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My PCM 2 > Back > Flashcards

Back Flashcards

1
Q

Lumbar spine inspection- posture

A

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?

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2
Q

Lumbar spine inspection: Gait

A

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

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3
Q

Lumbar spine palpation

A 
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

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4
Q

Muscle strength scale

A

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

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5
Q

neurologic exam

A

reflexes
sensation
strength

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6
Q

Lumbar neuro exam: L4

A

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

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7
Q

Lumbar neuro exam: L5

A

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

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8
Q

Lumbar neuro exam: S1

A

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

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9
Q

common causes of low back pain

A 
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”
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10
Q

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

A

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

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11
Q

Scoliosis

A

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)

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12
Q

Spondyloarthritis: axial or peripheral

A

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

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13
Q

Reiter Syndrome

A

Triad of arthritis, conjunctivitis/uveitis, urethritis.

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14
Q

Osteoarthritis

A

“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

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15
Q

Osteoporosis: Thinning of bone

A

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

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16
Q

Sciatica

A

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

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17
Q

Straight Leg raise

A

(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

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18
Q

Pelvic Unit dysfunctions

A 
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
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19
Q

Synovial Joints

A

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.

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20
Q

What type of joint is the hip?

A

spheroidal, synovial

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21
Q

Hip ROM

A

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˚)

22
Q

Inguinal ligament- inspection

A

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

23
Q

Trendelenburg test

A

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

24
Q

Thomas test

A

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

25
Q

Patrick or Faber Test

A

“F”lexion “AB”duction “External Rotation”

Most specific for hip joint.
Trying to reproduce their pain.
May elicit SI tenderness

26
Q

Special hip tests

A

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
27
Q

Knee/ Lower leg assessment

A

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

28
Q

Knee: structures to examine

A 
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

29
Q

Palpate Knee

A 
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
30
Q

Knee: testing ROM

A

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˚

31
Q

Knee tests: bursitis

A

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

32
Q

Patellofemoral grind test

A

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

33
Q

Knee apprehension test

A

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

34
Q

Knee testing: ACL

A

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

35
Q

what’s important about ACL testing?

A

Always test both knees

Asymmetric findings most important

36
Q

Knee testing: PCL

A

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

37
Q

McMurray Test

A

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%

38
Q

Apley’s Compression test

A

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

39
Q

Key features of patient presentation for a meniscal tear include:

A

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.

40
Q

Thessaly test

A

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.

41
Q

Knee testing: MCL/ LCL

A

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

42
Q

Lateral Collateral Ligament

A

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

43
Q

Lower Leg Exam: Calf and Achilles

A

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.

44
Q

what does the thompson test test?

A

achilles integrity

45
Q

What does homan’s sign indicate?

A

calf thrombosis

46
Q

Ankle/Foot Pathology

A

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

47
Q

Ankle/ Foot anatomy

A 
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)
48
Q

ankle/ foot exam

A

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

49
Q

Talar Tilt Test

A

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

50
Q

Ankle Sprains:

A

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

51
Q

Ottawa Rules

A

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

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