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D...
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       •    Suboccipitals
 ...
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Motion              Contact ...
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Motion              Contact...
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DO THE CORE LUMBAR SPIN...
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     myofascial syndromes, ...
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Motion               Contac...
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1. Sham SLR: patient is in the ...
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   • flexion and rotation
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   • Extension may be limit...
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Motion               Contac...
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Motion                 Cont...
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SI joint syndrome
a. Gaenslen’s...
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   • Extension may be limit...
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7. Soft tissue palpation
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Motion              Contact...
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       disease.
   b. rotationa...
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Motion              Contact...
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7. Soft tissue palpation
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  1. 1. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 1 of 107 Table of contents Do the core cervical orthopaedic examination and test for facet joint irritation............................................................3 Do the core lumbar spine examination on a pain-focused patient. Test the integrity of the L4 nerve root...................7 Do the cervical orthopedic examination, check for cervicogenic dorsalgia and differential diagnosis cervicogenic vertigo from vestibulocochlear causes..........................................................................................................................11 Do the core lumbar spine examination and check for SI joint syndrome.....................................................................16 Do the core lumbar spine examination and rule out ankylosing spondylitis. Test the integrity of L5 nerve root.......21 Do the core cervical orthopedic examination and check for nerve root tension signs on a patient you are suspecting C5 cervical radiculopathy.............................................................................................................................................24 Do the core lumbar orthopedic examination and ddx lumbar facet joint irritation from thoracolumbar syndrome. Test the integrity of L5 nerve root................................................................................................................................29 Do the core cervical orthopedic examination and ddx cervical sprain versus cervical strain. Test the integrity of C6 nerve root......................................................................................................................................................................32 Do the core lumbar orthopedic examination and ddx piriformis syndrome from SI syndrome...................................37 Do core lumbar orthopedic examination and do a full neurological and vascular examination of the lower limb......42 Do the core cervical orthopedic examination and test for TOCS. Test the integrity of the T1 nerve root...................47 Do the lumbar orthopedic examination and rule out nerve root tension signs in the lower limbs. Test the integrity of the S1 nerve...................................................................................................................................................................52 Do the core cervical orthopedic examination and rule out meningeal irritation. Test the integrity of C7 nerve root.. 55 Do the core lumbar spine examination and check for a lumbar disc herniation. Test the integrity of SI nerve root.. 60 Do the core cervical orthopedic examination and test for cervical disc herniation. test the integrity of C6 nerve root. .......................................................................................................................................................................................63 Do the core cervical orthopedic examination and rule out vertrobasilar insufficiency. Test the integrity of C7 nerve root................................................................................................................................................................................68 Do a thorough orthopedic examination of the thoracic spine and check for scoliosis..................................................... Do the core orthopedic examination of the shoulder and check for labral tears............................................................... do the core exmination of the knee and check for a meniscal tear................................................................................... Do the core orthopedic examination of the knee and rule out patellofemoral syndromes............................................... do the core orthopedic examination of the knee and check for an ACL tear.................................................................... Do the core orthopedic examination of the wrist and hand.............................................................................................. Do a thorough orthopedic examination of the foot and ankle..........................................................................................
  2. 2. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 2 of 107 Do the core orthopedic examination of the shoulder and check for bicipital tendonitis.................................................. Do a core examination of the hip and explain the difference between Barlow’s and Ortolani’s tests............................. Do a thorough orthopedic examination of the TMJ.......................................................................................................... Do the core orthopedic examination of the shoulder and check for posterior shoulder instability.................................. Do a thorough orthopedic examination of the elbow........................................................................................................ Do the core orthopedic examination of the shoulder and rule out an anterior shoulder instability.................................. Do the core orthopedic examination of the knee and rule out a plica...............................................................................
  3. 3. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 3 of 107 DO THE CORE CERVICAL ORTHOPAEDIC EXAMINATION AND TEST FOR FACET JOINT IRRITATION. Core tests: 1. Observation – general, postural a. facial expression à indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vertebrobasilar testing – must be done before any cervical adjustments Houle à positive is vertigo, dizziness, nausea, and nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination C5 C6 C7 C8 T1 Motor Shoulder Wrist extension Wrist flexion Finger flexion Finger abduction and finger (curl fingers) abduction and extension adduction Sensation Lateral arm Lateral Middle finger Medial Medial arm forearm, forearm, ring thumb and and small index finger finger Reflex Biceps Brachioradialis triceps 4. Cervical ROM testing Flexion: 45 à 60 Extension: 45 à 75 Rotation: 70 à 90 Lateral flexion: 20à45 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation. 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain. 7. Soft tissue palpation • Scalenes
  4. 4. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 4 of 107 • Suboccipitals • Trapezius • Levator scapulae • Posterior cervical muscle group • SCM • Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower cervical motion palpation Motion Contact hand Control hand Normal Abnormal Flexion Thumb on On patient’s Articular pillar Articular pillar articular pillar; forehead. will glide fails to go index finger Patient’s head anterior and anterior and wrapped around and neck is superior superior TVP of segment flexed and below returned to neutral. Lateral flexion Three-finger On patient’s top TVPs A break in the contact on lateral of head. Lateral approximate a ‘C’ curve may aspect of TVPs. flexes head and smooth ‘C’ curve indicate DJD in neck towards is appreciated joints of Luschka contact hand, and or possible returns to neutral scaleni/intertrans verarii hypertonicity Spinous Thumb contact On top of Spinous process Loss of spinous deviation against two patient’s head. deviates to deviation and/or adjacent Lateral flexes convexity. spinous reversal spinouses. head towards (possible contact hand and contralateral SS returns to neutral and/or splenius involvement) Anterior rotation Three-fingered Rotates face Articular pillars Restricted end contact on three away from move anterior in feel with lack of adjacent articular contact hand and a stair stepping anterior motion. pillars, control returned to motion. Possible small hand on patient’s neutral. cervical rotators forehead. Posterior rotation Patient leans On patient’s head TVPs move Restricted end back against or chin. Guides posteriorly feel to the doctor as contact face towards allowing a slight posterior motion with 2-3 fingers contact while “give” and fullness placed over contact hand under fingers or anterior aspect of pulls posterior joint (possible
  5. 5. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 5 of 107 Motion Contact hand Control hand Normal Abnormal TVPs and superior scalenii) Upper Cervical motion palpation Motion Contact finger Control fingers Normal Abnormal Jawjut Middle finger on a. index on Space between a. space does anterior of C1 ramus of TVP and not open, mandible mandible extension b. ring finger on increases, restriction mastoid allowing a “give” (rectus c. thumb on top capitus of head anterior) Patient’s head is b. space does pushed down and not increase, slightly anterior flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM) Rotation Middle finger on a. index on Space between Space between anterior of C1 ramus of C1 TVP and C1 and mandible TVP mandible mandible does not increase b. ring finger on increase on (contralateral mastoid contralateral side superior c. thumb on top oblique) of head Head is rotated to each side Lateral flexion of Middle finger on a. index on Occiput A. Restricted occiput on C1 superior aspect ramus of approximates C1 end feel of C1 TVP mandible TVP and B. Lack of b. ring finger on separates on lateral mastoid contralateral flexion c. thumb on top side. (contralateral of head. rectus capitus Head is laterally lateral) flexed to each side Lateral flexion of Middle finger on a. index on C1 TVP Restricted end C1 on C2 inferior aspect of ramus of approximates on feel ipsilateral C1 TVP mandible C2 TVP joint and a lack b. ring finger on ipsilaterally and of separation on mastoid then separates contralateral side c. thumb on top contralaterally (contralateral
  6. 6. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 6 of 107 Motion Contact finger Control fingers Normal Abnormal of head intertransversarii Head is laterally ) flexed to each side Rotation of C1 Contact index On forehead. First 25 degrees C2 spinous and on C2 finger on Head is rotated C1 TVP rotates C1 TVP do not posterolateral away from anterior, then C2 separates aspect of C1 contacts spinous rotates to (inferior oblique TVP and thumb the same side ipsilaterally) on C2 spinous. Occiput-Atlas- a. index finger On forehead. Spaces between a. posterior Axis flexion on occiput Head is flexed. fingers increase tubercle with rim, tubercle occiput b. 3rd finger on (possible space (post of rectus capitus C1) minor) c. 4th finger on b. C2 spinous C2 spinous rides up with occiput (rectus capitus major) Semispinalis a. thumb on On forehead. Springy end feel Restricted end Capitus stretch occiput rim Head and neck is and give feel, lack of (ipsilateral) just lateral to flexed and flexion of midline challenged with occiput b. index finger contact hooked around anterior aspect of C2 Splenius capitis a. 2-3 fingers on On forehead. Springy end feel Restricted end stretch posterior of Head is flexed and give feel, lack of (ipsilateral) mastoid. and rotated (face flexion and away from the rotation of contact) and occiput challenged with contact
  7. 7. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 7 of 107 DO THE CORE LUMBAR SPINE EXAMINATION ON A PAIN- FOCUSED PATIENT. TEST THE INTEGRITY OF THE L4 NERVE ROOT Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg). Exaggerations. b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: a. reflex, sensory and motor testing Reflex Sensory Motor L4 Patellar Medial calf and medial Tibialis anterior (ankle side of foot inversion) L5 No reflex or medial Lateral leg and dorsum of Extensor digitorum hamstring tendon foot including web of big longus, extensor hallucis toe (divided by crest of longus, walk on heels tibia) S1 Achilles Lateral malleolus, lateral Peroneus longus and and plantar surfaces of brevis (ankle eversion), foot gastrocnemius (plantar flexion), walk on toes b. plantar reflex – normally down going c. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression d. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing • Forward flexion 40 – 60 degrees à dramatic refusal may be suggestive of a non- organic problem • Extension 20-35 degrees • Lateral flexion 15-20 degrees • Rotation 3 – 18 degrees • Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology • Extension may be limited due to inflamed posterior apophyseal joints, disc herniation,
  8. 8. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 8 of 107 myofascial syndromes, spondylolisthesis • Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test 6. Non-organic testing a. simulation tests – axial loading, trochanteric rotation b. distraction tests – sitting SLR 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip problem, an irritated SI or L/S facet joint – may indicate tight adductors, intrinsic hip problem, an irritated SI or L/S facet joint c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Motion Contact finger Control fingers Normal Abnormal Flexion Three finger Patient is flexed Spinous No separation – contact on and returned to processes flexion interspinous neutral separate. restriction, spaces extension malposition may be due to shorted supraspinous and/or
  9. 9. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 9 of 107 Motion Contact finger Control fingers Normal Abnormal interspinous ligaments Extension Make a fist and Extended by Spinous No use a thumb lifting elbows processes will approximation. contact on and returned to approximate Extension interspinous neutral restriction of flexion malposition. Lateral flexion Hook and push Laterally flexed Superior spinous Spinous will not contact away from will rotate to rotate or reverse doctor and turned concavity. into convexity to neutral (sacrospinalis and/or multifidus) Lateral flexion Thumb contact Laterally flexed Springy end feel Hard end feel, no (spinous on lateral aspect away toward as disc is wedge lateral flexion: challenge) of 2 adjacent Doctor and open on a. disc spinous returned to contralateral side protrusion/he neutral rniation b. hypertonic intertransvers arii QL. Rotation Hook-push or Rotated toward Spinous rotates Spinous remains thumb-push Dr. and returned away from in midline and/or to neutral. superior finger fails to rotate (multifidus) Special test for Pain-focused patients –Waddell’s Tests 1. Tenderness – light touch on the back causes pain or if deep tenderness spreads over large areas of the body – test is positive. 2. Simulation test – scored positive if 1 to 2 pounds of axial pressure applied to the head causes back pain or leg pain or if gentle axial rotation of the pelvis and shoulders together, causes back pain. 3. Distraction test – patient is sitting as the heel is raised with one hand and the doctor’s other had palpates the dorsalis pedal pulse (leg extended and hip joint is flexed). Can be sciatic if leans back. Also can be nonorganic or functional disease if positive for supine SLR < 20 degrees but negative at sitting with hip flexed to 90 degrees (a.k.a. positive Flip test) 4. Regional disturbances – positive if non-neuroanatomic numbness in the absence of peripheral neuropathy, or if the patient demonstrates cogwheel weakness associated with extrapyramidal systemic disease 5. Over-reaction sign –patient uses excessive body language, gestures, moans and groans, sweats profusely, trembles. Not a Waddell’s test but still for pain focused patient.
  10. 10. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 10 of 107 1. Sham SLR: patient is in the seated position with straight legs and foot dorsiflexed. LBP à pain amplification or non-organic lesion.
  11. 11. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 11 of 107 DO THE CERVICAL ORTHOPEDIC EXAMINATION, CHECK FOR CERVICOGENIC DORSALGIA AND DIFFERENTIAL DIAGNOSIS CERVICOGENIC VERTIGO FROM VESTIBULOCOCHLEAR CAUSES Core tests: 1. Observation – general, postural a. facial expression à indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vertebrobasilar testing Houle à positive is vertigo, dizziness, nausea, and nystagmus. It indicates possible stenosis or compression of the vertebral basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination C5 C6 C7 C8 T1 Motor Shoulder Wrist Wrist flexion Finger flexion Finger abduction extension and finger (curl fingers) abduction and extension adduction Sensation Lateral arm Lateral Middle finger Medial Medial arm forearm, thumb forearm, ring and index and small finger finger Reflex Biceps Brachioradialis Triceps 4. Cervical ROM testing Flexion: 45 à 60 Extension: 45 à 75 Rotation: 70 à 90 Lateral flexion: 20à45 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation.
  12. 12. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 12 of 107 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain. 7. Soft tissue palpation • Scalenes • Suboccipitals • Trapezius • Levator scapulae • Posterior cervical muscle group • SCM • Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower cervical motion palpation Motion Contact hand Control hand Normal Abnormal Flexion Thumb on On patient’s Articular pillar Articular pillar articular pillar; forehead. will glide fails to go index finger Patient’s head anterior and anterior and wrapped around and neck is superior superior TVP of segment flexed and below returned to neutral. Lateral flexion Three-finger On patient’s top TVPs A break in the contact on lateral of head. Lateral approximate a ‘C’ curve may aspect of TVPs. flexes head and smooth ‘C’ curve indicate DJD in neck towards is appreciated joints of Luschka contact hand, and or possible returns to neutral scaleni/intertrans verarii hypertonicity Spinous Thumb contact On top of Spinous process Loss of spinous deviation against two patient’s head. deviates to deviation and/or adjacent Lateral flexes convexity. spinous reversal spinouses. head towards (possible contact hand and contralateral SS returns to neutral and/or splenius involvement) Anterior rotation Three-fingered Rotates face Articular pillars Restricted end contact on three away from move anterior in feel with lack of adjacent articular contact hand and a stair stepping anterior motion. pillars, control returned to motion. Possible small hand on patient’s neutral. cervical rotators forehead. Posterior rotation Patient leans On patient’s head TVPs move Restricted end back against or chin. Guides posteriorly feel to the
  13. 13. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 13 of 107 Motion Contact hand Control hand Normal Abnormal doctor as contact face towards allowing a slight posterior motion with 2-3 fingers contact while “give” and fullness placed over contact hand under fingers or anterior aspect of pulls posterior joint (possible TVPs and superior scalenii) Upper Cervical motion palpation Motion Contact finger Control fingers Normal Abnormal Jawjut Middle finger on d. index on Space between c. space does anterior of C1 ramus of TVP and not open, mandible mandible extension e. ring finger on increases, restriction mastoid allowing a “give” (rectus f. thumb on top capitus of head anterior) Patient’s head is d. space does pushed down and not increase, slightly anterior flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM) Rotation Middle finger on d. index on Space between Space between anterior of C1 ramus of C1 TVP and C1 and mandible TVP mandible mandible does not increase e. ring finger on increase on (contralateral mastoid contralateral side superior f. thumb on top oblique) of head Head is rotated to each side Lateral flexion of Middle finger on d. index on Occiput C. Restricted occiput on C1 superior aspect ramus of approximates C1 end feel of C1 TVP mandible TVP and D. Lack of e. ring finger on separates on lateral mastoid contralateral flexion f. thumb on top side. (contralateral of head. rectus capitus Head is laterally lateral) flexed to each side Lateral flexion of Middle finger on d. index on C1 TVP Restricted end C1 on C2 inferior aspect of ramus of approximates on feel ipsilateral
  14. 14. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 14 of 107 Motion Contact finger Control fingers Normal Abnormal C1 TVP mandible C2 TVP joint and a lack e. ring finger on ipsilaterally and of separation on mastoid then separates contralateral side f. thumb on top contralaterally (contralateral of head intertransversarii Head is laterally ) flexed to each side Rotation of C1 Contact index On forehead. First 25 degrees C2 spinous and on C2 finger on Head is rotated C1 TVP rotates C1 TVP do not posterolateral away from anterior, then C2 separates aspect of C1 contacts spinous rotates to (inferior oblique TVP and thumb the same side ipsilaterally) on C2 spinous. Occiput-Atlas- d. index finger On forehead. Spaces between c. posterior Axis flexion on occiput Head is flexed. fingers increase tubercle with rim, tubercle occiput e. 3rd finger on (possible space (post of rectus capitus C1) minor) f. 4th finger on d. C2 spinous C2 spinous rides up with occiput (rectus capitus major) Semispinalis c. thumb on On forehead. Springy end feel Restricted end Capitus stretch occiput rim Head and neck is and give feel, lack of (ipsilateral) just lateral to flexed and flexion of midline challenged with occiput d. index finger contact hooked around anterior aspect of C2 Splenius capitis a. 2-3 fingers on On forehead. Springy end feel Restricted end stretch posterior of Head is flexed and give feel, lack of (ipsilateral) mastoid. and rotated (face flexion and away from the rotation of contact) and occiput challenged with contact Cervical dorsalgia tests a. In the seated position:
  15. 15. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 15 of 107 • flexion and rotation • deep palpation (facet rub) for referral • PA spinous challenge • lateral spinous challenge C6/7 • interspinous challenge rub the ligament b. In supine position: • skin rolling T2/3, T5/6 • point testing T2,T5/6 digital pressure – tightness and tenderness on palpation • dorsal spinous challenge lateral and PA c. cervical doorbell test is done in the seated position. The examiner palpates the anterolateral aspect of the lower cervical spine. Maintain this mild to moderate pressure for 3 to 5 seconds. Be careful not to occlude the carotid artery. A positive sign is the reproduction or aggravation of pain in the patient’s interscapular region. May be a sign of cervicogenic dorsalgia, pressure over an irritated nerve root may cause radicular arm pain or pain in the interscapular region or hypertonic scalene muscles. Cervicogenic vertigo from vestibulocochlear causes a. rotary chair test Part one – patient sits on stool that rotates with eyes closed and shake head from side to side. Vertigo may be from vestibular nuclei or from the muscles and joints in the cervical spine. Part two – Have rotate head side from side as examine stands behind the patient and holds their head steady while the patient continues to rotate their body. If there is vertigo, it most likely originates form the tissues of the cervical spine. If there is no vertigo, it most likely originates from the vestibular nuclei. b. VBI testing c. Romberg’s – patient stands with eyes closed. The position is held for 20 to 30 seconds. If the body begins to sway excessively or the patient loses balance, the test is considered positive for an upper motor neuron lesion. d. BPV test • have patient sit near the middle of the table so that if lying down, head can be supported off the table. The doctor holds the patient’s head (rotates and extends) and instructs the patient to fall back (reassure the patient you are maintaining contact. Hold in that position for 5 to 10 seconds. Look for nystagmus. • Caloric test. The examiner alternately applies hot and cold test tubes just behind the patient’s ears on the side of the head; each side is done in turn. A positive test is associated with the inducement of vertigo, which indicates inner ear problems.
  16. 16. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 16 of 107 DO THE CORE LUMBAR SPINE EXAMINATION AND CHECK FOR SI JOINT SYNDROME. Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg) b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: a. reflex, sensory and motor testing Reflex Sensory Motor L4 Patellar Medial calf and Tibialis anterior medial side of foot (ankle inversion) L5 No reflex or medial Lateral leg and Extensor digitorum hamstring tendon dorsum of foot longus, extensor including web of big hallucis longus, walk toe (divided by crest on heels of tibia) S1 Achilles Lateral malleolus, Peroneus longus and lateral and plantar brevis (ankle surfaces of foot eversion), gastrocnemius (plantar flexion), walk on toes b. plantar reflex – normally down going c. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression d. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing • Forward flexion 40 – 60 degrees • Extension 20-35 degrees • Lateral flexion 15-20 degrees • Rotation 3 – 18 degrees. • Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology
  17. 17. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 17 of 107 • Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis • Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test 6. Non-organic testing c. simulation tests – axial loading, trochanteric rotation d. distraction tests – sitting SLR 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip problem, an irritated SI or L/S facet joint – increased pain may indicate SI pain c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test – indicates sacroiliac joint irritation 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Lumbar spine Motion Contact finger Control fingers Normal Abnormal Flexion Three finger Patient is flexed Spinous No separation – contact on and returned to processes flexion interspinous neutral separate. restriction, spaces extension malposition may be due to shorted supraspinous and/or
  18. 18. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 18 of 107 Motion Contact finger Control fingers Normal Abnormal interspinous ligaments Extension Make a fist and Extended by Spinous No use a thumb lifting elbows processes will approximation. contact on and returned to approximate Extension interspinous neutral restriction of flexion malposition. Lateral flexion Hook and push Laterally flexed Superior spinous Spinous will not contact away from will rotate to rotate or reverse doctor and turned concavity. into convexity to neutral (sacrospinalis and/or multifidus) Lateral flexion Thumb contact Laterally flexed Springy end feel Hard end feel, no (spinous on lateral aspect away toward as disc is wedge lateral flexion: challenge) of 2 adjacent Doctor and open on c. disc spinous returned to contralateral side protrusion/he neutral rniation d. hypertonic intertransvers arii QL. Rotation Hook-push or Rotated toward Spinous rotates Spinous remains thumb-push Dr. and returned away from in midline and/or to neutral. superior finger fails to rotate (multifidus) SI joint evaluation Motion Contact finger Control fingers Normal Abnormal 1. pelvic flexion a. Index or Stabilizes pelvis. Sacrospinalis and a. Lumbar spine on acetabulum middle finger Patient bends hamstrings will not flex under PSIS forward elongate. (tight b. Thumb Relatively sacrospinalis) contact on sacrum will b. Patient will sacral apex slightly flex knees extend/counternu (tight tate on the hamstrings) innominate c. Innominate fails to flex d. No counternutati on 2. pelvic lateral a. thumbs under Hands firmly Lumbar spine a. Limited or no flexion PSIS grasp pelvis. laterally flexes in pelvic shift Patient laterally a smooth C- (tight
  19. 19. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 19 of 107 Motion Contact finger Control fingers Normal Abnormal bends to each curve with abd/add) side opposite thigh b. Pelvic abduction and rotation adduction (psoas) elongation to c. PSIS elevates allow a slight on opposite pelvic shift side (tight QL) d. Limited lumbar lateral flexion 3. ilium flexion Thumbs contact Doctor’s hands PSIS will move a. PSIS fails to under PSIS. stabilize pelvis as posterior and move patient stabilizes inferior b. As leg lowers with hand against will see psoas wall. shimmer Patient lifts leg as if climbing stairs 4a. iliosacral Thumb contact Patient stabilizes PSIS will move a. PSIS fails to motion under PSIS. with hand against posterior and move Other thumb wall. inferior b. PSIS and contact lateral to Patient lifts leg sacral base S1 tubercle contact lateral to move S1 tubercle to 90 together degrees. posterior 4b. sacroiliac Thumb contact Patient stabilizes Sacrum moves Sacrum fails to motion under PSIS. with hand against posterior and move posterior Other thumb wall. inferior on the and/or inferior contact lateral to Patient lifts leg flexed S1 tubercle. contact innominate contralateral to S1 tubercle to 90 degrees. 5. sacroischial Thumb contact Patient stabilizes Ischium moves a. Ischium fails motion on sacral apex. with hand against slightly anterior to move Other thumb wall. and lateral anterior and contact on soft Patient lifts leg lateral tissue over on side of ischial b. Sacral apex posterior ischium contact to 90 moves with degrees. ischium.
  20. 20. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 20 of 107 SI joint syndrome a. Gaenslen’s test – Patient is supine and bring knee to chest on unaffected side. The affected limb is off the table and hyperextended by the examiner with increasing force. Pain on hyperexteded side may indicate an SI lesion b. Yeoman’s test – patient is prone as the examiner flexes the knee, extends the hip joint and applies pressure on ipsilateral PSIS. Increased pain may indicate an SI lesion c. Hibb’s test – the examiner flexes the patient’s leg (prone) on his thigh to 90 degrees and then moves it laterally causing internal rotation of the hip joint. Increased pain may indicate a hip joint lesion, SI lesion or piriformis spasm
  21. 21. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 21 of 107 DO THE CORE LUMBAR SPINE EXAMINATION AND RULE OUT ANKYLOSING SPONDYLITIS. TEST THE INTEGRITY OF L5 NERVE ROOT Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg) b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: Reflex Sensory Motor L4 Patellar Medial calf and Tibialis anterior medial side of foot (ankle inversion) L5 No reflex or medial Lateral leg and Extensor digitorum hamstring tendon dorsum of foot longus, extensor including web of big hallucis longus, walk toe (divided by crest on heels of tibia) S1 Achilles Lateral malleolus, Peroneus longus and lateral and plantar brevis (ankle surfaces of foot eversion), gastrocnemius (plantar flexion), walk on toes a. plantar reflex – normally down going b. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression c. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing • Forward flexion 40 – 60 degrees • Extension 20-35 degrees • Lateral flexion 15-20 degrees • Rotation 3 – 18 degrees. • Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology
  22. 22. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 22 of 107 • Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis • Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test 6. Non-organic testing a. simulation tests – axial loading, trochanteric rotation b. distraction tests – sitting SLR 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip problem, an irritated SI or L/S facet joint – increased pain may indicate SI pain c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test – indicates sacroiliac joint irritation 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Lumbar spine Motion Contact finger Control fingers Normal Abnormal Flexion Three finger Patient is flexed Spinous No separation – contact on and returned to processes flexion interspinous neutral separate. restriction, spaces extension malposition may be due to shorted supraspinous and/or interspinous ligaments
  23. 23. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 23 of 107 Motion Contact finger Control fingers Normal Abnormal Extension Make a fist and Extended by Spinous No use a thumb lifting elbows processes will approximation. contact on and returned to approximate Extension interspinous neutral restriction of flexion malposition. Lateral flexion Hook and push Laterally flexed Superior spinous Spinous will not contact away from will rotate to rotate or reverse doctor and turned concavity. into convexity to neutral (sacrospinalis and/or multifidus) Lateral flexion Thumb contact Laterally flexed Springy end feel Hard end feel, no (spinous on lateral aspect away toward as disc is wedge lateral flexion: challenge) of 2 adjacent Doctor and open on e. disc spinous returned to contralateral side protrusion/he neutral rniation f. hypertonic intertransvers arii QL. Rotation Hook-push or Rotated toward Spinous rotates Spinous remains thumb-push Dr. and returned away from in midline and/or to neutral. superior finger fails to rotate (multifidus) Special test: 1. Trendelenburg test – Patient stands on one leg so that gluteus medius on supported side contracts to elevate opposite side. If not, this may indicate L4 root lesion or hip disease. 2. Schober’s test. Take out a tape measure and find the dimples of Venus (or the PSIS bilaterally). Draw an imaginary line across the PSIS at the S2 level. Now place the 10 cm point of the tape measure at the S2 level. With the left hand fix the O point of the tape measure onto the spine, which should now be at about the L1 level. With the right hand, hold the tape measure loosely and find the 15 cm point which should be around the apex of the sacrum. Now as you ask the patient to forward flex, the inferior (right hand) allows the tape measure to slide between the fingers and the measurement should normally increase approximately 7 cm, from 15 cm to 22 cm. Any movement less than 3 cm is considered to be positive Schoeber’s test and is highly indicative of seronegative spondyloarthropathy.
  24. 24. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 24 of 107 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND CHECK FOR NERVE ROOT TENSION SIGNS ON A PATIENT YOU ARE SUSPECTING C5 CERVICAL RADICULOPATHY. Core tests: 1. Observation – general, postural a. facial expression à indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vertebrobasilar testing Houle à positive is vertigo, dizziness, nausea, nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination C5 C6 C7 C8 T1 Motor Shoulder Wrist extension Wrist flexion Finger flexion Finger abduction and finger (curl fingers) abduction and extension adduction Sensation Lateral arm Lateral forearm, Middle finger Medial Medial arm thumb and index forearm, ring finger and small finger Reflex Biceps Brachioradialis triceps 4. Cervical ROM testing Flexion: 45 à 60 Extension: 45 à 75 Rotation: 70 à 90 Lateral flexion: 20à45 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation. 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain.
  25. 25. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 25 of 107 7. Soft tissue palpation • Scalenes • Suboccipitals • Trapezius • Levator scapulae • Posterior cervical muscle group • SCM • Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower Cervical motion palpation Motion Contact hand Control hand Normal Abnormal Flexion Thumb on On patient’s Articular pillar Articular pillar articular pillar; forehead. will glide fails to go index finger Patient’s head anterior and anterior and wrapped around and neck is superior superior TVP of segment flexed and below returned to neutral. Lateral flexion Three-finger On patient’s top TVPs A break in the contact on lateral of head. Lateral approximate a ‘C’ curve may aspect of TVPs. flexes head and smooth ‘C’ curve indicate DJD in neck towards is appreciated joints of Luschka contact hand, and or possible returns to neutral scaleni/intertrans verarii hypertonicity Spinous Thumb contact On top of Spinous process Loss of spinous deviation against two patient’s head. deviates to deviation and/or adjacent Lateral flexes convexity. spinous reversal spinouses. head towards (possible contact hand and contralateral SS returns to neutral and/or splenius involvement) Anterior rotation Three-fingered Rotates face Articular pillars Restricted end contact on three away from move anterior in feel with lack of adjacent articular contact hand and a stair stepping anterior motion. pillars, control returned to motion. Possible small hand on patient’s neutral. cervical rotators forehead. Posterior rotation Patient leans On patient’s head TVPs move Restricted end back against or chin. Guides posteriorly feel to the doctor as contact face towards allowing a slight posterior motion with 2-3 fingers contact while “give” and fullness placed over contact hand under fingers or
  26. 26. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 26 of 107 Motion Contact hand Control hand Normal Abnormal anterior aspect of pulls posterior joint (possible TVPs and superior scalenii) Upper Cervical motion palpation Motion Contact finger Control fingers Normal Abnormal Jawjut Middle finger on g. index on Space between e. space does anterior of C1 ramus of TVP and not open, mandible mandible extension h. ring finger on increases, restriction mastoid allowing a “give” (rectus i. thumb on top capitus of head anterior) Patient’s head is f. space does pushed down and not increase, slightly anterior flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM) Rotation Middle finger on g. index on Space between Space between anterior of C1 ramus of C1 TVP and C1 and mandible TVP mandible mandible does not increase h. ring finger on increase on (contralateral mastoid contralateral side superior i. thumb on top oblique) of head Head is rotated to each side Lateral flexion of Middle finger on g. index on Occiput E. Restricted occiput on C1 superior aspect ramus of approximates C1 end feel of C1 TVP mandible TVP and F. Lack of h. ring finger on separates on lateral mastoid contralateral flexion i. thumb on top side. (contralateral of head. rectus capitus Head is laterally lateral) flexed to each side Lateral flexion of Middle finger on g. index on C1 TVP Restricted end C1 on C2 inferior aspect of ramus of approximates on feel ipsilateral C1 TVP mandible C2 TVP joint and a lack h. ring finger on ipsilaterally and of separation on mastoid then separates contralateral side
  27. 27. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 27 of 107 Motion Contact finger Control fingers Normal Abnormal i. thumb on top contralaterally (contralateral of head intertransversarii Head is laterally ) flexed to each side Rotation of C1 Contact index On forehead. First 25 degrees C2 spinous and on C2 finger on Head is rotated C1 TVP rotates C1 TVP do not posterolateral away from anterior, then C2 separates aspect of C1 contacts spinous rotates to (inferior oblique TVP and thumb the same side ipsilaterally) on C2 spinous. Occiput-Atlas- g. index finger On forehead. Spaces between e. posterior Axis flexion on occiput Head is flexed. fingers increase tubercle with rim, tubercle occiput h. 3rd finger on (possible space (post of rectus capitus C1) minor) i. 4th finger on f. C2 spinous C2 spinous rides up with occiput (rectus capitus major) Semispinalis e. thumb on On forehead. Springy end feel Restricted end Capitus stretch occiput rim Head and neck is and give feel, lack of (ipsilateral) just lateral to flexed and flexion of midline challenged with occiput f. index finger contact hooked around anterior aspect of C2 Splenius capitis a. 2-3 fingers on On forehead. Springy end feel Restricted end stretch posterior of Head is flexed and give feel, lack of (ipsilateral) mastoid. and rotated (face flexion and away from the rotation of contact) and occiput challenged with contact Special tests for nerve root irritation: 1. compression tests a. lateral cervical compression will close IVF on side of flexion. The appearance or aggravation of radicular pain, paresthesia, or numbness in the shoulder, or upper arm and in the forearm or hand may mean nerve root compression possibly due to cervical disc
  28. 28. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 28 of 107 disease. b. rotational cervical compression test is positive when there is appearance or aggravation of radicular pain, paresthesia, or numbness in the shoulder or upper arm and in the forearm or hand. This may be due to cervical disc disease 2. axial manual tract test is done supine. May decrease or dissipate radicular symptoms. 3. shoulder abduction test is done in the sitting position with the patient’s hand lifted above his or head and holds it there for 30 seconds. A positive is a decrease or disappearance of radicular symptom. May be due to nerve root compression possibly due to cervical disc disease. 4. cervical doorbell test is done in the seated position. The examiner palpates the anterolateral aspect of the lower cervical spine. Maintain this mild to moderate pressure for 3 to 5 seconds. Be careful not to occlude the carotid artery. A positive sign is the reproduction or aggravation of pain in the patient’s interscapular region. May be a sign of cervicogenic dorsalgia, pressure over an irritated nerve root may cause radicular arm pain or pain in the interscapular region or hypertonic scalene muscles.
  29. 29. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 29 of 107 DO THE CORE LUMBAR ORTHOPEDIC EXAMINATION AND DDX LUMBAR FACET JOINT IRRITATION FROM THORACOLUMBAR SYNDROME. TEST THE INTEGRITY OF L5 NERVE ROOT. Core 1. Observation a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg) b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciatica c. antalgic posture (side of sciatica?) d. plumb line e. muscle spasm – bilateral or unilateral? f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creases g. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum 2. Neurological examination: Reflex Sensory Motor L4 Patellar Medial calf and medial Tibialis anterior (ankle side of foot inversion) L5 No reflex or medial Lateral leg and Extensor digitorum hamstring tendon dorsum of foot longus, extensor including web of big hallucis longus, walk toe (divided by crest of on heels tibia) S1 Achilles Lateral malleolus, Peroneus longus and lateral and plantar brevis (ankle eversion), surfaces of foot gastrocnemius (plantar flexion), walk on toes a. plantar reflex – normally down going b. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to walk on toes may indicate S1 root compression c. muscle girth testing 3. Gait analysis 4. Lumbar ROM testing • Forward flexion 40 – 60 degrees • Extension 20-35 degrees • Lateral flexion 15-20 degrees • Rotation 3 – 18 degrees. • Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology
  30. 30. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 30 of 107 • Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis • Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm 5. Standing Kemp’s test – aggravates an inflamed facet joint and/or disc herniation 6. Non-organic testing a. simulation tests – axial loading, trochanteric rotation c. distraction tests – sitting SLR 7. Straight leg raise 8. Crossed SLR test 9. Muscle stretch tests a. SLR b. Fabere’s – may indicate tight adductors, intrinsic hip plebe, an irritated SI or L/S facet joint – increased pain may indicate SI pain c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) d. Psoas palpation e. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root. 10. SI provocation test a. SI compression test – indicates sacroiliac joint irritation 11. Spinous tenderness 12. Soft tissue palpation 13. Motion palpation and joint play analysis (say only) Lumbar spine Motion Contact finger Control fingers Normal Abnormal Flexion Three finger Patient is flexed Spinous No separation – contact on and returned to processes flexion interspinous neutral separate. restriction, spaces extension malposition may be due to shorted supraspinous and/or interspinous ligaments
  31. 31. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 31 of 107 Motion Contact finger Control fingers Normal Abnormal Extension Make a fist and Extended by Spinous No use a thumb lifting elbows processes will approximation. contact on and returned to approximate Extension interspinous neutral restriction of flexion malposition. Lateral flexion Hook and push Laterally flexed Superior spinous Spinous will not contact away from will rotate to rotate or reverse doctor and turned concavity. into convexity to neutral (sacrospinalis and/or multifidus) Lateral flexion Thumb contact Laterally flexed Springy end feel Hard end feel, no (spinous on lateral aspect away toward as disc is wedge lateral flexion: challenge) of 2 adjacent Doctor and open on g. disc spinous returned to contralateral side protrusion/he neutral rniation h. hypertonic intertransvers arii QL. Rotation Hook-push or Rotated toward Spinous rotates Spinous remains thumb-push Dr. and returned away from in midline and/or to neutral. superior finger fails to rotate (multifidus) Special tests for lumbar facet joint from thoracolumbar syndrome 1. spinal percussion – the patient leans froward the examiner percusses each lumbar vertebrae with a reflex hammer. Localized pain may indicate a facet syndrome or possible vertebral fracture. 2. Do skin roll 3. Motion palpation 4. Pain in hip and buttock
  32. 32. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 32 of 107 DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND DDX CERVICAL SPRAIN VERSUS CERVICAL STRAIN. TEST THE INTEGRITY OF C6 NERVE ROOT. Core tests: 1. Observation – general, postural a. facial expression à indicator of pain perception b. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior head carriage, the stiff neck look, level of mastoids c. shoulder levels: traps, levator scapulae, winging of scapulae d. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoid e. swelling/masses 2. Vertebrobasilar testing Houle à positive is vertigo, dizziness, nausea, nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites. 3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination C5 C6 C7 C8 T1 Motor Shoulder Wrist extension Wrist flexion Finger flexion Finger abduction and finger (curl fingers) abduction and extension adduction Sensation Lateral arm Lateral Middle finger Medial Medial arm forearm, forearm, ring thumb and and small index finger finger Reflex Biceps Brachioradialis triceps 4. Cervical ROM testing Flexion: 45 à 60 Extension: 45 à 75 Rotation: 70 à 90 Lateral flexion: 20à45 Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain). Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain) Pain on all types of ROM is a combination of muscular and ligamentous pain 5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation. 6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain.
  33. 33. C:docume~1abarri~1applic~1qualcommeudoraattachOntarioBoardLabnotes.doc Page 33 of 107 7. Soft tissue palpation • Scalenes • Suboccipitals • Trapezius • Levator scapulae • Posterior cervical muscle group • SCM • Mastoid process 8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation. Lower Cervical motion palpation Motion Contact hand Control hand Normal Abnormal Flexion Thumb on On patient’s Articular pillar Articular pillar articular pillar; forehead. will glide fails to go index finger Patient’s head anterior and anterior and wrapped around and neck is superior superior TVP of segment flexed and below returned to neutral. Lateral flexion Three-finger On patient’s top TVPs A break in the contact on lateral of head. Lateral approximate a ‘C’ curve may aspect of TVPs. flexes head and smooth ‘C’ curve indicate DJD in neck towards is appreciated joints of Luschka contact hand, and or possible returns to neutral scaleni/intertrans verarii hypertonicity Spinous Thumb contact On top of Spinous process Loss of spinous deviation against two patient’s head. deviates to deviation and/or adjacent Lateral flexes convexity. spinous reversal spinouses. head towards (possible contact hand and contralateral SS returns to neutral and/or splenius involvement) Anterior rotation Three-fingered Rotates face Articular pillars Restricted end contact on three away from move anterior in feel with lack of adjacent articular contact hand and a stair stepping anterior motion. pillars, control returned to motion. Possible small hand on patient’s neutral. cervical rotators forehead. Posterior rotation Patient leans On patient’s head TVPs move Restricted end back against or chin. Guides posteriorly feel to the doctor as contact face towards allowing a slight posterior motion with 2-3 fingers contact while “give” and fullness

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