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PT General Examination Procedure: Special Tests-Musculoskeletal Injuries -Observe the patient as they are moving around in the clinic: gives you a general idea of the patient's mobility.-Subjective History: most of the information important that will guide your examination/evaluation will come from here!-Observe the patient's posture: are they slouched, favoring one side, etc.-AROM: stresses both the contractile and non-contractile tissues.-PROM/end-range feel: tests the opposite direction's tissues and limitations to the patient's end-range.-Resistance Testing: determines the strength of the patient and puts alternate stresses on the contractile and non-contractile tissues.-Neuro Assessment: test the myotomes, dermatomes, reflexes, and nerve distributions.-Palpation/Accessory Motion: spend a lot of time palpating ligaments, joints, muscle attachments, joint motion, etc.-Special Tests: let the patient's subjective history and results of the rest of your exam guide which special tests you choose from due to how many there are.ShoulderDrop Arm SignPurpose of Test: To test for the presence of a full-thickness rotator cuff tear.Test Position: Sitting or standingPerforming the Test: The patient is told to actively elevate the arm in the scapular plane, followed by slowly reversing the motion. The test is positive if the arm drops suddenly or the patient experiences pain.Diagnostic Accuracy: Sensitivity: 7.8; Specificity: 97.2; +LR: 2.79; -LR: .95?Importance of Test: Elevating your arm in the scapular plane is a natural movement of the shoulder that places the proximal and distal attachments of the supraspinatus muscle along a straight line. If there is injury to the supraspinatus muscle, the glenohumeral stabilizers will not be able to support the arm and it will either drop suddenly or the patient will have complaints of pain.?Similar to the hawkins-kennedy test for impingement, it is again important to cluster this test’s results with other tests and measures when assessing for rotator cuff tears. The cluster for a full thickness rotator cuff tear includes 1. the Drop-arm sign, 2. the painful arc sign, and 3. infraspinatus manual muscle test.?If all three tests are positive, the +LR is?15.6. ?(Note is 3/3 are positive and the patient is greater than 60 years old the +LR increases to 28)If all three tests are negative the -LR is .16If ? tests are positive the +LR is 3.6Note: Two of the three tests for this cluster are the same as the impingement syndrome cluster. The differentiating factor between impingement and rotator cuff tear is the drop arm sign for full thickness rotator cuff tears and hawkins-kennedy for subacromial impingement.Note: these tests should only be used by properly trained health care practitioners. ElbowPush-up Sign/Active ApprehensionPurpose: To determine the presence of a lateral collateral ligament insufficiency of the elbow.Test Position: Prone.Performing the Test: The patient begins in the pushup position with the arms abducted to greater than shoulder width.? Have the patient extend their elbows.? A positive test is if there is apprehension with terminal extension of the involved elbow. Diagnostic Accuracy: Unknown.Importance of Test: According to Neumann, the lateral collateral ligament complex of the elbow involves the radial collateral ligament and the lateral (ulnar) collateral ligament. Both parts have a common attachment to the lateral epicondyle. The RCL blends with the annular ligament, while the lateral (ulnar) collateral ligament attaches to the supinator crest of the ulna. They help resist varus forces and also provide posterolateral stability. With posterolateral instability, apprehension is felt with external rotation of the forearm due to increased risk of subluxation of the humeroulnar and humeroradial joints.Note: these tests should only be used by properly trained health care practitioners? ??HipHop TestPurpose: To assess for a fracture in the LE.Test Position: Standing.Performing the Test: Have the patient hop up and down on the affected limb several times barefoot. A large amount of pain in a localized area of the lower extremity is a positive test and may signify a fracture.Diagnostic Accuracy: Unknown.Importance of Test: Our bones are covered by a layer of tissue known as the periosteum. It is highly innervated and very sensitive to injury. When a bone is fractured, the periosteum is more easily stimulated and thus pain is experienced. By hopping on one leg, a large vibratory/compression force is sent through the limb that stimulates the injured site. It should be noted that the hop test can produce pain in non-musuloskeletal ailments as well, such as psoas abscess, appendicitis, etc. It is important to utilize your subjective history, tests and measures, and general systems screenings to triangulate your findings.Note: these tests should only be used by properly trained health care practitioners.KneeLachman TestPurpose:?To assess the integrity of the ACL.Test Position:?Supine.Performing the Test:?The patient should be relaxed for this test, especially the tested extremity. The examiner places the tested leg into about 20 degrees of flexion, by placing the examiner's knee under the patient's thigh. Use one hand to stabilize the distal femur near the joint line on the anterior side, while palpating the joint line. Place the thumb of the other hand on the anterior side of the tibia and the fingers grasping the posterior side of the tibia near the joint line. Apply quick posterior-to-anteriorly directed forces through the tibia. There should be a firm end-feel. A positive test is excessive movement or the lack of a firm end-feel.?An alternate method involves holding the femur and tibia without the examiner's knee under the patient's thigh. It is important that the correct joint angle is used for this test, because a position closer to full extension, naturally has less anterior translation of the tibia and can result in a false end-point ("Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis").Diagnostic Accuracy:?Acute: Sensitivity: .94, Specificity: .97, +LR: 9.4, -LR: .1; Chronic: Sensitivity: .95, Specificity: .9, +LR: 7.1, -LR: .4 ("Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis").Importance of Test:?The anterior cruciate ligament stabilizes against anterior translation of the tibia on the femur, due to the attachment at the anterior tibial plateau and posteriorly on the medial side of the lateral femoral condyle (Neumann 534).?The force applied by the examiner stresses the ligament, and is a better test for assessing the integrity of the ACL in acute injuries compared to the Anterior Drawer Test for various reasons. The position of 20 degrees of knee flexion is a less painful position than the 90 degrees required for the Anterior Drawer Test; thus, there is a lower chance of protective spasms from the hamstrings. Also, in 20 degrees of flexion, the ACL is more maximally stressed and can be assessed more accurately, because other tissues due not limit anterior translation of the tibia ("Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis"). It should be noted that patients with a torn PCL may test positive with a Lachman test. In the starting position of the Lachman test, the tibia will rest further posterior than usual due to the absence of the PCL, leading to increased excursion during the test (Manske, 2006). This means PCL integrity should be assessed prior to looking at ACL integrity. Often with ACL injuries, other tissues and structures can be injured as well. One of the more significant findings recently has been bone contusions with ACL injuries. Look for research on the topic coming out soon!Note: these tests should only be used by properly trained health care practitioners.AnkleAnterior Drawer TestPurpose:?To test for ligamentous laxity or instability in the ankle. This test primarily assesses the strength of the Anterior Talofibular Ligament.?Test Position:?Supine or Sitting.Performing the Test:?The examiner stabilizes the anterior distal leg with one hand & grasps the patient's calcaneus and rear foot with their second hand. The examiner then places the patient's foot into 10-15 degrees of plantar flexion and translates the rear foot anteriorly. A?positive?test results if the talus translates forward. Positive test results are often graded on a "0 to 3 ?scale", with 0 indicating no laxity & 3 indicating gross laxity.?Diagnostic Accuracy:?Sensitivity: .71; Specificity: .33; +LR: 1.06, -LR: .88Importance of Test:?The anterior drawer test is a beneficial test to perform in a patient following an inversion ankle sprain (injury to the lateral collateral ligaments).?The 3 main components of the Lateral Collateral Ligaments of the ankle include the anterior talofibular ligament (ATFL), calcaneofibular ligament, and posterior talofibular ligament. The ATFL courses from the anterior aspect of the lateral malleolus to the anterior medial aspect of the neck of the talus. The function of the ATFL is to resist anterior translation of the ankle and prevent internal rotation of the talus on the tibia. Based off the anatomical orientation, placing the ankle into 10-15 degrees of plantar flexion puts a stress on the ligament, which is enhanced when a posterior to anterior translation is applied. Because there is a subjective grading scale (0-3) for laxity, it is important for the novice clinician to critically assess the motion and patient's response during the test.Note: these tests should only be used by properly trained health care practitioners. ................
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