Dr Rubin’s Top Ten Physical Exam Techniques Every Sports Medicine Physician Should Know
Some may argue that the art of the physical exam is dying. That is not true with musculoskeletal based specialties where the physical exam is critical. One of the key components of the musculoskeletal exam are the special tests. It is easy to get lost in the weeds and sports medicine providers can often be buried under the mountain of available special tests. When evaluating the literature, there are often at least 2-3 special tests for every condition. Unfortunately, not all of these tests are evidence-based and can stand up to inter-operator reliability. As a result, we wanted to highlight some of our favorite physical exam techniques and how to perform them properly. Below you will find our “top ten” physical exam techniques that every sports medicine provider should master.
1. Lachman’s Test (ACL)
Diagnosing an acute knee injury is a common part of sports medicine sideline coverage. One diagnosis we do not want to get wrong is a missed ACL injury. Historically in medical training, students are taught about the anterior drawer test to diagnose an ACL tear. However, we would like to highlight the Lachman test as our first must-have physical exam technique in every sports medicine doctor’s repertoire. When diagnosing an ACL tear, there are mechanical advantages to a Lachman test as opposed to an anterior drawer test. By placing the knee in 20 to 30 degrees of flexion, you can overcome resistance from the hamstring when anteriorly translating the tibia (R Bronstein, 2017). A positive Lachman test is when there is a soft end point with anterior translation of the tibia with the knee flexed at 20 to 30 degrees (R Bronstein, 2017). One common mistake we see in trainees is they do not allow for slight external rotation of the patient’s hip when positioning the patient (R Bronstein, 2017). Allowing external rotation of the hip allows the patient to be more relaxed and the patient is less likely be tightening the surrounding muscles. In addition, it is important for a provider to compare a Lachman test on both knees. Patients with concurrent medial meniscus tears were found to have higher grade Lachman tests (Robert Magnussen, 2016). Lachman tests can be graded based on the amount of anterior tibia displacement, which is graded by 1-5mm is grade I, 6-10 is grade II, and >10 is grade III (R Bronstein, 2017).
2. TFCC Stress Test
The triangular fibrocartilage complex or TFCC is one of the most frequently overlooked areas in medical school and many residents and attendings are unfamiliar with it. Injury to this structure should be considered in all patients with ulnar sided wrist pain. The TFCC is made up of a meniscus homolog, ECU sheath, and both distal radioulnar and ulnocarpal ligaments (Manuel DaSilva, 2017). It acts as a stabilizer of the distal radioulnar joint and radiocarpal joint (Ji Hun Park, 2018). The TFCC can be injured by both trauma and overuse. One provocative maneuver to test for a TFCC tear is by ulnar deviating the wrist and then providing an axial load to the joint (Nagle, 2000). A positive test is pain within the TFCC (Nagle, 2000). This test tries to reproduce pain in the TFCC by compressing the TFCC between the distal portion of the ulna and the carpal bones (Bengtson, 2017). One other physical exam test that has been found to have 100% sensitivity for TFCC tear is the Press test. This test involves having the patient push off from a chair using the affected wrist and a positive test is ulnar sided wrist pain (B lester, 1995).
3. Stress Test of the Ulnar Collateral Ligament (UCL) of Thumb
Also known as the gamekeeper thumb, an injury to the ulnar collateral ligament of the thumb is commonly seen in sports medicine clinics. The capsule of the MCP joint of the thumb is supported by the ulnar collateral ligament, which spans from the metacarpal head to the base of the proximal phalanx (Frank McCue, 1974). This ligament is typically injured with forceful abduction of the thumb. The ligament is typically ruptured at the site of its distal attachment (Heyman, 1997). As a result, when testing for ligament stability, applying a force in abduction will stress the ulnar collateral ligament (Frank McCue, 1974). Current guidelines recommend stressing the joint at both 0 degrees of extension and in 30 degrees of flexion (Tang, 2011). The provider needs to grasp the first metacarpal just proximal to the first MCP joint in order to prevent rotation at the MCP joint (Heyman, 1997).
4. Medial Collateral Ligament (UCL) of the Elbow Moving Valgus Stress Test
The medial collateral ligament of the elbow prevents the valgus torque applied to the elbow during late cocking and early acceleration of the arm (Shawn O'Driscoll R. L., 2005). The most frequently affected ligament is the anterior bundle of the medial collateral ligament (Shawn O'Driscoll R. L., 2005). In order to assess for medial collateral ligament insufficiency, the moving valgus stress test is used. This test involves placing the patient’s shoulder in 90 degrees of abduction and then applying a valgus torque to the elbow. Once the shoulder reaches its limit in external rotation, the elbow is extended to 30 degrees while maintaining the valgus torque (Shawn O'Driscoll R. L., 2005). A positive test is when the patient reports pain during extension of the elbow between 120 degrees of flexion and 70 degrees of flexion as the provider extends the elbow (Shawn O'Driscoll R. L., 2005). When comparing a valgus stress test to a moving valgus stress test the sensitivity and specificity are both higher in the moving valgus stress test (Shawn O'Driscoll R. L., 2005).
5. Evaluating a Knee Effusion
When evaluating a knee after an acute injury, it is important to assess for a knee effusion. A knee effusion can clue you in to an ACL injury or cartilage injury. Physicians must be able to differentiate between prepatellar effusion verse intra-articular effusions. One of the best ways to palpate for a knee effusion is to milk the fluid from the suprapatellar recess into the joint (Ro Bronstein, 2017). The physician grasps the knee under the patella and feels for any fluid wave that is milked into the joint space below the patella (Ro Bronstein, 2017). The size of the effusion can be graded based on a scale devised by Sturgill in the Journal of Orthopaedic & Sports Physical Therapy in 2009. A grade of zero is no fluid wave and progresses up to 3+ which is a large effusion that does not allow fluid wave (LP Sturgill, 2009).
6. FADIR Test of the Hip
It is often challenging for physicians to differentiate hip joint pathology verse muscular injury. The FADIR test, which stands for hip flexion, adduction, and internal rotation, helps to identify anterior hip impingement. The test is performed by flexing the hip to 90 degrees and then internally rotating and then adducting the hip (Jeffrey Nepple, 2013). A positive test is pain in the groin with internal rotation and adduction (Jeffrey Nepple, 2013). By flexing and adducting the hip the goal is to create contact between the femoral neck and acetabular rim to reproduce pain (Javad Parvizi, 2007). The sensitivity of the test has been looked at in multiple studies and sensitivities range between 95-100% (Brian Krabak, 2017).
7. High Ankle Sprain (Syndesmosis)
After an ankle sprain, the provider must evaluate for ankle stability. Injury to the tibiofibular syndesmosis can lead to prolonged courses of rehab and ankle instability (Kenneth Hunt, 2015). A review of physical exam tests looking for ankle syndesmosis injury was published in 2013 in the British Journal of Sports Medicine. What they found was that the diagnostic accuracy of physical exam tests aimed at diagnosing syndesmotic injuries was low (Amy Sman, 2013). However, a previous study published in AJSM in 2001 showed that using the dorsiflexion external rotation stress test in combination with radiographic studies can aid in accurately diagnosing a syndesmotic injury (Eric Nussbaum, 2001). In order to perform the external rotation stress test, the ankle needs to be dorsiflexed to its end point and then externally rotating the ankle (Eric Nussbaum, 2001). A positive test is syndesmotic pain (Eric Nussbaum, 2001).
8. Apprehension Test & Jobe Test for Glenoid Labrum
The anterior apprehension test and Jobe relocation are used to diagnose anterior shoulder instability. The anterior apprehension test is done by abducting the shoulder to 90 degrees and then externally rotating the shoulder while applying anterior pressure to the humeral head (K Hippensteel, 2018). A positive test is the patient experiencing apprehension while externally rotating the shoulder (K Hippensteel, 2018). The Jobe relocation adds a posteriorly directed force to the humeral head while it is abducted and maximally externally rotated. A positive test is resolution of symptoms (K Hippensteel, 2018). In a study published in the Journal of Bone & Joint Surgery in 2006, they found that apprehension was more accurate in predicting anterior instability than if the patient experienced pain during the maneuver (Adam Farber, 2006).
9. Dial test (Posterolateral Corner of the Knee)
The posterolateral corner is another area frequently overlooked in medical training. The posterolateral corner of the knee is made up of the lateral collateral ligament, popliteus tendon and popliteofibular ligament (R Bronstein, 2017). An injury to the posterolateral corner rarely occurs in isolation but is typically found in multiligament injuries (R Bronstein, 2017). The first step in performing the dial test is to have the patient lay in prone position and flex the knees to 30 degrees. With the ankles in maximum dorsiflexion, the tibias are externally rotated on both sides and the provider measures the degree of increased external rotation between sides (Ro Bronstein, 2017). The test is then repeated at 90 degrees of knee flexion. If there is increased external rotation at 30 degrees, then a posterolateral corner injury is suspected. If there is also more than 10 degrees of external rotation at 90 degrees, then the patient also has a PCL injury (Ro Bronstein, 2017).
10. O’Brien’s test for Glenoid Labrum
The glenoid labrum aids in shoulder joint stability by deepening the glenoid rim (Jay Keener, 2009). Throwing athletes can develop tears in the superior labrum in an anterior to posterior direction (Jay Keener, 2009). These tears are often difficult to diagnose clinically because 88% of SLAP tears occur concurrently with additional pathology (Jay Keener, 2009). There are multiple tests that aim to provoke pain in a shoulder with a SLAP lesion. The O’Brien test is commonly used and is done by flexing the shoulder to 90 degrees, adducting the shoulder, and then internally rotating the shoulder (Jay Keener, 2009). A positive test occurs when pain is reproduced with resisted shoulder flexion and shoulder pain improves when the shoulder is externally rotated by supinating the arm (Jay Keener, 2009). Dr. Stephen O’Brien first published his labral compression test in a 1998 article in the American Journal of Sports Medicine. They found the sensitivity for labral tear at 100% and specificity of 98.5% (Stephen O'Brien, 1998)
In summary, when evaluating a patient with a musculoskeletal complaint, a thorough physical exam is a useful tool in guiding the physician towards a correct diagnosis. There is a wide variability among exam styles and utilization of special tests. However, as you can see above, the sensitivity and specificities of some of these tests are lacking. The results of these special tests must be taken into account after a thorough history is obtained and any imaging studies are reviewed. Ultimately, each provider may become comfortable with different special tests but the ones listed above should be part of every providers repertoire.
Adam Farber, R. C. (2006). Clinical Assessment of Three Common Tests for Traumatic Anterior Shoulder Instability. The Journal of Bone & Joint Surgery, 1467-1474.
Amy Sman, C. H. (2013). Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review. British Journal of Sports Medicine, 620-628.
B lester, J. H. (1995). "Press Test" for office diagnosis of triangular fibrocartilage complex tears of the wrist. Annals of Plastic Surgery, 41-45.
Bengtson, K. (2017). Examination of the Wrist and Hand. In K. M. Gerard Malanga, Musculoskeletal Physical Examination: An Evidence-Based Approach (pp. 88-105). Philadelphia: Elsevier.
Brian Krabak, W. S. (2017). Physical Examination of the Pelvis and Hip. In K. M. Gerard Malanga, Musculoskeletal Physical Examination: An Evience-Based Approach (pp. 145-172). Philadelphia: Elsevier.
Eric Nussbaum, T. H. (2001). Prospective Evaluation of Syndesmotic Ankle Sprains without Diastasis. The American Journal of Sports Medicine.
Frank McCue, M. H. (1974). Ulnar collateral ligament injuries of the thumb in athletes. The Journal of Sports Medicine, 70-80.
Heyman, P. (1997). Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint. Journal of the American Academy of Orthopaedic Surgeons, 224-229.
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Manuel DaSilva, A. G. (2017). Evaluation of Ulnar-sided Wrist Pain. Journal of American Academy of Orthopedic Surgery, e150-e156.
Nagle, D. (2000). Evaluation of Chronic Wrist Pain. Journal of the American Academy of Orthopaedic Surgeons, 45-55.
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Robert Magnussen, E. R. (2016). Factors Associated with High-Grade Lachman, Pivot Shift, and Anterior Drawer at the Time of Anterior Cruciate Ligament Reconstruction. Arthroscopy: The Journal of Arthroscopic and Related Surgery.
Robert Miller, F. A. (2017). Knee Injuries. In J. B. Frederick Azar, Campbell's Operative Orthopaedics (pp. 2121-2297). Philadelphia: Elsevier.
Shawn O'Driscoll, R. L. (2005). The "Moving Valgus Stress Test" for Medial Collateral Ligament Tears. The American Journal of Sports Medicine.
Shawn O'Driscoll, R. L. (2005). The "Moving Valgus Stress Test" for Medial Collateral Ligament Tears of the Elbow. The American Journal of Sports Medicine.
Stephen O'Brien, M. P. (1998). The Active Compression Test: A New and Effective Test for Diagnosing Labral Tears and Acromioclavicular Joint Abnormality. The American Journal of Sports Medicine, 610-613.
Tang, P. (2011). Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint. American Academy of Orthopaedic Surgeon, 287-296.