Physical Medicine and Rehabilita1on Approach to the Physical Exam Neurological/Musculoskeletal Examina5on Elizabeth Huntoon MS, MD Assistant Professor Department of Physical Medicine and Rehabilita5on Vanderbilt University School of Medicine Physical Exam •  Be consistent with your examina1on process •  Find a sequence that works for you and s1ck with it consistently •  May be helpful if the exam starts with the least painful aspect then progresses to site of actual complaint (i.e-­‐poten1ally most painful area) Focus on func1on •  Exam begins by just watching the pa1ent •  This can occur as they are checking in to the clinic or being escorted into the exam room (outpa1ent seGng) –  Are they moving all 4 extremi1es –  Do they walk with an altered gait (antalgia) –  Are they interac1ve with their surroundings/others –  Do they seem cogni1vely intact? Inspec1on •  Start exam with the least painful part-­‐ inspec1on! •  Is there asymmetry? This is important in both upper and lower extremi1es •  Muscle bulk, defects, leg length discrepancy •  Are there any contractures? Sensory •  Dermatome points to test with pinprick: Upper extremity C5 – lateral epicondyle C6 – thumb C7 – middle finger C8 – liZle finger T1 – medial epicondyle Sensory •  Lower extremity L1 – proximal medial thigh at groin L2 – anterior mid-­‐thigh L3 – medial knee L4 – medial malleolus L5 – 1st webspace S1 – lateral malleolus Motor •
Muscle strength grading (0-­‐5) 5 – normal strength against resistance 4 – examiner can overcome pa1ent’s strength, pa1ent able to give resistance 3 – pa1ent unable to give significant resistance to examiner, but can move the muscle through its complete range of mo1on against gravity 2 – pa1ent unable to give resistance to examiner, but can move the muscle through its complete range of mo1on with gravity eliminated 1 – pa1ent unable to give resistance to examiner, but can move the muscle through par1al range of mo1on with gravity eliminated 0 – no movement Myotomes upper limbs Root/Muscle(s) Innerva5on C5 – Deltoids axillary n. C5 -­‐-­‐ Biceps musculocutaneous n C6 – wrist extensors, extensor carpi radialis longus and brevis
radial n. C7 – Triceps radial n. Myotomes upper limbs Root/Muscle (s) Innerva5on C7 Wrist flexors, flexor carpi radialis Median n. C7 Flexor carpi ulnaris Ulnar n. C7 Finger extensors, extensor digitorum communis
Radial n. C7 Extensor digi1 indicis/ extensor digi1 minimi Radial n. Myotomes upper limbs Root/Muscle (s) Innerva5on C8 -­‐ Finger flexors, flexor digitorum superficialis (PIP) flexor digitorum profundis (DIP) Interossei mm.
median n. median n. (radial side) ulnar n. (ulnar side) ulnar n. T1 -­‐ Interossei mm., Finger abductors, dorsal interossei, Abductor digi1 quin1 ulnar n. Myotomes-­‐ lower limbs Root/Muscle (s) Innerva5on L2 -­‐ Iliopsoas nerves from T12-­‐L3 L3 -­‐ Quadriceps
femoral n. L3 -­‐ Hip adductors, adductor longus (primary) L4 -­‐ Tibialis anterior
deep peroneal n. L5 -­‐ Extensor hallucis longus (great toe extensor) deep peroneal n. L5 -­‐ Extensor digitorum longus /brevis deep peroneal n. L5 -­‐ Gluteus medius
superior gluteal n. obturator n. S1 -­‐ Gastrocnemius-­‐Soleus S1 -­‐ Peroneus longus and brevis S1 -­‐ Gluteus maximus 1bial n. superficial peroneal n. inferior gluteal n. Cervical Spine-­‐Range of Mo1on (ROM) Pa1ent looks at Roof (extension) Pa1ent looks at Floor (flexion) Pa1ent looks over shoulder (rota1on) Pa1ent touches ears to each shoulder (abduc1on) •  ROM: flexion, extension, rota1on, side bending •
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Lumbar Spine-­‐ ROM •  Flexion-­‐ have pa1ent touch floor –  Can measure distance finger 1p-­‐to-­‐floor •  Extension-­‐ pa1ent leans back •  Rota1on-­‐ can be done in seated or standing posi1on. When seated, the pelvis is stabilized •  Side bending Provoca1ve Tests* •
Facet loading-­‐ While seated have pa1ent twist torso then extend, loading the facet joint •
Straight leg raise test, siGng and supine-­‐ puts tension on the neural structures: beware false posi1ves….almost everyone has 1ght hamstrings m. •
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Patrick’s test/FABER (flexion, abduc1on, external rota1on); (+ ) test s/o hip involvement Gaenslen’s sign/Iliac compression test Spurlings – Cervical spine * Only a few provaca1ve tests have been included here-­‐please refer to the literature for addi1onal tests as appropriate Gaenslen’s Test Provoca1ve tests for the lumbar spine-­‐
con’t •  Gaenslen's test can indicate the presence or absence of a sacroiliac joint lesion, pubic symphysis instability, hip pathology,L4 nerve root lesion; it also stress the femoral nerve. Iliac compression test Hip/Pelvis •
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ROM: Internal/external rota1on Greater trochanteric bursa Tensor fascia lata/ilio1bial band Trendelenberg test ; tests for weak hip abductors; also + for lumbar strain/root irrita1on or hip joint dysfunc1on Trendelenburg's sign Shoulder •  Complex series of ar1cula1ons of the shoulder allows a wide range of mo1on •  The affected extremity should be compared with the unaffected. •  Ac1ve and passive ranges should be assessed. For example, a pa1ent with loss of ac1ve mo1on alone is more likely to have weakness of the affected muscles than joint disease. Shoulder-­‐The Apley scratch test •  Useful maneuver to assess shoulder ROM •  abduc1on and external rota1on are measured by having the pa1ent reach behind the head and touch the superior aspect of the opposite scapula. •  Internal rota1on and adduc1on of the shoulder are tested by having the pa1ent reach behind the back and touch the inferior aspect of the opposite scapula. •  External rota1on should be measured with the pa1ent's arms at the side and elbows flexed to 90 degrees. The Apley scratch test Shoulder •  Rotator cuff: SITS (supraspinatus, infraspinatus, teres minor, subscapularis) •  Palpate inser1on of SITS mm. •  Palpate subacromial bursa •  Biceps (long head) tendon •  Palpate in bicipital groove Shoulder special tests: •  EVALUATING THE ROTATOR CUFF: •  Supraspinatus examina1on (“empty can” test). The pa1ent aZempts to elevate the arms against resistance while the elbows are extended, the arms are abducted and the thumbs are poin1ng downward. Shoulder special tests-­‐Drop arm test •  Possible rotator cuff tear can be evaluated with the drop-­‐arm test. •  Passively abduct the pa1ent's shoulder, then observing as the pa1ent slowly lowers the arm to the waist. •  Osen, the arm will drop to the side if the pa1ent has a rotator cuff tear or supraspinatus dysfunc1on. •  The pa1ent may be able to lower the arm slowly to 90 degrees (because this is a func1on mostly of the deltoid muscle) but will be unable to con1nue the maneuver as far as the waist. Shoulder special tests •  Neer's impingement sign •  Posi1ve when the pa1ent's rotator cuff tendons are pinched under the coracoacromial arch •  Arm in forced flexion with the arm fully pronated •  The scapula should be stabilized during the maneuver to prevent scapulothoracic mo1on. Pain with this maneuver is a sign of subacromial impingement. Shoulder special tests •  HAWKINS' TEST-­‐another commonly performed assessment of impingement. •  Performed by eleva1ng the pa1ent's arm forward to 90 degrees while forcibly internally rota1ng the shoulder •  Pain with this maneuver suggests subacromial impingement or rotator cuff tendoni1s. •  Hawkins' test may be more sensi1ve for impingement than Neer's test. Shoulder special tests Hawkins Test
Neer’s Test
Shoulder •  No physical examina1on in a pa1ent with shoulder pain is complete without excluding cervical spine disease. •  Referred or radicular pain from disc disease should be considered in pa1ents who have shoulder pain that does not respond to conserva1ve treatment Knee •
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Compare with less affected knee Observa1on Ecchymosis Knee Effusion with obscured landmarks •  Previous surgical scars •  Knee res1ng posi1on •  Quadriceps muscle atrophy –  Evaluate Vastus Medialis muscle specifically •  Atrophy osen on side of ligamentous injury Knee •  Normal Range of Mo1on •  Flexion: 135 degrees •  Extension: 0 to 10 degrees above horizontal plane Knee •
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Tenderness to Palpa1on Patella Tibial tubercle Patellar tendon Quadriceps tendon Joint line Knee •  Menisci •  McMurray test •  Flex knee, externally rotate leg, placed valgus stress across knee, extend knee •  Patella •  Patellar tracking •  Patellar femoral grinding test Knee •
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Cruciate ligaments Anterior drawer sign (ACL) Posterior drawer sign (PCL) Lachman test (ACL + PCL)