Lecture two (LOWER), EXAM 3

Question 1

• Each spinal nerve is formed from what?
• Posterior branches are what? Anterior?

Answer 1

Each spinal nerve is formed from anterior and posterior roots on the spinal cord. The posterior branches are afferent (sensory) nerves; the anterior branches are efferent (motor) nerves.

Question 2

What is stenosis?

Answer 2

narrowing of the vertebral foramen around the spinal cord or narrowing of the intervertebral foramina where the nerve roots exit – fairly large foramina in the lumbar spine and smaller in the cervical spine

osteophyte can narrow

Question 3

• What is a myelopathy?
• Bilateral symptoms/weakness often possibly with what?

Answer 3

an injury to the spinal cord due to severe compression that may result from trauma, congenital stenosis, degenerative disease or disc herniation
* Bilateral symptoms/weakness often possibly with bowel and bladder problem

Question 4

What is radiculopathy?
Symptoms are unilateral affecting what?

Answer 4

njury or compression to a nerve root in the cervical, thoracic, or lumbar region with symptoms including pain, weakness, numbness, or tingling
* Symptoms are unilateral affecting the myotome and dermatome for that level

Question 5

What is spondylosis?

Answer 5

degeneration of the intervertebral disc

Question 6

Osteoporosis & Osteopenia:
* How many adults have osteopenia?
* How many adults have osteoporosis at the femoral neck or lumbar spine?
* What are the risk factors

Answer 6

• over 40% of adults age ≥ 50 in US have osteopenia – 40 million people/17 million are male
• 10.3% of adults over age 50 years have osteoporosis at the femoral neck or lumbar spine, 15.4% of women and 4.3% of men
• Risk factors include; age>50, low BMI, tobacco, ETOH, low physical activity, 1st degree relative with dx, certain pharmaceuticals

Question 7

Osteoporosis & Osteopenia:
* Half of all postmenopausal women sustain what?
* How many fx’s/yr. in US from osteoporosis?
* Current recommendation for bone density screening?

Answer 7

• Half of all postmenopausal women sustain an osteoporosis-related fracture during their lifetime – 25% vertebral, 15% hip
• 2 million fx’s/yr. in US from osteoporosis
• Current recommendation for bone density screening – all women over 65, and post menopausal women under 65, men over 70 or younger men who have increased risk for low bone mass.

Question 8

What part of the spine can be abnormal? What can this cause?

Answer 8

Sacrum and coccyx can be abnormal
* Can be longer and cause problems with sitting and pain+ulcers
* Can fracture when people get older

Question 9

• What is one of the most frequent causes of adult outpatient visits? How much is the cost?
• What is the poor correlation?

Answer 9

• Back pain is one of the most frequent causes of adult outpatient visits with costs estimated to exceed $100 billion from diagnosing, managing, and lost productivity
• Poor correlation between imaging and functional outcome.

Question 10

What do you need to obtain when getting history with patients with back pain?

Answer 10

Question 11

Back pain can refer to what?

Answer 11

abdominal or thorax

Question 12

What do you need to inspect for the back?

Answer 12

• observe anteriorly, posteriorly, and laterally looking for symmetry
• Soft tissue contours
• Inspect the alignment of the shoulders, the iliac crests, and the gluteal folds
• are the normal lordotic and kyphotic curves present?
• Observe their posture
• Observe their gait

Question 13

What do you need to palpate for the lumbosacral region?

Answer 13

Palpate vertebral spinous processes, facet joints, the sacroiliac joint, iliac crests, and posterior superior iliac spines (tenderness); paravertebral muscles (tenderness, spasm); and lumbosacral vertebrae (step-offs or slippage).

Question 14

What are the cervial ranges of motion?

Answer 14

Question 15

What is the spine range of motion?

Answer 15

• Flexion – Extension – Side Flexion – Rotation
• Observe for scoliosis while in flexion

Question 16

What is the brudzinki’s portion of the spinal test?

Answer 16

In Brudzinki’s portion of the test, the patient lies supine and elevates the head from the table. When the head is lifted, the patient complains of neck and low back discomfort and attempts to relieve the meningeal irritation by involuntary flexion of the knees and hips.

Question 17

What is the kernig portion of the spinal test?

Answer 17

In the Kernig portion of the test, the patient lies supine with the hip and knee flexed to 90°. The patient then extends the knee. If the patient complains of pain in the lower back, neck, or head on knee extension, it is suggestive of meningeal irritation. Returning to knee flexion will relieve the pain.

Question 18

What is the straight leg raise test for? How do you do it?

Answer 18

Test for sciatica:
A, Radicular symptoms are precipitated on the same side with straight leg raising.
B, The leg is lowered slowly until pain is relieved.
C, The foot is then dorsiflexed, causing a return of symptoms; this indicates a positive test.
D, To make the symptoms more provocative, the neck can be flexed by lifting the head at the same time as the foot is dorsiflexed

Question 19

Beyond the erector spinae muscle groups of the back the cervical adds what?

Answer 19

adds musculature including the splenius, semispinalis, and scalene groups as well as other musculature to support our 11-pound head on the cervical vertebrae

Question 20

What are the cervical-provocation test?

Answer 20

Nerve root impingement increased in narrowed foramina

Question 21

What is cervical compression test?

Answer 21

apply pressure with the head in neutral, then side flexion and/or extension. Pain must radiate to shoulder and/or are to be a positive test

cervical reticulopathy

Question 22

What is the spurling test?

Answer 22

Performed in three steps, extension and check for symptoms, add side flexion and check, apply downward pressure. Pain radiates to upper limb when positive

cervical reticulopathy

Question 23

Iliac crests at what spinal level? PSIS?

Answer 23

Question 24

What do you need to inspect for the hip?

Answer 24

• Observe anteriorly, posteriorly, and laterally looking for symmetry
• Soft tissue contours
• Inspect the alignment of the iliac crests, the skin creases below the buttocks (gluteal folds), and the leg alignment (knock-kneed/bow-legged, toe-in/out)
• Observe their gait (look mostly in the back)
• Swelling in the area of the hip and pelvis is usually very difficult to see

Question 25

What do you need to palpate on the hip area?

Answer 25

• Palpate noticing temperature, swelling, point tenderness
• Palpate SI joint – PSIS
• Palpate iliac crests
• Palpation over the trochanteric bursa, usually painful on the posterior aspect of the trochanter

Question 26

What is the range of motion for the hip?

Answer 26

Question 27

Again what are the range of motions for the hip?

Answer 27

A. Hip flexion with knee flexed – 110-120 degrees
B. Hip extension – 10-15 degrees
C. Hip abduction – 30-50 degrees, Hip adduction 30 degrees
D. Hip Medial or Internal Rotation – 30-40 degrees, Lateral or External Rotation 40- 60 degrees (note the foot goes out on medial rotation of the hip and in on lateral rotation

Question 28

What is genu valgum and genu varum?

Answer 28

Question 29

What are the ottawa knee rules for radiographs

Answer 29

• Patient age 55 or older
• Fibular head tenderness
• Patellar tenderness
• Inability to flex knee to 90°
• Inability to bear weight and walk four steps when examined and at time of injury

PIPI F

Question 30

What are the pittsburgh knee rules for radiographs

Answer 30

• Blunt trauma or fall
• Patient age younger than 12 years or older than 50 years
• Inability to walk four weightbearing steps on affected leg

Question 31

What do you need to palpate on the knee?

Answer 31

Question 32

What is the valgus and varus stress tests?

Answer 32

Question 33

What is the drawer test and posterior sag?

Answer 33

Question 34

What is the lachman test for ACL?

Answer 34

Question 35

What are the signs of meniscal tears?

Answer 35

• Late swelling-after 12 or 24 hours
• locking: physical sign so need to go to OR
• Pain at the joint line
• Pain at the extremes of flexion and extensions (everything else is good)
• Baker’s cyst (back of knee)

Question 36

• How do you test meniscal tears?
• What are the different meniscal tears?

Answer 36

Test with McMurray’s and Thessaly’s

Question 37

What is the mcmurray test

Answer 37

The hip and knee are flexed, and the clinician stabilizes the lower leg with one hand and laterally rotates the tibia. The other hand is placed over the anterior knee with the fingers on the joint line. The clinician slowly extends the leg. If a loose body is in the medial meniscus, this action causes a snap or click. Internally rotating the leg and repeating the test with the thumb over the lateral joint line tests for lateral meniscus damage.

Question 38

What is the patellar apprehension test

Answer 38

Question 39

What is this?

Answer 39

Skyline (sunrise) view of patellofemoral joints. Note the lateral displacement of both patellae and shallow trochlea (trochlear dysplasia), especially the one on the right. Note also the alpine hunter’s cap shape of patella.

Question 40

What is the patellar tap test (ballotable patella)

Answer 40

• With the patient’s knee extended or flexed to discomfort, the examiner applies a slight tap or pressure over the patella.
• When this is done, a floating of the patella should be felt.
• This is sometimes called the “dancing patella” sign. A modification of this test calls

Question 41

What is a medical emergency of the knee?

Answer 41

Posterior dislocation of the knee dt blood supply

Question 42

What is hallux valgus and bunion?

Answer 42

Increase risk: family and high heels

Question 43

What are the ankle and toe ROM?

Answer 43

A, Plantar flexion
B, Dorsiflexion
C, Supination/Inversion
D, Pronation/Eversion
E, Toe extension
F, Toe flexion
G, Toe abduction
H, Toe adduction

Question 44

What are th ottawa ankle rules for radiography?

Answer 44

Question 45

What is the thompson test?

Answer 45

• For Achilles Tendon Rupture
• Kneeling or prone
• Foot should plantarflex when the muscle is squeezed, lack of motion is a positive test

Question 46

A 62-year-old patient with rheumatoid arthritis (RA) complains of increased joint stiffness. What characteristic(s) are consistent with her diagnosis of RA?
1. Swelling of the synovial tissue is seen in joints and tendon sheaths.
2. Joint distribution is asymmetrical.
3. Tophi are found in the subcutaneous tissue.
4. It most frequently involves the first metatarsophalangeal joint.
5. Stiffness follows joint activity.

Answer 46

1. Swelling of the synovial tissue is seen in joints and tendon sheaths.

Question 47

During an evaluation of an athletic 30-year-old patient, the clinician conducts an active range of motion evaluation at the neck. Which muscle is being assessed when the patient is asked to flex the neck?
1. Trapezius
2. Sacrospinalis
3. Splenius cervicis
4. Splenius capitis
5. Sternocleidomastoid

Answer 47

5. Sternocleidomastoid (SCM)

Rationale:
The SCM muscle flexes and rotates the neck. Splenius capitis is incorrect; the splenius capitis extends the neck. Trapezius is incorrect; the trapezius extends the neck. Splenius cervicis is incorrect; the splenius cervicis attaches to the posterior aspect of the spine and extends the neck. Sacrospinalis is incorrect; the sacrospinalis attaches to the posterior aspect of the spine. When muscles attached to the posterior aspect of the spine contract, the spine extends.

Question 48

An obese 50-year-old patient presents with a long history of back trouble. What structure in the spine supports the body’s weight?
1. Vertebral body
2. Transverse process
3. Vertebral arch
4. Intervertebral disk
5. Spinous process

Answer 48

1. Vertebral body

Rationale:
The vertebral body is a weight-bearing structure of the spine. Vertebral arch is incorrect; the vertebral arch encloses the spinal cord. Intervertebral disk is incorrect; the intervertebral disk provides a cushion between the vertebrae. Transverse process and Spinous process are incorrect; these structures serve as a site of muscle attachment.

Question 49

During a musculoskeletal examination, the clinician instructs the patient to look over one shoulder, and then the other shoulder. This action assesses the movement of which muscle(s)?
1. Scalenes
2. Prevertebral muscles
3. Splenius cervicis
4. Sternocleidomastoid (SCM)
5. Splenius capitis

Answer 49

4. Sternocleidomastoid (SCM)

Rationale:
The action is rotation of the neck. The muscles responsible for rotation of the neck are the SCM and the small intrinsic neck muscles. Scalenes is incorrect; the action of the scalene muscle is to flex the neck. The scalenes also laterally bend the neck. Splenius capitis is incorrect; the action of the splenius capitis muscle is to extend the neck. Prevertebral muscles is incorrect; the action of the prevertebral muscles is to flex the neck. Splenius cervicis is incorrect; the action of the splenius cervicis muscle is to extend the neck.

Question 50

During a musculoskeletal examination of the spine, what is the action(s) of the erector spinae muscle group?
1. Flexion of the spine
2. Lateral bending of the spine
3. Rotation of the spine
4. Extension of the spine
5. Rotation and lateral bending of the spine

Answer 50

4. Extension of the spine

Rationale:
The erector spinae muscle group is one of the deep intrinsic muscle groups of the back that extend the spine. Rotation of the spine is incorrect; the muscles that rotate the spine are the abdominal muscles and the intrinsic muscles of the back. Flexion of the spine is incorrect; the muscles that flex the spine are the psoas major and minor, quadratus lumborum, and the abdominal muscles. Lateral bending of the spine is incorrect; the muscles that laterally bend the spine are the abdominal muscles and the intrinsic muscles of the back. Rotation and lateral bending of the spine is incorrect; the muscles that laterally bend the spine are the abdominal muscles and the intrinsic muscles of the back.

Question 51

A thin, 58-year-old patient complains of lower back pain for years. On examination, the clinician finds that the patient has tenderness over the sacroiliac area. Which of the following conditions is most consistent with this physical sign?
1. Torticollis
2. Infection
3. Osteoporosis
4. Ankylosing spondylitis
5. Malignancy

Answer 51

4. Ankylosing spondylitis

Rationale:
Tenderness over the sacroiliac joint is common in sacroilitis and also seen in ankylosing spondylitis. Osteoporosis is incorrect; osteoporosis may be associated with pain on percussion of the spine. Malignancy is incorrect; malignancy may be associated with pain on percussion of the spine. Infection is incorrect; infection may be associated with pain on percussion of the spine. Torticollis is incorrect; torticollis is caused by contraction of the sternocleidomastoid muscle and presents as lateral deviation and rotation of the head.

Question 52

The clinician is seeing a middle-aged patient who has a diagnosis of lumbar spinal stenosis. The patient’s history is consistent with this diagnosis as he has pain in the back with walking that improves with rest. Which physical sign(s) are most consistent with his diagnosis?
1. Positive straight-leg raise
2.Hyperreflexia of the lower limb
3. Thoracic kyphosis
4. Flexed forward posture with lower extremity weakness
5. Pelvic tilt or drop

Answer 52

4. Flexed forward posture with lower extremity weakness

Rationale:
The physical signs of lumbar spinal stenosis include flexed forward posture and weakness of the lower extremities. Hyperreflexia of the lower limb is incorrect; hyporeflexia of the lower extremities is consistent with lumbar spinal stenosis. Pelvic tilt or drop is incorrect; weakness of the pelvic stabilizers—the gluteus medius and minimus are not consistent with lumbar spinal stenosis. Thoracic kyphosis is incorrect; thoracic kyphosis is not associated with lumbar spinal stenosis. Positive straight leg raise is incorrect; the straight-leg test is usually negative in lumbar spinal stenosis.

Question 53

A 31-year-old day care worker presents with a worsening stiff, painful neck. On inspection, the patient’s head is laterally deviated toward the shoulder and rotated. At this point of the examination, what is the most likely diagnosis?
1. Spondylolisthesis
2. Torticollis
3. Ankylosing spondylitis
4. Thoracic kyphosis
5. Osteoarthritis (OA)

Answer 53

2. Torticollis

Rationale:
The characteristic physical signs of torticollis are head rotation and lateral deviation. Spondylolisthesis is incorrect; spondylolisthesis is the slippage between vertebrae and does not present with the head rotated laterally and downward. OA is incorrect. Although it can cause a stiff and painful neck, it would not cause the head to be laterally deviated toward the shoulder and rotated. Thoracic kyphosis is incorrect; thoracic kyphosis is increased flexion of the thoracic vertebrae and occurs with aging. Ankylosing spondylitis is incorrect; ankylosing spondylitis does not present with the head rotated laterally and downward.

Question 54

The clinician is seeing a 58-year-old patient with a diagnosis of arthritis. The patient complains of pain in his knees, hips, hands, wrists, neck, and low back. Based on which joints are involved, the patient most likely has which joint problem?
1. Osteoarthritis (OA)
2.Psoriatic arthritis
3. Rheumatoid arthritis (RA)
4. Gout
5. Polymyalgia rheumatica

Answer 54

1. Osteoarthritis (OA)

Rationale:
The common locations of joints involved with OA are the knees, hips, hands, wrists, neck, and lower back. RA is incorrect; the common locations of joints involved with RA are the small joints of the hands, feet, wrists, and ankles, and also the joints of the elbows and knees. This patient has involvement of the hips, which is not characteristic of RA. Psoriatic arthritis is incorrect; psoriatic arthritis is a mono/oligoarthritis—involving one to three joints. This patient has at least six joints involved. Gout is incorrect; the common locations of joints involved with acute gout are the base of the big toe, foot, ankles, knees, and elbows. The common locations of joints involved with chronic tophaceous gout are the feet, ankles, wrists, fingers, and elbows. This patient has involvement of the hips, neck, and low back which is not characteristic of gout. Polymyalgia rheumatica is incorrect; the common locations of pain in polymyalgia rheumatica are the muscles surrounding the hip and shoulder joints.

Question 55

A young adult patient presents to the clinic stating that something is wrong as he looks in the mirror and sees that his shoulders are uneven. He fractured his left arm 8 weeks ago and remains in a cast. He noticed the uneven shoulders over the last week. Upon inspection, his shoulder heights are unequal and there is winging of the scapula. As the examination continues, which of the following maneuvers would confirm a likely diagnosis?
1. Compare the strength of his trapezia muscles
2. Assess his ability to extend his back
3. Check for listing of his trunk
4. Assess the lateral bending movement of his neck
5. Assess his ability to touch his toes

Answer 55

1. Compare the strength of his trapezia muscles

Rationale:
One cause of winged scapula is the contralateral weakness of the trapezius muscle. As this patient has had his left arm immobilized for 8 weeks, he may have muscle wasting and weakness of the left trapezius relative to his right side. Assess his ability to touch his toes is incorrect; touching toes assesses the muscles that flex the back as well as looks for scoliosis (differences in the height of scapulae). Assess the lateral bending movement of his neck is incorrect; this action assesses the function of the scalene and small intrinsic neck muscles. Assess his ability to extend his back is incorrect; this action assesses the function of the deep intrinsic muscles of the back. Check for listing of his trunk is incorrect; this sign may be present with a herniated disk.