Physical Examination of the Spesific Joints

1. Physical Examination of the Spesific Joints

2. Neck • The clinical examination begins with broadly observing the patient's gait and head and neck posture. • Further palpation, range of motion testing, and neurologic signs, including motor signs, reflexes, sensory signs, autonomic signs, and articular signs, are assessed • Posteriorly and posterolaterally, the occiput, inion, superior nuchal line, mastoid processes, and spinous processes of C2 and C7-T1 are palpable.

3. Range of motion examination may reveal pain or limitations in flexion-extension, lateral bending, and rotation. • Sensation testing for light touch, pin prick, temperature, and proprioception should be performed. • These tests are subjective, and both upper extremities should be compared to assess differences in sensation.

4. Dermatomally, C1 and C2 innervate the occiput region; C3 and C4, the nape of the neck; C5, the deltoid region; C6, the radial aspect of the forearm; C7, the long finger; C8, the ulnar border of the hand; and T1, the medial border of the arm • Motor function should be graded using the standard 0-to-5 nomenclature • A cursory examination can be performed assessing C5 with elbow flexion, C6 with wrist extension, C7 with elbow extensors or wrist flexion, C8 with finger flexion of the middle finger, and T1 with finger abduction of the fifth finger • Deep tendon stretch reflexes should be performed and graded 0 to 3 with 0 being no response, 1 being hyporeflexive, 2 being normal, and 3 being hyperreflexive. C5 is tested by striking the biceps tendon; C6, brachioradialis; C7, triceps

5. Provocative tests that can be helpful in confirming compressive extradural monoradiculopathy include • Spurling's test • The axial compression test • Adson Test • Provocative tests that are helpful in diagnosing myelopathy : • Hoffmann's sign • Lhermitte's sign

6. Shoulder • Contour and symmetry • Spinatus muscle atrophy • scapular winging • Range of motion • scapulothoracic motion • glenohumeral motion. • Palpation of the biceps tendon, coracoid, lesser and greater tuberosities, and posterior cuff is done, and any tenderness is gauged.

7. Examination • Inspection: • Posture • Deformity • Swelling • Atrophy • Skin lesions • Palpation • ROM: • Flexion-abduction: 180 • Adduction, external rotation, extension:45, internal rotation: 55 • Scapular movements: elevation, depresion, rotation, protraction • Neurologic examination • Muscle strength • Sensory: c4-c5-t1-t2 Special tests

10. resim • impingement sign • Speed's test • Yergason's sign • Apprehension test • Drop arm test

11. ELBOW • The elbow joint is composed of three bony articulations. The principal articulation is the humeroulnar joint. • The radiohumeral and proximal radioulnar articulations allow rotation of the forearm. • examine the skin: psoriatic plaques, rheumatoid nodules, or tophi. • palpate the olecranon bursa to exclude the presence of small nodules or tophi. • Synovitis or effusion generally results in limitation of elbow extension. • In lateral epicondylitis, discomfort can be elicited by resisted supination of the forearm or resisted extension of the pronated wrist. In medial epicondylitis, discomfort can be elicited by resisted flexion of the supinated wrist.

12. WRIST • Movements of the wrist include flexion (palmar flexion), extension (dorsiflexion), radial deviation, ulnar deviation, and circumduction. • Pronation and supination of the hand and forearm occur primarily at the proximal and distal radioulnar joints. • The wrist normally can be extended to 70 to 80 degrees and flexed to 80 to 90 degrees. Ulnar and radial deviation should allow 50 degrees (ulnar) and 20 to 30 degrees (radial) of movement.

13. Positive table tab test • The Finkelstein test

14. Dactylitis and sausage digit • Swan neck deformity • Boutonnière deformity • Telescoping or shortening of the digits

15. A mallet finger • Bony hypertrophy: Heberden nodes, Bouchard nodes.

16. LOMBER SPINE Anterior Elements: – Vertebral body: provide bulk and height; Sustain compression loads. • Middle Elements: – Pedicles: transfer forces from posterior to anterior elements. • Posterior Elements: – Articular processes and facet jts, laminae, spinous processes. – Lock spine to prevent forward sliding and twisting; Insertion sites for muscle.

17. 3 JointComplex: • – Intervertebraldisc: principaljointbetween vertebrae • – 2 FacetJoints: formedbysuperiorandinferior articularprocesses • Discconsists of: – Nucleuspolposus – Annulusfibrosis

18. 3 major groups: – Psoas major and minor: provide hip flexion. – Quadratus lumborum: assists lateral flexion. – Paraspinous muscles (erector spinae): control flexion,extension and twist. • Multifidus • Interspinalis • Iliocostalis

19. Interspinous Ligament: connects spinous process. • Ligamenum Flavum: connects laminae; roof for spinal canal. • Ant / Post longitudinal ligaments: cover vertebral body for stability.

20. Inspection Inspect back for symmetry; – List, scoliosis or other deformity. – Redness (infx), Lipoma or hair growth (spina bifida). From the side, observe lumber lordosis. Check pelvic obliquity: – Line between PSIS should be parallel to floor. Affected by leg length or scoliosis. Ask patient to point to area of maximal pain.

21. Palpation • Spinous processes and ligaments: – Feel for step-off at L4-L5-S1 (spondylolisthesis). – Tender with ligament sprains, fracture, etc. • Facet joints: deep and lateral to processes; Tender with OA • Paraspinous muscles: for tenderness or spasm. • Top of Iliac crests at L4-L5 disc space; Follow around to PSIS: – Sacroiliac joints: below and lateral to PSIS. – Sciatic notch: mid way btw PSIS and ischial tuberosity; Aggravates sciatica.

22. Range of Motion • Forward flexion (80-90o): – Loads discs and stretches sciatic nerve; More likely to increase disc pain. – Observe from behind bending forward for asymmetry, suggestive of scoliosis. • Extension(20-30o): more likely to increase pain from facets or spinal stenosis. • Lateral bending (20-30o): loads muscle and discs. • Twisting (30-40o): loads muscle.

23. Neuro: Strength Testing • Resisted hip flexion (iliopsoas muscle) tests L1 and L2. • Resisted knee extension (quad muscle) tests L3. • Resisted ankle dorsiflexion tests L4. • Resisted dorsiflexion of great toe tests L5. • Resisted ankle plantarflexion test S1. • S2-4 supply bladder and anal sphincter.

24. Neuro: Strength Testing • Heel walking –Ankle dorsiflexors (Tibialis anterior) – L4. • Toe walking –Gastroc-soleus muscle group. – L5 and S1. Neuro: Sensory Testing • Check light touch and sharp/dull. – L4: medial leg and ankle. – L5: dorsum of foot. –S1: lateral ankle and foot

25. Neuro: DTR’s and Clonus • Deep tendon reflexes –Knee jerk: L4. – Ankle jerk: S1. • Ankle clonus –Check if DTR’s excessively brisk. –Elicit with sudden ankle dorsiflexion. –Suggests upper motor neuron lesion

26. Nerve Tension Tests • Test for nerve root compression. • Key nerves for lumbar and sacral roots: – Femoral nerve (L2, L3, L4) runs down antero-medial thigh. – Sciatic nerve (L4, L5, S1,S2, S3) runs down posterior thigh. Straight Leg Raise (SLR) • With patient supine or sitting, flex hip and extend knee. – Note angle at which pain or tightness occurs (normal 70-90o). – Pain radiating past knee suggests sciatica and lesion at L5 or S1 roots. – Dorsiflexion of ankle increases sciatic tension and pain (Lasegue’s test). – Plantar flexion of ankle or flexion of knee relieves sciatic tension and pain

27. Femoral Nerve Stretch Test • Used to assess compression at L2-3-4 nerves roots. • With patient prone on exam table and knee flexed, extend hip by lifting thigh off table. – Positive with high lumbar disc herniation. – Reproduces radicular pain to anterior thigh.

28. Other Tests for Disc Herniation • Crossed SLR Test: pain radiating down opposite leg highly suggestive of HNP. • Valsalva Maneuver: – increases intrathecal pressure – Aggravates pain caused by pressure on cord or roots (HNP, tumor, etc).

29. HIP • The principal hip flexor is the iliopsoas • Hip adduction: adductors (longus, brevis, and magnus) • The gluteus medius is the major hip abductor, the gluteus maximus and hamstrings extend the hip. • There are several clinically important bursae around the hip joint. • stance and gait: the anterior iliac spines are visible. Pelvic tilt or obliquity structural scoliosis, anatomic leg-length discrepancy, or hip disease. • resim

30. Antalgic (limping) gait • Trendelenburg gait • Trendelenburg test

31. The motion of the hip should be assessed with the patient in the supine position. The range of motion of the hip includes flexion (120), extension, abduction (45), adduction (20-30), internal and external rotation (40-45). • The Thomas test

32. The Patrick test or FABERE maneuver (FABERE —flexion, abduction, external rotation, and extension.)

33. Measurement for leg-length discrepancy: anterior superior iliac spine

34. KNEE • Examination of the knees should always include observation of the patient while standing and walking. • Deviation of the knees, including genu varum, genu valgum and genu recurvatum, • Inspection: asymmetry that may be caused by swelling or muscle atrophy, Patellar alignment, Baker cyst

35. Palpation of the knee: • Swelling, thickening, nodules, loose bodies, tenderness, and warmth should be noted. • Bulge sign (patellar schock)

36. Apprehension test

37. The normal knee range of motion should be from full extension (0 degrees) to full flexion of 120 to 150 degrees. • Ligamentous instability is tested by applying valgus and varus stress to the knee and by using the drawer test. • The abduction or valgus test: • The adduction or varus test

38. Lachman test • A posterior drawer test • Mcmurray test • Apley test

39. ANKLE • 20 degrees of dorsiflexion and about 45 degrees of plantar flexion. • Inversion and eversion of the foot occur mainly at the subtalar and other intertarsal joints. • 20 degrees of eversion • 30 degrees of inversion

40. A general assessment of muscular strength of the ankle can be obtained by asking the patient to walk on toes and on heels. • The principal flexors of the ankle are the gastrocnemius (nerve roots S1 and S2) and the soleus (S1 and S2) muscles. • The principal extensor (dorsiflexors) of the ankle is the tibialis anterior muscle (L4, L5, and S1). The tibialis posterior muscle (L5 and S1) is the principal inverter. To test the tibialis posterior muscle, the foot should be in plantar flexion. • The principal everters of the foot are the peroneus longus (L4, L5, and S1) and peroneus brevis (L4, L5, and S1) muscles. • asymmetry, hypertrophy, or atrophy. The distribution of the atrophy should be noted because this may indicate the underlying cause. • Muscle tone