Advanced Physical Assessment
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| Risk factors for osteoporosis | women over age 50, diabetes, thyrotoxicosis, steroids, other meds, use dexa scan to screen Osteoporosis: T score < – 2.5 Osteopenia: T score between – 1.0 and – 2.5
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| To treat osteoporosis | calcium and vitamin D
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| The special exam maneuvers for different joints should be performed on | both the right and left limbs to determine what is normal for the patient
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| Assess the 4 signs of inflammation | swelling, warmth, redness, tenderness
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| Crepitus | osteoarthritis
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| Musculoskeletal strength | grades 0-5, look for the middle which is 3- Can move joint against gravity but not against resistance
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| Barlow-Ortolani maneuver to detect hip | dislocation or subluxation should be performed each time you examine the infant during the first year of life
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| Allis sign to detect hip dislocation: | when one knee appears lower than the other, the Allis sign is positive- Examination for the Allis sign. Unequal upper leg length would indicate a positive sign
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| Shoulder has 3 joints | sternoclavicular joint, acromioclavicular joint and glenohumeral joint
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| Shoulder girdle is supported by the | muscles of the rotator cuff- SITS- suprasoinatus, infrasoinatus, teres minor and subscapularis for support
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| Knock-knees | genu valgum
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| Bowlegs | genu varum
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| Evaluate rising from seated position-The “W” or reverse tailor position | is commonly seen in children with in-toeing associated with femoral anteversion
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| Abduction for the shoulder | the deltoid
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| TMJ | asymmetry, swelling of joints, inflammation, dislocation, crepitus, The masseters: externally at the angle of the mandible, The temporals: externally, during clenching/ relaxation of jaw, The pterygoids: internally, between tonsillar pillars & mandible
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| TMJ arthritis/ dislocation/ and syndrome | swelling, tenderness & ↓ROM, also trauma and pain & tenderness with palpation respectively
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| The shoulder is made of 3 joints > shoulder girdle | The sternoclavicular (SC) joint, The acromioclavicular (AC) joint, and the The glenohumeral (GH) joint→ shoulder girdle →
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| The Shoulder Girdle: The muscles of the rotator cuff (SITS) | Supraspinatus, Infraspinatus, Teres minor, and Subscapularis→responsible for stability the head of the humerus in the glenoid fossa, but they also contribute to some movements of the shoulder.
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| Adduction for the shoulder | PECTORALIS MAJOR, teres major and latissimus tori
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| The deltoid muscle is key for maintaining shoulder | abduction but relies on the supraspinatus muscle to initiate abduction.
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| Adduction of the shoulder is mediated by the | pectoralis major, teres major, and the latissimus dorsi.
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| The subscapularis internally rotates (AKA medially rotates) the | humerus, while the infraspinatus and teres minor externally rotate (laterally rotate) the humerus.
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| Contraction of the posterior deltoid and latissimus dorsi results in | extension, while the anterior deltoid, pectoralis major, coracobrachialis, and biceps mediate flexion.
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| 5 maneuvers to assess the SITS/rotator cuff d/o | 1) painful arc test, 3) strength tests (internal/external lag test) and drop arm test, 1) external rotation resistance test
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| Test Painful arc test | provoke pain- abduct arm from 0-180 and if there’s pain from 60-120
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| Painful arc test | Fully abduct the patient’s arm from 0∘ to 180∘- Shoulder pain from 60∘ to 120∘ is a + test for the following disorders: subacromial impingement* & rotator cuff tendinitis.
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| Impingement | tendon is trapped between 2 moving bones
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| Ten things can go wrong with the shoulder | Gleno-humeral joint dislocation, Degenerative cervical disc, Impingement syndrome: THE MOST COMMON CAUSE, Calcific tendinitis, bicipital tendinitis, Tears/Inflammation of the rotator cuff
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| Gleno-humeral joint dislocation (Anterior dislocation of the humerus) | is a cause of acute severe shoulder pain and limited range of motion- Could be traumatic or habitual (due to Multidirectional instability), Frozen shoulder (Adhesive capsulitis), Frozen shoulder (Adhesive capsulitis), Septic Shoulder, angina
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| Degenerative cervical disc | disc will press on cervical nerve 5th, 6th and 7th root
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| Calcific tendinitis | Calcification and degeneration of a rotator cuff tendon (most commonly the supraspinatus), X-ray,Diabetes and hypothyroidism increase the risk
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| Bicipital tendinitis | The tendon of the long head of the biceps passes into the shoulder joint through the bicipital groove- is the usual site of bicipital tendinitis- just cut it
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| What is the best test for rotator cuff? | MRI
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| Anatomical position | pinky to thigh- ulna, radius goes with thumb
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| Tenderness: distal to the epicondyle is common | in lateral epicondylitis (tennis elbow) and less common in medial epicondylitis (tennis/golfer’s elbow)
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| 5 causes of elbow pain | 1) Olecranon bursitis (trauma, gout, RA)- separate from->septic arthritis hurts more, 2) SQ rheumatoid nodules near ulna, 3) arthritis (OA, RA or septic), 4)cubital tunnel syndrome (Tinel’s sign), 5)epicondilytis/lateral or medial
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| Cubital tunnel syndrome | ulnal nerve, medial side of the elbow- tinel’s sign (funny bone)-Numbness and tingling of the ring and small fingers, particularly at night – keeping the elbow flexed long time causes this
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| Lateral epicondylitis | tennis elbow-repetitive extension of the wrist or pronation/supination of the forearm-Pain on the outside elbow- grasping, or handshake make worse- Wrist extension against resistance increases pain
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| Medial epicondylitis | golfer’s elbow- inside- repetitive wrist flexion-Wrist flexion against resistance increases pain- Complications: Ulnar nerve neuropathy and/or palsy (long-term pressure/damage) Complains of numbness/tingling on the little finger and weakness of the hand.
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| Worse-case scenario of medial epicondylitis/ golfer’s elbow | is development of a permanent deformity called a “claw hand”
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| Scaphoid bone | can be missed in XR- needs to be repeated in a couple of weeks- painful and takes a long time to heal- sometimes doesn’t heal normal
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| MCP- metacarpal pharyngeal joints | RA loves
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| DIP | distal intralaryngeal joint- the tip- RA does not affect but OA with nodules (as well as PIP)
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| Carpal tunnel | medial nerve- runs under flexor retinaculum (connects radius and ulna) and when compressed numbs 3 fingers (thumb, pointer, middle, ½ ring) – atrophy of thenar eminence
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| OA nodes in hands | loss of cartilage and friction-new bone formation- Heberden nodes in DIP joints & Bouchard nodes in PIP joints
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| RA deformities in hands | Symmetric deformities in PIP, MCP, and wrist joints. Later, subluxation and ulnar deviation of MCP joints
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| Carpal tunnel syndrome | median nerve compression causes thenar atrophy (more common)
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| Ulnar nerve compression | leads to hypothenar atrophy (the side of your pinky)
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| Snuffbox Tenderness: | with the wrist in ulnar deviation and pain at the scaphoid tubercle are suggestive for occult scaphoid fx.
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| Anatomic snuffbox | hollow space distal to the radial styloid process; thumb extensor & abductor tendons
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| The MCPs are often boggy and tender | in RA but are rarely involved In OR
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| OA: Heberden nodes hard dorsolateral nodules on DIP ONLY in | OA and never affected in RA
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| Psoriatic arthritis | DIP joints are also involved
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| Test Sensation of hand, median, ulnar and radial | Median- thumb, pointer, index, ½ ring (↓carpal tunnel) Ulnar: 5th finger/pinky and ½ ring, Radial: web of thumb and index finger
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| Hand grip- Ask the patient to grasp your 2nd and 3rd fingers using the thumb side of hand d/t | 1) degenerative arthritis 2)epicondylitis 3) carpal tunnel syndrome 4) cervical radiculopathy- Grip weakness + wrist pain = de Quervain tenosynovitis
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| Thumb movement | (Finkelstein test)-grasp the thumb against the palm for an ulnar deviation of wrist- Pain= de Quervain tenosynovitis from inflammation of the abductor pollicis longus and extensor pollicis brevis tendons and tendon sheathe
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| Carpal tunnel compression testing for median nerve compression- none very good | (Durkan’s)- Most sensitive Pain/paresthesia in the median nerve after pressing for 30 sec. 2)thumb abduction, 3)Tinel sign 4)Phalen sign
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| Acute Rheumatoid arthritis | tender, painful, stiff joints, usually symmetric involvement on both sides of the bodyThe MCP, PIP, and wrist are commonly affected; (DIP much less commonly affected)
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| Chronic Rheumatoid arthritis | Swelling and thickening of MCP & PIP; (DIP much less commonly affected), Limited ROM with ulnar deviation of fingers, Swan neck deformity & boutonnière deformity & rheumatoid nodules
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| Osteoarthritis: (Degenerative joint disease) | Heberden nodes on the dorsolateral aspects of the DIP joints (hard& painless) and Bouchard nodes: on the PIP joints are less common; MCP joints are spared
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| Chronic Tophaceous Gout | Deformities in hand joints that mimic RA and OA; less symmetric than in RA- Knobby swellings around the joints ulcerate and discharge- white chalk-like urates
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| Dupuytren Contracture | Thickened band overlying the flexor tendons of the 4th (or 5th ) finger- Subsequently the skin puckers and a fibrotic cord develops between the palm & finger
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| Trigger Finger | Caused by a painless nodule in the flexor tendon of a finger in the palm. A palpable& audible snap is noticed on attempting extending/flexing the finger with extra effort/assistance. (watch, listen & palpate the nodule on ext./flex.)
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| Thenar Atrophy | Suggests a median nerve disorder as carpal tunnel syndrome
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| Ganglion | Cystic, round, usually nontender swellings along tendon sheathes or joint capsules, frequently at the dorsum of the wrist (but could happen anteriorly too). They can disappear spontaneously, or might need aspiration or excision
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| Acute tenosynovitis | Inflammation of the flexor tendon sheaths may follow local injury, overuse, or infections; tenderness& swelling along the course of the tendonThe finger is held in slight flexion, finger extension is very painful
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| De Quervain’s tenosynovitis | tenosynovitis of APL and EPB tendons- caused by repetitive grasping, turning/wringing motions (golfers, racquet sports)- also postpartum- pain,creaking w/movement of thumb & gripping or raising objects-may go up forearm or down the thumb. do Finkelstein
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| avulsion fracture | bone comes off by the tendon- yanks it off by force
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| Colle’s fracture left wrist | dinner fork deformity, pt fell on am- distal radius broken
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| Anatomy to know in the hip | Iliac crest, Iliac tubercle, Anterior superior iliac spine (muscles attached to it), Greater trochanter (covered by burssa- pain), Pubic tubercle, Posterior superior iliac spine, Greater trochanter, Ischial tuberosity, Sacroiliac joint
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| Iliopsoas | appendicitis
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| Stance phase | 60% weight bearing- most hip issues here
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| Swing phase | when walking- 40% walking cycle
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| Palpate the Bony Landmarks of the Hip | Anterior: Iliac crest, Iliac tubercle, Anterior superior iliac spine, Greater trochanter, Pubic tubercle, Posterior: Posterior superior iliac spine, Greater trochanter, Ischial tuberosity, Sacroiliac joint
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| Palpate the Inguinal Structures | inguinal ligament (Anterior superior iliac spine to Pubic tubercle) Lat. To Med NAVEL: Nerve- Artery- Vein- Empty space- Lymph node
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| Causes of groin tenderness are | synovitis of hip joint, arthritis, bursitis, or psoas abscess
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| Palpate the Trochanteric bursa | resting on one side and the hip flexed and internally rotated, palpate the trochanteric bursa, over the greater trochanter for tenderness of trochanteric bursitis
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| Palpate the Ischiogluteal bursa | For tenderness of ischiogluteal bursitis or “weaver’s bottom” from prolonged sitting
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| Specific Hip Joint Tests- Thomas Test | Is used to Detect flexion contractures of hip masked by excessive lumbar lordosis Lifting the extended leg off the examining table indicates hip flexion contracture in the extended leg
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| Trendelenburg Test | Detect weak hip abductor muscle When the iliac crest drops on the side of the lifted leg, the hip abductor muscles on the weight-bearing side are weak
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| FABER Test (AKA Patrick's test) | the heel of the leg is placed on the medial side of the extended opposite knee= flexing the hip and the knee (“figure 4”position).The flexed knee is slowly moved laterally to the table, which places the hip in Flexion, ABduction, and External Rotation
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| FABER Test (AKA Patrick's test) positive result | - Pain in the hip or low back, or limitation in ROM, suggests intra- articular hip lesions, iliopsoas pain, or sacroiliac disease (if pain is posterior)
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| FADIR Test | performed by Flexing the patient’s hip to 90 degrees, and then ADducting and Internally Rotating the hip. If the patient has hip or groin pain, the test is positive, suggesting FAI (femoracetabular impingement) or a tear of the hip labrum.
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| Greater Trochanteric bursitis | (MOST COMMON CAUSE HIP PAIN )Pain occurs laterally over hip just posterior to greater trochanteric bursa and radiate down the lateral leg to the foot mimicking sciatica- when they stand- improves with limited walking
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| Lumbar Spine Disorders | herniated lumbar disc may cause sharp or "lightning like" pain in the hip or buttocks due to pain radiation down the dermatome of the involved nerve root
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| Intra-abdominal pathology | Retroperitoneal bleeding may present with pain in the anterior thigh, also Inguinal hernias may present as hip pain, Aortoiliac occlusive disease (Leriche’s syndrome) may present as buttock, hip and thigh claudication
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| Septic hip | would present with inability to bear weight and severe acute pain that worsens with attempted hip ROM (range of motion), including with log roll.
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| 7 things to look for in the knee | 1. Medial meniscus 2. Lateral meniscus 3. Lateral collateral ligament 4. Medial collateral ligament 5. Anterior cruciate ligament 6. Posterior cruciate ligament 7. Patellar tendon
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| What do you look for in a knee exam | the gait- the knee should be extended when the heel strikes the ground and should be flexed at all other times- if they are “giving way”- could be quadriceps weakness
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| Swellings of the knee | Swelling over the patella occurs in prepatellar bursitis (housemaid’s knee). Swelling over the tibial tuberosity suggests infrapatellar bursitis
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| Medial & Lateral Menisci | medial more common- tenderness after trauma- palpated along the medial and lateral sides respectively- anterior/cruciate ligament injury cannot continue the game- meniscus can
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| Prepatellar bursitis | is triggered by excessive kneeling; in front of patella- housemaid bursitis
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| anserine buritis | from running, valgus knee deformity or OA. On lateral side
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| Baker cyst | from RA- on posterior side
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| Patellofemoral Pain Syndrome | diagnosed by any two of the following- pain with quadriceps contraction- pain with squatting- pain with palpation of the posteromedial/or lateral patellar border
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| Knee joint effusion testing- The bulge sign | (for minor effusions). A fluid wave or bulge on the medial side between the patella and the femur after a lateral tap is a positive test for effusion
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| The balloon sign:(for major effusions) | A palpable fluid wave is positive for effusion, or a palpable returning fluid wave into the suprapatellar pouch further confirms a major effusion
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| What is the test for meniscus injury | Mcmurray- click or pop is positive- McMurray Test:
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| A palpable click or pop along the medial joint line is a positive test for | a tear of the posterior portion of the medial meniscus. External rotation of the lower leg, stresses the medial meniscus. Internal rotation of the lower leg, stresses the lateral meniscus
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| Can you get back to the game with meniscus injury? | Yes but you have a serious injury
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| Testing the Posterior Cruciate Ligament* | Posterior Drawer Sign: If the proximal tibia falls back, this is a positive test for PCL injury-
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| Test question? Which test do you start with, the anterior or the posterior drawer? | posterior drawer- always exclude the PCL before the anterior cruciate ligament
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| Testing the Anterior Cruciate Ligament* | Anterior Drawer Sign: Better sensitivity and specificity in chronic ACL- Forward slide of proximal tibia is a positive sign in ACL tear- always test PCL 1st
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| Lachman Test | for ACL also- Significant forward excursion of the tibia is a sign of ACL tear (better in chronic cases)- always test PCL 1st
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| ACL injuries result from | knee hyperextension, direct blows to the knee, and twisting or landing on an extended hip or knee
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| Ottawa Knee Rules: Knee X-ray Indications, A knee x-ray is required for knee injury patients in any of the following FIVE conditions | 1) Age ≥ 55 years, 2) Isolated patella tenderness, 3)Tenderness at head of fibula, 4) Inability to flex knee 90∘, 5) inability to bear weight,(4 steps) immediately after injury and in the ED
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| Abnormalities of the knee- Degenerative Arthritis (Osteoarthritis) | after age 50; obesity, medial joint line tenderness, palpable osteophytes, bowleg appearance, suprapatellar bursae and joint effusion, also RA- Swelling, systemic involvement, SQ nodules
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| Abnormalities of the knee- bursitis | Inflammation and thickening of bursa seen in repetitive motion and overuse syndromes- prepatellar bursa (“housemaid’s knee”) or pes anserine bursa medially (runners)
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| Iliotibial band friction syndrome | the most common cause of lateral knee pain in long distance runners and bicyclists-friction of the iliotibial band on a bursa that overlies the lateral femoral condyle when the knee is repeatedly bent and straightened-tightness/ burning pain
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| Iliotibial band friction syndrome | Exam shows tenderness over the lateral femoral epicondyle, and the lateral knee pain is reproduced when the patient squats- runners/bicyclists
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| Chondromalacia (aka: Patellofemoral Syndrome) | Aggravation of ant knee pain during wt bearing w/the knee in flexion (stair climbing, arising from a sitting position) suggests chondromalacia of articular surface of the patella (AKA patellofemoral syndrome)- +grind - quadriceps are weak- young female
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| chondromalacia develops when the patella is | pulled off toward one side of knee by the quadriceps ms (associated w/ increased Q angle: the angle between a line drawn from anterior superior iliac spine (ASIS) to the middle of patella) or cartilage of posterior side of patella wears down d/t OA
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| J-sign | in chostochondritis- the patella tracks in the shape of a J, starting too far lateral when the knee is fully extended, and then “jumping” into the trochlear groove early in flexion
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| Which 2 menisus get injured the most? | the medial and anterior
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| How do we test for the posterior and the anterior? | posterior- the posterior drawer- for the anterior, the anterior drawer and lashman test
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| How do you test for meniscal tear? | mcmurray sign
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| Special tests for meniscal tear? | Thessaly Test, McMurray Test, Apley’s Test
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| Test question- Meniscal tear is r/t | Joint line tenderness is the most sensitive physical finding- Ask the patient to squat. Posterior knee pain with squatting is indicative of a possible meniscal tear
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| ACL tears commonly occur | with noncontact pivoting (twisting) injuries to the knee, popping sensation, severe pain, commonly produces a bloody knee effusion, Tense swelling during the immediate two-hours- cannot return to the game like meniscal tear
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| PCL tears occur | dashboard injury- a blow to the anterior- Swelling is prominent and occurs almost immediately-ligament is outside the knee joint, bleeding into the joint does not typically occur.
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| Baker cyst | on the back/popliteal surface – occurs in RA- complaints of aching or fullness behind the knee.
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| Septic Knee | an infection inside the knee joint that would present with inability to bear weight and severe acute painthat worsens with attempt
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