The objective of this in-service presentation was to provided inpatient physical therapists and occupational therapists with the clinical decision making skills to properly evaluate common orthopedic dysfunctions encountered in the acute care setting.

1. Examination of Common
Orthopedic Conditions
Encountered in Acute Care
Alexander Ohmes, SPT
January 4, 2016
UC Health – Poudre Valley Hospital

2. Objectives
• By the end of this presentation, the audience will be able to:
• Define the statistical terms of sensitivity, specificity, +LR, and –LR and apply
them when determining the usefulness of clinical tests.
• Perform clinically relevant tests for the diagnosis of knee OA, ACL pathology,
and meniscal pathology.
• Perform clinically relevant tests for the diagnosis of hip OA and hip labral
pathology.
• Perform clinically relevant tests to determined appropriate treatment for low
back pain based on patient presentation.
• Perform clinically relevant tests for the diagnosis of shoulder subacromial
impingement syndrome and rotator cuff pathology.

3. Psychometric Properties of Clinical Tests
• Sensitivity (Sn) – refers to the percentage of people who test positive
for a specific disease among a group of people who have the disease
• SnOUT – high sensitivity tests are good for ruling out a disorder (when test is
negative)
• Specificity (Sp) – refers to the percentage of people who test negative
for a specific disease among a group of people who do not have the
disease
• SpIN – high specificity tests are good for ruling in a disorder (when test is
positive)
• Airport scanner analogy

4. Psychometric Properties of Clinical Tests
• Positive Likelihood Ratio (+LR) =
sensitivity / (1 – specificity)
• Negative Likelihood Ratio (-LR) =
(1 – sensitivity) / specificity

5. Knee OA
• EULAR Recommendations1
• Persistent knee pain
• Limited morning stiffness
• Reduced function
• Crepitus
• Restricted movement
• Bony enlargement of knee
• Probability of having radiographic
knee OA = 99% when all 6 signs &
symptoms present
• Altman’s Criteria2
• Age > 50
• Morning stiffness < 30 min
• Crepitus
• Bony tenderness
• Bony enlargement of knee
• Absence of palpable warmth
• 3 positive criteria:
• Sn = .95
• Sp = .69
• +LR = 3.1

6. Knee ACL Pathology
• Lachman Test
• Sn = 85%, Sp = 95%3
• +LR = 25.0, -LR = 0.14
• Anterior Drawer Test
• Sn = 62%, Sp = 88%5
• +LR = 3.8, -LR = 0.34
• Composite Exam: Anterior Drawer
+ Lachman
• +LR = 25.0, -LR = 0.044
• Pivot Shift (Jerk) Test
• Sn = 32%, Sp = 98%5
• If you have to chose 1 test:
Lachman6

7. Knee Meniscal Pathology
• McMurray Test
• Sn = 45%, Sp = 76%7
• +LR = 1.3, -LR = 0.84
• Joint Line Tenderness
• +LR = 0.9, -LR = 1.14
• Composite: McMurray + JLT
• +LR = 2.7, -LR = 0.44
• Thessaly Test
• At 5º: Sn = 65%, Sp = 83%7
• At 20º: Sn = 80%, Sp = 91%7
• At 20º: Sn = 90.3%, Sp = 97.7%, +LR =
39.38

8. Hip OA
• Sutlive’s criteria9
• Self-reported squatting as aggravating factor
• Active hip flexion causing lateral hip pain
• Scour test causing lateral hip or groin pain
• Active hip extension causing hip
• Passive IR of less than or equal to 25
• 4/5 criteria: +LR = 24.3

9. Hip Labral Pathology
• FADIR – passive flexion,
adduction, IR
• Sn = 99%, Sp = 7%10
• +LR = 1.06, -LR = 0.1510
• + test = pain reproduction in
groin

10. Hip Labral Pathology
• FABER – passive flexion,
abduction, ER
• Sn = 42-81%, Sp = 18-75%10
• +LR = 0.73 – 1.7, -LR = 0.72-2.210
• + test = pain reproduction in
groin

11. Hip Labral Pathology
• McCarthy Test
• Sn = 82%, Sp = 92%10
• +LR = 11.1, -LR = 0.1210
• + test = pain reproduction in
groin

12. Check your knowledge
• TRUE / FALSE
• You have a patient whom you suspect has hip labral pathology. You
perform the FADIR test (Sn = 99%, Sp = 7%) and the result is positive
for pain reproduction. Because of the positive result, you can
confidently say this patient has pathology of their hip’s labrum.
FALSE

13. Low Back Pain
• Diagnosis not as important
• There is little relationship between
physical pathology (as seen on
imaging) & associated pain and
disability.
• High incidence of “pathology” in
the asymptomatic population
• Lots of potential pain generators
• Muscles, ligaments, fascia, facet
joints, bone, discs, nerves, dura
mater, SIJ, hip joint
• Normal aging process

14. Low Back Pain – TBC for acute patient

15. LBP – Manipulation Group11

16. LBP – Stabilization Group12
• Factors predicting success:
1. Positive Prone Instability Test
(PIT)
2. Aberrant motions during lumbar
flexion/extension testing
3. Segmental hypermobility
4. Age < 40 years old
5. SLR ROM > 91
# of positive
factors
Pre-test
probability of
success
Post-test
probability of
success
3/5 factors
present
33% 67%
2/5 factors
present
72% 94%

17. LBP – Specific Exercise Group13
• Factors predicting success:
1. Centralization phenomenon
with movement exam
2. Postural preference

18. LBP – Traction Group14
• Factors predicting success:
1. Neurological signs
2. Leg symptoms (distal to knee)
3. Peripheralization with
movement exam
4. Positive crossed-SLR test

19. LBP – Manual traction techniques
Side-lying Traction
Hook-lying Traction Long-axis Traction

20. Shoulder Impingement Syndrome (SIS)15
• Hawkins-Kennedy Test
• Painful Arc Sign
• Infraspinatus Muscle Test
SIS Cluster Sensitivity Specificity +LR -LR
3/3 tests + 26.4% 97.5% 10.65 0.75
2/3 tests + 37.2% 92.6% 5.01 0.68
1/3 tests + 26.0% 71.1% 0.90 1.04
0/3 tests + 10.4% 38.8% 0.17 2.3

21. Full Rotator Cuff Tear15
• Drop Arm Test
• Painful Arc Sign
• Infraspinatus Muscle Test
Full RC Tear
Cluster
Sensitivity Specificity +LR -LR
3/3 tests + 32.7% 97.9% 15.93 0.69
2/3 tests + 34.6% 90.3% 3.55 0.72
1/3 tests + 23.8% 70.3% 0.80 1.08
0/3 tests + 9.2% 41.5% 0.15 2.2

22. Check your knowledge
• Which 3 tests, if positive, give a +LR of 10.65 for subacromial
impingement syndrome?
• Painful Arc Sign
• Drop Arm Test
• Hawkins-Kennedy Test
• Neer’s Test
• Speed’s Test
• Infraspinatus Muscle Test
Painful Arc Sign
Hawkins-Kennedy Test
Infraspinatus Muscle Test

23. Summary
• Clinical tests with high sensitivity are useful for ruling out pathology.
• Clinical tests with high specificity are useful for ruling in pathology.
• Cluster testing tends to provide better diagnostic accuracy than only
performing one test.
• Diagnosing pathology in patients with LBP is not as important as
determining which treatment they will respond to best.

24. References
1. Zhang W, Doherty M, Peat G, et al. EULAR evidence-based recommendations for the diagnosis
of knee osteoarthritis. Ann Rheum Dis. 2010;69(3):483-9.
2. Altman et al. Development of criteria for the classification and reporting of osteoarthritis.
Arthritis Rheum. 1986;29:1039
3. Meuffels, D. E., Poldervaart, M. T., Diercks, R. L., Fievez, A. W., Patt, T. W., van Hart, C. P., …
Saris, D. B. F. (2012). Guideline on anterior cruciate ligament injury: A multidisciplinary review
by the Dutch Orthopaedic Association. Acta Orthopaedica, 83(4), 379–386.
4. Solomon D H, Simel D L, Bates D W, Katz J N, Schaffer J L. The rational clinical examination.
Does this patient have a torn meniscus or ligament of the knee? Value of the physical
examination. JAMA 2001; 286: 1610-20.
5. Prins M. The Lachman test is the most sensitive and the pivot shift the most specific test for
the diagnosis of ACL rupture. Aust J Physiother. 2006;52(1):66.
6. Ostrowski, J. A. (2006). Accuracy of 3 Diagnostic Tests for Anterior Cruciate Ligament
Tears. Journal of Athletic Training, 41(1), 120–121.
7. Karachalios T, Hantes M, Zibis AH, Zachos V, Karantanas AH, Malizos KN. Diagnostic accuracy of
a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg
Am. 2005;87(5):955-62.

25. References
8. Harrison BK, Abell BE, Gibson TW. The Thessaly test for detection of meniscal tears: validation of a new
physical examination technique for primary care medicine. Clin J Sport Med. 2009;19(1):9-12.
9. Sutlive T, Lopez H, Childs J, et al. Development of a clinical prediction rule for diagnosing hip osteoarthritis
in individuals with unilateral hip pain. The Journal Of Orthopaedic And Sports Physical Therapy [serial
online]. September 2008;38(9):542-550.
10. Reiman MP, Goode AP, Cook CE, Hölmich P, Thorborg K. Diagnostic accuracy of clinical tests for the
diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. Br J
Sports Med. 2015;49(12):811.
11. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who
demonstrate short-term improvement with spinal manipulation. Spine. 2002;27(24):2835-43.
12. Hicks GE, Fritz JM, Delitto A, Mcgill SM. Preliminary development of a clinical prediction rule for
determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys
Med Rehabil. 2005;86(9):1753-62.
13. Browder DA, Childs JD, Cleland JA, Fritz JM. Effectiveness of an extension-oriented treatment approach in
a subgroup of subjects with low back pain: a randomized clinical trial. Phys Ther. 2007;87(12):1608-18.
14. Fritz JM, Lindsay W, Matheson JW, et al. Is there a subgroup of patients with low back pain likely to
benefit from mechanical traction? Results of a randomized clinical trial and subgrouping analysis. Spine.
2007;32(26):E793-800.
15. Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different
degrees of subacromial impingement syndrome. J Bone Joint Surg Am. Jul 2005;87(7):1446-1455.