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Question 1

Lumbar spine inspection- posture

Answer 1

Posture
Position of the pelvis and iliac crests, spinal curves from posterior and lateral view
Sacral base: look at sulcus dimples at SI joint
Laterally- Ear in line with the shoulder, greater trochanter, fibular head, and lateral malleolus; can you drop a plum line?

Question 2

Lumbar spine inspection: Gait

Answer 2

Gait: Inspect/Observe—passively
Gait should be smooth
Stance-foot on the ground (60% walk cycle) weight bearing
Swing-foot moves forward (40% walk cycle) non-weight bearing
Reflects issues related to spine, pelvis, knee, feet

Question 3

Lumbar spine palpation

Answer 3

Tenderness, position, mobility, tightness: TART
	   Skin changes
	  Paraspinal muscles 
Transverse process
Spinous processes landmarks
T3 spine of scapula
T7 inferior angle scapula
L4 located at level of Iliac crest

SI joint = bilateral sulci

Question 4

Muscle strength scale

Answer 4

0= no movement
1= muscle twitch without joint movement
2= movement only with gravity eliminated
3= movement against gravity only
4= movement against gravity + some resistance
5= movement against gravity + full resistance

Question 5

neurologic exam

Answer 5

reflexes
sensation
strength

Question 6

Lumbar neuro exam: L4

Answer 6

motor- anterior tibialis, reflex- patellar tendon, sensation: medial strip ankle to large toe

Question 7

Lumbar neuro exam: L5

Answer 7

motor- extensor hallucis longus, no reflex, sensation: mid top of foot and most of plantar surface

Question 8

Lumbar neuro exam: S1

Answer 8

motor: gastroc-soleus (toe raises), reflex: achilles tendon, dermatome: lateral strip of foot

Question 9

common causes of low back pain

Answer 9

Sprains, Strains, Muscle Spasms & General Deconditioning
Herniated or Bulging Discs, Spinal Stenosis, Facet Syndrome
Osteoarthritis
Scoliosis
Spondylolisthesis (forward slippage 
	of one vertebra on another)
Sacroiliitis, Sciatica
Infection (bowel, pelvic organs, bone)
Osteoporosis, Vertebral Fractures
Metastasis/Malignancy
Referred Pain from Hip “Unit”

Question 10

most common area of injury or source of pain from the lumbar spine

Answer 10

L5-S1 is the most common area of injury or source of pain from the lumbar spine

Posterior Longitudinal Ligament narrows as it descends down lumbar spine making herniation of the disc into the cord space easier. Rarely bilateral

Question 11

Scoliosis

Answer 11

Lateral curvature of the spine
Evaluate the extent and level of curvature
Measure leg lengths in conjunction with scoliosis
(distance from ASIS to medial malleolus)

Question 12

Spondyloarthritis: axial or peripheral

Answer 12

Axial=Chronic LBP, younger age
Both often associated with uveitis, psoriasis and inflammatory bowel disease
Ankylosing Spondylitis: chronic inflammatory disease of spine with progressive stiffening, often involves hips and peripheral
inflammatory signs. +HLA-B27

Question 13

Reiter Syndrome

Answer 13

Triad of arthritis, conjunctivitis/uveitis, urethritis.

Question 14

Osteoarthritis

Answer 14

“Degenerative Disc Disease”
Common in lumbar spine, especially at L5-S1
Worse due to being a postural transition point
Deterioration and loss of cartilage and normal bone
Low grade inflammatory issue

Question 15

Osteoporosis: Thinning of bone

Answer 15

Affects lumbar spine and hips commonly (Dexa Scan)
1:2 women and 1:4 men over age 50 will have an osteoporosis related fracture. Steroids increase risk
Loss of height, Dowager’s hump
Compression fractures cause the pain

Question 16

Sciatica

Answer 16

Lumbar Radiculopathy vs Peripheral Nerve Compression.
It can be caused by either of these.
Sciatic nerve combination of L4, L5, S1, S2, S3 nerve roots (largest nerve in body)
Find Sciatic nerve with patient
lying on side opposite of pain.
Pain unilateral from L5, through buttock, down lateral leg to the lateral foot.
Often shooting; worse with sitting or Valsalva
Consider herniated disc, spinal stenosis, lumbar facet pain, SI joint or mass lesion vs peripheral compression

Question 17

Straight Leg raise

Answer 17

(sciatica vs. hamstrings)
Raise leg, if reproduce leg pain radiation, lower leg just to point of no pain then dorsiflex foot. This stretches sciatic nerve so if dermatomal pain reproduced again, more likely is sciatic nerve. Most commonly positive for sciatica if pain found between 40-60 degrees of extension

Question 18

Pelvic Unit dysfunctions

Answer 18

Osteoarthritis (limitation to motion esp. abduction)
Inguinal Hernia 
Bursitis
Trochanteric
Ischial 
Sciatica
Lumbar spasms
Fractures (trauma, osteoporosis)
Scoliosis/leg length discrepancies
Infections (bone, bursa, tissue)
May include referred pain

Question 19

Synovial Joints

Answer 19

Joints freely movable; Bones do not touch
Bone ends covered with cartilage, lined with synovial membrane that secretes fluid lubricant, joined by capsule and ligaments and strengthened by muscles attached crossing the joint.

Question 20

What type of joint is the hip?

Answer 20

spheroidal, synovial

Question 21

Hip ROM

Answer 21

Flexion-supine, pull knee to chest (135˚ approx.)
Extension-prone, extend leg at hip (30˚)
Abduction-stabilize opposite hip (outward motion until iliac spine moves = limitation of motion ~ 45˚)
Adduction-stabilize opposite and move medially (20˚)
Rotation-flex leg 90˚ at hip and flex lower leg at knee
Move lower leg medial (varus) causes external rotation at hip (50˚)
Move lower leg lateral (valgus) causes internal rotation at hip (30˚)

Question 22

Inguinal ligament- inspection

Answer 22

Patient Supine-place heel on opposite knee to inspect inguinal ligament
Palpate ASIS to pubic tubercle
NAVEL (lateral to medial = nerve, artery, vein, empty space, lymph nodes)

True Hip Pain is deep inguinal, not lateral.
Check trochanteric bursa with complaint of lateral hip pain

Question 23

Trendelenburg test

Answer 23

Evaluates gluteus medius muscle
Observe PSIS dimples standing on both legs
Next have patient stand on one leg
Gluteus medius on the standing leg should contract keeping the pelvis level (negative test = normal)
If the pelvis cannot remain level, the gluteus medius is weak on the standing leg side.
Gluteus medius keeps hips stable during gait

Question 24

Thomas test

Answer 24

For flexion contractures of the hip due to tight Psoas (Iliopsoas)
Flex hip(s) with patient supine so thigh touches abdomen
Upon extending one hip should lie flat on table
Positive test if hip does not fully extend

Question 25

Patrick or Faber Test

Answer 25

“F”lexion “AB”duction “External Rotation” Most specific for hip joint. Trying to reproduce their pain. May elicit SI tenderness

Question 26

Special hip tests

Answer 26

Leg length: Measure distance from ASIS to medial malleolus Consider shortened femur, tibia, scoliosis, or from adduction and/or flexion deformity of hip Psoas strength test: Seated, raise knee, resist pressure down ``` Piriformis exam: Primarily by palpation Supine, knees to chest and hold heels, rotate knees left and right comparing ROM ```

Question 27

Knee/ Lower leg assessment

Answer 27

Inspect/Observe: both at rest and walking; gait should be smooth, flowing Palpation: Bursa, Patella ROM: Hinge joint involving Femur, Patella, Tibia Stability Testing: Ligaments provide passive stability Menisci assist walking stability

Question 28

Knee: structures to examine

Answer 28

``` Ligaments: Anterior/Posterior Cruciates Lateral/Collateral Menisci Medial/Lateral Tendon Insertion Points (Pes) Bursa: Prepatellar, pes anserine, suprapatellar pouch is a bursa ``` Bulge sign-minor effusions Balloon sign-large effusions Balloting -large effusions

Question 29

Palpate Knee

Answer 29

``` Have patient sit on edge of table or laying supine Flexing knee to 90 deg. accesses the joint space well Note pain, swelling, fluid, redness, crepitus Femoral condyles both medial and lateral Tibial Plateau both medial and lateral Patellar tendon and patella Tibial Tubercle ```

Question 30

Knee: testing ROM

Answer 30

Note symmetry and tenderness Flexion = 135˚ Extension = 10-15˚ Internal Rotation at 90 deg (rotate foot medially) = 10-30˚ External Rotation at 90 deg (rotate foot laterally) = 10-40˚

Question 31

Knee tests: bursitis

Answer 31

Prepatellar Bursitis: Anterior Dome swelling over patella associated with tenderness From excessive kneeling Housemaid’s knee Anserine Bursitis: Medial Medial aspect of knee – tibial plateau Excessive running common cause Also from valgus knee deformity (Q angle) and arthritis Hard to tell from a Pes Anserine tendonitis Baker’s Cyst: Posterior Cyst in the popliteal fossa, most often medial Leg extended check posterior/medial aspect of knee for swelling or fullness, sometimes tenderness as well

Question 32

Patellofemoral grind test

Answer 32

Patient supine with knee extended Compress patella against femur Instruct patient to tighten quads. Assess for roughness of motion, crepitus, pain Pain associated with going up stairs or rising from chair, consider Chondromalacia or patellofemoral syndrome

Question 33

Knee apprehension test

Answer 33

Tests for dislocation or subluxation of patella Attempt to manually dislocate patella laterally Observe patient’s facial expressions

Question 34

Knee testing: ACL

Answer 34

Anterior Drawer Sign: Patient supine flex knees and hips 90˚ Pull tibia forward to check for movement anteriorly Compare to opposite side. Positive test = ACL tear Lachman test: only good for ACL Knee flexed 15˚ and externally rotated if possible Grasp femur with one hand and tibia with other Move femur and tibia in opposite directions Asymmetric, forward movement of tibia against femur suggests positive test = ACL tear

Question 35

what's important about ACL testing?

Answer 35

Always test both knees | Asymmetric findings most important

Question 36

Knee testing: PCL

Answer 36

Posterior Drawer Sign: Patient supine with hip and knee flexed to 90˚ Push tibia posteriorly checking for movement against femur Compare to opposite side. Positive test = PCL tear

Question 37

McMurray Test

Answer 37

knee test- meniscus Heel points the direction of the meniscus getting tested Patient supine grasp heel and fully flex the knee Hold knee joint with other hand palpating along joint line Rotate the lower leg internally to engage the lateral meniscus and extend the leg. Note pain; “pop” or “click” during the motion. Repeat using external rotation for the medial meniscus. Not a very specific test. Medial Meniscus: Externally rotate tibia = heel points in/toward midline Extend knee feeling for click, looking for pain Lateral Meniscus: Internally rotate tibia = heel points out/away from midline Extend knee feeling for click, looking for pain Not very sensitive test for meniscus, ie, can still have injury without positive findings. Specificity=85-95% Sensitivity=50-65%

Question 38

Apley's Compression test

Answer 38

knee test- meniscus Patient prone with knee flexed to 90˚ Stabilize thigh with one hand while leaning onto heel compressing medial and lateral menisci. Rotate heel during compression noting any pain

Question 39

Key features of patient presentation for a meniscal tear include:

Answer 39

Locking or giving out: sensation of or actual occurrence Not feeling they can trust the knee when walking or stepping off a curb A catching sensation or true catching of the knee: sudden pain stops ROM, ie, suddenly cannot extend the leg fully.

Question 40

Thessaly test

Answer 40

Standing, rotatory motion on one leg at 5-10 deg, and again at 20 degrees. More sensitive and specific for mensical injury or tear than McMurray, bent knee position best.

Question 41

Knee testing: MCL/ LCL

Answer 41

Valgus Stress Test: (Abduction Stress Test) Patient supine and flex knee slightly One hand against lateral knee the other around medial ankle Push medially against knee while laterally against ankle

Question 42

Lateral Collateral Ligament

Answer 42

Varus Stress Test: (Adduction Stress Test) Position patient same as for Valgus test Hands against medial knee and lateral ankle Push laterally against knee while medially against ankle

Question 43

Lower Leg Exam: Calf and Achilles

Answer 43

Palpate Gastrocnemius and Soleus muscles for pain and swelling; look carefully for asymmetry Homan’s Sign: Evaluates for DVT (deep venous thrombosis) Dorsiflex patient’s ankle with leg extended at knee. Pain in calf is a positive sign. Thompson Test: Patient prone, leg bent 90 deg, squeeze calf and observe for normal passive plantar flexion. Best to determine achilles rupture if done in 48 hrs.

Question 44

what does the thompson test test?

Answer 44

achilles integrity

Question 45

What does homan's sign indicate?

Answer 45

calf thrombosis

Question 46

Ankle/Foot Pathology

Answer 46

Bone spurs—bottom of calcaneus; causes point tenderness Plantar Fasciitis—heel and arch pain especially with initial weight bearing in morning Pes Planus—loss of longitudinal arch of foot (flat feet) Hallux Valgus—abnormal abduction of great toe (bunion) Gout—redness/swelling/pain at MTP of great toe Uric acid crystal deposition Pseudogout – looks the same, from calcium pyrophosphate crystal deposition Rheumatoid Arthritis—compressive tenderness Osteoarthritis

Question 47

Ankle/ Foot anatomy

Answer 47

``` Hinge Joint formed from articulating surface of the tibia, fibula and talus. Principal joints of the hinge are: Tibiotalar joint Subtalar (Talocalcaneal) joint Medial Malleolus: Deltoid ligament Lateral Malleolus: Posterior talofibular/Calcaneofibular/Ant.talofibular Transverse Tarsal Joint Metatarsal Phalangeal Joints (MTP) ```

Question 48

ankle/ foot exam

Answer 48

Inspect/Observe both at rest and walking Check for swelling, lumps, redness, limp/gait, nodules, warts, bunions, etc. Palpate: Can you reproduce their pain? Entire ankle joint; compare bilaterally Achilles tendon for pain, swelling, masses Metatarsal Phalangeal joints (MTP) both dorsal and plantar using thumb and forefinger Heel and arch for pain, redness, lumps, contour Range of Motion: Tenderness? Symmetry? Ankle dorsiflex/plantar flex (Tibiotalar joint) Inversion/eversion (Talocalcaneal joint = Subtalar Joint) Anterior Drawers : General ligament stability, ?symmetric Grip calcaneus in palm of one hand and lower tibia with other Pull calcaneus forward while pushing tibia posterior. Should not move or “feel” lax. - Foot = inversion/eversion (Transverse Tarsal joint) MTP = Compress forefoot, palpate each MTP Toes = flexion/extension Special Testing: Neurovascular distribution to foot = pulses, sensation ?atrophy

Question 49

Talar Tilt Test

Answer 49

Pt is sitting with legs dangling off table Doc inverts the calcaneus If the talus gaps or rocks in the ankle mortise, the ATF & calcaneofibular ligs are torn and the test is positive

Question 50

Ankle Sprains:

Answer 50

Abnormal stretching or tearing of ligament(s) First to third degree sprains, third is full tear Anterior talofibular ligament and Calcaneofibular Most commonly injured (Lateral) Caused by inversion force High ankle sprain = Syndesmosis between Fibula and Tibia

Question 51

Ottawa Rules

Answer 51

Developed to avoid unnecessary radiography in ankle injury. Perform an xray expecting to find a fracture only if: Pain around the malleolus and tenderness in posterior malleolar area or tip of fibula OR Pain around the malleolus and unable to weight bear immediately and more than 4 steps in ED OR Pain in mid-foot and either 1. Tenderness at base of 5th metatarsal or navicular, OR 2. Inability to weight bear immediately OR more than 4 steps in ED