name the ranges of motion for the knee
Flexion 135
Extension 0
external rotation
internal rotation
name the bony landmarks for bony palpation for the knee
- patella
- medial tibial plateau
- tibial tubercle
- medial femoral condyle
- lateral tibial plateau
- Lateral femoral condyle
- fibula head
name the soft tissue palpation for the knee
- quadriceps muscle
- vastuc lateralis
- vastus medialis
- Vastus intermedius
- Rectus femoris - infrapatellar tendon
- bursae
- prepatellar
- superficial infrapatellar - Medial meniscus
- lateral meniscus
- Pes aserine
- Gracilis
- Sartorius
- semitendinosus - Popliteal fossa
- Lateral collateral ligament
- medial collateral ligament
- gastrocnemius muscle
McMurray Sign
Positive= Clicking sound or pain by knee joint
indicates= tear of medial meniscus if positive on external rotation
- tear of lateral meniscus if positive on internal rotation
the higher the leg is raised during extension when positive is elicited, the more posterior of the meniscal injury
Medial collateral test , aka abduction stress test aka valgus stress test
- positive = gapping and/or elicited pain above/at/or below joint line
- indicates= torn medial collateral ligament
lateral collateral test aka adduction stress test aka varus test
- positive= gapping and/or elicited pain above/ at/ or below the knee joint
indicates= torn lateral collateral ligament
Bounce home test
- positive= knee does not go into full extension (slight flexion remains)
- indicates = diffuse swelling of the knee, accumulation of fluid, due to possible torn meniscus
Drawer test
positive
- Gapping> 6mm tibia moves posterior when the leg is pushed
- Gapping > 6mm tibia moves anterior when the leg is pulled
indicates:
1. torn posterior cruciate ligament
2. torn anterior cruciate ligament
Lachman test
positive : Gapping with the tibia moving away from the femur
indicates: anterior cruciate ligament or posterior oblique ligament instability
Apprehension test for the patella
positive: apprehension, distress of facial expression, contraction of quadriceps to bring patella back on line
indicates: chronic patella dislocation or pre- disposition to dislocation
Patella Femoral Grinding test ( Clarke sign)
positive : retropatellar pain and the pt is unable to hold quadriceps contraction
indicates: degenerative changes of the patellar facets and/ or within the trochlear groove ( chondromalacia patella)
Patella Ballottment test
Positive: a floating sensation of the patella
indicates: a large amount of swelling in the knee
Apley compression test
positive= pattient points to side of pain
indicates= pain on medial side is medial meniscus tear.
pain on lateral side is lateral meniscus tear
Apely distraction test
Positive= pt will point to side of pain
indicates= pain on the medial side indicates medial collateral ligament tear, pain on the lateral side indicates lateral collateral ligament tear
say the verbals for the heart examination for pulsations
- check A.P.E.T.M.E areas for pulsations
- aortic
- pulmonic
- Erb’s point
- tricuspid
- Mitral — while at this location, check for an apical impulse for location and amplitude
- Epigastric Pulsations ( hand flat toward oft shoulder)
- pulsations coming from superior to inferior may be right ventricular enlargement
- pulsations coming inferior to superior (P-A) may indicate abdominal aortic aneurysm)
- Check A.P.E.T.M.E areas for thrills (ball of hand)
Thrills turbulent flow, causing palpable vibrations
- check same areas as before (A.P.E.T.M.E)ol,
Verbal the auscultation for high pitch sounds of the heart
Using the DIAPHRAGM
- aortic - right side at 2nd ICS at the right sterna border
- pulmonic : left side at 2nd ICS at the left sternal border
S2 is best heard at this location / listen for accentuated or diminished or splitting sounds
- Erb’s Point : left side 3rd ICS at the left sternal border listen for general cardiac sounds
- Tricuspid: left side 4th ICS at the left sternal border
listen for general cardiac sounds
- Mitral : left side 5th IS , mid-clavicular line
S1 is best heard at this location
listen for accentuated,dimished or splitting sounds
at the mitral area use the diaphragm and auscultate for S1 while palpating the carotid pulse to see for pairing - Epigastric: soft tissue inferior to tip of typhoid process listen for the presence of high pitched sounds
Verbal auscultation for low pitch heart sounds
using the bell
- Aortic: right side at 2nd ICS at right sternal border
- Pulmonic : Left side at 2nd ICS at the left sternal border , listen for accentuated, diminished or splitting of sounds
- Erb’s point Left side 3rd ICS at the left border
- Tricuspid : left 4th ICS
- Mitral Left side 5th ICS , mid - clavicular line
listen for accentuated, diminished or splitting of sounds - Epigastric: Soft tissue inferior to tip of typhoid process.. Have the patient take a deep breath in and hold … listen for bruits
state the special maneuver for mitral murmurs
- patient in left lateral recumbent position
- use the bell (low pitch) at apical impulse area
- ask pt to take a deep breath in and hold
State the special maneuver for Aortic murmurs
- pt in seated position
- listen at left sternal border ( Erb’s point) for best heard heart sounds using the diaphragm (high pitched)
- ask pt to take deep breath in and lean forward while exhaling all the air
Name the bony palpations for the foot and ankle
- calcaneus
- sustentaculum
- medial malleolus
- lateral malleolus
- talus
- navicular
- cunoid
- 3 cuneiforms
- 5 metatarsals
- metatarsalphalangeal joints
name the soft tissue palpation of the foot and ankle
- tibialis posterior tendon
- spring ligament
- tibialis anterior tendon
- deltoid ligament
- fibular/ peroneus brevis
- achilles tendon
- plantar aponeurosis
- anterior talofibular ligament
- posterior tibial artery
- dorsal tibial artery
name the ranges of motion for the ankle and foot
- ankle dorsiflexion 20
- ankle plantar flexion 50
- subtalar inversion 5
- subtalar eversion 5
- 1st MTP joint flexion
- 1st MTP joint extension
Drawer sign
positive = translation with the talus moving away from or toward the tibia
indicates
1. with the tibia being pushed/ foot pulled = tear/instability of the anterior talofibular ligament
2. with the tibia pulled/ foot pushed = a tear/ instability of posterior talofibular ligament
Ankle dorsiflexion test ( Hoppenfield)
Positive:
1. the foot cannot dorsiflex with knee extend, but is able to with knee flexed
2. the foot cannot dorsiflex in either knee position
Indicates:
1. contracture of the gastrocnemius muscle
2. contracture of the soles muscle
Rigid or supple feet test
Positive :
1. absence of medial longitudinal arch in both positions
2. presence of medial longitudinal arch while seated with a loss of medial longitudinal arch while standing
Indicates :
1. Rigid flat feet
2. Supple flat feet
Homans sign
Positive :
deep pain in the calf
indicates: deep vein thrombophlebitis
Thompson test
positive : absence of foot plantar flexion motion
Indicates: achilles tendon rupture
Morton Test
Positive: Sharp pain in the forefoot
Indicates: Metatarsalgia or neuroma ( usually at the 3rd and 4th metatarsal interspace )
range of motion for hip and pelvis
flaxion 120 extension 30 abduction 45 adduction 45 internal rotation 45 external rotation 45 flexion, adduction flexion,abduction and external rotation
range of motion for lumbar
flexion 25 extension 30 left lateral bending 25 right lateral bending left rotation 30 right rotation 30
Hoover sign
Positive : lack of counter- pressure on the healthy side
Indicates : lack of organic basis for paralysis (Malingering/hysteria) with organic hemiplagia, the patient will still exert downward pressure when attempting to raise paralyzed leg
Straight leg raiser (SLR)
Positive: Radiating pain and/or dull posterior thigh pain
Indicates : sciatic radiculopathy or thigh hamstrings
Positive between 35-70 degrees= possible discogenic sciatic radiculopathy
> 70 degrees = tight hamstrings
Goldthwaith sign
Positive: localized pain, low back or radiating pain down the leg
indicates: Lumbo-sacral or scaroiliac pathology . Pain occurring after the lumbar spinouses move= possible limbo-sacral problem ….. pain occurring before the lumbars move= possible sacroiliac problem
braggard sign
Positive: radiating pain in posterior thigh
indicates: Sciatic radiculopathy
Buckling Sign
Positive: Pain in the posterior thigh with sudden knee flexion (buckle)
Indicates: Sciatic radiculopathy
Bowstring Sign
Positive: Pain in the lumbar region or radiculopathy
indicates: Sciatic nerve root compression, helps rule out tight hamstrings
Lasegue Test
Positive: reproduction of sciatic pain before 60 degrees
indicates: Sciatica
Milgram Test
Positive: inability to perform test and / or low back pain
indicates: weak abdominal muscles or space occupying lesion
Valsalva Maneuver
Positive: Radiating pain from site of lesion (usually recreating the complaint in cervical or lumbar area of the spine)
Indicates: Space occupying lesion (disc pathology)
Bechterew Test
Positive: reproduction or radicular pain or inability to perform correctly due to tripod sign
indicates: Sciatic Radiculopathy
Neri Bowing Test
Postitive: pain accompanied by flexion of the knee on the affected side and body rotation away from the affected side
Indicates: Positive with a variety of low back pathologies. Hamstring tension on the pelvis may trigger the response
Anterior Innominate test aka Mazion Pelvic Maneuver (Advancement Sign)
Positive: the inability to bend at the waist more than 45 degrees, because of either/or
- radiating pain along sciatic nerve, either unilateral or bilateral
- Low back pain ( lumbar or pelvic regions)
Indicates:
- Sciatic neuralgia or radiculopathy , etc possibly due to lumbar disc pathology
- anterior ( rotational) displacement of the ilium relative to the sacrum
Lewin Standing Test
Positive : Radiating pain down the leg causing flexion of the knees
Indicates: Gluteal, Lumbosacral or sacroiliac pathologies
Heel walk
Positive: Inability to perform test
indicates: L4-L5 disc lesion (L5 nerve root)
Toe walk
Positive: Patient walks on toes
Indicates : L5- S1 disc lesion ( S1 nerve root)
Ely Heel to Buttock Test
Positive
- inability to raise thigh
- pain in the anterior thigh
- pain in the lumbar region
Indicates
- Iliopsoas spasm
- Inflammation of lumbar nerve roots
- Lumbar nerve root adhesions
Minor’s Sign
Positive:
knee flexion of affected leg while supporting upper body weight on the unaffected side
Indicates:
Sciatica, lumbosacral or SI joint lesion
Belt test ( supported adam test, supported bending test)
Positive:
Low back pain
indicates:
- pain during unsupported and supported bending= Lumbar involvement
- Pain during unsupported but no pain during supported= pelvic involvement
Kemp’s test
Positive:
1. pain radicular, recreating existing sciatic pain
indicates : disc protrusion
- medial disc- positive pt leans away from side of pain
- lateral disc - positive pt leans into side of pain
2. positive - local pain
indicates: localized pain may indicate lumbar spasm or facet capsulitis
Linder’s Sign
Positive: pain along sciatic distribution or sharp, diffuse pain
indicates: sciatic radiculopathy
Turyn’s Sign
Positive : pain in the gluteal region or radiating sciatic pain
indicates: sciatic radiculopathy
Sicard’s Sign
(like braggarts except flex big toe)
Positive: posterior thigh pain
indicates: Sciatic radiculopathy , usually from disc lesion
Bonnet’s Sign
Positive: pain in the posterior thigh or leg
indicates: Sciatic ( possibly piriformis syndrome) = pain in immediately or before SLR
Fajersztajn’s test aka well- leg raising test aka cross over sign
positive: 1. Pain down affected leg
2. decreased in pain down affected leg
Indicates - 1. medial disc protrusion ( cross over sign)
2. Lateral Disc Protrusion
Femoral stretch Test
Positive : pain in the anterior portion of the thigh
Indicates : traction on the femoral nerve indicating involvement of the 2nd, 3rd, and 4th lumbar nerve roots
L4 nerve root
- disc level L3
- Muscle test: foot dorsiflexion and inversion : tibialis anterior ( deep fibular nerve)
Reflex: patellar tendon
sensation: medial aspect of leg, medial foot , medial aspect of big toe
L5 nerve root
disc level L4
Muscle test- foot dorsiflexion
- Big toe dorsiflexion: extensor hallucis longus ( depp fibular )
- Toes 2,3,4 dorsiflexion: extensor digitorum longus and brevis ( deep fibular )
- Hip and Pelvis abduction: gluteus medius and minimus ( superior gluteal nerve)
Reflex : none
Sensation : Lateral leg, dorsum of foot and middle three toes
S1 nerve root
- disc level L5
- Muscle tests (3)
- foot plantar flexion : gastrocnemius and soles ( tibial nerve )
- Foot platnar flexion and eversion: fibular/ peroneus longs and brevis ( superficial fibular/ peroneal nerve)
- Hip extension: gluteus maximus ( inferior gluteus nerve)
- foot plantar flexion : gastrocnemius and soles ( tibial nerve )
Reflex: achilles
Sensation : posterior aspect of the leg, lateral aspect of foot, and lateral aspect of little toe
Leg Length Discrepancy
Positive : different measurements
True = bony abnormality above or below level of trochanter difference ( anatomical short leg)
Apparent = pelvic obliquity (tilted pelvis)
Allis sign (galeazzi sign)
Positive : differnece in height and anteriority of the knees
Indicate:
- if one knee is lower= ipsilateral congenital hip dislocation or tibial discrepancy ( anatomical short leg0
- if one knee is anterior= ipsilateral congenital hip dislocation or femoral discrepancy ( contralateral anatomical short leg)
Thomas Test
Positive: Lumbar spine remains lordosis (should flatten) and hip or leg flexes
indicates : contracture of the hip flexors (iliospoas)
Anvil test
Positive : Localized pain in long bone or in hip joint
Indicates : possible fracture of long bones or hip joint pathology
Patrick Test aka FABERE sign
Positive: pain in the hip region
Indicates: hip joint pathology
Laguerre Test
Positive: 1. pain in the hip joint 2. pain in the sacroiliac joint Indicates: 1. Hip joint pathology 2. mechanical problem of the sacroiliac joint
Gaenslen Test
Positive: pain on the affected SI joint stressed into exstention
indicates: general sacroiliac joint lesion, anterior sacroiliac ligament sprain, or inflammation of the SI joint
Lewin_ Gaenslen test
Positive: pain on the affected SI joint stressed into extension
Indicates : genral sacroiliac joint lesion, anterior sacroiliac ligament sprain, or inflammation of the SI joint
Hibb test
Positive:
- pain in the hip region
- pain in the buttock/pelvic region
indicates:
1. Hip joint pathology
2. sacroiliac joint lesion
Ober test
Positive : affected thigh remains in abduction ( normal biomechanics , thigh will adduct)
Indicates: contraction of the iliotibial band or tense fascia kata
Pelvic rock test aka iliac compression test
Positive: pain in either sacroiliac joint
indicates: sacroiliac joint lesion
nachlas test
positive: pain in the buttock and/or lumbar region
indicates: sacroiliac joint lesion, or lumbar pathology
Yeoman Test
Positive: pain deep in Si joint
indicates: sprain of the anterior sacroiliac ligaments
Ely sign
Positive : hipe on side being tested will flex causing the buttock to raise off the table
indicates: rectus femoris or hip flexor contracture
Ely heel to buttock
Positive:
- inability to raise the thigh
- pain in the anterior thigh
- pain in the lumbar region
Indicates:
- iliopsoas spasm
- inflammation of lumbar nerve roots
- lumbar nerve root adhesions
Trendelenburg Test
Positive: high iliac crest on supported side and low crest on side of elevated leg
Inidcates:
weak gluteus medius muscle on the supported side
Range od motion for the cervical spine
- flexion 50
- extension 60
- lateral bending left 45
lateral bending right 45 - left rotation 80
- right rotation 80
Foraminal Compression Test
Positive:
- Exacerbation of localized cervical pain
- exacerbation of cervical pain with a radicular component
Inidcates :
- Foraminal encroachment or facet pathology without nerve root compression
- foraminal enchraochment or facet pathology with nerve root compression
Cervical Distraction Test
Positive:
- diminished or absence of pain
- increase of cervical pain
Indicates:
- foraminal encroachment (local pain dimities), nerve root compression (radicular pain dimities)
- Muscular strain, ligamentous sprain , myospasm, facet capsulitis
Spinal Percussion test
Positive:
1. Local pain
.2. Radiating pain
Indicates:
1. Localized pain — dural sleeve adhesion, and muscular adhesion/contracture, or spasm or ligamentous injury
- Radiating Pain — on side being tested neuromuscular bundle compression, dural sleeve adhesions or thoracic outlet syndrome
- on opposite side being tested foramina enchjroachment with nerve root compression
Swallowing Test
Positive :
Difficulty Swallowing
Indicates:
Space - occupying lesion at the anterior portion or cervical spine. Possibly esophageal or pharyngeal injury, anterior disc defect, muscle spasm or osteophytes etc.
Soto - Hall Sign
Positive:
Genralized pain in the cervial region, which may extend down to the level of T2
Inidcates:
non- specific test for structural integrity of cervical region
Kernig Sign
Positive:
Inability to fully extend the leg and/or pain ( usually in the neck region)
Indicates: Meningeal irritation / meningitis
O’Donoghue Maneuver
Positive:
- pain during passive range of motion
- Pain during resisted range of motion
Indicates:
- ligamentous sprain (passive ROM stresses ligaments)
- Muslce/ tendon strain (active ROM stresses muscles and tendons
Brudzinkis sign
Positive:
- involuntary knee flexion
Indicates:
- meningeal irritation or nerve root lesion
Jackson Compression Test
Positive :
- Exacerbation of localized pain
- Exacerbation of radicular pain
Indicates:
- Foraminal enchroachment w/o nerve root compression or facet pathology
- foraminal enchroachment with nerve root compression
Maximal Compression Test
Positive
- pain on the concave side
- pain on the convex side
Indicates
- foraminal enchroachment with or w/o nerve root compression
- Muscular strain
Bakody Sign ( shoulder abduction Test)
Positive:
decrease or absence of radiating pain
Indicates:
cervical foraminal compression, nerve root entrapment ( usually C5-C6)
Tinel wrist sign
positive: reproduction of pain, tenderness and/ or paresthesia in the median nerve distribution area ( thumb, 2nd, 3rd and the lateral 1/2 of the 4th digit)
Phalen sign ( reverse Phalen)
positive: reproduction of pain, tenderness and or paresthesia in the median nerve distribution area ( thumb, 2nd, 3rd, and the lateral 1/2 of the 4th digit)
Finkelstein Test
Postive: pain distal to the radial styloid process
Indicates: stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons ( DeQuervain’s disease)
Bunnel- Littler test
Positive
1. flexion of the proximal interphalangeal joint cannot be achieved
2. Flexion of the proximal interphalangeal joint is achieved
Inidcates:
1. Joint capsule contracture
2. tight intrinsic muscles
Retinacular Test
Positivee :
- flexion of the distal interphalangeal joint cannot be achieved
- Flexion of the distal interphalangeal joint is achieved
Indicates:
- joint capsule contracture
- tight intrinsic muscles
Allen Test
Positive:
delay of more than 10seconds in returning a reddish color in the hand
Indicates :
radial or ulnar artery insufficiency. the artery being held or occluded by the examiner is not the artery being tested
Fromet paper sign
Positive:
the patient is unable to maintain grip on the paper
Indicates: ulnar nerve paralysis
Direct light reflex
Response: ipsilateral pupillary constriction when light is shined in the eye
Afferent: Optic Nerve II
Integrating Center: Midbrain
Efferent: Oculomotor nerve III
Indirect Light
Response: contralateral pupillary constriction
State the pathology for percussion of the chest and lung
- normal sound is resonant
- hyper- resonance indicates air in the lungs = emphysema or bronchial obstruction
- Dullness or flat sound indicates fluid or mass in the lung = lung consolidation, compressed lung or tumor
State the pathology for tactile fremitus
- decreased/ absent is caused by air in the lungs= - emphysema or bronchial obstruction
increased fremitus is caused by fluid or mass in the lungs = lung consolidation, compressed lung or tumor
State the breath sounds for chest and lung
- vesicular - heard over most lung fields … low pitched short expirations, listening for abnormal audible breath sound
- bronchovesicular- heard over main bronchus and upper right posterior field medium pitch and expiration equals inspiration