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Musculoskeletal 2

Advanced Physical Assessment

QuestionAnswer
The foot and ankle, upon inspection, you look for nodules (RA), deformities, tenderness, arthritis- plantar fasciitis of the heel
Test- Ottawa ankle rules- ankle xr indications boney tenderness at the lateral malleolar zone, boney tenderness at the medial malleolar, inability to walk four weight bearing steps immediately after the injury and in the emergency department
Test- Ottawa foot rules get XR when- bone tenderness at Navicular bone, bone tenderness at base of the 5th metatarsal, inability to weight bear both immediately and in the ED
Test- Most common joint to get sprained is the ankle ATFL (anterior talofibular ligament)- pt will have point tenderness and swelling over involved ligament(s) (can bear wt) and NOT over the malleoli, which is a fracture.
The second most common is a sprain of ankle is both the ATFL and the CFL (calcaneofibular ligament).
Sprain vs strain sprain a joint and strain a muscle
Achilles tendonitis describes inflammation middle portion of posterior ankle- quinolones/levo can cause-improper shoes and inadequate stretching prior to athletic activities- worse when standing/walking down stairs.
Flat feet/pes planus not always abnormal- examine shoes-
Plantar fasciitis: a common inflammation of the plantar fascia at its origin on the calcaneus- overuse injury that develops of repeated overstretching of the plantar fascia- 1st arising from bed you feel it
Morton’s neuroma perineural fibrosis of the common digital nerve=Tenderness over the plantar surface between the 3rd and 4th metatarsal heads
Neuropathic wart under foot- painless- diabetic pts
Plantar wart under foot- HPV
Podagra gout- red inflamed, give nsaids, steroids, cochesine- chronic allopurinol
How many types of lordosis do we have? 2- cervical and lumbar- also, thoracic kyphosis (aging)
Test- Herniated intervertebral discs, most common at L5 – S1 or L4 – L5, may cause tenderness- will ask about L4-5 or L5-S1, not both
Test- the most important test for the spine straight leg raises- for herniated disc-
Test- An ipsilateral positive straight leg test same leg that has issue is lifted- feels pain- is a sensitive test for the presence of radiculopathy-compressed nerve root- (80% sensitive, 40% specific)
Test- A contralateral (crossed) positive straight leg test opposite leg is lifted- feels pain- is a more specific test for the presence of radiculopathy- compressed nerve root- (90% specific).
Cervical Radiculopathy: (from Nerve Root Compression) Sharp burning or tingling pain in the neck and ONE arm, with associated paresthesias and weakness.
Physical Signs of cervical radiculopathy C7 root is MOST often affected, with weakness in triceps and finger flexors and extensors. C6 root will cause weakness in biceps, brachioradialis, wrist extensors
C5 Shoulder abduction, Elbow flexion (palm up) for deltoid and biceps, sensory left arm below deltoid, deep tendon reflex is the bicep
C6 Elbow flexion (thumb up), Wrist extension for Brachioradialis, Extensor carpi radialis longus, sensory is thumb and radial hand- DTR is brachioradialia
C7 Elbow extension, Wrist flexion for Triceps, Flexor carpi radialis- sensory Index, long finger, ring finger, DTR- triceps
.Cervical Myelopathy from Cervical Cord Compression- bilateral-Neck pain with BILATERAL weakness and paresthesias in BOTH upper and lower extremities- canbe caused by Cervical spondylosis, RA, (para) central herniation
Cervical myelopathy physical findings Hyperreflexia; clonus at the wrist, knee, or ankle- + Babinski and Lhermitte sign: neck flexion results in sensation of electrical shock
simple muscle strain is the most common cause of low back pain- on exam, the paraspinal muscles may be palpably spasming, ROM ↓
Lumbosacral disc herniation The discs between the L4-5 and L5-S1) are the most commonly herniated discs (most weight-supporting ones).
Radicular pain (AKA radiculopathy) typically is a unilateral- burning/ shock- like pain that starts in the buttocks and shoots down the leg on the affected side (layman’s term: “sciatica”), following the dermatome of the compressed nerve root
Leg pain that goes past the knee indicates a pinched nerve from a herniated disc, while buttock or leg pain that does not extend past the knee may be referred pain from the back, but is not from a pinched nerve root.
The straight leg raise test (SLR) is a valuable maneuver to assess compression of the nerve roots contributing to the sciatic nerve, as occurs with a lumbosacral herniated disc:
An ipsilateral positive straight leg test is a sensitive test for the presence of radiculopathy
A contralateral (crossed) positive straight leg test is a more specific test for the presence of radiculopathy
neurogenic claudication pain in buttocks and legs that worsens with prolonged upright standing or walking- relieved when sitting
Vascular claudication is relieved by standing at rest, while neurogenic needs to sit
shopping cart sign Standing straight makes pain worse/while leaning forward alleviates the pain-pts often fine when walking/leaning on the shopping cart, but when walking the few minutes across the parking lot to their car, they are in severe pain- lumbar spine stenosis
Cauda Equina Syndrome lower back pain and leg pain- often bilateral) associated with lower extremity weakness and bowel/ bladder symptoms (incontinence)- saddle anesthesia- does it feel weird when you wipe- do rectal exam-
Screening for scoliosis is best done by the “Adam’s forward bend test”- use scoliometer- forward bend device- 7 degrees or higher is a referral d/t curvature of 20 degrees or more
Test- Osgood-Schlatter Disease “hurts at my knee” A traction apophysitis (inflammation of a bony outgrowth) of the anterior aspect of the tibial tubercle- inflammation of anterior patellar tendon-self-limiting d/o- common in boys between 9-15 yo
Muscular dystrophy/Duchenne Muscle atrophy and weakness with a waddling gait- A positive Gower sign- Progressive loss of function, including ability to walk
Created by: arsho453