Ortho I Orthopedics Tests SG Alex Ashby
Reference: Orthopedic Physical Assessment 2nd Edition By: Ronald C. Evans
Examinations:
I Inspect
P Palpate/Percuss
R ROM
O Orthopedic Testing
N Neurological Testing
Differential Diagnosis (VICTANE)
V Vascular
I Infection
C Congenital
T Trauma
A Arthritides (generally age related, but no necessarily)
N Neoplasm
E Endocrine
Pain Descriptions of Related Structures
Type of Pain:
Cramping, dull, aching
Sharp, shooting
Sharp, bright, lightning-like
Burning, pressure-like, aching
Structure
Muscle
Nerve Root
Nerve
Deep, nagging, dull BONE
Sharp, severe, intolerableFRACTURE
Throbbing, diffuseVASCULATURE
Treatment
A Adjustment
P Physical Therapy
O Orthopedic Support
S Supplementation
E Exercise/Educate
Spinal Tracts
Lateral Spinothalamic Tract Sensation of Pain & Temp
Ventral Spinothalamic Tract Light touch
Corticospinal Tract Controls motor
During recovery from a n. root injury, Pain returns before light touch
Dermatomes & Myotomes
Dermatome: Area of sensation on the skin supplied by a single spinal segment
Myotomes: Groups of muscles innervated by a single spinal segment
ALWAYS test DTR, myotomes & dermatomes
ALWAYS test bilaterally
Dermatomes:
Note: T1 position higher on ant. aspect (just inf. to C5-under clavicle)
Lower on post. aspect (just inf. to C8)
T4 - Breast & T10 - Umbilicus
Neuro
DTR=Deep Tendon Reflex
Sensation anterior & lateral spinothalamic tract
T12: Lower abdomen proximal to inguinal ligament
L1: Upper thigh just distal to inguinal ligament
L2: Mid thigh
L3: Lower thigh
L4: Medial leg-medial side of foot
L5: Lateral leg dorsum of foot
S1: Lateral side of foot
S2: Longitudinal strip, post. thigh
Deep Tendon Reflex Stretch reflex
An involuntary response illustrating the simplest unit of sensory & motor function
Monosynaptic
Tapping on a tendon of a partially stretched muscle stretches sensory fibers creating an impulse that travels through a peripheral nerve into the sp. Cord
The stimulated sensory fiber synapses with the anterior horn cell which stimulates a muscle contraction
Thus, the DTR is relayed over both CNS & PNS
It depends on:
Intact sensory
Functional synapses in the sp. cord
Intact motor nerve fibers
Functional neuromuscular junction
Competent muscle fibers
Knowledge of the reflex level can help locate the lesion level
L4 Patellar
L5 Medial hamstring/Post. tibialis
S1 Achilles tendon
Unilateral HYPOreflexiamay indicate a n. root deficit
Loss of reflex unilaterallymay indicate interruption in the reflex arc (LMNL)
Unilateral HYPERreflexiamay indicate an (UMNL)
Reflex Grading ALWAYS check well side firstthen grade accordingly
0 Absent
+1 HYPOreflexia
+2 Normal
+3 HYPERreflexia
Clonus (keeps it going)
Transientgoes one time & then stops (+4)
Sustainedkeeps going until physically stopped (+5)
Ex. Parkinsons
L4 Patellar Reflex (Will def. be asked)
Easy way to remember
Patellar tendon is innervated by L4
Assoc. w/ 4 quad muscles
Neurological level 4
L5 Reflex There are 2 spots you can test
Supine or Prone Position
Medial Hamstring Tendon (medial side)
Found within the Popliteal Fossa
Tibialis Posterior Tendon
Post-Sup to Medial Malleolus
Focus more on the info above rather than how to actually perform test
S1 Achilles Reflex (Will def. be asked)
Dorsiflex foot
Patient distraction if needed
Several variations
Myotomes (Grading)
5 Complete ROM against gravity w/ full resistance
4 Complete ROM against gravity w/ some resistance
3 Complete ROM w/ gravity
2 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 muscle
Grade 0-4 unilaterally possible neuro deficiency
If sensory is intactsuspect S/S of Illiopsoas muscle
Testing L2, L3, L4 Quadriceps
Place one hand above knee
Have pt. extend knee
With other hand, offer pressure above ankle while pt. resists
Check bilaterally
Extension Lag
If 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 supine
Instruct pt. to Abduct leg on top & move it posteriorly, then lower leg is ADDucted
Apply pressure as Pt. attempts to resist
Testing 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 resistance
REMEMBER:
L4 refelexPatellar tendon
L4 sensory1st toe, medial aspect
Testing L5-S1
Gluteus medius (L5)
Allow Pt. to fully Abduct leg
While stabilizing the pelvis, apply pressure medially @ knee joint while pt. resists
REMEMBER:
L5 sensorylateral 1st toe, 2-4 toes, medial 5th toe
Testing S1
Peroneus longus/brevis Common Peroneal n.
Pt. everts foot
Dr. attempts to bring foot to neutral as Pt. Resists
Check bilaterally & grade accordingly
Gluteus Maximus Inf. Gluteal n.
Pt. proneextends hip
Dr. applies pressure against Pt. resistance
Check bilaterally
Grade accordingly
Range of Motion
Assess musculoskeletal function
Objective measurement
Rule in or out a differential Dx
Distinguish mechanical BP from non-mechanical
The full range of motion in which a body part moves (ex. joint range of motion)
ROM Examination
Extension Pain Response
Early Facet Sprain & Pars Pathology
Mid-Terminal Range & Muscular Strain
Flexion Pain Response
Early Mid-Range - Disc Disease, Muscular Spasm, SI Sprain (acute)
Terminal Range, Facet Stretch/Inflammation, SI Sprain (subacute)
Lateral Flexion w/ Rotation (coupling)Post. Joint Dysfunction
Isolated Lateral FlexionAcute Muscle Spasm
Posterolateral Disc Displacement
Factors Affecting ROM
Demographics (age, sex, occupation)
Injuries (skin, bone, joint, muscles, ligaments)
Subjective influences (pain)
Examiner Variability
Proper body position
Instrument application
Measuring technique
Recording method
Diagnostic Tools
Inclinometers - IM (measures 360 degrees)
Petrometer
Baseline bubble inclinometer
Goniometer (measures 180 degrees)
ROM Testing (Thoracic Spine)
Flexion 20-40 degrees
Extension 25-45 degrees
Lat. Flexion 20-40 degrees
Rotation 35-50 degrees
IM is always @ T1 & T12
Ortho Tests:
1) Adams Test (p. 312) Tests for scoliosis
a) Curvatures of spine (rib hump)
b) Functional - hump/curve goes away during flexion
c) Structural Hump remains
2) Trendelenbergs Test (p.562) Hip Joint Pathology
a) Assessment for: Insufficiency of the Hip Abductor Sys.
b) Normal muscle/hipsIliac crest is low on standing side & high on side of elevated leg
c) Weak muscle/hips involvedIliac crest is high on standing side & low on side of elevated leg
d) Clinical Pearl Positive as a result of:
i) Gluteal paralyis or weakness (from polio)
ii) Gluteal inhibition (from pain arising in hip joint)
iii) Gluteal insufficiency from coxa vera
iv) Congenital dislocation of the hip
(1) ~False-positive tests have been recorded in approx. 10% of pts. w/ hip pain~
3) Straight-Leg-Raising Test (p. 465)
a) Assessment for: Space occupying mass in the path of a n. root, SI inflammation, & Lumbosacral involvement
b) Normally Leg can be raised 15-30 degrees before n. root is tractioned thru IVF
c) Painduplicating sciatica during maneuverindicates space-occupying lesion
i) Ex. lumbar disc protrusion, tumor, adhesions, edema, tiss. inflammation at nerve root levelPain on same side
d) Supine position
e) Place one hand under the heel of pt.s affected legother hand on knee
f) With extended limb, examiner flexes pt.s thigh on the pelvis
g) Positive Test: Maneuever limited due to painmay suggest:
i) Sciatica, (from LS or SI lesions) Subluxation syndrome, disc lesions, spondylothesis, adhesions, or IVF occlusion.
h) Clinical Pearl Sciatica that is in the leg & produced from 30-60 degrees is probably caused by SI joint diseaseabove 60 degrees = LS disease
4) Fajersztajn Test (p. 373) a.k.a. - Well-Leg-Raising Test
a) Assessment for: Lumbar n. root lesion caused by IVD Syndrome or Dural Sleeve Adhesion
b) St
