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HistoryGather personal Information (Name, sport, age, gender, doctor referral, diagnosis, etc)Ask simple open ended questionsProvocationQualityRegionSeverityTimingMOIHear anythingPrevious HistoryMedicationsWhat makes it better (ease factors)What makes it worse (agg. Factors)What have they done for it (self treatment / ease factors) ObservationUninjured limb first/then injuredDiscolorationScarsDeformityPostural abnormalitiesBleedingSwellingTorticollis PalpationUninjured limb first/then injuredPoint of tendernessDeformity/CrepitusSwelling5. Temperature ChangeBoney PalpationCervical VertebraeSpinous Processes (C2-T1)Atlas/Axis - C1 (the atlas) does not have a SP; it has a posterior tubercle. To palpate the posterior tubercle of C1, palpate between the SP of C2 and the occiput, pressing anteriorly into the soft tissue.ClavicleFirst Rib Soft Tissue PalpationLigamentum Flavum- a pair of elastic ligaments connecting the lamina of one vertebra to the lamina of the vertebra above it on the posterior margin of the vertebral canal. It limits flexion and rotation of the spineLigamentum Nuchae- the supraspinous ligament becomes this in the cervical spine. A triangular septum that serves as a broad area for muscle attachment. It restricts flexion in the cervical spine.Articulation PalpationCervical Intervertebral ArticulationQualitative ROM TestingFlexionChin to ChestExtensionLook at ceiling directly aboveLateral BendingKeep shoulders level. Laterally flex the neck to bring ear to A-C joint. Should be approximately 45 degreesLateral RotationRotate head to the right to look directly over the A-C joint. Repeat to the left.Quantitative ROM Testing:Flexion & ExtensionFulcrum @ external auditory meatus. Norm Flx: 40-70; Norm Ext: 60-80Lateral BendingNorm: 40-50 degrees Fulcrum @ patient’s sterna notch. RotationNorm: 70-90 degrees Fulcrum @ center of patient’s headWC: #4Manual Muscle TestingAnterolateral Neck FlexorsMuslces Tested: chiefly stnernocleidomastoid and scalenes Posterolateral Neck Extensors Muscles Tested: chiefly the splenius capitus and cervicis, semispinalis capitis and cervices, and cervical Erector spinae Anterior Neck Flexors Note patient arm position. Anterior abdominal muscles must be strong enough to give anterior fixation of thorax to pelvis before the head can be raised by the neck flexors. If abs are weak, the examiner can give fixation by firm downward pressure on the thorax. Pressure: posterior, as shown in picture. Note: If the anterior vertebral neck flexors (L.Capitus/L.Colli, anterior scalnes) are weak, an individual cab raise the head from the table (as shown in the WRONG picture)Muscles Tested: Longus Capitus, Longus Colli, anterior scalenes Trapezius Middle FibersO: Spinous Processes of T1-T5 I: Medial margin of the acromion and superior lip of spine of the scapula A: Adduction of the scapula Patient prone Patient adducts the scapula, by placing the shoulder in 90 degrees of abduction with the thumb pointed toward the ceiling Examiner stabilizes the opposite shoulder and applies pressure against the forearm in a downward directionLower TrapeziusProne. The examiner gives fixation by placing one hand below the scapula on the opposite side (not shown). Test: Adduction and depression of the scapula with lateral rotation of the inferior angle. Thumb up. Pressure: against forearm in a downward direction toward table.Upper TrapeziusElevation of the acromial end of the clavical and scapula; posteriolateral extension of neck. Pressure: Against shoulder in direction of depression, and against the head in the direction of flexion and anteriolaterallly. WC: #2Circulatory CheckCarotid PulseSeated or supine. Using the index and middle fingers to locate the thyroid cartilage, move the fingers to either direction to find the common carotid artery between the thyroid cartilage and the SCM muscle. 60-100 bpm normal; well trained 40-60; Tachcardia >100; bradycardia < 60. WC: #4Neurologic Exam. (M-R-S: Motor-Reflex-Sensory) Neurological CheckDTRsHow do I grade & document deep tendon reflexes? By convention the deep tendon reflexes are graded as follows:0 = no response; always abnormal1+ = a slight but definitely present response; may or may not be normal2+ = a brisk response; normal3+ = a very brisk response; may or may not be normal4+ = a tap elicits a repeating reflex (clonus); always abnormalWC: #4C1 DermatomeTop of the headC1 MyotomeTested with C2C1 ReflexNoneC2 DermatomeTop of head, back of head, faceC2 MyotomeNeck flexionC2 ReflexNoneC3 DermatomeSide of NeckC3 MyotomeNeck Side FlexionC3 ReflexNoneC4 DermatomeUpper Trapezius AreaC4 MyotomeResisted Shoulder ShrugC4 ReflexNoneC5 DermatomeLateral Deltoid Area (Lateral Patch)C5 MyotomeShoulder AbductionC5 ReflexBiceps Reflex: Patient sitting. Examiner stands to the side of the athlete with the forearm cradled in one arm. The thumb is placed over the biceps tendon below the elbow. The thumb is tapped with the reflex hammer.C6 DermatomeLateral Forearm, thumb and index fingerC6 MyotomeElbow Flexion, Wrist extensionC6 ReflexBrachioradialis Reflex: Patient sitting. Examiner cradles the arm of the athlete. The distal portion of the brachioradialis tendon is tapped with the reflex hammerC7 DermatomeMiddle FingerC7 MyotomeElbow Extension, Wrist FlexionC7 ReflexTriceps Reflex: Patient sitting. The examiner supports the athlete’s shoulder with it abducted to 90 degrees and the elbow flexed to 90 degrees. The distal triceps tendon is tapped with the reflex hammerC8 DermatomeRing and Pinky FingersC8 MyotomeUlnar DeviationC8 ReflexNoneT1 DermatomeMedial ForearmT1 MyotomeAbduction and Adduction of the FingersT1 ReflexNonePostureGoodBadWC: #1Special TestsValsalva’s ManeuverPatient sitting. Patient takes and holds a deep breath while bearing down similar to performing a bowel movementWC: #1Cervical Compress./Distract. Patient sitting (distraction can be done supine as shown. Examiner stands behind the patient with hands interlocked over the top of the patient’s head. Examiner then presses down on the crown of the patients head. A test is positive if there is an increase in pain as the cervical structures are being compressed. For the distraction test, everything is the same, except the examiner will pull up on the head looking to relieve the symptomsSpurling’s TestExaminer stands behind the patient with hands interlocked over the top of the patient’s head. Examiner then presses down on the crown of the patients head. If no pain or discomfort is felt, the patient is asked to extend the neck back and the examiner will press down on the crown of the patient’s head. If no pain or discomfort is felt, the patient is asked to then laterally flex the neck to the affected side keeping the extension. The examiner will press down on the crown of the patient’s head. Tests for nerve root impingementShoulder Depression TestPatient seated or standing Examiner stands behind the patient. One and placed on the side of the patient’s head, the other hand placed over the AC joint The cervical spine is laterally bent and the opposite shoulder depressed Pain radiating through the upper arm in a dermatomal pattern would indicate a positive test for brachial plexus injuryWC: #4Vertebral Artery TestPatient supine. Examiner seated at the head of the patient with the hands placed under the occiput to stabilize the head. The examiner passively extends and laterally flexes the cervical spine. The head is then rotated toward the laterally flexed side and held for 30 seconds. Tinel’s SignExaminer is to tap at Erb’s point, located 2 to 3 cm above the clavicle in front of the transverse process of the sixth cervical vertebraWC: #3Injuries and Conditions to KnowCervical DislocationDefinition: Displacement of 1+ vertebrae MOI: blunt trauma Cervical SubluxationDefinition: Mildly displaced vertebraMOI: blunt traumaCervical SprainDefinition: Over lengthening to inert tissue in the neck e.g. joint capsule of facet jointMOI: forced ROM beyond normal Cervical StrainDefinition: Over lengthening of contractile tissue in the neck e.g. upper trap.MOI: external force, asynchronous firing during neck motion Neck ContusionDefinition: muscle damage + bleed MOI: blunt trauma Neck BurnerDefinition: Compression or traction injury to the nerve supply of the upper arm occurring either at the neck or shoulder, brachial plexus.MOI: often in collision sports if head is forcefully laterally flexed and flexed, over stretching / pinching the nervesNeck Muscle AtrophyDefinition: Shrinking of neck muscle MOI: nerve root or peripheral neuropathy, postural, lack of use e.g. with prolonged usage of cervical brace Vertebral FractureDefinition: Fracture of a vertebra MOI: likely a ‘crush’ type mechanism e.g. an axial load through column (body fracture) or blunt trauma (transverse or spinous process fracture), or hyper extension mechanism (pars interarticularis fracture). Faulty Head and Neck PostureDefinition: abnormal posture of head and or neck e.g. forward head posture. MOI: likely postural, could have neuro. etiology Disc HerniationDefinition: herniated nucleus pulposus MOI: acute episode Nerve Root CompressionDefinition: abnormal pressure on a spinal nerve root MOI: can be from intervertebral stenosis or an HNP Spinal Cord IschemiaDefinition: Reduced blood flow to the spinal cord which is supplied by the anterior spinal artery and the paired posterior spinal arteries.MOI: ?arteriosclerosis, trauma, emboli, diseases of the aorta, and other disorders. Prolonged ischemia may lead to?infarction?of spinal cord tissue.?TorticollisDefinition: abnormal rotation of the cervical vertebrae; wry neck.MOI: May be congenital or may develop as a result of neurological or muscular damage. Visable shortening of the neck muscles and the head will tilt toward to affected side while the chin points to the opposite side. Treatment of congenital torticollis involves stretching the shortened neck muscles, the sternocleidomastoid, surgery heat, massage, anticholinergic drugs. On athletic performance this can have greater biomechanical implications, headache, visual problems, compression of nerve roots. Brachial Plexus NeuropathyDefinition: pathology of brachial plexus MOI: compression, stretch, nerve root compression Vertebral Artery OcclusionDefinition: closing off of vertebral artery MOI: ? Other Cool StuffRED FLAGS! (may need to zoom into word doc. to see text in image)WC: #4Mnemonic: Randy Travis Drinks Cold BeerRoots > Trunks > Divisons > Cords > Branches Works CitedWC: #1Hoppenfeld, S. (1976). Physical Examination of the Spine and Extremities. Upper Saddle River, NJ: Prentice-Hall. WC: #2Kendall, P. F., McCreary, K. E., Provance, G. P. (1993). Muscles Testing and Function, Ed. 4. Philadelphia, PA: Lippincott Williams & Wilkins. WC: #3Konin, G. J., Wiksten, L. D., Isear, A. J., Brader, H. (2006). Special Tests for Orthopedic Examination, Ed. 3. Thorofare, NJ: SLACK Incorporated. WC: #4Starkey, C., Brown, D. S., & Ryan, J. (2010). Examination of Orthopedic and Athletic Injuries, Ed. 3. Philadelphia, PA: F.A. Davis Company. ................
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