physiotherapy special test .Evidenced based.pptx

by Dr Ammar Kakar. Physiotherapist.

1. Evidenced based Special test : By Dr Ammar kakar pt Lecturer Physiotherapy , Alhamd Islamic University,Quetta  

2. Lumbar region:                           radiculopathy Straight leg raise test(SLR) Wel leg SLR

3. 1)Straight leg raise( leasegue's test): Sensitivity is 91% (that’s why it have high clinical value) Specificity is 26% Procedure: Supine lying position  Passively flexes the leg to 75 degrees  If pain occurs at 30 to 70 *it is positive test then,less than 30* pain is hamstring pain and above 75*pain is from hip or SI joint pain Modification:  Bragards sign: ankle dorsi flexion to put more stretch on sciatic nerve  Neri's sign:  is to maximally flexes the neck to put further pressure on nerve  and make diagnosis  Indication: Lumbar radiculopathy Herniated discs Discogenic disorders  (89% sensitive and 14% specific) tumor

4. DR AMMAR PT

5. 2)well leg raise test/ crossed leg slr : Sensitivity of  28 % Specificity is 90% (that’s why it have moderate clinical value) Procedure: Supine lying patient Raise the well or crossed leg to 60 to 70 *  If pain increases in the affected leg it’s a positive test Pain occurs because the dura matter pushes the nerve root from normal to affected side which further put stress on the affected side nerve root Indication: Lumbar protrusion Discogenic problems

6. 2)Discogenic disorders: Centralization Crossed SLR Slumps test Heel raise weakness Reflex absence (knee and ankle)

7. 1)Centralization: Sensitivity is 40%  Specificity is 94% in discogenic problems  Centralization is decreasing the amount of pain and their symptom return back to normal and restricting it centrally to the spine which is a good sign. Can be occur due to Mckenzi exercises or in any normal positions While peripheralization is the increase of pain , down to leg peripherally which is a bad sign 

8. Centralization  is a clinical marker commonly used in the assessment of patients with spinal pain.  Centralization was originally noticed by Robin McKenzie in 1956, in the treatment of a patient with acute low back pain whose symptoms originating from the spine abolished and/or regressed as a result of an accidental therapeutic position  Since then, it has been one of the key features of the  McKenzie method   as well as other classification systems in the management of  neck  and  low back  pain.   The reverse of centralization, peripheralization, has also been described, as the phenomenon of pain (originating from the spine) spreading distally into the limb. 

9. 3)Slumps test: Sensitivity is s 44-87% Specificity is 23-63% Procedure: Patient sitting position near the edge of the table Flexes the spine anteriorly  Flexes the neck/head anteriorly Simultaneously extend the knee( if pain occurs at only knee extension stop the test and its positive) Dorsiflexes the foot Indication: Herniated disc Active pathology of the spine Dural pathology Stenosis

10. 4) heel raise weakness L5-S1 Sensitivity:14% Specificity:96% Procedure: Patient in standing position Ask him to do Heel raise single/ both=S1 myotome Ask him to walk on toe =S1 myotome //          //             //  heel=L4-L5 myotome //          //           //    inversion walk=L4-L5 myotome //          //           //  eversion=S1 myotome Indication: Problem in the motor nerve root L5-S1 //             //              //            //       L4-L5

11. 5)knee or ankle reflexes: Sensitivity is 14% Specificity is 96% Indication: Discogenic problem  Motor neuropathy mainly  lower motor neuron Procedure : Patient sitting or lying supine Hit reflex hammer on the Achillis tendon or quadriceps tendon    And check for the movement or flicker of the muscle  Compare to reflex grading system for hyper or hyporeflexia 

12. 3) spinal stenosis: Cook rule 3/5 positive findings means  results spinal stenosis Also called cluster of cook  Sensitivity 96% Specificity is 98% if more than 4 findings are positive  Used to diagnose spinal canal stenosis which could be cause due to  Osteophyte formation Joint hypertrophy due to osteophyte  Ligamentum flavum hypertrophy Intervertebral canal narrowing spondylosis  Spondylolesthesis tumors

13. Rules: Age >48 Bilateral symptoms Leg pain worse than back Pain on walking or standing  Sitting relieves pain 

14. 4)Hypomobility: 1)posterior anterior glides(springing test) --- and 95% Procedure : Prone lying position  Palpate the posterior superior iliac spine  Find out the spinous process of L5  Put your thenar eminence on patients  spinous process and give glide PA  And feel the end feel to find out the ROM of the specific vertebrae Do it for the each vertebrae

15. 4)instability: PLET (passive lumbar extension test)=84-90% Aberrant movement sign=17.0-95.2%  Instability catch sign =26.3-85.7% Apprehension sign=18.4-88.1%

16. 1)PLET(passive lumbar extension test) Sensitivity is 84% Specificity 90% Procedure:  Prone lying Passively extend the patient legs 30cms above the Coutch at thigh region Pull the legs to check if any pain ,heaviness or instability occurs or if the patient think that his back will come off Indication : Instability due to  Loss of motor control of erector spine muscles  Ligament tear Weakness Pain Loss of movement rhythm heaviness Come off lumbar 

17. 2) aberrant movement sign: These are some movements that help us to find the lumbar instability  Sensitivity =17.9 Specificity=95.2 Procedure: Standing position Ask the patient to touch the legs by bending forward and touch your toes and check for any aberrant movements Reversal of lumbopelvic rhythm (when you know there is a lock in the lumbar and the pelvic is activated to extend the spine so the rhythm is affected ) Gowers sign or lift off sign or thigh walking( when the patient is walking or extending spine   while putting their hands on thighs) Instability catch sign=26.3%-85.7%=(when you told patient to flexes your spine anteriorly and he follow a lateral deviation or stop moving  during his movement ,pain or weakness) Pain on flexion or extension

18. 5)Lumbar facet syndrome : Kemps test or (lumbar quadrant test) Revels rule /criteria Sensitivity is 70% No specificity Indication: Facet joint problem or syndromes radiculopathy Procedure Patient Sitting on bed Passively move his spine posteriorly then laterally to the affected side  Or   flexes the spine together with circumduction of the spine combined with lateral bending  Findings is ,if pain predominate and restrict till back the condition is more likely to be facet joint  BUT  if the radicular symptoms arise the condition is more likely to be radicular or nerve root prolem

19. 2) Revels rule /criteria Low sensitivity of 17% Specificity of 90% Procedure: Patient Standing  Lumbar flexion Lumbar extension Lumbar side rotation Lumbar bend

20. Constituents: Age more than 65 Pain relieve in recumbent position Pain not increased with cough Pain do not increased from rising from flexion  Pain not increased with forward flexion Pain not increased with hyperextension Pain do not increased with extension or rotation

21. Revels criteria Range of motion Range of motion should be assessed through flexion, extension, lateral bending, and rotation. With facet joint–mediated LBP, pain is often increased while standing, with extension, flexion, (axial)rotation of the lumbar spine, and it might be either focal or radiating. Also sitting and rising from sitting can induce the pain. A supine position can improve the pain. Mostly coughing, straightening from flexion, extension combined with extension and hyperextension doesn’t worsen the pain

22. 6) Spondylolesthesis : Manual hypermobility test=46-81%(palpate the vertebras manually) Slipping by palpation=88-100% Passive lumbar extension test=84-90%

23. 2)palpation or Sill(L) sign: Sensitivity =88% Specificity=100% Procedure: Patient standing Remove the shirt to see and palpate the spine Check for sill sign which look like a 'L' On palpation the vertebras are tendor Indication  Slip disc

24. Passsive lumbar extension test See earlier slides

25. Stork test: Some places say that it is for SI joint test but some say it is for the pars articularis fracture test or spondylolisthesis  and also Procedure : Patient standing  Ask patient to flexes his leg with bend knee  Now extend the spine  If pain starts ,sill sign made on lumbar means the test is positive for spondylolisthesis But if radicular sign arise it mean there is radiculopathy

26. Stork test (Gillet test) Sensitivity=43% Specificity=68% Indication: Sacro iliac joint dysfunction Procedure : Patient standing position Palpate the S2 and PSIS  Put left hand thumb on S2 and right hand thumb on PSIS Now ask the patient to flex the thigh at hip joint till 90 degree with bend knee Check the movement of PSIS in relation to S2  Normally the PSIS will move a bit downward compare to S2 If PSIS do not move or move minimally then test is positive 

27. 4) Hip region: Osteoarthritis criteria: Sensitivity =86% Specificity=75% moderate clinical value Constituents: Presence of Hip pain  3 planes movement restrictions or loss( mainly internal rotation is less than 15* and flexion is less than 115*) Age more than 50  Morning stiffness less than 60 minutes 

28. 4b) Femoroacetabular impingment : 1)  Faddir  (flexion, adduction ,internal rotation)test (or)  femoroacetabular  impingement test (or )Anterior apprehension test  =99-5% Faber test

29. 1) Faddir (flexion, adduction ,internal rotation)test (or)  femoroacetabular impingement test (or )Anterior apprehension test  Sensitivity =99% Specificity=5% weak clinical value Indication acetab ular impingement  Acetabular rim Labral tear Procedure: Supine lying  Flex the hip with bend knee Adduct the hip ,internally rotate the hip Any pain or restriction means positive test Make sure to compaire both side 

30. 2)Faber test(flexion abduction external rotation) (or ) patrick test  (or) figure of four test  Sensitivity=96% Indication : Spams of iliopsoas Femoroacetabular impingement  Sacroiliac dysfunction Procedure Supine lying patient Flex hip with   bend knee Abduct the hip  Externally rotate the hip and put the leg on the opposite thigh Now put pressure on the knee downward  Positive test will elicit pain or decrease ROM( below the level of other leg)

31. 4c) Gluteal tendinopathy : or )greater trochanteric pain syndrome (GTPS): Greater trochanteric palpation=89-46% Add/add-r (adduction test)=20-68.7% Fadder test=30-68.7% Fadder -R test=44-93%

32. 1)Greater trochanter palpation test: Sensitivity=89% Specificity=46% Indication: Gluteal muscles tendinopathy at the region of greater trochanter  Procedure: Side lying position Knee together on side Palpate on the insertion point of tendons(laterally to hip) Pain is the indication of positive test

33. 2)Add/add-r(resistance) (adduction test) Sensitivity =38% Specificity=93% moderate clinical value Procedure: Side lying position on unaffected side With bend knees  erextend the hip so the ASIS become perpendicular to treatment table Hyperadduct the hip passively Ask the patient to abduct the hip isometrically to put pressure on these tendons Positive test will aggravate pain on greater trochanter  Indication: Gluteus medieus and minimus tendinopathy

34. 3)Fader test 4)Fader-R test Fader =30-68% Fader-R=44-93% moderate clinical value Indication: Gluteal tendinopathy GTPS(gluteal tendinopathic pain syndrome) Procedure: Patient supine lying position FADER=Flexion of hip, adduction of hip, external rotation of hip FADER-R=flexion of hip ,adduction of hip, external rotation of hip and ask patient to isometrically do internal rotation If pain aggravate the test  is positive  

35. 4c) Micro instability : Ab-Heer test=(abduction hyperextension external rotation) Sensitivity =80% Specificity =89% moderate clinical value Indication: Micro hip joint instability( problem in stabilizers) Procedure: Side lying on unaffected side  30-45* of abduction Hip  hyperextension  External rotation of hip  Put your other hand on the posterior side of hip joint or head of femur and now anteriorly translate the hip joint Pain on the anterior side of the hip means positive test Before starting your test you should be confident about Beighton hypermobility test

36. 4d)Sacroiliac joint : S.I joint dysfunction Palpation of long dorsal ligament=98% Thigh thrust=88-69% Distraction60-81% Pubic symphysis Pubic symphysis palpation=81%

37. 1)Palpation of long dorsal ligament Sensitivity=98% Procedure: Side lying patient Palpate between PSIS till ischial tuberosity(long dorsal ligament) If the area is tender the test is positive then  Indication: S.I joint dysfunction

38. 2)Thigh thrust test: Sensitivity=88% Specificity=69% moderate clinical value Procedure: Patient supine lying  Flex the hip to 90* with bend knees Slight adduction Put your one hand beneath patient sacrum And other and on the top of knee cap  Now give thrust to the knee top downward 3-4 thrusts If pain increase the test is positive Indication: S.I joint dysfunction

39. 4)distraction test: Sensitivity=88% Specificity=69% Indication Sacroiliac joint dysfunction Procedure: Supine lying patient Put your both hands on the ASIS of patient Now give moderate intensity thrust and gradually increase the thrust Pain aggravate means positive test

40. 4e)pubic symphysis: Pubic symphysis palpation test (99% specificity, 60% sensitivity and 0.89 Kappa coefficient) Palpate the pubic symphysis by fingers and push the pubic symphysis Palpation with the patient in supine of the entire anterior surface of the symphysis pubis elicits pain that stays for more than 5 seconds after the removal of the examiner's hand . 

41. 4f)iliotibial band : Renne's test  Obers test Nobles test

42. 1)Renne's test : Have a weak clinical value Indication: It band syndrome Procedure: Patient standing Ask the patient to flex the knee 30-40* If pain aggravate the test positive

43. 2)Obers test Procedure: Patient side lying position Passively abduct the hip Slight extension Passively slowly bring back the into adduction and light hyper adduction while stabilizing the hip Test is positive when the hip stays in the air and do not touch the table  Indication: Tight tensor fascia Latae Tight spastic IT band

44. 3)Nobles test Have a weak clinical value  because the test Is not specific to IT band  Indication : IT-band syndrome Procedure: Patient in standing position , or supine lying. Ask the patient to actively lung while palpating the lateral and medial epicondyle  Flexes the knee to 30-40* and extend the knee while palpating the medial and lateral epicondyle  If pain occurs the test is positive

45. 4g)Iliopsoas contracture or IT band contracture: Thomas test: Procedure: Patient in supine lying position Flex the knee towards the chest by patient hands Ask patient to feel the stretch at groin Check the extended leg  If it is flexing automatically =iliopsoas contracture If the leg is abducting=IT band contracture

46. 5)Knee region: Meniscus ACL  PCL Chondromalacia/patellofemoral pain Knee OA Infra patellar fat pad pain Patellar dissolocation

47. 1)meniscus test: Thesaly's test=M=89% & L=92%-M=92% & L=89% Dynamic test=85%-90% Mcmmurys test=61%-84% Eges test or weight bearing mcmurry = M=67% &L64%- M=81%-L=(0% Aply's test =58% occuracy rate 

48. 1)Thessaly's test: sensitivity=M=89% & L=92% Specificity=M=92% & L=89% moderate clinical value More specific than aply's and mcmmurys test Indication: Meniscus tear Procedure: Patient standing Ask the patient to flexes the knee to 20*  medially and laterally rotate the knee 3 times each side  Pain is positive sign 

49. 2)Dynamic test: sensitivity=85% Specificity=90% Procedure : Supine lying patient Flexes the knee 60* Externally rotate the femur Internally rotate the tibia and fabula Now move the bended leg outward and inward while palpating Pain on lateral side means a positive test Indication: Lateral meniscus lesion

50. 3) Eage's test: Sensitivity=64-67% Specificity =81-91% Procedure: Patient standing  Leave a gap of 30-40cm in between the feet Now ask the patient to maximally Internally rotate the feet and do squat as much as possible=lateral meniscus For medial meniscus =ask patient to maximally externally  rotate the feet and squat as much as possible If pain,locking ,clicking  aggravate it means positive test Indication: Medial and lateral meniscus tear  Test can be questionable in case of OA ,IT band syndrome and Knee effusion

51. 4) Mcmmury's test: Sensitivity=61% Specificity=84% Procedure: Supine lying patient Passively maximally flexes the knee  Internally rotate passively and extend the knee Flexes the knee and external rotate the knee to put pressure on medial meniscus Any pain , clicking, locking is a positive test Indication: Meniscus lesion  Anterior half of meniscus is not affected in this test

52. 5) aply's test: Ocuracy is 58% Procedure: Patient in prone lying position Fixate the poosterior thigh of patient by your own leg Flexes the knee to 90* Distract the knee distally from shin Now rotate medially and laterally the tibia and check for ROM and pain Now put pressure on dorsum of feet and rotate the knee internally and externally and check for ROM and pain Indication: On distraction if ROM is more than normal with pain indicate ligamentous problem On pressurizing the dorsum of foot if pain aggravate and decreased ROM the lesion is more likely to be meniscus lesion

53. 2)ACL (anterior cruciate ligament) : Lachman's test Sensitivity=85% Specificity=94% Indication: ACL lesion ,the test is positive if tibia translate more than 3mm comparing to other leg You have to do PCL test before ACL because in PCL lesion the knee sag posteriorly which can give more ROM (translation) This test will give ou good result in chronic condition than acute condition because of spams,swelling Procedure Patient lying supine Flexes the knee to 30* Minor external rotation Anteriorly translate the knee  passively

54. 3)PCL lesions: Posterior drawer test Posterior sag sign 

55. 1)Posterior drawer test Sensitivity is 90% Procedure: Patient in supine lying 90* flexes the knee at tibia and fabula 45* flexes the hip Stabilize the feet b your hip Give moderate thrust posteriorly to the knee if soft endfeel or pain aggravate the test is positive  Indication: Pcl lesion

56. 2)Posterior sag sign (or) Step off test: Sensitivity of 79% Specificity of 100% that why it have strong clinical value Procedure: Patient in supine lying Flexes the hip to 45* Flexes the knee90* Now watch the knee from side to check for the sag sign if there is 1cm space in between the tibia and femur the test is positive Modified version of this test is Godfreys sign which is actually the 90* flexion of hip with 90* of knee flexion with the feet on hand of therapist  and check for the sag sign /step sign. Furthermore if you want to confirm the test ask patient to flexes the quads while stabilizing the posterior thigh  where the tibia will translate anteriorly to its own position Indication: PCL lesion

57. Godfrey sign  Sag sign 

58. 4)patellofemoral pain  or  chondromalacia: Clarke's sign or patellar grind test: Positive Likelihood ratio is 0.-7.4 Negative likelihood ratio Is 0.7-11 weak clinical value Procedure : Supine lying patient With normally leg extended  hip extended  Passively hold the superior aspect of the patella and ask the patient to contract the quadricep Do the same procedure at various levels to check any point dysfunction If pain aggravate the test is positive  You can simply palpate the patella called as patellar grind test Indication: Patellofemoral pain syndrome chondromalacia

59. 5)Knee OA criteria: According to "NICE" guidelines Following constituents can diagnosis the Knee OA without radiograph Age over 45 Has activity related pain Morning stiffness less than 30 minuts

60. According to ACR guidelines: Sensitivity is 95% Specificity is 69% According to studies the NICE guideline is more accurate than ACR guideline  The patient of OA have more than 3 positive among these Age>50  Morning stiffness<30 mnts Crepitus on active movement Tenderness on the bony margins of the joint Bony enlargement No palpable warmth 

61. 6)Infrapatellar fat pad syndrome: Hoffas test: Indication: Patellar fat pad pain aggravate due to highly vascularised area which causes nociception Procedure: Patient supine lying Flexes the knee to 60-90 * Palpate the medial and lateral pad of the patella  Repeate the same while knee in extension Pain means positive test

62. 7)patellar disolocation: Patellar aprehension test: Have a positive liklihood ratio of 1.3 and  Negative liklihood ratio of 1=weak clinical value Procedure Supine lyng or sitting position Flexe the knee to 30* and should be In resting on table  Now move the patella laterally to check for disolocation or discomfort  Indication Patient with patellar disolocation will stop you from doing test or actively flexes the quads 

63. 8)Ankle region: Anterior ankle impingement Acute ATFL (anterior talofibular ligament) rupture/chronic ankle laxity Lateral ankle sprain(ATFL,CFL,PTFL) Syndesmosis injury  Achillis tendon rupture Foot over pronation Ankle fracture Peripheral nerve injury Tarsal tunnel syndrome

64. a)Anterior ankle impingement: Forced dorsiflexion test Sensitivity=95% Specificity=88% Procedure: Patient sitting on table while hanging their leg  Grasp the patient calcaneus from posterior side by your hand and thumb at anterolateral side  By grasping the planter surface of the patient by your other hand  Passively dorsiflexes the foot  while applying pressure by your thumb at anterolateral side Positive test will aggravate pain due to impingement of talus and lateral malleolus  Indication Anterior ankle impingement due to synovial hypertrophy ,scar formation , osteophyte , proliferation , calcification ,repetitive trauma ,sports injuries like strain and sprain in the anterolateral gutter

65. Prone lumbar instability test Phalen Dickson  sign Spondylolisthesis( Stork test ,springing test,kemps test)

66. 2)Acute ATFL (anterior talofibular ligament) rupture/chronic ankle laxity Anterior drawer test: Sensitivity:96%                                For AFTL rupture =strong clinical value Specificity:84% Procedure: Sensitivity for chronic laxity is=83%                                                                        Weak clinical value Specificity //       //        //    //  =40% Patient lying supine on bed  30*of knee flexion while putting something beneath the knee  10*-15 of foot dorsiflexion Grasp the planter surface of foot by the anterior surface of your forearm and hold the calcaneum by your fingers Stabilize the tibia and fabula by your other hand  Now translate the foot anteriorly  Test is positive when there is more laxity and pain at the ATFL Indication: ATFL rupture Chronic ankle laxity or instability

67. Alternative way of Ankle anterior drawer test: Procedure: Patient in half sitting  Knee 80-90* flexion Put the roll beneath the foot  Where foot should be 10-15* of dorsiflexion Now stabilize the tibia  And grasp the dorsum of foot by your other hand Now posteriorly translate the ankle joint that the pressurised the AFTL Now note the anterior translation at AFTL or dimple if is there then it would be a positive test

68. 3)lateral ankle sprain(ATFL,CFL,PTFL): Talar tilt test: Sensitivity=50% Specificity=88% Procedure: Patient sitting while hanging leg Planter flexes the feet to 30* Grasp the feet from calcaneum  Invert the foot passively to stress the ATFL(anterior talofibular ligament) Indication: Strain of ATFL , CFL , deltoid ligament and PTFL

69. For CFL(calcaneofibular ligament): Procedure: Same as above  But put the foot in normal anatomical position  Grasp the calcaneus by other hand Now invert the foot for CFL  If any pain or laxity the test is positive

70. For deltoid ligament: Same as above (CFL) But do the foot eversion  passively Any pain or laxity means deltoid ligament problem

71. For PTFL posterior talofibular ligament: Same as above  But put the feet in dorsiflexion passively Now pressurised the foot in max dorsiflexion and do inversion Pain and laxity means positive test

72. 4)syndesmosis injury: Syndesmosis Squeeze test Dorsiflexion external test Rotation stress test

73. Syndesmosis Squeeze test: Sensitivity=30% Specificity=94% Procedure: Patient in supine lying position 90* flexes the knee Now start squeezing the medial and lateral side of the leg together by your both hands Do it proximal then move downward and do the same  Pain is positive sign of test Indication: Rupture of syndesmosis if pain is felt proximally Syndesmosis(interosseous tissue between tibia and fabula) injury or repetitive internal and external rotation

74. 2)dorsiflexion external stress test: Sensitivity=71% Specificity=63% weak clinical value Procedure: Patient sitting while feet hanging downward Passively grasp the patient planter surface by anterior surface of your forearm And stabilize the tibia Now dorsiflex the injured foot  And externally rotate  Indication: Interosseous membrane rupture (the incidence of Interosseous rupture is less 1-24% in ankle injuries ) All the interosseous membrane ,ligaments like anterior inferior tibiofibular ,posterior inferior tibiofibular and transverse ligament are stressed in this test

75. 5)Achillies tendon rupture: Thompson test: Sensitivity =96% Specificity=93% strong clinical value Indication: Achillies tendon rupture Procedure: Prone lying position Feet are out of the edge of table  Squeeze the calves muscle 3 time  If the feet do not dorsiflex the test is positive

76. 6)Foot overpronation : Navicular drop test: Indication: Over pronation of the foot/flat foot Which is caused or secondary to planter fasciitis ,medial tibial stress syndrome and patellofemoral pain syndrome Procedure: Patient in standing position Palpate the navicular tuberosity and mark it Now measure the distance from ground to navicular tuberosity Ask the patient to put weight on the foot  Again measure the distance from ground to navicular tuberosity If the distance from ground to navicular tuberosity is more than 1 cm the test is positive

77. 7)Ankle fracture: Ottawa rule: Sensitivity:99% If 1/3 of these test are positive there is 25-50% of chances of fracture and ask the patient to do X-rays  But if all 3 of these are negative there is 100% of no fracture Specificity:47% Procedure: Patient in sitting/lying position Palpate medial and lateral malleoli start distally and move 6cm upward Palpate navicular bone Palpate 6th metatarsal Ask the patient to walk (no problem if he is limping) Indication: Ankle fracture

78. 8)Peripheral nerve injury: Tinel sign at ankle: Sensitivity=58 Indication: Nerve injury Procedure: Patient in sitting or lying  Tap on the anterior side of ankle for anterior tibial nerve (branch of deep peroneal nerve) Tap of the medial side of the foot near tarsal tunnel for 3> times for posterior tibial nerve  Any tingling ,paraesthesia means positive test

79. 9)tarsal tunnel syndrome: Triple compression stress test: Sensitivity =86% Strong clinical value Specificity=100% Indication : Tarsal tunnel syndrome posterior tibial nerve and its branches  Procedure: Patient in semi sitting position Leg and foot in resting position Plantarflex the foot passively max  And maximally inversion Palpate the tarsal tunnel  near to medial malleoli for at least 30 seconds If paraesthesia and pain occur it means the test is positive

80. 7)shoulder region: Tendon tests Impingement test Labral tear

81. a)tendon test : Speed test=90-13% Yergansons test=32-88% Internal rotation lag sign=92-100%

82. A)Speed test=90-13% Procedure : Patient in standing Supinate the forearm Elbow extended Ask the patient to flexes the shoulder till 90* Examiner isometrically put downward pressure and the patient resist it  Ancient way of performing this test is  Flexion of the shoulder while examiner resist it  Indication: Firstly it is use for long head of bicep tenosynovitis but afterward it become the test for bicep pathology Positive test will give symptoms of pain in bicipital groove or if in shoulder it is pain related to superior Labrum from where the tendon of bicep originate= labral tears

83. B) Yergason's test=32-88% Indication: Humeral transverse ligament lesion Bicep tendon pathology Slap lesion  Procedure: Patient standing 90* flexes the elbow  Supinate the forearm  Now therapist should resist forearm  Ask the patient to isometrically flexes the elbow Simultaneously Palpate  tip of the shoulder where transverse bicipital ligament is present if it is popping out of the groove test is positive  If pain in tendon =bicipital tendon pathology If pain in shoulder=SLAP lesion

84. C)internal rotation lag sign: 100-84% Indication: Subscapularis  muscle tear Procedure: Patient in standing position Extend the arm at shoulder Internal rotation with flexion of elbow at posterior side of spine Now passively  externally rotate the arm and hold it Release the arm of patient simultaneously ask patient to hold the position If the patient is unable to hold the position test is positive 

85. D) lift off sign: 92-100 various Authers give various specificity and various sensitivity  Indication: Lesion of subscapularis  Strength of subscapularis muscle Procedure: Patient in standing position  Extend the arm at shoulder joint Internally rotate the arm  Now ask the patient to lift off the arm from back If patient do it than there is no lesion of subscapularis  If the patient lift of the arm isometrically resist the arm to check the arm 

86. f)impingement test: Jobe's test=74-30% Yoakum's test=64.3-96% Neer's test=72-60 Hawkins's Kennedy test=63-62% Post impingement=75-85%

87. A)Jobe's test: 74-30% Indication: Subacromial impingement Procedure: Patient in standing Ask patient to elevate the arm In scapular angle ( scaption ) Internally rotate the arm Elbow extended thumb following downward Isometrically hold the arm and push it downward Any pain at shoulder is positive sign 

88. Full can test: rotator cuff tear(suprascapular tear)

89. Yoakum's test 79-40 for subscapularis lesion 80-30 for subacromial and subdeltoid bursitis Procedure: Patient sitting position Make arm in scarf wearing position(flexion of shoulder, horizontal abduction of shoulder ,flexion of elbow ,minor internal rotation) Ask patient to flexes further the shoulder after the above positions Patient with pain is positive sign Indication: Subscapularis muscle lesion Subacromial and subdeltoid bursitis

90. c)Neer's test: 72-60 Procedure: Patient in sitting position Stabilize the posterior side of spine of scapula Flexes the arm of patient actively  Pain means positive test Indication: Subacromial impingement 

91. d) Hawkins's Kennedy test= Hawkins's Kennedy test=63-62% Procedure: Patient in sitting position 90* flexion of shoulder 90* flexion of elbow  90*Internal rotation Stabilize the shoulder from posterior side  Now passively further internally rotate the arm  Pain means positive test Indication: Subacromial impingement( syndrome due to coracoacromial ligament and the anterior 1/3 of the acromion)

92. E) Post impingement sign= 76-85% Procedure: Patient supine lying Abduct the shoulder to 100* Extend the shoulder to 10* Support the arm at elbow and at wrist Passively Externally rotate the forearm 80-90* Indication: Rotator Cuff tear  Internal Impingement  in between supra and infraspinatus with superior aspect of glenoid Labrum  (greater tuberosity of humorous +articular surface of rotator cuffs +posterior superior glenoid {when the shoulder is abducted and eternally rotated} Labrum tear 

93. 5)Labral test: Bicep load test=90-10% Crank test=46-73%

94. Bicep load test=90-10% Procedure: Patient in supine lying position Abduct the shoulder to 90* Flex the elbow to 90* Supinate the forearm that the wrist is facing patientward Passively externally rotate the elbow til apprehension Now ask the patient to load(contract) the bicep  Pain or apprehension means positive test Indication: Slap lesion

95. Crank test=46-73% Procedure: Patient in supine lying  160*shoulder elevation in axial plane 90* elbow flexion Now passively load the arm near bicep toward the axial plane Passively internally rotate and then eternally rotate the arm to impinge the torn Labrum Positive test will aggravate pain Indication: Labrum tear

96. 5)Cervical region: Ultt=97-22% Positive distraction test=44-90% Positive spurling test=50-83%

97. A)ULTT(upper limb tension test)=97-22% There are four ULLTs  for each nerve Median nerve ,anterior interosseous nerve (C5-C7) Median nerve ,axillary nerve ,musculocutaneous nerve Radial nerve  Ulnar nerve (C8-T1) Indication radiculopathy

98. ULTT 1 : median nerve ,ant interosseous nerve ,(C5-C7) Procedure: Patient supine lying Abduct shoulder to 90* Flex the elbow to 90* External rotation Extend wrist and fingers Slowly extend the elbow until symptoms provokes Furthermore: to provoke symptoms Depresses the shoulder  Laterally bend the head 

99. ULTT2: median nerve ,axillary nerve  ,musculocutaneous nerve: Supine lying  Depress the shoulder by your thigh  Abduct the arm to 10* Flex the elbow to 90* Supinate the forearm Extend the finger and wrist Slowly   extend the elbow until symptom provoked Furthermore Laterally bend the head 

100. ULTT3: Radial nerve  Supine lying patient  Depress the shoulder  10* abduction of shoulder Flex elbow 90* Pronate the forearm Flex the fingers Extend the elbow passively until symptoms provoked Furthermore  Laterally bend the neck 

101. ULTT4:Ulnar nerve C8-T1 Supine lying  Depress the shoulder 90* abduction of shoulder Pronate forearm Extend finger and wrist Go into lateral rotation Slowly bring his fingers till ears Furthermore: Laterally bend the neck

102. Positive distraction test=44-90%(M) Indication: Cervical radiculiopathy Procedure: Supine lying Grasp the occiput of patient  And distract it longitudinally Positive test will reduce the symptoms

103. C)Positive spurling test=50-83% Procedure: Patient in sitting position Extend the neck  Laterally bend the neck to the affected side Axial load the neck  Indication: Cervical radiculopathy(spondylosis , lysis ,  lesthesis  , itis,etc )

104. Upper cervical instability: Sharp persuer test =69-98% Cervical flexion rotation test=90-91% (S) Posterior anterior glide test=100-41%

105. Sharp  persuer  test =69-98% Indication: It show transverse ligament rupture/lesion/instability which is fixed into odontoid process of 1st vertebrae Procedure: Patient in sitting position Head in neutral position Hold the head of patient from frontal area And other hand on C2 vertebrae 10-20* flex the head  Now anteriorly translate the head simultaneously hold it from anterior side  Any pain ,radicular symptoms at both sides and more laxity positive test

106. b)cervical flexion rotation test:91-90%(S) Indication: Cervicogenic headache (91-90%) Cervical joint problems Cervical instability ROM Procedure: Patient in supine ly ing   Flex the head 30-40* or max  Laterally rotate the head once on the left and once on the right  Decrease ROM ,pain ,visual defects means positive test

107. Facet joint dysfunction: Spurling test=60-92% (see earlier slides) PA unilateral hypomobile =79-82%

108. PA unilateral hypomobile =79-82% PIVM(passive intervertebral assessment of mid cervical spine) Indication: ROM End feel Pain provocation Procedure: Supine lying position Stabilize the occiput by one hand Hold and stabilize the spinous process of the C7 vertebrae If you want to observe the C2-C3 joint simply stabilize the C3 spinous process Now rotate your upper hand (occiput)in left rotation to check the mobility left side's facet joints  And then rotate it to right side to check the Mobility of the facet joints of right side

109. 6)Acromioclavicular joint: Obrien's test=41-100%--95-97% Resisted AC joint extension test =72%-85% Paxino's test=80%-50%

110. Obrien's test=41-100%--95-97% Procedure: Patient in standing position Flexes the arm at shoulder joint till 90* Abduct it to 20* Extended elbow Fully supinate the arm and ask patient to resist it isometrically Then fully pronate the forearm and ask the patient to resist it isometrically Most importantly ask the patient to pin point the pain  Pain at AC=ac joint dysfunction While pain at posterior side of shoulder is labrum pain Indication: Labrum tear A.C joint dysfunction

111. Resisted AC joint extension test =72%-85% Indication: A.C joint dysfunction Procedure: Patient in standing or sitting position Flex the shoulder 90* Internally rotate it to 90* Ask patient to resist horizontal adduction isometrically Any pain indicate positive test 

112. Paxino's  test=80%-50%: Procedure: Patient in sitting position Arms ,head ,legs in neutral position Just put your thumb on the posterior surface of the shoulder And index finger of the other hand on the shaft of clavicle proximally Now apply anterosuperior direction pressure by your both fingers at that region Pain is the sign of positive test Indication: AC joint dysfunction

113. 7)Elbow region: Tendon: Millis test(ECRBS,ECRI)=88% Golfers elbow =85-90% Instability Moving valgus test =100-85% Chair push up test =88%

114. Tendon test: Milli's test=88% Procedure: Patient in standing position Hold the posterior side of humerus distally  Pronate the forearm Extend the wrist  Simultaneously extend the elbow  Indication: Strain of  ECRB (extensor carpi radialis brevis) ERCL(extensor carpi radialis longus)

115. B)Golfer's elbow:(85-90%) Procedure: Patient in standing position  Grasp the posterior side of the humerus distally  Palpate the medial epicondyle Supinate the forearm Extend the elbow passively Positive test will increase pain  Indication: Medial epicondylitis

116. 2)Instability= Moving valgus test:100-75% Chair push up test=88%

117. A)Moving valgus test:100-75% Procedure: Patient in sitting position Abduct the shoulder 80* Flex the elbow full Now passively apply medial torque towards the elbow At forearm Extend the elbow passively  and  quickly to 30*  Ask patient about the arc of pain(70-120*)this arc is called share angle Indication: MCl lesion (the pain should not be sudden in nature(

118. Chair push up test=88% stand :up test Procedure: Patient sitting on a chair which have handles  Grasp both the handles of the chair  Using patient body weight push upward or axial load  The  positive test will cause pain ,subluxation , dislocation of posterolateral side of elbow(PLII) Indication: Posterior lateral instability  Which may be caused due to LCL tear ,and posterior lateral subluxation of elbow

119. 8)Wrist region: Carpel tunnel syndrome Phallen test=91-88% Tinel sign=53-95% Carpel compression test=87-95% Instability test: Scaphoid shift test  Piano key test Ulnar collateral ligament stress test

120. A)Phallen test=91-88% Procedure: Sitting position Flex the elbow to 90* Internally rotate the arm at shoulder to 90* Put the dorsum of both hands together  Press them actively Indication: Positive test will cause paresthesia at thumb ,index finger, and half of ring finger

121. Tinnel sign:53-95% Procedure Patient in sitting position along hand on table with facing upward Therapist tap of the median  nerve right before flexor retinaculum  Indication: Carpal tunnel syndrome median nerve entrapment

122. Carpel compression test:80-95% Procedure: Patient In sitting position Forearm should be on the table facing upward Compress the thenar and hypothenar eminence for 30 secs Indication: Positive test will cause paraesthesia in the territory of median nerve As carpel tunnel syndrome

123. 2)Instability test:  Scaphoid shift test=69-66% Piano key test=66-68% Ulnar collateral ligament stress test=96-100%

124. Scaphoid shift test (or) Watson test=69-66% Procedure: Patient in sitting position Flex the elbow to 30* Pronate to 90* like handshaking Grasp the scaphoid by the thumb of your left hand Simultaneously stabilize the wrist radius  by the fingers of the same hand Grasp the metacarpal of the patient by your other hand  Do little ulnar deviation (the long axix of scaphoid is aligned with the axis of radius) Do extension of wrist Now during palpating and pressurizing the scaphoid radially deviate the wrist(due to this motion the scaphoid will move toward the direction of movement if it is lax) Indication: Scapholunate ligament rupture Pain at scaphoid region DISI (dorsal intercalated segmental instability)between scaphoid and lunate

125. Piano key test=66-68% Procedure: Patient In sitting  Arm on table Extended elbow Pronated forearm Stabilize the carpels by your one hand And apply pressure to ulna from dorsal side  and counter pressure to radius palmar side  simultaneously (up and down) Indication: Positive test will give information about distal radioulnar joint  More laxity Pain  Swelling (increased ROM, pain)

126. Ulnar collateral ligament stress test=96-100% Procedure: Shake hand  Distal forearm by your other hand Medially deviated the wrist for MCL For LCL hold the forearm distally and  Laterally deviate the wrist by grasping wrist from 5th metacarpal Indication: Lesion or sprain of  MCL LCL

127. Revels criteria :