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PACS > Advanced MSK > Flashcards

Advanced MSK Flashcards

1
Q

Shoulder Exam

what to inspect for?

A
  • swelling, signs of trauma
  • shoulder muscle atrophy
  • inspection during ROM
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2
Q

Shoulder Exam

what to palpate for tenderness, prominence, or crepitus?

A
  • sternoclavicular joint
  • acromioclavicular joint
  • glenohumeral joint
  • scapulohtoracic articulation
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3
Q

Shoulder Exam

which soft tissue structures do you palpate for?

A
  • neck, shoulder, parascapular areas
  • rotator cuff muscles
  • biceps muscle and bicipital tendon in intertubercular groover
  • subacromial/subdeltoid bursa
  • axilla
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4
Q

Shoulder Exam

what muscles compose the rotator cuff?

A
  • Supraspinatus
  • Infraspinatus
  • Teres minor
  • Subscapularis

SITS

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5
Q

Shoulder Exam

ROM for shoulder

A
  • flexion- 180 deg
  • extension- 50 deg
  • abduction- 180 deg
  • adduction- 45-50deg
  • external rotation- 90 deg
  • internal rotation- 90 deg
  • scapular elevation (shoulder shrug)
  • retration (at attenetion)
  • protraction (shoulders forward)
  • horizontal abduction (90 deg) and adduction (130 deg)
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5
Q
A
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6
Q

Shoulder Exam

MSK strength testing

A
  • ROMs against resistance
  • biceps/triceps
  • serratus anterior nerve damage (push up against wall, look for scapular winging)
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7
Q

Shoulder Exam

how to test for bursal tenderness

A

palpate under edge of acromion or over deltoid muscle

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8
Q

Shoulder Exam

how to test for fibromyalgia

A

check for pinch roll tenderness with one finger localized tender or trigger points

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9
Q

Shoulder Exam

tests for the bicipital tendon

4

A
  • bicipital groove tenderness: palp for localized tenderness over biceps tendon in the intertubercular groove
  • speed’s test: with elbow fully extended and palm forward, flex shoulder against resistance
  • yergason’s test: with elbow at 90deg flexion and held against the hip, externally rotate patient’s shoulder against resistance while pulling down elbow.
  • check for ruptured long head of biceps muscle (popeye muscle)
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10
Q

Shoulder Exam

Tests of the AC joint

4

A
  • check for crepitus at AC joint w/ overhead ROMs
  • raise elbow to chin level and bring shoulder under the chin
  • Cross Over Test: tests AC adduction, w/ the arm straight, adduct it across the body
  • Piano Key Sign: w/ separation of the AC joint, the distal clavicle will translate superiorly. press down on the clavicle and you will see rebound (when the joint is separated)
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11
Q

Shoulder Exam

tests of rotator cuff impingement

2

A
  • Neer Impingement Sign: arm up to ear and rotate, pain w/ flexion and pronation. subacromial impingement or rotator cuff tear.
  • Hawkin Impingement Test: to test for subacromial impingement or rotator cuff tendonitis abduct the shoulder to 90 deg, forward flex to 30 deg, and forcibly internally rotate (induced pain!)
  • for rotator cuff impingment syndrome: press down on acromion as the supraspinatus muscle isolation test is done and adduct the arm behind the back
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12
Q

Shoulder Exam

tests for rotator cuff tears

2

A
  • inspect for atrophy of supraspinatus or infraspinatus muscles
  • test for resistance of pt to abduct the shoulder actively and against resistance
  • Drop Arm Test: from fully abducted position, slowly lower the arm to the side, noting pain starting at approx 90deg followed up sudden drop of arm.
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13
Q

Shoulder Exam

tests to isolate injured rotator cuff muscles

A
  • empty can test: supraspinatus muscle isolation; with arm straight and shoulder abducted to 90deg and forward flexed 30deg, point thumb at ground and lift arm against resistance
  • Infraspinatus/Teres Minor test: w/ elbow at 90deg, externally rotate the shoulder against resistance
  • no test to isolate subscapularis
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14
Q

Shoulder Exam

Tests of anterior stability of the GH joint/ligament stability

A
  • Apprehension Test: shoulder abducted to 90 deg and elbow flexed to 90 deg, examiner then externally rotates the shoulder and looks for signs of apprehension on pt’s face
  • Apprehension reloaction test: repeat test while exerting anterior pressure over shoulder to prevent shoulder from subluxing/dislocating anteriorly
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15
Q

Shoulder Exam

tests of inferior stability with GH joint/ligament stability?

A
  • sulcus sign gap: felt between acromion and humeral head due to inferior subluxation or dislocation
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16
Q

Shoulder Exam

tests of neuromuscular disorders?

A
  • check for scapular winging due to serratus anterior msk inury or long thoracic nerve palsy
  • check for rhomboid muscle strain: pt’s arm behind back internally rotated and adducted, pt then pushes hand away from body against resistance which makes rhomboid muscle available to palpation between the spine and scapula
  • check the spinal nerves and peripheral nerves in shoulders/arms
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17
Q

Shoulder Exam

tests of related areas which can cause referred pain to shoulder

thoracic outlet compression tests

A
  • Adson’s Maneuver: pt mildly abducts and extends shoulder, extends and rotates C-spine toward that shoulder, and takes a deep breath. palpate the radial pulse before and after this maneuver (pos result = diminished pulse)
  • Costoclavicular Maneuver: pt stands at attention w/ shoulder’s drawn backward and downward as radial pulse is examined- pos result = diminished pulse, also auscultate supra and infra clavucular regions for bruits
  • AER Position: “arms in external rotation”; shoulders abducted to 90 deg, elbows flexed at 90 deg, arms held in this position for up to 3 min; palpate pulse and auscultate for bruits. most reliable test
  • examine C-spine as potential cause of referred pain to shoulder; always examine joint above and below complaint
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18
Q

Knee Exam

components of inspection

A
  • gait
  • leg length discrepancy
  • quad mass and symmetry
  • inspect for genu varus, valgus, recurvatum
  • obvious bony/soft tissue deformities, swelling, erythema, signs of trauma
  • inspect for effusion (loss of normal concavities on each side of patella)
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19
Q

Knee Exam

what to palpate for

A
  • quads for tone
  • patella/patellar tendon
  • tibial tuberosity
  • area of pes anserine burse (in flare of medial tibial tuberosity)
  • tibial plateau
  • medial/lateral joint margins and collateral ligaments
  • femoral condyles
  • head to fibula
  • popliteal fossa, popliteal pulse, hamstring tendons
  • joint line (knee flexed to 90 deg)
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20
Q

Knee Exam

ROM for knee

A
  • flexion (135 deg)
  • extension (0 neutral to -15)
  • tibial internal/external rotation (10 deg)
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21
Q

Knee Exam

tests for effusion

A
  • Bulge Sign: for minor effusions; milk fluid from suprapatellar pouch and one side of knee to other side of knee; tap over fluid on one side of knee and watch for fluid wave
  • Patellar Ballottement: for larger effusions; compress the suprapatellar pouch toward the patella, then push down the patella and note how it springs up and down on cushion of abnormal knee fluid
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22
Q

Knee Exam

tests of patello-femoral function

A
  • common complaint is knee pain going up stairs
  • assess “tracking” of patellar in patellofemoral groove with ROM and, if abnormal, suspect symmetrical quad muscle strength (alternative: with knees extended, look/palpate for deviation of patellar during tensing of quads)
  • Patellar Apprehension Test: for suspected recurrent lateral dislocation of patella; with knee fully extended, displace patellar laterally and note any pt apprehension
  • Patellofemoral Grinding Test: test for chondromalacia patellae; push down on patella while having pt do straight leg raise OR push patella distal w/ leg in extension and tighten quads
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23
Q

Knee Exam

tests of collateral ligaments (medial collateral/lateral collateral ligaments)

A
  • Varus/Valgus Stress: cradle ankle in axilla and apply VARUS stress (push knee out) to test LCL; then apply valgus stress (push knee IN) to test MCL
24
Q

Knee Exam

tests of cruciate ligaments

A
  • Anterior Drawer Test: for ACL tear; flex knee to 90 deg and sit on pt’s foot; attempt to pull tibia anteriorly toward you (ACL tear = anterior tibia shift); and then repeat with the tibia in internal rotation to test posteriolateral joint capsule and in external rotation to test posteriomedial joint capsule
  • Lachman Test: for ACL tear; flex knee to approx 20 deg; grasp lower leg, with one hand, use other hand to grasp thight; pull tibia foward while pushing femur back
  • Modified Pivot Shift Test: for ACL tear causing rotary instability; with knee flexed and hanging over end of exam table, internally rotate the tibia and look for abnormal forward rotation of lateral tibial plateau
  • Posterior Drawer Test: for PCL tear- flex knee to 90 deg and sit on pt’s foot; attempt to push tibia posteriorly away you (PCL tear = posteior tibia shift)
  • Sag Sign for PCL tear: inspect if tibia sags posteriorly when knee is relaxed at 90 deg flexion
25
Q

Knee Exam

Tests of meniscal integrity

A
  • Medial McMurray Test: fully flex knee, then hold foot in external rotation and apply valgus force to knee while extended knee
  • Lateral McMurray Test: fully flex knee, hold foot in internal rotation and apply varus force to knee while extending knee
  • Apley’s Meniscal Compression Test: with patient prone, grind tibia against femur in rotating motion to see if it elicits meniscal pain
  • Apley’s Meniscal Distraction Test: same as above, except tibia is pulled away from femur; pain may indicate ligamentous injury or malingering rather than meniscal injury.
26
Q

Lumbar Spine

components of inspection

A
  • posutre, symmetry of shoulders, and pelvis
  • spinal alignment
  • for skin lesions (which could indicate possible underlying neruologic pathology)
27
Q

Lumbar Spine

components of palpation

A
  • spinous processes for tenderness and “step offs” from spondyloisthesis (slip)
  • paraspinous muscles for spasm
  • pelvic bones, SI joints, sacrum, cocyx
  • sciatic nerve area (with knee flexed, palpate between ischial tuberosity and greater trochanter)
28
Q

Lumbar Spine

AROM/PROM

A
  • flexion (75-90 deg)
  • extension (30 deg)
  • R&L rotation (30 deg)
  • R&L bending (35 deg)
29
Q

Lumbar Spine

Test of vertebral motion

A
  • Schober’s Test: make mark at L5/S1 level and another 10cm above that. Have the pt bend forward and record how much the line increases in length (normal is 5-8cm)
  • Alternate Schober’s Test: place index and middle fingers in line w/ lower L spine and see how far they spread (less accurate)
30
Q

Lumbar Spine

tests of nerve root irritation (sciatica)

A

Straight Leg Rase Tests
* Bragard’s SLR: pt does a straight leg lift to the limit of pain; examiner then lowers the leg slightly and dorsiflexes ankle; sciatic pain with this maneuver suggests nerve root irritation rather than only hamstring tightness
* Lasague’s SLR: examiner passively flexes the knee and hip, then extends the knee; sciatic pain with this maneuver suggests nerve root irritation.
* Well-Leg (Cross Leg Raise)- CLR: sciatic pain elicited by SLR on the uninvolved leg suggests space occupying lesion (or herniated disc)
* Hoover Test for Malingering: aka faking it; absence of downward pressure of the opposite heel during straight leg raising indicates malingering (not trying)

31
Q

Lumbar Spine

Localizing nerve root disorder of L4

A
  • disc space: L3/4
  • root: L4
  • DTR: patellar reflex
  • motor resting: quadriceps strength (flex thigh, extend knee)
  • sensory testing: anterolateral thigh, medial calf, medial side of foot
32
Q

Lumbar Spine

Localizing nerve root disorders of L5

A
  • disc space: L4/5
  • root: l5
  • DTR: none
  • Motor testing: walk on heels (dorsiflex), dorsiflex great toe
  • Sensory: posterior calf, posterior thigh, mid dorsum of foot
33
Q

Lumbar Spine

Localizing nerve root disorders of S1

A
  • disc space: L5/S1
  • root: S1
  • DTR: achille’s
  • Motor: walk on toes
  • Sensory: posterior calf, thigh, lat side of food
34
Q

Lumbar Spine

tests of increased intrathecal pressure

A
  • valsalva maneuver (bear down)
  • Milgram Test: if pt can simultaneously hold both legs 2 in off table for 30s, intrathecal pathology is unlikely
35
Q

Lumbar Spine

tests of SI joint

A
  • Pelvic Rock: pt supine, hands on ileum, thumbs on ASIS, push inward on iliac crest
  • Gaenstein’s Test: pt supine on edge of table, one butt cheek extended over edge, pt draws both legs onto chest, then lowers leg while opposite leg remains flexed
36
Q

Lumbar Spine

Tests of related areas causing referred pain to lumbar spine

A
  • check for abd aortic aneurysm and other masses
  • CVA tenderness
  • Pelvic rock test
  • Patrick (Faber) Test: pt supine, place ankle on opposite knee and let hip fully externally rotate; pain in inguinal area = hip pain; if the knee is then pushed down, increased pain from the SI joint is suspected. (PAIN ON SIDE OF CROSSED LEG IS POSITIVE)
37
Q

Cervical Spine

inspection

A

inspect for alignment and head positioning

38
Q

Cervical Spine

palpation

A

spinous processes (C7/T1), paraspinous muscles, crepitus

39
Q

Cervical Spine

ROM

A
  • flexion (chin to chest)
  • extension (look at ceiling directly)
  • R/L rotation: chin aligned with shoulder
  • R/L lateral bending: 45 deg
40
Q

Cervical Spine

localizing nerve root disorders of C5

A
  • disc space: C4/5
  • root: C5
  • DTR: biceps reflex
  • Motor: deltoid (shoulder abduction)
  • Sensory: radial side of upper arm
41
Q

Cervical Spine

localizing nerve root disorders to C6

A
  • disc space: C6
  • root: C5/6
  • DTR: brachioradialis
  • Motor: wrist extension
  • Sensory: radial side of forearm, thumb/index finger (palmar)
42
Q

Cervical Spine Disorders

localizing nerve root disorders to C7

A
  • disc space: C6/7
  • root: C7
  • DTR: triceps reflex
  • Motor: wrist flexion, finger extension
  • Sensory: palmar side of middle finger
43
Q

Cervical Spine

localizing nerve root disorders to C8

A
  • disc space: C7/T1
  • root: C8
  • DTR: none
  • Motor: finger flexion, abduction, adduction
  • Sensory: ring/pinky fingers, ulnar side of forearm
44
Q

Cervical Spine

localizing nerve root disorders to T1

A
  • disc space: T1/T2
  • root: T1
  • DTR: none
  • Motor: finger abduction, adduction
  • Sensory: medial distal upper arm
45
Q

Cervical Spine

Sensory testing to detect common peripheral nerve disorders

A
  • Radial Nerve: dorsal web space between thumb/index finger
  • Median Nerve: palmar aspect of thumb, index, middle, radial side of ring finger
  • Ulnar Nerve: entire ulnar side of palm, includes ring and pinky
  • Axillary Nerve: regimental bade area over deltoid muscle
46
Q

Cervical Spine

Misc Tests

A
  • Fibromyalgia: pinch roll tenderness
  • Swallowing: dysphagia can result from ant vertebral body spurs, ant spondylolisthesis, spinal/vertebral tumors, hematomas, or infections
  • Cervical Compression Test: gently push down on head to compress cervical spine; worsened pain if due to facet arthritis, nerve impingement, neurovertebral foramen narrowing, and muscle spasm
  • Cervical Distraction Test: dently lift head up to reduce pressure on C-spine which may reduce pain and suggest cervical traction as a therapeutic intervention
47
Q

Elbow Exam

what is absent in elbow dislocation?

A

Triangle sign

48
Q

Elbow Exam

testing for lateral epicondylitis

A
  • aka tennis elbow
  • tap on lateral condyle (tender/pain with palp or percuss)
  • forced wrist extension against resistance causes pain at lateral epicondyle
49
Q

Elbow Exam

testing for medial epicondylitis

A
  • aka Golfer’s Elbow
  • percussion test: tap on medial condyle (tender/pain)
  • forced wrist extension against resistance causes pain at medial epicondyle
50
Q

Elbow Exam

varus/valgus stress test

A

w/ elbow extended apply valgus stress (to test UCL) and varus stress (to test RCL)

51
Q

Wrist Exam

Carpal Tunnel tests

A
  • look for atrophy or thenar eminence, sensory deficits in palmar aspect of thumb, index, middle, and radial side of ring fungers
  • reduced 2 pt discrimination
  • Tinel’s: tap over median nerve –> sx reproduced
  • Phalen’s: hold max flexion of wrist for 1 minute –> sx reproduced
52
Q

Wrist Exam

DeQuervain’s Tenosynovitis

A
  • tendonitis of abductor pollicis brevis and longus tendons
  • Finkelstein Test: pt makes fist with enclosed thum, examiner passively flexes and ulnar deviates wrist to stretch tendons and reproduce sx
53
Q

Wrist Exam

what does snuff box tenderness mean

A

scaphoid (navicular) bone fracture

54
Q

Hand Exams

Misc specialized tests

A
  • inspect for Dupuytren’s Contractures (palmar fascial thickening w/ associated fibrous bands, puckering of skin, and +/- contractures of palmar digits
  • palpate for stenosing tenosynovitis (trigger finger): fingers get stuck in flexed position and require manual release
55
Q

Hand Exams

specialized hip exams

A
  • Thomas Test: detects flexion contractures of hip; w/ pt supine, flex hip (knee to chest) and observe if opposite leg raises.
  • Trendelenberg Test: detects glute medius weakness; pt stands on one leg, if pelvis drops to non-wt bearing side there is weakness.
56
Q

Hand Exams

neonate hip exams

A
  • Barlow Click: adduct thigh, downward pressure and femur to attempt disengagement of femoral head from acetabulum
  • Ortolani: slowly abduct and feel for click/listen for sensation
  • Allis Sign: for hip dislocation of shortened femur, infant supine, knees flexed, feet on table; observe height of knees (misaligned is pos)
57
Q

Specialized Ankle Exams

Specialized Ankle Exams

A
  • Anterior Drawer Test of Ankle: stablize ankle, pull heel forward; pos test = tear of ATF ligament
  • Talar Tilt Test w/ Ankle Inversion: ankle inversion w/ palpable gap in lat ankle suggests tear of ATF and CF ligaments
  • Talar Tilt Test w/ Ankle Eversion: ankle eversion w/ palpable gap in medial ankle joint suggests tear of deltoid ligaments (DL)
  • Tarsal Tunnel Test: Tinel sign but for tarsal tunnel (over posterior tibialis pulse)
  • Thompson Test: for achilles tendon rupture; squeeze post calf to see if foot dorsiflexes (it should, if it doesn’t = tear)

PACS (5 decks)

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