Clinical Assessment
Orthopedic and Neurological Tests
Gene Desepoli. LMT, D.C.
Descriptions of the Common Orthopedic Tests
Neck/Cervical Spine
Ranges of motion:
Flexion 45
Extension 45
Lateral flexion 45
Rotation 60-80
An orthopedic, as well as a neurological evaluation of the cervical spine is based on the fact that pathology in the cervical spine such as a herniated disc, is frequently reflected to the upper extremity via the brachial plexus (C5-T1) which is the innervation to the entire extremity. When signs and symptoms involve the upper extremity, one must be sure to evaluate the cervical spine first before evaluating the integrity of the brachial plexus. In fact, symptoms may be referred to the hand from the elbow, shoulder and the cervical spine. The possible causes of referred pain to the hand may included a) herniated cervical disc b) osteoarthritis c) cervical spondylosis and d) thoracic outlet syndromes.
Brachial Plexus Tension Test
Purpose: To detect nerve root compression.
Position: Patient lies supine
Procedure: The patient slowly abducts and externally rotates the shoulder just to the
point of pain. The forearm is then supinated and the wrist if flexed, while you are supporting the shoulder and forearm.
Positive: The test is positive if the patient's symptoms are reproduced or increased.
Shoulder Abduction Test (Bakody's Sign)
Purpose: To assess for nerve root irritation due to cervical foraminal compression.
Position: Patient is seated.
Procedure: The patient with cervical radicular pain is instructed to place their hand on top of their
head with the elbow at head level.
Positive: The reduction or elimination of radicular pain is a positive sign. Significance: This signifies a nerve root irritation due to foraminal compression
Note: The Reverse Bakody's Sign is an increase in pain while performing the test, which is
significant for thoracic outlet syndrome (stretches the neurovascular bundle and compresses
between the clavicle and the first rib, similar to Wright's test) or for the presence of a dural root adhesion.
Cervical Distraction Test pure distraction
Purpose: A test designed to identify nerve root compression/foraminal encroachment or a musculo-ligamentous problem.
Position: The patient is seated.
Procedure: Place one hand under the patient's chin and the other under the occiput. Lift the head slowly to distract it.
Positive: A positive test is the elimination or the reduction of pain.
The patient with cervical and or radicular pain gets relief when traction is applied to the head. Relief of pain signifies a nerve root compression due to foraminal encroachment. However, a patient with musculo-ligamentous injury or dural adhesions may experience increased pain with distraction.
Note: The are two ways to perform this test:
-1. 1. distract from neutral (passive)
-1. 2. have the patient actively rotate the head until radicular pain is produced, followed
-1. by passive traction. The examiner then distracts with the hands behind the
-1. mastoids and pulls upwards.
Also note that muscle spasm will result in local pain.
Distraction Test
Purpose: To detect nerve root compression from foraminal encroachment or from a disc lesion.
Position: The patient is seated.
Procedure: The patient actively rotates his head until radicular pain is produced. Then, from the neutral position, you apply a strong traction and assists the patient in rotating the head to the
point that had previously caused pain. A variation of this test is to simply distract the head
from the neutral position.
Positive: Decreased pain at the rotation position that had originally produced pain.
Signifies: Reduction in pain may signify and relieve foraminal compression or a facet capsulitis. Increased pain may be caused by muscle spasm.
Rotation Cervical Compression Test
Purpose: To detect foraminal compression.
Position: The patient is seated.
Procedure: Rotate the head toward the side being examined and exert a strong downward pressure on the head.
Positive: The exacerbation of cervical and/or radicular pain.
Analysis: Pain is caused by narrowing of the intervertebral foramina.
Hyperextension Cervical Compression Test
Purpose: To detect foraminal compression.
Position: The patient is seated.
Procedure: The patient performs passive hyperextension of the head/neck followed by your strong downward pressure on the head.
Positive: The exacerbation of cervical and/or radicular pain.
Analysis: Pain is caused by narrowing of the intervertebral foramina.
Foraminal Compression Test
Purpose: To detect nerve root compression due to foraminal encroachment.
Position: You are standing behind the seated patient whose head is in the neutral position.
Procedure: The patient rotates her head toward the side of pain and then you apply a strong
downward pressure to the top of the patient's head. The test is repeated with pressure on the head in the neutral position.
Positive: The test is positive if pain is increased in the neck or arm.
Analysis: The downward pressure approximates the vertebrae, thus the pedicles which are the
superior and inferior boundaries of the IVF, shortens the IVF.
If the pain radiates as far as the wrists or fingers, it is indicative of a cervical
disc lesion.
Radiating (radicular) pain indicates nerve root compression due to foraminal encroachment.
Jackson's Compression Test
Purpose: To detect nerve root compression due to foraminal encroachment.
Position: The examiner is standing behind the seated patient.
Procedure: Instruct the patient to laterally flex the head (to approximate the shoulder) on the effected side. Clasp your hands over the patient's head and exerts strong downward pressure. The test is repeated on the opposite side as well.
Positive: The test is positive if cervical or radiating pain is experienced into the arm toward the flexed side.
Shoulder Abduction Test
Purpose: To identify extra-dural compression, such as a herniated disc, epidural pain compression
or nerve root compression most commonly at C5 or C6.
Position: The patient is in a sitting or a lying position.
Procedure: The patient's arm is abducted actively or passively so that the hand or forearm of the patient
rests on their head.
Positive: The test is positive if there is a decrease in symptoms.
Shoulder Depression Test
Purpose: To detect nerve root adhesions or dural sleeve adhesions
Position: Patient is lying supine.
Procedure: Stand at the head of the table and perform 3 steps:
-1. 1. apply downward pressure to the shoulder of the effected side
-1. 2. laterally flex the head to the opposite side
-1. 3. rotate the head to the opposite side
Positive: Radiating pain produced or aggravated by the first maneuver and confirmed/worsened by the succeeding steps signifies a positive test.
Note: Some sources state that pain on the side being tested is a positive sign.
Valsalva Maneuver
Purpose: To detect a space-occupying lesion in the cervical spine, such as a herniated disc or an
osteophyte
Position: The patent is seated.
Procedure: Instruct the patient to take a deep breath and to "bear down," as if they are having a bowel
movement. (The patient can also place a thumb in their mouth and simulate blowing up their
hand like a balloon.)
Positive: The test is positive if the symptoms are reproduced (radicular pain) or increased upon
straining. Ask the patient to localizes the source of pain if present.
Analysis: This test increases intrathoracic pressure. Local pain would signify a space-occupying
lesion, such as a tumor, osteophyte or a disc herniation.
Note: This test is for cervical problems. Milgram's is the test for lumbar and spinal disc pain. Dejerine's Sign is a related test, but for lumbar disc pathology and includes coughing and
sneezing.
Note: Intrathecal pressure tests include Dejerine's, Valsalva, Milgram's and Nafzinger's and signify
space-occupying lesions. A prolapsed disc will give a negative result on these tests.
Dejerine's Test adds coughing or sneezing to the Valsalva maneuver. 6
Maximal Foraminal Compression Test (Maximal Cervical/Rotatory Compression Test)
Purpose: To detect nerve root impingement
Position: The patient is seated.
Procedure: The patient actively laterally bends the head to bring the ear to the shoulder on the
affected side, and then rotates the head to bring the chin to the same shoulder. Ipsilateral radicular pain
Analysis: These movements significantly narrow the intervertebral foramina. This test may be
performed passively.
Extension Compression Test Cip 48 graphic
Purpose: To assess for
Position: The patient is seated. Ask the patient to extend his head approximately 30 degrees.
Procedure: Place downward pressure on the extended head.
Positive: An increase in cervical and/or radicular symptoms may indicate a disc lesion.
Analysis: Flexion of the head/neck places pressure on the disc and causes the posterior aspect of the disc to bulge. Some books state that this maneuver causes the disc to bulge anteriorly, removing a posterior bulge, and taking pressure off of the nerve roots.
Note: The apophyseal joints may be irrtated with this maneuver causing local cervical pain.
Upper extremity pain with this maneuver may be due to its decreasing of the intervertebral foramina size.
Flexion Compression Test Cip 49 graphic
Purpose: The patient is seated. Ask the patient to flex his head and neck. Place downward pressure on the flexed head.
Positive: An increase in cervical and/or radicular symptoms may indicate a disc lesion.
Analysis: Flexion of the head/neck places pressure on the disc and causes the posterior aspect of the disc
to bulge
Note: A decrease in (scleratogenous) pain with flexion may signify an apophyseal joint lesion.
Soto-Hall Test Cip 42 graphic
Purpose: To check for possible spinous or body fractures or for ligamentous disease.
Position: The patient is supine.
Procedure: Apply downward pressure to the sternum and then flex the patient's chin to his chest.
Positive: A positive test will cause localized pain in the cervical or cervico-thoracic region.
Signifies: A positive finding may indicate an anterior vertebral body collapse (bony compression) or a ligamentous problem.
Analysis: Pain is usually elicited at the level of the lesion due to the tightening of the posterior interspinous ligament at all levels.
Note: Used to diagnose and localize bony disease in the cervical spine, especially compression fractures. If the patient flexes both knees, suspect meningeal irritation.
Spurling's Test
Purpose: To detect nerve root irritation due to disc disease or cervical spondylosis.
Position: The examiner stands behind the seated patient.
Procedure: Maximally rotate and laterally flex the patient's neck to the same side and then hyperextend it. Then, apply a downward blow to your hand, which you have placed on top of the patient's head.
Positive: A significant increase of any combination of neck, shoulder or arm pain when the blow is
delivered.
Analysis: This test stimulates nerve root irritation or other pain-sensitive tissue related to disc disease or
cervical spondylosis.
O'Donohue Test
Purpose: To determine if the source of pain is from either contractile or non-contractile tissue.
Position: The patient is seated.
Procedure: The examiner and patient put the cervical spine through various active and then passive
ranges of motion. (The patient actively moves the part against resistance, then the examiner passively moves the part through a full range of motion.)
Positive: The presence of pain
Analysis: Pain during passive range of motion indicates a ligamentous problem (sprain).
Note: Pain during active range of motion indicates a musculo-tendinous problem (strain or
tendonitis ).
Note: This test can be used for any joint to determine the source of pain, from active/contractile
tissue or from passive, inert tissue.
Swallowing Test
Purpose: To determine the presence of a bony or soft-tissue mass anterior to the cervical spine.
Procedure: The patient is seated.
Position: The patient is instructed to swallow.
Positive: Difficulty swallowing or pain upon swallowing.
Note: Several causes include tumors, osteophytes, a large disc protrusion. hematoma, cranial nerve lesion and DISH (diffuse idiopathic skeletal hyperostosis which is calcification of the anterior longitudinal ligament. The is the most common cause of dysphagia and exists in 5-7% of the populatioin, males greater than females and in diabetecs.
Include x-rays of these conditions
Neurovascular Compression Syndromes
Allen's Test Cip 144 graphic
Purpose: To detect occlusions in either the radial or ulnar arteries.
Procedure: The patient is seated with the forearms supinated and resting on the thighs.
Position: First palpate and occlude the radial and ulnar arteries. Ask the patient to open and close his or her fingers rapidly for about 10 seconds to cause palmar blanching. Pressure is then released from either the radial or ulnar artery, and the rapidity with which the hand regains color is noted.
The test is repeated with release of the other artery.
Positive: A failure or a delay of more than 10 seconds for the blood to return may indicate a possible occlusion of the corresponding (non-occluded) artery. This signifies a diminished or absent communication between the superficial ulnar arch and deep ulnar arch. Be sure to compare the other wrist.
Note: Allen's test should be done before performing either Adson's, Eden's or Wright's tests.
Adson's Test (Scalenus Anticus Syndrome or Cervical Rib Syndrome) subclavian artery
Cip 106 + graphic
Purpose: The detection of thoracic outlet syndrome or for the presence of a cervical rib.
Procedure: The patient is seated and the radial pulse is palpated.
Position: Hold the patient's arm in slight extension and palpate the radial pulse. Ask the patient to rotate and then extend the head toward the involved side. A deep breath-hold is then taken by the patient.
Positive: A decrease or an elimination of the radial pulse and/or duplication of the patient's symptoms indicates a thoracic outlet (scalenius anticus) syndrome. Be sure to compare the well side to rule out false positive findings.
Note: If the above test is negative, turn the head to the opposite side (Modified Adson's Test) and look for the same results. This "Modified Adson's Maneuver" tests obstruction by the scalene anterior???(medius) muscle or from a cervical rib.
Costoclavicluar Test Cip 107 + graphic
Purpose: To detect costoclavicular syndrome.
Position The patient is standing and the examiner monitors the radial pulse.
Procedure: The patient actively forces the shoulders backward and downward and then flexes the chin to his chest.
Positive: A positive test is the presence of any of the following: