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ASSESSMENT

PELVIS

PASSIVE MOVEMENTS • no true passive movements but provoking or stress tests

• goal: look for reproduction of patient` s symptoms!!!!

LIMB LENGTH TEST

Leg length test:

• perform if you expect SI joint lesion

• usually if iliac bone on one side is lower the leg on that side is longer (????page 590)

• supine position

• SIASs level

• Distance SIAS to med or lat malleolus

• Normal difference 1 – 1, 3cm

Functional test:

• Patient standing relaxed

• palpate SIASs and SIPSs, note differences

Sign of buttock test:

• supine

• passive unilat straight leg raising

• if resistance: flex knee while holding thigh in same position

• if u can go further: hamstring, or lumbar spine problem

• if u cannot: patho of buttock, e.g. bursitis, tumor, abscess

Trendlenburg` s sign :

• stand or balance on one leg

• pelvis on nonstance leg raises : neg

• palvis drops : positive

Functional Hamstring Length

• sit on table with knees flexed to 90°

• spine neutral

• sit behind p and palpate SIPS with one thumb, other parallel on sacrum

• patient asked to extend knee

• normally possible without post pelvic rot or flex lumbar spine

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• tight hamstrings would cause pelvis post rot or spine flex

Thoracolumbar fascia length

• patient sitting on table, knees 90° flexed

• PT stands behind patient

• Patient asked to rot left and right fully

• Note ROM

• Patient then asked to flex forward arms to 90°

• To lat rot, add arms, so little fingers touch each other

• Holding this rot left and right

• Restricted ROM: fascia or lat dorsi are tight

Straight leg raise test

....

JOINT PLAY – SEE MODULE 1!!

Swing = if movement is taking place the angle changes

REFLEXES AND CUTANEOUS DISTRIBUTION

• after special test

• WHEN?:

If examiner is unsure wheather there is neurological involvement

Can be diminution (hyporeflexia) or loss (arereflexia) of stretch reflex

Upper motor neuron lesions: spasticity, hyperreflexia, hypertonicity, extensor plantar

responses, reduced or absent superficial reflexes, weakness of distal muscle

Lower motor neuron lesion: involve nerve roots, peripherial nerve produce findings of flaccidity

• WHY? / AIM:

To find out if there is neurolog. Involvement

Test reflexes and sensation (s.b.)

Deep tendon reflexes are performed to test the tegrity of spinal reflex

• HOW? / DEMANDS:

1) deep tendon reflexes:

• muscle and patient must be relaxed

• tendon put into light stretch

• drop reflex hammer 5-6 time onto tendon to uncover any fading reflex response

3

• if difficult to elicit: patient asked to clench teeth or squeeze hands together (Jendrassik

maneuver) when testing lower limb – the legs, when testing upper limb

• à increase facilitative activity of spinal cord and accentuate minimally active reflexes

2) superficial reflexes:

• stroking skin with sharp object

• REFLEX • NORMAL RESPONSE • CENTRAL NERVOUS

SYSTEM SEGMENT

• Upper abdominal • Umbilicus moves up and

towards area being stroked

• T7 – T9

• Lower abdominal • Umbilicus moves down and

toward area being stroked

• T11 – T12

• Cremasteric • Scrotum elevates • T12 – L1

• Plantar • Flexion of toes • S1 – S2

• Gluteal • Skin tenses in gluteal area • L4 – L5; S1 – S3

• Anal • Contraction of anal

sphincter muscles

• S2 – S4

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3) pathological reflexes

• indicate upper motor neuron lesions if present on both sides

• indicate lower motor neuron lesions if present on one side

• Hyporeflexia or areflexia indicates lesion of peripheral nerve or spinal nerve roots

• Hyporeflexia or areflexia can be seen in absence of muscle weakness or atrophy because of

involvement of efferent loop

• Hyperreflexia indicates upper motor neuron lesion

• If cervical enlargement is involved some reflexes are exaggerated, some decreased

SENSORY SCANNING EXAMINATION

WHEN?:

• same time as reflex tests

WHY? / AIM:

• to check cutaneous distribution of various peripheral nerves and dermatomes around joint being

examined

• determine the extent of sensory loss

• determine whether loss is caused by nerve root lesions, peripheral nerve lesions or compressive

tunnel syndromes

• determine degree of functional impairment

HOW?:

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• Examiner must be able to differentiate between sensory loss involving a nerve root

(dermatome!) or a peripheral nerve!

• Quick scan: examiner runs relaxed hand over skin to be tested bilaterally; ask patient whether

there are any differencesin sensation

• Patients eyes may be open

• If there is difference: detailed sensory assessment:

• Distal and proximal sensitivities should be compared

• Patient`s eyes closed

• WHY? / AIM?: to mark out or delinate specific area of altered sensation

• !! altered sensation does not necessary come from the indicated nerve root or peripheral nerve

• à referred pain may come from any structur supplied by that nerve root

• HOW?:

• Superficial tactile sensation:

Tasted with wisp of cotton, soft hairbrush,..

Light tapping with at least 2 sec elapsed between each stimulus to avoid summation

Tested: group II afferent fibres

• Sensitivity to temperature ( lat. Spinothalamic tract)

Tested: group III fibres

2 test tubes: cold, warm water

normal response doesnt mean normal temperature sensation

à p. can distinguish between hot and cold but not between different degrees of hot and cold

• Deep pressure pain:

Tested: group II Aß fibres

Squeezing achilles tendon, trapezius, web space between thumb and index fingers

• Proprioception and motion:

Tested: group I and II fibres

Patient`s fingers or toes passively moved and p. asked to indicate direction of movement

à important: test digit grasped between thumb and index finger to ensure that pressure on

p. skin cannot be used as clue to direction

• Cortical and discriminatory sensations:

Tested: stereognostic function ( identification of familiar obj. In hand)

Recognition of letters or numbers written with finger on skin: also tests integrity of dorsal

column and lemniscal systems

JOINT PLAY ( ACCESSORY )MOVEMENTS • Definition: small ROM that can be obtained only passively by examiner

• Joint dysfunction signifies a loss of joint play movements

• Normally less than 4 mm in any one direction

• May be similar to passive movements

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• WHEN?:

• if there are capsular patterns

• WHY / AIM?:

• ???

• HOW / DEMANDS:

• 1) patient should be relaxed and fully supported

• 2) examiner should be relaxed and should use a firm but confortable grasp

• 3) one joint should be examined at a time

• 4) one movement should be examined at a time

• 5) the unaffected side should be tested first

• 6) one articular surface is stabilized while the other is moved

• 7) movements must be normal and not forced

• 8) movements should not cause undue discomfort

LOOSE PACKED (RESTING) POSITION

When / why?:

• joint s.t. in this position

• joint under least amount of stress

• position in which capsule has greatest capacity

• minimal congruency between articular surfaces and joint capsule with ligg.

• Advantage: joint surface contact area reduced and always changing to decrease friction

and erosion in the joints

• Position also provides proper joint lubrication and allows spin, slide and rolling

JOINT POSITION

Facet (spine) Midway between flexion and extension

Temporomandibular Mouth slightly open

Glenohumeral 55° abduction, 30° horizontal adduction

Acromioclavicular Arm resting by side in normal physiolog.

Position

Sternoclavicular Arm resting by side in normal physiolog.

Position

Ulnohumeral (elbow) 70° flexion, 10° supination

Radiohumeral Full extension, full supination

Proximal radioulnar 70°flexion; 35° supination

Distal radioulnar 10° supination

Radiocarpal (wrist) Neutral with slight ulnar deviation

Carpometacarpal Midway: abduction – adduction, flex – extension

Metacarpophalangeal Slight flexion

Interphalangeal Slight flexion

Hip 30° flexion, 30° adduction, slight lat rotation

Knee 25° flexion

Talocrural (ankle) 10° plantar flexion,. Midway: max inversion –

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exversion

Subtalar Midway: extremes of ROM

Midtarsal Midway extremes of ROM

Tarsometatarsal Midway: extremes ROM

Metatarsophalangeal Neutral

Interphalangeal Slight flexion

CLOSE PACKED ( SYNARTHRODIAL) POSITION

When / Why ?: used to stabilize the joint if an adjacent joint is being treated

• Should be avoided as much as possible : joint surfaces under max tension

• Two joint surfaces fit together

• Ligg and capsule max tight

• Cannot be achieved if joint is swollen

• No accessory movement possible

JOINT POSITION

Facet ( spine) Extension

Temporomandibular Clenched teeth

Glenohumeral Abduction and lat. Rotation

Acromioclavicular Arm abduction 90 °

Sternoclavicular Max shoulder elevation

Ulnohumeral (elbow) Extension

Radiohumeral Elbow flexed 90° ; forearm supinated 5°

Proximal radioulnar 5° supination

Distal radioulnar 5° supination

Radiocarpal (wrist) Extension with radial deviation

Metacarpophalangeal ( fingers) Full flexion

Metacarpophalangeal ( thumb) Full opposition

Interphalangeal Full extension

Hip Full extension, med rotation

Knee Full extension, lat rotation of tibia

Talocrural (ankle) Max dorsiflexion

Subtalar Supination

Midtarsal Supination

Tarsometatarsal Supination

Metatarsophalangeal Full extension

Interphalangeal Full extension

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PALPATION

WHEN?:

Only after tissue at fault has been identified

WHY / AIM? :

Palpation for tenderness used to determine the exact extent of lesion within that tissue

Only if tissue lies superficial and within easy reach of fingers

HOW?!

1) discriminate differences in tissue tension and muscle tone:

spasticity,

collapse of muscletone during testing,

rigidity = involuntary resistance during passive movement without collapse

flaccidity = no muscle tone

2) differences in tissue texture

direction of fibres

presence of fibrous bands

3) shapes, structures, tissue types

4) tissue thickness, texture

pliable, soft, resilient

edema

swelling: à comes on soon after injury à blood

à comes on after 8 – 24 hours à synovial

à boggy, spongy feeling à synovial

à harder, tense feeling within warmth à blood

à taugh, dry à callus

à leathery thickening àchronic

à soft, fluctuating à acute

à hard à bone

à thick, slow – moving à pitting edema

5) joint tenderness by applying firm pressure to joint

6) variations in temperature

7) tremors,

fasciculations => contraction of number of muscles innervated by a single motor axon

pulses:

ARTERY LOCATION

Carotid Anterior m. sternocleidomastoideus

Brachial Med. of arm midway shoulder – elbow

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Radial Wrist lat m. flex. Carpi radialis tendon

Ulnar Wrist between m.flex. digitorum

superficialis and flex. Carpi ulnaris tendons

Femoral Femoral triangle: sartorius, add. Longus, lig.

Inguinale

Popliteal Post aspect of knee, deep and hard to

palpate

Post. Tibial Post aspect of med. malleolus

Dorsalis pedis Between first and sec metatarsal bones

superior

8) pathological state of tissue in and surround joint

thickening

tenderness

9) dryness, excessive moisture of skin

gouty joints tend to be dry

septic joints tend to be moisty

10) abnormal sensation:

dysesthesia (diminished sensation)

hyperesthesia ( increased sensation)

anesthesia ( absence of sensation)

crepitus

loud, snapping, pain free noises of tendons usually caused by cavitation in which gas bubbles form

suddenly and transiently owing to negative pressure in joint!