The April 2018 National Physical Therapy Examination is quickly approaching. Since >50% of the examination covers musculoskeletal and neuromuscular content, it is important to spend ample time reviewing Orthopedic evaluation and examination. A portion of the Orthopedic examination is the special tests. While many of these special tests do not demonstrate good reliability individually, the diagnostic accuracy improves when clustered together. In this post, I outline the top 5 most important tests to know for the NPTE.
NPTE Studying Posts
Important Special Tests for NPTE
Importance of Test: The anterior cruciate ligament stabilizes against anterior translation of the tibia on the femur, due to the attachment at the anterior tibial plateau and posteriorly on the medial side of the lateral femoral condyle (Neumann 534). The force applied by the examiner stresses the ligament, and is a better test for assessing the integrity of the ACL in acute injuries compared to the Anterior Drawer Test for various reasons. The position of 20 degrees of knee flexion is a less painful position than the 90 degrees required for the Anterior Drawer Test; thus, there is a lower chance of protective spasms from the hamstrings. Also, in 20 degrees of flexion, the ACL is more maximally stressed and can be assessed more accurately, because other tissues due not limit anterior translation of the tibia ("Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis"). It should be noted that patients with a torn PCL may test positive with a Lachman test. In the starting position of the Lachman test, the tibia will rest further posterior than usual due to the absence of the PCL, leading to increased excursion during the test (Manske, 2006). This means PCL integrity should be assessed prior to looking at ACL integrity. Often with ACL injuries, other tissues and structures can be injured as well. One of the more significant findings recently has been bone contusions with ACL injuries. Look for research on the topic coming out soon!
Similar to the hawkins-kennedy test for impingement, it is again important to cluster this test’s results with other tests and measures when assessing for rotator cuff tears. The cluster for a full thickness rotator cuff tear includes 1. the Drop-arm sign, 2. the painful arc sign, and 3. infraspinatus manual muscle test.
If all three tests are positive, the +LR is 15.6.
(Note is 3/3 are positive and the patient is greater than 60 years old the +LR increases to 28)
If all three tests are negative the -LR is .16
If ⅔ tests are positive the +LR is 3.6
Note: Two of the three tests for this cluster are the same as the impingement syndrome cluster. The differentiating factor between impingement and rotator cuff tear is the drop arm sign for full thickness rotator cuff tears and hawkins-kennedy for subacromial impingement.
Importance of Test: This test's results can be interpreted in multiple ways. Like other neural tension tests, the test may indicate if a patient is experiencing symptoms related to nerves adhering to various tissues while travelling throughout the body. The patient may experience stretching, pain, or other neurological sensation in the area of adhesions. Another use for the test is detecting lumbar disc herniations. With the flexed lumbar spine and hip completed simultaneously with the extended LE, the sciatic nerve and its respective nerve roots are put on tension to detect the potential of a disc herniation. The results of the test should be interpreted based on the patient's pain/symptoms for which they are seeking treatment.
Looking for a more efficient way to incorporate the special tests into your examination? Check out Dr. Heafner's Guide to Efficient PT Examination.
Importance of Test: If a patient tests positive on the Vertebral Artery test, they may have Vertebrobasilar Insufficiency (VBI), but if they test negative on it, you CANNOT rule out Vertebrobasilar Insufficiency. The theory behind this test is to maximally stress the opposite vertebral artery by stretching it to decrease the space in the lumen of the artery. The position of extension with contralateral rotation has been shown to decrease the diameter of the artery, but, again, the diagnostic accuracy of the test is still poor.
Importance of Test: Whenever a you encounter a patient that has neck pain as a result of trauma or cervical instability, you should always inspect the integrity of the transverse ligament before any other exam measures. The transverse ligament is responsible for keeping the anterior facet of the atlas against the dens of the axis. It attaches on the medial side of each large, lateral process of the atlas with the anterior side of the middle part touching the odontoid process. This creates a wide space in the vertebral canal for the spinal cord to pass through, posteriorly. When the transverse ligament is damaged, the atlas can slide forward on the dens, decreasing the size of the vertebral canal for the spinal cord to go through. This can result in neurological symptoms, such as pain, weakness, a lump in the throat, etc. In this compromised position, any movements can impinge upon the spinal cord and cause potentially irreversible damage. The supine transverse ligament stress test works to reproduce symptoms in an instability patient, because the test works to decrease the space of the vertebral canal by pushing the atlas anterior on the axis. This motion is normally blocked by the transverse ligament. The Sharp-Purser test should be performed before the Transverse Ligament Stress Test, because the Sharp-Purser test works to reduce symptoms, while the Transverse Ligament Stress Test works to reproduce symptoms. (“Clinical Testing for the Craniovertebral Hypermobility Syndrome”).
Any Tests We Missed?
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-Jim Heafner PT, DPT, OCS
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