Special Joint Tests: Hip, Knee, Spine & More

Special Joint Tests Overview

• The document outlines special tests for various joints, including the hip, knee, ankle & foot, lumbar spine, shoulder, elbow, wrist & hand, and cervical spine
• It includes the aim of each test, the patient position, and the positive sign indicating a particular condition or dysfunction

Hip Joint Tests

• Thomas test aims to identify tightness of hip flexors
  • The patient lies supine, flexing one hip and knee to the chest while keeping the opposite limb straight
  • A positive sign is indicated by the straight limb's hip flexing or inability to remain flat
• Ober’s test identifies tightness of the tensor fascia latae and/or iliotibial band
  • The patient lies on their side, with the lower limb flexed at the hip and knee
  • Passively extend and abduct the testing hip with the knee flexed to 90 degrees
  • A positive sign occurs if the uppermost limb cannot rest on the table
• Ely test identifies tightness of the rectus femoris
  • The patient lies prone, and the knee of the testing limb is flexed
  • A positive sign is indicated if the hip of the testing limb flexes
• 90-90 Hamstring test identifies hamstring tightness
  • The patient lies supine, with the hip and knee of the testing limb supported in 90 degrees of flexion
  • Passively extend the knee of the testing limb
  • A positive sign is the knee’s inability to reach full extension.
• Piriformis test identifies tightness of the piriformis muscle
  • The patient is supine with the tested leg's foot placed lateral to the opposite limb's knee
  • The testing hip is adducted while observing the testing knee relative to the opposite one
  • A positive sign is the testing knee's inability to pass over the resting knee and/or reproduction of pain in the buttock/sciatic nerve distribution
• Patrick/FABER test identifies dysfunction of hip and sacroiliac joints, such as mobility restriction
  • The patient lies supine while passively flexing, abducting, and externally rotating the tested leg so that the foot rests above the opposite knee
  • Slowly lower the testing leg towards the table surface
  • A positive sign exists when the involved knee cannot assume a relaxed position and/or painful symptoms are reproduced
• Standing flexion test identifies sacroiliac joint dysfunction
  • The patient stands with their feet apart while the therapist stands behind, placing thumbs on the PSIS
  • Instruct the patient to flex forward as much as possible, while the therapist observes the PSIS
  • A positive sign exists when one PSIS moves further cranially than the other
• Long sitting test identifies anteriorly or posteriorly rotated innominate based on leg length differences
  • The patient is supine with hips and knees extended
  • The therapist stands with thumbs on the patient's medial malleoli
  • Have the patient slowly assume the long-sitting position and reassess the malleolar position
  • A positive sign exists when the leg appears longer in supine but shorter in long sitting, indicating anterior innominate rotation
  • The opposite indicates posterior innominate rotation
• Trendelenberg’s sign identifies weakness of the gluteus medius or an unstable hip
  • The patient stands and balances on one leg (flexing the opposite knee)
  • Observe the pelvis on the stance leg.
  • The test is positive when the contralateral pelvis drops when the lower limb support is removed
• Leg length test identifies true leg length discrepancy
  • The patient lies supine with pelvis balanced and aligned with lower limbs and trunk
  • Measure the distance from ASIS to medial malleolus on each limb
  • Note a difference in lengths between limbs, indicating a true leg length discrepancy

Knee Joint Tests

• Collateral ligament instability tests (valgus & varus stress tests) identifies collateral ligaments laxity (patient supine, knee in 20-30° flexion)
  • Valgus force tests the medial collateral ligament
  • Varus force tests the lateral collateral ligament
  • Primary finding(positive sign) is laxity, but pain may also be noted
• Lachman stress test indicates the integrity of the anterior/posterior cruciate ligament (ACL/ PCL):
  • The patient lies supine with the testing knee flexed 20-30°, stabilizing the femur and gliding the tibia anterior (posterior)
  • An excessive anterior (posterior) glide of the tibia is a positive sign
• Anterior (posterior) drawer test indicates the integrity of the anterior (posterior) cruciate ligament
  • The patient lies supine with the testing hip flexed to 45 degrees and knee flexed to 90 degrees
  • Passively glide the tibia anteriorly (posteriorly) following the joint plane
  • Excessive anterior (posterior) glide is a positive sign
• McMurray test identifies meniscal tears
  • The patient lies supine with testing knee in maximal flexion
  • Passively internally rotate and extend the knee to test the lateral meniscus
  • Rotate the tibia into lateral rotation to test the medial meniscus
  • Reproduction of click and/or pain in the knee joint is a positive finding
• Apley test helps differentiate between meniscal tears and ligamentous lesions:
  • The patient lies prone with the testing knee flexed to 90 degrees and the thigh stabilized
  • Passively distract the knee joint then slowly rotate the tibia internally and externally
  • The next step is to apply a compressive load to the knee joint and once again slowly rotate the tibia internally and externally
  • Pain or decreased motion during compression indicates a meniscal dysfunction
  • Pain or decreased motion during distraction indicates a ligamentous dysfunction
• Clarke’s sign indicates Patellofemoral dysfunction:
  • The patient lies supine with knee in extension resting on the table
  • Push posterior on the superior pole of the patella then ask the patient to perform active contraction of the quadriceps muscle
  • Pain is produced in the knee as a result of the test (positive sign)
• Patellar tap test (Ballotable patella) indicates infrapatellar effusion
  • The patient lies supine with knee in extension resting on the table
  • Apply a soft tap over the central patella
  • Perception of the patella floating (dancing patella sign) is a positive finding
• Patellar apprehension test indicates a past history of patella dislocation:
  • The patient lies supine and the patella is passively glided laterally
  • A positive sign is the patient does not allow movement
  • The patella doesn’t glide laterally

Ankle & Foot Joint Tests

• Anterior drawer test identifies ligament instability (particularly anterior talofibular-ATF ligament):
  • The patient is supine with the heel just off the edge of the table in 20° plantar flexion
  • Stabilize the lower leg and grasp foot, then pull the foot (talus) anteriorly
  • A positive sign is excessive anterior glide of the foot (talus) and/or pain
• Talar tilt (Kleiger) identifies ligament instability (particularly calcaneofibular ligament)
  • The patient lies on their side with the knee slightly flexed and the ankle in neutral
  • Move the foot into adduction to test the calcaneofibular ligament
  • Move the foot into abduction to test the deltoid ligament
  • Positive sign: excessive adduction or abduction occurs and/ or pain is noted
• Thompson test evaluates the integrity of the Achilles tendon
  • The patient is prone with foot off the edge of the table
  • The examiner squeezes the calf muscles
  • Positive sign: No movement of the foot while squeezing the calf indicates
• Homan’s test tests for deep vein thrombosis (DVT)
  • The patient is supine or sitting with knee flexed
  • Forcibly dorsiflex the patient's ankle then palpate the calf muscle
  • Pain in the calf is a positive sign that should be referred
• Squeeze test identifies integrity of the syndesmotic ligaments:
  • The patient is supine or sitting with knee flexed
  • The examiner places their hand 6 to 8 inches below the knee and squeezes the tibia and fibula together
  • Positive test results in pain in the ankle indicate injury of the syndesmotic ligament and a possible high ankle sprain
• Feiss Line identifies the position of the navicular (the keystone of the medial longitudinal arch)
  • While the patient is NWB, mark the inner apex of the medial malleolus and plantar aspect of the 1st metatarsalphalangeal joint
  • The patient stands 8 – 15 cm apart, palpate the navicular tuberosity while noting where it is in line to the other landmarks
  • A navicular drop of more than 10 mm indicates pes planus (flat foot)

Lumbar Spine Tests

• Straight Leg Raising (SLR)/Lasegue Test identifies dysfunction in neurologic structures supplying the lower limb
  • It also indicates the unilateral dysfunction of the sacroiliac joint
  • Patient is supine with legs resting on the table, hip is passively flexed with the knee extended, if the patient complains of pain in the lower limb
  • Slowly lower limb until pain subsides, then passively dorsiflex the foot
  • Positive finding is reproduction of pathologic neurologic symptoms when the foot is dorsiflexed
  • The range of motion can demonstrate problems in different areas, 0 – 30° equals hip pathology or severely inflamed nerve root, 30 – 50° indicates sciatic nerve involvement, 50 – 70° is probable hamstring involvement, 70 – 90° when sacroiliac joint is stressed
• Neural tension & mobilization for the lower quadrant is performed using several variations while the patient is supine (ankle dorsiflexion, ankle plantar flexion with inversion, hip adduction, hip medial rotation, and passive neck flexion)
  • The maneuver may also be performed long-sitting (slump-sitting position) and side-lying
  • Used to differentiate tight or strained hamstrings from possible sites of restriction or nerve mobility in the lumbosacral plexus and sciatic nerve
  • Once the position is found, maintain the stretch position and then move one of the joints a few degrees in and out of the stretch position (ankle plantar flexion and dorsiflexion, or knee flexion and extension)
• Ankle dorsiflexion with eversion places more tension on the tibial tract.
• Ankle dorsiflexion with inversion places tension on the sural nerve.
• Ankle plantar flexion with inversion places tension on the common peroneal tract.
• Adduction of the hip while doing SLR places further tension on the nervous system because the sciatic nerve is lateral to the ischial tuberosity
  • Medial rotation of the hip while doing SLR also increases tension on the sciatic nerve.
• Passive neck flexion while doing SLR pulls the spinal cord cranially and places the entire nervous system on a stretch (SLR modification test)
• Well Leg/Crossed SLR Test has the same aim as for SLR test
  • The patient is supine with the unaffected leg raised
  • Positive finding: pain on the back of the affected leg
• Tension Sign for Sciatic Nerve identifies sciatic nerve irritation
  • The patient is supine with hip and knee flexed to 90°, the examiner grasps the heel with one hand and the other grasps the thigh
  • Knee is then extended as far as possible with the examiner palpating the tibial portion of the sciatic nerve as it passes behind popliteal space
  • Tenderness and the reproduction of sciatica symptoms are positive findings
• Bowstring Test (Cram Test) indicates sciatic nerve tension
  • The patient is supine with passive SLR on the involved side
  • The examiner flexes the subject’s knee to approximately 20° in attempt to reduce pain
  • Pressure then applied to the popliteal area to reproduce radicular pain
  • Painful radicular reproduction with popliteal compression is a positive finding
• Femoral Nerve Traction Test identifies compression of the femoral nerve anywhere along its course
  • The patient lies on the non-painful side with the trunk in neutral, the head slightly flexed, and the lower limb's hip and knee flexed
  • Passively extend the hip while the knee of the painful limb is in extension
  • If no reproduction of symptoms, flex the knee of the painful leg
  • Positive finding is neurologic pain in the anterior thigh
• Slump Test detects sciatica or dural irritation
  • Begin with the patient sitting upright
  • Have the patient slump by flexing the neck, thorax, and low back
  • Apply overpressure to the cervical spine, dorsiflex the ankle, and extend the knee as much as possible to the point of tissue resistance and symptom reproduction
  • Release the overpressure on the spine and have the patient actively extend the neck to see if symptoms decrease. Increase and release the stretch force by moving one joint in the chain (knee flexion and extension or ankle dorsiflexion and plantar flexion)
  • Positive finding is sciatic pain or the reproduction of other neurological symptoms
• Kernig/Brudzinski Test identifies nerve root pathology or dural irritation
  • The patient is supine and actively lifts the head, flexing the cervical spine while actively extending the leg with flexing the hip until pain is felt, then flexes the knee
  • Pain disappears when they flex the knee (positive sign)
• Quadrant Test identifies compression of neural structures at the intervertebral foramen and facet dysfunction
  • The patient is stride standing, the examiner stands behind him grasping the shoulders
  • The patient extends the spine
  • Side bend and rotate to the affected side
  • The examiner provides overpressure through the shoulders
  • Radicular pain indicates compression of the intervertebral foramina that impinges on the lumbar nerve roots (positive sign)
  • Local pain (not radiating) indicates facet joint pathology, symptoms isolated to the area of the PSIS may indicate SI joint dysfunction
• Valsava maneuver identifies a space-occupying lesion
  • The patient is sitting and take a deep breath and hold while bearing down as if having a bowel movement
  • Increased low back pain or neurologic symptoms into the lower extremity indicate a positive finding
• Bicycle (van Gelderen) test differentiates between intermittent claudication & spinal stenosis
  • The patient is seated on a stationary bicycle and rides with time recorded when sitting erect at a set pace/speed
  • After a rest period and at the same speed, the patient rides bike while in a slumped position, recording time
  • The determination is based on how long patient can ride bike sitting upright versus sitting slumped
  • Should ride longer while slumped if pain related to spinal stenosis
• Stork standing test identifies spondylolisthesis
  • The patient balances and stands on one leg
  • Cue patient bends into trunk extension
  • Then, repeat with the opposite leg on the ground
  • Low back pain with the ipsilateral leg on the ground indicates a positive finding

Shoulder Joint Tests

• Yergason's test identifies the integrity of the transverse ligament & bicipital tendonitis
  • The patient is sitting with the shoulder stabilized in neutral against trunk, elbow at 90°, & forearm pronated
  • The therapist resists supination of the forearm & external rotation of the shoulder
  • The tendon of biceps long head will "pop out" of groove & cause pain on the long head of the biceps tendon (positive sign)
• Speed’s test (Biceps straight arm) identifies bicipital tendonitis
  • Patient is sitting or standing with upper limb in full extension & forearm supinated
  • The therapist resists shoulder flexion, and places the shoulder in 90° flexion & pushes upper limb into extension causing eccentric contraction of biceps
  • If long head pain occurs it is a positive sign
• Drop arm test identifies tear &/or full rupture of rotator cuff
  • The patient sits with the shoulder passively abducted to 120°
  • Instruct the patient to slowly bring the arm down to their side
  • Patient’s arm is unable to lower back down to its side, indicating a positive sign
• Empty can test identifies tear &/or impingement of the supraspinatus tendon or suprascapular nerve neuropathy
  • The patient sits with the shoulder at 90° & no rotation. Resist shoulder abduction
  • Place shoulder in "empty can" position (internal rotation and 30° forward/horizontal adduction), with the patient’s thumb pointing to the floor
  • Resist abduction while determining a difference if pain is present between the two arm positions
  • Thumb up “full can” tests for maximum contraction of supraspinatus & resist abduction
  • Reproducing pain &/or weakness indicates positive finding related to supraspinatus tendon
• Lift-off test identifies tear/weakness of subscapularis muscle & scapula instability
  • The patient stands & places the dorsum of the hand against the mid lumbar spine
  • Help the patient lift their hand away from the back
  • If the patient can, apply a load pushing the hand toward back to test the strength of the subscapularis and test how the scapula acts under dynamic loading
  • An inability to move the dorsum off the back indicates subscapularis rupture or dysfunction
• Belly-Press (abdominal compression) test identifies tear/weakness of subscapularis muscle especially if the patient cannot medially rotate the shoulder behind their back
  • The examiner places their hand on the patient’s abdomen to feel the contraction
  • The patient places their the hand of the tested shoulder on the examiner’s hand & pushes as hard as they can, while bringing their elbow forward to cause greater medially shoulder rotation
  • Inability to maintain the pressure on the examiner’s hand while moving elbow forwards is a positive sign
• Neer test identifies impingement of the supraspinatus tendon or long head of biceps
  • The patient is sitting & the shoulder is passively internally rotated & fully abducted
  • A positive sign reproduces pain within the shoulder region
• Hawkins-Kennedy test identifies impingement of the rotator cuff
  • The patient is sitting with their arm flexed at 90° & elbow flexed to 90°, the examiner stabilizes proximal to the elbow with their outside hand & holds just proximal to the patient’s wrist with their other hand
  • The arm is passively moved into internal rotation
  • Pain in the sub-acromial space is a positive sign
• Posterior internal impingement test identifies impingement between rotator cuff & greater tuberosity or posterior glenoid and labrum
  • To perform the test, have patient supine and move shoulder into 90° abduction, maximum external rotation, and 15°-20° horizontal adduction
  • Reproduction of pain in posterior shoulder during test indicates a positive test
• Anterior apprehension (Crank) test identifies past history of anterior shoulder dislocation
  • The patient lies supine with the shoulder in 90° abduction
  • Slowly take the shoulder into external rotation
  • The patient does not allow motion and/or does not like the shoulder to move in a direction to simulate anterior dislocation (positive sign)
• Posterior apprehension test identifies past history of posterior shoulder dislocation
  • The patient is supine with shoulder elevated 90° (in plane of scapula) with the scapula stabilized by the table
  • Apply a posterior force through the shoulder via force on patient's elbow while simultaneously moving the shoulder into medial rotation and horizontal adduction
  • Patient does not allow movement and/or does not like the shoulder to move in a direction to simulate posterior dislocation (positive sign)
• Anterior/Posterior drawer test of shoulder identifies laxity or insufficiency of the anterior/posterior capsular mechanism
  • Patient is supine, and the affected shoulder is abducted at 80-120°, 20° flexion & 30° external rotation
  • The examiner holds the patient’s scapula spine forward with their index and middle fingers, the thumb exerts counter pressure on the coracoid, fixing the scapula
  • The examiner uses their right hand to grasp the patient's relaxed upper arm and draws it anteriorly/posteriorly with a force
  • Positive sign: Gliding of the hummers, click may indicates labral tear
• Sulcus sign identifies inferior shoulder instability or glenohumeral laxity
  • To perform test, patient is sitting with their arm in a neutral position
  • The examiner pulls downward on the elbow while observing the shoulder area for a sulcus or depression lateral or inferior to the acromion
  • A depression lateral or inferior to the acromion indicates a positive test
• Clunk test identifies a glenoid labrum tear
  • The patient lies supine with the shoulder in full abduction
  • Push the humeral head anterior while rotating hummers externally
  • Audible “clunk” is heard while performing the test (positive sign)
• SLAP Prehension test identifies SLAP lesion (superior labrum, anterior posterior)
  • The patient is sitting/standing with their arm abducted 90°, elbow extended & forearm pronated (thumb down)
  • Have the patient horizontally adduct the arm, then repeat the movement with supination (thumb up)
  • If pain is felt in the bicipital groove in the first case (pronation) and is lessened or absent in the second case (supination) this the presence of a SLAP lesion (positive sign)
• Adson's test identifies pathology of structures that pass through the thoracic inlet
  • The patient is sitting & find the radial pulse of the extremity being tested
  • Rotate the head towards the extremity being tested then extend & externally rotate the shoulder while extending the head
  • Neurologic and/or vascular symptoms (disappearance of pulse) will be reproduced in the upper limb (positive sign)
• Costoclavicular syndrome (military brace)/ Edens’ test identifies pathology of structures that pass through the thoracic inlet
  • The patient is sitting, and the radial pulse is palpated on the extremity being tested
  • The involved shoulder is moved down and back
  • Neurologic and/or vascular symptoms (disappearance of pulse) occur indicate a positive sign
• Wright (hyperabduction) test identifies pathology of structures that pass through the thoracic inlet
  • The patient is sitting, find the radial pulse in the extremity being tested
  • Move the shoulder into maximal abduction and external rotation
  • Have the patient take a deep breath and the rotating the head to the opposite side and be tested to accentuate symptoms
  • Neurologic and/or vascular symptoms (disappearance of pulse) being reproduced indicate a positive sign reproduced in the upper limb
• Roos elevated arm / EAST (elevated arm stress test) identifies pathology of structures that pass through the thoracic inlet
  • The patient is standing with shoulders fully externally rotated, 90° abducted, & slightly horizontally abducted
  • Have the Elbows flexed to 90° and patient opens/closes hands for three minutes slowly
  • Neurologic and/or vascular symptoms (disappearance of pulse) being reproduced indicate a positive sign

Elbow Joint Tests

• Ligament instability tests (valgus & varus stress tests) identifies collateral ligaments laxity or restriction
  • Patient is sitting or supine, the entire upper limb is supported & stabilized and the elbow is placed in 20°-30° of flexion
  • Place Valgus force through the elbow to tests ulnar collateral ligament
  • Place Varus force through the elbow to test the radial collateral ligament
  • Primary finding is laxity, but pain may be noted as well
• Lateral epicondylities/Tennis Elbow (Cozen) Test indicates lateral or medial epicodylitis
  • The patient is sitting with the elbow in 90° & supported and the arm resisting wrist extension, wrist radial deviation & forearm pronation with fingers fully flexed (fist) simultaneously
• Medial epicondylities/Golfer Elbow test indicates lateral or medial epicodylitis
  • Patient is sitting with elbow in 90° & supported, passively supinate forearm, extend elbow & wrist
  • Pain at Lateral epicondyle for tennis elbow and at medial epicondyle for golfer elbow is a positive sign
• Pronator teres syndrome test identifies a median nerve entrapment within the pronator teres
  • Patient the patients is sitting with the elbow in 90° flexion & supported
  • Resistance happens at forearm pronation and elbow extension simultaneously
  • Reproducting of a tingling or paresthesia within the median nerve distribution indicates a positive
• Tinel's sign:
  • Identifies dysfunction of the ulnar nerve at the olecranon
  • The patient sits and the region where the ulnar nerve passes through the cubital tunnel is tapped
  • Positive sign: Reproduces a tingling sensation in ulnar distribution

Wrist & Hand Tests

• Finkelstein test identifies De-Quervain's tenosynovitis
  • Patient makes a fist with the thumb within the confines of the fingers then, the tested arm is passively moved in ulnar deviation
  • Reproduction of pain in the wrist indicates a positive sign. Often patients are painful even with no pathology present, so this results should be analyzed carefully.
• Bunnel-Littler test identifies tightness in structures surrounding the MCP joints
  • The MCP joint is stabilized in slight extension while PIP joint is flexed
  • When the MCP joint is then is flexed the same joint is flexed
  • The results should differentiate between a tight capsule and tight intrinsic muscles
  • If flexion is limited in both cases the capsule is tight. If more PIP flexion with MCP flexion, then intrinsic muscles are tight
• Froment's sign identifies ulnar nerve dysfunction
  • Patient grasps paper between the 1st and second digits of the hand then, while the paper is tried to be pulled look for IP flexion of the thumb, which is compensation due to weakness of adductor pollicis
  • If unable to perform test without compensating, it may indicate ulnar nerve dysfunction
• Phalen's test identifies carpal tunnel compression of the median nerve
  • The patient maximally flexes both wrists, holding them against each other for one minute
  • Reproduces tingling and/or paresthesia into the hand following median nerve distribution, indicating a positive

Cervical Joint Tests

• Vertebral artery test identifies integrity of the vertebrobasilar artery (vertebrobasilar insufficiency)
  • The patient is supine; the examiner takes the patient’s head & neck into extension, right & left rotation, & side bending and holds each position 10-30 sec unless symptoms are evoked
  • Dizziness, visual disturbances, disorientation, blurred speech, nausea, and vomiting are positive finding
• Hautant's test differentiates vascular versus vestibular causes of dizziness/vertigo in two performed positions -a) Patient is sitting with shoulders at 90° flexion & palms up - Have patient close their eyes and remain in this position for 30 s - If the arm position is lost vestibular condition -b) Patient is sitting with shoulders at 90° flexion & palms up - Patient closes' their eyes & cue patient into head and neck extension with rotation - The position is remain in each position for 30 seconds - If a test patient's arms lost their position the condition may be vascular in nature
• Foraminal compression (Spurling's) test.
  • It identifies dysfunction (typically compression) of the cervical nerve root
  • Perform Spurling's test on compression is applied with the head involved or side bent
  • Then, the test apply the pressure through the head, moving straight The The test is performed in three ways.
  • If the symptom the pressure can then will not be done on the next procedure during the first stage.
  • It will the pressure during head as neutral second will the flexion with the final rotation the affected on the third portion involves.
  • Positive finding: Positive finding is pain for both the dermatone which the both is compression on the compression
• Distraction test indicates compression of neural structures at the intervertebral foramen or facet joint dysfunction
  • The patient either seated. supine or if the examiner is able in applying with
    • One hand will be the placed with the patient will be chin and the hand with occur during both with
    • Then to the distraction.
      • Positive finding: will occur those found to be the decrease both for both of its joint compression as well will compression of the joint
• Shoulder abduction test (Bakody’s sign)
  • Compression of neutral structure which include joint
  • The seated and both put is the head with for the top the opposite and.
    • The result the compress
    • This will cause more on structure result with neutral compression as well is the area

Lab Activities

• Lumbosacral plexuses
• Dermatomes & myotomes of the lower limbs
• Pathway & the origin of each of the lower limbs from the nerves with
• Locations for common sites will there with one of each.
• There the to limb
• Brachial plexuses
  • Dermatomes and myotomes from there the to limb
  • Pathway the with for the to limb The area for with can result each of site each.
    • Limb the with

References

• Magee David J: Orthopedic Physical Assessment, 6e (Musculoskeletal Rehabilitation), 2013. Elsevier Saunders.
• Dutton M: Orthopedic examination, evaluation, & intervention. 2004, Mc Graw Hill.
• Gross et al: Musculoskeletal examination, 4th ed, 2016. Wiley & Sons, Ltd