Download Physical Examination of the Spesific Joints

Assoc. Prof. Dr. Ercan MADENCI
Istanbul Medeniyet University
Medical School
Department of PMR
Neck
Shoulder
Elbow
Lomber
spine
Wrist
Hip
Knee
Ankle
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Examination
 Inspection:
 Posture
 Deformity
 Swelling
 Atrophy
 Skin lesions
 Palpation
 ROM:
 Flexion-extension
 Adduction-Abduktion
 Rotation
 Neurologic examination
 Muscle strength
 Sensory
 Special tests
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Neck
 The clinical examination begins with broadly observing the
patient's gait and head and neck posture
 Further palpation, range of motion testing, and neurologic
signs, including motor signs, reflexes, sensory signs,
autonomic signs, and articular signs, are assessed
 Posteriorly and posterolaterally, the occiput, inion, superior
nuchal line, mastoid processes, and spinous processes of
C2 and C7-T1 are palpable
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 Range of motion examination may reveal pain or
limitations in flexion-extension, lateral bending, and
rotation
 Sensation testing for light touch, pin prick,
temperature, and proprioception should be performed
 These tests are subjective, and both upper extremities
should be compared to assess differences in sensation
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 Dermatomally, C1 and C2 innervate the
occiput region; C3 and C4, the nape of the
neck; C5, the deltoid region; C6, the radial
aspect of the forearm; C7, the long finger;
C8, the ulnar border of the hand; and T1,
the medial border of the arm
 Motor function should be graded using the
standard 0-to-5 nomenclature
 A cursory examination can be performed
assessing C5 with elbow flexion, C6 with
wrist extension, C7 with elbow extensors
or wrist flexion, C8 with finger flexion of
the middle finger, and T1 with finger
abduction of the fifth finger
 Deep tendon stretch reflexes should be
performed and graded 0 to 3 with 0 being
no response, 1 being hyporeflexive, 2 being
normal, and 3 being hyperreflexive. C5 is
tested by striking the biceps tendon; C6,
brachioradialis; C7, triceps
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 Provocative tests that can be helpful
in confirming compressive
extradural monoradiculopathy
include
 Spurling's test
 The axial compression test
 Adson Test
 Provocative tests that are helpful in
diagnosing myelopathy :
 Hoffmann's sign
 Lhermitte's sign
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Shoulder
 Contour and symmetry
 Spinatus muscle atrophy
 scapular winging
 Range of motion
 scapulothoracic motion
 glenohumeral motion
 Palpation of the biceps
tendon, coracoid, lesser and
greater tuberosities, and
posterior cuff is done, and
any tenderness is gauged
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Examination
 Inspection:
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Posture
Deformity
Swelling
Atrophy
Skin lesions
 Palpation
 ROM:
 Flexion-abduction: 180
 Adduction, external rotation, extension:45, internal rotation: 55
 Scapular movements: elevation, depresion, rotation, protraction
 Neurologic examination
 Muscle strength
 Sensory: c4-c5-t1-t2
 Special tests
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 impingement sign
 resim
 Speed's test
 Yergason's sign
 Apprehension test
 Subscapularis test
 Drop arm test
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ELBOW
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The elbow joint is composed of three bony articulations. The principal articulation is the
humeroulnar joint.
The radiohumeral and proximal radioulnar articulations allow rotation of the forearm.
examine the skin: psoriatic plaques, rheumatoid nodules, or tophi.
palpate the olecranon bursa to exclude the presence of small nodules or tophi.
Synovitis or effusion generally results in limitation of elbow extension.
In lateral epicondylitis, discomfort can be elicited by resisted supination of the forearm or resisted
extension of the pronated wrist. In medial epicondylitis, discomfort can be elicited by resisted flexion
of the supinated wrist.
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WRIST
 Movements of the wrist include flexion (palmar
flexion), extension (dorsiflexion), radial deviation,
ulnar deviation, and circumduction
 Pronation and supination of the hand and forearm
occur primarily at the proximal and distal radioulnar
joints
 The wrist normally can be extended to 70 to 80
degrees and flexed to 80 to 90 degrees. Ulnar and
radial deviation should allow 50 degrees (ulnar) and
20 to 30 degrees (radial) of movement
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 Positive table tab test
 The Finkelstein test
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 dactylitis and sausage
digit
 Swan neck deformity
 Boutonnière deformity
 telescoping or
shortening of the digits
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 A mallet finger
 Bony hypertrophy:
Heberden nodes,
Bouchard nodes
 The ability to oppose
fingers, especially the
thumb, is crucial to hand
function because of the
necessity to grasp or at
least pinch for objects
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LOMBER SPINE
• Anterior Elements:
– Vertebral body: provide bulk and height; Sustain compression loads
• Middle Elements:
– Pedicles: transfer forces from posterior to anterior element
• Posterior Elements:
– Articular processes and facet jts, laminae, spinous processes.
– Lock spine to prevent forward sliding and twisting; Insertion sites for
muscle
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3 Joint Complex:
1– Intervertebral disc:
principal joint between
vertebrae
2-Facet Joints: formed
by superior and inferior
articular processes
3-Disc consists of:
– Nucleus polposus
– Annulus fibrosis
– Vertebral endplates
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3 major groups:
1– Psoas major and minor:
provide hip flexion.
2– Quadratus lumborum:
assists lateral flexion.
3– Paraspinous muscles
(erector spinae): control
flexion,extension and twist.
• Multifidus
• Interspinalis
• Iliocostalis
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 Interspinous Ligament:
connects spinous process
 Ligamenum Flavum:
connects laminae; roof
for spinal canal
 Ant / Post longitudinal
ligaments: cover
vertebral body for
stability
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Inspection
 Inspect back for symmetry;
– List, scoliosis or other deformity.
– Redness (infx), Lipoma or hair growth (spina bifida).
 From the side, observe lumber lordosis.
 Check pelvic obliquity:
– Line between PSIS should be parallel to floor.
Affected by leg length or scoliosis.
 Ask patient to point to area of maximal pain.
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Palpation
• Spinous processes and ligaments:
– Feel for step-off at L4-L5-S1 (spondylolisthesis)
– Tender with ligament sprains, fracture, etc.
• Facet joints: deep and lateral to processes;
Tender with OA
• Paraspinous muscles: for tenderness or spasm
• Top of Iliac crests at L4-L5 disc space;
Follow around to PSIS:
– Sacroiliac joints: below and lateral to PSIS.
– Sciatic notch: mid way btw PSIS and ischial
tuberosity; Aggravates sciatica.
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Range of Motion
• Forward flexion (80-90):
– Loads discs and stretches sciatic
nerve; More likely to increase disc pain
– Observe from behind bending forward
for asymmetry, suggestive of scoliosis
• Extension(20-30): more likely to increase
pain from facets or spinal stenosis
• Lateral bending (20-30): loads muscle and
discs
• Twisting (30-40): loads muscle
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Neuro: Strength Testing
• Resisted hip flexion (iliopsoas muscle) tests L1 and L2.
• Resisted knee extension (quad muscle) tests L3.
• Resisted ankle dorsiflexion tests L4.
• Resisted dorsiflexion of great toe tests L5.
• Resisted ankle plantarflexion test S1.
• S2-4 supply bladder and anal sphincter.
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Neuro: Strength Testing
• Heel walking
–Ankle dorsiflexors (Tibialis anterior)
– L4.
• Toe walking
–Gastroc-soleus muscle group.
– L5 and S1
Neuro: Sensory Testing
• Check light touch and sharp/dull
– L4: medial leg and ankle.
– L5: dorsum of foot.
–S1: lateral ankle and foot
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Neuro: DTR’s and Clonus
• Deep tendon reflexes
–Knee jerk: L4.
– Ankle jerk: S1.
– Reinforce if weak
• Ankle clonus
–Check if DTR’s excessively brisk.
–Elicit with sudden ankle dorsiflexion.
–Suggests upper motor neuron lesion
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Nerve Tension Tests
• Test for nerve root compression.
• Key nerves for lumbar and sacral roots:
– Femoral nerve (L2, L3, L4) runs down
antero-medial thigh.
– Sciatic nerve (L4, L5, S1,S2, S3) runs down
posterior thigh.
Straight Leg Raise (SLR)
• With patient supine or sitting, flex hip and extend knee.
– Note angle at which pain or tightness occurs (normal 70-90o).
– Pain radiating past knee suggests sciatica and lesion at L5 or S1 roots.
– Dorsiflexion of ankle increases sciatic tension and pain (Lasegue’s test).
– Plantar flexion of ankle or flexion of knee relieves sciatic tension
and pain
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Femoral Nerve Stretch Test
• Used to assess compression at L2-3-4
nerves roots
• With patient prone on exam table and
knee flexed, extend hip by lifting thigh off
table
– Positive with high lumbar disc
herniation.
– Reproduces radicular pain to
anterior thigh.
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Other Tests for Disc
Herniation
• Crossed SLR Test: pain radiating
down opposite leg highly suggestive of
HNP
• Valsalva Maneuver:
– increases intrathecal pressure
– Aggravates pain caused by
pressure on cord or roots (HNP,
tumor, etc).
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HIP
 The principal hip flexor is the iliopsoas
 Hip adduction: adductors (longus, brevis, and magnus)
 The gluteus medius is the major hip abductor, the gluteus maximus and
hamstrings extend the hip.
 There are several clinically important bursae around the hip joint.
 stance and gait: the anterior iliac spines are visible. Pelvic tilt or obliquity
structural scoliosis, anatomic leg-length discrepancy, or hip disease.
 resim
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 resim
 Antalgic (limping) gait
 Trendelenburg gait
 The Trendelenburg test
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 The motion of the hip
should be assessed with
the patient in the supine
position. The range of
motion of the hip includes
flexion (120), extension,
abduction (45), adduction
(20-30), internal and
external rotation (40-45).
 The Thomas test
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 The Patrick test or
FABERE maneuver
(FABERE —flexion,
abduction, external
rotation, and
extension.)
 The Ober test
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 Measurement for leg-length discrepancy: anterior
superior iliac spine
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KNEE
 Examination of the knees
should always include
observation of the patient
while standing and
walking
 Deviation of the knees,
including genu varum,
genu valgum and genu
recurvatum
 Inspection: asymmetry
that may be caused by
swelling or muscle atrophy,
Patellar alignment, Baker
cyst
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Palpation of the knee
 Swelling, thickening,
nodules, loose bodies,
tenderness, and warmth
should be noted
 bulge sign (patellar
schock)
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apprehension test
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 The normal knee range of
motion should be from full
extension (0 degrees) to
full flexion of 120 to 150
degrees
 Ligamentous instability is
tested by applying valgus
and varus stress to the
knee and by using the
drawer test
 The abduction or valgus
test:
 The adduction or varus test
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 Lachman test
 A posterior drawer test
 Mcmurray test
 Apley test
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ANKLE
 20 degrees of dorsiflexion and about 45 degrees of
plantar flexion
 Inversion and eversion of the foot occur mainly at the
subtalar and other intertarsal joints
 20 degrees of eversion
 30 degrees of inversion
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 A general assessment of muscular strength of the ankle can be obtained by asking the
patient to walk on toes and on heels.
 The principal flexors of the ankle are the gastrocnemius (nerve roots S1 and S2) and the
soleus (S1 and S2) muscles.
 The principal extensor (dorsiflexors) of the ankle is the tibialis anterior muscle (L4, L5, and
S1). The tibialis posterior muscle (L5 and S1) is the principal inverter. To test the tibialis
posterior muscle, the foot should be in plantar flexion.
 The principal everters of the foot are the peroneus longus (L4, L5, and S1) and peroneus
brevis (L4, L5, and S1) muscles.
 asymmetry, hypertrophy, or atrophy. The distribution of the atrophy should be noted
because this may indicate the underlying cause.
 Muscle tone
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