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ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 1

Test Patient Picture


Myotomes – Manual Muscle Testing
Primary Tenet of MMT: each muscle should be tested The examiner must place the
just proximal to the next distal joint of the muscle's subject in positions that will
insertion • isolate the specific muscle/s
being examined
• eliminate substitution of
agonist muscles

UPPER EXTREMITY
C5 myotome Reporting:
• Testing the biceps 0 – none

1 – visible/palpable contractions
only

2 – can move with gravity eliminated


• Place on a flat surface, so that
its movement would parallel
that flat surface
◦ Ex. C5 myotome testing
against gravity: place the
medial surface of the
C6 myotome elbow on a table and ask
• Testing the extensor carpi radialis the patient to flex

3 – can move against gravity


• Ex. C5 myotome: simply asking
the patient to flex the elbow
would elicit this level

4 – can move with minimal


resistance
• Make sure you start testing
with the joint to be tested
C7 myotome already flexed/extended
• Testing the Triceps • If the patient can keep the
tension on the joint against
minimal effort only, it elicits
this level

5 – can move against maximal


resistance
• If the patient can keep the
tension with the physicians
maximal effort to counteract
it, it elicits this level

C8/T1 myotome
• Testing the hand intrinsic muscles
◦ C8 – thumb extension
▪ Extensor pollicis longus
▪ Extensor pollicis brevis
◦ T1 – finger abduction
▪ Dorsal interossei
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 2

LOWER EXTREMITY
L2 myotome
• Hip flexors
◦ Psoas major
◦ Iliacus muscle
◦ Rectus femoris (part of Quadriceps)
◦ Sartorius muscle

(Source: Acland's Video Atlas of Human Anatomy


website)

L3 myotome
• Knee extensors
◦ Quadriceps

L4 myotome
• Ankle Dorsiflexors
◦ Tibialis anterior

L5 myotome
• Great toe extensors
◦ Extensor hallucis longus

S1 myotome
• Ankle Plantarflexors
◦ Gastrocnemius
◦ Soleus
◦ Plantaris
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 3

Dermatomes
UPPER EXTREMITY
C5 dermatome
• above the deltoid muscle

C6 dermatome
• lateral epicondyle

C7 dermatome
• web between 3rd and 4th digits

C8 dermatome
• web between 4th and 5th digits

T1 dermatome
• medial epicondyle
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 4

LOWER EXTREMITY
L3 dermatome
• dorsum of the foot

L4 dermatome
• medial lower leg

L5 dermatome
• dorsum of the foot

S1 dermatome
• lateral foot
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 5

Reflexes
Muscle stretch reflexes are elicited
by a sharp, short blow with a tendon
hammer delievered to a tendon of a
gently extended msucle
UPPER EXTREMITY
C5/6 Reflex Reporting (depending on the
• Biceps elicited jerk or contraction of the
• Brachioradialis muscle being tested)
• + - hyporeflexia
• ++ - normal reflex
• +++ - hyperreflexia
• ++++ - clonus

Biceps

Brachioradialis
C6/7 Reflex
• Pronator teres – by tapping the distal
radiostyloid

C7/8 Reflex
• Triceps
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 6

LOWER EXTREMITY
L3/4 reflex
• Knee Jerk

L5 reflex
• Medial Hamstring

S1 reflex
• Ankle reflex

Neck
Spurling's Test A positive test is reproduction of
• Passive lateral flexion and compression of the symptoms, distant from the neck
head
• Sensitivity: 40-60% Test for cervical radiculopathy
• Specificity: 92-100% (nerve root pain)

(+) Spurlings: electrical sensation


towards the side where you flexed
the neck

(+) Reverse Spurling: sensation is


felt away from the side where you
flexed the neck

Distraction Test (+) Relief or reduction of cervical


• involves the examiner grasping the paitnets radicular symptoms
head on the occiput and chin and apply a • Nerve root compression and
distractional force. facet joint pressure
• Sensitivty 40-43%
• Specificty: 100% Grade of the pressure would be
decided by the amount of pressure
and pain relieved while performing
the test
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 7

Lhermitte's Sign (+) Electric sensations down the


• Involves passive anterior cervical flexion spine or extremities

Upper Extremity
Adson's Test (+) Obliteration, or alteration of the
• involves abduction of the arm with palpation of radial pulse
the radial artery, Inspiration, chin elevation and
head rotation to the affected side

Tinnel's Test' (+) Wrist: Paresthesias of the


• at the wrist - is performed by the examiner median nerve innervated digits
tapping with a reflex hammer over the median
nerve as it passes through the carpal tunnel (+)ulnar groove: Paresthesias of the
◦ Sensitivity: 25% ulnar nerve innervated digits (4th
◦ Specificity: 96% and 5th digits)
• at the ulnar groove – the examiner taps the
ulnar nerve as it passes through the medial
epicondyle in the ulnar groove.

Wrist

Ulnar Groove
Finklesteins Test (+) Pain is experienced on the styloid
• the patient's thumb is placed within the hand process of the radius
and held tightly with the other fingers, the wrist
is then ulnarly deviated
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 8

Hoffman's Sign (+) Upper motor neuron lesion


• Determine the presence of nerve damage • Flexion of the index
• Flick the nail of the middle or ring finger finger to the thumb
• Sensitivity: 56%
• Specificity: 76%

Phalen's Test (Reverse Prayer) (+) Carpal Tunnel Syndrome


• performed by asking the patient to hold the • Median nerve compression
forearms vertically and allow both hands to drop • Immediate aggriavation of the
into flexion at the wrist for approx. 1 min numbness and paresthesia in
• instead of just letting the wrist drop, you can ask the fingers
the patient to press the dorsum of each hand to
each other for 1 min, eliciting the same response
• Sensitivity: 80%
• Specificity: 20%

Reverse Phalen's Test (Prayer)


• he patient is asked to keep both hands, palm
together with the wrist in complete dorsal
extension for approximately 1 minute
• Sensitivity: 43%
• Specificity: 74%

Cozen's Test (+) Lateral Epicondylitis


• the patient holds the elbow extended, and the • Cozen's: If pain is noted at the
wrist in flexion. The patient is then asked to origin of the extensor carpi
perform extension while the examiner provides radialis, then this is suggestive
resistance. The patient should hold this position of lateral epicondylitis
while the examiner continues to apply • Middle Finger: Pain localized
resistance. to the lateral elbow
• Mills Test: Increased pain
noted at the lateral
epicondyle

Resisted middle finger extension test


• atient is asked to hold the elbow, wrist and
fingers in full extension. While the examiner
applies a force to the extensor surface of the
middle finger
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 9

Mill's Test (Resisted wrist extension test)


• patient holds the elbow and wrist in extension
and the examiner applies a force upon the
extensor surface of the wrist extensors

Yergason's test (+) Pain localized to the biccipital


• elbow flexed at 90o and forearm pronated. The groove
examiner then reisists supination • Yergasons:
• Sensitivity: 37% ◦ used to check the ability
• Specificty: 86.1% of the transverse
humeral ligament to
hold the biceps tendon
the bicipital groove
• Speeds
◦ Pathology of the long
head of the biceps in its
groove
◦ Assessment of Superior
Labral Antero-posterior
lesions(SLAP)
Speed's Test
• arm externally rotated, and forward flexed
against resistance with the elbow fully extended.
• Sensitivity: 68.5%
• Specificity: 55.5%

Drop arm test (+) Rotator cuff tear


• passively abduct the patient's shoulder. The • inabilty to return the arm
patient is then asked to slowly lower the arm to slowly to the side
the side

Empty Can test (+) Supraspinatus pathology


• the arm is abducted to 90o in the plane of the • Weakness and or pain
scapula and maximally internally rotated. ◦ Located at subacromial
Resistance is provided. region
• Tendonitis
◦ Sensitivity: 77.2%
◦ Specificity: 38%
• Tear
◦ Sensitivity 18.7%
◦ Specificity: 100%
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 10

Hawkin's Test (+) pain by the greater tuberosity


• umerus is forward flexed to 90o with the elbow impinging onto the coracoacromial
at 90o, the humerus is then internally rotated. ligament

Crank Test (+) Pain with or without clicks


• patient is supine, the arm elevated to 160o at
o
the scapular plane with the elbow flexted to 90 .
An axial load is placed along the humerus, while
glenulohumeroal internal external rotation are
performed.

Lower Extremity
Patrick/FABER Test (+) Pain is localized to the groin
• FABER : Flexion (F), Abduction (AB), External • Hip pathology
Rotation (ER)
• atient is placed in the supine position. The (+) Pain is localized to the lower
examiner flexes, abducts and externaly rotates lumbar spine
the hip, with the ankle resting on the • Sacroiliac joint pathology
contralateral knee. The examiner then stablizes
the pelvis by applying pressure on the
contralateral ileum. Pressure is then applied
dorsally to the knee to further externally rotate
the hip.
• Sensitivity: 77%
• Specificity: 100%

Gaenslen's Test (+) Pain referred to the ipsilateral


• the patient in the supine position with the sacroiliac joint
affected limb dangling off the examination
table. The opposite limb is placed in flexion. The
examiner assists with control of hip flexion while
applying a downward pressure on the affected
limb.
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 11

Ober Test (+) Abduction contracture


• patient lies on their side with the thigh next to • leg will remain more or less
the table flexed to obliterate lumbar lordosis. passively abducted.
The upper leg is flexed at a right angle at the
knee. The examiner grasps the ankle lightly with
one hand and steadies the patient's hip with the
other. The uper leg is abducted widely and
extended so that the thigh is in line with the
body.

Thomas Test (+) Flexure contracture


• patient lies supine. The examiner flexes the • Contralateral leg raises off of
paitents hip bring the knee to the chest to the table
flatten out the lumbar spinea, and the patient • Angle of the contracture can
holds the flexed hip against the chest. be measured

Straight Leg Raise (+) angle is between 30-70o and pain


• Performed with the patient supine, the examiner is reproduced down to the posterior
passively raises the affected leg. The elvation is thigh below the knee.
stopped when the patient begins to feel pain.
The type and distribution of pain is recorded.
• Sensitivity: 95%
• Specificity: 14%

Cross-Straight leg raise (+) radicular symptoms are


• the patient is supine. The asymptomatic leg is reproduced in the contralateral leg.
raised with the knee extended. The elevation of
the leg is stopped when the patient begins to
feel pain and the type and distribution of the
pain, as well as the angle of elevation is
recorded.

Patellar Apprehension Test (+) Patient becomes uncomfortable


• performed with the paitne supine, and the knee and/or apprehensive
flexed to approximately 30o with the quadriceps
relaxed. The examiner presses along the medial
aspect of the patella to exert a laterally directed
pressure force
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 12

Valgus Stress test (+) Medial Collateral Ligament Tear


• the patient supine on the exam table. The knee • Asymetric laxity
is flexed to approximately 30o of flexion. The • Lack of a firm endpoint
examiner places one hand about the lateral
aspect of the knee, and grabs the ankle with the (+) MCL Damage
other hand. A valgus force is applied to the knee • May also indicate capsular or
• Valgus force – directed from the lateral aspect cruciate ligament laxity
towards the middle
• Sensitivity: 96%

Varus Tress test (+) Asymetric laxity when compared


• the patient supine on the examination table. The to the other knee
o
knee is flexed to aproximately 30 . One hand is
placed about the medial knee and the other (+) LCL Damage
grasps the ankle. A varus force is applied to the
knee.
• Varus force – directed from the medial aspect
towards the lateral side
• Sensitivity: 25%

Anterior drawer Test (+) Anterior Cruciate Ligament tear


• patient is supine with the hip flexed to 45o and • there is increased tibial
the knee flexed to 90o. The examiner sits on the displacement compared to the
subjects foot with hands behind the proximal oppsite side, or a soft end
tibia and the thumbs on the tibial plateau. point
Anterior force is applied to the proximal tibia.
• Sensitivity: 40%
• Specificity: 95.2%

Lachman test
• patient supine, knee is held in approximately 15o
of flexion. The femur is stabilized with one hand
while firm pressure is applied to the postierior
aspect of the proximal tibia and attempt to
translate it anteriorly.
• Sensitivity: 99%

Posterior drawer test (+) Posterior Cruciate Ligament tear


• ubject supine, hip flexed to 45o and the knee • Increased posterior tibial
flexed to 90o, with the foot on the neutral displacement as compared to
position. The examiner sits on the subjects foot the uninvolved side
with hands behind the proximal tibia and the
thumbs on the tibial plateau. A posterior force is
applied to the proximal tibia.
• Sensitivity: 90%
• Specificity: 99%
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 13

McMurray Test (+) Meniscal Tear


• patient supine, knee is first fully flexed with the • Painful click or thud
foot held by grasping the heel. The medial
meniscus is assessed witht the tibia externally
rotated while the lateral meniscus is assessed
with internal rotation of the tibia, with varying
degrees of flexion
• Sensitivity: 29%
• Specificity: 95%

Apley Test 90%


• Patient lies flat on his stomach, and similar to
McMurrays, you assess the meniscus by
◦ Externally rotating the tibia for the medial
meniscus
◦ Internally rotating the tibia for the lateral
meniscus
• With varyying degrees of flexion
• Sensitivity: 13%
• Specificity: 90%

Talar Tilt Test (+) Ligament Tear


• ankle in slight plantar flexion. The examiner • Asymetric laxity
stabilizes the tibia and passively inverts the ankle • Lack of a firm endpoint

Syndesmosis Squeeze test (+) Pain over the syndesmotic


• manually compressing the fibula to the tibia, ligament
above the midpoint of the calf
• Sensitivity:

Anterior Drawer test of the ankle (+) Asymetric laxity


• ankle in the neutral position. The examiner
stabilizes the tibia with his top hand, and grasps
the calcaneous, moving the talus forward, in an
anterior direction
ProcrastiNotes: Rehabilitation Medicione OSCE Reviewer 14

Thompson Test (+) Achilles tendon rupture if foot


• Patient prone with feet over edge of table, does not plantar flex
tester stands to the side of the patient and
squeezes the belly of calf

Pediatric

Readiology