Most patient assessment is the taking of the history itself: Listen to the patients; they will tell you what is wrong with them. Physical examination then serves as a confirmation of your suspicions. Spine, neuromuscular, and musculoskeletal disorders comprise the bulk of conditions seen in the pain clinic, so basic physical exam is reviewed here. The reader is urged to refer to classic texts for more detail regarding this expansive topic: The single vade mecum is Hoppenfeld’s Physical Examination of the Spine and Extremities.¹ Comprehensive instruction in all musculoskeletal examination maneuvers is found in Magee’s Orthopedic Physical Assessment.² Musculoskeletal examination as well as anatomy, imaging, and management are covered in detail in the “Essentials.”³ A complete text for neurological exam is DeJong’s The Neurologic Examination.⁴ Beyond reading, practice over years is encouraged to attain mastery. We cite utility of common tests in terms of sensitivity and specificity when available. Beyond the science, the art and the truth are that the physical examination is a bonding ritual with patients.

The physical exam begins as soon as you see the patient walking into the room, with the assessment of gait. For the most careful assessment, it is best to have the patient disrobe. Common themes of physical examination include inspection, palpation, motion testing, and provocation or special tests, which are often eponymous. Spine and musculoskeletal range of motion values are not universally agreed upon, and values here are for reference. Many special physical exam protocols exist, and a few with practical application in pain are included at the close of this chapter.

Inspection: Visually inspect spine alignment, including normal curvatures, sagittal and coronal balance, or any scoliosis or excess kyphosis. The four normal curves exist only in the sagittal plane and include cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacral kyphosis. Normal sagittal balance is the arrangement of these curves so that an imagined plumb line from C7 would pass through S1.

Scoliosis is a three-dimensional curvature of the spine as the spine deviates from midline in the coronal plane with maximal rotation occurring at the apex of the curve—the majority of which are idiopathic and seen in the thoracic and lumbar spine. The curve is named for the side of the apex. To evaluate for spinal curves, the patient slowly bends forward at the waist with knees straight. Paraspinal or rib humping correlates with the apex of the curve (hump on the left is levoscoliosis, on the right is dextroscoliosis).

Palpation: Palpate bony landmarks and paraspinal regions. Cervical and thoracic bony landmarks include spinous process, mastoid process, inion, and paraspinal regions corresponding to facet joints. Lumbosacral bony landmarks include spinous process, coccyx, iliac bone including posterior superior iliac spine, and paraspinal regions corresponding to sacroiliac and facet joints.

Provocation: Provocation includes range of motion testing as well as special tests (Table 9-1). Range of motion in the cervical and lumbar spine includes flexion, extension, rotation, and lateral bending. In the cervical spine, 50% of flexion and extension occurs between the occiput and C1, and the other 50% is distributed throughout the cervical spine; 50% rotation is at C1–C2, with the other 50% evenly distributed again. Normal range of motion in the cervical spine is 65° of flexion (chin to chest), 45° extension (look at ceiling), 35–45° lateral flexion, and 50° or more rotation (chin to shoulder). Normal ranges for the lumbar spine include 85° of true lumbar flexion (not including hip motion), 60° extension, 40° lateral flexion, and 50° rotation.^1,5 Lumbopelvic rhythm refers to the ratio of motion when a patient bends at the waist to touch the toes. Most of the initial arc is motion in the lumbar spine, while the latter portion involves hip joint flexion.⁵ In contrast, there is very little motion appreciated in the thoracic and sacral regions.

We routinely use inclinometry to document lumbar and cervical spine range of motion. Total lumbosacral flexion is easily measured by holding an inclinometer at T12–L1 and having the patient bend forward at the waist while keeping the legs (knees) straight. This measures true lumbar flexion plus flexion due to hip motion. This simple measure correlates well with true lumbar flexion, is easier to obtain, and may be more correlated with disability measures in patients with back pain.⁶ Many techniques have been described for cervical spine inclinometry, including simple methods.⁷

Surface landmarks of the spine for inspection, palpation, and provocation are noted in Table 9-2.

There are numerous special tests of the spine. The modified Schober’s test evaluates true lumbar flexion. A line is drawn between right and left posterior superior iliac spines (L5), and mark number one is made 5 cm below and mark number two 10 cm above this line. The patient bends forward, and the distance between mark numbers one and two should increase at least an additional 5 cm. An abnormal test indicates decreased lumbar mobility.^1,5 The modified Schober’s test is thought to be abnormal in conditions such as ankylosing spondylitis.

There are perhaps dozens of eponymous tests for the sacroiliac joint. Patrick’s test, also known as FABER (flexion, abduction, external rotation), can test for sacroiliac or femoroacetabular (hip) joint problems. With the symptomatic side hip joint flexed, abducted, and externally rotated, inguinal pain suggests hip arthritis, or pain from surrounding muscles. The ipsilateral sacroiliac joint can be stressed by simultaneously pressing the ipsilateral knee and contralateral anterior superior iliac spine. The sensitivity and specificity of the Patrick test alone for sacroiliac joint origin are poor. Sensitivity ranges from 48% to 77% and specificity has been reported to be as low as 16%.^8,9 However, if Patrick’s test is combined with other tests for sacroiliac pain source, such as Gaenslen’s test, thigh thrust, distraction test, compression test, or sacral thrust, and if three or more tests are positive, the sensitivity and specificity of the combination of tests increase to 91% and 87%, respectively.¹⁰

Facet joint tests include facet loading maneuvers and paraspinal tenderness. The latter may be more valid, and anesthetic blocks under fluoroscopic guidance may be more valid still. Facet loading maneuvers, like sacroiliac provocation, are very nonspecific.^11,12

Tenderness upon percussion of the midline is 87.5% sensitive and 90% specific for acute vertebral compression fractures.¹³

SHOULDER

Four “joints” make up the shoulder girdle: sternoclavicular, acromioclavicular, glenohumeral, and the scapulothoracic articulation. Inspect and compare side to side, for bony prominences, muscle bulk, and limb position, as well as motion of the shoulders. Normal range of motion is 170–180° flexion, 40–45° extension, 180° abduction, 40–45° adduction, 45–90° external rotation, and 55–70° internal rotation. Internal and external rotation varies, depending on the degree of abduction. Inspect for symmetry of scapula position or any winging of the scapula. Medial winging indicates serratus anterior dysfunction, while lateral winging is suggestive of the trapezius.

Palpable structures include clavicle, acromion, coracoid, spine of scapula, and greater and lesser tuberosities of the humerus. Palpable joints include sternoclavicular and acromioclavicular.

Special tests: Motion of the shoulder girdle includes abduction, adduction, extension, flexion, internal rotation, and external rotation. The Apley scratch test assesses active shoulder range of motion, wherein the patient reaches first behind the head for the superior contralateral scapula, then in front across to the contralateral acromion, and then inferiorly behind to the inferior aspect of contralateral scapula; sides are compared. Scapulohumeral rhythm is the normal 2:1 ratio of motion of the glenohumeral and scapulothoracic articulations during abduction and adduction of the shoulder. For example, abnormal scapulohumeral rhythm, such as a 1:1 ratio, would suggest a possible “frozen shoulder” or adhesive capsulitis.

The apprehension test involves abduction and external rotation of the arm. The patient may exhibit apprehension, expecting dislocation of the shoulder, especially if the patient experiences chronic shoulder dislocations.

The Yergason test assesses the biceps tendon in his position in the bicipital groove, between the greater and lesser trochanters. The patient flexes the elbow. The patient’s arm is externally rotated while pulling down the elbow, all while the patient resists. If the biceps tendon subluxes, it will reproduce symptoms. The Yergason test will also be positive, eliciting shoulder pain, when superior labral tears are present (as this is the origin of the long head of biceps). In general, Yergason’s test has low sensitivity (9–43%), but high specificity (79–96%).^14–16

The drop arm and empty can tests assess the rotator cuff, particularly the supraspinatus. In the drop arm, the patient starts with arm abducted and slowly lowers the arm to the side. With a supraspinatus tear, the patient will not be able to do this in a smooth motion because the rotator cuff ordinarily provides much of the action in the lowest part of the abduction arc. The position for the empty can test, also known as the Jobe test, involves bilateral shoulders abducted to 90°, forward flexed 30°, and internally rotated so the thumbs are down. Resistance is applied and is positive for a rotator cuff tear if it produces pain or demonstrates weakness. Sensitivity is high (89–99%), but it is not very specific (43–50%).^17,18

Neer and Hawkins-Kennedy tests are used to aid in the diagnosis of subacromial impingement. The Neer test is passive full flexion of the shoulder, while the arm is pronated and while the examiner stabilizes the scapula with one hand. A positive test is shoulder pain at the end range.¹⁹ For impingement, the test is relatively sensitive (68–86%) but not very specific (30–68%).^20–22 Hawkins-Kennedy test (often called “Hawkins”) is shoulder flexion to 90° combined with passive internal rotation, which reproduces pain when supraspinatus tendon impingement is present. The sensitivity (63–74%) and specificity (50–66%) for impingement with Hawkins are slightly lower than Neer.^20,22,23 While both Neer and Hawkins tests are most sensitive and specific for subacromial impingement, they can also be positive in labral and biceps tears.¹⁹

The cross-arm test is forward flexion of the shoulder to 90° and active adduction, also known as cross-body adduction, which elicits pain from acromioclavicular joint. Cross-arm has a sensitivity and specificity of 77% and 79%, respectively.²⁴

ELBOW

Inspect the elbow for the carrying angle—that is, the angle between the forearm and the humerus. This is typically a valgus angle, more pronounced in women than men. Palpable structures include medial and lateral epicondyles, olecranon, and radial head. Flexion of the elbow should be such that the hand can touch the ipsilateral shoulder, or 130–150°, and extension is 0–10° of hyperextension. Supination and pronation together total 180°.^1,5

A common special test is the tennis elbow test, or Cozen’s test. With elbow extended, the patient makes a fist and extends the wrists against resistance while the examiner palpates the lateral epicondyle. This will reproduce the pain of tennis elbow at the common origin of the wrists extensors at the lateral epicondyle—that is, at the origin of extensor carpi radialis longus and brevis. There are few data in the literature on the sensitivity or specificity of this maneuver.¹⁹

HAND

Inspect the hand for bony integrity, symmetry, and condition of nails and skin. Inspect for Heberden and Bouchard nodes. A Heberden node is hypertrophy of the distal interphalangeal (DIP) joint and is associated with osteoarthritis; a Bouchard node is hypertrophy of the proximal interphalangeal (PIP) joint and is associated with rheumatoid arthritis (RA).

Inspect for mallet finger, swan neck, or boutonniere deformities. In mallet finger, the distal phalanx remains in flexion when the finger is extended, due to rupture or avulsion of the DIP extensor tendon. Swan neck is flexion of the metacarpophalangeal (MCP) and DIP joints and extension of the PIP joint caused by contracture of the intrinsic muscles. A boutonniere deformity is extension of the MCP and DIP joints and flexion of the PIP joint from rupture of the extensor hood. Both swan neck and boutonniere deformities can be secondary to trauma or RA.

Palpate the radial and ulnar styloid processes, and the anatomic snuffbox, the floor of which is the navicular (scaphoid) bone. Tenderness can indicate scaphoid fracture, which is often missed on x-ray. In Cascade sign, the flexed fingertips should converge toward the scaphoid tubercle on the radial side of the wrist. A deviation indicates that the finger may have been fractured.

Palpate for ganglion cysts on the dorsal or volar surface of the wrists. These are swellings around tendons and joints, of uncertain clinical significance. Palpate for trigger finger, a nodule of the finger flexor tendon. Finkelstein’s test for de Quervian’s tenosynovitis is performed by the patient closing a fist around his or her thumb while deviating the wrist to the ulnar side. A positive test elicits pain in abductor pollicis longus or extensor pollicis brevis tendons along the anatomic snuff box.

HIP

Assess gait and test for the Trendelenburg sign, caused by weakness of the hip abductors of the leg in stance, especially the gluteus medius. For example, a positive Trendelenburg on the left is a drop of the right hip while standing on the right leg; this can also be accompanied by a lean to the left in order to maintain balance. Observe stance for symmetry, and note any apparent pelvic obliquity. Assess for leg length discrepancy (discussed later).

Palpate the anterior superior iliac spine, iliac crest and tubercle, greater trochanter, posterior superior iliac spine, and ischial tuberosity.

Passive internal rotation of the hip is the most common method of assessing for hip arthritis. Normal range of motion for hip internal rotation is 30–40° with the knee flexed at 90°.^1,5 Limited range of motion and reproduction of pain, typically inguinal pain, is associated with hip arthritis. Limited range of motion with internal rotation alone has only a sensitivity and specificity of 66% and 72%, respectively. However, if the patient has also either decreased hip flexion (<115°) or the triad of pain with internal rotation, prolonged morning stiffness, and and is over 50 years old, then the sensitivity and specificity increase to 86% and 75%, respectively.²⁵ “Hip scour” is a variant of passive hip range of motion (ROM) in which in which the examiner flexes the hip to 90° and flexes the knee to end range. The examiner then applies a downward force through the femur while internally and externally rotating the hip. A positive test is pain, apprehension, or catching and can indicate almost any intra-articular hip pathology. These hip provocation tests should be done with care because they can cause great pain in a patient with hip arthritis.

The Thomas test assesses for hip flexion contractures as well as hip range of motion. In this test, the patient in a supine position flexes one hip as far as possible up toward the trunk, and the presence of contralateral flexion contractures is confirmed if the other leg is unable to remain extended on the table. The Ober test has the patient lie in a lateral decubitus position with the symptomatic side up. This symptomatic leg is abducted toward the table with the knee flexed in an attempt to drop the knee down to the table. If the knee does not reach the table, it suggests decreased range of motion of the iliotibial band. Sensitivity or specificity are not established for the Thomas or Ober tests, although studies have demonstrated their reliability.¹⁹

KNEE

Inspect the knee during gait. Note the alignment of the knee in stance, including varus or valgus angulation in the coronal plane as well as either recurvatum or incomplete extension in the sagittal plane. Note the Q angle, the physiologic knee valgus angle between the tibia and a straight line through the femur to the ground. The normal Q angles are 11–17° for men and 14–20° for women.⁵ Inspect for any swelling. Note the muscle bulk, particularly the vastus medialis. Palpate the joint line of the knee medially and laterally. Test the patella for mobility. Palpate to assess for temperature symmetry and for effusion or bursa swelling.

Provocative tests of the knee include varus and valgus stress to test the lateral and medial collateral ligaments, respectively. Drawer signs test the cruciate ligaments. The anterior drawer sign tests the anterior cruciate ligament. The patient lies supine with knee flexed 90° as the examiner stabilizes the foot and pulls the tibia anteriorly. Sides are compared, and a positive test is increased laxity in the affected knee. The Lachman test is performed in a similar manner, but at only 15° of knee flexion; it has superior sensitivity and specificity.¹⁹ Anterior drawer and Lachman’s tests have specificity of 86–100% and 100%, respectively, but the anterior drawer’s sensitivity is only 52–78% while the Lachman’s is 91–96%.^26,27 Posterior drawer sign uses the same positioning as anterior drawer, but with posterior pressure on the tibia. Asymmetry or laxity with these tests suggests cruciate ligament damage. Range of motion should include flexion to 130–135° and extension neutral to −10° of hyperextension.^1,5 Extension lag is decreased extension at the end range, which frequently suggests pathology.

FOOT AND ANKLE

Inspect the alignment of the foot and ankle in stance. Inspect the shape of the foot, including the arch; identify pes planus or pes cavus. Inspect and palpate for edema. Palpate the dorsalis pedis and posterior tibial pulses. Like the hand, the dorsum of the foot can also have ganglion cysts. Inspection of the feet may also include inspection of the wear pattern of the shoes, which can help determine if there is subtle gait dysfunction. Compare right and left passive range of motion and stability. Palpate the major ligaments, including anterior and posterior talofibular, calcanofibular, and deltoid. Tenderness may indicate sprain.

Anterior drawer of the ankle tests for sprain of the anterior talofibular ligament. The examiner provides an anterior force to the talus and calcaneus at the heel while stabilizing the tibia. Sides are compared, and increased laxity is a positive test. The sensitivity and specificity are 78% and 75%, respectively. The talar tilt test also tests for laxity in the lateral ligaments and is performed by the examiner applying medial pressure to the calcaneus while stabilizing the ankle at the malleoli. Again, sides are compared, and a positive test is increased laxity. The sensitivity is lower than the anterior drawer (67%), but the specificity is comparable (75%).²⁸