: Peripheral Nerve Entrapments, Plexopathies & Thoracic Outlet Syndrome
High-yield osteopathic and orthopedic localization of thoracic outlet compression sites, brachial and lumbosacral plexopathies, upper/lower extremity tunnel syndromes, and myofascial release.
Key Takeaway
Thoracic Outlet Syndrome occurs across three anatomical bottlenecks: the interscalene triangle (anterior/middle scalenes + 1st rib, tested by Adson test), costoclavicular space (clavicle + 1st rib, tested by military brace), and retropectoralis minor space (coracoid + pectoralis minor, tested by Wright hyperabduction).
Shoulder Physical Examination: Impingement, Rotator Cuff & Labrum
<p class="text-base leading-relaxed text-offwhite/90 mb-4">The shoulder possesses the greatest range of motion of any joint, relying primarily on dynamic muscular stabilization from the rotator cuff (SITS: Supraspinatus, Infraspinatus, Teres Minor, Subscapularis). Orthopedic testing isolates discrete anatomical components:</p>
1. Subacromial Impingement Tests
<ul class="list-disc list-inside text-sm text-offwhite/85 space-y-2 mb-3"><li><strong>Hawkins-Kennedy Test:</strong> Physician flexes the patient's shoulder and elbow to 90°, then forcefully internally rotates the humerus. Drives the greater tuberosity against the coracoacromial ligament. <em>Positive:</em> Pain, indicating subacromial impingement or supraspinatus tendinopathy.</li><li><strong>Neer Impingement Test:</strong> Physician stabilizes the scapula and passively elevates the pronated arm into full forward flexion. Jams the greater tuberosity against the anteroinferior acromion. <em>Positive:</em> Subacromial pain.</li></ul>
2. Rotator Cuff Integrity Tests
<ul class="list-disc list-inside text-sm text-offwhite/85 space-y-2 mb-3"><li><strong>Empty Can Test (Jobe's Test):</strong> Arms abducted to 90° and horizontally adducted 30° into the scapular plane with thumbs pointed downward (full internal rotation). Patient resists downward pressure. <em>Positive:</em> Pain or weakness indicates <span class="hy-pearl font-bold">Supraspinatus</span> tendinopathy or tear.</li><li><strong>Drop Arm Test:</strong> Patient's arm is passively abducted to 180° and they are asked to slowly lower it to the side. <em>Positive:</em> Arm suddenly drops uncontrollably around 90°, diagnostic of a <span class="hy-pearl font-bold">massive full-thickness Supraspinatus tear</span>.</li><li><strong>Lift-Off & Belly-Press Tests:</strong> Patient places dorsum of hand on lumbar spine and lifts hand away from back. <em>Positive:</em> Inability to lift off indicates a <span class="hy-pearl font-bold">Subscapularis</span> tear (internal rotator).</li><li><strong>External Rotation Lag Sign:</strong> Arm held in 90° elbow flexion and 20° shoulder abduction, fully externally rotated by examiner. Patient asked to hold position. <em>Positive:</em> Forearm springs back into internal rotation, diagnostic of <span class="hy-pearl font-bold">Infraspinatus & Teres Minor</span> tear.</li></ul>
3. Biceps Tendon & Glenoid Labrum Tests
<ul class="list-disc list-inside text-sm text-offwhite/85 space-y-1.5 mb-3"><li><strong>Speed's Test:</strong> 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.</li><li><strong>Yergason's Test:</strong> 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.</li><li><strong>O'Brien's Active Compression Test (SLAP Lesion):</strong> Arm flexed to 90° and adducted 10° across chest with thumb down (internal rotation). Downward force applied. Repeated with thumb up (supination). <em>Positive:</em> Pain inside joint with thumb down that resolves with thumb up indicates a superior labrum anterior-to-posterior (SLAP) tear.</li></ul>
| Anatomical Structure | Innervation & Action | Special Provocative Tests | Positive Test Execution & Clinical Pathology |
|---|---|---|---|
| Supraspinatus (#1 Rotator Cuff Tear) & Subacromial Bursa | Suprascapular Nerve (C5–C6); initiates the first 0°–15° of shoulder abduction | Empty Can (Jobe) Test, Drop Arm Test, Neer Impingement Test, Hawkins-Kennedy Impingement Test, Painful Arc (60°–120°) | Empty Can: 90° abduction in scapular plane (30° forward) with full internal rotation (thumbs down) against downward force. Hawkins: 90° forward flexion + forced internal rotation |
| Infraspinatus & Teres Minor (Posterior Cuff) | Infraspinatus: Suprascapular Nerve (C5–C6). Teres Minor: Axillary Nerve (C5–C6). Both externally rotate the humerus | External Rotation Lag Sign & Resisted External Rotation at 0° Abduction (elbows at sides) | Patient cannot maintain passive full external rotation or shows weakness against medial pressure with elbows flexed 90° at sides |
| Subscapularis (Anterior Cuff — Lesser Tubercle) | Upper & Lower Subscapular Nerves (C5–C7); internally rotates and adducts the humerus | Gerber Lift-Off Test & Belly-Press (Napoleon) Test | Lift-Off Test: patient places dorsum of hand against mid-lumbar spine and cannot lift hand posteriorly away from the back against resistance |
| Long Head of Biceps Tendon & Superior Labrum (SLAP Tear) | Musculocutaneous Nerve (C5–C7); tendon courses in bicipital groove and attaches to supraglenoid tubercle / superior labrum | Speed Test, Yergason Test (Biceps tendon/transverse humeral ligament), and O'Brien Active Compression Test (SLAP tear) | Speed: pain in bicipital groove with resisted shoulder forward flexion (elbow extended, forearm supinated). Yergason: resisted supination with elbow flexed 90°. O'Brien: 90° flexion, 15° adduction—pain with thumb down relieved with palm up |
| Glenohumeral Capsule & Inferior Labrum (Bankart Lesion) | Anterior-inferior glenohumeral joint stability (95% of shoulder dislocations are Anterior!) | Anterior Apprehension & Relocation Test, Sulcus Sign (multidirectional instability), and Scarf (Cross-Body Adduction) Test (AC joint) | Apprehension: 90° abduction + 90° external rotation produces feeling of impending anterior dislocation, relieved by posterior humeral force (Relocation); always check Axillary Nerve sensation over lateral deltoid! |
Knee Examination: Cruciates, Collaterals & Menisci
<p class="text-base leading-relaxed text-offwhite/90 mb-4">The knee joint is a modified hinge joint stabilized by four primary ligaments and two fibrocartilaginous menisci:</p>
1. Anterior & Posterior Cruciate Ligament (ACL & PCL) Testing
<ul class="list-disc list-inside text-sm text-offwhite/85 space-y-2 mb-3"><li><strong>Lachman Test (Gold Standard for ACL):</strong> Knee flexed to <span class="hy-pearl font-bold">30°</span>. Physician stabilizes the distal femur with one hand and pulls the proximal tibia anteriorly with the other. <em>Positive:</em> Increased anterior tibial translation (> 3 mm) or soft, mushy end-feel. Has <strong>85% to 95% sensitivity</strong> for acute ACL tear (far superior to Anterior Drawer because hamstring guarding is minimized at 30°).</li><li><strong>Anterior Drawer Test:</strong> 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.</li><li><strong>Posterior Drawer Test (PCL):</strong> Knee flexed to 90°. Proximal tibia pushed posteriorly. Tests PCL integrity.</li><li><strong>Posterior Sag Sign (Godfrey's Test):</strong> 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.</li></ul>
2. Meniscal Evaluation: McMurray & Thessaly Tests
<ul class="list-disc list-inside text-sm text-offwhite/85 space-y-2 mb-3"><li><strong>McMurray Test:</strong> Knee fully flexed, examiner rotates tibia while applying axial load and extending the knee:<br>• <strong>Medial Meniscus:</strong> Tibia <span class="hy-pearl font-bold">EXTERNALLY ROTATED</span> with <span class="hy-pearl font-bold">VALGUS STRESS</span> while extending.<br>• <strong>Lateral Meniscus:</strong> Tibia <span class="hy-pearl font-bold">INTERNALLY ROTATED</span> with <span class="hy-pearl font-bold">VARUS STRESS</span> while extending.<br>• <em>Positive:</em> A palpable click or pop along the joint line with localized pain.</li><li><strong>Thessaly Test:</strong> 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.</li></ul>
| Knee Structure | Anatomical Attachments & Biomechanical Restraint | Special Provocative Tests | Positive Test Execution & Clinical Triad Pearl |
|---|---|---|---|
| Anterior Cruciate Ligament (ACL) | Lateral femoral condyle → Anterior intercondylar area of tibia; prevents ANTERIOR translation and internal rotation of tibia on femur | Lachman Test (MOST SENSITIVE — performed at 20°–30° flexion), Anterior Drawer Test (90° flexion), Pivot Shift Test | Non-contact pivoting injury with audible 'pop' and rapid hemarthrosis (<2 hr). O'Donoghue Unhappy Triad = ACL + MCL + Medial Meniscus (attached to deep MCL) |
| Posterior Cruciate Ligament (PCL) | Medial femoral condyle → Posterior intercondylar area of tibia; prevents POSTERIOR translation of tibia on femur | Posterior Drawer Test (90° flexion), Posterior Sag (Godfrey) Sign, Quadriceps Active Test | 'Dashboard Injury' (direct anterior blow to proximal tibia with knee flexed 90° in MVA) or falling onto a flexed knee with foot plantarflexed |
| Medial Collateral Ligament (MCL — Tibial Collateral) | Medial femoral epicondyle → Medial tibial condyle/shaft (deep fibers fuse with Medial Meniscus) | Valgus Stress Test at 0° (tests MCL + cruciates/capsule) and 30° Knee Flexion (isolates superficial MCL) | Lateral-to-medial blow to the outside of the knee (valgus force) produces medial joint line gapping and pain at 30° flexion |
| Lateral Collateral Ligament (LCL — Fibular Collateral) | Lateral femoral epicondyle → Head of Fibula (extracapsular; does NOT attach to Lateral Meniscus) | Varus Stress Test at 0° and 30° Knee Flexion | Medial-to-lateral blow to the inside of the knee (varus force) produces lateral joint line gapping; screen Common Peroneal Nerve function |
| Medial & Lateral Menisci | Fibrocartilaginous wedges deepening tibial plateau (outer 1/3 'Red Zone' vascularized; inner 2/3 'White Zone' avascular) | McMurray Test, Thessaly Test (MOST ACCURATE — 20° single-leg rotation), and Apley Compression vs. Distraction Test | Joint line tenderness, mechanical locking/catching. McMurray Medial Meniscus: Flex knee → Externally rotate tibia + Valgus force + Extend. Lateral Meniscus: Flex knee → Internally rotate tibia + Varus force + Extend |
Hip, Pelvis, Ankle & Spine Orthopedic Discriminators
<p class="text-base leading-relaxed text-offwhite/90 mb-4">Provocative testing across the spine, pelvis, and lower extremities isolates radiculopathy, muscular contractures, and ligamentous ruptures:</p> <p>Differentiating lumbar radiculopathy, sacroiliac joint somatic dysfunction, iliopsoas/iliotibial band contracture, and intra-articular femoroacetabular pathology requires a targeted sequence of provocative hip and lumbosacral maneuvers.</p>
Contracture & Abductor Stability Tests: Thomas, Ober & Trendelenburg
<p>The <strong>Thomas test</strong> evaluates for a fixed <strong>iliopsoas hip flexion contracture</strong>: 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 <strong>Ober test</strong> assesses for <strong>iliotibial (IT) band and tensor fasciae latae (TFL) contracture</strong>: 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 <strong>Trendelenburg test</strong> evaluates the <strong>superior gluteal nerve (L4–S1)</strong> and hip abductors (<strong>gluteus medius and minimus</strong>): when standing on one leg, if the contralateral pelvis drops downward, the <strong>stance-leg (ipsilateral) gluteus medius/minimus</strong> is weak.</p>
Intra-Articular Hip vs. Sacroiliac vs. Sciatic Provocation: FABER, FADIR & Straight Leg Raise
<p>The <strong>FABER (Patrick) test</strong> (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 <strong>anterior groin pain</strong> indicates intra-articular hip pathology (osteoarthritis, avascular necrosis), whereas reproducing <strong>posterior buttock pain over the PSIS</strong> indicates sacroiliac joint dysfunction. Conversely, the <strong>FADIR test</strong> (Flexion, Adduction, Internal Rotation) compresses the anterior femoral neck against the acetabular rim and is the most sensitive screen for <strong>anterior femoroacetabular impingement (FAI) and anterior labral tears</strong>. In the spine, a positive <strong>Straight Leg Raise (Lasègue test)</strong> reproducing radiating dermatomal pain below the knee between <strong>30 and 70 degrees of hip flexion</strong> indicates L4–S1 nerve root tension (herniated nucleus pulposus), confirmed by Bragard sign (worsening with ankle dorsiflexion).</p>
| Orthopedic Test | Target Anatomic Structure | Examination Maneuver | Positive Finding & Clinical Significance |
|---|---|---|---|
| FABER (Patrick's Test) | Hip Joint vs. Sacroiliac Joint | Hip placed in <strong>F</strong>lexion, <strong>AB</strong>duction, and <strong>E</strong>xternal <strong>R</strong>otation (figure-4) | Groin pain = <span class="hy-pearl">Hip osteoarthritis</span>.<br>Posterior buttock pain = <span class="hy-pearl">Sacroiliac joint pathology</span>. |
| FADIR Test | Femoroacetabular Impingement (FAI) | Hip placed in <strong>F</strong>lexion, <strong>AD</strong>duction, and <strong>I</strong>nternal <strong>R</strong>otation | Anterolateral hip pain / click indicating labral tear or cam/pincer FAI |
| Thomas Test | Iliopsoas Muscle (Hip Flexors) | Patient supine, flexes contralateral knee to chest | Affected thigh lifts off table, confirming <span class="hy-pearl">psoas spasm / hip flexion contracture</span> |
| Ober's Test | Iliotibial Band & Tensor Fasciae Latae | Patient side-lying, examiner abducts & extends hip with knee flexed 90°, then releases | Thigh remains abducted above horizontal, confirming <span class="hy-pearl">IT band contracture</span> |
| Trendelenburg Test | Gluteus Medius / Superior Gluteal Nerve | Patient stands on one leg | Pelvis drops on the unsupported contralateral swinging side, confirming <span class="hy-pearl">gluteus medius weakness</span> |
| Straight Leg Raise (Lasegue) | L4–S1 Sciatic Nerve Roots | Passive elevation of extended lower extremity (positive between 30° and 70°) | Sharp radicular pain radiating below knee. <span class="hy-pearl">Braggard's test</span> (ankle dorsiflexion) confirms dural origin |
| Thompson Squeeze Test | Achilles Tendon (Calcaneal Tendon) | Patient prone with feet hanging off table; physician squeezes calf belly | <span class="hy-pearl font-bold">Absence of passive plantarflexion</span> confirms complete Achilles tendon rupture |
| Anterior Drawer (Ankle) | Anterior Talofibular Ligament (ATFL) | Anterior translation of talus with calcaneus cupped | Increased anterior translation / sulcus sign confirms <span class="hy-pearl">ATFL inversion sprain</span> |
| Finkelstein's Test | APL & EPB Tendons (1st Dorsal Compartment) | Thumb tucked inside fist, wrist forcefully ulnar-deviated | Sharp pain over radial styloid confirms <span class="hy-pearl">de Quervain tenosynovitis</span> |
Cervical Spine, Thoracic Outlet & Wrist Provocative Tests
<p class="text-base leading-relaxed text-offwhite/90 mb-4">Provocative orthopedic tests isolate specific mechanical bottlenecks, impingements, and ligamentous instabilities. Mastering their precise positioning, sensitivity, and clinical implications is essential for board success:</p>
1. Cervical Radiculopathy Provocative Tests
<ul class="list-disc list-inside text-sm text-offwhite/85 space-y-1.5 mb-3"><li><strong>Spurling Test (Neck Compression):</strong> 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 <strong>cervical radiculopathy (cervical nerve root compression)</strong>. Highly specific (> 90%).</li><li><strong>Shoulder Abduction (Bakody) Relief Sign:</strong> 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).</li><li><strong>Lhermitte Sign:</strong> Passive neck flexion elicits an electric shock-like sensation shooting down the spine into the extremities; indicates <strong>cervical spinal cord compression (myelopathy) or multiple sclerosis</strong>.</li></ul>
2. Thoracic Outlet Syndrome (TOS) Provocative Battery
<ul class="list-disc list-inside text-sm text-offwhite/85 space-y-1.5 mb-3"><li><strong>Adson Test:</strong> Patient seated; physician palpates radial pulse, abducts arm slightly, and asks patient to extend neck and rotate head <span class="hy-pearl font-bold">TOWARD the affected side</span>, taking a deep breath and holding it. Diminution or loss of radial pulse indicates compression between the <strong>Anterior and Middle Scalenes</strong> (hypertrophy or cervical rib).</li><li><strong>Wright Hyperabduction Test:</strong> 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 <strong>Pectoralis Minor tendon and coracoid process</strong>.</li><li><strong>Eden / Costoclavicular Test:</strong> 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 <strong>Clavicle and 1st Rib</strong>.</li></ul>
| Orthopedic Special Test | Target Anatomical Structure | Physical Maneuver | Positive Test Finding | Diagnostic Clinical Significance |
|---|---|---|---|---|
| Spurling Test | Cervical Neuroforamen | Axial compression with neck extended and ipsilaterally sidebent | Sharp radicular arm pain along dermatome | Cervical disc herniation or foraminal stenosis |
| Adson Test | Interscalene Triangle | Neck extended, head rotated toward affected side + deep inhalation | Diminution or disappearance of radial pulse | Scalene-induced Thoracic Outlet Syndrome |
| Wright Test | Retropectoral Space | Arm hyperabducted > 90° and externally rotated | Obliteration of radial pulse or paroxysmal paresthesias | Pectoralis minor Thoracic Outlet Syndrome |
| Finkelstein Test | 1st Dorsal Extensor Wrist Compartment | Thumb inside clenched fist, passive ulnar wrist deviation | Severe, sharp pain over radial styloid process | De Quervain tenosynovitis (APL & EPB) |
| Phalen Test | Carpal Tunnel | Dorsal wrists pressed together in 90° flexion for 60 seconds | Median nerve paresthesias in thumb, index, middle fingers | Carpal Tunnel Syndrome |
| Durkan Test | Carpal Tunnel | Direct thumb compression over median nerve for 30 seconds | Reproduction of median nerve numbness and tingling | Carpal Tunnel Syndrome (Highest Sensitivity) |
Elbow, Forearm, Wrist & Hand Provocative Examination Matrix
<p>Upper extremity distal orthopedic examination requires precise isolation of epicondylar tendons, collateral ligaments, and peripheral nerve tunnels (Median, Ulnar, and Radial nerves).</p> <p>Distal upper extremity orthopedic tests localize tendinopathies of the medial and lateral epicondyles, stenosing tenosynovitis of the first dorsal wrist compartment, collateral ligament instability, and peripheral entrapment of the median and ulnar nerves.</p>
Epicondylitis, Collateral Ligament Stress & De Quervain Tenosynovitis Maneuvers
<p><strong>Cozen test</strong> (resisted wrist extension and radial deviation with a pronated forearm reproducing lateral epicondyle pain) and <strong>Mill test</strong> (passive wrist flexion with the elbow fully extended and forearm pronated) diagnose <strong>lateral epicondylitis ('tennis elbow')</strong>, caused by angiofibroblastic tendinosis of the <strong>extensor carpi radialis brevis (ECRB)</strong> origin. Conversely, pain at the medial epicondyle during resisted wrist flexion and forearm pronation diagnoses <strong>medial epicondylitis ('golfer's/pitcher's elbow')</strong> of the pronator teres and flexor carpi radialis origin. At the radial styloid, <strong>Finkelstein test</strong> (grasping the thumb inside a closed fist and passively deviating the wrist ulnarly) reproduces sharp pain over the first dorsal extensor compartment—containing the <strong>abductor pollicis longus (APL) and extensor pollicis brevis (EPB)</strong> tendons—confirming <strong>de Quervain tenosynovitis</strong>.</p>
Median & Ulnar Nerve Hand Provocative Signs & Allen Vascular Test
<p><strong>Carpal tunnel syndrome</strong> (median nerve compression beneath the transverse carpal ligament) is provoked by <strong>Phalen maneuver</strong> (holding maximal wrist flexion for 60 seconds), <strong>Carpal Compression (Durkan) test</strong> (direct thumb pressure over the carpal tunnel for 30 seconds, the most sensitive bedside maneuver), and <strong>Tinel sign</strong> at the volar wrist, producing paresthesias in the thumb, index, middle, and radial half of the ring finger. <strong>Ulnar neuropathy</strong> (cubital tunnel or Guyon canal) is tested via <strong>Froment sign</strong>: when pinching a sheet of paper between the thumb and index finger, weakness of the ulnar-innervated <strong>adductor pollicis</strong> forces the patient to flex the thumb interphalangeal joint using the median-innervated <strong>flexor pollicis longus (AIN)</strong>. Prior to radial arterial line placement or ABG sampling, the <strong>Modified Allen test</strong> verifies patent collateral palmar arch perfusion via the ulnar artery.</p>
| Special Test | Exact Clinical Execution | Positive Finding | Anatomical Structure / Pathology | Primary Management & OMT |
|---|---|---|---|---|
| Cozen Test & Mill Test | Cozen: Patient makes a fist, pronates forearm, and radially deviates/extends wrist against operator resistance while operator palpates lateral epicondyle. Mill: Passive full elbow extension with forearm pronated and wrist fully flexed. | Sharp reproducible pain over the Lateral Epicondyle of the humerus. | Lateral Epicondylitis ('Tennis Elbow') — angiofibroblastic tendinosis of Extensor Carpi Radialis Brevis (ECRB) origin. | Counterstrain (Lateral Epicondyle / RAD TP), Wrist Extensor MET, forearm counterforce brace, eccentric strengthening. |
| Golfer's Elbow Test | Operator palpates the medial epicondyle while passively supinating the forearm and extending the elbow and wrist (or resisting wrist flexion/pronation). | Pain localized over the Medial Epicondyle. | Medial Epicondylitis ('Golfer's Elbow' / 'Little League Elbow') — Flexor Carpi Radialis & Pronator Teres origin. | Medial Epicondyle Counterstrain (MED TP: Flex elbow, Pronate, Flex wrist), Wrist Flexor MET. |
| Valgus vs. Varus Elbow Stress Test | Elbow flexed 20°–30° (to unlock the olecranon from the olecranon fossa!) while applying Valgus force (abducting forearm) or Varus force (adducting forearm). | Joint line gapping/laxity or medial/lateral pain. | Valgus Stress = Ulnar Collateral Ligament (UCL — injured in overhead baseball pitchers; reconstructed via Tommy John surgery). Varus Stress = Radial Collateral Ligament (RCL). | Rest/hinged brace for Grade I–II sprains; UCL reconstruction (palmaris longus autograft) for competitive throwers with complete tear. |
| Phalen, Reverse Phalen, Durkan & Tinel at Wrist | Phalen: Dorsal aspects of both hands pressed together in 90° wrist flexion for 60s. Durkan (Most Sensitive!): Direct thumb compression over carpal tunnel for 30s. Tinel: Percussion over palmaris longus / flexor retinaculum. | Numbness, tingling, and paresthesias radiating into the thumb, index, middle, and radial half of the ring finger (sparing the palm — palmar cutaneous branch travels superficial to retinaculum!). | Carpal Tunnel Syndrome — Median Nerve (C5–T1) compression beneath the Transverse Carpal Ligament (Flexor Retinaculum). | Nocturnal neutral wrist splinting, Opponens Roll MFR, carpal glide HVLA/MET, corticosteroid injection, or surgical flexor retinaculum release (if thenar atrophy). |
| Froment Sign & Wartenberg Sign | Froment: Patient pinches a sheet of paper between thumb and index finger (key pinch) while operator pulls the paper away. Wartenberg: Patient attempts to adduct all fingers together. | Froment: Patient flexes the thumb IP joint (using Flexor Pollicis Longus [AIN / Median nerve]) because Adductor Pollicis is paralyzed. Wartenberg: 5th digit remains abducted (unopposed EDM pull). | Ulnar Nerve (C8–T1) Neuropathy (at Cubital Tunnel or Guyon Canal) causing paralysis of Adductor Pollicis and Palmar Interossei. | Elbow extension night splint (cubital tunnel), padded cycling gloves (Guyon canal), or surgical nerve decompression/transposition. |
| Finkelstein & Eichhoff Tests | Finkelstein: Operator grasps the patient's thumb and sharply deviates the wrist ulnarly. Eichhoff: Patient tucks thumb inside closed fist and ulnarly deviates wrist. | Sharp pain over the radial styloid process and 1st dorsal extensor compartment. | De Quervain Tenosynovitis — stenosing tenosynovitis of Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB). | Thumb spica splint (immobilizing BOTH wrist and thumb MCP), NSAIDs, radial head/carpal OMT, or corticosteroid injection into 1st compartment. |
| Allen Test | Patient clenches fist rapidly while operator occludes BOTH radial and ulnar arteries at the wrist; patient opens hand (blanched palm), and operator releases ONLY the ulnar artery (then repeats releasing only radial). | Failure of palmar blush to return within <5–7 seconds upon releasing the ulnar artery indicates an incomplete superficial palmar arch. | Assesses collateral ulnar arterial perfusion prior to Radial Artery cannulation (ABG / arterial line) or radial forearm harvest. | If Allen test is abnormal (positive for insufficiency), DO NOT cannulate the radial artery (risks ischemic hand necrosis!). |
Thoracolumbar, Sacroiliac, Hip, Pediatric & Ankle Special Tests Master Matrix
<p>Lower quarter orthopedic testing differentiates lumbar radiculopathy, sacroiliac joint dysfunction, intra-articular hip pathology, gluteal nerve injury, and ligamentous ankle tears.</p> <p>Lower extremity stability maneuvers systematically evaluate the three lateral ankle ligaments, the medial deltoid ligament complex, the distal tibiofibular syndesmosis, the Achilles tendon, and pediatric developmental hip stability.</p>
Ankle Ligamentous Stability, High Ankle Syndesmosis & Thompson Achilles Testing
<p>The <strong>Anterior Drawer test of the ankle</strong> evaluates the <strong>anterior talofibular ligament (ATFL)</strong>—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 <strong>Talar Tilt (Inversion Stress) test</strong> inverts the calcaneus with the ankle in neutral dorsiflexion to test the <strong>calcaneofibular ligament (CFL)</strong> (or everts the calcaneus to test the medial deltoid ligament). A <strong>high ankle (syndesmotic) sprain</strong>—involving the anterior inferior tibiofibular ligament (AITFL) and interosseous membrane from forced external rotation/hyperdorsiflexion—is diagnosed by the <strong>Squeeze (Hopkins) test</strong> (compressing the mid-calf tibia and fibula together reproduces distal syndesmotic pain) and the <strong>Kleiger (External Rotation Stress) test</strong>. Complete <strong>Achilles tendon rupture</strong> (S1–S2) is confirmed by a positive <strong>Thompson test</strong>: squeezing the gastrocnemius-soleus calf belly with the patient prone fails to elicit passive plantarflexion.</p>
Sacroiliac Provocation & Pediatric Ortolani/Barlow Hip Screening
<p>To isolate sacroiliac joint pathology from lumbar spine pain, the <strong>Gaenslen test</strong> 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 <strong>Developmental Dysplasia of the Hip (DDH)</strong> utilizes two complementary maneuvers: the <strong>Barlow maneuver</strong> attempts to <em>dislocate</em> an unstable femoral head posteriorly out of the acetabulum via hip <strong>adduction and gentle posterior pressure</strong>, whereas the <strong>Ortolani maneuver</strong> <em>reduces</em> a posteriorly dislocated femoral head back into the acetabulum via hip <strong>abduction and anterior upward lifting</strong> of the greater trochanter, producing a palpable 'clunk.'</p>
| Special Test | Exact Clinical Execution | Positive Finding | Anatomical Structure / Pathology | High-Yield Board Pearl |
|---|---|---|---|---|
| Straight Leg Raise (SLR / Lasègue) & Bragard Test | Patient supine; operator passively elevates the straight leg by the heel with the knee fully extended. Bragard: Lower leg slightly below pain threshold and dorsiflex the ankle. | Radicular shooting pain radiating BELOW THE KNEE into the calf/foot at 30°–70° of hip flexion (isolated hamstring tightness in posterior thigh is NEGATIVE!). | L4, L5, or S1 Nerve Root Compression (Sciatic nerve tension from posterolateral lumbar HNP). | Crossed SLR (elevating the UNAFFECTED leg reproduces radicular pain down the AFFECTED leg) has lower sensitivity (~30%) but very HIGH SPECIFICITY (>90%) for a large central/paracentral disc herniation! |
| Femoral Nerve Stretch (Reverse SLR / Ely-like) Test | Patient prone (or lateral recumbent); operator flexes the knee to 90° and passively extends the hip. | Radiating pain into the ANTERIOR THIGH and medial shin. | High Lumbar Radiculopathy (L2, L3, or L4 Nerve Root compression). | Distinguishes L2–L4 radiculopathy (Femoral nerve) from L5–S1 radiculopathy (Sciatic nerve / SLR). |
| Stork (Single-Leg Hyperextension) Test | Patient stands on one leg and extends the lumbar spine backward (repeats on opposite leg). | Unilateral localized lower back pain on the weight-bearing side. | Spondylolysis (Pars Interarticularis stress fracture, typically at L5 in adolescent gymnasts/divers/linemen). | Confirm with oblique lumbar X-ray ('Scotty Dog with a collar/broken neck') or thin-slice CT/MRI; treat with activity restriction and TLSO bracing. |
| Schober Test | Mark L5 spinous process (dimples of Venus) and a point 10 cm superior while patient stands erect; ask patient to bend forward maximally and remeasure distance. | Distance increases by <5 cm (i.e., total length <15 cm on maximal lumbar flexion). | Decreased lumbar flexion excursion classic for Ankylosing Spondylitis (seronegative spondyloarthropathy, HLA-B27+). | Combined with sacroiliitis on pelvic X-ray, morning stiffness >30 min improving with exercise, and anterior uveitis. |
| FABER (Patrick) vs. FADIR Test | FABER: Supine figure-4 (Flexion, Abduction, External Rotation) with downward pressure on flexed knee and contralateral ASIS. FADIR: Supine Flexion (90°), Adduction, Internal Rotation. | FABER: Posterior buttock pain = Sacroiliac (SI) joint pathology; Anterior groin pain = Intra-articular Hip pathology (OA, labral tear, psoas). FADIR: Anterior groin pain = Femoroacetabular Impingement (FAI) / Anterior Labral Tear; Posterior pain = Piriformis Syndrome (FAIR test). | Differentiates SI Joint vs. Hip Joint vs. Piriformis Syndrome. | Always look at WHERE the pain is reproduced during FABER: Groin = Hip joint; Posterior PSIS/buttock = SI joint! |
| Thomas Test vs. Ober Test | Thomas: Supine patient pulls one knee tightly to chest while contralateral leg hangs flat on table. Ober: Lateral recumbent (affected side UP); operator abducts and extends hip with knee flexed 90°, then allows thigh to adduct toward table. | Thomas: Contralateral thigh rises off the table. Ober: Affected thigh remains suspended in abduction (fails to drop below horizontal). | Thomas = Iliopsoas Flexion Contracture (contralateral hip). Ober = Iliotibial (IT) Band / Tensor Fasciae Latae (TFL) Contracture. | If the knee extends when pressing the thigh down in Thomas test, suspect Rectus Femoris contracture (Kendall test)! |
| Trendelenburg Sign | Patient stands on ONE leg (e.g., Right leg) while operator observes the iliac crests/PSIS from behind. | The CONTRALATERAL (non-weight-bearing Left) pelvis drops inferiorly. | Weakness of the IPSILATERAL (weight-bearing Right) Gluteus Medius & Minimus muscles or injury to the IPSILATERAL Superior Gluteal Nerve (L4–S1, e.g., after superomedial gluteal IM injection or posterior hip surgery). | Compensatory gait ('Trendelenburg lurch'): Patient leans their trunk TOWARD the weak (stance) side to shift the center of gravity over the weak hip! |
| Ortolani & Barlow Maneuvers + Galeazzi Sign | Performed in newborns/infants <4–6 months: Barlow adducts hip with gentle posterior pressure (checks if hip is dislocatable); Ortolani abducts hip while lifting greater trochanter anteriorly with index/middle fingers (relocates a dislocated femoral head). Galeazzi: Supine hips flexed 45°, knees flexed 90°. | Palpable/audible 'clunk' (not a benign high-pitched click!) or unequal knee heights (femoral shortening on dislocated side on Galeazzi). | Developmental Dysplasia of the Hip (DDH) — risk factors: female, breech presentation, oligohydramnios, firstborn. | Screen with Hip Ultrasound (<4–6 months, prior to femoral head ossification) or AP Pelvic X-ray (>4–6 months); treat with Pavlik harness! |
| Ankle Anterior Drawer, Talar Tilt, Kleiger & Thompson Tests | Anterior Drawer: Pull calcaneus anteriorly relative to stabilized tibia. Talar Tilt: Invert calcaneus sharply. Kleiger: Dorsiflex and externally rotate foot. Thompson: Prone patient with feet hanging off table; squeeze gastrocnemius belly. | Anterior Drawer = Anterior Talofibular Ligament (ATFL — #1 injured ankle ligament!). Talar Tilt = Calcaneofibular Ligament (CFL). Kleiger/Squeeze = Syndesmotic High Ankle Sprain (AITFL). Thompson = Absence of passive plantarflexion. | ATFL, CFL, AITFL (high ankle sprain), and Achilles Tendon Rupture (S1 — fluoroquinolone or steroid risk!). | Ottawa Ankle Rules: Obtain ankle X-ray only if bone tenderness at posterior edge/tip of lateral or medial malleolus OR inability to bear weight for 4 steps. |
Board-Style Active-Recall Clinical Vignette Drills
Source
Based on the publicly available table of contents and topic organization of OMM Review: A Comprehensive Review of Osteopathic Medicine. All notes are original; no copyrighted text, figures, or full source material is included.