The Clinical Special Tests provides High Yield information that is needed for the USMLE Step 1,2,3, COMLEX Level 1, 2, and 3, Medical School, Residency, and as a practicing Physician.
Table Of Contents
Clinical Special Tests
Neurologic
Anterior spinothalamic tract
- have the patient close their eyes and you squeeze their gastrocnemius or biceps brachii (crude touch).
- the patient unable to feel this indicates damage to the anterior spinothalamic tract
Cerebral cortex
Lateral spinothalamic tract
- place tube of hot or cold water in the patient’s hands and ask them to tell which is which. inabilty to discern indicates damage to the lateral spinothalamic tract
- a patient inability to tell that you are touching them with a sharp object (pain) indicates damage to the lateral spinothalamic tract
Posterior columns
- a patient unable to feel light touch indicates damage to the posterior columns
- test for proprioception by grabbing the patients big toe, and have them tell you whether it is up, down or in the middle. inabiltiy indicates damage to the posterior columns
- ask the patient to close their eyes and use a tuning fork to cause vibration on a bony prominence distally on the arm or leg. if no vibration is felt, this indicates damage to the posterior columns
Vision
Corneal light reflex
Cover uncover test
- Ask the patient to focus straight ahead at a near fixed point like your nose
- Cover one of the patient’s eyes
- Inspect for movement of the other eye as it focuses on your nose
- Remove the cover and watch again as the eyes refocus
- Repeat test on the opposite eye looks for nystagmus which would indicate strabismus
Hearing
Rinne test
- strike the tuning fork, put it on patient’s mastoid, once they tell you they can’t hear it anymore then move the tuning fork to beside their ear and wait for them to not be able to hear it anymore.
- air conduction should be heard twice as long as bone conduction.
- if bone conduction is longer than air conduction on the side of lateralization ==> conductive hearing loss.
- if air conduction is longer than bone conduction on the side of lateralization ==> sensorineural hearing loss
Weber test
- strike the tuning fork, put it into the middle of the patients head and ask them if it is equal.
- lateralization to the deaf ear = conductive hearing loss
- while lateralization of the good ear = sensorineural hearing loss
Heart
Aortic regurgitation
Aortic stenosis
Mitral regurgitation
Mitral stenosis
Chest
Bronchophony
- listen to the different lung fields and ask the patient to repeat “99”.
- the increased sound indicates consolidation in that segment
Chest excursion
- place both hands on the chest and watch for symmetric movement.
- asymmetric movement of hands may indicate a problem with one/both lungs
Crepitus
Egophony
- listen to the different lung fields and ask the patient to repeat “E-E-E”.
- if it is heard as “A-A-A” this suggests consolidation
Pleural friction rub
- grating sound heard when auscultation of the chest.
- stops when the patient holds their breath.
- indicates inflammation of the pleural space
Tactile fremitus
- place ulnar surface on the chest wall. ask the patient to say 99.
- increased sound transmission indicates fluid or mass.
- decreased sound transmission indicates bronchial obstruction or emphysema
Whispered pectoriloquy
- ask the patient to whisper “1-2-3”. listen to the different lung fields.
- increased sound that is more clear indicates consolidation
Neck
Brudzinski sign
- lay the patient supine. flex the head and neck. positive sign = flexion of the hips/lower extremities with nuchal pain.
- the positive sign indicates meningeal irritation (meningitis or intracranial hemorrhage)
Kernig sign
- with the patient supine, flex the patient’s hip 90 degrees, and then extend the leg.
- inability to extend the leg fully due to pain indicates meningeal irritation (meningitis or intracranial hemorrhage)
Shoulder
Adson’s Test
- Test: Thoracic Outlet Syndrome
- Patient: extends neck in same direction as pulse is being taken with extended arm
- Physician: feels pulse
- Positive: diminished or absent pulse
- ext and ext rot arm turn head toward the arm
Apley scratch
Apprehension test
- Test: anterior shoulder subluxation and/or anterior laxity/instability
- Patient: supine
- Physician: put the arm in 90/90 position and slowly ER arm. can apply posterior force to encourage translation
- Positive: apprehension of pain
Apprehension test (posterior)
- Test: posterior capsule laxity or posterior subluxation
- Patient: supine with arm flexed 90° and elbow flexed so the forearm is in front of the chest.
- Physician: axial load is applied at the elbow
- Positive: patient is apprehensive/ there is pain
Distraction test (AC)
- Test: AC ligament or CC ligament sprain
- Same as sulcus sign but observing AC joint
- Patient: standing or seated.
- Physician: apply a distraction force to the arm and observe the AC joint
- Positive: pain and/or movement downward at AC joint
- alleviates sx= n. root impingement or herniation
Drop arm test
- abd shoulder to 90, then slowly lowers arm. a light tap on the patient’s arm.
- + won’t smoothly drop, it will drop. the arm cannot be adducted slowly.
- positive = supraspinatus injury.
Costoclavicular
Feagin Test
- Test: inferior instability of GH joint
- Patient: have arm of patient resting level on your shoulder.
- Physician: put your hand on humerus and apply inferior pull
- Positive: inferior translation of the shoulder at the GH joint
Hawkins test (impingement test)
- Test: supraspinatus shoulder impingement/rotator cuff injury
- Patient: flex the elbow, abduct arm 90 degrees
- Physician: internally rotate the arm.
- Positive: pain and/or apprehension
Jerk test
- flex shoulder 90 degrees, flex elbow 90 degrees, apply force to the elbow in a posterior direction.
- tests for posterior shoulder subluxation
Jobe Relocation Test
- Test: anterior capsule laxity
- Same at Apprehension test but you stabilize humerus to prevent pain
- Patient: supine
- Physician: put the arm in 90/90 position and slowly ER arm while stabilizing the humerus to prevent pain. can apply posterior force to encourage translation
- Positive: reduction or relief of pain
Load and Shift Test
- Test: Glenohumeral instability
- Patient: seated with forearms resting in lap
- Positive: translation greater than 1/4 inch
Military Brace/ Eden Test
- Test: Thoracic Outlet Syndrome
- Patient: both arms extended and patient looking up
- Physician: take pulse with both arms extended and patient looking up
- Positive: pulse diminished or absent
Neer Impingement Test
- Test: shoulder impingement of supraspinatus and/or biceps tendon
- Patient: Sitting or standing
- Physician: perform maximal flexion with maximal IR on patient passively as they are sitting or standing. stabilizing scapula posteriorly and grasping wrist with another hand
- Positive: pain and/or apprehension
Shoulder Glides/Shoulder Drawer
- Test: Glenohumeral instability
- Patient: supine with arm abducted 70-80°.
- Physician: one hand stabilizes scapula another hand on the mid humerus. move humerus anteriorly, posteriorly, and inferiorly
- Positive: increased laxity compared bilaterally
Speeds test
Spurlings test
- compress
- Ext, Sb
- + radiating down the arm
- pain that goes down opp arm= m. spasm
- extend, side-bend, and rotate the patient’s head to the side of possible nerve compression and push the head down.
- positive = radiating pain = nerve root impingement.
Sulcus test
- Test: inferior shoulder subluxation, multidirectional GH instability
- Patient: standing or seated.
- Physician: apply a distraction force to the arm
- Positive: visible gap or sulcus in GH joint
Underberg tests
Wallenberg
Wrights test
Yergasons
- Test: biceps tendon stability and tendonitis
- Patient: flex elbow 90 degrees and supinates against resistance
- Physician: palpate the biceps brachii tendon in the bicipital groove and have the patient externally rotate the arm against resistance or have them try to supinate against resistance.
- Positive: bicipital instability “pops out”
Elbow
Golfer’s elbow test
- Test: medial epicondylitis at the elbow
- Patient: straighten the arm
- Physician: applies pressure from the medial side of the elbow
- Positive: pain on the medial side of the elbow
Ligamentous stability test of the elbow
- cup the elbow in one hand and with the other hand on the distal forearm, apply valgus and varus stress.
- check for excessive gapping, which would indicate instability of the MCL or the LCL of the elbow
Tennis elbow test (cozen’s sign)
- Test: lateral epicondylitis at the elbow
- Patient: straighten the arm
- Physician: applies pressure from the lateral side of the elbow
- Positive: pain on the lateral side of the elbow
Tinel’s sign at the elbow
- locate the groove between the medial epicondyle and the olecranon at the elbow.
- gently tap and see if there is a tingling sensation down the forearm to the ulnar distribution of the hand.
- this would indicate ulnar nerve entrapment
Wrist/Hand
Rhcastilhos, Public domain, via Wikimedia Commons
Finkelstein’s
- DeQuervan Tenosynovitis
- abd pollicis longus
- ext pollicis brevis tendons
- fist over thumb, then ulnar deviation
Phalen test
Tinel’s test
Fingers/Toes
Capillary refill
- squeeze the fingertips and see how long it takes to return to normal color.
- longer than 2 seconds indicates dehydration or a peripheral perfusion issue
Abdomen
Carnett’s sign
- have patient raise both legs off the table while you palpate the abdomen, patient pain intensifies
- the easing of the pain of abdominal palpation with tightening of the abdominal muscles.
- Ex: Hematoma in the abdominal wall
- If the cause is visceral, the taut abdominal muscles could guard the source of pain from the examining hand.
- In contrast, intensification of pain with this maneuver points to a source of pain within the abdominal wall itself.
Cullen’s sign
Kehr’s sign
- abdominal pain radiating to the left shoulder
- indicates splenic rupture, renal caliculi, ectopic pregnancy
Iliopsoas muscle test
Murphy’s sign
- palpate the gallbladder and ask the patient to take a deep breath.
- halting of inspiration due to pain indicates gallbladder inflammation
Lumbar
Breggars test
Grey turner’s sign
Lloyd’s sign
Lumbosacral spring
Straight Leg
- >30 pain
- + the pain radiates below the knee
- indicates nerve root irritation or lumbar disc herniation
- Lift the leg with knee extended while the patient is sitting or supine
- Radiation of pain past the knee suggests sciatica, frequently caused by L5-S1 disc herniation
- Ankle dorsiflexion increases sciatic pain
- Ankle plantarflexion decreases sciatic pain
Hip
Ely’s Test
- Test: Rectus Femoris
- Patient: Prone
- Physician: Flex pt knees
- Positive Test: The hip on ipsilateral side spontaneous flexes
FABER / Patrick Test
- Test: Hip or SI Joint
- FABER
- Flexion
- Abduction
- External Rotation
- Patient: Supine
- Physician: Cross pt one leg over other, F, AB, ER the hip
- Positive: Anterior – Hip, Posterior – SI joint
FADIR
- Test: Femoral Acetabular Impingement
- FADIR
- Flexion
- Adduction
- Internal Rotation
- Patient: Supine
- Physician: Beside pt, F, ADD, IR the hip
- Positive: Anterior Lateral Hip Pain, “C” Sign
Flexion Test
- Standing
- Physician seated, pt standing, Thumbs on PSIS
- Pt forward flexes at waist
- POSITIVE – asymmetry
- Indicates: Iliosacral SD on ipsilateral side
- Seated
- Pt seated on stool/table, physician thumbs on PSIS, pt forward flexes
- POSITIVE – asymmetry
- Indicates: sacroiliac SD on ipsilateral side
Fulcrum Test
- Test: Stress Fracture Femur
- Patient: Seated, Knees extended
- Physician – one hand under femur, other hand on top of knee, applies pressure
- Positive – elicits pain in femur
Hamstring Test
- Test: Hamstring
- Patient: Supine
- Physician: Flex pt hip to 90, then extend knee
- Positive: Inability to extend the knee, Measure the contracture
Hoover sign (leg paresis)
- Test: Leg paresis, functional weakness / conversion disorder
- Involuntary extension of the normal hip occurs when flexing the contralateral hip against resistance
- Patient: Supine
- Physician: hold one hand under the heel of the normal limb and ask the patient to flex the contralateral hip against resistance, asking the patient to keep the weak leg straight while raising it.
- Positive: Physician does not feel the normal leg’s heel pushing down as the patient flexes the hip of the weak limb, then this suggests functional weakness (aka conversion disorder), effort is not being transmitted to either leg.
Obers test
- Test: + IT band tight, test for contraction of the tensor fascia lata and ITB
- Patient: Lateral Recumbant
- Physician: Behind pt, stabilize pelvis with one hand and support the pt leg with other, abduct hip and flex knee to 90, allow leg to drop to table
- Positive: Leg stays abducted
Pelvic Rock Test
- Test: Restriction or SD of SI joints or pelvis
- Innominate Rock Test
- Patient: Supine
- Physician: Both hands over ASIS, apply alternating forces
- Positive – Firm palpatory findings
Pelvic side shift
Quadricep Test
- Test: Quadriceps
- Patient: Prone
- Physician: Flex pt knee, heel to
buttock - Positive: Inability for heel to touch buttocks, Measure the contracture
Spring Test
- Test: Sacral dysfunction
- Patient: Prone
- Physician: Gentle pressure
- Positive: Resistance to force
- Indicates: Sacral SD – unilateral or bilateral backward sacrum
Stork Tests
- Stork test (one-leg standing hyperextension test) – exacerbates pain
- related to spondylolysis, spondylolisthesis, or sacroiliac joint dysfunction
Thomas test
- psoas
- flexion of one hip causes greater than 15 degrees of flexion contracture in the other hip.
- indicates a tight iliopsoas muscle
- Detailed:
- Test: Iliopsoas, Rectus Femoris, TFL, ITB, Flexion Contracture
- Patient: Supine
- Physician: Stabilize pelvis w/hand under lumbar spine, Flex both pt legs until lumbar flattens, pt extends one leg
- Positive Test: unable to have:
- RF – 90 degrees of knee flexion;
- IP – neutral angle of hip; or
- TFL/ITB – 15 degrees of hip ABD.
Trendelenburg test (Hip drop test)
- assess SB of L-spine
- shift wt to one leg
- positive sign = iliac crest drops on the side of the lifted leg.
- it means the hip adductors on the weight-bearing leg are weak
Knee
Anterior drawer
- have the patient flex the knee 90 degrees and sit on
- their foot. pull anterior on the knee.
- greater than 2cm movement = ACL tear.
Apley’s Compression
- Meniscus and Ligaments
- lie the patient prone, flex the knee, apply a force downward on the leg, and internally/externally rotate the leg.
- pain indicates medial or lateral meniscus injury
Apley Distraction Test
- lie the patient prone, flex the knee, put your knee on the patient’s hamstring, apply external/internal traction to the leg.
- pain indicates MCL or LCL injury
Ballottement
Howship-romberg sign
Lachman’s test
Ligamentous stability test of the knee
McMurray
- Meniscus- posterior aspects
- flex the hip and knee, apply lateral pressure to the knee while internally rotating the leg,
- apply medial pressure while externally rotating the leg
- extend the hip out.
- an audible click indicates medial or lateral meniscus tear
Patellar grind
Posterior drawer test
- have the patient flex the knee 90 degrees and sit on their foot. push posterior on the knee.
- greater than 2cm movement = PCL tear.
Valgus
Varus
Calf
Gordon sign
- squeeze the calf briefly and see if the big toe extends.
- the positive sign indicates upper motor neuron lesion, pyramidal tract lesion, stroke
Homan’s sign
- have the patient lie supine. place one hand on the calf and with the other hand, dorsiflex the foot.
- pain in the calf could mean a DVT
Moses’ sign
Oppenheim sign
- press knuckles into the shin and observe to see if the big toe extends.
- positive sign indicates upper motor neuron lesion, pyramidal tract lesion, stroke
Schaeffer sign
- squeeze the Achilles tendon and observe to see if the big toe extends.
- positive sign indicates upper motor neuron lesion, pyramidal tract lesion, stroke
Thompson-Doherty Squeeze Test
- squeeze the calf to see if the foot plantarflexes.
- no plantarflexion indicates an Achilles tendon rupture
Ankle
Anterior drawer of ankle
- pull the heel in an anterior direction.
- +laxity
- extreme-forward displacement indicates anterior talofibular ligament injury (ATF)
Foot
Babinski or Chaddock sign
Gonda or Stransky sign
- pull the 4th toe downward and outward briefly and quickly release and see if the big toe extends.
- the positive sign indicates upper motor neuron lesion, pyramidal tract lesion, stroke
