Chapter 3:
Orthopedic and Neurologic Procedures in Chiropractic

From R. C. Schafer, DC, PhD, FICC's best-selling book:

“Basic Chiropractic Procedural Manual”

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Selected Neurologic Problems  
  Types of Neuritides 
    Peripheral Neuritis 
    Local Neuritis 
    Disassociated Anesthesias in Cord Lesions 
  Cervical Lesions and Cerebral Vasomotor Disturbances 
    The Pyramidal System 
    The Extrapyramidal System 
    Cerebellar Lesions 
  Localizing Symptoms and Signs of Intracranial Lesions 
    Examination of Cranial Nerves 
    Additional Signs of Intracranial Lesions 
  Principles of Neurologic Examination 
    Sensory Disturbances 
    Motor Disturbances 
  Differentiation of Upper and Lower Motor Neuron Lesions 
  Superficial and Deep Reflexes 
  Neurologic Aspects of Subluxation Syndromes 
    Nerve Root Insults 
    Reflex Irritations 
    Other Causes 
  Closing Remarks 

Orthopedic and Neurologic Tests and Signs
  A PhysicaI Examination Routine 

Geriatric Considerations

Pediatric Considerations
  Cranial and Thoracic Measurements 
  Developmental Progress 
  Height Estimation During Development 
  Percent of Mature Height Anticipated

Chapter 3:   Orthopedic and Neurologic Procedures in Chiropractic

This chapter presents the general diagnostic methods currently used in differential diagnosis of selected orthopedic and neurologic conditions.



The typical patient presents the challenge of differential diagnosis of a number of neurologic conditions. These range from a variety of peripheral neuritides that may be completely reversible to serious degenerations of the central nervous system.

The tendency of the geriatric patient to develop neurologic problems is often related to the aging process: loss of tissue elasticity, particularly that of the musculoskeletal system. This is manifested by greater rigidity of the spinal column with the appearance of fixation subluxations. These, together with dehydration and subsequent thinning of the intervertebral discs, predispose to radiculitis, neuritis, and vasomotor disturbances and metabolic effects on the cord and brain. The neurologic disturbances can be superimposed on already degenerating arteriosclerotic vessels and alter metabolism of the gastrointestinal and other systems, which may cause serious problems unless recognized early and prompt corrective measures are administered.

Types of Neuritides

      Peripheral Neuritis

Peripheral neuritis is a general peripheral neuritis such as that which may be present in such disorders as diabetes, anemia, and vitamin deficiency. Diminution of all sensation will be noted, with proprioception affected most. A stocking distribution with an ill-defined border is commonly witnessed. Glove distribution may appear later, along with paresthesias in the distal areas of sensory distribution. The clinical picture does not conform to either dermatome or nerve patterns of distribution. The cause for this is unknown.

      Local Neuritis

Acute.   Pain and hyperalgesia are witnessed in the area of nerve distribution, along with tenderness on palpation of the nerve trunk and muscles supplied by the nerve. One or more trigger points may be found. Reflexes are either unaffected or possibly increased.

Chronic.   Paresthesias are reported over the area of nerve distribution, along with tenderness over nerve fibers and muscles supplied by the involved nerve. Hypoesthesia and hypoalgesia are usually present. Diminished reflexes and motor weakness of muscles supplied by affected nerve are typical.

Radiculitis.   Paresthesia and sensory changes are witnessed similar to those present in neuritis, but the area affected corresponds to the dermatome, myotome, or sclerotome of affected roots. Coughing, straining, jugular compression, and other causes of increased cerebral spinal fluid pressure increase symptoms. In chronic cases, there may be paresis of muscles partly supplied by the affected root but not overt paralysis.

      Disassociated Anesthesias in Cord Lesions

Unilateral partial loss of sensation requires complete sensory evaluation of the area of complaint and contralateral side. For example, loss of proprioception in one leg with retention of pain, temperature, and light touch sensation in the same leg, but loss of pain, temperature, and light touch sensation with retention of proprioception in the opposite leg can only occur with an unilateral cord lesion. A classic example is seen in the Brown-Sequard syndrome of hemisection of the cord. This is the result of interruption of the gracilis pathway that runs ipsilateral in the cord and interruption of the spinothalamic tract that lies contralateral in the cord. Other patterns of disassociated anesthesias from cord lesions include:

Syringomyelia.   The typical signs are a shawl loss of pain, temperature, and epicritic sense.

Subacute combined degeneration of the cord.   Bilateral reduction of proprioception and decrease of pain, temperature, and epicritic sense, particularly in the feet and hands are typical, as is a bilateral increase in myotactic reflexes.

Tabes dorsalis.   Bilateral loss of proprioception manifested by locomotor ataxia, and loss of position and vibratory senses with retention of pain, temperature, and light touch are typical.

Cervical Lesions and Cerebral Vasomotor Disturbances

The course of the vertebral arteries through the foramen transversarium and over the arch of the atlas and their frequent inequality of size predispose them to compression and vasomotor disturbances when cervical subluxation exists. Manifestation of cerebral vasomotor disturbances is presented chiefly as alterations of motor function.

      The Pyramidal System

The pyramidal system is composed of upper motor neurons that extend from the motor area of the cerebral cortex through the internal capsule, the basilar parts of the mesencephalon and pons, the pyramid of the medulla where the majority of the fibers decussate to the opposite side, and the posterior portion of the lateral funiculus of the cord. Lesions anywhere along this pathway result in symptoms of an upper motor neuron lesion. These include:

Spastic Paralysis.   The affected part is in firm contraction and efforts to move it are greatly resisted.

Hyperactive Myotactic Reflexes.   These refer to the tendon stretch reflexes in the affected area. The biceps, triceps, quadriceps, or Achilles reflexes are exaggerated when compared with the unaffected side or with the normal when both sides are involved.

Pathologic Reflexes.   These responses appear only with a pyramidal tract lesion. The classical response is the Babinski reflex where the great toe dorsiflexes and the remaining toes fan in abduction when the bottom of the foot is firmly stroked from the heel to the base of the great toe. Similar responses may be elicited by squeezing the Achilles tendon (Schaeffer's sign), by squeezing the calf muscles (Gordon's sign), by stroking near the lateral maleolus (Chaddock's sign), or by stroking downward on the tibia (Oppenheim's sign). In contrast, lower motor neuron lesions show flaccid paralysis, decreased or absent reflexes, muscle atrophy, and reaction of degeneration appearing in 10–14 days.

      The Extrapyramidal System

Basal ganglia lesions are characterized by hypertonic muscles, rigidity, uncontrolled and involuntary movements, resting tremor, an attitude of flexion, and a festination gait. The rigidity is of the "lead pipe" type where passive movement is resisted but can be achieved. In moving the part, there is a "cog-wheel" effect; and clonus can be demonstrated at the ankle, patella, or wrist, depending on the site of the lesion.

      Cerebellar Lesions

These lesions are characterized by a lack of coordination, an intention tremor, disturbances of equilibrium, and nystagmus. In contrast to most lesions of the brain, cerebellar symptoms are ipsilateral with the lesion. Tests for cerebellar function include Romberg's, finger-to-finger, finger-to-nose, and heel-to-shin tests, along with rapid pronation and supination of hands, attempting to drum rhythmically on a desk top, and the ability to quickly stop a movement as in Holmes' rebound phenomenon. Nystagmus, when present, shows the fast component when looking toward the side of the lesion.

Localizing Symptoms and Signs of Intracranial Lesions

      Examination of Cranial Nerves

Olfactory Nerve.   The 1st cranial nerve may be affected by frontal lobe tumors, fracture of the anterior fossa of the skull, pituitary tumors, cerebral vascular accidents, postconcussion syndrome, meningitis, hydrocephalus, drug intoxications, neuroses, psychoses, and congenital defects. Each nostril should be tested separately for ability to recognize familiar odors such as peppermint, menthol, vanilla, cinnamon, coffee, oil of cloves, etc. Avoid use of irritant substances such as ammonia and vinegar. The patient, with eyes shut and one nostril held closed, should be asked to identify the test substances, which are rapidly passed inward from a distance of about a yard from the patient.

Optic Nerve.   After ruling out local ocular causes of disturbance of vision, patterns of visual loss offer one of the best means of locating intracranial lesions when the lesion affects a visual pathway. Tests should always include ophthalmoscopy of both the retina and optic disc. Papilledema appears with increased intracranial pressure. Visual fields: bitemporal hemianopsia indicates a lesion at the optic chiasma. Homonymous contralateral hemianopsia indicates a lesion at the optic tract or optic radiation. Homonymous contralateral quadrantopsia indicates a lesion at the upper or lower area of optic radiation. Complete blindness of one eye indicates a lesion of the optic nerve. For color blindness, test with colored yarn or test cards. For visual acuity testing, a Snellen chart may be used. Jaeger or similar test charts can be used at the bedside. The visual fields may be roughly tested by confrontation. More accurate visual field determination requires the use of a perimeter or tangent screen.

Oculomotor Nerve.   The 3rd cranial nerve supplies all muscles that move the eye except the superior oblique and rectus lateralis. It also supplies the sphincter pupillae and ciliaris muscles. Test eye movements, particularly medial upward and downward. Then test pupillary response to light and accommodation.

Trochlear Nerve.   The 4th cranial nerve supplies only the superior oblique muscle of the eye. Test for ability to move the eye downward and inward. The size and shape of each pupil should be noted. Check consensual light reaction and accommodation-convergence response.

Trigeminal Nerve.   The 5th cranial nerve is the great sensory nerve to the face and the motor supply to the muscles of mastication. Test for usual modalities of sensation over each of the three divisions of the trigeminal. The corneal reflex is tested as the patient looks upward by approaching the cornea from the side and touching it with a strand of cotton. Palpate the masseter and temporalis muscles after the patient is asked to "bite down."

Abducens Nerve.   The 6th cranial nerve supplies only the rectus lateralis muscle of the eye. Test for ability to move the eye laterally.

Facial Nerve.   The 7th cranial nerve (mixed) is the great motor nerve to the muscles of the face, provides the sense of taste to the anterior 2/3rds of the tongue, and parasympathetic fibers to the mucosa of the nasal cavity and roof of the mouth. Test for action of facial muscles when asking the patient to raise the eyebrows, frown, smile and whistle. For taste, have the patient identify a drop of solution of sugar, salt, vinegar, and alum when each substance is placed on the anterior part of the tongue.

Auditory Nerve.   The 8th cranial is the nerve of hearing and equilibrium. Test the cochlear division for hearing by using a tuning fork. Bone conduction (with base of fork on vertex or occiput) should be equal in both ears. Closing one ear should shift the sound to the closed ear (Weber's lateralization test). When sound is no longer heard with bone conduction, bringing the fork near the ear without setting it in vibration again, should again be heard by air conduction (Rinne's test).

Test the vestibular division for symptoms of vertigo, nausea, or disturbance of coordination on the affected side. Nystagmus may be present. A caloric test should be considered. Normally, nystagmus, vertigo, and nausea will appear within 30–40 seconds. A lack of response shows decreased or absent nerve function.

Glossopharyngeal Nerve.   The 9th cranial nerve consist of

(1) sensory fibers from the isthmus faucium, posterior 1/3rd of the tongue, and the pharynx;

(2) motor fibers to the stylopharyngeus muscle; and

(3) parasympathetic fibers to the parotid gland. Test with the gag reflex by touching the posterior part of the tongue or pharyngeal wall.

Vagus Nerve.   The 10th cranial is the motor nerve to the pharynx, uvula, larynx, and upper part of the esophagus; sensory nerve to the pharynx, larynx, and upper esophagus; and parasympathetic nerve to the thoracic and upper abdominal viscera. Test for motor response to the gag reflex and for movement of pharyngeal and laryngeal muscles on phonation. Test the ocuIocardiac reflex.

Spinal Accessory Nerve.   The 11th cranial is the motor nerve to the sternocleidomastoideus and upper trapezius muscles. Test the ability to bring the occiput toward the shoulder (lateral flexion) against resistance and the ability to shrug the shoulders.

Hypoglossal Nerve.   The 12th cranial is the motor nerve to the muscles of the tongue. Test by having patient protrude tongue, The tongue deviates toward the side of paralysis.

      Additional Signs of Intracranial Lesions

Other localizing signs and symptoms may include speech difficulties (aphasias), which suggest a lesion of the parietal lobe and/or adjacent areas of frontal, occipital, and temporal lobes. Personality changes suggest a lesion in the prefrontal region of the frontal lobe, and difficulty of movement with spastic paralysis and/or hypertonicity and rigidity of the contralateral side implies a lesion of the precentral gyrus and adjacent frontal gyri.

Several other signs are important. For example, loss of memory for recent events suggests temporal lobe lesion. Disturbances of recognition of ordinary sensations suggest postcentral gyrus lesions, cranial impairment of the visual sense relate to the occipital lobe, and disturbances in recognition of sounds and their significance suggest a temporal lobe lesion. Vasomotor and autonomic disturbances appear with lesions of the hypothalamus, and severe, intractable, poorly localized pain arises with thalamic lesions.

Principles of Neurologic Examination

      Sensory Disturbances Pain and Paresthesia. Causative factors include:

  1. Direct trauma or injury, which may be obvious.

  2. Reflex pain from internal visceral reflexes. These affect certain areas and should always be suspected.

  3. Reflex pain from musculoskeletal lesions, which deep pressure often exaggerates. Such areas may be termed trigger areas, and their area of referred pain can be fairly well charted.

  4. Peripheral nerve injury (eg, as in causalgia) results in an intense burning superficial pain. A history of injury may help to differentiate this disorder.

  5. The presence of nerve inflammations and degenerations of the peripheral or central nervous system. They frequently cause other changes indicative of such lesions.

  6. Vascular disease, which is usually associated with other changes such as swelling, redness, blanching, or other vascular disorder signs —depending on whether it is an arterial or venous problem. There are some characteristic neurovascular syndromes that may also be associated with pain and paresthesia. Vasomotor disturbances may be caused or aggravated by vertebral subluxations such as with the deep congestive leg aches associated with upper lumbar lesions, or the vasomotor headaches or other symptoms of cervical subluxation.

  7. Nerve root insults that may be due to the many factors previously discussed. Sensory root pressure is characterized by pain, paresthesia, and often abnormal sensitivity to touch along the course of the involved nerve root's segmental skin supply or dermatome. Therefore, this becomes an important consideration and needs to be traced and demarcated to see if the area corresponds to a specific dermatome. A brush or cotton wisp is often used for light touch, while a sharp object such as a sterile Wartenberg pinwheel is used for pressure and pain testing.

    Pain and other sensory disturbances caused by subluxation may be due to direct nerve root involvement and, therefore, of the nature just described. They may also be due to reflex irritation of intra-articular mechanoreceptors or of the perivertebral ligaments, tendons, or muscles and, like other myofascial trigger areas, refer pain into somatic areas that do not correlate to direct dermatomes or specific nerve roots.

    Sensory Loss.   This may be due to the same factors that produce pain, as just described; however, upper motor neuron lesions (ie, brain or cord injuries or disease) may also exist. In such cases, abnormal reflexes and other signs manifest such as loss of superficial reflexes, exaggerated deep tendon reflexes, and spastic paralysis.

      Motor Disturbances

Motor disorders may be caused by the same disease processes as are sensory disturbances such as from direct nerve injury, disease, reflexes from visceral organs, nerve root involvement, or upper motor neuron lesions. These last two etiologies are particularly significant.

Motor nerve root involvement may be characterized by deep pain in the muscles innervated. In early stages, hypertonicity or muscular spasm is evident. In late stages or in chronic conditions, loss of tendon reflexes, muscular weakness, atrophy, and trophic changes in the overlying skin may manifest.

Differentiation of Upper and Lower Motor Neuron Lesions

See Table 3.1

     Table 3.1. Differentiation of Upper and Lower Motor Neuron Lesions
                       Upper Motor            Lower Motor
Consideration          Neuron Lesion          Neuron Lesion             
Site                   Cerebral cortex or     Anterior horn or peripheral
                         pyramidal tract        motor neuron

Distribution           Diffuse or patchy      Segmental (number)

Paralysis type         Spastic and rigid      Flaccid

Superficial reflex     Absent                 Absent

Deep reflex            Exaggerated            Absent

Atrophy                Disuse                 Rapid extension, trophic

Trophic lesions        Minimal                Intense and extensive

Pathologic signs       Present                Absent

Superficial and Deep Reflexes

See Table 3.2.

     Table 3.2. Chart of Superficial and Deep Reflexes
                    Afferent          Center        Efferent
Corneal             V                 Pons          VII
Uvular              IX                Medulla       X
Upper Abdominal     T7–T9             Cord          T7–T9
Lower Abdominal     T10–T12           Cord          T10–T12
Cremasteric         Femoral           L1            Genitofemoral
Plantar             Tibial            S1–S2         Tibial
Anal                Pudendal          S4–S5         Prudential
Consensual          II                Midbrain      III
Accommodation       II                Occipital     III
Ciliospinal         Sensory nerve     T1–T2         Cervical sympathetics
Oculocardiac        V                 Medulla       X
Carotic Sinus       IX                Medulla       X

Deep Reflexes
Biceps              Musculocutaneous  C5–C6         C5–C6
Triceps             Radial            C6–C7         C6–C7
Radial              Radial            C6–C8         C6–C8
Patellar            Femoral           L2–L4         L2–L4
Achilles            Tibial            S1–S2         S1–S2
Jaw jerk            Trigeminal        Pons          Trigeminal

Neurologic Aspects of Subluxation Syndromes

As previously described, the disturbances of neurologic function associated with subluxation syndromes are manifested as abnormalities in sensory interpretations and/or motor activities. These disturbances may be through one of two primary mechanisms: direct nerve or root disorders, or of a reflex nature.

      Nerve Root Insults

When direct involvement occurs on the posterior root of a specific neuromere, it manifests as an increase or decrease in awareness over the dermatome; ie, the superficial skin area supplied by this segment. Such a manifestation is often tested by a cotton wisp and sterile pinwheel. Typical examples might include foraminal occlusion or irritating factors manifesting hyperesthesia, particularly on the:

  • Dorsal and lateral aspects of the thumb and radial side of the hand when involvement occurs between C5 and C6.

  • Dorsum of the hand, the index and middle fingers, and the ventral-radial side of the forearm, thumb, index and middle fingers when involvement occurs between C6 and C7.

  • Anterolateral aspect of the leg, medial foot, and great toe when involvement occurs between L4 and L5.

  • Posterolateral aspect of the lower leg, lateral foot and toes when involvement occurs between L5 and S1.

In other instances, nerve root involvement may cause hypertonicity and the sensation of deep pain in the muscles supplied by this neuromere. For example:

(1) C6 involvement — deep pain in the biceps;

(2) C7 involvement — deep pain in the triceps and supinators of forearm; and

(3) L4 and L5 involvements — deep pain or cramping sensations in the buttock, posterior thigh and calf, and/or anterior tibial muscles. In addition, pressure against the nerve root and/or its distribution may be particularly painful.

Nerve root insults from subluxations also may be evident as disturbances in motor reflexes and/or muscular strength. Examples include the deep tendon reflexes such as:

(1) reduced biceps reflex when involvement occurs between C5 and C6;

(2) reduced triceps reflex when involvement occurs between C6 and C7; and

(3) reduced patellar and Achilles reflexes when involvement occurs between L4 and L5. These reflexes must always be compared, one side to the other, to judge whether a hyporeflexia is unilaterally present. And, of course, unilateral hyperreflexia is pathognomonic of an upper motor neuron lesion.

Muscle strength may be tested in various manners, depending on which muscles are involved. The common procedure is to compare the isometric strength of resistance against counterpressure. For example:

(1) weakness in the biceps when involvement occurs between C5 and C6;

(2) weakness in triceps when involvement occurs between C6 and C7;

(3) weakness in the anterior tibialis when involvement occurs between L4 and L5;

(4) weakness in the posterior calf when involvement occurs between L5 and S1.

Prolonged and/or severe nerve root irritation may also produce evidence of trophic changes in the tissues supplied. This may be characterized by obvious atrophy, but such a sign is particularly objective when the circumference of an involved limb is measured at the greatest girth in the initial stage and this value is compared to measurements taken in later stages. The calf, thigh, forearm, and upper arm are therefore measured and recorded in many routine examinations.

      Reflex Irritations

In addition to nerve root involvement and/or peripheral irritations, many sensory disturbances can be caused by reflex irritation to somatic musculoskeletal tissues. These symptoms lack the typical features of nerve root involvement such as seen with cervical compression tests, and they usually do not create significant motor changes. They often arise from inflammatory tissues or fibrotic muscles, tendons, or ligaments, which characteristically act as "trigger" areas. That is, their stimulation such as with deep pressure initiates reflex pain. Injured musculoskeletal tissues may be an effect of a subluxation syndrome or they may exist as a primary injury that will cause and/or perpetuate abnormal articular position and motion.

Some typical reflex neuralgias are:

  • The marked hypertonicity and tenderness of the occipital musculature and the consequent C1 or C2 neuralgia associated with upper cervical subluxations.

  • The hypertonicity and tenderness of the muscles and tendons of the rotator cuff consequent to rotator-cuff tendinitis and associated with referred pain into the posterolateral arm and often encouraged by cervical subluxations and spondyloarthrosis.

  • The hypertonicity and tenderness of muscles about the scapula are common to the scapulocostal syndrome. These areas often cause reflex pain along the ulnar side of the upper extremity and are frequently encouraged by a regional thoracic scoliosis with thoracocostal subluxations.

  • The hypertonicity and tenderness of the gluteal muscles and sacroiliac ligaments, which may reflect pain over the sciatic trajectory and are often causing or being effected by sacroiliac subluxations.

  • The hypertonicity and tenderness of the piriformis (which may cause a posterior sciatic reflex neuralgia) and peripheral nerve pressure, which is common to many sacral subluxations.

  • The hypertonicity and tenderness of the tensor fascia latae and the consequent reflex pain along the lateral thigh, associated with iliofemoral tendinitis and innominate subluxation.

There are many other examples of this type of referred pain from irritations in musculoskeletal tissue, and the relationships of these supporting tissues to the subluxation syndrome must always be appraised. That is, are they an effect or are they due to primary injury? Will they create a subluxation syndrome that may now perpetuate these neuropathic processes? Consequently, the proper treatment of sprain and strain injuries, tendinitides, myositides, fibrositides, and so forth, becomes important to the prevention and/or correction of a subluxation syndrome.

      Other Causes

There are other causes of abnormalities of sensation or pain such as direct traumatic injury, nerve inflammations or degenerations of a peripheral or central nature, local peripheral nerve injury or causalgia, vascular disease and occlusions, and reflex pains from diseased internal viscera. Thus, a complete case history and clinical examination are often required to rule out these possible conditions or determine their relationship with a subluxation syndrome.

There are still many other clinical features associated with or pathognomonic of a subluxation syndrome, but the features developed here are those which are the more commonly appraised and evaluated. The necessary factor is that a correlation and evaluation of all pertinent signs and symptoms be made, not only a few isolated findings.

Closing Remarks

Favorable response to chiropractic spinal adjustments is witnessed when symptoms are due to angiospastic and other vasomotor disorders. When signs and symptoms suggest an etiology such as tumor, grave cerebral vascular accidents, and intracranial infectious diseases, the case should have immediate consultation with possible referral for specialized care.


Glossary of Common Orthopedic and Neurologic Tests, Signs, Maneuvers,
Reflexes, Syndromes, and Related Clinical Phenomena

Jump to: | B | C | D | E | F | G | H | I | J | K | L | M |
  | N | O | P | Q | R | S | T | U | V | W | Y |

Abadie's sign.   A lack of deep pain during strong pinching of the Achilles tendon. It is an early sign of tabes dorsalis.

Abarognosis test.   The blindfolded patient is asked to estimate the weight of several objects.

Abbott-Saunders test.   A modification of Yergason's test that forces the biceps tendon against the lesser tuberosity which will stress an instable tendon. The arm of the sitting patient is brought into full abduction, rotated externally, and then lowered to the patient's side. A "click" felt or heard, frequently accompanied by pain and a reproduction of symptoms, indicates subluxation or dislocation of the biceps tendon.

Abdominal reflexes.   Skin reflexes tested by light stroking with a blunt instrument such as a tongue blade toward the middle of the abdomen from the lateral border, at the level of the umbilicus, and above and below it. Some authorities recommend that a sterile pinwheel be used. The upper abdominals are supplied by T8 T10; lower, T10 T12. Contraction of the abdominal muscles of the same side causes a pulling of the umbilicus toward the stimulus. This test of superficial reflexes is unreliable in the obese, pregnant, or those with lax abdominal walls. Similar contraction effects elicited by tapping neighboring bony structures are called deep abdominal reflexes.

Accommodation reflex.   The normal dilation and contraction of the pupil for far and near vision. It is progressively weakened and may be lost in the presbyopic and development of cataract but is persistent with the Argyll Robertson pupil sign of tabes.

Accommodation test.   The patient is instructed to face the light and look at some object about 2 feet from the eyes and then look toward a distant object. When looking at a near object, accommodation should accompany convergence and pupil constriction. A pupil acting better to accommodation than to light indicates an Argyll Robertson pupil (eg, in syphilis). A normally dilated pupil in room light that reacts sluggishly to both accommodation and light but constricts with prolonged stimulation is an Adie's pupil (eg, in ciliary ganglion disease).

Achilles reflex.   The ankle jerk is obtained best by having the patient kneel in a padded chair with the feet projecting. The patient is asked to relax the feet, then the Achilles tendon is tapped just below the level of the malleoli, comparing the two sides. Ankle jerks are absent bilaterally in tabes dorsalis and frequently in normal old age. The response is increased in lesions of the pyramidal tract. A reduced or absent reflex may point toward an IVD herniation between L5 and S1 or L4 and L5. If the patient is in bed, flex and externally rotate the thigh and leg to about 45° until the knee rests on the bed or pillow. Grasp the foot with one hand and hold it easily at right angles to the leg. Then tap the Achilles tendon as previously described.

Achilles tap test.   With the patient prone, the patient's knee is flexed to a right angle. With a reflex hammer, the Achilles tendon is tapped about an inch above its insertion at the calcaneus. If pain is induced or the normal plantar flexion reflex of the foot is absent, a rupture of the Achilles tendon should be suspected.

Acromial reflex.   A short, sharp percussion blow is made on the acromion or coracoid process, evoking reflex flexion of the forearm with external rotation of the hand. This pathologic reflex is often seen in hyperkinetic states such as tetany and sometimes in disseminated and lateral sclerosis.

Adams' sign.   If the patient has a S or C scoliosis, note if the scoliosis straightens when the spine is flexed forward. If it does, it is a negative sign and evidence of functional scoliosis. A positive sign is noted when the scoliosis is not improved, thus evidence of a structural scoliosis.

Adaptive constriction test.   Along with convergence and accommodation, the pupils should normally contract on looking at a near object. The pupils are narrowed as an optical aid to regulate the depth of focus. This type of near-object pupil constriction does not depend on changes in illumination and is separate from direct and consensual light reflexes.

Adductor magnus reflex.   With the patient supine and the thigh moderately abducted, a normal response is seen when the tendon of the adductor magnus is tapped and a contraction of the muscle occurs. This reflex reaction tests the integrity of the obturator nerve and L2–L4 segments of the spinal cord, as does the patellar reflex.

Adiadochokinesia test.   The patient is asked to perform rapid alternating movements of a limb (eg, wide hand clapping).

Adie's sign.   A benign disorder of the pupil featuring a very weak light reflex, which is delayed for several seconds, and near-point impairment. The pupil does react to light, but it is slow or delayed in its response. It can be confused with the Argyll Robertson pupil. Adie's pupil is larger than normal and often found in young women with decreased or absent tendon reflexes. It is sometimes called the tonic pupil sign.

Adson's test.   With the patient sitting or standing, the examiner palpates the radial pulse and advises the patient to bend the head obliquely backward toward the side being examined, take a deep breath, and tighten the neck and chest muscles on the side tested. The maneuver decreases the interscalene space (anterior and middle scalene muscles) and increases any existing compression of the subclavian artery and lower components (C8 and T1) of the brachial plexus against the 1st rib. Marked weakening of the pulse or increased paresthesias indicate a positive sign of pressure on the neurovascular bundle, particularly of the subclavian artery as it passes between or through the scaleni musculature, thus indicating a probable cervical rib or scalenus anticus syndrome. This test is sometimes called the scalene maneuver.

Alarm points.   Eighteen specific sites located on the anterior thorax and the abdomen offer diagnostic clues to meridian malfunction in Oriental medicine. All alarm (mo) points are located on the ventral surface of the thorax and the abdomen, and each point is associated with one of the 12 main meridians and its function. Six of the meridian alarm points are located on the central conception vessel meridian, thus they are unilateral. The other six alarm points are bilateral, giving a total of 18 alarm points in all. It is thought by Oriental physicians that tenderness or pain elicited by light pressure on or spontaneous pain at any of these points indicates that the meridian has excessive energy (Chi). Tenderness only on heavy pressure suggests that there is a deficiency of Chi. Increased or decreased electropermeability is thought to have the same significance as light or deep tenderness. Generally, the alarm points are associated with the Yin types of diseases; viz, those diseases associated with cold, depression, and weakness.

Allen's-test.   The sitting patient elevates the arm and is instructed to make a tight fist to express blood from the palm. The examiner occludes the radial and ulnar arteries by finger pressure. The patient then lowers the hand and relaxes fist, and the examiner releases the arteries one at a time. Some examiners prefer to test the radial and ulnar arteries individually in two tests. The sign is negative if the pale skin of the palm flushes immediately when the artery is released. The patient should be instructed not to hyperextend the palm as this will constrict skin capillaries and render a false positive sign. The sign is positive if the skin of the palm remains blanched for more than 3 seconds. This test, which should be performed before Wright's test, is significant in vascular occlusion of the artery tested.

Allis' hip sign.   Relaxation of the fascia between the crest of the ilium and the greater trochanter. It suggests a fracture of the neck of the femur.

Allis' knee sign.   With the patient supine, knees flexed, and soles of feet flat on the table, the examiner observes the heights of knees superiorly from the foot of the table. If the top of one knee is lower than the other, it is indicative of a unilateral hip dislocation, a severe coxa disorder, or a short femur.

Anal reflex.   Normal contraction of the anal sphincter induced on light stimulation of the anal skin. This reflex is also initiated when a gloved finger is inserted into the rectum, as during a prostate examination. It is absent in posterior column diseases such as tabes dorsalis and advanced pernicious anemia, and in lesions of the cauda equina or conus medullaris. In such conditions, extreme anal dilation is not painful. The anal reflex becomes highly sensitive and causes a painful sphincter spasm with such conditions as anal fissures and inflamed crypts.

Andre-Thomas signs.   This sign occurs in cerebellar disease and consists of a rebound when the finger-to-nose test is conducted; ie, the patient will touch the nose several times. When asked to raise the arm above the head and suddenly told to let it drop upon the head, it will rebound. A sign such as this is also called the spring-like phenomenon.

Ankle clonus.   The examiner flexes the patient's leg and thigh to a 45° angle with one hand, while the other hand brings the foot smartly up to acute flexion. Ankle clonus exhibits as pathologic rapid contractions and relaxations of the foot, but a rapidly exhaustible ankle clonus may be normal. Note if the clonus is sustained. Ankle clonus has the same clinical significance as patella clonus and is often associated with it.

Ankle dorsiflexion test.   Limitation of the gastrocnemius or soleus muscle restricting ankle dorsiflexion can be differentiated by this test. Have the patient sit on the examining table with the knees flexed and relaxed. Grasp the foot and flex the knee to slacken the gastrocnemius, then dorsiflex the ankle. If this can be achieved, the gastrocnemius is the cause of the restriction. If the soleus is at fault, it will not be affected by knee flexion; ie, it will be the same in either knee flexion or extension.

Ankle lateral-medial (eversion-inversion) stability tests.   Gross lateral instability results when both the anterior talofibular and calcaneofibular ligaments are torn. To test lateral stability, stabilize the patient's leg and invert the heel back and forth, noting if the talus rocks loosely in the ankle mortise. Medial instability is the result of a tear or stretch of the deltoid ligament. To test medial stability, stabilize the patient's leg and evert the heel back and forth, noting any gap at the ankle mortise.

Ankle tourniquet test.   A sphygmomanometer cuff is wrapped around the suspected ankle, inflated to a point slightly above the patient's systolic blood pressure, and maintained for 1 2 minutes. An increase in foot pain signifies tarsal tunnel syndrome or a similar circulatory deficit.

Anterior doorbell sign.   The examiner faces the sitting patient. A slight pressure is exerted over the emerging ventral roots of the cervical spine. Contact is made with the thumbs held horizontally. A positive sign is the reproduction or exaggeration of patient symptoms (eg, upper-extremity pain, paresthesia).

Anterior drawer sign.   The anterior and posterior cruciate ligaments provide A-P stability to the knee joint. These intracapsular ligaments arise from the tibia and insert onto the inner aspects of the femoral condyles. To evaluate anterior stability, place the patient supine and flex the knees to 90° so that the feet are flat on the table. The examiner should sit sideways so that his hip can stabilize the patient's feet from moving during the tests. The examiner positions his hands around the knee being examined, similar to but lower than the bony palpation starting position; ie, thumbs pointing superiorly over the lateral and medial joint lines with fingers wrapped around the lateral and medial insertions of the hamstrings. In this position, the examiner pulls the tibia forward. When a distinct sliding forward of the tibia from under the femur is noted, it indicates a torn anterior cruciate ligament. Slight anterior sliding, however, is often normal. A positive sign should be confirmed by repeating the maneuver with the patient's leg internally rotated 30° and externally rotated 15°. The reason for this is that even if the anterior cruciate ligament is torn, external rotation should reduce forward movement of the tibia; if it does not, both the anterior cruciate and the anteromedial joint capsule may be torn. Likewise, even if the anterior cruciate ligament is torn, internal rotation should reduce forward movement of the tibia. If it does not, both the anterior cruciate and the anterolateral joint capsule may be torn. The medial collateral ligaments may also be involved in loss of A-P stability. Also see posterior drawer sign.

Apley's compression test.   The patient is placed prone with one leg flexed at 90°. The examiner stabilizes the patient's thigh with a knee and grasps the patient's foot. Downward pressure is applied to the foot to compress the medial and lateral menisci between the tibia and femur. The examiner then rotates the tibia internally and externally on the femur, holding downward pressure. Pain during this maneuver indicates probable meniscal or collateral damage. Medial knee pain suggests medial meniscus damage; lateral pain, lateral meniscus injury.

Apley's distraction test.   Apley designed this test to follow his compression test as an aid in differentiating meniscal from ligamentous knee problems. With the patient and the examiner in the same position as in the compression test, the examiner applies traction (rather than compression) while the leg is rotated internally and externally. This maneuver reduces pressure upon the menisci but stretches the medial and lateral ligaments of the knee.

Apley's scratch test.   This is a two-phase test:

(1) The patient (sitting or standing) is asked to raise the arm on the involved side overhead, flex the elbow, and then place the fingers as far down on the opposite shoulder blade as possible.

(2) The patient is then asked to relax his arm at the side, then place the hand behind his back and attempt to touch as far up on the opposite scapula as possible. If either of these maneuvers increases shoulder pain, inflammation of one of the rotator cuff's tendons should be suspected. The supraspinatus tendon is most commonly involved. Restricted motion without sharp pain points to osteoarthritis or shortened soft tissues.

Argyll Robertson sign.   This is an abnormally small pupil that fails to respond to the light reflex but does constrict with accommodation and convergence a well-established sign of CNS syphilis. The pupils are irregular and unequal in diameter, fail to change in size in reaction to light both directly and consensually, and exhibit a normal near response.

Arm drop test.   Hold the patient's arm horizontally at 90° abduction and then ask the patient to hold that position without assistance. If this cannot be done actively for a few moments without pain, it suggests a torn rotator cuff. In lesser tears, the patient may be able to hold the abduction (a slight tap on the forearm will make it drop) and slowly lower it against the side, but the motion will not be smooth.

Arm extension tests.   Have the patient in the erect position with the eyes closed extend the arms straight forward with the hands parallel. This position is held for 20 30 seconds; then the arms are extended straight upward over the head with the palms facing forward and held for 20 30 seconds. Note if there is any drooping of an arm or for a tendency of an arm and hand to flex and rotate internally because this is one of the earliest signs of CNS paresis. A drift of the upper extremity down and out suggests a cerebellar disorder. Senile and familial tremors appear in the outstretched hands. They disappear at rest and are aggravated by stress.

Babinski's plantar reflex.   The foot should always be warm before testing. With the patient prone or supine, stroking the sole of the relaxed foot with a moderately sharp instrument will usually result in rapid plantar flexion of the toes. Normally, all the toes plantar flex. When the small toes fan in plantar flexion and the great toe simultaneously moves upward in strong dorsiflexion, a positive Babinski sign is elicited. A positive sign is normal in children up to 5 years; in adults, it is indicative of pyramidal tract involvement in cerebral edema, brain injuries, meningitis, and after the use of morphine. Depending on the cause, the sign may be bilateral or unilateral as in the case of hemiplegia. If the plantar reflex is in any way abnormal, it should be recorded even if a typical Babinski sign is not present. A Babinski plantar response is the most constant of all pathologic reflexes.

Babinski's sciatica sign.   A lessening or lack of the patellar tendon reflex in sciatica.

Babinski-Weil sign.   The patient is instructed to walk several steps straight forward and then backward with the eyes closed. In cases of internal ear disease (eg, labyrinthitis), the patient will bend to one side while walking forward and then to the other side when walking backward. If the patient leans to only one side when walking either forward or backward, it signifies an ipsilateral cerebellar lesion.

Bakody's test.   The sitting patient is asked to raise the arm laterally to a horizontal position, flex the elbow, and then place the open palm on the top of the head. This maneuver should relieve traction on the ipsilateral lower cervical roots and offer relief of nerve root irritation in cases of a brachial plexus syndrome.

Baron's sign.   The patient is placed supine, relaxed, and instructed to breath deeply. The examiner's fingers are placed on Poupart's ligament and pressure is made in the direction of the psoas muscle. The patient is then told to elevate the leg of the same side with the knee extended, forming about a 45° angle at the hip. In this position, the examiner's fingers can readily palpate the now tensed psoas muscle. Similar palpation should be made bilaterally for comparison. In suspected cases of chronic appendicitis, Baron found that the right psoas muscle was frequently hypersensitive to pressure. Even in the healthy individual, a tensed psoas may be tender, but when the appendix or right ovary is involved, the tenderness is more marked on the right side. It is also important to realize that because the psoas is covered by peritoneum it can be painful in the presence of sacrospinal and gluteal myalgias; in lumbar, lumbosacral, and iliosacral arthrosis; and sometimes in sciatica.

Barre-Lieou test.   The sitting patient is asked to slowly but firmly rotate the head first to one side and then to the other. Transient mechanical occlusion of the vertebral artery may be precipitated by simply turning the head, and this phenomenon is attributed to the compressive action of the longus colli and scalene muscles on the vertebral artery, just before its course through the IVF of C6. A positive sign is exhibited if dizziness, faintness, nausea, nystagmus, vertigo, and/or visual blurring result, indicative of buckling or compression of the vertebral artery.

Battle sign.   An area of ecchymosis occurring over the course of the posterior auricular artery that develops first near the tip of the mastoid process: an important sign of basilar fracture.

Bechterew's test.   The patient in the sitting position attempts to extend each leg one at a time followed by an attempt to extend both legs. The sign is positive if backache or sciatic pain is increased or the maneuver is impossible. In disc involvements, extending both legs will usually increase spinal and sciatic discomfort.

Beery's sign.   This sign is positive if a patient with a history of lower trunk discomfort and fatigue is fairly comfortable when sitting with the knees flexed but experiences discomfort in the standing position. It is typically seen in spasticity or contractures of the posterior thigh and/or calf muscles.

Beevor's sign.   The examiner notes the position of the umbilicus when the patient tenses the abdominal muscles as in trying to rise from a recumbent position with the hands behind the head. Movement of the umbilicus upward signifies paralysis or weakness of the lower abdominal muscles. If the umbilicus moves right, weakness of left abdominal muscles is indicated. If the umbilicus moves left, weakness of the right abdominal muscles is indicated. A positive sign points to segments T6 T10 such as in spinal cord or vertebral injury, disease, or tumor; eg, vertebral tumor, anterior poliomyelitis, transverse myelitis, compression fracture, multiple sclerosis, or disc protrusions.

Belt test.   The standing male patient, with feet about 12–15 inches apart, flexes forward with the examiner holding the patient's belt at the back. If bending over without support is more painful than with support, it suggests a sacroiliac lesion. Conversely, if bending over with support is more painful than without support, it suggests a lumbosacral or lumbar involvement. A variation of this test is to stand behind the patient and place your hands so that they firmly support the patient's innominates. Some examiners brace a hip against the patient's sacrum when the patient flexes forward to stabilize the pelvis.

Bent-knee pull test.   This maneuver attempts to duplicate the pain pattern in patients with an upper lumbar root lesion. The examiner pulls the prone patient's bent knee upward (posterior) while putting downward (anterior) pressure on the ipsilateral buttock. This test may prove positive even if Lasegue's SLR test is negative.

Biceps reflex.   The muscles of the patient's arm are bared and relaxed, and then the arm is flexed at the elbow. The examiner places a thumb over the biceps tendon and makes a light blow with a percussion hammer. Note if the biceps muscle contracts, how quickly it contracts, and with what force. The biceps reflex, a normal response, tests C5–C6 segments in terms of integrity of the musculocutaneous nerve. It is hyperactive in the same disorders that cause a hyperactive knee jerk.

Bikele's test.   The sitting patient is asked to raise the arm laterally to a horizontal and slightly backward position, flex the elbow, and laterally flex the neck to the opposite side. If active extension of the elbow, which stretches the brachial plexus, produces resistance and increased cervicothoracic radicular pain, the test is said to be positive for a nerve root or spinal cord inflammatory process (eg, brachial neuritis, meningitis).

Bing's test.   A tuning fork is placed on the vertex of the patient's head and one ear is covered. Because of bone conduction, the covered ear normally hears the tuning fork better than the uncovered ear. If no sound is heard in the covered ear (a positive sign), nerve deafness is indicated.

Bladder reflex.   Normal sphincter control of the bladder is under the control of the pelvic autonomic nerves. If motor fibers to the sphincter are impaired, incontinency results. If sensory fibers are impaired, distention and dribbling result because the urge to urinate has been diminished (eg, tabes dorsalis).

Bonnet's sign.   The lower limb of the supine patient is internally rotated and adducted, and then a Lasegue's SLR test is conducted. A positive sign occurs when pain occurs sooner than during a normal SLR test, indicative of sciatic radiculopathy.

Booth-Marvel test.   The examiner abducts the patient's arm laterally to the horizontal position, flexes the elbow to a right angle, and deeply palpates the bicipital groove as the humerus is passively rotated internally and externally. If the transverse humeral ligament has been stretched, a painful and palpable snap will be felt and sometimes heard as the tendon of the long head displaces from the bicipital groove.

Bounce-home test.   The patient is placed supine. The examiner cups one hand under the patient's heel and slightly flexes the patient's knee with the other hand. While the patient's heel is held, the patient's knee is allowed to passively drop gently toward the top of the table in full extension, normally with an abrupt stop. If this full extension is not achieved and passive pressure elicits a "rubbery" resistance to extension, a motion block is likely. This lack of full extension points to a torn meniscus, intracapsular swelling, or a loose fragment within the knee joint.

Bowstring sign.   If pain occurs during Lasegue's SLR test, the knee is slightly flexed and the patient's foot is allowed to rest on the examiner's shoulder. When the pain subsides, manual pressure is applied against the hamstrings. If this does not increase pain, manual pressure is quickly applied to the popliteal fossa while holding the knee as straight as patient comfort will allow. Although local pain in the popliteal fossa is of minor consequence, a reproduction of leg or back pain is highly significant of an IVD rupture producing nerve root compression.

Bracelet test.   In rheumatoid arthritis, compression of the distal ends of the radius and ulnar initiates acute pain in the forearm, wrist, and/or hand.

Bradburne's sign.   During the acute stage of cervical cord contusion or compression (with or without vertebral fracture), a sign of spinal cord damage in the area of C5 and C6 is exhibited by bilateral abduction of the arms and then flexion with external rotation of the forearms.

Bragard's test.   If Lasegue's SLR test is positive at a given point, the leg is lowered below this point and dorsiflexion of the foot is induced. The sign is negative if pain is not increased. A positive sign is a finding in sciatic neuritis, spinal cord tumors, IVD lesions, and spinal nerve irritations. A negative sign points to muscular involvement such as tight hamstrings. Bragard's test does not stress the sacroiliac or lumbosacral articulations.

Brudzinski's hip sign.   When one lower limb of a supine patient is passively flexed at the hip, the opposite leg flexes. This sign, also known as the contralateral reflex, occurs in acute cerebroleptomeningitis.

Brudzinski's neck sign.   A positive sign is elicited when the patient's head is passively flexed toward the chest which is followed by involuntary flexion of the lower limbs. Such a reaction is indicative of meningeal irritation. In such cases, the neck is rigid and painful to flexion and, in most cases, also to rotation. This test is unreliable in children to 2 years.

Bryant's sign.   A posttraumatic ipsilateral lowering of the axillary folds (anterior and posterior pillars of the armpit) with level shoulders suggests dislocation of the glenohumeral articulation.

Buckling sign.   Automatic flexion of the knee to relieve traction on the sciatic nerve when Lasegue's SLR test is conducted: significant of sciatic radiculopathy.

Buerger's test.   The patient is placed supine with the knees extended in a relaxed position, and the examiner lifts a leg with the knee extended so that the lower limb is flexed on the hip to about a 45° angle. The patient is then instructed to move the ankle up and down (dorsiflex and plantar flex the foot) for a minimum of 2 minutes. The limb is then lowered, the patient is asked to sit up, the legs are allowed to hang down loosely over the edge of the table, and the color of the exercised foot is noted. Positive signs of arterial insufficiency are found if

(1) the skin of the foot blanches and the superficial veins collapse when the leg is in the raised position and/or

(2) it takes more than a minute for the veins of the foot to fill and for the foot to turn a reddish cyanotic color when the limb is lowered.

Bunnel-Littler test.   Hold the patient's metacarpophalangeal joint in slight extension and try to flex the proximal interphalangeal joint of any finger being tested. If the joint cannot be flexed in this position, it is a positive sign that the intrinsic muscles are tight or capsule contractures exist. To distinguish between intrinsic muscle tightness and capsule contractures, let the involved metacarpophalangeal joint flex slightly, relaxing intrinsics, and move the proximal interphalangeal joint into flexion. Full flexion of the joint shows tight intrinsics; limited flexion suggests probable contracture of the interphalangeal joint capsule. This is sometimes called the retinacular test or finger contracture test.

Buttock sign.   A lower extremity of a supine patient is passively flexed at the hip with the knee extended as in an SLR test. If the flexion of the limb on the trunk is restricted by local or radiating buttock pain (rather than pain in the hip or lower back), it is significant of an inflammatory pelvic lesion such as ischiorectal abscess, osteomyelitis of or near the hip joint, coxa bursitis, sacroiliac septic arthritis, or an advanced pelvic neoplasm.

Caloric test.   Alternately douche warm and cold water into an ear, after determining that the eardrum is not perforated. The patient should be seated with the head tilted backward about 60° to bring the horizontal semicircular canal into a vertical plane. Normally, warm water (not exceeding 120°F) produces rotary nystagmus, first away and then toward the irrigated ear. Cold water produces an opposite effect nystagmus first toward and then away from the ear irrigated. The final response normally appears within 30–40 seconds. Lack of response shows decreased or absent vestibular nerve function; ie, no nystagmus results if the labyrinth is diseased. The test should be discontinued if there is no reaction within 3 minutes. This procedure is also called Barany's test or the thermal test.

Carnett's maneuver.   This is used by some to differentiate tenderness of visceral origin to that of the parietes. The abdominals are tightened by having the supine patient raise the head or ballooning the abdomen outward and fixing it in that position to prevent the examiner from making pressure on an underlying viscus. If tenderness still remains, it points to hypersensitive parietes, resulting from a visceroparietal reflex or transference of pain to the parietes supplied by a spinal nerve in the same spinal segment as that innervating the diseased organ. Superficial tenderness is often of parietal origin, frequently due to spinal arthritis or curvatures.

Carotid sinus reflex.   Pressure applied to the carotid area slows the heart rate and produces a fall in blood pressure. The reflex originates in the wall of the sinus of the internal carotid artery. If heavy, prolonged pressure is applied, dizziness or fainting may result. This normal reflex becomes hyperactive during attacks of vasomotor instability and hypoactive in lesions of Cranial IX (afferent portion) and Cranial X (efferent portion).

Cervical active rotary compression test.   With the patient sitting, observe while the patient voluntarily laterally flexes the head toward the side being examined. With the neck flexed, the patient is then instructed to rotate the chin toward the same side, which narrows the IVF diameters on the side of concavity. Pain or reduplication of other symptoms suggests a physiologic narrowing of one or more IVFs.

Cervical distraction test.   With the patient sitting, the examiner stands to the side of the patient and places one hand under the patient's chin and the other hand under the base of the occiput. Slowly and gradually the patient's head is lifted to remove weight from the cervical spine. This maneuver elongates the IVFs, decreases the pressure on the joint capsules around the facets, and stretches the perivertebral muscles. If the maneuver decreases pain and relieves other symptoms, it suggests narrowing of one or more IVFs, cervical facet syndrome, or spastic perivertebral muscles.

Cervical compression tests.   Two tests are involved. First, with the patient sitting, the examiner stands behind the patient and the patient's head is laterally flexed and rotated about 45° toward the side being examined. Interlocked fingers are placed on the patient's scalp and gently pressed caudally. If an IVF is physiologically narrowed, this maneuver will further insult the foramen by compressing the disc and narrowing the foramen, causing pain and reduplication of other symptoms. In the second test, the patient's neck is extended by the examiner placing interlocked hands on the patient's scalp and gently pressing caudally. If an IVF is physiologically narrowed, this maneuver mechanically compromises the foraminal diameters bilaterally and causes pain and reduplication of related symptoms.

Cervical percussion test.   The neck of a sitting patient is flexed to about 45° while the examiner percusses each of the cervical spinous processes and adjacent superficial soft tissues with a rubber-tipped reflex hammer. Evidence of point tenderness suggests a fractured or acutely subluxated vertebra or localized sprain or strain, while symptoms of radicular pain suggest radiculitis or an IVD lesion.

Chaddock's ankle reflex.   Stroking the lower leg just behind and under the external malleolus with the handle of a reflex hammer elicits a Babinski-like sign. It is positive in conditions involving the pyramidal tract.

Chapman's test.   With the patient in the supine position, the examiner stabilizes the patient's legs and asks the patient to attempt to flex the trunk to the sitting position without using the hands. This test, which requires strong contraction of the abdominals, is positive for abdominal weakness if the patient is unable to sit upright but abdominal pain is not produced. If abdominal pain occurs during the attempt, an inflammatory abdominal lesion should be suspected.

Chest expansion test.   With the patient standing, chest measurements are taken around the circumference of the thorax near the nipple level: first after the patient inhales and then after the patient exhales completely. A 2-inch difference (possibly less in females) is a negative sign. A positive sign is indicated by no or very little difference in measurements a suspicion of osteoarthritic ankylosis or ankylosing spondylitis.

Childress' test.   This is a two-phase test:

(1) The patient is asked to stand with the feet separated 12–18 inches apart, assume a "knock-kneed" position by rotating the thighs inward, and then attempt to squat as low as possible. Pain, joint restriction, or a clicking sensation suggests a lesion of the medial meniscus.

(2) The test is then conducted with the patient assuming a "bowed-leg" position by rotating the thighs outward before squatting. Pain, joint restriction, or a clicking sensation when attempting to squat suggests a lesion of the lateral meniscus.

Chvostek's sign.   In cases of tetany, percussion over the masseter muscle (just below and in front of the ear) when the mouth is partly open produces spasmotic contraction of the ipsilateral facial muscles due to facial nerve hyperexcitability.

Ciliary reflex.   The normal actions of the pupil during accommodation to light or distance.

Ciliospinal reflex.   This normal reflex is produced by pinching the skin, particularly at the neck, which results in dilation of the pupils. The reaction depends on the integrity of the cervical sympathetic nerves (eg, interrupted in Horner's syndrome). It should be noted, however, that a painful stimulus applied to any part of the body will normally produce pupil dilation.

Clarke's sign.   The supine patient extends the knee and relaxes the quadriceps. The examiner places the web of a hand against the superior aspect of the patella and depresses it distally. The patient then actively contracts the quadriceps as the examiner compresses the patella against the condyles of the distal femur. The sign is positive if the patient cannot maintain contraction without producing sharp pain.

Claudication test.   If lower extremity claudication is suspected, the patient is instructed to walk on a treadmill at a rate of 120 steps/minute. If cramping, and sometimes a skin color change, occurs, the approximate level of the local lesion can be identified. The time span between the beginning of the test and the occurrence of symptoms is used to record the "claudication time," which is usually recorded in seconds.

Cochleopapillary reflex.   The normal blinking reaction of the eyelids and pupil contraction followed by dilation after hearing an unexpected loud noise. It is absent in labyrinthine disease.

Codman's sign.   This is a variation of the shoulder abduction stress test and the arm drop test. If the patient's arm can be passively abducted laterally to about 100° without pain, the examiner removes support so the position is held actively by the patient. This produces sudden deltoid contraction. When a rupture of the supraspinatus tendon or strain of the rotator cuff exists, the pain produced causes the patient to hunch the shoulder and lower the arm.

Cogwheel sign.   This sign consists of irregular jerky movements when a hypertonic muscle is passively stretched. Often called Negro's sign, it is characteristic of paralysis agitans and other disorders of the extrapyramidal system of the basal ganglia.

Cold test.   This test is used to determine the vasospastic gradient in cases of essential hypertension. It is done by immersing the patient's hand and wrist in ice water with salt added to produce a temperature of approximately 4°C. Blood pressure readings are determined before and at intervals during and after the hand has been immersed from 15 to 30 seconds. Where there is no great element of vasospasm or vasomotor activity present, namely, in the normal individual, a rise of approximately 8–10 mm Hg takes place. Where vasospastic phenomena play a part in the elevation of blood pressure, a marked rise, often as high as 50 mm Hg takes place promptly, and, if this occurs, a large vasomotor element is undoubtedly present.

Consensual reflex.   Contraction of both pupils normally occurs when light stimulates one eye. It is sometimes called the crossed ocular reflex.

Convergence test.   A finger or another object held several feet away from the patient is moved toward the patient's eyes, midway between them. When the patient's eyes follow the object, the eyes should move inward, and the pupils should contract. The medial recti muscles normally contract to move the eyes into alignment so that images in each eye focus on the same part of the retina to avoid diplopia. An inability to converge the eyes commonly occurs in encephalitis and vascular diseases of the midbrain.

Corneal reflex.   Forceful rapid contraction of the eyelids when the cornea of one eye is stimulated with a wisp of cotton. This normal reflex is usually diminished unilaterally from either a central or peripheral lesion. Positive signs will be seen in such disorders as tic douloureux, alcoholism, neuritis, cerebellopontine angle tumors, and lock jaw.

Costoclavicular-maneuver.   With the patient sitting, the examiner monitors the radial pulse of the patient from the posterior on the side being examined. The examiner brings the patient's shoulder and arm posterior and then depresses the shoulder on the side being examined. This maneuver narrows the costoclavicular space by approximating the clavicle to the first rib, tending to compress the neurovascular structures between. When the shoulder is retracted, the clavicle moves backward on the sternoclavicular joint and rotates in a counterclockwise direction. An alteration or obliteration of the radial pulse or a reduplication of other symptoms suggests compression of the neurovascular bundle passing between the clavicle and the first rib (costoclavicular syndrome).

Cover test.   When there is a tendency for one eye to turn medially, it is called esophoria; laterally, exophoria. If compensated, these conditions can be appreciated through the cover test: Have the patient focus on a light source and alternately cover one eye. The covered eye will normally return to its position of rest. Thus, the eye will turn nasally in esophoria; and in exophoria, it will turn laterally. This will be noticed when the uncovered eye quickly moves medial-central in esophoria and lateral-central in exophoria.

Cozen's test.   With the patient's forearm stabilized, the patient is instructed to make a fist and extend the wrist. The examiner then grips the patient's elbow with the stabilizing hand and the top of the patient's fist with the active hand and attempts to force the wrist into flexion against patient resistance. A sign of tennis elbow is a severe sudden pain at the lateral epicondyle area.

Cremasteric reflex.   The cremasteric reflex (L1–L2) is especially active in young men by stroking the upper-inner aspect of the thigh. Observe the contraction of the cremasteric muscle of the same side, which causes the testicle to be drawn upward. An absent or diminished response indicates lesions of the corticospinal tract and lesions of the femoral and genitofemoral nerves.

Cunningham's sign.   This is a vasopressor sign of potential hypertension. Systolic pressure is noted as the mercury column of the manometer is rising at a moderate rate. The column is then raised quickly 30 mm higher and allowed to fall slowly. If the systolic reading on falling is 20 mm or more higher than on rising, the patient is believed to be a candidate for hypertension. This appears to be due to a hyperirritability of the vasocardiac reflex because it is not found in hypertensive heart disease. In the normal individual, the second reading is the same or no more than 12 mm higher.

Dalrymple's sign.   This sign is exhibited by widening of the eyelid slits, thus producing the expression of fright. The phenomenon is due to a sympathicotonia of the autonomic fibers of the oculomotor nerve that supply the levator palpebrae.

Dawbarn's test.   With the patient sitting, the examiner stands behind the patient and deeply palpates the area just below the acromion process to determine symptoms of focal tenderness or referred pain. Then, while still maintaining this palpatory pressure to patient tolerance, the examiner grasps the wrist of the patient with the other hand and brings the arm to the lateral extended position so that it is abducted to about 100°. If subacromial bursitis exists, the pain produced on initial palpation should decrease substantially when the arm is raised because the deltoid will cover the spot below the acromion during abduction. If the pain remains unaltered or is increased by this abduction maneuver, subacromial bursitis can usually be ruled out.

Dejerine's sign.   This sign constitutes aggravated symptoms of radiculitis, resulting from a space-occupying lesion within the spinal cord, during any Valsalva maneuver (eg, coughing, sneezing, abdominal straining) that would increase intrathecal pressure.

DeKleyn's test.   The patient is placed supine on an adjusting table, and the head rest is lowered. The examiner extends and rotates the patient's head, and this position is held for about 15–40 seconds on each side. A positive sign suggests vertebrobasilar ischemia.

Deltoid reflex.   Abduct the arm and percuss the insertion of the deltoid muscle at the junction of the upper and middle third of the lateral aspect of the humerus. This reflex is carried by the axillary nerve (C5–C6).

Demianoff's test.   This is a variant of Lasegue's SLR test used by many in lumbago and IVF funiculitis with the intent of differentiating between lumbago and sciatica. When the affected limb is first extended and then flexed at the hip, the corresponding half of the body becomes lowered and with it the muscle fibers fixed to the lumbosacral segment. This act, which stretches the muscles, can induce sharp lumbar pain. Lasegue's sign is thus negative as the pain is caused by stretching the affected muscles at the posterior portion of the pelvis rather than stretching the sciatic nerve. To accomplish this test with the patient supine, the pelvis is fixed by the examiner's hand firmly placed on the ASIS, and the other hand elevates the leg on the same side. No pain results when the leg is raised to an 80° angle. When lumbago and sciatica coexist, Demianoff's sign is negative on the affected side but positive on the opposite side unless the pelvis is stabilized. The sign is also negative in bilateral sciatica with lumbago. The stabilization of the pelvis prevents stretching the sciatic nerve, and any undue pain experienced is usually associated with ischiotrochanteric groove adhesions or soft-tissue shortening.

Deyelle-May test.   This test may be helpful in differentiating the various etiologies of sciatic pain and is particularly designed to differentiate between pain from pressure on the nerve or its roots and pain due to other mechanisms in the lower back. Compression or traction on muscles, ligaments, tendons, or bursae may cause reflex pain that often mimics actual direct nerve irritation. Reflex pain does not usually follow the pattern of a specific nerve root, is more vague, does not cause sensory disturbances in the skin, comes and goes, but may be a very intense ache. The procedure in the sitting position is to instruct the patient to sit very still and braced by the hands in a chair. The painful leg is passively extended until it causes pain, then lowered just below this point. The leg is then held by the examiner's knees and deep palpation is applied to the sciatic nerve high in the popliteal space that has been made taut (bow string) by the maneuver. Severe pain on palpation indicates a definite sciatic syndrome as opposed to other causes of back and leg pain such as the stretching of strained muscles and tendons or the movements of sprained sublumbar articulations.

Disconjugate gaze.   The is the inability to either

(1) move the eyeball sharply medial while the contralateral abducting eye exhibits nystagmus (bilateral internal rectus ophthalmoplegia) as the result of an oculomotor lesion or

(2) move the eyeball sharply lateral while the contralateral adducting eye exhibits nystagmus (bilateral external rectus ophthalmoplegia) as the result of an abducens lesion. In either case, the nystagmus indicates associated cerebellar involvement and the sign strongly points to multiple sclerosis.

Double-leg raise test.   This is a two-phase test:

(1) The patient is placed supine, and a straight-leg-raising (SLR) test is performed on each limb: first on one side, and then on the other.

(2) The SLR test is then performed on both limbs simultaneously; ie, a bilateral SLR test. If pain occurs at a lower angle when both legs are raised together than when performing the monolateral SLR maneuver, the test is considered positive for a lumbosacral area lesion.

Draw Sign.   Tears of the anterior talofibular ligament produce joint instability, allowing the talus to slide forward (subluxate) on the tibia. To test for instability and subluxation of the tibia and talus, place one hand on the anterior aspect of the sitting patient's lower tibia and grip the heel within your other palm. When the calcaneus and talus are pulled anteriorly and the tibia is simultaneously pushed posteriorly, the anterior talofibular ligament should allow no forward movement of the talus on the tibia. The test is positive if the talus slides anteriorly from under the cover of the ankle mortise. Sometimes the abnormal bone movement can be heard as well as felt during the maneuver.

Dreyer's sign.   The patient is placed supine with the legs extended in the relaxed position and asked to raise the involved thigh while keeping the knee extended. If the patient is unable to do this, the examiner grasps the large quadriceps tendon just above the knee to anchor it against the femur and the patient is asked to try to lift the limb again. If the patient is then able to lift the limb when the quadriceps tendon is stabilized, a fractured patella should be suspected. The reason for this is the rectus femoris (a primary hip flexor) attaches to the patella by way of the quadriceps tendon.

Duchenne's test.   The patient is placed supine with the lower limbs extended in a relaxed position. The examiner's thumb is placed on the plantar aspect of the head of the 1st metatarsal on the involved side, and the patient is instructed to plantar flex the foot. If during this action the head of the 1st metatarsal offers little or no pressure against the examiner's thumb, the medial border of the foot dorsiflexes while the lateral border plantar flexes, and the arch disappears, the test is positive for peroneus longus paralysis (L4–S1).

Dugas' test.   The patient places the hand on the opposite shoulder and attempts to touch the chest wall with the elbow and then raise the elbow to chin level. If it is impossible to touch the chest with the elbow or to raise the elbow to chin level, it is a positive sign of a dislocated shoulder.

Eden's test.   With the patient seated, the examiner palpates the radial pulse and instructs the patient to pull the shoulders backward, throw the chest outward in a "military posture," and hold a deep inspiration as the pulse is examined. The test is positive if weakening or loss of the pulse occurs, indicating pressure on the neurovascular bundle as it passes between the clavicle and the 1st rib, and thus a costoclavicular syndrome.

Elbow abduction/adduction stress test.   To roughly judge the stability of the medial and lateral collateral ligaments of the elbow, hold the patient's wrist with one hand and cup your stabilizing hand under the patient's distal humerus. As the patient is directed to slightly flex his elbow,

(1) push medially with your active hand and laterally with your stabilizing hand, then

(2) push laterally with your active hand and medially with your stabilizing hand. With the fingers of your stabilizing hand, note any joint gap felt during either the valgus or varus stress maneuver. Painful instability indicates torn ligaments.

Elbow extension/flexion stress test.   The patient's elbow is passively extended and flexed. Painful instability indicates sprain or destructive joint pathology, while discomfort with limited motion suggests contractures or degenerative arthritis.

Ely's test.   To support iliopsoas spasm suspicions, the patient is placed prone with the toes hanging over the edge of the table, legs relaxed. Either heel is approximated to the opposite buttock. After flexion of the knee, pain in the hip will make it impossible to carry out the test if there is any irritation of the psoas muscle or its sheath. The buttock will tend to rise on the involved side. However, a positive Ely's test also can be an indication of rectus femoris contraction, a lumbar lesion, a contracture of the tensor fascia lata, or an osseous hip lesion.

Epigastric reflex.   Contraction of the abdominal muscles caused by stimulating the skin of the epigastrium or over the 5th and 6th intercostal spaces near the axilla. See abdominal reflexes.

Erb's sign.   Tetanizing contraction rather than the normal "make and break" contraction of a muscle when a galvanic current is applied, significant of peripheral hyperexcitability (eg, tetany).

Erben's-reflex.   A slowing of the pulse when the head is bent strongly forward. It is marked in those who are distinctly vagotonic.

Erichsen's test.   With the patient supine, the examiner places the hands on the patient's iliac crests. The examiner's thumbs are placed on the patient's ASISs and forcibly compress the pelvis toward the midline. This tends to separate the sacroiliac joints. If conducted carefully, this test can be quite specific. Pain experienced in the sacroiliac joint suggests a joint lesion (postural, traumatic, or infectious).

Extensor digitorum communis test.   The patient is instructed to flex and then extend a finger. The inability to extend any finger indicates a lesion of that extensor digitorum communis tendon.

External tibial torsion sign.   A markedly posterior position of the lateral malleolus relative to the medial malleolus in weight-bearing and supine positions. An everted heel and flat arch is commonly associated.

Facial motor function signs.   Weakness of the muscles supplied by the facial nerve may be evidenced by the presence of drooping of the corner of the mouth, smoothing out of the nasolabial fold, drooping of the lower lid, or the inability to close the eye such as seen in Bell's palsy where the signs are unilateral. If the frontalis muscle is involved, the forehead is smoothed on the affected side. Note presence or absence of atrophy, abnormal movements, contractures, etc.

Facial motor function tests.   The patient is asked to raise the eyebrows, frown, tightly close both eyes, close each eye separately, show the teeth, open the mouth wide, retract the lips, whistle, and smile. The inability to perform such tests normally indicates a weakness or paralysis of the facial nerve. All facial movements should be equal bilaterally, but some patients habitually talk, smile, and chew more on one side than the other.

Fajersztajn's test.   When straight-leg raising and dorsiflexion of the foot are performed on the asymptomatic side of a sciatic patient and this causes pain on the symptomatic side, there is a positive Fajersztajn's sign, which is said to be particularly indicative of a sciatic nerve root involvement such as a disc syndrome, dural root sleeve adhesions, or some other space-occupying lesion. This is sometimes called the well-leg or cross-leg straight-leg-raising test. From a biomechanical viewpoint, this test would be suggestive but not indicative.

Femoral retroversion sign.   When the femur is retroverted, external rotation of the femur will be much greater (20°–30°) than internal rotation.

Finger-to-finger test.   The patient abducts both arms horizontally and extends the elbows so that the limbs are outstretched, then attempts to approximate the tips of the index fingers. This test has the same clinical significance as the finger-to-nose test.

Finger-to-nose tests.   If the patient is supine, have the arms outstretched at the sides; if sitting, have the hands rest on the knees; if standing, have the arms relaxed at the sides. Direct the patient to touch the tip of the nose with the tip of the forefinger, first with the eyes open, then closed. Note the line between the starting point and the nose to determine if it is straight, curved, or if there is a jerking, irregular motion. Observe whether the finger becomes coarsely tremulous as the nose is touched (intention tremor). If a tremor is present, it indicates a proprioceptive (sensory) defect when the defect is noted primarily when the eyes are closed. Note if the finger goes beyond the nose (hypermetria), or fails to reach the nose (hypometria). The term dysmetria is used to denote if the finger goes beyond the nose or fails to reach it. The action should be smooth, rapid, and the arms should remain in the same plane. Note whether there is a difference when the eyes are closed or if the same degree of incoordination is present with them open. If there is a defect, it is technically called dysdiadochokinesis and is a part of cerebellar dyssynergia. Failure to perform these tests normally indicates a lesion of the posterior columns or polyneuritis.

Finger winkle test.   The functioning of upper extremity sympathetic nerves is tested by placing the patient's hands in warm water for 30 minutes and observing if the skin of the fingers wrinkles after the soaking. The skin will normally wrinkle after such soaking, but it will not in diseases of the sympathetic nervous system. Thus, the test is indicated when there is a suspicion of diabetes mellitus, Guillain-Barre syndrome, Raynaud's disease, and other disorders associated with autonomic imbalance.

Finkelstein's test.   The patient is asked to make a fist with the thumb tucked inside the palm. The examiner stabilizes the patient's distal forearm with one hand and ulnar deviates the wrist with his other hand. Sharp pain in the area of the first wrist tunnel (radial side) strongly points toward stenosing tenosynovitis (De Quervain's disease) wherein inflammation of the synovial lining of the tunnel narrows the tunnel opening and causes pain on tendon movement.

Finsterer's test.   This is a two-phase test for Kienbock's disease:

(1) If when clenching the fist firmly the normal prominence of the middle knuckle is not produced, the test is initially positive.

(2) If percussion of the 3rd metacarpal just distal to the dorsal aspect of the midpoint of the wrist elicits abnormal tenderness, the test is confirmed.

Flexor digitorum profundus test.   This sign is based on the fact that flexor digitorum profundus tendons work only in unison. The examiner stabilizes the metacarpophalangeal and interphalangeal joints in extension. The patient then flexes the finger being tested at the distal interphalangeal joint. If the patient cannot do this, the sign is positive and indicates a cut tendon or denervated muscle.

Flexor digitorum superficialis test.   To test the integrity of the flexor digitorum superficialis tendon, the examiner holds all of the patient's fingers in extension except for the finger being tested. The patient then flexes the finger being tested at the proximal interphalangeal joint. If the patient cannot do this, the sign is positive for a cut or absent tendon.

Foot-to-buttock test.   The prone patient is asked to flex the thigh and leg, bringing the foot up near the buttock. Note any swaying of the knee from side to side (dyssynergia). Many examiners also perform this test with the patient standing.

Forearm pronation/supination stress test.   The patient's forearm is passively pronated and supinated. Painful instability indicates sprain or destructive joint pathology, while discomfort with limited motion suggests contractures or degenerative arthritis.

Forestier's sign.   The patient in the upright position is asked to bend laterally, first to one side and then to the other. Normally, the contralateral perivertebral muscles will bulge because of the normal coupling rotation of the lumbar spine (exhibited by the spinous processes pointing to the ipsilateral side of lateral flexion). However, in ankylosing spondylitis (Marie-Strumpell's disease) or a state of extensive spinal fixation, the musculature will appear to bulge greater on the side of the curve's concavity.

Fouchet's test.   The patient is placed supine with the limbs extended in the relaxed position. If firm pressure on the patella produces pain and focal tenderness at the margin of the patella, chondromalacia of the patella should be suspected.

Froment's (cone) sign.   In paralysis of the ulnar nerve, there is an inability to approximate the tips of fingers to the thumb to form a cone or make an "O" with the thumb and index finger. Likewise, early palsy weakness is exhibited by the inability to firmly hold a piece of paper between the thumb and fingertips against resistance.

Gaenslen's test.   In this test, the patient is placed supine with knees and hips acutely flexed by the patient who clasps the knees with both hands and pulls them toward the abdomen. This brings the lumbar spine firmly in contact with the table and fixes both the pelvis and lumbar spine. With the examiner standing at right angles to the patient, the patient is brought well to the side of the table and the examiner slowly hyperextends the opposite thigh by gradually increasing force by pressure of one hand on top of the patient's knee while the examiner's other hand is on the patient's flexed knee for support in fixing the lumbar spine and pelvis. Some examiners allow the hyperextended limb to fall from the table edge. The hyperextension of the hip exerts a rotating force on the corresponding half of the pelvis. The pull is made on the ilium through the Y ligament and the muscles attached to the AIISs. The test is positive if the thigh is hyperextended and pain is felt in the sacroiliac area or referred down the thigh, providing that the opposite sacroiliac joint is normal and the sacrum moves as a unit with the side of the pelvis opposite to that being tested. The test should be conducted bilaterally. A positive sign may be elicited in a sacroiliac, hip, or lower lumbar nerve root lesion. If the L4 nerve is involved, pain is usually referred anteriorly to the groin or upper thigh. If the sign is negative, a lumbosacral lesion should be the first suspicion. This test is usually contraindicated in the elderly.

Gag reflex.   The gagging normally induced by irritating the posterior pharyngeal wall. Absence of the reflex signifies a lesion of cranial nerve IX (sensory component) or cranial nerve X (motor component).

Gauvain's sign.   With the patient in the sidelying position, the examiner stabilizes the patient's uppermost iliac crest with the heel of the hand and the fingerpads are fixed against the patient's lower abdomen. With the patient's uppermost knee extended, the examiner grasps the patient's upper ankle with the other hand, moderately abducts the limb, and firmly rotates it internally and externally. With the patient's knee locked in extension, these rotary maneuvers will affect the entire limb, as far superiorly as the head of the femur. A positive sign is seen when a strong abdominal contraction occurs, indicating a somatosomatic reflex spasm that is usually attributed to hip pathology (eg, coxa tuberculosis).

Gelle's test.   The examiner applies a vibrating tuning fork over the patient's mastoid process. If it is heard, the air in the external auditory canal is compressed by a rubber tube inserted into the auditory canal and a hand bulb. This fixates the stapes in the oval window, and the sound no longer is heard. However, it is again perceived if the air pressure is released, thus testing the mobility of the ossicles.

George's tests.   With the patient sitting, blood pressure and the radial pulse rate are taken bilaterally and recorded. Stenosis or occlusion of the subclavian artery is suggested when a difference of 10 mm Hg between the two systolic blood pressures and a feeble or absent pulse is found on the involved side. Even if these signs are absent, a subclavian deficit may be exhibited by finding auscultated bruits in the supraclavicular fossa.

Giegel's reflex.   With the patient supine, the skin of the upper thigh is stimulated from the midline toward the groin. A normal response is an abdominal contraction at the upper edge of Poupart's ligament. This reflex (L1–L2) is essentially the female counterpart of the cremasteric reflex in the male. It is often referred to as the inguinal reflex.

Gilcrest's sign.   The patient is instructed to lift a 5-lb weight (eg, dumbbell) overhead and then to externally rotate the arm and slowly lower it to the lateral horizontal position. Pain and/or reduplication of symptoms during this maneuver (with or without tendon displacement from the groove) is said to indicate instability of the long head of the biceps and probable tenosynovitis.

Gillis' test.   With the patient prone and the examiner standing on the side of involvement, the examiner reaches over and stabilizes the uninvolved sacroiliac joint while the thigh on the involved side is extended at the hip. Pain initiated by this maneuver in the sacroiliac area of the involved side is a positive sign of acute sacroiliac sprain/subluxation or sacroiliac disease.

Goldthwait's test.   The patient is placed supine. The examiner places one hand under the lumbar spine with each fingerpad pressed firmly against the interspinous spaces. The other hand of the examiner is used to slowly conduct an SLR test. If pain occurs or is aggravated before the lumbar processes open (1°–30°), a sacroiliac lesion should be suspected. In general, Goldthwait believed that if pain occurred while the processes were opening at 30°–60°, a lumbosacral lesion was suggested; at 60°–90°, an L1–L4 disc lesion. When pain is brought on before the lumbar spine begins to move, a lesion, either arthritic or a sprain involving the sacroiliac joint, is probably present. If pain does not come on until after the lumbar spine begins to move, the disorder is more likely to have its site in the lumbosacral area or less commonly in the sacroiliac areas. The test should be repeated with the unaffected limb. A positive sign of a lumbosacral lesion is elicited if pain occurs at about the same height as it did with the first limb. When the unaffected limb can be raised higher than the affected limb, it is thought to be significant of sacroiliac involvement of the affected side.

Gonda's sign.   This Babinski-like reflex response is elicited by pressing downward on the third toe and suddenly releasing it with a snap, causing an upward movement of the great toe.

Gordon's toe sign.   A Babinski-like dorsiflexion of the great toe, and possibly others, occurs when sudden kneading pressure is made upon the deep flexor muscles of the calf when the pyramidal tracts are involved.

Gower's sign.   The patient uses the hands on the thighs in progressive short steps upward to extend the trunk to the erect position when arising from a sitting or forward flexed position. This sign is positive in cases of severe degeneration (eg, muscular dystrophy) of the lumbopelvic extensors or a low back disorder with bilateral implications (eg, spondylolisthesis).

Graphesthesia test.   This refers to the ability to recognize figures written on the skin. This faculty becomes impaired (graphanesthesia) in some forms of organic brain disease.

Grasp reflex.   Light radialward stroking the palm of the patient's hand elicits a grasp response (finger flexion) and reluctance to let go. A variation is to hold the patient's relaxed hand with one hand while the other hand lightly pulls the patient's fingers from the hypothenar eminence to the thumb and forefinger. A positive response is seen when the patient involuntarily squeezes the examiner's fingers, and the reflex is broken by stroking the back of the patient's fingers. The reflex is normal in infants up to 10 months of age, but pathologic in adults and usually signifies toxic or anoxic dementia. When firm stroking is required to produce this sign, it is called a positive forced grasping sign.

Hamilton's sign.   Normally, a straight edge (eg, a yardstick) held against the lateral aspect of the arm cannot be placed simultaneously on the tip of the acromion process and the lateral epicondyle of the elbow. If these two points do touch the straight edge, it signifies a dislocated shoulder.

Hamstring reflex.   The patient is placed supine with the knees flexed and the thighs moderately abducted. The tendons of the semitendinosus and semimembranosus are hooked by the examiner's index finger and the finger is percussed. Normally, a palpable contraction of the hamstrings occurs. An exaggerated response indicates an upper motor neuron lesion above L4, and it may be associated with a reflex flexion of the knee (Stookey response). An absent response signifies a lower motor neuron lesion affecting the L4–S1 segments, as do absent Achilles and plantar reflexes.

Hautant's test.   The examiner places a sitting patient's upper limbs so that they are abducted forward with the palms turned upward. The patient is instructed to close the eyes, and the examiner extends and rotates the patient's head. This position is held for 15–40 seconds on each side. A positive sign of vertebrobasilar insufficiency is for one or both arms to drop into a pronated position.

Heel-to-knee test.   The supine patient touches a knee (or shin) with the heel of the opposite foot, and the examiner makes bilateral comparison. Signs of a curve in the line of motion, irregular movement, hypermetria, or hypometria should be noted. The test should be conducted with the patient's eyes opened and closed. In cerebellar lesions, the patient will overhit or underhit the mark, and then finally get there. Also observe for a last-minute intention tremor. The patient may also have difficulty from a proprioceptive loss, but this would indicate a defect due to loss of joint sensation rather than a loss of cerebellar coordination. Many examiners find it advisable to also perform such tests with the patient in the standing position.

Heel-to-toe test.   This is a variant of the heel-to-knee test that has the same general significance.

Heel walk test.   A patient should normally be able to walk several steps on the heels with the forefoot dorsiflexed. With the exception of a localized heel disorder (eg, calcaneal spur) or contracted calf muscles, an inability to do this because of low back pain or weakness can suggest a L5 lesion.

Helfet's test.   This test is designed to detect the presence of an intra-articular "loose body" that disturbs the normal biomechanics of the joint. To test normal knee locking, a dot is made with a skin pencil in the center of the patella and another is made over the tibial tubercle when the knee is flexed. The knee is then passively extended and the motion of the dot relative to the patella is observed. A positive Helfet test occurs when there is lack of full lateral movement of the dot. Palpation of the tibial tubercle during this passive test allows for more subtle determination of disturbed joint mechanics. Aside from intra-articular bodies, both a lack of rotational joint play at the tibiofemoral articulation and imbalance in the tone of the internal and external rotators of the tibia could promote the pathomechanics observed during the test. It should also be noted that all but two of these muscles find their origin in the pelvis.

Hibb's test.   The patient is placed in the prone position, and the examiner stands next to the patient on the side of involvement. The examiner stabilizes the patient's contralateral uninvolved hip, flexes the patient's knee on the involved side toward the buttock, and then slowly adducts the leg, which externally rotates the femur. Pain initiated in the hip joint indicates a hip lesion; pain rising in the sacroiliac joint, but not the hip, points to a sacroiliac lesion.

Hip abduction stress test.   The patient is placed in the sidelying position with the underneath lower limb flexed acutely at the hip and knee. With the upper limb held straight and extended at the knee, the patient is instructed to attempt to abduct the upper limb while the examiner applies resistance. Pain initiated in the area of the uppermost sacroiliac joint or the hip joint suggests an inflammatory process of the respective joint.

Hip adduction deformity sign.   When a patient with hip disease walks or stands, it may be noted that the iliac crest is elevated on the affected side, the heel is elevated, and the patient walks on the toes of affected side. The sign is positive if measurement from umbilicus to each medial malleolus shows one leg short but measurements from the right ASIS to the right medial malleolus and from the left ASIS to the left medial malleolus shows limbs to be the same length. This is significant of adduction deformity of the hip of the apparently short limb and suspicious of tuberculosis. This stage often precedes the actual shortening of the involved limb by destruction of the femur head or coxa.

Hip spasm differentiation tests.   In the hip joint, two forms of spasm are common:

(1) that which is due to irritation of the psoas alone, and

(2) that in which all the muscles moving the joint are more or less contracted. The normal range of hip flexion is 120°. In isolated psoas spasm, motions of the hip (rotation, adduction, abduction, and flexion) are not impeded. General spasm of the hip muscles is tested with the patient supine up a table or bed and the leg flexed at a right angle, both at the knee and at the hip. A child may be tested on its parent's lap. Using the sound leg as a standard of comparison, the examiner then draws the knee away from the midline (abduction), toward and past the midline (adduction), and toward the patient's chest (flexion). Rotation is tested by holding the knee still and moving the foot away from the median line of the body or toward and across it.

Hirschberg's sign.   A pathologic sign exhibited by internal rotation and adduction of the foot when friction is applied to the lateral aspect of the plantar surface. It indicates motor tract involvement.

Hoffa's signs.   The patient is placed prone with the relaxed feet and ankles hanging over the edge of the table. A positive sign of an avulsion fracture of the calcaneus is found if the examiner by deep palpation finds that

(1) the Achilles tendon is lax,

(2) relaxed dorsiflexion is greater, and, possibly,

(3) a bone fragment is felt behind either malleolus on the involved side.

Hoffman's reflex.   The examiner holds the wrist of a patient, suspected of having pyramidal tract disease, in one hand, and allows the hand to relax. The examiner then grasps the patient's middle finger between his thumb and forefinger and snaps the terminal phalanx sharply without dorsiflexing the finger. If Hoffman's sign is present, the thumb is seen to flex slightly. Often, a brisk apposition of the thumb and forefinger occurs. It may occasionally occur in exalted nervous states or in hysteria, but it's then apt to be bilateral. This reflex is also known as Trommer's sign. The sign is positive with upper motor neuron lesions and often found in hemiplegia, but it is not as reliable as Babinski's plantar reflex.

Holmes' rebound phenomenon.   A positive sign is noted when the patient flexes his arm against the resistance of the examiner, and when the arm is suddenly released, it strikes the patient's chest. This is a significant finding in ipsilateral cerebellar disease.

Homan's sign.   The patient is placed supine with the knees extended in a relaxed position. The examiner, facing the patient from the involved side, raises the involved leg, sharply dorsiflexes the ankle with one hand, and firmly squeezes the calf with the other hand. If this induces a deep-seated pain in the calf, a strong indication of thrombophlebitis is found.

Hoover's test.   This is a test for malingering associated with an active straight-leg-raising test. When the patient attempts to raise his leg, the examiner cups one hand under the heel of the opposite foot. When the typical patient tries to raise his affected limb, he normally applies pressure on the heel of the opposite limb for leverage and a downward pressure can be felt. If this pressure is not felt, the patient is probably not really trying.

Hughston's jerk sign.   This is a modification of McIntosh's test. With the patient supine, the foot is grasped with one hand while the other hand rests over the proximal lateral aspect of the leg just distal to the patella. The knee is flexed to 90°, and valgus stress is applied as the tibia is rotated internally. The knee is then gradually extended. The lateral tibial plateau is initially in a reduced position to the femoral condyle; however, as the knee is extended to about 35° of flexion, the lateral tibial plateau suddenly subluxates forward in relation to the femoral condyle with a jerking sensation. The lateral plateau slowly obtains its reduced position, which completes on full extension as the knee is extended.

Iliac compression test.   The patient is placed on the side with the affected side up. The examiner places his forearm over the iliac crest and leans pressure downward for about 30 seconds. This tends to compress the sacroiliac and pubic joints. A positive sign of joint inflammation or sprain is seen with an increase in pain; however, absence of pain does not necessarily rule out sacroiliac involvement. This test is usually contraindicated in geriatrics and pediatrics or with any sign of a hip lesion or osseous pelvic pathology.

Iliopsoas contracture test.   Bilateral iliopsoas shortening results in lumbar rigidity, anterior pelvic tilt, and hip flexion. When associated with acute back pain, the patient tends to flex the knees and the hip to help decrease the degree of pelvic tilt and lordosis. When the hip flexors are short, the lumbar region does not flatten in the supine position unless the knees and hips are flexed.

Iliopsoas spasm sign.   Increased tone tends to pull the lumbar spine into anterior and inferior flexion, and externally rotate and flex the thigh. The thigh is usually somewhat flexed on the trunk, although this is usually concealed by forward bending of the trunk.

Iliopsoas spasm test.   Iliopsoas hypertonicity can be confirmed by tension and pain during deep palpation of the abdomen below the umbilicus, lateral to the linea alba, medial to and slightly inferior to the ASIS. It will feel as a taut longitudinal bundle. It is also palpable in the upper sulcus of the pubic arch.

Impingement syndrome test.   The patient is placed supine with the arms resting loosely at the sides. The elbow on the involved side is then flexed to a right angle and the arm is rotated internally so that it rests comfortably on the patient's upper abdomen. The examiner places one hand on the patient's shoulder and the other hand on the patient's elbow. A compressive force is then applied, which pushes the humerus against the inferior aspect of the acromion process and the glenohumeral fossa. Pain and/or a reduplication of symptoms indicates an impingement syndrome of the supraspinatus and/or bicipital tendon.

Infraspinatus reflex.   This normal reflex (C5 C6) is exhibited by external rotation of the arm and simultaneous extension of the elbow when the medial border of the scapula is lightly stimulated.

Internal femoral torsion signs.   Internal femoral torsion can be observed if the patellae are marked with a skin pencil and these points are observed during gait. There will be toe-in, the patellae will face medially, an internal contracture of the hips will usually be found, and there will be excessive anteversion of the femur. If there is toe-in and the patellae face forward (as is normal), the cause of the toe-in will be distal to the knee. An internal rotation deformity likely exists at the hip when internal rotation exceeds external rotation by more than 30°.

Internal tibial torsion test.   To confirm a suspicion of internal tibial torsion, have the patient sit on a table with the knee flexed at 90°. The tibial tubercle will palpate as if it faces straight anterior. The examiner grasps the malleoli by the thumb and index finger to determine the position of the ankle joint. In normal adults, about 20°–30° of external tibial torsion is present and the lateral malleolus will be posterior to the medial malleolus. If internal tibial torsion exists, the lateral malleolus will be anterior to its medial mate.

Inverted radial reflex.   The normal radial reflex produces forearm flexion. This pathologic reflex exhibits hand and finger flexion rather than forearm flexion, indicating a C5 lesion.

Jaw jack.   This is a pathologic trigeminal reflex exhibited by clonic contraction of the muscles of mastication and inferior maxilla when a finger placed on the center of the relaxed and open jaw is percussed. It is prominent in impaired cortical innervation (eg, dementia) and multiple sclerosis when upper motor neurons are involved. In unilateral frontal lobe lesions, the reflex will be increased only on the opposite side of the lesion. Some authorities state that the reflex is present in many normal individuals.

Jendrassik's maneuver.   When it is impossible to obtain a patellar reflex by usual methods, re-enforcement may be tried. Ask the patient to clasp the hands and pull strongly. While the patient's attention is on the pull and the thigh muscles are relaxed, the examiner taps the patellar tendon.

Joint position and motion sense tests.   With the patient's eyes closed and extremities relaxed, ask the patient to tell in what position a particular joint has been placed or what joint is being moved. Try each part being examined several times, and note the findings. The patient should be able to perceive joint motion with the eyes closed. The examiner should be cautious that the patient completely relaxes the joints being manipulated. The best joints to test for position and motion senses are those of the great toe and thumb. The joint sensation or perception of articular motion is arthresthesia. The prefixes hyper and hypo are used to indicate exaggerated or diminished findings.

Kaplan's test.   This is a two-phase test:

(1) The sitting patient is given a hand dynamometer and instructed to extend the involved upper limb straight forward and squeeze the instrument as hard as possible. Induced pain and grip strength are noted.

(2) The test is then repeated except that this time the examiner firmly encircles the patient's forearm with both hands (placed about 1–2 inches below the antecubital crease). Induced pain and grip strength are noted. If the second phase of the test shows reduced pain and increased grip strength when the muscles of the proximal forearm are compressed, lateral epicondylitis is indicated.

Kemp's test.   While in a seated position, the patient is supported by the examiner who reaches around the patient's shoulders and upper chest from behind. The patient is directed to lean forward to one side and then around to eventually bend obliquely backward by placing the palm on the buttock and sliding it down the back of the thigh and leg as far as possible. The maneuver is similar to that used in oblique cervical compression tests. If this compression causes or aggravates a pattern of radicular pain in the thigh and leg, the sign is positive and suggests nerve root compression. It may also indicate a strain or sprain and thus be present when the patient leans obliquely forward or at any point in motion. Not to be dismissed lightly would be the possibility of shortened contralateral perispinal ligaments and tendons forcing erratic motion on the side of lateral flexion.

Kernig's neck test.   Biomechanically, this test is the cephalad representation of Lasegue's SLR test. The supine patient is asked to place both hands behind his head and forcibly flex his head toward his chest. Pain in either the neck, lower back, or down the lower extremities indicates meningeal irritation, nerve root involvement, or irritation of the dural coverings of the nerve root. That is, some hypersensitive tissue is being aggravated by the tensile forces. When the examiner passively flexes the patient's neck and trunk, it is called the Soto-Hall test or Lindner's test, depending on the examiner's position.

Knee anterolateral rotary instability test.   The leg of the supine patient is grasped with one hand and secured under the examiner's arm. The examiner's other hand is placed over the lateral proximal aspect of the patient's leg, and the leg is extended. A valgus stress is applied and the leg internally rotated as the knee is flexed. During flexion of the knee, the lateral tibial plateau can be felt to subluxate anteriorly in relation to the lateral condyle. The iliotibial tract tightens, lateral crepitation may be felt, and a slight resistance to flexion may be perceived. When the knee is in about 35° of flexion, the iliotibial band tightens, passes behind the transverse axis of rotation, and the tibial plateau is suddenly reduced, often with a "clunk-like" sensation both felt and heard.

Knee effusion test.   If a joint is greatly swollen from a major effusion, the patient is placed in a relaxed supine position. The limb is relaxed, and the knee is slowly extended. The patella is then pushed into the trochlear groove and released quickly. This will force fluid under the patella to the sides of the joint and then to return under the patella. This rebound is referred to as a ballottable patella. Minimal effusion, however, will not ballot the patella. In cases of minor effusion, it is necessary to "milk" the fluid from the suprapatellar pouch and lateral side to the medial side of the joint. Once the fluid has been moved medially, tapping over the fluid will return it to the lateral side.

Knee external rotation-recurvatum test.   The patient is placed supine, and the examiner grasps the patient's heel with one hand and supports the calf with the other hand. The knee is allowed to pass from about 10° flexion into full extension. A positive test occurs when the knee assumes a position of slight recurvatum, the tibia rotates externally, and there is increased tibia vara. Such a sign indicates injury to the arcuate complex, lateral half of the posterior capsule, and a degree of injury to the posterior cruciate ligament.

Knee hyperextension stress test.   The patient is placed prone with the knees extended in the relaxed position. The examiner places a fist under the distal thigh of the involved side, flexes the patient's knee to about 30° with the other hand, and then allows the leg to drop without assistance when the muscles are relaxed. Most knee lesions limit extension to some degree. Thus, if extension is limited or the rebound is abnormal during this "knee drop" test (as compared to the contralateral knee), some type of knee disorder should be suspected and may possibly be localized.

Knee hyperflexion stress test.   With the patient in the supine position, the examiner places one hand on the involved knee and the other on the ipsilateral ankle. The patient's knee is moderately flexed, the thigh is brought towards the patient's abdomen, and the patient's heel is slowly pushed toward the patient's buttock. Unless the patient is considerably obese, the normal knee can be flexed without pain so that it touches the buttock. If knee pain or severe discomfort is induced by this maneuver, a subtle localized knee lesion may be brought out.

Knee lateral stability stress tests.   The collateral ligaments provide medial and lateral stability to the knee joint. To examine sideways stability, the patient is placed supine and the knee is flexed just enough to free it from extension. To test the integrity of the medial collateral ligament, valgus stress is applied to open the knee joint on the medial side. The lateral collateral ligament is tested by applying stress to open the knee joint on the lateral side. In these maneuvers, the ankle is secured with one hand, the other hand is placed on the opposite side of the knee of the ligaments being tested, and pressure is applied toward the ligaments being tested. More knowledge can be gained, however, if the examiner locks the patient's ankle between his arm and chest and uses this hand to palpate the ligaments in question and the underlying joint gap during the test.

Knee posterolateral rotary instability test.   Posterolateral rotary instability arises from a posterior subluxation of the lateral tibial plateau in relation to the lateral femoral condyle, accompanied by abnormal external tibial rotation. To test for posterolateral rotary instability, the external rotation-recurvatum and a posterior drawer test are performed. Excessive posterior sag of the lateral tibial plateau with external tibial rotation should be noted. This type of instability results from laxity of the arcuate complex, the lateral half of the posterior capsule, and a degree of failure of the posterior cruciate ligament.

Lachman's test.   With the patient supine, the examiner slightly flexes the involved knee (about 20°), cups a palm against the proximal calf, and attempts to pull the tibia forward. Excessive anterior translation of tibia from the femur (anterior drawer sign) and lack of a definite end point suggest a rupture of the anterior cruciate ligament.

Laguere's test.   With the patient supine, the thigh and knee are flexed and the thigh is abducted and rotated outward. This forces the head of the femur against the anterior portion of the coxa capsule. Increased groin pain and spasm are usually positive signs of a lesion of the hip joint, iliopsoas muscle spasm, or a sacroiliac lesion. It can help to differentiate from a lumbar disorder.

Lasegue's differential sign.   This test is used to rule out hip disease. A patient with sciatic symptoms is placed supine. If pain is elicited on flexing the thigh on the trunk with the knee extended but not produced when the thigh is flexed on the trunk with the knee relaxed (flexed), coxa pathology can usually be ruled out.

Lasegue's rebound test.   At the conclusion of a positive sign during Lasegue's supine SLR test, the examiner allows the limb to drop to a pillow without warning. If this rebound test causes a marked increase in pain and muscle spasm, then a disc involvement is said to be suspect. However, it would appear that any site of irritation in the lower back and pelvis would be aggravated by such a maneuver.

Lasegue's standing test.   The patient attempts to touch the floor with the fingers while the knees are held in extension during the standing position. Under these conditions, the knee of the affected side will flex, the heel will slightly elevate, and the body will elevate more or less to the painful side. It should be noted that this would also be true with shortened posterior thigh and calf muscles.

Lasegue's straight-leg-raising (SLR) test.   The patient lies supine with legs extended. The examiner places one hand under the heel of the affected side and the other hand is placed on the knee to prevent the knee from bending. With the limb extended, the examiner most cautiously flexes the thigh on the pelvis to the point of pain, keeping the knee straight. The patient will normally be able to have the limb extended to almost 90° without pain. If this maneuver is markedly limited by pain, the test is positive and suggests sciatica from a disc lesion, lumbosacral or sacroiliac lesion, subluxation syndrome, tight hamstring, spondylolisthetic adhesion, IVF occlusion, or a similar disorder.

Lax shoulder capsule test.   To determine a lax capsule, the patient clasps the fingers behind the head and laterally abducts the elbows. The axilla is palpated high over the glenohumeral capsule while posterior force is applied on the patient's flexed elbow. While laxity of the anterior capsule can always be demonstrated by this maneuver, care must be taken not to dislocate the humerus within a loose capsule.

Leotta's maneuvers.   When intestinal adhesions are suspected, the fingers of the examiner are placed on the upper right abdominal quadrant of the patient and pressed inward while the patient exhales completely. If adhesions exist between the colon and gallbladder or liver, this pressure will pull on the colon and increase patient distress. To determine the possible existence of adhesions between the parietal peritoneum and ascending colon, traction and pressure are made transversely from the lateral abdominal line toward the median line and from the median line outward. The direction of stretching and pressure necessary to elicit pain suggests the site of adhesions. A positive sign may be seen in cholecystitis, gastric ulcers, duodenal ulcers, or as the result of past abdominal surgery.

Lewin-Gaenslen test.   The patient is placed in the sidelying position with the underneath lower limb flexed acutely at the hip and knee. The examiner stabilizes the uppermost hip with one hand. With the other hand, the uppermost leg is grasped near the knee and the thigh is extended on the hip. Initiated or aggravated pain suggests a sacroiliac lesion.

Lewin's knee sign.   If quick extension of a knee in the standing position produces pain and a sharp flexion response, hamstring spasm should be suspected.

Lewin's standing test.   With the patient standing with the back to the examiner, the examiner cautiously forces first the right and then the left knee into complete extension. Then both knees are straightened at the same time. In lumbosacral, lower lumbar, sacroiliac, and gluteal disturbances, these movements will be accompanied by increased pain and the knee will snap back into flexion.

Lewin's supine test.   This test is almost identical to Chapman's test, except that Lewin believes a positive sign is especially indicative of an ankylosing dorsolumbar lesion. With the patient supine, the examiner places his arms or a strap across the patient's thighs just above the knees. The patient is directed to sit up straight without using the hands. The sign is positive if the patient is unable to do this maneuver, and during the attempt, the patient is frequently able to localize the site of pain. It is frequently associated with lumbar arthritis, lumbar fibrosis, degenerative disc thinning with protrusion, sacroiliac or lumbosacral arthritis, or sciatica.

Lhermitte's test.   With the patient seated, flexing of the patient's neck and hips simultaneously with the patient's knees in full extension may produce sharp pain or shock-like sensations radiating down the spine and/or into the upper extremities. When this is elicited, it is a sign of cervical pathology suggesting spinal cord myelopathy by a protruded cervical disc, tumor, fracture, or multiple sclerosis.

Libman's test.   This refers to pressing the mastoid processes to evaluate a patient's sensitivity to pressure pain.

Lindner's test.   The patient is placed supine, and the examiner slowly flexes the patient's head forward so that the neck and thoracic spine curve forward. This test often helps to localize diffuse spinal pain. Essentially, it is the passive form of Kernig's neck test and quite similar to the Soto-Hall test except for the examiner's position.

Lippman's test.   In the relaxed seated position, the sitting patient is asked to flex the elbow on the involved side and rest the forearm in the lap. The examiner palpates for the tendon of the long head of the biceps about 3 inches distal from the glenohumeral joint. An attempt is made to displace the tendon laterally or medially from its groove. Pain, reduplication of other symptoms, and a palpable displacement of the tendon from its groove signifies tenosynovitis with instability.

Losee's test.   With the patient supine and the knee flexed, the examiner applies valgus stress to the tibia with one hand while the head of the fibula is pushed anterior with the other hand. If an anterior subluxation occurs at the lateral tibial plateau when the knee approaches full extension, anterolateral rotatory instability is indicated.

Loven's reflex.   When an afferent nerve of an organ is sufficiently stimulated, vasodilation results that produces a corresponding increase in the size of the organ.

Lucid interval.   The classic sign of middle meningeal (extradural) hemorrhage is a lucid interval: the patient regains consciousness and shortly thereafter lapses into unconsciousness again.

Magnan's sign.   Paresthesia of cocaine addicts that is perceived as if foreign bodies were under the skin.

Maigne's test.   The examiner places a seated patient's head in extension and rotation, and this position is held 15 40 seconds on each side. A positive sign is indicated by nystagmus or symptoms of vertebrobasilar ischemia.

Maisonneuve's sign.   Excessive dorsiflexion of the wrist as seen in Colles' fracture.

Mannkopf's test.   This is an old, but reliable, objective test for pain, and it is not restricted to musculoskeletal complaints. The patient is placed in a relaxed position and the pulse is taken. The examiner then precipitates the pain (eg, by probing, applying heat or electrostimulation, etc). The pulse rate is then re-evaluated. In situations of true pain, the pulse rate will increase a minimum of 10%. Also see Robertson's test.

McBride's test.   The patient is asked to stand on the limb opposite the side of a low back complaint and raise the knee of the other leg upward with the help of his hands. According to McBride, this maneuver usually relieves most low back complaints or at least is done with relative ease. The examiner should stand nearby in the event that the patient might lose balance. While often contraindicated in geriatrics, if the younger patient refuses this maneuver or complains of undue pain, one may suspect the possibility of malingering.

McIntosh's test.   The patient is placed supine, the lower extremity is supported at the heel with one hand, and the other hand is placed laterally over the proximal tibia just distal to the patella. The examiner's caudad hand applies valgus stress and internally rotates the tibia as the knee is gradually moved from full extension into flexion. During flexion of the knee, the lateral tibial plateau can be felt to subluxate anteriorly in relation to the lateral condyle. Lateral crepitation may be felt, and a slight resistance to flexion may be perceived. When the knee is at about 35° flexion, the iliotibial band tightens, passes behind the transverse axis of rotation, and the tibial plateau is suddenly reduced, often with a "clunking" sensation that can often be both felt and heard.

McMurray's test.   In this two-part test, the patient is placed supine with the thigh and leg flexed until the heel approaches the buttock. One hand of the examiner is placed on the patient's knee, the other hand on the patient's ankle. The examiner internally rotates the patient's leg, then slowly extends the leg. Then the examiner externally rotates the leg and slowly extends the leg. The test is positive if at some point in the arc a painful click or snap is heard. This sign can be significant of meniscus injury. The point in the arc where the snap is heard locates the site of injury of the meniscus; eg, if noted with internal rotation, the lateral meniscus will be involved. The higher the leg is raised when the snap is heard, the more posterior the lesion is in the meniscus. If noted with external rotation, the medial meniscus will usually be involved. Unfortunately, false positive and false negative signs are not uncommon.

Medial epicondyle test.   On the side of involvement, the patient is instructed to flex the elbow about 90° and supinate the hand. If severe pain arises over the medial epicondyle when the patient in this position attempts to extend the elbow against resistance, medial epicondylitis (golfer's elbow) is suggested.

Mendel-Bechterew sign.   In organic hemiplegia or cerebellar tract disease, plantar flexion of the lateral toes results from percussing the dorsum of the foot in the area of the cuboid. Under normal conditions, dorsiflexion of the lateral four toes occurs. In pathologic states, plantar flexion is produced.

Mennell's tests.   The patient is placed prone, and one hand of the examiner is used to stabilize the contralateral pelvis. With the palpating hand, the examiner places a thumb over the patient's PSIS and exerts pressure, then slides his thumb outward and then inward. The sign is positive if tenderness is increased. When sliding outward, trigger deposits in structures on the gluteal aspect of the PSIS may be noted. If when sliding inward tenderness is increased, it suggests sprain of the superior sacroiliac ligaments. Confirmation is positive when tenderness is increased when the examiner pulls the ASIS posterior while standing behind the patient or when the examiner pulls the PSIS forward while standing in front of the supine patient. These tests are helpful in determining that sacroiliac tenderness is due to overstressed superior sacroiliac ligaments.

Milgram's test.   The supine patient is asked to keep the knees straight and lift both legs off the table about 2 inches and to hold this position for as long as possible. The test stretches the anterior abdominal and iliopsoas muscles and increases intrathecal pressure. Intrathecal pressure can be ruled out if the patient can hold this position for 20 seconds without pain. If this position cannot be held or if pain is experienced early during the test, a positive sign is offered that indicates pressure upon the cord from some source (eg, cord pathology, IVD lesion).

Mills' test.   The patient makes a fist; flexes the forearm, wrist, and fingers; pronates the forearm, and then attempts to extend the forearm against the examiner's resistance. This stretches the extensors and supinators attached to the lateral epicondyle. Pain at the elbow during this maneuver is an indication of radiohumeral epicondylitis (tennis elbow).

Minor's sign.   Sciatic radiculitis is suggested by the manner in which the patient with this condition rises from a sitting position. The weight is supported on the uninvolved side by holding on to the chair for firm support in arising or the patient places the hands on the knees or thighs while working into the upright position, balances on the healthy leg, places one hand on the back, and flexes the leg and extends the thigh of the affected limb. The sign is often positive in sacroiliac lesions, lumbosacral strains and sprains, fractures, disc syndromes, dystrophies and myotonias.

Mittlemeyer's sign.   The situation in which the patient is instructed to march in place and there is automatic turning toward one side. This pathologic sign indicates vestibular disease.

Morton's test.   This test is positive when deep transverse pressure across the heads of the metatarsals, especially between the 2nd and 3rd metatarsal, causes a sharp pain in metatarsalgia.

Nachlas' test.   The patient is placed in the prone position. The examiner flexes the patient's knee to a right angle, then, with pressure against the anterior surface of the ankle, the heel is slowly directed straight toward the ipsilateral buttock. The contralateral ilium should be stabilized by the examiner's other hand. If a sharp pain is elicited in the ipsilateral buttock or sacral area, a sacroiliac disorder should be suspected. If pain occurs in the lower back area or is sciatic-like in nature, a lower lumbar disorder (especially L3 or L4) is indicated. If pain occurs in the upper lumbar area, groin, or anterior thigh, quadriceps spasticity/contracture or a femoral nerve lesion should be suspected.

Naffziger's test.   This test essentially offers a suspicion of an abnormal space-occupying mass such as a spinal tumor or disc protrusion. It is performed by having the patient sit or recline while the examiner holds digital pressure over the jugular veins for 30–45 seconds. The patient is then instructed to cough deeply. Pain following the distribution of a nerve suggests nerve root compression. Though more commonly used for low back involvements, thoracic and cervical root compression may also be aggravated. Local pain in the spine does not positively indicate nerve compression; it may indicate the site of a strain, sprain, or another lesion. The sign is almost always positive in the presence of cord tumors, particularly spinal meningiomas. The resulting increased intrathecal pressure above the tumor or disc protrusion causes the mass to compress or pull upon sensory structures to produce radicular pain. The test is contraindicated in geriatrics and extreme care should be taken with anyone suspected of having atherosclerosis. In all cases, the patient should be alerted that jugular pressure may result in vertigo.

Neri's bowing sign.   This sign is positive when a standing patient can flex the trunk further without low back discomfort when the ipsilateral leg is flexed than when both knees are held in extension. A positive sign suggests hamstring spasm, contractures of the posterior thigh and/or leg muscles, sciatic neuritis, a lumbar IVD lesion, or a sacroiliac subluxation syndrome.

Neuroma squeeze test.   If needle-like shooting pains occur when the forefoot is gripped and slowly squeezed, the probability of neuroma should be considered.

Ober's test.   This is a common test for iliotibial band contractures. The patient is placed directly on his side with the unaffected side next to the table. The examiner places one hand on the pelvis or under the thigh to steady it and grasps the patient's ankle with the other hand, holding the knee flexed at a right angle. The thigh is abducted and extended in the coronal plane of the body. In the presence of iliotibial band contracture, the leg will remain abducted the degree of abduction depending upon the amount of contracture present.

O'Connell's test.   This test is conducted in a manner similar to that of the double leg raise test except that both limbs are flexed on the trunk to an angle just below the patient's pain threshold. Then the limb on the opposite side of involvement is lowered. If this exacerbates the pain, the test is positive for sciatic neuritis.

Oculocardiac reflex.   Compression of the eyeball upon closed lids for about 30 seconds and without producing pain, while the patient is in the recumbent position, may produce slowing of the heart by 5–10 beats. In people who are distinctly vagotonic, it has been found that this slowing may amount to 12 beats or more. Under conditions of excessive pressure, in marked parasympathicotonics, the heart has often been temporarily inhibited. In people of stable nerve balance, neither inclined to sympathicotonia or parasympathicotonia, the slowing is usually less than 10 beats; in fact, in those who are markedly sympathicotonic, no slowing may occur. The reflex is caused by stimulating the ocular fibers of the trigeminus, through which the impulse is transmitted to the cardiac inhibitory fibers of the vagus. In individuals who are distinctly vagotonic, the reflex may show itself in the gastrointestinal tract as well as in the heart. Pressure over the vagus in the neck will result in a similar manifestation.

O'Donoghue's maneuvers.   The cervical spine of a sitting patient is passively flexed, extended, laterally flexed to both sides, and rotated in both directions against patient resistance. Pain precipitated by such isometric contraction indicates cervical strain. The test is then repeated without patient resistance. Pain precipitated by passive unrestricted motion suggests cervical sprain.

Oppenheim's reflex.   This response is met with in spastic conditions of the legs. The sign is elicited by striking the median surface of the leg posteriorly from the upper posterior portion of the tibia downward. This causes contraction of the tibialis anticus, extensor hallucis longus, extensor digitorum communis, and, in some instances, also the peroneal muscle. It has Babinski implications and is a variant of Gordon's reflex.

Palatal reflex.   The normal swallowing response induced by stimulating the soft palate.

Pallesthesia test.   A vibrating tuning fork is placed over bony prominences (eg, the lower ends of the radius and ulna, the ASISs, and the external and internal malleoli), then the patient is asked to state when he feels a vibration or humming sensation. When the vibratory sense is lost, the patient cannot differentiate between a vibrating fork and a silent one. Testing begins at the patient's head and proceeds to the feet, with the examiner comparing with his own hand or other bony prominences. A nonvibrating fork is alternately placed over a point to determine if the patient is guessing. Definite findings should be noted. The normal perception of vibration from the fork when placed against any subcutaneous bony prominence is called pallesthesia. Decreased sensation is recorded as pallhypesthesia; loss of sensation, pallanesthesia. If the patient fails to feel the vibration, it is indicative of an impairment of the tracts of the posterior columns of the spinal cord that convey the vibratory impulses. Normal vibratory perception is commonly impaired in tabes dorsalis, subacute sclerosis of the cord following pernicious anemia, and in generalized arteriosclerosis. It is first detected with a c-268 tuning fork and later by a c-128.

Parkinson's sign.   The immobile mask-like expression of individuals with postencephalitic disorders, with or without paralysis agitans.

Patella apprehension sign.   The patella displaces laterally with vigorous quadriceps contraction. When a person strongly extends the flexed knee with the leg externally rotated, the patella may dislocate if its attachments are weakened. If a patella is prone to dislocation, any attempt by the examiner to produce such a dislocation will be met with by sharp patient resistance. In testing, the patient is placed in the relaxed neutral supine position, and the examiner applies increasing pressure against the patella. If a chronic weakness exists, the patient will become increasing apprehensive as the patella begins to dislocate.

Patella clonus.   Patellar clonus (or trepidation sign) is a rapid up-and-down movement when the leg is in extension and relaxed while the patient is supine. With the lower extremities completely at rest on a bed or padded table, the examiner pushes down quickly on the patella (use discretion) and maintains the pressure. This will bring out any tendency to patellar clonus, which is indicative of lateral tract disease, disseminated sclerosis, or hysteria.

Patella reflex.   A rolled hard pillow is placed beneath the knees of a supine patient. With the muscles completely relaxed, the patellar tendon is tapped, and the contraction of the quadriceps muscles (L2–L4) is noted. Do not rely on the movement of the foot in response to the tapping. Place one hand on the quadriceps muscle of the thigh, using the other hand for the percussion hammer. Test bilaterally, and compare the force of contraction and quickness of response of the two sides. Absence of the reflex is Westphal's sign. Normal reflex response depends upon the integrity of the femoral nerve and the lumbar segments. Other positions for obtaining the knee reflexes are with the patient sitting on the edge of a bed with muscles relaxed or sitting on a chair with the feet resting on the floor in parallel position. The thighs should be bared and the same methods employed as stated previously. Absent or diminished knee jerks are found in peripheral nerve lesions, anterior horn cell disease, and posterior column lesions. IVD herniation at the level of L2–L4 will diminish the response. Hyperactive responses will be seen in tense patients, corticospinal tract lesions, general pareses, cord tumor compression or bone compression above L3, multiple sclerosis, and early hemiplegia. The knee jerk is often wanting or feeble in young infants. It varies a great deal in persons of different temperament. In high-strung or overly sensitive people, and often in the Jewish race, lively knee jerks are often seen without disease.

Patella wobble sign.   A patient in the sitting position is instructed to extend a knee while the examiner cups a palm over the patella. If erratic patellar motion is felt during the last phase of extension, an irregular retropatellar growth or some type of incomplete obstruction is indicated (eg, hypertrophied infrapatellar synovial folds, hardened fat pad).

Patrick's F-AB-ER-E test.   This test helps to confirm a suspicion of hip joint pathology. The patient lies supine, and the examiner grasps the ankle and the flexed knee. The thigh is flexed (F), abducted (AB), externally rotated (ER), and extended (E). Pain in the hip during the maneuvers, particularly on abduction and external rotation, is a positive sign of coxa pathology.

Payr's sign.   The patient is asked to sit flat on the floor with the legs crossed and folded in so that the femurs are internally rotated, the knees are flexed and abducted, and the feet are plantar-flexed. If pain occurs on the medial side of a knee when the examiner applies downward (valgus) pressure on the knee, a lesion at the posterior horn of the medial meniscus is suggested.

Pectoralis flexibility test.   With the patient placed supine and the hands clasped behind the head, the elbows are allowed to slowly lower laterally toward the table. If the elbows do not approximate the tabletop, shortening (eg, spasm, inflexibility, contracture) of the pectoralis group is indicated.

Pectoral reflex.   With the patient's arm placed halfway between adduction and abduction, the examiner's finger is placed in the pectoral tendon near the humerus. A sharp blow on the finger elicits adduction and slight internal rotation of the patient's arm.

Pende's reflex.   In subjects who are distinctly sympathicotonic, stroking of the skin (especially of the abdomen) may produce a "goose flesh" response; ie, a pilomotor reflex.

Perkin's tests.   The patient is placed in a relaxed supine position. The examiner locks the top of the patella between the thumb and first finger and applies pressure towards the patient's foot while the patient is asked to tighten the quadriceps by hyperextending the knee. As the patella moves proximally, its movement should be smooth and gliding. An alternative method is for the examiner to place a firm double hand contact over the anterior knee, lean over the limb, and displace the patella from side to side while simultaneously applying pressure from the anterior to the posterior. Induced pain, grating, or crepitation (palpable or audible) during this maneuver is a positive sign, suggesting roughening as in chondromalacia patellae, osteochondral defects, or when degenerative changes within the trochlear groove occur (eg, retropatellar arthritis).

Perthe's tourniquet test.   An elastic bandage is applied to the upper thigh of a standing patient sufficient to compress the long saphenous vein, and the patient is instructed to walk briskly around the room for approximately 2 minutes. The varicosities are then examined. This exercise with the thigh under pressure should cause the blood in the superficial (long saphenous) system to empty into the deep system via the communicating veins. Thus:

(1) If the varicosities increase in their distention (become more prominent) and possibly become painful, it is an indication that the deep veins are obstructed and the valves of the communicating veins are incompetent.

(2) If the superficial varicosities remain unchanged, the valves of both the long saphenous and communicating veins are incompetent.

(3) If the superficial varicosities disappear, the valves of the long saphenous and the communicating veins are normal.

Phalen's test.   The patient places both flexed wrists into apposition and applies moderate pressure for 30–45 seconds. A positive sign of carpal tunnel syndrome is the production of symptoms (eg, pain, tingling).

Pharyngeal reflex.   The response from stimulating the palate, fauces, or posterior pharyngeal wall that normally results in swallowing.

Phelp's test.   The patient is placed in the prone position with both lower limbs extended in the relaxed position. In this position, the patient's thighs are abducted just short of the patient's threshold of pain, and then the examiner flexes the patient's knees to 90° angles with the thighs. If this flexion allows greater abduction of a thigh on the hip without undue discomfort, a contracture of the gracilis muscle is suggested.

Piedallu's sign.   When a sacral base is subluxated unilaterally anteroinferior and lateral so that the adjacent ilium is displaced posteroinferior and medial, the ipsilateral PSIS on the side of inferiority will be low in the standing and sitting positions. If this PSIS becomes higher than the contralateral PSIS during forward flexion, the phenomenon is called a positive Piedallu's sign. Such a sign signifies either ipsilateral sacroiliac locking where the sacrum and ilium move as a whole or muscular contraction that prevents motion of the sacrum on the ilium. Regardless, it shows that sacral dysfunction is probably present.

Piriformis myofascitis tests.   The patient is seated on a table with the hips and knees flexed. Resistance is applied by the examiner as the patient attempts to separate the knees. In piriformis myofascitis, pain and weakness will be noted on resisted abduction and external rotation of the thigh. Inflammation will be confirmed by rectal examination exhibiting acute tenderness over the lateral pelvic wall proximal to the ischial spine.

Piriformis spasm signs.   If the patient has deep gluteal pain, sciatic neuralgia, and walks with the foot noticeably everted on the side of involvement, involvement of the piriformis should be suspected. Increased piriformis tone tends to subluxate the sacrum anteriorly and externally rotate the thigh.

Piriformis spasm test.   The patient is placed supine on a firm flat table. The heels are grasped and firmly inverted and abducted, and the feet are externally rotated. If one foot resists this effort and the act is attended by pain in the gluteal area, piriformis spasm should be suspected. Differentiation of piriformis spasm from other causes can often be elicited by reproducing the pain on internal rotation of the femur when it is at a lower level than the original point of pain.

Plantar tension test.   The patient is placed supine and the involved foot and toes are dorsiflexed so that the plantar fascia is tensed. If pain occurs or if bead-like swellings and irregularities are found as the examiner deeply runs his thumb vertically along the plantar surface, plantar fascitis is suggested.

Pollicis longus tests.   The examiner stabilizes the proximal phalanx of the patient's thumb, and the patient is instructed to flex and extend the distal phalanx. Inability to flex the phalanx indicates an injury to the tendon of the flexor pollicis longus. Inability to extend the phalanx indicates an injury to the tendon of the extensor pollicis longus.

Posterior drawer sign.   With the patient supine and the knees flexed, the stability of the posterior cruciate ligament is tested in the same manner as the anterior cruciate except the tibia of the flexed knee is pushed backward rather than pulled forward. Thus, it can be done in one continuous movement with the anterior drawer test. When a distinct sliding backward of the tibia from under the femur is noted, it indicates a torn posterior cruciate ligament. A positive drawer sign is less common than the anterior counterpart. Also see anterior drawer sign.

Pupillary reflex.   When light is quickly shined on the retina of one eye of a patient staring at a distant object, both pupils normally contract with the contralateral eye contracting to a lesser degree. Failure to do so indicates a lesion of the optic afferents or the contralateral oculomotor efferents.

Q-angle sign.   The patient is placed in the supine position with the knees extended in a relaxed position, and the quadriceps (Q) angle of the knee is measured. The Q-angle is formed by a line drawn along the long axis of the femur that is intersected by a line drawn through the center of the patella and the tibial tubercle. To make a recording, a goniometer is centered on its side over the patella with one arm aimed at the ipsilateral ASIS and the other arm placed in line with the center of the patellar tendon. This angle is normally 10° in men and 15° in women. In external tibial rotation and/or genu varus, however, the Q-angle can be markedly increased; ie, the angle increases as the tibial tubercle is displaced laterally or when the distal femur and proximal tibia are angled toward the midline.

Quadriceps flexion test.   Scar tissue within muscle invariably limit the working length of all muscles in the group. Quadriceps contracture is exhibited by placing the patient prone, flexing the leg toward the buttocks to tolerance, and measuring the distance from heel to buttock. Once the point of tolerance is measured, the lumbosacral spine will arch and the buttocks will rise to prevent further stretch. This test may prove a lesion too deep to palpate as well as evaluate progress during therapy.

Radial reflex.   With the patient's arm relaxed, flexed, and well supported, tapping the relaxed forearm over the lower radius results in flexion of the elbow. The response, a periosteal rather than a tendon reflex, tests the C5 C6 segments and has the same significance as the biceps tendon reflex. This periosteal reflex, absent in many healthy individuals, is frequently referred to as the brachioradialis reflex. In C5 C6 segment lesions, an inverted radial reflex may be seen where the fingers flex but the forearm remains relaxed.

Radial stress sign.   Pain over the medial aspect of the wrist is produced when the examiner forces the wrist into radial deviation. The sign is positive in posttraumatic disorders or pathology of the medial wrist.

Rebound tenderness sign.   Release of palpating pressure by quickly removing the examining hand(s) causes rebound pain in the abdomen if visceral or peritoneal irritation exists. The pain is often referred to that abdominal quadrant where the involved viscus exists.

Red reflex.   This is the normal diffusely red-orange appearance of the retina as seen with an ophthalmoscope from a distance of about 20 inches or more from the patient. The examiner looks through the window of an ophthalmoscope and shines a beam of light into the patient's line of sight. The ocular media (aqueous humor, lens, and vitreous) are normally transparent and allow the fundus to reflect a red-orange glow from the beamed light. This is the red reflex. If the ocular media contains any opacities, they will appear as dark shadows within this red glow.

Repetitive heel raise test.   The standing patient is asked to raise the heels (ie, toe stand) repetitively several times. If this induces ankle pain, instability, a posterior compartment syndrome or a subluxation complex should be suspected. If this exercise is unable to be performed because of weakness and ankle pain is absent, a gastrocnemius weakness or neurologic deficit should be suspected.

Rinne's test.   To test for deafness, a tuning fork is vibrated and placed next to each ear opening (for air conduction) and then against the mastoid bone (for bone conduction) to see which tone is heard longer. Normally, the tone will be heard longer through the otic canal via air conduction.

Robertson's test.   Pressure on any painful tissue will invariably produce dilation of the pupils. This reaction will not occur in the malingerer with alleged pain. To this author's knowledge, Robertson's test and Mannkopf's test (which see) are the only objective tests in physical diagnosis for pain.

Romberg's station test.   During this test, the examiner must stand close to the patient in the event the patient loses balance. The patient is asked to stand in a relaxed position and to close the eyes. If this cannot be accomplished without falling or severe swaying that requires the feet to be moved to regain balance, a positive sign is established that rules out cerebellar or labyrinthine disease. A positive sign is seen in locomotor ataxia associated with marked alcoholic neuritis, spinocerebellar tract disease, and in pernicious anemia when the columns of Goll and Burdach are affected and is highly indicative of a neurologic lesion interrupting the proprioceptive pathways between the lower limbs and the cerebellum. While a patient with cerebellar or labyrinthine disease may have difficulty standing, the position is usually taken equally well with or without visual support.

Rossolimo's sign.   A pathologic plantar reflex (Babinski variant) that occurring in lesions of the pyramidal tract, as in organic hemiplegia. When the great toe of the paralyzed side is lightly percussed, or stroked upon its plantar surface, extension or abduction of the toe results.

RUM tests.   Three quick RUM (radial, ulnar, medial nerve) tests are as follows:

(1) Radial nerve: have the patient extend the wrist. Nerve pathology causes wrist drop.

(2) Ulnar nerve: have the patient hold a piece of paper by opposing the thumb and index finger (Froman's cone sign). The examiner tries to pull the piece of paper away while the patient resists. If the patient cannot hold the slip, the weakness suggests ulnar nerve pathology.

(3) Median nerve: the median nerve is tested by asking the patient to touch each finger with the thumb. Remember that the median nerve is under the transverse carpal ligament. If carpal tunnel syndrome is suspected, test by holding the patient's wrist in flexion for 30 seconds. Induced pain is a positive sign.

Sacroiliac-lumbosacral differentiation test.   To differentiate these two common disorders, the patient is placed supine on a firm flat table. A folded towel is placed transversely under the small of the patient's back. The doctor stabilizes the patient's pelvis by cupping the hands over the ASISs and exerting moderate pressure. The patient is instructed to raise both extremities simultaneously with the legs held straight. If the patient senses discomfort or an increase of discomfort in the low back or over the sacrum and gluteal area at about 25°–50° leg raise and before the small of the back wedges against the towel, sacroiliac involvement is suspected. If, on the other hand, discomfort is experienced or augmented only after the legs have been raised beyond 50° and the small of the back wedges firmly against the towel, lumbosacral involvement should be the first suspicion.

Sacroiliac stretch test.   The patient is placed supine. The examiner, standing to face the patient, crosses his arms and places a hand on the contralateral ASIS and the other hand on the ipsilateral ASIS. Oblique (posterolateral) pressure is then applied to spread the anterior aspects of the ilia laterally. A positive sign of sacroiliac sprain is a deep-seated pelvic pain that may radiate into the buttock or groin. While the iliac compression test is designed to stretch the posterior sacroiliac ligaments, this test stretches the ligaments on the anterior aspect of the joints.

Salivation response.   This is a normal reflex of the vagal system. When a drop of weak acid such as vinegar is placed on the tongue, the salivary glands will normally increase their output of saliva, which can be observed. The sensation is carried by the facial nerve with action by the parasympathetics to the salivary glands.

Sargent's sign.   This sign is produced by a light stroke drawn in the median line from above downward over the abdominal wall. When a white line appears, it indicates increased sympathetic tonus or hyperadrenia.

Scapular reflex.   A mild stimulus applied between the scapulae normally contracts the scapular muscles. It is often called the interscapular reflex.

Scapulohumeral reflex.   Normal adduction with outward rotation of the humerus produced by percussing along the medial edge of the scapula.

Schaeffer's sign.   This reflex occurs in organic hemiplegia. When the middle portion of the Achilles tendon is firmly pinched, plantar flexion of the foot and dorsiflexion of the toes, especially the great toe, results in a Babinski-like fashion.

Schultz's test.   Standing behind the sitting patient with acromioclavicular separation, face the affected side. Place one hand under the flexed elbow and push up while the other hand placed over the acromioclavicular joint applies firm pressure. The more "give" that is felt in the joint, the greater the separation.

Schwabach's test.   To screen deafness, the physician with good hearing vibrates a tuning fork and compares his perception of tone with that of the patient. A series of several tuning forks of different tones is used and the number of seconds is noted in which the patient can hear each by air and bone conduction.

Serial sevens subtraction test.   Attention span can be tested clinically simply by serial subtraction with a patient with an IQ over that of an average third-grade student. For example, the patient can be asked to begin with the number 100, subtract 7, then subtract 7 from the answer, and continue this process and give a verbal answer until zero nears. An occasional mistake can be attributed to carelessness.

Shober's sign.   This procedure is an excellent method for grossly evaluating the extent of lumbar flexion. One mark is placed over the L5 spinous process when the patient is standing erect and a second mark is made on the spine exactly 10 cm above. The patient is then asked to flex forward in the Adams position, and the distance between the two marks is measured. A difference of less than 4–5 cm is a positive sign of ankylosing spondylitis or some irritation producing severe lumbar spasm.

Shoulder abduction stress test.   The sitting patient is asked to abduct the arm laterally to the horizontal position with the elbow extended while the examiner applies resistance. If this causes pain in the area of the insertion of the supraspinatus tendon, acute or degenerative shoulder tendinitis is suggested.

Shoulder apprehension test.   If chronic shoulder dislocation is suspected, slowly and gently abduct and externally rotate the patient's arm with the elbow flexed toward a point where the shoulder might easily dislocate. If shoulder dislocation exists, the patient will become quite apprehensive, symptoms may be reproduced, and the maneuver is resisted as further motion is attempted.

Shoulder depression test.   With the patient sitting, the examiner stands behind the subject and the patient's head is laterally flexed away from the side being examined. The doctor stabilizes the patient's shoulder with one hand and applies pressure alongside the patient's head with the palm of the other hand; stretching the dural root sleeves and nerve roots or aggravating radicular pain if the nerve roots adhere to the foramina. Extravasations, edema, encroachments, and conversion of fibrinogen into fibrin may result in interfascicular, foraminal, and articular adhesions and inflammations that will restrict fascicular glide and the ingress and egress of the foraminal contents. Thus, pain and reduplication of other symptoms during the test suggest adhesions between the nerve's dura sleeve and other structures around the IVF.

Sicard's sign.   During Lasegue's SLR test, the limb is lowered slightly to a point just below the level of pain, the examiner then dorsiflexes the big toe to induce traction on the sciatic nerve. Pain arising in the posterior thigh or calf indicates sciatic radiculopathy.

Simmond's test.   The patient is placed prone and the knee is flexed to a right angle. The examiner grasps the center of the leg with both hands and applies strong pressure so that the calf muscles are squeezed against the tibia and fibula. Normally, the foot will plantarflex slightly; if not, a ruptured Achilles tendon is indicated. This test is a common variant of Thompson's test.

Slocum's test.   This is a modification of McIntosh's test. The patient is placed in the lateral recumbent position with the involved knee uppermost. The under extremity is flexed at 90° at both the hip and knee. The pelvis is rotated slightly posterior about 30°, and the weight of the extremity is supported by the inner aspect of the foot and heel. This position causes valgus stress at the knee and a slight internal rotation of the leg. The examiner then grips the distal thigh with one hand and the proximal leg with the other hand and presses back of the fibula and femoral condyle with the thumbs. The knee is then gently pushed from extension into flexion and, as the iliotibial tract passes behind the transverse axis of rotation at about 35°, the lateral tibial plateau, which has subluxated forward, is reduced with a palpable "clunk" or "giving way" sensation.

Smith-Peterson test.   If it is possible during Goldthwait's test to raise the limb on the unaffected side to a greater level without pain than the involved side, a positive Smith-Peterson sign is found, which confirms a sacroiliac lesion; ie, pain usually occurs at the same level for either leg when a lumbosacral lesion is present.

Snellen's test.   The common visual acuity test in which the patient attempts to read a chart composed of rows of letters of decreasing size that is placed at a specific distance from the subject.

Soto-Hall test.   This test is primarily employed when fracture of a vertebra is suspected. The patient is placed supine without pillows. One hand of the examiner is placed on the sternum of the patient, and a slight pressure is exerted to prevent flexion at either the lumbar or thoracic regions of the spine. The other hand of the examiner is placed under the patient's occiput, and the head is slowly flexed toward the chest. Flexion of the head and neck upon the chest progressively produces a pull on the posterior spinous ligaments from above, and when the spinous process of the injured vertebra is reached, an acute local pain is experienced by the patient.

Speech test.   Articulation is a complex coordinated function involving the cooperation of muscles supplied by the cranial V, VII, IX, and XII nerves. Note whether the speech is clear, distinct, slurring, scanning, or tremulous. Test phrases are used such as "truly rural" or "Methodist Episcopal." The dysarthrias should be differentiated from the aphasias.

Spinal hyperextension tests.   These two screening tests help in localizing the origin of low back pain.

(1) The patient is placed prone. With one hand the doctor stabilizes the contralateral ilium, and the other hand is used to extend the patient's thigh on the hip with the knee slightly flexed. If pain radiates down the front of the thigh during this extension, inflamed L3–L4 nerve roots should be suspected if acute spasm of the quadriceps or hip pathology have been ruled out.

(2) With the patient remaining in the relaxed prone position, the examiner stabilizes the patient's lower legs and instructs the patient to attempt to extend the spine by lifting the head and shoulders as high as possible from the table by extending the elbows bilaterally. If localized pain occurs, the patient is then asked to place a finger on the focal point.

Spinal percussion test.   With the patient prone or in a sitting forward-flexed position, the examiner percusses the spinous process of the involved area. Induced pain suggests intervertebral sprain, fracture, acute subluxation, IVD lesion, or dislocation. If negative, the perivertebral soft tissues (about 1–2 inches lateral) are percussed. Induced pain suggests strain, radiculitis, transverse process fracture, or a costovertebral lesion. A variation of this test is to place a c–128 tuning fork on suspected segments to see if symptoms are aggravated. A positive sign is often present during the acute phase.

Spurling's tests.   With the patient in the seated position and the examiner standing behind, the patient's head is rotated and laterally flexed to one side. With the patient actively holding the head and neck in this position, the examiner places a palm on the patient's scalp and vertically strikes it moderately with the other fist. The patient's head is then rotated and laterally flexed to the opposite side, and the test is repeated. If these tests can be tolerated by the patient without undue discomfort, the procedure is repeated with hyperextension added. In radiculitis, sensitive spondylosis, IVD syndromes, and other inflammatory or space-occupying conditions in or near the IVF or posterior facets, pain will be increased by the induced compression.

Steinmann's sign.   In meniscus disorders, tenderness moves posteriorly when the knee is flexed and anteriorly when the knee is extended. This displaced tenderness is said not to occur in degenerative osteoarthrosis.

Stenger's test.   With the patient blindfolded, two tuning forks of the same tone are simultaneously vibrated and placed about an inch from each ear. The forks are then moved away from the ears. The tone is normally heard equally in each ear from similar distances. If one ear is impaired, the healthy ear will hear the tone at a greater distance.

Stereognosis test.   This refers to the ability to sense form, nature, and solidity of objects through the sense of touch; eg, familiar objects as keys, coins, marbles, pencils, etc. Place different objects in either hand when the patient's eyes are closed. Ask the patient to handle them and to name them. Loss of the ability to recognize familiar objects occurs in contralateral brain lesions in the parietal area.

Sternal compression test.   Downward pressure is slowly applied against the sternum of a supine patient. Sharp, localized pain arising laterally suggests a fractured rib.

Strabismus Test.   In testing for strabismus, the examiner stands about 2 feet in front of the patient and shines a pen light at the patient's supranasal notch (between the eyebrows). The light will normally be reflected in each eye nearly centered in each pupil. If the light is reflected at a different point on each eye, it indicates strabismus.

Strunsky's test.   This test is designed essentially for the recognition of lesions of the metatarsal arch. Under normal conditions when the toes are grasped and quickly flexed, the procedure is painless. Pain results if there is any inflammatory lesion of the metatarsal arch. This test is often positive in tendinitis of toe extensors.

Subacromial button sign.   The examiner stands behind the sitting patient, cups a palm over the involved shoulder, and applies finger pressure over the subacromial bursa. If this produces pain or unusual tenderness, subacromial bursitis is indicated.

Suprapatellar reflex.   With the leg extended and the index finger of the examiner crooked above the patella, a tap results in a kick-back of the patella. Jendrassik's reinforcement maneuver may be necessary.

Supraspinatus press test.   With the patient in the relaxed seated position, the examiner applies strong thumb pressure directed toward the midline in the soft tissues located superior to the midpoint of the scapular spine. The production of pain signifies an inflammatory process in the supraspinatus muscle (eg, strain, rupture, tendinitis).

Swallowing test.   The sitting patient is asked to drink some water. If a pharyngeal lesion is ruled out (eg, tonsillitis), painfully difficult swallowing may suggest a space-occupying lesion at the anterior aspect of the cervical spine (eg, abscess, tumor, osteophytes, etc).

Talar slide test.   This test evaluates ankle joint play (translation) in the horizontal plane. With the patient in either the prone or supine position, the doctor stands to the side and faces the ankle to be tested. The examiner's cephalad hand grasps the patient's lower leg just above the malleoli and the caudad hand grasps the heel just below the malleoli. A pull is made with the upper hand on the lower leg while the lower hand pushes the heel horizontally. Then a push is made with the upper hand while the lower hand pulls the heel horizontally. Excessive lateral or medial motion with pain indicates ligament instability.

Taste tests.   Taste perception is tested by means of solutions of sour (vinegar), sweet (sugar), and salty (salt) substances. It is good procedure to arrange certain signals with the patient before the test is made. For instance, holding up two fingers may mean that no taste is recognized and three fingers may mean that a taste is recognized. Then the applicator is dipped in the solution, and the patient is told to protrude his tongue. Keep it protruded with the aid of a sterile pad, and apply a solution to one side of the tongue. After the patient has signaled tasting or not tasting, request that the flavor be named. The taste buds of the anterior two-thirds of the tongue are supplied by the facial nerve, those of the posterior third are supplied by the glossopharyngeal nerve. Thus, the front, back, and each side of the tongue should be tested separately. It is best to have the patient rinse his mouth with warm water after each solution is used to avoid confusion between the solutions.

Teres spasm sign.   When the relaxed standing patient is viewed from behind, the arms normally rest so that the palms face the thighs. If a palm faces distinctly backward (toward the examiner) on the involved side, a spastic contraction of the teres major muscle is suggested.

Thermesthesia test.   Thermesthesia (thermoesthesia) refers to the capability of sensing and differentiating degrees of heat and cold. Areas of impaired temperature differentiation follow a cutaneous pattern that is identical to areas of impaired pain sensations. Fibers and cells serving the sensory path for temperature perception follow the same course as those of the pain pathway. The two systems are so closely associated in the CNS that they can scarcely be distinguished anatomically, and an injury to one affects the other to a similar degree. Thus, for most practical clinical purposes, testing either pain or temperature sensibility accomplishes the same result.

Thomas' test.   This test is used to determine excessive iliopsoas tension. The supine patient holds one flexed knee against his abdomen with his hands while the other limb is allowed to fully extend. The patient's lumbar spine should normally flatten. If the extended limb does not extend fully (ie, the knee flexes from the table) or if the patient rocks his chest forward or arches his back, a fixed flexion contracture of the hip is indicated, as from a shortened iliopsoas muscle. This should always be tested bilaterally. Some examiners use the degree of pain elicited on forceful extension of the flexed knee as their criterion of iliopsoas tension.

Thompson's test.   To detect a rupture of the Achilles tendon, the patient kneels on a chair with the feet extended over the edge. The middle third of the calf is squeezed. If the Achilles tendon is ruptured, especially the soleus portion, the squeeze will not cause the normal plantar flexion response.

Tinel's elbow test.   The groove between the olecranon process and the medial epicondyle is percussed. A hyperactive response indicates an irritable lesion of the ulnar nerve (eg, neuritis, neuroma).

Tinel's foot test.   With the patient prone and the knee flexed to a right angle, the posterior tibial nerve is percussed as it passes behind the lateral malleolus. If this induces paresthesias in the foot, tarsal tunnel syndrome is suggested.

Tinel's sign.   Normally, percussion of a nerve above or below a point of complete severance elicits no subjective sensations. In cases of partial severance or in cases of compression of this given peripheral nerve where some conduction is preserved, percussion distal to the involvement will elicit a tingling paresthesia below the point of tapping. This represents a positive Tinel's sign. This sign, if positive, is also indicative of nerve regeneration if it is elicited over a nerve that had previously been negative on percussion. In this respect, it may have prognostic as well as diagnostic value.

Tinel's wrist test.   The hand of a sitting patient is supinated, and the volar surface of the wrist is percussed. If this induces pain in all fingers except the first digit, carpal tunnel syndrome is indicated.

Toe-in sign.   Excessive toe-in, especially in children, may be the result of excessive internal rotation of the tibia caused by a fixed point at either end of the tibia. Common points of fixation are at the malleoli in the ankle or the tibial tubercle below the knee. The ankle mortise normally faces 15° externally; in internal tibial torsion, the ankle mortise faces anteriorly or internally.

Toe-to-finger test.   The supine patient attempts to touch the examiner's finger with the great toe as the examiner moves the finger to different stationary positions that can easily be reached. Inability or severe awkwardness in performing this test indicates a proprioceptive defect from either a posterior column or cerebellar lesion.

Toe walk test.   Walking for several steps on the base of the toes with the heels raised will normally produce no discomfort to the patient. With the exception of a localized forefoot disorder (eg, plantar wart, neuroma) or an anterior leg syndrome (eg, shin splints), an inability to do this because of low back pain or weakness can suggest an S1–S2 lesion.

Toynbee maneuver.   The patient swallows while the nose and lips are firmly closed. It is a mild test compared to the Valsalva maneuver in seeking signs of eustachian tube obstruction.

Traction test.   With the patient sitting and the arm held in the anatomical position, the radial pulse is determined while traction is firmly applied to the patient's wrist. If a decreased pulse is found on one side but not the other, a thoracic outlet disorder may be suspected on the side of the decreased pulse.

Trendelenburg's hip test.   If the hip and its muscles are normal, the iliac crest and sacral dimple will be slightly low on the weight-bearing side and high on the leg-elevated side when one leg is lifted. To test, have the patient with a suspected hip involvement stand on one foot, on the side of involvement, and raise the other foot and leg in hip and knee flexion. If there is hip joint involvement and muscle weakness, the iliac crest and sacral dimple will be markedly high on the standing side and low on the side the leg is elevated. A positive sign suggests that the gluteus medius and minimus muscles on the supported side are weak. The gait will exhibit a characteristic lurch to counteract the imbalance caused by the descended hip. The sign is also commonly positive in a developing Legg-Calve-Perthe's disease, poliomyelitis, muscular dystrophy, coxa vara, Otto's pelvis, epiphyseal separation, pathology of the superior gluteal nerve, coxa ankylosis, hip dislocation, fracture, or chronic subluxation of L4, L5, or the sacral base.

Triceps reflex.   The patient's arm should be relaxed and flexed at the elbow. Support the elbow and tap the triceps tendon where it crosses the olecranon fossa, observing the same phenomena as in the biceps reflex. The triceps reflex tests C6 C8 segments and the radial nerve. Upper extremity reflexes are often diminished in healthy patients.

Tripod sign.   The patient is placed prone with the knees flexed over the edge of the table as in Huntington's test, and active and passive muscle strength and range of motion of knee extension are evaluated. If the patient must lean back (extend the trunk on the pelvis) and grasp the table to support body weight on the arms when the knees are bilaterally extended, hamstring spasm is indicated. This may be the result of any lower motor irritation located between the midthoracic area and the lower sacrum.

Trousseau's line sign.   The production of a bright red line where the finger is drawn across the trunk or forehead. It commonly occurs in meningitis.

Turgor test.   This is a screening test to judge tissue hydration/collagen content. First, the examiner lightly pinches and lifts the skin on the back of the patient's hand with the thumb and forefinger. The suspended skin is held taut for 30 seconds, released, and the area is observed. It should quickly begin to flatten and be complete within 3–5 seconds (a negative sign). If the area that has been pinched very gradually creeps back to its normal state, the test is considered positive for probable collagen deficiency and/or an associated sign of osteoporosis.

Two-point discrimination test.   In impairment of the proprioceptive pathway, there is loss of the normal ability to recognize two points simultaneously applied to the skin as distinct from one single point. Normally, a patient will be able to distinguish two points that are 2–3 mm apart on the fingertips. If a lesion is located peripherally, the patient will not be able to distinguish two points that are less than 5 mm apart. If a cortical lesion is present, the patient will be unable to consistently distinguish two points from one.

Ulnar reflex.   Tapping the styloid process of the ulnar resulting in pronation of the hand. This is a highly unreliable normal reflex.

Ulnar stress sign.   Pain arises over the lateral aspect of the wrist when the examiner forces the patient's wrist into ulnar deviation, indicating posttraumatic or pathology of the lateral wrist.

Ulnar tunnel triad.   Hypothenar wasting, tenderness of the ulnar tunnel, and flexion contracture of the ring finger are the three classic signs of entrapment compression of the ulnar nerve in the tunnel of Guyon.

Unterberger's test.   The patient is asked to stand with his upper limbs outstretched, his eyes closed, and then to march in place about 50 times. The examiner should stand close to the patient during the test because a positive sign is a loss of balance. In vestibular lesions, the patient will tend to slowly but continuously rotate towards the side of the lesion. Many normal people can be expected to rotate once during the test, and mostly to the left, but not more than 45° total. Some examiners add additional stress during the test by having the patient extend and rotate the neck 45°. If this procedure is used, 30 steps in place is usually sufficient for evaluation.

Uvular reflex.   The patient is asked to open his mouth and say "Ah." Raising of the uvula (uvular reflex) in phonation or from irritation is absent in disorders of the cranial IX or X nerves. It is important to make this test with the patient's head in the midline and not turned to the side.

Valsalva's maneuver.   The sitting patient is asked to bear down firmly (abdominal push), as if straining at the stool. This act increases intrathecal pressure, which tends to elicit localized pain in the presence of a space-occupying lesion (eg, IVD protrusion, cord tumor, bony encroachment) or of an acute inflammatory disorder of the cord (eg, arachnoiditis). Deep coughing will produce the same effect under like circumstances.

Vanzetti's sign.   In sciatica, the pelvis tends to maintain a horizontal position despite any induced degree of scoliosis, unlike other conditions in which scoliosis occurs where the pelvis is tilted.

Vertebrobasilar artery maneuvers.

(1) With the patient seated and the head placed in the neutral position, the carotid and subclavian arteries are palpated for abnormal pulsations and auscultated for bruits. If pulse abnormalities or bruits are found, the test is positive for carotid, vertebral, or basilar artery obstruction (stenosis or compression), and the second maneuver should not be conducted.

(2) If palpatory and auscultory signs are negative in the neutral position, the patient is asked to slowly rotate and hyperextend the neck first in one direction and then the other to place a motion-induced compression on the vertebral arteries. Positive signs include faintness, nausea, nystagmus, vertigo, and/or visual blurring. Also see Maigne's test, DeKleyn's test, Hautant's test, and Unterberger's test.

Viet's test.   See Naffziger's test.

Vincent's sign.   See Argyll Robertson sign.

Visual-fixation reflex.   This normal reflex is demonstrated by an auto passenger looking out a side window at the passing scenery. The head and eyes turn slowly in the direction of apparent movement and then jump ahead quickly to fix the gaze on a new approaching site. This is done without conscious effort or awareness that the eyes are moving: a true optokinetic reflex. This reflex is also demonstrated and tested as in reading from line to line, which normally presents a combination of jerky eye movements interspaced with pauses.

Von Graefer's sign.   This pathologic sign is seen when the upper lids do not readily follow the cornea when the eyes are lowered, and the upper movement occurs in a jerky manner. It is caused by the same etiology as Dalrymple's sign, hypertonia of the levator muscles.

Walking test.   The patient is instructed to close the eyes and take two steps forward and two steps backward several times. If a labyrinthine disturbance exists, the patient will turn gradually to the involved side.

Wartenberg's sign.   The patient is instructed to spread the hands out so that the palms face downward, the fingers are extended, and the thumbs are adducted; then raise the hands toward the face so that the palms appose. If the index fingers touch but the thumbs do not meet, paralysis of the abductor pollicis brevis is indicated.

Weber's test.   To test for deafness and lateralization, the base of a vibrating tuning fork is placed in the center of the forehead at the hairline and the patient is asked if the tone is heard better in one ear than the other. Normally, the tone is heard equally in both ears.

Westphal's sign.   This term has been used to represent loss of any deep reflex, thus indicative of lower motor neuron involvement. It is especially applied to loss of the patellar-quadriceps reflex.

Williamson's sign.   Definite lessening of blood pressure in the leg as compared with the pressure of the ipsilateral arm in pneumothorax.

Wilson's sign.   The patient is placed supine with the legs in an extended, relaxed position. This is a two-phase test:

(1) The knee of the involved side is flexed to a right angle, the leg is firmly rotated internally, and then the knee is slowly extended while maintaining the leg in internal rotation. If osteochondritis of the knee is present, the patient will complain of pain in front of the medial condyle of the distal femur.

(2) However, if the leg is then externally rotated, the pain will subside.

Wright's test.   With the patient sitting, the radial pulse is palpated from the posterior in the downward position and as the arm is passively moved through an 180° arc. If the pulse diminishes or disappears in this arc or if neurologic symptoms develop, it may indicate pressure on the axillary artery and vein under the pectoralis minor tendon and coracoid process or compression in the retroclavicular spaces between the clavicle and 1st rib, and thus be a hyperabduction syndrome.

Wrist clonus.   This refers to a spasmotic contraction of the muscles of the hand induced by forcibly bending the hand backwards.

Wrist drop sign.   The two opposing palms are placed together with the hands in dorsiflexion. On separation, failure to maintain dorsiflexion indicates a positive test and is significant of radial nerve impairment.

Wrist flexion/extension stress tests.   The examiner moves the wrist firmly into flexion and extension. If pain is induced, wrist fracture, subluxation, sprain, acute tendinitis, or pathology are suggested. If negative, the movements are repeated against patient resistance. Induced pain then indicates wrist strain, rupture, acute or chronic tendinitis, or pathology.

Wrist tourniquet test.   A sphygmomanometer cuff is wrapped around the suspected wrist, inflated to a point slightly above the patient's systolic blood pressure, and maintained for 1–2 minutes. An increase in forearm, wrist, or hand pain indicates carpal tunnel syndrome.

Yeoman's test.   The patient is placed prone. With one hand, firm pressure is applied by the examiner over the suspected sacroiliac joint, fixing the patient's anterior pelvis to the table. With the other hand, the patient's leg is flexed on the affected side to the limit, and the thigh is hyperextended by the examiner lifting the knee off the examining table. If pain is increased in the sacroiliac area, it is significant of a ventral sacroiliac or hip lesion because of the stress on the anterior sacroiliac ligaments. Normally, no pain should be felt on this maneuver.

Yergason's test.   The patient flexes the elbow, pronates the forearm, and attempts elbow flexion, forearm supination, and humeral external rotation against the resistance of the examiner. The doctor stabilizes the patient's elbow with one hand while offering resistance to the patient's distal forearm with his other hand during the maneuver. Severe pain in the shoulder during this test is usually a positive indication of a bicipital tendon lesion, a tear of the transverse humeral ligament, or bicipital tendinitis.

Note: The descriptions within the preceding glossary of clinical signs and tests have been reproduced with permission for this edition; (C) 1985, R.C. Schafer, D.C.

A Physical Examination Routine

Table 3.3 offers an outline of examination procedures carried out in clinical practice. (
see Table 3.3 at the end of the Chapter) While vital signs, color blindness examination, and visual acuity tests can be conducted by a trained assistant, other procedures are usually performed by the examining chiropractic physician. On first observation, the listing appears time consuming; however, in actual practice the full examination seldom exceeds 30 minutes because most tests require only a few seconds and the positions smoothly evolve through standing, sitting, supine, side-lying, prone, Sims', knee-chest, and lithotomy positions, and then conclude with final upright and sitting examinations. During the examination, it is important to consider the general physical and mental condition of the patient. Care should be given not to create anxiety and to hold orthopedic maneuvers within the tolerance of the individual being examined, ever keeping in mind the possibility of underlying pathologic conditions such as fracture, osteoporosis, atherosclerosis, and other degenerative changes associated with the aging process.


The geriatric case history and physical examination are an office-oriented sequence of procedures with the following primary objectives:

(1) To evaluate the patient's general health status.

(2) To collect clinical data by which judgments may be made that a health problem exists.

(3) To establish etiologic possibilities; particularly as they relate to chiropractic management and as a prerequisite to roentgenographic evaluation.

It is emphasized that the examination is not intended as a total diagnostic workup in itself. It is the "mechanics" by which information is gathered to enable such judgments to be made. That is, the basis of this examination should be correlated with roentgenographic, clinical laboratory, and other special studies when indicated. Thus, the procedures incorporated in the physical examination should be selected with the specific patient in mind; ie, with concern for obtaining the greatest amount of information without subjecting the patient to excessive and/or unnecessary strain. In this respect, the geriatric patient in the seventies, eighties, nineties, etc, cannot be handled in the same manner as younger patients. Geriatric joints do not bend with the same ease, geriatric bones are much more prone to fracture, geriatric skin and subcutaneous tissues are more sensitive, and geriatric stamina is severely limited as compared to younger patients.

Rather than being a separate clinical specialty, as the term might imply, chiropractic clinical geriatrics is an integral part of chiropractic general practice dealing with the elderly patient; the evaluation of the general health status to advise on proper adaptation to the aging process, and the evaluation of any specific health problems that may be evident and in need of attention —either by routine chiropractic methods or by referral to other health-care practitioners.

With respect to these clinical objectives, it is necessary that a routine office-oriented case history and examination be conducted on all older patients at the time of their initial visit and at periodic intervals of no longer than a year thereafter, regardless of the specific entrance complaint. This routine case history and physical examination should also be supplemented by laboratory, roentgenographic, and other special studies when indicated.

With special concern for those aspects of chiropractic clinical geriatrics that deal with the Medicare patient, it is emphasized that present chiropractic services are confined to ascertaining spinal subluxations and their manual correction. Since it is judged to be an imprudent practice to expose patients to the harmful effects of ionizing radiations, unless such procedures are clinically justified beforehand, then the case history and physical examination must be considered the appropriate means by which this justification is accomplished. Therefore, in regards to the objectives of chiropractic clinical geriatrics, the determination that a subluxation is clinically evident is a paramount concern of the case history and physical examination, particularly as these objectives relate to Medicare procedure.

For purposes of further clarification, the chiropractic subluxation is a "biomechanical-pathophysiologic cause-and-effect syndrome" that has profound and far-reaching clinical implications. From the causative viewpoint, two major categories should be considered:

  1. Inequality in muscular balance, which may be initiated by trauma, postural compensations, intrinsic biochemical alterations, psychologic stress, primary neuromuscular disease processes, and secondary reactions of the muscular system to somatovisceral sensory irritations.

  2. Structural errors in position or motion due to mechanical alterations common to developmental abnormalities, acquired disease processes, and/or residual effects from past major- or micro-traumas.

    From the effect (the result of the cause) standpoint, the subluxation may be clinically manifested in one or more of three major categories:

    1. The immediate local effects of tissue irritation, degeneration, or other disease processes.

    2. The structural effects of mechanical errors in position or motion to biomechanical function.

    3. Neurologic effects of subluxation such as:

      (1) Physical nerve pressure that may be responsible for motor or sensory alterations.

      (2) Local circulatory changes that may result in edema, hyperemia, or ischemia.

      (3) Meningeal irritations or mechanical pressure on the dural-root sleeve that may result in abnormal motor or sensory disturbances.

      (4) Mechanical alterations in the circulation of cerebrospinal fluid.

      (5) Proprioceptive stimulation as a result of stress on the interosseous soft tissues, which may initiate motor responses in the muscles of the spinal column, somatovisceral reflexes, or sensory interpretation of pain.

    Note that an abnormal orthopedic finding may suggest a possible neurologic insult at a specific spinal motor unit, or a positive neurologic test may suggest a possible biomechanical disorder. Thus, the examination of the patient should be a systematic but not exhaustive survey of the patient's general health status. However, one should be constantly alert to signs that a problem exists that might require other procedures. The typical examination should include a systems review with spinal examination and orthopedic and neurologic evaluation. Tests should be conducted in a sequence that expedites the procedures. The most efficient method is to conduct the examination according to patient position; ie, standing, sitting, supine, and prone.

    No single test or procedure can be taken at face value as a positive indication of a specific disease entity; but when a "pattern" of signs develops on the basis of "overlapping" positive signs, clinical judgments of a particular health problem requiring roentgenographic or other evaluation may be made. Most neurologic tests are indicative; most orthopedic tests are suggestive.


Cranial and Thoracic Measurements

The following list shows normal cranial and thoracic circumference measurements in inches from birth to 5 years:

    Age     Head    Thorax
    Birth   13.7    13.7
    2 mo.   15.8    15.3
    4 mo.   16.8    16.7
    6 mo.   17.4    17.2
    1 yr.   18.4    18.3
    2 yr.   19.2    19.4
    3 yr.   19.6    20.3
    4 yr.   20.0    21.0
    5 yr.   20.3    21.7

Developmental Progress

The following list shows selected normals for motor, language, and social skills related to an average age from 1 to 6 years:

    Skill                                   Avg. Age
    Regards face                            1.0 mo.
    Visually follows finger to midline      1.3 mo.
    Responds to bell                        1.6 mo.
    Head up, prone                          3.2 mo.
    Laughs                                  3.3 mo.
    Puts hands together                     3.7 mo.
    Visually follows finger 180~            4.0 mo.
    Grasps small objects                    4.2 mo.
    Sits, head steady                       4.2 mo.
    Arm support                             4.3 mo.
    Squeals                                 4.5 mo.
    Rolls over                              4.7 mo.
    Smiles spontaneously                    5.0 mo.
    Reaches for objects                     5.0 mo.
    Bears some weight on legs               6.3 mo.
    Learns to chew                          6.5 mo.
    Looks for familiar objects              7.5 mo.
    Accepts objects in hands                7.5 mo.
    Pulls to sitting position               7.7 mo,
    Sits without support                    7.8 mo.
    Feeds self a cracker, cookie            8.0 mo.
    Turns toward spoken voice               8.3 mo.
    Plays "peek-a-boo"                      9.7 mo.
    Says "dada" and "mama"                 10.0 mo.
    Resists toy pull                       10.0 mo.
    Pulls to standing position             10.0 mo.
    Thumb-finger grasp                     10.6 mo.
    Stands briefly, no support             13.0 mo.
    Plays "pat-a-cake"                     13.0 mo.
    Walks forward                          13.3 mo.
    Indicates desires without crying       14.3 mo.
    Drinks from cup                        14.3 mo.
    Imitates housework                     19.5 mo.
    Towers two blocks                      20.0 mo.
    Speaks three words                     20.5 mo.
    Walks backward                         21.5 mo.
    Removes garment without help           21.9 mo.
    Combines two words                     23.0 mo,
    Helps with simple tasks                23.5 mo.
    Uses spoon                             23.5 mo.
    Kicks ball                              2.0 yr.
    Scribbles                               2.1 yr.
    Towers four blocks                      2.2 yr.
    Names a picture                         2.5 yr.
    Throws a ball                           2.6 yr.
    Puts on shoes, untied                   3.0 yr.
    Rides tricycle                          3.0 yr.
    Washes and dries hands                  3.2 yr.
    Uses plurals in speech                  3.2 yr,
    Towers eight blocks                     3.4 yr.
    Dresses self with help                  3.5 yr.
    Plays tag                               3.5 yr.
    Gives first and last name               3.8 yr.
    Buttons-up clothing                     4.2 yr.
    Copies letters "O" and "X"              4.4 yr.
    Recognizes three colors                 4.9 yr.
    Hops on one foot                        4.9 yr.
    Dresses without help                    5.0 yr.
    Draws a square                          5.0 yr.
    Draws three-part person                 5.2 yr.
    Catches ball                            5.5 yr.
    Defines six words                       6.3 yr.

Height Estimation During Development

The following list shows a means to estimate probable height at maturity during development. Multiply child's height in inches by 100 and divide by the percentage figure listed at the right.

Percent of Mature Height Anticipated

    Age         Males     Females
    1.0 mo.     32.4      30.2
    2.0 mo.     34.5      32.4
    3.0 mo.     36.0      33.9
    4.0 mo.     37.5      35.2
    5.0 mo.     38.8      36.5
    6.0 mo.     39.8      37.7
    7.0 mo.     40.7      38.4
    8.0 mo.     39.2      41.8
    9.0 mo.     40.1      42.2
    10.0 mo.    40.8      43.1
    11.0 mo.    41.5      44.1
     1.0 yr.    42.2      44.7
     1.3 yr.    44.0      46.9
     1.5 yr.    45.6      48.8
     2.0 yr.    48.6      52.2
     2.5 yr.    51.1      54.8
     3.0 yr.    53.5      57.2
     3.5 yr.    55.6      59.5
     4.0 yr.    57.7      61.8
     5.5 yr.    59.8      64.0
     5.0 yr.    61.6      66.2
     5.5 yr.    63.4      68.2
     6.0 yr.    65.3      70.3
     6.5 yr.    67.1      72.0
     7.0 yr.    69.1      74.3
     7.5 yr.    70.7      75.9
     8.0 yr.    72.4      77.6
     8.5 yr.    74.0      79.4
     9.0 yr.    75.6      81.2
     9.5 yr.    77.2      83.1
    10.0 yr.    78.4      84.8
    10.5 yr.    79.8      86.9
    11.0 yr.    81.3      88.7
    11.5 yr.    82.5      90.8
    12.0 yr.    84.0      92.6
    12.5 yr.    85.4      94.7
    13.0 yr.    87.3      96.0
    13.5 yr.    89.2      97.2
    14.0 yr.    91.0      98.3
    14.5 yr.    92.6      98.7
    15.0 yr.    94.6      99.3
    15.5 yr.    96.0      99.4
    16.0 yr.    97.1      99.5
    16.5 yr.    98.0      99.6
    17.0 yr.    98.8      99.7
    17.5 yr.    99.3      99.8
    18.0 yr.    99.6      99.9


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Joint Motion, Methods of Measuring and Recording.
Chicago, American Academy of Orthopedic Surgeons, 1965.

American Orthopedic Association:
Manual of Orthopedic Surgery.
Chicago, American Academy of Orthopedic Surgeons, 1966.

Alpers BJ, Mancall EL
Clinical Neurology, ed 6.
Philadelphia, F.A. Davis Company, 1971.

Arnold LE:
Chiropractic Procedural Examination.
Seminol, FL, Seminole Printing, 1978.

Baker AB, Baker LH:
Clinical Neurology.
New York, Harper & Row, 1971.

Boyd W:
A Textbook of Pathology, ed 6.
Philadelphia, Lea & Febiger, 1955.

Buie LA:
Practical Proctology, ed 2.
Springfield, Illinois, Charles C. Thomas, 1965.

Burnside JW:
Adams' Physical Diagnosis.
Baltimore, Williams & Wilkins, 1974.

Cabot RC:
Physical Diagnosis.
New York, William Wood, 1919.

CaIlomon FT, Wilson JF:
The Nonvenereal Diseases of the Genitals.
Springfield, Illinois, Charles C. Thomas, 1965.

Chusid JG:
Correlative Neuroanatomy & Functional Neurology, ed 19.
Los Altos, CA, Lange Medical, 1985.

Crossen RJ:
Synopsis of Gynecology, ed 4. St. Louis, C.V.
Mosby Company, 1956.

D'Ambrosia RD (ed):
Musculoskeletal Disorders.
Philadelphia, J.B. Lippincott, 1977.

Davis D:
Radicular Syndromes with Emphasis on Chest Pain Simulating Coronary Disease.
Chicago, Year Book Publishers, 1957.

Fowler NO:
Cardiac Diagnosis.
New York, Harper & Row, Hoeber Medical Division, 1968.

Gilroy J, Meyer JS:
Medical Neurology.
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Greenhill JP:
Office Gynecology, ed 4.
Chicago, Year Book Medical Publishers, 1971.

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Common Vertebral Joint Problems.
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Hart FD (ed):
French's Index of Differential Diagnosis, ed 12.
Bristol, Wright, 1985.

Hoppenfeld S:
Physical Examination of the Spine and Extremities.
New York, Appleton-Century-Crofts, 1976.

Kendall HO, Kendall FP, Wadsworth GE:
Muscles Testing and Function, ed 2.
Baltimore, Williams & Wilkins, 1971.

Lewin P:
The Back and Its Disc Syndromes.
Philadelphia, Lea & Febiger, 1955.

Logan AL:
Clinical Application of Chiropractic: Low Back and Pelvis.
Westminster, CA, West-Print, 1977.

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Signs and Symptoms, ed 5.
Philadelphia, J.B. Lippincott, 1970.

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Physical Diagnosis, ed 5.
Philadelphia, W.B. Saunders, 1959.

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Illustrated Manual of Neurological Reflexes/Signs/Tests, Orthopedic Signs/Tests/Maneuvers, ed 2.
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Practical Neurology for the Primary Care Physician.
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Mays Manual of the Diseases of the Eye, ed 22.
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Pinckney C, Pinckney ER:
The Encyclopedia of Medical Tests. New York, Pocket Books, 1978.

Robertson WE, Robertson HF: Diagnostic Signs, Reflexes, and Syndromes.
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Schafer RC:
Auscultation of the neck and related tests.
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Basic Principles of Chiropractic: The Neuroscience Foundation of Clinical Practice.
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Chiropractic Management of Sports and Recreational Injuries, ed 2.
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Chiropractic Physical and Spinal Diagnosis.
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Clinical Biomechanics: Musculoskeletal Actions and Reactions, ed 2.
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Physical Diagnosis: Procedures and Methodology in Chiropractic Practice.
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Symptomatology and Differential Diagnosis: Conspectus of Clinical Semeiographies.
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Chiropractic Orthopedics and Roentgenology.
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     Table 3.3. Checkpoints in a Physical Examination Routine
I. Vital Signs 
1. Temperature                           4. Blood pressure
2. Height                                5. Pulse
3. Weight                                6. Respiration

II. Standing Examination 
 7. Gait test                            23. Tandem Romberg (eyes open)
 8. General appearance                   24. Tandem Romberg (eyes closed)
 9. Minor's sign                         25. Heel-to-knee
10. Position-holding test                26. Heel-to-shin
11. Adiachokinesia test                  27. Heel walk
12. Patting with hands                   28. Toe walk
13. Finger-to-finger (eyes open)         29. Adams position, anterior
14. Finger-to-nose (eyes open)           30. Adams position, posterior
15. Finger-to-finger (eyes closed)       31. Trendelenburg's hip test
16. Finger-to-nose (eyes closed)         32. Neri's bowing test
17. Romberg's position (eyes closed)     33. Lewin's standing test
18. Romberg's position (eyes open)       34. Kemp's test
19. Finger-to-doctor's finger (eyes      35. Quadratus lumborum muscle test
     open)                               36. Thoracic spine range of motion
20. Finger-to-doctor's finger (eyes      37. Lumbar spine range of motion
     closed)                             38. Serratus anterior muscle test
21. Pat doctor's hand (hands together)   39. Longissimus dorsi muscle test
22. Pat doctor's hand (right, left)      40. Spinous process percussion test

III. Sitting Examination 
41. Cervical spine palpation             60. Gag reflex
42. Cervical range of motion             61. Tongue against tongue depressor
43. Libman's test                        62. Pharyngeal reflex
44. Olfactory examination                63. Bite on tongue depressor
45. Otoscopic examination                64. Wink
46. Rhinoscopic examination              65. Smile
47. Ophthalmoscopic examination          66. Whistle
48. Ciliary reflex                       67. Close eyelids
49. Accommodation to light (direct       68. Blow out cheeks
     and indirect)                       69. Weber's test
50. Accommodation to distance            70. Rinne's test
51. Ocular motion test                   71. Pallesthesia test
52. Nystagmus check                      72. Jaw (jack) jerk
53. Field of vision                      73. Chvostek's test
54. Ciliospinal reflex                   74. Jaw clonus test
55. Carotid sinus reflex                 75. Pectoral reflex
56. Corneal reflex                       76. Deltoid reflex
57. Thumb pressure on eyeballs           77. Scapulohumeral reflex
     (oculocardiac reflex)               78. Scapular reflex
58. Tongue extension test                79. Biceps reflex
59. "Ah" reflex                          80. Triceps reflex

   Table 3.3, continued

 81. Radial (periosteal) reflex          111. Radial nerve test  — ability to
 82. Ulnar (periosteal) reflex                 grasp objects
 83. Hoffman's reflex                    112. Radial nerve test  — make a fist
 84. Patellar reflex                     113. Radial nerve test  — ability to
 85. Suprapatellar reflex                      oppose or flex thumb
 86. Achilles reflex                     114. Ulnar nerve test  — claw hand
 87. Bechterew's test                    115. Ulnar nerve test  — ability to
 88. Quadriceps muscle test                    separate fingers
 89. Piriformis muscle test              116. Dorsiflex hand (at wrist):
 90. Popliteus muscle test                     No resistance
 91. Cervical compression test                 Against resistance
 92. Shoulder shrug test:                117. Palmarflex hand (at wrist):
      No resistance                            No resistance
      Against resistance                       Against resistance
 93. Upper trapezius muscle test         118. Radial deviation of hand (wrist):
 94. Adson's test                              No resistance
 95. Allen's test                              Against resistance
 96. Wright's test                       119. Ulnar deviation of hand (wrist):
 97. Shoulder depression (costoclavic-         No resistance
      ular syndrome)                           Against resistance
 98. Shoulder depression (neurologic     120. Individual finger range motion
      test)                              121. Individual finger stretch
 99. Dugas' test                         122. Hoffman's reflex recheck
100. Yergason's test                     123. Pinwheel examination
101. Mills' test                         124. Cotton ball (sensory examination)
102. Hand-patting recheck                125. Two-point discrimination
103. Biceps muscle strength test         126. Stereognosis test
104. Triceps muscle strength test        127. Barognosis test
105. Holmes' rebound test                128. Trousseau's test
106. Froment's sign                      129. Naffziger's test (Valsalva stress)
107. Finkelstein's test                  130. Naffziger's test (patient coughing)
108. Wrist clonus                        131. Spinal percussion
109. Radial nerve test  — ability to      132. Spinal motion palpation
      extend thumb                       133. Cardiopulmonary systems exam.
110. Radial nerve test  — wrist drop      134. Cervical range of motion

IV. Supine Examination 
135. Lindner's test                     	146. Heel-to-knee test
136. Beevor's test                       147. Heel-to-shin test
137. Soto-Hall test                      148. Toe-to-doctor's hand test
138. Teres minor muscle test             149. Lasegue's test (S-L-R)
139. Pectoralis major muscle test,       150. Bragard's test
      sternal division                   151. Fajersztajn's test
140. Pectoralis major muscle test,       152. Lasegue's rebound test
      clavicular division                153. Goldthwait's test
141. Serratus anterior muscle test       154. Kernig's test
142. Pectoralis minor muscle test        155. Thomas' test
143. Anterior neck flexors muscle test   156. Patrick's test
144. Sternocleidomastoideus muscle test  157. Gauvain's test
145. Lewin's supine test                 158. Laguere's test

   Table 3.3, continued
159. Allis' knee test                    186. Epigastric reflex
160. Anterior drawer test                187. Abdominal reflex, superficial
161. Posterior drawer test               188. Abdominal reflex, deep
162. McMurray's test                     189. Graphesthesia test
163. Psoas muscle test                   190. Sensory neurologic examination:
164. Sartorius muscle test                     Pinwheel
165. Tensor fascia lata test                   Pin
166. Hoover's test                             Ring reflex (variant)
167. Homan's test                              Two-point discrimination
168. Ankle clonus                              Brush
169. Schaeffer's test                          Thermesthesia
170. Gordon's test                       191. Cardiopulmonary system recheck
171. Patellar clonus                     192. Check circulatory system:
172. Dorsiflexion of foot:                     Carotids
      No resistance                            Abdominal aorta
      Against resistance                       Femoral artery pulse
173. Plantar flex foot:                        Popliteal artery pulse
      No resistance                            Dorsal pedis artery pulse
      Against resistance                       Posterior tibial artery pulse
174. Dorsiflex great toe:                      Compare popliteal to posterior
      No resistance                             tibial pulse
      Against resistance                       Compare popliteal to dorsal pedis
175. Plantar flex great toe:                    pulse
      No resistance                      193. Auscultate abdomen
      Against resistance                 194. Palpate abdomen, knees straight
176. Babinski's plantar reflex           195. Palpate abdomen, knees flexed
177. Rossolimo's reflex                  196. Check general strength of lower
178. Oppenheim's reflex                        extremities
179. Chaddock's ankle reflex             197. Anterior abdominal muscle tests
180. Hirschberg's test                   198. Gaenslen's test
181. Mendel-Bechterew's test             199. Mensuration
182. Achilles reflex                     200. Range of motion examination
183. Patellar reflex                     201. Oscilometer examination
184. Hamstring reflex                    202. Laryngoscopic examination
185. Gonda reflex

V. Lateral Recumbent Examination 
203. Ober's test                         206. Gluteus medius muscle test
204. Compression of iliac crests         207. Adductor muscle test
205. Gluteus minimus muscle test

VI. Prone Examination 

208. Mennell's test                      216. Gracilis muscle test
209. Hibb's test                         217. Inner hamstring muscle test
210. Nachlas' test                       218. Outer hamstring muscle test
211. Yeoman's test                       219. Gluteus maximus muscle test
212. Ely's heel-to-buttock test          220. Hyperextension muscle test
213. Quadratus lumborum muscle test      221. Posterior neck extensors muscle
214. Gastrocnemius muscle test                 test: posterior, right, left
215. Soleus muscle test

  Table 3.3, continued
222. Lower trapezius muscle test         230. Sensory examination of the back:
223. Middle trapezius muscle test              Pinwheel
224. Rhomboid major and minor muscle           Two-point discrimination
      test                                     Sharp
225. Levator scapulae muscle test              Dull
226. Teres major muscle test                   Cotton ball
227. Palpation                                 Thermesthesia
228. Spinous process percussion                Pallesthesia
229. Achilles' reflex recheck                  Graphesthesia

VII. Sims' Position Examination  
231. Rectal examination:                 232. Rectal examination: anoscopic (if
      Rectal surface                           patient is prepared)
      Prostate or uterus                 233. Anal reflex

VIII. Knee-Chest Position Examination  
234. Babinski's reflex recheck           236. Sigmoidoscopic examination (if
235. Achilles' reflex recheck                  patient is prepared)

IX. Lithotomy Position Examination   
237. Gynecologic pelvic examination

X. Upright Examination  

238. Rupture check                       242. Cremasteric reflex
239. Testis, epididymis, vas check       243. Mensuration
240. Scrotum palpation                   244. Color blindness examination
241. Penis inspection                    245. Snellen eye chart examination

XI. Sitting Examination   

246. Spirometer examination              247. Tonometer examination (if legal)

XII. Other Clinical Examinations   
248. Electrocardiography                 251. Laboratory
249. Roentgenography                     252. Electromyography
250. Thermography