Limb MSK Assessment Reference

Normal ROM

Special tests

• Apprehension / Relocation test
  Abduct + externally rotate arm at 90°; patient apprehensive/resists = positive.
  Rules in: anterior shoulder instability/dislocation.
• Empty can test (Jobe's)
  Arms abducted 90°, thumbs down, resist downward pressure.
  Rules in: supraspinatus tear/impingement.
• Drop arm test
  Passively abduct arm to 90°, ask patient to slowly lower — sudden drop/pain = positive.
  Rules in: significant rotator cuff tear.
• Neer's / Hawkins-Kennedy
  Neer's: passively flex arm fully overhead with scapula stabilised. Hawkins: flex to 90°, internally rotate.
  Rules in: subacromial impingement.
• Cross-body adduction test
  Passively adduct arm across chest.
  Rules in: AC joint pathology.
• Palpation + active ROM
  Bony tenderness over clavicle, acromion, proximal humerus; gross deformity, inability to actively move.
  Best prehospital fracture flag — no validated clinical decision rule exists for shoulder like Ottawa rules; low threshold to immobilise + convey/image if deformity, crepitus, or refusal to move.

Normal ROM

Special tests

• Elbow Extension Test clinical rule
  Patient fully extends elbow actively (seated, arms out). Can they fully extend without pain?
  Rules out: fracture with good NPV (~95-98% in studies) if full painless extension achieved — reasonable prehospital fracture-exclusion tool, best evidence in adults; use caution in children/high-energy trauma.
• Golfer's/Tennis elbow tests
  Resisted wrist flexion (medial epicondylitis) / resisted wrist extension (lateral epicondylitis) reproduces pain at epicondyle.
  Rules in: epicondylitis, not fracture-relevant.
• Varus/Valgus stress test
  Stabilise humerus, apply varus/valgus force at ~20-30° flexion.
  Rules in: collateral ligament instability.
• Palpation
  Radial head, olecranon, medial/lateral epicondyles — bony point tenderness + effusion (fat pad sign equivalent) raises fracture suspicion, especially radial head in FOOSH mechanism.

Normal ROM (wrist)

Special tests / clinical rules

• Ottawa Wrist / Distal Radius reasoning
  Less formalised than ankle/knee, but same logic: bony tenderness distal radius/ulna, inability to bear weight through hand, visible deformity.
  Rules in need for imaging: point bony tenderness or deformity.
• Anatomical snuffbox tenderness
  Palpate snuffbox (base of thumb) after FOOSH.
  Rules in: high suspicion scaphoid fracture — notoriously occult on initial X-ray; immobilise and refer even with normal imaging if clinically suspicious.
• Scaphoid compression / axial thumb loading
  Axial pressure along thumb metacarpal reproducing wrist pain.
  Adds to: scaphoid fracture suspicion.
• Finkelstein's test
  Thumb tucked into fist, ulnar-deviate wrist.
  Rules in: De Quervain's tenosynovitis — not fracture relevant.
• Tinel's / Phalen's test
  Tinel's: tap over carpal tunnel. Phalen's: wrists flexed together 60 sec.
  Rules in: carpal tunnel/median nerve compression — relevant post-fracture neuro check too.

Normal ROM

Special tests

• Log roll test
  Passively internally/externally rotate the extended leg — pain with gentle rotation.
  Rules in: intracapsular hip fracture — one of the most sensitive bedside tests for occult NOF#, low false-negative rate.
• Leg length + rotation deformity (inspection)
  Classic shortened, externally rotated leg.
  Rules in: displaced NOF fracture — but absence doesn't exclude undisplaced/impacted fracture.
• Axial loading / heel strike test
  Gentle percussion/thump to heel with leg extended, or axial load through femur.
  Rules in: occult hip/femoral fracture if pain reproduced at hip.
• FABER (Patrick's) test
  Flexion-Abduction-External Rotation, ankle on opposite knee, gentle downward pressure on flexed knee.
  Rules in: hip joint or SI joint pathology — not fracture-specific.
• Weight-bearing assessment
  Can they straight-leg raise / weight bear at all, even partially?
  Inability to weight bear post-fall in elderly = high suspicion NOF# regardless of exam findings; low threshold to treat as fracture and convey accordingly.

Normal ROM

Ottawa Knee Rule validated clinical decision rule

• Age ≥ 55 years
• Isolated tenderness of patella
  No tenderness elsewhere on knee
• Tenderness at head of fibula
• Inability to flex knee to 90°
• Inability to bear weight both immediately AND in the ED/on scene
  4 steps, regardless of limping

Ligamentous/meniscal special tests

• Anterior/Posterior drawer test
  Knee flexed 90°, draw tibia forward (ACL) or push backward (PCL).
  Rules in: ACL/PCL laxity.
• Lachman's test
  Knee flexed ~20-30°, stabilise femur, pull tibia forward.
  Rules in: ACL tear — more sensitive than drawer test.
• Varus/Valgus stress test
  Apply varus/valgus stress at 0° and 30° flexion.
  Rules in: collateral ligament (LCL/MCL) injury.
• McMurray's test
  Flex knee fully, rotate tibia while extending, palpate for click/pain along joint line.
  Rules in: meniscal tear — not fracture relevant.
• Patellar tap / ballottement
  Milk fluid down thigh, push patella down onto femur.
  Rules in: joint effusion/haemarthrosis — significant effusion post-trauma raises fracture/ligament rupture suspicion.

Normal ROM

Ottawa Ankle Rule validated clinical decision rule

• Bone tenderness at posterior edge/tip of lateral malleolus
  Distal 6cm
• Bone tenderness at posterior edge/tip of medial malleolus
  Distal 6cm
• Inability to weight bear
  4 steps, both immediately after injury and on assessment

Ottawa Foot Rule validated clinical decision rule

• Bone tenderness at base of 5th metatarsal
• Bone tenderness at navicular
• Inability to weight bear
  4 steps, immediately and on assessment

Other special tests

• Squeeze test (Hopkins)
  Squeeze tibia/fibula together mid-calf, away from injury site.
  Rules in: syndesmosis (high ankle sprain) injury if pain at ankle referred distally.
• External rotation (Kleiger's) test
  Stabilise tibia, externally rotate foot with knee flexed 90°.
  Rules in: syndesmotic injury / deltoid ligament injury.
• Anterior drawer test (ankle)
  Stabilise tibia, draw calcaneus/foot forward.
  Rules in: ATFL laxity/rupture.
• Talar tilt test
  Invert the calcaneus with ankle in neutral.
  Rules in: CFL/lateral ligament complex injury.