Exam 2 Flashcards
Carpal Tunnel Syndrome Tests
A 45 year old right hand dominant male with history of hypertension complains of left wrist pain and weakness. Upon palpation of the radial artery, you find the pulse feels brisk (normal).
How would you grade his pulse?
a) 0
b) 1+
c) 2+
d) 3+
e) 4+
2+
Ankle Flexion
M?
pt instructions?
(plantar flexion)
Gastrocnemius, soleus, plantaris, tibialis posterior
“Point your foot toward the floor.”
Biceps reflex
–C5
•Arm partially flexed at elbow with palm down
Active ROM of the wrist: extension- what do tell pt
–“With your palms facing the floor, point your fingers toward the ceiling”
Chronic gout sympt
bony destruction, deposit of tophi (crystallized uric acid).
May or may not be associated with inflammation
Active ROM of the wrist: flexion - what do tell pt
–“With your palms down, point your fingers toward the floor”
scale for grading reflexes: 1+
physical findings
- somewhat diminished
low normal
An 18 year old male with no significant medical history presents with right knee pain after playing football. On physical examination, you note increased swelling and tenderness over the right knee. He has significant forward excursion of the right tibia when you perform the Lachman test when compared with the left. Based on this information, what is your most likely diagnosis?
a) Medial collateral ligament tear
b) Lateral collateral ligament tear
c) Anterior cruciate ligament tear
d) Posterior cruciate ligament tear
c)Anterior cruciate ligament tear
Anatomic Snuff Box
–Hollowed out depression distal to the radial styloid process
–Instruct the patient to perform wrist pronation and extension of their fingers and thumb
–Radial border?
- Abductor pollicis longus
- Extensor pollicis brevis
–Ulnar border?
•Extensor pollicis longus
–Floor?
•Navicular (also know as the scaphoid) bone
A 46 year old male, recreational softball player, with no past medical history complains of left posterior lower leg pain after an injury. He is well known to you and his last complete physical was 8 months ago.
Which of the following components of the history would be important in your evaluation of his symptoms?
a) The core components of the social history
b) Foot dominance and hand dominance
c) Weight bearing ability after injury
d) Weight bearing ability after injury and at time of evaluation
a)Weight bearing ability after injury and at time of evaluation
Drop Arm Test
- Assesses: Rotator cuff tear
- Technique:
- Pt full abducts arm
- Ask pt to slowly lower arm to side. If tear present, arm will drop from position of 90°
- If pt can hold arm in abduction, tap on forearm will cause arm to fall if tear is present
Deep Vein Thrombosis (DVT)
tight, bursting pain –> may be painless, swollen, increased warmth
aggravated by walking
relieved by leg elevation
M grading chart: 4
- good
complete ROM agiainst gravity with some resistence
Monoarticular Joint Pain suggests
injury, monoarticular arthritis, tendinitis, bursitis
“FOOSH” Injury
“Fall On Out Stretched Hand”
tender anatomic snuff box
scaphoid - most common carpal bone injury
Apley Scratch Test
•Demonstrates:
–External Rotation & Abduction
–Internal Rotation & Adduction
–Combination of movements
•Note:
– limitation of motion
– normal/abnormal motion
– symmetry
Active Range of Motion Testing means pt moves….
unassisted
Hypesthesia
decreased sens
Soft Tissue Palpation of Elbow: Zone 3
Lateral aspect
- Wrist Extensors:
- Brachioradialis: only muscle that extends from distal end of one bone to the distal end of another
- Extensor Carpi Radialis Longus and Brevis
- Lateral Collateral Ligament
- Annular ligament
Sensation Testing of Foot and Ankle
Dermatomes:
L4, L5, S1
Triceps reflex
–C7
- Flex arm at elbow
- Strike above elbow from behind
A 34 year old left-handed male with no past medical history complains of right hand and wrist pain. He works as a professional house painter. As part of the examination, you have him cover his thumb with the fingers of his right hand (forming a fist). You then gently deviate the patient’s right wrist towards their right ulna. This maneuver reproduces the patient’s pain. The most likely diagnosis is:
a) Trigger finger
b) Gout
c) Dupuytren’s Contracture
d) De Quervain’s Tenosynovitis
e) Osteoarthritis
a)De Quervain’s Tenosynovitis
Muscle Strength Testing
Supination
- stand in front of pt, support flexed elbow, prox to elow joint
* pt elbow at their side - pt in pronation
- thenar eminence on radius, wrap fingers around ulna
- pt supinate and you resist
- increase P to detm max resistance
most common causes os sensory disturbances
DM
thiamine dific
neurotoxin dmg (ex: insecticides)
An 82yo female presents to your office complaining of changes in the appearance of her fingers on both hands. You note on exam that she has fixed flexion of the DIP joints with hyperextension of the PIP joints. This is most commonly referred to as?
A.Rheumatoid Arthritis
B.Swan neck deformity
C.Boutonniere deformity
D.Heberden’s nodes
A.Swan neck deformity
M grading chart: 5
- normal
complete ROM agiainst gravity with full resistence
scale for grading reflexes: 0
physical findings
- no response
abnormal = usually indicative of N dmg and/or disease
Passive Range of Motion Testing means pt moves ….
by examiner
•Dorsalis Pedis Pulse
lateral to EHL
medial to EDL
distal to navicular
An 80 year old female with no significant medical history presents to your office with a tender mass and swelling of the left popliteal fossa. She denies any trauma. Upon examination the mass is most apparent when the patient is standing and the left knee is fully extended. The mass disappears when you flex her left knee. This is most likely:
a) Anserine Bursitis
b) A Baker’s cyst
c) An effusion
d) Housemaid’s knee
e) Osteoarthritis
a)A Baker’s cyst
A 31 year old female with no past medical history presents to your office complaining of right knee pain. She states she is a recreational runner and runs 3 miles, 3 times a week. Upon palpation of the anteromedial side of her right knee you feel effusion and thickening. This is most suggestive of:
a) Prepatellar bursitis
b) Superficial infrapatellar bursitis
c) Anserine bursitis
d) Deep infrapatellar bursitis
●
a)Anserine bursitis
Sensation Testing: light touch
cotton swab
A 24 year old male with no past medical history presents with left knee pain after playing baseball. On exam you position the patient in supine position with his left knee flexed to 90 degrees and foot flat on the table. You cup your hands around the knee with your thumbs on the medial and lateral joint lines and your fingers on the medial and lateral hamstrings. You then push the tibia posteriorly and observe backward movement of the tibia on the femur. You then perform this test on the right side and compare bilaterally. If there is an isolated left PCL tear you would observe:
a) Decreased laxity of the PCL of the left knee as compared to the right knee causing the proximal tibia to jerk forward
b) Increased laxity of the PCL of the left knee as compared to the right knee causing the proximal tibia to jerk forward
c) Decreased laxity of the PCL of the left knee as compared to the right knee causing the proximal tibia to have increased backward movement
d) Increased laxity of the PCL of the left knee as compared to the right knee causing the proximal tibia to have increased backward movement
Increased laxity of the PCL of the left knee as compared to the right knee causing the proximal tibia to have increased backward movement
PCL pevents tibia from slipping backward on femur – posterior drawer sign
Lateral epicondylitis aka Tennis Elbow
- Overuse syndrome
- Repetitive wrist extension
- Commonly occurs as a result of occupation rather than tennis
- Maximal tenderness to palpation is at the origin of the extensor carpi radialis ~ 1cm distal to lateral epicondyle
- Pain and decreased strength with hand grip, supination and extension
Medial Epicondylitis aka Golfer’s Elbow
- Overuse syndrome
- Repetitive wrist flexion
- Common in golfers, bowlers, archers and manual laborers
- tenderness to palpation is just distal to the medial epicondyle near the insertion of the wrist flexor tendons
- Reproducible pain with wrist flexion and pronation
- Not as common as lateral epicondylitis
Pattern of Examination is the same for all musculoskeletal structures
- Skin
- Bone
- Joint
- Soft tissue
•Posterior Tibialis Pulse
–behind and slightly below the medial malleolus
This 45 year old right-hand dominant male with no significant past medical history has had right shoulder pain for 3 months. The pain is worse when lifting objects above his head. He is a sanitation worker and enjoys gardening on the weekends. On physical exam, inspection of the shoulder was normal. You identify the spine of scapula and palpate along it to the bony lateral endpoint and elicit tenderness in the region inferior to that endpoint.
The most lateral bony structure you palpated after identifying and palpating the spine of scapula is the:
a) Acromioclavicular joint
b) Coracoid process
c) Acromion
d) Lesser tubercle of the humerus
Acromion
tx Scaphoid Fracture by
: preventing supination and pronation of the wrist with:
long arm cast or short arm thumb spica or Cast and shoulder splint
Thompson test
Osteoarthritis (OA)
related mostly to previous trauma, overuse
mcp joints spared
4 Cardinal features of inflammation
–swelling, warmth, redness and pain
Inversion
M?
instructions?
Peroneus longus and brevis
“Bend your heel outward.”
Achilles Tendon Rupture
•Disruption of the Achilles tendon (heel cord) usually occurs 5 to 7 cm proximal to the insertion of the tendon on the calcaneus
- •Sudden, severe calf pain described as a “gunshot wound” or as a “hit from a racquet.”
- Commonly affects middle-aged men who play quick, stop-and-go sports such as tennis and basketball
- Partial tears of the tendon can also occur at the calcaneal insertion
- •can be described as strains or a “calf pull.”
how to do Allen test
- pt open close hand several times and then make tight first
* forces blood out of palm - pressure radial and ulnar A
- pt open fist
* palm = pale - release 1 A while maintaining other
- color return = 3-5 s
- delayed return = compromise of A released
Rheumatoid Arthritis (RA) deformities
–Swan neck deformities of fingers
- Fixed flexion of the distal inter-phalangeal (DIP )joints with hyperextension of the PIP joints
–Boutonniere deformity
- Flexion of the proximal inter-phalangeal (PIP) joints with
Thompson test is most reliable
within 48 hours of rupture
Range of Motion; shoulder mvmt
Patient:
- abducts arms to 90° with palms down
- turn palms up bring palms together over head
- Demonstrates full bilateral
- abduction
- Compare both sides
Diabetic Foot Ulcers
common complication of DM
A patient who presents to clinic complaining of hand pain says she was told by a friend that it is most likely carpal tunnel syndrome. Upon assessing the patient, you note the following findings. Which would be suggestive of carpal tunnel syndrome?
A.Hand pain when holding both hands in acute extension
B.Numbness and tingling when tapping over the course of the radial nerve
C.Symptoms related to compression are evident in all of the fingers
D.None of the above
none of above
A 23yo female TouroCom Medical student went skateboarding over the weekend and fell on her left outstretched hand. The most likely injury is a fracture to the scaphoid, located in the floor of the anatomical snuff box. Which of the following is true?
A.The anatomical snuff box is best palpated when the patient extends her thumb laterally away from her fingers
B.The scaphoid is located on the patient’s ulnar side
C.Radial deviation of the fingers causes the anatomical snuffbox to become more palpable
A.The anatomical snuff box is best palpated when the patient extends her thumb laterally away from her fingers
most common cause Meniscus Injury/Tear
a twisting injury with the foot fixed
- Soccer
- Basketball
- Football
–Sports that involve sudden deceleration and change in direction
–Older individuals can develop a degenerative tear with minimal or no trauma
Pes cavus
high arch
Pes Planus
flat foot
shoes ofr excess wear on inner sides of soles and heels
post tib tendon dysfunction
- obesity, diabetes, prior foot injury
Which of the following tests/signs help to diagnose rotator cuff impingement?
a) Tinel’s sign
b) Reinforcement
c) Neer’s sign
d) Apprehension test
e) Yergason’s test
a)Neer’s sign
Apprehension Test
Indication: determine if patella is prone to dislocation
Technique:
- Pt supine
- Legs flat and quadriceps relaxed
- Press against medial border of patella with thumb
Interpretation:
Positive: pt with apprehensive expression on face as patella dislocates
This 45 year old right-hand dominant male with no significant past medical history has had right shoulder pain for 3 months. The pain is worse when lifting objects above his head. He is a sanitation worker and enjoys gardening on the weekends. On physical exam, inspection of the shoulder was normal. After identifying the spine of scapula and palpating along it to the bony lateral endpoint, you slightly extend the arm and elicit tenderness in the region immediately inferior to that bone.
A possible cause of tenderness in that region is:
a) Inflammation of tendons of the rotator cuff
b) Dislocated shoulder
c) Frozen shoulder
d) Acromioclavicular arthritis
a)Inflammation of tendons of the rotator cuff
Lister’s Tubercle
Tubercle of radius
Pes planus
flat foot
A 64 year old male with a history of arthritis presents with a complaint of right knee swelling and stiffness. On inspection of his knee, you note the right knee is larger than the left knee. On further examination of his knee swelling, you extend the right knee, instruct him to relax his quadriceps muscles, you push the patella into the trochlear groove and quickly release it.
If this test is positive, it would most likely suggest:
a) Minor effusion of the knee joint
b) Major effusion of the knee joint
c) Pre-patellar bursitis
d) Infra-patellar bursitis
a)Major effusion of the knee joint
–Bouchard’s nodes
- Proximal interphalangeal (PIP) joints
- Less common in OA
Tinel Sign
- tap middle of carpal tunnel @ distal wrist crease
- positive (abnormal) = pain/numb/tingle in median N distribution in response
Mcmurray test
deformities of OA
–Bony outgrowths
- •Hard
- •Usually painless
–Heberden’s nodes
- •Distal interphalangeal (DIP) joints
- •More common
–Bouchard’s nodes
- •Proximal interphalangeal (PIP) joints
- •Less common
a)Apley scratch test
clinical features of carpal tunnel syndrome
pain in first 3 fingers of hand, especially at night
loss of sensation of median N
pain described as burning, shooting, shock-like
Special Test of the Ankle: Tilt Test
- Assesses: Anterior talofibular & calcaneofibular ligament stability
- Technique:
–Pt seated, knee flexed 90°;ankle in 20° plantar flexion
–Stabilize medial aspect of distal tibia with one hand, above medial malleolus
–Place other hand inferolateral to calcaneus
–Invert the hindfoot
M test: opposition
- pt opposition
- hold thenar eminence in one hand, hold hypothenar eminence in other
- try to full opposition apart
acute gout sympt
•red, warm, swollen, and very tender joints
Tibial Torsion Test
- Tibia is rotated inwardly (internally) or outwardly (externally) along its long axis with rotation of the foot and ankle
- Parent may notice patient with internal tibial torsion that the child is tripping and falling frequently
- There is no limp or pain
scale for grading reflexes: 3+
physical findings
- brisker than average
not necessarily indicative of disease
Rheumatoid Arthritis (RA)
•Inflammatory, systemic, autoimmune disease
m strength testing : C6 root - action and how to
- extension
–Stabilize patient’s forearm with one of your hands (this inhibits patient’s use of their forearm)
–Instruct the patient to move their wrist up (extend the wrist) and to maintain that position
–When wrist is fully extended, try to resist it fully (try to force it into flexion therefore test wrist extensors)
Muscle Strength Testing
Finger Extension
tests c7
- stab wrist in neutral
- ask pt to extend MCP while you felx their PIP
- try to force their fingers into flexion
what does hand grip strength evaluate?
instrinsic hand M & joints
function of wrist joints
hand flexors
Delayed Cap Refill can indicate:
poor vasc supply to hand
hypoT
dehydration
shock
Healthy people experience stiffness and muscular soreness after:
unusually strenuous M exertion
usually peaking within 2 days
ROM Thumb: flexion/extension
“move your thumb across your palm and touch the base of your pinky and then move your thumb back across your hand and away from your fingers
Sensation Testing: pain
•use wood/non-cotton end of long tipped Q-tip
Sensation Testing: Prepping the Patient
- explain touching each dermatome
- show pt plan to do
- show obj for use
- demostrate, light, sharp, cold
- instruct pt to respond when you touch them
A 32 yo female with no significant past medical history presents with knee pain while playing soccer.
Which of the following tests would check for meniscal tear?
a) Patella femoral grind test
b) Tinel sign
c) Apprehension test of the knee
d) McMurray test
a)McMurray test
Elbow: Active Range of Motion Testing including degrees
–Flexion - 135
–Extension - 0 (young children = 10-15 hyperextend)
–Supination - 90
–Pronation - 90
Heberden’s nodes
•Distal interphalangeal (DIP) joints
more common deformity in OA
hard and painless
Anesthesia
absense of touch sensation
Muscle Strength Testing
Pronation
- stand in front of pt, supprt flex elbow
* pt elbow at side - begin in supination
- your thenar eminence against pt’s distal radius, wrap fingers around posterior ulna
- pt pronate!
- resist until detm max P
a)Scaphoid fracture
carpal tunnel syndrome caused by
medial N compression within carpal tunner
stiffness >30 minutes suggests
RA
M testing : thumb flexion
- pt touch hypothenar eminence with thumb
- try to pull out of flexion
reflexes in wrist/hand
no pure ones!
a)External rotation and abduction
associated numbness or tingling with lower back pain means:
bowel or bladder dysfunction
a)Abduction
A 23 year old female with no past medical history comes to your office for her annual comprehensive history and physical exam. Upon observation you note the medial side of her feet touches the floor when she is standing. This condition is known as:
a) Pes cavus
b) Foot drop
c) Varus deformity
d) Pes planus
a)Pes planus
–Boutonniere deformity
•Flexion of the proximal inter-phalangeal (PIP) joints with hyperextension of the DIP
reflex arc components
sensory nerve fibers
spinal cord synapse
motor nerve fibers
neuromuscular junction
muscle fibers
Trigger Finger
•inflammation and subsequent stenosis/narrowing of the first annular (A1) pulley of the flexor sheath in the palm
- lump/knot
- prevents tendon moving during extension
painful bend/straighten finger
- “snap” when tendon moves during manual extension
lower back pain - sciatica symptoms
radiated to buttocks, lower extremity
S1 distribution
increases with cough/valsalva
Muscle Strength Testing
Finger Flexion
tests c8
- pt flex all phalangeal joints (loose fist)
- curl, and lock your fingers into pt’s and try to pull into extension
Shoulder: Passive Range of Motion Testing; abduction motions
Abduction:
- Occurs in glenohumeral joint and scaphothoracic articulation
- Stand behind patient
- Examiner anchors scapula inferior angle
- Other hand abducts arm
- Movement of scapula starts at 20°
- glenohumeral:scapula movement 2:1
- Suspect frozen shoulder if ↓glenohumeral movement
scale for grading reflexes: 4+
physical findings
- very brisk
- hyperactive with clonus
- rhythmic oscillation between flex and extend
non-midline lower back pain
M strain
sacroilitis
trochanteric bursitis
sciatica
hip arthritis
pyeloephrities
Tinel Sign
- Assesses: Ulnar nerve compression or neuroma of the nerve
- Technique:
–Tap over ulnar nerve in the groove between olecranon and medial epicondyle
•Interpretation:
–Positive-tingling sensation indicating compression of nerve possibly due to neuroma or scar tissue
arthralgia
joint pain with no inflammation
how to Test muscle strength of each muscle group
ask pt to actively resist your mvmt
test each side to detect asymm
Ottawa ankle rules
Established clinical guidelines to determine the need for radiography of the ankle to rule out fracture
•Inability to walk 4 steps with posterior tenderness of either malleoli suspicious for fracture
joints most commonly affected in RA
pip, mcp
dip joints spared
Range of Motion of the Fingers: extension
–“open your fist and spread your fingers apart ”
Neer’s Impingement Sign
- Assesses: Rotator cuff abnormality
- Technique:
–Press on the scapula to prevent scapular motion with one hand
–Raise the patient’s arm with the other hand
•Interpretation:
–Maneuver compresses the greater tuberosity of the humerus against the acromion
–Pain during the test=positive test=possible rotator cuff tear
supination of foot and ankle is a combo of….
inversion, adduction, plantarflex
Eversion
M?
instructions?
Tibialis posterior and anterior
“Bend your heel inward.”
M test: Pinch Mechanism
- pt make “o” with thumb and 2nd finger
- hook your index into “o”
- try to pull out of “o”
* moderate pull = maintain “o”
* tests several mvmts but does not replace indiv M test
A 23yo right-hand dominant male complains of left wrist pain and weakness. When you instruct him to flex his wrist against your resistance, you note complete range of motion against gravity with some resistance. How would you grade his muscle strength?
A. 1
B. 2
C. 3
D. 4
E. 5
Apprehension Test
- Assesses: chronic shoulder instability and dislocation
- Technique:
–Abduct and externally rotate arm
•Interpretation:
–If shoulder is about to dislocate a look of apprehension on his face will occur and he will resist further motion
Soft Tissue Palpation of Elbow: Zone 2
Posterior aspect
•Olecranon Bursa
–Note: bogginess or thickening, nodules
•Triceps Muscle
A 22 year old female with no significant medical history presents with right knee pain. She is a professional tennis player and tripped. Upon exam, you note right knee medial joint line tenderness. With the patient supine, performing which of the following tests determines if there is a medial collateral ligament injury?
a) Varus Stress
b) Valgus Stress
c) McMurray
d) Apley Compression
a)Valgus Stress
M grading chart: 2
- poor
complete ROM with gravity eliminated
M test: Thumb Extension
- pt extend thumb
- push into flexion by press distal phalanx
M grading chart: 0
- zero
no contractility
Shoulder: Range of Motion Testing
- Flexion - 180⁰
- Extension - 45⁰
- Abduction - 90⁰ (with palms down)
–90-150 ⁰ with palms up= scapulothroacic motion
–150 ⁰ - 180 ⁰ = combined glenohumeral and scapulothoracic motion
- Adduction - 45⁰
- Internal Rotation - ~ 55⁰
- External Rotation - 40⁰ - 45⁰
–Swan neck deformities of fingers
•Fixed flexion of the distal inter-phalangeal (DIP )joints with hyperextension of the PIP joints
Active
If you ask a patient to move their thumb across their palm and touch the base of their pinky and then move their thumb back across their hand and away from their fingers, what type of motion if this?
A.Adduction and Abduction
B.Flexion and Extension
C.Opposition
B.Flexion and Extension
Rotator Cuff Tear
- common cause of shoulder pain in mid-aged pts
- Inflammation of the subacromial bursa and underlying rotator cuff tendons
- Rotator cuff pathology spans a continuum:
–edema and hemorrhage to
–chronic inflammation and fibrosis to
–microscopic tendon fiber failure progressing to
–full-thickness rotator cuff tears
•Etiology is likely a combination of factors
–loss of microvascular blood supply to the tendon
–repeated mechanical insult as the tendon passes under the coracoacromial arch.
Zone 4 Soft Tissue Palpation of Shoulder
Major Shoulder Girdle Muscles:
- Sternocleidomastoid
- Pectoralis Major
- Costochondral joints
- Biceps
- Deltoid
- Trapezius
- Rhomboid Major and Minor
- Latissimus dorsi
- Serratus anterior
vascular scale for grading pulse
0 : absent
1+ : diminshed, weaker than expected
2+ : brisk, expected (normal)
3+ : bounding
M testing: hand grip strength
pt grab your 2nd and 3rd extended fingers
compare grip bilat
Polyarticular Joint Pain suggests:
rheumatic fever, gonococcal arthritis, rheumatoid arthritis
Empty Can Test
- Assesses: Supraspinatus m strength
- Technique:
–Elevate the arms to 90 degrees and internally rotate the arms with the thumbs pointing down, as if emptying a can
–Ask pt to resist as you place downward pressure on the arms
•Interpretation:
–Pt with pain and weakness with maneuver: partial tear of muscle or tendon
–Pt unable to elevate arms: complete muscle disruption (these patients compensate by using deltoid muscle)
Elbow Tendinopathy
Rotator Cuff Tendinitis (Impingement Syndrome)
- commonly involving the supraspinatus tendon
- Acute, recurrent, or chronic pain may result, often aggravated by activity
- sharp catches of pain, grating, and weakness when lifting the arm overhead
- supraspinatus tendon involvement - maximal tenderness below tip of acromion
- older adults, bone spurs on the undersurface of the acromion may contribute to symptoms
Special Test of the Ankle: Anterior Draw Sign
assess: anterior talofibular lig
•Technique:
–Pt seated, knee flexed 90°; ankle in plantar flexion 20°
–Stabilize anterior aspect of distal tibia with one hand
–Cup palm of other hand around calcaneus
–Draw the calcaneus anteriorly and push the tibia posteriorly
dermatome test of shoulder
pain, light touch, temp
Foot & Ankle: Passive Range of Motion Testing: aDduction, aBduction
- Passive ROM Technique:
- Stabilize pt’s foot at the calcaneus with one hand
- Foot is in neutral position
- Move foot medially (adduction) and laterally (abduction) with other hand
difference between claw toe and hammar toe
Clonus
series of rapid & rhythmic muscle contractions & relaxations
lower back pain red flags
- Age > 50
- Cancer history
- Unintentional weight loss
- Pain > 1month
- Pain not responsive to treatment
- Night pain, rest pain
- Intravenous drug use history
- Infection
midline lower back pain problems:
musculoligamentous injury
disc herniation
verterbral collapse
SC abscess
epidural abscess
Range of Motion of the Fingers: aBduction, aDduction
aBduction
•“spread your fingers apart”
Adduction
•“Bring your fingers back together”
Sensation Testing: cold
•metal part of reflex hammer or tuning fork
risk factors of carpal tunnel syndrome
hereditary
hand use over time
occupation/hobbies
pregancy hormonal changes
age : more common in older people
medical conditions: DM, RA, thyroid disfunction
Ankle Extension
(dorsiflexion)
Tibialis anterior, extensor digitorum longus, and extensor hallucis longus
“Point your foot toward the ceiling.”
Ankle Sprain
- Most common are inversion injuries to the lateral ankle ligaments
- Anterior talofibular ligament (ATFL) is the most common injured
Rotator Cuff Disorders
most affected and where/
- Supraspinatus tendon is most commonly affected
- Pain is located in the anterior and superior aspect of the shoulder during abduction
- •supraspinatus tendon involvement - maximal tenderness below tip of acromion
- •sharp catches of pain, grating, and weakness when lifting the arm overhead
a)Achilles tendon
Gout
hyperuricemia
mimic RA, OA
- mistaken for cellulitis
- Metatarsophalangeal joint of first toe is the initial site of attack in 50% of episodes of acute gouty arthritis
- Signs and symptoms: painful and tender, hot, dusky red swelling that extends beyond the margin of the joint
internal rotation lag test
pt place dorsum of hang on lower back with elbow flexed to 90, lift hand off back and as kpt to keep hand in this position
Inability of the patient to hold the hand in this position is positive test for a subscapularis disorder
Achilles Reflex
- pt seated
- slightly dorsiflex foot at ankle
- strike achilles with flat hammer
–>plantarflex
S1
Range of Motion of the Fingers: flexion
–“make a tight fist with each hand, thumb across the knuckles”
Yergason Test
- Assesses: stability of long head of biceps tendon in bicipital groove
- Technique:
–Pt flexes elbow to 90°
–Examiner grasps elbow in one hand and wrist in other hand as you externally rotate arm while patient resists
–And pull down on elbow
•Interpretation: unstable biceps tendon pops out of groove with pain
Thompson Test
- Assesses: Achilles tendon tear
- Technique:
–Pt lying prone on exam table with feet dangling off
–Knee and ankle are at 90°
–Squeeze gastrocnemius muscle
should have plantarflex
Hold the reflex hammer….
loosely betwen thumb and index finger
zone 1 soft tissue palpation of shoulder
Zone 1: Rotator Cuff
- Supraspinatus
- Infraspinatus
- Teres Minor
Soft Tissue Palpation of Elbow: Zone 4
Anterior aspect
- Cubital Fossa
- Biceps Tendon
- Brachial Artery
- Medial nerve
Allen test tests for:
adequancy of A blood supply to hand
A 31 yo right-handed female, with a PMH of well-controlled asthma presents with the complaint of right elbow pain. She works as a nanny, denies any trauma and admits to recently playing tennis everyday. On physical examination, you find tenderness of arm the 1cm distal to the lateral epicondyle of the humerus.
Which of the following positive findings on special testing of the elbow would confirm this diagnosis?
a) Pain with resisted wrist supination and extension
b) Pain with resisted wrist supination and flexion
c) Pain with resisted wrist pronation and extension
d) Pain with resisted wrist pronation and flexion
a)Pain with resisted wrist supination and extension
A 58 year old female presents to your office complaining of left knee pain. With the patient in the prone position and her left knee flexed to 90 degrees, you gently kneel on the back of her left thigh to stabilize it. At the same time you apply gentle pressure on her heel, then you rotate the tibia internally and externally on the femur. The patient complains of pain on the lateral side of her knee. This suggests:
a) Lateral collateral ligament tear
b) Lateral meniscal tear
c) Vastus lateralis tear
d) Semitendinosus tear
Lateral meniscal tear
Apleys tests for meniscal tears!
Deep Tendon Reflexes: Ankle Clonus
•Technique:
- Pt supine, lift & support knee in slight flexion
- Grasp foot & jerk into dorsiflexion
- Hold foot in slight dorsiflexion
* rhythmic oscillation between dorsiflex and plantarflex = hyperactive reflexes
- 4+
- sustained clonus = CNS disease
This 45 year old right-hand dominant male with no significant past medical history has had right shoulder pain for 3 months. The pain is worse when lifting objects above his head. He is a sanitation worker and enjoys gardening on the weekends. On physical exam, inspection of the shoulder was normal. After identifying the spine of scapula and palpating along it to the bony lateral endpoint, you slightly extend the arm and elicit tenderness in the region immediately inferior to that bone.
The tender structure you found on palpation is the:
a) Glenoid fossa
b) Subacromial bursa
c) Axilla
d) Bicipital tendon
a)Subacromial bursa
Lateral Epicondylitis test
- Assesses: inflammation of lateral epicondyle; “Tennis Elbow” test
- Inflammation of the wrist extensors
- Technique:
–Pt extends wrist
–Ask pt to resist as you attempt to straighten out wrist
•Interpretation:
–Pain at the site of the wrist extensors common origin - lateral epicondyle
A 45 year old male with no past medical history, complains of right shoulder pain. His last complete physical was 5 months ago.
Which of the following components of the history would be most relevant in your evaluation of his symptoms?
a) Childhood vaccinations, religious and spiritual beliefs
b) Changes in attention span, easy bruising or bleeding
c) Urinary symptoms, heat or cold intolerance
d) Hand dominance, occupation and sports participation
a)Hand dominance, occupation and sports participation
Patellar Grind Test
Indication: determine quality of articulating surfaces of patella
Technique:
- Pt supine
- Push patella distally in trochlear groove
- Ask pt to tighten quadriceps
- Palpate and offer resistance to patella
Interpretation:
Positive = Pain, Roughness, or Crepitus
The motions of pronation of the foot and ankle are a combination of:
a) Inversion, abduction, dorsiflexion
b) Inversion, adduction, plantar flexion
c) Eversion, abduction, dorsiflexion
d) Eversion, adduction, plantar flexion
Eversion, adduction, dorsiflexion
Monoarticular Joint Pain
pain in small joints = more sharply localized (ex: hands/feet)
Cross-Over Test
- Assesses: acromioclavicular inflammation or arthritis
- Technique:
- Adduct the patient’s arm across the chest
- Interpretation: pain at joint indicates inflammation or arthritis
M grading chart:3
- fair
complete ROM agiainst gravity without resistence
Gout
•Inflammatory arthritis
muscles that strengthens the glenohumeral joint
• supraspinatus, infraspinatus, teres minor and subscapularis
Finkelstein test
- pt put thumb into fist
- deviate wrist in ulnar direction
- positive (abnormal) = pain
* tenosynovitis
Ganglion Cyst
- within hand or wrist; dorsal or volar aspect
- Jelly-like consistency
- Round, soft, often non-tender swelling
- Flexion/Extension makes cyst more/less prominent
Arm reflexes reinforcement
pt clench teeth
squeeze on thigh with opposite hand
Upon further examination, the pt has no tenderness to palpation of the bony parts of his leg and foot. He does have swelling and tenderness to palpation of the distal left Achilles tendon.
Based upon his history and physical examination at this time, what do you suspect?
a) Ankle sprain
b) Heel spur
c) Achilles tendon rupture
d) Calcaneal fracture
a)Achilles tendon rupture
cap refill color should return in
whats the manuever
–less than 2 seconds
–Gently press down on the nail so that the nail bed blanches (pales) (one nail on each hand)
Hallux Valgus
- Lateral deviation (abduction) of the great toe (in relation to the first metatarsal)
- With medial deviation of the first metatarsal
- Great toe may overlap the second toe
Fluctuant means:
compressible, wave-like, fluid filled area
Cauda equina syndrome
compression on spinal N roots
permanent dmg = incontinence, possibly permanent paralysis of legs
TART
–Tissue texture changes
–Asymmetry
–Restriction
–Tenderness
ROM thumb: opposition
–Movement is primarily at the carpometacarpal joint of the thumb
ask pt to touch thumb to each other finger tips
A 45 year old right hand dominant male with history of hypertension complains of left wrist pain and weakness. When you instruct him to flex his wrist against your resistance, you observe a slight contraction of the muscle, but there is no motion of the wrist (joint). How would you grade his muscle strength?
a) 0
b) 1
c) 2
d) 3
e) 4
1
Bunion
hallux valgus –> bursa may be inflammed
- medial deviation of 1st MT
more common (10x) in women than men
Homans’ Sign
- Assesses: Deep vein thrombosis (DVT)
- Technique:
–Pt seated or lying supine
–Forcibly dorsiflex ankle with leg extended
•Interpretation:
–Negative (normal) test - no pain
–Positive (abnormal) test - pain in calf with dorsiflexion or deep palpation
–Positive (abnormal) test result is indicative of DVT
Adduction
zone 2 soft tissue palpation of shoulder
Subacromial and Subdeltoid Bursa
- Bursa located inferior to acromion and extends under deltoid muscle
- Passive extension of shoulder rotates subacromial bursa anteriorly
What is the normal response of the foot in the Thompson test?
a) Plantar flexion
b) Dorsiflexion
c) Adduction
d) Abduction
a)Plantar flexion
M grading chart: 1
- trace
slight contractility, no joing motion
Abnormal Carrying Angle causes:
- Cubitus varus
- Varus angulation
- Gunstock deformity
- Decreased carrying angle
- Usually due to trauma
–Supracondylar fracture
•Observe bilaterally
What is the order and components of the musculosketlal exam?
- Inspection
- Palpation (2 parts)
a) Bony
b) Soft Tissue – muscle, tendons, ligaments, etc. - Range of Motion (2 parts )
a) Active
b) Passive - Neurologic Examination (3 parts)
a) Motor Strength
b) Sensation
c) Reflex testing - Vascular Examination
- Special Tests (variable?)
–Applies to specific body part
–Based on pt complaint, hx and PE up to this point
leg reflexes reinforcement
Pt locks fingers & pulls one hand against the other prior to striking the tendon
Muscle Strength Testing
Finger Adduction
tests T1
- pt in pronated with fingers extended and aDducted
- put paper b/w fingers - ask to maintain
- try to pull paper out
* less precise - if pt cannot complete task = indiv assess
external rotation lag test
with pt’s arm flexed to 0 with palm up, rotate arm into full ext rot
Inability of the patient to maintain external rotation is a positive test for supraspinatus and infraspinatus disorders
diopathic lower back pain means
sprain, strain
Pes Cavus
•High instep, high arch, talipes cavus
idiopathic or congenital
difference between ROM and muscle testing
ROM = joint mobility
M testing = determine m strength - have pt resist
M test: thumb abduction
- stab mc and wrist
- pt full aBduct thumb
- try push thumb towards palm
to elicit reflex….
•briskly tap on tendon of a partially stretched muscle
Adhesive Capsulitis – Frozen shoulder
- fibrosis of glenohumeral joint capsule
- diffuse, dull, aching pain in the shoulder
- progressive restriction of active and passive range of motion, especially in external rotation, with localized tenderness.
- unilateral
- Common in diabetes, 20% of diabetics
- 6 months to 2 years to resolve
- Stretching exercises may help
Hawkin’s Impingement Sign
- Assesses: Rotator cuff abnormalities
- Technique:
–Flex pt’s shoulder and elbow to 90 degrees with the palm facing down
–Then, with one hand on the forearm and one on the arm, rotate the arm internally
- Interpretation:
- Maneuver compresses the greater tuberosity against the coracoacromial ligament
- Pain during test=positive test=possible rotator cuff tear or inflammation
phalen’s test
test for carpal tunnel
- hold flexed wrists together for 1 min
- positive (abnormal) = sympt of carpal tunnel within 60s
45yo male presents to your office complaining that his left hand by his thumb is smaller than his right. You note that he has thenar muscle atrophy. This is most likely due to:
A. Carpal tunnel – ulnar nerve compression
B. Carpal tunnel – median nerve compression
C. Radial nerve compression
D. Radial artery occlusion
Carpal tunnel – median nerve compression
hip joint pain may present as:
groin, buttocks, knee pain
normal carrying angle of elbow
men = 5
women = 10-15
Active ROM of the wrist: ulnar deviation- what do tell pt
–“With your palms facing the floor bring your fingers away from the midline”
Brachioradialis Reflex
•C6
–Support patient’s arm. Patient’s rests on abdomen or lap
–Forearm partly pronated
–Strike hammer 1-2 inches above wrist
–Use the flat portion of the reflex hammer
myalgia
generalized aches and pain
_____thyroidism presents what # for reflex grading
hyper = 3+
hypo = 1+
Active ROM of the wrist: Radial deviation- what do tell pt
–“With your palms facing the floor, bring your fingers toward the midline”
Extra-articular Joint Pain symptoms
Loss of active but not passive motion and tenderness outside the joint
neck pain that radiates to arms means:
spinal N compression
usually due to degen joint changes
pronation of foot and ankle is a combo of….
eversion, dorsiflex, abduction
late signs of carpal tunnel syndrome
decrease/loss sensation to hand from median N
thenar atrophy
A 25yoTouroCOM medical students palpates his wrist in the skills lab and feels a brisk, expected (normal) pulse. How would you grade his pulse?
A.3+
B.2+
C.1+
D.0
2+
Shoulder: Active Range of Motion Testing
- Flexion
- Extension
- Abduction
- Adduction
- Internal Rotation
- External Rotation
history Components specific to shoulder and elbow:
–Dominant hand
–Occupation
–Sport activity
–Functional ability: do shoulder symptoms prevent normal work, hobbies, or sports participation
–Elicit if there is: stiffness, locking, or catching
Neurologic Examination:
Motor Strength Testing of shoulder
Vascular Examination of the Shoulder
•Brachial Artery
–Medial to biceps tendon
what disease does a postiive Finkelstein test indicate?
tenosynovitis
painful arch test
abduct pt’s arm fully from 0-180
Shoulder pain from 60° to 120° is a positive test for a subacromial impingement/rotator cuff tendinitis disorder
valsalva
Leg pain that resolves with rest and/or lumbar forward flexion occurs in spinal stenosis
An 82 year old right-handed male with a history of hypertension presents with 2 years of progressive right hand pain. The hand pain is provoked by use and relieved with rest. On inspection of his right hand you note several bony outgrowths over his DIP and PIP joints. The outgrowths are not tender. His MCP joints are not affected. His left hand is not affected. The lesions at his DIP joints are most likely:
a) Swan neck deformities
b) Ganglion cysts
c) Heberden’s nodes
d) Acute Gout
a)Heberden’s nodes
Order of the Musculoskeletal Examination
- Inspection
- Palpation
–Bony
–Soft Tissue
•Range of Motion
–Active
–Passive
•Neurologic Examination
–Motor Strength
–Sensation
–Reflex testing
- Vascular Examination
- Special Tests
–Applies to specific body part
Soft Tissue Palpation of Elbow: zone 1
Medial aspect
- Ulnar nerve
- Wrist Flexor-Pronator Muscle Group: 4 muscles
- Medial Collateral Ligament: check for tenderness
- Supracondylar Lymph Nodes
A 38 year old right-handed female presents with 5 years of right hand pain, numbness and tingling. Her symptoms are localized to the radial aspect of her palm and to the volar (palmar) aspect of her right thumb, index finger, middle finger and radial ½ of the ring finger. The pain is worse at night.
Which of the following would you most likely find on examination?
a) Thenar atrophy
b) Decreased sensation to light touch in the radial nerve distribution
c) Decreased capillary refill to the thumb, index and middle fingers
d) A positive Allen test
e) A positive Finkelstein test
a)Thenar atrophy
carpal tunnel
Soft Tissue Palpation of Elbow Zones
Four Zones:
1) Medial aspect
2) Posterior aspect
3) Lateral aspect
4) Anterior aspect
abduction
What is the main purpose of Range of Motion testing?
a) To evaluate for asymmetry of tissue texture
b) To assess joint mobility
c) To determine muscle strength
d) To localize a lesion to a level in the spinal cord level, nerve root, or peripheral nerve
a)To assess joint mobility
•Wasting of the musculature of the thenar eminence….
•Suggests neurologic disorder such as carpal tunnel syndrome (median nerve)
Brachioradialis Reflex
test c6
- support pt arm (can be resting on abdomen,lap)
- forearm partly pronated
- strike hammer 1-2 inches about wrist using flat portion
- grade
a)Hawkin’s impingement sign
Musculoskeletal Palpation Osteopathic Considerations
TART
tissue texture changes
asymmetry
restriction
tenderness
Vascular Examination of Elbow
•Brachial Artery
–Medial to biceps tendon
•Radial Artery
–Lateral aspect of wrist flexor
surface
•Ulnar Artery
–Difficult to palpate
zone 3 soft tissue palpation of shoulder
axilla
- apex
* lymph nodes, brachial plexus, ax A - Medial wall
* ribs, serratus anterior - lateral wall
* bicip groove of humerous, brachial A - anterior wall
* pec major - posterior wall
* lat dorsi
Sensation on the palmar and dorsal surfaces innervated by
•median, ulnar, & radial nerves
m strength testing : C7 root - action and how to
- flexion
–Instruct the patient to make a fist
–Stabilize patient’s wrist with one of your hands
–Ask patient to flex his closed fist at the wrist and to maintain that position
–When the patient’s wrist is flexed, place your other hand over the patient’s fist and try to pull the patient’s wrist out of flexion (force it into extension/force out of flexion)
De Quervain’s Tenosynovitis
inflam aBductor pollicis longus and extensor pollicis brevis tendons and tendon sheaths
Range of Motion of hand:
•Wrist motions
–Flexion 80°
–Extension 70°
–Radial (adduction) Deviation 20°
–Ulnar (abduction) Deviation 30°
–Forearm Supination
–Forearm Pronation
Medial Epicondylitis test
- Assesses: inflammation of medial epicondyle; “Golf Elbow” test
- Inflammation of the wrist flexors
- Technique:
–Pt flexes wrist
–Ask pt to resist as you attempt to straighten out wrist
•Interpretation:
–Pain at the site of the wrist flexors common origin - medial epicondyle
–Reproduces the patient’s pain
A 50 year old female presents for an evaluation. Upon examination of her left biceps muscle, you find she can flex her elbow against your full resistance; this corresponds to a motor strength grade of:
a) 1/5
b) 2/5
c) 3/5
d) 4/5
e) 5/5
e)5/5
scale for grading reflexes: 2+
physical findings
- average briskness
normal
Dupuytren’s Contracture
•Flexion contraction of the third, ring and/or fifth fingers
small nodles/plaques in aponeurosis
- skin puckers
- flexion contractures
When performing the vascular examination of the foot and ankle, the posterior tibial artery should be palpated:
a) Anterior to the tibialis posterior tendon
b) Posterior to the flexor hallucis longus tendon
c) Posterior to the flexor digitorum longus tendon
d) Posterior to the tibial nerve
Posterior to the flexor digitorum longus tendon
Muscle Strength Testing
Finger Abduction
tests T1
- pt aBduct fingers
- force each pair of fingers towards midline
A 45 year old right hand dominant male with history of hypertension complains of left wrist pain and weakness. Upon examination, you find he has a normal left brachioradialis reflex.
How would you grade his reflex response?
a) 0
b) 1+
c) 2+
d) 3+
e) 4+
c)2+
articular joint pain
Pain, swelling, loss of active and passive motion, or “locking”
A 75-year old right-handed male with a past medical history of hypertension presents for his yearly physical. He has taken your advice and started an exercise program and now complains of left shoulder pain. Which question would give you the most information?
a) “Can you tell me more about your shoulder pain?”
b) “When did you notice the pain?”
c) “Does the pain travel anywhere?”
d) “What makes the pain better?”
a)“Can you tell me more about your shoulder pain?”
