Physical Diagnosis of Pain An Atlas of Signs and Symptoms 3rd Edition Compress

PHYSICAL
DIAGNOSIS
OF PAIN
AN ATLAS OF SIGNS
AND SYMPTOMS
3 rd
Edition
PHYSICAL
DIAGNOSIS
OF PAINAN ATLAS OF SIGNS
AND SYMPTOMS
STEVEN D. WALDMAN, MD, JD

Chairman and Professor
Department of Medical Humanities and Bioethics
Clinical Professor of Anesthesiology
University of Missouri–Kansas City School of Medicine
Kansas City, Missouri
3251 Riverport Lane
St. Louis, Missouri 63043
PHYSICAL DIAGNOSIS OF PAIN: AN ATLAS OF SIGNS ISBN: 978-0-323-37748-5

AND SYMPTOMS, Third Edition
Copyright © 2016 by Elsevier Inc. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

Waldman, Steven D., author.
Physical diagnosis of pain : an atlas of signs and symptoms / Steven D. Waldman.—Third edition.
p. ; cm.
Includes index.
ISBN 978-0-323-37748-5 (hardcover)
I. Title.
[DNLM: 1. Musculoskeletal Diseases—diagnosis—Atlases. 2. Pain—diagnosis—Atlases. 3. Physical
Examination—methods—Atlases. WE 17]
RC925.7
616.7′07540223—dc23
2015032343
Publishing Manager: Michael Houston

Content Development Manager: Margaret Nelson
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Senior Project Manager: Clay S. Broeker
Design Direction: Amy Buxton
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Every Long Journey Begins with a First Step
Confucius
This book is dedicated to my children—

David Mayo, Corey, Jennifer, and Reid—
all of whom are sick of hearing me invoke the above quote …
but have nevertheless steadfastly followed its timeless wisdom
in their daily lives!
Preface
ring disappear rather than diagnosis anything, as he was in

love with his much younger and sexier x-ray tech!) Be that
as it may, from that point on, physicians have constantly
been looking for a way to make the diagnosis without actu-
ally examining the patient. X-ray gave way to fluoroscopy,
which gave way to computerized tomography, which gave
way to ultrasound, which gave way to magnetic resonance
imaging, which has recently given way to PET scanning.
Each modality’s initial promise of an easier way to make the
diagnosis always seemed to fall short of the mark. Yet hope
springs eternal in the human breast, and many hope that
rather than medical imaging, it will be the human genome
that finally releases the medical profession from actually
having to examine the patient!
In our perennial search for a less up close and personal
way to come up with what’s wrong with the patient, we
must constantly be reminded that “some things never
change” … and one of those things is the amazing clinical
utility of the properly taken history and properly performed
physical examination. Yes, we actually have to touch the
patient. Yes, we actually have to exert some effort. However,
“I knew it was too good to be true … some things never change!” can you think of anything that has a higher yield for the
(From Kaplan EL, Mhoon D, Kaplan SP, Angelos P. Radiation-induced patient and physician alike? I certainly can’t.
thyroid cancer: The Chicago experience. Surgery 146:979, 2009.) In reviewing the Prefaces for the first and second editions
of this text, I was struck by the spot-on accuracy of the
musing of the great baseball player Yogi Berra when he said,
While it’s true that I hadn’t quite finished medical school “It’s like déjà vu all over again!” Put another way, when all
when Wilhelm Roentgen took an x-ray of his wife’s hand, else fails … EXAMINE THE PATIENT!
there is no doubt in my mind that this simple act forever
changed the way medicine would be practiced. (Rumor has Steven D. Waldman
it he was actually trying to find a way to make her wedding Summer 2015
vii
Video Contents
Chapter 9 The C5 Neurologic Level Chapter 81 The Compression Test for Lateral
Chapter 10 The C6 Neurologic Level Antebrachial Cutaneous Nerve
Chapter 11 The C7 Neurologic Level Entrapment Syndrome
Chapter 12 The C8 Neurologic Level Chapter 82 The Snap Sign for Snapping Triceps
Chapter 13 The Spurling Test for Cervical Syndrome
Radiculopathy Secondary to Herniated Chapter 85 The Tennis Elbow Test
Disc or Cervical Spondylosis Chapter 91 The Compression Test for Radial Tunnel
Chapter 26 The Anterior Drawer Test Syndrome
Chapter 31 The Posterior Drawer Test for Posterior Chapter 92 The Forced Pronation Test for Pronator
Shoulder Instability Syndrome
Chapter 37 The Neer Test for Shoulder Impingement Chapter 104 The Finkelstein Test for de Quervain
Syndromes Tenosynovitis
Chapter 42 The Speed Test for Bicipital Tendinitis Chapter 109 The Tinel Sign for Carpal Tunnel Syndrome
Chapter 43 The Yergason Test for Bicipital Chapter 110 The Phalen Test for Carpal Tunnel
Tendinitis Syndrome
Chapter 45 The Gerber Lift-Off Test for Rupture of Chapter 111 The Opponens Weakness Test for Carpal
the Subscapularis Muscle Tunnel Syndrome
Chapter 46 The Gerber Belly Press Test for Chapter 112 The Opponens Pinch Test for Carpal
Subscapularis Weakness Tunnel Syndrome
Chapter 47 The Internal Rotation Lag Sign for Rupture Chapter 115 The Spread Sign for Ulnar Tunnel
of the Subscapularis Tendon Syndrome
Chapter 52 The Drop Arm Test for Complete Rotator Chapter 121 The Catching Tendon Sign for Trigger
Cuff Tear Finger Syndrome
Chapter 53 The External Rotation Lag Sign for Chapter 132 The Shrug Test for Sternoclavicular
Rupture of the Supraspinatus or Joint Dysfunction
Infraspinatus Tendons Chapter 144 The L4 Neurologic Level
Chapter 56 The Jobe Supraspinatus Test Chapter 145 The L5 Neurologic Level
Chapter 58 The External Rotation Stress Test for Chapter 146 The S1 Neurologic Level
Impairment of the Infraspinatus and Teres Chapter 152 The Spurling Test for Lumbar Nerve
Minor Muscles Root Irritation
Chapter 60 The Adduction Release Test for Chapter 154 The Ely Test for Lumbar Nerve
Subcoracoid Bursitis Root Irritation
Chapter 62 The Chin Adduction Test for Chapter 170 The Femoral Stretch Test
Acromioclavicular Joint Dysfunction Chapter 185 The Patrick/FABER Test for Hip Pathology
Chapter 65 The Adson Maneuver for Thoracic Chapter 187 The Resisted Hip Extension Test for
Outlet Syndrome Ischial Bursitis
Chapter 67 The Hyperabduction Test for Thoracic Chapter 188 The Resisted Hip Abduction Test for
Outlet Syndrome Gluteal Bursitis
Chapter 78 The Wartenberg Sign for Ulnar Nerve Chapter 189 The Resisted Hip Adduction Test for
Entrapment at the Elbow Iliopsoas Bursitis
Chapter 79 The Little Finger Adduction Test for Ulnar Chapter 203 The Ballottement Test for Large Joint
Nerve Entrapment at the Elbow Effusions
xiv
1 Functional Anatomy of the Bony
Cervical Spine
THE VERTEBRAE OF THE CERVICAL SPINE primary function of facilitating focused movement of the
head to allow the optimal functioning of the eyes, ears,
To fully understand the functional anatomy of the cervical nose, and throat. The uppermost two functional units are
spine and the role its unique characteristics play in the susceptible to trauma and the inflammatory arthritides as
evolution of the myriad painful conditions that have the well as to the degenerative changes that occur as a result of
cervical spine as their nidus, one must first recognize that the aging process.
unlike the thoracic and lumbar spine, whose functional The second type of functional unit that makes up the
units are quite similar, the cervical spine must be thought cervical spine is very similar to the functional units of the
of as being composed of two distinct and dissimilar func- thoracic and lumbar spine and serves primarily as a struc-
tional units. The first type of functional unit consists of the tural support for the head and secondarily functions to aid
atlanto-occipital unit and the atlantoaxial units (Figs. 1-1 in the positioning of the sense organs located in the head
and 1-2). While these units help to provide structural static (Fig. 1-3, A-C). Disruption of this second type of functional
support for the head, they are uniquely adapted to their unit, which comprises the lower five cervical vertebrae and
Odontoid process of axis
Atlas
Atlas
Axis
• Figure 1-1 Atlanto-occipital unit. • Figure 1-2 Atlantoaxial unit.
Normal Flexion Extension
A B C
• Figure 1-3 Functional units of the cervical spine in normal (A), flexed (B), and extended
(C) positions.
2
CHAPTER 1 Functional Anatomy of the Bony Cervical Spine 3
their corresponding intervertebral discs, is responsible for functional disability or pain; however, in disease, these
the majority of painful conditions encountered in clinical movements may result in nerve impingement with its atten-
practice (see Chapter 15). dant pain and functional disability.
THE MOBILITY OF THE CERVICAL SPINE THE CERVICAL VERTEBRAL CANAL

The cervical spine has the greatest range of motion of the The bony cervical vertebral canal serves as a protective
entire spinal column and allows movement in all planes. Its conduit for the spinal cord and as an exit point of the
greatest movement occurs from the atlanto-occipital joint cervical nerve roots. Owing to the bulging of the cervical
to the third cervical vertebra. Movement of the cervical neuromeres as well as the other fibers that must traverse
spine occurs as a synchronized effort of the entire cervical the cervical vertebral canal to reach the lower portions of
spine and its associated musculature, with the upper two the body, the cervical spinal cord occupies a significantly
cervical segments providing the greatest contribution to greater proportion of the space available in the spinal
rotation, flexion, extension, and lateral bending. During canal relative to the space occupied by the thoracic and
flexion of the cervical spine, the spinal canal is lengthened, lumbar spinal cord. This decreased space results in less
the intervertebral foramina become larger, and the anterior shock-absorbing effect of the spinal fluid during trauma
portion of the intervertebral disc becomes compressed (Fig. and also results in compression of the cervical spinal
1-3, B). During extension of the cervical spine, the spinal cord with attendant myelopathy when bone or interverte-
canal becomes shortened, the intervertebral foramina bral disc compromises the spinal canal (Fig. 1-4). Such
become smaller, and the posterior portion of the anterior encroachment of the cervical cord by degenerative changes
disc becomes compressed (Fig. 1-3, C). With lateral bending or disc herniation can occur over a period of time, and
or rotation, the contralateral intervertebral foramina become the resultant loss of neurologic function due to myelopa-
larger, while the ipsilateral intervertebral foramina become thy can be subtle; as a result, a delay in diagnosis is not
smaller. In health, none of these changes in size results in uncommon.
A B
• Figure 1-4 Cervical spondylosis. Sagittal T1-weighted spin echo (A) and sagittal T2-weighted fast spin
echo (B) magnetic resonance images of the cervical spine demonstrate disc degeneration at essentially
every cervical level, in addition to loss of disc space height and, in B, diminished signal intensity. Severe
central canal stenosis is related to both anterior disc herniation with osteophytes and posterior ligamen-
tous hypertrophy at most of the cervical levels. A focal area of high signal intensity within the cord at the
C5-C6 level reflects posttraumatic myelomalacia. (From Resnick D, Kransdorf MJ, editors: Bone and joint
imaging, ed 3, Philadelphia, 2005, Saunders, p 147.)
4 SECTION 1 The Cervical Spine
The cervical vertebral canal is funnel-shaped, with its

largest diameter at the atlantoaxial space and progressing C3 nerve root
to its narrowest point at the C5-C6 interspace. It is not
surprising that this narrow point serves as the nidus of many
painful conditions of the cervical spine. The shape of the
cervical vertebral canal in humans is triangular but is subject C3
to much anatomic variability among patients. Those patients C4 nerve root
with a more trifoil shape generally are more susceptible to
cervical radiculopathy in the face of any pathologic process
C4
that narrows the cervical vertebral canal or negatively affects
C5 nerve root
the normal range of motion of the cervical spine.
C5
THE CERVICAL NERVES AND
C6 nerve root
THEIR RELATION TO
THE CERVICAL VERTEBRAE
C6
The cervical nerve roots are each composed of fibers from C7 nerve root
a dorsal root that carries primarily sensory information and
a ventral root that carries primarily motor information. As
the dorsal and ventral contributions to the cervical nerve
roots move away from the cervical spinal cord, they coalesce C7 C8 nerve root
into a single anatomic structure that becomes the individual
cervical nerve roots. As these coalescing nerve fibers pass
through the intervertebral foramen, they give off small • Figure 1-5 Position of cervical nerves relative to cervical
branches, with the anterior portion of the nerve providing vertebrae.
innervation to the anterior pseudo-joint of Luschka and the
annulus of the disc and the posterior portion of the nerve
providing innervation to the zygapophyseal joints of each IMPLICATIONS FOR THE CLINICIAN
adjacent vertebra between which the nerve root is exiting.
These nerve fibers are thought to carry pain impulses from The bony cervical spine is a truly amazing anatomic struc-
these anatomic structures, and this notion of the interver- ture in terms of both its structure and its function. The two
tebral disc and zygapophyseal joint as distinct pain genera- uppermost segments of the cervical spine are vitally impor-
tors diverges from the more conventional view of the tant to a human’s day-to-day safety and survival, but with
compressed spinal nerve root as the sole source of pain the exception of cervicogenic and tension-type headaches,
emanating from the cervical spine. As the nerve fibers exit they are not the source of the majority of painful conditions
the intervertebral foramen, they fully coalesce into a single involving the cervical spine that are commonly encountered
nerve root and travel forward and downward into the pro- in clinical practice. However, the lower five segments
tective gutter made up of the transverse process of the provide ample opportunity for the evolution of myriad
vertebral body to provide innervation to the head, neck, and common painful complaints, most notably cervical radicu-
upper extremities (Fig. 1-5). lopathy and cervicalgia, including cervical facet syndrome.
2 Functional Anatomy of the Cervical
Intervertebral Disc
The cervical intervertebral disc has two major functions: mucopolysaccharide gel-like substance called the nucleus
(1) to serve as the major shock-absorbing structure of the pulposus (see Fig. 2-1). The nucleus is incompressible and
cervical spine and (2) to facilitate the synchronized move- transmits any pressure placed on one portion of the disc to
ment of the cervical spine while at the same time helping the surrounding nucleus. In health, the water-filled gel
to prevent impingement of the neural structures and vascu- creates a positive intradiscal pressure that forces the adjacent
lature that traverse the cervical spine. Both the shock- vertebrae apart and helps to protect the spinal cord and
absorbing function and the movement and protective exiting nerve roots. When the cervical spine moves, the
function of the cervical intervertebral disc are a function incompressible nature of the nucleus propulsus maintains a
of the disc’s structure as well as the laws of physics that constant intradiscal pressure, while some fibers of the disc
affect it. relax and others contract.
To understand how the cervical intervertebral disc func- As the cervical intervertebral disc ages, it becomes
tions in health and becomes dysfunctional in disease, it is less vascular and loses its ability to absorb water into
useful to think of the disc as a closed, fluid-filled container. the disc. This results in a degradation of the disc’s
The outside of the container is made up of a top and a shock-absorbing and motion-facilitating functions. This
bottom called the endplates, which are composed of rela- problem is made worse by degeneration of the annulus,
tively inflexible hyaline cartilage. The sides of the cervical which allows portions of the disc wall to bulge, distort-
intervertebral disc are made up of a woven crisscrossing ing the ability of the nucleus pulposus to evenly distrib-
matrix of fibroelastic fibers that tightly attaches to the top ute the forces placed on it through the entire disc. This
and bottom endplates. This woven matrix of fibers is called exacerbates the disc dysfunction and can contribute to
the annulus, and it completely surrounds the sides of the further disc deterioration, which can ultimately lead
disc (Fig. 2-1). The interlaced structure of the annulus to actual complete disruption of the annulus and extru-
results in an enclosing mesh that is extremely strong yet at sion of the nucleus as well as render the disc more sus-
the same time very flexible, which facilitates the compres- ceptible to damage from even minor trauma (Fig. 2-3;
sion of the disc during the wide range of motion of the also see Chapter 3). The deterioration of the disc is
cervical spine (Fig. 2-2). responsible for many of the painful conditions that
Inside this container of the top and bottom end- emanate from the cervical spine that are encountered in
plates and surrounding annulus is water that contains a clinical practice (see Chapter 15).
Nucleus
pulposus Annulus
fibrosus
Normal Compressed Flexion

• Figure 2-1 The cervical intervertebral disc can be thought of as a • Figure 2-2 The cervical intervertebral disc is a strong yet flexible
closed, fluid-filled container. structure, shown here in the range of motion of the cervical spine.
5
A B
• Figure 2-3 Posttraumatic discovertebral injury: lucent annular cleft sign. A, Hyperextension
injury. Lateral radiograph shows a linear collection of gas within the annular fibers of the intervertebral
disc adjacent to the vertebral endplate. The lucent cleft sign (arrow), often seen after hyperextension
injuries, is believed to represent traumatic avulsion of the annulus fibrosus from its attachment to the
anterior cartilaginous endplate. B, Hyperflexion injury. Observe the gas density within the posterior portion
of the C4-C5 disc (arrow) on this lateral radiograph obtained in flexion. This patient was recently involved
in a rear-end impact motor vehicle collision and had severe neck pain. (From Taylor JAM, Hughes
TH, Resnick D: Skeletal imaging: atlas of the spine and extremities, ed 2, St. Louis, 2010, WB
Saunders.)
3 Nomenclature of the Diseased
Cervical Disc
Much confusion surrounds the nomenclature that is used Nucleus pulposus Intervertebral
to describe the diseased cervical disc. Such confusion exists Transverse disc
in part because of the use of a system of nomenclature that foramen
was devised before the advent of computed tomography and
magnetic resonance imaging and in part because of the
focus by radiologists and clinicians alike on the impinge-
ment of the intervertebral disc on neural structures as the
sole source of pain emanating from the spine. This second
viewpoint ignores the disc and facet joint as an independent
source of spine pain and leads to misdiagnosis, treatment Articular
plans with little chance of success, and needless suffering facet
for the patient. By standardizing the nomenclature of the Annulus
diseased cervical disc, the radiologist and clinician can do fibrosus
much to avoid these pitfalls when caring for the patient with
spinal pain. The following classification system will allow Spinous process
the radiologist and clinician to communicate with each • Figure 3-1 Normal cervical disc.
other in the same language. It also takes into account the
fact that the intervertebral disc may be the sole source of
spinal pain and that certain findings on magnetic resonance As the degenerative process occurs, the nucleus pulposus
imaging should point the clinician toward a discogenic begins to lose its ability to maintain an adequate level of
source of pain and an early consideration of discography as hydration as well as its ability to maintain a proper mixture
a diagnostic maneuver prior to surgical interventions. More of proteoglycans necessary to keep the gel-like consistency
than 90% of clinically significant disc abnormalities of the of the nuclear material. Degenerative clefts develop within
cervical spine occur at C5-C6 or C6-C7. the nuclear matrix, and portions of the nucleus become
replaced with collagen, which leads to a further degradation
THE NORMAL DISC of the shock-absorbing abilities and flexibility of the disc.
As this process continues, the disc’s ability to maintain an
As was discussed in Chapter 2, the normal disc consists of adequate intradiscal pressure to push the adjacent vertebrae
the central gel-like nucleus pulposus, which is surrounded apart begins to break down, leading to a further deteriora-
concentrically by a dense fibroelastic ring called the annulus. tion of function with the onset of clinical symptoms.
The top and bottom of the disc are made up of cartilaginous In addition to degenerative changes affecting the nucleus
endplates that are adjacent to the vertebral body. The laws pulposus, the degenerative process affects the annulus as
of physics (primarily Pascal’s law) allow the disc to maintain well (Fig. 3-2). As the annulus ages, the complex interwoven
an adequate intradiscal pressure to push the adjacent verte- mesh of fibroelastic fibers begins to break down, with small
brae apart. On magnetic resonance imaging, the normal tears within the mesh occurring. As these tears occur, the
cervical disc appears symmetrical with low signal intensity exposed collagen fibers stimulate the ingrowth of richly
on T1-weighted images and high signal intensity through- innervated granulation tissue that can account for disco-
out the disc on T2-weighted images. In health, the margins genic pain. These tears can be easily demonstrated in mag-
of the cervical disc do not extend beyond the margins of netic resonance imaging as linear structures of high signal
the adjacent vertebral bodies (Fig. 3-1). intensity on T2-weighted images that correlate with positive
results when provocative discography is performed on the
THE DEGENERATED DISC affected disc. When identified as the source of pain on dis-
cography, these annular tears can be treated with intradiscal
As the disc ages, both the nucleus and the annulus undergo electrothermal annuloplasty with good results (Fig. 3-3).
structural and biochemical changes that affect both the
disc’s appearance on magnetic resonance imaging and the THE DIFFUSELY BULGING DISC
disc’s ability to function properly. Although this degenera-
tive process is a normal part of aging, it can be accelerated As the degenerative process continues, further breakdown
by trauma to the cervical spine, infection, and smoking. If and tearing of the annular fibers and continued loss of
the degenerative process is severe enough, many but not all hydration of the nucleus propulsus lead to a loss of intradis-
patients will experience clinical symptoms. cal pressure with resultant disc space narrowing, which can
7
from the disc annulus itself (Fig. 3-5). These findings are
clearly demonstrated on magnetic resonance imaging and
should alert the clinician to the possibility of multifactorial
sources of the patient’s pain and functional disability.
R C4 THE FOCAL DISC PROTRUSION

As the disc annulus and nucleus propulsus continue to
degenerate, the ability of the annulus to completely contain
C5 and compress the nucleus propulsus is lost and with it the
incompressible nature of the nucleus propulsus. This leads
to focal areas of annular wall weakness, which allow the
C6 nucleus propulsus to protrude into the spinal canal or
against pain-sensitive structures (Fig. 3-4, C). Such protru-
sions are focal in nature and are easily seen on both T1- and
C7 T2-weighted magnetic resonance images (Fig. 3-6). These
focal disc protrusions may be either relatively asymptomatic
if the focal bulge does not impinge on any pain-sensitive
structures or highly symptomatic, presenting clinically as
pure discogenic pain or as radicular pain if the focal protru-
sion extends into a neural foramen or the spinal canal.
• Figure 3-2 Contrast within the epidural space suggesting complete
disruption of the disc annulus. R, Right. (From Waldman SD: Atlas of
interventional pain management, ed 2, Philadelphia, 2004, Saunders, THE FOCAL DISC EXTRUSION
p 554.)
Focal disc extrusion is frequently symptomatic because the
disc material often migrates cranially or caudally, resulting
Anterior in impingement of exiting nerve roots and the creation of
an intense inflammatory reaction as the nuclear material
irritates the nerve root. This chemical irritation is thought
Electrothermal to be responsible for the intense pain that is experienced by
catheter
many patients with focal disc extrusion and may be seen on
magnetic resonance imaging as high-intensity signals on
T2-weighted images (Fig. 3-7). Although more pronounced
than a focal disc protrusion, focal disc extrusion is similar
Introducer in that the extruded disc material remains contiguous with
needle
the parent disc material (Fig. 3-4, D).
Posterior
THE SEQUESTERED DISC

When a portion of the nuclear material detaches itself from
its parent disc material and migrates, the disc fragment is
called a sequestered disc (Fig. 3-4, E). Sequestered disc frag-
ments frequently migrate in a cranial or caudal direction
and become impacted beneath a nerve root or between the
posterior longitudinal ligament and the bony spine. Seques-
tered disc fragments can cause significant clinical symptoms
• Figure 3-3 Intradiscal electrothermal annuloplasty: schematic view. and pain and often require surgical intervention. Seques-
(From Waldman SD: Atlas of interventional pain management, tered disc fragments will often enhance on contrast-
ed 2, Philadelphia, 2004, Saunders, p 554.)
enhanced T1-weighted images and demonstrate a peripheral
rim of high-intensity signal due to the inflammatory reac-
tion the nuclear material elicits on T2-weighted images.
lead to an exacerbation of clinical symptoms. As the disc Failure to identify and remove sequestered disc fragments
space gradually narrows owing to decreased intradiscal pres- often leads to a poor surgical result. Magnetic resonance
sure, the anterior and posterior longitudinal ligaments imaging of the cervical spine, cervical myelography with
grow less taut and allow the discs to bulge beyond the contrast-enhanced computed tomography, and discography
margins of the vertebral body (Fig. 3-4, A, B). This causes will help the clinician to further delineate the type of disc
impingement of bone or disc on nerve and spinal cord, herniation the patient is suffering from and aid in formula-
adding impingement-induced pain to the pain emanating tion of a treatment plan (Fig. 3-8).
CHAPTER 3 Nomenclature of the Diseased Cervical Disc 9
A Diffuse disc bulge B Broad-based protrusion
C Focal disc protrusion D Disc extrusion
E Disc sequestration
• Figure 3-4 Various types of cervical disc degeneration.

• Figure 3-5 Sagittal T2-weighted MRI scan showing significant cer-

vical degenerative disk disease with broad-based disk bulging at
C3-4, C5-6, and C6-7. Cord signal changes are evident at C3-4
and C5-6 (arrows). (From Jandial R, Garfin SR, Ames CP: Best
evidence for spine surgery: 20 cardinal cases, Philadelphia, 2012,
Saunders/Elsevier, p 152, fig 13-2.)
• Figure 3-6 T2-weighted, sagittal MRI image in a patient with C3-4

disc protrusion, causing compressive intramedullary signal change in
the cervical spinal cord (arrow). (From Davis W, Allouni AK, Mankad K,
et al: Modern spinal instrumentation. Part 1: normal spinal implants,
Clin Radiol 68(1):65, 2013, fig 1a.)
CHAPTER 3 Nomenclature of the Diseased Cervical Disc 11
A B C
• Figure 3-7 A, Midline sagittal magnetic resonance (MR) image, showing extrusion of disk material into
spinal canal at fifth cervical interspace (arrow). Disk material extends both above and below level of
interspace. (Repetition time [TR] = 1,500 ms; echo time [TE] = 60 ms.) B, Axial MR image, confirming
large disk extrusion in midline and extending to the left. Note considerable compression of spinal cord
and subarachnoid space (arrow). Image is “noisy” because of small slice thickness and small field of view
required when imaging the cervical spine. (TR = 400 ms; TE = 20 ms; flip angle = 10 degrees.) C, Post-
myelographic computed tomogram, showing better detail of large disk protrusion. Note substantial
compression of spinal cord (arrows) within dural sac. (From Miller GM, Forbes GS, Onofrio BM: Magnetic
resonance imaging of the spine, Mayo Clin Proc 64(8):986–1004, 1989, fig 3.)
• Figure 3-8 Magnetic resonance imaging of the cervical spine

depicting a sequestered disc (white arrow) at C4-5 causing moderate
cervical cord compression. (From Fung GPG, Chan KY: Cervical
myelopathy in an adolescent with hallervorden-spatz disease, Pediatr
Neurol 29(4):337–340, 2003, fig 2.)
A B
C D
• Figure 3-9 MR images of cervical disk herniation. Sagittal fast spin-echo, T1-weighted (A) and axial gradient-echo
(B) images show a small central disk herniation (arrows). In the cervical spine, herniations can be quite subtle. Sagittal
fast spin-echo, T1-weighted (C) and T2-weighted (D) images of multiple disk herniations (arrows) in the same patient.
(From Haaga J, Lanzieri C, Gilkeson R, editors: CT and MR imaging of the whole body, ed 4, Philadelphia, 2002,
Mosby.)
4 Painful Conditions Emanating from
the Cervical Spine
The initial general physical examination of the cervical to improve the diagnostic accuracy of the clinician con-
spine and cervical dermatomes guides the clinician in nar- fronted with the patient complaining of neck or upper
rowing his or her differential diagnosis and helps suggest extremity pain and dysfunction and help him or her to
which specialized physical examination maneuvers and avoid overlooking less common diagnoses. Although the
laboratory and radiographic testing will aid in confirming list is by no means comprehensive, it does aid the clini-
the cause of the patient’s neck and upper extremity pain cian in organizing the potential sources of pathology that
and dysfunction. For the clinician to make best use of presents as pain and dysfunction emanating from the cer-
the initial information gleaned from the general physical vical spine. It should be noted that the most commonly
examination of the cervical spine and cervical derma- missed categories of neck and upper extremity pain and
tomes, a grouping of the common causes of pain and the categories that most often result in misadventures in
dysfunction emanating from the cervical spine is exceed- diagnosis and treatment are the last three categories in the
ingly helpful. Although no classification of cervical spine table. The knowledge of this potential pitfall should help
pain and dysfunction can be all inclusive or all exclusive, the clinician to keep these sometimes overlooked causes of
owing to the frequently overlapping and multifactorial neck and upper extremity pain and dysfunction in the
nature of cervical spine pathology, Table 4-1 should help differential diagnosis.
TABLE
Overview of Causes of Neck and Upper Extremity Pain
4-1
Localized Bony, Disc Referred from
Space, or Joint Primary Shoulder Sympathetically Other Body
Space Pathology Pathology Systemic Disease Mediated Pain Areas
Vertebral fracture Bursitis Rheumatoid arthritis Causalgia Thyroiditis
Primary bone tumor Tendinitis Collagen vascular Reflex sympathetic Eagle’s syndrome
Facet joint disease Rotator cuff tear disease dystrophy Hyoid syndrome
Localized or generalized Impingement syndromes Reiter syndrome Shoulder/hand Malignancy of the
degenerative arthritis Adhesive capsulitis Gout syndrome retropharyngeal
Osteophyte formation Joint instability Other crystal Dressler syndrome space
Disc space infection Muscle strain arthropathies Intrathoracic tumors Brachial
Herniated cervical disc Muscle sprain Charcot’s neuropathic Fibromyalgia plexopathy
Degenerative disc Periarticular infection not arthritis Myofascial pain
disease involving joint space Multiple sclerosis syndromes such as
Whiplash injuries Entrapment neuropathies Ischemic pain secondary scapulocostal
Primary spinal cord Ankylosing spondylitis to peripheral vascular syndrome
pathology Subdiaphragmatic pathology insufficiency Parsonage-Turner
Osteomyelitis such as subcapsular Thoracic outlet syndrome (idiopathic
Epidural abscess hematoma of the spleen syndrome brachial neuritis)
Epidural hematoma with positive Kerr sign Pneumothorax
13
5 Visual Inspection of the Cervical Spine
Physical examination of the cervical spine should begin with
a visual inspection of the anterior, lateral, and posterior
cervical spine. The clinician should note the presence or
absence of the normal cervical lordotic curve (Figs. 5-1 and
5-2). Loss or straightening of the cervical lordotic curve is
often indicative of spasm of the cervical paraspinal muscu-
lature caused by pain. This finding can be confirmed on
lateral radiographic imaging of the spine. The clinician then
notes any abnormality in head or neck position suggestive
of a central neurologic process such as spasmodic torticollis.
The clinician then looks for any skin lesions, including
vesicular lesions suggestive of acute herpes zoster, as well as
any abnormal mass that might be suggestive of primary or
metastatic tumor (Fig. 5-3).
C B A
• Figure 5-2 Plain lateral radiograph of a normal cervical spine. Lines

joining the anterior part of the vertebral body (A), the posterior aspect
of the vertebral body (B), and the anterior border of the laminae
(C) should describe a smooth arc. (From Klippel JH, Dieppe PA:
Rheumatology, ed 2, London, 1998, Mosby, p 5.5.)
• Figure 5-1 Normal cervical spine on visual inspection. • Figure 5-3 Cervical adenopathy in a patient with neck pain and
fever. (From Scuccimarri R: Kawasaki disease, Pediatr Clin North Am
14 59(2):425–445.)
6 Palpation of the Cervical Spine
Palpation of the cervical spine is carried out primarily to

identify abnormalities of the soft tissues. Careful palpation
of the anterior cervical region is performed to identify
abnormalities of the thyroid, including thyroiditis, deep
lesions such as thyroglossal duct cysts, primary or metastatic
tumors, and carotidynia (Figs. 6-1 and 6-2). The lateral
cervical region is also palpated to identify spasm of the
sternocleidomastoid muscles and occult abnormal mass
(Fig. 6-3). The posterior cervical spine is palpated to identify
any obvious bony abnormality that might be suggestive of
severe degenerative disease or primary or metastatic tumor.
The clinician should always be on the lookout for abnormal
mass of the paraspinous musculature, including sarcoma.
Spasm of the posterior cervical paraspinous musculature is a
common finding following trauma (Fig. 6-4). A careful pal-
pation of the posterior cervical paraspinous musculature will
allow the clinician to identify myofascial trigger points that
suggest fibromyalgia. Palpation of these trigger points should
elicit a positive “jump” sign, which is pathognomonic for
fibromyalgia (Fig. 6-5). Diffuse muscle tenderness should
suggest the possibility of collagen vascular disease such as
polymyositis or lupus, and this finding should cue the clini-
cian to order appropriate laboratory testing to confirm the
diagnosis.
• Figure 6-2 Thyroglossal duct cyst. (From Marom T, Dagan D,
Weiser G, et al: Pediatric otolaryngology in a field hospital in the
Philippines, Int J Pediatr Otorhinolaryngol 78(5):807–811, 2014, fig 5a.)
• Figure 6-1 Palpation of the anterior cervical spine. • Figure 6-3 Palpation of the lateral cervical spine.
15
• Figure 6-5 Palpation of a trigger point will result in a positive

“jump” sign. (From Waldman SD: Atlas of common pain syndromes,
Philadelphia, 2002, Saunders, p 53.)
• Figure 6-4 Palpation of the posterior cervical spine.

7 Physical Examination of the Cervical
Spine Range of Motion
As was mentioned in Chapter 1, the cervical spine has a
wide and varied range of motion due to the unique nature
of the upper two segments, namely, the atlanto-occipital
and atlantoaxial joints. In fact, the majority of movement
of the cervical spine occurs in the upper three segments.
In health, movement of the cervical spine requires syn-
chronized movement of all the elements of the spine. In
disease, problems at one level can cause functional disability
at other levels.
FLEXION AND EXTENSION

To assess the range of motion of the cervical spine, the clini-
cian has the patient place his or her spine in neutral position
(Fig. 7-1). The patient is then asked to flex his or her cervical
spine forward while the clinician observes for any limitation
in range of motion or a lack of a smooth, synchronized
flexion that is indicative of pain or spinal segment dysfunc-
tion. In general, patients with normal flexion of the cervical
spine should be able to smoothly and easily touch the chin
to the chest. The patient is then asked to return the cervical
spine to neutral position and then to extend the cervical
spine while the clinician observes for any limitation in range
of motion or a lack of a smooth, synchronized extension
that might be indicative of pain or spinal segment dysfunc- • Figure 7-1 Neutral position.
tion (Fig. 7-2, A and B). With both of these maneuvers, the
clinician should be sure that movement occurs only at the
level of the cervical spine and that the patient is not using
A B
• Figure 7-2 A, Flexed position. B, Extended position.
17
the thoracic spine to compensate for a limitation of range

of motion of the cervical segments.
ROTATION AND LATERAL BENDING

To assess the range of motion of rotation of the cervical
spine, the clinician has the patient place his or her spine in
neutral position. The patient is then asked to fully rotate
his or her cervical spine in both the left and right directions
while the clinician observes for any limitation in range of
motion or a lack of a smooth, synchronized rotation that
might be indicative of pain or spinal segment dysfunction
(Fig. 7-3). The patient is then asked to return the cervical
spine to neutral position and then to laterally bend the
cervical spine while the clinician observes for any limitation
in range of motion or a lack of a smooth, synchronized
lateral bending that might be indicative of pain or spinal
segment dysfunction (Fig. 7-4). With both of these maneu-
vers, the clinician should be sure that movement occurs only
at the level of the cervical spine and that the patient is not
using the thoracic spine to compensate for a limitation of
range of motion of the cervical segments. It should be
remembered that the clinician should use care when per-
forming these maneuvers in any patient with symptoms
suggestive of cervical myelopathy, cervical radiculopathy, or • Figure 7-4 Lateral bending of the cervical spine.
carotid or vertebral artery insufficiency to avoid precipitat-
ing an acute neurologic event. Care should also be exercised
when performing these maneuvers in patients suffering
from rheumatoid arthritis, as occult erosion of the odontoid
process can render the upper cervical spine extremely sus-
ceptible to instability (Fig. 7-5).
• Figure 7-5 Combined computerized tomography and magnetic

resonance imaging of the odontoid process demonstrating significant
bony erosions and synovitis in a patient presenting with difficulty
walking and urinary and fecal incontinence. (From de Parisot A, Ltaief-
Boudrigua A, Villani A-P, et al: Spontaneous odontoid fracture on a
tophus responsible for spinal cord compression: a case report, Joint
• Figure 7-3 Rotation of the cervical spine. Bone Spine 80(5):550–551, 2013, fig 2.)
8 The Cervical Dermatomes
In humans, the innervation of the skin, muscles, and deep muscles innervated by higher spinal segments than the cor-
structures is determined embryologically at an early stage responding dorsal muscles. It should be remembered that
of fetal development, and there is amazingly little inter- pain perceived in the region of a given muscle or joint might
subject variability. Each segment of the spinal cord and not be coming from the muscle or joint but simply be
its corresponding spinal nerves have a consistent seg- referred by problems at the same cervical spinal segment
mental relationship that allows the clinician to ascertain that innervated the muscles.
the probable spinal level of dysfunction based on the Furthermore, the clinician needs to be aware that the
pattern of pain, muscle weakness, and deep tendon reflex relatively consistent pattern of dermatomal and myotomal
changes. distribution breaks down when the pain is perceived in the
Figure 8-1 is a dermatomal chart that the clinician will deep structures of the upper extremity, such as the joints
find useful in determining the specific spinal level that and tendinous insertions. With pain in these regions, the
subserves a patient’s pain. In general, the cervical spinal clinician should refer to the sclerotomal chart in Figure 8-2.
segments move down the upper extremity from cephalad to This is particularly important if a neurodestructive proce-
caudad on the lateral border of the upper extremity and dure at the spinal cord level is being considered, as the
from caudad to cephalad on the medial border. sclerotomal level of the nerves subserving the pain might be
In general, in humans, the more proximal the muscle, several segments higher or lower than the dermatomal or
the more cephalad is the spinal segment, with the ventral myotomal levels the clinician would expect.
C2
C3
C4
C4
C5
C5
C6
C6
C7 C7
C8 C8
• Figure 8-1 Cervical dermatomal chart. • Figure 8-2 Cervical sclerotomal chart.
19
9 The C5 Neurologic Level
The concept of diagnosing a problem at a specific neuro- to proximal lesions of the spinal cord, such as a syrinx; more
logic level via physical examination has its basis in the fact distal lesions of the C5 nerve root, such as impingement by
that pathology at the cervical spinal cord or cervical nerve a herniated disc; or a lesion of the more peripheral axillary
root level manifests itself in a relatively consistent manner nerve. For this reason, correlation with manual muscle
by dysfunction, numbness, and pain of the upper extremity, testing and evaluation of the deep tendon reflex combined
which occurs in a dermatomal distribution. Although not with radiographic and electromyographic testing can help
foolproof, a careful physical examination of the upper to determine the exact site of pathology.
extremity with an eye to the neurologic level affected can Testing for the C5 myotome is best carried out by
frequently guide the clinician in designing a more targeted manual muscle testing of the deltoid muscle. The deltoid
workup and treatment plan (Video 9-1). By overlapping muscle is primarily innervated by the C5 nerve with a small
the information gleaned from physical examination with contribution in most patients from the C6 nerve. Because
the neuroanatomic information gained from magnetic reso- in most patients abduction of the deltoid is a C5 function,
nance imaging and the neurophysiologic information from the muscle should be tested as follows. The patient is placed
electromyography, a highly accurate diagnosis can be made in the standing position with the affected extremity resting
as to which level of the cervical spine is responsible for the against the patient’s side. The patient is asked to flex the
patient’s symptoms. elbow to 90 degrees and then asked to forcefully abduct the
Testing for the C5 dermatome is best carried out by a affected extremity at the shoulder (Fig. 9-2). If the manual
careful sensory evaluation of the lateral aspect of the more muscle testing is normal, the examiner should not be able
cephalad portion of the upper extremity (Fig. 9-1). to resist abduction nor to force the arm back toward the
Decreased sensation in this anatomic region can be ascribed patient’s side. If the patient has primary shoulder pathology
C2
C3
C4
C5
C6
C7
C8
• Figure 9-1 Sensory distribution of the C5 dermatome.
20
CHAPTER 9 The C5 Neurologic Level 21
C5
Motor
Deltoid Sensory
Biceps
Reflex
• Figure 9-2 C5 myotome integrity testing.

A B
C D
• Figure 9-3 Pilocytic astrocytoma in an 18-year-old male patient
with slowly progressive symptoms of cervical myelopathy. A, Sagittal
T2 weighted image (WI) shows a moderate-sized intramedullary
space-occupying lesion within the uppermost part of the cervical cord
spanning the C1-C2 levels. This lesion has a mostly cystic septated
well-defined component causing expansion of the cervical cord at that
region. B, Sagittal post contrast T1 WI shows an associated small solid
intensely enhancing component along the superior left aspect of this
cystic lesion. C and D, Magnetic resonance tractography of the cord
particularly emphasizing that such lesion is splaying apart the projec-
tional fibers of the cord. The overall pattern as such confirms that this
is a low-grade neoplastic lesion with no infiltration of destruction. (From
El Maati AAA, Chalabi N: Diffusion tensor tractography as a supple-
mentary tool to conventional MRI for evaluating patients with myelopa-
thy, Egyptian J Radiol Nuclear Med 45(4):1223–1231, 2014, fig 1.)
that precludes this test, the clinician may test the strength arm. The clinician then strikes the biceps tendon at the
of flexion of the biceps, which is also primarily innervated elbow with a neurologic hammer and grades the response
by C5. (see Fig. 9-2). A diminished or absent reflex might point to
The biceps deep tendon reflex is mediated via the C5 compromise of the C5 segment, whereas a hyperactive
spinal segment. To test the biceps reflex, the patient is asked response might suggest an upper motor neuron lesion, such
to relax and lay the affected extremity against the clinician’s as cervical myelopathy (Fig. 9-3).
The concept of diagnosing a problem at a specific neuro-
logic level via physical examination has its basis in the fact
that pathology at the cervical spinal cord or cervical nerve
C2
root level manifests itself in a relatively consistent manner
by dysfunction, numbness, and pain of the upper extremity,
C3
which occurs in a dermatomal distribution. Although not
foolproof, a careful physical examination of the upper C4
extremity with an eye to the neurologic level affected can
frequently guide the clinician in designing a more targeted C5
workup and treatment plan (Video 10-1). By overlapping
the information gleaned from physical examination with C6
the neuroanatomic information gained from magnetic reso-
nance imaging and the neurophysiologic information from C7
electromyography, a highly accurate diagnosis can be made
as to which level of the cervical spine is responsible for the C8
patient’s symptomatology.
Testing for the C6 dermatome is best carried out by a
careful sensory evaluation of the lateral aspect of the more
distal portion of the upper extremity (Fig. 10-1). Decreased
sensation in this anatomic region can be ascribed to proxi-
mal lesions of the spinal cord, such as a syrinx; more distal
lesions of the C6 nerve root, such as impingement by a
herniated disc; or a lesion of the more peripheral portion
of the nerve (Fig. 10-2). For this reason, correlation with • Figure 10-1 Sensory distribution of the C6 dermatome.
A C D
• Figure 10-2 Focal syrinx of the cervical spinal cord in patient with cervical myelopathy. Sagittal (A)
and axial (B) T2-weighted images demonstrate a focal syrinx in the central spinal cord at the C3 level.
C, Axial color-coded fractional anisotropy map demonstrates no fiber tracts running through the lesion.
D, Tractography shows displacement of the fiber tracts around the syrinx. Identical tractography findings
are seen with spinal cord ependymomas. In contradistinction spinal cord astrocytoma tractography would
show infiltrated or attenuated fibers traversing the lesion. (From Lerner A, Mogensen MA, Kim PE, et al:
Clinical applications of diffusion tensor imaging, World Neurosurg 82(1–2):96–109, 2014, Fig. 3.)
23
C6
Sensory
Motor
Wrist extensors
Reflex
manual muscle testing and evaluation of the deep tendon for the C6 myotome is normal, the examiner should not
reflex combined with radiographic and electromyographic be able to resist the radial wrist extension. If the C6
testing can help to determine the exact site of pathology. myotome is compromised and the C7 myotome is intact,
Testing for the C6 myotome is best carried out by then the clinician will observe ulnar wrist deviation on
manual muscle testing of the radial wrist extensors. The extension.
radial wrist extensors are primarily innervated by the C6 The brachioradialis deep tendon reflex is mediated via
nerve. Because extension on the radial of the wrist is a C6 the C6 spinal segment. To test the brachioradialis reflex, the
function, with C7 providing innervation for the ulnar patient is asked to relax and lay the affected extremity
wrist extensor, C6 integrity should be tested as follows. against the clinician’s arm. The clinician then strikes the
The patient is placed in the sitting position with the brachioradialis tendon with a neurologic hammer and
fingers slightly flexed to avoid any extensor activity of the grades the response (see Fig. 10-3). A diminished or absent
muscles of finger extension. The patient is then asked to reflex might point to compromise of the C6 segment,
extend the wrist in a radial direction while the clinician whereas a hyperactive response might suggest an upper
applies resistance (Fig. 10-3). If the manual muscle testing motor neuron lesion, such as cervical myelopathy.
The concept of diagnosing a problem at a specific neuro-

logic level via physical examination has its basis in the fact
that pathology at the cervical spinal cord or cervical nerve
C2
root level manifests itself in a relatively consistent manner
by dysfunction, numbness, and pain of the upper extremity,
C3
which occurs in a dermatomal distribution. Although not
foolproof, a careful physical examination of the upper C4
extremity with an eye to the neurologic level affected can
frequently guide the clinician in designing a more targeted C5
workup and treatment plan (Video 11-1). By overlapping
the information gleaned from physical examination with C6
the neuroanatomic information gained from magnetic
resonance imaging and the neurophysiologic information C7
gleaned from electromyography, a highly accurate diagnosis
can be made as to which level of the cervical spine is respon- C8
sible for the patient’s symptomatology.
Testing for the C7 dermatome is best carried out by a
careful sensory evaluation of the middle finger of the hand
of the affected upper extremity (Fig. 11-1). The clinician
should be aware that there is some interpatient variability
in the sensory innervation of the middle finger, with some
patients having contribution of either C6 or C8. Decreased
sensation in this anatomic region can be ascribed to proxi-
mal lesions of the spinal cord, such as a syrinx; more distal • Figure 11-1 Sensory distribution of the C7 dermatome.
lesions of the C7 nerve root, such as impingement by a
herniated disc; or a lesion of the more peripheral portion
of the nerve (Fig. 11-2). For this reason, correlation with
A B C
• Figure 11-2 Magnetic resonance (MR) images of a patient with left-sided radicular symptoms. A, The
midline sagittal T2W MR image shows disc degeneration at C5-C6 with disc space narrowing. There is
less marked disc narrowing at C6-C7, but there is also a posterior disc herniation, which is much more
prominent on the parasagittal T2W MR image (B). C, The axial T2W MR image demonstrates a large
paracentral disc herniation (black arrow) that is compressing the cervical cord (white arrow).
25
C7
Motor
Sensory
Triceps
Wrist flexors
Finger extensors
Reflex
manual muscle testing and evaluation of the deep tendon normal, the examiner should not be able to resist the radial
reflex combined with radiographic and electromyographic wrist flexion. If the C7 myotome is compromised and the
testing can help to determine the exact site of pathology. C8 myotome is intact, then the clinician will observe ulnar
Testing for the C7 myotome is best carried out by wrist deviation on flexion.
manual muscle testing of the flexor carpi radialis. The wrist The triceps deep tendon reflex is mediated via the C7
extensors are primarily innervated by the C7 nerve, with spinal segment. To test the triceps reflex, the patient is asked
the flexor carpi ulnaris usually innervated by C8. C7 to relax and lay the affected extremity against the clinician’s
myotome integrity should be tested as follows. The patient arm. The clinician then strikes the distal triceps tendon
is placed in the sitting position with the fingers in extension with a neurologic hammer and grades the response (see Fig.
to eliminate any finger flexor activity of the muscles of 11-3). A diminished or absent reflex might point to com-
finger flexion. The patient is then asked to flex the wrist in promise of the C7 segment, whereas a hyperactive response
a radial direction while the clinician applies resistance (Fig. might suggest an upper motor neuron lesion, such as cervi-
11-3). If the manual muscle testing for the C7 myotome is cal myelopathy.
The concept of diagnosing a problem at a specific neuro- resonance imaging and the neurophysiologic information
logic level via physical examination has its basis in the fact gleaned from electromyography, a highly accurate diagnosis
that pathology at the cervical spinal cord or cervical nerve can be made as to which level of the cervical spine is respon-
root level manifests itself in a relatively consistent manner sible for the patient’s symptomatology.
by dysfunction, numbness, and pain of the upper extremity, Testing for the C8 dermatome is best carried out by
which occurs in a dermatomal distribution. Although not a careful sensory evaluation of the ulnar aspect of the
foolproof, a careful physical examination of the upper little finger of the hand of the affected upper extremity
extremity with an eye to the neurologic level affected can (Fig. 12-1). The clinician should be aware that there is some
frequently guide the clinician in designing a more targeted interpatient variability in the sensory innervation of the
workup and treatment plan (Video 12-1). By overlap- little finger, with most patients having sensory innervation
ping the information gleaned from physical examination from the ulnar nerve, which is made up of predominantly
with the neuroanatomic information gained from magnetic C8 fibers. Decreased sensation in this anatomic region can
C2
C3
C4
C5
C6
C7
C8
• Figure 12-1 Sensory distribution of the C8 dermatome.
27
C8
Motor
Sensory
Finger flexors
Interossei muscles
No reflex
be ascribed to proximal lesions of the spinal cord, such as a the ring finger. The finger flexors are primarily innervated
syrinx; more distal lesions of the C8 nerve root, such as by the C8 nerve, with the flexor digitorum sublimus pre-
impingement by a herniated disc; or a lesion of the more dominantly innervated by C8. The C8 myotome integrity
peripheral portion of the nerve. For this reason, correlation should be tested as follows. The patient is placed in the
with manual muscle testing and evaluation of the deep sitting position with the middle, index, and little fingers
tendon reflex combined with radiographic and electromyo- stabilized in extension. The patient is then asked to flex
graphic testing can help to determine the exact site of the ring finger while the clinician applies resistance
pathology. (Fig. 12-2).
Testing for the C8 myotome is best carried out by There is no deep tendon reflex that is mediated predomi-
manual muscle testing of the flexor digitorum sublimus of nantly by the C8 spinal segment.
13 The Spurling Test for Cervical
Radiculopathy Secondary to Herniated
Disc or Cervical Spondylosis
The Spurling test for cervical radiculopathy secondary to extend the neck while tilting the head to the affected side
herniated disc or cervical spondylosis is performed by (Fig. 13-1). Patients who suffer from cervical radiculopathy
having the patient assume the standing position. The exam- will experience a marked increase in pain secondary to
iner stands behind the patient and examines the cervical compression of the nerve root as the neural foramen narrows
spine for any abnormality. The examiner then has the patient with the maneuver (Video 13-1).
• Figure 13-1 The Spurling test for cervical radiculopathy.
29
14 The Axial Loading Test for Cervical
Discogenic Disease
The axial loading test for cervical discogenic disease is per- pressure on the top of the patient’s head, thereby loading
formed by having the patient assume the standing posi- the axial spine (Fig. 14-1). Patients who suffer from cervi-
tion. The examiner stands behind the patient and cal discogenic disease will experience a marked increase in
examines the cervical spine for any abnormality. The neck and upper extremity radicular pain secondary to
examiner then has the patient place the neck in neutral compression of the nerve root as the cervical discs are
position while the examiner applies a steady downward compressed.
• Figure 14-1 The axial loading test for cervical discogenic disease.
30
15 The Hoffmann Test for
Cervical Myelopathy
The Hoffmann test or reflex can help the clinician identify the patient’s hand is cradled gently in the examiner’s hand.
patients who suffer from cervical myelopathy. The basis The examiner then flicks the nail of the patient’s middle
of the test is compression of the long tract fibers of the finger and observes the hand for reflex flexion of the thumb
spinal cord. To perform the Hoffmann test, the examiner and index finger (Fig. 15-1).
places the patient in a comfortable, relaxed position, and
• Figure 15-1 The Hoffmann test for cervical myelopathy.
31
16 The Sharp Purser Test for Atlantoaxial
Joint Instability
The Sharp Purser test can help the clinician identify patients relationship with the odontoid process with the ring formed
who suffer from instability of the atlantoaxial joint. This by the anterior arch and the transverse ligament of the atlas
condition is most commonly seen in patients suffering from (Fig. 16-2). When this functional integrity is lost, atlas (C1
rheumatoid arthritis (Fig. 16-1). The basis of the test is vertebra) will translate forward relative to axis (C2 vertebra).
identification of the loss of the functional integrity of the To perform the Sharp Purser test, the examiner places the
A B C
• Figure 16-1 A, Lateral radiograph of the cervical spine in extension shows normal C1-C2 alignment.
B, On cervical flexion, however, there is widening of the predental space due to C1-C2 instability (double-
headed arrow). C, The sagittal T1W magnetic resonance image shows erosion of the dorsal aspect of
the odontoid peg.
Dens
Articular surface of
skull’s occipital bone
Axis (C2) transverse

ligament of atlas
(holding dens)
Vertebral canal
Rotation of atlas
and skull lying above
• Figure 16-2 The anatomy of atlas and axis demonstrating the

relationship of the odontoid process to the anterior arch and transverse
ligament of atlas (C1 vertebra) with the odontoid process (dens) of axis
(C2 vertebra). (From Waldman SD, Campbell, RSD: Imaging of pain,
Philadelphia, 2010, Saunders/Elsevier, p 66, fig 24-1.)
32
CHAPTER 16 The Sharp Purser Test for Atlantoaxial Joint Instability 33
• Figure 16-3 The Sharp Purser test for atlantoaxial joint instability,
step 1. The examiner places the patient in a comfortable, relaxed
sitting position, and the patient’s forehead is cradled gently in the
examiner’s hand. The examiner then places his or her thumb and index
finger of the contralateral hand on the tip of axis (C2). • Figure 16-5 Sagittal T2W magnetic resonance image of a patient
with chronic rheumatoid arthritis with cranial settling. The odontoid peg
projects through the foramen magnum (dotted line), and there is
impingement of the brainstem. (From Waldman SD, Campbell, RSD:
Imaging of pain, Philadelphia, 2010, Saunders/Elsevier, p 66, fig 24-3.)
patient in a comfortable, relaxed sitting position, and the

patient’s forehead is cradled gently in the examiner’s hand.
The examiner then places his or her thumb and index finger
of the contralateral hand on the tip of axis (C2) (Fig. 16-3).
The patient is then asked to slowly nod, which will flex
the patient’s cervical spine forward while the examiner
simultaneously firmly presses on the patient’s forehead in
a controlled manner (Fig. 16-4). If the test is positive,
the examiner will perceive a sliding motion of the patient’s
head in relationship to axis (C2). The patient may also
perceive a clunk or click in the roof of the mouth as atlas
translates forward in relationship to axis. It should be noted
that this test should be used with extreme caution in patients
• Figure 16-4 The Sharp Purser test for atlantoaxial joint instability,
step 2. The patient is asked to slowly nod, which will flex the patient’s suffering from long-standing rheumatoid arthritis or in the
cervical spine forward while the examiner simultaneously firmly presses presence of trauma to avoid serious neurological sequella
on the patient’s forehead in a controlled manner. (Fig. 16-5).
17 Functional Anatomy of
the Shoulder Joint
The shoulder is a unique joint for a variety of reasons. • The glenohumeral joint
Unlike the knee and the hip, with their inherent primary • The scapulothoracic joint
stability that results from their solid bony architecture, the The glenohumeral joint is responsible for the main func-
shoulder is a relatively unstable joint that is held together tional mobility of the shoulder joint, and each of the other
by a complex combination of ligaments, tendons, muscles, joints works synergistically with its counterparts to allow
and unique soft tissues, most notably the labrum and rotator for the extensive and extremely varied range of motion of
cuff. What the shoulder lacks in stability, it more than the shoulder joint. This unique range of motion is further
makes up for in its extensive range of motion. Although not enhanced by the unusual physical characteristics of the
a true weight-bearing joint like the hip or knee, the shoulder humeral head and the glenoid fossa. Whereas the articular
joint is subjected to extreme mechanical forces owing to surfaces of most joints are well matched in terms of their
its extensive range of motion. Common activities such as complementary shape with one another, such as the acetab-
lifting objects overhead or throwing can magnify these ulum and the femoral head, the large, rounded humeral
mechanical load factors and make the joint susceptible to head is amazingly mismatched to the much smaller and
repetitive motion injuries. shallower, ovoid-shaped glenoid fossa (Fig. 17-3). This mis-
To make the most of the information that is gleaned from match allows for the unique range of motion of the shoulder
the physical examination of the shoulder, one must fully joint, but it also contributes to the relative instability of the
understand the functional anatomy of the shoulder. To fully joint and is in large part responsible for the shoulder joint’s
understand the functional anatomy of the shoulder, one propensity for injury. As a result, the shoulder joint is the
must recognize that the shoulder joint cannot be thought most commonly dislocated large joint in the body.
of as a single joint like the knee but must be thought of as The unique nature of the shoulder joint has been
four separate joints working in concert to function as one the subject of medical commentary since early recorded
(Figs. 17-1 and 17-2). These four joints are as follows: medical history, with Hippocrates discussing the diagnosis
• The sternoclavicular joint and treatment of shoulder dislocation some 300 years b.c.,
• The acromioclavicular joint and the recent advances of magnetic resonance imaging,
Sternoclavicular 2
Acromioclavicular joint joint 5
1 3
• Figure 17-2 Anterior-posterior radiograph of the shoulder. 1, greater

tuberosity; 2, acromion; 3, coracoid process; 4, glenoid (anterior rim);
5, scapula spine; white solid arrows, lesser tuberosity; black solid
Scapulothoracic joint arrow, acromioclavicular joint; white open arrow, glenohumeral joint;
dashed line, subdeltoid fat plane (outline of subacromial bursa). (From
Glenohumeral joint
Waldman SD, Campbell, RSD: Imaging of pain, Philadelphia, 2010,
• Figure 17-1 Four joints constituting the shoulder. Saunders/Elsevier, p 218, fig 85-1.)
36
CHAPTER 17 Functional Anatomy of the Shoulder Joint 37
Deltoid m Acromion
Coracoacromial lig
Coracohumeral lig Supraspinatus m & t
Coracoid process
Biceps t, long head
Humerus, head
Corabrachialis m
Infraspinatus m & t
Ant glenoid labrum
Post glenoid labrum
Deltoid m
Glenoid
Subscapularis m & t
Pectoralis major m Teres minor m

Axillary a &
brachial plexus
Teres major m
Latissimus dorsi m
Deltoid m Acromion
Coracoacromial lig Supraspinatus m & t
Coracohumeral lig
Biceps t, long head
Coracoid process
Sup glenohumeral lig Humerus, head
Middle glenohumeral lig Post glenoid labrum

Coracobrachialis m Infraspinatus m & t
Subscapularis m & t Glenoid
Axillary a & Deltoid m

brachial plexus
Teres minor m
Axillary v
Pectoralis major m
Teres major m
Latissimus dorsi m
• Figure 17-3 Sagittal view of the shoulder. A, Magnetic resonance (MR) image. B, Anatomic
image. (From Kang HS, Ahn JM, Resnick D: MRI of the extremities, ed 2, Philadelphia, Saunders,
2002, pp 32–33.)
38 SECTION 2 The Shoulder
8 1
2
7
6
• Figure 17-4 Axial T1-weighted magnetic resonance arthrogram

image of the shoulder. 1, lesser tuberosity; 2, greater tuberosity; 3,
glenoid; 4, subscapularis muscle; 5, anterior deltoid muscle; 6, pos-
terior deltoid muscle; 7, teres minor muscle; 8, subscapularis tendon;
white arrow, long head of biceps tendon; open white arrow, teres minor
tendon; black arrow, glenoid labrum. (From Waldman SD, Campbell,
RSD: Imaging of pain, Philadelphia, 2010, Saunders/Elsevier, p 218,
fig 85-3.)
Deltoid muscle
Subscapularis
Coracoid process Articular

cartilage
Humeral head
Anterior labrum
• Figure 17-5 Ultrasound anatomy of the glenohumeral joint.
arthroscopy, and dynamic sonography have provided a imaging and arthroscopy findings (Figs. 17-4 and 17-5).
clearer understanding of the shoulder joint in health and The information provided in the following chapters draws
disease. This information has allowed the clinician to fine- heavily on this recently gained knowledge and should
tune his or her physical examination skills by correlating aid the clinician in the care of the patient suffering from
the patient’s physical findings with magnetic resonance shoulder pain or dysfunction.
18 Visual Inspection of the Shoulder
The starting point in the physical examination of the tear. Careful inspection of the acromioclavicular (AC) joints
shoulder is the visual inspection of the joint and surround- for asymmetry that suggests AC joint separation should be
ing structures. Asking the patient whether he or she is carried out next. The examiner should then evaluate the
having any problem putting on undergarments or shirts position of the shoulders relative to the neck and thorax to
can provide the examiner with useful clues as to the pres- identify protective “splinting” or overprotraction of the
ence and etiology of shoulder dysfunction. For example, joint that might be indicative of a painful or unstable joint
the inability to fasten or unfasten a bra might suggest ante- (Fig. 18-1). Special attention should be paid to any evidence
rior shoulder instability, adhesive capsulitis, or some other of scapular winging that might be suggestive of weakness of
problem. the serratus anterior muscle or compromise of the long
The visual inspection of the shoulder must be carried out thoracic nerve of Bell.
with the patient undressed to avoid missing physical signs Positive findings during the initial visual inspection of
that might be masked by clothing. The anterior, lateral, and the shoulder should help guide the examiner in his or her
posterior aspects of the shoulder should be observed for additional physical examination as well as provide a guide
muscle wasting, swelling, erythema, or ecchymosis that is as to the ordering of specialized plain radiographic views
suggestive of acute and chronic shoulder pathology, includ- and magnetic resonance imaging to further ascertain the
ing traumatic rupture of tendons or chronic rotator cuff etiology of the patient’s shoulder pain and dysfunction.
• Figure 18-1 Visual inspection of the shoulder should include evalu-

ation of the position of the shoulders relative to the neck and thorax.
39
19 Palpation of the Shoulder
Careful palpation of the shoulder joint and surrounding palpation of the tendinous insertions of the rotator cuff will
structures should be the next step after visual inspection of assist the examiner in identifying tendinitis that might also
the shoulder in examining the patient who presents with be contributing to the patient’s shoulder pain and dysfunc-
shoulder pain and dysfunction. tion. The examiner should also assess the shoulder for the
Palpation of the shoulder must be carried out with the presence of joint instability and crepitus that are suggestive
patient undressed to avoid missing physical signs, such as of tendinitis, adhesive capsulitis, or arthritis. The examiner
increased temperature, that may be masked by clothing. The should also examine the neck and the intrascapular and
anterior, lateral, and posterior aspects of the shoulder as well subscapular regions for the presence of myofascial trigger
as the axilla should be palpated for abnormal mass, swelling, points as characterized by a positive “jump” sign that might
increased temperature, joint effusion, and bone spurs. be responsible for referred pain to the shoulder.
Targeted palpation of the bursae of the shoulder with Positive findings during the palpation of the shoulder
particular attention to the subacromial and subdeltoid should help guide the examiner in his or her additional
bursae will allow the examiner to identify inflamed and physical examination as well as provide a guide to the order-
painful bursae that could serve as either a primary or a ing of specialized plain radiographic views, ultrasound, and
contributing cause of the patient’s shoulder pain and magnetic resonance imaging to further ascertain the etiol-
dysfunction (Fig. 19-1 and Fig. 19-2). Targeted palpation ogy of the patient’s shoulder pain and dysfunction
of the tendon of the long head of the biceps as well as (see Fig. 19-2).
Subdeltoid
B.T.
bursitis
Humeral head
Proximal Distal
Longitudinal long head of the biceps tendon view
• Figure 19-1 Palpation of the shoulder. • Figure 19-2 Longitudinal ultrasound image demonstrating subdel-
toid bursitis. B.T., Biceps tendon.
40
20 External Rotation of the Shoulder
To adequately assess external rotation of the shoulder and If either test is positive, physical examination for specific
identify subtle pathology, evaluation must be carried out pathologic processes of the shoulder should then be carried
with the arm first fully adducted and then abducted to at out, such as the Neer impingement test or apprehension
least 90 degrees. With the patient in the sitting position test for anterior and posterior instability, as well as obtain-
and the arms fully adducted, ask the patient to slowly ing plain radiographs, ultrasound, and magnetic resonance
externally rotate both arms (Fig. 20-1). The arms should imaging of the affected joints and surrounding soft tissue
move back rather than up as they reach the full extent to further clarify the pathology that is responsible for the
of external rotation. Observe the patient for asymmetry patient’s shoulder pain and dysfunction.
of motion or apprehension that is suggestive of primary
shoulder pathology.
Next, ask the patient to slowly abduct the arms to 90
degrees. Then have the patient slowly externally rotate the
arm as far as it will go (Fig. 20-2). The normal shoulder
should allow external rotation of the arm to at least parallel
to the floor. Ascertain any limitation of the range of motion
or pain on range of motion that would suggest primary
shoulder pathology.
• Figure 20-1 External rotation of the shoulder with the arms fully • Figure 20-2 External rotation of the shoulder with the arm abducted
adducted. to 90 degrees.
41
21 Internal Rotation of the Shoulder
To adequately assess internal rotation of the shoulder, ask If this test is positive, physical examination for specific
the patient to fully adduct the arm with the palm facing pathologic processes of the shoulder should then be carried
toward the back. Then have the patient reach behind the out, such as the Neer impingement test or apprehen-
back and, using the fully extended thumb, touch the upper- sion test for anterior and posterior instability. The
most spinal process that he or she can reach (Fig. 21-1). examiner should also obtain plain radiographs, ultrasound,
After noting the level that the patient was able to reach, and magnetic resonance imaging of the affected joints
have the patient repeat this maneuver with the contralateral and surrounding soft tissue to further clarify the pathology
arm, and note any asymmetry of movement or apprehen- that is responsible for the patient’s shoulder pain and
sion that is suggestive of primary shoulder pathology. dysfunction.
• Figure 21-1 Internal rotation of the shoulder.
42
22 Crossed-Arm Adduction of the Shoulder
Evaluation of shoulder adduction using the crossed-arm pathology should be able to grasp the contralateral triceps
maneuver is useful in identifying problems in the posterior without difficulty.
shoulder, including adhesive capsulitis, bursitis, and tendi- If this test is positive, physical examination for specific
nopathy. To perform this maneuver, place the patient in the pathologic processes of the shoulder should then be carried
seated position and have the patient slowly bring the arm out, such as the Neer impingement test or apprehension
across the chest, observing for any hesitancy or unevenness test for anterior and posterior instability. The examiner
in movement that might be suggestive of pain (Fig. 22-1). should also obtain plain radiographs, ultrasound, and mag-
The maneuver is then repeated with the contralateral arm, netic resonance imaging of the affected joints and sur-
and the ranges of motion are compared. The patient with a rounding soft tissue to further clarify the pathology that is
normal shoulder or a minimal amount of primary shoulder responsible for the patient’s shoulder pain and dysfunction.
• Figure 22-1 Crossed-arm adduction of the shoulder.
43
23 Abduction of the Shoulder
Evaluation of shoulder abduction is useful in identifying observing for any asymmetry, apprehension, or limitation
primary shoulder pathology, including tendinopathy, bur- of motion (Fig. 23-1). Then ask the patient to fully abduct
sitis, and impingement syndromes. To evaluate shoulder each shoulder, again observing for any asymmetry or limita-
abduction, have the patient stand, and ask the patient to tion of motion (Fig. 23-2).
fully extend the arms as far as they will go behind the back, If this test is positive, physical examination for specific
pathologic processes of the shoulder should then be carried
out, such as the Neer impingement test or apprehension test
for anterior and posterior instability. The examiner should
also obtain plain radiographs, ultrasound, and magnetic
resonance imaging of the affected joints and surrounding
soft tissue to further clarify the pathology that is responsible
for the patient’s shoulder pain and dysfunction.
• Figure 23-1 Begin assessment of shoulder abduction by asking

the patient to fully extend the arms as far as they will go behind the • Figure 23-2 Continue assessment by asking the patient to fully
back. abduct each shoulder.
44
24 Painful Conditions of the Shoulder
As was previously indicated, it is the initial general physical The list in Table 24-1 is by no means comprehensive, but
examination of the shoulder that guides the clinician in it does aid the clinician in organizing the potential sources
narrowing his or her differential diagnosis and helps to of pathology that present as shoulder pain and dysfunction.
suggest which specialized physical examination maneuvers It should be noted that the most commonly missed catego-
and laboratory and radiographic testing will aid in confirm- ries of shoulder pain and the categories that most often
ing the cause of the patient’s shoulder pain and dysfunction. result in misadventures in diagnosis and treatment are the
For the clinician to make best use of the initial information last three categories. The knowledge of this potential pitfall
gleaned from the general physical examination of the shoul- should help clinicians keep these sometimes overlooked
der, a grouping of the common causes of shoulder pain and causes of shoulder pain and dysfunction in their differential
dysfunction is exceedingly helpful. Although no classifica- diagnosis. Table 24-2 provides a graphic correlation of the
tion of shoulder pain and dysfunction can be all-inclusive signs and symptoms of some of the more common causes
or all-exclusive owing to the frequently overlapping and of shoulder pain and dysfunction; it should aid the clinician
multifactorial nature of shoulder pathology, Table 24-1 in narrowing the differential diagnosis and ordering appro-
should help to improve the diagnostic accuracy and help priate diagnostic testing to help confirm the diagnosis and
the clinician to avoid overlooking less common diagnoses. guide treatment.
TABLE
Causes of Shoulder Pain
24-1
Localized Bony or
Joint Space Periarticular Sympathetically Referred from Other
Pathology Pathology Systemic Disease Mediated Pain Body Areas
Fracture Bursitis Rheumatoid arthritis Causalgia Brachial plexopathy
Primary bone tumor Tendinitis Collagen vascular Reflex sympathetic Cervical radiculopathy
Primary synovial Rotator cuff tear disease dystrophy Cervical spondylosis
tissue tumor Impingement Reiter syndrome Shoulder-hand Fibromyalgia
Joint instability syndromes Gout syndrome Myofascial pain syndromes
Localized arthritis Adhesive capsulitis Other crystal Dressler syndrome such as scapulocostal
Osteophyte formation Joint instability arthropathies Postmyocardial syndrome
Joint space infection Muscle strain Charcot’s neuropathic infarction adhesive Parsonage-Turner syndrome
Hemarthrosis Periarticular infection arthritis capsulitis of the (idiopathic brachial neuritis)
Villonodular synovitis not involving joint shoulder Thoracic outlet syndrome
Intraarticular foreign space Entrapment neuropathies
body Muscle sprain Intrathoracic tumors
Pneumothorax
Subdiaphragmatic pathology
such as subcapsular
hematoma of the spleen
with Kerr sign
45
TABLE
Differential Diagnosis of Shoulder Pain
24-2
Type of Location Night Active Range Passive Range Impingement Radiation Radiographic Special
Diagnosis Age Onset of Pain Pain of Motion of Motion Signs of Pain Paresthesia Weakness Instability Changes Features
Rotator cuff Any Acute or Deltoid region + ↓↓ Guarding Normal +++ — — Only due to Look for In chronic cases Painful arc of
tendinitis chronic pain abduction
Rotator cuff tears Older than Often Deltoid region ++ ↓↓ Normal (may ++ — — ++ — + Wasting of cuff
(chronic) 40 years chronic later ↓) muscles
Bicipital tendinitis Any Overuse Anterior — ↓ Guarding Normal + Occasionally — Only due to Look for None Special
into pain examination
biceps tests
Calcific tendinitis 30-60 Acute Point of ++ ↓↓ Guarding Normal except +++ — — Only due to — ++ Tenderness ++
years shoulder for pain pain
Capsulitis Older than Insidious Deep in ++ ↓↓ ↓↓ + — — — — — Global range

(“frozen 40 years shoulder of motion ↓
shoulder”)
Acromioclavicular Any Acute or Over joint Lying ↓ Full elevation Normal — — — — — In chronic cases Local
joint chronic on tenderness
side
Osteoarthrosis of Older than Insidious Deep in ++ ↓↓ ↓↓ — — — May have — +++ Crepitus

glenohumeral 40 years shoulder mild +
joint usually with acute
episodes
Glenohumeral 25 years Episodic Anterior or — Only Only Possible — + With acute +++ Often Stress tests
instability posterior apprehension apprehension episodes
Cervical Older than Insidious Suprascapular Often Normal Normal — ++ +++ + — In cervical spine Pain with neck
spondylosis 40 years movement
Thoracic outlet Any Usually Neck, — Normal Normal — ++ ++ ++ — — Special

syndrome with shoulder, examination
activity arm tests
Sympathetically Any With Neck, Often ↓ Guarding ↓ Guarding Possible Ill-defined — With disuse — + Bone scan, Vasomotor and
mediated pain contact shoulder, articular sudomotor
arm diffuse changes, and changes
demineralization
Modified from Dalton SE: The shoulder. In Klippel JH, Dieppe PA, editors: Rheumatology, ed 2, London, 1998, Mosby, p 76.
25 Shoulder Instability Syndromes
The father of modern medicine, Hippocrates, was no problem occurs. Chronic shoulder instability is arbitrarily
stranger to the problems of shoulder joint instability, as defined in those patients who seek medical attention for a
evidenced by his description of how to reduce an anterior shoulder problem that has existed longer than 25 hours.
shoulder dislocation in a treatise on medicine written Many patients with chronic shoulder instability have
around 300 b.c. While the knowledge of shoulder instabil- recurrent shoulder dislocations with attenuated pain and,
ity advanced in tandem with the other great advances in because of the decreased amount of pain, often delay
medicine, including anatomic dissection, asepsis for surgery, seeking medical attention. At first glance, it might seem
anesthesia, and radiography, it was not until the advent of unlikely that a person would delay seeking treatment for a
magnetic resonance imaging (MRI), dynamic ultrasound, shoulder dislocation, but it is in fact not uncommon for the
and arthroscopy that the construct of shoulder dislocation diagnosis of posterior shoulder dislocation to be delayed for
à la Bankhart as a primary model of shoulder instability a period of days, especially if other shoulder pathology is
gave way to a new, more comprehensive construct that present.
embraced a continuum of dysfunction that ranged from Shoulder instability can be further classified as to the
subluxation to frank shoulder dislocation. direction in which the humeral head moves relative to the
This new, refined construct allows the clinician to iden- glenoid fossa. The most common direction of shoulder
tify more subtle physical findings that point to the cause of instability is anterior, with more than 90% of all shoulder
shoulder pain and dysfunction and allow for a more com- dislocations occurring in this direction. Anterior sublux-
prehensive range of conservative treatment short of open or ation may be identified on physical examination by per-
laparoscopic surgical procedures. To understand this new forming the anterior drawer test (see Chapter 26), the
construct, the clinician might find the following definitions apprehension test (see Chapter 28), and the Jobe relocation
of subluxation and dislocation useful. Subluxation is defined test (see Chapter 29). Anterior dislocations can be divided
as an abnormal movement of the humeral head relative to on the basis of where the humeral head dislocates and
the glenoid. It is often transient in nature, making its rec- becomes fixed in order of frequency as follows:
ognition by the patient and unsuspecting clinician more • Subcoracoid (Fig. 25-1)
difficult than the more obvious shoulder dislocation. Dis- • Subglenoid (Fig. 25-2)
location, with its complete lack of contact between the • Subclavicular (Fig. 25-3)
surfaces of the humeral head and glenoid fossa, is more • Intrathoracic
dramatic and often (especially in the acute setting) does not Posterior subluxation may be diagnosed on physical
resolve itself spontaneously, forcing the patient to seek examination with the posterior drawer test and the jerk test
urgent medical attention. (see Chapter 31). True posterior shoulder dislocations are
For the purposes of diagnosis of shoulder instability much less common than anterior shoulder dislocations and
syndromes, the clinician will find it useful to categorize often are missed on initial evaluation in spite of a history
the abnormalities of shoulder instability that are identi- of trauma to the outstretched arm. Such delay in diagnosis
fied during physical examination on the basis of the often results in the subsequent development of severe sec-
following: ondary osteoarthritis of the affected joint. Posterior disloca-
• Acuity, such as acute or chronic tions of the shoulder can be divided on the basis of where
• Direction of instability, such as anterior, posterior, supe- the humeral head dislocates and becomes fixed in order of
rior, or inferior frequency as follows:
• The degree of instability, such as subluxation versus com- • Subacromial (Fig. 25-4)
plete dislocation • Subglenoid (Fig. 25-5)
• The pathogenesis of the instability, if known, such as • Subspinous (Fig. 25-6)
MRI-proven labral tear Superior and inferior subluxation of the shoulder are
It should be noted that an individual patient may suffer less common than anterior or posterior subluxation but
from more than one type of shoulder instability and that are by no means uncommon. True superior or inferior dis-
the same shoulder might undergo anterior dislocation and locations are extremely rare, however, and are invariably
also be subject to posterior, inferior, or superior subluxation associated with significant trauma such as falls from a great
or dislocation if different forces are placed on it. height or acceleration or deceleration injuries (Figs. 25-7
The classifying of shoulder instability as acute or chronic and 25-8). Concomitant fractures of the glenoid rim, acro-
is based on the chronology of the instability, with acute mion, clavicle, and humerus are also commonly associated
shoulder instability arbitrarily defined in those patients who with posterior shoulder dislocations, further confusing the
seek medical attention within 25 hours after a shoulder diagnosis.
47
A B
• Figure 25-1 A and B, Anterior dislocations of the shoulder: subcoracoid.
A B
• Figure 25-2 A and B, Anterior dislocations of the shoulder: subglenoid.
CHAPTER 25 Shoulder Instability Syndromes 49
A B
• Figure 25-3 A and B, Anterior dislocations of the shoulder: subclavicular.
A B
• Figure 25-4 A and B, Posterior dislocations of the shoulder: subacromial. (B from Resnick D: Diag-
nosis of bone and joint disorders, ed 4, Philadelphia, 2002, Saunders, p 2793.)
A B
• Figure 25-5 A and B, Posterior dislocations of the shoulder: subglenoid. (B from Resnick D: Diagnosis
of bone and joint disorders, Philadelphia, 2002, Saunders, p 2793.)
A B
• Figure 25-6 A and B, Posterior dislocations of the shoulder: subspinous. (B from Resnick D: Diagnosis
of bone and joint disorders, Philadelphia, 2002, Saunders, p 2793.)
CHAPTER 25 Shoulder Instability Syndromes 51
A A
B
B
• Figure 25-7 A and B, True superior dislocation of the shoulder.
(B from Resnick D, Kang HS: Internal derangements of joints: empha- • Figure 25-8 A and B, True inferior dislocation of the shoulder.
sis on MR imaging, Philadelphia, 1997, Saunders, p 239.) (B from Resnick D, Kang HS: Internal derangements of joints: empha-
sis on MR imaging, Philadelphia, 1997, Saunders, p 239.)
Deltoid
Careful physical examination should identify the shoul-
der instability in the majority of patients. The astute clini-
cian should recognize that it is possible for shoulder
instability to be multidirectional, and treatment should be Infraspinatus tendon
aimed at reducing the instability in the plane in which it
occurs. Specialized radiographic views, dynamic ultrasound,
computed views with 3-dimensional reconstructions, and Humeral head
MRI will help to clarify many of the structural lesions that Glenoid
are responsible for shoulder instability (Fig. 25-9). Arthros-
copy with active visualization of the shoulder during actual Posterior Anterior
movement of the affected joint might also be required for Image longitudinal to right humeral head view
the clinician to fully appreciate the functional abnormalities
that are contributing to the patient’s shoulder pain and • Figure 25-9 Longitudinal ultrasound image of patient with rotator
dysfunction. cuff tear and resultant high riding humeral head.
26 The Anterior Drawer Test
The anterior drawer test is useful in identifying anterior of the humeral head with a firm, definite, and relatively
shoulder instability, especially after trauma to the shoulder. painless endpoint. If there is a sudden slippage, pain, or
With the patient in the seated position, the examiner sta- apprehension, the examiner should suspect anterior joint
bilizes the patient’s clavicle and scapula with one hand and instability (Video 26-1).
identifies the humeral head with the other. Anterior force Anterior stability with resultant anterior shoulder dislo-
is then gradually applied to the humeral head (Fig. 26-1). cation should be relatively straightforward to diagnose on
The normal shoulder will allow slight anterior translation physical examination because of the obvious gross shoulder
deformity associated with anterior dislocation (Fig. 26-2).
This is not the case with posterior dislocations, which are
often missed during initial evaluation following shoulder
trauma.
• Figure 26-2 Typical appearance of a dislocation of the left shoulder.

(From Lahrach K, Bennani A, Marzouki A, et al: Luxation antérieure de
l’épaule associée à une fracture de la diaphyse humérale homolatérale
(à propos d’un cas), Journal de Traumatologie du Sport 27(1):20–22,
• Figure 26-1 The anterior drawer test. 2010.)
52
27 The Shift and Load Test for
Shoulder Instability
With the patient in the sitting position with the affected

arm positioned with 0 degrees abduction, the examiner
places one hand along the edge of the scapula to stabilize
it. With the opposite hand, the examiner grasps the head
of the humerus and gently pushes the head into the glenoid
fossa. The examiner then applies firm anterior and posterior
pressure on the head of the humerus to assess the degree of
anterior and posterior translation (Fig. 27-1). Subluxation
of the humeral head in either direction indicates shoulder
instability, and evaluation of the condition of the glenoid
fossa, humeral head, and the supporting structures of the
shoulder including the labrum with plain radiography,
shoulder arthrography, computed tomography, sonography,
and magnetic resonance imaging is indicated (Fig. 27-2).
• Figure 27-1 The shift and load test for shoulder instability.
A B C
• Figure 27-2 Glenohumeral joint instability: computed tomography (CT)—capsular, ligamentous, and
labral abnormalities. Three transaxial CT arthrographic images obtained at the level of the superior aspect
of the joint (level 1) (A), the midglenoid level (level 3) (B), and the inferior glenoid level (level 4) (C) show
a number of abnormalities indicative of previous anterior glenohumeral joint dislocation. In A, observe a
Hill-Sachs lesion (arrow), irregularity of the superior glenohumeral ligament (open arrow), and nonvisualiza-
tion of the superoanterior portion of the labrum. In B, findings include avulsion of the anterior portion of
the labrum at the site of attachment of the middle glenohumeral ligament (arrow) and a redundant anterior
capsule. In C, observe a fracture (arrow) of the anterior surface of the glenoid rim. (From Resnick D,
Kransdorf MJ, editors: Bone and joint imaging, ed 3, Philadelphia, 2005, Saunders, p 930.)
53
28 The Apprehension Test for Anterior
The apprehension test is useful in helping the clinician arm to the side to avoid subluxation or dislocation. If the
identify anterior shoulder instability and other painful con- patient is suffering from pathology of the anterior shoulder,
ditions of the anterior shoulder. The test is performed by such as tendinitis or bursitis, the patient will actively resist
placing the patient in the sitting position and asking the further backward movement of the arm to avoid pain. It is
patient to position his or her arm as if to throw a baseball. important that the examiner avoid any sudden or excessive
The examiner then slowly and gradually pulls the patient’s application of backward pressure to the arm, if anterior
hand backward to force the shoulder into ever-increasing stability is suspected, to avoid inadvertently dislocating the
extension and external rotation (Fig. 28-1). If there is ante- patient’s shoulder.
rior shoulder instability, the patient will actively drop the
• Figure 28-1 Apprehension test for anterior shoulder instability.
54
29 The Jobe Relocation Test for Anterior
The Jobe relocation test for anterior shoulder instability is position, and the clinician then repeats the apprehension
useful in helping the clinician to confirm the clinical sus- test for anterior shoulder instability by asking the patient
picion of anterior shoulder instability following a positive to position his or her arm as if to throw a baseball (see
apprehension test. The test is performed by placing the Fig. 29-1). The examiner then slowly and gradually pulls
patient in the sitting position and applying firm posterior the patient’s hand backward to force the shoulder into
pressure to the anterior shoulder. The patient is then ever-increasing extension and external rotation while con-
asked to place his or her arm in the baseball-throwing tinuing to apply firm posterior pressure on the anterior
• Figure 29-1 Jobe relocation test for anterior shoulder instability.
A B C
• Figure 29-2 Bankart lesion, magnetic resonance (MR) imaging. Color diagram in the axial plane
(A) reveals a tear and detachment of the anterior labrum (black arrow), with corresponding tear of the
scapular periosteum (white arrow). Axial indirect MR arthrogram images (B, C) reveal a tear and detach-
ment (white arrow) of the anterior inferior labrum. Also note some associated bone loss along the subja-
cent bony glenoid but no bone Bankart fragment. In C, note the displaced labral fragment. (From Zlatkin
MB, Sanders TG: Magnetic resonance imaging of the glenoid labrum, Radiol Clin North Am 51(2):
279–297, 2013.)
55
• Figure 29-3 Three-dimensional computed tomography with

humerus digitally subtracted of right shoulder. Bony Bankart lesion
visible off anterior-inferior glenoid. (From Harris JD, Romeo AA:
Arthroscopic management of the contact athlete with instability,
Clin Sports Med 32(4):709–730, 2013.)
shoulder (Fig. 29-1). If the presence of this posterior force believe that a positive relocation test following a positive
delays the point at which the patient demonstrates a posi- apprehension test is pathognomonic for a Bankart lesion,
tive apprehension sign, there is a very high probability which is a disruption of the bony attachment of the
of anterior shoulder instability, and magnetic resonance anterior labrum to the rim of the glenoid (Figs. 29-2
imaging of the shoulder is indicated. Many clinicians and 29-3).
30 The Andrews Anterior Apprehension
Test for Anterior Shoulder Instability
The Andrews anterior apprehension test for anterior shoul- to relax. The patient is reassured by the examiner that he
der instability is a useful technique to help confirm the or she will be gentle and that by relaxing, the patient can
physical findings suggesting anterior instability of the avoid any needless discomfort. The patient’s affected arm is
shoulder seen on the anterior apprehension test and Jobe then gently abducted and externally rotated while gentle
relocation test. It is especially useful when evaluating the pressure is placed on the posterior shoulder with the
patient with shoulder pain who is unable to fully relax examiner’s opposite hand (Fig. 30-1). The patient’s shoulder
because of fear of pain or inadvertent shoulder dislocation is assessed for abnormal anterior movement as well as
during shoulder examination. To perform the Andrews sudden apprehension due to pain. Care must be taken not
anterior apprehension test for anterior shoulder instability, to accidentally dislocate the patient’s shoulder during this
the patient is placed in the prone position and encouraged maneuver.
• Figure 30-1 The Andrews anterior apprehension test for anterior

shoulder instability.
57
31 The Posterior Drawer Test for Posterior
The posterior drawer test is useful in identifying posterior

shoulder instability, especially after trauma to the shoulder.
With the patient in the seated position, the examiner sta-
bilizes the patient’s clavicle and scapula with one hand and
identifies the humeral head with the other. Posterior force
is then gradually applied to the humeral head (Fig. 31-1).
The normal shoulder will allow slight posterior translation
of the humeral head with a firm, definite, and relatively
painless endpoint. If there is a sudden slippage, pain, or
apprehension, the examiner should suspect posterior joint
instability (Video 31-1).
In contradistinction to anterior instability with resultant
anterior shoulder dislocation, which is easy to diagnose
because of its obvious shoulder deformity, posterior disloca-
tions are often missed even by experienced clinicians because
of the less obvious shoulder deformity being limited to a
subtle flattening of the anterior shoulder and slight poste-
rior prominence associated with limited external rotation
and forward elevation of the shoulder. Magnetic resonance
and/or ultrasound imaging will help clarify the clinical • Figure 31-1 Posterior drawer test for posterior shoulder instability.
diagnosis (Fig. 31-2).
A B
• Figure 31-2 Posterior shoulder instability. Axial T2 FS magnetic resonance image (A) and correspond-
ing diagram (B). Note the torn and detached posterior labrum with disruption of the scapular periosteum
posteriorly consistent with a reverse Bankart lesion (white arrow in A, black arrow in B). Note the reverse
Hill-Sachs lesion anteromedially in A (longer white arrow). (From Zlatkin MB, Sanders TG: Magnetic reso-
nance imaging of the glenoid labrum. Radiol Clin North Am 51(2):279–297, 2013.)
58
32 The Jerk Test for Posterior
The jerk test is useful in identifying posterior shoulder insta-

bility and, when combined with the posterior drawer test,
will increase the clinical accuracy of the diagnosis of the
commonly misdiagnosed shoulder pathology. The jerk test
is performed with the patient in the sitting position. The
patient is asked to fully internally rotate the arm and then
flex the arm at the elbow to 90 degrees. The examiner then
exerts steady, even posterior force to the arm at the elbow,
and the arm is then slowly moved across the body (Fig.
32-1). A sudden jerk may be felt as the humeral head slides
off the back of the glenoid. This jerk may again be appreci-
ated when the arm is then moved back to its original posi-
tion of full rotation and 90-degree flexion as the head of
the humerus slides back into the glenoid fossa. If this test
is positive, further evaluation with plain radiographs,
arthrography, computed tomography, and magnetic reso-
nance imaging is indicated (Fig. 32-2).
• Figure 32-1 Jerk test for posterior shoulder instability.
A B
• Figure 32-2 Posterior glenohumeral joint instability. A, Transaxial SPGR (TR/TE, 45/15; flip angle, 20
degrees) magnetic resonance image shows posterior subluxation of the humeral head, irregularity of the
posterior glenoid rim (solid arrow), and a trough fracture (open arrow) involving the anterior surface of the
humeral head. B, Transaxial computed tomography scan at a slightly lower level in the same patient
confirms posterior displacement of the humeral head, a fracture of the posterior glenoid region
(solid arrow), and a trough fracture of the humeral head (open arrow). (Courtesy of M. Schweitzer, MD,
Philadelphia, PA; in Resnick D, Kransdorf MJ, editors: Bone and joint imaging, ed 3, Philadelphia,
2005, Saunders, p 932.)
59
33 The Posterior Clunk Test for Posterior
The posterior clunk test is useful in helping identify poste-

rior shoulder instability and is often used in combination
with the posterior drawer test and jerk test to confirm the
suspicion of posterior shoulder instability. To perform the
posterior clunk test, the patient is placed in the sitting posi-
tion and the affected shoulder is internally rotated and then
abducted to 90 degrees with the elbow flexed (Fig. 33-1).
The examiner then places gentle posterior pressure on the
elbow while the affected extremity is moved toward the
patient’s contralateral shoulder (Fig. 33-2). A clunk is
appreciated by both patient and examiner as the humeral
head subluxes posteriorly. The patient may also experience
pain as the humeral head subluxes. Care must be taken not
to apply too much posterior pressure to the elbow when
performing this test or the shoulder may inadvertently be • Figure 33-2 Clunk test maneuver.
dislocated posteriorly (Fig. 33-3).
• Figure 33-3 Glenohumeral joint: posterior dislocation. Findings on

the anteroposterior radiograph include distortion of the normal elliptic
radiodense region created by the overlying humeral head and glenoid
fossa (arrowhead), a “vacant” glenoid cavity (solid arrow), loss of paral-
lelism between the articular surfaces of the glenoid cavity and humeral
head, internal rotation of the humerus, and an impaction fracture (open
arrows). (From Resnick D, Kransdorf MJ, editors: Bone and joint
• Figure 33-1 Initial positioning for the posterior clunk test. imaging, ed 3, Philadelphia, 2005, Saunders, p 833.)
60
34 The Sulcus Sign Test for Inferior
Glenohumeral Instability
A positive sulcus sign is highly suggestive of inferior gleno- for the appearance of a dimple, or sulcus, between the acro-
humeral instability. To perform the sulcus sign test, the mion and humeral head (Fig. 34-1). More than 2 cm of
patient is placed in the sitting position with the affected inferior subluxation is highly suggestive of inferior glenohu-
upper extremity relaxed. The examiner then exerts firm infe- meral instability, especially if the sulcus sign remains present
rior traction on the affected upper extremity while observing as the affected extremity is abducted from 0 to 45 degrees.
• Figure 34-1 The positive sulcus sign. (Courtesy of Dr. Tom R. Norris
of the San Francisco Shoulder, Elbow, and Hand Clinic.)
61
35 The Crank Test for Injury of the Labrum
of the Glenohumeral Joint
A positive crank test is highly suggestive of injury to the pressure against the elbow to push the humeral head firmly
labrum of the glenohumeral joint (Fig. 35-1). To perform into the glenohumeral joint (see Fig. 35-2). The humerus is
the crank test, the patient is placed in the sitting position then internally and externally rotated like a “crank” (Fig.
with the affected upper extremity abducted and the elbow 35-3). The test is positive if the rotation of the humerus
flexed 90 degrees (Fig. 35-2). The examiner then exerts firm elicits pain and/or a painful catching or clicking sensation.
A B C
• Figure 35-1 Axial (A), coronal (B), and sagittal (C) magnetic resonance arthrogram images demon-
strating tearing of both the anterior superior (black arrows) and posterior superior labrum (white arrows)
with posterior predominance. Some posterior inferior extension is best seen on the sagittal views. (From
Zlatkin MB, Sanders TG: Magnetic resonance imaging of the glenoid labrum, Radiol Clin North Am
51(2):279–297, 2013, fig 15.)
• Figure 35-2 To perform the crank test, the patient is placed in the
sitting position with the affected upper extremity abducted and the
elbow flexed 90 degrees. The examiner then exerts firm pressure
against the elbow to push the humeral head firmly into the glenohu-
meral joint.
62
CHAPTER 35 The Crank Test for Injury of the Labrum of the Glenohumeral Joint 63
B
• Figure 35-3 A and B, The humerus is then internally and externally
rotated like a “crank.”
36 An Overview of Shoulder
Impingement Syndromes
Just as with the pathology of shoulder instability, the under- pathologic states have in common is constriction of the
standing of shoulder impingement syndromes has been space bounded by the coracohumeral arch above and
greatly enhanced by information obtained from magnetic the humeral head and greater and lesser tuberosities of the
resonance imaging (MRI) and direct arthroscopic visualiza- humerus below (Figs. 36-1 to 36-3). Through this space
tion of the shoulder joint in health and disease. Unfortu- pass the tendons of the rotator cuff, the coracohumeral liga-
nately, as can be seen from Table 36-1, rather than ment, and, with forward flexion of the humerus, the long
simplifying the classification system for shoulder impinge- tendon of the biceps (Fig. 36-4). In health, the movement
ment, this new knowledge served to confirm what many of these structures underneath the coracohumeral arch is
clinicians had long suspected: that rather than being a facilitated by lubrication from the subacromial and subdel-
disease that results from a single or unified pathology, shoul- toid bursae, although inflammation, infection, or calcifica-
der impingement syndrome is in fact a clinical manifesta- tion of these bursae can in fact cause a shoulder impingement
tion of myriad pathologic states. syndrome by themselves.
Fortunately, in spite of the large number of things that In spite of the multiple potential causes of shoulder
can cause shoulder impingement syndrome, what these impingement syndrome, in most patients, its clinical
TABLE
Factors Potentially Increasing Rotator Cuff Impingement
36-1
Structural Factors Functional Factors
Acromioclavicular joint Scapula
Congenital abnormality Abnormal position
Degenerative spurs Thoracic kyphosis
Nonsurgical foreign body in joint space Acromioclavicular separation
Pins, wires, or sutures projecting into joint space Abnormal motion
Acromion Paralysis (e.g., of trapezius)
Unfused (bipartite acromion) Fascioscapulohumeral muscular dystrophy
Abnormal shape (flat or overhanging) Restriction of motion at the scapulothoracic joint
Degenerative spur Loss of normal humeral head depression mechanism
Nonunion of fracture Rotator cuff weakness (e.g., suprascapular nerve palsy or
Malunion of fracture C5-C6 radiculopathy)
Coracoid Rotator cuff tear (partial or full thickness)
Congenital abnormality Constitutional or posttraumatic rotator cuff laxity
Posttraumatic change in shape or location Rupture of long head of biceps
Postsurgical change in shape or location Tightness of posterior shoulder capsule forcing the humeral
Bursa head to rise up against the acromion during shoulder
Primary inflammatory bursitis (e.g., rheumatoid arthritis) flexion
Chronic thickening from previous injury, inflammation, or Capsular laxity
injection
Nonsurgical foreign bodies in bursal space
Pins, wires, or sutures projecting into the bursal space
Rotator cuff
Thickening related to chronic calcium deposits
Thickening from retraction of partial-thickness tears
Flaps and other irregularities of upper surface due to
partial or complete tearing
Postoperative or posttraumatic scarring
Humerus
Congenital abnormalities or fracture malunions producing
relative or absolute prominence of the greater tuberosity
Abnormally inferior position of humeral head prosthesis
producing relative prominence of the greater tuberosity
Modified from O’Brien SJ, Amoczky SP, Warren RF, et al: Developmental anatomy of the shoulder and anatomy of the glenohumeral joint. In Rockford CA Jr,
Matsen FA III, editors: The shoulder, Philadelphia, 1990, Saunders, p 627.
64
CHAPTER 36 An Overview of Shoulder Impingement Syndromes 65
Coracoacromial Clavicle
ligament
Biceps
tendon
• Figure 36-1 Anatomic depiction of the shoulder impingement • Figure 36-4 Hypertrophy of the supraspinatus muscle. Impinge-
syndrome. ment symptoms may accompany severe hypertrophy of the supra-
spinatus muscle in the presence of a normal bony arch. Contour
changes of the superior margin of the supraspinatus muscle from a
normal AC joint may be seen in this process (arrow). (From Stark DD,
Bradley WG: Magnetic resonance imaging, ed 3, St. Louis, 1999,
Mosby, p 707.)
Large supraspinatus tendon tear
Biceps
tendon
• Figure 36-2 Acromioclavicular (AC) joint impingement: short-TE

oblique coronal image. Callus and osteophyte at the AC joint may be
more extensive than represented on plain radiographs and commonly
cause shoulder impingement (arrow). The portion of the tendon
involved in the impingement process is thickened, with increased
Medial Lateral
signal intensity and indistinct margins (arrowheads). (From Stark DD,
Bradley WG: Magnetic resonance imaging, ed 3, St. Louis, 1999, Transverse supraspinatus tendon view
Mosby, p 706.)
• Figure 36-5 Transverse ultrasound image demonstrating tear of

the supraspinatus tendon.
Bursal bulging
Note increase in
bursa fluid
Distal
acromion presentation is classic and easily distinguished from other
Note bulging causes of shoulder pain and dysfunction on physical exami-
of supraspinatus
Supraspinatus tendon tendon nation. It must be emphasized, however, that other patho-
logic conditions of the shoulder frequently coexist with
Humeral head shoulder impingement syndrome, most notably anterior
joint instability and rotator cuff tendinitis, and these
Longitudinal to supraspinatus tendon coexistent pathologic conditions might confuse the clinical
Medial Lateral diagnosis (Fig. 36-5).
Shoulder impingement syndrome most often presents as
• Figure 36-3 Longitudinal ultrasound image demonstrating changes ill-defined shoulder pain that is worse after overhead activi-
consistent with subacromial impingement syndrome. ties or overuse of the shoulder. People in occupations that
Supraspinatus m.
Infraspinatus
m.
• Figure 36-7 Manual muscle testing for shoulder impingement

syndrome.
• Figure 36-6 Atrophy of the supraspinatus and infraspinatus

muscles in shoulder impingement syndrome.
require repetitive overhead activity, such as fruit pickers,

carpenters, painters, and drywall hangers, are particularly
susceptible to the development of shoulder impingement
syndrome. Swimming, throwing, and tennis playing have
also been implicated in the development of this painful
condition.
If the pathologic process that is responsible for the shoul-
der impingement continues, the ill-defined pain will fre-
quently localize to the anterior and lateral shoulder. The
patient will often present to the clinician with the complaint
of being unable to lie on the affected side at night. The pain
is often worse at night, and the patient will begin to notice
the inability to perform simple overhead tasks, such as
putting dishes away or changing a light bulb.
On physical examination, the anterior and lateral shoul- • Figure 36-8 Shoulder impingement syndrome: routine radiographic
abnormalities. A frontal radiograph of the shoulder shows a large
der may be acutely tender to palpation, and there may be enthesophyte (arrow) with osteophytes at the acromioclavicular joint
crepitus and apprehension when the patient actively raises and in the inferior portion of the humeral head. (From Resnick D,
the arm above 60 degrees. Chronically, inspection of the Kang HS: Internal derangements of joints: emphasis on MR imaging,
shoulder may reveal atrophy of the muscles of the rotator Philadelphia, 1997, Saunders, p 185.)
cuff, most commonly the supraspinatus and infraspinatus
muscles (Fig. 36-6). There may also be rather marked limi-
tation of range of motion on elevation of the upper extrem-
ity. The shoulder may “catch” as the patient raises his or her including the anterior drawer sign, the apprehension test,
arm. Manual muscle testing may reveal weakness of the and the relocation test should be performed on any patient
muscles of the rotator cuff, in particular the supraspinatus who is suspected of suffering from shoulder impingement
(Fig. 36-7). syndrome.
Specialized physical examination tests for shoulder Plain radiographs including axillary views of the shoul-
impingement include the Neer and Hawkins tests for der will often demonstrate significant osteophyte formation
shoulder impingement (see Figs. 37-1 and 38-1). As was arising from the anteroinferior portion of the acromion
mentioned previously, because anterior instability of the (Fig. 36-8). If the clinical presentation and physical exami-
glenohumeral joint is thought to be the most common nation suggest shoulder impingement syndrome, magnetic
contributing factor to the development of shoulder resonance and ultrasound images of the shoulder joint
impingement syndrome, specific physical examination tests and surrounding soft tissues should also be obtained, with
CHAPTER 36 An Overview of Shoulder Impingement Syndromes 67
Deltoid
Subdeltoid bursitis
Rice
bodies
Humeral head
Humeral
Medial head erosion Lateral
Image transverse to biceps tendon view
• Figure 36-9 Transverse ultrasound image demonstrating subdel-

toid bursitis with significant erosion of the humeral head. Note the Rice
bodies within the subdeltoid bursa.
special attention to the acromion, the rotator cuff, the long of this testing is to try to identify the structural abnormality
tendon of the biceps, and the subacromial and subdeltoid that is responsible for the evolution of the shoulder impinge-
bursae (Fig. 36-9). Computed tomographic scanning with ment syndrome with an eye to finding pathologic processes
3-dimensional reconstruction of the coracohumeral arch that are amenable to physical therapy, injection with corti-
may also be of value. It should be noted that the purpose costeroid, or surgical correction.
37 The Neer Test for Shoulder
In the Neer test for shoulder impingement syndromes, the paying particular attention to any pain or apprehension that
patient is asked to assume a sitting position. While applying occurs when the arm moves above 60 degrees of elevation
firm forward pressure on the patient’s scapula, the examiner as structures are impinged by the humerus against the acro-
actively raises the patient’s arm to an overhead position, mioclavicular arch (Fig. 37-1 and Video 37-1).
• Figure 37-1 Neer test for shoulder impingement syndrome.
68
38 The Hawkins Test for Shoulder
The Hawkins test for shoulder impingement is thought to the throwing position. The examiner then flexes the arm
identify patients whose shoulder impingement syndrome is forward approximately 30 degrees and firmly internally
caused by impingement of the supraspinatus tendon against rotates the humerus (Fig. 38-1). Reproducible pain during
the coracoacromial ligament. In the Hawkins test for shoul- internal rotation is considered a positive test and is highly
der impingement syndromes, the patient is placed in the suggestive of impingement of the supraspinatus tendon
sitting position and is then asked to place his or her arm in against the coracoacromial ligament.
• Figure 38-1 Hawkins test for shoulder impingement syndrome.
69
39 The Gerber Subcoracoid
Impingement Test
The Gerber subcoracoid impingement test is useful in iden- then adducted 15 to 20 degrees across the body to bring
tifying shoulder impingement caused by impingement the lesser tuberosity of the humerus into contact with
between the rotator cuff and the coracoid process (Fig. the coracoid process (Fig. 39-2). Pain during the maneuver
39-1). To perform the Gerber subcoracoid impingement is highly suggestive of an impingement syndrome, and
test, the patient is placed in the sitting position and the imaging of the shoulder is indicated to further delineate the
affected upper extremity is flexed forward 90 degrees and diagnosis.
Bulging of bursa
under internal
rotation
Coracoid
Subscap tendon
process
Humeral head
Anterior impingement syndrome. Longitudinal

subscapularis tendon view Lateral
• Figure 39-1 Longitudinal ultrasound image demonstrating sub-

coracoid impingement. Note the bulging of the bursa.
• Figure 39-2 The Gerber subcoracoid impingement test.
70
40 The Zaslav Rotation Resistance Test for
Shoulder Impingement
The Zaslav rotation resistance test is a useful confirmatory

test in patients who exhibit a positive Neer or Hawkins
impingement test and may aid the examiner in determining
whether the shoulder impingement is occurring at the sub-
acromial outlet or is internal, that is, has an intraarticular
source. To perform the Zaslav rotation resistance test for
shoulder impingement, the patient is placed in the sitting
position with the examiner standing behind the patient.
The patient’s affected upper extremity is then moved to the
90-degree abducted position, and the patient is asked to
externally rotate the extremity while the examiner evaluates
the patient’s muscle strength to approximately 80 degrees
(Fig. 40-1). The examiner then repeats the test by asking
the patient to internally rotate the affected extremity while
the examiner evaluates the patient’s muscle strength with
internal rotation (Fig. 40-2). If the examiner notes that
the patient’s external rotation strength is normal and the
patient’s internal rotation strength is weak, the test suggests
internal impingement. If the examiner notes that the • Figure 40-2 Step two of the Zaslav rotation resistance test is to
assess the patient’s muscle strength when internally rotating his or her
patient’s internal rotation strength is normal and the shoulder.
patient’s external rotation strength is weak, the test suggests
a more classic outlet impingement (Fig. 40-3).
Fluid in the
subdeltoid bursa
Distal
acromion
Supraspinatus
Medial tendon Lateral
Humeral head
Arm is abducted
Image longitudinal to the right supraspinatus tendon
• Figure 40-1 Step one of the Zaslav rotation resistance test is to • Figure 40-3 Longitudinal ultrasound image demonstrating sub-
assess the patient’s muscle strength when externally rotating his or acromial or outlet impingement with the patient’s right upper extremity
her shoulder. abducted.
71
41 Bicipital Tendinitis
Bicipital tendinitis is a common cause of anterior shoulder biceps tendon to sublux with resultant greatly magnified
pain. Although more commonly seen in the fifth and sixth forces when the tendon flexes the elbow, leading to damage
decades, this painful condition can occur at an early age as to the tendon over time.
a result of overuse. Activities that are frequently implicated The patient with bicipital tendinitis most often presents
as inciting factors of bicipital tendinitis include throwing with anterior shoulder pain that is made worse with over-
activities, swimming, and golf. Mothers may present with head activities and improved with rest. The patient fre-
bicipital tendinitis as a result of carrying their infants for quently gives a history of shoulder overuse, although in the
long periods of time. cases of narrowing of the bicipital groove or in the setting
In the absence of acute overuse of the shoulder, bicipital of chronic shoulder instability, the onset may be more insid-
tendinitis rarely exists as an isolated pathologic condition ious. On physical examination, the patient is exquisitely
but most often coexists with shoulder instability and shoul- tender to palpation of the tendon as it passes over the
der impingement syndromes. This fact is not surprising, bicipital groove (Fig. 41-3). Shoulder extension and elbow
given that the long tendon of the biceps works with the flexion also exacerbate the pain. The Speed and Yergason
rotator cuff to help stabilize the shoulder during movement. provocation tests for bicipital tendinitis are specific for this
This role as shoulder stabilizer is increased in the presence disorder and aid the clinician in diagnosis and treatment
of rotator cuff tendinopathies or complete rotator cuff (see Figs. 42-1 and 43-1).
tears and puts significant additional strain on the biceps As mentioned previously, because bicipital tendinitis fre-
tendon. quently coexists with shoulder instability or impingement
Bicipital tendinitis may also occur as the result of nar- syndromes, specific physical examination tests including the
rowing or osteophyte formation along the course of the anterior and posterior drawer signs, the apprehension test,
bicipital groove (Fig. 41-1). These changes lead to chronic the relocation test, and the jerk test as well as the Neer and
tendon inflammation and damage and, if untreated, can Hawkins tests should be performed to identify potential
result in acute tendon rupture, especially during an episode sources of underlying pathology responsible for the evolu-
of heavy lifting (Fig. 41-2). Less commonly, rupture of the tion of bicipital tendonitis.
transverse humeral ligament, which serves as a fulcrum and Plain radiographs of the shoulder, including special views
tether for the biceps tendon, may rupture, allowing the of the bicipital groove, as well as computed tomographic
A B
• Figure 41-1 Tendon of the long head of the biceps brachii muscle, showing bone proliferation around
the bicipital groove. Photograph (A) and radiograph (B) show marked osseous proliferation along the
course of the bicipital groove (arrows). (From Cone RO, Danzig G, Resnick D, et al: The bicipital groove:
radiographic, anatomic, and pathologic study, AJR 141:781, 1983. Copyright 1983 by American Roent-
gen Ray Society.)
72
CHAPTER 41 Bicipital Tendinitis 73
Empty bicipital groove Lateral

Medial
Humeral head
Subscapularis
tendon
Note absence of supraspinatus fibers and very scant
subscapularis tendon fibers of the right shoulder
• Figure 41-2 Ultrasound image demonstrating complete rupture of

the biceps tendon as evidenced by the empty bicipital groove. Note
abnormalities of the musculotendinous units of the supraspinatus and
subscapularis components of the rotator cuff.
• Figure 41-3 Palpation of the bicipital tendon.
Fluid haloing of the biceps tendon
B.T.
Greater
tuberosity
Lesser tuberosity
Transverse long head of the biceps

Right shoulder
• Figure 41-4 Transverse ultrasound image demonstrating bicipital

tendinitis. Note the haloing of fluid around the inflamed tendon.
images of the humeral head with 3-dimensional reconstruc- rotator cuff tears that might be responsible for the patient’s
tion of the bicipital groove will help to identify narrowing bicipital tendinitis (Figs. 41-4 and 41-5). Specialized MRI
or osteophyte formation that might be irritating and dam- views of the transverse humeral ligament may identify
aging the biceps tendon. Magnetic resonance imaging rupture of the ligament and resultant subluxation of the
(MRI) and ultrasound imaging of the shoulder should aid biceps tendon.
the clinician in identifying abnormalities of the bicipital Treatment of bicipital tendinitis should be aimed at
tendon as well as rotator cuff tendinopathy or complete treating the underlying pathology whenever it can be
A B
C D
• Figure 41-5 Axial (A to C) and sagittal oblique (D) T1W with fat suppression (FST1W) magnetic reso-
nance arthogram images of the long head of biceps (LHB) tendon (white arrows) in a patient with pain
over the biceps. A, The LHB tendon in the distal tendon sheath is normal. B, More proximally, the tendon
is attenuated and is surrounded by intermediate–signal intensity (SI) soft tissue thickening, with osteo-
phytes arising from the lesser tuberosity in the medial aspect of the bicipital groove. C and D, In the
rotator interval, the tendon is thickened and demonstrates areas of increased SI due to tendinopathy.
(From Waldman SD, Campbell, RSD: Imaging of pain, Philadelphia, 2010, Saunders/Elsevier, fig 96-1.)
identified. Avoidance of activities that provoke or exacerbate injection into the already compromised biceps tendon can
the patient’s symptoms as well as a short course of antiin- lead to acute rupture. To provide long-lasting relief, surgical
flammatory agents will provide symptomatic relief for most treatment may ultimately be required in cases of narrowing
patients. Careful injection of corticosteriods around the of the bicipital groove or rupture of the transverse humeral
inflamed tendon may also be of value, although inadvertent ligament.
42 The Speed Test for Bicipital Tendinitis
To perform the Speed test for bicipital tendinitis, the patient fossa and asks the patient to flex the affected shoulder
should assume the standing position with his or her elbow against resistance (Fig. 42-1). The test is considered positive
fully extended and the arm supinated. The examiner then if the patient complains of pain when flexing the shoulder
exerts firm downward force at the level of the antecubital against resistance (Video 42-1).
• Figure 42-1 Speed test for bicipital tendinitis.
75
43 The Yergason Test for Bicipital Tendinitis
To perform the Yergason test for bicipital tendinitis, have that arm against resistance (Fig. 43-1). The test is considered
the patient assume the standing position with his or her positive if the patient complains of pain when supinating
elbow flexed to 90 degrees. The examiner then grasps the the arm against resistance (Video 43-1).
wrist of the affected arm and asks the patient to supinate
• Figure 43-1 Yergason test for bicipital tendinitis.
76
44 The Snap Test for Subluxing Biceps
Tendon Syndrome
As mentioned in previous chapters, the knowledge gained The subluxing biceps tendon syndrome is most often
from advances in magnetic resonance imaging (MRI) and seen in individuals who perform strenuous overhead work,
dynamic ultrasound imaging and arthroscopy of the shoul- such as drywall hangers, javelin throwers, quarterbacks, and
der has led to a greater understanding of the important role competitive swimmers. The patient with subluxing biceps
that the biceps tendon plays in the maintenance of shoulder tendon syndrome most often complains of the combination
stability. When there is irritation or mild displacement of of pain and a popping or clicking sensation in the shoulder
the biceps tendon, the patient frequently first presents with as the biceps tendon moves into and out of the bicipital
bicipital tendinitis. If the pathologic condition remains groove during shoulder abduction, external rotation, and
untreated, cumulative trauma to the biceps tendon and elevation (Fig. 44-2).
surrounding structures can lead to scarring with chronic These clinical symptoms are by no means pathogno-
medial displacement of the tendon or, in extreme cases, monic for this syndrome, and the clinician will need several
complete tendon rupture. Such medial displacement puts sources of information to determine the underlying pathol-
additional abnormal stress on the coracohumeral ligament ogy that is responsible for the subluxation (Fig. 44-3).
and the subscapularis muscle. Over time, both of these These sources include specialized physical examination tests,
structures may tear, allowing further subluxation of the such as the snap test for biceps tendon subluxation and the
biceps tendon and exacerbation of the patient’s shoulder Gerber lift-off test (see Chapter 45) for subscapularis muscle
dysfunction (Fig. 44-1). The clinical scenario is known as rupture. Further information can be obtained from targeted
the subluxing biceps tendon syndrome. MRI of the biceps tendon and bicipital groove, looking at
Deltoid
Biceps
tendon
Distal acromion
Subscapularis
Subdeltoid bursa Humeral head

being impinged
Bursal surface tearing of
subscapularis tendon
Peritenon
Modified Crass maneuver with impingement testing transverse biceps tendon view
Right shoulder
224/224
• Figure 44-1 Ultrasound imaging of the subscapularis muscle and biceps tendon demonstrating the
interrelationship between the subscapularis musculotendinous unit and the proximal biceps tendon.
77
A B
• Figure 44-2 Biceps tendon subluxation. A, This axial (2000/20) image shows the biceps tendon
subluxing onto the lesser tuberosity (arrow). B, The T2-weighted (2000/80) image shows similar findings
(arrow). High-signal fluid is seen adjacent to the tendon at the point of subluxation. Fluid is not seen in
the glenohumeral joint or in other portions of the tendon sheath. (From Crues JV, Stoller DW, Ryu RKN:
Shoulder. In Stark DD, Bradley WG, editors: Magnetic resonance imaging, ed 3, St. Louis, 1999, Mosby,
p 714.)
• Figure 44-4 Snap test for subluxing biceps tendon syndrome.
• Figure 44-3 Tendon of the long head of the biceps brachii muscle:
medial dislocation (magnetic resonance [MR] imaging). A 54-year-old
man fell on his shoulder while skiing and subsequently was unable to
abduct his arm. A transaxial proton density-weighted (TR/TE, 2000/30) present with the primary symptoms of pain and a clicking
spin echo MR image shows that the biceps tendon (solid straight or popping sensation with shoulder movement. The snap
arrow) has slipped medially over the lesser tuberosity (open arrow) test is performed with the patient in the standing position.
and appears to be lying between the partially displaced fibers (arrow- The patient is asked to fully abduct, externally rotate, and
heads) of the subscapularis tendon. The transverse humeral ligament
elevate the affected shoulder. The examiner then palpates
(curved arrow) appears intact. (From Resnick D, Kang HS: Internal
derangements of joints: emphasis on MR imaging, Philadelphia, 1997, the shoulder as the patient slowly lowers his or her arm. An
Saunders, p 305.) audible or palpable snap is appreciated as the biceps tendon
subluxes back into the bicipital groove (Fig. 44-4).
Unfortunately, a positive snap test for subluxing biceps
tendon syndrome does not point the examiner to the
the special relationships of the two structures as the shoul- specific pathology that is responsible for tendon sublux-
der is imaged in various degrees of abduction, external ation, such as a ruptured coracohumeral ligament or a rup-
rotation, and elevation. This information also gives the tured subscapularis muscle; it indicates only that biceps
orthopedic surgeon a road map for how to surgically repair tendon subluxation is likely. To narrow the potential causes,
the underlying pathology that is responsible for the tendon the examiner should then perform the Gerber lift-off test
subluxation. to identify rupture of the subscapularis muscle. Confirma-
The snap test for subluxing tendon biceps aids the clini- tory targeted magnetic resonance scanning with the affected
cian in separating this pathologic condition of the shoulder shoulder in various stages of abduction, external rotation,
from other pathologic conditions of the shoulder that and elevation is also indicated.
45 The Gerber Lift-Off Test for Rupture
of the Subscapularis Muscle
The Gerber lift-off test will aid the clinician in determining

whether the patient’s subluxing biceps tendon is due to
rupture of the subscapularis muscle. To perform the test,
the patient is asked to stand and place his or her fully pro-
nated hand behind his or her back at the level of the belt
line (Fig. 45-1). The examiner then puts firm pressure
against the patient’s hand and asks the patient to push the
examiner’s hand away (Fig. 45-2). Patients with significant
trauma to the subscapularis muscle and its tendinous inser-
tions will be unable to push the examiner’s hand away.
Confirmatory targeted magnetic resonance imaging and
dynamic ultrasound images with the affected shoulder in
various stages of abduction, external rotation, and elevation
as well as specific images of the musculotendinous units of
the rotator cuff, in particular the subscapularis, is also indi-
cated to confirm the diagnosis and guide treatment options
(Fig. 45-3 and Video 45-1).
• Figure 45-2 Gerber lift-off test for rupture of the subscapularis

muscle: note placement of examiner’s hands.
Deltoid
Greater
B.T. tuberosity
Lesser
Subscapularis tuberosity
multiple spurs
• Figure 45-3 Transverse ultrasound image demonstrating intersub-

• Figure 45-1 Gerber lift-off test for rupture of the subscapularis stance tears of the subscapularis musculotendinous unit. Note osteo-
muscle: patient positioning. phytes of the lesser tuberosity of the humerus. B.T., Biceps tendon.
79
46 The Gerber Belly Press Test for
Subscapularis Weakness
Weakness of internal rotation of the shoulder is highly sug- rotation. If internal rotational strength is normal, the patient
gestive of weakness of the subscapularis muscle. The Gerber will be able to keep his or her elbow in front of the trunk
belly press test is an easy way to confirm such weakness. To (Fig. 46-1). If the strength of internal rotation of the affected
perform the Gerber belly press test, the patient is placed upper extremity is diminished, the patient will tend to
in the sitting position and instructed to firmly press the maintain pressure on the abdomen by externally rotating
palm of the hand of the affected upper extremity against his the shoulder and flexing the wrist, the ipsilateral elbow
or her belly while keeping the arm in maximum internal dropping behind the trunk (Fig. 46-2 and Video 46-1).
• Figure 46-1 The Gerber belly press test for subscapularis weak- • Figure 46-2 The Gerber belly press test for subscapularis weak-
ness: if internal rotational strength is normal, the patient will be able to ness: if the strength of internal rotation of the affected upper extremity
keep his or her elbow in front of the trunk. is diminished, the patient will tend to maintain pressure on the abdomen
by externally rotating the shoulder and flexing the wrist, the ipsilateral
elbow dropping behind the trunk.
80
47 The Internal Rotation Lag Sign for
Rupture of the Subscapularis Tendon
To perform the internal rotation lag sign test for rupture of the examiner supporting the patient’s elbow but releasing
the subscapularis tendon, the examiner stands behind the the wrist (Fig. 47-1). The test is considered positive if any
patient and the patient’s affected upper extremity is held by significant lag is observed when the examiner releases the
the examiner in almost maximal internal rotation behind patient’s wrist (Video 47-1). Such a lag is highly suggestive
the patient’s back. The elbow is then flexed to 90 degrees, of rupture of the subscapularis tendon. Rupture of the
and the shoulder is held at 20 degrees of elevation and 20 tendon can be confirmed with ultrasound and/or magnetic
degrees of extension. The examiner then gently lifts the resonance imaging (Fig. 47-2).
affected upper extremity away from the patient’s lumbar
region until maximal internal rotation is reached. The
patient is then asked to actively maintain that position with
Deltoid
Biceps
tendon
Greater
Area of retraction Bicipital groove tuberosity
Lesser
tuberosity
Retracted
bulk of
subscapularis
muscle
• Figure 47-1 The internal rotation lag sign test for rupture of the Right Transverse long head of biceps tendon view
subscapularis tendon. The test is considered positive if any significant
lag is observed when the examiner releases the patient’s wrist. Such • Figure 47-2 Transverse ultrasound image demonstrating complete
a lag is highly suggestive of rupture of the subscapularis tendon. tear and retraction of the subscapularis musculotendinous unit.
81
48 The Snapping Scapula Test
Snapping scapula syndrome is an abnormal condition of the

shoulder characterized by an audible or tactile snapping or
popping associated with movement of the scapula across its
thoracic articulation (Fig. 48-1). Snapping scapula syn-
drome may be associated with pain or may be painless.
There are many causes of the snapping scapula syndrome,
but all causes find their basis in one of three general patho-
logic categories: (1) changes in congruence of the anterior
scapula where it interfaces with the posterior chest wall,
(2) changes in the soft tissues that lie between the anterior
scapula and posterior chest wall, and (3) abnormalities of
the posterior chest wall.
Changes in the congruence of the anterior scapula
can occur as a result of either a physical alteration of the
scapula or pathologic processes that alter the way the scapula
slides across the posterior chest wall. Examples of physical
alterations of the scapula that have been implicated in
the evolution of snapping scapula syndrome include scapu-
lar fracture, bone tumor (most notably osteochondroma),
and the development of bony enthesophytes as a result
of chronic shoulder dysfunction (Fig. 48-2). Examples of • Figure 48-1 The snapping scapula test.
A B
• Figure 48-2 A and B, Anteroposterior computed tomography scans show extension of fracture
through the scapular spine (arrow in B) isolating the upper glenoid fragment and coracoid. (From Browner
BE, Jupiter JB, Levine AM, et al: Skeletal trauma, ed 2, Philadelphia, 1998, Saunders, p 1659.)
82
CHAPTER 48 The Snapping Scapula Test 83
of snapping scapula syndrome include bursitis, muscle

hypertrophy, muscle atrophy, and muscle inflammation
from polymyositis.
Changes in the posterior chest wall that have been
implicated in the evolution of snapping scapula syndrome
include chest wall tumor and poorly healed fractured
ribs. It should be noted that any one of these three primary
pathologic processes can cause a secondary pathologic
process to occur, further exacerbating the patient’s symp-
toms, such as secondary bursitis as a result of chronic irrita-
tion by a bony enthesophyte.
Because tumors of the thorax and scapula are frequently
the cause of snapping scapula syndrome, all patients suffer-
ing from this shoulder disorder should undergo careful
radiographic evaluation of the scapula and posterior chest
wall as well as computed tomography (CT) of the scapula
• Figure 48-3 Winged scapula, typical symptomatology for brachial
neuritis or Parsonage-Turner syndrome. (From Deroux A, Brion JP, with 3-dimensional reconstruction and CT of the posterior
Hyerle L, et al: Association between hepatitis E and neurological dis- chest wall. Magnetic resonance imaging (MRI) of the
orders: two case studies and literature review, J Clin Virol 60(1):60–62, affected area with and without contrast should also be per-
2014, fig 1.) formed to help identify potential soft tissue abnormalities
that might be serving as the primary or secondary patho-
logic processes responsible for the development of snapping
pathologic processes that alter the way the scapula slides scapula syndrome. MRI of the brain with and without
against the posterior chest wall that have been implicated contrast should be performed on all patients who are
in the evolution of snapping scapula syndrome include thought to have a neurologic process as the source of their
neurologic compromise of scapular function by cerebrovas- scapular dysfunction. The information gleaned from the
cular accident, brachial plexopathy, trauma to the long tho- MRI should then be combined with information obtained
racic nerve of Bell, and entrapment of the suprascapular from electromyography and nerve conduction velocities of
nerve (Fig. 48-3). the cervical nerve roots, brachial plexus, suprascapular
Changes in the soft tissues between the scapula and poste- nerve, and long thoracic nerve of Bell to further characterize
rior chest wall that have been implicated in the evolution the neurologic pathologic process.
49 The Ludington Test for Ruptured Long
Tendon of the Biceps
Rupture of the long head of the biceps tendon occurs sud- giving the arm a “Popeye the Sailor Man” appearance (Fig.
denly and often without warning. The pathology responsi- 49-2). Ecchymosis running distally into the antecubital
ble for biceps tendon rupture is in most cases a long time fossa is common as blood flows down the empty tendon
in happening, however. Repetitive stress placed on the sheath. Tenderness over the bicipital groove is common, and
biceps tendon because of dysfunction of the shoulder joint, a defect along the course of the biceps muscle is easily pal-
in particular shoulder impingement syndromes, rotator cuff pable (Fig. 49-3).
tear, and anterior shoulder instability, will initially result in The diagnosis of rupture of the biceps tendon can be
bicipital tendinitis. Left untreated, over time, bicipital ten- confirmed by performing the Ludington test for rupture of
dinitis will cause fibrosis, calcification, and weakening of the long head of the biceps. Any doubt about the diagnosis
the biceps tendon (Fig. 49-1). The tendon most commonly can be removed by obtaining magnetic resonance imaging
ruptures at its weakest point, which is where the long head (MRI) or ultrasound imaging along the entire course of the
of the tendon exits the joint capsule. Rarely the long head biceps tendon (Figs. 49-4 and 49-5).
of the biceps tendon will rupture more distally when sub- The Ludington test for ruptured long tendon of the
jected to extreme abnormal force. Even more rare is rupture biceps is useful in helping the clinician to confirm the clini-
of the short head of the biceps. Rupture of the short head cal suspicion of biceps tendon rupture. The test is per-
occurs with extremely rapid and forceful adduction and formed by placing the patient in the sitting position and
flexion of the elbow. having the patient place the hand of the affected extremity
In most patients over 40 years of age, the long head of
the biceps tendon will rupture without obvious provoca-
tion. Occasionally, the long head of the biceps tendon will
rupture in younger patients during a period of extreme
stress on the tendon, such as during power weight lifting.
Clinically, when the long head of the biceps tendon
ruptures, the patient will experience a sudden sharp pain in
the anterior shoulder accompanied by an audible popping
as the tendon ruptures and retracts. The patient with rupture
of the long head of the biceps tendon will present with a
characteristic soft tissue abnormality known as the “Popeye”
sign, as the biceps muscle bunches up as it retracts distally,
GE
Le
Deltoid Deformity
Stage III Long head of

Proximal calcification biceps tendon
Distal
Longitudinal long head of left biceps view

• Figure 49-2 “Popeye” deformity associated with ruptured long
• Figure 49-1 Longitudinal ultrasound image demonstrating severe tendon of the biceps. (From Shawn Chillag, Kim Chillag: Popeye
tendinopathy of the long head of the biceps tendon. Note the deformity—an augenblick diagnosis, Am J Med 127(5):385, 2014,
calcification. fig 1.)
84
CHAPTER 49 The Ludington Test for Ruptured Long Tendon of the Biceps 85
GT LT
• Figure 49-5 Transverse ultrasound image of the proximal humerus

demonstrating an empty bicipital groove (white arrow). However, the
long head of the biceps tendon is subluxated medially and is clearly
visible lying on the lesser tuberosity (broken white arrow). When the
• Figure 49-3 Palpation of the long tendon of the biceps. tendon is dislocated more medially, it can be difficult to identify and
can be mistaken for a tendon rupture. GT, Greater tuberosity; LT,
lesser tuberosity.
P
“Popeye”
deformity
• Figure 49-4 Long head of the biceps tendon tear. Axial image
reveals absence of the biceps tendon in the intertuberous groove
(arrow). This patient also has a large rotator cuff tear. (From Stark DD,
Bradley WG: Magnetic resonance imaging, ed 3, St. Louis, 1999,
Mosby, p 712.)
• Figure 49-6 The Ludington test for ruptured long tendon of the
biceps. C, Contraction of biceps; P, pressure applied.
behind his or her head. The patient is then asked to push rupture. If the Ludington test is positive, MRI of the
against the back of the head and simultaneously contract affected shoulder and upper extremity along the entire
the affected biceps muscle (Fig. 49-6). If the long tendon course of the biceps is indicated to delineate the point of
of the biceps is ruptured, this maneuver will accentuate the rupture and the relative position of the distal end of the
pathognomonic “Popeye” deformity associated with tendon biceps tendon.
50 The Squeeze Test for Distal Rupture of
the Biceps Tendon
To perform the squeeze test for distal rupture of the biceps on the distal myotendinous junction and the other hand
tendon, the patient is placed in the seated position with the around the belly of the biceps muscle (Fig. 50-1). The exam-
elbow of the affected extremity flexed approximately 75 iner then squeezes both hands simultaneously, which causes
degrees to reduce the tension on the brachialis muscle to the belly of the biceps muscle to retract anteriorly. If the
allow the examiner to focus on the biceps muscle. The myotendinous unit is intact, the forearm will supinate. If
forearm is then slightly pronated to increase tension on the there is rupture of either the tendon or the muscle itself, the
biceps brachii tendon. The examiner then places one hand forearm will not supinate and the test is considered positive.
• Figure 50-1 If the myotendinous unit is intact, the forearm will

supinate. If there is rupture of either the tendon or the muscle itself,
the forearm will not supinate and the test is considered positive.
86
51 Clinical Correlates: Diseases of
the Rotator Cuff
Ask any physician which muscles make up the rotator cuff, capsule (see Chapter 17). The supraspinatus and infraspi-
and you will probably get a correct answer. Analogous to natus musculotendinous unit help to reinforce the superior
cranial nerves “On Old Olympus” and so on, the use of the aspect of the glenohumeral joint capsule; the teres minor
acronym SITS seems to fix the supraspinatus, infraspinatus, musculotendinous unit helps to reinforce the posterior
teres minor, and subscapularis muscles indelibly in every aspect of the joint capsule; and the subscapularis musculo-
doctor’s mind. Yet ask the same doctor what the rotator cuff tendinous unit helps to reinforce the anterior portion of the
does, and beyond vague comments about lifting the shoul- joint capsule. The rotator cuff also serves as an important
der, things quickly become quite muddled. The purpose of initiator of abduction of the upper extremity. In addition
this chapter is to clearly define what the rotator cuff is, what to these functions, the rotator cuff helps to stabilize the
it does, and which diseases affect it. shoulder by counterbalancing the inherent upward force of
the deltoid muscle during shoulder motion.
In thinking about the role of the rotator cuff in shoulder
WHAT THE ROTATOR CUFF IS AND motion, it is useful to think of all of the muscles and their
WHAT IT DOES associated fasciae and tendons actively working as a single
unit. They work in concert to maintain the stability of the
When asked what the rotator cuff is, most physicians would shoulder joint throughout a wide and varied range of
answer that it is a structure of the shoulder made up of the motion. The rotator cuff accomplishes this amazing task by
supraspinatus, infraspinatus, teres minor, and subscapularis allowing each component muscle to smoothly and subtly
muscles. This is partially correct, but the answer is in fact vary the strength and velocity of contraction and relaxation
significantly more complicated than that. To fully under- as the shoulder moves through its range of motion. It is also
stand the role of the rotator cuff in health and disease, the important to recognize that the rotator cuff does not func-
clinician must first appreciate that the rotator cuff must be tion as an isolated structure but works with the other
thought of as a functional musculotendinous unit rather
than four discrete muscles. Although it is true that each of
these four muscles contributes to the rotator cuff, it is not
only the muscles but also their fasciae and, most important,
their tendons that make up the functional unit that we call
the rotator cuff (Fig. 51-1).
Arising from the superior aspect of the scapula, the Supraspinatus
supraspinatus muscle and its covering fascia wrap them-
selves around the superior humeral head and terminate as
a strong tendon that inserts into the uppermost facet of the
greater tuberosity of the humerus. The infraspinatus muscle
arises from the inferior aspect of the scapula, and its muscle
fibers and fascia transform and merge into a dense tendon Rotator
that passes behind the capsule of the glenohumeral joint to cuff
insert into the middle facet of the greater tuberosity of the
humerus. The teres minor muscle arises from the mediolat-
eral portion of the scapula and the fascia of the infraspinatus
muscle, and its muscle fibers and fascia transform into a
Infraspinatus
tendon that passes behind and below the glenohumeral
Humerus
capsule to insert into the inferior facet of the greater tuber-
osity of the humerus. The subscapularis muscle arises from
Teres minor
the medial portion of the anterior surface of the scapula,
and as its muscle fibers transform into a tendon, they extend
laterally to attach to the lesser tubercle of the humerus.
One of the primary functions of the musculotendinous Subscapularis
units that make up the rotator cuff is to provide stabilization
of the glenohumeral joint during shoulder motion as well • Figure 51-1 The rotator cuff is a functional musculotendinous unit
as to strengthen the relatively weak glenohumeral joint composed of four muscles, their fasciae, and tendons.
87
muscles and structures of the shoulder, including the deltoid hypovascularity is most pronounced in the distal portion of
muscle, the long tendon of the biceps muscle, and the cora- the supraspinatus tendon, which, not surprisingly, is one of
cohumeral and glenohumeral ligaments, to allow a complex the most common locations of complete rotator cuff tear.
and unique range of motion of the shoulder relative to the Although the clinical presentation of acute complete rotator
other joints of the body. cuff tear is dramatic, the clinician should recognize that
Given the complex interaction of these musculotendi- there is a continuum of rotator cuff tendinopathy that is
nous units with each other as well as with their surrounding responsible for a significant amount of shoulder pain and
structures, it should not be surprising that disease of one dysfunction encountered in clinical practice.
structure can severely affect the function of the other inter- At one end of the continuum is mild tendinitis, which
dependent structures. Because of the tenuous nature of the is often accompanied by bursitis (Figs. 51-2 and 51-3).
blood supply to the tendons of the rotator cuff, these struc- Clinically, this can present as diffuse shoulder pain that is
tures are particularly vulnerable to damage. Weakening of made worse with range of motion, nocturnal pain with
the tendons as a result of ischemic changes and chronic difficulty sleeping on the affected shoulder, and a catching
inflammation can first lead to rotator cuff tendinopathy or grating sensation with shoulder abduction. These symp-
and, if left untreated, ultimately to rotator cuff tear. toms usually respond to conservative therapy consisting
of nonsteroidal antiinflammatory agents, local application
of heat and ice, physical therapy, and local injection of
THE PATHOGENESIS OF corticosteroid.
ROTATOR CUFF DISEASE If untreated, this mild tendinitis can worsen, with further
degeneration of the tendons leading to calcific tendinitis
As was mentioned earlier, the poor blood supply to the and ultimately a frozen shoulder (Figs. 51-4 and 51-5).
musculotendinous units that make up the rotator cuff Clinically, the patient will experience extreme pain on range
make these structures especially vulnerable to damage. This of motion with a limited ability to reach above the head.
A B
C
• Figure 51-2 Early rotator cuff degeneration. A, Oblique coronal short-TE image shows normal supra-
spinatus muscle and tendon, with myotendinous junction near the 12 o’clock position of the humeral
head (curved arrow). The tendon is black along its entire course from the myotendinous junction to its
attachment on the greater tuberosity (arrowheads). The tendon is uniform in thickness and sharply mar-
ginated. The subdeltoid and subacromial fat planes are intact. Despite the normal supraspinatus muscle
and tendon, a small erosion is seen at the insertion of the infraspinatus tendon (straight arrow). B, Short-TE
images show early degenerative changes in the rotator cuff with high signal intensity within the cuff (arrow).
C, Long-TE images reveal low signal intensity within the cuff (arrow). (From Crues JV, Stoller DW, Ruy
RKN: Shoulder. In Stark DD, Bradley WG, editors: Magnetic resonance imaging, ed 3, St. Louis, 1999,
Mosby, p 708.)
CHAPTER 51 Clinical Correlates: Diseases of the Rotator Cuff 89
Damaged tendons and infiltrate
4
Supraspinatus 2 1
tendon Lateral
Medial
Cortical Cortical surface tearing
tear
Longitudinal supraspinatus tendon view
Humeral head
• Figure 51-5 Severe tendinopathy of the supraspinatus tendon is

demonstrated on this longitudinal ultrasound image of a patient with
Transverse supraspinatus tendon view chronic shoulder pain. Note the loss of the normal sonographic tendon
architecture as well as significant cortical tearing.
• Figure 51-3 Longitudinal ultrasound image demonstrating mild

tendinopathy of the supraspinatus tendon. Note the small cortical tear.
A B
• Figure 51-4 Severe degenerative changes within the rotator cuff. Increased signal intensity within the
rotator cuff on short-TE images (arrow in A) is as bright as or brighter than fat on long-TE images (arrow
in B). This finding is compatible with severe degenerative changes and poor mechanical properties of the
cuff. (From Crues JV, Stoller DW, Ruy RKN: Shoulder. In Stark DD, Bradley WG, editors: Magnetic reso-
nance imaging, ed 3, St. Louis, 1999, Mosby, p 709.)
Careful examination of the posterior shoulder might result of a specific traumatic event (Figs. 51-8 and 51-9) or
also reveal atrophy of the supraspinatus and infraspinatus spontaneously without an obvious inciting event as the
muscles from disuse. At this point, treatment not only must weakened tendon suddenly fails (Figs. 51-10 and 51-11).
be aimed at treating the inflammatory aspect of the disease Such spontaneous ruptures usually occur in the over-51 age
and trying to restore function but also must include a group, and the sudden and dramatic nature of the event can
careful evaluation for other inciting causes of rotator cuff be quite upsetting to the patient.
dysfunction, including impingement syndromes, shoulder On clinical examination, the patient with a complete
instability, and diseases of the surrounding structures. rotator cuff tear will be able only to shrug or hike the
Extreme care must be taken in injecting corticosteroids affected shoulder. The patient will exhibit a positive drop
around the rotator cuff at this stage of the disease, as the arm sign, which is highly suggestive of complete rotator cuff
already damaged and weakened tendons are extremely sus- tear (see Fig. 50-1). Magnetic resonance imaging (MRI),
ceptible to rupture. ultrasound imaging, or arthrography of the shoulder will
Untreated, chronic rotator cuff tendinopathy will pro confirm the diagnosis of complete rotator cuff tear and
gress to partial thickness or complete rotator cuff tears distinguish this diagnosis from other internal derangements
(Figs. 51-6 and 51-7). These tears can occur acutely as a of the shoulder. Complete rotator cuff tears require surgery,
A B
• Figure 51-6 Partial rotator cuff tear. Small and partial rotator cuff tears present with increased signal
within the cuff on short-TE (arrow in A) and long-TE (arrow in B) images. The erosion at the insertion of
the infraspinatus and supraspinatus tendons results from chronic trauma during the deceleration phase
of throwing (arrowheads). (From Crues JV, Stoller DW, Ruy RKN: Shoulder. In Stark DD, Bradley WG,
editors: Magnetic resonance imaging, ed 3, St. Louis, 1999, Mosby, p 710.)
Large supraspinatus tendon tear
Biceps
tendon
Medial Lateral
Transverse supraspinatus tendon view
• Figure 51-7 Transverse ultrasound image demonstrating a large

tear of the supraspinatus tendon in a patient with acute shoulder
trauma.
CHAPTER 51 Clinical Correlates: Diseases of the Rotator Cuff 91
A B
C
• Figure 51-8 Complete supraspinatus tear. A, T1 coronal oblique image, shoulder. The distal 2 cm of
the supraspinatus tendon (between arrowheads) is intermediate, rather than the normal low signal inten-
sity, and thickened. B, T2* coronal oblique image, shoulder. High-signal fluid (arrow) fills the defect in the
supraspinatus tendon. Fluid is present in the subacromial/subdeltoid bursa (arrowheads). There is no
retraction of the musculotendinous junction. C, T2* sagittal oblique image, shoulder. There is focal high
signal (arrow) in the defect of the torn supraspinatus tendon, where normally a low-signal oval tendon
should be evident. (From Kaplan PA, Helms CA, Dussault R, et al: Musculoskeletal MRI, Philadelphia,
2001, Saunders, p 187.)
Tearing of the supraspinatus tendon.

Full thickness irregular shaped.
Note bursal contour defect.
Biceps tendon
Medial
Humeral head
Transverse to the long axis of the biceps tendon view

Left shoulder
• Figure 51-9 Transverse ultrasound image demonstrating a complex

full thickness tear of the supraspinatus tendon without significant
retraction.
A B
• Figure 51-10 Proximal retraction of the myotendinous junction of the supraspinatus muscle.
A, Short-TE image. B, Long-TE image. A characteristic finding in large rotator cuff tears is retraction of
the myotendinous junction from unopposed traction of the muscle (arrow). The extent of retraction is
helpful in estimating the size of the tear. At surgery, the tear in this cuff measured approximately 2.5 cm.
The extent of high signal intensity in the region of the distal cuff is also compatible with a 2.5-cm tear
(curved arrow). (From Crues JV, Stoller DW, Ruy RKN: Shoulder. In Stark DD, Bradley WG, editors: Mag-
netic resonance imaging, ed 3. St. Louis, 1999, Mosby, p 711.)
Bursal contour defect
Floating 1
ligament Supraspinatus tendon
Retraction
B.T.
Medial
Humeral head
Image transverse to long head of biceps

Right shoulder
• Figure 51-11 Transverse ultrasound image demonstrating a com-

plete rupture of the supraspinatus tendon with retraction.
which can usually be performed arthroscopically if done and is usually associated with other shoulder pathology,
within a short time after the tear. If surgical treatment is such as bursitis, impingement syndromes, and shoulder
delayed, an open procedure might be required to retrieve instability, and (2) shoulder pain and dysfunction that
the retracted ends of the torn tendon. mimics rotator cuff disease may arise from diseases occur-
The clinician should be aware of two caveats when diag- ring outside the shoulder, such as brachial plexopathies and
nosing and treating diseases of the rotator cuff: (1) rotator tumors and Pancoast tumor; failure to assiduously search
cuff disease rarely exists as an isolated pathologic process for such problems can yield disastrous results.
52 The Drop Arm Test for Complete
Rotator Cuff Tear
The drop arm test is useful in helping the clinician to iden- cuff and the deltoid to keep the arm in the abducted posi-
tify those patients with complete rotator cuff tear. As men- tion (Fig. 52-2). If the drop arm test is positive, the clinician
tioned in Chapter 51, complete rotator cuff tear can occur should obtain a magnetic resonance image, ultrasound
spontaneously and without an obvious inciting event. The imaging, or arthrogram of the affected shoulder to confirm
sudden and dramatic presentation of this problem can be the diagnosis of complete rotator cuff tear (Video 52-1).
quite upsetting and perplexing to the patient. In the drop
arm test for complete rotator cuff tear, the patient is asked
to assume the standing position and relax the affected shoul-
der with the arm resting comfortably at the patient’s side.
The clinician then gently abducts the affected extremity to
90 degrees and holds the arm in this position (Fig. 52-1).
The clinician then informs the patient that the clinician is
going to release the arm and the patient must try to hold
the arm at 90 degrees abduction. If the patient has a com-
plete rotator cuff tear, he or she will be unable to hold
the arm in the abducted position, and the arm will fall to
the patient’s side. The patient will often shrug or hitch the
shoulder forward to use the intact muscles of the rotator
• Figure 52-2 A patient with a complete rotator cuff tear will be

unable to hold the arm in the abducted position, and it will fall to the
patient’s side. The patient will often shrug or hitch the shoulder forward
to use the intact muscles of the rotator cuff and the deltoid to keep
• Figure 52-1 The drop arm test for complete rotator cuff tear. the arm in the abducted position.
93
53 The External Rotation Lag Sign for
Rupture of the Supraspinatus or
Infraspinatus Tendon
The external rotation lag sign test is useful in identifying externally to within 5 degrees of maximal external rotation.
rupture of the supraspinatus or infraspinatus tendon. To The examiner supports the patient’s wrist and elbow and
perform the external rotation lag sign test, the patient is then asks the patient to maintain the position of the affected
placed in the sitting position and the examiner passively extremity (Fig. 53-1). The examiner continues to support
flexes the elbow of the patient’s affected extremity to 90 the elbow and releases the wrist (Fig. 53-2). If there is a
degrees and elevates the patient’s shoulder approximately rupture of the supraspinatus or infraspinatus tendon or
20 degrees. The patient’s affected shoulder is then rotated both, the examiner will observe a lag or drop (Video 53-1).
• Figure 53-1 The external rotation lag sign test for rupture of the • Figure 53-2 The external rotation lag sign test for rupture of the
supraspinatus or infraspinatus tendon: the examiner supports the supraspinatus or infraspinatus tendons: the examiner continues to
patient’s wrist and elbow and then asks the patient to maintain support the elbow and releases the wrist. If there is a rupture of the
the position of the affected extremity. supraspinatus or infraspinatus tendon or both, the examiner will
observe a lag or drop.
94
54 The Dawbarn Sign for
Supraspinatus Tendinitis
The musculotendinous unit of the shoulder joint is suscep- will often awaken at night when he or she rolls over onto
tible to the development of tendinitis for several reasons. the affected shoulder.
First, the joint is subjected to a wide range of motions that The patient suffering from supraspinatus tendinitis may
are often repetitive in nature. Second, the space in which attempt to splint the inflamed tendon by elevating the
the musculotendinous unit functions is restricted by the scapula to remove tension from the ligament, giving the
coracoacromial arch, making impingement a likely possibil- patient a “shrugging” appearance. There is usually point
ity with extreme movements of the joint. Third, the blood tenderness over the greater tuberosity. The patient will
supply to the musculotendinous unit is poor, making exhibit a painful arc of abduction and will complain of a
healing of microtrauma more difficult. All of these factors catch or sudden onset of pain in the midrange of the arc
can contribute to tendinitis of one or more of the tendons due to subacromial impingement and/or impingement of
of the shoulder joint, and the supraspinatus tendon is no the humeral head onto the supraspinatus tendon (Figs. 54-1
exception. to 54-4). Patients with supraspinatus tendinitis will exhibit
Supraspinatus tendinitis can present as either an acute or a positive Dawbarn sign.
chronic painful condition of the shoulder. Acute supraspi- The Dawbarn sign test for supraspinatus tendonitis is
natus tendinitis will usually occur in a younger group of performed by having the patient assume the standing posi-
patients following overuse or misuse of the shoulder joint. tion. The clinician then palpates the superior aspect of the
Inciting factors may include carrying heavy loads in front greater tuberosity of the humerus. In patients who suffer
and away from the body, throwing injuries, or the vigorous from supraspinatus tendonitis, this maneuver will repro-
use of exercise equipment. Chronic supraspinatus tendinitis duce the pain that the patient experiences with range of
tends to occur in an older group of patients and to present motion of the shoulder. The affected arm is then gradually
in a more gradual or insidious manner without a single abducted to its fullest extent. As the arm approaches the top
specific event of antecedent trauma. The pain of supraspi- of the painful arc, the pain will disappear, suggesting a
natus tendinitis will be constant and severe, with sleep supraspinatus tendonitis (Fig. 54-5). The clinician should
disturbance often reported. The pain of supraspinatus ten- be aware that the Dawbarn sign may also be positive in
dinitis is felt primarily in the deltoid region. It is moderate patients who suffer from subacromial bursitis. Magnetic
to severe in intensity and may be associated with a gradual resonance imaging (MRI) and/or ultrasound testing of the
loss of range of motion of the affected shoulder. The patient affected shoulder should be performed in patients who are
• Figure 54-1 Drawing (coronal plane, cut section) of left shoulder • Figure 54-2 Drawing (coronal plane, cut section) of left shoulder
during active elevation of arm halfway between flexion and abduction during active elevation of arm halfway between flexion and abduction
with hand in pronation explicitly depicts pooling of fluid in lateral aspect with hand in pronation shows upward migration of humeral head in
of subacromial-subdeltoid bursa (arrow) and alteration of normally relation to glenoid cavity, which prevents passage of greater tuberosity
convex surface of supraspinatus tendon (arrowhead) as arm is ele- (T) and soft-tissue structures of supraspinatus outlet beneath acro-
vated. Supraspinatus tendon is not always involved in grade 2 sub- mion. (From El-Liethy N, Kamal H, Abdelwahab N, et al: Value of
acromial impingement. There is also evidence of supraspinatus dynamic sonography in the management of shoulder pain in patients
tendinosis and inflammatory changes in bursa. (From El-Liethy N, with rheumatoid arthritis, Egyptian J Radiol Nuclear Med 45(4):1171–
Kamal H, Abdelwahab N, et al: Value of dynamic sonography in the 1182, fig 6.)
management of shoulder pain in patients with rheumatoid arthritis,
Egyptian J Radiol Nuclear Med 45(4):1171–1182, fig 5.)
95
Tendon bulging Bursal fluid

Fluid extruded Biceps Supraspinatus
with impingement tendon
Intersubstance testing
tear
Supraspinatus Humeral head

Biceps Humeral head tendon Subscapularis
tendon
Rotator cuff interval
Transverse scan of supraspinatus under strain
Transverse long head of biceps view Lateral
• Figure 54-3 Transverse ultrasound image obtained during dynamic

ultrasound imaging demonstrating impingement of the supraspinatus
musculotendinous unit in a patient with a positive Dawbarn sign. Note • Figure 54-4 Transverse ultrasound image obtained during dynamic
the bunching up of the tendon and extruded bursal fluid as well as ultrasound imaging demonstrating impingement of the supraspinatus
significant tendinopathy. musculotendinous unit in a patient with a positive Dawbarn sign. Note
the pooling of fluid with abduction.
• Figure 54-5 The Dawbarn sign for supraspinatus tendinitis.
thought to be suffering from supraspinatus tendonitis, to experience a gradual decrease in functional ability with
help differentiate these clinically distinct entities as well as decreasing shoulder range of motion, making simple every-
to rule out rotator cuff tear. day tasks, such as hair combing, fastening a brassiere, or
Early in the course of the disease, passive range of reaching overhead, quite difficult. With continued disuse,
motion is full and without pain. As the disease progresses, muscle wasting may occur, and a frozen shoulder might
patients who suffer from supraspinatus tendinitis will often develop.
55 The Empty Can Test for
Supraspinatus Tendinitis
The musculotendinous unit of the shoulder joint is suscep- specific event of antecedent trauma. The pain of supraspi-
tible to the development of tendinitis for several reasons. natus tendinitis will be constant and severe, with sleep
First, the joint is subjected to a wide range of motions that disturbance often reported. The pain of supraspinatus ten-
are often repetitive in nature. Second, the space in which dinitis is felt primarily in the deltoid region. It is moderate
the musculotendinous unit functions is restricted by the to severe in intensity and may be associated with a gradual
coracoacromial arch, making impingement a likely possibil- loss of range of motion of the affected shoulder. The patient
ity with extreme movements of the joint (Fig. 55-1). Third, will often awaken at night when he or she rolls over onto
the blood supply to the musculotendinous unit is poor, the affected shoulder.
making healing of microtrauma more difficult. All of these The patient suffering from supraspinatus tendinitis may
factors can contribute to tendinitis of one or more of the attempt to splint the inflamed tendon by elevating the
tendons of the shoulder joint, and the supraspinatus tendon scapula to remove tension from the ligament, giving the
is no exception. patient a “shrugging” appearance. There is usually point
Supraspinatus tendinitis can present as either an acute or tenderness over the greater tuberosity. The patient will
chronic painful condition of the shoulder. Acute supraspi- exhibit a painful arc of abduction and will complain of a
natus tendinitis will usually occur in a younger group of catch or sudden onset of pain in the midrange of the arc
patients following overuse or misuse of the shoulder joint. due to subacromial impingement and/or impingement of
Inciting factors may include carrying heavy loads in front the humeral head onto the supraspinatus tendon (Figs. 55-2
and away from the body, throwing injuries, or the vigorous and 55-3). Patients with supraspinatus tendinitis will exhibit
use of exercise equipment. Chronic supraspinatus tendinitis a positive empty can test.
tends to occur in an older group of patients and to present The empty can test for supraspinatus tendonitis is per-
in a more gradual or insidious manner without a single formed by having the patient assume the standing position.
• Figure 55-1 Drawing (coronal plane, cut section) of subacromial

space of the left shoulder during active elevation of arm halfway
between flexion and abduction with hand in pronation shows normal
relationships between acromion (A), greater tuberosity (T) of humeral
head, and intervening soft tissues—namely, supraspinatus tendon (S)
and subacromial-subdeltoid bursa (arrow). D, Deltoid muscle. (From
El-Liethy N, Kamal H, Abdelwahab N, et al: Value of dynamic sonog-
raphy in the management of shoulder pain in patients with rheumatoid
arthritis, Egyptian J Radiol Nuclear Med 45(4):1171–1182, 2014.)
97
Fluid in the
subdeltoid bursa
Distal
acromion
Supraspinatus
Medial tendon Lateral
Humeral head
Arm is abducted
Image longitudinal to the right supraspinatus tendon
• Figure 55-3 Ultrasound image longitudinal to the supraspinatus

tendon obtained during dynamic ultrasound imaging in a patient with
a positive empty can test demonstrating subacromial impingement of
the supraspinatous musculotendinous unit. Note fluid in the subdeltoid
bursa.
A
B • Figure 55-4 The empty can test for supraspinatus tendonitis is

performed by having the patient assume the standing position. The
• Figure 55-2 Coronal T1-weighted (T1W) (A) and T2W with fat affected arm is then gradually elevated to 90 degrees in the scapular
suppression (FST2W) (B) magnetic resonance arthrogram images plan with the elbow fully extended, the arm in full internal rotation, and
demonstrating enthesopathy of the acromion (white arrows) with the forearm pronated, as if the patient is trying to shake the last
impingement of the supraspinatus tendon, which is thickened and few drops out of an empty can. The examiner then exerts downward
tendinopathic. There is early subacromial bursitis. (From Waldman SD, pressure to the affected arm. The test is considered positive if the
Campbell, RSD: Imaging of pain, Philadelphia, 2010, Saunders/ patient experiences a significant increase in pain or demonstrates
Elsevier, p 250, fig 98-2.) weakness.
CHAPTER 55 The Empty Can Test for Supraspinatus Tendinitis 99
Deltoid muscle
Rice bodies
Englarged
subdeltoid
bursa
Subscapularis Biceps
tendon
Medial
Transverse long head of biceps
• Figure 55-5 Transverse ultrasound image demonstrating subdel-

toid bursitis.
The affected arm is then gradually elevated to 90 degrees in The clinician should be aware that the empty can test
the scapular plan with the elbow fully extended, the arm in may also be positive in patients who suffer from subacro-
full internal rotation, and the forearm pronated, as if the mial bursitis (Fig. 55-5). Magnetic resonance imaging and/
patient is trying to shake the last few drops out of an empty or ultrasound testing of the affected shoulder should be
can (Fig. 55-4). The examiner then exerts downward pres- performed in patients who are thought to be suffering
sure to the affected arm. The test is considered positive if from supraspinatus tendonitis, to help differentiate these
the patient experiences a significant increase in pain or clinically distinct entities as well as to rule out rotator cuff
demonstrates weakness. tear.
56 The Jobe Supraspinatus Test
To perform the Jobe supraspinatus test, the patient is placed asked to maintain this position while the examiner exerts
in the seated position and is asked to abduct both shoulders firm downward pressure to assess and compare the strength
to 90 degrees. The patient then is asked to rotate both arms of the supraspinatus muscle on both sides (Fig. 56-1). The
internally so the thumbs point downward and to forward test is positive if the examiner identifies weakness or insuf-
flex his or her shoulders 30 degrees. The patient is then ficiency on either side (Video 56-1).
• Figure 56-1 The Jobe supraspinatus test.
100
57 The Midarc Abduction Test for
Infraspinatus Tendinitis
The musculotendinous unit of the shoulder joint is suscep- may be associated with a gradual loss of range of motion of
tible to the development of tendinitis for several reasons. the affected shoulder. The patient will often awaken at night
First, the joint is subjected to a wide range of motions, when he or she rolls over onto the affected shoulder.
which are often repetitive in nature. Second, the space in The patient might attempt to splint the inflamed infra-
which the musculotendinous unit functions is restricted by spinatus tendon by rotating the scapula posteriorly to
the coracoacromial arch, making impingement a likely pos- remove tension from the tendon (Fig. 57-2). There is usually
sibility with extreme movements of the joint. Third, the point tenderness over the greater tuberosity. The patient will
blood supply to the musculotendinous unit is poor, making exhibit a painful arc of abduction and will complain of a
healing of microtrauma more difficult. All of these factors catch or sudden onset of pain in the midrange of the arc
can contribute to tendinitis of one or more of the tendons with the pain improving as the patient reaches the top of
of the shoulder joint, and the infraspinatus tendon is no the arc of abduction (Fig. 57-3). Early in the course of the
exception (Fig. 57-1). disease, passive range of motion is full and without pain. As
Infraspinatus tendinitis can present as either an acute or the disease progresses, patients who suffer from infraspina-
chronic painful condition of the shoulder. Acute infraspi- tus tendinitis will often experience a gradual decrease in
natus tendinitis will usually occur in a younger group of functional ability, with decreasing shoulder range of motion
patients following overuse or misuse of the shoulder joint. making simple everyday tasks, such as hair combing, fasten-
Inciting factors may include activities that require repeated ing a brassiere, or reaching overhead, quite difficult. With
abduction and lateral rotation of the humerus, such as continued disuse, muscle wasting may occur, and a frozen
installing brake pads during assembly line work. The vigor- shoulder might develop.
ous use of exercise equipment has also been implicated.
The pain of infraspinatus tendinitis is constant and severe
and is localized in the deltoid area. Significant sleep distur-
bance is often reported. Patients with infraspinatus tendi-
nitis will exhibit pain with lateral rotation of the humerus
and on active abduction and will exhibit a painful midarc
abduction test. Chronic infraspinatus tendinitis tends to
occur in an older group of patients and to present in a more
gradual or insidious manner without a single specific event
of antecedent trauma. The pain of infraspinatus tendinitis
Note full
thickness
tear with
Deltoid bursal contour
defect.
Infraspinatus
tendon
Humeral head
Anterior Posterior
Longitudinal infraspinatus tendon view
• Figure 57-1 Longitudinal ultrasound image demonstrating a full

thickness tear of the infraspinatus tendon in a patient with an acute • Figure 57-2 Patients might attempt to rotate the scapula posteri-
shoulder injury. orly to relieve tension from the inflamed infraspinatus tendon.
101
B
• Figure 57-3 A and B, Midarc abduction test for infraspinatus tendinitis.
58 The External Rotation Stress Test for
Impairment of the Infraspinatus and
Teres Minor Muscles
The external rotation stress test is useful in helping the rotated 50 to 60 degrees. The examiner then applies internal
examiner identify impairment of the infraspinatus and rotational force against the dorsum of the patient’s hands
teres minor muscles, which serve as the primary external with the patient resisting the examiner’s efforts to rotate
rotators of the shoulder. To perform the external rotation the shoulders internally to neutral (Fig. 58-1). The test
test, the patient is placed in the sitting position with is considered positive if pain or weakness is identified
his or her shoulders in neutral position and externally (Video 58-1).
• Figure 58-1 The external rotation stress test for impairment of the
infraspinatus and teres minor muscles.
103
59 The Drop Arm Test for
Subdeltoid Bursitis
In the drop arm test for subdeltoid bursitis, the patient is tear, he or she will be unable to support the affected extrem-
placed in the standing position with the affected arm resting ity, and it will fall to the patient’s side (see Chapter 52). If
at the patient’s side. The examiner then slowly abducts the the patient has subdeltoid bursitis, the patient will wince
affected arm, watching for signs of pain. When the arm is and cry out in pain when the arm is released. It should be
abducted as far as the patient will tolerate, it is supported remembered that partial rotator cuff tear and subdeltoid
there for a few seconds and then suddenly released (Figs. bursitis can coexist; for this reason, magnetic resonance
59-1 and 59-2). If the patient has a complete rotator cuff imaging and/or ultrasound imaging of the shoulder should
be performed on all patients with a positive drop arm test
for subdeltoid bursitis to avoid missing this potentially
problematic coexistent pathology (Fig. 59-3).
Subdeltoid
B.T.
• Figure 59-1 The drop arm test for subdeltoid bursitis: the examiner bursitis
supports the abducted arm.
Humeral head
Proximal Distal
Longitudinal long head of the biceps tendon view
• Figure 59-3 Longitudinal ultrasound image demonstrating subdel-

toid bursitis and tears and tendinosis of the supraspinatus musculo-
tendinous unit. B.T., Biceps tendon.
• Figure 59-2 The drop arm test for subdeltoid bursitis: the abducted
arm is released.
104
60 The Adduction Release Test for
Subcoracoid Bursitis
The subcoracoid bursa is vulnerable to injury from both Subcoracoid bursitis

acute trauma and repeated microtrauma. Acute injuries fre- Coracoid process
quently take the form of direct trauma to the shoulder when
a person plays sports or falls on the shoulder. The repeated Subdeltoid bursitis
strain associated with repetitive motion can result in inflam-
mation of the subcoracoid bursa. If the inflammation of the
subcoracoid bursa becomes chronic, calcification of the
bursa can occur.
The subcoracoid bursa lies between the joint capsule and
the coracoid process. It is susceptible to irritation by pres-
sure from the coracoid process against the head of the
humerus during extreme arm movement or when previous
damage to the musculotendinous unit of the shoulder
allows abnormal movement of the head of the humerus in
the glenoid fossa.
The patient who suffers from subcoracoid bursitis fre-
quently complains of pain with forward movement with
adduction of the shoulder. The pain is localized to the area
over the coracoid process, with referred pain noted at the
medial shoulder. Often the patient is unable to sleep on the
affected shoulder and may complain of a sharp, “catching”
sensation when abducting the shoulder, especially on first
awakening. Physical examination might reveal point tender-
ness over the coracoid process. Subcoracoid bursitis can be
• Figure 60-1 Subcoracoid bursitis can be reproduced with palpa-
distinguished from subdeltoid bursitis in that the pain of tion directly over the coracoid process.
subcoracoid bursitis is reproduced with palpation directly
over the coracoid process, whereas the pain of subdeltoid
bursitis is reproduced with palpation of a point more infe-
rior to the coracoid on the deltoid muscle (Fig. 60-1).
Patients who suffer from subcoracoid bursitis will also
exhibit a positive adduction release test.
The adduction release test for subcoracoid bursitis is
performed by having the patient assume the standing
position with the affected arm at his or her side. The
patient is then asked to internally rotate the affected arm
until the pain the patient has been experiencing is repro-
duced (Fig. 60-2). The examiner then supports the affected
arm and asks the patient to begin adducting the arm against
the examiner’s resistance (Fig. 60-3). The examiner sud-
denly releases the resistance to adduction (Fig. 60-4). If the
patient is suffering from subcoracoid bursitis, the patient
will experience a marked increase in pain (Video 60-1). The
clinical impression of subcoracoid bursitis can then be con- • Figure 60-2 The adduction release test for subcoracoid bursitis:
firmed by magnetic resonance and/or ultrasound imaging the patient is asked to internally rotate the affected arm until the pain
(Fig. 60-5). is reproduced.
105
• Figure 60-3 The adduction release test for subcoracoid bursitis:

the examiner supports the affected arm and asks the patient to begin
adducting the arm against the examiner’s resistance.
• Figure 60-4 The adduction release test for subcoracoid bursitis: if

the patient is suffering from subcoracoid bursitis, he or she will experi-
ence a marked increase in pain following a sudden release of the
resistance to adduction.
The conjoint tendon
Coracoid
Coracoid
A Bursal effusion B Bursal effusion
Coracoid
Coracoid
The conjoint
tendon
Bursal effusion
Subscapularis tendon
Bursal effusion
C D
• Figure 60-5 Transverse ultrasound view (A) of subcoracoid bursitis with effusion between the coracoid
process and subscapularis tendon. Longitudinal view (B) of conjoined tendon attached to the coracoid
process demonstrates the subcoracoid bursal effusion under the coracoid process and surrounding
conjoined tendon. Fat-suppressed axial (C) and sagittal (D) magnetic resonance images demonstrate
distension of subcoracoid bursa with effusion. (From Drakes S, Thomas S, Kim S, et al: Ultrasonography
of subcoracoid bursal impingement syndrome, PM R 7(3):329–333, 2015, fig 3.)
61 The Adduction Stress Test for
Acromioclavicular Joint Dysfunction
The acromioclavicular joint is vulnerable to injury from ligaments of the acromioclavicular joint, these maneuvers
both acute trauma and repeated microtrauma. Acute inju- might reveal joint instability, and obvious deformity of
ries frequently take the form of falls directly onto the shoul- the affected shoulder will be evident. With disruption of
der in playing sports or falling from bicycles. Repeated the ligaments, elevation of the clavicle with widening of the
strain from throwing injuries or working with the arm distance between the clavicle and acromion as well as a
raised across the body can also result in trauma to the joint. positive step-off sign will be noted on plain radiography,
Following trauma, the joint may become acutely inflamed, magnetic resonance, and ultrasound imaging (Figs. 61-3
and if the condition becomes chronic, arthritis of the acro- and 61-4).
mioclavicular joint might develop. Injuries to the acromio- To perform the adduction stress test for acromioclavicu-
clavicular joint can range from sprains and strains of the lar joint dysfunction, the patient is asked to remove his or
acromioclavicular joint with all ligaments remaining intact her shirt. The patient is asked to assume the standing posi-
(Fig. 61-1, A) to situations in which only the acromiocla- tion, and the examiner stands behind the patient examining
vicular ligament is disrupted (Fig. 61-1, B) to complete the shoulders for any asymmetry that might be suggestive
disruption of the ligaments of the acromioclavicular joint of disruption of the acromioclavicular ligaments. The exam-
with dislocation of the joint (Fig. 61-1, C). iner then has the patient maximally extend the affected
The patient who suffers from acromioclavicular joint shoulder and arm behind him or her while the examiner
dysfunction will frequently complain of pain when reaching exerts forward pressure on the scapula (Fig. 61-5). The
across the chest (Fig. 61-2). Often the patient will be unable affected arm is then slowly adducted behind the back.
to sleep on the affected shoulder and might complain of a Patients with acromioclavicular joint dysfunction will expe-
grinding sensation in the joint, especially on first awaken- rience a marked increase in pain with this passive adduction,
ing. Physical examination may reveal enlargement or swell- and the examiner might notice an increase in shoulder
ing of the joint with tenderness to palpation. Patients with deformity as stress is placed on the joint (Fig. 61-6). The
acromioclavicular joint dysfunction will often exhibit a examiner should avoid sudden or forceful movements when
positive adduction stress test and a positive chin adduction adducting the affected arm to avoid further damage to the
test (see Chapter 62). If there is significant disruption of the ligaments.
107
Acromioclavicular
ligament strain
Torn acromioclavicular
ligament
Torn coracoclavicular
ligaments
C
• Figure 61-1 Acromioclavicular joint injuries range from sprains and strains with all ligaments remaining
intact (A) to situations in which only the acromioclavicular ligament is disrupted (B) to complete disruption
of the ligaments of the acromioclavicular joint with dislocation of the joint (C).
CHAPTER 61 The Adduction Stress Test for Acromioclavicular Joint Dysfunction 109
• Figure 61-5 To perform the adduction stress test for acromiocla-

vicular joint dysfunction, the examiner has the patient maximally extend
the affected shoulder and arm behind him or her while the examiner
exerts forward pressure on the scapula.
• Figure 61-2 The patient suffering from acromioclavicular joint dys-

function will frequently complain of pain when reaching across the
chest.
• Figure 61-3 Widening of the acromioclavicular joint after disruption

of the acromioclavicular ligament: type 3 injury—stress radiography.
Compare the radiographic findings on the normal left side and the
abnormal right side. The involved clavicle (arrow) is elevated, with
an increased distance between the coracoid process and the
inferior surface of the clavicle. (From Resnick D, Kang HS: Internal
derangements of joints: emphasis on MR imaging, Philadelphia, 1997,
Saunders, p 286.)
A/C joint capsule

Clavicle Distension
Medial Lateral
Acromion
Transverse acromioclavicular joint view • Figure 61-6 The affected arm is then slowly adducted behind the
back.
Blue line representing step off
• Figure 61-4 Transverse ultrasound image demonstrating complete

acromioclavicular separation. Note the positive step-off sign.
62 The Chin Adduction Test for
Acromioclavicular Joint Dysfunction
The chin adduction test for acromioclavicular joint dysfunc- abduct the affected arm to 90 degrees. The patient is then
tion is performed by having the patient assume the standing instructed to adduct the affected arm and shoulder directly
position with his or her shirt off. The examiner stands in under the chin and grasp the contralateral shoulder
front of the patient and examines the acromioclavicular (Fig. 62-1). Patients who suffer from acromioclavicular
joints for any evidence of asymmetry with the patient’s arms joint dysfunction will experience a marked increase in pain
in neutral position. The examiner then has the patient with adduction (Video 62-1).
• Figure 62-1 The chin adduction test for acromioclavicular joint

dysfunction.
110
63 The Paxino Test for Acromioclavicular
Joint Dysfunction
To perform the Paxino test for acromioclavicular joint dys- places his or her thumb under the posteriolateral aspect of
function, the patient is asked to remove his or her shirt. The the acromion and the index finger of the same hand is
patient is asked to assume the standing position, and the placed superior to the mid clavicle (Fig. 63-1). The exam-
examiner stands behind the patient examining the shoulders iner then squeezes the palpating fingers together. The test is
for any asymmetry that might be suggestive of disruption considered positive if pain is elicited or increased at the
of the acromioclavicular ligaments. The examiner then acromioclavicular joint.
• Figure 63-1 To perform the Paxino test for acromioclavicular joint

dysfunction, the examiner places his or her thumb under the posteri-
olateral aspect of the acromion and the index finger of the same hand
is placed superior to the mid clavicle. The examiner then squeezes the
palpating fingers together. The test is considered positive if pain is
elicited or increased at the acromioclavicular joint.
111
64 The Sergeant’s Chevron Test for Axillary
Nerve Deficits
The axillary nerve is susceptible to injury from fracture of chevron and then, working from the center of the area
the proximal humerus, shoulder dislocation, or inflamma- outward, checks for diminished cutaneous sensation with a
tory conditions involving the brachial plexus. The axillary sterile needle (Fig. 64-2). The patient’s crying out in pain
nerve arises from the posterior cord of the brachial plexus as the needle moves from the area of diminished sensation
and provides motor innervation to the teres minor and in the distribution of the axillary nerve into the intact area
deltoid muscles. Compromise of the motor division of the supplied by the posterior, lateral, or medial cutaneous
axillary nerve will result in weakness of shoulder abduction branches of the radial nerves constitutes a positive sergeant’s
between 15 and 90 degrees. If the lesion persists, clinically chevron test. A positive test should direct the clinician to
apparent wasting of the deltoid muscle will result. The axil- obtain careful electromyographic testing to determine the
lary nerve also provides cutaneous innervation to an ovoid exact anatomic site of the lesion that is responsible for
area of the skin overlying the approximate area of where a the axillary nerve deficit, with careful attention being paid
sergeant’s chevron would be placed, thus giving the basis for to the brachial plexus. If brachial plexus lesions are
the name of the sergeant’s chevron test (Fig. 64-1). identified, chest radiographs with apical lordotic views to
To perform the sergeant’s chevron test, the clinician rule out superior sulcus (Pancoast) tumor and magnetic
identifies the imaginary area that would underlie a sergeant’s resonance and ultrasound imaging of the shoulder should
be carried out.
• Figure 64-1 Cutaneous distribution of the axillary nerve. • Figure 64-2 The sergeant’s chevron test.
112
65 The Adson Maneuver for Thoracic
Outlet Syndrome
Like the Homan sign, the Adson maneuver is one of the The thoracic outlet can be thought of as a series of
most maligned tests in clinical medicine because of its high narrow rapids or cataracts through which the subclavian
incidence of false positive results in otherwise normal indi- artery and vein and the lower trunk of the brachial plexus
viduals. In spite of this fact, the Adson maneuver provides must pass on their way to the arm. The first narrowing and
useful additional clinical information when combined with point of possible entrapment is where these structures pass
the subjective information that is gleaned from a careful between the anterior scalene and medial scalene muscles at
history and physical examination as well as objective infor- their point of attachment on the first rib. A rudimentary
mation obtained from electromyography and imaging cervical rib may be present in some patients and may further
modalities. It is thought that the Adson maneuver identifies complicate the anatomic entrapment at this level (Fig.
compression of the subclavian artery and vein and the lower 65-2). The second potential site of entrapment is where
cord of the brachial plexus by the anterior scalene muscles these structures pass between the clavicle anteriorly, the first
and the other structures that might be causing compromise rib posteromedially, and the superior edge of the scapula
of the scalene triangle and is useful in the diagnosis of tho- posterolaterally. The final point of possible neural compro-
racic outlet syndrome. mise is where the subclavian artery and vein and fibers from
Thoracic outlet syndrome is the name that is given to a the lower trunk of the brachial plexus pass under the cora-
number of sometimes overlapping clinical entities that have coid process and beneath the tendinous insertion of the
in common the ability to produce a constellation of symp- pectoralis minor muscle. These neurovascular elements may
toms, including numbness and paresthesia radiating into be compromised at any and all points along their path, and
the affected upper extremity (most commonly in the distri- the compromise may on rare occasions be limited to just
bution of the ulnar nerve) combined with a deep aching one of these structures, leaving the others apparently
pain in the neck, shoulder, and arm that is made worse with unharmed.
prolonged abduction of the shoulder. Sometimes clumsiness Thoracic outlet syndrome has historically been both mis-
and weakness of the affected extremity are also present, diagnosed and overdiagnosed owing to the myriad patho-
especially if the arm is abducted for long periods of time, logic conditions that can cause the constellation of symptoms
such as when painting a ceiling. What all of these clinical
entities have in common is compression of the nerves or
arteries and veins as they pass through the closed space
known as the thoracic outlet (Fig. 65-1).
Middle scalene m.
Anterior scalene m.
Brachial plexus
Subclavian artery
Coracoid process
Pectoralis minor m.
• Figure 65-2 Computed tomographic reconstruction of a right cer-
vical rib, which is a common cause of thoracic outlet syndrome. Note
how the cervical rib articulates with the first rib. (From Pindrik J, Allan
• Figure 65-1 Possible sites of nerve and artery compression in J: Belzberg, Peripheral nerve surgery: primer for the imagers, Neuro-
thoracic outlet syndrome. imaging Clin N Am 24(1):193–210, 2014, fig 1.)
113
• Figure 65-3 Computed tomography of an 18-year-old basketball • Figure 65-4 The Adson maneuver for thoracic outlet syndrome.
player with arterial thoracic outlet syndrome identified bilateral subcla-
vian artery aneurysms. (From de Mooij T, Duncan AA, Kakar S: Vas-
cular injuries in the upper extremity in athletes, Hand Clinics
31(1):39–52, 2015, fig 4.)
patient’s radial pulse at the wrist to obtain a baseline reading.
The patient is then asked to extend his or her head fully
and inhale as deeply as possible while the examiner moni-
thought of as thoracic outlet syndrome, such as cervical tors the radial pulse for any diminution of the pulse pressure
radiculopathy, brachial plexopathies, aneurysms, and vascu- (Fig. 65-4 and Video 65-1).
litides (Fig. 65-3). This was especially true in the days before The Adson maneuver should be considered positive only
electromyography, computed tomography ultrasound, and if two criteria are met: (1) there is a diminution of the
magnetic resonance imaging. For this reason, thoracic outlet patient’s radial pulse at the wrist when the maneuver is
syndrome as a discrete clinical diagnosis should be thought performed, and (2) the maneuver recreates the patient’s
of as a diagnosis of exclusion. symptoms. If only one of these positive findings is
To perform the Adson maneuver, the patient is placed in present, the clinician should look for causes other than
the sitting position and asked to turn his or her head toward thoracic outlet syndrome as an explanation of the patient’s
the side being examined. The examiner then palpates the symptoms.
66 The Costoclavicular Test for Thoracic
Outlet Syndrome
The costoclavicular test for thoracic outlet syndrome pro- military attention. The examiner then palpates the patient’s
vides the clinician with useful additional clinical informa- radial pulse at the wrists to obtain a baseline reading.
tion when combined with the subjective information that The patient is then asked to thrust his or her shoulders
is gleaned from a careful history and physical examination fully backward and downward while the examiner monitors
as well as objective information obtained from electromy- the radial pulse for any diminution of the pulse pressure
ography and imaging modalities (see Chapter 65). It is (Fig. 66-1).
thought that the costoclavicular test identifies compression The costoclavicular test should be considered positive
of the subclavian artery and vein and the lower cord of only if two criteria are met: (1) there is a diminution of the
the brachial plexus by the clavicle and first rib, which patient’s radial pulse at the wrist when the maneuver is per-
will present clinically as thoracic outlet syndrome (see formed, and (2) the maneuver recreates the patient’s symp-
Fig. 65-1). toms. If only one of these positive findings is present, the
In the costoclavicular test, the patient is placed in the clinician should look for causes other than thoracic outlet
sitting position and asked to assume a position of extreme syndrome as an explanation of the patient’s symptoms.
• Figure 66-1 The costoclavicular test.
115
67 The Hyperabduction Test for Thoracic
Outlet Syndrome
The hyperabduction test for thoracic outlet syndrome pro- radial pulse at the wrists to obtain a baseline reading. The
vides the clinician with useful additional clinical informa- patient is then asked to raise both arms above the head with
tion when combined with the subjective information that the elbows flexed approximately 10 degrees and the arms
is gleaned from a careful history and physical examination slightly extended out from the body while the examiner
as well as objective information obtained from electromy- monitors the radial pulse for any diminution of the pulse
ography and imaging modalities (see Chapters 65 and 66). pressure (Fig. 67-1 and Video 67-1).
It is believed that this test will help identify compression of The hyperabduction test should be considered positive
the subclavian artery and vein and lower cord of the brachial only if two criteria are met: (1) there is a diminution of the
plexus by the pectoralis minor muscle and the coracoid patient’s radial pulse at the wrist when the maneuver is per-
process, which will present clinically as thoracic outlet syn- formed, and (2) the maneuver recreates the patient’s symp-
drome (see Fig. 65-1). toms. If only one of these positive findings is present, the
In the hyperabduction test, the patient is placed in the clinician should look for causes other than thoracic outlet
sitting position. The examiner then palpates the patient’s syndrome as an explanation of the patient’s symptoms.
• Figure 67-1 Hyperabduction test for thoracic outlet syndrome.
116
68 Functional Anatomy of the Elbow Joint
The proper functioning of the elbow is essential for success- disorders: (1) the humeral-ulnar interface, (2) the humeral-
fully carrying out the activities of daily living. One only has radial interface, and (3) the radial-ulnar interface. The
to ask anyone who has suffered from a seemingly minor humeral-ulnar interface comprises the area surrounding and
elbow malady such as tennis elbow to confirm this fact. including the trochlea of the humerus and the trochlear
With elbow dysfunction, bathing, getting dressed, and even notch, coronoid process, and olecranon of the ulna (Fig.
using the toilet become problematic. For this reason, the 68-2). The humeral-radial interface comprises the area sur-
clinician needs a clear understanding of the functional rounding and including the capitulum of the humerus and
anatomy of this complex joint, as clinical diagnosis of elbow the radial head (Fig. 68-3). The radial-ulnar interface com-
problems (e.g., lateral epicondylitis, pronator syndrome) is prises the area surrounding and including the head of the
based in the anatomic structure that is dysfunctional. radius and the radial notch of the ulna (Fig. 68-4).
Although conventionally thought of as a hinge joint The humeral-radial interface and the humeral-ulnar
analogous to the knee, the elbow in fact has a unique com- interface allow for the elbow’s hinge-type movement. These
pound range of motion that is due to the interplay between articular interfaces and the joint surrounding ligaments
the hinge-type function and the rotational pronation and contribute to the stability of the elbow in flexion and, to a
supination that allows precise positioning of the hand with lesser extent, extension. In health, this hinge portion of the
its highly mobile fingers and opposing thumb. Each of the elbow can traverse approximately 150 degrees. Because of
three bones that make up the joint—the humerus, the ulna, the shape of the humeral trochlea and the ulnar trochlear
and the radius—has specialized ends to facilitate the elbow notch, the arm moves into a valgus position of the forearm
function and strength (Fig. 68-1). in extension. This valgus position is called the carrying angle
From a functional anatomy viewpoint, the elbow has and is 10 to 15 degrees in men and up to 18 degrees in
three areas that are involved in the majority of elbow women. When the arm flexes, it moves into a more varus
Humerus
Radial fossa
Coronoid fossa
Lateral epicondyle
Medial
epicondyle
Capitulum
Trochlea
Trochlear
notch
Head of radius Coronoid

process
Radial notch
Radius
Ulna
• Figure 68-1 Bony anatomy of the elbow joint.
118
CHAPTER 68 Functional Anatomy of the Elbow Joint 119
Biceps m
Triceps m & t
Ant fat pad

Post fat pad
Brachialis m
Olecranon
Trochlea
Bicipital apon
Brachial a
Coronoid
Flexor digitorum
Pronator teres m profundus m
Median n
Pronator teres m, ulnar head
Ulnar a
Brachioradialis m
• Figure 68-2 Humeral-ulnar interface. (From Kang HS, Ahn JM, Resnick D: MRI of the extremities,
120 SECTION 3 The Elbow
Biceps m
Triceps m
Brachialis m
Capitulum
Annular lig Radius, head
Brachioradialis m
Anconeus m
Radial recurrent a
Supinator m Biceps t
Radius, tuberosity
Ulna
Radial n, superficial
branch Supinator m
Flexor digitorum
profundus m
• Figure 68-3 Humeral-radial interface. (From Kang HS, Ahn JM, Resnick D: MRI of the extremities,
CHAPTER 68 Functional Anatomy of the Elbow Joint 121
Median n Brachial a
Bicipital apon
Pronator teres m
Biceps t
Ant ulnar recurrent a Brachioradialis m
Flexor carpi radialis m Radial n, superficial branch
Palmaris longus m
Radial n, deep branch
Brachialis m & t
Extensor carpi radialis longus m
Flexor digitorum
superficialis m Supinator m
Ulnar n Radius, head
Flexor carpi ulnaris m Extensor digitorum m

Ulna
Flexor digitorum Extensor carpi ulnaris m
profundus m
Anconeus m Annular lig
Median n Brachial a
Pronator teres m
Flexor carpi radialis m Bicipital apon
Palmaris longus m Brachioradialis m
Ant ulnar recurrent a Biceps t
Flexor digitorum
superficialis m Radial n, superficial branch
Brachialis m & t Radial n, deep branch
Ulnar n Extensor carpi
Flexor carpi radialis longus m
ulnaris m
Supinator m
Flexor digitorum
profundus m Radius, head
Ulna Extensor digitorum m
Anconeus m
Extensor carpi ulnaris m
Annular lig
• Figure 68-4 Radial-ulnar interface. (From Kang HS, Ahn JM, Resnick D: MRI of the extremities, ed 2,
position, which functionally puts the hand in closer prox-

Triceps tendon imity to the mouth to aid in feeding. Flexion of the arm at
the elbow is carried out primarily by the biceps and bra-
chialis muscles, with extension carried out primarily by the
Triceps muscle opposing triceps muscle. The insertion points of the mus-
Olecranon
process culotendinous units are common sites of elbow pain and
dysfunction (Fig. 68-5).
Joint effusion In addition to the bony architecture and surrounding
Fat pad
ligaments, the elbow is richly endowed with bursae to facili-
Humerus
tate the joint’s varied movements. These bursae are extremely
Cephalad susceptible to overuse, inflammation, and even infection
and are also common sites of elbow pain and dysfunction.
Olecranon fossa
Most notably, the olecranon and cubital bursae are com-
monly affected (Fig. 68-5). When these bursae become
Longitudinal posterior elbow view inflamed, they can impinge on and irritate their associated
tendons and tendinous insertions, with resultant tendinitis
• Figure 68-5 Longitudinal ultrasound image demonstrating the
and occasionally nerve entrapment.
insertion of the triceps musculotendinous unit into the olecranon
process. Note the mild tendinosis and posterior joint effusion.
69 Visual Inspection of the Elbow
Because of the lack of soft tissue overlying the elbow joint, rubor that might be suggestive of a crystal arthropathy, an
many of the structures that are susceptible to disease are inflammatory process, or infection (Fig. 69-3). Areas of
easily visualized on inspection. The anterior and posterior special interest should include the antecubital fossa, where
elbow should be inspected in the neutral, flexed, and careful inspection for needle marks that might be suggestive
extended positions. The examiner should note the carrying of intravenous drug abuse or localized swelling that might
angle; the normal valgus position is 10 to 15 degrees in men be suggestive of cubital bursitis should be carried out. The
and up to 18 degrees in women (Figs. 69-1 and 69-2). An area surrounding the olecranon process should be observed
increased carrying angle is seen following ligamentous for edema or localized swelling that might be suggestive of
injury or fracture and with congenital disorders such as an olecranon bursitis (Fig. 69-4). Subcutaneous nodules
Turner syndrome. The examiner should also look for diffuse along the posterior ulna are highly suggestive of rheumatoid
swelling of the joint that might be suggestive of arthritis or arthritis (see Fig. 69-4).
• Figure 69-1 The carrying angle of the normal valgus position in • Figure 69-2 The carrying angle of the normal valgus position in
males should be 10 to 15 degrees. females should not exceed 18 degrees.
122
CHAPTER 69 Visual Inspection of the Elbow 123
Triceps tendon
Effusion
Capitulum
Trochlea
Lateral
Posterior elbow transverse view • Figure 69-4 Olecranon bursitis in a patient with rheumatoid arthri-
tis. A rheumatoid nodule is also shown. (From Careet S, Canoso J:
The spine. In Klippel JH, Dieppe PA editors: Rheumatology, ed 2,
• Figure 69-3 Transverse ultrasound image demonstrating a signifi- London, 1998, Mosby, p 84.)
cant effusion of the elbow joint.
70 Palpation of the Elbow
Because of the subcutaneous nature of many of the struc- epicondyle is then palpated to identify radial tunnel syn-
tures within the elbow joint that are prone to disease, careful drome, which is caused by entrapment of the posterior
palpation of the joint and surrounding tissues is extremely interosseous branch of the radial nerve (Fig. 70-3). The
important in the diagnosis of elbow pain and dysfunction. medial epicondyle should then be palpated to identify
The antecubital fossa should be palpated to identify any golfer’s elbow (Figs. 70-4 and 70-5). The examiner should
swelling or soft tissue mass. Bursitis or lipoma should be then turn his or her attention to the posterior elbow, and
readily identifiable, as should phlebitic veins or arterial the area surrounding the olecranon should be carefully pal-
aneurysm from previous arterial puncture. The lateral epi- pated to identify gouty tophi, loose bodies from previous
condyle should be palpated to identify tennis elbow (Figs. fracture, and boggy edema and soft tissue mass that might
70-1 and 70-2). The area just distal and lateral to the lateral suggest olecranon bursitis.
Common extensor tendon
Muscle
Lateral
epicondyle
Proximal
Tearing
of the
common
extensor
tendon
Fibula
Longitudinal elbow lateral quadrant view
Tendon has swollen, thickened appearance

with edematous fibers
RIGHT
• Figure 70-1 Palpation of the lateral epicondyle. • Figure 70-2 Longitudinal ultrasound image demonstrating lateral
epicondylitis (tennis elbow). Note the tearing of the common extensor
tendon and the loss of the normal sonographic fibular tendon
architecture.
124
CHAPTER 70 Palpation of the Elbow 125
Posterior interosseous
nerve
Deltoid m.
Triceps brachii m. Lateral

epicondyle
Biceps brachii m.
Brachialis m.
Brachioradialis m.
B
• Figure 70-3A and B, Palpation of the area distally and laterally from the lateral epicondyle. (B from
Waldman SW: Atlas of pain management techniques, Philadelphia, 2000, Saunders, p 85.)
Common extensor
tendons
Medial
epicondyle
Ulnar collateral
ligament
• Figure 70-4 Palpation of the medial epicondyle.
Longitudinal view—ulnar collateral ligament
• Figure 70-5 Longitudinal ultrasound image demonstrating mild

tendinosis of the common flexor tendon in a patient suffering from
golfer’s elbow.
71 Flexion and Extension of the Elbow
The range of motion of the elbow should be assessed in (Fig. 71-1, A). Normal elbow flexion in adults is approxi-
flexion, extension, and forearm pronation and supination. mately 135 to 140 degrees, although most of the activities
Although young children can extend their elbows 10 to of daily living require less than complete elbow flexion
15 degrees, most adults have little if any elbow extension (Fig. 71-1, B).
A B
• Figure 71-1 A, Normal elbow extension. B, Normal elbow flexion.
126
72 Supination and Pronation of the Elbow
Supination and pronation of the elbow are essential for degrees. The patient is then asked to place his or her thumbs
humans to carry out their essential activities of daily living, in alignment with the humerus (Fig. 72-1, A). The patient
including feeding. The complex movement of forearm rota- is then asked to turn his or her palms upward (Fig. 72-1,
tion requires movement both at the radiohumeral joint and B). Normal elbow supination is 75 to 80 degrees.
at the proximal and distal radioulnar joints. Fortunately, To assess the range of motion of the elbow in pronation,
because of the wide range of motion of the shoulder, com- the patient is asked to assume the standing position with
promise of rotation of the forearm can be partially compen- the arms against the chest wall and the elbows flexed to
sated for, albeit in a functionally inefficient way, by increased 90 degrees. The patient is then asked to place his or her
reliance on shoulder movement. thumbs in alignment with the humerus (Fig. 72-2, A).
To assess the range of motion of the elbow in supination, The patient is then asked to turn his or her palms
the patient is asked to assume the standing position with downward (Fig. 72-2, B). Normal elbow pronation is 75 to
the arms against the chest wall and the elbows flexed to 90 80 degrees.
A B
• Figure 72-1 A and B, Assessment of elbow supination.
A B
• Figure 72-2 A and B, Assessment of elbow pronation.
127
73 The Valgus Stress Flexion Test for Medial
Ligamentous Incompetence
The valgus stress flexion test is useful in the identification to approximately 75 to 80 degrees. The patient is then asked
of medial ligamentous incompetence of the elbow. To to flex his or her elbow to approximately 30 degrees. The
perform the valgus stress flexion test, the patient is asked to examiner then exerts valgus stress on the elbow (Fig. 73-1).
assume the standing position and to abduct the shoulder The test is considered positive if medial laxity is identified.
• Figure 73-1 The valgus stress flexion test for medial ligamentous
incompetence.
128
74 The Varus Stress Flexion Test for Lateral
Ligamentous Incompetence
The varus stress flexion test is useful in the identification of approximately 75 to 80 degrees. The patient is then asked
lateral ligamentous incompetence of the elbow. To perform to flex his or her elbow to approximately 30 degrees. The
the varus stress flexion test, the patient is asked to examiner then exerts varus stress on the elbow (Fig. 74-1).
assume the standing position and to abduct the shoulder to The test is considered positive if lateral laxity is identified.
• Figure 74-1 The varus stress flexion test for lateral ligamentous
incompetence.
129
75 The Lateral Pivot-Shift Test for
Posterolateral Insufficiency
The lateral pivot-shift test helps the examiner to identify the patient’s head, and the shoulder is rotated externally
laxity of the ulnar part of the lateral collateral ligament. (Fig. 75-1). While standing at the head of the table, the
When there is laxity of the ulnar part of the lateral collateral examiner then supinates the patient’s forearm and simulta-
ligament, the resulting instability allows the humeroulnar neously applies valgus stress and axial compression and
joint to sublux, with secondary dislocation of the humero- flexion of the elbow (Fig. 75-2). Apprehension in the awake
radial joint. To perform the lateral pivot-shift test for pos- patient indicates a positive test and is highly suggestive of
terolateral insufficiency, the patient is placed in the supine insufficiency of the ulnar part of the lateral collateral liga-
position. The affected extremity is then extended back over ment of the elbow.
• Figure 75-1 The lateral pivot-shift test for posterolateral insuffi- • Figure 75-2 The lateral pivot-shift test for posterolateral insuffi-
ciency: the examiner extends the affected extremity up over the ciency: the examiner supinates the patient’s forearm and applies
patient’s head and externally rotates the shoulder. valgus stress and axial compression and flexion of the elbow.
130
76 The Froment Paper Sign for Ulnar Nerve
Entrapment at the Elbow
Ulnar nerve entrapment at the elbow is the second most The Froment paper sign for ulnar nerve entrapment at
common upper extremity nerve entrapment syndrome, the elbow is an elegant test that reveals a classic deformity
after carpal tunnel syndrome. The patient presenting with of the thumb while trying to pinch caused by weakness of
ulnar nerve entrapment at the elbow will frequently com- the adductor pollicis brevis and the flexor pollicis brevis,
plain of difficulty turning a key, using a hammer, or holding which stabilize the metacarpophalangeal joint of the thumb.
a fishing rod. These disabilities are due to a combination of This loss of stabilization of the metacarpophalangeal joint
factors, including: (1) loss of pinch strength between the causes a hyperextension of this joint with compensatory
thumb and adjacent fingers, (2) loss of synchronization of flexion of the interphalangeal joint of the thumb. As the
finger flexion while trying to grasp, and (3) loss of coordina- patient tries to increase pinch strength to overcome the
tion between the thumb and digits while trying to grasp. weakness of the adductor pollicis brevis and the flexor pol-
Unfortunately, the nomenclature of ulnar nerve entrap- licis brevis, this loss of the compensatory flexion deformity
ment at the elbow is sometimes confusing because of a lack increases, producing a positive Froment paper sign.
of consistency in associating the underlying pathologic To perform this test, the patient is asked to lightly grasp
process with the naming of the clinical syndrome. For the a piece of paper between the thumb and index finger of each
purposes of the clinician trying to utilize physical examina- hand. If ulnar entrapment is present, the examiner will
tion to identify the source of upper extremity neurologic notice that the interphalangeal joint of the thumb of the
dysfunction or pain, the following clinical syndromes will affected extremity will flex in an effort to grasp the paper
present in an essentially identical manner: (Fig. 76-1). The examiner then asks the patient to more
• Cubital tunnel syndrome tightly grasp the paper. If ulnar nerve entrapment is present,
• Tardy ulnar palsy the flexion deformity should increase in comparison to the
• Ulnar palsy thumb of the unaffected extremity (Fig. 76-2). This increased
Once the clinician has identified compromise of ulnar flexion is considered a positive Froment paper sign and is
nerve function and suspects one of these clinical syndromes, highly suggestive of ulnar nerve entrapment at the elbow.
electromyography and magnetic resonance imaging (MRI) In a small subset of patients, lesions of the brachial plexus
and/or ultrasound imaging will be required to pinpoint the or entrapment of the ulnar nerve above the elbow or in the
anatomic site and cause of ulnar nerve entrapment at the forearm or wrist can also produce a positive Froment paper
elbow. sign. For this reason, careful electromyography, MRI, and
ultrasound imaging at the level of suspected ulnar nerve
entrapment should be carried out.
• Figure 76-1 The Froment paper test is performed by asking the

patient to lightly grasp a piece of paper between the thumb and
index finger of each hand and monitoring the flexion of the thumb
interphalangeal joint on the affected side. Increased pinch strength is
required to compensate for weakness, causing an increased flexion • Figure 76-2 Positive Forment paper sign as indicated by the flexion
deformity. deformity.
131
77 The Jeanne Sign for Ulnar Nerve
Ulnar nerve entrapment at the elbow is the second most and/or ultrasound imaging will be required to pinpoint the
common upper extremity nerve entrapment syndrome, anatomic site and cause of ulnar nerve entrapment at the
after carpal tunnel syndrome. The patient presenting with elbow.
ulnar nerve entrapment at the elbow will frequently com- The Jeanne sign for ulnar nerve entrapment at the elbow
plain of difficulty turning a key, using a hammer, or holding is similar to the Froment paper sign. In addition to the
a fishing rod. These disabilities are due to a combination of compensatory flexion of the interphalangeal joint seen in
factors, including: (1) loss of pinch strength between the Froment paper sign, with Jeanne sign, there is hyperexten-
thumb and adjacent fingers, (2) loss of synchronization of sion of the metacarpophalangeal joint of the thumb due to
finger flexion while trying to grasp, and (3) loss of coordina- denervation-induced weakness of the flexor pollicis brevis
tion between the thumb and digits while trying to grasp. muscle. The positive test for Jeanne sign is often seen in
Unfortunately, the nomenclature of ulnar nerve entrap- conjunction with a positive test for Froment paper sign.
ment at the elbow is sometimes confusing because of a lack To perform the test for Jeanne sign, the patient is asked
of consistency in associating the underlying pathologic to lightly grasp a key between the thumb and radial aspect
process with the naming of the clinical syndrome. For the of the index finger of the affected hand (Fig. 77-1). The
purposes of the clinician trying to utilize physical examina- patient is then asked to grasp the key more tightly. If ulnar
tion to identify the source of upper extremity neurologic entrapment is present, the examiner will note that the meta-
dysfunction or pain, the following clinical syndromes will carpophalangeal joint of the thumb hyperextends to help
present in an essentially identical manner: stabilize the weakened joint to increase the grasp pressure
• Cubital tunnel syndrome (Fig. 77-2). In a small subset of patients, lesions of the
• Tardy ulnar palsy brachial plexus or entrapment of the ulnar nerve above the
• Ulnar palsy elbow or in the forearm or wrist can also produce a positive
Once the clinician has identified compromise of ulnar Jeanne and/or Froment paper sign. For this reason, careful
nerve function and suspects one of these clinical syndromes, electromyography, MRI, and ultrasound imaging at the level
electromyography and magnetic resonance imaging (MRI) of suspected ulnar nerve entrapment should be carried out.
• Figure 77-1 The test for Jeanne sign is performed by asking the • Figure 77-2 The patient is then asked to grasp the key more
patient to lightly grasp a key between the thumb and radial aspect of tightly. The test for Jeanne sign is positive if the metacarpophalangeal
the index finger of each hand and monitoring the flexion of the thumb joint of the affected thumb hyperextends in order to stabilize the joint
interphalangeal joint on the affected side. to increase grasp pressure.
132
78 The Wartenberg Sign for Ulnar Nerve
Patients suffering from ulnar nerve entrapment at the elbow affected side (Video 78-1). The patient is then asked to
often complain of an inability to reach into their pockets reach into the pocket and retrieve the object. If there is
because the little finger catches on the opening of the weakness of the adductors of the affected little finger, the
pockets. This disability, while seemingly mild, causes a sig- finger will catch on the opening of the pocket, and the
nificant amount of distress and is caused by the weakness patient will not be able to get his or her hand fully into
of the adductors of the little finger. the pocket to retrieve the object (Fig. 78-2). Such weakness
The Wartenberg sign for ulnar nerve entrapment at the can be confirmed by performing a little finger adduction
elbow is a simple way to identify the inability to adduct test (see Chapter 79). A positive test for Wartenberg sign
the little finger. Such weakness primarily results from the and a positive little finger adduction test are highly sugges-
compromise of the third palmar interosseous muscle com- tive of ulnar nerve entrapment at the elbow.
bined with the other functional disabilities associated with
ulnar nerve entrapment discussed in Chapter 76. Clinically,
this weakness presents as a chronically abducted posture
of the little finger when the forearm is pronated and the
fingers are fully extended, which is also known as a positive
Wartenberg sign (Fig. 78-1).
To perform the test for Wartenberg sign for ulnar nerve
entrapment at the elbow, the patient is asked to place an
object such as a ring of keys into the pants pocket on the
• Figure 78-1 Clinically, the Wartenberg sign presents as a chroni-

cally abducted posture of the little finger when the forearm is pronated • Figure 78-2 The test for Wartenberg sign for ulnar nerve entrap-
and the fingers are fully extended. ment at the elbow.
133
79 The Little Finger Adduction Test for
Ulnar Nerve Entrapment at the Elbow
The little finger adduction test for ulnar nerve entrapment 79-1). This maneuver requires that the strength of the
at the elbow is a simple way to identify an inability to interosseous muscles be relatively intact, and an inability
adduct the little finger. Such weakness primarily results to perform such a task constitutes a positive little finger
from the compromise of the interosseous muscles combined adduction test.
with the other functional disabilities associated with ulnar A positive little finger adduction test as well as a positive
nerve entrapment discussed in Chapters 76, 77, and 78. Froment paper sign (see Chapter 76) or a positive Warten-
To perform the little finger adduction test for ulnar nerve berg sign (see Chapter 78) are highly suggestive of ulnar
entrapment at the elbow, the patient is asked to touch his nerve entrapment at the elbow. As discussed previously, in
or her little finger to the index finger (Fig. 79-1 and Video some patients, lesions of the brachial plexus or entrapment
of the ulnar nerve above the elbow or in the forearm or wrist
may produce similar physical findings. Careful electromy-
ography and magnetic resonance and ultrasound imaging
at the level of suspected ulnar nerve entrapment should be
carried out (Fig. 79-2).
Ulnar nerve FCU
FCU
Synovitis
Medial epicondyle
Olecranon
Medial
With elbow flexion, transverse to ulnar nerve view
• Figure 79-2 Transverse ultrasound image demonstrating compres-

sion of the ulnar nerve at the elbow by exuberant synovitis in a patient
• Figure 79-1 Little finger adduction test. suffering from rheumatoid arthritis. FCU, Flexor carpi ulnaris.
134
80 The Valgus Extension Overload Test for
Olecranon Impingement
The valgus extension overload test aids the examiner in hand, pronates the forearm while simultaneously applying
identifying the presence of a posteromedial olecranon osteo- a firm valgus force and quickly maximally extending the
phyte or olecranon fossa overgrowth or compression by elbow (Fig. 80-2). The test is considered positive if the rapid
calcification due to inflammatory processes (Fig. 80-1). To extension of the elbow causes posteromedial pain, presum-
perform the valgus extension overload test, the examiner ably due to the tip of the olecranon osteophyte or calcifica-
stabilizes the humerus with one hand and, with the opposite tion being forced into engagement into the olecranon fossa.
A B
• Figure 80-1 Elbow abnormalities in gout. (A) Olecranon changes consisting of soft tissue swelling and
subajacent osseous erosion (arrowhead) are seen. Additional soft tissue swelling is also evident (arrow).
(B) Similar changes in another patient with a tophus containing calcification. (From Resnick D, Kransdorf
MJ, editors: Bone and joint imaging, ed 3, Philadelphia, 2005, Saunders, p 451.)
• Figure 80-2 The valgus extension overload test. The examiner

stabilizes the humerus with one hand, and with the opposite hand,
pronates the forearm while simultaneously applying a firm valgus force
and quickly maximally extending the elbow.
135
81 The Compression Test for Lateral
Antebrachial Cutaneous Nerve
Entrapment Syndrome
Lateral antebrachial cutaneous nerve entrapment syndrome half of the volar surface of the forearm. It passes anterior to
is caused by entrapment of the lateral antebrachial cutane- the radial artery at the wrist to provide sensation to the base
ous nerve by the biceps tendon or the brachialis muscle. of the thumb. The dorsal branch provides sensation to the
Clinically, the patient who suffers from lateral antebrachial dorsal lateral surface of the forearm.
cutaneous nerve entrapment syndrome complains of pain The pain of lateral antebrachial cutaneous nerve entrap-
and paresthesias radiating from the elbow to the base of the ment syndrome may develop after an acute twisting injury
thumb. Dull aching of the radial aspect of the forearm, to the elbow or direct trauma to the soft tissues overlying
which often worsens if the arm is left in a partially flexed the lateral antebrachial cutaneous nerve, or the onset of pain
position, is also a common complaint. The lateral ante- may be more insidious, without an obvious inciting factor.
brachial cutaneous nerve is a continuation of the musculo- The carrying of heavy purses or grocery bags in the crook
cutaneous nerve. The musculocutaneous nerve passes of the elbow has also been implicated in compression of the
through the fascia lateral to the biceps tendon before it nerve. The pain is constant and is made worse with use of
continues into the forearm as the lateral antebrachial cuta- the elbow. Patients with lateral antebrachial cutaneous nerve
neous nerve (Fig. 81-1). The nerve is susceptible to entrap- entrapment syndrome often note increasing pain while key-
ment at this point. The lateral antebrachial cutaneous nerve boarding or playing the piano. Sleep disturbance is common.
passes behind the cephalic vein, where it divides into a volar On physical examination, there is tenderness to palpation
branch that continues along the radial border of the forearm, of the lateral antebrachial cutaneous nerve at the elbow at
providing sensory innervation to the skin over the lateral a point just lateral to the biceps tendon. Elbow range of
Biceps m.
Lat. antebrachial
cutaneous n.
Radial a.
• Figure 81-1 Lateral antebrachial cutaneous nerve entrapment:

relevant soft tissue anatomy.
136
CHAPTER 81 The Compression Test for Lateral Antebrachial Cutaneous Nerve Entrapment Syndrome 137
• Figure 81-2 Compression test for lateral antebrachial cutaneous

nerve entrapment.
motion is normal. Patients with lateral antebrachial cutane- and paresthesias in the distribution of the antebrachial cuta-
ous nerve entrapment syndrome exhibit pain on active neous nerve (Video 81-1).
resisted flexion or rotation of the forearm. Patients with Because cervical radiculopathy and tennis elbow can
antebrachial cutaneous nerve entrapment syndrome will sometimes mimic lateral antebrachial cutaneous nerve
usually exhibit a positive compression test. entrapment syndrome, careful electromyography should be
The compression test for antebrachial cutaneous nerve performed to distinguish C6 radiculopathy from entrap-
entrapment syndrome is performed by having the patient ment of the antebrachial cutaneous nerve and to rule out a
assume the seated position with the affected arm partially double crush syndrome. Magnetic resonance imaging and/
flexed (Fig. 81-2). The examiner compresses the area or ultrasound imaging of the elbow is indicated if joint
lateral to the biceps tendon at the elbow tightly for 30 instability or mass is suspected. Injection of the lateral ante-
seconds. Patients suffering from antebrachial cutaneous brachial cutaneous nerve with local anesthetic can serve as
nerve entrapment syndrome will note an increase in pain both a diagnostic and a therapeutic maneuver.
82 The Snap Sign for Snapping
Triceps Syndrome
The causes of ulnar nerve entrapment of the elbow are many To elicit the snap sign for snapping triceps syndrome,
and include thickening of the retinaculum of the roof the patient is placed in a seated position and is asked to
of the cubital tunnel (the Osborne lesion), thickening of repeatedly flex the affected arm rapidly while the examiner
the floor of the cubital tunnel, osteophyte development of cups the elbow in his or her hand (Fig. 82-2). An audible
the bones surrounding the ulnar nerve, compression of the or palpable snap constitutes a positive snap sign, and mag-
ulnar nerve by soft tissue mass or tumor, and abnormal netic resonance imaging of the elbow in both the flexed and
subluxation of the ulnar nerve out of the cubital tunnel extended positions should be obtained to ascertain the ana-
(Fig. 82-1). This abnormal movement may be caused by a tomic abnormality responsible for the snapping triceps syn-
hypoplastic retinaculum or with subluxation of the medial drome (Video 82-1). Electromyography and cross-elbow
head of the triceps muscle during flexion of the elbow. nerve conduction studies can help to identify the anatomic
When subluxation of the triceps muscle occurs, a palpable site of ulnar nerve entrapment and to rule out radiculopathy
and at times audible snapping of the elbow can be identi- and plexopathy that may be confusing the clinical picture.
fied. These findings form the basis for the snap sign for
snapping triceps syndrome.
FCU
Medial epicondyle
Synovitis
Olecranon
Ulnar nerve
Medial Lateral
Transverse ulnar nerve wrist in relaxed extended

position view in RA patient
• Figure 82-1 Transverse ultrasound image demonstrating compro-

mise of the ulnar nerve by synovitis formation in a patient with rheu-
matoid arthritis. FCU, Flexor carpi ulnaris; RA, rheumatoid arthritis. • Figure 82-2 Eliciting the snap sign for snapping triceps syndrome.
138
83 The Creaking Tendon Sign for
Triceps Tendinitis
Olecranon bursitis is by far the most common cause of To identify the creaking tendon sign for triceps tendini-
posterior elbow pain. Less common, although as painful, is tis, the patient is placed in the sitting position and asked to
triceps tendinitis. Triceps tendinitis can occur from a repeti- perform active resisted extension of the arm while the exam-
tive stress injury such as repeated resisted extension when iner places his or her index finger over the distal triceps
using exercise equipment, direct trauma to the posterior tendon (Fig. 83-1). If triceps tendinitis is present, pressure
elbow with the elbow in extension (e.g., a quarterback sack exerted by the examiner on the distal tendon may increase
while passing a football), or a sudden decelerating counter- the patient’s pain, and the examiner may appreciate a creak-
force during active extension of the arm (e.g., warding off ing of the tendon as the arm extends. These findings con-
a blow during kickboxing). Triceps tendinitis presents with stitute a positive creaking tendon test for triceps tendinitis
pain on extension of the elbow. In contradistinction to and should lead the examiner to obtain magnetic resonance
olecranon bursitis, there is minimal joint effusion or swell- imaging of the elbow to identify any bony or soft tissue
ing, and the main physical finding is a tender, hot distal abnormality that is responsible for the tendinopathy and to
triceps tendon that may creak during extension of the rule out partial tears of the triceps tendon.
affected extremity. The creaking forms the basis for the
creaking tendon sign.
• Figure 83-1 Creaking tendon sign for triceps tendinitis.
139
84 The Ballottement Test for
Olecranon Bursitis
The olecranon bursa is vulnerable to injury from both acute Patients suffering from olecranon bursitis will also exhibit
trauma and repeated microtrauma. Acute injuries frequently a positive ballottement test.
take the form of direct trauma to the elbow when playing To perform the ballottement test for olecranon bursitis,
sports such as hockey or falling directly onto the olecranon the patient is asked to assume the sitting position, and the
process. Repeated pressure from leaning on the elbow to rise affected extremity is allowed to rest lightly in the examiner’s
or from working long hours at a drafting table can result in arm. The examiner then gently ballottes the swollen area
inflammation and swelling of the olecranon bursa (Fig. over the olecranon. The ballottement should reveal a soft,
84-1). Gout or bacterial infection rarely may precipitate nonfluctuant fluid-filled swelling that ballots easily. Lack of
acute olecranon bursitis. If the inflammation of the olecra- ballottement suggests abscess or another pathologic process.
non bursa becomes chronic, calcification of the bursa may Magnetic resonance and/or ultrasound imaging can help
occur, with residual nodules called gravel. clarify the cause of the posterior elbow swelling if the diag-
The patient who suffers from olecranon bursitis will fre- nosis is in doubt (Figs. 84-2 and 84-3).
quently complain of pain and swelling with any movement
of the elbow but especially with extension. The pain is local-
ized to the olecranon area, with referred pain often noted
above the elbow joint. Often, the patient is more concerned
about the swelling around the bursa than about the pain
because the swelling is dramatic and its onset is abrupt.
Physical examination reveals point tenderness over the olec-
ranon and swelling of the bursa, which at times can be quite
extensive. Passive extension and resisted shoulder flexion
reproduce the pain, as does any pressure over the bursa.
• Figure 84-2 Olecranon bursitis. Sagittal T2-weighted magnetic

• Figure 84-1 Olecranon bursitis in early rheumatoid arthritis. (From resonance image shows a focal fluid collection posteriorly (arrows)
Groff GD: Axial and peripheral joints: olecranon bursitis. In Klippel JH, in a patient with triceps tendon tear (not shown in this image).
Dieppe PA, editors: Rheumatology, ed 2, London, 1998, Mosby, (From Kaplan PA, Helms CA, Dussault R, et al: Musculoskeletal MRI,
p 143.) Philadelphia, 2001, Saunders, p 235.)
140
CHAPTER 84 The Ballottement Test for Olecranon Bursitis 141
*
*
Ulna
* *
Ulna
C
• Figure 84-3 Longitudinal (A) and axial (B) ultrasound images of a patient with olecranon bursitis.
There is a low-echo, fluid-filled bursa (asterisks) superficial to the proximal ulna, and the distal triceps
tendon is visualized on the longitudinal image (white arrows). (C) The Doppler ultrasound image demon-
strates increased vascularity in the periphery of the bursa consistent with mild inflammatory synovitis.
(From Waldman SD, Campbell, RSD: Imaging of pain, Philadelphia, 2010, Saunders/Elsevier, p 275,
fig 108-1.)
85 The Tennis Elbow Test
Tennis elbow (also known as lateral epicondylitis) is caused On physical examination, there is tenderness along the
by repetitive microtrauma to the extensor tendons of the extensor tendons at or just below the lateral epicondyle.
forearm. The pathophysiology of tennis elbow is initially Many patients with tennis elbow exhibit a bandlike thicken-
caused by microtearing at the origin of extensor carpi radia- ing within the affected extensor tendons. Elbow range of
lis and extensor carpi ulnaris. Secondary inflammation may motion is normal. Grip strength on the affected side is
occur and can become chronic as the result of continued diminished. Patients with tennis elbow demonstrate a
overuse or misuse of the extensors of the forearm. Coexis- positive tennis elbow test. The test is performed by stabiliz-
tent bursitis, arthritis, and gout also may perpetuate the ing the patient’s forearm and then having the patient clench
pain and disability of tennis elbow. his or her fist and actively extend the wrist (Video 85-1).
Tennis elbow occurs in patients who engage in repetitive The examiner then attempts to force the wrist into flexion
activities that include hand grasping, such as politicians (Fig. 85-2). Sudden, severe pain is highly suggestive of
shaking hands, or high-torque wrist turning, such as scoop- tennis elbow.
ing ice cream at an ice cream parlor. Tennis players develop Radial tunnel syndrome and occasionally C6-C7 radicu-
tennis elbow by two separate mechanisms: increased pres- lopathy can mimic tennis elbow. Radial tunnel syndrome is
sure grip strain as a result of playing with too heavy a an entrapment neuropathy that results from entrapment of
racquet and making backhand shots with a leading shoulder the radial nerve below the elbow (see Chapter 91). Radial
and elbow rather than keeping the shoulder and elbow tunnel syndrome can be distinguished from tennis elbow in
parallel to the net (Fig. 85-1). Other racquet sport players that with radial tunnel syndrome, the maximal tenderness
also are susceptible to the development of tennis elbow. to palpation is distal to the lateral epicondyle over the radial
The pain of tennis elbow is localized to the region of the nerve, whereas with tennis elbow, the maximal tenderness
lateral epicondyle. It is constant and is made worse with to palpation is over the lateral epicondyle (Fig. 85-3). Elec-
active contraction of the wrist. Patients note the inability to tromyography helps to distinguish cervical radiculopathy
hold a coffee cup or hammer. Sleep disturbance is common. and radial tunnel syndrome from tennis elbow. Plain radio-
graphs are indicated in all patients who present with tennis
elbow to rule out joint mice and other occult bony pathol-
ogy. Magnetic resonance imaging and/or ultrasound imaging
of the elbow is indicated to confirm the diagnosis and when
joint instability is suspected (Figs. 85-4 and 85-5).
• Figure 85-1 Mechanism of elbow injury in tennis players. • Figure 85-2 Test for tennis elbow.
142
CHAPTER 85 The Tennis Elbow Test 143
• Figure 85-3 Patients who suffer from radial tunnel syndrome will
experience maximal tenderness over the radial nerve.
A B C
• Figure 85-4 Coronal proton density (A) and FST2W (B) magnetic resonance (MR) images of a patient
with tennis elbow. There are thickening and increased SI within the common extensor tendon (broken
white arrow) along with associated underlying bone marrow edema (curved arrow). C, The bone marrow
is also seen on the axial FST2W MR image (curved arrow) and the soft tissue thickening and increased
SI posterior to the extensor tendon probably reflect associated soft tissue impingement (black arrow).
(From Waldman SD, Campbell, RSD: Imaging of pain, Philadelphia, 2010, Saunders/Elsevier, fig 103-2.)
Common extensor tendon
Irregularity of
tendinous insertion Radial head
Lateral epicondyle
Proximal Distal
Longitudinal to the common extensor tendon view
• Figure 85-5 Longitudinal ultrasound image demonstrating irregu-

larity of the insertion of the common extensor tendon, a classic sono-
graphic finding in patients suffering from tennis elbow.
86 The Maudsley Test for Lateral
Epicondylitis
To perform the Maudsley test for lateral epicondylitis, the resistance (Fig. 86-2). The test is positive if the patient
patient is placed in the sitting position with the patient’s experiences pain at the lateral epicondyle. The pain elicited
forearm resting comfortably on a table and the hand and by this test is believed to be caused by inflammation of the
wrist hanging off the edge of the table (Fig. 86-1). The insertion extensor digitorum communis muscle into the
examiner then stabilizes the forearm and asks the patient to lateral epicondyle.
forcefully extend his or her middle finger against examiner
• Figure 86-1 To perform the Maudsley test for lateral epicondylitis, • Figure 86-2 The examiner then stabilizes the forearm and asks the
the patient is placed in the sitting position with the patient’s forearm patient to forcefully extend his or her middle finger against examiner
resting comfortably on a table and the hand and wrist hanging off the resistance.
edge of the table.
144
87 The Chair Lift Test for Lateral
Epicondylitis
To perform the chair lift test for lateral epicondylitis, the
patient is asked to stand behind a chair with his or her
elbows fully extended and the forearms pronated (Fig.
87-1). The patient is then asked to grasp the back of the
chair with a 3-finger pinch using the thumb, index, and
long fingers (Fig. 87-2). The patient is then asked to lift the
chair (Fig. 87-3). The test is positive if the patient experi-
ences sharp pain at the insertion of the common extensor
tendon on the lateral epicondyle when lifting the chair.
• Figure 87-1 To perform the chair lift test for lateral epicondylitis,
the patient is asked to stand behind a chair with his or her elbows fully
extended and the forearms pronated.
• Figure 87-2 The patient is then asked to grasp the back of the • Figure 87-3 The patient is then asked to lift the chair.
chair with a 3-finger pinch using the thumb, index, and long fingers.
145
88 The Golfer’s Elbow Test
Golfer’s elbow (also known as medial epicondylitis) is examination, there is tenderness along the flexor tendons at
caused by repetitive microtrauma to the flexor tendons of or just below the medial epicondyle. Many patients with
the forearm in a manner analogous to tennis elbow. The golfer’s elbow exhibit a bandlike thickening within the
pathophysiology of golfer’s elbow is initially caused by affected flexor tendons. Elbow range of motion is normal.
microtearing at the origin of the pronator teres, flexor carpi Grip strength on the affected side is diminished. Patients
radialis and flexor carpi ulnaris, and palmaris longus. Sec- with golfer’s elbow demonstrate a positive golfer’s elbow
ondary inflammation may occur and can become chronic test. The test is performed by stabilizing the patient’s forearm
as the result of continued overuse or misuse of the flexors and then having the patient actively flex the wrist. The
of the forearm. Coexistent bursitis, arthritis, and gout may examiner then attempts to force the wrist into extension
also perpetuate the pain and disability of golfer’s elbow. (Fig. 88-1). Sudden, severe pain is highly suggestive of
Golfer’s elbow occurs in patients who engage in repeti- golfer’s elbow.
tive flexion activities, including throwing baseballs, carrying Occasionally, C6-C7 radiculopathy can mimic golfer’s
heavy suitcases, and driving golf balls. These activities have elbow. The patient suffering from cervical radiculopathy
in common repetitive flexion of the wrist and strain on the usually has neck pain and proximal upper extremity pain in
flexor tendons caused by excessive weight or sudden arrested addition to symptoms below the elbow. Electromyography
motion. Many of the activities that can cause tennis elbow helps to distinguish radiculopathy from golfer’s elbow. Plain
can also cause golfer’s elbow. radiographs are indicated for all patients who present with
The pain of golfer’s elbow is localized to the region of golfer’s elbow to rule out joint mice and other occult bony
the medial epicondyle. It is constant and is made worse with pathology. Magnetic resonance imaging and/or ultrasound
active contraction of the wrist. Patients note the inability to imaging of the elbow is indicated to confirm the diagnosis
hold a golf club. Sleep disturbance is common. On physical and when joint instability is suspected (Fig. 88-2).
Common flexor tendons
Medial Ulnar collateral ligament

epicondyle
Trochlea
Coronoid
process
• Figure 88-2 Longitudinal ultrasound image of the common flexor

• Figure 88-1 Test for golfer’s elbow. tendons. Note mild tendinosis.
146
89 The Polk Test to Differentiate Lateral
and Medial Epicondylitis
Some patients find it difficult to localize the specific ana- over the lateral epicondyle, the diagnosis is most likely
tomic location of their elbow pain, especially if the source tennis elbow. The patient is then asked to turn his or her
of pain is from multiple pathologic processes. The Polk test palm upward (supination of the forearm and hand) so that
is helpful in accurately differentiating lateral from medial the palm is facing the ceiling (Fig. 89-4). The patient is then
epicondylitis. To perform the test, the patient is asked to
assume the seated position and flex the elbows 90 degrees
(Fig. 89-1). The patient is then asked to turn his or her palm
downward (pronation of the forearm and hand) so that the
palm is facing the floor (Fig. 89-2). The patient is then
asked to grasp the handles of a reusable shopping bag with
contents that weigh at least 6 pounds and then lift the bag
(Fig. 89-3). If the lifting of the bag produces sudden pain
• Figure 89-3 Step 3 of the Polk test. The patient is then asked to
grasp the handles of a reusable shopping bag with contents that weigh
at least 6 pounds and then lift the bag.
• Figure 89-1 Step 1 of the Polk test. The patient is asked to assume
the seated position and flex the elbows 90 degrees.
• Figure 89-2 Step 2 of the Polk test. The patient is then asked to • Figure 89-4 Step 4 of the Polk test. The patient is then asked to
turn his or her palm downward (pronation of the forearm and hand) so turn his or her palm upward (supination of the forearm and hand) so
that the palm is facing the floor. that the palm is facing the ceiling.
147
148 SECTION 3 The Elbow
Medial
Lateral epicondyle
Calcification
Tearing of
common extensor
tendon
Transverse lateral epicondyle view
• Figure 89-6 Transverse ultrasound image demonstrating calcific

tendinitis and lateral epicondylitis in a patient with diffuse elbow pain.
• Figure 89-5 Step 5 of the Polk test. The patient is then again asked
to grasp the handles of a reusable shopping bag with contents that
weigh at least 6 pounds and then lift the bag.
again asked to grasp the handles of a reusable shopping bag have difficulty localizing their pain often suffer from more
with contents that weigh at least 6 pounds and then lift the than one pathologic process. In this setting, magnetic reso-
bag (Fig. 89-5). If the lifting of the bag produces sudden nance imaging and/or ultrasound imaging of the elbow is
pain over the medial epicondyle, the diagnosis is most likely almost always indicated to confirm the diagnosis and if joint
golfer’s elbow. It should be remembered that patients who instability is suspected (Fig. 89-6).
90 The Brachialis Jump Test for
Climber’s Elbow
Because of its more protected nature relative to the distal

biceps musculotendinous unit, which is the most com-
monly injured tendon of the elbow, the distal musculoten-
dinous unit of the brachialis muscle is injured much less
commonly. Inciting factors include repetitive stress injuries
from pull-ups, sudden extension against a fully contracted
brachialis muscle during competitive arm wrestling, and,
most commonly, strain during rock climbing (Fig. 90-1).
To perform the brachialis jump test for climber’s
elbow, the patient is placed in the standing position with
the elbow slightly flexed. The patient is then asked to
contract the forearm against resistance. The examiner then
palpates the distal musculotendinous unit of the muscle in
a manner analogous to the palpation of a trigger point
(Fig. 90-2). If the distal musculotendinous unit is strained • Figure 90-2 Brachialis jump test for climber’s elbow.
or inflamed, the palpation will elicit a positive jump sign.
Magnetic resonance and/or ultrasound imaging will reveal
injury or inflammation on fast STIR and T2-weighted
images (Fig. 90-3).
• Figure 90-3 Climber’s elbow. Axial STIR imaging shows abnormal

feathery hyperintensity in the brachialis muscle belly in this patient who
• Figure 90-1 Strain during rock climbing is a common cause of suffered an injury while doing pull-ups. (From Wenzke DR: MR imaging
injury to the distal musculotendinous unit of the brachialis muscle of the elbow in the injured athlete, Radiol Clin North Am 51(2):195–213,
(climber’s elbow). 2013.)
149
91 The Compression Test for Radial
Tunnel Syndrome
Radial tunnel syndrome is an entrapment neuropathy of the syndrome, the maximal tenderness to palpation is distal to
radial nerve that is often clinically misdiagnosed as resistant the lateral epicondyle over the posterior interosseous branch
tennis elbow. In radial tunnel syndrome, the posterior inter- of the radial nerve, whereas with tennis elbow, the maximal
osseous branch of the radial nerve is entrapped by a variety tenderness to palpation is over the lateral epicondyle (Fig.
of mechanisms that have a similar clinical presentation in 91-2). Patients with radial tunnel syndrome will exhibit a
common. These mechanisms include aberrant fibrous bands positive compression test for radial tunnel syndrome.
in front of the radial head, anomalous blood vessels that To perform the compression test for radial tunnel syn-
compress the nerve, and a sharp tendinous margin of the drome, the examiner tightly compresses the area over
extensor carpi radialis brevis (Fig. 91-1). These entrapments the radial nerve for 30 seconds (Fig. 91-3). The test is
can exist alone or in combination.
Regardless of the mechanism of entrapment of the radial
nerve, the common clinical feature of radial tunnel syn-
drome is pain just below the lateral epicondyle of the
humerus. The pain of radial tunnel syndrome may develop
after an acute twisting injury or direct trauma to the soft
tissues overlying the posterior interosseous branch of the
radial nerve, or the onset may be more insidious, without
an obvious inciting factor. The pain is constant and made
worse with active supination of the wrist. Patients often
note the inability to hold a coffee cup or hammer. Sleep
disturbance is common. On physical examination, there is
tenderness to palpation of the posterior interosseous branch
of the radial nerve just below the lateral epicondyle. Elbow
range of motion is normal. Grip strength on the affected
side may be diminished. Patients with radial tunnel syn-
drome exhibit pain on active resisted supination of the
forearm.
Cervical radiculopathy and tennis elbow can mimic
radial tunnel syndrome. Radial tunnel syndrome can be
distinguished from tennis elbow in that with radial tunnel • Figure 91-2 Palpation of the lateral epicondyle.
Arcade of Frohse
Brachioradialis muscle
Deep
branch
Supinator radial
nerve
Anterior
Radial head
Transverse radius view
• Figure 91-1 Transverse ultrasound image demonstrating the rela-

tionship of the deep branch of the radial nerve to the arcade of Frohse
and the supinator and brachioradialis muscles. • Figure 91-3 The compression test for radial tunnel syndrome.
152
CHAPTER 91 The Compression Test for Radial Tunnel Syndrome 153
considered positive if the patient complains of pain and Magnetic resonance and/or ultrasound imaging of the
paresthesias into the distribution of the radial nerve and elbow and forearm is indicated to confirm the diagnosis
increasing weakness of grip strength as the compression of and may help elucidate the exact cause of radial nerve
the nerve continues (Video 91-1). compression.
Electromyography helps to distinguish cervical radicu-
lopathy and radial tunnel syndrome from tennis elbow.
92 The Forced Pronation Test for
Pronator Syndrome
Pronator syndrome is due to median nerve compression by patient’s fully supinated arm—is highly suggestive of com-
the pronator teres muscle. The onset of symptoms usually pression of the median nerve by the pronator teres muscle
occurs after repetitive elbow motions such as chopping (Fig. 92-2 and Video 92-1).
wood, sculling, or cleaning fish. It has also been reported Median nerve entrapment by the ligament of Struthers
in musicians such as harpists and violinists. Clinically, pro- presents clinically as unexplained persistent forearm pain
nator syndrome presents as a chronic aching sensation local- caused by compression of the median nerve by an aberrant
ized to the forearm with pain occasionally radiating into the ligament that runs from a supracondylar process to the
elbow. Patients with pronator syndrome may complain medial epicondyle. Clinically, it is difficult to distinguish
about a tired or heavy sensation in the forearm with minimal from pronator syndrome. The diagnosis is made by electro-
activity as well as clumsiness of the affected extremity. myography and nerve conduction velocity testing, which
In contradistinction to carpal tunnel syndrome, nighttime demonstrate compression of the median nerve at the elbow,
symptoms are uncommon with pronator syndrome. combined with the radiographic and sonographic finding
Physical findings include tenderness over the forearm in of a supracondylar process.
the region of the pronator teres muscle. Unilateral hyper- Both of these entrapment neuropathies can be differenti-
trophy of the pronator teres muscle may be identified ated from isolated compression of the anterior interosseous
(Fig. 92-1). A positive Tinel sign over the median nerve as nerve, which occurs some 6 to 8 cm below the elbow. These
it passes beneath the pronator teres muscle also may be syndromes also should be differentiated from cervical radic-
present. Weakness of the intrinsic muscles of the forearm ulopathy involving the C6 or C7 roots, which may at times
and hand that are innervated by the median nerve may be mimic median nerve compression. Furthermore, it should
identified with careful manual muscle testing. A positive be remembered that cervical radiculopathy and median
pronator syndrome test—pain on forced pronation of the nerve entrapment can coexist as the so-called double crush
syndrome. The double crush syndrome is seen most com-
monly with median nerve entrapment at the wrist or carpal
tunnel syndrome.
Brachial a.
Median n.
Pronator teres m.
• Figure 92-1 Pronator syndrome: relevant soft tissue anatomy. • Figure 92-2 The forced pronation test for pronator syndrome.
154
93 The Pinch Test for Anterior
Interosseous Syndrome
Anterior interosseous syndrome is an uncommon condition Physical findings include the inability to flex the inter-
that is occasionally encountered by the pain practitioner. phalangeal joint of the thumb and the distal interphalan-
Although the condition is uncommon, the characteristic geal joint of the index finger caused by paralysis of the
physical findings of anterior interosseous syndrome make it flexor pollicis longus and the flexor digitorum profundus
easy to diagnose. The pain and weakness of anterior interos- (Fig. 93-1). Tenderness over the forearm in the region of
seous syndrome is caused by median nerve compression the pronator teres muscle is seen in some patients who suffer
below the elbow by the tendinous origins of the pronator from anterior interosseous syndrome. A positive Tinel sign
teres muscle and flexor digitorum superficialis muscle of the over the anterior interosseous branch of the median nerve
long finger or by aberrant blood vessels. The onset of symp- approximately 6 or 8 cm below the elbow also may be
toms usually occurs after acute trauma to the forearm or present. Patients who suffer from anterior interosseous syn-
after repetitive forearm and elbow motions such as using an drome will exhibit a positive pinch test. To perform the
ice pick. An inflammatory cause analogous to Parsonage- pinch test for anterior interosseous syndrome, the patient is
Turner syndrome also has been suggested as a cause of asked to tightly pinch a key between the thumb and index
anterior interosseous syndrome. finger. If compromise of the anterior interosseous nerve is
Clinically, anterior interosseous syndrome presents as present, the examiner will note flattening of the pinch
an acute pain in the proximal forearm. As the syndrome pattern consistent with weakness of the flexor pollicis longus
progresses, patients with anterior interosseous syndrome and flexor digitorum profundus (Fig. 93-2).
may complain about a tired or heavy sensation in the The anterior interosseous syndrome also should be dif-
forearm with minimal activity, as well as the inability to ferentiated from cervical radiculopathy involving the C6 or
pinch items between the thumb and index fingers because C7 roots, which may at times mimic median nerve com-
of paralysis of the flexor pollicis longus and the flexor digi- pression. Furthermore, it should be remembered that cervi-
torum profundus. cal radiculopathy and median nerve entrapment can coexist
as the so-called double crush syndrome. The double crush
syndrome is seen most commonly with median nerve
entrapment at the wrist or with carpal tunnel syndrome.
• Figure 93-1 Anterior interosseous nerve paralysis. The hand on the

left demonstrates loss of function of flexor pollicis longus and flexor
digitorum profundus muscles, resulting in a characteristic flattened
pinch pattern. (From Nashel DJ: Entrapment neuropathies. In Klippel
JH, Dieppe PA, editors: Rheumatology, ed 2, London, 1998, Mosby,
p 164.) • Figure 93-2 The pinch test for anterior interosseous syndrome.
155
94 The Creaking Tendon Test for
Intersection Syndrome
Intersection syndrome is an overuse syndrome character- approximately 8 to 10 cm above the radiocarpal joint. These
ized by pain and swelling at the crossing point of the patients will exhibit a positive creaking tendon test caused
abductor pollicis longus and extensor pollicis brevis and the by tenosynovitis. To perform the creaking tendon test for
extensor carpi radialis longus and extensor carpi radialis intersection syndrome, the patient rests his or her arm in
brevis (Fig. 94-1). The intersection of these muscle groups the examiner’s, and the examiner palpates the point of inter-
is approximately 8 to 10 cm above the radiocarpal joint. section of the inflamed tendons (Fig. 94-2). The patient is
The syndrome is commonly precipitated by vigorous use of then asked to move his or her thumb and flex and extend
rowing machines and aggressive weight training. The pain the wrist. The test is positive if the examiner appreciates a
of intersection syndrome can be quite debilitating. creaking or crepitant sensation as the inflamed tendons pass
On physical examination, patients suffering from inter- over one another.
section syndrome will have a swollen, diffusely tender area
Ext. carpi radialis

brevis m.
Ext. carpi radialis
long m.
Abductor pollicis
longus m.
Ext. pollicis brevis m.
• Figure 94-1 Intersection syndrome: relevant soft tissue anatomy.
• Figure 94-2 The creaking tendon test for intersection syndrome.
156
95 Functional Anatomy of the Wrist
In humans, the wrist functions to transfer the forces and triangular fibroelastic cartilage (TFC). A comprehensive
motions of the hand to the forearm and proximal upper review of the ligaments of the wrist is beyond the scope and
extremity. The wrist allows movement in three planes: purpose of this chapter, but it is helpful for the clinician to
• Flexion/extension understand the basic anatomy. In general, the ligaments can
• Radial/ulnar deviation be thought of as being intrinsic to the wrist, that is, having
• Pronation/supination their origin and insertion on the carpal bones, or extrinsic
To understand the functional anatomy of the wrist, it is to the wrist, that is, having their origin on the distal radius
important for the clinician to understand that the wrist is or ulna and insertion on the carpal bones. All of the liga-
not a single joint, but in fact a complex of five separate ments of the wrist have in common a close proximity to the
joints or compartments that work in concert to allow one bones of the wrist, which increases their ability to transfer
to carry out activities of daily living (Fig. 95-1). These five force to the forearm and proximal upper extremity. This lack
joints are: of interposing muscle or soft tissue also makes the ligamen-
• The distal radioulnar joint, which comprises the distal tous structures of the wrist—and the nerves, blood vessels,
radius and ulna and their interosseous membrane and bones beneath them—more susceptible to injury.
• The radiocarpal joint, which comprises the distal radius Located primarily between the distal ulna and the lunate
and the proximal surfaces of the scaphoid and lunate and triquetrum, the TFC is a unique structure that in ways
bones functions in a manner analogous to an intervertebral disc
• The ulnar carpal joint, which comprises the distal ulna and in ways more like a ligament (Fig. 95-2). The TFC is
and the triangular fibroelastic cartilage whose function made up of very strong fibroelastic fibers, and it acts like an
is to connect the distal ulna with the lunate and intervertebral disc in that it serves as the primary shock
triquetrum absorber of the wrist and acts like a ligament in that it serves
• The proximal carpal joints, which connect the scaphoid, as the primary stabilizer for the distal radioulnar joint. The
lunate, and triquetrum via the dorsal, palmar, and inter- TFC is susceptible to trauma and, because of its poor vas-
osseous ligaments cular supply, often heals poorly after injury or surgical inter-
• The midcarpal joints, which comprise the capitate, ventions, especially on its radial surface.
hamate, trapezium, and trapezoid bones The musculotendinous units that are responsible for
The interaction of the many osseous elements that make wrist movement find their origins at the elbow and insert
up the wrist is made possible by a complex collection of on the metacarpals. They can be grouped as flexors, exten-
ligamentous structures and a unique structure called the sors, and deviators. The primary wrist flexors are the flexor
Capitate
Hamate
Trapezoid
Pisiform
Trapezium
Scaphoid Triquetrum
Lunate
Radius
Ulna
• Figure 95-1 Bony anatomy of the wrist.
158
CHAPTER 95 Functional Anatomy of the Wrist 159
Interosseous mm
Extensor digiti
minimi t Adductor pollicis m
3rd Metacarpal
4th Metacarpal
2nd Metacarpal
5th Metacarpal Trapezium
Radial a
Hamate Trapezoid
Extensor Capitate
carpi ulnaris t Scaphoid
Triquetrum Radial collateral lig
Lunate
Triangular Scapholunate lig
fibrocartilage
& complex
Radius
Ulna
Extensor pollicis
brevis t
• Figure 95-2 The triangular fibroelastic cartilage. (From Kang HS, Ahn JM, Resnick D: MRI of the
extremities, ed 2, Philadelphia, 2002, Saunders, p 163.)
carpi radialis and the flexor carpi ulnaris. The primary wrist place by the flexor retinaculum, which extends laterally
extensors are the extensor carpi radialis longus and the from the trapezium and scaphoid to the pisiform and hook
extensor carpi radialis brevis. The primary radial deviator is of the hamate bone. It is estimated that, by preventing
the abductor pollicis longus, and the primary ulnar deviator bowing of the flexor tendons under load, the flexor reti-
is the extensor carpi ulnaris. The flexor tendons are held in naculum increases the force of the flexor tendons fivefold.
96 Visual Inspection of the Wrist and Hand
DORSAL ASPECT SIDE VIEW

The patient is asked to place the hands with the palms The patient is then asked to position his or her hands with
downward, and the examiner inspects the fingers and wrists the thumbs pointing toward the ceiling (Fig. 96-3). A careful
for any swelling or rubor that might suggest an inflamma- assessment of the thenar eminence will sometimes lead the
tory or infectious process (Fig. 96-1). The examiner then examiner to a diagnosis of median nerve entrapment. The
looks for ulnar deviation of the fingers and wrists that might position also allows the examiner to assess the carpometa-
suggest rheumatoid arthritis. Degenerative changes, includ- carpal joint of the thumb for degenerative changes.
ing Heberden and Bouchard nodes of the fingers, are sought
out. The presence or absence of any characteristic swelling
over the wrists that might suggest ganglion cyst is also
noted. Atrophy of the muscles between the metacarpals,
which suggests nerve compromise, is also looked for.
PALMAR ASPECT
The patient is then asked to place the palms upward toward
the ceiling (Fig. 96-2). The examiner looks for atrophy
of the thenar muscles that might be suggestive of a median
nerve lesion or atrophy of the hypothenar muscles that
might be suggestive of an ulnar lesion. Degenerative changes,
especially of the carpometacarpal joint of the thumb, are
looked for, as is the classic thickening of the palmar fascia
indicative of Dupuytren contracture.
• Figure 96-2 Palmar view of the hands.
• Figure 96-1 Dorsal view of the hands. • Figure 96-3 Side view of the hands.
160
97 Palpation of the Wrist and Hand
Palpation of the wrist often leads the examiner to an accu- Dupuytren contracture is then carried out (Fig. 97-2).
rate diagnosis. The patient is asked to relax the wrist and Special attention is paid to the carpometacarpal joint of the
forearm and rest it in the examiner’s hands. Because of the thumbs, as this is a common site for degenerative arthritis.
dense network of flexor tendons and the flexor retinaculum, Attention is then turned to the proximal and distal inter-
subtle pathology of the palmar surface may be missed. phalangeal joints. Each joint is palpated for effusion and
Having the patient place the wrist in slight palmar flexion synovial swelling and is stressed for instability. Finger teno-
will help. The dorsal surface of the wrist is palpated for synovitis is identified by crepitus, volar swelling, and tendon
synovial thickening, swelling, effusion, and color that might thickening.
suggest an inflammatory or infectious disease (Fig. 97-1).
Crepitus of the wrist may be appreciated when the wrist is
passively moved through its range of motion if tenosynovitis
is present. Palpation of the dorsal aspect of the wrist for
ganglion cyst and the plantar surface of the hand for
B
• Figure 97-2 A and B, Classic findings of Dupuytren contracture.
(From Sibaud V, Chevreau C: Abrupt development of Dupuytren’s
contractures with the BRAF inhibitor vemurafenib, Joint Bone Spine
• Figure 97-1 Palpation of the dorsal surface of the wrist. 81(4):373–374, 2014.)
161
98 Extension of the Wrist and Hand
To assess wrist extension, the patient is asked to place the tenosynovitis as well as joint effusions will limit the patient’s
arms at the side and flex the elbows to 98 degrees. The ability to extend the wrist, as will abnormalities of any
patient is then asked to maximally extend or dorsiflex of the joints associated with wrist movement (Fig. 98-2)
his or her wrists (Fig. 98-1). The normal wrist will extend (see Chapter 95).
to approximately 75 degrees. Arthritis, ganglion cysts, or
• Figure 98-1 Lateral view of the extended wrist.
• Figure 98-2 Dorsal or volar ganglion may limit the ability to extend
the wrist. (From Meena S, Gupta A: Dorsal wrist ganglion: current
review of literature, J Clin Orthop Trauma 5(2):59–64, 2014.)
162
99 Flexion of the Wrist and Hand
To assess wrist flexion, the patient is asked to place the arms Arthritis, ganglion cysts, or tenosynovitis as well as joint
at the side and flex the elbows to 90 degrees. The patient is effusions will limit the patient’s ability to flex the wrist, as
then asked to maximally flex his or her wrists (Fig. 99-1). will abnormalities of any of the joints associated with wrist
The normal wrist will flex to approximately 80 degrees. movement (Fig. 99-2) (see Chapter 95).
• Figure 99-1 Lateral view of the flexed wrist.
Median
nerve
Effusion Lateral
• Figure 99-2 Transverse ultrasound image demonstrating a signifi-

cant wrist effusion.
163
100 Adduction of the Wrist and Hand
When the wrists are fully flexed or extended, little adduc- 90 degrees. The patient is then asked to maximally adduct
tion is possible. However, in neutral position, the normal his or her wrists (Fig. 100-1). Arthritis, ganglion cysts, or
wrist will allow approximately 45 degrees of adduction. To tenosynovitis as well as joint effusions will limit the patient’s
assess wrist adduction, the patient is asked to place his or ability to adduct the wrist, as will abnormalities of any of
her arms at the side and flex the elbows to approximately the joints associated with wrist movement (see Chapter 95).
• Figure 100-1 Lateral view of the adducted wrist.
164
101 Abduction of the Wrist and Hand
When the wrists are fully flexed or extended, little abduc- his or her wrists (Fig. 101-1). Arthritis, ganglion cysts, or
tion is possible. However, in neutral position, the normal tenosynovitis as well as joint effusions will limit the patient’s
wrist will allow approximately 18 degrees of abduction. To ability to abduct the wrist, as will abnormalities of any of
assess wrist abduction, the patient is asked to place his or the joints associated with wrist movement (Fig. 101-2) (see
her arms at the sides and flex the elbows to approximately Chapter 95).
90 degrees. The patient is then asked to maximally abduct
• Figure 101-1 Lateral view of the abducted wrist.
Flexor carpi radialis tendon
Proximal Trapezium
Scaphoid
Longitudinal wrist view
• Figure 101-2 Longitudinal ultrasound image demonstrating flexor

tenosynovitis at the wrist. Note the effusion beneath the tendon.
165
102 Painful Conditions of the Wrist
and Hand
The wrist and hand are susceptible to a variety of painful It is important for the clinician to recognize that pain
conditions. More than 90% of them fall into the following perceived in the wrist or hand may have its origin in a distant
categories: anatomic region or pathologic process, such as Pancoast
• Carpal tunnel syndrome tumor or pronator syndrome. Pain in the wrist and hand may
• Carpometacarpal arthritis of the thumb also be referred, and the clinician should always be aware that
• Ganglion cyst angina may present as a dull aching in the wrist and hand.
• Radiocarpal arthritis Table 102-1 provides the clinician with an organizational
• Trigger finger framework on painful conditions of the hand and wrist.
TABLE
Common Painful Conditions of the Wrist and Hand
102-1
Bony Abnormalities Neurologic Abnormalities
Fracture Median nerve entrapment
Tumor Carpal tunnel syndrome
Osteomyelitis Pronator syndrome
Osteonecrosis Anterior interosseous nerve syndrome
Kienböck disease and Preiser disease Ulnar nerve entrapment
Ulnar tunnel syndrome
Articular Abnormalities Cubital tunnel syndrome
Osteoarthritis Cheiralgia paresthetica
Rheumatoid arthritis Lower brachial plexus lesions
Cervical nerve root lesions
Collagen Vascular Diseases
Spinal cord lesions
Reiter syndrome Syringomyelia
Psoriatic arthritis Spinal cord tumors
Crystal Deposition Diseases Reflex sympathetic dystrophy
Causalgia
Gout
Pseudogout Vascular Abnormalities
Pigmented villonodular synovitis Vasculitis
Sprain Raynaud syndrome
Strain Takayasu arteritis
Hemarthrosis Scleroderma
Periarticular Abnormalities Referred Pain
Tendon sheath disorders Shoulder-hand syndrome
Trigger finger Angina
Flexor tenosynovitis
Extensor tenosynovitis
de Quervain tenosynovitis
Dupuytren contracture
Ganglion cyst
Gouty tophi
Subcutaneous nodules associated with rheumatoid arthritis
Glomus tumor
166
103 The Wristwatch Test for Cheiralgia
Paresthetica
Cheiralgia paresthetica is an uncommon cause of wrist and present, although, as mentioned earlier, the overlap of the
hand pain and numbness; it is also known as handcuff lateral antebrachial cutaneous nerve can result in a confus-
neuropathy. The onset of symptoms usually occurs after ing clinical presentation. Flexion and pronation of the
compression of the sensory branch of the radial nerve at wrist, as well as adduction, often cause paresthesias in the
the wrist by tight handcuffs, wristwatch bands, or casts distribution of the sensory branch of the radial nerve
(Fig. 103-1). Cheiralgia paresthetica presents as pain and
associated paresthesias and numbness of the radial aspect of
the dorsum of the hand to the base of the thumb. Because
there is significant interpatient variability in the distribution
of the sensory branch of the radial nerve caused by overlap
of the lateral antebrachial cutaneous nerve, the signs and
symptoms of cheiralgia paresthetica may vary from patient
to patient, and localization of the nerve by ultrasound
imaging may be useful in difficult cases (Fig. 103-2). Direct
trauma to the nerve at this level by radial fracture or surgical
trauma during de Quervain tenosynovitis surgery can also
result in a similar clinical presentation.
Physical findings of cheiralgia paresthetica include ten-
derness over the radial nerve at the wrist. A positive Tinel
sign over the radial nerve at the distal forearm usually is
present (Fig. 103-3). Decreased sensation in the distribu-
tion of the sensory branch of the radial nerve often is
Superficial radial nerve
Dorsal digital nerves

• Figure 103-2 The positive Tinel sign over the radial nerve in chei-
ralgia paresthetica.
Radial
nerve
Radial
artery
• Figure 103-1 Cheiralgia paresthetica presents as pain, paresthe-

sia, and numbness of the radial aspect of the dorsum or the hand to
the base of the thumb. (From Waldman SD: Atlas of uncommon pain • Figure 103-3 Color Doppler image demonstrating the anatomic
syndromes, Philadelphia, 2003, Saunders, p 99.) relationship of the radial artery and nerve at the wrist.
167
168 SECTION 5 The Wrist and Hand
• Figure 103-4 The wristwatch test for cheiralgia paresthetica.
in patients who suffer from cheiralgia paresthetica. Most then exerts firm pressure over the radial nerve at the wrist
patients suffering from cheiralgia paresthetica will also and then instructs the patient to fully adduct his or her wrist
exhibit a positive wristwatch test. To perform the wrist- (Fig. 103-4). The wristwatch sign is considered positive if
watch test for cheiralgia paresthetica, the examiner has the the patient experiences pain, paresthesias, or numbness with
patient fully pronate the affected extremity. The examiner this maneuver.
104 The Finkelstein Test for de Quervain
Tenosynovitis
De Quervain tenosynovitis is caused by inflammation and (Fig. 104-3). De Quervain tenosynovitis also may develop
swelling of the tendons of the abductor pollicis longus and without obvious antecedent trauma in the patient.
extensor pollicis brevis at the level of the radial styloid The pain of de Quervain tenosynovitis is localized to the
process. The inflammation and swelling are usually the region of the radial styloid. It is constant and made worse
result of trauma to the tendon from repetitive twisting with active pinching activities of the thumb or ulnar devia-
motions. If the inflammation and swelling become chronic, tion of the wrist. Patients note an inability to hold a coffee
a thickening of the tendon sheath occurs, with a resulting cup or turn a screwdriver. Sleep disturbance is common. On
constriction of the sheath (Figs. 104-1 and 104-2). A trig- physical examination, there are tenderness and swelling over
gering phenomenon may result, with the tendon catching the tendons and tendon sheaths along the distal radius, with
within the sheath, causing the thumb to lock or “trigger.” point tenderness over the radial styloid (Fig. 104-4). Many
Arthritis and gout of the first metacarpal joint also may patients with de Quervain tenosynovitis exhibit a creaking
coexist with and exacerbate the pain and disability of de sensation with flexion and extension of the thumb. Range
Quervain tenosynovitis. of motion of the thumb may be decreased because of the
De Quervain tenosynovitis occurs in patients who pain, and a trigger thumb phenomenon may be noted.
engage in repetitive activities that include hand grasping, Patients with de Quervain tenosynovitis demonstrate a posi-
such as politicians shaking hands, or high-torque wrist tive Finkelstein test. The Finkelstein test is performed by
turning, such as scooping ice cream at an ice cream parlor stabilizing the patient’s forearm and having the patient fully
A B
C
• Figure 104-1 A, T1 axial image, wrist. Painful mass over the radial styloid process in this postpartum
woman proved to be fibrosis surrounding the extensor pollicis brevis and abductor pollicis longus tendons
(arrowheads), causing obliteration of the subcutaneous fat that normally surrounds these tendons. B, T1
axial image, wrist (different patient than in A). The tendons of the first dorsal compartment are not discrete,
low-signal structures like other wrist tendons and appear enlarged (arrowheads). The subcutaneous fat
surrounding the tendons remains normal in this patient. C, T1 fat-saturation image, with contrast, axial
wrist (different patient than in A and B). There is increased signal and size of the tendons of the first dorsal
compartment and contrast enhancement surrounding the tendons (arrowheads) from extensive tenosy-
novitis. (From Kaplan PA, Helms CA, Dussault R, et al: Musculoskeletal MRI, Philadelphia, 2001, Saunders,
p 259.)
169
MB Extensor pollicus longus

Brevis
Posterior
Note “halo” sign of the Radius

common tendon sheeth.
Transverse distal forearm view
• Figure 104-2 Transverse ultrasound image demonstrating de Quervain tenosynovitis. Note the positive
halo sign indicating fluid surrounding the inflamed tendons.
• Figure 104-3 De Quervain tenosynovitis occurs in patients who

engage in repetitive activities that include hand grasping, such as politi-
cians shaking hands, or high-torque wrist turning, such as scooping
ice cream at an ice cream parlor.
B
• Figure 104-5 A and B, The Finkelstein test for de Quervain
tenosynovitis.
flex his or her thumb into the palm (Fig. 104-5, A). The
examiner then actively forces the wrist toward the ulna
(Fig. 104-5, B). Sudden severe pain is highly suggestive of
de Quervain tenosynovitis (Video 104-1).
Entrapment of the lateral antebrachial cutaneous nerve,
arthritis of the first metacarpal joint, gout, cheiralgia pares-
thetica, and, occasionally, C6-C7 radiculopathy can mimic
de Quervain tenosynovitis. Cheiralgia paresthetica is an
entrapment neuropathy, the result of entrapment of the
• Figure 104-4 De Quervain tenosynovitis. (From Fam AG: The wrist
superficial branch of the radial nerve at the wrist. Electro-
and hand. In Klippel JH, Dieppe PA, editors: Rheumatology, ed 2, myography helps to distinguish cervical radiculopathy and
London, 1998, Mosby, pp 4-6.9.) cheiralgia paresthetica from de Quervain tenosynovitis.
105 The Allen Test for Patency of the
Radial and Ulnar Arteries at the Wrist
The Allen test for patency of the radial and ulnar arteries is indicating occlusion of the radial and ulnar arteries at the
useful in helping the clinician identify compromise of the wrist by the examiner (Fig. 105-3). The radial artery is then
superficial and deep palmar arches, which are continuations released by the examiner. If the radial artery is patent, the
of the ulnar and radial arteries, respectively. Although color will immediately return to the patient’s hand (Fig.
trauma to the arteries is the most common cause of com- 105-4). If the color does not return to the hand, the Allen
promise of the vasculature of the hand, embolism, throm- test is considered positive for occlusion of the radial artery
bosis, aneurysm, and vasculitis are but a few of the other at the wrist. The test is then repeated, with the examiner
problems that can result in ischemic pain and associated this time releasing the ulnar artery first. If the ulnar artery
dysfunction of the hand (Fig. 105-1). is patent, the color will return to the hand. If the color does
To perform the Allen test, the patient is asked to raise not return to the hand, the Allen test is positive for occlu-
his or her hand and to make a fist while the examiner sion of the ulnar artery.
occludes the radial and ulnar arteries at the wrist (Fig.
105-2). The patient is then asked to extend his or her hand,
and blanching of the palmar surface should be seen,
• Figure 105-1 Digital tip infarction in polyarteritis nodosa. (From • Figure 105-2 The Allen test for patency of the radial and ulnar
Hochberg MC, Silman AJ, Smolen JS, et al, editors: Rheumatology, arteries at the wrist: the examiner occludes the radial and ulnar arteries
ed 4, vol 2, Philadelphia, 2008, Mosby, p 1515.) at the wrist.
171
• Figure 105-4 The Allen test for patency of the radial and ulnar
• Figure 105-3 The Allen test for patency of the radial and ulnar arteries at the wrist: if the radial artery is patent, the color will imme-
arteries at the wrist: the patient is asked to extend his or her hand, diately return to the patient’s hand.
and blanching of the palmar surface should be seen, indicating occlu-
sion of the radial and ulnar arteries at the wrist by the examiner.
106 The Watson Stress Test for Arthritis
of the Carpometacarpal Joint of
the Thumb
The carpometacarpal joint of the thumb is susceptible to Some patients complain of a grating or “popping” sensation
the development of arthritis from a variety of conditions with use of the joint, and crepitus may be present on physi-
that have in common the ability to damage the joint carti- cal examination. The Watson stress test is positive in patients
lage. Osteoarthritis of the joint is the most common form who suffer from inflammation and arthritis of the carpo-
of arthritis that results in pain in the carpometacarpal joint metacarpal joint of the thumb.
of the thumb (Fig. 106-1). Rheumatoid arthritis, posttrau- The Watson test is performed by having the patient place
matic arthritis, and psoriatic arthritis are also common the dorsum of the hand against a table with the fingers fully
causes of carpometacarpal joint pain secondary to arthritis. extended and then pushing the thumb back toward the
Less common causes of arthritis-induced carpometacarpal table (Fig. 106-2). The test is positive if the patient’s pain
pain include the collagen vascular diseases, infection, and is reproduced.
Lyme disease. In addition to the above-mentioned pain, patients
The majority of patients with carpometacarpal pain sec- who suffer from arthritis of the carpometacarpal joint often
ondary to osteoarthritis and posttraumatic arthritis pain experience a gradual decrease in functional ability, with
present with the complaint of pain that is localized to the decreasing pinch and grip strength, thereby making every-
base of the thumb. Activity, especially with pinching and day tasks such as using a pencil or opening a jar quite dif-
gripping motions, exacerbates the pain, with rest and heat ficult. With continued disuse, muscle wasting may occur,
providing some relief. The pain is constant and is character- and an adhesive capsulitis with subsequent ankylosis may
ized as aching in nature. The pain may interfere with sleep. develop.
• Figure 106-1 Plain radiograph demonstrating osteoarthritis of the

first carpometacarpal and scaphotrapeziotrapezoid joint in a patient
with a positive Watson test. (From Waldman SD, Campbell, RSD:
Imaging of pain, Philadelphia, 2010, Saunders/Elsevier, p 298, • Figure 106-2 The Watson stress test for arthritis of the carpometa-
fig 117-1.) carpal joint of the thumb.
173
107 The Ulnar Click Test for Ulnar
Impaction Syndrome
Ulnar impaction syndrome is an overuse syndrome associ- worse with ulnar loading. Most patients with ulnar impac-
ated with repetitive activities that have in common the tion syndrome will also exhibit a positive click test with
gripping of heavy objects held away from the body. Ulnar ulnar loading.
impaction syndrome is seen in chefs and candymakers who To perform the ulnar click test for ulnar impaction
hold hot, heavy pots or frying pans by the handle away syndrome, the examiner has the patient flex the elbow of
from their bodies. To maximize grip strength, the wrist is the affected extremity to 90 degrees and then has the
forced into a slightly plantar-flexed position with significant patient maximally clench the fist on the affected side
ulnar deviation. This results in an excessive load-bearing (Fig. 107-2, A). The examiner then exerts increasingly heavy
across the ulnar aspect of the wrist. Over time, chronic loading onto the ulnar aspect of the wrist (Fig. 107-2, B).
impaction of the ulnar head against the triangular fibroelas- If ulnar impaction syndrome is present, a palpable and
tic cartilage, triquetrum, and lunate results in degenerative occasionally audible click will be appreciated as the ulnar
changes (Fig. 107-1). load-bearing components of the wrist fail.
Patients who present with ulnar impaction syndrome
will complain of pain across the ulnar aspect of the wrist
and an increasing inability to perform the task that caused
the syndrome in the first place. On physical examination,
the examiner will often identify swelling and diffuse tender-
ness across the ulnar aspect of the wrist. Decreased grip
strength is often present, and the patient’s pain is made
• Figure 107-1 Plain radiography of the ulnar impaction syndrome. B

Note cysts and sclerosis (arrows) in the lunate bone. (From Resnick
D, Kang HS: Internal derangement of the joints: emphasis on MR • Figure 107-2 A and B, The ulnar click test for ulnar impaction
imaging, Philadelphia, 1997, Saunders.) syndrome.
174
108 Carpal Tunnel Syndrome
Carpal tunnel syndrome is caused by compression of the The most common causes of compression of the median
median nerve as it passes through the carpal canal at nerve at this anatomic location include flexor tenosynovitis,
the wrist. The median nerve is made up of fibers from the rheumatoid arthritis, pregnancy, amyloidosis, and space-
C5-T1 spinal roots. The nerve lies anterior and superior to occupying lesions including abnormalities of the median
the axillary artery in the 12 o’clock to 3 o’clock quadrant. nerve and artery, for example, persistent median artery, that
Exiting the axilla, the median nerve descends into the upper compromise the median nerve as it passes though this closed
arm along with the brachial artery. At the level of the elbow, space (Fig. 108-3). This entrapment neuropathy presents as
the brachial artery is just medial to the biceps muscle. At pain, numbness, paresthesias, and associated weakness in
this level, the median nerve lies just medial to the brachial the hand and wrist that radiates to the thumb, index and
artery. As the median nerve proceeds downward into the
forearm, it gives off numerous branches that provide motor
innervation to the flexor muscles of the forearm. These
branches are susceptible to nerve entrapment by aberrant
ligaments, muscle hypertrophy, and direct trauma. The
nerve approaches the wrist overlying the radius. It lies deep
within and between the tendons of the palmaris longus
muscle and the flexor carpi radialis muscle at the wrist. Intercostobrachial n.
The median nerve then passes beneath the flexor reti- Med. cutaneous n.
Ulnar n.
naculum and through the carpal tunnel, with the nerve’s
terminal branches providing sensory innervation to a Radial n.
portion of the palmar surface of the hand as well as the Median n.
palmar surface of the thumb, index and middle fingers, and
radial portion of the ring finger (Figs. 108-1 and 108-2).
The median nerve also provides sensory innervation to the
distal dorsal surface of the index and middle fingers and the
radial portion of the ring finger (see Fig. 108-2). The carpal
tunnel is bounded on three sides by the carpal bones and is
covered by the transverse carpal ligament. In addition to the
median nerve, it contains a number of flexor tendon sheaths,
blood vessels, and lymphatics.
Median n.
• Figure 108-2 The sensory distribution of the median nerve.

(From Waldman S: Atlas of interventional pain management, ed 4,
Philadelphia, 2015, Elsevier, p 267, fig 59-7.)
Ulnar a. Persistent median artery
Transverse Median nerve

carpal ligament
Flexor digitorum
Median n.
Transverse left wrist scan
• Figure 108-3 Transverse ultrasound image demonstrating a per-

sistent median artery compressing the median nerve within the carpal
• Figure 108-1 Carpal tunnel syndrome: relevant anatomy. tunnel.
175
middle fingers, and radial half of the ring finger. These reflex changes, and motor and sensory changes are limited
symptoms also may radiate proximal to the entrapment into to the distal median nerve. Diabetic polyneuropathy gener-
the forearm. Untreated, progressive motor deficit and ulti- ally presents as symmetric sensory deficit involving the
mately flexion contracture of the affected fingers can result. entire hand, rather than limited just to the distribution of
The onset of symptoms is usually after repetitive wrist the median nerve. Because carpal tunnel syndrome is com-
motions or from repeated pressure on the wrist, such as monly seen in patients with diabetes, it is not surprising
resting the wrists on the edge of a computer keyboard. that diabetic polyneuropathy is usually present in diabetic
Direct trauma to the median nerve as it enters the carpal patients with carpal tunnel syndrome.
tunnel also may result in a similar clinical presentation. The Electromyography helps distinguish cervical radiculopa-
pain of carpal tunnel syndrome is often worse at night, with thy and diabetic polyneuropathy from carpal tunnel syn-
the patient awakened from a sound sleep to find his or her drome. Plain radiographs are indicated in all patients who
hand numb and a need to shake the affected hands to get present with carpal tunnel syndrome to rule out occult bony
the “circulation going.” pathology. On the basis of the patient’s clinical presentation,
Physical findings include tenderness over the median additional testing might be indicated, including complete
nerve at the wrist. A positive Tinel sign over the median blood count, uric acid, sedimentation rate, and antinuclear
nerve as it passes beneath the flexor retinaculum usually is antibody testing. Magnetic resonance and ultrasound
present (see Chapter 109). A positive Phalen test is also imaging of the wrist might also help identify not only the
highly suggestive of carpal tunnel syndrome (see Chapter presence of median nerve entrapment at the wrist but also
110). Weakness of thumb opposition and wasting of the the anatomic structures that are responsible for the entrap-
thenar eminence often are seen in advanced carpal tunnel ment (Fig. 108-5). Ultrasound imaging with measurement
syndrome, although because of the complex motion of
the thumb, subtle motor deficits easily may be missed
(Fig. 108-4; see also Chapters 111 and 112). Early in the
course of the evolution of carpal tunnel syndrome, the only
physical finding other than tenderness over the nerve may
be the loss of sensation in the above-mentioned fingers,
which can be most easily identified with the two-point
discrimination test (see Chapter 113). Later in the disease,
the examiner may appreciate a hotdog-shaped swelling
along the ulnar side of the palmaris longus tendon extend-
ing proximally from the wrist crease (see Chapter 114).
Carpal tunnel syndrome is often misdiagnosed as arthri-
tis of the carpometacarpal joint of the thumb, cervical
radiculopathy, or diabetic polyneuropathy. Patients with
arthritis of the carpometacarpal joint of the thumb have a
positive Watson test and radiographic evidence of arthritis. • Figure 108-4 Thenar muscle atrophy. Chronic entrapment of the
median nerve in the carpal tunnel or more proximally can produce
Most patients who suffer from a cervical radiculopathy have thenar atrophy as seen in the patient. (From Nahsel DJ: Soft tissue.
reflex, motor, and sensory changes associated with neck In: Klippel JH, Dieppe PA, editors: Rheumatology, ed 2, London, 1998,
pain, whereas patients with carpal tunnel syndrome have no Mosby, pp 4–16.7.)
A B
• Figure 108-5 A, T2* axial image, wrist at the distal radioulnar joint. The median nerve (arrowheads)
has a normal size and signal prior to entering the carpal tunnel. B, T2* axial magnetic resonance (MR)
image, wrist at the pisiform. The median nerve (arrowheads) is enlarged and has a high signal. The flexor
retinaculum is bowed volarly, and there is increased signal and space between flexor tendons from teno-
synovitis. (From Kaplan PA, Helms CA, Dussault R, et al: Musculoskeletal MRI, Philadelphia, 2001,
Saunders, p 263.)
CHAPTER 108 Carpal Tunnel Syndrome 177
Ulnar a. Median n.
Ulnar Radial
B Lunate
1 Circ 16.8 mm
Transverse wrist scan Area 14 mm2
380/380
• Figure 108-6 Transverse ultrasound image demonstrating an

enlarged median nerve at the level of the proximal wrist crease with a
cross-sectional area 14 mm2. Cross-sectional measurement of the
median nerve at this level of greater than 11 mm2 strongly suggests a
diagnosis of carpal tunnel syndrome.
of the cross-sectional area of the median nerve at the level roots, which at times mimics median nerve compression.
of the proximal wrist crease has been shown to be highly Furthermore, it should be remembered that cervical radicu-
accurate in helping diagnose carpal tunnel syndrome, with lopathy and median nerve entrapment may coexist in the
nerves with a cross-sectional area greater than 11 mm2 so-called double crush syndrome. The double crush syn-
highly suggestive of the diagnosis of carpal tunnel syndrome drome is seen most commonly with median nerve entrap-
(Fig. 108-6). ment at the wrist or carpal tunnel syndrome.
Carpal tunnel syndrome also should be differentiated
from cervical radiculopathy involving the cervical nerve
109 The Tinel Sign for Carpal
Tunnel Syndrome
There are a number of clinical tests and signs to aid the the overlying flexor retinaculum and flexor tendons (Fig.
clinician in the physical diagnosis of carpal tunnel syn- 109-1). The examiner then percusses the median nerve
drome. Perhaps the most famous is the Tinel sign. using the broad side of a neurologic hammer, which is more
To elicit the Tinel sign for carpal tunnel syndrome, the effective at compressing the entire transverse carpal liga-
patient is asked to relax the affected extremity. The patient ment over the nerve. The Tinel sign is positive if the patient
is then asked to place the palm upward, and the examiner perceives paresthesias that radiate distally into the thumb
brings the affected hand into a full but not forced and index and middle fingers (Video 109-1).
dorsiflexed position to compress the carpal tunnel with
• Figure 109-1 The Tinel sign for carpal tunnel syndrome.
178
110 The Phalen Test for Carpal
Tunnel Syndrome
To perform the Phalen test for carpal tunnel syndrome, the palmar-flexed position for a minimum of 30 seconds (Fig.
patient is asked to relax both upper extremities with the 110-1). The Phalen test is positive for a presumptive diag-
arms held at the patient’s sides. The patient is then asked to nosis of carpal tunnel syndrome if the patient’s symptoms
allow the wrists to hang downward in a fully, but not forced, are reproduced or worsened (Video 110-1).
• Figure 110-1 The Phalen test for carpal tunnel syndrome.
179
111 The Opponens Weakness Test for
Carpal Tunnel Syndrome
The opponens weakness test, which tests the strength of the is then asked to adduct the thumb toward the little finger
adductor pollicis brevis muscle, is another of the many tests (Fig. 111-1, A) and then to abduct the thumb against the
that aid in diagnosis of carpal tunnel syndrome. examiner’s resistance against the distal phalanx (Fig. 111-1,
To perform the opponens weakness test for carpal tunnel B). The opponens weakness test is positive for a presumptive
syndrome, the patient is asked to relax the affected upper diagnosis of carpal tunnel syndrome if the patient demon-
extremity, with the dorsal surface of the affected hand strates weakness of adduction indicating compromise of the
resting comfortably on the examination table. The patient adductor pollicis brevis muscle (Video 111-1).
A B
• Figure 111-1 A and B, The opponens weakness test for carpal tunnel syndrome.
180
112 The Opponens Pinch Test for Carpal
Tunnel Syndrome
The opponens pinch test evaluates the strength of the pinch as tightly as possible. The examiner then tries to break
adductor pollicis muscle. To perform the opponens pinch the pinch against the patient’s resistance (Fig. 112-1). The
test for carpal tunnel syndrome, the patient is asked to opponens pinch test is positive for a presumptive diagnosis
relax the affected upper extremity, with the dorsal surface of carpal tunnel syndrome if the patient demonstrates an
of the affected hand resting comfortably on the examina- inability to hold the pinch, which indicates compromise of
tion table. The patient is then asked to pinch the thumb the adductor pollicis muscle (Video 112-1).
against the little finger. The patient is asked to hold the
• Figure 112-1 The opponens pinch test for carpal tunnel syndrome.
181
113 The Two-Point Discrimination Test for
Among the number of clinical tests and signs to aid in touching the tip of the index finger. The points of the cali-
physical diagnosis is the two-point discrimination test, pers are initially placed 1 cm apart and are gradually brought
which tests the sensory fibers of the median nerve. To together (Fig. 113-1). The two-point discrimination test is
perform the two-point discrimination test for carpal tunnel positive for a presumptive diagnosis of carpal tunnel syn-
syndrome, the patient is asked to relax the affected upper drome if the patient demonstrates an inability to distinguish
extremity, with the dorsal surface of the affected hand whether the tip of the index finger is being touched by 1
resting comfortably on the examination table. The examiner or 2 points as the calipers are brought closer than 0.5 cm
then uses an electrocardiograph caliper to test the ability of together, which indicates compromise of the sensory fibers
the patient to distinguish whether there are 1 or 2 points of the median nerve.
• Figure 113-1 The two-point discrimination test for carpal tunnel

syndrome.
182
114 The Dowart Hotdog Sign for
The Dowart hotdog sign is thought to be caused by The palmaris longus tendon is then identified by asking
the bowing out of the flexor retinaculum and flexor the patient to flex his or her wrist against resistance. After the
tendons because of pressure from an enlarged median nerve tendon is identified, the patient is asked to again relax the
(Fig. 114-1). affected hand and wrist. The Dowart hotdog sign is consid-
The Dowart hotdog sign is identified by having the ered positive if the examiner observes a hotdog-shaped
patient relax the affected upper extremity and rest the swelling along the ulnar side of the palmaris longus tendon
dorsum of the hand comfortably on the examination table. that extends proximally from the wrist crease (Fig. 114-2).
Note the bulging and thickened

transverse carpal ligament
Note swollen appearance of nerve

with loss of internal architecture
Ulnar
artery
Note lesion of the median nerve
Transverse carpal tunnel view
• Figure 114-1 Transverse ultrasound image demonstrating a

bulging and thickened transverse carpal ligament.
Dowart
hotdog sign
Palmaris
Median n. longus tendon
• Figure 114-2 The Dowart hotdog sign for carpal tunnel syndrome.
183
115 The Spread Sign for Ulnar
Tunnel Syndrome
Ulnar tunnel syndrome is caused by compression of the neuropathy presents most commonly as a pure motor neu-
ulnar nerve as it passes through Guyon canal at the wrist. ropathy without pain, which is caused by compression of
The most common causes of compression of the ulnar nerve the deep palmar branch of the ulnar nerve as it passes
at this anatomic location are space-occupying lesions, through Guyon canal (see Figs. 115-1 and 115-2). This pure
including ganglion cysts and ulnar artery aneurysms; frac- motor neuropathy presents as painless paralysis of the
tures of the distal ulna and carpals; and repetitive motion intrinsic muscles of the hand.
injuries that compromise the ulnar nerve as it passes though Ulnar tunnel syndrome may also present as a mixed
this closed space (Figs. 115-1 and 115-2). This entrapment sensory and motor neuropathy. Clinically this mixed neu-
ropathy presents as pain, numbness, and paresthesias of the
wrist that radiate into the ulnar aspect of the palm and
dorsum of the hand and the little finger, as well as the ulnar
half of the ring finger. These symptoms also may radiate
proximal to the nerve entrapment into the forearm. Like
carpal tunnel syndrome, the pain of ulnar tunnel syndrome
is frequently worse at night and made worse by vigorous
flexion and extension of the wrist. If it is left untreated,
progressive motor deficit and ultimately flexion contracture
of the affected fingers can result. The onset of symptoms is
h usually after repetitive wrist motions or from direct trauma
to the wrist, such as wrist fractures or direct trauma to the
proximal hypothenar eminence, which may occur when the
hand is used to hammer on hubcaps or from handlebar
compression during long-distance cycling (Fig. 115-3).
• Figure 115-1 T2* axial magnetic resonance (MR) image, wrist.

There is a ganglion cyst (arrow) in the ulnar tunnel adjacent to the hook
of the hamate (h), causing a compressive neuropathy of the ulnar
nerve. (From Kaplan PA, Helms CA, Dussault R, et al: Musculoskeletal
MRI, Philadelphia, 2001, Saunders, p 265.)
Ulnar
nerve
Pisaform
bone
Ulnar
Ulnar artery
nerve
• Figure 115-2 Transverse color Doppler image demonstrating the • Figure 115-3 The onset of ulnar tunnel syndrome is usually after
anatomic relationship of the ulnar artery and nerve as they pass repetitive wrist motions. (From Waldman SD: Atlas of pain manage-
through Guyon canal. ment injection techniques, Philadelphia, 2000, Saunders, p 151.)
184
CHAPTER 115 The Spread Sign for Ulnar Tunnel Syndrome 185
Physical findings include tenderness over the ulnar nerve

at the wrist. A positive Tinel sign over the ulnar nerve as it
passes beneath the transverse carpal ligament is usually
present. If the sensory branches are involved, there is
decreased sensation into the ulnar aspect of the hand and
the little finger as well as the ulnar half of the ring finger.
Depending on the location of neural compromise, the
patient might have weakness of the intrinsic muscles of the
hand, as evidenced by the inability to spread the fingers, or
weakness of the hypothenar eminence. This weakness of the
intrinsic hand muscles is called a positive spread sign.
To perform the spread sign, the patient is asked to relax
the affected extremity and comfortably rest the wrist on the
examination table. The patient is then asked to spread his
or her fingers apart as far as possible. A positive spread sign
is observed if the patient is unable to spread 2 or more
fingers apart (Fig. 115-4). The examiner should be aware
that the little finger is often spared while at the same time
the patient is unable to spread apart the other fingers
because the compromise is limited to the deep palmar
branch of the ulnar nerve (Video 115-1).
Ulnar tunnel syndrome is often misdiagnosed as arthritis
of the carpometacarpal joints, cervical radiculopathy, or
diabetic polyneuropathy. Patients with arthritis of the car-
• Figure 115-4 The spread sign for ulnar tunnel syndrome.
pometacarpal joint usually have radiographic evidence and
physical findings that might be suggestive of arthritis. Most
patients who suffer from a cervical radiculopathy have
reflex, motor, and sensory changes associated with neck
pain, whereas patients with ulnar tunnel syndrome have no entrapment and should be ruled out by apical lordotic chest
reflex changes, and motor and sensory changes are limited radiograph.
to the distal ulnar nerve. Diabetic polyneuropathy generally Electromyography helps distinguish cervical radiculopa-
presents as symmetric sensory deficit involving the entire thy, diabetic polyneuropathy, and Pancoast tumor from
hand, rather than being limited just to the distribution of ulnar tunnel syndrome. Plain radiographs are indicated in
the ulnar nerve. It should be remembered that cervical all patients who present with ulnar tunnel syndrome to rule
radiculopathy and ulnar nerve entrapment may coexist as out occult bony pathology. On the basis of the patient’s
the so-called double crush syndrome. Furthermore, because clinical presentation, additional testing including complete
ulnar tunnel syndrome is commonly seen in patients with blood count, uric acid, sedimentation rate, and antinuclear
diabetes, it is not surprising that diabetic polyneuropathy is antibody testing might be indicated. Magnetic resonance
usually present in diabetic patients with ulnar tunnel syn- and ultrasound imaging of the wrist is indicated if joint
drome. Pancoast tumor invading the medial cord of the instability or a space-occupying lesion is suspected and to
brachial plexus also may mimic an isolated ulnar nerve help confirm the diagnosis.
116 Flexion/Extension Test for Ganglion
Cysts of the Wrist
The dorsal and volar aspect of the wrist is especially suscep- transilluminates with a penlight, in contradistinction to
tible to the development of ganglion cysts. These cysts are solid tumors, which do not transilluminate. Palpation of the
thought to form as the result of herniation of synovial ganglion may increase the pain. Patients with ganglion cysts
fluid–containing tissues from joint capsules or tendon of the dorsal and volar aspect of the wrist will exhibit a
sheaths. This tissue may then become irritated and begin to positive extreme flexion/extension test.
produce increased amounts of synovial fluid, which can To perform the extreme flexion/extension test for gan-
pool in cystlike cavities overlying the tendons and joint glion cyst of the wrist, the examiner first localizes the
space. A one-way valve phenomenon may cause these cyst- ganglion cyst to the dorsal or volar aspect of the wrist
like cavities to expand, because the fluid cannot flow freely (Fig. 116-2). If the ganglion is on the dorsal aspect, the
back into the synovial cavity. examiner forcefully flexes the patient’s affected wrist. If the
Activity, especially extreme flexion and extension, makes ganglion cyst is located on the volar aspect of the wrist,
the pain worse, with rest and heat providing some relief. the examiner forcefully extends the patient’s affected wrist.
The pain is constant and is characterized as aching in nature. The extreme flexion/extension test is positive if the forceful
It is often the unsightly nature of the ganglion cyst, rather flexion or extension of the wrist causes a marked increase
than the pain, that causes the patient to seek medical atten- in the patient’s pain.
tion (Fig. 116-1). The ganglion is smooth to palpation and
Ganglion cyst
• Figure 116-1 A ganglion on the volar aspect of the wrist. (From

Fam AG: The wrist and hand. In Klippel JH, Dieppe PA, editors: Rheu-
matology, ed 2, London, 1998, Mosby, pp 4-9.3.) • Figure 116-2 Localization of the ganglion cyst of the wrist.
186
117 The Hunchback Carpal Sign for
Carpal Boss
Carpal boss, which is also known as os styloideum, is the

term used to described a painful exostosis that arises along
the dorsal surface of the second or third carpometacarpal
joints. The carpal boss is thought to be the result of repeti-
tive microtrauma or fusion of an accessory ossicle that
results in this development of bony exostosis. The patient
with carpal boss presents with aching across the dorsal
surface of the wrist in the area of the second and third
carpometacarpal joints that is made worse with strenuous
activity that requires repetitive finger or wrist extension.
This bony excrescence is often mistaken for a dorsal
ganglion cyst (Fig. 117-1). Palpation of this area reveals
point tenderness, and the examiner may appreciate a dorsal
bony prominence known as the hunchback carpal sign
(Fig. 117-2). Extreme flexion will often make identifica-
tion easier (Fig. 117-3). Plain radiographs or magnetic reso-
nance and/or ultrasound imaging will confirm the clinical
diagnosis of carpal boss and guide treatment, which consists
of local injections of corticosteroid and surgical removal
(Fig. 117-4).
• Figure 117-2 The hunchback carpal sign for carpal boss.
• Figure 117-3 Extreme flexion of the wrist may simplify the identifi-
• Figure 117-1 Appearance of a carpal boss (arrow). (From Park MJ, cation of a carpal boss (arrow). (From Park MJ, Namdari S, Weiss A-P:
Namdari S, Weiss A-P: The carpal boss: review of diagnosis and treat- The carpal boss: review of diagnosis and treatment. J Hand Surg
ment. J Hand Surg 33(3):446–449, 2008, fig 1.) 33(3):446–449, 2008, fig 2.)
187
A B
C
• Figure 117-4 A to C, Arrows indicate a bony exostosis consistent with a carpal boss. (From Resnick
D: Diagnosis of bone and joint disorders, Philadelphia, 2002, Saunders, p 1312.)
118 The Tuck Sign for Extensor
Tenosynovitis of the Wrist
The extensor tendons of the wrist pass beneath the extensor tuck sign. To elicit a tuck sign, the examiner has the patient
retinaculum via six tendon sheaths. These tendon sheaths lightly clench his or her fist for 30 seconds. The examiner
are susceptible to inflammation and scarring, which can observes the dorsum of the clenched fist for swelling that is
cause pain and functional disability. As this process becomes consistent with extensor tenosynovitis (Fig. 118-1). If it is
chronic, a thickening of the extensor tendon sheaths results present, the examiner has the patient gradually fully extend
in an ovoid swelling on the dorsum of the hand. On physi- the fingers of the clenched fist. The tuck sign for extensor
cal examination, this swollen area is warm and tender. On tenosynovitis of the wrist is considered positive if as the
palpation, the examiner may appreciate a creaking sensation patient extends his or her hand, the area of swelling moves
as the fingers move through the inflamed and narrowed proximally and folds under the flexor retinaculum like a
tendon sheaths. In addition, many patients with active sheet being tucked under a mattress (Fig. 118-2).
extensor tenosynovitis of the wrist will exhibit a positive
Tendon
sheaths
Tendon
sheaths
Extensor
retinaculum Extensor
retinaculum
• Figure 118-1 The examiner should observe the dorsum of the

clenched fist for swelling consistent with extensor tenosynovitis. • Figure 118-2 The tuck sign for extensor tenosynovitis of the wrist.
189
119 The Palmar Band Sign for
Dupuytren Contracture
Dupuytren contracture is caused by a progressive fibrosis of In the early stages of the disease, hard, fibrotic nodules
the palmar fascia. Initially, the patient might notice fibrotic may be palpated along the path of the flexor tendons. These
nodules that are tender to palpation along the course of the nodules often are misdiagnosed as calluses or warts. At this
flexor tendons of the hand. These nodules arise from the early stage, pain is invariably present. As the disease pro-
palmar fascia and initially do not involve the flexor tendons gresses, the clinician notes taut, fibrous bands that may cross
(Fig. 119-1). As the disease advances, these fibrous nodules the metacarpophalangeal joint and ultimately the proximal
coalesce and form fibrous bands that gradually thicken and interphalangeal joint, which constitutes a positive palmar
contract around the flexor tendons, a process that has the band sign that is pathognomonic for Dupuytren contrac-
effect of drawing the affected fingers into flexion. Although ture (Fig. 119-2). As the disease progresses, these bands
all fingers can develop Dupuytren contracture, the ring and become less painful to palpation, and although they limit
little fingers are most commonly affected. If untreated, the finger extension, finger flexion remains relatively normal. It
fingers will develop permanent flexion contractures. The is at this point that patients often seek medical advice, as
pain of Dupuytren contracture seems to burn itself out as they begin having difficulty putting on gloves and reaching
the disease progresses. into their pockets to retrieve keys. In the final stages of the
Dupuytren contracture is thought to have a genetic basis disease, the flexion contracture develops with its attendant
and occurs most frequently in males of northern Scandina- negative impact on function. Arthritis and gout involving
vian descent. The disease also may be associated with trauma the metacarpal and interphalangeal joints and trigger finger
to the palm, diabetes, alcoholism, and chronic barbiturate may coexist with and exacerbate the pain and disability of
use. The disease rarely occurs before the fourth decade. The Dupuytren contracture.
plantar fascia also may be concurrently affected.
Fibromatosis
Flexor tendons
Proximal phalanx
Metacarpal
head
Longitudinal MCP joints view
• Figure 119-1 Longitudinal ultrasound image demonstrating the • Figure 119-2 Dupuytren contracture of the palmar fascia. (From
classic palmar fibrosis associated with Dupuytren contracture. Fam AG: The wrist and hand. In Klippel JH, Dieppe PA, editors: Rheu-
Note that there is no involvement of the flexor tendon. MCP, matology, ed 2, London, 1998, Mosby, p 4-9.7.)
Metacarpophalangeal.
190
120 The Allen Test for Patency of the
Digital Arteries of the Fingers
The Allen test for patency of the digital arteries is useful in

helping the clinician identify compromise of the digital
arteries. Although trauma to the arteries is the most common
cause of compromise of the vasculature of the fingers,
embolism, thrombosis, aneurysm, and vasculitis are but a
few of the other problems that can result in ischemic pain
and associated dysfunction of the fingers (see Fig. 105-1).
To perform the Allen test, the patient is asked to raise
his or her hand and to tightly flex the affected digit
while the examiner occludes the digital arteries on each side
of the digit (Fig. 120-1). The patient is then asked to extend
the affected finger, and blanching of the finger should be
seen, indicating occlusion of digital arteries by the examiner
(Fig. 120-2). The digital artery on the radial side of the
finger is then released by the examiner. If the artery is
patent, the color will immediately return to the patient’s • Figure 120-2 The Allen test for patency of the digital arteries of the
fingers: the patient is asked to extend the affected finger; blanching of
finger (Fig. 120-3). If the color does not return to the finger, the finger should be seen, indicating occlusion of digital arteries by the
the Allen test is considered positive for occlusion of the examiner.
digital artery on the radial side of the finger. The test is then
repeated, with the examiner this time releasing the artery
on the ulnar side of the artery first. If that digital artery is
patent, the color will return to the finger. If the color does
not return to the finger, the Allen test is positive for occlu-
sion of the digital artery on the ulnar side of the affected
finger.
• Figure 120-3 The Allen test for patency of the digital arteries of the
fingers: the digital artery on the radial side of the finger is released by
• Figure 120-1 The Allen test for patency of the digital arteries of the the examiner. If the artery is patent, the color will immediately return
fingers: the patient is asked to raise his or her hand and to tightly flex to the patient’s finger. If the color does not return to the finger, the Allen
the affected digit while the examiner occludes the digital arteries on test is considered positive for occlusion of the digital artery on the
each side of the digit. radial side of the finger.
191
121 The Catching Tendon Sign for Trigger
Finger Syndrome
Trigger finger is caused by inflammation and swelling of the trigger finger is constant and is made worse with active
tendons of the flexor digitorum superficialis muscle caused gripping activities of the hand. Patients note significant
by compression and irritation of the tendons by the heads stiffness when flexing the fingers. Sleep disturbance is
of the metacarpal bones (Fig. 121-1). Sesamoid bones in common, and the patient often awakens to find that the
this region also may cause compression and trauma to the finger has become locked in a flexed position during sleep.
tendons. The inflammation and swelling of the tendon are On physical examination, there are tenderness and swelling
usually the result of trauma to the tendon from repetitive over the tendon with maximal point tenderness over the
motion or pressure overlying the tendon as it passes over heads of the metacarpals. Many patients with trigger finger
these bony prominences. If the inflammation and swelling exhibit a “creaking” sensation with flexion and extension of
become chronic, a thickening of the tendon sheath occurs, the fingers. Range of motion of the fingers may be decreased
with a resulting constriction of the sheath. Frequently, a because of the pain, and a trigger finger phenomenon may
nodule develops on the tendon due to chronic pressure and be noted. Patients with trigger finger often have palpable
irritation. These nodules often can be palpated when the nodules on the tendons of the flexor digitorum superficialis
patient flexes and extends the fingers. Such nodules may muscle as well as a positive catching tendon sign on passive
catch in the tendon sheath as the nodule passes under a extension of the tendon.
restraining tendon pulley and cause a triggering phenome- To identify the catching tendon sign for trigger finger,
non, causing the finger to catch or lock as the nodule the examiner has the patient hold his or her fist in a tightly
catches on the pulley (Fig. 121-2). clenched position for 30 seconds. The examiner then
Coexistent arthritis and gout of the metacarpal and instructs the patient to relax but not open his or her fist.
interphalangeal joints may also exacerbate the pain and dis- The examiner then passively extends the affected finger. The
ability of trigger finger. Trigger finger occurs in patients who catching tendon sign is positive if the examiner appreciates
engage in repetitive activities that include hand clenching, a locking, popping, or catching of the tendon as the finger
such as gripping a steering wheel or holding a horse’s reins is straightened (Fig. 121-3 and Video 121-1).
too tightly.
The pain of trigger finger is localized to the distal palm,
with tender tendon nodules often palpated. The pain of
Palmar retinaculum
Superficial Superficial
tendon tendon Fluid
Deep tendon
Deep Inflamed nodule
tendon
distal to pulley
Inflamed nodule
3rd proximal to pulley
4th
Transverse flexor tendons of the hand proximal to A1 pulley
• Figure 121-1 Transverse ultrasound image demonstrating inflam- • Figure 121-2 Inflamed nodules on the tendon distal and proximal
mation of the flexor tendon sheaths in a patient with triggering of the to the pulley. (From Waldman SD: Atlas of pain management injection
ring finger. Note the effusion surrounding the tendon of the ring finger. techniques, Philadelphia, 2000, Saunders, p 135.)
192
CHAPTER 121 The Catching Tendon Sign for Trigger Finger Syndrome 193
• Figure 121-3 The catching tendon sign for trigger finger syndrome.
122 The Sausage Finger Sign for
Psoriatic Arthritis
Physical examination of the joints of the fingers can provide When the inflammatory process extends beyond the joint
important diagnostic information if the clinician under- proper and involves the surrounding structures, including
stands the patterns of joint disease and their relationship to tendons and ligaments, it is called an enthesopathy. If
specific pathologic processes. Inflammation, pain, or swell- this inflammatory process involves a digit and progresses
ing of a single joint of the hand points to an infectious or unchecked, inflammation of the entire digit can result. This
localized process, such as septic joint, gouty arthritis, and generalized inflammation and swelling are called dactylitis.
foreign body arthritis, as opposed to a more symmetric Dactylitis occurs commonly in patients who suffer from
pattern of inflammation, pain, or swelling, which is more psoriatic arthritis, resulting in a classic appearing digit called
indicative of a systemic arthritis, such as rheumatoid arthri- a sausage finger (Fig. 122-1). A positive sausage finger sign
tis, psoriatic arthritis, or the collagen vascular diseases. is considered pathognomonic for psoriatic arthritis.
• Figure 122-1 Sausage fingers in psoriatic arthropathy; note dorsal

and volar aspects of dactylitis at the third finger. (From Hubscher O:
Pattern recognition. In Klippel JH, Dieppe PA editors: Rheumatology,
ed 2, London, 1998, Mosby, p 2-3.4.)
194
123 The Swan Neck Deformity Sign
The swan neck deformity consists of hyperextension of spasticity of intrinsic hand muscles, and malunion of a
the proximal interphalangeal joint, flexion of the distal fracture of the middle or proximal phalanx. Swan neck
interphalangeal joint, and sometimes flexion of the meta- deformity results in the inability to compensate for hyper-
carpophalangeal joint (Fig. 123-1). It is most commonly extension of the proximal interphalangeal joint; it makes
associated with rheumatoid arthritis that has been inade- finger closure impossible and can cause severe disability.
quately treated (Fig. 123-2). Other causes of swan neck
deformity include rupture of the flexor tendon of the proxi-
mal interphalangeal (PIP) joint, untreated mallet finger,
laxity of the ligaments of the volar aspect of the PIP joint,
Normal joint
Swan neck deformity
• Figure 123-2 Fixed rheumatoid swan neck deformity, with proximal

• Figure 123-1 The swan neck deformity consists of hyperextension interphalangeal joint hyperextension and distal interphalangeal joint
of the proximal interphalangeal joint, flexion of the distal interphalangeal flexion. (From Canale ST, Beaty J, editors: Campbell’s operative ortho-
joint, and sometimes flexion of the metacarpophalangeal joint. paedics, ed 11, vol 4, Philadelphia, 2007, Mosby, p 4204.)
195
124 The Boutonnière Deformity Sign
Commonly associated with rheumatoid arthritis, the bou- lateral bands of the extensor tendon in a manner analogous
tonnière deformity consists of flexion of the proximal inter- to a button passing through a buttonhole. Frequently, other
phalangeal joint accompanied by hyperextension of the deformities such as the swan neck deformity can be seen in
distal interphalangeal joint (Fig. 124-1). Other causes of conjunction with the boutonnière deformity (Fig. 124-2)
the boutonnière deformity include extensor tendon lacera- (see Chapter 123).
tions, fractures of the phalanges, dislocations, and severe
osteoarthritis. What these pathologic processes have in
common is disruption of the central slip attachment of
the extensor tendon to the base of the middle phalanx,
allowing the proximal phalanx to protrude between the
• Figure 124-2 Boutonnière and swan neck deformities of the digits.

A typical swan neck deformity of the third and fourth digits (open
• Figure 124-1 Thumb with fixed rheumatoid boutonnière deformity arrows) and boutonnière deformity of the second digit (closed arrow)
(type 1). Note tight metacarpophalangeal flexion and interphalangeal are evident in this patient with rheumatoid arthritis. (From Resnick D,
hyperextension. (From Canale ST, Beaty J, editors: Campbell’s opera- Kransdorf MJ, editors: Bone and joint imaging, ed 3, Philadelphia,
tive orthopaedics, vol 4, ed 11, Philadelphia, 2007, Mosby, p 4197.) 2005, Saunders, p 230.)
196
125 The Heberden Node Sign for
Osteoarthritis of the Distal
Interphalangeal Joints
Although William Heberden is most famous for his classic are several known risk factors, including overuse of the
description of angina pectoris, he is also credited with the joints, especially by excessive precision gripping; being of
first description of the classic finger deformity associated female gender; previous trauma to the distal interphalangeal
with osteoarthritis that bears his name. The Heberden node joints; and having a genetic predisposition. A positive
is the name given to the deformity of a distal interphalan- Heberden node sign is pathognomonic for osteoarthritis of
geal joint when it is damaged by osteoarthritis (Fig. 125-1). the distal interphalangeal joint.
The exact cause of this deformity is not known, but there
• Figure 125-1 The Heberden node sign (arrows) for osteoarthritis

of the distal interphalangeal joints.
197
126 The Bouchard Node Sign for
Osteoarthritis of the Proximal
Interphalangeal Joints
The nineteenth-century French physician Charles Jacques factors, including overuse of the joints, especially by exces-
Bouchard is credited with the first description of the classic sive precision gripping; being of the female gender; previous
finger deformity associated with osteoarthritis that bears trauma to the proximal interphalangeal joints; and having
his name. The Bouchard node is the name given to the a genetic predisposition. A positive Bouchard node sign is
deformity of a proximal interphalangeal joint when it is pathognomonic for osteoarthritis of the proximal interpha-
damaged by osteoarthritis (Fig. 126-1). Although the exact langeal joint.
cause of this deformity is not known, there are several risk
• Figure 126-1 The Bouchard node sign (arrows) for osteoarthritis

of the proximal interphalangeal joints.
198
127 The Ice Water Test for Glomus Tumor
of the Finger
Glomus tumor of the hand is an uncommon cause of distal tumor is present, the characteristic lancinating, boring pain
finger pain. It is the result of tumor formation of the glomus will occur within 30 to 60 seconds, constituting a positive
body, which is a neuromyoarterial apparatus whose function ice water test. Placing other unaffected fingers of the same
is to regulate peripheral blood flow in the digits. The major- hand in ice water will not trigger the pain in the affected
ity of patients who suffer from glomus tumor are females finger. Nail bed ridging is present in many patients with
between the ages of 30 and 50 years. The pain is very severe glomus tumor of the hand, and a small blue or dark red
and is lancinating and boring in nature. The tumor fre- spot at the base of the nail is visible in 10% to 15% of
quently involves the nail bed and may invade the distal patients suffering from the disease (Fig. 127-1). The patient
phalanx. Patients suffering from glomus tumor of the hand with glomus tumor of the hand will frequently wear a finger
will exhibit the classic triad of excruciating distal finger protector on the affected digit and will guard against hitting
pain, cold intolerance, and tenderness to palpation of the the digit on anything to avoid triggering the pain.
affected digit. Multiple glomus tumors are present in Magnetic resonance image scanning of the affected
approximately 25% of patients who are diagnosed with this digit will often reveal the actual glomus tumor and may
disease. Glomus tumors can also occur in the foot and also reveal erosion or a perforating lesion of the phalanx
occasionally in other parts of the body. beneath the tumor. The tumor will appear as a very
The diagnosis of glomus tumor of the hand is based high and homogeneous signal on T2-weighted images
primarily on 3 points in the patient’s clinical history: (Fig. 127-2). Ultrasound and color Doppler imaging may
(1) excruciating pain that is localized to a distal digit, also reveal the size and exact localization of the tumor
(2) the ability to trigger the pain by palpating the area, and (Fig. 127-3). The bony changes associated with glomus
(3) marked intolerance to cold. Patients who suffer from tumor of the hand may also appear on plain radiographs if
glomus tumor of the digit will exhibit a positive ice water a careful comparison of the corresponding contralateral
test. The pain of glomus tumor can be reproduced by digit is made. Radionuclide bone scan may also reveal local-
placing the affected digit in a glass of ice water. If glomus ized bony destruction.
• Figure 127-1 Glomus tumor is characterized by (1) excruciating

distal digit pain, (2) ability to trigger the pain by palpation, and
(3) marked intolerance to cold. It is easily diagonsed by the ice water
test. (From Waldman SD: Atlas of uncommon pain syndromes,
199
A B
C
• Figure 127-2 Glomus tumor of the finger. A, Classic clinical appearance of the tumor as demonstrated
by bluish discoloration at the base of the nail. B, MRI slice confirming location of the tumor. C, Intraopera-
tive appearance of the subungual glomus tumor. (From Joory K, Mikalef P, Rajive MJ: Smoking and glomus
tumours, J Plast Reconstr Aesthet Surg 67(11):1600–1601, 2014, fig 1.)
A B
C D
• Figure 127-3 A, Characteristic nail ridging dystrophy on the medial face of the first finger of the right
hand in a patient with glomus tumor. B, B mode Doppler image showing a well-defined, solid hypoechoic
lesion with an oval form and regular borders. C, In color Doppler mode, extensive vascularization can be
seen in the nail bed. D, Spectral analysis shows low-grade systolic arterial flow within the lesion. (From
Gómez-Sánchez ME, Alfageme-Roldán F, Roustán-Gullón G, et al: The usefulness of ultrasound imaging
in digital and extradigital glomus tumors, Actas Dermosifiliogr 105(7):e45–e49, 2014, fig 2.)
128 The Winged Scapula Sign for
Entrapment of the Long Thoracic
Nerve of Bell
Long thoracic nerve entrapment syndrome is caused by of winged scapula sign. The winged scapula sign is the result
compression or stretching of the long thoracic nerve as it of the inability of the serratus anterior muscle to hold the
passes beneath the subscapularis muscle to innervate the scapula firmly against the posterior chest wall. The winged
serratus anterior muscle (Fig. 128-1). The most common scapula sign can be identified by having the patient place
causes of compression of the long thoracic nerve at this both hands against the wall and press outward. The clini-
anatomic location include direct trauma to the nerve during cian, by observing the patient from behind, identifies the
surgical procedures, such as radical mastectomy and surgery affected scapula projecting posteriorly or winging away
for thoracic outlet syndrome. Direct blunt trauma from from the posterior chest wall (Fig. 128-2). The patient with
heavy items falling from shelves also can cause long thoracic long thoracic nerve syndrome also is unable to fully extend
nerve entrapment syndrome. Damage to the long thoracic the upper extremity overhead on the affected side, the last
nerve following first rib fracture also has been reported. 25 to 30 degrees of extension being lost.
Stretch injuries to the long thoracic nerve often occur from Electromyography helps to diagnose long thoracic nerve
prolonged heavy labor or wearing improperly fitting heavy entrapment syndrome. Plain radiographs are indicated in
backpacks. all patients who present with long thoracic nerve entrap-
Clinically the patient presents with painless paralysis of ment syndrome to rule out occult bony pathology, includ-
the serratus anterior muscle that results in the classic finding ing scapular and first rib fractures.
Long thoracic n.
Serratus anterior m.
• Figure 128-2 Winged scapula. Note how the scapula projects
posteriorly and wings away from the posterior chest wall. (Fig. 1 from.
• Figure 128-1 Long thoracic nerve entrapment syndrome: relevant Deroux JP, Brion L, Hyerle A, et al: Association between hepatitis E
anatomy. (From Waldman SD: Atlas of pain management injection and neurological disorders: two case studies and literature review,
techniques, Philadelphia, 2000, Saunders, p 167.) J Clin Virol 60(1):60–62, 2014.)
202
129 The Suprascapular Notch Sign
for Suprascapular Nerve
Entrapment Syndrome
Suprascapular nerve entrapment syndrome is caused by football injuries and in falls from trampolines (see Fig.
compression of the suprascapular nerve as it passes through 129-1). This entrapment neuropathy presents most com-
the suprascapular notch (Fig. 129-1). The most common monly as a severe, deep, aching pain that radiates from the
causes of compression of the suprascapular nerve at this top of the scapula to the ipsilateral shoulder. On physical
anatomic location include the prolonged wearing of heavy examination, patients who are suffering from suprascapular
backpacks and direct blows to the nerve such as occur in nerve entrapment will exhibit a positive suprascapular notch
sign. Tenderness over the suprascapular notch is usually
present. Shoulder movement, especially reaching across
the chest, may increase the pain. If suprascapular nerve
entrapment remains untreated, weakness and atrophy of
Suprascapular the supraspinatus and infraspinatus muscles will occur.
nerve To elicit the suprascapular notch sign for suprascapular
Suprascapular nerve entrapment, the patient is asked to face away from
notch the examiner with the arms hanging loosely at the sides.
The examiner then identifies the patient’s suprascapular
notch and exerts a sudden, firm pressure on the notch
(Fig. 129-2, A). Patients who are suffering from suprascapu-
Axillary lar nerve entrapment will note that this pressure reproduces
nerve their pain, and they will reflexively withdraw away from the
palpating finger (Fig. 129-2, B).
Suprascapular nerve entrapment syndrome is often mis-
diagnosed as bursitis, tendinitis, or arthritis of the shoulder.
Cervical radiculopathy of the C5 nerve root also can mimic
the clinical presentation of suprascapular nerve entrapment
• Figure 129-1 Suprascapular nerve entrapment syndrome: relevant syndrome. Parsonage-Turner syndrome (idiopathic brachial
anatomy. neuritis) also may present as a sudden onset of shoulder pain
A B
• Figure 129-2 A and B, Eliciting the suprascapular notch sign for suprascapular nerve entrapment
syndrome.
203
204 SECTION 6 The Chest Wall, Thorax, and Thoracic Spine
Suprascapular Transverse
nerve ligament
Suprascapular
artery
• Figure 129-3 Color Doppler image demonstrating the relationship

of the suprascapular artery and nerve as they pass beneath the trans-
verse suprascapular ligament.
and can be confused with suprascapular nerve entrapment. nerve entrapment syndrome. Plain radiographs are indi-
A tumor that involves the superior scapular region or shoul- cated in all patients who present with suprascapular nerve
der also should be considered in the differential diagnosis entrapment syndrome to rule out occult bony pathology.
of suprascapular nerve entrapment syndrome. Ultrasound and color Doppler imaging can also aid in iden-
Electromyography helps to distinguish cervical radicu- tification of the cause of suprascapular nerve entrapment
lopathy and Parsonage-Turner syndrome from suprascapular (Fig. 129-3).
130 The Shoulder Retraction Test for
Costosternal Syndrome
The costosternal joints can serve as a source of pain that can Physical examination of patients who suffer from cos-
often mimic the pain of cardiac origin. The costosternal tosternal syndrome reveals that the patient will vigorously
joints are susceptible to the development of arthritis, includ- attempt to splint the joints by keeping the shoulders stiffly
ing osteoarthritis, rheumatoid arthritis, ankylosing spondy- in neutral position. Such patients will also exhibit a positive
litis, Reiter syndrome, and psoriatic arthritis. The joints shoulder retraction test.
often are traumatized during acceleration/deceleration inju- To elicit a shoulder retraction test in patients who are
ries and blunt trauma to the chest. With severe trauma, the suspected of suffering from costosternal syndrome, the
joints may sublux or dislocate. Overuse or misuse also can patient is placed in the standing position with the shoulders
result in acute inflammation of the costosternal joint, which in neutral position, facing the examiner. The patient is then
can be quite debilitating. The joints also are subject to asked to retract the shoulder vigorously (Fig. 130-1). The
invasion by tumor from primary malignancies, including shoulder retraction test is considered positive if the retraction
thymoma, as well as by metastatic disease. maneuver reproduces the patient’s anterior chest wall pain.
• Figure 130-1 The shoulder retraction test for costosternal

syndrome.
205
131 The Swollen Costosternal Joint Sign
for Tietze Syndrome
Tietze syndrome is distinct from costosternal syndrome (see syndrome. The costosternal joints, especially the second and
Chapter 130). First described in 1921, Tietze syndrome is third, are swollen and exquisitely tender to palpation. This
characterized by acute painful swelling of the costal carti- swelling constitutes a positive swollen costosternal joint
lages. The second and third costal cartilages are most sign, which is pathognomonic for Tietze syndrome. Mag-
commonly involved. In contradistinction to costosternal netic resonance and ultrasound imaging can help confirm
syndrome, which usually occurs no earlier than the fourth the diagnosis (Fig. 131-3).
decade of life, Tietze syndrome is a disease of the second
and third decades of life. The onset is acute and often
associated with a concurrent viral respiratory tract infection
(Fig. 131-1). It has been postulated that microtrauma to
the costosternal joints from severe coughing or heavy
labor might also cause Tietze syndrome. Painful swelling
of the second and third costochondral joints is the sine
qua non of Tietze syndrome, and this swelling forms the
basis for the swollen costosternal joint sign for Tietze syn-
drome (Fig. 131-2). Such swelling is absent in costosternal
syndrome, which occurs much more frequently than Tietze
syndrome.
Physical examination reveals that the patient who suffers
from Tietze syndrome will vigorously attempt to splint
the joints by keeping the shoulders stiffly in neutral posi-
tion. Pain is reproduced with active protraction or retrac-
tion of the shoulder, deep inspiration, and full elevation of
the arm. Shrugging of the shoulder also can reproduce the
pain. Coughing may be difficult, and this can lead to inad- • Figure 131-2 Inspection of the costosternal joint for swelling indic-
equate pulmonary toilet in patients who suffer from Tietze ative of Tietze syndrome.
• Figure 131-1 Acute pain and swelling of the second and third • Figure 131-3 Tietze syndrome: a coronal short TI inversion recov-
costochondral joints associated with an upper respiratory tract infec- ery magnetic resonance image of the thorax, showing high-intensity
tion is the hallmark sign of Tietze syndrome. (From Waldman SD: signal at the costosternal joint. (From Resnick D, editor: Diagnosis of
Tietze’s syndrome. In: Atlas of common pain syndromes, Philadelphia, bone and joint disorders, ed 4, Philadelphia, 2002, WB Saunders,
2002, WB Saunders, p 159.) p 2605.)
206
132 The Shrug Test for Sternoclavicular
Joint Dysfunction
The sternoclavicular joint can serve as a source of pain that from primary malignancies, including thymoma, as well as
often mimics pain of cardiac origin. The sternoclavicular from metastatic disease. Rarely, the sternoclavicular joint
joint is a double gliding joint with an actual synovial cavity. can become infected (Fig. 132-1).
Articulation occurs between the sternal end of the clavicle, Physical examination reveals that the patient will vigor-
the sternal manubrium, and the cartilage of the first rib. The ously attempt to splint the joint by keeping the shoulders
clavicle and sternal manubrium are separated by an articular stiffly in neutral position. The sternoclavicular joint may be
disc. The joint is reinforced in front and back by the ster- tender to palpation and feel hot and swollen if acutely
noclavicular ligaments. Additional support is provided by inflamed. Pain is reproduced by active protraction or retrac-
the costoclavicular ligament, which runs from the junction tion of the shoulder as well as full elevation of the arm.
of the first rib and its costal cartilage to the inferior surface Patients who are suffering from sternoclavicular joint dys-
of the clavicle. function will also exhibit a positive shrug test.
The sternoclavicular joint is susceptible to the develop- To perform the shrug test for sternoclavicular joint
ment of arthritis, including osteoarthritis, rheumatoid dysfunction, the patient is asked to stand facing the
arthritis, ankylosing spondylitis, Reiter syndrome, and examiner with the shoulders and upper extremities in a
psoriatic arthritis. The joint is often traumatized during relaxed, neutral position. The examiner places his or her
acceleration/deceleration injuries and blunt trauma to the hand over the affected sternoclavicular joint (Fig. 132-2, A)
chest. With severe trauma, the joint may sublux or dislo- and then has the patient rapidly shrug the affected
cate. Overuse or misuse can also result in acute inflamma- shoulder (Fig. 132-2, B). The shrug test is positive if the
tion of the sternoclavicular joint, which can be quite examiner appreciates a click with maximum shoulder shrug
debilitating. The joint is also subject to invasion by tumor (Video 132-1).
• Figure 132-1 Sternoclavicular joint infection and osteomyelitis in a

48-year-old man with an infected subclavian venous catheter. Sagittal
T1-weighted (repetition time [TR] = 400 ms, echo time [TE] = 12 ms)
magnetic resonance image shows abnormal areas of low signal inten-
sity (smaller arrows) in the sternal marrow, consistent with osteomy-
elitis. Surrounding low signal intensity (thick arrow) in the soft
tissues is consistent with abscess. (From Knisely BL, Broderick LS,
Kuhlman JE: MR imaging of the pleura and chest wall, MRI Clin
North Am 8:125, 2000.)
207
208 SECTION 6 The Chest Wall, Thorax, and Thoracic Spine
A B
• Figure 132-2 A and B, The shrug test for sternoclavicular joint dysfunction.
133 The Hooking Maneuver Test for
Slipping Rib Syndrome
Slipping rib syndrome is a constellation of symptoms, reproduced with pressure on the affected costal cartilage.
including severe knife-like pain emanating from the lower Patients with slipping rib syndrome exhibit a positive
costal cartilages associated with hypermobility of the ante- hooking maneuver test. The hooking maneuver test is per-
rior end of the lower costal cartilages. The tenth rib is formed by having the patient lie in the supine position with
most commonly involved, but the eight and ninth ribs also the abdominal muscles relaxed while the clinician hooks his
can be affected. This syndrome is also known as rib-tip or her fingers under the lower rib cage and pulls gently
syndrome. Slipping rib syndrome is almost always associ- outward (Fig. 133-1). Pain and a clicking or snapping sensa-
ated with trauma to the costal cartilage of the lower ribs. tion of the affected ribs and cartilage indicate a positive test.
These cartilages often are traumatized during acceleration/ Plain radiographs are indicated for all patients who
deceleration injuries and blunt trauma to the chest. With present with pain that is thought to be emanating from
severe trauma, the cartilage may sublux or dislocate from the lower costal cartilage and ribs to rule out occult bony
the ribs. Patients with slipping rib syndrome also may com- pathology, including rib fracture and tumor. On the basis
plain of a “clicking” sensation with movement of the affected of the patient’s clinical presentation, additional testing may
ribs and associated cartilage and may exhibit a positive be indicated, including complete blood count, prostate-
hooking maneuver test. specific antigen, sedimentation rate, and antinuclear anti-
Physical examination reveals that the patient will vigor- body testing. Magnetic resonance and ultrasound imaging
ously attempt to splint the affected costal cartilage joints by of the affected ribs and cartilage is indicated if joint instabil-
keeping the thoracolumbar spine slightly flexed. Pain is ity or occult mass is suspected.
• Figure 133-1 The hooking maneuver test for slipping rib syndrome.
209
134 The Flexion Test for Acute Thoracic
Vertebral Compression Fracture
Thoracic vertebral compression fracture is one of the most Compression fractures of the thoracic vertebrae are
common causes of thoracic spine pain. Vertebral compres- aggravated by deep inspiration, coughing, and any move-
sion fracture is most commonly the result of osteoporosis ment of the dorsal spine (Fig. 134-1). Palpation of the
of the dorsal spine. It is also associated with trauma to the affected vertebrae may elicit pain and reflex spasm of the
dorsal spine due to acceleration/deceleration injuries. In paraspinous musculature of the dorsal spine. If trauma has
osteoporotic patients or in patients with primary tumors or occurred, hematoma and ecchymosis overlying the fracture
metastatic disease involving the thoracic vertebrae, these site might be present. If trauma has occurred, the clinician
fractures can occur with coughing (tussive fractures) or should be aware of the possibility of damage to the bony
spontaneously. thorax and the intraabdominal and intrathoracic contents.
The pain and functional disability that are associated Damage to the spinal nerves may produce abdominal ileus
with vertebral fractures is determined in large part by the and severe pain, with resulting splinting of the paraspinous
severity of injury (e.g., the number of vertebrae involved) muscles of the dorsal spine, further compromising the
and the nature of the injury (e.g., whether the fracture patient’s ability to walk and pulmonary status. Failure to
allows impingement on the spinal nerves or the spinal cord aggressively treat this pain and splinting can result in a
itself ). The severity of pain associated with thoracic verte- negative cycle of hypoventilation, atelectasis, and ultimately
bral compression fracture can range from a dull, deep ache pneumonia. Patients with acute thoracic vertebral compres-
with minimal compression of the vertebrae without nerve sion fracture will exhibit a positive flexion test.
impingement to severe sharp, stabbing pain that limits the To perform the flexion test for acute vertebral compres-
patient’s ability to ambulate and cough. sion fracture, the examiner asks the patient to stand and
• Figure 134-1 Osteoporosis is a common cause of thoracic verte-

bral fractures. (From Waldman SD: Atlas of common pain syndromes,
210
CHAPTER 134 The Flexion Test for Acute Thoracic Vertebral Compression Fracture 211
A B
• Figure 134-2 A and B, The flexion test for acute thoracic vertebral compression fracture.
assumes a position alongside the patient to keep the patient will begin to flex and then stop and suddenly extend as
from falling. The examiner then places one arm across the the flexion of the vertebra impinges on the spinal nerve
patient’s lower abdomen while palpating the suspected area roots or other pain-sensitive structures (Fig. 134-2, B).
of fracture with the other hand. The patient is then asked The examiner should be prepared to help stabilize the
to gently flex the thoracolumbar spine (Fig. 134-2, A). patient as the patient suddenly extends the spine to avoid
If acute thoracic vertebrae fracture is present, the patient falling.
135 Functional Anatomy of
the Lumbar Spine
THE BONY ELEMENTS inferior adjacent vertebra (Fig. 135-3). This configuration
allows flexion, extension, and a limited degree of lateral
The lumbar spine comprises 5 vertebrae numbered from bending while at the same time contributing significantly
cephalad to caudad L1 to L5. The primary function of the to the lateral stability of the lumbar spine.
lumbar vertebrae is to bear the weight of the upper body
and to allow for coordinated movement of the lower back
and pelvis in flexion, extension, and lateral bending. Like
the rest of the spine, the lumbar vertebrae serve a secondary
protective role by enclosing the cauda equina and related
structures in a bony canal. Unlike the specialized cervical
and thoracic vertebrae, which are dissimilar from their lower
counterparts, the lumbar vertebrae are structurally similar. Superior
vertebral
Each vertebra is made up of an anterior weight-bearing endplate
vertebral body and a posterior neural arch. The posterior
neural arch has 3 specialized processes that allow attach-
ment of the muscles of posture and a variety of ligaments Nucleus
(Fig. 135-1). These processes are the spinous process, which pulposus
lies in the midline posteriorly, and the 2 transverse pro-
cesses, which lie laterally. The area of the neural arch between
the spinous process and the transverse process is called the Inferior
lamina. The area between the transverse process and the vertebral
endplate
vertebral body is called the pedicle.
MOVEMENT
Movement of adjacent lumbar vertebrae is allowed by 3
joints. The first comprises the inferior and superior end- • Figure 135-2 Movement of adjacent lumbar vertebrae is allowed
plates of the vertebral bodies and their interposed interver- by 3 joints. The first comprises the inferior and superior endplates of
tebral disc (Fig. 135-2). The second and third are the 2 facet the vertebral bodies and their interposed intervertebral disc.
joints, also known as zygapophyseal joints, which are made
up of the inferior articular process of the superior adjacent
vertebra and the ipsilateral superior articular process of the
Inferior
articular
facet
Inferior
Vertebral body articular
process
Transverse
process
Superior
articular
process
Superior
articular
facet
Spinous process
• Figure 135-3 The zygapophyseal joints are made up of the inferior
articular process of the superior adjacent vertebra and the ipsilateral
• Figure 135-1 The processes of the posterior neural arch. superior articular process of the inferior adjacent vertebra.
214
CHAPTER 135 Functional Anatomy of the Lumbar Spine 215
THE INTERVERTEBRAL DISC Inside this container made of the top and bottom end-
plates and the surrounding annulus is the water-containing
The lumbar intervertebral disc has 2 major functions: mucopolysaccharide gel-like substance called the nucleus
(1) to serve as the major shock-absorbing structure of pulposus (see Fig. 135-2). The nucleus pulposus is incom-
the lumbar spine and (2) to facilitate the synchronized pressible, and any pressure that is placed on one portion of
movement of the lumbar spine while helping to prevent the disc is transmitted throughout the entire nucleus pulpo-
impingement of the neural structures and associated struc- sus. In health, the water-filled gel creates a positive intradis-
tures that traverse the lumbar spine. Both the shock- cal pressure that forces the adjacent vertebrae apart and
absorbing function and the movement/protective function helps to protect the spinal cord and exiting nerve roots.
of the lumbar intervertebral disc are functions of the disc’s When the lumbar spine moves, the incompressible nature
structure as well as the laws of physics that affect it (see later of the nucleus pulposus maintains a constant intradiscal
discussion). pressure while some fibers of the disc relax and others
To understand how the lumbar intervertebral disc func- contract.
tions in health and becomes dysfunctional in disease, it is As the lumbar intervertebral disc ages, it becomes less
useful to think of the disc as a closed, fluid-filled con- vascular and loses its ability to absorb water into the disc.
tainer. The outside of the container is made up of a top This results in a degradation of the disc’s shock-absorbing
and bottom called the endplates, which are composed of and motion-facilitating functions. This problem is made
relatively inflexible hyaline cartilage. The sides of the worse by degeneration of the annulus, which allows por-
lumbar intervertebral disc are made up of a woven criss- tions of the disc wall to bulge, distorting the ability of the
crossing matrix of fibroelastic fibers that tightly attaches to nucleus pulposus to evenly distribute the forces that are
the top and bottom endplates. This woven matrix of fibers placed on it throughout the entire disc. This exacerbates the
is called the annulus, and it completely surrounds the sides disc dysfunction and can contribute to further disc deterio-
of the disc (see Fig. 135-2). The interlaced structure of the ration, which can ultimately lead to complete disruption of
annulus results in an enclosing mesh that is extremely the annulus and extrusion of the nucleus. The deterioration
strong yet very flexible, which facilitates the compression of the disc is responsible for many of the painful conditions
of the disc during the wide range of motion of the lumbar that emanate from the lumbar spine and are encountered
spine. in clinical practice.
136 An Overview of the Nomenclature of
the Diseased Lumbar Disc
Much confusion surrounds the nomenclature that is used Nucleus

pulposus
to describe the diseased lumbar disc. Such confusion exists Intervertebral
in part because of a system of nomenclature that was devised disc
before the advent of computed tomography and magnetic Annulus
fibrosus
resonance imaging (MRI) and in part because of the focus
by radiologists and clinicians alike on the impingement of
the intervertebral disc on neural structures as the sole source
of pain emanating from the spine.
This second viewpoint ignores the disc and facet joint as
an independent source of spine pain and leads to misdiag-
nosis, treatment plans with little chance of success, and
needless suffering of the patient. By standardizing the
nomenclature of the diseased lumbar disc, the radiologist
and clinician can do much to avoid these pitfalls when
caring for the patient with spinal pain.
• Figure 136-1 Normal lumbar disc.
The following classification system will allow the radiolo-
gist and clinician to communicate with each other in the
same language. It also takes into account the fact that the hydration as well as its ability to maintain a proper mixture
intervertebral disc might be the sole source of spinal pain of proteoglycans necessary to keep the gel-like consis-
and that certain findings on MRI should point the clinician tency of the nuclear material (Fig. 136-2). Degenerative
to a discogenic source of pain and an early consideration clefts develop within the nuclear matrix, and portions of
of discography as a diagnostic maneuver prior to surgical the nucleus become replaced with collagen, which leads to
interventions. More than 90% of clinically significant disc a further degradation of the shock-absorbing abilities and
abnormalities of the lumbar spine occur at L4-L5 or L5-S1. flexibility of the disc. As this process continues, the disc’s
ability to maintain an adequate intradiscal pressure to push
THE NORMAL DISC the adjacent vertebrae apart begins to deteriorate, leading
to a further deterioration of function with the onset of
As discussed in Chapter 137, the normal disc consists of the clinical symptoms.
central gel-like nucleus pulposus, which is surrounded con- In addition to changes that affect the nucleus pulposus,
centrically by a dense fibroelastic ring called the annulus. the degenerative process affects the annulus as well. As the
The top and bottom of the disc are contained by a cartilagi- annulus ages, the complex interwoven mesh of fibroelastic
nous endplate that is adjacent to the vertebral body. On fibers begins to break down, and small tears occur within
MRI, the normal lumbar disc appears symmetrical with low the mesh. As these tears occur, the exposed collagen fibers
signal intensity on T1-weighted images and high signal stimulate the ingrowth of richly innervated granulation
intensity throughout the disc on T2-weighted images. In tissue that can account for discogenic pain. These tears can
health, the margins of the lumbar disc do not extend beyond be easily demonstrated on MRI as linear structures of high
the margins of the adjacent vertebral bodies (Fig. 136-1). signal intensity on T2-weighted images, which correlate
with positive results when provocative discography is per-
THE DEGENERATED DISC formed on the affected disc (Figs. 136-2 and 136-3). When
identified as the source of pain on discography, these annular
As the disc ages, both the nucleus pulposus and the annulus tears can be treated with intradiscal electrothermal annulo-
undergo structural and biochemical changes that affect both plasty with good results (Fig. 136-4).
the disc’s appearance on MRI and the disc’s ability to func-
tion properly. This degenerative process is a normal part of THE DIFFUSELY BULGING DISC
aging, and it can be accelerated by trauma to the lumbar
spine, infection, and smoking. If the degenerative process As the degenerative process continues, further breakdown
is severe enough, many but not all patients will experience and tearing of the annular fibers and continued loss of
clinical symptoms. hydration of the nucleus pulposus lead to a loss of intradis-
As the degenerative process occurs, the nucleus pulposus cal pressure with resultant disc space narrowing, which can
begins to lose its ability to maintain an adequate level of lead to an exacerbation of clinical symptoms. As the disc
216
CHAPTER 136 An Overview of the Nomenclature of the Diseased Lumbar Disc 217
• Figure 136-2 Sagittal T1W (A) and

T2W (B) magnetic resonance (MR)
images of the lumbar spine. The SI of
the intervertebral discs is normal on the
T1W MR images, but there is disc
space narrowing at L2-L3 and L3-L4.
The T2W MR image shows early loss
of disc hydration with low–signal intensity
changes at L2-L3, L3-L4, and L4-L5.
In addition, there is bulging of the
posterior discs beyond the posterior
margin vertebral body wall at these 3
levels, which is most marked at L3-L4.
C, An axial T2W MR image shows that
the posterior margin of the disc is flat,
A B but without significant narrowing of the
lateral recesses and with no compres-
sion of the thecal sac. D, An axial T2W
MR image of a normal L3-L4 disc
shows that the posterior margin of the
disc should be slightly concave. (From
Waldman SD, Campbell, RSD: Imaging
of pain, Philadelphia, 2010, Saunders/
Elsevier, p 120, fig 47-1.)
C D
A B
• Figure 136-3 A, Fluoroscopic discogram demonstrating an annular fissure extending from the nucleus
pulposus to the posterior disc margin (arrow). B, The same appearance is seen on a computed tomog-
raphy discogram, with high-density contrast medium extending into a posterior annular fissure (broken
arrow). (From Waldman SD, Campbell, RSD: Imaging of pain, Philadelphia, 2010, Saunders/Elsevier,
p 124, fig 49-2.)
218 SECTION 7 The Lumbar Spine
A Diffuse disc bulge B Broad-based protrusion
• Figure 136-4 Fluoroscopic image taken during an intradiscal elec-

trothermal annuloplasty procedure. The electrothermal wires are
placed within the L4-L5 and L5-S1 discs. (From Derby R, Lee SH,
Chen YC: Injection therapies, nerve ablation, and intradiscal electro- C Focal disc protrusion D Disc extrusion
thermal annuloplasty for degenerative lumbar conditions. Semin Spine
Surg 15(4):393–410, 2003.)
E Disc sequestration
• Figure 136-5 Various types of lumbar disc degeneration.
• Figure 136-6 Sagittal T1W

(A), T2W (B), and short T1 inver-
sion recovery (STIR) (C) MR
images in a patient with severe
disc degeneration at L4-L5.
There are disc narrowing and
discovertebral erosion. High SI
within the disc is apparent on the
T2W and STIR images. There are
Modic type 1 changes with verte-
bral endplate edema, which has
low SI on the T1W MR image and
high SI on the T2W and STIR
images. These features mimic
disc space infection, but there
are no paravertebral inflammatory
changes. Multilevel disc degener-
ation and disc bulging are present
at the other lumbar levels. (From
Waldman SD, Campbell, RSD:
Imaging of pain, Philadelphia,
2010, Saunders/Elsevier, p 122,
fig 48-3.)
A B C
space gradually narrows because of decreased intradiscal impingement-induced pain to the pain emanating from the
pressure, the anterior and posterior longitudinal ligaments disc annulus itself. These findings are clearly demonstrated
grow less taut and allow the discs to bulge beyond the on MRI and should alert the clinician to the possibility of
margins of the vertebral body (Fig. 136-5, A and B). This multifactorial sources of the patient’s pain and functional
can cause impingement of bone or disc on nerve, adding disability (Fig. 136-6).
CHAPTER 136 An Overview of the Nomenclature of the Diseased Lumbar Disc 219
• Figure 136-7 Axial T2-weighted MR image of the lumbar spine.

Arrows point to an annular fissure associated with a focal disc protru-
sion. (From Chou R, Deyo RA, Jarvik JG: Appropriate use of lumbar
imaging for evaluation of low back pain, Radiol Clin North Am 50(4):569–
585, 2012, fig 5.)
• Figure 136-8 Sagittal T1W (A) and T2W (B) MR images of a young
woman with cauda equina syndrome and radicular left leg pain. There is a
large disc extrusion at the L4-L5 level, which has intermediate SI on both
the T1W and T2W MR images. C, An axial T2W MR image shows compres-
sion of the thecal sac, which is displaced to the right (white arrow). D, More
proximally, the disc protrusion obliterates the traversing nerve root within the
lateral recess (black arrow). Compare with the normal appearance of the
thecal sac at the L3-L4 level (E). (From Waldman SD, Campbell, RSD:
A B
C D E
THE FOCAL DISC PROTRUSION

As the disc annulus and nucleus pulposus continue to
degenerate, the ability of the annulus to completely contain
and compress the nucleus pulposus is lost and with it the
incompressible nature of the nucleus pulposus. This leads
to focal areas of annular wall weakness, which allow the
nucleus pulposus to protrude into the spinal canal or against
pain-sensitive structures (Fig. 136-5, C). Such protrusions
are focal in nature and are easily seen on both T1- and
T2-weighted MRI (Fig. 136-7). These focal disc protrusions
can be either relatively asymptomatic if the focal bulge does
not impinge on any pain-sensitive structures or highly
symptomatic, presenting clinically as pure discogenic pain
or as radicular pain if the focal protrusion extends into a
neural foramen or the spinal canal.
THE FOCAL DISC EXTRUSION

Focal disc extrusion is frequently symptomatic because the
disc material frequently migrates cranially or caudally, • Figure 136-9 Axial T2-weighted MR image of the lumbar spine.
resulting in impingement of exiting nerve roots and the Arrows point to an annular fissure associated with a focal disc protru-
creation of an intense inflammatory reaction as the nuclear sion. (From Chou R, Deyo RA, Jarvik JG: Appropriate use of lumbar
material irritates the nerve root. This chemical irritation is imaging for evaluation of low back pain. Radiol Clin North Am
thought to be responsible for the intense pain that is expe- 50(4):569–585, 2012, fig 4.)
rienced by many patients with focal disc extrusion and can
be seen on MRI as high-intensity signals on T2-weighted
images (Fig. 136-8). Although more pronounced than a
focal disc protrusion, focal disc extrusion is similar in that and become impacted beneath a nerve root or between the
the extruded disc material remains contiguous with the posterior longitudinal ligament and the bony spine. Seques-
parent disc material (Fig. 136-5, D). tered disc fragments can cause significant clinical pain and
often require surgical intervention. Sequestered disc frag-
THE SEQUESTERED DISC ments will often enhance on contrast-enhanced T1-weighted
images and demonstrate a peripheral rim of high-intensity
When a portion of the nuclear material detaches itself from signal caused by the inflammatory reaction that the nuclear
its parent disc material and migrates, the disc fragment is material elicits on T2-weighted images (Fig. 136-9). Failure
called a sequestered disc (Fig. 136-5, E). Sequestered disc to identify and remove sequestered disc fragments often
fragments frequently migrate in a cranial or caudal direction leads to a poor surgical result.
137 An Overview of Painful Conditions
Emanating from the Lumbar Spine
The initial general physical examination of the lumbar of the clinician who is confronted with the patient com-
spine and lumbar dermatomes guides the clinician in nar- plaining of low back or lower extremity pain and dysfunc-
rowing his or her differential diagnosis and helps to suggest tion and help the clinician avoid overlooking less common
which specialized physical examination maneuvers and diagnoses.
laboratory and radiographic testing will aid in confirming The list in Table 137-1 is by no means comprehensive,
the cause of the patient’s low back pain and dysfunction. but it does aid the clinician in organizing the potential
For the clinician to make best use of the initial information sources of pathology presenting as pain and dysfunction
gleaned from the general physical examination of the emanating from the lumbar spine. It should be noted that
lumbar spine and lumbar dermatomes, a grouping of the the most commonly missed categories of low back and
common causes of pain and dysfunction emanating from lower extremity pain and the categories that most often
the lumbar spine is exceedingly helpful. Although no clas- result in misadventures in diagnosis and treatment are the
sification of lumbar spine pain and dysfunction can be all last 3 categories. The knowledge of this potential pitfall
inclusive or all exclusive, because of the frequently overlap- should help clinicians keep these sometimes overlooked
ping and multifactorial nature of lumbar spine pathology, causes of low back and lower extremity pain and dysfunc-
Table 137-1 should help to improve the diagnostic accuracy tion in their differential diagnosis.
TABLE
Overview of Causes of Low Back and/or Lower Extremity Pain
137-1
Localized Bony,
Disc Space, or Joint Primary Hip Sympathetically Pain Referred from
Space Pathology Pathology Systemic Disease Mediated Pain Other Body Areas
Vertebral fracture Bursitis Rheumatoid arthritis Causalgia Pancreatitis
Primary bone tumor Tendinitis Collagen vascular Reflex sympathetic Malignancy of the
Facet joint disease Aseptic necrosis disease dystrophy retroperitoneal space
Localized or generalized Osteoarthritis Reiter syndrome Postthrombophlebitis Lumbar
degenerative arthritis Joint instability Gout pain (milk leg) Plexopathy
Osteophyte formation Muscle strain Other crystal Fibromyalgia
Disc space infection Muscle sprain arthropathies Myofascial pain
Herniated lumbar disc Periarticular infection Charcot neuropathic syndromes
Degenerative disc disease not involving joint arthritis Entrapment
Primary spinal cord and/or space Multiple sclerosis neuropathies
cauda equina pathology Ischemic pain secondary Intraabdominal tumors
Osteomyelitis to peripheral vascular
Epidural abcess insufficiency
Epidural hematoma Ankylosing spondylitis
221
138 Visual Inspection of the Lumbar Spine
Physical examination of the lumbar spine should begin with radiographic imaging of the spine. The clinician then notes
a visual inspection of the anterior, lateral, and posterior any abnormality in the lumbar position that might be sug-
lumbar spine. The clinician should note the presence or gestive of muscle spasm, such as lumbar list (Fig. 138-2).
absence of the normal lumbar lordotic curve (Fig. 138-1). The clinician then looks for any skin lesions, including
Loss or straightening of the lumbar lordotic curve is vesicular lesions that might be suggestive of acute herpes
often indicative of spasm of the lumbar paraspinal muscu- zoster, as well as any abnormal mass suggestive of primary
lature due to pain. This finding can be confirmed on lateral or metastatic tumor.
• Figure 138-1 Normal lumbar spine on visual inspection. • Figure 138-2 Lumbar list.
222
139 Palpation of the Lumbar Spine
Palpation of the lumbar spine is carried out primarily to paraspinous musculature will allow the clinician to identify
identify abnormalities of the soft tissues. The posterior myofascial trigger points that suggest fibromyalgia (Fig.
lumbar spine is palpated to identify any obvious bony 139-1). Palpation of these trigger points should elicit a posi-
abnormality that might be suggestive of severe degenerative tive “jump” sign, which is pathognomonic for fibromyalgia.
disease or primary or metastatic tumor. The clinician should Diffuse muscle tenderness should suggest the possibility of
always be on the lookout for abnormal mass of the para- collagen vascular disease such as polymyositis or lupus, and
spinous musculature, including sarcoma. Spasm of the pos- this finding should cue the clinician to order appropriate
terior lumbar paraspinous musculature is a common finding laboratory testing to confirm the diagnosis.
after trauma. A careful palpation of the posterior lumbar
• Figure 139-1 Palpation of the lumbar spine.
223
140 Range of Motion of the Lumbar Spine
The lumbar spine has movement among all 5 of its struc- ROTATION AND LATERAL BENDING
tural elements, with the major movements of flexion and
limited extension and lateral bending facilitated by the facet To assess the range of motion of rotation of the lumbar
joints, which are paired diarthrodial planar joints. In health, spine, the clinician has the patient place the spine in neutral
movement of the lumbar spine requires synchronized move- position. The patient is then asked to fully rotate his or her
ment of all the elements of the spine. In disease, problems lumbar spine in both the left and right directions while the
at one level can cause functional disability at other levels. clinician observes for any limitation in range of motion or
a lack of a smooth, synchronized rotation that might indi-
FLEXION AND EXTENSION cate pain or spinal segment dysfunction (Fig. 140-3). The
facet joints allow relatively limited rotation, although some
To assess the range of motion of the lumbar spine, the clini- rotation does occur at the L5-S1 joint because of its more
cian has the patient place the spine in a neutral position. coronal orientation.
The patient is then asked to flex his or her lumbar spine The patient is then asked to return the lumbar spine to
forward while the clinician observes for any limitation in neutral position and to laterally bend the lumbar spine
range of motion and a lack of a smooth, synchronized while the clinician observes for any limitation in range of
flexion that might be indicative of pain or spinal segment motion or a lack of smooth, synchronized lateral bending
dysfunction (Fig. 140-1). The patient is then asked to return that might indicate pain or spinal segment dysfunction (Fig.
the lumbar spine to neutral position and then to extend the 140-4). With both of these maneuvers, the clinician should
lumbar spine while the clinician observes for any limitation be sure that movement occurs only at the level of the lumbar
in range of motion or a lack of a smooth, synchronized spine and that the patient is not using the thoracic or cervi-
extension that might indicate pain or spinal segment dys- cal spine to compensate for a limitation of range of motion
function (Fig. 140-2). With both of these maneuvers, the of the lumbar segments.
clinician should be sure that movement occurs only at the
level of the lumbar spine and that the patient is not using
the thoracic or cervical spine to compensate for a limitation
of range of motion of the lumbar segments.
• Figure 140-1 Flexion of the lumbar spine. • Figure 140-2 Extension of the lumbar spine.
224
CHAPTER 140 Range of Motion of the Lumbar Spine 225
• Figure 140-4 Lateral bending of the lumbar spine.

• Figure 140-3 Rotation of the lumbar spine.
141 The Schober Test for Lumbar
Spine Flexion
First described in 1937, the Schober test for lumbar spine the sacral dimples and then identifies the midline at that
flexion is useful in helping the clinician to quantify the level and places a mark (Fig. 141-1). The examiner then
actual degree of lumbar spine flexion by isolating the move- marks a point 10 cm above that point and 5 cm below that
ment for the lumbar spine from that of flexion of the hips, point (Fig. 141-2). The patient is then asked to touch his
which the patient may be utilizing to compensate for or her toes to maximally flex the lumbar spine. The exam-
decreased flexion of the lumbar spine. The test is especially iner then measures the distance between the upper and
useful in identifying patients with undiagnosed ankylosing lower marks while the patient’s spine is maximally flexed
spondylitis. (Fig. 141-3). The distance should increase to more than
To perform the Schober test for lumbar flexion, with the 21 cm if the patient’s lumbar spine flexion is normal.
patient in the standing position, the examiner first identifies
• Figure 141-1 Identification of sacral dimples and midline mark. • Figure 141-2 Markings at 10 cm above and 5 cm below the
midline mark.
• Figure 141-3 Measurement between upper and lower marks as

patient’s back is maximally flexed. A distance of 21 cm or more indi-
cates normal lumbar spine flexion.
226
142 The Kemp Test for Lumbar Facet
Joint Pain
The Kemp test for lumbar facet joint pain is useful in from the most painful side. The patient is then asked to
helping the clinician to identify if the facet joint is the nidus rotate the shoulder on the less painful side posteriorly
of the patient’s low back pain as well as to determine if there while the examiner exerts firm downward pressure on the
is a radicular component to the patient’s pain. shoulder (Fig. 142-2). The test is positive if it reproduces
To perform the Kemp test to identify lumbar facet and/or exacerbates the patient’s back pain. If the patient also
joint pain, with the patient in the standing position, the experiences pain that radiates from the low back to below
examiner first identifies the side that the pain is on. The the knee in either lower extremity, a radicular component
examiner then has the patient extend the spine (Fig. 142-1). is also present.
The patient is then asked to laterally bend the spine away
• Figure 142-1 With the patient in the standing position, he or she • Figure 142-2 The patient is then asked to rotate the shoulder on
is asked to extend the lumbar spine. the less painful side backward while the examiner exerts firm down-
ward pressure on the shoulder.
227
143 The Lumbar Dermatomes
In humans, the innervation of the skin, muscles, and deep a specific spinal segment. It should be remembered that pain
structures is determined embryologically at an early stage of that is perceived in the region of a given muscle or joint
fetal development, and there is amazingly little intersubject might not be coming from that muscle or joint but might
variability. Each segment of the spinal cord and its corre- simply be referred pain, caused by problems at the same
sponding spinal nerve has a consistent segmental relation- lumbar spinal segment that innervated the muscles.
ship that allows the clinician to ascertain the probable spinal Furthermore, the clinician needs to be aware that the
level of dysfunction based on the pattern of pain, muscle relatively consistent pattern of dermatomal and myotomal
weakness, and deep tendon reflex changes. distribution breaks down when the pain is perceived in the
Figure 143-1 is a dermatome chart that the clinician will deep structures of the upper extremity, such as the joints
find useful in determining the specific spinal level subserv- and tendinous insertions. With pain in these regions, the
ing a patient’s pain. In general, in humans, the more proxi- clinician should refer to the sclerotomal chart in Figure
mal the muscle, the more cephalad the spinal segment, with 143-3. This is particularly important if a neurodestructive
the ventral muscles innervated by higher spinal segments procedure at the spinal cord level is being considered, as the
than the corresponding dorsal muscles. sclerotomal level of the nerves subserving the pain may be
Figure 143-2 is a myotome chart that the clinician will several segments higher or lower than the dermatomal or
find useful when trying to correlate clinical weakness with myotomal levels that the clinician would expect.
Hip flexors
L1
L1 Adductors
L2
L2
L3 Knee
L3 extensors
L4
L4
L5
Foot and ankle
L5 extensors and
invertors
• Figure 143-1 Lumbar dermatomes. • Figure 143-2 Lumbar myotomes.
228
CHAPTER 143 The Lumbar Dermatomes 229
L1
L2
L3
L4
L5
• Figure 143-3 Lumbar sclerotomes.

144 The L4 Neurologic Level
The concept of diagnosing a problem at a specific neuro- electromyographic testing can help to determine the exact
logic level via physical examination has its basis in the fact site of pathology.
that pathology at the lumbar spinal cord or lumbar nerve Testing for the L4 myotome is best carried out by manual
root level manifests itself in a relatively consistent manner muscle testing of the tibialis anterior muscle. The tibialis
by dysfunction, numbness, and pain of the upper extremity anterior muscle is innervated primarily by the L4 nerve,
that occurs in a dermatomal distribution. Although not with a small contribution in most patients from the L5
foolproof, a careful physical examination of the lower nerve. Because in most patients foot inversion by the tibialis
extremity with an eye to the neurologic level that is affected anterior muscle is primarily an L4 function, the muscle
can frequently guide the clinician in designing a more tar- should be tested as follows. The patient is placed in the
geted workup and treatment plan. By overlapping the sitting position with the knee flexed at 90 degrees and the
information gleaned from physical examination with the affected extremity hanging comfortably off the examination
neuroanatomic information gained from magnetic resonance table. The patient is asked to forcefully invert the foot of
imaging and the neurophysiologic information gleaned the affected extremity against the examiner’s resistance (Fig.
from electromyography, a highly accurate diagnosis as to 144-2). If the manual muscle testing is normal, the exam-
which level of the lumbar spine is responsible for the iner should not be able to resist the foot inversion or to
patient’s symptoms can be made (Video 144-1). force the foot back toward neutral position.
Testing for the L4 dermatome is best carried out by a The patellar deep tendon reflex is mediated via the L4
careful sensory evaluation of the medial side of the great toe spinal segment. To test the patellar reflex, the patient is
(Fig. 144-1). Decreased sensation in this anatomic region placed in the sitting position with the knee flexed at 90
can be ascribed to proximal lesions of the spinal cord and degrees and the affected extremity hanging comfortably off
cauda equina, such as a syrinx or spinal cord tumor; to the examination table. The clinician then strikes the inferior
more distal lesions of the L4 nerve root, such as impinge- patellar tendon at the elbow with a neurologic hammer and
ment by herniated disc; or to a lesion of a more peripheral grades the response (Fig. 144-3). A diminished or absent
nerve, such as the deep peroneal nerve. For this reason, reflex may point to compromise of the L4 segment, whereas
correlation with manual muscle testing and evaluation of a hyperactive response may suggest an upper motor neuron
the deep tendon reflex combined with radiographic and lesion, such as myelopathy.
MOTOR
SENSORY
L4
Tibialis anterior
• Figure 144-1 Sensory distribution of the L4 dermatome. • Figure 144-2 L4 myotome integrity testing.
230
CHAPTER 144 The L4 Neurologic Level 231
REFLEX
• Figure 144-3 Patellar deep tendon reflex.

145 The L5 Neurologic Level
Testing for the L5 dermatome is best carried out by a extensor digitorum longus muscle is primarily innervated
careful sensory evaluation of the dorsum of the foot (Fig. by the L5 nerve. Because in most patients extension of
145-1). Decreased sensation in this anatomic region can the great toe by the extensor digitorum longus muscle is
be ascribed to proximal lesions of the spinal cord and primarily an L5 function, the muscle should be tested as
cauda equina, such as a syrinx or spinal cord tumor; to follows. The patient is placed in the sitting position with
more distal lesions of the L5 nerve root, such as impinge- the knee flexed at 90 degrees and the affected extremity
ment by herniated disc; or to a lesion of a more peripheral hanging comfortably off the examination table. The patient
nerve, such as the deep peroneal nerve. For this reason, is asked to forcefully extend the middle toes of the affected
correlation with manual muscle testing and evaluation of extremity against the examiner’s resistance (Fig. 145-2). If
the deep tendon reflex combined with radiographic and the manual muscle testing is normal, the examiner should
electromyographic testing can help to determine the exact not be able to resist the extension of the toes or to force the
site of pathology. toe back toward neutral position (Video 145-1). There is
Testing for the L5 myotome is best carried out by manual no deep tendon reflex that can allow clinically useful testing
muscle testing of the extensor digitorum longus muscle. The of the L5 spinal segment.
SENSORY
MOTOR
L5
Extensor digitorum longus
• Figure 145-1 Sensory distribution of the L5 dermatome. • Figure 145-2 L5 myotome integrity testing.
232
146 The S1 Neurologic Level
Testing for the S1 dermatome is best carried out by a the L5 nerve. The peroneal longus muscle has contribution
careful sensory evaluation of the lateral side of the little toe from both S1 and L5. Because in most patients foot ever-
(Fig. 146-1). Decreased sensation in this anatomic region sion by these muscles is primarily an S1 function, the
can be ascribed to proximal lesions of the spinal cord and muscle should be tested as follows. The patient is placed in
cauda equina, such as a syrinx or spinal cord tumor; to more the sitting position with the knee flexed at 90 degrees
distal lesions of the S1 nerve root, such as impingement by and the affected extremity hanging comfortably off the
herniated disc; or to a lesion of a more peripheral nerve, examination table. The patient is asked to forcefully evert
such as the tibial nerve. For this reason, correlation with the foot of the affected extremity against the examiner’s
manual muscle testing and evaluation of the deep tendon resistance (Fig. 146-2). If the manual muscle testing is
reflex combined with radiographic and electromyographic normal, the examiner should not be able to resist the foot
testing can help to determine the exact site of pathology. eversion or to force the foot back toward neutral position
Testing for the S1 myotome is best carried out by manual (Video 146-1).
muscle testing of the peroneus brevis and longus muscles. The Achilles deep tendon reflex is mediated via the S1
The peroneal brevis muscle is innervated primarily by the spinal segment. To test the Achilles reflex, the patient is
S1 nerve, with a small contribution in some patients from placed in the sitting position with the knee flexed at 90
degrees and the affected extremity hanging comfortably off
the examination table. The clinician then strikes the Achilles
tendon at the ankle with a neurologic hammer and grades
SENSORY
the response (Fig. 146-3). A diminished or absent reflex
may point to compromise of the S1 segment, whereas a
hyperactive response may suggest an upper motor neuron
lesion, such as myelopathy.
MOTOR
S1
Peroneus longus myotome
Peroneus brevis
• Figure 146-1 Sensory distribution of the S1 dermatome. • Figure 146-2 S1 myotome integrity testing.
233
REFLEX
• Figure 146-3 Achilles deep tendon reflex.

147 The Lasegue Straight Leg Raising Test
for Lumbar Root Irritation
The basis for the Lasegue straight leg raising test is the belief and the affected leg placed flat against the table (Fig. 147-1).
that the stretching of the lumbar nerve trunks that make With the ankle of the affected leg placed at 90 degrees
up the sciatic nerve is nonpainful in health and is painful of flexion, the examiner slowly raises the affected leg
when any nerve is irritated or entrapped. Although not toward the ceiling while keeping the knee fully extended
diagnostic for lumbar herniated disc, as believed by many (Fig. 147-2). The test is positive if the patient complains of
clinicians, the Lasegue straight leg raising test is consistently pain and paresthesias into the affected extremity that are
positive when irritation or entrapment of the lower lumbar similar to the pain that the patient has been experiencing.
nerves is present. This test also has good correlation with If this maneuver reproduces the patient’s pain, the test
positive findings on myelography and magnetic resonance may be considered positive, and additional investigation,
imaging (MRI) of the lumbar spine and lumbar plexus as including MRI of the lumbar spine, myelography, and
well as electromyography. The ease of performance of this electromyography, is indicated. Other confirmatory tests
test combined with excellent intraobserver consistency include the sitting straight leg raising test, the Naffziger
makes it a good starting point on the physical examination test, the flip test, the buckling knee test, the Spurling
of patients who present with low back pain that radiates test, the Bragard test, the Ely test, and the Fajersztajn test
into the lower extremity. (see Chapters 148 to 155).
To perform the Lasegue straight leg raising test, the
patient is placed in the supine position on the examination
table with the unaffected leg flexed to 45 degrees at the knee
• Figure 147-1 The Lasegue straight leg raising test: the patient is • Figure 147-2 The Lasegue straight leg raising test: with the ankle
in the supine position with the unaffected leg flexed to 45 degrees at of the affected leg placed at 90 degrees of flexion, the affected leg is
the knee and the affected leg placed flat against the table. slowly raised toward the ceiling while the knee is kept fully extended.
235
148 The Sitting Straight Leg Raising Test
for Lumbar Root Irritation
Some investigators believe that performing the straight leg the patient complains of pain and paresthesias into the
raising test in the sitting position provides the examiner affected extremity that are similar to the pain that the
with more accurate test results when compared with the patient has been experiencing.
classic Lasegue straight leg raising test (see Chapter 147). Tight hamstring muscles might confuse the examination
To perform the sitting straight leg raising test, the patient and lead to false positive results. If the results are in ques-
is placed in the sitting position. The examiner then has tion, the examiner should note the amount of elevation
the patient lean slightly forward to increase tension on the necessary to elicit the patient’s symptoms. Then, after
lumbar nerve roots (Fig. 148-1). With the ankle of the lowering the patient’s affected extremity back to the table,
affected leg placed at 90 degrees of flexion, the examiner the examiner reelevates the leg to a level just below the
slowly raises the affected leg toward the ceiling while keeping degree of elevation necessary to reproduce the patient pain.
the knee fully extended (Fig. 148-2). The test is positive if The examiner holds the leg at that level for 10 seconds
and then dorsiflexes the foot. If this maneuver reproduces
the patient’s pain, the test may be considered positive,
and additional investigation, including magnetic resonance
imaging of the lumbar spine and electromyography, is
indicated. Other confirmatory tests include the Lasegue
straight leg raising test (see Chapter 147) and the Naffziger
test (see Chapter 149).
• Figure 148-1 Sitting straight leg raising test: the patient is in the • Figure 148-2 Sitting straight leg raising test: with the ankle of the
sitting position. The patient should lean forward slightly to increase affected leg at 90 degrees of flexion, the leg is slowly raised toward
tension on the lumbar nerve roots. the ceiling while the knee is kept fully extended.
236
149 The Naffziger Jugular Compression
Test for an Equivocal Lasegue Straight
Leg Raising Test
The Lasegue straight leg raising test remains a mainstay in raising test as follows. The patient is placed in the supine
the physical diagnosis of lower lumber nerve irritation. It position on the examination table with the unaffected leg
has good correlation with positive findings on magnetic flexed to 45 degrees at the knee and the affected leg
resonance imaging of the lumbar spine and lumbar plexus placed flat against the table (see Fig. 147-1). With the ankle
as well as electromyography. The ease of performance of this of the affected leg placed at 90 degrees of flexion, the exam-
test combined with excellent intraobserver consistency iner slowly raises the affected leg toward the ceiling while
makes it a good starting point in the physical examination the knee is kept fully extended (see Fig. 147-2). At this
of patients who present with low back pain that radiates point, if the results of the straight leg raising test are equivo-
into the lower extremity. Unfortunately, the results of this cal, the examiner has his or her assistant compress the
test are sometimes equivocal. When this occurs, the test may patient’s jugular veins bilaterally, which will increase the
be repeated in the sitting position (see Chapter 148) or the intraspinal pressure by distending the spinal venous plexus
Naffziger jugular compression test can be added to improve (Fig. 149-1). The Naffziger test is considered positive if
the diagnostic accuracy of the physical examination. the patient’s pain and paresthesias are reproduced within
To perform the Naffziger jugular compression test, the 15 seconds.
examiner first performs the classic Lasegue straight leg
• Figure 149-1 The Naffziger jugular compression test.
237
150 The Flip Test for Lumbar Nerve
Root Irritation
The flip test for lumbar nerve root irritation is an additional table. The examiner then diverts the patient by asking
test that is available to the clinician who is faced with a whether he or she is having any trouble with the knee of
patient suffering from low back pain that radiates into the affected leg (Fig. 150-1). The examiner then lifts the
the lower extremities. It can be used as a confirmatory foot and extends the knee. If the patient is suffering from
test to the straight leg raising tests described in Chapters significant lumbar nerve root irritation or entrapment, the
147 to 149. patient will “flip” backward to relieve the tension on the
To perform the flip test, the examiner has the patient sit affected lumbar nerve root (Fig. 150-2). The examiner
on the side of the examining table with his or her legs dan- should take care that the patient does not hit his or her head
gling comfortably and the hands resting on the edge of the against the wall when he or she flips backward.
• Figure 150-2 The patient suffering from significant lumbar nerve

root irritation or entrapment will “flip” backward to relieve the tension
• Figure 150-1 The flip test for lumbar nerve root irritation. on the affected lumbar nerve root.
238
151 The Buckling Knee Test for Lumbar
Nerve Root Irritation
To perform the buckling knee test, the patient is placed in and involuntarily withdraws the affected knee to reduce
the supine position on the examination table with the unaf- pressure on the irritated or entrapped lumbar nerve roots
fected leg flexed to 45 degrees at the knee and the foot (Fig. 151-2).
of the unaffected leg placed flat against the table (see If this maneuver reproduces the patient’s pain, the buck-
Fig. 147-1). With the ankle of the affected leg placed at 90 ling knee test for lumbar nerve root irritation may be
degrees of flexion, the examiner slowly raises the affected considered positive, and additional investigation, includ-
leg toward the ceiling while keeping the knee fully extended ing magnetic resonance imaging of the lumbar spine and
(Fig. 151-1). The test is positive if the patient complains electromyography, is indicated.
of pain and paresthesias into the affected extremity that
are similar to those that he or she has been experiencing
• Figure 151-1 The buckling knee test for lumbar nerve root • Figure 151-2 The buckling knee test is considered positive if it
irritation. reproduces the patient’s pain and paresthesias and the patient invol-
untarily withdraws the affected knee to reduce pressure on the lumbar
nerve root.
239
152 The Spurling Test for Lumbar Nerve
Root Irritation
To perform the Spurling test, the patient is placed in the the examiner carefully elevates the leg to a point just below
supine position on the examination table with the unaf- the one at which the patient began to experience the pain.
fected leg flexed to 45 degrees at the knee and the foot of At this point, the examiner forcefully dorsiflexes the patient’s
the unaffected leg placed flat against the table (see Fig. 147- foot (Fig. 152-1). The Spurling test is considered positive if
1). With the ankle of the unaffected leg placed at 90 degrees this maneuver reproduces the patient’s pain (Video 152-1).
of flexion, the examiner slowly raises the affected leg toward Modifications of this test abound and include the Sicard
the ceiling while keeping the knee fully extended. The test test, which involves forced dorsiflexion of the great toe on
is positive if the patient complains of pain and paresthesias the affected extremity (Fig. 152-2).
into the affected extremity that are similar to those that the If this maneuver reproduces the patient’s pain, the Spurl-
patient has been experiencing. The examiner notes the ing test for lumbar nerve root irritation may be considered
degree of elevation that begins to elicit the patient’s positive, and additional investigation, including magnetic
pain and then returns the affected leg to the table. After resonance imaging of the lumbar spine and electromyogra-
allowing the patient’s pain to subside for a few moments, phy, is indicated.
• Figure 152-1 The Spurling test for lumbar nerve root irritation. • Figure 152-2 Sicard test for lumbar nerve root irritation.
240
153 The Bragard Test for Lumbar Nerve
Root Irritation
To perform the Bragard test, the patient is placed in the At this point, the examiner forcefully dorsiflexes the foot of
supine position on the examination table with the unaf- the affected leg (Fig. 153-3).
fected leg flexed to 45 degrees at the knee and the foot The Bragard test is considered positive if this maneuver
of the unaffected leg placed flat against the table (see Fig. exacerbates the patient’s pain. If this maneuver reproduces
137-1). The knee of the patient’s affected leg is then flexed the patient’s pain, additional investigation, including mag-
toward his or her abdomen (Fig. 153-1). The examiner then netic resonance imaging of the lumbar spine and electro-
gradually extends the knee until the leg is straight or the myography, is indicated.
patient’s pain and paresthesias are reproduced (Fig. 153-2).
• Figure 153-1 The Bragard test: the knee of the affected leg is • Figure 153-2 The Bragard test: the knee is then gradually extended
flexed toward the abdomen. until the leg is straight or the patient’s pain and paresthesias are
reproduced.
• Figure 153-3 The Bragard test: the foot of the affected leg is then
forcefully dorsiflexed.
241
154 The Ely Test for Lumbar Nerve
Root Irritation
To perform the Ely test for lumbar nerve root irritation, the maneuver reproduces the patient’s pain, the test may be
patient is placed in the prone position. The examiner then considered positive, and additional investigation, including
has the patient flex the affected leg back toward the buttocks magnetic resonance imaging of the lumbar spine and elec-
(Fig. 154-1) and then has him or her lift the chest off the tromyography, is indicated (Video 154-1).
examining table to extend the back (Fig. 154-2). If this
• Figure 154-1 The Ely test for lumbar nerve root irritation: with the • Figure 154-2 The Ely test for lumbar nerve root irritation: next, the
patient in prone position, the affected leg is flexed back toward the patient lifts the chest off the examining table to extend the back.
buttocks.
242
155 The Fajersztajn Test for Lumbar Nerve
Root Irritation
To perform the Fajersztajn test, the patient is placed in the extremity that are similar to the pain that the patient has
supine position on the examination table with the affected been experiencing. A positive test suggests that additional
leg flexed to 45 degrees at the knee and the foot of investigation, including magnetic resonance imaging of the
the affected leg placed flat against the table (Fig. 155-1). lumbar spine and electromyography, is indicated.
With the ankle of the unaffected leg placed at 90 degrees
of flexion, the examiner slowly raises the unaffected leg
toward the ceiling while keeping the knee fully extended
(Fig. 155-2). The Fajersztajn test is positive if the patient Unaffected leg
complains of pain and paresthesias into the affected
Affected leg
• Figure 155-1 Patient position for the Fajersztajn test for lumbar • Figure 155-2 The examiner slowly raises the unaffected leg toward
nerve root irritation. the ceiling while keeping the knee fully extended.
243
156 The Stoop Test for Spinal Stenosis
Patients suffering from spinal stenosis often experience a Patients with a positive stoop test should undergo magnetic
constellation of symptoms consisting of cramping, tired- resonance scanning, computed tomographic scanning, and
ness, weakness, and numbness with walking or running electromyography with nerve conduction velocities as an
known as pseudoclaudication or neurogenic claudication. initial workup. Myelography of the suspected area of steno-
These symptoms are generally absent until the patient sis may also be indicated.
reaches a maximum distance known as the threshold dis-
tance. Once the patient exceeds the threshold distance, the
symptoms continue to worsen until the patient is forced to
stoop. As the patient begins to experience the symptoms
of pseudoclaudication, he or she may assume a simian
posture with a forward-flexed trunk and slightly bent knees
(Fig. 156-1). This posture is thought to increase the capacity
of the spinal canal and improve blood flow to the nerve
roots that have become ischemic and unable to keep up with
the increased metabolic demands of ambulation. The stoop
test has its basis in this hypothesis, and this construct is
further reinforced by the fact that a given patient’s threshold
distance will often be longer when walking up a hill because
of the forward-flexed posture that is assumed and, con-
versely, shortened on the trip back down the hill because of
the extended posture that is assumed when walking down
a hill.
To perform the stoop test, the patient is asked to walk
briskly for 2 or 3 minutes until the threshold distance is
identified. The patient is then asked to continue walking for
30 seconds and then to sit upright in a straight-back chair
(Fig. 156-2, A). The patient is then asked to lean forward
in the chair (Fig. 156-2, B). The stoop test is positive if the
patient’s pain is relieved by leaning forward and presents the • Figure 156-1 The simian posture with a forward-flexed trunk and
examiner with a presumptive diagnosis of spinal stenosis. slightly bent knees.
A B
• Figure 156-2 A and B, Stoop test for spinal stenosis.
244
157 The Babinski Sign for Diseases of
the Corticospinal System
In health, stimulation of the plantar surface of the foot will exposed. The lateral plantar surface is then lightly stroked
elicit the consistent response of flexion of the toes with the from the heel forward with a blunt object such as a broken
flexion of the little toe greater than that of the great toe. tongue depressor (Fig. 157-1, A). The stimulus should be
With disease of the corticospinal system, this normal light, as more pressure can elicit a nociceptive withdrawal
response is reversed: stimulation of the plantar surface of response and produce a false negative test. A positive Babin-
the foot elicits dorsiflexion of the toes with the dorsiflexion ski sign is produced when light stroking of the plantar
of the great toe greater than that of the little toe. Babinski surface produces rapid dorsiflexion of the toes with con-
described this pathologic reflex as phenomene des orteils, or comitant fanning of the toes, which is strongly suggestive
dorsiflexion of the toes. He also described another consis- of disease of the corticospinal tract (Fig. 157-1, B). As was
tent finding in patients with disease of the corticospinal mentioned previously, plantar flexion of the toes is consid-
system that he called signe de l’eventail, or fanning of the ered a normal reflex. A positive Babinski sign is a significant
toes. This classic constellation of symptoms has become physical finding and should prompt the clinician to imme-
known as the Babinski sign and has become synonymous diately begin evaluation of the corticospinal system.
with diseases of the corticospinal system.
To elicit the Babinski sign, the patient is placed in a
comfortable position with the plantar surface of the foot
A B
• Figure 157-1 A and B, Eliciting the Babinski sign.
245
158 The Chaddock Sign for Diseases of
Although less sensitive than the Babinski sign, the Chad- with a blunt object such as a broken tongue depressor (Fig.
dock sign is useful as a confirmatory test in patients with 158-1, A). The stimulus should be light, as more pressure
an equivocal Babinski sign in whom disease of the cortico- can elicit a nociceptive withdrawal response and produce a
spinal tract is suspected. The Chaddock sign is also useful false negative test. A positive Chaddock sign is produced
in patients with plantar keratosis or open wounds of the when light stroking of the plantar surface produces rapid
plantar surface of the foot, which can make eliciting the dorsiflexion of the toes with concomitant fanning of the
Babinski sign difficult if not impossible. toes, which is strongly suggestive of disease of the cortico-
To elicit the Chaddock sign, the patient is placed in a spinal tract (Fig. 158-1, B). Plantar flexion of the toes is
comfortable position with the plantar surface of the foot considered a normal reflex. A positive Chaddock sign is a
exposed. The lateral surface of the foot is then lightly stroked significant physical finding and should prompt the clinician
from the lateral aspect of the heel forward to the little toe to immediately begin evaluation of the corticospinal system.
A B
• Figure 158-1 A and B, Eliciting the Chaddock sign.
246
159 The Oppenheim Sign for Diseases of
Although less sensitive than the Babinski or Chaddock The stimulus should be firm but not painful, as more
signs, the Oppenheim sign is useful as a confirmatory test pressure may elicit a nociceptive withdrawal response and
in patients with an equivocal Babinski sign in whom disease produce a false negative test. A positive Oppenheim sign is
of the corticospinal tract is suspected. The Oppenheim sign produced when this maneuver produces rapid dorsiflexion
is also useful in patients with plantar keratosis or open of the toes with concomitant fanning of the toes, which is
wounds of the plantar or lateral surface of the foot, which strongly suggestive of disease of the corticospinal tract (Fig.
can make eliciting the Babinski or Chaddock sign difficult 159-1, B). Plantar flexion of the toes is considered a normal
if not impossible. reflex. A positive Oppenheim sign is a significant physical
To elicit the Oppenheim sign, the patient is placed in a finding and should prompt the clinician to immediately
comfortable position with the anterior tibial surface and begin evaluation of the corticospinal system.
foot exposed. The anterior surface of the tibia is firmly
rubbed, starting just below the knee and progressing rapidly
downward to the ankle (Fig. 159-1, A).
A B
• Figure 159-1 A and B, Eliciting the Oppenheim sign.
247
160 The Gordon Reflex for Diseases of
Since 1896, when Babinski first described the sign that from disorders of the corticospinal system, the examiner
bears his name, a number of clinicians have described other firmly squeezes the patient’s calf while observing the patient’s
signs that are thought to be indicative of diseases of the ipsilateral great toe (Fig. 160-1). Fanning or extension of the
corticospinal system. One of these is the Gordon reflex. To great toe indicates a positive Gordon reflex and is thought to
elicit the Gordon reflex in patients suspected of suffering be indicative of diseases of the corticospinal system.
• Figure 160-1 The Gordon reflex for diseases of the corticospinal

system, as observed by flexion of the great toe while the examiner
pinches the patient’s calf.
248
161 The Sit-Up Sign for Anterior Cutaneous
Nerve Entrapment Syndrome
Anterior cutaneous nerve entrapment syndrome is a con- of the rectus abdominis muscle. It is at this point that the
stellation of symptoms, including severe, knife-like pain anterior cutaneous branch of the intercostal nerve turns
emanating from the anterior abdominal wall associated with sharply in an anterior direction to provide innervation to
point tenderness over the affected anterior cutaneous nerve. the anterior wall (Figs. 161-1 and 161-2). The nerve passes
The pain radiates medially to the linea alba but in almost through a firm, fibrous ring as it pierces the fascia; it is at
all cases does not cross the midline. Anterior cutaneous this point that the nerve is subject to entrapment. The nerve
nerve entrapment syndrome occurs most commonly in is accompanied through the fascia by an epigastric artery
young females. The patient can often localize the source of and vein. There is the potential for small amounts of
pain quite accurately by pointing to the spot at which the abdominal fat to herniate through this fascial ring and
anterior cutaneous branch of the affected intercostal nerve become incarcerated, which results in further entrapment
pierces the fascia of the abdominal wall at the lateral border of the nerve. Contraction of the abdominal muscles puts
Fat pad
Fibrotic band
Anterior cutaneous
branch, thoracic n.
Intraabdominal
pressure
Rectus abdominis m.
Transverse abdominis m.
Internal oblique m.
External oblique m.
Carrico & Shavell
• Figure 161-1 The source of pain in anterior cutaneous nerve entrapment syndrome can often be
localized to the spot at which the anterior cutaneous branch of the affected intercostal nerve pierces the
fascia of the abdominal wall at the lateral border of the rectus abdominis muscle. (From Waldman SD:
Atlas of pain management injection techniques, Philadelphia, 2000, Saunders, p 193.)
250
CHAPTER 161 The Sit-Up Sign for Anterior Cutaneous Nerve Entrapment Syndrome 251
Epigastric Anterior
vessels cutaneous N.
Rectus
muscle
Liver
Peritoneum
• Figure 161-2 Ultrasound image demonstrating the anterior cuta-

neous nerve and its relationship to the rectus muscles.
additional pressure on the nerve and may elicit sudden, the abdominal wall at the lateral border of the rectus
sharp, lancinating pain in the distribution of the affected abdominis muscle. Patients with anterior cutaneous nerve
anterior cutaneous nerve. entrapment syndrome will exhibit a positive sit-up sign. To
Physical examination reveals that the patient will attempt elicit the sit-up sign, the patient is asked to assume the
to splint the affected nerve by keeping the thoracolumbar supine position with his or her knees flexed and the feet flat
spine slightly flexed to avoid increasing tension on the on the examining table. The patient is then asked to take a
abdominal musculature. Pain is reproduced with pressure deep breath and hold it and then to execute a partial sit-up.
on the anterior cutaneous branch of the affected intercostal The sit-up sign is considered positive if the partial sit-up
nerve at the point at which the nerve pierces the fascia of reproduces the patient’s pain.
162 The Waddling Gait Sign for Osteitis
Pubis Syndrome
Osteitis pubis syndrome is a constellation of symptoms that On physical examination, the patient exhibits point ten-
includes a localized tenderness over the symphysis pubis, derness over the symphysis pubis. The patient might be
pain radiating into the inner thigh, and a waddling gait. tender over the anterior pelvis and might note that the pain
Characteristic radiographic changes of erosion, sclerosis, radiates into the inner thigh with palpation of the symphy-
and widening of the symphysis pubis are pathognomonic sis pubis. Patients with osteitis pubis will invariably dem-
for osteitis pubis (Fig. 162-1). A disease of the second to onstrate a positive waddling gait sign. This dysfunctional
fourth decades, osteitis pubis affects females more frequently gait might result in lower extremity bursitis and tendinitis,
than males. Osteitis pubis occurs most commonly following which can confuse the clinical picture and further increase
bladder, inguinal, or prostate surgery and is thought to be the patient’s pain and disability. To elicit the waddling
caused by hematogenous spread of infection to the relatively gait sign in patients who are suspected of suffering from
avascular symphysis pubis. Osteitis pubis can appear without osteitis pubis, the patient is asked to walk rapidly toward
obvious inciting factors or infection. A pain syndrome that the examiner. Patients with a positive sign will assume a
is clinically similar to osteitis pubis can be seen in patients waddling gait and will be unable to walk rapidly as they try
who suffer from rheumatoid arthritis and ankylosing spon- to minimize movement of the inflamed symphysis pubis
dylitis but without the characteristic radiographic changes (Figs. 162-2 and 162-3).
of osteitis pubis.
• Figure 162-1 Osteitis pubis. Anteroposterior radiograph of the pelvis demonstrating chronic stress-
related noninfective changes around the symphysis pubis with bony sclerosis and erosion of the bony
margins. L, Left. (From Waldman SD, Campbell, RSD: Imaging of pain, Philadelphia, 2010, Saunders/
252
CHAPTER 162 The Waddling Gait Sign for Osteitis Pubis Syndrome 253
• Figure 162-2 Coronal short T1 inversion recovery magnetic resonance image of osteitis pubis with
high signal intensity marrow edma in both pubic bones (arrows). There is also minor periosteal edema.
(From Waldman SD, Campbell, RSD: Imaging of pain, Philadelphia, 2010, Saunders/Elsevier, p 208,
fig 82-2.)
• Figure 162-3 Eliciting the waddling gait sign.

163 The Yeoman Test for Sacroiliac
Joint Pain
Yeoman’s test in a physical exam is performed to determine (Fig. 163-1). The examiner then displaces the ipsilateral
if a person has sacroiliitis. With the subject prone, the test ilium with firm downward pressure (Fig. 163-2). The exam-
is performed by rotating the ilium with one hand and iner then extends the ipsilateral hip. The test is positive
extending the hip while the knee is extended. Pain over the if the pain is in the region of the sacroiliac joint
ipsilateral posterior sacroiliac joint area is indicative of (Fig. 163-3).
sacroiliitis. If this maneuver reproduces the patient’s pain, the test
To perform the Yeoman test to determine if the nidus of may be considered positive, and additional investigation,
the patient’s pain is the sacroiliac joint, the patient is placed including plain radiographs, computed tomography, and
in the prone position. The examiner then has the patient magnetic resonance imaging of the sacroiliac joint, is
flex the affected leg back toward the buttocks to 90 degrees indicated.
• Figure 163-1 The Yeoman test: with the patient in prone position, • Figure 163-2 The Yeoman test: the examiner then displaces the
the affected leg is flexed back toward the buttocks to 90 degrees. ipsilateral ilium with firm downward pressure.
• Figure 163-3 The Yeoman test: the examiner then extends the
ipsilateral hip.
254
164 The Van Durson Standing Flexion Test
for Sacroiliac Joint Pain
To perform the Van Durson standing flexion test to deter-

mine if the nidus of the patient’s pain is the sacroiliac joint,
the patient is placed in the standing position with examiner
behind the patient. The pelvis is examined for any asym-
metry. The examiner then places his or her thumbs on the
patient’s posterior superior iliac spines (Fig. 164-1). The
patient is then asked to tuck his or her chin and then slowly
bend forward at the waist (Fig. 164-2). If there is sacroiliac
dysfunction, the side with the painful sacroiliac joint will
elevate to reduce the stress on the affected sacroiliac joint.
This will cause the examiner’s thumb on the painful side to
rise (Fig. 164-3).
If this maneuver reproduces the patient’s pain, the test
may be considered positive, and additional investigation,
including plain radiographs, computed tomography, and • Figure 164-2 The Van Durson standing flexion test: the patient is
then asked to tuck his or her chin and slowly bend forward at the
magnetic resonance imaging of the sacroiliac joint, is waist.
indicated.
• Figure 164-3 The Van Durson standing flexion test: as the patient
• Figure 164-1 The Van Durson standing flexion test: the patient is bends forward, it places stress on the sacroiliac joints. The patient will
placed in the standing position with the examiner behind the patient. elevate the sacroiliac joint on the affected side in an effort to relieve
The examiner places his or her thumbs over the patient’s posterior the stress and resulting pain emanating from the painful joint. This will
superior iliac spines. cause the examiner’s thumb to rise.
255
165 The Piedallu Seated Flexion Test for
Sacroiliac Joint Pain
To perform the Piedallu seated flexion test to determine if with the painful sacroiliac joint will elevate to reduce the
the nidus of the patient’s pain is the sacroiliac joint, the stress on the affected sacroiliac joint. This will cause the
patient is placed in the sitting position with his or her feet examiner’s thumb on the painful side to rise (Fig. 165-3).
flat on the floor and the examiner seated behind the patient. If this maneuver reproduces the patient’s pain, the
The pelvis is examined for any asymmetry. The examiner test may be considered positive, and additional investiga-
then places his or her thumbs on the patient’s posterior tion, including plain radiographs, computed tomography,
superior iliac spines (Fig. 165-1). The patient is then asked and magnetic resonance imaging of the sacroiliac joint, is
to tuck his or her chin and then slowly bend forward at the indicated.
waist (Fig. 165-2). If there is sacroiliac dysfunction, the side
• Figure 165-1 The Piedallu seated flexion test: the patient is placed • Figure 165-2 The Piedallu seated flexion test: the patient is then
in the seated position with the examiner seated behind the patient. asked to tuck his or her chin and slowly bend forward at the waist.
The examiner places his or her thumbs over the patient’s posterior
superior iliac spines.
• Figure 165-3 The Piedallu seated flexion test: as the patient bends
forward, it places stress on the sacroiliac joints. The patient will elevate
the sacroiliac joint on the affected side in an effort to relieve the stress
and resulting pain emanating from the painful joint. This will cause the
examiner’s thumb to rise.
256
166 The Stork Test for Sacroiliac
Joint Dysfunction
To perform the Stork test to determine if there is dysfunc- dorsocaudal direction to brace the pelvis to aid the other
tion of the sacroiliac joint, the patient is placed in the leg in receiving the full weight of the upper body (Fig. 166-
standing position with examiner seated behind the patient. 3). If there is hypomobility of the sacroiliac joint on the
The pelvis is examined for any asymmetry. The examiner painful side, the posterior superior iliac spine of the flexed
then places one thumb on the patient’s posterior superior leg will not drop, as the ilium is unable to rotate in a dor-
iliac spine and the other thumb on the base of the sacrum socaudal direction to brace the pelvis.
(Fig. 166-1). The patient is then asked to flex his or her hip If this maneuver reproduces the patient’s pain, the
and knee on the nonpainful side to at least 90 degrees while test may be considered positive, and additional investi
standing on the contralateral leg (Fig. 166-2). If there is no gation, including plain radiographs, computed tomogra-
sacroiliac dysfunction, as the patient flexes his or her hip phy, and magnetic resonance imaging of the sacroiliac joint,
and knee, the thumb on the patient’s posterior superior iliac is indicated.
spine of the flexed leg will drop as the ilium rotates in a
• Figure 166-1 The Stork test: the patient is placed in the standing • Figure 166-2 The Stork test: the patient is then asked to flex his
position with the examiner seated behind the patient. The examiner or her hip and knee on the nonpainful side to at least 90 degrees while
places one thumb on the patient’s posterior superior iliac spine and standing on the contralateral leg.
the other thumb on the base of the sacrum.
• Figure 166-3 The Stork test: if there is no sacroiliac dysfunction,

as the patient flexes his or her hip and knee, the thumb on the patient’s
posterior superior iliac spine of the flexed leg will drop as the ilium
rotates in a dorsocaudal direction to brace the pelvis to aid the other
leg in receiving the full weight of the upper body.
257
167 The Gaenslen Test for Sacroiliac
Joint Dysfunction
The patient begins in a supine positioned with the painful edge of the examination table. The patient is then asked to
leg resting on the edge of the treatment table. The examiner move the leg on the painful side so it can hang partially
sagitally flexes the nonsymptomatic hip, while the knee is off the examination table (Fig. 167-1). The examiner sagi-
also flexed (up to 90 degrees). The patient should hold tally flexes the hip on the nonpainful side while flexing the
the asymptomatic leg with both arms while the therapist knee until patient’s lumbar spine assumes physiologic lor-
stabilizes the pelvis and applies passive pressure to the dosis (Fig. 167-2). The patient holds the hip and knee
symptomatic leg to hold it in a hyperextended position. in that position while the examiner stabilizes the pelvis
A downward force is applied to the lower leg (symp- and hip on the nonpainful side by applying firm pressure
tomatic side) putting it into hyperextension at the hip, to the flexed knee and hip. The examiner then applies
while a flexion-based counterforce is applied to the flexed firm downward pressure to hyperextend the lower extrem-
leg, pushing it in the cephalad direction and causing torque ity that is hanging off the table to put stress on the
to the pelvis. symptomatic sacroiliac joint (Figs. 167-3 and 167-4). The
If the patient’s normal pain is reproduced, the test is test is positive if the downward pressure on the symptom-
considered positive for a sacroiliac joint lesion, hip pathol- atic sacroiliac joint reproduces or causes an exacerbation of
ogy, pubic synthesis instability, or an L4 nerve root lesion. the patient’s pain.
Meanwhile the femoral nerve may also be stressed by If this maneuver reproduces the patient’s pain, the
this test. test may be considered positive, and additional investiga-
To perform the Gaenslen test to determine if there is tion, including plain radiographs, computed tomography,
dysfunction of the sacroiliac joint, the patient is placed in and magnetic resonance imaging of the sacroiliac joint, is
the supine position with painful hip and leg resting on the indicated.
• Figure 167-1 The Gaenslen test: to perform the Gaenslen test to • Figure 167-2 The Gaenslen test: the patient is then asked to flex
determine if there is dysfunction of the sacroiliac joint, the patient is his or her hip and knee on the nonpainful side to at least 90 degrees
placed in the supine position with painful hip and leg resting on the and then hold the leg in that position.
edge of the examination table. The patient is then asked to move the
leg on the painful side so it can hang partially off the examination table.
258
CHAPTER 167 The Gaenslen Test for Sacroiliac Joint Dysfunction 259
• Figure 167-3 The Gaenslen test: the patient holds the hip and
knee in that position while the examiner stabilizes the pelvis and hip • Figure 167-4 Arrows indicate the direction of forces placed on the
on the nonpainful side by applying firm pressure to the flexed knee painful and nonpainful sacroiliac joints.
and hip. The examiner then applies firm downward pressure to hyper-
extend the lower extremity that is hanging off the table to put stress
on the symptomatic sacroiliac joint.
168 The Numb Medial Thigh Sign
for Obturator Nerve
Entrapment Syndrome
Obturator nerve entrapment syndrome is caused by com- needle at the midthigh, starting at the apex of the thigh
pression of the obturator nerve as it passes through the (Fig. 168-2, A) and moving medially (Fig. 168-2, B). The
upper part of the obturator canal (Fig. 168-1). The most patient is instructed to say “there” at the first sign of dimi-
common causes of compression of the obturator nerve at nution of sensation. It should be remembered that lesions
this anatomic location involve trauma, including gunshot of the lumbar plexus from trauma, hematoma, tumor, dia-
wounds, pelvic fractures, herniation of cement after total betic neuropathy, or inflammation are much more common
hip arthroplasty, and, rarely, damage during childbirth. causes of medial thigh pain and hip adductor weakness than
Obturator nerve entrapment presents as paresthesias and are isolated lesions of the obturator nerve. Electromyogra-
pain in the medial thigh. The pain rarely radiates below the phy helps to distinguish obturator nerve entrapment from
knee and is made worse by extension or lateral movement lumbar plexopathy, lumbar radiculopathy, and diabetic
of the lower extremity, which puts traction on the nerve. polyneuropathy. Plain radiographs of the hip and pelvis are
Untreated, progressive motor deficit consisting of hip indicated for all patients who present with obturator nerve
adductor weakness can lead to significant functional dis- entrapment syndrome to rule out occult bony pathology.
ability because of the inability to stabilize the hip joint. This On the basis of the patient’s clinical presentation, additional
instability causes the patient to assume a wide-based gait testing may be indicated, including complete blood count,
with the hip held in a fully abducted position. uric acid, sedimentation rate, and antinuclear antibody
Patients with entrapment of the obturator nerve will testing. Magnetic resonance imaging scan of the lumbar
exhibit a positive numb medial thigh sign. To elicit this sign, plexus is indicated if tumor or hematoma is suspected.
the patient is placed in the supine position and the clinician Ultrasound imaging may help identify abnormalities of the
begins to perform sequential sensory testing with a sterile obturator nerve (Fig. 168-3).
Obturator
nerve
• Figure 168-1 The patient who suffers from obturator nerve entrap-
ment syndrome will experience symptoms in the medial thigh. (From B
Waldman SD: Atlas of uncommon pain syndromes, Philadelphia,
2003, Saunders, p 198.) • Figure 168-2 A and B, Eliciting the numb medial thigh sign.
260
CHAPTER 168 The Numb Medial Thigh Sign for Obturator Nerve Entrapment Syndrome 261
Pectineus Adductor Anterior

muscle longus branch
obturator
nerve
Adductor Posterior
brevis branch
obturator
nerve
Adductor
magnus
• Figure 168-3 Ultrasound image demonstrating the branches of the

obturator nerve.
169 The Novice Skier Sign for Ilioinguinal
Nerve Entrapment Syndrome
Ilioinguinal nerve entrapment syndrome is caused by com abdominal wall muscles may occur. This bulging can be
pression of the ilioinguinal nerve as it passes through the confused with inguinal hernia. Physical findings include
transverse abdominis muscle at the level of the anterior sensory deficit in the inner thigh, scrotum, or labia in the
superior iliac spine. The most common causes of compres distribution of the ilioinguinal nerve. Weakness of the ante
sion of the ilioinguinal nerve at this anatomic location rior abdominal wall musculature may be present. The Tinel
involve injury to the nerve induced by trauma, including sign may be elicited by tapping over the ilioinguinal nerve
direct blunt trauma to the nerve, as well as damage during at the point at which it pierces the transverse abdominis
inguinal herniorrhaphy and pelvic surgery. Rarely, ilioin muscle.
guinal nerve entrapment syndrome occurs spontaneously. The patient who is suffering from ilioinguinal neuralgia
Ilioinguinal nerve entrapment syndrome presents as pares will exhibit a positive novice skier sign. To elicit this sign,
thesias, burning pain, and, occasionally, numbness over the the patient is asked to assume the standing position and
lower abdomen that radiates into the scrotum or labia and walk toward the examiner. If the patient assumes the novice
occasionally into the inner upper thigh. The pain does not skier position, the examiner extends the patient’s lumbar
radiate below the knee. The pain of ilioinguinal nerve spine (Fig. 169-1, B). If this maneuver reproduces the
entrapment syndrome is made worse by extension of the patient’s pain, the novice skier sign is considered positive.
lumbar spine, which puts traction on the nerve. Patients It should be remembered that lesions of the lumbar plexus
who are suffering from ilioinguinal nerve entrapment syn from trauma, hematoma, tumor, diabetic neuropathy, or
drome often assume a bent-forward novice skier position inflammation can mimic the pain, numbness, and weakness
(Fig. 169-1, A). If the syndrome remains untreated, progres of ilioinguinal neuralgia and must be included in the dif
sive motor deficit consisting of bulging of the anterior ferential diagnosis.
A B
• Figure 169-1 A and B, Eliciting the novice skier sign.
262
CHAPTER 169 The Novice Skier Sign for Ilioinguinal Nerve Entrapment Syndrome 263
External oblique
Iliohypogastric Internal
nerve oblique
Ilioinguinal
nerve Anterior
superior
iliac
spine
Transverse abdominis
Peritoneum
• Figure 169-2 Ultrasound imaging can help identify the cause and
anatomic location of entrapment of the ilioinguinal nerve.
Electromyography helps to distinguish ilioinguinal nerve ilioinguinal nerve (Fig. 169-2). On the basis of the patient’s
entrapment from lumbar plexopathy, lumbar radiculopathy, clinical presentation, additional testing might be indicated,
and diabetic polyneuropathy. Plain radiographs of the hip including complete blood count, uric acid, sedimentation
and pelvis are indicated in all patients who present with rate, and antinuclear antibody testing. Magnetic resonance
ilioinguinal nerve entrapment syndrome to rule out occult imaging of the lumbar plexus is indicated if tumor or hema
bony pathology. Ultrasound imaging can help identify toma is suspected.
the cause and anatomic location of entrapment of the
170 The Femoral Stretch Test
The femoral nerve stretch test can help the examiner distin- the knee as far back as it will go (Fig. 170-1). The test is
guish pain emanating from the femoral nerve from radicular considered positive if the patient complains of pain in the
pain. To perform the femoral nerve stretch test, the patient ipsilateral thigh and the pain does not extend below the
is placed in the prone position. The examiner then flexes knee (Video 170-1).
• Figure 170-1 Have the patient lie prone. Passively flex the knee as
far as it goes. In a positive test the patient should feel pain in the
ipsilateral anterior thigh (i.e., the distribution of the femoral nerve). Also,
pain may be exacerbated on hip extension.
264
171 The Burning Lateral Thigh Sign for
Meralgia Paresthetica
Meralgia paresthetica is caused by compression of the lateral Patients who are suffering from meralgia paresthetica will
femoral cutaneous nerve by the inguinal ligament as it exhibit a positive lateral burning thigh sign. To elicit this
passes through or under the inguinal ligament (Fig. 171-1). sign, the clinician begins careful sensory testing with a
This entrapment neuropathy presents as pain, numbness, sterile needle at the midthigh beginning at the apex of the
and dysesthesias in the distribution of the lateral femoral thigh and working laterally (Fig. 171-2, A). The patient is
cutaneous nerve. These symptoms often begin as a burning asked to say “there” at the first sign of diminution of sensa-
pain in the lateral thigh with associated cutaneous sensitiv- tion (Fig. 171-2, B). The burning lateral thigh sign is con-
ity. Patients who suffer from meralgia paresthetica note that sidered positive if there is diminished sensation in the
sitting, squatting, or wearing wide belts that compress the distribution of the lateral femoral cutaneous nerve. No
lateral femoral cutaneous nerve cause the symptoms to motor deficit should be present.
worsen. Although traumatic lesions to the lateral femoral Meralgia paresthetica is often misdiagnosed as lumbar
cutaneous nerve have been implicated in the onset of meral- radiculopathy or trochanteric bursitis or is attributed to
gia paresthetica, in most patients no obvious antecedent primary hip pathology. Radiographs and ultrasound imaging
trauma can be identified. Physical findings include tender- of the lateral femoral cutaneous nerve and hip, as well as
ness over the lateral femoral cutaneous nerve at the origin electromyography, help distinguish meralgia paresthetica
of the inguinal ligament at the anterior superior iliac from radiculopathy or pain emanating from the hip
spine. A positive Tinel sign may be present over the lateral (Figs. 171-3 and 171-4). Most patients who suffer from a
femoral cutaneous nerve as it passes beneath the inguinal lumbar radiculopathy have back pain associated with reflex,
ligament. motor, and sensory changes and lower extremity pain,
Lat. femoral cutaneous n.
A
Inguinal ligament
B
• Figure 171-1 Meralgia paresthetica is caused by compression of
the lateral femoral cutaneous nerve by the inguinal ligament as it • Figure 171-2 A and B, Eliciting the burning lateral thigh sign for
passes through or under the inguinal ligament. meralgia paresthetica.
265
266 SECTION 8 The Abdominal Wall and Pelvis
LFCN
Tensor
fascia
lata
Femoral
nerve
Sartorius
A
Iliacus
ng
c wi
Ilia
• Figure 171-4 Ultrasound imaging can also aid in the diagnosis and
provide accurate guidance for blockade of the lateral femoral cutane-
ous nerve with local anesthetic, which can also serve as a diagnostic
B and therapeutic maneuver.
• Figure 171-3 A, Axial T1-weighted magnetic resonance image
demonstrating the lateral cutaneous nerve of the thigh on both sides
(arrows), lying on the surface of the iliacus muscle just proximal to the
level of the inguinal ligament. B, An oblique ultrasound image in a dif- Electromyography helps to distinguish lumbar radicu-
ferent subject shows the round nerve (broken arrow) lying on the
lopathy and diabetic femoral neuropathy from meralgia
surface of the iliacus muscle immediately deep to the echo-bright
inguinal ligament (arrows). paresthetica. Plain radiographs of the back, hip, and pelvis
are indicated for all patients who present with meralgia
paresthetica to rule out occult bony pathology. On the basis
of the patient’s clinical presentation, additional testing,
including complete blood count, uric acid, sedimentation
whereas patients with meralgia paresthetica have no back rate, and antinuclear antibody testing, might be indicated.
pain and no motor or reflex changes. The sensory changes Magnetic resonance imaging of the spine and pelvis is indi-
of meralgia paresthetica are limited to the distribution of cated if herniated disc, spinal stenosis, or a space-occupying
the lateral femoral cutaneous nerve and should not extend lesion is suspected and to help identify the cause of entrap-
below the knee. It should be remembered that lumbar ment of the lateral femoral cutaneous nerve. Ultrasound
radiculopathy and lateral femoral cutaneous nerve entrap- imaging can also aid in the diagnosis and provide accurate
ment may coexist as the so-called double crush syndrome. guidance for blockade of the lateral femoral cutaneous nerve
Occasionally, diabetic femoral neuropathy produces ante- with local anesthetic, which can also serve as a diagnostic
rior thigh pain, which can confuse the diagnosis. and therapeutic maneuver.
172 Functional Anatomy of the Hip
The hip is a ball-and-socket joint that comprises the femoral deeper. This deeper, cup-shaped configuration of the ace-
head and the cup-shaped acetabulum (Fig. 172-1). The tabulum adds much stability to the hip joint when com-
femoral head is completely covered with hyaline cartilage pared with the shoulder, whose stability is primarily from
except for a central area called the fovea, which is the point the ligaments and labrum. The cup of the acetabulum is
of attachment for the ligamentum teres. In contradistinc- endowed with a horseshoe-shaped articular cartilage with
tion to its homolog, the glenoid fossa of the shoulder, which the open portion of the horseshoe allowing passage of the
is very shallow, the acetabulum, which comprises the con- ligamentum teres (Fig. 172-2). Within the ligamentum
fluence of the ilium, ischium, and pubic bones, is much teres is the central branch of the obturator artery, which
Ilium
Gluteus ••
medius m
••
•• Acetabulum
Gluteus
minimus m •• Femur, head
••
Sup acetabular •• Synovial
labrum •• membrane,
•• acetabular
Iliofemoral lig fossa
•• Obturator
internus m
Obturator
Tensor fasciae externus m
latae m
••
••
Med femoral
••
Rectus femoris m
•• •• circumflex a
•• •• Ischium
••
••
A Iliopsoas m & t Pectineus & adductor mm
Sup acetabular labrum
Gluteus
medius m
•• Acetabulum
Femur, head
••
Gluteus
minimus m
•• •• Synovial
membrane,
••
•• acetabular
•• fossa
Iliofemoral lig
•• •• Obturator
internus m
Tensor fasciae ••
latae m Inf acetabular
labrum
••
Rectus
femoris m
••
• externus m
Vastus ••
•• •• Med femoral
lateralis m • circumflex a
B Iliopsoas m & t Pectineus & adductor mm
• Figure 172-1 A and B, Hip, coronal view. (From Kang HS, Ahn JM, Resnick D: MRI of the extremities,
268
CHAPTER 172 Functional Anatomy of the Hip 269
Iliopsoas m & t Femoral n
••
Sartorius m •• •• •• Pubis
••
••
Rectus femoris •• Lig teres &
m&t
synovial
Iliofemoral lig •• • membrane
Tensor fasciae •• •• Femur, head
latae m
••
Obturator
Gluteus •• •• internus m
minimus m & t
Post acetabular
labrum
Gluteus ••
•• •• Ischiofemoral lig
medius m & t
•• Ischium
••
•
••
Iliotibial tract
••
internus t
Gluteus •• •• Sciatic n
maximus m
Sacrotuberous lig
A Greater trochanter Inf gemellus m
Iliopsoas m & t Femoral n

Femoral a & v
•• •• Pectineus m
••
••
••
Sartorius m Pubis
•• •• •• Ant acetabular
••
••
Rectus femoris •• labrum

m&t Lig teres &
•• •• synovial
Iliofemoral lig membrane
••
••
Tensor fasciae •• Femur, head

latae m •• Obturator
Gluteus •• internus m
minimus m & t Post acetabular
•• •• labrum
Gluteus
medius m & t
•• Ischiofemoral lig
••
••
•• Ischium
••
Iliotibial tract
••
••
••
Gluteus Obturator
maximus m
•• internus t
Sciatic n
B Greater trochanter Inf gemellus m
• Figure 172-2 A and B, Hip, transverse view. (From Kang HS, Ahn JM, Resnick D: MRI of the extremi-
ties, ed 2, Philadelphia, 2002, Saunders, p 240.)
provides blood supply to the fovea of the femoral head. This outcroppings at the junction of the femoral neck and shaft
blood supply is very susceptible to disruption from trauma of the femur: the greater trochanter and the lesser trochan-
and, if compromised, may cause avascular osteonecrosis ter. The greater trochanter on the lateral femoral neck serves
of the femoral head (Fig. 172-3). as the attachment point for the gluteal muscles, and the
The femoral head is connected to the femoral shaft by medially situated lesser trochanter serves as the attachment
the neck of the femur, which in health forms an angle of point for the hip adductors (see Fig. 172-3).
125 to 140 degrees with the femoral shaft and serves to align The hip joint is further strengthened by a fibrous artic
the femoral head in the coronal plane with the femoral ular capsule and a trio of ligaments: the iliofemoral,
condyles in the standing adult. There are 2 major bony ischiofemoral, and pubofemoral ligaments. The iliofemoral
270 SECTION 9 The Hip
Greater Fovea
trochanter
Head
Neck
Lesser trochanter
• Figure 172-3 The central branch of the obturator artery provides

blood supply to the fovea of the femoral head. This blood supply is
very susceptible to disruption from trauma and, if compromised, can
cause avascular osteonecrosis of the femoral head.
ligament provides support anteriorly, and the ischiofemoral medius and gluteus minimus muscles with adduction pro-
and pubofemoral ligaments provide the majority of poste- vided primarily by the adductor longus and brevis muscles.
rior support. External rotation is provided primarily by the obturator,
The muscles of the hip provide movement in 3 planes: quadratus femoris, and gemelli muscles with internal rota-
(1) flexion and extension, (2) adduction and abduction, and tion provided by the tensor fascia lata, gluteus medius, and
(3) internal and external rotation. Flexion of the hip is gluteus minimus muscles. Movement of these muscles is
provided primarily by the iliopsoas muscle with extension facilitated by a number of bursae, which are subject to
provided primarily by the gluteus maximus and hamstrings. inflammation and can serve as a nidus of hip dysfunction
Abduction of the hip is provided primarily by the gluteus and pain.
173 Visual Inspection of the Hip Joint
The starting point in the physical examination of the hip is additional physical examination as well as providing a guide
the visual inspection of the joint and surrounding struc- as to the ordering of specialized plain radiographic views,
tures. Asking the patient whether he or she is having any ultrasound imaging, and magnetic resonance imaging to
problem putting on undergarments or pants can provide further ascertain the cause of the patient’s hip pain and
the examiner with useful clues as to the presence and cause dysfunction (Figs. 173-2 and 173-3).
of hip dysfunction.
The visual inspection of the hip must be carried out with
the patient undressed to avoid missing physical signs that
could be masked by clothing. The anterior, lateral, and
posterior aspects of the hip should be observed for muscle
wasting, swelling, erythema, or ecchymosis that might
suggest acute and chronic hip pathology (Fig. 173-1).
Careful inspection of the hip joints for asymmetry suggest-
ing chronic dislocation or osteonecrosis should be carried
out next. The examiner should then evaluate the position
of the hips relative to the pelvis to identify protective
“splinting” of the joint that might indicate a painful or
unstable joint. Tilting of the pelvis should also be noted, as
this is suggestive of hip disease or leg length discrepancy.
The gluteal skinfolds will be higher on the side with the
longer leg.
Positive findings during the initial visual inspection of
• Figure 173-2 Anteroposterior radiograph of the pelvis demonstrat-
the hip should help guide the examiner in his or her ing bilateral avascular necrosis (AVN) of the femoral heads. On the left
side there is stage IV disease, with a subchondral sclerotic crescent
and subchondral collapse (arrow). On the right side there is stage III
AVN with crescentic sclerosis but without subchondral collapse
(broken arrow).
Cephalad Caudad
Iliopsoas muscle
Anterior labrum
Acetabulum
Femoral head
Anterior labral tear
Longitudinal hip joint view
• Figure 173-3 Longitudinal ultrasound image demonstrating an

anterior tear of the labrum in a patient with hip pain following a skating
• Figure 173-1 Visual inspection of the hip. accident.
271
174 Palpation of the Hip
Careful palpation of the hip joint and surrounding struc- the examiner to identify inflamed and painful bursae that
tures should be the next step after visual inspection of the may serve as either a primary or contributing cause of the
hip in examining the patient who presents with hip pain patient’s hip pain and dysfunction (Fig. 174-1). Targeted
and dysfunction. Because of the overlying muscles and soft palpation of the inguinal region assists the examiner in
tissue, direct palpation of the hip joint is difficult, even in identifying inguinal hernia that may also be contributing to
thin individuals. the patient’s hip pain and dysfunction. The examiner should
Palpation of the hip must be carried out with the patient also assess the hip for the presence of joint instability and
undressed to avoid missing physical signs, such as increased crepitus that might be suggestive of tendinitis, adhesive
temperature, that could be masked by clothing. The ante- capsulitis, or arthritis.
rior, lateral, and posterior aspects of the hip as well as the Positive findings during the palpation of the hip should
inguinal region should be palpated for abnormal mass, help guide the examiner in additional physical examination
swelling, increased temperature, joint effusion, and bony as well as provide a guide as to the ordering of specialized
abnormalities. plain radiographic views, ultrasound imaging, and magnetic
Targeted palpation of the bursae of the hip with particu- resonance imaging to further ascertain the cause of the
lar attention to the ischial and trochanteric bursae will allow patient’s hip pain and dysfunction.
• Figure 174-1 Palpation of the hip.
272
175 Flexion of the Hip
To assess hip flexion, the patient is placed in the supine extended to approximately 90 degrees. Hip flexion deformi-
position with the knee flexed to 90 degrees (Fig. 175-1). ties are not uncommon findings in patients with chronically
The patient is then asked to maximally flex his or her hips painful hips. The Thomas flexion deformity test can help
(Fig. 175-2). The normal hip will flex to approximately 135 the clinician identify occult hip flexion deformities (see
degrees with the knee flexed to 90 degrees and the knee fully Chapter 182).
• Figure 175-1 Patient positioning for assessment of hip flexion.
• Figure 175-2 Maximum flexion of the hip.
273
176 Extension of the Hip
To assess hip extension, the patient is asked to assume the extend his or her hips one at a time (Fig. 176-1). The
prone position. The patient is then asked to maximally normal hip will extend to approximately 25 degrees.
• Figure 176-1 Lateral view of the extended hip.
274
177 Abduction of the Hip
The normal hip will allow approximately 45 to 50 degrees while the examiner palpates the pelvis (Fig. 177-1). As the
of abduction. To assess hip abduction, the patient is asked hip joint reaches its maximal point of abduction, the pelvis
to assume the supine position and place the legs together. will begin to move superiorly (Fig. 177-2).
The patient is then asked to slowly abduct his or her hip
• Figure 177-1 Patient positioning for assessment of hip abduction. • Figure 177-2 Maximum abduction of the hip.
275
178 Adduction of the Hip
The normal hip will allow approximately 30 degrees of her hip while the examiner palpates the pelvis (Fig. 178-1).
adduction. For assessment of hip adduction, the patient is As the hip joint reaches its maximal point of adduction, the
asked to assume the supine position and place the legs pelvis will begin to move superiorly (Fig. 178-2).
together. The patient is then asked to slowly adduct his or
• Figure 178-1 Patient positioning for assessment of hip adduction. • Figure 178-2 Maximum adduction of the hip.
276
179 Internal Rotation of the Hip
The normal hip will allow approximately 35 degrees of then asked to slowly move his or her feet apart. If there is
internal rotation. To assess hip internal rotation, the patient limitation of internal rotation, the affected hip will stop
is asked to assume the prone position with the knees moving but the unaffected hip will continue to internally
together and flexed 90 degrees (Fig. 179-1). The patient is rotate.
• Figure 179-1 Internal rotation of the hip.
277
180 External Rotation of the Hip
The normal hip will allow approximately 45 degrees of (Fig. 180-1). The patient is then asked to slowly move his
external rotation. To assess hip external rotation, the patient or her feet together. If there is limitation of external rota-
is asked to assume the prone position with the knees tion, the affected hip will stop moving but the unaffected
together and flexed 90 degrees and the legs crossed hip will continue to externally rotate.
• Figure 180-1 External rotation of the hip.
278
181 Painful Conditions of the Hip
As was previously indicated, the initial general physical diagnostic accuracy of the clinician who is confronted with
examination of the hip guides the clinician in narrowing his a patient complaining of hip pain and dysfunction and help
or her differential diagnosis and suggests which specialized the clinician avoid overlooking less common diagnoses.
physical examination maneuvers, laboratory testing, and The list in Table 181-1 is by no means comprehensive,
radiographic testing will aid in confirming the cause of the but it does aid the clinician in organizing the potential
patient’s hip pain and dysfunction. For the clinician to sources of pathology that present as hip pain and dysfunc-
make the best use of the initial information that is gleaned tion. It should be noted that the most commonly missed
from the general physical examination of the hip, a group- categories of hip pain and the categories that most often
ing of the common causes of hip pain and dysfunction is result in misadventures in diagnosis and treatment are the
exceedingly helpful. Although no classification of hip pain last 3 categories. The knowledge of this potential pitfall
and dysfunction can be all-inclusive or all-exclusive because should help the clinician to keep these sometimes over-
of the frequently overlapping and multifactoral nature of looked causes of hip pain and dysfunction in the differential
hip pathology, Table 181-1 should help to improve the diagnosis.
TABLE
Causes of Hip Pain and Dysfunction
181-1
Referred from
Localized Bony or Periarticular Systemic Sympathetically Other Body Vascular
Joint Space Pathology Pathology Disease Mediated Pain Areas Disease
Fracture Bursitis Rheumatoid Causalgia Lumbar Aortoiliac
Primary bone tumor Tendinitis arthritis Reflex sympathetic plexopathy atherosclerosis
Primary synovial tissue Adhesive Collagen dystrophy Lumbar Internal iliac artery
tumor capsulitis vascular radiculopathy occlusion
Joint instability Joint instability disease Lumbar
Localized arthritis Muscle strain Reiter syndrome spondylosis
Osteophyte formation Muscle sprain Gout Fibromyalgia
Osteonecrosis of the Periarticular Other crystal Myofascial pain
femoral head infection not arthropathies syndromes
Joint space infection involving Charcot Inguinal hernia
Hemarthrosis joint space neuropathic Entrapment
Villonodular synovitis arthritis neuropathies
Intraarticular foreign body Intrapelvic tumors
Slipped capital femoral Retroperitoneal
epiphysis (Legg-Perthes tumors
disease)
Chronic dislocation of
the hip
279
182 The Thomas Test for Flexion Deformity
of the Hip
Flexion contractures of the hip are not uncommon in thigh of the leg that is not being tested against the abdomen
patients who suffer from chronic hip pain and dysfunction. (Fig. 182-1, A). This position will eliminate any compen-
The Thomas test for flexion deformity will aid the clinician satory lumbar hyperlordosis. The patient is then asked to
in identifying these sometimes unrecognized flexion con- place the leg being tested against the examination table.
tractures of the hip. Failure to fully extend the leg against the table suggests the
To perform the Thomas test for flexion deformity of presence of a flexion contracture of the hip (Figs. 182-1, B,
the hip, the patient is placed in the supine position on the and 182-2). When this occurs, the Thomas test is consid-
examination table. The patient is then asked to fully flex the ered positive.
• Figure 182-2 Positive Thomas test. Note how the lumbar spine is
forced flat against the table by the flexion of the hip of the nonpainful
side. The patient is unable to fully extend his leg against the table due
to flexion contracture of the hip. (From Benjamin A. Hasan: The pre-
senting symptoms, differential diagnosis, and physical examination of
B
patients presenting with hip pain, Disease-a-Month 58(9):477–491,
• Figure 182-1 A and B, Thomas test for flexion deformity of the hip. 2012, fig 6.)
280
183 The Trendelenburg Test for Weak
Hip Abductors
The Trendelenburg test will allow the clinician to identify side with the raised knee, then the Trendelenburg test is
patients in whom weak hip abductors are the cause of, or a positive and is indicative of weak hip abductors on that side
contributing factor to, the patient’s hip pain and hip dys- (Figs. 183-1, B, and 183-2).
function. To perform the Trendelenburg test for weak hip Patients who exhibit a positive Trendelenburg sign will
abductors, the patient is asked to assume the standing posi- invariably have an abnormal gait that is manifested clini-
tion and balance on the unaffected leg. The patient is then cally as a limp, with the patient swaying the body over the
asked to slowly flex the other knee to 45 degrees while the side of the weak abductors to help maintain balance. This
clinician carefully observes the pelvis. If the pelvis rises on abnormal gait is known as a Trendelenburg or abductor gait.
the side with the raised knee, the Trendelenburg test is nega- If the patient has concomitant pain, the patient might also
tive, as the raising of the pelvis indicates adequate hip exhibit an antalgic gait, which can further confuse the clini-
abductor strength (Fig. 183-1, A). If the pelvis drops on the cal picture (see Chapter 184).
A B
• Figure 183-1 A and B, Trendelenburg test for weak hip abductors.
281
• Figure 183-2 Positive Trendelenberg test. Note that the right hip
drops due to left adductor weakness. (From Benjamin A. Hasan: The
presenting symptoms, differential diagnosis, and physical examination
of patients presenting with hip pain, Disease-a-Month 58(9):477–491,
2012, fig 4.)
184 The Hopalong Cassidy Sign for
Antalgic Gait
Assessment of gait abnormalities can provide the clinician Patients with a painful hip will often exhibit a positive
with valuable information as to the nature of a patient’s hip Hopalong Cassidy sign, which is synonymous with an ant
pain and dysfunction. Although in theory gait assessment algic gait. The sign is named after the hero of numerous
is relatively straightforward, in practice, because of the over Western books, movies, and a television show who was
lapping physical findings, gait assessment can be somewhat named Hopalong due to his antalgic gait after being shot
more difficult. One of the common confusing factors in in the leg (Fig. 184-2). To elicit the Hopalong Cassidy sign
assessing abnormal gait is the superimposed sign of an ant for antalgic gait, the patient is asked to stand and bear
algic or painful gait. weight on both legs and then to walk away from the exam
To understand gait assessment, the clinician must under iner. If the patient’s hip is painful, the patient will automati
stand the two components of normal gait: (1) the stance cally attempt to shorten the stance phase to minimize
phase and (2) the swing phase. The stance phase begins the amount of time that the painful hip is bearing the
when the heel strikes the floor and ends with the lift-off of weight of the upper body (Fig. 184-3). The attempt by the
the toes from the floor (Fig. 184-1, A). The swing phase patient to hurry off the painful hip produces a positive
begins with toe lift-off from the floor and ends with heel Hopalong Cassidy sign due to the characteristic antalgic gait
strike (Fig. 184-1, B). (Fig. 184-4).
A
• Figure 184-1 Two components of normal gait. A, The stance phase. B, The swing phase.
283
• Figure 184-3 The Hopalong Cassidy sign. With a painful hip, the
stance phase of gait is shortened. Hip extension is avoided by keeping
the joint in a slightly flexed position. This slight flexion creates a func-
tional leg length discrepancy with shortening on the involved side and
may partially create a lurch.
• Figure 184-2 Movie poster from 1936 depicting Hopalong Cassidy.

Note his antalgic gait as he shortens his stance phase as he stares
down an outlaw.
A B
• Figure 184-4 A and B, Eliciting the Hopalong Cassidy sign.
185 The Patrick/FABER Test for
Hip Pathology
The Patrick/FABER test for internal derangement allows Plain radiographs of the hip and pelvis are indicated in
the examiner to quickly identify the presence of hip pathol- all patients who exhibit a positive Patrick/FABER test to
ogy. FABER is an acronym that helps to remind the exam- rule out occult bony pathology. On the basis of the patient’s
iner that he or she is checking for limitation of pain of clinical presentation, additional testing, including complete
Flexion, ABduction and External Rotation. To perform the blood count, uric acid, sedimentation rate, and antinuclear
Patrick/FABER test, the patient is placed in the supine antibody testing, might be indicated. Magnetic resonance
position and the knee and hip are flexed to 90 degrees imaging or ultrasound scanning of the hip and pelvis is
(Fig. 185-1, A). The examiner then has the patient place the indicated if osteonecrosis of the femoral head or a space-
foot of his or her affected extremity on the opposite knee. occupying lesion is suspected. Blockade of the obturator
The thigh is then slowly abducted and externally rotated nerve with local anesthetic can also serve as a diagnostic and
toward the examination table (Fig. 185-1, B). The test is therapeutic maneuver.
considered positive if the patient complains of groin pain
or spasm or the examiner identifies limited range of motion
of the hip (Video 185-1).
A B
• Figure 185-1 A and B, Eliciting the Patrick/FABER test.
285
186 The Waldman Knee Squeeze Test for
Adductor Tendinitis
The musculotendinous unit of the hip joint that is respon- resisted adduction reproduces the pain, as does passive
sible for hip adduction is susceptible to the development of abduction. Patients who suffer from adductor tendinitis will
tendinitis due to overuse or trauma from stretch injuries. also exhibit a positive Waldman knee squeeze test. To
Inciting factors may include the vigorous use of exercise perform the knee squeeze test, the patient is placed in the
equipment for lower-extremity strengthening and acute sitting position with the legs hanging over the edge of
stretching of the musculotendinous units as a result of pro- the examination table. A tennis ball is then placed between
longed horseback riding or from straddle injuries. The pain the patient’s knees (Fig. 186-1). The patient is then asked
of adductor tendinitis is sharp, constant, and severe, with to quickly squeeze the ball between the knees as hard as
sleep disturbance often reported. The patient may attempt possible. Patients who are suffering from adductor tendini-
to splint the inflamed tendons by adopting an adductor tis will reflexly extend the affected extremity because of the
lurch type of gait, that is, shifting the trunk of the body sudden pain from forced adduction, causing the knees to
over the affected extremity when walking. The pain of open and the tennis ball to fall (Fig. 186-2). The dropping
adductor tendinitis is primarily localized to the medial thigh of the tennis ball is considered a positive Waldman knee
at the groin crease, in contradistinction to the pain of ilio- squeeze test for adductor tendinitis.
psoas bursitis, which is also made worse with resisted adduc- It is important for the clinician to remember that tendi-
tion but is localized to the anterior groin just below the nitis of the musculotendinous unit of the hip frequently
groin crease (see Chapter 189). coexists with bursitis of the associated bursae of the hip
On physical examination, the patient will report pain on joint, creating additional pain and functional disability. In
palpation of the origins of the adductor tendons. Active addition to this pain, patients who suffer from adductor
Tennis ball
• Figure 186-1 To perform the Waldman knee squeeze test for

adductor tendinitis, the patient quickly squeezes the ball between the • Figure 186-2 The Waldman knee squeeze test for adductor
legs. tendinitis.
286
CHAPTER 186 The Waldman Knee Squeeze Test for Adductor Tendinitis 287
Fatty infiltration Torn portion
Proximal
Femoral artery
Longitudinal view of proximal adductor muscles
• Figure 186-3 Longitudinal ultrasound image demonstrating tearing

of the proximal adductor muscles.
tendinitis often experience a gradual decrease in functional presentation, additional testing may be indicated, including
ability with decreasing hip range of motion, making simple, complete blood count, sedimentation rate, and antinu-
everyday tasks such as getting into or out of a car quite clear antibody testing. Magnetic resonance imaging and
difficult. With continued disuse, muscle wasting can occur ultrasound scanning of the hip and the proximal adductor
and an adhesive capsulitis of the hip may develop. muscles is indicated if aseptic necrosis of the hip, occult
Plain radiographs are indicated for all patients who mass, or tearing of the adductor muscles are suspected
present with hip pain. On the basis of the patient’s clinical (Fig. 186-3).
187 The Resisted Hip Extension Test for
Ischial Bursitis
The ischial bursa lies between the gluteus maximus muscle (Fig. 187-1). The resisted hip extension test for ischial bur-
and the bone of the ischial tuberosity. It may exist as a single sitis is considered positive if this maneuver causes a repro-
bursal sac or, in some patients, as a multisegmented series duction of the patient’s pain that is localized to the base of
of sacs that may be loculated in nature. The ischial bursa is the buttock. Sudden release of resistance during this maneu-
vulnerable to injury from both acute trauma and repeated ver will markedly increase the pain and further strengthen
microtrauma. Acute injuries frequently take the form of the clinical diagnosis of ischial bursitis (Video 187-1).
direct trauma to the bursa from falls directly onto the but- Plain radiographs of the hip may reveal calcification of
tocks and from overuse, such as prolonged riding of horses the bursa and associated structures that is consistent with
or bicycles. Running on uneven or soft surfaces such as sand chronic inflammation. Magnetic resonance imaging and
also may cause ischial bursitis. If the inflammation of ultrasound scanning is indicated if disruption of the ham-
the ischial bursa becomes chronic, calcification of the bursa string musculotendinous unit is suspected as well as to
may occur. confirm the diagnosis of ischial bursitis (Fig. 187-2).
The patient who is suffering from ischial bursitis fre-
quently complains of pain at the base of the buttock with
ambulation. The pain is localized to the area over the ischial
tuberosity with referred pain noted into the hamstring
muscle, which also may develop coexistent tendinitis. Often
the patient is unable to sleep on the affected hip and may
complain of a sharp, “catching” sensation when extending
and flexing the hip, especially on first awakening. Physical
examination may reveal point tenderness over the ischial
tuberosity. Passive straight leg raising of the affected lower
extremity reproduces the pain. Patients who suffer from
ischial bursitis will exhibit a positive resisted hip extension
test. To perform the resisted hip extension test for ischial
bursitis, the patient is placed in the prone position on the A
edge of the examination table. The examiner firmly grasps
the thigh of the affected extremity and has the patient force-
fully extend his or her hip against the examiner’s resistance
B
• Figure 187-2 A, Axial T1W magnetic resonance image of a middle-
aged woman with poorly localized hip pain demonstrates reduced
space between the lesser trochanter and the ischium on the left
side (double-headed white arrow) due to ischiofemoral impingement.
B, The axial FST2W magnetic resonance image shows high-SI edema
within the quadratus femoris muscle and adjacent ischiogluteal bursa
(white arrow). (From Waldman SD, Campbell, RSD: Imaging of pain,
• Figure 187-1 The resisted hip extension test for ischial bursitis. Philadelphia, 2010, Saunders/Elsevier, p 350, fig 173-3.)
288
188 The Resisted Hip Abduction Test for
Gluteal Bursitis
The gluteal bursae lie between the gluteal maximus, medius, on first awakening. Physical examination may reveal point
and minimus muscles as well as between these muscles and tenderness in the upper outer quadrant of the buttock.
the underlying bone. These bursae may exist as a single Passive flexion and adduction may reproduce the pain.
bursal sac or, in some patients, as a multisegmented series Patients who suffer from gluteal bursitis will exhibit a
of sacs that may be loculated in nature. resisted hip abduction test. To perform the resisted hip
The gluteal bursae are vulnerable to injury from both abduction test, the patient is asked to assume the lateral
acute trauma and repeated microtrauma. Acute injuries fre- position with the unaffected leg down. The examiner then
quently take the form of direct trauma to the bursae from firmly grabs the lateral thigh of the affected leg and has
falls directly onto the buttocks or repeated intramuscular the patient forcefully abduct the affected leg against the
injections, as well as from overuse such as running for long examiner’s resistance (Fig. 188-1). The resisted hip abduc-
distances, especially on soft or uneven surfaces. If the tion test is considered positive if this maneuver reproduces
inflammation of the gluteal bursae becomes chronic, calci- the patient’s gluteal pain. Sudden release of resistance
fication of the bursae may occur. during this maneuver should markedly increase the pain
The patient who suffers from gluteal bursitis frequently of gluteal bursitis and further strengthens the diagnosis
complains of pain in the upper outer quadrant of the (Video 188-1).
buttock. The pain is localized to the area over the upper Plain radiographs of the hip may reveal calcification of
outer quadrant of the buttock with referred pain noted into the bursa and associated structures that is consistent with
the sciatic notch. Often the patient is unable to sleep on chronic inflammation. Magnetic resonance imaging and
the affected hip and may complain of a sharp, “catching” ultrasound scanning is indicated if occult mass or tumor of
sensation when extending and abducting the hip, especially the hip is suspected as well as to confirm the diagnosis.
• Figure 188-1 The resisted hip abduction test for gluteal bursitis.
289
189 The Resisted Hip Adduction Test for
Iliopsoas Bursitis
The iliopsoas bursa lies medially in the femoral triangle pain, as will the resisted adduction test for iliopsoas bursitis.
between the psoas tendon and the anterior aspect of the To perform the resisted adduction test for iliopsoas bursitis,
neck of the femur (Fig. 189-1). This bursa may exist as a the patient is asked to assume the sitting position with his
single bursal sac or, in some patients, as a multisegmented or her legs hanging over the edge of the examination table
series of sacs that may be loculated in nature. and the knees slightly apart. The examiner then firmly
The iliopsoas bursa is vulnerable to injury from both grasps the medial thigh of the affected extremity and
acute trauma and repeated microtrauma. Acute injuries fre- instructs the patient to forcefully adduct the hip against
quently take the form of direct trauma to the bursa from the examiner’s resistance (Fig. 189-2). The test is consid-
seat-belt injuries as well as from overuse injuries that ered positive if this maneuver reproduces the patient’s ante-
required repeated hip flexion, such as javelin throwing and rior groin pain. Sudden release of resistance during this
ballet dancing. If the inflammation of the iliopsoas bursa maneuver markedly increases the anterior groin pain,
becomes chronic, calcification of the bursa may occur. which further strengthens the diagnosis of iliopsoas bursitis.
The patient who suffers from iliopsoas bursitis frequently If this maneuver causes the patient to experience medial
complains of pain in the groin. The pain is localized to the groin pain, the diagnosis of adductor bursitis should be
area just below the crease of the groin anteriorly, with considered (Video 189-1).
referred pain noted into the hip joint. The anterior location Plain radiographs of the hip may reveal calcification of
of the pain is in contradistinction to the pain of adductor the bursa and associated structures that is consistent with
tendinitis, in which the pain is localized to the medial thigh chronic inflammation. Magnetic resonance imaging and
at the groin crease (see Chapter 186). Often, the patient ultrasound scanning is indicated if occult mass or tumor of
with iliopsoas bursitis is unable to sleep on the affected hip the hip or groin is suspected as well as to confirm the
and may complain of a sharp, “catching” sensation with diagnosis.
range of motion of the hip.
Physical examination may reveal point tenderness in the
upper thigh just below the crease of the groin. Passive
flexion, adduction, and abduction as well as active resisted
flexion of the affected lower extremity will reproduce the
• Figure 189-1 Iliopsoas bursitis. Axial T2-weighted magnetic reso-

nance image in a 67-year-old woman with rheumatoid arthritis and
right hip pain. High-signal mass is noted adjacent to the iliopsoas
muscle (arrow), consistent with an iliopsoas bursitis. (From Kaplan PA,
Helms CA, Dussault R, et al: Musculoskeletal MRI, Philadelphia, 2001,
Saunders, p 350.) • Figure 189-2 The resisted hip adduction test for iliopsoas bursitis.
290
190 The Piriformis Test for
Piriformis Syndrome
An uncommon cause of sciatica, piriformis syndrome is then pushes the patient’s knee on the symptomatic side
caused by entrapment and compression of the sciatic nerve upward and inward toward the patient’s opposite shoulder
by the piriformis muscle at the level of the sciatic notch (Fig. 190-3). If this maneuver reproduces the patient’s pain,
(Fig. 190-1). Patients suffering from piriformis syndrome the test may be considered positive, and additional investi-
complain of pain that begins in the buttocks and radiates gation, including plain radiographs, computerized tomog-
into the affected leg all the way to the foot. There is associ- raphy, ultrasonography, and magnetic resonance imaging of
ated numbness and dysesthesias as well as weakness in the the sacroiliac joint is indicated.
distribution of the sciatic nerve. To perform the piriformis
test for piriformis syndrome, the patient is placed in the
supine position and the symptomatic lower extremity is
flexed at the hip to 90 degrees (Fig. 190-2). The examiner
• Figure 190-2 The patient is placed in the supine position and the
symptomatic lower extremity is flexed at the hip to 90 degrees.
• Figure 190-1 Posterior view of the right gluteal region. The sciatic
nerve (black arrow) passes through the infrapiriform foramen, bordered
superiorly by the piriformis muscle (white arrow) and inferiorly by the • Figure 190-3 The examiner then pushes the patient’s knee on the
portion of the obturator internus muscle that is outside the pelvis symptomatic side upward and inward toward the patient’s opposite
(arrowhead). shoulder.
291
191 The Resisted Abduction Release Test
for Trochanteric Bursitis Pain
The trochanteric bursa lies between the greater trochanter The trochanteric bursa is vulnerable to injury from both
and the tendon of the gluteus medius and the iliotibial tract acute trauma and repeated microtrauma. Acute injuries fre-
(Fig. 191-1). This bursa may exist as a single bursal sac or, quently take the form of direct trauma to the bursa via falls
in some patients, as a multisegmented series of sacs that may directly onto the greater trochanter or from previous hip
be loculated in nature. surgery, as well as from overuse injuries, including running
on soft or uneven surfaces. If the inflammation of the tro-
chanteric bursa becomes chronic, calcification of the bursa
may occur.
The patient who suffers from trochanteric bursitis fre-
quently complains of pain in the lateral hip that can radiate
down the leg, mimicking sciatica. The pain is localized to
the area over the greater trochanter. Often, the patient is
unable to sleep on the affected hip and may complain of a
sharp, “catching” sensation with range of motion of the hip,
especially on first rising. The patient might note that walking
upstairs is increasingly difficult. Trochanteric bursitis often
coexists with arthritis of the hip joint, back and sacroiliac
joint disease, and gait disturbance.
Physical examination may reveal point tenderness in
the lateral thigh just over the greater trochanter. Passive
adduction and abduction, as well as active resisted abduc-
tion of the affected lower extremity, reproduces the pain.
Patients suffering from trochanteric bursitis will also exhibit
a positive resisted abduction release test. To perform the
resisted abduction release test, the examiner has the patient
assume the lateral position with the unaffected leg down.
The examiner then firmly grasps the lateral thigh and
has the patient abduct the hip against the examiner’s resis-
tance (Fig. 191-2, A). The examiner then suddenly releases
• Figure 191-1 Coronal T2 magnetic resonance (MR) image of the resistance against the patient’s active abduction. This
a patient with trochanteric bursitis. Note the high signal intensity
sudden release of resistance during this maneuver will
fluid lying between the iliotibial tract (broken arrows) and the
gluteus minimus tendon (solid arrows). (From Waldman SD, Campbell, markedly increase the pain in the lateral thigh over the
RSD: Imaging of pain, Philadelphia, 2010, Saunders/Elsevier, p 362, greater trochanter if the patient suffers from trochanteric
fig 142-2.) bursitis (Fig. 191-2, B). This sudden increase in localized
A B
• Figure 191-2 A and B, The resisted abduction release test.
292
CHAPTER 191 The Resisted Abduction Release Test for Trochanteric Bursitis Pain 293
lateral thigh pain is considered a positive resisted abduction Plain radiographs of the hip may reveal calcification of
release test. the bursa and associated structures that is consistent with
The clinician should be aware that patients who suffer chronic inflammation. Magnetic resonance imaging and
from trochanteric bursitis should exhibit no sensory deficit ultrasound scanning is indicated if occult mass or tumor of
in the distribution of the lateral femoral cutaneous nerve, the hip or groin is suspected. Electromyography helps to
as is seen with meralgia paresthetica, which is often con- distinguish trochanteric bursitis from meralgia paresthetica
fused with trochanteric bursitis. and sciatica.
192 The Fulcrum Test for Stress Fractures
of the Femoral Shaft
Stress fractures of the femur are a not uncommon cause of highly sensitive in identifying stress fractures of the femur.
thigh pain in runners, military recruits, and in patients To perform the fulcrum test, the patient is placed in the
suffering from osteoporosis. These fractures are often ini- sitting position, and the examiner places his or her arm
tially misdiagnosed, as plain radiographs of the femur are beneath the patient’s painful lower extremity and grasps the
often read as negative (Fig. 192-1). The fulcrum test is contralateral thigh (Fig. 192-2). The examiner’s arm serves
A B C
• Figure 192-1 Femoral stress fractures are often initially missed on plain radiographs, as a classic
fracture line may not be evident. A, Initial radiograph from an athlete suspected of having a distal femoral
stress fracture. B and C, Radiographs reveal progressive stages of healing in the stress fracture of the
distal femoral cortex after initial radiograph was obtained. (From DeFranco MJ, Recht M, Schils J, Parker
RD: Stress fractures of the femur in athletes, Clin Sports Med 25(1):89–103, 2006, fig 5.)
• Figure 192-2 The patient is placed in the sitting position, and the • Figure 192-3 The examiner then grasps the thigh of the painful
examiner places his or her arm beneath the patient’s painful lower lower extremity and exerts a firm downward pressure, which increases
extremity and grasps the contralateral thigh. stress on the shaft of the femur.
294
CHAPTER 192 The Fulcrum Test for Stress Fractures of the Femoral Shaft 295
as a fulcrum. The examiner then grasps the thigh of the pain and will often exhibit apprehension as the downward
painful lower extremity and exerts a firm downward pres- pressure is applied. The test can be repeated as the examiner
sure, which increases stress on the shaft of the femur moves his or her arm more proximally to further localize
(Fig. 192-3). If there is a stress fracture present, the patient the site of the fracture.
will experience a reproduction or exacerbation of their thigh
193 The Ober Test for Iliotibial
Band Contracture
Contracture of the iliotibial band, which is an extension of The affected leg is then extended and fully abducted
the deep fascia of the thigh, can occur following trauma (Fig. 193-2, A). The examiner then slowly allows the extrem-
of acute inflammation of the iliotibial band (Fig. 193-1). ity to passively adduct while he or she gently supports the
Such contractures can lead to difficulty in hip adduction weight of the extremity against gravity. If there is contrac-
and can make getting into and out of a car extremely ture of the iliotibial band, the affected extremity will not
difficult. The Ober test for iliotibial band contracture is completely drop back toward the examination table and
performed by having the patient assume the lateral posi- will remain partially abducted after the examiner removes
tion with the unaffected extremity on the bottom with his or her supporting hands (Fig. 193-2, B).
the hip and the knee flexed to eliminate lumbar lordosis.
Iliotibial band
Cephalad
Edema in
Lateral Gerdy
Iliotibial
femoral tubercle
band
condyle fibers
Effusion of
lateral
Lateral right knee longitudinal view knee joint
• Figure 193-1 Longitudinal ultrasound image demonstrating inflammation and edema of the distal
iliotibial band.
A B
• Figure 193-2 A and B, The Ober test for iliotibial band contracture.
296
194 The Snap Sign for Snapping
Hip Syndrome
Snapping hip syndrome is a constellation of symptoms that or, if unable to squat, to sit in a straight-backed chair. The
includes a snapping sensation in the lateral hip associated examiner then places his or her hand over the greater tro-
with sudden, sharp pain in the area of the greater trochanter. chanter and has the patient quickly move from the squat-
The snapping sensation and pain are the result of the ting or sitting position to a standing position (Fig. 194-1,
iliopsoas tendon subluxing over the greater trochanter or A). The snap test for snapping hip syndrome is considered
iliopectineal eminence. The symptoms of snapping hip positive if the examiner can appreciate a snapping sensation
syndrome occur most commonly when the patient rises as the iliopsoas tendon subluxes over the greater trochanter
from a sitting to a standing position or when walking or iliopectineal eminence (Fig. 194-1, B). In some severe
briskly. Often trochanteric bursitis coexists with snapping cases, the examiner will also hear an audible snap.
hip syndrome, further increasing the patient’s pain and Plain radiographs are indicated in all patients who
disability. present with pain that is thought to be emanating from the
Physical examination reveals that the patient can recreate hip to rule out occult bony pathology and tumor. On the
the snapping and pain by moving from a sitting to a basis of the patient’s clinical presentation, additional testing
standing position and adducting the hip. Point tender- may be indicated, including complete blood count, prostate-
ness over the trochanteric bursa that is indicative of tro- specific antigen, sedimentation rate, and antinuclear anti-
chanteric bursitis also is often present. Patients who suffer body testing. Magnetic resonance, fluoroscopy (Fig. 194-2),
from the snapping hip syndrome will exhibit a positive and ultrasound imaging of the affected hip is indicated if
snap test. To perform the snap test for snapping hip syn- occult mass or aseptic necrosis is suspected and to help
drome, the patient is asked to assume the squatting position confirm the diagnosis.
A B
• Figure 194-1 A and B, Eliciting the snap sign.
297
• Figure 194-2 Snapping hip syndrome. Direct fluoroscopic injection

into the tendon sheath outlines the tendon margins (arrows) before
assessment for abnormal excursion. (From Lazarus ML: Imaging of
femoroacetabular impingement and acetabular labral tears of the hip,
Dis Mon 58(9):495–542, 2012, fig 26.)
195 Functional Anatomy of the Knee
Many clinicians approach examination of the knee with the 2 fibrocartilaginous structures known as the medial and
idea that the knee is a relatively straightforward, simple lateral menisci (Fig. 195-2). The menisci help transmit the
hinge joint that flexes and extends. Nothing could be farther forces placed on the femur across the joint onto the tibia.
from the truth. The largest joint in the body in terms of The menisci have the property of plasticity in that they are
articular surface and joint volume, the knee is capable of able to change their shape in response to the variable forces
amazingly complex movements that encompass highly placed on the joint through its complex range of motion.
coordinated flexion and extension. The knee joint is best The medial and lateral menisci are relatively avascular and
thought of as a cam that is capable of locking in a stable receive the bulk of their nourishment from the synovial
position. Even the simplest movements of the knee involve fluid, which means that there is little potential for healing
an elegantly coordinated set of rolling and gliding move- when these important structures are traumatized.
ments of the femur on the tibia. Because of the complex The primary function of the femoral-patellar joint is
nature of these movements, the knee is extremely suscep- to use the patella, which is a large sesamoid bone embed-
tible to functional abnormalities with relatively minor alter- ded in the quadriceps tendon, to improve the mechanical
ations in the anatomy from arthritis or damage to the advantage of the quadriceps muscle. The medial and lateral
cartilage or ligaments. articular surfaces of the sesamoid interface with the articular
Although both clinicians and laypeople think of the knee groove of the femur (Fig. 195-3). In extension, only the
joint as a single joint, from the viewpoint of understanding superior pole of the patella is in contact with the articular
the functional anatomy, it is more helpful to think of the surface of the femur. As the knee flexes, the patella is drawn
knee as 2 separate but interrelated joints: the femoral-tibial superiorly into the trochlear groove of the femur.
joint and the femoral-patellar joint (Fig. 195-1). The 2 The majority of the knee joint’s stability comes from the
joints share a common synovial cavity, and dysfunction of ligaments and muscles surrounding it with little contribu-
1 joint can easily affect the function of the other. tion from the bony elements. The main ligaments of the
The femoral-tibial joint is made up of the articulation of knee are the anterior and posterior cruciate ligaments,
the femur and the tibia. Interposed between the 2 bones are which provide much of the anteroposterior stability of the
Femur
Patella
Tibia
Fibula
• Figure 195-1 Functional anatomy of the knee is easier to under-

stand if it is viewed as two separate but interrelated joints: the femoral-
tibial and the femoral-patellar joints.
300
CHAPTER 195 Functional Anatomy of the Knee 301
Vastus medialis m
Vastus lateralis m
Iliotibial tract
Med sup genicular a
Lat sup genicular a
Adductor magnus t
Femur
Iliotibial tract
Popliteus t
Post cruciate lig
Ant cruciate lig
Med meniscus
Lat meniscus Tibial collateral lig
Sartorius t
Peroneus longus and
extensor digitorum Tibia
longus mm Med inf genicular a
Gracilis and
Ant tibial recurrent a
semitendinosus tt
• Figure 195-2 Coronal view of the knee. (From Kang HS, Ahn JM, Resnick D: MRI of the extremities.
knee, and the medial and lateral collateral ligaments, which The knee is well endowed with a variety of bursae to
provide much of the valgus and varus stability (Fig. 195-4). facilitate movement. Bursae are formed from synovial sacs
All of these ligaments also help prevent excessive rotation whose purpose is to allow easy sliding of muscles and
of the tibia in either direction. There are also a number of tendons across one another at areas of repeated movement
secondary ligaments that add further stability to this inher- (Fig. 195-5). These synovial sacs are lined with a synovial
ently unstable joint. membrane that is invested with a network of blood vessels
The main extensor of the knee is the quadriceps muscle, that secrete synovial fluid. Inflammation of the bursa results
which attaches to the patella via the quadriceps tendon. in an increase in the production of synovial fluid and swell-
Fibrotendinous expansions of the vastus medialis and vastus ing of the bursal sac. With overuse or misuse, these bursae
lateralis insert into the sides of the patella and are subject may become inflamed, enlarged, and, on rare occasions,
to strain and sprain. The hamstrings are the main flexors of infected. Given that the knee shares a common synovial
the hip, with help from the gastrocnemius, sartorius, and cavity, inflammation of one bursa can cause significant dys-
gracilis muscles. Medial rotation of the flexed knee is via function and pain of the entire knee.
the medial hamstring muscle, and lateral rotation of the
knee is controlled by the biceps femoris muscle.
302 SECTION 10 The Knee
Tibial n
Rectus femoris m
Prefemoral fat body

Quadriceps t
Lat sup genicular a
Suprapatellar bursa
Tibial n
Suprapatellar fat Femur
body
Oblique popliteal lig
and joint capsule
Patella Ant cruciate lig
Post
meniscofemoral lig
Transverse lig of Wrisberg
Lat inf genicular a
Post cruciate lig
Infrapatellar fat
body Gastrocnemius,
Patellar lig lat head, and
plantaris mm
Popliteal v and
tibial n
Popliteus m
Tibia Soleus m
• Figure 195-3 Sagittal view of the knee. (From Kang HS, Ahn JM, Resnick D: MRI of the extremities.
Suprapatellar plica—local tenderness

with dynamic impingement
Suprapatellar
bursitis
Osteophyte with
Posterior cruciate patella-femoral
ligament degeneration
Lateral condyle
Anterior cruciate Medial condyle
ligament
Medial meniscus
Lateral meniscus Distal Proximal
Longitudinal suprapatellar effusion with probe backward
• Figure 195-5 Longitudinal ultrasound image demonstrating supra-

• Figure 195-4 The main ligaments of the knee. patellar bursitis. Note the suprapatellar plica.
196 Visual Inspection of the Knee
Because of the lack of soft tissue overlying the knee joint, with careful measurement at a point 12 cm above the upper
visual inspection can provide the clinician with important margin of the patella with the knee fully extended. The
clues to the causes of knee pain and dysfunction. The start- presence of rubor above, below, or alongside the patella,
ing point to visual inspection of the knee is an observation which might suggest infection, swelling, or an inflamma-
of the patient both standing and walking. The degree of tory process (including bursitis and tendinitis), is also
valgus or varus of the knee with weight bearing should be noted. The posterior knee is then inspected for the presence
noted, as should any other obvious bony deformity (Fig. of a popliteal fossa mass that might suggest a Baker cyst
196-1). The clinician should then look for evidence of (Fig. 196-2).
quadriceps wasting, which, if identified, can be quantified
Semitendinosis Baker cyst—note thickened walls,

tendon probable previous rupture
Medial Lateral
Medial head of gastrocnemius
Transverse to long axis of the leg
• Figure 196-1 Visual inspection of the knee. • Figure 196-2 Transverse ultrasound imaged demonstrating a
Baker cyst.
303
197 Palpation of the Knee
Careful palpation of the knee will often provide the exam- The bony elements of the knee, including the medial and
iner with valuable clues to the cause of the patient’s knee lateral femoral condyles, the patella, and the tibial tubercle,
pain and dysfunction. The examiner palpates the tempera- are then palpated. The patellar tendon is then palpated to
ture of both knees, as a localized increase in temperature identify patellar tendinitis, or jumper’s knee (Fig. 197-1).
may indicate inflammation or infection. The presence of The popliteal fossa is then palpated for evidence of a mass
swelling in the suprapatellar, prepatellar, or infrapatellar or Baker cyst. The knee joint is then ranged through flexion,
regions that might suggest suprapatellar, prepatellar, or extension, and medial and lateral rotation to identify crepi-
infrapatellar bursitis is then identified. Generalized joint tus or limitation of range of motion.
effusion may be identified by performing the bulge test (see
Chapter 202).
• Figure 197-1 Palpation of the knee.
304
198 Flexion of the Knee
The patient is asked to assume the prone position on the The degree of flexion is then compared with that of
examination table. The posterior knee joints are inspected the opposite leg. The extent of flexion of the normal knee
for evidence of mass or swelling. The patient is then asked is limited by the soft tissues of the thigh, calf, and
to actively flex the knee as far as it will flex (Fig. 198-1). buttocks.
• Figure 198-1 Flexion of the knee.
305
199 Extension of the Knee
The patient is asked to sit on the edge of the examination degree of extension is then compared with that of the
table. The anterior knee joints are inspected for evidence opposite leg. The patient should be able to extend the knees
of mass or swelling. The patient is then asked to actively to 0 degrees of flexion.
extend the knee as far as it will extend (Fig. 199-1). The
• Figure 199-1 Extension of the knee.
306
200 Rotation of the Knee
The patient is asked to sit on the edge of the examination the opposite leg. The process is repeated with the patient
table. The anterior knee joints are inspected for evidence externally rotating the knee. Pain on rotation is suggestive
of mass or swelling. The patient is then asked to actively of medial or collateral ligament strain or sprain, medial
internally rotate the knee as far as possible (Fig. 200-1). meniscal tear, or bursitis of the knee (Fig. 200-2).
The degree of internal rotation is compared with that of
Note bulging byond the joint line,

with small fissure,
absence of deeper MCL
regions
Femur
Tibia
Proximal
Medial meniscus with

degenerative signs
Longitudinal knee quadrant view
• Figure 200-2 Longitudinal ultrasound image of the knee demon-

strating degenerative changes of the medial meniscus. Note the
bulging of the meniscus and displacement of the medial collateral
ligament (MCL).
• Figure 200-1 Internal rotation of the knee.
307
201 An Overview of Painful Conditions
of the Knee
The initial general physical examination of the knee guides is confronted with a patient complaining of knee pain and
the clinician in narrowing his or her differential diagnosis dysfunction and will help the clinician avoid overlooking
and helps the clinician determine which specialized physical less common diagnoses.
examination maneuvers, laboratory tests, and radiographic The list in Table 201-1 is by no means comprehensive,
testing will aid in confirming the cause of the patient’s knee but it does aid the clinician in organizing the potential
pain and dysfunction. For the clinician to make the best use sources of pathology that present as knee pain and dysfunc-
of the initial information that is gleaned from the general tion. It should be noted that the most commonly missed
physical examination of the knee, a grouping of the common causes of knee pain that most often result in misadventures
causes of knee pain and dysfunction is exceedingly helpful. in diagnosis and treatment are systemic disease, sympatheti-
Although no classification of knee pain and dysfunction can cally mediated pain, and pain that is referred from other
be absolute, because of the frequently overlapping and body areas. The knowledge of this potential pitfall should
multifactoral nature of knee pathology, Table 201-1 should help the clinician keep these sometimes overlooked causes
help improve the diagnostic accuracy of the clinician who of knee pain and dysfunction in the differential diagnosis.
TABLE
Most Common Causes of Knee Pain
201-1
Localized Bony or Joint Periarticular Sympathetically Referred from Other
Space Pathology Pathology Systemic Disease Mediated Pain Body Areas
Fracture Bursitis Rheumatoid arthritis Causalgia Lumbar plexopathy
Primary bone tumor Tendinitis Collagen vascular Reflex sympathetic Lumbar radiculopathy
Primary synovial tissue tumor Adhesive capsulitis disease dystrophy Lumbar spondylosis
Joint instability Joint instability Reiter syndrome Fibromyalgia
Localized arthritis Muscle strain Gout Myofascial pain syndromes
Osteophyte formation Muscle sprain Other crystal Inguinal hernia
Joint space infection Periarticular infection arthropathies Entrapment neuropathies
Hemarthrosis not involving joint Charcot neuropathic Intrapelvic tumors
Villonodular synovitis space arthritis Retroperitoneal tumors
Intraarticular foreign body
Osgood-Schlatter disease
Chronic dislocation of the
patella
Patellofemoral pain
syndrome
Patella alta
308
202 The Bulge Sign for Small
Joint Effusions
The bulge sign is a useful indicator of joint effusion in the hand in an upward motion along the medial patellar margin
knee. To elicit the bulge sign, the patient is asked to assume (Fig. 202-1). The examiner then milks the fluid down from
the supine position on the examination table and fully the suprapatellar region by milking along the lateral margin
extend and relax the affected knees. The examiner milks of the patella. Clinically significant joint effusions will form
the effusion up into the suprapatellar area by moving the a bulge at the medial patellar margin.
• Figure 202-1 Eliciting the bulge sign for small joint effusions.
309
203 The Ballottement Test for Large
Joint Effusions
The ballottement test is a useful indicator of joint effusion suprapatellar pouch into the joint, which elevates the patella
in the knee. To perform the ballottement test, the patient (Figs. 203-1, A, 203-2, A, and Fig. 203-3). The examiner
is asked to assume the supine position on the examination then performs ballottement on the patella (Figs. 203-1, B
table and fully extend and relax the knees. The examiner and 203-2, B). The test is considered positive if the patella
then grasps the affected knee just above the joint space ballottes easily (Video 203-1).
and applies pressure, displacing synovial fluid from the
A B
• Figure 203-1 A and B, The ballottement test for large joint effusions.
A B
• Figure 203-2 The ballottement test. A, The examiner displaces synovial fluid from the suprapatellar
pouch into the joint. B, The examiner performs ballottement on the patella.
310
CHAPTER 203 The Ballottement Test for Large Joint Effusions 311
Quadriceps tendon
Medial
Suprapatellar effusion
Medial femoral
condyle
Transverse suprapatellar knee view
• Figure 203-3 Longitudinal ultrasound image demonstrating a

large suprapatellar effusion.
204 The Valgus Stress Test for Medial
Collateral Ligament Integrity
The valgus stress test provides the clinician with useful above the knee to stabilize the thigh. With the other hand,
information regarding the integrity of the medial collateral the examiner forces the lower leg away from the midline
ligaments (Fig. 204-1). To perform the valgus stress test, the while observing for widening of the medial joint compart-
patient is placed in a supine position on the examination ment and pain (Fig. 204-2). The maneuver is repeated with
table with the knee flexed 35 degrees and the entire affected the other lower extremity, and the results are compared.
extremity relaxed. The examiner places his or her hand
• Figure 204-2 The valgus stress test for medial collateral ligament
integrity. Pull in the direction of the arrow.
• Figure 204-1 Coronal sagittal T2-weighted with fat suppression

magnetic resonance image of an acute grade 2 tear of the medial
collateral ligament with poorly defined ligament fibers and surrounding
soft tissue edema. (From Waldman SD, Campbell RSD Imaging of
pain, Philadelphia, 2010, Saunders/Elsevier, p 382, fig 149-3.)
312
205 The Varus Stress Test for Lateral
Collateral Ligament Integrity
The varus stress test provides the clinician with useful infor- above the knee to stabilize the thigh. With the other hand,
mation regarding the integrity of the lateral collateral liga- the examiner forces the lower leg toward the midline while
ments (Fig. 205-1). To perform the varus stress test, the observing for widening of the medial joint compartment
patient is placed in a supine position on the examination and pain (Fig. 205-2). The maneuver is repeated with the
table with the knee flexed 35 degrees and the entire affected other lower extremity, and the results are compared.
extremity relaxed. The examiner places his or her hand
A B C
• Figure 205-1 Magnetic resonance (MR) images of a patient with a combined lateral collateral ligament
(LCL) and posterior cruciate ligament injury with lateral meniscal tear. A, The coronal protein-density (PD)
MR image demonstrates nonvisualization of the proximal LCL due to complete disruption of the ligament
(arrow). There are also thickening and increased signal intensity within the conjoint tendon on the coronal
PD MR image (B) and the sagittal T2-weighted with fat suppression MR image (C), due to associated
partial tendon tear (broken arrows). Note also the surrounding soft tissue edema and joint effusion.
(From Waldman SD, Campbell RSD Imaging of pain, Philadelphia, 2010, Saunders/Elsevier, p 386,
fig 150-2.)
• Figure 205-2 The varus stress test for lateral collateral ligament
integrity. Push in the direction of the arrow.
313
206 The Anterior Drawer Test for Anterior
Cruciate Ligament Integrity
The anterior drawer test is useful in helping the clinician foot placed flat on the table. The examiner grasps the
assess the integrity of the anterior cruciate ligament. To affected leg below the knee with both hands and pulls the
perform the anterior drawer test, the patient is placed in the lower leg forward while stabilizing the foot (Fig. 206-1).
supine position on the examination table with the patient’s The test is considered positive if there is more than 5 mm
head on a pillow to help relax the hamstring muscles. The of anterior motion.
patient’s hip is then flexed to 45 degrees with the patient’s
• Figure 206-1 The anterior drawer test for anterior cruciate ligament
integrity. Pull in the direction of the arrow.
314
207 The Flexion-Rotation Anterior
Drawer Test for Anterior Cruciate
Ligament Instability
By testing the integrity of the anterior cruciate ligament in femur to move posteriorly and rotate externally with antero-
2 planes, some investigators believe the flexion-rotation lateral tibial subluxation if the anterior cruciate ligament is
anterior drawer test for anterior cruciate ligament instability unstable. The examiner then exerts mild anterior pressure
is more accurate than the more commonly utilized anterior on the patient’s calf and valgus stress as the knee is gently
drawer test. To perform the flexion-rotation anterior drawer flexed to reduce the joint (Fig. 207-2). Reduction of the
test for anterior cruciate ligament instability, the examiner joint with this mild anterior pressure and valgus stress is
lifts the patient’s affected leg upward, taking care not to considered a positive test, and magnetic resonance imaging
hyperextend the knee joint (Fig. 207-1). This allows the of the knee is indicated.
• Figure 207-1 The flexion-rotation anterior drawer test: the exam- • Figure 207-2 The flexion-rotation anterior drawer test: the exam-
iner lifts the patient’s affected leg upward, taking care not to hyper iner exerts mild anterior pressure on the patient’s calf and valgus stress
extend the knee joint. as the knee is gently flexed to reduce the joint.
315
208 The Lachman Test for Anterior
Cruciate Ligament Integrity
The Lachman test is useful in helping the clinician assess the the examiner. The examiner flexes the patient’s affected
integrity of the anterior cruciate ligament. To perform the knee, grasps the tibia of the affected leg, and applies anterior
Lachman test, the patient is placed in the supine position pressure on the posteromedial portion of the tibia while
on the examination table with the patient’s head on a pillow stabilizing the femur (Fig. 208-1). The test is considered
to help relax the hamstring muscles. The patient’s hip is positive if there is more than 5 mm of anterior motion.
flexed to 30 degrees with the patient’s femur supported by
• Figure 208-1 The Lachman test for anterior cruciate ligament

integrity. Push in the direction of the arrow.
316
209 The Posterior Drawer Test for
Posterior Cruciate Ligament Integrity
The posterior drawer test is useful in helping the clinician degrees with the patient’s foot placed flat on the table. The
assess the integrity of the posterior cruciate ligament examiner grasps the affected leg below the knee with both
(Fig. 209-1). To perform the posterior drawer test, the hands and pushes the lower leg backward while stabilizing
patient is placed in the supine position on the examination the foot (Fig. 209-2). The test is considered positive if there
table with his or her head on a pillow to help relax the is more than 5 mm of posterior motion.
hamstring muscles. The patient’s hip is then flexed to 45
A B C
• Figure 209-1 A, Subacute posterior cruciate ligament (PCL) tear with diffuse increased signal intensity
within the ligament substance (arrow) on the sagittal protein-density (PD) magnetic resonance (MR) image.
B, The coronal PD image also shows the abnormal PCL (white arrow), and there is an associated grade
2 tear of the medial collateral ligament (black arrow). C, The axial T2-weighted with fat suppression
(FST2W) MR image shows the thickened high-SI PCL (arrow) within the intercondylar notch, adjacent to
the normal, low-SI anterior cruciate ligament (broken arrow). (From Waldman SD, Campbell RSD: Imaging
of pain, Philadelphia, 2010, Saunders/Elsevier, p 380, fig 148-2.)
• Figure 209-2 The posterior drawer test for posterior cruciate

ligament integrity.
317
210 The Hughston External
Rotation–Recurvatum Test for
Posterior Cruciate Ligament Instability
The Hughston external rotation-recurvatum test for poste- The examiner then lifts each lower extremity off the examin-
rior cruciate ligament instability is performed by placing ing table by grasping the patient’s great toes (Fig. 210-1).
the patient in the supine position. The examiner then exam- The examiner then compares each knee for the relative
ines the relative portion of the tibia in the resting position. amount of recurvatum and external rotation of the tibia.
• Figure 210-1 The Hughston external rotation-recurvatum test for

posterior cruciate ligament instability.
318
211 The Quadriceps Active Test for
Posterior Cruciate Ligament Integrity
To perform the quadriceps active test for posterior cruciate contract the quadriceps muscle of the affected leg to shift
ligament integrity, the patient is placed in the supine posi- the tibia without extending the knee. If the posterior cruci-
tion and the examiner supports the relaxed knee at the ate ligament is disrupted, the tibia will sag into posterior
thigh as he or she moves the knee to 90 degrees of flexion subluxation and the patellar ligament will shift from its
(Fig. 211-1). The patient is then instructed to gently normal slightly posterior position anteriorly.
• Figure 211-1 The quadriceps active test for posterior cruciate liga-
ment integrity.
319
212 The Pivot Shift Test for Anterolateral
Rotary Instability
The pivot shift test is useful in helping the clinician assess the lower leg outward (Fig. 212-1). The test is considered posi-
integrity of the anterior cruciate ligament. To perform the tive for anterior cruciate ligament insufficiency if the tibia
pivot shift test, the patient is placed in the supine position subluxes anteriorly. The examiner can reduce the tibial sub-
on the examination table with the ankle and foot of the luxation by flexing the knee further, to 40 degrees, which
patient’s affected leg held firmly under the examiner’s axilla. will tighten the iliotibial band and pull the anteriorly dis-
The patient’s knee is placed in 20 degrees of flexion, and placed tibia back into place.
the tibia is rotated internally while the examiner pulls the
• Figure 212-1 The pivot shift test for anterolateral rotary instability.
320
213 The Reverse Pivot Shift Test of Jakob
for Posterolateral Instability
The reverse pivot shift test of Jakob is useful in the identi- ligament, at approximately 10 degrees of flexion, the exam-
fication of posterolateral instability of the knee. To perform iner will appreciate a jolt-like shift of the lateral tibial
the reverse pivot shift test of Jakob, the examiner places the plateau as it moves suddenly from a position of posterior
patient’s affected lower extremity in full extension and subluxation and external rotation into a position of reduc-
neutral rotation (Fig. 213-1). The examiner then quickly tion and neutral rotation.
flexes the patient’s affected extremity while placing firm
continuous valgus stress and allowing the foot to rotate
externally (Fig. 213-2). If there is disruption of the posterior
cruciate ligament, arcuate complex, and the lateral collateral
• Figure 213-1 The reverse pivot shift test of Jakob: the examiner • Figure 213-2 The reverse pivot shift test of Jakob: the examiner
places the patient’s affected lower extremity in full extension and then quickly flexes the patient’s affected extremity while placing firm
neutral rotation. continuous valgus stress and allowing the foot to rotate externally.
321
214 The Tibial External Rotation Test for
Injury to the Posterolateral Corner
To perform the tibial external rotation test for injury to the then flexed to 90 degrees with the examiner observing the
posterolateral corner, the patient is placed in the prone feet; a decrease in external rotation as the knees are flexed
position with the feet in neutral rotational position and toward 90 degrees is indicative of posterolateral corner
the knees flexed to 30 degrees (Fig. 214-1). The knees are injury (Fig. 214-2).
• Figure 214-1 The tibial external rotation test for injury to the pos-
terolateral corner: the patient is placed in the prone position with the
feet in neutral rotational position and the knees flexed to 30 degrees.
• Figure 214-2 The tibial external rotation test for injury to the pos-
terolateral corner: the patient’s knees are flexed to 90 degrees with the
examiner observing the feet; a decrease in external rotation as the
knees are flexed toward 90 degrees is indicative of posterorlateral
corner injury.
322
215 The Perkins Test for Patellofemoral
Pain Syndrome
The Perkins test for patellofemoral pain syndrome can is slightly flexed. With the knee relaxed, the examiner
provide the clinician with useful information as to whether moves the patella laterally and medially (Fig. 215-1). The
the patellofemoral joint is responsible for the patient’s ante- test is considered positive for patellofemoral pain syndrome
rior knee pain. To perform the Perkins test for patellofemo- if the side-to-side movement of the patella reproduces the
ral pain syndrome, the examiner has the patient assume patient’s pain.
the supine position on the examination table, and the knee
• Figure 215-1 The Perkins test for patellofemoral pain syndrome.
323
216 The Patellar Grind Test for
Patellofemoral Pain Syndrome
The patellar grind test is useful in the identification of patel- the patient with such movement is highly suggestive of
lofemoral pathology. To perform the patellar grind test, patellofemoral pathology, and plain radiographs, ultrasound
the patient is placed in the supine position and the exam- imaging, and magnetic resonance imaging of the knees
iner applies pressure to the patella and then displaces it should be considered (Fig. 216-2).
medially, laterally, superiorly, and inferiorly (Fig. 216-1).
Any complaint of pain or apprehension on the part of
Proximal Distal
Quadriceps tendon
Patella
Femur
Note decrease in
patellofemoral joint space
Longitudinal patellofemoral quadrant view
• Figure 216-1 The patellar grind test for patellofemoral pain • Figure 216-2 Longitudinal ultrasound view of the patellar-femoral
syndrome. quadrant.
324
217 The Fairbanks Apprehension Test for
Lateral Patellar Subluxation
The Fairbanks apprehension test for lateral patellar sublux- the examination table, and the knee is flexed 30 degrees.
ation can provide the clinician with useful information With the knee relaxed, the examiner exerts constant
as to whether the patellar subluxation is responsible for lateral pressure on the medial border of the mid-patella
the patient’s anterior knee pain. To perform the Fairbanks (Fig. 217-1). The test is considered positive for lateral patel-
apprehension test for lateral patellar subluxation, the lar subluxation if the lateral pressure causes the patient
examiner has the patient assume the supine position on apprehension.
• Figure 217-1 The Fairbanks apprehension test for lateral patellar

subluxation.
325
218 The Patellar Tilt Test for Lateral
Retinacular Dysfunction
The patellar tilt test is useful in the identification of exces- thumb on the lateral aspect (Fig. 218-1). The examiner then
sive lateral retinacular tightness that may be responsible for attempts to gently raise the lateral aspect of the patella to
patellofemoral pain syndrome. To perform the patellar tilt the horizontal plane of the affected knee (Fig. 218-2). The
test for lateral retinacular dysfunction, the patient is placed inability to raise the lateral aspect of the patella that far
in the supine position. The examiner places his or her indicates excessive lateral retinacular tightness that may be
fingers on the medial border of the patella and his or her responsible for the patient’s anterior knee pain.
• Figure 218-1 The patellar tilt test: the examiner places his or her • Figure 218-2 The patellar tilt test: the examiner then attempts to
fingers on the medial border of the patella and his or her thumb on gently raise the lateral aspect of the patella to the horizontal plane of
the lateral aspect. the affected knee.
326
219 The McMurray Test for Torn Meniscus
The McMurray test for torn meniscus can provide the clini- affected extremity relaxed, the examiner grasps the ankle
cian with useful information as to whether a torn medial or and palpates the knee while simultaneously rotating the
lateral meniscus is responsible for the patient’s knee pain. lower leg internally and externally and extending the knee
To perform the McMurray test for torn meniscus, the exam- (Fig. 219-1). The test is considered positive for torn menis-
iner has the patient assume the supine position on the cus if the examiner appreciates a palpable or auditory click
examination table with the knee maximally flexed. With the while rotating and extending the knee.
• Figure 219-1 The McMurray test for torn meniscus.
327
220 The Apley Grinding Test for
Meniscal Tear
The Apley grinding test for meniscal tear can provide the The examiner then pushes down on the foot of the affected
clinician with useful information as to whether a torn extremity and internally and externally rotates the lower
medial or lateral meniscus is responsible for the patient’s leg (Fig. 220-1). The Apley grinding test is considered posi-
knee pain. To perform the Apley test for torn meniscus, the tive if the patient complains of pain, if the examiner appre-
examiner has the patient assume the prone position on the ciates an audible or palpable click, or if there is locking of
examination table. The examiner has the patient flex his or the knee.
her knee 90 degrees and relax the entire lower extremity.
• Figure 220-1 The Apley grinding test for meniscal tear.
328
221 The Squat Test for Meniscal Tear
The squat test for meniscal tear is a useful confirmatory intensity of pain with internal rotation of the legs and feet
test in those patients who have a positive McMurray test is suggestive of a torn lateral meniscus, and an increase in
or Apley grinding test for torn meniscus (Figs. 221-1 and pain with external rotation of the legs and feet is suggestive
221-2; also see Chapters 219 and 220). To perform the of a torn medial meniscus.
squat test for torn meniscus, the patient is asked to perform
2 successive full squats, the first with the feet and legs fully
externally rotated (Fig. 221-3) and the second with the feet
and legs fully internally rotated (Fig. 221-4). The location
of pain is usually the strongest indicator of the location of
the torn meniscus, with medial pain highly suggestive of a
torn medial meniscus and lateral pain highly suggestive of
a lateral torn meniscus. Furthermore, an increase in the
Layer 1 MCL
Layer 2 MCL
Proximal
Tibia
Femur
Tear
Medial meniscus
• Figure 221-3 The squat test for meniscal tear: the patient is asked
Radial tearing of the medial meniscus in longitudinal first to perform a full squat with the feet and legs fully externally rotated.
medial quadrant view
• Figure 221-1 Longitudinal ultrasound image of the medial knee

demonstrating a radial tear of the medial meniscus. MCL, Medial col-
lateral ligament.
Lateral collateral
ligmaent
Proximal Tibia
Femoral Tearing
condyle
Lateral meniscus
Lateral joint quadrant longitudinal view
• Figure 221-4 The squat test for meniscal tear: the patient is then
• Figure 221-2 Longitudinal ultrasound image of the lateral knee asked to perform a full squat with the feet and legs fully internally
demonstrating a torn lateral meniscus. rotated.
329
222 The Thessaly Test for Meniscal Tear
The premise behind the Thessaly test for meniscal tear is to flex the painful knee approximately 5 degrees (Fig.
that abnormal loading of the diseased meniscus of the knee 222-2). The patient then is asked to rotate his or her body
is likely to reproduce the knee pain, locking, and clicking and knee externally and internally 3 times with the weight-
that the patient is experiencing. To perform the Thessaly bearing knee kept at 5 degrees flexion (Fig. 222-3). The test
test, the patient is asked to stand with both feet flat on the is then repeated with the weight-bearing knee flexed to 20
floor while the examiner helps stabilize the patient by degrees (Fig. 222-4). The test is now repeated with the
holding both of the patient’s hands (Fig. 222-1). The patient painful knee bearing the weight. The test is positive if the
is then asked to stand on the nonpainful lower extremity patient experiences reproduction and/or exacerbation of
and lift the affected lower extremity off the floor by flexing the pain, locking, and clicking in the painful knee.
the nonaffected knee 90 degrees. The patient is then asked
• Figure 222-1 To perform the Thessaly test, the patient is asked to • Figure 222-2 The patient is then asked to stand on the nonpainful
stand with both feet flat on the floor while the examiner helps stabilize lower extremity and lift the affected lower extremity off the floor by
the patient by holding both of the patient’s hands. flexing the nonaffected knee 90 degrees. The patient is then asked to
flex the painful knee approximately 5 degrees.
330
CHAPTER 222 The Thessaly Test for Meniscal Tear 331
• Figure 222-3 The patient then is asked to rotate his or her body • Figure 222-4 The same procedure is then repeated with the
and knee externally and internally 3 times with the weight-bearing knee weight-bearing knee flexed to 20 degrees.
kept at 5 degrees flexion.
223 The Twist Test for Semimembranosus
Insertion Syndrome
Semimembranosus insertion syndrome is a constellation regimens. Direct trauma to the posterior knee by kicks
of symptoms including a localized tenderness over the or tackles during football also can result in the develop-
posterior aspect of the medial knee joint with severe ment of semimembranosus insertion syndrome. Coexisting
pain being elicited on palpation of the attachment of inflammation of the semimembranosus bursa that lies
the semimembranosus muscle at the posterior medial between the medial head of the gastrocnemius muscle, the
condyle of the tibia (Fig. 223-1). Semimembranosus inser- medial femoral epicondyle, and the semimembranosus
tion syndrome occurs most commonly following overuse tendon can exacerbate the pain of semimembranosus inser-
or misuse of the knee, often after overaggressive exercise tion syndrome.
Semimembranosus
muscle
Semimembranosus
tendon
Oblique popliteal
ligament
• Figure 223-1 Semimembranosus insertion syndrome. (From Waldman SD: Atlas of uncommon pain
syndromes, Philadelphia, 2003, Saunders, p 213.)
332
CHAPTER 223 The Twist Test for Semimembranosus Insertion Syndrome 333
• Figure 223-2 The twist test for semimembranosus insertion syn-

drome. The patient is supine.
To perform the twist test for semimembranosus inser- examiner applies pressure with his or her thumb over the
tion syndrome, the patient is placed in the supine position point of attachment of the semimembranosus muscle on
on the examination table with the ankle and foot of the posterior lateral tibial condyle of the affected leg (Fig.
the patient’s affected leg held firmly under the examiner’s 223-2). The test is considered positive for semimembrano-
axilla. The patient’s knee is placed in 20 degrees of flexion, sus insertion syndrome if the patient experiences point ten-
and the tibia is rotated internally and externally while the derness beneath the examiner’s thumb during rotation.
224 The Knee Extension Test for
Quadriceps Expansion Syndrome
The quadriceps tendon is made up of fibers from the 4 tendon proper is subject to the development of tendinitis
muscles that make up the quadriceps muscle: the vastus (Fig. 224-2). The quadriceps tendon also is subject to
lateralis, the vastus intermedius, the vastus medialis, and the acute calcific tendinitis, which can coexist with acute strain
rectus femoris. These muscles are the primary extensors injuries. Calcific tendinitis of the quadriceps has a charac-
of the lower extremity at the knee. The tendons of these teristic radiographic appearance of whiskers on the antero-
muscles converge and unite to form a single, exceedingly superior patella.
strong tendon. The patella functions as a sesamoid bone The quadriceps expansion syndrome is characterized by
within the quadriceps tendon, with fibers of the tendon pain at the superior pole of the patella. It is usually the result
expanding around the patella and forming the medial of overuse or misuse of the knee joint, such as running
and lateral patella retinacula, which help strengthen the marathons, or direct trauma to the quadriceps tendon, such
knee joint (Fig. 224-1). These fibers are called the quadri- as that from kicks or head butts during football. Patients
ceps or patellar expansions and are subject to strain; the with quadriceps expansion syndrome present with pain over
Infrapatellar
Quadriceps t Patella fat body
Lat patellar
retinaculum
Med patellar
Vastus lateralis t retinaculum
Lat femoral condyle
Iliotibial tract Post cruciate lig
Tibial collateral lig
Ant cruciate lig
Popliteus t
Fibular collateral lig Med femoral
condyle
Biceps femoris m and t Greater
Gastrocnemius, saphenous v
lat head and Sartorius m and t
plantaris mm Gracilis t
Common peroneal n Semimembranosus t
Lat sural Semitendinosus t
cutaneous n Oblique popliteal Tibial n Popliteal Gastrocnemius m and t, med head
lig and joint capsule a and v
• Figure 224-1 Quadriceps expansions. (From Kang HS, Ahn JM, Resnick D: MRI of the extremities,
Patella cortical
surface
Medial Lateral
patella
expansion
• Figure 224-2 Ultrasound image demonstrating the medial patellar

(quadriceps) expansion.
334
CHAPTER 224 The Knee Extension Test for Quadriceps Expansion Syndrome 335
• Figure 224-3 The knee extension test for quadriceps expansion

syndrome.
the superior pole of the sesamoid, more commonly on the knee extension test for quadriceps expansion syndrome, the
medial side. The patient notes increased pain on walking patient is placed in the supine position on the examina-
down slopes or stairs. Activity that uses the knee makes the tion table and is then asked to maximally flex his or her
pain worse, with rest and heat providing some relief. The affected knee. The examiner places his or her thumb on the
pain is constant and is characterized as aching in nature. superior medial pole of the patella of the affected leg and
The pain may interfere with sleep. then has the patient extend the leg against active resistance
On physical examination, there is tenderness under (Fig. 224-3). The knee extension test for quadriceps expan-
the superior edge of the patella, more commonly on the sion syndrome is considered positive if the patient experi-
medial side. Patients with quadriceps expansion syndrome ences sharp pain at the superior medial pole of the patella
also exhibit a positive knee extension test. To perform the as the affected leg extends.
225 Bursitis of the Knee
Because of the complex nature of the knee’s range of motion clinically relevant bursae, including the suprapatellar, pre-
and the tremendous and varied physical stresses that are patellar, superficial and deep infrapatellar, and pes anserine
placed on the knee, it is not surprising that the knee is one bursae, that are commonly the cause of a painful knee. It is
of the most common anatomic sites for the occurrence of important for the clinician to remember, when considering
bursitis. Bursae are formed from synovial sacs whose purpose the diagnosis of bursitis of the knee, that bursitis frequently
is to allow easy sliding of muscles and tendons across one coexists with other pathologic processes and might not be
another at areas of repeated movement. These synovial sacs the sole source of the patient’s pain and joint dysfunction.
are lined with a synovial membrane that is invested with a This chapter discusses some of the more common types of
network of blood vessels that secrete synovial fluid. Inflam- knee bursitis encountered in clinical practice.
mation of the bursa results in an increase in the production
of synovial fluid with swelling of the bursal sac. With SUPRAPATELLAR BURSITIS
overuse or misuse, the bursa may become inflamed, enlarged,
and, on rare occasions, infected. Although there is signifi- The suprapatellar bursa extends superiorly from beneath the
cant intrapatient variability as to the number, size, and patella under the quadriceps femoris muscle and its tendon
location of bursae, anatomists have identified a number of (Fig. 225-1). The bursa is held in place by a small portion
Rectus femoris m Lesser

saphenous v
Semimembranosus m
Femur
Prefemoral fat body

Med sup
Quadriceps t genicular a
Suprapatellar bursa Popliteal a and v
Suprapatellar fat
body
Joint capsule
Patella Post
meniscofemoral lig
of Wrisberg
Patellar lig Post cruciate lig
Med inf genicular a
Infrapatellar fat body
Patellar lig
Popliteal a and v
Tibia
Gastrocnemius m,
med head
Popliteus m
Soleus m
• Figure 225-1 Sagittal view of the knee. (From Kang HS, Ahn JM, Resnick D: MRI of the extremities,
336
CHAPTER 225 Bursitis of the Knee 337
of the vastus intermedius muscle, called the articularis genus bursal sac or, in some patients, as a multisegmented series
muscle. This bursa may exist as a single bursal sac or, in of sacs that may be loculated in nature.
some patients, as a multisegmented series of sacs that may The prepatellar bursa is vulnerable to injury from both
be loculated in nature. The suprapatellar bursa is vulnerable acute trauma and repeated microtrauma. Acute injuries fre-
to injury from both acute trauma and repeated microtrauma quently take the form of direct trauma to the bursa via falls
(Fig. 225-2). Acute injuries frequently take the form of
direct trauma to the bursa via falls directly onto the knee
or from patellar fractures, as well as from overuse injuries,
including running on soft or uneven surfaces, or from jobs
that require crawling on the knees, such as carpet laying.
If the inflammation of the suprapatellar bursa becomes
chronic, calcification of the bursa may occur.
The patient who suffers from suprapatellar bursitis will
frequently complain of pain in the anterior knee above the
patella that can radiate superiorly into the distal anterior
thigh. Often the patient is unable to kneel or walk down
stairs. The patient also might complain of a sharp “catching”
sensation with range of motion of the knee, especially on
first rising. Suprapatellar bursitis often coexists with arthri-
tis and tendinitis of the quadriceps tendon, and these other
pathologic processes can confuse the clinical picture.
Physical examination may reveal point tenderness in the
anterior knee just above the patella. Passive flexion and
active resisted extension of the knee reproduce the pain.
Sudden release of resistance during this maneuver markedly
increases the pain. There may be swelling in the suprapatel-
lar region with a “boggy” feeling to palpation. Occasionally
the suprapatellar bursa may become infected, with systemic
symptoms, including fever and malaise, as well as local
symptoms, including rubor, color, and dolor being present.
• Figure 225-2 Sagittal T2W magnetic resonance (MR) image of an
PREPATELLAR BURSITIS imperforate plica (black arrow) in a patient with a loculated hematoma
in the suprapatellar bursa (white arrow) following an acute injury. (From
The prepatellar bursa lies between the subcutaneous tissues Waldman SD, Campbell, RSD: Imaging of pain, Philadelphia, 2010,
and the patella (Fig. 225-3). This bursa may exist as a single Saunders/Elsevier, p 402, fig 156-2.)
A B T
• Figure 225-3 A, Sagittal T2W magnetic resonance (MR) image showing prominent high signal intensity
(SI) fluid within the prepatellar bursa. There is also an advanced osteoarthritic change in the patellofemoral
joint. B, The corresponding longitudinal ultrasound image shows the extensive low-echo fluid collection.
P, Patella; T, tibia. (From Waldman SD, Campbell, RSD: Imaging of pain, Philadelphia, 2010, Saunders/
338 SECTION 10 The Knee
directly onto the knee or from patellar fractures, as well as unable to kneel or walk down stairs. The patient also may
from overuse injuries, including running on soft or uneven complain of a sharp, “catching” sensation with range of
surfaces. Prepatellar bursitis also may result from jobs that motion of the knee, especially on first rising. Prepatellar
require crawling or kneeling, such as carpet laying or bursitis often coexists with arthritis and tendinitis of the
scrubbing floors; the other name for prepatellar bursitis knee joint, and these other pathologic processes can confuse
is housemaid’s knee (Fig. 225-4). If the inflammation of the clinical picture.
the prepatellar bursa becomes chronic, calcification of the Physical examination may reveal point tenderness in the
bursa can occur. anterior knee just above the patella. Swelling and fluid
The patient who suffers from prepatellar bursitis fre- accumulation surrounding the patella are often present.
quently complains of pain and swelling in the anterior knee Passive flexion and active resisted extension of the knee
over the patella that can radiate superiorly and inferiorly reproduce the pain. Sudden release of resistance during
into the area surrounding the knee. Often the patient is this maneuver markedly increases the pain. The prepatellar
bursa can become infected, with systemic symptoms,
including fever and malaise, as well as local symptoms,
including rubor, color, and dolor, also present.
SUPERFICIAL AND DEEP

INFRAPATELLAR BURSITIS
The superficial infrapatellar bursa lies between the subcuta-
neous tissues and the upper part of the ligamentum patellae
(Fig. 225-5). The deep infrapatellar bursa lies between the
ligamentum patellae and the tibia (Fig. 225-6). These bursae
may exist as single bursal sacs or, in some patients, as a
multisegmented series of sacs that may be loculated in
nature.
Both infrapatellar bursae are vulnerable to injury from
both acute trauma and repeated microtrauma. Acute inju-
ries frequently take the form of direct trauma to the bursae
via falls directly onto the knee or from patellar fractures,
• Figure 225-4 Prepatellar bursitis is also known as housemaid’s
knee because of its prevalence in people whose work requires pro- as well as from overuse injuries, including long-distance
longed crawling or kneeling. (From Waldman SD: Atlas of common running. Infrapatellar bursitis also can result from jobs
pain syndromes, Philadelphia, 2002, Saunders, p 259.) that require crawling or kneeling, such as carpet laying or
A B C
• Figure 225-5 A, Sagittal T2-weighted with fat suppression (FST2W) magnetic resonance (MR) image
demonstrating a small area of high signal intensity (SI) fluid superficial to the distal patellar tendon and
tibial tuberosity (arrow). B, This area of fluid (arrow) is also evident on the axial FST2W MR image. A small
amount of fluid may be a normal finding. C, In this case, however, more extensive diffuse high-SI edema
(broken arrows) is demonstrated in the adjacent soft tissues on the proximal axial FST2W MR
image, representing a diffuse advential bursitis. (From Waldman SD, Campbell, RSD: Imaging of pain,
Philadelphia, 2010, Saunders/Elsevier, p 406, fig 158-1.)
CHAPTER 225 Bursitis of the Knee 339
Medial
Patellar tendon
Bursitis
Tibia
• Figure 225-6 Longitudinal ultrasound image demonstrating deep

infrapatellar bursitis.
scrubbing floors. If the inflammation of the infrapatellar

bursae becomes chronic, calcification of the bursae can
occur.
• Figure 225-7 Pes anserine bursitis. This coronal gradient echo
The patient who suffers from infrapatellar bursitis fre- image shows a fluid collection medially, just inferior to the joint line.
quently complains of pain and swelling in the anterior knee (From Kaplan PA, Helms CA, Dussault R, et al: Musculoskeletal MRI,
below the patella that can radiate inferiorly into the area Philadelphia, 2001, Saunders, p 385.)
surrounding the knee. Often the patient is unable to kneel
or walk down stairs. The patient also may complain of a
sharp, “catching” sensation with range of motion of the
knee, especially on first rising. Infrapatellar bursitis often
coexists with arthritis and tendinitis of the knee joint, and the patient is unable to kneel or walk down stairs. The pain
these other pathologic processes can confuse the clinical is constant and characterized as aching in nature. The pain
picture. may interfere with sleep. Coexistent bursitis, tendinitis,
Physical examination may reveal point tenderness in the arthritis, or internal derangement of the knee can confuse
anterior knee just below the patella. Swelling and fluid the clinical picture after trauma to the knee joint. Fre-
accumulation that surround the lower patella are often quently the medial collateral ligament also is involved if the
present. Passive flexion and active resisted extension of the patient has sustained trauma to the medial knee joint. If the
knee reproduce the pain. Sudden release of resistance during inflammation of the pes anserine bursa becomes chronic,
this maneuver markedly increases the pain. The superficial calcification of the bursa can occur.
infrapatellar bursa can become infected, with systemic Physical examination may reveal point tenderness in the
symptoms, including fever and malaise, as well as local anterior knee just below the medial knee joint at the tendi-
symptoms, including rubor, color, and dolor, also present. nous insertion of the pes anserine tendon. Swelling and
fluid accumulation that surrounds the bursa are often
PES ANSERINE BURSITIS present. Active resisted flexion of the knee reproduces the
pain. Sudden release of resistance during this maneuver
The pes anserine bursa lies beneath the pes anserine tendon, markedly increases the pain. Rarely the pes anserine bursa
which is the insertional tendon of the sartorius, gracilis, becomes infected in a manner analogous to infection of the
and semitendinous muscle to the medial side of the tibia prepatellar bursa.
(Fig. 225-7). This bursa may exist as a single bursal sac or, Plain radiographs of the knee are indicated for all patients
in some patients, as a multisegmented series of sacs that may who suffer from bursitis. These may reveal calcification of
be loculated in nature. the bursa and associated structures, including ligaments
Patients with pes anserine bursitis present with pain over and tendons, indicating inflammation. Magnetic resonance
the medial knee joint and increased pain on passive valgus imaging is indicated if internal derangement, occult mass,
and external rotation of the knee. Activity, especially that or tumor of the knee is suspected. Electromyography helps
involving flexion and external rotation of the knee, makes to distinguish bursitis from neuropathy, lumbar radiculopa-
the pain worse. Rest and heat provide some relief. Often thy, and plexopathy.
226 The Creaking Tendon Sign for
Hamstring Tendinitis
The musculotendinous insertion of the hamstring group factors may include long-distance running, dancing inju-
of muscles is susceptible to the development of tendinitis ries, or the vigorous use of exercise equipment for lower
for 2 reasons. First, the knee joint is subjected to signifi- extremity strengthening. The pain is constant and severe,
cant repetitive motion under weight-bearing conditions. with sleep disturbance often reported. The patient may
Second, the blood supply to the musculotendinous unit is attempt to splint the inflamed tendon by holding the knee
poor, making healing of microtrauma difficult (Fig. 226-1). in a slightly flexed position and assuming a lurch-type antal
Calcium deposition around the tendon can occur if the gic gait. Patients with hamstring tendinitis exhibit severe
inflammation continues, thereby complicating subsequent pain to palpation over the tendinous insertion, the medial
treatment. If the inflammation of the tendinous insertions portion of the tendon being affected more commonly than
of these muscles becomes chronic, they may rupture if the lateral portion.
subjected to sudden trauma during exercise or injection. Patients who suffer from hamstring tendinitis will exhibit
Tendinitis of the musculotendinous insertion of the ham- a positive creaking tendon sign. To elicit a creaking tendon
string frequently coexists with bursitis of the associated sign for hamstring tendinitis, the patient is placed prone on
bursae of the knee joint, creating additional pain and func- the examination table with the knee of the affected leg
tional disability. extended. The examiner palpates the tendinous insertion
The onset of hamstring tendinitis is usually acute, occur- of the hamstrings and then has the patient flex his or
ring after overuse or misuse of the muscle group. Inciting her knee (Fig. 226-2). The creaking tendon sign for ham-
string tendinitis is positive if the examiner appreciates a
creaking sensation over the tendon while the patient flexes
the affected knee.
Gluteus
maximus
Semitendinosis
Medial
Ischial tuberosity
Sciatic n. Semimembranous
Biceps femoris
Transverse ischial tuberosity view
• Figure 226-1 Ultrasound image demonstrating the insertion of the • Figure 226-2 Eliciting the creaking tendon sign for hamstring
muscles that comprise the hamstring. tendinitis.
340
227 The Nobel Compression Test for
Iliotibial Band Syndrome
The Nobel compression test is a useful indicator of iliotibial examiner will feel the iliotibial band translate anteriorly over
band syndrome. To perform the Nobel compression test for the lateral femoral epicondyle. A snapping or popping sen-
iliotibial band syndrome, the patient is placed in the supine sation may be appreciated by both the patient and the
position on the examination table and is asked to flex the examiner. The test is positive if the pain is reproduced as
affected knee to 90 degrees. The examiner then applies firm the iliotibial band pops anteriorly over the lateral femoral
pressure with his or her thumb to the lateral femoral condyle condyle. Ultrasound and magnetic resonance imaging may
(Fig. 227-1). The patient’s knee is then passively extended help identify pathology of the iliotibial band responsible
(Fig. 227-2). At approximately 30 degrees of extension, the for the patient’s pain (Fig. 227-3).
• Figure 227-1 The examiner applies firm pressure with his or her • Figure 227-2 The patient’s knee is then passively extended.
thumb to the lateral femoral condyle.
lliotibial band
Cephalad
Lateral Gerdy Edema in

femoral tubercle IIiotibial
condyle band
fibers
Effusion of
lateral
Lateral right knee longitudinal view knee joint
• Figure 227-3 Longitudinal ultrasound image demonstrating edema and loss of normal echotexture of
the iliotibial band. Note the effusion in the lateral knee joint.
341
228 The Bump Sign for Baker Cyst of
the Knee
A Baker cyst of the knee is the result of an abnormal accu- inferiorly into the calf. Patients who suffer from rheumatoid
mulation of synovial fluid in the medial aspect of the pop- arthritis are prone to this phenomenon, and the pain associ-
liteal fossa. Overproduction of synovial fluid from the knee ated with dissection into the calf might be confused with
joint results in the formation of a cystic sac (Fig. 228-1). thrombophlebitis and treated inappropriately with antico-
This sac often communicates with the knee joint, with a agulants. Occasionally the Baker cyst will spontaneously
one-way valve effect causing a gradual expansion of the rupture, usually after frequent squatting.
cyst. Often a tear of the medial meniscus or tendinitis of On physical examination, the patient who suffers from
the medial hamstring tendon is the inciting factor that is a Baker cyst has a cystic swelling in the medial aspect of the
responsible for the development of a Baker cyst. Patients popliteal fossa, which is known as a bump sign (Fig. 228-2).
who suffer from rheumatoid arthritis are especially suscep- Baker cysts can become quite large, especially in patients
tible to the development of Baker cysts (Fig. 228-2). who suffer from rheumatoid arthritis. Activity, including
Patients with Baker cysts complain of a feeling of fullness squatting or walking, makes the pain of Baker cyst worse,
behind the knee. Often they notice a lump behind the knee with rest and heat providing some relief. The pain is
that becomes more apparent when they flex the affected constant and is characterized as aching in nature. The pain
knee. The cyst may continue to enlarge and may dissect may interfere with sleep. A Baker cyst may spontaneously
rupture, and there may be rubor and color in the calf that
can mimic thrombophlebitis. The Homans sign is negative,
and no cords are palpable. Occasionally, tendinitis of the
medial hamstring tendon can be confused with a Baker cyst.
Magnetic resonance and ultrasound imaging of the knee is
indicated if internal derangement or occult mass or tumor
is suspected and is also useful in confirming the presence of
a Baker cyst (see Figs. 228-3 and 228-4).
• Figure 228-1 The patient who suffers from a Baker cyst will often
complain of a sensation of fullness or a lump behind the knee. (From
Waldman SD: Atlas of common pain syndromes, Philadelphia, 2002, • Figure 228-2 A positive bump sign in a patient with a Baker cyst
Saunders, p 267.) of the left knee.
342
CHAPTER 228 The Bump Sign for Baker Cyst of the Knee 343
Calcification inside Baker cyst
Cyst
Cyst
Cephalad Caudad
Longitudinal posterior knee view
• Figure 228-4 Longitudinal ultrasound image demonstrating a

large, calcified Baker cyst.
• Figure 228-3 Rheumatoid arthritis: synovial cysts. This sagittal fat-
suppressed, fast spin echo (TR/TE, 2900/34) magnetic resonance
image reveals a synovial cyst (arrow) with extravasation of fluid (arrow-
head) indicative of rupture. (From Resnick D: Diagnosis of bone and
Joint disorders, Philadelphia, 2002, Saunders, p 865.)
229 Functional Anatomy of the Ankle
and Foot
To understand the functional anatomy of the ankle and often the source of ankle pain and dysfunction after seem-
foot, the clinician is best served by viewing the ankle and ingly minor trauma.
foot as being composed of 3 distinct functional units: the The talocalcaneal joint, which lies between the talus and
hindfoot, made up of the calcaneus and talus; the midfoot, the calcaneus, allows for additional range of motion of the
made up of the 5 tarsal bones; and the forefoot, made up ankle joint and makes up for the limitations of motion
of the metatarsals and phalanges (Fig. 229-1). Although placed on the joint by the mortise structure of the talus and
these units are functionally distinct, normal walking requires medial and lateral malleoli by permitting approximately 30
a highly and subtly coordinated interaction among them. degrees of foot inversion and 15 to 20 degrees of foot ever-
sion, which allow walking on uneven surfaces.
THE HINDFOOT
THE MIDFOOT
The distal joint between the tibia and fibula allows very little
movement, with the hinge joint formed by the distal ends The midtarsal joints are made up of the calcaneocuboid
of the tibia and fibula and the talus providing dorsiflexion and talonavicular joints. These joints contribute to further
and plantar flexion needed for ambulation. The medial range of motion by allowing 20 degrees of adduction of
and lateral malleoli extend along the sides of the talus to the foot and approximately 10 degrees of abduction of the
form a mortise that provides stability and prevents ankle foot. These movements add to the flexibility of the foot
rotation (Fig. 229-2). This joint is further strengthened by and are thought to aid in climbing; they are aided by the
the deltoid ligament medially and the anterior talofibular, gliding motions of the intertarsal joints between the navicu-
posterior talofibular, and calcaneofibular ligaments laterally. lar, cuneiform, and cuboid bones.
These ligaments are subject to strain and sprain and are
Phalanges
Tibia
Fibula
Metatarsals
Lateral
Cuneiform bones malleolus
Talus
Navicular Cuboid
Talus
Calcaneus Calcaneus
• Figure 229-1 The foot and ankle. • Figure 229-2 The hindfoot.
346
CHAPTER 229 Functional Anatomy of the Ankle and Foot 347
THE FOREFOOT metatarsophalangeal joints allow about 40 to 50 degrees of

plantar flexion and about 35 to 40 degrees of plantar flexion.
The metatarsophalangeal joints allow additional dorsiflex- The interphalangeal joints are made up of proximal
ion and plantar flexion of the foot, the first joint allowing and distal units. The proximal interphalangeal joints do not
80 to 90 degrees of dorsiflexion and the remaining meta- extend but allow approximately 50 degrees of plantar
tarsophalangeal joints allowing approximately 40 degrees of flexion. The distal interphalangeal joints allow approxi-
dorsiflexion. The first metatarsophalangeal joint allows mately 25 degrees of dorsiflexion and 40 to 50 degrees of
about 40 to 50 degrees of plantar flexion; the remaining plantar flexion.
230 Visual Inspection of the Ankle
and Foot
The foot and ankle are susceptible to a variety of pathologic nail changes, or obvious bony abnormalities that are pathog-
processes that can be diagnosed by careful inspection. The nomonic for specific diseases such as rheumatoid arthritis
examiner should first carefully examine the ankle and foot (Figs. 230-1 and 230-2). Careful attention should be paid
(with the shoes and socks off ), both while they are bearing to the region of the Achilles tendon for obvious rheumatoid
weight and while they are resting, to identify any obvious nodules or gouty tophi. The toes are then inspected for
deformity, including pes cavus or pes planus. The examiner corns, callus formation, gouty tophi, or obvious bony
should carefully examine the ankle and dorsal and plantar abnormality (Figs. 230-3 and 230-4).
aspects of the foot for erythema, swelling, ulceration, nodules,
• Figure 230-1 Rheumatoid forefoot. (From Klippel JH, Dieppe PA: • Figure 230-2 Digital tip infarcts in a patient with rheumatoid arthri-
Rheumatology, ed 2, London, 1998, Mosby, p 5–3.11.) tis. (From Klippel JH, Dieppe PA: Rheumatology, ed 2, London, 1998,
Mosby, p 5–4.7.)
348
CHAPTER 230 Visual Inspection of the Ankle and Foot 349
A B
• Figure 230-3 Bony abnormalities of the foot. A, A bunion (hallux valgus) develops at the base of the
big toe as an enlargement of bone or tissue around the metatarsophalangeal joint. There is often a notice-
able bump on the big toe joint. The big toe may turn in toward the second toe (displacement), and the
tissues surrounding the joint may be swollen and tender. B, A bunionette (tailor’s bunion) develops at the
base of the little toe. When the metatarsal bone bends away from the foot, the little toe bends inward,
and the joint swells or enlarges.
Normal toe Cock-up toe
A
B
Mallet toe Hammer toe
C
D
• Figure 230-4 Various deformities of the toes. A, Normal toe. B, Cock-up toe. C, Mallet toe.
D, Hammer toe.
231 Palpation of the Ankle and Foot
Palpation of the ankle joint can provide the examiner with The Achilles tendon should be palpated for nodules or
much information as to the cause of ankle and foot pain. insertional tendinitis. Retrocalcaneal bursitis will present
To adequately palpate the ankle and foot, the patient should as a swelling to palpation overlying the distal Achilles
be seated comfortably on the edge of the examination table tendon. The plantar surface of the foot should be palpated
with the shoes and socks removed. The affected ankle is for localized heel pain caused by subcalcaneal bursitis
allowed to assume its natural slightly plantar-flexed posi- or calcaneal spur. The plantar surface should be palpated
tion, and the examiner gently palpates the anterior aspect for painful sesamoid bones, plantar warts, cysts, plantar
of the joint with his or her thumbs while gently supporting fasciitis, and plantar nodular fibromatosis, which is the
the joint with the other fingers (Fig. 231-1). The examiner foot’s analog of a Dupuytren contracture in the hand
should be readily able to identify synovial thickening or (Figs. 231-2 and 231-3).
joint effusion. Tenosynovitis will be palpated as a tender, The midtarsal joints are then palpated by supporting the
linear swelling that extends across the joint. Bursitis of foot with the fingers and using the thumb of the examining
the medial and lateral malleolar bursae or last bursae will hand to palpate the dorsal surface. Careful palpation of this
be easily palpated as painful areas over the medial or lateral area should readily reveal any bony abnormality and syno-
malleoli. vial thickening (Fig. 231-4).
The metatarsophalangeal and interphalangeal joints are
then each individually palpated to identify obvious bony
abnormality, pain, or synovial thickening (Fig. 231-5). Pal-
pation of the metatarsophalangeal and interphalangeal
joints is best carried out by using the thumbs of both hands
(Fig. 231-6).
Epidermal inclusion cyst
Distal
Proximal
Lateral foot longitudinal view
• Figure 231-1 Palpation of the ankle. • Figure 231-2 Longitudinal ultrasound image of the plantar surface
of the foot demonstrating large epidermoid cysts.
350
CHAPTER 231 Palpation of the Ankle and Foot 351
A B C
• Figure 231-3 A, Lateral radiograph of a plantar spur on the calcaneus. B, The sagittal T1W magnetic
resonance (MR) image demonstrates thickening and increased signal intensity (SI) within the plantar fascia
origin (black arrow). There is high-SI fatty marrow within the bony spur. C, High-SI fluid (white arrow) is
seen within the plantar fascia origin on the sagittal FST2W MR image. The appearances are consistent
with plantar fasciitis and partial tearing of the origin of the fascia. (From Waldman SD, Campbell, RSD:
Proximal
Synovitis
Proximal phalanx
First metatarsal
Longitudinal MTP joint view
• Figure 231-5 Longitudinal ultrasound image of the first metatarso-

• Figure 231-4 Palpation of the midtarsal joints. phalangeal joint demonstrating active synovitis in a patient with rheu-
matoid arthritis. MTP, Metatarsophalangeal.
• Figure 231-6 Palpation of the metatarsophalangeal and interpha-

langeal joints.
232 The Wave Test for Ankle Joint Effusion
Effusions of the ankle joint are commonly seen in patients examination table with the shoes and socks removed. The
who suffer from rheumatoid arthritis and other collagen affected ankle is allowed to assume its natural slightly
vascular diseases. Although small effusions of the ankle plantar-flexed position. The examiner places pressure on
joint can be missed owing to the strong overlying ligaments the anterolateral ankle while palpating the opposite side
and multiple tendons, larger effusions can be identified with of the ankle joint for a transmission of excess fluid
the wave test. (Fig. 232-1).
To perform the wave test for ankle joint effusion, the
patient should be seated comfortably on the edge of the
• Figure 232-1 The wave test for ankle joint effusion.
352
233 The Anterior Drawer Test for Anterior
Talofibular Ligament Insufficiency
The anterior drawer test for insufficiency of the talofibular ankle in his or her other hand and firmly draws these bones
ligament is performed by having the patient sit comfortably forward (Fig. 233-1). Movement of greater than 5 mm is
on the edge of the examination table with the shoes and considered positive and highly suspect for insufficiency of
socks removed. The affected ankle is allowed to assume its the talofibular ligament. Magnetic resonance and ultra-
natural slightly plantar-flexed position, and the distal tibia sound imaging can quantify the extent of talofibular liga-
and fibula are stabilized by being grasped. The examiner ment damage and also help to identify other ankle pathology
then cups the calcaneus and talus of the patient’s affected (Figs. 233-2 and 233-3).
Tibia
Fibula
Ant. talofibular
lig.
• Figure 233-1 The anterior drawer test for anterior talofibular liga-
ment insufficiency.
353
354 SECTION 11 The Ankle and Foot
* *
A B
• Figure 233-2 A and B, Consecutive axial T1W magnetic resonance arthrogram images demonstrating
complete rupture of the talofibular ligament with only a small proximal remnant (broken arrows). High
signal intensity fluid has extravasated outside the normal joint recesses (asterisks). (From Waldman SD,
Campbell, RSD: Imaging of pain, Philadelphia, 2010, Saunders/Elsevier, p 438, fig 170-2.)
Effusion from ATFL injury
Tear
Anterior
Talus ATFL
Fibula
Mild avulsion
Transverse lateral ankle view

• Figure 233-3 Transverse ultrasound image of the lateral ankle of a
patient with an acute injury to the ankle from a skating accident dem-
onstrating a tear of the anterior talofibular ligament (ATFL). Note the
effusion of the ankle joint.
234 The Inversion Test for Anterior
Talofibular Ligament Insufficiency
The anterior talofibular ligament is susceptible to strain The ankle inversion test is performed by having the
from acute injury from sudden inversion of the ankle or patient sit comfortably on the edge of the examination
from repetitive microtrauma to the ligament from overuse table with the shoes and socks removed. The affected
or misuse, such as long-distance running on soft or uneven ankle is allowed to assume its natural slightly plantar-
surfaces. The anterior talofibular ligament runs from the flexed position, and the distal tibia and fibula are sta-
anterior border of the lateral malleolus to the lateral surface bilized by being grasped. The examiner then cups the
of the talus. Patients with injury to the anterior talofibular calcaneus and talus of the patient’s affected ankle in his
ligament complain of pain just below the lateral malleolus. or her other hand and firmly inverts the ankle joint
Activities that require plantar flexion and inversion of the (Fig. 234-1). The ankle inversion test is considered positive
ankle joint exacerbate the pain. if the patient experiences localized pain over the lateral mal-
On physical examination, patients who are suffering leolus. To confirm the diagnosis of anterior talofibular liga-
from insufficiency of the anterior talofibular ligament will ment insufficiency and to rule out coexistent fracture or
exhibit point tenderness over the lateral malleolus. With bursitis, plain radiographs and sonographic and magnetic
acute trauma, ecchymosis over the ligament may be noted. resonance images of the ankle should be obtained
Patients who are suffering from insufficiency of the anterior (Figs. 234-2 and 234-3).
talofibular ligament will also exhibit a positive ankle inver-
sion test.
• Figure 234-1 The inversion test for anterior talofibular ligament

insufficiency. Push in the direction of the arrow.
355
A B
• Figure 234-2 T2* axial images, ankle. A, The anterior talofibular ligament (arrowhead) and striated
posterior talofibular ligament (arrows) are well seen on the level of the malleolar fossa. B, In a different
patient, the lateral aspect of the anterior talofibular ligament is markedly thickened (arrowheads) and
has low signal. This indicates previous rupture with scarring and fibrosis that mimics an intact ligament.
(From Kaplan PA, Helms CA, Dussault R, et al: Musculoskeletal MRI, Philadelphia, 2001, Saunders,
pp 408–409.)
Anterior Soft tissue edema
Talus
Lateral malleolus
ATFL
Retracted fibers
• Figure 234-3 Ultrasound image demonstrating a high grade tear

of the anterior talofibular ligament (ATFL) in a patient who suffered an
acute inversion injury to the ankle when stepping in a gopher hole.
235 The Eversion Test for Deltoid
Ligament Insufficiency
The deltoid ligament is susceptible to strain from acute The ankle eversion test is performed by having the
injury from sudden overpronation of the ankle or from patient sit comfortably on the edge of the examination table
repetitive microtrauma to the ligament from overuse or with the shoes and socks removed. The affected ankle is
misuse, such as long-distance running on soft or uneven allowed to assume its natural slightly plantar-flexed posi-
surfaces. The deltoid ligament has 2 layers. Both attach tion, and the distal tibia and fibula are stabilized by being
above to the medial malleolus (Fig. 235-1). A deep layer grasped. The examiner then cups the calcaneus and talus of
attaches below to the medial body of the talus, with the the patient’s affected ankle in his or her other hand and
superficial fibers attaching to the medial talus, the susten- firmly everts the ankle joint (Fig. 235-2). The ankle eversion
taculum tali of the calcaneus, and the navicular tuberosity. test is considered positive if the patient experiences localized
Patients with strain of the deltoid ligament complain of pain over the medial malleolus. To confirm the diagnosis of
pain just below the medial malleolus. Activities that require deltoid ligament insufficiency and to rule out coexistent
plantar flexion and eversion of the ankle joint exacerbate fracture or bursitis, plain radiographs and sonographic and
the pain. magnetic resonance images of the ankle should be obtained
On physical examination, patients who are suffering (Figs. 235-3 and 235-4).
from insufficiency of the deltoid ligament will exhibit point
tenderness over the medial malleolus. With acute trauma,
ecchymosis over the ligament may be noted. Patients who
are suffering from insufficiency of the deltoid ligament will
also exhibit a positive ankle eversion test.
Tibia
Deltoid
ligament
Talus
• Figure 235-1 Longitudinal ultrasound image of the deltoid liga-

ment. Note the proximal attachment to the medial malleolus of the • Figure 235-2 The eversion test for deltoid ligament insufficiency.
tibia. Push in the direction of the arrow.
357
A B C
D E
• Figure 235-3 A, Sagittal FST2W magnetic resonance (MR) image of an athlete with a subacute ever-
sion ankle sprain. There is marrow edema in the tip of the medial malleolus (arrow) and a possible small
bony avulsion injury (broken arrow). B, The coronal FST2W MR image also shows the marrow edema
(arrow), and there is high signal intensity (SI) within the deltoid ligament edema (curved arrow) as a result
of partial tearing. C and D, Consecutive axial FST2W MR images more clearly demonstrate the deltoid
ligament edema (curved arrow) anterior to the flexor tendons (arrows). The bony avulsion fragment is
demonstrated as a small round area of low SI (broken arrow). E, The coronal computed tomographic
image confirms the presence of an avulsion fracture of the tip of the medial malleolus. (From Waldman
SD, Campbell, RSD: Imaging of pain, Philadelphia, 2010, Saunders/Elsevier, p 441, fig 171-2.)
CHAPTER 235 The Eversion Test for Deltoid Ligament Insufficiency 359
Neovascularization
of deltoid ligament
Tibia
Talus
• Figure 235-4 Color Doppler image of a severe sprain of the deltoid

ligament in a patient who sustained an acute eversion injury to the
ankle when a step was missed. Note the significant neovascularization
of the ligament.
236 The Squeeze Test for Syndesmosis
Ankle Strain
Rupture of the ligaments that hold the distal tibia and fibula occur, and the only other finding is concurrent rupture of
is usually associated with trauma severe enough to cause the deltoid ligament. With disruption of the tibiofibular
fractures of the medial and lateral malleolus, although occa- ligaments, with or without fractures of the distal tibia and
sionally isolated disruption in the absence of fractures can fibula, widening of the ankle mortise occurs with significant
pain and dysfunction (Fig. 236-1). In the absence of frac-
tures, the patient’s pain may seem out of proportion to the
demonstrable injury on x-ray; the squeeze test may help
identify damage to the tibiofibular ligaments.
To perform the squeeze test for syndesmosis ankle
strain, the patient is placed in the sitting position and the
calf of the affected extremity is squeezed by the examiner
(Fig. 236-2). Distal pain and spreading of the tibia and
fibula is strongly suggestive of significant ankle strain
including disruption of the tibiofibular ligaments.
• Figure 236-1 Axial computed tomographic image of the lower leg

demonstrates disruption of the distal tibia and fibular articulation, with
the fibula subluxated anteriorly out of its sulcus (long arrow). A large
avulsion fragment is seen at the tibial insertion of the anterior tibio-
fibular ligament (short arrow). This avulsion represents an adult Tillaux
fracture. (From Haaga J, Lanzieri C, Gilkeson R, editors: CT and MR • Figure 236-2 The squeeze test for syndesmosis ankle strain: the
imaging of the whole body, vol 2, ed 4, Philadelphia, 2002, Mosby, patient is placed in the sitting position and the calf of the affected
p 1857.) extremity is squeezed by the examiner.
360
237 The External Rotation Test for
Syndesmosis Ankle Strain
Rupture of the ligaments that hold the distal tibia and fibula the demonstrable injury on x-ray; the external rotation test
is usually associated with trauma severe enough to cause may help identify damage to the tibiofibular ligaments.
fractures of the medial and lateral malleolus, although occa- To perform the external rotation test for syndesmosis
sionally isolated disruption in the absence of fractures can ankle strain, the patient is placed in the sitting position and
occur, and the only other finding is concurrent rupture of the knee of the affected extremity is grasped to stabilize the
the deltoid ligament. With disruption of the tibiofibular knee in 90 degrees of flexion while the examiner gently
ligaments, with or without fractures of the distal tibia and externally rotates the foot and ankle (Fig. 237-1). Pain on
fibula, widening of the ankle mortise occurs with significant external rotation over the anterior or posterior tibiofibular
pain and dysfunction (see Fig. 236-1). In the absence of ligaments is strongly suggestive of significant ankle strain
fractures, the patient’s pain may seem out of proportion to including disruption of the tibiofibular ligaments.
• Figure 237-1 The external rotation test for syndesmosis ankle

strain.
361
238 The Tinel Sign for Anterior Tarsal
Tunnel Syndrome
Anterior tarsal tunnel syndrome is caused by compression Physical findings include tenderness over the deep pero-
of the deep peroneal nerve as it passes beneath the superfi- neal nerve at the dorsum of the foot. A positive Tinel
cial fascia of the ankle (Fig. 238-1). The most common sign just medial to the dorsalis pedis pulse over the deep
cause of compression of the deep peroneal nerve at this peroneal nerve as it passes beneath the fascia usually is
anatomic location is trauma to the dorsum of the foot. present (Fig. 238-2). Active plantar flexion often reproduces
Severe, acute plantar flexion of the foot has been implicated the symptoms of anterior tarsal tunnel syndrome. Weakness
in anterior tarsal tunnel syndrome, as has the wearing of of the extensor digitorum brevis muscle may be present if
overly tight shoes or squatting and bending forward, as the lateral branch of the deep peroneal nerve is affected.
when planting flowers. Anterior tarsal tunnel syndrome is Anterior tarsal tunnel syndrome is often misdiagnosed as
much less common than posterior tarsal tunnel syndrome. arthritis of the ankle joint, lumbar radiculopathy, or dia-
This entrapment neuropathy presents primarily as pain, betic polyneuropathy. Patients with arthritis of the ankle
numbness, and paresthesias of the dorsum of the foot joint have radiographic evidence of arthritis. Most patients
that radiates into the first dorsal web space. These symptoms who suffer from a lumbar radiculopathy have reflex, motor,
also may radiate proximal to the entrapment into the and sensory changes associated with back pain, whereas
anterior ankle. There is no motor involvement unless the patients with anterior tarsal tunnel syndrome have no reflex
distal lateral division of the deep peroneal nerve is changes, and motor and sensory changes are limited to the
involved. Nighttime foot pain analogous to the nocturnal distal deep peroneal nerve. Diabetic polyneuropathy gener-
pain of carpal tunnel syndrome often is present. The patient ally presents as symmetric sensory deficit involving the
may report that holding the foot in the everted position entire foot, rather than being limited to the distribution of
decreases the pain and paresthesias of anterior tarsal tunnel the deep peroneal nerve. It should be remembered that
syndrome. lumbar radiculopathy and deep peroneal nerve entrapment
• Figure 238-1 Anterior tarsal tunnel syndrome will present as deep,

aching pain in the dorsum of the foot, weakness of the extensor
digitorum brevis, and numbness in the distribution of the deep pero-
neal nerve. (From Waldman SD: Atlas of common pain syndromes, • Figure 238-2 Eliciting the Tinel sign for anterior tarsal tunnel
Philadelphia, 2002, Saunders, p 287.) syndrome.
362
CHAPTER 238 The Tinel Sign for Anterior Tarsal Tunnel Syndrome 363
A B C
• Figure 238-3 Axial T1W (A) and FST2W (B) magnetic resonance (MR) images of a patient with ankle
pain and paresthesia over the dorsal aspect of the foot. A mass of synovitis arising from the ankle joint
surrounds the extensor tendons and the anterior neurovascular bundle. The synovium has intermediate
signal intensity on both images and also on the coronal T2W MR image (C). There is also bony erosion.
These appearances are typical pigmented villondular synovitis.
may coexist as the so-called double crush syndrome. Fur- patients who present with anterior tarsal syndrome to rule
thermore, because anterior tarsal tunnel syndrome is seen out occult bony pathology. On the basis of the patient’s
in patients with diabetes, it is not surprising that diabetic clinical presentation, additional testing may be indicated,
polyneuropathy is usually present in diabetic patients with including complete blood count, uric acid, sedimentation
anterior tarsal tunnel syndrome. rate, and antinuclear antibody testing. Magnetic resonance
Electromyography helps to distinguish lumbar radicu- and ultrasound imaging of the ankle and foot is indicated
lopathy and diabetic polyneuropathy from anterior tarsal if joint instability or a space-occupying lesion is suspected
tunnel syndrome. Plain radiographs are indicated for all (Fig. 238-3).
239 The Tinel Sign for Posterior Tarsal
Tunnel Syndrome
Posterior tarsal tunnel syndrome is caused by compression higher incidence of posterior tarsal tunnel syndrome than
of the posterior tibial nerve as it passes through the posterior does the general population. Posterior tarsal tunnel syn-
tarsal tunnel. The posterior tarsal tunnel is made up of the drome is much more common than anterior tarsal tunnel
flexor retinaculum, the bones of the ankle, and the lacunate syndrome.
ligament. In addition to the posterior tibial nerve, the Posterior tarsal tunnel syndrome presents in a manner
tunnel contains the posterior tibial artery and a number analogous to carpal tunnel syndrome. The patient com-
of flexor tendons, which are subject to tenosynovitis (Fig. plains of pain, numbness, and paresthesias of the sole of the
239-1). The most common cause of compression of the foot. These symptoms also may radiate proximally to the
posterior tibial nerve at this anatomic location is trauma to entrapment into the medial ankle. The medial and lateral
the ankle, including fracture, dislocation, and crush inju- plantar divisions of the posterior tibial nerve provide motor
ries. Thrombophlebitis involving the posterior tibial artery innervation to the intrinsic muscles of the foot. The patient
also has been implicated in the evolution of posterior tarsal might note weakness of the toe flexors and instability of
tunnel syndrome. Patients with rheumatoid arthritis have a the foot caused by weakness of the lumbrical muscles.
Extensor hallucis Tibialis ant t

longus m and t
Inf extensor
retinaculum
Ant tibial a
Greater
Deep peroneal n saphenous v
Extensor digitorum
longus m and t
Peroneus tertius m Tibia
Ant inf Tibialis post t

tibiofibular lig
Flexor digitorum
longus m and t
Fibula
Post tibial a
Tibial n
Peroneus longus t
Flexor hallucis
Peroneus brevis longus m and t
m and t
Tendo calcaneus
• Figure 239-1 The structure of the posterior tarsal tunnel. (From Kang HS, Ahn JM, Resnick D: MRI
of the extremities, Philadelphia, 2003, Saunders, p 411.)
364
CHAPTER 239 The Tinel Sign for Posterior Tarsal Tunnel Syndrome 365
Nighttime foot pain analogous to the nocturnal pain of Posterior tarsal tunnel syndrome is often misdiagnosed
carpal tunnel syndrome is often present. as arthritis of the ankle joint, lumbar radiculopathy, or
Physical findings include tenderness over the posterior diabetic polyneuropathy. Patients with arthritis of the ankle
tibial nerve at the medial malleolus. A positive Tinel sign joint have radiographic evidence of arthritis. Most patients
just below and behind the medial malleolus over the poste- who suffer from a lumbar radiculopathy have reflex, motor,
rior tibial nerve is usually present (Fig. 239-2). Active inver- and sensory changes associated with back pain, whereas
sion of the ankle often reproduces the symptoms of the patients with posterior tarsal tunnel syndrome have no
posterior tarsal tunnel syndrome. Weakness of the flexor reflex changes, and motor and sensory changes are limited
digitorum brevis and the lumbrical muscles may be present to the distal posterior tibial nerve. Diabetic polyneuropathy
if the medial and lateral branches of the posterior tibial generally presents as a symmetric sensory deficit involving
nerve are affected. the entire foot, rather than being limited to the distribution
of the posterior tibial nerve. It should be remembered that
lumbar radiculopathy and posterior tibial nerve entrapment
may coexist as the so-called double crush syndrome. Fur-
thermore, because posterior tarsal tunnel syndrome is seen
in patients with diabetes, it is not surprising that diabetic
polyneuropathy is usually present in diabetic patients with
posterior tarsal tunnel syndrome.
Electromyography helps to distinguish lumbar radicu-
lopathy and diabetic polyneuropathy from posterior tarsal
tunnel syndrome. Plain radiographs are indicated for all
patients who present with posterior tarsal tunnel syndrome
to rule out occult bony pathology. On the basis of the
patient’s clinical presentation, additional testing may be
indicated, including complete blood count, uric acid, sedi-
mentation rate, and antinuclear antibody testing. Magnetic
resonance and ultrasound imaging of the ankle and foot is
• Figure 239-2 Eliciting the Tinel sign for posterior tarsal tunnel indicated if joint instability or a space-occupying lesion is
syndrome. suspected (Figs. 239-3 and 239-4).
A B C
• Figure 239-3 Axial proton density (PD) (A) and T2-weighted (T2W) (B) magnetic resonance (MR)
images of the ankle in a patient with medial foot pain. There is a discrete rounded lesion (white arrow)
within the tarsal tunnel. It has intermediate signal intensity (SI) on the PD MR images and high SI on the
T2W MR images consistent with a fluid-filled ganglion cyst. (C) The sagittal T1W MR image demonstrates
the mass posterior to the talus and the flexor hallucis longus tendon (broken arrow), and one of the
posterior tibial vessels runs over the superficial surface of the mass (black arrow). The cyst is causing
mass effect within the tarsal tunnel, compressing the posterior tibial nerve and producing symptoms of
posterior tarsal tunnel syndrome. (Reproduced with permission from Spratt JD et al: The role of diagnostic
radiology in compressive and entrapment neuropathies, European Radiology 12:2352–2364, 2002.)
Tibial vein Calcaneous

branch
Very large neuroma

of the posterior tibial nerve
Transverse posterior tibial nerve view
• Figure 239-4 Transverse ultrasound image of the ankle demon-

strating a large posttraumatic neuroma of the posterior tibial nerve
in a patient presenting with symptoms of posterior tarsal tunnel
syndrome.
240 The Creak Sign for Achilles Tendinitis
The Achilles tendon is susceptible to the development of development of Achilles tendinitis, as well as contributing
tendinitis both at its insertion on the calcaneus and at to acute tendon rupture. The pain of Achilles tendinitis is
its narrowest part, at a point approximately 5 cm above constant and severe and is localized in the posterior ankle.
its insertion. The Achilles tendon is subject to repetitive Significant sleep disturbance is often reported. The patient
motion, which can result in microtrauma that heals poorly might attempt to splint the inflamed Achilles tendon by
because of the tendon’s avascular nature. Running is often adopting a flat-footed gait to avoid plantar-flexing the
implicated as the inciting factor of acute Achilles tendinitis affected tendon. Patients with Achilles tendinitis exhibit
(Fig. 240-1). Tendinitis of the Achilles tendon frequently pain with resisted plantar flexion of the foot as well as a
coexists with bursitis of the associated bursae of the tendon positive creak sign. To elicit the creak sign for Achilles ten-
and ankle joint, creating additional pain and functional dinitis, the patient is asked to sit on the side of the examina-
disability. Calcium deposition around the tendon can occur tion table with his or her legs hanging over the side of the
if the inflammation continues, making subsequent treat- table. The examiner then palpates the area overlying the
ment more difficult. Continued trauma to the inflamed Achilles tendon and with the other hand passively plantar-
tendon ultimately might result in tendon rupture. flexes and dorsi-flexes the foot (Fig. 240-2). The creak sign
The onset of Achilles tendinitis usually is acute, occur- is considered positive if the examiner can appreciate a creak-
ring after overuse or misuse of the ankle joint. Inciting ing or grating sensation with these movements.
factors may include activities such as running and sudden Plain radiographs are indicated for all patients who
stopping and starting, as occurs when playing tennis. present with posterior ankle pain. On the basis of the
Improper stretching of the gastrocnemius and Achilles patient’s clinical presentation, additional testing may be
tendon prior to exercise also has been implicated in the indicated, including complete blood count, sedimentation
rate, and antinuclear antibody testing. Magnetic resonance
and ultrasound imaging of the ankle will help to confirm
the extent of damage to the Achilles tendon and to identify
Achilles bursitis or bone spurs or xanthomas that might
be causing repetitive trauma to the tendon (Figs. 240-3
Achilles tendon and 240-4).
Achilles tendon
Calcaneous Calcaneous
RT LT
Achilles tendon longitudinal view right vs. left foot
• Figure 240-1 Longitudinal color Doppler images of the left and • Figure 240-2 Eliciting the creak sign for Achilles tendinitis.
right ankles in the same patient demonstrating Achilles tendinitis. Note
the neovascularization of the tendon on the left.
367
Bruising
Achilles tendon
Achillles
tendon 1
Retro-
calcaneal Calcaneous
bursitis
Proximal
Calcaneous
Longitudinal achilles tendon view Longitudinal posterior leg view

Note loss of fiber homogeneity
decreased echogenicity of tendon
• Figure 240-3 Longitudinal ultrasound image of the Achilles tendon

in a patient with an acute ankle injury demonstrating significant tendi- • Figure 240-4 Longitudinal ultrasound image demonstrating retro-
nopathy of the Achilles tendon. Note the subcutaneous bruising and calcaneal bursitis in a long-distance runner.
the loss of the normal echotexture of the tendon.
241 The Toe Raise Test for Achilles
Tendon Rupture
The Achilles tendon is susceptible to rupture following weight-bearing forefoot. The toe raise test is useful in the
either direct trauma to the tendon or sudden forced dorsi- identification of rupture of the Achilles tendon. To perform
flexion of the ankle or plantar-flexed foot. Push-off injuries the toe raise test for Achilles tendon rupture, the patient is
to the tendon occur when sudden stress is placed on the asked to stand in a comfortable position and then to raise
himself or herself up on tiptoes (Fig. 241-1). An inability
to perform a toe raise on the affected side provides a pre-
sumptive diagnosis of rupture of the Achilles tendon, and
magnetic resonance and/or ultrasound imaging of the
tendon is indicated (Figs. 241-2 and 241-3).
Calcaneum
Soleus *
• Figure 241-2 Longitudinal ultrasound image of an acute mid-

Achilles tendon rupture. The distal tendon (arrows) appears relatively
normal, although there is some low-reflective fluid within the deep
portion of the paratenon. The torn ends of the tendon are visualized
• Figure 241-1 To perform the toe raise test for Achilles tendon (broken arrows), and there is a low-reflective hematoma in the tendon
rupture, the patient is asked to stand in a comfortable position and gap (asterisk). (From Waldman SD, Campbell, RSD: Imaging of pain,
then to raise himself or herself up on tiptoes. Philadelphia, 2010, Saunders/Elsevier, p 432, fig 167-1.)
369
A B C
• Figure 241-3 A, Sagittal T1-weighted (T1W) magnetic resonance (MR) image of a patient with a failed
Achilles tendon repair. The midportion of the tendon is thickened, irregular, and of intermediate signal
intensity (SI) (arrows). There are some areas of susceptibility artifact due to the previous tendon repair
(broken arrow). The sagittal (B) and axial (C) T2W with fat suppression (FST2W) MR images demonstrate
the tendon gap filled by high-SI hematoma (curved arrows).
242 The Thompson Squeeze Test for
Achilles Tendon Rupture
The Achilles tendon is susceptible to rupture following with his or her feet hanging off the examination table.
either direct trauma to the tendon or sudden forced dorsi- The examiner then grasps the calf on the patient’s affected
flexion of the ankle or plantar-flexed foot. Push-off injuries side just below the point of the calf ’s maximum girth
to the tendon occur when sudden stress is placed on the and firmly squeezes the calf (Fig. 242-1). The absence
weight-bearing forefoot. The Thompson squeeze test is of plantar flexion on the affected side provides a presump-
useful in the identification of rupture of the Achilles tendon. tive diagnosis of rupture of the Achilles tendon, and
To perform the Thompson squeeze test for Achilles tendon magnetic resonance imaging of the tendon is indicated
rupture, the patient is asked to assume the sitting position (see Figs. 241-2 and 241-3).
• Figure 242-1 To perform the Thompson squeeze test for Achilles

tendon rupture, the examiner grasps the calf on the patient’s affected
side just below the point of the calf’s maximum girth and firmly
squeezes the calf. Absence of plantar flexion on the affected side
provides a presumptive diagnosis of rupture of the Achilles tendon.
371
243 The Matles Test for Achilles
Tendon Rupture
The Achilles tendon is susceptible to rupture following asked to assume the prone position with his or her feet
either direct trauma to the tendon or sudden forced dorsi- hanging off the examination table. The examiner then pas-
flexion of the ankle or plantar-flexed foot. Push-off injuries sively flexes the patient’s knees to 90 degrees while both of
to the tendon occur when sudden stress is placed on the the patient’s feet are in neutral position. If the Achilles
weight-bearing forefoot. The Matles test is useful in the tendon is ruptured, there will be no plantar flexion of the
identification of rupture of the Achilles tendon. To perform affected foot (Fig. 243-1).
the Matles test for Achilles tendon rupture, the patient is
• Figure 243-1 To perform the Matles test for Achilles tendon

rupture, the patient is placed in the prone position and the examiner
passively flexes the patient’s knees to 90 degrees while both of the
patient’s feet are in neutral position. If the Achilles tendon is ruptured,
there will be no plantar flexion of the affected foot.
372
244 The Calcaneal Jump Sign for
Plantar Fasciitis
Plantar fasciitis is characterized by pain and tenderness Plain radiographs are indicated for all patients who
over the plantar surface of the calcaneus. Occurring twice present with pain that is thought to emanate from plantar
as often in women as in men, plantar fasciitis is thought fasciitis to rule out occult bony pathology and tumor. On
to be caused by an inflammation of the plantar fascia. the basis of the patient’s clinical presentation, additional
This inflammation can occur alone or as part of a systemic testing including complete blood count, prostate-specific
inflammatory condition, such as rheumatoid arthritis, antigen, sedimentation rate, and antinuclear antibody
Reiter syndrome, or gout. Obesity also seems to predispose testing might be indicated. Magnetic resonance and ultra-
one to the development of plantar fasciitis, as does going sound imaging of the plantar surface of the foot can help
barefoot or wearing house slippers for prolonged periods. to confirm the clinical diagnosis of plantar fasciitis and
High-impact aerobic exercise has also been implicated. The to rule out occult mass, fracture, or tumor (Figs. 244-2
pain of plantar fasciitis is most severe on first walking after and 244-3).
not bearing weight and is made worse by prolonged stand-
ing or walking.
On physical examination, the patient who suffers from
plantar fasciitis will exhibit a positive calcaneal jump sign.
To elicit the calcaneal jump sign, the patient is placed in a
prone position on the examination table. The examiner uses
his or her index finger to firmly press on the skin overlying
the plantar medial calcaneal tuberosity (Fig. 244-1). The
calcaneal jump sign is considered positive if this maneuver
reproduces the patient’s pain and causes the patient to jump
or withdraw from the sudden onset of pain. The patient
with plantar fasciitis also may have tenderness along the
plantar fascia as it moves anteriorly. Pain is increased
by dorsiflexing the toes, which pulls the plantar fascia taut,
and then palpating along the fascia from the heel to the
forefoot. • Figure 244-1 Eliciting the calcaneal jump sign for plantar fasciitis.
A B C
• Figure 244-2 A, Lateral radiograph of a plantar spur on the calcaneus. B, The sagittal T1W magnetic
resonance (MR) image demonstrates thickening and increased signal intensity (SI) within the plantar fascia
origin (black arrow). There is high-SI fatty marrow within the bony spur. C, High-SI fluid (white arrow) is
seen within the plantar fascia origin on the sagittal FST2W MR image. The appearances are consistent
with plantar fasciitis and partial tearing of the origin of the fascia.
373
Calcaneus Plantar fascia
• Figure 244-3 Longitudinal ultrasound image demonstrating the

insertion of the plantar fascia on the calcaneus.
245 The Windlass Test for Plantar Fasciitis
The plantar fascia plays an important role in stabilizing the

calcaneus and the metatarsal heads when walking and
running during the terminal stance when the heel is off the
ground and the toes are in dorsiflexion. This is because
dorsiflexion of the toes tightens the plantar fascia around
the convex surface of the metatarsal heads, producing the
windlass effect (Fig. 245-1). To perform the windlass test
for plantar fasciitis, the patient is placed in the supine posi-
tion with the knee flexed to 90 degrees and the affected
foot in neutral position. The examiner then stabilizes the
head of the first metatarsal and dorsiflexes the great toe
(Fig. 245-2). The test is positive if it reproduces or exacer-
bates the patient’s pain.
• Figure 245-2 To perform the windlass test for plantar fasciitis, the
patient is placed in the supine position and the examiner then stabilizes
the head of the first metatarsal and dorsiflexes the great toe. The test
is positive if it reproduces or exacerbates the patient’s pain.
Plantar fascia
Great toe
dorsiflexes
Arch
height increases
Plantar fascia
tightens
• Figure 245-1 The windlass effect. Note how dorsiflexion of the toes tightens the plantar fascia.
375
246 The Mulder Sign for Morton Neuroma
Morton neuroma is one of the most common pain syn- the tender area remains over the metatarsal heads, with
dromes that affects the forefoot. Morton neuroma is char- Morton neuroma the tender area is localized to only the
acterized by tenderness and burning pain in the plantar plantar surface of the affected interspace, with paresthesias
surface of the forefoot, with associated painful paresthesias radiating into the 2 affected toes. The patient with Morton
into the affected 2 toes. This pain syndrome is thought to neuroma often exhibits an antalgic gait in an effort to
be caused by perineural fibrosis of the interdigital nerves. reduce weight bearing during walking.
Although the nerves between the third and fourth toes are Plain radiographs are indicated in all patients who
most commonly affected, the second and third toes and, present with Morton neuroma to rule out stress fractures
rarely, the fourth and fifth toes can be affected. The patient and to identify sesamoid bones that might have become
often feels that he or she is walking with a stone in his or inflamed. On the basis of the patient’s clinical presentation,
her shoe. The pain of Morton neuroma worsens with pro- additional testing might be indicated, including complete
longed standing or walking for long distances and is exac- blood count, sedimentation rate, and antinuclear antibody
erbated by improperly fitted or padded shoes. As with testing. Magnetic resonance and ultrasound imaging of the
bunion, bunionette, and hammer toe deformities, Morton foot with contrast enhancement will readily identify Morton
neuroma is most often associated with the wearing of tight, neuroma and is also useful if joint instability, occult mass,
narrow-toed shoes. or tumor is suspected (Figs. 246-2 and 246-3). Radionucle-
On physical examination, patients who suffer from otide bone scanning may be useful in identifying subtle
Morton neuroma will exhibit a positive Mulder sign. To stress fractures of the metatarsal bones or fractures of the
elicit the Mulder sign, the examiner has the patient assume sesamoid bones that might be missed on plain radiographs
the supine position on the examination table. The pain of of the foot.
Morton neuroma can be reproduced by firmly squeezing
the 2 metatarsal heads together with 1 hand while placing
firm pressure on the interdigital space with the other hand
(Fig. 246-1). In contradistinction to metatarsalgia, in which
B
• Figure 246-2 A and B, Consecutive coronal T1W magnetic reso-
nance images of a low signal intensity Morton neuroma (arrows) arising
• Figure 246-1 Mulder’s maneuver is accomplished by firmly squeez- between the third and fourth metatarsal heads. (From Waldman SD,
ing the 2 metatarsal heads together with 1 hand while placing firm Campbell, RSD: Imaging of pain, Philadelphia, 2010, Saunders/
pressure on the interdigital space with the other hand. Elsevier, p 460, fig 179-2.)
376
CHAPTER 246 The Mulder Sign for Morton Neuroma 377
MT
MT
• Figure 246-3 Transverse ultrasound image of an echogenic inter-

metatarsal bursa (arrows) arising between the metatarsal necks (MT).
The mass was easily compressible with sonopalpitation. (From
Waldman SD, Campbell, RSD: Imaging of pain, Philadelphia, 2010,
Saunders/Elsevier, p 460, fig 179-3.)

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PHYSICAL

STEVEN D. WALDMAN, MD, JD

PHYSICAL DIAGNOSIS OF PAIN: AN ATLAS OF SIGNS ISBN: 978-0-323-37748-5

Copyright © 2016 by Elsevier Inc. All rights reserved.

Library of Congress Cataloging-in-Publication Data

Publishing Manager: Michael Houston

Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to my children—

ring disappear rather than diagnosis anything, as he was in

Odontoid process of axis

• Figure 1-1 Atlanto-occipital unit. • Figure 1-2 Atlantoaxial unit.

Normal Flexion Extension

THE MOBILITY OF THE CERVICAL SPINE THE CERVICAL VERTEBRAL CANAL

The cervical vertebral canal is funnel-shaped, with its

Normal Compressed Flexion

R C4 THE FOCAL DISC PROTRUSION

THE SEQUESTERED DISC

A Diffuse disc bulge B Broad-based protrusion

C Focal disc protrusion D Disc extrusion

• Figure 3-4 Various types of cervical disc degeneration.

• Figure 3-5 Sagittal T2-weighted MRI scan showing significant cer-

• Figure 3-6 T2-weighted, sagittal MRI image in a patient with C3-4

• Figure 3-8 Magnetic resonance imaging of the cervical spine

• Figure 5-2 Plain lateral radiograph of a normal cervical spine. Lines

Palpation of the cervical spine is carried out primarily to

• Figure 6-5 Palpation of a trigger point will result in a positive

• Figure 6-4 Palpation of the posterior cervical spine.

FLEXION AND EXTENSION

the thoracic spine to compensate for a limitation of range

ROTATION AND LATERAL BENDING

• Figure 7-5 Combined computerized tomography and magnetic

• Figure 9-1 Sensory distribution of the C5 dermatome.

• Figure 9-2 C5 myotome integrity testing.

• Figure 10-3 C6 myotome integrity testing.

The concept of diagnosing a problem at a specific neuro-

• Figure 11-3 C7 myotome integrity testing.

• Figure 12-1 Sensory distribution of the C8 dermatome.

• Figure 12-2 C8 myotome integrity testing.

• Figure 13-1 The Spurling test for cervical radiculopathy.

• Figure 15-1 The Hoffmann test for cervical myelopathy.

Axis (C2) transverse

• Figure 16-2 The anatomy of atlas and axis demonstrating the

patient in a comfortable, relaxed sitting position, and the

• Figure 17-2 Anterior-posterior radiograph of the shoulder. 1, greater

Pectoralis major m Teres minor m

Middle glenohumeral lig Post glenoid labrum

Subscapularis m & t Glenoid

Axillary a & Deltoid m

• Figure 17-4 Axial T1-weighted magnetic resonance arthrogram

Coracoid process Articular

• Figure 17-5 Ultrasound anatomy of the glenohumeral joint.

• Figure 18-1 Visual inspection of the shoulder should include evalu-

Longitudinal long head of the biceps tendon view

• Figure 21-1 Internal rotation of the shoulder.

• Figure 22-1 Crossed-arm adduction of the shoulder.

• Figure 23-1 Begin assessment of shoulder abduction by asking

Capsulitis Older than Insidious Deep in ++ ↓↓ ↓↓ + — — — — — Global range

Osteoarthrosis of Older than Insidious Deep in ++ ↓↓ ↓↓ — — — May have — +++ Crepitus

Thoracic outlet Any Usually Neck, — Normal Normal — ++ ++ ++ — — Special