Clinical Orthopedic Examination: Special Tests & MSK Discriminators

• Hawkins-Kennedy Test: Physician flexes the patient's shoulder and elbow to 90°, then forcefully internally rotates the humerus. Drives the greater tuberosity against the coracoacromial ligament. Positive: Pain, indicating subacromial impingement or supraspinatus tendinopathy.
• Neer Impingement Test: Physician stabilizes the scapula and passively elevates the pronated arm into full forward flexion. Jams the greater tuberosity against the anteroinferior acromion. Positive: Subacromial pain.

• Empty Can Test (Jobe's Test): Arms abducted to 90° and horizontally adducted 30° into the scapular plane with thumbs pointed downward (full internal rotation). Patient resists downward pressure. Positive: Pain or weakness indicates Supraspinatus tendinopathy or tear.
• Drop Arm Test: Patient's arm is passively abducted to 180° and they are asked to slowly lower it to the side. Positive: Arm suddenly drops uncontrollably around 90°, diagnostic of a massive full-thickness Supraspinatus tear.
• Lift-Off & Belly-Press Tests: Patient places dorsum of hand on lumbar spine and lifts hand away from back. Positive: Inability to lift off indicates a Subscapularis tear (internal rotator).
• External Rotation Lag Sign: Arm held in 90° elbow flexion and 20° shoulder abduction, fully externally rotated by examiner. Patient asked to hold position. Positive: Forearm springs back into internal rotation, diagnostic of Infraspinatus & Teres Minor tear.

• Speed's Test: Patient resists downward force with arm in 90° forward flexion, elbow extended, and forearm fully supinated. Pain localized to the bicipital groove indicates long head of biceps tendinitis.
• Yergason's Test: Patient's elbow flexed to 90°; patient attempts to supinate forearm against physician resistance while physician palpates bicipital groove. Pain indicates biceps tendinitis or transverse humeral ligament tear.
• O'Brien's Active Compression Test (SLAP Lesion): Arm flexed to 90° and adducted 10° across chest with thumb down (internal rotation). Downward force applied. Repeated with thumb up (supination). Positive: Pain inside joint with thumb down that resolves with thumb up indicates a superior labrum anterior-to-posterior (SLAP) tear.

• Lachman Test (Gold Standard for ACL): Knee flexed to 30°. Physician stabilizes the distal femur with one hand and pulls the proximal tibia anteriorly with the other. Positive: Increased anterior tibial translation (> 3 mm) or soft, mushy end-feel. Has 85% to 95% sensitivity for acute ACL tear (far superior to Anterior Drawer because hamstring guarding is minimized at 30°).
• Anterior Drawer Test: Knee flexed to 90°, foot stabilized on table. Proximal tibia pulled anteriorly. Tests ACL, but frequently falsely negative in acute tears due to hemarthrosis and hamstring spasm.
• Posterior Drawer Test (PCL): Knee flexed to 90°. Proximal tibia pushed posteriorly. Tests PCL integrity.
• Posterior Sag Sign (Godfrey's Test): Patient supine with hips and knees flexed to 90°. A torn PCL allows gravity to pull the tibia posteriorly, creating a visible concave 'sag' below the patella.

• McMurray Test: Knee fully flexed, examiner rotates tibia while applying axial load and extending the knee:
  • Medial Meniscus: Tibia EXTERNALLY ROTATED with VALGUS STRESS while extending.
  • Lateral Meniscus: Tibia INTERNALLY ROTATED with VARUS STRESS while extending.
  • Positive: A palpable click or pop along the joint line with localized pain.
• Thessaly Test: Patient stands on one foot with knee flexed to 20° and twists trunk internally and externally 3 times. Reproduction of joint-line clicking or locking has highest sensitivity (> 90%) for meniscal tear.

The Thomas test evaluates for a fixed iliopsoas hip flexion contracture: with the patient supine, flexing one knee fully to the chest obliterates compensatory lumbar lordosis; if the contralateral thigh rises off the examination table, the contralateral iliopsoas is contracted (and if the knee simultaneously extends, the rectus femoris is also tight). The Ober test assesses for iliotibial (IT) band and tensor fasciae latae (TFL) contracture: with the patient in the lateral recumbent position and the top hip extended and abducted with the knee flexed to 90 degrees, failure of the top thigh to drop passively toward the table into adduction indicates IT band tightness. The Trendelenburg test evaluates the superior gluteal nerve (L4–S1) and hip abductors (gluteus medius and minimus): when standing on one leg, if the contralateral pelvis drops downward, the stance-leg (ipsilateral) gluteus medius/minimus is weak.

The FABER (Patrick) test (Flexion, Abduction, External Rotation with the lateral malleolus resting on the contralateral knee) differentiates intra-articular hip pathology from sacroiliac dysfunction: applying downward pressure on the flexed knee that reproduces anterior groin pain indicates intra-articular hip pathology (osteoarthritis, avascular necrosis), whereas reproducing posterior buttock pain over the PSIS indicates sacroiliac joint dysfunction. Conversely, the FADIR test (Flexion, Adduction, Internal Rotation) compresses the anterior femoral neck against the acetabular rim and is the most sensitive screen for anterior femoroacetabular impingement (FAI) and anterior labral tears. In the spine, a positive Straight Leg Raise (Lasègue test) reproducing radiating dermatomal pain below the knee between 30 and 70 degrees of hip flexion indicates L4–S1 nerve root tension (herniated nucleus pulposus), confirmed by Bragard sign (worsening with ankle dorsiflexion).

• Spurling Test (Neck Compression): Patient extends neck and sidebends toward the affected symptomatic side while the physician applies downward axial compression onto the vertex. Reproduction of sharp radiating pain down the ipsilateral arm confirms cervical radiculopathy (cervical nerve root compression). Highly specific (> 90%).
• Shoulder Abduction (Bakody) Relief Sign: Patient actively places the palm of the symptomatic hand on top of their head. Relief or significant reduction of radicular arm symptoms indicates cervical nerve root compression (abduction unweighs the lower cervical nerve roots, C5–C7).
• Lhermitte Sign: Passive neck flexion elicits an electric shock-like sensation shooting down the spine into the extremities; indicates cervical spinal cord compression (myelopathy) or multiple sclerosis.

• Adson Test: Patient seated; physician palpates radial pulse, abducts arm slightly, and asks patient to extend neck and rotate head TOWARD the affected side, taking a deep breath and holding it. Diminution or loss of radial pulse indicates compression between the Anterior and Middle Scalenes (hypertrophy or cervical rib).
• Wright Hyperabduction Test: Physician monitors radial pulse while hyperabducting the patient's arm beyond 90° in external rotation. Obliteration of pulse indicates compression of axillary neurovascular bundle beneath the Pectoralis Minor tendon and coracoid process.
• Eden / Costoclavicular Test: Physician monitors radial pulse while the patient pushes their shoulders backward and downward in exaggerated military posture. Obliteration of pulse indicates compression in the costoclavicular space between the Clavicle and 1st Rib.

Cozen test (resisted wrist extension and radial deviation with a pronated forearm reproducing lateral epicondyle pain) and Mill test (passive wrist flexion with the elbow fully extended and forearm pronated) diagnose lateral epicondylitis ('tennis elbow'), caused by angiofibroblastic tendinosis of the extensor carpi radialis brevis (ECRB) origin. Conversely, pain at the medial epicondyle during resisted wrist flexion and forearm pronation diagnoses medial epicondylitis ('golfer's/pitcher's elbow') of the pronator teres and flexor carpi radialis origin. At the radial styloid, Finkelstein test (grasping the thumb inside a closed fist and passively deviating the wrist ulnarly) reproduces sharp pain over the first dorsal extensor compartment—containing the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons—confirming de Quervain tenosynovitis.

Carpal tunnel syndrome (median nerve compression beneath the transverse carpal ligament) is provoked by Phalen maneuver (holding maximal wrist flexion for 60 seconds), Carpal Compression (Durkan) test (direct thumb pressure over the carpal tunnel for 30 seconds, the most sensitive bedside maneuver), and Tinel sign at the volar wrist, producing paresthesias in the thumb, index, middle, and radial half of the ring finger. Ulnar neuropathy (cubital tunnel or Guyon canal) is tested via Froment sign: when pinching a sheet of paper between the thumb and index finger, weakness of the ulnar-innervated adductor pollicis forces the patient to flex the thumb interphalangeal joint using the median-innervated flexor pollicis longus (AIN). Prior to radial arterial line placement or ABG sampling, the Modified Allen test verifies patent collateral palmar arch perfusion via the ulnar artery.

The Anterior Drawer test of the ankle evaluates the anterior talofibular ligament (ATFL)—the weakest and most frequently torn ligament in an inversion-plantarflexion ankle sprain—by stabilizing the distal tibia/fibula with one hand and pulling the calcaneus/talus anteriorly with the ankle in 10 to 20 degrees of plantarflexion. The Talar Tilt (Inversion Stress) test inverts the calcaneus with the ankle in neutral dorsiflexion to test the calcaneofibular ligament (CFL) (or everts the calcaneus to test the medial deltoid ligament). A high ankle (syndesmotic) sprain—involving the anterior inferior tibiofibular ligament (AITFL) and interosseous membrane from forced external rotation/hyperdorsiflexion—is diagnosed by the Squeeze (Hopkins) test (compressing the mid-calf tibia and fibula together reproduces distal syndesmotic pain) and the Kleiger (External Rotation Stress) test. Complete Achilles tendon rupture (S1–S2) is confirmed by a positive Thompson test: squeezing the gastrocnemius-soleus calf belly with the patient prone fails to elicit passive plantarflexion.

To isolate sacroiliac joint pathology from lumbar spine pain, the Gaenslen test places the patient supine with one hip flexed maximally to the chest while the opposite leg is hyperextended off the edge of the table, applying torsional shear across both sacroiliac joints simultaneously. In neonates and infants younger than 3 to 4 months, screening for Developmental Dysplasia of the Hip (DDH) utilizes two complementary maneuvers: the Barlow maneuver attempts to dislocate an unstable femoral head posteriorly out of the acetabulum via hip adduction and gentle posterior pressure, whereas the Ortolani maneuver reduces a posteriorly dislocated femoral head back into the acetabulum via hip abduction and anterior upward lifting of the greater trochanter, producing a palpable 'clunk.'

Under the Ottawa Ankle Rules, ankle radiographs are required only if there is pain in the malleolar zone plus either (1) bony tenderness along the posterior edge or tip of the distal 6 cm of the lateral or medial malleolus, or (2) inability to bear weight for four steps both immediately and in the emergency department. Similarly, Ottawa Foot radiographs are required only for midfoot pain plus bony tenderness at the base of the 5th metatarsal or the navicular bone, or inability to bear weight for four steps. Under the Ottawa Knee Rules, knee radiographs are indicated for any of five criteria: age >= 55 years, isolated tenderness of the patella, tenderness at the head of the fibula, inability to flex the knee to 90 degrees, or inability to bear weight for four steps. For cervical trauma, the NEXUS low-risk criteria (mnemonic: NSAID) clear the C-spine clinically without imaging if all five are absent: Neurologic deficit, Spinal midline tenderness, Altered mental status (GCS < 15), Intoxication, and Distracting painful injury.

Because the cartilaginous physis (growth plate) is biomechanically weaker than surrounding ligaments and mineralized bone in children, trauma that would sprain an adult ligament frequently fractures the pediatric physis. The SALTER mnemonic classifies Types I through V from epiphysis downward: Type I (S = Straight across) separates the physis alone without metaphyseal or epiphyseal fracture lines (radiographs may appear normal except for soft tissue swelling; excellent prognosis with closed immobilization). Type II (A = Above) fractures through the physis and exits superiorly through the metaphysis (the most common type, ~75% of cases; Thurston-Holland fragment; good prognosis). Type III (L = Lower / Below) fractures through the physis and exits inferiorly through the epiphysis into the joint space (intra-articular; requires open reduction and internal fixation [ORIF]). Type IV (TE = Through Everything) passes through the metaphysis, physis, and epiphysis (intra-articular; requires anatomic ORIF). Type V (R = Rammed / Crushed) represents axial compression crushing the germinal zone of the physis, carrying the worst prognosis due to premature physeal arrest and limb-length discrepancy.