The Pain Source

Patient Position

• Supine or seated
• Knee flexed to 20-30°

Procedure Steps

• Grab behind the proximal tibia and pull anteriorly (perpendicular to the tibia).
  • Stabilize the femur with one hand (so it doesn’t track forward).
• Perform the same steps on the opposite (unaffected) knee.

Positive Sign / Significance

• Increased anterior translation compared to the other side (or a mushy, soft end-feel) = Anterior cruciate ligament injury

Comments

• When the knee is flexed to 90°, the hamstring tendons and iliotibial band also prevent anterior translation of the tibia in relation to the femur.  Therefore, this Lachman’s test is preferred over the anterior drawer test.

Related Content:

• Ultrasound – Knee Exam Setup
• Ultrasound – Femoral Condyle Cartilage Exam
• Ultrasound – Quadriceps Tendon Exam
• Ultrasound – Iliotibial Band Exam
• Ultrasound – Lateral Collateral Ligament Exam

Patient Position

• Supine (or seated)

Procedure Steps

Supine testing

• Stand to the outside of the patient.
• Drop the leg off the table and flex the knee to 30°.
• Put fingers of proximal hand over the medial joint line.
• Place your hip against the lateral knee and use it as a fulcrum to apply a valgus force at the knee (distal hand at the foot/ankle).
• Compare to the opposite, unaffected side.

Seated testing

• Flex the involved knee to 30°
• Support the medial ankle with one hand
• Apply a valgus force (lateral to medial) at the knee – check for pain
• Put your fingers along the medial joint line while applying the force to feel for gapping or a soft end-feel
• Compare to the opposite, unaffected side.

Positive Sign / Significance

• Significantly increased medial joint space gapping (compared to other side) = Medial collateral ligament tear (grade 3 complete tear)
• Increased medial knee pain with valgus pressure = MCL sprain
  

Related Content:

• Ultrasound – Medial Collateral Ligament Exam
• Acromioclavicular Joint Injection – Technique and Tips
• Pes Anserine Bursitis

Patient Position

• Supine (or seated)

Procedure Steps

Supine testing

• Drop the leg off the table and flex the knee to 30°.
• Put fingers over the lateral joint line.
• Grab the ankle/foot and apply a varus stress to the knee (using the medial knee against the outside of the table as a fulcrum and pushing the ankle lateral to medial).
• Compare to the opposite, unaffected side.

Seated testing

• Grasp the lateral ankle on the involved side of the body
• Flex the knee to 20-30°
• With the other hand, apply a medial-to-lateral varus force against the medial knee

Positive Sign / Significance

• Significantly increased lateral joint space gapping = Lateral collateral ligament injury (grade 3 complete tear)
• Pain over the lateral knee = Lateral collateral ligament sprain

Related Content:

• Ultrasound – Lateral Collateral Ligament Exam

Patient Position

• Seated or standing
• Shoulder elevated to 90° in the scapular plane
• Forearms fully pronated (thumb UP)

Procedure Steps

• Examiner instructs the patient to resist downward pressure on the elbow.

Positive Sign / Significance

• Pain, weakness in shoulder = Supraspinatus tendinitis/tear

Comments

• The supraspinatus is best isolated with the thumb UP (full can test), rather than with the thumb DOWN (empty can test)
• The empty can test is more likely to cause pain, and therefore may not show true weakness of the supraspinatus (due to a tear).
  • The full can test is now thought to be better because of this.

Related Content:

• Empty Can Test
• Diagnosis of Hip Pathology: The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology
• VIDEO: Subacromial Bursa Injection under fluoroscopy
• VIDEO: Cervical Facet Injection
• Speed’s Test

aka. “Supraspinatus Press Test”

Patient Position

• Seated or standing
• Shoulder elevated to 90° in the scapular plane
• Forearms fully pronated (thumb down)

Procedure Steps

• Examiner instructs the patient to resist downward pressure on the elbow.

Positive Sign / Significance

• Pain, weakness in shoulder = Supraspinatus tendinitis/tear

Comments

• The supraspinatus is best isolated with the thumb UP (full can test).
• The empty can test is more likely to cause pain, and therefore may not show true weakness of the supraspinatus (due to a tear).
  • The full can test is now thought to be better because of this.

Related Content:

• Full Can Test
• Diagnosis of Hip Pathology: The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology
• VIDEO: Subacromial Bursa Injection under fluoroscopy
• VIDEO: Cervical Facet Injection
• Speed’s Test

Patient Position

• Seated

Procedure Steps

• Patient’s arm is forward flexed to ~60°, elbow fully extended, and forearm supinated.
• Examiner resists further forward flexion by the patient, by applying downward pressure on the forearm.

Positive Sign / Significance

• Pain over the bicep tendon in the bicipital groove = Bicipital tendinitis or tear (long head of biceps)

Comments

• May also cause vague shoulder pain with a superior labral anterior-posterior tear (SLAP lesion)

Related Content:

• Full Can Test
• Empty Can Test
• Tinel’s Sign at the Wrist
• Phalen’s Test
• Cozen’s Test

Patient Position

• Seated or standing

Procedure Steps

• Forward flexes the affected shoulder to 90°.
• Adduct the shoulder horizontally across the chest

Positive Sign / Significance

• Localized pain over the acromioclavicular joint = Acromioclavicular joint painful osteoarthritis

Related Content:

• Acromioclavicular Joint Injection – Technique and Tips
• Ultrasound-Guided versus Palpation-Guided Acromioclavicular Joint Injections
• VIDEO: Subacromial Bursa Injection under fluoroscopy
• VIDEO: Cervical Facet Injection
• Full Can Test

aka. “Tinel’s Test at the Wrist”

Tinel's Sign at the Wrist

Patient Position

• Seated (or standing)
• Elbow flexed, forearm supinated, and wrist in slight extension

Procedure Steps

• Examiner taps the median nerve as it travels through the carpal tunnel and also just proximal to it [can use reflex hammer or fingers]

Positive Sign / Significance

• Tingling or pain in the median nerve distribution (thumb, index, middle, and half of the ring fingers) = Carpal tunnel syndrome

• Also useful in identifying the most proximal point of nerve regeneration, or the most distal point of nerve degeneration.
• For more details on carpal tunnel syndrome (CTS), click here

Related Content:

• Phalen’s Test
• Ultrasound – Carpal Tunnel Injection
• Ultrasound – Wrist Exam
• Carpal Tunnel Syndrome: A Review
• Full Can Test

Patient Position

Phalen's Test

• Seated (or standing)
• Arms abducted, elbows flexed, forearms pronated, and the wrists fully flexed

Procedure Steps

• Patient is instructed to put the back of both hands together and place them in front of the their chest.
• Hold the position for 30-60 seconds (or until symptoms appear)

Positive Sign / Significance

• Reproduction of median nerve symptoms (pain, paresthesias) into the hand in the median nerve distribution = Carpal tunnel syndrome

Related Content:

• Tinel’s Sign at the Wrist
• Ultrasound – Carpal Tunnel Injection
• Ultrasound – Wrist Exam
• Carpal Tunnel Syndrome: A Review
• Full Can Test

Patient Position

Cozen's Test

• Seated or standing
• Elbow extended, forearm pronated, and the wrist extended.

Procedure Steps

• The patient is asked to keep the wrist extended while the examiner pulls the wrist into flexion.

MODIFICATION (see the video below)

• Note: This is my own modification of the Cozen’s test.  I haven’t seen this written anywhere, or seen any research noting its effectiveness in diagnosis lateral epicondylitis.  From my experience, this modified maneuver is more sensitive.
• Roll up a towel or patient gown, such that it fills up their hands in girth.
• Have the patient grasp the towel firmly with both hands out in front of them.  Then, with their involved side hand, reach over so their firm grasp is with the hand now in flexion (instead of neutral).  With a firm grip with both hands, the patient should now twist the towel backwards into wrist extension with their involved side.

Positive Sign / Significance

• Pain in the region 1-2cm distal to the lateral epicondyle = Lateral epicondylitis (tennis elbow)

Comments

• The extensor carpi radialis brevis (ECRB) is the muscle/tendon most involved.

Related Content:

• Lateral Epicondyle Injection – Technique and Tips
• Lateral Epicondylitis
• Full Can Test
• Empty Can Test
• Tinel’s Sign at the Wrist