Why do orthopedic tests matter?

What is the underlying mechanism that makes these test relevant?

How is this actually applicable for treatment of elbow pain?

What if this doesn’t fix everything!?


The One Big Idea: The Secret is in the sequence


I wanted to write this because I have no heard this idea thought out elsewhere though it seems incredibly simply and exponentially useful. In terms of a complete treatment plan for elbow pain this is by no means exhaustive. I would categorize this essay as a closely zoomed in view of google maps so please do not neglect zooming out to see the larger picture of each patient. However, let’s dig into some known processes and see if we cant rescue some gems from the often far to familiar and very neglected rubble of orthopedics tests for lateral elbow pain.

Sequence, set up & squeeze

The big 3 confirmatory tests for Tennis Elbow, or elbow pain on the outside of the elbow, are Maudsley’s, Cozen’s and Mill’s. Each has a particular sequence of steps wherein the attempt is to isolate a contraction of a certain movement to test it’s relation to the lateral epicondyle. More simply put, they line things up mechanically to test whether or not a movement aggravates the elbow. The 3 movements tested are finger extension, wrist extension and elbow extension and the set up up allows for the best isolation of these groups to the lateral elbow.

Why do these tests matter? Think about the sequential set up as directions from the your house to the party. Your house is the muscle group and the party is the lateral epicondyle in this scenario. The sequence and set up for these tests answer the question; How can one determine if (insert action of muscle group) is involved in aggravating the lateral epicondyle? The response is the directions given, or if you 1) stabilize humerus 2) make a fist 3) pronate forearm etc etc then you should arrive at the party the ICD-10 calls Lateral Epicondylitis.

Now that we have a basic understanding of the tests let’s quickly review so you have a proper perspective as we move forward. We’ll start at the bottom of the chain and move upward, but as you watch these see if you can discover any other similarities between the tests. 



 

What is the underlying mechanism? These tests tell you that the primary mechanism for lateral elbow pain is extension of the fingers, wrist or elbow. From a patients perspective though it often seems reversed. If your elbow pain is like most elbow pain then beyond these tests it is common for people to complain that the pain is aggravated by grabbing things, holding things or otherwise initialed seemingly by the primary action of engaging the fingers in a state of flexion. We can marry the two findings by saying that engaging in too much flexion will diminish their ability to extend; hence, the previously stated ortho tests focus on various points of extension and now our focus on restoring extension to alleviate the amount of stress and pain of flexion.

How is this applicable to treatment? Let’s bring back this idea of sequencing. We know that the orthopedic tests for lateral epicondylitis are sequence to provide the easiest path from the muscle group to the condyle, but what if we altered one step? It would change the focus of the tension.

Let’s start with Maudsley’s. If this test was positive we should conclude that one goal of our treatment plan would be to restore finger extension. How could we restore finger extension working within the framework of the test that just proved positive? Reverse a step or two so that we can stress finger extension without that stress “getting” to the lateral epicondyle. More specifically, rather than pronating the forearm, we instead supinate the forearm. Then instead of a neutral or extended wrist, we flex the wrist. Then extending the fingers we can do a simple PNF stretch with a contract and relax sequence.

This sequence will isolate the previously provocative action from the patients perspective of finger flexion, or grabbing and holding things, as well as our positive finding of Maudsley’s Test without allowing that action of the finger flexion and the position of extension to “get to” the lateral epicondyle. The sequence and re-positioning of forearm will essentially put a road block between the desired action and the point of pain. Now the same idea can be used for the other two tests as well.

What if this doesn’t fix everything? First, it likely won’t, but it’s a great start and this fundamental understanding of the pain process will hopefully lead to a more thorough treatment plan overall. Second, there is another gem here and it’s literally the first step of each of these tests. These tests assume that the humerus is stable and even if it is not the doctor is instructed to “stabilize” the humerus. As such, we can make a strong argument that though these test seem to stress the various extensors below the elbow the primary (first step) is the stabilization of the humerus. So while addressing the extensor groups is absolutely useful it may all be lost without stabilizing the humerus first.

There are of course many other avenues and factors to consider in a balanced treatment of an elbow, but I hope you find this useful for your patients.

 

PS: I’d like to thank my friends Casey and Erik for this idea. They worked very hard to help docs like me understand the value of orthopedic tests by creating a massive index of tests that has helped me tremendously. Thanks, friends. Also, thanks to the good people at Physio Tutors for the info!


Please remember that this essay is not for you. I write to shame my mind of it’s frivolous internal banter and turn it into something useful for those who have entrusted me with their care.

Note: if you want to skip the nerdy stuff on the front end, the last bit of the post talks about the different viewpoints of various ideologies. 


  1. What is range of motion?
  2. What does range of motion tell us? 
  3. What is range of motion based on?
  4. What is range of motion related to? 
  5. Is more range of motion really good for you?
  6. Can we rule out pathology by combining range of motion?
  7. How to use combined range of motion to our benefit

After ‘pain’ it seems that range of motion might have the biggest target on it’s back whether your means are manual therapy, exercise, rehab, stretching, neurological, psychological, tool assisted, physiological, surgical, occupational, postural, performance or otherwise, it seems that range of motion hovers over these like an inescapable tyrant. So what precisely is range of motion anyways? One definition is that range of motion is the full movement potential for a given joint. Another adds a bit more when they define range of motion as a measurement of the distance and direction a joint can move to its full potential. While a third states ROM is the linear or angular distance that a moving object may normally travel while properly attached to another. 

First, range of motion can tell us many things, but primarily range of motion describes our skeletal system. Many people prefer to infer muscular dysfunction as it relates to range of motion and a small minority will describe the soft tissue structures around a joint like ligaments, capsules, bursa’s and the like, but let’s stick with the basics of the bones for now. Being a practitioner I have a hard time working when no one is on my table or in my office, so let’s hallucinate what we can infer from the passive range of motion of a hip.

In parsing out hip range of motion we must again consider the portion of the definition that states that the direction and distance in question is what it is only while properly attached to another. Basically, normal femoral movement assumes a normal fixed or stationary pelvis to move upon. Any statement made about femoral movement must include either implicitly or explicitly something about that hemi-pelvis it is attached to. If during our exam we discover femoral movement is either reduced or excessive, then subsequently the pelvic position is corresponds to an equal degree. Such that if we collect enough data on passive ranges of motion of both femurs we can then assume the resting position of the pelvis. Essentially, we can logically infer what ones pelvis looks like on an x-ray without all the fun of radiation. For all my semantically inclined friends I have been careful in choosing these descriptions. All we can infer from passive tests are resting positions at worst or perhaps starting positions prior to active movement.

What’s the minimum we can infer when testing femur on pelvic range of motion? In keeping with our definition, the direction the femur can move on a pelvis is flexion and extension, adduction and abduction and lastly, internal and external rotation. The primary introduction to this concept is widely used and abused by many when we describe femoral flexion as it relates to the dreaded anterior pelvic tilt.

While tragically important to hip mechanics, it is really only one of the twelve movements we need to realize as we must take both legs into account. It’s the premise here that needs expansion. This notion that because joints by their very name are connected that you cannot describe one without the other. It’s seeing the mermaid’s head but not the dragon’s tail, and thinking we can cut off just what we want with that which we cannot see. So then to the degree in excess or diminished range of femoral flexion we find we must also consider the half of the pelvis with which it is connected to have the same finding.

If we can roundly accept our anterior pelvic tilt coincides with decreased femoral flexion then what does that tell us about the other 5 possibilities? Most of you are already there, but it bears spelling out. Limited passive femoral adduction tells me that pelvis is laterally bound in adduction. Excessive adduction of a femur says that the pelvis is assisting that movement by being in a state of abduction. Limited external rotation of a femur really describes an externally (or some say laterally) rotated pelvis. The pelvis is laterally rotated away from the mid-line and the starting position of the femur is already rotated in external rotation as a compensation to balance the system. This idea repeats itself over and over.

I only went through one half of the directions and immediate relationships, but we cannot assume the other half is following the trend. By testing it’s opposite we can confirm what we found through the first, but if the opposite range of motion is not congruent with the first then our results are likely telling us more about the joint itself and the corresponding ligaments or tendons. For example, if we were to find excessive femoral flexion and excessive extension it would tell us more about a pathology at the joint rather than the position of the pelvis. Corresponding and alternating excess of movement in a joint is should raise eyebrows and red flags, but congruent limitation should raise smiles because these we can work with and Ill describe how I do that shortly.

Are femoral to pelvic range of motion exponentially variable? Sure, but I would say the variables are more so within the degrees of limitation rather than each one of the twelve femoral movement being either limited or hyper-mobile. This is because, thankfully, there is no pure movement in the body, or nothing works by itself. Just as femoral movement is tied to half a pelvis, each directional movement is tied to another. It’s quite easy to imagine that one cannot perfectly externally rotate their femur without a bit of abduction and conversely adduct their femur without some internal rotation going along for the ride. While there may be one primary movement there is still a degree shared with at least one other and often less so a third. My personal favorite is the combined yet primary movement of femoral extension that is likely not fully complete without adduction and internal rotation. So we can work backwards and say that if we find a adduction and internal rotation lacking their normal range of motion we can infer that extension is also similarly limited. This is obviously confirmed through testing. Hopefully, we find extension limited, but if we do not then ill refer you to the previous paragraph in our discussion of joint pathology. This is how it is possible to find normal range of motion yet still have pathology. It’s this line of logic that helped me diagnose my seemingly healthy 32yo friend with some hip pathology. I had no idea of what sort, but sending her for an MRI after our first visit we discovered she had avascular hip necrosis. Things like that are the reason we should be well versed in digging into seemingly basic concepts like range of motion.

Beyond discovering joint pathology, how is this useful? Obviously, different schools of thought use this information in different ways, but as a student of none of them I can only give you a superficial idea for now. They seem to be a dying breed these days, but Osteopathic doctors used to do a lot of manual manipulation to the body. Their main idea is that each joint should alternate as gait is the commonality between us mortal human units. It starts from the bigger picture that in walking one should notice that the arms and legs swing in an alternating fashion to each other. However, the skilled osteopath begins to asses joints specifically as we discussed above and begins their treatment as they see fit. The treatment is to literally just do the opposite of what they found. In finding decreased internal rotation, they would block the pelvis into external rotation while they twisted the femur back to the desired internal rotation. If they noticed a femoral extension limitation they would hold that side of the pelvis in flexion as they pulled the femur into extension. They better of a picture they get however the more they could combine pelvic position blocks with multiple femoral directional pulls or decompression as some say.

Each major faction of the musculoskeletal world has some form of this “create a stable base from which one can move” concept. They who move very heavy weights understand how much grip, foot position and pressure relate to quality movement so much so that wraps and braces are industries in an of themselves. If it makes sense that it’s easier to squat when you are not on a frozen lake and that a solid foot position can seemingly make you stronger; then you’re well ahead of the game. This is not a far cry from Dynamic Neuromuscular Stabilization and their fixed point, mobile point concept. They are just more explicit about the points which should be fixed and mobile through their use of developmental positions. Even the mildly popular and highly controversial Postural Restoration Institute calls these fixed or blocked, or stable areas ‘references’ in their jargon. DNS also has their idea of joint centration, which is a more intense variation of the osteopathic and PRI notion of a neutral joint. The DNS concept of joint centration is then not a far cry from Dr. Spina and his ever growing FRS, FRC following in the brilliant principle of having the requisite joint capability prior to loading larger movements. Requisite joint capability is a much more robust phrase than range of motion as it implies far more than just passive movement. Each has their own merit and learning curve and as long as doctors, therapists or trainers are focus on their patient/client goals first before ideology; then I am a happy man.

 

“The height of the pinnacle is determined by the breadth of the base.” -Ralph Waldo Emerson

Chains of muscle fibers throughout the body

If you work with the body, coaching, rehab, therapy, yoga, movement, training and the like you use this concept every day whether you realize it or not. Certain camps of thinking label and outline this specifically while others do it more generally, but either way we all do it. The idea is that in order for a thing to move there must be another thing not moving from which to move upon. Kinetic and potential energy must exist simultaneously. All movement is relative and often our freedom of movement is based on what we relate that movement to. I promise ill break this down more simply in a minute but it’s very important you realize your capacity for a particular movement is regulated by the integrity of its foundation. You could also say that ones range of motion is limited due to it’s support or the freedom of movement equals the stability of the infrastructure. My plan is to make the abstract nonsense I just wrote into practical use and to do so through the various schools of thought that I find popular in today’s healthcare industry.

My first introduction to this concept was with FMS then shortly after that the SFMA. They establish that movement is based off of different positions. They are probably most well known for evaluating people by watching them squat, but this is just one of the big 7 positional patterns they evaluate. I want to quickly walk through evaluating a toe touch and show how one can test the same pattern and that by simply changing the base of the movement we can logically rule out culprits and discover the sources of dysfunction.Let’s start by assuming like Sherlock Holmes taught me that everyone is a suspect even though our hypothetical low back pain patient is quite sure he’s slipped a disc. So we begin with a toe touch. Feet together and reaching down for our toes in order to get a baseline before we treat. Clinically we are considering a symmetrical stance holding still while hip and spinal flexion move. The patient’s hands get to their knees and they stop as the back pain has been provoked. Many times the testing stops here, numerous assumptions can be made and only if those assumptions are dead on, and the treatment to correct the assumptions is executed correctly will there be a positive outcome, but I don’t like those odds for myself or my patient. So we refine our testing.

Measure twice and cut once. -English Proverb

For now I will leave aside other various and important facets of a well balanced treatment model and strictly focus on the mechanical. To do so let’s assume our injury can either be caused by direct strain, like hit by a baseball bat, or indirect like bending down to put on shoes. The direct strain isn’t as fun so lets also assume the vast majority of patients will be indirect strain. In realizing there is no direct force to the injured area (from a baseball bat or otherwise) and recognizing the legs below the back on the ground and the thoracic spine, arms and head above as the necessary distributors of force to the back we need to figure out which one is funneling strain into the low back. We can describe this concept of discovering the trigger as being ascending or descending. Though their are a few more specific labels for categorizing strain even in the purely mechanical model, let’s stick to these two. Beyond that we must now pretend that ideally movement is the ability to control tension in the body for some purpose. The presence of pain also tells us that there is a dysfunction in our ability to control that tension, but without further testing we are just guessing.

So, from a purely orthopedic and mechanical perspective, the course of testing should strategically funnel various tension from adjacent structures to the area of pain to realize which adjacent movement provokes or relieves the pain. Which is why we cannot rule out much as the primary trigger with a simple toe touch could be anything in the body that is creating tension. The majority of the tension and pain is clearly in the low back in such a case, perhaps the paraspinals and QLs, but if the patient is looking down during the test must we also consider the inferior rectus of the eye? It’s a rare day when a patient feels the same kind of strain in their low back as they do in their hip flexors during a toe touch, but that hasnt stopped doctors from working on a psoas to help low back pain. Nor should it, but taken to its logical limit we must still consider the eye tension. Which is why the FMS is a proponent of movements over muscles. It’s a very helpful way to begin to look at correcting dysfunctional movement.

Now that we have considered dysfunctional tension as having a source above or below the sight of pain let’s find out how to use these concepts.After the initial toe touch stops at knee height due to pain we might consider putting a small stool under one foot in order to take some tension off of that leg and test whether the patients toe touch improves, stays the same or gets worse. Granted we are not take ALL the tension off of the foot, knee and hip on the stool but it can be helpful. Quite often you’ll find a difference though. If when the right foot is on the ground, the left foot on the stool, the patient reaches for their toes and their range of motion increases such that they can now touch the ground, what can one assume? That putting more tension through their right leg is a good thing as movement increased and also that something on the left may be a source of dysfunction. We can confirm this if by alternating the foot on a stool the movement goes back to the same range as when both feet are on the ground. If however the opposite leg up on the stool also increases the range of motion it’s time to consider the spinal structures above the sight of pain as a more likely trigger. This can easily be done by having the patient sit down, legs straight in front of them and have them reach for their toes in a seated position. So now the hips and legs are on the ground with secondary static tension and the primary movement or changing dynamic tension is coming from the spine, thoracic rib cage, arms, neck and head. If this were to reproduce the pain we would consider those dynamically moving structures. To further isolate the upper structures a seated spinal rotation test left and right may give us more information. While this simple process is not totally complete it should highlight some principles that you can use to make up your own process that makes sense to you.

If none of these movements reveal the trigger to our low back pain then passive orthopedic tests will very likely give you a great idea of what is going on. The principle still remains though. From the macro level toe touch to the micro level passive straight leg raise we realize each level of testing is simply funneling strain to a given area. The major reason for starting with the macro test first is that it gives us a ton of possibilities rather than the joint isolating done in passive orthopedic testing. Which is why it has been said:

Passive tests will get you passive results

As it only gives you a small passive picture we cannot be surprised if we find ourselves limited to a small window for treatment options. By testing both the macro down through to the micro we give ourselves more options from treatment to rehabilitation. There are though other schools of thought that find a lot of success with simple passive tests and isolated joint evaluation. It requires a subtly different perspective but it absolutely can be made useful. We’ll get into that next time though…

“You only treat what you see. You only see what you look for and you only look for what you know.” -Goethe

Before we try to answer this question, perhaps we should get some background on where this all came from. I’m no historian, so I will try to simply make this quick and relevant. Whether you know it or not James Cyriax and Vladimir Janda are two of the foundations for all orthopedics and musculoskeletal medicine. Cyriax is known as the “Father of orthopedic medicine” and Janda is probably best known for coining “upper/lower cross syndrome“. If you work in this industry it’s very likely you’re standing on the shoulders of these giants, so I thought it prudent to dig a little deeper into some of their philosophies. Specifically, how can you use their principles in a treatment and rehab setting today. 

Perhaps one of the lesser known and used ideas Cyriax had was the importance of always testing above and below the site of pain. Specifically, orthopedic joint testing of the major articulations. This can be taken more broadly as well when we consider the three dimensional nature of our bodies in testing joints immediately surrounding the site of pain. So, if we were to properly assess knee pain following Cyriax’s idea we might consider the ankle below and the hip above the knee. Testing these joints through their passive and active range of motion would be the least allowable amount of testing. If a range of motion tested was found limited the practitioner would follow that rabbit hole with the appropriate orthopedic testing. The algorithms that ensue from finding dysfunctional range of motion into specific orthopedic testing are beyond the scope of this essay, but sufficed to say, the testing can become exhaustive and time consuming especially if one should discover limitations at the corresponding joints and then be required to repeated the testing with that joints neighbors as well. This methodology taken to its extreme can justify the mysticism surrounding ideas like cranial-sacral technique and the like, but who has the two and a half hours to test and explain coherently why your sphenoid is torqued on the left and correcting that will help your right low back pain?

Let’s skip over these frivolous subtleties. -Seneca

Beyond the onslaught of tests this line of thinking can bombard us with there is another gap that I cannot justify rationally. Given the three dimensional nature of our bodies, above and below seems insufficient. For instance, if we are to stick strictly to the above and below idea how does one reconcile right SI joint pain? Do we not consider the left SI laterally, or are we to only test L5 on the right? Do we test the right femoral acetabular and not the left? These are some basic considerations and I don’t think that I have the answer to these questions, but I do think it wise to realize one needs to consider the surrounding joint complexes in relation to pain. I also think that Charlie Weingroff has actually answered this question masterly in his expansion of the alternating mobility stability model which originated with Janda his fellow Prague school thinkers.

Now how does Janda’s work help add to this concept? I personally think volumes should be written about this idea, and perhaps Karel Lewit and Pavel Kolar already have, but the notion that every test is an exercise and every exercise is a test is one of the most profound far reaching statements I’ve come across in this industry. If you have ever seen someone attempting to asses another’s squat, treat, then have the patient squat again to see if the treatment was successful, you are more aware of this thinking than you know. Janda and his crew were a bit more methodical in their approach, but this is what it has mutated into today. Ill spare you my definition of mutation in this instance for another time, but this process of testing and retesting is fantastically clear from a patients perspective as it clearly shows if the treatment rendered was sufficient to change the tests. This also assumes that the patient realizes that a squat is an important part of the reason they have pain or that the clinician has taken the time to connect a squat to their specific problem. Unfortunately this kind of coherent communication is rare as abstract concepts of pain and perfect squats can be challenging to relate since pain is often localized and squats involve literally every joint. If you dont believe me squat with one shoe on and one off or put one arm in the air overhead while the other reaches back behind you. Everything effects everything to some degree. If the person squatting looks to the right as they squat must we consider the six muscles of the eye? 

What is commonly called functional testing is far better understood if we rename it pattern testing. The squat is an obvious victim here, but the toe touch is just as guilty. The mistake is not incorporating a dash Cyriax into the testing. Taking larger patterns like the squat and breaking them down into understandable pieces to realize dysfunctions. The closest modern day interpretation of this is the SFMA though I am sure Craig Leibenson would argue he has a closer connection to Janda, but it seems that lately he is directing his work to the fitness world.

Ultimately, the focus must be on what connects best with your particular style of treatment, your personality and the goals of the people you treat. Hopefully, in future posts ill go into some more specifics on the testing and how they relate to treatment and rehab. For now let’s leave it here with one final thought:

Whether you have a strict algorithm that you follow or an eye for the large patterns, the intrinsic complexity of the human body would tell us that there is more than one way to change this complex system.

 

External rotation of the hip is easy and hip internal rotation is a great predictor of overall hip health. (I stole that line from Dr. Andreo Spina, one day ill have an original thought) Specifically the ability to control internal rotation of the hip.

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