List of tests and manoeuvres A-F

Active compression test

A test to display intra-articular shoulder lesions or acromioclavicular joint problems. The standing athlete forward flexes the arm to 90 degrees, with the elbow in full extension, and then adducts the arm 10-15 degrees medial to the sagittal plane of the body and internally rotates it to point the thumb downwards. The examiner applies uniform download pressure on the arm. The manoeuvre is repeated with the palm upwards. The test is positive if pain is elicited in the first manoeuvre and reduced in the second. The acromioclavicular joint sufferer “points” to the top of the shoulder and the labral tear produces pain and clicking “inside” the shoulder.

Adson’s manoeuvre

For arm pain. Abduct the elbow to 90 degrees with the shoulder and add external rotation of the arm. Pain reproduced on looking towards the painful arm equals a possible disc. Pain on looking away, or a decrease in pulse volume, equals a possible thoracic outlet syndrome.

Allen’s test

Pressure is applied at the wrist on both the radial and ulnar arteries to exclude the blood flow and, with the release of one at a time, a flush of the hand occurs as the blood flow returns and indicates whether each artery is patent.

Anterior apprehension test of the shoulder

The athlete faces a mirror. The clinician stands behind the athlete, flexes the shoulder to 90 degrees and externally rotates the shoulder as fully as possible. The clinician then applies pressure on the posterior aspect of the humeral head to increase anterior translation. Apprehension of pain, which can be seen in the reflection of the patient’s face in the mirror, is a positive test for subluxing or unstable shoulder.

Anterior draw test

The knee is flexed to 90 degrees and the tibia rotated internally. The clinician sits on the patient foot so that the distal tibia is fixed. The proximal tibia is then drawn anteriorly. Increased translation is permitted by a torn or ruptured anterior cruciate ligament. The starting position must be noted, as any sag caused by a posterior cruciate rupture will then allow an increased, apparent anterior gliding, and a false positive. Comparison must be made with the other leg.

Anterior translation of the talus can be produced by the clinician restraining the tibia with one hand and then forcing the calcaneum forward with the other hand. Ligamentous strains and talar osetochondral defects produce pain. The amount of anterior draw can be visualized on X-ray by supporting the heel on a block and applying a weight over the tibia. The upper limit of normal translation is 6mm.

Shoulder instability can display increased movement, when the humerus is translated forwards.

Apley’s test

For the knee. Compression and distraction manoeuvres of the tibia are performed on a flexed knee at 90 degrees through to 180 degrees, with the athlete lying prone. Pain only on distraction suggests a ligamentous cause, whereas pain and grinding on compression and rotation suggests meniscal or articular surface damage.

Babcock’s triangle

A triangle that can be imagined on the superior surface of the femoral neck and which lies between the femoral head, the greater trochanter and the inferior surface.

Bayonet sign

A sign indicative of possible pattelar maltrackiing. The patella tendon insertion lies well lateral on the tibia, thus producing a valgus alignment of the patella tendon from the lower patellar pole to its insertion on the tibia, giving the appearance of a bayonet on a rifle.

Beighton – Horan score

A score for ligamentous laxity. Score 1 point for right side and 1 point for left side:

• Little finger extending to 90 degrees
• Hyperextension of the elbow beyond 15 degrees
• Hyperextension of the knee
• An ability to touch the back of the thumb onto the front of the forearm

Score 1 point for:

• Touching the flat of the hands onto the floor

Bowstring sign

The bowstring sign attempts to differentiate between a hamstring lesion and sciatica. The straight leg raise is taken up to the onset of pain, then the knee is allowed to flex until the pain disappears, at which stage pressure is applied to the popliteal fossa to restretch the sciatic nerve. A recurrence of pain suggests sciatica.

Bulge test

A small amount of fluid in the knee may be displayed by compressing one side of the knee to move all the fluid to the other side. The suprapatellar pouch is compressed during this manoeuvre. The opposite side of the knee is then compressed with a stroking movement. Fluid will return again to the first side and is seen as an increasing bulge. Too much fluid, 20 mL or so, will not empty from one side to the other and is palpated by balloting the fluid with one hand and feeling the impulse with the other. A volume of 30mL or more will show as a patellar tap, because increased fluid lifts the patella off the femur, from where it may be pressed down onto the femur but springs out again when the pressure is removed.

Calcaneotibial compression test

Because standing on tiptoe can load the Achilles or compress the posterior structures of the ankle, this test is used to differentiate Achilles lesions from posterior ankle and talar/subtalar lesions. With the patient lying prone, the foot is whipped into passive plantar flexion to impinge the superior surface of the calcaneum against the posterior structures of the ankle. No pain occurs with Achilles lesions as the Achilles is shortened, but does occur if structures at the back of the ankle are damaged.

Chair test

The athlete lies on its back with their feet resting on the seat of a chair. Without help from their arms, they raise their buttocks as high as they can off the ground. A damaged hamstring will cause pain or be weak. The test may be repeated, using one leg at a time or by increasing the number of repetitions. This is also a very good method of strengthening the hamstring without expensive equipment.

Clarke’s test

This is a compression test of the patella to display patello-femoral pain. The clinician compresses the patella in a distal direction and then the athlete contracts the quadriceps. This may produce total inhibition of quadriceps contraction, pain and/or grating under the patella. Clarke’s test is an indicative test, rather than an absolutely positive test, and the test on one side should be compared with the other side as a normal knee may produce positive signs.

Clunk test

Circumduction of the shoulder in full abduction. A clunk or grinding suggests internal derangement.

Congruence angles

These are the angles, measured on X-ray, between the patellar and femoral condyles at 45 degrees of flexion that are used to assess malalignment of the patella.

Cram test

Pressure is applied by the clinician on the sciatic nerve at the popliteal fossa to exacerbate the tensioning of the sciatic nerve, produced by the straight leg raise test. See bowstring sign at the top of the thread.

Crank test

The circumducted arm is moved backwards and forwards between external and internal rotation, and pressure is exerted axially through the arm towards the joint. Pain and clunking suggest possible internal ligamentous disruption.

DOMS

Delayed-onset muscle soreness. Endurance events, eccentric muscle work and muscle overtraining cause muscle stiffness and pain some 24-48 hours after the exercise, which may last 5-7 days. During this time creatinine kinase is raised.

Downing’s sign

The supine leg is flexed at the hip, externally rotated and then straightened. An apparent leg lengthening, registered by the medial maleolus, indicates the sacroiliac joint is mobile. This apparent lengthening reduces with hip flexion, adduction and straightening of the leg. It is not an accurate test but may help to decide whether a sacroiliac joint should be manipulated of sclerosed. The mobile joint does not need manipulationg.

Drop tests for shoulder

The examiner passively abducts the humerus 20 degrees and supports it. The humerus is then passively rotated to 5 degrees less than maximum and the support removed from the arm. Damage to the supra- and/or infraspinatus will not allow the patient to hold this position actively.

The examiner supports the elbow with the shoulder in 90 degrees of abduction and almost full external rotation, with the elbow flexed. The support at the wrist is released, but not that at the elbow. Damage to the infraspinatus is shown by the inability of the patient to hold external rotation.

The humerus is passively extended behind the back to 20 degrees and is 20 degrees abducted away from the body, with nearly full internal rotation. Inability to hold this position is shown by subscapularis weakness.

Duck waddle

This is a test used for subtle meniscal pathology. Moving forward in a full squat position is painful, but an effusion, lack of full extension, pain on full flexion and patellofemoral problems may complicate this test.

Faber’s test

Flexion, abduction and external rotation of the hip, while the ankle is placed on the opposite knee. Groin pain and limited abduction suggest hip or iliopsoas problems. Back pain may be from the sacroiliac joint. This test is very similar to the figure- of- four test.

Facet joint  and sacroiliac joint stress tests

Tests for the facet joint and sacroiliac joint dysfunction are only indicative rather than absolutely diagnostic, as stress tests almost certainly impinge on both elements. One must also remember that, with even a minor disc disturbance, there may well be associated disturbance of the other articular structures, such as the facet joints:

a)      Facet joint rocking. With the athlete lying prone, the ilium is pulled posteriorly, whilst the butt on the other hand holds down the transverse process of L5, thus forcing the facet of the sacrum to be impinged onto the facet of the adjacent L5. This is repeated by rodking L5 into L4,etc. The examiner tests each segment at a time, and then the other side.

b)      Facet joint rolling. If there are no signs of dural tensioning, then rolling the supine patient into a ball, and taking both legs towards first one shoulder and then the other will gap the facet joints – if there is capsular irritation then this will produce pain.

c)      Local palpation. The facet joints lie level with the gaps between the spinous processes, and local pressure about 2cm out may be tender. Rocking the spinous process only shows the dysfunctional level, not the underlying cause.

Femoral stretch

A dural tensioning test for the femoral nerve where the athlete is laid on their side with legs held straight. The upper straight leg is taken backwards to extend the hip; however, as this movement can also extend the lumbar spine, pain produced at this stage may be from the spine and not the nerve. Then the knee is flexed to stretch the femoral nerve, and pain produced in the back or down the front of the thigh that is similar to the athlete’s pain is a positive test.

“Figure-of-four” sign

For popliteal muscle strain. Flex the knee and externally rotate the hip, whilst resting the ankle on the contralateral thigh.

Finklestein’s test

For extensor tenosynovitis of the thumb, where the wrist is ulnar flexed and the thumb passively flexed across the palm. Pain on this manoeuvre, over the dorsum of the wrist, is a positive test.

Fitch catch

The athlete leans backwards, trying to grab the back of one Achilles with the opposite hand. This test provokes greater lumbar extension with some rotation and, plus the one-legged hyperextension test, may be the only tests to hurt with facet joint or pars interarticularis lesions.

Freiberg’s sign

Passive internal rotation of the hip causes pain. Possibly diagnostic for piriformis syndrome; however, the hip joint, sacroiliac joint and trochanteric bursa may also cause pain.

Froment’s sign

A test for ulnar nerve damage where a piece of paper is gripped between the straight thumb and index finger – if the adductor pollicis does not work then the long flexors help and the thumb bends at the proximal interphalangeal joint to maintain the grip. The damage must be proximal to Guyon’s canal to involve the motor branches. Damage at Guyon’s canal at the wrist(sensory branch) will not produce that sign.

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