Clinical Pearls
123 pearls across 9 body regions
1
Painful arc (60–120°) + normal strength → Impingement / RCRSP — not a tear
2
Global stiffness with capsular pattern (ER > ABD > IR) → Frozen Shoulder — confirm with firm end-feel
3
True weakness + ER lag sign → Full-thickness Rotator Cuff Tear — refer for imaging
4
Apprehension + relocation relief → Anterior GH Instability — high specificity combination
5
Neck pain + dermatomal arm radiation → Cervical Referral — always clear the cervical spine first in shoulder assessments
6
Night pain + constant ache at rest → Screen red flags before diagnosing — bone pathology, malignancy
7
Pain ≤ 3/10 during exercise is acceptable; pain persisting > 24 h post-session = too much load
8
Hawkins-Kennedy + Neer + Painful Arc (3 tests) — if all 3 positive, specificity for impingement rises significantly
9
Scapular dyskinesis is a contributing factor, not a primary diagnosis — always assess scapular control under load
10
Frozen shoulder has 3 stages: Freezing (pain dominant) → Frozen (stiffness dominant) → Thawing — treatment differs per stage
11
Do NOT aggressively stretch a freezing shoulder — it worsens pain and inflammation; prioritise pain management first
12
AC joint pathology: pain on top of shoulder + cross-body adduction pain + O'Brien's positive at top of shoulder
13
Rotator cuff tendinopathy responds best to progressive heavy slow resistance (HSR) — avoid complete rest
14
C5 radiculopathy mimics rotator cuff pathology (deltoid weakness, lateral arm pain) — always test cervical myotomes
15
Posterior capsule tightness causes internal impingement — treat with sleeper stretches and posterior capsule mobilisation
1
Lateral epicondyle pain + gripping → Tennis Elbow (Lateral Epicondylalgia) — Cozen's test is most sensitive
2
Medial epicondyle pain + wrist flexion/pronation → Golfer's Elbow (Medial Epicondylalgia)
3
Ring/little finger tingling + elbow flexion → Cubital Tunnel Syndrome — ulnar nerve compression at elbow
4
Cannot hook biceps tendon on supination → Distal Biceps Rupture — Hook test is gold standard
5
Tennis Elbow: start with isometrics (pain relief), progress to heavy slow resistance (HSR) for structural adaptation
6
Cubital Tunnel: avoid prolonged elbow flexion > 90°, use night splint in extension, modify workstation
7
Always clear the cervical spine (C6–C7 dermatomes) before diagnosing elbow tendinopathy — referred pain is common
8
Lateral epicondylalgia: eccentric and HSR loading outperforms passive treatment — avoid complete rest
9
Elbow OA: restricted extension is the first movement lost — springy end-feel suggests loose body
10
UCL (medial collateral) injury: valgus stress test + milking manoeuvre — common in throwing athletes
11
Posterior elbow pain + extension → Olecranon bursitis or triceps tendinopathy — differentiate by palpation
12
Radial tunnel syndrome mimics Tennis Elbow — pain 4–5 cm distal to lateral epicondyle, resisted middle finger extension reproduces pain
13
Pronator teres syndrome: median nerve compression — pain with resisted pronation + forearm ache, no nocturnal symptoms (unlike CTS)
1
FOOSH + anatomical snuffbox tenderness → Scaphoid fracture until proven otherwise — X-ray may be negative; MRI or CT if high suspicion
2
Nocturnal hand tingling + Phalen's positive → Carpal Tunnel Syndrome — thenar wasting = advanced; refer for nerve conduction
3
Radial wrist pain + Finkelstein's positive → De Quervain's Tenosynovitis — APL and EPB tendons at first dorsal compartment
4
Ulnar wrist pain + forearm rotation → TFCC tear — MRI arthrogram is gold standard; positive fovea sign
5
Finger locking/triggering → Trigger Finger (stenosing tenosynovitis at A1 pulley) — corticosteroid injection highly effective
6
Multiple joints + morning stiffness > 45 min + bilateral → Screen for Rheumatoid Arthritis (RF, anti-CCP, CRP)
7
CTS: night splint + nerve gliding exercises; corticosteroid injection for short-term relief; surgery if thenar wasting present
8
Mallet finger: DIP joint held in flexion after forced flexion — treat with 6–8 weeks DIP extension splinting
9
Dupuytren's contracture: ring and little finger MCP/PIP flexion contracture — refer when functional impairment develops
10
Gamekeeper's / Skier's thumb: UCL of thumb MCP — valgus stress test; surgical referral if complete rupture
11
DRUJ instability: positive piano key sign — ulnar head prominence with forearm rotation; often missed after distal radius fractures
12
Ganglion cyst: most common wrist mass — dorsal > volar; transilluminates; most resolve spontaneously
13
Kienbock's disease: lunate avascular necrosis — radial wrist pain in young adults, X-ray may appear normal early; MRI confirms
1
Groin pain + FADDIR positive → FAI or Labral Tear — MRI arthrogram is gold standard for labral pathology
2
Lateral hip pain + Trendelenburg gait → Gluteal Tendinopathy — AVOID stretching (increases compressive load on tendon)
3
Limited IR + groin pain + older patient → Hip OA — capsular pattern: flexion > IR > ABD
4
Buttock pain + radiating to leg → Always clear the lumbar spine first before diagnosing hip pathology
5
GTPS (Greater Trochanteric Pain Syndrome): avoid compressive postures — no crossing legs, no side-lying on affected hip
6
Hip fracture in elderly: red flag — shortened and externally rotated leg + inability to weight bear; refer immediately
7
Log Roll test: high specificity for intra-articular hip pathology — pain or apprehension = positive
8
Snapping hip (coxa saltans): external = ITB over GT; internal = iliopsoas over iliopectineal eminence — differentiate by location
9
Piriformis syndrome: deep buttock pain + sciatic radiation — provoked by seated positions; FAIR test positive
10
Adductor-related groin pain: pain on resisted adduction + adductor origin tenderness — common in footballers
11
Hip OA: pain relief exercise + education + weight management are first-line; manual therapy adjunct only
12
FAI: cam morphology (young males) vs pincer morphology (females) — both cause labral damage with repetitive impingement
13
Meralgia paraesthetica: lateral thigh burning/numbness → lateral femoral cutaneous nerve compression at inguinal ligament
14
Stress fracture of femoral neck: groin pain in runners — X-ray may be negative; MRI if suspected; non-weight-bearing until confirmed
1
Anterior knee pain + stairs/squatting/prolonged sitting → PFPS — assess VMO activation, hip abductor strength, and foot pronation
2
Pop + immediate haemarthrosis (rapid swelling within 2 h) → ACL tear — Lachman test is gold standard (Sn 85%, Sp 94%)
3
Joint line tenderness + locking/giving way → Meniscus tear — Thessaly test most sensitive; MRI for confirmation
4
Valgus force + medial joint line pain → MCL injury — Grade I/II: conservative; Grade III: consider surgical review
5
Lateral knee pain + running (especially downhill) → IT Band Syndrome — Noble compression test; address hip abductor weakness
6
Diffuse pain + crepitus + older patient → Knee OA — exercise therapy is first-line; avoid unnecessary imaging early
7
Ottawa Knee Rules: bony tenderness at fibula head, patella, or tibial tuberosity + unable to weight bear → X-ray first
8
Posterior knee pain + popliteal swelling → Baker's Cyst — usually secondary to intra-articular pathology; treat the cause
9
Patellar tendinopathy: inferior pole pain + loading activities — HSR loading is gold standard; avoid complete rest
10
ACL rehabilitation: return-to-sport criteria-based (not time-based) — limb symmetry index > 90% before return
11
Degenerative meniscus tears in patients > 40: exercise therapy equals surgery (ESCAPE trial) — avoid early surgical referral
12
PCL injury: posterior sag sign + posterior drawer — often missed; mechanism is dashboard injury or hyperflexion
13
Osgood-Schlatter disease: adolescent + tibial tuberosity pain — load management + quadriceps stretching; self-limiting
14
Plica syndrome: medial knee pain + snapping + tender medial plica — often misdiagnosed as meniscus; responds to VMO strengthening
1
Ottawa Ankle Rules positive (bony tenderness at malleoli or navicular/5th MT base + unable to weight bear) → X-ray first, always
2
Thompson test positive (no plantarflexion on calf squeeze) → Achilles tendon rupture — urgent orthopaedic referral
3
Inversion mechanism + lateral ankle pain → Lateral ankle sprain — ATFL most commonly torn; RICE + early mobilisation
4
Plantar heel pain worst in first steps of morning → Plantar Fasciitis — Windlass test + palpation at medial calcaneal tubercle
5
Achilles insertional tendinopathy: AVOID stretching and heel drops below neutral — compressive load worsens symptoms
6
Achilles mid-portion tendinopathy: eccentric loading (Alfredson protocol) or HSR loading — both evidence-based
7
Syndesmotic (high ankle) sprain: longer recovery than lateral sprain (6–12 weeks) — positive squeeze test + external rotation stress test
8
Peroneal tendinopathy: lateral ankle pain + pain with resisted eversion — often misdiagnosed as chronic lateral sprain
9
Sinus tarsi syndrome: lateral hindfoot pain + instability after ankle sprain — sinus tarsi palpation reproduces pain
10
FHL tendinopathy: posterior ankle pain in ballet dancers + pain with resisted great toe flexion — posterior impingement
11
Tarsal tunnel syndrome: medial ankle + plantar foot tingling — Tinel's at tarsal tunnel; differentiate from plantar fasciitis
12
Lisfranc injury: midfoot pain + bruising on plantar surface after axial load — X-ray weight-bearing; often missed; refer if suspected
13
Stress fractures in runners: localised bony tenderness + pain with activity — navicular and 5th MT base are high-risk; MRI if X-ray negative
1
Saddle anaesthesia + bilateral leg weakness + bladder/bowel dysfunction → EMERGENCY — Cauda Equina Syndrome; immediate ED referral
2
SLR positive < 60° with radicular reproduction → Disc herniation / nerve root compression — sensitise with dorsiflexion
3
Worse with extension + walking (relieved by flexion/sitting) → Lumbar Spinal Stenosis or Facet Joint pain
4
Worse with flexion + sitting + centralisation with extension → Disc pathology — McKenzie extension principle
5
Morning stiffness > 45 min + young adult + buttock pain + improves with activity → Screen for Ankylosing Spondylitis (HLA-B27, MRI SI joints)
6
Non-specific LBP: stay active, avoid bed rest, address psychosocial yellow flags (fear-avoidance, catastrophising)
7
L4 radiculopathy: knee extension weakness + reduced patellar reflex; L5: EHL weakness + no reflex change; S1: plantarflexion + reduced Achilles reflex
8
Crossed SLR (contralateral SLR reproduces ipsilateral symptoms) → high specificity for large central disc herniation
9
Waddell's signs: 3 or more positive signs suggest non-organic component — do not dismiss; address psychosocial factors
10
Piriformis syndrome: deep buttock pain + sciatic radiation — provoked by sitting; FAIR test positive; differentiate from true radiculopathy
11
Lumbar instability: pain with sitting to standing transition + catch with movement — multifidus and deep stabiliser retraining is key
12
Facet joint pain: localised paraspinal pain + worse with extension/rotation + relieved by flexion — no neurological signs
13
Maigne's syndrome (thoracolumbar junction): referred pain to buttock/groin from T12–L1 — often misdiagnosed as hip or SI joint pathology
14
NICE guidelines: do not routinely X-ray or MRI non-specific LBP — imaging rarely changes management and may increase fear-avoidance
1
Bilateral leg symptoms + UMN signs (hyperreflexia, clonus, Babinski) → Thoracic Myelopathy — URGENT MRI; do not manipulate
2
Thoracic pain worse with deep breathing/coughing → Costovertebral joint dysfunction — highly responsive to manual therapy
3
Band-like chest pain + dermatomal distribution → Thoracic radiculopathy — also rule out herpes zoster (shingles) before treatment
4
Adolescent + progressive kyphosis → Scheuermann's disease — X-ray: Schmorl's nodes + ≥ 3 consecutive vertebrae with > 5° wedging
5
Elderly + sudden onset thoracic pain after minor trauma or coughing → Osteoporotic vertebral fracture — X-ray + DEXA scan
6
Thoracic facet joint pain: unilateral paraspinal pain + restricted rotation — foam roller extension + thoracic rotation exercises are first-line
7
Always rule out cardiac (angina, MI) and pulmonary (PE, pneumothorax) causes for thoracic/chest pain before treating musculoskeletally
8
DISH (Diffuse Idiopathic Skeletal Hyperostosis): flowing ossification on right side of thoracic spine — restricted thoracic mobility in older males
9
Thoracic outlet syndrome: arm pain + paraesthesia + provoked by overhead activities — EAST test, Roos test; rule out cervical and shoulder pathology
10
Rib stress fracture: localised rib pain in rowers/throwers — X-ray often negative; bone scan or MRI confirms; modify load
11
Postural thoracic kyphosis vs structural kyphosis: postural corrects on extension; structural (Scheuermann's) does not — important distinction for management
12
Thoracic manipulation is one of the most effective interventions for acute thoracic pain — short-term pain relief and mobility gains are well-evidenced
13
T4 syndrome: diffuse upper limb paraesthesia + mid-thoracic pain — poorly understood; responds to thoracic mobilisation at T4
1
Bilateral arm symptoms + gait disturbance + UMN signs → Cervical Myelopathy — URGENT MRI; do not manipulate
2
Shoulder abduction relief sign (hand on head relieves arm pain) → highly specific for cervical radiculopathy
3
C5 radiculopathy mimics rotator cuff pathology (deltoid weakness, lateral arm pain) — always test cervical myotomes in shoulder assessments
4
Flexion-Rotation Test < 32° on symptomatic side → best single test for cervicogenic headache (C1–C2 dysfunction)
5
WAD (Whiplash Associated Disorder): early active movement + reassurance is superior to collar use and rest — avoid medicalisation
6
VBI screen before cervical manipulation: 5 Ds + 3 Ns — dizziness, diplopia, dysarthria, dysphagia, drop attacks + nausea, nystagmus, numbness
7
C7 is the most commonly affected level in cervical disc herniation — triceps weakness, middle finger numbness, reduced triceps reflex
8
Spurling's test (cervical compression + lateral flexion to symptomatic side) → high specificity for radiculopathy (Sp 93%) — use to confirm, not screen
9
Cervical radiculopathy: most cases resolve conservatively within 8–12 weeks — neural mobilisation + cervical traction + exercise
10
Upper cervical instability (C1–C2): Sharp-Purser test + alar ligament test — always screen in Down syndrome, RA, and post-trauma
11
Cervicogenic dizziness: dizziness provoked by neck movement or position, not by head position alone — differentiate from BPPV
12
Cervical OA/spondylosis: most common cause of neck pain in patients > 50 — imaging findings do not correlate with symptoms; treat the patient, not the scan
13
Thoracic outlet syndrome: arm pain + paraesthesia + provoked by overhead activities — Adson's test, EAST test; rule out cervical and shoulder pathology
14
Cervical manipulation carries a very low but real risk of vertebral artery dissection — always obtain informed consent and screen for VBI risk factors
Physio Pearls — 123 Clinical Pearls across 9 MSK Body Regions