Exam 2 Flashcards
Achilles Reflex
- Tests what root?
- Tests S1 (+ S2)
- Seated, leg hanging, hold ankle up & tap tendon, feel PF response
- Jendrassik if needed, document
- Rate 0 to 3+ “Achilles reflex 1+”
Implications of hyperreflexia or hyporeflexia
Hyperreflexia in Upper motor neuron lesion
Hypo/areflexia in lower motor neuron lesion
Babinski Reflex
- Pt supine or sitting, make “J” toward big toe
- Positive: extension & fanning of toes
- Implies UMN lesion
- Document: positive Babinski on left
Sensory Screen
- Areas
- Light touch, ask if feels the same on both sides
- lateral upper thigh
- medial knee
- medial malleolus
- dorsum of foot
- web space of 1st/2nd MTP
- lateral heel
- medial posterior knee
Dermatome & Peripheral nerve for key regions
- Lat upper thigh = L2 or lat fem cut
- Medial knee = L3 or femoral
- Medial malleolus = L4 or saphenous
- Dorsum foot = L5/S1 or superficial peroneal
- Web space = L5 or deep peroneal
- Lateral heel = S1 or sural
- Med post knee = S2 or post fem cut
Light Touch Sensory Testing
- Test in specific region if sensory screen positive
- Pt. closes eyes, “yes” when stimulus felt
- Stimulus 5X within impaired region, randomize
- Pattern of peripheral nerve or spinal nerve dermatome?
- Document: “Sensation to light touch is impaired on the dorsum and absent on the sole of the right foot”
Pin Prick Sensory Test
- 2 parts
- Pt. closes eyes, touch with sharp or dull side of pin
- 5X stimulus within impaired region, randomize
- part 2: impaired area, only sharp moving from middle outward, ask pt. to tell when sensation changes
- Document or draw: “sensation to pin testing is absent in L4 and L5 dermatomes”
Vibration testing
- Pt. closes eyes, “start/stop” vibration
- 128 Hz tuning fork, randomly stop vibration, 5X in impaired region
- Document “Vibratory sense is impaired at the left great toe”
Clinical importance of vibration testing
Often 1st sense to be lost in peripheral neuropathy/diabetes, a good screen
Romberg Test
Sharpened Romburg
- Gait belt, Pt. stands with feet together, crossed arms, closed eyes for 30 sec
- Sharpened: feet heel to toe
- Screens sensory/vestibular
- Positive: takes a step, excessive sway, or can’t hold for 30 sec
- Document: “positive Romburg with loss of balance to the left”
Heel Walking/Toe Walking
- Nerve roots tested
Gait belt
- Pt. walks 10 feet on heels & on toes
- Functional strength: Heel walking (L4-L5) and toe walking (S1)
- Document “Patient is unable to walk on heels”
Myotome Screen
- MMT, compare bilaterally, Pt. seated until calf raises
- Do additional screening if you suspect a peripheral nerve
- Hip flexion (L2), knee extension (L3), ankle dorsiflexion (L4), great toe extension (L5), ankle PF (S1)
90/90 Position Knee Extension ROM
- Purpose, landmarks, normal value
- Assesses hamstring muscle length, PROM only
- Pt. supine w/ hip flexed to 90º and other leg extended
- Landmarks: midline of femur, axis: lat epicondyle of femur, moving: midline of shank toward lat malleolus
- Documentation & normal values: “90/90º PROM R Knee Ext: 155º with a firm endfeel” (muscular)
How much PROM indicates a significant hamstring flexibility deficit?
Less than 125º in supine 90/90 knee extension test
normal is 155º
SLR Position Hip Flexion ROM
- Hamstring muscle length test
- Palpate ASIS, PROM until pelvis rotates, no endfeel
- Landmarks: trunk midline, axis: greater troch, moving: midline femur toward lat epicondyle
- Document/normal values: “Supine PROM R Hip Flexion 62º”
Modified Thomas Test
- Normal findings
- Hip flexor length test
- Pt. sits on edge of table, holds non testing leg, assist to lay back
- Palpate ASIS, test leg at 90º, lower until rotates (Iliopsoas), extend knee to slack Rec Fem, abduct leg to slack TFL
- Normal: thigh parallel to table at midline with knee flexed >100º
- Document: “Iliopsoas and Rectus Femoris flexibility deficit on R”
Patellar Reflex
- Nerve root tested?
- Pt. sitting with leg hanging, tap patellar ligament with hammer
- Jendrassik maneuver (pull hands apart with closed eyes) if needed
- Tests L4 (also L3)
- Rate: 0, 1+, 2+ normal, 3+
- Document: Patellar reflex 2+ with Jendrassik maneuver
Posterior Glide of Tibia on Femur
- Pt. seated w legs dangling
- flex knee to open-pack, palpate joint line, weight shift on tibia while supporting lower leg
Anterior Glide of Tibia on Femur
- Pt prone w knee off table. Leg guitar
- Flex knee to open pack, weight shift to tibia while supporting lower leg, try to palpate joint line
Patellofemoral Glides
Superior/Inferior, use web space
Medial/Lateral, use thumbs
- hyper/normal/hypomobile?
Valgus & Varus Stress Test
- Pt supine. PT cradles calf, applies force w flat hand on femur at joint line. Do in full knee extension, then 20-30º flexion with tibia turned towards you
- Valgus: on outside of leg, stresses MCL
- Varus: on inside of leg, stresses LCL
Thessaly Test
- Pt standing on one leg, hold hands and you rotate around them. Test with leg in full extension, then flexed 20º
- Meniscal tear –> locks/catches/pain at joint line
Lachman Test
- Pt supine, knee flexed 20º (bolster or your knee). Stabilize thigh, pull tibia up with thumb on tibial tuberosity
- ACL injury (more specific than anterior drawer) –> hypermobile, endfeel soft rather than firm
Anterior Drawer Test
- Pt supine w 1 knee flexed to 90º
- Pull tibia w both hands
- ACL injury –> hypermobile
- Assess ROM slowly first, pull fast so muscles can’t guard
Posterior Drawer Test
- Pt supine, knee flexed to 90º
- Push tibia w both hands. Assess ROM slowly first, then test fast
- PCL injury –> hypermobile
Godfrey’s Test
- Pt supine
- Hold both knees up to 90/90 position
- PCL tear –> posterior sag of tibia
McMurray Test
- Pt supine
- Flex knee, IR tibia while extending & flexing. Then ER tibia and repeat.
- Meniscal tear –> catch/pop/pain. Can’t tell if medial or lateral
Quad set with inferior patellar compression
- PT supine
- Hold patella w webspace while pt flexes quads
- Testing if patellofemoral pain due to articular surface lesion. Positive = pain
Quad set with posterior patellar compression
- Pt supine or long sitting w towel roll under knee
- Gently squash patella, pt contracts quads
- Pain = positive, articular patellofemoral lesion
LAQ with posterior compression
- Pt sitting w feet dangling
- Squash patella w palm, stabilize posterior knee, pt extends knee
- Positive = pain, patellofemoral articular lesion
LAQ with inferior compression
- Pt sitting w dangling feet
- Hold patella inferior w webspace while pt extends knee
- Positive = pain, patellofemoral articular lesion
Long Axis Hip Traction
- Pt supine, mobilization belt around pelvis just below ASIS
- put hip in resting position (30 FL, 30 ABD, slight ER), hold ankle or thigh, weight shift
- Document amt of motion / endfeel / change in symptoms
Lateral Hip Traction
- Mobilization belt attached to table on opposite side
- Pt supine, close to side of table, hip in 1) resting position, and 2) hip at point in FL/IR/ER that is end range/provocative
- Towel burrito!! W/o belt, hands close to joint line, hug femur. w/ belt around your butt. weight shift
- Document amt. mobility/change in symptoms
Compression/scour test
- Determine intraarticular composition to symptoms
- Pt supine at side of table
- Compress down knee or prox. femur if PFJ problems
- Flex to 90º and full ADD, then compress & move in flexion/ABD arc
- neutral ER/IR
- Positive = symptoms reproduced
FABER test
- Screens hip/lumbar/SIJ dysfunction. Positive = reproduction of symptoms OR asymmetry
- Pt supine. Flex, ABduct, and ER leg by putting foot on thigh, stabilize opposite ASIS, look at resting distance from table, gentle overpressure if no symptoms
FAI (Femoral Acetabular Impingement) test
- Looks for impingement of anterior superior labrum/acetabular rim
- Pt. supine, hands on distal femur & tibia, flex/ADD/IR hip to max available ROM, gentle overpressure in all 3 directions if no symptoms
- Positive: ant. hip symptoms
Ober test/Modified Ober
- TFL/IT length test
- Pt. sidelying close to edge, bottom leg flexed 90/90, stabilize pelvis in neutral**, hand cradling medial knee
- Flex knee to 90º, ABD & extend hip to 0º, slowly adduct (don’t allow IR/FL) until pelvis tilts
- Modified Ober: can leg go further if knee extended?
- Negative: femur reaches 0º or Add
Ely Test
- Rectus femoris muscle length
- Pt. prone or sidelying with femur held in neutral
- Prone: stabilize pelvis, flex knee
- S/L: cradle femur, flex knee
- Positve: hip flexes as knee is passively flexed
Name 7 Red Flags
- Fever/chills/night sweats
- Recent unexplained weight loss/gain
- Parasthesias (tingling/abnormal sensation)
- Malaise/fatigue
- Unexplained nausea/vomiting
- Shortness of breath
- Dizziness
Areas that refer pain to the hip
- Lumbar spine
- SI joint
- Knee
Most common areas where the hip refers pain
- anterior groin
- medial knee
- buttock
- greater trochanter
- anterior thigh
- (also SI/lumbar spine)
Squat Dorsiflexion
- DL or SL, squat maximally
- note compensations
- stationary arm: floor
- moving arm: shaft fibula
Knee-Wall Measure
- DL or SL measure of composite DF
- Furthest distance where heel stays on floor w knee touching wall, watch for femur IR*
- Measure from wall to prominent toe, compare bilaterally, no “normal”
Anterior Reach
- Dynamic/balancing measure of composite DF
- stand on 1 leg w toe touching yardstick, squat maximally & tap
- document quality & quantity motion!
Ankle DF in STJN
- Pt. prone w feet off table
- Find subtalar joint neutral, landmarks = fibular shaft, base of calcaneus
- Measure in extension, then 90º knee flexion
- PROM only, should find 10º increase going to flexed knee
STJ Inversion/Eversion ROM
- Draw lines bisecting calcaneus and lower 1/3 leg
- Assess motion & end feel
- Firm in inversion, hard in eversion
First Ray Posture and Mobility
- Find STJN, pinch w thumb on 1st MTP, other thumb on rest of plantar surface
- Document plantar flexed/dorsiflexed/neutral first ray
- In line with other MTPs? Normal mobility = a thumb’s thickness into DF and PF
Talonavicular Joint Motion
- Place calcaneus in full eversion first, then inversion
- Grip navicular with other hand (tuberosity on medial side), move in eversion/inversion
- Should be more mobile in everted position
Calcaneocuboid Joint Motion
- Pt prone, place calcaneus in full eversion first, then inversion
- Pincher grip on cuboid, assess transverse plane mvt (ABD/Add)
- Should be more mobile in eversion
Talocrural distraction
- Pt supine, foot by head hole, belt around ankle to stabilize
- Ankle in resting 15º PF, weight shift posterior to distract
Ankle Posterior Drawer Test
- Pt supine w foot off table, maybe belted down to prevent knee movement
- Place LE in slight IR, ankle in 15º PF
- Stabilize distal shin, weight shift with web space over talus
- Positive: hypermobile, ankle sprain
- Hypomobile: DF limited
Ankle Anterior Drawer Test
- Pt prone with foot off edge
- LE slightly IR, ankle in 15º PF
- stabilize distal tibia, weight shift with webspace over calcaneus, don’t allow DF*
- Positive: hypermobile/endfeel not firm –> often ATFL, also ATT
- Hypomobile: PF limited
Thompson Test
- Pt prone or kneeling
- Gently squeeze calf and foot should plantar flex
- Positive: no foot PF –> complete rupture of Achilles
Skill Based Approach to documentation (3 components)
Ability to accomplish specific goal with
1) consistency (document accuracy)
2) flexibility (varied environments)
3) efficiency (physical & mental automaticity- document time to complete/HR change)
Velocity requirements for
- Household walking
- Community walking
- Typical comfortable velocity
- 0.4 m/s = minimum for household
- > 0.8 m/s = unlimited community walking
- typical walking: 1.3-1.5 m/s (3 mph)
Where do upper motor neurons synapse on lower motor neurons?
Anterior horn of the spinal cord
Upper Motor Neuron lesion - 4 signs
- Muscle weakness
- Hyperreflexia
- Clonus (‘beating’ of gastroc)
- Abnormal reflexes (Babinski)
Lower Motor Neuron lesion (4 signs)
- Muscle weakness
- Hyporeflexia
- Fasciculations (twitching)
- Atrophy
Clinical presentation of autonomic involvement
- Ringing ears, dizziness
- Blurred vision, photophobia (light sensitivity)
- Lacrimation (tearing), Rhinorrhea (runny nose), sweating
- Increased HR, vasodilation, flushing
- Generalized loss of muscle strength
Skin Signs for Peripheral Nerve Lesions
- Dryness- loss of sweat glands
- No goosebumps - loss of pilomotor response
- Loss of sensation, loss of vasomotor tone
- Scaly or smooth/shiny skin
- Nail changes - brittle, irregular, no luster
Neurologic Red Flags (4)
- Bowel/bladder and/or sexual dysfunction –> spinal cord
- Onset of peripheral symptoms with acute neck/back pain
- Severe headache with other neurologic signs (subarachnoid hemorrhage)
- Fever + stiff neck (meningitis)
Dermatome and Myotome Definitions
- dermatome = sensory band of skin innervated by one spinal nerve
- Myotome = all muscles innervated by one spinal nerve
Polyneuropathy
- Multiple peripheral nerves affected, usually bilateral
- Diabetes: sock/glove pattern
- Other causes: nutrition, infection, autoimmune, toxins, meds, chemo
Berg Balance Scale - Fall risk cutoff
45 (out of 56 - 14 tests with 4 possible points each)
No assistive devices!!
Timed Up & Go Test (TUG)
- fall risk
3 m path (10 ft) from chair
Start timing at GO
13.5 sec = fall risk cutoff
FGA (functional gait assessment) fall risk
22 (out of 30)
