MPT Clinical Examination and Differential Diagnosis 1 — Questions and Answers
Question 1: A positive Spurling test (foraminal compression test) is most indicative of:
- Thoracic outlet syndrome
- Cervical nerve root compression (Correct answer)
- Vertebral artery insufficiency
- Cervical facet syndrome
Correct answer: Cervical nerve root compression
Spurling test (cervical compression with lateral flexion toward the symptomatic side) reproduces radicular arm pain when a cervical nerve root is compressed, indicating cervical radiculopathy.
Spurling test is performed by applying axial compression to the cervical spine with the head laterally flexed toward the symptomatic side. A positive test reproduces radicular pain (not just local neck pain) into the ipsilateral arm, indicating nerve root compression within the intervertebral foramen. Sensitivity is approximately 50% but specificity is 86-93%. A positive result combined with dermatomal sensory changes, myotomal weakness, and diminished reflexes strongly supports cervical radiculopathy. PTs use the cluster of Spurling + upper limb tension test + distraction test for clinical diagnosis.
Question 2: Which special test is used to assess the integrity of the posterior cruciate ligament (PCL)?
- Lachman test
- Anterior drawer test
- Posterior drawer test (Correct answer)
- McMurray test
Correct answer: Posterior drawer test
The posterior drawer test assesses PCL integrity by applying a posterior force to the proximal tibia at 90 degrees knee flexion. Excessive posterior tibial translation indicates PCL laxity.
The PCL is the primary restraint to posterior tibial translation. In the posterior drawer test, the patient is supine with hip flexed 45 degrees and knee flexed 90 degrees. The examiner stabilizes the foot and applies posterior force to the proximal tibia. Normal displacement is less than 5 mm. Greater translation indicates PCL laxity. The posterior sag sign (tibia sagging posteriorly at 90 degrees flexion) is an additional PCL test. PCL injuries are less common than ACL injuries and often treated conservatively with PT unless combined with posterolateral corner injury.
Question 3: A patient presents with progressive weakness and atrophy of intrinsic hand muscles bilaterally, spastic legs, and hyperreflexia. This clinical picture is most consistent with:
- Bilateral carpal tunnel syndrome
- Cervical myelopathy (Correct answer)
- Peripheral polyneuropathy
- Lateral epicondylitis
Correct answer: Cervical myelopathy
Cervical myelopathy presents with upper extremity LMN signs (atrophy, weakness) combined with lower extremity UMN signs (spasticity, hyperreflexia) due to spinal cord compression at the cervical level.
Cervical myelopathy results from spinal cord compression (typically from osteophytes, disc herniation, or ligamentum flavum hypertrophy) at the cervical level. The cord compression causes LMN signs at the level of compression (intrinsic hand muscle wasting, diminished upper limb reflexes) and UMN signs below the compression level (spastic paraparesis, hyperreflexia, Babinski sign). Gait disturbance (myelopathic gait) is common. PT recognizes this pattern for urgent surgical referral, as delay worsens prognosis. Post-surgical PT focuses on strengthening, balance, and functional mobility.
Question 4: The FABER test (Flexion, ABduction, External Rotation) reproduces groin or hip pain. This finding is most suggestive of:
- Sacroiliac joint dysfunction or hip joint pathology (Correct answer)
- Femoral nerve entrapment
- Piriformis syndrome
- Patellar tracking dysfunction
Correct answer: Sacroiliac joint dysfunction or hip joint pathology
A positive FABER test (groin pain) suggests hip joint pathology (labral tear, FAI, arthritis) or sacroiliac joint dysfunction, depending on pain location (groin vs. posterior SI region).
The FABER test places the hip in a figure-4 position (flexion, abduction, external rotation). Pain in the groin implicates intra-articular hip pathology (osteoarthritis, femoroacetabular impingement, labral tear). Pain in the posterior pelvis over the PSIS implicates SI joint pathology. Lateral hip pain may implicate psoas tendinopathy or hip flexor involvement. Sensitivity for hip pathology is approximately 57%, specificity approximately 71%. Combined with other tests (FADIR for impingement, scour test, log roll), FABER contributes to a clinical diagnosis cluster for hip examination.
Question 5: During a sensory examination, the patient cannot distinguish between a sharp and dull stimulus but accurately identifies light touch. This finding indicates dysfunction of which sensory pathway?
- Dorsal column (posterior funiculus)
- Spinothalamic tract (anterolateral system) (Correct answer)
- Dorsal spinocerebellar tract
- Corticospinal tract
Correct answer: Spinothalamic tract (anterolateral system)
Pain and temperature discrimination (and crude touch) are transmitted via the spinothalamic tract. Loss of sharp-dull discrimination with intact light touch indicates anterolateral system dysfunction.
The dorsal column-medial lemniscal pathway transmits fine touch, vibration, proprioception, and two-point discrimination, decussating at the medulla. The spinothalamic tract transmits pain, temperature, and crude touch, decussating within 1-2 spinal cord levels of entry. Brown-Sequard syndrome demonstrates this dissociation: ipsilateral dorsal column loss (proprioception, vibration) plus contralateral spinothalamic loss (pain, temperature). PTs perform comprehensive sensory examinations to map deficits, guide safety interventions, and monitor neurological recovery.
Question 6: A patient presents with shoulder pain reproduced by the Hawkins-Kennedy test. This test most specifically assesses for:
- Acromioclavicular joint sprain
- Subacromial impingement (supraspinatus or subacromial bursa compression) (Correct answer)
- Bicipital tendinopathy
- Posterior glenohumeral instability
Correct answer: Subacromial impingement (supraspinatus or subacromial bursa compression)
The Hawkins-Kennedy test (shoulder flexion to 90 degrees plus internal rotation) compresses the supraspinatus and subacromial bursa under the coracoacromial arch, reproducing impingement pain.
In the Hawkins-Kennedy test, the shoulder is elevated to 90 degrees in the scapular plane and forcibly internally rotated, driving the supraspinatus tendon and subacromial bursa against the coracoacromial ligament. Reproduction of shoulder pain indicates a positive test for subacromial impingement. Sensitivity is approximately 72-79%, specificity 56-66%. The Neer sign (passive forward flexion) is a complementary impingement test. Together with the empty can test (supraspinatus strength) and subacromial injection test, PTs use these findings to diagnose impingement syndrome and guide interventions.
MPT Clinical Examination and Differential Diagnosis 1
A positive Spurling test (foraminal compression test) is most indicative of: