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Ortho I – Orthopedics Tests SG – Alex AshbyReference: Orthopedic Physical Assessment – 2nd Edition – By: Ronald C. EvansExaminations:I – InspectP – Palpate/PercussR – ROMO – Orthopedic TestingN – Neurological TestingDifferential Diagnosis (VICTANE)V – VascularI – InfectionC – CongenitalT – TraumaA – Arthritides (generally age related, but no necessarily)N – NeoplasmE – EndocrinePain Descriptions of Related StructuresType of Pain:Cramping, dull, achingSharp, shootingSharp, bright, lightning-likeBurning, pressure-like, achingStructureMuscleNerve RootNerveDeep, nagging, dull BONESharp, severe, intolerableFRACTUREThrobbing, diffuseVASCULATURETreatmentA – AdjustmentP – Physical TherapyO – Orthopedic SupportS – SupplementationE – Exercise/EducateSpinal TractsLateral Spinothalamic Tract – Sensation of Pain & TempVentral Spinothalamic Tract – Light touchCorticospinal Tract – Controls motorDuring recovery from a n. root injury, Pain returns before light touchDermatomes & Myotomes Dermatome: Area of sensation on the skin supplied by a single spinal segmentMyotomes: Groups of muscles innervated by a single spinal segmentALWAYS test DTR, myotomes & dermatomesALWAYS test bilaterallyDermatomes:Note: T1 position higher on ant. aspect (just inf. to C5-under clavicle) Lower on post. aspect (just inf. to C8)T4 - Breast & T10 - UmbilicusNeuroDTR=Deep Tendon ReflexSensation – anterior & lateral spinothalamic tractT12: Lower abdomen proximal to inguinal ligamentL1: Upper thigh just distal to inguinal ligamentL2: Mid thighL3: Lower thighL4: Medial leg-medial side of footL5: Lateral leg – dorsum of footS1: Lateral side of footS2: Longitudinal strip, post. thigh Deep Tendon Reflex – Stretch reflexAn involuntary response illustrating the simplest unit of sensory & motor functionMonosynapticTapping on a tendon of a partially stretched muscle stretches sensory fibers creating an impulse that travels through a peripheral nerve into the sp. CordThe stimulated sensory fiber synapses with the anterior horn cell which stimulates a muscle contractionThus, the DTR is relayed over both CNS & PNSIt depends on:Intact sensoryFunctional synapses in the sp. cordIntact motor nerve fibersFunctional neuromuscular junctionCompetent muscle fibersKnowledge of the reflex level can help locate the lesion levelL4 – PatellarL5 – Medial hamstring/Post. tibialisS1 – Achilles tendonUnilateral HYPOreflexiamay indicate a n. root deficitLoss of reflex unilaterallymay indicate interruption in the reflex arc (LMNL)Unilateral HYPERreflexiamay indicate an (UMNL)Reflex Grading – ALWAYS check well side firstthen grade accordingly0 – Absent+1 – HYPOreflexia+2 – Normal+3 – HYPERreflexiaClonus (keeps it going)Transientgoes one time & then stops (+4)Sustainedkeeps going until physically stopped (+5)Ex. Parkinson’s L4 Patellar Reflex (Will def. be asked)Easy way to rememberPatellar tendon is innervated by L4Assoc. w/ 4 quad musclesNeurological level 4L5 Reflex – There are 2 spots you can test Supine or Prone PositionMedial Hamstring Tendon (medial side)Found within the Popliteal FossaTibialis Posterior TendonPost-Sup to Medial MalleolusFocus more on the info above rather than how to actually perform testS1 Achilles Reflex (Will def. be asked)Dorsiflex foot Patient distraction if neededSeveral variationsMyotomes – (Grading)5 – Complete ROM against gravity w/ full resistance4 – Complete ROM against gravity w/ some resistance3 – Complete ROM w/ gravity2 – Complete ROM w/ gravity eliminated 1 – Evidence of slight contractility (No jt. Motion)0 – No evidence of contractility Muscle Testing (Myotomes)Levels T12, L1, L2, L3 Illiopsoas muscleGrade 0-4 unilaterally possible neuro deficiencyIf sensory is intactsuspect S/S of Illiopsoas muscleTesting L2, L3, L4 QuadricepsPlace one hand above kneeHave pt. extend kneeWith other hand, offer pressure above ankle while pt. resistsCheck bilaterallyExtension LagIf pt. has great difficulty extending the knee through the last 10 degrees this is considered “extension lag” & can be caused by weak quadriceps Testing L2, L3, L4 Hip ADDuctors – Obturator n.Pt. is on side or supineInstruct pt. to Abduct leg on top & move it posteriorly, then lower leg is ADDuctedApply pressure as Pt. attempts to resistTesting n. root L4 – Tibialis ant. – Deep Peroneal n.Heel walk w/ feet inverted OR…Pt. seated dorsiflexes & inverts foot while Dr. attempts to plantar flex & evert foot against resistanceREMEMBER:L4 refelexPatellar tendonL4 sensory1st toe, medial aspectTesting L5-S1Gluteus medius (L5)Allow Pt. to fully Abduct legWhile stabilizing the pelvis, apply pressure medially @ knee joint while pt. resistsREMEMBER:L5 sensorylateral 1st toe, 2-4 toes, medial 5th toeTesting S1Peroneus longus/brevis – Common Peroneal n.Pt. everts footDr. attempts to bring foot to neutral as Pt. ResistsCheck bilaterally & grade accordinglyGluteus Maximus – Inf. Gluteal n.Pt. proneextends hipDr. applies pressure against Pt. resistanceCheck bilaterallyGrade accordinglyRange of MotionAssess musculoskeletal function Objective measurementRule in or out a differential DxDistinguish mechanical BP from non-mechanicalThe full range of motion in which a body part moves (ex. joint range of motion)ROM ExaminationExtension Pain ResponseEarly Facet Sprain & Pars PathologyMid-Terminal Range & Muscular StrainFlexion Pain ResponseEarly Mid-Range - Disc Disease, Muscular Spasm, SI Sprain (acute)Terminal Range, Facet Stretch/Inflammation, SI Sprain (subacute)Lateral Flexion w/ Rotation (coupling)Post. Joint DysfunctionIsolated Lateral FlexionAcute Muscle SpasmPosterolateral Disc DisplacementFactors Affecting ROMDemographics (age, sex, occupation)Injuries (skin, bone, joint, muscles, ligaments)Subjective influences (pain)Examiner Variability Proper body positionInstrument applicationMeasuring techniqueRecording methodDiagnostic ToolsInclinometers - IM (measures 360 degrees)PetrometerBaseline bubble inclinometerGoniometer (measures 180 degrees)ROM Testing (Thoracic Spine)Flexion – 20-40 degreesExtension – 25-45 degreesLat. Flexion – 20-40 degreesRotation – 35-50 degreesIM is always @ T1 & T12Ortho Tests:38862009906000Adam’s Test (p. 312) – Tests for scoliosis Curvatures of spine (rib hump)Functional - hump/curve goes away during flexionStructural – Hump remains457200016002000274320016002000Trendelenberg’s Test (p.562) – Hip Joint PathologyAssessment for: Insufficiency of the Hip Abductor Sys.Normal muscle/hipsIliac crest is low on standing side & high on side of elevated legWeak muscle/hips involvedIliac crest is high on standing side & low on side of elevated leg Clinical Pearl – Positive as a result of:Gluteal paralyis or weakness (from polio)Gluteal inhibition (from pain arising in hip joint)Gluteal insufficiency from coxa vera Congenital dislocation of the hip~False-positive tests have been recorded in approx. 10% of pts. w/ hip pain~Straight-Leg-Raising Test (p. 465)Assessment for: Space occupying mass in the path of a n. root, SI inflammation, & Lumbosacral involvement38862006032500Normally – Leg can be raised 15-30 degrees before n. root is tractioned thru IVFPainduplicating sciatica during maneuverindicates space-occupying lesionEx. lumbar disc protrusion, tumor, adhesions, edema, tiss. inflammation at nerve root levelPain on same sideSupine positionPlace one hand under the heel of pt.’s affected legother hand on kneeWith extended limb, examiner flexes pt.’s thigh on the pelvisPositive Test: Maneuever limited due to painmay suggest:Sciatica, (from LS or SI lesions) Subluxation syndrome, disc lesions, spondylothesis, adhesions, or IVF occlusion.Clinical Pearl – Sciatica that is in the leg & produced from 30-60 degrees is probably caused by SI joint diseaseabove 60 degrees = LS diseaseFajersztajn Test (p. 373) a.k.a. - Well-Leg-Raising Test Assessment for: Lumbar n. root lesion caused by IVD Syndrome or Dural Sleeve AdhesionStraight leg raise & dorsiflexion of foot performed on asymptomatic (unaffected leg) side of sciatic patient 457200022860000303974522860000If pain is caused during leg raiselower leg to a point just below that which produces sciatica symptoms in affected legOnce lowered, dorsiflex pt.’s footif causes pain = positive Bragard’s signPositive Fajersztajn sign = Test causes pain on symptomatic sideIndicates sciatic n. root involvement ex. medial disc protrusion syndrome or dural root sleeve adhesionsClincial Pearl – Several factors may produce pain in LB/lower ext. Some causes:Tumors of sp. Cord or cauda equineTumors of sp. ColumnTuberculosis of spineOsteoarthritis Tumors of the ilium or sacrumSpondylolisthesis Prolapsed IVDAnkylosing spondylitis Vascular occlusionIntrapelvic massHip arthritis All poss. Causes must be considered in differential diagnosis388620013779500Bragard Sign (p. 373) Assessment for: Sciatic Neuritis, Sp. Cord tumor, IVD lesions, Sp. N. irritationDuring Well-Leg-Raise or Straight-Leg Raise, after pain upon raisingleg is lowered below point of discomfort & foot is sharply dorsiflexedPositive sign – Pain during dorsiflexionClinical Pearl – Must be accomplished as a finishing maneuver in any pos. straight-leg raise test Pain inc. during dorsiflexion = inflamed n. rootNo pain inc. = problem in hamstring area or LS/SI joints Sicard Sign (p. 454) – Sciatic Neuropathy457200014541500320040014541500Assessment for: Sciatic RadiculopathySupine PositionExtended (affected) leg is raised to a point just short of that which produces painOnce lowered to point just below point at which symptoms are producedsharply dorsiflex great toePositive sign - dorsiflexion of great toe reproduces sciatic pain (sciatic radiculopathy) Clincial Pearl – The 2nd, 3rd, & 4th n. roots don’t have an increase in tension during straight leg raisethey don’t increase in tension during femoral stretch testsTuryn Sign (p. 468) – Sciatic Radiculopathy NO LEG RAISE41148002794000Assessment for: Sciatic RadiculopathySupine PositionLegs extended, resting on tableDorsiflex Great toePositive Sign – Pain in gluteal region (sciatic radiculopathy)Clincial Pearl – Because there is no movement on L4 during SLRT Turyn sign indicates large disc protrusion at level of L5-S1 n. root Sacroiliac Stretch Test (p. 489) – Gapping Test 43434005080000Assessment for: Sprain of ant. SI ligamentsSupine PositionPlace both hands on Pt.’s ASIS’spress laterally downwardCrossing the arms inc. lateral component of strain on ligaments DO NOT allow the pelvis to rock it causes the L/S to move Expected finding is not localrather aggravation of gluteal symptomsPositive Test – Only if unilateral gluteal or post. crural pain is elicitedSignificant for ASIL sprainClinical Pearl – most delicate test for SI joint If a pt. has symptoms referable to SI jointthis maneuver will elicit them Patrick FABERE Test (p. 558) – a.k.a. Sign of 4 – (Flex., Abd., Ext-Rot., Ext.)411480011176000Assessment for: Intracapsular Coxa Pathologic conditionsDifferential test for SI vs. HipParticular value in geriatric casesindicates hip joint diseaseSupine position 411480015049500Grasp Pt.’s ankleflex the kneeThigh is flexed, abducted, externally rotated, & extendedPositive Sign – Pain in hip during maneuverparticularly on Abduction & External rotation (Coxa Pathologic condition)Clinical Pearl – An intracapsular fracture can cut off bld. supply to the femoral head completelycan lead to: aseptic necrosis, non-union, or bothb/c fracture is inside capsule, bld. is contained within itthis trapped bld. raises intracapsular pressuredamages femoral head even morePrevents visible bruising b/c bld. cannot reach subcutaneous tissuesGoldthwait Test (p. 491) Assessment for: SI sprain vs. LS spine abnormality Supine positionRaise Pt.’s affected leg with one handplace other hand under Lumbar region38862003810000Pain before Lumbar movement poss. SI lesionMay be caused by arthritis or ligament sprain that involves SI jointPain after Lumbar movementorigin in LS region (Si region – less common)Repeat test with unaffected leg 38862007620000Lumbosacral (LS) lesion positive sign – pain occurs at approx. same height as it did with affected limbSacroiliac (SI) involvement of affected leg – unaffected leg can be raised higher than affected leg Clinical Pearl – Similar to Lasegue test, SLRT, & Smith-Petersen TestAll of these tests use the affected leg as a lever to stretch the suspect tissue (whether neutral or ligamentous)Key to differentiationdetermination of movement of L5-S1 separation (reflecting LS movement) Laguerre Test (p. 499) – “FABERE IN THE AIR”Assessment for: SI Intraarticular Abnormality 4343400311150029718003111500Supine PositionPt.’s involved hipflex, abd, lat. rotateOpposite ASIS is stabilizedOverpressure at end ROM is applied Positive Test – SI joint painNeed to be alert for Coxa signs of diseaseClinical Pearl – Test reveals mechanical problem of SI jointInvolvement of joint in osteitis condensans ilii can be confirmed only thru diagnostic imaging Gaenslen’s Test (p. 487)Assessment for SI disease37960309207500Supine PositionAcutely flex Pt.’s knee & thigh (unaffected leg) into abdomenThis brings L/S into contact w/ table & fixes both pelvis & L/SWhile standing at right angle to pt. bring Pt. closer to side of table Slowly hyperextend Pt.’s affected thighThis is accomplished by gradually increasing the pressure of one hand on top of knee while other hand is on flexed kneeHyperextension of affected hip exerts a rotating force on corresponding half of pelvisThe pull is made on the ilium, through Y-ligament, & the muscles attached to ant. Iliac spinePositive Test – pain felt in the SI area or referred down thighNegative Test – Possible LS lesionPerform bilaterally Test is usually contraindicated in older patientsClinical Pearl – SI involvement produces local pain over joint or pain that’s referred to: 1. The groin on same side 2. Post. thigh on same side 3. Down leg (less often)Pain often increases by lying on affected side Cox Sign (p. 374) 43434006096000Assessment for: Prolapse of IVD nucleusSupine positionPositive Sign – During straight leg raise pelvis rises from table instead of hip flexingPresent when Pt. has prolapsed nucleus into IV foramenClinical Pearl – Cox sign is consistent finding assoc. with disc prolapse Often overlooked in Pt.’s pain presentationFalse-negative test – may occur if you don’t observe the movements of buttocks on opposite side The sign is present the moment hip flexion motion is locked and the buttock rises from the table Lasegue Differential Sign (p. 403)Assessment for: Intervertebral Radiculopathy vs. Hip Joint Disease 480060017589500Supine positionLeg is brought to degree of SLRFor Sciatica Pt. flex Pt.’s hip while knee is extended elicits painFlexing thigh on pelvis while knee is flexedno sciatic pain This would be a positive sign (rules out hip joint disease)Clinical Pearl – Extending the knee while hip is flexed stretches the Sciatic n. this creates great deal of pain for Sciatica pts.When you flex the kneerelieves painThis rxn is the classic leg raising signVariations of this sign, w/ interpretations of its meaning lend much more knowledge to the examiner than just noting at what degree of leg raise that the pt. experiences back pain, leg pain, or both Milgram’s Test (p. 437) Assessment for: Intervertebral Disc Syndrome or Space-Occupying MassSupine position (Legs extended)Tell Pt. to raise legs until heels are 6 in. off tablehold as long as poss.3657600-228600005029200-22860000Positive Test – Pt. experiences LBPPt. may have pathologic condition such as herniated disc (in or outside sp. cord. Sheath)This maneuver increases the subarachnoid pressurePt. can hold position for 30 seconds w/ out painpathologic condition of intrathecal origin can be ruled outClinical Pearl – This test increases thecal pressure Ability to hold it for any amount of time, rules out a pathologic condition of thecal origin Bowstring Sign (p. 371)Assessment for Lumbar nerve root compression43434006096000Supine PositionMove Pt.’s leg until above your shoulderAt this point, exert firm pressure on hamstring musclesNo painapply pressure to popliteal fossaPositive sign – Pain in lumbar region or radiculopathy (N. root compression)Clinical Pearl – Nerve roots must change their lengths, depending on degree of flexion, extension, lateral flexion, & rotation of L/S.Lumbar n. roots that are limited in motion by fibrosis of either intraspinal or extraspinal origin will create traction on the n. root complexThis causes ischemia & secondary neural dysfunction Lindner’s Sign (p. 428) Assessment for: Lumbar n. root irritation/inflammationSupine, seated, or standingPassively flex pt. head to chest388620010223500Positive test – Pain in L/S & along sciatic distribution Indicates n. root sciaticaClinical Pearl: head flex to chest inc. traction of n. root against disc bulgeContained disc – annulus not rupturedFlexion or maintenance of flexed pos. of trunk obliterates disc bulgeSource of pain – motion of irritated n. root over a bulging discRelief – trunk flexonly b/c disc bulge disappears Thomas Test (p. 561) Assessment for: Flexion contracture involving IlliopsoasSupine PositionHave Pt. flex thigh w/ knee bent toward abdomen3200400-228600004572000-22860000Pt.’s L/S should normally flatten or flexPositive Test – The spine maintains a lordosis Indicates hip flexion contracture (from shortened Illiopsoas) Clinical Pearl – Restricted hip flexion may be compensated by an increase in lumbar lordosisThe increase masks the fixed flexion deformityFixed flexion, external rotation, & abduction accumulate sequentially as the hip disease progresses Soto-Hall Sign (p. 138) – Primarily used for suspected vertebrae fracture38862002349500Assessment for: C/S subluxation, exostoses, (bone thickening) musc/lig sprain, vertebrae fracture, meningeal irritation (febrile) Supine positionOne hand on pt.’s sternum w. slight press. prevents flexion @ T/S or L/S388620014478000Other hand on pt.’s occiputflex head toward chestThis produces a pull on post. spinous ligaments SP’s of injured vertebrae reached pt. has local painPositive Test – subluxation, exostoses, disc lesion, sprain/strain, vertebral fracture, meningeal irritation, elevated temp must be present for corroborationMeningeal irritation - must have elevated temp Clinical Pearl: Nonspecific test w/ limited capacity to localize conditions of C/S & UT/SOften misapplied in the assessment of fractures/sprains for entire spineWhen used to draw conclusions below T8”often a guessing game”Kernig or Brudzinski sign (Soto-Hall variation) – high risk for meningitisFlexion of the knees occurs when you flex the neckPt.’s temp must be assessed with this phenomena (possible fever)Beevor’s Sign (p. 321) – not an abdominal reflex, seen during examinationAssessment for: Myelopathy (sp. Cord lesion) assoc. w/ T10 sp. Level 4343400457200027813004572000Supine PositionHold pt.’s legs downhave pt. lift head off table Normally, upper/lower abd. Muscles contract equally 45720008445500Umbilicus does not move or driftWhen lower abd. Muscles alone are weakendUmbilicus is drawn up by intact upper musculatureClinical Pearl: Test should be used in the case of: Prolonged illness followed by lower ext. parathesia (regardless of age)Positive sign affords an early, noninvasive indicator of the existence of thoracic spinal cord myelopathy411480026670000SI Resisted Abduction Test (p. 505) – Specific for SI sprain/subluxationAssessment for: Generalized Abductor Muscular Weakness/Sprain/Subluxation of SI jointSide Posture Position (unaffected side down)affected leg extended/slightly abducted If the Pt. does not feel stable in this positionhave them flex unaffected leg at hip & kneeFrom this position, exert downward position on the abducted leg against the Pt.’s resistance Repeat test on opposite sidePositive Test – Pelvic pain elicited near PSISClinical Pearl – Slight, unilateral hip-abductor weakness is found in assoc. with lateral pelvic tiltAbductors are weak on slightly elevated side of pelvis The beginning weakness in the abductors (as seen in nonparalytic individuals) is usually assoc. w/ handedness & is a strain weakness from postural or occupational causes Lewin-Gaenslen Test (p. 500) – Modification of Gaenslen Test 502920011303000346202013779500Assessment for: SI Abnormality Side Posture Position (unaffected side down)knee to chestStand behind the Pt.Have the Pt. hold affected thigh in extensionProvide pressure by hyperextending the affected thigh3524250539750050292005397500Positive Test – Pain produced in SI jointSignificant for SI lesionsClinical Pearl – Due to strength of SI ligaments, sprains are uncommonBending movements (lifting, hyperextension, etc.) which produce a torsion sprain on the jointmore likely to cause sprain of thinner capsular ligaments in the small LS joints Iliac Compression Test (p. 495) – Compression of Iliac CrestsAssessment for: SI Lesions, Sprain, Inflammation, Subluxation, & FractureSide Posture Position (legs extended)Compress Pt.’s Sup. Ilium toward the floorForward rolling motion of sacrum occursIncreased pressure in SI joint suggests SI lesion4343400000This pressure may also indicate sprain of post. SI ligamentsPositive Finding – Significant for SI lesionsClinical Pearl – Fractures of pelvis may result in long-term disability More important – these fractures are often complicated by damage to soft tissues, urethra, bladder, bowel, blood vessels, & nerves (can be fatal)Genitourinary complications occur in approx. 20% of pelvic fractures (overall mortality5%) Yeoman’s Test (p. 514)Assessment for: Anterior SI Ligament injury 4800600762000Prone PositionWith one hand, apply firm pressure to suspected SI joint (fixing pelvis to table)With other hand, flex Pt.’s affected leg & hyperextend thigh by lifting knee of tablePositive Test - Pain increased in SI area = SI Lesion48006009906000Caused by strain placed on ant. SI ligaments In Pt. without SI lesion, pain will not be felt during maneuverClinical Pearl – Due to scar tissue forming at the site of repair, ruptured SI ligaments do not heal soundly (even if accurately repaired)Conservative management may be equally as effective as surgery for these ruptured ligaments Nachlas Test (p. 442)Assessment for: SI or LS DisorderProne position (eliminates LS muscular influence)480060063500Pain in LB & Lower Extremity is noted during passive flexion of kneePositive Test – Pain in SI or LS area OR pain radiates down thigh or legIndicates a SI or LS disorder 480060026733500Clinical Pearl – Concealed disc or occult disc: intermittent prolapse of nuclear material Degenerated nuclear material still within the annulus (may be weakened by degeneration, but still intact) may bulge beyond its normal limits when the spine is subject to certain stresses Depending on stresses, the prolapse appears & then disappears Extension & hyperextension of the spine favor the prolapse When the spine is relieved of stress, such as when the Pt. is relaxed & lying in the prone positionthe defect disappears Hibbs Test (p. 493) 45720005334000Assessment for: SI DiseaseProne PositionStabilize the Pt.’s pelvis on the nearest side by placing one hand firmly on the dorsum of the iliac bone With other hand around Pt.’s ankleflex opposite knee to a right angle457200014478000Knee is flexed to max. w/ out elevating the thigh from tableFrom this position, slowly push the Pt.’s leg laterally (causes strong internal rotation of the femoral head)Perform test bilaterally Positive Test – Pelvic Pain Significant for SI Lesion45720006096000In the absence of hip involvement, stress is transmitted through the hip joints into the SI mechanismproduces painClinical Pearl – Not specific for Tuberculosis of the SI joint but is correlated w/ other systemic findings that may suggest the existence of this type of TuberculosisHibbs reveals mechanical dysfunction of SI joint Ely Sign (p. 382) – Heel-to-Buttock Test457200025971500Assessment for: Lumbar Radicular or Femoral Nerve InflammationProne Position (legs relaxed w/ toes hanging over edge of table)Bring one heel to opposite buttockAfter flexing the knee, the thigh is hyperextendedWith significant hip lesionimpossible to perform test457200012255500With Iliopsoas irritationthigh extension is impossibleThis test will aggravate inflammation of Lumbar n. roots & will be accompanied by production of femoral radicular painThis test will also stretch Lumbar n. root adhesionsAccompanied by upper Lumbar discomfort Dejerine’s Triad (p. 95) – Indicates Space Occupying LesionAssessment for: Herniated or Protruding IVD & Sp. Cord Tumor or Sp. Compression Fracture48006009207500Coughing, sneezing, & straining during defecation may aggravate radiculitis symptomsThis aggravation results from mechanical obstruction of sp. fluid flow Dejerine sign is present when one of the following exists: herniated or protruding IVD, sp. cord tumor, sp. compression fractureThe course of the radiculitis helps ID the location of the lesion Valsalva Test (p. 151) Assessment for: Space Occupying Lesion, Tumor, IVD herniation, or Osteophytes502793010668000365760016002000Seated PositionHave Pt. take deep breath & hold it while bearing down abdominallyPositive Test – Increased pain (caused by increasing intrathecal pressure)Usually caused by a space occupying lesion (herniated disc, tumor, osteophytes, etc.)Perform test w/ care & cautionPt. may become dizzy & pass out while or shortly after performing the testThis is b/c the procedure can block bld. supply to the brain 5029200609600036576006096000Tripod Test (p. 757) – Bilateral Leg Fluttering Test Assessment for: Simulated Lumbar PainSeated PositionPt. may attempt to fake a leg paralysis as the result of a further faked Lumbar IVD syndrome502920032766000365760032766000In this instance, have Pt. sit on table, knees flexed at 90 degrees & legs hanging dependentDirect Pt. to extend & relax, or flex, the legs rapidly & repeatedly Lumbar disc involvement existsPt. will have to lean back in order to perform the maneuver (if able to do it at all)The Pt. feigning disc involvement can accomplish the maneuver w/out assuming such a tripod posture Bechterew Sitting Test (p. 367)45720005397500Assessment for: Sciatica, IVD Lesion, Vertebral Exostoses, Dural Sleeve Adhesions, Muscular Spasm, or Vertebral SubluxationSeated PositionHave Pt. attempt to extend each leg (one at a time)45720009207500Then, restrict Pt.’s attempt at hip flexion with downward pressure on the thighThis extension is followed by an attempt to extend both legsPositive Test – Backache or sciatic pain is increased or if the maneuver is impossibleIndicates sciatica, disc lesion, exostoses, adhesions, spasm, or subluxation4572000825500In disc involvement, extending both legs will usually increase the spinal & sciatic discomfort Clinical Pearl – Simple flattening or even reversing the lumbar curve is often not assoc. w/ radicular painThe pain is localized in the lower lumbar spine, and any movement of the spine accentuates the painIn these instances, the prime pathologic feature is sprain of an intervertebral joint rather than root irritation 502920014478000365760014478000Belt Test (p. 483) – Supported Adam’s Test Assessment for: SI ligament Sprain or LS Capsular SprainStanding Position (Pt. express LB symptoms)Have Pt. flex forwardnote amount of movement required to aggravate pain495808023622000365760023622000Stand behind Pt. Grasp Pt.’s Iliac crests & brace your hip against the Pt.’s sacrumHave Pt. flex forward again while immobilizing his/her pelvisIf lesion is of pelvic nature, flexing the spine w/ pelvis immobilized will NOT produce discomfortIf lesion is of a spinal nature, the pain will be aggravated in both instances Antalgia Sign (p. 363) 57150008445500Assessment for: Posterolateral, Posteromedial, & Posterocentral IVD ProtrusionLateral disc protrusion = Pt. leans away from side of lesionMedial disc protrusion = Pt. leans toward side of lesionCentral disc protrusion = Pt. flexes L/S forward (with or without leaning)Protrusion under n. root = Pt. may not lean at allClinical Pearl – If antalgia is not readily apparent in a static posture, it will appear with forward flexion of the trunk457200063500If disc protrusion existstrunk flexion exerts enough pressure to irritate the inflamed muscle or to stretch neural structures over bulging disc Antalgia is manifested at this pointPts. w/ LBP might stiffen the trunk & pelvis & hyperextended the knees in an effort to decrease the number of degrees of freedom 50292009207500Minor Sign (p. 440)Assessment for: SI Lesions, LS strains/sprains, Lumbopelvic Fractures, IVD syndrome, muscular dystrophy, & dystoniaSciatic radiculitis is suggested by how a Pt. with this condition rises from seated positionPt. supports body w/ uninvolved side by balancing on the healthy leg, placing one hand on the back, & flexing the knee & hip of the affected leg 4572000-22860000Kemp Test (p. 397) Assessment for: Intervertebral Nerve Root Encroachment, Muscular Strain, Ligamentous Sprain, or Pericapsular InflammationSeated or Standing Position457200026606500Seated Position – Stand behind Pt Support Pt. Reach around Pt.’shoulders & upper chest Lean Pt. forward to one side, then around until Pt. is eventually bending obliquely backwardPositive Test – Pattern of radicular pain in thigh & leg (Nerve Root Compression)Local BP should be notedbut not considered Positive sign (may indicate strain/sprain and occurs when Pt. leans obliquely forward or at any point in motion48006006096000This test must elicit a more positive finding when Pt. is standing rather than sittingOther Considerations – DJD, Exostoses, Inflammatory or Fibrotic residues, narrowing from disc degeneration, & tumorsNOTE: Kemps can also produce localized pain from facet irritationClinical Pearl – Sitting increases intradiscal pressure & therefor maximizes stress on the disc Standing increases weight bearing & maximizes stress to the facets Test should be performed in both positions3429000762000Chest Expansion Test (p. 324)Assessment for: Spinal Ankylosis If measurement is less suspect Standing or SeatedChest diameter measured at T4Measure when pt. fully exhalesMeasure when pt. fully inhalesRecord differenceNormal male – 2 inNormal female – 1.5 inLess than normbreathing obstructionoften times caused by:Ankylosing Spondylitis – Entire sp. goes into total calcification (becomes a rock)Joints are replaced by fibrous tiss. that eventually ossifiesPos. Test = poss. Rib involvement @ costotransverse or costovertebral jts.With this type of Pt. send right to X-Ray434340016065500Sternal Compression (p. 341) Assessment for: Costal structure fracturePt. Supine – arms @ side/crossed over lower abd. Place reinforced knife edge on Pt.’s sternum w/ post. press.Localized pain @ lat. border of ribs = rib fracture5029200692150038862006921500Schepelmann’s Sign (p. 332) – Identifies rib integrityAssessment for: Costal & intercostal tissue integrity Standing/Seated position 525780013017500Pt. raises arms & bends laterally41148005397500Pain:Concave side = intercostal neuritis 5029200160655Convex = myofascitis0Convex = myofascitis3429000160655Concave = neuritis0Concave = neuritisConvex side = intercostal myofascitismust be differentiated from the fibrous inflammation of pleurisyClinical Pearl: Test provides efficient method for localizing rib injuryPt. moves actively & can limit the motion according to painSpinous Percussion Test (p. 334)Assessment for: Spinal osseous & Paraspinal soft-tissue integritySeated or Standing positionT/S slightly flexedUse a reflex hammer to percuss SP’s & assoc. musculature of T-vertebraeOver SP’s: (Pos. Test)Localized pain = poss. Fractured vertebrae 4572000-45720000Radicular pain = poss. Disc lesionOver Paraspinal regions:Poss. Muscular S/SPositive Test - nonspecificother conditions will elicit pos. pain responseLigamentous sprain Paraspinal musculatureClinical Pearl: Complaint is reproduced w/ soft-tissue percussionUltrasound may also create this phenomenonTherapy like this should be delayed until soft tissue is no longer reactive to percussion43434007683500Passive Scapular Approximation Test (p. 330)Assessment for: T1 or T2 N. Root Problem Standing positionApproximate Pt.’s scapula pulling sh. Tips backwardScapular pain = T1-T2 n. root lesion ................
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