Back and Lower Extremity Exam Flashcards
Stance of the Gait cycle
foot on the ground- weight bearing
Swing of the gait cycle
foot moves forward- non weight bearing
Lumbar Spine Major ROM
Flexion
Extension
Side Bending
Rotation
Muscle Strength Scale : 0
no movement
Muscle Strength Scale : 1
muscle twitch without joint movement
Muscle Strength Scale : 2
movement only with gravity eliminated
Muscle Strength Scale : 3
movement against gravity only
Muscle Strength Scale : 4
movement against gravity + some resistance
Muscle Strength Scale : 5
movement against gravity + full resistance
L4 dermatome
medial side of foot to big toe
L5 dermatome
top of foot and plantar surface
S1 dermatome
lateral foot to little toe
L4 reflex
patellar tendon
S1 reflex
achilles
L4 major motor
anterior tibialis (dorsiflexion)
L5 major motor
extensor hallucis longus (big toe up)
S1 major motor
Gastroc-soleus ( toe raises)
Most common area of injury and source of pain in the low back?
L5
Small Intestine Viscerosomatic Reflex Levels
T10-11
Colon and Rectum Viscerosomatic Reflex Levels
T12-L2
Bladder Viscerosomatic Reflex Levels
T12-L2
Uterus Viscerosomatic Reflex Levels
T12-L2
Prostate Viscerosomatic Reflex Levels
T12-L2
Ovaries/ Testes Viscerosomatic Reflex Levels
T10-11
Why is a disc herniation most common L5-S1?
The posterior longitudinal ligament narrows as it descends- makes herniation easier. Usually one sided- rarely bilateral
Scoliosis
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)
Spondyloarthritis: axial
Source of chronic low back pain in young people
Associates with uveitis (eye infection), psoriasis, and IBS
Ankylosing Spondylitis
chronic inflammatory disease of spine with progressive stiffening, often involves hips and peripheral inflammatory signs. +HLA-B27
Osteoarthritis
“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
Osteoporosis
Thinning of bone
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
Sciatica- causes
Lumbar radiculopathy or peripheral nerve compression
Sciatic nerve roots
L4, L5, S1, S2, S3
Sciatica- symptoms
Pain unilateral from L5, through buttock, down lateral leg to the lateral foot.
Often shooting; worse with sitting or Valsalva
Sciatica Straight Leg Raise Test
Raise leg- if this reproduces the pain, lower leg just to the point of no pain and then dorsiflex the foot. If pain is reproduced = sciatic nerve pain.
Most commonly positive if found between angles 40-60 degrees
What motion provides the most sensitive exam for pathology of the hip?
internal and external rotation
Complaint of lateral hip pain?
Check trochanteric bursa
Trendelenberg Test- what does it evaluate?
Gluteus Medius- keeps the hips stable during the gait cycle
Trendelenberg Test- procedure
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.
Thomas Test- what does it evaluate?
Psoas muscle dysfuntion.
(For flexion contractures of the hip due to tight Psoas (Iliopsoas))
“Thomas has a tight illiopsoas:
Thomas Test procedure
Pt. Supine:
Flex hip(s) with so thigh touches abdomen
Upon extending one leg, it should should extend to lie flat on table
Positive test if hip does not fully extend
Ober Test- what does it evaluate?
IT Band
Ober test- procedure
Pt lateral with side evaluating up
Hold leg, flex the knee to 90, abduct it and let go. It should fall back- if it does not = IT band contracture
Patrick or Faber Test- what does it evaluate?
The hip joint
–> Not the labrum
Patrick or Faber test- set up?
The figure 4 one, press on ASIS of leg extended and knee of leg bent.
Faber stands for?
Flexion
ABduction
ER: External Rotation
Leg Length?
ASIS to medial malleolu
discrepency in leg length?
Think: shortended femur or tibia. Scoliosis, or hip deformity
Psoas strength test- procedure?
Seated, raise knee, resist pressure down
Piriformis exam procedure?
Primarily by palpation
Supine, knees to chest and hold heels, rotate knees left and right comparing ROM
Pes anserinus- what attaches?
sartorius, gracilis, semitendinosus
bulge sign
sign of minor effusion in the knee. Milk downward, apply medial pressure then tap and look for a fluid wave.
balloon sign
sing of a large effusion in the knee
balloting
technique to examine a large effusuion in the knee. Compress suprapatellar pouch, use other hand to sharply press patella to feel for fluid returning to suprapateallar pouch. Also for large effusions
Housemaids Knee
prepatellar bursitis- swelling over patella from excessive kneeling
Anserine Bursitis
Medial aspect of knee – tibial plateau
Excessive running common cause
Also from valgus knee deformity (Q angle) and arthritis
Baker’s Cyst
Cyst in the popliteal fossa, most often medial
Leg extended check posterior/medial aspect of knee for swelling or fullness, sometimes tenderness as well
Pain with tendonitis?
occurs more with active ROM
Pain with bursitis?
Is equal with passive or active ROM
Patellofemoral grind test- technique
The pt lays supine with knees extended. You compress the patella against the femur and instruct the pt to tighten their quads- asses for roughness of motion, crepitus, or pain
Patellofemoral grind test- test when?
The pt c/o of knee pain when going up stairs or rising from a chair. Consider chondromalacia or patellofemoral syndrome
Apprehension test of the knee- evaluates what?
Tests for dislocation or subluxation of the patella
Apprehension test of the knee- technique?
Attempt to manually dislocate the patella laterally and observe the patients facial expression
Anterior Drawer Sign- evaluates what?
The ACL
Anterior drawer sign- technique
The pt is supine and knees and hips flexed to 90 degrees, grasp the femur with one hand and the tibia with the other and attempt to move the forward.
Lachman Test evaluates what?
The ACL
Lachman Test- technique?
Pt supine, knees flexed to 15 degrees. Grasp tibia with one hand and femur with the other and move them in opposite directions- asymmetric forward movement of the tibia suggests a positive test- ACL tear
Posterior Drawer Sign evaluates what
The PCL
Posterior draw sign technique?
Pt supine with hips and knees flexed to 90. Push the tibia posterior- compare to opposite side. Movement suggests PCL tear
McMurray Test evaluates what?
Meniscus
Apley’s compression test evaluates what?
Meniscus
McMurray test technique?
Pt supine- grasp heel and fully flex the knee. Hold the knee joint with the other palpating along the joint line. Rotate the lower leg internally to engage the lateral meniscus and extend the leg. Pop’s or clicks during motion are a poise test. Not very specific- Can rotate externally to test medial meniscus. Heel point to the meniscus being tested
Apley’s compression test technique
Pt is prone with knees flexed to 90. Stabilize the thigh with one hand while pushing down to compress the medial and lateral menisci. Rotate the heel during compression notate any pain.
Key features of patient presentation for a meniscal tear?
- 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.
Thessaly Test evaluates what?
Meniscus
Thessaly Test technique
The dance!
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.
Valgus Stress Test evaluates what?
Medial collateral ligament
Varus Stress test evaluates what?
Lateral colleteral ligament
Valgus Stress Test- procedure?
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
Varus Stress Test- procedure?
Adduction Stress Test
Patient supine and flex knee slightly
One hand against lateral knee the other around medial ankle
Push laterally against knee while medial against ankle
Homans sign evaluates for what?
DVT
Homan’s sign procedure
Dorsiflex patient’s ankle with leg extended at knee. Pain in calf is a positive sign
Thompson’s test evaluates what?
Achilles rupture
Thompson’s test procedure?
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.
Pes Planus
loss of longitudinal arch of foot- flat feet
Hallux Valgus
bunion- abnormal abduction of big toe
pseudogout
calcium pyrophosphate crystal deposition (normal gout is uric acid crystals)
Plantar Fasciitis
heel and arch pain especially with initial weight bearing in morning
Rheumatoid Arthritis
compressive tenderness
Hammertoes
hyperextension of MTP joint and flexion of IP joint (second toe most common)
Corns
painful thickening of skin from abnormal pressure over bony prominence (fifth toe)
Plantar Warts
viral, plantar aspect of foot, thickening of skin with dark stippling spots
Onychomycosis
Fungus infected nails
ligaments of the medial malleolus
deltoid
ligaments of the lateral malleolus
posterior talofibular, calcanoefibular, anterior talofibular
joints of the hinge joint are
tibiotalar and talocalcaneal joint (subtalar)
Talar Tilt Test- procedure
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
according to the ottawa rules do you preform an X-ray if the pt is unable to bear weight or walk more then 4 steps in the ER
yes-If there is pain in the mid-foot or around the the malleolus
according to the ottawa rules do you preform an X-ray if there is tenderness in the posterior malleolar area?
only of if there is pain around the malleolus as well of the pt cannot bear weight
Acording to the ottawa rules do you preform an X-ray if there is pain in the mid-foot
Only if there is tenderness at the base of the 5th metatarsal or the pt cannot bear weight