Download muscle grading

Orthopedics II
Bozark
1 of 15
Spring 05
MUSCLE GRADING
5- Normal
4- Good
3- Fair
2- Poor
1- Trace
0- Zero
Complete range of motion against gravity with full resistance
Complete range of motion against gravity with some resistance
Complete range of motion against gravity
Complete range of motion against gravity eliminated
Evidence of slight contractility. No joint motion.
No evidence of contractility
It is not fair to only test in one area. You need to take it through the full range of motion.
Start testing at 3. Have the patient see if they can go through the full range of motion.
Then see if some resistance can be given and then apply a little more resistance and see if
the patient can complete it.
5 or 4 are acceptable.
You might need to move the patient to get them in the right position to perform the test.
If you were testing the muscle before it might be a different position for
performing the grading of the muscle.
When testing the abduction you can test the muscle in the prone position, but
when grading the muscle they have to lie on their side.
Many times you are testing for strength and symmetry (ROM).
Biceps – C5  bicep flexion
Triceps – C7 elbow extension
Wrist extension – C6
Wrist flexion – C7
Digital Extension – C7
Gripping (8) – C8
Fan/ in between fingers – T1
Deep tendon reflex (DTR) – note if there is reinforcement used, so if testing again you
can recreate the results again.
 Distract the patient while testing since sometimes people can inhibit the reflex
 Physical reinforcement can also be applied. For a patellar distraction the grip
their hands and try to pull them apart. This can also try to allow a DTR.
4+
 Very brisk, hyperactive; often indicative of disease; often associated with
clonus (rhythmic oscillations between flexion and extension)
Orthopedics II
Bozark
3+
2+
1+
0
2 of 15
Spring 05
 Brisker than average; possibly but not necessarily indicative of disease
 normal; average
 Somewhat diminished; low normal
 no response
Usually a person who is a well trained athlete will have diminished reflexes.
Coffee drinking could increase them.
Alcohol and marijuana can cause the reflexes to diminish.
Biceps tendon - C5
Brachio Radialis – C6
Triceps tendon – C7
Dermatomes
Always check the unaffected side first.
Ask the patient if they can feel the sharp or dull pain. If they can not differentiate then
you can see there is decreased in sensation.
HOMEWORK!!  Due Friday the 21st
3 different types of dermatomal maps – compare and contrast the 3 sources
You can do 1 – 4 pages of work. Also you can do written, table, or other forms of
comparing.
Tri 4 proficiency Check Sheet handed out. Dr. O’Brian to do tests. Sign up sheet with
Linda. (this is required to complete orthopedics)
Neurological Tests
C5 – deltoid
If wanting to see if the nerve root then test other muscles with C5 Innervation
When testing the bicep you use your thumb at crease at elbow. Due not stretch the bicep
because this will diminish the reflex. Hit your thumb nail with the hammer. 5 fingers
should come up with the test.
Epaulette (little shoulder) is the area with the True axillary nerve innervation
Brachio radialis is an elbow flexor.
C6 will flex the fingers and thumb
C7 will flex middle finger dermatome,
Orthopedics II
Bozark
3 of 15
Spring 05
C8 dermatome is medial forearm
T1 dermatome is medial arm, motor is interossie on fingers
Read Chapter on cervical and lumbar. In the Hoppenfeld book.
1-19-05
Talked about inclinometers. Many different kind. (inclinometer is a goniometer and a
goniometer is not always an inclinometer.
Taking Measurements
Take 3 measurements with each range and they should be within 10% of each other.
Average them and then round to the nearest 5.
Normal Values of ROM.
Cervical, Shoulder, elbow, knee, ankle, wrist
Regional Exam
 Inspection  antalgic posture, lesions of skin, asymmetry,
 Palpation  tissue tone, swelling
 ROM
o Active  what the patient can do
o Passive or over passive  you can apply a little more ROM without
pain
 Orthopedic
 Neurologic
o Sensory/motor/reflex DTR/superficial (skin (babinksi sign is testing
the plantar reflex and is called babinksi’s sign when there is abnormal
extensor) or mucosa)/pathologic
Differential Diagnosis
 consider the likely possibilities
 rule in or rule out with Examination and relevant questions in History
 Decide which Special tests may be informative
 “Clinically Indicated” if the test results will affect your treatment plan
X-ray is necessary on children sometimes when your treatment would change on the
information received from the X-ray.
Special tests
 X-ray
 Other imaging
 Lab
o Blood
o Urine
o Other (hemoccult)
 EMG, Nerve Conduction Velocity, etc.
1-21-04
Coding
Orthopedics II
Bozark
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4 of 15
Spring 05
these are located in the conditions manual
800 codes  trauma, 700  subluxation
these codes allow you to talk to the payer and other doctors
Cervical strain and sprain are the same code (however there are differences)
o Strain  muscular injury by definition
o Sprain  is a ligamentous injury
Grading
 1 (ONE)
o Simple strain/sprain – minimal disruption of adjacent fibers
o 1-10% fiber damaged
o Decreased motion due to swelling (sometimes)
o Minimal pain, splinting, minimal palpatory pain
o Trigger points, some loss of ROM (due to swelling or pain)
o Fixation & decreased joint play in spine
 2 (TWO)
o Moderate strain/sprain – partial tearing of the ligaments or muscle,
hemorrhage, marked pain & splinting
o Mechanical stimulation of nociceptors along with chemicals given off
by damage
o 11-50% fiber damage – this can add to sloppy motion (hyper mobile)
o Stretching ligaments results in pain
o Athletic injury, lifting, trauma
o Same clinical picture as above but more severe
o Discoloration will be present and can be worse when lymphatic
drainage is not present. (RICE) Rest, Ice, Compression, Elevation
o Elevation can help with discoloration
o The more immobilized the are the less the lymphatics will work
 3 (THREE)
o Severe strain/sprain – may be complete laceration
o Refer for surgical evaluation (51-100% Fiber damage)
 At 100% rupture you must referral out
 At 51- 65% it may be feasible to treat the patient
 A complete strain is not manageable either (ACL)
o Ecchymosis
o Some say that there is no pain due to no tension, but there is due to
other problems
o Marked dysfunction
o Palpate torn muscle
Tendons are more vascular that ligaments
Differential diagnosis testing (BE ABLE TO REPRODUCE THIS CHART)!!! (NMS)
Passive ROM
 STRAIN  mid to no pain except at end range (muscle stretch)
 SPRAIN  Pain – ligaments are stretched
Orthopedics II
Bozark
5 of 15
Spring 05
Active ROM
 STRAIN  painful (decreased ROM due to pain)
 SPRAIN  Painful (decreased ROM due to pain)
Isometric Contraction
 STRAIN  Pain
 SPRAIN  Mid or No Pain
STRAIN  muscle
SPRAIN  ligamentous
Inclinometers
Lumbar
Lateral Bending  Subtract the inferior from the superior one (coronal plane)
Make sure that both are in the same orientation and plane.
Flexion  support them as in belts test and watch for the hips to move.
Extension  make sure that they keep the lower body stationary and focus the
motion on the area being tested (Lumbar)
Cervical Spine
Flexion / Extension Cranium & at T1
Lateral bending
Cranium & at T1
Need ROM equipment (read intro plus ch 1&2 from hoppenfeld)
5 cervical documentations for ROM
ROM
Cervical Orthopedics Lab
 Valsalva  individual is going to hold breath and bear down. This increases
intrathecal pressure. (this will show space occupying lesion) (DO NOT
PERFORM IF KNOWN CARDIOVASCULAR DISEASE IS PRESENT)
 Spinal percussion  tap down the spinouses to try and reproduce the pain.
This helps with localizing the pain and with knowing where the subluxations
are present. (spinous can show level, interspinous level reproduction can show
CT problem / ligament sprain)
 O’Donoghue maneuver  Resisted motion (compare with passive  this
can show ligamentous problems)
 Maximal cervical compression test  involves rotation and lateral bending
and the patient is instructed only on this test
 Foraminal compression test straight down in axis and this will compress
the IVF. Do one face forward and one on each rotational side
 Jackson compression test Lateral bending trying to close joints on
concave side (BE CAREFUL WITH THIS TEST)
Orthopedics II
Bozark
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6 of 15
Spring 05
Spurlings test doctor drops hand onto his other hand that is placed on
patients head. (lateral bending with some rotation / extension)
Cervical Distraction  should relieve pain when distraction is done
Swallowing test 
Rust’s sign
Cervical Facet syndrome – usually this type of fixation will be localized and is not
dermatomal, but can be scleratomal (signs will follow spurlings test and relief will be
given in cervical distraction)
IVF – radicular symptoms, and present in compression
Ligamentous problem – signs on distraction (pain)
Tissue healing and repair
 deals with rabbit ligaments from Woo
 What is normal tissue healing?
Clinical Phases of Recovery
 Phase 1: acute inflammation
o First 72 hours
o Hematoma/inflammation
o Redness, pain, heat, swelling
o White cells, phagocytes, and later
o Fibroblasts are active at the site of injury
 Phase II: repair/ regeneration of cellular matrix
o 28-72 hours until 6 weeks
o Inflammation subsides and healing begins  caution patient since the
area may feel better even though it is not totally healed
o Organization of blood clot
o Granulation tissue and fibroblasts produce extracellular matrix
(disorganized)
o Increase in collagen concentration/elastin appears
 Phase III: remodeling / maturation
o May require 12 months or more (ins. Will normally try to take away
the patients money for care, yet they are not the one responsible)
o Vascularity and cellularity decrease
o Density of collagen increases, fibrils increase in diameter
o Tensile strength may be only 50-70% after the healing is complete
(this can set the stage for re-injury
 Phase IV: Maturation
o Woo, et al
o Rabbit MCL
o Timing details of healing are ligament and individual specific
o May be influenced by systemic and local factors
Orthopedics II
Bozark
7 of 15
Spring 05
Patient had whiplash from accident
 aka: cervical acceleration/ deceleration injury (CAD)
 CODE = 847.0, this code can be manipulated to fit a little better
 Cervical Strain (muscle)
 Cervical Sprain (ligament)
 Strain/Sprain implies injury to both, often misused
 If strain or sprain treat correctly, do not use strain/sprain freely
Picture  of accident of rear end crash
Acceleration
 Torso is thrown forward and the head cannot follow so it hyper extends
 Lap belt keeps the body from ramping (pelvis lifts up and cervical spin is then
the fulcrum
 Lumbar can also hyperextend.
 The seat is accelerating forward, this can cause the leg and knee to go
backward and the force can be thrown into the hip
Deceleration
 body forward, seat belt holds person (it may save the persons life, but it can
destroy tissue and produce injury)
 Now head is going forward due to deceleration, the seat belt holding you in,
and the extensors firing with a flexion response. Plus sometimes the seat can
help catapult the head forward again
Temperomandibular joint can be over stretched. Try extending with your mouth closed.
Then try it with your mouth open.
The symptoms are the same between the joint and cervical damage. So, make sure
you are looking for the damaged joint as this can be affected by the accident.
Make sure you evaluate all the cranial nerves too. (this takes 90 sec)
Funduscopic exam. You actually look at the nerve and tissue.
OBGYN, kidney, spleen, abdominal exam.
Terms
Active care – directed to ward returning the patient from an injury or illness to pre
clinical status
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relief care  rendered to reduce symptoms to a tolerable level and improve
function
Therapeutic care  directed to further reduce symptomatology and improve
function through correction of subluxation and its various component. This
should enable a patient to perform most normal daily activities without
frequent reoccurrences
Rehabilitative care  restoration of strength and stability
Supportive care  permanent, on going problem
Orthopedics II
Bozark
8 of 15
Spring 05
Acute – sharp, poignant, having a short and relatively severe course. Acute in this
instance is meant to designate the new condition in less than 12 months
 mild  no major joint involvement, a slight strain in back or neck with no
prior history
 Moderate  this condition usually requires rehabilitative care, but may not
require supportive care in the mil-to-moderate case.
 severe  severe, may reach maximum medical improvement (MMI),
permanent change is structure
Chronic – persisting over a long period of time, more than 12 months, reoccurring
condition
 Mild  without acute exacerbation, this condition may require little or no
intensive relief care, but will require therapeutic, rehabilitative and supportive
care
 Moderate  with acute exacerbation, this condition will require all four levels
of care
 Severe  with serious acute exacerbation, this condition requires extended
periods of all four levels of treatment
Using the orthopedic tests you can see if your treatments are making a difference. With
each level, mil to severe, a level of care will be determined for each. How long you do
each type of care whether relief, therapeutic, rehab, or supportive care. Each will be
different.
TOS  read the shoulder chapter in Evans (4 syndromes listed below)
There are several specific types of TOS
Scalene anterior syndrome
Looking at the scalene and the compression which is sometimes called the interscalene
pressure
The floor is the 1st rib. Anterior and middle scalene make the walls of the triangle
C2- C5 and T1 will be the effecting vertebrae.
There can also be clavicle involvement sometimes, so look for it.
Symptoms  C7-T1 distribution of problems and it is called a plexopathy. The chief
complaint in paresthesia which would be tingling or pain.
Subclavian artery is also involved. So this TOS is a neuro/vascular problem. In order for
the blood to move through a high velocity high pressure jet is formed. (this can blow out
the blood vessel wall and even possibly start an aneurysm. Sometimes there will be a
sound with this (a train or blowing across the top of a bottle sound), but normally there
should not be any sound unless it is coming from the heart.
It can be positional or permanent depending on the movement.
Orthopedics II
Bozark
9 of 15
Spring 05
Know the fundamentals of this for your practice. That way you can manage the area
appropriately.
BRUIT  French word for sound
Costo-clavicular compression
 Anterior weight bearing of the head and low shoulders. The patient will show
this posture
 The clavicle is very mobile and is a major role in shoulder complaint.
 Pec major, clavicular, platisma, SCM, all attach to the Clavicle Bone
 Scoliosis  this will also cause torque on the clavicle
 A broken clavicle can heal with large cartilage bundle. This could also cause
compression at some point.
TESTS
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retraction and rotation is one test
exaggerated military stance
Bringing the clavicle down
Double crush syndrome  more than one sight of compression and the clavicle is
compressing it
Pec minor/ coraco syndrome, Hyperabduction syndrome
 pec minor attaches to the coracoid process and to the 3rd-5th ribs.
 The nerves are wrapped around the artery (axillary)
 Hyper abduction will aggravate the syndrome the most
 Postural component and chief complaint always makes up the TOS syndrome
Cervical Rib
 an anomaly which is just an enlargement of the cervical TP at C7
2/2/05
Anterior Head Carriage
 Extensors are working all the time, weakness of the deep flexors.
 Use kickball and flex your neck to your chest, flexing joint by joint. Also
doing abdominal, core work in order to change the posture.
Stabilize the sternum Figure 3-62
Soto Hall – Doctor will flex head
This can show cord problems
With this watch for knee flexion
Lhermitte’s sign Figure 3-47
Passively flex head and neck  if the patient experiences sharp radiating pain or
paresthesia…this could show cord involvement
Orthopedics II
Bozark
10 of 15
Spring 05
Nattzigers Test Figure 3-52
Looking for back up of venous pressure with radicular pain…this would show pain from
space occupying lesion  do not apply bi lateral pressure on the neck (principle the same
as valsalvas
Swallowing Test Figure 3-70
Direct esophageal problems or space occupying lesion. this can also be a test for people
with normal mechanical activity
Rust’s Sign Figure 3-56 (NB TEST)
They are holding the weight of the cervical spine up because the neck is not stable…this
could happen with a diver and this could be a sign of a fractured atlas
While laying down they hold their head up is also the same sign.
Read the book by next wed. 2-9-04
Whip Lash
 make sure you are not fictitious with findings
 some victims get a lawyer so you might have to communicate the records to
other people
 Hyperflexion / hyperextension
 Know what windows might have been cracked and if their head hit it. (door
window or windshield) this could cause mild traumatic brain injury
 Inside the cranium
o The frontal bone will slam into the frontal cortex. Then the brain slams
back into the occiput. (this term is called contra coup. The head
continues the slam back in forth in the calvarium until the energy is
dissipated.
Common Symptoms of PCS (post conclusive syndrome) (40 – 60% of the time some
of these symptoms will arise.
 light headedness (top one)
 Vertigo/Dizziness (top one)
 Neck pain
 Headache
 Photophobia
 Phonophobia
 Tinnitus
 Impaired Memory
 Easy Distractibility
 Impaired Comprehension – this is hard on a
 Forgetfulness
 Impaired Logical Thought
 Difficulty with New or Abstract concepts
Orthopedics II
Bozark
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11 of 15
Spring 05
Insomnia
Irritability
Easy fatigability
Apathy
Outbursts of Anger
Mood Swings
Depression
Loss of libido
Personality change
Intolerance to alcohol – this can also be a sign of a person who has had a
stroke
These are all significant if the symptoms carry on over time
Patients who have chronic pain for any reason can sometimes come up with some of
these syndromes.
PET  positron electron transmission
 this looks at the brain to see what frequencies are going on
CMT  Chiropractic manipulative treatment
 98940  Chiropractic manipulative treatment (CMT) : spinal, one to two
regions
 98941  spinal, three to four regions
 98942  spinal, five regions
 98943  extraspinal, one or more regions
Fee Facts  this is a reference book that can be found in the library
Sensory motor and reflex testing, cervical spine, TOS, ROM (KNOW THIS FOR LAB)
FEB 22nd lab test, Feb 23rd written
2-7-05
Types of shoulder problems
Strain – muscle
Shoulder sprain – rotator cuff sprain (ligamentous)
Bursitis  zip lock bag with some oil in it w/ no air. This is kind of how the bursa work.
Since there is synovial fluid in it when synovitis occurs the fluid swells and can rupture.
Abnormal movement usually causes this. Bursitis is usually a secondary trauma.
(subdeltoid bursa and subacromial bursa  moves with humerous head and would
reproduce pain if shoulder is brought back)
Tendonitis  just means inflammation of the tendon. This can be caused by low grade
irritation. (biceps long head tendon has a transverse ligament that covers it.
4 different muscles to consider  supraspinous, infraspinous, teres minor, subscapular
Orthopedics II
Bozark
12 of 15
Spring 05
Flexion, Extension, Abduction  , Adduction  can be inhibited by breast or
abdomen, internal and external rotation  bend arm at elbow and then measure
Dawbarns sign  palpating the bursa, come inferior to acromian with pressure posterior
and rotate arm back (this should create pain)
Then abduct shoulder with palpation  this will give relief to patient
Appley’s test (scratch test)  sometimes a camera might help with showing the patient
the abnormalities. Reach behind back from above and below. (you can mark spinouses to
measure differences. There should also be no pain with this test.) – deep knee bend is the
equivalent for the lower extremity.
Yergason’s test  palpating long head of biceps tendon (palpate on anterior side of the
humerous) looking at elbow flexion and forearm supination
Speed’s test  shoulder flexion and supinator resisted (palpate long head of bicep
tendon)
Transverse Humeral ligament test  looks a lot like the shoulder ROM – internally
and externally rotate the arm…seeing if the biceps tendon is coming out of the groove
Abbott-Saunders  palpate the transverse humeral ligament (long head) abduct the
shoulder then swing it into external rotation…is the ligament staying in the groove
Ludington’s Test  procedure used for inspection and palpation of the biceps – patients
hands on head and then ask them to flex (used to see if a tendon has ruptured)
Codman’s sign or Codman’s drop arm  if the patient has a torn rotator cuff (most
common tear is supraspinatous) then the arm will not be able to stop at 90° when the
doctor lets go. This is to test the integrity of the rotator cuff and bursa involved.
Supraspinatous press test 4-65  tests for deltoid strength and supraspinatous – move
arms in anterior and externally rotate from being abducted at 90°.
120% from glenohumeral joint
60% rotation from 30% at AcromioClavicular (AC) joint and 30% at SternoClavicular
(SC) joint
Impingement syndrome – chronic / repetitive
Supra spinatous tendon and long head tendon of the biceps
Great tuberosity and acromian process
- rolling and sliding of the joint is needed
o if it can roll but not glide and the humerous stays high, then it is lacking
inferior slide (this is common too)
o pure abduction  supra spinatous, flexion  long head
Orthopedics II
Bozark
13 of 15
Spring 05
o calcific tendonitis  there is calcium there to try and reinforce the area that
has been chronically weakened (it is also radiopaque)
o Bursa is also nearby – the calcification can rupture the bursa
 Acute is smaller, Chronic is bigger calcification
Adhesive capsulitis
Passive and active motion is equal and reduced
MUA  manipulation under anesthesia
Treatment protocol  adjustment how often
Exercise protocol  all exercises should be performed vigorously at least 8 times a day.
Joint motion should be carried into painful range. (pendulum and circular swing)
Osteoporosis  make sure you are careful with this
Rotator cuff tear 
Subscapularis is torn and on the verge of tearing are the subscapularis and infraspinatous
tendons.
Ludingtons Test
Rupture of Biceps brachii  this can happen with trauma, or with tendon degeneration
It Ends up as a big lump of flesh in arm. Function is lost also
De Quervains Disease  Stenosing Tenosynovitis
Tendons that have a synovial sheath around it. And when narrowing happens the tendon
then begins to wear. In the extensor retinaculum there is inflammation
Usually cause pain in the snuff box
Finkle Steins Test checks for this
Involve abductor pollicis longus & Extenser pollicis brevis
Trigger finger  Stenosing Tenosynovitis
Proximal to the distal metacarpal hand…what happens is that the tendon cannot slide
through the retinaculum. It meets resistance
Ganglionic cyst of the wrist
Synovial hernia, a blow out form some synovial sheath. Begnin. Some people slam this
with a book to make it go away or if it gets adjusted it could be corrected
Dupuytrens contracture  palmar apenuroisis is all over grown, they do not know what
causes this.
Conditions manual 124-125pg (NB part 2)
Orthopedics II
Bozark
14 of 15
Spring 05
Finish shoulder up in lab
Shoulder dislocation
This will not require guessing in the acute situation.
Bryant’s sign 4-29
Inspection finding. We are to be looking at the axilla. The inferior portion will be more
inferior on the side of dislocation. This could also be present in a scoliotic patient.
In a patient who has it there will be a step off from the acromion process.
Calloway’s Test 4-30
Tape measure used to check to see if there is asymmetry. An increased measurement
could be from swelling. Atrophy can cause decreased measurement.
Hamiltons test 4-46
Straight edge and go from lat. Epicondyl and touch the acromion process then the
humerus has shifted
Dugas Test 4-40
Patient places the hand on opposite shoulder. Then have patient bring elbow down to
chest wall. This could not happen if a dislocation was present.
Mazion Shoulder Maneuver 4-53
Hand on chest of opposite shoulder. Then lift the shoulder up. From chest up across
brow. This is a test would increase pain if present.
Apprehension test 4-25
Used for the old dislocation to see how intact the shoulder is and to see what type of
reaction the patient will have. This should illicit a pain or fear response. You need to be
able to see the facial response of fear. There are really three tests, Anterior, posterior, and
another.
House maids knee  the knee blows out and is swollen. Pre-patellar bursitis
Olecranon bursitis  students elbow
Ischial bursitis  deep pain and tenderness over ischial tuberosity
Acillobursitis
VBAI  RED BOOK pg 37 MEMORIZE THIS
5Ds and 3Ns ataxia also exists
1. Dizziness – know this from vascular and neurology etiology. Different things cause
you to be dizzy.
2. Drop Attacks – loss of consciousness (syncope). Could be due to drop in blood
pressure.
3. Diplopia – vision problems /
4. Dysarthria – speech problems
Orthopedics II
Bozark
15 of 15
Spring 05
5. Dysphasia
6. Ataxia of gait
7. Nausea – possible vomiting
8. Numbness
9. Nystagmus
(Transient ischemic attack) TIA  short term ischemic attack to the brain
Stroke  permanent neurological damage (brain cells destroyed). Typically when these
happen there is no recognizable cause or event that set the causes for the stroke.
A common site is between C1 and C2 area. Rotational stretching is the main ideology. C2
and C3 is another common area too.
Vascular accidents with cause  childbirth, anesthesia, yoga, hanging up laundry,
backing car up, dental work, amusement rides, break dancing, swimming, beauty parlor,
football, intercourse, tai chi, star gazing, sleeping position.
Intimal tearing of the arteries can cause the damage that could create a stroke condition.
Thrombus can cause additional problems if things build up. Then if it breaks loose it
becomes an embolism.
Dissecting aneurysm is when the blood starts filling up into the vascular tissue
Infarct stroke
Wallenburg syndrome  1895. the vessel most commonly associated PICA (posterior
inferior cerebellar artery)
Lockdens syndrome  middle portion of basilar artery (persistive vegetative State)
In your history look for(smoking, oral contraceptives,
Heart disease is not the number one cause of death now in country. It is number one in
heart problems though.
Warfarin  used ion heart problems