Clinical History Taking & Assessment

Basic Special Tests

AUTHOR
DR MUHAMMAD UMAR HABIB
DPT, MS OMPT, MSC SEM
Diagnosis is a matter of applying

one’s anatomy

James Cyriax

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 CLINICAL PRACTICE
CLINICAL EDUCATION OF STUDENTS
The term clinical education refers to the supervised practice of professional skills in a
clinical setting.
The purpose of clinical education is to provide student clinicians with opportunities to:
1. Observe and work with a variety of patients under professional supervision and in
diverse professional settings, and to integrate knowledge and skills at progressively higher
levels of performance and responsibility.
2. Work in situations where they can practice interpersonal skills and develop
characteristics essential to productive working relationships.
3. Develop clinical reasoning skills and management skills, as well as master techniques
that develop competence at the level of a beginning practitioner.
4. Applying the principles of Physiotherapy Practice under the guidance of CI and
specifically designed clinical learning experience assist in the transition of student
therapist to an entry level practitioner.
5. By progressing through the series of clinical placements, the student acquire the entry
level clinical experience.
6. Students are encouraged to adopt a problem solving holistic approach to professional
practice in conjunction with developing strong logical evaluating skills.
7. As the student becomes increasingly competent in client management together with
gaining the high level of evaluative, recording, communicative and organizational skills.
The degree of guidance is gradually decreased

Rationale for Practice Placements

Practice education is an integral and significant component of the total curriculum that
enables students to demonstrate and achieve competence. It forms an indispensable part of
the learning process. Learning gained in practice settings is vital to the students’
educational and professional development. Experience gained enables the acquisition of
new knowledge and skills as well as the application, consolidation and reflection upon the
learning gained in the university environment.

Role of the Student

Students are expected to take an active responsibility for their own education by
identifying their own learning needs, assisting in the planning and implementation of the
learning experiences, being familiar with and adhering to procedures and rules of the
academic institution and the affiliating center, and evaluating their own performance.

Learning Outcomes, Aims and Objectives of Practice

Placements
Before commencing the practice placement, students will have a pre-clinical preparation
to introduce and familiarize themselves with the clinical setting, discuss possible case
scenario’s and objectives, highlight any concerns the students may have and identify any
pre-placement reading material and preparation required.

Student Role & Responsibilities

At all times during the Clinical Placement, The students are expected to:

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a. Display expected standards of safety.
b. Demonstrate care and compassion for the Patient
c. Maintain an accurate records of the condition observed and managed in each clinical
placement by using the clinical logbooks provided.
d. Follow the administrative procedures and duties.
e. Maintain professional standard of dress and behavior.
f. Be able to communicate with patient and attendant of patient.
g. It is the duty of the student to develop inter-professional communication skills and
professional confidence.
Attendance requirement
1. Full attendance is Compulsory in all Clinical Placements.
2. If for any reason the student can not attend his placement, the student must inform his
CI/CS on that day and submit the leave application with valid reason & proof.
3. Student who will be absent due to illness will submit the Medical certificate. The doctor
should specify the sick leave granted and specify the date or period of the sick leave.
4. If you must be absent from Clinical Placement due to other legitimate reason, must
submit well in advance an application to CI/CS and get prior approval of the leave with
specified period.
5. If a student will be absent 20% of his/her any one placement , he will be awarded grade
“I” (incomplete) and will have to make up for the missed hours or retake the whole
placement subject to the assessment of CI/CS.
6. After completion of makeup hours the respective grade based on student performance
will replace the initial grade “I”.
7. A student who will not complete the Clinical Placement without legitimate reason will
be awarded grade “F” and need to retake the whole placement when offered at a later date.
Regulations governing clinical education
I. Students must complete satisfactorily hours of clinical education.
2. Full attendance is a pre-requisite for progression to any subsequent clinical placements.
If a student is absent, with legitimate reasons, for more than 20% of anyone placement,
he/she will be required to make up for missed hours (or equivalent as endorsed by the
Subject Assessment Review Panel) when it is offered at a later time.
3. Each student placed in any Clinical Placement must be wearing an overall all the time
during his/her Clinical Placement.
4. Each student must have his/her own Assessment tools including;
a. A Goniometer
b. A Tape Measure.
c. A Patellar Hammer with a Needle and a Brush for Sensory Assessment.
d. A Stethoscope (Optional for Placement in the Wards).
5. For passing any clinical education placement, the student must reach a
'SATISFACTORY' level of performance (grade 'C' or above).

Guidelines for student physiotherapists handling patients' data In

Clinical placement
1. Patient data
a. All patient data are confidential.

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b. The name, address, phone number are sensitive. In preparing reports or case discussion,
no identifiable particulars, including ward and bed number. No identifier should be taken
away from hospital.
2. Data access
a. Students should access to the data for the patients under their care and organizational
need to-know basis.
b. Log off electronic data after use.
3. Data retrieval and export
If students take care, patients' information in their own notes and may bring home for
revising or preparation for the next day, appropriate measures must be taken to
a. protect the security of the retrieved content – e.g. (patient X).
b. protect the security of the hard copies of case file and learning points in a safe and
secured environment. Do not allow unauthorized person to view and protect the
documents during transport. Destroy the record / document in a confidential manner if it is
no longer required.
c. protect the security of the electronic self created case files by password.
4. Electronic patient images
a. All clinical photos or videos without patients' face masking should be securely stored
with no
b. identifiable personal particulars.
c. Any pieces of e-files or folders should not be written with patients' names, and protected
with password.
d. Students should not take any physiotherapy record away from the hospital, no matter
written by the student or not.
5. For any loss of patient data, the student must report to the Clinical Instructor
immediately. The CI, through the department head should consider reporting the case to
the appropriate.
6. Students should follow the respective departmental guideline on patient data security
during clinical placement.

Safety guidelines for physiotherapy students during Clinical placement

Communication with Clinical Instructor (CI) (apply to all settings).
1. Always seek advice/clarification from (CI) whenever there is anything doubtful.
2. Seek (CI) guidance in any case that you do not feel competent e.g. the patient type that
you are going to handle for the first time.
3. Report to (CI) immediately in case of any unexpected event.
4. Student should consult (CI) and obtain approval prior to giving any treatment to any
patient despite even in the presence of Clinical Staff.

Part l. In-patient setting

A. General
1. Student must go through the basic infection control training before they have any hands
on treatment to patients. There may be different infection control standards of individual
placement requirement, which student should comply strictly.
2. Read bed notes and vital signs to get the most updated information concerning the
patient under care before proceeding to assessment or treatment.
3. Students should informed CE when there are new laboratory test results, new XR, new
investigations results like U.S. Doppler, Echo cardiogram, OGD etc.
4. Students must inform CE before carrying out the following procedures:
a. Performing suction to patient
b. Head down postural drainage

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c. Change of level of oxygen supplement to patients
d. Before applying any electrotherapy modalities, e.g. hot & cold treatment, traction,
SWD, laser etc.
e. Change of treatment protocol
5. Any other signs or symptoms that may indicate deterioration of patients' condition or
threaten their health.
6. Students must stop and report to CI at once if any of the following occurs during or
after
assessment / treatment
a. Patient falls
b. Resting Sp02 < 90%
c. Undue redness of skin or pain after treatment
7. Change in mental status e.g. increased dullness, aggressive behaviors, suicidal thoughts
etc.
a. Severe SOB
b. Deterioration in motor control
c. Abnormal bony alignment
d. Un-documented abrasion, swelling or bruising
e. Increase in pain or discomfort.
f. Increase in dizziness. palpitation, cold sweating, pallor
g. A change in systolic blood pressure >20 mmHg
h. Any other changes that may indicate deterioration of patients'
condition or threaten their health
8. Make sure that every patient under care is safe, comfortable and properly positioned
before, during and after assessment and treatment. The height of bed, bed-side rail,
restrainer and urinary bags etc ... should always be considered. Any patient, who is put on
the restrainer, must be properly secured after finishing physiotherapy intervention, or
between treatment sessions for patients to rest.
9. For applying electrotherapeutic therapy, exercise and manual therapy, please refer to the
safety guide lines in part II.

B. Mobilizing a patient
1. Students must inform CI before carrying out the following procedures:
a. First time mobilizing a patient. .
b. All patients' transfer, standing, level ground walking and stair climbing.
2. Do not leave unstable, elderly or mentally deficient patients unattended during
unsupported sitting, standing, walking, or attempting any other unstable positions.
3. The student needs to be aware of the patient's clothing and shoe wear being properly
fitted before starting any weight-bearing exercise or walking training.
4. Whenever a patient stands or walks, the responsible student should have properly
evaluated the patient's performance beforehand. He should understand the patient's ability
and limitation. Then select the most appropriate walking aids and estimate the level of
assistance to the patient.
5. Stay close to the patient (beware of the safe distance between therapist and patient,
handhold and safe working posture) and be ready to give support as needed, or when the
patient is practicing exercise.

Part II. Out-patient setting

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A. Electrotherapy Application
1. Practice the electrotherapy modalities up to standard before applying onto patients.
2. Discuss with and get the approval from CI for the choice and parameters of the
electrotherapy modality for the first time and in any case of progression of the treatment.
3. Check all contraindications and precautions specific to the individual electrotherapy
modality.
4. Seek verbal consent from patients.
5. Explain the application procedures to the patient.
6. Carry out the appropriate skin sensation and pre-treatment tests as well as recheck
whenever indicated.
7. Check the machine every time before use.
8. Give proper instructions and warnings to patients during and after treatment. Make sure
the patient fully understands.
9. Ensure the accurate application of the machine and the optimal comfort of the patient.
10. Safety cords should be given to patients wherever they are available.
11. Wait for CI to check the set up before start.
12. Review the patient regularly during treatment session. Stop immediately when patient
feels discomfort and monitor the patient.
13. Reassess the patient during and after treatment.

B. Exercise Therapy Application

1. Discuss with and get the approval from CI for the choice and parameters of the
exercises for the first time and in any case of progression of exercises.
2. Check all contraindications and precautions for the exercise to patient.
3. Check the vital signs for high risk group patients before doing exercises, and whenever
indicated.
4. Explain to patient the aims and procedures of the exercise.
5. Demonstrate the exercise first and highlight the important points.
6. Give proper instructions and warnings. Make sure the patient fully understands.
7. Make sure the exercises to be performed accurately.
8. Review the patient regularly during exercise session. Stop immediately when patient
feels discomfort and monitor the patient.
9. Reassess the patient after exercise.
10. Stay close to the patient and be ready to give support whenever the patient is losing
stability.
11. Ensure the safe transfer in and out of the hydrotherapy pool. Stay close to the patient
throughout the treatment session

C. Manual Therapy Application

1. Discuss with and get the approval from CE for the choice and parameters of the
exercises for the first time and in any case of progression of manual techniques.
2. Check all contraindications and precautions for the exercise to patient.
3. Check the vital signs for high risk group patients before doing manual techniques, and
whenever indicated.
4. Explain to patient the aims and procedures of the manual techniques.
5. Give proper instructions and warnings (possible post treatment soreness). Make sure the
patient fully understands.
6. Make sure the manual techniques to be performed accurately
7. Review the patient regularly during treatment session. Stop immediately when patient
feels
discomfort and monitor the patient.

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8. Reassess the patient after the manual techniques.
9. Stay close to the patient and be ready to give support whenever the patient is losing
stability.

Kind Regards

DR Muhammad Umar Habib

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 History Taking Guide

DEMOGRAPHIC HISTORY
• Name, age, and gender of patient, Occupation

Chief Complaint
• A concise statement describing the major health problem or concern, and its time course
(e.g. knee pain for past 4 hours).
• In short, the primary problem of the patient
• OA of knee patient can have back pain, hip pain, or even ankle pain, but his primary
problem remains eminent.

How to proceed
• Open End Questions

History of Present Illness

• details about the chief complaint (OLD CARTS)
• Onset—when did it start?
• Location/Radiation—where is it located?
• Duration—how long has this gone on?
• Character—does it change with any specific activities? Does the patient use any descriptive
words to describe the quality of the symptom?
• Aggravating factors – what makes it worse?
• Reliving factors – what makes it better?
• Timing—is it constant, cyclic, or does it come and go?
• Severity—how bothersome, disruptive, or painful is the problem?

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Past Medical History
Past medical history (abbreviated PMH),is the total sum of a patient's health status prior to the
presenting problem.
• General state of health: e.g. good, poor
• Past illnesses: e.g. cancer, heart disease hypertension, diabetes.
• Hospitalizations:
• Injuries, or accidents: note the type and date of injury.
• Surgeries
• Current medications: note name, dosage, frequency of any medication,
• Allergies
• Immunizations:
• Substance abuse/Personal History
• Diet
• Sleep
• Alternative therapies: e.g. acupuncture, massage, herbal medicine, chiropractic.
• Obstetric/Gynecologic history (if female): pregnancies, whether they are full term, preterm,
miscarriages, abortions, menopause
• Psychiatric history
ACRONYMS
• "PAM HUGS FOSS"for
• Previous presence of the symptom (same chief complaint)
• Allergies (drugs, foods, chemicals, dust, etc.)
• Medicines (any drugs the patient used)
• Hospitalization for any illness in the past
• Urinary changes (especially if diabetic or elderly)
• Gastrointestinal complaints (diet changes, bowel movements, etc.)
• Sleep pattern (waking up/going to sleep, etc.)
• Family history (similar chief complaints/serious illness)
• OB/GYN history (LMP, abortions, etc.)
• Sexual habits (active/preferences/STD, etc.)
• Social life (job/house/smoking/alcohol, etc.)

Family History
• A family medical history is a record of health information about a person and his or he close
relatives
• Includes children, brothers and sisters, parents, aunts and uncles, nieces and nephews,
grandparents, and cousins.
• E.g. heart disease, high blood pressure, stroke, certain cancers, and diabetes.

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Pain History
SOCRATES
• S - site
O - onset
C - characteristics
R - radiation
A - associated
T - timing
E - exacerbating/alleviating
S - severity
Objective Evaluation
• Inspection
• Palpation
• ROM
• Accessory movements
• Girth
• Effusion
• Painful Arc
• Gait

OUTCOME MEASURES
• Outcome Measures measure outcome
• E.g. Pain Scales
• Oswestry disability Index Scale

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 Special
Musculoskeltal
Tests

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 Biceps Tendon Pathology
o Speed Test
Purpose
To identify biceps tendon pathology in the bicipital groove and unstable
superior labral anterior posterior (SLAP) lesions.
Technique
Patient position
Sitting or standing with the affected shoulder in 60–90° of forward flexion.
The elbow is fully extended and forearm supinated.
Clinician position
Standing on the affected side, one hand stabilizes the patient’s shoulder while
the other is placed on the anterior surface of the lower forearm.
Action
The patient is asked to maintain the start position as downward pressure on
the lower forearm is applied by the clinician.
Positive test
Pain localized to the bicipital groove may indicate a tendinopathy or a true tenosynovitis of the
long head of biceps. Deeper-seated pain may implicate biceps/labral complex injury.

o Ludington’s test
Patient position & Action
Patient places both hands on top or back of the head with the fingers interlocked. The patient then contracts
and relaxes the biceps on both sides as the clinician attempts to palpate the biceps tendon proximally.
Positive test
If it is not possible to palpate the tendon on the affected side, a complete rupture of the long head is possible.

Supraspinatus Tendon Pathology

o Empty Can Test/Full Can Test

Also called Jobe’s Test
Purpose
To detect the presence of supraspinatus tendinopathy, a partial/complete tear or neurogenic weakness of
supraspinatus.
Technique
Patient position
Standing or sitting on the edge of a treatment couch.
Clinician position
Standing on the affected side facing the patient.
Action
The shoulder is passively elevated to 90° in the scapular plane and taken into full internal rotation with the
forearm in pronation so that the thumb is pointing to the floor (empty can test). The clinician stabilizes the
scapula with one hand and places the other on the upper surface of the patient’s forearm. Downward
pressure is then applied to the arm while the patient maintains this position. The test is then repeated with the
arm externally rotated so that the thumb points upwards (full can test).
Positive test
Reproduction of the patient’s pain without weakness is suggestive of supraspinatus impingement or
tendinopathy while painful. Weakness may indicate a partial or complete tear.

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 Infraspinatus Tendon Pathology

o External Rotation Lag Sign

Purpose
To assess the integrity of the infraspinatus tendon and expose weakness associated with suprascapular
neuropathy.
Technique
Patient position
Sitting or standing with the affected arm in a dependent position with the elbow flexed to 90°.
Clinician position
The clinician stands adjacent to the affected side, using one hand to support the patient’s elbow and the other
to take hold of the patient’s arm just above the wrist. The shoulder is passively elevated 20° in the scapular
plane, then taken to about 5° short of full external rotation.
Action
Still supporting the patient’s elbow, the tester asks the patient to maintain the external rotation, and then
releases the wrist.
Positive test
A positive test is recorded if the patient is unable to maintain the rotated position and there is a ‘lag’ or
‘spring back’ towards the start position.

o Drop Sign
The drop sign repeats the ERLS in 90° of abduction in the scapular plane .Again, an inability to maintain the
position signifies an infraspinatus tear or neuropathy. This test is unsuitable for patients with stiff shoulders.

Teres Minor Pathology

o Hornblower’s Sign
Technique
Patient position
Patient is sitting on the couch

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Action & Positive Findings
The patient is unable to externally rotate the abducted arm so when asked to take both hands simultaneously
to the mouth (as if holding a wind instrument) the position cannot be maintained on the affected side and the
shoulder falls into an internally rotated position.

o Patte’s Test
Technique
Patient position
Sitting or standing with the affected arm in a dependent position with the elbow flexed to 90°.
Clinician position

The clinician stands adjacent to the affected side, using one hand to support the patient’s elbow and the other
to take hold of the patient’s arm just above the wrist. The shoulder is passively elevated 20° in the scapular
plane, then

taken to about 5° short of full external rotation, standing on the affected side and slightly behind the patient,
stabilizes the flexed elbow and adds resistance to external rotation by placing the other hand on the posterior
aspect of the lower forearm
Positive test
A positive test, pain and/or weakness.

Subscapularis Tendon Pathology

o Lift-off sign
Purpose
To test for a partial or complete tear of subscapularis.
Technique
Patient position
Standing or sitting on the edge of a treatment couch with the shoulder internally rotated so
That the dorsum of the hand rests against the mid-lumbar spine.
Clinician position
Standing behind the patient, the distal end of the patient’s forearm is lifted away from
The lumbar spine, so that the shoulder is fully internally rotated.
Action
With the arm passively ‘lifted off’, the patient is asked to maintain the position without
Extending the elbow as the support of the clinician’s hand is removed.
Positive test
An inability to maintain the lifted-off position signifies a complete tear of the
Subscapularis tendon.

o Gerber push-off test

May be used if the patient is able to maintain the ‘lift-off’ position. The patient is asked to maintain the lift-
off position while the clinician applies an anteriorly directed force against the lower forearm. This
supplementary isometric action preferentially activates subscapularis and is a pain-provocative manoeuvre.

Labral Tests
o Crank test
Purpose
To assess for an unstable superior labral anterior posterior (SLAP) lesion.
Technique
Patient position
Supine or sitting with the elbow flexed to 90°.
Clinician position
Standing adjacent to the affected shoulder, holding the patient’s flexed elbow and forearm.

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Action
The patient’s arm is passively elevated in the scapular plane to full range. While applying a gentle axial load
through the longitudinal axis of the humerus, the shoulder is taken into full external and then internal
rotation using the forearm as a lever.

Positive test
The patient’s pain, a catching sensation, painful clicking or a combination of these are considered positive
indicators of a labral tear and are most likely to be elicited during the external rotation part of the test

o Biceps load II test

Purpose
To assess for an unstable superior labral anterior posterior (SLAP)
lesion.
Technique
Patient position
Lying supine towards the side of the couch.
Clinician position
Standing adjacent to the affected shoulder, the patient’s elbow is
flexed to 90° and with one hand placed just above the elbow joint
and the other supporting the lower forearm, the arm is abducted
to 120° before full external rotation is applied. The forearm is positioned
in as much supination as possible in order to achieve maximum
stress on the long head of biceps tendon during testing.
Action
Isometric resistance is given to elbow flexion in this position.
Positive test
Shoulder pain provoked by resisted elbow flexion.

o SLAP Prehension Test (Slapper Test)

To assess for an unstable superior labral anterior posterior (SLAP)
lesion.
Technique
Patient position
Standing or sitting.
Clinician position
Standing adjacent to the affected arm and observing the patient’s response to the test. The clinician can place
their hand over the shoulder to palpate for a click.
Action
The patient elevates the affected shoulder in the scapular plane to 90°, with the elbow extended and the
forearm fully pronated, and horizontally adducts the arm across the chest . The presence of pain is noted and
the arm is returned to the abducted start position. The same movement is then repeated with the forearm in
supination and any pain noted.

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Positive test
Localized anterior shoulder pain, sometimes combined with an audible or palpable click that is more
pronounced during the first test, is suggestive of an unstable SLAP lesion

o O’Brien’s test
Purpose
To identify a symptomatic acromioclavicular joint (ACJ) and/or a
superior labral anterior posterior (SLAP) lesion.
Technique
Patient position
Standing.
Clinician position
Standing adjacent to the affected arm and stabilizing the scapula
with one hand.
Action
The patient adopts the starting position for this test by actively
elevating the arm through flexion to 90° and adducting 10–15°,
keeping the elbow fully extended throughout. In this position, the
patient internally rotates the shoulder and fully pronates the forearm,
so that the thumb points downwards. The examiner places
one hand over the superior aspect of the patient’s distal forearm
and exerts a uniform downward pressure, instructing the patient
to resist this. The test is then repeated with the patient’s
palm facing upwards.

Positive test
SLAP lesion: pain felt deep inside the shoulder, with or without a click, on testing with the thumb pointing
down, relieved when repeated with the palm facing upwards.
ACJ disorder: pain felt on top of the shoulder, with or without a click, on testing with the thumb pointing
down, relieved when repeated with the palm facing upwards.

o Scarf test
Purpose
To test primarily for acromioclavicular joint (ACJ) lesions.
Technique
Patient position
Sitting or standing.
Clinician position
Standing adjacent to the patient, one hand is placed on the upper scapula of the unaffected side to provide
counter-pressure during the test. The other hand supports the flexed elbow of the affected arm and passively
takes the shoulder into 90° of forward flexion, ensuring the shoulder is held in internal rotation and the palm
of the hand faces the floor.
Action
From the starting position, the shoulder is horizontally adducted passively across the patient’s body to the
end of available range.
Positive test
Localized pain over the joint line or the C4 (epaulette area) dermatome is a positive finding and indicates
ACJ injury or pathology.

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 ELBOW JOINT
o Tennis elbow test
Purpose
To test for a contractile lesion of the wrist extensor tendons most
commonly involving the common extensor origin (CEO).
Technique
Patient position
Standing with the affected elbow fully extended and the forearm
pronated.
Clinician position
Standing on the affected side, the clinician supports the patient’s
arm by allowing it to rest on his or her own upper arm. Both the
clinician’s arms are then extended and pronated so that the thumbs
can be placed on the palmar aspect of the patient’s wrist to provide
support and counter-pressure while the fingers are placed over the
dorsum of the extended wrist.
Action and positive test
The patient contracts the wrist extensors isometrically as strongly as
possible against resistance. A positive test is indicated by reproduction
of pain over the lateral aspect of the elbow

o Mills’ test
involves the application of a passive longitudinal stretch to the tendon. The patient sits with the
shoulder slightly abducted, elbow flexed to 90°, forearm pronated and wrist flexed so that the palm of
the hand is facing
the ceiling. Standing behind the patient on the affected side, one hand cups the upper arm for support
and takes the arm into about 70° of abduction. The thumb of the other hand is then placed in the
patient’s palm between the index finger and thumb and the fingers wrapped around the dorsum of the
wrist, which enables the
forearm to be maintained in full pronation and the wrist in flexion. While maintaining this position, the
elbow is extended slowly A positive test is indicated by reproduction of the patient’s pain over the
common extensors and, depending on the chronicity and severity, will occur in varying degrees of
terminal extension. This test can also place considerable stress
on the radial nerve and careful discrimination should therefore be exercised to exclude neural
involvement. Stress on the nerve can be minimized by any or all of the following: reducing the degree
of shoulder abduction, avoiding taking the shoulder into extension, allowing some elevation of the
shoulder girdle, and placing the cervical spine in a degree of side-flexion towards the painful elbow.

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Tennis Elbow Test
Test To check lateral epicondylitis
Procedure Passively extend elbow, pronate forearm and flex wrist and fingers
while palpating lateral epicondyle
Positive Sign Reproduction of symptoms

o Golfer’s elbow test

Purpose
To test for a contractile lesion of the wrist flexor tendons most commonly
involving the common flexor origin (CFO).
Technique
Patient position
Sitting or standing with the elbow fully extended and the forearm
pronated.
Clinician position
Standing adjacent to the patient’s affected side using the hand nearest
the patient, the clinician fixes the lower forearm while supporting
the patient’s upper arm over the crook of the elbow. The other
hand is formed into a fist and placed in the palm of the patient’s
flexed wrist.
Action and positive test
The patient contracts the wrist flexors isometrically as strongly as
possible against resistance. A positive test is indicated by reproduction
of pain over the medial aspect of the elbow

Golfer’s Elbow Test

Test To check medial epicondylitis
Procedure Passively extend elbow, Supinate forearm and extend wrist and
fingers while palpating medial epicondyle
Positive Sign Reproduction of symptoms

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 Tennis Elbow Test Golfer’s Elbow Test

o Valgus test
Also named as Jobe’s test
Purpose
To test the integrity of the medial collateral ligament (MCL) of the
elbow.
Technique
Patient position
Standing with the elbow flexed to 20–30° and fully supinated.
Clinician position
Standing on the affected side, one hand stabilizes the humerus by
holding it in external rotation above the lateral aspect of the elbow,
while being able to palpate the joint line medially with the fingers.
The other hand wraps around the medial aspect of the lower
forearm.
Action and positive test
A valgus stress is applied to the elbow by abducting the forearm on
the humerus. Tension in the ligament can often be felt as the stress
is applied. Pain, excessive valgus movement or loss of the normal
ligamentous end-feel indicate a positive test.

o Varus test
Purpose
To test the integrity of the lateral collateral ligament of the elbow.
Technique
Patient position
Standing with the elbow flexed to 20–30° and fully supinated.
Clinician position
Standing in front of the patient, one hand stabilizes the humerus at
the elbow by gently gripping above the medial aspect of the elbow
while being able to palpate the radiohumeral joint line laterally. The
other hand wraps around the lateral aspect of the lower forearm.
Action and positive test

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A varus stress is applied to the elbow by adducting the forearm on
the humerus. Tension in the ligament can often be felt as the stress
is applied. Pain, excessive varus movement or loss of the normal
ligamentous end-feel indicates a positive test.

WRIST & HAND

o Radial collateral ligament stress test

Purpose
To stress the radial collateral ligament (RCL) and lateral capsule of
the wrist in order to detect pain and/or laxity.
Technique
Patient position
Sitting with the wrist supported on a table.
Clinician position
One hand fixes the distal forearm by wrapping the fingers around
the radius and ulna while the other grasps the hand, taking care not
to involve the fingers or thumb.
Action
With the forearm fixed, the distal hand takes the wrist into ulnar deviation
(wrist adduction) where normal range is between 30° and 45°.
Positive test
Pain is the most likely outcome but further evaluation would be
needed if excessive range was noted suggesting significant disruption
to the joint.

o Ulnar collateral ligament stress test

Purpose
To stress the ulnar collateral ligament (UCL) and medial capsule of
the wrist in order to detect pain and/or laxity.
Technique
Patient position
Sitting with the wrist supported on a table.
Clinician position
One hand fixes the distal forearm by wrapping fingers around the
radius and ulna while the other grasps the hand, taking care not to
involve the fingers or thumb.
Action
With the forearm fixed, the distal hand takes the wrist into radial
deviation (wrist abduction) where normal range is around 15°.
Positive test
Pain is the most likely outcome but further evaluation would be
needed if excessive range was noted, suggesting significant disruption
to the joint.

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 o TFCC Load Test
Also called Ulnar meniscal grind test
Purpose
To reproduce pain and/or apprehension indicating a tear or degeneration
of the TFCC.
Technique
Patient position
Sitting or standing.
Clinician position
Facing the patient, the examiner stabilizes the patient’s forearm
with one hand and, as if shaking hands, places their other hand in
the palm where it is held firmly.
Action
Axial compression is then applied through the patient’s hand while
ulnar deviation is added. This part of the manoeuvre has been
described as the ulnar impaction test. This may be enough to reproduce
localized pain at the base of the ulna negating the need for
further loading. If asymptomatic, stress on the TFCC is increased by
‘scooping’ the hand from flexion to extension while maintaining the

ulnar deviation and compression

Positive test
Localized pain at the ulnar side of the wrist joint is sometimes accompanied
by apprehension and/or a click or crepitus on movement.

o Finkelstein’s test
Purpose
To detect pain and limitation caused by inflammation between the
tendons of abductor pollicis longus (APL) and extensor pollicis
brevis (EPB) and their shared synovial sheath at the distal end of
the radius (de Quervain’s tenosynovitis).
Technique
Patient position
With the forearm positioned in pronation, the patient is asked to
flex the thumb and close their fingers over it.
Clinician position and action
The lower forearm is fixed with one hand and the patient’s hand
taken into ulnar deviation passively with the other.
Positive test
As the wrist is taken towards ulnar deviation, significant pain is
reproduced over the radial aspect of the wrist

o Phalen’s test
Test Median Nerve Pathology, Carpal Tunnel Syndrome (CTS)

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 Procedure Place dorsal aspect of hands together with wrist flexed. Hold for 1
minute
Positive Sign Tingling in distribution of median nerve

o Reverse Phalen’s Test

Test Median Nerve Pathology
Procedure Place palm of hands together with wrist extended. Hold for 1 minute
Positive Sign Tingling in distribution of median nerve

Reverse Phalen’s Test

Phalen’s Test

Finkelstein Test

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 HIP

o FAIR test
Impingement test
Posterior labral tear test
Apprehension sign
Piriformis test
Psoas test
Purpose
To reproduce pain and/or apprehension and increase the likelihood
of detecting a range of conditions such as articular pathology (e.g.
femoro-acetabular impingement (FAI), labral and hip joint pathology
and instability), piriformis syndrome and psoas bursitis.
Technique
Patient position
Lying supine.
Clinician position
Standing on the affected side.
Action
The hip and knee are taken into 90° of flexion and then full internal
rotation is added by applying a stabilizing pressure on the outside at
the knee with the cephalic hand and drawing the lower leg outwards
by using the heel as a lever with the caudal hand. The final component
is adduction, achieved by passively moving the knee towards
the opposite hip.
Positive test
Reproduction of the patient’s pain can be considered to be a positive
test although the site of this will vary depending on the
pathology.
l Articular pathology/psoas bursitis: pain in the groin which may
be accompanied by a click if the labrum is involved.
l Piriformis syndrome: buttock or radicular pain.

o Scour/quadrant/flexion adduction test

is a modification of FAIR Test where
the hip is passively flexed to 90° and adducted. The clinician’s hands
are interlocked and placed over the patient’s flexed knee. Leaning
over the knee so that the examiner’s body weight can be used to Scour Test
good effect, a compressive force is applied through the longitudinal
axis of the femur. Small passive movements are made into flexion
and extension in order to ‘scour’ the joint. A positive test is
indicated by reproduction of the patient’s symptoms.

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 o McCarthy test
Technique
Patient position
Lying supine with the hips and knees flexed and both feet resting
on the couch.
Clinician position
The affected hip is taken into full passive flexion, with one hand
supporting the flexed knee and the other supporting the foot.
Action
External rotation is then added as the affected hip is gradually
taken down towards extension. If this does not elicit
McCarthy Start Position
a positive response, the manoeuvre is repeated with the addition of
internal rotation instead.
Positive test
Reproduction of the patient’s hip pain or click.

McCarthy test.
End position
in external
rotation. The
o FABER test test can then
The ‘4’ test be repeated
moving the hip
Patrick’s test
into internal
Jansen’s test rotation
Purpose
To test primarily for articular pathology in the hip joint. Also
stresses the sacro-iliac joint (SIJ), iliopsoas tendon and the lumbar
spine.
Technique
Patient position
The patient lies supine and the affected leg is flexed and externally
rotated so that the lateral aspect of the ankle is positioned just above
the opposite knee joint. If this starting position is uncomfortable for
the patient, the knee can be brought more into the midline to reduce
hip abduction.
Clinician position
Standing at the patient’s affected side, the pelvis is stabilized by applying
gentle pressure over the opposite anterior superior iliac spine.
Action
The patient is asked to lower the knee towards the couch and if full
range is achieved, gentle overpressure can be applied to the medial
aspect of the knee to assess full passive range and end-feel.
Positive test
A positive test is indicated by the reproduction of the patient’s pain
or reduced range of movement. If the knee lowers to a point which
is level to the opposite knee or the range is equivalent to the contralateral
side, range is considered to be normal.

Ober’s Test
Test Tensor Fasia lata and Illiotibial band contractures

Procedure Procedure Patient in side lying with hip and knee of lower leg flexed.
Stabilized
pelvis with one hip and knee of lower leg flexed. Stabilized
pelvis with one hand and passively abduct and extend upper leg with
knee extended or flexed to 90. Then allow leg to drop toward plinth
Positive Sign Upper leg remains
Positive Sign Upper leg remains abducted and does not lower to plinth immediately
after dropping

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Thomas Test
Test Rectus Femoris Contracture)

Procedure Procedure Patient supine with knee flexed to 90 over edge of

plinth. Patient hugs other knee to chest

Positive Sign Opposite leg lifts off the plinth, apply pressure downward, knee
over
edge of plinth extend

Obers Test Thomas Test

o Trendelenburg test
Purpose
To test for stability of the pelvic/hip complex and strength of the
hip abductors.
Technique
Patient position
Standing.
Clinician position
Standing facing the patient in order to observe the outcome of the
test and provide some support to the patient with the hands if
required.
Action
The patient is asked to transfer their weight onto the affected leg
and lift the unaffected foot off the ground by flexing both the hip
and knee. The clinician observes the movement as the weight is
transferred onto the symptomatic side.
Positive test
A positive/abnormal test is recorded if the pelvis on the non-weightbearing
side drops because the gluteal muscles on the weight-bearing
side cannot maintain the pelvis in a neutral position. Normally
the glutei will produce a slight uplift of the pelvis on the nonweight-
bearing side as weight is borne on the opposite leg. In a
study of normal volunteers the change in position of the pelvis on the
femur was measured at a barely detectable 4° and, that being the case,
normal abductor performance could be assumed

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 o Sign of the buttock
Purpose
To test for a serious lesion in the buttock or hip region, e.g. fracture, neoplasm or infection.
Technique
Patient position
Lying supine.
Clinician position and action
Standing adjacent to the side being tested the clinician performs a straight leg raise (SLR) on the affected leg
and the angle achieved is noted. At the point where increased pain is reported by the patient, the tension in
the posterior thigh, buttock and sciatic nerve is removed by flexing the knee while maintaining the hip at the
same angle. Further hip flexion is then attempted. Under normal circumstances, it should then be possible to
move the hip into further flexion.
Positive test
Once the knee is flexed, further hip flexion would be expected but in fact none is possible as this increases
the patient’s buttock pain. This may be accompanied by voluntary muscle spasm and the patient stopping
further movement taking place

KNEE
o Valgus test
Purpose
To primarily detect pain and/or laxity of the medial collateral ligament
(MCL).
Technique
Patient position
Lying supine with the leg relaxed.
Clinician position
Standing on the outside of the affected leg; the patient’s lower leg is
lifted and supported between the waist and the inside of the clinician’s
elbow with the knee flexed to about 20–30° and the hip positioned
in a degree of internal rotation and abduction. The heel of
the outside hand is placed just above the lateral joint line, the inside
hand is placed just below the medial joint line where the thumb can
palpate the medial tibiofemoral joint line.
Action
Firm inward pressure is applied with the outside hand and outward
pressure with the inside hand while rotating the body away
from the end of the couch to achieve a valgus stress to the knee. The
test can then be repeated with the knee in full extension.

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Positive test
The reproduction of medial knee pain alone is suggestive of injury
to the MCL. An intact ligament produces a normal ligamentous
end-feel where firm resistance to the valgus stress is noted. Loss
of this normal resistance and an increase in valgus movement (in
excess of 15°) suggests structural damage to the MCL indicative of a
more significant injury involving other structures.
In full extension stability to the joint is afforded by the cruciate ligaments
and laxity in this position is likely to represent major disruption
to the knee and concurrent injury to the posterior capsule, posterior cruciate
ligament (PCL) and possibly the anterior cruciate ligament (ACL)
should be suspected

o Varus test
Purpose
To primarily detect pain and/or laxity of the lateral collateral ligament
(LCL).
Technique
Patient position
Lying supine towards the edge of the couch.
Clinician position
Standing on the affected side, the leg is lifted off the couch and
the hip is passively abducted far enough to allow the clinician to
stand in the space between the inside of the leg and the side of the
couch. The patient’s lower leg is supported between the waist and
the outer elbow and the hip is positioned in some degree of internal
rotation. The heel of the outside hand is placed on the upper tibia
just below the lateral joint line and the inside hand is placed just
above the medial joint line on the lower femur.
Action
With the knee in about 20° of flexion and the hip internally rotated,
firm pressure is applied with both hands to achieve a varus stress
while rotating the body in order to increase leverage.
Positive test
Lateral knee pain or laxity on stress testing

o Posterior Drawer test

Purpose
To detect posterior (one-plane) instability and posterior cruciate ligament
(PCL) laxity.
Technique
Patient position
Supine with the hip flexed to 45°, the knee flexed to 90° and the foot
placed on the couch.
Clinician position
The lower leg is stabilized by sitting on the dorsum of the forefoot.
Both hands grasp around the upper tibia with thumbs placed
anteriorly over the joint line with the thenar area of both hands
positioned over the upper tibia. The fingers can also palpate the
hamstring tendons posteriorly to ensure they are relaxed.
Action
The tibia is pushed backwards with both hands. The quality of the
joint end-feel should be appreciated and a ligamentous ‘stop’ noted
if the ligament remains intact.
Positive test
A positive test is indicated by increased posterior excursion of the

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tibia and an associated loss of the normal end-feel. An increase in
the slope of the infrapatellar tendon may also be noted.

o Anterior Drawer Test

Purpose
To detect anterior (one-plane) instability and anterior cruciate ligament (ACL) laxity
Technique
Patient position
Lying supine with the knee flexed to 90° and foot placed on the couch.
Clinician position
The patient’s foot is stabilized by sitting on the dorsum of the forefoot. Both hands grasp around the upper
tibia with thumbs placed anteriorly over the joint line. Also, in this position the hamstring tendons can easily
be palpated to ensure the muscle is completely relaxed and that voluntary or involuntary resistance to the test
is avoided.
Action
The tibia is drawn forwards with both hands and a comparison of the degree of anterior translation is made
with the other knee. The quality of the joint end-feel should be appreciated and a ligamentous ‘stop’ noted if
the ligament remains intact.
Positive test
Increased anterior excursion of the tibia accompanied by the loss of normal ligamentous resistance usually
indicates significant injury. In a healthy knee, it is normal for approximately 6 mm of anterior tibial
translation to be present. If the ACL is injured in combination with the medial ligament/capsule, a much
greater degree of anterior translation will be present (15 mm or more).

o Lachman’s test
Purpose
To detect anterior (one-plane) instability and anterior cruciate ligament
(ACL) laxity.
Technique
Patient position
Lying supine.
Clinician position
The patient’s foot is stabilized between the clinician’s thigh and
the couch. The outside hand is placed over the lateral aspect of the
thigh just above the knee joint and the fingers wrapped around the
back of the lower thigh while counterpressure is applied anteriorly
with the thumb. The inside hand is placed over the medial aspect
of the leg just below the knee joint using an identical grip, with the
thumb placed over the tibial tuberosity and the knee positioned in
about 10–30° of flexion.
Action
With the outside hand stabilizing the femur, the lower hand firmly pulls the tibia forwards in an attempt to
generate anterior translation. The quality of the joint end-feel should be appreciated and a firm ligamentous
‘stop’ noted in the normal knee.

Positive test
Increased anterior excursion of the tibia on the femur with an accompanying change in the end-feel usually
indicates a significant injury. The firm resistance gives way to a softer or even absent endfeel. The normal
slope of the infrapatellar tendon also diminishes.

o Apley’s test
Apley’s grinding test
Purpose
To elicit pain and/or apprehension resulting from meniscal injury or pathology.
Technique

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Patient position
Prone lying with the knee positioned in 90° flexion. The couch needs to be low enough to allow the
clinician’s knee to fix the lower thigh during the manoeuvre.

Clinician position
The clinician’s cephalic knee is positioned over the patient’s lower thigh and a firm but comfortable pressure
is applied to maintain the thigh’s position against the couch during the test.
Action
This test involves rotation of the tibia with both distraction and compression.
Firstly, rotation with distraction is tested. Cupping the dorsum of the foot with the caudal hand and applying
a firm hold around the ankle with the other, the knee is distracted by pulling longitudinally along the line of
the tibia, using both hands to achieve this. Once the distraction is on, internal and external tibial rotation is
applied with both hands.
Rotation under compression is then applied. Both hands change position. The caudal hand fixes the forefoot
in a plantigrade position while the other is placed over the heel in order to apply compression along the
longitudinal axis of the tibia. Once the compression is added, internal and external tibial rotation is applied,
using the foot as a lever.
Positive test
Pain and/or apprehension elicited when rotation is applied under compression which reduces when the test is
repeated with distraction.

o McMurray’s test
Purpose
To elicit pain and/or apprehension resulting from meniscal injury
or pathology.
Technique
Patient position
Lying supine.
Clinician position
The cephalic hand is placed above the patella and, using the index
finger and thumb, the medial and lateral joint lines are palpated in
order to detect clicking during the test. The patient’s heel is cupped

with the caudal hand so that the forearm lies along the medial
aspect of the foot enabling it to be used as a lever, so the tibia can be
rotated externally.

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Action
With the knee positioned in full flexion and external rotation, the
leg is steadily extended to around 90°.
The test can then be repeated with the tibia held in internal rotation.
The caudal hand is re-positioned so that the fingers cup the
calcaneus medially with the thumb on the lateral aspect.

McConnell test
Purpose
To detect pain emanating from the patellofemoral articulation.
Technique
Patient position
The patient sits on the edge of a raised couch, with the femur externally rotated and the knee flexed over the
side.
Clinician position
Sitting on a low stool, resistance to isometric extension is given by one hand which is positioned over the
front of the shin while the other hand stabilizes the thigh.
Action
The patient holds an isometric contraction of the quadriceps for several seconds in varying degrees of
flexion (120°, 90°, 60°, 30° and 0°). If pain is reproduced in any of these positions the test is repeated while
the clinician passively maintains a medial glide to the patella.
Positive test
Patellofemoral pain is indicated if pain is reproduced on isometric quadriceps contraction and lessened when
the medial glide is applied in any of the positions tested.

o Patellofemoral grind test

Purpose
To elicit pain and/or apprehension emanating from the patellofemoral joint.
Technique
Patient position
Lying supine with the knee extended.
Clinician position

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Using a pinch grip of the index finger and thumb of both hands, the superior and inferior poles of the patella
are fixed.

Action
The patella is gradually compressed against the femur and moved inferiorly and superiorly, sliding the
posterior surface of the patella against the femoral condyles.
Positive test
Reproduction of the patient’s anterior knee pain.

Ankle and Foot

Anterior Drawer Test

Test Anterior talofibular ligament Test
Procedure Stabilize tibia. Apply anterior stress to foot and ankle
Positive Anterior translation indicates ligament lexity
Sign

Posterior Drawer Test

Test Posterior talofibular ligament
Procedure Stabilize tibia. Apply posterior stress to foot and ankle
Positive Posterior translation indicates ligament lexity

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 Sign

Thompson’s Test
Test Achilies tendon rupture
Procedure Patient prone with feet over edge of plinth. Squeeze calf
muscles
Positive Absence of plantarflexion
Sign

Anterior Drawer Test Posterior Drawer Test

Cervical Spine
Spurling’s Test: (Symptom Provoking)
Test Nerve root compression
Procedure Patient in sitting. Extend neck and rotate head. Apple pressure
downward
Positive Sign Radiating pain to arm or shoulder on side to which head is rotated

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Distraction Test: (Symptom Alleviating Test)
Test Nerve root compression
Procedure Patient in sitting. Place one hand under chin and other under occiput.
Gently Lift head
Positive Sign Decrease or relieve of pain

Spurling’s Test Distraction Test

Vertebral artery Test:

Test To rule out treatment risk due to vertebral artery insufficiency
Starting Position Patient supine, with head beyond edge of treatment table
Hand Placement Hold patient’s head in your hands
Procedure Slowly lower the patient’s head simultaneously into cervical
extension with side bending and rotaion to right, then hold the
patient’s head in this position
Positive Sign Left Vertebral Artery Insufficiency (Dizziness, Nystagmus etc.)
In Middle and Lower Cervical Spine: Right Vertebral Artery may be
Compromised by arthritic changes or bony spur

Lumbar Spine

Ely's Test
Test Femoral Nerve or radicular inflamation
Procedure Approximate the heel to the opposite buttock in the prone patient.

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 Positive Sign With a hip lesion or psoas irritation the prone patient will be unable
to do this test normally. This test aggravates inflammation of the
lumbar nerve roots and will cause femoral radicular pain to the
anterior thigh. It will also stretch lumbar nerve root adhesions
causing upper lumbar discomfort

Braggard's Test
Test Sciatic neuritis, spinal cord tumors, IVD
lesions, spinal nerve irritation
Procedure If a SLR is positive, lower the leg just
below the angle of pain production and
sharply dorsiflex the foot.
Positive Sign Reproduction of symptoms

Sicard's Test
Test Sciatic radiculopathy
Procedure A SLR is performed to the point at which
symptoms are reproduced. The leg is then
lowered to below that point and the
examiner sharply dorsiflexes the big toe of
the affected foot
Positive Sign Reproduction of symptoms

o Slump Test
Patient is seated on the edge of the table with the legs supported, the hips in neutral
posistion, and the hands behind the back. The exam is performed in steps.
1) ask patient to "slump" the back into thoracic and lumbar flexion, with chin in neutral
2) use one arm to apply overpressure across the client's shoulders to maintain flexion of
back - ask client to actively flex the cervical spine and head as far as possible.
3) Apply overpressure to all 3 parts (if there is no pain) and then hold client's foot in max
dorsiflexion.
4) If there is still no pain, maintain hold on head, neck, and foot, then ask client to
straighten knee.
5) Test each leg, then both together
Test is positive if the client is unable to extend leg due to pain, can extend knee farther if
the neck is also extended or if the test position increases the client's symptoms.

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References:

Evidence based musculoskeletal examination by Paul Hattam

Pocket book for physical therapists

Orthopedic Assesment by David J.Magee

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 Myotomes
Root Joint Action
C1-C2 Cervical Flexion
C3 Cervical Lateral Flexion
C4 Shoulder Girdle Elevation
C5 Shoulder Abduction
C6 Elbow Flexion
C7 Elbow Extension
C8 Thumb Extension
T1 Finger Abduction/aduction
T1-L1 No Muscle test
L2 Hip Flexion
L3 Knee Extension
L4 Ankle Dorsiflexion
L5 Great toe Extension
S1 Ankle eversion/ hip extension/ ankle planter
flexion/ knee flexion
S2 Knee flexion

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 Reflexes
Deep Tendon Root Nerve
Reflex
Biceps Jerk C5-C6 Musculocutaneous
Brachioradialis Jerk C5-C6 Radial
Triceps Jerk C7-C8 Radial
Knee jerk L3-L4 Femoral
Ankle jerk S1-S2 Tibial

Grades of Reflexes

O or - Absent

1 or – Diminished

2 or + Average/ Normal

3 or + + Exaggerated

4 or + + + Clonus

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 MMT
Grade Response
0 No Movement
1 Flicker of contraction
2 Active movement with gravity eliminated
3 Active movements against gravity
4 Active movement against submaximal resistance
5 Active movement against maximum movement

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