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Back Pain
A. History
I. Chief Complaint
a. Onset
b. Duration
c. Location
d. Radiation
e. Intensity
f. Character
g. Time of day
h. Aggravating factors
i. Alleviating factors
j. Associated Symptoms
i. Loss of sensation, pins and needles sensation
ii. Weakness of legs
iii. Urinary/fecal incontinence
iv. Sexual dysfunction
v. Fever
vi. Weight loss
k. Any recent trauma/ lifting?
l. Did this happen in the past?
m. How has the back pain affected your work, social life?
II. Past medical Hx
a. Previous surgeries: back surgery
b. Diagnosis of cancer
c. Hemoptysis
d. Have you examined your breast recently, mammogram?
e. Previous trauma
f. Previous fractures (especially if menopausal)
g. TB
h. Immunosuppresion
III. Medications
i. HRT
ii. Steroids (prone to fracture)
iii. Calcium supplements
IV. Family Hx
RA, AS, SLE
B. Physical Examination
A. Gait
- observe the patient walking
B. Inspection
- Observe from behind and from each side
- Cervical and lumbar lordotic curvatures are intact
- no obvious lateral curvature of the spine
C. Palpation
- Can you point to me where you feel pain.
- I am going to touch your spine, tell me if you feel any pain
1. each vertebral body from cervical to lumbar with the index finger of the right hand
2. sacro-iliac joint with the thumbs of both hands
3. paraspinal muscle spasm from cervical to lumbar with the thumbs of both hands
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D. Movement
1. Cervical
i. (flexion) Touch your chest with your chin
ii. (extension) Look upwards
iii. (lateral flexion) Bend your neck sideways by touching your shoulder with your ear
iv. (rotation) Turn your head by looking over each shoulder
2. Thoracic
- with your arms folded over your chest, can you move your trunk sideways
3. Lumbar
i. (forward flexion) with your knees straight can you lean forward and try touching
your toes
ii. (extension) while supporting the patient's waist: can you lean backwards
iii. (lateral flexion) with your hands on the sides can you bend sideways as far as you
can.
iv. ( lateral rotation) can you turn your trunk sideways
E. Neurological Examination
1. Motor
i.
toe walk tests calf muscles and mostly S1 nerve root
ii.
heel walk tests ankle and toe dorsiflexors, mostly L5
iii.
squat and rise test quadriceps, mostly L4 nerve root
2.. Sensory
-pinprick to check dermatomes
3. DTR's
i. L4 - inversion of foot
knee reflex
sensory to medial aspect of leg
ii. L5 - dorsiflexion of foot
sensory of dorsum of foot
iii. S1 - eversion of foot
ankle reflex'
sensory to lateral aspect foot
4. Calf and Thigh Circumference
- to detect muscle atrophy (significant if > 2cm difference)
F. Special Tests
1. Schober's test (to quantify lumbar flexion; seen in AS)
- right above the anal cleft is joint bet lumbar and sacral vertebra -> mark with a pen ->
measure 10 cm above -> ask pt to bend forward as far as possible -> if less than 15 cm ->
positive Schober's test
2. Chest Expansion
- measure chest diameter at the level of the nipples -> ask pt to inhale all the way in and all the
way out -> a difference of greater than 5 cm is normal while less than 3 cm shows limitation
( AS)
3. Straight Leg Raising
- positive if pain on the involved side and reproduces pain on dorsiflexion of the foot
positive if back pain (radicular pain bet 30-60 degrees) on the involved side induced by straight leg
raising the non-involved leg.
G. Other Tests
a.
b.
Examine abdomen (for masses or bruits)
Asses legs for vascular insufficiency
i. Loss of hair and color changes
ii. Temperature and tenderness
iii. Femoral, popliteal and pedal pulses
c. Pelvic and rectal exam
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Joint pain
Chief Complaint
I. Joint pains
Onset
Course (intermittent, gradual progression with acute exacerbation)
Duration
Character
Location/ radiation (symmetrical, polyarthritic)
Aggravating (Is pain worse with rest or movement?)
alleviating factors
Severity
Associated swelling?
Morning stiffness?
Heat?
Weakness?
Locking, instability?
II. Associated symptoms
General fatigue
Weight loss
Trauma
Sleep disturbance
Skin
Rash
Location
Shape
Onset, duration
Aggravating factors (photosensitivity)
Eyes
Red eyes/ eye discharge
Blurring of vision/ loss of vision
Cardio Chest pains
Pulmo DOB
Recurrent infection, throat infection
Gastro Oral ulcers
Abdominal pain
Difficulty swallowing
Black tarry stools
Neuro
Weakness
Numbness
Fecal/urinary incontinence
Renal blood in urine
Dysuria/urethral discharge
Hema Fatigue
Increased bleeding tendencies
Other infectious sources
Fever
III. Is pain bad enough that it interferes with your daily activities such as
DEATH
Dressing, Eating, Ambulation, Toileting, Hygiene
IV.
Past Medical
Sexual hx, Allergies, Gout, Syphilis, Ca, DM, HTN, Previous fractures, Depression,
Chron’s Disease
V.
Medication
Steroids, NSAIDs
VI.
Social
Occupation
Smoking, alcohol, IV drug abuse
DDx
SLE< RA< OA<Gout, Septic Arthritis, Rheumatic Fever
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Labs
CBC, BUN, Creatinine
ESR, C3, C4, Albumin
Serum complement, ANA, Anti-dsDNA, anti –Sm (SLE)
RF (RA)
EMG, CPK, muscle biopsy (DMY, PMY)
Synovial fluid analysis
x-ray
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Chronic Pain
Chief Complaint
Onset
Progression
Character ( associated tenderness, swelling, warmth, stiffness)
What is new about the pain?
Severity
Location
Aggravating/alleviating factors
Associated factors:
Fatigue
Depression
Fever
Weight loss
Recent trauma
Headache
Diarrhea
Lack of concentration
Past Medical Hx
Cancers
Thyroid dis
Sugical procedures
Family Hx
Social Hx
Smoking, alcohol
How has the pain affected your family, work, school and activities of daily living
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Unilateral Knee pain and swelling with fever
Chief complaint
Onset
Progress
Severity
Aggravating/alleviating factors
Associated symptoms:
Fever
Skin changes
STD’s
Lung involvement
GU involvement
Skin rashes
Previous similar problem
Recent trauma to the knee?
Past Medical Hx
DM, RA, gout
Steroid use
Social Hx
IV drug abuse
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Shoulder Pain
History
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What is your usual activity?
Did you notice how it first started?
What were you doing when pain started?
Have you ever had a problem with your shoulders before?
Since you started having problems with your shoulder did you notice if it is getting worse, better or the
same?
Can you point with one finger where it hurts?
Can you tell me what you do that makes that triggers the pain or make it worse?
How would you describe the discomfort that you have?
Does your shoulder feel loose or unstable?
What treatments have you received for the shoulder?
When you finish the activity that initially caused the pain how long after does the pain last?
Are you able to lie on your right shoulder?
Does the pain wake you up at night?
Did you have an x ray done?
How do your shoulders feel in the morning?
Do you feel any pins and needles?
What do you feel is the biggest problem with your shoulders?
ROS that could cause referred pain to the shoulders? (cardiovascular, respiratory, gastrointestinal)
How has the shoulder pain affected your activities?
I have asked you a lot of questions, Is there anything that you want to mention that we haven’t
Talked about?
Physical Examination
A. Inspection
- examine from the front, back and sides and compare with the other side (do so in each step of the
exam)
- examine (SEADS): swelling, erythema, atrophy of muscles, deformity and skin changes
B. Palpation
i. sternoclavicular jt,
ii. acromioclavicular jt,
iii. anterior, lateral and posterior compartments of glenohumeral jt
iv. temp of shoulder
v. crepitus (one hand overlies shoulder while other moves the shoulder along a rotatory mvmnt)
C. Movement
1. Active
Can you follow what I am doing and tell if you feel any pain
- flexion, extension, adduction, abduction, external rotation, and internal rotation
(with the thumb pressing on the apex of the scapula, support the scapula when px is abducting the
arm;glenohumeral jt is involved in the first 90 degrees; after 90 degrees both the glenohumeral jt
and scapulothoracic jts are involved)
2. Passive
This time just relax and let me all the work through the different movements.
D. Neurological
1. Motor
i. push out (abduction -C5)
ii. push in (adduction - C5,C6,C7)
iii. push forward (flexion - C5,C6)
iv. push backwards (extension -C7)
2. Sensory
-pinprick on the lateral aspect of deltoid (C5)
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3. DTR's
-none
E. Assess for Arterial Blood Flow
1. color, warmth and nailbed capillary refill time
2. radial, ulnar and brachial pulses
F. Special Tests
1. Painful Arc
- Can you do this (abduction of arm)
- when do you feel pain? (positive if pain at 30-90 degrees)
2. Drop Arm Test
- Can you put your arms up (90 degrees) and slowly put them to your sides
- if positive (rotator cuff tendinitis/tear), arms will drop to the side fast
- if there is partial tear, slight push will cause arms to drop to side fast
3. Yergason Test
- test stability of long head of biceps muscles
- apply valgus force on forearm while pulling elbows inferiorly (positive test if there is pain on
shoulder)
4. Aprehension Test
- test for shoulder dislocation
- with the shoulders abducted at 90 degrees, externally rotate
 positive if patient looks apprehensive
G. In the absence of trauma, check neck, chest, abdomen and heart for sources of referred pain
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Wrist Pain
I. History
A. Chief Complaint
Onset
Weakness of the hand
Distribution of the tingling and numbness
Radiation of the tingling to the arm or neck
Aggravating factors (activity or rest)
Alleviating factors
Signs of a stroke
Speech difficulty
Face numbness
Leg or arm weakness
Repetitive movement at work or hobby?
Handedness
Does the pain prevent you from doing your work?
Does the pain wake you up from sleep?
Recent trauma to hand, wrist or elbow?
Any symptoms in the other hand?
B. Past medical Hx
DM
Thyroid Dis
Pregnancy
Acromegaly, amyloidosis
Rheumatoid arthritis, Gout
C. Medications
D. Social Hx
Smoking, alcohol
Occupation, tasks at work
II. Physical Examination
A. Inspection
(check both dorsum and palm, symmetry)
(SEADS) Swelling; Erythema; Atrophy of thenar, hypothenar and lumbricals;
Deformity: ulnar deviation, DIP and PIP jt enlargement; Skin/nail changes
B. Palpation
o check for local heat, swelling, nodules (fingers and elbows), tenderness, effusion
 proximal forearm for tenderness
 forearm just proximal and radial to the anatomic “snuff box” for tenderness
C. Neurological
a. Median nerve (LOAF)
1. Motor
i. Lateral two lumbricals
- index and middle finger (radial 3.5 fingers)
ii.Opponens Policis
- tip of thumb to touch base of little finger
iii. Abductor Policis Brevis
- push thumb towards the ceiling against examining finger
iv. Flexor Policis Brevis
- bend the thumb to touch the palm
2. Sensory (middle and index finger)
- I will touch the side of your fingers either with one or two points. With your
eyes closed tell me how many points you feel.
3. Special Tests (for Carpal Tunnel Syndrome)
i. Phalen's sign
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- ask patient to form a funnel with his hands for one minute and check
for any numbness or tingling in the distribution of the median nerve
ii. Tinel sign
- percuss ventral aspect of the middle of the wrist 2-3 times
b. Ulnar Nerve
1. Motor
i. medial two lumbricals
ii.abductor digiti minimi
- push out
iii. interosseus muscles
- spread the fingers and keep them apart
- insert paper and pull out, keep your fingers together
iv. Adductor Policis
-Fromen's sign: I will place a paper between your thumb and fingers.
Hold on the paper tight and don't let me pull it out.
2. Sensory (ulnar 1.5 fingers)
- I will touch the side of your fingers either with one or two points. With your
eyes closed tell me how many points you feel.
D. Vascular Exam -capillary refill and radial pulses
III. DDx
Carpal Tunnel Syndrome
TIA
Cervical radiculopathy
Ulnar neuropathy
Thoracic outlet syndrome
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Hip Examination
A. Gait
- general appearance: in pain?
- ask pt to walk across the room
B. Inspection
- from front and back
symmetry of skin creases, atrophy of buttock muscles & thighs
- Trendelenberg Test
Can you stand on one leg. (gluteus muscles should contract)
Normally, the contralateral pelvis is tilted upwards.
If pt has a diseased hip, ask him to stand on the affected hip. Positive test: contralateral hip is tilted
downwards.
C. Palpation (with patient lying)
- press on the groin area for tenderness
D. Movement
1. Active
i. bend your thighs (flexion)
ii. spread your thighs (abduction)
iii. put one leg over the other (adduction)
iv. with patient lying on hi side: move leg backwards (extension)
2. Passive
i. flexion (with knees bent)
ii. abduction (support ASIS on opposite side and pull on the opposite ankle until you feel the hip
(ASIS) moving)
iii. adduction
iv. internal rotation (w/ kness at 90)
v. external rotation
E. Neurological
1. Motor Strength
i. flexion (push up)
ii. extension (push down)
iii. adduction (push your knees together)
iv. abduction (spread your legs)
2. Sensory
-check L4 L5 S1 for pinprick
F. Vascular
- femoral, popliteal, dorsalis pedis, posterior tibial a (compare both sides)
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G. Special Tests
1. Leg Length
a. apparent leg length
- measure from the umbilicus to the medial malleolus (if unequal -> pelvis is tilted)
- two legs are equal but they look unequal bec the pelvis is tilted
b. true leg length
- measure from ASIS to the medial malleolus of same side (if unequal -> hip pathology)
2. Thomas Test
- to check for flexion contracture of the hip joint
- with hand inserted at the lumbar lordosis ask pt: bend your hips and knees and hold your knees
with both hands
-with flexion contracture, lumbar lordosis reappears before full extension of the ip (measure angle
between the thigh and the bed)
Questions:
1. xray changes in osteoarthritis?
(BOSS: bone cyst, osteophyte formation, sclerosis, loss of jt space)
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Knee Injury
A.
History
Chief complaint
i. What happened?
ii. what was the position of your leg when this happened?
iii. What does the pain feel like? How would you describe it.
iv. How would you describe the intensity of the pain?
v. Do you have the pain all the time?
vi. Were you able to bear weight after the injury?
vii. Did you notice any sensation of a “pop,” a “snap,” or any locking of the joint?
viii. When and where did you first notice any swelling or bruising?
ix. Was there any associated pain in the leg, knee or foot?
x. Is there anything you do that makes the pain worse? (walking, weight bearing, squatting)
xi. Can you point where there is greatest pain?
xii. Is it better or is it worse than when it started?
xiii. Did you have any previous similar injury?
xiv. Did you have any fever, chills or night sweats?
xv. Did you ever feel any pins or needles in your knee or feet?
xvi. Did you start any treatment by yourself?
xvii. What type of work do you do? What are the physical demands of your job?
xviii. What leisure activities or sports do you participate in?
Past Medical
Previous injury
Allergies
Are you taking medications for the pain?
Social Hx
Athlete? How will the injury affect their life?
Steroids
B. Physical Examination
1. Gait
2. Inspection
- SEADS
- observe with patient standing and sitting with knees flexed at 90 degrees
3. Palpation
-TTC: temperature, tenderness, crepitus
i.
distal thigh
a. quadriceps
b. hamstrings
c. thigh girth
ii
patella
- around joint line (tenderness at jt line suggests meniscal tear whereas tenderness slightly
above or below suggests ligament damage)
4. Movement
i. Active
- bend your knee, straighten your knee
ii. Passive
5. Neurological (?)
i. Motor
- push up against my hand (flex)
-push down agst my hand (extend)
ii. Sensory
- check pinprick over the knees (L3)
iii. Reflexes
- Patellar reflex (L4)
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6. Vascular (?)
- popliteal, dorsalis pedis, posterior tibial arteries
7. Special Tests
i. Test for Fluid in the knee joint
i. bulge sign ( if minimal effusion)
-milk fluid from medial side upwards (3x) and from lateral side
upwards ->
watch for fluid bulge
ii. Patellar tap (if large amount of effusion)
- milk with one hand from superior to inferior of the patella -> push patella
posteriorly -> feel for fluid thrill on border of the hand
ii.
Assess Mobility of Patella
- flex knee at 30 degrees and apply medial and lateral pressure to determine
amount of subluxation possible
iii. Assess Ligament Stability
A. Cruciate Ligament
i. Anterior cruciate ligament
- anterior drawer sign
ii. Posterior cruciate ligament
- posterior drawer sign
B. Collateral Ligament
i. Medial collateral ligament
- apply valgus force and feel for a gap in medial aspect of knee
ii Lateral collateral ligament
-apply varus force and feel for a gap in the latl aspect of knee
iv. Assess Meniscus
i.
Medial menisci
- flex knee, ext rotate the knee, abduct and extend knee
-> feel for click in the medial jt line and ask if painful
ii.
Lateral menisci
- int rot/adduct
8. Examine Hip and Back
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Ankle Sprain
C. History
1.
2.
3.
4.
5.
6.
7.
8.
What happened?
what was the position of your foot when this happened?
Were you able to bear weight after the injury?
Did you notice any sensation of a “pop,” a “snap,” or any locking of the joint?
When and where did you first notice any swelling or bruising?
Was there any associated pain in the leg, knee or foot?
Did you have any previous similar injury?
Did you start any treatment by yourself?
D. Physical Examination
1. Gait
2. Examination (SEADS)
i. Compare injured side with unaffected side
ii. Examine most painful area last
iii. Observe ankle, concentrate on the lateral and medial aspects of the foot and ankle
3. Neurovascular status
i. Dorsalis pedis
ii. Posterior tibial
4. Palpation
i.
Bony structures
a. Shaft of fibula
b. Distal fibula over lateral malleolus
c. Medial malleolus
d. Base of the fifth metatarsal
e. All the tarsals
f. Phalanges
ii.
Ligamentous structures
a. anterior tibiofibular ligament
b. anterior talofibular ligament
c. calcaneofibular ligament
d. medial compartment (deltoid ligament)
iii.
Tendons
a. Achilles
b. Peroneal tendons
5. Movement
a. Active
i.ankle joint
- dorsiflexion and plantar flexion (point your toes upwards/downwards)
ii. ant talofibular ligament/ deltoid ligament
- inversion/eversion (turn the sole of your foot inwards and outwards)
b. Passive
- this time just relax and let me do the work
i. ankle joint
-dorsiflexion, plantar flexion, adduction and abduction
ii. midfoot
- hold the ankle in the left hand and the forefoot in the right -> invert the sole
inwards and evert outwards
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6. Special tests
i.
ii.
iii.
iv.
Anterior Drawer Test
-to assess the anterior talofibular and other ligaments of the lateral side of the
ankle
- positive test is graded 1+ for slight movement, 2+ for moderate movement, 3+
for marked movement
Talar Tilt Test
- to assess stability of the calcaneofibular ligament
- if the talar tilt is 5-10 deg greater around injured than around uninjured ankle,
ligaments damaged
Squeeze Test
- Done if medial or severe lateral injury
- Examiner’s hands placed 6 in inferior to the knee with thumbs on the fibula
and fingers on the medial tibia
- Leg is squeezed as if to bring fibula and tibia together
- Pain denotes syndesmotic injury
Assess joints above and below injury
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