2.2.2. SG Physical Exam Flashcards by Don Rees

5 key aspects of the history

Overuse versus Traumatic mechanism of Injury
Insidious versus acute onset of pain
Presence or absence of swelling
Past history or previous injury or surgery
Presence of systemic symptoms like fever, weight loss, fatigue, night sweats, etc.

How well did you know this?

Not at all

Perfectly

Inspection Steps

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

First step of palpation exam

Wash hands

How well did you know this?

Not at all

Perfectly

Last step of palpation exam

Wash hands

How well did you know this?

Not at all

Perfectly

Two things you need to do when doing palpation portion of exam

Need to know the anatomy

2. Check temperature

How well did you know this?

Not at all

Perfectly

What is the warm cold warm test?

Place back of hand on thigh (warm)
Place back of hand on kneecap or just medially (cold)
Place back of hand on lateral calf (warm)

How well did you know this?

Not at all

Perfectly

What does Warm-Cold-Warm mean for the Warm cold warm test?

Warm-Cold-Warm means no irritation or inflammation in the joint

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What does Warm-Hot-Warm mean for the Warm cold warm test?

Warm-hot-warm almost always means joint infection, accompanied by swelling, redness

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

Two considerations for the strength-neurological testing

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
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

How well did you know this?

Not at all

Perfectly

Steps to the Physical Exam

Inspection
Palpation
ROM
Strength
Special Tests

How well did you know this?

Not at all

Perfectly

First thing you do when a patient complains of back pain

Check the spine

How well did you know this?

Not at all

Perfectly

How does cervical innervation differ from lumbar/thoracic vertebrae?

Cervical nerve roots named for the vertebrae below

How well did you know this?

Not at all

Perfectly

Where does the C5 nerve root exit out of?

Between the C4 and C5 vertebrae

How well did you know this?

Not at all

Perfectly

C5 nerve Motor

Deltoid, Biceps

How well did you know this?

Not at all

Perfectly

C5 nerve Reflex

Biceps

How well did you know this?

Not at all

Perfectly

C5 nerve Sensation

Lateral Arm

How well did you know this?

Not at all

Perfectly

C6 nerve motor

Wrist Extensors, biceps

How well did you know this?

Not at all

Perfectly

C6 nerve reflex

Brachioradialis

How well did you know this?

Not at all

Perfectly

C6 nerve sensation

Thumb/index finger

How well did you know this?

Not at all

Perfectly

C7 nerve motor

Triceps, wrist flexors

How well did you know this?

Not at all

Perfectly

C7 nerve reflex

Triceps

C7 nerve sensation

Long finger

C8 nerve motor

Finger Flexors

C8 nerve reflex

None

C8 nerve sensation

Ulnar forearm, palmar pinky

T1 nerve motor

Finger Abduction

T1 nerve reflex

None

T1 nerve sensation

Medial elbow

Nickname for the nerve C5

Blocker

Nickname for the nerve C6

Beggar

Nickname for the nerve C7

Kisser

Nickname for the nerve C8

Grabber

Nickname for the nerve T1

Spock

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

Spinous processes Trapezius muscles SCM muscles

Examination of Cervical Thoracic Spine - ROM

Cervical Flexion Cervical Extension 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

Spurling's Maneuver

Sperling's Maneuver

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

Lumbar lordosis Thoracic Kyphosis Scoliosis (More than 10 degrees of curvature) Skin changes (rash, erythema, etc)

Palpation part of L Spine exam

Spinous processes Paraspinous muscles Sacroiliac joints (SI joints)

ROM portion of L spine exam

Spine Flexion | Spine Extension

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

L4 Motor

Tibialis Anterior

L4 Reflex

Quads

L4 Sensation

Medial Foot ankle

L5 Motor

Hallucis longus

L5 Reflex

None

L5 Sensation

Dorsal ankle/foot

S-1 Motor

Peroneals

S1 Reflex

Achilles

S1 Sensation

Lateral 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

Spondylolysis

Stress fracture of pars intraarticularis

Lumbago

Low back pain

S1, 2 - "buckle my shoe"

Achilles reflex

L3, 4 - "kick the door"

Patellar reflex

C5, 6 - "pick up sticks"

Biceps reflex

C7, 8 - "lay them straight"

Triceps reflex