial plateau at 30°-50°

Ligament tests
Patellar tendon
External rotation Internal rotation

\
b\ .
Anterior cruciate ligament
Traverse ligament of the knee
m"'b'"
I
capsular ligament

\i9.
Medial collateral
m
,",

I
Arcuate popliteal
Posterior oblique ligament

a
\

\
Posterior cruciate
ligament 7'"'
Fig.277a, b. The capsuloligamentous structures about the knee. a Tibial plateau with ligament attachments
(after Muhr and Wagner)
 Examination Technique 379

Fig.277 b. Function of the collateral and cruciate ligaments during internal and external rotation (modified from
Kapandji)

11\1..- -- ":~~J'Ir· lIIlr_~ ..:::s;;.....""llr .

Fig. 278 a-d. Danger posed to the menisci by a lax capsule and ligaments. a Lax medial collateralligament. b Ab-
duction. c Adduction. d Meniscallesion
380 Examination Technique

flexion. The iliotibial tract is in front of the flex- Abduction (valgus) + extenS ion + internal rotation of the foot
ion axis of the knee in extension and behind it
when the knee is sharply flexed.
Because these injuries are generally diagnosed
and treated in patients who have been hospital-
ized in a trauma center, only two of these tests -
the jerk test and pivot shift test - will be de-
scribed.

Jerk Test (of Hughston) (Fig. 279)

Starting Position Subluxation in extension
The knee is flexed 90°, the tibia is internally ro-
Fig.279. The jerk test
tated and abducted.
Sub luxation in extension
Procedure
The knee joint is extended while the tibia is held Internal rotation
in internal rotation and abduction. A positive +
test is marked by an abrupt forward subluxation extension
of the lateral tibial plateau at about 30° of flex-
+
ion. This Signifies an anterolateral instability abduction
caused by injury of the ACL and lateral capsular
ligament and by the pull of the iliotibial tract,
which runs anterior to the flexion-extension axis
past about 30° of knee flexion.

Pivot Shift Test (of MacIntosh) (Fig. 280)

This test is practically the opposite of the jerk
test and may be performed immediately after
the jerk test by reversing the movements. Inabil-
ity of the ACL to maintain normal rolling-glid-
Fig.280. The pivot shift test
ing of the femoral condyles leads to pure gliding
of the condyles when the ACL and lateral capsu-
lar ligament are damaged. axis and tends to pull the upper tibia backward.
The same phenomenon has been described by
Procedure numerous authors:
One hand holds the tibia in an internally rotated
position while the other hand holds the upper - Jerk test (Hughston 1976): The tibia subluxates
tibia in an abducted position from the lateral anterolaterally on extension of the flexed knee
side. In a positive test this is sufficient to cause joint.
forward subluxation of the lateral tibial plateau
due to a lesion of the ACL, lateral capsular liga- - Pivot shift test (MacIntosh 1976): The sublux-
ment, posterolateral capsule, and the pull of the ated tibia is reduced by slightly flexing the knee
iliotibial tract (as described in the previous test). joint from the extended position.
If the knee is then flexed while the tibia is held in
abduction and internal rotation, the pull of the - Slocum 's test (1976). Resubluxation of the tibia
iliotibial tract will reduce the sub luxated tibial is evoked by slightly flexing the knee from the
plateau at about 30° of flexion, since in that posi- extended position. Here the same test is per-
tion the tract runs behind the flexion-extension formed in the lateral position.
 Examination Technique 381

Pathologic fmdings associated with ligamentous injuries (after Mohr and Wagner)

Pathoanatomic classification: Mild sprain

Partial rupture (interstitial tearing)
Rupture
Grades of severity: mild (up to 5 mm of joint opening)
2 moderate (up to 10 mm of joint opening)
3 severe (more than 10 mm of joint opening)
Type of test Grade of severity Injured structures
of the injury
Abduction in Posterior capsule
0° position POL
(Fig. 277 a) Partial rupture of MCL
2 Plus: medial capsular ligament
Possible tear of ACL
3 Plus: both cruciate ligaments
Abduction in Medial capsular ligament
30° flexion 2 Plus:MCL
(Fig. 277b) POL
3 Plus:ACL
Adduction in 1 Arcuate popliteal ligament
0° position Lateral capsular ligament
(Fig. 277 c) Partial rupture of LCL
2 Plus:LCL
Popliteus tendon
3 Plus: iliotibial tract
ACL
Adduction in 1 Lateral capsular ligament
30° flexion Partial rupture of LCL
(Fig. 277 d) 2 Plus: iliotibial tract
3 Plus: popliteus tendon
Arcuate popliteal ligament
Anterior drawer
in neutral position ACL
(Fig. 267) 2 Plus: partial rupture of medial and
lateral capsular ligaments
Partial rupture of MCL and LCL
3 Plus: medial capsular ligament and MCL
Possible tears of lateral capsular ligament and LCL
Iliotibial tract
Anterior rotary 1 Medial capsular ligament, possible
drawer in ER involvement of POL
= anteromedial
2 Plus: POL
rotary instability Possible involvement of ACL
(Fig. 267 a)
3 Plus:MCL
ACL
Anterior rotary drawer in IR PCL
= anterolateral Posterior and lateral ligaments
rotary instability
(Fig. 267 b)
382 Overview of knee examination

Overview of knee examination

Rotation

5
"'---l"~ Flexion/extenSion in
rotation (McMurrey)
IR-abd.-ftex.
(Payer test)

Figs. 263, 264, p. 365 1) FemoropateUar joint: patellar gliding/test ligaments (retinacula )/qua-
driceps shortening
Fig. 269, p. 372 2) Maximum knee flexion: angular gliding of the joint/test extensor appara-
tus/compression of posterior horns of menisci
Fig. 276 b, p. 378 3) Payer test: combined test for capsule, ligaments, posterior horns of me-
nisci
Fig. 274a-c, p. 375 4) Rotation: tibia: tibial gliding/medial and lateral capsuloligamentous
structures
Fig.275a-c, p.376 5) Flexion/extension of the knee in rotation: meniscal tests: McMurrey,
Bragard test
Fig. 273 b, d, p. 374 6) Adduction and abduction in flexion: 30° flexion + internal and external
rotation = test for the lateral and medial capsule and ligaments
Fig. 273 a, c, p. 374 7) Adduction and abduction in extension: stability of the posterior cap-
sUle/compression of medial and lateral menisci/stability of collateral
ligaments
Fig. 269 a, p. 372 8) Hyperextension: stability of the posterior capsule/compression of the
anterior horns of the menisci
Fig. 267 a, b, p. 369 9) Drawer test: in internal and external rotation = test for cruciate and
collateral ligaments/test for tibial translation
Fig. 268 a-d, p. 370 10) Tibiofibular joints: gliding tests for superior and inferior tibiofibular
joints
Joints of the Feet and Toes

1 Inspection
1.1 Shape and Position ofthe Foot
1.2 Contour Changes
1.3 Skin Changes

2 Active and Passive Motion Testing of

the Pedal Joints
2.1 Active Movements
2.2 Passive Movements

3 Palpation Field of the Foot

3.1 Medial Border ofthe Foot
3.2 Lateral Border of the Foot
3.3 Dorsum of the Foot
3.4 Sole of the Foot

4 Tests of Joint Translation

4.1 Inferior Tibiofibular Joint (Distal
Tibiofibular Syndesmosis)
4.2 TarsaiJoints (Ten Tests)
4.3 Metatarsal Joints (Five Tests)
4.4 Phalangeal Joints (Five Tests)

5 Resistance Testing ofthe Foot and Toe

Muscles
5.1 Foot Muscles
5.2 Toe Muscles
384 Inspection

1 Inspection malleolus is more anterior than the lateral

malleolus. The talus forms about a 100°-110°
1.1 Shape and Position of the Foot angle (obtuse dorsally) with the axis of the
1.2 Contour Changes tibia.
1.3 Skin Changes
4) Position of the Forefoot
The longitudinal axes through the calcaneus
and the second metatarsal are parallel to eacb
1.1 Shape and Position of the Foot other.
Sites of uneven shoe wear or deformation can
provide clues to the presence of a dysfunction. 5) Position of the Toes
When the patient is supine, the feet are normal- The metatarsophalangeal (MP) joints are ex-
ly angled 15°-20° outward and are slightly tended, while the proximal interpbalangeal
supinated. The relative positions of the individu- (PIP) and distal interpbahalgeal (DIP) joints
al components of the foot determine the general are slightly flexed. The big toe is in continuity
shape of the foot. Inspection is performed with with the medial border of the foot.
the foot placed flat on the examination table or
floor or with the patient standing erect.
Attention is given to: Pathologic Findings
1) Pedal Arches
1) The pedal arches (during weight bearing)
Pes Cavus (Claw Foot). Marked by an abnor-
2) The heel axis (position of calcaneus)
mally high longitudinal arch caused by a fixed
3) The malleolar axis (position of talus)
dorsiflexion of the talus at the ankle joint and
4) The position of the forefoot
plantar flexion of the forefoot. This deformity
5) The position of the toes
concentrates stress on the heads of the first and
Normal Findings fifth metatarsals.
From dorsal to ventral:
Pes Planus (Flatfoot). Marked by a depressed
1) Pedal Arches (During Weight Bearing) longitudinal arch in which the navicular touches
Longitudinal arch: the ground. The deformity may be classified as
Heigbt of the arcb at tbe navicular: approxi- flexible or rigid.
mately 15-18 mm.
Height of the arch at tbe cuboid: approxi- Pes Transversus (Splayed Foot). Marked by a
mately 3-5 mm . flattened transverse arch in which the forefoot is
Transverse arch: broadened and the heads of the central
Maximum height at tbe second metatarsal: metatarsals touch the ground.
approximately 9 mm.
2) Hee/Axis
2) Heel Axis (Position of Calcaneus) In pes valgus the heel axis is angled outward and
The heel axis is vertical (neutral position) or the calcaneus is tilted medially (deficiency of the
shows up to about 6° of valgus angulation. medial ligaments), so that the foot is abducted
The calcaneus is not tilted. and pronated (i. e., the lateral border of the foot
is raised). The longitudinal arch is flattened and
3) Malleolar Axis (position of Talus) usually painful because the head of the talus is
The malleolar axis is angled approximately deviated medially downward from the talonavic-
15° toward the fibular side with respect to the ular joint onto the calcaneonavicular ligament.
longitudinal axis of tbe foot, i. e., the medial In pes varus the heel axis is angled inward, and
the foot is adducted and supinated (i.e., the
 Inspection 385

medial border of the foot is raised). The vis and a predominance of the adductor hallucis.
longitudinal arch is elevated. The head of This condition leads to a pseudoexostosis, often
the first metatarsal is excessively prominent, combined with an inflamed bursa. Hallux valgus
and in some cases the entire metatarsus is ad- always occurs in patients with a splayed-foot de-
ducted. formity.
Hallux varus is a congenital deformity caused by
3) Malleolar Axis (Position of Talus) obliquity of the articular surface of the medial
Changes in the malleolar axis are usually sec- cuneiform.
ondary to a change in the limb axis or trauma. Digitus superductus is a congenital deformity in
Pes equinus is characterized by a fixed plantar which one toe, usually the second or fifth, over-
flexion of the ankle joint, pes calcaneus by dorsi- laps the medially adjacent toe (congenital).
flexion of the ankle joint. Digitus quintus varus is a medial subluxation of
the small toe with pseudoexostosis and the po-
4) Position of the Forefoot tential for bursal inflammation as in hallux val-
Pes adductus is marked by a medial deviation of gus.
the forefoot, pes abductus by a lateral deviation
of the forefoot. Combined Deformities
The majority of foot deformities represent com-
5) Position of the Toes binations of the abnormalities described under
1) and 4) above.
Contractures
Hammer toes (often with corns): (a) flexion con- Congenital Foot Deformities
tracture of the PIP joint (proximal hammer toe)
with hyperextension of the MP joint and exten- • Clubfoot (pes equinovarus adductus):
sion or hyperextension of the DIP joint or (b) - Varus angUlation ofthe heel
flexion contracture ofthe DIP joint (distal ham- - Forefoot in equinus with a shortened
mer toe) with extension of the PIP and MP Achilles tendon
joints. - General supination of the foot with medial
Claw toes: hyperextension contracture of the subluxation of the navicular
MP joint with flexion contracture of the PIP and - Adduction of the forefoot at the transverse
DIP joints. Frequently coexists with pes cavus. If tarsal and tarsometatarsal joints
the pads of the toes do not touch the ground, one - Shortening of the soft tissues on the medial
should suspect damage to the nerve supply of and plantar sides of the foot
the small pedal muscles or rheumatoid contrac- - Atrophy of the muscles of the foot and low-
tures. erleg
Hallux rigidus is an ankylosis of the MP joint of
the great toe caused by degenerative arthritis, • Pes calcaneus:
often associated with joint swelling and medial - Dorsal extension of the forefoot
callosity (frequently combined with osteoarthri- - Valgus angulation of the heel
tis ofthe first carpometacarpal joint and Heber- - Slight abduction of the forefoot due to
den's nodules). shortening of the tibialis anterior
- Stretched, atrophic calf muscles
Angular Deformities
Hallux valgus is marked by a lateral subluxation • Flatfoot (congenital pes planovalgus): (Syn-
of the proximal phalanx of the great toe on an onyms: shoval or inkblotter foot, Chaplin
excessively rounded first metatarsal head due to foot.)
ligament deficiency and/or faulty muscular trac- - Fixed valgus deviation of the heel
tion, e. g., oblique traction from the flexor and - Strong plantar flexion of the talus
extensor hallucis longus and flexor hallucis bre- - Plantar convexity of the longitudinal arch
386 Inspection

- Forefoot abducted, displaced dorsally at • Pes cavus (or excavatus):

the transverse tarsal joint - Heel frequently in varus
- Fixed high longitudinal arch
• Functional differential diagnosis from pes - Displacement of the highest point of the
planovalgus. Pes planovalgus is distinguished longitudinal arch distally and medially into
by the following morphologic changes: the naviculocuneiform joint
When the patient stands on the toes, the tri- - Plantar flexion contracture of the talonavic-
ceps surae causes varus deviation of the heel. ular and naviculocuneiform joints
When the toes are flexed, the arch is straight- - Weight shifted toward the lateral side of the
ened by the deep flexors. foot
When the patient stands on the outside of the
foot, the pedal arch is deepened to a condition • Pes valgus and cavus: The symptoms are like
of pes valgus and cavus. those of pes cavus, but with valgus deviation
When the lower leg is externally rotated with of the heel added.
the knee slightly flexed, the longitudinal arch
• Pes cavus and transversus: Presents a combi-
is straightened.
nation of the changes described for the sepa-
rate deformities.
• Sickle foot (pes adductus, metatarsus varus):
- The heel is usually in valgus.
• Pes equinus: The heel cannot be lowered to
- The forefoot is adducted.
the ground in standing, and the forefoot can-
- Sometimes hallux varus is the only de-
not be raised.
formity.
- Muscular equinus:
Shortening of triceps surae
• Supination deformity (pes supinatus) is a rare
Spastic paresis
deformity in which:
- Capsular equinus:
- The heel is centered and there is free mobil-
Dorsal contracture of the joint capsules
ity in the ankle joint.
- Osseous equinus:
- There is a supination contracture of the
Deficient correction of clubfoot
forefoot at the transverse tarsal joint.
Differential diagnosis is accomplished by ra-
diography: With clubfoot, the longitudinal
Foot Deformities Acquired in Later Life
axes of the talus and calcaneus appear parallel
on the dorsoplantar projection.
• Pes planovalgus is a correctible deformity ac-
- Pareticequinus:
quired after about the second year of life and
Dropping ofthe forefoot with peroneal pal-
characterized by:
sy
- Excessive valgus deviation of the heel dur-
- Compensatory equinus:
ing weight bearing
Quadriceps paralysis
- Flattening of the longitudinal arch by de-
Leg shortening
viation of the head of the talus medially
These conditions require differentiation from
downward from the talonavicular joint
pseudoequinus due to a steep first metatarsal
onto the calcaneonavicular ligament. The
in pes cavus.
head of the talus is abnormally prominent
below the medial malleolus ("second mal-
1.2 Contour Changes
leolus").
- Internal rotation of the ankle mortise Swellings and deformities can produce charac-
- Pronation of the forefoot teristic changes in specific areas of the foot.

• Functional differential diagnosis from congen- Heel Profile

ital pes planovalgus is discussed above. Increased projection of the calcaneus due to hy-
 Active and Passive Motion Testing ofthe Pedal Joints 387

pertrophy of the posterior calcanean process Varicose Veins and Ulcers

(Haglund's exostosis). This is usually associated
Callosities
with:
Calluses are normally present on the heel and
- Swelling above the heel (subachilleal bursitis) over the heads of the first and fifth metatarsals.
- Swelling below the lateral malleolus (periten- Abnormal callosity can occur over the heads of
dinitis of the peroneus tendons) the second through fourth metatarsal heads in
- Swelling behind both malleoli (Achilles peri- the splayed foot, and on the medial side of the
tendinitis) great toe in hallux rigid us.

Bony Contours Corns (Clavi)

"Second malleolus" caused by a prominent head Caused by pressure from footwear at exposed
of the talus in pes planovalgus. bony prominences.
Increased prominence of the navicular bone:
cornuate navicular or os tibiale extern urn. NodularString-of-Beads Thickening ofthe
Differentiation: An os tibiale externum is dis- Plantar Aponeurosis
placeable! The cornuate navicular bone usually (Dupuytren's Contracture)
causes no complaints, while the os tibiale exter- Differentiated from fibrosarcoma by biopsy.
num can cause significant complaints due to the
formation of a pressure callus and bursal inflam- Warts
mation. Common in children (papillomas). Deep exten-
sion can cause severe pain.
Metatarsal Arch
Toenails
Prominence of the medial cuneiform and first
Onychogryphosis (clawlike deformity of the
metatarsal: "metatarsal exostosis" (possibly
nails), fungal infections (mycoses) , spontaneous
with bursitis) occurs in pes cavus.
splitting or breaking (onychorrhexis).
Distal prominence of the head of the second or
third metatarsal: Kohler's disease (Freiberg-
Kohler disease).

Phalangeal Joints 2 Active and Passive Motion

Thickening of the MP joint of the great toe due Testing of the Pedal Joints
to degenerative arthritis (hallux rigidus).
Pseudoexostoses at the first and fifth MP joints: 2.1 Active Movements
hallux valgus or digitus quintus varus. 2.2 Passive Movements

1.3 Skin Changes 2.1 Active Movements

Circulatory Problems Starting Position
Pale or livid discoloration. Unilateral pallor, yel- Sitting or supine. The foot projects over the edge
lowish and waxy with arterial occlusion. of the table. The knee is flexed approximately
20° (over a roll).
Swellings
Ankle, SubtaIar, and Transverse Tarsal Joints
At the heel: bursitis, Achilles tendinitis (see
Sect. 1.2). Normal Findings (after Debrunner)
At the malleolus: Unilateral swelling is traumat- The total range of motion is 45° in dorsiflex-
ic, bilateral swellings are usually caused by car- ion and 60° in plantar flexion.
diac disease or lymphatic obstruction.
388 Active and Passive Motion Testing ofthe Pedal Joints

1. Ankle joint (talocruraljoint). Motion ofthe

Ankle, Subtalar, and Transverse Tarsal Joints
talus in tbe bony ankle mortise:
Dorsiflexion: 20°-30° Ankle Joint
Plantar flexion: 40°- 50°
Starting Position
2. Subtalar Jomt (talocalcaneonavicular The examiner grasps the back of the patient's
joint). Motion of the talus and calcaneus lower leg with one hand just above the malleoli.
relative to eacb other and to the navicular: The other hand grasps the forefoot with the
Eversion: 30° thumb on the plantar side and the fingers on the
Inversion: 60° dorsal side.

3. Transverse tarsal joint (midtarsal joint, Procedure

Chopart's joint). Plantar flexion tests the anterior fibers of the
Pronation: 15° collateral ligaments as well as the talocrural joint
Supination: 30°. itself. Passive adduction at the ankle additional-
Movements in the subtalar and transverse ly tests the anterior talofibular and calcaneo-
tarsal joints are accompanied by approxi- fibular ligaments. The end-feel is firm-elastic.
mately 300 of abduction and adduction. Dorsiflexion tests the stability of the posterior
collateral ligament fibers: the deltoid ligament
(posterior tibiotalar portion) and the posterior
The combination of movements in the subtalar talofibular ligament. It also tests the stability of
and transverse tarsal joints consists of inversion the ankle mortise, i. e., the tibiofibular ligaments.
(adduction, supination, and plantar flexion) and Limitation of motion with a soft-elastic end-feel
eversion (abduction, pronation, and dorsi- may be caused by shortening of the triceps surae
flexion). (with the knee extended) or soleus (with the knee
flexed). Otherwise the end-feel is firm-elastic.
Phalangeal Joints

Normal Findings (After Debrunner) Subtalar Joint

Plantar flexion: Starting Position
MP joints 40° (great toe 45°) The ankle mortise is immobilized as before. The
PIP joints 30° other hand grasps the calcaneus from the plantar
DIP joints 60° (great toe 80°) side.
Dorsiflexion:
MP joints 70° (great toe 70°) Procedure
DIP joints 30° The calcaneus is adducted medially to test the
The second through fiftb PIP joints cannot be calcaneofibular ligament and subtalar joint. The
dorsiflexed past 0°. calcaneus is abducted laterally to test the stabili-
ty of the deltoid ligament (tibiocalcanean
fibers).
2.2 Passive Movements
Transverse Tarsal Joint (Chopart's Joint Line)
During passive motion testing, the examiner im-
(Fig. 281)
mobilizes the proximal joint member as needed
in order to test the separate components of the Starting Position
combined movement (e. g., abduction, prona- The immobilizing hand grasps the ankle and cal-
tion, and dorsiflexion). caneus from the posterolateral aspect. The other
hand grasps the forefoot from the medial side at
a point just distal to the immobilizing hand.
 Active and Passive Motion Testing ofthe Pedal Joints 389

Passive movement of pedal joints

a I--'=-_........ b

Fig. 281 a, b. Transverse tarsal joint (Chopart's joint)

Fig. 282 a, b. Tarsometatarsal joints (Lisfranc's joint line)

Procedure Starting Position and Procedure

The mobilizing hand alternately pro nates and Same as for the transverse tarsal joint, except
supinates the forefoot at the talonavicular and that the fingers of the proximal, immobilizing
calcaneocuboid joints relative to the fixed hind- hand are placed dorsally over the cuneiforms
foot. and cuboid while the thumb is placed over the
same bones on the plantar side. The distal, mo-
Tarsometatarsal Joints (Lisfranc's Joint Line) bilizing hand is placed over the bases of the
(Fig. 282) metatarsals.
390 Palpation Field ofthe Foot

The examiner twists the metatarsus in pronation Pathologic Findings (for Active and Passive
and supination to test the mobility of the tar- Tests)
sometatarsal joints. Painful limitation of motion occurs with various
types of joint pathology.
Phalangeal Joints (Fig. 283) Ligament pain is noted with sprains. Arthro-
genic equinus is differentiated from muscular
Starting Position and Procedure
equinus by flexing the knee joint. If impairment
The immobilizing hand is placed with the index
of foot dorsiflexion persists, the limitation is
finger on the dorsal side of the metatarsal heads
arthrogenic.
and the thumb on the plantar side (tendons are
pushed aside). The other hand moves the pha-
langes of the toes. The proximal phalanx is im- • Note
Calf pain during passive dorsiflexion of the foot
mobilized when the distal joints are tested.
may signify shortening of the calf muscles or
deep venous thrombosis in the lower leg
Normal Findings (Hohmann's sign).
Movements are painless and how equal
ranges on both sides, with a firm-elastic liga-
mentous restraint.
3 Palpation Field of the Foot

3.1 Medial Border ofthe Foot

3.2 Lateral Border of the Foot
3.3 Dorsum of the Foot
3.4 Sole ofthe Foot

3.1 Medial Border of the Foot (Fig. 284)

The following sites are palpated distally from
the medial malleolus to the MP joint of the great
toe:

1) Medial malleolus
The medial malleolus gives attachment to the
deltoid ligament, whose constituent fiber bands
are distributed in various directions.

Anteriorly
- A tibionavicular band to the tuberosity of the
navicular
- An anterior tibiotalar band to the neck of the
talus

Inferiorly
- A tibiocalcanean band to the sustentaculum
Fig. 283 a,b. Phalangeal joints. aDorsiflexion, bplan- tali of the calcaneus, below the tip of the
tar flexion malleolus
 Palpation Field of the Foot 391

Palpation field of the foot

CD Medial malleolus ~ .

X
®
3 Navicular bone TaI US~
~ ~ I
I

~~
o
Medial cuneiform bone /

~
Posterior p rocess
First metatarsal -,- -- "r-- of thetal us
~

®
"'--- - - - ; - Sustentaculum tali
(of the calcaneus)

® Calcaneus

MP joint of the big toe

Fig. 284 a. Medial border of the foot: topography (after Lanz-Wachsmuth): joint contour and palpation points

Posteriorly Tendon dislocations and tendovaginitis occur in

this area as well as tarsal tunnel syndrome (com-
- A posterior tibiotalar band to the medial tu-
pression of the posterior tibial artery and nerve)
bercle ofthe posterior process ofthe talus Gust
with dysesthesia at the heel and/or the sides of
posteroinferior to the tip of the malleolus)
the foot. This is also the site where "ankle ten-
For simplicity, the constituent bands of the del- derness" occurs secondary to deep vein throm-
toid ligament are hereafter referred to as sepa- bosis of the lower leg.
rate ligaments (e. g.,the tibionavicular ligament,
etc.). The deltoid ligament is made tense by 2) Sustentaculum Tali of the Calcaneus
eversion of the foot (provocative test). The long The following structures are palpable in various
saphenous vein courses directly in front of the directions from the sustentaculum tali:
medial malleolus. The sulcus malleoli medialis
Superiorly
on the posterior surface of the medial malleolus
lodges the tendon sheaths of the: - Tibiocalcanean ligament (usually difficult to
palpate)
- Tibialis posterior - Tibialis posterior and flexor digitorum longus
- Flexor digitorum longus tendon sheaths
- Flexor hallucis longus (not palpable I) - Subtalar joint space
 v.l
~
I r;;1 Achilles tendon

• ~~ : fI Soleus muscle
Long saphenous vein

CD Tibialis anterior
i
CD ~
Medial malleolus [0', A ", P,-I ;> Tibialis posterior
~
Deltoid ilgament: ...... I '\':' Blf< ; CD Flexor So
A: tibionavicular band
digitorum longus Tendon sheaths e-
/I>

B: anterior tibiota lar band ~

C: tibioca lcanean band CD Flexor hallucis So
D: posterior tibiotalar band longus

Joint spaces:
Talocalcaneonavicular joint - -- - - _ .,,---- Talus
Cuneonavicular joint .....
First tarsometatarsal joint
·~N . . 4\ \l'~ tibial artery and nerve
® Posterior(tarsal tunnel syndrome)
f4\ Base of the first
~ metatarsal
"r Posterior process of the talus
(medial tubercle)

.......
®
Sustentaculum tali
(of the calcaneus)

@Insertion of
tibialis
Sesamoid bone anterior
®
Metatarsophalangeal
® Tendon sheath
of flexor
joint of the big toe hallucis longus

® Navicular bone
Fig. 284 b. Medial border of the foot: anatomic structuresand palpation points (after Lanz-Wachsmuth)
 Palpation Field ofthe Foot 393

Posteriorly Dorsal Aspect

- Medial talocalcanean ligament to the posterior - The calcaneonavicular ligament, the medial
process of the talus (medial tubercle) slip of the bifurcate ligament on the dorsum of
the foot. Together with the lateral slip to the
Anteriorly cuboid, it maintains apposition of the trans-
verse tarsal joint (Chopart's joint).
- Plantar calcaneonavicular ligament, which
also arises from the body of the talus. The tib- Navicular tenderness is common in cases of
ialis posterior tendon runs plantar to the liga- pes cavus and osteonecrosis (Kohler II) in chil-
ment, between the sustentaculum and navicu- dren.
lar, and the flexor digitorum longus tendon
runs over the origin of the ligament on the 4) Base ofthe First Metatarsal
bone. Both tendons perform a supportive This is the site of insertion of the tibialis anterior
function. (which also inserts on the medial cuneiform).
First metatarsocuneiform joint (first tarsome-
Inferiorly tatarsal joint). Identification of the joint space is
aided by dorsoplantar movement of the first
- Flexor hallucis longus tendon sheath. Usually
metatarsal or by contraction of the tibialis ante-
the tendon is difficult to palpate because of its
rior.
depth.
- The posterior tibial artery is palpable behind
5) Metatarsophalangeal Joint of the Great Toe
and below the medial tubercle of the posterior
Tenderness and swelling are common accompa-
process of the talus.
niments of hallux rigidus, hallux valgus, and gout
Flexor tenderness associated with tarsal tunnel (podagra). An inflamed bursa on the medial
syndrome occurs farther distally, below the reti- side of the metatarsal head is another common
naculum. finding.
Point tenderness in the ball of the great toe usu-
3) Navicular Bone ally emanates from the sesamoid bone.
The navicular forms the most prominent point Pain behind the ball of the great toe occurs in
on the medial border of the foot. The following Morton's disease. Excessive length ofthe second
structures insert on the navicular and are palpa- metatarsal can lead to hypermobility of the
ble: first metatarsal with secondary degenerative
changes in the first and second tarsometatarsal
Plantar Aspect joints.
- Plantar calcaneonavicular ligament from the 3.2 Lateral Border of the Foot (Fig. 285)
sustentaculum tali. It is the strongest ligament
The following sites are palpated distally from
and helps to form the socket of the talonavic-
the lateral malleolus to the MP joint of the small
ular joint. It is reinforced by the tibialis poste-
toe:
rior and flexor digitorum longus tendons.
1) Lateral Malleolus
Medial Aspect
The lateral malleolus is more distal and posteri-
- The tibialis posterior, which inserts at the same or than the medial malleolus and thus functions
site as the calcaneonavicular ligament, is the as a restraint against excessive pronation.
guide muscle for the talonavicular joint space
proximally and the cuneonavicular joint space Insertions of the Lateral Collateral Ligaments
distally. The anterior talofibular ligament runs anteriorly
- The tibionavicular ligament (of the deltoid) to the neck of the talus. This ligament is com-
from the medial malleolus monly injured in ankle sprains.
 394 Palpation Field ofthe Foot

CD Neck of talus
Sinus tarsi
Lateral malleolus
® Cuboid bone
Cuneiform bone
Poster ior process of t alus,_t---~ ~~;r-"""7"-"""'7- Metata rsa ls
Latera l process 01 talus -+----------'~

®2 -----T----.,.-----\II~,
,. ,
Peroneal trochlea
(troch lea r process)

r - - - - - -............ t-----------+-'~-·-.."""""'-
Tuber calcanei @ ® Metatarsophalangeal joint
Tuberosity of the of the small toe
fifth metatarsal
Fig. 285 a. Lateral border of the foot: joint contour and palpation points (after Lanz-Wachsmuth)

The calcaneofibular ligament descends to its tu- - The peroneus brevis tendon superiorly
bercle of insertion on the lateral aspect of the - The peroneus longus tendon inferiorly
calcaneus. The peroneus tendons are palpable
behind the ligament.
3) Cuboid Bone
The posterior talofibular ligament runs posteri-
The following structures are palpable about the
orly to the lateral tubercle of the posterior pro-
cuboid:
cess of the talus.
The ligaments are made tense (provocative test) - Lateral: The tendons of peroneus longus (in
by supination of the foot. Additionally the ante- the sulcus) and abductor digiti minimi.
rior talofibular ligament is tightened by plantar - Proximal: The calcaneocuboid joint, the later-
flexion, and the posterior talofibular ligament al end of the transverse tarsal joint line.
by dorsiflexion. - Distal: The metatarsocuboid joint, the lateral
Posterior to the lateral malleolus is the sulcus end of the tarsometatarsal joint line.
malleoli lateralis with the sheath and retinacu-
lum for the peroneus tendons. Recurrent tendon 4) Tuberosity of the Fifth Metatarsal
dislocations can occur in this area. The insertion of the peroneus brevis is palpated
along with the bursa over the tuberosity, which
2) Peroneal Trochlea often becomes inflamed due to pressure ("tai-
This is located inferior and slightly anterior to lor's bursitis").
the tip of the lateral malleolus and is analogous
to the sustentaculum tali on the medial side. The 5) Metatarsophalangeal Joint of the SmaU Toe
following structures are palpable in the trochlea: The insertions of abductor digiti quinti and op-
ponens digiti quinti are palpable at this site.
 G) Lateral malleolus II ';; ' 1,4 "iii ® Tarsometatarsal jOint
(metatarsocuboid joint)
Peroneus brevis }-Tendon sheath
in sulcus
Peroneus longus malleoli lateralis
Peroneus tertius
CD Posterior talofibular ligament J/

CD Calcaneofibular ligament -ft1

Inferior peroneal retinaculum I \ ', . /'

II>
ig.
®
Peroneal trochlea " =
of calcaneus ~
(troch lear process) ® e
...
Metatarsophalengeal joint f
of small toe ~
s.
o Tuberosity of fifth metatarsal
UJ
\0
Fig. 285 b. Lateral border of the foot : anatomic structures and palpation points (after Lanz-Wachsmuth) VI
396 Palpation Field ofthe Foot

._----,+------f1\ Joint space

\V of the ankle
® ._- - - ' + - - - -- - ® Neck of talus
Sinus tarsi \
Traverse tarsal joint ___ ./
-------~
Cuboid bone - - - - -- - - - - + - - - - - - Navicular bone
Tarsometatarsal joint , )
'-, --4--===?TJ=i~
::::t---- Cuneiform bone

" ' . . . .r-----+--c,

.. ------ -® Dorsal artery of the foot
Tarsometatarsal (Lisfranc's) joint line

--....:..!--'---=~.----------I----- Metatarsals

Fig. 286 a. Dorsum of the foot: joint contour and palpation points (after Lanz-Wachsmuth)

3.3 Dorsum of the Foot (Fig. 286) ful following disruption of the ankle mor-
tise.
1) Ankle Joint Space
Palpation is performed with the foot in plantar Distal
flexion and slight supination. The distal reflection of the joint capsule is locat-
ed at the junction of the neck and trochlear sur-
Proximal face of the talus. The ankle joint capsule is pal-
The proximal reflection of the talocrural joint pable only if it is painful or has undergone
capsule is palpable above the joint line on the inflammatory change.
tibia. It may be tender and enlarged as a result of
effusion, chronic inflammation, chondroma to- 2) Neck ortbe TaJus
sis, or osteochondritis dissecans. The foot is plantar flexed for palpation of the
The anterior tibiofibular ligament is very pain- neck of the talus. The insertion of the deltoid lig-
 Palpation Field ofthe Foot 397

Extensor digitorum longus ------H~~ ~+-~r------ Tibia l is ante rior

1"t---t-7'-:7-~\---- Extensor hallucis longus
..y!t---- - -Joint capsu le

CD Anterior tibiofibular ligament - ----'lk'<-- )

CD
Joint space
of the angle
® ------ - Joi nt capsule on
the talus
Sinus tarsi - - - -----
® Neck of the talus
@ Extensor digitorum brevis o Extensor tendons
@ Tibialis anterior

Extensor h allucis longus

@ Extensor digitorum longus tendon sheath

® Dorsal artery
of the foot 8) Extensor hallucis brevis

Fig. 286 b. Dorsum of the foot: anatomic structures and palpation points (after Lanz-Wachsmuth)

ament (anterior tibiotalar band) is palpable me- - Inferiorly: the superior surface of the calca-
dially, and that of the anterior talofibular liga- neus and the calcaneocuboid joint with the
ment is palpable laterally. Sometimes a bone origin of extensor digitorum brevis.
spur is found at the attachment of the joint cap- - Medially: the lateral aspect of the neck of the
sule in competitive athletes. talus (easier to palpate during inversion of the
foot).
3) Sinus Tarsi - Deeply: the anterior talofibular ligament and
The sinus tarsi is a groove below the lateral the bifurcate ligament.
malleolus, lateral to the neck of the talus. The
following structures are palpable in the sinus:
398 Palpation Field ofthe Foot

Tenderness of the sinus tarsi occurs with frac- Rupture of the Achilles tendon is marked by the
tures and inflammations involving the anterior appearance of a recess approximately 3 cm
portion of the subtalar joint (talocalcaneonavic- above the tendon insertion. Rupture of the tri-
ular joint). ceps surae is marked by tenderness at the mid-
calflevel.
4) Extensor Tendons Effusions and chronic joint irritations are
The five dorsiflexors of the foot are, from medi- marked by palpable swellings adjacent to the
al to lateral: Achilles tendon.
- Tibialis anterior Palpable bony mass at the tendon insertion:
- Extensor hallucis longus superior (posterior) calcaneal spur.
- Extensor hallucis brevis With Achilles tenosynovitis, the site of maxi-
- Extensor digitorum longus mum tenderness is approximately 3 cm above
- Extensor digitorum brevis the tendon insertion.
The short extensors have their origin in the sinus
Laterally
tarsi and the lateral portion of the cruciform liga-
Bilateral tenderness occurs with fractures of the
ment (inferior extensor retinaculum). Shoe pres-
calcaneus (swelling, widening ofthe bone). U ni-
sure can affect the tendons of the tibialis anterior
lateral tenderness can occur in Sl syndrome.
at the tibia and the tendon of extensor hallucis
longus dorsally at the navicular and cuneiform
Inferiorly
bones. Tenderness of the extensor tendons also
The medial process of the tuber calcanei bears
occurs with chronic joint inflammations. Fine
the body weight. The following ligaments and
crepitus during motion is suggestive of tendo-
muscles insert on the medial process (from prox-
vaginitis, coarse crepitation of osteoarthritis.
imal to distal):
A space-occupying process in the tibialis anterior
compartment can lead to pain in the pretibial re- - The plantar aponeurosis, whose fanlike ex-
gion and eventual dysesthesia and paresis of the pansions radiate to the metatarsal heads
foot and toe extensors, with associated sensory - The long plantar ligament, which runs to the
disturbances between the first and second toes. bases of the metatarsals
- The plantar calcaneonavicular ligament,
5) Dorsal Artery ofthe Foot which runs to the plantar side of the navicular
Pulsations of the dorsal pedal artery are palpa- - The abductor hallucis (from the medial pro-
ble between the tendons of extensor hallucis cess of the tuber calcanei)
longus and extensor digitorum longus in the first - The flexor digitorum brevis (also from the me-
interosseous space. dial process)
A painful bony spur and bursitis sometimes
3.4 Sole of the Foot (Fig. 287) develop at the attachment of the plantar
aponeurosis (inferior plantar calcaneal spur).
1) Plantar Skin Calcaneal apophysitis causes tenderness
See Sect. 1.3. (Haglund heel).

2) Tuber Calcanei
3) Metatarsals
The following structures are palpable about the
tuber calcanei: Muscle Insertions
On the base of the first metatarsal:
Superiorly
Insertion of the Achilles tendon with the - Tibialis anterior (also on the medial
Achilles bursa lateral to the tendon and the sub- cuneiform)
achilleal bursa below it. - Peroneus longus
 Palpation Field ofthe Foot 399

On the base ofthe first proximal phalanx: Freiberg disease) or with synovitis in early
- Abductor hallucis rheumatoid arthritis. Tenderness of the first
through fourth metatarsals occurs with fatigue
On the base (tuberosity) of the fifth metatarsal: fractures.
- Peroneus brevis
4) Morton's Neuralgia
On the base of the fifth proximal phalanx:
- Abductor digiti minimi This refers to neuralgic pain between the sec-
ond through fourth metatarsal heads due to the
Tenderness of the second or third metatarsal entrapment of interdigital nerves (metatar-
head occurs with growth disturbances (Kohler- salgia).

® Achilles tendon

® Abductor hallucis

Ti bialis posterior -------,fL----1~

-----=---
®
Quadralus plantae

Payer's poi nt -....."..-=-.,.,:-;.----,----"I---+~-... ....,~I-'----:-----

Tuberosity of navicular

®
CD Plantar skin
Insertion of tibia lis ------- fi\ Palpation point
anterior and
peroneus longus
\,.~....-"--'~:-:r-:~-\.±I of Morton's neuralgia

® ®
--.+---- Insertion of abductor
Insertion of - - - - - - -..,---,r41 digiti minimi
abductor hallucis

® Metatarsals
® KOhler-Freiberg disease
(growth disturbance)

Fig.287. Sole of the foot: anatomic structures and palpation points (after Lanz-Wachsmuth)
400 Tests of Joint Translation

5) Payer's Venous Pressure Point anterior, the index finger posterior) and tests the
This tender point is located over the center of the anteroposterior play of the distal end of the fibu-
longitudinal arch on the medial side during pas- la (Fig. 288 a).
sive dorsiflexion of the great toe. Striking the sole If pain or limited motion is detected, the superi-
of the foot with the edge of the hand is painful or tibiofibular joint is also tested (Fig. 288 b; see
with deep venous thrombosis of the lower leg. E/Knee Joint/Sect. 4.5, p. 369). Both joints can also
be tested in the prone or semisitting position.

4.2 Tarsal Joints (Ten Tests)

4 Tests of Joint Translation (Figs. 289-294)
The following joints are tested (see Fig. 289):
4.1 Inferior Tibiofibular Joint (Distal
Tibiofibular Syndesmosis)
- Distal tarsal joints
4.2 Tarsal Joints (Ten Tests)
- Transverse tarsal joint (talonavicular and cal-
4.3 Metatarsal Joints (Five Tests)
caneocuboid joints, Chopart's joint line)
4.4 PhalangeaIJoints (Five Tests)
- Subtalar joint
- Ankle (talocrural) joint
The techniques below are described for exami-
The tests are performed in four groups:
nation of the right foot.
- Distal tarsal joints (tests 1-3)
- Joints at the medial border of the foot
4.1 Inferior Tibiofibular Joint (Distal (tests 4, 5)
Tibiofibular Syndesmosis) (Fig. 288 a) - Joint at the lateral border of the foot (test 6)
- Ankle and subtalar joints (tests 7-10)
Starting Position In each case the proximal joint member is immo-
Supine with the knee flexed about 90°. The foot bilized while translation is tested. For testing the
is placed on the examination table or supported distal tarsal joints, the lateral or intermediate
against the examiner's body. The examiner's cuneiform is immobilized.
right hand grasps the ankle from the medial side In contrast to the tests on the carpal joints,
and holds it stationary on the table. Kaltenborn included testing of the tar-
sometatarsal joints in the tarsal series even
Procedure though they are counted among the metatarsal
The left hand grasps the fibula betwen the joints (q. v.).
thumb and index finger (the thumb and thenar

Fig. 288 a, b. Tibiofibular joints. a Superior, b inferior

 Tests of Joint Translation 401

Tarsal jOints
(1 O-part test)

Ankle and subtalar joints (4)

• •
Tarsal joints

(1) lateral
--+
1 • •
(3) Distal jOints

Met atar sal j oints

5-~

Phalangeal j oints
4~5
3
2
4~5
3

Fig. 289. Tests of joint translation in the foot (overview). The numbers in the area of the tarsal joints correspond
to the sequence of the examinations in the " 10 test"
• = Stationary joint member
+- = Movingjoint 2/3 = Dorsoplantar gliding
1 = Traction 4/5 = Mediolateral gliding

Distal Tarsal Joints: Tests 1-3 (Fig. 290) thumbs on the plantar side (or vice-versa). For
test 1 he immobilizes the lateral cuneiform at its
Starting Position articulation with the cuboid while the other
Supine. The knee is slightly flexed over a roll, hand grasps the cuboid from the lateral side be-
and the heel of the examined foot is placed on tween the thumb and index finger and tests
the table or supported against the examiner's dorsovolar gliding in the joint.
body. The photographs illustrate the technique For test 2, the right hand "slips" medially (on the
for the right foot. right foot) and immobilizes the intermediate
cuneiform while the left hand grasps and tests
Procedure (Fig. 290) the lateral cuneiform from the lateral side. For
The examiner stands distal to the foot and grasps test 3, the lateral (left) hand immobilizes the in-
it from the medial and lateral sides with both termediate cuneiform while the medial hand
hands, the fingers on the dorsal side and the now grasps and moves the medial cuneiform.
402 Tests of Joint Translation

Fig. 290 a-g. The joints in the distal row of tarsal bones
(3):
Test 1: Lateral cuneiform and navicular-cuboid (a-c)
Test 2: Intermediate cuneiform-lateral cuneiform
(d,e)
Test 3: Intermediate cuneiform-medial cuneiform
(f,g)
 Tests of Joint Translation 403

It should be noted that the gliding planes for Starting Position

these first three tests converge from the dorsal to The lateral border of the foot is steadied against
the plantar side due to the wedge shape of the the examiner's body.
cuneiforms.
The sequence, then, is as follows: Procedure

• Test 1 (Fig. 290 a-c): Fix the lateral cuneiform • Test 4 (Fig. 291 a,b): Fix the navicular, test dor-
(and possibly the navicular), test dorsoplantar soplantar gliding of the three cuneiforms (sep-
gliding of the cuboid. arately as illustrated, or together).

• Test 2 (Fig.290d,e): Fix the intermediate cu- • Test 5 (Fig. 291 c,d): Fix the talus, test dorso-
neiform, test dorsoplantar gliding of the later- plantar gliding of the navicular. The hand
al cuneiform. placement for tests 4 and 5 is the same, except
that the immobilizing and mobilizing hands
• Test 3 (Fig.290f,g): Fix the intermediate cu- are placed more proximally.
neiform, test dorsoplantar gliding of the medi-
al cuneiform.
One Joint at the Lateral Border of the Foot:
Test 6 (Fig. 292)
Joints at the Medial Border ofthe Foot:
Tests 4 and 5 (Fig. 291)

Fig.291a-d. Joints at the medial borderofthe foot (2). Test 5: Talus-navicular (c, d)
Test 4: Navicular-cuneiforms. (a, b)
 404 Tests of Joint Translation

a a

b
Fig.292a,b. Joint at the lateral border of thefoot (1).
Test 6: Calcaneus-cuboid

Starting Position
The examiner stands opposite the patient (pho-
to) or on the lateral side of the foot.

Procedure
One hand hold the calcaneus from behind while
the other hand grasps the cuboid from the later-
al side. The fingers are on the dorsum of the foot c
and the thumb on the plantar side, grasping the
cuboid directly at its articulation with the calca-
neus.

• Test 6 (Fig. 292): Fix the calcaneus, test dorso-

plantar gliding of the cuboid.

Ankle and Subtalar Joints: Tests 7-10 (Figs.

293,294) (Traction and Gliding)
Starting Position
The examiner stands opposite the patient. d
Again, the photographs illustrate the technique Fig.293a~. Subtalar joint (2).
for the right foot. Test 7: Distal displacement of the calcaneus (traction)
(a,b)
Procedure: Subtalar Joint (Fig. 293) Test 8: Mediolateral displacement of the calcaneus
The patient's leg is in slight external rotation. (c,d)
The foot projects past the edge of the table.
 Tests of Joint Translation 405

8 _ __ _ __

b l___ _ _ ____
d

Fig.294a-e. Ankle joint (2).

Test 9: Distal displacement of the talus (traction) (a, b)
Test 10: Anteroposterior gliding of the lower leg (fore-
foot immobilized) in various flexion angles (c, d). Total
mobility (forefoot not immobilized) (e) e

One hand grasps the ankle joint from braced in this posItion against the exami-
above, placing the index finger over the supe- ner's thigh. The other hand grips the patient's
rior and medial surface of the head of the talus calcaneus from below and performs the motion
("pistol grip"). The foot is now dorsiflexed tests:
to fix the talus in the ankle mortise without
restricting movement of the calcaneus by • Test 7 (Fig. 293 a,b): Apply distal traction to the
tension from the triceps surae (especially if calcaneus.
this muscle is shortened). The forefoot is
406 Tests of Joint Translation

• Test 8 (Fig. 293 c,d): Test mediolateral gliding hand). Meanwhile, it is logical from an anatomic
of the calcaneus. standpoint to omit the somewhat artificial inclu-
sion of the tarsometatarsal joints in the ten-part
test, as these joints actually belong to the
Procedure: Ankle Joint (Fig. 294)
metatarsal region.
• Test 9 (Fig. 294 a,b): Apply distal traction to the
talus Both hands grasp the forefoot with an Summary
overlapping grip, placing the small fingers on A ten-part test that is confined strictly to the
the head of the talus and the thumbs on the tarsal joints should proceed in the following se-
plantar side. The leg is extended, and the foot quence (in each case the immobilized bone is
is in slight plantar flexion so that caudal dis- listed first):
placement of the talus is not restricted by tight-
1. Distal tarsus
ening of the Achilles tendon or by wedging of
- Test1: Cuboid-lateral cuneiform' (Fig.290
the talus in the ankle mortise.
a-c)
- Test 2: Intermediate cuneiform-lateral
• Test 10 (Fig. 294c,d): Test anteroposterior glid-
cuneiform (Fig. 290 d, e)
ing of the lower leg.
- Test 3: Intermediate cuneiform-medial
Starting Position. The knee is flexed approxi-
cuneiform (Fig. 290 f, g)
mately 90°. The heel is steadied by holding it on
the table. The examiner grasps the forefoot with
2. Medial border of the foot
one hand and permits concomitant dorsoplantar
- Test 4: Navicular-medial through lateral
motion of the foot during the test to evaluate to-
cuneiforms (Fig. 291a,b)
tal angular displacement (Fig. 294 e). He can
- Test 5: Talus-navicular (Fig. 291 c,d)
also fix the forefoot in various flexion angles rel-
ative to the lower leg to test straight translation-
3. Lateral border of the foot
al gliding in a given joint position (Fig. 294 c,d).
- Test 6: Calcaneus-cuboid (Fig. 292)
Procednre. The other hand grasps the lower leg
from the front, placing the thenar and hy-
4. Ankle and subtalar joints
pothenar near the joint on the tibial margin, and
- Test 7: Talus-calcaneus traction (Fig.292
tests anteroposterior gliding.
a,b)
- Test 8: Talus-calcaneus mediolateral gliding
• Note (Fig. 293 c,d)
The author has found that the ten-part test for
- Test 9: Crus-talus traction (Fig. 294a,b)
the tarsus first published by Kaltenborn does not
- Test 10: Talus-crus anteroposterior gliding
always satisfy clinical requirements, especially
(Fig. 294 c-e)
in examinations of the injured foot (bony and
ligamentous injuries). The joints between the
cuneiforms, the only true arched construction in
the foot (due mainly to the wedge shape of the 4.3 Metatarsal Joints (Five Tests)
intermediate cuneiform), are not examined at (Figs. 295-299)
all. It also may be necessary to test the articula-
tion between the cuboid and the navicular, Test 1: Tarsometatarsal Joints: Traction
which are bound together by the bifurcate liga- Figure 295 a,b shows traction testing of the first
ment, separately from the lateral cuneiform (see tarsometatarsal joint, and Fig. 295 c-e shows dis-
test 1). It may additionally be necessary to test tal gliding in the intertarsal joints accompanying
the connections of the three cuneiforms with the traction on the second through fifth tar-
navicular individually, despite the fact that these sometatarsal joints. In this case the traction is
bones form a functional unit (much as the joint not applied adjacent to the joint line but at the
between the trapezium and trapezoid in the metatarsal head.
 Tests of Joint Translation 407

........ c

Fig. 295 a-e. Test 1: Tarsometatarsal joints: traction. a, b First tarsometatarsal joint, c-e second tarsometatarsal
joint (e traction applied with a different hand placement)

Test 2: Tarsometatarsal Joints: Dorsoplantar Procedure (Fig. 297 a-c)

Gliding The right hand grasps the foot in the same way
Figure 296a,b shows dorsoplantar gliding in the from the lateral side, the thenar on the third
first tarsometatarsal joint, Fig. 296 c in the sec- metatarsal, but is placed distal to the Lisfranc
ond, and Fig. 296 d,e in the fourth and fifth joints. line. In this position the hand moves the third
metatarsal relative to the second metatarsal in
the dorsoplantar plane. There are no concomi-
Test 3: Intermetatarsal Joints (Figs. 297, 298).
tant movements in the tarsometatarsal joints.
Starting Position All the intermetatarsal joints can be tested in
The examiner stands on the lateral side of the this way by shifting the hands medially and later-
foot with his back to the patient. The patient's ally, interchanging the mobilizing and immobi-
foot rests on the table. The photographs illus- lizing hands as required.
trate examination of the right foot. The left hand Figure 297c shows the same technique using a
grasps the metatarsus from the medial and prox- reverse hand placement.
imal sides, the thenar on the second metatarsal,
and immobilizes the foot on the table.
408 Tests of Joint Translation

Fig. 297 a-c. Test 3: Intermetatarsaljoints: dorsoplan-

tar gliding. a,b Second/third intermetatarsal joint,
c same test using reverse hand placement

...
Fig.296a~. Test 2: Tarsometatarsal joints: dorso-
plantar gliding. a, b First tarsometatarsal joint, c sec-
ond tarsometatarsal joint, d,e fourth and fifth tar-
sometatarsal joints
 Tests ofJoint Translation 409

Fig.299. Test 5: Transverse compression of the inter-

metatarsal joints (Gaensslen's test)

Test 4: Metatarsal Heads (Fig. 298) (inter-

metatarsal syndesmoses)
The hands are moved distally to test mobility be-
tween the metatarsal heads. This is a ligament
b
test rather than a joint test.
The foot may be grasped from the proximal
(Fig. 298 a-c) or distal side (Fig. 298 d).

Test 5: Transverse Compression of the Inter-

metatarsal Joints (Fig. 299) (Gaensslen's test)

4.4 Phalangeal Joints: Five Tests

(Figs. 300--302)
The techniques are illustrated for the right foot.

Starting Position
The examiner sits on the examination table and
grasps the patient's foot with the left hand from
the medial side. The thumb (dorsal) and index
finger (plantar) immobilize the selected proxi-
mal joint member. The tested joint should be in
the resting position of approximately 10° dorsal

Fig.298a-d. Test 4: Ligament test (deep transverse

metatarsal ligament ) and test of intermetatarsal bursa.
a-i: Dorsoplantar movement of the metatarsal heads,
d same test using reverse hand placement
410 Tests of Joint Translation

Fig. 300 a, b. Test 1: MP joint of the big toe. Traction on Fig.301a,b. Tests 2 and 3: Proximal phalanx, dorso-
the proximal phalanx plantar gliding

extension. The foot is fixed on the examination For tests 4 and 5, immobilization is applied in the
table, against the examiner's body, or with a mediolateral plane.
sandbag.
Tests 4 and 5 (Fig. 302): Mediolateral gliding.

Procedure Normal Findings

At each joint the right hand grasps the distal Gliding movements are clearly perceptible in
joint member from the distal side and performs the ankle and subtalar joints, the inter-
the following tests: metatarsal syndesmoses, and tbe phalangeal
joints. There is very slight mobility, or at least
Test 1 (Fig. 300): traction (distally) springiness, in the tarsal, tarsometatarsal, and
intermetatarsaljoints.
Tests 2 and 3 (Fig. 301): Dorsoplantar gliding.
 Resistance Testing of the Foot and Toe Muscles 411

Fig.303. Plantar flexors

Fig.302a,b. Tests 4 and 5: Proximal phalanx, medio-

lateral gliding

Fig.304. Tibialis posterior

5 Resistance Testing of the Foot Procedure

and Toe Muscles Resistance is applied to the sole of the foot in the
proximal direction while the patient pushes the
foot plantarward against the resistance. Drop-
5.1 Foot Muscles
ping of the point of the foot and flexion of the
5.2 Toe Muscles toes signify predominance of the auxiliary mus-
cles (Fig. 303).
Differentiation of the soleus is accomplished by
plantar flexion with the knee flexed (to deacti-
5.1 Foot Muscles (Figs. 303-308) vate the gastrocnemius muscles).
Differentiation of the tibialis posterior (Ls-S],
Plantar Flexors (Figs. 303-305) tibial nerve) is accomplished by supination in
Triceps surae (Sl-S2, tibial nerve), tibialis poste- plantar flexion (Fig. 304). The left hand immobi-
rior, plantaris. lizes the lower leg, or the foot projects past the
table edge and is plantar flexed.
Starting Position Resistance to plantar flexion and supination is
Supine with the knee in the neutral position. The applied at the medial border of the foot. The
examiner stands on the lateral side of the tested toes must be relaxed (to avoid substitution by
foot or distal to it. the long toe extensors).
412 Resistance Testing of the Foot and Toe Muscles

Fig.305. Peroneus longus Fig.307. Tibialis anterior

Fig.306. Dorsiflexors Fig.308. Peroneus tertius

Differentiation of the peroneus longus and brevis Procedure

(Ls-SJ, superficial peroneal nerve) is accom- The forefoot is immobilized by distal pressure
plished by pronation in plantar flexion (Fig. 305). while the patient attempts to raise the foot
Resistance to plantar flexion and pronation is against the applied resistance (Fig. 306).
applied at the lateral border of the foot. The toes Differentiation of the tibialis anterior (Lj-Ls,
must be relaxed (to avoid substitution by exten- deep peroneal nerve) is accomplished by supina-
sor digitorum longus). tion with dorsiflexion (Fig. 307).
Resistance to dorsiflexion and supination is
Dorsiflexors (Fig. 306-308) applied at the first metatarsal. The toe muscles
Tibialis anterior, extensor hallucis longus, exten- must be relaxed, especially extensor hallucis
sor digitorum longus, extensor hallucis brevis, longus.
extensor digitorum brevis, peroneus tertius. Differentiation of the peroneus tertius (Ls-S j , su-
perficial peroneal nerve) is accomplished by
Starting Position pronation with dorsiflexion (Fig. 308).
The lower leg is immobilized and the knee is ex- Resistance to dorsiflexion and pronation is ap-
tended, as for the plantar flexors. plied at the fifth metatarsal.
 Resistance Testing of the Foot and Toe Muscles 413

a b

Fig.309a,b. Resistance testing of the phalangeal muscles. aToe flexors, b toe extensors

5.2 Toe Muscles (Fig. 309) - Flexor digitorum brevis (Ls-SJ, medial plan-
tar nerve)
Flexors (Fig. 309 a) - Flexor hallucis longus (LS-S2' tibial nerve)
Starting Position
The leg is extended with the foot in the interme- Extensors (Dorsiflexors, see Fig. 309 b)
diate position.
Starting Position and Procedure
Same as for the flexors . Plantarward resistance is
Procedure
applied at the dorsal aspect of the proximal pha-
For each muscle the proximal joint member is
langes to test:
immobilized between the thumb and index fin-
ger. Resistance to the action of the muscle is ap- - Extensor digitorum brevis
plied at the distal joint member. - Extensor hallucis brevis
Dorsalward resistance is applied at the plantar
aspect of the proximal phalanx to test:
Resistance is applied at the distal phalanges to
- Lumbricales (LS-S3, medial and lateral plan- test:
tar nerves)
- Flexor hallucis brevis (Ls-SJ, medial and lat- - Extensor digitorum longus
eral plantar nerves) - Extensor hallucis longus

Resistance is applied at the middle phalanges All the muscles are supplied by the deep per-
(distal phalanx of the great toe) to test: oneal nerve (LS-Sl)'
Radiography
Special Diagnostic Procedures

The basic examination of the locomotive system

by means of inspection, the testing of active and
passive motion, and subtle palpation, in particu-
lar of joint mobility and the musculotendinous
apparatus, can do no more than indicate the im-
mediate functional disturbance. For a number of
symptoms a complete examination must there-
fore include the following additional examina-
tions:
Neurologic examination, including testing of re-
flexes, sensitivity, and motoricity, is to elicit pure-
ly neurologic causes. Examination of distur-
bances of coordination and of brain nerves is of-
ten also necessary to differentiate causes rooted
in peripheral nerves from those in the central
nervous system.
In some cases, examination of the vascular sys-
tem is essential to determine the ultimate cause
of a condition.
These examinations are not presented here,
however, since they are standard medical proce-
dures. The same is true of other supplementary
examinations, such as laboratory tests, histologi-
cal tissue examinations, and electrodiagnostics.
Of the radiographic examinations, which as a
rule are essential, only functional diagnosis of
the spine is presented here; this has proven itself
for years now as a reliable supplementary proce-
dure for verifying functional disturbances of the
spine. The standard works on radiology are also
a good source for reviewing the criteria for clari-
fying morphologic questions.
Radiography Radiographic Examinations

1 Rules for the Radiographic Examina-

tion ofthe Vertebral Column and the
Joints of the Extremities

12 Analysis of the X-Ray huage

3 Techniques for the Radiographic

Examination ofthe Vertebral Column
3.1 Anteroposterior Projection of the LPH
Region (after Gutmann)
3.2 Lateral Projection of the Lumbar Spine
3.3 Thoracic Spine
3.4 Anteroposterior Projection of the
Cervical Spine (after Sandberg-
Gutmann)
3.5 Anteroposterior Functional Views of the
Cervical Spine (with Sidebending)
3.6 Lateral Projection of the Cervical Spine
3.7 Lateral Functional Views of the Cervical
Spine (Forward and Backward Bending)
3.8 Arlen's Quantitative Technique for the
Functional Evaluation of the Cervical
Spine
418 Analysis ofthe X-Ray Image

The radiographic examination follows the phys- 4. Decubitus radiographs are indicated if struc-
ical examination in selected cases where addi- tural detail in the erect position does not permit
tional diagnostic information is needed to sup- a satisfactory diagnosis (motion unsharpness).
plement previous findings. The most commonly They are also used for more complicated special
used techniques are: projections (see Sect. 3.4, p. 431).
5. Special projections (coned views, tomograms,
1. Standard projections: radiographs taken in functional views, contrast films) should not be
the anteroposterior (sagittal) and lateral obtained routinely and are necessary only if the
(frontal) projections diagnosis cannot be established by the clinical
2. Special projections: views outside the stan- examination and standard projections, or if they
dard projections, such as views with tube an- are needed to confirm a clinical diagnosis with
gulation, functional radiographs (terminal po- significant therapeutic implications (indication
sition), and stress radiographs for surgery).
3. Contrast films to demonstrate cavities and The radiographs can be taken in the following
nonradiopaque structures: discograms, arthro- patient positions:
grams, myelograms, arteriograms, intra-
1. Decubitus (non-weight-bearing: supine,
osseous venograms
prone, lateral)
4. Body-section radiographs (tomograms, CT
2. Standing or sitting position (weight bearing)
scans) to establish the precise location and ex-
3. With (additional) weights applied
tent of a pathologic process
4. Stress radiographs of the extremity joints
5. Stereo radiographs for localizing intraarticular
(when pathologic hypermobility raises suspi-
loose bodies or foreign bodies
cion of a capsuloligamentous lesion)
5. In the terminal position of a movement (func-
tional views)

1 Rules for the Radiographic Radiographs of the extremity joints serve to

Examination of the Vertebral demonstrate morphologic changes that may be
traumatic, degenerative, inflammatory, or neo-
Column and the Joints plastic in origin. Stress radiographs employing
of the Extremities traction or parallel displacement of the articulat-
ing surfaces may be needed to demonstrate
pathologic hypermobility.
1. Full-length views (30 x 90-cm film size) are
needed only in exceptional cases. Their informa-
tion content does not justify the additional radi-
ation burden. 2 Analysis of the X-Ray Image
2. Detail views of the lumbar spine and pelvis
(LPH region) (30 x 40 cm anteroposterior, 20 x
40 cm lateral), the thoracic spine (20 x 40 em), The first step in analyzing the X-ray image is to
and cervical spine (18 x 24 cm) usually give ade- check the radiographic technique (orthograde
quate visualization of the most common sites of projection) in order to avoid misinterpretations
dysfunction (SIJ, hip joints, craniovertebral due to projection effects. This particularly ap-
joints) that have a significant impact on spinal plies to radiographs of the vertebral column.
posture. The systematic analysis consists of five stages:
3. Radiographs in an erect position (weight-bear-
ing position) are generally preferable to decubi- 1. The position (extremity joints) and posture
tus radiographs (recumbent, non-weight-bear- (vertebral column) of the bony structures ap-
ing position) in the standard anteroposterior pearing on the film
(AP) and lateral projections. 2. The shape of the individual bony structures
 Analysis ofthe X-Ray Image 419

3. The contours of the bones and joints preferably, 40 x 40-cm film. The pelvis is the base
4. The structure (density) of the bones of the vertebral column. Symptoms emanating
5. Soft-tissue changes from the SIJs, hip joints, and pubic symphysis
overlap with vertebral symptoms so frequently
Practical Approach to the Analysis that low back pain is apt to be misinterpreted,
of X-Ray Films and a pelvic survey film will have to be obtained
to clarify the diagnosis.
The following questions should be addressed: A 20 x 40-cm film size is adequate for a lateral
projection of the lumbar spine, making certain
1. Are the bony structures portrayed in a true or-
that the image includes the superior margin of
thograde projection, or is the projection faulty
the femoral heads (on which the pelvis is bal-
or imprecise?
anced). Centering the image on L4 is advanta-
2. If the projection is accurate, are there any de-
geous since most pathologic conditions occur in
viations of posture or position on the film
the lower lumbar segments.
(analysis of reference lines in the vertebral
The changes recorded on the standard projec-
column)?
tions are assigned to one of Jive musculoskeletal
3. Are there any morphologic changes (shape,
disease groups based on radiographic and other
contour, structure, soft-tissue changes) to
findings:
which these deviations can be referred?
4. Were these changes visible on previous radio- 1. Trauma
graphs, and what is their diagnostic signifi- 2. Degenerative conditions (osteoarthritis)
cance? 3. Symptomatic conditions of varying etiology
5. Are additional views needed to investigate a (arthropathies)
functional or morphologic abnormality, and if 4. Inflammatory conditions (arthritis)
so, what views? 5. Neoplasia
The need for a standard radiographic technique Every radiographic analysis includes making a
that satisfies diagnostic requirements is appar- record of the morphologic and functional abnor-
ent. The standard radiographs should be survey malities that are discovered. It is not sufficient
views that portray as much detail as possible. merely to state a diagnosis. Not only may the di-
They should convey both morphologic and func- agnosis be wrong, but a terse formulation does
tional information. The omission of important not permit findings to be compared with the
details (such as the SIJ or hip joints) does not of- findings of previous or subsequent radiographs
fer true radiation protection because it may taken by other examiners.
necessitate additional exposures, although the The discussions that follow should permit even
dose can be reduced by collimating the X-ray the nonradiologist to correlate the radiographic
field to a smaller size for investigating patholog- features of a dysfunction with the clinical find-
ic details. ings and to recognize morphologic deviations
I t is important to indicate whether the radiograph from normal radiographic anatomy. The precise
was taken in the decubitus, sitting, or standing interpretation of morphologic abnormalities, es-
position. This information is essential for a func- pecially rare forms, is reserved for the radiolo-
tional evaluation of the vertebral column. Except gist, orthopedist, or rheumatologist.
in cases where an inflammatory or other osteo-
lytic process is suspected, the radiographs should
be taken in an erect position (sitting for the cer-
vical spine), because the complaints associated
with most spinal disorders appear when the
patient assumes an upright posture.
The standard AP projection of the pelvis and
lumbar spine should be taken on a 30 x 40- or,
420 Radiographic Examination of the LPH Region, a. p. Projection

3 Techniques for the Radiographic 3. A slight lateral deviation of the pelvis is not
corrected. It should be noted that the pelvis
Examination of the Vertebral
may be slightly elevated on the side of the
Column shift without causing leg-length discrepancy
("trochanter phenorrienon" of Edinger). A
3.1 Anteroposterior Projection of the LPH marked pelvic shift should be compensated by
Region (after Gutmann) adjusting the position of the cassette. Any ro-
3.2 Lateral Projection of the Lumbar Spine tational deviation of the pelvis is left alone.
3.3 Thoracic Spine
3.4 Anteroposterior Projection of the Equipment Adjustments
Cervical Spine (After Sandberg-
Gutmann) 4. The lower border of the cassette should at
3.5 Anteroposterior Functional Views of the least pass through the center of the vertical di-
Cervical Spine (with Sidebending) mension of the pubic symphysis. In small pa-
3.6 Lateral Projection of the Cervical Spine tients it is placed even with the lower margin
3.7 Lateral Functional Views of the Cervical of the symphysis.
Spine (Forward and Backward Bending) 5. The central ray is at the level of the iliac crest
3.8 Arlen's Quantitative Technique for the (L4).
Functional Evaluation of the The PA view suggested by de Seze is advanta-
Cervical Spine geous over the AP view in that the beam diver-
gence gives a more orthogonal projection of the
intervertebral disk spaces. On the other hand,
Radiographs useful for the analysis of (static and some loss of structural detail generally occurs
dynamic) functional disturbances should be tak- due to the increased distance of the vertebral
en in the posture that is natural for the individu- column from the film plane, even with abdomi-
al patient. The views of the vertebral column nal compression. In this case better image quali-
described below are particularly useful for the ty can be obtained in the lithotomy position.
evaluation of morphologic and function details
in that region. Sequence ofthe X-Ray Analysis
1) Position of the pelvis
2) Sacroiliac joints
3.1 Anteroposterior Projection 3) Hip joints
of the LPH Region (After Gutmann) 4) Pubic symphysis
5) Lumbar spine
Technique
Standing position.
Film size 30 x 40 cm upright or 40 x 40 cm. Normal Findings (Fig. 310)
Focus-film distance 1-1.5 m. On the orthograde projection of the pelvis the
median sacral cre t and pubic symphysis are
Positioning in the median plane and are centered on the
midline of the film.
1. The feet are aligned on a cross frame whose
sagittal bar is at the center of the film (median
1) Position of the Pelvis
plane). The front bar of the frame is parallel to
The following reference lines are horizontal
the film plane.
and parallel to one another on an orthograde
2. The patient stands in a relaxed posture with
projection of the morphologically normal
the body weight distributed equally on both pelvis:
legs (have the patient stand for 1 min). The pa-
The femoral head line (FHL) passes through
tient may lean against the diaphragm. The
the superior margin of both femoral heads.
knees and hip joints are extended.
 Radiographic Examination of the LPH Region, a. p. Projection 421

__-t""'''t--~---- End plates

parallel

Parallel
,
't::::+tt:::-:::!{ ---/ /, Inferolatera l beaks symmetrical

position of: / Spinous processes on the

// midline
Iliac crestline '.J..-n:z:-..~ /' lel

SB

POL

FHL

Basal

Femoral neck ang le

Fig.310. Normal radiographic findings in the LPH region

The iliac crest line (ICL) connects the highest Thediameters (normaLly3--4 cm) are measured
points on both iliac crests. NormalJy this line at the level ofthe posterior iliac spine line. The
passes through the body of the fourth lumbar vertical SIJ diameters are equal on both sides.
vertebra. Both anterior contours of the SUs converge in
Thesacraf base (SB). the superolateral to inferomedial direction.
The posterior iliac spine line (PIL) connects
the inferior poles of the posterior superior ili- 3) Hip Jo;nts
acspines. Both hip joints display symmetric height and
The pelvic outlet line (POL) passes through shape. The femoral neck angle (CCD angle) is
the inferior border of both sacroiliac joints. 120°-130°.

2) Sacroiliac Joints (S1Js) 4) Pubic Symphysis

The horizontal diameter through both "SU The pubic symphysis displays a normal width
ovals" (ovals formed by the anterior and pos- and smooth borders. The pubic rami are at
terior joint boundaries) is equal on both sides. equal heights (no stepoff at the symphysis).
422 Radiographic Examination ofthe LPH Region, a. p. Projection

- Vertebral restriction involving the craniover-

5) Lumbar Spine
tebraljoints (less common)
VerticaJ alignment of the vertebra l bodie
- Congenital lumbar scoliosis (pelvic shift to-
with no tilting of the vertebrae and no disk-
ward the concavity)
space narrowing.
1.3) Pelvic Rotation
Pathologic Findings The median sacral crest and pubic symphysis are
A perpendicular line dropped from the external no longer on one line. The horizontal SIJ diame-
occipital protuberance (the "cranial plumb ters are unequal, i. e., widened on the side of the
line") normally lies on the median plane of the pelvis that is "twisted back."
body. Deviation toward one side indicates in- Pelvic rotation can result from:
creased loading ofthe leg on the side ofthe devi-
- Unilateral flexion contracture of the hip (the
ation.
hemipelvis on the contracted side rotates
backward)
a) Position of the Pelvis - Antalgic posture for a vertebral restriction or
disk prolapse in the lumbar spine
1.1) Pelvic Obliquity
- Vertebral restriction involving the craniover-
A unilateral tilt of all horizontal reference lines
tebral joints
toward the same side signifies an anatomic leg-
length discrepancy or acquired morphologic de-
fect caused by: 2) Sacroiliac Joints

- Deficient growth ofthe ipsilateral leg (may re- 2.1) Position

sult from paralysis during the growth period, See Position of the Pelvis.
poliomyelitis)
- Severe unilateral pes valgus or flatfoot 2.2) Shape
- Unilateral genu varum or valgum Different widths of the horizontal Sf] diameters
- Acetabular dysplasia (unilateral or affecting on an orthograde projection of the pelvis signify
one side more than the other) an SIJ sprain or anatomic asymmetry.
- Unilateral flattening of the femoral head Narrowing of the horizonal Sf] diameters
(e. g., in Perthes' disease) «2 cm) and vertical, nonconvergent sacroiliac
- Sequel to leg fracture joint lines are suspicious for SIJ instability (e. g.,
with a loose pelvis after Gutmann). Subchondral
Convergence of all the horizontal reference lines sclerosis of the articular surfaces is common in
toward the same side signifies a congenital or ac- longstanding cases.
quired growth deficiency involving one half of
the pelvis (paralysis). 2.3) Contours
Unilateral obliquity and convergence of the Radiographs may show signs of destruction,
FHL, fCL, and PfL with a horizontal femoral sclerosis, or ankylosis (Dihlmann) that can
head line and widened SIJ diameter in the lower serve to distinguish ankylosing spondylitis
hemipelvis suggests a sprain of the SIJ (loosen- (Bekhterev's disease) from other inflammatory
ing of the pelvic ring, SIJ displacement). The di- or degenerative conditions.
agnosis is established by clinical findings (mo- Destructive processes:
tion testing and palpation).
- Widening of the joint space (smooth borders)
due to posttraumatic joint instability
1.2) Pelvic Shift
- Pseudo-widening of the joint space (garland-
- SIJ sprain like, indistinct borders) due to Bekhterev's
- Antalgic posture for a vertebral restriction or disease (usually bilateral, with small string-of-
disk prolapse in the lumbar spine beads erosions); bacterial infection (usually
 Radiographic Examination of the LPH Region, a. p. Projection 423

affects only one side, with larger foci of ero- (Albers-Schoenberg disease), hyperparathy-
sion and osteolysis); gout; osteomalacia; hy- roidism
perparathyroidism - Bilateral iliac sclerosis due to ankylosing
spondylitis, chiefly in males. Additional signs:
Ankylosis:
elevated ESR, HLA factor positive, erosive
This type of immobility can result from intraar-
lesions in the joint space, no subchondral scle-
ticular or capsuloligamentous ossification.
rosis
- Traumatic following capsuloligamentous
Circular or bandlike forms:
tears
Ossification due to capsular strain. The ossifica-
- Congenital disorders (not accompanied by
tion covers the joint space. There are no erosive
signs of destruction)
lesions.
- Overuse pathology (no signs of destruction)
Circular forms:
- Ankylosing spondylitis (Bekhterev's disease):
Sites of destruction and sclerosis coexist with - Periarticular osteolytic foci are seen in inflam-
bridge-like bony bars or more general ossifi- matory conditions (osteomyelitis) and with
cation affecting the anterior joint space al- bone cysts (enchondroma, fibroma). Tenden-
most exclusively cy toward ankylosis in osteomyelitis
- Rheumatoid arthritis (with foci of osteoporo- - Densities about the eroded joint space with no
sis and erosion on tomograms but no signs of tendency toward ankylosis in circumscribed
sclerosis) sacroilitis (Dihlmann, SchOler)
Loosening ofthe pelvic ring versus pelvic rigidity
Osteoporosis with erosive joint-space lesions
can be diagnosed by. taking functional views of
(visible only on tomograms) and ankylosis are
the sacroiliac joint space in the oblique diameter
seen in rheumatoid arthritis. There is no evi-
and of the pubic symphysis in the axial projec-
dence of sclerosis.
tion while the patient shifts the body weight
from one leg to the other (Kamieth s technique).
The principal signs on these images are: unilat- 3) Hip Joints
eral descent of the sacral baseline in the nontilt-
3.1) Position
ed, symmetrically shaped pelvis accompanied by
The femoral heads are at unequal heights (see
a step of 1-2 mm at the pubic symphysis.
Pelvic Obliquity).
2.4) Structure (Density)
3.2) Shape
Sclerotic foci appear as triangular, circular, or
Femoral neck angle (CCD angle 1260 in adults,
bandlike ossifications in the area of the joint
up to 1440 in infants and small children).
space.
Coxa vara: decreased angle.
Triangular forms:
Coxa valga: increased angle due to limb shorten-
- Bilateral iliac shadows in ostitis condensans ing, amputation, paralysis, disease of the proxi-
ilii, most common in obese women (multi- mal femoral epiphysis, congenital dislocation of
parae). Additional signs: subchondral sclero- the hip, or rheumatoid arthritis.
sis at the joint line, no erosive lesions, spurring Flattening of the femoral head due to growth
of the inferior joint margin (static adaptive de- disturbances (Perthes' disease), epiphyseal
generative processes) plate separation, or inflammatory processes.
- Bilateral iliac sclerosis due to disease in the Abnormal shape of the acetabular roof: hip dys-
pressure-bearing zone of the SIJ, appearing plasia.
during the florid stage (compliance of the When unilateral, the foregoing changes can
bone) in Paget's disease of bone (osteodys- cause leg-length discrepancy with its associ-
trophia deformans), primary bone tumors, os- ated static effects on the SIJ and vertebral col-
teoplastic metastases, marble bone disease umn.
424 Radiographic Examination of the LPH Region, a. p. Projection

The rest ofthe hip evaluation is based on the car- - Symphyseal tuberculosis
dinal radiographic sign. - Pubic ostitis (rare)
- Aseptic necrosis
4) Pubic Symphysis
Neoplasia: osteolytic and osteoplastic metas-
Axial views are sometimes needed to demon-
tases.
strate the anterior and posterior surfaces of the
symphysis. These views clearly reveal relative
motion of one pubic ramus with respect to the 5) Lumbar Spine
other (weight shifted alternately to both legs) in
5.1) Lumbar Spinal Posture and Position of
cases where loosening of the pelvic ring is sus-
the Vertebral Bodies
pected.
Scoliotic postural faults (reversible scoliosis)
require differentiation from the irreversible de-
4.1) Position
formity of fixed scoliosis. In a morphologically
Pelvic radiographs demonstrate a step at the pu-
and functionally intact spinal column, the verte-
bic symphysis in approximately one-fifth of the
bral bodies form a smooth, even arch. So we
adult population. This is commonly associated
must distinguish between postural faults in-
with sacral pain. The symphyseal step generally
volving the entire vertebral region and a seg-
signifies laxness of the SUs. As noted above, lax-
mental fault involving one or more vertebral
ness vs. rigidity of the SUs can be differentiated
segments.
by functional radiographs of the SUs and sym-
Postural changes: The greater the degree of
physis with alternation of weight bearing
lumbar lordosis, the more pronounced the pos-
between the legs (Kamieth's technique). The in-
tural scoliosis. The postural fault is compen-
creased mobility frequently leads to degenera-
sated if the thoracolumbar and lumbosacral
tive changes in the pubic symphysis.
junctions are aligned on a common perpendicu-
lar.
4.2) Shape
- Mild scoliosis with a unilateral pelvic tilt: stat-
Changes in the width of the pubic symphysis can
ic scoliosis due to an anatomic or functional
result from:
leg-length discrepancy
- Traumatic diastasis (with other signs of in- - Scoliosis with a horizontal pelvis and oblique
jury) sacral base: static scoliosis due to sacral asym-
- Birth trauma (with no other signs of injury) metry
- Hormonal influences - Scoliosis with a horizontal pelvis and sacral
- Multiparity (slight) base: usually congenital due to a wedge-
- Gracilis syndrome in competitive athletes shaped vertebral deformity (most commonly
(contour defect at the attachment of the gra- LS) but occasionally due to a craniovertebral
cilis with a zone of increased density and evi- joint restriction
dence of symphyseal laxness and cartilage - Severe scoliosis with a horizontal but rotated
wear) pelvis: lumbar herniated disk

Degenerative changes with osteoarthritic fea- Segmental vertebral position fault: This almost
tures are seen in ochronotic osteoarthropathy, always results from changes in the intervertebral
while more arthritic changes are found in renal disk or asymmetry of the vertebral body. Sym-
osteopathy and hyperparathyroidism. metric or asymmetric disk-space narrowing is
Inflammatory changes may be due to: common in the setting of degenerative and in-
flammatory conditions but is rather uncommon
- Rheumatoid arthritis
with injuries and neoplasms.
- Ankylosing spondylitis (late symptom)
- Local bacterial infection Symmetric disk-space narrowing with no verte-
- Hematogenous osteomyelitis bral position fault:
 Radiographic Examination of the LPH Region, a. p. Projection 425

- Disk hypoplasia Degenerative changes:

- Growth abnormalities, Scheuermann's dis- - Schmorl's nodes and end-plate irregularities
ease (associated with end-plate irregularities, in Scheuermann's disease
Schmorl's nodes, edge herniations) - Osteophyte formation in spondylosis defor-
- Postoperative disk-space narrowing (after mans. The osteophytes grow above the edge
surgery for disk prolapse) of the vertebral body and may not produce
- Chondrosis and osteochondrosis (end-plate disk-space narrowing. They often grow more
sclerosis) horizontally under the pressure of a displaced
- Spondylitis (end-plate defect, osteoporosis) disk.
- Forrestier's disease (hyperostotic spondylo-
Asymmetric disk-space narrowing with tilting of sis)
the vertebra:
- Disk prolapse Inflammatory changes:
- Vertebral restriction - Syndesmophytes in ankylosing spondylitis.
- Spondylolisthesis (with concomitant rotation They develop from the outer portion of the
of the vertebra toward the convexity of the anulus fibrosis, from the edge of the vertebral
scoliotic curve) body, and exhibit a more craniocaudal growth
pattern than osteophytes. The late form is a
Vertebral rotation is recognized from the follow- "bamboo stick" figure that generally does not
ingsigns: transgress the anterior longitudinal ligament
- Deviation of the spinous process and pedicle on the lateral projection.
away from the side to which the vertebra is ro- - Syndesmophytes in spinal osteomyelitis.
tated ' - Mixed osteophytes are syndesmophytes in a
- Widening of the pedicle on the side to which spine that has already undergone degenera-
the vertebra is rotated, and widening of the tive change. Their direction of growth is
vertebral edge segment projected through the mixed, consisting of a vertical and a horizontal
vertebral arch component. Parasyndesmophytes are horn-
- Better visualization of the joint space on the shaped bony excresences arising from the ver-
side to which the vertebra is rotated tebral body, often associated with paraspinal
- Shortening and narrowing of the transverse new bone formation that is separate from the
process on the side to which the vertebra is ro- vertebral body. Parasyndesmophytes occur in
tated psoriatic arthritis and Reiter's disease.

5.2) Shape Neoplasia:

Alterations in the shape of the vertebral bodies - Spiny or knobby excrescences due to pe-
are appreciated better in the lateral projection riosteal irritation by tumors (malignant osteo-
and are described under that heading. phytosis)
- Contour defects in the vertebral body and
5.3) Contour pedicle ("one-eyed" vertebra) or transverse
Traumatic changes: process due to neoplastic disease (metas-
- Depressed cortical outline due to fracture tases)
- Edge fragments
- Transverse process fractures 5.4) Structure (Density)
- Syndesmophyte formation (rare) as an ex- The structure of the lumbar vertebral bodies is
pression of reparative osteophytosis displayed best (clear of the vertebral arches) on
lateral radiographs and is discussed under that
heading.
426 Radiographic Examination ofthe Lumbar Spine, Lateral Projection

5.5) Soft-Tissue Changes

Normal Findings
Ossification of the ligaments about the vertebral
1) Pelvic Position (Fig. 311)
column is most conspicuous in ankylosing
Normal pelvi (after Gutmann): The sacral
spondylitis ("bamboo spine"). Ossification of
ba e angle (a) and the angle of the posterior
the supraspinal and in terspinal ligamen ts also oc-
sacral border (d) are approximately 45° with
curs as a response to excessive loading, and tho-
respect to the horizontal. The transver e axi
racic spinal involvement can occur in the setting
of the hip joint is atUerior to the sacral
ofhyperostotic spondylosis. Smoothly marginat-
promontory and to the cranial and ba al
ed, pinlike foci of fibro-ostosis are sometimes
plumb lines. The L4/L5 intervertebral disk is
seen on the spinous processes of older patients.
level with the iliac crest line.
The iliolumbar ligament may occasionally ossify.
The body load is distributed uniformly on the
L5/S1 disk. the a ociated facet joint, and the
superior pole of the SlJ. Disorders may affect
3.2 Lateral Projection of the Lumbar the disk itself (protru ion. prolapse), the
Spine L5/S1 facet joint, or the SlJ (re trictions).
Technique
Spinal Posture
Standing position.
The cranial plumb line (perpendicular from
Film size 20 x 40 cm upright.
the external auditory meatus) and the basal
Focus-film distance 1-1.5 m.
plumb line (1 cm anterior to the ankle mor-
If low-power X-ray equipment is used, or if it is
tise) coincide, both passing through the
necessary to bring out structural details, the ex-
femoral head. The thoracolumbar junction is
posure can be taken in the recumbent position.
slightly more po terior than the lumbosacral
junction.
Positioning
1. The feet are aligned with a cross frame as for
2) Vertebral Posilion
the anteroposterior projection (see p.420).
The vertebral bodies form a mooth arc with
2. The patient's heels should be at the same level
no teps in the anterior and po terior verte-
on the sagittal bar of the positioning frame.
bral body contour or in the line ofthespinous
The medial malleoli should be approximately
proce e and no tilting of the vertebrae.
2 cm behind the front bar of the frame (cranial
plumb line). The patient may lean lightly
3) Vertebral Shape
against the film support.
o pathologic deviation .
3. Lateral deviations are left alone, but pelvic ro-
tation is corrected.
4) Vertebral Contours
The po terior border of the vertebral bodie
Equipment Adjustments
should not present a double contour (which
4. The lower border of the cassette should be
would signify vertebral rotation) or steplike
level with the greater trochanters (to demon-
discontinuities.
strate the femoral heads).
5. The exposure is cen tered on the iliac crest (L4) .
5) Vertebral StruclIIre
o changes in trabecular structure or calcium
Sequence of the X-Ray Analysis
content.
1) Pelvic position and spinal posture
2) Position of the vertebrae
6) Sofl- Tissue Challges
3) Shape ofthe vertebrae
o calcifications or ossifications.
4) Vertebral contours
5) Vertebral structure
6) Soft-tissue changes
 Radiographic Examination of the Lumbar Spine, Lateral Projection 427

Cranial + basal Fig.311. Neutral (normal) pelvis.

plumb line 0= 3S°-4So,
a = 35°--4So
H = Hip joint slightly anterior to the promontory
L = Main load: posterior portion ofthe L5/S 1 disk
Mechanical disturbances apt to occur in this con-
figuration:
Restriction of facet joints
Restriction of sacroiliac joints
Neutral (normal) pelvis
Posterior expulsion of nucleus pulposus
Posterior muscular fixation

Basal plumb line Cranial plumb fine

Ll
Fig. 312. Horizontal ("osteoarthritic") pelvis (after Gut-
mann). Horizontal pelvis
0= 1so-30°, a = 45°-70° '
H = Hip joint below S1 or S2, i. e., posterior to the
promontory
L = Load is concentrated on the joints: LS/S1, SIJ, hip
With aging, the upper body stoops forward (cranial
plumb line moves forward), placing greater stress on
the joints ofthe knees and feet.
(Schemati representation showing major tendencies)
Cranial + basal ~
plumb line ~

Upright pelvis

Fig. 313. Upright ("osteochondrotic") pelvis (after Gut-

mann).
o = Sacral slope angle (posterior border of Sj, S2lhori-
zontal) Soo-70°,
a = Sacral base angle (after Leger) 1so-30°
H = Transverse axis of hip joint well in front of the
promontory
L = Main load: central portion of LS/S1 disk
Mechanical disturbances apt to occur in this configura-
tion:
Excessive wear of LS/S1 disk, osteochondrosis at L5/S1
L5/S1 motion segment laxness, posterior displacement of
L5
Lumbosacroiliac instability
(Schematic representation showing major tendencies)
428 Radiographic Examination ofthe Lumbar Spine, Lateral Projection

Pathologic Findings curvatures ofthe spine (at C2, C7, Ll, and Sl) lie
on the static axis. If deviations from the physio-
1) Pelvic Position logic curvatures are noted, their etiology must
Horizontal pelvis ("overloaded" or "os- be determined. Absence of the physiologic lum-
teoarthritic" pelvis). Radiographic signs (see bar lordosis is considered pathologic.
Fig.312): Decreased lordosis (hypolordosis) is seen with:
- The sacrum is nearly horizontal, with a low - An upright pelvis
promontory. - Intervertebral disk prolapse
- The cranial and basal plumb lines are anterior - Lax vertebrae
to the transverse hip axis and do not coincide. - Restricted vertebrae
- ,) angle = 15°_30°,a angle = 45°-70°. - Scheuermann's disease in the lumbar spine
- The L5 vertebral body and L5/S1 disk are
wedge shaped. Increased lordosis (hyperlordosis) is seen with:
- The L4/L5 disk space is below the iliac crest
- Sacrum acutum (identical to overloaded
line.
pelvis?)
- Increased lumbar lordosis.
- SIJ sprain with psoas hypertonicity
There is increased loading of the joints (L5/S1 - Flexion contracture of the hip joint
facet joints, superior pole of SIJ, hip joint) with - Abdominal muscle weakness (shortened
osteoarthritic degeneration. This may eventual- erector spinae)
ly lead to forward stooping of the upper body - Trophostatic syndrome in postmenopausal
with increased joint loading at the knees and women
feet. - Obesity
Upright pelvis (steep, vertical, or osteochondrot- - Pregnancy
ic pelvis after Gutmann), high assimilation
pelvis (Erdmann). Radiographic signs (see 2) Vertebral Position
Fig. 313): More important than a postural deviation is the
segmental position fault. Normally the interver-
- The sacrum is nearly vertical, with a high
tebral disk conforms to the curvature of the
promontory.
spinal column, i. e., higher anteriorly than poste-
- The cranial and basal plumb lines are well be-
riorly in lordotic areas and higher posteriorly in
hind the transverse hip axis and roughly coin-
kyphotic areas.
cide.
Segmental straightening or kyphotic tilting with
- ,) angle = 50°-70°, a angle = 15°-30°.
posterior gaping of the disk space is usually
- Rectangular L5 vertebral body, high L5/S1
caused by the posterior protrusion or prolapse of
disk space.
disk material. Widening of the posterior disk
- The superior margin of the L5 vertebral body
space and intervertebral foramina creates addi-
is above the iliac crest line.
tional room for the disk tissue (nucleus pulpo-
- Decreased lumbar lordosis (straight lumbar
sus) to occupy, thereby relieving pressure on the
spine).
nerve roots. With a unilateral protrusion, the AP
This configuration concentrates stress on the radiograph will also demonstrate vertebral rota-
L5/S1 disk, leading to excessive disk wear and tion, which again serves a decompressive func-
lumbosacral instability (motion segment lax- tion.
ness). The same significance is attributed to the
straightening of several vertebrae (Guntz's sign)
Spinal Posture over a lax vertebral segment. Potential causes
The curvatures of the morphologically and func- include traumatic, inflammatory, and neoplastic
tionally intact vertebral column are smooth and changes as well as reflex locking by a restriction
uniform. The transition points of the physiologic in the facet joints.
 Radiographic Examination of the Lumbar Spine, Lateral Projection 429

A step created by anterior or posterior displace- 3) Shape ofthe Vertebrae

ment in a segment is always a pathologic finding. Tall vertebrae (increased vertical diameter) re-
Functional views in the terminal positions of for- sult from deficient loading or as a compensatory
ward and backward bending are necessary to de- response to the destruction of adjacent verte-
termine whether the vertebral displacement is brae during the growth period.
fixed or labile. Persistence of the step with ex- Short vertebrae of diminished height occur con-
treme flexion and extension indicates a fixed po- genitally (chondrodystrophy) or may be ac-
sition fault. Similarly, the absence of disk distor- quired due to destructive vertebral processes
tion at the limits of the movements indicates such as trauma (which usually produces contour
significant disk degeneration even if the height changes) and Scheuermann's disease (short and
reduction is not yet pronounced. wedge-shaped vertebrae).
A more severe posterior or anterior slip (spondy- Wedge-shaped vertebrae with no structural ab-
lolisthesis) typically occurs at the level of the normalities are usually congenital. They appear
fourth or fifth lumbar vertebra. The anterior slip as posterior hemivertebrae on the lateral projec-
is caused by a separation (spondylolysis) or dys- tion or lateral hemivertebrae on the AP projec-
plasia (pseudospondylolisthesis) of the pars in- tion.
terarticularis. The condition may be congenital Wedge-shaped vertebrae may be acquired trau-
or acquired. Because the laminar arch of the af- matically in a hyperflexion injury of the spine. In
fected vertebra remains in place while the verte- spontaneous fractures, a search must be made
bral body slips forward, the anterior displace- for structural alterations (inflammation or
ment (of the spinous process) is palpable only in metastasis). Osteolytic processes almost always
the segment above. lead to gibbus formation that is apparent on X-
Pseudospondylolisthesis (Junghanns) denotes a rays but often not externally.
slip resulting from hypoplasia of the articular In box vertebrae the walls of the vertebral body
processes or degenerative changes in the facet have become straightened by marginal osteo-
joints in the setting of osteochondrosis. phytosis.
Radiographic features: Spondylolisthesis is Barrel-shaped vertebrae (with a bulging anterior
marked by a step in the line of the vertebral surface) can result from:
bodies and a "collar" (retrosomatic defect) or
- Trauma
"chest band" figure (retroisthmic defect) in
- Endochondral dystosis
"Lachapele's dog" on the oblique projection.
- Scheuermann's growth disturbance
Pars dysplasia presents as a "dog with a long
- Ankylosing spondylitis
neck."
Posterior slip (retrospondylolisthesis) also oc- In ftsh vertebrae the weakened end plates have
curs as a result of disk degeneration. Due to the become bowed inward by pressure from the nu-
reduced height of the disk space, the upper ver- cleus pulposus. Osteoporosis is usually present
tebra slips slightly backward on the facet joint as an underlying disease.
surface, producing a posterior step in the line of Cleft vertebrae (appearing as "butterfly verte-
the vertebral bodies. brae" in the AP projection) and hemivertebrae
"Pseudo-retrospondylolisthesis" (Dihlmann) are congenital anomalies.
refers to an apparent posterior slip, unassociated Block vertebrae result from the synostosis of two
with disk degeneration, caused by a disparity in or more vertebrae due to absence or destruction
the sagittal diameters ofLS and S1. This is detect- of the intervertebral disk (often with narrow in-
ed radiographically by noting that the upper ar- tervertebral foramina). With congenital block
ticular process of S1 does not approach the arch vertebrae, the vertebral arches and spinous pro-
of LS as it does in true retrospondylolisthesis. cesses are also fused. With acquired block verte-
Contact between the spinous processes ("kissing brae secondary to trauma or inflammatory dis-
spines," Baastrup phenomenon) results from ease, the vertebral arches are separate, the disk
hyperlordosis with an overloaded pelvis. is hypoplastic, and the joint space is absent. Ac-
430 Radiographic Examination of the Thoracic Spine

quired block vertebrae can result from child- Spontaneous fractures caused by tumors are
hood rheumatoid disease, synostosing osteo- accompanied by a rarefaction of the bony struc-
chondrosis, or aging. They are usually accompa- ture.
nied by gibbus formation.
Rectangular vertebra (fifth lumbar vertebral 5) Vertebral Structure
body), usually associated with a high LS/Sl in- As in all bones, the structural changes represent
tervertebral disk space and a high assimilation changes in the normal trabecular structure. The
pelvis (Erdmann) or "loose pelvis" (Gutmann). density of the bone is determined by its calcium
Predisposes to isolated osteochondrosis at LS/S content and its capacity for radiation absorp-
or prolapse (Klasmeier). tion. Decalcified areas appear darker on radio-
graphs, while calcified areas appear bright.
4) Vertebral Contours Observable structural changes include:
Traumatic changes: - Cortical thinning in osteoporosis (accentuat-
- Fractures of the anterosuperior edge of the ed marginal contours)
vertebra in hyperftexion injuries - Honeycomb structure with hemangiomas
- End-plate depression in axial compression - Cotton-wool bone texture in Paget's disease
fractures - Patchy structure with vertebral metastases
- Articular process, transverse process and ("ivory vertebrae")
spinous process fractures
Traumatic changes are usually associated with 6) Soft-Tissue Changes
an increase in structural density. Sclerosis of the longitudinal ligaments, interver-
tebral disks, and iliolumbar ligament.
Degenerative processes:
Marginal osteophytes in spondylosis deformans.
3.3 Thoracic Spine
Anterior border: retromarginal hernias and per-
sistent apophyses in Scheuermann's disease. Radiography of the thoracic spine does not re-
Posterior border: posterior retromarginal disk quire a specialized technique as in lumbar radi-
prolapse. Nontraumatic posterior vertebral ography, although the accurate diagnosis of ver-
body separations. tebral position faults still requires an orthograde
End plates: Schmorl's nodes in Scheuermann's projection (a lateral projection, for example,
disease. that aligns the costal arches on both sides).
Vertebral arches: cleft formation in spondyloly- A 20 x 40-cm film size is used.
sis and spina bifida ("harelip vertebrae").
Facet joints: capsular ossification, subchondral AP View (Sagittal Projection)
sclerosis, and erosive defects occur in both de- Scoliotic curves are a common finding. The ac-
generative and inflammatory joint disorders. companying vertebral rotation is usually toward
Symptomatic processes. the convexity of the curve (with the formation of
End-plate depression in osteoporosis and osteo- a rib hump). The same criteria apply to segmen-
malacia. tal changes like those noted in the section on the
Inflammatory processes. lumbar spine.
Vertebral body defects can occur in anterior
spondylitis and spondylitides of various etiolo- Lateral View (Frontal Projection)
gies. These defects usually have indistinct mar- The statements made about kyphotic and lor-
gins ("potholes") and may be associated with dotic deviations in the lumbar region also apply
marginal osteophytosis. Inflammatory changes to the thoracic spine. Anterior and posterior
of the facet joints are described above. displacements of vertebrae are practically un-
Neoplasia. known in the thoracic region owing to the stabi-
Tumors can efface the contours of the vertebral lizing effect of the rib cage. Vertebral deformi-
bodies and pedicles. ties due to morphologic causes are common.
 Techniques for the Radiographic Examination ofthe Vertebral Column 431

Pathologic Findings an assistant. This process is repeated to check

for lateral deviation of the head and deter-
Increased Thoracic Kyphosis
mine whether it was incidental.
The cause can sometimes be deduced from the
2. A constant lateral deviation of the head is not
level of the apex of the kyphotic curve.
corrected, but a rotational deviation generally
High kyphotic apex: ankylosing spondylitis.
is corrected. (Lateral deviation requires a cor-
Kyphotic apex at the midthoracic level:
responding position adjustment of the cas-
- Increased lumbar lordosis (overloaded pelvis, sette.) Gutmann contends that a (repro-
etc.) ducible) spontaneous neck rotation should
- Labile posture in adolescents not be corrected.
3. The mouth is opened as wide as possible (this
Low kyphotic apex: position may be secured with a plexiglass bite
block or cork). The chin-forehead line should
- Kyphosis due to a faulty sitting posture in in-
be parallel to the table surface. The patient
fants
looks straight ahead.
- Scheuermann's disease
- Age-related kyphosis
Equipment Adjustments
- Flat back in the upper thoracic region
4. The X-ray tube is placed at shoulder level and
Decreased Thoracic Kyphosis angled approximately 15°-20° cephalad. The
This can result from: upper border of the cassette is slightly above
the patient's ear.
- Decreased lumbar lordosis (high assimilation
5. The central ray is aimed by means of a string
pelvis, etc.)
attached to the center of the tube (X-ray fo-
- A flat back in adolescents
cus). The collimator cannot be used due to the
- A circumscribed decrease of kyphosis in ado-
distortion of the light beam by craniofacial
lescents may be an early sign of a spinal tumor
contours.
(Jirout).
The patient's head is positioned such that the
3.4 Anteroposterior Projection string bisects the angle of the open mouth (i. e.,
of the Cervical Spine approximately 1 cm below the upper premo-
(After Sandberg-Gutmann) lars). Finally the tube center is aligned on the
string.
Technique
As it is difficult for the erect patient to maintain Coverage
the complicated position required for this expo- With an orthograde projection, the exposure
sure, the radiograph is taken in the supine posi- will cover the entire cervical spine down to the
tion. Moreover, the comparison of a lateral ra- upper thoracic spine, the skull base, and the first
diograph in the erect position (weight-bearing and second cervical vertebrae.
position) with a supine radiograph (non-weight-
bearing position) can be very helpful for func-
Sequence of the X-Ray Analysis
tional assessment, especially in the cranioverte-
1) Check for orthograde projection (faulty
bral joint region.
technique ?)
Film size: 18 x 24 cm upright.
2) Vertebral position (reference lines,
Focus-film distance: 1 m.
spinous processes)
3) Vertebral shape (transverse processes,
Positioning
uncinate processes, pedicles)
1. The patient sits with the anal fissure centered
4) Facet joints and intervertebral disks
on the Bucky table and leans back to the
5) Soft-tissue changes
supine position, aided by gentle support from
432 Radiographic Examination oftbe Cervical Spine, Segment CO-C2

Normal Findings (Figs. 314, 315) 4) The spinous processes line up on the mid
The following structures are silllated on the line.
midline (median plane): 5) The uncinate processes are pointed and
show no sign of degeneration.
1) Nasal septum, central interspace of upper
and lower incisor teeth. dens, external oc- COIC] segment (Fig. 315 aJ
cipital protuberance. 1) Verlebral body. Symmetry of the occipital
2) The vertebral end plates are horizontal condyle, foramen magnum, and the later-
and parallel. al masses, transverse foramina, and trans-
3) The ovoid pedicles lie on paramedian per- ver e proces e of the atlas.
pendiculars that flank the median plane. 2) Reference lines. The condylar line through
The e lines also mark the boundaries of the the lowest points of the occipital condyles
central canal and terminate cranially at the and the alias line through the inferior mar-
foramen magnum. gins of the atlas are horizontal and parallel.

Cranial plumb line

... s. Fig. 315 a, b.

1 Symmetrical
vertebral bodies
2 Parallel
end plates
3 Pedicles on
parallel perpendiculars
4 Spinous processes 2
on the midline

Fig.314. Normal radiographic findings in the cervical spine (radiographic tracing)

 Radiographic Examination ofthe Cervical Spine, Segment CO--C2 433

3) loillf space. Symmetry of the articulating ClIC2 segmellt (Fig. 3J5b)

atlanto-occipital surfaces.
4) Position of the atlas. With a normally posi- 1) Vertebral bodies. Symmetric shape of the
tioned atlas showing a normal morphology, atlas (see above) and axis.
the diagonal atlas diameters through the 2) Reference lines. As at CO/C1, the condy-
inferolateral and superomedial margins of lar and atlas lines are horizontal and paral-
the lateral masses intersect at the center of lel.
the foramen magnum. The lowest point of 3) WidthofdellS- Cl space. Symmetric dis-
the posterior arch of the atlas i on the mid tance between the dens and the lateral-
line. masses.
5) Transverse processes of the allas. The trans- 4) Position of the alIas. The lowest point of the
verse processes are of equal length and are posterior arch of the atlas is on the midline,
equidistant from the skull base. and the inferolateral beaks of the lateral
masses are symmetric.

CO/C1 segment
Left ~ __ 1 ___ """, Right
1 Symmetry of condyles and lateral masses '?symmetry of condyl~.
2 Lines paralle l and lateral masses
3 Joint space symmetrical
4 Central position of the atlas

2
'\
'\
'\
'\
' 4 Atlas position
a

Midline
Cl/C2 segment
1 Symmetry of the
lateral masses
~} Same as COIC 1 segment
3 Equal widths of lateral
dens-Cl spaces
4 Symmetrica l beaks
5 Symmetrical jOints
6 Dens on the midline
7 Equal angles
of jO
int surfaces
8 Transve rse foramina 5 + 7 Symmetry
symmetrical
9 Symmetrical distances f
r+ +\ of the joint surfaces
f \
10 Spinous process on the f \
midline / '....
8 Symmetry of the 8
foramina
Li Re
b

Fig_31Sa,b_ Normal radiographic findings. a COfCI segment, b CIfC2 segment

434 Radiographic Examination ofthe Cervical Spine, Segment CO--C2

5) Joint space. Symmetric articulating ur- Changes occur only with congenital asymme-
faces and qual joint-space widths in the try or rotation of the atlas.
lower craniovertebral joints (atlantoaxial). Joint space: The areas of atlanto-occipital
contact become asymmetric, i.e., longer on
These criteria apply only wheo the axis is noo-
the concave ide than on the convex side due
rotated and symmetric. The axis is considered
to gliding of the condyles toward the opposite
to be symmetric and centered when the fol-
side.
lowing criteria are met:
Position of the atlas: The point of intersection
- Dens is on the midline. of the diagonal atlas diameters in the foramen
- Symmetric lateral joint sLtlfaces (length and magnum is shifted to the side toward which
ioclina tion). the atlas i displaced i. e., the side toward
- Symmetric transverse foramina. which the head is inclined.
- Symmetric distances of tlte axis pedicles The atlantal transverse process and lateral
from the axis spine and lateral vertebral Inass are clo er to the occiput on the concave
margin. than on the convex side.
- Spinous process on the midline.
Cl/C2 Segment
Vertebral bodies:
Pathologic Findings Atlas: Asymmetric horizontal diameters of
Deviations from the normal criteria listed above the lateral masses, asymmetry of the medial
indicate morphologic or functional changes that lucencie at the ba es of the anterior arch and
warrant further investigation by manual exami- of the transverse foramina, which appear
nation or the functional radiographs described larger on the concave side.
below. Axis: Rotation toward the convex ide lead
to asymmetric slope of the articular surfaces
3.5 Anteroposterior Functional Views and asymmetry of the transverse foramina.
of the Cervical Spine (with Sidebending) The spinous process is shifted toward the con-
Technique vex side (away from the direction of atlas ro-
Initial preparations are the same as for the AP tation).
supine projection. Then the head is placed in a Referellce lines: The condylar and atlas lines
position of maximum sidebending without rota- converge on the ide toward which the atlas is
tion. shifted ( ee above).
The cassette position is adjusted for the side bent The dens- Cl space is widened only slightly on
head position. One exposure each is taken with the concave ide, because the opposite rota-
side bending to the left and right. tions of the atlas and axis (caused chiefly by
rotation of C2 on C3) tend to reduce the theo-
retical separation of the dens and CIon pure
Normal Findings (Fig. 316) sidebending by the rotational migration of the
With normal vertebral morphology and func- dens toward the concave side.
tion , the atla move to the side toward which Posterior arch of the atlas: The lowest point
the head is inclined (rotation toward th on the posterior arch of the atlas is shifted
concave side). This produces the following toward the concave side in relation to the
physiologic changes in the standard AP find- axi .
ings: Joilll space: In the maximum sidebent posi-
tion the inferolateral beak of the atlas may
COIC] Segment project past the lateral margin of the axis,
Vertebral body: The contours of the condyles forming a step. The CI-C2 joint space ap-
and foramen magnum are uncbanged. pear widened.
 Radiographic Examination of the Cervical Spine, Sidebending 435

C21C6 Segment Pathologic Findings in the Cervical Spine

Vertebral bodies: The vertebral bodies are tilt- Most of the normal findings on sidebending
ed toward the concave side and lie on a described above are considered pathologic
smoothly arched curve. when noted in the neutrally positioned cervical
Spinous processes: The spinous processes are spine.
shifted toward the convexity of the curve and
occupy asymmetric positions between the • Lateral Displacement of the Atlas
pecticles. The following changes are noted on the con-
Intervertebral spaces: The di k spaces are cave side (toward which the atlas is displaced):
asymmetric and wedge haped. The lines of • Reference lines. The condylar and atlas lines
the adjacent end plates converge toward the converge.
concave side. • The dens-Cl space is slightly widened on the
The uncinate processes appear widened on concave side.
the convex side. • Joint space: Asymmetric lengths of the articu-
lating atlanto-occipital surfaces, lateral pro-
jection of the atlas over the axis on the concave
side. The CI-C2 joint space is widened.
• The intersection of the diagonal atlas diameters
is shifted toward the concave side.

/.' _ _ ____ Asymmetry of th e

/ ~ condyler and atlas lines
__ _ _ __ Shift of the aUas
/ toward the concave side

__ Change in the infero-

lateral beaks
Axis rotation
(shift of spinous process
to the convex side)

Wide ning of the

dens-C 1 space I
/
/
I
Nonapposed beaks
ofC1 and C2
(at the limit of motion)
Transverse foramen appears
enlarged

Fig.316. Normal radiographic findings on sidebending ofthe cervical spine (radiographic tracing)
436 Radiographic Examination ofthe Cervical Spine, Lateral Projection

• The atlantal transverse process and lateral tated position of the vertebrae. Vertebral posi-
mass are approximated on the concave side. tion faults in themselves are not proof of dys-
function, however. The mobility fault must be
Atlas Rotation demonstrated by a manual segmental examina-
The following changes are noted on the side of tion or by radiographs of side bending to both
the atlas that moves forward (away from the film sides.
plane), e. g., on the right side during rotation to
the left:
3.6 Lateral Projection of the Cervical
• Vertebral bodies: The horizontal diameter of
the lateral mass and medial lucency increases.
Spine
• The posterior arch ofthe atlas moves to the side Technique
opposite the rotation, reducing the size of the Sitting position.
inferolateral beak, transverse foramen, and Film size 18 x 24 cm upright.
transverse process on that side. Focus-film distance 1-1.5 m.
• The dens-Cl space narrows.
• The Cl-C2 joint space widens. Positioning
A positive step may appear between the beaks 1. Relaxed sitting posture with the hands resting
of Cl and C2 at the end of the range of motion. on the thighs. The patient should "drop" the
• Side bending and rotation of C2-C6. Because shoulders to provide a clear projection of the
rotation in these segments is coupled with lower cervical spine.
sidebending, the signs are largely the same: 2. The head is parallel to the film plane, i. e., any
• Vertebral bodies: The vertebrae tilt and rotate sidebending and rotation are corrected along
to the same side. The lateral articular surfaces with anteflexion or retroflexion of the head.
at C2 appear asymmetric due to the rotation. 3. The patient fixates on a target at eye level
The spinous process, like the plumb line, (neutral position).
moves from the midline through the pedicles
to the side opposite the direction of rotation. Equipment Adjustments
• The transverse foramina appear smaller on the 4. The upper border of the cassette is approxi-
side opposite the rotation. mately 1 cm above the auditory meatus.
• The intervertebral spaces are widened on the 5. The exposure is centered on a point below the
convex side. auditory meatus, i. e., the central ray is direct-
• The dens is shifted in the direction of the rota- ed at the atlas.
tion.
Coverage
Clinical Remarks The lateral views should encompass the skull
The "lateral shift" (rotation) of the atlas is more base including the clivus and sella turcica and
pronounced in the erect position due to the the horizontal line of the hard palate. The rami
weight of the head than in the supine position. of the mandible should align. The lower border
Jirout (quoted in Lewit) characterizes the axis as of the image is level with the upper thoracic ver-
the key vertebra. If C2 is restricted, sidebending tebra.
and rotation do not progress caudally past that
level. By contrast, a restriction in the COICI seg-
Normal Findings (Fig. 317)
ment causes little interference with side bending.
Iflateral displacement (rotation) of the atlas was
1) Reference Lines
already present in the neutral position, it is not
McRae's line: the plane of the foramen mag-
accentuated by sidebending.
num between the end of the clivus, tbe basion,
Lewit states that the most common signs of a
and tbe posterior border of the foramen mag-
functional disturbance in the cervical region are
num (the opisthion).
scoliotic curvature of the cervical spine and a ro-
 Radiographic Examination of the Cervical Spine, Lateral Projection 437

Atlas plane: the horizontal line bi ecting the 3) Vertebral Body Lines
atlas. The anterior and posterior vertebral body
Axis plane: the plane from the inferior margin lines and the line of the vertebral arches are
of the pedicle to the inferior margin of the nearly parallel and form a smooth arc. The
lamina. posterior vertebral body line and the verte-
These lines hould be parallel to one another bral arch line encompa s the central canal,
when the head is in the neutral position. Con- which expands cranially and should be no less
vergence of the lines anteriorly signifies ante- than 13 mm in diameter.
flexion of the upper vertebra relative to the
lower vertebra; convergence of the lines pos- 4) Joint Space and InteTllertebral Spaces
teriorly signifies retroflexion. The facet joints are well visualized since they
are oriented approximately on the frontal
2) Position of the Dens plane, except for the C2IC3 joint, which may
The dens is below the clivus and the palato- be poorly demonstrated due to it more sagit-
occipital line (Chamberlain's line). The tal orientation.
c1ivus-dens angle is approximately 160°. The anterior dens-Cl space (between the
dens and the anterior arch of the atlas) is nor-

c' /
:=:----:s~~~~~'s'/jne \ --M.::..Rae' .
-
//

Allantodental
-~----:::-~~~
!........ ISO....;::...-=-.....
separation 2-6 mm ----I...... CliVUS-den - - -
/ -.... / Sangle --
/ -""-....-.... McGregor's ilne
.... I.
'b .....
!J " ........ Atlas line
/
// .,-~~

/1 V,
Equal heights / / 1......._...".
of intervertebral ~--J.-- I
spaces " I U
"
I
I
I
\
\
\
\
'\
'\ Diameter of spinal
\ canal 16- 20 mm
'\
\ 3 Li ne of the vertebral arches
~
"" 2 Posterior vertebral body line
'\ ' 1 Ante rior vertebra l body line:
All lines form a smooth curve

Fig.317. Normal findings on the lateral projection ofthe cervical spine (radiographic tracing)
438 Radiographic Examination ofthe Cervical Spine, Forward and Backward Bending

mally no wider than 2 mm (maximum of Normal Findings with Forward Bending

5 mm in children). The articulating urfaces (Fig.318)
are paraUe\. The " nodding" component of forward neck
The intervertebral disk spaces are equal in bending (as well as the "back-nodding" com-
beight. ponenl of backward bending) occurs at the
craniovertebral joints between the occiput,
5) Vertebral Arch Structures atlas, and axis. Physiologic movements and
The vertebral arch tructure are symmetric disturbances of the nodding movements are
on both sides and are largely superimposed. detected most accurately by observation of
the reference lines.

3.7 Lateral Functional Views of the 1) Reference Lines

Cervical Spine - McRae's line (foramen magnum line) (a)
(Forward and Backward Bending) - Atlas line (b)
The radiographs are again taken in the sitting - Axis line (c)
position. While restrictions are clearly appreci-
Lines a, b, and c diverge posteriorly during
ated on sidebending views, sites of hypermobili- forward bending, losing their parallel ar-
ty are demonstrated better by forward and back-
ward bending.

Interspinous distance
------7 increased by separation
. / of the vertebral bodies
/
I
I
Clivus-dens

')
angle 160·

/
~
./''\
Steps in the
posterior
vertebral line

Posterior vertebral
Anterior vertebral body line
body line

Fig.3I8. Normal radiographic findings on forward bending ofthe cervical spine (radiographic tracing)
 Radiographic Examination of the Cervical Spine, Forward and Backward Bending 439

rangement. At the end of the movement they creased anterior displacement of the upper
rcconverge at the atlanto-occipital level until vertebra. Rarely thi step formation occurs in
they are almost parallel again. The behavior the anterior vertebral body line a well.
of the atlas between the plane of the foramen The anterior atlas-dens joint space assumes a
magnum and the axis plane is termed "para- gaping V shape (inferior position of the atlas).
doxical atlas tilt" (Gutmann). This forward The intervertebral disks become distorted,
tilt of the atlas afiercrossing the line of gravity the adjacent end plates of the vertebral bodies
is driven by the weight of the head and takes assuming a more parallel alignment than in
place on the convex lateral joint surfaces of the neutral position.
the axis (reapproximation of the atlas line to
the occiput). The atlas tilt serves to protect 5) Vertebral Arch Structures
the medulla oblongata by maintaining a con- The vertebral arch elements on both sides are
tant c1ivus-dens angle (160°). Lines a and b, still aligned and superimposed in the absence
which previously diverged, reassume an al- of a ymmetries.
most parallel course. Lewit notes that usually
the atlas is already in slight anteflexion even
Normal Findings on Backward Bending
in the neutral po ition, with the anterior arch
of the atlas in a slight inferior position. J) Reference Lines
Lines band c between the atlas and axi con-
2) Position of the Dens verge posteriorly. The convergence of lines a
ormally the dens is below the palato-occipi- and b (between the occiput and atlas) i mini-
tal line (between the palatine bone and mal in the erect position (weight of the head)
opisthion , Chamberlain's Line) or below Mc- but is pronounced in the supine position.
Gregor' line (between the palatine bone and
the lowest point of the occiput). The normal 2) Clivus-DeliS Allgle
clivus-dens angle is 160°.Jt decreases during This angle remains largely unchanged.
forward bending of the neck before again
reaching it initial value due to tilting of the 3) Vertebral Body Lines
atlas. The lordotic curve of the neutral position is
increased. In labile or hypermobile joints,
3) Vertebral Body Lines steps present in the neutral position may dis-
The lordotic curve of these lines becomes flat- appear or new step may form, though less
tened. Any dorsal incongruity of the upper commonly than with forward bending.
vertebra with respect to the vertebra below
(dorsal step) in the neutral position disap- 4) Joint Space Ql/d Intervertebral Spaces
pears, or new steps may form (motion seg- The convergent movement of the facet joints
ment laxness). Steps that persist in both the that accompanies backward bending leads to
intermediate and terminal positions indicate maximum contact of the articular surfaces in
a segmental restriction. terms of the length of the contact area and the
joint pre sure (sclerosis). In labile or hyper-
4) Joint Space and Intervertebral Spaces mobile joint, this can lead to anterior gaping
The area of articular contact in the facet of the joint space and to dorsal step formation
joints are decreased by the divergent move- in the posterior vertebral body line. The ante-
ment that accompanies forward bending. Es- rior atla -d n joint assume a gaping invert-
pecially in labile joints (e.g., in children), the ed-V shape when the neck is fully dorsi flexed
flexion culminates in a gaping of the dorsal (superior position of the atlas). The interver-
joint elements and the formation of steps in tebral di ks undergo an asymmetric deforma-
the posterior vetebral body line due to in- tion (higher anteriorly than posteriorly).
440 Radiographic Examination of the Cervical Spine, Technique after Arlen

bent position is considered to indicate patholog-

5) Vertebral Arch Structures
ic segmental laxness.
The arch structures on both sides of the verte-
Superior and inferior positions of the atlas (V-
brae align in the lateral projection. As in the
shaped joint space) in the neutral position usual-
AP projection, some of the pby iologic
ly signify an atlas restriction. Step formation is
changes in the vertebral relations during for-
discussed in "Vertebral Body Lines."
ward and backward bending are considered
pathologic if they are also demonstrated in
5) Vertebral Arch Structures
the neutral position.
With asymmetry of the vertebral arch struc-
tures or articular processes, the different slope
angles of the articular surfaces lead to physio-
Pathologic Findings
logic positions of vertebral rotation. The verte-
1) Reference Lines bral arch structures no longer precisely align in
Marked inferior or superior position of the atlas the lateral projection, and double contours
in the neutrally positioned cervical spine. appear.
The pseudo-superior position of the atlas in the Lewit states that marked asymmetry can com-
frequent instances of a "retroangulated" dens promise blood flow in the vertebral artery, lead-
(dens lordosis) is considered a physiologic vari- ing to syncopal attacks.
ant. In these cases the articular surfaces in the
anterior dens-C1 space do not gape in V-shape 3.8 Arlen's Quantitative Techniquefor
fashion but remain parallel. the Functional Evaluation of the Cervical
Spine
2) Position of the Dens
In this technique, measurements are taken from
Tip of the dens extends past the palato-occipital
the cervical radiographs and evaluated to pro-
line (Chamberlain's line): basilar impression.
vide a quantitative assessment of the interverte-
Clivus-dens angle is less than 160 0 in the neutral
bral mobility of segments CO-C7 in the sagittal
position: atlas restriction; on forward bending of
plane.
the cervical spine: hypermobile craniovertebral
joint ligaments.
Applications
- Provides objective data in posttraumatic
3) Vertebral Body Lines
syndromes for purposes of disability assess-
Partial elimination of cervical lordosis (plateau
ment.
formation) on forward and backward bending
- Demonstrates cervical segmental mobility
occurs with segmental hypermobility and with
faults in patients with neurovascular, neuro-
restriction (muscular fixation). A generally up-
logic, and clinically asymptomatic segmental
right position of the cervical spine in children
dysfunctions.
and adolescents and in "loose-jointed" adults is
still generally considered a physiologic variant.
Radiographic Technique
The formation of anterior or posterior steps in
Three lateral radiographs of the cervical spine
the vertebral body lines occurs with motion seg-
are obtained (see Fig. 320):
ment laxness secondary to disk degeneration,
occurring above restricted segments or above 1. In the neutral (habitual) position.
congenital blocks. Usually there is subtle associ- 2. In maximum cervical flexion (the cervical
ated evidence of disk narrowing. spine is "rolled up," apposing the chin to the
manubrium sterni).
4) Joint Space 3. In maximum cervical extension.
Gaping of the joint space and the formation of
steps in just one or two segments in the neutral Except for gross rotation or side bending, devia-
position and/or in the forward- or backward- tions of neck position are not corrected.
 Radiographic Examination of the Cervical Spine, Technique after Arlen 441

Evaluation ofthe Radiographs All these lines are carried across the perpendic-
The following reference lines are drawn on the ular so that angular measurements can be per-
films (Fig. 319): formed.
- A perpendicular line parallel to the film bor- - In all three views, the right upper angles
der. Several perpendiculars may be needed formed by the intersection of the refer-
on the flexion view (see Fig. 324b). ence lines with the perpendicular are mea-
- The palata-occipital line (McGregor's line) sured (Fig.319) and entered in the table in
from the posterior margin of the hard palate Fig. 320. These base angles are used to deter-
to the lowest point on the occiput mine:
- The atlas line bisecting the atlas through the - The intervertebral angles for the flexed, nor-
anterior and posterior arches mal (neutral). and extended positions by sub-
- The vertebral base lines of C2-C7 from the an- tracting the upper base angle from the next
teroinferior margin of the vertebral body to lower base angle (e.g., CO from C1. C1 from
the intersection of the lamina with the inferior C2, etc.). Positive or negative values may be
border of the spinous process obtained.

Fig.319. Measurement ofthe base angles

442 Radiographic Examination of the Cervical Spine, Technique after Arlen

- The mobility values of the individual seg- same sign (+ or -) or the sum if the numbers
ments. These are calculated from the angular have different signs. The total mobility is de-
change between the neutral and flexed posi- termined by adding together all the values for
tions and the neutral and extended positions, flexion or extension.
taking the difference if the numbers have the

Base angle

Reference pOi nts

Reference lines Intervertebral ang le

X-RAY BIOMETRIC ASSESSMENT OF CERTICAL SPINE FUNCTION

Last name First name Date of birth Date of study No.

STATIC DYNAMIC MOBILITY DIAGRAM

Base angle Interverteb. angle Intervertebral mobility
Fle:(.. Norm. Ext. Flex. Norm. Ext. Norm. Norm. Flex . Pathol. Flexion Extension
Flell.. Ext. Ext. level

OC
OC'Ct
C1
I
C2 C1'C2

C3
C2'C3
C4 I
CS C3,C4
I

C6
C4,CS
C7
i
CS,CS
C2, _
C6 I C6'C7
i 25 20 '5 '0 5 0 5 10 '5 20 25

Remarks:

Fig.320. Table for base angles, intervertebral angles, and mobility diagram
 Radiographic Examination of the Cervical Spine, Technique after Arlen 443

Interverteb ral mobility

Fig.321. Normal cervical function in a 22-year-old male

OC - Cl ' 10,110

Cl - C2

C2 - C3

C3 - C4

C4 - Cs

7,90
C5 - C6

-7,63
C6 - C1
Fig.322. Mobility diagram based on 1t1O""'S"32'~'
the mean mobility values of 100 sub-
jects with no cervical symptoms Confidence interval of the mean values: p < 0 ,01
444 Radiographic Examination of the Cervical Spine, Technique after Arlen

PATIENT DATA

Last name

First name Sebastian

Date of Birth: 01.09.1936

Admission date: 25.05.1987

Catalog number 17

Remarks: RL

-------------------------------------
Mobility values

Base angle Intervertebral angle Intervertebral mobility

Fl e:<. Norm. E:< t. Fl e:<. Norm. E:·;t. Nann. Norm. Flex. F%

FIe:·; . E:{t. E:.;t.
36 87 126 3 3 0 51 39 90 56

65 100 124 29 1:5 -2 16 15 31 51

55 86 107 -10 -14 -17 4 3 7 57

44 75 95 -11 -11 -12 0 0

36 65 81 -8 -10 -14 2 4 6 33

-:r.-\
__\.L
53 68 -4 -12 -1::"; 8 9 88

36 55 64 4 2 -4 2 6 8 25

40 62 58 4 7 -6 3 13 10 30

Mobiliy diagram

Flexion Extension

COICI

WC2
X~X 1
/1

C2IC3

C3/C4
\ XI X
/
'\X

\
/X
C4/C5 I X
X""
C5/Cb X 1

WC7
I
1 ~X
30 25 20 15 10 5 10 15 20 25
Fig.323. Computer evaluation of a functional diagram
 Radiographic Examination of the Cervical Spine, Technique after Arlen 445

- Absence of atlas tilt (see Normal Findings) or

Normal Findings (Figs. 321, 322)
presence of atlas tilt during extension
- Paradoxical vertebral tilt during flexion or ex-
- Mobility appropriate for age (no limita-
tension in one of the remaining cervical seg-
tion). Mobility is greatest at C4--C6 and
ments (C1-C7) .
smallest at Cl-C3
- Approximately uniform distribution of
mobility in flexion and extension (dorsi- • Note
Arlen states that it is normal to find low mobility
flexion)
- Paradoxical atlas tilt (see also p.439) dur- in extension at C6/C7 and high mobility at
COICl.
ing flexion. (The intervertebral angle at
CO/C1 is smaller in flexion than in the neu-
tral position and represents a negative val- Clinical AppHcation
Four clinical examples of cervical function dia-
ue when total mobility is calculated)
- A decline in total mobility with aging (ap- grams are presented below. (The perpendiculars
are indicated by dotted lines on the radio-
proximately 5% per decade)
graphs.)
The clinical diagnoses were as follows:
Pathologic Findings 1. Cervicoencephalic syndrome (Fig. 324, dia-
gramp.448)
- Suspension of physiologic mobility (less than
2. Migraine, cervical myalgia, vertigo (Fig. 325,
2° in one direction of motion)
diagram p. 448)
- Unequal mobility (less than 2° in one direc-
3. Headache, arm pain, chronic low backache
tion) with retention of total mobility in the
(Fig. 326, diagram p. 451)
segment
4. Low backache, recurrent pelvic pain (Fig. 327,
- Limitation of motion (mobility values not
diagram p. 451)
more than 3°-4° in one direction) without a
complete suspension of mobility The illustrative radiographs and charts were fur-
- Hypermobility (mobility values approximate- nished by Dr. A. Arlen.
ly 20° for one direction of motion. High values
are normal only for extension at COIC1)
 446 Radiographic Examination ofthe Cervical Spine, Technique after Arlen

Fig. 324a-c. Patient: Anne v., date of birth 8-3-56.

Clinical diagnosis: cervicoencephalic syndrome.
Mobility values and diagram, p. 448

b c
 Radiographic Examination ofthe Cervical Spine, Technique after Arlen 447

Fig. 325 a-i!. Patient: Beatrice X, date of birth 5-1-

39. Clinical diagnosis: migraine, cervical myalgia,
vertigo. Mobility values and diagram, p. 448

b
448 Radiographic Examination of the Cervical Spine, Technique after Arlen

EXPLORATION RADIO-FoNCTIONNELLE DE LA COLONNE CERVICALE

Nom v. Prenom 00 (e) date N'

STATIOUE DYNAMIOUE DIAGRAMME de MOBILITE

Angles de base Angles inter-vert. Mobilite inter-vertebrale
Flex. Norm. Ext. Flex. Norm. Ext. Norm. Norm. Flex.
Flex. Ext.
n,
Ext.
Flexion Extension

OC 1 P't Alo "lS' 3' lilA A

OC'CI ,
Cl Z? JOt At«} +.(q -l-2.S +20 -4- ?, -A T
,,
C2 )A ¥S }N -H -Z'l -2(, } 2- q Cl'C2
C3 )8 82- )H ~ t -.( - 3 ~ 2 '(0 j
C4 H, :}, qg .,. ft -~ -n )'t 1- 2A
C2'C3
\
C5 '3<f H YA +t -q -,0- ;{l- e 2S'" C3'C4
/ \.
1
ca If~ G~ ~q +n -~ -u U' 'f 'l.'f
C4'C5 J
C7 S4- B ~2. t8' -A -1- q 6 ,.IS' \
Hi" -74 -sa b" 3.1- ;Os C5'C6
1\
~,

).03
t- C2&i_~~
C6'C7
25 20 15 10 5 0 5
J 10 15 20 25

Chart for patient in Fig. 324. (Legend see p. 446)

EXPLORATION RADIO-FONCTIONNELLE DE LA COLONNE CERVICALE

Nom oo(e) --!' 5 39". date ,ff. .f' '11

STATIOUE DYNAMIOUE DIAGRAMME de MOBILITE

Angles de base Angles inter-vert. Mobilit" inter-vertebrale
Flex. Norm. Ext. Flex. Norm. Ext. Norm. Norm. Flex. Flexion Extension
Fle",_ Ext. Ext. F'lI.
OC .13 .70 159 61 49 fir

t\
OC'CI
Cl gg 9g IlfD 1-'] IS ;1 f
'i b V
C2 ,iLt '18 111 -Itt -~ ( is
g /~ Cl'C2
C3
29 go -/03 IS ,51 - '3 3 -II 4'-1 1\
C2'C3
C4 ]( gf 33 II II -10 t' 1-1 41 II
C5 42 ff2 8f It: ;1 -11 :) 13 f3 C3,C4
ca 50 18 10 IS 3 -11 111 ~ .11
C4'C5 \
C7 56 14 to f( -5 -10 -II 5 ..If V j
V
li7 Af - '13 n b''3 -'he C5'C6

43 rJ'3 c2&iN
ca'C7
J I
A{ 4 25 20 15 10 5 0 5 10 15 20 25

Chart for patient in Fig. 325. (Legend see p. 447)

 Radiographic Examination ofthe Cervical Spine, Technique after Arlen 449

Fig. 326 11-<. Patient: Anna Elisabeth, date of birth

6-14-35. Clinical diagnosis: headache, arm pain, chron-
ic low back pain. Mobility values and diagram, p. 551

b
 450 Radiographic Examination of the Cervical Spine, Technique after Arlen

Fig.327a-c. Patient: Elisabeth, date of birth 1-13-38.

Clinical diagnosis: low back pain, recurrent pelvic
pain. Mobility values and diagram, p. 551

b
c
 Radiographic Examination ortbe Cervical Spine, Technique after Arlen 451

EXPLORATION RADIO-FoNCTIONNELLE DE LA COLONNE CERVICALE

Nom

STATJQUE DYNAMIOUE DlAGRAMME de MOBIUTE

Angles de base Angles inIer-Y«t MobiIite inter--'~ale
Flu. Norm. Ext. Flex. Norm. Ext. Norm. Norm. Flex.
Flex. Ext. F ..
Ext.
Flexion Extension

OC 1,3 flit -1St, 51 to -Iff OC'C1

C1 (b -/14 154 113 1,10 0 3 !Q 33 I /
V
50 g4 126 .16 ·10 .i'i '-t g 1.2
-
C2 C1'C2
V
C3 43 9,1 -/13 . t ·IJ .,fJ ) 1 ({ C2,C3 /
C4
C5
4.2 ,It leo ·1 . <t ·13 f !J 1t
4~ '11 ~6' f6 .3 . i+ J 11 ,10 C3,C4 J \
ca '51 tt 11 14 ·It . ./i ~ ./1 19 C4,C5
I 1\
C7 /,1 q (-1 No 0 .10 4) .fo 1'0
113 ·1,/ ·33 % 66" 11/ C5,C6

Y6 66 C2,-.f'!
ca' ca'C7
-1 ~ f 252015105 0 5 10 15 20 25

Chart for patient in Fig. 326. (Legend see p. 449)

EXPLORATION RADIO - FoNCTIONNELLE DE LA COLONNE CERVICALE

Nom date ./4? ~6

STATJQUE DYNAMIOUE DlAGRAMME de MOBIUTE

Angles de base Angles inter--'. MobIIite intlll'Wrt~1e
Flex. Norm. Ext. Flex. Nann. Ext. '1!l:: Norm. FI&i.
Ext. F .. Aexion Extension

OC 41 91 -lifo 50 43 gg
OC'C1
C1 5,j f1d~
-I"S- 111 113 1-5" If] g 6" I
I

JS 'I" -113 .1it .~ -JJ 6" Ij I\.

C2
4 C1'C2
C3 3'6'IJ /0.2 0 ·5 -11 .) 6 11 C2,C3 J
C4
C5
38 r! 8:1 0 .j.
43 11 'I"f 15" 0
·/3
.f}
~
s
-II 11
IJ If C3,C4 \ \
ca 49 go 1] f6 13 .J 3 () ?
,.-
C4,C5
/ 1\
C7 5f) 'If 66 Ie .5" .9 /1 Lt -I~
/111 .le -'flf 30 58 U C5'C6 \ V
Jt 53 C2~_ 4 /
ca'C7
S~ 11 25 20 15 10 5 0 5 10 15 20 25

Chart for patient in Fig. 327. (Legend see p. 450)

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Subject Index

A Bragard's test 375 coracoid process 281

abdominal wall changes 80 Brudzinski's sign 158 corneal reflex 240
abduction test bursitis 22 corns 387
- with knee extended 373 - tailor'S 394 costal joints 210
- in30oflexion 373 costotransverse joints 184
acromioclavicular joint 281, 288 C counternutation 141
adduction test callosities 387 crus varum 353
- with knee extended 374 calcaneonavicular ligament,plan- cuboid bone 394
- in 30 °flexion 374 tar 393, 398
adductor tubercle 359 carpal tunnel 325
D
agonists 36 carpometacarpal joint ofthumb deformities
analysis 335 -, axial limb 156
- of pain during history taking 20 cervical spine -, fingers 315
-, sequence of 426, 431 -, anteroposterior 431 -, ulna 316
-, X-ray image 418 -, examination in supine position
de Kleyn's hanging test 215, 247
angle, pelvis-leg 120 244
dens position 439
ankle joint 388 -, functional evaluation 440
Derbolowsky 163
antagonists 36 -, functional views
deviation, ulnar 316
anterior drawer -, -, anteroposterior 434 digitus quintus varus 385
- in 30 °external rotation 376 -, -, lateral 438 digitus superductus 385
- in 15 °internal rotation 377 chest expansion, measurement of
disease groups 18
- in neutral rotation 377 182 dislocation
ape hand 316 Chopart's joint 388
-, recurrent patellar 356
Arlen's technique 440 circulation -, shoulder 257
artery, vertebral 231 - changes 82 disturbances, trophic 44
-, provocative test 247 - problems 387
documentation of findings 68
-, tests 231 clavi 387
dorsal artery offoot 398
arthron 3 claw hand 316
drawer testing 376
assistive devices 82 clawingoffingers 315
drop hand 316
asymmetries, facial 82 claw toes 385
Dupuytren's contracture 387
atlas clubfoot 385 dysmelias 315
- plane 437 clubhand 316 dystonias 45
- traction 252 complex instability 377
atrophic changes 317 -, anterolateral 377
static axes 76, 78 -, posterolateral 377 E
axis plane 437 -, posteromedial 377 elbow
compression 34, 232 -, flexor side 304
B -, thorax 193 -, nursemaid's 300, 301
back extensors 147 congenital defects 315 endurance 41
Bayonet position, wrist 316 contour changes epicondyle
biomechanical considerations -,lowerextremityjoints 78 -, lateral femoral 361
114, 128, 165 -, muscle 39, 78 -, medial femoral 359
body contours examination
- proportions 75, 77 -, bony 387 - LPHregion
- regions 17 -, patellar 353 -, -, lateral position 148
body lines, vertebral 437 -, vertebral 426, 430 -, -, prone position 119
Bohler-Kromertest 373 contractions, muscular -, -, sitting position 103
Bohler's test 371, 372 -, pathologic 43 -, -, standing position 83
Bonnet's sign 158 -, spontaneous 43 -, -, supine position 155
Bragard's sign 158 coordination disturbances 39 examination positions 16
460 Subject Index

extosis -, systematic 6, 61 K
-, Haglund's 387 humeral fornix 263 Kernig's sign 158
-, metatarsal 387 humeral head 267 keyring test 132
eyes 239 humeroradialjoint 301 Kibler's skin rolling test 134
humeroulnarjoint 309 knee muscles 145
F HUter's triangle 297 Kohler-Freiberg disease 399
facet joint gliding, tests 232 hydrops 352 Kohler's disease 387
femoropatellar joint 359 hyperabduction 161
fibula, head of 362 hyperextension test, external rota- L
findings tion 371 Lasegue'ssign 158
- in arthron, structurally specific hypermobility test 252 leg
-, special neuropathological 43 hypertonicity 45 -, anatomically shorter 89
-, touch palpation 10 hypothenar atrophy 317 -, functionally shorter 78
finger 327 hypotonicity 45 - girth discrepancy 156
flatfoot 384, 385 - length discrepancy 78, 89,
flexion contracture 120, 130, 156
-,knee 354 iliotibial tract 363 - raising test, straight 158
-, thumb 337 infrapatellar fat pad 352, ligament
flexion test 358 -, bifurcatum 397
-, seated 110 inspection 7, 24, 32, 39 -, deltoid 390
-, standing 90 -, general 71 -, radial annular 301
floating ribs 184 intercarpal joints 325, 330 -, radial collateral 302
foot interossei 317 -, ulnar collateral 304
-,outeredge,standingon 101 interosseus space 317 ligament damage, cardinal signs
- shape 384 irritation points for testing 371
- position 384 - of Sell 196 ligamentous injury 371
foramen magnum plane 436 -, segmental 10 Lisfranc's joint 389
funnel chest 181 irritation zones 195 LPH region, anteroposterior pro-
G -, testing 54 jection 420
gait 72 lumbar spine 135, 422, 424,
gapping test 142 J 426
genurecurvatum 354 jaw movements and swallowing -, compression 97, 101
-, valgum 353 240 -, traction 96, 169
-, varum 353 jerk test 380
gibbus formation 104, 109 joint, examination of 24 M
gliding, convergent/divergent 254 joint involvement pattern 62 malleolus
joint play 26 -, lateral 393
H joint tests -, medial 390
Haglund heel 398 -,carpometacarpal 335 McMurrey test 376
hallux rigidus 385 -, clavicle 285 medial meniscus 359
hallux valgus 385 -, compression 232 meralgias 20
hallux varus 385 -, gliding movements of patella metacarpal, first 320
hammer toes 385 364 metatarsal, first 393
head -, gliding movements, meniscotib- metatarsophalangeal joint
-, examination in sitting position ialjoint 366 -, greattoe 393
238 -, intercarpal joints 330 -, small toe 394
- position 81 -, metatarsal joints 406 mimetic activity 239
- shape 81 -, phalangeal joints 341 mobility
heel -, scapula 285 -, patellar 356
- axis 384 -, tarsal bones 402 -, testing
- profile 386 -, temporomandibular joints 341 -, -, lower ribs 205
hip drop test 92 -, tibiofibular joint 369 -, -, thoracic spine 203
hip joint -, traction 231 -, -, upper ribs, segmental 209
- compression 171 -, wrist joint 328 morphology 181
- rotation 123, 143 jointtranslation tests 96, 115, Morton'sneuralgia 399
- traction 171 135, 152, 169, 192, 199, motion testing 11, 24, 32, 39
hip joints 421, 423 211, 231, 250, 267 -, active 24
hip muscles 144 -, humeroradialjoint 305 -, cervicothoracic junction 188,
history -, humeroulnarjoint 309 204, 229
-, interpretation of 62 -, radioulnar 305 -, passive 24
 SnbjectIndex 461

-, ribs 189 -, diffuse 63 Payr's test 317

-, segmental 111 -, episodic 63 pectus
-, thoracic spine 186 -, exertional 63 - carinatum 181
motor sequences, complex 43 -, influences on 64 - excavatum 181
movement pattern 36 -,joint pelvis, upright 428
movements -, -, degenerative 29 percussion, tenderness to 11
-, ordinary 43, 72 -, -, inflammatory 21 peroneal trochlea 394
-, respiratory, ribs 181, 182 -, ligament 21 pesabductus 385, 386
-, rib 197, 208 -, local 19 pes adductus 385
muscle contour 39 -, localized 62 pes anserinus 360
muscle groups 36 -, multifocal 62 pes calcaneus 385
muscles -,muscle 21 pescavus 384, 386
-, examination of 35 -, muscle stretch 45 -, and transversus 386
-, lingual 243 -,nerve 22 pesequinus 385, 386
-, masticatory 243 -, nerve stretch 45 pes excavatus 386
-, neutralizing 36 -,night 63 pes planovalgus 386
-, ocular 243 -, patterns of 20 pes planus 384
-, phasic 36 -, periodic 63 pes supinatus 386
-, postural 36 -, projected 19 pes transversus 384
-, stabilizing 36 -, pseudoradicular 23 pes valgus 353, 384
muscle shortening 40 -, radicular 23 -, andcavus 386
muscle stretch tests 40 -, referred 19, 63 pes varus 353, 384
muscle tests 97, 101, 201, 211 -, rest 63 phalangeal joints 341, 409
-, cervical 234, 255 - rosette 131 phenomena, associated 64
-, hip 144 -, shaking 132 physical examination, basic 6
-, hip and abdominal 173 -, types of 19 pigeon breast 181
-, lingual 243 -, vascular 23 pisiform star 323
-, masticatory 243 -, vertebragenic 23 pivot shift test 380
-, mimetic 242 painful arc 260 plateau formation 109
-, ocular 243 palmar soft tissues 327 platycnemia 354
palmofhand 317 poikilotonia 45
N palpation 8, 26, 34, 40, 149 points
nail changes 317 -, cervical spine 216 -, irritation
navicular bone 393 - during movement 9 -, -, segmental 127, 133, 134
nerve lesions -, facet joints 133 -, -, testing
-, differential diagnosis 46 -, first rib 186 -, maximal 40
-, symptoms 46 - for tenderness 9 popliteal fossa 354, 363
nerve pressure points 46 -,lumbar spine, segmental 131 position
nervous disorders, autonomic 45 -, pressure, thrusting 9 -, clavicular 81
nervous system, examination of -, ribs 208 -, high shoulder 257
42 -, sacroiliac joint 88 -, iliac, faulty 89
neural trigger points 133 -, SI1/lumbarspine 109, 124 -, malleolar 165
nutation 142 -, temporomandibularjoints 241 -, patellar 352
-, thoracic joints 184, 195 -, pelvic 77, 79, 83, 104, 422,
o -, touch,atrest 9 426
oath hand 316 palpation field -, -, gluteal profile 120
obliquity, pelvic 422 -, dorsal pelvis 134 -, pharoah 204
olecranon 300 -,face 240 -, sacral 165
- fossa 300 -, thorax -, -, faulty 90, 129
- tip 300 -, -, anterior 208 -, scapular 81
Ott'ssign 84 -, -, posterior 195, 196 -, vertebral 426, 428
-, ventral pelvis 166 posterior drawer 377
P patella posture 74
pain -, "dancing" 356 -, erect sitting 104
-, autonomic 22 -, border -, relaxed 104
-, bilateral 20 -, -, inferior 358 -, spinal 426, 428
-, character 64 -, -, pain 357 power 41
-, chest-wall 183 -, -, superior 357 pressure points, trigeminal 240
-,cold 63 Patrick-Kubis test 161 procedures, adjunctive special di-
-, continuous 63 Payer's venous pressure point 400 agnostic 15
462 Subject Index

program, five/five 4 snuffbox 320 tendovaginitis 22

provocative test for motion seg- - tendons 322 testing of menisci, cardinal signs
mentlaxness 215 spasticity 45 370
pseudo-Lasegue's sign 158 spine 32 thorax examination
pubic symphysis 421, 424 - changes 80 -, in prone position 194
-, examination of 32 -, in sitting position 180
R spinous processes, -, in supine position 207
radioulnar joints, proximal and -, palpating tips for tenderness tibial condyle 359
distal 305 131 tibiofibular joint, inferior 400
radiographic techniques, standard -, thrusting 132 thenar atrophy 317
418 Sprengel's deformity 257 Thomsen'ssign 158
recoil phenomenon 91, 95 springing test 133 thoracic cage, shape 181
reference lines 422 -, four-point 137 thoracic segments 199
resistance testing - over sacrum 139 three-phase squat 100
-, finger muscles 346 - over ilium 140 three-phase test 121
-, foot muscles 411 -, two-stage 131 thumb 327
-, hand muscles 344 Steinmann I (Merke'ssign) 375 toes, standing on 100
resistance tests 41 Steinmann II 371 tone 40
-, elbow joint muscles 310 sternoclavicular joint 280, 288 torsional movement, sacrum 129
-, foot and toe muscles 411 strength, maximum 41 torticollis
-, hip and abdominal muscles 173 strength tests, isotonic 41 -, muscular 236
-, isometric 41 -, rules 41 -, rheumatic 237
-, shoulder girdle muscles 291 stroke test, connective tissue 9, -, spastic 237
-, shoulder muscles 269 135 traction, three-dimensional 232,
respiration structural analysis 250
-, abdominal 182 -, functional 19 tragus, pressure on 241
-,flank 182 -, patient history 19 trapezium 320
-, thoracic 182 structure, vertebral 426, 430 Trendelenburg phenomenon 97
- type 181 studies trigger points, muscular and neural
rib -, adjunctive 196
-, first 282 -, -, angiologic 14 trunk contours 77, 80
-, restrictions 183 -, -, neurologic 14 trochanter, greater 126
-, -, primary 186 -, electrodiagnostic 15 tuber calcanei 398
-, -, secondary 186 -, laboratory 15 tuberosity
rigor 45 -, organ 15 -, deltoid 263
rotation, pelvic 422 -, radiologic 15 -, greater 263
styloid process -, lesser 263
S - of radius 320 -, tibial 352
sacral push, craniocaudal 140 - of ulna 322
sacrum, flexion and extension subluxation of ulna 316 V
movements 128 subtalarjoint 388 valgus, physiologic 297
scaphoid 320 sustentaculum tali 391 vertebral bodies, tenderness to
scapula 199 symbols, standard 68 percussion 11
-, winged 257 synchondroses vertebral column
scapulothoracic joint 289 -, sternal 184 -, alignment 120
Schober's sign 84 -, costal 184 -, techniquesforradiographicex-
Sell's traction-assisted test 143 syndrome, patellar 356 amination 420
shape, vertebral 426, 429 synergists, 36
shift, pelvic 422 swelling W
shortening tests 176 -,offingers 316 weakness, postural 80
shoulder girdle -,ofhand 316 weight-bearing test 100
-, depressor muscles 282 -, at wrist 316 wrist joint 328
-,levatormuscles 282
SIJ springing test 172 T
sinus tarsi 397 talus, neck of 396
skin 82 tarsal joints 400
- changes 317 tarsometatarsal joints 389, 406
skin rolling test, Kibler's 9 tendon compartments 323