Special Tests in Rheumatology
Many musculoskeletal abnormalities can be evaluated and diagnosed by special testing.
History and physical examination are the corner stones of a proper diagnosis. History will contribute up to 80% to the diagnosis, followed by physical exmination (6%) and tests (14%). Many musculoskeletal abnormalities can be evaluated and diagnosed by special testing.
Adson's Test for Thoracic Outlet Syndrome
Procedure:
Adson's maneuver is a test looking for the reduction or obliteration ot
the radial artery pulse with compression at the interscalene triangle.
The examiner extends and rotates the patient's shoulder with the arm at
the patient's side. The cervical spine is then rotated so that the patient's
chin faces the hand on the examined side. The patient is then asked to
inspire deeply and hold her breath. With deep inspiration, the subclavian
artery may be compressed between the pectoralis minor muscle and the chest
wall.
Anterior Drawer Sing For cruciate ligament injury in flexion
Procedure:
The knee is flexed to 90 degrees and the foot rested on the table. The
femur is grasped with one hand while the tibia is pulled forward and the
amount of excursion noted. In normal subjects no forward movement is elicited.
Apley's Tests Helpful in the diagnosis of a torn meniscus
Procedure:
The patient will lie prone on the examining table with one leg flexed
to 90 degrees. While pushing down on the foot rotate the knee medially
or laterally. Pain on either side will indicate a meniscal tear.
Finkelstein Test For testing of tenosynovitis of the abductor pollicis longus and extensor pollicis brevis
Procedure:
Instruct the patient to make a fist, with the thumb tucked inside of the
other fingers. Stabilize the forearm with one hand and deviated the wrist
to the ulnar side. If there is sharp pain in the area of the tendons,
there is strong evidence for tenosynovitis.
Gaenslen's Test for detection of sacroiliac joint abnormalities
Procedure:
The patient will lie supine on the examining table with both legs drawn
to the chest. Then shift the patient to the side of the table so that
one buttock extends over the edge while the other remains on it. Allow
the unsupported leg to drop over the edge while the other leg remains
flexed. SI joint abnormalities will elicit pain of the stressed joint.
Godfrey's Test For testing of posterior cruciate ligament injury
This test is used for evaluation of posterior cruciate ligament (PCL) injury
Procedure:
The examiner raises the patient's foot (hips and knees flexed 90 degrees)
and views the tibial tubercle from the side. Posterior sagging of the
tibia relative to the femur indicates significant PCL injury and the need
for orthopedic evaluation.
Hawkins Sign For rotator cuff injury
Procedure:
In the test for the Hawkins sign, the patient flexes the humerus forward
to 90 degrees. The examiner places the shoulder in horizontal adduction
and internal rotation. Pain is caused by cuff abrasion on the coracoacromial
ligament and indicates impingement.
Ischemic Forearm Testing
Metabolic myopathies are rare disorders. Before considering an EMG and muscle biopsy ischemic forearm testing will help in establishing the correct diagnosis.
Ischemic forearm testing is an extremely valuable tool in the diagnosis of metabolic myopathies. These include:
- Glycogen storage diseases
- Myodenylate deaminase deficiency
- Clinical muscle examination may be un-revealing
- Muscle strength is often normal
- Muscle enzymes may only be elevated during symptomatic periods
- Electromyograms are frequently normal or demonstrate unspecific changes
- Immunohistochemistry, biochemical assays, and molecular analysis will allow a definitive diagnosis
Protocol for the Ischemic Forearm Test
The test is performed by contracting the forearm to fatigue with a blood
pressure cuff inflated to greater than systolic pressure. Antecubital
blood samples for lactate and ammonia are collected before and following
exercise at 0, 1, 2, 5, and 10 minutes. Ischemia blocks oxidative phosphorylation
and ensures dependence on anaerobic glycogenolysis lactate normally rises
at least fourfold within 1 to 2 minutes of exercise ammonia rises fivefold
within 2 to 3 minutes.
Lactate concetration will rise several-fold under ischemic conditions in normal subjects (o-o-o). There will be no or minimal rise in patients with myophosphorylase deficiency (McArdle's disease)
In myoadenylate deaminase deficiency ammonia (NH3) levels will show a delayed rise with lower maximal concentrations compared to normal controls
Lachman Test for cruciate ligament injury in extension
If the knee after an acute injury cannot flex to 90 degrees the Lachman test should be performed.
Procedure:
The femur is grasped with one hand while the tibia is pulled forward and
the amount of excursion noted. In normal subjects no forward movement
is elicited.
31P Magnetic Resonance Spectroscopy
Metabolic myopathies can be detected by this non-invasive method.
McMurray Test For knee meniscal injury
Procedure:
The knee is flexed to 90 degrees; then foot is grasped and rotated internally
or externally. The leg is then slowly extended while applying valgus stress.
If an audible or palpable click is noted there is probably a tear of the
medial meniscus present. This finding can be supported by pain of the
medial knee joint line.
Neer Sign For rotator cuff injury
Procedure:
To test for the Neer impingement sign, the examiner elevates the humerus
with one hand while depressing the scapula to restrict movement with the
other. Pain at greater than 120 degrees of forward flexion constitutes
a positive result
Patrick's Test Also named Fabere test
It is used to detect pathology in the hip as well as the sacroiliac joint.
Procedure:
The patient will lie supine on the examining table. Place the foot of
his involved side on the opposite knee. Pain in the inguinal area indicates
hip disease. To stress the sacroileac joint, extend the range of motion
by pushing on the flexed knee as well as on the superior ileac spine of
the opposite side. Pain in the sacroileac joint line indicates abnormalities.
Spurling Sign For testing of Cervical Radiculopathy
This test is used for evaluation of cervical spine radiculopathy
Procedure:
The patient laterally bends the neck to each side while maintaining a
posture of cervical extension. Pain intesified with ipsilateral bending
strongly suggests a diagnosis of radiculopathy. Pain with contralateral
bending suggests a musculo-ligamentous origin.
Steinberg Test For testing of Marfan syndrome
This test is used for the clinical evaluation of Marfan patients.
Procedure:
Instruct the patient to fold his thumb into the closed fist. This test
is positive if the thumb tip extends from palm of hand.
Walker-Murdoch Sign For testing of Marfan syndrome
This test is used for the evaluation of patients with Marfan syndrome.
Procedure:
Instruct the patient to grip his wrist with his opposite hand. If thumb
and fifth finger of the hand overlap with each other, this represents
a positive Walker-Murdoch sign.
Wright's Test for Thoracic Outlet Syndrome
Procedure:
Wright's maneuver is carried out by abducting the shoulder of the patient
and externally rotating the humerus with the head and chin in neutral
position. The Wright's test is positive if there is a reproduction of
the patient's symptoms with ablation of the radial pulse. It has been
estimated, however, that in up to 30% of normal controls there is a decreased
pulse in this position.
Yergason Test For testing of biceps tendon stability in bicipital groove
This test is used for evaluation of a biceps tendon injury
Procedure:
The elbow is flexed to 90 degrees, the patient is asked to resists while
externally rotating the arm. A positive test result is indicated by a
snap and pain when the biceps tendon slips over the lesser tubercle