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PCOM #100

PCOM Ortho Neuro Exam 2 - midterm

TESTTECHNIQUEPOSITIVE SIGNDIAGNOSIS
Distraction Test Patient seated: remove: earrings, glasses, bluetooth or hearing aids!!! (1) w pt's head in neutral, examiner places base of both palms under the mastoid processes and cup the ears, use thumbs to push any hair out of way (2) slowly lift head ~ 2 seconds RELIEF OF PAIN (+) relief of pain, or decreased pain indicates nerve root lesion (-) increased pain can indicate muscle spasm or sprain, ligament sprain, dural irritability, disc herniation IVFE, nerve root lesion: disc herniation, facet pathology, stenosis; differentiate by dermatome
Shoulder Depression Test Patient seated: (1) examiner uses left palm on left side of pt's head to passively flex neck into lateral flexion toward right side, while (2) using right hand to push pt's left shoulder inferiorly NECK PAIN (+) pain on extended side indicates dural adhesions or irritation (+) pain on side of flexion indicates foraminal irritation or nerve root compression brachial plexus lesion, nerve root compression or dural adhesions
Shoulder Abduction (Relief) Test Patient seated or supine: (1) pt actively elevates their arm through abduction so the hand or forearm rests on top of their head. RELIEF OF PAIN (+) decrease in or relief of symptoms indicates a cervical or extradural compression problem, or Bakody's sign (-) increased pain indicates increased pressure in the interscalene triangle, scalene syndrome or TOS cervical herniated disc, nerve root compression (usually in C4 to C6 area; differentiate by dermatome)
Valsalva Test Patient seated: (1) examiner asks pt to take deep breath and hold it while bearing down, as if moving a bowel. Care should be taken because patient can become dizzy or pass out if blood supply to brain is blocked by test. INCREASED PAIN (+) increased pain anywhere along the spinal column indicates intra-dural SOL (+) pain radiating to extremities indicates extra-dural SOL (within spinal canal) space occupying lesion (SOL): disc herniation, tumor or oseteophytes
Soto-Hall Test Patient supine: (1) pt bends knees w hips flexed to 135° (2) examiner passively flexes pt's head to chest, applying slight pressure in direction of flexion. [optionally, pt actively flexes chin to chest while examiner applies pressure to the flexed head] SHARP PAIN (+) sharp, electric shock-like pain down the spine and into the upper or lower limbs (-) local neck and upper back pain indicating cervical sprain or strain dural or meningeal irritation in the spine, possible cervical myelopathy
O’Donoghue Maneuver Patient seated: (1) examiner passively moves pt's head through all ROM of the cervical spine. (2) pt actively moves head through all ROM of the cervical spine PAIN (+) PROM pain is deep & pinpoint, indicating ligment sprain, pain is on opposite or contralateral side (+) AROM pain indicates muscle strain on same side cervical muscle sprain / strain.
Dizziness (Swivel Chair) Test Patient seated: (1) examiner has pt rotate head to one side as far as possible while shoulders are stationary; (2) examiner has pt rotate shoulders to one side as far as possible while keeping head facing forward, hold both 10-30 seconds DIZZINESS (+) dizziness in both steps, problem lies in vertebral arteries (+) in head only, problem lies in semicircular canals of the inner ear vertebral artery pathology, semicircular canal pathology
Vertebral Artery (Cervical Quadrant) Test Patient supine: (1) examiner moves pt's head into extension w lateral flexion, then rotates neck to the same side; hold ~30 seconds DIZZINESS, NYSTAGMUS (+) referring symptoms (dizziness, nstagmus, nausea) indicate opposite vertebral artery is compressed; (-) radiculopathy or pain indicates lower cervical spine nerve root compression or TOS vertebral artery compression
Allen Test Patient seated: (1) examiner has pt open & close the hand several times quickly, then form a tight fist; (2) examiner compresses radial and ulnar arteries w thumbs; pt opens fist; (3) examiner releases pressure on arteries one at a time DELAYED FLUSHING (+) if either side of hand takes > 10 seconds for color to return to normal, radial / ulnar artery occlusion is indicated (+) if both sides have delayed flushing, or color does not return, TOS is indicated thoracic outlet syndrome (TOS), or radial or ulnar artery occlusion
Adson Maneuver Patient seated: (1) examiner finds radial pulse; (2) examiner abd & sl. extends pt's arm; arm should be in 80° abduction just post. to frontal plane, wrist below HT (3) pt laterally rotates & extends head toward examiner & takes deep breath; hold 30 secs DECREASED INTENSITY OF RADIAL PULSE (+) decrease in intensity of pulse or disappearance altogether indicates vascular problem (-) pulse normal, but symptoms present down the arm indicates a compression of the brachial plexus TOS: occlusion of subclavian artery due to m. anterior scalene or cervical rib
Allen Maneuver Patient seated: (1) examiner finds radial pulse; (2) examiner laterally rotates & abducts pt's shoulder and flexes pt's elbow to 90°: arm should be in line w the frontal plane (3) pt laterally rotates head to opposite side DECREASED INTENSITY OF RADIAL PULSE (+) decrease in intensity of radial pulse or disappearance altogether indicates TOS TOS: occlusion of subclavian artery
Roos Test (EAST: Elevated Arm Stress Test) Patient standing: (1) examiner has pt abduct both arms and flex elbows to 90°: fingers point upward, elbows are slightly behind the frontal plane (2) examiner asks pt to open and close palms slowly for 3 minutes UNABLE TO FINISH TEST (+) pt gives up test in < 3 minutes due to sensation of ischemic pain, heaviness, numbness, tingling or profound weakness of the arm TOS
Wright Test Patient seated (or supine): (1) examiner finds radial pulse on test side; (2) examiner laterally rotates & abducts/flexes pt's shoulder to 180°: arm is straight overhead with elbow and arm in the frontal plane DECREASED INTENSITY OF RADIAL PULSE (+) decrease in intensity of radial pulse or disappearance altogether indicates TOS qualified by costoclavicular compression TOS: occlusion of subclavian artery due to m. pectoralis minor or cervical rib
Costoclavicular Syndrome (Military Brace) Test Patient seated: (1) examiner asks pt to extend both arms, so that hands rest on table behind their back (2) examiner finds both radial pulses (3) examiner asks pt to depress & adduct scapulas, looking for a change in pulse DECREASED INTENSITY OF RADIAL PULSE (+) decrease in intensity of radial pulse or disappearance altogether indicates TOS qualified by costoclavicular compression TOS/costoclavicular syndrome: occlusion of subclavian artery due to subluxation of the clavicle and/or first rib or cervical rib
Adam’s Position (Skyline View) Patient standing: (1) examiner observes pt's back, looking for assymetry along the spinal column (2) examiner asks pt to bend forward; examiner palpates along spinal column for any deviation; (3) examiner observes from behind, looking for hump on one side UNILATERAL HUMP (+) any assymetry while standing that presents as a unilateral hump after pt bends forward indicates structural scoliosis (-) any assymetry that goes away when the patient bends forward is a functional scoliosis Scoliosis (structural)
Slump (Sitting Dural Stretch) Test Patient seated: examiner.. (1) asks pt to "slump" such that pt's spine & shoulders flex (shoulders sag); examiner supports pt's chin & head in an erect position; (2) flexes pt's neck, holds head & shoulders down (3) extends pt's knee (4) dorsiflexes foot SCIATICA (+) if at any stage symptoms are reproduced, this indicates a lesion of the sciatic nerve at location where pain presents impingement of dura and spinal cord or nerve roots
Mazion's (Dugas') Test Patient seated or standing: (1) examiner has pt cross palm of affected side over to the opposite shoulder (2) examiner then asks patient to lower the elbow to the chest SHOULDER PAIN (+) pain and inability to lower the elbow to the chest indicates an anterior dislocation of the GH joint (-) inability to initiate raising arm to other side indicates a neck pathology, i.e., nerve root lesion anterior dislocation of the glenohumeral (GH) joint, nerve root lesion or acromioclavicular joint pathology
Apprehension (Crank) Test for Anterior Shoulder Dislocation Patient supine: (1) examiner flexes pt's elbow & abducts pt's shoulder to 90°; (2) examiner slowly moves the shoulder into lateral rotation (hand is cranked back toward table; forearm moved into the frontal plane. LOOK OF APPREHENSION (+) if patient has an expression of alarm or there is resistance to any further motion, shoulder pathology is indicated GH anterior instability, subluxation, dislocation
Relocation Test (Jobe’s Relocation) Patient supine: (1) while performing an Apprehension Test, examiner applies a posterior translation stress to the head of the humerus with his palm, by bracing the front of the shoulder against the table RELIEF OF PAIN (+) decrease of pain indicates GH instability, w or w/out apprehension (+) no decrease in pain indicates primary impingement (+) decrease in posterior pain when doing this test posteriorly indicates posterior internal impingement GH instablity, subluxation or dislocation or impingement
Sulcus Sign Patient standing: (1) examiner grasps pt's forearm below the elbow and applies traction, pulling arm distally; repeat test on both sides (bilaterally) SULCUS SIGN (+) the apperance of a unilateral sulcus deformity / groove below the acromion process indicates laxity to the GH ligaments (-) bilateral sulcus sign is not as clinically significant as unilateral sign GH inferior instability or GH laxity
Clunk Test Patient supine: (1) examiner stands behind pt, places superior hand under humeral head; other hand gasps pt's humerus above elbow & flexes arm overhead; (2) pressure is applied beneath humeral head while laterally rotating humerus with other hand CLUNK or GRINDING SOUND (+) a clunk or grinding sound indicates a tear of the labrum (+) apprehension may indicate additional anterior instability labral tear
Spring Test Patient seated: (1) examiner applies downward pressure on pt's distal clavicle, while stabilizing the inferior angle of scapula with the other. PAIN or POPPING (+) w pressure, clavicle depresses at the AC joint, then pops back on release indicates AC instability (+) pain in the shoulder indicates possible AC instability acromioclavicular (AC) joint instability
Acromioclavicular Shear Test Patient seated: (1) examiner cups both hands over pt's deltoid, one on the clavicle, one on spine of scapula (2) examiner then squeezes heels of the hands together PAIN or ABNORMAL MOVEMENT (+) pain or movement at AC joint indicates AC joint pathology AC joint pathology: sprain or dislocation
Supraspinatus ("Empty Can" or Jobe) Test Patient seated: (1) Pt abducts arm/s to 90° w no rotation; examiner provides resistance; (2) resistance is repeated while pt medially rotates arms (thumbs down) and angles them forward to 30° in a scapular plane & laterally rotates arms (thumbs up) PAIN or WEAKNESS (+) pain or weakness in the shoulder indicates a tear to the supraspinatus tendon or muscle, or neuropathy of the suprascapular nerve supraspinatus tendonosis/itis: muscle or tendon tear, suprascapular nerve neuropathy
Drop-Arm (Codman's) Test Patient seated/standing: (1) examiner abducts pt's shoulder to 90° (180°), ask pt to slowly lower arm to side ARM DROPS or SEVERE PAIN (+) patient unable to return arm to the side slowly or has severe pain when attempting to do so indicates a tear in the rotator cuff comple xrotator cuff tear
Neer Impingement Test Patient seated: (1) examiner maximally medially rotates the pt's arm, then forcibly flexes/abducts the arm in the scapular plane to full elevation PAIN (+) sharp localized pain on the superior aspect of the shoulder, it indicates an overuse injury to m. supraspinatus and sometimes to the biceps tendon. (-) pain with lateral rotation indicates a pathology with the AC joint overuse injury of the m. supraspinatus or biceps tendon (long head)
Speed’s (Biceps or Straight-Arm) Test Patient seated: (1) with pt's forearm in supination, pt flexes shoulder to 45° with elbow fully extended. (2) examiner resists further flexion by patient PAIN (+) increased tenderness or pain in the bicepital groove indicates bicipital paratenonitis or tendinosis bicipital paratenonitis or tendinosis
Yergason’s Test Patient seated: (1) w arm stabilized against side (pt's thorax), pt flexes elbow to 90° and pronates forearm (2) holding pt's forearm, examiner resists supination and lateral rotation of pt's arm, while palpating biceps tendon at groove TENDON POPS OUT (+) bicipital tendon will be felt to pop out of the groove if the transverse humeral ligament is torn and can no longer hold in place (-) tenderness in the groove may indicate biciptal paratenonitis or tendinosis torn transverse (humeral) ligament
Ligamentous Instability Test for the Elbow Patient seated: (1) pt's arm is flexed to 45°, elbow is sl. flexed to 20°. Examiner cups elbow w one hand while stabilizing pt's forearm proximal to wrist w the other. (2) examiner applies medial (lateral) pressure on joint while palpating the MCL (LCL) EXCESSIVE MOVEMENT (+) excessive medial (lateral) deviation of elbow can indicate valgus (varus) instability; both indicate laxity of collateral ligament/s. medial (MCL) or lateral collateral ligament (LCL) sprain
Cozen's Test Patient seated: (1) pt makes a fist, pronates forearm, extends and radially deviates wrist; (2) examiner stabilizes pt's elbow w one thumb on the lateral epicondyle; while providing resistance w other hand to the pt's wrist flexion LATERAL ELBOW PAIN (+) sudden severe pain in the area of the lateral epicondyle of the humerus indicates lateral epicondylitis lateral epicondylitis
Mill's Test Patient seated: (1) examiner has pt pronate forearm, flex wrist and extend elbow. (2) with one hand stabilizing pt's shoulder, the examiner uses the other hand to try to extend the wrist against pt's resistance. LATERAL ELBOW PAIN (+) pain over lateral epicondyle of the humerus indicates lateral epicondylitis (-) this maneuver also puts stress on the radial nerve, which can mimic symptoms similar to those of tennis elbow lateral epicondylitis or compression of radial nerve
Extensor Digitorum Communis Test Patient seated: (1) examiner resists extension of the third digit of the hand, distal to the Proximal Interphalangeal (PIP) joint, stressing the extensor digitorum muscle and tendon LATERAL ELBOW PAIN (+) pain over lateral epicondyle of the humerus indicates lateral epicondylitis lateral epicondylitis
Golfer’s Elbow Test Patient seated: (1) pt extends elbow and flexes wrist (2) examiner stabilizes pt's elbow or shoulder (palpating the medial epicondyle) & grabs the pt's fist with his other hand. (3) examiner instructs pt to resist as examiner extends pt's wrist MEDIAL ELBOW PAIN (+) pain over the medial epicondyle of the humerus indicates medial epicondylitis medial epicondylitis
Tinel’s Sign for Ulnar Nerve Patient seated: (1) examiner taps ulnar nerve in the groove between the olecranon process and medial epicondyle (aka "funny bone") TINGLING (+) tingling sensation in ulnar distribution of forearm and hand distal to the point of compression of the nerve indicates regeneration of sensory fibers up to point of most distal abnormal sensation ulnar neuropathy
Ligamentous Instability Test for the Fingers Patient seated: (1) examiner stabilizes pt's finger with one hand proximal to joint tested (PIP or DIP joint); other hand grasps finger & applies a varus or valgus pressure distal to the PIP or DIP joint (2) test is repeated on involved hand (bilaterally) UNILATERAL LAXITY (+) excessive movement on involved side compared to uninvolved side indicates ligament laxity collateral ligament sprain or laxity
Thumb Grind Test Patient seated: (1) examiner stabilizes pt's hand with one hand and grasp thumb below the Metacar-pophalangeal (MCP) joint w other hand (2) examiner applies axial compression and rotation to MCP joint PAIN / GRINDING (+) pain and/or grinding in the joint indicates degenerative joint disease in the MCP or metacarpotrapezial joints degenerative joint disease (DJD) of metacarpalphalangeal (MCP) or trapeziometacarpal joints
Finkelstein Test Patient seated: (1) pt makes a fist around their thumb (2) examiner stabilizes forearm and ulnar deviates the pt's wrist [optionally: patient actively deviates both wrists same time] UNILATERAL PAIN (+) asymmetric discomfort or pain over m. abductor pollicus longus and m. extensor pollucis brevis at wrist indicates paratenonitis of these two tendons de Quervain's Syndrome (paratenonitis) or stenosing tenosynovitis of the thumb
Phalen’s (Wrist Flexion) Test Patient seated: (1) pt places the dorsum of both hands together with forearms paralell to the floor, and fingers pointing down; hold 1 minute TINGLING / PARASTHESIA (+) tingling or parasthesia into thumb, index, middle and lateral half of ring finger indicates CTS carpal tunnel syndrome (CTS) or Median nerve neuropathy
Reverse Phalen’s (Prayer) Test Patient seated: (1) pt places the palms of both hands together with forearms paralell to the floor, and fingers pointing to the ceiling; hold for 1 minute TINGLING / PARASTHESIA (+) tingling or parasthesia into thumb, index, middle and lateral half of ring finger indicates CTS carpal tunnel syndrome (CTS) or Median nerve neuropathy
Carpal Compression Test Patient seated: (1) Examiner holds supinated wrist in both hands and applies direct, even pressure over the median nerve in the carpal tunnel for up to 30 seconds TINGLING / PARASTHESIA (+) tingling or parasthesia into thumb, index, middle and lateral half of ring finger indicates CTS carpal tunnel syndrome (CTS) or Median nerve neuropathy
Pinch Test Patient seated: (1) examiner asks pt to pinch the tips of the index finger and thumb together, like an "ok" sign PULP-TO-PULP (+) patient's inability to pinch tip-to-tip (instead has abnormal pulp-to-pulp pinch) indicates possible entrapment of anterior interosseous nerve, such that m. flexor pollicis longus and m. flexor digitorum profundis have resulting weakness entrapment of the anterior interosseous nerve (branch of median nerve) as it passes between the two heads of the m. pronator teres
Foraminal Compression (Spurling’s) Test Patient seated: (1) w pt's head in neutral, examiner carefully presses down w clasped hands for 2 seconds; (2) examiner repeats pressure w pt's head in extention, and rotation to each side NECK PAIN (+) pain radiating into arm along dermatomes, toward side that head is flexed indicates pressure on a nerve root. (-) non-radiating pain indicates facet pathology. (-) pain on opposite side indicates muscle spasm & is called "Reverse Spurling's" intervertebral foramen encroachment (IVFE), nerve root lesion: disc herniation, facet pathology, stenosis; differentiate by dermatome
Jackson Compression Test Patient seated: (1) examiner places pt's head in lateral flexion to unaffected side, then carefully presses straight down on the head with clasped hands ~ 2 seconds; (1a) repeat on affected side (bilaterally). NECK PAIN (+) pain radiating into arm along the dermatomes indicates nerve root lesion IVFE, nerve root lesion: disc herniation, facet pathology, stenosis; differentiate by dermatome
Created by: kellyjelly