Note any pain or laxity. Focal spinal tenderness to palpation or gentle percussion in the absence of neurologic symptoms or signs of malignancy or infection increases the likelihood of a possible compression fracture. Use your right hand with their right hand and vice versa and sup port the back of their hand and wrist with your other hand to avoid unnecessarily squeezing their fingers Fig. Most importantly, this program will prepare you to perform an organized, integrated, and clinically useful regional examination of the low back. Patient's with true sciatica secondary to disk herniation will often lean backward during the seated straight leg raise, in an effort to reduce the angle of leg elevation and nerve root irri tation Fig. Practicing this examination and integrating it into your complete physical examination will increase your reliability and speed. Special Testing Suspected Myelopathy If cervical myelopathy is suspected, check for the presence of pathologic reflexes, possibly indicating an upper motor neuron lesion.
I and note any atrophy of the thenar or hypothenar eminences Fig. Move your fingers inferiorly to the medial border of the scapula and assess tenderness in this location on each side Fig. Reassurance and gentleness on the part of the examiner will help the patient perform with maximal effort. Note any laxity or pain. Knee Joint Line With the knee still in -70° to 90° of flexion, palpate carefully along the joint line and note any focal tenderness or palpable abnormality Fig.
Assess finger extension by asking the patient to spread the fingers. Mary Betty Stevens, a won derful physician and teacher at johns Hopkins. Note any asymmetry or weakness Fig. Ask the patient to extend the elbows fully while you move their arms into a position of- 70° to 80° of abduction and 30° of forward! The skills involved require practice and careful attention to technique. Meniscal Tears The medial and lateral menisci are shock-absorbing, internal-stabilizing fibrocartilages which may be torn as the result of acute traumatic injury or chronic degeneration. Inspect for the normal thoracic kyphosis and lumbar lordosis. Patients with prepatellar bursitis of any severity are able to lie with the knee in full extension an important clue that the knee joint itself is not the primary site of pathology.
Shaped like a bow tie or thyroid gland, it cushions the anterior joint line during kneeling. We suggest starling with digit 5, then 1 lfl 4, 3, and 2 of one hand followed by digit 5, then 4, 3, and 2 of the other, with thumbs assessed subseqLtently. This recommendation is of particular importance in connection with new or infrequently used drugs. Inspect the calf muscles for bulk and symmetry, noting any muscle atrophy. Supraspinatus and Infraspinatus Tendons Assess for pain or weakness in the rotator cuff by testing the supraspinatus and infraspinatus muscles. Next, ask the patient to sit up. Next, check knee and ankle reflexes.
Simultaneously sup porting the low back with one hand and one shoulder with the other hand provides stability and permits you to heliJ the patient into full extension Fig. Chapter 4 The Regional Musculoskeletal Examination of the Shoulder Chapter 5 The Regional Musculoskeletal Examination of the Knee Chapter 6 The Regional Musculoskeletal Examination of the Neck. When testing shoulder function, instructing the patient while demon strating y ourself speeds comprehension and enhances cooperation. Look for deformity, visible swelling, or asymmetry and compare side to side. Set aside some blocks of time to practice the examination with a friend, roommate, or your spouse. Locate the normal depression that lies Vl z 0 between the medial edge of the patella and the medial femoral epicondyle on the inner aspect of each knee. The Screening Musculoskeletal Examination Chapter 3.
See C1 assessment,256, Achilles tendon reflex, 254, 254f Cont. Perform and record the modified Schober test see Fig. Deep flexion should bring the patient's heel nearly to the buttock, and extension should bring the knee out to nearly 90° of flexion Fig. Small Effusions A small volume of fluid will tend to pool medially, causing a slight bulge to develop where there was previously a normal concavity. Fam's Musculoskeletal Examination and Joint Injection Techniques, 2nd ed. The patient's hand should be relaxed with the palm down.
Inspect for deformity, visible swelling, or muscle atrophy; palpate for joint swelling; and assess range of motion. Move the thigh up toward the thorax Fig. Check dorsiflexion, plantar flexion, and subtalar motion at each ankle. Now, repeat the straight leg raise on the opposite side. The Regional Musculoskeletal Examination of the Neck Chapter 7. Begin with the fifth toe.
It is intended to provide a comprehensive assessment of joint inflammation through the use of palpation and permits the recognition of joint swelling, essential to the physical diagnosis of arthritis. Moving the ankle laterally assesses hip internal rotation. I am forever grateful I pursued my second choice. Palpate the medial and lateral patellar facets and note any tenderness. As expected, a large volume of sy novial fluid will first cause loss of the normal concavity at the medial side of the knee, fol lowed by a visible bulge superolaterally. Note any flexion contracture deficit in full extension. Since each of the three component examinations has specific diagnostic utility, this program encour ages learners to develop the skills necessary to recognize which examination is most appropriate to a given chief complaint and clinical context.
The Regional Musculoskeletal Examination of the Knee Chapter 6. In the supine position, the patient is more likely to relax. Elbow extension returns the joint to the outstretched anatomical position. With the patient's leg relaxed, apply alternating downward pressure on the superior and inferior poles of the patella, gently but firmly rocking it in the femoral groove. That love and respect has continued to grow ever since.