Examination of Back and major

Joints

By Dr. Nataliya Fesun

March 4th, 2011.

 General tips for a joint exam

Usual pattern:
1.General Inspection (SEADS: Swelling, Erythema,
Atrophy, Deformity, Skin changes)

2. Palpation
3. ROM
4. Special tests
The common topics that have been tested in OSCE
exams:

 Back pain, acute and chronic.

 Sciatica
 Neck pain/ trauma.
 Ankylosing spondilitis.
 Osteoarthritis.
 Inflammatory arthritis/ Rheumatoid.
 Septic arthritis.
 Osteoporosis.
 History for back pain

Pain intensity, and duration of the current episode of low back

pain. (use LOTARP)
Any congenital spinal problems.
Any type of arthritis in your spine.
Previous episodes of low back pain and treatment.
Previous accidents or injuries involving the back.
Bladder/ Bowel symptoms
Family history of low back pain. Pattern
 Cont. History:
Work history.
Sports and other leisure activities.
History of cancer and other illnesses, such as abdominal/pelvic
disease, or osteoporosis.
Recent fever or unexplained weight loss.
Corticosteroid use.
Smoking history.
Depression questions to see how the pain is affecting the patient’s
life.
Ask them to rate their job satisfaction, support system at home and
work.
Physical:
During the physical exam, do a series of movements to elicit/reproduce
the pain: standing, sitting, lying down. This makes it possible to assess
muscular and sensory problems contributing to the low back pain. The
physical exam will also include:
1. Observation and Measurements (symmetry, edema, deformity, sings of
trauma and/or inflammation, scars, abnormal gait)
2. Palpation, feel for tenderness and joint alignment and check pulses in
legs.
3. ROM (forward flection, extention, lateral flextion, rotation).
3. Deep tendon reflex test.
4.Sensation test. Muscle strength tests can detect true muscle weakness,
which is one sign of pressure on a nerve root. (Sometimes leg
weakness is actually due to pain, not pressure on a nerve.) Most people
who have herniated discs that cause symptoms also have some nerve
root compression.
 Cont...
Since specific muscles receive impulses from specific nerves, finding out
which muscles are weak show where nerve roots are being
compressed.
Muscle strength:
1. Hip flexion. Pt. Sits on the edge of the table with legs hanging down.
Push down near the patient’s knee as they lift their thigh. If one
painful leg is weaker than the other leg, there may be a nerve root
compression at the higher part of the lower back, in the area of the last
thoracic and the first, second, and third lumbar vertebrae (T12, L1, L2,
L3 region).
 Cont...
2. Knee extension. Patient in the sitting position, straightens out knee
while you push down on the leg near the ankle. If one leg is weaker
than the other leg, nerve root compression at the third and fourth
lumbar vertebrae (L3 or L4 region).
3. Ankle dorsiflexion. Patient sitting, push down on the ankle while they
pull their ankle upward. Weakness is a sign of possible nerve root
compression the level of the fifth lumbar vertebra (L4 or L5 region).
4. Great toe extension. Patient sitting, push down on big toe while
patient tries to extend. Nerve root compression at L5 region.
5. Plantar flexion power. “Push on the gas pedal”. Possible S1 nerve
root compression.
 Cont...
Movement tests.
Walking.
Flexion – have them touch their toes, watch for muscle sensitivity/spasm
Extension. Hyperextend back by bending backward and bending from
side to side at the waist.
Rotation. Rotate back by keeping your hips still and turn upper body
from side to side.
Side bending. Bend to one side, then the other, keeping hips level and not
letting body rotate.
 Cont...
In general, increased pain on bending forward (flexion) suggests a disc
problem. Pain that increases when bending backward (extending the
spine) suggests degenerative changes, spinal stenosis , or
spondylolisthesis . Side bending and rotation – look for assymetry.
Spasms of the muscles next to the spine can create pain with any of
these tests.
Straight leg test .
Muscle strength tests (neurologic testing) .
General abdominal, pelvic, rectal, and leg exams( if you have time, but
always mention to the examiner)
 Post encounter questions, what to know...
 Two surgical emergencies: Cauda equina syndrome and
abdominal aortic aneurism/ rupture.
 Symtoms for CE: Saddle anesthesia, decreased anal tone,
fecal incontinence, urinary retention, progressive
neurodeficit.
 Red flags: Hx of recent bacterial infections, malignancies,
inflamation, IV drug use, chronic disease, age older 50.
 Knee examination
 Inspection (use SEADS):
 S Swelling - look for loss of normal hollow around patella
 E Erythema
 A Atrophy of quadriceps muscle (measure quadriceps size 15 cm
above tibial tubercle)
 D Deformity (varus/valgus/recurvatum, symmetry, alignment)
 S Skin changes (scars, bruising)
 Palpation – tenderness, effusion, swelling,
temperature, crepitus, atrophy
 Knee extended
 Tenderness, effusion, nodules, or warmth
 Patella (effusions are accompanied by warmth)
 Patellar tendon
 Tibial tuberosity
 Medial fat pad – tender in fibromyalgia
 Crepitation on flexion/extention ALSO IT WILL TEST ROM
Ligaments stability.
 Feel for a solid end point; if ligament torn, the end
of ROM would be soft
 MCL: valgus stress test
 LCL: varus stress test
 ACL: anterior drawer test, Lachman
 PCL: posterior drawer test
 Lachman’s (externally rotate hip, bend knee 15o, pull up on tibia and
push back on femur)

 McMurray's manoeuvre (patient supine, knee bent at 90°, feel for

obvious click along joint line on medial/lateral sides)
 Hip exam...
Make sure Pt is comfortable and supine.
1. Test gate first (Trendelenburg)
2.Inspection:
 compensatory posture
 True leg length
 Apparent leg length
 Symmetry/deformity/inflamation
Palpation:
Grater trochanter and bursa
ROM: Flexion/extention, abdaction/adduction,
internal/external rotation.
Specal manoevres: Thomas test (Place your hand under the
patient's lumbar spine to stop any lumbar movements and fully flex one of
the hips. Observe the other hip, if it lifts off the couch then it suggests a
fixed flexion deformity of that hip)
Always thank the patient
after your examination
is complete!
 Tips to prepare....

 Know the pattern

 Watch on-line videos
 Always time yourself
 Use family members/friends as your “patients”
 Create own style, if needed.
 PRACTICE!!!
Questions???

Practice time!!!