> [!symptoms] Look, Feel, Move > The MSK physical exam is based on the principles of "LOOK, FEEL, MOVE". > > [!multi-column] > >> [!blank] > >> ###### ① LOOK > >>Use the ***SEADS*** acronym: > >> - **S**welling > >> - **E**rythema > >> - **A**trophy > >> - **D**eformities > >> - **S**cars or skin changes > >> - (⭐️) add **GAIT** for hip & lower extremity exams > > > >> [!blank] > >> ###### ② FEEL > >>Palpate bony structures, muscles, ligaments, tendons, bursae. > >> - *does it hurt to touch?* > >> - *if it hurts to touch, where?* > >> - *does it feel hot?* > > > >> [!blank] > >> ###### ③ MOVE > >>***Active ROM*** = patient moves it themselves; ***Passive ROM*** = you move it for them > >> - *is active ROM restricted?* (e.g., pain, weakness, tendon problem) > >> - *is passive ROM restricted?* (i.e., problem with joint itself) # Cervical Spine <iframe width="560" height="315" src="https://www.youtube.com/embed/_jTZ1MTHVuM?si=UAv0KgCf55LTTdaL" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> #### ① LOOK ###### S = Swelling Usually not apparent, unless there is a history of trauma/surgery. > [!danger] Expanding Neck Hematoma > An [[expanding neck hematoma]] is an EMERGENCY that presents with rapid swelling of the neck (i.e., as blood pools inside). It can occur due to neck trauma causing soft tissue damage or dissection of the major arteries in the neck, or post-surgically. > - AIRWAY MANAGEMENT!!! > - drain hematoma if possible > - measure [[hemoglobin|Hb]] and do a [[blood typing|group & screen]] if you are considering a blood transfusion > ###### E = Erythema Can occur over the anterior neck. Consider rashes. ###### A = Atrophy This is an important step in the cervical spine neurological examination as well. Look for asymmetry/atrophy of any of the following: - [[sternocleidomastoid muscle|sternocleidomastoid]] - [[trapezius muscle|trapezius]] - [[deltoid muscle]] ###### D = Deformities > [!multi-column] >> [!blank] >> Look for <mark class="hltr-green">normal cervical lordosis</mark>. Neutral cervical curvature or kyphosis are abnormal - can be indicated by: >> - forward set head posture >> - head tilt (could also indicate [[torticollis]]; "looking away, flexing towards" the affected muscle) >> > > > [!condition] Torticollis >> > An abnormal head tilt could indicate [[torticollis]], which is a contracture of the [[sternocleidomastoid muscle|SCM]]. The patient will have a posture that is "***looking away, flexing towards***" the affected muscle. > > >> [!blank] >> ![[normal vs. abnormal cervical spine curvature.png]] ###### S = Scars > [!multi-column] >> [!blank] >> Anterior or posterior scars from prior cervical spine surgery. On recent scars, look for: >> - redness / inflammation >> - pus >> - dehiscence of the wound > >> [!blank] >> ![[cervical spine surgery scars.png]] #### ② FEEL ###### Bony Structures Ask the patient to report if they feel pain while palpating: - [[spinous process]]es of all [[cervical vertebrae]] (i.e., midline) - [[transverse processes]] of all [[cervical vertebrae]] - occiput of the head ###### Soft Tissues Feel for atrophy/asymmetry, and ask the patient to report if they feel pain while palpating: > [!multi-column] >> [!muscles] Muscles >> - [[sternocleidomastoid muscle|sternocleidomastoid]] >> - cervical paraspinal muscles > >> [!infection] Lymph Nodes >> - [[superficial cervical lymph nodes]] or [[deep cervical lymph nodes]] >>- [[supraclavicular lymph node]]s > >>[!palpation] Neck Cartilages >>- [[thyroid cartilage]] >>- [[cricoid cartilage]] ###### Carotid Pulse Palpate and measure the carotid pulse on either side of the neck. - <mark class="hltr-orange">REMEMBER</mark>: don't palpate both carotid pulses at the same time - this can occlude blood supply to the brain #### ③ MOVE Evaluate BOTH active and passive range of motion. > [!check] Canadian C-Spine Rule > Use the [[Canadian C-Spine Rule]] as a guide to know if it is safe to proceed with ROM testing if you are suspicious of a [[cervical spine fractures|cervical spine fracture]]. ###### Extension & Flexion - normal neck extension = ~<mark class="hltr-green">60°</mark> - normal neck flexion = <mark class="hltr-green">~50°</mark> > [!multi-column] >> [!blank] >> ![[extension of the neck.png]] > >> [!blank] >> ![[flexion of the neck.png]] > [!multi-column] >> [!blank] >> ###### Rotation >> - normal neck rotation = ~<mark class="hltr-green">80°</mark> in either direction >> ![[rotation of the neck.png]] > >> [!blank] >> ###### Lateral Flexion >> - normal lateral flexion = ~<mark class="hltr-green">45°</mark> in either direction >> ![[lateral flexion of the neck.png]] #### ④ SPECIAL TESTS > [!multi-column] >> [!blank] >> ###### [[Spurling test|Spurling Test]] >> - tests for [[cervical radiculopathy]] >> - <mark class="hltr-green">positive test</mark> = patient reports burning/electrical pain (i.e., neuropathic pain) down the arm of the affected side (i.e., the side the head is turned towards) >> <iframe width="560" height="315" src="https://www.youtube.com/embed/rAF_60JFFyY?si=iSwiVs7pupctCfBF" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[cervical distraction test]] >> - tests for [[cervical radiculopathy]] >> - <mark class="hltr-green">positive test</mark> = patient reports decrease or alleviation of symptoms (i.e., neuropathic pain goes away with test) >> <iframe width="560" height="315" src="https://www.youtube.com/embed/xEPfB43lmPg?si=quaEvWuWeWlbLaCh" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> #### ⑤ C-SPINE NEUROVASCULAR EXAM From a vascular perspective, measure: - carotid pulse - radial pulse The following tests are designed to elicit problems with the [[cervical spinal nerves]]. Use the [[ASIA Impairment Scale.pdf]] for quick & easy reference. ###### Myotomes (Motor) > [!multi-column] >> [!blank] >> - [[spinal nerve C5|C5]] = [[flexion of the elbow.png|elbow flexion]] (or [[aBduction of the arm.png|shoulder aBduction]]) >> - [[spinal nerve C6|C6]] = [[extension of the wrist.png|wrist extension]] >> - [[spinal nerve C7|C7]] = [[extension of the elbow.png|elbow extension]] >> - [[spinal nerve C8|C8]] = [[flexion of the fingers (IP).png|finger flexion]] (grip) >> - [[spinal nerve T1|T1]] = [[aBduction of the fingers.png|finger aBduction]] > >> [!blank|wide-2] >> | Grade | Description | >> | ---------------------------------- | --------------------------------------------- | >> | <mark class="hltr-grey">0</mark> | total paralysis | >> | <mark class="hltr-red">1</mark> | fasciculations (palpable/visual contractions) | >> | <mark class="hltr-pink">2</mark> | active movement, gravity eliminated | >> | <mark class="hltr-orange">3</mark> | active movement, against gravity only | >> | <mark class="hltr-yellow">4</mark> | active movement, against some resistance | >> | <mark class="hltr-green">5</mark> | active movement, against full resistance | ###### Dermatomes (Sensory) > [!multi-column] >> [!blank] >> - [[spinal nerve C5|C5]] = lateral shoulder >> - [[spinal nerve C6|C6]] = tip of thumb >> - [[spinal nerve C7|C7]] = tip of middle finger >> - [[spinal nerve C8|C8]] = tip of little finger >> - [[spinal nerve T1|T1]] = medial forearm > >> [!blank|wide-3] >> | Grade | Description | >> | ---------------------------------- | ------------------ | >> | <mark class="hltr-orange">0</mark> | sensation absent | >> | <mark class="hltr-yellow">1</mark> | sensation impaired | >> | <mark class="hltr-green">2</mark> | normal | ###### Reflexes > [!multi-column] >> [!orange] Hyperreflexia >> ↑ reflex = [[upper motor neuron lesion]] > >> [!light-blue] Hyporeflexia >> ↓ reflex = [[lower motor neuron lesion]] > [!multi-column] >> [!blank] >> - [[spinal nerve C5|C5]] = [[brachioradialis reflex]] >> - [[spinal nerve C6|C6]] = [[biceps reflex]] >> - [[spinal nerve C7|C7]] = [[triceps reflex]] > >> [!blank|wide-3] >> | Grade | Description | >> | ---------------------------------- | --------------------------------------------------------- | >> | <mark class="hltr-orange">0</mark> | reflex absent | >> | <mark class="hltr-yellow">1</mark> | lower limit of normal (reflex present with reinforcement) | >> | <mark class="hltr-green">2</mark> | normal | >> | <mark class="hltr-yellow">3</mark> | more than average, brisk | >> | <mark class="hltr-orange">4</mark> | clonus, pathologically increased # Shoulder Joint > [!multi-column] >> [!blank] >> <iframe width="560" height="315" src="https://www.youtube.com/embed/Z8rzxIk6Kj0?si=--9b0pJW-v3DGNTo" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!tip] Clinical Pearls >> - An inflammatory arthritis results in a global loss of ROM of the shoulder (especially abduction) along with pain at end range in all spheres. Sometimes inflammation in a shoulder can be confused as a "frozen" shoulder. >> - Differences in active and passive ROM are important clues to pathology (tendon vs inflammatory vs neuromuscular problem) >> - Remember to think of non-MSK causes of shoulder pain (ie. cardiac, splenic pathology) #### ① LOOK ###### S = Swelling - [[acromioclavicular joint|AC joint]] - [[sternoclavicular joint|SC joint]] - [[glenohumeral joint|GH joint]] (anterior dislocation can look like "swelling") ###### E = Erythema Usually would occur over the anterior [[glenohumeral joint|GH joint]] or over the [[acromioclavicular joint|AC joint]] / [[sternoclavicular joint|SC joint]]. ###### A = Atrophy > [!multi-column] >> [!blank] >> Look for wasting of the: >> - (⭐️) [[rotator cuff muscles]] → the majority of patients over the age of 60 have a rotator cuff tear and WILL have atrophy - most are asymptomatic >> - (⭐️) look for ***squaring of the shoulder***, indicating atrophy of the [[deltoid muscle]] (e.g., damage to the [[axillary nerve]]) > >> [!blank] >> ![[squared shoulder (deltoid atrophy).png]] ###### D = Deformity Look for deformities such as: - anterior dislocation (squared shoulder, prominent bulge on anterior shoudler) - clavicle deformity (tented = impending open fracture) - [[winged scapula]] = observe back when patient pushes against wall ###### S = Scars - anterior GH incision - GH arthroscopy incision - AC joint incision #### ② FEEL ###### Bony Structures Ask the patient to report if they feel pain while palpating: - [[sternoclavicular joint|SC joint]] - [[clavicle]] - [[acromioclavicular joint|AC joint]] - [[coracoid process]] (you have to go quite deep) - [[acromion process]] - [[glenohumeral joint|GH joint]] - [[head of the humerus]] - [[greater tubercle|greater tuberosity]] - [[spine of the scapula]] - inferior angle of the scapula ###### Soft Tissues Feel for atrophy/asymmetry, and ask the patient to report if they feel pain while palpating any of the following muscles: - [[deltoid muscle]] bulk - [[rotator cuff muscles]] - [[trapezius muscle|trapezius]] - [[biceps brachii muscle|biceps]] bulk - [[triceps bulk]] - [[biceps brachii muscle|long tendon of the biceps brachii muscle]] (on the anterior shoulder → you can't actually feel this because it's too deep, but pushing on it will cause pain if the biceps tendon is affected) #### ③ MOVE ###### Flexion & Extension - normal shoulder flexion = <mark class="hltr-green">0-180°</mark> - normal shoulder extension = <mark class="hltr-green">0-50°</mark> > [!multi-column] >> [!blank] >> ![[flexion of the shoulder.png]] > >> [!blank] >> ![[extension of the shoulder.png]] ###### ABduction & ADDuction - normal shoulder aBduction = <mark class="hltr-green">0-180°</mark> - normal shoulder aDDuction = <mark class="hltr-green">0-45°</mark> > [!multi-column] >> [!blank] >> ![[aBduction of the arm.png]] > >> [!blank] >> ![[aDDuction of the arm.png]] ###### External & Internal Rotation - normal shoulder external rotation = <mark class="hltr-green">0-50°</mark> - normal shoulder internal rotation = <mark class="hltr-green">0-50°</mark> > [!multi-column] >> [!blank] >> ![[lateral (external) rotation of the arm.png]] > >> [!blank] >> ![[medial (internal) rotation of the arm.png]] #### ④ SPECIAL TESTS ###### Tests of Rotator Cuff Tendinopathy *These tests involve active, resisted movements that the rotator cuff muscles are responsible for.* > [!multi-column] >> [!blank] >> ###### [[empty can test|Empty Can Test]] >> *Note - ensure you bring the arms 30° forward and rotate the thumbs towards the ground.* >> - tests the [[supraspinatus muscle]] >> - <mark class="hltr-green">positive test</mark> = pain or weakness of resisted aBduction + internal rotation >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/tjQzMGrvI3U?si=yTRCucLDCyJgpTSV" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[external rotation test|Resisted External Rotation]] >> *Note - you can hold the elbow to ensure they don't use shoulder aBduction to compensate.* >> - tests the [[teres minor muscle]] and the [[infraspinatus muscle]] >> - <mark class="hltr-green">positive test</mark> = pain or weakness of resisted external rotation of the arm >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/14fwIZqm_1U?si=i5qEUi5FayjQi0pg" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > [!multi-column] >> [!blank] >> ###### [[lift off test|Lift Off Test]] >> - tests the [[subscapularis muscle]] >> - <mark class="hltr-green">positive test</mark> = pain or weakness with resisted internal rotation of the arm >> >> <iframe width="560" height="315" src="https://www.youtube.com/embed/Ojr2CLmiuTA?si=bJ7Ev6w2lygwYmPV" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[belly press test|Belly Press Test]] >> - tests the [[subscapularis muscle]] >> - <mark class="hltr-green">positive test</mark> = pain or weakness with resisted internal rotation of the arm >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/tqHBxKWu3_Q?si=cTd4gDvrz0LmuhK1" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Tests of Shoulder Impingement *These tests involve passive movement of the arm to narrow the subacromial space.* > [!multi-column] >> [!blank] >> ###### [[Hawkins test|Hawkins Test]] >> - tests for [[rotator cuff tendinopathy|shoulder impingement]] >> - <mark class="hltr-green">positive test</mark> = pain in the subacromial space >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/oj_qHdDVhq8?si=zLiCUPNurJB6u004" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> >> >> > >> [!blank] >> ###### [[Neer's test|Neer's Test]] >> *Remember that Neer's is by the ear! Don't forget to point the thumb forward (internal rotation).* >> - tests for [[rotator cuff tendinopathy|shoulder impingement]] >> - <mark class="hltr-green">positive test</mark> = pain in the subacromial space > > > ><iframe width="560" height="315" src="https://www.youtube.com/embed/On8U6Czh9wU?si=4dHqtU4qVQPiOnMj" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Tests of Bicipital Tendinopathy *These tests assess active, resisted movements that the biceps muscle is responsible for.* > [!multi-column] >> [!blank] >> ###### [[Speed's test|Speed's Test]] >> - tests for [[proximal biceps tendinopathy]] >> - <mark class="hltr-green">positive test</mark> = pain in the [[intertubercular groove|bicipital groove]] >><iframe width="560" height="315" src="https://www.youtube.com/embed/S6AKVgdU7TU?si=SEB7dOGdIoOczfHJ" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> >> > >> [!blank] >> ###### [[Yerguson’s test|Yergasen's Test]] >> *Tip - show the patient how you want them to try to rotate (supinate) their hand before you do it.* >> - tests for [[proximal biceps tendinopathy]] >> - <mark class="hltr-green">positive test</mark> = pain on resisted supination >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/-UfyAjaymt4?si=boHfyAHQSsT-VZ0a" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Tests of Anterior GH Joint Instability > [!multi-column] >> [!blank] >> ###### [[shoulder apprehension and relocation test|Apprehension Test]] >> - tests for anterior [[glenohumeral instability|GH instability]] >> - <mark class="hltr-green">positive test</mark> = patient feels like their [[glenohumeral joint|GH joint]] could dislocate / is unstable >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/K2XpphO6Wls?si=S7EWRkkvN1J_ULsf" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > > > >> [!blank] >> ###### [[shoulder apprehension and relocation test|Relocation Test]] >> - tests for anterior [[glenohumeral instability|GH instability]] >> - <mark class="hltr-green">positive test</mark> = feeling of GH instability is relieved as you push the joint back into place >><iframe width="560" height="315" src="https://www.youtube.com/embed/HnjKGuaxOeU?si=BQkVaI6n6OxHzXwn" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> >> ###### [[scarf test|Scarf Test]] - tests for [[AC joint instability]] or [[AC joint osteoarthritis|AC joint arthritis]] - <mark class="hltr-green">positive test</mark> = pain over the [[acromioclavicular joint|AC joint]] <iframe width="560" height="315" src="https://www.youtube.com/embed/Mom3l3MMxxs?si=gD35UmNixPQLPuYw" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> # Elbow Joint > [!multi-column] >> [!blank] >> <iframe width="560" height="315" src="https://www.youtube.com/embed/Qo24cRKYxpU?si=dNrylZt0mX5kByMe" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!tip] Clinical Pearls >> - Feel if the elbow is warm compared to the other elbow – this is an important clue for inflammation >> - Make sure to distinguish between elbow joint swelling and olecranon bursal swelling. >> - When an elbow swells it is held in a flexed position and the patient will have difficulty straightening it completely. >> - Tennis elbow is very common – resisted movement of any of the muscles that originate at the lateral epicondyle may reproduce the patient’s symptoms (resisted wrist extension, finger extension, supination) >> - Remember to consider pain from cervical radiculopathy or other more proximal pathology #### ① LOOK ###### S = Swelling - swelling of the joint capsule - swelling of the olecranon bursa - swelling of the radial head - (⭐️) loss of para-olecranon grooves ###### E = Erythema Usually would occur over the olecranon bursa. ###### A = Atrophy Look for wasting of the: - [[anterior compartment of the arm|flexors of the arm]] - [[triceps brachii muscle|extensors of the arm]] - [[anterior compartment of the forearm|flexors of the forearm]] - [[posterior compartment of the forearm|extensors of the forearm]] ###### D = Deformities Examine the [[carrying angle abnormalities|carrying angle]] for [[cubitus valgus]] or [[cubitus varus]]. ![[carrying angle.png]] ###### S = Scars Commonly a midline incision. #### ② FEEL ###### Bony Structures Ask the patient to report if they feel pain while palpating: - [[olecranon|olecranon process]] - [[radial head]] - [[lateral epicondyle of the humerus]] - [[medial epicondyle of the humerus]] ###### Soft Tissues Feel for atrophy/asymmetry, and ask the patient to report if they feel pain while palpating any of the following muscles: - common insertion of the [[posterior compartment of the forearm|wrist extensors]] into the [[lateral epicondyle of the humerus|lateral epicondyle]] - common insertion of the [[posterior compartment of the forearm|wrist flexors]] into the [[medial epicondyle of the humerus|medial epicondyle]] - insertion of the [[triceps brachii muscle|triceps]] into the [[olecranon]] - [[ulnar collateral ligament]] (medial) - [[radial collateral ligament]] (lateral) - olecranon bursa #### ③ MOVE Evaluate BOTH active and passive range of motion. Examine whether the motion is smooth and (where applicable) symmetric. ###### Extension & Flexion - normal elbow extension = <mark class="hltr-green">0-5°</mark> - normal elbow flexion = <mark class="hltr-green">0-145°</mark> > [!multi-column] >> [!blank] >> ![[extension of the elbow.png]] > >> [!blank] >> ![[flexion of the elbow.png]] ###### Supination & Pronation > [!multi-column] >> [!blank] >> - normal supination = <mark class="hltr-green">90°</mark> >> - normal pronation = <mark class="hltr-green">90°</mark> > > > [!tip|wide-5] Isolate the Elbow > > When assessing supination and pronation, isolate the elbow by having the patient flex the elbow to 90 degrees while supinating and pronating. It prevents them from using their shoulder to help supinate / pronate. > [!multi-column] >> [!blank] >> ![[supination of the forearm.png]] > >> [!blank] >> ![[pronation of the forearm.png]] #### ④ SPECIAL TESTS ###### Tests of Elbow Instability > [!multi-column] >> [!blank] >> ###### [[valgus stress test|Elbow Valgus Stress Test]] >> - tests for [[ulnar collateral ligament tear]] (MCL tear) >> - <mark class="hltr-green">positive test</mark> = increased laxity > >> [!blank] >> ###### [[varus stress test|Elbow Varus Stress Test]] >> - tests for [[radial collateral ligament tear]] (LCL tear) >> - <mark class="hltr-green">poistive test</mark> = increased laxity >> <iframe width="560" height="315" src="https://www.youtube.com/embed/bCqPTSgW3-c?si=K6BbatFfQ6eeBrlQ" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Tests of Epicondylitis > [!tip] Isolate the Joint > When testing for epicondylitis, isolate the joint by ***supporting the patient's elbow*** while you get them to perform resisted extension & flexion of the wrist. > [!multi-column] >> [!blank] >> ###### Resisted Extension >> - tests for [[lateral epicondylosis]] (tennis elbow) >> - <mark class="hltr-green">positive test</mark> = pain at the [[lateral epicondyle of the humerus]] >><iframe width="560" height="315" src="https://www.youtube.com/embed/xa4op1Hv-L8?si=eigINnv596fmEe7M" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### Resisted Flexion >> - tests for [[medial epicondylosis]] (golfer's elbow) >> - <mark class="hltr-green">positive test</mark> = pain at the [[medial epicondyle of the humerus]] >><iframe width="560" height="315" src="https://www.youtube.com/embed/P3s1H09SVu8?si=-bVXMtZGAaip4BrC" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### [[Tinel sign|Tinel's Test]] - tests for [[cubital tunnel syndrome]] - <mark class="hltr-green">positive test</mark> = parasthesia in the medial 1 ½ digits and medial hand <iframe width="560" height="315" src="https://www.youtube.com/embed/OJ9wEeJEA3o?si=SFkIrWJ48U_3_JWr" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> # Wrist Joint > [!multi-column] >> [!blank] >> <iframe width="560" height="315" src="https://www.youtube.com/embed/MjT1Cn6hygE?si=9Q76coJOvCVmIyAp" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!tip] Clinical Pearls >> - The most common place in the hand affected by osteoarthritis is the first CMC resulting in poor grip and pain at the base of the thumb. Osteoarthritis also affects the DIPs and PIPs. >> - Remember, numbness in the thumb and index finger doesn’t always equate to carpal tunnel syndrome and may represent a more proximal lesion (ie. a C6 radiculopathy) #### ① LOOK ###### S = Swelling - [[distal interphalangeal joint|DIP joints]], [[proximal interphalangeal joint|PIP joints]], [[metacarpophalangeal joints|MCP joints]], and/or [[carpometacarpal joints|CMC joints]] - wrist - palm (flexor tendons) - extensor tendons specifically [[extensor carpi ulnaris muscle|ECU]], [[extensor pollicis brevis muscle|EPB]], and [[abductor pollicis longus muscle|APL]] ###### E = Erythema - [[distal interphalangeal joint|DIP joints]], [[proximal interphalangeal joint|PIP joints]], [[metacarpophalangeal joints|MCP joints]] - wrist - extensor tendons & flexor tendons ###### A = Atrophy Look for wasting of the: - [[intrinsic muscles of the hand]] - [[thenar compartment|thenar muscles]] - [[hypothenar compartment|hypothenar muscles]] ###### D = Deformities > [!multi-column] >> [!bones] Signs of Osteoarthritis >> - [[Heberden's nodes]] (at the DIPs) >> - [[Bouchard's nodes]] (at the PIPs) >> - [[Z deformity of the thumb]] >> - [[squaring of the thumb]] > >> [!dna|wide-3] Signs of Rheumatoid Arthritis >> - [[swan neck deformity]] >> - [[boutonniere deformity]] >> - [[volar subluxation|MCP subluxation]] >> - [[radial drift]] (wrist) >> - [[ulnar drift]] (fingers) >> - [[rheumatoid nodules]] ![[OA vs. RA hand involvement.png]] ###### S = Scars You might be able to observe a scar on the wrist from [[carpal tunnel release]] surgery. ![[carpal tunnel release surgery incisions.png]] #### ② FEEL ###### Temperature Feel for warmth over the joints compared to the surrounding tissue. ###### Bony Structures Ask the patient to report if they feel pain while palpating: - [[styloid process of the ulna]] - [[distal radioulnar joint]] - [[scaphoid bone]] (found within the [[anatomical snuffbox]]) - [[hamate bone|hook of the hamate]] - [[metacarpals]] ###### Soft Tissues Feel for atrophy/asymmetry, and ask the patient to report if they feel pain while palpating any of the following muscles: - [[extensor pollicis brevis muscle|EPB]] and [[abductor pollicis longus muscle|APL]] tendons - [[anterior compartment of the forearm|flexor tendons]] in the palm of the hand #### ③ MOVE Evaluate BOTH active and passive range of motion. Examine whether the motion is smooth and (where applicable) symmetric. ###### Extension & Flexion - normal wrist extension = <mark class="hltr-green">0-80°</mark> - normal wrist flexion = <mark class="hltr-green">0-80°</mark> > [!multi-column] >> [!blank] >> ![[extension of the wrist.png]] > >> [!blank] >> ![[flexion of the wrist.png]] ###### Supination & Pronation > [!multi-column] >> [!blank] >> - normal supination = <mark class="hltr-green">90°</mark> >> - normal pronation = <mark class="hltr-green">90°</mark> > > > [!tip|wide-5] Isolate the Elbow > > When assessing supination and pronation, isolate the elbow by having the patient flex the elbow to 90 degrees while supinating and pronating. It prevents them from using their shoulder to help supinate / pronate. > [!multi-column] >> [!blank] >> ![[supination of the forearm.png]] > >> [!blank] >> ![[pronation of the forearm.png]] ###### Ulnar & Radial Deviation - normal ulnar deviation = <mark class="hltr-green">30°</mark> - normal radial deviation = <mark class="hltr-green">15°</mark> > [!multi-column] >> [!blank] >> ![[aDDuction of the wrist (ulnar deviation).png]] > >> [!blank] >> ![[aBduction of the wrist (radial deviation).png]] ###### Finger Flexion & Extension - normal finger flexion = <mark class="hltr-green">patient should be able to make a full fist</mark> - normal finger extension = <mark class="hltr-green">patient should be able to make a flat hand</mark> > [!multi-column] >> [!blank] >> ![[flexion of the fingers (IP).png]] > >>[!blank] >>![[extension of the fingers (IP).png]] ###### Finger ABduction & ADDuction - normal finger aBduction = <mark class="hltr-green">~25°</mark> from midline > [!multi-column] >> [!blank] >> ![[aBduction of the fingers.png]] > >> [!blank] >> ![[aDDuction of the fingers.png]] #### ④ SPECIAL TESTS > [!multi-column] >> [!blank] >> ###### [[Tinel sign]] >> - tests for [[carpal tunnel syndrome]] >> - <mark class="hltr-green">positive test</mark> = reproduction of parasthesia in the lateral hand and lateral 3 ½ digits >> >> <iframe width="560" height="315" src="https://www.youtube.com/embed/mlZS2Rctxj0?si=dcXwqK0yOEtPyIoL" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >>[!blank] >>###### [[Phalen's sign]] >>- tests for [[carpal tunnel syndrome]] >>- <mark class="hltr-green">positive test</mark> = reproduction of parasthesia in the lateral hand and lateral 3 ½ digits >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/LyoMPOqh_YM?si=lIVlQdzMDCj-uqNn" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > [!multi-column] >> [!blank] >> ###### [[Finkelstein's test]] >> - tests for [[de Quervain syndrome]] >> - <mark class="hltr-green">positive test</mark> = pain through the lateral wrist/forearm >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/Dm-_pumHt9c?si=X0EfrUt0ho0-SMiL" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[CMC grind test|CMC Grind Test]] >>- tests for [[trapeziometacarpal osteoarthritis]] >>- <mark class="hltr-green">positive test</mark> = pain and crepitus are elicited >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/1kJtO4NLzBY?si=Z6f0kgvmwVIydKmC" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> # Lumbar Spine <iframe width="560" height="315" src="https://www.youtube.com/embed/XgnSiFVQl8U?si=6NhZ_N92ymwYbXNx" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> #### ① LOOK ###### S = Swelling Usually not apparent, unless there is a history of trauma/surgery. ###### E = Erythema Can occur over the posterior [[erector spinae muscles|paraspinal muscles]]. Consider rashes. ###### A = Atrophy This is an important step in the cervical spine neurological examination as well. Look for asymmetry/atrophy of any of the following: - [[lower extremity]] - [[erector spinae muscles]] ###### D = Deformities > [!multi-column] >> [!blank] >> Look for <mark class="hltr-green">normal lumbar lordosis</mark>. Abnormal findings include: >> - exaggerated lumbar curvature (i.e., [[lordosis]]) >> - [[scoliosis]] (look for lumbar crests at the same height) > >> [!blank] >> > [!multi-column] >>>> [!blank] >>>> ![[lordosis.png]] >>> >>>> [!blank] >>>> ![[scoliosis.png]] ###### S = Scars > [!multi-column] >> [!blank] >> Midline posterior scars from prior lumbar spine surgery. On recent scar(s), look for: >> - redness / inflammation >> - pus >> - dehiscence of the wound > >> [!blank] >> ![[lumbar spine surgery scars.png]] ###### Others - signs of [[neural tube defects]] (e.g., hairy patches, sacral dimple) - café au lait spots - muscular fasciculations - lower extremity alignment while standing - gait #### ② FEEL ###### Bony Structures Ask the patient to report if they feel pain while palpating: - [[spinous process]]es of all [[lumbar vertebrae]] (i.e., midline) - [[transverse processes]] of all [[lumbar vertebrae]] - [[iliac crest]]s - [[posterior superior iliac spine|PSIS]] - [[ischial tuberosity]] - [[greater trochanter]]s - [[sacroiliac joint|SI joint]] (midline to the dimples of Venus) ###### Soft Tissues Feel for atrophy/asymmetry, and ask the patient to report if they feel pain while palpating any of the following muscles: - [[erector spinae muscles]] - [[gluteal muscles]] - [[piriformis muscle]] #### ③ MOVE Evaluate BOTH active and passive range of motion. Examine whether the motion is smooth and (where applicable) symmetric. ###### Extension & Flexion - normal lumbar extension = ~<mark class="hltr-green">25°</mark> - normal lumbar flexion = <mark class="hltr-green">~45-50°</mark> > [!multi-column] >> [!blank] >> ![[extension of the spine.png|Ask patient to perform this with their anterior thighs against the exam table, to prevent use of other muscles.]] > >> [!blank] >> ![[flexion of the spine.png]] > [!multi-column] >> [!blank] >> ###### Rotation >> - normal lumbar rotation = ~<mark class="hltr-green">30°</mark> in either direction >>![[rotation of the spine.png]] > >> [!blank] >> ###### Lateral Flexion >> - normal lateral flexion = ~<mark class="hltr-green">25°</mark> in either direction >> ![[lateral flexion of the spine.png]] #### ④ SPECIAL TESTS ###### Tests of Scoliosis and Bone Deformities > [!multi-column] >> [!blank] >> ###### [[Adam's forward bend test|Adam's Forward Bend Test]] >> - tests for [[scoliosis]] >> - <mark class="hltr-green">positive test</mark> = asymmetry of the scapulae with spine flexion >> <iframe width="560" height="315" src="https://www.youtube.com/embed/6QUufpstXwY?si=K9BZheRl-Yk6QRsr" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[True Leg Length Measurement]] >> - measure from the [[anterior superior iliac spine|ASIS]] to the [[medial malleolus]] >> - tests for [[leg length discrepancy]] >> - <mark class="hltr-green">positive test</mark> = difference of >1-2 cm between legs >> <iframe width="560" height="315" src="https://www.youtube.com/embed/HTqifTH98K4?si=IGLFnEhvWeGVjxzw" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Tests of SI Joint Pathology >[!multi-column] > > [!blank] > > ###### [[Gaenslen's test|Gaenslen's Test]] > > - tests for [[sacroiliac joint dysfunction|SI joint dysfunction]] > > - <mark class="hltr-green">positive test</mark> = pain in the [[sacroiliac joint|SI joint]] > > > ><iframe width="560" height="315" src="https://www.youtube.com/embed/sHXxhnh8SMM?si=MjIQ_ILWfulme-Dc" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[FABER test|FABER Test]] >> - tests for [[sacroiliac joint dysfunction|SI joint dysfunction]] >> - <mark class="hltr-green">positive test</mark> = pain in the [[sacroiliac joint|SI joint]] >> <iframe width="560" height="315" src="https://www.youtube.com/embed/oLJVWmMatCw?si=ePpY-S-s1d0j7Rxp" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Test for Ankylosing Spondylitis ###### [[modified Schober test|Modified Schober Test]] - tests for [[ankylosing spondylitis]] - <mark class="hltr-green">positive test</mark> = <5 cm increase between marks <iframe width="560" height="315" src="https://www.youtube.com/embed/A11EaLF82zM?si=5G2YfUHxG0pOpt5h" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Test for Hip Flexion Contracture > [!blank] > ###### [[Thomas test|Thomas Test]] > - tests for [[hip flexion contracture]] > - <mark class="hltr-green">positive test</mark> = patient is unable to extend leg without lifting lumbar spine off the table > > <iframe width="560" height="315" src="https://www.youtube.com/embed/vJe-LLRZItw?si=fxElz7kAeXwGgWRL" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Tests of Lumbar Radiculopathy (i.e., Lumbar Disc Herniation) > [!multi-column] >> [!blank] >> ###### [[straight leg raise|Straight Leg Raise]] >> - tests for [[lumbar radiculopathy]] >> - <mark class="hltr-green">positive test</mark> = neuropathic pain down the raised leg >><iframe width="560" height="315" src="https://www.youtube.com/embed/zTiSe4SKq_Y?si=I78kqlLKH1x2myJE" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[crossed straight leg raise|Crossed Straight Leg Raise]] >> - tests for [[lumbar radiculopathy]] >> - <mark class="hltr-green">positive test</mark> = neuropathic pain down the stationary leg >> <iframe width="560" height="315" src="https://www.youtube.com/embed/4hI2Kn6DnLM?si=TzEI6s-_-NHLLelO" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > [!multi-column] >> [!blank] >> ###### [[Braggard's sign|Braggard's Sign]] >> - tests for [[lumbar radiculopathy]] >> - <mark class="hltr-green">positive test</mark> = reproduction of neuropathic pain down the raised & dorsiflexed leg >><iframe width="560" height="315" src="https://www.youtube.com/embed/GprEZqhTcYc?si=JYHxTw_WIKEGNvze" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[Bowstring sign|Bowstring Sign]] >> - tests for [[lumbar radiculopathy]] >> - <mark class="hltr-green">positive test</mark> = reproduction of neuropathic pain down the raised & dorsiflexed leg >> <iframe width="560" height="315" src="https://www.youtube.com/embed/rkoNokTzyW8?si=QpM_hr6kr8pO9OGl" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > [!blank] > ###### [[femoral nerve stretch test|Femoral Stretch Test]] > - tests for [[lumbar radiculopathy]] > - <mark class="hltr-green">positive test</mark> = pain is reproduced in the anterior thigh > > <iframe width="560" height="315" src="https://www.youtube.com/embed/w6bqDypQJ-w?si=sasj8ti2mRqERhDZ" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> #### ⑤ L-SPINE NEUROVASCULAR EXAM From a vascular perspective, measure: - pedal pulse - [[ankle-brachial index]] From a neurologic perspective, examine the [[lumbar spinal nerves]]. Use the [[ASIA Impairment Scale.pdf]] for quick & easy reference. ###### Myotomes (Motor) > [!multi-column] >> [!blank] >> - [[spinal nerve L2|L2]] = [[flexion of the hip.png|hip flexion]] >> - [[spinal nerve L3|L3]] = [[extension of the knee.png|knee extension]] >> - [[spinal nerve L4|L4]] = [[dorsiflexion.png|ankle dorsiflexion]] >> - [[spinal nerve L5|L5]] = [[extension of the toes.png|toe extension]] >> - [[spinal nerve S1|S1]] = [[plantarflexion.png|ankle plantarflexion]] > >> [!blank|wide-2] >> | Grade | Description | >> | ---------------------------------- | --------------------------------------------- | >> | <mark class="hltr-grey">0</mark> | total paralysis | >> | <mark class="hltr-red">1</mark> | fasciculations (palpable/visual contractions) | >> | <mark class="hltr-pink">2</mark> | active movement, gravity eliminated | >> | <mark class="hltr-orange">3</mark> | active movement, against gravity only | >> | <mark class="hltr-yellow">4</mark> | active movement, against some resistance | >> | <mark class="hltr-green">5</mark> | active movement, against full resistance | ###### Dermatomes (Sensory) > [!multi-column] >> [!blank] >> - [[spinal nerve L2|L2]] = medial thigh >> - [[spinal nerve L3|L3]] = medial knee >> - [[spinal nerve L4|L4]] = medial ankle >> - [[spinal nerve L5|L5]] = 1st web between toes >> - [[spinal nerve S1|S1]] = lateral ankle > >> [!blank|wide-3] >> | Grade | Description | >> | ---------------------------------- | ------------------ | >> | <mark class="hltr-orange">0</mark> | sensation absent | >> | <mark class="hltr-yellow">1</mark> | sensation impaired | >> | <mark class="hltr-green">2</mark> | normal | ###### Reflexes > [!multi-column] >> [!orange] Hyperreflexia >> ↑ reflex = [[upper motor neuron lesion]] > >> [!light-blue] Hyporeflexia >> ↓ reflex = [[lower motor neuron lesion]] > [!multi-column] >> [!blank] >> - [[spinal nerve L2|L2]], [[spinal nerve L3|L3]], [[spinal nerve L4|L4]] = [[patellar reflex]] >> - [[spinal nerve S1|S1]] = [[achilles tendon reflex]] > >> [!blank|wide-3] >> | Grade | Description | >> | ---------------------------------- | --------------------------------------------------------- | >> | <mark class="hltr-orange">0</mark> | reflex absent | >> | <mark class="hltr-yellow">1</mark> | lower limit of normal (reflex present with reinforcement) | >> | <mark class="hltr-green">2</mark> | normal | >> | <mark class="hltr-yellow">3</mark> | more than average, brisk | >> | <mark class="hltr-orange">4</mark> | clonus, pathologically increased # Hip Joint > [!multi-column] >> [!blank] >> <iframe width="560" height="315" src="https://www.youtube.com/embed/zQIxJ4hLF28?si=bKxovUul4ttQPGma" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!tip] Clinical Pearls >> - Pain from pathology in the femoral acetabular joint is typically felt in the anterior groin. >> - Lateral thigh pain and buttock pain is not usually due to femoral acetabular pathology. >> - When evaluating ROM, make sure you look for side to side asymmetries >> - Pain in the hip can come from alignment problems through the lower extremities – correcting those problems will go a long way to making the hip feel better #### ① LOOK ###### S = Swelling - swelling of the inguinal region - hip joint swelling is NOT observable ###### E = Erythema - erythema over the [[trochanteric bursa]] can indicate [[trochanteric bursitis]] ###### A = Atrophy Look for wasting of the: - [[gluteal region]] ###### D = Deformities - [[hip flexion contracture]] - accentuated lumbar [[lordosis]] - pelvic obliquity - abnormal lower extremity alignment (hip to toe) ###### S = Scars Commonly a lateral incision (for hip arthroplasty or fracture repair). ###### G = Gait Observe the patient while they walk. Look for the following: - [[antalgic gait]] - [[Trendelenburg gait]] #### ② FEEL ###### Bony Structures Ask the patient to report if they feel pain while palpating: - [[greater trochanter]] - [[pubic symphysis]] - [[iliac crest]] - [[anterior superior iliac spine|ASIS]] - [[posterior superior iliac spine|PSIS]] - [[sacrum]] - [[sacroiliac joint|SI joint]] - [[ischial tuberosity]] ###### Soft Tissues Feel for atrophy/asymmetry, and ask the patient to report if they feel pain while palpating any of the following soft tissues or muscles: - [[inguinal ligament]] - [[inguinal lymph nodes]] ([[deep inguinal lymph nodes|deep]] and [[superficial inguinal lymph nodes|superficial]]) - [[femoral artery]] - muscles of the [[gluteal region]] - [[piriformis muscle]] - [[iliotibial band|IT band]] #### ③ MOVE Evaluate BOTH active and passive range of motion. Examine whether the motion is smooth and (where applicable) symmetric. ###### Flexion & Extension - normal hip flexion = <mark class="hltr-green">135°</mark> - normal hip extension = <mark class="hltr-green">20°</mark> > [!multi-column] >> [!blank] >> ![[flexion of the hip.png]] > >>[!blank] >>![[extension of the hip.png]] ###### ABduction & ADDuction - normal hip aBduction = <mark class="hltr-green">45°</mark> - normal hip aDDuction = <mark class="hltr-green">20°</mark> > [!multi-column] >> [!blank] >> ![[aBduction of the hip.png]] > >> [!blank] >> ![[aDDuction of the hip.png]] ###### Internal & External Rotation - normal internal rotation = <mark class="hltr-green">35°</mark> - normal external rotation = <mark class="hltr-green">45°</mark> > [!multi-column] >> [!blank] >> ![[medial (internal) rotation of the thigh.png]] > >> [!blank] >> ![[lateral (external) rotation of the thigh.png]] #### ④ SPECIAL TESTS > [!multi-column] >> [!blank] >> ###### [[FABER test]] >> - tests for [[sacroiliac joint dysfunction|SI joint dysfunction]] >> - <mark class="hltr-green">positive test</mark> = pain in the [[sacroiliac joint|SI joint]] >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/oLJVWmMatCw?si=C0YupUaDRkWIF_o-" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > > >> [!blank] >> ###### [[FADIR test]] >> - tests for [[hip osteoarthritis|hip OA]] or [[femoroacetabular impingement|FAI]] >> - <mark class="hltr-green">positive test</mark> = anterior hip pain >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/36hGS6xf_8Y?si=5jK-5j7qEQ3eGQok" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > [!multi-column] >> [!blank] >> ###### [[Stinchfield test]] >> - tests for [[hip osteoarthritis|hip OA]] >> - <mark class="hltr-green">positive test</mark> = pain in the anterior groin >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/NchWw6kxSgA?si=LrTO1hiaTdONzVmn" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[Ober's test]] >> - tests for [[IT band syndrome]] >> - <mark class="hltr-green">positive test</mark> = space between the knee and the table >><iframe width="560" height="315" src="https://www.youtube.com/embed/gasJOqYGWrk?si=Lh1KF2WrmbBwGJW6" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > [!multi-column] >> [!blank] >> ###### [[Thomas test]] >> - tests for [[hip flexion contracture]] >> - <mark class="hltr-green">positive test</mark> = patient is unable to straighten the leg during hip extension without lifting the lumbar spine off the table >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/vJe-LLRZItw?si=fxElz7kAeXwGgWRL" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[Trendelenburg gait|Trendelenburg sign]] >> - tests for weakness of the [[gluteus medius muscle|gluteus medius]] >> - <mark class="hltr-green">positive test</mark> = CONTRALATERAL HIP to the pathology drops when its leg is raised off the ground >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/olZYoe3gr2Q?si=g2NWWwLKKTBF0OaN" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> # Knee Joint > [!multi-column] >> [!blank] >> <iframe width="560" height="315" src="https://www.youtube.com/embed/5LGPjQyA3hs?si=sUOVL_KgARoGL8Xx" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!tip] Clinical Pearls >> - Feel if the knee is warm compared to the other knee – this is an important clue for inflammation >> - Don't miss joint swelling. Stand at the end of the bed and ask yourself if one knee looks bigger than the other. Mod to large effusions will be apparent using the ballotment technique; fluid wave test is only good for small effusions >> - Don’t forget to look at alignment (knees are at risk of different problems depending on lower extremity alignment) >> - Remember when testing ligaments, you MUST compare to the other side (not all loose ligaments are pathologic!) ① LOOK #### ① LOOK ###### S = Swelling - loss of the peri-patellar grooves - suprapatellar fullness - [[popliteal cyst|Baker's cyst]] (i.e., popliteal swelling) - pre-patellar bursal swelling ###### E = Erythema - over and around the joint ###### A = Atrophy Look for wasting of the: - [[quadriceps femoris muscles|quadriceps]] ###### D = Deformities - [[genu varum]] (bow legged) or [[genu valgum]] (knock knees) - [[genu recurvatum]] (hyperextended knees) - [[hip flexion contracture]] ###### S = Scars Commonly a midline scar for [[knee arthroplasty]], or a few small incisions for knee arthroscopy. ###### G = Gait Observe the patient while they walk. Look for the following: - [[antalgic gait]] #### ② FEEL ###### Temperature Feel for warmth in the joint vs. the surrounding tissue. ###### Effusion - [[wipe test]] is the best (can feel for both small and large effusions) ###### Bony Structures Ask the patient to report if they feel pain while palpating: - [[medial condyle of the femur|medial femoral condyle]] & [[lateral condyle of the femur|lateral femoral condyle]] - medial & lateral joint lines of the knee - [[patella]] - [[head of the fibula]] - [[tibial tuberosity]] ###### Soft Tissues Feel for atrophy/asymmetry, and ask the patient to report if they feel pain while palpating any of the following soft tissues or muscles: - [[tibial collateral ligament|MCL]] - [[fibular collateral ligament|LCL]] - [[iliotibial band|IT band]] - [[patellar tendon|quadriceps tendon]] & [[patellar tendon]] - [[posterior compartment of the thigh|hamstring tendons]] - [[popliteal fossa]] #### ③ MOVE Evaluate BOTH active and passive range of motion. Examine whether the motion is smooth and (where applicable) symmetric. ###### Extension & Flexion - normal knee extension = <mark class="hltr-green">-10°</mark> of hyperextension - normal knee flexion = <mark class="hltr-green">0-135°</mark> > [!multi-column] >> [!blank] >> ![[extension of the knee.png]] > >> [!blank] >> ![[flexion of the knee.png]] #### ④ SPECIAL TESTS ###### Tests of Lateral & Medial Stability > [!multi-column] >> [!blank] >> ###### [[varus stress test|Varus Stress Test]] >> - tests for [[LCL injury]] >> - <mark class="hltr-green">positive test</mark> = ↑ laxity compared to the contralateral side >> > >> [!blank] >> ###### [[valgus stress test|Valgus Stress Test]] >> - tests for [[MCL injury]] >> - <mark class="hltr-green">positive test</mark> = ↑ laxity compared to the contralateral side <iframe width="560" height="315" src="https://www.youtube.com/embed/s2cV7rrKT_c?si=QfmT2PiHD4Mcrap-" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Tests of ACL & PCL Injuries > [!multi-column] >> [!blank] >> ###### [[anterior drawer test|Anterior Drawer Test]] >> - tests for [[ACL injury]] >> - <mark class="hltr-green">positive test</mark> = ↑ anterior laxity anteriorly compared to the contralateral side >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/hRVIhtkTTPc?si=JH8qgvxL_R3DuKT9" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[Lachman maneuvers]] >> - tests for [[ACL injury]] and [[PCL injury]] >> - <mark class="hltr-green">positive test</mark> = ↑ anterior laxity anteriorly compared to the contralateral side >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/Zud2P1odAnk?si=GpSnO4ILTME2Eyq6" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > [!multi-column] >> [!blank] >> ###### [[posterior drawer test|Posterior Drawer Test]] >> - tests for [[PCL injury]] >> - <mark class="hltr-green">positive test</mark> = ↑ anterior laxity anteriorly compared to the contralateral side >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/PK40Epjn-PA?si=BO2fOMyGPrZUsOlx" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > > >> [!blank] >> ###### [[sag sign|Sag Sign]] >> - tests for [[PCL injury]] >> - <mark class="hltr-green">positive test</mark> = affected tibia is displaced posteriorly >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/djXyAStgQyc?si=TzblPsJVMwVTKb0M" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Tests of Meniscal Tears > [!multi-column] >> [!blank] >> ###### [[McMurray's test]] >> - tests for [[meniscus tear]] >> - <mark class="hltr-green">positive test</mark> = hearing or feeling a painful click, or knee locks >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/UeWDBV2J0DM?si=jd0yL2tfw8cXJVdq" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[Thessaly's test]] >> - tests for [[meniscus tear]] >> - <mark class="hltr-green">positive test</mark> = pain at the joint line, or if the joint locks or catches >> >> <iframe width="560" height="315" src="https://www.youtube.com/embed/FKcstpKaHhQ?si=ZKlmV5mhOGVuedTs" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Tests of Patellar Pathology > [!multi-column] >> [!blank] >> ###### [[patellar apprehension test|Patellar Apprehension Test]] >>- tests for [[patellar instability]] >>- <mark class="hltr-green">positive test</mark> = patient feels a sensation of instability >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/28cb9Uml0LU?si=bVhCOrCyWSh4IdKa" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[patellar grind test|Patellar Grind Test]] >> - tests for [[patellofemoral pain syndrome]] >> - <mark class="hltr-green">positive test</mark> = pain or inability to perform the test >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/w_fJSvrJ6RE?si=sRWgJTK0t2jfv6Sc" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> # Ankle Joint >[!multi-column] > > [!blank] > > <iframe width="560" height="315" src="https://www.youtube.com/embed/17ZZUBkGfXc?si=tqJ1lLKD6v6rX2x_" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > > > [!tip] Clinical Pearls > > - Most bunions are actually osteoarthritis of the first MTP > > - If a patient complains of ankle pain have them stand on each foot on their toes. If a patient cannot stand on the toes one side think of rupture of the posterior tibial tendon. > > - Pes planus may be rigid or supple – you can check for this by having the patient rise onto their toes (if the arch reappears, it’s supple pes planus); pes planus can lead to other “upstream” (leg, knee, hip, back) problems, so it’s important to identify >[!bones] **[[Ottawa Foot and Ankle Rules]]** > - Age >/= 18 > - Inability to bear weight both immediately and in the emergency department for four steps > - Bony tenderness at distal tibia (within 6 cm of medial malleolus), or distal fibula (within 6cm of tip of lateral malleolus) > - Bony tenderness at base of the fifth metatarsal, and bony tenderness at the navicular bone. #### ① LOOK ###### S = Swelling - across the [[metatarsophalangeal joint|MTP joint]] - [[dactylitis]] of the toes - [[ankle joint]] swelling - peri-tendinous swelling ([[tibialis posterior muscle|tibialis posterior]], [[peroneus brevis muscle|peroneus brevis]] and [[peroneus longus muscle|peroneus longus]], or [[calcaneal tendon|Achille's tendon]]) ###### E = Erythema - over and around the joint - bruising over the lateral ankle (due to sprain) ###### A = Atrophy Look for wasting of the: - intrinsic muscles of the foot ###### D = Deformities - [[hallux valgus]] - claw toes - hammer toes - [[too many toes sign]] - [[pes planus]] or [[pes cavus]] ###### S = Scars Commonly a lateral incision of the ankle, or a metatarsal incision. ###### G = Gait Observe the patient while they walk. Look for the following: - [[antalgic gait]] #### ② FEEL ###### Bony Structures Ask the patient to report if they feel pain while palpating: - ankle rules: [[navicular bone]], [[5th metatarsal|tuberosity of the 5th metatarsal]], [[lateral malleolus]], [[medial malleolus]] - [[metatarsophalangeal joint|MTP joints]] (for bunions) ###### Soft Tissues Feel for atrophy/asymmetry, and ask the patient to report if they feel pain while palpating any of the following soft tissues or muscles: - [[deltoid ligament]] (medial ankle) - [[anterior talofibular ligament|ATFL]], [[calcanealfibular ligament|CFL]], [[posterior talofibular ligament|PTFL]] (lateral ankle) - [[plantar fascia]] - [[calcaneal tendon|Achille's tendon]] #### ③ MOVE ###### Plantarflexion & Dorsiflexion - normal plantarflexion = <mark class="hltr-green">0-50°</mark> - normal dorsiflexion = <mark class="hltr-green">0-20°</mark> > [!multi-column] >> [!blank] >> ![[plantarflexion.png]] > >> [!blank] >> ![[dorsiflexion.png]] ###### Inversion & Eversion - normal inversion = <mark class="hltr-green">0-35°</mark> - normal eversion = <mark class="hltr-green">0-20°</mark> > [!multi-column] >> [!blank] >> ![[inversion.png]] > >> [!blank] >> ![[eversion.png]] ###### Toe Flexion & Extension - normal flexion of the toes = <mark class="hltr-green">0-45°</mark> - normal extension of the toes = <mark class="hltr-green">0-70°</mark> > [!multi-column] >> [!blank] >> ![[flexion of the toes.png]] > >> [!blank] >> ![[extension of the toes.png]] #### ④ SPECIAL TESTS > [!multi-column] >> [!blank] >> ###### [[Thompson test]] >> - tests for [[Achilles tendinopathy|Achilles tendon rupture]] >> - <mark class="hltr-green">positive test</mark> = no foot movement >> >> <iframe width="560" height="315" src="https://www.youtube.com/embed/73QnuVHogxo?si=9SFMOeCVwAT0M8zT" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >>[!blank] >>###### [[talar tilt test|Talar Tilt Test]] >>- tests for lateral [[ankle sprain]] >>- <mark class="hltr-green">positive test</mark> = pain and ↑ laxity >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/6pyltK6sjuE?si=-GeGN2QRkM8D1u4M" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### Tests of Lateral Ankle Sprain > [!multi-column] >> [!blank] >> ###### [[anterior drawer test of the ankle|Anterior Drawer Test]] >> - tests for lateral [[ankle sprain]] (specifically the [[anterior talofibular ligament|ATFL]]) >> - <mark class="hltr-green">positive test</mark> = pain and ↑ laxity >> >> <iframe width="560" height="315" src="https://www.youtube.com/embed/kgp7pxiQ2eY?si=BS65LHp_l1EqH-YZ" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >>[!blank] >>###### [[talar tilt test|Talar Tilt Test]] >>- tests for lateral [[ankle sprain]] (specifically the [[calcanealfibular ligament|CFL]]) >>- <mark class="hltr-green">positive test</mark> = pain and ↑ laxity >> >><iframe width="560" height="315" src="https://www.youtube.com/embed/6pyltK6sjuE?si=-GeGN2QRkM8D1u4M" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> ###### [[tests of ankle ligaments|Lateral Ankle Ligament Testing]] - tests for the [[anterior talofibular ligament|ATFL]], [[calcanealfibular ligament|CFL]], and the [[posterior talofibular ligament|PTFL]] - <mark class="hltr-green">positive test</mark> = pain and ↑ laxity <iframe width="560" height="315" src="https://www.youtube.com/embed/8RDYfw0yyIc?si=Tg_nPO7ZI6Rxb__t" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > [!multi-column] >> [!blank] >> ###### [[metatarsal squeeze test|Metatarsal Squeeze Test]] >> - tests for [[Morton's neuroma]] >> - <mark class="hltr-green">positive test</mark> = pain and/or a "click" sound >> >> <iframe width="560" height="315" src="https://www.youtube.com/embed/BGdfKqMbtac?si=eQg4DK5spBTi18BP" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> > >> [!blank] >> ###### [[Homan's test]] >> - tests for [[deep vein thrombosis|DVT]] >> - <mark class="hltr-green">positive test</mark> = severe pain upon passive dorsiflexion >> >> <iframe width="560" height="315" src="https://www.youtube.com/embed/AqHLtzzJWVI?si=HZbyj_qiDkfVneNS" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe>