List of tests and manoeuvres P-Y

Pattelar apprehension test

Whilst the athlete is sitting, knees extended and relaxed, the patella is pulled laterally by the clinician. The athlete with the dislocating or subluxing patella will be worried that it might dislocate, or the patient may experience discomfort if the patella has been maltracking, and this fear shows on the athletes’ face, which should be watched throughout this test.

Phalen’s test

Tingling, within the first, second, and third fingers, with the wrist held in flexion for 60 seconds, is produced with a carpal tunnel syndrome. Phalen’s and Tinel’s sign have a good specificity but not a high sensitivity.

Piedallu’s sign

The examiner places the thumbs on the posterior inferior iliac spines(PIIS) and asks the patient to raise a knee towards the chest. The PIIS should move downwards on that side and, in the abnormal fixed sacroiliac joint, may elevate. Fixation and elevation of the PIIS may indicate sacroiliac joint dysfunction. However, one must be careful when assuming that we humans are absolutely symmetrical creatures, as too many manipulations to correct a non-painful, probably non-pathological asymmetry can produce ligamentous laxity and further problems. Intra-examiner agreement is only fair in this test.

Pivot shift

A test for cruciate ligament instability. The 20 degrees flexed knee is internally rotated and a valgus force is applied. In the cruciate-deficient knee, the lateral side of the tibial plateau subluxes anteriorly and this is increased by thumb pressure over the proximal fibular head. As the knee is extended, the iliotibial band pulls the subluxed tibia backwards into place with an appreciable jump. An athlete who has pain with this movement may resist the test, in which case this sign can be exposed only under general anaesthetic.

Point sign

When acromioclavicular joint is involved, the athlete points directly at the joint to indicate the source of pain.

Pope’s sign

Flexion contracture of fourth and fifth fingers due to ulnar nerve palsy.

Posterior apprehension test

For posterior subluxation of the shoulder when, with the patient lying supine, the humerus is flexed to 90 degrees and axial pressure is added through the elbow to force the humeral head posteriorly. If this produces a click, or apprehension, and is relieved by external rotation of the humerus, and a feeling of anterior shift of the humeral head when the posterior aspect of the joint is palpated, it is a positive test.

Prone-lying knee flexion(PLKF)

A femoral nerve stretch test, where the patient lies prone and the knee is bent passively. Increased pain in the thigh or the back is a positive test, whilst flexing the hip as well will increase any neural tension. Extension of the hip can produce facetal discomfort, so the knee movement, which stretches the femoral nerve, is the important indicator.

Q angle

Relates to the knee. The Q angle is the angle, whilst standing or lying supine, that is subtended by a line drawn from the femoral head to the centre of the patella, and a line from the central patella to the tibial tuberosity. It is generally accepted that 15 degrees or less of valgus is normal.

Relocation test/Jobe’s test

For the anterior subluxing shoulder. Whilst lying supine, the arm is taken into 90 degrees circumduction, the elbow is flexed to 90 degrees and the shoulder taken into increasing external rotation. If the pain produced by this manoeuvre is reduced by pressure on the anterior humeral head, but worse on release of this pressure, then this is a positive test for anterior subluxation of the shoulder. If the pain is relieved by the anterior pressure then the shoulder may be taken a little further into external rotation and, on release of the restraining hand on the humeral head, will sublux forward, producing sudden pain.

Renne’s test

For iliotibial tract syndrome. Stand on the painful leg, with the knee bent to 30-40 degrees. Pain at the lateral femoral condyle is indicative. Hopping may accentuate the problem. It should be noted that the external rotators of the hip will be affected by this manoeuvre as well and can also refer pain towards the knee.

Reverse pivot shift

For the anterior  cruciate ligament. Start with the athlete lying supine and relaxed, the knee bent and tibia externally rotated. Straightening takes the knee into subluxation and back to location, in full extension. This movement can be appreciated.

Rock onto heels test

An individual displays an inability to perform this manoeuvre when weakness of the tibialis anterior, extensor hallucis and extensor digitorum exist, usually from an L4 to L5 nerve root palsy.

Roos’ test

For thoracic outlet syndrome. The patient sits or stands with the arms abducted to 90 degrees and externally rotated, at which stage the elbows are flexed to 90 degrees, with the shoulders slightly braced. The athlete opens and closes the fingers slowly and steadily for 3 minutes. Drooping of the shoulders, decreasing rate of finger contraction or reproduction of the symptoms is considered positive.

Sacroiliac stress tests

a)      Pelvic spring. Distracting, or compressing the anterior wing of the ilium will produce the opposite effect on the posterior structures. This is thought to be a test for the sacroiliac joint but, quite obviously, when one can reduce some types of pain from this test by supporting the L4/5 segments on the athlete’s hand, then other structures must be involved as well.

b)      MJO. With the patient supine, the hip is flexed and a posterior compression and internal rotation force is applied, in an axial direction, through the femur, by downward pressure through the knee. Pain over the sacroiliac joint is indicative. With the hip in full flexion and the force directed from the region of the contralateral shoulder, the stress is thought to be across the sacrotuberous ligament; mid-range, across the sacroiliac ligaments; and with the knee being tensioned from the direction of the mid-opposite thigh, across the iliolumbar ligaments.

c)      Direct compression of the sacroiliac joint may be painful.

Sag sign

When the knee is flexed at 90 degrees and the athlete is lying supine, the tibia gives the appearance of sliding backwards under the femur. This indicates a posterior cruciate ligament tear. Note that this starting position, therefore, may produce a false-positive anterior draw sign.

Schober’s test

For ankylosis of the spine:

a)      Dorsal vertebrae. A measuring tape is placed on the vertebral prominence and 30cm measured off and marked on the skin; full vertebral flexion should increase this distance by 3cm.

b)      Lumbar vertebrae. Mark up 10cm from the spinal dimples. Full flexion should increase this distance by 5cm, or mark up 10cm and down 5cm from the dimples, when full flexion should be 20cm plus.

Segond’s sign

Avulsion of the lateral or medial collateral ligament of the knee; leaves a small flake of avulsed bone visible on X-ray and scans.

Shaving test

An anterior interosseus nerve neuropathy where the individual cannot put the tips of the first and second fingers together, only pulps, owing to weak flexor digitoris profundus and flexor pollicis longus.

Slocum’s test

A test for rotatory instability of the knee in athletes with large heavy legs. Positive anterior draw fails to tighten in 25 degrees of external rotation.

Slump test

The slump test is a dural and neural stress test. Flexion of the neck and spine, added to a straight leg raise and Laseque’s test, is perforemed in the sitting position. The test is positive if the pain is relieved by neck extension. The interpretation of a positive test, and no relief of pain by reduction of neck flexion, is open to interpretation.

Speed’s test

For bicipital impingement and tendonitis. Resisted flexion, adduction and supination of the humerus, with the elbow extended, produces pain at the shoulder. See Yergason’s test.

Spurling’s manoeuvre

For cervical root entrapment, where extension and rotation of the neck pinches the nerve in the lateral canal of the neck, producing nerve root symptoms.

Steinmann’s test

Similar to McMurray, but the object is to record pain rather than clunks over the joint line. Pain that moves posteriorly with increasing degrees of flexion suggests meniscal pathology. See McMurray test.

Step down test

The athlete stands on a bench or raised dais and steps slowly forwards to the ground. Higher loads can be achieved by jumping down. The clinician compares the left with the right side and observes the tracking of the knee, and also whether the leg can hold the movement. Failure to control the movement indicates weakness, maltracking or pain and will produce an increased force of foot impact. This can be heard as well as seen.

Stork view

For the pelvis. The pelvis is X-rayed with the athlete standing on one leg and then on the other. A shift in the pubic symphysis of over 2mm is significant.

Straight leg raise(SLR)

A neural stress test for lumbar disc and sciatic nerve, but by itself represents tensioning of the nerve roots and sciatic nerve.

Sulcus sign

For shoulder instability. If inferior subluxation is present, a sulcus shows between the humeral head and the acromion when there is downward traction of the humerus.

Syndesmotic(syndesmal) stress test

For syndesmotic disruption between the tibia and fibula, at the ankle. One hand prevents the tibia and fibula from rotating whilst the other forces dorsiflexion of the foot, and then external and internal rotation of the foot.

Terry Thomas sign

The wrist, with widening of the scaphoid lunate gap on X-ray, shows ligamentous damage.

Thomas’s test

For hip contraction. Flex the hip until the lumbar lordosis reduces and the back is flat on the couch. If the contralateral hip is tight, it will have lifted off the couch.

Thomas’s test, modified

This extends the contralateral hip, as in the Thomas’s test, with a straight knee to test psoas contracture. Then, with the hip extended, the knee is flexed as far as it will go to assess rectus femoris tightness. If both have a full range, but the knee moves laterally, it is because the tensor fasciae latae is tight.

Thompson’s test

For ruptured Achilles. First described by Simmonds. With the athlete lying prone, squeezing the calf muscle produces a plantar flexion of the foot if the Achilles tendon is intact, and no movement with an Achilles rupture. Note, however, that too wide a grip of the calf muscle may squeeze the posterior tibialis and produce some plantar flexion movement.

Tinel’s sign

Tapping over a nerve produces pain and tingling, or paraesthesia, distal to the point of pressure. This test is used particularly for the median nerve at the wrist(carpal tunnel) and the posterior tibial nerve(tarsal tunnel).

Trendelburg gait

Whilst standing, the abductors of the hip tighten to support the pelvis. When the contralateral leg is raised, the pelvis should remain parallel or rise on the contralateral side. Lowering or excessive side flexion to the ipsilateral side is positive. The sign occurs with an osteoarthritic hip, stress fracture of the hip and trauma to the abductors.

Valsalva

A dural stress test. Exhalation against a closed glottis, or “popping an ear”, increases intraspinal pressure.

Ward’s triangle

An area of weakness, noted in the trabecular lines in the inferior neck of the femur, that may be the site of a stress fracture – the compression stress fracture.

Watson test

When the wrist is moved into ulnar deviation, the scaphoid bone flexes. Watson’s positive pivot test is performed by holding the poles of the scaphoid between the fingers and then ulnar deviating the wrist. In the normal wrist, the scaphoid can be felt pressing into the finger, but with scapholunate dissociation the scaphoid subluxes with a click and some pain.

Wright’s manoeuvre

The pulse of the abducted and externally rotated arm disappears when the neck is rotated to the opposite side, the shoulders depressed, and a deep breath taken. This may be positive for thoracic outlet syndrome. False positives occur.

Yergason’s test

For bicipital tenditinis, where resisted flexion and supination in the neutral position of the arm are painful over the biceps. See Speed’s test.

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English