What CN is it associated with?
How do you palpate it?
Place tips of index fingers just in from of tragus of each ear and ask pt to open mouth. Fingertips should drop into joint spaces as mouth opens. Check for smooth range of motion. Note any swelling or tenderness. Snapping or clicking may be felt or heard in normal people.
ROM for neck
We seem to use extension instead of hyperextension
When you palpate joints, what are you feeling for?
crepitus, tenderness, inflammation/swelling
UE Joints to palpate
Shoulders, elbows (olecranon and epicondyles), wrists, fingers
Where are the olecranon & epicondyles?
Olecranon is bony point of elbow
Bones of wrist/hands
Joints of wrist/hands
No hyperextension in Bates
Flexion: "Raise your arms in front of you and overhead"
Extension: "Raise your arms behind you"
Abduction: "Raise your arms out to the side and overhead"
Adduction: "cross your arm in front of your body"
Internal Rotation: "Place one hand behind yoru back and touch your shoulder blade" (could also be as pictured)
External Rotation: "Raise your arm to shoulder level; bend your elbow and rotate your forearm to the ceiling" OR "Place one hand behind your neck or head as if you are brushing your hair"
Flexion, extension, supination, pronation
Supination: "have some soup"
Flexion: Make a tight fist with each hand, thumb across knuckles
Extension: Extend and spread the fingers
Abduction: spread fingers apart
Adduction: Bring fingers back together
Flexion: move thumb across palm, touch base of 5th finger
Extension: move thumb back across palm and away from fingers
Abduction: place fingers and thumb in neutral position with palm up, then have patient move thumb anteriorly away from the palm
Adduction: bring thumb back to palm
Opposition: touch thumb to each of fingertips
Grading Muscle Tone & Strength
0 - No muscular contraction detected
1 - A barely detectable flicker or trace of contraction
2 - active movement of body part with gravity eliminated
3 - Active movement against gravity
4 - Active movement against gravity and some resistance
5 - Active movement against full resistance without evident fatigue. This is normal muscle strength
Positive suggests carpal tunnel
For median nerve compression. Lightly tap overcourse of median nerve in carpal tunnel. Positive: aching & numbness in median nerve distribution
For carpal tunnel
ask pt to hold wrists in flexion 60 seconds. OR backs of both hands together to form right angles (compresses median nerve)
pt lies flat and provider passively flexes head up, noting no nuchal rigidity, neck stiffness, hip or knee flexion
B for “bend neck”
w/ pt supine, provider bends knee to 90 degrees and then straightens, noting there is no resistance from pt
K for “knee”
Lower Extremities to Palpate
Hips, Knees, ankles, toes
+ internal & external rotaton
Straight leg raise
provider passively elevates straight leg to see if any pain is produced in back and down leg. Seated or supine.
Positive for lumbar radiculopathy if pain radiates down leg in radicular pattern
with full hip flexion, look for full extension of opposite hip and flattening of lumbar lordosis; repeat w/ other leg
Measure distance between affected thigh and table
Physiologic in first 3mths of life
Checking for hip flexion contractures
With your dominant hand, milk down towards the patella and then hold pressure. Now press the medial aspect of the knee to force any fluid within the joint laterally. Now, take your hand and press quickly along the lateral (i.e., opposite) aspect of the knee. If you see a fluid wave medially, that is a positive bulge sign.
if bulge present, you would check for ballottment.
For larger effusions
compress suprapatellar pouch and “ballotte” or push the patella
sharply against the femur. Watch for fluid returning to the
Collateral ligament assessment: Valgus Test
abduction. With patient supine and knee slightly flexed, move thigh about 30 degrees laterally to the side of the table. Place one hand against lateral knee and stabilize the femur and the other hand around the medial ankle. Ush medially against the knee and pull laterally at the ankle to open the knee joint on the medial side (valgus stress). Pain or gap in medial joint line points to ligamentous laxity and a partial tear of the medial collateral ligament. Most injuries on medial side.
genovalgum: "gum between your knees"
Collateral ligament assessment: Varus stress
adduction. With thigh and knee in same position, change your position so you can place one hand against medial surface of the knee and push other around the lateral ankle. Push laterally against the knee and pull medially at the ankle to open the knee joint on the lateral side
Hold heel. Trap meniscus between tibia and femoral condyle. Knee hyperflexed and go back and forth w/ ankle to trap meniscus. To test medial meniscus, feel medial side w/ fingers. Keep knee hyperflexed with ankle inversion and extend in varus position. To test lateral meniscus, feel lateral side w/ fingers. Knee hyperflexed with ankle eversion. Leg in valgus position and extend. Feel for pop/click. If pain with pop/click, this is a positive McMurray. (Tests Meniscus)
Click or pop along medial joint w/valgus stress, external rotation and leg extension suggests a probably tear of posterior portion of medial meniscus. Tear may displace meniscal tissue, causing “locking” on full knee extension. McMurray + locking: medial meniscus tear 8.2 and 3.2 times more likely
ACL/PCL assessment: Drawer Test: (Anterior and Posterior)
w/ pt's knees bent and feet flat on table
Cup hands around knee w/thumbs on medial and lateral joint line and fingers on medial and lateral insertion of hamstrings.
pull lower leg forward (anterior test) and push it back (posterior test)
Place knee in 15 degrees of flexion and external rotation. Grasp distal femur on lateral side w/one hand and proximal tibia on medial side w/other. With thumb of tibial hand on joint line, simultaneously pull the tibia forward and the femur back. Estimate degree of forward excursion.
Palpate spinal process
C1-C7, T1-T12, L1-L5, sacral curve
Walk your fingers down, "tell me if you have pain"
Spinal Curvature Disorders
Cerebellar function tests
- Finger to nose
- Heel down shin - length of knee to great toe
- RAMS w/each hand (pronation, supination) or thumb finger to finger
- Pronator Drift
- Tandem Walking
- Heel walking
- Toe Walking
Feet together, eyes open. Close them 30 to 60 seconds. Excessive swaying/falling. Guard patient!
20 to 30 seconds, arms straight forward, palms up. Eyes closed. Tap briskly telling them to maintain horizontal position.
ataxia (jerky, unsteady)
antalgic (limping b/c hurts)
Types of Joints
Synovial: freely movable (e.g., knee, shoulder)
Cartilaginous: slightly moveable (e.g., vertebral bodies of the spine
Fibrous: immovable (e.g., skull sutures)
include joint capsule and articular cartilage, synovium and synovial fluid, intra-articular ligaments, and juxta-articular bone.
Articular disease typically involves swelling and tenderness of entire joint and limits both active and passive ROM d/t either stiffness or pan
LIgaments: collagen fibrils, rope-like, connect bone to bone
Tendons: collagen fibers connecting muscle to bone
Bursae: pouches of synovial fluid that cushion movement of tendons and muscle over bone or other joiint structures
extra-articular disease typically involves selected regions of joint and types of movement
Types of synovial joints
Spheroidal (ball & socket): e.g., shoulder and hip
Hinge: IP joints of hand and foot, elbow
Condylar: knee, TMJ
Low back pain
85% is idiopathic. Usually d/t muculoligamentous injuries and age-related degenerative processes
Back pain: midline or off the midline
midline: musculoligamentous injury, disc herniation, vertebral collapse, spinal cord metasteses, and rarely, epidural abscess
off the midline: muscle strain, sacroiliitis, trochanteric bursitis, sciatica, hip arthritis; also renal conditions e.g., pyelonephritis or stones
Cauda equina syndrome
from S2-4 midline disc or tumor
consider if patient c/o bowel or bladder dysfunction (usually urinary retntion w/overflow incontinence), especially if saddle anesthesia or perineal numbness
Pain in one joint, consider...
injury, monoarticular arthritis, possible tendinitis, or bursitis. Lateral hip pain near greater trochanter suggsts trochanteric bursitis
polyarticular pain: always ask about pattern of involvement
Migratory or steadily spreading? Symmetric?
Migratory: consider rheumatic fever, cgonococcal arthritis
Progressive additive & symmetric: rheumatoid arthritis
Severe pain, rapid onset in a red swollen joint, consider...
acute septic arthritis or gout. In children, consider osteomyelitis in bone contiguous to a joint
Joints: pain swelling, loss of active and passive motion, or "locking", consider....
articular joint pain
Joints: loss of active but not passive motion + tenderness outside the joing, consider...
At what age is peak bone mass reached and what is the speed of age related bone degeneration?
Age related declines in estrogen and testosterone cause initially rapid bone loss which later becomes slow and continuous
Palpable bogginess or doughiness of synovial membrane, often accompanied by effusion, consider...
joint fluid + tenderness over tendon sheaths, consider
Acromioclavicular joint: palpate and compare both joints for swelling or tenderness. Adduct patient's arm across chest.
Localized tenderness or pain suggests inflammation or arthritis of the acromioclaviular joint
Apley scratch test
Rotator cuff d/o or adhesive capsulitis
Neer's impingement SIgn
Press on scapula to prevent scapular motion w/one hand and raise patient's arm w/other. This compresses the grater tuberosity of the humerus against the acromion.
Pain --> inflammation or rotator cuff tear
Flex patient's shoulder and elbow to 90 degrees w/palm facing down. Then, with one hand on forearm and one on arm, rotate arm internally. This compresses greater tuberosity against coracoacromial ligament.
pain: inflammation or rotator cuff tear
Testing Supraspinatus Strength
Empty can test
elevate arms to 90 degrees adn internall rotate arms, w/thumbs pointed down, as if emptying a can. Ask pt to resist you as you place downward pressure on arms
weakness: possible rotator cuff tear
Testing infraspinatus Strength
Ask patient to place arms at side and flex elbows to 90 degrees with thumbs turned up. Provide resistance as patient presses the forearms outward
Weakness: rotator cuff tear, bicipital tendinitis
Ask ptient to fully abduct the arm to shoulder level (or up to 90 degrees - not above, then it's deltoid) and lower it slowly.
If can't hold arm out or control lowering the arm, positive for rotator cuff tear
Nerve distribution to hands
Hands of those with chronic rheumatoid arthritis
ulnar deviation, swollen thickened metacarpophalangeal and proximal interphalangeal joints, boutonniere deformity, swan neck defomity
Signs of osteoarthritis in hand
Heberden's node, bouchard's node, radial deviation of distal phalanx
(metacarpophalangeal joints uninvolved)
Chronic tophaceous gout - hands
can mimic rheumatoid and osteo-arthritis
BUT, not usually symmetrical like rheumatoid is. And knobby swellings ulcerate and discharge white chalklike urates.