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Common Orthopedic Tests
Adam’s sign: A patient with scoliosis (lateral
curvature of the spine) when bending over will have no
straightening of the curve and give a “positive” result.
A straightening of the curve would indicate a “negative”
result.
Adson’s sign: The patient is
asked to take and hold a deep breath: The neck is
extended, then the patient is asked to turn his head
from one side to the other side. Downward pressure on
the patient’s arm will cause an obliteration of the
pulse, in which case, the test is positive and indicates
a thoracic outlet syndrome.
Allen’s test: Procedure to test
for occlusion of the ulnar or radial arteries. The
patient makes a tight fist so as to express the blood
from the skin of the palm and fingers, the examiner
makes digital compression on either the radial or the
ulnar artery. If upon opening the hand blood fails to
return to the palm and fingers an obstruction is
indicated in the artery that has not been compressed.
Anterior drawer: With the knee
flexed approximately 90 degrees, the proximal tibia is
pulled forward. If excessive movement is found, the test
is indicative of a tear of the anterior cruciate
ligament.
Apley test: The patient is
placed prone on the examining table and the knee is
flexed 90 degrees. While compressing the knee, the lower
leg is rotated in both directions. If this maneuver
elicits pain it is probable that a meniscal tear is
present.
Apprehension test of the shoulder:
The shoulder is forcefully abducted and externally
rotated. Patients who have experienced either
dislocation or subluxation of the shoulder will become
extremely apprehensive with this maneuver.
Axial compression: The patient
is either sitting or lying and the examiner presses down
upon the top of the patient’s head. Narrowing of the
neural foramen, pressure on the facet joints, or muscle
spasm can cause increased pain and the test may indicate
a pressure upon a nerve and the neurologic level of
existing pathology.
Babinski’s test: Normally, when
the lateral aspect of the sole of the relaxed foot is
stroked the great toe is flexed. If the toe extends
instead of flexes and the other toes spread out, the
test is positive and would indicate upper motor (brain
and spinal cord) involvement.
Bracelet test: In rheumatoid
patients compression of the distal radius and ulna
causes pain.
Brudzinski’s test: Flexion of
the neck causes foot, ankle or thigh flexion in patients
with meningitis.
Chest expansion test: The chest
expansion is measured from maximal exhalation to maximal
inspiration. An expansion of less than one inch is
indicative of forms of arthritis, which can affect the
spine and rib cage, most notably ankylosing spondylitis.
Clonus: The foot is dorsiflexed
by the examiner, eliciting repetitive, uncontrolled up
and down motion of the ankle. A positive test indicates
pressure upon the spinal cord.
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Ely’s test: The patient is
asked to lie prone upon the examining table. The
examiner then flexes the leg upon the thigh, making the
heel touch the buttock. During the flexion, the pelvis
rises from the table to find a positive reaction. The
reaction occurs in inflammatory or traumatic lesions.
Finkelstein’s test: With the
thumb inside the palm, the wrist and hand are ulnarly
deviated, causing pain in the abductor tendons of the
thumb at the radial styloid. A positive result indicates
deQuervain’s tendonitis of the wrist.
Gaenslen’s sign: With the
patient on his back on a table, the knee and hip of one
leg are held in a flexed position by the patient, while
the other leg, hanging over the edge of the table is
pressed down by the examiner to produce hyperextension
of the hip. A positive test will produce pain on the
affected side in the lumbosacral disease.
Goldthwait’s test: (Straight
leg raising test.) Performed with the patient lying
supine, the entire lower extremity is flexed at the hip
with the knee extended and the foot held in a 90-degree
dorsiflexed position. As a result the gastrocnemius and
hamstrings are tensed and leverage is transmitted to the
side of the pelvis being tested.
Hoffman’s signs: The fingernail
of the long finger is pinched and the examiner notes
flexion of the distal phalanx of the digits. The sign is
indicative of pathology affecting the spinal cord in the
cervical region.
Homan’s test: A positive test
will produce discomfort behind the knee on forced
dorsiflexion of the foot and would indicate a thrombosis
in the veins of the calf.
Iliac compression test: Also
called Erichsen’s test. The examiner presses the iliac
crests together. If pain is felt over the joint the
reaction is regarded as evidence of an intra-articular
sacroiliac lesion. Forcible separation of the iliac
crests is more likely to cause pain by stretching the
anterior sacroiliac ligaments when the sacroiliac joint
is affected.
Impingement test: The shoulder
is forcefully abducted or adducted and internally
rotated causing the greater tuberosity to press against
the undersurface of the acromion. A positive test
indicates an impingement syndrome.
Jansen’s test: The patient is
asked to cross his legs at a point just above the ankle.
This motion is impossible when osteoarthritis of the hip
is present.
Lachman test: With the knee
flexed approximately 20 degrees, the proximal tibia is
pulled forward. Excessive motion of the tibia anteriorly
is indicative of a tear of the anterior cruciate
ligament. This is found to be the most accurate clinical
test for tear of the anterior cruciate ligament.
Laguere’s test: Carried out
with the patient’s spine. The knee is flexed and the hip
flexed and abducted. The examiner then presses down upon
the opposite anterior superior iliac spine and at the
knee. The adductors of the hip are put under tension and
the iliac portion of the sacroiliac joint is forced
against the sacral surface. The joint is put under
strain without pulling upon the sciatic nerve and
gluteal structures.
Lasegue’s test: (Bragard’s
test) Flexion of the affected limb’s hip is not painful,
but extension of the knee while the hip is flexed is
painful. Such pain would indicate sciatica and spinal
cord nerve root compression.
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McMurray’s test: As the patient
lies supine with knee fully flexed the examiner rotates
the patient’s foot fully outward and the knee is slowly
extended; a painful “click” indicates a tear of the
medial meniscus of the knee joint. Inward rotation of
the foot with pain indicates a tear in the lateral
meniscus.
Minell’s sign: The examiner
places a thumb over the posterior superior iliac spine
and applies pressure outward and then inward. Pain
experienced during this procedure indicates sensitive
ligaments related to the sacroiliac joint.
Minor’s sign: The method of
rising from a sitting position characteristic of the
patient with sciatica; the patient will support himself
on the healthy side placing one hand on the back holding
the affected leg and balancing on the healthy leg.
Ober’s test: This test for
contracted fascia lata is done by having the patient lie
upon his sound side, his hands grasping the lower flexed
knee to hold the lower hip in full flexion. The upper
thigh is relaxed. The knee on the affected side is then
flexed to a right angle, lifted into a position of
moderate abduction with the thigh in the coronal plane.
When the thigh is relaxed, it remains in abduction if
the fascia is contracted. Normally the knee can touch
the examining table. The test is used in backache or
sciatica to determine whether a contracted fascia lata
or iliotibial tract is the cause of symptoms.
Patellar apprehension test:
With the knee slightly flexed, the examiner attempts to
push the patella (knee cap) in a lateral direction.
Patients who have experienced a subluxation or
dislocation of the patella will become very apprehensive
at this point and attempt to stop the examiner from
completing the test.
Patrick’s test: (Faber) This
test for disease of the hip joint is carried out with
the patient supine. The knee is flexed on the affected
side and the external malleolus placed over the patella
of the opposite left to make a figure 4. Pressure is
then exerted on the flexed knee. A positive reaction
causes pain. When the test is performed in a healthy
individual or in one with sciatica, pain is not
produced. Discomfort is elicited in hip disorders, also
in lesions of the sacroiliac ligaments, at the site
involved.
Phalen’s test: Flexion of the
wrist reproduces the paresthesias and pain of median
nerve compression at the wrist (carpal tunnel syndrome).
The reverse Phalen maneuver involves hyperextension of
the wrist with the resultant median nerve paresthesias.
Pivot shift: This is a test for
anterior cruciate ligament deficiency of the knee and is
performed by grasping the foot in one hand and placing
pressure on the outside of the knee with the opposite
hand. With the foot internally rotated and the lower leg
pulled outward, the knee is flexed and extended. A
positive test is experienced when the joint (clicks) in
and out of place during the maneuver.
Posterior drawer: With the knee
flexed approximately 90 degrees, the proximal tibia is
pushed posteriorly. Excessive movement is indicative of
a tear in the posterior cruciate ligament.
Quadriceps inhibition test:
Pressure is placed over the superior aspect of the
patella and the patient is asked to perform a straight
leg-raising maneuver. Pain and grinding with this
maneuver is indicative of chondromalacia of the patella.
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Slocum test: With the knee
flexed approximately 90 degrees, the foot is placed in
both internal and external rotation for separate test.
The proximal tibia is then pulled forward. Excessive
anterior motion of the tibia indicates rotatory
instability of the knee, either anteromedial or
anterolateral, depending upon the direction of rotation
of the foot.
Straight leg raising: With the
knee extended and the patient supine or seated, the hip
is flexed (with the leg straight). A positive test
results in pain in the sciatic nerve distribution and
suggests a disc herniation.
Supraspinatous isolation:
Strength of abduction of the shoulder is tested by
abducting and forward flexing the arm with the forearms
in internal rotation. This isolates the supraspinatous
muscle, the most common area of weakness in a rotator
cuff tear. If weakness is demonstrated this test is very
suggestive for a rotator cuff tear.
Thomas test: With the patient
supine, the opposite hip from that to be tested is
flexed maximally. With the opposite leg held on the
chest, the degree of flexion found in the hip to be
tested indicates a flexion contracture.
Tinel’s sign: A tingling
sensation in the distal end of a limb when percussion is
made over the site of a divided nerve. It indicates a
partial lesion or the beginning of regeneration of the
nerve.
Toryn’s sign: In sciatica, if
the toe is dorsiflexed the patient will feel pain in the
greater sciatic notch (buttocks).
Trendelenburg test: The patient
standing erect with back to examiner is told to lift one
leg and then the other. When weight is supported by the
affected limb the pelvis on the healthy side falls
instead of rising. A positive test indicates a gluteus
medias weakness or a dislocated hip.
Vanzetti’s sign: With sciatica
the pelvis will always be level in spite of scoliosis,
but in other lesions with scoliosis the pelvis is
inclined.
Villaret’s sign: The great toe
will flex upon tapping the Achilles’ tendon in sciatica.
Waddell test: The patient is
tested for appropriateness of response to tenderness,
axial loading, rotation, straight leg raising in the
seated position, regional disturbances and overreaction.
An inappropriate response in three of the five areas is
very suggestive of functional overlay in patients with
back problems.
Common
Chiropractic Tests and Signs
Bakody: Sign
Procedure: The patient with cervical
radicular pain actively places the palm of the affected
extremity flat on the top of the head raising the elbow
to a height approximately level with the head. The sign
is present when the radiating pain is lessened or absent
by this maneuver.
Significance: Nerve root irritation by
way of cervical foraminal compression.
Synonym: Cervical foraminal
compression test.
Belt: Test
Procedure: The patient with low back
symptomatology in the standing position flexes the
dorsolumbar spine while the examiner notes the amount of
flexion necessary to significantly aggravate the pain.
The examiner then standing behind the patient wraps his
arms around the patient interlocking his fingers
together over the abdomen below the iliac crests while
bracing a hip against the patient’s sacrum. The patient
is directed to flex the spine again to the same degree
as the examiner holds his position immobilizing the
patient’s pelvis.
Significance: If the lesion is pelvic
in nature, flexing the spine with the pelvis immobilized
will not aggravate the discomfort, if spinal in nature,
the pain will be aggravated in both instances.
Synonym: The supported Adam’s test.
Bragard: Sign
Procedure: With the patient supine and
both lower limbs straight and parallel, the whole
extremity on the affected side is flexed on the hip
until the patient experiences pain with the lower limb
held in this position the foot is strongly dorsiflexed.
The sign is present if there is an increase in radicular
pain from this action.
Significance: Peripheral or nerve root
irritation of the sciatic nerve.
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Ely’s: Sign
Procedure: With the patient prone, the
knee is flexed toward the buttock on the same side. The
sign is present when the pelvis rises from the table
somewhat in unison with the knee flexion and the thigh
goes into abduction at the hip joint.
Significance: Rectus femoris and/or
lateral thigh fascia contracture.
Ely heel to buttock: Test
Procedure: This is a two-stage test
performed with the patient prone; in the first stage the
knee is flexed approximating the heel to the opposite
buttock, from this position the thigh is hyperextended.
Significance: 1. In any significant
hip lesion it will be impossible to do the test
normally. 2. In the irritation of the iliopsoas muscle
or its sheath it will be impossible to extend the thigh
to any normal degree. 3. Inflammation of the lumbar
nerve roots will be aggravated with production of
femoral radicular pain. 4. Lumbar nerve root adhesions
will be stretched with the production of upper lumbar
discomfort.
Fajersztajn’s: Test
In unilateral sciatica the examiner
straight leg raises the unaffected limb until it causes
or increases the opposite side radiculitis; if none is
produced by this maneuver, strong dorsiflexion of the
foot is added to the straight leg raising. The
production of radicular pain on the opposite side by
either of these two actions is a positive test.
Significance: Sciatica produced at the
nerve root level is a confirmatory test for a ruptured
disc lesion.
Synonym: Well leg raising test;
crossed sciatic sign; Lasegue contralateral sign.
Gaenslen’s: Test
Procedure: The patient is supine, the
affected side lying close to the edge of the table, the
hip and knee of the non-affected side (if the lower
trunk pain is unilateral) are flexed. The patient is
directed to clasp his hands around the flexed knee and
hold it to his chest. The patient is then brought toward
the side of the table and the opposite lower limb is
extended over the table edge at the hip. The examiner
then applies downward pressure against the clasped knee
and against the knee of the extended hip. Exacerbation
of pain from the pelvis constitutes a positive test.
Significance: The test is specific of
a sacroiliac joint lesion.
Note: The Gaenslen’s test is to
sacroiliac disease what the Babinski sign is to
corticospinal tract disease, but its validity is
compromised with the presence of a hip or knee lesion,
or adhesions of the upper lumbar nerve roots.
Classically the hyperextension movement brings out the
sacroiliac symptomatology, however, with the tremendous
torsion stress that is put into the pelvis through the
sacroiliac joints, if there is any significant lesion on
either side, this maneuver will bring it out, especially
in cases of wide, general bilateral pain.
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Jackson compression: Test
Procedure: The patient is sitting
upright with the examiner standing behind. The patient
is directed to laterally flex the neck and head in an
attempt and without undue discomfort to approximate the
ear on the effected side to the shoulder. The examiner
then clasps his hands over the patient’s head and exerts
downward pressure. An exacerbation of cervical and/or
radicular pain indicates a positive test.
Significance: Nerve root compression.
Kemp’s: Test
Procedure: The test is performed with
the patient either standing or sitting. In the former
position the examiner, standing behind the patient,
while one hand anchors the pelvis and sacrum and with
the other he grasps the opposite shoulder; holding the
pelvis, the shoulder is firmly forced obliquely
backward, downward and medialward. In the latter
position the examiner stands in front of the patient who
is sitting with arms folded across the body and legs
dangling over the examining table. With one hand
stabilizing the pelvis by firmly pressing down on the
thigh, the examiner with the other hand pushes the
homolateral shoulder obliquely backwards putting the
lower spine on the opposite side in a combined position
of rotation, lateral bending and extension as was also
the objective in the standing position. Low back pain
radiating into the lower extremity indicates a positive
test but may have different interpretations.
Significance: In disk protrusion or
prolapse the disc nuclear material may lie in a medial,
lateral or inferior position relative to the nerve root.
In disk material medial to the nerve root, the patient
will lean into the side of the disk compression and the
Kemp test will be primarily positive when leaning away
from the side of the lower extremity dermatogenous pain
and mildly positive when leaning into the side of pain.
In disk material lateral to the nerve root, the relief
position of the patient will be away from the side of
the pain and negative when leaning away. In an
inferiorly placed disk, the patient resists bending to
either side and prefers to stay in a strict flexed
attitude of the lumbar spine.
Note: Local pain in the low back does
not constitute a positive Kemp’s test, but rather is
indicative of a strain or sprain of the posterior
articular facets and their pericapsular tissue. The pain
into the lower extremity will be that of a pattern of
dermatogenous radiation relative to the involved nerve
root being compressed by discal protrusion or prolapse
when the test is positive.
Laguerre’s: Sign/Test
Procedure: With the patient lying
supine, the thigh and knee are flexed to right angles,
the thigh is then abducted and rotated outward much like
the Patrick test except for the heel not approximating
the opposite knee. The head of the femur is forced
against the anterior portion of the hip joint capsule by
this action and when this produces pain the test is
positive.
Significance: The negative value or
what the test does not aggravate is important. Pain will
be elicited in a homolateral hip joint lesion, iliopsoas
muscle spasm or a sacroiliac lesion but not in a lumbar
or lumbosacral lesion.
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Lasegue: Test
Procedure: With the patient supine and
the knee in extension, the examiner with one hand under
the heel to lift and the other hand over the knee to
prevent its flexion, slowly flexes the thigh on the
pelvis to a right angle or ninety degrees. The test is
positive when the straight leg cannot be raised
painlessly to this level because of aggravation of low
back and sciatic pain. The angle of flexion at which
pain occurs as well as the site and degree of pain are
always recorded.
Significance: To many the test is of
no particular diagnostic significance. To some it is of
limited significant value and to a few it is one of the
most important tests in differential diagnosis of low
back radiculopathy. Almost all agree, however, that the
test in and of itself is at best, equivocal. When used
in conjunction with other special orthopedic tests and
signs, or when modified from the classical procedure it
may be a valuable aid. For instance, if the sciatic
neuralgia and foot dorsiflexion increases this pain,
this is evidence of radiculopathy; if pain occurs at
fifteen degrees of straight leg raising before the nerve
roots are stretched, this is evidence of spasmophilia;
if pain occurs at eighty degrees of flexion which is
when the fifth lumbar nerve root is under maximum pull,
this may indicate an L4-5 disk herniation. Thus the test
by itself may signify a diversity of diagnoses. Indeed!
Even its name shows inconsistencies, the test described
by Lasegue was that of hip flexion to ninety degrees
followed by knee extension (The Kernig test). The term
“Lasegue” now has clinical acceptance as being
synonymous with straight leg raising.
Synonym: The straight leg-raising
test, the SLR test.
Lasegue differential: Sign
If in a patient with sciatica, the
examiner elicits pain on flexing the hip with the knee
extended, but flexing the thigh on the pelvis with the
knee flexed produces no sciatic pain, the sign is
present.
Significance: Hip joint disease is
ruled out.
Lasegue rebound: Sign
Procedure: With the patient supine,
arms at the sides and legs straight out, the examiner
performs straight leg raising slowly on the side of the
main complaint; at the point where the straight leg
raising produces muscle resistance as recognized by the
examiner, or pain as indicated by the patient, the leg
is suddenly dropped, without warning, into a pillow or
the examiner’s other hand. When this act aggravates
backache and sciatic pain and increases low back muscle
spasm the test is positive.
Significance: The test is particularly
diagnostic of psoas spasm or irritation, and generally
indicative of an intervertebral disc lesion above the
lumbosacral level.
Synonyms: Lewin’s Lasegue test in
reverse, the drop Lasegue test.
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Lasegue sitting: Test
Procedure: The patient with legs
dangling, is sitting upright on the edge of a table or
chair, which has not backrest. The examiner faces the
patient and usually under the guise of “checking the
circulation,” or feeling the skin or “checking for flat
feet,” extends the patient’s legs below the knee, one at
a time, so that the lower limb from the hip to the foot
is parallel with the floor. In the absence of
radiculoneuropathy the patient should notice no
discomfort by this action.
Significance: Initially the same as
the Lasegue test, the modification of the straight leg
raise in this sitting position, however, has several
other advantages:
1. In the supine position straight leg
raising may be difficult as the patient may squirm and
shift the pelvis making the leg abduct and rotate. 2.
The apprehensive patient may attempt to ward off
anticipated pain and make the test positive sooner than
warranted. 3. In the sitting position the patient faces
the examiner, feels more secure and at ease, is less
likely to even know he is being tested under the various
guises mentioned and thus there was a disarming and
distracting effect. The test is performed mostly with
complete unawareness on the part of the patient in those
suspected of simulating, falsifying or magnifying their
symptoms.
4. The test has excellent objective
value when the examiner is able to determine immediately
the slightest attempt on the part of the patient to
withdraw by leaning back from the induced pain.
Synonym: Sitting straight leg raising
test.
Lindner’s: Sign
With the patient supine, the examiner
standing behind the patient’s head puts both hands in
back of the occiput and enforces head, neck and
dorsolumbar flexion, rounding the trunk into one large
“C-shaped” curve. The sign is present when it aggravates
or reduplicates the radicular pain of the main
complaint.
Significance: Low back nerve root
compression.
Maximum cervical compression: Test
Procedure: The patient, in a sitting
position, is directed to actively bring the ear of the
involved side as close to the ipsilateral shoulder as
possible. From this posture the patient is further
directed to bring the chin as close as possible to the
same shoulder. Eliciting radicular pain on the side of
the lateral flexion and rotation constitutes a positive
test. The test may be repeated passively if there is no
response from active motion.
Significance: Cervical nerve root
compression, lateral flexion combined with the
above-described rotation will narrow the diameters of
the intervertebral foramina as much as anatomically
possible and any significant impingement upon the nerve
roots will be revealed.
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Minor’s: Sign
A method of arising from a chair
whereby the patient grasps both arms of the chair with
his hands, leans forward, jackknifing the thighs and the
dorsolumbar spine so that his head is over the feet.
Thus bringing the elbows into acute flexion the patient
then pushes himself to an upright position by
straightening out the elbows and in this way spares
lower limb effort. The patient may substitute his knees
for chair arms and more or less climb up the thighs
using the same aforementioned movements. Or the patient
may also support himself on the healthy side, placing
one hand on the back, bending the affected side and
balancing on the healthy leg.
Significance: The sign is
characteristic for patients with sciatica.
Ober’s: Test
Procedure: The patient lies on the
side. The side to be tested is superiorward. The
underneath hip and knee are flexed at right angles to
flatten the lumbar spine and to give stability to the
patient. The lower limb to be tested is straight and
parallel with the trunk. The examiner with one hand
gives firm downward pressure over the ilia not allowing
it to move during the test, with the other hand the
examiner grasps the patient’s ankle, abducts and extends
the lower limb. When the hip is fully extended the
examiner allows the straight limb to fall into
adduction. Normally the limb when in a straight line
with the trunk will fall beyond the midline to the
table. If the leg remains more or less passively
abducted and does not fall to the table the test is
positive.
Significance: Abduction contracture of
the hip: Shortening of the iliotibial band, this band
can be easily felt with the examining fingers between
the crest of the ilium and the anterior aspect of the
greater trochanter. In some cases the pain on one side
can be increased by doing the abduction test on the
opposite side. The angle the thigh makes with a
horizontal line parallel to the table represents the
degree of contracture. The sign is present both in the
conscious and comatose patient.
Synonym: Abduction test.
Patrick’s: Test
Procedure: With the patient supine,
the examiner places the external malleolus of the
suspected limb over the patella of the opposite side.
Downward pressure on the thigh is then exerted by the
hand of the examiner. A positive test is revealed when
hip pain, especially in the area of the hip flexors, is
elicited.
Significance: Hip joint disease – the
test mainly antagonizes hip flexor spasm brought on by
an inflammatory lesion.
Synonym: Called the FABERE sign from
the acronym of the maneuvers involved: Flexion,
abduction, external rotation and extension; also called
the Sign of Four test.
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Wright’s: Test
Before this test is given, an Allen’s
test is performed to establish patency of the radial
arteries so it can be determined that Wright’s test was
responsible for the results as opposed to them already
being there from another underlying pathology.
Procedure: The patient is seated
upright with both arms hanging at the sides, the
examiner is behind, facing the patient’s back. With the
examiner palpating the radial pulse, both arms in turn
are abducted to one hundred and eighty degrees actively
and passively, the examiner noting at how many degrees
of abduction the radial pulse on the affected side
diminishes or disappears when compared with the opposite
side.
Significance: Neurovascular
compression of the Axillary Artery as seen in the
Hyperabduction Thoracic Outlet Syndrome.
Note: Many patients have cessation of
the radial pulse upon abduction in the absence of the
Hyperabduction Syndrome, for this reason the
non-affected side is used for comparison. If the
non-affected limb shows radial pulse dampening or
cessation both actively and passively at the same
approximate degree of abduction as the affected side,
the test is not positive for Hyperabduction Syndrome.
Synonym: The Hyperabduction maneuver.
Yeoman’s: Test
Procedure: With the patient prone, the
examiner with one hand exerts downward pressure over the
suspected sacroiliac joint while with the other hand the
examiner maximally flexes the ipsilateral knee and from
this position hyperextends the thigh lifting it from the
table while holding down the pelvis with the other hand.
Pain deep in the sacroiliac joint constitutes a positive
test.
Significance: Strain of the anterior
sacroiliac ligaments. |