Back and Lower Extremity Exam - Schaffner Flashcards
What are the things to note in the inspection component of the physical exam?
Posture, position, deformity, edema, erythema, lesions, symmetry
Each joint has its own range of motion with either a hard or soft…
End feel.
What are the three components of the neurologic testing that should be assessed?
Sensation (soft, sharp,vibration), Reflexes, Strength
What are the ROM associated with the lumbar spine?
Flexion
Extension
Side bending
Rotation
Muscle strength is documented on a scale of?
0-5
In the lumbar neuro exam where do we test L4?
Motor at Anterior Tibialis
Reflex at patellar tendon
Sensation on dorsal aspect of digit 1 and first meta tarsal
Where do we test L5?
Motor at extensor hallucis longus
Reflex - none
Sensation - L5 dermatome, plantar surface of metatarsals-calcaneous
Where do we test S1?
Motor - gastroc-soleus (repetitive toe raises)
Reflex - Achilles tendon
Sensation - S1 dermatome, dorsal foot except for digit 1
Cord levels of small intestine?
T10-11
Cord levels of colon and rectum?
T12-L2
Cord levels of bladder?
T12-L2
Cord levels of ovaries and testes?
T10-11
Cord levels of the uterus?
T`2-L2
Cord levels of the prostate?
T12-L2
List a handful of common causes of low back pain
üSprains, Strains, Muscle Spasms & General Deconditioning
üHerniated 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”
What is the most common area of injury or source of pain from the lumbar spine?
How is the posterior longitudinal ligament involved?
L5-S1
Posterior Longitudinal Ligament narrows as it descends down lumbar spine making herniation of the disc into the cord space easier. Rarely bilateral
What is described here?
Hereditary, chronic inflammatory disease (HLA-B27)
Pronounced lumbar lordosis
Sacroiliac tenderness (sacroilitis) often the source of their “back pain”
Other body systems affected as well: uveitis (photophobia,pain)
general synovial arthritis (hip/shoulder most common) enthesopathathies (inflammation at tendon insertion)
Ankylosing spondylitis
Osteoarthritis, or degenerative disc disease is common in the lumbar spine, particularly at L5-S1, and is worse here since it is a transition point. What is involved in this condition?
–Deterioration and loss of cartilage and normal bone
–Low grade inflammatory issue
What two things can cause Sciatica? What must be present?
Pain must radiate below the knee.
Either lumbar radiculopathy or peripheral nerve compression
How would you test for sciatica?
Straight leg raise will let you determine sciatica vs. hamstrings.
How is the straight leg raise performed?
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
What does the Trendelenburg test evaluate?
Gluteus medius muscle.
If the pelvis cannot remain level, the gluteus medius is weak on the standing leg side.
What does the Ober test evaluate? How do you do it?
–Evaluates iliotibial tract (ITB syndrome)
–Patient lies on side opposite side being tested
–Flex knee to 90˚ and abduct leg at hip as far as possible
–Release leg in question
•Normal test = leg returning to normal position
•Abnormal test = leg remaining in abducted position
What does the Thomas test evaluate?
How is it performed?
What is a positive test?
–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
What is the Patrick test also known as?
What is it for?
The Faber test.
“F”lexion “AB”duction “External Rotation”
Most specific for hip joint.Trying to reproduce their pain. May elicit SI tenderness
You measure leg length between what two landmarks?
Measure distance from ASIS to medial malleolus
How do you perform the psoas strength test?
•Seated, raise knee, resist pressure down
How is the piriformis examined?
Primarily by palpation
Supine, knees to chest and hold heels, rotate knees left and right
comparing ROM.
Name a bunch of pelvic unit dysfunctions.
•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
What is housemaids knee, and how does one get it?
•Prepatellar Bursitis: Anterior
–Dome swelling over patella associated with tenderness
–From excessive kneeling
What is a common cause of anserine bursitis?
–Excessive running common cause
–Also from valgus knee deformity (Q angle) and arthritis
Where is a Baker’s cyst found? How do you check for one?
–Cyst in the popliteal fossa, most often medial
–Leg extended check posterior/medial aspect of knee for swelling or fullness, sometimes tenderness as well
How do you check for bulge sign?
Bulge Sign: minor effusions in Suprapatellar pouch
How is ballotting done?
Ballotting: Compress suprapatellar pouch, use other hand to sharply press patella to feel for fluid returning to suprapateallar pouch. Also for large effusions
What does patellofemoral grind test identify?
How is it done?
Chondromalacia or patellofemoral syndrome
Patient supine with knee extended
Compress patella against femur
Instruct patient to tighten quads.
Assess for roughness of motion, crepitus, pain
How do you perform the apprehension test, and what is it good for?
Tests for dislocation or subluxation of patella
Attempt to manually dislocate patella laterally
Observe patient’s facial expressions
What is the meaning of a positive anterior drawer sign?
ACL tear
What is the Lachman test good for?
How is it done?
Only 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
What is the result of a + Posterior drawer sign?
PCL tear
What does the McMurray test evaluate?
How is it done?
Meniscus
- 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.
What does Apley’s compression test evaluate?
How is it done?
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
What are three key features of 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.
In the McMurray test, with the knee at 90 degrees how would you test the medial meniscus?
Externally rotate tibia = heel points in/toward midline
Extend knee feeling for click, looking for pain
In the McMurray test, with the knee at 90 degrees how would you test the lateral meniscus?
Internally rotate tibia = heel points out/away from midline
Extend knee feeling for click, looking for pain
How specific is the McMurray test?
Not very sensitive test for meniscus, ie, can still have injury without positive findings.
Specificity=85-95%
Sensitivity=50-65%
What is a more sensitive and specific test for meniscal injury or tear than McMurray?
How is it done?
Thessaly test
Standing, rotatory motion on one leg bent to 5-10 deg, and again at 20 degrees.
What stress test is used to evaluate the MCL?
How is it done?
Valgus 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
What is the stress test for the LCL, and how is it done?
•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
What does Homan’s sign look for?
How is it done?
Evaluates for DVT (deep venous thrombosis)
Dorsiflex patient’s ankle with leg extended at knee. Pain in calf is a positive sign.
What does the Thompson test evaluate?
How is it done?
Tests achilles
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.
What ankle ligaments are most commonly injured in sprains?
Anterior Talofibular (ATF = Always tears first)
Calcaneofibular
How do you test for Morton’s Neuroma?
Compress the forefoot
How is the Talar Tilt Test performed?
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
A high ankle sprain impacts what joint?
Syndesmosis between Fibula and Tibia
According to the Ottawa rules, you would perform and X-ray 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. Unability to weight bear immediately OR more than 4 steps in ED
What is Kleiger’s test for?
High Ankle sprain, Deltoid ligament
Hammertoes:
•hyperextension of MTP joint and flexion of IP joint (second toe most common)
What is this?
•Onychomycosis: Fungus infected nails
What are corns?
•painful thickening of skin from abnormal pressure over bony prominence (fifth toe)
