MSK UQ Skills Flashcards
Perform an UQ Scanning Exam from start to finish.
Observation/pt history
Cervical AROM (OP as appropriate)
UE ROM (shoulder, elbow, wrist, hand)
Myotomes (C5-T1)
Dermatomes (C4-T1)
Cervical compression/distraction
NPT (ULTT 1)
Common UQ DTRs
Pathologic reflexes
Palpation (pulses, glands, lymph nodes)
Cervical AROM
Procedure:
Upper Cervical
*CV Flexion / CV Extension (slight chin nods, extension is bringing chin up to neutral) - use thenar eminence at chin for OP / no goni just appreciate
Lower Cervical
*Flex / ext / SB / rotation / quadrant testing (L/R flex, L/R ext) - assess deficits with goni or inclinometer
*PROM assessed in supine if AROM deficits are present (pain and no deficits / pain and deficits - see if pain persists throughout PROM)
*Have pt perform each motion actively
*Apply OP in the case of each movement (if active movement is pain-free, pain is the ONLY contra, OP is okay if deficit is present)
What Are We Looking For?:
*Reproduction of local or remote symptoms
*The absence of an impact on symptoms (w/ or w/o mobility deficits)
C-Spine Goniometry Measurements
Flexion / Extension
R / L SB
R / L Rotation
Flexion (80-90 degrees) / Extension (60-70 degrees):
*Axis: External Auditory Meatus
*Stationary Arm: Perpendicular to ground
*Moving Arm: Base of nose
R / L SB (20-45 degrees):
*Axis: C7 SP
*Stationary Arm: T-spine
*Moving Arm: Midline of head (Occipital Protuberance)
R / L Rotation (75-90 degrees):
*Axis: Center of head
*Stationary Arm: Parallel to line between acromion processes
*Moving Arm: Tip of the nose
UE AROM
Procedure:
*Shoulder (up and out to side for flex / abd, hands behind head for ER , hands behind back for IR)
*Elbow (flex / ext, pronation / supination)
*Wrist (flex / ext / radial + ulnar dev)
*Hand (open / close)
*AROM followed by OP (if pain-free) - no OP on elbow extension / open and close of hand
What Are We Looking For?:
*Reproduction of local or remote symptoms
*The absence of an impact on symptoms (w/ or w/o mobility deficits)
*Any dysfunction should prompt you to formally assess joint (goni)
Shoulder Goniometry Measurements
Flexion
Abduction
ER / IR
Flexion: Pt supine w/ knees flexed
*Axis: Greater Tubercle
*Stationary Arm: Midaxillary line
*Moving Arm: Lateral Epicondyle
Abduction: Pt supine w/ elbow flexed and shoulder in ER
*Axis: Anterior Acromion
*Stationary Arm: Parallel to midline of sternum
*Moving Arm: Anterior midline of humerus (Medial Epicondyle)
ER / IR: Pt supine with shoulder abducted to 90 degrees / elbow flexed to 90 degrees (towel under distal humerus)
*Axis: Olecranon Process
*Stationary Arm: Perpendicular to ground
*Moving Arm: Midline of Ulna (towards ulnar styloid process)
Elbow Goniometry Measurements
Flexion / Extension
Pronation
Supination
Flexion / Extension: Pt supine w/ forearm supinated
*Axis: Lateral Epicondyle
*Stationary Arm: Acromion
*Moving Arm: Lateral midline of Radius (Radial Styloid Process)
Pronation: Arm by pt’s side / flexed to 90 degrees
*Axis: Lateral to Ulnar Styloid Process
*Stationary Arm: Midline of Humerus
*Moving Arm: Dorsal wrist / proximal and parallel to styloid processes
Supination: Arm by pt’s side / flexed to 90 degrees
*Axis: Ventral / proximal to Ulnar Styloid Process
*Stationary Arm: Midline of Humerus
*Moving Arm: Ventral wrist / proximal and parallel to styloid processes
Wrist Goniometry Measurements
Flexion / Extension
Radial Deviation
Ulnar Deviation
Flexion / Extension: Pt sitting w/ proximal forearm supported, shoulder abducted and elbow extended
*Axis: To the side of Triquetrum (medial wrist in anatomical position)
*Stationary Arm: Lateral midline of Ulna
*Moving Arm: Midline of 5th metacarpal
RD / UD: Pt sitting w/ proximal forearm supported, shoulder abducted and elbow flexed to 90 degrees
*Axis: Dorsal wrist (over Capitate)
*Stationary Arm: Dorsal midline of forearm (directed to Lateral Epicondyle)
*Moving Arm: Dorsal midline of 3rd Metacarpal
UE Myotomes
Procedure:
*Shoulder Flexion: C5
*Elbow Flexion/Wrist Extension: C6
*Elbow Extension/Wrist Flexion: C7
*Finger Flexion (have pt grip both of your index fingers): C8
*Finger Abduction: T1
*3-5 second hold on each side
*Repeat test for 3+ reps if weakness detected (Neurologic weakness is fatiguable, muscle weakness is not!)
What Are We Looking For?:
*Find gaps to determine if weakness is localized/CNS or PNS dysfunction
*Spinal nerve root vs. peripheral nerve function, NOT specific muscle function
https://www.youtube.com/watch?v=1W25yRKmAPw
UE Dermatomes (C4-T1)
Procedure:
*Explain procedure - “I’m going to assess what you can feel on the skin of your arms”
*Give pt reference of what stimulus should feel like (cheek)
*“I’m going to ask you three questions - When do you feel it? / Where do you feel it? / Does it feel the same as your face?”
*Have pt close eyes
What Are We Looking For?:
*Find gaps to determine if sensory changes/loss are localized/CNS or PNS dysfunction
*Assessing sensory function of spinal nerve root or peripheral nerve (intact / impaired / absent)
Cervical Compression / Distraction
Procedure:
*Do compression first (hands on top of head) / then distraction (hands below mastoid process)
*Maintain pressure 5-8 seconds
*Gradually release pressure
What Are We Looking For?
*Have symptoms improved / worsened with pressure?
*Clarify symptom location
ULTT 1
Median N. bias
Procedure:
*Pt supine and PT on ipsi side
*C-spine neutral - shoulder depression - GH abduction - wrist/finger extension, forearm supination - GH ER - elbow extension - c-spine contra side bending
What Are We Looking For?:
*Differences between limbs in elbow ROM
*Reproduction of concordant neurologic symptoms in UE w/ movement of distant component
*Different symptoms between two extremities
*Record sensitized position and joint angle if appropriate for re-assessment
If positive during scan, you opt to do the other 2 ULTTs
Median Nerve Glides
USING ARM OF AFFECTED SIDE
*Glide: Pt seated / neutral c-spine, shoulder at 90 degrees abduction and elbow at 90 degrees flexion / extend fingers, wrist, and elbow while simultaneously SB head towards affected side / reverse position by flexing wrist and elbow while SB away from affected side: 2-3 sets of 10-20 reps
Tensioner: Pt seated / extension of wrist, fingers, and elbow while SB away from affected side / proceed to flex fingers, wrist, and elbow while SB towards affected side
Stretch: Find sensitizing position and hold stretch 10-15 seconds for 3-5 reps
UQ DTRs
Procedure:
*Biceps (C5 - 6): Place finger over bicep tendon before hammer strike - bicep contraction
*Brachioradialis (C5 - 6): Position pt’s arm between sup and pro, strike hammer along radial side proximal to wrist - elbow flexion w/ or w/o forearm pro
*Triceps (C7 - 8): Lift pt’s relaxed arm and strike along triceps tendon - elbow ext
What Are We Looking For?:
*Side to side differences
*Grading
0 - absent
1 - slight (hyporeflexia)
2 - normal
3 - brisk (still considered norm)
4 - enhanced (hyperreflexia including clonus if present)
Pathologic Reflexes
Hoffman / Babinski / Lhermitte
Hoffman: Briskly pinch or flick middle fingernail / (+) test involves adduction and opposition of thumb plus finger flexion in remaining digits
Babinski: Run stimulus along lateral border of sole of foot / across metatarsal heads / (+) test involves great toe extension w/ fanning of toes 2-5 / (-) test involves slight flexion of all toes
Lhermitte: Pt flexes head and neck / (+) test involves shock-like sensation that radiates down spinal column into UEs and sometimes LEs
Cranial Nerve Testing
Procedure:
*CN I: Cover 1 nostril / with pt’s EC have them identify smell
*CN II/CN III: Shield 1 eye and shine light obliquely in other / look for constriction of both pupils / do on both sides
*CN IV/CN VI: “H” test / down and in for CN IV (sup. oblique) / abduction (lateral rectus)
*CN V: Palpate masseter and temporalis while pt clinches teeth / sensation testing on forehead , cheekbone, jaw
*CN VII: Smile, frown, raise eyebrows / taste on anterior 2/3 tongue (watch for tongue deviations toward weak side for CN XII)
*CN VIII: 30 seconds looking at thumb with c-spine rotation / pt EC rub fingers together on each side (when do you hear it? / do they sound the same?)
*CN IX/CN X: Speech (“Can you repeat these 3 words after me?”)
*CN XI: Resisted shoulder shrug
Pulse Assessment
Procedure:
*Start distal if you do not suspect any problems (Radial / Ulnar)
*If distal pulse appears reduced, work in a proximal to distal pattern (Axillary - Brachial - Radial / Ulnar)
What Are We Looking For?:
*Assessing HR / potency
*Scale:
0 - absent
1 - markedly reduced
2 - slightly reduced
3 - normal
4 - bounding pulse
Thyroid Gland Palpation
Procedure
*Palpate in diagonal motion along anterior portion of the neck
What Are We Looking For?:
*Pain / tenderness upon palpation
*Any bumps or possible nodules
Deep Cervical Lymph Node Palpation
What Are We Looking For?:
*Pain / tenderness upon palpation
*Any bumps or possible nodules
Slump Test
Procedure:
*Pt sitting / hips and knees flexed / hands behind back
*Slump into slouched posture / bring chin to chest
*Straighten knee / ankle DF (OP cervical flexion / DF if necessary)
*Do NOT progress pt to the next position if symptoms increase at any point
What Are We Looking For?:
*Record sensitized position and joint angle if appropriate for re-assessment following treatment
Slump Test Nerve Glides
Glide: Pt seated / moves limb into sensitizing position while simultaneously extending cervical spine / reverse position (flexing c-spine while simultaneously flexing knee and/or PF ankle): 2-3 sets of 10-20 reps
Tensioner: Pt seated / move limb into sensitizing position and flex c-spine / proceed to extend c-spine and flex knee and/or PF ankle
Stretch: Find sensitizing position and hold stretch 10-15 seconds for 3-5 reps
ULTT 2
Radial N. bias
Procedure:
*Pt supine and PT on ipsi side
*C-spine neutral - shoulder depression - GH IR - wrist/finger flexion, forearm pronation - elbow extension - GH abduction - c-spine contra side bending
What Are We Looking For?:
*Differences between limbs in elbow ROM
*Reproduction of concordant neurologic symptoms in UE w/ movement of distant component
*Different symptoms between two extremities
*Record sensitized position and joint angle if appropriate for re-assessment
Radial Nerve Glides
USING ARM OF AFFECTED SIDE
Glide: Pt standing / neutral c-spine with arm at their side and elbow extended / Flex fingers, wrist and abduct shoulder while simultaneously SB towards affected side / reverse position by extending fingers and wrist while SB away from affected side: 2-3 sets of 10-20 reps
Tensioner: Pt standing / flex fingers, wrist and abduct shoulder while SB away from affected side / proceed to extend fingers, wrist while SB towards affected side
Stretch: Find sensitizing position and hold stretch 10-15 seconds for 3-5 reps
ULTT 3
Ulnar N. bias
Procedure:
*Pt supine and PT on ipsi side
*C-spine neutral - shoulder depression - GH abduction - GH ER - wrist/finger extension, forearm pronation - elbow flexion - c-spine contra side bending
What Are We Looking For?:
*Differences between limbs in elbow ROM
*Reproduction of concordant neurologic symptoms in UE w/ movement of distant component
*Different symptoms between two extremities
*Record sensitized position and joint angle if appropriate for re-assessment
Ulnar Nerve Glides
USING ARM OF AFFECTED SIDE
Glide: Pt seated or standing / shoulder abducted and elbow flexed to 90 degrees / Extend fingers, wrist and flex elbow towards face while simultaneously SB towards affected side / reverse position by flexing fingers and wrist while SB away from affected side: 2-3 sets of 10-20 reps
Tensioner: Pt sitting or standing / extend fingers, wrist and flex elbow towards face while SB away from affected side / proceed to flex fingers, wrist while SB towards affected side
Stretch: Find sensitizing position and hold stretch 10-15 seconds for 3-5 reps
Cervical Spine Clearing Tests
Order does NOT matter
Do these before deciding whether or not to scan!
Transverse Ligament (AA Joint Stability):
*Modified Sharp Purser: Pt seated w/ PT standing at the pt’s side / ask pt to engage in CV flexion and inquire about S&S (5 D’s / 3 N’s) + hearing or feeling a “clunk” (indicates anterior displacement of C1) / PT stabilizes C2 SP with pincer or key grip with 1 hand and provides posterior + upward (45 degree) force with the other hand REGARDLESS if pt is experiencing symptoms (which would theoretically realign C1/C2) / (+) test if S&S are reduced with posterior force - this is a RELOCATION test
*Supine Lift-Off: Pt supine w/ PT at pt’s head / PT places both index fingers horizontally along C1 while supporting base of skull with remaining fingers / PT shears occiput and C1 in anterior direction (immediate neck flexion should occur) / (+) test = excessive upper cervical mobility suggesting ligamentous laxity or damage - this is a MOBILITY test
Alar Ligament (OA Joint Stability): Pt supine w/ PT at pt’s head / PT places 1 hand on C2 SP using pincer grip while using other hand to grip top of pt’s head / PT performs passive CV L and R SB / should immediately feel C2 SP movement (movement to the R tightens L Alar Ligament - should feel L side of C2 move into patient’s finger) / (+) test is NOT feeling immediate movement of C2 SP into PT’s fingers suggesting ligamentous laxity or damage - this is a MOBILITY test
VBI Screen (Assess integrity / function of Vertebral Basilar Artery): Pt supine with PT holding pt’s head in air / engage in the following positions: extension, L rotation, R rotation - each time ask pt to fixate their eyes on a spot and count back from 10 w/ EO / can do extension combined with both L and R rotation if no symptoms present in initial positions / if symptoms evoked in extension then rotation tells you which portion of the artery is affected (R rotation eliciting symptoms = R artery affected) / (+) test is presence of 5 D’s and 3 N’s (particularly nystagmus, diplopia, dysarthria, facial numbness, and dizziness) in any position
If ANY of the above tests are positive, send pt to urgent care / same-day doc for clearance before beginning any PT treatment
Cervical Muscle Strength (MMT)
Assess in neutral position
5 second hold
Weakness? Test again!
Flexion - tests key muscles for C1-2 and CN XI
Extension
L/R SB - tests key muscles for C3 and CN XI
L/R Rotation - tests key muscles for C2
Upper Trapezius Muscle Length Test
Pt supine / flex, contra SB, ipsilateral rotation / PT depresses ipsilateral shoulder
Normal Muscle Length: ~45 degrees of rotation with soft barrier at end range
Decreased Muscle Length: <45 degrees of rotation and/or hard barrier at end range
Levator Scapulae Muscle Length Test
Pt supine / flex, contralateral rotation and SB / PT depresses ipsilateral shoulder
Normal Muscle Length: ~45 degrees of rotation with soft barrier at end range
Decreased Muscle Length: <45 degrees of rotation and/or TTP at muscle insertion
SCM Muscle Length Test
Pt supine / contralateral SB with extension / PT stabilizes ipsilateral shoulder and rotates neck ipsilaterally
Normal Muscle Length: Equal ROM bilaterally
Decreased Muscle Length: Unequal ROM bilaterally w/ or w/o TTP and hypertonicity
Scalenes Muscle Length Test
Pt in supine / extension and contralateral SB while stabilizing ipsilateral shoulder
Normal Muscle Length: ~45 degrees of SB ROM
Decreased Muscle Length: <45 degrees of SB ROM w/ or w/o TTP and hypertonicity
OA Joint Mobility
Assessment For:
Opening Restriction on R: CV flexion and L to R sideglide
Opening Restriction on L: CV flexion and R to L sideglide
Closing Restriction on R: CV extension and R to L sideglide
Closing Restriction on L: CV extension and L to R sideglide
Observing for normal mobility or hyper- / hypo mobility at each segment - facet joint dysfunction
AA Joint Mobility
PT flexed mid-lower c-spine to “take up slack” / PT rotates to L followed by R
Assessing for normal mobility or hyper- / hypo mobility at each segment
Joint Mobility - PA Springing (C2 - T1)
Prone CPAs: PT’s thumb on or around SP / assess C1 - T1
Prone R and L UPAs (not necessary if CPA is clear): PT’s thumbs on or around lamina / assess R and L sides of C1 - T1 /
*Have pt flex neck towards plinth
*Assess for hyper- / hypomobility at each segment
*Do in addition to joint mobility sideglides
Joint Mobility - Side Glides (C2 - T1)
In Flexion: PT flexes neck up to segment being assessed / glide R to L to open L side and L to R to open R side / repeat action at each segment
In Extension: PT extends neck up to segment being assessed / glide R to L to close R side and L to R to close L side / repeat action at each segment
Line of force at 45 degrees (to resemble facet joint orientation)
Assess for hyper- or hypomobility at each segment
Spurling Test
Compresses foramina to test for cervical radiculopathy
Pt seated with PT standing behind pt
PT asks pt to SB head and then applies an inferior force (towards floor) for 5-8 seconds - stabilize shoulder contra to SB
Test is repeated on opposite side
(+) test = reproduction of symptoms into ipsilateral UE
Cranio-Cervical Flexion Test (CCFT)
Good for putting peeps in Neck Pain w/ Movement Coordination Impairments (WAD) / stability bucket
Assesses activation and endurance of deep cervical neck flexors
Pt supine in hooklying with head and neck in neutral / BP cuff placed under lordotic curve of c-spine (to fill in gaps of lordosis) / inflate cuff to 20 mmHg and add 2 mmHg each time - 10 second hold at each interval until 30 mmHg
Test ends when pt is no longer able to maintain desired pressure for 10 seconds
Activation Score = Max pressure achieved and held for 10 seconds
Performance Index = (Max pressure achieved and held for 10 seconds) x (# of reps that max pressure was maintained for 10 seconds, up to 10 reps)
Neck Flexor Endurance Test
Good for putting peeps in Neck Pain w/ Movement Coordination Impairments (WAD) / stability bucket
Assesses for neck flexor endurance and motor control
Pt supine in hooklying position / pt tucks chin and lifts head ~1 inch off table while maintaining chin tuck
Tests ends when pt is no longer able to maintain chin tuck / head falls back to the table / neck extends
(+) test for men = <38.9 seconds, <29.4 seconds for women
Cervical Flexion-Rotation Test (CFRT)
ONLY do if you suspect Neck Pain w/ Cervicogenic HA Bucket
Assessing for presence of cervicogenic HA (ROM and symptom provocation test)
Pt in supine w/ PT at pt’s head (resting symptoms are noted) / pt asked to maximally flex head and hold that position / PT applies pressure throughout full rotation to both sides and notes any change in symptoms
(+) test = rotation ROM loss to 1 side > or = 10 degrees compared to opposite side and/or reproduction/exacerbation of pt’s symptoms
Shoulder Abduction Test
Assess for presence of radicular symptoms
Shortens distance nerve has to travel / takes pressure off
Pt seated and asked to place hand of affected limb on top of head
(+) test = pt’s symptoms are reduced or relieved with testing position - Cervical Radiculopathy
