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Netter’s Orthopaedic

Clinical Examination
An Evidence-Based Approach
THIRD EDITION

Joshua A. Cleland, PT, DPT, PhD


Professor, Physical Therapy Program
Franklin Pierce University
Manchester, New Hampshire

Shane Koppenhaver, PT, PhD


Lieutenant Colonel, Army Medical Specialist Corps
Associate Professor, U.S. Army–Baylor University
Doctoral Physical Therapy Program
Fort Sam Houston, Texas

Jonathan Su, PT, DPT, LMT


Captain, Army Medical Specialist Corps
Brigade Physical Therapist
2nd Stryker Brigade Combat Team, 25th Infantry Division
Schofield Barracks, Hawaii

Illustrations by Frank H. Netter, MD


Contributing Illustrators
Carlos A. G. Machado, MD
John A. Craig, MD
1600 John F. Kennedy Blvd.
Ste. 1800
Philadelphia, PA 19103-2899

NETTER’S ORTHOPAEDIC CLINICAL EXAMINATION: ISBN: 978-0-323-34063-2


AN EVIDENCE-BASED APPROACH, THIRD EDITION

Copyright © 2016, 2011, 2005 by Elsevier Inc.


Previous editions copyrighted 2011, 2005 Saunders, an imprint of Elsevier Inc.
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Notices

Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge
in evaluating and using any information, methods, compounds, or experiments described
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and the safety of others, including parties for whom they have a professional
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responsibility of practitioners, relying on their own experience and knowledge of their
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individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of any
methods, products, instructions, or ideas contained in the material herein.

International Standard Book Number: 978-0-323-34063-2

Senior Content Strategist: Elyse O’Grady


Senior Content Development Specialist: Marybeth Thiel
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Senior Project Manager: John Casey
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Printed in China
Last digit is the print number:  9  8  7  6  5  4  3  2  1
To our incredible mentors and colleagues
who have fostered our passion for
evidence-based practice and orthopaedics.

To our photography models (Jessica Palmer, Nicole Koppenhaver,


and Farah Faize) and photographers (Sara Randall, Lindsey Browne,
Jeff Hebert, and Patrick Moon) for spending more hours
and retakes than we’d like to admit.

To Dr. Frank Netter and the Elsevier editorial staff


who turned our ideas into a fantastic literary guide.

And, most important, to our wonderful families,


whose sacrifices and support
made this considerable endeavor possible.
About the Authors
Joshua A. Cleland, PT, DPT, PhD
Dr. Cleland earned a Master of Physical Therapy degree from Notre Dame College in 2000 and a
Doctor of Physical Therapy degree from Creighton University in 2001. In February of 2006 he
received a PhD from Nova Southeastern University. He received board certification from the
American Physical Therapy Association as an Orthopaedic Clinical Specialist in 2002 and com-
pleted a fellowship in manual therapy through Regis University in Denver in 2005. Josh is pres-
ently a Professor in the Doctor of Physical Therapy Program at Franklin Pierce University. He
practices clinically in outpatient orthopaedics at Rehabilitation Services of Concord Hospital,
Concord, New Hampshire. Dr. Cleland is actively involved in numerous clinical research studies
investigating the effectiveness of manual physical therapy and exercise in the management of
spine and extremities disorders. He has published over 170 manuscripts in peer-reviewed journals
and is an Editorial Review Board Member for the Journal of Orthopaedic and Sports Physical Therapy.
He is currently an author/editor on 4 textbooks. Dr. Cleland is a well-known speaker both nation-
ally and internationally. He is the recipient of the 2015 Rothstein Golden Pen Award for Scientific
Writing, the 2011 Chattanooga Research Award, the 2009 Eugene Michels New Investigator Award,
and the 2008 Jack Walker Award, all from the American Physical Therapy Association. In addition,
he received the Rose Excellence in Research Award from the Orthopaedic Section of the American
Physical Therapy Association in 2013, 2014, and 2015.

Shane Koppenhaver, PT, PhD


Dr. Koppenhaver received his Master of Physical Therapy degree from the U.S. Army–Baylor Uni-
versity Graduate Program in 1998 and a PhD in Exercise Physiology from the University of Utah
in 2009. He became board certified in Orthopedic Physical Therapy in 2001 and completed a fel-
lowship in manual therapy through Regis University in 2009. Dr. Koppenhaver is a Lieutenant
Colonel in the U.S. Army and an Associate Professor and Research Director in the U.S. Army–Baylor
University Doctoral Program in Physical Therapy. He has published numerous studies on low back
pain, spinal manipulation, and the use of ultrasound imaging in the measurement of muscle
function. His primary research interests concern mechanistic and clinical outcomes associated
with manual therapy and dry needling, especially as they apply to clinical reasoning and manage-
ment of patients with neuromusculoskeletal conditions.

Jonathan Su, PT, DPT, LMT


Dr. Su earned a Doctor of Physical Therapy degree from U.S. Army–Baylor University in 2013 and
received board certification as a Sports Clinical Specialist from the American Physical Therapy
Association in 2015. Dr. Su is a Captain in the U.S. Army embedded with the 2nd Stryker Brigade
Combat Team, 25th Infantry Division, and serves as the unit’s subject matter expert on human
performance optimization, rehabilitation/reconditioning, and injury prevention. He operates a
direct access sports/orthopaedic physical therapy clinic and advises key leaders on the design and
implementation of physical training programs to maximize combat readiness for the unit’s 4,400
soldiers. Dr. Su was inducted as an Honorary Member of the U.S. Army’s 14th Infantry Regiment
in 2015 for his contributions to soldier wellness and performance. His primary interest is in trans-
lating research into clinical practice to ensure the highest quality care.

vii
About the Artists
Frank H. Netter, MD
Frank H. Netter was born in 1906 in New York City. He studied art at the Art Students League and
the National Academy of Design before entering medical school at New York University, where
he received his medical degree in 1931. During his student years, Dr. Netter’s notebook sketches
attracted the attention of the medical faculty and other physicians, allowing him to augment his
income by illustrating articles and textbooks. He continued illustrating as a sideline after estab-
lishing a surgical practice in 1933, but he ultimately opted to give up his practice in favor of a
full-time commitment to art. After service in the United States Army during World War II, Dr.
Netter began his long collaboration with the CIBA Pharmaceutical Company (now Novartis Phar-
maceuticals). This 45-year partnership resulted in the production of the extraordinary collection
of medical art so familiar to physicians and other medical professionals worldwide.
In 2005, Elsevier, Inc. purchased the Netter Collection and all publications from Icon Learning
Systems. More than 50 publications feature the art of Dr. Netter and are available through Elsevier,
Inc. (in the US: www.us.elsevierhealth.com/Netter and outside the US: www.elsevierhealth.com).
Dr. Netter’s works are among the finest examples of the use of illustration in the teaching of
medical concepts. The 13-book Netter Collection of Medical Illustrations, which includes the greater
part of the more than 20,000 paintings created by Dr. Netter, became and remains one of the
most famous medical works ever published. The Netter Atlas of Human Anatomy, first published
in 1989, presents the anatomical paintings from the Netter Collection. Now translated into 16
languages, it is the anatomy atlas of choice among medical and health professions students the
world over.
The Netter illustrations are appreciated not only for their aesthetic qualities, but, more impor-
tant, for their intellectual content. As Dr. Netter wrote in 1949, “. . . clarification of a subject is
the aim and goal of illustration. No matter how beautifully painted, how delicately and subtly
rendered a subject may be, it is of little value as a medical illustration if it does not serve to make
clear some medical point.” Dr. Netter’s planning, conception, point of view, and approach are
what inform his paintings and what makes them so intellectually valuable.
Frank H. Netter, MD, physician and artist, died in 1991.
Learn more about the physician-artist whose work has inspired the Netter Reference collection:
http://www.netterimages.com/artist/netter.htm.

Carlos A. G. Machado, MD
Carlos Machado was chosen by Novartis to be Dr. Netter’s successor. He continues to be the main
artist who contributes to the Netter collection of medical illustrations.
Self-taught in medical illustration, cardiologist Carlos Machado has contributed meticulous
updates to some of Dr. Netter’s original plates and has created many paintings of his own in the
style of Netter as an extension of the Netter collection. Dr. Machado’s photorealistic expertise and
his keen insight into the physician/patient relationship inform his vivid and unforgettable visual
style. His dedication to researching each topic and subject he paints places him among the premier
medical illustrators at work today.
Learn more about his background and see more of his art at: http://www.netterimages.com/
artist/machado.htm.

viii
Foreword
Appropriate treatment decisions depend on an in-depth understanding of anatomy and an accu-
rate diagnosis. This book is unique in that it combines the extensive library of classic Netter
anatomical drawings with high-quality photos and now even video in this edition demonstrating
special tests. The authors should be applauded for including quality ratings for 269 studies inves-
tigating a test’s reliability using the 11-item “Quality Appraisal of Diagnostic Reliability Checklist.”
This edition includes 84 new studies, 34 new photos, and 25 new videos demonstrating special
tests. As a PT/ATC and director of a PT sports medicine doctoral program, I see great utility for
this reference from the entry level student athletic trainer and physical therapist to ortho/sports
residency and fellowship training PTs and MDs. The book is extremely user-friendly and well
organized as it walks the reader through the anatomy, clinical exam, and then critically reviews
all literature for given diagnostic tests. As we constantly strive for better evidence-based medicine,
new and old clinicians would be well served by such a powerful book detailing the utility of
diagnostic tests and even evaluating evidence for treatment modalities when available.
Thank you for this extremely helpful tool.

Don Goss, PT, PhD


Program Director
PT Sports Medicine Doctoral Program
U.S. Army–Baylor University

If we can make the correct diagnosis, the healing can begin.


—A. Weil
As an occupational therapist and certified hand therapist, I naturally gravitate toward the
chapters on the upper limb. These chapters are exceptional! This is a must-have text for therapists
at all levels of experience. The up-to-date tables that provide quality ratings on research facilitate
evidence-based practice. The photos demonstrating special tests are invaluable for new learners,
as are the supplemental videos included in this third edition. This book signifies a clear intent of
the authors to provide a critical resource for therapists. It also shows commitment to education,
a desire to translate research into advanced clinical practice, and a vision to advance rehabilitation
science through accurate diagnostic evaluation. As I staff upper limb orthopedic cases of my stu-
dents in training, this book is in my hands and on my clinic exam table as an open-book, go-to
reference. It’s an educator’s dream to have all this valuable information in one text!

Kathleen Yancosek, PhD


LTC, SP, US Army
Program Director
Doctor of Science in Occupational Therapy
U.S. Army–Baylor University

ix
Preface
Over the past several years evidence-based practice has become the standard in the medical and
healthcare professions. As described by Sackett and colleagues (Evidence-Based Medicine: How to
Practice and Teach EBM, 2nd ed, London, 2000, Harcourt Publishers Limited), evidence-based
practice is a combination of three elements: the best available evidence, clinical experience, and
patient values. Sackett has further reported that “when these three elements are integrated, clini-
cians and patients form a diagnostic and therapeutic alliance which optimizes clinical outcomes
and quality of life.” Each element contributes significantly to the clinical reasoning process by
helping to identify a diagnosis or prognosis or establish an effective and efficient plan of care.
Unfortunately, the evidence-based approach confronts a number of barriers that may limit the
clinician’s ability to use the best available evidence to guide decisions about patient care, most
significantly a lack of time and resources. Given the increasing prevalence of new clinical tests in
the orthopaedic setting and the frequent omission from textbooks of information about their
diagnostic utility, the need was clear for a quick reference guide for students and busy clinicians
that would enhance their ability to incorporate evidence into clinical decision making.
The purpose of Netter’s Orthopaedic Clinical Examination: An Evidence-Based Approach is twofold:
to serve as a textbook for musculoskeletal evaluation courses in an academic setting and to provide
a quick, user-friendly guide and reference for clinicians who want to locate the evidence related
to the diagnostic utility of commonly utilized tests and measures.
The first chapter is intended to introduce the reader to the essential concepts underlying evi-
dence-based practice, including the statistical methods it employs and the critical analysis of
research articles. The remainder of the book consists of chapters devoted to individual body
regions. Each chapter begins with a review of the relevant osteology, arthrology, myology, and
neurology and is liberally illustrated with images by the well-known medical artist Frank H. Netter,
MD. The second portion of each chapter provides information related to patient complaints and
physical examination findings. Reliability and diagnostic utility estimates (sensitivity, specificity,
and likelihood ratios) are presented for each patient complaint and physical examination finding
and are accompanied by quick access interpretation guides. Test descriptions and definitions of
positive test findings are included as reported by the original study authors, both to minimize
any alteration of information and to provide readers insight into difference values reported by
different studies. At the end of each chapter are tables listing information on commonly used
outcome measures and quality ratings for all the studies investigating tests’ diagnostic utility. For
this new edition, we’ve also included quality ratings for all the studies investigating tests’ reli-
ability. Additionally, new video content demonstrating select tests from each body region can be
accessed online.
We hope that clinicians will find Netter’s Orthopaedic Clinical Examination a user-friendly clinical
resource for determining the relevance of findings from the orthopaedic examination. We also
hope that students and educators will find this a valuable guide to incorporate into courses related
to musculoskeletal evaluation and treatment.

Joshua A. Cleland
Shane Koppenhaver
Jonathan Su

x
Video Contents

2 Temporomandibular Joint 8 Foot and Ankle


Video 2-1   Pain During Mandibular Video 8-1   Impingement Sign
Movements Video 8-2   Anterior Drawer Test
Video 2-2   Dynamic/Static Video 8-3   Medial Talar Tilt Stress
Test
3 Cervical Spine Video 8-4   Triple Compression
Video 3-1   Spurling’s Test Stress Test
Video 3-2   Cervical Manipulation
Video 3-3   Thoracic Manipulation 9 Shoulder
Video 9-1   Lateral Jobe Test
4 Thoracolumbar Spine Video 9-2   Bear-Hug Test
Video 4-1   Slump Knee Bend Test Video 9-3   Belly-Press Test
Video 4-2   Passive Lumbar
Extension Test 10 Elbow and Forearm
Video 10-1   Shoulder Internal
5 Sacroiliac Region Rotation Test
Video 5-1   Gaenslen Test Video 10-2   Moving Valgus Stress
Video 5-2   PSIS Distraction Test Test

6 Hip and Pelvis 11 Hand


Video 6-1   Patrick’s Test Video 11-1   Upper Limb Tension
Video 6-2   FADIR Impingement Test Test A
Video 11-2   Upper Limb Tension
7 Knee Test B
Video 7-1   Prone Lachman Test Video 11-3   Wrist Hyperflexion and
Video 7-2   Loss of Extension Test Abduction of the Thumb
Test

xii
The Reliability and Diagnostic Utility of
the Orthopaedic Clinical Examination 1 
Reliability, 2

Diagnostic Accuracy, 3
2×2 Contingency Table, 3
Overall Accuracy, 4
Positive and Negative Predictive Values, 4
Sensitivity, 4
Specificity, 5
Likelihood Ratios, 6

Confidence Intervals, 8

Pretest and Posttest Probability, 8

Calculating Posttest Probability, 8

Assessment of Study Quality, 9

Summary, 11

References, 12

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 1


Reliability
The health sciences and medical professions are undergoing a paradigm shift toward evidence-based
practice defined as the integration of the best available research evidence and clinical expertise
with the patient’s values.1,2 Evidence should be incorporated into all aspects of physical therapy
patient and client management, including the examination, evaluation, diagnosis, prognosis, and
intervention. Perhaps the most crucial component is a careful, succinct clinical examination that
can lead to an accurate diagnosis, the selection of appropriate interventions, and the determina-
tion of a prognosis. Thus, it is of utmost importance to incorporate evidence of how well clinical
tests and measures can distinguish between patients who present with specific musculoskeletal
disorders and patients who do not.1,2
The diagnostic process entails obtaining a patient history, developing a working hypothesis,
and selecting specific tests and measures to confirm or refute the formulated hypothesis. The
clinician must determine the pretest (before the evaluation) probability that the patient has a
particular disorder. Based on this information the clinician selects appropriate tests and measures
that will help determine the posttest (after the evaluation) probability of the patient having the
disorder, until a degree of certainty has been reached such that patient management can begin
(the treatment threshold). The purpose of clinical tests is not to obtain diagnostic certainty but
rather to reduce the level of uncertainty until the treatment threshold is reached.2 The concepts
of pretest and posttest probability and treatment threshold are elaborated later in this chapter.
As the number of reported clinical tests and measures continues to grow, it is essential to thor-
oughly evaluate a test’s diagnostic properties before incorporating the test into clinical practice.3
Integrating the best evidence available for the diagnostic utility of each clinical test is essential
in determining an accurate diagnosis and implementing effective, efficient treatment. It seems
only sensible for clinicians and students to be aware of the diagnostic properties of tests and
measures and to know which have clinical utility. This text assists clinicians and students in
selecting tests and measures to ensure the appropriate classification of patients and to allow for
quick implementation of effective management strategies.
The assessment of diagnostic tests involves examining a number of properties, including reli-
ability and diagnostic accuracy. A test is considered reliable if it produces precise and reproducible
information. A test is considered to have diagnostic accuracy if it has the ability to discriminate
between patients who have a specific disorder and patients who do not have it.4 Scientific evalu-
ation of the clinical utility of physical therapy tests and measures involves comparing the exami-
nation results with reference standards such as radiographic studies (which represent the closest
measure of the truth). Using statistical methods from the field of epidemiology, the diagnostic
accuracy of the test, that is, its ability to determine which patients have a disorder and which do
not, is then calculated. This chapter focuses on the characteristics that define the reliability and
diagnostic accuracy of specific tests and measures. The chapter concludes with a discussion of the
quality assessment of studies investigating diagnostic utility.

Reliability
For a clinical test to provide information that can be used to guide clinical decision making, it
must be reliable. Reliability is the degree of consistency with which an instrument or rater measures
a particular attribute.5 When we investigate the reliability of a measurement, we are determining
the proportion of that measurement that is a true representation and the proportion that is the
result of measurement error.6
When discussing the clinical examination process, it is important to consider two forms of
reliability: intraexaminer and interexaminer reliability. Intraexaminer reliability is the ability of a
single rater to obtain identical measurements during separate performances of the same test.
Interexaminer reliability is a measure of the ability of two or more raters to obtain identical results
with the same test.
The kappa coefficient (κ) is a measure of the proportion of potential agreement after chance is
removed1,5,7; it is the reliability coefficient most often used for categorical data (positive or nega-
tive).5 The correlation coefficient commonly used to determine the reliability of data that are
continuous in nature (e.g., range-of-motion data) is the intra-class correlation coefficient (ICC).7
Although interpretations of reliability vary, coefficients are often evaluated by the criteria described

2 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Diagnostic Accuracy  •  2×2 Contingency Table
8
by Shrout, with values less than 0.10 indicating no reliability, values between 0.11 and 0.40

1 
indicating slight reliability, values between 0.41 and 0.60 indicating fair reliability, values between
0.61 and 0.80 indicating moderate reliability, and values greater than 0.81 indicating substantial

The Reliability and Diagnostic Utility of the Orthopaedic Clinical Examination


reliability. “Acceptable reliability” must be decided by the clinician using the specific test or
measure9 and should be based on the variable being tested, the reason a particular test is impor-
tant, and the patient on whom the test will be used.6 For example, a 5% measurement error may
be very acceptable when measuring joint range of motion but is not nearly as acceptable when
measuring pediatric core body temperature.

Diagnostic Accuracy
Clinical tests and measures can never absolutely confirm or exclude the presence of a specific
disease.10 However, clinical tests can be used to alter the clinician’s estimate of the probability
that a patient has a specific musculoskeletal disorder. The accuracy of a test is determined by the
measure of agreement between the clinical test and a reference standard.11,12 A reference standard
is the criterion considered the closest representation of the truth of a disorder being present.1 The
results obtained with the reference standard are compared with the results obtained with the test
under investigation to determine the percentage of people correctly diagnosed, or the diagnostic
accuracy.13 Because the diagnostic utility statistics are completely dependent on both the reference
standard used and the population studied, we have specifically listed these within this text to
provide information to consider when selecting the tests and measures reported. Diagnostic accu-
racy is often expressed in terms of positive and negative predictive values (PPVs and NPVs), sen-
sitivity and specificity, and likelihood ratios (LRs).1,14

2 ×2 Contingency Table
To determine the clinical utility of a test or measure, the results of the reference standard are
compared with the results of the test under investigation in a 2×2 contingency table, which pro-
vides a direct comparison between the reference standard and the test under investigation.15 It
allows for the calculation of the values associated with diagnostic accuracy to assist with deter-
mining the utility of the clinical test under investigation (Table 1-1).
The 2×2 contingency table is divided into four cells (a, b, c, d) for the determination of the
test’s ability to correctly identify true positives (cell a) and rule out true negatives (cell d). Cell b
represents the false-positive findings wherein the diagnostic test was found to be positive yet the
reference standard obtained a negative result. Cell c represents the false-negative findings wherein
the diagnostic test was found to be negative yet the reference standard obtained a positive result.
Once a study investigating the diagnostic utility of a clinical test has been completed and the
comparison with the reference standard has been performed in the 2×2 contingency table, deter-
mination of the clinical utility in terms of overall accuracy, PPVs and NPVs, sensitivity and speci-
ficity, and LRs can be calculated. These statistics are useful in determining whether a diagnostic
test is useful for either ruling in or ruling out a disorder.

Table 1-1  2×2 Contingency Table Used to Compare the Results of the Reference Standard with Those
of the Test under Investigation
Reference Standard Positive Reference Standard Negative
Clinical Test Positive True-positive results False-positive results
a b

Clinical Test Negative False-negative results True-negative results


c d

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 3


Diagnostic Accuracy  •  2×2 Contingency Table
Table 1-2  2×2 Contingency Table Showing the Calculation of Positive Predictive Values (PPVs) and
Negative Predictive Values (NPVs) Horizontally and Sensitivity and Specificity Vertically
Reference Standard Positive Reference Standard Negative
Clinical Test Positive True positives False positives PPV = a/(a + b)
a b

Clinical Test Negative c d NPV = d/(c + d)


False negatives True negatives

Sensitivity = a/(a + c) Specificity = d/(b + d)

Overall Accuracy
The overall accuracy of a diagnostic test is determined by dividing the correct responses (true
positives and true negatives) by the total number of patients.16 Using the 2×2 contingency table,
the overall accuracy is determined by the following equation:
Overall accuracy = 100% × ( a + d) ( a + b + c + d) (1-1)

A perfect test would exhibit an overall accuracy of 100%. This is most likely unobtainable in
that no clinical test is perfect and each will always exhibit at least a small degree of uncertainty.
The accuracy of a diagnostic test should not be used to determine the clinical utility of the test,
because the overall accuracy can be a bit misleading. The accuracy of a test can be significantly
influenced by the prevalence of a disease, or the total instances of the disease in the population
at a given time.5,6

Positive and Negative Predictive Values


PPVs estimate the likelihood that a patient with a positive test actually has a disease.5,6,17 PPVs are
calculated horizontally in the 2×2 contingency table (Table 1-2) and indicate the percentage of
patients accurately identified as having the disorder (true positive) divided by all the positive
results of the test under investigation. A high PPV indicates that a positive result is a strong pre-
dictor that the patient has the disorder.5,6 The formula for the PPV is:
PPV = 100% × a ( a + b ) (1-2)

NPVs estimate the likelihood that a patient with a negative test does not have the disorder.5,6
NPVs are also calculated horizontally in the 2×2 contingency table (see Table 1-2) and indicate
the percentage of patients accurately identified as not having the disorder (true negative) divided
by all the negative results of the test under investigation.11 The formula for the NPV is as follows:
NPV = 100% × d ( c + d) (1-3)
11
The predictive values are significantly influenced by the prevalence of the condition. Hence,
we have not specifically reported these in this text.

Sensitivity
The sensitivity of a diagnostic test indicates the test’s ability to detect those patients who actually
have a disorder as indicated by the reference standard. This is also referred to as the true-positive
rate.1 Tests with high sensitivity are good for ruling out a particular disorder. The acronym SnNout
can be used to remember that a test with high Sensitivity and a Negative result is good for ruling
out the disorder.1
Consider, for example, a clinical test that, compared with the reference standard, exhibits a
high sensitivity for detecting lumbar spinal stenosis. Considering the rule above, if the test is
negative it reliably rules out lumbar spinal stenosis. If the test is positive, it is likely to accurately
identify a high percentage of patients presenting with stenosis. However, it also may identify as

4 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Diagnostic Accuracy  •  2×2 Contingency Table
20 Patients with the disease 20 Patients without the disease

1 
The Reliability and Diagnostic Utility of the Orthopaedic Clinical Examination
Figure 1-1
Sensitivity and specificity example. Twenty patients with and 20 patients without the disorder.

Figure 1-2
100% Sensitivity. One hundred percent sensitivity infers that if the test is positive, all those with the disease will be captured.
However, although this test captured all those with the disease, it also captured many without it. Yet if the test result is negative, we
are confident that the disorder can be ruled out (SnNout).

positive many of those without the disorder (false positives). Thus, although a negative result can
be relied on, a positive test result does not allow us to draw any conclusions (Figs. 1-1 and 1-2).
The sensitivity of a test also can be calculated from the 2×2 contingency tables. However, it is
calculated vertically (see Table 1-2). The formula for calculating a test’s sensitivity is as follows:
Sensitivity = 100% × a ( a + c ) (1-4)

Specificity
The specificity of a diagnostic test simply indicates the test’s ability to detect those patients who
actually do not have the disorder as indicated by the reference standard. This is also referred to
as the true-negative rate.1 Tests with high specificity are good for ruling in a disorder. The acronym
SpPin can be used to remember that a test with high Specificity and a Positive result is good for
ruling in the disorder.16,18,19
Consider a test with high specificity. It would demonstrate a strong ability to accurately identify
all patients who do not have a disorder. If a highly specific clinical test is negative, it is likely to
identify a high percentage of those patients who do not have the disorder. However, it is also
possible that the highly specific test with a negative result will identify a number of patients who
actually have the disease as being negative (false negative). Therefore, we can be fairly confident
that a highly specific test with a positive finding indicates that the disorder is present (Fig. 1-3).
The formula for calculating test specificity is as follows:
Specificity = 100% × d (b + d) (1-5)

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 5


Diagnostic Accuracy  •  2×2 Contingency Table

Figure 1-3
100% Specificity. One hundred percent specificity infers that if the test is negative, all those without the disease will be captured.
However, although this test captured all those without the disease, it also captured many with it. Yet if the test is positive, we are
confident that the patient has the disorder (SpPin).

Sensitivity and specificity have been used for decades to determine a test’s diagnostic utility;
however, they possess a few clinical limitations.11 Although sensitivity and specificity can be useful
in assisting clinicians in selecting tests that are good for ruling in or out a particular disorder, few
clinical tests demonstrate both high sensitivity and high specificity.11 Also the sensitivity and
specificity do not provide information regarding a change in the probability of a patient having
a disorder if the test results are positive or negative.18,20 Instead, LRs have been advocated as the
optimal statistics for determining a shift in pretest probability that a patient has a specific
disorder.

Likelihood Ratios
A test’s result is valuable only if it alters the pretest probability of a patient having a disorder.21
LRs combine a test’s sensitivity and specificity to develop an indication in the shift of probability
given the specific test result and are valuable in guiding clinical decision making.20 LRs are a
powerful measure that can significantly increase or reduce the probability of a patient having a
disease.22
LRs can be either positive or negative. A positive LR indicates a shift in probability favoring
the existence of a disorder, whereas a negative LR indicates a shift in probability favoring the
absence of a disorder. Although LRs are often not reported in studies investigating the diagnostic
utility of the clinical examination, they can be calculated easily if a test’s sensitivity and specificity
are available. Throughout this text, for studies that did not report LRs but did document a test’s
sensitivity and specificity, the LRs were calculated by the authors.
The formula used to determine a positive LR is as follows:
LR = Sensitivity (1− Specificity ) (1-6)

The formula used to determine a negative LR is as follows:


LR = (1− Sensitivity ) Specificity (1-7)

A guide to interpreting test results can be found in Table 1-3. Positive LRs higher than 1 increase
the odds of the disorder given a positive test, and negative LRs less than 1 decrease the odds of
the disorder given a negative test.22 However, it is the magnitude of the shifts in probability that
determines the usefulness of a clinical test. Positive LRs higher than 10 and negative LRs close to
zero often represent large and conclusive shifts in probability. An LR of 1 (either positive or nega-
tive) does not alter the probability that the patient does or does not have the particular disorder
and is of little clinical value.22 Once the LRs have been calculated, they can be applied to the
nomogram (Fig. 1-4)23 or a mathematical equation24 can be used to determine more precisely the
shifts in probability given a specific test result. Both methods are described in further detail later
in the chapter.

6 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Diagnostic Accuracy  •  2×2 Contingency Table
Table 1-3  Interpretation of Likelihood Ratios

1 
Positive Likelihood Ratio Negative Likelihood Ratio Interpretation

The Reliability and Diagnostic Utility of the Orthopaedic Clinical Examination


>10 <0.1 Generate large and often conclusive shifts in probability

5 to 10 0.1 to 0.2 Generate moderate shifts in probability

2 to 5 0.2 to 0.5 Generate small but sometimes important shifts in


probability

1 to 2 0.5 to 1.0 Alter probability to a small and rarely important degree


Adapted from Jaeschke R, Guyatt GH, Sackett DL III. How to use an article about a diagnostic test. B. What are the results and will they help me in
caring for my patients? JAMA. 1994;271:703-707.

.1 99

.2

.5 95

1 1000 90
500
2 200 80
100
50 70
5
20 60
10 10 50
5 40
Percent (%)

Percent (%)

20 2 30
1
30 .5 20
40 .2
50 .1 10
60 .05
5
70 .02
.01
80 .005 2
.002
90 .001 1

95 .5

.2

99 .1
Pretest Likelihood Posttest
Probability Ratio Probability

Figure 1-4
Fagan’s nomogram. (Adapted with permission from Fagan TJ. Letter: nomogram for Bayes theorem. N Engl J Med. 1975;293:257.
Copyright 2005, Massachusetts Medical Society. All rights reserved.)

If a diagnostic test exhibits a specificity of 1, the positive LR cannot be calculated because the
equation will result in a zero for the denominator. In these circumstances, a suggestion has been
made to modify the 2×2 contingency table by adding 0.5 to each cell in the table to allow for the
calculation of LRs.25
Consider, for example, the diagnostic utility of the Crank test5,26 in detecting labral tears com-
pared with arthroscopic examination, the reference standard. This is revealed in a 2×2 contingency
table (Table 1-4). The inability to calculate a positive LR becomes obvious in the following:
Positive LR = Sensitivity (1− Specificity ) = 1 (1− 1) = 1 0 (1-8)

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 7


Confidence Intervals
Table 1-4  Results of the Crank Test in Detecting Labral Tears When Compared with the Reference
Standard of Arthroscopic Examination
Arthroscopic Arthroscopic
Examination Positive Examination Negative
(n = 12) (n = 3)
Crank Test Positive 10 0 PPV = 100 × 10/10 = 100%
a b

Crank Test Negative c d NPV = 100 × 3/5 = 60%


2 3

Sensitivity = 100% × 10/12 Specificity = 100% × 3/3 =


= 83% 100%

Because zero cannot be the denominator in a fraction, the 2×2 contingency table is modified
by adding 0.5 to each cell.
Although the addition of 0.5 to each cell is the only reported method of modifying the con-
tingency table to prevent zero in the denominator of an LR calculation, considering the changes
that occur with the diagnostic properties of sensitivity, specificity, and predictive values, this
technique has not been used in this text. In circumstances in which the specificity is zero and
the positive LR cannot be calculated, it is documented as “undefined” (UD). In these cases,
although we are not calculating the positive LR, the test is indicative of a large shift in
probability.

Confidence Intervals
Calculations of sensitivity, specificity, and LRs are known as point estimates. That is, they are the
single best estimates of the population values.5 However, because point estimates are based on
small subsets of people (samples), it is unlikely that they are a perfect representation of the larger
population. It is more accurate, therefore, to include a range of values (interval estimate) in which
the population value is likely to fall. A confidence interval (CI) is a range of scores around the point
estimate that likely contains the population value.27 Commonly, the 95% CI is calculated for
studies investigating the diagnostic utility of the clinical examination. A 95% CI indicates the
spread of scores in which we can be 95% confident that they contain the population value.5 In
this text, the 95% CI is reported for all studies that provided this information.

Pretest and Posttest Probability


Pretest probability is the likelihood that a patient exhibits a specific disorder before the clinical
examination. Often prevalence rates are used as an indication of pretest probability, but when
prevalence rates are unknown, the pretest probability is based on a combination of the patient’s
medical history, the results of previous tests, and the clinician’s experience.16 Determining the
pretest probability is the first step in the decision-making process for clinicians. Pretest probability
is an estimate by the clinician and can be expressed as a percentage (e.g., 75%, 80%) or as a quali-
tative measure (e.g., somewhat likely, very likely).11,16 Once the pretest probability of a patient
having a particular disorder is identified, tests and measures that have the potential to alter the
probability should be selected for the physical examination. Posttest probability is the likelihood
that a patient has a specific disorder after the clinical examination procedures have been
performed.

Calculating Posttest Probability


As previously mentioned, LRs can assist with determining the shifts in probability that would
occur following a given test result and depend on the respective LR ratios of that given test. The
quickest method to use to determine the shifts in probability once an LR is known for a specific

8 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Assessment of Study Quality
.1 99

1 
.2

The Reliability and Diagnostic Utility of the Orthopaedic Clinical Examination


.5 95

1 1000 90
500
2 200 80
100
50 70
5
20 60
10 10 50
5 40
Percent (%)

Percent (%)
20 2 30
1
30 .5 20
40 .2
50 .1 10
60 .05
5
70 .02
.01
80 .005 2
.002
90 .001 1

95 .5

.2

99 .1
Pretest Likelihood Posttest
Probability Ratio Probability

Figure 1-5
Nomogram representing the change in pretest probability from 42% if the test was positive (positive likelihood ratio = 4.2) to a
posttest probability of 71%. (Adapted with permission from Fagan TJ. Letter: nomogram for Bayes theorem. N Engl J Med.
1975;293:257. Copyright 2005, Massachusetts Medical Society. All rights reserved.)

test is the nomogram (Fig. 1-5).23 The nomogram is a diagram that illustrates the pretest prob-
ability on the left and the posttest probability on the right, with the LRs in the middle. To deter-
mine the shift in probability, a mark is placed on the nomogram representing the pretest probability.
Then a mark is made on the nomogram at the level of the LR (either negative or positive).
The two lines are connected with a straight line and the line is carried through the right of the
diagram. The point at which the line crosses the posttest probability scale indicates the shift in
probability.
A more precise determination of the shift in probability can be calculated algebraically with
the following formula16:
Step 1. Pretest odds = Pretest probability 1− Pretest probability (1-9)

Step 2. Pretest odds × LR = Posttest odds (1-10)

Step 3. Posttest odds Posttest odds + 1 = Posttest probability (1-11)

The clinician must make a determination of when the posttest probability is either low enough
to rule out the presence of a certain disease or when the posttest probability is high enough that
the clinician feels confident in having established the presence of a disorder. The level at which
evaluation ceases and treatment begins is known as the treatment threshold (Fig. 1-6).16

Assessment of Study Quality


Once relevant articles are retrieved, the next step is critical analysis of their content for adequate
methodologic rigor. It has been reported that the methodologic quality of studies investigating

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 9


Assessment of Study Quality
Treatment Threshold

Informational
Contribution
Pretest Posttest
Probability Probability

Probability of Disease

0 50% 100%

Figure 1-6
Treatment threshold. Clinicians must use the pretest probability and likelihood ratios to determine the treatment threshold as
indicated in this illustration.

the diagnostic utility of the clinical examination is generally inferior to that of studies investigat-
ing the effectiveness of therapies.28,29 Unfortunately, studies with significant methodologic flaws
reporting the usefulness of specific tests and measures can lead to premature incorporation of
ineffective tests. This can result in inaccurate diagnoses and poor patient management. Alterna-
tively, identification and use of rigorously appraised clinical tests can improve patient care and
outcomes.29
The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) was developed to assess the
quality of diagnostic accuracy studies.30 A four-round Delphi panel identified 14 criteria that are
used to assess a study’s methodologic quality (see tables at the end of Chapters 2 through 11).
Each item is scored as “yes,” “no,” or “unclear.” The QUADAS is not intended to quantify a score
for each study but rather provides a qualitative assessment of the study with the identification of
weaknesses.30 The QUADAS has demonstrated adequate agreement for the individual items in the
checklist.31 We have used the QUADAS to evaluate each study referenced in this text and have
included details of the quality assessments in the appendix of each chapter. Studies deemed to be
of poor methodologic quality (represented by red symbols) have not been included in the diag-
nostic utility tables throughout the chapters unless they are the only studies that examine the
diagnostic test in question. Green symbols indicate a high level of methodologic quality and imply
that readers can be confident in study results. Yellow symbols indicate fair methodologic quality
and imply that readers should interpret such study results with caution. Red symbols indicate
poor methodologic quality and imply that readers should interpret such study results with strong
caution.
The Quality Appraisal for Reliability Studies (QAREL) was developed to assess the quality of
diagnostic reliability studies.32 The QAREL is an 11-item checklist developed in consultation with
a reference group of experts in diagnostic research and quality appraisal that is used to assess a
study’s methodologic quality (see tables at the end of Chapters 2 through 11). Each item is scored
as “yes,” “no,” “unclear,” or “N/A.” The QAREL has been found to be a reliable assessment tool
when reviewers are given the opportunity to discuss the criteria by which to interpret each item.33
Reliability of 9 of the 11 items was identified as good reliability, whereas reliability of only 2 of
the 11 items was identified as fair reliability.33 We have used the QAREL to evaluate each study
related to reliability referenced in this text and have included details of the quality assessments
in the appendix of each chapter. Studies deemed to be of poor methodologic quality (represented
by red symbols) have not been included in the diagnostic utility tables throughout the chapters
unless they are the only studies that examine the diagnostic test in question. Green symbols
indicate a high level of methodologic quality and imply that readers can be confident in study
results. Yellow symbols indicate fair methodologic quality and imply that readers should interpret

10 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Summary
such study results with caution. Red symbols indicate poor methodologic quality and imply that

1 
readers should interpret such study results with strong caution.

Summary

The Reliability and Diagnostic Utility of the Orthopaedic Clinical Examination


It is important to consider the reliability and diagnostic utility of tests and measures before includ-
ing them as components of the clinical examination. Tests and measures should demonstrate
adequate reliability before they are used to guide clinical decision making. Throughout this text,
the reliability of many tests and measures is reported. It is essential that clinicians consider these
reported levels of reliability in the context of their own practice.
Before implementing tests and measures into the orthopaedic examination, it is first essential
to consider each test’s diagnostic utility. Table 1-5 summarizes the statistics related to diagnostic
accuracy as well as the mathematical equations and operational definitions for each. The useful-
ness of a test or measure is most commonly considered in terms of the respective test’s diagnostic
properties. These can be described in terms of sensitivity, specificity, PPVs, and NPVs. However,
perhaps the most useful diagnostic property is the LR, which can assist in altering the probability
that a patient has a specific disorder.
No clinical test or measure provides absolute certainty as to the presence or absence of disease.
However, clinicians can determine when enough data have been collected to alter the probability
beyond the treatment threshold where the evaluation can cease and therapeutic management can
begin. Furthermore, careful methodologic assessment provides greater insight into the scientific
rigor of each study and its performance, applicability, reliability, and reproducibility within a given
clinical practice.

Table 1-5  2×2 Contingency Table and Statistics Used to Determine the Diagnostic Utility of a Test
or Measure
Reference Standard Positive Reference Standard Negative
Diagnostic Test Positive True-positive results False-positive results
a b

Diagnostic Test Negative c d


False-negative results True-negative results

Statistic Formula Description


Overall accuracy (a + d)/(a + b + c + d) The percentage of individuals who are correctly
diagnosed

Sensitivity a /(a + c) The proportion of patients with the condition who


have a positive test result

Specificity d/(b + d) The proportion of patients without the condition who


have a negative test result

Positive predictive value a/(a + b) The proportion of individuals with a positive test
result who have the condition

Negative predictive value d/(c + d) The proportion of individuals with a negative test
result who do not have the condition

Positive likelihood ratio Sensitivity/(1 − Specificity) If the test is positive, the increase in odds favoring
the condition

Negative likelihood ratio (1 − Sensitivity)/Specificity If the test is positive, the decrease in odds favoring
the condition

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 11


References
1. Sackett DL, Straws SE, Richardson WS, et al. Evidence- or wrong turn? Med Decis Making. 1994;14:
Based Medicine: How to Practice and Teach EBM. 2nd 175-180.
ed. London: Harcourt Publishers Limited; 2000. 19. Riddle DL, Stratford PW. Interpreting validity
2. Kassirer JP. Our stubborn quest for diagnostic cer- indexes for diagnostic tests: an illustration using the
tainty: a cause of excessive testing. N Engl J Med. Berg balance test. Phys Ther. 1999;79:939-948.
1989;320:1489-1491. 20. Hayden SR, Brown MD. Likelihood ratio: a powerful
3. Lijmer JG, Mol BW, Heisterkamp S, et al. Empirical tool for incorporating the results of a diagnostic test
evidence of design-related bias in studies of diagnos- into clinical decision making. Ann Emerg Med.
tic tests. JAMA. 1999;282:1061-1066. 1999;33:575-580.
4. Schwartz JS. Evaluating diagnostic tests: what is 21. Simel DL, Samsa GP, Matchar DB. Likelihood ratios
done−what needs to be done. J G Intern Med. 1986; with confidence: sample size estimation for diagnos-
1:266-267. tic test studies. J Clin Epidemiol. 1991;44:763-770.
5. Portney LG, Watkins MP. Foundations of Clinical 22. Jaeschke R, Guyatt GH, Sackett DL. How to use an
Research: Applications to Practice. 2nd ed. Upper article about a diagnostic test. B. What are the
Saddle River, NJ: Prentice Hall Health; 2000. results and will they help me in caring for my
6. Rothstein JM, Echternach JL. Primer on Measurement: patients? JAMA. 1994;271:703-707.
An Introductory Guide to Measurement Issues. Alexan- 23. Fagan TJ. Letter: nomogram for Bayes theorem. N
dria, VA: American Physical Therapy Association; Engl J Med. 1975;293:257.
1999. 24. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clini-
7. Domholdt E. Physical Therapy Research. 2nd ed. Phil- cal Epidemiology: A Basic Science for Clinical Medicine.
adelphia: WB Saunders; 2000. Boston: Little, Brown; 1991.
8. Shrout PE. Measurement reliability and agreement 25. Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability and
in psychiatry. Stat Methods Med Res. 1998;7: diagnostic accuracy of the clinical examination and
301-317. patient self-report measures for cervical radiculopa-
9. Van Genderen F, De Bie R, Helders P, Van Meeteren thy. Spine. 2003;28:52-62.
N. Reliability research: towards a more clinically rel- 26. Mimori K, Muneta T, Nakagawa T, Shinomiya K.
evant approach. Physical Therapy Reviews. 2003;8: A new pain provocation test for superior labral
169-176. tears of the shoulder. Am J Sports Med. 1999;27:
10. Bossuyt PMM, Reitsma JB, Bruns DE, et al. Towards 137-142.
complete and accurate reporting of studies of diag- 27. Fidler F, Thomason N, Cumming G, et al. Editors
nostic accuracy: the STARD initiative. Clin Chem. can lead researchers to confidence intervals, but
2003;49:1-6. can’t make them think. Psychol Sci. 2004;15:
11. Fritz JM, Wainner RS. Examining diagnostic tests: 119-126.
an evidence-based perspective. Phys Ther. 2001;81: 28. Moons KGM, Biesheuvel CJ, Grobbee DE. Test
1546-1564. research versus diagnostic research. Clin Chem.
12. Jaeschke R, Guyatt GH, Sackett DL III. How to use 2004;50:473-476.
an article about a diagnostic test. A. Are the results 29. Reid MC, Lachs MS, Feinstein AR. Use of method-
of the study valid? JAMA. 1994;271:389-391. ological standards in diagnostic test research. JAMA.
13. Bossuyt PMM, Reitsma JB, Bruns DE, et al. The 1995;274:645-651.
STARD statement for reporting studies of diagnostic 30. Whiting P, Harbord R, Kleijnen J. No role for quality
accuracy: explanation and elaboration. Clin Chem. scores in systematic reviews of diagnostic accuracy
2003;49:7-18. studies. BMC Med Res Methodol. 2005;5:19.
14. McGinn T, Guyatt G, Wyer P, et al. Users’ guides 31. Whiting PF, Weswood ME, Rutjes AW, et al. Evalua-
to the medical literature XXII: how to use articles tion of QUADAS, a tool for the quality assessment
about clinical decision rules. JAMA. 2000;284: of diagnostic accuracy studies. BMC Med Res Meth-
79-84. odol. 2006;6:9.
15. Greenhalgh T. Papers that report diagnostic or 32. Lucas NP, Macaskill P, Irwig L, Bogduk N. The devel-
screening tests. BMJ. 1997;315:540-543. opment of a quality appraisal tool for studies of
16. Bernstein J. Decision analysis (current concepts diagnostic reliability (QAREL). J Clin Epidemiol.
review). J Bone Joint Surg. 1997;79:1404-1414. 2010;63(8):854-861.
17. Potter NA, Rothstein JM. Intertester reliability for 33. Lucas N, Macaskill P, Irwig L, et al. The reliability of
selected clinical tests of the sacroiliac joint. Phys a quality appraisal tool for studies of diagnostic reli-
Ther. 1985;65:1671-1675. ability (QAREL). BMC Med Res Methodol. 2013;13:
18. Boyko EJ. Ruling out or ruling in disease with the 111.
most sensitive or specific diagnostic test: short cut

12 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Temporomandibular Joint 2 
CLINICAL SUMMARY AND RECOMMENDATIONS, 14
Anatomy, 15
Osteology, 15
Arthrology, 18
Ligaments, 19
Muscles, 20
Nerves, 24

Patient History, 25
Initial Hypotheses Based on Patient History, 25
Reliability of Patient’s Reports of Pain in Temporomandibular Dysfunction, 26
Diagnostic Utility of Patient History in Identifying Anterior Disc Displacement, 27
Self-Reported Temporomandibular Pain, 29

Diagnostic Criteria for TMD, 31


Reliability and Diagnostic Criteria for Pain-Related TMD, 31
Reliability and Diagnostic Criteria for Intraarticular TMD, 33

Physical Examination Tests, 35


Palpation, 35
Joint Sounds, 40
Range-of-Motion Measurements, 43
Dynamic Movement Measurements, 48
Other Tests, 54
Combinations of Tests, 56

Outcome Measures, 62

Appendix, 63

References, 67

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 13


Clinical Summary and Recommendations

Patient History
Questions • Screening instruments have been shown to be very good at identifying temporomandibular
disorder (TMD) pain (+LR [likelihood ratio] of 33).
• A subject complaint of “periodic restriction” (the inability to open the mouth as wide as was
previously possible) has been found to be the best single history item to identify anterior
disc displacement, both in patients with reducing discs and in those with nonreducing discs.

Physical Examination
Palpation • Reproducing pain during palpation of the temporomandibular joint (TMJ) and related muscles
has been found to be moderately reliable and appears to demonstrate good diagnostic utility
for identifying TMJ effusion by magnetic resonance imaging (MRI) and TMD when compared
with a comprehensive physical examination. We recommend that palpation at least include
the TMJ (+LR = 4.87 to 5.67), the temporalis muscle (+LR = 2.73 to 4.12), and the
masseter muscle (+LR = 3.65 to 4.87).
• If clinically feasible, pressure pain threshold (PPT) testing is helpful because it demonstrates
superior diagnostic utility in identifying TMD when compared with a comprehensive physical
examination.

Joint Sounds • Detecting joint sounds (clicking and crepitus) during jaw motion is a generally unreliable sign
demonstrating poor diagnostic utility except in attempts to detect moderate to severe
osteoarthritis (+LR = 4.79) and nonreducing anterior disc displacement (+LR = 7.1 to 15.2).

Range-of-Motion and • Measuring mouth range of motion appears to be a highly reliable test, and when the range
Dynamic Movement of motion is restricted or deviated from the midline, the measurement has moderate
Measurements diagnostic utility in identifying nonreducing anterior disc displacement.
• Detecting pain during motion is a less reliable sign, but it also demonstrates moderate to
good diagnostic utility in identifying nonreducing anterior disc displacement and self-
reported TMJ pain.
• The combination of motion restriction and pain during assisted opening has been found to
be the best combination for identifying nonreducing anterior disc displacement (+LR = 7.71).
• Consistent with assessment of other body regions, assessment of “joint play” and “end feel”
is highly unreliable and has unknown diagnostic utility.

Interventions • Patients with TMD who report (1) symptoms ≥4/10 (10 being severe pain) and (2) pain for
10 months’ duration or less may benefit from nightly wearing of an occlusal stabilization
splint, especially if they have (3) nonreducing anterior disc displacement and (4) show
improvement after 2 months (+LR = 10.8 if all four factors are present).

14 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Osteology

Temporal bone

Sphenoid bone

2 
Temporal fossa

Temporomandibular Joint
Zygomatic arch

Condylar process of mandible

Mandibular notch

Coronoid process of mandible

Lateral pterygoid plate


(broken line)

Hamulus of medial pterygoid plate


(broken line)
Mastoid
Pterygomandibular raphe process
(broken line)
External
acoustic meatus
Ramus
Mandible Atlas (C1)
Angle
Body Styloid process
Axis (C2)
Stylohyoid lig.
Stylomandibular lig.

Body C3 vertebra
Hyoid bone Lesser horn
Greater horn
Epiglottis C7 vertebra

Thyroid cartilage
Cricoid cartilage

Trachea T1 vertebra

1st rib

Figure 2-1
Bony framework of head and neck.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 15


Anatomy  •  Osteology

Head
Condylar process
Pterygoid fovea
Coronoid process
Mandibular notch Neck

Mylohyoid groove Lingula

Mandibular
foramen
Submandibular fossa

Mylohyoid line

Sublingual fossa
Oblique line

Interalveolar septa Ramus

Alveolar part (crest)


Mental foramen
Mental protuberance Angle
Mental tubercle
Base of mandible
Mandible of adult:
Body anterolateral superior view

Coronoid process
Head Condylar process
Neck Lingula
Mandibular notch
Pterygoid fovea
Mandibular foramen
Mylohyoid line
Ramus

Mylohyoid groove

Angle

y
Bod
Submandibular fossa

Sublingual fossa
Mental spines
Digastric fossa
Mandible of adult:
left posterior view

Figure 2-2
Mandible.

16 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Osteology

2 
Temporomandibular Joint
Sphenoid bone Parietal bone Temporal fossa Temporal bone
Greater wing
Superior temporal line Squamous part

Frontal bone Inferior temporal line Zygomatic process


Coronal suture
Supraorbital Articular tubercle
notch (foramen) Pterion
Groove for posterior
Glabella deep temporal a.
Ethmoid bone External acoustic
meatus
Orbital plate
Mastoid process
Lacrimal bone

Lambdoid suture
Fossa for
lacrimal sac

Nasal bone Occipital bone

Maxilla External
Frontal process occipital
protuberance
Infraorbital
foramen
Anterior
nasal spine
Alveolar process Mandible
Head of condylar process
Zygomatic bone Mandibular notch
Zygomaticofacial Coronoid process
foramen Ramus
Temporal process Oblique line
Body
Mental foramen
Zygomatic arch

Figure 2-3
Lateral skull.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 17


Anatomy  •  Arthrology
Articular tubercle
Jaws closed Mandibular fossa

Articular disc

Joint capsule

Figure 2-4
Temporomandibular joint.

The temporomandibular joint (TMJ) is divided by an intraarticular biconcave disc that separates
the joint cavity into two distinct functional components. The upper joint is a plane, or gliding,
joint that permits translation of the mandibular condyles. The lower joint is a hinge joint that
permits rotation of the condyles. The closed pack position of the TMJ is full occlusion. A unilateral
restriction pattern primarily limits contralateral excursion but also affects mouth opening and
protrusion.

Jaws slightly opened Jaws widely opened


(hinge action predominates) (hinge and gliding actions combined)

Figure 2-5
Temporomandibular joint mechanics.

During mandibular depression from a closed mouth position, the initial movement occurs at
the lower joint as the condyles pivot on the intraarticular disc. This motion continues to approxi-
mately 11 mm of depression. With further mandibular depression, motion begins to occur at the
upper joint and causes anterior translation of the disc on the articular eminence. Normal man-
dibular depression is between 40 and 50 mm.

18 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Ligaments

2 
Lateral view

Temporomandibular Joint
Joint capsule

Lateral (temporomandibular) lig.

Sphenomandibular lig.

Sphenomandibular lig. (phantom)

Styloid process

Stylomandibular lig.

Medial view
Mandibular n.
and otic ganglion

Joint capsule
Middle meningeal a.
Auriculotemporal n.
Maxillary a.
Inferior alveolar n.
Lingual n.
Sphenomandibular lig.
Stylomandibular lig.
Mylohyoid branch of
inferior alveolar a.
and mylohyoid n.

Figure 2-6
Temporomandibular joint ligaments.

Ligaments Attachments Function


Temporomandibular Thickening of anterior joint capsule extending Strengthen the TMJ laterally
from neck of mandible to zygomatic arch

Sphenomandibular Sphenoid bone to mandible Serve as a fulcrum for and reinforcer


of TMJ motion

Stylomandibular Styloid process to angle of mandible Provide minimal support for joint

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 19


Anatomy  •  Muscles
Muscles Involved in Mastication

Temporalis m. Temporal fascia


Superficial layer
Deep layer
Levator labii
superioris Zygomatic arch
alaeque nasi m.
Levator labii Articular disc of
superioris m. temporomandibular joint

Zygomaticus
minor m. Deep part
Masseter m.
Superficial part
Zygomaticus
major m.
Parotid duct
Levator
anguli Buccinator m.
oris m.
Orbicularis
oris m.
Mentalis m.

Depressor labii Temporalis m.


inferioris m.
Depressor anguli Insertion of
oris m. temporalis m.
to coronoid
process of mandible

Buccinator m.
Lateral pterygoid m.
Orbicularis oris m. Masseteric n. and a.
Maxillary a.
Insertion of
masseter m.

Parotid duct

Figure 2-7
Muscles involved in mastication, lateral views.

Nerve and
Muscle Proximal Attachment Distal Attachment Segmental Level Action
Temporalis Temporal fossa Coronoid process and Deep temporal branches Elevate mandible
anterior ramus of mandible of mandibular nerve

Masseter Inferior and medial Coronoid process and Mandibular nerve via Elevate and
aspects of zygomatic arch lateral ramus of mandible masseteric nerve protrude mandible

20 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Muscles
Muscles Involved in Mastication (continued)

Lateral view

2 
Temporomandibular Joint
Lateral pterygoid m.

Sphenomandibular lig.

Medial pterygoid m.
Parotid duct
Articular disc of
Buccinator m.
temporomandibular
Pterygomandibular joint
raphe Articular tubercle
Superior pharyngeal
constrictor m.

Posterior view Cartilaginous part of


Sphenomandibular lig. pharyngotympanic
Otic ganglion Choanae (auditory) tube
Masseteric n. Lateral pterygoid
Middle meningeal a. plate
Temporomandibular
Auriculotemporal n. joint
Masseteric a. Lateral pterygoid m.
Maxillary a. Medial pterygoid m.
Inferior alveolar n.
Lingual n.
Medial pterygoid m.
Tensor veli palatini m.
Medial pterygoid plate Levator veli palatini m.
Pterygoid hamulus Pterygoid hamulus

N. to mylohyoid

Figure 2-8
Muscles involved in mastication, lateral and posterior views.

Nerve and
Muscle Proximal Attachment Distal Attachment Segmental Level Action
Medial pterygoid Medial surface of lateral Medial aspect of Mandibular nerve Elevate and protrude
pterygoid plate, mandibular ramus via medial mandible
pyramidal process of pterygoid nerve
palatine bone, and
tuberosity of maxilla

Lateral pterygoid Lateral surface of greater Acting bilaterally: protrude


(superior head) wing of sphenoid bone Neck of mandible, Mandibular nerve and depress mandible
articular disc, and via lateral pterygoid
Lateral pterygoid Lateral surface of lateral TMJ capsule nerve Acting unilaterally:
(inferior head) pterygoid plate laterally deviate mandible

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 21


Anatomy  •  Muscles
Muscles of the Floor of the Mouth

Lateral, slightly inferior view

Hyoglossus m.

Mylohyoid m.

Fibrous loop for intermediate Mastoid


digastric tendon process
Styloid process
Digastric m. (anterior belly)
Digastric m.
(posterior belly)
Median raphe between
mylohyoid mm. Stylohyoid m.
Greater horn
Lesser horn Hyoid bone
Body
Thyrohyoid m.
Omohyoid m.
Sternohyoid m.

Figure 2-9
Floor of mouth, inferior view.

Proximal Distal Nerve and


Muscle Attachment Attachment Segmental Level Action
Mylohyoid Mylohyoid line of Hyoid bone Mylohyoid nerve (branch Elevates hyoid bone
mandible of cranial nerve [CN] V3)

Stylohyoid Styloid process of Hyoid bone Cervical branch of facial Elevates and
temporal bone nerve retracts hyoid bone

Geniohyoid Inferior mental Hyoid bone C1 via hypoglossal Elevates hyoid bone
spine of mandible nerve anterosuperiorly

Digastric Digastric fossa of Mylohyoid nerve Depresses mandible;


(anterior belly) mandible Intermediate raises and stabilizes
tendon to hyoid bone
Digastric Mastoid notch of hyoid bone Facial nerve
(posterior belly) temporal bone

22 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Muscles
Muscles of the Floor of the Mouth (continued)

2 
Anteroinferior

Temporomandibular Joint
view

Digastric m. (anterior belly)

Mylohyoid m.

Stylohyoid m.

Digastric m. (posterior belly)


Hyoglossus m.
Fibrous loop for
intermediate digastric tendon

Sublingual gland
Posterosuperior view Lingual n.

Inferior alveolar n. and a.

Mylohyoid n. and a.

Submandibular gland and duct

Mylohyoid m.

Geniohyoid m.
Superior mental spine for
Lesser horn origin of genioglossus m.
Hyoid bone Body
Greater horn Hyoglossus
m. (cut)

Figure 2-10
Floor of mouth, anteroinferior and posterosuperior views.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 23


Anatomy  •  Nerves
Mandibular Nerve
Medial view Trigeminal (semilunar) Motor root Geniculum
ganglion
Sensory root
Ophthalmic n. (V1) Tympanic cavity
Maxillary n. (V2)
Chorda tympani n.
Mandibular n. (V3)
Facial n. (VII)
Anterior division
Tensor tympani
Tensor veli palatini m. and n.
n. and m.
Otic ganglion Lesser petrosal n.
Auriculotemporal n.
Chorda tympani n.
Maxillary a.
Medial pterygoid
n. and m. (cut) Mylohyoid n.
Pterygoid hamulus Inferior alveolar n. entering
mandibular foramen
Lingual n.

Temporal fascia
Anterior division
and temporalis m. Posterior
Lateral view Posterior division Deep temporal nerves
Anterior
Foramen ovale
Meningeal branch Masseteric n.
Foramen spinosum
Lateral pterygoid
Middle
n. and m.
meningeal a.
Auriculotemporal n.
Posterior
auricular n.
Facial n. (VII) Buccal n. and
Chorda tympani n. buccinator m.
Lingual n. (cut)
Inferior alveolar n. (cut) Submandibular
N. to mylohyoid ganglion
Medial pterygoid m. (cut) Sublingual
Digastric m. (posterior belly) gland
Mylohyoid
Stylohyoid m.
m. (cut)
Hypoglossal n.
Mental n.
Submandibular gland
Inferior alveolar n. (cut)
Sublingual n.
Digastric m. (anterior belly)

Figure 2-11
Mandibular nerve, medial and lateral views.

Segmental
Nerves Levels Sensory Motor
Mandibular CN V3 Skin of inferior third of face Temporalis, masseter, lateral pterygoid,
medial pterygoid, digastric, mylohyoid
Nerve to mylohyoid CN V3 No sensory Mylohyoid
Buccal CN V3 Cheek lining and gingiva No motor
Lingual CN V3 Anterior tongue and floor of mouth No motor
Maxillary CN V2 Skin of middle third of face No motor
Ophthalmic CN V1 Skin of superior third of face No motor
CN V, trigeminal nerve.

24 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Patient History  •  Initial Hypotheses Based on Patient History

Patient Reports Initial Hypothesis


Patient reports jaw crepitus and pain during mouth opening Possible osteoarthrosis
and closing. Might also report limited opening with Possible capsulitis
translation of the jaw to the affected side at the end range Possible internal derangement consisting of an anterior disc
of opening displacement that does not reduce1-3

2 
Patient reports jaw clicking and pain during opening and Possible internal derangement consisting of anterior disc

Temporomandibular Joint
closing of the mouth displacement with reduction1,4,5

Patient reports limited motion to about 20 mm with no joint Possible capsulitis
noise Possible internal derangement consisting of an anterior disc
displacement that does not reduce1

The Association of Oral Habits with Temporomandibular Disorders

Figure 2-12
Frequent leaning of head on the palm.

Gavish and colleagues6 investigated the association of oral habits with signs and symptoms of
TMDs in 248 randomly selected female high school students. Although sensitivity and specificity
were not reported, the results demonstrated that chewing gum, jaw play (nonfunctional jaw
movements), chewing ice, and frequent leaning of the head on the palm were associated with the
presence of TMJ disorders.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 25


Patient History  •  Reliability of Patient’s Reports of Pain in Temporomandibular Dysfunction

Figure 2-13
Temporomandibular joint pain.

Historical Finding and Description and Positive


Study Quality Findings Population Test-Retest Reliability
Visual analog scale (VAS)7 ● A 100-mm line, with ends κ = .38
defined as “no pain” and
“worst pain imaginable”

Numerical scale7 ● An 11-point scale, with 0 κ = .36


indicating “no pain” and 10
representing “worst pain” 38 consecutive patients
referred with TMD
Behavior rating scale7 ● A 6-point scale ranging from κ = .68
“minor discomfort” to “very
strong discomfort”

Verbal scale7 ● A 5-point scale ranging from κ = .44


“no pain” to “very severe pain”

26 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Patient History  •  Diagnostic Utility of Patient History in Identifying Anterior Disc Displacement

2 
Temporomandibular Joint
Temporal
bone

Anterior
displacement Meniscus
of TMJ meniscus

Pterygoid m.

Mandible Condyle

Joint capsule

Figure 2-14
Anterior disc displacement.

Historical Finding Description and Reference


and Study Quality Positive Findings Population Standard Sens Spec +LR −LR
Clicking8 ● Momentary In presence of reducing disc
snapping sound
during opening or .82 .19 1.01 .95
functioning
In presence of nonreducing disc

.86 .24 1.13 .58

Locking8 ● Sudden onset of In presence of reducing disc


restricted movement 70 patients (90
during opening or TMJs) referred Anterior disc .53 .22 .68 2.14
closing with complaints of displacement
craniomandibular via MRI In presence of nonreducing disc
pain
.86 .52 1.79 .27

Restriction after Inability to open as In presence of reducing disc


clicking8 ● wide as was
previously possible .26 .40 .43 1.85
after clicking
In presence of nonreducing disc

.66 .74 2.54 .46


Continued

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 27


Patient History  •  Diagnostic Utility of Patient History in Identifying Anterior Disc Displacement

Historical Finding Description and Reference


and Study Quality Positive Findings Population Standard Sens Spec +LR −LR
Periodic restriction8 ● Periodic inability to In presence of reducing disc
open as wide as
was previously .60 .90 6.0 .44
possible
In presence of nonreducing disc

.12 .95 2.4 .93

Continuous restriction8 ● Continuous inability In presence of reducing disc


to open as wide as
was previously .35 .26 .47 2.5
possible
In presence of nonreducing disc

.78 .62 2.05 .35

Function related to joint In presence of reducing disc


pain8 ●
.82 .10 .91 1.8

In presence of nonreducing disc

.96 .24 1.26 .17

Complaint of clicking8 ● In presence of reducing disc

.28 .24 .37 3.00

In presence of nonreducing disc

.82 .69 2.65 .26


Not reported
Complaint of movement- In presence of reducing disc
related pain8 ●
.71 .31 1.03 .94

In presence of nonreducing disc

.74 .36 1.16 .72

Complaint of severe In presence of reducing disc


restriction8 ●
.60 .65 1.71 .62

In presence of nonreducing disc

.38 .93 5.43 .67

28 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Patient History  •  Self-Reported Temporomandibular Pain
Reliability of Self-Reported Temporomandibular Pain

2 
Temporomandibular Joint
Adhesions Rupture of
forming meniscus
within joint causing bony
surfaces to rub

Figure 2-15
Temporomandibular arthrosis.

Historical Finding and Description and Positive


Study Quality Findings Population Reliability
Self-report of TMJ pain9 ● See diagnostic table on following 120 adolescents: 60 with Test-retest κ = .83
page. Participants were asked self-reported TMJ pain and 60 (.74, .93)
same questions 2 weeks apart age- and sex-matched controls

TMD pain screening See diagnostic table on following 549 participants: 212 with ICC = .83
questionnaire10 ● page. Participants were asked pain-related TMD, 116 with
same questions 2 to 7 days apart TMD, 80 with odontalgia, 45
with headache without TMD
pain, and 96 healthy controls

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 29


Patient History  •  Self-Reported Temporomandibular Pain
Diagnostic Utility of Self-Reported Temporomandibular Pain
Historical
Finding and Description and Positive Reference
Study Quality Findings Population Standard Sens Spec +LR −LR
Self-report of Participants were asked: 120 RDC/TMD .98 .90 9.8 .02
TMJ pain9 ● (1) “Do you have pain in your adolescents: diagnosis of (4.8, (.00,
temple, face, TMJ, or jaw 60 with myofascial 20.0) .16)
once a week or more?” self-reported pain or
(2) “Do you have pain when TMJ pain and arthralgia,
you open your mouth wide 60 age- and arthritis, and
or chew once a week or sex-matched arthrosis
more?” controls
If answer was “yes” to either
question, test was positive

TMD pain Participants were asked: 549 RDC/TMD .99 .97 33.0 .01
screening (1) “In the last 30 days, on participants: assessment
questionnaire10 ◆ average, how long did any 212 with protocol
pain in your jaw or temple pain-related
area on either side last?” TMD, 116 with
(a) There was no pain TMJ disorder,
(b) Pain lasted from a very 80 with
brief time to more than odontalgia, 45
a week, but it did stop with headache
(c) Pain was continuous without TMD
(2) “In the last 30 days, have pain, and 96
you had pain or stiffness in healthy
your jaw on awakening?” controls
(a) No
(b) Yes
(3) “In the last 30 days, did
[…] chewing hard or tough
food […] change any pain
(i.e., make it better or
make it worse) in your jaw
or temple area on either
side?”
(a) No
(b) Yes
An (a) response received 0
points, a (b) response received
1 point, and a (c) response
received 2 points.
The test was positive for
scores of 2 or higher
RDC/TMD, Research Diagnostic Criteria for Temporomandibular Disorders
diagnostic accuracy statistics reported for participants with pain-related TMD versus healthy controls.

30 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Diagnostic Criteria for TMD  •  Reliability and Diagnostic Criteria for Pain-Related TMD
The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) provides evidence-based
criteria for assessing patients with TMD. It superseded the Research Diagnostic Criteria for Tem-
poromandibular Disorders (RDC/TMD) as of 2014 and is intended for immediate implementa-
tion in both clinical and research settings.11 All tools required for clinical implementation are
available at the International RDC-TMD Consortium website (www.rdc-tmdinternational.org/,
accessed February 2015). A summary of the DC/TMD is presented here along with the associated

2 
reliability and diagnostic utility statistics. However, because the sources of the statistical estimates
were not always clear, we were unable to assess the quality of the studies that provided the reli-

Temporomandibular Joint
ability and diagnostic utility values. The previous version of RDC/TMD showed fair to moderate
agreement for most diagnoses and no to slight agreement for some diagnoses.

Interexaminer
Diagnosis History Examination Reliability Sens Spec +LR −LR
Myalgia Positive for both: Positive for both: κ = .94 (.83, .90 .99 90.0 .10
1. Pain in jaw, 1. Confirmation of pain in 1.00)
temple, ear, temporalis or masseter
front of ear muscle
2. Pain modified 2. Report of familiar pain
with jaw with one or more of
movement, following:
function, or (a) Palpation of
parafunction temporalis muscle;
(b) Palpation of
masseter muscle;
(c) Maximum
unassisted or
assisted opening
movement

Local Positive for both: Positive for all: Not reported Not Not Not Not
myalgia 1. Pain in jaw, 1. Confirmation of pain in estab­ estab­ estab­ estab­
temple, ear, temporalis or masseter lished lished lished lished
or front of ear muscle
2. Pain modified 2. Report of familiar pain
with jaw with palpation of
movement, temporalis or masseter
function, or muscle
parafunction 3. Report of pain localized
to site of palpation

Myofascial Positive for both: Positive for all: Not reported Not Not Not Not
pain 1. Pain in jaw, 1. Confirmation of pain in estab­ estab­ estab­ estab­
temple, ear, temporalis or masseter lished lished lished lished
or front of ear muscle
2. Pain modified 2. Report of familiar pain
with jaw with palpation of
movement, temporalis or masseter
function, or muscle
parafunction 3. Report of pain
spreading beyond site
of palpation but within
boundary of muscle
Continued

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 31


Diagnostic Criteria for TMD  •  Reliability and Diagnostic Criteria for Pain-Related TMD

Interexaminer
Diagnosis History Examination Reliability Sens Spec +LR −LR
Myofascial Positive for both: Positive for all: κ = .85 (.55, .86 .98 43.0 .14
pain with 1. Pain in jaw, 1. Confirmation of pain in 1.00)
referral temple, ear, temporalis or masseter
or front of ear muscle
2. Pain modified 2. Report of familiar pain
with jaw with palpation of
movement, temporalis or masseter
function, or muscle
parafunction 3. Report of pain at site
beyond boundary of
muscle palpated

Arthralgia Positive for both: Positive for both: κ = .86 (.75, .89 .98 44.5 .11
1. Pain in jaw, 1. Confirmation of pain in .97)
temple, ear, area of TMJ
or front of ear 2. Report of familiar pain
2. Pain modified in TMJ with at least
with jaw one of the following
movement, provocation tests:
function, or (a) Palpation of lateral
parafunction pole or around
lateral pole
(b) Maximum
unassisted or
assisted opening,
right or left lateral,
or protrusive
movement

Headache Positive for both: Positive for both: Not reported .89 .87 6.85 .13
attributed 1. Headache of 1. Confirmation of
to TMD any type in headache in area of
temple temporalis muscle
2. Headache 2. Report of familiar
modified headache in temple
with jaw with at least one of the
movement, following provocation
function, or tests:
parafunction (a) Palpation of
temporalis muscle
(b) Maximum
unassisted or
assisted opening,
right or left lateral,
or protrusive
movement
Note: Reliability and validity are derived from the datasets of the Validation Project and TMJ Impact Project Finalization of DC/TMD.11

32 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Diagnostic Criteria for TMD  •  Reliability and Diagnostic Criteria for Intraarticular TMD

Interexaminer
Diagnosis History Examination Reliability Sens Spec +LR −LR
Disc Positive for at least Positive for at least one: κ = .58 (.33, .34 .92 4.25 .72
displacement one: 1. Clicking, popping, .84)
with reduction 1. In last 30 days, and/or snapping

2 
any TMJ noise noise during both
present with jaw opening and closing

Temporomandibular Joint
movement or movements,
function detected with
2. Patient reports palpation during at
any noise least one of three
present during repetitions of jaw
examination opening and closing
movements
2. Clicking, popping,
and/or snapping
noise detected with
palpation during at
least one of three
repetitions of
opening or closing
movements AND
right or left lateral or
protrusive
movement(s)

Disc Positive for both: Positive for at least one: Not reported .38 .98 19.0 .63
displacement 1. In last 30 days, 1. Clicking, popping,
with reduction any TMJ noise and/or snapping
with with jaw noise during both
intermittent movement or opening and closing
locking function or movements,
patient reports detected with
any noise palpation during at
present during least one of three
examination repetitions of jaw
2. In last 30 days, opening and closing
jaw locks with movements
limited mouth 2. Clicking, popping,
opening and and/or snapping
then unlocks noise detected with
palpation during at
least one of three
repetitions of
opening or closing
movements AND
right or left lateral or
protrusive movement
Continued

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 33


Diagnostic Criteria for TMD  •  Reliability and Diagnostic Criteria for Intraarticular TMD

Interexaminer
Diagnosis History Examination Reliability Sens Spec +LR −LR
Disc Positive for both: Positive for the Not reported .80 .97 26.7 .21
displacement 1. Jaw locked so following:
without that mouth 1. Maximum assisted
reduction with would not open opening (passive
limited opening all the way stretch) movement,
2. Limitation in jaw including vertical
opening severe incisal overlap less
enough to limit than 40 mm
jaw opening and
interfere with
ability to eat

Disc Positive for both of Positive for the κ = .84 (.38, .54 .79 2.57 .58
displacement the following in the following: 1.00)
without past: 1. Maximum assisted
reduction 1. Jaw locked so opening (passive
without limited that mouth stretch) movement,
opening would not open including vertical
all the way incisal overlap of
2. Limitation in jaw 40 mm or more
opening severe
enough to limit
jaw opening and
interfere with
ability to eat

Degenerative Positive for at least Positive for the κ = .33 (.01, .55 .61 1.41 .74
joint disease one: following: .65)
1. In last 30 days, 1. Crepitus detected
any TMJ noise with palpation during
present with jaw at least one of the
movement or following: opening,
function closing, right or left
2. Patient reports lateral movement, or
any noise protrusive movement
present during
examination

Subluxation Positive for both: No examination findings Not reported .98 1.00 Undefined .02
1. In last 30 days, required
jaw locking or
catching in a
wide-open
mouth position
so could not
close from
wide-open
position
2. Inability to close
mouth from
wide-open
position without
a self-maneuver
Note: Reliability and validity are derived from the datasets of the Validation Project and TMJ Impact Project Finalization of DC/TMD.11

34 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Palpation
Reliability in Determining the Presence of Pain during Muscle Palpation
Finding and Study Interexaminer
Quality Description and Positive Findings Population Reliability
Extraoral12 ● Examiner palpates the temporalis, masseter, κ = .91

2 
posterior cervical, and sternocleidomastoid
muscles
64 healthy volunteers

Temporomandibular Joint
Intraoral12 ● Examiner palpates tendon of the temporalis, κ = .90
lateral pterygoid, and masseter muscles and
body of the tongue

Masseter13 ● Examiner palpates the midbelly of the masseter κ = .33


muscle
79 randomly selected
Temporalis13 ● Examiner palpates the midbelly of the temporalis patients referred to κ = .42
muscle craniomandibular
disorder department
Medial pterygoid13 ● Examiner palpates the insertion of the medial κ = .23
pterygoid muscle

Masseter14 ● Examiner palpates the superficial and deep κ = .33


portions of the masseter muscle
79 patients referred
Temporalis14 ● Examiner palpates the anterior and posterior κ = .42
to TMD and orofacial
aspects of the temporalis muscle
pain department
Medial pterygoid14 Examiner palpates the medial pterygoid muscles κ = .23
attachment ● extraorally

Masseter15 ◆ Examiner palpates the origin, body, and insertion κ (Right) = .78
of the masseter muscle (Left) = .56

Temporalis15 ◆ Examiner palpates the origin, body, and insertion κ (Right) = .87
27 TMD patients
of the temporalis muscle (Left) = .91

Tendon of temporalis15 ◆ Examiner palpates the tendon of the temporalis κ (Right) = .53
muscle (Left) = .48

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 35


Physical Examination Tests  •  Palpation
Reliability in Determining the Presence of Pain during Temporomandibular Joint  
Regional Palpation

Temporalis (posterior temporalis


fibers retract jaw)
External
pterygoid Internal
pterygoid
Tongue
Masseter

Buccinator
Orbicularis orb

Geniohyoid
Mylohyoid (deep to other mm.)

Digastric
(anterior belly)
Figure 2-16
Musculature of the temporomandibular joint.

Finding and Study Description and Positive


Quality Findings Population Reliability
Lateral palpation16 ● Examiner palpates anterior to the ear 61 patients with TMJ Intraexaminer κ = .53
over the TMJ pain

Posterior palpation16 ● Examiner palpates TMJ through 61 patients with TMJ Intraexaminer κ = .48
external meatus pain

Palpation of TMJ13 ● Examiner palpates the lateral and 79 randomly selected Interexaminer κ = .33
dorsal aspects of the condyle patients referred to
craniomandibular
disorder department

Masseter14 ● Examiner palpates the superficial and Interexaminer κ = .33


deep portions of the masseter muscle

Palpation of TMJ14 ● Examiner palpates the lateral pole of 79 patients referred Interexaminer κ = .33
the condyle in open and closed mouth to TMD and orofacial
positions. The dorsal pole is palpated pain department
posteriorly through the external
auditory meatus

Retromandibular region15 ◆ Interexaminer κ (Right) =


.56 (Left) = .50

Submandibular region15 ◆ Interexaminer κ (Right) =


Examiner palpation consistent with .73 (Left) = .68
27 TMD patients
Lateral pterygoid area15 ◆ RDC/TMD guidelines Interexaminer κ (Right) =
.50 (Left) = .37

Lateral pole and posterior Interexaminer κ (Right) =


attachment of TMJ15 ◆ .43 (Left) = .46

36 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Palpation

2 
Temporomandibular Joint
Lateral palpation of the temporomandibular joint Posterior palpation of the temporomandibular joint
through external auditory meatus

Palpation of the temporalis Palpation of the masseter

Figure 2-17
Palpation of the medial pterygoid Palpation tests.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 37


Physical Examination Tests  •  Palpation
Diagnostic Utility of Palpation in Identifying Temporomandibular Conditions
Test and Description and Positive Reference
Study Quality Findings Population Standard Sens Spec +LR −LR
Lateral Examiner palpates the lateral .83 .69 2.68 .25
palpation16 ◆ pole of the condyle with the
index finger. Positive if pain
is present Presence of
61 patients with
Posterior Examiner palpates the TMJ effusion .85 .62 2.24 .24
TMJ pain
palpation16 ◆ posterior portion of the via MRI
condyle with the little finger
in the patient’s ear. Positive
if pain is present
Palpation17 ● Palpation of lateral and 84 patients with TMJ synovitis .92 .21 1.16 .38
posterior aspects of the TMJ symptoms of TMJ via arthroscopic
and assessment of pain pain investigation
response with active
movements. Positive if
patient reports pain
Palpation18 ● Examiner palpates lateral 200 consecutive TMJ synovitis .88 .36 1.38 .33
and posterior aspects of the patients with TMJ via arthroscopic
TMJ with one finger and disease investigation
determines the presence of
tenderness
Tender joint on Examiner palpates the lateral 70 patients (90 Detecting In presence of reducing disc
palpation8 ● and posterior aspects of the TMJs) referred with anterior disc .38 .41 .64 1.51
joint. Positive if pain is complaints of displacement
present craniomandibular via MRI In presence of nonreducing disc
pain .66 .67 2.0 .51
19
Palpation ● Examiner palpates the TMJ 147 patients Patient report .75 .67 2.27 .37
laterally and posteriorly, the referred for of tenderness
temporalis muscle, and the craniomandibular in masticatory
masseter muscle. Pain complaints and 103 muscles,
recorded via VAS using a asymptomatic preauricular
cutoff value to maximize individuals area, or TMJ in
sensitivity and specificity past month
Palpation of Right side*
temporalis .60 .78 2.73 .51
muscle20 ●
Performed with index Left side*
and middle fingers for .70 .83 4.12 .36
2 to 4 seconds with
Palpation of 40 patients Right side*
approximately 3 pounds of
TMJ20 ● diagnosed with TMD diagnosis .68 .88 5.67 .36
pressure on the muscle and
TMD and 40 from RCD/TMD
2 pounds of pressure on the Left side*
asymptomatic evaluation
joint. Pain recorded via VAS
patients .73 .85 4.87 .32
with cutoff values at 1
Palpation of standard deviation from the Right side*
masseter mean* .73 .85 4.87 .32
muscle20 ●
Left side*
.73 .80 3.65 .34
20
*Gomes and colleagues also calculated sensitivity and specificity for cutoff values of 1.5 and 2 standard deviations. Values showed almost perfect
specificity but poor sensitivity.

38 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Palpation
Diagnostic Utility of Pressure Pain Thresholds in Identifying Temporomandibular Disorder
Test and Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
PPT of temporalis Right side

2 
muscle20 ●
.68 .88 5.67 .36

Temporomandibular Joint
Left side

.63 .90 6.30 .41


Used pressure
PPT of TMJ20 ● algometer fitted with a Right side
40 patients
rubber tip. PPT defined
diagnosed with .56 .95 11.20 .46
as lightest pressure to
TMD and 40
cause pain. Cutoff Left side
asymptomatic
values represent 1
patients
standard deviation .75 .95 15.00 .26
from the mean*
PPT of masseter Right side
muscle20 ●
TMD diagnosis .75 .90 7.50 .28
from RCD/TMD
evaluation Left side

.78 .90 7.80 .24

PPT of anterior .77 .91 8.37 .25


temporalis
muscle21 ● Used pressure
algometer pressed into
PPT of middle relaxed muscle belly. .73 .91 7.93 .30
temporalis 99 women
PPT defined as lightest
muscle21 ● with dental or
pressure to cause
intraarticular
PPT of posterior pain. Cutoff values .67 .91 7.28 .36
TMJ pain
temporalis chosen from receiver
muscle21 ● operator curve when
specificity was .91
PPT of masseter .55 .91 5.98 .50
muscle21 ●
*Gomes and colleagues20 also calculated sensitivity and specificity for cutoff values of 1.5 and 2 standard deviations. Values showed almost perfect
specificity but poor sensitivity.
PPT, pressure pain threshold.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 39


Physical Examination Tests  •  Joint Sounds
Reliability of Detecting Joint Sounds during Active Motion
Description and Positive
Test and Study Quality Findings Population Reliability
Click sounds during mouth During mouth opening, examiner Intraexaminer κ = .12
opening16 ● records the presence of a click
sound
61 patients with TMJ pain
Crepitus sounds during During mouth opening, examiner Intraexaminer κ = .15
mouth opening16 ● records the presence of a
grating or grinding sound

Clicking during active Intensity of clicking and Interexaminer κ = .70


maximal mouth opening13 ● crepitation is graded on a scale 79 randomly selected
Crepitation during active of 0 to 2 from “none” to “clearly patients referred to Interexaminer κ = .29
maximal mouth opening13 ● audible” craniomandibular disorder
department
Joint noise13 ● Presence of joint noises is Interexaminer κ = .24
recorded by examiner

Opening14 ● Interexaminer κ = .59


Examiner records the presence
Lateral excursion, right14 ● of joint sounds during 79 patients referred to Interexaminer κ = .57
mandibular opening, lateral TMD and orofacial pain
Lateral excursion, left14 ● excursion to right and left, and department Interexaminer κ = .50
protrusion
Protrusion14 ● Interexaminer κ = .47

TMJ sounds15 ◆ Presence of joint noises is 27 TMD patients Interexaminer κ (Right) =


recorded by examiner during .52 (Left) = .25
mouth opening

Reliability of Detecting Joint Sounds during Joint Play


Test and Study Description and Positive
Quality Findings Population Reliability
Joint noise during Examiner records presence of joint 79 randomly selected patients Interexaminer κ = −.01
joint play13 ● noise during traction and translation referred to craniomandibular
disorder department

Traction, right14 ● Examiner moves the mandibular Interexaminer κ = −.02


condyle in an inferior direction for
Traction, left14 ● traction and in a mediolateral 79 patients referred to TMD Interexaminer κ = .66

Translation, right14 ● direction for translation. Examiner and orofacial pain department Interexaminer κ = .07
records presence of joint sound
Translation, left14 ● during translation and traction Interexaminer κ = −.02

40 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Joint Sounds
Diagnostic Utility of Clicking in Identifying Temporomandibular Conditions

2 
Temporomandibular Joint
Figure 2-18
Auscultation performed with a stethoscope.

Test and Description and Positive Reference


Study Quality Findings Population Standard Sens Spec +LR −LR
Clicking3 ◆ Examiner palpates the lateral 146 patients Anterior disc .51 .83 3.0 .59
aspect of the TMJ during attending TMJ displacement
opening and closing. and craniofacial with reduction
Examiner records audible, pain clinic via MRI
palpable clicking

Clicking16 ◆ Examiner auscultates for 61 patients with Presence of .69 .51 1.41 .61
sounds during joint TMJ pain TMJ effusion
movement. Presence of a via MRI
click sound is considered
positive

Reproducible Auscultation with a In presence of reducing disc


clicking8 ● stethoscope. Considered
positive if observed at least .10 .40 .17 2.25
four times during five
In presence of nonreducing disc
repetitions of mouth opening 70 patients (90
Detecting
TMJs) referred .71 .90 7.10 .32
anterior disc
with complaints of
Reciprocal Auscultation with a displacement In presence of reducing disc
craniomandibular
clicking8 ● stethoscope. Considered via MRI
pain
(see Video 2-1) positive if a click on opening .40 .52 .83 1.15
is followed by a click on
In presence of nonreducing disc
closing
.76 .95 15.2 .25

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 41


Physical Examination Tests  •  Joint Sounds
Diagnostic Utility of Crepitus in Identifying Temporomandibular Conditions
Test and Description and Reference
Study Quality Positive Findings Population Standard Sens Spec +LR −LR
Presence of Examiner auscultates for 61 patients with Presence of TMJ .85 .30 1.21 .50
crepitus16 ◆ sounds during joint TMJ pain effusion via MRI
movement. Presence of
grating or grinding noise is
considered positive

Presence of Osteoarthritis based on 84 patients with TMJ osteoarthritis .70 .43 1.23 .70
crepitus17 ● presence of crepitus during symptoms of via arthroscopic
auscultation. Presence of TMJ pain investigation
crepitus is considered
positive

Presence of Auscultation performed with Minor osteoarthritis*


crepitus18 ● stethoscope. Presence of
crepitus is considered 200 consecutive TMJ osteoarthritis .45 .84 2.81 .65
positive patients with via arthroscopic
TMJ disease investigation Severe osteoarthritis*

.67 .86 4.79 .38


*Minor osteoarthritis is defined as the presence of smooth, glossy white surfaces of the disc and fibrocartilage. Severe osteoarthritis is defined as the
presence of one or more of the following features: (1) pronounced fibrillation of the articular cartilage and disc; (2) exposure of subchondral bone; and
(3) disc perforation.

42 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Range-of-Motion Measurements
Reliability of Range-of-Motion Measurements of the Temporomandibular Joint  
during Mouth Opening

2 
Temporomandibular Joint
Figure 2-19 Figure 2-20
Measurement of mouth opening active range of motion. Plastic vernier caliper used to measure mandibular position.

Description and Positive


Test and Study Quality Findings Population Reliability
Opening22 ◆ Without TMJ Patient is instructed to open Interexaminer ICC = .98
disorder mouth as much as possible 15 subjects with TMJ Intraexaminer ICC = .77
without causing pain. disorder and 15 to .89
Interincisal distance is subjects without this
With TMJ disorder measured to the nearest disorder Interexaminer ICC = .99
millimeter with a plastic ruler Intraexaminer ICC = .94

Unassisted In older adults Interexaminer ICC = .88


opening without (.78, .94)
pain23 ●
In young adults Interexaminer ICC = .91
(.83, .95)
43 asymptomatic
Maximum In older adults older adults (age 68 Interexaminer ICC = .95
unassisted to 96 years) and 44 (.91, .97)
opening23 ● asymptomatic young
In young adults Interexaminer ICC = .98
Measured in millimeters with adults (age 18 to 45 (.96, .99)
ruler consistent with RMC/ years)
Maximum In older adults TMD guidelines Interexaminer ICC = .96
assisted (.92, .98)
opening23 ●
In young adults Interexaminer ICC = .98
(.96, .99)

Unassisted opening without pain15 ◆ Interexaminer ICC = .83

Maximum unassisted opening15 ◆ 27 TMD patients Interexaminer ICC = .89

Maximum assisted opening15 ◆ Interexaminer ICC = .93

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 43


Physical Examination Tests  •  Range-of-Motion Measurements
Reliability of Range-of-Motion Measurements of the Temporomandibular Joint
Description and Positive
Test and Study Quality Findings Population Reliability
Overbite22 ◆ Without TMJ A horizontal line is made on Interexaminer ICC = .98
disorder the lower incisor at the level Intraexaminer ICC = .90 to .96
of the upper incisor with the
With TMJ TMJ closed. The vertical Interexaminer ICC = .95
disorder distance between the line, Intraexaminer ICC = .90 to .97
and the superior aspect of
the lower incisor is measured

Excursion, Without TMJ Interexaminer ICC = .95


left22 ◆ disorder Vertical marks are made in Intraexaminer ICC = .91 to .92
the median plane on the
With TMJ anterior surface of the lower Interexaminer ICC = .94
disorder central incisors in Intraexaminer ICC = .85 to .92
relationship to the upper 15 subjects
Excursion, Without TMJ central incisors. Patient is with TMJ Interexaminer ICC = .90
right22 ◆ disorder instructed to move the jaw disorder and Intraexaminer ICC = .70 to .87
as far lateral as possible, and 15 subjects
With TMJ the measurement is recorded Interexaminer ICC = .96
disorder without TMJ Intraexaminer ICC = .75 to .82
disorder
Protrusion22 ◆ Without TMJ Two vertical lines are made Interexaminer ICC = .95
disorder on the first upper and lower Intraexaminer ICC = .85 to .93
canine incisors. Subject is
With TMJ instructed to move the jaw Interexaminer ICC = .98
disorder as far forward as possible, Intraexaminer ICC = .89 to .93
and a measurement is made
between the two marks

Overjet22 ◆ Without TMJ The horizontal distance Interexaminer ICC = 1.0


disorder between the upper and lower Intraexaminer ICC = .98

With TMJ incisors is measured when Interexaminer ICC = .99


disorder the mouth is closed Intraexaminer ICC = .98 to .99

Maximum In older adults 43 older Interexaminer ICC = .71 (.45, .84)


laterotrusion23 ● asymptomatic
In young adults adults (age 68 Interexaminer ICC = .77 (.57, .88)
to 96 years)
Maximum In older adults Interexaminer ICC = .78 (.59, .88)
and 44 young
protrusion23 ●
In young adults asymptomatic Interexaminer ICC = .90 (.81, .95)
Measured in millimeters with adults (age 18
ruler consistent with RMC/ to 45 years)
TMD guidelines
Lateral excursion, right15 ◆ Interexaminer ICC = .41

Lateral excursion, left15 ◆ 27 TMD Interexaminer ICC = .40


15
Horizontal overbite ◆ patients Interexaminer ICC = .79

Vertical overlap15 ◆ Interexaminer ICC = .70

44 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Range-of-Motion Measurements
Reliability of Range-of-Motion Measurements of the Temporomandibular Joint (continued)
Description and Positive
Test and Study Quality Findings Population Reliability
Opening24 ● Interexaminer ICC = .95

2 
Intraexaminer ICC = .97

Protrusion24 ● Interexaminer ICC = .77

Temporomandibular Joint
Intraexaminer ICC = .95

Laterotrusion right24 ● Interexaminer ICC = .50


A plastic vernier caliper was Intraexaminer ICC = .90
30 healthy
used to measure mandibular
Laterotrusion left24 ● subjects Interexaminer ICC = .42
position
Intraexaminer ICC = .92

Overbite24 ● Interexaminer ICC = .70


Intraexaminer ICC = .93

Overjet24 ● Interexaminer ICC = .70


Intraexaminer ICC = .96

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 45


Physical Examination Tests  •  Range-of-Motion Measurements
Reliability of Joint Play and End-Feel Assessment of the Temporomandibular Joint

Figure 2-21
Translation of mandible, left.

Description and Positive


Test and Study Quality Findings Population Reliability
Traction and Restriction Examiner records the presence of 79 randomly selected Interexaminer κ = .08
translation13 ● of movement restriction of movement at end patients referred to
feel during traction and translation craniomandibular
End feel of the TMJ disorder department Interexaminer κ = .07

Traction, Joint play Interexaminer κ = −.03


right14 ●
End feel Interexaminer κ = −.05

Traction, Joint play Examiner moves the mandibular Interexaminer κ = .08


left14 ● condyle in an inferior direction for
End feel traction and a mediolateral 79 patients referred to Interexaminer κ = .20
direction for translation. The TMD and orofacial pain
Translation, Joint play extent of joint play and end feel is department Interexaminer κ = −.05
right14 ● graded as “normal” or
End feel “abnormal” Interexaminer κ = −.05

Translation, Joint play Interexaminer κ = −.10


left14 ●
End feel Interexaminer κ = −.13

Reliability of Measuring Mandibular Opening with Different Head Positions


Test and Study Quality Description and Positive Findings Population Reliability
Forward head position25 ● Patient is instructed to slide the jaw forward Interexaminer ICC = .92
as far as possible, and a measurement of Intraexaminer ICC = .97
vertical mandibular opening is recorded

Neutral head position25 ● Patient is placed in a position where a plumb Interexaminer ICC = .93
40 healthy
line bisects the ear, and a measurement of Intraexaminer ICC = .93
subjects
vertical mandibular opening is recorded

Retracted head position25 ● Patient is instructed to slide the jaw backward Interexaminer ICC = .92
as far as possible, and a measurement of Intraexaminer ICC = .92
vertical mandibular opening is recorded

46 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Range-of-Motion Measurements
Diagnostic Utility of Limited Range of Motion in Identifying Anterior Disc Displacement
Test and
Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR

2 
Restriction of Examiner asks patient to .69 .81 3.63 .38
condylar maximally open mouth while

Temporomandibular Joint
translation3 ◆ palpating condylar movement.
Examiner records any limitation Anterior disc
146 patients
of condylar translation displacement
attending TMJ and
without
Restriction of Examiner asks patient to craniofacial pain .32 .83 1.88 .82
reduction
range of maximally open mouth and clinic
via MRI
functional measures the distance in
opening3 ◆ millimeters. Less than 40 mm
is considered a restriction

Restriction of Measurement is taken at the In presence of reducing disc


range of end range of active mouth
functional opening. Definition of positive .38 .21 .48 2.95
opening8 ● not reported
In presence of nonreducing disc

.86 .62 2.26 .23

Restriction of Measurement is taken at the In presence of reducing disc


range of end range of passive mouth
passive opening after 15 seconds. .29 .29 .41 2.45
opening8 ● Definition of positive not
In presence of nonreducing disc
reported
.76 .69 2.45 .35

Restricted Not reported In presence of reducing disc


translation8 ● 70 patients (90
TMJs) referred Anterior disc .15 .38 .24 2.24
with complaints of displacement
craniomandibular via MRI In presence of nonreducing disc
pain
.66 .81 3.47 .42

Restricted Measurement is taken at the In presence of reducing disc


protrusion8 ● end range of active mandibular
protrusion. Definition of .29 .38 .47 1.87
positive not reported
In presence of nonreducing disc

.62 .64 1.72 .59

Restricted Measurement is taken at the In presence of reducing disc


contralateral end of contralateral movement
movement8 ● from the midline. Definition of .15 .34 .23 2.50
positive not reported
In presence of nonreducing disc

.66 .76 2.75 .45

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 47


Physical Examination Tests  •  Dynamic Movement Measurements
Diagnostic Utility of Deviations in Movement in Identifying Anterior Disc Displacement
Test and
Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
Deviation of Patient is asked to 146 patients Anterior disc .32 .87 2.46 .78
mandible3 ◆ maximally open the mouth. attending TMJ displacement
If the midline of the upper and craniofacial without reduction
and lower incisors does not pain clinic via MRI
line up, then the test is
considered positive

Deviation of Examiner observes active In presence of reducing disc


mandible with mouth opening. Test is
correction8 ● considered positive if a .14 .57 .33 1.51
deviation occurs and the
In presence of nonreducing disc
mandible returns to midline 70 patients (90
TMJs) referred Anterior disc .44 .83 2.59 .67
with complaints of displacement
Deviation of Examiner observes active craniomandibular via MRI In presence of reducing disc
mandible mouth opening. Test is pain
without considered positive if the .18 .41 .31 2.0
correction8 ● mandible does not return
In presence of nonreducing disc
to midline after deviation
.66 .83 3.88 .41

48 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Dynamic Movement Measurements
Reliability of Determining the Presence of Pain during Dynamic Movements

2 
Temporomandibular Joint
Figure 2-22
Assessment of pain during passive opening.

Description and Positive


Test and Study Quality Findings Population Reliability
Mandibular movements16 ● Patient is asked if pain is felt Intraexaminer κ = .43
during opening, closing, lateral
excursion, protrusion, and
retrusion 61 patients with
TMJ pain
Maximum assisted Examiner applies overpressure to Intraexaminer κ = −.05
opening16 ● the end range of mandibular
depression

Pain on opening14 ● Patient is asked to maximally Interexaminer κ = .28


open mouth

Pain on lateral excursion, Patient is asked to move the Interexaminer κ = .28


right14 ● mandible in a lateral direction as 79 patients referred
far as possible to TMD and orofacial
Pain on lateral excursion, pain department Interexaminer κ = .28
left14 ●

Pain on protrusion14 ● Patient is asked to actively Interexaminer κ = .36


protrude the jaw

Passive opening13 ● At the end of active opening the Interexaminer κ = .34


examiner applies a passive 79 randomly selected
stretch to increase mouth opening patients referred to
craniomandibular
Active opening13 ● Patient is asked to open mouth as disorder department Interexaminer κ = .32
wide as possible

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 49


Physical Examination Tests  •  Dynamic Movement Measurements
Reliability of Detecting Pain during Resistance Tests

Figure 2-23
Manual resistance applied during lateral deviation.

Test and Study Quality Description and Positive Findings Population Reliability
Dynamic tests16 ● Patient performs opening, closing, 61 patients with TMJ Intraexaminer κ = .20
lateral excursion, protrusion, and pain
retrusion movements while examiner
applies resistance

Opening14 ● Interexaminer κ = .24


Examiner applies isometric resistance
Closing14 ● 79 patients referred Interexaminer κ = .30
during opening, closing, and lateral
to TMD and orofacial
Lateral excursion, right14 ● excursions to the right and left of the Interexaminer κ = .28
pain department
TMJ. The presence of pain is recorded
Lateral excursion, left14 ● Interexaminer κ = .26

Static pain test13 ● The examiner applies resistance against 79 randomly selected Interexaminer κ = .15
the patient’s mandible in upward, patients referred to
downward, and lateral directions craniomandibular
disorder department

50 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Dynamic Movement Measurements
Reliability of Determining the Presence of Pain during Joint Play

2 
Temporomandibular Joint
Figure 2-24
Temporomandibular traction.

Test and Study Description and Positive


Quality Findings Population Reliability
Joint play test12 ● Examiner performs passive traction 61 patients with TMJ pain Intraexaminer ICC = .20
and translation movements

Joint play test14 ● Examiner applies a traction and a 79 randomly selected patients Interexaminer ICC = .46
translation (mediolateral) force referred to craniomandibular
through the TMJ disorder department

Traction, right15 ◆ Interexaminer ICC = −.08


Examiner moves the mandibular
Traction, left15 ◆ condyle in an inferior direction Interexaminer ICC = .25
79 patients referred to TMD
for traction and a mediolateral
Translation, right ◆ and orofacial pain department Interexaminer ICC = .50
direction for translation. The
presence of pain is recorded
Translation, left15 ◆ Interexaminer ICC = .28

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 51


Physical Examination Tests  •  Dynamic Movement Measurements
Diagnostic Utility of Pain in Identifying Temporomandibular Conditions

Mouth opening Mouth closing

Figure 2-25
Manual resistance applied during mouth opening and closing.

Test and
Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
Pain during Patient is asked to open, .82 .61 2.10 .30
mandibular close, protrude, retrude,
movements16 and perform lateral
◆ excursion of the mandible.
Positive if pain present

Pain during Patient is asked to perform .93 .16 .95 4.38


maximum the movements above
opening and while examiner applies
overpressure16 resistance. Positive if pain
◆ present 61 patients with Presence of TMJ
TMJ pain effusion via MRI
Pain during Patient is instructed to .74 .44 1.32 .59
dynamic open the mouth as wide as
tests16 ◆ possible, and examiner
applies overpressure.
Positive if pain present

Pain during Examiner passively .80 .39 1.31 .51


joint play16 ◆ performs translation and
traction of the TMJ.
Positive if pain present

TMJ pain At the end of maximal 146 patients Anterior disc .55 .91 6.11 .49
during mouth opening, examiner attending TMJ displacement
assisted applies 2 to 3 pounds of and craniofacial without reduction
opening3 ◆ overpressure. The pain clinic via MRI
(see Video presence or absence of
2-2) pain is recorded

52 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Dynamic Movement Measurements
Diagnostic Utility of Pain in Identifying Temporomandibular Conditions (continued)
Test and
Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR

2 
Joint pain on Patient is asked to open In presence of reducing
opening8 ● mouth as wide as possible. disc

Temporomandibular Joint
Positive if pain present
.44 .31 .64 1.81

In presence of nonreducing
70 patients (90 disc
TMJs) referred Anterior disc
with complaints of displacement via .74 .57 1.72 .46

Pain with Patient is asked to perform craniomandibular MRI In presence of reducing disc
contralateral lateral excursion pain
motion8 ● contralateral to the side of .60 .69 1.94 .58
joint involvement. Positive
In presence of nonreducing
if pain present
disc

.34 .93 4.86 .71

Dynamic/ Manual resistance was .63 .93 .90 .40


static19 ● applied during mouth
opening, closing,
protrusion, and lateral
deviation. Pain was
recorded via VAS using a
cutoff value to maximize
sensitivity and specificity

Active Patient was asked to Patient report of .87 .67 2.64 .19
147 patients
movements19 maximally depress tenderness in
referred for
● mandible, protrude it, and masticatory
craniomandibular
deviate it right and left. muscles,
complaints and
Pain was recorded via VAS preauricular area, or
103 asymptomatic
using a cutoff value to temporomandibular
individuals
maximize sensitivity and area in past month
specificity

Passive At the end of maximal .80 .64 2.22 .31


movements19 mouth opening, examiner
● gently applied
overpressure. Pain was
recorded via VAS using a
cutoff value to maximize
sensitivity and specificity

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 53


Physical Examination Tests  •  Other Tests
Reliability of the Compression Test

Figure 2-26
Bilateral temporomandibular compression.

Test and Study Description and


Quality Positive Findings Population Reliability
Compression, Pain Interexaminer κ = .19
right14 ●
Sounds The examiner loads the 79 patients referred to TMD Not reported
intraarticular structures by and orofacial pain department
Compression, Pain Interexaminer κ = .47
moving the mandible in a
left14 ●
Sounds dorsocranial direction. The Interexaminer κ = 1.0
presence of pain and joint
Compression12 ● Pain sounds are recorded 79 randomly selected patients Interexaminer κ = .40
referred to craniomandibular
Joint noises disorder department Interexaminer κ = .66

54 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Other Tests
Diagnostic Utility of Lower Extremity Measurements
Description and Positive
Test and Study Quality Findings Population Reliability
Leg length inequality26 ● With patient supine, examiner Interexaminer κ = .33 to .39

2 
visually compares the position of the
medial malleoli. Considered positive
if leg length inequality is .5 cm or

Temporomandibular Joint
more

Internal foot rotation test26 ● With patient supine, examiner exerts 41 dental students Interexaminer κ = .15 to .27
forced internal rotation of the foot
and assesses the amount of end
play. Considered positive if
difference in rotation is 15 degrees
or more

Test and Description and Positive Reference


Study Quality Findings Population Standard Sens Spec +LR −LR
Leg length With patient supine, examiner Jaw muscle .43 .41 .73 1.39
inequality26 ● visually compares the position myofascial pain
of the medial malleoli. from RCD/TMD
Considered positive if leg evaluation
length inequality is .5 cm or
more Anterior TMJ disc .50 .41 .85 1.22
displacement
from RCD/TMD
41 dental evaluation

Internal foot With patient supine, examiner students Jaw muscle .43 .47 .81 1.21
rotation test26 ● exerts forced internal rotation myofascial pain
of the foot and assesses the from RCD/TMD
amount of end play. evaluation
Considered positive if
difference in rotation is 15 Anterior TMJ disc .57 .52 1.19 .83
degrees or more displacement
from RCD/TMD
evaluation

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 55


Physical Examination Tests  •  Combinations of Tests
Diagnostic Utility of Combined Tests for Detecting Anterior Disc Displacement with Reduction

Closing click

6 2

Opening click

5 3

Figure 2-27
Anterior disc displacement with reduction.

56 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Combinations of Tests
Diagnostic Utility of Combined Tests for Detecting Anterior Disc Displacement with Reduction
(continued)
Description
and Positive Reference
Test and Study Quality Findings Population Standard Sens Spec +LR −LR

2 
No deviation of mandible; no .76 .30 1.09 .80

Temporomandibular Joint
pain during assisted
opening3 ◆

No deviation of mandible; no .76 .27 1.04 .89


limitation of opening3 ◆

No deviation of mandible; no .75 .37 1.19 .68


restriction of condylar
translation3 ◆

No deviation of mandible; .51 .85 3.40 .58


clicking3 ◆
See previous 146 patients
Anterior disc
No deviation of mandible; no descriptions attending TMJ .71 .35 1.09 .83
displacement with
pain during opening; no under single and craniofacial
reduction via MRI
limitation of opening3 ◆ test items pain clinic

No deviation of mandible; no .68 .37 1.08 .86


pain during opening; no
limitation of opening; no
restriction of condylar
translation3 ◆

No deviation of mandible; no .44 .86 3.14 .65


pain during opening; no
limitation of opening; no
restriction of condylar
translation; clicking3 ◆

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 57


Physical Examination Tests  •  Combinations of Tests
Diagnostic Utility of Combined Tests for Detecting Anterior Disc Displacement  
without Reduction

6 2

5 3

Figure 2-28
Anterior disc displacement without reduction.

58 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Combinations of Tests
Diagnostic Utility of Combined Tests for Detecting Anterior Disc Displacement  
without Reduction (continued)
Test and Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR

2 
Motion restriction; no .61 .82 3.39 .48
clicking3 ◆

Temporomandibular Joint
Motion restriction; pain .54 .93 7.71 .49
during assisted
opening3 ◆

Motion restriction; .31 .87 2.38 .79


limitation of maximal
mouth opening3 ◆

Motion restriction; .30 .90 3.0 .78


deviation of
mandible3 ◆
146 patients Anterior disc
Motion restriction; no See previous .46 .94 7.67 .59
attending TMJ displacement
clicking, TMJ pain with descriptions under
and craniofacial without reduction
assistive opening3 ◆ single test items
pain clinic via MRI
Motion restriction; no .22 .96 5.50 .81
clicking; TMJ pain with
assistive opening;
limitation of maximum
mouth opening3 ◆

Motion restriction; no .11 .98 5.5 .91


clicking; TMJ pain
with assistive
opening; limitation of
maximum mouth
opening; deviation of
mandible3 ◆

Clinical diagnosis using Examination using 69 patients Anterior disc .75 .83 4.41 .3
history and combined Clinical Diagnostic referred with displacement
tests27 ◆ Criteria for TMD without reduction
Temporomandibular via MRI
Disorders (CDC/TMD)

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 59


Physical Examination Tests  •  Combinations of Tests
Predicting Treatment Success with Nightly Wear of Occlusal Stabilization Splint

Figure 2-29
Occlusal stabilization splint.

Test and Description and Reference


Study Quality Positive Findings Population Standard Sens Spec +LR −LR*
Time since 42 weeks or less .62 .69 2.0 .55
pain28 ◆ (.49, .73) (.54, .80) (1.3, 3.0)

Baseline pain 40 mm or more on .48 .72 1.7 .72


level28 ◆ VAS (.35, .60) (.57, .83) (1.0, 2.7)

Change in VAS 15 mm or more on .72 .91, 3.9 .31


level at 2 VAS (.75, .93) (.64, .88) (2.3, 6.5)
months28 ◆ Treatment
119 success (more
Disc As observed on MRI consecutive than 70% .25 .91 2.7 .82
displacement patients reduction in (.15, .37) (.79, .97) (1.0, 6.8)
without referred to VAS) after 6
reduction28 ◆ TMD clinic months with
diagnosed with nightly wear
Four positive Four of the four unilateral TMJ of occlusal .10 .99 10.8 .91
tests28 ◆ findings listed arthralgia stabilization (.04, .20) (.90, (.62,
above splint 1.00) 188.1)

Three or more Three or four of the .23, .91 2.5 .85


positive tests28 four findings listed (.14, .36) (.79, .97) (.97, 6.4)
◆ above

Two or more Two to four of the .49 .85 3.3 .60


positive tests28 four findings listed (.37, .62) (.72, .93) (1.7, 6.6)
◆ above
*−LRs were not reported in the study and, therefore, were calculated by the authors of this book.
VAS, visual analog scale.

60 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Combinations of Tests
Predicting Treatment Failure with Nightly Wear of Occlusal Stabilization Splint
Test and Description and Reference
Study Quality Positive Findings Population Standard Sens Spec +LR −LR*
Time since More than 43 weeks .56 .65 1.68 .68

2 
pain28 ◆ (.45, .67) (.47, .79) (.52, .89)

Baseline pain Less than 40 mm .76 .68 2.38 .36

Temporomandibular Joint
level28 ◆ on VAS (.65, .84) (.50, .82) (.24, .54)

Change in VAS 9 mm or less on .82 .97 27.33 .19


level at 2 VAS (.71, .89) (.84, .99) (.12, .30)
months28 ◆ Treatment
119 consecutive failure after
Disc As observed on MRI .10 .57 .23 1.59
patients referred 6 months
displacement (.05, .19) (.40, .73) (1.42,
to TMD clinic with nightly
with reduction28 1.78)
diagnosed with wear of

unilateral TMJ occlusal
Four positive Four of the four arthralgia stabilization .96 .76 4.00 .05
tests28 ◆ findings listed above splint (.67, 1.0) (.67, .84) (.00, .77)

Three or more Three or four of the .19 .96 4.75 .84


positive tests28 four findings listed (.09, .36) (.89, .99) (.72, .98)
◆ above

Two or more Two to four of the .38 .78 1.73 .80


positive tests28 four findings listed (.23, .55) (.67, .86) (.62, 1.0)
◆ above
*−LRs were not reported in the study and, therefore, were calculated by the authors of this book.
VAS, visual analog scale.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 61


Outcome Measures

Outcome Measure Scoring and Interpretation Test-Retest Reliability MCID


Mandibular Function Users rate perceived level of difficulty on a Likert Spearman’s r = .69 to .9629,30 ● 1429
Impairment scale ranging from 0 (no difficulty) to 4 (very great
Questionnaire (MFIQ) difficulty or impossible without help) on a series of
17 questions about jaw function. The sum item
score for function impairment ranges from 0 to 68,
with higher scores representing more disability

Numeric Pain Rating Users rate their level of pain on an 11-point scale ICC = .7231 ● 232,33
Scale (NPRS) ranging from 0 to 10, with high scores representing
more pain. Often asked as current pain or least,
worst, and average pain in the past 24 hours
MCID, minimum clinically important difference.

62 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Appendix
Quality Appraisal of Reliability Studies for Temporomandibular Disorders Using QAREL

Lobbezoo-Scholte 199413
Magnusson 19957

Manfredini 200316
Dworkin 199012

2 
de Wijer 199514

Walker 200022
Nilsson 20069

Hassel 200623
Leher 200515
John 200534

Temporomandibular Joint
1. Was the test evaluated in a sample of Y Y Y Y Y Y Y Y Y Y
subjects who were representative of those to
whom the authors intended the results to be
applied?

2. Was the test performed by raters who were Y Y Y Y Y Y Y Y Y Y


representative of those to whom the authors
intended the results to be applied?

3. Were raters blinded to the findings of other U Y Y U U U Y Y Y U


raters during the study?

4. Were raters blinded to their own prior U N/A N/A N/A N/A N/A N/A N/A Y N/A
findings of the test under evaluation?

5. Were raters blinded to the results of the N/A N/A Y N/A N/A N/A N/A Y N/A N/A
reference standard for the target disorder (or
variable) being evaluated?

6. Were raters blinded to clinical information U U U U U U U U U U


that was not intended to be provided as part
of the testing procedure or study design?

7. Were raters blinded to additional cues that U U U U U U U U U U


were not part of the test?

8. Was the order of examination varied? U U Y U U U Y U Y U

9. Was the time interval between repeated Y Y Y Y Y Y Y Y Y Y


measurements compatible with the stability
(or theoretical stability) of the variable being
measured?

10. Was the test applied correctly and Y Y Y Y Y Y Y Y Y Y


interpreted appropriately?

11. Were appropriate statistical measures of Y Y Y Y Y Y Y Y Y Y


agreement used?

Quality Summary Rating: ● ● ◆ ● ● ● ◆ ● ◆ ●


Y = yes, U = unclear, N/A = not applicable. ◆ Good quality (Y to N = 9 to 11) ● Fair quality (Y to N = 6 to 8) ■ Poor quality (Y to N ≤5).

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 63


Appendix
Quality Appraisal of Reliability Studies for Temporomandibular Disorders Using QAREL
(continued)

Kropmans 199929

Gonzalez 201110
Farella 200526
Higbie 199925

Undt 200630

Best 201324
Li 200731
1. Was the test evaluated in a sample of subjects who were Y Y Y Y Y Y Y
representative of those to whom the authors intended the results
to be applied?

2. Was the test performed by raters who were representative of those Y Y Y Y Y Y Y


to whom the authors intended the results to be applied?

3. Were raters blinded to the findings of other raters during the U Y U U U U Y


study?

4. Were raters blinded to their own prior findings of the test under U N/A U U U N/A N
evaluation?

5. Were raters blinded to the results of the reference standard for the N/A N/A N/A N/A N/A U N/A
target disorder (or variable) being evaluated?

6. Were raters blinded to clinical information that was not intended to U U U U U U U


be provided as part of the testing procedure or study design?

7. Were raters blinded to additional cues that were not part of the U U U U U U U
test?

8. Was the order of examination varied? Y N U U U N/A U

9. Was the time interval between repeated measurements compatible Y Y Y Y Y Y Y


with the stability (or theoretical stability) of the variable being
measured?

10. Was the test applied correctly and interpreted appropriately? Y Y Y Y Y Y Y

11. Were appropriate statistical measures of agreement used? Y Y Y Y Y Y Y

Quality Summary Rating: ● ● ● ● ● ● ●


Y = yes, N = no, U = unclear, N/A = not applicable. ◆ Good quality (Y to N = 9 to 11) ● Fair quality (Y to N = 6 to 8) ■ Poor quality (Y to N ≤5).

64 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Appendix
Quality Assessment of Diagnostic Studies for Temporomandibular Disorders Using QUADAS

Holmlund 199618
Stegenga 19928

Visscher 200019

Emshoff 200227
Paesani 199235

Israel 199817

Orsini 19993

2 
Temporomandibular Joint
1. Was the spectrum of patients representative of the patients who will receive Y N Y Y Y N Y
the test in practice?

2. Were selection criteria clearly described? Y N N Y Y Y Y

3. Is the reference standard likely to correctly classify the target condition? Y U Y Y Y U Y

4. Is the time period between reference standard and index test short enough to U U U U U U Y
be reasonably sure that the target condition did not change between the two
tests?

5. Did the whole sample, or a random selection of the sample, receive Y N Y Y Y Y Y


verification using a reference standard of diagnosis?

6. Did patients receive the same reference standard regardless of the index test Y U Y Y Y Y Y
result?

7. Was the reference standard independent of the index test (i.e., the index test Y Y Y Y Y Y Y
did not form part of the reference standard)?

8. Was the execution of the index test described in sufficient detail to permit Y Y Y Y Y Y Y
replication of the test?

9. Was the execution of the reference standard described in sufficient detail to Y U Y U Y Y Y


permit its replication?

10. Were the index test results interpreted without knowledge of the results of U U U U Y Y Y
the reference test?

11. Were the reference standard results interpreted without knowledge of the U U U U Y Y Y
results of the index test?

12. Were the same clinical data available when test results were interpreted as U U U Y U U U
would be available when the test is used in practice?

13. Were uninterpretable/intermediate test results reported? U U Y Y Y U Y

14. Were withdrawals from the study explained? U U Y Y U U Y

Quality Summary Rating: ● ■ ● ● ◆ ● ◆


Y = yes, N = no, U = unclear. ◆ Good quality (Y to N = 9 to 11) ● Fair quality (Y to N = 6 to 8) ■ Poor quality (Y to N ≤5).

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 65


Appendix
Quality Assessment of Diagnostic Studies for Temporomandibular Disorders Using QUADAS
(continued)

Manfredini 200316

Schmitter 200436

Gonzalez 201110
Emshoff 200828
Farella 200526

Gomes 200820
Nilsson 20069
Silva 200521
1. Was the spectrum of patients representative of the patients who will Y Y N Y Y Y Y Y
receive the test in practice?

2. Were selection criteria clearly described? U Y Y Y N Y U Y

3. Is the reference standard likely to correctly classify the target Y Y Y Y Y Y Y Y


condition?

4. Is the time period between reference standard and index test short Y N U U Y Y U Y
enough to be reasonably sure that the target condition did not change
between the two tests?

5. Did the whole sample, or a random selection of the sample, receive Y Y U Y Y Y U Y


verification using a reference standard of diagnosis?

6. Did patients receive the same reference standard regardless of the Y Y Y Y Y Y U Y


index test result?

7. Was the reference standard independent of the index test (i.e., the Y Y Y U Y Y N U
index test did not form part of the reference standard)?

8. Was the execution of the index test described in sufficient detail to Y Y Y Y Y Y Y Y


permit replication of the test?

9. Was the execution of the reference standard described in sufficient Y Y Y Y Y Y Y Y


detail to permit its replication?

10. Were the index test results interpreted without knowledge of the results Y Y U U U Y Y U
of the reference test?

11. Were the reference standard results interpreted without knowledge of Y Y U U U Y Y U


the results of the index test?

12. Were the same clinical data available when test results were Y U U U U Y U Y
interpreted as would be available when the test is used in practice?

13. Were uninterpretable/intermediate test results reported? U Y U U Y Y U Y

14. Were withdrawals from the study explained? Y Y U U Y Y Y Y

Quality Summary Rating: ◆ ◆ ● ● ● ◆ ● ◆


Y = yes, N = no, U = unclear. ◆ Good quality (Y to N = 10 to 14) ● Fair quality (Y to N = 5 to 9) ■ Poor quality (Y to N ≤4).

66 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


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68 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Cervical Spine 3 
CLINICAL SUMMARY AND RECOMMENDATIONS, 70
Anatomy, 71
Osteology, 71
Arthrology, 73
Ligaments, 74
Muscles, 76
Nerves, 82

Patient History, 84
Initial Hypotheses Based on Patient History, 84
Cervical Zygapophyseal Pain Syndromes, 84
Reliability of the Cervical Spine Historical Examination, 86
Diagnostic Utility of Patient Complaints for Cervical Radiculopathy, 87

Physical Examination Tests, 89


Neurologic Examination, 89
Screening for Cervical Spine Injury, 94
Range-of-Motion Measurements, 97
Cervical Strength and Endurance, 102
Passive Intervertebral Motion, 103
Palpation, 108
Postural and Muscle Length Assessment, 110
Spurling’s and Neck Compression Tests, 112
Neck Distraction and Traction Tests, 115
Cervical Flexion-Rotation Test, 116
Shoulder Abduction Test, 117
Neural Tension Tests, 118
Sharp-Purser Test, 121
Arm Squeeze Test, 122
Compression of Brachial Plexus, 123
Cervical Myelopathy Tests, 124
Combinations of Tests, 128
Interventions, 130

Outcome Measures, 138

Appendix, 139

References, 145

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 69


Clinical Summary and Recommendations

Patient History
Complaints • The utility of the patient history has been studied only in the context of identifying cervical
radiculopathy. Subjective reports of symptoms were generally not helpful, with diagnoses including
complaints of “weakness,” “numbness,” “tingling,” “burning,” or “arm pain.”
• The patient complaints most useful in diagnosing cervical radiculopathy were (1) a report of
symptoms most bothersome in the scapular area (+LR [likelihood ratio] = 2.30) and (2) a report
that symptoms improve with moving the neck (+LR = 2.23).

Physical Examination
Screening • Traditional neurologic screening (sensation, reflex, and manual muscle testing [MMT]) is of
moderate utility in identifying cervical radiculopathy. Sensation testing (pinprick at any location)
and MMT of the muscles in the lower arm and hand are unhelpful. Muscle stretch reflex (MSR)
and MMT of the muscles in the upper arm (especially the biceps brachii muscle) exhibit good
diagnostic utility and are recommended.
• A 2012 systematic review1 evaluating the accuracy of the Canadian C-Spine Rule (CCR) and the
NEXUS Low-Risk Criteria in screening for clinically important cervical spine injury in patients
following blunt trauma concluded that the CCR appears to have better diagnostic accuracy than
the NEXUS Criteria at ruling out clinically important cervical spine injuries that require diagnostic
imaging. We recommend use of the CCR because it has been consistently shown to have perfect
sensitivity (−LR = .00).

Range-of-Motion • Measuring the cervical range of motion is consistently reliable but is of unknown diagnostic utility.
and Manual • The results of studies assessing the reliability of passive intervertebral motion are highly variable,
Assessment but generally, the results show that this maneuver has poor reliability as an assessment for
limitations of movement and moderate reliability as an assessment for pain.
• Assessing for both pain and limited movement during manual assessment is highly sensitive for
zygapophyseal joint pain and is recommended to rule out zygapophyseal involvement (−LR = .00
to .23).

Special Tests • Multiple studies demonstrate the high diagnostic utility of Spurling’s test in identifying cervical
radiculopathy, cervical disc prolapse, and neck pain (+LR = 1.9 to 18.6).
• Using a combination of Spurling’s A test, the upper limb tension test A, a distraction test, and
assessment for cervical rotation of less than 60 degrees to the ipsilateral side is very good for
identifying cervical radiculopathy and is recommended (+LR = 30.3 if all four factors are present).
• Using a combination of gait deviation, the Hoffmann test, the inverted supinator sign, the Babinski
test, and age more than 45 years is very good at identifying cervical myelopathy and is
recommended (+LR = 30.9 if three of five factors are present).

Interventions • Factors associated with improvement from cervical thrust manipulation in patients with neck pain
include symptom duration of less than 38 days, a positive expectation that manipulation will help,
a side-to-side difference in cervical rotation range of motion of 10 degrees or greater, and pain
with posteroanterior spring testing of the middle cervical spine (+LR 13.5 if three or more of the
four factors are present).
• Patients with neck pain for less than 30 days have a high probability of rapid improvement if
treated with thoracic manipulation (+LR = 6.4). Other factors associated with improved thoracic
manipulation, especially in combination, are (1) no symptoms distal to the shoulder, (2) low
fear-avoidance behavior, (3) patient reports that looking up does not aggravate symptoms, (4) a
cervical extension range of motion of less than 30 degrees, and (5) decreased upper thoracic
spine kyphosis (+LR = 12 if any four of six factors are present).
• Because the risks of thoracic manipulation are minimal, we recommend such treatment be
considered a first-line intervention for patients with neck pain (and no contraindications).

70 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Osteology
Temporal fossa Temporal bone
Sphenoid bone

Zygomatic arch

Condylar process of mandible

Mandibular notch

Coronoid process of mandible


Lateral pterygoid plate
(broken line)

3 
Hamulus of medial pterygoid plate
(broken line)

Cervical Spine
Pterygomandibular raphe Mastoid process
(broken line)
External acoustic meatus
Ramus
Mandible Angle Atlas (C1)
Body Styloid process
Axis (C2)
Stylohyoid lig.
Stylomandibular lig.
Body C3 vertebra
Hyoid bone Lesser horn
Greater horn
Spine of sphenoid bone Epiglottis
Thyroid cartilage
Foramen spinosum
Cricoid cartilage
C7 vertebra
Foramen ovale Trachea
T1 vertebra

1st rib

Sphenopalatine foramen
Pterygopalatine fossa
Choanae (posterior nares)
Lateral plate
of pterygoid
Medial plate
process
Hamulus
Tuberosity of maxilla
Infratemporal Pyramidal process of palatine bone
fossa
Alveolar process
of maxilla
Figure 3-1
Bony framework of the head and neck.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 71


Anatomy  •  Osteology
Anterior Anterior articular
Tubercle for arch Anterior tubercle facet (for anterior
transverse arch of atlas)
lig. of atlas Articular facet Dens
for dens
Superior articular Pedicle
Transverse Lateral
process facet for atlas
mass

Vertebral Interarticular
Transverse foramen part
foramen
Posterior arch
Superior articular Transverse
surface of lateral Posterior tubercle Inferior articular Body process
mass for occipital Groove for vertebral a. facet for C3
condyle

Atlas (C1): superior view Axis (C2): anterior view

Posterior tubercle Dens


Inferior articular Posterior arch
surface of lateral Superior articular
Posterior articular
mass for axis facet for atlas
facet (for transverse
Transverse lig. of atlas)
Vertebral
process foramen
Interarticular
part Transverse
Articular facet process
Transverse for dens
foramen
Anterior Anterior Inferior Spinous process
arch tubercle articular process

Atlas (C1): inferior view Axis (C2): posterosuperior view

Anterior Transverse process


tubercle Body Body
Groove for
spinal n. Anterior tubercle

Posterior Transverse
tubercle foramen
Pedicle
Superior
articular facet Posterior
tubercle
Inferior articular process
Lamina
Vertebral foramen
Lamina
Spinous process

4th cervical vertebra:


superior view 7th cervical vertebra:
superior view

Figure 3-2
Cervical vertebrae.

72 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Arthrology
Posterior articular facet
(for transverse lig. of atlas) Dens
Superior articular
surface for occipital Atlas (C1)
condyle
Dens

Cervical curvature
C2
Intervertebral Axis (C2)
foramina
for spinal nn.

3 
Spinous processes C3
C3

Cervical Spine
C4
C4
Articular pillar
formed by articular
processes and Upper cervical
interarticular parts C5
vertebrae, assembled:
posterosuperior view
C6

Zygapophyseal joints
C7 Intervertebral joint
(symphysis)
(disc removed)
Costal facets (for 1st rib)
T1 Uncus (uncinate process)

2nd cervical to 1st thoracic vertebra: Interarticular part


C3
right lateral view
Zygapophyseal
joint
C4

C5 Intervertebral
foramen for
spinal n.

3rd, 4th and 5th cervical vertebrae:


anterior view
Figure 3-3
Joints of the cervical spine.

Joint Type and Classification Closed Packed Position Capsular Pattern


Atlantooccipital Synovial: plane Not reported Not reported

Atlantoodontoid/dens Synovial: trochoid Extension Not reported

Atlantoaxial Synovial: plane Extension Not reported


apophyseal joints

C3-C7 Apophyseal joints Synovial: plane Full extension Limitation in side-bending =


rotation = extension

C3-C7 Intervertebral Amphiarthrodial Not applicable Not applicable


joints

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 73


Anatomy  •  Ligaments
Clivus (surface feature)
of basilar part of occipital bone
Capsule of
atlantooccipital
joint

Tectorial membrane

Atlas (C1)
Capsule of lateral Deeper (accessory) part
atlantoaxial joint of tectorial membrane
Alar ligs.
Axis (C2)
Posterior
longitudinal lig.
Capsule of
zygapophyseal
joint (C2-C3)
Superior longitudinal band Atlas (C1)
Cruciate lig. Transverse lig. of atlas
Inferior longitudinal band
Upper part of vertebral canal with
spinous processes and parts of vertebral Axis (C2)
arches removed to expose ligaments on
posterior vertebral bodies: posterior view
Deeper (accessory) part
Apical lig. of dens of tectorial membrane

Principal part of tectorial membrane removed


Alar lig. to expose deeper ligaments: posterior view

Atlas (C1)
Posterior articular facet of dens
(for transverse lig. of atlas)
Dens
Anterior tubercle of atlas
Axis (C2)
Alar lig. Synovial cavities

Cruciate ligament removed to show


deepest ligaments: posterior view

Transverse lig.
of atlas
Median atlantoaxial joint: superior view

Figure 3-4
Ligaments of the atlantooccipital joint.

Ligaments Attachments Function


Alar Sides of dens to lateral aspects of foramen Limits ipsilateral head rotation and
magnum contralateral side-bending

Apical Dens to posterior aspect of foramen magnum Limits separation of dens from occiput

Tectorial membrane Body of C2 to occiput Limits forward flexion

Cruciform ligament (superior Transverse ligament to occiput


longitudinal)
Maintains contact between dens and
Cruciform ligament (transverse) Extends between lateral tubercles of C1 anterior arch of atlas

Cruciform ligament (inferior) Transverse ligament to body of C2

74 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Ligaments
Anterior view

Basilar part of occipital bone


Pharyngeal tubercle
Anterior atlantooccipital membrane
Capsule of atlantooccipital joint
Atlas (C1)
Posterior atlantooccipital membrane
Capsule of lateral
atlantoaxial joint Lateral atlantoaxial joint (opened up)

Axis (C2) Posterior atlantooccipital membrane


Posterior view
Anterior

3 
longitudinal lig. Skull
Capsule of

Cervical Spine
zygapophyseal
joint (C3-C4) Capsule of
atlantooccipital joint
Transverse process
of atlas (C1)
Posterior Capsule of
atlantooccipital atlantooccipital Capsule of lateral
Right lateral view membrane joint atlantoaxial joint
Vertebral a. Axis (C2)

Anterior Ligamenta flava


atlantooccipital
Suboccipital n. (dorsal
membrane
ramus of C1 spinal n.)
Atlas (C1)

Ligamenta flava Body of axis (C2)

Ligamentum nuchae Intervertebral discs (C2–C3 and C3–C4)

Zygapophyseal joints (C4–C5 and C5–C6)

Anterior tubercle of C6 vertebra (carotid tubercle)


Spinous process
of C7 vertebra Vertebral a.
(vertebra prominens)

T1 vertebra
Supraspinous lig.

Figure 3-5
Spinal ligaments.

Ligaments Attachments Function


Anterior longitudinal Extends from anterior sacrum to anterior tubercle of Maintains stability of vertebral body joints
C1. Connects anterolateral vertebral bodies and discs and prevents hyperextension of vertebral
column

Posterior longitudinal Extends from sacrum to C2. Runs within vertebral Prevents hyperflexion of vertebral column
canal attaching posterior vertebral bodies and posterior disc protrusion

Ligamentum nuchae An extension of supraspinous ligament (occipital Prevents cervical hyperflexion


protuberance to C7)

Ligamenta flava Attaches lamina above each vertebra to lamina below Prevents separation of vertebral lamina

Supraspinous Connects apices of spinous processes C7-S1 Limits separation of spinous processes

Interspinous Connects adjoining spinous processes C1-S1 Limits separation of spinous processes

Intertransverse Connects adjacent transverse processes of vertebrae Limits separation of transverse processes

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 75


Anatomy  •  Muscles
Anterior Muscles of the Neck
Digastric m. (anterior belly)
Masseter m.
Mylohyoid m.
Parotid gland Submandibular gland
Platysma m. Fibrous loop for
(cut away) intermediate
digastic tendon
Mastoid process Stylohyoid m.
Digastric m.
Hyoid bone (posterior belly)
Carotid sheath External carotid a.
Internal jugular v.
Fascia of infrahyoid Thyrohyoid m.
mm. and cut edge
Omohyoid m.
Thyroid cartilage
(superior belly)
Investing layer of (deep)
cervical fascia and cut edge Sternohyoid m.

Cricoid
Scalene mm.
cartilage
Trapezius m.

Deltoid m.

Clavicle
Omohyoid m.
Pretracheal layer (inferior belly)
of (deep) cervical fascia Pectoralis major m.
over thyroid gland Suprasternal Clavicular head Sternocleidomastoid m.
and trachea space Sternal head
Manubrium Jugular
of sternum notch Sternothyroid m.

Figure 3-6
Anterior muscles of the neck.

Proximal Nerve and


Muscle Attachment Distal Attachment Segmental Level Action
Sternocleidomastoid Lateral aspect of Sternal head: anterior Spinal root of Neck flexion, ipsilateral
mastoid process aspect of manubrium accessory nerve side-bending, and
and lateral superior Clavicular head: contralateral rotation
nuchal line superomedial aspect
of clavicle
Scalene (anterior) Transverse First rib C4, C5, C6 Elevates first rib, ipsilateral
processes of side-bending, and
vertebrae C4-C6 contralateral rotation
Scalene (middle) Superior aspect of Ventral rami of Elevates first rib, ipsilateral
first rib cervical spinal side-bending, contralateral
Transverse nerves rotation
processes of
Scalene (posterior) vertebrae C1-C4 External aspect of Ventral rami of Elevates second rib,
second rib cervical spinal ipsilateral side-bending,
nerves C3, C4 contralateral rotation
Platysma Inferior mandible Fascia of pectoralis Cervical branch of Draws skin of neck superiorly
major and deltoid facial nerve with clenched jaw, draws
corners of mouth inferiorly

76 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Muscles
Suprahyoid and Infrahyoid Muscles
Nerve and
Muscle Proximal Attachment Distal Attachment Segmental Level Action
Suprahyoids

Mylohyoid Mandibular mylohyoid line Hyoid bone Mylohyoid nerve Elevates hyoid bone, floor
of mouth, and tongue

Geniohyoid Mental spine of mandible Body of hyoid bone Hypoglossal nerve Elevates hyoid bone
anterosuperiorly, widens

3 
pharynx

Cervical Spine
Stylohyoid Styloid process of Body of hyoid bone Cervical branch of Elevates and retracts hyoid
temporal bone facial nerve bone

Digastric Anterior belly: digastric Greater horn of hyoid Anterior belly: Depresses mandible and
fossa of mandible bone mylohyoid nerve raises hyoid
Posterior belly: mastoid Posterior belly: facial
notch of temporal bone nerve

Infrahyoids

Sternohyoid Manubrium and medial Body of hyoid bone Branch of ansa Depresses hyoid bone after
clavicle cervicalis it has been elevated
(C1, C2, C3)

Omohyoid Superior border of scapula Inferior aspect of Branch of ansa Depresses and retracts
hyoid bone cervicalis hyoid bone
(C1, C2, C3)

Sternothyroid Posterior aspect of Thyroid cartilage Branch of ansa Depresses hyoid bone and
manubrium cervicalis larynx
(C2, C3)

Thyrohyoid Thyroid cartilage Body and greater Hypoglossal nerve Depresses hyoid bone,
horn of hyoid bone (C1) elevates larynx

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 77


Anatomy  •  Muscles
Suprahyoid and Infrahyoid Muscles (continued)
Hyoid bone Digastric m. (anterior belly)

Thyrohyoid membrane Mylohyoid m.

External carotid a. Hyoglossus m.

Stylohyoid m.
Internal jugular v.
Digastric m.
Thyrohyoid m.
(posterior belly)
Thyroid cartilage Fibrous loop for intermediate
digastric tendon
Omohyoid m. Sternohyoid and omohyoid
(superior belly) mm. (cut)
Sternohyoid m.
Thyrohyoid m.
Median
cricothyroid lig. Oblique line of
thyroid cartilage
Cricoid cartilage
Cricothyroid m.
Scalene mm. Sternothyroid m.
Omohyoid m.
Trapezius m.
(superior
belly) (cut)

Thyroid gland
Omohyoid m. Sternohyoid m. (cut)
(inferior belly)
Clavicle
Trachea

Styloid process
Mastoid process

Stylohyoid muscle
Mylohyoid muscle
Digastric muscle (posterior belly)

Digastric muscle (anterior belly)


Thyrohyoid muscle

Geniohyoid muscle Oblique line of thyroid cartilage

Sternohyoid muscle

Omohyoid muscle Omohyoid muscle (inferior belly)


(superior belly)

Sternothyroid
muscle
Infrahyoid and
suprahyoid muscles and Sternum Scapula
their action: schema

Figure 3-7
Suprahyoid and infrahyoid muscles.

78 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Muscles
Scalene and Prevertebral Muscles

Basilar part of
occipital bone Longus capitis m. (cut)
Jugular process of
occipital bone Occipital condyle
Rectus capitis
anterior m.
Mastoid process Rectus capitis
lateralis m.
Styloid process

3 
Transverse process of atlas (C1)
Longus capitis m.

Cervical Spine
Anterior Tubercles of transverse
Posterior tubercle of Posterior process of C3 vertebra
transverse process
of axis (C2)
Slips of origin of anterior
Longus colli m. scalene m. (cut)

Slips of origin of
Anterior
Scalene posterior scalene m.
Middle
mm. Middle
Posterior Scalene mm.
Posterior
Posterior tubercle of
Phrenic n. transverse process
of C7 vertebra
Brachial plexus Anterior scalene
m. (cut)

1st rib

Subclavian a. Internal
jugular v. Common
Subclavian v.
carotid a.
Figure 3-8
Scalene and prevertebral muscles.

Proximal Nerve and


Muscle Attachment Distal Attachment Segmental Level Action
Longus capitis Basilar aspect of Anterior tubercles of Ventral rami of Flexes head on neck
occipital bone transverse processes C1-C3 spinal nerves
C3-C6

Longus colli Anterior tubercle of C1, Bodies of C3-T3 and Ventral rami of Neck flexion, ipsilateral
bodies of C1-C3, and transverse processes of C2-C6 spinal nerves side-bending, and rotation
transverse processes C3-C5
of C3-C6

Rectus capitis Base of skull anterior Anterior aspect of lateral Flexes head on neck
anterior to occipital condyle mass of C1 Branches from loop
between C1 and C2
Rectus capitis Jugular process of Transverse process of C1 spinal nerves Flexes head and assists in
lateralis occipital bone stabilizing head on neck

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 79


Anatomy  •  Muscles
Posterior Muscles of the Neck
Proximal Nerve and
Muscle Attachment Distal Attachment Segmental Level Action
Upper trapezius Superior nuchal line, Lateral clavicle, Spinal root of Elevates scapula
occipital protuberance, acromion, and spine accessory nerve
nuchal ligament, of scapula
spinous processes
C7-T12

Levator scapulae Transverse processes Superomedial border Dorsal scapular nerve Elevates scapula and
of C1-C4 of scapula (C3, C4, C5) inferiorly rotates
glenoid fossa

Semispinalis capitis Cervical and thoracic Superior spinous Dorsal rami of spinal Bilaterally: extends
and cervicis spinous processes processes and nerves neck
occipital bone Unilaterally: ipsilateral
side-bending

Splenius capitis and Spinous processes Mastoid process and Dorsal rami of middle Bilaterally: head and
cervicis T1-T6 and ligamentum lateral superior nuchal cervical spinal nerves neck extension
nuchae line Unilaterally: ipsilateral
rotation

Longissimus capitis Superior thoracic Mastoid process of Dorsal rami of Head extension,
and cervicis transverse processes temporal bone and cervical spinal nerves ipsilateral side-
and cervical transverse cervical transverse bending, and rotation
processes processes of head and neck

Spinalis cervicis Lower cervical spinous Upper cervical spinous Dorsal rami of spinal Bilaterally: extends
processes of vertebrae processes of nerves neck
vertebrae Unilaterally: ipsilateral
side-bending of neck

Suboccipital Muscles

Rectus capitis Spinous process of C2 Lateral inferior nuchal Suboccipital nerve Head extension and
posterior major line of occipital bone (C1) ipsilateral rotation

Rectus capitis Posterior arch of C1 Medial inferior nuchal Suboccipital nerve Head extension and
posterior minor line (C1) ipsilateral rotation

Obliquus capitis Transverse process of Occipital bone Suboccipital nerve Head extension and
superior C1 (C1) side-bending

Obliquus capitis Spinous process of C2 Transverse process of Suboccipital nerve Ipsilateral neck
inferior C1 (C1) rotation

80 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Muscles
Posterior Muscles of the Neck (continued)
Rectus capitis posterior minor m.

Rectus capitis posterior major m.


Epicranial aponeurosis
(galea aponeurotica) Semispinalis capitis m.
(cut and reflected)
Occipital belly (occipitalis) of
Vertebral a.
occipitofrontalis m.
(atlantic part)
Obliquus capitis
Greater occipital n. superior m.
(dorsal ramus of C2

3 
spinal n.) Suboccipital n.
(dorsal ramus of C1

Cervical Spine
Occipital a. spinal n.)

3rd (least) occipital n. Posterior arch of


(dorsal ramus of C3 atlas (C1 vertebra)
spinal n.)
Occipital a.

Semispinalis capitis and Obliquus capitis


splenius capitis mm. in inferior m.
posterior triangle of neck Greater occipital
n. (dorsal ramus
of C2 spinal n.)
Posterior auricular a.
Splenius capitis m.
(cut and reflected)

3rd (least) occipital n.


Great auricular n. (dorsal ramus of C3
(cervical plexus C2, C3) spinal n.)

Lesser occipital n. Longissimus capitis m.


(cervical plexus C2, C3)
Splenius cervicis m.

Sternocleidomastoid m. Semispinalis cervicis m.

Trapezius m. Semispinalis capitis m. (cut)


Posterior cutaneous branches of Splenius capitis m. (cut)
dorsal rami of C4-C6 spinal nn.

Figure 3-9
Posterior muscles of the neck.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 81


Anatomy  •  Nerves

Segmental
Nerves Levels Sensory Motor
Dorsal scapular C4, C5 No sensory Rhomboids, levator scapulae

Suprascapular C4, C5, C6 No sensory Supraspinatus, infraspinatus

Nerve to subclavius C5, C6 No sensory Subclavius

Lateral pectoral C5, C6, C7 No sensory Pectoralis major

Medial pectoral C8, T1 No sensory Pectoralis major


Pectoralis minor

Long thoracic C5, C6, C7 No sensory Serratus anterior

Medial cutaneous of arm C8, T1 Medial aspect of arm No motor

Medial cutaneous of C8, T1 Medial aspect of forearm No motor


forearm

Upper subscapular C5, C6 No sensory Subscapularis

Lower subscapular C5, C6, C7 No sensory Subscapularis, teres major

Thoracodorsal C6, C7, C8 No sensory Latissimus dorsi

Axillary C5, C6 Lateral shoulder Deltoid, teres minor

Radial C5, C6, C7, C8, T1 Dorsal lateral aspect of hand, Triceps brachii, brachioradialis,
including the thumb and up anconeus, extensor carpi radialis
to the base of digits 2 and 3 longus, extensor carpi radialis brevis

Median C5, C6, C7, C8, T1 Palmar aspect of lateral Pronator teres, flexor carpi radialis,
hand, including lateral half of palmaris longus, flexor digitorum
digit 4, dorsal distal half of superficialis, flexor pollicis longus,
digits 1-3, and lateral border flexor digitorum profundus (lateral half),
of digit 4 pronator quadratus, lumbricals to digits
2 and 3, thenar muscles

Ulnar C8, T1 Medial border of both palmar Flexor carpi ulnaris, flexor digitorum
and dorsal hand, including profundus (medial half), palmar
medial half of digit 4 interossei, adductor pollicis, palmaris
brevis, dorsal interossei, lumbricals to
digits 4 and 5, hypothenar muscles

Musculocutaneous C5, C6, C7 Lateral forearm Coracobrachialis, biceps brachii,


brachialis

82 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Nerves
ts
Note: Usual composition shown. 5 roorami of Contribution
Prefixed plexus has large C4 t r a l )
(venpinal nn. from C4
contribution but lacks T1. s
Postfixed plexus lacks C5 but s Dorsal scapular
unk Dorsal
has T2 contribution 3 tr n. (C5) ramus
To
ns Suprascapular phrenic n.
sio ns
d ivi isio n. (C5, C6) C5
r iv
rio r d To subclavius
a nte terio m. (C5, C6)
3 pos
3 C6

s e rior
rd Sup

3 
co C7
3
Lateral pectoral dle

Cervical Spine
n. (C5, C6, C7) Mid C8
al
in s
r m che
Te ran
b al or T1
er eri
La
t Inf
Musculocutaneous
or
n. (C5, C6, C7) teri Contribution
Pos from T2
To longus colli
Axillary 1st rib and scalene mm.
n. (C5, C6)
l (C5, C6, C7, C8)
dia
Radial n. Me 1st intercostal n.
(C5, C6, C7, C8, T1)
Long thoracic
Median n. Medial pectoral n. (C8, T1) n. (C5, C6, C7)
(C5, C6, C7, C8, T1) Medial cutaneous n. of arm (T1)
Medial cutaneous n. of forearm (C8, T1)
Ulnar n.
(C7, C8, T1) Upper subscapular n. (C5, C6)
Thoracodorsal (middle subscapular) n. (C6, C7, C8)
Inconstant contribution Lower subscapular n. (C5, C6)

Figure 3-10
Nerves of the neck.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 83


Patient History  •  Initial Hypotheses Based on Patient History

History Initial Hypotheses


Patient reports diffuse nonspecific neck pain that is exacerbated by neck Mechanical neck pain2
movements Cervical facet syndrome3
Cervical muscle strain or sprain

Patient reports pain in certain postures that is alleviated by positional Upper crossed postural syndrome
changes

Traumatic mechanism of injury with complaint of nonspecific cervical Cervical instability, especially if patient reports
symptoms that are exacerbated in the vertical positions and relieved with dysesthesias of the face occurring with neck
the head supported in the supine position movement

Reports of nonspecific neck pain with numbness and tingling into one Cervical radiculopathy
upper extremity

Reports of neck pain with bilateral upper extremity symptoms with Cervical myelopathy
occasional reports of loss of balance or lack of coordination of the lower
extremities

Cervical Zygapophyseal Pain Syndromes

C2/3

C3/4
C4/5
C5/6
C6/7

Figure 3-11
Pain referral patterns. Distribution of zygapophyseal pain referral patterns as described by Dwyer and colleagues.4 (Dwyer A, Aprill C,
Bogduk N. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine. 1990;15:453-457.)

84 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Patient History  •  Cervical Zygapophyseal Pain Syndromes
C1-2: 14%
C2-3: 81%
C3-4: 5%

C1-2: 2%
C2-3: 92%
C1-2: 17% C3-4: 6%
C2-3: 76%
C3-4: 8% C1-2: 5%
C2-3: 92%

3 
C3-4: 3%

Cervical Spine
C2-3: 89%
C3-4: 11%

C5-6: 100%

C4-5: 7%
C5-6: 73%
C6-7: 46%

C4-5: 1%
C5-6: 77%
C6-7: 22%
C5-6: 54%
C6-7: 46%

C5-6: 35% C5-6: 87%


C6-7: 65% C6-7: 13%

Figure 3-12
Pain referral patterns. Probability of zygapophyseal joints at the segments indicated being the source of pain, as described by Cooper
and colleagues.5 (Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med. 2007;8:344-353.)

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 85


Patient History  •  Reliability of the Cervical Spine Historical Examination

Historical Question and Interexaminer


Study Quality Possible Responses Population Reliability
Mode of onset6 ◆ Gradual, sudden, or κ = .72 (.47, .96)
traumatic

Nature of neck symptoms6 ◆ Constant or intermittent κ = .81 (.56, 1.0)

Prior episode of neck pain6 ◆ Yes or No κ = .90 (.70, 1.0)

Turning the head aggravates Yes or No 22 patients with (Right) κ = −.04 (2.11, .02)*
symptoms6 ◆ mechanical neck pain (Left) κ = 1.0 (1.0, 1.0)

Looking up and down aggravates Yes or No (Down) κ = .79 (.51, 1.0)


symptoms6 ◆ (Up) κ = .80 (.55, 1.0)

Driving aggravates symptoms6 ◆ Yes or No κ = −.06 (−.39, .26)*

Sleeping aggravates symptoms6 ◆ Yes or No κ = .90 (.72, 1.0)

Which of the following symptoms • Pain κ = .74 (.55, .93)


are most bothersome for you?7 ◆ • Numbness and tingling
• Loss of feeling

Where are your symptoms most • Neck κ = .83 (.68, .96)


bothersome?7 ◆ • Shoulder or shoulder
blade
• Arm above elbow
• Arm below elbow
• Hands and/or fingers 50 patients with
suspected cervical
Which of the following best • Constant radiculopathy or carpal κ = .57 (.35, .79)
describes the behavior of your • Intermittent tunnel syndrome
symptoms?7 ◆ • Variable

Does your entire affected limb Yes or No κ = .53 (.26, .81)


and/or hand feel numb?7 ◆

Do your symptoms keep you from Yes or No κ = .70 (.48, .92)


falling asleep?7 ◆

Do your symptoms improve with Yes or No κ = .67 (.44, .90)


moving your neck?7 ◆
*Question had a high percentage of agreement but a low κ because 95% of participants answered “yes.”

86 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Patient History  •  Diagnostic Utility of Patient Complaints for Cervical Radiculopathy

3 
Cervical Spine
Herniated disc
compressing
n. root and
associated neck
and arm symptoms

Figure 3-13
Cervical radiculopathy.

Complaint and Description and Reference


Study Quality Positive Findings Population Standard Sens Spec +LR −LR
Weakness8 ◆ .65 .39 1.07 .90

Numbness8 ◆ .79 .25 1.05 .84


183 patients
Arm pain8 ◆ Cervical .65 .26 .88 1.35
Not specifically referred to
radiculopathy via
Neck pain8 ◆ described electrodiagnostic .62 .35 .95 1.09
electrodiagnostics
laboratories
Tingling8 ◆ .72 .25 .96 1.92

Burning8 ◆ .33 .63 .89 1.06

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 87


Patient History  •  Diagnostic Utility of Patient Complaints for Cervical Radiculopathy

Complaint Description
and Study and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR*
Which of the Pain .47 .52 .99 1.02
following (.23, .71) (.41, .65) (.56, 1.7)
symptoms
are most Numbness .47 .56 1.1 .95
bothersome and tingling (.23, .71) (.42, .68) (.6, 1.9)
for you?7 ◆
Loss of feeling .06 .92 .74 1.02
(.00, .17) (.85, .99) (.09, 5.9)

Where are Neck .19 .90 1.9 .90


your (.00, .35) (.83, .98) (.54, 6.9)
82 consecutive
symptoms
Shoulder or patients referred to .38 .84 2.3 .74
most Cervical
scapula electrophysiologic (.19, .73) (.75, .93) (1.0, 5.4)
bothersome?7 radiculopathy via
laboratory with
◆ needle
Arm above suspected .03 .93 .41 1.04
electromyography
elbow diagnosis of (.14, .61) (.86, .99) (.02, 7.3)
and nerve
cervical
Arm below conduction .06 .84 .39 1.12
radiculopathy or
elbow studies (.00, .11) (.75, .93) (.05, 2.8)
carpal tunnel
syndrome
Hands and/or .38 .48 .73 1.29
fingers (.14, .48) (.36, .61) (.37, 1.4)

Which of the Constant .12 .84 .74 1.05


following best (.00, .27) (.75, .93) (.18, 3.1)
describes the
behavior of Intermittent .35 .62 .93 1.05
your (.13, .58) (.50, .74) (.45, 1.9)
symptoms?7
Variable .53 .54 1.2 .87
◆ (.29, .77) (.42, .66) (.68, 1.9)

Does your .24 .73 .87 1.04


entire (.03, .44) (.62, .84) (.34, 2.3)
affected limb
and/or hand
feel numb?7

Do your .47 .60 1.19 .88


symptoms (.23, .71) (.48, .72) (.66, 2.1)
Yes or No
keep you
from falling
asleep?7 ◆

Do your .65 .71 2.23 .49


symptoms (.42, .87) (.60, .82) (1.3, 3.8)
improve with
moving your
neck?7 ◆
*−LR in this table has been calculated by the authors.

88 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Neurologic Examination
Reliability of Sensation Testing

3 
Cervical Spine
C2
C3
C6
Anterior view C4
C5

T1
C6 C5
C7
T1
C8

C8

C2

C3

C4
C5
C6 Posterior view
C7 C6
C8
T1 C7
C8

Figure 3-14
Dermatomes of the upper limb.

Description and
Test and Study Quality Positive Findings Population Reliability
Identifying sensory deficits No details given 8924 adult patients who presented to Interexaminer κ = .60
in extremities9 ◆ emergency department after blunt trauma
to head/neck and had Glasgow Coma Score
of 15

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 89


Physical Examination Tests  •  Neurologic Examination
Diagnostic Utility of Pinprick Sensation Testing for Cervical Radiculopathy
Test and Description
Study and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
C5 .29 .86 2.1 .82
Dermatome7 (.08, .51) (.77, .94) (.79, 5.3) (.60, 1.1)

C6 82 consecutive .24 .66 .69 1.16


Dermatome7 patients (.03, .44) (.54, .78) (.28, 1.8) (.84, 1.6)
◆ referred to Cervical
Pinprick
electrophysiologic radiculopathy via
sensation
C7 laboratory with needle .18 .77 .76 1.07
testing.
Dermatome7 suspected electromyography (.00, .36) (.66, .87) (.25, 2.3) (.83, 1.4)
Graded as
◆ diagnosis of and nerve
“normal” or
cervical conduction
C8 “abnormal” .12 .81 .61 1.09
radiculopathy or studies
Dermatome7 carpal tunnel (.00, .27) (.71, .90) (.15, 2.5) (.88, 1.4)
◆ syndrome
T1 .18 .79 .83 1.05
Dermatome7 (.00, .36) (.68, .89) (.27, 2.6) (.81, 1.4)

Decreased Not 183 patients Cervical .49 .64 1.36 .80


sensation to specifically referred to radiculopathy via
pinprick8 ◆ described electrodiagnostic electrodiagnostics
laboratories

90 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Neurologic Examination
Reliability of Manual Muscle Testing

Level Motor signs (weakness)

3 
Deltoid

Cervical Spine
C5

Biceps brachii
C6

Triceps brachii
C7

Interossei

C8

Figure 3-15
Manual muscle testing of the upper limb.

Description and
Test and Study Quality Positive Findings Population Reliability
Identifying motor deficits No details given 8924 adult patients who presented to Interexaminer κ = .93
in the extremities9 ◆ emergency department after blunt trauma
to head/neck and had Glasgow Coma Score
of 15

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 91


Physical Examination Tests  •  Neurologic Examination
Diagnostic Utility of Manual Muscle Testing for Cervical Radiculopathy
Test and Description
Study and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
MMT .24 .89 2.1 .86
deltoid7 ◆ (.03, .44) (.81, .97) (.70, 6.4) (.65, 1.1)

MMT biceps .24 .94 3.7 .82


brachii7 ◆ (.03, .44) (.88, 1.0) (1.0, (.62, 1.1)
13.3)

MMT .12 .90 1.2 .98


extensor (.00, .27) (.83, .98) (.27, 5.6) (.81, 1.2)
carpi 82 consecutive
radialis Standard patients
longus/ strength referred to Cervical
brevis7 ◆ testing using electrophysiologic radiculopathy
methods of laboratory with via needle
MMT triceps .12 .94 1.9 .94
Kendall and suspected electromyography
brachii7 ◆ (.00, .27) (.88, 1.0) (.37, 9.3) (.78, 1.1)
McCreary. diagnosis of and nerve
MMT flexor Graded as cervical conduction .06 .89 .55 1.05
carpi “normal” or radiculopathy or studies (.00, .17) (.82, .97) (.07, 4.2) (.91, 1.2)
radialis7 ◆ “abnormal” carpal tunnel
syndrome
MMT .06 .84 .37 1.12
abductor (.00, .17) (.75, .93) (.05, 2.7) (.95, 1.3)
pollicis
brevis7 ◆

MMT first .03 .93 .40 1.05


dorsal (.00, .10) (.87, .99) (.02, 7.0) (.94, 1.2)
interosseus7

92 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Neurologic Examination
Diagnostic Utility of Muscle Stretch Reflex Testing for Cervical Radiculopathy

Biceps brachii

3 
Weak

Cervical Spine
or
absent
reflex
Triceps brachii

Weak or
absent reflex

Figure 3-16
Reflex testing.

Description
Test and and
Study Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Biceps brachii 82 consecutive .24 .95 4.9 .80
MSR7 ◆ Tested patients (.3, .44) (.90, 1.0) (1.2, (.61, 1.1)
bilaterally referred to Cervical 20.0)
using electrophysiologic radiculopathy
Brachioradialis standard laboratory with via needle .06 .95 1.2 .99
MSR7 ◆ reflex suspected electromyography (.00, .17) (.90, 1.9) (.14, (.87, 1.1)
hammer. diagnosis of and nerve 11.1)
Graded as cervical conduction
Triceps MSR7 .03 .93 .40 1.05
“normal” or radiculopathy or studies
◆ (.00, .10) (.87, .99) (.02, 7.0) (.94, 1.2)
“abnormal” carpal tunnel
syndrome

Biceps8 ◆ .10 .99 10.0 .91


183 patients
Not Cervical
Triceps8 ◆ referred to .10 .95 2.0 .95
specifically radiculopathy via
electrodiagnostic
Brachioradialis8 described electrodiagnostics .08 .99 8.0 .93
laboratories

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 93


Physical Examination Tests  •  Screening for Cervical Spine Injury

Type III. Fracture through entire vertebral body


with fragmentation of its anterior portion.
Posterior cortex intact but projects into spinal X-ray film: Type III fracture of C5
canal causing damage to cord and/or nerve roots

Type IV. “Burst” fracture. Entire vertebral


body crushed, with intraspinal bone fragments
X-ray film: Type IV fracture of C6

Dislocated bone
fragments
compressing spinal
cord and anterior
spinal artery. Blood
supply to anterior
two thirds of spinal
cord is impaired

Figure 3-17
Compression fracture of the cervical spine.

NEXUS Low-Risk Criteria10


1. No posterior midline cervical spine tenderness

2. No evidence of intoxication
Cervical spine radiography is indicated for patients with trauma unless
3. Normal level of alertness
they meet all of the following criteria:
4. No focal neurologic deficit

5. No painful distracting injuries

94 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Screening for Cervical Spine Injury
Diagnostic Utility of the Clinical Examination for Identifying Cervical Spine Injury
Test and
Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
NEXUS 34,069 patients who Clinically .99 .13 1.14 .08
Low-Risk presented to important cervical (.98, 1.0) (.13, .13)
Criteria11 ◆ emergency spine injury
department after demonstrated by
blunt trauma and radiography,

3 
had cervical spine computed
radiography tomography (CT),

Cervical Spine
or magnetic
See Figure 3-18 resonance
imaging (MRI)

NEXUS 320 elderly patients Clinically .66 .60 1.65 .57


Low-Risk (65 years or older) important cervical
Criteria12 ◆ who presented to spine injury
emergency demonstrated by
department after CT
blunt trauma

NEXUS 8924 alert adult .93 .38 1.50 .18


Low-Risk patients who (.87, .96) (.37, .39)
Criteria13 ◆ presented to
emergency
department after
See Figure 3-18 blunt trauma to Clinically
head/neck important cervical
spine injury
NEXUS 7438 alert adult defined as any .91 .37 1.44 .24
Low-Risk patients who fracture, (.85, .94) (.36, .38)
Criteria10 ◆ presented to dislocation, or
emergency ligamentous
Canadian department after instability .99 .45 1.80 .02
C-Spine blunt trauma to demonstrated by (.96, 1.0) (.44, .46)
Rule10 ◆ head/neck radiography, CT,
and/or a
Canadian 8924 alert adult telephone 1.0 .43 1.75 .00
C-Spine See Figure 3-18 patients who follow-up (.98, 1.0) (.40, .44)
Rule9 ◆ presented to
emergency
Canadian department after 1.0 .44 1.79 .00
C-Spine blunt trauma to (.94, 1.0) (.43, .45)
Rule14 ● head/neck

Physician Physicians were asked 6265 alert adult Clinically .92 .54 2.00 .15
judgment14 to estimate the patients who important cervical (.82, .96) (.53, .55)
● probability that the presented to spine injury
patient would have a emergency demonstrated by
clinically important department after radiography, CT,
cervical spine injury by trauma to head/neck and/or a
circling one of the telephone
following: 0%, 1%, follow-up
2%, 3%, 4%, 5%,
10%, 20%, 30%, 40%,
50%, 75%, or 100%

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 95


Physical Examination Tests  •  Screening for Cervical Spine Injury
Diagnostic Utility of the Clinical Examination for Identifying Cervical Spine Injury (continued)
Test and Description and Positive Reference
Study Quality Findings Population Standard Sens Spec +LR −LR
Patient history, including .77 .55 1.70 .42
mechanism of injury and
subjective complaints of neck
pain and/or neurologic deficits,
followed by physical
examination of tenderness to 534 patients
palpation, abnormalities to consulting a level Cervical
Clinical
palpation, and neurologic I trauma center fracture
examination15 ●
deficits after blunt trauma via CT
to head/neck
Among subset of patients with .67 .62 1.76 .54
a Glasgow Coma Score of 15
(i.e., alert), who were not
intoxicated, and who did not
have a distracting injury

1. Any high-risk factor that mandates


radiography? Yes
a. Age ≥65 years
b. Dangerous mechanisma

No

2. Any low-risk factor that allows safe


assessment of range of motion?
a. Simple rear-end motor vehicle collisionb No Radiography
b. Sitting position in emergency department
c. Paresthesias in extremities
d. Ambulatory at any time

Yes

3. Able to actively rotate neck 45° left


and right? Unable

Yes

No radiography

a
A dangerous mechanism is considered to be a fall from an elevation of 3 feet or greater or three to five stairs; an axial load to the
head (e.g., diving); a motor vehicle collision at high speed (>100 km/hr) or with rollover or ejection.
b
A simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a roll-
over, or being hit by a high-speed vehicle.

Figure 3-18
Canadian C-Spine Rule. (See Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk
criteria in patients with trauma. N Engl J Med. 2003;349:2510-2518.)

96 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Range-of-Motion Measurements

3 
Cervical Spine
Positioning of inclinometer to measure Measurement of flexion
flexion and extension

Measurement of extension Positioning of inclinometer


to measure side bending

Measurement of side-
bending to the right

Figure 3-19
Range of motion.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 97


Physical Examination Tests  •  Range-of-Motion Measurements
Reliability of Measuring Range of Motion
Test and Study Quality Instrumentation Population Interexaminer Reliability
Extension16 ◆ ICC = .86 (.73, .93)

Flexion ◆16
ICC = .78 (.59, .89)

Rotation in flexion16 ◆ (Right) ICC = .78 (.60, .89)


30 patients with (Left) ICC = .89 (.78, .95)
Inclinometer
neck pain
Lateral bending ◆ 16
(Right) ICC = .87 (.75, .94)
(Left) ICC = .85 (.70, .92)

Rotation16 ◆ (Right) ICC = .86 (.74, .93)


(Left) ICC = .91 (.82, .96)

Flexion6 ◆ ICC = .75 (.50, .89)

Extension6 ◆ ICC = .74 (.48, .88)


Inclinometer 22 patients with
Side-bending ◆ 6
mechanical neck (Right) ICC = .66 (.33, .84)
pain (Left) ICC = .69 (.40, .86)

Rotation6 ◆ Goniometer (Right) ICC = .78 (.55, .90)


(Left) ICC = .77 (.52, .90)

Flexion-extension17 ◆ Single measurement ICC = .89 (.77, .94)


Mean of 2 measurements ICC = .95 (.90, .98)
32 patients with
Lateral flexion17 ◆ Single measurement ICC = .77 (.58, .88)
Digital inclinometer neck pain referred
Mean of 2 measurements ICC = .89 (.77, .94)
to physical therapy
Rotation17 ◆ Single measurement ICC = .88 (.78, .94)
Mean of 2 measurements ICC = .95 (.90, .98)

Flexion7 ◆ ICC = .79 (.65, .88)


Inclinometer
Extension7 ◆ ICC = .84 (.70, .95)
50 patients with
Left rotation7 ◆ suspected cervical ICC = .75 (.59, .85)
Goniometer radiculopathy or
Right rotation7 ◆ carpal tunnel ICC = .63 (.22, .82)
syndrome
Left side-bending7 ◆ ICC = .63 (.40, .78)
Inclinometer
Right side-bending7 ◆ ICC = .68 (.62, .87)
ICC, intraclass correlation coefficient.

98 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Range-of-Motion Measurements
Reliability of Measuring Range of Motion (continued)
Interexaminer
Test and Study Quality Instrumentation Population Reliability
Flexion18 ● ICC = .58
18
Extension ● ICC = .97

Right side-bending18 ● ICC = .96

Left side-bending18 ● Cervical range-of-motion ICC = .94

3 
60 patients with neck pain
Right rotation18 ● (CROM) instrument ICC = .96

Cervical Spine
Left rotation18 ● ICC = .98
18
Protraction ● ICC = .49

Retraction18 ● ICC = .35

Flexion-extension19 ● Inclinometer ICC = .84


CROM ICC = .88

Side-bending19 ● Inclinometer ICC = .82


Inclinometer and CROM 30 asymptomatic subjects
CROM ICC = .84

Rotation19 ● Inclinometer ICC = .81


CROM ICC = .92

Flexion20 ● CROM ICC = .86


Goniometer ICC = .57
Visual estimation ICC = .42

Extension20 ● CROM ICC = .86


Goniometer ICC = .79
Visual estimation ICC = .42

Left side-bending20 ● CROM ICC = .73


60 patients in whom the Goniometer ICC = .79
CROM, universal Visual estimation ICC = .63
assessment of CROM testing
goniometer, and visual
Right side-bending20 ● would be appropriate during CROM ICC = .73
estimation
the physical therapy evaluation Goniometer ICC = .79
Visual estimation ICC = .63

Left rotation20 ● CROM ICC = .82


Goniometer ICC = .54
Visual estimation ICC = .70

Right rotation20 ● CROM ICC = .92


Goniometer ICC = .62
Visual estimation ICC = .82

Identifying ability to actively 8924 adult patients who κ = .67


rotate neck 45 degrees left presented to emergency
and right9 ◆ No details given department after blunt trauma
Identifying ability to actively to head/neck and had Glasgow κ = .63
flex neck9 ◆ Coma Score of 15

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 99


Physical Examination Tests  •  Range-of-Motion Measurements
Reliability of Pain Responses during Active Physiologic Range of Motion
Test and Study Interexaminer
Quality Description and Positive Findings Population Reliability
Extension16 ◆ κ = .65 (.54, .76)
16
Flexion ◆ κ = .87 (.81, .94)
Symptom response recorded as “no
Rotation in flexion16 ◆ (Right) κ = .25 (.12, .39)
effect,” “increases symptoms,”
30 patients with neck (Left) κ = .69 (.59, .78)
“decreases symptoms,” “centralizes
pain
Lateral bending16 ◆ symptoms,” or “peripheralizes (Right) κ = .75 (.66, .84)
symptoms” (Left) κ = .28 (.15, .41)

Rotation16 ◆ (Right) κ = .76 (.67, .84)


(Left) κ = .74 (.64, .84)

Flexion6 ◆ κ = .55 (.23, .87)

Extension6 ◆ Patient asked about change in κ = .23 (.09, .37)


symptoms during active range of
Side-bending ◆ 6 22 patients with (Right) κ = .81 (.57, 1.0)
motion (AROM). Answers were “no
mechanical neck pain (Left) κ = .00 (−.22, .23)
change,” “increased pain,” or
“decreased pain”
Rotation6 ◆ (Right) κ = .40 (−.07, .87)
(Left) κ = .73 (.46, 1.0)

Flexion6 ◆ κ = 1.0 (1.0, 1.0)


The effect of each movement on
Extension6 ◆ centralization (the movement caused κ = .44 (.17, .71)
the pain and/or paresthesias to move
Side-bending6 ◆ 22 patients with (Right) κ = −.06 (−.15, .03)
proximally) or peripheralization of
mechanical neck pain (Left) κ = .02 (−.25, .66)
symptoms (the movement caused the
pain and/or paresthesias to move more
Rotation6 ◆ distally) was recorded (Right) κ = −.05 (−.15, .03)
(Left) κ = −.10 (−.21, .00)

Flexion21 ◆ κ = .63

Extension21 ◆ Patient seated with back supported. κ = .71


Patient is asked to perform full flexion,
Rotation, right21 ◆ and pressure is applied by examiner. κ = .70
21
Rotation, left ◆ Pain responses are recorded on an κ = .66
11-point numeric pain rating scale 32 patients with neck
Side-bending, right21 ◆ (NPRS) pain κ = .65

Side-bending, left21 ◆ κ = .45

Flexion C0-C121 ◆ Patient is asked to perform high κ = .36


cervical flexion/extension by nodding.
Extension C0-C121 ◆ Pain responses are recorded on an κ = .56
11-point NPRS

Flexion22 ● κ = .53 (.17, .89)

Extension22 ● Patient performs AROM, and pain is κ = .67 (.34, .99)


24 patients with
determined to be either present or not
Rotation, right ● 22 headaches κ = .65 (.31, .99)
present
Rotation, left22 ● κ = .46 (.10, .79)

100 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Range-of-Motion Measurements
Diagnostic Utility of Pain Responses during Active Physiologic Range of Motion

3 
Cervical Spine
Testing flexion with overpressure

Testing side-bending with overpressure

Figure 3-20
Overpressure testing.

Test and Test Procedure and


Measure Determination of Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
Active flexion Active flexion and extension 75 males (22 with Patient reports .27 .90 2.70 .81
and extension performed to the extremes of neck pain) of neck pain
of the neck23 ● the range. Positive if subject
reported pain with procedure

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 101


Physical Examination Tests  •  Cervical Strength and Endurance
Reliability of Cervical Strength and Endurance Testing

Figure 3-21
Cervical flexor endurance.

Test and
Study Quality Description and Positive Findings Population Reliability
Neck flexor With patient supine with knees flexed, examiner’s 21 patients with Interexaminer ICC = .93
muscle hand is placed behind occiput and the subject postural neck pain (.86, .97)
endurance gently flexes the upper neck and lifts the head off
test24 ◆ the examiner’s hand while retaining the upper
neck flexion. The test was timed and terminated
when the subject was unable to maintain the
position of the head off the examiner’s hand

Chin tuck neck With patient supine, subject tucks the chin and 22 patients with Interexaminer ICC = .57
flexion test6 ◆ lifts the head approximately 1 inch. The test was mechanical neck (.14, .81)
timed with a stopwatch and terminated when the pain
patient’s position deviated

Cervical flexor With patient supine, knees flexed, and chin 27 asymptomatic Intraexaminer ICC = 0.74
endurance25 ● maximally retracted, subject lifts the head slightly. subjects (.50, .87)
The test was timed with a stopwatch and Interexaminer
terminated when the subject lost maximal Test #1 ICC = .54 (.31, .73)
retraction, flexed the neck, or could not continue Test #2 ICC = .66 (.46, .81)

Cervical flexor With patient supine with knees flexed and chin 20 asymptomatic Intraexaminer ICC = .82−.91
endurance26 ● maximally retracted, subject lifts the head subjects Interexaminer ICC = .67−.78
approximately 1 inch. The test was timed with a
stopwatch and terminated when the subject lost 20 patients with Interexaminer ICC = .67
maximal retraction neck pain

Craniocervical With patient supine with a pressure biofeedback 10 asymptomatic Intraexaminer κ = .72
flexion test27 ● unit placed suboccipitally, subject performs a subjects
gentle head-nodding action of craniocervical
flexion for five 10-second incremental stages of
increasing range (22, 24, 26, 28, and 30 mm Hg).
Performance was measured by the highest level of
pressure the individual could hold for 10 seconds

Cervical flexor With patient supine with knees flexed, subject 30 patients with Interexaminer ICC = .96
endurance28 ● holds the tongue on the roof of the mouth and grade II whiplash-
breathes normally. Subject then lifts his or her associated
head off the table and holds it as long as possible disorders
with the neck in a neutral position. The test was
timed with a stopwatch and terminated when the
head moved more than 5 degrees either forward
or backward

102 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Passive Intervertebral Motion
Reliability of Assessing Limited Passive Intervertebral Motion

3 
Cervical Spine
Testing rotation of C1-C2

Testing of stiffness of 1st rib

Figure 3-22
Assessing limited passive intervertebral motion.

Test and Interexaminer


Study Quality Description and Positive Findings Population Reliability
Rotation of With patient seated, C2 is stabilized while C1 is rotated on κ = .28
C1-C229 ◆ C2 until the end of passive range of motion. Positive if
decreased rotation is seen on one side compared with the
contralateral side

Lateral flexion With patient supine, examiner’s left hand stabilizes the κ = .43
of C2-C329 ◆ patient’s head while the right hand performs side-bending
flexion of C2-C3 until the end of passive range of motion.
This is repeated in the contralateral direction. Positive if
lateral flexion on one side is reduced compared with 61 patients with
contralateral side nonspecific neck
problems
Flexion and With patient side-lying, examiner stabilizes the patient’s κ = .36
extension29 ◆ neck with one hand while palpating the movement at
C7-T1 with the other. Positive if flexion and extension are
“stiff” compared with the vertebrae superior and inferior

First rib29 ◆ With patient supine, the cervical spine is rotated toward κ = .35
the side being tested. The first rib is pressed in a ventral
and caudal direction. Positive if the rib is more “stiff” than
the contralateral side

Identification of With subject sitting, examiner palpates passive physiologic Three asymptomatic κ = .68
hypomobile intervertebral motion at each cervical vertebra in rotation patients with
segment30 ◆ and lateral flexion and determines the most hypomobile single-level congenital
segment fusions in the cervical
spine (two at C2-C3
and one at C5-C6)

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 103


Physical Examination Tests  •  Passive Intervertebral Motion
Reliability of Assessing Limited and Painful Passive Intervertebral Motion
Interexaminer Reliability
Test and Limited Movements Pain
Study Description and Positive
Quality Findings Population Right Left Right Left
C0-C16 ◆ With patient supine, examiner κ = −.26 κ = .46 κ = −.52 κ = .08
cradles the occiput with both hands (−.57, .07) (.06, .86) (−.09, −.14) (−.37, .54)
and rotates the head 30 degrees
toward the side to be tested; an
anterior-to-posterior glide is
performed to assess the amount of
available motion compared with the
contralateral side 22 patients
with
C1-C26 ◆ With patient supine, examiner mechanical κ = .72 κ = .74 κ = .15 κ = −.16
passively and maximally flexes the neck pain (.43, .91) (.40, 1.0) (−.05, .36) (−.56, .22)
neck and then performs passive
cervical rotation to one side and
then to the other. The amount of
motion to each side is compared,
and if one side is determined to
have less motion, it is considered to
be “hypomobile”

C0-C121 ◆ With patient supine, passive flexion κ = .29 Not ICC = .73 Not
is performed. Motion is classified as reported reported
“limited” or “not limited” and
patient pain response is assessed
on 11-point numeric pain rating
(NPR) scale

C1-C221 ◆ With patient supine, rotation is κ = .20 κ = .37 ICC = .56 ICC = .35
performed and classified as
“limited” or “not limited.” Patient
pain response is assessed on
11-point NPR scale 32 patients
with neck
C2-C321 ◆ pain κ = .34 κ = .63 ICC = .50 ICC = .78
21
C3-C4 ◆ κ = .20 κ = .26 ICC = .62 ICC = .75
With patient supine, fixation of lower
C4-C521 ◆ segment with side-bending to the κ = .16 κ = −.09 ICC = .62 ICC = .55
right and left. Motion classified as
C5-C621 ◆ κ = .17 κ = .09 ICC = .66 ICC = .65
“limited” or “not limited” and
C6-C721 ◆ patient pain response assessed on κ = .34 κ = .03 ICC = .59 ICC = .22
11-point NPR scale
C7-T121 ◆ κ = .08 κ = .14 ICC = .45 ICC = .34

T1-T221 ◆ κ = .33 κ = .46 ICC = .80 ICC = .54

104 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Passive Intervertebral Motion
Reliability of Assessing Limited and Painful Passive Intervertebral Motion

3 
Cervical Spine
Testing side-bending of C5-C6

Figure 3-23
Assessing limited and painful passive intervertebral motion.

Interexaminer Reliability
Test and Study Description and Positive Limited
Quality Findings Population Movements Pain
C26 ◆ κ = .01 (−.35, .38) κ = .13 (−.04, .31)

C36 ◆ Posterior-to-anterior spring κ = .10 (−.25, .44) κ = .13 (−.21, .47)


testing centrally over the
C46 ◆ spinous process of the 22 patients with κ = .10 (−.22, .40) κ = .27 (−.12, .67)
vertebrae. Mobility judged as mechanical neck
C56 ◆ “normal,” “hypomobile,” or pain κ = .10 (−.15, .35) κ = .12 (−.09, .42)
“hypermobile” and as
C66 ◆ “painful” or “not painful” κ = .01 (−.21, .24) κ = .55 (.22, .88)

C76 ◆ κ = .54 (0.2, .88) κ = .90 (.72, 1.0)

C0-C1 lateral glide16 ◆ κ = .81 (.72, .91) κ =32 (.15, .49)

C0-C1 lateral bend16 ◆ κ = .35 (.08, .62) κ = .35 (.15, .55)

C1-C2 rotation in full κ = .21 (.08, .34) κ = .36 (.24, .49)


flexion16 ◆
Mobility was recorded as
C1-C2 full lateral “normal” or “hypomobile” κ = .30 (.17, .43) κ = .61 (.50, .72)
flexion16 ◆ when compared with the 30 patients with
contralateral side. Pain neck pain
C2 lateral glide16 ◆ κ = .46 (.33, .59) κ = .42 (.28, .56)
reproduction recorded as
C3 lateral glide16 ◆ “pain” or “no pain” κ = .25 (.12, .38) κ = .29 (.16, .43)

C4 lateral glide16 ◆ κ = .27 (.13, .40) κ = .65 (.54, .76)

C5 lateral glide16 ◆ κ = .18 (.03, .33) κ = .55 (.43, .67)

C6 lateral glide16 ◆ κ = −.07 (−.34, .20) κ = .76 (.64, .87)

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 105


Physical Examination Tests  •  Passive Intervertebral Motion
Reliability of Assessing Passive Mobility in the Upper Cervical Spine for Detecting Ligament
and Membrane Injuries
Test and Study Quality Description and Positive Findings Population Reliability
Alar ligament, right31 ● Passive stretching of the ligament or 92 subjects with Interexaminer
membrane by the examiner with the patient chronic whiplash- κ = .71 (.58, .83)
sitting in a chair is compared with MRI associated
Alar ligament, left31 ● findings. Positive for examination if disorder and 30 κ = .69 (.57, .82)
subjectively rated to have moderate or healthy individuals
Transverse ligament31 ● κ = .69 (.55, .83)
extensively increased motion by examiner.
Tectorial membrane31 ● Positive for MRI when more than one third of κ = .93 (.83, 1.03)
structure showed increased signal intensity
Atlantooccipital membrane31 ● κ = .97 (.92, 1.03)

Diagnostic Utility of Assessing Passive Mobility in the Upper Cervical Spine for Detecting
Ligament and Membrane Injuries
Test and
Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
Alar ligament, Passive stretching of .69 1.00 Undefined .31
right31 ◆ the ligament or (.56, .81) (1.00, 1.00)
membrane by
Alar ligament, examiner with the .72 .96 18 .29
left31 ◆ patient sitting in a (.60, .84) (.91, 1.00)
chair is compared
Transverse 92 subjects .65 .99 65 .35
with MRI findings.
ligament31 ◆ with chronic (.51, .79) (.96, 1.01)
Positive for
whiplash-
Tectorial examination if .94 .99 94 .06
associated MRI
membrane31 ◆ subjectively rated to (.82, 1.06) (.97, 1.01)
disorder and
have moderate or
30 healthy
Atlantooccipital extensively increased .96 1.00 Undefined .04
individuals
membrane31 ◆ motion by examiner. (.87, 1.04) (1.00, 1.00)
Positive for MRI when
more than one third
of structure showed
increased signal
intensity

106 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Passive Intervertebral Motion
Diagnostic Utility of Assessing Limited and Painful Passive Intervertebral Motion

3 
Cervical Spine
Figure 3-24
Posteroanterior central glides to the mid cervical spine Assessing limited and painful passive intervertebral motion.

Test and
Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
Manual Subjective 173 patients Level of .89 .47 1.7 .23
examination32 examination, followed with cervical zygapophyseal (.82, .96) (.37, .57) (1.2, 2.5)
◆ by central posterior- pain pain via
to-anterior glides, radiologically
Manual followed by passive 20 patients controlled 1.0 1.0 Undefined .00
examination33 physiologic with cervical diagnostic (.81, 1.0)* (.51, 1.0)*
◆ intervertebral pain nerve block
movements of flexion,
extension, side-
bending, and rotation.
Joint dysfunction is
diagnosed if the
examiner concludes
that the joint
demonstrates an
abnormal end feel
and abnormal quality
of resistance to
motion and there is
reproduction of pain

Identification With subject sitting, Three Level of .98 .74 3.77 .03
of hypomobile examiner palpates asymptomatic congenital
segment30 ● passive physiologic patients with cervical fusion
intervertebral motion single-level
at each cervical congenital
vertebra in rotation fusions in
and lateral flexion and cervical spine
determines the most (two at C2-C3
hypomobile segment and one at
C5-C6)
*Confidence intervals were not originally reported by Jull and colleagues33 but were later calculated and presented by King and colleagues.32

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 107


Physical Examination Tests  •  Palpation
Reliability of Assessing Pain with Palpation
Description and Interexaminer
Test and Study Quality Positive Findings Population Reliability
Upper cervical spinous process34 ● κ = .47

Lower cervical spinous process ● 34


κ = .52
Patient supine. Graded
Right side of neck34 ● as “no tenderness,” κ = .24
52 patients referred for
“moderate
Suprascapular area34 ● cervical myelography (Right) κ = .42
tenderness,” or
“marked tenderness” (Left) κ = .44

Scapular area34 ● (Right) κ = .34


(Left) κ = .56

Zygapophyseal joint High cervical Method of κ = .14 (−.12, .39)


pressure22 ● classification for high,
Middle cervical κ = .37 (.12, .85)
middle, and low not
Low cervical described κ = .31 (.28, .90)
22
Occiput ● No details (Right) κ = .00 (−1.00, .77)
(Left) κ = .16 (−.31, .61)

Mastoid process22 ● κ = .77 (.34, 1.00)

Sternocleidomastoid Insertion Sternocleidomastoid (Right) κ = .68 (.29, 1.00)


muscle22 ● insertion on occiput 24 patients with (Left) κ = .35 (−.17, .86)
(minor occipital nerve) headaches

Anterior Just anterior to (Right) κ = .35 (−.17, .86)


sternocleidomastoid (Left) κ = .55 (.10, .99)
muscle border

Middle At sternocleidomastoid (Right) κ = .52 (.12, .92)


muscle border (Left) κ = .42 (.01, .82)

Posterior Just posterior to (Right) κ = .60 (.19, 1.00)


sternocleidomastoid (Left) κ = .87 (.62, 1.00)
muscle border

Midline neck tenderness9 ◆ No details given 8924 adult patients who κ = .78
presented to emergency
Posterolateral neck tenderness9 ◆ department after blunt κ = .32
trauma to head/neck
Maximal tenderness at midline9 ◆ κ = .72
and had Glasgow Coma
Score of 15

108 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Palpation
Reliability of Assessing Pain with Palpation with and without a Patient History
Interexaminer Reliability
Test and Study Description and Without Knowledge With Knowledge
Quality Positive Findings Population of History of History
Spinous processes κ = .60 κ = .49
C2-C335 ◆

Spinous processes κ = .42 κ = .50


C4-C735 ◆

3 
Spinous processes κ = .55 κ = .79

Cervical Spine
T1-T335 ◆

Paraspinal joints 100 patients with κ = .32 κ = .22


C1-C335 ◆ neck and/or
No details given shoulder problems
Paraspinal joints with or without κ = .34 κ = .55
C4-C735 ◆ radiating pain

Paraspinal joints κ = .41 κ = .51


T1-T335 ◆

Neck muscles35 ◆ κ = .32 κ = .46

Brachial plexus35 ◆ κ = .27 κ = .22

Paraspinal muscles35 ◆ κ = −.04 κ = .46

Reliability of Assessing Pain with Palpation in Patients with Cervicogenic Headache


Interexaminer
Test and Study Quality Description and Positive Findings Population Reliability
Articular pillars C0-C136 ◆ κ = .64 (.40, .88)
Patient prone with neck in neutral 60 patients with
Articular pillars C1-C236 ◆ position. Examiner applies progressive cervicogenic headache κ = .71 (.51, .91)
unilateral posteroanterior pressure over based on criteria developed
Articular pillars C2-C336 ◆ articular pillars. Positive if patient’s by International Headache κ = .70 (.52, .88)
headache symptoms are reproduced Society
Articular pillars C3-C436 ◆ κ = .61 (.37, .85)

Diagnostic Utility of Assessing Pain with Palpation


Test and Test Procedure and
Measure Determination of Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
Palpation over Articulations were palpated 75 males (22 Patient .82 .79 3.90 .23
the facet joints 2 cm lateral to the spinous with neck pain) reports of
in the cervical process. Positive if patient neck pain
spine23 ● reported pain with procedure

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 109


Physical Examination Tests  •  Postural and Muscle Length Assessment
Reliability of Postural Assessment

Unlike postural defect, kyphosis of Scheuermann’s


disease persists when patient is prone and thoracic
spine extended or hyperextended (above) and
accentuated when patient bends forward (below)

In adolescent, exaggerated thoracic


kyphosis and compensatory lumbar
lordosis due to Scheuermann’s disease
may be mistaken for postural defect

Figure 3-25
Thoracic kyphosis.

Interexaminer
Test and Study Quality Description and Positive Findings Population Reliability
Forward head6 ◆ Answered “yes” if the patient’s external κ = −.10 (−.20, −.00)
auditory meatus was anteriorly deviated
(anterior to the lumbar spine)

Excessive shoulder Answered “yes” if the patient’s acromions κ = .83 (.51, 1.0)
protraction6 ◆ were anteriorly deviated (anterior to the
lumbar spine)
22 patients with
C7-T2 excessive kyphosis6 ◆ mechanical κ = .79 (.51, 1.0)
Recorded as “normal” (no deviation), neck pain
T3-5 excessive kyphosis6 ◆ “excessive kyphosis,” or “diminished κ = .69 (.30, 1.0)
kyphosis.” Excessive kyphosis was defined
T3-5 decreased kyphosis6 ◆ as an increase in the convexity, and κ = .58 (.22, .95)
diminished kyphosis was defined as a
T6-10 excessive kyphosis6 ◆ flattening of the convexity of the thoracic κ = .90 (.74, 1.0)
spine (at each segmental group)
T6-10 decreased kyphosis6 ◆ κ = .90 (.73, 1.0)

110 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Postural and Muscle Length Assessment
Reliability of Muscle Length Assessment

3 
Cervical Spine
Figure 3-26
Muscle length assessment.

Description and Positive Interexaminer


Test and Study Quality Findings Population Reliability
Latissimus dorsi6 ◆ (Right) κ = .80 (.53, 1.0)
(Left) κ = .69 (.30, 1.0)

Pectoralis minor6 ◆ (Right) κ = .81 (.57, 1.0)


(Left) κ = .71 (.43, 1.0)

Pectoralis major6 ◆ (Right) κ = .90 (.72, 1.0)


(Left) κ = .50 (.01, 1.0)

Levator scapulae6 ◆ Each muscle was recorded as 22 patients with (Right) κ = .61 (.26, .95)
“normal” or “restricted length” mechanical neck pain (Left) κ = .54 (.19, .90)

Upper trapezius6 ◆ (Right) κ = .79 (.52, 1.0)


(Left) κ = .63 (.31, .96)

Anterior and middle scalenes6 ◆ (Right) κ = .81 (.57, 1.0)


(Left) κ = .62 (.29, .96)

Suboccipitals6 ◆ (Right) κ = .63 (.26, 1.0)


(Left) κ = .58 (.15, 1.0)

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 111


Physical Examination Tests  •  Spurling’s and Neck Compression Tests
Reliability of Spurling’s and Neck Compression Tests

Figure 3-27
Cervical compression test.

Description and Positive Interexaminer


Test and Study Quality Findings Population Reliability
Straight compression35 ◆ Patient seated with examiner 100 patients with κ = .34 without knowledge
standing behind patient. Examiner neck and/or of patient history
exerts pressure on head. Positive if shoulder problems κ = .44 with knowledge of
pain is provoked with or without patient history
radiating pain

Right shoulder/ (Right) κ = .61


arm pain Cervical compression performed (Left) Not available
with patient sitting. Examiner
Left shoulder/ passively rotates and side-bends 52 patients (Right) Not available
Neck arm pain (Left) κ = .40
the head to the right and/or left. A referred for
compression
Right forearm/ compression force of 7 kg is cervical (Right) κ = .77
with34: ●
hand pain applied. Presence and location of myelography (Left) κ = .54
pain, paresthesias, or numbness are
Left forearm/ recorded (Right) Not available
hand pain (Left) κ = .62

Spurling’s A7 ◆ Patient seated with neck side-bent κ = .60 (.32, .87)


toward ipsilateral side; 7 kg of 50 patients with
overpressure is applied suspected cervical
radiculopathy or
Spurling’s B7 ◆ Patient seated with extension and carpal tunnel κ = .62 (.25, .99)
side-bending/rotation to ipsilateral syndrome
side; 7 kg of overpressure is applied

Spurling’s to the right35 ◆ Cervical compression performed κ = .37 without knowledge


with patient seated. Examiner of patient history
100 patients with κ = .28 with knowledge of
passively rotates and side-bends
neck and/or patient history
head to right or left and applies
shoulder problems
Spurling’s to the left35 ◆ compression force of 7 kg. κ = .37 without knowledge
with or without
Presence and location of pain, of patient history
radiating pain
paresthesias, or numbness are κ = .46 with knowledge of
recorded patient history

112 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Spurling’s and Neck Compression Tests
Diagnostic Utility of Spurling’s Test

3 
Cervical Spine
Spurling’s A test Spurling’s B test

Figure 3-28
Spurling’s test.

Test and
Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Spurling’s Patient is seated, the neck is 82 consecutive Cervical .50 .86 3.5 .58
A7 ◆ side-bent toward the patients referred to radiculopathy via (.27, (.77, (1.6, (.36,
ipsilateral side, and 7 kg of electrophysiologic needle .73) .94) 7.5) .94)
overpressure is applied (see laboratory with electromyography
Fig. 3-28). Positive if suspected and nerve
symptoms are reproduced diagnosis of conduction
cervical studies
Spurling’s Patient seated. Extension and radiculopathy or .50 .74 1.9 .67
B7 ◆ side-bending/rotation to the carpal tunnel (.27, (.63, (1.0, (.42,
ipsilateral side and then 7 kg syndrome .73) .85) 3.6) 1.1)
of overpressure is applied (see
Fig. 3-28). Positive if
symptoms are reproduced
Continued

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 113


Physical Examination Tests  •  Spurling’s and Neck Compression Tests
Diagnostic Utility of Spurling’s Test (continued)
Test and
Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Spurling’s The patient’s neck is extended 257 patients who Cervical .95 .94 15.8 .05
test37 ◆ and rotated for the suspected had symptoms of radiculopathy via
(see Video involved side prior to axial unilateral cervical CT scanning
3-1) compression. Positive with radiculopathy
radicular pain that radiates lasting for at least
into the upper extremity 4 weeks

Spurling’s The patient’s neck is extended 50 patients Soft lateral .93 .95 18.6 .07
test38◆ and laterally flexed toward the presenting to cervical disc (.84, (.86,
involved side, and downward neurosurgery with prolapse via MRI 1.0) 1.0)
axial pressure is applied on neck and arm pain
the head. Positive if radicular suggestive of
pain or tingling in the upper radicular pain
limb is reproduced or
aggravated

Spurling’s Patient side-bends and 255 consecutive Cervical .30 .93 4.29 .75
test39 ● extends the neck, and patients referred to radiculopathy via
examiner applies compression. physiatrist for electrodiagnostic
Positive if pain or tingling that upper extremity testing
starts in the shoulder radiates nerve disorders
distally to the elbow

Spurling’s Extension of the neck with 75 males (22 with Patient reports of .77 .92 9.63 .25
test23 ● rotation and side-bending to neck pain) neck pain
the same side. Positive if
subject reports pain with
procedure

114 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Neck Distraction and Traction Tests
Reliability of Neck Distraction and Traction Tests

3 
Cervical Spine
Neck distraction test

Traction test
Figure 3-29
Neck distraction and traction tests.

Test and Study Description and Positive


Quality Findings Population Interexaminer Reliability
Axial manual With patient supine, examiner 52 patients referred for κ = .50
traction34 ● applies axial distraction force of cervical myelography
10-15 kg. Positive if radicular
symptoms decrease

Neck distraction With patient supine, examiner 50 patients with κ = .88 (.64, 1.0)
test7 ◆ grasps patient under chin and suspected cervical
occiput while slightly flexing radiculopathy or carpal
patient’s neck while applying tunnel syndrome
distraction force of 14 pounds.
Positive if symptoms are reduced

Traction35 ◆ With patient seated, examiner 100 patients with neck κ = .56 without knowledge of history
stands behind patient with hands and/or shoulder κ = .41 with knowledge of history
underneath each maxilla and problems with or
thumbs on the back of the head. without radiating pain
Positive if symptoms are reduced
during traction

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 115


Physical Examination Tests  •  Cervical Flexion-Rotation Test
Reliability of Cervical Flexion-Rotation Test
Test and Study Interexaminer
Quality Description and Positive Findings Population Reliability
Cervical flexion-rotation With patient supine and the cervical spine 15 subjects with cervicogenic κ = .50
test40 ● passively maximally flexed, the examiner headache evaluated on
passively rotates head left and right. headache-free days and 10
Positive if subject reports onset of pain or if asymptomatic subjects
examiner encounters firm resistance at an
estimated range of motion that is reduced
by more than 10 degrees from normal of
44 degrees

116 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Shoulder Abduction Test

3 
Cervical Spine
Figure 3-30
Shoulder abduction test.

Reliability of Shoulder Abduction Test


Interexaminer
Test and Study Quality Description and Positive Findings Population Reliability
Shoulder abduction test7 ◆ Patient is seated and asked to place the 50 patients with suspected κ = .20 (.00, .59)
symptomatic extremity on head. Positive cervical radiculopathy or
if symptoms are reduced carpal tunnel syndrome

Shoulder abduction test34 ● Patient is seated and asked to raise the 52 patients referred for (Right) κ = .21
symptomatic extremity above the head. cervical myelography (Left) κ = .40
Positive if symptoms are reduced

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 117


Physical Examination Tests  •  Neural Tension Tests
Reliability of Neural Tension Tests
Test and Study Interexaminer
Quality Description and Positive Findings Population Reliability
Upper limb With patient supine, examiner performs the κ = .76 (.51, 1.0)
tension test A7 ◆ following movements:
1. Scapular depression
2. Shoulder abduction
3. Forearm supination
4. Wrist and finger extension
5. Shoulder lateral rotation
6. Elbow extension
7. Contralateral/ipsilateral cervical side-bending
Positive response defined by any of the following:
1. Patient symptoms reproduced
2. Side-to-side differences in elbow extension of
more than 10 degrees
3. Contralateral cervical side-bending increases
50 patients with
symptoms or ipsilateral side-bending
suspected cervical
decreases symptoms
radiculopathy or
Upper limb With patient supine and shoulder abducted 30 carpal tunnel κ = .83 (.65, 1.0)
tension test B7 ◆ degrees, examiner performs the following syndrome
movements:
1. Scapular depression
2. Shoulder medial rotation
3. Full elbow extension
4. Wrist and finger flexion
5. Contralateral/ipsilateral cervical side-bending
Positive response defined by any of the following:
1. Patient symptoms reproduced
2. Side-to-side differences in wrist flexion of
more than 10 degrees
3. Contralateral cervical side-bending increases
symptoms or ipsilateral side-bending
decreases symptoms

Brachial plexus With patient supine, examiner abducts the 52 patients referred (Right) κ = .35
test34 ● humerus to the limit of pain-free motion and then for cervical Left was not calculated
adds lateral rotation of the arm and elbow flexion. myelography because prevalence of
If no limitation of motion is noted, the humerus is positive findings was
abducted to 90 degrees. The appearance of less than 10%
symptoms is recorded

118 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Neural Tension Tests
Reliability of Neural Tension Tests

3 
Cervical Spine
Test A

Test B
Figure 3-31
Upper limb tension tests.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 119


Physical Examination Tests  •  Neural Tension Tests
Diagnostic Utility of Neural Tension Tests for Cervical Radiculopathy
Test and
Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Upper With patient supine, examiner .97 .22 1.3 .12
limb performs the following (.90, (.12, (1.1, (.01,
tension movements: 1.0) .33) 1.5) 1.9)
test A7 ● 1. Scapular depression
2. Shoulder abduction
3. Forearm supination
4. Wrist and finger extension
5. Shoulder lateral rotation
6. Elbow extension
7. Contralateral and ipsilateral
cervical side-bending
Positive response defined by any
of the following:
1. Patient symptoms reproduced
2. Side-to-side differences in
elbow extension of more than
10 degrees 82 consecutive
3. Contralateral cervical patients referred
side-bending increases to Cervical
symptoms or ipsilateral electrophysiologic radiculopathy
side-bending decreases laboratory with via needle
symptoms suspected electromyography
diagnosis of and nerve
Upper With patient supine and patient’s cervical conduction .72 .33 1.1 .85,
limb shoulder abducted 30 degrees, radiculopathy or studies (.52, (.21, (.77, (.37,
tension examiner performs the following carpal tunnel .93) .45) 1.5) 1.9)
test B7 ● movements: syndrome
1. Scapular depression
2. Shoulder medial rotation
3. Full elbow extension
4. Wrist and finger flexion
5. Contralateral and ipsilateral
cervical side-bending
Positive response defined by any
of the following:
1. Patient symptoms reproduced
2. Side-to-side differences in
wrist flexion of more than 10
degrees
3. Contralateral cervical side-
bending increases symptoms
or ipsilateral side-bending
decreases symptoms

Upper With patient seated and arm in 75 males (22 with Patient reports of .77 .94 12.83 .25
limb extension, abduction and external neck pain) neck pain
tension rotation of the glenohumeral joint,
test23 ● extension of the elbow, the
forearm in supination, and the
wrist and fingers in extension.
Contralateral flexion of the neck is
added. Positive if patient reported
pain with procedure

120 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Sharp-Purser Test
Diagnostic Utility of the Sharp-Purser Test for Cervical Instability

3 
Cervical Spine
Figure 3-32
Sharp-Purser test.

Test and
Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
Sharp-Purser Patient sits with neck in a 123 consecutive Full flexion and .69 .96 17.25 .32
test41 ● (see semiflexed position. outpatients with extension lateral
Video 3-2) Examiner places palm of rheumatoid arthritis radiographs.
one hand on patient’s Atlantodens
forehead and index finger interval greater
of the other hand on the than 3 mm was
spinous process of axis. considered
When posterior pressure is abnormal
applied through the
forehead, a sliding motion
of the head posteriorly in
relation to axis indicates a
positive test for atlantoaxial
instability

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 121


Physical Examination Tests  •  Arm Squeeze Test
Reliability of the Arm Squeeze Test in Distinguishing Cervical Nerve Root Compression from
Shoulder Pain

Figure 3-33
Arm squeeze test.

Test and Study Quality Description and Positive Findings Population Reliability
42
Arm squeeze test ● Examiner squeezes the middle third of the 305 patients with cervical Intraexaminer
(see Video 3-3) patient’s upper arm with thumb on nerve root compression, κ = .87 (.85, .89)
patient’s triceps and fingers on patient’s 903 patients with rotator Interexaminer
biceps with moderate compression (5.9 to cuff tear, and 350 healthy κ = .81 (.79, .82)
8.1 kg). Positive if patient reports 3 points volunteers
or higher on visual analog scale (VAS)
with pressure on middle third of upper
arm compared with acromioclavicular
joint and subacromial area

Diagnostic Utility of the Arm Squeeze Test in Distinguishing Cervical Nerve Root Compression
from Shoulder Pain
Test and
Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
Arm Examiner squeezes the 305 patients with Diagnosis of .96 .96 24 .04
squeeze middle third of the cervical nerve cervical nerve (.85, .99) (.86, .98)
test42 ◆ patient’s upper arm with root compression, root compression
thumb on patient’s 903 patients with (C5-T1) based on
triceps and fingers on rotator cuff tear, clinical
patient’s biceps with and 350 healthy examination,
moderate compression volunteers electromyography,
(5.9 to 8.1 kg). Positive x-rays, and MRI
if patient reports 3
points or higher on
VAS with pressure on
middle third of upper
arm compared with
acromioclavicular joint
and subacromial area

122 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Compression of Brachial Plexus
Diagnostic Utility of Brachial Plexus Compression for Cervical Cord Compression

Spinal cord

3 
Cervical Spine
C5
C6

Demonstration of herniated nucleus pulposus


at C3-4 interspace with compression of
spinal canal

Compression
by nucleus
pulposus Sagittal
herniation view
Central cord compression
by herniated nucleus pulposus

Nucleus
C6 Anterior pulposus
Superior view spinal
artery

Lateral spinothalamic Upper limb


tract Trunk
(pain and temperature) Lower limb
Lateral corticospinal Upper limb
tract Trunk
Lower limb
Posterolateral
spinal artery
Posterior columns
(position sense)

Figure 3-34
Cervical disc herniation causing cord compression.

Test and Description and Positive Reference


Study Quality Findings Population Standard Sens Spec +LR −LR
Compression Firm compression and squeezing 65 patients who Cervical cord .69 .83 4.06 .37
of brachial of the brachial plexus with the had undergone compression
plexus43 ● thumb. Positive only when pain MRI of cervical via MRI
radiates to the shoulder or upper spine as result
extremity of radiating pain

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 123


Physical Examination Tests  •  Cervical Myelopathy Tests
Reliability of Tests for Cervical Myelopathy
Test and Study Interexaminer
Quality Description and Positive Findings Population Reliability
Hoffmann sign44 ◆ With the patient standing or sitting, the clinician stabilizes κ = .76 (.56, .96)
the proximal interphalangeal joint of the middle finger
and applies a stimulus to the middle finger by “flicking”
the fingernail between his thumb and index finger into a
flexed position. Positive with adduction of the thumb and
flexion of the fingers

Deep tendon reflex In biceps tendon testing, the patient assumes a sitting κ = .73 (.50, .95)
test44 ◆ position while the clinician places the patient’s slightly
supinated forearm on the clinician’s own forearm,
ensuring relaxation. The clinician’s thumb is placed on
the patient’s biceps tendon, and the clinician strikes his
own thumb with quick strikes of a reflex hammer. In
triceps tendon testing, the sitting patient’s elbow is
flexed passively via shoulder elevation to approximately
90 degrees. The clinician then places his thumb over the
distal aspect of the triceps tendon and applies a series of
quick strikes of the reflex hammer to his own thumb.
Positive with hyperreflexia

Inverted supinator With the patient in a seated position, the clinician places κ = .52 (.26, .78)
sign44 ◆ the patient’s slightly pronated forearm on his forearm to
ensure relaxation. The clinician applies a series of quick
strikes near the styloid process of the radius at the
attachment of the brachioradialis tendon. The test is 51 patients with
performed in the same manner as a brachioradialis cervical pain as
tendon reflex test. Positive with finger flexion or slight primary complaint
elbow extension

Suprapatellar With the patient sitting with his or her feet off the κ = .68 (.46, .89)
quadriceps test44 ◆ ground, the clinician applies quick strikes of the reflex
hammer to the suprapatellar tendon. Positive with
hyperreflexive knee extension

Hand withdrawal With the patient sitting or standing, the clinician grasps κ = .55 (.34, .82)
reflex44 ◆ the patient’s palm and strikes the dorsum of the patient’s
hand with a reflex hammer. Positive with abnormal flexor
response

Babinski sign44 ◆ With the patient supine, the clinician supports the κ = .56 (.24, .89)
patient’s foot in neutral and applies stimulation to the
plantar aspect of the foot (typically from lateral to medial
from heel to metatarsal) with the blunt end of a reflex
hammer. Positive with great toe extension and fanning of
the second through fifth toes

Clonus44 ◆ With the patient sitting with his or her feet off the κ = .66 (.03, .99)
ground, the clinician applies a quick stretch to the
Achilles tendon via rapid passive dorsiflexion of the
ankle. Positive when ankle “beats” in and out of
dorsiflexion for at least three beats

124 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Cervical Myelopathy Tests
Diagnostic Utility of Tests for Cervical Myelopathy
Test and
Study Reference
Quality Description and Positive Findings Population Standard Sens Spec +LR −LR
Hoffmann With the patient standing or sitting, the .44 .75 1.8 .70
sign44 ◆ clinician stabilizes the proximal (.28, (.63, (.80, (.50,
interphalangeal joint of the middle .58) .86) 4.1) 1.1)
finger and applies a stimulus to the
middle finger by “flicking” the fingernail

3 
between his thumb and index finger
into a flexed position. Positive with

Cervical Spine
adduction of the thumb and flexion of
the fingers

Deep tendon In biceps tendon testing, clinician .44 .71 1.5 .80
reflex test44 places the patient’s slightly supinated (.28, (.59, (.70, (.50,
◆ forearm on his own forearm, ensuring .59) .82) 3.4) 1.2)
relaxation. The clinician’s thumb is
placed on the patient’s biceps tendon,
and the clinician strikes his own thumb
with quick strikes of a reflex hammer.
In triceps tendon testing, the patient’s
elbow is flexed passively via shoulder
elevation to approximately 90 degrees. 51 patients
The clinician then places his thumb with cervical Cervical
over the distal aspect of the triceps pain as myelopathy
tendon and applies a series of quick primary via MRI
strikes of the reflex hammer to his own complaint
thumb. Positive with hyperreflexia

Inverted With the patient in a seated position, .61 .78 2.8 .50
supinator the clinician places the patient’s slightly (.44, (.65, (1.2, (.30,
sign44 ◆ pronated forearm on his forearm to .74) .88) 6.4) .90)
ensure relaxation. The clinician applies
a series of quick strikes near the styloid
process of the radius at the attachment
of the brachioradialis tendon. The test
is performed in the same manner as a
brachioradialis tendon reflex test.
Positive with finger flexion or slight
elbow extension

Suprapatellar With the patient sitting with his or her .56 .33 .80 1.3
quadriceps feet off the ground, the clinician applies (.39, (.22, (.50, (.60,
test44 ◆ quick strikes of the reflex hammer to .72) .46) 1.3) 2.8)
the suprapatellar tendon. Positive with
hyperreflexive knee extension

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 125


Physical Examination Tests  •  Cervical Myelopathy Tests
Diagnostic Utility of Tests for Cervical Myelopathy (continued)

Figure 3-35
Inverted supinator sign.

Figure 3-36
Hand withdrawal reflex.

126 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Cervical Myelopathy Tests
Diagnostic Utility of Tests for Cervical Myelopathy (continued)
Test and
Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Hand With the patient sitting or standing, .41 .63 1.1 .90
withdrawal the clinician grasps the patient’s (.25, (.51, (.50, (.60,
reflex44 ◆ palm and strikes the dorsum of the .58) .75) 2.3) 1.5)
patient’s hand with a reflex
hammer. Positive with abnormal

3 
flexor response

Babinski With the patient supine, the .33 .92 4.0 .70

Cervical Spine
sign44 ◆ clinician supports the patient’s foot (.19, (.81, (1.1, (.60,
in neutral and applies stimulation 82 .41) .98) 16.6) .90)
to the plantar aspect of the foot consecutively
(typically from lateral to medial referred
from heel to metatarsal) with the patients with Electrophysiologic
blunt end of a reflex hammer. suspected examination
Positive with great toe extension cervical
and fanning of the second through radiculopathy
fifth toes or CTS

Clonus44 With the patient sitting with his or .11 .96 2.7 .90
◆ her feet off the ground, the (.30, (.90, (.40, (.80,
clinician applies a quick stretch to .16) .99) 20.1) 1.1)
the Achilles tendon via rapid
passive dorsiflexion of the ankle.
Positive when ankle “beats” in and
out of dorsiflexion for at least three
beats

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 127


Physical Examination Tests  •  Combinations of Tests
Diagnostic Utility of Clusters of Tests for Cervical Myelopathy
Cook and colleagues45 identified a test item cluster, or an optimal combination of clinical exami-
nation tests, that may be useful in identifying patients with cervical myelopathy. The five clinical
findings listed below demonstrated the capacity to rule out cervical myelopathy when clustered
into one of five positive findings and rule in cervical myelopathy when clustered into three of
five positive findings.

Test and Study Description and Reference


Quality Positive Findings Population Standard Sens Spec +LR −LR
Gait deviation One of five positive .94 .31 1.4 .18
+ tests (.89, (.27, (1.2, (.12,
Positive Hoffmann .97) .32) 1.4) .42)
test
Three of five 249 consecutive Diagnosis of .19 .99 30.9 .81
+
positive tests patients with primary cervical (.15, (.97, (5.5, (.79,
Inverted supinator
complaint of cervical myelopathy was .20) .99) 181.8) .87)
sign
pain or dysfunction confirmed or
+
seen at university ruled out using
Positive Babinski
spine surgery center MRI
test
+
Age over 45
years45 ◆

128 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Combinations of Tests
Diagnostic Utility of Clusters of Tests for Cervical Radiculopathy
Wainner and colleagues7 identified a test item cluster, or an optimal combination of clinical
examination tests, that can determine the likelihood that a patient is presenting with cervical
radiculopathy. The four predictor variables most likely to identify patients presenting with cervical
radiculopathy are the upper limb tension test A, the Spurling’s A test, the distraction test, and
cervical rotation of less than 60 degrees to the ipsilateral side.

Test and
Study Description and Reference
+LR −LR

3 
Quality Positive Findings Population Standard Sens Spec
Upper limb All four tests positive .24 .99 30.3

Cervical Spine
tension test A (.05, (.97, (1.7,
+ .43) 1.0) 38.2)
82 consecutive
Spurling’s A
Any three tests patients referred to .39 .94 6.1
test
positive electrophysiologic Cervical (.16, (.88, (2.0,
+
laboratory with radiculopathy .61) 1.0) 18.6)
Distraction
suspected via needle Not
test
Any two tests diagnosis of electromyography .39 .56 .88 reported
+
positive cervical and nerve (.16, (.43, (1.5,
Cervical
radiculopathy or conduction studies .61) .68) 2.5)
rotation of
carpal tunnel
less than 60
syndrome
degrees to the
ipsilateral
side7 ◆

.1 99

.2

.5 95

1 1000 90
500
2 200 80
100
50 70
5
20 60
10 10 50
5 40
Percent (%)

Percent (%)

20 2 30
1
30 .5 20
40 .2
50 .1 10
60 .05
5
70 .02
.01
80 .005 Figure 3-37
2
.002 Fagan’s nomogram. Considering the 20% prevalence or pretest probability of
90 .001 1 cervical radiculopathy in the study by Wainner and colleagues, the nomogram
95 .5 demonstrates the major shifts in probability that occur when all four tests from
the cluster are positive (see Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability
.2
and diagnostic accuracy of the clinical examination and patient self-report
measures for cervical radiculopathy. Spine. 2003;28:52-62). (Reprinted with
99 .1 permission from Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med.
Pretest Likelihood Posttest 1975;293:257. Copyright 2005, Massachusetts Medical Society. All rights
Probability Ratio Probability reserved.)

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 129


Physical Examination Tests  •  Interventions
Clinical Prediction Rule to Identify Patients with Neck Pain Who Are Likely to Benefit from
Cervical Thrust Manipulation
Puentedura and colleagues46 developed a clinical prediction rule for identifying patients with neck
pain who are likely to benefit from cervical thrust manipulation. The result of their study dem-
onstrated that if three or more of the four attributes (symptom duration less than 38 days, positive
expectation that manipulation will help, side-to-side difference in cervical rotation range of
motion of 10 degrees or more, and pain with posteroanterior spring testing of the middle cervical
spine) were present, the +LR was 13.5 (95% CI 1.0, 328.3) and the probability of experiencing a
successful outcome improved from 39% to 90%.

Diagnostic Utility of Single Factors and Combinations of Factors for Identifying a Positive
Short-Term Clinical Outcome for Cervical Radiculopathy
We used the baseline examination and physical therapy interventions received to investigate
predictors for short-term improvement in patients with cervical radiculopathy.47 Patients were
treated at the discretion of their physical therapist for a mean of 6.4 visits over an average of 28
days. In addition to identifying the single factors most strongly associated with improvement, we
used logistic regression to identify the combination of factors most predictive of short-term
improvement.

Test and Study Description and Reference


Quality Positive Findings Population Standard Sens Spec +LR −LR
Age less than 54 Self-report .76 .52 1.5
years47 ◆ (.64, (.38, (1.2,
.89) .67) 2.1)

Dominant arm is not Self-report .74 .52 1.5


affected47 ◆ (.62, (.38, (1.1,
.86) .67) 2.2)

Looking down does Self-report .68 .48 1.3


not worsen 96 patients (.55, (.34, (.93,
symptoms47 ◆ referred to .81) .62) 1.8)
physical therapy
More than 30 degrees Patient sitting. Used .56 .59 1.4
with cervical Improvement
of cervical flexion47 ◆ an inclinometer (.42, (.44, (.89,
radiculopathy as at physical
after two warm-up .70) .73) 2.1)
defined by being therapy
repetitions
positive on all discharge as
Age less than 54 All four tests four items in defined by .18 .98 8.3 Not
years positive Wainner’s surpassing (.07, (.94, (1.9, reported
+ diagnostic test the minimal .29) 1.0) 63.9)
Dominant arm is not item cluster7 (see detectable
affected Any three tests previous section change in all .68 .87 5.2
+ positive on Diagnostic outcome (.55, (.77, (2.4,
Looking down does Utility of Clusters measures .81) .97) 11.3)
not worsen symptoms of Tests for
Any two tests Cervical .94 .37 1.5
+
positive Radiculopathy) (.87, (.23, (1.2,
Provided with
1.0) .51) 1.9)
multimodal treatment,
including manual Any one test 1.0 .08 1.1
therapy, cervical positive (1.0, (.01, (1.0,
traction, and deep 1.0) .20) 2.0)
neck flexor muscle
strengthening for
50% or more of
visits47 ◆

130 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Interventions
Diagnostic Utility of Historical and Physical Examination Findings for Immediate
Improvement with Cervical Manipulation

3 
Cervical Spine
Figure 3-38
Cervical manipulation. Delivered by Tseng and colleagues at the discretion of the therapist to the most hypomobile segments. “Once
a hypomobile segment was localized, the manipulator carefully flexed and sidebent the patient’s neck to lock the facet joints of other
spinal segments until the barrier was reached. A specific cervical manipulation with a high-velocity, low-amplitude thrust force was
then exerted on the specific, manipulable lesion to gap the facet.” (See Tseng YL, Wang WT, Chen WY, et al. Predictors for the
immediate responders to cervical manipulation in patients with neck pain. Man Ther. 2006;11:306-315.)

Description
Test and Study and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Initial Neck Five or six Immediate .07 1.00 Undefined
Disability Index tests positive improvement after (.00, (1.00,
score over 11.5 cervical manipulation .13) 1.00)
+ as determined by
Bilateral Any four tests any of the following: .40 .93 5.33
involvement pattern positive 1. Decrease of 50% (.28, (.84, (1.72,
+ or more in score .52) 1.00) 16.54)
Not performing on NPRS
Any three .43 .78 1.93
sedentary work for 2. Score of 4 or
tests positive 100 patients (.31, (.65, (1.01,
longer than 5 higher (much
referred to .56) .90) 3.67)
hours/day improved) on Not
physical
+ Any two tests Global Rating of .08 .57 .20 (.08, reported
therapy for
Feeling better while positive Change (GROC) (.01, (.42, .49)
neck pain
moving the neck scale .15) .73)
+ 3. Patient
Without feeling Any one test satisfaction rating .02 .75 .07 (.01,
worse while positive of “very (−.02, (.62, .50)
extending the neck satisfied” after .05) .88)
+ manipulation
Diagnosis of
spondylosis without
radiculopathy48 ◆

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 131


Physical Examination Tests  •  Interventions
Diagnostic Utility of Historical and Physical Examination Findings for Immediate
Improvement with Thoracic Manipulation
Test and Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR
Symptom duration for .36 .94 6.4
less than 30 days49 ◆ (.22, (.80, (1.60,
.52) .99) 26.3)
Self-report
No symptoms distal to .67 .53 1.4
the shoulder49 ◆ (.50, (.36, (.94,
.80) .69) 2.2)

FABQPA score of less .28 .91 3.4


than 1249 ◆ Questionnaire to quantify (.16, (.76, (1.05,
a person’s beliefs about .45) .98) 11.20)
the influence of work
FABQW score of less and activity on person’s .55 .69 1.8
than 1049 ◆ own neck pain (.39, (.52, (1.02,
.70) .83) 3.15)
Improvement after
Three or more prior several standardized .23 .83 1.9
episodes of neck pain49 78 patients thoracic manipulations (.15, (.54, (1.3,
◆ referred to and cervical range-of- .35) .96) 2.7)
physical motion exercise as
Patient reports that therapy with determined by a score .67 .86 4.8
looking up does not mechanical of 5 or higher (“quite (.50, (.70, (2.07,
Self-report
aggravate symptoms49 neck pain a bit better”) on the .80) .95) 11.03)
◆ GROC scale on the
second or third visit
Exercises more than .65 .67 1.9
three times/week49 ◆ (.50, (.46, (1.1,
.76) .83) 3.4)

Cervical extension Measured with .62 .75 2.5


range of motion of less inclinometer (.46, (.57, (1.34,
than 30 degrees49 ◆ .76) .87) 4.57)

Decreased upper Increased convexity at .54 .64 1.1


thoracic spine T3-T5 (.42, (.48, (.77,
kyphosis49 ◆ .65) .78) 1.60)

Shoulders protracted49 Positive if acromion was .65 .76 2.7


◆ noted to be anterior to (.51, (.52, (1.6,
the lumbar spine .77) .90) 3.0)
FABQPA, Fear-Avoidance Beliefs Questionnaire physical activity subscale; FABQW: Fear-Avoidance Beliefs Questionnaire work subscale. –LR not reported.
GROC scale, Global Rating of Change scale.

132 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Interventions
Diagnostic Utility of a Cluster of Historical and Physical Examination Findings for Immediate
Improvement with Thoracic Manipulation
Description
Test and Study and Positive Reference
Quality Findings Population Standard Sens Spec +LR
Symptom duration for All six tests .05 1.0 Undefined
less than 30 days positive (.00, .17) (.97,
+ 1.00)
No symptoms distal to

3 
the shoulder At least five .12 1.0 Undefined
+ tests positive (.04, .25) (.94,
Improvement after 1.00)

Cervical Spine
FABQPA score of less several standardized
than 12 thoracic manipulations
At least four 78 patients .33 .97 12
+ and cervical
tests positive referred to (.26, .35) (.89, (2.28,
Patient reports that range-of-motion
physical 1.00) 70.8)
looking up does not exercise as
aggravate symptoms At least three therapy with .76 .86 5.49
determined by a score
+ tests positive mechanical (.67, .82) (.75, .93) (2.72,
of 5 or higher (“quite
Cervical extension neck pain 12.0)
a bit better”) on the
range of motion of less GROC scale on the
than 30 degrees At least two second or third visit .93 .56 2.09
+ tests positive (.84, .97) (.46, .61) (1.54,
Decreased upper 2.49)
thoracic spine
kyphosis (T3-T5)49 ◆ At least one 1.00 .17 1.2
test positive (.95, (.11, .24) (1.06, 1.2)
1.00)
FABQPA, Fear-Avoidance Beliefs Questionnaire physical activity subscale; FABQW, Fear-Avoidance Beliefs Questionnaire work subscale. –LR not reported.
GROC scale, Global Rating of Change scale.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 133


Physical Examination Tests  •  Interventions
Diagnostic Utility of a Cluster of Historical and Physical Examination Findings for Immediate
Improvement with Thoracic Manipulation (continued)

All patients received a standardized series of 3 thrust manipulations directed at the thoracic spine. In the first
technique (A), with the patient sitting, the therapist uses his or her sternum as a fulcrum on the patient’s middle
thoracic spine and applies a high-velocity distraction thrust in an upward direction. The second and third
techniques (B) are delivered supine. The therapist uses his or her body to push down through the patient’s arms
to perform a high-velocity, low-amplitude thrust directed toward either T1 through T4 or T5 through T8.40

After the manipulations, patients were instructed in a cervical range-of-motion exercise to perform 3-4 times/day.40

Figure 3-39
Thoracic spine manipulation and active range of motion.

134 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Interventions
Diagnostic Utility of Historical and Physical Examination Findings for Improvement with
Three Weeks of Mechanical Cervical Traction
Test and
Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Neck Patient lies supine and the .83 .50 1.67 .33
distraction neck is comfortably (.66, (.35, (1.18, (.14,
test50 ◆ positioned. Examiner .93) .65) 2.45) .73)
securely grasps the patient’s

3 
head under the occiput and
chin and gradually applies an

Cervical Spine
axial traction force of up to
approximately 30 pounds.
Positive response defined by
reduction of symptoms
Improvement after
Shoulder While sitting, the patient is .33 .87 2.53 .77
six treatments
abduction instructed to place the hand (.19, (.73, (1.01, (.55,
over 3 weeks of
test50 ◆ of the affected extremity on .51) .94) 6.50) 1.00)
mechanical
the head in order to support 68 patients
cervical traction
the extremity in the scapular referred to
and postural/deep
plane. Positive response physical therapy
neck flexor
defined by alleviation of with neck pain
strengthening
symptoms with or without
exercise as
upper extremity
Positive With patient supine, determined by a .80 .37 1.27 .54
symptoms
ULTT A50 ◆ examiner performs the score of +7 or (.63, (.23, (.93, (.23,
following movements: higher (“a very .90) .53) 1.75) 1.18)
1. Scapular depression great deal better”)
2. Shoulder abduction on GROC scale
3. Forearm supination
4. Wrist and finger
extension
5. Shoulder lateral rotation
6. Elbow extension
7. Contralateral and
ipsilateral cervical
side-bending
Positive response defined by
reproduction of symptoms
ULTT, upper limb tension test.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 135


Physical Examination Tests  •  Interventions
Diagnostic Utility of Historical and Physical Examination Findings for Improvement with
Three Weeks of Mechanical Cervical Traction (continued)
Description
Test and Study and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Pain with manual .63 .71 2.19 .52
muscle testing50 ◆ (.46, (.55, (1.27, (.30,
.78) .83) 3.92) .82)

Body mass index .67 .68 2.11 .49


score of 28.4 or (.49, (.53, (1.26, (.27,
higher50 ◆ .81) .81) 3.66) .81)

Frequency of past .70 .67 2.10 .45


episodes50 ◆ (.48, (.47, (1.15, (.21,
.85) .82) 4.08) .87)

Symptoms distal to .67 .58 1.58 .58


the shoulder41 ◆ (.49, (.42, (1.01, (.32,
.81) .72) 2.53) .99)

Headaches50 ◆ .43 .55 .97 1.02


Improvement (.27, (.40, (.56, (.65,
after six .61) .70) 1.65) 1.57)
treatments over 3
Diminished weeks of .43 .76 1.83 .74
strength50 ◆ mechanical (.27, (.61, (.92, (.50,
cervical traction .61) .87) 3.69) 1.04)
68 patients referred
and postural/deep
Peripheralization to physical therapy .37 .82 1.99 .78
No details neck flexor
with central with neck pain with (.22, (.67, (.90, (.54,
given strengthening
posteroanterior or without upper .54) .91) 4.47) 1.04)
exercise as
motion testing at extremity symptoms
determined by a
lower cervical C4-C7 score of +7 or
spine50 ◆ higher (“a very
great deal
Ipsilateral rotation of better”) on the .43 .66 1.27 .86
less than 60 GROC scale (.27, (.50, (.69, (.57,
degrees50 ◆ .61) .79) 2.31) 1.26)

Patient-reported .43 .34 .66 1.65


neck stiffness50 ◆ (.27, (.21, (.40, (.97,
.61) .50) 1.02) 2.88)

Flexion active range .60 .55 1.34 .72


of motion of less (.42, (.40, (.84, (.42,
than 55 degrees50 ◆ .75) .70) 2.14) 1.19)

Age of 55 years or .47 .89 4.43 .60


older50 ◆ (.30, (.76, (1.74, (.40,
.64) .96) 11.89) .81)

Ipsilateral side- .73 .45 1.33 .60


bending of less than (.56, (.30, (.92, (.29,
40 degrees50 ◆ .86) .60) 1.93) 1.14)
GROC scale, Global Rating of Change scale.

136 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Interventions
Diagnostic Utility of a Cluster of Historical and Physical Examination Findings for
Improvement with Three Weeks of Mechanical Cervical Traction

3 
Cervical Spine
Figure 3-40
Cervical traction. The cervical traction in this study was performed with the patient supine and the legs supported on a stool. The
neck was flexed to 24 degrees for patients with full cervical range of motion and to 15 degrees otherwise. The traction force was set
at 10 to 12 pounds initially and adjusted upward during the first treatment session to optimally relieve symptoms. Each traction
session lasted approximately 15 minutes and alternated between 60 seconds of pull and 20 seconds of release at 50% force. (See
Raney NH, Petersen EJ, Smith TA, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit
from cervical traction and exercise. Eur Spine J. 2009;18(3):382-391.)

Test and Study Description and Reference


Quality Positive Findings Population Standard Sens Spec +LR −LR
Age 55 years or At least four tests 68 patients Improvement after .30 1.0 23.1 .71
older positive referred to six treatments (.17, (.91, (2.50, (.53,
+ physical therapy over 3 weeks of .48) 1.0) 227.9) .85)
Positive shoulder with neck pain mechanical
abduction test At least three tests with or without cervical traction .63 .87 4.81 .42
+ positive upper extremity and postural/deep (.46, (.73, (2.17, (.25,
Positive ULTT A symptoms neck flexor .78) .94) 11.4) .65)
+ strengthening
At least two tests .30 .97 1.44 .40
Symptom exercise as
positive (.17, (.87, (1.05, (.16,
peripheralization determined by a
.48) 1.00) 2.03) .90)
with central score of +7 or
posteroanterior At least one test higher (“a very .07 .97 1.15 .21
motion testing at positive great deal better”) (.02, (.87, (.97, (.03,
lower cervical on the GROC scale .21) 1.00) 1.4) 1.23)
(C4-C7) spine
+
Positive neck
distraction test50 ◆
GROC scale, Global Rating of Change scale; ULTT, upper limb tension test.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 137


Outcome Measures

Outcome Measure Scoring and Interpretation Test-Retest Reliability MCID


Neck Disability Index Users are asked to rate the difficulty of performing ICC = .6451 ◆ 10.251
(NDI) 10 functional tasks on a scale of 0 to 5 with
different descriptors for each task. A total score out
of 100 is calculated by summing each score and
doubling the total. The answers provide a score
between 0 and 100, with higher scores representing
more disability

Fear-Avoidance Users are asked to rate their level of agreement FABQW: ICC = .82 Not available
Beliefs Questionnaire with statements concerning beliefs about the FABQPA: ICC = .6652 ●
(FABQ) relationship between physical activity, work, and
their back pain (“neck” can be substituted for
“back”). Level of agreement is answered on a
Likert-type scale ranging from 0 (completely
disagree) to 7 (completely agree). The FABQ is
composed of two parts: a seven-item work subscale
(FABQW) and a four-item physical activity subscale
(FABQPA). Each scale is scored separately, with
higher scores representing higher levels of fear
avoidance

Numeric Pain Rating Users rate their level of pain on an 11-point scale ICC = .7653 ● 1.353
Scale (NPRS) ranging from 0 to 10, with high scores representing
more pain. Often asked as “current pain” and
“least,” “worst,” and “average pain” in the past 24
hours
MCID, minimum clinically important difference.

138 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Appendix
Quality Appraisal of Reliability Studies Using QAREL

Van Suijlekom 200022


Wainner 20037

Youdas 199120
Hoving 200517
Cleland 20066

Olson 200018

Hole 199519

Pool 200421
Stiell 20019

Piva 200616

3 
1. Was the test evaluated in a sample of Y Y Y Y Y Y Y Y Y Y
subjects who were representative of those to

Cervical Spine
whom the authors intended the results to be
applied?

2. Was the test performed by raters who were Y Y Y Y Y Y Y Y Y Y


representative of those to whom the authors
intended the results to be applied?

3. Were raters blinded to the findings of other Y Y Y Y Y U U U Y U


raters during the study?

4. Were raters blinded to their own prior N/A N/A N/A N/A Y N U U N/A N/A
findings of the test under evaluation?

5. Were raters blinded to the results of the N/A Y Y N/A N/A N/A N/A N/A N/A N/A
reference standard for the target disorder (or
variable) being evaluated?

6. Were raters blinded to clinical information U Y U U U U U U U U


that was not intended to be provided as part
of the testing procedure or study design?

7. Were raters blinded to additional cues that U U U U U U U U U U


were not part of the test?

8. Was the order of examination varied? N/A U N/A Y Y Y Y Y Y Y

9. Was the time interval between repeated Y Y Y Y Y Y Y Y Y Y


measurements compatible with the stability
(or theoretical stability) of the variable being
measured?

10. Was the test applied correctly and Y Y Y Y Y Y Y Y Y Y


interpreted appropriately?

11. Were appropriate statistical measures of Y Y Y Y Y Y Y Y Y Y


agreement used?

Quality Summary Rating: ◆ ◆ ◆ ◆ ◆ ● ● ● ◆ ●


Y = yes, N = no, U = unclear, N/A = not applicable. ◆ Good quality (Y - N = 9 to 11) ● Fair quality (Y - N = 6 to 8) ■ Poor quality (Y - N ≤ 5).

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 139


Appendix
Quality Appraisal of Reliability Studies Using QAREL

Viikari-Juntura 198734
Edmondston 200824

Humphreys 200430
Smedmark 200029
Kumbhare 200528

Bertilson 200335

Cleland 200853
Harris 200526
Olson 200625

Chiu 200527
1. Was the test evaluated in a sample of Y Y Y Y Y Y Y Y Y Y
subjects who were representative of those to
whom the authors intended the results to be
applied?

2. Was the test performed by raters who were Y Y Y Y Y Y Y Y Y Y


representative of those to whom the authors
intended the results to be applied?

3. Were raters blinded to the findings of other N/A U Y Y U Y Y U Y U


raters during the study?

4. Were raters blinded to their own prior Y U U U N/A N/A N/A N/A N/A U
findings of the test under evaluation?

5. Were raters blinded to the results of the N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
reference standard for the target disorder (or
variable) being evaluated?

6. Were raters blinded to clinical information U U U U U U U U U U


that was not intended to be provided as part
of the testing procedure or study design?

7. Were raters blinded to additional cues that U U U U U Y U Y U U


were not part of the test?

8. Was the order of examination varied? Y Y N U Y Y U U Y U

9. Was the time interval between repeated Y Y Y Y Y Y Y Y Y Y


measurements compatible with the stability
(or theoretical stability) of the variable being
measured?

10. Was the test applied correctly and Y Y Y Y Y Y Y Y Y Y


interpreted appropriately?

11. Were appropriate statistical measures of Y Y Y Y Y Y Y Y Y Y


agreement used?

Quality Summary Rating: ◆ ● ● ● ● ◆ ◆ ● ◆ ●


Y = yes, N = no, U = unclear, N/A = not applicable. ◆ Good quality (Y - N = 9 to 11) ● Fair quality (Y - N = 6 to 8) ■ Poor quality (Y - N ≤ 5).

140 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Appendix
Quality Appraisal of Reliability Studies Using QAREL

Gumina 201342
Hall 2010 (2)40

Young 200951
Grotle 200652

Kaale 200831

Cook 200944
Hall 201036
1. Was the test evaluated in a sample of subjects who were Y Y Y Y Y Y Y
representative of those to whom the authors intended the results to
be applied?

3 
2. Was the test performed by raters who were representative of those Y Y Y Y Y Y Y

Cervical Spine
to whom the authors intended the results to be applied?

3. Were raters blinded to the findings of other raters during the study? U Y N/A Y Y Y Y

4. Were raters blinded to their own prior findings of the test under U N/A N U N/A N N/A
evaluation?

5. Were raters blinded to the results of the reference standard for the N/A Y N N/A Y Y Y
target disorder (or variable) being evaluated?

6. Were raters blinded to clinical information that was not intended to U Y Y Y U U Y


be provided as part of the testing procedure or study design?

7. Were raters blinded to additional cues that were not part of the test? U U U U U U U

8. Was the order of examination varied? U N/A N/A Y U U Y

9. Was the time interval between repeated measurements compatible Y Y Y Y Y Y Y


with the stability (or theoretical stability) of the variable being
measured?

10. Was the test applied correctly and interpreted appropriately? Y Y Y Y Y Y Y

11. Were appropriate statistical measures of agreement used? Y Y Y Y Y Y Y

Quality Summary Rating: ● ◆ ● ◆ ● ● ◆


Y = yes, N = no, U = unclear, N/A = not applicable. ◆ Good quality (Y - N = 9 to 11) ● Fair quality (Y - N = 6 to 8) ■ Poor quality (Y - N ≤ 5).

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 141


Appendix
Quality Assessment of Diagnostic Studies Using QUADAS

Viikari-Juntura 198954

Sandmark 199523
Uchihara 199443

Hoffman 200011
Uitvlugt 198841

Wainner 20037
Lauder 20008

Tong 200239
Stiell 20019
Jull 198833
1. Was the spectrum of patients representative of the patients Y Y N U N Y Y Y Y Y
who will receive the test in practice?

2. Were selection criteria clearly described? Y N N N Y Y Y Y Y Y

3. Is the reference standard likely to correctly classify the Y Y U Y N Y Y Y Y Y


target condition?

4. Is the time period between reference standard and index N U Y U U Y Y U U U


test short enough to be reasonably sure that the target
condition did not change between the two tests?

5. Did the whole sample or a random selection of the sample Y Y U Y Y Y Y Y U Y


receive verification using a reference standard of
diagnosis?

6. Did patients receive the same reference standard Y Y U Y Y Y Y N Y Y


regardless of the index test result?

7. Was the reference standard independent of the index test Y Y N Y Y Y Y Y Y Y


(i.e., the index test did not form part of the reference
standard)?

8. Was the execution of the index test described in sufficient Y Y Y Y Y Y Y Y Y Y


detail to permit replication of the test?

9. Was the execution of the reference standard described in Y Y N Y Y Y Y Y Y Y


sufficient detail to permit its replication?

10. Were the index test results interpreted without knowledge Y U N Y Y Y Y Y Y Y


of the results of the reference test?

11. Were the reference standard results interpreted without U U N Y Y U Y Y U Y


knowledge of the results of the index test?

12. Were the same clinical data available when test results U Y Y Y N Y Y Y Y Y
were interpreted as would be available when the test is
used in practice?

13. Were uninterpretable/intermediate test results reported? Y Y U Y Y U Y Y U U

14. Were withdrawals from the study explained? Y Y U Y Y U Y Y U Y

Quality Summary Rating: ◆ ● ■ ◆ ● ◆ ◆ ◆ ● ◆


Y = yes, N = no, U = unclear. ◆ Good quality (Y - N = 10 to 14) ● Fair quality (Y - N = 5 to 9) ■ Poor quality (Y - N ≤ 4).

142 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Appendix
Quality Assessment of Diagnostic Studies Using QUADAS

Humphreys 200430
Dickinson 200413
Bandiera 200314

Cleland 200747
Duane 200715

Raney 200950
Tseng 200648
Shah 200438
Stiell 200310

King 200732
1. Was the spectrum of patients representative of the patients Y Y Y N Y Y Y Y Y Y

3 
who will receive the test in practice?

2. Were selection criteria clearly described? Y Y Y Y Y Y U Y Y Y

Cervical Spine
3. Is the reference standard likely to correctly classify the Y Y Y N Y U Y Y Y Y
target condition?

4. Is the time period between reference standard and index U U U U U Y U Y U Y


test short enough to be reasonably sure that the target
condition did not change between the two tests?

5. Did the whole sample or a random selection of the sample Y Y Y Y Y Y Y Y N Y


receive verification using a reference standard of
diagnosis?

6. Did patients receive the same reference standard N N N Y Y Y Y Y Y Y


regardless of the index test result?

7. Was the reference standard independent of the index test Y Y Y Y Y Y Y Y Y Y


(i.e., the index test did not form part of the reference
standard)?

8. Was the execution of the index test described in sufficient U Y Y Y Y U N Y Y Y


detail to permit replication of the test?

9. Was the execution of the reference standard described in Y Y Y Y Y Y U Y Y Y


sufficient detail to permit its replication?

10. Were the index test results interpreted without knowledge U Y Y Y U Y U Y Y Y


of the results of the reference test?

11. Were the reference standard results interpreted without U Y Y Y Y Y U Y U Y


knowledge of the results of the index test?

12. Were the same clinical data available when test results Y Y Y N Y Y U Y Y Y
were interpreted as would be available when the test is
used in practice?

13. Were uninterpretable/intermediate test results reported? Y Y Y Y Y Y Y Y Y U

14. Were withdrawals from the study explained? Y Y Y Y Y Y Y Y Y U

Quality Summary Rating: ● ◆ ◆ ● ◆ ◆ ● ◆ ◆ ◆


Y = yes, N = no, U = unclear. ◆ Good quality (Y - N = 10 to 14) ● Fair quality (Y - N = 5 to 9) ■ Poor quality (Y - N ≤ 4).

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 143


Appendix
Quality Assessment of Diagnostic Studies Using QUADAS

Gumina 201342

Shabat 201237
Goode 201412

Kaale 200831

Cook 201045

Cook 200944
1. Was the spectrum of patients representative of the patients who will receive the Y Y Y Y Y Y
test in practice?

2. Were selection criteria clearly described? Y Y Y Y N Y

3. Is the reference standard likely to correctly classify the target condition? Y Y Y Y Y Y

4. Is the time period between reference standard and index test short enough to be U Y U Y Y Y
reasonably sure that the target condition did not change between the two tests?

5. Did the whole sample or a random selection of the sample receive verification Y Y Y Y Y Y
using a reference standard of diagnosis?

6. Did patients receive the same reference standard regardless of the index test Y Y Y Y Y Y
result?

7. Was the reference standard independent of the index test (i.e., the index test did Y Y Y Y Y Y
not form part of the reference standard)?

8. Was the execution of the index test described in sufficient detail to permit Y N Y N Y Y
replication of the test?

9. Was the execution of the reference standard described in sufficient detail to permit Y Y Y Y Y Y
its replication?

10. Were the index test results interpreted without knowledge of the results of the Y Y Y Y Y Y
reference test?

11. Were the reference standard results interpreted without knowledge of the results of U Y Y U U Y
the index test?

12. Were the same clinical data available when test results were interpreted as would Y Y U Y Y Y
be available when the test is used in practice?

13. Were uninterpretable/intermediate test results reported? U Y Y N Y Y

14. Were withdrawals from the study explained? Y Y Y N Y Y

Quality Summary Rating: ◆ ◆ ◆ ◆ ◆ ◆


Y = yes, N = no, U = unclear. ◆ Good quality (Y - N = 10 to 14) ● Fair quality (Y - N = 5 to 9) ■ Poor quality (Y - N ≤ 4).

144 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


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34. Viikari-Juntura E. Interexaminer reliability of obser- 46. Puentedura EJ, Cleland JA, Landers MR, et al. Devel-
vations in physical examinations of the neck. Phys opment of a clinical prediction rule to identify
Ther. 1987;67:1526-1532. patients with neck pain likely to benefit from thrust
35. Bertilson BC, Grunnesjo M, Strender LE. Reliability joint manipulation to the cervical spine. J Orthop
of clinical tests in the assessment of patients with Sports Phys Ther. 2012;42(7):577-592.
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146 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Thoracolumbar Spine 4 
CLINICAL SUMMARY AND RECOMMENDATIONS, 148
Anatomy, 149
Osteology, 149
Arthrology, 150
Ligaments, 153
Muscles, 155
Fascia, 159
Nerves, 160
Patient History, 163
Initial Hypotheses Based on the Patient History, 163
Lumbar Zygapophyseal Joint Referral Patterns, 164
Thoracic Zygapophyseal Joint Referral Patterns, 165
Reliability of the Historical Examination, 166
Diagnostic Utility of Patient History in Identifying Lumbar Spinal Stenosis, 167
Diagnostic Utility of Patient History in Identifying Lumbar Radiculopathy, 168
Diagnostic Utility of Patient History in Identifying Ankylosing Spondylitis, 169
Physical Examination Tests, 170
Neurologic Examination, 170
Range-of-Motion Measurements, 173
Thoracolumbar Strength and Endurance Tests, 177
Postural Assessment, 178
Motor Control Assessment, 180
Passive Intervertebral Motion Assessment, 181
Palpation, 187
Centralization Phenomenon, 189
Straight-Leg Raise Test, 191
Crossed Straight-Leg Raise Test, 193
Slump Test, 194
Slump Knee Bend Test, 197
Tests for Lumbar Segmental Instability, 198
Tests for Lumbar Spinal Stenosis, 200
Tests for Radiographic Lumbar Instability, 201
Tests for Ankylosing Spondylitis, 204
Classification Methods, 205
Interventions, 207
Outcome Measures, 210

Appendix, 211

References, 218

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 147


Clinical Summary and Recommendations

Patient History
Complaints • A few subjective complaints appear to be useful in identifying specific spinal pathologic
conditions. A report of “no pain when seated” is the answer to the single question with the
best diagnostic utility for lumbar spinal stenosis (+LR [likelihood ratio] = 6.6). “Pain not
relieved by lying down,” “back pain at night,” and “morning stiffness for longer than 1/2
hour” are all somewhat helpful in identifying ankylosing spondylitis (+LR = 1.51 to 1.57).
Subjective complaints of weakness, numbness, tingling, and/or burning do not appear to be
especially helpful, at least in identifying lumbar radiculopathy.

Physical Examination
Neurologic Screening • Traditional neurologic screening (sensation, reflex, and manual muscle testing) is reasonably
useful in identifying lumbar radiculopathy. When tested in isolation, weakness with manual
muscle testing and, even more so, reduced reflexes are suggestive of lumbar radiculopathy,
especially at the L3-L4 spinal levels. Sensation testing (vibration and pinprick) alone does not
seem to be especially useful. However, when changes in reflexes, muscular strength, and
sensation are found in conjunction with a positive straight-leg raise test, lumbar radiculopathy
is highly likely (+LR = 6.0).
• In addition, a finding of decreased sensation (vibration and pinprick), muscle weakness, or
reflex changes is modestly helpful in identifying lumbar spinal stenosis (+LR = 2.1 to 2.8).

Range-of-Motion, • Measuring both thoracolumbar range of motion and motor control, as well as trunk strength,
Strength, and has consistently been shown to be reliable, but the findings are of unknown diagnostic utility.
Manual Assessment • The results of studies assessing the reliability of passive intervertebral motion (PIVM) are
highly variable, but generally, the reports are of poor reliability when assessing for limited or
excessive movement and of moderate reliability when assessing for pain.
• Diagnostic studies assessing PIVM suggest that abnormal segmental motion is moderately
useful both in identifying radiographic hypomobility/hypermobility and in predicting the
responses to certain conservative treatments. However, restricted PIVM may have little or no
association with low back pain.

Special Tests • The centralization phenomenon (movement of symptoms from distal/lateral regions to more
central regions) has been shown to be both highly reliable and decidedly useful in identifying
painful lumbar discs (+LR = 6.9).
• The straight-leg raise test, crossed straight-leg raise test, and slump test have all been
shown to be moderately useful in identifying disc pathologic conditions, including bulges,
herniations, and extrusions.
• A 2011 systematic review1 identified the passive lumbar extension test as a useful clinical
test in identifying lumbar segmental instability (+LR = 8.8).
• Both the Romberg test and a two-stage treadmill test have been found to be moderately
useful in identifying lumbar spinal stenosis.

Interventions • Patients with low back pain of less than 16 days’ duration and no symptoms distal to the
knees and/or patients who meet at least four out of the five criteria proposed by Flynn and
colleagues2 should be treated with lumbosacral manipulation.
• Patients with low back pain who meet at least three out of the five criteria proposed by
Hicks3 should be treated with lumbar stabilization exercises.

148 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Osteology

Vertebral foramen Body Superior articular


Superior process and facet
costal facet
Superior Superior Pedicle
vertebral notch costal facet Body Transverse
(forms lower costal facet
margin of Pedicle
intervertebral Transverse
foramen) process
Transverse Inferior
costal facet articular
Lamina Inferior
costal facet process
Superior Spinous
articular facet Spinous process Inferior process

4 
vertebral notch
T6 vertebra: superior view
T6 vertebra: lateral view

Thoracolumbar Spine
Superior articular
process and facet
Costal facet
Body
Transverse process

Inferior articular Spinous


process and facet process

T12 vertebra: lateral view


Figure 4-1
Thoracic vertebrae.

Vertebral body

Vertebral foramen

Pedicle Annulus fibrosus

Nucleus
Transverse process
pulposus

Superior articular Accessory process


process Intervertebral disc
Mammillary process
Lamina Spinous process

L2 vertebra: superior view

Figure 4-2
Lumbar vertebrae.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 149


Anatomy  •  Arthrology
Joints of the Thoracic Spine

Vertebral canal
Superior articular
process and facet
7th rib

Spinous process of
T7 vertebra

Transverse process of
T9 vertebra

Inferior articular process (T9)


Lamina

Spinous process (T9)

Figure 4-3
T7, T8, and T9 vertebrae, posterior view.

Interclavicular lig.
Clavicle Articular disc
Manubrium

1 Costoclavicular lig.
Rib Articular cavity
Manubriosternal joint Intraarticular
2 sternocostal lig.
Articular cavities
Costal cartilages
3
Costochondral joints

Radiate sternocostal ligs. Costal cartilages

5
Interchondral joints

6 Xiphoid
process
7 8 Costoxiphoid lig.

Figure 4-4
Sternocostal articulations, anterior view.

150 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Arthrology
Joints of the Thoracic Spine (continued)

Anterior longitudinal lig.


Transverse costal facet (for tubercle of
rib of same number as vertebra)

Lateral costotransverse lig.


Inferior costal facet (for head
of rib one number higher)
Intertransverse lig.

Interarticular lig. of head of rib Superior costotransverse lig.

4 
Thoracolumbar Spine
Superior costal facet (for head
of rib of same number)

Radiate lig. of head of rib

Left lateral view

Superior articular
facet of rib head

Intraarticular lig.

Radiate lig.
Synovial
of head of rib
cavities

Superior costotransverse lig. (cut)

Lateral costotransverse lig.


Costotransverse lig.

Transverse section: superior view

Figure 4-5
Costovertebral joints.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 151


Anatomy  •  Arthrology
Joints of the Lumbar Spine

Superior articular process


Mammillary process
Pedicle
Transverse process
Spinous process
Vertebral body 1 Inferior
Vertebral canal articular
Superior Intervertebral disc process
articular process
Vertebral body Inferior
Mammillary process 2 vertebral notch
Intervertebral
Transverse process
foramen
Superior
vertebral
3 notch
Accessory
process
Spinous
process
4

Lamina
5
Inferior
articular process Articular facet
for sacrum

L3 and L4 vertebrae: Lumbar vertebrae, assembled:


posterior view left lateral view

Figure 4-6
Lumbar spine.

Thoracolumbar Type and Closed Packed


Joints Classification Position Capsular Pattern
Zygapophyseal Synovial: plane Extension Lumbar: significant limitation of side-bending bilaterally and
joints limitations of flexion and extension
Thoracic: limitation of extension, side-bending, and rotation;
less limitation of flexion

Intervertebral Amphiarthrodial Not applicable Not applicable


joints

Type and Closed Packed Capsular


Thoracic Spine Classification Position Pattern
Costotransverse Synovial Not reported Not reported

Costovertebral Synovial Not reported Not reported

Costochondral Synchondroses Not reported Not reported

Interchondral Synovial Not reported Not reported

Sternocostal (first joint) Amphiarthrodial Not applicable Not applicable

Sternocostal (second to seventh joints) Synovial Not reported Not reported

152 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Ligaments
Costovertebral Ligaments

Anterior longitudinal lig. Transverse costal facet (for tubercle of rib


of same number as vertebra)
Inferior costal Lateral costotransverse lig.
facet (for head of
rib one number higher)
Intertransverse lig.
Interarticular
lig. of head of rib
Superior costal Superior
facet (for head of costotransverse lig.
rib of same number) Superior articular
facet of rib head
Radiate lig. Intraarticular lig.
of head of rib
Radiate lig.
of head of rib Synovial

4 
cavities
Left lateral view

Thoracolumbar Spine
Superior costotransverse lig. (cut)

Superior costal
facet (for head of rib
Transverse process of same number)
(cut off)
Costotransverse lig.
Lateral costotransverse lig.
Transverse section: superior view
Radiate lig. of head of rib

Costotransverse lig.

Lateral costotransverse lig.

Superior costotransverse lig.

Intertransverse lig.

Right posterolateral view

Figure 4-7
Costovertebral ligaments.

Ligaments Attachments Function


Radiate sternocostal Costal cartilage to the anterior and posterior Reinforces joint capsule
aspects of the sternum

Interchondral Connect adjacent borders of articulations Reinforces joint capsule


between costal cartilages 6 and 7, 7 and 8,
and 8 and 9

Radiate ligament of Lateral vertebral body to head of rib Prevents separation of rib head
head of rib from vertebra

Costotransverse Posterior aspect of rib to anterior aspect of Prevents separation of rib from
transverse process of vertebra transverse process

Intraarticular Crest of the rib head to intervertebral disc Divides joint into two cavities

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 153


Anatomy  •  Ligaments
Thoracolumbar Ligaments

Left lateral view Inferior articular process


(partially sectioned Capsule of zygapophyseal joint
in median plane) (partially opened)
Anterior Superior articular process
longitudinal lig.
Transverse process
Lumbar vertebral body Spinous process
Intervertebral disc Ligamentum flavum
Interspinous lig.
Anterior
longitudinal lig. Supraspinous lig.

Posterior
longitudinal lig.
Intervertebral foramen

Posterior vertebral segments:


anterior view
Anterior vertebral segments:
posterior view Pedicle (cut surface)
(pedicles sectioned)

Pedicle (cut surface)


Ligamentum flavum

Posterior surface
of vertebral bodies Lamina

Posterior Superior articular


longitudinal lig. process

Intervertebral disc
Transverse process

Inferior articular facet

Figure 4-8
Thoracolumbar ligaments.

Ligaments Attachments Function


Anterior longitudinal Extends from anterior sacrum to anterior tubercle of Maintains stability and prevents
C1. Connects anterolateral vertebral bodies and discs excessive extension of spinal column

Posterior Extends from the sacrum to C2. Runs within the Prevents excessive flexion of spinal
longitudinal vertebral canal attaching the posterior vertebral bodies column and posterior disc protrusion

Ligamenta flava Binds the lamina above each vertebra to the lamina Prevents separation of the vertebral
below laminae

Supraspinous Connect spinous processes of C7-S1 Limits separation of spinous processes

Interspinous Connect spinous processes of C1-S1 Limits separation of spinous processes

Intertransverse Connect adjacent transverse processes of vertebrae Limits separation of transverse processes

Iliolumbar Transverse processes of L5 to posterior aspect of iliac Stabilizes L5 and prevents anterior shear
crest

154 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Muscles
Thoracolumbar Muscles: Superficial Layers
Superior nuchal line of skull Semispinalis capitis m.

Spinous process of C2 vertebra Splenius capitis m.

Sternocleidomastoid m. Spinous process of C7 vertebra


Posterior triangle of neck Splenius cervicis m.
Trapezius m. Levator scapulae m.
Spine of scapula Rhomboid minor m. (cut)
Deltoid m. Supraspinatus m.
Serratus
Infraspinatus posterior
fascia superior m.
Rhomboid
Teres minor m. major m.
(cut)

4 
Teres major m. Infraspinatus
fascia (over
infraspinatus

Thoracolumbar Spine
Latissimus m.)
dorsi m. Teres minor
and major
Spinous process mm.
of T12 vertebra
Latissimus dorsi m. (cut)
Thoracolumbar fascia Serratus anterior m.
Serratus posterior inferior m.
External oblique m. 12th rib
Internal oblique m. Erector spinae m.
in lumbar triangle
External oblique m.
Iliac crest
Gluteal aponeurosis
(over gluteus medius m.) Gluteus maximus m. Internal oblique m.

Figure 4-9
Muscles of the back, superficial layers.

Distal Nerve and


Muscles Proximal Attachment Attachment Segmental Level Action
Latissimus dorsi Spinous processes of T6-T12, Intertubercular Thoracodorsal Humerus extension,
thoracolumbar fascia, iliac groove of humerus nerve (C6, C7, C8) adduction, and internal
crest, inferior four ribs rotation

Trapezius (middle) Superior nuchal line, occipital Lateral clavicle, Accessory nerve Retracts scapula
protuberance, nuchal acromion, and (CN XI)
Trapezius (lower) ligament, spinous processes spine of scapula Depresses scapula
of T1-T12

Rhomboid major Spinous processes of T2-T5 Inferior medial Dorsal scapular Retracts scapula,
border of scapula nerve (C4, C5) inferiorly rotates
glenoid fossa, stabilizes
Rhomboid minor Spinous processes of C7-T1 Superior medial scapula to thoracic wall
and nuchal ligament border of scapula

Serratus posterior Spinous processes of C7-T3, Superior surface Intercostal nerves Elevates ribs
superior ligamentum nuchae of ribs 2-4 2-5

Serratus posterior Spinous processes of T11-L2 Inferior surface of Ventral rami of Depresses ribs
inferior ribs 8-12 thoracic spinal
nerves 9-12
CN, cranial nerve.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 155


Anatomy  •  Muscles
Thoracolumbar Muscles: Intermediate Layer
Superior nuchal line of skull Rectus capitis posterior minor m.

Posterior tubercle of atlas (C1) Obliquus capitis superior m.

Rectus capitis posterior major m.


Longissimus capitis m.
Obliquus capitis inferior m.
Semispinalis capitis m.
Longissimus capitis m.
Splenius capitis and
splenius cervicis mm. Semispinalis capitis m. (cut)

Serratus posterior superior m. Spinalis cervicis m.


Spinous process of C7 vertebra
Iliocostalis m. Longissimus cervicis m.
Erector Iliocostalis cervicis m.
spinae Longissimus m.
muscle Iliocostalis thoracis m.

Spinalis m. Hook
Spinalis thoracis m.
Longissimus thoracis m.
Serratus posterior
Iliocostalis lumborum m.
inferior m.
Spinous process of
Tendon of origin of T12 vertebra
transversus abdominis m.
Transversus abdominis
Internal oblique m. m. and tendon of origin

External oblique
m. (cut) Thoracolumbar fascia
(cut edge)
Iliac crest

Figure 4-10
Muscles of the back, intermediate layer.

Nerve and
Muscles Proximal Attachment Distal Attachment Segmental Level Action
Iliocostalis Cervical transverse processes
thoracis and superior angles of lower
ribs

Iliocostalis Iliac crest, posterior Inferior surface of ribs 4-12


lumborum sacrum, spinous Bilaterally: extend
processes of sacrum Dorsal rami of spinal column
Longissimus Thoracic transverse processes
and inferior lumbar spinal nerves Unilaterally: side-bend
thoracis and superior surface of ribs
vertebrae, supraspinous spinal column
Longissimus ligament Transverse process of lumbar
lumborum vertebrae

Spinalis Upper thoracic spinous


thoracis processes

156 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Muscles
Thoracolumbar Muscles: Deep Layer

Superior nuchal line of skull


Rectus capitis posterior minor m.
Mastoid process
Obliquus capitis superior m.
Posterior tubercle of atlas
(C1 vertebra) Rectus capitis posterior major m.
Spinous process of axis Transverse process of atlas (C1)
(C2 vertebra) Obliquus capitis inferior m.
Semispinalis capitis m. Longus
Brevis Rotatores cervicis mm.
Spinous process
Interspinalis cervicis m.
of C7 vertebra
Levator costae m.
External intercostal mm.

Longus Rotatores

4 
Brevis thoracis mm.
Semispinalis thoracis m.

Thoracolumbar Spine
Brevis Levatores
Longus costarum mm.
Multifidi mm.

Thoracolumbar fascia
(anterior layer) Interspinalis lumborum m.
Thoracolumbar fascia
(posterior layer) (cut) Lateral intertransversarius m.

Transversus abdominis m. Quadratus lumborum m.


and tendon of origin Iliac crest

Multifidi mm.
Multifidi mm. (cut)
Erector spinae m. (cut)

Figure 4-11
Muscles of the back, deep layer.

Proximal Nerve and


Muscles Attachment Distal Attachment Segmental Level Action
Rotatores Transverse processes Spinous process of Dorsal rami of spinal Vertebral stabilization,
of vertebrae vertebra one to two nerves assists with rotation
segments above origin and extension

Interspinalis Superior aspect of Inferior aspect of spinous Dorsal rami of spinal Extension and rotation
cervical and lumbar process superior to nerves of vertebral column
spinous processes vertebrae of origin

Intertransversarius Cervical and lumbar Transverse process of Dorsal and ventral Bilaterally stabilizes
transverse processes adjacent vertebrae rami of spinal nerves vertebral column.
Ipsilaterally side-bends
vertebral column

Multifidi Sacrum, ilium, Spinous process of Dorsal rami of spinal Stabilizes vertebrae
transverse processes vertebra two to four nerves
of T1-T3, articular segments above origin
processes of C4-C7

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 157


Anatomy  •  Muscles
Anterior Abdominal Wall

Extensor mm.
Corset Spinalis
Longissimus
Iliocostalis

Flexor mm.
Psoas
External oblique
Internal oblique
Transversus
Rectus abdominis

Figure 4-12
Dynamic “corset” concept of lumbar stability.

Nerve and
Segmental
Muscles Proximal Attachment Distal Attachment Level Action
Rectus abdominis Pubic symphysis and pubic Costal cartilages 5-7 Ventral rami of Flexes trunk
crest and xiphoid process T6-T12

Internal oblique Thoracolumbar fascia, anterior Inferior border of ribs Ventral rami of Flexes and rotates trunk
iliac crest, and lateral inguinal 10-12, linea alba, T6-L1
ligament and pecten pubis

External oblique External aspects of ribs 5-12 Anterior iliac crest, Ventral rami of Flexes and rotates trunk
linea alba, and pubic T6-T12 and
tubercle subcostal nerve

Transversus Internal aspects of costal Linea alba, pecten Ventral rami of Supports abdominal
abdominis cartilages 7-12, thoracolumbar pubis, and pubic T6-L1 viscera and increases
fascia, iliac crest, and lateral crest intraabdominal pressure
inguinal ligament

158 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Fascia

Thoracolumbar
fascia (superficial
and deep laminae

4 
of posterior layer)

Thoracolumbar Spine
Transversus
abdominis

Figure 4-13
Transverse abdominis. The transverse abdominis exerts a force through the thoracolumbar fascia, creating a stabilizing force through
the lumbar spine. (From Kay AG. An extensive literature review of the lumbar multifidus: biomechanics. J Man Manip Ther.
2001;9:17-39.)

The thoracolumbar fascia is a dense layer of connective tissue running from the thoracic region
to the sacrum.4 It is composed of three separate and distinct layers: anterior, middle, and posterior.
The middle and posterior layers blend together to form a dense fascia referred to as the lateral
raphe.5 The posterior layer consists of two distinctly separate laminae. The superficial lamina fibers
are angled downward and the deep lamina fibers are angled upward. Bergmark6 has reported that
the thoracolumbar fascia serves three purposes: (1) to transfer forces from muscles to the spine,
(2) to transfer forces between spinal segments, and (3) to transfer forces from the thoracolumbar
spine to the retinaculum of the erector spinae muscles. The transverse abdominis attaches to the
middle layer of the thoracolumbar fascia and exerts a force through the lateral raphe, resulting
in a cephalad tension through the deep layer and a caudal tension through the superficial layer
of the posterior lamina.4,5,7 The result is a stabilizing force exerted through the lumbar spine, which
has been reported to provide stability and assist with controlling intersegmental motion of the
lumbar spine.8-10

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 159


Anatomy  •  Nerves
Trapezius m.
Spinal nerve trunk Erector spinae m.
Ventral (anterior) ramus of spinal nerve (intercostal nerve)
Meningeal branch Medial branch,
Lateral branch of Collateral branch
Spinal sensory
(dorsal root) ganglion Dorsal (posterior) External intercostal m.
ramus Internal intercostal m.
Innermost intercostal m.
Dorsal root
Latissimus dorsi m.
Ventral root
Subcostal mm.

Internal
intercostal m.

Serratus
anterior m.
Lateral
Communicating cutaneous
Greater and lesser branch
splanchnic nn. branch Window cut
in innermost Collateral branch
intercostal m. rejoining intercostal n.
Internal intercostal
Sympathetic trunk membranes anterior to Innermost
external intercostal mm. intercostal m.
Gray and white Internal
rami communicantes Superior costotransverse ligs. intercostal m.
Slip of costal part
Rectus abdominis m. Transversus of diaphragm External intercostal m.
abdominis m.
Linea alba External intercostal
membrane
External
oblique m.
Costal cartilage
Anterior cutaneous
branch

Figure 4-14
Nerves of the thoracic spine.

Nerve Segmental
Ventral Rami Level Sensory Motor
Intercostals T1-T11 Anterior and lateral aspect Intercostals, serratus posterior, levator costarum,
of the thorax and abdomen transversus thoracis
Subcostals T12 Part of external oblique
Dorsal rami T1- T12 Posterior thorax and back Splenius, iliocostalis, longissimus, spinalis,
interspinales, intertransversarii, multifidi,
semispinalis, rotatores
Subcostal nerve T12 Lateral hip External oblique
Iliohypogastric nerve T12, L1 Posterolateral gluteal region Internal oblique, transverse abdominis
Ilioinguinal L1 Superior medial thigh Internal oblique, transverse abdominis
Genitofemoral L1, L2 Superior anterior thigh No motor
Lateral cutaneous L2, L3 Lateral thigh No motor
Branch to iliacus L2, L3, L4 No sensory Iliacus
Femoral nerve L2, L3, L4 Thigh via cutaneous nerves Iliacus, sartorius, quadriceps femoris, articularis
genu, pectineus
Obturator nerve L2, L3, L4 Medial thigh Adductor longus, adductor brevis, adductor magnus
(adductor part), gracilis, obturator externus
Sciatic L4, L5, S1, Hip joint Knee flexors and all muscles of the lower leg and
S2, S3 foot

160 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Anatomy  •  Nerves
Subcostal n. (T12) T12

White and gray rami communicantes


L1

Iliohypogastric n.

L2
Ilioinguinal n.

Genitofemoral n.
Ventral rami of
L3 spinal nn.
Lateral cutaneous
n. of thigh

Gray rami communicantes


L4

4 
Muscular branches
to psoas and iliacus mm.

Thoracolumbar Spine
L5
Femoral n.

Accessory obturator n. (often absent)


Anterior division
Obturator n. Posterior division
Lumbosacral trunk

White and gray


Diaphragm (cut) rami communicantes

Subcostal n. (T12) Subcostal n. (T12)


Sympathetic trunk Iliohypogastric n.
L1
Ilioinguinal n.
Iliohypogastric n.
L2 Transversus abdominis m.
Ilioinguinal n.
L3 Quadratus lumborum m.
Genitofemoral n. (cut)
Psoas major m.
L4
Lateral cutaneous Gray rami communicantes
n. of thigh
Genitofemoral n.
Femoral n. Iliacus m.

Obturator n. Lateral cutaneous n. of thigh

Psoas major m. (cut) Femoral n.

Lumbosacral trunks Genital branch and


Femoral branch of
Inguinal lig. (Poupart) genitofemoral n.

Obturator n.

Figure 4-15
Nerves of the lumbar spine.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 161


Anatomy  •  Nerves
Intercostal n. (T11)
Anterior division
Subcostal n. (T12) T12
Posterior division
Iliohypogastric n.
(T12, L1) Sympathetic trunk

Ilioinguinal n. (L1) Rami


L1
communicantes
To psoas major and
psoas minor mm.
Genitofemoral n. (L1, 2)
Lateral cutaneous n.
of thigh (L2, 3) L2
Genital branch and Lumbar plexus
Femoral branch
of genitofemoral n.
To psoas major and L3
iliacus mm.
Anterior branches
and
lateral branches
of subcostal and L4
iliohypogastric nn.
Lumbosacral trunk
N. to quadratus
femoris (and inferior L5
gemellus) (L4, 5, S1)
N. to obturator
Sacral plexus
internus (and superior S1
gemellus) (L5, S1, 2)
Superior gluteal S2
n. (L4, 5, S1)
N. to piriformis (S1, 2) S3
Obturator n. (L2, 3, 4)
Accessory obturator n. S4
(L3, 4) (inconstant) S5 Coccygeal plexus
Inferior gluteal n. (L5, S1, 2) Co
Pelvic splanchnic nn.
Femoral n. (L2, 3, 4) Perforating cutaneous
n. (S2, 3)
Sciatic n.
N. to levator ani
Posterior cutaneous and coccygeus (S3, 4)
n. of thigh (S1, 2, 3) Perineal branch of
Pudendal n. (S2, 3, 4) 4th sacral n.
Anococcygeal nn.
Common fibular
(peroneal) n. Obturator n.
Sciatic n. (L4, 5, S1, 2) Inferior anal
Tibial n. Posterior (rectal) n.
(L4, 5, S1, 2, 3) cutaneous Dorsal n. of penis/clitoris
n. of thigh Perineal n. and posterior scrotal/labial branches

Figure 4-16
Nerves of the lumbar spine.

162 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Patient History  •  Initial Hypotheses Based on the Patient History

History Initial Hypothesis


Reports of restricted motion of the lumbar spine associated with low back or buttock Zygapophyseal joint pain
pain exacerbated by a pattern of movement that indicates possible opening or closing syndromes11-13
joint restriction (i.e., decreased extension, right side-bending, and right rotation)

Reports of centralization or peripheralization of symptoms during repetitive movements Possible discogenic pain14
or prolonged periods in certain positions

Reports of lower extremity pain/paresthesia that is worse than the low back pain. May Possible sciatica or lumbar
report experiencing episodes of lower extremity weakness radiculopathy15

Pain in the lower extremities that is exacerbated by extension and quickly relieved by Possible spinal stenosis16
flexion of the spine

Reports of recurrent locking, catching, or giving way of the low back during active Possible lumbar instability17,18
motion

4 
Reports of low back pain that is exacerbated by stretching of either the ligaments or Muscle/ligamentous sprain/strain

Thoracolumbar Spine
muscles. Might also report pain with contraction of muscular tissues

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 163


Patient History  •  Lumbar Zygapophyseal Joint Referral Patterns

Lumbar spine
region

Groin region

Gluteal region
Trochanteric
region

Lateral thigh
Posterior thigh region
region

Figure 4-17
Lumbar zygapophyseal joint pain referral patterns. Zygapophyseal pain patterns of the lumbar spine as described by Fukui and
colleagues. Lumbar zygapophyseal joints L1-L2, L2-L3, and L4-L5 always referred pain to the lumbar spine region. Primary referral
to the gluteal region was from L5-S1 (68% of the time). Levels L2-L3, L3-L4, L4-L5, and L5-S1 occasionally referred pain to the
trochanteric region (10% to 16% of the time). Primary referral to the lateral thigh, posterior thigh, and groin regions was most often
from L3-L4, L4-L5, and L5-S1 (5% to 30% of the time). (From Fukui S, Ohseto K, Shiotani M, et al. Distribution of referred pain
from the lumbar zygapophyseal joints and dorsal rami. Clin J Pain. 1997;13:303-307.)

Percentage of Patients Presenting with Pain


Area of Pain Referral (n = 176 Patients with Low Back Pain)*
Left groin 15%

Right groin 3%

Left buttock 42%

Right buttock 15%

Left thigh 38%

Right thigh 38%

Left calf 27%

Right calf 15%

Left foot 31%

Right foot 8%
*Prevalence of pain referral patterns in patients with zygapophyseal joint pain syndromes as confirmed by diagnostic blocks.13 In a subsequent study,19
it was determined that in a cohort of 63 patients with chronic low back pain, the prevalence of zygapophyseal joint pain was 40%.

164 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Patient History  •  Thoracic Zygapophyseal Joint Referral Patterns

T3-4
T4-5

T5-6
T6-7
T7-8

4 
T8-9
T9-10
T10-11

Thoracolumbar Spine
As described by Dreyfuss et al19

T2-3

T9-10

As described by Fukui et al90

Figure 4-18
Zygapophyseal pain patterns of the thoracic spine.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 165


Patient History  •  Reliability of the Historical Examination

Historical Question and Study Quality Population Reliability


Patient report of 20 ●: Foot pain Interexaminer κ = .12 to .73

Leg pain Interexaminer κ = .53 to .96


Two separate groups of patients with
Thigh pain Interexaminer κ = .39 to .78
low back pain (n1 = 50, n2 = 33).
Buttock pain Interexaminer κ = .33 to .44

Back pain Interexaminer κ = −.19 to .16

Increased pain with21 ●: Sitting Test-retest κ = .46


53 subjects with a primary complaint
Standing Test-retest κ = .70
of low back pain
Walking Test-retest κ = .67

Increased pain with22 ◆: Sitting Interexaminer κ = .49

Standing A random selection of 91 patients Interexaminer κ = 1.0

Walking with low back pain Interexaminer κ = .56

Lying down Interexaminer κ = .41

Pain with sitting23 ◆ Interexaminer κ = .99 to 1.0


95 patients with low back pain
Pain with bending23 ◆ Interexaminer κ = .98 to .99

Pain with bending21 ● 53 subjects with a primary complaint Test-retest κ = .65


of low back pain

Pain with bending20 ● Two separate groups of patients with Interexaminer κ = .51 to .56
low back pain (n1 = 50, n2 = 33).

Increased pain with coughing/sneezing22 ◆ A random selection of 91 patients Interexaminer κ = .64


with low back pain

Increased pain with coughing21 ● 53 subjects with a primary complaint Test-retest κ = .75
of low back pain
Pain with pushing/lifting/carrying21 ● Test-retest κ = .77 to .89

166 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Patient History  •  Diagnostic Utility of Patient History in Identifying Lumbar Spinal Stenosis

Historical Question Patient Reference


and Study Quality Population Standard Sens Spec +LR −LR
Age over 65 years24 ◆ .77 (.64, .90) .69 (.53, .85) 2.5 .33

Pain below knees?24 ◆ .56 (.41, .71) .63 (.46, .80) 1.5 .70

Pain below buttocks?24 .88 (.78, .98) .34 (.18, .50) 1.3 .35
Lumbar spinal
◆ stenosis per
No pain when seated?24 attending .46 (.30, .62) .93 (.84, 1.0) 6.6 .58
◆ physician’s
93 patients with impression;
Severe lower extremity low back pain 88% also .65 (.51, .79) .67 (.51, .83) 2.0 .52
pain?24 ◆ 40 years old or supported by
older computed
Symptoms improved tomography (CT) .52 (.37, .67) .83 (.70, .96) 3.1 .58

4 
while seated?24 ◆ or magnetic
resonance

Thoracolumbar Spine
Worse when walking?24 .71 (.57, .85) .30 (.14, .46) 1.0 .97
imaging (MRI)

Numbness24 ◆ .63 (.49, .74) .59 (.42, .76) 1.5 .63

Poor balance24 ◆ .70 (.56, .84) .53 (.36, .70) 1.5 .57

Do you get pain in your .81 (.66, .96) .16 (.00, .32) .82 (.63, 1.1) 1.27
legs with walking that is
relieved by sitting?16 ●

Are you able to walk 45 patients with .63 (.42, .85) .67 (.40, .93) 1.9 (.80, 4.5) .55
better when holding onto low back and
a shopping cart?16 ● Lumbar spinal
leg pain and
stenosis per
Sitting reported as best self-reported .89 (.76, 1.0) .39 (.16, .61) 1.5 (.90, 2.4) .28
MRI or CT
posture with regard to limitations in
imaging
symptoms16 ● walking
tolerance
Walking/standing .89 (.76, 1.0) .33 (.12, .55) 1.3 (.80, 2.2) .33
reported as worst
posture with regard to
symptoms16 ●

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 167


Patient History  •  Diagnostic Utility of Patient History in Identifying Lumbar Radiculopathy

Historical Question
and Study Quality Patient Population Reference Standard Sens Spec +LR −LR
Patient reports of:

Weakness25 ◆ .70 .41 1.19 .73

Numbness25 ◆ 170 patients with low Lumbosacral radiculopathy per .68 .34 1.03 .94
back and leg symptoms electrodiagnostics

Tingling25 ◆ .67 .31 .97 1.06

Burning25 ◆ .40 .60 1.0 1.0

168 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Patient History  •  Diagnostic Utility of Patient History in Identifying Ankylosing Spondylitis

In early stages (sacroiliitis


only), back contour may In more advanced
appear normal but flexion sacroiliac plus lower
may be limited spine involvement, back
is straightened with
“ironed-out” appearance
Bilateral sacroiliitis is early radiographic
sign. Thinning of cartilage and bone
Anterior longitudinal lig. condensation on both sides of sacroiliac

4 
joints

Thoracolumbar Spine
Radiate lig. of head of rib

Costotransverse ligs.

Rib

Ossification of radiate and


costotransverse ligaments limits
chest expansion

Characteristic posture
in late stage of
disease. Measurement
at nipple line demon-
strates diminished
chest expansion

Ossification of annulus fibrosus of intervertebral discs, apophyseal


joints, and anterior longitudinal and interspinal ligaments

Figure 4-19
Ankylosing spondylitis.

Patient Reference
Clinical Symptom and Study Quality Population Standard Sens Spec +LR −LR
26
Pain not relieved by lying down ◆ .80 .49 1.57 .41
The New York
Back pain at night27 ◆ 449 randomly criteria and .71 .53 1.51 .55
selected patients radiographic
Morning stiffness for longer than 1 26
hour ◆ with low back pain .64 .59 1.56 .68
2
confirmation
Pain or stiffness relieved by exercise26 ◆ of ankylosing .74 .43 1.30 .60
26
spondylitis
Age of onset 40 years or less ◆ 1.0 .07 1.07 .00

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 169


Physical Examination Tests  •  Neurologic Examination
Diagnostic Utility of Sensation Testing, Manual Muscle Testing, and Reflex Testing for
Lumbosacral Radiculopathy
Description
Test and Study and Positive
Quality Findings Population Reference Standard Sens Spec +LR −LR
Sensation (vibration and Considered .50 .62 1.32 .81
pinprick)25 ◆ abnormal when
either vibration
or pinprick was
reduced on the
side of the lesion Electrodiagnostic testing.
Radiculopathy defined as
Gastroc­ S1 = S1 = 1.96 .70
the presence of positive
nemius .47 .76
sharp waves; fibrillation
and soleus
potentials; complex
Extensor Weakness was 170 patients repetitive discharges; L5 = L5 = 1.36 .71
Weakness 25 hallucis defined as any with low high-amplitude, long- .61 .55
longus grade of less back and duration motor unit

than 5/5 lower potentials; reduced
Hip flexors extremity recruitment; or increased L3-L4 L3-L4 4.38 .36
symptoms polyphasic motor unit = .70 = .84
Quadriceps potentials (of more than L3-L4 L3-L4 3.64 .67
30%) in two or more = .40 = .89
muscles innervated by the
Achilles Considered same nerve root level but S1 = S1 = 4.70 .59
abnormal when different peripheral nerves .47 .9
the reflex on the
Reflexes25 Patellar side of the lesion L3-L4 L3-L4 7.14 .54
◆ was reduced = .50 = .93
compared with
the opposite side

Achilles S1 = S1 = 1.93 .30


100 patients
.83 .57
with lumbar Lumbar disc herniation
Reflexes28 Medial Test is positive if disc diagnosed by MRI with L5 = L5 = 5.07 .28
◆ hamstring reflex is absent herniation level of herniation .76 .85
diagnosed intraoperatively confirmed
Patellar L3-L4 L3-L4 6.29 .14
by MRI
= .88 = .86
Reflexes All three Electrodiagnostic testing. .12 .97 4.00 .91
+ abnormal Radiculopathy defined as
Weakness the presence of positive
+ sharp waves; fibrillation
Sensory25 ◆ potentials; complex
170 patients repetitive discharges;
with low high-amplitude, long-
All four abnormal .06 .99 6.00 .95
back and duration motor unit
Reflexes lower potentials; reduced
+ extremity recruitment; or increased
Weakness symptoms polyphasic motor unit
+ potentials (of more than
Sensory Any of four .87 .35 1.34 .37
30%) in two or more
+ abnormal
muscles innervated by the
Straight-leg raise test25 ◆ same nerve root level but
different peripheral nerves

170 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Neurologic Examination
Level of Herniation Pain Numbness Weakness Atrophy Reflexes

L3

L4
L4
L5

S
Lower back,
L3-4 disc; hip, posterolateral Antero- Knee jerk
4th lumbar thigh, anterior leg medial thigh Quadriceps Quadriceps diminished
nerve root and knee

L3

4 
L4 Changes
Over
uncommon

Thoracolumbar Spine
sacro-
Dorsifexion Minor (absent or
L5 iliac
of great toe diminished
joint,
L5 hip, and foot; posterior
S difficulty tibial
lateral
walking on reflex)
thigh,
L4-5 disc; Lateral leg, heels; foot
and leg
5th lumbar web of great drop may
nerve root toe occur

L4 Over Plantar
sacro- flexion of
iliac foot and
L5 joint, great toe
hip, may be
S postero- affected;
lateral difficulty
S1 thigh, walking on
and leg Back of calf; toes Ankle jerk
to heel lateral heel, diminished
L5-S1 disc;
foot and toe Gastrocne- or absent
1st sacral
nerve root mius and
soleus

L4
Lower back, Thighs, Variable
thighs, legs, legs, paralysis or
L5
and/or feet, and/or paresis of
L5 perineum perineum; legs and/or May be
S depending variable; bowel and extensive
S1 on level of may be bladder
S2 lesion; bilateral inconti-
may be nence Ankle jerk
S3 Massive diminished
S4 midline bilateral
S5 or absent
protrusion
Coccygeal

Figure 4-20
Clinical features of herniated lumbar nucleus pulposus.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 171


Physical Examination Tests  •  Neurologic Examination
Diagnostic Utility of Sensation Testing, Manual Muscle Testing, and Reflex Testing for
Lumbar Spinal Stenosis

Strength testing of extensor


hallucis longus muscle

Pin prick test

Figure 4-21
Lumbar spinal stenosis testing.

Test and
Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Vibration Assessed at the first metatarsal .53 .81 2.8 .58
deficit24 ◆ head with a 128-Hz tuning fork. (.38, (.67,
Considered abnormal if patient did .68) .95)
not perceive any vibration

Pinprick Sensation tested at the dorsomedial 93 patients .47 .81 2.5 .65
deficit24 ◆ foot, dorsolateral foot, and medial Diagnosis of (.32, (.67,
with back
and lateral calf. Graded as spinal stenosis .62) .95)
pain with or
“decreased” or “normal” by retrospective
without
chart review
Weakness24 Strength of knee flexors, knee radiation to .47 .78 2.1 .68
and confirmed
extensors, and hallucis longus the lower (.32, (.64,
◆ by MRI or CT
muscles was tested. Graded from 0 extremities .62) .92)
(no movement) to 5 (normal)

Absent Reflex testing of the Achilles tendon. .46 .78 2.1 .69
Achilles Graded from 0 (no response) to 4 (.31, (.64,
reflex24 ◆ (clonus) .61) .92)

172 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Range-of-Motion Measurements
Reliability of Range-of-Motion Measurements
Reliability
Measurement and
Study Quality Instrumentation Population Intraexaminer* Interexaminer
Forward bending29 ◆ Measured distance from Heterogeneous group (n Not tested ICC = .93 (.90,
fingertips to floor = 98) including .95)
participants with low
back pain and/or pelvic
girdle pain and
participants with no pain

Forward bending30 ● Intraclass ICC = .99 (.98,


correlation .10)
coefficient (ICC)
= .95 (.89, .99)

4 
Lateral bending30 ● Measured distance that 30 patients with back ICC (right) = .99 ICC (right) = .93

Thoracolumbar Spine
fingertip slid down lateral pain and 20 (.95, 1.0) (.89, .96)
thigh asymptomatic subjects ICC (left) = .94 ICC (left) = .95
(only asymptomatic (.82, .98) (.91, .97)

Trunk rotation30 ● Patients sat with horizontal subjects were used for ICC (right) = .92 ICC (right) = .82
bar on sternum. Plumb intraexaminer (.76, .97) (.70, .89)
weight hung down to floor, comparisons) ICC (left) = .96 ICC (left) = .85
and angle was measured (.87, .99) (.75, .91)
with a protractor

Modified Schober test30 Distances between ICC = .87 (.68, ICC = .79 (.67,
● lumbosacral junction, .96) .88)

Modified Schober test29 5 cm below, and 10 cm Heterogeneous group (n Not tested ICC = .77 (.67,
above, were measured = 98) including .84)

with patient in erect participants with low
standing position and back pain and/or pelvic
while maximally bending girdle pain and
forward participants with no pain

Flexion Back range-of-motion 47 asymptomatic ICC = .91 ICC = .77


Extension instrument students ICC = .63 ICC = .35
Left rotation ICC = .56 ICC = .37
Right rotation ICC = .57 ICC = .35
Left side-bending ICC = .92 ICC = .81
Right side-bending31 ● ICC = .89 ICC = .89

Active rotation in Patients stood with a 24 asymptomatic golfers ICC (right) = .86 ICC (right) = .74
standing32 ◆ horizontal bar resting on (.70, .94) (.49, .88)
their shoulders. A plumb ICC (left) = .80 ICC (left) = .78
weight hung from the end (.58, .92) (.56, .90)
of the bar to the floor
Continued

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 173


Physical Examination Tests  •  Range-of-Motion Measurements
Reliability of Range-of-Motion Measurements (continued)
Reliability
Measurement and
Study Quality Instrumentation Population Intraexaminer* Interexaminer
Thoracolumbar ICC = .97 (.93, ICC = .98 (.95,
flexion33 ◆ .98) .99)

Thoracolumbar ICC = .80 (.58, ICC = .81 (.60,


extension33 ◆ iPhone inclinometer 30 asymptomatic adult .90) .91)
application participants
Thoracolumbar lateral ICC (right) = .82 ICC (right) = .93
flexion33 ◆ (.61, .91) (.86, .97)
ICC (left) = .84 ICC (left) = .90
(.67, .92) (.77, .96)

Lumbar flexion34 ◆ 49 patients with low Interexaminer ICC = .60 (.33, .79)
back pain referred for
Lumbar extension34 ◆ flexion-extension Interexaminer ICC = .61 (.37, .78)
radiographs
Single inclinometer
Lumbar flexion ◆ 35
123 patients with low Interexaminer ICC = .74 (.60, .84)
back pain of less than
Lumbar extension35 ◆ 90 days’ duration Interexaminer ICC = .61 (.42, .75)

*In the case of multiple examiners, intraexaminer estimates are presented for the first examiner only.

174 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Range-of-Motion Measurements
Reliability of Range-of-Motion Measurements (continued)

4 
Thoracolumbar Spine
Inclinometer placement at the spinous
process of the 12th thoracic vertebra

Measurement of thoracolumbar flexion

Measurement of thoracolumbar extension


Figure 4-22
Range-of-motion measurement.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 175


Physical Examination Tests  •  Range-of-Motion Measurements
Reliability of Pain Provocation during Range-of-Motion Measurements

Flexion, side-bending, and rotation Extension, side-bending, and rotation

Figure 4-23
Pain provocation during active movements.

Test and Study


Quality Description and Positive Findings Population Reliability
Side-bending27 ◆ Patient stands with arms at sides. Patient slides hand κ = .60 (.40, .79)
down the outside of the thigh

Rotation27 ◆ Patient stands with arms at sides. Patient rotates the κ =.17 (−.08, .42)
trunk

Side-bend rotation27 Patient stands with arms at sides. Patient moves the κ = .29 (.06, .51)
◆ pelvis to one side, creating a side-bend rotation to the 35 patients with
opposite side low back pain

Flexion, side-bending, Patient stands and the therapist guides the patient κ = .39 (.18, .61)
and rotation27 ◆ into lumbar flexion, then side-bending, then rotation

Extension, side- Patient stands and the therapist guides the patient κ = .29 (.06, .52)
bending, and into lumbar extension, then side-bending, then
rotation27 ◆ rotation

Thoracic rotation, Patient places hands on the opposite shoulders and κ = −.03 (−.11, .04)
right36 ◆ rotates the trunk as far as possible in each direction. 22 patients with
Examiner then determines the effect of each mechanical
Thoracic rotation, movement on the patient’s symptoms as “no effect,” neck pain κ = 0.7 (.40, 1.0)
left36 ◆ “increases symptoms,” or “decreases symptoms”

176 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Thoracolumbar Strength and Endurance Tests
Reliability of Assessing Thoracolumbar Strength and Endurance

4 
Thoracolumbar Spine
Figure 4-24
Modified Biering-Sorensen test.

Measurement
and Study Quality Description and Positive Findings Population Reliability
Abdominal From a supine hook-lying position, the Intraexaminer ICC =
endurance30 ● patient curls up to touch fingertips to the .90 (.75, .97)
superior patellae and holds the position for Interexaminer ICC =
as long as possible. Time in seconds is 30 patients with back pain .92 (.87, .96)
measured with a stopwatch and 20 asymptomatic
Modified Biering- Patient starts prone with pelvis and legs subjects (only asymptomatic Intraexaminer ICC =
Sorensen test30 ● supported on couch and trunk hanging off subjects were used for .92 (.75, .97)
the edge supported by a chair. The patient intraexaminer comparisons) Interexaminer ICC =
then extends the trunk and holds a neutral .91 (.85, .95)
position for as long as possible. Time in
seconds is measured with a stopwatch

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 177


Physical Examination Tests  •  Postural Assessment
Reliability of Postural Assessment
Test and Study Interexaminer
Quality Description and Positive Findings Population Reliability
Forward head36 ◆ “Yes” if the patient’s external auditory κ = −.10 (−.20, .00)
meatus was anteriorly deviated (anterior to
the lumbar spine)

Excessive shoulder “Yes” if the patient’s acromions were κ = .83 (.51, 1.0)
protraction36 ◆ anteriorly deviated (anterior to the lumbar
spine)

C7-T2 excessive κ = .79 (.51, 1.0)


kyphosis36 ◆
22 patients with mechanical
T3-T5 excessive Recorded as “normal” (no deviation), neck pain κ = .69 (.30, 1.0)
kyphosis36 ◆ “excessive kyphosis,” or “diminished
kyphosis.” Excessive kyphosis was defined
T3-T5 decreased κ = .58 (.22, .95)
as an increase in the convexity, and
kyphosis36 ◆
diminished kyphosis was defined as a
T6-T10 excessive flattening of the convexity of the thoracic κ = .90 (.74, 1.0)
kyphosis36 ◆ spine (at each segmental group)

T6-T10 decreased κ = .90 (.73, 1.0)


kyphosis36 ◆

Kyphosis37 ● With patient standing, examiner inspects κ = .21


posture from the side. Graded as “present”
or “absent”

Scoliosis37 ● With patient standing, examiner runs finger κ = .33


111 adults age 60 years of
along spinous processes. Patient bends
age or older with chronic
over and examiner assesses height of
low back pain and 20
paraspinal musculature. Graded as
asymptomatic patients
“present” or “absent”

Functional leg length Compared height of bilateral iliac crests κ = .00


discrepancy37 ● with patient standing. Graded as
“symmetric” or “asymmetric”

178 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Postural Assessment
Reliability of Postural Assessment (continued)

Ribs close
together on
concave side
of curve, widely
separated on
convex side;
vertebrae rotated
with spinous
processes and

4 
pedicles toward
concavity

Thoracolumbar Spine
Gauging
trunk
alignment
with plumb
line

Spinous process
deviated to
concave side
Lamina thinner,
vertebral canal
narrower on Rib pushed
concave side posteriorly;
thoracic cage
narrowed

Vertebral body
distorted toward
convex side
Rib pushed
laterally and
anteriorly

Convex side

Concave side

Section through scoliotic vertebrae;


decreased vertebral height and disc Characteristic distortion of vertebra
thickness on concave side and rib in thoracic scoliosis (inferior view)
Figure 4-25
Pathologic anatomy of scoliosis.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 179


Physical Examination Tests  •  Motor Control Assessment
Reliability of Tests for Lumbar Motor Control

Figure 4-26
Sitting forward lean.

Test and Interexaminer


Study Quality Description and Positive Findings Population Reliability
Repositioning38 Subject seated with feet supported and with low back in neutral. A ICC = .90 (.81,
◆ 5-cm tape measure is taped at S1 (0 cm) and marked by a laser .94)
pointer. The subject is instructed to actively move the pelvis twice
from maximum anterior tilt to maximum posterior tilt. Subject then
repositions the pelvis back to neutral, and the distance is measured
between S1 (0 cm) and the laser pointer

Sitting forward Subject seated with feet supported and low back in neutral. S1 and ICC = .96 (.92,
lean38 ◆ a point 10 cm above S1 are marked. Subject instructed to maintain .98)
distance between the two points while performing 5 repetitions of
hip flexion to a maximum of 120 degrees. The distance between
marks (0 cm and 10 cm) is measured

Sitting knee Same setup as for the repositioning test but with feet unsupported. ICC = .95 (.90,
extension38 ◆ The low back is in neutral with a 5-cm tape measure taped at S1 .97)
(0 cm) and marked by a laser pointer. Five repetitions of active
25 subjects
knee extension to −10 degrees are performed while maintaining the
with
pelvis in neutral. The distance is measured between S1 (0 cm) and
nonspecific
the laser pointer
low back
Bent knee Subject supine with one knee flexed 120 degrees and pelvis in pain and 15 ICC = .94 (.88,
fall-out38 ◆ neutral. A 5-cm tape measure is placed between the right and left subjects .97)
anterior superior iliac spines, with a 0-cm mark and laser pointer without it
placed lateral to the anterior superior iliac spine opposite the bent
leg (with the laser pointing medially to the 0-cm mark). Five
repetitions of abduction/external hip rotation of the bent leg to 45
degrees are performed. Movement of the pelvis is measured
between 0 cm on the tape measure and the laser pointer

Leg lowering38 Subject supine with hips at 90 degrees of flexion, knees in ICC = .98 (.96,
◆ maximum relaxed flexion, and low back in neutral. A pressure .99)
biofeedback unit is placed under the low back and inflated to
40 mm Hg. The subject is asked to actively push the low back
downward, increasing the pressure to 45 mm Hg. Then the subject
is instructed to lower the feet to just above the surface of the plinth.
Five repetitions are performed while attempting to maintain 45 mm
Hg. Pressure is recorded when the feet are as close as possible to
the plinth

180 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Passive Intervertebral Motion Assessment
Reliability of Assessing Limited or Excessive Passive Intervertebral Motion
Test and Study
Quality Description and Positive Findings Population Reliability
Upper lumbar (Spinous) Interexaminer κ =.02
segmental mobility39 ● (−.27, .32)
(Left facet) Interexaminer κ
With patient prone, examiner applies a =.17 (−.14, .48)
posteroanterior force to the spinous (Right facet) Interexaminer κ =
process and lumbar facets of each 39 patients with −.01 (−.33, .30)

Lower lumbar lumbar vertebra. Mobility of each low back pain (Spinous) Interexaminer κ =
segmental mobility39 ● segment is judged as “normal” or −.05 (−.36, .27)
“restricted” (Left facet) Interexaminer κ =
−.17 (−.41, .06)
(Right facet) Interexaminer κ =

4 
−.12 (−.41, .18)

Thoracolumbar Spine
Identifying the least Interexaminer κ = .71 (.48, .94)
mobile segment40 ● With patient prone, examiner applies a 29 patients with
posteroanterior force to the spinous central low
Identifying the most process of each lumbar vertebra back pain Interexaminer κ = .29 (−.13,
mobile segment40 ● .71)

Posterior-to-anterior Intraexaminer κ = .54


stiffness40 ◆ Intraexaminer (±1 level) κ = .64
Interexaminer κ = .23
Interexaminer (±1 level) κ = .52

Segmental side Intraexaminer κ = .57


flexion41 ◆ Each level of the lumbar spine was Intraexaminer (±1 level) κ = .69
evaluated for segmental dysfunction. Interexaminer κ = .22
With patient prone, examiner assessed Interexaminer (±1 level) κ = .45
posterior-to-anterior stiffness and
Segmental ventral Intraexaminer κ = .31
multifidus hypertonicity. With patient
flexion41 ◆ 60 patients with Intraexaminer (±1 level) κ = .45
side-lying, side flexion and ventral
low back pain Interexaminer κ = .22
flexion were assessed by moving the
Interexaminer (±1 level) κ = .44
patient’s legs. After performing all four
Multifidus examination procedures, examiners Intraexaminer κ = .51
hypertonicity41 ◆ identified the level of maximal Intraexaminer (±1 level) κ = .60
dysfunction Interexaminer κ = .12
Interexaminer (±1 level) κ = .57

Maximal level of Intraexaminer κ = .60


segmental Intraexaminer (±1 level) κ = .70
dysfunction41 ◆ Interexaminer κ = .21
Interexaminer (±1 level) κ = .57

Segmental mobility42 ◆ With patient side-lying, examiner 20 patients with Interexaminer κ ranged from
palpates adjacent spinous processes low back pain −.25 to .53 depending on
while moving the patient’s legs to examiners and vertebral level
produce passive flexion and extension of
the lumbar spine. Segmental mobility
was graded on a 5-point scale

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 181


Physical Examination Tests  •  Passive Intervertebral Motion Assessment
Reliability of Assessing Limited or Excessive Passive Intervertebral Motion (continued)
Test and Study
Quality Description and Positive Findings Population Reliability
Determination of 60 asymptomatic Intraexaminer κ ranged
segmental volunteers from −.09 to .39
fixations43 ● Passive motion palpation is performed, and Interexaminer κ ranged
the segment is considered fixated if a hard from −.06 to .17

Passive motion end feel is noted during the assessment 21 symptomatic and 25 Interexaminer κ = ranged
palpation44 ◆ asymptomatic subjects from −.03 to .23, with
a mean of .07

Segmental mobility With patient side-lying with hips and knees 71 patients with low Interexaminer κ = .54
testing45 ◆ flexed, examiner assesses mobility while back pain
passively moving the patient. Examiner
determines whether mobility of the
segment is “decreased,” “normal,” or
“increased”

Hypermobility at With patient prone, examiner applies a 49 patients with low Interexaminer κ = .48
any level34 ◆ posteroanterior force to the spinous back pain referred for (.35, .61)
process of each lumbar vertebra. Mobility flexion-extension
Hypomobility at any of each segment is judged as “normal,” radiographs Interexaminer κ = .38
level34 ◆ “hypermobile,” or “hypomobile” (.22, .54)

Determination of Five raters tested lumbar spinal levels for 40 asymptomatic Interexaminer ICC in the
posteroanterior posteroanterior mobility and graded each individuals first study = .55 (.32,
spinal stiffness46 ● on an 11-point scale ranging from .79)
“markedly reduced stiffness” to “markedly Interexaminer ICC in the
increased stiffness” second study = .77
(.57, .89)

Posteroanterior With the patient prone, examiner evaluates 18 patients with low Interexaminer ICC = .25
mobility testing47 ● posteroanterior motion mobility. Mobility is back pain (.00, .39)
scored on a 9-point scale ranging from
“severe excess motion” to “no motion,”
and the presence of pain is recorded

Segmental mobility With patient prone, examiner applies an 63 patients with current Interexaminer κ ranged
testing48 ● anteriorly directed force over the spinous low back pain from −.20 to .26
process of the segment to be tested. depending on level
Examiner grades the mobility as tested
“hypermobile,” “normal,” or “hypomobile”

Identification of a Static palpation is used to determine the 21 symptomatic and 25 Interexaminer κ ranged
misaligned relationship of one vertebra to the vertebra asymptomatic subjects from −.04 to .03, with
vertebra44 ◆ below a mean of .00

Detection of a Two clinicians used visual postural 19 patients with Intraexaminer κ = −.08
segmental lesion at analysis, pain descriptions, leg length chronic mechanical low to .43
T11-L5/S149 ● discrepancy, neurologic examination, back pain Interexaminer κ = −.16
motion palpation, static palpation, and any to .25
special orthopaedic tests to determine the
level of segmental lesion

182 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Passive Intervertebral Motion Assessment
Reliability of Assessing Painful Passive Intervertebral Motion

4 
Thoracolumbar Spine
Figure 4-27
Assessment of posteroanterior segmental mobility.

Reliability
Test and Description and Positive
Study Quality Findings Population Intraexaminer Interexaminer
Spring test With patients in the prone κ = .73 (.39 to 1.0) κ =.12 (−.18 to .41)
T10-T750 ● position the therapist applies 84 subjects, of whom
a posteroanterior force to the 53% reported
Spring test spinous processes of T7-L5. experiencing low κ = .78 (.49 to 1.0) κ = .36 (.07 to .66)
L2-T1150 ● The pressure of each force is back symptoms
held for 20 seconds. within the last 12
Spring test κ = .56 (.18 to .94) κ = .41 (.12 to .70)
Considered positive if the months
L5-L350 ●
force produces pain

Pain with upper With patient prone, examiner (Spinous) Interexaminer κ =.21 (−.10, .53)
lumbar mobility applies a posteroanterior force (Left facet) Interexaminer κ = .46 (.17, .75)
testing39 ● to the spinous processes and (Right facet) Interexaminer κ = .38 (.06, .69)
39 patients with low
lumbar facets of each lumbar
Pain with lower back pain (Spinous) Interexaminer κ = .57 (.32, .83)
vertebra. Response at each
lumbar mobility segment is judged as (Left facet) Interexaminer κ = .73 (.51, .95)
testing39 ● “painful” or “not painful” (Right facet) Interexaminer κ = .52 (.25, .79)

Pain With patient prone, examiner 63 patients with Interexaminer κ ranged from .25 to .55
provocation48 ● applies an anteriorly directed current low back pain depending on the segmental level tested
force over the spinous
Pain during processes of the segment to 49 patients with low Interexaminer κ = .57 (.43, .71)
mobility be tested. Considered positive back pain referred for
testing34 ◆ if pain is reproduced flexion-extension
radiographs

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 183


Physical Examination Tests  •  Passive Intervertebral Motion Assessment
Diagnostic Utility of Assessing Limited and Painful Passive Intervertebral Motion

Motion palpation, seated Motion palpation of side-bending, right

Figure 4-28
Segmental mobility examination.

Test and
Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Active range Quantity of forward-bending active .75 .60 1.88 .42
of motion51 ◆ range of motion. Rated as (.36, (.27, (.57, (.07,
“hypomobile,” “normal,” or Flexion and .94) .86) 6.80) 1.90)
“hypermobile” extension
lateral
Abnormality Examiner judged presence of abnormal radiographs. .43 .88 3.60 .65
of segmental segmental motion during active range Segments (.19, (.70, (.84, (.28,
motion of motion. Rated as “hypomobile,” were .71) .96) 15.38) 1.06)
(AbnROM)51 ◆ “normal,” or “hypermobile considered
9 patients
Passive Examiner applies central hypomobile if .75 .35 1.16 .71
with low
accessory posteroanterior pressure. Passive motion was (.36, (.20, (.44, (.12,
back pain
intervertebral accessory intervertebral motion was more than 2 .94) .55) 3.03) 2.75)
motion rated as “hypomobile,” “normal,” or standard
(PAIVM)51 ◆ “hypermobile” deviations
from the
Passive With patient side-lying, examiner mean of a .42 .89 3.86 .64
physiologic palpates amount of PPIVM during normal (.19, (.71, (.89, (.28,
intervertebral forward bending. Rated as population .71) .96) 16.31) 1.04)
motion “hypomobile,” “normal,” or
(PPIVM)51 ◆ “hypermobile”
Motion Palpation of a motion segment during .42 .57 .98 1.02
palpation52 ● either passive or active motion.
Examiners evaluated for limited motion Self-reported
Pain 184 twins .54 .77 2.35 .60
(i.e., “fixation”). Patient’s pain reaction low back pain
reaction52 ●
was noted after motion palpation of
each segment

184 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Passive Intervertebral Motion Assessment
Association of Limited Passive Intervertebral Motion with Low Back Pain
As part of a larger epidemiologic study, Leboeuf-Yde and associates52 evaluated 184 twins as to the
prevalence of restricted intervertebral motion and its relation to low back pain. As can be seen in
the figure, motion restrictions were no more prevalent in people with current or recent back pain
than in those who had never experienced back pain.

4 
Thoracolumbar Spine
LBP today

LBP in past week

LBP in past month

LBP in past year

LBP ever

LBP never

0 10 20 30 40 50 60

Prevalence rates of “fixations”


detected during motion palpation

Figure 4-29
Prevalence rates of “fixations” detected during motion palpation. (From Leboeuf-Yde C, van Dijk J, Franz C, et al. Motion palpation
findings and self-reported low back pain in a population-based study sample. J Manipulative Physiol Ther. 2002;25:80-87.)

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 185


Physical Examination Tests  •  Passive Intervertebral Motion Assessment
Diagnostic Utility of Assessing Excessive Passive Intervertebral Motion

Figure 4-30
Assessing lumbar passive physiologic
Lumbar flexion Lumbar extension intervertebral motion (PPIVM).

Test and Description and Reference


Study Quality Positive Findings Population Standard Sens Spec +LR −LR
Passive Examiner applies central Rotational Lumbar Segmental
accessory posteroanterior pressure. Instability
intervertebral PAIVM was rated as
motion “hypomobile,” “normal,” .33 .88 2.74 .76
(PAIVM)53 ◆ or “hypermobile” (.12, (.83, (1.01, (.48,
.65) .92) 7.42) 1.21)

Translational Lumbar Segmental


Instability

.29 .89 2.52 .81


(.14, (.83, (1.15, (.61,
.50) .93) 5.53) 1.06)

Flexion passive With patient side-lying, Rotational Lumbar Segmental


physiologic examiner palpates Instability
intervertebral amount of PPIVM during Flexion and extension
motion forward bending. Rated lateral radiographs. .05 .99 .12 .96
Patients
(PPIVM)53 ◆ as “hypomobile,” Segments were (.01, (.96, (.21, (.83,
with a new
“normal,” or considered .36) 1.00) 80.3) 1.11)
episode of
“hypermobile” hypermobile if motion
recurrent or Translational Lumbar Segmental
was more than 2
chronic low Instability
standard deviations
back pain
from the mean of a
normal population .05 .99 8.73 .96
(.01, (.97, (.57, (.88,
.22) 1.00) 134.7) 1.05)

Extension With patient side-lying, Rotational Lumbar Segmental


PPIVM53 ◆ examiner palpates Instability
amount of PPIVM during
backward bending. Rated .22 .97 8.40 .80
as “hypomobile,” (.06, (.94, (1.88, (.56,
“normal,” or .55) .99) 37.55) 1.13)
“hypermobile”
Translational Lumbar Segmental
Instability

.16 .98 7.07 .86


(.06, (.94, (1.71, (.71,
.38) .99) 29.2) 1.05)

186 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Palpation
Reliability of Identifying Segmental Levels
Procedure Performed Interexaminer
and Quality Description of Procedure Patient Population Reliability
Detection of segmental With patient prone, examiner identifies 20 patients with low κ = .69
levels in the lumbar nominated levels of the lumbar spine. back pain
spine54 ◆ Examiner marks the specific level with a pen
containing ink that can only be seen under
ultraviolet light

Examiner judgment of With the patient prone, one spinous process is 18 patients with low ICC = .69 (.53, .82)
marked segmental arbitrarily marked on each patient. Examiners back pain
level47 ● identify the level of the marked segment

Identification of lumbar With the patient prone, each examiner used 60 subjects age 20 to κ = .81 (.79, .83)
spinous process using all of the following landmarks to determine 60 years

4 
multiple bony the location of the spinous processes for
landmarks55 ◆ L1-L4:

Thoracolumbar Spine
1. Identification of T12 by the smaller size of
its spinous process compared with that of
L1 to determine the location of L1.
2. Identification of 12th ribs and their
attachment site at T12 to determine the
location of T12 and its spinous process
and, subsequently, the location of L1.
3. Identification of iliac crests to
approximately determine the location of
the vertebral body of L4.
4. Identification of sacral base to determine
the location of L5.
5. Identification of L5 spinous process by the
smaller size of its spinous process to
determine the location of L4.
Accuracy of the skin marker placement over
the corresponding spinous process
determined by radiograph

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 187


Physical Examination Tests  •  Palpation
Reliability of Identifying Tenderness to Palpation
Procedure Performed Interexaminer
and Quality Description of Procedure Patient Population Reliability
Lumbar paravertebral κ = .34
myofascial pain37 ●

Piriformis myofascial Reports of pain with deep thumb pressure κ = .66


pain37 ● (4 kg)

Tensor fasciae latae κ = .75


myofascial pain37 ●

Fibromyalgia tender Reports of pain with enough pressure to κ = .87


points37 ● blanch thumbnail at: 111 adults age 60 years
1. Occiput at suboccipital muscle insertions with chronic low back
2. Low cervical region at the anterior pain and 20 asymptomatic
aspects of the intertransverse spaces at subjects
C5-C7
3. Trapezius, midpoint of upper border
4. Supraspinatus at origin
5. Rib 2 at the second costochondral
junction
6. 2 cm distal to the epicondyle
7. Medial fat pad of the knee
8. Greater trochanter
9. Gluteal at upper outer quadrant of
buttocks

Osseous pain of each With the subject prone, examiner applies 21 symptomatic and 25 Mean κ for all
joint T11/L1-L5/S144 ◆ pressure over the bony structures of each asymptomatic subjects levels = .48
joint

Intersegmental With patient prone, examiner palpates the 71 patients with low back κ = .55
tenderness45 ◆ area between the spinous processes. pain
Increased tenderness is considered positive

Reliability of Assessing Lumbar Multifidus Muscle Function via Palpation


Procedure Performed Interexaminer
and Quality Description of Procedure Patient Population Reliability
Multifidus lift test Participant prone with arms flexed to κ = .75 (.52, .97)
L4-L556 ◆ approximately 120 degrees and elbows flexed
to approximately 90 degrees, the patient is
Multifidus lift test 32 adults with κ = .81 (.62, 1.00)
instructed to raise contralateral arm toward
L5-S156 ◆ current low back pain
the ceiling approximately 5 cm. Test is positive
when little or no palpable contraction of the
muscle is identified during the arm lift

188 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Centralization Phenomenon
Reliability of Identifying the Centralization Phenomenon
Test and Study Description and Positive
Quality Findings Population Interexaminer Reliability
Centralization and Two examiners with more than 5 39 patients with low κ if centralization occurred
directional preference57 years of training in the McKenzie back pain = .70
◆ method evaluated all patients and
determined whether centralization κ related to centralization
occurred during repeated movements. and directional preference
If centralization occurred, the clinician = .90
recorded the directional preference

Judgments of Therapists (without formal training in 12 patients receiving Between physical therapists
centralization58 ◆ McKenzie methods) and students physical therapy for κ = .82 (.81, .84)
viewed videotapes of patients low back pain Between physical therapy
students κ = .76 (.76, .77)

4 
undergoing a thorough examination
by one therapist. All therapists and
students watching the videos were

Thoracolumbar Spine
asked to make an assessment
regarding the change in symptoms
based on movement status

Status change with κ = .55 (.28, .81)


flexion in sitting35 ◆

Status change with κ = .46 (.23, .69)


repeated flexion in
sitting35 ◆
10 different examiners assessed
123 patients with low
Status change with symptom change (centralization, κ = .51 (.29, .72)
back pain of less than
extension35 ◆ peripheralization, or no change) with
90 days’ duration
single or repeated movements
Status change with κ =.15 (.06, .36)
repeated extension35 ◆

Status change with κ = .28 (.10, .47)


sustained prone
extension35 ◆

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 189


Physical Examination Tests  •  Centralization Phenomenon
Diagnostic Utility of the Centralization Phenomenon

Centralization

Peripheralization

During specific movements, range of motion and movement


of pain noted. Movement of pain from peripheral to central
location (centralization) predicts outcome and appropriateness
of therapy.

Figure 4-31
Centralization of pain.

Test and
Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Centralization59 Centralization present if pain 69 patients with At least one .40 .94 6.9 .63
◆ in the furthermost region persistent low painful disc (.28, (.73, (1.0, (.49,
from midline was abolished back pain with adjacent to a .54) .99) 47.3) .82)
or reduced with a or without nonpainful disc
McKenzie-styled repeated referred leg pain with discography
motion examination

190 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Straight-Leg Raise Test
Reliability of the Straight-Leg Raise Test

4 
Straight-leg raise

Thoracolumbar Spine
Straight-leg raise with sensitizing Figure 4-32
maneuver of cervical flexion Straight-leg raise test.

Test and Study


Quality Description and Positive Findings Population Interexaminer Reliability
Passive straight- With patient supine, examiner passively 91 patients with For typical dermatomal pain, κ = .68
leg raise test22 ◆ flexes the hip and extends the knee. low back pain For any pain in the leg, κ = .36
Examiner measures the angle of randomly selected For straight-leg raising of less than
straight-leg raising and determines if 45 degrees, κ = .43
symptoms occurred in a dermatomal
fashion

Passive straight- With patient supine, examiner 18 physiotherapy ICC Right = .86, Left = .83
leg raise test60 ● maintains the knee in extension while students
passively flexing the hip. The hip is
flexed until examiner feels resistance.
A range-of-motion measurement is
recorded

Passive straight- Passive elevation of the leg with knee 27 patients with κ = .32
leg raise test61 ● extended. Considered positive if pain in low back pain
the low back or buttock is experienced

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 191


Physical Examination Tests  •  Straight-Leg Raise Test
Diagnostic Utility of the Straight-Leg Raise Test for Detecting Disc Bulge or Herniation
Deville and colleagues62 compiled the results of 15 studies investigating the accuracy of the
straight-leg raise test for detecting disc herniation. Ten of the studies included information about
both the sensitivity and specificity of the straight-leg raise test and were used for statistical pooling
of estimates. However, numerous variations of the straight-leg raise maneuver have been reported,
and no consistency was noted among the studies selected for the Deville and colleagues review.
Similarly, a 2011 Cochrane Review63 investigating the accuracy of the straight-leg raise test for
detecting disc herniation used nine studies for statistical pooling of estimates; all nine were the
same as those used by the Deville and colleagues study, reported above. The results of each study,
as well as the pooled estimates, are listed here.

Straight-Leg Raise Description and Reference


Study and Quality Positive Findings Standard Sens Spec +LR −LR
Albeck et al64 ◆ With the patient supine, Herniated lumbar .82 (.70, .90) .21 (.07, .46) 1.0 .86
the knee fully extended, disc observed
65
Charnley et al ◆ and the ankle in neutral during surgery. .85 (.75, .92) .57 (.30, .81) 1.98 .26
dorsiflexion, examiner Herniation was
Gurdjian et al66 ◆ .81 (.78, .83) .52 (.32, .72) 1.69 .37
then passively flexes defined as an
Hakelius et al67 ◆ the hip while extruded, .96 (.95, .97) .14 (.11, .18) 1.12 .29
maintaining the knee in protruded, and
Hirsch et al68 ◆ extension. Positive test bulging disc or a .91 (.85, .94) .32 (.20, .46) 1.34 2.8
defined by reproduction sequestrated disc
Jonsson et al69 ◆ of sciatic pain between in most studies .87 (.81, .91) .22 (.07, .48) 1.12 .59
70 30 degrees and 60 to
Kosteljanetz et al ◆ .89 (.75, .96) .14 (.01, .58) 1.03 .79
75 degrees
Kosteljanetz et al71 ◆ .78 (.64, .87) .48 (.32, .63) 1.5 .49

Knutsson et al72 ◆ .95 (.91, .98) .10 (.02, .33) 1.05 .50

Spangfort et al73 ◆ .97 (.96, .97) .11 (.08, .15) 1.09 .27

Pooled estimate of the .91 (.82, .94) .26 (.16, .38) 1.23 .35
above listed 10 studies
as calculated by
Deville et al62 ◆

Pooled estimate of 9 As above As above .92 (.87, .95) .28 (.18, .40) 1.3 .29
studies from 2011
Cochrane Review63 ◆

Straight-leg raise test74 With patient supine, MRI findings of .52 (.42, .58) .89 (.79, .95) 4.73 .54
◆ examiner slowly lifts the disc bulges,
symptomatic straight herniations, and/
leg until maximal hip or extrusions in
flexion is reached or the 75 patients with
patient asks to stop. complaints of
The angle between the acute or
leg and the table is recurrent low
measured. Positive if back and/or leg
reproduction of familiar pain of 12
radicular pain occurs weeks’ duration
or less

192 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Crossed Straight-Leg Raise Test
Diagnostic Utility of the Crossed Straight-Leg Raise Test for Detecting Disc Bulging  
or Herniation
Deville and colleagues62 also compiled the results of eight studies investigating the accuracy of
the crossed straight-leg raise test for detecting disc herniation. Five of the studies included infor-
mation about both the sensitivity and specificity of the crossed straight-leg raise test and were
used for statistical pooling of estimates. Similarly, a 2011 Cochrane Review63 investigating the
accuracy of the crossed straight-leg raise test for detecting disc herniation used five studies for
statistical pooling of estimates. Four of the five studies used for the pooled estimate were the same
as those used by the Deville and colleagues62 study, reported above. The results of each study, as
well as the pooled estimates, are listed here.

Crossed Straight-Leg Description


Raise Study and and Positive Reference
Quality Findings Standard Sens Spec +LR −LR

4 
Hakelius et al67 ◆ Performed Herniated lumbar .28 (.25, .30) .88 (.84, .90) 2.33 .82
identically to the disc observed

Thoracolumbar Spine
69
Jonsson et al ◆ straight-leg raise during surgery. .22 (.16, .30) .93 (.64, 1.0) 3.14 .84
test except the Herniation was
Kosteljanetz et al70 ◆ .57 (.34, .79) 1.0 (.03, 1.0) Undefined .43
uninvolved lower defined as
Knutsson et al72 ◆ extremity is extruded, .25 (.18, .32) .93 (.73, 1.0) 3.57 .81
lifted. A positive protruded, and
Spangfort et al73 ◆ test is defined bulging disc or .23 (.21, .25) .88 (.84, .91) 1.92 .88
as reproducing sequestrated
Pooled estimate for the pain in the disc in most .29 (.24, .34) .88 (.86, .90) 2.42 .81
five studies listed above involved lower studies
as calculated by Deville extremity
and colleagues62 ◆

Pooled estimate of five As above As above .28 (.22, .35) .90 (.85, .94) 2.8 .80
studies from 2011
Cochrane Review63 ◆

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 193


Physical Examination Tests  •  Slump Test
Reliability of the Slump Test

Figure 4-33
Slump test.

Test and Study


Quality Description and Positive Findings Population Intraexaminer Reliability
Knee extension range Subject sitting maximally slumped with 20 asymptomatic With cervical flexion: ICC = .95
of motion during the one thigh flexed 25 degrees to the subjects With cervical extension: ICC = .95
slump test75 ● horizontal plane. Starting with the knee
at 90 degrees and maximal ankle
dorsiflexion, the knee was slowly
extended to maximal discomfort and
measured with an electrogoniometer

194 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Slump Test
Diagnostic Utility of the Slump Test for Detecting Disc Bulging or Herniation

Peripheral annulus fibrosus and posterior longitudinal lig.


supplied with nociceptors (small unmyelinated n. fibers
with free or small capsular-type n. endings). Nociceptors
Injury connect to sinuvertebral n. and/or to somatic afferent nn.
carried within the sympathetic chain to the upper lumbar
levels, which lead to dorsal root ganglion in spinal n. root.

Injury to disc initiates inflammatory


process in nucleus pulposus.

4 
Recurrent
meningeal

Thoracolumbar Spine
(sinuvertebral)
Dorsal root Discogenic pain Herniated nucleus pulposus
ganglion

Neovascularization of disc

Nucleus pulposus
Fissure in
annulus Phospholipase A2
Prostaglandins Inflammatory
fibrosus cell infiltrate
Nitric oxide
Recurrent meningeal Metalloproteinases (chemical
(sinuvertebral) ? Unidentified signal for
inflammatory revascularization)
Nociceptors
in annulus agents
fibrosus

Dorsal
root ganglion

Nerve root–dura interface


Chemicals may reach
may be involved by
nociceptors via fissure
inflammatory process.
to lower threshold for firing.
Chemical factors and
Pain caused by mechanical
compression both
forces superimposed on
contribute to lumbar
chemically activated
pain.
nociceptors.

Figure 4-34
Role of inflammation in lumbar pain.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 195


Physical Examination Tests  •  Slump Test
Diagnostic Utility of the Slump Test for Detecting Disc Bulging or Herniation (continued)
Test and
Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Slump Sitting with the back straight, 75 patients with MRI findings .84 .83 4.94 .19
test74 ◆ the patient is encouraged to complaints of of disc bulges, (.74, .90) (.73, .90)
slump into lumbar and acute or herniations,
thoracic flexion while looking recurrent low and/or
straight ahead. Then the back pain and/or extrusions
patient fully flexes the neck leg pain of 12
and extends one knee. Last, weeks’ duration
the patient dorsiflexes the or less
ipsilateral foot. Positive if
reproduction of familiar
radicular pain occurs

196 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Slump Knee Bend Test
Reliability of the Slump Knee Bend Test

4 
Thoracolumbar Spine
Figure 4-35
Slump knee bend test.

Intraexaminer
Test and Study Quality Description and Positive Findings Population Reliability
Slump knee bend test76 ◆ Subject side-lying with no pillow, slightly Sixteen patients with κ = .71 (.33, 1.00)
(see Video 4-1) “cuddling” underside leg with cervical and radicular leg pain
thoracic spines flexed. Clinician stands behind
subject supporting upper leg in neutral (no
adduction/abduction). With the subject’s
upper knee flexed, clinician extends the hip
until symptom is evoked. The subject is
asked to extend the neck. Positive if symptom
diminishes with neck extension

Diagnostic Utility of the Slump Knee Bend Test in Detecting Nerve Root Compression
Test and Description
Study and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Slump knee As above in As above in MRI findings of nerve 1.00 .83 6.00 0.0
bend test76 ◆ reliability section reliability section root compression (.40, (.52, (1.58, (0.0,
1.00) .98) 19.4) .60)

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 197


Physical Examination Tests  •  Tests for Lumbar Segmental Instability
Reliability of Tests for Lumbar Segmental Instability
Test and Study Interexaminer
Quality Description and Positive Findings Population Reliability
Hip extension test77 Prone patient extends one hip at a time. Positive if 42 patients with κ = .72 (left)
◆ lateral shift, rotation, or hyperextension of the chronic low back pain κ = .76 (right)
lumbar spine occurs

Painful arc in Patient reports symptoms at a particular point in κ = .69 (.54, .84)
flexion48 ● the movement but the symptoms are not present
before or after the movement

Painful arc on Patient experiences symptoms when returning κ = .61 (.44, .78)
return from from the flexed position
flexion48 ●

Instability catch48 Patient experiences a sudden acclimation of κ =.25 (−.10, .60)


● deceleration of trunk movements outside the 63 patients with
primary plane of movement current low back pain
Gower sign48 ● Patient pushes up from thighs with the hands κ =.00 (−1.09, 1.09)
when returning to upright from a flexed position

Reversal of On attempting to return from the flexed position, κ =.16 (−.15, .46)
lumbopelvic the patient bends the knees and shifts the pelvis
rhythm48 ● anteriorly

Aberrant movement κ = .60 (.47, .73)


pattern48 ●
If the patient demonstrates any of the above five
Aberrant movement 123 patients with low κ =.18 (−.07, .43)
possible movement patterns, the patient is
pattern35 ◆ back pain of less than
considered to be positive for an aberrant
90 days’ duration
movement pattern
Aberrant movement 30 patients with low κ =.64 (.32, .90)
pattern78 ● back pain

Posterior shear With patient standing with arms crossed over the κ = .35 (.20, .51)
test48 ● abdomen, examiner places one hand over the
patient’s crossed arms while the other stabilizes
the pelvis. Examiner uses the index finger to
palpate the L5-S1 interspace. Examiner then
applies a posterior force through the patient’s 63 patients with
crossed arms. This procedure is performed at current low back pain
each level. A positive test is indicated by
provocation of symptoms

Prone instability The patient is prone with the edge of the torso on κ = .87 (.80, .94)
test48 ● the plinth while the legs are over the edge and
feet are resting on the floor. Examiner performs a
Prone instability posteroanterior pressure maneuver and notes the 123 patients with low κ = .28 (.10, .47)
test35 ◆ provocation of any symptoms. The patient then back pain of less than
lifts the feet off the floor, and examiner again 90 days’ duration
performs the posteroanterior pressure maneuver.
Prone instability 39 patients with low κ = .46 (.15, .77)
Provocation of symptoms is reported. Test is
test39 ● back pain
considered positive if the patient experiences
Prone instability symptoms while feet are on the floor but 30 patients with low κ = .67 (.29, 1.00)
test78 ● symptoms disappear when the feet are lifted off back pain
the floor

198 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Tests for Lumbar Segmental Instability
Reliability of Tests for Lumbar Segmental Instability (continued)

Test and Study Interexaminer


Quality Description and Positive Findings Population Reliability
Trendelenburg79 ◆ While standing, the patient flexes one hip to 30 κ = .83 (left)
degrees and lifts the ipsilateral pelvis above the κ = .75 (right)
transiliac line. The test is positive if the patient
cannot hold the position for 30 seconds or needs 36 patients with
more than one finger for balance chronic low back pain

Active straight-leg The patient is supine with straight legs and feet κ = .70 (left)
raise test80 ◆ 20 cm apart. The patient is instructed to “try to κ = .71 (right)
raise your legs, one after the other, above the
Active straight-leg couch without bending the knee.” The patient is 50 females with Test-retest ICC = .83
raise test80 ● asked to score the maneuver on a 6-point scale lumbopelvic pain

4 
ranging from “not difficult at all” to “unable to do”
Active straight-leg 30 patients with low κ = .53 (.20, .84)
raise test78 ● back pain

Thoracolumbar Spine

Figure 4-36
Prone instability test.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 199


Physical Examination Tests  •  Tests for Lumbar Spinal Stenosis
Diagnostic Utility of Tests for Lumbar Spinal Stenosis

Radiograph of thoracic Degeneration of lumbar intervertebral Schematic cross-section


spine shows narrowing discs and hypertrophic changes at showing compression of
of intervertebral spaces vertebral margins with spur formation. nerve root.
and spur formation. Osteophytic encroachment on
intervertebral foramina compresses
spinal nerves.

Figure 4-37
Degenerative disc disease and lumbar spinal stenosis.

Test and
Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Abnormal Patient stands with feet 93 patients Diagnosis of .39 .91 4.3 .67
Romberg together and eyes closed for with back pain spinal stenosis (.24, (.81,
test24 ◆ 10 seconds. Considered with or without by retrospective .54) 1.0)
abnormal if compensatory radiation to chart review
movements were required to the lower and confirmed
keep feet planted extremities by MRI or CT

Thigh pain Patient performs hip extension .51 .69 1.6 .71
with 30 for 30 seconds. Positive if (.36, (.53,
seconds of patient has pain in the thigh .66) .85)
extension24 ◆ following or during extension

Two-stage Subjects ambulate on a level 45 subjects Diagnosis of Time to onset of symptoms


treadmill and inclined (15 degrees) with low back spinal stenosis
test16 ● treadmill for 10 minutes. The and lower by MRI or CT .68 .83 4.07 .39
patient rests for 10 minutes extremity pain scanning (.50, (.66, (1.40,
while sitting upright in a chair .86) 1.0) 11.8)
after each treadmill test
Longer total walking time during
the inclined test

.50 .92 6.46 .54


(.38, (.78, (3.1,
.63) 1.0) 13.5)

Prolonged recovery after level


walking

.82 .68 2.59 .26


(.66 to (.48, (1.3,
.98) .90) 5.2)

200 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Tests for Radiographic Lumbar Instability
Diagnostic Utility of Tests for Radiographic Lumbar Instability
Test and Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
Passive lumbar With subject in the prone 122 patients Flexion- .84 .90 8.8 .20
extension test1 ◆ position, both lower with low back extension (.68, (.82, (4.5, (.10,
2011 Systematic extremities are passively pain with mean radiograph .93) .96) 17.3) .40)
Review (see Video elevated, concurrently, to age of 68.9 with
4-2) a height of about 30 cm years translation
while maintaining the motion of
knees extended and gently 5 mm
pulling the legs. Positive
with low back pain or
discomfort during test

Age younger than History collected prior to .57 .81 3.0 .53

4 
37 years34 ◆ physical examination (.39, (.60, (1.2, (.33,
.74) .92) 7.7) .85)

Thoracolumbar Spine
Lumbar flexion Range of motion .68 .86 4.8 .38
greater than 53 demonstrated by single (.49, (.65, (1.6, (.21,
degrees34 ◆ inclinometer .82) .94) 14.0) .66)
Radiologic
Total extension Range of motion findings .50 .76 2.1 .66
greater than 26 demonstrated by single revealed (.33, (.55, (.90, (.42,
degrees34 ◆ inclinometer either two .67) .89) 4.9) 1.0)
49 patients segments
Lack of With patient prone, with low back with .43 .95 9.0 .60
hypomobility during examiner applies a pain referred rotational/ (.27, (.77, (1.3, (.43,
intervertebral posteroanterior force to for flexion- translational .61) .99) 63.9) .84)
testing34 ◆ the spinous process of extension instability or
each lumbar vertebra. radiographs one segment
Any hypermobility Mobility of each segment .46 .81 2.4 .66
with both
during intervertebral was judged as “normal,” (.30, (.60, (.93, (.44,
rotational and
motion testing34 ◆ “hypermobile,” or .64) .92) 6.4) .99)
translational
“hypomobile” instability
Lumbar flexion Combination of both .29 .98 12.8 .72
greater than 53 factors above (.13, (.91, (.79, (.55,
degrees + Lack of .46) 1.0) 211.6) .94)
hypomobility during
intervertebral
testing34 ◆

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 201


Physical Examination Tests  •  Tests for Radiographic Lumbar Instability
Diagnostic Utility of Tests for Radiographic Lumbar Instability (continued)

Figure 4-38
Passive lumbar extension test.

202 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Tests for Radiographic Lumbar Instability
Diagnostic Utility of Tests for Radiographic Lumbar Instability (continued)
Fritz and colleagues81 investigated the accuracy of the clinical examination in 49 patients with radio-
graphically determined lumbar instability. Results revealed that two predictor variables, including lack
of hypomobility of the lumbar spine and lumbar flexion greater than 53 degrees, demonstrated a +LR
of 12.8 (.79, 211.6). The nomogram below represents the change in pretest probability (57% in this
study) to a posttest probability of 94.3%.

4 
.1 99

.2

Thoracolumbar Spine
.5 95

1 1000 90
500
2 200 80
100
50 70
5
20 60
10 10 50
5 40
Percent (%)

Percent (%)

20 2 30
1
30 .5 20
40 .2
50 .1 10
60 .05
5
70 .02
.01
80 .005 2
.002
90 .001 1

95 .5

.2

99 .1
Pretest Likelihood Posttest
Probability Ratio Probability

Figure 4-39
Nomogram representing the posttest probability of lumbar instability given the presence of hypomobility in the lumbar spine and
lumbar flexion greater than 53 degrees. (Adapted with permission from Fagan TJ. Nomogram for Baye’s theorem. N Engl J Med.
1975;293-257. Copyright 2005, Massachusetts Medical Society. All rights reserved.)

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 203


Physical Examination Tests  •  Tests for Ankylosing Spondylitis
Diagnostic Utility of Tests for Ankylosing Spondylitis
Test and Study Description and Positive Reference
Quality Findings Population Standard Sens Spec +LR −LR
Measurements of Less than 7 cm (procedure .63 .53 1.34 .70
chest expansion26 ◆ not reported)

Less than 2.5 cm (procedure .91 .99 .91 .09


not reported)

Schober test less With patient standing, .30 .86 2.14 .81
than 4 cm26 ◆ examiner marks a point
5 cm below and 10 cm
above S2. This distance is
then measured in the The New York
upright position and then in 449 randomly criteria and
full flexion. The difference selected radiographic
between the two patients with confirmation
measurements is calculated low back pain of ankylosing
and recorded to the closest spondylitis
centimeter

Decreased lumbar Visual observation .36 .80 1.8 .80


lordosis26 ◆ individually judged by each
examiner

Direct tenderness Direct pressure over the .27 .68 .84 1.07
over sacroiliac joint26 joint with the patient in an
◆ upright position. Positive if
patient reports pain

204 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Classification Methods
Reliability of Low Back Pain Classification Systems
Test and Study Interexaminer
Quality Description and Positive Findings Population Reliability
McKenzie Therapists (of which only 32% had ever 363 patients referred κ for classification = .26
classification for low taken any form of McKenzie training) to physical therapists κ for lateral shift = .26
back pain82 ◆ completed a McKenzie evaluation form for the treatment of
and classified the patient as exhibiting a low back pain
postural, dysfunction, or derangement
syndrome. Therapists also determined if
the patient presented with a lateral shift

McKenzie Two examiners with more than 5 years of 39 patients with low κ for classification = .70
classification for low training in the McKenzie method evaluated back pain κ for lateral shift = .20
back pain57 ◆ all patients. Therapists completed a
McKenzie evaluation form and classified

4 
the patient as exhibiting a postural,
dysfunction, or derangement syndrome.

Thoracolumbar Spine
Therapists also determined if the patient
presented with a lateral shift

McKenzie Examination consisted of history taking, 46 consecutive Classification of syndrome


evaluation83 ◆ evaluation of spinal range of motion, and patients presenting κ = .70
specified test movements with low back pain Derangement subsyndrome
κ = .96
Presence of lateral shift
κ = .52
Deformity of sagittal plane
κ = 1.0

Movement Examiners used a standardized history and 24 patients with κ for classification = .61
impairment–based physical examination to assess patients chronic low back pain
classification system and classify them into one of five lumbar
for lumbar spine spine categories
syndromes84 ◆

Treatment-based 30 examiners used a standardized history 123 patients with low κ for classification = .61
classification35 ◆ and physical examination to assess back pain for less (.56, .64)
patients and classify them into one of than 90 days’ duration
three treatment-based categories

Treatment-based Examiners used a standardized history and 120 patients with low κ for classification = .56
classification81 ◆ physical examination to assess patients back pain
and classify them into one of four
treatment-based categories

Treatment-based Examiners used a standardized history and 45 patients with low κ for classification = .45
classification85 ◆ physical examination to assess patients back pain
and classify them into one of four
treatment-based categories after a 1-day
training session

Stabilization Each examiner rated the subject’s status 30 patients with low κ for subgroup = .86 (.65,
subgroup from on the stabilization subgroup based on back pain 1.00)
treatment-based age and the rating of aberrant movement,
classification78 ● straight-leg raise, and prone instability test
scores. If a subject presented with three
or more positive tests, his or her status
was considered positive

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 205


Physical Examination Tests  •  Classification Methods
Treatment-Based Classification Method86
Subgroup Criteria Treatment Approach
Specific Extension
Exercise
Subgroup • Symptoms distal to the buttock • End-range extension exercises
• Symptoms centralize with lumbar extension • Mobilization to promote extension
• Symptoms peripheralize with lumbar flexion • Avoidance of flexion activities
• Directional preference for extension

Flexion

• Older age (over 50 years) • End-range flexion exercises


• Directional preference for flexion • Mobilization or manipulation of the spine and/or
• Imaging evidence of lumbar spine stenosis lower extremities
• Exercise to address impairments of strength or
flexibility
• Body weight−supported ambulation

Stabilization • Age (under 40 years) • Exercises to strengthen large spinal muscles


Subgroup • Average straight-leg raise (more than 91 (erector spinae, oblique abdominals)
degrees) • Exercises to promote contraction of deep spinal
• Aberrant movement present muscles (multifidus, transversus abdominis)
• Positive prone instability test

Manipulation • No symptoms distal to knee • Manipulation techniques for the lumbopelvic region
Subgroup • Duration of symptoms less than 16 days • Active lumbar range-of-motion exercises
• Lumbar hypomobility
• FABQW less than 19
• Hip internal rotation range of motion of more
than 35 degrees

Traction • Symptoms extend distal to the buttock(s) • Prone mechanical traction


Subgroup • Signs of nerve root compression are present • Extension-specific exercise activities
• Peripheralization occurs with extension
movement or positive findings on
contralateral straight-leg raise test

Rather than attempt to classify low back pain based on pathologic anatomy, the Treatment-Based
Classification (TBC) system identifies subgroups of patients thought to respond to specific con-
servative treatment interventions. Although its initial proposal was based on experience and
clinical reasoning,87 researchers have since systematically identified many of the historical and
clinical examination factors associated with each subgroup using clinical prediction rule research
methodology.2,3,88

206 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Interventions
Diagnostic Utility of Single Factors for Identifying Patients Likely to Benefit from  
Spinal Manipulation
Test and Study Description and Reference
Quality Criteria Population Standard Sens Spec +LR −LR
Symptoms for less .56 .87 4.39
than 16 days’ (.39, (.73, (1.83,
duration2 ◆ .72) .94) 10.51)

FABQ work subscale .84 .49 1.65


score less than 192 Self-report (.68, (.34, (1.17,
◆ .93) .64) 2.31)

No symptoms distal .88 .36 1.36


to the knee2 ◆ (.72, (.23, (1.04,
Reduction of .95) .52) 1.79)

4 
50% or more in
At least one hip with With patient prone, back pain− .50 .85 3.25

Thoracolumbar Spine
more than 35 measured with 71 patients (.34, (.70, (1.44,
related disability Not
degrees of internal standard goniometer with low .66) .93) 7.33)
within 1 week reported
rotation range of back pain
as measured by
motion2 ◆ the Oswestry
questionnaire
Hypomobility in the With patient prone, .97 .23 1.26
lumbar spine2 ◆ examiner applies a (.84, (.13, (1.05,
posteroanterior force .99) .38) 1.51)
to the spinous process
of each lumbar
vertebra. Mobility of
each segment was
judged as “normal,”
“hypermobile,” or
“hypomobile”

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 207


Physical Examination Tests  •  Interventions
Diagnostic Utility of Combinations of Factors for Identifying Patients Likely to Benefit from
Spinal Manipulation

Figure 4-40
Spinal manipulation technique used by Flynn and colleagues. The patient is passively side-bent toward the side to be manipulated
(away from the therapist). The therapist then rotates the patient away from the side to be manipulated (toward the therapist) and
delivers a quick thrust through the anterior superior iliac spine in a posteroinferior direction. (From Flynn T, Fritz J, Whitman J, et al.
A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal
manipulation. Spine. 2002;27:2835-2843.)

Test and Study Description Reference


Quality and Criteria Population Standard Sens Spec +LR −LR
Symptoms of less than All five tests .19 1.00 Undefined
16 days’ duration positive (.09, (.91,
+ .35) 1.00)
No symptoms distal to
the knee Four or more .63 .97 24.38
+ tests positive (.45 to (.87 to (4.63 to
Hypomobility in the .77) 1.0) 139.41)
lumbar spine Reduction of
Three or more 71 patients 50% or more .94 .64 2.61
+
tests positive with low in back (.80, (.48, (1.78,
FABQ work subscale
back pain pain−related .98) .77) 4.15)
score less than 19 Not
+ Two or more disability within 1.00 .15 1.18 reported
At least one hip with tests positive 1 week as (.89, (.07, (1.09,
more than 35 degrees of measured by 1.0) .30) 1.42)
internal rotation range of the Oswestry
motion2 ◆ One or more questionnaire 1.00 .03 1.03
tests positive (.89, (.005, (1.01,
1.0) .13) 1.15)

Symptoms of less than Must meet 141 patients .56 .92 7.2 (3.2,
16 days’ duration + No both criteria with low (.43, (.84, 16.1)
symptoms distal to the back pain .67) .96)
knee88 ◆

208 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Physical Examination Tests  •  Interventions
Diagnostic Utility of Single Factors and Combinations of Factors in Identifying Patients Likely
to Benefit from Lumbar Stabilization Exercises
Test and
Study Description and Reference
Quality Positive Findings Population Standard Sens Spec +LR −LR
Age younger Self-report .61 .83 3.7 .47
than 40 years3 (.39, (.68, (1.6, (.26,
◆ .80) .92) 8.3) .85)

Average Measured with an .28 .92 3.3 .79


straight-leg inclinometer (.13, (.78, (.90, (.58,
raise test of .51) .97) 12.4) 1.1)
more than 91
degrees3 ◆

4 
Aberrant Presence of any of the .78 .50 1.6 .44
movement following during flexion (.55, (.35, (1.0, (.18,

Thoracolumbar Spine
present3 ◆ range of motion: Reduction of 50% .91) .66) 2.3) 1.1)
• Instability catch or more in back
• Painful arc of motion pain−related
• “Thigh climbing” (Gower 54 patients with disability after 8
sign) low back pain weeks of lumbar
• Reversal of lumbopelvic with or without stabilization
rhythm leg pain exercises as
measured by the
Positive prone See description under Tests .72 .58 1.7 .48
Oswestry
instability test3 for Lumbar Segmental (.49, (.42, (1.1, (.22,
questionnaire
◆ Instability .88) .73) 2.8) 1.1)

Combination Three or more tests positive .56 .86 4.0 .52


of any four (.34, (.71, (1.6, (.30,
factors above3 .75) .94) 10.0) .88)

Two or more tests positive .83 .56 1.9 .30
(.61, (.40, (1.2, (.10,
.94) .71) 2.9) .88)

One or more 1 tests positive .94 .28 1.3 .20


(.74, (.16, (1.0, (.03,
.99) .44) 1.6) 1.4)

Clinical Prediction Rule to Identify Patients with Low Back Pain Likely to Benefit from
Pilates-Based Exercise
Stolze and colleagues89 developed a clinical prediction rule for identifying patients with low back
pain who are likely to benefit from Pilates-based exercise. The result of their study demonstrated
that if three or more of the five attributes (total trunk flexion range of motion of 70 degrees or
less, duration of current symptoms of 6 months or less, no leg symptoms in the last week, body
mass index of 25 kg/m2 or greater, and left or right hip average rotation range of motion of 25
degrees or greater) were present, the +LR was 10.64 (95% CI 3.52, 32.14) and the probability of
experiencing a successful outcome improved from 54% to 93%.

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 209


Outcome Measures

Outcome Measure Scoring and Interpretation Test-Retest Reliability MCID


Oswestry Disability Users are asked to rate the difficulty of performing ICC = .9190 ● 1191
Index (ODI) 10 functional tasks on a scale of 0 to 5 with
different descriptors for each task. A total score
out of 100 is calculated by summing each score
and doubling the total. The answers provide a
score between 0 and 100, with higher scores
representing more disability

Modified Oswestry As above, except the modified ODI replaces the ICC = .9092 ● 692
Disability Index sex life question with an employment/
(modified ODI) homemaking question

Roland-Morris Disability Users are asked to answer 23 or 24 questions ICC = .9193 ● 591
Questionnaire (RMDQ) (depending on the version) about their back pain
and related disability. The RMDQ is scored by
adding the number of items checked by the
patient, with higher numbers indicating more
disability

Fear-Avoidance Beliefs Users are asked to rate their level of agreement FABQW: ICC = .82 Not available
Questionnaire (FABQ) with statements concerning beliefs about the FABQPA: ICC = .6694 ●
relationship between physical activity, work, and
their back pain. Level of agreement is answered
on a Likert-type scale ranging from 0 (completely
disagree) to 7 (completely agree). The FABQ has
two parts: a seven-item work subscale (FABQW)
and a four-item physical activity subscale
(FABQPA). Each scale is scored separately, with
higher scores representing greater fear avoidance

Numeric Pain Rating Users rate their level of pain on an 11-point scale ICC = .7295 ● 296,97
Scale (NPRS) ranging from 0 to 10, with high scores
representing more pain. Often asked as “current
pain” and “least,” “worst,” and “average” pain in
the past 24 hours
MCID, Minimum clinically important difference.

210 Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach


Appendix
Quality Appraisal of Reliability Studies for Thoracolumbar Spine Disorders Using QAREL

Van Dillen 199823


McCombe 198920

Vroomen 200022

Haswell 200427
Lindell 200730

Breum 199531
Roach 199721

Evans 200632

Fritz 200534

Fritz 200635
1. Was the test evaluated in a sample of Y Y Y Y Y Y Y Y Y Y
subjects who were representative of those to
whom the authors intended the results to be
applied?

2. Was the test performed by raters who were Y Y Y Y Y Y Y Y Y Y


representative of those to whom the authors

4 
intended the results to be applied?

3. Were raters blinded to the findings of other U N/A Y Y Y Y Y Y Y Y

Thoracolumbar Spine
raters during the study?

4. Were raters blinded to their own prior N/A U N/A N/A U U Y Y N/A N/A
findings of the test under evaluation?

5. Were raters blinded to the results of the N/A N/A N/A N/A N/A N/A N/A Y N/A N/A
reference standard for the target disorder (or
variable) being evaluated?

6. Were raters blinded to clinical information U U U U U U U U U U


that was not intended to be provided as part
of the testing procedure or study design?

7. Were raters blinded to additional cues that U U U U U U U U U U


were not part of the test?

8. Was the order of examination varied? U N/A Y Y Y Y Y Y Y Y

9. Was the time interval between repeated Y Y Y Y Y Y Y Y Y Y


measurements compatible with the stability
(or theoretical stability) of the variable being
measured?

10. Was the test applied correctly and Y Y Y Y Y Y Y Y Y Y


interpreted appropriately?

11. Were appropriate statistical measures of Y Y Y Y Y Y Y Y Y Y


agreement used?

Quality Summary Rating: ● ● ◆ ◆ ● ● ◆ ◆ ◆ ◆


Y = yes, N = no, U = unclear, N/A = not applicable. ◆ Good quality (Y - N = 9 to 11) ● Fair quality (Y - N = 6 to 8) ■ Poor quality (Y - N ≤ 5).

Netter’s Orthopaedic Clinical Examination  An Evidence-Based Approach 211


Appendix
Quality Appraisal of Reliability Studies for Thoracolumbar Spine Disorders Using QAREL

Johansson 200642
Qvistgaard 200741
Schneider 200839