An Evidence-Based Approach to the Orthopedic Physical Exam – Part 4: The Lower Extremity

Original Article

An Evidence-Based Approach to the Orthopedic Physical Exam –

Part 4: The Lower Extremity

Christopher B. Roecker, DC, MS, DACO1, Emma Forlow Livingway, ATC2, Zachary Jipp, DC3

1Assistant Professor, Palmer College of Chiropractic Life Science & Foundations Department

2 Student, Doctor of Chiropractic Program, Palmer College of Chiropractic, Davenport, IA

3Doctor of Chiropractic, Colorado Occupational Medical Partners, Denver, CO

Published: December 2017

Journal of the Academy of Chiropractic Orthopedists

December 2017, Volume 14, Issue 4

This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: http://www.dcorthoacademy.com. © 2017 Roecker/Livingway/Jipp and the Academy of Chiropractic Orthopedists.

ABSTRACT

This narrative review article aims to examine the current evidence surrounding the orthopedic physical exam procedures related to various lower extremity conditions and provide an overview of these examinations. A narrative review was performed using online databases, authoritative textbooks, and a mobile orthopedic exam application. When multiple studies existed for a single orthopedic test, we reported results from the highest-quality studies and used studies with the highest Quality Assessment of Diagnostic Accuracy Studies (QUADAS) scores. Additionally, we attempted to highlight when orthopedic physical exams were described, but have yet to be evaluated in order to establish diagnostic accuracy. The purpose of this article is to provide an overview of the evidence-based orthopedic physical exams for many lower extremity conditions.

KEY WORDS (MeSH terms)

Evidence Based Practice; Injury, Leg; Injuries, Hip; Injury, Knee; Injury, Ankle; Injuries, Foot

INTRODUCTION

Clinical decision-making involves clinicians engaging in the process of probabilistic thinking, which evaluates the probability that a patient’s clinical presentation is due to a given pathology.1,2 Clinicians tend to represent this decision-making process in the context of establishing a list of differential diagnoses, but at its core the process of winnowing down a list of differential diagnoses is the same as probabilistic thinking.2

Framing clinical decision-making in the context of probabilistic thinking is not new. Pauker and Kassirer first described this approach in 1980.1 We feel this work of Pauker and Kassirer clearly outlines the process of clinical decision-making. They describe the concepts of a testing threshold and a diagnostic threshold in the context of establishing a differential diagnosis. Every diagnostic challenge incorporates multitudes of information, such as the patient’s chief complaint, findings from the physical examination, and even the clinician’s instincts (likely from his/her education or clinical experience);3 each of these pieces of information adds to or subtracts from the probability that any given pathology is responsible for the patient’s condition (i.e. disease state).

Testing Threshold and Diagnostic Threshold

Many times the probability that a condition is responsible for a patient’s condition is so unlikely that a clinician may exclude it from consideration without consciously thinking about it; when this is the case, the condition does not rise to the testing threshold. When conditions fail to reach the testing threshold, no further investigation into the presence of such an unlikely condition is warranted (see Figure 1).

Figure 1: Probabilistic Decision-Making*

*Figure adapted from Pauker SG, Kassirer JP. The threshold approach to clinical decision making. N Engl J Med. 1980 May 15;302(20):1109-17.

If a patient’s chief complaint or past health history lead a clinician to consider a given condition, this potential diagnosis may pass the testing threshold and further diagnostic investigation is warranted. At this point the clinician is likely to place this condition on his/her list of differential diagnoses; additional probing questions and diagnostic tests are used to modify the probability that this differential diagnosis is responsible for the patient’s presentation. Here we will use a lower extremity injury as an example of how performing a sequence of orthopedic tests may influence the probability of a condition being present, to the point of crossing a diagnostic threshold.

Clinical Scenario

A 22 year old female presents at your office with a sudden onset of knee pain and she points to the medial joint line of her right knee. She explains the pain came on suddenly while playing volleyball yesterday and that the pain has been intermittent ever since. She also describes the pain being associated with a locking or pinching sensation, as well as describing a sensation of her knee giving way.

This clinical scenario is likely to have elicited a short list of differential diagnoses for many of you who are clinicians or students. It’s likely that you feel the patient’s presentation may be due to a meniscus injury, an anterior cruciate ligament injury, or an injury to a collateral ligament of the knee. These are all examples of conditions that have passed your testing threshold. Are you ready to say that it is any one of these conditions? It is unlikely. It seems reasonable that you’d want to perform a few orthopedic tests to the area. These tests will serve two purposes; they will add to the probability that the correct diagnosis is identified, while also lowering the probability of other, incorrect, diagnoses. Essentially, you are investigating the clinical scenario to build a case for the correct diagnosis and pass your diagnostic threshold. Orthopedic tests serve to modify the probability that a given condition is responsible for the patient’s presentation. Positive tests are likely to raise the probability of the correct diagnosis, while negative tests are likely to lower the probability of competing differential diagnoses. Figure 2 demonstrates how a series of two tests, used in tandem, serve to increase the probability of a condition to the point where it passes the diagnostic threshold. It is also worth noting that tests with greater diagnostic utility will have a larger impact on the probability that a condition is or is not responsible for the patient’s presentation.

Figure 2: Use of Two Diagnostic Tests to Cross the Diagnostic Threshold

Likelihood Ratios

Likelihood ratios are reported to be the best measure of diagnostic accuracy and allow clinicians to quickly compare the diagnostic utility of various orthopedic tests for the same diagnosis.4 This is why we’ve decided to focus on reporting likelihood ratios throughout this four part review series. While nomograms are typically used to teach the concept of likelihood ratios, these are rarely accessible and seldom used in clinical practice.4 While likelihood ratios are continuous in nature, ranging from 0 to infinity (∞), Table 1 provides a quick way to estimate the influence of positive likelihood ratios (LR+) and negative likelihood ratios (LR-). The purpose of Table 1 is to allow clinicians to memorize the influence of a short list of likelihood ratios for practical purposes, instead of relying on a nomogram.

Table 1: Estimated Influence of Likelihood Ratios*


*Figure adapted from McGee S. Simplifying likelihood ratios. J Gen Intern Med. 2002 Aug;17(8):646-9.

LR+ = positive likelihood ratio; LR- = negative likelihood ratio

We would like to point out that larger positive likelihood ratios have a greater influence on clinical decision-making compared to positive likelihood ratios that are smaller. As a positive likelihood ratio approaches 1.0 it becomes less useful and likelihood ratios approximating 1.0 lack any diagnostic value.4 This relationship is reversed for negative likelihood ratios. Smaller negative likelihood ratios (e.g. LR- = 0.1) have a greater influence on clinical decision-making, while larger negative likelihood ratios that approach 1.0 are of minimal use.

The purpose of this article is to provide a succinct review of the literature related to lower extremity conditions as well as the orthopedic physical exam procedures reported to evaluate for the presence of these conditions. This article intends to focus on orthopedic exams demonstrating the most diagnostic utility, while also calling attention to orthopedic exams that have yet to establish diagnostic utility (i.e. have yet to be studied).

METHODS

This is a narrative review of the evidence-based orthopedic exams for various lower extremity conditions. Information was collected from a variety of sources (outlined in Table 2) that were combined with targeted searches of www.PubMed.gov. Original source articles were obtained when additional information was needed to verify study methods or results. Material presented in this review was selected because it originates from research articles with the highest QUADAS scores or originated from the most recent meta-analysis related to the relevant orthopedic test.

Table 2: Sources Used for this Narrative Review

Cook CE, Hegedus EJ. Orthopedic Physical Examination Tests: An Evidence-Based Approach, 2nd Ed. Indianapolis, IN. Pearson Education; 2013

Clinically Relevant Technologies, CORE – Clinical ORthopedic Exam, version 5.3.3, iOS application, last updated on October 20, 2015

Cleland JA, Koppenhaver S. Netter’s Orthopedic Clinical Examination: An Evidence-Based Approach, 2nd Ed. Philadelphia, PA. Saunders Elsevier; 2011

Malanga, Gerard A., and Scott F. Nadler. Musculoskeletal Physical Examination: an Evidence-Based Approach. Elsevier Mosby, 2006.

Prentice WE. Principles of Athletic Training A Competency-Based Approach. 14th ed. New York, NY: McGraw-Hill; 2011.

Starkey, C., Brown, S. D., & Ryan, J. (2015). Examination of Orthopedic & Athletic Injuries (3rd ed.). Philadelphia: F.A. Davis Company.

Souza Thomas A. Differential Diagnosis and Management for the Chiropractor. Massachusetts: Jones & Bartlett Learning, 2016. Print.

 

DISCUSSION

Organization of this Article

This narrative review of the literature is focused on evidence-based orthopedic exams for lower extremity conditions. This article uses a regional approach to presenting material related to the lower extremity and begins with the hip and proceeding distally.

Hip, Groin, & Thigh Complaints

Orthopedic examination of the hip joint is very accurate in detecting the presence of a problem, with a study conducted by JW Thomas et al. showing 98% accuracy during clinical evaluation. Yet, exact diagnosis is complicated by coexisting pathologies and secondary dysfunction.5 Hip joint dysfunction commonly coexists with lumbar spine dysfunction (i.e. disk related issues) due to biomechanical compensation.5 In addition, overlapping symptoms lead to complications in accurate diagnosis while distinguishing between bone, musculotendinous structures, bursal structures, neurological structures, and visceral disorders, which may refer pain to the hip region.5 Table 3 provides a list of a few clinical hypotheses, based upon the patient’s presentation.

Table 3: Patient’s Presentation for a Hip Complaint and the Associated Clinical Hypotheses*

Patient’s Presentation or History

Initial Clinical Hypothesis

Reports of pain at the lateral thigh. Pain exacerbated when transferring from sitting to standing.

Greater trochanteric bursitis

Muscle strain

Age > 60. Reports of pain and stiffness in the hip with possible radiation into the groin.

Osteoarthritis

Reports of clicking or catching in the hip joint. Pain exacerbated by full flexion or extension.

Labral tear

Reports of repetitive or overuse injury.

Muscle sprain/strain

Deep aching throb in the hip or groin. Possible history of prolonged steroid use.

Avascular necrosis

Sharp pain in groin. Often misdiagnosed by multiple providers.

Femoroacetabular (anterior) impingement

Pain in the gluteal region with occasional radiation into the posterior thigh and calf.

Piriformis syndrome, hamstring strain,
or ischial bursitis

* Adapted from Cleland J, Koppenhaver S. Netter’s Orthopaedic Clinical Examination: An Evidence-Based Approach. 2nd Ed., Elsevier Health Sciences; 2015.

Femoral Neck Fracture (Hip Fracture)

The neck is considered to be the weakest part of the femur, and when coupled with predisposing factors such as being an older, osteoporotic woman, injury is more likely to occur. Other risk factors that contribute to an increased risk of femoral neck fractures are listed below (Table 4). They are delineated into two groups, modifiable factors that can be altered to decrease risk of fracture, and nonmodifiable that cannot be changed.

Table 4: Risk Factors for Hip Fractures*

Nonmodifiable

Modifiable

Age > 65 years

Chronic medications: Levothyroxine, Loop diuretics, Proton Pump Inhibitors, Selective Serotonin Reuptake Inhibitors, Sedatives

Family history of hip fracture

Decreased bone mineral density (osteoporosis)

Female sex

Risk of falls

Low socioeconomic status

Reduced level of activity

Previous hip fracture

Vitamin D deficiency

*Adapted from LeBlanc KE, Muncie HL Jr, LeBlanc LL. Hip fracture: diagnosis, treatment, and secondary prevention. Am Fam Physician. 2014 Jun 15;89(12):945-51.

In elderly patients, the mechanism of injury is typically a fall directly onto the hip or a twisting mechanism with the patient’s foot planted as the body rotates. In younger patients, femoral neck fractures can occur during significant trauma such as a vehicle collision. Patients present with an inability to bear weight and ambulate normally, pain in the groin or buttock, and possible referred pain into the distal femur and superior knee.6 There can be significant complications post injury, such as avascular necrosis and nonunion. Hip fractures increase the risk of death in patients with advanced age.6

Of tests described in Table 5, the Patellar-Pubic Percussion Test was found to have the highest diagnostic accuracy, not only in one study but in two. In addition, the Fulcrum Test had a moderate diagnostic utility, whereas the Log Roll Test had only minimal utility for femoral neck fractures.

Table 5: Orthopedic Tests for Femoral Neck Fracture

Test

LR+

LR-

Patellar-Pubic Percussion Test*

Reimab MP, et al.7

Borgerding LJ, et al.8

 

6.11

17.37

 

0.07

0.22

Fulcrum Test7

3.7

0.09

Log Roll Test9

1.5

0.10

*Multiple high-quality studies have been published; therefore multiple results are reported

Hip Osteoarthritis

The hip is the most common joint in the body to be affected by osteoarthritis (OA) which affects between 10 and 25% of the population over the age of 55.10 Derangement of the joint can manifest due to many factors including age, repetitive trauma, acute trauma, or improper boney arrangement. An increase in body weight, especially coupled with a family history of hip OA, can increase loads transmitted through the joint, therefore increasing stress on tissues and creating dysfunctional changes in these tissues. In the initial stages of dysfunction, the primary complaint is typically pain specifically while weight bearing, with pain becoming more constant as derangement progresses. The gold standard test for the detection of hip OA is a standing anteroposterior radiograph of the pelvis.10 Of the tests mentioned below, most have little to moderate diagnostic accuracy, yet when tests are utilized concurrently (as a cluster), accuracy increases as described below (see Cluster Testing for Hip Osteoarthritis). Abduction or adduction causing groin pain has the highest likelihood ratio showing the highest diagnostic accuracy for hip osteoarthritis. Table 6 provides a list of orthopedic tests used to evaluate for the presence of OA at the femoroacetabular (hip) joint.

Table 6: Orthopedic Tests for Hip Osteoarthritis

Test

LR+

LR-

Squat causing posterior pain10

6.1

0.79

Patrick’s Test, <60 degrees10

1.9

0.61

Hip Scour, with adduction10

2.4

0.51

Active hip flexion causing lateral hip pain10

3.6

0.65

Active hip extension causing pain10

2.7

0.59

Abduction or adduction causing groin pain10

5.7

0.71

Passive Internal Rotation ≤25°10

1.9

0.39

Trendelenburg’s Sign7,10

1.83

0.82

 

Cluster Testing for Hip Osteoarthritis

Sutlive et al. created a clinical prediction rule for identifying hip OA, which evaluated the first seven tests listed in Table 6, and the aggregate diagnostic accuracy was assessed. 10 This study revealed that having multiple positive tests for hip OA increases the specificity of the diagnosis. Additionally, this study demonstrated that having any 3 out of the 7 tests positive yielded a positive LR+ of 5.3, while at least 4 positive tests yielded a LR+ of 24.3.10

Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is associated with the abnormal anatomical relationship between the acetabulum and femur. The classifications that cause dysfunction can be described as either a cam lesion, pincer lesion, or combination lesion where both are present. The cam deformity is characterized by an additional bony prominence in the femoral head or neck region. The pincer lesion features an additional bony protrusion on the acetabulum. The existence of FAI is a recent discovery for clinicians, yet FAI has proven important to recognize due to its contribution to a multitude of hip related morbidities such as labral injuries and early OA in the active population.11 Imaging techniques such as radiograph and MRI can be utilized for diagnosis. In addition, relief post anesthetic injection can be utilized as a confirmatory test.11

As established in the table below, there is only minimal evidence to support the diagnostic accuracy of test that are typically utilized to identify FAI pathology. Patient history and physical examination are crucial to early detection and treatment. Table 7 provides a list of orthopedic tests used to evaluate for the presence of FAI.

Table 7: Orthopedic Tests for Femoroacetabular Impingement

Test

LR+

LR-

FABER (Patrick’s Test)11

1.09

0.72

Scour Test11

0.82

1.72

Stinchfield Test
(Resisted Straight Leg Raise)11

0.87

1.28

Maximal Squat Test12

1.27

0.61

FABER: abbreviation for flexion, abduction, and external rotation

Acetabular Labral Injuries

Acetabular labral injuries occur due to mechanical stresses placed on the fibrous rim of cartilage and tissue associated with the acetabulum. Patients typically present with anterior hip or groin pain, as well as an associated catching or clicking sensation within the joint. MRI, which is considered the gold standard, is commonly utilized in diagnosing acetabular labral tears. The Thomas and Modified Thomas tests have the greatest diagnostic utility in comparison to other orthopedic examinations that are commonly associated with acetabular labral injuries. Table 8 provides a list of orthopedic tests used to evaluate for the presence of acetabular labral injuries.

Table 8: Orthopedic Tests for Acetabular Labral Injuries

Test

LR+

LR-

Hip Scour Test (Quadrant Test)13

1.32

0.58

Impingement Test (FADIR Test)7

1.02

0.48

FABER/Patrick Test

Martin et al. 200614

Sutlive et al. 200810

 

0.73

1.9

 

2.2

0.61

Resisted Straight Leg Raise10,15

0.87

1.28

Fitzgerald Test10

2.4

not reported

Thomas Test7,10

11.1

0.12

Modified Thomas Test13

11.13

0.12

Trochanteric Bursitis/Greater Trochanteric Pain Syndrome

Trochanteric Bursitis typically occurs due to friction from the iliotibial band crossing the bursa during hip flexion, extension, internal rotation, and external rotation. The bursa lies between the insertion of the gluteus medius and minimus muscles as they attach onto the greater trochanter and shaft of the femur. Symptoms include pain and tenderness over the lateral hip, pain with walking, inability to comfortably lie on the affected side, and paresthesia.16 The incidence of trochanteric bursitis is approximately 1.8 per 1000 per year with women being most affected,17 who are possibly predisposed due to increased Q angle. Clinicians should ensure that the patient does not have a femoral neck injury, as trochanteric bursitis can mask its signs and symptoms. Ober’s Test was described for the identification of trochanteric bursitis, with a positive test causing pain over the greater trochanter.18 Although it was described in literature, it was not evaluated for diagnostic accuracy. Trendelenburg test was evaluated for diagnostic accuracy for trochanteric bursitis and proved to be a good measure for identification of this pathology. Table 9 outlines two orthopedic tests used to evaluate for the presence of trochanteric bursitis.

Table 9: Orthopedic Tests for Trochanteric Bursitis

Test

LR+

LR-

Trendelenburg Test19

3.64

0.82

Ober’s18

described, but not evaluated

Coxa Saltans/Snapping Hip Syndrome

Snapping Hip Syndrome, also known as coxa saltans or dancer’s hip, is characterized by a snapping sensation felt when the hip is flexed and extended. There may be an audible pop or snap associated with this sensation, as well as pain or discomfort. This sensation is caused by a taut iliopsoas tendon or iliotibial band (IT band) passing over the greater trochanter of the femur. If the cause stems from the iliopsoas it is termed internal coxa saltans, whereas if the IT band is involved it is considered external coxa saltans which presents more laterally. The FABER and Ober’s tests are utilized to distinguish between internal and external snapping hip, respectively. A palpable or audible snap is considered a positive FABER’s test for internal snapping hip. It is important to distinguish iliopsoas tendon or IT band snapping from intra-articular disorders that also cause popping or snapping sensations. The snapping sensation of coxa saltans may be solicited with more ease during dynamic movements performed by the patient.20 Other methods of evaluating snapping hip syndrome include ultrasonography. Patient history, primarily self-reported symptoms, is crucial to consider when evaluating snapping hip. Although described in literature, diagnostic accuracy for snapping hip syndrome has not been evaluated. Diagnosis of these conditions relies heavily on history and inspection.

Athletic Pubalgia/Sports Hernia

Athletic pubalgia, also known as a sports hernia, is typically the result of increased muscular loads, due to high velocity twisting motions. Overuse or muscular imbalance of the abdominal, hip and pelvic musculature places increased stress on the pubic symphysis or pubic bone. Pain related to athletic pubalgia is associated with stresses placed on the transversalis fascia, tendons of the adductor group, insertion of the rectus abdominis, insertion of the internal oblique and aponeurosis of the external oblique, as well as the genital branches of the ilioinguinal or genitofemoral nerves. Repeated stress across the pubic symphysis can lead to weakening or tearing of the pelvic floor musculature. The tests listed below are pain provocative test which place a shearing force across the pubic symphysis. The tests listed below in Table 10 have moderate clinical diagnostic accuracy for the presence of athletic pubalgia, with the Bilateral Adductor Test having the most clinical accuracy.

Table 10: Orthopedic Tests for Athletic Pubalgia

Test

LR+

LR-

Adductor Squeeze Test21

4.78

0.63

Single adductor21

3.33

0.77

Bilateral Adductor Test21

7.71

0.49

Piriformis Syndrome

Pain in the gluteal region is becoming a more commonly recognized complaint.22 The pain associated with piriformis syndrome stems from the compression of the sciatic nerve by the overlying piriformis musculature.23 The diagnosis of piriformis syndrome is considered one of exclusion, and examined only after lumbar disease (i.e. disk related issues) were thoroughly investigated.23 Early consideration and diagnosis of piriformis syndrome can aid in avoiding unsuccessful treatment and prolonged disability.24 The examinations listed below have a mild to moderate level of diagnostic accuracy for identifying piriformis syndrome. There is no recognized gold standard for evaluating piriformis syndrome.25 Table 11 provides a list of orthopedic tests used to evaluate for the presence of piriformis syndrome.

Table 11: Orthopedic Tests for Piriformis Syndrome

Test

LR+

LR-

Piriformis/FAIR test26

5.18

0.14

Straight Leg Raise Test22

3.20

0.90

Active Piriformis Test22

3.90

0.27

Seated Piriformis Stretch Test22

5.22

0.53

Combined Active Piriformis Test and Seated Piriformis Stretch Test22

4.57

0.11

FAIR: abbreviation for flexion, adduction and internal rotation as abbreviated by the cited source

Hip Flexor Pathology

The commonly referred to hip flexor muscular group, is comprised of the psoas major and iliacus muscles. The rectus femoris of the quadriceps group performs hip flexion, and when injured can lead to hip flexion dysfunction.27 If the range of motion of the hip flexor muscle group (including the iliopsoas and rectus femoris) is decreased or restricted, it can predispose patients to musculoskeletal injuries of the lower extremity. In fact, it has been theorized that pathology of the hip flexors can act as a reciprocal inhibitor to the gluteus maximus.27,28 The inhibition of the gluteus maximus then causes other hip extensors to be overworked, causing greater tissue stress and dysfunction.27,28 According to a study conducted by Eckard et al. assessing the epidemiology of hip flexor injury in sport, men’s soccer and men’s hockey have the highest number of hip flexor strains than any other sport; Furthermore, men’s soccer athletes injured their hip flexors more often than women’s soccer athletes.27 Of the orthopedic examinations listed below, Ely’s test has the highest diagnostic usefulness, whereas the Modified Thomas test has very limited usefulness during an assessment. The Thomas Test, which is commonly described in assessing hip flexor pathologies, has not been evaluated for diagnostic accuracy. Table 12 provides a list of orthopedic tests used to evaluate for the presence of hip flexor pathology.

Table 12: Orthopedic Tests for Hip Flexor Pathology

Test

LR+

LR-

Thomas Test29

described, but not evaluated

Ely’s Test (Duncan-Ely’s Test)30

2.25

0.57

Modified Thomas31

0.74

1.19

 

Iliotibial Band Friction Syndrome

IT band friction syndrome is a frequent overuse injury caused by excess friction between the IT band and the lateral femoral epicondyle. IT band issues account for the sixth most common overuse injury in runners.32 The biomechanics associated with the weight bearing movements expose the tissue to an increase in friction and inflammation. Early in the swing phase of gait, the IT band is anterior to the greater trochanter to aid in hip flexion. Yet, as the leg transitions into hip extension, the tissue is pulled across the greater trochanter proximally and the lateral femoral condyle distally, possibly causing friction.32 Excess friction is caused by improper mechanics including genu valgum, excessive foot pronation, and leg length discrepancy, as well as training behaviors such as running excessive distances and changing running surfaces too quickly. Along with proper mechanics and training habits, orthotics and a consistent stretching routine can assist with prevention and treatment of IT band friction syndrome.32 Several orthopedic examinations have been indicated in assessing the IT band including Noble’s Compression Test, Ober’s Test, and Rennes Test. Unfortunately, there is a lack of evidence that evaluates the reliability of these examinations. Therefore, further studies need to be conducted to evaluate their diagnostic accuracy.32-34

Knee Complaints

Knee pain is a common reason for patients to seek care from health care providers, and knee injuries are among the most common sports-related injuries.35 A wide variety of pathologic conditions may cause knee pain, which include acute trauma to the knee, overuse injuries, or inflammatory arthritides. Soft tissue injuries to the knee commonly present with a sudden onset of pain and are characteristically associated with specific mechanisms of onset. Clinicians are presented with a diagnostic challenge each time a patient presents with knee pain and are challenged with formulating a working list of diagnoses during the history and physical exam process. Table 13 outlines characteristic patient presentations related to knee pain.

Table 13: Patient’s Presentation for a Knee Complaint and the Associated Clinical Hypotheses*

Patient’s Presentation or History

Initial Clinical Hypothesis

Locking or clicking within the knee, joint line tenderness, and edema

Meniscal tear

Loose bodies within the joint (joint mice)

Traumatic onset of knee pain after jumping, twisting, or pivoting on a planted foot

Ligamentous injury (e.g. torn ACL)

Meniscal tear

Patellar dislocation

Quadriceps muscle strain or rupture

Traumatic onset of knee pain and/or deformity following posteriorly-directed force to the tibia while the knee is in a flexed position

Posterior cruciate ligament (PCL) injury

Traumatic onset of knee pain following a varus or valgus force to the knee

Collateral ligament injury

  • Valgus force = MCL injury
  • Varus force = LCL injury

Anterior knee pain following jumping activities and/or deep flexion of the knee, while ascending/descending stairs, or while performing squats

Patellar tendonitis

Patellofemoral pain syndrome

Osgood-Schlatter disease, with pain at the tibial tubercle

Morning stiffness that diminishes following
10-60 minutes of becoming active

Osteoarthritis of the knee joint

* Adapted from Cleland J, Koppenhaver S. Netter’s Orthopaedic Clinical Examination: An Evidence-Based Approach.
2nd Ed., Elsevier Health Sciences; 2015.

ACL, anterior cruciate ligament; PCL, posterior cruciate ligament; MCL, medial collateral ligament; LCL, lateral collateral ligament; OA, osteoarthritis

Evaluating for Fracture around the Knee

Acute injury to the knee may require advanced imaging. While ultrasound or MRI are frequently used to assist in the evaluation of soft tissue injuries of the knee, plain film radiography may be required to evaluate for the presence of an osseous fracture. The Ottawa Knee Rules are a set of clinical features that are strongly associated with fracture in the area of the knee (see Table 14). The presence of at least one of the five clinical features indicates that radiography should be performed. The Ottawa Knee Rules are extremely sensitive (100% sensitive) for acute fracture;36 therefore, use of this decision making aid is ideal for screening patients for a knee fracture. The absence of each of the five clinical features dramatically reduces the need for x-ray and has been shown to reduce the use of unnecessary x-rays following acute knee injury.36,37

Table 14: Ottawa Knee Rules for Assessing Fracture of the Knee*

≥55-years-old

Tenderness at the fibular head

Patellar Tenderness

Inability to flex the knee more than 90°

Inability to bear weight ( ≥4 steps) on the involved knee

  • Immediately following trauma
  • In emergency room (clinical setting)

* Adapted from Stiell IG, Greenberg GH, Wells GA. Derivation of a decision rule for
the use of radiography in acute knee injuries. Ann Emerg Med. 1995 Oct;26(4):405-13.

Meniscal Injury at the Knee

A meniscus injury of the knee frequently occurs during an athletic activity as the knee twists while the foot is planted on the ground or a shear force is applied to the knee.38 Each knee joint contains a medial meniscus and a lateral meniscus; injury to the medial meniscus is about five times more common, and meniscus injuries are commonly associated with injuries to other ligaments of the knee.39 Patients suspected of having suffered a meniscus injury will frequently have an acute onset of joint line tenderness, edema/effusion, limited range of motion, or report a “catching” or locking” sensation.40,41. Table 15 provides an overview of the orthopedic exams associated with evaluating for the presence of a meniscus injury of the knee.

Table 15: Orthopedic Tests for a Meniscus Injury of the Knee*

Orthopedic Test

LR+

LR-

McMurray’s Test**

   

Miao Y, et al. 201142

6.25

0.78

Jaddue, et al. 201043

Medial = 2.27

(no lateral reported)

Medial = 0.64

(no lateral reported)

Pookarnjanamorakot C, et al. 200444

3.5

0.78

Akseki D, et al. 200440

Medial = 2.2

Lateral = 4.4

Medial = 0.48

Lateral = 0.53

Apley’s Compression Test45

1.0

0.91

Apley’s Distraction Test46

0.13

1.87

Thessaly Test*

   

Pookarnjanamorakot C, et al. 200444

6.8

0.76

Mirzatolooei F, et al. 201047

1.3

0.51

Harrison BK, et al. 200948

39.3

0.10

Ege’s Test (Akseki Test)40

Medial = 3.5

Lateral = 6.4

Medial = 0.41

Lateral = 0.40

Axial Pivot-shift Test49

4.2

0.35

Steinmann I Sign43

Medial = 3.88

(no lateral reported)

Medial = 0.41

(no lateral reported)

Dynamic Test (for lateral meniscus injury)50

Lateral = 3.88

(no medial reported)

Lateral = 0.41

(no medial reported)

Bounce Home Test (Forced Extension Test)49

1.4

0.70

Childress Test (Squat Test or Duck Waddle Test)44

1.7

0.53

Payr Test/Sign44,45

0.96

1.05

* Results are reported for combined meniscal injury (medial or lateral), unless medial or lateral are directly listed

** Multiple high-quality studies have been reported; therefore, we’ve included the results from a few of the most rigorous studies.

Cluster Testing for a Meniscus Injury

The use of multiple orthopedic tests may be useful for clinicians attempting to diagnose a suspected meniscal injury of the knee. Miao, et al. evaluated the combination of 4 clinical features (edema, joint line tenderness, a sensation of “locking,” and a positive McMurray’s test).42 This evaluation of the cluster combination discovered that the presence of any 2 of the 4 clinical features is highly useful for diagnosing a meniscal injury with a positive likelihood ratio of 14.5 and a negative likelihood ratio of 0.44.

Anterior Cruciate Ligament Injury

Injury to the anterior cruciate ligament (ACL) is a common knee injury among adolescent athletes. The sports which place individuals at the greatest risk for suffering an ACL injury are soccer, football, basketball, skiing, and lacrosse.51 Additionally, females participating in sport are about 1.5-to-10 times more likely than males to injure their ACL, depending on the specific sport.52,53 Table 16 provides a list of orthopedic tests used to evaluate for the presence of an ACL injury.

Table 16: Orthopedic Tests for an Anterior Cruciate Ligament Injury

Orthopedic Test

LR+

LR-

Lachman’s Test54

10.2

0.2

Prone Lachman’s Test55

20.17

0.32

Active Lachman’s Test56

described, but never evaluated

Anterior Drawer Test57

1.67

0.91

Anterior Drawer Test in External Rotation58

described, but never evaluated

Anterior Drawer Test in Internal Rotation58

described, but never evaluated

Lever Sign Test (Lelli’s test)59

6.3

0.41

Pivot-Shift Test54

8.5

0.90

Fibular Head Sign60

described, but never evaluated

Cluster Testing for ACL Injury

Wagemakers et al. established how accurately a clinician could identify ACL injury by evaluating for a few clinical features (effusion around the knee, a “popping sensation,” and a sensation of “giving way”) and assessing the ACL utilizing the anterior drawer test.61 When they evaluated patients with knee pain for this combination of findings, their study yielded a positive likelihood ratio (LR+) of 19.9 and a negative likelihood ratio (LR-) of 0.80. These findings suggest that patients presenting with swelling around the knee, combined with popping, and a sensation of giving way may only require an additional positive anterior drawer test before clinicians can be fairly confident that the patient has a torn ACL.

Posterior Cruciate Ligament Injury

The posterior cruciate ligament (PCL) is broader and stronger than the ACL and is also injured less frequently than the ACL.62 The PCL prevents excessive posterior translation of the tibia, relative to the femur, and PCL injuries characteristically involve a history of knee hyperextension or posteriorly-directed force to the patient’s flexed knee (e.g. during an automobile accident).63 Also, when compared to ACL injuries, PCL injuries are less likely to be associated with a “popping” sound at the time of onset.64 Table 17 provides a list of orthopedic tests used to evaluate for the presence a PCL injury.

Table 17: Orthopedic Tests for a Posterior Cruciate Ligament (PCL) Injury

Orthopedic Test

LR+

LR-

Posterior Drawer Test65

90

0.10

Posterior Functional Drawer Test66

described, but never evaluated

Posterolateral Drawer Test67

described, but never evaluated

Modified Posterolateral Drawer Test (Loomer’s Test)68

described, but never evaluated

Posterior Sag Sign (Godfrey’s Test, Gravity Drawer Test)69

0.21

Reverse Lachman’s Test (Trillat’s Test)65

5.64

0.43

Quadriceps Active Test65

18.0

0.47

Reverse Pivot-Shift Test65

5.2

0.78

Varus/Valgus Stress at 0° Flexion70

described, but conclusions about diagnostic utility are possible, due to methodological issues

External Rotation Recurvatum Test65

3.0

0.98

Anterior Abrasion Sign71

described, but never evaluated

Proximal Tibial Percussion Test66

described, but never evaluated

Dial Test (Posterolateral Rotation Test)72

described, but never evaluated

Standing Apprehension Test73

described, but never evaluated

∞ = infinity, which occurs when the sensitivity or specificity of an exam is 100%, thus preventing the ability to calculate a likelihood ratio. In clinical practice, this should be thought of as a test that is of very high quality.

Collateral Ligament Injuries of the Knee

Medial collateral ligament (MCL) injury occurs when a valgus force is applied to the knee, and injuries to the MCL are much more common than injuries to the lateral collateral ligament (LCL).74 Many MCL injuries occur when a traumatic force is applied to a partially flexed knee and patients may be able to ambulate following the injury.

The Valgus Stress Test is performed at 0° and 30° of flexion and is the hallmark orthopedic test for evaluating for an MCL injury. Pain on the Valgus Stress Test equals a LR+ of 2.3 and the absence of pain equals a LR- of 0.30, while laxity on the Valgus Stress Tests equals a LR+ of 1.8 and the absence of laxity equals a LR- of 0.20.75

A test cluster for evaluating an MCL injury has also been developed.75 Kastelein et al. discovered that patients who have experienced either trauma by external force to the leg or rotational trauma to the leg along with laxity and pain on the Valgus Stress Test have a LR+ of 6.4 and a LR- of 0.5.75 This shows that combining information from the history and orthopedic exam may provide the most useful information when evaluating potential MCL injuries.

The LCL is one component of a complex of ligaments known as the posterolateral corner of the knee. Injury to the LCL occurs when a varus force is applied to the knee, which results in localized pain, edema, and a sensation of instability in more severe cases.

The Varus Stress Test is also performed at 0° and 30° of flexion and is the hallmark orthopedic test for evaluating for an LCL injury. Unfortunately, the studies that have attempted to evaluate the clinical utility of the Varus Stress Test have methodological issues, which limits the ability to draw conclusions from these studies.7677

Anterior Knee Pain

Anterior knee pain, sometimes called patellofemoral pain is a symptom that may originate from various pathologies.78 Anterior knee pain is most likely to affect adolescents and young adults and is more commonly reported among females.79 While the features of anterior knee pain vary by individual diagnosis, common symptoms include pain with activity, such as those that involving walking down stairs, squatting, prolonged sitting, or when wearing high-heels.7880 We have provided a brief overview of the common causes of anterior knee pain in Table 18, along with the relevant orthopedic tests for each diagnosis.

Table 18: Causes and Orthopedic Tests for Anterior Knee Pain

Condition

Orthopedic Test

LR+

LR-

Patellofemoral Pain Syndrome

(chondromalacia patella)

Waldron Test, Phase I81

Waldron Test, Phase II81

Pain During Resisted Knee Extension80

Medial & Lateral Movement of the Patella80

Patellar Compression80

Pain During Functional Activity (squatting)80

History of “pain with squatting”82

History of peripatellar pain82

History of pain while navigating stairs or sitting82

1.7

1.05

2.2

1.5

1.5

1.8

5.4

19.0

11.6

0.81

0.99

0.75

0.80

0.60

0.20

0.66

0.43

0.44

Patellar Dislocation

Patellar Apprehension (Fairbank’s Test)81

2.3

0.79

Patellar Instability

Passive Patellar Tilt Test83
Lateral Pull Test (Active Instability Test)83

Moving Patellar Apprehension Test84

Medial and Lateral Patellar Glide Tests85

5.4

8.62

not evaluated

0.62

0.75

0.0

not evaluated

Abnormal Patellofemoral Tracking

Vastus Medialis Coordination Test81

2.26

0.90

Patellofemoral Joint Pathology

Clarke’s Sign (Patellar Grind Test)81

1.94

0.69

Patellofemoral Joint Dysfunction

Eccentric Step Test81

2.34

0.71

Plica Syndrome*

Medial Patellar Plica Test (MPP Test)81,86

Plica Stutter Test87

8.18

not evaluated

0.11

not evaluated

Patella Alta

Patella Alta Test83

1.75

0.71

Patellar Tendinopathy
(Jumper’s Knee)

Palpation of the inferior pole of the patella for moderate or severe pain88

2.18

0.76

Chondral Fracture
(osteochondritis dissecans)

Wilson’s Test89

described, but not evaluated

Osgood-Schlatter’s

Physical examination and radiography90

described, but not evaluated

Patellofemoral Bursitis

(Housemaid’s Knee)

Physical examination combined with a history of frequent kneeling91

described, but not evaluated

Infrapatellar Fat Pad Injury

(Hoffa’s disease)

Physical examination and MRI92,93

described, but not evaluated

∞ = infinity, which occurs when the sensitivity or specificity of an exam is 100%, thus preventing the ability to calculate a likelihood ratio

* Many tests have been described with the intention to diagnoses plica syndrome, but nearly all have not been evaluated for diagnostic accuracy

Leg Complaints

Complaints of the leg can present as a challenge for clinicians to properly diagnose as many of them have overlapping symptoms. It is important for the clinician to recognize subtle differences in the presentation and formulate a correct diagnosis, as management strategies vary greatly with each condition. Although not an exhaustive list, the three leg conditions focused on in this article are medial tibial stress syndrome, chronic exertional compartment syndrome, and stress fracture. Table 19 provides a list of a few clinical hypotheses for patients presenting with leg pain, based upon the patient’s presentation.

Table 19: Patient’s Presentation for a Leg Complaint and the Associated Clinical Hypotheses*

History/Presentation

Initial Hypothesis

Runner, pain at distal third of posteromedial tibia, worse at the beginning and conclusion of activity/sport

Medial tibial stress syndrome (shin splints)

Pain in the lower leg, oftentimes described as burning or cramping, experienced with exercise. Symptoms resolve with rest

Chronic Exertional Compartment Syndrome

An insidious onset of pain with a concurrent reported change in activity, localized bony pain

Tibial Stress Fracture

* Adapted from Cleland J, Koppenhaver S. Netter’s Orthopaedic Clinical Examination: An Evidence-Based Approach.
2nd Ed., Elsevier Health Sciences; 2015.

Medial Tibial Stress Syndrome

Medial tibial stress syndrome (MTSS), commonly referred to as shin splints, affects many runners and persons involved in other activities that involve running and jumping on hard surfaces. Although the exact etiology of MTSS is unknown, it is believed that bony overload and periosteal inflammation or traction are involved.94,95 There are no orthopedic tests designed to evaluate for MTSS. Research has shown that it can be reliably clinically diagnosed using history and physical examination findings.96 Common features of MTSS include;

  • Pain provoked upon palpation of the posteromedial tibia over an area of at least 5 cm
  • Pain located within the distal third of the tibia
  • Pain improves with relative rest
  • Pain exacerbated with physical activity, especially at the beginning and end

Chronic Exertional Compartment Syndrome

Chronic exertional compartment syndrome (CECS) is a rare condition that typically affects young adult distance runners and other running athletes. There is an increase in pressure within the confinement of a closed fascial compartment during exercise. There are currently no orthopedic tests used to evaluate CECS. A good history is paramount, as the physical exam is often unrevealing.97 It is important to note for the chiropractor that CECS can mimic other conditions, such as MTSS, and that there is an average 2 year delay in diagnosis, making it important to rule out other causes.98 The gold standard in diagnosis is intracompartmental pressure testing, which is outside the scope of a chiropractor. Common history findings for CECS include;

  • Bilateral symptoms 70-80% of the time
  • Pain, swelling, sensation of burning, cramping, tightness develop during exercise
  • Development of pain in a certain area of the leg develops at the same time, distance, or intensity of the exercise
  • Pain is relieved with rest

Stress Fracture

Stress fractures of the leg are associated with repetitive activities of impact, such as running and marching. They most commonly occur in the tibia, although they can occur in the fibula. Common physical exam findings associated with a stress fracture include;99,100

  • Recent increase in physical activity
  • Gradual onset
  • Pain with weight bearing
  • Localized bony pain
  • Begins as pain with stress, eventually progressing to pain at rest and at night

Although radiographs are commonly the first image ordered, they have a poor sensitivity in the diagnosis of stress fractures, as they are not visible on radiographs for 2-6 weeks post injury. Scintigraphy and MRI are considered the gold standard in diagnosing stress fractures. Although there are no traditional orthopedic tests used in helping diagnose stress fractures, the use of a tuning fork and therapeutic ultrasound have been studied; reproduction of pain following the application of the tuning fork or ultrasound to the bone is a positive finding for a stress fracture. Table 20 provides an overview of the exams associated with evaluating for the presence of a stress fracture in the lower leg.

Table 20: Orthopedic Tests for a Stress Fracture

Exam

LR+

LR-

Tuning Fork (128-Hz)101

2.3

0.3

Ultrasound102

2.1

0.3

Ankle Complaints

Ankle sprains are the most common musculoskeletal injuries seen by primary care providers.103 Although sprains are the most common injury to the ankle, other conditions (ex. tendinopathy, fracture, nerve compression, arthritis, etc.) can cause pain and dysfunction in the ankle. Table 21 outlines characteristic patient presentations associated with ankle pain.

Table 21: Patient’s Presentation for an Ankle Complaint and the Associated Clinical Hypotheses*

Patient’s Presentation or History

Initial Clinical Hypothesis

Patient reports a traumatic incident in either forced inversion or eversion

Possible ankle sprain

Possible fracture

Possible peroneal nerve involvement (with inversion)

Patient reports trauma to ankle that included tibial rotation on a planted foot

Possible syndesmotic sprain

Patient reports traumatic event resulting in inability to plantarflex the ankle

Possible Achilles tendon rupture

Patient reports pain with stretch of calf muscles and during gait (toe push off)

Possible Achilles tendonitis

Possible Sever’s disease

* Adapted from Cleland J, Koppenhaver S. Netter’s Orthopaedic Clinical Examination: An Evidence-Based Approach.
2nd Ed., Elsevier Health Sciences; 2015.

Ankle Sprain

An ankle sprain is the most frequent injury to the ankle, with inversion sprain being the most prevalent. An inversion ankle sprain damages the anterior talofibular ligament most commonly, but can also affect the calcaneofibular and posterior talofibular ligaments.104 Eversion ankle sprains can damage the deltoid ligament, and are commonly associated with fractures of the medial malleolus and syndesmotic injuries.105 Common exam findings include tenderness, swelling, and bruising around the ankle with an inability or difficulty bearing weight on the affected side. Acute injury to the ankle may necessitate advanced imaging to screen for fracture. The Ottawa Ankle Rules (OAR) (Table 22) were developed to guide clinicians as to when advanced imaging of the ankle is appropriate after injury. The absence of each of the five clinical features dramatically reduces the need for an x-ray and has been shown to reduce the use of unnecessary x-rays following acute ankle injury.106 If any of the below features are present, then an x-ray should be obtained. The OAR were found to have a LR+ of 1.52 and a LR- of 0.03, which means that they are best used to rule out a fracture. The extremely low LR- provides the clinician with a lot of confidence that if none of the below findings are present, then the patient is very unlikely to have a fracture.107 Table 23 outlines the orthopedic tests for evaluating patients who may have a sprained ankle.

Table 22: Ottawa Ankle Rules to Evaluate for Fracture Following an Ankle Injury*

Bony tenderness along the distal 6 cm of posterior edge of fibula or tip of lateral malleolus

Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus

Bony tenderness at the base of the 5th Metatarsal

Bony tenderness at the navicular

Inability to bear weight both immediately after injury and for 4 steps during initial evaluation

*Adapted from Stiell IG, McKnight RD, Greenberg GH. Implementation of the Ottawa ankle rules. JAMA. 1994 Mar 16;271(11):827-32.

Syndesmotic Injuries

Syndesmotic injuries, also known as “high ankle sprains” are a relatively rare ankle injury, with the incidence estimated from 1-11% of all ankle sprains. These injuries are usually a result of an external rotation force combined with dorsiflexion and/or eversion, which can sprain or rupture the syndesmosis between the tibia and fibula.108 Table 23 outlines the orthopedic tests for evaluating patients who may have a syndesmotic injury.

Ankle Impingement

Ankle impingement is divided into anterior and posterior ankle impingement. Anterior impingement is a condition in which pain is experienced at the front of the ankle due to compression of bony or soft tissue structures in the ankle mortise joint during maximal dorsiflexion. Posterior impingement refers to pain felt at the back of the ankle due to compression of structures in the ankle mortise during maximal plantar flexion. There are no orthopedic tests in the literature that have been studied for posterior ankle impingement. There has been one orthopedic test studied for anterior impingement, the forced dorsiflexion test. It should be noted that this study had a high risk of bias.109 Table 23 outlines the orthopedic test for evaluating patients who are suspected of ankle impingement.

Achilles Rupture and Achilles Tendinopathy

The Achilles tendon is the most commonly ruptured tendon. The main causes are a forceful contraction of the calf muscles, overstretching of the tendon, and a fall from a height. As opposed to a complete rupture, some patients’ tendon will still be intact and will have Achilles tendinopathy, which is usually associated with overuse. Table 23 outlines the orthopedic tests for evaluating patients who may have Achilles tendon rupture or tendinopathy.

Table 23: Causes and Orthopedic Tests for Ankle Pain

Condition

Orthopedic Test

LR+

LR-

Inversion Ankle Sprain

Anterior Drawer Test

Croy T, et al.104

Schwieterman B, et al.110

1.4

0.41

0.42

Inversion Talar Tilt Test110

4.00

0.57

Posterior Drawer Test

described, but never evaluated

Eversion Ankle Sprain

  • Eversion Talar Tilt Test

described, but never evaluated

Syndesmotic Injury

External Rotation Stress Test (Kleiger’s Test)110

only a specificity of 99% was reported

Squeeze Test110

4.60

0.75

Fibular Translation110

6.30

0.28

Anterior Ankle Impingement

Forced Dorsiflexion 109

8.06

0.06

Achilles Rupture)

Thompson Test110

13.47

0.04

Matles Test110

6.18

0.14

Palpable Gap Test110

6.81

0.30

Copeland Test110

only a sensitivity of 78% was reported

Achilles Tendinopathy

Palpation111

3.15

0.48

Arc Sign111

3.24

0.68

Royal London Hospital Test111

3.84

0.54

Foot

The foot is a complex structure of the body with all of its associated weight-bearing bones, joints, ligaments, and tendons. Due to the complexity and frequent use of the foot, there are a multitude of injuries that can occur, many of which do not have any associated orthopedic test. This article will attempt to cover the most common foot injuries that have orthopedic tests. Table 24 outlines a characteristic patient presentation related to foot pain.

Table 24: Patient’s Presentation for an Ankle Complaint and the Associated Clinical Hypotheses*

Patient’s Presentation or History

Initial Clinical Hypothesis

Patient reports pain at heel with first few steps out of bed after prolonged periods of walking

Possible plantar fasciitis

Patient reports pain or paresthesias in plantar surface of foot

Possible tarsal tunnel syndrome

Possible sciatica

Possible lumbar radiculopathy

Patient reports pain on plantar surface of foot between 3rd and 4th metatarsals. Might also state that pain is worse when walking with shoes compared with barefoot

Possible Morton’s neuroma

Possible metatarsalgia

* Adapted from Cleland J, Koppenhaver S. Netter’s Orthopaedic Clinical Examination: An Evidence-Based Approach.
2nd Ed., Elsevier Health Sciences; 2015.

Turf Toe

Turf toe is a hyperextension injury of the first metatarsophalangeal joint, usually combined with axial compression. It can damage a variety of structures of the capsular ligamentous complex that supports the joint.112 It is suggested in the literature to assess the joint with valgus and varus stress tests along with a Dorsoplantar Drawer test, although these tests have not been studied to determine diagnostic accuracy. Table 25 outlines the orthopedic tests for evaluating patients who may have turf toe.

Morton’s Neuroma

Morton’s Neuroma is a condition associated with the common plantar digital nerves and is thought to occur from repetitive trauma, which leads to a disorganized overgrowth of neuronal and fibrous tissues. Morton’s neuroma may produce pain or numbness in the foot, and the most common locations of a Morton’s neuroma are the second and third intermetatarsal spaces.113 Table 25 outlines the orthopedic tests for evaluating patients suspected of having a Morton’s neuroma.

Plantar Fasciitis

Plantar fasciitis can be a cause of plantar heel pain that usually localizes to the anterior, medial heel. It is commonly seen in runners, as it is one of the top three most common running injuries, but is also seen in people who have recently increased their amount of physical activity.114 The pain is commonly at its worse the first thing in the morning, or after a period of non-weight bearing, but usually improves with light activity.115 Table 25 outlines the orthopedic tests for evaluating patients who may have plantar fasciitis.

Sever’s Disease

Sever’s disease, also called calcaneal apophysitis, is a traction apophysitis that occurs where the Achilles tendon attaches to the calcaneus. It causes inferior heel pain in children and adolescents. The pain is usually absent in the mornings and is aggravated by physical activity, particularly running and jumping.116 Table 25 outlines the orthopedic tests that have been reported for evaluating Sever’s disease.

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve as it passes under the flexor retinaculum of the tarsal tunnel. Common symptoms include paresthesia and pain on the plantar surface of the foot and the medial ankle.117 Table 25 outlines the orthopedic tests for evaluating patients suspected of having tarsal tunnel syndrome.

Hallux Valgus

Hallux valgus is a progressive foot deformity in which the first metatarsal deviates medially while the first phalange deviates laterally, creating a characteristic foot deformity (see Figure 3). Hallux valgus can lead to bony and soft tissue changes that result in the formation of a bunion, along with pain and functional deficits. Although no orthopedic tests have been reported to diagnose hallux valgus, the Manchester scale was developed to grade the level of severity of hallux valgus. The Manchester scale is pragmatic in that no advanced imaging is required and can be applied by both clinician and patient. It has been shown to be reliable in terms of retest and inter-rater reliability.118-120

Figure 3: Gross and Radiological Appearance of Hallux Valgus*


* Image “Best Shoes for Bunions,” licensed under Creative Commons (CC) BY 2.0, accesses on Nov. 11, 2017 at: https://c2.staticflickr.com/6/5599/30475577936_94dbfba526_b.jpg

Table 25: Causes and Orthopedic Tests for Foot Pain

Condition

Orthopedic Test

LR+

LR-

Turf Toe

Valgus/Varus Stress Test

described, but never evaluated

Dorsoplantar drawer test

described, but never evaluated

Morton’s Neuroma

Thumb Index Finger Squeeze121

0.04

Mulder’s Click121

0.38

Foot Squeeze121

0.41

Plantar Percussion121

0.64

Dorsal Percussion121

0.74

Abnormal Light Touch/Pin Prick121

0.75

Digital Nerve Stretch Test122

only reported a sensitivity of 100%

Plantar Fasciitis

Windlass Test123

0.68

Sever’s Disease

One-Leg Heel Standing124

0

Calcaneal Squeeze Test124

0.03

Palpation Test124

0.2

Tarsal Tunnel Syndrome

Tinel’s Sign110

only reported a sensitivity of 58%

Triple Compression Test110

0.14

Dorsiflexion Eversion Test110

  • when a + sign was increased palpatory tenderness at posterior tibial nerve in tarsal tunnel

0.02

  • when a + sign was increase in pain in foot/ankle

0.43

  • when a + sign was increased numbness in foot/ankle

0.75

LIMITATIONS

Due to the nature of this being a narrative review, selection bias may have influenced our selection of relevant reference articles or source materials. Also, the lack of search criteria, which would have been involved with a systematic review, make it so our results are less reproducible. While we attempted to select the highest quality reference materials, using the QUADAS grading scale, we did not systematically grade every source article that was used in this report.

CONCLUSION

The purpose of this article is to provide clinicians with an evidence-based overview of the available orthopedic tests for a variety of lower extremity conditions. Additionally, we have attempted to emphasize when orthopedic tests do not exist or when they have only been described, but have never been evaluated for accuracy. Many orthopedic tests for lower extremity conditions have limited utility. When no test exists or when the available tests are not of a high quality, we would like to emphasize that this is when clinical decision-making should rely more heavily on the other aspects of an evaluation such as the history, patient’s presentation, doctor’s experience, and even the patient’s preferences.

Throughout this 4-part orthopedic review series the authors have attempted to encourage clinicians to adopt an evidence-based approach to clinical decision-making. We have suggested that clinicians adapt the use of likelihood ratios as one of the best ways to quickly judge the usefulness of orthopedic exams. Our hope is that this review series will assist clinicians in their ability to provide a concise orthopedic exam. Using the fewest number of exams that are of the highest utility is intended to yield the most accurate results. Additionally, the use of high-quality exams is intended to reduce the rate of false positive and false negative exam findings, which may mislead a clinician in achieving an accurate diagnosis. Orthopedic tests are tools to assist clinicians, and the usefulness of these tests is highly variable. While clinical decision-making must be made in the face of uncertainty, we hope this 4-part series will help to provide a framework for clinicians to successfully navigate this process.

List of Abbreviations

ACL = anterior cruciate ligament of the knee

CECS = Chronic Exertional Compartment Syndrome

FABER = abbreviation for flexion, abduction, and external rotation

FAI = Femoroacetabular impingement

IT band = Iliotibial band

LCL = lateral collateral ligament of the knee

LR+ = Positive Likelihood Ratio

LR- = Negative Likelihood Ratio

MCL = medial collateral ligament of the knee

MRI = Magnetic Resonance Imaging

MTSS = Medial Tibial Stress Syndrome

OAR= Ottawa Ankle Rules

OA = Osteoarthritis

PCL = posterior cruciate ligament of the knee

∞ = infinity

Competing Interests

Each of the three authors declare that they have no competing interests related to this work.

Author’s Contributions

CBR conceived this project and CBR, EFL, and ZJ each contributed to the literature review and participated in the drafting and revisions of this work. Each of the three authors of this article have met the criteria for authorship.

Acknowledgements

The lead author (CBR) of this 4-part orthopedic review series would like to thank each of the co-authors that have agreed to take part in the writing of this series of articles. Each of the co-authors (listed below) who were gracious enough to share their time, talents, and unique perspectives in order to make this review series as useful as possible. This series of articles would not have been possible without help from each of you.

List of co-authors involved with this this 4-part series:

  • Dr. Rebecca Warnecke: Palmer College of Chiropractic DC student at the time of writing
  • Dr. Milad Asefi: practicing doctor of chiropractic
  • Dr. Casey Okamoto: practicing doctor of chiropractic
  • Mrs. Emma Forlow Livingway: Palmer College of Chiropractic DC student at the time of writing
  • Dr. Zachary Jipp: practicing doctor of chiropractic

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