An Evidence-Based Approach to the Orthopedic Physical Exam –Part 3: The Head, Neck, and Thoracic Spine
Christopher B. Roecker, DC, MS, DACO1, Casey S. Okamoto, DC2
1Assistant Professor, Palmer College of Chiropractic Life Science & Foundations Department
2 Doctor of Chiropractic, VA Medical Center Minneapolis, MN
Published: September 2017
Journal of the Academy of Chiropractic Orthopedists
September 2017, Volume 14, Issue 3
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/Okamoto and the Academy of Chiropractic Orthopedists.
Head, neck, and thoracic spine-related disorders are frequent causes of neuromusculoskeletal complaints. Establishing an accurate diagnosis for these conditions is expected to guide clinical management and improve patient care. This narrative review of the literature will provide an overview of the evidence-based orthopedic physical exams for many head, neck, and thoracic spine-related disorders. We have highlighted orthopedic physical exams that have demonstrated the highest diagnostic utility and pointed out when no such test exists. We encourage clinicians to utilize the best available orthopedic tests in an attempt to maximize their diagnostic accuracy and provide optimal patient care.
Key Words (MeSH terms)
Evidence Based Practice; Chiropractic; Spine; Differential Diagnosis; Pain, Neck; Pain, Back; Cervical Radiculopathy; Injuries, Whiplash
Evaluating patients for the presence of an orthopedic condition is a complex process. This process requires clinicians to collect information from the patient’s history and combine it with information from the physical exam. The clinician selects from a variety of orthopedic physical exams, applying those with the highest utility based on the patient’s unique presentation.1 By selecting useful orthopedic tests, the clinician can rule in or rule out a given condition, narrowing the list of differential diagnoses. Unfortunately, not all orthopedic tests aid in quality patient assessment; some have been shown to provide useful information, while others have been shown to provide misleading or confusing information. Additionally, many orthopedic tests have yet to be evaluated and their clinical utility remains unknown.
When orthopedic tests are evaluated for usefulness, results are compared to more complex procedures, such surgery or advanced imaging, and a variety of diagnostic test parameters are provided. These results have traditionally been reported via sensitivity, specificity, or positive and negative predictive values.2 It has been noted that these types of tests do not always translate well into clinical practice.3 Why these test results do not translate well into practice is not well understood, but it may be due to the cumbersome nature of having to known multiple test statistics, as with sensitivity and specificity, or that statistics such as positive or negative predictive values require clinicians to be aware of the underlying prevalence of disease.3
Fortunately, there is a test statistic that allows clinicians to move beyond sensitivity and specificity or positive and negative predictive values, helping clinicians to quickly understand the usefulness of an orthopedic test; these test results are likelihood ratios. Likelihood ratios incorporate and orthopedic test’s sensitivity and specificity into a single, easy to use, number.1 If a test result is positive, the positive likelihood ratio (LR+) is used, and when a test is negative, the negative likelihood ratio (LR-) is used. In short, the tests with the most usefulness have a high LR+ and/or a low LR-.1,4 Table 1 provides an overview on interpretation of positive and negative likelihood ratios. The current transformation of healthcare towards an evidence-informed model, discussed in Parts 1 and 2 of this 4-part series, has correlated with an increase in the reporting and use of likelihood ratios for orthopedic exams.
Table 1: Interpreting Likelihood Ratios
Very useful — yield large and often conclusive shifts in probability
Moderately useful — yield substantial shifts in probability
5 – 10
0.1 – 0.2
Rarely useful — yield small shifts in probability
2 – 5
0.2 – 0.5
Not useful — yield unimportant shifts in probability
1 – 2
0.5 – 1.0
Adapted from Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to the medical literature. 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? The Evidence-Based Medicine Working Group. JAMA. 1994 Mar 2;271(9):703–7.
+LR = positive likelihood ratio; -LR = negative likelihood ratio
The purpose of this article is to provide an overview of the various orthopedic physical exam procedures used for assessment of head, neck, and thoracic spine conditions, to report when no such tests exist, and to inform of commonly used tests have yet to establish diagnostic utility.
This project is a narrative review of the evidence-based orthopedic physical exams reported to be used in the evaluation of head, neck, and thoracic spine-related disorders. Information used to write this article was collected from various sources, listed in Table 2. As the aim of this narrative review was to focus on background information, authoritative textbooks on the topic of evidence-based orthopedic exams were emphasized. The original source articles were obtained when additional information was needed and to verify information. All sources were assessed for quality using a QUADAS grading system. When multiple sources existed for a particular test, we reported information from the article with the highest QUADAS scores. Additionally, we used the iOS application titled CORE Orthopedics by Clinically Relevant Technologies to assist in our review of the literature; this was chosen because it has the ability to link a wide-variety of orthopedic exam procedures with their original source articles, via hyperlinks to the associated articles on PubMed.gov, which expedited the process of identifying source data for the orthopedic exams discussed in this narrative review.
Table 2 – Sources Used for this Narrative Review
Murphy DR. Clinical Reasoning in Spine Pain. Volume II — Primary Management of Cervical Disorders Using the CRISP Protocols. Pawtucket, RI. CRISP Education and Research, LLC; 2016
Clinically Relevant Technologies, CORE – Clinical ORthopedic Exam, version 5.3.3, iOS application, last updated on October 20, 2015
Cook CE, Hegedus EJ. Orthopedic Physical Examination Tests: An Evidence-Based Approach, 2nd Ed. Indianapolis, IN. Pearson Education; 2013
Cleland JA, Koppenhaver S. Netter’s Orthopedic Clinical Examination: An Evidence-Based Approach, 2nd Ed. Philadelphia, PA. Saunders Elsevier; 2011
Glynn PE, Weisbach PC. Clinical Prediction Rules: A Physical Therapy Reference Manual. India. Jones and Bartlett Publishers; 2011
Unsurprisingly, there exists a wide range of orthopedic physical exam procedures with equally wide-ranging measure of clinical utility (levels of usefulness). While orthopedic test results may appear to be straightforward, reported as positive or negative, such dichotomous results are overly simplistic. Orthopedic tests do reveal positive or negative findings, but the degree of accuracy varies from test-to-test and the assumption of uncertainty should be considered in clinical practice.5
Much has been written on the complexities surrounding the management of spine-related disorders. This article will present an approach to the diagnosis and management of head, neck, thoracic spine, and upper extremity conditions that are related to the spine, based upon the Clinical Reasoning in Spine Pain (CRISP) model reported by Murphy.6,7
Introduction to the Clinical Reasoning in Spine Pain Approach
The Clinical Reasoning in Spine Pain (CRISP) approach to caring for patients with spine pain is intended to provide a framework for evaluating patients to arrive at an accurate diagnosis and understand contributions to the patient’s experience. Three questions are used to aid the practitioner in arriving at an accurate understanding of the patient’s condition:7
- Do the patient’s symptoms reflect a visceral disorder or life-threatening pathology?
- What is the origin of the pain?
- Is anything happening to this person, as a whole, that may alter the patient’s pain experience?
Do the symptoms reflect a visceral disorder or life-threatening pathology?
Due to the potential lethality of failing to recognize a visceral disorder or serious pathology, it is sound judgement to rule out these “red flags” prior to moving on to a neuromusculoskeletal cause of the patient’s pain. Table 3 provides an overview of the red flags that may be associated with head, neck, or thoracic spine pain.
Table 3: Features That Indicate a Serious Pathology May Be causing Head, Neck, or Thoracic Spine Pain*
Condition and Associated Clinical Features
Cervical Artery Dysfunction / Dissection
*Adapted from Murphy DR. Clinical Reasoning in Spine Pain. Volume II — Primary Management of Cervical Disorders Using the CRISP Protocols. Pawtucket, RI. CRISP Education and Research, LLC; 2016, page 20
Cervical Artery Dysfunction
Cervical artery dysfunction (CAD) is a general term used to represent a range of pathologies that may produce cervico-cranial ischemia. Much debate and confusion exists regarding the safety and utility of orthopedic test (AKA provocative exams) for the evaluation of cervical artery dysfunction. While several exams have been reported to evaluate for CAD,5 these exams have either never been studied to establish diagnostic utility, or have been shown to have no clinical usefulness (e.g. +LR = 0).5,8
Many of the exams that report to evaluate for CAD involve placing physical stress on the arteries of the cervical spine (e.g. end-range motion). Placing additional stress on potentially damaged or dysfunctional cervical arteries may worsen a potentially life-threatening clinical situation. The lack of established benefit, combined with a potential for harm, leads us to recommend against performing orthopedic exams for the evaluation of CAD. Patients presenting with signs and symptoms that are suggestive of CAD should be referred for medical evaluation. Please see the “Cervical Artery Dysfunction / Dissection” section of Table 3 for a review of the signs and symptoms associated with CAD.9
Canadian C-Spine Rule
The Canadian C-Spine Rule is a highly sensitive (98-100% sensitive) decision rule that is used to determine when cervical spine radiography is not necessary in an alert and stable trauma patient.10 This brief algorithm (see Figure 1) has been validated to provide high-quality information related to determining the need for cervical spine radiography.11 Because this decision rule is intended to help clinicians decide when radiography is not necessary, the focus of this test is on its negative likelihood ratio (LR-). Remember, a low LR- (<0.1) is most useful and the Canadian C-Spine Rules demonstrate an average LR- = 0. 18.11,12 It should be pointed out that this decision rule should not be used in patients with any of the following: a Glasgow Coma Scale score <15, unstable vital signs, age <16 years, acute paralysis, known vertebral disease, past cervical spine surgery, or pregnancy. Also, this decision rule does not consider “simple motor vehicle collision” to include: being hit by a large truck, rollover accidents, being hit by a high speed vehicle, or being pushed into oncoming traffic.10
Figure 1. Canadian C-Spine Rules*
Figure adapted from Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25;349(26):2510–8
*Please review the details regarding when this decision rule should not be utilized in the source article or in the paragraph above.
Spinal Percussion Test
Spinal percussion is a simple test that is used to evaluate for spinal fractures. This test has been evaluated for its utility in the identification of acute osteoporotic vertebral body compression fractures and has been shown to have a sensitivity of 87.5% and a specificity of 90%, which equates to a LR+ = 8.7 as well as a LR- = 0.14.13 These diagnostic statistics are encouraging and support the inclusion this quick, simple, and accurate test for the evaluation of suspected vertebral body compression fractures.
What is the pain’s origin?
Categories of Head, Neck, and Thoracic Spine Disorders include disc derangement, joint dysfunction, radiculopathy, myelopathy, and myofascial pain syndrome (trigger points).7,13
Patient History for Cervical Spine Conditions
The patient’s clinical presentation serves to narrow the list of possible causative conditions; therefore, narrowing the list of relevant orthopedic tests. Table 4 provides an overview of the patient’s history and the associated category of pain generating condition (initial hypothesis).
Table 4: Patient History and Initial Hypotheses
Diffuse neck pain that is nonspecific and exacerbated upon neck movement
Cervical muscle strain or sprain
Traumatic onset of neck pain, exacerbation when vertical, relief with external support or when unloaded (supine), dysesthesias of the face upon neck movement, muscle spasm
Cervical spine instability14
Neck pain in a younger patient, made worse by static postures, commonly lower cervical flexion, and improved with movement
Neck pain combined with unilateral paresthesia into the upper extremity
Neck pain combined with bilateral upper extremity motor and sensory symptoms, possible lower extremity ataxia
Diffuse pain of an achy quality that may radiate between the periscapular region, shoulder, neck, and head
Myofascial pain syndrome (trigger points)7
Neck and/or upper thoracic spine pain, anterior head carriage, forward rounded shoulders,
Upper crossed syndrome
Adapted from Cleland J, Koppenhaver S, Su J. Netter’s Orthopaedic Clinical Examination: An Evidence-based Approach. Elsevier Health Sciences; 2015.
The zygapophyseal or facet joints are estimated to drive between 36% to 55% of axial neck pain.15–17 The prevalence could be as high as 60% in cases of whiplash associated disorders (WAD).18 A zygapophyseal joint is composed of an inferior and superior articular process, articular cartilage, a joint capsule and synovial membrane, menisci, and fibrous or fatty inclusions called meniscoids.
Facet mediated pain is caused by trauma to the zygapophyseal joint or to degenerative changes. Trauma may cause compression of the zygapophyseal joint and articular cartilage or stretch of the joint capsule beyond its physiological limit. Likewise intervertebral disc degeneration and associated loss of disc height can result in disproportionate stress on the zygapophyseal joints, leading to cartilage degeneration and osseous proliferation. In some patients the meniscoids, fibrous folds of synovial membrane, can become trapped between the zygapophyses causing a painful locking sensation.19 Pain referral patterns for the cervical spine are shown in Figure 2 and for the thoracic spine in Figure 3.
Though many orthopedic tests for the cervical spine apply compressive, distractive, torsional, and shearing forces to the zygapophyseal joints, they do so incidentally while testing for other pathology (e.g., nerve compression). To our knowledge no specific orthopedic tests have been shown to be accurate in diagnosing zygapophyseal joint pain. Murphy suggests four tests that may be clustered with the aim of increasing diagnostic utility.7
- Palpation for segmental tenderness (PST)
- Manual joint palpation (MJP)
- Extension-Rotation Test – applied in the mid- and lower cervical spine
- Flexion-Rotation Test – applied in the upper cervical spine
Figure 2. Referred Pain Patterns for the Cervical Zygapophyseal Joints
Figure adapted from Fukui S, Ohseto K, Shiotani M, Ohno K, Karasawa H, Naganuma Y, et al. Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami. Pain. 1996 Nov;68(1):79–83.
Figure 3. Referred Pain Patterns for the Thoracic Zygapophyseal Joints
Figure adapted from Dreyfuss P, Tibiletti C, Dreyer SJ. Thoracic zygapophyseal joint pain patterns. A study in normal volunteers. Spine. 1994 Apr 1;19(7):807–11.
The zygapophyseal joints have been demonstrated to produce specific referral patterns when injected with contrast medium or when the dorsal rami innervating the joint are electrically stimulated.20 Such referral patterns, either revealed as part of the history or elicited during provocative maneuvers, may be considered when making a diagnosis.
Instability of the cervical spine is a poorly-defined set of conditions that involves ligamentous, muscular, or bony disturbances. Cervical instability involves tissue injury, which reduces the ability of the spine to maintain its normal anatomical relationships and protect the underlying neurological structures.21 While acute trauma or degenerative changes are common cause of cervical instability, it is important to remember instability may be associated with other mechanisms. Clinicians should stay mindful that developmental anomalies, such as Down syndrome, or inflammatory conditions, such as rheumatoid arthritis, are also associated with atlanto-axial instability.21,22 Table 5 provides an overview of the orthopedic tests reported to evaluate for cervical spine instability.
Table 5: Orthopedic Tests for Cervical Instability
Modified Sharp-Purser Test23
Alar Ligament Stability Test24
Left = 18
Right =as high as possible (∞)
Left = 0.29
Right = 0.31
Anterior Stability Test (of the atlanto-occipital joint)24
Tectorial Membrane Test24
Posterior Atlanto-Occipital Membrane Test24
As high as possible (∞)
+LR = positive likelihood ratio; -LR = negative likelihood ratio; RA = rheumatoid arthritis; ∞ = infinity; this results from an inability to calculate likelihood ratios when the sensitivity or specificity of a test is 100%
Whiplash Associated Disorders
Whiplash Associated Disorders (WAD) refer to injuries of the neck caused by an acceleration/deceleration injury. WAD injuries are chiefly associated with neck pain but sequelae may also include dizziness, upper extremity pain and paresthesia, and headache. It has been estimated that 300 per 100,000 people are seen in United States and Australian emergency departments for WAD each year, most of which occur following a motor vehicle accident (MVA).25 It is thought that symptoms are more likely the result of sprains and strains of neck ligaments and muscles rather than trauma to the zygapophyseal joints and intervertebral discs, though this does likely occur.
Whiplash Associated Disorders are diagnosed and graded based on the presence of symptoms and physical exam findings. Table 6 provides an outline of the criteria for each of the WAD grades.
Table 6: Whiplash Associated Disorder Grading
Grade 0 WAD
No neck complaints and no physical signs
Grade I WAD
Injuries involving complaints of neck pain, stiffness, or tenderness, without physical signs.
Grade II WAD
Neck complaints accompanied by decreased range of motion and point tenderness
Grade III WAD
Neck complaints accompanied by neurologic signs (e.g., decreased or absent myotatic reflexes, weakness, or sensory deficits)
Grade IV WAD
Neck complaints accompanied by fracture or dislocation
Attendant symptoms such as deafness, dizziness, tinnitus, headache, memory loss, dysphagia, and temporomandibular joint pain can be present in all grades.
Adapted from Carroll LJ, Holm LW, Hogg-Johnson S, Côté P, Cassidy JD, Haldeman S, et al. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine . 2008 Feb 15;33(4 Suppl):S83–92.
Disc derangement is a cause of discogenic pain. Static postures can place asymmetrical loads on the nucleus pulposus, resulting in relative displacement of the intradiscal material. Such an asymmetry may result in stiffness and pain upon movement in a given direction and could predispose or exacerbate tearing of the annulus fibrosus, the outer ⅓ of which is highly innervated.
Disc derangement is diagnosed based on a combination of historical factors and an end-range loading (ERL) exam. Patients with a disc derangement will often present with pain that is worse in the morning, improving toward mid-day and with movement. Younger people are more likely to experience a disc derangement as their discs are richer in hydrophilic proteoglycans and are thus better able imbibe fluid, resulting in a higher intradiscal pressure. The pain is provoked by static postures, most commonly lower cervical flexion but possibly others depending on the orientation of the derangement.
An ERL exam refers to the active and sometimes passive loading of the cervical spine in extension, flexion, lateral bending, rotation, protraction, and retraction in order to discern a direction of benefit and a direction of detriment. Once a direction of benefit has been identified the spine is repeatedly loaded in that direction with the goal of diminishing symptom severity or moving the symptoms nearer to midline (i.e., centralization). The ERL exam uses a progression of force from least to most invasive, allowing for active loading prior to passive (clinician assisted) loading.7
A herniated nucleus pulposus (HNP) is the most common cause of cervical spine radiculopathy26 and the C6 and C7 nerve roots are the most commonly involved nerve roots at 60% and 25%, respectively.27 Acute trauma to the brachial plexus or nerve roots may also produce upper extremity radiculopathy, such as in the case of a “burner” or a “stinger,” following traumatic depression of the shoulder.28
There are several orthopedic tests that reportedly test for upper extremity radiculopathy. Many have been evaluated to establish their diagnostic utility, but others have not. Table 7 outlines many of the orthopedic tests that are commonly reported to evaluate for cervical radiculopathy.
Table 7: Orthopedic Tests for Cervical Radiculopathy
Spurling’s Compression Test29
Left = 4.9
Right = 4.5
Left = 0.69
Right = 0.66
Brachial Plexus Compression Test31
Cervical Hyperflexion Test30
Cervical Hyperextension Test (Jackson’s Test)32
Cervical Distraction Test29
As high as possible (∞)
Upper Limb Tension Test A (median nerve bias)30
Upper Limb Tension Test B (radial nerve bias)30
Shoulder Abduction Test29
Left = 2.2
Right = 1.9
Left = 0.71
Right = 0.77
Shoulder abduction test (Bakody Sign)
Cervical Compression Test (Foraminal Compression Test)
Shoulder Depression Test
+LR = positive likelihood ratio; -LR = negative likelihood ratio; ERLS = External Rotation Lag Sign
∞ = infinity; this results from an inability to calculate likelihood ratios when the sensitivity or specificity of a test is 100%
Clinical Prediction Rule for Cervical Radiculopathy
A clinical prediction rule has been developed to assist clinicians in diagnosing the presence of cervical radiculopathy.30 This clinical prediction rule involves 4 orthopedic exam findings and the presence of 3 or more yields a LR+ = 6.1. Table 8 provides an overview of this clinical prediction rule.
Table 8: Cervical Radiculopathy Clinical Prediction Rule
Factors Predicting Response
1. Cervical rotation <60°, toward the involved side
2. Positive Upper Limb Tension Test A (median nerve bias)
3. Positive Cervical Distraction Test
4. Positive Spurling’s A Test
Predictors of Treatment Response
Cervical Traction Test Cluster
A clinical prediction rule has been developed that has been shown to help identify patients who are most likely to benefit from cervical spine traction. Table 9 outlines the features most useful for identifying patients who have the greatest likelihood of responding favorable to cervical traction.
Table 9: Factors Associated with Positive Response to Cervical Spine Traction
Factors Predicting Response
1. Lower cervical spine (C4-C7) produces peripheralization of the chief complaint
2. Positive Shoulder Abduction Test
3. Positive Upper Limb Tension Test A
4. Positive Distraction Test
5. Age ≥55 years
Adapted from Raney NH, Petersen EJ, Smith TA, Cowan JE, Rendeiro DG, Deyle GD, 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 Mar;18(3):382–91
Cervical Spondylotic Myelopathy
Cervical spondylotic myelopathy (CSM) results from the degeneration changes in the cervical spine, such as osteophytosis, hypertrophy of the ligamentum flavum, or zygapophyseal joint degeneration, and is the most common spinal cord disorder in individuals over the age of 45.33 These degenerative changes produce encroachment upon the spinal cord (spinal stenosis) resulting in compression and irritation. The features of CSM are frequently reported to involve deep aching neck pain and upper extremity radicular pain or clumsiness. Additionally, patients may manifest with signs of an upper motor neuron lesion in the upper and lower extremities.30,3433
The Japanese Orthopedic Association Score (JOA) allows clinicians to measure the severity of the myelopathy, and categorizes the severity of the patient’s clinical features.33,35 Patients with mild CSM features (JOA score <12) may be managed with conservative spine care, but patients with a moderate or severe JOA score (JOA score ≥12) should receive a surgical consultation.36
A select cluster of clinical exam findings have the ability to dramatically increase the accuracy of diagnosing CSM.33,36 These five clinical exam findings are outlined in Table 10. Patients presenting with at least three of these five features have a high probability for CSM (94-99% probability)33 and should follow-up with a cervical MRI to evaluate for potential cord compression.37
Table 10: Features Associated with Cervical Spondylotic Myelopathy
1. Gait Deviation (abnormally wide based gait, ataxia, spastic gait)
2. Positive Hoffmann’s Test
3. Inverted supinator Sign
4. Positive Babinski Test
As high as possible (∞)
5. Age >45 years
*Adapted from Cook C, Brown C, Isaacs R, Roman M, Davis S, Richardson W. Clustered clinical findings for diagnosis of cervical spine myelopathy. J Man Manip Ther. 2010 Dec;18(4):175–80
∞ = infinity; this results from an inability to calculate likelihood ratios when the sensitivity or specificity of a test is 100%; +LR = positive likelihood ratio; -LR = negative likelihood ratio
Syringomyelia is a rare cause (9-130 per 100,000)38 of myelopathy in which a cyst or “syrinx” forms in the spinal cord parenchyma, causing compression of the decussating spinothalamic tracts and, in severe cases, the posterior columns. Though most syrinxes form before the age of 30, an affected individual may not experience symptoms until several years later.7
The majority of syringomyelia cases involve the cervical cord, but cases have also been reported in the thoracic and lumbar regions.3940 Most cases of syringomyelia are associated with Type I Chiari malformations, but may also form following trauma, tumor, or infection.40,41
Though a syrinx can remain asymptomatic, those that grow large enough to compress the surrounding neural structures will cause a host of sensory and even motor abnormalities. As the syrinx compresses the decussating spinothalamic fibers, dissociated sensory deficits may occur. In such cases the patient will experience diminished temperature and pain sensation while light touch and joint position sense is spared. The shoulders and upper extremities are classically affected in what is described as a “shawl” distribution. If the syrinx grows large enough compression of the posterior columns can result in diminished vibration and joint position sense.7,41 Upper motor neuron signs (e.g., Babinski, Hoffmann’s) are often present in cases of cervical myelopathy. See Table. 3 for a review of clinical exam findings which can be clustered to increase diagnostic accuracy.
Myofascial Pain Syndrome
Myofascial pain syndrome is caused by a myofascial trigger point (MTrP), described as “…hyperirritable spots, usually within a taut band of skeletal muscle or in the muscle’s fascia that is painful on compression and can give rise to characteristic referred pain, tenderness, and autonomic phenomena.”42 MTrPs are common and may present as a primary pain generator or in concert with other painful conditions like whiplash, joint dysfunction, and headaches. Skootsky, et al. reported that of 56 patients presenting to a general internal medicine clinic for a painful condition, 30% met the clinical criteria for myofascial pain syndrome.43
A diagnosis of MTrPs is often made based on history, clinical presentation, and palpation. Objective measures like high definition ultrasound, magnetic resonance elastography, computed tomography, and electromyography may be used to identify MTrPs, but are more likely to be utilized in the context of research.44 Simons and Travell identified 7 clinical features of a trigger point.42
- A taut band within the muscle.
- Exquisite tenderness at a point on the taut band
- Reproduction of the patient’s pain
- Local twitch response
- Referred pain
- Restricted range of motion
- Autonomic signs (e.g., piloerection, erythema, or tearing)
To this list, others have added weakness of the affected muscle. It has also been suggested that only features 1-3 are essential for diagnosing a trigger point, while the others may or may not be part of the presentation.44 A review on the variability of criteria used to diagnose MTrPs identified 19 different diagnostic criteria. The four most common features were tender spot in a taut band of skeletal muscle, patient pain recognition, predicted pain referral pattern, and local twitch response.45 While studies regarding interrater reliability have found that palpation can be an effective tool to identify MTrPs, it should be noted that specific features (e.g., referred pain sensation) are more reliably agreed upon than others (e.g., eliciting a local twitch response).46,47
Thoracic Outlet Syndrome
Thoracic outlet syndrome (TOS) is a controversial condition reported to involve compression of the neurological or vascular structures that exit the thoracic outlet, which include the brachial plexus, subclavian artery, and subclavian vein.46 Compression of these neurovascular structures originates from various anomalies (e.g. cervical rib or prolonged transverse process), repetitive trauma, acute trauma, poor posture, or more rarely from tumors or infections.47 TOS is commonly categorized as primarily compressing the neurological structures or the vascular structures. The neurological form of TOS is reported to be the most common form, whereas the vascular form of TOS represents only about 5% of all cases.46,47 Clinicians should be aware that the vast majority of all orthopedic tests used to evaluate for suspected TOS are addressing this more rare vascular form of TOS and that these orthopedic tests have been reported to have high rates of false positives.48
Thoracic outlet syndrome most commonly affects young adults and is four times more likely to affect females.46 TOS may manifest with a variety of signs or symptoms, but characteristically produces upper extremity sensory abnormalities, such as paresthesia or heaviness, and may also cause skin changes (color or temperature) to the upper extremity.47 These features are typically exacerbated during upper extremity abduction or other physical activities, such as throwing, painting, or driving.46,49 Table 11 provides an overview of the tests that are used to evaluate for the presence of TOS.
Table 11: Orthopedic Tests to Evaluate for the Presence of Thoracic Outlet Syndrome
Elevated Arm Stress Test (Roos Test)50
Wright’s Hyperabduction Maneuver (Wright’s Test)46
Only a specificity of 85-98% has been reported
Costoclavicular Maneuver (Eden’s Test)51
Only a specificity of 53-100% has been reported
Only a specificity of 77-97% has been reported
Upper Limb Tension Test A (median nerve bias)30
Upper limb tension tests are occasionally reported to evaluate for neurogenic TOS (17826254), but have never been evaluated for this purpose
Upper Limb Tension Test B (radial nerve bias)30
Cervical rotation lateral flexion test52
Only a sensitivity of 100% has been reported
Allen’s Test (Allen maneuver)
described, but never evaluated
described, but never evaluated
described, but never evaluated
Shoulder Abduction Test (Reverse Bakody Test) 53
described, but never evaluated
∞ = infinity; this results from an inability to calculate likelihood ratios when the sensitivity or specificity of a test is 100%; +LR = positive likelihood ratio; -LR = negative likelihood ratio; TOS = thoracic outlet syndrome
Scoliosis is defined as the abnormal lateral curvature of the spine with a Cobb angle of greater than 10 degrees53,54 and affects approximately 3% of all pediatrics ages 10 to 16 years.55 While this condition may develop as result of congenital or developmental osseous or neurologic abnormalities, most cases of scoliosis develop during adolescence and are idiopathic.54 Traditionally, Adam’s Forward Bend test (Adam’s test) has been used to visualize the structural effects of suspected scoliosis. The accuracy of Adam’s test improves as the Cobb angle increases, but at a 10 degree Cobb angle the Adam’s test yields a LR+ = 12.85 and a LR- = 0.17.
In the past, Adam’s test was used to screen school-age children for this condition, but guidelines published by the U.S. Preventative Services Task Force now recommends against the routine screening of asymptomatic adolescents for idiopathic scoliosis (Grade D Recommendation).56 The rationale for this recommendation follows a lack of evidence that routine scoliosis screening in asymptomatic individuals has not been shown to detect this condition earlier than detection without screening.
Thoracolumbar Junction Syndrome (Maigne’s Syndrome)
Thoracolumbar junction syndrome (also known as Maigne’s syndrome, posterior rami syndrome, or lumbar dorsal ramus syndrome) was proposed by the French physician Robert Maigne in the 1970s. Dr. Maigne proposed that dysfunctional thoracolumbar facets (T11-L3) may refer pain to the various regions supplied by the posterior rami and peripheral nerves originating at the dysfunctional thoracolumbar facets.57 The areas of pain referral were reported to include the sacroiliac region, groin/inguinal region, and lateral thigh in a non-dermatomal in distribution.58 Clinicians should be aware that this condition is sparsely reported in the literature and uniform acknowledgement for the existence and legitimacy of this condition is lacking.
The diagnostic evaluation for thoracolumbar junction syndrome is accomplished by raising a fold of skin from the thoracolumbar region and “rolling” the skin between thumb and forefinger or via posterior-to-anterior pressure on the thoracolumbar facets.58 Reproduction of the patient’s distant pain complaint (e.g. sacroiliac, lateral thigh, groin) is considered a positive test result. We were unable to identify any tests evaluating the diagnostic procedure for thoracolumbar junction syndrome.
Is there anything happening to this person, as a whole, that may alter the patient’s pain experience?
Yellow flags are psychosocial factors which may result in perpetuation or amplification of a pain state. Such factors may predate or be sequelae of the patient’s pain condition. It may also be that these factors and persistent pain mutually maintain one another. Murphy includes 5 psychological factors and 4 contributing factors in his description of yellow flags;7 Table 12 for an overview of these yellow flags.
Table 12: Yellow Flags
A patient may experience a disproportionate amount of fear with regard to their condition. This can result in maladaptive behaviors including avoidance of activity for fear of worsening their condition or, less often, too much activity for fear of losing their ability to be active.
A tendency to assume that the worse possible outcome will occur. The patient may feel hopeless, convinced that their condition will never improve.
Passive coping is the practice of relying on external forces to provide healing, a cure, or relief. Strategies vary but examples include self-medication or frequently switching providers in search of a “fix”.
Those with low self-efficacy have little confidence in their ability to manage their symptoms or improve their condition.
A persistently low mood and attendant feelings of hopelessness. Depression may or may not be related to the patient’s pain condition, but can profoundly impact their ability to recover.
This occurs when a patient perceives that someone or something is at fault for their condition. They feel as though they have been robbed of their pre-injury selves and this “perceived injustice” can affect the patient’s ability to recover.
Hypervigilance for symptoms
The patient is constantly taking inventory of internal and external threats. It is a preoccupation with one’s symptoms.
While fear was specific to the patient’s condition, anxiety is state of fear that may or may not be related to the patient’s condition. The psychological and physiological changes that accompany an anxiety state may impact the patient’s ability to recover.
This is a condition in which the patient fuses their assumptions, beliefs, and cognitions about pain with the experience of pain, resulting in an inaccurate assessment of danger.
Adapted from Murphy D. Clinical Reasoning in Spine Pain Volume II: Primary Management of Cervical Disorders Using the CRISP Protocols Case Studies in Primary Spine Care. 2016.
As this is a narrative review, selection bias may be introduced during the selection of relevant reference articles. Also, search results may be less reproducible than in a systematic review. While we attempted to select the highest quality reference materials, we did not formally grade all the articles used in this report.
The purpose of this article is to provide clinicians with an evidence-based overview of orthopedic tests for conditions of the head, neck, and thoracic region and also to point out when no such tests exist. Many of the traditional tests have demonstrated limited utility when used in isolation. For this reason, we recommend clinicians utilize clusters of tests when available. When quality orthopedic tests do not exist for a particular condition, clinicians should rely on their own clinical experience while remaining mindful of the patient’s values and preferences.
List of Abbreviations
+LR = positive likelihood ratio
-LR = negative likelihood ratio
∞ = infinity
CAD = cervical artery dysfunction
HNP = herniated nucleus pulposus
MJP = Manual joint palpation (MJP)
PST = Palpation for segmental tenderness
RA = rheumatoid arthritis
TOS = thoracic outlet syndrome
WAD = whiplash associated disorders
The authors declare that they have no competing interests related to this work.
CBR and CSO conceived this project, contributed to the literature review, and participated in the drafting and revisions of this work.
None. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of Veterans Affairs or the US Government.
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