1
Q
Shoulder Exam
what to inspect for?
A
- swelling, signs of trauma
- shoulder muscle atrophy
- inspection during ROM
2
Q
Shoulder Exam
what to palpate for tenderness, prominence, or crepitus?
A
- sternoclavicular joint
- acromioclavicular joint
- glenohumeral joint
- scapulohtoracic articulation
3
Q
Shoulder Exam
which soft tissue structures do you palpate for?
A
- neck, shoulder, parascapular areas
- rotator cuff muscles
- biceps muscle and bicipital tendon in intertubercular groover
- subacromial/subdeltoid bursa
- axilla
4
Q
Shoulder Exam
what muscles compose the rotator cuff?
A
- Supraspinatus
- Infraspinatus
- Teres minor
- Subscapularis
SITS
5
Q
Shoulder Exam
ROM for shoulder
A
- flexion- 180 deg
- extension- 50 deg
- abduction- 180 deg
- adduction- 45-50deg
- external rotation- 90 deg
- internal rotation- 90 deg
- scapular elevation (shoulder shrug)
- retration (at attenetion)
- protraction (shoulders forward)
- horizontal abduction (90 deg) and adduction (130 deg)
5
Q
A
6
Q
Shoulder Exam
MSK strength testing
A
- ROMs against resistance
- biceps/triceps
- serratus anterior nerve damage (push up against wall, look for scapular winging)
7
Q
Shoulder Exam
how to test for bursal tenderness
A
palpate under edge of acromion or over deltoid muscle
8
Q
Shoulder Exam
how to test for fibromyalgia
A
check for pinch roll tenderness with one finger localized tender or trigger points
9
Q
Shoulder Exam
tests for the bicipital tendon
4
A
- bicipital groove tenderness: palp for localized tenderness over biceps tendon in the intertubercular groove
- speed’s test: with elbow fully extended and palm forward, flex shoulder against resistance
- yergason’s test: with elbow at 90deg flexion and held against the hip, externally rotate patient’s shoulder against resistance while pulling down elbow.
- check for ruptured long head of biceps muscle (popeye muscle)
10
Q
Shoulder Exam
Tests of the AC joint
4
A
- check for crepitus at AC joint w/ overhead ROMs
- raise elbow to chin level and bring shoulder under the chin
- Cross Over Test: tests AC adduction, w/ the arm straight, adduct it across the body
- Piano Key Sign: w/ separation of the AC joint, the distal clavicle will translate superiorly. press down on the clavicle and you will see rebound (when the joint is separated)
11
Q
Shoulder Exam
tests of rotator cuff impingement
2
A
- Neer Impingement Sign: arm up to ear and rotate, pain w/ flexion and pronation. subacromial impingement or rotator cuff tear.
- Hawkin Impingement Test: to test for subacromial impingement or rotator cuff tendonitis abduct the shoulder to 90 deg, forward flex to 30 deg, and forcibly internally rotate (induced pain!)
- for rotator cuff impingment syndrome: press down on acromion as the supraspinatus muscle isolation test is done and adduct the arm behind the back
12
Q
Shoulder Exam
tests for rotator cuff tears
2
A
- inspect for atrophy of supraspinatus or infraspinatus muscles
- test for resistance of pt to abduct the shoulder actively and against resistance
- Drop Arm Test: from fully abducted position, slowly lower the arm to the side, noting pain starting at approx 90deg followed up sudden drop of arm.
13
Q
Shoulder Exam
tests to isolate injured rotator cuff muscles
A
- empty can test: supraspinatus muscle isolation; with arm straight and shoulder abducted to 90deg and forward flexed 30deg, point thumb at ground and lift arm against resistance
- Infraspinatus/Teres Minor test: w/ elbow at 90deg, externally rotate the shoulder against resistance
- no test to isolate subscapularis
14
Q
Shoulder Exam
Tests of anterior stability of the GH joint/ligament stability
A
- Apprehension Test: shoulder abducted to 90 deg and elbow flexed to 90 deg, examiner then externally rotates the shoulder and looks for signs of apprehension on pt’s face
- Apprehension reloaction test: repeat test while exerting anterior pressure over shoulder to prevent shoulder from subluxing/dislocating anteriorly
15
Q
Shoulder Exam
tests of inferior stability with GH joint/ligament stability?
A
- sulcus sign gap: felt between acromion and humeral head due to inferior subluxation or dislocation
16
Q
Shoulder Exam
tests of neuromuscular disorders?
A
- check for scapular winging due to serratus anterior msk inury or long thoracic nerve palsy
- check for rhomboid muscle strain: pt’s arm behind back internally rotated and adducted, pt then pushes hand away from body against resistance which makes rhomboid muscle available to palpation between the spine and scapula
- check the spinal nerves and peripheral nerves in shoulders/arms
17
Q
Shoulder Exam
tests of related areas which can cause referred pain to shoulder
thoracic outlet compression tests
A
- Adson’s Maneuver: pt mildly abducts and extends shoulder, extends and rotates C-spine toward that shoulder, and takes a deep breath. palpate the radial pulse before and after this maneuver (pos result = diminished pulse)
- Costoclavicular Maneuver: pt stands at attention w/ shoulder’s drawn backward and downward as radial pulse is examined- pos result = diminished pulse, also auscultate supra and infra clavucular regions for bruits
- AER Position: “arms in external rotation”; shoulders abducted to 90 deg, elbows flexed at 90 deg, arms held in this position for up to 3 min; palpate pulse and auscultate for bruits. most reliable test
- examine C-spine as potential cause of referred pain to shoulder; always examine joint above and below complaint
18
Q
Knee Exam
components of inspection
A
- gait
- leg length discrepancy
- quad mass and symmetry
- inspect for genu varus, valgus, recurvatum
- obvious bony/soft tissue deformities, swelling, erythema, signs of trauma
- inspect for effusion (loss of normal concavities on each side of patella)
19
Q
Knee Exam
what to palpate for
A
- quads for tone
- patella/patellar tendon
- tibial tuberosity
- area of pes anserine burse (in flare of medial tibial tuberosity)
- tibial plateau
- medial/lateral joint margins and collateral ligaments
- femoral condyles
- head to fibula
- popliteal fossa, popliteal pulse, hamstring tendons
- joint line (knee flexed to 90 deg)
20
Q
Knee Exam
ROM for knee
A
- flexion (135 deg)
- extension (0 neutral to -15)
- tibial internal/external rotation (10 deg)
21
Q
Knee Exam
tests for effusion
A
- Bulge Sign: for minor effusions; milk fluid from suprapatellar pouch and one side of knee to other side of knee; tap over fluid on one side of knee and watch for fluid wave
- Patellar Ballottement: for larger effusions; compress the suprapatellar pouch toward the patella, then push down the patella and note how it springs up and down on cushion of abnormal knee fluid
22
Q
Knee Exam
tests of patello-femoral function
A
- common complaint is knee pain going up stairs
- assess “tracking” of patellar in patellofemoral groove with ROM and, if abnormal, suspect symmetrical quad muscle strength (alternative: with knees extended, look/palpate for deviation of patellar during tensing of quads)
- Patellar Apprehension Test: for suspected recurrent lateral dislocation of patella; with knee fully extended, displace patellar laterally and note any pt apprehension
- Patellofemoral Grinding Test: test for chondromalacia patellae; push down on patella while having pt do straight leg raise OR push patella distal w/ leg in extension and tighten quads
23
Q
Knee Exam
tests of collateral ligaments (medial collateral/lateral collateral ligaments)
A
- Varus/Valgus Stress: cradle ankle in axilla and apply VARUS stress (push knee out) to test LCL; then apply valgus stress (push knee IN) to test MCL
24
# Knee Exam
tests of cruciate ligaments
* **Anterior Drawer Test**: for ACL tear; flex knee to 90 deg and sit on pt's foot; attempt to pull tibia anteriorly toward you (ACL tear = anterior tibia shift); and then repeat with the tibia in internal rotation to test posteriolateral joint capsule and in external rotation to test posteriomedial joint capsule
* **Lachman Test**: for ACL tear; flex knee to approx 20 deg; grasp lower leg, with one hand, use other hand to grasp thight; pull tibia foward while pushing femur back
* **Modified Pivot Shift Test**: for ACL tear causing rotary instability; with knee flexed and hanging over end of exam table, internally rotate the tibia and look for abnormal forward rotation of lateral tibial plateau
* **Posterior Drawer Test**: for PCL tear- flex knee to 90 deg and sit on pt's foot; attempt to push tibia posteriorly away you (PCL tear = posteior tibia shift)
* **Sag Sign for PCL tear**: inspect if tibia sags posteriorly when knee is relaxed at 90 deg flexion
25
# Knee Exam
Tests of meniscal integrity
* **Medial McMurray Test**: fully flex knee, then hold foot in external rotation and apply valgus force to knee while extended knee
* **Lateral McMurray Test**: fully flex knee, hold foot in internal rotation and apply varus force to knee while extending knee
* **Apley's Meniscal Compression Test**: with patient prone, grind tibia against femur in rotating motion to see if it elicits meniscal pain
* **Apley's Meniscal Distraction Test**: same as above, except tibia is pulled away from femur; pain may indicate ligamentous injury or malingering rather than meniscal injury.
26
# Lumbar Spine
components of inspection
* posutre, symmetry of shoulders, and pelvis
* spinal alignment
* for skin lesions (which could indicate possible underlying neruologic pathology)
27
# Lumbar Spine
components of palpation
* spinous processes for tenderness and "step offs" from spondyloisthesis (slip)
* paraspinous muscles for spasm
* pelvic bones, SI joints, sacrum, cocyx
* sciatic nerve area (with knee flexed, palpate between ischial tuberosity and greater trochanter)
28
# Lumbar Spine
AROM/PROM
* flexion (75-90 deg)
* extension (30 deg)
* R&L rotation (30 deg)
* R&L bending (35 deg)
29
# Lumbar Spine
Test of vertebral motion
* **Schober's Test**: make mark at L5/S1 level and another 10cm above that. Have the pt bend forward and record how much the line increases in length (normal is 5-8cm)
* **Alternate Schober's Test**: place index and middle fingers in line w/ lower L spine and see how far they spread (less accurate)
30
# Lumbar Spine
tests of nerve root irritation (sciatica)
**Straight Leg Rase Tests**
* **Bragard's SLR**: pt does a straight leg lift to the limit of pain; examiner then lowers the leg slightly and dorsiflexes ankle; sciatic pain with this maneuver suggests nerve root irritation rather than only hamstring tightness
* **Lasague's SLR**: examiner passively flexes the knee and hip, then extends the knee; sciatic pain with this maneuver suggests nerve root irritation.
* **Well-Leg (Cross Leg Raise)- CLR**: sciatic pain elicited by SLR on the uninvolved leg suggests space occupying lesion (or herniated disc)
* **Hoover Test for Malingering**: aka faking it; absence of downward pressure of the opposite heel during straight leg raising indicates malingering (not trying)
31
# Lumbar Spine
Localizing nerve root disorder of L4
* disc space: L3/4
* root: L4
* DTR: patellar reflex
* motor resting: quadriceps strength (flex thigh, extend knee)
* sensory testing: anterolateral thigh, medial calf, medial side of foot
32
# Lumbar Spine
Localizing nerve root disorders of L5
* disc space: L4/5
* root: l5
* DTR: none
* Motor testing: walk on heels (dorsiflex), dorsiflex great toe
* Sensory: posterior calf, posterior thigh, mid dorsum of foot
33
# Lumbar Spine
Localizing nerve root disorders of S1
* disc space: L5/S1
* root: S1
* DTR: achille's
* Motor: walk on toes
* Sensory: posterior calf, thigh, lat side of food
34
# Lumbar Spine
tests of increased intrathecal pressure
* valsalva maneuver (bear down)
* **Milgram Test**: if pt can simultaneously hold both legs 2 in off table for 30s, intrathecal pathology is unlikely
35
# Lumbar Spine
tests of SI joint
* **Pelvic Rock**: pt supine, hands on ileum, thumbs on ASIS, push inward on iliac crest
* **Gaenstein's Test**: pt supine on edge of table, one butt cheek extended over edge, pt draws both legs onto chest, then lowers leg while opposite leg remains flexed
36
# Lumbar Spine
Tests of related areas causing referred pain to lumbar spine
* check for abd aortic aneurysm and other masses
* CVA tenderness
* Pelvic rock test
* **Patrick (Faber) Test**: pt supine, place ankle on opposite knee and let hip fully externally rotate; pain in inguinal area = hip pain; if the knee is then pushed down, increased pain from the SI joint is suspected. (PAIN ON SIDE OF CROSSED LEG IS POSITIVE)
37
# Cervical Spine
inspection
inspect for alignment and head positioning
38
# Cervical Spine
palpation
spinous processes (C7/T1), paraspinous muscles, crepitus
39
# Cervical Spine
ROM
* flexion (chin to chest)
* extension (look at ceiling directly)
* R/L rotation: chin aligned with shoulder
* R/L lateral bending: 45 deg
40
# Cervical Spine
localizing nerve root disorders of C5
* disc space: C4/5
* root: C5
* DTR: biceps reflex
* Motor: deltoid (shoulder abduction)
* Sensory: radial side of upper arm
41
# Cervical Spine
localizing nerve root disorders to C6
* disc space: C6
* root: C5/6
* DTR: brachioradialis
* Motor: wrist extension
* Sensory: radial side of forearm, thumb/index finger (palmar)
42
# Cervical Spine Disorders
localizing nerve root disorders to C7
* disc space: C6/7
* root: C7
* DTR: triceps reflex
* Motor: wrist flexion, finger extension
* Sensory: palmar side of middle finger
43
# Cervical Spine
localizing nerve root disorders to C8
* disc space: C7/T1
* root: C8
* DTR: none
* Motor: finger flexion, abduction, adduction
* Sensory: ring/pinky fingers, ulnar side of forearm
44
# Cervical Spine
localizing nerve root disorders to T1
* disc space: T1/T2
* root: T1
* DTR: none
* Motor: finger abduction, adduction
* Sensory: medial distal upper arm
45
# Cervical Spine
Sensory testing to detect common peripheral nerve disorders
* Radial Nerve: dorsal web space between thumb/index finger
* Median Nerve: palmar aspect of thumb, index, middle, radial side of ring finger
* Ulnar Nerve: entire ulnar side of palm, includes ring and pinky
* Axillary Nerve: regimental bade area over deltoid muscle
46
# Cervical Spine
Misc Tests
* **Fibromyalgia**: pinch roll tenderness
* **Swallowing**: dysphagia can result from ant vertebral body spurs, ant spondylolisthesis, spinal/vertebral tumors, hematomas, or infections
* **Cervical Compression Test**: gently push down on head to compress cervical spine; worsened pain if due to facet arthritis, nerve impingement, neurovertebral foramen narrowing, and muscle spasm
* **Cervical Distraction Test**: dently lift head up to reduce pressure on C-spine which may reduce pain and suggest cervical traction as a therapeutic intervention
47
# Elbow Exam
what is absent in elbow dislocation?
Triangle sign
48
# Elbow Exam
testing for lateral epicondylitis
* aka tennis elbow
* tap on lateral condyle (tender/pain with palp or percuss)
* forced wrist extension against resistance causes pain at lateral epicondyle
49
# Elbow Exam
testing for medial epicondylitis
* aka Golfer's Elbow
* percussion test: tap on medial condyle (tender/pain)
* forced wrist extension against resistance causes pain at medial epicondyle
50
# Elbow Exam
varus/valgus stress test
w/ elbow extended apply valgus stress (to test UCL) and varus stress (to test RCL)
51
# Wrist Exam
Carpal Tunnel tests
* look for atrophy or thenar eminence, sensory deficits in palmar aspect of thumb, index, middle, and radial side of ring fungers
* reduced 2 pt discrimination
* **Tinel's**: tap over median nerve --> sx reproduced
* **Phalen's**: hold max flexion of wrist for 1 minute --> sx reproduced
52
# Wrist Exam
DeQuervain's Tenosynovitis
* tendonitis of abductor pollicis brevis and longus tendons
* **Finkelstein Test**: pt makes fist with enclosed thum, examiner passively flexes and ulnar deviates wrist to stretch tendons and reproduce sx
53
# Wrist Exam
what does snuff box tenderness mean
scaphoid (navicular) bone fracture
54
# Hand Exams
Misc specialized tests
* inspect for Dupuytren's Contractures (palmar fascial thickening w/ associated fibrous bands, puckering of skin, and +/- contractures of palmar digits
* palpate for stenosing tenosynovitis (trigger finger): fingers get stuck in flexed position and require manual release
55
# Hand Exams
specialized hip exams
* **Thomas Test**: detects flexion contractures of hip; w/ pt supine, flex hip (knee to chest) and observe if opposite leg raises.
* **Trendelenberg Test**: detects glute medius weakness; pt stands on one leg, if pelvis drops to non-wt bearing side there is weakness.
56
# Hand Exams
neonate hip exams
* **Barlow Click**: adduct thigh, downward pressure and femur to attempt disengagement of femoral head from acetabulum
* **Ortolani**: slowly abduct and feel for click/listen for sensation
* **Allis Sign**: for hip dislocation of shortened femur, infant supine, knees flexed, feet on table; observe height of knees (misaligned is pos)
57
# Specialized Ankle Exams
Specialized Ankle Exams
* **Anterior Drawer Test of Ankle**: stablize ankle, pull heel forward; pos test = tear of ATF ligament
* **Talar Tilt Test w/ Ankle Inversion**: ankle inversion w/ palpable gap in lat ankle suggests tear of ATF and CF ligaments
* **Talar Tilt Test w/ Ankle Eversion**: ankle eversion w/ palpable gap in medial ankle joint suggests tear of deltoid ligaments (DL)
* **Tarsal Tunnel Test**: Tinel sign but for tarsal tunnel (over posterior tibialis pulse)
* **Thompson Test**: for achilles tendon rupture; squeeze post calf to see if foot dorsiflexes (it should, if it doesn't = tear)
PACS
flashcards
Decks in class (5)
# Cards
