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Special Tests
Comprehensive OMT reference hub, interactive cheat sheets, and board review notes for COMLEX Level 1, 2-CE, and 3.
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Key Takeaway
Special physical exam tests localize anatomical entrapments, ligamentous tears, and somatic dysfunctions. Master positive findings, patient positioning, and clinical traps for rapid COMLEX recognition.
Diagnostic Matrix: Quick Reference Guide
The following master table synthesizes the most frequently tested orthopedic and osteopathic special tests across all anatomical regions, their target pathology, positive test mechanics, and classic COMLEX clinical pearls.
| Anatomical Region | Special Test | Target Pathology / Structure | Positive Test Finding & Mechanism |
|---|---|---|---|
| Cervical Spine | Spurling Test (Neck Compression) | Cervical radiculopathy / Neural foraminal stenosis | Extension + sidebending to ipsilateral side with downward axial pressure reproduces radicular arm pain/paresthesias. |
| Cervical Spine | Wallenberg Test (DeKleyn Test) | Vertebral artery insufficiency | Cervical extension + rotation held for 10-30s produces dizziness, nystagmus, or visual changes; absolute contraindication to HVLA. |
| Cervical Spine | Cervical Distraction Test | Cervical nerve root compression | Cephalad axial traction relieves radicular neck and arm symptoms by enlarging intervertebral neural foramina. |
| Shoulder | Neer Impingement Test | Subacromial impingement / Supraspinatus tendon | Passive maximal forward flexion with internal rotation reproduces anterior/anterolateral shoulder pain. |
| Shoulder | Hawkins-Kennedy Test | Subacromial impingement (Supraspinatus vs coracoacromial ligament) | Arm flexed 90° and elbow 90°, passive internal rotation compresses supraspinatus against coracoacromial arch. |
| Shoulder | Empty Can (Jobe) Test | Supraspinatus muscle / tendon tear or tendinopathy | Arm abducted 90°, horizontally adducted 30° (scapular plane), internally rotated (thumbs down); pain/weakness against downward force. |
| Shoulder | Drop Arm Test | Full-thickness rotator cuff tear (Supraspinatus) | Patient passively abducted to 90° is unable to slowly control lowering the arm; arm suddenly drops around 90°. |
| Shoulder | Speed's Test | Biceps tendon pathology / Tenosynovitis in bicipital groove | Arm forward flexed 90°, elbow extended, forearm supinated; patient resists downward force, reproducing anterior groove pain. |
| Shoulder | Yergason's Test | Biceps tendon instability / Transverse humeral ligament rupture | Elbow flexed 90°, patient actively supinates and flexes forearm against physician's resistance while physician palpates groove; tendon pops out or causes pain. |
| Shoulder | Apley's Scratch Test | Gross active shoulder range of motion | Abduction + external rotation (touch opposite superior scapula) vs Adduction + internal rotation (touch opposite inferior angle). |
| Thoracic Outlet | Adson's Test | Thoracic outlet syndrome (Anterior & Middle Scalenes) | Palpate radial pulse, extend elbow, extend/abduct/externally rotate shoulder; patient deeply inhales and rotates head toward ipsilateral side; diminished pulse = positive. |
| Thoracic Outlet | Wright's Hyperabduction Test | Thoracic outlet syndrome (Pectoralis Minor & Coracoid) | Palpate radial pulse while hyperabducting arm above head in coronal plane with extension; diminished pulse indicates pec minor compression. |
| Thoracic Outlet | Military Posture (Costoclavicular) Test | Thoracic outlet syndrome (Clavicle & First Rib) | Palpate radial pulse while patient depresses and retracts shoulders (shoulders back and down); compression between clavicle and 1st rib. |
| Wrist & Hand | Phalen's Test | Carpal tunnel syndrome (Median nerve) | Maximal bilateral wrist flexion with dorsal surfaces together held for 60s; paresthesias in lateral 3.5 digits. |
| Wrist & Hand | Reverse Phalen's (Prayer) Test | Carpal tunnel syndrome (Median nerve) | Maximal wrist extension with palms pressed together in prayer pose held for 60s; increases intracarpal canal pressure. |
| Wrist & Hand | Tinel's Sign | Peripheral nerve entrapment (Median, Ulnar, Fibular, Tibial) | Light percussion over flexor retinaculum generates electric tingling in median distribution; also positive at cubital tunnel (ulnar) or fibular head (peroneal). |
| Wrist & Hand | Finkelstein Test | De Quervain's tenosynovitis | Patient tucks thumb into closed fist; physician passively ulnar-deviates wrist, eliciting sharp pain at radial styloid (APL & EPB tendons). |
| Wrist & Hand | Allen's Test | Adequacy of collateral arterial supply (Radial vs Ulnar) | Patient makes fist, physician occludes both radial and ulnar arteries; patient opens hand (blanched), one artery released; normal refill < 5-7 seconds. |
| Lumbar Spine | Straight Leg Raise (Lasegue's Test) | Sciatic nerve root irritation / Lumbar disc herniation (L4-S1) | Passive leg elevation with knee straight elicits radicular pain below the knee between 30° and 70°. |
| Lumbar Spine | Braggard's Test | Confirms sciatic nerve etiology vs hamstring tightness | Lower straight leg 5° below pain threshold, then passively dorsiflex ankle; reproduction of pain confirms nerve traction (hamstrings are unaffected). |
| Lumbar Spine | Hip-Drop Test | Lumbar & thoracolumbar sidebending compliance | Patient bends one knee while keeping heel on floor; normal lumbar sidebends away from straight leg with pelvic drop >= 20-25°; failure indicates lumbar restriction. |
| Pelvis & Sacrum | ASIS Compression Test | Laterality of sacroiliac dysfunction | Physician applies posterior/medial spring to alternating ASIS; side of increased resistance indicates dysfunctional sacroiliac joint. |
| Pelvis & Sacrum | Standing Flexion Test | Iliopelvic / Innominate dysfunction (Ilium on Sacrum) | Patient bends forward while thumbs monitor PSIS; the PSIS that moves further cephalad indicates somatic dysfunction on that side. |
| Pelvis & Sacrum | Seated Flexion Test | Sacroiliac dysfunction (Sacrum on Ilium) | Patient bends forward while seated; eliminates lower extremity tension; cephalad PSIS motion identifies the side of sacral dysfunction. |
| Pelvis & Sacrum | Lumbosacral Spring Test | Sacral base motion / Backward torsion vs Forward torsion | Springing force over lumbosacral junction (S1/S2): good spring = forward torsion or flexion (negative test); rigid/poor spring = backward torsion or extension (positive test). |
| Pelvis & Sacrum | Sphinx (Backward Bending) Test | Sacral base motion differentiation | Patient props up on elbows; sacral sulci asymmetry that becomes more symmetric = forward torsion/flexion; asymmetry that worsens = backward torsion/extension. |
| Pelvis & Sacrum | Pelvic Side Shift Test | Sacral midline alignment & psoas contracture | Translating pelvis laterally; deviation away from the side of a lumbar curve or toward the side of psoas hypertonicity. |
| Pelvis & Sacrum | Trendelenburg Test | Gluteus medius weakness (Superior gluteal nerve L4-S1) | Patient stands on one leg; contralateral pelvis drops down due to abductor weakness of the stance leg. |
| Hip Joint | Thomas Test | Psoas / Hip flexor contracture | Patient lies supine and hugs contralateral knee to chest; positive if test leg lifts off the table or lumbar lordosis increases. |
| Hip Joint | Patrick (FABER) Test | Hip osteoarthritis vs Sacroiliac pathology | Flexion, ABduction, External Rotation; anterior groin pain indicates hip joint pathology; posterior SI pain indicates sacroiliac dysfunction. |
| Hip Joint | Ober's Test | Tensor fasciae latae & Iliotibial (IT) band contracture | Patient in lateral recumbent, physician abducts and extends hip with knee flexed 90°, then releases; failure of thigh to adduct past midline is positive. |
| Knee Joint | Lachman's Test | Anterior cruciate ligament (ACL) rupture | Knee flexed 20-30°, stabilize femur and anteriorly translate tibia; increased translation and soft mushy end-point (highest sensitivity for ACL tears). |
| Knee Joint | Anterior Drawer Test (Knee) | Anterior cruciate ligament (ACL) rupture | Knee flexed 90°, patient foot stabilized, anterior translation of proximal tibia; lower sensitivity than Lachman due to hamstring spasm. |
| Knee Joint | Posterior Drawer Test | Posterior cruciate ligament (PCL) rupture | Knee flexed 90°, posterior force directed on proximal tibia; tibial sagging (Sag Sign) and excessive posterior glide confirm PCL tear. |
| Knee Joint | McMurray Test | Meniscal tear (Medial vs Lateral) | Knee fully flexed: External rotation + valgus stress + extension tests Medial Meniscus; Internal rotation + varus stress + extension tests Lateral Meniscus (click or pain). |
| Knee Joint | Apley Compression & Distraction Test | Meniscal tear vs Collateral ligament sprain | Patient prone with knee flexed 90°: axial downward compression + rotation reproduces meniscal pain; upward distraction + rotation reproduces ligamentous pain. |
| Knee Joint | Patellar Grind (Clark's) Test | Chondromalacia patellae / Patellofemoral syndrome | Physician pushes patella inferiorly into trochlear groove while patient gently contracts quadriceps; retropatellar pain and crepitus indicate cartilage wear. |
| Knee Joint | Bounce Home Test | Meniscal tear or joint effusion causing extension block | Patient supine, knee passively flexed then allowed to passively extend into gravity; incomplete extension or springy rubbery block indicates meniscal tear. |
Cervical Spine Special Tests
Cervical tests evaluate neuroforaminal stenosis, nerve root irritation, and vertebral artery blood flow before initiating cervical osteopathic manipulative treatment.
COMLEX Board Trap — Wallenberg Test Safety: Always screen for vertebral basilar insufficiency prior to performing cervical HVLA. If the patient develops nystagmus, lightheadedness, dysarthria, or nausea during extension and rotation, cervical HVLA is strictly contraindicated! Referral for vascular imaging (MRA/CTA) is indicated.
- Spurling Test (Neck Compression): The patient is seated. The physician sidebends and extends the cervical spine toward the affected side and applies a downward axial compressive force to the vertex of the cranium. A positive test produces radicular pain or paresthesias radiating into the ipsilateral upper extremity along the dermatomal distribution of the compressed nerve root.
- Wallenberg Test (DeKleyn Test): Patient is supine. The physician extends and rotates the cervical spine to one side, holding the position for 10 to 30 seconds while observing the patient’s eyes and asking about neurologic symptoms. A positive test indicates compromised blood flow through the contralateral vertebral artery within the transverse foramina.
- Cervical Distraction Test: With the patient supine, the physician grasps under the occiput and chin or forehead, applying gentle cephalad axial traction. Alleviation or substantial decrease of cervical or radicular pain confirms nerve root compression within the intervertebral foramina.
Practice Drill
Q: A 48-year-old carpenter presents with shooting right arm pain and paresthesias into his index and middle fingers. On exam, Spurling test is positive on the right. Which cervical nerve root is most likely affected?
Shoulder Joint & Thoracic Outlet Maneuvers
Shoulder special tests localize tears to specific rotator cuff tendons, assess bicipital tendon stability in the bicipital groove, and pinpoint compression sites in Thoracic Outlet Syndrome (TOS).
| Thoracic Outlet Test | Specific Anatomical Compression Site | Physical Maneuver | Vascular / Neurologic Sign |
|---|---|---|---|
| Adson's Test | Interscalene Triangle (Between Anterior and Middle Scalene muscles) | Elbow extended, shoulder extended, abducted, externally rotated; patient takes a deep breath and turns head towards ipsilateral side. | Marked diminution or complete obliteration of radial pulse; reproduces upper extremity paresthesias. |
| Wright's Test (Hyperabduction) | Subcoracoid space beneath Pectoralis Minor tendon and coracoid process | Physician passively hyperabducts the patient's arm overhead (>180°) in the coronal plane with mild extension. | Radial pulse diminishes or disappears due to pec minor tendon compression against the rib cage. |
| Military Posture (Costoclavicular) Test | Costoclavicular space between Clavicle and First Rib | Physician depresses and retracts the patient's shoulders while palpating radial pulse ('shoulders back and down'). | Radial pulse decreases as neurovascular bundle is pinched between clavicle and first rib. |
High-Yield Rotator Cuff Anatomy Hook: Remember the SITS muscles and their individual actions: • Supraspinatus (Suprascapular n., C5-C6): First 0-15° abduction; evaluated by Empty Can (Jobe) and Drop Arm tests. • Infraspinatus (Suprascapular n., C5-C6): External rotation; evaluated by resisted external rotation at 0° abduction. • Teres Minor (Axillary n., C5-C6): External rotation; evaluated by Hornblower's test. • Subscapularis (Upper and Lower Subscapular n., C5-C6): Internal rotation; evaluated by Lift-off test and Belly-press test.
Wrist, Hand & Neuropathies
Tests in the wrist assess median nerve compression under the flexor retinaculum, tenosynovitis of the first dorsal extensor compartment, and collateral blood flow.
- Phalen's Test: The patient holds both wrists in unforced maximal flexion (dorsal surfaces pressed together) for 60 seconds. A positive test reproduces numbness and tingling in the median nerve distribution (palmar aspect of the thumb, index, middle, and radial half of the ring finger).
- Reverse Phalen's (Prayer) Test: The patient presses palmar surfaces together in maximal wrist extension with elbows at 90° for 60 seconds. This elevates carpal tunnel pressure even higher than flexion, precipitating median nerve ischemia.
- Tinel's Sign: Percussion directly over a suspected nerve entrapment site. While most famous at the carpal tunnel (median nerve), COMLEX also tests Tinel sign at the cubital tunnel (ulnar nerve), fibular head (common fibular nerve), and behind the medial malleolus (tibial nerve in tarsal tunnel).
- Finkelstein Test: The patient flexes the thumb into the palm and folds the fingers over it, followed by passive ulnar deviation of the wrist. Sharp, severe pain over the radial styloid confirms De Quervain’s tenosynovitis involving the Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB) tendons.
- Allen's Test: Evaluates radial and ulnar artery collateral supply before arterial blood gas (ABG) puncture or radial artery catheterization. Normal capillary refill returns within 5 to 7 seconds after releasing one artery while maintaining compression on the other.
Sacrum, Pelvis & Innominate Tests
Accurate diagnosis of pelvic dysfunctions requires a stepwise diagnostic algorithm using standing vs seated flexion tests, ASIS compression, and spring/sphinx tests.
| Test Step | Clinical Test Name | Negative Result (Normal) | Positive Result (Pathologic) |
|---|---|---|---|
| Step 1: Innominate Laterality | Standing Flexion Test | Both PSIS move symmetrically cephalad. | One PSIS moves further superiorly: indicates iliosacral / innominate dysfunction on that side. |
| Step 2: Sacral Laterality | Seated Flexion Test | Both PSIS move symmetrically cephalad. | One PSIS moves further superiorly: indicates sacroiliac / sacral dysfunction on that side. |
| Equivocal Tie-Breaker | ASIS Compression Test | Equal, bilateral compliance and spring. | Increased resistance to posterior-medial spring confirms dysfunction laterality. |
| Step 3: Forward vs Backward | Lumbosacral Spring Test | Good, springy motion felt at S1/S2 base. | Rigid, absent spring ('table feels like concrete'): indicates backward torsion or sacral extension. |
| Step 3 Alternative | Sphinx (Backward Bending) Test | Sulcus asymmetry becomes symmetric in extension. | Sulcus asymmetry worsens in extension: indicates backward torsion or sacral extension. |
Sacral Diagnostic Rule Matrix: • If Seated Flexion is positive on the Right, the dysfunction is either a Right unilateral shear OR a sacral torsion engaging an oblique axis. • If Spring Test is Negative (good spring) and Sphinx makes sulci symmetric, the sacrum has moved forward (Forward Torsion: R/R or L/L; or Unilateral Flexion). • If Spring Test is Positive (poor spring) and Sphinx makes sulci asymmetric/worse, the sacrum is stuck backward (Backward Torsion: R/L or L/R; or Unilateral Extension).
Hip & Lower Extremity Special Tests
Lower extremity tests isolate intra-articular hip pathology, muscle contractures, cruciate/collateral ligament tears, and meniscal blockages.
- Thomas Test: Identifies psoas contracture / tight hip flexors. The patient lies supine and pulls one knee to the chest. If the opposite leg rises off the examination table or if lumbar lordosis remains elevated, psoas spasm is present on the side of the extended leg.
- Patrick (FABER) Test: Evaluates Flexion, ABduction, and External Rotation. Anterior hip/groin pain suggests femoral head or acetabular pathology (osteoarthritis, labral tear). Posterior pain over the sacroiliac joint indicates sacroiliac joint inflammation or dysfunction.
- Ober's Test: Evaluates contracture of the Tensor Fasciae Latae (TFL) and Iliotibial (IT) band. Patient lies in lateral recumbent on unaffected side. The physician abducts and extends the affected hip with the knee bent to 90°, then releases the leg. If the thigh remains elevated and fails to adduct past midline, the IT band is tight.
- Lachman's Test: Gold standard physical examination test for Anterior Cruciate Ligament (ACL) integrity. Performed at 20-30° of knee flexion with anterior tibial translation. Superior to Anterior Drawer test because it eliminates hamstring guarding and posterior horn meniscal blocking.
- McMurray Test: With the patient supine, the physician flexes the knee and places fingers over the medial and lateral joint lines. Medial Meniscus: External rotation of foot + Valgus stress + slow extension. Lateral Meniscus: Internal rotation of foot + Varus stress + slow extension. A palpable click or pop with localized joint line pain confirms a meniscal tear.
- Apley Compression vs Distraction Test: Patient prone with knee flexed 90°. Downward axial compression plus internal/external rotation stresses the menisci. Upward distraction plus rotation relieves meniscal pressure and stresses the medial and lateral collateral ligaments (MCL and LCL).
- Bounce Home Test: The physician supports the patient’s heel while gently allowing the knee to passively drop into full extension. A springy, rubbery block preventing full extension indicates a bucket-handle meniscal tear or joint effusion.
Practice Drill: Rapid Active Recall
Practice Drill
Q: A 24-year-old female runner presents with lateral knee pain that worsens when running downhill. On physical exam, Ober's test is positive. Which muscle and fascial structure are contracted?
Practice Drill
Q: During a routine OMM exam, a patient displays a positive seated flexion test on the left, a deep right sacral sulcus, a prominent left ILA, and a positive spring test (rigid, no spring). What is the exact diagnosis?
Practice Drill
Q: A 35-year-old woman experiences severe sharp pain at the radial styloid when making a fist around her thumb and ulnar-deviating her wrist. What two tendons travel together through the affected synovial sheath?
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.