Flashcards in 2.2.2. SG Physical Exam Deck (84)
5 key aspects of the history
1. Overuse versus Traumatic mechanism of Injury
2. Insidious versus acute onset of pain
3. Presence or absence of swelling
4. Past history or previous injury or surgery
5. Presence of systemic symptoms like fever, weight loss, fatigue, night sweats, etc.
Begins with patient walking in. Look for changes in gait, arm swing, seating, and other observations can provide clues
Make sure to actually observe the skin of the patient
Also check to see if the joint appears swollen, which is often caused by joint effusion
What are joint effusions?
Joint effusions are collections of fluid inside the joint capsule, which is like the plastic bag around the joint. Can vary from obvious redness to swelling to far more subtle
First step of palpation exam
Last step of palpation exam
Two things you need to do when doing palpation portion of exam
1. Need to know the anatomy
2. Check temperature
What is the warm cold warm test?
1. Place back of hand on thigh (warm)
2. Place back of hand on kneecap or just medially (cold)
3. Place back of hand on lateral calf (warm)
What does Warm-Cold-Warm mean for the Warm cold warm test?
Warm-Cold-Warm means no irritation or inflammation in the joint
What does Warm-Warm-Warm mean for the Warm cold warm test?
Warm-warm-warm means something is irritating the joint. Not normal, could be chronic or acute
What does Warm-Hot-Warm mean for the Warm cold warm test?
Warm-hot-warm almost always means joint infection, accompanied by swelling, redness
Two types of ROM
Active vs. Passive
Active is how much they can do on their own, passive is how much you can do for them
What are we looking for with active ROM testing?
Ask patient to describe any pain during that motion, watch for catching and locking and look for any changes bilaterally (usually the same on both sides)
Two considerations for the strength-neurological testing
1. Place limb so that the muscle being tested is activated or contracted and then put force on it with the patient resisting in the opposite way
2. When testing nerve innervations, use muscles that are weaker to test if there really is a problem, don’t use muscles that even at a “weak” state are still very strong
Steps to the Physical Exam
First thing you do when a patient complains of back pain
Check the spine
How does cervical innervation differ from lumbar/thoracic vertebrae?
Cervical nerve roots named for the vertebrae below
Where does the C5 nerve root exit out of?
Between the C4 and C5 vertebrae
C5 nerve Motor
C5 nerve Reflex
C5 nerve Sensation
C6 nerve motor
Wrist Extensors, biceps
C6 nerve reflex
C6 nerve sensation
C7 nerve motor
Triceps, wrist flexors
C7 nerve reflex
C7 nerve sensation
C8 nerve motor
C8 nerve reflex
C8 nerve sensation
Ulnar forearm, palmar pinky
T1 nerve motor
T1 nerve reflex
T1 nerve sensation
Nickname for the nerve C5
Nickname for the nerve C6
Nickname for the nerve C7
Nickname for the nerve C8
Nickname for the nerve T1
Examination of Cervical Thoracic Spine - Inspection
1. Loss of cervical lordosis
2. Thoracic Kyphosis
3. Skin changes (rash erythema, etc)
Examination of Cervical Thoracic Spine - Palpation
Examination of Cervical Thoracic Spine - ROM
Rotation, left and right
Lateral bending left and right
Examination of Cervical Thoracic Spine - Strength/Neurovascular
C5 - T1
Examination of Cervical Thoracic Spine - Special Tests
1. Have patient laterally bend and rotate to affected side
2. Apply slight axial loading pressure to top of head
3. If not painful, have patient repeat the lateral bending and rotation but add the extension as well. Instruct patient to try and look in the back pocket of your jeans
4. Again apply slight axial loading pressure
5. If the patient experiences pain in the contralateral (opposite side) of the neck or upper extremity, then they have a “Reverse Spurling Sign” caused by the distraction of a cervical nerve root
Caudal equina syndrome
Compression of the terminal nerve roots in the spine
Inspection for L Spine
Scoliosis (More than 10 degrees of curvature)
Skin changes (rash, erythema, etc)
Palpation part of L Spine exam
Sacroiliac joints (SI joints)
ROM portion of L spine exam
What stress does spine flexion cause?
Spine flexion causes anterior compression between vertebral bodies which causes nucleus pulposus, the goo inside of the intervertebral discs, to get pushed posteriorly. Normal discs don’t do this, but a herniated or ruptured one will, and it will press on the nerve roots with this bulge causing pain
Complaint common to flexion abnormalities
Unbearable to bend over and tie my shoes
What stress does spine etension cause
Compresses posterior elements of the spine
Normal posterior elements leave enough room between them for the nerve roots to get out unscathed, but abnormal elements like fractures, arthritis or congenital stenosis can, under extension, cause nerve root compression
Complaint common to extension abnormalities
Patient will want to be bent forward
Palpation portion of L spine exam
Need to distinguish boney vs. non-bony pain (spinous processes vs. paraspinal muscles). Bony means xray, nonbony needs time and fitness
What do we order and what are we worried about with someone who has history of cancer
Recurrent cancer, order xrays of the spine
What do we order and what are we worried about with someone who has unrelenting nocturnal pain
Cancer or osteoid osteoma. Order xrays for the cancer and CT for the osteoid
What do we order and what are we worried about with someone who has unclear injury mechanism
Cancer or an infection. Xrays for the cancer and labs for the infection
What do we order and what are we worried about with someone who has constitutional changes like fever, weight loss or night sweats?
Cancer, infection, or rheumatologic disease. Xrays for cancer, labs for the others
What do we order and what are we worried about with someone who is over the age of 50?
Cancer, do xrays
What do we order and what are we worried about with someone who is younger than 18?
Infection, stressfracture, discitis. Labs for infection, Xrays for others
What do we order and what are we worried about with someone who has a history of trauma
Fracture or Nerve root compression, just need xrays
What do we order and what are we worried about with someone who has numbness or sensation change in dermatomal distribution?
Cauda Equina Syndrome. Get that person an MRI within 2 hours and neurosurgery TODAY
During the exam, if a patient has neurological deficits, what are we worried about?
Nerve root compression. Do Xrays and follow closely for exam progression
During the exam, if a patient has saddle sensation changes in the groin or upper thigh, what are we worried about?
Cauda Equina - MRI within 2 hours and neurosurgery TODAY
Medial Foot ankle
Strength tests for lower spine
Ankle inversion and dorsiflexion for L4
Great toe dorsiflexion for L5
Ankle Eversion for S1
Reflex tests for lower spine
Patellar reflex for L4
Achilles reflex for S1
Sensation tests for lower spine
Medial Leg/ankle for L4
Dorsum of foot for L5
Lateral leg/ankle for S1
Special Tests for the lower spine
Straight leg raise
Patrick's Faber Test
Single Leg Stork
Straight leg raise
1. Passively elevates patients leg with knee locked
2a. Pain radiating into the leg at 30 degrees or less suggests neural tension
2b. Pain in the calf at less than 30 degrees also is suggestive of neural tension
Patrick's FABER Test
Flexion, ABduction, External Rotation - Looking for pain at SI joint or pain in hip
Single Leg Stork Test
1. Patient stands on one leg and extends spine (leans back)
2. Pain in lumbar region on stance suggests spondylolysis
3. Repeat on opposite leg
Stress fracture of pars intraarticularis
Low back pain
S1, 2 - "buckle my shoe"
L3, 4 - "kick the door"
C5, 6 - "pick up sticks"