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D:\478162668.doc Page 1 of 107 Table of contents DO THE CORE CERVICAL ORTHOPAEDIC EXAMINATION AND TEST FOR FACET JOINT IRRITATION. ............................................................................................................................................................. 3 DO THE CORE LUMBAR SPINE EXAMINATION ON A PAIN-FOCUSED PATIENT. TEST THE INTEGRITY OF THE L4 NERVE ROOT ............................................................................................................... 7 DO THE CERVICAL ORTHOPEDIC EXAMINATION, CHECK FOR CERVICOGENIC DORSALGIA AND DIFFERENTIAL DIAGNOSIS CERVICOGENIC VERTIGO FROM VESTIBULOCOCHLEAR CAUSES ..................................................................................................................................................................... 11 DO THE CORE LUMBAR SPINE EXAMINATION AND CHECK FOR SI JOINT SYNDROME. .............. 16 DO THE CORE LUMBAR SPINE EXAMINATION AND RULE OUT ANKYLOSING SPONDYLITIS. TEST THE INTEGRITY OF L5 NERVE ROOT .................................................................................................. 21 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND CHECK FOR NERVE ROOT TENSION SIGNS ON A PATIENT YOU ARE SUSPECTING C5 CERVICAL RADICULOPATHY. .......... 24 DO THE CORE LUMBAR ORTHOPEDIC EXAMINATION AND DDX LUMBAR FACET JOINT IRRITATION FROM THORACOLUMBAR SYNDROME. TEST THE INTEGRITY OF L5 NERVE ROOT. ........................................................................................................................................................................ 29 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND DDX CERVICAL SPRAIN VERSUS CERVICAL STRAIN. TEST THE INTEGRITY OF C6 NERVE ROOT. ......................................................... 32 DO THE CORE LUMBAR ORTHOPEDIC EXAMINATION AND DDX PIRIFORMIS SYNDROME FROM SI SYNDROME. ........................................................................................................................................... 37 DO CORE LUMBAR ORTHOPEDIC EXAMINATION AND DO A FULL NEUROLOGICAL AND VASCULAR EXAMINATION OF THE LOWER LIMB. .................................................................................... 42 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND TEST FOR TOCS. TEST THE INTEGRITY OF THE T1 NERVE ROOT. ............................................................................................................ 47 DO THE LUMBAR ORTHOPEDIC EXAMINATION AND RULE OUT NERVE ROOT TENSION SIGNS IN THE LOWER LIMBS. TEST THE INTEGRITY OF THE S1 NERVE. ....................................................... 52 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND RULE OUT MENINGEAL IRRITATION. TEST THE INTEGRITY OF C7 NERVE ROOT. ...................................................................... 55 DO THE CORE LUMBAR SPINE EXAMINATION AND CHECK FOR A LUMBAR DISC HERNIATION. TEST THE INTEGRITY OF SI NERVE ROOT. .................................................................................................. 60 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND TEST FOR CERVICAL DISC HERNIATION. TEST THE INTEGRITY OF C6 NERVE ROOT. ..................................................................... 63 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND RULE OUT VERTROBASILAR INSUFFICIENCY. TEST THE INTEGRITY OF C7 NERVE ROOT. ............................................................... 68 DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE THORACIC SPINE AND CHECK FOR SCOLIOSIS................................................................................................................................................................ 73 D:\478162668.doc Page 2 of 107 DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR LABRAL TEARS ........................................................................................................................................................................ 76 DO THE CORE EXMINATION OF THE KNEE AND CHECK FOR A MENISCAL TEAR ......................... 79 DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND RULE OUT PATELLOFEMORAL SYNDROMES ................................................................................................................... 82 DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND CHECK FOR AN ACL TEAR .... 85 DO THE CORE ORTHOPEDIC EXAMINATION OF THE WRIST AND HAND .......................................... 88 DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE FOOT AND ANKLE ................................... 90 DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR BICIPITAL TENDONITIS ............................................................................................................................................................ 91 DO A CORE EXAMINATION OF THE HIP AND EXPLAIN THE DIFFERENCE BETWEEN BARLOW’S AND ORTOLANI’S TESTS. .................................................................................................................................... 94 DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE TMJ .............................................................. 96 DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR POSTERIOR SHOULDER INSTABILITY .................................................................................................................................... 98 DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE ELBOW ...................................................... 101 DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND RULE OUT AN ANTERIOR SHOULDER INSTABILITY ........................................................................................................... 103 DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND RULE OUT A PLICA ................ 106 D:\478162668.doc Page 3 of 107 DO THE CORE CERVICAL ORTHOPAEDIC EXAMINATION AND TEST FOR FACET JOINT IRRITATION. Core tests: 1. Observation – general, postural a. facial expression indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vertebrobasilar testing – must be done before any cervical adjustments Houle positive is vertigo, dizziness, nausea, and nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination C5 C7 C8 T1 C6 Motor Shoulder Wrist extension Wrist flexion Finger flexion Finger abduction and finger (curl fingers) abduction and extension adduction Sensation Lateral arm Middle finger Medial Medial arm Lateral forearm, ring forearm, and small thumb and finger index finger Reflex Biceps Brachioradialis triceps 4. Cervical ROM testing Flexion: 45 60 Extension: 45 75 Rotation: 70 90 Lateral flexion: 2045 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation. 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain. 7. Soft tissue palpation Scalenes Suboccipitals D:\478162668.doc Page 4 of 107 Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower cervical motion palpation Motion Contact hand Flexion Thumb on articular pillar; index finger wrapped around TVP of segment below Control hand On patient’s forehead. Patient’s head and neck is flexed and returned to neutral. On patient’s top of head. Lateral flexes head and neck towards contact hand, and returns to neutral Normal Articular pillar will glide anterior and superior Abnormal Articular pillar fails to go anterior and superior TVPs approximate a smooth ‘C’ curve is appreciated A break in the ‘C’ curve may indicate DJD in joints of Luschka or possible scaleni/intertrans verarii hypertonicity Loss of spinous deviation and/or spinous reversal (possible contralateral SS and/or splenius involvement) Restricted end feel with lack of anterior motion. Possible small cervical rotators Lateral flexion Three-finger contact on lateral aspect of TVPs. Spinous deviation Thumb contact against two adjacent spinouses. On top of patient’s head. Lateral flexes head towards contact hand and returns to neutral Spinous process deviates to convexity. Anterior rotation Three-fingered contact on three adjacent articular pillars, control hand on patient’s forehead. Patient leans back against doctor as contact with 2-3 fingers placed over anterior aspect of TVPs Rotates face away from contact hand and returned to neutral. Articular pillars move anterior in a stair stepping motion. On patient’s head or chin. Guides face towards contact while contact hand pulls posterior and superior TVPs move posteriorly allowing a slight “give” Posterior rotation Restricted end feel to the posterior motion and fullness under fingers or joint (possible scalenii) D:\478162668.doc Upper Cervical motion palpation Motion Contact finger Jawjut Middle finger on anterior of C1 Rotation Middle finger on anterior of C1 TVP Lateral flexion of Middle finger on occiput on C1 superior aspect of C1 TVP Lateral flexion of Middle finger on C1 on C2 inferior aspect of C1 TVP Control fingers a. index on ramus of mandible b. ring finger on mastoid c. thumb on top of head Patient’s head is pushed down and slightly anterior Page 5 of 107 Normal Abnormal Space between a. space does TVP and not open, mandible extension increases, restriction allowing a “give” (rectus capitus anterior) b. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM) a. index on Space between Space between ramus of C1 TVP and C1 and mandible mandible mandible does not increase b. ring finger on increase on (contralateral mastoid contralateral side superior c. thumb on top oblique) of head Head is rotated to each side a. index on Occiput A. Restricted ramus of approximates C1 end feel mandible TVP and B. Lack of b. ring finger on separates on lateral mastoid contralateral flexion c. thumb on top side. (contralateral of head. rectus capitus Head is laterally lateral) flexed to each side a. index on C1 TVP Restricted end ramus of approximates on feel ipsilateral mandible C2 TVP joint and a lack b. ring finger on ipsilaterally and of separation on mastoid then separates contralateral side c. thumb on top contralaterally (contralateral of head intertransversarii Head is laterally ) D:\478162668.doc Motion Contact finger Rotation of C1 on C2 Occiput-AtlasAxis flexion Semispinalis Capitus stretch (ipsilateral) Splenius capitis stretch (ipsilateral) Control fingers flexed to each side On forehead. Head is rotated away from contacts Page 6 of 107 Normal Abnormal Contact index finger on posterolateral aspect of C1 TVP and thumb on C2 spinous. a. index finger On forehead. on occiput Head is flexed. rim, tubercle b. 3rd finger on space (post of C1) c. 4th finger on C2 spinous First 25 degrees C1 TVP rotates anterior, then C2 spinous rotates to the same side C2 spinous and C1 TVP do not separates (inferior oblique ipsilaterally) Spaces between fingers increase a. thumb on occiput rim just lateral to midline b. index finger hooked around anterior aspect of C2 a. 2-3 fingers on posterior of mastoid. On forehead. Head and neck is flexed and challenged with contact Springy end feel and give a. posterior tubercle with occiput (possible rectus capitus minor) b. C2 spinous rides up with occiput (rectus capitus major) Restricted end feel, lack of flexion of occiput On forehead. Head is flexed and rotated (face away from the contact) and challenged with contact Springy end feel and give Restricted end feel, lack of flexion and rotation of occiput D:\478162668.doc Page 7 of 107 DO THE CORE LUMBAR SPINE EXAMINATION ON A PAINFOCUSED PATIENT. TEST THE INTEGRITY OF THE L4 NERVE ROOT Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg). Exaggerations. b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: a. reflex, sensory and motor testing Reflex Patellar L4 L5 No reflex or medial hamstring tendon S1 Achilles Sensory Medial calf and medial side of foot Lateral leg and dorsum of foot including web of big toe (divided by crest of tibia) Lateral malleolus, lateral and plantar surfaces of foot Motor Tibialis anterior (ankle inversion) Extensor digitorum longus, extensor hallucis longus, walk on heels Peroneus longus and brevis (ankle eversion), gastrocnemius (plantar flexion), walk on toes b. plantar reflex – normally down going c. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression d. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing Forward flexion 40 – 60 degrees dramatic refusal may be suggestive of a nonorganic problem Extension 20-35 degrees Lateral flexion 15-20 degrees Rotation 3 – 18 degrees Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis D:\478162668.doc Page 8 of 107 Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test 6. Non-organic testing a. simulation tests – axial loading, trochanteric rotation b. distraction tests – sitting SLR 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip problem, an irritated SI or L/S facet joint – may indicate tight adductors, intrinsic hip problem, an irritated SI or L/S facet joint c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Motion Contact finger Control fingers Flexion Three finger Patient is flexed contact on and returned to interspinous neutral spaces Normal Spinous processes separate. Abnormal No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or interspinous D:\478162668.doc Page 9 of 107 Motion Contact finger Control fingers Normal Extension Make a fist and use a thumb contact on interspinous Extended by lifting elbows and returned to neutral Spinous processes will approximate Lateral flexion Hook and push contact Laterally flexed Superior spinous away from will rotate to doctor and turned concavity. to neutral Lateral flexion (spinous challenge) Thumb contact on lateral aspect of 2 adjacent spinous Laterally flexed away toward Doctor and returned to neutral Springy end feel as disc is wedge open on contralateral side Rotation Hook-push or thumb-push Rotated toward Dr. and returned to neutral. Spinous rotates away from superior finger Abnormal ligaments No approximation. Extension restriction of flexion malposition. Spinous will not rotate or reverse into convexity (sacrospinalis and/or multifidus) Hard end feel, no lateral flexion: a. disc protrusion/he rniation b. hypertonic intertransvers arii QL. Spinous remains in midline and/or fails to rotate (multifidus) Special test for Pain-focused patients –Waddell’s Tests 1. Tenderness – light touch on the back causes pain or if deep tenderness spreads over large areas of the body – test is positive. 2. Simulation test – scored positive if 1 to 2 pounds of axial pressure applied to the head causes back pain or leg pain or if gentle axial rotation of the pelvis and shoulders together, causes back pain. 3. Distraction test – patient is sitting as the heel is raised with one hand and the doctor’s other had palpates the dorsalis pedal pulse (leg extended and hip joint is flexed). Can be sciatic if leans back. Also can be nonorganic or functional disease if positive for supine SLR < 20 degrees but negative at sitting with hip flexed to 90 degrees (a.k.a. positive Flip test) 4. Regional disturbances – positive if non-neuroanatomic numbness in the absence of peripheral neuropathy, or if the patient demonstrates cogwheel weakness associated with extrapyramidal systemic disease 5. Over-reaction sign –patient uses excessive body language, gestures, moans and groans, sweats profusely, trembles. Not a Waddell’s test but still for pain focused patient. D:\478162668.doc Page 10 of 107 1. Sham SLR: patient is in the seated position with straight legs and foot dorsiflexed. LBP pain amplification or non-organic lesion. D:\478162668.doc Page 11 of 107 DO THE CERVICAL ORTHOPEDIC EXAMINATION, CHECK FOR CERVICOGENIC DORSALGIA AND DIFFERENTIAL DIAGNOSIS CERVICOGENIC VERTIGO FROM VESTIBULOCOCHLEAR CAUSES Core tests: 1. Observation – general, postural a. facial expression indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vertebrobasilar testing Houle positive is vertigo, dizziness, nausea, and nystagmus. It indicates possible stenosis or compression of the vertebral basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination C6 C7 C8 T1 C5 Motor Wrist Wrist flexion Finger flexion Finger Shoulder extension and finger (curl fingers) abduction and abduction extension adduction Sensation Lateral arm Lateral Middle finger Medial Medial arm forearm, thumb forearm, ring and index and small finger finger Reflex Brachioradialis Triceps Biceps 4. Cervical ROM testing Flexion: 45 60 Extension: 45 75 Rotation: 70 90 Lateral flexion: 2045 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation. 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain. D:\478162668.doc Page 12 of 107 7. Soft tissue palpation Scalenes Suboccipitals Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower cervical motion palpation Motion Contact hand Control hand Normal Abnormal Flexion Thumb on On patient’s Articular pillar Articular pillar articular pillar; forehead. will glide fails to go index finger Patient’s head anterior and anterior and wrapped around and neck is superior superior TVP of segment flexed and below returned to neutral. Lateral flexion Three-finger On patient’s top TVPs A break in the contact on lateral of head. Lateral approximate a ‘C’ curve may aspect of TVPs. flexes head and smooth ‘C’ curve indicate DJD in neck towards is appreciated joints of Luschka contact hand, and or possible returns to neutral scaleni/intertrans verarii hypertonicity Spinous Thumb contact On top of Spinous process Loss of spinous deviation against two patient’s head. deviates to deviation and/or adjacent Lateral flexes convexity. spinous reversal spinouses. head towards (possible contact hand and contralateral SS returns to neutral and/or splenius involvement) Anterior rotation Three-fingered Rotates face Articular pillars Restricted end contact on three away from move anterior in feel with lack of adjacent articular contact hand and a stair stepping anterior motion. pillars, control returned to motion. Possible small hand on patient’s neutral. cervical rotators forehead. Posterior rotation Patient leans On patient’s head TVPs move Restricted end back against or chin. Guides posteriorly feel to the doctor as contact face towards allowing a slight posterior motion with 2-3 fingers contact while “give” and fullness D:\478162668.doc Motion Contact hand placed over anterior aspect of TVPs Upper Cervical motion palpation Motion Contact finger Jawjut Middle finger on anterior of C1 Rotation Middle finger on anterior of C1 TVP Lateral flexion of Middle finger on occiput on C1 superior aspect of C1 TVP Lateral flexion of Middle finger on C1 on C2 inferior aspect of C1 TVP Control hand contact hand pulls posterior and superior Control fingers d. index on ramus of mandible e. ring finger on mastoid f. thumb on top of head Patient’s head is pushed down and slightly anterior Page 13 of 107 Normal Abnormal under fingers or joint (possible scalenii) Normal Abnormal Space between c. space does TVP and not open, mandible extension increases, restriction allowing a “give” (rectus capitus anterior) d. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM) d. index on Space between Space between ramus of C1 TVP and C1 and mandible mandible mandible does not increase e. ring finger on increase on (contralateral mastoid contralateral side superior f. thumb on top oblique) of head Head is rotated to each side d. index on Occiput C. Restricted ramus of approximates C1 end feel mandible TVP and D. Lack of e. ring finger on separates on lateral mastoid contralateral flexion f. thumb on top side. (contralateral of head. rectus capitus Head is laterally lateral) flexed to each side d. index on C1 TVP Restricted end ramus of approximates on feel ipsilateral mandible C2 TVP joint and a lack e. ring finger on ipsilaterally and of separation on D:\478162668.doc Motion Contact finger Rotation of C1 on C2 Occiput-AtlasAxis flexion Semispinalis Capitus stretch (ipsilateral) Splenius capitis stretch (ipsilateral) Control fingers mastoid f. thumb on top of head Head is laterally flexed to each side On forehead. Head is rotated away from contacts Page 14 of 107 Normal then separates contralaterally Abnormal contralateral side (contralateral intertransversarii ) Contact index finger on posterolateral aspect of C1 TVP and thumb on C2 spinous. d. index finger On forehead. on occiput Head is flexed. rim, tubercle e. 3rd finger on space (post of C1) f. 4th finger on C2 spinous First 25 degrees C1 TVP rotates anterior, then C2 spinous rotates to the same side C2 spinous and C1 TVP do not separates (inferior oblique ipsilaterally) Spaces between fingers increase c. thumb on occiput rim just lateral to midline d. index finger hooked around anterior aspect of C2 a. 2-3 fingers on posterior of mastoid. On forehead. Head and neck is flexed and challenged with contact Springy end feel and give c. posterior tubercle with occiput (possible rectus capitus minor) d. C2 spinous rides up with occiput (rectus capitus major) Restricted end feel, lack of flexion of occiput On forehead. Head is flexed and rotated (face away from the contact) and challenged with contact Springy end feel and give Cervical dorsalgia tests a. In the seated position: flexion and rotation deep palpation (facet rub) for referral Restricted end feel, lack of flexion and rotation of occiput D:\478162668.doc Page 15 of 107 PA spinous challenge lateral spinous challenge C6/7 interspinous challenge rub the ligament b. In supine position: skin rolling T2/3, T5/6 point testing T2,T5/6 digital pressure – tightness and tenderness on palpation dorsal spinous challenge lateral and PA c. cervical doorbell test is done in the seated position. The examiner palpates the anterolateral aspect of the lower cervical spine. Maintain this mild to moderate pressure for 3 to 5 seconds. Be careful not to occlude the carotid artery. A positive sign is the reproduction or aggravation of pain in the patient’s interscapular region. May be a sign of cervicogenic dorsalgia, pressure over an irritated nerve root may cause radicular arm pain or pain in the interscapular region or hypertonic scalene muscles. Cervicogenic vertigo from vestibulocochlear causes a. rotary chair test Part one – patient sits on stool that rotates with eyes closed and shake head from side to side. Vertigo may be from vestibular nuclei or from the muscles and joints in the cervical spine. Part two – Have rotate head side from side as examine stands behind the patient and holds their head steady while the patient continues to rotate their body. If there is vertigo, it most likely originates form the tissues of the cervical spine. If there is no vertigo, it most likely originates from the vestibular nuclei. b. VBI testing c. Romberg’s – patient stands with eyes closed. The position is held for 20 to 30 seconds. If the body begins to sway excessively or the patient loses balance, the test is considered positive for an upper motor neuron lesion. d. BPV test have patient sit near the middle of the table so that if lying down, head can be supported off the table. The doctor holds the patient’s head (rotates and extends) and instructs the patient to fall back (reassure the patient you are maintaining contact. Hold in that position for 5 to 10 seconds. Look for nystagmus. Caloric test. The examiner alternately applies hot and cold test tubes just behind the patient’s ears on the side of the head; each side is done in turn. A positive test is associated with the inducement of vertigo, which indicates inner ear problems. D:\478162668.doc Page 16 of 107 DO THE CORE LUMBAR SPINE EXAMINATION AND CHECK FOR SI JOINT SYNDROME. Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg) b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: a. reflex, sensory and motor testing Reflex L4 Patellar L5 No reflex or medial hamstring tendon S1 Achilles Sensory Medial calf and medial side of foot Lateral leg and dorsum of foot including web of big toe (divided by crest of tibia) Lateral malleolus, lateral and plantar surfaces of foot Motor Tibialis anterior (ankle inversion) Extensor digitorum longus, extensor hallucis longus, walk on heels Peroneus longus and brevis (ankle eversion), gastrocnemius (plantar flexion), walk on toes b. plantar reflex – normally down going c. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression d. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing Forward flexion 40 – 60 degrees Extension 20-35 degrees Lateral flexion 15-20 degrees Rotation 3 – 18 degrees. Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology D:\478162668.doc Page 17 of 107 Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test 6. Non-organic testing c. simulation tests – axial loading, trochanteric rotation d. distraction tests – sitting SLR 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip problem, an irritated SI or L/S facet joint – increased pain may indicate SI pain c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test – indicates sacroiliac joint irritation 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Lumbar spine Motion Flexion Contact finger Three finger contact on interspinous spaces Control fingers Patient is flexed and returned to neutral Normal Spinous processes separate. Abnormal No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or D:\478162668.doc Page 18 of 107 Motion Contact finger Control fingers Normal Extension Make a fist and use a thumb contact on interspinous Extended by lifting elbows and returned to neutral Spinous processes will approximate Lateral flexion Hook and push contact Laterally flexed Superior spinous away from will rotate to doctor and turned concavity. to neutral Lateral flexion (spinous challenge) Thumb contact on lateral aspect of 2 adjacent spinous Laterally flexed away toward Doctor and returned to neutral Springy end feel as disc is wedge open on contralateral side Rotation Hook-push or thumb-push Rotated toward Dr. and returned to neutral. Spinous rotates away from superior finger Control fingers Stabilizes pelvis. Patient bends forward Normal Sacrospinalis and hamstrings elongate. Relatively sacrum will slightly extend/counternu tate on the innominate Hands firmly grasp pelvis. Patient laterally Lumbar spine laterally flexes in a smooth C- SI joint evaluation Motion Contact finger 1. pelvic flexion a. Index or on acetabulum middle finger under PSIS b. Thumb contact on sacral apex 2. pelvic lateral flexion a. thumbs under PSIS Abnormal interspinous ligaments No approximation. Extension restriction of flexion malposition. Spinous will not rotate or reverse into convexity (sacrospinalis and/or multifidus) Hard end feel, no lateral flexion: c. disc protrusion/he rniation d. hypertonic intertransvers arii QL. Spinous remains in midline and/or fails to rotate (multifidus) Abnormal a. Lumbar spine will not flex (tight sacrospinalis) b. Patient will flex knees (tight hamstrings) c. Innominate fails to flex d. No counternutati on a. Limited or no pelvic shift (tight D:\478162668.doc Page 19 of 107 Motion Contact finger Control fingers bends to each side Normal curve with opposite thigh abduction and adduction elongation to allow a slight pelvic shift 3. ilium flexion Thumbs contact under PSIS. PSIS will move posterior and inferior 4a. iliosacral motion Thumb contact under PSIS. Other thumb contact lateral to S1 tubercle 4b. sacroiliac motion Thumb contact under PSIS. Other thumb contact lateral to S1 tubercle. 5. sacroischial motion Thumb contact on sacral apex. Other thumb contact on soft tissue over posterior ischium Doctor’s hands stabilize pelvis as patient stabilizes with hand against wall. Patient lifts leg as if climbing stairs Patient stabilizes with hand against wall. Patient lifts leg contact lateral to S1 tubercle to 90 degrees. Patient stabilizes with hand against wall. Patient lifts leg contact contralateral to S1 tubercle to 90 degrees. Patient stabilizes with hand against wall. Patient lifts leg on side of ischial contact to 90 degrees. PSIS will move posterior and inferior Sacrum moves posterior and inferior on the flexed innominate Ischium moves slightly anterior and lateral Abnormal abd/add) b. Pelvic rotation (psoas) c. PSIS elevates on opposite side (tight QL) d. Limited lumbar lateral flexion a. PSIS fails to move b. As leg lowers will see psoas shimmer a. PSIS fails to move b. PSIS and sacral base move together posterior Sacrum fails to move posterior and/or inferior a. Ischium fails to move anterior and lateral b. Sacral apex moves with ischium. D:\478162668.doc Page 20 of 107 SI joint syndrome a. Gaenslen’s test – Patient is supine and bring knee to chest on unaffected side. The affected limb is off the table and hyperextended by the examiner with increasing force. Pain on hyperexteded side may indicate an SI lesion b. Yeoman’s test – patient is prone as the examiner flexes the knee, extends the hip joint and applies pressure on ipsilateral PSIS. Increased pain may indicate an SI lesion c. Hibb’s test – the examiner flexes the patient’s leg (prone) on his thigh to 90 degrees and then moves it laterally causing internal rotation of the hip joint. Increased pain may indicate a hip joint lesion, SI lesion or piriformis spasm D:\478162668.doc Page 21 of 107 DO THE CORE LUMBAR SPINE EXAMINATION AND RULE OUT ANKYLOSING SPONDYLITIS. TEST THE INTEGRITY OF L5 NERVE ROOT Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg) b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: Reflex L4 Patellar L5 No reflex or medial hamstring tendon S1 Achilles Sensory Medial calf and medial side of foot Lateral leg and dorsum of foot including web of big toe (divided by crest of tibia) Lateral malleolus, lateral and plantar surfaces of foot Motor Tibialis anterior (ankle inversion) Extensor digitorum longus, extensor hallucis longus, walk on heels Peroneus longus and brevis (ankle eversion), gastrocnemius (plantar flexion), walk on toes a. plantar reflex – normally down going b. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression c. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing Forward flexion 40 – 60 degrees Extension 20-35 degrees Lateral flexion 15-20 degrees Rotation 3 – 18 degrees. Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology D:\478162668.doc Page 22 of 107 Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test 6. Non-organic testing a. simulation tests – axial loading, trochanteric rotation b. distraction tests – sitting SLR 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip problem, an irritated SI or L/S facet joint – increased pain may indicate SI pain c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test – indicates sacroiliac joint irritation 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Lumbar spine Motion Contact finger Control fingers Flexion Three finger Patient is flexed contact on and returned to interspinous neutral spaces Normal Spinous processes separate. Abnormal No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or interspinous ligaments D:\478162668.doc Page 23 of 107 Motion Extension Contact finger Make a fist and use a thumb contact on interspinous Control fingers Extended by lifting elbows and returned to neutral Normal Spinous processes will approximate Lateral flexion Hook and push contact Laterally flexed Superior spinous away from will rotate to doctor and turned concavity. to neutral Lateral flexion (spinous challenge) Thumb contact on lateral aspect of 2 adjacent spinous Laterally flexed away toward Doctor and returned to neutral Springy end feel as disc is wedge open on contralateral side Rotation Hook-push or thumb-push Rotated toward Dr. and returned to neutral. Spinous rotates away from superior finger Abnormal No approximation. Extension restriction of flexion malposition. Spinous will not rotate or reverse into convexity (sacrospinalis and/or multifidus) Hard end feel, no lateral flexion: e. disc protrusion/he rniation f. hypertonic intertransvers arii QL. Spinous remains in midline and/or fails to rotate (multifidus) Special test: 1. Trendelenburg test – Patient stands on one leg so that gluteus medius on supported side contracts to elevate opposite side. If not, this may indicate L4 root lesion or hip disease. 2. Schober’s test. Take out a tape measure and find the dimples of Venus (or the PSIS bilaterally). Draw an imaginary line across the PSIS at the S2 level. Now place the 10 cm point of the tape measure at the S2 level. With the left hand fix the O point of the tape measure onto the spine, which should now be at about the L1 level. With the right hand, hold the tape measure loosely and find the 15 cm point which should be around the apex of the sacrum. Now as you ask the patient to forward flex, the inferior (right hand) allows the tape measure to slide between the fingers and the measurement should normally increase approximately 7 cm, from 15 cm to 22 cm. Any movement less than 3 cm is considered to be positive Schoeber’s test and is highly indicative of seronegative spondyloarthropathy. D:\478162668.doc Page 24 of 107 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND CHECK FOR NERVE ROOT TENSION SIGNS ON A PATIENT YOU ARE SUSPECTING C5 CERVICAL RADICULOPATHY. Core tests: 1. Observation – general, postural a. facial expression indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vertebrobasilar testing Houle positive is vertigo, dizziness, nausea, nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination C6 C7 C8 T1 C5 Motor Wrist extension Wrist flexion Finger flexion Finger Shoulder and finger (curl fingers) abduction and abduction extension adduction Sensation Lateral arm Lateral forearm, Middle finger Medial Medial arm thumb and index forearm, ring finger and small finger Reflex Brachioradialis triceps Biceps 4. Cervical ROM testing Flexion: 45 60 Extension: 45 75 Rotation: 70 90 Lateral flexion: 2045 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation. 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain. 7. Soft tissue palpation D:\478162668.doc Page 25 of 107 Scalenes Suboccipitals Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower Cervical motion palpation Motion Contact hand Control hand Normal Abnormal Flexion Thumb on On patient’s Articular pillar Articular pillar articular pillar; forehead. will glide fails to go index finger Patient’s head anterior and anterior and wrapped around and neck is superior superior TVP of segment flexed and below returned to neutral. Lateral flexion Three-finger On patient’s top TVPs A break in the contact on lateral of head. Lateral approximate a ‘C’ curve may aspect of TVPs. flexes head and smooth ‘C’ curve indicate DJD in neck towards is appreciated joints of Luschka contact hand, and or possible returns to neutral scaleni/intertrans verarii hypertonicity Spinous Thumb contact On top of Spinous process Loss of spinous deviation against two patient’s head. deviates to deviation and/or adjacent Lateral flexes convexity. spinous reversal spinouses. head towards (possible contact hand and contralateral SS returns to neutral and/or splenius involvement) Anterior rotation Three-fingered Rotates face Articular pillars Restricted end contact on three away from move anterior in feel with lack of adjacent articular contact hand and a stair stepping anterior motion. pillars, control returned to motion. Possible small hand on patient’s neutral. cervical rotators forehead. Posterior rotation Patient leans On patient’s head TVPs move Restricted end back against or chin. Guides posteriorly feel to the doctor as contact face towards allowing a slight posterior motion with 2-3 fingers contact while “give” and fullness placed over contact hand under fingers or anterior aspect of pulls posterior joint (possible D:\478162668.doc Motion Contact hand TVPs Upper Cervical motion palpation Motion Contact finger Jawjut Middle finger on anterior of C1 Rotation Middle finger on anterior of C1 TVP Lateral flexion of Middle finger on occiput on C1 superior aspect of C1 TVP Lateral flexion of Middle finger on C1 on C2 inferior aspect of C1 TVP Control hand and superior Control fingers g. index on ramus of mandible h. ring finger on mastoid i. thumb on top of head Patient’s head is pushed down and slightly anterior Page 26 of 107 Normal Abnormal scalenii) Normal Abnormal Space between e. space does TVP and not open, mandible extension increases, restriction allowing a “give” (rectus capitus anterior) f. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM) g. index on Space between Space between ramus of C1 TVP and C1 and mandible mandible mandible does not increase h. ring finger on increase on (contralateral mastoid contralateral side superior i. thumb on top oblique) of head Head is rotated to each side g. index on Occiput E. Restricted ramus of approximates C1 end feel mandible TVP and F. Lack of h. ring finger on separates on lateral mastoid contralateral flexion i. thumb on top side. (contralateral of head. rectus capitus Head is laterally lateral) flexed to each side g. index on C1 TVP Restricted end ramus of approximates on feel ipsilateral mandible C2 TVP joint and a lack h. ring finger on ipsilaterally and of separation on mastoid then separates contralateral side i. thumb on top contralaterally (contralateral D:\478162668.doc Motion Contact finger Rotation of C1 on C2 Occiput-AtlasAxis flexion Semispinalis Capitus stretch (ipsilateral) Splenius capitis stretch (ipsilateral) Control fingers of head Head is laterally flexed to each side On forehead. Head is rotated away from contacts Page 27 of 107 Normal Abnormal intertransversarii ) Contact index finger on posterolateral aspect of C1 TVP and thumb on C2 spinous. g. index finger On forehead. on occiput Head is flexed. rim, tubercle h. 3rd finger on space (post of C1) i. 4th finger on C2 spinous First 25 degrees C1 TVP rotates anterior, then C2 spinous rotates to the same side C2 spinous and C1 TVP do not separates (inferior oblique ipsilaterally) Spaces between fingers increase e. thumb on occiput rim just lateral to midline f. index finger hooked around anterior aspect of C2 a. 2-3 fingers on posterior of mastoid. On forehead. Head and neck is flexed and challenged with contact Springy end feel and give e. posterior tubercle with occiput (possible rectus capitus minor) f. C2 spinous rides up with occiput (rectus capitus major) Restricted end feel, lack of flexion of occiput On forehead. Head is flexed and rotated (face away from the contact) and challenged with contact Springy end feel and give Restricted end feel, lack of flexion and rotation of occiput Special tests for nerve root irritation: 1. compression tests a. lateral cervical compression will close IVF on side of flexion. The appearance or aggravation of radicular pain, paresthesia, or numbness in the shoulder, or upper arm and in the forearm or hand may mean nerve root compression possibly due to cervical disc disease. D:\478162668.doc Page 28 of 107 b. rotational cervical compression test is positive when there is appearance or aggravation of radicular pain, paresthesia, or numbness in the shoulder or upper arm and in the forearm or hand. This may be due to cervical disc disease 2. axial manual tract test is done supine. May decrease or dissipate radicular symptoms. 3. shoulder abduction test is done in the sitting position with the patient’s hand lifted above his or head and holds it there for 30 seconds. A positive is a decrease or disappearance of radicular symptom. May be due to nerve root compression possibly due to cervical disc disease. 4. cervical doorbell test is done in the seated position. The examiner palpates the anterolateral aspect of the lower cervical spine. Maintain this mild to moderate pressure for 3 to 5 seconds. Be careful not to occlude the carotid artery. A positive sign is the reproduction or aggravation of pain in the patient’s interscapular region. May be a sign of cervicogenic dorsalgia, pressure over an irritated nerve root may cause radicular arm pain or pain in the interscapular region or hypertonic scalene muscles. D:\478162668.doc Page 29 of 107 DO THE CORE LUMBAR ORTHOPEDIC EXAMINATION AND DDX LUMBAR FACET JOINT IRRITATION FROM THORACOLUMBAR SYNDROME. TEST THE INTEGRITY OF L5 NERVE ROOT. Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg) b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: Reflex Patellar L4 L5 No reflex or medial hamstring tendon S1 Achilles Sensory Medial calf and medial side of foot Lateral leg and dorsum of foot including web of big toe (divided by crest of tibia) Lateral malleolus, lateral and plantar surfaces of foot Motor Tibialis anterior (ankle inversion) Extensor digitorum longus, extensor hallucis longus, walk on heels Peroneus longus and brevis (ankle eversion), gastrocnemius (plantar flexion), walk on toes a. plantar reflex – normally down going b. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression c. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing Forward flexion 40 – 60 degrees Extension 20-35 degrees Lateral flexion 15-20 degrees Rotation 3 – 18 degrees. Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis D:\478162668.doc Page 30 of 107 Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test – aggravates an inflamed facet joint and/or disc herniation 6. Non-organic testing a. simulation tests – axial loading, trochanteric rotation c. distraction tests – sitting SLR 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip plebe, an irritated SI or L/S facet joint – increased pain may indicate SI pain c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test – indicates sacroiliac joint irritation 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Lumbar spine Motion Contact finger Control fingers Flexion Three finger Patient is flexed contact on and returned to interspinous neutral spaces Extension Make a fist and use a thumb Extended by lifting elbows Normal Spinous processes separate. Spinous processes will Abnormal No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or interspinous ligaments No approximation. D:\478162668.doc Page 31 of 107 Motion Contact finger contact on interspinous Control fingers and returned to neutral Normal approximate Lateral flexion Hook and push contact Laterally flexed Superior spinous away from will rotate to doctor and turned concavity. to neutral Lateral flexion (spinous challenge) Thumb contact on lateral aspect of 2 adjacent spinous Laterally flexed away toward Doctor and returned to neutral Springy end feel as disc is wedge open on contralateral side Rotation Hook-push or thumb-push Rotated toward Dr. and returned to neutral. Spinous rotates away from superior finger Abnormal Extension restriction of flexion malposition. Spinous will not rotate or reverse into convexity (sacrospinalis and/or multifidus) Hard end feel, no lateral flexion: g. disc protrusion/he rniation h. hypertonic intertransvers arii QL. Spinous remains in midline and/or fails to rotate (multifidus) Special tests for lumbar facet joint from thoracolumbar syndrome 1. spinal percussion – the patient leans froward the examiner percusses each lumbar vertebrae with a reflex hammer. Localized pain may indicate a facet syndrome or possible vertebral fracture. 2. Do skin roll 3. Motion palpation 4. Pain in hip and buttock D:\478162668.doc Page 32 of 107 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND DDX CERVICAL SPRAIN VERSUS CERVICAL STRAIN. TEST THE INTEGRITY OF C6 NERVE ROOT. Core tests: 1. Observation – general, postural a. facial expression indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vertebrobasilar testing Houle positive is vertigo, dizziness, nausea, nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination C5 C7 C8 T1 C6 Motor Shoulder Wrist extension Wrist flexion Finger flexion Finger abduction and finger (curl fingers) abduction and extension adduction Sensation Lateral arm Middle finger Medial Medial arm Lateral forearm, ring forearm, and small thumb and finger index finger Reflex Biceps Brachioradialis triceps 4. Cervical ROM testing Flexion: 45 60 Extension: 45 75 Rotation: 70 90 Lateral flexion: 2045 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation. 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain. D:\478162668.doc Page 33 of 107 7. Soft tissue palpation Scalenes Suboccipitals Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower Cervical motion palpation Motion Contact hand Control hand Normal Abnormal Flexion Thumb on On patient’s Articular pillar Articular pillar articular pillar; forehead. will glide fails to go index finger Patient’s head anterior and anterior and wrapped around and neck is superior superior TVP of segment flexed and below returned to neutral. Lateral flexion Three-finger On patient’s top TVPs A break in the contact on lateral of head. Lateral approximate a ‘C’ curve may aspect of TVPs. flexes head and smooth ‘C’ curve indicate DJD in neck towards is appreciated joints of Luschka contact hand, and or possible returns to neutral scaleni/intertrans verarii hypertonicity Spinous Thumb contact On top of Spinous process Loss of spinous deviation against two patient’s head. deviates to deviation and/or adjacent Lateral flexes convexity. spinous reversal spinouses. head towards (possible contact hand and contralateral SS returns to neutral and/or splenius involvement) Anterior rotation Three-fingered Rotates face Articular pillars Restricted end contact on three away from move anterior in feel with lack of adjacent articular contact hand and a stair stepping anterior motion. pillars, control returned to motion. Possible small hand on patient’s neutral. cervical rotators forehead. Posterior rotation Patient leans On patient’s head TVPs move Restricted end back against or chin. Guides posteriorly feel to the doctor as contact face towards allowing a slight posterior motion with 2-3 fingers contact while “give” and fullness placed over contact hand under fingers or D:\478162668.doc Motion Contact hand anterior aspect of TVPs Upper Cervical motion palpation Motion Contact finger Jawjut Middle finger on anterior of C1 Rotation Middle finger on anterior of C1 TVP Lateral flexion of Middle finger on occiput on C1 superior aspect of C1 TVP Lateral flexion of Middle finger on C1 on C2 inferior aspect of C1 TVP Control hand pulls posterior and superior Control fingers j. index on ramus of mandible k. ring finger on mastoid l. thumb on top of head Patient’s head is pushed down and slightly anterior Page 34 of 107 Normal Abnormal joint (possible scalenii) Normal Abnormal Space between g. space does TVP and not open, mandible extension increases, restriction allowing a “give” (rectus capitus anterior) h. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM) j. index on Space between Space between ramus of C1 TVP and C1 and mandible mandible mandible does not increase k. ring finger on increase on (contralateral mastoid contralateral side superior l. thumb on top oblique) of head Head is rotated to each side j. index on Occiput G. Restricted ramus of approximates C1 end feel mandible TVP and H. Lack of k. ring finger on separates on lateral mastoid contralateral flexion l. thumb on top side. (contralateral of head. rectus capitus Head is laterally lateral) flexed to each side j. index on C1 TVP Restricted end ramus of approximates on feel ipsilateral mandible C2 TVP joint and a lack k. ring finger on ipsilaterally and of separation on mastoid then separates contralateral side D:\478162668.doc Motion Contact finger Rotation of C1 on C2 Occiput-AtlasAxis flexion Semispinalis Capitus stretch (ipsilateral) Splenius capitis stretch (ipsilateral) Control fingers l. thumb on top of head Head is laterally flexed to each side On forehead. Head is rotated away from contacts Page 35 of 107 Normal contralaterally Abnormal (contralateral intertransversarii ) Contact index finger on posterolateral aspect of C1 TVP and thumb on C2 spinous. j. index finger On forehead. on occiput Head is flexed. rim, tubercle k. 3rd finger on space (post of C1) l. 4th finger on C2 spinous First 25 degrees C1 TVP rotates anterior, then C2 spinous rotates to the same side C2 spinous and C1 TVP do not separates (inferior oblique ipsilaterally) Spaces between fingers increase g. thumb on occiput rim just lateral to midline h. index finger hooked around anterior aspect of C2 a. 2-3 fingers on posterior of mastoid. On forehead. Head and neck is flexed and challenged with contact Springy end feel and give g. posterior tubercle with occiput (possible rectus capitus minor) h. C2 spinous rides up with occiput (rectus capitus major) Restricted end feel, lack of flexion of occiput On forehead. Head is flexed and rotated (face away from the contact) and challenged with contact Springy end feel and give Restricted end feel, lack of flexion and rotation of occiput Special test for ddx of cervical strain versus sprain. After performing the active ranges of motion, put the cervical spine through passive ranges of motion then through resisted ranges of motion. All are done with the patient sitting. a. muscular pain (strain) – pain is elicited during resisted ROM or isometric contraction but little pain during passive ROM D:\478162668.doc Page 36 of 107 b. articular or ligamentous pain (sprain) – pain is elicited during passive ROM but little pain during isometric (resisted) contraction c. combination – pain is elicited in all types of ranges of motion. D:\478162668.doc Page 37 of 107 DO THE CORE LUMBAR ORTHOPEDIC EXAMINATION AND DDX PIRIFORMIS SYNDROME FROM SI SYNDROME. Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg) b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: a. reflex, sensory and motor testing Reflex L4 Patellar L5 No reflex or medial hamstring tendon S1 Achilles Sensory Medial calf and medial side of foot Lateral leg and dorsum of foot including web of big toe (divided by crest of tibia) Lateral malleolus, lateral and plantar surfaces of foot Motor Tibialis anterior (ankle inversion) Extensor digitorum longus, extensor hallucis longus, walk on heels Peroneus longus and brevis (ankle eversion), gastrocnemius (plantar flexion), walk on toes b. plantar reflex – normally down going c. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression d. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing Forward flexion 40 – 60 degrees Extension 20-35 degrees Lateral flexion 15-20 degrees Rotation 3 – 18 degrees. Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology D:\478162668.doc Page 38 of 107 Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test – aggravates an inflamed facet joint and/or disc herniation 6. Non-organic testing a. simulation tests – axial loading, trochanteric rotation b. distraction tests – sitting SLR while palpating pedal pulse 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip plebe, an irritated SI or L/S facet joint – increased pain may indicate SI pain c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test – indicates sacroiliac joint irritation 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Lumbar spine Motion Contact finger Control fingers Flexion Three finger Patient is flexed contact on and returned to interspinous neutral spaces Normal Spinous processes separate. Abnormal No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or interspinous ligaments D:\478162668.doc Page 39 of 107 Motion Extension Contact finger Make a fist and use a thumb contact on interspinous Control fingers Extended by lifting elbows and returned to neutral Lateral flexion Hook and push contact Laterally flexed Superior spinous away from will rotate to doctor and turned concavity. to neutral Lateral flexion (spinous challenge) Thumb contact on lateral aspect of 2 adjacent spinous Laterally flexed away toward Doctor and returned to neutral Springy end feel as disc is wedge open on contralateral side Rotation Hook-push or thumb-push Rotated toward Dr. and returned to neutral. Spinous rotates away from superior finger Control fingers Stabilizes pelvis. Patient bends forward Normal Sacrospinalis and hamstrings elongate. Relatively sacrum will slightly extend/counternu tate on the innominate Hands firmly grasp pelvis. Patient laterally bends to each side Lumbar spine laterally flexes in a smooth Ccurve with opposite thigh SI joint evaluation Motion Contact finger 1. pelvic flexion c. Index or on acetabulum middle finger under PSIS d. Thumb contact on sacral apex 2. pelvic lateral flexion a. thumbs under PSIS Normal Spinous processes will approximate Abnormal No approximation. Extension restriction of flexion malposition. Spinous will not rotate or reverse into convexity (sacrospinalis and/or multifidus) Hard end feel, no lateral flexion: i. disc protrusion/he rniation j. hypertonic intertransvers arii QL. Spinous remains in midline and/or fails to rotate (multifidus) Abnormal e. Lumbar spine will not flex (tight sacrospinalis) f. Patient will flex knees (tight hamstrings) g. Innominate fails to flex h. No counternutati on e. Limited or no pelvic shift (tight abd/add) f. Pelvic D:\478162668.doc Page 40 of 107 Motion Contact finger Control fingers Normal abduction and adduction elongation to allow a slight pelvic shift 3. ilium flexion Thumbs contact under PSIS. PSIS will move posterior and inferior 4a. iliosacral motion Thumb contact under PSIS. Other thumb contact lateral to S1 tubercle 4b. sacroiliac motion Thumb contact under PSIS. Other thumb contact lateral to S1 tubercle. 5. sacroischial motion Thumb contact on sacral apex. Other thumb contact on soft tissue over posterior ischium Doctor’s hands stabilize pelvis as patient stabilizes with hand against wall. Patient lifts leg as if climbing stairs Patient stabilizes with hand against wall. Patient lifts leg contact lateral to S1 tubercle to 90 degrees. Patient stabilizes with hand against wall. Patient lifts leg contact contralateral to S1 tubercle to 90 degrees. Patient stabilizes with hand against wall. Patient lifts leg on side of ischial contact to 90 degrees. PSIS will move posterior and inferior Sacrum moves posterior and inferior on the flexed innominate Ischium moves slightly anterior and lateral Abnormal rotation (psoas) g. PSIS elevates on opposite side (tight QL) h. Limited lumbar lateral flexion c. PSIS fails to move d. As leg lowers will see psoas shimmer c. PSIS fails to move d. PSIS and sacral base move together posterior Sacrum fails to move posterior and/or inferior c. Ischium fails to move anterior and lateral d. Sacral apex moves with ischium. SI joint syndrome a. Gaenslen’s test – Supine. Patient is supine and bring knee to chest on unaffected side. The affected limb is off the table and hyperextended by the examiner with increasing force. Pain on hyperexteded side may indicate an SI lesion D:\478162668.doc Page 41 of 107 b. Yeoman’s test – Prone. patient is prone as the examiner flexes the knee, extends the hip joint and applies pressure on ipsilateral PSIS. Increased pain may indicate an SI lesion c. Hibb’s test – Prone. The examiner flexes the patient’s leg (prone) on his thigh to 90 degrees and then moves it laterally causing internal rotation of the hip joint. Increased pain may indicate a hip joint lesion, SI lesion or piriformis spasm. d. Sciatic notch tenderness: Prone. Examiner should press with his/her thumb into the sciatic notch (2 inches lateral to mid-sacral level)-Reproduces or increases reported leg pain. Positive for nerve root tension or a trigger for piriformis. D:\478162668.doc Page 42 of 107 DO CORE LUMBAR ORTHOPEDIC EXAMINATION AND DO A FULL NEUROLOGICAL AND VASCULAR EXAMINATION OF THE LOWER LIMB. Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg) b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: Reflex Patellar L4 L5 No reflex or medial hamstring tendon S1 Achilles Sensory Medial calf and medial side of foot Lateral leg and dorsum of foot including web of big toe (divided by crest of tibia) Lateral malleolus, lateral and plantar surfaces of foot Motor Tibialis anterior (ankle inversion) Extensor digitorum longus, extensor hallucis longus, walk on heels Peroneus longus and brevis (ankle eversion), gastrocnemius (plantar flexion), walk on toes a. plantar reflex – normally down going b. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression c. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing Forward flexion 40 – 60 degrees Extension 20-35 degrees Lateral flexion 15-20 degrees Rotation 3 – 18 degrees. Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test – aggravates an inflamed facet joint and/or disc herniation D:\478162668.doc Page 43 of 107 6. Non-organic testing a. simulation tests – axial loading, trochanteric rotation b. distraction tests – sitting SLR while palpating pedal pulse 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip plebe, an irritated SI or L/S facet joint – increased pain may indicate SI pain c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test – indicates sacroiliac joint irritation 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Lumbar spine Motion Contact finger Control fingers Flexion Three finger Patient is flexed contact on and returned to interspinous neutral spaces Extension Make a fist and use a thumb contact on interspinous Extended by lifting elbows and returned to neutral Normal Spinous processes separate. Spinous processes will approximate Abnormal No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or interspinous ligaments No approximation. Extension restriction of flexion D:\478162668.doc Page 44 of 107 Motion Contact finger Control fingers Normal Lateral flexion Hook and push contact Laterally flexed Superior spinous away from will rotate to doctor and turned concavity. to neutral Lateral flexion (spinous challenge) Thumb contact on lateral aspect of 2 adjacent spinous Laterally flexed away toward Doctor and returned to neutral Springy end feel as disc is wedge open on contralateral side Rotation Hook-push or thumb-push Rotated toward Dr. and returned to neutral. Spinous rotates away from superior finger Abnormal malposition. Spinous will not rotate or reverse into convexity (sacrospinalis and/or multifidus) Hard end feel, no lateral flexion: k. disc protrusion/he rniation l. hypertonic intertransvers arii QL. Spinous remains in midline and/or fails to rotate (multifidus) Special tests for peripheral vascular: Inspect both legs from the groin and buttocks to the feet a. note size, symmetry and any swelling edema causes swelling that may obscure veins, tendons and bony prominences Measure legs at forefoot, smallest possible circumference above the ankle, the largest circumference at the calf and the midthigh a measure distance above the patella with the knee extended. Compare one side with the other. A difference >1cm just above the ankle or 2 cm difference between calves suggests edema b. venous pattern and any venous enlargement varicosities that are tortuous and dilated ask the patient to stand and inspect the saphenous system. The veins may be dilated and tortuous. c. pigmentation, rashes, scars d. color and texture of skin, color of nail beds and the distribution of hair on the lower legs, feet and toes. thin and shiny in chronic arterial insufficiency thick and brown in chronic venous insufficiency ulcers at the toes (chronic arterial insufficiency) or sides of the medial ankle (chronic venous insufficiency) e. palpation of peripheral pulses Popliteal pulse-Patient’s knee is somewhat flexed. Place the fingertips of both hands so that they just meet in the midline behind the knees and press them deeply into the popliteal fossa. Exaggerated, widened pulse aneurysm of popliteal artery. Primarily in men over 50. If absent iliac, femoral or popliteal occlusion D:\478162668.doc Page 45 of 107 e. f. g. h. Dorsalis pedis pulse-Feel the dorsum of the foot, just lateral to the extensor tendon of the great toe. A decreased or absent pulses with normal femoral and popliteal pulses suggest occlusive disease in the lower popliteal artery diabetes mellitus Posterior tibial pulse-Curve fingers behind and slightly below the medial malleolus of ankle. A sudden occlusion i.e. embolism or thrombosis pain and numbness or tingling. Limb distal to occlusion becomes cold, pale and pulseless. Palpation of Temperature – compare extremities. Note the temperature of the feet and legs with the backs of your fingers. Bilateral coldness – cold environment or anxiety. Unilateral coldness – arterial insufficiency, inadequate arterial circulation Palpation of Edema. Press firmly but gently with your thumb for at least 5 seconds in the following locations: a. over the dorsum of each foot b. behind each medial malleolus c. over the shins Look for pitting. Normally there is none. The severity of edema is graded on a 4-point scale, from slight to very marked. Right-handed congestive heart failure first appears in the feet and legs Hypoalbuminemia – edema first appears in the loose subcutaneous tissues of the eyelids Venous stasis secondary to obstruction or insufficiency – limited to the area of blockage, often on a leg or on both legs or on an arm. Palpation for Phlebitis. The affected vein may be palpated as firm and cord-like. Test using Homan’s sign. Palpate the groin just medial to the femoral pulse for tenderness of the femoral vein With the knee flexed and relaxed, palpate the calf. With your fingerpads, gently compress the calf muscles against the tibia and search for any tenderness or cords. Homan’s sign – calf pain produced by sudden dorsiflexion of the patient’s foot with the knee slightly flexed. Pain is provoked by muscular effort Phlebitis may lead to pulmonary embolism If inspection of saphenous system indicated varicosities, palpate them for any signs of thrombophlebitis Palpation of superficial inguinal nodes. Palpate both the horizontal group and vertical groups. Note their size, consistency and discreteness and note any tenderness. Nontender, discrete inguinal nodes up to 1cm or 2 cm in diameter are frequently palpable in normal people. Lymphadenopathy – enlargement of nodes with or without tenderness Special maneuvers 1. Trendelenburg test (retrograde filling). This tests venous competency. Start with patient supine. Elevate on leg to 90 degrees to empty venous blood. Occlude great saphenous vein in upper thigh by manual compression. Ask patient to stand and keep vein occluded and watch for venous filling in the leg Normally the saphenous vein fills from below taking about 35 s. Rapid filling of superficial veins while the saphenous vein is occluded indicates incompetent valves in the communicating veins. D:\478162668.doc Page 46 of 107 After the patient has stood for 20s, release the compression and look for any additional venous filling. Normally none. When both steps are normal a.k.a. negative-negative Positive-positive is abnormal Sudden additional filling of superficial veins after release of compression indicates incompetent valves in the saphenous veins. D:\478162668.doc Page 47 of 107 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND TEST FOR TOCS. TEST THE INTEGRITY OF THE T1 NERVE ROOT. Core tests: 1. Observation – general, postural a. facial expression indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vestrobrobasilar testing Houle positive is vertigo, dizziness, nausea, nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination C5 C6 C7 C8 T1 Motor Shoulder Wrist extension Wrist flexion Finger flexion Finger abduction and finger (curl fingers) abduction extension and adduction Sensation Lateral arm Lateral forearm, Middle finger Medial Medial arm thumb and index forearm, ring finger and small finger Reflex Biceps Brachioradialis triceps 4. Cervical ROM testing Flexion: 45 60 Extension: 45 75 Rotation: 70 90 Lateral flexion: 2045 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation. 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain. D:\478162668.doc Page 48 of 107 7. Soft tissue palpation Scalenes Suboccipitals Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower Cervical motion palpation Motion Contact hand Flexion Thumb on articular pillar; index finger wrapped around TVP of segment below Control hand On patient’s forehead. Patient’s head and neck is flexed and returned to neutral. On patient’s top of head. Lateral flexes head and neck towards contact hand, and returns to neutral Normal Articular pillar will glide anterior and superior Abnormal Articular pillar fails to go anterior and superior TVPs approximate a smooth ‘C’ curve is appreciated A break in the ‘C’ curve may indicate DJD in joints of Luschka or possible scaleni/intertrans verarii hypertonicity Loss of spinous deviation and/or spinous reversal (possible contralateral SS and/or splenius involvement) Restricted end feel with lack of anterior motion. Possible small cervical rotators Lateral flexion Three-finger contact on lateral aspect of TVPs. Spinous deviation Thumb contact against two adjacent spinouses. On top of patient’s head. Lateral flexes head towards contact hand and returns to neutral Spinous process deviates to convexity. Anterior rotation Three-fingered contact on three adjacent articular pillars, control hand on patient’s forehead. Patient leans back against doctor as contact with 2-3 fingers Rotates face away from contact hand and returned to neutral. Articular pillars move anterior in a stair stepping motion. On patient’s head or chin. Guides face towards contact while TVPs move posteriorly allowing a slight “give” Posterior rotation Restricted end feel to the posterior motion and fullness D:\478162668.doc Motion Contact hand placed over anterior aspect of TVPs Upper Cervical motion palpation Motion Contact finger Jawjut Middle finger on anterior of C1 Rotation Middle finger on anterior of C1 TVP Lateral flexion of Middle finger on occiput on C1 superior aspect of C1 TVP Lateral flexion of Middle finger on C1 on C2 inferior aspect of C1 TVP Control hand contact hand pulls posterior and superior Control fingers m. index on ramus of mandible n. ring finger on mastoid o. thumb on top of head Patient’s head is pushed down and slightly anterior Page 49 of 107 Normal Abnormal under fingers or joint (possible scalenii) Normal Abnormal Space between i. space does TVP and not open, mandible extension increases, restriction allowing a “give” (rectus capitus anterior) j. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM) m. index on Space between Space between ramus of C1 TVP and C1 and mandible mandible mandible does not increase n. ring finger on increase on (contralateral mastoid contralateral side superior o. thumb on top oblique) of head Head is rotated to each side m. index on Occiput I. Restricted ramus of approximates C1 end feel mandible TVP and J. Lack of n. ring finger on separates on lateral mastoid contralateral flexion o. thumb on top side. (contralateral of head. rectus capitus Head is laterally lateral) flexed to each side m. index on C1 TVP Restricted end ramus of approximates on feel ipsilateral mandible C2 TVP joint and a lack n. ring finger on ipsilaterally and of separation on D:\478162668.doc Motion Contact finger Rotation of C1 on C2 Occiput-AtlasAxis flexion Semispinalis Capitus stretch (ipsilateral) Splenius capitis stretch (ipsilateral) Control fingers mastoid o. thumb on top of head Head is laterally flexed to each side On forehead. Head is rotated away from contacts Page 50 of 107 Normal then separates contralaterally Abnormal contralateral side (contralateral intertransversarii ) Contact index finger on posterolateral aspect of C1 TVP and thumb on C2 spinous. m. index finger On forehead. on occiput Head is flexed. rim, tubercle n. 3rd finger on space (post of C1) o. 4th finger on C2 spinous First 25 degrees C1 TVP rotates anterior, then C2 spinous rotates to the same side C2 spinous and C1 TVP do not separates (inferior oblique ipsilaterally) Spaces between fingers increase i. thumb on occiput rim just lateral to midline j. index finger hooked around anterior aspect of C2 a. 2-3 fingers on posterior of mastoid. On forehead. Head and neck is flexed and challenged with contact Springy end feel and give i. posterior tubercle with occiput (possible rectus capitus minor) j. C2 spinous rides up with occiput (rectus capitus major) Restricted end feel, lack of flexion of occiput On forehead. Head is flexed and rotated (face away from the contact) and challenged with contact Springy end feel and give Restricted end feel, lack of flexion and rotation of occiput Special tests for TOS Test EAST maneuver (elevated arm stress test) Procedure Elevate arms 90 degrees in abduction externally, Positive sign Gradual increase in pain beginning in the back of Significance Most reliable test for TOCS D:\478162668.doc Test Procedure rotated position, with the shoulders and elbows braced back, similar to a military posture. The hands are opened and closed at a moderate speed for 3 minutes. Adson’s With the patient sitting, establish a radial pulse. Have the patient rotate the head and elevate the chin to the side being tested. Have them take a breath and hold it for as long as they can. Modified Adson’s requires the head turned in the opposite direction. With the patient in the sitting position, establish the radial pulse. Hyperabduct and slightly extend the arm while checking the pulse. Hold for 30 seconds. With the patient seated, establish a radial pulse. Take the patient’s shoulder posteriorly and inferiorly and have them flex their chin to their chest. Hold for 30 seconds. Hyperabduction (Wright’s) Costoclavicular (Eden’s) Page 51 of 107 Positive sign the neck and shoulders and progressing down the arm across the forearms into the hands. Paresthesias develop in the lower arm, forearm and fingers often causing the patients to be unable to complete the entire 3 minutes Decreased or absent radial pulse. Paresthesias or radiculopathy in the upper limb. Need both. Significance Decrease or absence of the radial pulse. Paresthesias in upper limb. Compression of the axillary artery by either the pectoralis minor muscle or the coracoid process Decrease or absence of the radial pulse. Paresthesia or radiculopathy in the upper extremity Compression of the neurovascular bundle in the costoclavicular space due to a decrease in the space between the clavicle and the first rib. Compression of the neurovascular bundle in the costoclavicular space by the scalenus anterior muscle or the presence of a cervical rib. D:\478162668.doc Page 52 of 107 DO THE LUMBAR ORTHOPEDIC EXAMINATION AND RULE OUT NERVE ROOT TENSION SIGNS IN THE LOWER LIMBS. TEST THE INTEGRITY OF THE S1 NERVE. Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg) b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: a. reflex, sensory and motor testing Reflex Patellar L4 L5 No reflex or medial hamstring tendon S1 Achilles Sensory Medial calf and medial side of foot Lateral leg and dorsum of foot including web of big toe (divided by crest of tibia) Lateral malleolus, lateral and plantar surfaces of foot Motor Tibialis anterior (ankle inversion) Extensor digitorum longus, extensor hallucis longus, walk on heels Peroneus longus and brevis (ankle eversion), gastrocnemius (plantar flexion), walk on toes b. plantar reflex – normally down going c. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression d. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing Forward flexion 40 – 60 degrees Extension 20-35 degrees Lateral flexion 15-20 degrees Rotation 3 – 18 degrees. Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology D:\478162668.doc Page 53 of 107 Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test – aggravates an inflamed facet joint and/or disc herniation 6. Non-organic testing a. simulation tests – axial loading, trochanteric rotation b. distraction tests – sitting SLR while palpating pedal pulse 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip plebe, an irritated SI or L/S facet joint – increased pain may indicate SI pain c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test – indicates sacroiliac joint irritation 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Lumbar spine Motion Contact finger Control fingers Flexion Three finger Patient is flexed contact on and returned to interspinous neutral spaces Normal Spinous processes separate. Abnormal No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or interspinous ligaments D:\478162668.doc Page 54 of 107 Motion Extension Contact finger Make a fist and use a thumb contact on interspinous Control fingers Extended by lifting elbows and returned to neutral Normal Spinous processes will approximate Lateral flexion Hook and push contact Laterally flexed Superior spinous away from will rotate to doctor and turned concavity. to neutral Lateral flexion (spinous challenge) Thumb contact on lateral aspect of 2 adjacent spinous Laterally flexed away toward Doctor and returned to neutral Springy end feel as disc is wedge open on contralateral side Rotation Hook-push or thumb-push Rotated toward Dr. and returned to neutral. Spinous rotates away from superior finger Abnormal No approximation. Extension restriction of flexion malposition. Spinous will not rotate or reverse into convexity (sacrospinalis and/or multifidus) Hard end feel, no lateral flexion: m. disc protrusion/he rniation n. hypertonic intertransvers arii QL. Spinous remains in midline and/or fails to rotate (multifidus) Special tests for nerve root tension signs Test Braggard’s Bowstring Femoral nerve stretch (Ely’s) Sciatic notch tenderness Procedure Supine. Examiner lowers the patient’s straight leg about 5-10 degrees from the point of pain and dorsiflexes the patient’s foot. Supine. Patient’s hip and knee are flexed but not to the point of pain. Examiner rests the patient’s leg on his shoulder and presses his thumbs into the popliteal fossa Prone. Examiner approximates the patient’s heel to his buttock. Positive Report pain Significance Disc lesion, sciatic neuritis or spinal cord tumor Pain in low back, thigh or lower limb Limited SLR is due to nerve root irritation An inability to complete this motion. Pain. Tight rectus femoris or psoas. Hip or SI lesion. Radicular symptoms from an irritated L2, L3 or L4 nerve root Prone. Examiner should press with his/her thumb into the sciatic notch (2 inches lateral to mid-sacral level) Reproduces or increases reported leg pain. Positive for nerve root tension. Trigger for piriformis. D:\478162668.doc Page 55 of 107 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND RULE OUT MENINGEAL IRRITATION. TEST THE INTEGRITY OF C7 NERVE ROOT. Core tests: 1. Observation – general, postural a. facial expression indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vestrobrobasilar testing Houle positive is vertigo, dizziness, nausea, nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination C5 C6 C8 T1 C7 Motor Shoulder Wrist extension Wrist flexion Finger flexion Finger abduction (curl fingers) abduction and and finger adduction extension Sensation Lateral arm Lateral forearm, Middle Medial Medial arm thumb and index finger forearm, ring finger and small finger Reflex Biceps Brachioradialis triceps 4. Cervical ROM testing Flexion: 45 60 Extension: 45 75 Rotation: 70 90 Lateral flexion: 2045 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation. 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain. 7. Soft tissue palpation D:\478162668.doc Page 56 of 107 Scalenes Suboccipitals Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower Cervical motion palpation Motion Contact hand Flexion Thumb on articular pillar; index finger wrapped around TVP of segment below Control hand On patient’s forehead. Patient’s head and neck is flexed and returned to neutral. On patient’s top of head. Lateral flexes head and neck towards contact hand, and returns to neutral Normal Articular pillar will glide anterior and superior Abnormal Articular pillar fails to go anterior and superior TVPs approximate a smooth ‘C’ curve is appreciated A break in the ‘C’ curve may indicate DJD in joints of Luschka or possible scaleni/intertrans verarii hypertonicity Loss of spinous deviation and/or spinous reversal (possible contralateral SS and/or splenius involvement) Restricted end feel with lack of anterior motion. Possible small cervical rotators Lateral flexion Three-finger contact on lateral aspect of TVPs. Spinous deviation Thumb contact against two adjacent spinouses. On top of patient’s head. Lateral flexes head towards contact hand and returns to neutral Spinous process deviates to convexity. Anterior rotation Three-fingered contact on three adjacent articular pillars, control hand on patient’s forehead. Patient leans back against doctor as contact with 2-3 fingers placed over Rotates face away from contact hand and returned to neutral. Articular pillars move anterior in a stair stepping motion. On patient’s head or chin. Guides face towards contact while contact hand TVPs move posteriorly allowing a slight “give” Posterior rotation Restricted end feel to the posterior motion and fullness under fingers or D:\478162668.doc Motion Contact hand anterior aspect of TVPs Upper Cervical motion palpation Motion Contact finger Jawjut Middle finger on anterior of C1 Rotation Middle finger on anterior of C1 TVP Lateral flexion of Middle finger on occiput on C1 superior aspect of C1 TVP Lateral flexion of Middle finger on C1 on C2 inferior aspect of C1 TVP Control hand pulls posterior and superior Control fingers p. index on ramus of mandible q. ring finger on mastoid r. thumb on top of head Patient’s head is pushed down and slightly anterior Page 57 of 107 Normal Abnormal joint (possible scalenii) Normal Abnormal Space between k. space does TVP and not open, mandible extension increases, restriction allowing a “give” (rectus capitus anterior) l. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM) p. index on Space between Space between ramus of C1 TVP and C1 and mandible mandible mandible does not increase q. ring finger on increase on (contralateral mastoid contralateral side superior r. thumb on top oblique) of head Head is rotated to each side p. index on Occiput K. Restricted ramus of approximates C1 end feel mandible TVP and L. Lack of q. ring finger on separates on lateral mastoid contralateral flexion r. thumb on top side. (contralateral of head. rectus capitus Head is laterally lateral) flexed to each side p. index on C1 TVP Restricted end ramus of approximates on feel ipsilateral mandible C2 TVP joint and a lack q. ring finger on ipsilaterally and of separation on mastoid then separates contralateral side D:\478162668.doc Motion Contact finger Rotation of C1 on C2 Occiput-AtlasAxis flexion Semispinalis Capitus stretch (ipsilateral) Splenius capitis stretch (ipsilateral) Control fingers r. thumb on top of head Head is laterally flexed to each side On forehead. Head is rotated away from contacts Page 58 of 107 Normal contralaterally Abnormal (contralateral intertransversarii ) Contact index finger on posterolateral aspect of C1 TVP and thumb on C2 spinous. p. index finger On forehead. on occiput Head is flexed. rim, tubercle q. 3rd finger on space (post of C1) r. 4th finger on C2 spinous First 25 degrees C1 TVP rotates anterior, then C2 spinous rotates to the same side C2 spinous and C1 TVP do not separates (inferior oblique ipsilaterally) Spaces between fingers increase k. thumb on occiput rim just lateral to midline l. index finger hooked around anterior aspect of C2 a. 2-3 fingers on posterior of mastoid. On forehead. Head and neck is flexed and challenged with contact Springy end feel and give k. posterior tubercle with occiput (possible rectus capitus minor) l. C2 spinous rides up with occiput (rectus capitus major) Restricted end feel, lack of flexion of occiput On forehead. Head is flexed and rotated (face away from the contact) and challenged with contact Springy end feel and give Special test for meningeal irritation tests Test Procedure Kernig’s a.k.a Supine with hip and Leseague knee flexed to 90 degrees. Patient Positive Inability to straighten and/or back pain Restricted end feel, lack of flexion and rotation of occiput Significance Meningeal irritation D:\478162668.doc Brudzinski’s L’Hermitte’s extends the leg being test Supine as examiner flexes the patent’s neck to the chest Sitting with legs extended on the table. Examiner passively flexes the patient’s head and hips simultaneously Neck and low back pain with involuntary flexion of the knees and hips Sharp pain or lightning bolt down the spine and into the upper or lower limb Page 59 of 107 Meningeal irritation Meningeal irritation D:\478162668.doc Page 60 of 107 DO THE CORE LUMBAR SPINE EXAMINATION AND CHECK FOR A LUMBAR DISC HERNIATION. TEST THE INTEGRITY OF SI NERVE ROOT. Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg) b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: a. reflex, sensory and motor testing Reflex Patellar L4 L5 No reflex or medial hamstring tendon S1 Achilles Sensory Medial calf and medial side of foot Lateral leg and dorsum of foot including web of big toe (divided by crest of tibia) Lateral malleolus, lateral and plantar surfaces of foot Motor Tibialis anterior (ankle inversion) Extensor digitorum longus, extensor hallucis longus, walk on heels Peroneus longus and brevis (ankle eversion), gastrocnemius (plantar flexion), walk on toes b. plantar reflex – normally down going c. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression d. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing Forward flexion 40 – 60 degrees Extension 20-35 degrees Lateral flexion 15-20 degrees Rotation 3 – 18 degrees. Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test – aggravates an inflamed facet joint and/or disc herniation D:\478162668.doc Page 61 of 107 6. Non-organic testing a. simulation tests – axial loading, trochanteric rotation b. distraction tests – sitting SLR while palpating pedal pulse 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip plebe, an irritated SI or L/S facet joint – increased pain may indicate SI pain c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test – indicates sacroiliac joint irritation 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Lumbar spine Motion Contact finger Control fingers Flexion Three finger Patient is flexed contact on and returned to interspinous neutral spaces Extension Make a fist and use a thumb contact on interspinous Extended by lifting elbows and returned to neutral Normal Spinous processes separate. Spinous processes will approximate Abnormal No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or interspinous ligaments No approximation. Extension restriction of flexion D:\478162668.doc Page 62 of 107 Motion Contact finger Control fingers Normal Lateral flexion Hook and push contact Laterally flexed Superior spinous away from will rotate to doctor and turned concavity. to neutral Lateral flexion (spinous challenge) Thumb contact on lateral aspect of 2 adjacent spinous Laterally flexed away toward Doctor and returned to neutral Springy end feel as disc is wedge open on contralateral side Rotation Hook-push or thumb-push Rotated toward Dr. and returned to neutral. Spinous rotates away from superior finger Abnormal malposition. Spinous will not rotate or reverse into convexity (sacrospinalis and/or multifidus) Hard end feel, no lateral flexion: o. disc protrusion/he rniation p. hypertonic intertransvers arii QL. Spinous remains in midline and/or fails to rotate (multifidus) Special test for disc herniation Sitting position 1. Valsalva’s test – may be due to space occupying lesion such as disc or tumor. 2. Spinal percussion – local pain indicates a facet syndrome or possible vertebral fracture. Radicular pain indicates possible disc lesion Supine position 1. SLR – radiating leg pain may indicate lumbar radiculopathy from a disc herniation. 2. Crossed SLR – contralateral leg pain may be considered positive for a lumbar disc herniation. 3. Braggard’s – pain may be due to disc lesion, sciatic neuritis or spinal cord tumor. Prone position 1. Herron-pheasants’ test. Examiner approximates both the patient’s heels to the buttocks and holds them in this position for a minute. Retest motor reflex. This position may irritate a disc bulge enough or spinal stenosis to cause alterations in a previously performed test. 2. Spinous tenderness. Pain may indicate facet joint irritation or discogenic disorder. D:\478162668.doc Page 63 of 107 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND TEST FOR CERVICAL DISC HERNIATION. TEST THE INTEGRITY OF C6 NERVE ROOT. Core tests: 1. Observation – general, postural a. facial expression indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vertebrobasilar testing Houle positive is vertigo, dizziness, nausea, nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination Grip strength weakness Dermatomal paresthesias, loss of sensation Diminished motor power (3-4 out of 5) Diminished to absent deep tendon reflexes C5 C7 C8 T1 C6 Motor Shoulder Wrist extension Wrist flexion Finger flexion Finger abduction and finger (curl fingers) abduction and extension adduction Sensation Lateral arm Middle finger Medial Medial arm Lateral forearm, ring forearm, and small thumb and finger index finger Reflex Biceps Brachioradialis triceps 4. Cervical ROM testing Flexion: 45 60 Extension: 45 75 Rotation: 70 90 Lateral flexion: 2045 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation. D:\478162668.doc Page 64 of 107 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain. positive 7. Soft tissue palpation –paraspinal muscle spasm/hypertonicity Scalenes Suboccipitals Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower Cervical motion palpation Motion Contact hand Flexion Thumb on articular pillar; index finger wrapped around TVP of segment below Control hand On patient’s forehead. Patient’s head and neck is flexed and returned to neutral. On patient’s top of head. Lateral flexes head and neck towards contact hand, and returns to neutral Normal Articular pillar will glide anterior and superior Abnormal Articular pillar fails to go anterior and superior TVPs approximate a smooth ‘C’ curve is appreciated A break in the ‘C’ curve may indicate DJD in joints of Luschka or possible scaleni/intertrans verarii hypertonicity Loss of spinous deviation and/or spinous reversal (possible contralateral SS and/or splenius involvement) Restricted end feel with lack of anterior motion. Possible small cervical rotators Lateral flexion Three-finger contact on lateral aspect of TVPs. Spinous deviation Thumb contact against two adjacent spinouses. On top of patient’s head. Lateral flexes head towards contact hand and returns to neutral Spinous process deviates to convexity. Anterior rotation Three-fingered contact on three adjacent articular pillars, control hand on patient’s forehead. Rotates face away from contact hand and returned to neutral. Articular pillars move anterior in a stair stepping motion. D:\478162668.doc Motion Posterior rotation Contact hand Patient leans back against doctor as contact with 2-3 fingers placed over anterior aspect of TVPs Upper Cervical motion palpation Motion Contact finger Jawjut Middle finger on anterior of C1 Rotation Middle finger on anterior of C1 TVP Lateral flexion of Middle finger on occiput on C1 superior aspect of C1 TVP Control hand On patient’s head or chin. Guides face towards contact while contact hand pulls posterior and superior Control fingers s. index on ramus of mandible t. ring finger on mastoid u. thumb on top of head Patient’s head is pushed down and slightly anterior Page 65 of 107 Normal TVPs move posteriorly allowing a slight “give” Abnormal Restricted end feel to the posterior motion and fullness under fingers or joint (possible scalenii) Normal Abnormal Space between m. space does TVP and not open, mandible extension increases, restriction allowing a “give” (rectus capitus anterior) n. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM) s. index on Space between Space between ramus of C1 TVP and C1 and mandible mandible mandible does not increase t. ring finger on increase on (contralateral mastoid contralateral side superior u. thumb on top oblique) of head Head is rotated to each side s. index on Occiput M. Restricted ramus of approximates C1 end feel mandible TVP and N. Lack of t. ring finger on separates on lateral mastoid contralateral flexion u. thumb on top side. (contralateral of head. rectus capitus Head is laterally lateral) flexed to each side D:\478162668.doc Motion Contact finger Lateral flexion of Middle finger on C1 on C2 inferior aspect of C1 TVP Rotation of C1 on C2 Occiput-AtlasAxis flexion Semispinalis Capitus stretch (ipsilateral) Splenius capitis stretch (ipsilateral) Control fingers s. index on ramus of mandible t. ring finger on mastoid u. thumb on top of head Head is laterally flexed to each side On forehead. Head is rotated away from contacts Page 66 of 107 Normal C1 TVP approximates on C2 TVP ipsilaterally and then separates contralaterally Abnormal Restricted end feel ipsilateral joint and a lack of separation on contralateral side (contralateral intertransversarii ) Contact index finger on posterolateral aspect of C1 TVP and thumb on C2 spinous. s. index finger On forehead. on occiput Head is flexed. rim, tubercle t. 3rd finger on space (post of C1) u. 4th finger on C2 spinous First 25 degrees C1 TVP rotates anterior, then C2 spinous rotates to the same side C2 spinous and C1 TVP do not separates (inferior oblique ipsilaterally) Spaces between fingers increase m. thumb on occiput rim just lateral to midline n. index finger hooked around anterior aspect of C2 a. 2-3 fingers on posterior of mastoid. On forehead. Head and neck is flexed and challenged with contact Springy end feel and give m. posterior tubercle with occiput (possible rectus capitus minor) n. C2 spinous rides up with occiput (rectus capitus major) Restricted end feel, lack of flexion of occiput On forehead. Head is flexed and rotated (face away from the contact) and challenged with contact Springy end feel and give Restricted end feel, lack of flexion and rotation of occiput D:\478162668.doc Special tests: Test Soto-Hall test Valsalva Naffziger’s test Procedure Supine. Passively flex the neck to the chest while applying pressure over the sternum Sitting. Sitting or supine. Examiner gently bilaterally compresses the jugular veins for approximately 10 s. patient’s face will flush Positive Localized cervical pain Increased pain in the cervical spine area Pain in the cervical spine Page 67 of 107 Significance Nonspecific. May be osseous, ligamentous, muscular, discal or space occupying lesion May be disc bulge, tumor Disc herniation D:\478162668.doc Page 68 of 107 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND RULE OUT VERTROBASILAR INSUFFICIENCY. TEST THE INTEGRITY OF C7 NERVE ROOT. Core tests: 1. Observation – general, postural a. facial expression indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vestrobrobasilar testing Houle positive is vertigo, dizziness, nausea, nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination C5 C6 C8 T1 C7 Motor Shoulder Wrist extension Wrist flexion Finger flexion Finger abduction (curl fingers) abduction and and finger adduction extension Sensation Lateral arm Lateral forearm, Middle Medial Medial arm thumb and index finger forearm, ring finger and small finger Reflex Biceps Brachioradialis triceps 4. Cervical ROM testing Flexion: 45 60 Extension: 45 75 Rotation: 70 90 Lateral flexion: 2045 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation. 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain. 7. Soft tissue palpation D:\478162668.doc Page 69 of 107 Scalenes Suboccipitals Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower Cervical motion palpation Motion Contact hand Control hand Normal Abnormal Flexion Thumb on On patient’s Articular pillar Articular pillar articular pillar; forehead. will glide fails to go index finger Patient’s head anterior and anterior and wrapped around and neck is superior superior TVP of segment flexed and below returned to neutral. Lateral flexion Three-finger On patient’s top TVPs A break in the contact on lateral of head. Lateral approximate a ‘C’ curve may aspect of TVPs. flexes head and smooth ‘C’ curve indicate DJD in neck towards is appreciated joints of Luschka contact hand, and or possible returns to neutral scaleni/intertrans verarii hypertonicity Spinous Thumb contact On top of Spinous process Loss of spinous deviation against two patient’s head. deviates to deviation and/or adjacent Lateral flexes convexity. spinous reversal spinouses. head towards (possible contact hand and contralateral SS returns to neutral and/or splenius involvement) Anterior rotation Three-fingered Rotates face Articular pillars Restricted end contact on three away from move anterior in feel with lack of adjacent articular contact hand and a stair stepping anterior motion. pillars, control returned to motion. Possible small hand on patient’s neutral. cervical rotators forehead. Posterior rotation Patient leans On patient’s head TVPs move Restricted end back against or chin. Guides posteriorly feel to the doctor as contact face towards allowing a slight posterior motion with 2-3 fingers contact while “give” and fullness placed over contact hand under fingers or anterior aspect of pulls posterior joint (possible D:\478162668.doc Motion Contact hand TVPs Upper Cervical motion palpation Motion Contact finger Jawjut Middle finger on anterior of C1 Rotation Middle finger on anterior of C1 TVP Lateral flexion of Middle finger on occiput on C1 superior aspect of C1 TVP Lateral flexion of Middle finger on C1 on C2 inferior aspect of C1 TVP Control hand and superior Control fingers v. index on ramus of mandible w. ring finger on mastoid x. thumb on top of head Patient’s head is pushed down and slightly anterior Page 70 of 107 Normal Abnormal scalenii) Normal Abnormal Space between o. space does TVP and not open, mandible extension increases, restriction allowing a “give” (rectus capitus anterior) p. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM) v. index on Space between Space between ramus of C1 TVP and C1 and mandible mandible mandible does not increase w. ring finger on increase on (contralateral mastoid contralateral side superior x. thumb on top oblique) of head Head is rotated to each side v. index on Occiput O. Restricted ramus of approximates C1 end feel mandible TVP and P. Lack of w. ring finger on separates on lateral mastoid contralateral flexion x. thumb on top side. (contralateral of head. rectus capitus Head is laterally lateral) flexed to each side v. index on C1 TVP Restricted end ramus of approximates on feel ipsilateral mandible C2 TVP joint and a lack w. ring finger on ipsilaterally and of separation on mastoid then separates contralateral side x. thumb on top contralaterally (contralateral D:\478162668.doc Motion Contact finger Rotation of C1 on C2 Occiput-AtlasAxis flexion Semispinalis Capitus stretch (ipsilateral) Splenius capitis stretch (ipsilateral) Control fingers of head Head is laterally flexed to each side On forehead. Head is rotated away from contacts Page 71 of 107 Normal Abnormal intertransversarii ) Contact index finger on posterolateral aspect of C1 TVP and thumb on C2 spinous. v. index finger On forehead. on occiput Head is flexed. rim, tubercle w. 3rd finger on space (post of C1) x. 4th finger on C2 spinous First 25 degrees C1 TVP rotates anterior, then C2 spinous rotates to the same side C2 spinous and C1 TVP do not separates (inferior oblique ipsilaterally) Spaces between fingers increase o. thumb on occiput rim just lateral to midline p. index finger hooked around anterior aspect of C2 a. 2-3 fingers on posterior of mastoid. On forehead. Head and neck is flexed and challenged with contact Springy end feel and give o. posterior tubercle with occiput (possible rectus capitus minor) p. C2 spinous rides up with occiput (rectus capitus major) Restricted end feel, lack of flexion of occiput On forehead. Head is flexed and rotated (face away from the contact) and challenged with contact Springy end feel and give Special test for vertebrobasilar insufficiency. Test Procedure Houle’s Prone with head off the table, extended and rotated for 40-60 Positive Vertigo, dizziness, nausea, nystagmus Restricted end feel, lack of flexion and rotation of occiput Significance Indicative of possible stenosis or compression of D:\478162668.doc seconds Hautant’s Auscultation of carotid arteries Blood pressure Patient questionnaire Get consent Seated with eyes closed. Arms extend outward in front of them with palms up and instruct the patient to extend and rotate their head to one side for 40 to 60 seconds Auscultate carotid arteries Take blood pressure Ask about signs and symptoms of VBI to identify risk factors Vertigo, dizziness, nausea, nystagmus and/or dropping of unilateral arm Page 72 of 107 vertebral, basilar or carotid artery Indicative of possible stenosis or compression of vertebral, basilar or carotid artery Bruits Possible occlusion Difference of 10 mmHg between the two systolic blood pressures Subclavian artery stenosis or occlusion D:\478162668.doc Page 73 of 107 DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE THORACIC SPINE AND CHECK FOR SCOLIOSIS. 1. Observations – general state of health, stature, habitus and sexual development. Observations should be made with reference to set anatomical landmarks. Observe from posterior, anterior and lateral views both in standing and sitting positions Inspect skin for any lesions (anatomical site, arrangement, type and colour): tinea vesicolour, vesicles, scales, moles, surgical scares, café au lait spots, hairy patches Note breathing rate and rhythm (normal is 8-16 breaths/minutes in an adult and up to 44 breaths, minute in an infant. Note are of complaint and be aware of possible underlying visceral disease Note any obvious or acquired deformities – pectus carinatum, pectus excavatum, barrel chest Note functional or structural scoliosis – unilateral scapular elevation in Sprengel’s/Klippel-Fiel’s deformities, increased thoracic kyphosis as in Scheuermann’s disease or ankylosing spondylitis, increased thoracic kyphosis due to thoracic vertebral body fractures (Dowager’s Hump, Gibbus deformity) 6. Neurological examination Test Procedure Deep tendon reflexes None for thoracic but do patellar and Achilles reflexes Abdominal reflex Stroke each quadrant. Upper quadrant is innervated by T7 to T10 and lower by T10 to T12 Plantar reflex Stroke bottom of foot Beevor’s sign Patient does an abdominal crunch as you look for umbilical deviation Sensation Vibration Soft touch and pinprick over T1 to T12 dermatomes Test over medial malleoli and ASIS Findings Hyperreflexia upper motor lesion Lack of reflex upper motor lesion Fanning pyramidal tract lesion Move cephalad bilateral T10 to T12 lesion Moves caudad bilateral T7 to T10 lesion Moves cephalad and laterally contralateral unilateral T10 to T12 lesion Moves caudad and laterally contralateral unilateral T7 to T10 nerve root lesion Inability lesion Upper motor neuron lesion 2. Ranges of motion – to be done active, passive, resisted Forward flexion 20 to 45 degrees Rib humping, side of deviations Extension 25 to 45 degrees > 2.5 cm decrease Lateral flexion 20 to 40 degrees Look for unwinding Rotation 35-50 degrees Done in forward flexed standing position D:\478162668.doc Page 74 of 107 Done seated to see whether there is irritation of the costovertebral joints Resisted ranges of motion are best done seated and active ranges should be repeated in the seated position to check for flexibility of scoliotic curves 3. To be done seated Test Slump test (sitting dural stretch test) T1 nerve stretch T2 nerve stretch Kemp’s test Chest expansion Passive scapular approximation test Cervical doorbell test Valsalva’s maneuver Kerning’s Brudzinki’s Procedure Patient slumps to flex spine and shoulders sag forward, the head is held erect. No symptoms – Dr. flexes head forward and applies overpressure No symptoms – leg is extended No symptoms, foot is dorsiflexed Patient abduct arm to 90 and flexes elbow to 90 with forearm pronated no symptoms. The patient then places hand behind the neck. Patient flexes arm to 90 and then adducts arm across chest while rotating head in opposite direction Patient rotates and extends upper body while Dr. applies a small amount of pressure to the ipsilateral shoulder Tape measure is placed at level of 4th intercostal space patient exhales and measured patient inhales and measured Examiner passively approximates the scapulae by lifting the shoulder up and backwards Palpate with index finger the anterolateral aspect of the lower cervical spine on one side at a time Patient bears down or blow with their lips sealed around their thumb Patient lies supine with the hip and knee flexed to 90 degrees and extend leg being tested With the patient supine, the examiner flexes the patient’s neck to their chest Findings Possible impingement of dura, spinal cord or nerve roots Ipsilateral scapular or arm pain may indicate T1 nerve root lesion or ulnar nerve lesion Ipsilateral arm pain may indicate a lesion Pain in thoracic may indicate an irritated facet joint Normal: difference of 3 to 7.5 cm. < 3cm may indicate ankylosing spondylitis Reproduction of pain in the scapular area is indicative of T1 or T2 nerve root lesion Reproduction or aggravation of mid-thoracic pain the patient’s interscapular region suggesting cervicogenic dorsalgia Increased pain in the thoracic spine area may indicate a space occupying lesion Inability to straighten the leg and/or back pain meningeal irritation Neck and low back or involuntary flexion of knees and hip meningeal irritation D:\478162668.doc Test L’hermitte’s 4. To be done supine Test SLR Procedure Patient is sitting with their legs extended on the table. Head passively flexed and hips Page 75 of 107 Findings Sharp lightning bolt down spine and into limbs meningeal irritation Beevor’s sign Findings Reproduction of thoracic spine pain may indicate a space occupying lesion of the thoracic Passively flex the neck to the chest Localized pain may indicate an while applying pressure over the osseous, ligamentous, muscular, sternum discal or space occupying lesion Dr. exerts pressure downwards Rib pain along the lateral margins over the sternum may suggest a possible rib fracture Measure distance from the ASIS to >2.5 cm differences may cause a the medial malleoli of the ankles functional scoliosis See neurological review 5. To be done prone Test Spinal percussion Procedure Percuss each spinous process Soto Hall test Sternal compression True leg length test Skin rolling Procedure Knee extended, raise patient’s leg Skin is rolled paraspinally over the thoracic spin Finding Localized pain may indicate possible fractured vertebrae. Pain may indicate ligamentous sprain, muscular strain or disc lesion Localized pain indicate muscular trigger points 7. Palpation Do superficial and deep palpation over the sternum, ribs, costal cartilage, clavicle and scapulae Do motion palpation Pain along costochondral margins may be suggestive of costochondritis D:\478162668.doc Page 76 of 107 DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR LABRAL TEARS 1. Observation a. Anteriorly Are head and neck in the midlines? No problem with the cervical spine or upper trapezius Look for step deformity over the lateral shoulder between the acromion and humeral head AC dislocation. If deformity appears with long axis traction to arm multidirectional instability leading to inferior subluxation of the GH joint a.k.a. SULCUS sign. Is the deltoid muscle round or flat? Flat anterior dislocation of GH joint or paralysis of the muscle. Look at bumps and alignment i.e. clavicle or sternum Height of shoulder. Dominant side will be lower than the non-dominant side, due to capsular and ligamentous stretching BUT the dominant side will be more muscular b. Posteriorly Note bony and soft tissue contours Winging of the scapula Sprengel’s deformity – congenitally high or undescending scapula Suprascapular fossa for tonicity of supraspinatus Infrascapular fossa for tonicity of infraspinatus and teres minor Kyphosis or scoliosis of thoracic spine Alignment of neck 2. Active movements *** do C-spine **** Range of motion Findings Motion () Forward flexion 160 to 180 Abduction 160 to 180 Lateral rotation 80 to 90 Most restricted in frozen capsular shoulder Medial rotation 60 to 100 Extension 50 to 60 Adduction 50 to 75 Horizontal adduction/abduction Circumduction Scapulohumeral rhythm is 1:2 ratio – look for shoulder hiking sign Any painful arc? 60 to 120 – rotator cuff tear; 120 to 180 – AC joint problem Is clavicle moving Apley’s scratch test: do extension/adduction/medial rotation Then do flexion/abduction/lateral rotation 3. passive movement D:\478162668.doc Page 77 of 107 Do supine with the shoulder girdle to be examined by side of table. If there are restrictions, note the end feel, muscular spasm or hypertonicity, and capsular pattern (lateral rotation/abduction, medial rotation) abduction medial and lateral rotation flexion locking test quadrant test 4. resisted isometric movements abduction – supraspinatus, (deltoid) painful arc – lesion superficial at tenoperiosteal junction pain of full passive elevation, lesion deep to tenoperiosteal junction no painful arc, no pain on full elevation – lesion at musculo-tendinous junction adduction – pectoralis major, latissimus dorsi, 2 teres to differentiate – bring arm first forwards than backward against resistance. If forward hurts, the pectoralis is at fault. If backward hurts If backward hurts, 3 other muscles – teres major (medial rotation), teres minor (lateral rotation), teres major and latissimus dorsi cannot be differentiated Weakness of adduction is found in severe cervical 7th root palsy due to weakness of latissimus dorsi muscle Lateral rotation – infraspinatus, teres minor Lateral rotation alone – infraspinatus Lateral rotation and adduction – teres minor Painful arc with infraspinatus, lesion distal and superficial fibers of tendon If lateral rotation plus infraspinatus – lesion distal and superficial fibers of tendon Medial rotation – subscapularis, pectoralis major, latissimus dorsi, teres major. The last three are adductors. If painful arc – lesion at uppermost part of tenoperiosteal junction If pain on passive adduction across front of chest, proximal aspect of tendon Resisted forward flexion – deltoid (ant fibers), pectoralis (clavicular fibres), coracobrachialis Most often coracobrachialis Resisted extension – deltoid (post fibres), 2 teres, latissimus dorsi, pectoralis major Resisted flexion and supination at the elbow – biceps brachii, brachioradialis, brachialis Pain – usually long head of biceps brachii Resisted extension at elbow – triceps, anconeus 5. Specific tests Yergason’s – bicipital tendonitis Speed’s test – bicipital tendonitis Drop arm test – tear in rotator cuff Ludington’s test – rupture of long head of biceps Empty can supraspinatus test – tear in supraspinatus Neer impingement sign – overuse injury or biceps tendon D:\478162668.doc Page 78 of 107 Hawkin’s Kennedy Impingement test – supraspinatus tendonitis Lift off sign – subscapularis 6. Anterior shoulder test a. Apprehension test: Patient is supine with arm abducted to 90 degrees. Laterally rotate patient’s shoulder slowly. A look or feeling of apprehension and resistance to further movement represents a positive test. If positive, examiner applies a posterior pressure and apprehension and pain decreases – anterior instability 7. Posterior shoulder test a. Posterior apprehension test. Patient is supine as the doctor flexes patient shoulder in sagittal plane to 90 degrees. Posterior force on patient’s elbow while adducting and medially rotating while doctor has one hand on the elbow and one to stabilize the scapula. Positive test is apprehension on patient’s face or pain production 8. Test for acromioclavicular injury a. horizontal adduction compression test: patient is seated, abduct arm to 90 degrees then horizontally adduct to full range. Pain occurs in AC joint before full adduction is reached 9. a. b. c. d. e. f. Joint play movements backward glide of the humerus forward glide of the humerus lateral distraction of the humerus backward glide of the humerus in abduction lateral distraction of the humerus in abduction scapular lift Special tests for labral tears: 1. Clunk test: patient is supine as examiner has one hand under the shoulder at humeral head. Examiner’s other hand holds humerus above the elbow. Examiner fully abducts arm over patient’s head. Examiner then pushes anteriorly with hand under humeral head and with other hand, rotates, humerus into lateral rotation. Positive – clunk or grinding indicate labrum tear 2. Compression rotation test: Patient is supine as examiner grasps arm, flexes elbow, with arm abducted to about 30 degrees. Examiner pushes or compresses humerus in glenoid by pushing up on elbow while rotating humerus medially and laterally. Stabilize acromion with medial hand. If snapping or catching sensation felt, positive for labral tests (coracohumeral) D:\478162668.doc Page 79 of 107 DO THE CORE EXMINATION OF THE KNEE AND CHECK FOR A MENISCAL TEAR Core tests Done standing 1. postural observation a. anterior: genu valgum/varum, bayonet sign, squinting patella (patella facing inward and increased femoral anteversion/tibial torsion b. lateral: genu recurvatum (hyperextended – 15 degrees) c. posterior – popliteal fossa – baker’s cysts 2. squatting – look for patellofemoral tracking problem 3. duck waddling – pain upon walking in the squatted position i.e. meniscal tear 4. Kneeling – pain may be prepatellar bursitis, patellofemoral arthralgia, meniscal/capsular 5. Gait – observe 6. Effusion – observation and palpation Done sitting 1. lateral postural observation a. knee flexed at 45 degrees – normal patella, patella baja, patella alta (camel sign), tender tibial tuberosity b. knee at 90 degrees – enlarged tibial tuberosity i.e. Osgood-Schlatter 3. Modified Helfet – extend knee from 90 degrees to 0. Normally the tibial tubercle should line up with the lateral border of the patella. If not, lateral rotation is blocked, indicating a possible meniscal or cruciate injury Done supine 1. Effusion 2. Knee ranges of motion (active and passive) Flexion – 0 to 135 degrees Extension – 0 to –15 degrees Medial rotation of tibia on the femur – 10 to 30 degrees Lateral rotation of tibia on the femur – 10 to 40 degrees 3. passive medial and lateral motion of the patella 4. joint line tenderness – with the knee in 90 degrees of flexion (foot flat on table) apply thumb pressure in the medial and lateral joint line. Joint line tenderness is highly sensitive for a meniscal tear. 5. Valgus stress – the knee is fully extended with a valgus stress applied, focussed at the knee joint. Significant pain and/or gapping at the medial knee is a positive sign for medial collateral ligament injury and/or capsular ligament injury 6. Varus stress – the knee is fully extended and a varus stress is applied, focused at the knee joint. Significant pain and/or gapping at the medial knee is a positive sign for lateral collateral ligament injury and/or capsular ligament injury (30 degrees of flexion) 7. Hyperextension test - the knee is fully extended, the foot is grasped at the heel and raise, flexing the legs at the hips. Significant hyperextension of the knees (> 15 degrees) is a positive sign for laxity of the cruciate ligaments and/or arcuate complex. Inability to fully the knee 20 to 30 degrees may indicate a loose body or meniscal tear. D:\478162668.doc Page 80 of 107 8. Bounce home test – the patient’s foot is cupped in the examiner’s hand and the patient’s knee is passively allowed to extend from full flexion. If extension is not complete or has a rubbery end feel, this is a positive sign for a possible torn meniscus, displaced meniscal flap, loose body, articular damage or torn ACL. 9. Posterior sag sign – the patient is supine with the hip flexed to 45 degrees and the knee to 90 degrees. In this position, the tibia will drop back or sag back on the femur if the posterior cruciate ligament is torn. 10. Anterior drawer test – with the hip flexed 45 degrees and the knee flexed 90 degrees, the patient’s foot is heel on the table the examiner’s body with the examiner sitting on the patient’s forefoot. The examiner’s hands are then placed around the proximal tibia and the tibia is then drawn forward on the femur. The test is positive fi the tibia moves forward on the femur, more than 0.5 cm indicating injury to the anterior cruciate ligament. 11. Posterior drawer test – same position as above except the tibia is pushed backward on the femur. The test is positive if the tibia moves backwards on the femur more than 0.5 cm, indicating injury to the posterior cruciate ligament 12. Lachman’s test – patient lies in a supine position and the examiner holds the patient’s knee between full extension and 30 degrees of flexion. The patient’s femur is stabilized with one of the examiner’s hands while the proximal aspect of the tibia is movement forward with the other hand. A positive sign is a mushy or soft end feel when the tibia is moved forward on the femur (anterior cruciate ligament). 13. McMurray’s test a. lateral rotation – the hip and knee are maximally flexed and the tibia is placed in lateral rotation. The knee is extended slowly while applying a valgus force. A click in the region of the medial joint line medial meniscus lesion. b. medial rotation – the hip and knee are maximally flexed and the tibia is placed in medial rotation. The knee is extended slowly while applying a varus force. A click in the region of the lateral joint line medial meniscus lesion. 14. Noble compression test – the patient lies in a supine position and the examiner flexes the knee to 90 degrees, accompanied by hip flexion. Pressure is then applied 1 to 2 cm proximal to the lateral femoral epicondyle with the thumb. While the pressure is maintained, the patient’s knee is passively extended. This is a positive test if at about 30 degrees of flexion, the patient complains of severe pain under the examiner’s thumb iliotibial band syndrome. Special tests: 1. Steinmann’s test – starting with the knee flexed to 90 degrees forced external rotation gives pain on the medial joint line. Conversely, internal rotation gives lateral joint pain. The test is formed with varying degrees of knee flexion. When joint line moves posteriorly with increasing degrees of flexion, it tends to distinguish meniscal pathology from injury of capsular ligaments. 2. Anderson’s medial-lateral grind test – with the patient lying supine, the examiner grasps the tibia firmly with one hand and the index finger and thumb of the opposite hand are placed over the anterior joint line. A valgus stress is applied as the knees is flexed to 45 degrees and a varus stress is applied as it is extended. This produces a circular motion and should be repeated with progressive stress. A longitudinal or flap tear of the meniscus produces a distinct grinding sensation at the joint line whereas a complex tear produces prolonged grinding (meniscus tear) D:\478162668.doc Page 81 of 107 To be done prone 1. Apley’s grind test – patient is prone, the knee is flexed 90 degrees and the joint is compressed while rotating the tibia internally and externally. Positive test is knee pain meniscal tear 2. Apley’s distraction test – the knee is flexed to 90 degrees and the patient’s thigh is then anchored to the table by the examiner’s knee. The examiner then medially and laterally rotates the tibia combined with distraction, noting any restriction or discomfort. A positive sign is pain and the lesion is probably ligamentous meniscal tear Soft tissue palpation a. quads and tendon b. VMO c. Hamstring muscles d. ITB e. Popliteus D:\478162668.doc Page 82 of 107 DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND RULE OUT PATELLOFEMORAL SYNDROMES Core tests Done standing 1. postural observation a. anterior: genu valgum/varum, bayonet sign, squinting patella (patella facing inward and increased femoral anteversion/tibial torsion b. lateral: genu recurvatum (hyperextended – 15 degrees) c. posterior – popliteal fossa – baker’s cysts 2. squatting – look for patellofemoral tracking problem 3. Kneeling – pain may be prepatellar bursitis, patellofemoral arthralgia, meniscal/capsular 4. Gait – observe 5. Effusion – observation and palpation Done sitting 1. lateral postural observation a. knee flexed at 45 degrees – normal patella, patella baja, patella alta (camel sign), tender tibial tuberosity b. knee at 90 degrees – enlarged tibial tuberosity i.e. Osgood-Schlatter 2. Modified Helfet – extend knee from 90 degrees to 0. Normally the tibial tubercle should line up with the lateral border of the patella. If not, lateral rotation is blocked, indicating a possible meniscal or cruciate injury. Done supine 1. Effusion 2. Knee ranges of motion (active and passive) Flexion – 0 to 135 degrees Extension – 0 to –15 degrees Medial rotation of tibia on the femur – 10 to 30 degrees Lateral rotation of tibia on the femur – 10 to 40 degrees 3. passive medial and lateral motion of the patella 4. joint line tenderness – with the knee in 90 degrees of flexion (foot flat on table) apply thumb pressure in the medial and lateral joint line. Joint line tenderness is highly sensitive for a meniscal tear. 5. Valgus stress – the knee is fully extended with a valgus stress applied, focussed at the knee joint. Significant pain and/or gapping at the medial knee is a positive sign for medial collateral ligament injury and/or capsular ligament injury 6. Varus stress – the knee is fully extended and a varus stress is applied, focused at the knee joint. Significant pain and/or gapping at the medial knee is a positive sign for lateral collateral ligament injury and/or capsular ligament injury (30 degrees of flexion) 7. Hyperextension test - the knee is fully extended, the foot is grasped at the heel and raise, flexing the legs at the hips. Significant hyperextension of the knees (> 15 degrees) is a positive sign for laxity of the cruciate ligaments and/or arcuate complex. Inability to fully the knee 20 to 30 degrees may indicate a loose body or meniscal tear. D:\478162668.doc Page 83 of 107 8. Posterior sag sign – the patient is supine with the hip flexed to 45 degrees and the knee to 90 degrees. In this position, the tibia will drop back or sag back on the femur if the posterior cruciate ligament is torn. 9. Anterior drawer test – with the hip flexed 45 degrees and the knee flexed 90 degrees, the patient’s foot is heel on the table the examiner’s body with the examiner sitting on the patient’s forefoot. The examiner’s hands are then placed around the proximal tibia and the tibia is then drawn forward on the femur. The test is positive fi the tibia moves forward on the femur, more than 0.5 cm indicating injury to the anterior cruciate ligament. 10. Posterior drawer test – same position as above except the tibia is pushed backward on the femur. The test is positive if the tibia moves backwards on the femur more than 0.5 cm, indicating injury to the posterior cruciate ligament 11. Lachman’s test – patient lies in a supine position and the examiner holds the patient’s knee between full extension and 30 degrees of flexion. The patient’s femur is stabilized with one of the examiner’s hands while the proximal aspect of the tibia is movement forward with the other hand. A positive sign is a mushy or soft end feel when the tibia is moved forward on the femur (anterior cruciate ligament). 12. McMurray’s test c. lateral rotation – the hip and knee are maximally flexed and the tibia is placed in lateral rotation. The knee is extended slowly while applying a valgus force. A click in the region of the medial joint line medial meniscus lesion. d. medial rotation – the hip and knee are maximally flexed and the tibia is placed in medial rotation. The knee is extended slowly while applying a varus force. A click in the region of the lateral joint line medial meniscus lesion. 13. Noble compression test – the patient lies in a supine position and the examiner flexes the knee to 90 degrees, accompanied by hip flexion. Pressure is then applied 1 to 2 cm proximal to the lateral femoral epicondyle with the thumb. While the pressure is maintained, the patient’s knee is passively extended. This is a positive test if at about 30 degrees of flexion, the patient complains of severe pain under the examiner’s thumb iliotibial band syndrome. Special tests done supine 1. Resisted knee extension – pain – retropatellar inflammation could indicate patellofemoral arthralgia 2. Compression test – with the knee in extension, the patella is compressed in the patellofemoral groove. Repeat the test with 30 degrees knee flexion. The test is positive if patellar pain is produced at both locations. It may indicate patellofemoral lesion, malalignment, and/or chondromalacia patella 3. Apprehension test – the patient’s quadriceps re relaxes and knee flexed to 30 degrees while the examiner carefully and slowly pushes the patella laterally. A positive test is when the patient contracts the quadriceps muscles to bring the patella back into line as he/she feels as if it is going to dislocate. This is a test for dislocation of the patella. 4. Clarke’s sign – the examiner presses down slightly proximal to the upper pole of the patella with the web of the hand as the patient lies relaxed with the knee extended. The patient is then asked to contract the quadriceps muscles while the examiner pushes down. If the pain causes retropatellar pain and the patient cannot hold a contraction, the test is considered positive chondromalacia patellae D:\478162668.doc Soft tissue palpation c. quads and tendon d. VMO e. Hamstring muscles f. ITB g. Popliteus Page 84 of 107 D:\478162668.doc Page 85 of 107 DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND CHECK FOR AN ACL TEAR Core tests Done standing 1. postural observation a. anterior: genu valgum/varum, bayonet sign, squinting patella (patella facing inward and increased femoral anteversion/tibial torsion b. lateral: genu recurvatum (hyperextended – 15 degrees) c. posterior – popliteal fossa – baker’s cysts 2. squatting – look for patellofemoral tracking problem 3. Gait – observe 4. Effusion – observation and palpation Done sitting 1. lateral postural observation a. knee flexed at 45 degrees – normal patella, patella baja, patella alta (camel sign), tender tibial tuberosity b. knee at 90 degrees – enlarged tibial tuberosity i.e. Osgood-Schlatter 2. Modified Helfet – extend knee from 90 degrees to 0. Normally the tibial tubercle should line up with the lateral border of the patella. If not, lateral rotation is blocked, indicating a possible meniscal or cruciate injury Done supine 1. Effusion 2. Knee ranges of motion (active and passive) Flexion – 0 to 135 degrees Extension – 0 to –15 degrees Medial rotation of tibia on the femur – 10 to 30 degrees Lateral rotation of tibia on the femur – 10 to 40 degrees 3. passive medial and lateral motion of the patella 4. joint line tenderness – with the knee in 90 degrees of flexion (foot flat on table) apply thumb pressure in the medial and lateral joint line. Joint line tenderness is highly sensitive for a meniscal tear. 5. Valgus stress – the knee is fully extended with a valgus stress applied, focussed at the knee joint. Significant pain and/or gapping at the medial knee is a positive sign for medial collateral ligament injury and/or capsular ligament injury 6. Varus stress – the knee is fully extended and a varus stress is applied, focused at the knee joint. Significant pain and/or gapping at the medial knee is a positive sign for lateral collateral ligament injury and/or capsular ligament injury (30 degrees of flexion) 7. Hyperextension test - the knee is fully extended, the foot is grasped at the heel and raise, flexing the legs at the hips. Significant hyperextension of the knees (> 15 degrees) is a positive sign for laxity of the cruciate ligaments and/or arcuate complex. Inability to fully the knee 20 to 30 degrees may indicate a loose body or meniscal tear. 8. Bounce home test – the patient’s foot is cupped in the examiner’s hand and the patient’s knee is passively allowed to extend from full flexion. If extension is not complete or has a D:\478162668.doc Page 86 of 107 rubbery end feel, this is a positive sign for a possible torn meniscus, displaced meniscal flap, loose body, articular damage or torn ACL. 9. Posterior sag sign – the patient is supine with the hip flexed to 45 degrees and the knee to 90 degrees. In this position, the tibia will drop back or sag back on the femur if the posterior cruciate ligament is torn. 10. Anterior drawer test – with the hip flexed 45 degrees and the knee flexed 90 degrees, the patient’s foot is heel on the table the examiner’s body with the examiner sitting on the patient’s forefoot. The examiner’s hands are then placed around the proximal tibia and the tibia is then drawn forward on the femur. The test is positive fi the tibia moves forward on the femur, more than 0.5 cm indicating injury to the anterior cruciate ligament. 11. Posterior drawer test – same position as above except the tibia is pushed backward on the femur. The test is positive if the tibia moves backwards on the femur more than 0.5 cm, indicating injury to the posterior cruciate ligament 12. Lachman’s test – patient lies in a supine position and the examiner holds the patient’s knee between full extension and 30 degrees of flexion. The patient’s femur is stabilized with one of the examiner’s hands while the proximal aspect of the femur is movement forward with the other hand. A positive sign is a mushy or soft end feel when the tibia is moved forward on the femur (anterior cruciate ligament). 13. McMurray’s test a. lateral rotation – the hip and knee are maximally flexed and the tibia is placed in lateral rotation. The knee is extended slowly while applying a valgus force. A click in the region of the medial joint line medial meniscus lesion. b. medial rotation – the hip and knee are maximally flexed and the tibia is placed in medial rotation. The knee is extended slowly while applying a varus force. A click in the region of the lateral joint line medial meniscus lesion. 14. Noble compression test – the patient lies in a supine position and the examiner flexes the knee to 90 degrees, accompanied by hip flexion. Pressure is then applied 1 to 2 cm proximal to the lateral femoral epicondyle with the thumb. While the pressure is maintained, the patient’s knee is passively extended. This is a positive test if at about 30 degrees of flexion, the patient complains of severe pain under the examiner’s thumb iliotibial band syndrome. Special tests done supine 1. Slocum test a. set as anterior drawer test, but the foot is first placed in 30 degrees medial rotation and the examiner draws the tibia forward. If excessive movement occurs it indicates an anterolateral rotary instability with possible injury to the anterior cruciate ligament and the lateral collateral ligament b. set as anterior drawer test, but the foot is placed in 15 degrees lateral rotation and the examiner draws the tibia forward. If excessive movement occurs it indicates an anteromedial rotary instability with possible injury to the anterior cruciate ligament and the medial collateral ligament. 2. Lateral Pivot shift maneuver – hip is flexed to 20 degrees. The examiner holds the patient’s foot with one hand while the other hand flexes the knee by placing it behind the fibula. The examiner then applies a valgus stress to the knee as it is flexed to 30 to 40 degrees and varus stress to ankle, while maintaining a medial rotation of the tibia. it is positive if the tibia D:\478162668.doc Page 87 of 107 reduces or jogs backward and the patient may feel as if it were giving way. This is for anterolateral rotary instability – anterior cruciate ligament. Soft tissue palpation a. quads and tendon b. VMO c. Hamstring muscles d. ITB e. Popliteus D:\478162668.doc Page 88 of 107 DO THE CORE ORTHOPEDIC EXAMINATION OF THE WRIST AND HAND 1. observation and palpation a. general – vasomotor changes, hypertrophy of one or more fingers, ulcerations, temperature or color changes b. palmar aspect – muscle wasting of thenar eminence (median), first dorsal interosseous muscle (C7) and hypothenar eminence (ulnar nerve) c. dorsum of hand – localized swelling, effusion and synovial thickening, Heberden’s nodes, Bouchard’s nodes, spoon shaped or clubbed fingernails 2. a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. Ranges of motion – active and passive and resisted pronation of the forearm supination of the forearm wrist abduction wrist adduction wrist flexion wrist extension finger flexion finger extension finger abduction finger adduction thumb flexion thumb extension thumb abduction thumb adduction opposition of little finger and thumb Capsular patterns Capsular pattern Distal radioulnar joint Wrist MCP and ICP Pain Full ROM with pain at the extremes of supination and pronation Equal limitation of flexion and extension Flexion more limited than extension Special orthopedic tests 1. Finkelstein’s test – the patient makes a fist with the thumb tucked inside the other fingers. The examiner stabilizes the lower forearm and with the other hand gently forces the wrist into ulnar deviation. Pain over the radial styloid process – stenosing tenosynovitis (de quervain’s disease) 2. Tinel’s sign at the wrist – the examiner taps over the median nerve at the wrist. Positive distal tingling in the thumb, index, middle and lateral half of ring finger carpal tunnel syndrome 3. Phalen’s test – the patient puts the backs of both hands together and holds the wrists in forced flexion for one minute. Positive is numbness and tingling along the median nerve distribution in the hand median nerve entrapment D:\478162668.doc Page 89 of 107 4. Froment’s sign – the patient attempts to grasp a piece of paper between the thumb and index paper. The examiner attempts to pull the paper away. Positive: the terminal phalanx of the thumb will flex because of paralysis of the adductor pollicus muscle ulnar nerve 5. Allen’s test – the patient is asked to open and close the hand several times as quickly as possible and then squeeze the hand tightly. The examiner’s thumb and index finger are placed over the radial and ulnar arteries. The patient then opens the hand while pressure is maintained over the arteries. One artery is tested by releasing the pressure over the artery to see if the hand flushes. Then the other artery is tested in a similar fashion. Positive: the hand does not flush when pressure is release reduced patency of the tested artery 6. Bunnel-Littler test – the MCP joint is held slightly extended the examiner passively moves the PIP joint into flexion, if possible. Positive: the PIP is not able to be flexed. Do dermatomes and cutaneous distribution. D:\478162668.doc Page 90 of 107 DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE FOOT AND ANKLE 1. Inspection – compare weight-bearing with non-weight-bearing. Look for: pes planus, supination/pronation, bumps, exostoses, forefoot splaying, swelling/pitting edema, toe deformities, Achilles tendon deviation, tibial varum 2. Check for muscle bulk, arches, wear pattern on shoes, hips, knees, tibia, fick angle, gait, include heel and toe walking and inner and outer border walking 3. ROM (active, passive and resisted) Dorsiflexion Plantar flexion Inversion Eversion Forefoot abduction Forefoot adduction Supination Pronation Orthopedic tests 1. anterior drawer 2. talar tilt – patient sitting, supine or side lying. Stabilize the tibia and fibular, introduce inversion to the talus. Positive: excessive motion indicates torn anterior talofibular and calcaneofibular ligaments. 3. Eversion test – same setup as talar tilt, but introduce eversion. Positive: excessive motion indicates a torn deltoid ligament. 4. Kleiger test – patient is sitting and introduce forefoot abduction. Positive test – excessive motion and indicates a torn deltoid ligament. 5. Homan’s sign – patient supine and introduced dorsiflexion of the ankle. Positive test – pain in the calf and indicates deep vein thrombophlebitis 6. Thompson test – patient prone or kneeling and squeeze the calf. Positive test is lack of plantar flexion and indicates a torn Achilles tendon 7. Forefoot neuroma – squeeze the forefoot. Positive test indicates a neuroma 8. Plantar fascia tenderness – palpate the anteroinferior portion of the calcaneous for tenderness. Pain is usually indicative of plantar fasciitis. D:\478162668.doc Page 91 of 107 DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR BICIPITAL TENDONITIS 1. a. Observation Anteriorly Are head and neck in the midlines? No problem with the cervical spine or upper trapezius Look for step deformity over the lateral shoulder between the acromion and humeral head AC dislocation. If deformity appears with long axis traction to arm multidirectional instability leading to inferior subluxation of the GH joint a.k.a. SULCUS sign. Is the deltoid muscle round or flat? Flat anterior dislocation of GH joint or paralysis of the muscle. Look at bumps and alignment i.e. clavicle or sternum Height of shoulder. Dominant side will be lower than the non-dominant side, due to capsular and ligamentous stretching BUT the dominant side will be more muscular b. Posteriorly Note bony and soft tissue contours Winging of the scapula Sprengel’s deformity – congenitally high or undescending scapula Suprascapular fossa for tonicity of supraspinatus Infrascapular fossa for tonicity of infraspinatus and teres minor Kyphosis or scoliosis of thoracic spine Alignment of neck 2. Active movements ***do C-spine*** Range of motion Motion () Forward flexion 160 to 180 Abduction 160 to 180 Lateral rotation 80 to 90 Medial rotation 60 to 100 Extension 50 to 60 Adduction 50 to 75 Horizontal adduction/abduction Circumduction Findings Most restricted in frozen capsular shoulder Scapulohumeral rhythm is 1:2 ration – look for shoulder hiking sign Any painful arc? 60 to 120 – rotator cuff tear; 120 to 180 – AC joint problem Is clavicle moving Apley’s scratch test: do extension/adduction/medial rotation Then do flexion/abduction/lateral rotation 3. passive movement D:\478162668.doc Page 92 of 107 Do supine with the shoulder girdle to be examined by side of table. If there are restrictions, note the end feel, muscular spasm or hypertonicity, and capsular pattern (lateral rotation/abduction, medial rotation) abduction medial and lateral rotation flexion locking test quadrant test 4. resisted isometric movements abduction – supraspinatus, (deltoid) painful arc – lesion superficial at tenoperiosteal junction pain of full passive elevation, lesion deep to tenoperiosteal junction no painful arc, no pain on full elevation – lesion at musculo-tendinous junction adduction – pectoralis major, latissimus dorsi, 2 teres to differentiate – bring arm first forwards than backward against resistance. If forward hurts, the pectoralis is at fault. If backward hurts If backward hurts, 3 other muscles – teres major (medial rotation), teres minor (lateral rotation), teres major and latissimus dorsi cannot be differentiated Weakness of adduction is found in severe cervical 7th root palsy due to weakness of latissimus dorsi muscle Lateral rotation – infraspinatus, teres minor Lateral rotation alone – infraspinatus Lateral rotation and adduction – teres minor Painful arc with infraspinatus, lesion distal and superficial fibers of tendon If lateral rotation plus infraspinatus – lesion distal and superficial fibers of tendon Medial rotation – subscapularis, pectoralis major, latissimus dorsi, teres major. The last three are adductors. If painful arc – lesion at uppermost part of tenoperiosteal junction If pain on passive adduction across front of chest, proximal aspect of tendon Resisted forward flexion – deltoid (ant fibers), pectoralis (clavicular fibres), coracobrachialis Most often coracobrachialis Resisted extension – deltoid (post fibres), 2 teres, latissimus dorsi, pectoralis major Resisted flexion and supination at the elbow – biceps brachii, brachioradialis, brachialis Pain – usually long head of biceps brachii Resisted extension at elbow – triceps, anconeus 5. Specific tests Yergason’s – bicipital tendonitis Speed’s test – bicipital tendonitis Drop arm test – tear in rotator cuff Ludington’s test – rupture of long head of biceps Empty can supraspinatus test – tear in supraspinatus Neer impingement sign – overuse injury or biceps tendon D:\478162668.doc Page 93 of 107 Hawkin’s Kennedy Impingement test – supraspinatus tendonitis Lift off sign – subscapularis 6. Anterior shoulder test a. Apprehension test: Patient is supine with arm abducted to 90 degrees. Laterally rotate patient’s shoulder slowly. A look or feeling of apprehension and resistance to further movement represents a positive test. If positive, examiner applies a posterior pressure and apprehension and pain decreases – anterior instability 7. Posterior shoulder test a. Posterior apprehension test. Patient is supine as the doctor flexes patient shoulder in sagittal plane to 90 degrees. Posterior force on patient’s elbow while adducting and medially rotating while doctor has one hand on the elbow and one to stabilize the scapula. Positive test is apprehension on patient’s face or pain production 8. Test for acromioclavicular injury a. horizontal adduction compression test: patient is seated, abduct arm to 90 degrees then horizontally adduct to full range. Pain occurs in AC joint before full adduction is reached 9. Joint play movements A . backward glide of the humerus b. forward glide of the humerus c. lateral distraction of the humerus d. backward glide of the humerus in abduction e. lateral distraction of the humerus in abduction f. general movement of the scapula upon thorax D:\478162668.doc Page 94 of 107 DO A CORE EXAMINATION OF THE HIP AND EXPLAIN THE DIFFERENCE BETWEEN BARLOW’S AND ORTOLANI’S TESTS. Do standing 1. Postural observation a. anterior – note any abnormality of the bony and soft tissue contours, swelling in the hip joint is difficult to detect, excessive femoral anteversion (toeing in), femoral retroversion (toeing out) b. lateral – abnormal contour of buttock, hip flexion deformity, increased lumbar lordosis (iliopsoas contracture) c. posterior – check bony and soft tissue contours, iliac crest height, PSIS 2. Trendelenburg test – pelvis on suspended side drops instead of rising. This indicates either a weak gluteus medius or an unstable hip on the weight-bearing side. 3. Gait analysis – antalgic limp, trendelenburg gait, OA (will not extend hip, no toe off) 4. Squatting – decrease flexibility Do supine 1. HIP ranges in of motion –active and passive a. flexion b. extension c. adduction d. abduction e. lateral rotation f. medial rotation 2. a. b. c. d. e. f. g. h. resisted isometric movements of the hip flexion – hip and knee are flexed at 90 degrees extension – hip is flexed minimally adduction abduction lateral rotation medial rotation knee flexion – knee is flexed at 90 degrees and hip is flexed at 45 degrees knee extension – knee is flexed at 60 degrees and hip is flexed at 30 degrees 3. True leg length – measure from ASIS to ipsilateral medial malleolus. 1 to 1.5 cm may be normal but may still cause symptoms 4. apparent leg length – measurements from umbilicus to the medial malleolus. A difference in leg length may indicate an iliopsoas 5. Thomas test – iliopsoas contracture and rectus femoris contracture D:\478162668.doc Page 95 of 107 6. Patrick’s fabere – if the test leg remains above the opposite straight leg, it may indicate a hip joint dysfunction, a sacroiliac joint dysfunction, an iliopsoas spasm or an adductor spasm. 7. Noble compression test – done supine Do side lying 1. Ober’s test – the patient is in the sidelying position with the lower leg flexed at the hip and knee for stability. The examiner then passively abducts and extends the patient’s upper leg with the knee straight. The examiner then lowers the upper limb. It is a positive sign for tensor fascia lata contracture if the test leg remains abducted and does not fall to the table. Do prone 1. Hip ranges of motion – extension (0 to 30 degrees) 2. Ely’s (femoral nerve stretch) test – the examiner passively flexes the patient’s knee while lying prone. A positive sign for rectus femoris contracture is anterior thigh pain or the patient’s ipsilateral hip will spontaneously flex. Severe anterior thigh pain upon knee flexion may be indicative of L3 nerve root irritation. The test is repeated on the other side. Orthopedic testing of the pediatric hip 1. Ortolani’s sign – with the infant supine, the thighs are grasped so that the examiner has his/her index and middle fingers over the greater trochanters. He/she then flexes the hips and with gentle traction the thighs are abducted and pressure is applied against the greater trochanters of the femur. If the examiner feels a “click”, “clunk”, or a “jerk”, the hips has reduced and is a positive test for Congenital Dislocation of the hip. 2. Barlow’s test – modification of Ortolani’s sign. Each hip is evaluated individually, while the other hand stabilizes the pelvis. The hip is taken into abduction while the examiner’s middle finger applies forward pressure behind the greater trochanter. If the femoral head slips forward into the acetabulum with click, clunk or jerk, the test is positive, indicating that the hip was dislocated. Then the examiner uses the thumb to apply pressure backward and outward on the inner thigh. If the femoral head slips out and reduces again, once the pressure is removed, it is a positive sign for an unstable hip. The hips is DISLOCATABLE, not DISLOCATED. The procedure is repeated for the other hip. 3. Galeazzi’s sign (Allis’ test) – the child lies in the supine position with the knees flexed to 90 degrees. If one knee is lower than the other it is a positive sign and may indicate a unilateral hip dislocation deformity. 4. Telescoping – the child lies supine and the examiner flexes the knee and hip to 90 degrees. The femur is pushed down into the table and then pulled up. In a normal hip little movement occurs. If a lot of relative movement occurs it is a positive sign for a possible dislocated hip. D:\478162668.doc Page 96 of 107 DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE TMJ History Inspection Facial asymmetry, mastoid, lips, cheek Hypertrophy, hypertonicity of muscles of mastication Posterior cervical muscles, accessory muscles of respiration Hands – evidence of RA Assess speech Auditory acuity Swallowing Posture Head carriage, head position, head tilt, head movement Resting position of the jaw Musculature of the head, neck, back, chest and leg Any tenderness to touch, trigger points or spasm ROM: active, passive and resisted for Cervical spine Shoulder Thoracic spine Lumbar Note: unleveling, scoliosis, kyphosis, leg length inequality Mandibular gait Opening 40 to 60 mm, three knuckle test Closing – pain or double contact Lateral deviation 5-10 mm Ratios of opening: lateral deviation –1:4 normal, 1:3 extracapsular, 1:6 intracapsular Protrusion 5 mm Retrusion 3-4 mm Palpation Joint tenderness to touch Crepitus, cracking, clicking Bruxomania Trigger points: lateral pterygoid, medial pterygoid, masseter, temporalis, SCM digastric Joint play and end feel a. distraction inferolateral at 20 degrees at rest (extraoral) and at open (intraoral) b. lateral deviation c. posterosuperior (disc, RDT) D:\478162668.doc Resisted muscle tests: Opening Masseter Temporalis Med Ptery Inf Later Ptery Digastric Sup lat Ptery Page 97 of 107 Closing Protrusion + + + + + Cervical spine exam Neurological exam Lateral deviation + + + + + + + + + Percussion general – sharply close teeth – pain periodontal disease specific – tap each tooth with a blunt instrument Vapocoolant spray test Retrusion + D:\478162668.doc Page 98 of 107 DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR POSTERIOR SHOULDER INSTABILITY 1. a. b. Observation Anteriorly Are head and neck in the midlines? No problem with the cervical spine or upper trapezius Look for step deformity over the lateral shoulder between the acromion and humeral head AC dislocation. If deformity appears with long axis traction to arm multidirectional instability leading to inferior subluxation of the GH joint a.k.a. SULCUS sign. Is the deltoid muscle round or flat? Flat anterior dislocation of GH joint or paralysis of the muscle. Look at bumps and alignment i.e. clavicle or sternum Height of shoulder. Dominant side will be lower than the non-dominant side, due to capsular and ligamentous stretching BUT the dominant side will be more muscular Posteriorly Note bony and soft tissue contours Winging of the scapula Sprengel’s deformity – congenitally high or undescending scapula Suprascapular fossa for tonicity of supraspinatus Infrascapular fossa for tonicity of infraspinatus and teres minor Kyphosis or scoliosis of thoracic spine Alignment of neck 2. Active movements *** do C-spine *** Range of motion Motion () Forward flexion 160 to 180 Abduction 160 to 180 Lateral rotation 80 to 90 Medial rotation 60 to 100 Extension 50 to 60 Adduction 50 to 75 Horizontal adduction/abduction Circumduction Findings Most restricted in frozen capsular shoulder Scapulohumeral rhythm is 1:2 ration – look for shoulder hiking sign Any painful arc? 60 to 120 – rotator cuff tear; 120 to 180 – AC joint problem Is clavicle moving Apley’s scratch test: do extension/adduction/medial rotation Then do flexion/abduction/lateral rotation 3. passive movement D:\478162668.doc Page 99 of 107 Do supine with the shoulder girdle to be examined by side of table. If there are restrictions, note the end feel, muscular spasm or hypertonicity, and capsular pattern (lateral rotation/abduction, medial rotation) abduction medial and lateral rotation flexion locking test quadrant test 4. resisted isometric movements abduction – supraspinatus, (deltoid) painful arc – lesion superficial at tenoperiosteal junction pain of full passive elevation, lesion deep to tenoperiosteal junction no painful arc, no pain on full elevation – lesion at musculo-tendinous junction adduction – pectoralis major, latissimus dorsi, 2 teres to differentiate – bring arm first forwards than backward against resistance. If forward hurts, the pectoralis is at fault. If backward hurts If backward hurts, 3 other muscles – teres major (medial rotation), teres minor (lateral rotation), teres major and latissimus dorsi cannot be differentiated Weakness of adduction is found in severe cervical 7th root palsy due to weakness of latissimus dorsi muscle Lateral rotation – infraspinatus, teres minor Lateral rotation alone – infraspinatus Lateral rotation and adduction – teres minor Painful arc with infraspinatus, lesion distal and superficial fibers of tendon If lateral rotation plus infraspinatus – lesion distal and superficial fibers of tendon Medial rotation – subscapularis, pectoralis major, latissimus dorsi, teres major. The last three are adductors. If painful arc – lesion at uppermost part of tenoperiosteal junction If pain on passive adduction across front of chest, proximal aspect of tendon Resisted forward flexion – deltoid (ant fibers), pectoralis (clavicular fibres), coracobrachialis Most often coracobrachialis Resisted extension – deltoid (post fibres), 2 teres, latissimus dorsi, pectoralis major Resisted flexion and supination at the elbow – biceps brachii, brachioradialis, brachialis Pain – usually long head of biceps brachii Resisted extension at elbow – triceps, anconeus 5. Specific tests Yergason’s – bicipital tendonitis Speed’s test – bicipital tendonitis Drop arm test – tear in rotator cuff Ludington’s test – rupture of long head of biceps Empty can supraspinatus test – tear in supraspinatus Neer impingement sign – overuse injury or biceps tendon D:\478162668.doc Page 100 of 107 Hawkin’s Kennedy Impingement test – supraspinatus tendonitis Lift off sign – subscapularis 6. Anterior shoulder test a. Apprehension test: Patient is supine with arm abducted to 90 degrees. Laterally rotate patient’s shoulder slowly. A look or feeling of apprehension and resistance to further movement represents a positive test. If positive, examiner applies a posterior pressure and apprehension and pain decreases – anterior instability 7. Posterior shoulder test a. Posterior apprehension test. Patient is supine as the doctor flexes patient shoulder in sagittal plane to 90 degrees. Posterior force on patient’s elbow while adducting and medially rotating while doctor has one hand on the elbow and one to stabilize the scapula. Positive test is apprehension on patient’s face or pain production b. load and shift test – patient sitting with arm resting on thigh. Examiner stands behind patient, stabilizes clavicle and scapula with one hand. With the other hand, examiner grasps the head of the humerus with the thumb over the posterior humeral head and fingers over anterior humeral head. The humerus is gently pushed in the glenoid fossa. The examiner then pushes the humeral pushes the humeral head anterior (anterior instability) and posterior (post instability). 25% of diameter of humeral head considered normal for anterior translation and 50% of diameter of humeral head considered normal for posterior translation. 8. Test for acromioclavicular injury a. horizontal adduction compression test: patient is seated, abduct arm to 90 degrees then horizontally adduct to full range. Pain occurs in AC joint before full adduction is reached 9. a. b. c. d. e. f. g. h. i. Joint play movements backward glide of the humerus forward glide of the humerus lateral distraction of the humerus caudal glide backward glide of the humerus in abduction lateral distraction of the humerus in abduction anteroposterior and cephalocaudal movement of the clavicle at the AC joint anteroposterior and cephalocaudal movement of the clavicle at the SC joint general movement of the scapula upon thorax D:\478162668.doc Page 101 of 107 DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE ELBOW Observation normal carrying angle 5 – 10 degrees in the male and 10 to 15 degrees swelling – general see approximately 70% of flexion; localized is olecranon bursitis normal bony and soft tissue contours – biceps tendon and contour normal functional position of the elbow Palpation can be done sitting or lying supine, palpate the following structures Anterior aspect Cubital fossa for biceps tendon and brachial artery) Coronoid process and head of radius The relevant muscles Medial aspect Medial epicondyle and common insertion of wrist flexor forearm pronator muscles (golfer’s) Medial collateral ligament Ulnar nerve Lateral aspect Lateral epicondyle and common extensor tendon (tennis) Lateral collateral ligament Annular ligament Posterior aspect Olecranon process and olecranon bursa Triceps muscle Range of motion Elbow flexion Elbow extension Supination of the forearm Pronation Wrist flexion Wrist extension Active + + + Passive + + + Resisted + + + + + + + + Special orthopedic tests 1. hyperextension/hyperflexion stress tests – the examiner tries to hyperextend/hyperflex the patient'’ elbow. Positive: pain, limited motion or excessive motion 2. valgus stress: the patient’s elbow is flexed a few degrees. With the superior hand, the examiner cups the posterior aspect of the patient’s elbow. The other hand grasps the medial aspect of the patient’s wrist. With the superior hand acting as a fulcrum, the wrist is forced laterally. Pain and or laxity at the medial side torn medial collateral ligament 3. varus stress – the patient’s elbow is flexed a few degrees. With his superior hand the examiner cups the posterior aspect of the patient’s wrist. With the superior hand acting as a fulcrum, the wrist is forced medially. Positive: pain and/or laxity at the lateral side of the elbow torn lateral collateral ligament. D:\478162668.doc Page 102 of 107 4. Cozen’s test – the patient flexes the elbow 90 degrees, pronates the forearm and extends the wrist. The examiner stabilizes the elbow (thumb placed on lateral epicondyle) with one hand and with the other applies pressure to force the wrist into flexion. The patient tries to resist. Positive: pain at the lateral epicondyle lateral epicondylitis. 5. Mill’s maneuver – the patient flexes the elbow 90 degrees, pronates the forearm, makes a fist and flexes the wrist. The examiner passively extends the elbow. Positive: pain at the lateral epicondyle lateral epicondylitis 6. Golfer’s elbow test – while the examiner palpates the patient’s medial epicondyle, the patient’s forearm is supinated and the elbow and wrist are extended by the examiner. Positive: pain at the medial epicondyle medial epicondylitis 7. Tinel’s sign – ulnar nerve is tapped. Positive: tingling sensation in the ulnar nerve distribution down the forearm and hand. Reflexes and cutaneous distribution Biceps – C5 Brachioradialis – C6 Triceps – C7 Nerve compression around elbow joint Nerve Syndrome Median nerve Pronator syndrome Anterior interosseous nerve Radial nerve Posterior interosseous nerve Ulnar nerve Compressed in cubital tunnel or between two heads of flex carp Characteristics Resisted pronation of the extended forearm stresses the pronator teres muscles Resisted elbow flexion and forearm supination stresses the laceratus fibrosus Resisted flexion of the long finger PIP joint stresses the flexor digitorum superficialis arch Pinch deformity Weakness of pronator quadratus – elbow fully flexed to eliminate pronator teres, then resist pronation Resistance to supination Long finger extension resistance test Tine’s sign Maintain full elbow flexion and pronation D:\478162668.doc Page 103 of 107 DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND RULE OUT AN ANTERIOR SHOULDER INSTABILITY 1. Observation a. Anteriorly Are head and neck in the midlines? No problem with the cervical spine or upper trapezius Look for step deformity over the lateral shoulder between the acromion and humeral head AC dislocation. If deformity appears with long axis traction to arm multidirectional instability leading to inferior subluxation of the GH joint a.k.a. SULCUS sign. Is the deltoid muscle round or flat? Flat anterior dislocation of GH joint or paralysis of the muscle. Look at bumps and alignment i.e. clavicle or sternum Height of shoulder. Dominant side will be lower than the non-dominant side, due to capsular and ligamentous stretching BUT the dominant side will be more muscular b. Posteriorly Note bony and soft tissue contours Winging of the scapula Sprengel’s deformity – congenitally high or undescending scapula Suprascapular fossa for tonicity of supraspinatus Infrascapular fossa for tonicity of infraspinatus and teres minor Kyphosis or scoliosis of thoracic spine Alignment of neck 2. Active movements *** Do C-spine*** Range of motion Motion () Forward flexion 160 to 180 Abduction 160 to 180 Lateral rotation 80 to 90 Medial rotation 60 to 100 Extension 50 to 60 Adduction 50 to 75 Horizontal adduction/abduction Circumduction Findings Most restricted in frozen capsular shoulder Scapulohumeral rhythm is 1:2 ration – look for shoulder hiking sign Any painful arc? 60 to 120 – rotator cuff tear; 120 to 180 – AC joint problem Is clavicle moving Apley’s scratch test: do extension/adduction/medial rotation Then do flexion/abduction/lateral rotation D:\478162668.doc Page 104 of 107 3. passive movement Do supine with the shoulder girdle to be examined by side of table. If there are restrictions, note the end feel, muscular spasm or hypertonicity, and capsular pattern (lateral rotation/abduction, medial rotation) abduction medial and lateral rotation flexion locking test quadrant test 4. resisted isometric movements abduction – supraspinatus, (deltoid) painful arc – lesion superficial at tenoperiosteal junction pain of full passive elevation, lesion deep to tenoperiosteal junction no painful arc, no pain on full elevation – lesion at musculo-tendinous junction adduction – pectoralis major, latissimus dorsi, 2 teres to differentiate – bring arm first forwards than backward against resistance. If forward hurts, the pectoralis is at fault. If backward hurts If backward hurts, 3 other muscles – teres major (medial rotation), teres minor (lateral rotation), teres major and latissimus dorsi cannot be differentiated Weakness of adduction is found in severe cervical 7th root palsy due to weakness of latissimus dorsi muscle Lateral rotation – infraspinatus, teres minor Lateral rotation alone – infraspinatus Lateral rotation and adduction – teres minor Painful arc with infraspinatus, lesion distal and superficial fibers of tendon If lateral rotation plus infraspinatus – lesion distal and superficial fibers of tendon Medial rotation – subscapularis, pectoralis major, latissimus dorsi, teres major. The last three are adductors. If painful arc – lesion at uppermost part of tenoperiosteal junction If pain on passive adduction across front of chest, proximal aspect of tendon Resisted forward flexion – deltoid (ant fibers), pectoralis (clavicular fibres), coracobrachialis Most often coracobrachialis Resisted extension – deltoid (post fibres), 2 teres, latissimus dorsi, pectoralis major Resisted flexion and supination at the elbow – biceps brachii, brachioradialis, brachialis Pain – usually long head of biceps brachii Resisted extension at elbow – triceps, anconeus 5. Specific tests Yergason’s – bicipital tendonitis Speed’s test – bicipital tendonitis Drop arm test – tear in rotator cuff Ludington’s test – rupture of long head of biceps Empty can supraspinatus test – tear in supraspinatus D:\478162668.doc Page 105 of 107 Neer impingement sign – overuse injury or biceps tendon Hawkin’s Kennedy Impingement test – supraspinatus tendonitis Lift off sign – subscapularis 6. Anterior shoulder test a. load and shift test: patient sitting with arm resting on thigh. Examiner stands behind patient, stabilizes clavicle and scapula with one hand. With the other hand, examiner grasps the head of the humerus with the thumb over the posterior humeral head and fingers over anterior humeral head. The humerus is gently pushed in the glenoid fossa. The examiner then pushes the humeral pushes the humeral head anterior and posterior. 25% of diameter of humeral head considered normal for anterior translation and 50% of diameter of humeral head considered normal for posterior translation. b. Apprehension test: Patient is supine with arm abducted to 90 degrees. Laterally rotate patient’s shoulder slowly. A look or feeling of apprehension and resistance to further movement represents a positive test. If positive, examiner applies a posterior pressure and apprehension and pain decreases – anterior instability c. Rowe test: patient is supine with hand behind the head. Examiner places clenched fist against posterior head of humerus and pushes while extending arm slightly. A look of apprehension is positive for anterior instability. 7. Posterior shoulder test a. Posterior apprehension test. Patient is supine as the doctor flexes patient shoulder in sagittal plane to 90 degrees. Posterior force on patient’s elbow while adducting and medially rotating while doctor has one hand on the elbow and one to stabilize the scapula. Positive test is apprehension on patient’s face or pain production 8. Test for acromioclavicular injury a. horizontal adduction compression test: patient is seated, abduct arm to 90 degrees then horizontally adduct to full range. Pain occurs in AC joint before full adduction is reached 9. a. b. c. d. e. f. g. h. i. Joint play movements backward glide of the humerus forward glide of the humerus lateral distraction of the humerus caudal glide backward glide of the humerus in abduction lateral distraction of the humerus in abduction anteroposterior and cephalocaudal movement of the clavicle at the AC joint anteroposterior and cephalocaudal movement of the clavicle at the SC joint general movement of the scapula upon thorax D:\478162668.doc Page 106 of 107 DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND RULE OUT A PLICA Core tests Done standing 1. postural observation a. anterior: genu valgum/varum, bayonet sign, squinting patella (patella facing inward and increased femoral anteversion/tibial torsion b. lateral: genu recurvatum (hyperextended – 15 degrees) c. posterior – popliteal fossa – baker’s cysts 2. squatting – look for patellofemoral tracking problem 3. Gait – observe 4. Effusion – observation and palpation Done sitting 1. lateral postural observation c. knee flexed at 45 degrees – normal patella, patella baja, patella alta (camel sign), tender tibial tuberosity d. knee at 90 degrees – enlarged tibial tuberosity i.e. Osgood-Schlatter 2. Modified Helfet – extend knee from 90 degrees to 0. Normally the tibial tubercle should line up with the lateral border of the patella. If not, lateral rotation is blocked, indicating a possible meniscal or cruciate injury Done supine 1. Effusion 2. Knee ranges of motion (active and passive) Flexion – 0 to 135 degrees Extension – 0 to –15 degrees Medial rotation of tibia on the femur – 10 to 30 degrees Lateral rotation of tibia on the femur – 10 to 40 degrees 3. passive medial and lateral motion of the patella 4. joint line tenderness – with the knee in 90 degrees of flexion (foot flat on table) apply thumb pressure in the medial and lateral joint line. Joint line tenderness is highly sensitive for a meniscal tear. 5. Valgus stress – the knee is fully extended with a valgus stress applied, focussed at the knee joint. Significant pain and/or gapping at the medial knee is a positive sign for medial collateral ligament injury and/or capsular ligament injury 6. Varus stress – the knee is fully extended and a varus stress is applied, focused at the knee joint. Significant pain and/or gapping at the medial knee is a positive sign for lateral collateral ligament injury and/or capsular ligament injury (30 degrees of flexion) 7. Hyperextension test - the knee is fully extended, the foot is grasped at the heel and raise, flexing the legs at the hips. Significant hyperextension of the knees (> 15 degrees) is a positive sign for laxity of the cruciate ligaments and/or arcuate complex. Inability to fully the knee 20 to 30 degrees may indicate a loose body or meniscal tear. 8. Bounce home test – the patient’s foot is cupped in the examiner’s hand and the patient’s knee is passively allowed to extend from full flexion. If extension is not complete or has a D:\478162668.doc Page 107 of 107 rubbery end feel, this is a positive sign for a possible torn meniscus, displaced meniscal flap, loose body, articular damage or torn ACL. 9. Posterior sag sign – the patient is supine with the hip flexed to 45 degrees and the knee to 90 degrees. In this position, the tibia will drop back or sag back on the femur if the posterior cruciate ligament is torn. 10. Anterior drawer test – with the hip flexed 45 degrees and the knee flexed 90 degrees, the patient’s foot is heel on the table the examiner’s body with the examiner sitting on the patient’s forefoot. The examiner’s hands are then placed around the proximal tibia and the tibia is then drawn forward on the femur. The test is positive fi the tibia moves forward on the femur, more than 0.5 cm indicating injury to the anterior cruciate ligament. 11. Posterior drawer test – same position as above except the tibia is pushed backward on the femur. The test is positive if the tibia moves backwards on the femur more than 0.5 cm, indicating injury to the posterior cruciate ligament 12. Lachman’s test – patient lies in a supine position and the examiner holds the patient’s knee between full extension and 30 degrees of flexion. The patient’s femur is stabilized with one of the examiner’s hands while the proximal aspect of the tibia is movement forward with the other hand. A positive sign is a mushy or soft end feel when the tibia is moved forward on the femur (anterior cruciate ligament). 13. McMurray’s test c. lateral rotation – the hip and knee are maximally flexed and the tibia is placed in lateral rotation. The knee is extended slowly while applying a valgus force. A click in the region of the medial joint line medial meniscus lesion. d. medial rotation – the hip and knee are maximally flexed and the tibia is placed in medial rotation. The knee is extended slowly while applying a varus force. A click in the region of the lateral joint line medial meniscus lesion. 14. Noble compression test – the patient lies in a supine position and the examiner flexes the knee to 90 degrees, accompanied by hip flexion. Pressure is then applied 1 to 2 cm proximal to the lateral femoral epicondyle with the thumb. While the pressure is maintained, the patient’s knee is passively extended. This is a positive test if at about 30 degrees of flexion, the patient complains of severe pain under the examiner’s thumb iliotibial band syndrome. Special tests done supine 15. Hughston plica test – patient’s knee is passively flexed and extended while palpating medially for a popping 16. Mediopatellar plica test – as the knee is flexed to 30 degrees, the patella is passively moved medially. If pain is felt, it could be a symptomatic plica Soft tissue palpation a. quads and tendon b. VMO c. Hamstring muscles d. ITB e. Popliteus
