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Herbert Frisch

Including Manual Medicine
Diagnostic Techniques

Translated by Terry C. Telger

With 327 Figures

in 709 Separate Illustrations

Berlin Heidelberg New York
London Paris Tokyo
Hong Kong Barcelona
Herbert Frisch, M. D.
Orthopedic Surgeon and Internist
Chairman ofthe Physicians' Seminar Hamm (FAC)
German Society of Manual Medicine
RheinstraBe 30
D-47226 Duisburg

Terry C. Telger
6112 Waco Way, Ft. Worth, TX 76133, USA

Title of the German Edition

Programrnierte Untersuchung des Bewegungsapparates
5. Auflage
ISBN 3-540-56347-4 Springer-Verlag
Berlin Heidelberg New York London Paris Tokyo
Hong Kong Barcelona Budapest

Library of Congress Cataloging-in-Publication Data

Frisch, Herbert. [programmierte Untersuchung des Bewegungsapparates. English] Systema-
tic musculoskeletal examination: including manual medicine diagnostic techniques 1Herbert
Frisch; translator, Terry C.Telger. p. em.
Translation of: Programrnierte Untersuchung des Bewegnngsapparates 1 Herbert Frisch.
5th Aufl. Includes bibliographical references and index.
ISBN-13: 978-3-642-75153-0 e-ISBN-13: 978-3-642-75151-6
DOl: 10.1007/978-3-642-75151-6
1. Musculoskeletal system-Examination. 2. Manipulation (Therapeutics) I. Title. [DNLM:
1. Musculoskeletal System. 2. Physical Examination. 3. Muscular Diseases-diagnosis. 4. Joint
Diseases-diagnosis. 5. Bone Diseases-diagnosis. WE 141 F917p 1993a]
RC925.7.F7513 1994 616.7' 0754-dc20 DNLMlDLC
for Library of Congress 93-30002

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use must always be obtained from Springer-Verlag. Violations are liable for prosecution under
the German Copyright Law.

© Springer-Verlag Berlin Heidelberg 1994

Softcover reprint of the hardcover 1st edition 1994

The use of general descriptive names, registered names, trademarks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.

Product liability: The publishers cannot guarantee the accuracy of any information about
dosage and application contained in this book. In every individual case the user must check
such information by consulting the relevant literature.

Cover: E. Kirchner, Heidelberg

TYpesetting: Appl, Wemding
SPIN 10007761 19/3130 - 5 4 3 2 1 0 - Printed on acid-free paper

This book is a revised, English version of Programmierte Untersuchung

des Bewegungsapparates, my very successful and award-winning book
now in its fifth edition in German. The original publication had a long his-
tory, growing out of an unpublished collection of summaries describing
the most effective and reliable techniques in manual medicine for con-
ducting examinations and treatment.
My experience at courses in manual medicine had convinced me that, in
order for these new methods to be incorporated into daily routine, it
would be necessary to put them in the context of the techniques already
being used to conduct orthopedic and neurologic examinations. Although
the combination of old and new examinations made diagnosis more pre-
cise, it also made it very time-consuming and thus impracticaL It was nec-
essary to develop a comprehensive, logical, and systematic scheme so as to
eliminate redundant and superfluous work. Furthermore, the sequence in
which the tests were conducted had to make it possible to analyze func-
tionally the various factors causing the disturbance. Such a structural
analysis of symptoms associated with the locomotive apparatus is a fun-
damental prerequisite for optimal therapy, and particularly for a specific
application of manual or physical therapies.
The result is the systematic musculoskeletal examination described in this
book. It comprises the components inspection, motion testing, palpation,
neurologic and angiologic tests, and special diagnostic procedures; each
of these has in turn been divided into five subgroups, providing the basis
for the name "5/5 scheme" occasionally used to refer to it. This systemat-
ic musculoskeletal examination combines precision with a shorter exami-
nation time.
This book is the product, first of all, of the knowledge I have gained from
30 years of work as therapist, educator, and head of the Physicians' Semi-
nar in Hamm, part of the German Society of Manual Medicine. It is based,
furthermore, on the experience of colleagues, both in Germany and
abroad, which I both studied in the literature and heard first hand, for ex-
ample through personal contacts with members of the College of Os-
teopathy at Michigan State Universty; this contact always prompted me
to critically reexamine my methods. Several such critical evaluations
based on functional anatomy and neurophysiological function are includ-
ed in the passages on biomechanics.
My gratitude goes to the participants at the Physicians' Seminar in Hamm,
to the staff of Springer-Verlag, and to the translator, Terry Telger, each of
whom has contributed in their own way to preparing an optimal product,
which I hope English-speaking readers will find an interesting enrichment
to the current literature.
H. Frisch

Examination Program

Introduction . . . . . . . 3
Patient-Oriented Aspects. . 3
Examiner-Oriented Aspects 3
Examination According to the 515 Program 4

Structure of the Systematic Examination

Systematic History . . . . . 6
Basic Physical Examination . 6
Inspection. . . . . . . . . . 7
Conduct of Examination 8
Palpation . . . . . . . . . . 8
Conduct of the Examination and Findings 10
Motion Testing . . . . . . . . . . . . . . . . . 11
Conduct of the Examination . . . . . . . . 12
Rationale for the Basic Physical Examination 13
Adjunctive Neurologic and Angiologic Studies ........ ~. 14
Neurologic Studies . . . . . 14
Conduct of the Examination . . . . . . 14
Angiologic Studies . . . . . . . . . . . 14
Adjunctive Special Diagnostic Procedures . 15
Examination Positions . . 16
Body Regions Examined. . . . . . . . . . . 17
Diagnosis . . . . . . . . . . . . . . . . . . . 18
Disease Groups Involving the Musculoskeletal System. 18

Structural Analysis of Function Using the Diagnostic Program 19

Structural Analysis in the Patient History with Reference to Pain 19
Types of Pain from a Structural Perspective 19
Basic Principles in the Analysis of Pain 20
Analysis of Pain During History Taking 20
Joint Pain . . . 20
Muscle Pain . . . . . . . 21
Ligament Pain 21
Bursitis, Tendovaginitis 22
Nerve Pain 22
Vascular Pain . . . . . . 23
Vertebragenic Pain . . . 23
Structurally Specific Findings in the Arthron 24
Examination of the Joint . . . . . . . . . . 24
VIII Contents

Inspection . . . . . . . . . . . . . . 24
Active and Passive Motion Testing 24
Palpation . . . . . . . . 26
Joint Play . . . . . . . . 26
Examination of the Spine 32
Inspection . . . 32
Motion Testing 32
Palpation . . . . 34
Joint Play . . . . 34
Examination of the Muscles. 35
Muscle Groups. . . . . . . 36
Findings of Muscle Examination. 39
Inspection . . . 39
Motion Testing. . 39
Palpation . . . . . 40
Resistance Tests . 41
Examination of the Nerves 42
Inspection . . . . . . . . 42
Active and Passive Motion Testing. 43
Palpation . . . . . . . . . . . . . . . 43
Muscle Tests . . . . . . . . . . . . . 43
Special Neuropathologic Findings During the Basic Physical
Examination . . , . . . . . . . . 43
Inspection . . . . . . . . . . . . . . . . 43
Complex Motor Sequences. . . . . . 43
Spontaneous Muscular Contractions 43
Trophic Disturbances (Chiefly Involving the Hands and Feet) 44
Active and Passive Motion Testing . 45
Active Motion Testing 45
Passive Motion Testing . . . . . 45
Palpation . . . . . . . . . . . . . . 45
Autonomic Nervous Disorders. 45
Nerve Pressure Points. . . . 46
Thickening of Nerve Trunks . . 46
Muscle Tests . . . . . . . . . . . . 46
Differential Diagnosis of Nerve Lesions 46
Symptoms of Nerve Lesions by Location 46
1. Muscular Nociceptive Symptoms (Nociceptive Reaction
of Wolff) . . . . . . . . . . . . . . . . . . 46
2. Symptoms of Peripheral Nerve Lesions. 47
3. Radicular Symptoms . . . . . . . . . . . 47
4. Symptoms of Plexus Damage . . . . . . 48
5. Symptoms Due to Disturbances Involving
the Neuromuscular Junction or Muscle Fiber. . . . . . . .. 48
6. Symptoms of Lesions ofthe Central Neuron
(Central Paralysis) . . . . . . . . . . . . . . . 48
Practical Relevance of the Structural Analysis of Function . 48
How Does the Control and Warning System Function? 48
Proprioception . . . . . . . . . . . . . . . . . . . . . . 48
Contents IX

Stability ... 50
Coordination 50
Nociception . 51
Testing of Irritation Zones. 54
Location of the Irritation Zones or Irritation Points 54
Examination Technique. . . . . . . . . . . . . . . . 55
Diagnostic Implications of Irritation Zone Testing. 57

Basic Examination of the Spine and the Joints of the Extremities

Detailed Introduction
Systematic History . . 61
Interpretation of the History. 62
Current Pain . . . . . . . . 62
1 Location of Pain: What Hurts? Where Does it Hurt? . 62
1.1 Localized Pain (Monoarticular, Monosegmental) 62
1.2 Multifocal Pain (Polyarticular, Vertebral Region
or Entire Spine). . . . . . . . . . . . . . . . . . . 62
1.3 Referred Pain (Muscle Chains, Nerve Pathways,
Vessels) . . . . . . . . . . . 63
1.4 Diffuse Pain. . . . . . . . . . . . . . . . 63
1.5 Unilateral or Bilateral Pain . . . . . . . 63
2 Pain Occurrence: When Does It Occur
and When Did It First Occur? . . . . . . 63
2.1 24-Hour Rhythm . . . . . . . . . . . . . 63
2.2 Periodic Pain (Ovarian Cycle, Seasons, Age) 63
2.3 Episodic Pain (With or Without a Change in Pain
Location) . . . . . 63
3 Nature of the Pain 63
3.1 Intensity. 63
3.2 Character . . . . . 64
3.3 Course . . . . . . . 64
4 What Precipitates on Changes the Pain? 64
4.1 Body Posture . . . . . . . . . 64
4.2 Body Movements. . . . . . . 64
4.3 Other Mechanical Influences 64
4.4 Miscellaneous Influences .. 64
5 Associated Phenomena: What Accompanies the Pain? . 64
5.1 Sensory Disturbances . . 64
5.2 Motor Disturbances . . . 64
5.3 Circulatory Disturbances 64
5.4 Trophic Disturbances .. 64
5.5 Psychological Disturbances 64
Previous Course, General State of Health,
Other Current Diseases . . . . . . . . . . . . . . . . . . 64
1 What Treatments Have Been Given in the Past? 64
2 What Improved or Changed the Pain? 65
3 How Are the Vital Functions? . . . . . . . . . . 65
X Contents

4 When Did Previous Pain Occur Involving

the Spine and Joints? . . . . . . . . . . . . 65
5 What Other Diseases or Disorders Does
the Patient Have Now? . . . . . . . . . . 65
The Basic Physical Examination: Preliminary Information. 65
Exceptions . . . . . . . . . . . . . . . . . . . . . . . . . 65
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . 66
Symbols Used in the Figures on Examination Techniques. 66
Checklist for Joint Examinations. . . . . 67
Checklist for Muscle Examinations. . . . 67
Documentation of Findings Using Symbols 68
Ten Standard Symbols 68
General Symbols 68
Inspection . . . 69
Palpation . . . . 69
Motion Testing. 69
Measurements 70
Joints. . 70
Muscles. . . 70

General Inspection in the Standing Position (A) 71

1 Ordinary Movements . . . . . . . . 72
1.1 Gait . . . . . . . . . . . . . . . 72
1.2 Other Ordinary Movements. 74
2 Posture . . . . . . . . . . . . . . 74
3 Body Contours and Proportions 74
4 Skin. . . . . . . . 82
5 Assistive Devices. . . . . . . . . 82

Examination o/the LPH Region in the Standing Position (AlII) .. 83

1 Inspection (see Generallnspection) . . . . . . . . . . . 84
2 Active and Passive Trunk Movements in Three Planes
(Regional Diagnosis). . . . . . . . . . . . . . . . . . . . 84
2.1 Sagittal Plane: Forward and Backward Bending. 84
2.2 Frontal Plane: Sidebending 87
2.3 Transverse Plane: Rotation 87
3 Palpation of the Pelvic Joints . . . 88
Palpation at Rest . . . . . . . . . . 88
3.1 Pelvic Position, Leg Length Discrepancy. 88
Palpation During Movement - Testing Joint Play in Both SIJs 90
3.2 Standing Flexion Test (SIJ) . . . . . . . 90
Unilateral Joint Play Testing . . . . . . . . . . 91
3.3 Recoil Phenomenon (SIJ), "Spine Test" 91
3.4 Hip Drop Test (Lumbar Spine) 92
3.5 Lateral Shift Test (SIJ) . . . . . 94
4 Tests of Joint Translation . . . . . . . 96
4.1 Traction on the Lumbar Spine. 96
4.2 Compression of the Lumbar Spine 97
5 Muscle Test. . . . . . . . . . . . . . . . . 97
Contents XI

General Examination of the Lower Extremities in the Standing

Position (All) (Supplement to Examination of the LPH Region) . 99
1 Three-Phase Squat. . 100
2 Standing on the Toes. . . . . . . . . . . 100
3 Standing on the Heels . . . . . . . . . . 101
4 Standing on the Outer Edge of the Foot 101
5 Muscle Tests . . . . . . . . . . . . . . . 101

Examination of the LPH Region in the Sitting Position (B/Il) . 103

1 Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 104
1.1 Relaxed and Erect Sitting Posture. . . . . . . . . . . .. 104
1.2 Pelvic Position - Comparison with Findings in Standing 104
2 Active and Passive Trunk Movements in Three Planes
(Regional Diagnosis). . . . . . . . . . . . . . . . . . . . . . . 105
Supplementary SIJ Test for Differentiating Motion Faults
in the SIJ and Lumbar Spine . . . . . . . . . . . . . . . . . 105
Regional Motion Testing ofthe Lumbar (and Thoracic) Spine
in Three Planes with the Pelvis Stationary. . . . . . . . . .. 105
3 Palpation of the SIJ and Lumbar Spine (Segmental Diagnosis) 109
Palpation at Rest. . . . . . . 109
3.1 Pelvic Position. . . . . . . . . . . . . . . . . . . . 109
Palpation During Movement . . . . . . . . . . . . . . . 110
3.2 Seated Flexion Test (for Asymmetric Excursion
ofthe Iliac Spines) . . . . . . . . . . . . . . . . . 110
3.3 Segmental Motion Testing of the Lumbar Spine . 111
4 Tests ofJoint Translation 115
4.1 Traction . . . 115
4.2 Compression . . . 115
5 Muscle Tests . . . . . . . 116
Resistance Tests of the Flexors, Rotators, Abductors,
and Adductors ofthe Hip. . . . . . . . . . . . . . . . . 116

Examination of the LPH Region in the Prone Position (ClIl) . . .. 118

1 Inspection. . . . . . . . . . . . . . . . . . 120
1.1 Pelvic Position and Gluteal Profile 120
1.2 Pelvis-Leg Angle . . . . . . . . 120
1.3 Leg Length Discrepancy . . . . . . 120
1.4 Asymmetric Muscle Contours. . . 120
1.5 Alignment ofthe Vertebral Column. 120
2 Active and Passive Hip and Knee Movements
(Regional Diagnosis . . . . . . . . . . . . .. . . . . . . . . . . 121
2.1 Hyperextension of the Hip Joint
(Extension from the Neutral Position) 121
2.2 Rotation ofthe Hip Joint. . . . . . . . 123
2.3 Flexion, Extension, Rotation of the Knee Joint 123
3 Palpation Field of the Dorsal Pelvis:
Lumbar Joints/Soft-Tissue Diagnosis (Segmental Diagnosis) 124
Palpation at Rest . . . . . . . . . . . . . . . 124
3.1 Palpation Field of the Dorsal Pelvis. . . . . . . . . . . 124
XII Contents

3.2 Test for Functional Leg Length Discrepancy

(Functionally Short Leg) . . . . . . . . . . . . . . . . . .. 130
3.3 Segmental Palpation of the Lumbar Spine (MobilitylPain) 131
3.4 Kibler's Skin Rolling Test . . . . . . . . . . . . . . . . .. 134
3.5 Connective-Tissue Stroke Test . . . . . . . . . . . . . .. 135
4 Tests ofJoint Translation . . . . . . . . . . . . . . . . . . . . .. 135
4.1 Lumbar Spine. . . . . . . . . . . . . . . . . . . . . . . .. 135
4.2 SacroiliacJoints. . . . . . . . . . . . . . . . . . . . . . .. 137
4.3 Hip Joints: Rotation . . . . . . . . . . . . . . . . . . . .. 143
5 Muscle Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 144
5.1 Resistance Tests of the Hip Muscles. . . . . . . . . . . .. 144
5.2 Knee Muscles . . . . . . . . . . . . . . . . . . . . . . . .. 145
5.3 Back Extensors . . . . . . . . . . . . . . . . . . . . . . .. 147
Examination o/the LPH Region in the Lateral Position (D/II) . .. 148
3 Palpation of the Lumbar Spine During Movement
(Segmental Mobility) . . . . . . . . . . . . . . . . . . . . . . .. 149
3.1 Forward and Backward Bending . . . . . . . . . . . . .. 149
3.2 Sidebending. . . . . . . . . . . . . . . . . . . . . . . . .. 149
3.3 Rotation. . . . . . . . . . . . . . . . . . . . . . . . . . .. 152
4 Tests ofJoint Translation . . . . . . . . . . . . . . . . . . . . .. 152
4.1 Hypermobility Test of the SIJ . . . . . . . . . . . . . . .. 152
4.2 Hypermobility Test ofthe Lumbar Spine. . . . . . . . .. 153
5 Muscle Tests (Resistance Tests of Hip Muscles). . . . . . . . .. 153
5.1 Abductors. . . . . . . . . . . . . . . . . . . . . . . . . .. 153
5.2 Adductors . . . . . . . . . . . . . . . . . . . . . . . . . .. 154
Examination o/the LPH Region in the Supine Position (EllI). . .. 155
1 Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 156
1.1 Legs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 156
1.2 Pelvic Position . . . . . . . . . . . . . . . . . . . . . . .. 157
1.3 Vertebral Column . . . . . . . . . . . . . . . . . . . . . . 157
1.4 Abdominal Wall . . . . . . . . . . . . . . . . . . . . . .. 157
2 Active and Passive Motion Testing: Hip and Knee Joints, SIJ,
and Lumbar Spine . . . . . . . . . . . . . . . . . . . . . . . . .. 157
2.1 Hip Flexion . . . . . . . . . . . . . . . . . . . . . . . . .. 157
2.2 Hip Rotation . . . . . . . . . .. . . . . . . . . . . . . .. 160
2.3 Hip Abduction . . . . . . . . . . . . . . . . . . . . . . .. 161
2.4 Knee Joint Screening Tests . . . . . . . . . . . . . . . . . 162
2.5 Differentiation of the LPH Joints: Hip Joint, SIJ,
Lumbar Spine, and Muscles . . . . . . . . . . . . . . . .. 163
3 Palpation Field ofthe Ventral Pelvis . . . . . . . . . . . . . . .. 166
Palpation at Rest. . . . . . . . . . . . . . . . . . . . . . . . . .. 166
4 Tests ofJoint Translation . . . . . . . . . . . . . . . . . . . . .. 169
4.1 Traction and Compression of the Lumbar Spine. . . . .. 169
4.2 Traction and Compression of the Hip Joint. . . . . . . .. 171
4.3 SIJ Springing Test via the Thigh . . . . . . . . . . . . . .. 172
5 Muscle Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 173
5.1 Resistance Tests ofthe Hip and Abdominal Muscles . .. 173
5.2 Shortening Tests . . . . . . . . . . . . . . . . . . . . . .. 176
Contents XIII

Examination of the Thora."'( (Thoracic Spine and Ribs)

in the Sitting Position (BIlll) . . . . . . . . . . . . . . . . . . . . .. 180
1 Inspection. . . . . . . . . . . . 181
1.1 Thoracic Morphology . . . . . . . . . . . . . . . 181
1.2 Respiratory Movements . . . . . . . . . . . . . . 181
2 Active and Passive Trunk Movements in Three Planes
(Regional Diagnosis) . . . . . . . . . . . . . . . . . . . 183
3 Palpation of the Thoracic Joints (Segmental Diagnosis) 184
Palpation at Rest . . . . . . . . . . . . . . . . . 184
3.1 Sternal and Costal Synchondroses
(Sternocostal Joints 2-7), Floating Ribs 184
3.2 Costotransverse Joints. 184
3.3 Segmental Muscles . . . . . . . . . . . . 186
Palpation During Movement . . . . . . . . . . 186
3.4 Segmental Motion Testing of the Thoracic Spine 186
3.5 Segmental Motion Testing ofthe Ribs ("Harp") . 190
4 Tests ofJoint Translation . . . . . . . . . . . . . . . . . 193
4.1 Bimanual Compression of the Thorax in the Frontal Plane 193
4.2 Bimanual Compression of the Thorax in the Sagittal Plane 193

Examination of the Thorax (Thoracic Spine and Ribs)

in the Prone Position (CIlll) . . . . . . . . . . . . . . . . . . . . .. 194
1 Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 195
2 Active Movements: Respiratory Movements (Deep Breathing)
(Regional Diagnosis) . . . . . . . . . . . . . . . . . . . 195
3 Palpation ofthe ThoracicJoints (Segmental Diagnosis) 195
Palpation at Rest. . . . . . . . . . . . . . . . . 195
3.1 Palpation Field ofthe Posterior Thorax 195
Palpation During Movement . . . . . . . . . . 197
3.2 Rib Movements and Intercostal Spaces. 197
4 Tests of Joint Translation 199
4.1 Thoracic Segments 199
4.2 Scapula 199
5 Muscle Tests . . . . . . . 201

Examination of the Thorax (Thoracic Spine and Ribs)

in the Lateral Position (DIlll) . . . . . . . . . . . . . . . . . . . .. 202
3 Palpation of the Thoracic Joints During Movement
(Segmental Diagnosis). . . . . . . . . . . . . . . . . . . . . . .. 203
3.1 Segmental Mobility Testing of the Thoracic Spine. . . .. 203
3.2 Segmental Mobility Testing of the Cervicothoracic1unction
(C6-T3) . . . . . . . . . . . . . . . . . . . . . . . . . . .. 204
3.3 Segmental Mobility Testing ofthe Lower (6th-12th) Ribs 205

Examination of the Thorax (Ribs) in the Supine Position (E/III) .. 207

1 Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
2 Active Movements: Respiratory Movements (Deep Breathing)
(Regional Diagnosis) . . . . . . . . . . . . . 208
3 Palpation of the Ribs (Segmental Diagnosis) . . . . . . . . . .. 208
XIV Contents

Palpation at Rest . . . . . . . . . . . . . . . . . 208

3.1 Palpation Field of the Anterior Thorax. 208
Palpation During Movement . . . . . . . . . . 209
3.2 Rib Movements and Intercostal Spaces. 209
3.3 Segmental Mobility Testing of the Upper (2nd-6th) Ribs. 210
4 Tests ofJoint Translation . . . . . . . . . . . . . . . . 211
4.1 CostalJoints. . . . . . . . . . . . . . . . . . . . . . 211
4.2 Sternoclavicular and Acromioclavicular Joint . . . 211
5 Muscle Test: Test for Shortening of the Pectoralis Major. 211

Examination of the Cervical Spine in the Sitting Position (BN) .. 213

1 Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 214
2 Active and Passive Movements of the Cervical Spine and Head
in Three Planes (Regional Diagnosis). . . . . . . . . . . 214
2.1 Sagittal Plane: Backward and Forward Bending. 214
2.2 Frontal Plane: Sidebending . . . . . . . . . . . 214
2.3 Transverse Plane: Rotation . . . . . . . . . . . 215
2.4 Provocative Testing of the Vertebral Segments
(Modified from de Kleyn) . . . . . . . . . . . . ...... 215
2.5 Provocative Test for Motion Segment Laxness
(Hypermobility). . . . . . . . . . . . . . . . . . . . . . . 215
3 Palpation of the Cervical Spine During Movement
(Segmental Diagnosis) . . . . . . . . . . . . . . . . . 216
3.1 Mobility Testing of the Occiput/Atlas (CO/C1) . 216
3.2 Mobility Testing of the Atlas/Axis (ClIC2). 220
3.3 Mobility Testing of the C2/C3 Segment .. 225
3.4 Mobility Testing of the C3-C5 Segments . 226
3.5 Mobility Testing of the C5-T3 Segments
(Cervicothoracic Junction). 229
4 Tests ofJoint Translation 231
4.1 Traction . . . . . . . . . . . 231
4.2 Compression . . . . . . . . 232
4.3 Tests of FacetJoint Gliding 233
5 Muscle Tests - Resistance Tests of the Cervical Muscles
(Synergists) . . . . . . . . . . . . . . . . . . . . . . . 235

Examination of the Head (Temporomandibular Joints,

Sensory Organs) in the Sitting Position (BN). . . . . . . . . . . .. 238
1 Inspection. . . . . . . . . . 239
1.1 Facial Asymmetries . 239
1.2 Mimetic Activity . . . 239
1.3 Sensory Organs: Eyes 239
2 Jaw Movements and Swallowing 240
2.1 Opening and Closing of the Jaw. 240
2.2 Protraction and Retraction of the Jaw. 240
2.3 Lateral Jaw Movements (Grinding Movements) . 240
3 Palpation Field ofthe Face . . . . . . . . . . . . . . . . 240
3.1 Trigeminal Pressure Points. . . . . . . . . . . . . 240
3.2 Corneal Reflex (First Division of the Trigeminal Nerve) 240
Contents XV

3.3 Pressure on the Tragus. . . . . . . . . . . . 241

3.4 Palpation of the Temporomandibular Joints . . . 241
3.5 Percussion of the Frontal and Maxillary Sinuses . 241
4 Passive Testing of Temporomandibular Joint Motion and Play 241
5 Muscle Tests . . . . . . . . 242
5.1 Mimetic Muscles . . 242
5.2 Masticatory Muscles 243
5.3 Lingual Muscles. 243
5.4 Ocular Muscles. . . 243

Examination of the Cervical Spine in the Supine Position (E/V) . 244

1 Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 245
2 Active and Passive Movements of the Cervical Spine and Head
in Three Planes (Regional Diagnosis) . . . . . . . . . . . . 245
2.1 Forward Bending, Backward Bending, Sidebending,
and Rotation. . . . . . . . . . . . . . . . . 245
2.2 Side-to-Side Head Movement. . . . . . . . . . . . . 245
2.3 Provocative Test for the Vertebral Artery
(De Kleyn's Hanging Test) . . . . . . . . . 247
3 Palpation of the Cervical Spine During Movement
(Segmental Diagnosis) .. 248
3.1 Forward Bending .. 248
3.2 Backward Bending . 248
3.3 Sidebending . . . . 248
3.4 Rotation . . . . . . . 248
4 Tests ofJoint Translation . 250
4.1 Three-Dimensional Traction on All Cervical Segments. 250
4.2 COIC1 Segment: Backward and Forward Gliding
of the Occipital Condyles on the Atlas (Forward
and Backward Nodding) . . . . . . . . . . 250
4.3 COICl/CZ Segment: Combined Movements
in the Craniovertebral Joints. . . . . . . . . . . . . . . .. 250
4.4 Cl/CZ Segment: Atlas Traction . . . . . . . . . . . . . .. 252
4.5 Cl/CZ Segment: Lateral Gliding of the Atlas on the Axis
(HypermobilityTest). . . . . . . . . . . . . . . . . 252
4.6 CZ-C7 Segments: ConvergentlDivergent Gliding
in the Facet Joints. . . . . . . . . . . . . . . . . . . 254
5 Muscle Tests - Resistance Testing of the Cervical Muscles. 255

Examination of the Upper Extremities in the Sitting Position (BIIV)

Shoulder Joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 256
1 Inspection. . . . . . . . . 257
1.1 Shoulder Position. . . . . . . . . . . . . . . . . 257
1.2 Shoulder Contours . . . . . . . . . . . . . . . . 258
2 Active and Passive Movements of the Shoulder Joint. 258
2.1 General Active Tests. . . . . . . . . . . . . . . 258
2.2 Frontal Plane: Abduction!Adduction and Rotation
ofthe Arms . . . . . . . . . . . . . . . . . . . . . . . 259
2.3 Sagittal Plane: Raising the Arms Forward and Behind 262
XVI Contents

3 Palpation Field of the Shoulder. . . . . . . . 263

4 Tests of Joint Translation (Humeral Head) . 267
5 Resistance Testing of the Shoulder Muscles . 269
5.1 Synergists (2x4) . . . . . . . 269
5.2 Differentiating Tests (3x5) . . . . . . . 272

Joints o/the Shoulder Girdle. . . . . . . . . . . . . . . . . . . . .. 277

1 Inspection (See B/Shoulder/Sect. 1) . . . . . . . . . . . 278
2.1 Raising and Lowering the Shoulder Girdle. . . 278
2.2 Advancing and Retracting the Shoulder Girdle 278
3 Palpation Field of the Shoulder Girdle. . . . . . . . . 278
3.1 Palpation of the Shoulder Girdle at Rest . . . . 280
3.2 Palpation of the Shoulder Girdle During Movement 283
4 Tests of Joint Translation - Clavicle and Scapula 285
Sternoclavicular Joint . . . . 285
Acromioclavicular Joint. . . . . . . . . . . . . . 288
Alternative Techniques . . . . . . . . . . . . . 288
5 Resistance Testing of the Muscles of the Shoulder Girdle 291
5.1 Synergists . . . . . . . . . . . . 291
5.2 Scapular Rotators. . . . . . . . 291
6 Examination of the Cervical Spine . . 293

Elbow foint, Upper Arm, and Forearm . . . . . . . . . . . . . . .. 296

1 Inspection. . . ... . . 297
1.1 Joint Position . . . . . . . . . . . . . . . . . . . . . . . .. 297
1.2 Joint Contours . . . . . . . . . . . . . . . . . . . . . . .. 297
1.3 Changes in the Muscle Contours of the Upper Extremity. 299
2 Active and Passive Elbow Movements . 299
2.1 FlexionlExtension . . 299
2.2 Pronation/Supination . . . . . . 299
2.3 Abduction/Adduction
(Collateral Ligament Stability Test ) . 300
3 Palpation Field of the Elbow/Arm . . 300
3.1 Extensor Side of the Elbow . . 300
3.2 Lateral (Radial) Epicondyle. 301
3.3 Medial (Ulnar) Epicondyle 302
3.4 Flexor Side of the Elbow . 304
3.5 Upper Arm and Forearm 305
4 Tests of Joint Translation . . . . 305
4.1 Humeroradial Joint ... 305
4.2 Proximal and Distal Radioulnar Joints. 305
4.3 Humeroulnar Joint. . . . . . . . . . . . 309
5 Resistance Testing of the Muscles ofthe Elbow Joint. 310
5.1 Flexors and Extensors . . 310
5.2 Pronators and Supinators 311

Hand and Finger f oints. . . . . . . 314

1 Inspection . . . . . . . . . . 315
1.1 Shape and Position . . 315
1.2 Contour Changes . . . 316
Contents XVII

1.3 Skin and Nail Changes . . . 317

Skin Changes . . . . . . . . 317
Nail Changes . . . . . . . . 318
2 Active and Passive Wrist and Finger Movements. 318
2.1 Wrist Movements in Two Planes. 318
2.2 Finger Movements in two Planes 319
2.3 Thumb Movements. . . . . 319
3 Palpation Field of the Hand. . . . 320
3.1 Radial Border ofthe Hand. 320
3.2 Ulnar Border of the Hand 322
3.3 Dorsum of the Hand 323
3.4 Palm of the Hand . . 325
3.5 Fingers and Thumb . 327
4 Tests of Joint Translation . 328
4.1 WristJoint (Five Tests) . 328
4.2 IntercarpaiJoints (Ten Tests) . . . . . . 330
4.3 CarpometacarpaiJoint of the Thumb (Five Tests) . 335
4.4 Second to Fifth Carpometacarpal and Intercarpal Joints
(Five Tests) . . . . . . . . . . . . . . . . . . . . 337
4.5 PhalangeaiJoints (Five Tests) . . . . . . . . . . 341
5 Resistance Testing of the Hand and Finger Muscles. . 344
5.1 Wrist Muscles . . 344
5.2 Finger Muscles . 346
5.3 Thumb Muscles. 347

Examination of the Lower Extremities in the Supine Position (Ell)

Hip Joint (LPH Region) . . . . . . . . . . . . . . . . . . . . . . .. 349

Knee Joint, Upper Leg, Lower Leg. . . . . . . . . . . . . . . . . .. 351

1 Inspection: Abnormalities of Shape and Position,
Contours of the Upper and Lower Leg. 352
1.1 Anterior Aspect 352
1.2 Lateral Aspect . . . . . . . . . . 353
1.3 Posterior Aspect . . . . . . . . . 354
2 Active and Passive Motion Testing of the Knee Joint
and Femoropatellar Joint 355
2.1 Knee Joint. . . . . . . . . . . . . . . . . . . . . . 355
2.2 Patellar Tracking . . . . . . . . . . . . . . . . . . 356
3 Palpation Field of the Knee Joint and Lower Extremity 356
Palpable Findings. . . . . . . . . . . . . . . . . . . . 357
3.1 Anterior Side of the Knee (Patellar Region) . . . 357
3.2 Medial Side ofthe Knee (Medial Condyle) . 359
3.3 Lateral Side of the Knee (Lateral Condyle) 361
3.4 Popliteal Fossa . . . . . . . . . . 363
3.5 Upper and Lower Leg Contours . . . . . . 364
4 Tests of Joint Translation . . . . . . . . . . . . . . 364
4.1 Mediolateral and Caudal Gliding Movements
of the Patella. . . . . . . . . . . . . . . . . . . . . . . . .. 364
XVIII Contents

4.2 Traction on the Meniscotibial Joint . 366

4.3 Mediolateral Gliding Movements in the Meniscotibial
Joint (Shear Test) . . . . . . . . . . . . . . . . . . . . . 366
4.4 Anteroposterior Gliding Movements
in the Meniscotibial Joint (Drawer Test) 367
4.5 Mobility in the Superior Tibiofibular Joint. 369
5 Tests of the Menisci and Ligaments. . 369
Testing of the Menisci . . . . . . . . . 370
Testing of the Capsule and Ligaments 371
Examination Technique . . . . . . . . 371
5.1 Test Group: Sagittal Plane (Tests 1-3) 371
Testing of the Menisci . . . . . . . . . 371
Testing of the Capsule and Ligaments. 371
5.2 Test Group: Frontal Plane (Tests 4-7) 372
Testing of the Menisci . . . . . . . . . 372
Testing of the Capsule and Ligaments. 373
5.3 Test Group: Transverse Plane. . . . . 375
Testing of the Menisci .. . . . . . . . 375
Testing of the Capsule and Ligaments 375
5.4 Testing the Posterior Horns of the Menisci
by a Combination of Flexion, Lateroduction,
and Rotation (Test 12) . . . . . . . . 377
5.5 Specific Tests for Rotary Instability. 378

Joints of the Feet and Toes . . . . . . . . . . . 383

1 Inspection. . . . . . . . . . . . . . . . 384
1.1 Shape and Position of the Foot 384
1.2 Contour Changes . . . . . . . . 386
1.3 Skin Changes . . . . . . . . . . 387
2 Active and Passive Motion Testing of the Pedal Joints 387
2.1 Active Movements . 387
2.2 Passive Movements . . . . 388
3 Palpation Field of the Foot . . . . 390
3.1 Medial Border ofthe Foot . 390
3.2 Lateral Border ofthe Foot. 393
3.3 Dorsum of the Foot. 396
3.4 Sole of the Foot. . . . . . 398
4 Tests of Joint Translation . . . . 400
4.1 Inferior Tibiofibular Joint
(Distal Tibiofibular Syndesmosis) . 400
4.2 TarsalJoints (Ten Tests) . . . 400
4.3 MetatarsalJoints (Five Tests) . . . 406
4.4 PhalangealJoints: Five Tests ... 409
5 Resistance Testing ofthe Foot and Toe Muscles. 411
5.1 Foot Muscles 411
5.2 Toe Muscles. . . . . . . . . . . . . . . . . 413
Contents XIX


Special Diagnostic Procedures. 416

Radiography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 417
1 Rules for the Radiographic Examination
ofthe Vertebral Column and the Joints ofthe Extremities. . .. 418
2 Analysis of the X-Ray Image . . . . . . . . . . . . . 418
Practical Approach to the Analysis of X-Ray Films 419
3 Techniques for the Radiographic Examination
ofthe Vertebral Column. . . . . . . . . . . . . . . . 420
3.1 Anteroposterior Projection of the LPH Region
(After Gutmann) . . . . . . . . . . . . . . . 420
3.2 Lateral Projection of the Lumbar Spine .. . . . 426
3.3 Thoracic Spine . . . . . . . . . . . . . . . . . . . 430
3.4 Anteroposterior Projection of the Cervical Spine
(After Sandberg-Gutmann) . . . . . . . . . . . . 431
3.5 Anteroposterior Functional Views of the Cervical Spine
(with Sidebending) . . . . . . . . . . . . . . . . 434
3.6 Lateral Projection ofthe Cervical Spine . . . . 436
3.7 Lateral Functional Views of the Cervical Spine
(Forward and Backward Bending) . . . . . . . 438
3.8 Arlen's Quantitative Technique
for the Functional Evaluation of the Cervical Spine 440

References . . . . . 453

Subject Index . . . 459


The musculoskeletal system - the spine and the gram is required. Such a program may be orient-
joints of the extremities - consists of: ed either toward the patient (complaints,
anatomic structures) or toward the diagnostic
- Mobile sites: joints, intervertebral disks, pubic
tools available to the examiner.
symphysis (material)
- Motivating structures: muscles and tendons
Patient-Oriented Aspects
- Motion-initiating structures: peripheral and The patient's description of his complaints is the
central nervous system (control) simplest and most commonly used guide helping
the physician make a diagnosis on the basis of his
This functional unit of material, force, and con-
experience and the symptoms associated with
trol is known as the arthron (i.e., total joint).
various pathologic states. These complaints can
Each of its components is subject to distur-
be classified as referring to:
bances of form and function, and careful analysis
is needed to determine which component is the - Pain
cause of a disturbance. It is also important to - Morphologic abnormality
establish the nature of the disturbance, i.e., - Functional disturbance
whether it relates to a pathoanatomic (macro-
A somewhat more precise method is to supple-
scopic or microscopic) change in morphology, or
ment the patient's description with information
whether it involves a purely functional (re-
obtained by performing general inspection and
versible) disturbance. Furthermore, a disorder
palpation and correlating the patient's com-
may be congenital or acquired, and it may have a
plaints to specific anatomic structures. An even
traumatic, degenerative, metabolic, hormonal,
more accurate approach is to analyze the func-
inflammatory, or neoplastic etiology.
tion of the structures by motion testing. The
Three basic questions need to be addressed in
anatomic structures of interest are:
the diagnostic process:
- Skin
1. Which part of the arthron is affected? - ·Muscles and tendons
Anatomic joint, muscles and tendons, tendon - Tendon sheaths and bursae
sheaths and bursae, nerve pathways, blood - Joints
vessels, central nervous system? - Neurovascular pathways
2. What is the nature of the disturbance? Trau-
Another factor to be considered in designing a
matic, degenerative, inflammatory, metabol-
diagnostic program is the need for patient coop-
ic, hormonal, neoplastic?
eration during the examination. This coopera-
3. To what clinical entity can the functional dis-
tion should be direct, limited, clearly defined,
turbance be assigned?
and easily comprehended by the patient.
To answer these questions, it may be necessary
Examiner-Oriented Aspects
to perform a number of individual tests and ex-
aminations on the structures of the arthron. If The basic diagnostic tools available to the exam-
these examinations are to be done efficiently iner are his sensory organs. He gathers informa-
and routinely, a standardized diagnostic pro- tionby
4 Examination According

- Listening Examination According to the

- Seeing 5/5 Program (Fig. 1)
- Touching
1. Systematic History. Thjs stage allows for in-
Usually these channels for gaining information dividual adaptation of the basic physical
function concurrently during the examination. examination that follows.
2. Basic Physical Examination. This examina-
Listening. The exchange of information be- tion consists of djagnostic measures that do
tween patient and physician during history tak- not require special instrumentation: in-
ing and during the examination itself (patient's spection, active and passive motion testing,
reports of pain) represents a subjective interpre- palpation, and joint and muscle tests.
tation of objective reality for both the patient 3. Neurologic and/or Angiologic Tests. These
and the physician. tests are necessary adjuncts when the histo-
ry or basic physical examination shows evi-
Seeing. By comparison, visual inspection is more dence of a neurologic or vascular disorder.
objective because it can be subjectively inter- 4. Special Diagnostic Procedures. The nature
preted only by the examiner. and scope of other, more specialjzed diag-
nostic procedures (e.g., radiologic sludies,
Touch. The same applies to the palpation of vis- laboratory studies, bjopsy) depend on the
ible and invisible alterations of form and func- results of the previous stages.
tion. 5. Diagnosis. The preljminary diagnosis is fi-
nalized to the definitive diagnosis on the
The number of examinations should be just suf- basis of the patient's response to trial ma-
ficient to permit an accurate diagnosis. It can be nipulation and any further investigations
reasonably limited by a synoptic interpretation of that may have been requjred.
the various tests and by the sequence of the ex-
aminations. The sequence of the examinations
should take into account all the above-men-
tioned criteria, should be easy to learn, and
should fit into the accustomed routine of a med-
ical examination. Consideration of these aspects
led us to devise a stepwise diagnostic workup
called the 5/5 program, an apt name for this sys-
tematic examination because it consists of five
parts, each of which in turn have five elements.
Examination According 5

Patient complaints Diagnostic tools

5/5 Program


Active and passive


Basic physical
Morphologic examination


Fig. I. The 515 diagnostic program

Structure of the Systematic Examination

Systematic History tion testing. It consists of five sets of examina-


A systematic history in the 5/5 program covers

1. Inspection
the following five items, each consisting of five
2. Active and passive motion testing
individual aspects:
3. Palpation
1. Current complaints 4. Tests of joint play
} Case history 5. Mu cle tests (resistance tests)
2. Previous course
3. Social history
4. Health history } Personal history
Each set of examinations consists of multiple
5. Family history
tests designed to permit a stepwise analysis of the
The first two items furnish basic information on patient's complaints (pain, morphologic change,
the patient's history to provide a guide for the dysfunction). Motion testing, for example, pro-
subsequent basic examination of the spine and ceeds in stages from the complex pattern of com-
the extremity joints. These five items should also bined movements and designated anatomic
be used to update a diagnosis (Gutmann), such joint motions to passive joint play and muscular
as when taking an intermediate history in chron- contraction without articular motion, following
ic cases or performing a follow-up examination the sequence: visible findings, visible and palpa-
after a prolonged period. ble findings, and findings that are palpable
The principal source of information in the basic
physical examination is palpation. Whenever the
Basic Physical Examination examiner touches the patient, he usually gains a
general palpatory impression of skin tem-
perature, moisture, superficial structural chan-
The basic physical examination described below ges, etc. (e.g., with the immobilizing hand during
is a rational approach to performing a basic passive motion testing). Detailed palpation with
functional evaluation of the spine and extremi- the hand or fingertips proceeds systematically
ties. It involves a stepwise analysis of diseases from superficial structures to deeper-lying struc-
and dysfunctions affecting the "arthron," which tures as the examiner attempts not just to differ-
is the complete functional unit consisting of the entiate the skin, subcutaneous tissue, muscles,
anatomic joint with its articulating bones; inter- tendons, tendon sheaths, bursae,joints, and neu-
nal joint structures (menisci); the joint capsule rovascular structures but also to detect abnor-
and reinforcing ligaments; related muscles, ten- malities. Palpatory findings are supplemented
dons, tendon sheaths, and bursae; neuroregula- by the examiner's noting of the visible and audi-
tory mechanisms from the peripheral nerves to ble reactions of the patient. The examiner uti-
the cerebrum (including the psyche); and the lizes his sensation of deeper-lying structures
arterial, venous, and lymphatic vascular sys- when testing joint play and muscle resistance.
tems. The basic physical examination includes a The sequence of the physical examinations is
combination of inspection, palpation, and mo- determined by the following principles:
Inspection 7

- The stepwise examination of a diminishing

path of motion.
- Inspection comes before palpation.
- Inspection and palpation are always per-
formed first at rest and then during move-
- Palpation covers all specific palpable findings
that can be perceived with the hand or finger-
tips, including palpable joint movements such
as those in the intervertebral facet joints.

The components of the basic physical examina-

tion can thus be defined as follows:

L Inspection: inspection at rest (except for

the observation of natural, complex move-
ments at the start of the examination)
2. Active motion testing: general inspection
of movements
Passive motion testing: general palpation
of de ignated joint movements in all three
planes of motion
3. Palpation: superficial fingertip palpation
exploring the details of palpable cuta-
neous, subcutaneous, articular, muscular,
and neurovascular structures at rest and
during movement
4. Tests of joint play: deep palpation of joint
5. Muscle tests (resistance tests): deep palpa-
tion of the muscles and tendons

Inspection (Fig. 2)

The examiner notes and records visible morpho-

logic abnormalities at rest and functional distur-
bances during movement.

11 Natural movements. How the patient walks,

sits down, stands up, dresses and undresses,

12 Posture (position). The patient's posture with Fig. 2

reference to the spine and the joints of the
extremities; favoring or faulty position of
8 Palpation

13 Body symmetry and contours. Congenital or

acquired alterations in body contours, hyper-
trophy, swelling, effusion, atrophy, deformity.

14 Skin. Color, circulatory disturbances, scars,

calluses, eczema, nevi.

15 Orthopedic aids. Corset, crutch, prosthesis,

harness, brace, cane.

Conduct ofExamination
The observation of natural movements precedes
inspection of the patient at rest. It begins as the
patient enters the office (11) and continues dur-
ing history taking (12) and while the patient is
disrobing for the examination (11). After the pa-
tient has undressed, more specific attention is
given to body symmetry, skin, orthopedic aids
(h-Is), and postural deviations.

Palpation (Fig. 3)

Tactile examination is used to evaluate the tissue

quality and tenderness of palpable morphologic
abnormalities at rest and of functional distur-
bances during movement.

PI Skin and subcutaneous tissue. Temperature,

perfusion, sweat secretion, ease of scar dis-
placement, skin rolling test (consistency of
the skin fold).

P 2 Muscles and tendons. Muscle tone at rest and

during movement, splinting, myegeloses,
ease of displacement of muscle layers, ten-
derness of tendon attachments.

P 3 Tendon sheaths and bursae. Pain, swelling,

crepitus, ease of displacement.

P 4 Bones and joints. Joint space, bony struc-

tures, deformities, attachments of joint cap-
sules, ligaments, menisci, joint play (transla-
tional joint mobility). Fig. 3

Ps Nerves and vessels. Tenderness over nerves

and vessels, sites of induration, pulses.
Palpation 9

In the following I distinguish between five pal- tenderness of tissues (at trigger points, maximal
patory techniques: points, or segmental irritation points).
Palpation for tenderness is an example of a
1 Touch Palpation at Rest provocative test. The pressure may be applied
With the patient in a relaxed position, the exam- perpendicular to the tissue surface or parallel to
iner lays his hand or fingertip very lightly upon it in a shearing motion. The palpated sites are
the site to be palpated. To palpate deeper tissue basically the same as in touch palpation.
layers, the examiner presses just hard enough on Applying pressure or thrust to a vertebral seg-
the superficial layers to make contact with the ment produces a compressing or distracting
deeper-lying tissue points. Too much pressure force across the intervertebral facet joint, espe-
may elicit pain and can also desensitize the re- cially in hypermobile segments. These provoca-
ceptors in the palpating finger to tactile informa- tive tests are frequently more rewarding than
tion (e.g., on tissue alterations). the tests of joint play.
Touch palpation may be passive or active. In the
passive technique, the examiner keeps his hand 4 Kibler's Skin RoBing Test (Hyperalgesic Skin
or finger stationary and progressively palpates Zone) (Fig.4S)
from the skin surface to deeper layers, as de- A skin fold that includes the subcutaneous tissue
scribed above, while evaluating the consistency layers is formed between the thumb and index
of the individual tissue layers. In the active tech- finger of each hand and is rolled perpendicular
nique, the palpating finger is actively moved to the course of the dermatomes on the trunk
along the tissue layer to explore structural de- (parallel to the spine) or on the extremities. The
tails such as the attachments of soft tissues to examiner notes: (1) the thickness and consisten-
bone (joint capsule, ligaments, tendons). cy of the skin fold, (2) the resistance to raising
and advancing the fold, and (3) tenderness. In
2 Palpation During Movement hyperalgesic zones, the skin fold is thickened
This is used in active, passive, and segmental and has a firm, doughy consistency. It is usually
motion testing, joint play testing, and resistance tender to light pressure and is relatively difficult
tests. In one technique the flat hand is used to to raise and advance. The skin frequently pre-
palpate active movements by the patient, such as sents a coarse "orange peel" texture.
muscular contractions and mobility, the motion
of tendon sheaths and bursae, respiration-de- • Note
pendent rib excursions, or "asymmetric excur- Some authors relate a tender skin fold at the eye-
sion" in an upper rib pair (apparent increase in brow, mandibular angle, side of the neck, and
the mobility of an unaffected rib relative to its lateral scalp to a dysfunction at the C2-C4level.
counterpart that is restricted by a segmental dys-
function). In another technique the palpating 5 Connective Tissue Stroke Test of Leube and
finger is used to examine more circumscribed Dicke (Fig. 46)
areas during active or passive movement, e. g.: This is another palpatory technique for evaluat-
ing the subcutaneous connective tissue and its
- Asymmetric excursions in the sacroiliac joints
ease of displacement. A bulge of skin is raised
- Active/passive mobility and joint play of the
with the middle and ring fingers and pulled
vertebral segments
along on the underlying fascia. As in the skin
- Joint play in the extremities
rolling test, the resistance felt in the subcuta-
neous tissue is recorded. This palpation (just like
3 Pressure Palpation, Thrusting, Percussion connective tissue massage) is performed on pa-
(Palpation for Tenderness) tients primarily in sitting.
These techniques are for detecting local tissue The connective tissue stroke test is suitable not
changes caused by increased muscle tone just for segmental diagnosis but also for detect-
(spasm, hypertonicity) and for evaluating the ing reactions of the connective tissue to toxins or
10 Palpation

to metabolic disturbances and diseases of the - Interpretation of the palpatory information;

connective tissue itself, like those occurring in this requires attentiveness, objectivity, and ex-
rheumatoid or collagen diseases. perience, especially since palpation may be in-
fluenced by other sensory impressions ("One
Segmental Irritation Points ofSeH feels what one wants to feel").
The category of trigger points or "maximal
points" in muscle tissue includes the segmental
Conduct of the Examination and Findings
irritation points of Sell. Sell regards these points
as foci of reflex tissue irritation with myalgic fea- Skin Subcutaneous Tissue (P J
tures which originate from restricted spinal seg- Palpation of the skin and subcutaneous tissue
ments and are palpable as sites of tenderness begins when the immobilizing hand is placed on
and myogelosis. They appear whenever the the skin during passive motion testing. Detailed
stimulation of nociceptors in the various struc- palpation is required if inspection reveals in-
tures of the active (mobile) spinal segment in- flammatory changes or trauma sequelae (scars,
cites hypertonicity of the short, deep, intrinsic altered muscle contours) or there is presumptive
back muscles. evidence of circulatory impairment.
The segmental irritation points are usually locat- The following findings may be noted:
ed near the site of emergence of the segmental Skin temperature: warm - cold (circulatory im-
spinal nerve. In the cervical region, they are lo- pairment, arteriosclerosis) - hot (inflammation)
cated either between the posterior border of the Sweat secretion: moist (autonomic lability) - dry
sternocleidomastoid muscle and the lateral bor- (peripheral nerve lesion, endocrine distur-
der of the nuchal ridge or on the occipital squa- bance)
ma at the nuchal line. They are palpated with the
cervical spine in the neutral position. • Note
The irritation points disappear after (therapeu- Disturbances and defects of sweat secretion usu-
tic) elimination of the joint restriction. They be- ally result from lesions of the nerve plexus and
come more prominent following a therapeutic peripheral nerve. Loss of sweat secretion ac-
maniplulation in the wrong direction (irritation companied by normal sensation implies a lesion
zone testing). of the sympathetic trunk.
Plantar anhidrosis with sensory disturbances
and paralysis of the muscles of the lower leg and
• Note foot is never radicular in origin and most com-
Touch palpation can be used to examine all tis-
monly results from injection trauma to the glu-
sue structures, whereas the skin rolling test and
teus maxim us.
connective tissue stroke test evaluate only the
Trophic status: soft - hard (scar, callus, hyper-
subcutaneous connective tissue, especially in the
keratosis). Thick - thin (e. g., after local corti-
segmental zones. Palpation during movement
sone injections). Rough - smooth.
and pressure palpation are most appropriate for
Subcutaneous tissue: easy to displace - fixed or
the examination of joints, muscles, and segmen-
difficult to displace (connective tissue zones,
tal irritation zones.
segmental zones corresponding to Kibler's fold).
Palpation is the most difficult method of muscu-
loskeletal examination and requires much prac-
Muscles and Tendons (P2 )
tice and experience. Beallists three essential el-
The patient's muscles should be relaxed (posi-
ements of a successful palpatory examination:
tioning). Muscle palpation shouid proceed sys-
- Perception, i. e., the ability to sense tactile im- tematically from origin to insertion, and the di-
pressions, which requires a trained hand rection of palpation should be at right angles to
- Conveyance of the tactile impressions by a the direction of the muscle fibers.
well-functioning proprioceptive system (re- The simultaneous palpation of the muscle ori-
laxation) gins or insertions during muscle function tests
Motion Testing 11

often permits the first accurate determination of - Fractures

which muscle or tendon attachment is part of the - Osteoporosis
synergy of a muscular dysfunction. The same ap- - Bekhterev's disease
plies to the palpation of bursae and tendon - Hemangioma
sheaths. Tendon attachments are palpated in the
Very marked tenderness to percussion is general-
direction of the tendon fibers.
ly associated with:
Findings - Herniated disk
Firm - hard (reflex splinting, irritation zones, 10- - Spondylitis
eal myegeloses) - lax and soft (hypotonicity, - Tumors
paresis). Elastic - rigid (rigor). Movable - fixed
(tumor, inflammation) Nerves and Vessels (P5)
The palpation of nerves and vessels is indicated
Tendon Sheaths and Bursae (P3) when previous examinations have been unable
Tendon sheaths and bursae are examined for to assign the cause of the disturbance to the
swelling and crepitation. anatomic joint or to musculotendinous struc-
tures including the tendon sheaths and bursae.
Bones and Joints (P4) Because peripheral nerves and vessels tend to
Findings follow common paths, it is prudent to check
The bone may be smooth or rough (exostoses, "neurologic tender points" (e. g., at narrow
periostitis, fracture sequelae). Joints are exam- anatomic passages for nerves and vessels) not
ined for joint-space width, the consistency of the just regionally during detailed palpation but also
joint capsule (thickened, tender), and tender- by a systematic palpation that proceeds in a
ness of the reinforcing ligaments and tendon at- proximal-to-distal (central-to-peripheral) direc-
tachments. After the joint structures have been tion. When palpating blood vessels, the exam-
palpated at rest (palpation zones), they are pal- iner notes whether the vessel wall is elastic or
pated during movement as part of function test- rigid (sclerosis) and checks for equal pulses on
ing. With few exceptions, then, joint palpation is both sides.
useful for evaluating not just the position of the
joint structures but also the mobility of any joint
not covered by an excessive thickness of soft tis-
sues (e. g., the shoulder joint, hip joint, most in-
I Motion Testing (FigA)
tervertebral facet joints).
The stepwise analysis of the affected portion of
Pathologic Findings the joint in articular dysfunctions is central in
In addition to the use of touch palpation and pal- motion testing. Again, the basic diagnostic tech-
pation for tenderness, it may be necessary to eval- niques used here are inspection and palpation.
uate the tenderness of vertebral bodies to percus- The following structures are evaluated by mo-
sion. tion testing:
Moderate tenderness to percussion is character-
istic of: Ml Active movements (functional move-
ments). All the structures of the arthron
- Hypermobile segments (contractile and noncontractile): anatomic
- Scheuermann's disease joint, muscles, tendons, tendon sheaths,
- Degenerative segmental changes bursae, and nervous system including the
Marked tenderness to percussion is noted psyche.
M2 Passive movements (mobility). All struc-
tures except the motor pathway.
12 Motion Testing

Active Passive Muscle tests

movements (8 1 ) movements (82) against a res istance (8 5 )
Joint: Muscles
gliding (8 4 )

1 Articular surface Articular surface 1 Articular su rface 3

r 1 Joint:
traction (8 3 )

2 Capsule + ligaments 2 Capsule + ligaments 2 Capsule + ligaments

Muscles Muscles

f 1
MJ Distraction and compression of the joint.
Distraction (called simply "traction" in the
test descriptions) and compression of the
joint members without muscular activity
3-----' 3----/ (tests translation of the articular surface ,
Nerve pathways internal structures, joint capsule, and liga-
ments) .

M4 Intraarticular gliding. Parallel gliding of the

joint members without muscular activity
(tests translation of the same structures as in
M3, especially the articular surfaces).

Ms Muscle resistance tests. The muscles and

tendons are tested for strength and tender-
ness without joint motion.

Conduct of the Examination

If active and passive movements (M I, M2) can be
performed without pain or limitation, motion
testing may be concluded. But if a painful or
even nonpainful hypo- or hypermobility is not-
Fig. 4. Motion testing ed, it is necessary to analyze the end-feel at the
absolute limit of the passive range of motion.
The elasticity of the end-feel tells the examiner
whether a motion restriction (hypomobility) is
caused by contractile (muscle) or noncontractile
structures (bone, capsule, ligaments).
Motion Testing 13

After passive motion testing is completed, fur- Rationale for the Basic Physical
ther differentiation, if needed, is accomplished Examination
by distraction of the joint (M3) perpendicular to
The synoptic assignment of findings to specific
the articular surface. Separating the articular
structures can reduce the number of individual
surfaces usually alleviates pain by lowering the
examinations that are necessary and/or make it
intraarticular pressure, whereas compression of
possible to organize the examinations more ra-
the articular surfaces produces the opposite ef-
tionally. Pathologic findings at any stage are an
fect. Gliding motions (M4) parallel to the articu-
indication for the necessity to conduct further
lar surface can disclose the direction of the
tests. If no pathologic findings are found, the ex-
motion disturbance, whether the articulating
amination may be concluded after passive mo-
surfaces are affected, and what portions of the
tion testing, and the examination of peripheral
capsule and ligaments are chiefly involved.
nerves and blood vessels may conclude with
If tests M3 and M4 are negative, the examination
their palpation. However, if the findings suggest
concludes with function testing of the muscles
damage of the peripheral nerves and vascular
and tendons. This consists of: resistance tests
system, these structures must be examined in
(Ms) of the muscular synergists in an intermedi-
greater detail.
ate position (right-left comparison) and/or the
differential diagnostic testing of individual mus-
cles in an intermediate position and in a position
of muscle stretch that places increased tension
on the tendon attachments. (The significance of
the individual motion tests is described more
fully on p.12f.)
14 Adjunctive Neurologic and Angiologic Studies

Adjunctive Neurologic and

Angiologic Studies

Neurologic Studies (Fig. 5)

Adjunctive neurologic studies are performed
when there is suspicion of damage to a nerve

Nt Reflexes and indicator muscles (segment)

N2 Sensory testing (superficial and deep sensa-
N3 Motor function (peripheral nerve)
N4 Coordination and autonomic regulation
Ns Cranial nerve examination

Conduct of the Examination

The inspection of ordinary patient movements
and motion testing, supplemented by the palpa-
tion of nerve pathways, have already given the
examiner a gross impression of nervous system
function. Thus, these additional tests are neces-
sary only in those circumstances when the na-
ture and extent of the disturbance remain un-
clear and in certain disease states that neces- Coordination
sitate a neurologic workup, e. g., reflex testing
(N1) and testing for sensory disturbances (N2 ) in
the approximately 3%-4% of disorders that are
associated with true radicular disturbances of
varying causes. The specific examination of mo-
tor function (N3) is indicated in all posttraumat-
ic states with peripheral nerve injury.
Coordination testing (N4 ) and the cranial nerve 4
examination (N s) are intended to establish Cranial nerve exam ination
whether the patient has a central neurogenic le-
sion or a disturbance of the sensory organs that
would warrant referral to a neurologist or organ

Angiologic Studies
Angiologic evaluation may be indicated on the
basis of the history, inspection, and palpation,
e. g., when there is suspicion of damage to blood Fig.S
Adjunctive Special Diagnostic Procedures 15

Radiologic stud ies - Vasogenic pain
- Limited walking distance (intermittent clau-
- Risk factors: advanced age, smoking, exces-
sive body weight, metabolic disorders, lack of
exercise, other vascular diseases (heart, kid-
neys), family history

Laboratory stud ies - Alteration of skin color, altered structure of
the superficial blood vessels, edema
- Limited walking distance

- Skin temperature
- Tissue turgor
2 - Tender points
Aspiration, biopsy - Pulse status

Adjunctive Special Diagnostic

Procedures (Fig. 6)

3 SI Radiologic studies. Basic morphologic eval-

Electrodiagnostic studies uation, X-ray function studies, motion-con-
trolled tomography. Contrast examinations,
CT, MRI, scintigraphy, isotope scans, and
sonography are not used routinely but are
reserved for selected cases according to set

S2 Laboratory studies. Basic workup for dis-

eases of the musculoskeletal system.

S3 Histologidcytologic studies. Aspiration,

percutaneous or open biopsy, arthroscopy,

S4 Electrodiagnostic studies. Peripheral elec-

trodiagnosis, chronaximetry, electromyog-
5 Organ studies raphy (EMG) , electroencephalography
Fig.6. Special diagnostic
procedures S5 Organ studies. Gynecologic, neurologic, an-
giologic, ophthalmologic, and other visceral
disorders, ENT diseases.
Examination Positions

Patient cooperation during the examination is C Prone (relaxation)

facilitated by minimizing the number of time- D Lateral (relaxation)
consuming changes in position. The following E Supine (relaxation)
five positions are employed in the sequence indi-
cated (Fig. 7 a): In each position, the particular spinal segments
and extremity joints are examined that are func-
A Standing (effort) tionally interrelated. The examination of these
B Sitting (effort) segments and joints is conducted by body region.

O( ;-::

A B 0
c1 =
Fig. 7. a Positions of examination E
Body Regions Examined

The following body regions are examined (from III Thorax Examination in Slttzng,
caudal to cranial) (Fig. 7b): prone, lateral, and supine
I Legs positions
II LPH region: lumbar spine, pelvis (SIJ), hip IV CSA region Examination in sitting po-
joints sition (also prone and su-
III Thorax: thoracic spine and ribs pinefor certain tests)
IV CSA region: cervical spine, shoulder girdle, V Cervical spine, Examination in sitting and
arm joints head supine positions
V Cervical spine, head
The data furnished by the history and examina-
The examination plan by body region is as fol- tion must still be correlated with specific patho-
lows: logic states. In my view, the "rheumatoid" classi-
I Legs Examination in all posi- fication of disease groups (Toronto 1957) is
tions inadequate for this purpose, and I therefore pro-
II LPH region Examination in all posi- pose the classification of disease groups given in
tions the next section.

v Cervical spine and head

IV CSA region : cervical spine,

shoulder girdle, arm joints
III Thorax (thoracic spine, ribs)

II l PH region : lumbar spine,

pelvis (sacroiliac joints),
hip joints


Fig. 7. b Body regions cov-

ered in the examination

The diagnosis suggested by the findings of the Group 6: Tumors

various examinations is considered to be prelim- Caution: The primary manifestation frequently
inary until it has been confirmed by response to consists of generalized soft-tissue symptoms or
trial therapy. For joint dysfunctions, this trial an inflammatory joint condition.
manipulation usually consists of articular dis-
traction. The diagnosis may not be regarded as It is common for physicians to prescribe medical
definitive until there has been positive response "antirheumatoid" therapy for pain and dysfunc-
to the trial manipulation. tion based on traumatic, degenerative, or symp-
tomatic joint disorders that can be managed
more safely (no side effects) and effectively by
other treatment methods.
Disease Groups Involving the In the six disease groups, the "laboratory line,"
Musculoskeletal System important for differential diagnosis, runs
through the middle of group 4 (articular involve-
The following is a simplified classification of dis- ment by diseases of other organ systems). This
ease groups and is proposed primarily for thera- means that abnormal laboratory findings are ob-
peutic reasons: tained in groups 5 and 6 and in certain diseases of
group 4.
Group 1: Functional disturbances not associated The laboratory line also marks the limit of the
with an objectively demonstrable lesion range of indications for manual and physical
therapeutic procedures. Thus, the relative indi-
Group 2: Trauma cations in this range, such as true rheumatoid
disorders, call for a highly critical approach. This
Group 3: Degenerative processes ("-osis," "-pa- classification of disorders of the musculoskeletal
thy"). Arthroses (osteoarthritides), ligamen- system greatly facilitates programming of the
toses, myoses, tendinopathies, periostoses, neu- treatment plan.
ropathies, venopathies. The above classification was retained with re-
gard to the clinical indications for special exami-
Group 4: Symptomatic disorders. The joint dis- nations of specific joints and the spine.
order is symptomatic of a disease process extrin-
sic to the joint. The articular manifestation may
be degenerative or inflammatory.

Group 5: Inflammatory processes ("-itis").

Arthritis (including activated degenerative dis-
ease!), myositis, tendinitis, periostitis, neuritis,
Structural Analysis of Function
Using the Diagnostic Program

Structural Analysis in the Patient Referred Receptor Pain. It is not felt at its point
History with Reference to Pain of origin but is referred to a site elsewhere. It is
produced by nociceptor stimulation in response
to tissue irritation inside the body Goints, mus-
Pain is not a reaction to specific environmental cles, viscera, etc.) and also by purely functional
stimuli, like seeing or hearing, but can originate disturbances not associated with a demonstrable
from all nociceptors in the body in response to a pathoanatomic substrate.
stimulus of adequate intensity. Nociception is The site of irritation and the painful site do not
nonspecific. The intensity of pain does not cor- coincide. The density and activation threshold
relate with the degree of tissue irritation or in- of the nociceptors are critical in the occurrence
jury. Also, as in referred pain, the site where pain of receptor pain. The pain itself is accompanied
is felt often does not correspond to the site by a somatic reaction to the pain (motor and
where the pain originates. Pain sensation, more- autonomic response) (H.D. Wolff). Receptor
over, is strongly linked to the central processing pain is associated with an increase in sensitivi-
of pain, i. e., the affective pain response. Thus, ty (hyperesthesia, hyperalgesia) but never with
pain has much in common with general sensa- decreased sensitivity (hypoesthesia, analgesia)
tions such as hunger, thirst, fatigue, and fear, or significant motor or reflex deficits. Most
which cannot be precisely assigned to a particu- vertebral and spondylogenic pain is receptor
lar body structure. Nevertheless, since pain as a pain.
clinical phenomenon is a warning sign of disease Two types of nociceptor have been identified:
or tissue injury, it is important to analyze pain
1. Nociceptors with thin, myelinated A b fibers,
with respect to its causation despite its often
which produce a "bright," sharp, cutting or
vague localization due to referral and subjective
stinging, well-localized pain that is felt imme-
diately after the painful stimulus and is called
"first pain." These nociceptors are most abun-
dant in the skin.
Types of Pain from a Structural 2. Nociceptors with thin, unmyelinated C fibers,
Perspective which produce a dull, burning, gnawing, or
boring pain of slower onset known as "second
The precise localization of pain and dysesthe- pain." These receptors are most numerous in
sia provides a guide for identifying the site the joints (articular capsules, ligaments), ten-
where the pain originates (tissue irritation). It dons, and internal organs.
programs the examination procedure that fol-
lows. Projected Neuralgic Pain. In this type of pain
The following types of pain are distinguished the irritation of a pain pathway (peripheral
(modified from Janzen): nerve, dorsal root) of the associated ganglion or
of relay points in the spinal cord causes pain to
Local Receptor Pain. It is associated with irrita- project to the related skin area. The site of irrita-
tion of the body surface. The painful site coin- tion can be inferred from the distribution of the
cides with the site of irritation. pain.
20 Analysis of Pain During History Taking

Pain in Circumscribed Portions ofthe Body and

Extremities (meralgia) associated with neuro- Analysis of Pain Dnring History Taking
circulatory or neurodystrophic disturbances.
The site of irritation is located in nerves that Five questions are of key importance in the anal-
transmit sympathetic fibers (plexus, median ysis of pain:
nerve, tibial nerve, C6-C8 roots) or large vessels What hurts (location) ?When, how, and by what
with perivascular plexuses of autonomic fibers. is the pain or dysfunction precipitated and
The autonomic disturbances permit the origin of changed?
the pain to be localized to a particular side. Uni- With what is the pain associated (accompanying
lateral pain that is not localized to a specific features)?
nerve area represents central pain (thalamus).
A delay in nerve conduction velocity is another The pain history may, furthermore, disclose any
sign suggesting an irritation site in the peripher- of seven patterns ofpain that are helpful in iden-
al nerve or plexus. tifying the most likely structural substrate of the
Meralgias (and merodysesthesias) are depen- presenting complaints. These patterns must be
dent on rhythmic processes such as diurnal supplemented and confirmed by corresponding
rhythm, unilateral occupational strains, the findings during the examination.
menstrual cycle, episodic processes (pregnancy,
puerperium), and metabolic disturbances. Joint Pain
Receptor pain arising from the synovial mem-
Bilateral Pain and/or Dysesthesia. They relate brane, joint capsule, or possibly from the sub-
both to a site of irritation and to systemic factors: chondral layers of the articular surface, perios-
- Inflammations . teum, ligaments, and capsular vessels. Joint pain
- Hematologic disorders may be degenerative or inflammatory.
- Metabolic disorders
- Intoxications Degenerative Joint Pain
- Tumors What
Joint or spinal pain radiating to the soft-tissue
Basic Principles in the Analysis structures about the joint (muscles, ligaments,
of Pain tendons).
1. Avoid a hasty diagnosis without a sys-
tematic exploration of complaints and When
a thorough evaluation. The "frequen - "Cold pain" after prolonged rest (morning
cy rule" is valid in looking for patho- pain); exertional and fatigue pain; later there is
logic processes but not in tbe interpre- often rest pain or nocturnal pain.
tation of phenomena (Janzen).
2. Any increase or change in pain (or
Dull, gnawing, boring (muscle pain); sharp
dysesthesia) may signify an exacerba-
acute pain with incarceration (meniscus, joint
tion of the disease process.
mouse); pain gradually increases with overuse.
3. Any sudden or unexpected "improve-
ment" in complaints may also signify By What
exacerbation (tissue destruction fol- Mechanical factors such as faulty or excessive
lowing a state of irritation). use, traumatization, fatigue; weather (humidi-
ty), temperature ; relieved by rest.

With What
Inspection: swelling (with activated degenera-
tive disease) , guarding.
Analysis of Pain During History Taking 21

Function: pain on motion, later motion restric- When

tion; muscle weakness, gait disturbances. Cold pain after prolonged immobility (e. g.,
Palpation: local tenderness to pressure. morning pain) or after prolonged maintenance of
Systemic manifestations are absent. the same posture or load (occupational strain).

Inflammatory Joint Pain How

Diffuse, dull, gnawing, boring, or tearing pain.
Myogelotic pain may be bright or sharp on pal-
Joint or spinal pain radiating diffusely to sur-
rounding tissues. Pain from a bone lesion does
not radiate but stays confined to the bone (pe-
By What
riosteum, medullary cavity).
Local myalgias: muscle splinting about restrict-
ed joints. Stretching of shortened or contracted
muscles in pathologic muscle stereotypes (reflex
Severe, persistent pain during rest and especial-
increase in resting tone). Faulty or excessive use
ly at night, worsening in the morning (with
(muscle soreness). Improved by heat (except
morning stiffness).
with an inflammatory cause) and movement.
General myalgias: can accompany viral diseases
(influenza), bacterial infections, and collagen
Intense, sharp, burning, boring or pulsating (ef-
diseases (elevated ESR, leukocytosis), especial-
fusion) pain. Bone lesions cause a dull ache; pe-
ly in rheumatoid polymyalgia. Not precipitated
riosteal involvement causes sharp inflammatory
by coughing, sneezing, or straining.
With What
By What
Function: muscle stiffness (rigor, cogwheel phe-
Inflammatory synovial changes, joint effusions,
nomenon), rapid fatigability, need for posture or
inflammatory bone diseases and tumors.
position change with muscular insufficiency and
hypermobility. Translational joint movements
With What
do not elicit pain.
Inspection: swelling, guarding (resting), possible
Palpation: local tenderness to pressure and
more general muscle splinting, possibly with
Function: early, verypainfullimitationofmotion.
hard foci in the muscle (trigger points, maximal
Palpation: heat, marked local tenderness.
points, segmental irritation points, myogeloses)
Systemic manifestations: malaise, fatigue, febrile
that may be knoblike or cordlike.
episodes, weight loss. In the late stages of degen-
Neurologic symptoms: no radicular symptoms,
erative or inflammatory processes, it can be dif-
possible dysesthesias.
ficult to differentiate joint pain (from the cap-
sule and ligaments) and bone pain (from the
Ligament Pain
periosteum and medullary cavity) due to spread
of the process to adjacent structures. Receptor pain arising from tendon and ligament
Muscle Pain
Receptor pain arising from muscle fibers and Local pain at the attachments of tendons and lig-
tendon attachments. aments, frequently radiating to associated mus-
Pain in individual muscles or synergies, usually When
showing a functional relationship to joints or After prolonged maintenance of the same pos-
segments (chain tendomyoses). ture, especially with muscular insufficiency. In
22 Analysis of Pain During History Taking

segments with incipient intervertebral disk de- How

generation (diskoligamentous tension imbal- Bright stabbing or cutting pain, prickling, lanci-
ance). nating. No tendency to spread within the nerve
Same character as muscle pain. By What
Local mechanical irritation at the site of origin:
By What compression or stretching of the nerve or nerve
Overuse, stretch, pressure, and tension. Acute root (Lasegue's sign), e.g., by coughing, sneez-
improvement by rest and immobility; perma- ing, straining, or with latent intervertebral disk
nent improvement by muscular training. Termi- protrusion; peripheral entrapment syndromes;
nal pain on passive movement of hypermobile constant radicular pain with disk prolapse (her-
joints. niation); trauma.

With What With What

Dysesthesia, hyperalgesia; tenderness over liga- Reflex disorders, sensory disturbances (hypes-
ment attachments, often with increased range of thesia, hypalgesia, paresthesia) in the der-
passive joint motion and joint play (hypermobil- matome or the area of the peripheral nerve, mo-
ity). tor deficits in the segmentally related muscles
(indicator muscles) or muscles of the peripheral
Bursitis, Tendovaginitis nerve; abnormal sweat secretion only with a pe-
ripheral nerve lesion. In the spine: antalgic pos-
Receptor pain. ture, restricted mobility, spasticity. No systemic
Local pain over bursae or tendon sheaths. Autonomic Pain
Direct stimulation of autonomic nerve fibers or
When receptor pain from inside the body.
Usually after overuse or monotonous work.
How Referred pain or meralgia: poorly localized pain
Gnawing, tearing. on the body surface with a tendency toward dif-
fuse spread.
By What
Single blunt trauma or repeated microtrauma, When
rheumatoid and metabolic diseases (gout), dis- Continuous pain, often experienced in waves.
turbances of the hormonal and vitamin balance The pain outlasts the pain stimulus!
(vitamin E). Improved by rest, exacerbated by
pressure or movement. How
Dull, smouldering, burning, cramping.
Nerve Pain
By What
Direct stimulation of the nerve pathway.
Stimulation of peripheral nerves containing
abundant autonomic fibers (e. g., median nerve,
Neuralgic Pain
tibial nerve). Nociception from the body interior
What (Head's zones, Mackenzie's zones) and/or from
Local or projected pain; superficial, sharply cir- the joints.
cumscribed pain in the distribution of a periph-
eral nerve or nerve root.
Analysis of Pain During History Taking 23

With What sibly from subchondral layers of the articular

Associated with autonomic disturbances: cold surface and from the segmental muscles over the
sensation, swelling sensation, sweating, circula- dorsal rami of the spinal nerves. The functional
tory impairment, trophic disturbances, malaise. interrelationship of all these structures gives rise
to the radicular and pseudoradicular pain pat-
Vascular Pain terns, which may be mixed and superimposed.
Pain about the course of a blood vessel. RadicuJarPain
Sharp local or radiating nerve pain.
Exertional pain (grade II) or constant pain
(grade III, IV) secondary to arterial occlusive
disease. Exertional pain is also characteristic of
Sudden and paroxysmal after trauma (micro-
acute thrombophlebitis.
trauma!) or mechanical loading.
Sudden paroxysmal pain distal to the site of the
Severe, stabbing pain in the dermatome.
vascular lesion (arterial pain), also cold sensa-
tion. Gradually increasing sensation of pressure,
By What
tension, and heaviness, calf pain (venous pain).
Irritation of the nerve root in the intervertebral
foramen by compression. Potential causes: disk
By What
protrusion or prolapse; faulty vertebral position;
Arterial pain is exacerbated by walking (inter-
swelling of the facet joint capsule, usually associ-
mittent claudication) and by cold or heat; ve-
ated with degenerative vertebral and joint
nous pain is exacerbated by standing (approx.
changes (spurring); circulatory impairment, ede-
20-30 min). Arterial pain is improved by placing
ma, or tumors in the region of the nerve root. The
the part in a dependent position; venous pain is
pain is usually initiated and exacerbatedby move-
improved by elevation and ambulation.
ment (coughing, sneezing, straining) and trauma.
With What
With What
Skin changes associated with arterial and venous
Inspection: painful postural deformity (antalgic
lesions: pallor and coldness (arterial), bluish dis-
coloration and heat (venous). Malaise with
Function: usually severe motion restriction at
the affected level and within the segment.
Palpation: local tenderness to pressure, unilat-
Vertebragenic Pain
eral muscle spasm.
The two forms of vertebragenic pain can be dif- Neurologic symptoms: nerve stretch pain
ficult to distinguish from each other because (Lasegue's sign), reflex deficits (later), sensory
they may coexist: deficits (paresthesias in the dermatome, hypes-
Direct irritation of the nerve pathway (radicular thesia, hypalgesia), motor deficits (only in se-
pain; see also Neuralgic Pain, p. 22) vere cases).
Receptor pain from the spinal segment ("pseu-
doradicular pain" after Brugger)
Receptor Pain from the Vertebral Segment,
The latter type of pain originates from the dorsal
Pseudoradicular Pain (after Briigger)
part of the anulus fibrosus, the posterior longitu-
dinal ligament, the inner portion of the facet What
joint capsule over the meningeal rami, from the Local or radiating pain in the muscle chain, with
outer portion of the facet joint capsule, and pos- or without autonomic symptoms.
24 Examination of the Joint

When Special Diagnostic Procedures

Usually a gradual onset after trauma (micro- Radiography: morphology of the articulating
trauma) or after faulty or excessive use. bones, pathologic changes in the soft-tissue en-
velope. Function studies: films at the limit of
How motion, stress films.
Diffuse, dull, boring, gnawing, tearing (myalgic Laboratory investigations: synovial fluid, blood
pain). studies.
Biopsy: synovium, bone.
By What The findings of the various examinations are de-
Receptor stimulation in the various structures of tailed below.
the vertebral segment, especially the facet joints,
caused by a diskoligamentous tension imbal- Inspection
ance presenting as a hypomobile dysfunction
Inspection gives evidence of visible congenital
(restriction) or a hypermobile dysfunction (gen-
(dysplasias, aplasias) and acquired morphologic
eral or local hypermobility) following trauma or
changes (trauma, inflammation, tumors).
after faulty or excessive use.
Active and Passive Motion Testing (Fig. 8)
With What
Inspection: usually little or no antalgic scoliosis. During functional movements, all the structures
Function: decreased mobility (restriction) or in- of the arthron are tested together. If active move-
creased mobility (hypermobility) of spinal sec- ment is painless and unrestricted, the examiner
tions or segments, often with positive ligament passively moves the jointfrom the end of its active
tests. range of motion (relative limit) to its absolute mo-
Palpation: positive tenderness in the segment, tion limit and evaluates the end-feel at that posi-
muscle spasm (restriction), occasional weakness tion (Fig. 8 a). If no pain or motion restriction is
of muscle groups, swollen subcutaneous cellular noted, the examination ofthe jointis concluded.
tissue (Kibler'S fold). Testing the end-feel during passive motion testing
Neurologic deficits are absent. (Fig. 8 b) helps determine whether the functional
disturbance is more likely to be located in the
anatomic joint or in musculotendinous structures.
In making this assessment, the examiner must
know whether joint motion is restrained chiefly by
Structurally Specific Findings bone or by soft tissues (muscles, ligaments), ac-
in the Arthron cording to the anatomic structure of the joint. A
springy end-feel is suggestive of incarceration
(e. g., of a meniscus or intraarticular loose body).
It should also be determined whether hypo- or hy-
Examination of the Joint
permobility exists. Hypo- or hypermobile joint
dysfunctions may arise from the joint itself or re-
Among the anatomic structures tested in the flexly from other components ofthe arthron. Hy-
synoptic examination procedure, priority is giv- pomobility arising from the joint itself is known as
en to the joint. The following articular findings restriction. A number of theories have been pro-
may be noted: posed regarding the pathogenesis of joint restric-
Inspection: congenital and acquired deformities. tion, but so far none have been proven. A rule of
Active and passive motion testing: restricted or thumb for motion restriction is that, during active
increased mobility and altered end-feel. and passive motion testing, an arthrogenic cause
Palpation: altered joint-space width and capsu- produces pain and restriction in the same direction
lar attachment, positional faults. of motion, whereas a myogenic cause produces
Joint play: absent, decreased, or increased. pain and restriction in opposite directions.
Examination ofthe Joint 25

Resting position
(Center, neutral
anatomiC position)

Normal The neutral position during flexion/

mobility extension is variable depending on
the degree of kyphosis or lordosis
movement Treatment position
motion limit

Passive movement ----t=;:~J._


Absolute Absolute
(anatomic) (anatomic)
motion limit motion limit

on sagittal plane

Lateral flex ion

on frontal plane Rotation
a on transverse plane

Soft-elastic Firm-elastic Hard-elastic

b (motion checked by muscle) (motion checked by ligaments, (motion checked by bone)
"capsular feel")
Fig. 8. a Normal and pathologic vertebral mobility (modified from Kimberley). b Qualities of end-feel (after Ka-
26 Examination orthe Joint

The presence of a motion restriction in only one other (distraction) or one member is shifted on a
or two directions suggests a contracted joint cap- straight path relative to the other, stationary
sule ("capsular pattern" of Cyriax). member (translation). Meanwhile the examiner
With a hypermobile joint, stability is reduced. evaluates the structure-dependent end-feel at
The pain associated with gliding movements in a the limit of the motion. .
hypermobile joint is of ligamentous origin. All active and passive joint movements consist
Further examination of the anatomic joint is ac- of two components, rotation (rolling) and glid-
complished by palpation. ing. Rotation is predominant between articular
surfaces that are incongruent, as in the knee
-Note joint, while gliding is predominant between
Articular dysfunction and/or its reflex effects more congruent surfaces, as in the interverter-
are alternately known as: bral facet joints (Fig. 9 a).
In rotation (rolling), illustrated by a wheel
- Nociceptive somatomotor blocking effect
rolling over a surface, new points on the wheel
successively come into contact with new points
- Somatic dysfunction
on the opposing surface. As the wheel turns, its
- Spondylogenic reflex syndrome (Sutter)
center, i. e., the axis of the moving body, travels
- Minor intervertebral derangement (Maigne)
from its starting point in the direction of the
rolling movement.
Palpation In gliding, one point on the gliding surface comes
into contact with numerous successive points on
Width of the Joint Space. The joint space may be
the opposing surface. Again, the center of the
narrowed due to degeneration of the articular
moving body (assuming flat or nearly flat sur-
cartilage or contracture of the surrounding soft
faces) travels in the direction of the gliding move-
tissues (e.g., with epicondylopathy in the radio-
ment as long as the linear motion continues.
humeral joint), or it may be widened as a result
These different modes of contact in rolling and
of effusion. Additionally, the cartilage margins
gliding may play a role the proprioceptive and
and menisci (knee joint) are palpated for tender-
nociceptive control of muscular activity from the
ness to pressure.
joint. It is important for the mechanics of joint
motion that the center about which the move-
Capsular Attachment. Tenderness and thicken-
ment occurs (the axis of rotation) remain in a rel-
ing of the capsular attachment are common in
atively fixed position. Otherwise the joint sur-
states of chronic joint irritation. Ligaments and
faces would tend to separate from each other
muscle attachments also may be tender to pres-
and dislocate, as illustrated by the femoral
sure. With synovitis, the consistency of the cap-
condyles rolling on the tibia or the humeral head
sule is soft, spongy, and fluctuant.
rolling on the glenoid (Fig. 9 b). To prevent this
tendency, the moving surface must roll and glide
Positional Faults of the Joint Members. When
simultaneously to maintain the constant, stable
caused by a post-traumatic or functional rela-
apposition that is essential for unimpaired joint
tional disturbance, such faults can sometimes be
function (Fig. 9 c,d). This rolling-gliding motion
detected by palpation.
prevents destabilizing distraction and trauma-
tizing compression of the articulating surfaces
Joint Play (Fig. 9)
Active and passive functional joint movements A basic distinction is drawn between the angular
can be analyzed in greater detail by breaking the gliding that occurs in active and passive rolling-
motions down into separate components. This is gliding (Fig. 9 d) and straight translational gliding
done by testing joint play. (Fig. 9 e). Translational gliding occurs most read-
Joint play refers to the passive mobility of the ily in the neutral resting position of a joint, i. e., the
joint as one joint member is lifted away from the central position of a physiologic path of motion
Examination ofthe Joint 27

Gliding Rolling

Stationary axis Movement of bone

j \ during traction
/ \
--+--. Movement
of bone in space


Glidi ng


Fig. 9 a. Components of
functional movements Rolling-gliding Joint play

Fig.9 b. Dislocation tendency when one joint member rolls without gliding, illustrated for the
knee and shoulder joints
28 Examination of the Joint

Fig.9 c. Nonunifonn separation (and apposition) of the articular surfaces when

angular rolling occurs without gliding

Fig.9 d. Unifonn separation and apposition when the moving member rolls and
glides simultaneously (angular rolling-gliding) during active and passive movements

where the surrounding soft-tissue structures (es- however small, will still be possible within the re-
pecially the capsule and ligaments) are lax and maining limits of motion when the joint is in its
there is little receptor activity. In this situation the displaced (virtual) resting position (Fig. 8 a).
articular surfaces are less firmly in contact with The translation gliding of a convex articular sur-
each other, so gliding can occur more easily. This face occurs in a direction opposite to its direc-
translational gliding, which I defined earlier as tion of rotation, whereas a concave articular sur-
joint play, is the fundamental partial function of face glides in the same direction that it rotates.
the joint. Even with a severe restriction of joint This is because the rotational axis is always lo-
mobility, some amount of translational gliding, cated at the center of the member whose articu-
Examination of the Joint 29

:,, ,

, I

, ~~,,---,

Fig.9 e. Uniform separation and apposition during passive translational (straight)


lar surface is convex (Fig. 9 d). Because all artic- Compression, on the other hand, by raising the
ular surfaces have some degree of curvature and pressure on the intraarticular contact surfaces,
mate with a surface of reciprocal shape, this generally accentuates the pain, just as does any
"convex-concave rule" (Kaltenborn) applies to general increase in pressure caused by joint effu-
all the joints in the body. It is the basic mechani- sion or by the pathological transformation of in-
cal principle of articular motion (Fig. 9 g). ternal structures (such as a meniscal lesion).
Joint play is tested in order to evaluate the par- However, the cartilage gliding surface itself can
tial functions of the joint. Distraction and com- be affected by a traumatic, inflammatory, or de-
pression are performed at right angles to the tan- generative pathology (e. g., an intraarticular
gential plane, while translations are performed loose body). All "meniscal tests" in the knee, for
parallel to the tangential plane, in the plane of example, consist of angular gliding movements
articular contact. The tangential plane ("treat- under pressure. The varying pressure in the con-
ment plane") passes through the outermost dis- tact area between the articular surfaces also
tal borders of the concave articular surface (usu- seems to playa significant role in the proprio-
ally the socket) and thus changes with every ceptive and nociceptive regulation of the joint,
change in position of that member (Fig. 9 f). This although it still has not been determined at
also applies to the actual treatment plane, run- which point the joint sensors detect this in-
ning parallel, in the area of articular contact. creased pressure.

Traction and Compression Translational Gliding (Parallel Gliding)

Traction, considered here to be synonymous Translational gliding movements, the most im-
with distraction, causes the articular surfaces to portant components of joint play, are, unlike the
separate from each other, leading to a decrease angular rolling-gliding of active and passive joint
in pressure within the joint (Fig.9h). This re- movements, short, straight parallel shifts of the
lieves the pain of inflammatory and degenera- moving bone relative to its stationary partner on
tive joint diseases or other lesions of the internal the plane of joint contact, to the degree permit-
structures (incarcerations). Even with a con- ted by the curvature of the joint surface and cap-
tracted joint capsule, traction temporarily low- sular constraints (Fig. ge). The translation can
ers the raised intraarticular pressure and re- be continued only after the position of the mov-
duces pain (trial manipulation). ing bone (joint angle) has been altered. This
30 Examination of the Joint

Stationary member Stationary member




Tangential plane Tangenlial plane

(treatmenl plane) moving (treatment plane) constant

Fig. 9 f. Direction changes during distraction (traction) and gliding on the tangential gliding plane ("treatment

- - - - of bone In space - - - - --

Stationary Stationary

Fig. 9 g. Convex-concave rule (after Kaltenborn)

member Moving

: }=
~ i:~t Taking up the slack
3 = Stretched

Fig. 9 h. Stages in the stretching of the joint capsule during translational joint movements
Examination ofthe Joint 31

Fig. 9 i. Separation and apposition of the articular surfaces in the resting

and locked positions

means that the translational gliding path is a por- ther course of cerebrally programmed angular
tion of the angular gliding path, the latter con- motion, the separation and coaptation of the
sisting of a series of short, straight motion seg- joint surfaces are disturbed. At the immobile
ments. Translational gliding movements cannot contact surface there is a sudden and nonphysio-
be actively and selectively performed. logical increase in pressure, and at the side away
The soft-tissue envelope of the joint (capsule from the movement there is an abrupt overex-
and reinforcing ligaments) also plays a major tension of the articular capsule.
role in the movements of the bony elements. The If there were a primary degenerative or inflam-
ligament apparatus acts with the cohesive forces matory change in the gliding surface itself, this
between the articular surfaces to maintain appo- capsuloligamentous contracture and the resul-
sition of the joint. Usually the collateral liga- tant motion restriction would have to be consid-
ments are responsible for keeping the joint sur- ered a nociceptive adaptation to the underlying
faces apposed and guiding their movements. change. This adaptation further increases the in-
Laxness of these guiding ligaments leads to loss traarticular pressure, initiating a vicious circle.
of coaptation and, in tum, to instability, unphys- The treatment of choice in all such cases is to
iologic loading of the joint surfaces, and prema- restore the translational gliding mobility in the
ture joint wear (flail joint, osteoarthritis). At the joint and, thus, restore angular rolling-gliding, in
same time, contractures of the capsule or liga- order to reestablish normal joint function. Trac-
ments and shortening of the muscles can alter tion and parallel gliding are applied therapeuti-
the uniform separation of the joint surfaces and cally to (1) separate the articular surfaces, (2)
hamper intra articular gliding, causing restric- tighten the joint capsule and its reinforcing liga-
tion of mobility. Contraction of portions of the ments, and (3) stretch the contracted portions of
capsule or ligaments shift the rotational axis for the capsule and ligaments of t/;le hypomobile
the gliding movement toward the side of the joint (Fig. 9 h). The starting point for the manip-
shortened or contracted structures (Fig.9j), ulation is not the resting position or the virtual
which prevents angular rolling-gliding corre- resting position in a restricted joint, where glid-
sponding to the axis because parallel gliding is ing is not obstructed. Experience has shown that
obstructed by the shift in the axis of movement increasing the joint play that is always present in
and the thus inadequate length of the ligaments. the resting position is not an adequate treat-
The area of contact that has lost its capacity for ment. Rather, the end point of the residual active
gliding becomes a new rotational axis. In the fur- motion range should form the starting point
32 Examination ofthe Spine

from which the restricted range of translational ed by rotating the spine in the opposite direc-
gliding is extended. I call this starting point the tion.
treatment position. If the translational tests demonstrate normal
joint play, the functionally related muscles must
be examined in greater detail (see p. 35).
Testing Joint Play
Since small translational movements are diffi-
cult to palpate, one of the joint members has to
be fixed manually and functionally. It is also of- Examination of the Spine
ten necessary, just as in treatment, to secure the
adjacent joint in a fixed position to avoid con- Examination of the spine differs from the exami-
comitant movements in that joint. This particu- nation of the extremity joints in that, besides the
larly applies to the closely spaced intervertebral two intervertebral facet joints, there is a third
facet joints. Immobilizing a joint in a locked po- mobile element, the intervertebral disk, that in-
sition (Fig. 9i) maximizes the contact area be- fluences the mechanics of the active segment and
tween the articular surfaces and presses them its susceptibility to dysfunction (J unghanns).
firmly together. The joint can be locked by posi-
tioning the joint capsule and reinforcing liga- Inspection
ments such that they are sufficiently taut to sta-
Congenital deformities such as kyphosis and sco-
bilize the joint and maximally restrain its motion
liosis; acquired deformities based on antalgic
in the direction of treatment.
posture, growth disturbances, and metabolic or
Joints in the vertebral column are locked by re-
inflammatory processes.
versing the physiologic joint mechanics, i. e., the
coupled rotation that accompanies sidebending
Motion Testing (Fig. 10)
of the spine. For example, if sidebending mobil-
ity between two vertebrae requires a conco- Active Motion Testing. The entire spine is tested
mitant rotation toward the side to which the in all three anatomic planes for restriction and
spine is bent, the desired locking can be achiev- deviation in one or more directions of motion.

Stabilizing muscles Normal jOint function

Axis of motion

Joint capsule

Fig. 9 j . Legend see page 33

Examination of the Spine 33

Pathologic joint function

~..,~-- muscle

Contracted ca psule

Cartilage d amage


Fig. 9 j.l-4 Models of restricted mobility joint. 1 Normal joint function. 2 Restricted mobility due to shorten-
ing of muscels, 3to contracture of the capsule, and 4 due to pathologic changes in the gliding surfaces
34 Examination of the Spine

Cervical Thoracic Lumbar

1-2 2-3 :i-4 4-5 5-6 6-7 1-2 2-3 3-4 4-5 5-6 6-77-88-99-10 HI-1111-12 1-2 2-3 3-4 4-5

Occiput- Cervico- Thoraco- Lumbo-

Atlas thoracic lumbar sacral
junction junction junction

Fig.tO. Spinal segmental mobilities during forward and backward bending, side bending, and rotation. Solid line,
Forward and backward bending; dashed line, side bending; dotted line, rotation

Passive Motion Testing. Motion is tested in all pled with a rotation of the vertebral bodies,
directions, proceeding by levels. which rotate toward the concavity of the curve
when the spine is ventrally flexed and toward the
convexity of the curve when the spine is dorsi-
flexed ("coupled rotation"). The amount of cou-
At Rest pled rotation depends on the position of the glid-
Superficial Palpation (Touch Palpation). Der- ing plane in the facet joint. Coupled rotation is
matomic changes with signs of a neurologic dis- always palpalted during side bending. The ab-
turbance (Kibler's fold). sence of rotation signifies a segmental dysfunc-
Deep Palpation (Palpation for Tenderness). tion.
Spasticity of the intrinsic muscles and long ex-
tensors; insertional tendinopathies at the
Joint Play (Fig. 11)
spinous processes; faulty position of individual
vertebrae. Tenderness of facet and costoverte- Disk Traction and Compression (Fig. 11 b)
bral joints. Traction involves the segmental decompression
of the intervertebral disks. The gliding apart of
During Movement the articular surfaces increases the craniocaudal
Segmental palpation of the excursions of the ver- diameter of the foramina, which causes a de-
tebra in all directions of passive movement compression of the nerve roots, accompanied by
(Fig.lO). Dorsiflexion (backward bending) a gliding movement in the facet joints. Compres-
causes maximal approximation of the interver- sion involves the loading of intervertebral disks
tebral facets (convergence) and increases the and emerging nerves as a result of the gliding to-
area of articular contact. Ventral flexion (for- gether of the facet joints, which leads to in-
ward bending) causes separation ofthe articular creased pressure on the disks and a restriction of
facets and the palpable spinous processes (diver- the intervertebral foramen.
gence) and reduces the area of articular contact.
Sidebending to the right causes the facet joints Facet Joint Play (Fig. 11 )
to converge on the right side and diverge on the Distraction of the facet joints in the cervical and
left side, while sidebending to the left produces thoracic spine is effected by backward move-
the opposite effect. Sidebending is always cou- ment and in the lumbar spine by rotational
Examination of the Muscles 35

proven, at least for restriction in the facet joints.

The motion deficit noted in a restricted segment
may well be caused by a hypertonic segmental
muscle response to nociceptive afference from
the vertebral segment. Moreover, the primary
nociceptive afference need not originate from
the facet joint itself but may come from, say, a
disk protrusion, which often cannot be reliably
distinguished from pure facet joint disturbances.
Fixed caudal
Some cases of facet joint hypomobility are due
vertebra to nociceptive afference originating outside the
spine (e. g., from the viscera).
H.D. Wolff, who has worked extensively with
the neurophysiologic aspects of hypomobile
joint dysfunction, believes that vertebral restric-
tion is a spinal and supraspinal response to noci-
ceptive afferent flow which, when relayed to the
second neuron in the posterior horn complex,
evokes corresponding motor, sensory, and auto-
nomic reactions.
The motor reactions consist of an increase in
muscle tone due to effects on the gamma loop
Stationary vertebra (the intrinsic control mechanism in muscle for
adjusting the stimulus threshold for muscle
Fig. 11 a,b. Translational joint movements in the tone). This leads to myalgias (lowered muscular
spinal segment
pain threshold), splinting, and myogelosis. The
autonomic effects caused by the linkage of the
posterior and lateral horns in the spinal cord in-
movement of the cranial vertebra relative to the volve the vasomotors, smooth muscle, and sweat
fixed adjacent vertebra below. In contrast, glid- glands. The pain sensations, like those arising
ing movements in the cervical and thoracic spine elsewhere (e.g., in the internal organs), are re-
are produced by cranial-caudal movement (di- ferred to the segmentally related skin zones
vergence-convergence) during flexion/exten- (Head's zones) or subcutaneous tissues (Kibler'S
sion or unilaterally by lateral flexion. The rota- zones).
tion that accompanies lateral flexion can be
detected by the lateral movement of the spinous
process relative to the fixed process below it
(Fig. 11 a). Translational gliding is produced in Examination of the Muscles
the lumbar spine by forward movement of the
caudal vertebra relative to the fixed adjacent Examination of the muscles is not entirely sepa-
vertebra above. rate from the examination of the joints and ner-
The purpose of testing translational mobility in vous system (see pp. 24 and 42) because the mus-
the individual segments is to detect vertebral re- cle contains peripheral receptors of the afferent
strictions (hypomobile or absent joint play) or nerve pathway and is also an end-organ of the ef-
hypermobility. The question arises whether ferent pathway. Thus, a question that always
there can in fact be a primary mechanical restric- arises during the examination is whether a dis-
tion in joints, aside from trapped menisci and in- turbance of muscular function is primarily myo-
traarticular loose bodies in the joints of the ex- genic or neurogenic. The muscle examination
tremities. So far no such analogies have been gives information on the condition of:
36 Examination of the Muscles

- the muscle itself Movement patterns arise through the interac-

- the tendon attachments tion of conditioned and unconditioned reflexes.
- the nerve pathway They develop during ontogenesis and include all
repetitive motor sequences that are carried out
Muscle Groups
during the activities of daily living. Because they
From a mechanical standpoint, we can distin- are largely specific for the individual, an individ-
guish the following types of muscle groups in ualized pattern tends to emerge. This pattern,
each direction of joint movement (after Janda): which forms gradually from the innervation of
The agonists (main muscles) are the main effec- individual muscles that is present shortly after
tors of the tested movement. They also perform birth, is controlled initially by the cortex and lat-
an auxiliary function in other directions of er by subcortical centers. The learning of move-
movement. ment patterns is a stringent task which accounts
Synergists (auxiliary muscles) do not effect the for the rapid fatigability of infants and small chil-
tested movement but act in the same direction as dren. In later life as well, the acquisition of new
the agonists and thus perform an auxiliary func- patterns in work and sports is fatiguing until the
tion. These muscles function chiefly in a different new motor sequence has become routine and
direction. They are temporally coordinated with can be performed with less effort (training ef-
the agonist but are anatomically separate from it. fect). Frequently, faulty movement patterns that
They support the main muscle and can partially have developed through environmental influ-
replace its function. Synergy refers to a muscle ences have to be restructured. The rapidity and
group composed of agonists and synergists. skill with which new patterns are acquired and
Antagonists act in opposition to the action of the faulty patterns are restructured depend on the
agonists. When the agonists are active, the an- learning ability of the brain.
tagonists are tense and stretched without limit- An ideal pattern, in which only those muscle
ing the normal range of motion. Restriction oc- groups are activated that can effect the desired
curs only if there is reflex splinting (nociceptive movement efficiently with minimum effort, is
co-contraction) or shortening of the muscles. practically nonexistent. Far more common are
Stabilizing muscles do not participate in the test- faulty movement patterns resulting from an im-
ed movement. They tend to fix the tested body balance of antagonistic muscles. The occurrence
region in a position favorable for exercise. Poor of these imbalances is due largely to the exis-
stabilizing muscles can simulate paresis of the tence of two functionally distinct types of striat-
agonists. During muscle tests, therefore, the ex- edmuscle:
aminer himself should fix (stabilize) the exam-
1. Postural tonic "slow-reacting" muscles, which
ined body part proximal to the tested joint in or-
perform the predominantly static function of
der to deactivate the stabilizing muscles. The
postural maintenance. The neurophysiologic
general rule is: fixation by the examiner is neces-
control of these muscles requires a constant
sary for the testing of polyarticular muscles,
nominal value for muscle length and tension,
weak muscles, and for muscle testing in children.
even when variable extrinsic forces are ap-
Neutralizing muscles are muscles that abolish
(neutralize) the auxiliary function of the main
2. Phasic "fast-reacting" muscles, which are
muscle but often support the tested movement
needed for the differentiated movements of
effected by the agonist. While the main move-
daily living. Muscle length and tension must
ments add together, the auxiliary movements
be rapidly adjusted by higher centers in re-
cancel out. The auxiliary function of the syner-
sponse to changing demands on the muscles.
gists can be used to differentiate the various
muscles of a synergy. A muscle can function si- All the muscles in the body have both a postural
multaneously as a synergist and a neutralizer. (tonic) and a phasic component, their ratio de-
All these muscles work in a functional relation- termining the definitive function of the muscle
ship called a "movement pattern." in a movement pattern. Every movement pat-
Examination ofthe Muscles 37

tern can, moreover, vary during the individual's Hip adductors: Pectineus, adductor longus, bre-
lifetime as a result of maturation and changing vis, and magnus, gracilis
demands. External rotators of the hip: Piriformis
The postural "red" muscles (Fig. 12) are phylo- Extensors of the spine: Erector spinae (longis-
genetically older, have a better blood supply and simus dorsi, multifidi, rotators)
lower O 2 demand, are prone to shortening and Elevators of the shoulder girdle: Trapezius (su-
contracture, are less subject to fatigue, have a perior portion), levator scapulae, sternocleido-
lower stimulus threshold, and are slower to atro- mastoid
phy. Muscle shortening, unlike contracture, is Other: Pectoralis major (sternal portion),
reversible because it merely involves a change in quadratus lumborum
elasticity. The principal postural muscles are: The phasic "white" muscles are phylogenetically
Plantar flexors: Triceps surae, gastrocnemius, younger, prone to weakness, fatigue rapidly,
soleus have a higher stimulus threshold, and atrophy
Knee flexors: Hamstrings (biceps femoris, semi- more quickly than the tonic muscles. The phasic
tendinosus, semimembranosus) muscles include:
Hip flexors: Psoas, rectus femoris, tensor fasciae Dorsiflexors of the foot: Tibialis anterior,
latae peronaei

.....-- - - - M. e
l vator scaputae
....._---- M. trapezius

,-+'\-_ _ __ M. pectora lis major

r---HH-+-it--- M. errector spinae

Flexors of the hand

m - ; - ;'\-It+\-- M. Quadratus .I"'ti- - - - and fingers

Hamstring group :
.""'t-'P--J'--- - - Adductor group

Ilr .• ft-'H'----- - - M. semitendinosus +-- - - - - M. rectus femoris

+-- - - - - M. bic eps femoriS

/ - - - - M.gastrocnemius

, .- -- - - - M. soleus

Fig. 12 a, b. Tonic muscles prone to shortening (after Janda)

38 Examination of the Muscles

Knee extensors: Vastus medialis and lateralis the apparatus is stimulated by stretch and simul-
Hip extensors: Gluteus maximus, medius, min- taneously facilitates the antagonist.
imus Tho structures playa key role in this control of
Abdominal muscles: Rectus abdominis, obliqu- muscular function, muscle spindles and Golgi
us externus and internus tendon bodies. The muscle spindles, which mon-
Inferior scapular stabilizers: Serratus anterior, itor change in muscle length, are arranged paral-
trapexius (middle and inferior portions), rhom- lel to the working muscle fibers and thus can
boids sense and respond to muscular stretch. The pro-
Superficial and deep neck flexors: Scaleni prioceptive afference from the muscle spindles
Other: Pectoralis major (inferior portion) acts at the spinal level to stimulate the a mo-
Imbalances between these two muscles groups toneurons in the anterior horn. This causes the
arise when the postural muscles, prone to short- muscle to contract until the length change in the
ening, inhibit the phasic antagonists at the spinal muscle spindle is reversed and the correspond-
level (weakening them to grade 4 or 3 in muscle ing proprioceptive input is terminated, thereby
strength tests). This can result in a faulty joint abolishing the contractile stimulus from the a
position that can accentuate the muscle imbal- motoneurons.
ance through proprioceptive feedback, setting The Golgi tendon bodies perform a complemen-
up a vicious cycle. The faulty movement pattern tary function to the muscle spindles. When ten-
can also be aggravated by the recruitment of sion in the muscle becomes excessive, they exert
synergists for the weakened muscle. an inhibitory effect on the a motoneurons, caus-
A position change of a few degrees in a joint fa- ing the muscle to relax. Their function may un-
cilitates (stimulates) the shortening-prone mus- derlie the muscle-relaxing effect of vibratory
cles that are functionally related to the joint and massage over the tendon attachment, for
inhibits (weakens) the antagonistic muscle example.
group. The stimulus threshold within the control sys-
The following reflex mechanisms are useful for tem is adjustable to ensure that the system is
the examination of movement patterns: flexible enough to adapt to changing demands.
Reflex effects originating from the joint: The y loop can raise the muscle tone in the face
of nociceptive afference and can sustain the
- An altered joint position facilitates postural
higher setting as long as the nociceptive inflow
muscles and inhibits phasic muscles.
persists. This process underlies the phenomenon
Reflex effects originating from the muscle: of muscle splinting and, in longer-standing cases,
myogelosis. The influence of psychological and
- Postural muscles inhibit phasic muscles.
autonomic effects on the y system can account
- Agonists inhibit the antagonists, which in turn
for some psychosomatic phenomena.
facilitate the agonists.
- Rapid activation of a muscle facilitates the an-
Examination ofthe Muscles During the Basic
tagonist as a protective mechanism (co-con-
Physical Examination
Inspection. Individual movement pattern during
- Maximum activation (contraction) of a mus-
ordinary actions (gait, posture, working posi-
cle causes a very brief postfacilitation inhibi-
tions); muscle contour changes due to atrophy,
tion (i. e., relaxation) that can be utilized ther-
hypertrophy, or injury (torn muscle).
- In the muscle: the muscle spindle, when
Active Motion Testing. Paresis, see Isometric
stretched, facilitates contraction of its parent
Resistance Tests, p.4l; Coordination distur-
muscle while simultaneously inhibiting the
bances. Marked general muscular hypotoni-
city in infants and small children is an early
The Golgi apparatus in the tendon attachment sign of neuromuscular disease ("floppy in-
inhibits (relaxes) the associated muscle when fant").
Examination of the Muscles 39

Passive Motion Testing. Alterations of tone, erative spinal processes, neuritis, poliomyelitis,
muscle shortening, contractures. or tumors. Disuse atrophy can occur after pro-
longed immobilization and sometimes after in-
Palpation. Touch palpation: hypo- or hypertonic jections.
changes. Pressure palpation: tenderness of mus- ' Neurogenic muscular atrophy is never seen in
cles and tendon attachments (tender points; see central paralytic states. Muscular atrophy in the
palpation tables), splinting, myogelosis. setting of myopathies (e. g., progressive muscu-
lar dystrophy, myositis, endocrine myopathies)
Resistance Tests. Pain (tendon attachments) and occurs in the presence of an intact reflex arc and
strength are tested by isometric resistance tests, is not associated with other neurologic symp-
strength (muscular weakness, true paresis) by toms.
isotonic resistance tests. Congenital muscle defects have been described
for the pectoralis, lateral serratus, trapezius,
Special Diagnostic Procedures infraspinatus, sternocleidomastoid, palmaris,
Radiography: sclerosis of the tendon attach- psoas, quadriceps femoris, tibialis anterior, and
ments, calcium deposits peroneus brevis muscles.

Laboratory studies: creatine, creatinine, en- Hypertrophy

zymes (CPK, aldolase, LOR, GOT, GPT) True hypertrophy, such as that in athletes, has a
firm consistency on palpation, whereas pseudo-
Electrodiagnostic studies: peripheral electrodi- hypertrophy feels flaccid.
agnosis, EMG
Muscle biopsy: see one of the relevant guides
Generalized hypertrophy is physiologic in ath-
Findings of Muscle Examination letes, pathologic in myotonia congenita.
Local hypertrophy may involve the calf ("gnome
Inspection calf"), quadriceps femoris, pectoralis, deltoid,
Muscle Contour Changes brachioradialis, or extensor digitorum brevis in
Changes in muscular contours are detected by cases of progressive muscular dystrophy and
comparison with the opposite side. The differ- spinal muscular atrophy.
ence in muscle volume is determined by girth
measurements. Motion Testing
Atrophy Active Motion Testing
Mild degrees of muscular atrophy are demon- Regarding paresis, see Isometric Resistance
strated more clearly by side-illumination. Atro- Tests, pAl. Coordination disturbances involve
phy generally results from paresis of the periph- disturbances of motor control with regard to the
eral neuron, and the site of the causative lesion force and temporal sequence of muscle activa-
(root, plexus, peripheral nerve) must be ascer- tion. Incoordination can occur:
tained. Muscular atrophy may be masked by
overlying subcutaneous fat. Edema and varicose - in an individual muscle
veins can also make it difficult to compare the - in a synergy
muscle girth with the opposite side. - between antagonists
- in completely independent muscle groups
Generalized atrophy in consumptive diseases or Uncoordinated movements lead to:
alimentary, senile, and cancer cachexia. - impaired performance
Local atrophy from lesions of peripheral - premature fatigue
nerves or nerve roots caused by trauma, degen- - faulty (increased) joint loading
40 Examination of the Muscles

Passive Motion Testing (for Muscle Shortening) Tone

Passive motion testing is usually performed im- The muscle tone may be increased or reduced.
mediately after the terminal phase of an active This can be assessed by comparison with the mus-
movement. As noted earlier, if further passive cle when it is tense (during the resistance test).
movement of the joint is not possible, it must be Hypotonicity is noted inweakened, paretic mus-
determined whether the cause lies in the joint cles.
itself (contracted capsule or mechanical block- Sustained hypertonicity is palpable as muscle
age), or whether terminal passive (and active) splinting incited reflexly by disturbances in the
movement are restricted by muscle splinting or related joint or spinal segment. A splinted mus-
shortening. cle is usually very tender to palpation.
If articular function is intact, the problem gener- Myotendinoses are circumscribed hard areas,
ally relates to a shortened muscle participating in oriented parallel to the course of the muscle
a faulty movement pattern. In this case all poten- fibers, which develop after prolonged splinting.
tiallyoffendingmuscles that are prone to shorten- Most common in poorly perfused areas about
ing must be examined. These muscles are listed on the origins and insertions of muscles, they prob-
p. 37. Thepsoasis the premier muscle in the pelvic ably result from the accumulation of fatigue
girdle, the pectoralis major in the shoulder girdle. products (lactic acid) following overuse. Myo-
tendinosis is less painful than splinting. Since
Muscle Stretch Tests both conditions diminish the local pain thresh-
These tests are conducted on the postural mus- old, they are a source of spontaneous pain dur-
cles that are prone to shortening. The muscle is ing exercise.
passively stretched to lengthen it while increas- Maximal points or trigger points (usually in the
ing its internal tension. region of tendon attachments) are most com-
The passive stretch should test the elastic limit of monly found in the following muscles (after Le-
the muscle without exceeding it. A healthy mus- wit):
cle presents a soft elastic end-feel. If motion is
limited due to causal factors unrelated to the - The adductors with disturbances of the hip
joint or CNS (spasticity), muscular shortening joint and sacroiliac joint (symphyseal region)
may be diagnosed. It is not caused by active mus- - The psoas with hip disturbances (lesser
cular contraction, increased activity of the ner- trochanter) and restrictions of the lower tho-
vous system (no increase in EMG activity), or racic segments. Cubis regards the psoas as the
reflex splinting. As noted earlier, shortening is indicator muscle for restricted thoracic verte-
most apt to affect the muscles of postural main- brae.
tenance, such as the leg muscles required for - The iliacus with a sacroiliac lesion (pelvic tor-
one-legged stance (loads in the stance phase of sion) and lumbosacral restrictions
gait are 85% those in one-legged stance) or the - The piriformis with restrictions of the IA/L5
arm muscles that are used for grasp. segment
The examination is conducted basically accord- - The segmental muscles of the erector spinae
ing to the same rules as the isotonic resistance with vertebral restrictions (segmental irrita-
tests described below. tion points)
- The pectoralis and interscapular muscles with
Palpation disturbances of the upper costotransverse
The examiner palpates the fully relaxed muscle
- The deltoid with disturbances in the shoulder
with the flat hand, gently palpating through the
joint (deltoid tuberosity)
superficial layers (skin and connective tissue).
The muscle is palpated over its entire course; -Note
tendinous areas are palpated in the direction of In myositis ossificans, muscle becomes ossified
their fibers, and the muscle belly at right angles due to the retraumatization (e. g., by massage) of
to its fibers. injured muscle tissue that has not completely
Examination ofthe Muscles 41

healed. The quadriceps femoris and adductors on the tendinous attachment to bone. The find-
are particularly susceptible (e. g., in riders, soc- ings can be interpreted as follows.
cer players, and ice hockey players).
Nonnal Finding
Resistance Tests The muscular contraction is strong and pain-
Up to this point, muscular function has been less.
evaluated by active motion testing (movement
pattern) and passive motion testing (for muscle
Pathologic Findings
shortening). The next step is to test the muscles
1. The contraction is strong and painful = mild
specifically for strength and pain. When testing
musculotendinous damage
muscle strength, several distinctions must be
2. The contraction is weak and painful = severe
made (according to Krejci and Koch):
musculotendinous damage
Maximum strength: the maximum force that a
3. The contraction is weak and painless = neuro-
muscle can develop to overcome a resistance,
logic lesion (paresis)
without regard for speed of movement. It is in-
creased most effectively by isometric exercises.
Isotonic Strength Tests
Power: the "explosive capability" of a muscle to
In these tests, shortening contraction of the
surmount a resistance at high speed. Power is
muscle affects movement. The tendon is
improved by isotonic training.
stretched but remains under constant tension.
Endurance: the length of time a force can be ex-
The patient should first perform the movement
erted until fatiguing occurs.
without correction (individual movement pat-
Strength, power, and endurance are mutually in-
tern). Then the strength of weakened or paretic
terdependent parameters.
muscles is tested according to the following
rules (Janda).
Isometric Resistance Tests for Pain
1. Test the complete range of movement slowly
and Strength
at a constant speed.
The resistance tests ("resisted movement," Cy-
2. Throughout the test, apply a constant resis-
riax) furnish information on muscle strength and
tance acting opposite to the direction of the
the tenderness of tendon attachments due to
movement. Do not apply resistance across
traumatic, degenerative, or inflammatory pro-
two joints.
cesses. The tendon attachments can be palpated
3. Limit the movement to only one joint.
while the resistance test is being performed. The
4. Fix the proximal joint member securely.
synergy is first tested against a maximum resis-
5. Do not press on the tendon or muscle belly
tance, starting either from the intermediate po-
sition (favorable working position) or from the
position of maximum stretch (unfavorable The test should be performed against maximal
working position), in which case pain may result resistance.
from the increased intraarticular pressure. Pain The test findings, i. e., muscle strength, are grad-
can be differentially assigned to a particular ed from 0 to 5 as follows:
muscle of the synergy by testing other synergies Grade 5 (100%) Moves joint against maximal
in which the muscle of interest is also active as an resistance
agonist or synergist. Grade 4 (75%) Moves joint against strong re-
Very little resistance should be used in testing an sistance
individual muscle to avoid activating the whole Grade 3 (50%) Moves joint against gravity
synergy. The resistance prevents shortening of Grade 2 (25%) Moves joint but not against
the muscle, and thus prevents movement. The gravity
resistance stretches the (elastic) tendinous por- Grade 1 (10%) Palpable contraction only
tion of the muscle and places increased tension Grade 0 (%) No contraction
42 Examination ofthe Nerves

The results can be further differentiated by rat- 5. Weakness

ing the individual grades (especially grade 4) - Reflex (inhibition)
as + or-. - Stretch-related (?)
The antagonists of postural muscles that are - Structural, neurogenic, myogenic
weakened by spinal inhibition usually score no - Disturbed movement pattern
better than grade 4 or (rarely) grade 3. More se-
vere degrees of paresis are generally due to neu- Muscular imbalance is a relational disturbance
rologic disease. affecting muscles with different actions. The dis-
The test cannot evaluate fatigability during pro- turbance may involve tension, activation, or
longed exertion. A gross assessment, without strength.
the formal grading of muscle strength, can be
made by comparing the responses of the right
and left sides to the same test. Examination of the Nerves
The muscle tests are not useful in patients with
central (spastic) paralysis or a primary muscular
Disturbances of joint mobility (material) are
disease (myopathy). The mimic muscles can be
caused chiefly by incipient or overt morphologic
tested only by comparison with the opposite
changes, and muscular dysfunctions (energy)
are usually considered a reflex response to these
The individual tests are described at the appro-
articular changes. But they can also result from a
priate places in the diagnostic program.
primary neurologic disorder (control), since
functional disturbances ofthe muscles and ner-
Pathologic Muscle Findings
vous system produce largely identical symp-
The following pathologic findings may account
toms. Thus, in dealing with purely functional
for a limitation of motion during muscle testing:
disturbances of the joints and muscles, it is
1. Increased resting tone (spasm, hypertonicity) important to establish the origin of the nocicep-
tive afference and the (morphologic) cause of
- Localized, circumscribed
the irritation so that effective causal treatment
• trigger point
can be provided.
• muscular maximal point
Localization of the irritation site is aided by the
• segmental irritation point
symptom complexes typically associated with
• myosis
specific lesion sites. These symptom complexes
- Tension increase in a whole muscle or muscle
are discussed in the section on Differential Diag-
nosis of Nerve Lesions (p.46).
- Generalized increase in muscle tone (e. g., fi-
In a synoptic interpretation of the spinal and
joint examinations, a general examination of the
2. Muscle shortening nervous system is conducted as part of the basic
physical examination. It consists of:
- Reflex shortening
- Reversible structural shortening
- Irreversible structural shortening (contrac-
ture) - Body symmetry and contours: muscular atro-
phy or hypertrophy (see Examination of the
3. Decreased resting tone (hypotonicity) Muscles)
- Reflex hypotonicity (inhibition) - Complex motor sequences, ordinary move-
- Peripheral paresis ments (gait, etc.), innervation, coordination
- Spontaneous muscular contractions (espe-
4. Impaired muscular activation cially with damage to the central neuron and
- Disturbed movement pattern subcortical centers) (see p.43)
- Paresis - Trophic skin changes (see p.44)
Inspection 43

Active and Passive Motion Testing Special Neuropathologic Findings

- Active: the entire neural pathway (innerva- During the Basic Physical
tion, coordination) Examination
- Passive: sensitivity to nerve stretch (on mus-
cle tone, see also Examination of the Muscles,
The neurologic findings described in this section
are limited to those that are noted with some fre-
quency during the regional physical examina-
- Autonomic disturbances (impaired blood tion and are characteristic of a joint or a particu-
flow and sweat secretion) lar body region.
- Nerve pressure points (Valleix pressure
points, irrigation points, see Palpation Zones)

Muscle Tests I Inspection

- Motor disturbances involving muscular syner-
Complex Motor Sequences
gies or individual muscles during resistance
testing Gait
Normal findings (see p.72), pathologic findings
(see pp. 73f.).
Neurologic junction testing is always indicat-
ed if the basic physical examination has dis- Ordinary Complex Movements
closed evidence of a primary lesion of the Sitting down - standing up
nerve pathway. Undressing - dressing
Lying down - sitting up
In this case adjunctive neurologic studies (N) are
Pathologic Findings
performed to test the reflexes and indicator
Flaccid pareses and coordination disturbances.
muscles (N1)' sensation (superficial and deep
sensation; N2), motor function (root, plexus, pe-
Spontaneous Muscular Contractions
ripheral nerve; N3), coordination (N4)' and cra-
nial nerves (Ns). Spontaneous muscular contractions can occur in
These studies may have to be supplemented by the calf muscles and the small muscles of the
special diagnostic procedures (S) performed by a hand, even in healthy individuals.
neurologist or radiologist:
Sl Special neuroradiologic investigations
Pathologic Muscnlar Contractions
S2 Laboratory studies: CSF analysis, Ninydrin
test (of Moberg) With Inability to Move
S3 Cerebral angiography Spasms (muscle cramps): painful muscular con-
S4 Electrodiagnostic studies: peripheral elec- tractions accompanied by painful limitation of
trodiagnosis, electromyography (EMG), motion, usually involving the lower extremities.
nerve conduction velocity, electroen- Frequent at night in response to cold or mechan-
cephalography (EEG), echoencephalogra- ical insult.
phy Tetanic muscle spasms in the hands and feet (car-
Ss Special examinations of the sensory organs popedal spasms) or involving the mimic muscles
(by a specialist) (facial tetany).
Obstetrician's hand, Trousseau's phenomenon-
accentuated by hyperventilation or an upper
arm tourniquet (3-5 min). Pronation of the foot
44 Inspection

on percussion of the peroneal nerve at the fibu- Jacksonian seizures: coarse, slow, rhythmic
lar head (peroneal nerve sign). clonic movements that may spread from a cir-
cumscribed area to adjacent muscles or the
Without Movement ofJoints whole body (Jacksonian epilepsy); secondary
Fibrillary and fascicular contractions: lightning- to lesions about the cerebral cortex (trauma,
like contractions of individual muscle fibers or vascular diseases, inflammatory diseases, tu-
fiber bundles secondary to anterior horn lesions mors).
or nerve/root lesions; can be triggered by cold
exposure in healthy individuals. Uncoordinated Movements
Myokymia: slower, irregular, quivering contrac- Torsion dystonia: slow, twisting movements of
tions involving large muscle areas; occurs after the head, neck, and trunk. Usually the head is
cold exposure and rarely in polyneuropathies. maximally rotated and cannot be voluntarily
turned forward, although it can do so against a
With Movement ofJoints resistance; seen with extrapyramidal lesions;
Tic: lightning-like muscular contractions involv- never psychogenic. Etiology is usually obscure.
ing a specific region (e. g., the facial nerve); may Athetoses: slow, writhing movements caused
be due to an organic brain lesion (e. g., posten- by alternating contraction of agonists and an-
cephalitic) or psychogenic. tagonists. Flexion-extension movements are
Myoclonus: individual or repeated, jerky mus- most pronounced in the extremities (fingers,
cular contractions of variable location; occur in toes), less so in the trunk, neck, and face. Bayo-
cerebrovascular sclerosis and postencephalitic nette-like finger positions. Secondary to early
states (midbrain lesion). childhood brain damage or brainstem syn-
Rhythmic Oscillatory Movements Chorea: brief, rapid, irregular, uncoordinated
Tremor most commonly affects the distal por- movements of varying intensity and location af-
tions ofthe extremities and the head (nodding or fecting the extremities, trunk, and face (grimac-
head-shaking tremor). ing, Vitus' dance). Accentuated by emotional
Several types can occur: stress. Occurs in chorea minor (rheumatism)
and other organic brain diseases (striatum).
1. Resting tremor, which is accentuated by emo- Hemiballism: rapid, forceful, slinging move-
tional stress and decreased by voluntary ments of the arm or leg on one side of the body,
movement. Fine tremor is seen with nervous- secondary to lesions of the thalamus and sub-
ness and hyperthyroidism, moderate tremor thalamic nucleus. The movements are intensi-
with cold and fatigue, coarse tremor with ex- fied by external stimuli and disappear during
cessive alcohol or drug use (essential tremor). sleep.
2. Intention tremor: coarse, jerky tremors that
are intensified by purposeful movements; due Trophic Disturbances (Chiefly Involving
to cerebellar lesions. the Hands and Feet)
3. Psychogenic tremor: coarse tremor affecting
Vasomotor impairment: initially hyperemia and
the proximal portions of the extremities; dis-
redness, later cyanosis and skin coolness.
appears when the patient is distracted or un-
Sudomotor impairment.
Skin atrophy: thin, smooth skin with flattened
All types of tremor are relieved by sleep and cutaneous ridges on the bulbs of the fingers.
general anesthesia! Hyperkeratoses.
Myorhythmias: very rapid, fine vibrations, Abnormalities of hair growth.
chiefly affecting the mimic muscles, also the soft Nail changes: increased transverse convexity of
palate; secondary to brainstem lesions. the nails, transverse ridges or pale bands (Mees'
Myorhythmias are not relieved by sleep or gen- stripes), thickened ridge of skin beneath the end
eral anesthesia. of the nail (nail-bed sign of AlfOldi).
Palpation 45

These include rapid, passive trunk rotations by

Active and Passive Motion Testing passive twisting of the shoulder girdle, and pas-
sive shaking movements of the forearm and
hand (wrist muscles).
Active Motion Testing
1. Hypotonicity (i. e., no resistance). The distal
The complete neural pathway is tested, including
extremities have a "rag doll" limpness. Hypo-
the central nervous system and the psychic will-
tonicity can result from lesions of the periph-
ingness of the patient.
eral nerves or pyramidal tract (acute stage),
cerebellar lesions, extrapyramidal diseases, or
Normal Findings myopathies.
Strong, painless, coordinat d movements. 2. Hypertonicity occurs in two forms:
Spasticity: Springy resistance to normal and
rapid passive movements, diminished at rest.
Pathologic Findings Secondary to cerebral or spinal lesions involv-
1. Painful active and passive limitation of mo- ing the pyramidal system.
tion [radicular irritation, nociceptive somato- Rigor: Firm, increasing resistance to passive
motor blocking effect (Brugger 1962)]. motion, unaffected by rest. Often presents as
2. Painless limitation of motion (paresis, paraly- a series of "catches" during passive motion
sis). (cogwheel phenomenon). Secondary to ex-
3. Coordination disturbances. trapyramidal diseases.
3. Poikilotonia: alternation between hypotonic-
Passive Motion Testing ity and an irregular rigor of varying intensity
and duration, seen in Huntington's chorea and
This tests the sensitivity of the nerve trunks to
stretch and muscle tone.

Normal Findings Palpation

No nerve stretch pain over the physiologic
range of joint motion.
o hypo- or hypertonicity. Autonomic Nervous Disorders

Normal Findings
Pathologic Findings Warm, moist skin of normal hue showing no
Nerve Stretch Pain significant visible or palpable sweat ecretion
at rest. Palpable nerve pathways are not thick-
1. Nerve stretch pain is a neuralgic (sharp, stab- ened or tender to palpation.
bing, or tearing) pain that radiates to the distri-
bution of the nerve or nerve root (dermatome).
It is perceived as superficial and welllocalized. Pathologic Findings
2. Muscle stretch pain is perceived as a dull or Dryness (anhidrotic area) is noted when the skin
gnawing pain that is poorly localized and oc- is stroked with the fingertip or back of the hand.
curs at a deeper level (myalgic pain). It is ag- Anhidrosis occurs with lesions of the peripheral
gravated by increasing muscle stretch. nerves or nerve plexus for all forms of sweat
secretion, whether thermoregulatory or in re-
Dystonias sponse to pharmacologic stimuli (peripheral
If passive joint movements show evidence of ab- dyshidrosis). With a preganglionic lesion (proxi-
normal muscle tone (hypo- or hypertonicity), mal to the sympathetic trunk), only centrogenic
this can be checked by special tonicity tests. (thermoregulatory) sweating is affected, while
46 Symptoms of Nerve Lesions by Location

sweating in response to drug stimuli (e. g., pilo- - monoparesis or monoplegias = partial or com-
carpine) is preserved = central dyshidrosis. This plete paralysis of one extremity.
occurs with intramedullary lesions and the in- By their degree:
traspinal compression of nerve roots by a herni- - paralysis (plegia) = complete paralysis
ated disk or tumor. Lesions above T21T3 and - paresis = incomplete paralysis.
below L3 do not affect sweat secretion due to the By the site of the lesion:
absence of efferent sweat fibers past those levels. - peripheral paralysis (peripheral neuron)
- central paralysis (central neuron).
Nerve Pressure Points
Diffuse sensitivity to nerve percussion is noted
distal to sites of nerve injury (Hoffmann-Tinel
sign). Symptoms of Nerve Lesions
by Location
Thickening of Nerve Trunks
Diffuse thickening of peripheral nerves is a fea- Lesions at different sites give rise to characteris-
ture of "hypertrophic neuritis," a special form of tic findings and frequently produce a character-
neural muscular atrophy. istic clinical picture.
Nodular thickenings are found in neurofibro-
matosis (von Recklinghausen's disease) and 1. Muscular Nociceptive Symptoms
leprosy. (Nociceptive Reaction of Wolff)
I Muscle Tests - Occur reflexly due to stimulation of joint noci-
ceptors by mechanical stresses (increased
Motor disturbances of individual muscles or syn- intraarticular pressure) or inflammatory
ergistic groups usually are already apparent dur- changes about the joint (articular surfaces
ingthe active and passive motion testing of ajoint. and/or capsule and ligaments). The location
Resistance and shortening tests further establish and function of proprioceptors and nocicep-
whether the cause of the disturbance is a faulty tors in the joints are summarized in Table l.
movement pattern or a true nerve paralysis. Nociceptive symptoms are probably also
caused by proprioceptive and especially noci-
ceptive input from pressure changes in the
subchondral layers at the momentary contact
Differential Diagnosis area between the articular surfaces.
of Nerve Lesions - Faulty muscular control (faulty movement
Pain and deficits are extremely diverse accord- Complaints: Myalgic pain: dull, boring, tearing,
ing to the location of the lesion. Clinical mani- burning; motion-dependent.
festations depend chiefly on the location and Inspection: Fasciculations to contracture.
severity of the damage. Active Movements: Restriction of terminal joint
Nerve paralyses are distinguished: motion, and rapid fatigability to paresis of seg-
By their location: mentally related muscles.
- tetrapareses or tetraplegias = partial or com- Passive Mobility: Rigor-like hypertonicity (of-
plete paralysis of all four limbs, ten with cogwheel phenomenon) to restriction
- parapareses or paraplegias = partial or com- in the direction of painful motion ("nociceptive
plete paralysis of both arms or legs, somatomotor blocking effect" of Brugger).
- hemipareses or hemiplegias = partial or com- Palpation: Myogeloses, trigger points at tendon
plete paralysis affecting one side of the body, attachments, segmental irritation zones.
Symptoms of Nerve Lesions by Location 47

Differentiating featores of peripheral and central paralysis:

Peripheral neuron Central neuron

(past anterior horn (in brain or spinal cord)
motor cell)
1. Inspection Muscular atrophy No muscular atrophy
2. Active movements Paresis or paralysis No paresis or paralysis
3. Passive movements Hypotonicity Hypertonicity
4. Reflexes H ypo- or areflexia, no Hyperreflexia, pathologic
pathologic reflexes reflexes
5. Special tests: Degeneration reaction No degeneration reaction
electro diagnostic Lengthening of chronaxy,
studies increase in rheobase

Autonomic Disturbances: Trophic disturbance loint Play: Pain aggravated by compression (im-
(circulatory impairment) may occur. paction, coughing, sneezing).
Neurologic Deficits: None. Neurologic Tests: Radicular neurologic deficits
after hours to days; require differentiation from
2. Symptoms of Peripheral Nerve Lesions peripheral nerve irritation.
Etiology: Exogenous pressure due to trauma Reflexes: Muscle stretch reflexes are not consis-
(including avulsions) or inflammatory changes tent with symptoms of a peripheral nerve lesion.
(e.g., herpes zoster, neuritides), intoxications, Sensation: Disturbance essentially limited to
tumors (entrapment syndromes). pain sensation, since the overlap for the pain
Polyneuropathies are usually caused by meta- zones is smaller than for other sensory modali-
bolic disturbances (e. g., diabetes). ties.
Complaints: Local pain radiating distally and Motor Function: With monoradicular deficit,
proximally along the course of the nerve. paresis of corresponding indicator muscles; with
Inspection: Atrophy (late symptom). polyradicular deficits, again no correlation with
Sensation: Hypo- to anesthesia, paresthesias. a peripheral nerve lesion.
Motor Function: Pareses with corresponding Autonomic Disturbances: No sudomotor or va-
EMG changes. somotor disturbance or impaired piloerection,
Autonomic Disturbances: Diminished sweat se- since autonomic innervation is via the sympa-
cretion. thetic trunk (T21T2 to L2/L3). With a lesion of
multiple adjacent roots, irritative phenomena
3. Radicular Symptoms may be present but do not correspond to the
Etiology: Approximately 90% caused by pro- analgesic areas.
lapsed disk impingement on the spinal root, also
by irritation from osteochondrosis and spondy- Symptoms of a Caudal Lesion
losis (spurring). Caused by medial disk prolapse (acute) or tu-
Complaints: Neuralgic pain radiating to the cor- mors (gradual).
responding dermatomes. Pain: Intractable "sciatica."
Reflexes: Loss of knee jerk, ankle jerk, and ad-
Symptoms of Disk Herniation ductor reflex.
Inspection: Painful postural abnormality. Sensation: "Saddle block anesthesia."
Active and Passive Motion Testing: Severe, Motor Function: Paresis of both triceps surae
painful limitation of motion. and the small muscles of the foot; bladder and
Palpation: Paravertebral muscle splinting. rectal paralysis.
48 Symptoms of Nerve Lesions by Location

4. Symptoms ofPlexus Damage Practical Relevance of the

Etiology: Trauma or tumors. Plexus damage is Structural Analysis of Function
uncommon in the lumbar region owing to the
protected position of the plexus. Entrapment
The uniting of material (joints) and effectors
syndromes do not occur in the lumbar region but
(muscles) by the control system (nerve path-
may occur at the cervical levels.
ways) into a functional unit not only forms the
Motor Function: Paresis or paralysis of entire
basis for the smooth, coordinated function of the
muscle groups. Rapid atrophy of the affected
joints of the locomotor apparatus but also pro-
vides a reliable mechanism for the detection of
Sensation: Sensory disturbances in the region of
functional disturbances and structural defects.
the damaged portions of the plexus.
Reflexes: Losses consistent with the location and
extent of the plexus damage.
Autonomic Disturbances: Homer's syndrome How Does the Control and Warning
(cervical) and other autonomic signs (degenera- System Function?
tion reaction).

5. Symptoms Due to Disturbances
Involving the Neuromuscular Junction Proprioception is concerned with the control of
or Muscle Fiber posture and movement and the orientation of
the body in space. It relies on afferent input from
the mechanoreceptors - the sensory end-organs
Inspection: No atrophy or fasciculations (atro-
of the control system that give information on
phy is present in myopathies).
position and changes of state in the locomotor
Motor Function: Diffuse paralysis of highly vari-
apparatus. This information is utilized to keep
able intensity, according to demand. Excessive
the center of gravity aligned over the area of sup-
port (statics) and to execute coordinated move-
Sensation: Intact.
ments (dynamics). Proprioceptive afference is
Occurrence in true muscular diseases:
transmitted from the entire functional unit of
- Progressive muscular dystrophy (progressive the joints and muscle and also from the skin and
degeneration of the muscle fibers). subcutaneous tissues. The afferents are located
- Myotonias (hyperexcitability of striated mus- in the joint capsule (types I and II), in the capsule
cle). and ligaments (type III), and perhaps in the sub-
- Myositides (inflammatory muscle diseases). chondral layers of the joint surfaces. All three
- Myopathies (metabolic, endocrine, or con- types exert a reflex (tonic or phasic) effect on the
genital muscle diseases). motor neurons of the spine and extremities (see
Table 1).
6. Symptoms ofLesions of the Central Additional afferent input is provided by the
Neuron (Central Paralysis) muscle spindles, which respond to changes in
muscle length. Arranged parallel to the extra-
Motor Function: Spastic pareses affecting one
fusal fibers, the spindles react to muscle stretch
whole extremity, one side of the body, or both
(depending on their threshold) by stimulating a
extremities (paraparesis). Increased muscle
reflex contraction of the working muscle (via al-
pha motor neurons). At the same time, the mus-
Reflexes: Increased; pyramidal signs; central
cle spindles adapt to the shortening ofthe work-
coordination defects.
ing muscle via the more slowly conducting
gamma motor neurons. A similar adaptation can
be effected by central nervous influences. Be-
How Does the Control and Warning System Fnnction? 49

Table 1. Function of joint receptors (after Wyke). Four types: mechanical receptors types I-III (proprioceptors),
type IV: nociceptors
Type Location Function Threshold Adaptation
Outer layer of Joint position Low Slow
joint capsule Signal tension in joint
Conduction capsule, inhibit nociception,
velocity: 30-70 rnIs have reflex tonic effect on
muscles (gamma system)
II Inner layer of Joint movement Low Rapid
joint capsule Briefly inhibit nociceptors
Conduction in response to brief
velocity: tension changes and
60-100 rnIs stimuli, have reflex phasic
effect on muscles
(gamma system)
III Ligaments and Alarm/stress situations High Very
tendon attachments (stretch receptors) Slow
Conduction Inhibit motor neurons
velocity 130 rnIs
IV Whole joint capsule Signals damage/pain High None
and ligaments Have reflex tonic effect on
(nociceptors) muscles (gamma system),
(conduction spine, and extremities;
velocity 1 rnIs) pain production;
Unimodal nociceptors have reflex tonic effect on
(mechanical) respiratory and circulatory
Polymodal nociceptors systems

Receptor: Organ that transforms a mechanical or chemical stimulus into electrical impulses that
are relayed along the nerve pathway.
Threshold: Minimum stimulus to which a receptor will respond.
Adaptation: Rate at which a receptor adjusts to a stimulus, the receptor ceasing to fire under conditions of
constant stimulation.

sides the extrafusal muscle, the afferent dis- and the contact area between the articular sur-
charge from the muscle spindles also activates faces.
synergistic muscles and inhibits antagonists. The joint capsule and the ligaments surrounding
The Golgi tendon organs register the tension of the joint undergo varying states of tension and re-
the muscle. If the tension becomes too great, laxation during articular motion. In response to
they exert an inhibitory effect on the surround- the capsular stresses, the joint receptors provide
ing muscle while also inhibiting the synergists information on joint position (type I) and the
and stimulating the antagonists. stress changes that accompany movement (type
The cutaneous receptors act to increase muscle II) while also signaling the danger of excessive
tone (in the related segments) while inhibiting stresses (type III) and the occurrence of those
the tone of the antagonists. stresses (nociception, type IV). Information from
As mentioned, the proprioceptors of the joint the mechanoreceptors is relayed by sensory
capsule and ligaments perform control func- nerves to the posterior horn of the spinal cord,
tions by providing information on joint position, where it is used to initiate the motor reflexes re-
intraarticular pressure, and joint movements. quired for the coordination of stability and move-
This underlies the neurophysiologic feedback ment. Also at this level, endorphins are released at
circuit driven by input from the joint capsule the interneuron to inhibit the transmission of pain
50 How Does the Control and Warning System Function?

signals. The spinothalamic pathways subsequent- tational axis for joint movements should always
1y relay the information to higher centers, culmi- be positioned so that only parallel gliding occurs
nating in an autonomic response to the input and at the point where the surfaces appose. This nat-
possibly a conscious awareness ofthe pain. urally requires a fine control of muscular tension
The joint capsule and the ligaments also perform in the agonists and aritagonists, and this can be
passive mechanical (stabilizing) functions, one accomplished most accurately by signals ema-
of which is to ensure that the rotational axis of nating from the loaded joint surface itself.
the joint remains within physiologic limits. Stability, then, is an active, dynamic process in
The practical importance of the proprioceptive which the tension of the small periarticular mus-
information sources can be summarized as fol- cles must constantly adjust to the movement of
lows: the joint, the accompanying stresses, and the
goal of the movement to ensure optimum
1. The Skin. Any contact with the skin, especial- rolling-gliding of the articular surfaces. In this
lyon the hands and feet, gives us information process the capsule and ligaments not only main-
from the pressure at the contact site and the tain passive mechanical stability by preventing
position of the extremity. We also utilize this subluxation during uncontrolled movements
information source when we have the patient (e.g., trauma) but also function as an organ for
ambulate with a cane or when we wrap the the proprioceptive control of the stabilizing
joint with an elastic bandage (other examples: muscles. This is evidenced by the poor joint sta-
corset, neck brace, taping). bility that follows operations in which torn joint
2. The Muscles and Tendons. These structures ligaments have been replaced by synthetic mate-
contain receptors sensitive to changes in mus- rials. The mechanoreceptors important for pro-
cle length and tension. These parameters prioception cannot be replaced by a prosthesis,
(tension and length) are constantly monitored although therapeutic exercises can indirectly
and adjusted to ensure that balance (statics), compensate for this loss to a degree. This also ap-
movements (dynamics), and stability in the plies to the loss of control afference caused by
joints remain within physiologic bounds. removal of the biological joint surfaces (e. g., in
3. The Capsules and Ligaments. They contain replacement arthroplasties).
mechanoreceptors that give information on
the position and movements of the joints.
Rolling-gliding is made possible by continual
adjustments in muscle tension. These tensions The coordinated interaction of different muscles
are controlled reflexly by the mechanorecep- helps to preserve joint stability and ensure that
tors in the capsules and ligaments. There is the execution of movements proceeds in an or-
much evidence that they are also controlled derly, harmonious fashion.
by input from the changing areas of interartic- Muscular activity is coordinated at various lev-
ular contact. els. At the articular level, the tone of the small
4. Other Sources of Information. These are the periarticular muscles should be sufficient to
sense organs, the eyes, and the otovestibular maintain satisfactory apposition of the joint sur-
system. faces. During all movements and under all loads,
the muscles should keep the joint surfaces in a
position in which gliding of the surfaces can oc-
cur without compression.
The joint stability afforded by the muscles, cap- Slightly farther from the joint, the tension of the
sule, and ligaments ensures that an optimum agonists and antagonists must be controlled in a
pressure is maintained at the contact site be- way that maintains optimum loading and move-
tween the articular surfaces. The pressure on the ment of the joint. At an even greater distance,
joint surface should be low enough to ensure that muscles that pass over the joint must provide for
the gliding surface is not damaged. Also, the ro- harmony of movement and coordinate the ac-
How Does the Control and Warning System Fnnction? 51

tions of different joints. Finally, in the body as a Nociception

whole, movements of the individual joints must
be coordinated in a way that preserves balance, The coordinated movements of joints are made
avoids pain, and provides for the optimum, har- possible by the sensorimotor mechanisms de-
monious execution of movements. This coordi- scribed above. Under pathologic conditions,
nation is accomplished chiefly in the brain and however, significant disturbances can arise in
the higher segments of the cervical spine. motor sequences and can irritate receptors that

1 Neocortex
2 Thalamus
3 Reticular formation



A= afferent pathways
Sympathetic E= efferent pathways

Fig. 13. a Synopsis ofthe theory of the spondylogenic nociceptive reaction leading to vertebral restriction. (Modi-
fied from H. D. Wolff)
52 How Does the Control and Warning System Function?

Table 2. Sites for intervention with medical treatment, manual therapy, physical therapy, or therapeutic exercises

II Skin Medical treatment: stimulation of cutaneous receptors by ointments,

local anesthesia (wheal)

Connective tissue massage

Lymphatic drainage
Reflex zone treatment
Acupuncture (acupressure)

Medical treatment: muscle relaxants, antirheumatic agen ts, local

anesthesia of tendon allachments

Active relaxation
PIR (postisometric relaxa tion)
MET (muscle energy training)
Muscle stretch
Coordination training (PNF, Vojta, Bobath, Brunkow)
Muscular training (stabilization)
Massage (tone, circulation, metabolism)
Thermo-, hydro-, electrotherapy

Medical treatment: antiinflammatory agents (also intraarticular)

Local anesthesia of capsule and ligaments Uoint receptors)

Immobilization: bed rest, stabilizing bandages,

neck brace, corset, other braces
Translational mobilization
Thermo-, hydro-, electrotherapy
Active and passive exe rcises
Automanipulations by the patient

Medical treatment:
Local anesthesia
Peripheral nerve
Spinal nerve (ganglion/sympath. trunk)
Posterior root
Tranquilizers (as needed)
Elastic wraps

Elect rostimulation (of peripheral nerves) for pareses

are sensitive to noxious or harmful stimuli. These acerbate the disturbance are inhibited to the
nociceptors (Wyke type IV) are present in all point of paralysis, while muscles that can protect
components of the locomotor apparatus (bones, a pathologic focus from further damage become
joints, muscles, tendons, tendon sheaths, bursae, hypertonic in an effort to immobilize the focus
nerves, vessels, skin, and subcutaneous tissue) as (reflex splinting). Initially this occurs without re-
well as in smooth muscle and the internal organs. gard for the cause of the disturbance, which may
Every disturbance signaled by the nociceptors be mechanical (loose body, incarcerated liga-
evokes a reflex change in the execution of a ment, disk prolapse) or inflammatory (arthritis,
movement. All muscles whose activity would ex- bursitis, tendovaginitis).
How Does the Control and Warning System Function? 53

Brugger calls this neuroautonomic reflex mecha- ceptive reaction can occur in all structures that are
nism for protecting a disease focus the "nocicep- related to the same segment, i. e., not just in the
tive somatomotor blocking effect" (1962). He skin (Head's zone) and muscles (Mackenzie's
applies the term "tendomyosis" to the associat- zone) but also in the vertebrae, leading to sec-
ed change in the functional state of the muscle. ondary restriction. The restriction may persist
Hypotonic muscles cause a painful, fatigued after the primary stimulus (e. g., from an internal
feeling and become more painful when they organ) has passed and in tum can incite a further
contract. Hypertonic muscles cause a painful nociceptive reaction in the muscle and skin
muscular rigidity (rigor) and become more (Fig. 13 a).
painful when they are stretched. Both types Thus, effective causal treatment can be provided
of muscle are prone to rapid fatigue. Hyperton- only if the irritation site is identified and appro-
ic muscles frequently contain sites of myo- priate measures are taken to eliminate the dis-
gelosis, whose nociceptive afferent discharge turbing factor.
can further accentuate the pathologic hyper- Since, in principle, there are only three struc-
tonicity. tures that can be influenced by manual therapy,
Brugger notes, however, that nociceptive hyper- physical therapy, or therapeutic exercises - the
tonicity and hypotonicity are not limited to joints, muscles, and nerves (Table 2) - it is clear
antagonistic muscle groups, but can coexist in the isolated application of portions of the thera-
the same muscle if the irritative focus requires it. peutic spectrum, such as massage, physical ther-
Moreover, the arthromuscular irritative phe- apy, soft-tissue treatments, or therapeutic exer-
nomena described above may be accompanied cises, is not an optimum approach. Optimum
by autonomic, vasomotor, and dystrophic management must include a structurally orient-
changes (e. g., reflex sympathetic dystrophy). ed combination of multiple therapeutic modali-
The nociceptive reactions in joints and muscles
are very similar and sometimes even identical. It
is imperative, then, to determine the site of ori- Table 3. Methods for treatment of musculoskeletal
gin of the nociceptive irritation so that causal disorders
treatment can be planned. This site may be lo- Pain
cated in the afferent or efferent limb of the pe- Medications (injections)
ripheral neuron. The nociceptive afference may Immobilization (bed rest, bandages)
Massage, joint traction, muscular training
emanate from the receptor fields of the arthro- Thermo-, hydro-, electrotherapy
muscular unit, from the skin, or from the inter- Surgical intervention
nal organs (Fig. 13 a). The nerve pathway may be
Functional disturbance
disturbed in the region of the sensory or mixed Decreased motion (hypomobility)
nerve, at the nerve root, or at the motor nerve Massage, active relaxation, muscle stretch
fibers (nerve compression or entrapment, disk Joint (segmental) mobilization, manipulation
prolapse). Automanipulation by the patient
Sensorimotor coordination training
Disturbances of the central neuron, by contrast,
(PNF, Vojta, Bobath)
are easily differentiated by their distinctive signs Electrostimulation (pareses)
(seep.49). Surgical mobilization
According to H.D. Wolff, a steady influx of no-
Excessive motion (hypermobility)
ciceptive impulses from various structures of the Stabilizing muscular training
body can cause a stimulus overload in the poste- Autostabilization by the patient
rior hom with a nociceptive reaction in the ante- Stabilizing bandages and appliances
rior hom, lateral hom, and center. Through con- Surgical stabilization
tinuous depolarization of the gamma motor Morphologic abnormality
neurons, this leads to increased tone in the seg- Medical treatment (joint effusions, swellings)
mental muscles and perhaps to secondary re- Postural and motor training
Surgical correction
striction of the associated vertebra. Thus, a noci-"
54 Testing of Irritation Zones

ties whose precise makeup is determined by terion, for they can be tested below the pain
whether pain, dysfunction, or morphologic ab- threshold. Sachse and Schildt claim that the cor-
normality is the most prominent feature of the relation with mechanical dysfunctions of the
condition requiring treatment (Table 3). spine is closer than that between pain and dys-
function. "For this reason," they write, "these re-
flex algetic signs of disease can be effectively used
as the sole criterion for therapeutic planning."
Testing of Irritation Zones (Figs. 13b-f, They also note,however, that the origin of the pri-
44a--c, 103a-d) mary irritation (internal organ or vertebral seg-
ment) cannot be positively identified. This is pos-
A number of authors (Sell, Caviezel, Maigne, sible only when there are neurologic deficits that
Bischoff, Dvorak) diagnose segmental dysfunc- point to a direct injury ofthe nerve pathway.
tion by testing for "zones of irritation" or similar Dvorak cautions that, in various regions of the
soft-tissue changes in addition to segmental mo- vertebral column, the examiner may confuse the
tion testing. Segmental motion restriction alone, irritation zone (IZ) with trigger points in other
unaccompanied by pain or tenderness, is not muscles. Bischoff further notes that segmental
considered an indication for manual medical irritation points can be found in association with
treatment unless it is associated with an irrita- disk protrusions, activated spinal arthrosis,
tion syndrome involving the soft-tissue enve- arthritis, and tumors, all of which would be a
lope of the affected joints. contraindication for manual therapy.
Thus, Bischoff states that the second diagnostic Bischoff lists the following structural causes:
step, following segmental motion testing, is to - Splinting of the intrinsic segmental muscles
search for the segmental irritation point (IP) or - Swelling of the periarticular connective tissue
irritation zone (IZ). The third step is then to de- - Painful protrusions of the joint capsule due to
termine the response of the IP to movements in extruded synovial fluid
the segment, noting that the increase or decrease
Dvorak believes that the irritation zones are
in pain intensity and the change in consistency of
caused by direct joint or muscle injury, excessive
the IP during designated movements are the es-
loading, or a "functional positional fault."
sential guide to the appropriate direction for
Tilscher believes that trigger points are the result
therapeutic manipulation.
of a nociceptive stimulus processing that can
Sachse and Schildt refer to the palpable tension
originate in various portions of the arthron
changes in the motor and autonomic efference
Goint, ligament, muscle, viscera) and necessi-
as "reflex algetic signs."
tates concomitant treatment of the primary
Synonyms for irritation point include:
source of the irritation.
- Trigger point (myofascial point) The activity of these IPs or muscular trigger
- Maximal point points can be decreased by stretching the mus-
- Myosis/tendinosis cle, administering local anesthesia, or applying a
- Paramedian tender point (Maigne) cooling spray.
The authors agree that a comparison of the me-
The structural changes thus designated are rec-
chanical mobility fault with the segmental irrita-
ognized as a local, circumscribed increase in the
tion is useful for assessing the reactivity (auto-
resting muscle tone (hypertonicity).
nomic lability) of the patient's nervous system.
According to Sachse and Schildt, the examiner
should test the responses of these palpable ten-
Location of the Irritation Zones
sion changes to pressure, traction, displacement,
or Irritation Points (Fig. 13 b)
and elevation and should compare them with the
responses of adjacent or contralateral tissues. There is considerable disagreement among
The authors regard these "reflex algetic signs" in some authors regarding the location ofthe irrita-
the muscle and skin as an objective diagnostic cri- tion points:
Testing ofirritation Zones 55

Lumbar Spine Thoracic Spine

The IPs for Ll-L4 are said to be located 1 finger- One fingerwidth lateral to the spinous processes
width lateral to the spinous processes (Bischoff (Bischoff and Neumann) or at the end of the
and Neumann) or at the end of the transverse transverse processes (Dvorak) where the longis-
processes (Dvorak). At L5, they are described as simus and semispinalis muscles attach.
occurring 2 fingerwidths lateral and 1-11/2 fin-
gerwidths above the tip of the spinous process of Ribs
L5 (Bischoff and Neumann) or 1 fingerwidth lat- The IPs for costotransverse joints II-IV are lo-
eral to and below the posterior iliac spine (Dvo- cated 2 fingerwidths lateral to the spinous pro-
rak). cesses; for joints V-XI, lateral to the costotrans-
verse joints (Neumann); other authors place
them at the costal angle.

Cervical Spine
The points for C2-C7 are located over the artic-
ular processes of the cervical vertebrae and on
the nuchal line (Sell). The IP for C7 is located lat-
eraly at the tip of the mastoid process, and the
other points are more medial, spaced at intervals
of 1 fingerwidth along the same line. C2 is on the
midline, with C1 below it (Bischoff and Neu-
mann). Dvorak places the IPs for C1 and C2lat-
erally at the superior end of the mastoid notch,
with an additional IP for C1 at the tip of the
transverse process.

Reports on IP locations show the greatest dis-
crepancy in the pelvic region. Bischoff and Neu-
mann state that the IP for Sl is 3 fingerwidths
lateral to the upper pole of the sacroiliac joint
and 4 fingerwidths caudal to the iliac spine,
while that for S3 is 1 fingerwidth lateral to the
lower joint pole (see also Fig. 34). Dvorak
places these points at the lateral border of the
sacrum between the posterior inferior iliac
spine and inferolateral angle and at the origins
of the erector spinae and gluteus maxim us mus-

Examination Technique
Thoracic and Lumbar Spine
The authors also describe various routes of ac-
• = Irritation points according to Bischoff and Neumann cess to the IPs: a medial route, a paraspinous
o = Irritation points according to Dvorak route, and a lateral route.
R = Irritation points oflhe ribs
Bischoff and Neumann use the paraspinous ap-
Fig. 13. b Testing of irritation zones (after Bischoff, proach between the spinous processes and the
Neumann, and Dvorak) erector spinae in the thoracic and lumbar re-
56 Testing of Irritation Zones

c .......;..,,;_

Fig. 13. c,d Provocative testing by rotation of the lumbar spine. e Provocative testing by flexion of the lumbar
spine. fProvocative testing by rotation ofthe thoracic spine

gions, pushing the erector muscle approximate- hooking around the semispinalis capitis. Inter-
ly 1 cm to the side and applying straight, perpen- vertebral joint play can be simultaneously as-
dicular finger pressure. sessed. Sell's bimanual palpation of the inser-
Dvorak, using a bimanual technique, reaches for tions of the splenius capitis and splenius cervicis
the tip of the transverse process from the lateral on the nuchal line and at the mastoid process was
side, parallel to the body surface, with the previously mentioned. A notable feature in this
thumbs placed medially between the iliocostal region is the segmental arrangement at the mas-
and abdominal muscles. The IP is located near toid, which Dvorak assigns to segments CO and
the costotransverse joint. The IPs of the superior Cl, while Bischoffplaces the IPs of C7 and C6 at
articular processes are, for Dvorak, "only of the mastoid and places the higher segments
theoretical importance." along the nuchal line, spaced at l-fingerwidth in-
tervals, so that C2 is adjacent to the midline with
Ribs Cl below. The tip of the transverse process of the
Here the IPs are accessed at the costotransverse atlas also has been reported for Cl.
joint (Bischoff), lateral to it (Neumann), or at
the costal angle (Dvorak) . Findings
The IPs are palpable as sites of increased tissue
Cervical Spine firmness that are tender to pressure and change
There is general agreement regarding access to with rotation, flexion, or extension of the affect-
the IPs in the cervical spine: The finger pushes ed area. A significant abatement of pain and
straight down toward the superior articular pro- firmness during the trial movements indicates
cess of the cervical vertebra or reaches it by the appropriate therapeutic direction.
Testing of Irritation Zones 57

Provocative Testing (to test for changes in the Maigne refers to the palpable changes in the
IPs) skin, muscle, and at the tendoperiosteal junction
During provocative maneuvers, the examiner as the "segmental cellulo-periosto-myalgic ver-
maintains a constant pressure on the IP with the tebral syndrome." He states that these changes
palpating finger while noting any increase or de- occur at specific paraspiilouS points and relate
crease in pain and firmness. closely to the affected metamere. The tissue
In the cervical region, flexion-extension and ro- changes can cause radicular joint pain or viscer-
tation of the cervical spine are used to test for IP al pain but also may produce no complaints.
changes over the facet joints and on the nuchal They are reversible when the primary causative
line. stimulus is removed but may become self-sus-
In the thoracic region, the thoracic spine is rotat- taining and outlast the primary irritant. During
ed by elevating the shoulder on the test side, or the examination of a painful segment, the tissue
the head is fully retroflexed (neck extension; changes are disclosed by axial (posteroanterior)
Bischoff). or lateral pressure to the spinous process and the
Dvorak tests for change by pressing laterally, up- resultant vertebral movement. They are caused,
ward, or downward on the spinous process using then, by a segmental dysfunction, herniated
a technique like that shown in Fig. 13 c,f. disk, or activated degenerative arthritis.
The ribs: Dvorak does provocative testing by Maigne, unlike Bischoff and Dvorak, gives no
pressing the rib in the sternal direction (placing details on the location of these palpable changes
traction on the costotransverse joint) or in the or their response to specific provocative move-
direction of the transverse process. Bischoff and ments. Nor does he draw therapeutic conclu-
Neumann merely test pain and firmness during sions from the provocative test findings.
inspiratory and exspiratory excursions (to pro-
duce gliding movements in the costovertebral
Diagnostic Implications of Irritation
Zone Testing
In the lumbar region (Ll-L4) , Bischoff per-
forms rotation testing, as in the thoracic spine, It is well established that reactions in the soft
by elevating the shoulder on the test side, and tissues about the joints and related muscles are
extension testing by elevating the leg on the test consistently evoked by functional disturbances
side to increase the lordotic curvature of the in the joints, analogous to Head zones and
lumbar spine. Mackenzie zones in the skin and muscle. These
The IP at L5 is palpated about 1.5 cm above and reactions are palpable by an examiner applying
2 em lateral to the spinous process, with pressure pressure or thrust to the vertebral segments
directed toward the lower facet joint. Provoca- (Figs. 42, 43). It is also known that these func-
tive testing is performed as described above. tional tissue changes respond to a change or
Dvorak seeks the IP of L5 over the inferior iliac elimination of the primary articular (or viscer-
spine, 1 fingerwidth lateral and caudal to the al) disturbance as a result of the nociceptive
superior iliac spine. His provocative maneuver processing of the disturbance (reaction) in the
consists of applying pressure at the thoracolum- soft-tissue envelope. The question remains,
bar junction, which, he feels, can correct a back- however, whether the investigation of these
ward positional fault in the tested segment. changes can add significant additional diagnos-
We believe that testing for a forward fault by po- tic and therapeutic information beyond that
sitioning the patient on a rubber ball is impracti- furnished by the mechanical testing of angular
cal for routine examinations. and segmental joint play and the evaluation of
Pelvis: Dvorak tests the IPs for S1-S3 at the lat- end-feel.
eral sacral border by pushing forward on the It would appear that the diagnostic implications
sacrum (to reduce pressure in the ISJ, see Fig. 51). of IP testing are inherently limited by the fact
Additional IPs are described at the origins of the that IPs are not pathognomonic for joint dys-
gluteus maximus and erector spinae muscles. function but may emanate from a variety of mor-
58 Testing of Irritation Zones

phologic joint disturbances and visceral abnor- pressure used for rib testing and the sacral pres-
malities. sure used for testing pelvic IPs, can account for
Another potential source of uncertainty is the the reaction of the IPs to the test maneuvers. It
fact that some authors who advocate IP testing is instructive to consider that the associated in-
disagree markedly with regard to the location of crease and decrease of pathologic pressure in
the IPs and their segmental and structural allo- the dysfunctional joint can alter the reactive
cations (Fig. 13 b). This may lead to confusion soft-tissue findings through changes in afferent
with trigger points in other structures. discharge. A similar change of afference is pro-
The same may be said of examination technique. duced by the change in articular contact area
An examiner using the medial paraspinous ap- during flexion testing (Fig. 13 e) and especially
proach described above can easily palpate other during extension testing.
structures. It is essential, then, that the test movements oc-
Another difficulty is that the examiner must cur precisely in the joint to be tested - a require-
apply uniform pressure to the IP during the ment that is often difficult to satisfy when long
provocative movement, which sometimes is lever arms are employed.
applied through distant levers (arm, leg) and This raises the final question of whether irrita-
across multiple joints. This requires consider- tion zone testing performed during the already
able practice and experience, and the desired time-consuming manual therapeutic examina-
force cannot always be exerted precisely on the tion contributes significant new information, not
targeted segment. This is more easily accom- furnished by joint play and end-feel, that will
plished by using short levers at the spinous pro- help establish a diagnosis and determine the ap-
cess of the affected segment (Fig. 13 c,f) or oth- propriate therapeutic direction. If so, the testing
er short levers sUGh as the pelvis for rotation of irritation zones should be an integral part of
testing in the lumbar region (Fig. 13d). The re- every examination. Given current knowledge
SUlting traction and compression effect in the and the discrepancies among published reports,
intervertebral joints, like that produced by however, there appears to be no justification for
Dvorak's traction techniques or the anterior this at the present time.
Examination of
the Spine and
the Joints of the
Detailed Introduction

Systematic History he may be able to offer additional information

that did not occur to him during the initial inter-
view. Another advantage is that the physician
The systematic history covers the following five does not have to record the history himself, but
question areas, each consisting of five individual need only supplement it. Also, this method
questions: avoids the problem of the patient interrupting
the examination later to offer afterthoughts on
1. Current complaints
} Case history his medical history.
2. Previous course
History taking in musculoskeletal diseases
3. Social history
should always cover the following points:
4. Health history } Personal history
5. Family history 1. Current Pain (Part one of case history)
Rather than begin with the family history, it is 1. What hurts and/or functions abnormally?
more pertinent to have the patient first describe (Localization)
the complaints that prompted him to seek medi- 2. When did the pain and/or dysfunction first oc-
cal attention (pain, dysfunction, morphologic cur? (Onset of the disturbance)
abnormality). The patient should be allowed to 3. How are the pain and/or dysfunction? (Na-
spf}ak as freely as possible. The nature of the de- ture ofthe disturbance)
scription often provides clues to the patient's 4. What brings on the pain and/or dysfunction?
personality. Seriously ill patients tend to give (Modalities that initiate or change the com-
more objective reports, whereas a tendency to plaint)
offer vague or multiple complaints often signi- 5. What accompanies the pain and/or dysfunc-
fies a neurotic component. Depressives tend to tion? (Associated symptoms)
give scant information. The examiner should in-
terrupt the spontaneous narrative with questions 2. Previous Course (General condition, other
only in order to: current diseases; part two of case history)
1. Clarify unclear statements 1. What treatments have been given in the
2. Elicit further information where needed past?
3. Prompt a hesitant patient to continue talking 2. What improved or changed the pain?
The patient should also be asked what he be- 3. How are the vital functions? (eating, drinking,
lieves the cause of his pain to be. stool, bladder habits, sleep, sexuality)
The past history, like any other findings, should 4. When did previous pain occur involving the
be recorded. This is often difficult in the outpa- spine and joints?
tient setting, but we have found that time can be 5. What other diseases (including risk factors,
saved by having an assistant take and record the focal lesions ) does the patient have at the pre-
history prior to the examination, following the sent time?
outline shown above. This has the advantage of
3. Social History (Part one of personal history)
letting the patient know what information is im-
portant for the examiner to know. Afterward, 1. Occupation (training, work performed; asso-
when discussing his history with the physician, ciated activities)
62 Current Pain

2. Sports and hobbies 2. Projected pain (from the nerve to the body
3. Injuries (work, household, sports, vehicular) surface)?
that have affected the patient's ability to func- 3. Referred receptor pain (from the body interi-
tion. or to the body surface) ?
4. Operations (on the spine and joints, on other 4. Unilateral circumscribed limb or quadrant
organs) that have affected the patient's ability pain (from involvement of autonomic nerve
to function. fibers)?
5. Home and family life 5. Bilateral pain (from involvement of systemic
4. Health History (Previous diseases by organ
systems; part two of personal history) Rule of Thumb. The more vaguely defined the
boundaries of the pain, the deeper or more cen-
1. Lower abdomen (gynecologic, urologic;
tral the location of the somatic irritation.
screening examinations).
The pattern ofjoint involvement often permits an
2. Abdominal organs (stomach and bowel)
immediate differential diagnosis of the problem
3. Thoracic organs (heart and lungs, respiratory
as degenerative, inflammatory, metabolic, or
4. Head (eyes, ears, teeth, central nervous sys-
1.1 Localized Pain
5. Mental status
(Monoarticular, Monosegmental)
5. Family History (Part three of personal history) Predominantly large joints:
Degenerative: osteoarthritis, posttraumatic, os-
1. Age of parents and cause of death (if appli-
teonecrosis, chondromatosis.
Inflammatory: chronic rheumatoid arthritis in
2. Chronic diseases of parents
children, infectious arthritis, psoriasis,
3. Chronic diseases of siblings
Bekhterev's disease.
4. Serious diseases of children
Metabolic: gouty arthritis, chondrocaIcinosis,
5. Congenital and other disorders (especially:
ochronosis, diabetes, tabetic arthropathy, sy-
cancer, rheumatism, diabetes, gout, tubercu-
ringomyelia, hemophilia.
losis); malformations, psychological illness.
Small joints: Gouty arthritis
Spine: Vertebral restriction, fractures, disk
prolapse, spondylolysis, acquired disk loosen-
Interpretation of the History
1.2 MultifocalPain
(Polyarticular, Vertebral Region or Entire Spine)
Current Pain
Large joints: Osteoarthritis, Reiter's disease (in
the lower extremities)
1 Location ofPain: What Hurts? Where Small joints: Rheumatoid arthritis, polyarthro-
Does it Hurt? sis, Heberden's and Bouchard's disease, psoriat-
ic arthritis, gout.
The patient should indicate the location of the
Proximal joints: Ankylosing spondylitis
pain as precisely as possible. The site can be fur-
Peripheral joints:
ther localized by asking "Where doesn't it
Psoriatic arthritis: Transverse type = all distal in-
hurt?" The maximum extent ofthe pain is criti-
terphalangealjoints; axial type = all joints of one
cal for assigning the pain to a particular struc-
finger or toe ray
ture. Is the patient experiencing:
Gouty arthritis (basal joint of big toe)
1. Localized receptor pain (body surface) ? Spine: Osteochondrosis, spondylosis, ankylos-
Current Pain 63

ing hyperostosis (Forrestier), hypermobility, Bekhterev's disease, inflammatory joint dis-

osteoporosis eases)
Continuous pain (inflammatory, neoplastic)
1.3 Referred Pain
(Muscle Chains, Nerve Pathways, Vessels) 2.2 Periodic Pain
The involvement of muscle chains is typical of (Ovarian Cycle, Seasons, Age)
nociceptive (pseudoradicular) syndromes. A monthly rhythm is sometimes observed in dis-
Radicular pain radiates to the dermatome, while eases with an autonomic component and in hy-
pain due to peripheral nerve damage radiates to permobile individuals (fluctuating hormone lev-
the area supplied by the nerve. els?). Aseasonalrhythm (warmandcoldperiods)
Pain associated with arterial stenosis is always is seen in rheumatoid diseases. Age is also a factor:
perceived distal to the stenosing lesion. Re- Childhood: inflammatory diseases.
ferred pain radiates to the derma tomes or my- Adolescence: growth disturbances, postural de-
otomes of the segments with which the internal fects.
organ is associated. Young adulthood: disk protrusions, Bekhterev's
disease, incipient joint degeneration.
1.4 Diffuse Pain
Older adulthood: degenerative processes,
Psychosomatic conditions, systemic diseases,
metabolic diseases, hormonal changes, tumors.
Old age: senile bone changes (osteoporosis, os-
1.5 Unilateral or Bilateral Pain teomalacia), tumors.
Chronic rheumatoid arthritis is usually bilateral. An increase in the duration and intensity of de-
generative, metabolic, hormonal, or inflamma-
tory processes signals a progression of the dis-
2 Pain Occurrence: When Does It Occur ease process. The results of earlier examinations
and When Did It First Occur? (X-ray films) should be taken into account.
Intermittent or episodic pain is characteristic of
all diseases of the locomotor apparatus. Various 2.3 Episodic Pain
rhythms can occur: (With or Without a Change in Pain Location)
Spinal syndromes may take an episodic or peri-
2.1 24-Hour Rhythm odic course.
Cold pain (mechanical pain)
Exertional pain (mechanical, inflammatory, in
3 Nature of the Pain
arterial blood flow disturbances)
Rest pain (ligamentous in hypermobile individu- 3.1 Intensity
als, inflammatory) Mild, moderate, severe, lancinating, excruciat-
Night pain (ligamentous, muscular insufficiency, ing.

Differentiation of degenerative ("-osis") from inflammatory (".itis") pain:

Type ofjoint pain Degenerative Inflammatory
Cold pain Brief, preexertional Severe morning pain
morning pain
Exertional pain During course of day During any exertion
Rest pain Minimal Usually present
Night pain None (except shoulder) Frequent
Continuous pain In late cases Only with severe
64 Previous Course, General State of Health, Other Current Diseases

3.2 Character 5 Associated Phenomena:

The character of the pain depends on the affect- What Accompanies the Pain?
ed receptors and conduction pathways.
5.1 Sensory Disturbances
Epicritical ("sharp"): piercing, stabbing, cutting,
Hypoesthesia, anesthesia
pinching, gnawing, twinging. Most common with
Hyperesthesia } with ~ociceptive
lesions of nerves and skin.
Paresthesia, dysesthesia reactIOn
Protopathic ("dull"): gnawing, tearing, boring,
burning, cramplike. Characteristic of deeper
Hypalgesia, analgesia (with nerve compression)
structures: muscles, joints, internal organs.
Vascular pains are described as pulsating,
pounding, throbbing, or hammering. 5.2 Motor Disturbances
Feeling of weakness (nociceptive somatomotor
blocking effect).
3.3 Course
Paresis, paralysis.
Acute, subacute, episodic, rhythmic, chronic,
Limitation of motion.
lightning-like, transient, startling, paroxysmal,
wavelike, persistent, constant, intractable, fre-
Bladder and bowel difficulties.
It should again be emphasized that the character
5.3 Circulatory Disturbances
of pain often gives only a vague clue to the af-
Pallor, coldness.
fected tissue structure and the site of the irrita-
Congestion, heat, swelling, livid discoloration.
tion due to subjective processing of the pain by
Migraine, headache, vertigo.
the patient. Usually the irritation site can be de-
Tinnitus, hearing loss.
termined only by reference to the overall pain
Syncopal attacks.
pattern and from the findings of the subsequent
5.4 Trophic Disturbances
Cutaneous changes.
4 What Precipitates or Changes
the Pain ?
Modalities that precipitate, change, exacerbate,
5.5 Psychological Disturbances
improve, or relieve the pain.
Feeling of inadequacy, depletion.
Anxiety, tension.
4.1 Body Posture
Sleep disturbances.
Lying, sitting, kneeling, standing, working pos-
Aggravation, dissimulation.
tures (stressful positions).
Feelings of "Iessness" (powerlessness, hopeless-
ness, etc.) associated with depression (Der-
4.2 Body Movements
Walking, bending over, sitting down, sitting up,
standing up, turning (stressful positions), lying
down (stress-relieving position).
Previous Course, General State
4.3 Other Mechanical Influences
of Health, Other Current Diseases
Lifting, carrying, work activities, sports activi-
ties, fatigue.
1 What Treatments Have Been Given
4.4 Miscellaneous Influences
in the Past?
Coughing, sneezing, straining. Heat/cold, mois- Pharmacologic (what medications, dosage, how
ture, climatic changes, excitement, stress. long; diet?).
The Basic Physical Examination: Preliminary Information 65

Physical (radiation, massages, baths, therapeu- Exceptions

tic exercises, how often ?).
1. Examination of the thoracic region in the sitting
Balneologic (spa treatments: where, how long,
position consists of only four test groups, since
most recent?).
muscle tests are not required. The muscles cov-
Orthopedic, surgical (operative).
ering the chest belong to the shoulder region
Manual therapy (by whom, how often, most re-
and are tested when the shoulder is examined.
2. Muscle tests are also omitted during exami-
Acupuncture, neurotherapy; other applications.
nation of the knee joint. These biarticular
muscles are examined together with the mus-
2 What Improved or Changed the Pain?
cles of the hip joint during the pelvic phase of
Associated features, intolerances, self-treat- the examination (LPH region). An addition-
ment. al group of meniscus and ligament tests is
added at the end of the knee examination,
3 How Are the Vital Functions? however.
3. The hip joint is examined together with the
Eating and drinking (appetite, diet, smoking, al-
sacroiliac joints and lumbar spine in the LPH
cohol, drugs?).
Bowel and bladder habits.
4. Examination ofthe shoulder girdle does not in-
clude inspection, as this was already done dur-
ing examination of the shoulder; rather, it
concludes with examination of the cervical
spine owing to its close functional relationship
4 When Did Previous Pain Occur
with the shoulder and arm.
Involving the Spine and Joints?
5. In the lateral position, only four groups of tests
At what age: childhood, puberty, middle age, cli- are performed on the lumbar spine and tho-
macteric, old age (see item 2.2, p. 63)? racic spine (palpation of lumbar segments,
sacroiliac joint play, hip muscle tests, palpa-
5 What Other Diseases or Disorders tion of thoracic segments).
Does the Patient Have Now?
The description of the individual examinations
Could these diseases be associated with joint covers:
problems (arthritides, arthropathies)? - Starting position
- Procedure
- Anticipated normal findings
- Principal pathologic findings
The Basic Physical Examination:
Preliminary Information In many cases special attention is given to exam-
ination criteria and technical points where this is
considered necessary to help the rea~er under-
After the history is taken according to the
stand the examination procedure.
scheme outlined above, all spinal regions and ex-
For conciseness, procedures are described in an
tremity joints are systematically investigated in
abbreviated "telegram" style using a tabular for-
the basic physical examination by means of:
mat and simple medical language. In decriptions
1. Inspection of muscle tests, the word "muscle" is usually
2. Active and passive movements omitted in references to muscle names, and the
3. Palpation at rest and during movement related segment and peripheral nerve are noted
4. Tests of joint play where appropriate.
5. Muscle tests against a resistance (also short- Special diagnostic procedures, except for X-rays
ening tests if needed). and laboratory tests, are mentioned only briefly
66 The Basic Physical Examination: Preliminary Information

in reference to their diagnostic value, since our CAS region Cervical spine/shoulder/arm
main focus is on the comprehensive basic physi- joints
cal examination. SIJ Sacroiliac joints
Because the examinations proceed by body re-
gions, overlaps and repetitions of methods and
findings were unavoidable. Since the book is Symbols Used in the Figures
also intended as a reference work, some items of on Examination Techniques
information or entire passages are repeated in
• = Point used for immobilization, support, or
different places and in different contexts.
counterpressure in muscle tests
Examination positions are designated by capital
letters, and examination regions by roman nu-
t = Arrows indicate the direction of an active
movement performed by the examiner or
merals (both appear in chapter headings):
patient. A small arrow with a "P" on the
A = Standing
examiner's fingers indicates deep contact
B = Sitting
during palpation (e. g., when palpating for
C = Prone
tenderness) .
D = Lateral
T=Traction decompressing the articular
E = Supine
I Lower extremities
II LPH region (lumbar spine/pelvis/hip)
f Arrows with a cross bar indicate active
movement by the patient against a resis-
III Thorax
tance. For technical reasons these symbols
IV CSA region (cervical spine/shoulder/arms)
were sometimes placed on the hand or arm
V Cervical spine and head
of the examiner applying the resistance,
but they still have the same meaning. They
were then marked with a "P."
The following abbreviations are used:
LPH region = Lumbar spine/pelvis (sacroiliac
joints )/hip joints
The Basic Physical Examination: Preliminary Information 67

Checklist for Joint Examinations Checklist for Muscle Examinations

1. Patient Position The synergistic muscle group, and in some

The joints to be examined or treated cases the individual muscle, are tested for:
should be held or placed in a relaxed posi-
tion that is as painless as possible. The ex- - Muscle (fiber) length
amined body part is well supported to en- - Muscle tension
sure muscular relaxation. - Coordination
- Pain
~ExanrinerPosition - Endurance cannot be tested during the
The examiner (therapist) starts in a stable, normal examination of the arthromuscu-
ergonomically favorable position close to lar functional unit.
the patient. For examination of the spine,
the patient should be supported in a way Muscle testing during the basic physical ex-
that permits free body movements by the amination:
- Active movements: coordination,
3.lmmDobllUingliand strength.
The joint member that is to be immobi- - Passive mobility: muscle length (end-
lized is graspedf/at-handed, directly adja- feel), pain (in stretched
cent to the joint line, in a way that causes no position).
pain (skin is pushed forward opposite the - Palpation: tension/pain on palpation of
direction of mobilization, delicate soft tis- the muscle (origin, insertion,
sues are pushed aside). In the spinal re- muscle belly; especially in
gion, the vertebral segments adjacent to stretched position).
the segment to be tested are immobilized - Resistance tests: strength (in inter-
by reversing the physiologic joint me- mediate position), pain
chanics (locking). The immobilizing hand (especially in stretched
palpates and controls the locked position position).
in the tested segment.
The clinical examination consists of the basic
4. MobllUing lIand physical examination and any adjunctive
The joint member that is to be moved is procedures that are required, including a
grasped in the same way, and the joint- trial manipulation.
play movement is carried out.
S. Execution
Determine the resting position (virtual
resting position or treatment position),
the gliding plane and the direction of
translational movement (traction, com-
pression, gliding). Determine the force
and duration of the movement, record the
end-feel (soft-, firm-, or hard-elastic).
68 Ten Standard Symbols

er can document 80%-90% of all findings in the

Documentation of Findings Using locomotor apparatus. The symbols are entered
Symbols on a skeletal diagram shown from the posterior
(dorsal) aspect; all anterior (ventral) or volar
The use of symbols for recording diagnostic findings are marked with. a v.
findings not only provides for efficient, repro- Blue symbols are used to record findings in
ducible documentation but also permits a more joints, nerves, and skin, and red symbols are used
rapid review of previous findings. By combining for muscles and tendons. All other findings can
the following ten standard symbols, the examin- be documented in words or with special symbols.

Ten Standard Symbols

Last, first name


o Right

Date of
General Symbols

1. + Form or function increased

c 2. - Form or function decreased

~(rt' 3.
4. 0
Form or function painful
Function abolished

(NP No pathologic findings)


11 JI
Dorsal aspect Dorsal aspect

Skeletal diagram for the documentation of find-

Ten Standard Symbols 69

Inspection Palpation
5. () Range of change noted in physiologic pa- 8.. Pressure point; tissue resistance
Example:. ! = Painful resistance
Example: R = Rubor (redness) (blue) (trigger point)
C = Calor (heat) o = Questionable pressure point,
= Dolor (pain) questionable resistance
+ = Tumor (swelling) • = Muscle ortendon attachments,
- = Atrophy (red) myogelosis(triggerpoint)
D = Deformity (bony de-
formities can also be Blue: Sensory disturbance (indicate seg-
indicated by redraw- ment or nerve )Red: Myalgia
ing contour lines in
the skeletal dia- Example: L5 = Paresthesia (in L5 seg-
gram.) ment)
= Hyperesthesia
6. Injury or inflammatory changes in the
= Hypoesthesia
skin or deeper tissue layers
= Hyperalgesia
= Analgesia
Example: W= Wound
A = Abscess
Ph = Phlegmon (cellulitis)
F = Fistula
S = Scar Motion Testing
10. -? Direction of movement
7. - Discontinuity in tissue

Example: -Fr = Fracture Sagittal plane: i = Flexion (forward

Amp = Amputation (indicate stump bending, anteflexion)
length) (anterior-posterior) J.. = Extension (backward

1 20
R = Rupture or tear in muscle or
tendon (indicate length) Frontal plane: =
bending, dorsiflexion)
Adduction (arrow to-

(medial-lateral) ward the body)
= Abduction (arrow
away from the body)
Transverse plane: r \ = Internal rotation,
l ~ pronation (arrow
toward the body)
= External rotation,
supination (arrow
away from the body)
70 Measurements

I Measurements Measurement of Spinal Mobility

The position of the vertebrae is documented
Joints i = Anteflexion J, = Dorsiflexion
±+ = Side bent to the left or right
Measurement of Joint Mobility
1. 1-3 - or 1-3+: moderate, severe, or very severe
n= Rotation to the left
limitation or increase of joint movement, re- n=Rotation to the right
Grades of mobility: 0 = Total restriction (no
2. State amount of limitation, e. g., - 113.
3. State angular degrees according to the neu-
1 = Severe restriction
tral-O method.
2 = Mild restriction
The neutral-O method (Cave and Roberts, quot- 3 =Normal
ed in Debrunner) measures the range of joint 4 = Hypermobility
motion from the normal anatomic position: up-
right stance with feet parallel, arms hanging Muscles
loosely, thumbs forward, gaze straight ahead.
Measurements are performed in the: Muscle is designated by its initial letters, for ex-
ample: i Bi= biceps muscle
- Sagittal plane (extension/flexion) J, Ext. dig. = extensor digitorum muscle
- Frontal plane (abduction/adduction) Movement against a resistance = i
- Transverse plane (external/internal rotation)
in the sequence: Symbols for changes in the physiologic state
1. Movements away from the body (extension, A shortened muscle is indicated by a crossed ar-
abduction, external rotation) row, e.g.:
2. Return to the neutral position iPs = Shortened psoas muscle
3. Movement past the neutral position in the op- K = Contracture
posite direction S = Spasticity
Example: Normal ranges of motion in the Measurement of muscle strength (after Krendall
shoulder joint
and Kendall)
Extension/flexion 45°-0°-180°
5 = Normal (moves joint aginst maximal resis-
Abduction/adduction 180°-0°- 45°
External/internal rotation 60°- 0°- 90° 4 = Good (moves joint against moderate resis-
If the neutral position is shifted due to motion
restriction, the zero point will be either before
3 = Weak (moves joint against gravity)
or behind the angular measurements. 2 = Very weak (moves joint but not against grav-
Example: Motion restriction in the hip joint
Extension/flexion 0°-1 0°-1 00°
1 = Trace (palpable contraction only)
Abduction/adduction 20°- 0°_ 20°
0= Zero (no contraction)
External/internal rotation 15°- 0°- 10°
General Inspection
in the Standing Position (A)

1 Ordinary Movements
1.1 Gait
1.2 Other Ordinary Movements

12 Posture

13 Body Contonrs and Proportions

14 Skin

Is Assistive Devi«:es
72 Ordinary Movements

In the general inspection, the examiner evalu- Between these two phases is a double-support
ates the overall static and dynamic situation and phase in which the body weight is borne on both
records congenital and acquired morphologic legs (25% of the total movement of the stance
defects. The inspection begins as the patient en- and swing phases). As the gait quickens, the
ters the consultation room. Initial general im- double-support phase becomes more brief until,
pressions are formed with regard to: with jogging, it disappears altogether.
In gait analysis, attention is given successively to
1. Sex
the symmetry of:
2. Age
3. Constitution 1. Leg loading (step length, step width, pace, co-
4. Physiognomy ordination, and directional stability)
5. Conduct 2. Pelvic position
3. Spinal excursions
This is followed by a systematic inspection of or-
4. Arm movements
dinary movements.
5. Head position

Normal Findings
1 Ordinary Movements 1. Leg loading: Equal step lengths, step width
no more than about a 10-cm intermalle-
1.1 Gait olar distance. Rhythmic, symmetrical load-
1.2 Other Ordinary Movements ing of both leg with equal heel-to-toe
rolling on both ides. The patient should
be able to walk a straight line with eyes
1.1 Gait closed.
2. Pelvic position: In stance, the pelvis hould
Owing to its importance, gait is inspected at the
be horizontal on the frontal plane. When
start of the examination to provide the first gen-
the leg is lifted for the wing pha e, the ipsi-
eral dynamic impression of the inspection, which
lateral half of the pelvis should rise (Tren-
otherwise is performed at rest. Gait consists of
delenburg's phenomenon) and there
two phases, the stance phase and the swing phase.
should be a full. rhythmic anterior leg swing
The stance phase (60% of the total cycle) con-
if the mechanics of the pelvic joints, espe-
sists of five events that describe the evolution of
cially the SIJ (nutation), are intact.
the step from heel strike to loading of the trans-
3. Movement of spine: Slight convex bend to-
verse arch and big toe:
ward the supporting leg. Maximum mobili-
1. Heel strike ty in the mid-lumbar region. Slight recipro-
2. Forefoot strike cal curve in the thoracic spine. Right-left
3. Midstance (approximate neutral position of alternation of curvatures synchronous with
all lower extremity joints) gait.
4. Heel takeoff 4. Ann movements: Each arm swings forward
5. Toe takeoff from the shoulder joint opposite the swing-
ing leg (associated movements). Scapulae
During the stance phase of gait, the pelvis un-
fixed. No significant shift in center of body
dergoes a slight abduction and internal rotation
relative to the thigh of the supporting leg.
5. Head position: upright, no significant asso-
The swing phase (40% of the total cycle) consists
ciated movement.
of three parts:
1. Acceleration (after takeoff)
2. Midswing
3. Deceleration (until heel strike)
Ordinary Movements 73

Pathologic Findings - With cerebellar ataxia, the gait abnormality is

not exacerbated by closing the eyes.
Asymmetric Gait (mildest abnormality of gait)
Trailing of one leg due to greater fatigability. Decreased step width: narrow gait (adductor
Occurrence: spasm)
- Incipient diseases of hip joint Occurrence:
- Functional disturbances involving the SIJ or - In patients with spastic limb stiffness (Little's
symphysis disease).

Careful, shuffling gait

Unequal Step Lengths
Increasedstep length of the affected leg, no ataxia.
- Inflammatory disorders of the lower extremi-
ties (arthritis, osteomyelitis, inflammatory
- Disturbances involving the toe joints, foot
vertebral diseases)
joints, or knee
- Peroneal paresis: steppage gait (plantar-
Slow, Laborious Gait caused by rapid fatigue
flexed foot is lifted higher than normal)
and general weakness.
- Hamstring paresis: genu recurvatum
- Quadriceps paresis: anterior swing of lower
- In consumptive diseases, Addison's disease,
leg, genu recurvatum
Decreased step length of the affected leg.
Biza"e Gait Patterns
They are usually psychogenic. Often associated
- Contracture or ankylosis of the hip joint in
with trembling, sweating, anxious behavior.
flexion (pendulum limp)
- Psoas contracture, paralysis of trunk or hip
Change in Pelvic Positon (Equilibrating Limp,
Waddling Gait)
- "Cowtow" limp due to severe hip contracture
Dropping of the pelvis (with equal step lengths)
with trunk bent forward
toward the nonsupporting swing leg side (equili-
brating limp), positive Trendelenburg sign (in
Decreased step length and brief "touch-down "on
milder cases, only truncal deviation toward the
the affected leg to relieve pain.
supporting leg side; see also Duchenne's sign).
Cause: Insufficiency of the hip abductors of the
- Painful leg disorders, especially involving the
supporting leg due to approximation of the ori-
hip joint and SIJ, such as coxitis, Perthes' dis-
gin and insertion of gluteus medius and minimus.
ease, epiphyseal plate separation, sciatica, in-
termittent claudication (history)
- Congenital dislocation of the hip (if bilateral:
Ligamentous pain is improved by ambulation. waddling gait), coxa vara
- Osteoarthritis of the hip
- Diseases that flatten the femoral head (e. g.,
Unequal Step Widths
Perthes' disease, avascular necrosis, slipped
Increased step width with a slow, lurching, wide-
capital epiphysis)
based gait.
- Early stages of progressive muscular dystro-
phy (together with lordotic pelvic tilt and ex-
cessive lumbar lordosis), polyneuritis, po-
- With disturbance of deep position sense and
cerebellar function (ataxic gait; reeling, stag-
gering; high step, slapping of the forefoot). Gait Elevation of the pelvis due to deficient joint flex-
abnormality is accentuated by closing the eyes. ion, dragging the sole of the foot (scraping
- Proprioceptive ataxia (polyneuropathy) sounds); slow, springy gait (spastic gait).
74 Body Contours and Proportions

Occurrence: 2 Posture (Fig.14a,b)

- Spastic diplegia (tendency of legs to cross in
front of each other)
- Amyotrophic lateral sclerosis In a physical sense, posture involves the dynam-
- Spastic spinal paralysis ic maintenance of an upright body position with
- Multiple sclerosis (with intention tremor of a normally shaped trunk and extremities and un-
legs) restricted joint mobility in the spine and extrem-
- Hemiplegia (circumduction of the extended ities. Little muscular effort is expended in postu-
leg) ral maintenance. Muscular activity is greatest in
the nuchal region and calf, occurring as a tonic
Leading pelvic rotation and forward leg swing
contraction of the triceps surae and phasic con-
with marked elevation of the hemipelvis and an
tractions of the anterolateral leg muscles, mani-
increased step width (stiff-legged limp).
fested by visible tendon movements on the dor-
sum of the foot.
- Fusion or ankylosis of the hip or knee joint
In a psychosomatic sense, posture is the mental
- Hemiplegia
and physical assertion of the human body in re-
- Prosthesis wearers
sponse to gravitational forces.
Posture is evaluated in the sitting and standing
1.2 Other Ordinary Movements
positions (see alsoBILPH Region/Sect.1,p.104).
Properly coordinated movements permit ac- Criteria for body posture
tions to be executed harmoniously at the lowest
1. Static axes of the spine and extremities
energy cost. The movement is lithe, i. e., esthetic
2. Pelvic position
and coordinated.
3. Spinal curvature in the frontal and sagittal
The following tests have been proposed for the
analysis of faulty movement patterns (after Le-
4. Shape of thorax (see BlThoracic Regionl1.1)
wit and Janda):
5. Position of shoulder girdle and arms
1. For the lumbar spine: Have the standing pa- 6. Shape and position of head and neck
tient pick up an object and place it on a high
shelf. (Bending and straightening the trunk to
full extension)
2. For the thoracic spine: Have the seated pa-
tient shelve an object behind and level with 3 Body Contours and Proportions
the head. (Fig. 14)
3. For the cervical spine: Have the patient turn
the head side to side and move it in circles.
Posture can be examined concurrently with
Also: body contours and proportions owing to the ef-
4. Have the patient dress, undress, sit down, fect of postural deviations on body contours.
stand up, lie down, sit up.
5. Have the patient assume typical working posi- Conduct of the Examination
tions and perform typical working move- The patient wears only a slip or undershorts dur-
ments. ing the examination. Side illumination helps to
disclose asymmetries and changes in muscular
relief. The examiner should stand 2-3 m from
the patient (distant inspection).
The examination proceeds from below upwards.
Based on the postural criteria listed above, the
distant inspection of posture, contours, and pro-
portions should address the following questions:
Body Contours and Proportions 75

1. Are there any deviations from normal body Normal Findings (Fig. 14)
proportions? I Body Proportio/lS (After Klein- Vogel-
2. Are there asymmetries with respect to the me-
dian plane caused by The line dividing the body into upper and
- Leg length discrepancy or pelvic obliquity? lower halves is approximately at the level of
- Deviations from the static axes (spinal axes, the pubic symphysis and the tip of the greater
leg axes)? trochanters. The upper body length is mea-
- The rotational position of the legs? sured from the vertex of the skuU to the cau-
- Alterations in the shape of the legs or arms? dal pole of the symphysis, and the lower body
length from that point to the sole of the foot
3. Shape and position of the trunk?
(see Fig. 14b).
4. Shape and position of the shoulder girdle and The upper body length can be ubdivided
S. Shape and position of the neck and head?

·t - - - - sy mmetr ical
skull shape

f - - - - - Neck:
length, muscularity
Top of shou lder -----~o--~ ~=:;;;~~-- Shoulders at same level,
Interscapular distance ---j~~=L\--­ equal roundness
Position of scapulae - -+--t:>_
Axillary fold ------1---1 Axillary folds
at same level

equal shape
and length --\-_+- Waist triangles
symmet rical
Iliac crests
at same level
Ana l
cleft vertica l -------.:Ir---+l'-:.,I~~ Anterior superior
iliac spines at same level
Tip of coccyx on the midlin,e--+--l--./ Posterior superior
iliac spines at same level
Gluteal folds
Muscularity symmetrica l at same level

Lower limb axes symmetr ica l

Popliteal fol ds
Muscularity symmetrical - - --I- at same level

Malleoli of both legs

1+-- -- symmetrical,
at equal levels
Perpendiculars from head
and base coincide

Fig. 14. a General inspection from behind

76 Body Contours and Proportions

Distance from symphysis to umbilicus = 115 2 Asymmetries with Respect to the Median
Distance from umbilicus to jugular notch = 2/5 Plane
Distance from jugular notch to cranial ver- Position of examination: comfortable stance
tex = 2/5 with the feet parallel and about 20 cm apart
In stance, then. the center of the body is ap- and the weight distributed evenly on both
proximately at the level of the symphysis. The legs.
sit/ing height is approximately half the total
- Equal leg length. Malleoli, knees, and
height (52:48).
gluteal folds at equal levels on both sides.
The greatest frontal chest diameter is roughly
- Static axes
equal to the intertrochanteric distance. The
distance between the right and left hip joints Lower limb axis on the frontal plane: through
is approximately half the distance between the center of the inguinal fold, patella, ankle
the right and left shoulder joints. The length mortise, second toe.
of the foot approximately equals the greatest Lower Limb axis on the sagittal plane: greater
anteroposterior diameter of the chest. trochanter, center of knee joint, navicular

-:; No gross
facia l


spinal curvatu res asymmetries

Cervical lordosis - - - - - - - - - Jugular notch


ThOracic kyphosis

Lumbar lordosis Umbilicus

Pelvic pOSi tion - - ---jfi'- 1/5 Upper body length


Lower body length

Fig. 14. b General inspection

from the side
Body Contours and Proportions 77

The femora l shaft should form about a 10° an- Sagittal plane: Harmonious pinal curva-
gIe to the frontal leg axis (physiologic genu tures, firm abdominal wall.
valgum, intermalleolar di tance up to 4 cm).
Transverse plane: 0 torsion of trunk or
The angle is larger in women due to their
pelvis, no scoliosis.
greater pelvic width.
Even if the spinous processes align, scoliosis
Phy~iologic genu varum in newborns (often
can still be present. This is recognized by
simulated by flexion of the knee and external
asymmetrical protrusions of the trunk
rotation at the hip).
(bulging of the ribs, lumbar bulge). Forward
Physiologic bilateral genu valgum from 2 to 6
bending of the trunk may be nece sary to dis-
years of age.
close milder curvatures.
Spinal axis on the frontal plane: perpendicu-
lar line through the external occipital protu-
4 Shoulder Girdle and Arms
berance and spinous process of Sl.
Arm are of equal shape and length, hang par-
Spinal axis on the agittal plane: perpendicu-
allel to the trunk.
lar line through the auditory meatu , C7 and
Shoulders and axillary folds are at the same
L5 spinous processes, behind the (ran verse
level , show symmetrical roundness.
hip axis, to the navicular bone.
Clavicles are horizontal, form a 60° angle to
- Legs are rotated 12° relative to the frontal the midsagittal plane.
plane due to physiologic antetorsion of the Scapulae are at the same level, superior bor-
femoral neck. The antetorsion is nullified der level with TI. Medial border and inferior
by maximum internaL rotation oCthe femur. angle are slightly rai ed from the chest wall.
- Joint and muscle contour are equal on Medial borders are equidi tant from the
both ides. spinous processes (about 5 COl) , inferior angle
- Horizontal pelvic position, i.e.: is approximately at T7 level.
Frontal plane: Anterior and posterior superi-
5 Neck and Head
or iliac spines and iliac crests are at equal lev-
Shape of the neck. eck is straight, shows
els on both side .
symmetrical muscularity.
Sagittal plane: Pubic ymphysis is lightly be-
Head position: Head is upright. Perpendicular
low the tip of the coccyx (sacral promontory
lines from the head (external occipital protu-
and symphysis form about a 60° angle to the
berance/S 1spinous process) and from the ba e
horizontal) .
(midline between medial malleoli) coincide.
Tran verse plane: No pelvic rotation. Iliac
Cranial shape is symmetrical, shows no devia-
crests, anterior and posterior iliac spine ,and
tion of size.
sacrum are each in the corresponding frontal
Face. 0 gros facial asymmetries or distur-
plan . Contours (soft-tissue signs): symmetri-
bances of mimic muscles.
cal gluteal prom inence, anal cleft on the mid-
line, gluteal folds at same level. Compare
finding in (he sitting and prone position .
Pathologic Findings
3 Trunk Contours
The trunk contours depend chiefly on pelvic 1 Body Proportions
position and the alignment of the spinal col- Increased trunk growth : pituitary gigantism.
umn in the frontal and sagittal planes. Increased leg growth: eunuchoid gigantism with
genital hypoplasia and atrophy of subcutaneous
Frontal plane: Spine i straight with no colio- fat: Marfan's syndrome (spider fingers).
sis. Symmetrical muscular prominence and Lengthened trunk, shortened extremities, short
waist triangles, symmetrical chest (see Tho- neck, pawlike hands, scaly skin, bristly hair : hy-
rax, B/III, Sect. 1.1, p.lS1). pothyroid dwarfism.
78 Body Contours and Proportions

Lengthened trunk, lordotic pelvis, crura vara, Talipes equinus with functional leg lengthening
short legs: chondrodystrophy (congenital sys- and elevation on the contracted side.
temic disease, e. g., Lilliputians).
Deficient longitudinal growth with normal body Deviations from the Static Axes
proportions: primordial dwarfism. Deviations from the static axes place increased
Deficient longitudinal growth with hypogenital- stresses on the postural muscles and lead to un-
ism. physiologic joint loads.
Enchondral dystoses (genetic damage). Deviations from the static leg axes are present
Dysproportionate form: dorsolumbar kyphosis, with genu varum and valgum, causing static mus-
often with scoliosis and platyspondylisis (Brails- cular pain (standing occupations) and foot de-
ford-Pfaundler-Hurler type). formities
Proportionate form: multiple symmetrical ver- Measurement: Position the feet parallel.
tebral growth disturbances, kyphosis (Rib- Genu valgum: Measure the intermalleolar dis-
bing-Millier type). tance with the knees touching.
Acquired dwarfism due to rickets, osteomalacia, Genu varum: Measure the distance between the
osteoporosis, spondylitis, scoliosis, kyphoscoliosis. femoral condyles with the malleoli touching.
In small children, make an outline drawing (child
2 Asymmetries With Respect to the Median sitting with legs extended and in neutral rota-
Plane tion) and take measurements from the drawing.
Unilateral genu valgum: congenital, epiphyseal
Leg Length Discrepancy plate disturbance, traumatic, to compensate for
a) Leg shortening hip adduction contracture.
Anatomically shotter leg: Unilateral genu varum: epiphyseal plate distur-
bance, rickets, hormonal during menopause.
- Growth disparity
Genu recurvatum: ligamentous laxity, epiphy-
- Unilateral flatfoot or planovalgus (supporting
seal plate injury, compensation for equinus.
leg in standing occupations)
- Trauma (femoral neck fractures, femoral and
Rotational Position of the Legs
tibial fractures)
Increased external rotation of one or both legs:
- Diseases that cause flattening of the femoral
head (Perthes' disease, coxitis, avascular - Posterior rotation of the ilium at the SIJ
necrosis, slipped capital epiphysis) - Psoas muscle shortening and states of psoas ir-
- Pareses (e. g., poliomyelitis) ritation (Moser's sign)
- Flexion contracture of the hip (osteoarthritis)
Functionally shorter leg: with flexion and adduction
- Faulty position of SIJ due to backward rota- - Congenital dislocation of the hip (compare
tion of the ipsilateral ilium or anteroinferior levels of greater trochanters on both sides)
rotation of the sacrum about the "oblique - Retrotorsion of the femoral head
sacral axis"
Increased internal rotation (usually bilateral)
- Muscle shortening (shortening of the ipsilat-
with increased ante torsion angle, accompanied
eral psoas or quadratus lumborum)
by hyperlordosis.
- Joint contractures: flexion contracture of the
Contour changes in lower extremity joints may
knee or hip joint with dropping of the pelvis
signify joint swelling, effusion, or ankle edema.
on the contracted side; abduction contracture
"Thick legs" represent a distal thickening of un-
of the hip joint with ipsilateral pelvic descent
known etiology.
and contralateral pelvic elevation
Changes in muscle contours may signify
b) Leg lengthening (functionally longer leg) Muscular hypertrophy: Congenital muscular hy-
Adduction contracture of the hip with elevation pertrophy or unilateral hypertrophy due to func-
on the contracted side. tion or neoplasia. "Gnome calves."
Body Contours and Proportions 79

Muscular atrophy: Disuse atrophy following im- Frontal plane:

mobilization for trauma or muscle disease; thigh - Posterior and anterior iliac spines are higher
atrophy secondary to knee disorders, such as on one side with an anatomically short leg.
atrophy of the vastus medialis in meniscopathy. - With a functionally short leg, the anterior and
Can also result from peripheral nerve palsies, posterior iliac spines are at different levels,
e.g., and the iliac crest is low on the displaced side.
- Femoral nerve on the front of the thigh, (See A/LPH Region/Sect. 3.1 (p.88).
L2-L4 (quadriceps femoris, sartorius) - Lateral displacement of the pelvis in congeni-
- Obturator nerve on the medial side of the tal or acquired lumbar scoliosis or due to SIJ
thigh, L2-L4 (adductors) displacement (countemutation) toward the
- Sciatic nerve on the back of the thigh, L4---S3 side of the longer leg when leg length discrep-
(knee flexors) ancy is present.
- In the lower legs and feet (foot flexors and ex-
tensors) Sagittal plane:
- With a "lordotic" pelvis, the sacrum is more
Indentations: horizontal (sacrum acutum), lumbar lordosis
With extensive ruptures of muscles or tendons, is accentuated, and the symphysis is low.
e.g., Greater strain is placed on the trunk exten-
- Rupture ofthe rectus femoris above the patella sors, and the increased hip load predisposes to
- Rupture of the triceps surae above the heel coxalgia and osteoarthritis ("coxarthrosis
pelvis" of Gutmann).
• Note - With a "kyphotic" pelvis, lumbar lordosis is
Increased tendon play with the feet close togeth- decreased or absent, and the sacrum is more
er that increases further with the eyes closed sig- vertical (see also Sect. 3, Trunk Contours).
nifies a coordination disturbance that may range The spine is less springy than normal, result-
to ataxia. Tendon play in a wide-based stance is ing in greater loading of the intervertebral
always indicative of ataxia. disks ("osteochondrosis pelvis" of Gutmann).

Transverse plane:
Pelvic Position - Asymmetry of the inferior lateral angles of
The position of the pelvis in the frontal plane the sacrum in the transverse and frontal
is determined by the length of the legs. A planes due to flexion or rotation of the sacrum
leg length discrepancy (anatomic or functio- about the oblique (diagonal) sacral axis (see
nal) causes pelvic obliquity with associated Fig. 40, p.130).
scoliotic deviation of the spine in the frontal
plane. Usually this assymetry can be detected only by
Pelvic position in the sagittal plane is determined palpation, and its significance is unclear due to
by morphologic changes in the hip joint and by the numerous congenital morphologic varia-
imbalances of the shortening-prone postural tions of the sacrum.
muscles (psoas and erector spinae) and of sec- Contour changes in the glutei (soft-tissue signs):
ondarily weakened phasic muscles (glutei and - Unilateral flattening with an SIJ restriction on
abdominal muscles). Pelvic position is further the same side
influenced by morphologic defects at the - Oblique anal cleft (may indicate faulty sacral
lumbosacral junction (high-assimilation pelvis, position)
sacrum acutum). This in tum affects trunk con- - Lower gluteal folds at different levels with
tours and spinal morphology. faulty hip position (e. g., congenital disloca-
The changes described above often have effects tion) or weakened gluteal muscles
in the transverse plane as well.
Findings associated with pelvic deformity in the: Soft-tissue signs are not reliable.
80 Body Contours and Proportions

3 Trunk Contours a) Muscle shortening (psoas/erector spi-

Spinal Changes
b) Muscle weakening (glutei/abdominal mus-
Frontal Plane. Scoliosis, i. e., asymmetric waist
cles) associated with general connective tissue
triangles, deepened on the concave side and flat-
tened on the convex side; bulging of ribs and
In most cases a) and b) coexist.
lumbar spine. Several types of scoliosis can oc-
cur: - Hip contracture secondary to inflammatory
or degenerative disease
- Static scoliosis caused by pelvic obliquity with
an anatomically or functionally short leg A flat back (flattening of all spinal curvatures)
- Antalgic scoliosis secondary to vertebral re- occurs in:
striction, disk protrusion or prolapse
- Vertebral restrictions (prolapses)
- Congenital scoliosis (often associated with
- Constitutional states (often combined with
bulging ribs in the thoracic region), idiopathic
impaired lumbosacral assimilation)
- Scoliosis secondary to pareses or muscular de- Increased thoracic kyphosis is seen with fixed
- hump back, Scheuermann's disease
- Posttraumatic scoliosis following vertebral in-
- Bekhterev's disease, spondylitis, osteoporosis
Transverse Plane. Torsion of the trunk or pelvis
Sagittal Plane. The physiologic curvatures of the (viewed from above) with vertebral or SIJ re-
spine may be accentuated (hollow back, hump striction or with hip contractures caused by in-
back) or decreased (flat back). flammatory or degenerative diseases of the hip
A major postural determinant is the apex of the joint or by paresis. Scoliosis.
spinal curvature. With a normally curved spine,
the apex is at C3/C4 in the cervical spine, TS/T6 Abdominal Wall Changes
in the thoracic spine, and L31L4 in the lumbar General protrusions:
spine. Fat roll overhanging the symphysis like an
Postural changes result from the cranial or cau- apron, often combined with a muscle roll. The
dal shift of these apices, and function testing is protrusion is most prominent about the umbili-
needed to determine whether the shift has a cus. Cannot be corrected by contraction of the
morphologic or functional cause. abdominal muscles. Leads to "lordotic pelvis"
The following apical deviations can occur: with excessive lumbar lordosis.
- Caudal deviation of the cervical apex in hy- Unilateral flank protrusions due to paralysis and
permobility scoliosis, frog belly, ascites.
- Cranial deviation of the thoracic apex in Bekh- Local protrusions:
terev's disease, osteoporosis, osteomalacia - Femoral hernia (DD: lymph nodes, gravita-
- Cranial deviation of the lumbar apex tion abscess)
secondary to restriction at the lumbosacral - Inguinal hernia ("soft groin," palpable only)
junction, lumbar Scheuermann's disease; - Scrotal hernia (DD: hydrocele)
caudal deviation occurs with spondylolisthe- - Umbilical hernia
sis. - Rectus hernia (gastric hernia), rectus diastasis
- Scar hernia
A hollow back with a low symphysis occurs in:
- Spondylolisthesis (with a cross-groove and Test for Postural Weakness
step above the sacrum in pronounced forms) With evidence of postural weakness in children,
- Muscular imbalances in the pelvis region inspection can be immediately followed by a
caused by: function test of the back extensors.
Body Contours and Proportions 81

In Matthias' arm holding test for postural weak- Changes in Scapular Position and Contours
ness, the patient stands erect and extends the arms Winged scapula (prominent medial border and
straight forward. The examiner measures the inferior angle) due to
length of time the patient can hold the arms in
- Serratus paresis
that position with no change in spinal curvatures.
- Weak scapular fixators (transverse part of
trapezius and rhomboids)
Normal Findings - Contracture of the pectoralis major ("poor
The posture can be maintained for at least posture")
Increased external rotation (inferior angle shift-
ed laterally) due to paresis of the rhomboids
Pathologic Findings and/or levator scapulae.
A premature change of posture by backward Increased internal rotation (inferior angle
displacement of the thorax, decreased lumbar shifted medially) due to paresis of the trapezius
lordosis, and dropping of the arms signifies pos- (ascending part) and/or serratus anterior.
tural weakness. Prominence of the scapular spine due to paresis
of supra- and/or infraspinatus with muscular at-
4 Shoulder Girdle and Arms rophy.
Dysmelia, paralysis. 5 Head and Neck
Shape of Neck
A short neck with raised shoulders occurs con-
- Raised position: stitutionally in Klippel-Feil syndrome (multiple
Hypertonicity of levator muscles of scapula, spinal anomalies with block and wedge verte-
trapezius (descending part or levator scapu- brae).
lae). Asymmetries may be caused by "swollen
Paresis of depressor muscles of scapula, trapez- glands," as in goiter (thyroid) or Hodgkin's-re-
ius (ascending part), or serratus anterior. lated lymphadenopathy.
Thoracic scoliosis on the convex side.
Sprengel's deformity (unilateral). Head Position
Torticollis (wryneck) = tilting and rotation of
- Contour changes:
the head toward the same side:
Thickening due to effusion (traumatic, inflam-
matory) or neoplasia. - Vertebral restriction in a divergent position
Flattening due to paresis of the deltoid muscle can cause head twist and rotation toward the
(axillary nerve), disuse atrophy. opposite side
Deformity due to dislocation. - Congenital torticollis, usually with facial
Anterior displacement due to labile posture, asymmetry
Scheuermann's disease, senile kyphosis. - Ocular torticollis due to ocular muscle palsy
- Due to cervical inflammation
Changes in Clavicular Position and Contours - Due to paralysis of the neck muscles
(shoulders forward) due to clavicular fractures - Due to meningeal irritation
and dislocations - In early Parkinson's disease
Deepening of supra- and infraclavicular fossae - Due to muscular dystrophy in children
due to labile posture (displacement of clavicle in
the transverse plane). Head Shape
Effacement of the fossae due to inflammatory or Congenital asymmetries: usually in patients
neoplastic processes. with spinal asymmetries, especially involving
82 Assistive Devices

the skull base and craniovertebral joints; Bluish, smooth, tense, glossy skin is characteris-
aplasias and dysplasias of the craniovertebral tic of remission periods in rheumatoid arthritis
joints; basilar impression, etc. and of reflex sympathetic dystrophy.
Traumatic defects: scars, bony defects. Redness and swelling of the skin is characteristic
Abnormalities of size: microcephalus, macro- of inflammations.
cephalus, external hydrocephalus, oxycephaly, 2. Skin changes that may be associated with joint
square skull (rickets). changes:
Erythema nodosum: painful nodules with color
Facial Asymmetries or Disturbances of the changes like those seen with hematoma. Hyper-
Mimic Muscles sensitivity reaction (streptococci, Tb, drug aller-
Facial palsy: ptosis, corner of mouth sags and is gy) predominantly affecting women and usually
drawn toward affected side, unilateral facial showing symmetrical involvement of the lower
rigidity. legs.
Oculomotor palsy: ptosis, strabismus, unequal Psoriasis: sharply circumscribed hyperemic
pupils. patches with a variable, silvery-white scale,
Parkinsonism: mimic rigidity, infrequent blink- chiefly affecting the extensor surfaces of the ex-
ing, salivation, seborrhea. tremities (knee, elbow), the sacral region, scalp,
Chorea: irregular grimacing. and nails. Psoriatic arthropathy tends to involve
Myasthenia: weak facial expressions due to at- the joints of the fingers and toes and the knee
rophy of facial muscles. joints.
Angioneurotic edema (Quincke's edema): uni- 3. Traumatic changes. Scars (injuries, opera-
lateral swelling of the eye or lip. tions) or healed inflammatory processes, fis-
4. Inflammatory changes. Pustules, pimples,
vesicles may signify an irritation of the der-
4 Skin matome, e. g., in herpes zoster.

Pathologic Findings 5 Assistive Devices

Foremost are cutaneous changes that may be as-
sociated with diseases of the locomotor appara-
tus or musculoskeletal pain. Prostheses are used for limb replacement.
Splints and splint apparatus are used to support
1. Circulatory changes or partially immobilize and rest the vertebral
Pale, yellowish, waxy skin (on one side of the ex- column or joints.
tremities) is seen with arterial occlusions. Pale, Bandages and corsets are used to support or to
slightly cyanotic or marbled skin (hands and feet of- partially immobilize and take the strain off the
ten cold and moist) in autonomically labile patients. spine or joints.
Pallor due to local circulatory disturbances, Orthopedic shoes or footwear modifications are
blood deficiency (anemia), shock (vasoconstric- worn to correct for foot deformities or leg length
tion), or chronic inflammatory diseases (nephri- discrepancies.
tis, endocarditis).
Bluish skin (cyanosis) due to circulatory and
respiratory insufficiency.
Examination of the LPH Region
in the Standing Position (AlII)

1 Inspection
(see General Inspection)

2 Active and Passive Trnnk

Movements in Three Planes
(Regional Diagnosis)
2.1 Sagittal Plane: Forward and Backward
2.2 Frontal Plane: Sidebending
2.3 Transverse Plane: Rotation

3 Palpation of the Pelvic Joints

Palpation at Rest
3.1 Pelvic Position
Palpation During Movement-
Testing Joint Play in Both SIJs
3.2 Standing Flexion Test (SU)
Unilateral Joint Play Testing
3.3 Recoil Phenomenon (SU), "Spine Test"
3.4 Hip Drop Test (Lumbar Spine)
3.5 Lateral Shift Test (SU)

4 Tests of Joint Translation

4.1 Traction on the Lumbar Spine
4.2 Compression of the Lumbar Spine

5 Muscle Test
First Phase: Trendelenburg
Phenomenon (Hip Abductors)
84 Active and Passive Trunk

1 Inspection (see General Inspection) causes an early, increased convergence in the

facet joints of the lumbar spine due to fixation of
the pelvis in anteflexion.
Inspection ofthe overall static and dynamic situ- Sidebending with the legs spread apart tests the
ation was described in the section on General In- range of lateral flexion in the mid- and upper
spection. lumbar spine. To stabilize the pelvis, the body
weight is shifted toward the concave side. As the
stance widens, the axis for the side bending
movement is increasingly shifted to a higher lev-
2 Active and Passive Trunk el. Segment L5/S1 is therefore tested with the
stance closed.
Movements in Three Planes
(Regional Diagnosis) 2.1 Sagittal Plane: Forward
and Backward Bending (Figs. 15, 16)
2.1 Sagittal Plane: Forward and Backward
Bending Normal Findings
2.2 Frontal Plane: Sidebending The spine forms a smooth arc with slight
2.3 Transverse Plane: Rotation residual lordosis over the sacrum during for-
ward bending.
Symmetrical paravertebral muscular con-
Active and passive trunk movements give an im-
pression of the mobility of the spinal column as a
Apex of the movement should be at L3/L4
whole. They are performed in all three planes of
during forward and backward bending. Maxi-
mum kyphosis at T2- T6 during forward bend-
Starting Position. Upright stance, feet parallel
The total range of motion is approximately
and 2 footwidths apart, knees extended.
70°. This can be estimated by measuring the
finger-to-floor distance (FFD) . The greatest
Procedure. The patient's arms hang loosely so
flexion should occur at the hip joints. The po-
that, on forward bending (anteflexion), the dis-
sition of the sacrum should also be noted.
tance from fingertips to floor can be measured.
At the end ofthe active range of motion (relative
limit, see Figs. 15a, 16a), the examiner holds and Schober's Sign. With the patient standing, a tape
steadies the pelvis with one hand, especially if measure is used to measure 10 cm upward from
there is painful motion restriction, and with the the SI spinous process. Then the patient bends
other gently pushes the trunk on to the limit of the trunk forward, and the increase in the dis-
passive flexion (absolute limit, see Figs. 15b, tance between the two reference points is mea-
16b), meanwhile testing the end-feel and record- sured. The normal increase is 4-6 cm. Smaller
ing the type and radiation of any associated pain. increases indicate hypomobility, greater increas-
Duringforward bending with the knees and hips es hypermobility.
flexed (Fig. 15c), a (painful) disability caused by A similar test is used in the thoracic spine. Ott's
shortening of the hamstrings and triceps surae sign is tested by measuring 30 cm down from the
can be largely eliminated. Flexion of the trunk is C7 spinous process. The normal increase on for-
increasingly performed by divergence of the ward bending is 8 cm.
facet joints in the lumbar spine, since the pelvis is Even with a vertebral restriction, the patient
largely fixed by co-contraction of the attached may still be able to touch the floor by flexion of
muscles. the hip joints, so the FFD is not a very reliable in-
During backward bending (dorsiflexion) with dex of spinal mobility.
the knees flexed (Fig. 16c), the rectus femoris End-feel: soft-elastic (muscular).
Active and Passive Trunk 85

a b

• Note
In a modification of Schober's sign, Erdmann
recommends measuring the distance from S5 to
Tl2, noting that the greater distance reduces
the range of error and that the spinous proces-
ses at L5 and Sl are sometimes difficult to pal-

Pathologic Findings
Asymmetric paravertebral muscle contours dur-
ing forward bending due to vertebral rotation in

Decreased Range of Forward Bending

The sacrum remains more or less upright, and an
excessive amount of lumbar lordosis remains.
- Restriction of divergence in the facet joints or Fig. 15a-c. Forward bending. a Active,
disk prolapse. (With radiating neuralgic pain: b passive, c increased lumbar motion due
test dermatomes and reflexes.) to increased pelvic fixation by co-contrac-
- Shortening of the hamstrings (myalgic pain): tion of the pelvic muscles
posterior thigh pain
- Shortening of the erector spinae: severe para-
vertebral back pain
- Decreased motion in the hip joint: diffuse
pain radiating to the thigh
86 Active and Passive 1hmk

a b c

d e

Fig.16a--c. Backward bending: a active, b passive, c increased lumbar motion due to increased pelvic fixation
by co-contraction of the pelvic muscles. d-fSidebending (d upper lumbar spine, e lower lumbar spine, fpassive)
Active and Passive Trunk 87

Increased Range of Forward Bending

toward the opposite side (e.g., rotation to the
The entire hand can be placed flat on the floor.
left during sidebending to the right). The spi-
The cause is general hypermobility.
nous processes move toward the concave ide.
The total range of sidebending of the lumbar
Decreased Range of Backward Bending
and tboracic pine is approximately 80°
(about 40° to each side).
- Restriction of convergence in the facet joints Mobility can be estimated by recording the
andlor disk protrusions lowest point tbat each middle finger can reach
- Sacrum acutum on the lateral aspect of the leg (compare both
- Baastrup's disease (kissing spines) sides!).
- Restriction of counternutation (posterior nu- End-feel: firm-elastic.
tation) in the SIJ
- Limitation of hip motion (hyperextension,
capsule pattern)
Pathologic Findings
Distorted Movement
Twisting ("painful arc") andlor lateral deviation Decreased Range of Sidebending (Uni- or
of the trunk during forward and backward bend- Bilateral)
ing. May be accompanied by pelvic rotation to-
- On the convex side of scoliosis
ward the same side and flexion of the knee on
- Muscle contractures (erector spinae, quadra-
the side of sciatic stretch pain.
tus lumborum)
- Vertebral restrictions or disk protrusions
- Vertebral restrictions - Spondylolisthesis, Bekhterev's disease
- Disk protrusions - SIJ lesions
- Painful arc - Painfullirnitation of ipsilateral side bendingis
also common in patients with hip joint disease.
• Note
In "painful arc" the restricted intervertebral Increased Range of Sidebending
joint or disk protrusion temporarily becomes The perpendicular line from the axillary fold
the center of rotation for the movement due to may move past the anal fissure, often to the lat-
protective fixation . This lateral deviation dur- eral pelvic margin on the opposite side. The
ing forward bending results from either an im- cause is general hypermobility.
pairment of divergence on the side of the de- Sachse notes that during sidebending of the
viation or an impairment of convergence on the trunk, the pelvis not only moves toward the op-
opposite side during backward bending. posite side but also makes a small forward rota-
tion on the concave side at the beginning and
2.2 Frontal Plane: Sidebending end of the sidebending movement. Absence of
this movement on one side may signify a func-
Normal Findings tional disturbance at the thoracolumbar or lum-
Weight borne by the leg on the concave ide bosacral junction or in the SIJ.
(supporting leg). Equal excursion on each
side culminating in a smooth arc' no forward or 2.3 Transverse Plane: Rotation
backward deviations from the frontal plane. A
perpendicular line from tbe axillary fo ld on the Normal Findings
convex side should pass through the anal fis- Equal excur ions on both ides, the spinous
sure. processes forming a flat scoliotic arc. Total
When lumbar lordosis is preserved, idebending range of rotation is approximately 75°.
is coupled with a rotation of the vertebral bodies End-feel: firm-elastic.
88 Palpation of the Pelvic Joints

Pathologic Findings 3 Palpation of the Pelvic Joints

Decreased rotation due to:
Palpation at Rest
- Restrictions or disk protrusions
3.1 Pelvic Position
- Bekhterev's disease
Palpation During Movement-
Local stiffness due to Testing Joint Play in Both SIJs
3.2 Standing Flexion Test (SI1)
- Vertebral position faults
Unilateral Joint Play Testing
- Disk-space narrowing (osteochondrosis)
3.3 Recoil Phenomenon (SI1), "Spine Test"
- End-plate fissures (trauma, Scheuermann's
3.4 Hip Drop Test (Lumbar Spine)
3.5 Lateral Shift Test (SI1)
- Vertebral body edge separations (persistent
- Block vertebrae
Palpation at Rest
Increased rotation
Common in pathologic hypermobile segments.
3.1 Pelvic Position, Leg Length
• Note Discrepancy (Fig. 17)
Rule of thumb for differentiating vertebral re-
The following landmarks are used:
striction from prolapse: The more directions in
which motion is limited, and the more severe the - Posterior superior iliac spines
limitation, the greater the likelihood of a disk - Iliac crests
protrusion or prolapse. - Greater trochanters
Limitation of motion in all directions is always - Anterior superior iliac spines
caused by a disk prolapse, inflammatory pro-
cess, or tumor. Starting Position
Provocative test for "sciatica" due to root incar- Same as before.
The examiner stands behind the patient as in the Procedure
previous examinations, grasps both shoulders The examiner palpates both posterior superior
firmly, and bends the trunk obliquely backward iliac spines with the thumbs from below while
in a direction between backward bending and placing the index fingers or palms over the iliac
sidebending. This maximally reduces the cranio- crests at sites equidistant from the midline.
caudal diameter of the intervertebral foramen, Somewhat greater palpatory pressure will be
which, when compounding a relative crowding needed if the overlying soft tissues are thick
due to disk narrowing and protrusion into the in- (Fig. 17 a). The examiner similarly palpates the
tervertebral foramen, causes absolute crowding tips of the greater trochanters and compare their
with radicular irritation (Kemp's sign). The heights (Fig. 17 c). He then moves to the anterior
examiner notes pain radiation to specific der- side to palpate the anterior superior iliac spines
matornic areas. The test also causes maximum (Fig. 17b).
convergence, and thus compression, of the joint
facets on the concave side.
Normal Findings
Both anterior and posterior iliac spines and
both iliac crests are at the same level on the
frontal plane (no leg length discrepancy) and
transverse plane (no pelvic rotation).
The tips of the trochanters also are at the
same level.
Palpation at Rest 89

a b c
Fig. 17a--c. Palpation of pelvic position. a Posterior superior iliac spines, b anterior superior iliac spines,
c greater trochanters

Pathologic Findings The result is a functionally short leg. The crest of

the posteriorly rotated ilium also moves back-
Leg Length Discrepancy
ward and, due to the anterior slope of the iliac
With an anatomic leg length discrepancy, the ili-
crests, is lower than on the opposite (nondis-
ac crests (and trochanters) and the iliac spines are
placed) side. Meanwhile the acetabulum of the
at different heights on each side, i. e., all the fore-
posteriorly rotated ilium is shifted slightly for-
going landmarks are lower on the side of an
ward and upward. The result of this "pelvic tor-
anatomically shorter leg.
sion" is a high acetabulum and a functionally
short lower limb.
Faulty Iliac Position Example:
Unequal heights of the posterior and anterior ili- Right posterior iliac spine and right iliac crest
ac spines due to backward or forward rotation of are lower than on the left side.
an iliac wing. Right anterior iliac spine is higher than on
Example: the left side (or possibly at the same level). The
One of the posterior iliac spines is lower than displacement of the acetabulum upward and
on the opposite side. The ipsilateral anterior forward leads to a functionally short right leg.
iliac spine is then higher than the anterior spine This is recognized by noting that the anterior
of the opposite ilium. The cause of this differ- and posterior iliac spines are at different lev-
ence in the heights of the posterior and anterior els on the side of the functionally shortened
iliac spines is a backward rotation of the ilium limb.
on the femoral head with a concomitant poste-
rior displacement with respect to the sacrum in Summary
the SIJ on the side of the lower posterior iliac With an anatomically short leg, both iliac spines,
spine. the iliac crest, and the greater trochanter on
As this occurs, the sacrum makes a relative the same side are lower than on the opposite
countermovement forward and downward (uni- side.
lateral nutation, "sacrum ventralisatum et cau- With a functionally short leg, the anterior
dalisatum" of Sell) and is usually fixed in this ter- and posterior iliac spines are at different lev-
minal position. els.
90 Palpation Dnring Movement - Testing Joint Play in Both SUs

An anatomically short opposite leg can compen-

Palpation Dnring Movement-
sate for the low position of the pelvis on the side
Testing Joint Play in Both SIJs
of the functionally short leg. An anatomically
short leg on the ipsilateral side can aggra-
3.2 Standing Flexion Test (SIJ) (Fig. IS a,b)
vate it.
Asymmetry of the posterior superior iliac spines Following the examination of pelvic position, the
in the transverse plane. If one posterior iliac posterior superior iliac spines are palpated in a
spine is more anterior than the other, it signifies position of maximum trunk flexion. This is a test
pelvic rotation caused, for example, by a distur- for movemen t of the sacrum relative to the ilia in
bance of the hip rotators (weakening of the me- the SIJs Goint play). Since the pelvis is not fixed
dial rotators, as in osteoarthritis of the hip). The by the ischial tuberosities and thighs as it is in the
opposite applies to an iliac spine that is located seated flexion test (see BII, Sect. 3.2, p.lIO),
more posteriorly than the other. Pelvic rotation muscular disturbances in the legs can affect the
can also result from a disk protrusion in the lum- mobility of the ilia at the SIJs owing to the attach-
bar spine. ments ofthose muscles to the iliac wings.
A low posterior iliac spine may be seen in pa-
tients with shortening of the ipsilateral ham- Starting Position
strings. Same as before. Any pelvic obliquity due to
anatomic leg length disparity is first corrected by
Faulty Sacral Position elevating the foot on the short side.
A unilateral positional fault in the SIJ (unilater-
al nutation) may originate from the ilium, as de- Procedure
scribed above, but it may also develop as a pri- The palpation technique is like that used for pal-
mary sacral position fault caused by the body pating the posterior iliac spines at rest. The exam-
weight. Unilateral nutation of the sacrum occurs iner places both hands over the ilia, palpating the
about the oblique axes through the sacrum (see posterior iliac spines with the abducted thumbs.
Fig.40). The patient then slowly bends completely for-
The examination is performed in the prone posi- ward while keeping the knees extended (maxi-
tion and is described in that chapter (see CILPH mum trunk flexion). If the findings are doubtful
Region/Sect. 3, pp.I29f.). or inconclusive, the flexion should be main"-

a b

Fig.1S a, b. Standing flexion test (for asymmetric excursion of the posterior iliac spines)
Unilateral Joint Play Testing 91

tained for up to 20 s so that an excursion caused

purely by muscular action can subside.
Unilateral Joint Play Testing

3.3 Recoil Phenomenon (SIJ), "Spine

NormaJ Findings Test"
The iliac spines are at the same level both be-
The term "spine test" is misleading, since the in-
fore and at the end of trunk flexion = unre-
tent is to test the joint play between the ilium and
stricted mobility in both sacroiliac joints.
sacrum. The test is actually a variant of the recoil
Pathologic Findings
One posterior iliac spine moves higher than the Starting Position
other, signifying restriction of the ipsilateral SIJ The patient stands on both legs, as for the stand-
(positive test). Even when flexion is maintained ing flexion test.
for 20 s, however, it cannot always be determined
whether the cause is an arthrogenic dysfunction First Procedure
or a myogenic pelvic torsion, and further tests In the spine test, the patient slightly raises the
may be required. foot on the side to be tested. Motion of the SIJ is
Bilateral limitation of iliac motion due to ham- palpated at the posterior superior iliac spine,
string shortening on both sides can prevent the which should move slightly backward and down-
recognition of a positive test. Similarly, unilater- ward due to posterior rotation of the ilium with
al shortening of the hamstrings can create a respect to the fixed sacrum. The sacrum is fixed
false-positive test on the opposite side, i. e., the by nutation of the SIJ on the weight-bearing side
side where motion is unrestricted. (Fig. 18c-e).

c d e
Fig. 18 c-e. Spine test using the iliac spine of the supporting leg as a landmark (c, e) ; alternative landmark on the
median sacral crest (d, e)
92 UnilateralJoint Play Testing

The usual reference point or landmark on the

Normal Findings
fixed sacrum is a point on the median sacral crest
With free mobility in the hip and knee joints
level with the iliac spine. The contralateral iliac
and unrestricted sacroiliacjointplay, the poste-
spine makes a better reference point, however,
rior iliac spine on the tested free-leg side first
as it allows for the detection of unintended con-
moves superiorly with the hemipelvis as a
comitant motion of the SIJ on the weight-bear-
whole (due to weight shift to the supporting
side), but in the terminal phase it "recoils" to a
lower position than on the weight-bearingside.
Normal Findings (Fig. 18 c-e)
Descent of the posterior superior iliac spine
Pathologic Findings
of the tested free leg by 0.5-2 cm.
If the iliac spine does not move lower on the un-
supported side than on the weight-bearing side,
Second Procedure it may signify SIJ restriction due to diminished
To test for the recoil phenomenon, the patient joint play or shortening of the erector spinae
maximally flexes the leg at the hip and knee and and/or quadratus lumborum.
manually holds the knee against the chest
(Fig. 18 f). The examiner, keeping the patient
3.4 Hip Drop Test (Lumbar Spine)
balanced, then inspects or palpates the position
(Fig. 181, m)
of the posterior iliac spines, comparing the right
and left sides (Fig. 18f-h). Starting Position
The posterior-rotating impetus on the ilium is Same as before.
probably produced by the direct pressure of the
maximally flexed thigh and/or the traction of the Procedure
posterior portions of the hip capsule; in the The patient flexes first the left and then the right
"spine test" it is produced by iliposoas tension knee (stands alternately on each leg), allowing
(Fig. 18i,k). the hemipelvis to sag on the side of the flexed
knee. The pelvic obliquity incites a compensato-
ry lumbar scoliosis. The examiner inspects or
palpates the posterior superior iliac spines to de-

Fig.1S f-h. Recoil phenomenon with comparison of both sides
Unilateral Joint Play Testing 93


iliac spine

Fig. 18 i,k. Joint mechanics in the spine test (i) and recoil test (k). (Modified from Kapandji)

Fig. 18 I,m. Hip drop test (lum-

bar spine) with comparison of
both sides m

termine which half of the pelvis drops more. A Pathologic Findings

valid test requires unrestricted mobility in the Asymmetric hip drop implies that sidebending
hip joints. in the lower lumbar spine is restricted on the side
of greater descent. Slight disparities of hip drop
Normal Findings can also result from SIJ lability on the unsup-
ported side.
Equal descent of each hemipelvis.
Pelvic drop is an indicator of free or restricted
convergence of the facet joints on the side oppo-
site the drop. Example: Greater descent of the
spine on the right side indicates better side bend-
ing to the left in the lower lumbar spine.
94 Unilateral Joint Play Testing

3.5 Lateral Shift Test (SIJ) consideration, a large portion of the SU tests
must be assigned to the group of introductory
Starting Position
tests that are of limited diagnostic value. This is
Same as before. The palpating thumbs are on the
true of all tests of motion used to determine SIJ
iliac spines and in the adjacent sulcus between
play in the context of test movements that in-
the sacrum and ilium.
volve the hip and the symphysis and that might
be caused or affected by the action of muscles at-
Procedure tached to the ilium. These muscles are, for bend-
The examiner pushes the pelvis alternately to ing, the iliopsoas and rectus femoris, for stretch-
each side in the frontal plane, causing a greater ing the gluteus maxim us and hamstrings, and in
nutation movement to occur on the side momen- the frontal plane the adductors and abductors.
tarily bearing the greater weight. Palpating the The transversal portion of the gluteus maximus,
spines and adjacent sulcus, he notes the posteri- which originates on the lateral surface of the ili-
or displacement of the corresponding ilium and um, and the piriform muscle - the only two mus-
compares it with the opposite side. The very cles that originate on the sacrum - probably pri-
small movement is difficult to palpate and is marily increase joint fit but do not initiate any
commonly confused with skin displacements be- significant movement in the SU.
neath the palpating finger. The numerous tests described for examining the
The diagnostic value of this test is minimal. It is SU can be divided into three groups:
likely that the examiner palpates only the chang-
ing tension of the hip adductors during the later- - General test of motion utilizing changes in the
al shift. position of the palpable bony protrusions (an-
terior and posterior spinous processes)
- Palpation of reactive muscle changes
Biomechanical Considerations
- Testing joint play with fixation of the corre-
In view of the clinical consequences of SIJ prob-
spondingjoint member
lems, testing joint play takes on great signifi-
cance. The question is which of the large number In the first group of tests, absence of joint play is
of SU tests enable the diagnostician to reliably checked with regard to a change in position of
ascertain the nature of the disturbance. In recent the spinous processes. These tests include:
years there have been numerous reports of un sat-
- Standing flexion test (see below)
isfactory experiences with individual tests;
- Spine test (recoil phenomenon) (see p. 95)
even experienced diagnosticians have reached
- Hip drop test (see p. 95)
very different results with the same tests. It
- Lateral shift test (see p. 95)
therefore seems appropriate to subject the
procedures for examining the SIJ to a critical re- A common feature of all four tests is that they
view. examine the change noted in the position of the
A relatively reliable evaluation of joint play, par- spinous processes on both sides in connection
ticularly in the case of the SU, is only possible if with bending involving primarily the hip and
one joint member is securely fixed before the only to a small extent the SU. Furthermore, the
motion of the corresponding member is tested motion of the ilium is also affected by the hip
for its translatory movement. In the process, all muscles that originate on it, practically all of
extra-articular factors must be eliminated, re- which tend to shorten.
gardless of whether they contribute to or ob- In the standing flexion test, the ilia are stabilized
struct motion. It must, for example, be deter- against posterior motion both by the upward
mined whether soft-tissue reactions such as pressure of the legs on the acetabula, which are
reactive muscle hardening (for example, in irri- anterior to the rotational axis of the ilia, and by
tation zones) might result from or be affected by the tension-band effect of the hamstring muscles
extra-articular factors. (and the rectus femoris). As the trunk is bent
Taking these criteria for articular function into forward, the initial movement is a segmental di-
Unilateral Joint Play Testing 95

vergence producing flexion in the lumbar spine manner, i. e., the thigh on the tested side is raised
(approx. 60°), followed by an anterior move- until there is maximum hip flexion, there is much
ment of the pelvis on the femoral heads. Be- more movement in the hip joint on the weight-
tween the movements of the lumbar segments bearing side. First, the rump and pelvis must be
and the movement of the pelvis on the femoral displaced to the weight-bearing side to reestab-
heads, bilateral nutation occurs as a result of lish balance; in the process, the abductive move-
joint play between the ilium and sacrum. This ment of the pelvis on the femoral head raises the
may occur between lumbar flexion and the onset spinous process on the side being tested. During
of hip flexion, driven by the pressure ofthe spine the subsequent complete flexion of the hip joint
on the sacrum, or it may occur at the end of hip on the side being tested, the ilium is displaced
flexion when further flexion of the ilia is checked posteriorly as a result of the tightening of the
by the posterior portions of the hip joint capsule. posterior portions of the joint capsule and the
This remains unclear. hamstrings and of the direct pressure of the
In the standing flexion test, the major part of the thigh against the iliac wing. This too is probably
forward trunk movement takes place in the hip. much more a matter of recoil of the entire pelvis
The forward movement of the spinous process, by means of posterior gliding on the femoral
which is supposed to indicate the blockage, i. e., head of the weight-bearing side. With these two
the absence of joint play on the forward-moving tests, it hardly seems possible to reliably distin-
side, can also be caused by a shortening of the guish the elements of this movement caused by
hamstring muscles or a gliding obstruction in the the hip joint from those by the SIJ. This is true
hip of the side not moving forward. Moreover, even if the fixation of the sacrum is considered
real blockage of the SIJ caused by shortened sufficient because of the nutation on the weight-
hamstrings on the same side can elude de- bearing side.
tection. In addition to these tests of movement in the sag-
In the recoil phenomenon, or spine test, descent ital plane, movements in the frontal plane are
of the posterior superior iliac spine on the un- also used to diagnose disturbances of the SIJ.
supported side relative to the weight-bearing Some authors consider the hip-drop test a means
side is considered proof of the presence of joint to evaluate the SIJ. The ability to let one hip sag
play. Which force might be the cause of the iliac while standing, i. e., the different amounts the
recoil phenomenon that is necessary for this to pelvis drops, is supposed to indicate absence of
occur? The different answers that have been giv- joint play, specifically in the SIJ of the unsup-
en show that opinions differ. ported side. Because the SIJ is fixed on the
If only the knee of the side being tested is pushed weight-bearing side, however, this effect is ques-
forward as far as possible, then the psoas insert- tionable since the test movement consists main-
ing on the lesser trochanter of the femur (as the ly of an adductive movement of the pelvis on the
initial phase of beginning flexion of the hip) can weight-bearing hip joint and sidebending of the
effect upward traction of the head of the femur- lower lumbar spine toward the weight-bearing
as long as it is still vertical under the joint - there- side with convergence of the facet joints. This
by possibly causing the posterior displacement test, then, while specific for convergence-diver-
of the ilium. This force, however, counteracts the gence in the lower lumbar segments when the
tendency of the pelvis to drop somewhat be- sides are compared, is of dubious value for test-
cause of gravity (Trendelenburg effect). This can ing motion in the SIJ.
also lead to a sinking of the iliac spine relative to The lateral shift test appears to be the least re-
the weight-bearing side; such a movement warding test of sacroiliac joint play. In it, the ex-
would, however, be elicited by the adductive aminer shifts the patient's pelvis laterally while
movement of the pelvis in the hip of the weight- the patient is standing on both legs. It is a global
bearing side and would not be proof of move- test that registers, on the one hand, nutation on
ment of the SIJ. the displaced side by means of the increasing
If the spine test is executed in the alternative depth of the sulcus between the posterior sur-
96 Tests of Joint Translation

face of the sacrum and the ilium, and on the oth- - SIl springing test over the upper thigh in a
er hand, the changing tension of the soft tissues supine postion
and any possible restrictions of motion. Here
too, it is impossible to reliably differentiate
the role of two joints in motion and of the
A common feature of all these tests is that they 4 Tests of Joint Translation
do not satisfy the requirements of a precise test
of joint play because ofthe absence of a possibil- 4.1 Traction on the Lumbar Spine
ity to fix one of the joint members being tested; 4.2 Compression of the Lumbar Spine
instead they register the very different mobility
of two joints. The same diagnostic limitations
also apply to the palpation of the reactive muscle These translation tests are used to test the play of
changes: the intervertebral disk and intervertebral joints.
Traction on the spine removes pressure from the
- Test of hyperabduction according to Patrick
disks while simultaneously producing a diver-
gent gliding movement in both facet joints. Com-
- Palpation of the contracted muscles (the ad-
pression increases disk pressure and produces
ductors, the iliac and piriform muscles) and
convergence of the joint surfaces (see Examina-
the spinal irritation zones
tion ofthe Spine, p. 32f.). Fixation is effected by
the weight of the pelvis and lower limbs.
They cannot serve as specific examinations since
Thus, the entire mobile segment is tested. Com-
the causes of muscle hardening and contraction
pression should be applied sparingly or even
can stem from either the hip joint or the SIl.
withheld if local or radiating pains show marked
All of the above-mentioned tests can thus only
improvement in response to traction. Traction
serve as guides. Yet despite the limitations in in-
and compression in the standing position chiefly
terpreting their results, they nonetheless de-
test the lumbar spine. Traction and compression
serve to retain their position in examinations of
of the other spinal segments are performed in
the SIl since they are easy to include in the se-
the sitting position.
quence of tests and, in part, are a necessary part
of examinations of the hip.
The techniques for testing joint play with fixa- 4.1 Traction on the Lumbar Spine
tion of one part of the joint are probably the only (Fig. 19)
specific tests since they satisfy the condition of
Starting Position
having one fixed and one mobile joint member.
The patient lets the arms hang loosely or crosses
They can be used both as a test of motion to de-
them in front of the chest. The examiner stands
termine the springy nature of displacement of
behind the patient with one leg before the other,
the freely mobile joint, and as a provocative test
places both arms around the chest below the ribs,
registering a hard-elastic end feeling and pain
and holds one of his wrists with the other hand.
that is also indicative of a possible end-position.
The patient stands fully relaxed, leaning back
These tests are:
against the examiner with the spine in slight
- Comparative palpation of the sulcus between kyphosis.
the posterior surface of the sacrum and the
edge of the ilium Procedure
- Four-point springing test (provocative test for Maintaining the lumbar kyphosis, the examiner
the upper pole of the SIl) exerts traction on the spine by shifting his body
- Springing test over the apex of the sacrum weight from the front to the rear leg.
- Springing test over ilium
- Craniocaudal sacral push
Muscle Test 97

Normal Findings
The traction is not painful.
The traction relieves pain that was present in
an upright weight-bearing po ture. In this
case traction is followed by com pre sion as a
provocative test.

Pathologic Findings
No pain relief with inflammatory or osteolytic
processes or with a disk prolapse if there is asso-
ciated facet joint restriction.

4.2 Compression of the Lumbar Spine

Starting Position
Heels raised.

The patient drops onto the heels.

NormaJ Findings
The spinal compression produced by drop-
ping onto the heels is not painful.
Fig.19. Traction on the lumbar spine

Pathologic Findings
Compression pain in the lumbar spine with in-
flammatory and osteolytic processes or with a
disk prolapse (pain may radiate to the corre-
sponding dermatomes).

5 Muscle Test

First Phase: Trendelenburg phenomenon (Hip


Starting Position
Usual standing position on both legs.

The patient flexes the hip and knee joints at right
Fig.20. Trendelenburg test
98 Muscle Test

Normal Findings - Congenital dislocation of the hip

The pelvis shouLd remain almost horizontal. - Coxa vara
The perpendicular line from the head should - Flattening of the femoral head (Perthes' dis-
show little shift toward the supporting leg. 0 ease, arthritis, osteoarthritis, epiphyseal plate
increase in lordosis. separation, avascular necrosis)
- Paresis of the hip abductors (L4-LS, superior
gluteal nerve)
Pathologic Findings 2. Marked shifting of the trunk toward the sup-
1. Dropping of the non-weight-bearing side of porting leg due to severe paresis (Duchenne's
the pelvis as a result of abductor insufficiency sign) or congenital dislocation of the hip.
(gluteus medius and minimus) on the weight-
bearing side due to
General Examination of the Lower Extremities
in the Standing Position (All)
(Supplement to Examination ofthe LPH Region)

1 Three-Phase Squat
(General Weight-Bearing Test for All
Lower Extremity Joints and Muscles, In-
nervation, Coordination)

2 Standing on the Toes

(Joint Test: Ankle and Toe Joints, Flexor
Muscles of Foot)

3 Standing on the Heels

(Joint Test: Ankle Joint, Extensor Muscles
of Foot)

4 Standing on the Outer Edge ofthe Foot

(Joint Test: Subtalar Joint, Supinators)

5 Muscle Tests
(Shortening Test: Iliopsoas and Triceps
100 General Examination orthe Lower Extremities

The legs are the static and dynamic foundation Pathologic Findings
for the LPH region. A gross evaluation of their
Phase I
functional status during weight bearing is indi-
Painful limitation of hip, knee, or ankle function
cated when the LPH examination shows evi-
due to degenerative or other joint process. Co-
dence of paralysis or lower limb shortening.
ordination defects.

Phase II
Patient experiences calf pain when heel touches
1 Three-Phase Squat floor due to soleus shortening.

Phase III
The three-phase squat test is a general weight-
Limitation due to paresis of the leg muscles:
bearing test for all the lower extremity joints and
muscles, innervation, and coordination. - Iliopsoas (~-L3, femoral nerve)
- Quadriceps (L3-L4, femoral nerve)
Starting Position - Plantar flexors (L4-S3, tibial nerve)
The test begins with the patient standing upright Coordination defects.
with the feet parallal and 1 foot wide apart,
knees extended. Have the younger patient or athlete rise to a
standing position on one leg, using an arm for
Procedure support, to:
- Test the stability of the knee ligaments
Phase I - Increase muscle loading to test for mild pare-
Test for ranges of hip and knee motion. Patient ses (compare both sides)
slowly goes down to a squatting position, allow- - Test the articular cartilage under weight bear-
ing the heels to rise. ing.

Phase II
Test for soleus shortening. Patient places both
heels on the floor.
2 Standing on the Toes
Phase III
Muscle test for foot flexors, knee, and hip exten-
sors. Patient returns to an upright position with Tests the ankle and toe joints and the flexor mus-
the heels raised. cles of the foot.

Normal Findings
Patient presses the toes against the floor to test
Phase I
the toe flexors (St, tibial nerve). Patient then ris-
The hips and knees can be maximally flexed
es up on the toes.
without limitation.
Performing the test on one leg also tests coordi-
Phase II
nation. Hopping on one leg brings out latent
The patient can place the heels on the floor
(barefoot) without pain.
Phase III
Patient rises smoothly to an upright posture. Normal Findings
Patient can stand on the toes with unrestrict-
ed motion in the ankle, subtalar joint, and toe
General Examination ofthe Lower Extremities 101

The longitudinal arch of the foot is deepened; 4 Standing on the Outer Edge
the calcaneus goes into varus. of the Foot

Pathologic Findings Standing on the outer edge of the foot is a test of

Pathologic findings in this test signify functional the subtalar joint and supinator muscles.
disturbances involving the joints of the foot and
toes: Normal Findings
- Paresis of the triceps surae (L4-S 3 , tibial In the test position the longitudinal arch is fIat
nerve) but prominent and there is unrestricted subta-
- Paresis of the foot and toe flexors (L4-S 3 , tib- lar joint motion.
ial nerve). Flexor hallucis longus is considered
an indicator muscle for Sj.
Pathologic Findings
Muscular disturbances in the foot result from Subtalar joint motion fault, paresis of supinators,
paresis of the short'toe flexors due to Sj paresis especially tibialis anterior and posterior (L4-S 3 ,
or a tarsal tunnel lesion. If the toes do not touch common peroneal nerve and tibial nerve).
the floor in standing, a disturbance in the inner-
vation of the small foot muscles should be sus-
5 Muscle Tests (Fig. 21)

The muscle tests are tests for shortening of the

3 Standing on the Heels iliopsoas and triceps surae.

Standing on the heels is a test of the ankle joint

and foot extensors.

The patient raises the forefoot from the floor.

Normal Findings
Patient can raise the forefoot with unrestrict-
ed ankle motion and intact dorsifJexors (ex-

Pathologic Findings
Functional disturbance in the ankle joint; pare-
sis of the dorsiflexors of the foot (L4-S Z, com-
mon peroneal nerve); extensor hallucis longus is
an indicator muscle for Ls.
Coordination defects.

Fig. 21. Test for shortening of the iliposoas and triceps

102 General Examination of the Lower Extremities

Starting Position
Normal Findings
The free leg is placed on the examination bench
The movement is painles and unrestricted.
or table. The weight -bearing leg is set as far back
The weight-bearing hip should reach 5°_10°
as possible, with the foot flat on the floor. The foot
of hyperextension.
is in the sagittal plane with no medial or lateral ro-
tation. The weight-bearing knee is extended. The
trunk and supporting leg form a straight line. Pathologic Findings
Limitation of motion with increasing muscle
Procedure pain in the groin area (psoas shortening) and/or
Patient maximally flexes the free leg at the hip calf (shortening of triceps surae) in the weight-
and knee while moving the trunk as far forward as bearing leg.
possible and keeping the lumbar spine straight.
Examination of the LPH Region
in the Sitting Position (Bill)

1 Inspection
1.1 Relaxed and Erect Sitting Posture
1.2 Pelvic Position - Comparison with
Findings in Standing

2 Active and Passive Trunk Movements

in Three Planes
(Regional Diagnosis)
Supplementary SIJ Test

3 Palpation of the SIJ and Lumbar Spine

(Segmental Diagnosis)
Palpation at Rest
3.1 Pelvic Position
Palpation During Movement
3.2 Seated Flexion Test
(For Asymmetric Excursion of the Iliac
3.3 Segmental Motion Testing of the Lum-
bar Spine

4 Tests of Joint Translation

4.1 Traction on the Thoracic and Lumbar
4.2 Compression ofthe Thoracic and Lum-
bar Spine

5 Muscle Tests
Resistance Testing of Hip Muscles
104 Examination ofthe LPH Region

1 Inspection High kyphosis: age-related degenerative

changes (senile kyphosis, osteoporosis, osteo-
malacia), ankylosing spondylitis, postural
1.1 Relaxed and Erect Sitting Posture kyphosis.
1.2 Pelvic Position - Comparison with Find- Low kyphosis: adolescent kyphosis (Scheuer-
ings in Standing mann). In children, kyphosis in sitting.
Apex of curve shifted to higher or lower level:
possible vertebral restriction.
Examiner tests the movement patterns associat- Gibbus formation: osteolytic processes and
ed with relaxed and erect sitting postures and fractures.
evaluates pelvic position. Local flattening of the spinal arch: vertebral re-
1.1 Relaxed and Erect Sitting Posture High (upper lumbar) lordosis: restriction at the
lumbosacral junction or ankylosis in the thoracic
Starting Position spine.
Patient sits on a stool or the examination table Low lordosis: spondylolisthesis with a palpable
with both feet on the floor. Changing from a re- (and perhaps visible) step.
laxed sitting posture to an erect sitting posture is
accompanied by changes in the pelvic position
and spinal curvatures. 1.2 Pelvic Position - Comparison
with Findings in Standing

Normal Findings Normal Findings

1. Relaxed posture Same as normal findings in the standing posi-
The pelvis is tilted back ("kyphotic" posi- tion.
tion), and there is a smooth, kyphotic spinal Frontal Plane
arch from C7 to L3. The apex of the arch is Anterior and posterior iliac spines and iliac
centrally located, with a normal range ofvari- crests are at equal levels on both sides. 0 lat-
ation from T6 to the upper lumbar spine. The eral deviation of the trunk.
center of body gravity is over the ischial Transverse Plalle (Overhead View)
tuberosities. The muscles are fully relaxed ex- Pelvis and trunk are not rotated.
cept for residual tension in the intrinsic back Sagittal PlmJe
mu cles. The scapulae are shifted laterally, Posterior pelvic tilt and general kyphosis in
and the arms hang loosely. the relaxed posture, anterior pelvic tilt and
2. Erect sitting posture lumbar lordosis in the erect posture.
On active change to an erect sitting posture,
the pelvis tilts forward ("lordotic" position). Pathologic Findings
The spinal arch straightens, leaving residual Pelvic obliquity noted in standing is not present
kypho is in the upper thoracic spine whi le the in the sitting position, i. e., the iliac spines and
lumbar and lower thoracic spine become crests are on equal levels. Sitting also abolishes
slightly lordotic with the apex at L2. The cer- any (static) scoliotic deformity (= anatomically
vical pine also is slightly lordotic. The back short leg).
extensors are tense, and tbe scapulae are Pelvic obliquity in standing is not present, but
shifted medially. the iliac spines are on different levels, i. e., the
contralateral low position of the iliac spines in
standing (possibly with pelvic rotation toward
Pathologic Findings the low side) persists in the sitting position
Marked kyphosis in the relaxed position: mus- (= functionally short leg due to SIJ restriction
cular and ligamentous weakness. with displacement).
Examination of the LPH Region 105

2 Active and Passive Frontal Plane: Sidebending (Fig. 23 a,b)

Patient bends actively to both sides with the
Trunk Movements in Three Planes
arms crossed over the chest (Fig. 23 a) or the
(Regional Diagnosis)
hands behind the neck (as in Fig. 24a), the el-
bows forward.
For passive testing, the examiner grasps both
Supplementary SIJ Testfor shoulders and continues the movement to its
Differentiating Motion Faults passive limit (Fig. 23 b).
in the SIJ and Lumbar Spine
Transverse Plane: Rotation (Fig. 24 a,b)
Procedure Active: patient rotates to both sides with the
Patient alternately crosses one leg over the other. hands behind the neck, the elbows forward to
serve as "pointers" to aid range-of-motion com-
parison on both sides.
Normal Findings
Passive: examiner continues the movement to
Each leg can be painlessly adducted to an
its passive limit, as in side bending.
equal degree (approximately 45°) and placed
upon the thigh of the opposite leg.
Alternative Technique: Guided Passive
Movements/or the Segmental Examination
Pathologic Findings (Fig. 25 a-d)
Limitation of motion, possibly accompanied by
pain over the SIl if there is restriction (displace- Sagittal Plane: Forward and Backward Bending
ment) in the ipsilatenil SIl. The arms are crossed over the chest or the hands
are placed behind the neck, the elbows forward.
The examiner stands to one side and reaches
Regional Motion Testing of the Lumbar
across the chest beneath the arms, placing the
(and Thoracic) Spine in Three Planes
flat hand against the axilla. From this position he
with the Pelvis Stationary (Figs. 22-25)
alternately guides the chest forward (= fixation
of thoracic spine by ligament tension, Fig. 25 a)
Starting Position (Fig. 22 a)
and backward (= fixation by facet joint conver-
Patient sits erect on the table (or stool) with
gence, Fig. 25 b). Movement in the lumbar spine
weight distributed equally on the buttocks. On
is accomplished by backward and forward tilting
forward bending, the arms hang loosely between
of the pelvis over the ischial tuberosities effected
the legs. During sidebending and rotation, the
by the anterior and posterior displacement of
arms are crossed over the chest or the hands are
the thorax on the transverse plane (Fig. 25a,b).
clasped behind the neck, the elbows pointing
Frontal Plane: Side bending
The examiner raises one shoulder (by extending
his own knee or standing on his toes) and pulls
Sagittal plane:/orward and backward bending the opposite shoulder downward, thereby bend-
(Fig. 22 a-e ) ing the entire thoracic and lumbar spine toward
Active movements are performed with the arms the opposite side (convexity toward the examin-
hanging loosely beside or between the legs. er, see Fig. 25 c). With the patient's hands behind
The examiner imparts an extra passive stretch at the neck and the elbows forward, the examiner
the end of, and in the same direction as, the ac- can place his own shoulder directly into the pa-
tive movement. With backward bending, coun- tient's axilla and thread his arm through the tri-
terpressure is applied to the pelvis (Fig. 22 e). angle formed by the patient's forearm and upper
arm to grasp the opposite shoulder (not shown).
This provides a greater leverage that acts mainly
106 Examination of the LPH Region

a b c

d e
Fig.22. a Starting position. b,c Active and passive forward bending. d,e Active and passive
backward bending
Examination of the LPH Region 107

a b

Fig. 23 a, b. Active and passive sidebending

a b

Fig. 24 a, b. Active and passive rotation

108 Examination ofthe LPH Region

on the thoracic spine, whereas the previous tech- Transverse Plane: Rotation
nique produces more sidebending at the lumbar Examiner position and hand placement are the
level due to the lower arm placement. Generally same as in the side bending test. Trunk rotation is
the examiner changes sides to test sidebending performed about the longitudinal body axis with
in the opposite direction, or he can stay on the no anteroposterior or mediolateral deviation.
same side and flex his knees. Rotation in the opposite direction may be tested

a b

c d

Fig. 25 a-d. Guided passive movements for segmental motion testing. a Forward bend-
ing, b backward bending, c sidebending, d rotation. (The arrows indicate the direction
of motion of the spinous processes that are palpated for the segmental examination)
Palpation at Rest 109

from the same position, or the examiner may 3. Gibbus formation occurs with a congenital or
change sides (Fig. 2Sd). acquired wedge-shaped vertebral deformity
Passive motion testing may be done after the ac- due to traumatic, degenerative, metabolic, in-
tive testing of all the above movements is com- flammatory, or neoplastic processes.
pleted, or the examiner can immediately contin- 4. Plateau formation in the uniform spinal arc oc-
ue each active movement to its passive limit. The curs with vertebral restriction or synostosis
first method is recommended if an active motion (block vertebrae).
fault (delayed onset, stiff or uncoordinated 5. Pain
movement, limitation of motion) is noted. In this Myogenic pain accompanying the divergent
case the examiner should test passive motion not movement of a facet joint.
just in the terminal range but over the whole Arthrogenic pain associated with a divergent
range of movement. or convergent movement of the joint.
Radicular pain caused by disk protrusion or
prolapse (dermatomal distribution).
Normal Findings When motion is abruptly restricted by a barri-
1. No limitation of motion and no deviation er, the normal firm-elastic end-feel becomes
from the given plane of motion harder and painful.
2. Smooth, uniform arch of the lumbar spine
in all terminal positions • Note
3. Equal ranges of sidebending and rotation Limitation of motion in a segment with unre-
on both sides stricted joint play is almost always myogenic.
4. No gibbus or plateau formation Limitation of side bending in a whole vertebral
S. Painless movements with a firm-elastic end- region may signify muscular shortening on the
feel opposite (convex) side.

Pathologic Findings
(See also NLPH Region/Sect. 2, pp.1OS)
3 Palpation of the SIJ
1. Forward bending and Lumbar Spine
Limitation in the sitting position but no limita- (Segmental Diagnosis)
tion in the standing position: hamstring short-
Limitation in the sitting and standing posi- Palpation at Rest
tions: vertebral restriction. 3.1 Pelvic Position
With the same lateral deviation (active) from Palpation During Movement
the plane of motion: vertebral restriction in 3.2 Seated Flexion Test
the convergent position on the side of the de- (For Asymmetric Excursion of the Iliac
viation. Spines)
With slight lateral deviation on backward 3.3 Segmental Motion Testing of the Lum-
bending: vertebral restriction in the divergent bar Spine
position on the side opposite the deviation.
Greater and more painful lateral deviation
(possibly with dermatomal distribution) oc- Palpation at Rest
curs with intervertebral disk protrusion or
2. Sidebending and rotation show a decrease or
3.1 Pelvic Position (Fig. 26 a)
painful limitation on one side: convergent
facet-joint restriction on the concave side Starting Position
and/or divergent restriction on the convex side. The patient sits on a stool or an examination
110 Palpation During Movement

table low enough to permit the feet to rest flat on must be performed to differentiate the lesion.
the floor. The legs are apart. Since both ilia are stabilized in the seated flex-
ion test by the ischial tuberosities and femurs,
Procedure this test evaluates the relative motion of the
The iliac crests and spines are palpated in the sacrum with respect to the ilia. Whereas the ili-
same way as in the standing test previously de- um requires only one rotational axis for its mo-
scribed. tion relative to the sacrum (approximately level
with the posterior iliac spines on the frontal
plane), the sacrum is assumed to have multiple
Normal Findings
frontal axes at various levels for flexion/exten-
The anterior and posterior iliac spines and the
sion during forward and backward bending of
iliac crest are at equal levels on both sides.
the trunk. Additionally there are two diagonal
The sitting position abolishes di parities due
axes for compensatory countermovements of
to anatomic leg length discrepancy.
the sacrum ("sacrum ventralisatum et caudali-
saturn per rotationem" after Sell) and the ilium
Pathologic Findings (see Fig.40).
Different heights of the iliac spines persist in the
sitting position: suspicious for an arthrogenic
SIJ restriction due to iliac rotation on one side or
upward "subluxation" (displacement) of one ili- Palpation During Movement
um (traumatic).
Tilted or rotated pelvis with motion-dependent
3.2 Seated Flexion Test (for Asymmetric
pain: suspicious for a spinal dysfunction, such as a
Excursion of the Iliac Spines) (Fig. 26 a,b)
lumbar prolapse, in which the pelvic position fault
represents a compensatory antalgic posture. Starting Position
With an abnormal pelvic position or positive The starting position for this test is the same as
standing flexion test, the seated flexion test that in Sect. 3.1.

a b

Fig.26a,b. Testing pelvic position and iliac spine excursions on forward bending (seat-
ed flexion test). a Starting position, b final position
Palpation During Movement 111

Procedure - Forward, producing dorsiflexion of the lum-

Again, the thumbs are placed on the poste- bar spine by anterior tilting of the pelvis on the
rior superior iliac spines from below. With ischial tuberosities (Fig. 27 b)
the arms hanging loosely, the patient slowly - Side bending ofthe lumbar spine (with a slight,
bends forward to the limit of active trunk opposite sidebending of the thoracic spine)
flexion (Fig. 26b). The final degrees of move- (Fig. 27 c)
ment are most critical in terms of palpable find- - Rotation (Fig. 27 d)
While performing these movements, the exam-
Normal Findings iner palpates two adjacent spinous processes and
The iliac spines move synchronously an equal notes their mobility relative to each other. The
distance forward (upward) and are at the axis of motion is always at the level of the palpat-
same level after the movement as before. ing finger. During forward and backward bend-
Mu c1e contours are symmetric on botb sides ing, the tips of the spinous processes are palpated
of the spinous processes. from the rear (Fig. 27a,b). During sidebending,
they are palpated from the concavity of the curve
(Fig. 27 c), the examiner recording the coupled
Pathologic Findings rotation by the motion of the spinous processes.
One iliac spine is higher than the other at the end During rotation, they are palpated from the side
of the movement: restriction of the SIJ on the opposite the direction of rotation, e. g., from the
"high" side (positive test). right side during rotation to the left (Fig. 27 d).
Determining the position in which the sacrum is
restricted requires additional tests, which are • Note
conducted during palpation of the dorsal pelvic The untested portion of the thoracic spine
field and are described in that section (see should be held in a stabilizing position of oppo-
C/LPH Region/Sect. 3.1, p.124). site curvature or ligament fixation so that mo-
Asymmetric paravertebral muscle contours in- tion occurs only in the lumbar spine.
dicate congenital (scoliosis) or functional distur- Example: When segmental divergence is tested
bances of the vertebral column, as does an irreg- during forward bending, the thoracic spine
ularity of the spinal arch in maximum trunk should be stabilized before the initiation of lum-
flexion. bar kyphosis to confine the divergent movement
to the lumbar segments. Pure kyphosis of the
spine as a whole would only produce a diver-
3.3 Segmental Motion Testing
gence effect in the lower thoracic segments.
of the Lumbar Spine (Fig. 27a-d)
Starting Position Combined Motion Testing (Fig. 28 a-d)
Erect sitting posture with both feet on the floor, The segmental motion testing of side bending
the hands behind the neck, the elbows forward. and rotation can be combined, since sidebend-
The examiner reaches across the front of the ing is consistently accompanied by "coupled ro-
chest and places his hand on the patient's oppo- tation." During sidebending the vertebral bod-
site shoulder. ies of the thoracic and lumbar spine rotate
toward the concavity of the curve when the spine
is ventrally flexed and toward the convexity of the
curve when the spine is dorsiflexed.
From this position the thorax is successively
Example: On sidebending to the right in ventral
moved as follows in the transverse plane:
flexion, the vertebral bodies rotate to the right
- Backward, producing ventral flexion of the while the spinous processes behind the rotation-
lumbar spine by posterior angulation of the al axis deviate to the left (Fig. 28a). The verte-
pelvis (Fig. 27 a) bral bodies also rotate to the right in dorsiflexion
112 Palpation During Movement

a b

c d

Fig.27a-d. Segmental motion testing in the anatomic planes. a Forward bending,

b backward bending, c sidebending, d rotation

when the patient side bends to the opposite side of the vertebral bodies, and in dorsiflexion by
(Fig. 28 b). left rotation of the vertebral bodies, the spin-
General vertebral rotation is tested by maintain- ous processes simultaneously deviating to the
ing the same degree of lateral flexion as the pa- right.
tient is moved from ventral flexion to dorsiflex-
ion (Fig.28c,d), since sidebending to the right in Combined Test for Side bending and Rotation
ventral flexion is accompanied by right rotation (Convergence-Divergence Test, Fig. 28 a-c)
Palpation During Movement 113

a b

c d

Fig.28a-d. Combined motion testing a in ventral flexion, b in dorsiflexion. c,d

Full vertebral rotation is obtained only by maintaining the same degree of

Starting Position hand atop the opposite shoulder. Alternatively,

Erect sitting position with the hands behind the thepatientmaycrossthearmsinfrontofthechest.
neck and the elbows forward . The examiner
stands on the patient's right side, for example, Procedure
reaches across the chest with his right arm (below The thorax is side bent toward the examiner and
the patient's arms), and places his hand on the op- also bent forward (and rotated to the right)
posite shoulder; or he may reach through the tri- (Fig. 28 a,c). The lower the level of the palpated
angle formed by the patient's arms and place his segment, the more forward bending and rota-
114 Palpation During Movement

tion are required. An attempt is made to keep Pathologic Findings

the thoracic spine as dorsiflexed as possible to Limited and/or painful motion in one or more
focus the movement on the lumbar region. The segments between adjacent, nonpainful seg-
spinous processes are palpated from the side op- ments of normal mobility may signify vertebral
posite the movement, as in simple rotation. restriction andlor disk protrusion.
Next the thorax is bent backward (and rotated to Hypermobility, usually with only slight terminal
the left) while maintaining the same amount of pain, in one or more segments may signify a
lateral flexion (Fig. 28d). The reversal of right loose intervertebral disk (motion segment lax-
vertebral rotation to left rotation is detected by ness) or bony instability (e. g., spondylolisthe-
palpating the spinous processes [with just the in- sis).
dex finger (illustration) or between the thumb
and index finger]. The rotation associated with Biomechanical Considerations on the Joint
backward bending is less than in forward bend- Mechanics of Combined Movements
ing, so it is more difficult to palpate. The mechanical principle underlying coupled
rotation of the vertebrae is that the joint facets
• Note on the concave side are immobilized by maxi-
If the thorax, sidebent to the right, is moved diag- mum convergence and become the center for ro-
onally from a ventrally flexed to a dorsiflexed po- tation in the spinal segment. Meanwhile, the
sition, i.e., sidebent toward the opposite (left) separation of the facets on the convex side per-
side with a concomitant rotation to the right mits the upper vertebra to rotate relative to its
(Fig. 28 b), there will be no change in the (right) partner below.
rotation of the individual vertebrae, as noted The direction of the coupled vertebral rotation
above. The spinous processes show markedly less depends on whether the side bent vertebra, or
rotation in the lumbar spine than in the lower tho- the plane of its articular surfaces, is inclined for-
racicspine. The combined motion test is less time- ward or backward with respect to the frontal
consuming than individual motion testing but is plane (neutral plane of motion). If the articulat-
technically more demanding as the examiner ing facets are angled forward with respect to the
must manipulate the thorax in three dimensions. frontal plane (range of ventral flexion), the ver-
tebra will rotate toward the concavity of the
Normal Findings curve.
Spinal mobility depends on the height of the Example: Sidebending to the right with the
intervertebral disk and the position of the spine bent forward causes the vertebral bodies
joint surfaces relative to the plane of motion. to rotate to the right.
If the facet joint surfaces in the segment are in-
Ranges of mOlion clined backward with respect to the frontal
Forward bending (ventral flexion): separa- plane (range of extension or dorsiflexion) , the
tion (divergence) of the spinous proces es. vertebrae will rotate toward the convexity of the
Mobility increase from Ll to LS decrea es curve.
markedly at LS/Sl. Example: Sidebending to the right causes the
Backward bending (dorsiflexion): approxima- vertebral bodies to rotate to the left.
tion (convergence) of the pinous processes. This applies to the thoracic as well as the lumbar
Mobility increases from L1 to Sl. vertebrae. The cervical vertebrae always rotate
Sidebending (lateral flexion): toward the concavity during sidebending (ex-
Mobility increases from L1 to L3 (LA) (total cept in the atlantoaxial segment) because these
range approximately 50°), decreases from L3 facets are consistently inclined 20°-70° forward
to LS , is greatly decreased at LS/Sl. in the sagittal plane, so divergence is associated
Rotation: mobility decreases from L1 to LS with a forward movement, and convergence
(see Fig. 10). with a backward movement, which together pro-
duce the vertebral rotation.
Tests ofJoint Translation 115

Sidebending and Coupled Rotation 4 Tests of Joint Translation

in a Segment
Sidebending is effected by shifting the weight to- 4.1 Traction on the Thoracic and Lumbar
ward one side. As the spine flexes laterally, the Spine
intervertebral disk space becomes asymmetric. 4.2 Compression of the Thoracic and Lum-
Panjabi notes that the pivot point for this move- bar Spine
ment is believed to be located in the facet joint of
the opposite (convex) side. The increased
weight on the concave side cause the facet joints
to converge.
Tests of joint translation are tests of loading and
The accompanying rotation proceeds automati-
unloading of the intervertebral disks and tests
cally as long as the sidebending continues and
for facet joint gliding.
there is associated convergence of the facets in
the ventrally or dorsally inclined gliding plane of
4.1 Traction (Fig.29a)
the joint. When the facets cease to converge, the
joint becomes immobile, and if sidebending con- Traction in the sitting position tests the interme-
tinues, the joint becomes the pivot point for all diate and lower thoracic segments more than the
further lateral movements in the segment, which lumbar segments, while traction in the standing
thereafter can occur only in the anterior or pos- position tests the lumbar segments more. If a pa-
terior direction (third dimension of motion). tient cannot be examined while standing, trac-
These voluntary lateral movements then take tion in the sitting position is acceptable for test-
place in the facet joint of the opposite, convex ing of the lumbar region.
side; the direction of the movement may be for-
ward by divergent gliding or backward by trac- Procedure (see Fig. 29 a)
tion in the joint. Same as for traction in the standing position (see
In forward movements, the pivot point probably p.96).
shifts slightly forward along the margin of the
vertebral body on the concave side. Alternative Technique
Occasionally there may be asymmetric articular The patient crosses the arms over the chest, and
surface orientations in the two facet joints of the the examiner grasps the elbows at the crossing
segment due to different angular positions of the point to keep them from separating laterally
two frontal gliding planes with respect to the ("pharoah grip").
sagittal plane (lumbar spine) or frontal plane
(cervical and thoracic spine). In some circum-
4.2 Compression (Fig.29b)
stances this asymmetry can hamper gliding in
the sagittal plane during flexion/extension as Procedure and Findings
well as optimum adjustment of the gliding plane Like traction, spinal compression by downward
during three-dimensional movements. Conver- pressure on both shoulders acts on the thoracic
gent gliding, which already is hampered by the spine more than the lumbar spine. The findings
increased joint pressure associated with increas- correspond to those for compression in the
ing articular surface contact and possible mor- standing position (see p. 97).
phologic changes in the joint surfaces, can be
markedly impaired by asymmetry of the articu-
lar surfaces.
116 Muscle Tests

a b

Fig.29. a Traction on the thoracic and lumbar spine. b Compression of the thoracic
and lumbar spine

5 Muscle Tests

Resistance Tests of the Flexors, Rotators,

Abductors, and Adductors of the Hip
(Figs. 30-32)
These resistance tests of the synergists with
the hip and knee in 90° flexion are for orien-
tation purposes, since only the final 30° of
the range of motion can be tested. A more dif-
ferentiated examination of the synergists with
the hip in the neutral position is performed in the
prone position (extensors, rotators) or supine
position (flexors, abductors, adductors), see
C/LPH Region/Sect.5, p.144, and E/LPH Re-
gion/Sect. 5, pp.173-178).

Starting Position
The patient sits on the table (or stool) as in the
previous tests, the hip and knee flexed 90°, the
legs slightly apart. The table should support the
thigh as far as the popliteal fossa to permit ade- Fig. 30 a, b. Resistance test of the iliopsoas (a) and
quate stabilization. quadriceps femoris (b)
Muscle Tests 117

Fig. 31 a, b. Resistance test of the external rotators (a) and internal rotators of the hip (b)

Fig. 32 a-d. Resistance test of the hip adductors (a, b) and abductors (c, d)
118 Muscle Tests

Procedure rotated to test the internal rotators (L4-S2' su-

The examiner applies resistance as follows: perior gluteal nerve) (Fig. 31 b).
4. Lateral resistance is applied to the medial as-
1. Downward pressure on the thigh (against pect ofboth knees with the hands, or by placing
flexion) to test the major hip flexor, the iliop- the legs between the slightly abducted legs of
soas muscle (LrL4, femoral nerve). The the patient, to test the adductor muscles of the
thigh should not rotate during the test hip (Lz-L4, obturator nerve) (Fig. 32 a,b).
(Fig.30a). 5. Medial resistance is applied to the lateral as-
Posterior resistance is applied above the malle- pect of both knees with the hands, or by pla-
olus to test the major knee extensor, the quadri- cing the examiner's legs outside the patient's
cepsfemoris (L3-L4' femoral nerve) (Fig. 30 b). legs, to test the abductor muscles of the hip
2. Lateral resistance is applied at the medial (L4-Sh superior gluteal nerve) (Fig. 32 c,d).
malleolus (against external thigh rotation)
with the thigh gently stabilized and internally The proper conduct of the tests can be checked
rotated to test the external rotators (L4-S2 , by simultaneously palpating the point of the
femoral nerve) (Fig. 31 a). greater trochanter. These orienting tests are suf-
3. Medial resistance is applied at the lateral ficient to test the gross function of all the hip
malleolus (against internal thigh rotation) muscles except for the extensors and tensor fas-
with the thigh gently stabilized and externally ciae latae.
Examination of the LPH Region
in the Prone Position (C/II)

1 Inspection
1.1 Pelvic Position and Gluteal Profile
1.2 Pelvis-Leg Angle
1.3 Leg Length Discrepancy
1.4 Asymmetric Muscle Contours
1.5 Alignment of the Vertebral Column

2 Active and Passive Hip and Knee

(Regional Diagnosis)
2.1 Hyperextension ofthe Hip Joint
(Extension from the Neutral Position)
2.2 Rotation of the Hip Joint
2.3 Flexion, Extension, Rotation of the
Knee Joint

3 Palpation Field of the Dorsal Pelvis:

Lnmbar Joints/Soft-Tissne
(Segmental Diagnosis)
Palpation at Rest
3.1 Palpation Field ofthe Dorsal Pelvis
3.2 Test for Functional Leg Length
3.3 Segmental Palpation of the Lumbar
3.4 Kibler's Skin Rolling Test
3.5 Connective-Tissue Stroke Test
3.6 Segmental Irritation Points of Sell
(Testing of Irritation Zones)

5 Mnscle Tests
4 Tests of Joint Translation 5.1 Resistance Tests of Hip Muscles
4.1 Lumbar Spine (Extensors and Rotators)
4.2 Sacroiliac Joints 5.2 Knee Muscles
4.3 Hip Joints: Rotation 5.3 Back Extensors
120 Inspection

1 Inspection Hyperlordosis of the lumbar spine secondary to

- Psoas shortening (usually with gluteal weak-
1.1 Pelvic Position and Gluteal Profile ness)
1.2 Pelvis-Leg Angle - Flexion contracture of the hip (osteoarthritis)
1.3 Leg Length Discrepancy
When shortened, the psoas accentuates lumbar
1.4 Asymmetric Muscle Contours
1.5 Alignment of the Vertebral Column

1.3 Leg Length Discrepancy

1.1 Pelvic Position and Gluteal Profile Normal Findings
The malleoli, popliteal folds, and gluteal folds
Normal Findings are at equal levels.
1. Pelvis horizontal, iljac crests at equal levels
2. 0 lateral shift of pelvis
3. Posterior superior iliac spines at equal lev- Pathologic Findings
els (rhomboid fossae) Leg length discrepancy due to an anatomically
4. Anal cleft (attachment at sacral apex) on or functionally short leg.
the midline Above- and below-knee disparities due to con-
5. Gluteal symmetry. genital growth discrepancies, trauma, paresis,

Pathologic Findings 1.4 Asymmetric Muscle Contours

1. Pelvic obliquity or restrictions in the lumbar
Normal Findings
spine or SIJ (with a functionally short leg)
Symmetric contours of the thigh and lower leg
2. Lateral pelvic shift associated with lumbar
muscles and erector trunci.
scoliosis or disk prolapse
3. Unequal heights of the iliac spines due to SIJ
displacement or an anatomically short leg Pathologic Findings
4. Deviation of the anal cleft from the midline, Asymmetric muscle contours, congenital or due
usually toward the site opposite a sacral posi- to paresis.
tion fault (e. g., due to SIJ displacement) Increased prominence of the erector trunci due
5. Decreased gluteal prominence: unilateral to muscle shortening or reflex splinting.
with old SIJ restriction and/or displacement
and with paresis; bilateral with muscular
weakness or paresis
1.5 Alignment of the Vertebral Column
Pathologic Findings
Decrease or accentuation or normal lordosis,
1.2 Pelvis-Leg Angle
scoliotic deformity.
Normal Findings
Hip joints in neutral position, perhaps show-
ing slight abduction and external rotation
(resting position).

Pathologic Findings
Buttock raised on one or both sides, visible an-
gulation between the trunk and thigh.
Active and Passive Hip and Knee Movements 121

2 Active and Passive Hip Phase I1

and Knee Movements Movement in the SU. While the leg is held in hy-
perextension, the free hand immobilizes the
(Regional Diagnosis)
sacrum parallel to the sacroiliac joint line
(Fig. 33 b) and tests the (very slight) joint play in
2.1 Hyperextension of the Hip Joint
the SU.
(Extension from the Neutral Position)
2.2 Rotation of the Hip Joint
2.3 Flexion, Extension, Rotation of the
Test for convergence of the lumbar facet joints,
Knee Joint
especially at the lumbosacral junction. For this
phase the lumbar spine is immobilized up to and
Movements in the posterior sagittal plane and including LS. Higher segments can also be tested
transverse plane by shifting the immobilizing hand cephalad
("Posterior sagittal plane" is the portion of the (Fig. 33 c).
sagittal plane located behind the neutral posi- The leg is held in hyperextension during all
tion.) phases of the test, and only the immobilizing
hand is repositioned. The leg is moved in the
sagittal plane with no mediolateral deviation.
2.1 Hyperextension of the Hip Joint
(Extension from the Neutral Position) Normal Findings
No abduction, adduction, or rotation of the
Active Hyperextension ofthe Straight Leg tested leg. Motion is painless and unrestricted
in all three phases.
Normal Findings Phase I
Normal movement pattern. Activity se- Range of hyperextension is approximately
quence: gluteus maxim us, hamstrings, erector 20° when slight terminal abduction i allowed
trunci of opposite side. (otherwise 10°_15°).
Motion is checked by tbe joint capsule and
iliofemoral ligament.
Range of motion: approximately 15°-20°.
Phase II
Painless limitation of joint play by the sacroil-
Pathologic Findings
iac ligaments.
Gluteus markedly weakened due to ipsilateral
Phase III
SIJ lesion and/or psoas shortening.
Painless hyperextension of the lumbar spine
at the lumbosacral junction.
Passive Hyperextension ofthe Straight Leg End-feel: firm-elastic changing to hard-ela tic
(Three-Phase Test) (Fig. 33 a-c) in phase III (facet closure at LS/Sl).
• Differential Diagnosis
Phase 1 Painful SI] and lumbar segments can be differ-
Hyperextension of the hip joint (stage 3 capsular entiated in phase II and III by lifting both legs
pattern after Cyriax). One hand stabilizes the simultaneously, a maneuver that elicits practi-
ilium on the test side at the level of the greater cally no motion in the SUs. Pain during this ma-
trochanter to keep the anterior iliac spine on the neuver (= hyperlordosis) is almost always refer-
table. The other hand grasps the extended leg able to a disturbance in the lower lumbar
above the knee and raises it into hyperextension vertebrae.
(Fig. 33 a). When the limit is reached, the immo-
bilizing hand is repositioned for phase II.
122 Active and Passive Hip and Knee Movements

Fig. 33 a-c. Three-phase test (from bottom to top). a Hip joint,
b sacroiliac joint, c lumbar segments

Pathologic Findings even adduction in the final degrees of hyperex-

Range of motion and painfulness are noted. De- tension.
viation of the leg from the sagittal plane signifies
a muscular imbalance. Phase II
Decreased motion with or without pain due to
Phase I SIJ restriction or other SIJ disorders (e. g., anky-
Pain and decreased motion due to: losing spondylitis).
- Psoas shortening (gradually increasing myal-
Phase III
gic pain at the front of the thigh in the inguinal
Pain and limited motion due to:
fold), soft end point
- Contracture of the joint capsule (iliofemoral - VertebralrestrictionatlA-Sl (slight limitation)
ligament) secondary to arthritis or degenera- - Disk protrusion or prolapse (L4-S1, with sig-
tive joint disease nificant limitation or total loss of motion)
Painless hypermobility permits hyperextension Hypermobility may be accompanied by signifi-
to 40 0 with approximately 20 0 of abduction or cant, nonpainfullordosis.
Active and Passive Hip and Knee Movements 123

Passive Hyperextension with the Knee Flexed and inferior, quadratus femoris, obturator inter-
90° nus and externus, gluteus medius, adductors).
Active resistance test for the external rotators of
the hip from a stretched position (see Fig.58b,
One hand immobilizes the ilium on the test side
(as above) while the other hand raises the leg,
flexed at the knee, posteriorly.
Passive medial movement of the lower leg
(= passive external hip rotation) and active in-
Normal Findings ternal rotation of the thigh. Combined joint-
Painless hyp rextension of approximately 20° muscle test for passive external rotation of the
with slight abduction . hip joint and active external rotation.
Passive external rotation stretches the internal
rotators of the hip (gluteus medius and minimus,
Pathologic Findings
tensor fasciae latae).
1. Osteoarthritis of the hip. The hip joint cannot Active resistance test for the internal rotators of
be hyperextended. the hip from a stretched position (see Fig. 58 a,
2. Rectus shortening. The pelvis rises from the p.145).
table at once when the knee is flexed. Myalgic
pain at the front of the thigh.
Normal Findings
3. Psoas and rectus shortening. The pelvis, al-
Rotation is painless and bilaterally equal, ex-
ready raised from the table by psoas shorten-
ternal rotation proceeding until elevation of
ing, rises even further on flexion of the knee.
the ipsilateral iliac spine, internal rotation un-
4. Stretched femoral nerve ("reverse Lasegue's
til elevation of tbe contralateral iliac spine.
sign," inguinal ligament syndrome). Sudden,
End-feel: firm-elastic in both directions.
shooting neuralgic pain in the front of the
thigh due to:
Internal rotation tightens the joint capsule and
- Root syndromes at L3 and L4 ischiocapsular ligament (phase one capsular
- Paresthetic meralgia: pain on the outside of pattern after Cyriax), while external rotation
the thigh due to incarceration and stretching tightens the iliofemoral ligament. Ranges of
of the lateral femoral cutaneous nerve in the motion: 30° internal rotation, 45° external rota-
inguinal ligament or of the fascia lata; also oc- tion.
curs in diabetic neuropathy with femoral
nerve involvement Pathologic Findings
Painful limitation of motion with deficient in-
2.2 Rotation of the Hip Joint traarticular gliding (first in internal rotation)
due to arthritis or degenerative joint disease.
Movements in the transverse plane with the hip
Paresis of the internal or external rotators.
joint in the neutral position and the knee flexed
Contracture of the internal or external rotators.
2.3 Flexion, Extension, Rotation
Passive lateral movement of the lower leg (= pas-
of the Knee Joint
sive internal hip rotation) and active external ro-
tation of the thigh. Combined joint-muscle test Combined joint-muscle test for gliding of the ar-
for passive internal rotation of the hip (capsular ticuarsurfaces and menisci of the knee.
pattern) and active external rotation. Active test- Active muscle test for the hamstring group:
ing of the external rotators immediately follows biceps femoris, semitendinosus, semimembra-
passive internal rotation (stretched position). nosus (L4-S 3, tibial nerve, fibular nerve) (= knee
Passive internal rotation stretches the external flexion) and the quadriceps femoris (Lz-L4 ,
rotators of the hip (piriformis, gemellus superior femoral nerve) (= knee extension).
124 Palpation at Rest

Passive stretch test for shortening of the rectus 3 Palpation Field of the
femoris muscle. Dorsal Pelvis: Lumbar Jointsl
Soft-Tissue Diagnosis
Normal Findings
(Segmental Diagnosis)
Painless flexion of the lower leg to approxi-
mately 130° (heel almost touches the but-
Palpation at Rest
tock). Extension to 0°.
3.1 Palpation Field of the Dorsal Pelvis
End-feel: firm-elastic.
3.2 Test for Functional Leg Length Discrep-
Pathologic Findings 3.3 Segmental Palpation of the Lumbar
Painful limitation of passive motion due to: Spine
- Shortening of the rectus femoris (terminal 3.4 Kibler's Skin Rolling Test
stretch pain) at the front of the thigh 3.5 Connective-Tissue Stroke Test
- Internal knee derangement (motion blocked 3.6 Segmental Irritation Points of Sell
by degenerative disease, meniscal pathology, (Testing of Irritation Zones)
intraarticular loose body)
Painless limitation of active motion due to:
- Knee flexor paresis, quadriceps paresis, or re-
flex weakening of these muscles
Palpation at Rest
• Differential Diagnosis
If knee flexion is impaired (meniscal pathology,
3.1 Palpation Field of the Dorsal Pelvis
ligamentous lesion), the Apley test is performed
(Fig. 265 e, f, see p. 367). All palpation (touch palpation, palpation for
tenderness) employs bimanual technique with
Procedure and Findings comparison of the right and left sides.
With the knee flexed 90°, The five landmarks for palpation in this field
(see Fig. 34) are as follows:
- The lower leg is rotated with compression:
painful with meniscallesion. 1. Ischial tuberosity
- The lower leg is rotated with traction: painful 2. Greater trochanter
with ligamentous lesion. 3. Posterior hip muscles
4. Posterior superior iliac spine, sacroiliac joint
line, SIJ irritation points
5. Inferior sacral contour, inferior lateral angle,
coccyx Qoint)

1) Ischial Tuberosity (Fig. 35 a,b)

The tuberosities are palpated with both thumbs.
The origin of the hamstrings is palpable posteri-
orly: semitendinosus, semimembranosus, biceps
femoris, long head (L4-S 3, tibial nerve).
Tendinopathies and bursitis may occur, also
apophyseal avulsions in young athletes (run-
ners, jumpers).
Medial to the muscle attachments: attachment
of the sacrotuberalligament (segment S2).
Palpation at Rest 125

Sacroiliac joint

Posterior hip muscles ®
Erector spinae • IP = irritation pOints at the superior pole (S, )
and inferior pole (8 3 ) of the jOints

-h~H-JR-It------ Latissimus dorsi

S1 - S3 irritation zones

H---~c3j Tensor fasciae latae

Greater trochanter

"+-+ 1 + f f l f f l - - -
Ischial tuberosity

H~,f-f+Hf*"H-I----~j i CE)PS femoris


Greater trochanter sacral contour
CD (inferior lateral ang le and coccyx)

Ischial tuberosity
Fig.34. Palpation field of the dorsal pelvis (general view)
126 Palpation at Rest

Findings: Painful hypertonicity may be found

with sacrum acutum.
Anteromedial to the ligament on the ischium:
adductor magnus (Lz-SJ, obturator nerve, sciat-
ic nerve).

Pain and tenderness in this area can also occur
with radicular syndromes of the lumbar spine
and with hamstring shortening. The adductor at-
tachments also may be tender in association with
hip joint lesions and restrictions of the SIJ (mus-
cle shortening).

2) Greater Trochanter (Fig. 36 a,b)

The trochanters are palpated with the index or
middle fingers, followed by the muscle and liga-
ment attachments.
Posteroinferiorly: the gluteus maximus at the
gluteal tuberosity (LS-S 2 , inferior gluteal nerve).
Fig. 35 a, b. Bimanual palpation of the ischial tubero- Posterior aspect of the trochanter: deeply, the ex-
sities (1) ternal rotators obturator externus and quadra-
tus femoris (LS-S 2 , inferior gluteal nerve) and
the trochanteric bursa.
Point of the trochanter: gluteus medius and min-
imus (L4-S 1, superior gluteal nerve) and, deep to
the trochanteric fossa, the piriformis (Sl/S2/
sacral plexus).

The small external rotators cannot be differenti-
ated. If the piriformis is shortened, however, it
can sometimes be felt in the area of the greater
a ischiadic foramen by palpating obliquely from
the posterior superior iliac spine toward the is-
chial tuberosity (Janda). The test for piriformis
shortening is described in E/LPH Region/5.2

Additional Findings
Tenderness to percussion of the greater
trochanter is noted with hip joint lesions (sub-
capital femoral fracture, growth disturbance, in-
flammation, tumor, tendinopathy, bursitis).
Abrupt slippage of the iliotibial tract over the
b greater trochanter occurs in a "snapping hip."
Fig.36a,b. Bimanual palpation of the greater Test by palpating flexion and extension of the
trochanters (2) hip joint with the thigh slightly adducted.
Palpation at Rest 127

3) Posterior Hip Muscles (Fig. 37 a-c) Erector spinae (iliocostalis) at the superior bor-
The following structures are palpated laterally der of the sacrum.
to medially: Iliac crest muscles and iliolumbar ligament from
Tensor fasciae latae over the greater trochanter medial to lateral (Fig. 37 c).
(Fig. 37 a). Hypertonicity of this muscle (and the
iliposoas) is common with SIJ restriction. Thick- - Iliolumbar ligament (to transverse process of
ening and tenderness are present in a "snapping L4 and LS) is tender to pressure when hyper-
hip." mobility is present.
Gluteus medius and minimus at the lateral supe- - Quadratus lumborum (Tl2 and L 1-L3, femoral
rior border of the ilium (Fig.37b). nerve) is a lateral flexor and is prone to short-
Check for myogeloses in the upper outer quad- ening, in which case its lateral border can be
rant (muscle sign of Sell). palpated on the midscapular line lateral to the
Gluteus maximus medially, parallel to the erector trunci. Lumbar sidebending to the op-
sacroiliac joint line. posite side is limited, and occasionally there is
Sell notes that myogeloses and decreased tone respiratory impairment (attachment to the
are found in the gluteals in association with twelfth rib). Increased paravertebral promi-
chronic restrictions and SIJ displacements on nence is noted during forward bending in the
the ipsilateral side. Usually there is accompany- sitting position. Trigger points are found at the
ing hypertonicity of the contralateral tensor fas- lower end of the muscle over the iliac crest.
ciae latae. Gluteal tenderness is also noted with - Obliquus abdominis externus (Ts-T12' inter-
hypermobility. costal nerves) (Mackenzie point).

4) Posterior Superior Iliac Spine, Sacral Sulcus,

Sacroiliac Joint (Fig. 38 a-e )
Initial palpation is bimanual as both thumbs are
placed over the posterior superior iliac spines,
sliding medially into the sulcus between the iliac
spine and median sacral crest. Then each sacroil-
iac joint line is palpated for its full extent (supe-
a '----'......._ _ • rior and inferior poles, Sl-S3) and compared
with the opposite side, giving attention to sulcus
depth, ligament tension (dorsal sacroiliac liga-
ments), and tenderness to pressure. This exami-
nation, like palpation of the inferior sacral con-
tour (especially the inferior lateral angle), aids in
detecting positional faults of the sacrum relative
to the ilia and the functional disturbances that
may result.
The SIJ irritation points (after Sell and Bischoff)
for Sl are located about 3 fingerwidths lateral to
the superior joint pole and about 4 fingerwidths
caudal to the iliac crest. The S3 points are about
1 fingerwidth lateral to the inferior joint pole.
An irritation point has not been described for S2
(see Fig. 34).
Dvorak places the irritation zones for the SIJ on
c the lateral border of the sacrum from the poste-
Fig.37a~. Bimanual palpation of the posterior hip rior inferior iliac spine (Sl) to the inferior later-
muscles al angle above the sacral cornu (S3). Sl-S3
128 Palpation at Rest

points are also arranged vertically on the pubic

bone adjacent to the symphysis. The author
claims that the finding of symphyseal irritation
zones signifies a general dysfunction involving
the pelvic ring rather than a disturbance con-
fined to the SU.

5) Inferior Sacral Contour, Inferior Lateral

Angle, and Coccyx (Sacrococcygeal Joint)
(Fig. 39 a-e)
The middle finger of the palpating hand slides
down the median sacral crest to the depression of
the sacral hiatus. The inferior lateral angles are
located by spreading the index and ring fingers to
the side. At this site both thumbs are placed on
the dorsal surface of the inferior sacral angle to
check for asymmetric posterior projection. This
area should be observed from the caudal aspect
to aid in detecting the very slight differences in
height. Finally the palpating thumbs slide to the
inferior border of the sacral angle (Fig. 39 a-c) to
check for craniocaudal asymmetry.
The last structure to be examined is the sacro-
coccygeal joint (Fig. 39 d,e). The tip of the coccyx
is tender to pressure in the anterior and lateral
direction in the case of positional faults and fol-
lowing sprains caused, for example, by a fall
onto the buttock. A painful sacrococcygeal joint
requires further transrectal examination of the
joint. The attachments of the gluteus maximus
(posterior), levator ani, and coccygeus muscles
and the sacrospinalligament (anterior, palpable
per rectum) also will show relative tenderness.
An open sacral hiatus is found in spina bifida.
Biomechanical Considerations
According to Mitchell et aI., palpation of the
sacral sulcus and inferior lateral angle permits
the diagnosis of sacral positional faults that can
lead to functional disturbances in the SUs (posi-
tive seated flexion test, see B!LPH Region!
Sect. 3.2, p.llO).
The axes for sacral movements are as follows

- Left and right diagonal axes for torsional

e movements of the sacrum
Fig. 38 a-e. Bimanual palpation of the sacroiliac - One or two transverse axes for flexion and ex-
joints tension movements of the sacrum
Palpation at Rest 129

Torsional movement of the sacrum about the left

or right diagonal axis is recognized by noting
that the sacral sulcus is deeper on one side than
on the other. This indicates that the base of the
sacrum has moved forward on the side of the
deeper sulcus. Meanwhile the opposite inferior
lateral angle moves backward, occupying a more
dorsal and caudal position than the ipsilateral in-
ferior angle. This positional fault can be accen-
tuated by pressing on the sacral base, producing
a palpable backward movement of the sacrum at
the opposite SU (in addition to precipitating or
aggravating pain). The fifth (and fourth) lumbar
vertebrae always make a relative countermove-
ment in response to this rotation of the sacral
base, because they are connected by the iliolum-
bar ligament with the ilium, which also under-
goes a relative countermovement ("dorsal rota-
tion") in response to sacral torsion. The result is
a slight rotation ofthe vertebrae toward the side
of the deeper sulcus. This exerts an opposite ro-
tatory stress on the fibrous ring ofthe LS-Sl disk
which, according to Farfan, may tear in its outer
layers if the stress exceeds the elastic limit (the
physiologic range of rotary motion in the lumbar
segments is only about 1°-2°). Subsequent fur-
ther tearing of the more central fibers of the
anulus lamellosus may culminate in prolapse of
the nucleus pulposus.
The sacrum can assume forward and backward
torsional positions by rotating about the diago-
nal axes, forward torsion accentuating lumbar
lordosis and backward torsion decreasing it. The
two torsional positions are differentiated by the
springing test (see Two-Stage Springing Test,
p.131). The test elicits an elastic springiness with
a lordotic lumbar spine and nonelastic rigidity
with lumbar kyphosis. Sacral torsion thus repre-
sents a functional adaptation to the lumbar cur-
vature, and vice-versa.
Flexion/extension movements of the sacrum oc-
cur on transverse axes at the level of the SU. The
movement may be a symmetric nutation ("nod-
ding") of the sacrum with respect to the ilia or a
unilateral nutation on the left or right side. With
unilateral nutation, we again find a deeper sul-
Fig.39a-e. Bimanual palpation of the inferior sacral cus on the side of the movement, but now the in-
contour (a~) and palpation of the sacrococcygeal ferior lateral angle of the sacrum moves down-
joint (d,e) ward and backward on the ipsilateral side. The
130 Palpation at Rest

Flexion Torsion

ligament Iliolumbar ligament Diagonal axes

1 Movements of the
sacrum and ilium
during sacral torsion
2 Countermovement of Ls
3 Movements of the sacrum
and ilium during sacral

Inferior lateral

Fig.40. Movements of the sacrum

effects on the vertebral column are the same, sacrum and ilium can produce a functional leg
i. e., sacral flexion accentuates lumbar lordosis. length discrepancy. This is tested before the joint
translation tests are performed (see Sects. 3.1
Summary Pelvic Position and 3.2 Seated Flexion Test).
The sacral sulcus is deeper on one side and dis-
placed posteroinferiorly relative to the opposite 3.2 Testfor Functional Leg Length
inferior angle: sacral torsion about the diagonal Discrepancy
axis. With forward torsion of the sacrum, the
The test for functional leg length discrepancy is
lumbar spine is lordotic (elastic in the springing
performed in the prone or supine position. The
test); with backward torsion, the lumbar spine is
legs must be parallel to the midline with no ad-
kyphotic (rigid in the springing test). The ipsilat-
duction or abduction. The examiner places his
eral inferior angle is displaced downward and
thumbs at the distal border of the medial malle-
backward: sacral flexion.
oli and determines whether they are at the same
The foregoing models of sacral positional faults
are a useful aid to interpreting the subsequent
tests of joint translation, for they help to show
the appropriate directions for corrective thera- Normal Findings
peutic manipulations on the SUs. These transla- The malleoli are at equal levels.
tion tests are provocative tests based on the ex-
perience that aggravating a positional fault of Pathologic Findings
articulating structures evokes (capsular) pain, A functionally short leg can result from a unilat-
while restoring a neutral fit relieves or reduces eral restriction of sacral nutation on the side of
presenting complaints. Positional faults of the the shorter limb.
Palpation at Rest 131

3.3 Segmental Palpation of the Lumbar

Spine (Mobility/Pain)
Five different palpatory tests are done to evalu-
ate the elasticity and tenderness of the lumbar
spine (and thoracic spine) and identify the af-
fected segment.

Starting Position
Prone with the spine in slight kyphosis.

1) Two-Stage Springing Test

(To establish the level of the disturbance)
(Fig.41 a-c) .
Test for springiness and tenderness to pressure.
Springing is a palpatory technique for testing the
general mobility ofthe spinal segments and is es-
pecially useful for preprogramming the segmen-
tal palpation for tenderness (the "pain rosette "),
which involves circular palpation about the
spinous process. It is most efficient to examine
the thoracic spine concurrently with the lumbar

The heel of the hand is placed on the spinous
processes of the area to be tested. The wrist is
dorsiflexed 90 0 ; the elbow is straight
(Fig.41 a-c).
Alternatively, the thumb may be placed on the
tip of the spinous process, and the pressure ap-
plied through the pisiform bone of the other
hand, which is placed over the thumb (Fig. 42c).
The two test stages are as follows:
1. Light thrusts are applied to test the springiness
of the segments below the heel of the hand. Fig. 41 a--c. Two-stage springing test
Springiness is usually lowest at the midtho-
racic level.
2. Tenderness is tested by applying greater pres- According to Lewit, a tender point on one side
sure to the spinous or transverse processes ofthe spinous process is always located opposite
(see Fig. 43). to a vertebral restriction. Thus, tenderness on
the right side of the spinous process would indi-
2) Palpating the Tips of the Spinous Processes cate a restriction of the left facet joint. It remains
for Tenderness ("Pain Rosette") (Fig. 42 a) unclear, though, whether the vertebra is restrict-
Moderate pressure is applied from all sides of ed with respect to the higher or lower adjacent
the spinous process to the attachments of the lig- vertebra, and whether the restriction is conver-
aments (supra- and infraspinal ligaments) and gent or divergent in nature. In most cases the
intrinsic muscles (interspinales, multifidus, restriction involves the vertebra above. This is
semispinalis) to test for tenderness. determined by the thrust technique described
132 Palpation at Rest

below, direct palpation of the facet joints (see

under Sect. 4), and tests of joint translation (see
C/LPH RegioniSect.4.1, p.135).

3) Thrusting of the Spinous Processes

(Fig.42 b-d)

The forceful application of an anteriorly direct-
ed (Fig.42 d) or cranially directed (Fig.42 b)
thrust to the spinous processes affects the entire
motion segment. It places tension on the liga-
ments about the vertebral arches and interverte-
bral disks, produces traction or anterior gliding
in the facet joints of the vertebra above and
some compression in the joints of the vertebra
below, and thus constitutes a test of translational
motion Goint play) in the sagittal plane that will
require additional tests of facet joint play if ten-
derness or pathologic motion is elicited (see
C/LPH Region/Sect. 4.1, p.135).

Increased pain in response to thrusting at L4 and
L5 may also indicate spondylolisthesis.
Pain in a spinous process elicited by shaking of
the process has similar significance as pain elicit-
ed by a thrust.

Keyring Test (ofMaigne)

A thrust applied between the spinous processes
toward the supra- and interspinous ligaments
differentiates ligament pain from joint pain.
Liagment pain is most commonly seen with seg-
mental loosening (motion segment laxness).

Normal Findings
The palpatory tests elicit a firm-elastic

Pathologic Findings
Springy resistance, muscular guarding, and ten-
derness due to joint effusion, disk protrusion, or
joint restriction.
Severe pain and boardlike muscular rigidity
occur with osteolytic processes.
Fig.42. a, b Pain rosette. c, d Thrust techniques
Palpation at Rest 133

4) Palpation ofthe Facet Joints (Springing

Test) and Segmental Muscles (Fig. 43 a-d)
The index and middle fingers, spread in V fash-
ion, are placed onto the articular processes di-
rectly adjacent to the spinous process (Fig. 43 b)
or onto the transverse processes about 2 cm lat-
eral to the spinous process (Fig.43 c). The facet
joints and segmental muscles are tested for ten-
derness by applying light, momentary, anteriorly
directed pressure to the palpating fingertips with
the ulnar border of the free hand. Forceful pres-
sure on the transverse processes has the same ef-
fect in the segment as a thrust applied to the
spinous process. This technique is a useful ad-
junct in cases where thrusting ofthe spinous pro-
cess has yielded equivocal results. This test, to-
gether with unilateral hypertonicity of the
segmental muscles, can accurately identify the
side affected by a restriction (see under 2
above). The LS/Sl segment is approached from
the cranial side (Fig. 43 d).

5) Palpation ofthe Segmental Neural Trigger

Dorsal spinal nerve roots incarcerated at the site
where they pierce the fascia, with or without ac-
companying fat herniation ("entrapment neu-
ropathy"), can be palpated a handswidth lateral
to the spinous processes in the lumbar and lower
thoracic region. Pain in the sacral region is local-
ized to the midline. Clinical differential diagno-
sis: pain is exacerbated by massage, often dra-
matically improved by local anesthesia.
Occurrence: relatively rare.

6) Segmental Irritation Points of SeD (Testing

of Irritation Zones) (Fig. 44 a-c)
Starting Position
Prone with the arms hanging loosely at the sides
to relax the back muscles.

The segmental IrrItation point is located by
placing the tip of the middle finger adjacent to
the line of the spinous processes, between the
spinous process and erector trunci, and pressing
in deeply (Fig. 44 a). The palpating finger push- Fig. 43 a-d. Springing test. a Starting position: the fin-
es aside the erector trunci about 1 fingerwidth gers are placed on the articular process (b) or trans-
verse process (c). d Hand placement for testing L5
134 Palpation at Rest

(Fig.44c). Sensitivity to forward bending is test-

ed by active flexion and sensitivity to backward
bending by passive hyperextension of the leg on
the palpated side (Fig. 44b).
The diagnostic criteria are pain and change in
firmness; an increase or decrease in these crite-
ria constitutes an indication for treatment. The
movement that produces a decrease in pain and
firmness indicates the appropriate direction for
therapeutic manipulation.
At the sacroiliac joints, Sell and Bischoff report
that the segmental IPs for Sl are located about 3
fingerwidths lateral to the superior joint pole
and about 4 fingerwidths caudal to the iliac crest,
while the IP for S3 is approximately 1 finger-
width lateral to the inferior joint pole.
Restriction is not described for S2, which is be-
lieved to represent the transverse axis for flex-
ion/extension movements of the sacrum. It ap-
pears, then, that irritation zones for S2 could
exist only with hypermobility of the SIJ (see
Fig. 34, p.125). Sutter and Dvorak state that the
IPs for Sl-S3 are located between the posterior
superior iliac spine and the sacral cornu, which
compromises their usefulness as diagnostic indi-

3.4 Kibler's Skin Rolling Test (Fig. 45)

This test is used for the evaluation ofhyperalget-
ic zones (Head's zones).

Fig.44a-c. Segmental irritation points of Sell

laterally to reach a tender, sharply circum-

scribed area of increased firmness about
0.5-1 cm in diameter: the irritation point (IP).
Keeping the palpating finger on the IP, the ex-
aminer notes its behavior in response to rota-
tion, forward bending, and backward bending
of the spine.
Sensitivity to rotation is tested by moving the pa-
tient's upper arm posteriorly until the lumbar
spine at the level of the IP begins to rotate Fig. 45. Skin rolling test
Tests of Joint Translation 135

Procedure 4 Tests of Joint Translation

A skin fold extending laterally from each side
of the midline is formed between the thumb
4.1 Lumbar Spine
and index finger and rolled upward toward
4.2 Sacroiliac Joints
the head, parallel to the spinous processes.
4.3 Hip Joints: Rotation
The examiner notes the thickness and consis-
tency of the fold and its resistance to displace-
While the palpatory tests at rest begin at the hip
Pathologic Findings
joint and proceed to the SUs and lumbar spine,
Excessive firmness of consistency, excessive re-
this sequence is reversed for the testing of joint
sistance to displacement, pain in the area of hy-
play. Mitchell et al. state, moreover, that func-
peralgetic zones.
tional disturbances in the vertebral column
Similar information is furnished by the connec-
should be treated before disturbances in the
tive-tissue stroke test.
pelvic region.
3.5 Connective-Tissue Stroke Test
4.1 LumbarSpine
All segments that exhibit tenderness in re-
The skin and subcutaneous tissue are displaced
sponse to firm palpation or thrusting must be
relative to the deeper layers (muscle, tendon,
tested for joint play (Fig.47 a) to establish the
location of the motion fault and, if possible,
identify the causative factor (facet joint, inter-
vertebral disk, segmental muscle) or detect pos-
The examiner's index finger is placed over the
sible hypermobility caused by destabilizing
middle finger, which is stroked firmly across the
structural changes.
skin to raise a bulge of soft tissue. The angle of
the finger to the body surface determines
Starting Position
whether a deeper or more superficial effect is
Prone with lumbar spine elevated to produce
Pathologically altered zones show signs similar
to those observed in the skin rolling test.
Procedure (Fig.47 a-e )
The spinous processes tender to palpation are
first rotated in one direction and then in the op-
posite direction while the next lower vertebra is
immobilized (Fig. 47 b,c). Spinous processes that
are painful in one direction of motion are rotat-
ed in that direction and held in the terminal posi-
tion. Then the spinous process of the next higher
and lower vertebrae are counterrotated
(Fig.47 d,e).
This maneuver first produces a slight gliding
movement in the frontally oriented joint sur-
faces, followed by compression of the facet joint
on the side of the movement (Fig. 47 d) and trac-
tion (decompression) of the joint on the oppo-
site side (Figs. 47e and 62b, p. 149). In each case
Fig. 46. Connective-tissue stroke of approximately the segmental muscles are tensed on the side op-
0.5-1 cm posite the movement.
136 Tests of Joint Translation

Fig.47a-g. Tests of joint play (rotation) in the lumbar

segments. a Finger placement. b,c Procedure. d,e
Identification of the affected level. f, g Testing the di-
rection oflimited or painful motion in the affected seg-
Tests of Joint Translation 137

segmental muscles. This mode of testing each

Normal Findings
segment yields further information on the ap-
The rotational movements are painless and
propriate direction for therapeutic manipula-
According to Brugger's theories, however, (pro-
Pathologic Findings
tective) spasm may occur on the unaffected side
A restriction exists in the segment in which
if this helps to prevent movement of the dam-
counterrotation is painful and/or limited. Oppo-
aged joint that would increase nociception
site rotation in the same segment generally
evokes little or no pain. If rotation in both direc-
In any case, the muscles that become hypertonic
tions produces significant pain, more severe disk
are those that help to prevent an increase of
involvement (prolapse or inflammatory change)
pressure within the damaged joint or segment.
should be suspected. Slight terminal pain associ-
ated with normal mobility or hypermobility is
more suggestive of motion segment laxness, 4.2 Sacroiliac Joints
which can be confirmed by the key ring test of
Because motion testing of the SIJ is difficult due
Maigne (see p.132).
to its irregular facetting and the very small am-
For hypermobility testing in the prone position
plitude of its movements, it is best to apply sev-
(Fig.6Sc, p.lS3), the examiner places his flat
eral tests to evaluate SIJ mobility. Provocative
hand above the symphysis below the abdomen
tests are the most rewarding, though care must
and lifts the abdomen slightly. The other hand
be taken to avoid concomitant movements in the
palpates the cranial spinous process to check
LS/Sl segment. Figure 48 illustrates the testing
for dorsal displacement due to pathologic
of passive and translational mobility at the lum-
laxness of the mobile segment. Pathologic mo-
bosacral junction.
tion is usually demonstrated more clearly by
pushing the caudal vertebra of the tested seg-
Four-Point Springing Test (Provocative Test
ment in the opposite direction (toward the
for the Upper Pole ofthe SU)
table) with the thenar eminence of the pal-
Pressure on the sacrum at the level of the poste-
pating hand.
rior superior iliac spine (Fig.49 a,b) exerts trac-
-Note tion on the SIJ, while pressure on the adjacent
Palpation of the segmental muscles and facet portion ofthe ilium (Fig.49c,d) exerts compres-
joint is also necessary for identifying the sion on the SIJ. The examiner notes which
restricted side of the segment. According to pre- movement elicits pain. The same pressure points
vious conceptual models, the restriction is gen- are tested on the contralateral SIJ, and both
erally located on the side opposite the paraver- sides are compared.
tebral muscle spasm, since, as in the extremities, Pressure is then applied to the upper outer
nociceptive muscle spasm occurs in the muscles border of the sacral base on one side to produce
that are functionally related to the joint. The in- sacral torsion (nutation) and on both sides to
trinsic back muscles of the medial tract extend produce sacral flexion. If the sacrum is already in
from spinous process to spinous process (inter- a position of flexion or torsion, so that the
spinal muscles), from transverse process to fibrous ring at LS/Sl is already under a rotary
transverse process (intertransverse muscles), strain produced by the automatic counterrota-
and from transverse process to spinous process tion of LS induced by these sacral positions, any
(short rotator muscles) of adjacent vertebrae. increase in rotation will elicit pain; decreasing
They become painful and hypertonic when the the rotary stress by applying a force in the oppo-
tender spinous process is rotated away from the site direction (pressure on the inferior lateral
spastic side and the spinous process below it is angle = counternutation) will alleviate pain
rotated toward that side (muscle stretch). Op- (Fig. SO a-f). The opposite points are tested at
posite rotation of the same vertebrae relaxes the the sacral base and at the inferior lateral angle
138 Tests of Joint Translation

Fig. 48. Pa sive and translational joint mobility at the

lumbosacral junction

Fig.49a-d. Four-point springing test. a,b Sacrum. c,d Ilium

Tests ofJoint Translation 139

using the same technique, and the results for

both sides are compared. Marked bilateral ten-
derness to pressure on the sacral base indicates
more severe L5/S1 disk pathology.

Springing Test Over the Sacrum (Test for

Countemutation/ Posterior Motion) (Fig. 51)
As one hand applies a springing pressure to the
sacral apex, the forefinger of the other hand pal-
pates the lower end of the posterior iliac spine
(Fig. 51 b) or the upper pole of the SIJ (Fig. 51 a)
to detect the small springy movement. This
movement, which is more traction than gliding,
is imparted chiefly to the inferior joint pole near
the site where the force is applied. The patient
must state whether the test movement is painful.
The pain may arise in a restricted joint or in an
overloaded joint showing compensatory hyper-
mobility. A dearly palpable movement of sub-
stantial amplitude accompanied by pain signifies

Fig.50a-f. Counternutation (nutation in the posterior

direction). a Same side (flexion axis). b Opposite side
(torsion axis). c-fMovements of the sacrum about the
diagonal axis (torsion axis). Clinical examination and
demonstration on a skeletal model

140 Tests of Joint Translation

a painful hypermobility. To avoid confusing skin where it can be palpated even without touching
tension caused by the sacral movement with the ilium. Absence or painful limitation of mo-
movement of the joint, the springing hand on the tion suggests an iliac positional fault in dorsal ro-
sacrum should push the skin slightly cephalad tation if there is concomitant deepening of the
before applying the springing pressure. adjacent sulcus.

lliac Lift Test (Motion Test in Nutation) Craniocaudal Sacral Push (Provocative Test
(Fig. 52 a,b) for the Lower Pole of the Sacrum)
One hand grasps the ilium at the anterior superi- This is a two-phase test that centers on the infe-
or iliac spine and applies a springing force di- rior pole of the sacrum. Its purpose is to identify
rected back toward the sacrum while the finger the therapeutic direction for manipulation or
of the other hand palpates the sulcus between mobilization of the joint in cases of sacroiliac
the ilium and sacrum, above the posterior supe- displacement (iliac rotation, sacral torsion or
rior iliac spine. The hypothenar of the palpating flexion) where the joint is fixed in a terminal po-
hand stabilizes the sacrum during the test so that sition. Again, the test is based on the concept
iliac motion is more clearly perceived. The and experience that pain is provoked by the at-
movement (posterior movement of the ilium rel- tempt to accentuate a positional fault in a joint,
ative to the sacrum) occurs chiefly at the upper while pain is relieved by moving the joint sur-
pole of the SIJ and is easier to palpate at that lo- faces back to an intermediate position of con-
cation. With a firm restriction of the joint, the il- gruency. This test movement is not accessible to
iac movement will be transmitted to the sacrum, digital palpation.

Fig. 51a,b. Springing test over the sacrum (counter- Fig.52a,b. Springing test over the ilium (lift test)
nutation) with simultaneous palpation of the lower with simultaneous palpation of the upper pole of the
pole ofthe SIJ SIJ
Tests of Joint Translation 141

Phase 1: Countemutation ("Backward

Nodding") of the Sacrum by an Upward Push
(Figs. 54 a-d, 53a; Fig. 54 a,b shows the
technique for the left SIJ, Fig. 54 c,d for the
right SIJ).
The immobilizing hand is placed so that the hy-
pothenar and little finger are over the iliac crest.
The pushing hand is placed so that the pisiform
bone is at the inferior lateral angle ofthe sacrum
next to the sacral hiatus. The hands and fore-
arms are positioned opposite to each other in the
direction of the push. The caudal hand pushes
upward to elicit a counternutational movement
of the sacrum. Example: Patient presents with
forward torsion or unilateral flexion of the
sacrum or dorsal rotation of the ilium. In this sit-
uation the base of the sacrum has moved down-
ward and forward in relation to the ilium on one
side (the side with the deeper sacral sulcus). It
should be possible to push the sacrum forward
and upward, causing the base to move posterior-
ly, without eliciting pain. If this movement is
painful, the opposite direction (nutation) must

f't--....L..._-'---f\. Iliac crest


a of test movement

c:::::J of test movement


Fig.54a-d. Counternutation test of the left (a, b) and
Fig.53a,b. Craniocaudal sacral push right sacroiliac joints (c, d)
142 Tests of Joint Translation

be tested by pushing the sacrum forward and ing the joint are twisted posteriorly to release
downward in relation to the ilium. This move- soft-tissue tension, then an anterolateral push is
ment should then be painless. applied deeply to the ilium while the contralat-
eral side of the sacrum is immobilized. The ante-
Phase II: Nutation ("Forward Nodding") of rior superior iliac spine should not rest directly
the Sacrum by a Downward Push (Figs. 55a,b, on the table (padding).
53b; right SIJ).
The pushing hand is placed so that the pisiform -Note
bone is on the base of the sacrum next to L5; the If the initial situation is reversed (backward tor-
immobilizing hand is placed with the hy- sion of the sacrum or forward rotation of the ili-
pothenar on the ischial tUberosity. Lumbar lor- um, the sacrum having moved upward and back-
dosis is eliminated to ensure that the pushing ward relative to the ilium on one side), the
hand has sufficient contact with the sacrum and principle remains the same. In this case an up-
that the lumbar segments, especially L5/Sl, do ward push on the sacrum (counternutation) will
not move. The cranial hand pushes downward to evoke pain by accentuating the positional fault,
elicit a forward and downward nutational move- while a downward push (nutation) will relieve
ment of the sacrum. pain by decompressing the joint.
Both tests are generally performed in succes-
sion. They may be followed by an anterolateral
Normal Findings
iliac push in which the hand is placed flat on the
Pushing in either direction does not elicit
ilium with the thumb and thenar parallel to the
sacroiliac joint line. First the soft tissues cover-

Pathologic Findings
In most cases the nutational push is painful while
the counternutational push relieves pain, since
the SIJ generally is displaced or restricted in a
position of terminal nutation. This is because in
an upright posture or while walking, the pre-
dominant joint movement is nutation due to the
weight of the torso. Excessive movement can
culminate in a restriction.
While the foregoing tests act on the joint mem-
bers themselves, in the following tests the exam-
iner transmits the motivating force through the
adjacent hip joint by using the lower extremity
as a lever arm.

Gapping Test (SIJ Traction) by Internal

Rotation of ihe Femur
As in the testing of internal hip rotation, the ex-
aminer flexes the knee 90° and grasps the ankle
to internally rotate the femur (as in Fig. 56a).
Motion at the hip joint should not be painful.
When the opposite iliac spine begins to lift up,
gapping of the ipsilateral SIJ can be detected
with the palpating finger (not shown in the fig-
ure). Similarly, the hyperextended femur (phase
Fig.SSa,b. Nutation test ofthe right sacroiliac joint 2 of the three-phase test) can be used as a lever
Tests of Joint Translation 143

to induce palpable counternutation of the Internal Rotation (Fig. 56 a)

sacrum in the ipsilateral SIJ (see p.122).
Starting Position
Sell's Traction-Assisted Test The examiner stands on the lateral side of the
In this technique the sites of induration com- tested leg. The thigh is slightly abducted, the
monly associated with SIJ restrictions and dis- knee flexed 90°.
placements are first palpated in the area of the
gluteus maximus, medius, or minimus (segmen- Procedure
tal irritation points, see p.133). Then a counter- The lower leg is moved laterally until the con-
nutation movement of the sacrum is produced at tralateral anterior superior iliac spine rises
the SIJ by pushing on the inferior lateral angle of about 5 em from the table. The examiner stead-
the sacrum in the cranial and/or anterior direc- ies the lower leg in that position against his body.
tion while supportive caudal traction is applied The other hand then presses the ipsilateral ilium
to the leg (gripped between examiner's arm and (with the acetabulum) anteriorly and medially
body). A palpable "softening" of the firm sites (toward the table) to produce a gliding move-
(irritation zones) and the patient's confirmation ment of the acetabulum relative to the fixed fe-
of decreased tenderness to palpation indicate mur, which thus undergoes a relative internal ro-
the therapeutic direction. One disadvantage of tation.
this test is that the anterior pull on the ilium is
transmitted across the intervening hip joint. External Rotation (Fig. 56 b)
Further SIJ tests are performed as needed in the
lateral and supine positions (see D/LPH Re- Starting Position
gion/Sect.4, p.152; E/LPH RegioniSect.4.3, The examiner stands on the side of the untested
p.l72). leg.

4.3 Hip Joints: Rotation (Fig. 56)

Internal rotation is the first motion that is re- The lower leg is brought medially toward the ex-
stricted in the presence of a joint lesion. aminer until the anterior superior iliac spine on

a b

Fig.56a,b. Hip joint rotation. a Internal rotation. b External rotation

144 Muscle Tests

the tested side rises about 5 cm from the table. Extensors (Fig. 57)
Again, the examiner steadies the lower leg in
Starting Position
that position against his body. The other hand
Leg is extended or flexed 90° at the knee. Leg
presses the ilium on the test side anteriorly and
position is intermediate between internal and
laterally (toward the table) to produce a relative
external rotation. Pelvis is immobilized.
external rotation of the fixed femur with respect
to the moving pelvis.
The examiner applies resistance as follows:
Normal Findings Below the knee with the leg extended: Resis-
Equa l ranges of painJess internal and external tance is applied anteriorly against extension by
rotation on both sides with a firm-elastic end- the gluteus maximus (Ls-S2' inferior gluteal
feel. nerve) and hamstrings (L4-S 3 , inferior gluteal
Ranges of motion: nerve, tibial nerve), Fig. 57 a.
Internal rotation 30°-40°
External rotation 40°-50° eNote
The pelvis should be well immobilized and mon-
itored for movement, e.g., by palpation of the
These tests can also be applied therapeutically in
greater trochanter.
patients with limitation of hip motion.
Above the knee: Resistance is applied anteriorly
against extension with the knee flexed 90° (to
deactivate the hamstrings), Fig.57b. The ten-
don attachment on the gluteal tuberosity (only
5 Muscle Tests gluteus maximus) can be simultaneously pal-
An even more accurate test for gluteus maximus
5.1 Resistance Tests of Hip Muscles
weakness is to support only the patient's trunk
(Extensors and Rotators)
on the examination table while the patient per-
5.2 Knee Muscles
forms the above tests, raising the leg without ex-
5.3 Back Extensors
ternal resistance. When weakness is present, the
leg cannot be raised past the horizontal and
5.1 Resistance Tests o/the Hip Muscles begins to deviate into abduction and external
(Figs. 57, 58) rotation.

Fig.57a,b. Resistance test of the hip extensors. a Hip extensor group. bGluteus maximus
Muscle Tests 145

a b

Fig.58a,b. Resistance test ofthe hip rotators. a Internal rotators. b External rotators

Rotators (Fig. 58)

With the knee flexed 90°, the internal rotators of
the hip are tested by applying resistance at the
lateral malleolus while the thigh is in neutral ro-
tation or maximum external rotation (Fig. 58 a).
Then, with the knee still flexed 90°, the external
rotators are tested by moving the lower leg later-
ally to a position of neutral or maximum internal
thigh rotation and applying resistance at the me-
dial malleolus (Fig. 58 b).
The pelvis must be immobilized for both tests.

5.2 Knee Muscles (Figs. 59,60)

Starting Position
The knee joint is moderately flexed to 70°-80°.

The examiner applies resistance as follows:
On the anterior side of the lower leg: Extension is
resisted to test the quadriceps femoris (Lz-L4 ,
femoral nerve), Fig. 59a. The femur must not ro- ____b
tate during the test.
On the posterior side of the lower leg: Flexion is Fig. 59 a, b. Resistance tests of the knee muscles.
resisted to test the hamstring muscles (L4-S 3, tib- a Knee extensors. b Knee flexors
146 Muscle Tests

ial and peroneal nerve), Fig. 59 b. The hip should

be slightly flexed during this test.

If the hip joint is in 0° flexion while the knee is
flexed 90° or more during the hamstring resis-
tance test, spasm may occur in the (weakened)
hamstrings if there is coexisting rectus shorten-
ing. This can be avoided by flexing the hip slight-
1y to relax the rectus.
Substitution by the sartorius tends to produce
a external rotation at the hip.

Differentiation of the Hamstrings

Starting Position
Knee flexed 30°-40°.

Flexion with the femur internally rotated, i. e.,
the lower leg swung laterally. Resistance to flex-
ion is applied at the medial malleolus (Fig. 60 a)
to test the semitendinosus, semimembranosus,
b-"'_ _-""_ and gracilis (L4-S 2 , tibial nerve).
Flexion with the femur externally rotated, i. e., the
Fig.60a,b. Differentiation of the flexors. a Semi- lower leg swung toward the median plane. Re-
tendinosus, semimembranosus, gracilis. b Biceps
sistance to flexion is applied at the lateral malle-
olus (Fig. 60 b) to test the biceps femoris (L4-S 3 ,
sciatic nerve).

Fig.61. Resistance test of the

back extensors
Muscle Tests 147

5.3 Back Extensors (Fig. 61) the same starting position. In this more difficult
version of the gluteus test, the tested leg is
Starting Position
extended while the other leg is braced against
The patient lies at the end of the table with part
the floor. Resistance to hip extension is ap-
of the pelvis extending past the table edge. The plied to the back of the thigh (see extensor
legs hang over the table edge, flexed at the hips
and k]1ees. The patient maintains the position by
holding onto the opposite end of the table.
Tests for shortening of the rectus femoris,
Procedure iliposoas, tensor fasciae latae, short adductors,
Extension of the lumbar spine is resisted by ap- piriformis, and hamstrings are performed in
plying caudally directed pressure to the sacrum. the supine position (see E/LPH Regionl
The gluteus maximus also can be tested from Sect. 5.2, p.176).
Examination of the LPH Region
in the Lateral Position (DIll)

3 Palpation ofthe Lumbar Spine During

(Segmental Mobility)
3.1 Forward and Backward Bending
3.2 Sidebending
3.3 Rotation

4 Tests of Joint Translation

4.1 Hypermobility Test ofthe S11
4.2 Hypermobility Test of the Lumbar Spine

5 Muscle Tests
Resistance Tests of Hip Musc1es
5.1 Abductors
5.2 Adductors
Palpation of the Lumbar Spine During Movement 149

3 Palpation of the Lumbar Spine Procedure

During Movement (Segmental Mobility) The patient's flexed knees are immobilized be-
tween the examiner's thighs. The examiner then
grasps the lower legs from the front and moves
3.1 Forward and Backward Bending
both legs cephalad to flex the lumbar spine, si-
3.2 Sidebending
multaneously imparting a slight back-and-forth
3.3 Rotation
action to aid the assessment of segmental mobil-
The backward bending test is performed in anal-
The movements in the facet joints of the lumbar ogous fashion (Fig. 63 b). Also, a posteriorly di-
spine are illustrated in Fig. 62. rected push is applied to the pelvis via the femo-
ra to increase the segmental motion.
During forward and backward bending of the
3.1 Forward and Backward Bending
spine, the index finger of the examiner's free
(Fig. 63 a,b)
hand palpates the interspaces between two adja-
cent spinous processes to assess their movement
Starting Position
relative to each other (Fig. 63 e).
Stable lateral position on the edge of the exami-
nation table. The hips and knees are flexed; the
head rests on the hand or forearm. Normal Findings
Divergence (separation) of tbe palpated
spinous proce ses during forward bending,
convergence (approximation) of the proces-
ses during backward bending. During forward
bending, the amount of movement at Ll-L5
increase while mobility in the L5-S1 segment
decrease . During backward bending, L5fSl
becomes more mobile (see also Fig. 10).

Pathologic Findings
- Limitation of segmental motion
- Pain on terminal motion that mayor may not
radiate (disk protrusionf nociceptive reaction
from the facet joint)

3.2 Sidebending (Fig. 63 c,d)

Starting Position
Same as before. The examiner stands in front of
Tra9tion the patient or at a 90° angle, i. e., facing the foot
( ;/--+
Direction of test movement of the table. The patient's hips and knees are
\: flexed 90°.

One hand grasps the patient's lower legs above
Fig. 62. a 1, Gliding during distraction, forward the malleoli and moves the legs and pelvis later-
bending, backward bending; 2, translational gliding. ally and superiorly, producing lateral flexion of
b Translational joint motion during rotation the lumbar spine with the concavity upward. The
150 Palpation of the Lumbar Spine During Movement

Fig.63a--e. Segmental exami-

nation during a forward
bending, b backward bend-
ing, c, d sidebending. e Pal-
pation of the spinous proces-
ses and palpable movements
Palpation ofthe Lumbar Spine During Movement 151

Fig.64a-d. Segmental exami-

nation during rotation: a ro-
tation of the upper vertebra
to the left, b, d rotation of the
lower vertebra to the right.
c Rotation with traction.
d Right rotation of the lower
vertebra on a skeletal model d
152 Tests of Joint Translation

index finger of the free hand palpates the con- left rotation and to the left with right rotation,
comitant rotation of the spinous processes from since the palpated spinous process is located be-
the concave (upper) side (Fig. 63 c) or from the hind the axis of vertebral rotation. If there is
other side if the lumbar spine is in kyphosis. Fig- suspicion of disk involvement (protrusion),
ure 63d illustrates sidebending produced by traction is superimposed upon the rotation
direct tilting of the pelvis. (Fig. 64c).

Normal Findings Normal Findings

Rotation of the spinous processes toward the Slight rotational mobility from Ll to L5 (max-
concavity if the lumbar spine is in lordosis, or imum 3°_7° according to Pulz ). Greatest cou-
away from the concavity if lumbar spine is in pled rotation (according to White and Pan-
kyphosis. Mobility increase from Ll- L3, de- jabi) in the L3/L4 segment. Greatest axial
creases from L3 to S1 (see Fig. 10). Mobility is rotation at the lumbosacral junction.
lowest at the lumbosacral junction.
Pathologic Findings
Decreased or increased mobility in one or more
Pathologic Findings
motion segments compared with the adjacent
- Decreased sidebending mobility segments.
- Pain on terminal motion

3.3 Rotation (Fig. 64 a-c) 4 Tests of Joint Translation

Starting Position
Unstable lateral position with the lower leg al- 4.1 Hypermobility Test ofthe SIJ
most extended and the upper leg flexed at the 4.2 Hypermobility Test of the Lumbar Spine
hip and knee so that the foot rests on the calf or
in the popliteal fossa of the lower leg.

4.1 Hypermobility TestoftheSIJ
The examiner either steadies the thorax with Mennell's test ofthe sacroiliac joint and ligaments
one hand and rotates the pelvis anteriorly (dorsal sacroiliac ligaments) (Fig. 65 a)
(Fig. 64 b) or steadies the pelvis and rotates the
thorax posteriorly (Fig.64a). Both maneuvers Starting Position
rotate a given vertebra to the left if the patient is Stable lateral position at the edge of the table.
on the right side, or to the right if the patient is on The knees and hips are both flexed about 90°,
the left side, relative to the vertebra below. Thus, the head resting in the hand.
the rotational movement can be initiated either
from the thigh (pelvic rotation) or from the Procedure
shoulder (thoracic rotation). With rotation of Brief, forceful compression is applied to the an-
the thorax (Fig. 64a), the tested segment should terolateral portion of the uppermost iliac wing
be in the neutral position or in slight kyphosis, and/or sustained pressure to the uppermost iliac
because rotation to full dorsiflexion leads to a wing for 1-2 min using the examiner's full body
facet closure that blocks further motion in the weight.
segment, especially in broad-shouldered pa-
Normal Findings
Vertebral rotation is assessed by palpating the
Brief compression or sustained pressure does
lateral movement of the spinous process rela-
not elicit pain.
tive to the process below, i. e., to the right with
Muscle Tests 153

4.2 Hypermobility Test of the Lumbar

Spine (Fig. 65 b,c)

Starting Position
Same as above (Sect. 4.1).

The upper leg is flexed past 90° until the liga-
ments in the tested joint begin to tighten (palpa-
tion). The examiner then applies a posteriorly
directed thrust via the flexed thighs and palpates
for a step between two adjacent spinous process-
es in the segment. Then the other hand pushes
back anteriorly and checks for disappearance of
the step. The test in the prone position (Fig. 65 c)
was described on p.137.

Normal Findings
No step between adjacent spinous processes,
no pain.

Pathologic Findings
A step signifies motion segment laxness.

5 Muscle Tests
(Resistance Tests of Hip Muscles)

Fig.65. a Test for SIJ hypennobility (Mennel's test). 5.1 Abducto"

b Test for hypennobility of the lumbar spine, c in the .1 5.2 Adductors
prone position

Pathologic Findings 5.1 Abductors (Fig. 66a)

Brief compression evokes or aggravates pain in
the dependent hip joint if hip disease is present. Starting Position
Pain occurs in one or both SIJs with inflammato- Lateral with the head resting in the hand, as be-
ry disease (sacroiliac arthritis, ankylosing fore. The lower leg is flexed at the hip and knee,
spondylitis). Sustained pressure for about 1-2 the upper leg is extended. The patient holds onto
min evokes stretch pain in the dorsal sacroiliac the front of the table with the upper arm to sta-
ligaments when SIJ hypermobility is present bilize the trunk.
(Fig. 65 a). Turning to a lateral recumbent posi-
tion is painful in the presence of SIJ lesions or Procedure
motion segment laxness in the lumbar spine. Ly- One hand immobilizes the uppermost iliac wing
ing on the side causes pain in the dependent os- from above, exerting caudally directed pres-
teoarthritic hip. Hip pain also occurs with SIJ re- sure, to keep the abdominal muscles or quadra-
striction and/or osteoarthritis on the same side. tus lumborum from supporting the gluteals.
154 Muscle Tests

The other hand applies steady counterpressure

to the lateral side of the extended thigh above
the knee as the patient actively abducts the leg
(with the hip in the neutral position) against the
resistance. The thigh must not deviate in flex-
ion, extension, or rotation to eliminate the re-
cruitment of other muscle groups.

Normal Findings
Painless abduction, equal on both ides, with
a muscular strength of 4-5.

Pathologic Findings
Muscular strength decreased as a result of:
Muscular insufficiency secondary to hip disor-
ders (dysplasia, congenital dislocation, coxa
vara, Perthes' disease, etc.). Evidenced by a de-
crease in the distance between the origin and in-
sertion of the gluteus medius and minimus (with
a positive Trendelenburg test).
Muscular insufficiency due to shortening of the
ipsilateral adductor group.
Paresis of the superior gluteal nerve (L4-S 1). ......_.. b

Fig.66a,b. Hip muscles. a Abductors, b adductors

5.2 Adductors (Fig. 66 b)
Starting Position
Normal Findings
Same as above.
Painless adduction with a muscular strength
of 4-5.
The patient's upper leg is steadied against the ex-
aminer's body. Manual resistance to adduction is Pathologic Findings
applied at the medial side of the thigh. Again, Decreased muscular strength with adductor
great care is taken to maintain a neutral hip posi- paralysis due to obturator nerve palsy (Lz-L4 ).
tion to avoid substitution by other flexor or ex- Pain at the symphysis, especially with gracilis
tensor muscles. syndrome, adductor tendopathy, or inflammato-
Usually the abductors and adductors are rou- ry bone lesions at the adductor attachments (pu-
tinely tested in the supine position (Fig. 82 b,c, bic osteitis: traumatic, rheumatoid, tuberculous,
p.173) or sitting position (Fig. 32 a-d, p.118). or from hormonal overdose).
Examination of the LPH Region
in the Supine Position (E/II)

1 Inspection
1.1 Legs
1.2 Pelvic Position
1.3 Vertebral Column
1.4 Abdominal Wall

2 Active and Passive Motion Testing:

Hip and Knee Joints, SIJ, and Lnmbar
2.1 Hip Flexion
2.2 Hip Rotation
2.3 Hip Abduction
2.4 Knee J oint Screening Tests
2.5 Differentiation of the LPH Joints:
Hip Joint, SIJ, Lumbar Spine, and

3 Palpation Field ofthe Ventral Pelvis

(Palpation at Rest)

4 Tests of Joint Translation

4.1 Traction and Compression of the
Lumbar Spine
4.2 Traction and Compression of the
Hip Joint
4.3 SIJ Springing Tests via the Thigh

5 Muscle Tests
5.1 Resistance Tests of the Hip and
Abdominal Muscles
5.2 Shortening Tests
156 Inspection

1 Inspection - Flexion contracture ofthe hip, e. g., secondary

to inflammatory or degenerative hip disease
1.1 Legs 2. Axial limb deformity (in the frontal plane)
1.2 Pelvic Position
- Genu varum or valgum
1.3 Vertebral Column
- Malunited femoral or tibial fracture
1.4 Abdominal Wall
3. increased external rotation of one or both legs

Starting Position - External rotation contracture of the hip joint

Relaxed supine position with the legs parallel (e. g., osteoarthritis)
and the pelvis horizontal. - Growth disturbance (e.g., Perthes' disease),
inflammatory diseases
- Congenital dislocation of the hip (compare
1.1 Legs trochanter levels)
Up to 60° increase of femoral neck antever-
Normal Findings
sion in an anteverted hip
1. Equal length and parallel alignment of the
Flexion, abduction, external rotation defor-
legs. Patellae in the frontal plane.
mity with a pubic (anterior) hip dislocation
2. No axial deformity. The leg axis should pass
Flexion, adduction, internal rotation deformi-
through the center of the femoral heads,
ty with an iliac or ischial hip dislocation
patellae, and ankle mortices. Note the rela-
- Psoas shortening (with a flexed joint posi-
tive positions of the patellae and feet.
tion): Reversible psoas shortening (Moser's
3. Physiologic external rotation of tbe lower
sign) can result from irritation at the psoas
extremity. There is a normal 12° antever-
origins (transverse processes T12-L4) or in
sion of the femoral neck (angle between
proximity to the muscle (appendix, kidneys,
condylar axis and femoral neck axis). Max-
ovaries, gravity abscess, hip joint irritation or
imum internal rotation of the leg nullifies
inflammation) or from restrictions of the SIJ
the physiologic anteversion of the femoral
or midlumbar spine
neck, placing the trochanters on the frontal
- Dorsal rotation of the ilium in the SIJ
plane. The iliotibial tract may run over or
behind the greater trochanter. 4. Leg girth discrepancy (contour changes,
4. Equal muscle girths on both sides, mea- swelling)
sured 20 cm and 10 cm above and 15 cm be- Girth increased:
low the medial joint line of the knee. - Thick legs (distal portions, thigh and lower
keg): etiology unknown
For inspection of the legs in standing (weight - Thrombosis, varicose veins, elephantitis, lym-
bearing), see NGeneral Inspection (p.76 f.). phedema
- Muscular hypertrophy (athletes)
Girth decreased:
Pathologic Findings
- Disuse atrophy (e.g., after prolonged immo-
i. Unequal leg lengths bilization)
- Peripheral nerve palsies (LZ-L4, femoral
- Anatomically short or long leg nerve; Lz-L4, obturator nerve; L4-Sj, sciatic
- Functional leg length discrepancy. Dorsal ro- nerve)
tation of the ipsilateral ilium and/or rotation - Muscle diseases
of the sacrum forward and downward about
its oblique axis produces a functionally short
- Psoas shortening
Active and Passive Motion Testing 157

1.2 Pelvic Position 2 Active and Passive Motion

Deviations in the frontal plane. Testing: Hip and Knee Joints, SIJ,
and Lumbar Spine
Normal Findings
Pel vi horizontal with no rotation. Anterior 2.1 Hip Flexion
2.2 Hip Rotation
2.3 Hip Abduction
2.4 Knee Joint Screening Tests
Pathologic Findings 2.5 Differentiation of the LPH Joints: Hip,
Pelvis high on one side due to hip contracture: SIJ, Lumbar Spine, and Muscles
- Adduction contracture: contracted side is
- Abduction contracture: contracted side is low.
2.1 Hip Flexion
Motion testing in the anterior sagittal plane
Lateral pelvic shift due to scoliosis of the lumbar
Tests are performed first with the knee extend-
spine (shifted toward the concavity), anatomic
ed, then flexed.
or functional pelvic torsion.
Starting Position
1.3 Vertebral Column Relaxed supine position.

Viewed from the side. The physiologic curva- a) Active Elevation of the Extended Legs to
tures are dependent on pelvic position. About 20° Flexion
Test for the hip flexors, iliopsoas, and rectus
Pathologic Findings femoris (~-L4' femoral nerve) and lower lum-
Flattening of the curvatures due to hypermobili- bar disk compression.
ty (high assimilation pelvis).
Hyperlordosis secondary to shortening of the
Normal Findings
psoas, rectus femoris, and/or erector trunci; hip
The movement is painless and unrestricted;
flexion contracture; congenital hip dislocation.
lumbar lordosis is increased.

1.4 Abdominal Wall Pathologic Findings

Pain on disk compression in the lower lumbar
Pathologic Findings
segments by psoas tension indicates a disk lesion
1. Scars and striae (motion segment laxness).
2. Hernial openings and swellings about the in-
guinalligament: b) Maximum Passive Elevation ofthe
Swelling above the inguinal ligament: in- Extended Legs and Return to the Neutral
guinal hernia Position
Swellings level with the inguinal ligament: This test, performed immediately after the pre-
usually lymph nodes vious test, involves a passive continuation of the
Swelling below the inguinal ligament: femoral active hip flexion.
hernia, gravity abscess, traumatic anterior hip
Normal Findings
Depression below the inguinal ligament: trau-
Painless hip flexion to 90°-120° and painless
matic posterior hip dislocation
extension to the neutral position. Lumbar lor-
See also AlGeneral Inspection/Sects. 1.2 and 3
dosis disappears during hip flexion.
158 Active and Passive Motion Testing

Pathologic Findings (external rotator). This can also be used to de-

Lumbar lordosis persists (and is painful): verte- tect aggravation in Laseque's sign (see Bon-
bral restriction in the lumbar spine or shortening net's sign).
of the erector trunci. Pain in the final motion • flLggard's sig!1 is used to distinguish a true
phase after the elimination of lumbar lordosis Laseque's sign from pseudo-Lasegue. When
indicates a lesion at the lumbosacral junction Lasegue-type pain is first elicited, the leg is
(pelvic rotation pain). Pain on sudden reversal lowered until the pain just disappears. In that
to hip extension signifies lumbosacral ligamen- position the foot is strongly dorsiflexed to
tous insufficiency, pathologic segmental laxness provoke typical sciatic stretch pain. This
(chondrosis, spondylolisthesis), or degenerative maneuver also can test for aggravation
irritation in the L5/S1 segment. tendencies. The sign is usually negative when
aggravation is present.
c) Active Elevation of One Leg • Crossed Lasegue: Sciatic pain is felt on the
involved side even when the leg on the healthy
Normal Filldings side is raised (Lasegue-Moutand-Martin sign)
- Painless active flexion to about 80°_90° due to transmission of the leg movement to
(with 10° additional passive flexion). the affected vertebral segment. This response
- Elimination of lumbar lordosis. is pathognomonic for an intervertebral disk
- Terminal external rotation of the leg by protrusion.
psoas predominance. • Thomsen s sig!1.: palpation of the painful sciat-
- More than 120° hip flexion is considered ic nerve above the popliteal fossa with the foot
hypermobile, 90 0 -120 0 i normal, and Ie s dorsiflexed and the knee flexed 90°-120°.
than 90° is hypomobile. • Kernigll1g!1.: Accentuation of pain on raising
the head or passive dorsiflexion of the big toe
(Turyn's sign) indicates significant sciatic
d) Passive Elevation of One Leg with the Knee irritation.
Extended (Straight Leg Raising Test)
• Note. Some believe that the sciatic pain in this
In patients with radiating leg pain, this test can
test is not caused by nerve stretch but by
differentiate the far more common myalgic pain
venous congestion and a change in the cross
(pseudo-Lasegue's sign) from the less common section of the spinal cord.
neuralgic pain (true Lasegue's sign).
• Bonnets sig!1.: sciatic pain evoked by adduct-
ing and internally rotating the leg flexed at the
Nonnal Filldings knee (piriformis sign).
Same as in previous test. • Brudzinski's sig!1.: Raising of the head (ante-
flexion) is accompanied by a slight flexion of
the knee and hip joints due to meningeal
Pathologic Filldings
Pain The same effect can be produced by pressure
• Lasegue's sig[h Sudden shooting neuralgic on the pubic symphysis (Brudzinski II).
pain along the back of the thigh, calf, and foot. • Note. Other symptoms of meningeal irrita-
Examiner notes the angle between the trunk tion are nausea, vomiting, circulatory impair-
and thigh at which pain occurs. ment, hypersensitivity to stimuli, and psychic
• Pseudo-Lasegue's sig!1 refers to a dull muscle changes.
ache of gradual onset due to hamstring
shortening. Decreased Passive Mobility
Lasegue's sign occurs earlier when the test is - With a dull, gradually increasing ache from
performed with the leg adducted and internal- the back of the thigh to the knee from about
ly rotated, which causes additional stretching 40°-50° due to shortening of the hamstrings
of the nerve as it passes below the piriformis (pseudo-Lasegue) and/or erector trunci
Active and Passive Motion Testing 159

- Due to a unilateral SIJ dysfunction accom- e) Active and Passive Maximum Flexion of the
panied by painless, unrestricted leg raising Hip and Knee Joints (Figs. 67, 68)
on both sides (backward pelvic tilt) Test of knee mobility, hip joints, and sacroiliac
- With sudden, sharp, lancinating ("bright") joints Goint play, stability, ligaments).
pain between about 20° and 50° due to radicu-
lar irritation (Lasegue's sign)
Normal Findillgs
- Motion limited by hip joint disease (stage III
Painless maximum hip flexion while the knee
capsular pattern of Cyriax)
is maximally flexed (eliminating lumbar lor-
- Irreversible external rotation and abduction
dosis) is possible in the following directions:
(Drehmann's sign) due to retroversion of the
I. Toward the patient's ipsilateral shoulder
slipped capital femoral femoral epiphysis rel-
(sacrotuberalligament) (Figs. 67b, 6Sa)
ative to the femoral neck
2. Toward the opposite shoulder (iliosacraJ
- Hip-lumbar extension deformity: The patient
and sacrospinalligament ) (Fig. 68 b)
can be painlessly lifted from the table with the
3. Toward the opposite hip (iliolumbar liga-
knees, hips, and lumbar spine rigidly extended.
ment) (Fig. 68 c)
Etiology is unclear (disk protrusion, tumor?).
When maximum flexion is reached, a painles
force is applied along the longitudinal axis of
Decreased Active Mobility the femur and maintained for several sec-
- Hip flexor paresis (LZ-L4, femoral nerve) dur- onds.
ing active testing
- Progressive muscular dystrophy
Pathologic Findings
Ligament pain in directions 1-3:
Increased Mobility
General hypermobility, indicated by hip flexion 1. Pain radiating along the back ofthe thigh with
past 120° (clasp-knife phenomenon) with the tenderness of the ischial tuberosity
knees extended. 2. Pain radiating to the S1 dermatome

Fig.67a,b. Hip and knee flexion, SIJ mobility (joint play), ligament tests. a Active, b passive
160 Active and Passive Motion Testing

a b c

Fig.68a-c. Hip and knee flexion, ligament tests. a Sacrotuberalligament, b sacrospinal and
sacroiliac ligaments, .c iliolumbar ligament

3. Pain radiating to the groin region (with hip Procedure

joint disease) The lower leg is first swung to its maximum lat-
erallimit (Fig. 69a) and then to its medial limit
Lumbar lordosis is not eliminated:
(Fig.69b) while range of motion and end-feel
- Lumbar vertebral restriction are assessed.
- Shortening of the erector trunci
Normal Findings
The contralateral leg rises from the table: Equal ranges of painless internal rotation
Flexion contracture of the hip of the rising leg or (30°--40°) and external rotation (40°-50°) on
shortening of the psoas muscle. both sides.

Maximum knee flexion is not possible and/or

Pathologic Findings
Limitation of motion and/or pain may be present:
Possible meniscal lesion (posterior horns), os-
With internal rotation (lower leg turned out-
teoarthritis of the knee.
ward) due to:
- Capsular contracture (stage I capsule pattern
2.2 Hip Rotation (Fig. 69a,b)
of Cyriax) secondary to hip joint disease (e. g.,
Motion testing in the transverse plane of the joint osteoarthritis)
- Shortening of the external rotators (e. g., the
Starting Position piriformis)
Hip and knee in 90° flexion. - Paresis of the internal rotators
Active and Passive Motion Testing 161

The examiner fixes the pelvis on the side oppo-
site the tested leg, then the patient lets the flexed
leg fall into abduction (Fig. 70 b). Tenderness at
the adductor attachments can be additionally
tested by continuing the abduction to its passive
limit (Fig. 70c). The test is done comparatively
on both sides, and the distance of the abducted
knee from the table is measured, or the range of
abduction is measured in angular degrees.

Nonnal Findings
Equal ranges of painless hlp abduction on
both side , bringing the knee to about a
handswidtb from the table surface (approx.
800 ).

Pathologic Findings
Limitation of abduction due to adductor short-
ening. This can occur in patients with:
- Hip joint disorders (e. g., osteoarthritis after
replacement arthroplasty)
- SIJ restrictions (Kubis)

b) Passive Abdnction in Neutral Hip Position

(Fig. 70 d,e)
Fig.69a,b. Hip rotation. a Internal rotation, b exter-
nal rotation Starting Position
Relaxed supine position with the legs extended.
Examiner stands next to the knee on the tested
With external rotation (lower leg turned inward)
side. He grasps the ankle with one hand and stead-
due to:
ies the opposite hip with the other (Fig. 70d).
- Paresis of the external rotators
- End-range pain common with lesions of the
SIJ or lower lumbar spine (see Patrick's sign,
The extended leg is abducted until the contralat-
Sect. 2.3.1).
eral anterior superior iliac spine begins to move.
The anterior superior iliac spines must remain in
the frontal plane (no pelvic tilt) and transverse
2.3 Hip Abduction (Fig. 70 a,b)
plane (no pelvic rotation). Then the knee is flexed
a) Active Hip Abduction: Hyperabduction over the edge of the table, and further abduction
Test (Patrick-Kubis Test) is attempted (Fig. 70e;seealsoFig. 86a,b,p.176).
Starting Position
Hip flexed approximately 45°, foot next to the
Normal Findings
knee of the untested leg (Fig.70a).
Equal ranges of painless hip abduction
(30°-40°) on each side, with and without knee
162 Active and Passive Motion Testing

8 b c

Pathologic Findings
Abduction limited by shortening of the ham-
strings and/or adductors. Differentiation is ac-
complished by flexing the knee at the end of ab-
duction. If the hip can be abducted slightly
farther after knee flexion, the initial abduction
limit was due to shortening of the hamstrings, es-
pecially the gracilis. If the hip cannot be abduct-
ed farther, the movement was limited by adduc-
tor shortening.
Abduction limited by contracture of the hip
joint capsule in dysplastic or osteoarthritic
hips, coxa valga luxans, coxitis, Perthes' disease,
etc. This limitation is not affected by knee flex-

2.4 Knee Joint Screening Tests

Given the overlapping symptoms of hip and
knee joint lesions and the predominantly biartic-
ular muscularity of the thigh, these screening
tests are important for differentiation. If an ab-
normal finding is noted, the knee joint is further
investigated according to the knee examination
protocol (see ElExamination of the Lower Ex-
Fig.70a-e. Active and passive hip abduction, hyper-
tremities: Knee Joint, p.351). abduction test (Patrick-Kubis sign). a Starting posi-
tion, b terminal position. c Passive abduction. d, e
Starting Position Passive hip abduction in the neutral position. Differ-
Relaxed supine position. Examiner stands on entiation of adductors and hamstrings from pure ad-
the side of the joint to be examined. ductor shortening and contracture of the joint capsule
Active and Passive Motion Testing 163

Procedure 2.5 Differentiation of the LPH Joints:

Hyperextension of the knee joint: screens for le- Hip Joint, SIJ, Lumbar Spine, and Muscles
sions of the menisci (anterior horns), posterior
capsule, and posterior cruciate ligament; see Supine Malleolar Excursion Test
Fig. 269 a. Variable Leg Length Discrepancy After Derbo-
Adduction of the lower leg: screens for lesions lowsky, Reverse Three-Phase Test (Figs. 71-73)
of the medial meniscus and lateral ligaments
(compression of the medial compartment and Starting Position
test for lateral compartment stability); see Relaxed supine position.
Abduction of the lower leg: screens for lesions
of the lateral meniscus and medial ligaments
(compression of the lateral compartment and 1. The examiner notes the relative heights and
test for medial compartment stability); see rotational positions of the medial malleoli
Fig.271b. with the legs parallel and extended (Fig. 71 a).

Fig.71a,b. Testing ofvari-

able leg length discrepancy
(supine leg excursion test).
a Starting position, b termi-
nal position
164 Active and Passive Motion Testing

Fig. 72 a, b. Malleolar posi-

tion in the supine excursion
test. a Starting position,
b pathologic terminal posi-
tion (asymmetric malleolar
a b

Fig.73. Differentiating test

for the lumbar spine, SU,
and muscles

The legs must not deviate laterally or medial- the position of the sacrum in the sagittal
ly from the midline, as this would cause an ap- plane.
parent leg length discrepancy (trochanter 3. Finally the patient is told to bend as far for-
phenomenon). The landmark for palpation is ward as possible, bringing the trunk as close
the distal border of the medial malleolus on to the extended knee joints as she can
each side (Fig. 72 a) . (Fig. 73).
2. The patient then moves to an upright sitting
position (assisted as needed) while keeping
Normal Findings
the legs extended. The examiner lifts the legs
1. Patient can sit upright without pain. Sitting
slightly from the table and again checks the
up does not significantly alter the posilion of
relative heights and rotational positions of
the malleoli in term of height or rotation.
the malleoli (Figs. ?lb, 72b). He also notes
Active and Passive Motion Testing 165

2. When the patient sits up with the leg ex- SIJ displacements are commonly associated
with lumbar scoliosis and external rotation of
tended, the sacrum assumes a vertical posi-
the leg on the side of the dorsally rotated ili-
tion. The knees should not flex as thi oc-
um. A positive {pseudo ) Lasegue's sign is not-
ed on the side of the SU displacement or re-
3. The trunk can bend forward until (he head
striction during maximum flexion.
is about 15 cm from the knees. The hip joint
is maximally flexed, the sacrum is slightly
BiomechanicaI Considerations
anteflexed, and the spine is smoothly
arcbed. The knees remain extended. Maxi- The phenomenon of variable leg length (with
mum forward bending is painless, although anatomically equal leg lengths) occurs when the
ilium is dorsally rotated at the SU relative to the
there may be sLight muscular tension at tbe
sacrum and is fixed in that position (=unilateral
back of the thigh and lower leg.
nutation of the sacrum) so that the acetabulum
and ischial tuberosity are higher and more ante-
rior than on the opposite side.
Pathologic Findings
The high acetabulum causes the leg to appear
1. Change in malleolar position (asymmetric ex- shortened in both the standing and recumbent
cursion of tbe malleoli, variable leg length dis- positions (functionally short leg), while the
crepancy after Derbolowsky). When the pa- more anterior position of the acetabulum causes
tient sits up, the initially symmetric malleolar the leg lengths to equalize when the patient as-
positions become asymmetric, i. e., the leg sumes a sitting position. Because the ischial
with a restricted SIJ becomes longer, or sitting tuberosity also is more anterior on the restricted
up corrects for a previous shortening due to side, "rolling" of the tuberosity during sitting up
SIJ restriction in nutation. If an anatomically is delayed and prolonged relative to the unaf-
short leg coexists with SIJ restriction in nuta- fected side, so that the leg on the restricted side
tion on the same side, sitting up will accentuate moves farther distally, i. e., appears to lengthen.
the leg length discrepancy. The test is meaningful only if the length discrep-
2. Sacral position ancy or change is at least 1-2 cm.
The sacrum assumes a vertical position, but it P. Wolff (personal communication) offers a dif-
is painful: suggestive of motion segment lax- ferent explanation for the phenomenon: When
ness in the upper lumbar spine. the patient sits up, the upper body rolls upon the
The sacrum does not assume a fully vertical ischii as on the sector of a wheel, so that both legs
position, and there is muscular pain at the undergo equal distal movement in a healthy sub-
back of the thigh : hamstring shortening. ject with freely mobile SUs. With a restricted SIJ,
With a disk protrusion or prolapse, vertical however, one joint is immobile (say, the right)
orientation of the sacrum is severely restrict- while the other is mobile. As the patient sits up,
ed, and there is radicular pain in the sciatic there is a point at which the center of body gravi-
nerve. ty passes over the SU and sacrum. At this point
3. Forward bending with the legs extended the sacrum normally undergoes a nutation ("for-
Marked limitation of maximum trunk flexion ward nodding") at the SUs under the weight of
and approximation of the head to the knees. the trunk. But if this can occur only in the mobile
Posterior thigh pain with normal spinal flexion joint (i. e., the left), forward progession ofthe left
(smooth arch) is usually caused by hamstring ilium is momentarily checked by gliding within
shortening. the joint, while the immobile (restricted) ilium is
Pain above the sacrum with nonuniform spinal still able to move. As a result, the right leg (on the
curvature is caused by shortening of the erec- restricted side) continues to move distally while
tor trunci or by a lumbar restriction or protru- the left leg is momentarily halted.
sion (the latter associated with neuralgic pain This process can be monitored: When the pa-
in the sciatic region) . tient starts to sit up, both legs move distally at an
166 Palpation Field ofthe Ventral Pelvis

equal rate. When the upper body is approxi- - Marked discrepancy (5-6 cm) with neuralgic
mately vertical, the feet are moving at different pain, pelvic rotation, and compensatory knee
rates. As trunk flexion continues past the verti- flexion: disk protrusion or prolapse.
cal, they again move distally at equal rates but
different lengths. The length discrepancy, i. e.,
the "functionally short leg," has been caused by
the brief period in which distal leg movement 3 Palpation Field
was suspended on the unaffected side. of the Ventral Pelvis
The test for variable leg length discrepancy is in-
terpreted as follows:
Palpation at Rest
- Slight discrepancy (1-2 cm): suspicion of SIJ
displacement (muscular) and/or restriction
(arthrogenic). Bimanual palpation is used whenever possible.
- Moderate discrepancy (often more than 2 cm) The examination of muscle attachments can be
with myalgic pain: hamstring shortening. combined with resistance testing.

Lateral femora l
cutaneous nerve

Iliacus muscle ------t-t----1~,.;,--

Anterior superior ---7-,Kr"
iliac spine Femora l nerve
CD Tensor fasciae lalae - -+-+...".

CD Sartorius muscle---f--I'--H+7HI<rt--

® Hip joint - -+MIHnf----IIP.-'l ' Pubic symphysis

and rami
Lesse r trochanter+----IW-I+f1I7B+..---+4IIr.
(insertion of iliopsoas)

Adductor longus
CD Rectus femoris --+-+-T-1f7-:--- \~"\

4--/------(,1) GraCilis

Fig.74. a Palpation field of the ventral pelvis (general view)

Palpation at Rest 167

The five landmarks for palpation in this field

(Fig. 74 a-e) are as follows:
1. Anterior superior iliac spine
2. Hip joint
3. Lesser trochanter
4. Pubic symphysis and pubic rami
5. Inguinal canal

Starting Position
Relaxed supine position.
1) Anterior superior iliac spine (Fig. 75)
The position of the iliac spines is examined and
compared with findings in the standing position.
The palpating thumbs are placed on the inferior
border of the spines. A height discrepancy may
be caused by iliac rotation on one side.
Then the muscle attachments are palpated.
Lateral: tensor fasciae latae, which is prone to
shortening. Hypertonicity and myogeloses are
often present with SIJ displacement or restric-
tion on the opposite side (Sell).
Anterior: sartorius stabilizer of the knee joint).
Medial: iliac muscle, painful hypertonicity with
ipsilateral SIJ displacement or restriction or
with L5/S1 segmental dysfunction.
Anterior inferior iliac spine: rectus femoris mus-
cle, which also is commonly shortened.

2) Hip joint (Fig. 76)

The coxofemoral joint is palpable at the inter-
section of the inguinal ligament and the femoral
artery or nerve (midway between the anterior
superior iliac spine and pubic symphysis).
Protrusions above the inguinal ligament signify
inguinal hernia; protrusions below the ligament,
femoral hernia. They occur in the crural triangle
formed by the sartorius, adductor longus, and in-

3) Lesser trochanter (Fig. 77)

The hip and knee joints are flexed by placing the
foot next to the opposite extended knee. The
Fig.74 b-e. Bony landmarks for palpation of the
thigh is abducted and externally rotated (Lauen- ventral pelvis. b Anterior superior iliac spine (1),
stein position) as in the abduction test (Fig. 70 b). c hip joint (2), d lesser trochanter (3), e pubic sym-
The landmark is reached by palpating upward physis (4)
from the adductors toward the greater
168 Palpation at Rest

Fig. 75 a, b. Palpation of the anterior superior iliac

Fig.76a,b. Palpation of the hip joint

trochanter. The insertion of the iliopsoas is often the ilium undergoes a rotational movement on
tender to pressure because of bursal pain (in ath- the weight-bearing side that must be compensat-
letes). Dull lumbar pain also can result from ed by rotation about a transverse axis through
shortening of the muscle (origins on the Ll-L4 the symphysis. To correct this symphyseal dis-
transverse processes) or from inflammatory irri- turbance, especially if it recurs frequently, the
tation about the course of the iliopsoas (appen- balance ofthe hip and abdominal muscles must
dicitis, gynecologic disorders; Moser's sign). be assessed and treated. The upper lumbar
nerve roots supplying these muscles also may re-
4. Pubic symphysis (Fig. 78) quire diagnosis and treatment.
The pubic tubercle, giving attachment to the rec- The attachment of the pectineus muscle can be
tus abdominis, is palpable superiorly at the same palpated lateral to the pubic tubercle. Painful
level as the greater trochanters. bursae may be found in athletes.
The height of the (bony!) tubercles is deter- Below the pubic tubercle: attachments of the ad-
mined by palpation with both index fingers and ductor longus and brevis muscles and the sym-
compared. A step at the symphysis may be physeal joint line.
caused by a high or low position of one ramus. A Symphyseal tenderness can result from loosen-
positional fault can be found on the side of a pos- ing of the symphysis (usually hormonal) during
itive malleolar excursion test. pregnancy or the latter half of the menstrual
According to Mitchell, the positional faults de- cycle, from a therapeutic hormonal overdose
velop due to imbalances of the hip and abdomi- (menopausal complaints, osteoporosis prophy-
nal muscles that insert about the symphysis. This laxis), or from general ligamentous laxity in hy-
concept is supported by the fact that, during gait, permobile women. The pains radiate to the
Tests ofJoint Translation 169

groin, especially after exertion such as prolonged

walking and standing. The loosening effect may
produce a visible step at the pubic symphysis
(pelvic ring loosening described by Kamieth).
At the inferior border and descending ramus: at-
tachments of the gracilis (gracilis syndrome in
athletes, especially soccer players) and adductor
magnus (as far as the tuber ischii).

• Note
With symptoms of meningeal irritation, pressure
a on the symphysis can cause reflex flexion of the
legs (Brudzinski II).

5. Inguinal canal (Fig. 74 a)

Medial: Hernial openings (inguinal hernias).
Lateral: Tender points above the inguinalliga-
ment at the passage of the ilioinguinal nerve and
iliohypogastric nerve (L1-L:!) and of the lateral
femoral cutaneous nerve in the inguinal liga-

Fig. 77 a, b. Palpation of the lesser trochanter 4 Tests of Joint Translation

4.1 Traction and Compression of the
Lumbar Spine
4.2 Traction and Compression ofthe
Hip Joint
4.3 SIJ Springing Test via the Thigh

A joint-play test in the supine position is avail-

able for each joint ofthe LPH region. These tests
are necessary, however, only if the previous ex-
amination has yielded equivocal pathologic

4.1 Traction and Compression

of the Lumbar Spine (Fig. 79)

Starting Position
Supine with the legs flexed at the hip and knee to
eliminate lumbar lordosis (Thomas' maneuver).
The feet are positioned on the table so that the
toes can be braced against the examiner's thighs.
The examiner stands at the foot of the table, one
leg back, and grasps the patient's calfs from be-
Fig. 78 a, b. Palpation of the pubic symphysis hind (Fig. 79 a). Or he can support the lower legs
170 Tests of Joint Translation

on his forearms and use his elbows to hold them shows the application ofthree-dimensional trac-
against his body (Fig. 79 b). tion using an antalgic posture.

Procedure Pathologic Findings

From the starting position, the examiner exerts In the presence of a painful lumbar spine dys-
traction on the lower extremities by shifting his function (restriction or posterolateral prolapse),
weight to his back leg. This produces a distract- traction generally alleviates pain while compres-
ing force in the lumbar spine if lordosis has been sion may exacerbate it. With a posteromedial
eliminated and the pelvis lifted so that it can prolapse, traction usually intensifies pain, serv-
slide down the table. Compression is applied ing to distinguish the lesion from a posterolater-
cephalad with the legs extended. Figure 79c al prolapse.

Fig. 79 a-c. Traction on the

lumbar spine
Tests of Joint Translation 171

4.2 Traction and Compression loose-packed position"). This corresponds to

of the Hip Joint (Fig. SO) approximately 30° flexion and abduction and
15°-20° external rotation at the hip. Both hands
Starting Position grasp the patient's foot at the ankle and dorsum
Relaxed supine position. and immobilize it against the examiner's body. In
this position the examiner exerts longitudinal
Procedure traction by shifting his body weight (Fig. SOa) or
The extended test leg is placed in the resting po- by pulling with the arms extended (Fig. SO b).
sition on both the sagittal and frontal planes (po- Compression is produced in the same position
sition of least muscular tension, or "maximally by applying force in the opposite direction.

Fig. 80 a4:. Traction on

the hip joint. a,b Stan-
dard technique. c Alter-
native technique for pa-
tients with lesions of the
knee joint
172 Tests of Joint Translation

In patients with knee joint lesions, the traction is 4.3 SIJ Springing Test via the Thigh
applied directly to the hip. The leg is flexed at (Fig. 81)
the hip and knee, and the foot rests on the table
or the knee lies relaxed on the examiner's shoul- Starting Position
der (Fig. 80 c). The examiner stands next to the hip on the non-
tested side. The leg, flexed approximately
1000 -1200 at the hip and knee, is adducted until
Normal Findings the side of the pelvis with the tested SIJ lifts up
Traction is painless or aUeviates pain. from the table (Fig. 81 a).

Pathologic Findings
The examiner slides his hand beneath the
With a lesion of the hip joint, traction reduces
gluteals of the tested leg, placing the palpating
pain while compression exacerbates it. This oc-
index finger in the sulcus between the ilium and
curs in:
sacrum so that it touches both the posterior iliac
- Osteoarthritis of the hip spine and the sacrum. The pelvis is returned to
- Coxitis the supine position, and the thigh is adducted
- Irritation of the hip joint capsule until slight gapping is felt in the posterior sacroil-

Fig. 81 a, b. SIJ springing test via

the femur. a Starting position,
Muscle Tests 173

iac joint space. Then the examiner uses his body 5.1 Resistance Tests of the Hip
weight to apply light pressure to the acetabulum and Abdominal Muscles (Figs. 82-85)
and ilium via the long axis of the patient's femur.
The following tests are used for the further dif-
This produces springing in the SIJ if the thigh ad-
ferentiation of conditions such as insertion
duction has not made the dorsal ligaments too
tendinopathies and pareses. In many cases pal-
tight (Fig. 81 b).
pation has already shown evidence of a lesion in
This test is a supplement to previous SIJ tests
a particular muscle.
and is done comparatively on both sides. It
requires considerable experience in the differ-
Flexors, Abductors, Adductors (Fig. 82)
entiation of palpable impressions, since the
It is most efficient to perform the tests in two
weight of the pelvis also rests on the palpating
groups, i. e., using two different starting posi-

Starting Position I
5 Muscle Tests Leg extended, hip and knee in neutral position.
One side of the pelvis is immobilized as required.
5.1 Resistance Tests ofthe Hip and
Abdominal Muscles Procedure
5.2 Shortening Tests
1. Leg is not rotated. Resistance to hip flexion is
applied above the knee (Fig. 82 a) to test the
The general resistance tests for the flexors, ab- iliopsoas.
ductors, adductors, internal rotators, and exter- 2. Leg is slightly abducted but not rotated. Resis-
nal rotators were described earlier in the section tance to abduction is applied above the lateral
on examinations in the sitting position (see malleolus (Fig. 82 b) to test the abductor
B/LPH Region/Sect. 5, p.116). The extensors group (gluteus minimus and medius and ten-
are tested in the prone position (see C/LPH Re- sor fasciae latae, L4-S 1 , superior gluteal
gion/Sect. 5, p.l44). nerve).

a b c

Fig.82a-c. Resistance tests ofthe hip muscles. a Flexors, b abductors, c adductors

174 Muscle Tests

Slight internal rotation is required for differ- Procedure

entiation of the gluteus medius and slight ex-
1. Abduction resistance is applied to the lateral
ternal rotation for the gluteus minirnus and
aspect of the knee (Fig. 83 a) to test the exter-
tensor fasciae latae.
nal rotators, abductors, and gluteus maxim us.
3. Leg is slightly abducted but not rotated. Resis-
Differentiation is accomplished by palpating
tance to adduction is applied above the medial
the muscle attachments:
malleolus (Fig. 82 c) to test the adductor brevis
Point of trochanter and intertrochanteric
and gracilis muscles (Lz-L4 , obturator nerve).
crest, external rotators ; gluteal tuberosity,
Differentiation is accomplished by palpating
gluteus maximus.
the muscle attachments: Pectineal line:
2. Adduction resistance is applied to the medial
pectineus; pubic tubercle : adductor brevis;
aspect of the knee (Fig. 83 b) to test the long ad-
next to symphysis: gracilis.
duetors (adductor magnus and longus ; Lz-L4,
obturator nerve). Both sides are tested and
Starting Position II
Hip flexed approximately 50 knee flexed ap-
0 ,

proximately 90 0 , foot flat on the table beside the

opposite knee.

Fig. 83 a, b. Resistance tests of the

hip muscles. a External rotators,
b long adductors (bimanual)
Muscle Tests 175

Sartorius Test (Fig. 84) Normal Findings

Starting Position Painless muscular tension with a strength of
Hip is abducted, externally rotated, and slightly 4-5.
flexed; knee is flexed approximately 120°. The
foot is held loosely; the opposite side of the
pelvis is immobilized. Abdominal Muscles (Rectus abdominis)
(Fig. 85)
Procedure Starting Position
Resistance to flexion, abduction, and external The legs are flexed at the hips and knees (to de-
rotation of the hip is applied at the knee and activate the iliopsoas). The feet are flat on the
lower leg. table, and the patient actively presses them

Fig.84. Resistance test of

the sartorius

Fig.85. Resistance test of

the abdomin al muscles
176 Muscle Tests

against the table surface. The hands are clasped 5.2 Shortening Tests (Figs. 86-88)
behind the head.
If previous tests have shown evidence of muscle
shortening in the LPH region, these findings can
The patient sits up gradually by successively be checked by the following tests, which employ
three different starting positions.
raising the cervical spine, the thoracic spine, and
finally the lumbar spine from the table without
Starting Position I
lifting the feet (Fig. 85). Attention is given to dis-
Relaxed supine position with both legs extend-
tortion of the umbilicus, which is drawn toward
the strongest muscle quadrant. The movement is
resisted by the weight of the trunk.

Normal Findings 1. Hamstrings

2. Hamstrings and adductors
Patient sits up lowly without pain.
3. Piriformis

Fig.86a,b. Differentiation of the

adductors and hamstrings. a Ad-
ductors and hamstrings. b Adduc-
Muscle Tests 177

The hamstrings, gracilis, short adductors, and

piriformis muscles are tested.

1. Hamstrings. Straight leg is maximally flexed at
the hip while the non tested leg is held station-
ary on the table. Gradually increasing pain at
the back of the thigh occurs with hamstring
shortening (pseudo-Lasegue sign).
2. Hamstrings and adductors. Straight leg is max-
imally abducted while the nontested leg is
steadied at the ilium or the inside of the thigh.
Pain, decreased motion, and possible slight Fig. 87. Differentiation of Lasegue's sign from pseu-
compensatory hip flexion suggest shortening do-Lasegue
of the (monoarticular) adductors (Fig. 86a) if
abduction cannot be continued after the knee
pain felt before the knee is extended is caused by
has been flexed (Fig. 86 b). Otherwise there is
sciatic nerve irritation (Lasegue's sign).
shortening of the biarticular muscles: gracilis,
biceps, semitendinosus, and semimembra-
Starting Position III
nosus (hamstrings).
The patient sits at the end of the examination
3. Piriformis. The hip and knee are maximally
flexed (Figs. 67b and 68a, pp.159, 160). The
pelvis is immobilized by pressing downward
Procedure (Fig. 88 a-c)
on the knee along the femoral axis (as in
The patient lies back with the examiner's help
Fig. 67 b). While one hand maintains this fixa-
while maximally flexing the hip and knee of the
tion, the other hand moves the knee toward
nontested leg to tilt the pelvis back and straight-
the opposite shoulder in maximum flexion, ad-
en the lumbar spine. The patient holds the flexed
duction (see Fig.68b), and also internal rota-
leg against the chest with both hands.
tion by turning the lower leg outward. Painful
The examiner supports this position (which fixes
limitation of adduction and internal rotation
the sacrum and eliminates lumbar lordosis)
in the terminal position suggest shortening of
while providing lateral support, if needed, to
the piriformis. This test also evaluates the ilio-
keep the flexed leg upright.
sacral ligaments and sacrospinalligament.

Starting Position II NormaJ Findings in the Starting Position

Patient sits at the foot of the table, the knee The thigh of the tested leg hangs freely in a
flexed 90 and the trunk in maximum active an-
horizontal or slightly lower position: The
teflexion. psoas is not shortened.
This test differentiates pseudo-Lasegue's sign The lower leg hangs almost perpendicular to
from true Lasegue's sign. the thigh: The rectus is not shortened.
The patella is centered or slightly lateralized.
No significant depression on the lateral side
of the thigh: Tensor fasciae latae is not short-
The examiner individually extends the patient's
legs at the knee joint (Fig. 87). If this evokes mus-
cular pain at the back of the thigh and the patient
is forced to straighten the trunk or even extend it Pathologic Findings
back past the vertical, hamstring shortening is Flexed position of the hip: shortening of the
present. A sudden, sharp, lancinating neuralgic iliopsoas.
178 Muscle Tests

Fig.88a--c. Tests for

shortening of the hip flex-
0rs. a Psoas, b rectus
femoris, c tensor fasciae
Muscle Tests 179

Lower leg flexed less than 90°: shortening of the ment provokes slight extension of the knee,
rectus femoris. the rectus femoris is shortened.
Lateralized patella with a depression on the lat- 2. Rectus femoris. Passively flex the knee by
eral side of the thigh: shortening of the tensor pressing backward on the tibia (Fig. 88 b).
fasciae latae. Pain and slight hip flexion in response to this
maneuver indicates shortening of the rectus
Tests (After Janda) femoris.
3. Tensor fasciae latae. Passively adduct the
1. Psoas major
flexed knee (Fig. 88c). If this provokes lateral
2. Rectus femoris
thigh pain with the formation or deepening
3. Tensor fasciae latae
of a hollow over the iliotibial tract, the tensor
1. Psoas major. Passively move the thigh an extra fasciae latae is shortened. Often this is asso-
10°-20° posteriorly (Fig. 88a). If this is not ciated with some lateral deviation of the
possible, the psoas is shortened. If the move- patella.
Examination of the Thorax (Thoracic Spine and Ribs)
in the Sitting Position (B/III)

1 Inspection
1.1 Thoracic Morphology
1.2 Respiratory Movements

2 Active and Passive Trunk Movements

in Three Planes
(Regional Diagnosis)

3 Palpation of the Thoracic Joints

(Segmental Diagnosis)
Palpation at Rest
3.1 Sternal and Costal Synchondroses
(Sternocostal Joints 2-7), Floating Ribs
3.2 Costotransverse Joints
3.3 Segmental Muscles
Palpation During Movement
3.4 Segmental Motion Testing of the
Thoracic Spine and Cervicothoracic
3.5 Segmental Motion Testing of the Ribs

4 Tests of Joint Translation

4.1 Bimanual Compression ofthe Thorax
in the Frontal Plane
4.2 Bimanual Compression of the Thorax
in the Sagittal Plane
Inspection 181

1 Inspection - Pectus excavatum ("funnel chest") = concavi-

ty of the sternum; cardiovascular complaints
1.1 Thoracic Morphology may develop in severe cases.
1.2 Respiratory Movements

3. Ribs
- Parasternal thickening of costal cartilages ( es-
pecially T2-T4) and/or sternoclavicular joints
(Tietze's syndrome)
1.1 Thoracic Morphology - Deepening of the intercostal spaces and
Normal Findings
supra- and infraclavicular fossae due to con-
1. Shape of the thoracic cage stricting lesions of the lungs and pleura
Narrow and slender in ectomorphs, short and - Protrusion ofthe intercostal spaces in emphy-
tocky in pyknics. sema
2. Sternum Clavicles
Slight protrusion of the sternal angle between Position, malposition, and deformity see
the body and manubrium of the sternum. B/Shoulder/Sect.1 (pp. 77,257,258).
3. Ribs
Symmetry of the arches and intercostal 4. Vertebral column
spaces, of the clavicular fossae (superior tho- - Scoliosis with bulging of the ribs (on the con-
racic aperture) , rib position, and inferior tho- vex side of idiopathic scoliosis)
racic aperture. - Apex of kyphosis shifted superiorly or inferi-
4. Vertebral column orly (see BILPH/Sect. 1, p.104), especially
Moderate kyphosis of the lumbar spine with with age-related kyphosis
the apex at T5- T6, no scoliosis.
5. Thoracic organs 5. Thoracic organs
No visible pulsations. Prominent apex beat and epigastric pulsations
due to cardiac disease (usually more obvious in
the supine position).
Pathologic Findings
1. Shape of the thoracic cage
1.2 Respiratory Movements
- Bell-shaped thorax: turned-up costal margins,
Respiratory movements are inspected to deter-
thoracic cage indrawn along the insertion of
the diaphragm (Harrison'S groove), costal
arch expansions (rickets, osteomalacia) 1. Type of respiration (predominance ofthoracic
- Flat chest: flattening ofthe thoracic arch (con- or abdominal respiration)
genital deformity) 2. Respiratory movements of the ribs (costal
- Piriform thorax: pear-shaped chest that is joints)
large above, small below (with restricted ab- 3. Chest expansion (measurement of chest cir-
dominal respiration) cumference)
- Barrel-shaped thorax: rounded like a barrel
Normal respiration relies on unrestricted mobil-
due to emphysema (with restricted expira-
ity of the costovertebral joints and the joints of
the lumbar spine. There should be no paresis of
- Phthisic thorax: narrow thoracic inlet
the respiratory muscles or the auxiliary muscles
2. Sternum of respiration. The examination covers sponta-
neous respiration as well as forced inspiration
and expiration (deep breathing).
- Pectus carinatum ("pigeon breast") = con-
vexity of the sternum
182 Inspection

Phases of Respiration tal chest diameter. This increase is slight because

the ribs are tethered by the quadratus lumborum.
Most easily palpable on the anterior axillary line.
The thoracic cage is raised during inspiration by
the external intercostal muscles and the auxil-
Measurement of Chest Expansion
iary respiratory muscles (sternocleidomastoid,
Chest expansion is determined by measuring the
scaleni) when the head and cervical spine are
change in thoracic circumference from full inspi-
fixed, also by the pectoralis major and latissimus
ration to full expiration. Expansion can be mea-
dorsi when the shoulder girdle and arms are
sured at three different levels:
fixed in abduction. Ascent of the thoracic cage is
further aided by the serratus posterior superior 1. Thoracic respiration: measured below the ax-
and intercostal muscles of the neck. illa with the arms hanging loosely. Expansion
The abdominal wall is expanded by contraction at this level is approximately 8 cm.
of the diaphragm (C3, C4 , phrenic nerve), which 2. Upper flank respiration: measured below the
pushes the abdominal viscera downward, in- breasts in women, above the nipple line inmen.
creases the vertical thoracic diameter by descent Expansion is approximately 9 cm (Fig. 89 a,b).
of the centrum tendineum, and increases the 3. Lower flank respiration: measured at the infe-
horizontal thoracic diameter by raising the low- rior border of the thoracic cage. Expansion is
er ribs. The activity of the abdominal muscles approximately 11 cm.
makes the ascent of the lower ribs possible by
raising the intraabdominal pressure. The ab-
dominal muscles thus increase their efficiency Normal Findings
through their antagonistic-synergistic relation- Equal respiratory movements and rib mobili-
ship to the diaphragm. ty on each side , interplay between thoracic
and abdominal respiration.
Expiration is a passive process in which the elas-
Ascent of the thoracic cage and enlargement
tic chondro-osseous elements of the thorax and
of the inferior thoracic aperture anteriorly
the lung parenchyma recoil to their resting posi-
and laterally.
tion, assisted by the internal intercostals, the
abdominal muscles, the lumbar intercostals,
longissimus, and quadratus lumborum.
Descent of the thoracic cage and flattening of
the abdominal arch by contraction of tbe ab-
Respiratory Movements ofthe Ribs dominal muscles and activation of the mus-
The first and second ribs move by the pump-han- cles that assist in lowering the rib (internal
dle mechanism (increases the sagittal and verti- intercostals and the group of secondary expi-
cal diameter of the chest). Palpable on the ante- ratory muscles). The ribs return to their prein-
rior side of the thorax. spira tory position.
The third through sixth ribs move by a combined Normal chest expansion measures at least
pump-handle and bucket-handle mechanism (in- 5-6 cm. The measurement of upper flank res-
creases the sagittal and horizontal diameter of piration is generally sufficient.
the chest). Palpable on the anterior axillary line.
The sixth through tenth ribs undergo a combined
bucket-handle and lateral movement (mainly in- Pathologic Findings
creases the horizontal chest diameter). Palpable Restricted or painful inspiration
at the side of the thorax. Unilateral or bilateral pain on deep inspiration
The eleventh and twelfth ribs undergo a pure lat- due to:
eral movement (outward, backward, and up- 1. Rib fixation in a position of expiration (prima-
ward) with an associated increase in the horizon- ry rib restriction)
Active and Passive Trunk 183

_ __ b
Fig.89a,b. Measurement of chest expansion. a Inspiration, bexpiration

2. Vertebral restnctlOfl in the thoracic spine may develop, however, in long-standing cases of
(secondary rib restriction) thoracic vertebral restriction. "Intercostal neu-
ralgia" is often not a true neuralgia but is caused
Restricted or painful expiration by a primary or secondary rib restriction.
Unilateral or bilateral pain on deep expiration
due to:
1. Rib fixation in a position of inspiration (pri-
mary rib restriction) 2 Active and Passive Trunk
2. Vertebral restriction in the thoracic spine Movements in Three Planes
(secondary rib restriction)
(Regional Diagnosis)
Painful limitation of inspiration and expiration
Staged motion testing of the thoracic spine (and
1. Inflammatory or neoplastic pleural diseases lumbar spine) in three planes with the pelvis sta-
2. Pericarditis tionary.
Starting position, procedure, and findings are
Painless limitation of inspiration and expiration
the same as in the examination of the lumbar
Occurs in ankylosing spondylitis.
spine (see p.1OS).
Painless limitation of expiration
1. Bronchial asthma
2. Emphysema

Chest- wall pain with no respiratory impairment

A restrictive positional fault of the thoracic ver-
tebrae can cause chest-wall pain with no associ-
ated respiratory impairment. Rib restrictions
184 Palpation of the Thoracic

3 Palpation of the Thoracic

Joints (Segmental Diagnosis)

Palpation at Rest
3.1 Sternal and Costal Synchondroses
(Sternocostal Joints 2-7), Floating Ribs
3.2 Costotransverse Joints
3.3 Segmental Muscles
Palpation During Movement
3.4 Segmental Motion Testing of the
Thoracic Spine and Cervicothoracic
3.5 Segmental Motion Testing of the Ribs

Palpation at Rest Fig.90. Palpation of sternocostal joints 2-7

3.1 Sternal and Costal Synchondroses Pathologic Findings

(Sternocostal Joints 2-7), Floating Ribs 1. Tenderness at the rib attachments with rib re-
(Figs. 90,91, 113)
Palpation for tenderness is performed bimanu- 2. Significant tenderness of the xiphoid process
ally, and both sides are compared. This is an ori- sometimes occurs with malformations, trau-
enting examination. If findings are equivocal, ma, and diseases of the internal organs (re-
the patient should also be examined in the flex: e. g., heart, stomach, duodenum, gall-
supine position (see ErrhoraxiSect.3.1, p.208). bladder) and may accompany restriction of
the seventh rib and seventh thoracic vertebra.
Starting Position
Upright sitting position. The examiner stands 3.2 Costotransverse Joints (Figs. 92a-c, 97,98)
behind the patient, who leans against the exam-
Functionally, it is reasonable to combine palpa-
tion of the thoracic segments (Fig. 92 a,b) and
costal joints (Fig. 92c). If there are positional
faults and/or restrictions of thoracic vertebrae,
The examination proceeds segmentally with pal-
the associated rib may follow the synchronous
pation of the sternal margin, sternocostal joints
movement of the adjacent ribs, leading to ten-
2-7 (Fig.90), costochondral junctions, xiphoid
sion and pain in the associated costovertebral
process (Fig. 91 a), and the tips of the floating
and costotransverse joint, or it may rigidly fol-
ribs (Fig. 91 b).
low the movements of the thoracic vertebral
body, leading to secondary functional distur-
Normal Findings
bances in the rib cage with complaints at the in-
The rib attachments are not tender to palpa-
tercostal connections (secondary rib restric-
tion. Springing palpation of the xiphoid pro-
cess in the anterior, posterior, and lateral di-
With normal position and mobility of the tho-
rections is painless and unrestricted.
racic vertebra, the rib may occupy a faulty posi-
tion in inspiration or expiration due to a primary
cause such as trauma (primary rib restriction).
Palpation at Rest 185

Fig.92a-c. Tactile and pressure palpation of the facet

joints and costotransverse joints. a, b Thoracic facet
joints, c costotransverse joints

The examiner stands next to the patient on the
unexamined (left) side, which he steadies
Fig.91. a Palpation of the xiphoid process, b of the
against his body. He then reaches around the
floating ribs
front of the patient's chest to immobilize the
right elbow and upper arm. He also pulls the left
Both types of restriction are associated with res- scapula as far forward as possible to place some
piration-dependent pain. primary tension on the capsule and ligaments of
the costovertebral joints. The patient now
a) Palpation of the Costotransverse Joints breathes in deeply, placing additional tension on
(Fig. 92 c) the costotransverse capsule and ligaments and
This examination is illustrated for the right cos- usually producing visible prominence of the
totransverse joints. costal tubercle.
The costotransverse joint is palpated by apply-
Starting Position ing firm, localized pressure with the tip of the
The patient places the arm of the examined thumb or index finger in a slightly lateral direc-
(right) side on the opposite (left) shoulder (not tion. The other hand is free to assist as needed
pictured). with compression or passive motion.
186 Palpation During Movement

Normal Findings The examiner evaluates for:

Palpation i virtually painJess (compare both - right-left symmetry ofthe first rib position
sides). - tenderness and mobility of the joint
See also: Palpation Field of the Shoulder Girdle
Pathologic Findings and Fig. 197, p.279.
Primary Rib Restriction
Tenderness to palpation usually occurs in the Normal Findings
following sequence: Slight, virtually painless springing of the joint.
1. Costotransverse joint
2. Intercostal pain Pathologic Findings
3. Sternocostal pain Fixation of the first rib in a high position is usu-
ally caused by abrupt upward movements of the
The joints of the thoracic spine are unaffected.
clavicle (costoclavicular ligament) or prolonged
overhead work.
Secondary Rib Restriction
Tenderness to palpation occurs in the following
3.3 Segmental Muscles
The segmental muscles are palpated for in-
1. Joints of the thoracic spine
creased tone, splinting, myogelosis, and tender-
2. Costotransverse joints
ness (irritation zones).
3. Possible intercostal pain in long-standing cases
Little or no tenderness in the sternocostal joints.
Rib restriction frequently causes chest-wall pain Palpation During Movement
with minimal respiratory impairment.

3.4 Segmental Motion Testing

• Differential Diagnosis
of the Thoracic Spine (Fig. 93a-i)
Pain at the attachments of the pectoralis major
and minor to the humerus, clavicle, sternum, Starting Position
ribs, and coracoid process (see Etrhoraxl Upright sitting position. The patient's hands are
Sect. 3.1, p. 208). clasped behind the neck, the elbows forward.

b) Palpation of the First Rib (see Fig. 202)
The examiner reaches in front of the patient's
Procedure thorax, which is successively bent forward,
The superior border of the trapezius is pushed backward, sideways, and rotated. The spinous
backward, and the first costotransverse joint is processes are palpated from behind during for-
palpated from above while the head is slightly ward and backward bending of the thoracic
tilted toward the examined side (to relax the spine (Fig. 93 a,b). During side bending (e. g., to
scalenes). The cervical spine permitting, the the right, Fig. 93 c), the coupled rotation is pal-
head also may be rotated toward the examined pated from the convex side. The same technique
side until there is concomitant movement of the is used for palpating pure rotation of the tho-
T1 spinous process, leading to dorsal rotation of racic spine (e. g., to the left, Fig. 93 d).
the transverse process and thus producing trac- The combined test for sidebending and cou-
tion in the costotransverse joint. The palpatory pled rotation (convergence-divergence test,
force is directed downward toward the con- Fig. 93 e-i) is performed from the same starting
tralateral hip and is synchronized with expira- position. Alternative arm placements and the
tion (Fig. 202). procedure were described in the section on lum-
Palpation During Movement 187

Fig. 93 a-f. See p.188

for legend

188 Palpation During Movement

9 h
Fig. 93 a-i. Segmental mobility testing. a Forward bending, b backward bending, c sidebending, d rotation,
e combined movement in ventral flexion, f combined movement in dorsiflexion. g Palpation of coupled rotation.
Combined movement (b) forward, (i) backward with palpation of full coupled rotation

Facet joint

a b

Fig.94. a 1, Movement of vertebral body; 2, gliding of costovertebral joints; 3, gliding of facet joint; 4, traction
on facet joint. bGliding movements during sidebending and rotation

bar spine examination in the sitting position (see left in dorsiflexion. Figures 93h and 93i show
BILPH/Sect.3.3, p.l11). the same sidebending to the right during
Figure 93e shows right rotation due to diver- forward and backward bending. In this case
gence of the left facet joints during sidebending the coupled rotation changes direction from a
to the right in ventral flexion. Figure 93 f shows rotation to the right to a rotation to the left, so
the same right rotation due to convergence of it is most clearly palpable during this move-
the left facet joints during side bending to the ment.
Palpation During Movement 189

• Note Motion Testing oftbe Cervicotboracic Junction

When lordosis extends to a high level, the cou- (C6-T3) (Fig. 95)
pled rotation of the lower thoracic vertebrae
Starting Position
may occur opposite to the direction of sidebend-
Upright sitting position. The hands are not
ing, as in the lumbar spine itself. This occurs
clasped behind the neck, but hang loosely.
when the articulating facet surfaces are oriented
backward rather than forward with respect to Procedure
the frontal plane. The examiner reaches in front of the patient's
Possible motions in the thoracic facet joints are head, bracing the forehead against his upper arm
illustrated in Fig. 94. and placing his flat hand on the back of the neck

c ....._ _ _ _!'..-_ _~_ _ _ _

Fig.95a-d. Segmental motion testing of the cervicothoracic junction. a Forward

bending, b backward bending, csidebending, d rotation
190 Palpation During Movement

to stabilize it. From this position the head is bent Mobility gradually increases from T9 to Ll.
forward and backward (Fig. 95 a,b), sideways All vertebral movements are painless and unre-
(Fig. 95c), and rotated (Fig. 95 d) while a simul- stricted.
taneous transverse pressure is maintained. The
excursions are palpated as described above. 3.5 Segmental Motion Testing of the Ribs
Active rotation at C6-T4 also can be assessed by ("Harp") (Figs. 96a,b, 97 , 98)
bimanual palpation of the spinous processes
Testing of bucket-ladle and lateral rib movements.
(Fig. 133, p.229). Although the thoracic excur-
Terrier's "harp" tests for widening of the inter-
sions are smaller, the movement is easily palpated
costal spaces during sidebending of the thorax.
by the long spinous processes (lever arms). The
Restrictions of the ribs can be observed and pal-
spinous processes are not approximately level
pated more clearly in this position.
with the associated transverse processes, as in the
lumbar spine, and they must be palpated at a sig- Starting Position (Fig. 96 a)
nificantly higher level than the tip of the spinous Relaxed sitting position. Example: test position
process: for palpation of the left ribs. The examiner stands
Tl-T4: 2 (patient's) fingerwidths higher behind the seated patient and places his right
T5-T9: 3 fingerwidths higher foot next to the patient's right hip on the exami-
TlO-T12: 2 fingerwidths higher nation table. The patient side bends over the ex-
aminer's thigh, causing separation of the ribs on
Normal Findings the left side. The patient's left arm is raised with
The palpable excursions in the thoracic re- the elbow over the temple; it is held in that posi-
gion are markedly mailer than in the lumbar tion by the examiner's right hand.
spine. This is due to the smaller disk height of
the thoracic egments and the relative rigidity Procedure
of the thorax. The rib movement is accentuated by further pas-
sive side bending of the thorax and by respira-
tion. The palpating index finger of the left hand
1. Forward bending (Figs. 93a and 95a) is placed on the anterior or posterior axillary line
The adjacent spinous processes separate. (Fig. 96 a,b), or several intercostal spaces can be
2. Backward bending (Figs. 93b and 95b) palpated at once by spreading the fingers and
The adjacent spinous processes approximate. placing a fingertip in each interspace. The
3. Sidebending (Figs. 93c and 95c) same starting position can be used when the ribs
The upper vertebra rotates toward the side to are immobilized for therapeutic purposes
which the trunk bends (i. e., to the right during (Fig. 96 b,c).
sidebending to the right). As this occurs, the up-
The examiner evaluates for:
per spinous process rotates toward the opposite
side and is palpated there. 1. Equal widths of the intercostal spaces (rib po-
4. Rotation (Figs. 93d and 95d) sition)
The upper spinous process rotates slightly more 2. Palpability and tenderness of the (blunt) su-
than the one below it toward the opposite side perior borders and (sharper) inferior borders
(e. g., to the right during rotation to the left). of the ribs
3. Asynchrony or limitation of rib movement, or
Excursions of the thoracic segments (Fig. 10). pain near the motion limit
Forward and backward bending:
Mobility gradually decreases from Tl to T8ff9.
Normal Findings
Mobility increases markedly from TlO to Ll.
1. Rib position
Side bending and rotation:
Equidistant from the upper and lower adja-
Mobility gradually decreases from Tl to T5ff6.
cent ribs. Interspaces narrowest about the
Mobility increases markedly from T6 to T8.
Palpation During Movement 191

Fig.96a-c. Palpation of rib mobility. The "harp" (Terrier). a Test

position for palpation of the ribs and intercostal spaces. b,c Fixation
of the lower rib for therapeutic purposes (mobilization)

sixth rib, becom ing wider superiorly and infe-

2. Rib tenderness
Tested by palpating the superior and inferior
borders of the rib bodies. Normally the supe-
rior border is more blunt than the relatively
sharp-edged inferior border. Neither is tender
to pressure. c
3. Rib mobility
During respiratory movements and during
blunt border of the rib is more easily palpated
separatjon of the ribs by sidebending, all the
by slight internal rotation in the costotrans-
ribs move in unison, the intercostal spaces
verse joint and is tender to pressure. Its mobili-
widening by equal amounts (Figs. 97, 98).
ty on deep inhalation is decreased and may be
Gliding movements in the costotransverse
painful at full inspiration. The uppermost mo-
joints should be unrestricted.
tion-restricted rib is the key rib (Greenman). It
4. Intercostal muscles
must be treated (mobilized) first.
No spasticity or tenderness to pressure
2. Expiratory restriction (i. e., fixation in a posi-
tion of inspiration). The restricted rib is not
centered between the adjacent ribs, being
Pathologic Findings
closer to the rib above than the rib below. The
1. Inspiratory restriction (i. e., fixation in a posi- lower, sharp border of the rib is more easily
tion ofexpiration). The restricted rib is notcen- palpated by slight external rotation in the cos-
tered between the adjacent ribs, being closer to totransverse joint and is often tender to pres-
the rib below than the rib above. The upper, sure. Its mobility on deep exhalation is de-
192 Tests of Joint Translation


Fig. 97. Mobility of the ribs at the costovertebral Fig.98. Bucket-handle motion ofthe ribs

Fig. 99 a, b. Thoracic compression. a Frontal, b sagittal

Tests oUoint Translation 193

creased and is painful at full expiration. The Procedure

lowermost motion-restricted rib is the key rib Both hands grasp the thorax with the palms flat
and should be treated first. and apply a springing pressure directed toward
Examination of the ribs in a recumbent posi- the midline.
tion is described in D/Ribs/Sect.3.3 (lower
ribs), p.20S, and ElThoraxiSects.3.2 and 3.3 4.2 Bimanual Compression of the
(upper ribs), pp. 208, 208. Thorax in the Sagittal Plane (Fig. 99 b)
This produces compression of the costotrans-
verse joints.
4 Tests of Joint Translation
4.1 Bimanual Compression of the Thorax One hand steadies the thorax from behind while
in the Frontal Plane the other hand applies a light springing pressure
4.2 Bimanual Compression of the Thorax to the sternum at the end of expiration. Alterna-
in the Sagittal Plane tively, each hemithorax may be compressed sep-

4.1 Bimanual Compression of the

Normal Findings
Thorax in the Frontal Plane (Fig. 99 a)
Painless, springy compression in both planes.
Test for pain and limitation of movement in the
costal joints.
Compression on the posterior axillary line ex- Pathologic Findings
erts pressure on the costovertebral joints while Resistance and tenderness are noted in patients
also pushing inward on the costotransverse with:
joints. If the compression is applied more on the
1. Restricted ribs
anterior axillary line (as in Fig. 99a), the greatest
2. Rib fractures (traumatic or spontaneous)
pressure is exerted on the sternocostal joints.
3. Inflammatory disorders of the costal joints
Starting Position
Relaxed sitting posture.
Examination of the Thorax (Thoracic Spine and Ribs)
in the Prone Position (C/III)

/1 Inspection

2 Active Movements: Respiratory

Movements (Deep Breathing)
(Regional Diagnosis)

3 Palpation of the Thoracic Joints

(Segmental Diagnosis)
Palpation at Rest
3.1 Palpation Field of the Posterior Thorax
Palpation During Movement
3.2 Rib Movements and Intercostal Spaces

4 Tests of Joint 'Iranslation

4.1 Thoracic Segments
4.2 Scapula

5 Muscle Tests
Scapular Fixators (Transverse Portion of
Trapezius, Rhomboids)
Palpation at Rest 195

These tests are indicated for cases that cannot be Pressure palpation in the anterior direction
adequately evaluated by examination in the sit- (Fig. 101 a) causes a tilting of the vertebra in the
ting position. sagittal plane that produces traction in the facet
Palpation and joint-translation testing of the joint above and compression in the facet joint
thoracic spine are usually performed during the below.
analogous examination of the lumbar spine. Upward pressure on the tip of the spinous pro-
Again, the entire vertebral column should be in cess (Fig. 101 b) exerts traction on the interverte-
a position of slight kyphosis. bral disk and causes parallel divergent gliding in
the facet joints.

b) Facet Joints and Transverse Processes

1 Inspection (Fig. 102 a)
These structures are palpated on a line approxi-
See Brrhorax/Sect.1 (p.1S1): Inspection of the mately 1 cm lateral to the spinous processes on
thorax in the sitting position. each side. It should be noted that the tip of a giv-
en spinous process is 2-3 fingerwidths lower
than the transverse processes of the same verte-
bra. Thus, at T1-T4 a tender spinous process is
2 Active Movements: Respiratory located 2 cm (2 fingerwidths) lower than the cor-
Movements (Deep Breathing) responding facet joints and costovertebral
(Regional Diagnosis) joints, at T5-T9 it is 3 cm (3 fingerwidths) lower,
and at TlO-T12 it is 2 cm (2 fingerwidths) lower.
Deep, active respiration can be evaluated by in- The transverse processes are palpated with the
spection and/or palpation. "yoke" formed by the adjacent index and middle
fingers, which are pressed down with the other
hand (Fig. 102 a).
Palpation over restricted facet joints will dis-
close small (1-2 cmZ) zones that are markedly
3 Palpation of the Thoracic Joints tender to pressure. Maigne states that these ar-
(Segmental Diagnosis) eas of trophic alteration and muscle spasm are
based either on a periarticular reaction about
Palpation at Rest the facet joint (irritation zones) or an irritation
3.1 Palpation Field of the Posterior Thorax of the dorsal ramus ofthe spinal nerve. The ten-
Palpation During Movement der zones are easily palpable in the cervical and
3.2 Rib Movements and Intercostal Spaces thoracic regions but are very difficult to detect in
the lumbar region when acute muscle splinting is
present (see also p.196).
I Palpation at Rest c) Costotransverse Joints (Fig. 102 b)
These joints are palpated approximately 3-5 cm
from the spinous processes, just lateral to the
3.1 Palpation Field of the Posterior
erector trunci muscles. Joint tenderness may re-
Thorax (Fig. 100)
sult from a positional fault or restriction involv-
a) Thoracic Segments ("Pain Rosette" About ing the costovertebral joint itself or the facet
the Spinous Processes) (Fig. 101 a,b) joints of the same thoracic segment (primary or
The examination technique, normal findings, secondary rib restriction). Whenever costo-
and pathologic findings are basically the same as transverse joint tenderness is present, even if
in palpation of the lumbar spine (see CILPH Re- respirations are unimpaired, the examiner
gion/Sect. 3.3, p.131), with these differences: should palpate rib movements and the inter-
196 Palpation at Rest

1 Spinous processes ("pain rosette")

2 Facet jOints, transverse processes
3 Costotransverse jOints
4 Segmental muscles
(trigger pOints)
5 Segmental irritation points
of Sell
Multifidus muscle ---:7"""----Hli),l'-<o~

""",,,, ::O~--7&\---+--+-I- _ _ costae

Fig.too. Palpation field of the posterior thorax

costal spaces and evaluate the translational mo- more painful in response to certain spinal move-
bility of the costovertebral joints in the supine ments and improve in response to others. The
position (see EffhoraxiSect.4.1, p.21O). latter movements signal the appropriate direc-
tion for therapeutic manipUlation.
d) Muscular and Neural Trigger Points The testing of irritation zones in the thoracic
As in the lumbar spine, paravertebral muscle spine follows basically the same technique used
splinting and myotendinoses due to nociceptive in the lumbar spine.
afference from the spinal segments are found
in association with restricted thoracic seg- Procedure
ments. These sites correspond very closely to The palpating finger is pressed in deeply about 1
the segmental irritation zones. Neural trigger fingerwidth lateral to the spinous process. The
points (entrapped dorsal rami of spinal nerves) paraspinous irritation point (IP) is felt as an area
are located about 1 cm from the midline in the of spasticity of the deep back muscles
upper thoracic and cervical region and a (Fig. 103 a). The IPs are tested for sensitivity to
handswidth from the midline in the lower tho- rotation and flexion by corresponding head
racic region. movements (Fig.103b) orrotational movements
of the shoulder girdle (Fig.103c,d).
e) Segmental Irritation Points ofSeU The IPs of the costotransverse joints are palpat-
(Fig. 103 a-d) ed about 2 fingerwidths lateral to the spinous
As described earlier (pp.54 and 127), these are processes; they are located beneath the erector
approximately lentil-sized areas of tissue firm- trunci muscle by proceeding medially along the
ness, tender to pressure, that become firmer and rib. Functional testing of the irritation zones in-
Palpation During Movement 197

Fig.lOla,b. Thoracic segments (pain rosette). a Pal- Fig. 102. a Palpation of the transverse processes.
pation with forward pressure on the spinous process. b Palpation of the costotransverse joints
b Palpation with upward pressure on the spinous pro-

volves palpating for structural changes in the IPs

Normal Findings
during inspiratory and expiratory rib excursions.
1. Equal width of the intercostal spaces on
both sides. The interspaces are narrowest
at the level of the 6th rib and become wider
Palpation During Movement in the cranial and caudal directions.
2. No tenderness to pressure at the (blunt) su-
perior borders and (sharp) inferior borders
3.2 Rib Movements
of the ribs.
and Intercostal Spaces (Fig. 104 a,b)
3. The amplitude of rib excursions during in-
Procedure spiration and expiration decreases from
The examiner, standing at the head of the table, about the mid-thoracic region upward. The
places both hands over the intercostal spaces so rib excursions are equal on both sides.
that the fingers are in the interspaces and checks 4. The intercostal muscles show equal tone on
for asymmetries of rib movements. Both normal the right and left sides and are nontender.
respiration and active deep respiration are tested.
198 Palpation During Movement

c d

Fig.l03a-d. Examination of irritation points. a Palpation at rest, b during backward bending, c, d during rota-
tion of the thoracic spine

Fig.l04a, b. Palpation of the intercostal spaces and rib movements. Springing of the costotransverse joints
Tests ofJoint Translation 199

4 Tests of Joint Translation

4.1 Thoracic Segments •

4.2 Scapula

4.1 Thoracic Segments (Fig. lOS)

The examination technique (Fig. lOS), normal
findings, and pathologic findings are the same as
in the lumbar region (see CILPH Region!
Sect.4.1, p.13S). Unlike the lumbar spine, how- a
ever, the articular surfaces in the thoracic spine
are oriented such that the facets do not experi- ~
ence compression on the side of rotation or trac-
tion on the side opposite the rotation; rather,
both facet joints undergo a lateral gliding in
translation. As in the lumbar spine, the adjacent
vertebrae above and below the fixed vertebra
are tested. (Figure 10Sa,b illustrates the test
technique, and c shows the test position and ver-
tebral mobility on a skeletal model.)

4.2 Scapula (Figs. 106, 107) b

These are shoulder-girdle tests that cannot

be performed in the sitting position. The scapula
is passively moved on the thorax to test the
1. Ease of scapular gliding on the thorax
2. Mobility of the acromioclavicular joint
3. Stretch sensitivity of muscle insertions on the

Starting position c
Relaxed prone position with the spine in slight
Fig. IDS a-c. Tests of joint translation in the thoracic
kyphosis. The arms are adjacent to the trunk and
internally rotated.

The examiner stands level with the pelvis on the between the scapula and thorax at the inferior
tested side (say, the right side). He places his angle. This lifts the scapula away from the thorax
right hand on the anterosuperior aspect of the so that the muscle attachments and a portion of
right shoulder so that the patient's upper arm the subscapularis can be palpated.
rests on the examiner's forearm. The other hand If necessary, the patient is moved to the lateral
is placed with the thumb at the inferior angle of position to test all movements of the shoulder
the scapula and the index finger at its medial girdle in the scapulothoracic joint (Fig. 107): di-
border (Fig. 106). The upper hand pushes the rections of movement, abduction (lateral) and
scapula caudally while the lower hand presses in adduction (medial) (Fig. 107 a,b), elevation (cra-
200 Tests of Joint Translation

Fig.l06a,b. Scapular mobility. a Caudocranial,

b craniocaudal

8 _ _ _ _ _ _ _ _ _ __ _
Fig.l07a--e. Tests of shoulder-girdle movements in the scapulothoracic joint. a,b Abduction and adduction,
c craniocaudal motion, d,e external and internal rotation
Muscle Tests 201

Fig.IOS. Resistance tests of the scapular fixators

nial) and depression (caudal) (Fig.107 c), exter- Starting Position

nal rotation (of the inferior angle) and internal Same as in Sect.4.2 (scapular motion test,
rotation (Fig. 107 d, e). Fig. 106).

Procedure (Fig.108)
The hands are crossed and placed on the inferior
5 Muscle Tests angles of the scapulae from below, the index fin-
ger at the medial border of the scapula and the
thumb at the lateral border. The palm is placed
Scapular Fixators (Transverse Portion of
flat against the thorax to resist adduction and in-
Trapezius, Rhomboids)
ternal rotation of the scapula.

This supplementary test to the shoulder-girdle

examination is seldom required.
Examination of the Thorax (Thoracic Spine and Ribs)
in the Lateral Position (D/III)

3 Palpation or the Thoracic Joints

During Movement
(Segmental Diagnosis)
3.1 Segmental Mobility Testing of the
Thoracic Spine
3.2 Segmental Mobility Testing of the
Cervicothoracic Junction (C6-T3)
3.3 Segmental Mobility Testing of the
Lower Ribs

Examination steps 1,2,4, and 5 are omitted.

Only the segmental mobility of the thoracic
spine and lower ribs is palpated in the lateral
Examination of the Thorax 203

3 Palpation of the Thoracic Joints 3.1 Segmental Mobility Testing

During Movement of the Thoracic Spine (Fig. 109)
(Segmental Diagnosis) The segmental mobility of the thoracic spine is
tested almost exclusively in conjunction with ex-
3.1 Segmental Mobility Testing of the amination of the lumbar spine. Generally, exami-
Thoracic Spine nation of the thoracic spine is more easily per-
3.2 Segmental Mobility Testing of the formed in the sitting position. Decubitus exami-
Cervicothoracic Junction (C6-T3) nationmaybenecessaryinbed-confinedpatients.
3.3 Segmental Mobility Testing of the Low-
erRibs Starting Position
The patient clasps the hands behind the neck (to
protect the cervical spine). The trunk is at the
edge of the table or bed and is steadied against
the examiner's body. The hips and knees are
slightly flexed.

Fig. 109 a-e. Segmental mobility testing of the tho-

racic spine. a, b Backward bending, c, d forward bend-
ing, erotation e
204 Examination ofthe Thorax

3. Rotation: The upper spinous process ro-
Sagittal Plane: Backward Bending tates to tbe side opposite tbe direction of
(Fig. 109 a,b) rotation, moving somewhat farther than
The patient's head and arms are cradled from be- the process below it. The facet joint on the
low so that they rest on the examiner's forearm. rotation side undergoes decompression
Segmental testing proceeds in a cranial to caudal (traction) at the motion limit.
direction with increasing lordotic curvature (dor-
siflexion) of the thoracic spine. The finger pal- Pathologic Findings
pates the approximation of 2 adjacent spinous Decreased or increased mobility in one or more
processes, the palpating finger serving as the ful- segments compared with the adjacent seg-
crum (pivot point) for the segmental motion. ments.

Sagittal Plane: Forward Bending (Fig. 109 c,d)

Position and hand placement are as before. Seg-
3.2 Segmental Mobility Testing o/the
mental testing proceeds in a cranial to caudal
CervicothoracicJunction (C6-T3)
(Fig. 110 a-d)
direction as the patient's trunk is increasingly
flexed forward, the finger palpating for separa- Starting Position
tion of the adjacent spinous processes. Same as before. The patient's arms are crossed
Sidebending requires elevation of the trunk, so over the chest or clasped behind the neck (to im-
this test is more conveniently done in the sitting mobilize the cervical spine).
position. Only (coupled) rotation is tested in de-
cubitus. Procedure
One hand cradles the back of the patient's
Transverse Plane: Rotation (Fig. 109 e) head and neck, the head resting on the examin-
The patient is in an "unstable" side-lying posi- er's forearm, the forehead on the upper arm
tion, the arms behind the head or crossed ("lipstick" technique). This is the starting
in front ("pharoah position"). The head rests on pOSItIOn from which forward bending
a flat cushion, the hips and knees are slightly (Fig. 110 a), backward bending (Fig. 110 b),
flexed. Palpation proceeds segmentally as the sidebending (Fig. 110 c), and rotation (Fig.
shoulder girdle and thorax are rotated back- 110d) are initiated.
ward. The palpating finger is placed between the As in the analogous tests of the lumbar spine, the
spinous processes or on the lower side (side op- palpating finger is placed between two spinous
posite the rotation) of the spinous processes of processes to assess their mobility relative to ad-
the motion segment (as in Fig. 64 a, p.15l). jacent segments. The findings are accentuated
by applying light cephalad traction to the spine.
With midcervical hypermobility, better control
Normal Findings is achieved by having the patient clasp the hands
Range of motion: Slight mobility should be behind the neck to immobilize the cervical spine.
noted in all vertebral segments. The examiner then cradles the patient's elbows
Forward and backward bending: Mobility de- and proceeds with the test.
creases to T9, increases to T12.
Rotation: Mobili ty decreases to TS, then in- Normal Findings
creases at lower levels. Ranges of motion:
(See also Bffhorax/Sect. 3.4.) Forward and backward bending: Mobility de-
1. Backward bending: The adjacent spinous creases sharply from C6 to Tl and is minimal
proces es converge. from T1 to T3.
2. Forward bending: The adjacent spinous Sidebending and TOtaton: Mobility is marked-
processes separate. ly decreased from C7 to T3 (ribs).
Examination ofthe Thorax 205

~ ___ _ ______~______ ~ _________ d

Fig.ll0a-d. Segmental mobility testing of the cervicothoracic junction. a Forward bending, b backward bend-
ing, c sidebending, d rotation

Pathologic Findings Procedure

Decreased mobility in one or more segments, The patient's uppermost arm is extended above
with or without pain on motion. the head and slighty flexed at the elbow. One
hand grasps this arm at the shoulder and, at
end-inspiration, pulls the arm cephalad to fur-
3.3 Segmental Mobility Testing of the
ther widen the intercostal spaces, which are pal-
Lower (6th-12th) Ribs (Figs. 111, 112)
pated (Fig. l11a,b). This inspiration is repeated
Bucket-handle and lateral rib movements are for each interspace. The palpating finger is in
tested in the lateral position. the intercostal space on the anterior or posteri-
or axillary line (Fig. 112 a-c).
Starting Position During expiration the finger palpates for nar-
Unstable side-lying position, the head resting on rowing of the intercostal spaces. At end-expira-
the hand and arm. The lower leg is flexed, the up- tion the costal margin is palpated to determine
per leg straight. The ribs to be tested are separat- whether further, passive caudal movement of
ed somewhat by placing a flat pillow beneath the the rib is possible.
thorax. The examiner stands at the head of the
table on the patient's anterior or posterior side.
206 Examination of the Thorax


Fig.llla,b. Testing the mobility of the lower ribs.

a Palpation of the ribs and intercostal spaces. b Fixa-
tion ofthe lower ribs during therapy (mobilization) b c
Fig. 112a-c. Palpation of the intercostal spaces and
costal margins

Normal Findings Pathologic Findings

1. Painful resistance to rib movements
1. Widening of the intercostal spaces during
inspiration. 2. Unequal intercostal spaces
2. Upward movement of the ribs during in- 3. Limited movement of one or more ribs ("key
rib") during inspiration and arm traction or
3. Painless, passive continuation of the up- during expiration
ward rib movement by arm traction
4. Opposite findings during expiration
Examination of the Thorax (Ribs)
in the Supine Position (E/III)

11 Inspection

2 Active Movements: Respiratory

Movements (Deep Breathing)
(Regional Diagnosis)

3 Palpation of the Ribs

(Segmental Diagnosis)
Palpation at Rest
3.1 Palpation Field of the Anterior Thorax
Palpation During Movement
3.2 Rib Movements and Intercostal Spaces
3.3 Segmental Mobility Testing of the Up-
per (2nd-6th) Ribs

4 Tests of Joint Translation

4.1 CostaiJoints
4.2 Sternoclavicular and Acromioclavicular

5 Muscle Test: Test for Shortening of the

Pectoralis Major
208 Palpation at Rest

This set of examinations is necessary only if the 3 Palpation of the Ribs

examinations in the sitting and prone positions (Segmental Diagnosis)
have not furnished adequate information on rib
mobility and the functional status of the ster-
nocostal joints. Palpation at Rest
3.1 Palpation Field of the Anterior Thorax
Palpation During Movement
3.2 Rib Movements and Intercostal Spaces
1 Inspection
3.3 Segmental Mobility Testing of the Up-
Thoracic asymmetries, posItIon of clavicles, per (2nd-6th) Ribs
shape of sternum, epigastric angle, thoracic or-
gans, and respiration are compared with the
findings in the sitting and prone positions. Palpation at Rest

Normal and Pathologic Findings

See B/Thorax/Sect.1 (pp.181-183). 3.1 Palpation Field
of the Anterior Thorax (Fig. 113 )
1) Sternoclavicular and Acromioclavicular
2 Active Movements: Respiratory Joints (Figs. 198, 199, p.280)
Movements (Deep Breathing) See Palpation Field of the Shoulder Girdle
(Regional Diagnosis) (B/Shoulder Girdle/Sect. 3, p. 278, and Fig. 197).

Normal respiration. and deep respirations are 2) Rib Synchondroses and Sternocostal Joints
evaluated by inspection and palpation. 2-7 (see Fig. 90)
Palpation and findings of the rib synchondroses
(chondrocostal and chondrosternal attach-

1 Clavicular joints
2 Rib synchondroses,
coslal joints
3 Xiphoid process
4 Floating ribs
5 Muscle attachments

Pectoralis - -+--+-- -t-n

o-==:=----t--t-- Pectoralis

Serratus - --I----i- +_

Fig.113. Palpation field ofthe anterior thorax

Palpation During Movement 209

ments) were described in the section on exami- costal space, the examiner can assess and com-
nation in the sitting position (see Bffhoraxi pare the widths of the interspaces, the position
Sect. 3.1, p.184). (margins) of the ribs, the symmetry of rib
movements and their synchrony with respira-
3) Xiphoid Process (see Fig. 91 a) tions, and the tension of the intercostal mus-
With tenderness of the xiphoid process, the mo- cles. The hands can also be placed on the up-
bility of the 7th rib and the associated thoracic per or lateral portions of the ribs from the
vertebra should be assessed. caudal side to check for synchrony of rib
movements on both sides. When asymmetry is
4) Floating Ribs (see Fig. 91 b) present, the greater excursion generally repre-
If the free ends ofthe 11th and 12th ribs are ten- sents normal function while the less mobile
der when palpated anteriorly, the associated cos- side signifies an inspiratory restriction that re-
tovertebral joints should be examined along quires further investigation by the segmental
with the 11th and 12th thoracic vertebrae. testing of rib motion. As in the prone examina-
tion, the rib movements and intercostal spaces
5) Muscle Origins (Fig. 113) are individually palpated and assessed (see
Origins of the three great fan-shaped muscles Cffhorax/Sect.3.2, p.197).
connecting the upper limb to the chest wall:
Serratus anterior: 1st-9th ribs on the mid-axil- Normal and Pathologic Findings
lary line. See B/Ribs/Sect.3.5 (p.189) and Cffhoraxl
Pectoralis major: inferior border of the medial Sect. 3.2 (p.197).
third of the clavicle, the lateral sternal border,
and the rectus abdominis sheath. 3.3 Segmental Mobility Testing
Pectoralis minor: 3rd-5th ribs, anterior to the of the Upper (2nd-6th) Ribs
serratus origins.
These muscle origins may be painful due to A sand bag is placed beneath the thoracic spine
strain (overuse, athletic injuries). In these cases to hyperextend it and increase the inspiratory
a rib fracture should always be excluded, and expansion of the thoracic cage.
the thoracic vertebrae and costal joints should
be examined. Starting Position
Relaxed supine position. The examiner stands at
the head of the table and grasps the patient's
I Palpation During Movement arm, extended above the head, proximal to the
slightly flexed elbow. This provides a reasonably
secure hold so that traction can be applied to the
3.2 Rib Movements and Intercostal Spaces arm without causing painful skin irritation. The
The pump-handle movements (upper ribs) and patient's forearm is steadied against the examin-
bucket-handle movements (lower ribs) are pal- er's body (Fig. 114).
pated and assessed.
Starting Position At end-inspiration, longitudinal traction is ap-
Relaxed supine position, perhaps using a roll to plied to the arm to increase expansion of the tho-
produce lordosis. The examiner stands at the racic cage and widen the separation of the inter-
head of the table to palpate the intercostal costal spaces. Meanwhile the index finger of the
spaces and rib movements. examiner's free hand is placed in the intercostal
space on the anterior axillary line for the seg-
Procedure mental palpation of individual rib movements
As in Fig. 104. With the hands on the anterolat- (see D/Ribs/Sect. 3.3, p. 205).
eral thorax so that each finger is in an inter-
210 Palpation During Movement

4 Tests of Joint Translation

4.1 Costal Joints

4.2 Sternoclavicular and Acromioclavicular

4.1 Costal Joints (Figs. l1Sa-c, 116)

Starting Position
Relaxed supine position. The arms are crossed
over the chest.

The examiner stands on the non tested side of
the thorax, grasps the shoulder, and turns the pa-
tient toward himself to a side-lying position. He
then places the flat palpating hand, fingers to-
gether, over the tested rib so that the tip of the
thumb touches the transverse process while the
thumb and thenar eminence lie along the tested
rib (Figs. l1Sa, 116).
Then the thorax is returned to the supine posi-
Fig. 114 a, b. Segmental mobility testing of the upper tion and further rotated toward the test side un-
ribs. a Pump-handle motion, bbucket-handle motion til the joint to be treated, and the costal angle,
are almost directly above the examiner's hand
(on the line of gravity). The examiner then
presses his body weight against the table surface
with a gentle springing action (Fig.11S b), the
thumb acting as a fulcrum to impart a springy an-
terior movement to the rib which distracts it
from the transverse process in the costotrans-
Normal and Pathologic Findings verse joint (Fig. 116).
See B/Ribs/Sect.3.5, p.189, and Crrhoraxl
Sect.3.2, p.197. • Note
Restrictions of the costotransverse joint can be
• Note treated using the same technique.
Disturbances of the uppermost ribs are a fre- All the ribs that showed pathologic findings on
quent source of shoulder pain and pain at the general motion testing or palpation are exam-
medial scapular margin. ined by this technique.
P Wolff states that lesions of the third rib can
cause refractory pain on the lateral side of the
4.2 Sternoclavicular and Acromio-
upper arm that radiates to the lateral epicondyle
clavicular Joint (See Figs. 208-211)
and the little finger.
For examination technique, see Palpation Field
of the Shoulder Girdle and Clavicular Joint
Normal Findings Tests, B/IV Shoulder Girdle, Sects.3 and 4
Painless, bilaterally symmetrical movements (pp. 278, 28S-288).
of the ribs during inspiration and expiration.
Muscle Test 211

Fig. US a-c. Testing of costotrans-

verse joint play. a Starting position.
b,c Technique

5 Muscle Test: Test for Shortening shoulders, humpback), the test is performed at
of the Pectoralis Major that point in the examination.

Starting Position
The test for shortening of the pectoralis major is Relaxed supine position. The patient has raised
the only test of the shoulder-girdle muscles that the arm (palm facing forward and medially) to
is reliably performed only in the supine position about 130 0 of abduction and is told to lower the
(Fig. 117 a,b). Since pectoralis shortening is a arm to the table surface. If the pectoralis is short-
major determinant of thoracic shape (drooping ened' the patient usually cannot lower the arm to
212 Muscle Test

Fig.116. Distraction of the rib from the

transverse process in the costotransverse

the table in this position, and inspection of the Pathologic Findings

muscle shows prominent tension compared with 1. The arm does not reach the table surface. Pas-
the opposite side. sive stretching of the pectoralis provokes a
The examiner stands on the tested side and twinging pain in the muscle = pectoralis short-
steadies the thorax with the free hand to prevent ening.
rolling of the thorax toward that side during 2. The arm can be moved back past the edge of
stretching of the pectoralis (e. g., in patients with the table = hypermobility (hypotonicity) of
fixed kyphosis). the muscle.

With the other hand the examiner grasps the pa-
tient's extended, externally rotated arm above
the elbow and attempts to push it closer to the
table, noting the degree to which this is possible
and whether it elicits pain in the pectoralis ma-
jor. The direction of motion is obliquely upward
and outward to test the abdominal portion of the
muscle (Fig. 117 a).
The arm is moved to a horizontal position of ap-
proximately 90° abduction to test the sternal
portion of the pectoralis (Fig. 117b), and to a
slightly lower position to test the clavicular por-
tion. The arm is kept in external rotation for all
three tests.

Normal Findings
From the starting position described, the arm
can be actively lowered to the table surface or
can be brought to that position by passively
continuing the active movement. Fig.117a,b. Test for shortening of the pectoralis ma-
----- jor. a Abdominal portion, b sternal portion
Examination of the Cervical Spine
in the Sitting Position (BN)

11 Inspection

2 Active and Passive Movements of the

Cervical Spine and Head in Three
(Regional Diagnosis)
2.1 Sagittal Plane: Backward and Forward
2.2 Frontal Plane: Sidebending
2.3 Transverse Plane: Rotation
2.4 Provocative Testing of the Vertebral
Segments (Modified from de Kleyn)
2.5 Provocative Test for Motion Segment
Laxness (Hypermobility)

3 Palpation of the Cervical Spine During

(Segmental Diagnosis)
3.1 Mobility Testing of the OcciputlAtlas
3.2 Mobility Testing of the AtlaslAxis
3.3 Mobility Testing of the C2/C3 Segment
3.4 Mobility Testing of the C3-C5 Segments
3.5 Mobility Testing of the C5-T3 Segments

4 Tests of Joint fianslation

4.1 Traction
4.2 Compression
4.3 Three Tests of Facet Joint Gliding

5 Muscle Tests: Resistance Tests of the

Cervical Muscles (Synergists)
214 Examination ofthe Cervical Spine

1 Inspection movement) of the facet joints that progresses

segmentally from above downward. Finally,
Shape of the neck, head position, cranial shape, maximum convergence of the articular facets
face. leads to a bony limitation of dorsiflexion, with
fixation of the joints.
Findings From that point the examiner continues the ac-
See A/General Inspection/Sect. 3 (pp. 77,81). tive movement to its passive limit by pressing
lightly on the patient's forehead.
End-feel: hard-elastic.
Rotation of the head in dorsiflexion aids in de-
2 Active and Passive Movements tecting restrictions below the axis (Lewit).
of the Cervical Spine and Head The test can also be done in stages to establish
in Three Planes the level of a lesion by grasping and immobiliz-
(Regional Diagnosis) ing the neck with one hand (yoke grip) at the lev-
el of the middle and lower cervical spine.
2.1 Sagittal Plane: Backward and Forward
Forward Bending
In this movement the occipital condyles glide
2.2 Frontal Plane: Sidebending
backward upon the atlas. Then the atlas tilts for-
2.3 Transverse Plane: Rotation
ward on the axis, followed by a segmental sepa-
2.4 Provocative Testing of the Vertebral
ration (divergent movement) of the facet joints.
Segments (Modified from de Kleyn)
The joints below the axis are fixed (locked) by
2.5 Provocative Test for Motion Segment
ligamentous tension. The active movement is
Laxness (Hypermobility)
carried to its passive limit by pressing lightly on
the occiput.
Testing the overall mobility of the cervical spine End-feel: firm-elastic. Often the motion limit
(staged testing). Potential sites of irritation in- has a muscular end-feel due to shortening of the
clude the facet joints, nerve roots, and vertebral dorsal neck extensors.
artery. Backward bending should be tested first, Rotation of the head in maximum anteflexion oc-
as it is best for revealing articular disturbances curs chiefly in the craniovertebral joints (at-
and root irritation. lanto-occipital and atlantoaxial). If these joints
are restricted, the anteflexed head cannot be ro-
Starting Position tated, or at the very least this rotation is limited
Upright sitting posture. and/or painful. This test, then, can differentiate a
craniovertebral joint restriction from a vertebral
Procedure restriction at a lower level (Lewit). A severe ro-
The examiner stands behind the patient and im- tation deficit suggests hypomobilityin the Cl/C2
mobilizes the thorax or shoulder, especially dur- segment, while a milder deficit suggests involve-
ing passive movements. During passive rotation, ment at the CO/C1 (atlanto-occipital) level.
the patient leans the head against the examiner's
2.2 Frontal Plane: Sidebending
2.1 Sagittal Plane: Backward
Side bending is assessed by a comparison of both
and Forward Bending
sides. The joints on the concave side are com-
Backward Bending pressed by a convergent movement, while those
Backward bending is marked initially by a for- on the convex side are decompressed by facet
ward gliding of the occipital condyles upon the separation. Side bending narrows the interverte-
atlas. Then the atlas tilts backward on the axis, bral foramina on the concave side, accompanied
followed by an approximation (convergent by a slight coupled rotation toward that side.
Examination of the Cervical Spine 215

Side bending can localize a painful limitation of The chin-in movement produces kyphosis at
motion on backward and/or forward bending to C1-C4 and lordosis at CS-C7. Counterpressure
a particular side, i.e., can establish which of the is applied to the upper thoracic spine, and the
two joints is involved in the disturbance. The ac- movement is increased by backward pressure on
tive movement is continued to its passive limit by the forehead. Pain usually occurs when motion
pressing on the temple on the convex side. segment laxness is present.
End-feel: firm-elastic.
Normal Findings 2.1-2.S
2.3 Transverse Plane: Rotation
Rotation, like sidebending, is tested and com- 1. Painless movements in all direction
pared on both sides. The joint facets approxi- 2. Uniform spinal curve at the end of all ex-
mate on the side toward which the neck rotates cursions
and separate on the opposite side. This is accom- 3. Equal excursions in sidebending and rota-
panied by a slight degree of side bending in the tion on both sides
direction of rotation. The active movement is 4. Rallges of malion (age-dependent):
continued to its passive limit by pressing on the - Backward bending approximately 70°
forward temple while the other hand immobi- (chin- forehead line in the horizontal
lizes the shoulder. plane).
End-feel: firm-elastic. - Forward bending approximately SO° (chin
can be placed on the sternum; may measure
2.4 Provocative Testing of the Vertebral distance from chin to sternal notCh).
Segments (Modified from de Kleyn) - Sidebending approximately 40° in both di-
Combined provocative test of the cervical spinal rections.
structures in maximum dorsiflexion and rotation. - Rotation approximately 90° in both direc-
The head is rotated while the cervical spine is in tions (including the upper thoracic spine).
maximum dorsiflexion. - Unrestricted rotation of the head in maxi-
This test causes maximum convergence and com- mum dorsiflexion and anteflexion .
pression of the facet joints on the side of the rota- S. End-feel: finn-elastic (springy) in anteflex-
tion while also provoking the nerve roots by max- ion and ide bending, bard-elastic in dorsi-
imally constricting the intervertebral foramina flexion
(Spurling's test) and partially occluding the verte-
bral artery in the craniovertebral joint region on
the side opposite the rotation (de Kleyn's test).
The test can furnish evidence of impaired blood Pathologic Findings
flow in the vertebral artery on the side to which 1. Painful limitation of motion in one or more di-
the head is rotated. It can also aid in the diagno- rections. The more painful and severe the lim-
sis of disk protrusions and facet joint restrictions itation, and the more directions it involves
or degenerative arthritis. within the segment, the greater the likelihood
of disk involvement (protrusion, prolapse) or
2.5 Provocative Testfor Motion Segment
inflammatory joint disease.
Laxness (Hypermobility)
Radiating neuralgic-type arm pain is sugges-
Chin out/chin in (provocative test in the sagittal tive of radicular irritation.
plane). The patient is told to "stick the chin 2. Limitation offorward bending may be caused
out" and then "tuck the chin in." The chin-out by shortening of the nuchal ligament or neck
position produces maximum lordosis at CI-C4 muscles or by meningeal irritation (Brudzin-
and kyphosis from CS to C7. Counterpressure is ski's sign).
applied at the sternum, and the movement is in- Limitation of backward bending or sidebend-
creased by forward pressure to the occiput. ing is usually caused by segmental restrictions
216 Examination of the Cervical Spine (CO/Cl)

Uoint restriction or disk protrusion). Another 3 Palpation of the Cervical Spine

common cause of decreased sidebending During Movement
is muscle shortening [trapezius, scaleni
(Segmental Diagnosis)
(prevertebral muscles)]. Limitation of head
rotation in dorsiflexion suggests a restriction
below C2, while limitation in anteflexion 3.1 Mobility Testing of the Occiput/Atlas
suggests a restriction in the craniovertebral (CO/C1)
joints (Lewit). 3.2 Mobility Testing of the Atlas/Axis
3. Vasomotor disturbances (worsening of (C1/C2)
headache, vertigo, tinnitus, possible syncope) 3.3 Mobility Testing of the C2/C3 Segment
imply an irritation of the vertebral artery 3.4 Mobility Testing of the C3-CS Segments
(positive de Kleyn test). 3.S Mobility Testing of the CS-T3 Segments
4. Brainstem symptoms (diencephalic symp- (Cervicothoracic Junction)
toms, especially after whiplash injury) are, ac-
cording to H.D. Wolff, strong evidence of a
craniovertebral joint dysfunction. Symptoms Segmental motion testing of the cervical spine in
include headache, vertigo, auditory and visual three planes, with loading imposed by the head
disturbances, tinnitus, autonomic dysfunction weight and the tone of the active neck muscles.
(disturbances of thermoregulation, diurnal The segmental muscles are tested for hypertonic
rhythm, peripheral vasomotor function), im- reactions due to articular disturbances.
paired concentration, rapid fatigability, psy-
chic lability. 3.1 Mobility Testing of the OcciputlAtlas
S. Painless limitation of motion with no associat- (COIC1) (Figs. 118-123)
ed cervical phenomena in older patients usu-
ally signifies age-related stiffness due to Starting Position
degenerative disease (osteochondrosis, spon- Relaxed sitting posture. The examiner stands
dylosis) in the motion segment. Therapeutic behind the patient so that he can provide light
posterior support. (Alternatively, the patient
mobilization is indicated only if the condition
causes painful functional disability. may sit on a chair with a back rest.)
6. Disruption of the uniform spinal curve by an-
gulations, straight sections, or abnormal pro- Examination ofthe Atlas
trusions must be investigated by palpation Procedure (Fig. 118)
and radiography to establish the etiology. The patient's head is grasped with both hands
7. Asymmetric excursions are most often caused from above with the fingers directed downward.
by unilateral restriction of the facet joints but The palpating fingers (index or middle fingers)
can also result from congenital or acquired on each side are placed in the angle between the
dysmorphias. mastoid and ascending mandibular ramus on the
8. End-feel: firm-elastic, usually painful, with in- tips of the transverse processes of the atlas. The
creased ranges of motion when hypermobility examiner first assesses the position of the trans-
is present. verse processes (Fig. 118 a-d) and then the mo~
A soft-to firm-elastic end-feel, with little pain, bility between the mastoid and the mandible,
is found when motion is limited, e. g., by mus- comparing both sides (Figs. 119-123).
cle shortening (upper trapezius, levator
scapulae) or spasm.
An almost hard-elastic end-feel with signifi-
Nonnal Findings
cant pain and limited motion is found with
Position ofthe transverse processes: If the bony
reflex muscle spasms secondary to vertebral
structures are symmetrical, the transverse pro-
restriction or traumatic or inflammatory
cesses, palpable as a point on each side, will be
Examination ofthe Cervical Spine (CO/Ct) 217

approximately midway between the mastoid

and mandible at the inferior border of the mas-
toid (Fig.1I8a), usually slightly closer to the
mastoid. Deviations from this position may
have an anatomic or functional cause. A low
position of the transverse processes suggests
prominent occiputal condyles; a high position
is common with basilar impression.

Examination During Movement

The tests below are presented in the order of
their diagnostic value.

Sidebending (Figs.1l9a-d, 124a)

With the thumb and hypothenar of both hands,
the examiner sidebends the patient's head to
each side. The rotational axis for the sidebend-
ing is approximately in the lower third of the cra-
nial cavity (level with the root of the nose).

Normal Findings
Equal lateral gliding of the occipital condyles
on the atlas joint surfaces toward the side op-
posite the movement. The atlas "shifts" to-
ward the side of the movement as a rotational
effect. When this occurs, the transverse pro-
cess is more easily palpated on the side to-
ward which the head is inclined.

Rotation (Figs. 120 a, b, combined movement)

Starting Position
Relaxed sitting posture. The cervical spine is
moderately flexed at C2-C7 for ligament fixa-
tion, and the craniovertebral joints (CO-C2) are
slightly extended.

Testing rotation as part of the combined move-
ment: Sidebending and rotation begins with
sidebending that is coupled with a rotation to the
opposite side. The examiner palpates the
springy end-feel between the transverse process
and mastoid, comparing both sides.
Testing rotation of co on Cl with the head maxi-
Fig.11S a-d. Examination of the atlas
mally rotated is illustrated in Fig.12l. The cervi-
cal spine is fixed below C2 by slight sidebending
218 Examination ofthe Cervical Spine (CO/Cl)

Fig. 120. a Combined movement (see also Fig. 127)

toward the palpated side, and the end-feel is as-

During rotation testing at COICI with the head
in maximal rotation (Fig. 121), the distance
between the transverse process and mandible in-
creases on the side away from the rotation with a
springy end-feel, while the transverse process
moves palpably closer to the mastoid. The cervi-
cal spine should be fixed below C2 in this test by
sidebending toward the palpated side.
Rotation in the Cl/C2 segment can be similarly
tested (Fig. 127) by employing more head rota-
tion and less sidebending. The examiner pal-
pates the range of motion and end-feel between
c the vertebral arches of Cl and C2 (interarcual

Differential Diagnosis
With a disparity of sidebending in the upper cer-
vical spine, the level of the affected segment can
be determined as follows:
a) C2/C3 segment: sidebending and rotation in
the same direction. The C2/C3 facet or C2
spinous process is palpated.
b) Cl/C2 segment: rotation and slight sidebend-
ing in the same direction. The Cl/C2 vertebral
Fig.l19 a-d. Mobility testing: sidebending arches are palpated.
c) COICI segment: sidebending with slight rota-
tion in the opposite direction. The space be-
tween the Cl transverse process and mastoid is
Examination ofthe Cervical Spine (CO/Cl) 219

~ Sidebending
to the left

Fig. 120. b Craniovertebral joint mechanics during a

combined movemen t. (Modified from Kapandji)

BackwardBending (Fig. 122 a) lower cranial third on the frontal plane. The cer-
The head is tilted backward (by anterior gliding vical spine is fixed below C2 by ligament tension
of the condyles on the atlas). The axis of rotation (cervical kyphosis) or facet closure (lordosis).
of this movement is in the lower cranial third on Figure 123 shows a different, "wrap-around"
the frontal plane. There is associated facet clo- hand placement for backward and forward
sure or ligament tightening below C2. bending, which also permits the application of
The palpating finger is on the atlantal transverse some traction.
process or behind the mastoid between the oc-
ciput and the posterior arch of the atlas (see
Fig. 124a), where motion between the arches of
Cl and C2 is usually easier to palpate.

Normal Findings
By the movement of the occiput, the trans-
verse proces of the atlas moves closer to the
mastoid and away from the mandibular ramus
on each side. The range of motion is very
small becau e it i palpated so close to the
motion axi .
End-feel: firm-elastic.

Forward Bending (Fig. 122 b) Fig.12l. Routine test in the terminal position (with
The head is flexed forward, the occiput gliding some sidebending of the cervical spine toward the pal-
backward on the atlas, on an axis located in the pated side to immobilize the segments below C2)
220 Examination of the Cervical Spine (CVC2)

L--L~ __ ~ ____________ ~~~ ____ b

Fig.122. a Backward bending, b forward bending Fig. 123 a, b. Backward and forward bending at COICl
using an alternate hand placement

Normal Findings 3.2 Mobility Testing of the Atlas/Axis

The distance between the mastoid and trans- (Cl/C2) (Figs. 124-128)
verse process increases on each side with for-
ward bending and decreases between the Figure 124 shows the gliding movements that
mandible and transverse process. Again, the occur at the ClIC2 articulation.
range of motion is very small because it is pal-
pated close to the axis of the motion. In pa- Sidebending (Fig.l25)
tients with weak nuchal muscles, the posterior
arch of the atlas will approach the occiput Starting Position
during backward bending and may separate Same as in Sect. 3.1.
from the occiput during forward bending.

With a painful limitation of motion, we recom- On the concave side of the neck, the atlas rotates
mend the hand placement in Fig. 123, where one forward (and laterally) on the axis. This rotation
hand is placed around the posterior circumfer- was already palpated at the atlantal transverse
ence of the occiput or the posterior arch of the process during sidebending in the CO/Cl seg-
atlas in the ClICZ segment and passively moves ment (see Fig. 119). Lewit states that sidebend-
the head. Often it is better to perform the for- ing in the atlanto-occipital joint is best palpated
ward and backward bending tests in the supine at the atlantal transverse process with the head
position (Figs. 156, 157) since better muscular in maximum rotation (to fix the lower cervical
relaxation is obtained. spine).
Examination ofthe Cervical Spine (Cl/C2) 221
Palpation of C1 position
Sidebending at CO/C1/C2
Rotation at CO/C1

Palpation Palpation
of rotation at C1/C2 of backward/forward bending
a Sidebending at C2/C3 and rotation at C 1fC2

Pa lpation of rotation at C l/C2

b Sidebending at C2/C3

Fig. 124. a, b Gliding movements and sites for palpation ofthe craniovertebral joints (CO, Cl, C2), rotation at Cl
and C2. c Craniovertebral joint mechanics during backward and forward bending of the cervical spine (c after
222 Examination or the Cervical Spine (CVC2)

Fig.12S a, b. Sidebending at ClICl

Fig.126. a Rotation ofthe atlas on the stationary axis.

b Rotation in terminal position. c,d Rotation test us-
ing an alternate hand placement
Examination of the Cervical Spine (Cl/C2) 223

Normal Findings
The atlas is more easily palpated on the side to
which the head is idebent.

Rotation (Figs. 125-127)

Starting Position
The examiner fixes the spine of the axis be-
tween the thumb and index finger, supporting
the hand on the back of the patient's neck
(Fig. 126a,c,d).

The examiner grasps the patient's head from
above with the free hand and rotates the head on
the longitudinal axis of the cervical spine Fig. U7. Rotation at ClIC2, combined movement
("twisting a light bulb"). The examiner deter-
mines the point at which the axis spine starts to
follow the movement (Fig. 126a) or palpates as
for rotation testing at the COIC1 segment
(Fig. 120b ). The end-feel is assessed as in the Atlas Rotation
COIC1 segment, but the palpating finger is posi- Atlas rotation can also be palpated as a com-
tioned along the vertebral arches from the joint bined movement, previously described in con-
facet to the spinous process of C2 (Fig. 124a). nection with motion testing at the COIC1 seg-
This palpation is more difficult. The hand place- ment (p.218, Fig. 120a). It is described below for
ment in Fig. 126 c,d is also suitable for therapeu- the ClIC2 segment (Fig. 127 a).
tic manipulation.
Starting Position
Cervical spine flexed for ligament fixation, cra-
Technique of Examination in Maximum Head
niovertebral joints slightly extended.
Rotation (Fig. 126b)
Starting Position Procedure
Maximum rotation and slight flexion of the cer- Rotation of the occiput and atlas with slight
vical spine. The craniovertebral joints are ex- sidebending to the opposite side, palpation of
tended. the springy end-feel between the vertebral
arches of C1 and C2.
Same as at COICl. Terminal rotation of the Forward and Backward Bending (Fig. 128 a--c)
occiput and atlas with slight side bending to- This is performed like forward and back-
ward the opposite side, and interarcual palpa- ward bending in the CO/Cl segment (Figs. 122,
tion of movement and end-feel between the two 123), but the palpating finger is between
vertebrae. the arches of C1 and C2, posterior to the
mastoid process (Fig.128c). This test is diffi-
cult and is usually easier to perform in the
Normal Findings
recumbent patient. It is less rewarding than
Motion of the axis spine begins at about
side bending and rotation. Figure 128a,b illus-
20°-25° on each side during movement of the
trates the alternate "wrap-around" hand place-
axis on C3. Springy end-feel.
224 Examination ofthe Cervical Spine (C2IC3)

Fig. 128a-c. Forward and backward bending at

Cl/C2. a, b Technique. c Palpation site on the verte-
b bral arches

a b

Fig.129a-i. Movements in the C2/C3 segment. a-c Sidebending: a,b Compara-

tive side bending to the left and right. c Coupled rotation in the skeletal model.
d,e Backward and forward bending in the skeletal model. f,g Divergent move-
ment, h,i convergent movement
Examination ofthe Cervical Spine (C1JC3) 225

Starting Position
Normal Findings
The examiner stands more to the side.
Approximation of the arches on backward
bending, separation on forward bending.
• Note Sidebending at C21C3 (Fig. 129a-c)
Craniovertebral joint restrictions can be treated One hand sidebends the patient's head while the
only after any shortening of the deep nuchal other palpates (Fig. 129 a,b). Figure 129 c shows
muscles has been corrected by stretching. the terminal positions from the dorsal aspect
during sidebending at C2/C3. The coupled rota-
3.3 Mobility Testing
tion of C2 on C3 that accompanies side bending
of the C21C3 Segment (Fig. 129 a-g)
is palpated at the C2 spinous process or at the
The C2/C3 segment is prone to dysfunction. The facet, as in Fig. 129 g, i.
gliding movements in this segment are tested dur-
ing sidebending, backward bending, and forward Backward and Forward Bending
bending. Combined movements are also tested. Figure 129d, e shows the combined movements

Fig. 129 c-e. See p. 224

226 Examination ofthe Cervical Spine (C3-C5)

Fig. 129f-i. See p. 224

of sidebending and rotation in flexion (diver- The lower vertebra is then fixed using the
gence; f, g) and extension (convergence; h, i). thumb-forefinger yoke of the palpating hand.
Divergent and convergent movements are pal-
3.4 Mobility Testing
pated on one side during combined movements
of the C3-CS Segments (Figs. 130, 131) (Fig. 131).
Since spinous and transverse processes are not Moving the head obliquely laterally and for-
available as palpation sites in the C3-C6 seg- ward or backward while rotating it toward the
ments, the divergent and convergent move- side to which it is inclined yields combined
ments are palpable only at the facet joints movements such as side bending, rotation, and
themselves. Both joints can be palpated simulta- forward bending to the left (i. e., divergence in
neously during forward and backward bending the right facet joint, Fig. 131 a,c) or sidebending,
(Fig.130). This technique can also be applied rotation, and backward bending to the right
therapeutically. (i. e., convergence in the right facet joint,
Examination ofthe Cervical Spine (C3-C5) 227

d e

Fig. 130 a-e. Technique for testing and therapy. a, d Forward bending. c, e Backward bending

Fig. 131 b, d). The little finger of the mobilizing For therapy, the lower vertebra of the segment
hand is positioned over the arch of the vertebra to be mobilized is again fixed with the
that is to be moved. The palpating finger of the thumb-forefinger yoke of the palpating hand.
other hand is placed on the joint facet immedi- Figure 131e illustrates rotation testing in the
ately below and palpates the movement of the terminal position.
228 Examination of the Cervical Spine (C3-C5)

Fig.131a-e. Combined movements. a,cDivergence, b,dconver-

gence. c,d Joint palpation illustrated on the model (which shows
decreased mobility of the atlas and of C3 and C6 in divergence).
e Rotation in the terminal position
Examination oftbe Cervical Spine (C5-TJ) 229

3.5 Mobility Testing of the C5-T3 occiput (Fig. 134 c,d). The free hand palpates the
Segments (Cervicothoracic Junction) joint facets. Generally, the spinous processes can
(Figs. 132-134) again be palpated beyond CS, although the
thumb and index finger of the palpating hand
Rotation (Fig. 133) can still palpate the joints on both sides and,
Rotation from C6 to T3 can be accomplished by when a motion fault is noted, differentiate the
active rotatory movements by the patient while sides by lateral flexion.
the spinous processes are simultaneously pal- See also BIIII Thoracic Spine, Sect.3.4, p. 186,
pated on both sides. and DIIII Cervical Spine in the Lateral Position,
Sect. 3.2, p. 204.
Backward and Forward Bending (Fig. 134a-d) Combined movements are tested by a combina-
As before, the patient's head is moved either by tion of sidebending and rotation in flexion or ex-
grasping the forehead with the forearm touching tension and are palpated at the articular surface,
the side of the head (Fig. 134a,b) or by "wrap- as in the higher segments.
ping" the arm around the head and holding the


Fig. 132 a, b. Gliding movements in the C6/C7 facet joints

a b c

Fig.133a-<. Active rotation at the cervicothoracic junction

230 Examination ofthe Cervical Spine (C5-T3)

Fig.134a-f. Motility testing at the cervicothoracic junction. a Backward bending,

b forward bending. c,d Same examination with a different hand placement (wrap-
around grip). e,fPalpation site and vertebral mobility (panel fshows hypomobili-
ty at C3/C4 and C617 during forward bending)
Examination ofthe Cervical Spine (C5-T3) 231

Vertebral Artery
NormaJ Findings
The following findings during the segmental ex-
Normal findings in the craniovertebral joints,
amination of the cervical spine suggest that the
see pp. 220-222.
vertebral artery may be endangered:
Ranges of motion at C2-C7 (see Fig. 10).
Backward and forward bending: increase in 1. Before reaching the end of an active range of
mobility from C2 to C5, marked decrease in movement, the patient experiences com-
mobiLity (rom C5 to T3. plaints or displays reflex resistance. This par-
Sidebending (with coupled rotation to the ticularly applies to examination of the cra-
same side): Moderate decrease in mobility niovertebral joints.
from C2 to C7, marked decrease in mobility 2. The passive movement pattern differs
from C7 toTI. markedly from that ordinarily associated with
a true restriction.
3. There are no signs of mechanical restriction,
Pathologic Findings (for Sects. 3.1-3.3) but clinical signs point to cervical spine in-
CO/Cl/C2 Segments
4. Reflex hypertonicity of the segmentally relat-
1. Unequal prominence: ed intrinsic muscles is either absent or atypical
- With tenderness of one transverse process in- in its location, intensity, and extent.
dicates vertebral displacement and possible 5. The segmental neurologic signs of restriction
restriction (function test!) (hyperesthesia and hyperalgia) are absent or
- Without tenderness or function impairment noncharacteristic.
indicates vertebral.asymmetry
Positive findings require further investigation
2. Sidebending: Decreased mobility usually af-
by the vertebral artery tests (de Kleyn's hanging
fects rotation to the opposite side as well.
test, Hautant's test, Unterberger's walking-in-
3. A suspected increase of mobility must be
place test).
checked by hypermobility testing in the
supine position.
4. On head rotation, the axis spine begins to fol-
low the movement after less than 20° rotation.
This indicates a restriction of CIon C2. 4 Tests of Joint Translation
C2-C7 Segments
4.1 Traction
1. The axis spine is not palpable in the median 4.2 Compression
plane with vertebral asymmetry, sidebending, 4.3 Tests of Facet Joint Gliding
or a rotary position fault.
2. Sidebending: The centered or asymmetrically
positioned axis spine does not rotate in the op- These tests are specific for disorders of the cervi-
posite direction from the start of the move- cal disks, facet joints, and nerve exits.
ment. The spine makes unequal excursions to
both sides. 4.1 Traction (Fig. 135 a)
3. There is painful limitation of sidebending in
Starting Position
one or more segments, and of coupled rota-
The examiner grasps the patient's head with
tion as well. Thus, with a restriction of facet
both hands, placing the thenar eminence over
joint convergence on one side, ipsilateral
the mastoid. The palm is placed loosely over the
rotation and backward bending are also re-
ear, the hypothenar below the zygoma.
232 Examination of the Cervical Spine

Slight sidebending and backward bending can be

used to differentiate the right and left facet joints.

Normal Findings
Compression and traction are tolerated with-
out pain.

Pathologic Findings
In patients with neck or arm complaints relating
to disk pathology, traction (always applied
first) alleviates pain while light, careful com-
pression may exacerbate pain, with associated
dermatomal projection, or it may aggravate der-
matomal pain (compression of the interverte-
bral foramen).
Exacerbation of pain by traction suggests a
spinal cord lesion (medulla oblongata impinge-
ment in the foramen magnum).

4.3 Tests of Facet Joint Gliding

Fig. 135. a Traction on the cervical spine. b Compres-
(Figs. 136-139)
sion of the cervical spine Principle of Examination
Isolated motion testing of a cervical segment by
immobilization of the lower vertebra and dis-
Procedure traction or gliding of the facet joints induced by
The examiner carefully extends the cervical backward or upward movements of the vertebra
spine on the longitudinal spinal axis by leaning above.
back with his own body. If there is a fault of
head posture, traction is first applied coaxial Starting Position
with the postural fault ("three-dimensional" The examiner stands beside the patient. With
traction), followed by the careful application of one hand he grasps the arch of the lower
traction in other directions, according to pain vertebra and immobilizes it at the level of the
tolerance. facet joint with the proximal phalanx of the
Cervical traction can also be applied segmental- thumb and index finger (thumb-forefinger
ly (see p.233, Fig. 136). yoke). The other hand reaches around and
grasps the next higher vertebra and, using
mainly the little finger and the ulnar edge of the
4.2 Compression (Fig. 135 b)
hand, immobilizes the inferior border of the
Starting Position vertebral arch, the wrist and forearm resting
Both hands are placed flat on the patient's hand, against the side of the patient's head. In accor-
the fingers of one hand slightly overlapping the dance with the orientation of the joint surfaces,
other. the examiner's elbow is placed level with the pa-
tient's forehead for translatory motion testing
Procedure of the upper cervical spine, and it is placed level
The examiner carefully presses downward with the cervicothoracic junction at the pa-
with both hands, directing the pressure along tient's chin or zygoma for testing the lower cer-
the longitudinal axis of the cervical spine. vical spine.
Examination ofthe Cervical Spine 233

Fig.136. Segmental traction (intervertebral disk) Fig.137. Segmental traction (facet joints)

Procedure - Downward, backward, and laterally with rota-

Longitudinal traction on the cervical spine tion to the same side, producing convergence
(Fig.l36) causes distraction of the intervertebral in the facet joint on the side to which the head
disk and superior gliding of the two upper facet is inclined (Fig.l38 b,c)
joints relative to the fixed lower joint surfaces.
This is particularly true in the lower cervical Normal Findings
spine, where there is less than 45° of forward
Equal, painless excur ion on both sides in the
inclination. In the upper cervical spine, the
individual motion segments.
test also produces some degree of facet joint
Backward pressure on the upper vertebra Pathologic Findings
(Fig.l37) relative to the adjacent lower vertebra Painful limitations of motion associated with
exerts a pure distracting force on the facet joints. vertebral restrictions, disk protrusions, or in-
The disk is subject to backward shearing. Poste- flammatory processes.
rior-to-anterior pressure on the atlas can test the Translational movements are increased when
strength of the ligament apparatus (transverse hypermobility is present.
and alar ligaments) in the C1fC2 segment (see
also examination of the cervical spine in the • Note
supine position, Sect. 4.5, p.252). Hypermobility in the ClIC2 segment contraindi-
Lateral pressure with no rotatory component cates therapeutic mobilization of the craniover-
causes a purely lateral gliding movement in the tebral joints.
facet joints. This is a very important test for hy-
permobility in the C1fC2 segment (see Figs.
158-161, pp.252, 253).
In combined movements (Fig. 138) the exam-
iner's cranial hand moves the head, and the test-
ed upper vertebra, as follows:
- Upward, forward, and laterally with rotation
to the same side, producing divergence on the
side away from the movement (Fig.l38 a,b)
234 Examination of the Cervical Spine

c Fig.138a-c. Seep.234

5 Muscle Tests: Resistance Tests Starting Position

of the Cervical Muscles (Synergists) Upright sitting posture.

This muscle group is also examined to some ex-
tent during testing of the shoulder girdle eleva- Forward Bending (Fig. 139)
tors (see p.291). From a position of slight ventral flexion, the pa-
tient bends the head in a forward arc toward the
Examination of the Cervical Spine 235

Fig.138a-e. Translation testing of the C2/C3 segment. a,b Divergent movement,

c convergent movement (here, in the examination of wryneck). d,e. Translatory di-
vergence and convergence in a patient with normal segmental mobility

sternum Uugular fossa) while the examiner ap- Sidebending (Fig. 142)
plies resistance at the forehead or zygomas with The patient bends the head to the side. The
both hands (Fig. 139): test for the superficial examiner applies resistance at the temple
neck flexors, i. e., the scaleni (C3-C8, cervical while placing the elbow on the patient's
plexus) and the sternocleidomastoid (Cz-C 3 , ac- acromion to steady the ipsilateral shoulder:
cessory nerve). test for upper trapezius, rectus capitis poste-
Forward nodding (Fig. 140): Resistance is ap- rior minor (C3-C4, accessory nerve), rectus
plied below the chin. capitis anterior, rectus capitis lateralis, and
Test for the deep neck flexors, i. e., longus capitis, scaleni (Cr C8 , cervical plexus) on the tested
longus colli, rectus capitis anterior, rectus capital side.
lateralis (C1-CS, cervical plexus).
Rotation (Fig. 143)
Backward Bending The patient turns the head to one side while
The patient bends the head backward while the bending it toward the opposite side (Fig. 143).
examiner applies occipital resistance with the The examiner applies resistance to rotation and
hand, his forearm placed between the scapulae sidebending: test for the sternocleidomastoid on
to steady the upper body: test for the upper one side, e. g., rotation to the left and sidebend-
trapezius (C3-C4, accessory nerve), levator ing to the right test the right sternocleidomas-
scapulae (CrCs, dorsal scapular nerve), erector toid muscle.
spinae (C1- T4).
Backward nodding (Fig. 141): Upward resis- Forward Head Movement
tance is applied below the occiput (occipital The patient moves the head straight forward in
squama): test for the deep neck extensors (dor- the sagittal plane with no flexion while the ex-
sal flexors), rectus capitis posterior major and aminer applies resistance to the forehead with
minor, obliquus capitis superior and inferior, both hands: test for both sternocleidomastoids
splenius capitis, semispinalis capitis. (Cz-C 3 , accessory nerve).
236 Examination of the Cervical Spine

Fig.139. Superficial ventral flexors Fig.141. Deep dorsal extensors

Fig.l40. Deep ventral flexors Fig.142. Lateral flexors

Examination ofthe Cervical Spine 237

Pathologic Findings

1. The deep neck flexors are prone to weakening.

This can be detected by sustained testing in
the supine position (see also E/Cervical
Spine/Sect. 5, p.255). The superficial flexors
(sternocleidomastoid and scalenus anterior)
often assume the function of the weakened
2. The neck extensors (trapezius, levator scapu-
lae, erector spinae), as tonic muscles, are
prone to shortening, which can lead to a high
shoulder position and muscular limitation of
forward bending and side bending when the Fig.l43. Sternocleidomastoid muscle
shoulder is fixed. (Test for levator scapulae
shortening in the supine position!)
3. Muscular torticollis (from unilateral stern-
ocleidomastoid contracture): The head is tilt-
ed to the same side and rotated to the opposite
Spastic torticollis ("rheumatic" torticollis): The
head is tilted and rotated to the side opposite the
restriction, i. e., the joint is in a convergent posi-
tion on the concave side and a divergent position
on the convex side. Function is restricted either
on the concave side for divergent movements or
on the convex side for convergent movements.
Examination of the Head (Temporomandibular Joints,
Sensory Organs) in the Sitting Position (BN)

1 Inspection
1.1 Facial Asymmetries
1.2 Mimetic Activity
1.3 Sensory Organs: Eyes

2 Jaw Movements and Swallowing

2.1 Opening and Closing ofthe Jaw
2.2 Protraction and Retraction of the Jaw
2.3 Lateral Jaw Movements
(Grinding Movements)
2.4 Swallowing

3 Palpation Field of the Face

3.1 Trigeminal Pressure Points
3.2 Corneal Reflex (First Division of
the Trigeminal Nerve)
3.3 Pressure on the Tragus
3.4 Palpation of the Temporomandibular
3.5 Percussion of the Frontal and Maxillary

4 Passive Testing of Temporomandi-

bnlar Joint Motion and Play

5 Muscle Tests
5.1 Mimetic Muscles
5.2 Masticatory Muscles
5.3 Lingual Muscles
5.4 Ocular Muscles
Inspection 239

1 Inspection Mydriasis
Abnormal bilateral pupillary dilation due to ex-
1.1 Facial Asymmetries citement, fear, pain, glaucoma.
1.2 Mimetic Activity Unilateral mydriasis accompanied by an in-
1.3 Sensory Organs: Eyes creased lid aperture and exophthalmos occurs
with sympathetic irritation ("inverse Horner").
This oculopupillary irritation syndrome may be
the initial stage of a true Horner's syndrome and
Almost all faces have an irregular shape. Asym-
has the same causes (Finke).
metry is the element which animates the face
and gives it character. The face reflects the inter-
Abnormal bilateral pupillary constriction oc-
curs with vascular sclerosis, neurosyphilis (ter-
1.1 Facial Asymmetries tiary syphilis), and drug use.
Congenital facial asymmetries frequently coex- Unilateral miosis combined with a decreased
ist with congenital deformities of the cervical lid aperture (ptosis, enophthalmos) occurs
spine and especially of the craniovertebral with sympathetic paralysis (Horner's syndro-
joints: "facial scoliosis" due to a congenital fault me).
of metameric segmentation (bony torticollis, Miosis results from root lesions at C8-T2, e. g., in
Klippel-Feil syndrome). radicular plexus paralysis, sympathetic trunk le-
Facial asymmetries can also occur with myo- sions (Pancoast's tumor, cervical ribs, struma),
genic torticollis (contracture of the sternocleido- carotid artery thrombosis (internal carotid
mastoid), an acquired form of wryneck that is artery), tumors or injUlies of the lower cervical
probably caused by obstetric trauma (sternoclei- and upper thoracic cord, and idiopathic causes
domastoid hematoma) and is common following (anomalies).
breech deliveries. They also result from paraly-
sis (facial palsy), marked by decreased promi- Anisocoria
nence of the nasolabial fold, sagging of the cor- (Unilateral pupillary dilation or constriction):
ners of the mouth, and lack of facial expression pupil enlarged in oculomotor paralysis, "inverse
on the affected side. Horner," amaurosis; constricted in sympathetic
paralysis (Horner'S syndrome), carotid occlu-
1.2 Mimetic Activity sion.

A decreased power of facial expression (hy- Ocular Position

pomimia) is seen in Parkinson's disease (loss of Asymmetric ocular position (dysconjugate
skin creases, masklike facies). gaze) due to oculomotor palsy.
Grossly exaggerated mimetic activity (compul- Function testing of the sensory organs.
sive laughing and crying) can occur with lesions
of the cerebral hemispheres.
Choreatic movements of the mimetic muscles
occur with lesions of the neostriatum.
Asymmetric mimetic activity is seen with facial

1.3 Sensory Organs: Eyes

Primary attention is given to the size (drugs?)
and shape ofthe pupils.
240 Palpation Field of the Face

2 Jaw Movements and SwaUowing 3 Palpation Field of the Face

2.1 Opening and Closing of the Jaw 3.1 Trigeminal Pressure Points
2.2 Protraction and Retraction of the Jaw 3.2 Corneal Reflex (First Division of
2.3 Lateral Jaw Movements the Trigeminal Nerve)
(Grinding Movements) 3.3 Pressure on the Tragus
2.4 Swallowing 3.4 Palpation of the Temporomandibular
2.1 Opening and Closing of the Jaw 3.5 Percussion of the Frontal and Maxillary
As the patient opens and closes the jaw, atten-
tion is given to any deviation of the mandible to
one side. With limitation of motion in one of the 3.1 Trigeminal Pressure Points
temporomandibular joints (TMJs), the jaw will
deviate toward the affected side. Above the eye (eyebrow): Supraorbital nerve
Jaw deviation is also observed in motor trigemi- Below the eye: Infraorbital nerve
nal paresis due to pterygoid dysfunction. The At the chin: Mental nerve
masseter reflex in these cases is diminished. Forcomparison, the area around the nerve exits is
With a TMJ lesion, jaw opening is impaired. also tested to exclude or confirm true nerve pres-
Bilateral flaccid paralysis of the third division of sure pain. Tenderness of the trigeminal nerve
the trigeminal nerve leads to sagging of the low- divisions to pressure can have various causes:
er jaw. With a unilateral lesion, masticatory pres- - Paranasal sinusitis
sure is decreased only on the affected side. - Diseases of the teeth and jaw
2.2 Protraction and Retraction ofthe Jaw - Meningeal irritation
- Increased intracranial pressure
Straight or angular protraction and retraction of - Less commonly, diseases of the trigeminal
the lower jaw require that joint function not be nerve itself (Finke).
2.3 Lateral Jaw Movements 3.2 Corneal (First Division
(Grinding Movements) of the Trigeminal Nerve)
With a restriction of one joint, movement to-
ward the opposite side is impaired. In patients Procedure
with trigeminal lesions, lateral jaw movements Touching the cornea with a wisp of cotton elicits
toward the healthy side are impaired due to an immediate bilateral blink response.
pterygoid dysfunction.
eNote Pathologic Findings
Active movements of the TMJ are a richer A diminished corneal reflex on one side, com-
source of diagnostic information than passive bined with normal lid closure (facial nerve), in-
movements because they demonstrate the qual- dicates a lesion of the first division of the trigem-
ity of muscular function. inalnerve.
2.4 Swallowing
Swallowing difficulties are experienced with Sensory function in the areas supplied by all
vagus nerve lesions. A globus sensation in the three trigeminal nerve divisions is tested with a
pharynx or esophagus, with no objective find- cotton wisp. Motor function (third division) is
ings, can also occur with cervical dysfunction evaluated by testing the masticatory muscles
(restriction of C2/C3/C4). Gaw clenching).
Passive Testing of Temporomandibular Joint Motion and Play 241

3.3 Pressure on the Tragus patient's neck and steadies the patient's head
against his own body. The border of the little fin-
Pressure on the tragus elicits pain in patients
ger is directly above the TMJ, parallel to the zy-
with TMJ disorders and inflammatory disorders
goma (as in Fig. 147).
of the ear canal. Differential diagnostic pressure
on the cartilaginous ear canal from behind is
painful only in the presence of auditory canal
Downward Movement (Fig. 144)
The other hand (wearing a sterile glove) grasps
3.4 Palpation the mandible between the thumb and index fin-
of the Temporomandibular Joints ger, placing the thumb inside the mouth on the
The examiner sits opposite the patient or stands molars and the index finger below the jaw on the
behind him and bimanually palpates both TMJs outside. With the hand thus positioned, the ex-
while the patient's mouth is open. aminer pulls downward on the lower jaw.
Tenderness of one TMJ to palpation indicates
joint irritation. This is usually accompanied by Forward Movement (Protraction) (Fig. 145)
pain during mastication. There may also be Forward traction can be applied with the same
spontaneous attacks of pain in front of the ear, in hand position by placing the index finger not be-
the temporal region, or affecting the whole side low the jaw but behind the ascending ramus of
of the head (Costen's syndrome). With the the mandible. This, combined with slight down-
mouth open and with the jaw tightly clenched, ward traction on the jaw, produces anterior glid-
the masseter muscle is palpated by pressing on ing in the TMJ. If the patient cannot open the
its insertion at the mandibular angle, and the mouth, the examiner simply grasps the jaw angle
temporalis muscle is palpated at the temporal externally between the thumb and forefinger
bone. and applies forward traction (Fig. 145).
Spontaneous pain, functional pain, and/or ten-
derness to palpation occur with degenerative Medial-Lateral Movement (Figs. 146, 147)
arthritis of the TMJ and especially with TMJ The examiner now stands behind the patient and
dysfunction due to occlusal disturbances: "myo- places the immobilizing hand on the side of the
fascial pain syndrome." patient's head, the edge of the hand directly
above the TMJ and parallel to the zygoma. The
3.5 Percussion of the Frontal other (mobilizing) hand cradles the chin with the
and Maxillary Sinuses thenar eminence directly below the opposite
TMJ and applies transverse, lateral-to-medial
Tenderness to percussion over the frontal and pressure. This moves the mandibular head adja-
maxillary sinus (zygoma) occurs with inflamma- cent to the mobilizing hand in a medial direction
tory disease (sinusitis). while the opposite mandibular head, below the
immobilizing hand, is moved laterally. Figure
147 shows the same test with a different hand
4 Passive Testing of placement.
Temporomandibular Joint Motion
and Play Normal Findings
Painless gliding of the mandible in all three
Downward, forward, medial, and lateral move-
ment of the head of the mandible.

Starting Position
The patient is seated. The examiner stands to
one side, places one arm around the back of the
242 Muscle Tests

Fig. 144. Downward traction on the head of the Fig. 145. Forward traction (protraction) on the head
mandible of the mandible

Fig.l46. Medial-lateral gliding Fig.147. Medial-lateral gliding (alternate hand place-


5 Muscle Tests - Knitting the brow (vertical crease over the

nasal root): corrugator glabellae
- Drawing the nostrils together: nasalis
5.1 Mimetic Muscles
- Whistling (puckering the lips): orbicularis
5.2 Masticatory Muscles
5.3 Lingual Muscles
- Laughing (raising the corner of the mouth):
5.4 Ocular Muscles
risorius, zygomaticus major
- Lowering the corner of the mouth: triangu-
5.1 Mimetic Muscles - Raising the corner of the mouth and nose:
caninus (levator anguli oris)
Function testing:
- Drawing the lower lip downward and lateral-
- Wrinkling the forehead: frontalis ly: quadratus labu mandibularis
- Shutting the eyes tightly: orbicularis oculi - Wrinkling the skin of the chin: mentalis
Muscle Tests 243

- Retracting the angle of the mouth (laugh- 5.4 Ocular Muscles

ing/crying): buccinator
During examination of the functional triad of
- Making a transverse crease between the eye-
nerves that supply the ocular muscles - the ocu-
brows: depressor glabellae
lomotor (third cranial), trochlear (fourth cra-
nial), and abducens (sixth cranial) - attention is
5.2 Masticatory Muscles
given to the following symptoms:
Function testing: Inspection:
Opening the mouth: digastricus, mylohyoideus, Ptosis, inferolateral eye position (pull from the
geniohyoideus. muscles of the fourth and sixth cranial nerves):
Closing the mouth: temporalis, masseter, ptery- ophthalmoplegia externa (oculomotor nerve).
goideus medialis. Large, nonreactive pupil, loss of accommoda-
Protracting the chin: temporalis, suprahyoid tion (functional loss ofthe intraocular muscles):
muscles. ophthalmoplegia interna (oculomotor nerve).
Lateral movements: ipsilateral temporalis, con- Function testing:
tralateral pterygoideus lateralis. Upward deviation of the eye during inferolateral
gaze: paresis of the trochlear nerve. Associated
5.3 Lingual Muscles diplopia. Compensatory inclination and rota-
tion of the head toward the opposite side.
All the muscles of the tongue are innervated by
Failure of lateral eye movement during gaze to
the hypoglossal nerve.
both sides: paresis of the abducens nerve. Severe
Function testing:
associated diplopia. Compensatory rotation of
Intraoral tongue position. With unilateral paral-
the head toward the opposite side.
ysis, there is deviation to the healthy side; with
atrophy, deviation to the affected side.
Extending the tongue. Unilateral paralysis and
atrophy cause deviation to the affected side.
Moving the tongue back andforth. With unilater-
al paralysis, movements toward the affected side
are slowed and of smaller amplitude.
Examination of the Cervical Spine
in the Supine Position (EN)

11 Inspection

2 Active and Passive Movements ofthe

Cervical Spine and Head in Three
Planes (Regional Diagnosis)
2.1 Forward Bending, Backward Bending,
Sidebending, and Rotation
2.2 Side-to-Side Head Movement
2.3 Provocative Test for the Vertebral
Artery (De Kleyn's Hanging Test)

3 Palpation ofthe Cervical Spine Dur-

ing Movement (Segmental Diagnosis)
3.1 Forward Bending
3.2 Backward Bending
3.3 Side bending
3.4 Rotation

4 Tests of Joint Translation

4.1 Three-Dimensional Traction on
All Cervical Segments
4.2 COIC1 Segment: Backward and Forward
Gliding of the Occipital Condyles on the
Atlas (Forward and Backward Nodding)
4.3 COIClIC2 Segment: Combined
Movements in the Craniovertebral
4.4 ClIC2 Segment: Atlas Traction
4.5 ClIC2 Segment: Lateral Gliding of the
Atlas on the Axis (Hypermobility Test)
4.6 C2-C7 Segments: Convergentl
Divergent Gliding in the Facet Joints

5 Muscle Tests - Resistance Testing of

the Cervical Muscles
Active and Passive Movements 245

1 Inspection

Findings are the same as in the sitting position.
Attention is given to any discrepancy of head
position between sitting and lying down. Faults
of head position due to anatomic variations in
the joints (e. g., different left and right facet in-
clinations in the same vertebra) or postural
guarding due to vertebral restrictions or disk
problems may lessen or even disappear in the re-
laxed, supine position.
See AlGeneralInspectioniSect. 3.1.5 (pp. 77,81).

2 Active and Passive Movements

of the Cervical Spine and Head
in Three Planes (Regional Diagnosis)

2.1 Forward Bending, Backward Bending,

Sidebending, and Rotation
2.2 Side-to-Side Head Movement Fig. 148a,b. Forward bending (a) and backward
2.3 Provocative Test for the Vertebral bending (b) of the cervical spine
Artery (De Kleyn's Hanging Test)

2.1 ForwardBending, BackwardBending, 1. Forward bending (Fig. 148a)

Sidebending, and Rotation (Figs. 148, 149) 2. Backward bending (Fig. 148 b)
3. Side bending (Fig. 149 a,b)
Starting Position 4. Rotation (Fig. 149c,d)
Relaxed supine position; the head position is not
adjusted or corrected.
For passive mobility testing, the supine patient Findings
slides upward until the head and cervical spine See B/Cervical Spine/Sect. 2 (p.214).
project past the upper end of the table. The ex-
aminer cradles the patient's head in both hands -Note
so that he can freely move it in flexion, exten- The same hand placement can be used for
sion, sidebending, and rotation. the segmental examination (see Figs. 151, 152,
The passive movements are supplemented by
2.2 Side-to-Side Head Movement
light traction on the longitudinal axis of the cervi-
(Fig. 150)
cal spine. This usually affords a slightly greater
range of movement than is obtained in the sitting Segmental lateral pressure:
position. The sides are compared and end-feel The passive motion test described below can al-
evaluated as in the seated examination. The low preliminary identification of the affected
sequence of the tests is as follows: segment.
246 Active and Passive Movements

Fig.149. a, b Sidebending, Cod rotation of the cervical spine

Starting Position site the movement, and the end-feel is assessed.

Same as above. The hands are placed so that the The test proceeds segmentally from above
radial sides of the index fingers are on the arches downward.
of the same vertebra.
Normal Findings
Painless, equal lateral gliding of the adjacent
The patient's head is moved as far as possible to
upper and lower vertebrae on both sides. The
one side, then to the other, parallel to the exam-
range of motion diminishes in the caudal
ination table (and shoulder girdle) without
sidebending. The index finger on the transverse End-feel: firm-elastic.
process slightly augments the lateral shift at the
end of the movement, causing sidebending (con-
vergence) of the palpated joint on the side oppo-
Active and Passive Movements 247

2.3 Provocative Test for the Vertebral

Artery (De Kleyn's Hanging Test)
De Kleyn's hanging test is a test for vertebral
artery insufficiency on the side toward which the
head is rotated, since blood flow on the side op-
posite the movement is normally occluded in the
terminal phase of rotation by stretching and
compression of the vessel.

Starting Position
The examiner initially supports the patient's
head, which projects past the end of the table,
and then lowers it into a freely hanging position.

The head is first placed in maximum dorsiflex-
ion, then rotated and held in that position for
about 20-30 s. The patient speak alouds (counts)
continuously during the test.

Normal Findings
The patient can tolerate the test for about
20-30 s with no adverse reaction or discom-

Pathologic Findings
- Apprehension
- Discontinuation of speech
- Nystagmus (horizontal or rotatory)
- Nausea and vertigo
- Facial paresthesias

Nausea, vertigo, and nystagmus occur

1. Immediately but then decrease in intensity:
Fig.150a-<. Side-to-side movement of the head vertebral restriction.
2. After 15-30 s and increase in intensity: verte-
bral arterial insufficiency.

Pathologic Findings • Note

Painfullirnitation of motion in one or more seg- The examiner should closely supervise the test
ments. due to its somewhat hazardous nature.
248 Palpation ofthe Cervical Spine During Movement

3 Palpation of the Cervical Spine facets. Slight traction applied in the cranial di-
rection will accentuate the movements.
During Movement
(Segmental Diagnosis)
3.2 Backward Bending (Fig. 152)
3.1 Forward Bending As in the forward bending test, both rows of
3.2 Backward Bending facet joints can be tested simultaneously.
3.3 Side bending
3.4 Rotation Starting Position
Same as before.

Segmental mobility testing of the cervical spine

The radial sides of the index fingers are placed
and craniovertebral joints (Figs. 151-154)
on the right and left articular facets of the same
The position is the same as for passive motion
segment. Then the neck is segmentally dorsi-
testing. The examiner supports and moves the
flexed, the fingers providing the fulcrum over
patient's head with his palms while using the fin-
gers for palpation. The vertex of the slightly an- which the head falls slightly backward under its
own weight. The examiner palpates the conver-
teflexed head rests against the examiner's body
gent movement of the facets in each segment.
without compressing the cervical spine.
The palpation sites (transverse process of the at-
las, posterior arch of the atlas, and articular 3.3 Sidebending (Fig. 153)
facets of C2 to C7) are the same as in the seated Starting Position
examination. During the segmental palpation of Same as before.
mobility, the range of motion in the individual
segments is usually greater and more easily as- Procedure
sessed in the supine position than in the sitting The head is sidebent by segments, the index fin-
position. gers palpating the convergent movement of the
It should be recalled that mobility can be opti- facets on the concave side and their divergent
mally palpated only if the head is moved such that movement on the convex side (Fig. 153 a). A
the axis of motion is always at the level of the pal- slight rotatory component to the same side dur-
pating finger. During palpation below the atlas, ing convergence and to the opposite side during
the palpating finger should always be placed be- divergence (Fig. 153 b) will make the gliding
hind the sternocleidomastoid. movements easier to palpate.
The movements associated with side bending are
more clearly appreciated if the head is simulta-
3.4 Rotation (Fig. 154)
neously rotated slightly toward the same side.
Starting Position
As before, except that the patient's head rests in
3.1 Forward Bending (Fig. 151)
one hand - the hand toward which the head and
Starting Position cervical spine are rotated (e. g., the right hand
Relaxed supine position. The patient's head pro- during rotation to the right).
jects past the upper end of the table, and the ex-
aminer supports it with both hands. Procedure
The head is slowly rotated with both hands, pro-
Procedure ducing a forward and upward segmental move-
Proceeding segmentally from above downward, ment of the facets on the side opposite the move-
the index fingers palpate the articular facets on ment (e. g., on the left side of the neck during
both sides, without applying pressure of their rotation to the right). The examiner palpates the
own, to assess the divergent movement of the divergence of the facets on the side away from
Palpation of the Cervical Spine During Movement 249

Fig.15I. Forward bending Fig.152. Backward bending

the rotation and their convergence on the side of

the rotation (as in Fig. 163).
The hand positions are switched for testing rota-
tion to the opposite side.

Normal Findings (for Sects. 3.1-3.4)

Soft, painless, unrestricted movement in all
directions (see Fig. 10).

Pathologic Findings (for Sects. 3.1-3.4)

During forward bending and rotation, the re-
stricted joint facet is palpable as a firm area that
is usually tender to palpation.

Fig.153a,b. Sidebending Fig.154. Rotation

250 Tests of Joint Translation

During sidebending and backward bending, the 4.2 COIC1 Segment: Backward and
hard-elastic end-feel is absent due to lack of Forward Gliding of the Occipital
facet convergence. Condyles on the Atlas (Forward and
The findings in these examinations may provide Backward Nodding) (Fig. 156)
an indication for proceeding with tests of joint
Starting Position
Relaxed supine position, the patient's head rest-
ing on the table. The thumb-forefinger yoke of
one hand grasps the posterior atlantal arch and
immobilizes it with forward pressure, the ulnar
4 Tests of Joint Translation
border of the hand resting on a small cushion.

4.1 Three-Dimensional Traction on Procedure

All Cervical Segments The other hand first pushes the skin downward,
4.2 CO/Cl Segment: Backward and Forward then grasps the occiput above the immobilizing
Gliding of the Occipital Condyles on the hand with the thumb-forefinger yoke and ap-
Atlas (Forward and Backward Nodding) plies upward and backward traction. With the
4.3 CO/Cl/C2 Segment: Combined atlas well fixed (by anterior pressure), this pro-
Movements in the Craniovertebral duces a small but palpable springing movement
Joints ("forward nodding") of the occiput on the atlas.
4.4 Cl/C2 Segment: Atlas Traction This movement can be accentuated by pressing
4.5 Cl/C2 Segment: Lateral Gliding of the gently downward on the patient's forehead with
Atlas on the Axis (Hypermobility Test) the shoulder. The rotational axis for the move-
4.6 C2-Cl Segments: Convergent/ ment is approximately in the lower third of the
Divergent Gliding in the Facet Joints cranium (Fig. 156 a).
"Backward nodding" of the occiput can be simi-
larly tested by approximating the occiput to the
stationary atlas (Fig. 156 b). The thumb yoke of
4.1 Three-Dimensional Traction the immobilizing hand fixes the atlantal trans-
on All Cervical Segments (Fig. 155) verse process by pressing backward from the an-
Starting Position terior side, while the occiput glides forward and
One hand supports the patient's occiput, the downward. This test is technically demanding
forefinger and thumb forming a yoke that cra- due to the difficulty of immobilizing the atlas
dles the head above the atlas. The other hand from the front, and often it cannot be successful-
grasps the chin. ly performed.

Procedure 4.3 COICl/C2 Segment: Combined

Both hands gently extend the cervical spine by Movements in the Craniovertebral Joints
pulling the head in the cranial direction (Fig. 157)
(Fig. 155 a). This is followed by: Starting Position
- Forward bending (Fig. 155 b) Relaxed supine. The patient's head is cradled in
- Backward bending (Fig. 155 c) both hands, the vertex resting lightly on the ex-
- Side bending (Fig. 155 d) aminer's abdomen to place the lower cervical
- Rotation (Fig. 155 e) spine in moderate flexion (ligament fixation).
The craniovertebral joints are slightly extended.
The examiner notes the directions in which pain
is relieved and/or mobility is increased. Procedure
The head is side bent at the craniovertebraljoints,
accompanied by slight rotation to the opposite
Tests of Joint Translation (CO/Cl) 251

_ _ _ _..... e

Fig.l55a-e. Three-dimensional traction on the cervi-

cal spine. a Axial, b forward, c backward, d lateral,

Fig.l56 a, b. COICl segment: backward gliding (a), forward gliding of the occipital condyles (b)
252 Tests of Joint Translation (CVC2)

Starting Position
The immobilizing hand supports the patient's
head, the radial side of the index finger fixing the
atlantal arch from the side at the spinous process
and posterior arch. The index finger of the other
hand is on the posterior atlantal arch of the op-
posite side.

One hand immobilizes the atlas on one side or
the axis on the opposite side as described above,
while the other hand pushes from posterolater-
ally to anteromedially against the immobilizing
hand, in alternating fashion, to test the ease of
Fig. IS7. Combined motion in the craniovertebral lateral displacement (ligament weakness) of the
joints (CO/ClIC2) atlas or axis.
The following tests are performed:
- With the axis immobilized on the left, the atlas
side. The palpating finger is between the atlantal is pushed to the left (Fig. 158).
transverse process and the mastoid for palpation - With the axis immobilized on the right, the at-
of the COIC1 segment, and between the vertebral las is pushed to the right (Fig. 159).
arches for palpation of the ClIC2 segment (see
Fig.128c, p.224). The examiner palpates the
springiness in the segment at the limit of motion.

4.4 ClIC2 Segment: Atlas Traction

Starting Position
Supine, as before. The hands are placed as in

As in the examination ofthe ClIC2 segment, the
immobilizing hand grasps the posterior atlantal
arch as described, and the mobilizing hand is
placed on the atlantal arch and occiput. Traction
is exerted on the joints of the ClIC2 segment,
producing an upward gliding of the atlas in the
anterior atlantoaxial joint. The examiner pal-
pates the tension buildup in the segment and the
springiness at the motion limit.

4.5 ClIC2 Segment: Lateral Gliding

of the Atlas on the Axis
(Hypermobility Test) (Figs. 158-161)
Since lateral gliding does not occur in the ClIC2
segment, this is the most important test of joint
play in the cervical spine as it can reveal hyper-
mobility in the ClIC2 segment (ligamentous in- Fig.IS8a,b. Hypermobility test at ClIC2: The atlas is
stability). pushed to the left
Tests of Joint Translation (CllC2) 253

Fig. 159 a, b. The atlas is pushed to the right Fig. 161 a, b. The axis is pushed to the left

- Or: With the atlas immobilized on the right,

the axis is pushed to the right (Fig. 160).
- With the atlas immobilized on the left, the axis
is pushed to the left (Fig. 161).

Normal Findings
Springy resistance but no lateral displace-

Pathologic Findings
Marked lateral displacement indicates hyper-
mobility (ligamentous weakness) in the Cl/C2
segment. Hypermobility is severe if the tested
vertebra can be displaced even when the head
is slightly inclined away from the direction
in which the vertebra is pushed (Figs. 158-161).

Fig. 160 a, b. The axis is pushed to the right

254 Tests of Joint Translation (C2-C7)

4.6 C2-C7 Segments: Convergent/ Procedure

Divergent Gliding in the Facet Joints The hand on the upper vertebra moves down-
(Figs. 162, 163) ward, backward, and laterally (toward the test-
ed joint) to test convergence (Fig. 163a) or up-
Starting Position ward, forward, and medially (away from the
Same as in Sect.4.2, i. e., one hand immobilizes tested joint) to test divergence (Fig. 163 b).
the arch of the lower vertebra with the yoke of The examiner's ipsilateral shoulder touches
the thumb and index finger. The volar side ofthe the patient's forehead and assists in the ma-
index finger of the other (mobilizing) hand is neuver (not shown in the photo). Convergence
placed around the upper vertebra (Fig. 162). is always tested first, because it is more fre-

Fig.162. Testing convergence/divergence at C2/C3

Fig. 163a,b. Testing convergence/divergence at C2/C3 on a skeletal

Muscle Tests - Resistance Testing ofthe Cervical Muscles 255

quently impaired and more diagnostically re-

The test is performed on both sides, proceeding
from above downward by segments.

Normal Findings
Equal mobility in the segments on both sides,
with motion decreasing in the more caudal
segments (see Fig. to).

Pathologic Findings
Decreased or increased mobility in one or more
segments. Pain is felt during the gliding move-
ments and especially during convergence.

5 Muscle Tests - Resistance

Testing of the Cervical Muscles

The technique of the principal muscle tests was c

described previously in the section on cervical
spine examination in the sitting position (see Fig. 164a-i:. Superficial neck flexors (a), deep neck
B/Cervical Spine/Sect. 5, p. 233). flexors (b), deep neck extensors (c)

Starting Position
Relaxed supine position. In patients with weak Normal Findings
abdominal muscles and in children, the thorax Cervical flexor muscle strength is normal if
must be immobilized. The shoulders should not the patient can actively hold the head in the
lift up from the examination table. flexed position for about 30 s without tremor.

Forward Nodding (Fig. 164 b)
Forward Bending One hand supports the patient's head while the
other applies resistance below the chin. The pa-
1. The examiner applies resistance to the chin
tient tries to nod the head forward against the re-
and forehead while the patient tries to raise
sistance: test for the deep flexors of the neck.
the head vertically from the table: test for the
Backward Nodding (Fig. 164 c)
2. The examiner applies resistance only to the
Resistance is applied at the occiput.
forehead while the patient tries to flex the
head forward and appose the chin to the jugu-
lar fossa: test for the superficial cervical flex-
The head is maximally rotated on the examina-
ors (scaleni, longus capitis, longus colli).
tion table. Resistance is applied to the uppermost
Alternatively, the patient can actively bend the side of the forehead with the flat hand while the
head forward slightly and attempt to hold it in patient tries to sidebend against the resistance:
that position (Fig. 164a). test for the cervical flexors on the concave side.
Examination of the Upper Extremities
in the Sitting Position (B/IV) Shoulder Joint

1 Inspection
1.1 Shoulder Position
1.2 Shoulder Contours

2 Active and Passive Movements ofthe

Shoulder Joint
2.1 General Active Tests
2.2 Frontal Plane: Abduction/Adduction
and Rotation of the Arms
2.3 Sagittal Plane: Raising the Arms
Forward and Behind

I 3 Palpation Field of the Shoulder

4 Tests of Joint Translation
(Humeral Head)

5 Resistance Testing of the Shoulder

5.1 Synergists (2 x 4)
5.2 DifferentiatingTests (3 x 5)
Inspection 257

1 Inspection Levator scapulae spasm due to irritation of the

dorsal scapular nerve in the scalenus medius.
1.1 Shoulder Position
Winged Scapula
1.2 Shoulder Contours
Markedly raised medial margin and inferior an-
gle ("angel wing") due to:
- Paresis of the serratus lateralis (secondary to
1.1 Shoulder Position long thoracic nerve lesion) following unilater-
al blunt trauma (carrying sacks) or strenuous
Normal Findings physical labor
The arms (at rest) hang paralJel to the trunk, - Contracture of the pectoralis major and minor
the shoulder are at equal levels, and there is - Weakened scapular adductors: trapezius
equal shoulder roundnes on both side. (transverse part) and rhomboids
- "Poor posture" (covers both points above)
- The clavicles are approximately in the - Exostoses ofthe scapula or chest wall (scapu-
transverse plane and form about a 600 angle lar crepitation)
to the median plane. - Occasionally in C6 syndrome
- The scapulae are at the same level, the su-
perior angle approximately level with the Scapular Rotation
second rib, the inferior angle level with the Externally rotated position (inferior angle shift-
7th rib. The medial margin is parallel to the ed laterally) with paresis of the rhomboids
vertebral column and is about 5 cm from and/or levator scapula. Occurs bilaterally in
the vertebral spinous processes on both myopathy.
sides. The medial margin and inferior pole Internally rotated position (inferior angle shift-
are u ually slightly elevated from the tho- ed medially) with paresis of the trapezius (de-
rax. scending part) due, say, to an accessory nerve le-
- The vertebral column shows no significant sion and/or serratus anterior paresis.
- The head is upright, i.e., "on the plumb Abduction Deformity
line." Swelling (inflammation) in the axilla.
Dislocation of the shoulder:
- Axillary dislocation (downward dislocation of
Pathologic Findings the humeral head into the axilla)
High Shoulder Position - Subcoracoid dislocation (forward beneath the
Hypertonicity of the trapezius (Bettmann's coracoid process)
shoulder-crest syndrome) to relieve tension and - Subarcomial dislocation (backward beneath
protect the shoulder joint (shortening of the the acromion)
trapezius and levator scapulae). - Infraspinous dislocation (backward beneath
Thoracic scoliosis. Bulging of the ribs on the the scapula)
convex side of the scoliosis.
Sprengel's deformity (rare): unilateral elevation All dislocations are associated with correspond-
of the scapula with winging (q. v.) and a supero- ing changes in the shoulder contours.
lateral to inferomedial course of the medial
scapular border due to shortening of the levator
scapulae. The size of the scapula is usually re-
duced, limiting elevation of the arm.
Paresis of the shoulder-girdle depressors (serra-
tus lateralis, trapezius inferior, subclavius).
258 Active and Passive Movements of the Shoulder Joint

1.2 Shoulder Contours 2 Active and Passive Movements

Pathologic Findings of the Shoulder Joint

Thickening of the Contours 2.1 General Active Tests

- Traumatic effusions (hematomas) 2.2 Frontal Plane: Abduction/Adduction
- Subacromial dislocation of the shoulder joint and Rotation of the Arms
- Joint inflammations 2.3 Sagittal Plane: Raising the Arms
- Tumors Forward and Behind

Flattening of the Contours

(Loss ofRoundness) The following criteria are evaluated during mo-
tion testing:
- Angular shoulder; deltoid atrophy due to axil-
lary nerve paresis - Range of motion
- Slight flattening (disuse atrophy) due to pro- - End-feel
longed immobilization of the joint (Desault - Pain
bandage, abduction splint) - Evasive movements
- Coordination (arm-scapula)
Starting Position
- Stepoff in the clavicle or acromioclavicular
Upright sitting posture. The examiner stands be-
joint: fracture or dislocation of the clavicle
hind the patient. During passive motion testing,
(acromioclavicular separation)
which follows the corresponding active tests, the
- Depression below the acromion: "empty
scapula on the tested side is immobilized and the
glenoid" following shoulder dislocation (axil-
elbow is extended. This starting position is used
lary); protrusion below the coracoid or next to
for practically all examinations.
the scapula: coracoid or infraspinous disloca-
- Prominence of the medial margin and inferior 2.1 General Active Tests (Fig. 165)
angle with winging of the scapula
- Prominence of the scapular spine with Starting Position
supraspinatus and/or infraspinatus atrophy Arms in the neutral position.
- Deepening of the supraspinous fossa (com-
pared with the opposite side) in "humero- Procedure
scapular periarthritis" (Duplay's disease) or The patient alternately crosses the hands behind
supraspinatus tendon rupture the back. The upper arm is flexed, adducted, and
- Deepening of the supra- and infraclavicular externally rotated while the lower arm is hyper-
fossae due to anterior prominence of the clav- extended, adducted, and internally rotated.
icles in individuals with "poor posture"
- Flattening of the supra- and infraclavicular Normal Findings
fossae due to inflammatory or neoplastic dis- The patient can touch the fingertips of both
ease (e. g., lymph nodes in gastric carcinoma hands together.
Pathologic Findings
Limitation of motion. The patient cannot touch
the fingertips together.
Hypermobility. The patient can place all or part
of one hand over the other.
Active and Passive Movements of the Shoulder Joint 259

2.2 Frontal Plane: Abduction/Adduction current dislocation). The movement is limited

and Rotation of the Arms (Figs. 166-169) by the joint capsule, coracohumeral ligament,
and internal rotators.
Starting Position I
Arms extended in neutral position. Forearm in Test 3: Internal Rotation (Fig. 167 b)
semipronation, hand parallel to the body. Performed as in the previous test. Examiner in-
ternally rotates the joint to its passive limit, de-
fined by the joint capsule and external rotators.
Test 1: Abduction Starting Position m
The arm is abducted to the vertical position Arm in the neutral position, elbow and forearm
(Fig. 166a). The examiner continues the abduc- as before (90° flexion, semipronation).
tion to its passive limit (frontal plane, Fig. 166 b)
and then flexes to the passive limit (sagittal Procedure
plane, Fig. 166c) while immobilizing the scapu-
la. The movement is limited by the adductors Test 4: External Rotation (Fig. 168 a)
and by the inferior and posterior portions of the The examiner externally rotates the patient's
capsule. upper arm, held at the side of the body, to its pas-
sive limit.
Starting Position II
Arm abducted 90°, elbow flexed 90°, forearm in Normal Findings
semipronation. Movements are painless and coordinated,
with equal ranges of motion on both sides and
Procedure no eva ive movements.
End-feel: firm-e la tic.
Test 2: External Rotation (Fig. 167 a)
The examiner holds the patient's upper arm in
the abducted position while externally rotating
the shoulder joint to its passive limit (test for re-
260 Active and Passive Movements of the Shoulder Joint

Fig.166a--c. Abduction.
a Active, b passive,
c passive flexion
a b c

Fig.167a,b. Rotation in
90° abduction. aExter-
nal rotation, binternal
a b

Pathologic Findings (pain from 70° to 100° abduction, improved or

relieved by externally rotating the arm or raising
Test 1: Abduction it past 100°) is usually caused by rotator cuff
Limitation may be caused by the shoulder joint pathology at the greater tuberosity or by sub-
(stage 2 capsular pattern of Cyriax) or by de- acromial bursitis. The pain is caused by acromial
creased motion in the sternoclavicular or impingement against the irritated tissue. Painful
acromioclavicular joint. Continuation of abduc- arc past 100° is usually due to a functional distur-
tion and flexion to their passive limit tests stabil- bance of the clavicular joints.
ity, with increased motion signifying hypermo- Limited motion can also result from trapezius
bility of the joint. The "painful arc" of Cyriax palsy (accessory nerve) or amyotrophic lateral
Active and Passive Movements of the Shoulder Joint 261

Fig. 168 a, b. Rotation

in the neutral position.
a External rotation,
b internal rotation
a b

Fig.169a,b. Adduction
a b

sclerosis (early symptom). With tears of the ro- Test 3: Internal Rotation
tator cuff, the arm cannot be held in abduction Often the last direction of motion restriction fol-
(arm drop test). lowing the improvement of shoulder stiffness.
Limitation of motion occurs with subcoracoid or
Test 2: External Rotation subscapular bursitis.
First direction of motion restriction with de-
generative or inflammatory joint disease (stage Tests 4 and 5: Rotation
1 capsular pattern of Cyriax). Limited mo- Same as tests 2 and 3.
tion also occurs with rotator cuff tears and bur-
262 Active and Passive Movements ofthe Shoulder Joint

Test 6: Adduction Normal Findings

Adduction is always markedly increased in pa- Painless, coordinated movements with equal
tients with general and local hypermobility. In
ranges on both ides. 0 evasive movements.
this case the forearm or elbow can be placed on End-feel: firm -elastic.
the opposite shoulder. There is associated hy-
perextensibility in other joints (cubitus valgus,
hyperextensible hand, finger, and knee joints).
Pathologic Findings

• Note Test 1: Flexion

Unlike Cyriax, Sachse believes that limitation of Limited with paresis of the external rotators of
abduction occurs earlier in the capsular pattern the scapula.
than limitation of external rotation.
Test 2: Hyperextension
2.3 Sagittal Plane: Raising the Arms Pain during this test may result from lesions of
Forward and Behind (Fig. 170) the long biceps tendon in the intertubercular
Starting Position Active movements of the shoulder joint are limit-
ed by arthrogenic lesions and by myogenic and
Arms in the neutral position. neurogenic lesions of the shoulder muscles such
as rheumatoid polymyalgia, dermatomyositis,
Procedure polymyositis, menopausal myopathy, and neu-
Test 1: Flexion rologic disorders (plexus lesions, pareses of pe-
The arm is raised forward to the vertical posi- ripheral nerves).
tion. Examiner continues the flexion to its pas- Passive movements are often limited (usually
sive limit (see Sect. 2.2., test 1, Fig. 166c). concentrically) after injuries and operations
(mastectomy), by capsular lesions (peri-
Test 2: Extension (Backward/rom 0°) arthropathy, frozen shoulder), reflexly (after
(Fig. 170 a) Examiner continues the extension myocardial infarction), and by inflammatory
to its passive limit while immobilizing the joint disease (synovitis, arthritis).

Fig. 170. a Extension

(from 0°), b internal ro-
tation in extension
a b
Palpation Field of the Shoulder 263

3 Palpation Field of the Shoulder tween the lesser and greater tuberosities. Patho-
logic changes in the tendon or groove can be
palpated when the externally rotated upper arm
The bony and muscular attachments between is passively moved in an anterolateral to pos-
the humerus and scapula are examined. The five teromedial direction, as this movement causes
palpation sites (Fig. 171 ) on the humeral head extensive biceps tendon gliding within the
and shaft are as follows: groove.
1. Lesser tuberosity
3) Greater Tuberosity (Fig. 175)
2. Bicipital groove
The anterior part of the approximately 2-cm-
3. Greater tuberosity
wide greater tuberosity (the supraspinatus in-
4. Humeral fornix
sertion) is palpable anteriorly, directly below the
5. Deltoid tuberosity
acromion, when the arm is maximally internally
These sites mark the attachments or gliding sur- rotated and extended (anterior point of the
faces of the muscles that connect the humerus to shoulder; Fig. 175 a). The posterior part (inser-
the scapula. Each side is palpated and compared tion of the infraspinatus and teres minor) is pal-
with the opposite side. If muscle attachments are pated below the posterolateral border of the
painful or tender, palpation can be followed im- acromion (posterior point of the shoulder;
mediately by resistance testing of the affected Fig. 175 b) when the patient's arm is maximally
muscle (see B/ShoulderlSect. 5, p. 269). adducted and externally rotated, bringing the
posterior part of the greater tuberosity beneath
1) Lesser Tuberosity (Fig. 173) the lateral (and posterior) border of the
The first palpation site is located most easily by acromion.
standing behind the seated patient and immobi-
lizing the shoulder with one hand while placing 4) Humeral Fornix (Subacromial Space)
the palpating finger on the front of the shoulder (Fig. 176)
(Fig. 172). With the patient's arm abducted With the upper arm abducted approximately
about 70° and the elbow flexed 90°, the exam- 60°, this space is palpable as a groove directly
iner rotates the upper arm approximately 20° in- below the lateral border of the acromion. The
ternally (Fig. 172 a) and externally (Fig. 172b). subacromial bursa and the supraspinatus ten-
The lesser tuberosity is palpable with the index don below it are accessible to palpation in this
finger of the immobilizing hand as a small, ante- area.
rior, subacromial bony prominence that moves
laterally or medially with the rotary movements 5) Deltoid Tuberosity (Fig. 177)
of the arm. Just medial to the lesser tuberosity is Palpable at the visible inferior end of the deltoid
a second prominence of equal size, the coracoid muscle. Below the muscle is the subdeltoid bursa.
process, which remains stationary during arm
Normal Findings
The lesser tuberosity (Fig. 173) (and the crest of
All the above site are nontender when pal-
the lesser tuberosity below it) is the site of inser-
pated at re t and during arm movements.
tion ofthe internal rotators: subscapularis, latis-
There are no palpable areas of increased firm-
simus dorsi, teres major. The fourth internal ro-
tator, the pectoralis major, inserts somewhat
more laterally and inferiorly on the crest of the
greater tuberosity. Pathologic Findings
Insertion tendinopathies are marked by tender-
2) Bicipital Groove (Fig. 174) ness on palpation of the tendon insertions
The bicipital groove is palpable just lateral to the during passive stretch or active contraction from
lesser tuberosity as a conspicuous groove be- a position of maximum stretch. Crepitation
264 Palpation Field of the Shoulder

..::..:..--_~~_-- Brachial plexus

- ---!!I.,------- Subclavian artery

.-- - ' T - - - + - - - - - - Humeral fornix
0 -+---:-----:--. ---~---1---CD Lesser tuberosity
® Bicipital groove
(long biceps tendon)


Scalene interval

Brachial plexus

Subclavian artery

Hu meral fornix - -i'---T'----'C--'------:-'>---. CD
" ---'t-+...,...-,:...-- + - - - Lesser tuberosity

Bicipital groove
(long biceps tendon)

Greater tuberosity

® Deltoid
5 tuberosity --t'--:--:-'!lII-:--'--i:'---=-4•. 1

Fig.I71a,b. Palpation field of the shoulder (palpation sites on the humeral head and shaft) (after Lanz-
Palpation Field ofthe Shoulder 265

Fig.l72. a, b Differentiation ofthe greater tuberosity, bicipital groove, lesser tuberosity, and coracoid process by
rotation of the upper arm. cDifferentiation of the palpation sites on the rotator cuff

at site 2 (bicipital groove) during passive arm

motion signifies a lesion of the long biceps ten-

• Note
Sometimes it may be necessary to palpate the
axilla (lymph nodes, axillary artery), as in post-
mastectomy patients.

Fig.l73. Test 1: lesser tuberosity (insertion of the sub-