Pocket Guide to Msukculoskeletal Assessment by RICHARD f. BAXlfR

Test Procedure Positive Sign PI's arm is stabilized with one of Laxity of involved elbow compared with examiner's hands placed at elbow and uninvolved Inote amount of laxity and end- other hand placed above PI's wrist. PI's feel) humerus is placed in full IR, and elbow is slightly flexed (15-20 degl as examiner applies varus force. PI's arm is stabilized with one of examiner's hands at elbow and other hand placed above PI's wrist. PI's humerus is placed in full ER, and elbow is slightly flexed (15-20 degl as examiner applies valgus force. Examiner palpates lat epicondyle while Pain/reproduction of PI's Sx over lat pronating PI's forearm and flexing PI's humeral epicondyle wrist fully with ulnar deviation and extending PI's elbow. Pain/reproduction of PI's Sx over lat humeral epicondyle Examiner resists ext of middle finger distal to PIP joint, stressing extensor digitorum muscle and tendon. Examiner palpates med epicondyle, Pain/reproduction of PI's Sx over med supinates PI's forearm, and extends PI's humeral epicondyle elbow and wrist fully with radial deviation. ling ling sensation in ulnar nerve distribution of forearm and hand distal to point of Examiner taps area of PI's ulnar nerve in tapping groove behind medial epicondyle. Most distal point at which abnormal sensation is felt represents limit of nerve Pt sits with hand resting on table. regeneration Examiner passively spreads PI's fingers and asks Pt to bring fingers together. Inability to adduct 5th digit back to other fingers Pt completely flexes elbow and holds it or 5 min. ling ling/paresthesia in ulnar nerve distribution PI sits with elbow flexed 90 deg. Examiner then attempts to supinate and ling ling/paresthesia in median nerve extend PI's elbow as PI resists. distribution

I TREATMENT OPTIONS FOR THE ELBOW Special Condition Hx/Symptoms UCL rupture Hx of elbow dislocation, throwing injury, or chronic overloading, as in a throwing athlete , Posterior elbow subluxation/dislocation Hx of FOOSH injury with shoulder abducted or elbow in hyperextension

Signs/Objective Findings Treatment Options Positive valgus stress test of elbow Acute: sling/immobilizer, ice, NSAIDs Mayor may not have tenderness over Refer to orthopedic surgeon. Surgery attachments of UCL may be considered Postop: sling for a few days to 1 wk; maintain fingers/wrist AROM and grip strength Cast brace 130-120 degl for 4 wk; allow AROM within this ROM Cast brace 10-120 degl for 8 wk; allow AROM within this ROM and begin strengthening between 8-12 wk postop. Begin with isometric elbow ftex/ext and wrist radial/ulnar deviation; progress to isotonic and isokinetic strengthening. In final stages, functional/return to sport activity should be initiated. Resume throwing at 6 mo Radiograph confirms subluxation or Cast bracing times and ROM limitations dislocation may vary, but AROM within allowable restrictions noted above and progressive Dislocation normally requires relocation strengthening should progress as by medical personnel clinically reasonable and as patient tolerates. Fx are common Ibeware!) Acute: ice, elevation, NSAIDs Be sure to perform a neurovascular If cleared by orthopedic surgeon (no Fx assessment that require ORIF or prevent initiation of rehabilitationl, may begin immediate motion Maintain wrist and hand motion and strength No instability: immediate unlimited motion without brace Valgus instability: immediate unlimited motion in a cast brace with forearm fully pronated Unstable In extension: immediate motion in cast brace that blocks full extension. Extension block may be gradually eliminated over 3-6 wk. Subacute/chronic: begin isometric elbow flex/ext!pronation/supination and wrist radial and ulnar deviation. Progress to isotonic and isokinetic strengthening. ( l 11111111 cl . .

I TREATMENT OPTIONS FOR THE ELBOW Continued Special Condition Hll/Symptoms Lateral epicondylitis (tennis elbow) Hx of overuse, heavy lifting, repetitive motions such as filing/keyboard work/ tennis strokes (forceful pronation and supinationi Med epicondylitis (golfer'S elbow) Hx of high-intensity flex/pronation/ gripping Pain during activity that increases after activity Olecranon bursitis Hx of direct trauma to olecranon process

Signs/Objective Findings Treatment Options Local tenderness to palpation over Acute: decrease inflammation lice, common wrist extensor origin (Iat NSAIDs, phonophoresis or iontophoresis) humeral epicondyle) Relative rest AGG: resisted wrist and middle finger Epicondylar splint ext Positive lat epicondylitis tests Subacute: stretching wrist extensors and R/O C6 radiculitis or radiculopathy flexors R/O posterior interosseous nerve Transverse friction massage entrapment Isometric strengthening for wrist flex/ ext/radial and ulnar deviation (initially performed with elbow flexed, then progress to performing exercises with elbow extended) Chronic: progress isometrics to isotonics Strength and endurance training is focused primarily on wrist extensors Pt education Local tenderness over med humeral Acute: decrease inflammation (ice, epicondyle NSAIDs, phonophoresis or iontophoresis) AGG: PROM into full wrist ext and Relative rest resisted isometric wrist flex with Epicondylar splint forearm pronation Positive med epicondylitis tests Subacute: stretching wrist flexors and extensors Swelling and erythema over olecranon Transverse friction massage process Isometric strengthening for wrist flex/ Exquisite tenderness directly over ext/radial and ulnar deviation (initially olecranon process and swollen bursa performed with elbow flexed, then progress to performing exercises with elbow extended) Chronic: progress isometrics to isotonics Strength and endurance training is focused primarily on wrist flexors Pt education Ice, NSAIOs, phonophoresis or iontophoresis May consider padding area for protection Ctmtillllcd T

~ TREATMENT OPTIONS FOR THE ELBOW Contmued Special Condition Hx/Symptoms Compression at elbow Paresthesia in thumb, index finger, and middle finger that is aggravated by activity Weakness in muscles of forearm and hand innervated by median nerve Pronator teres syndrome (median nerve Paresthesia in thumb, index finger, and compressed at pronator teres muscle) middle finger that is aggravated by activity Weakness in muscles of forearm and hand innervated by median nerve Anterior interosseous syndrome (branch Hx of sudden severe forearm pain that of median nerve) resolves in a few hours No reported loss of sensation Palmar cutaneous nerve compression Pain over thenar eminence and proximal palm Carpal tunnel syndrome See Special Tests for the Wrist and Hand table in Chapter 5 Radial Nerve Neuropathies Radial tunnel syndrome (compression of Pain over lat humeral epicondyle radial nerve at elbowl Tenderness reported along line of radial nerve over radial head Numbness in radial nerve distribution in hand Superficial radial nerve compression Numbness/decreased sensation over Posterior interosseous nerve syndrome dorsoradial hand Reported normal sensation Ino paresthesia) May have Hx of lat epicondylitis or increased use of supinator muscles .(.J.1.

Signs/Objective Findings Treatment Options Loss/weakness of pronator teres muscle Relative rest and NSAIDs in addition to muscles of hand Splinting innervated by median nerve Ultrasound and soft tissue mobilization R/D cervical pathology Phonophoresis or iontophoresis Surgical decompression if conservative Resisted forearm pronation and elbow Rx fails flex reproduce Sx Pronator teres muscle is spared when Relative rest and splinting for 4-6 wk compression is at this level vs. elbow NSAIDs (i.e., MMT of pronator teres reveals no Decrease AGG deficitl Ultrasound and soft tissue mobilization R/D cervical pathology Surgical decompression or steroid injections if conservative Rx fails Weakness of FPL, PO, and FOP Pt unable to pinch tip to tip or flex DIP Relative rest and splinting for 4-6 wk joints of digits 2 and 3 (positive pinch NSAIDs testl Decrease AGG Key is no loss of sensation Ultrasound and soft tissue mobilization R/D cervical pathology Surgical decompression or steroid injections if conservative Rx fails Positive linel's sign at palmar median Padding area of injury nerve site Phonophoresis or iontophoresis Local steroid injections Resisted middle finger ext reproduces Sx Relative rest more intensely than in lat epicondylitis Splinting Resisted supination may also reproduce NSAIDs Sx Ultrasound and soft tissue mobilization R/D cervical pathology and lat Phonophoresis or iontophoresis epicondylitis Neural stretching Positive linel's sign over superficial Remove tight wristwatch/band that may branch of radial nerve be causing compression. R/D cervical pathology Rest and splinting Reproduced Sx with forced wrist ext or Relative rest digital compression when wrist is in flex Splinting Wrist may deviate radially with wrist ext. NSAIDs Pt unable to extend thumb or fingers at Address aspects of job/ADLs requiring MCP joints increased use of supinator muscles R/D cervical pathology Surgical decompression if conservative R/D lat epicondylitis Rx fails

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------------53 References 1. Regan WD, Morrey BF: The physical examination of the elbow. In Morrey BF (ed): The Elbow and Its Disorders, 2nd ed. Philadelphia, WB Saunders, 1993. 2. Lister G: The Hand: Diagnosis and Indications, 2nd ed. New York, Churchill Livingstone, 1984 3. Hertling 0, Kessler RM: Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods, 2nd ed. Philadelphia, JB Lippincott, 1990. 4. Moldaver J: Tinel's sign: Its characteristics and significance. J Bone Joint Surg Am 60:412-413, 1978. 5. Hunter JM, Schneider LH, Mackin EJ, Callahan AD leds): Rehabilitation of the Hand: Surgery and Therapy, 3rd ed. St. Louis, CV Mosby, 1990. 6. Magee OJ: Orthopedic Physical Assessment, 3rd ed. Philadelphia, WB Saunders, 1997. 7. Spinner M, Linscheid RL: Nerve entrapment syndromes. In Morrey BF (ed): The Elbow and Its Disorders, 2nd ed. Philadelphia, WB Saunders, 1993 Bibliography Dellon AL, Hament W, Gittelshon A. Nonoperative management of cubital tunnel syndrome: An 8-year prospective study. Neurology 431673-1678, 1993. Fess EE, Philips CA: Hand Splinting: Principles and Methods, 2nd ed. St. Louis, CV Mosby, 1987 Galloway M, Demaio M, Mangine R: Rehabilitative techniques in the treatment of medial and lateral epicondylitis. Orthopedics 15:1089-1096,1992. Hertling 0, Kessler RM: Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods, 2nd ed. Philadelphia, JB Lippincott, 1990. Kisn~r C, Colby LA: Therapeutic Exercise: Foundations and Techniques, 2nd ed. Philadelphia, FA Davis, 1990. Linscheid RL, O'Driscol1 SW: Elbow dislocations. In Morrey BF (ed): The Elbow and Its Disorders, 2nd ed. Philadelphia, WB Saunders, 1993. Lister G: The Hand: Diagnosis and Indications, 2nd ed. New York, Churchill Livingstone, 1984. Nirschl RP: Muscle and tendon trauma: Tennis elbow. In Morrey BF led): The Elbow and Its Disorders, 2nd ed. Philadelphia, WB Saunders, 1993. O'Driscol1 SW: Classification and spectrum of elbow instability: Recurrent instability. In Morrey BF led): The Elbow and Its Disorders, 2nd ed. Philadelphia, WB Saunders, 1993.

54 - - - - - - - - - - - - - - Schantz K, Riegels-Nielsen P: The anterior interosseous nerve syndrome. J Hand Surg Sr 17:510-512,1992. Spinner M, Linscheid RL: Nerve entrapment syndromes. In Morrey SF (ed): The Elbow and Its Disorders, 2nd ed. Philadelphia, WS Saunders, 1993. Yocum LA: The diagnosis and nonoperative treatment of elbow problems in the athlete. Clin Sports Med 8:439-451,1989. m r oIJJ :?:

m.--------55 WRIST ANO HANO Subjective Examination t Pt Hx (region specific): dominant hand, functional limitations t SO (if applicable) o z <l: I o Z <l: l- (/) cc S Lt'l

56 - - - - - - - - - - - - - Objective Examination I. Sitting A. R/O cervical pathology (see Chapter 2), shoulder and elbow involvement/pathology B. Observation 1. Posture 2. Atrophy or deformities C. AROM (note quality, pain) 1. Wrist flex (70-80 deg) 2. Wrist ext (65-80 deg) 3. Wrist radial (15-25 deg) and ulnar deviation (30-40 deg) CJ'I 4. Digits flex/ext :2: 5. Opposition of digits :JJ D. PROM (same motions'if AROM limited) (f) E. GMMT and myotomal screen ----l »z 1. Elbow flex/wrist ext (C6) o »Iz 2. Elbow ext/wrist flex (C7) 3. Finger flex (C8) o 4. Finger abd (T1) 5. Grip strength with dynomometer F. MSRs 1. Biceps (C5) 2. Brachioradialis (C6) 3. Triceps (C7) G. Special tests (as applicable) 1. Carpal tunnel syndrome: Phalen's test, Tinel's sign at the wrist 2. Ulnar nerve paralysis: Froment's sign 3. Other tests for neuropathy: wrinkle (shrivel) test, sweat test, pinch test 4. Vascular disorder/compromise: Allen's test 5. Tenosynovitis/de Quervain's disease: Finkelstein's test

- - - - - - - - - - - - - - 57 6. Contractures: Bunnel-Littler test, test for «oz tight retinacular ligaments I 7. Dislocation/instability: varus/valgus stress of digits maneuver, hyperabduction o H. Sensation: LT, 2-point discrimination, sharp/ «z dull, hot/cold, monofilaments f- I. Palpation 1. Anatomic landmarks, especially the (f) anatomic \"snuff box\" 2. Soft tissue a: J. Joint play S 1. AP glides 2. Lat glides 3. Radial and ulnar deviation 4. Long-axis distraction

(c]oI III SPECIAL TESTS FOR THE WRIST AND HAND T Test Detects M h Nerve Lesiol Carpal tunnel syndrome M Phalen's test (wrist flex test!'- 2 h h Tinel's sign at wrist' < Wrinkle (shrivell test' E Carpal tunnel syndrome w Can also be used to chart regeneration of lost sensory fibers P a Denervation of fingers P o Sweat test (ninhydrin sweat test)S.6 Denervation of fingers P w 2-point discrimination test (static)' Decreased hand sensation m s Pinch test' Compromised anterior interosseous p Froment's sign' nerve g b Ulnar nerve paralysis 1 p n p U b p s P th m P b th p

Test Procedure Positive Sign Method 1: Pt has elbows on table with Tingling in thumb, index finger, middle hands up and wrists flexed for 1 min finger, and lat half of ring finger Method 2: Pt places dorsal surface of hands together, fully flexing wrists, and Tapping causes tingling/paresthesia into holds for 1 min thumb, index finger, and middle finger Tingling is distal to point of tapping Examiner taps over carpal tunnel at wrist Failure of fingers to wrinkle; normal fingers wrinkle, but denervated fingers remain PI's fingers are placed in warm water for smooth approx 30 min. Examiner then removes PI's fingers and observes whether skin over pulp of fingers is wrinkled. PI's hand is cleaned thoroughly and No change in color, indicating lack of wiped with alcohol. Pt then waits 5-30 sweating min and avoids contacting any other surface with fingers. Fingertips are then Inability to distinguish 2-point touch with pressed with moderate pressure against more than 6-mm separation of points good-quality bond paper that has not been touched. Fingers are held there for Pt unable to pinch tip-to-tip and has to 15 sec and traced on the paper with a resort to pulp-to-pulp pinch owing to pencil. Paper is then sprayed with weakness of FOP ninhydrin reagent to stain sweat areas PI's terminal phalanx of thumb flexes purple. Allow 24 hours to dry. because of paralysis/weakness of adductor pollicis Using an object with 2 points separated by a known distance, apply light pressure to fingertips with 2 points simultaneously. Pt attempts to pinch using only tips of humb and index finger or thumb and middle finger. Pt attempts to grasp a piece of paper between thumb and index finger (add of humb). Examiner then attempts to pull paper away.

o(j) III SPECIAL TESTS FOR THE WRIST AND HAND Continued T Test Detects P o Wartenberg's sign\" 9 Ulnar nerve neuritis/paralysis f t Miscellaneous Conditions Tenosynovitis in thumb IAPL and EPBI Finkelstein's test10 in de Ouervain's disease P f Bunnel-Littler test\" Differentiate tight intrinsic muscles f from PIP joint capsular tightness M e p Test for tight retinacular Differentiate tight retinacular ligaments ligaments\" from capsular tightness Varus and valgus stress test\" Ligamentous instability of digit Allen's test\" collateral ligaments Useful in gamekeepers/skiers thumb Occlusion of radial or ulnar artery

Test Procedure Positive Sign Pt sits with hand resting with palm flat Inability to adduct the 5th digit to other on table. Examiner passively spreads PI's fingers fingers and asks Pt to bring fingers back together. Pt makes fist with thumb held beneath Reproduction of PI's Sx over APL and EPB flexed fingers. Examiner stabilizes PI's tendons forearm and ulnarly deviates PI's wrist. PIP joint unable to flex. If MCP joint is then MCP joint held slightly extended while flexed a few deg and PIP joint is able to examiner moves PIP joint into flex if flex, it was due to tight intrinsic muscles. If possible. Pt unable to flex PIP joint in either position, it was due to tight joint capsule. PIP joint held in neutral position while Pt unable to flex DIP joint. If PIP joint is examiner flexes DIP joint then flexed and DIP joint flexes easily, it was due to tight retinacular ligaments. If Examiner grasps and stabilizes test DIP joint unable to flex in either position, it finger. was due to tight joint capsule Examiner then applies varus and valgus Laxity compared with uninvolved side force at MCP, PIp, or DIP joint. Failure of hand to flush red immediately Pt makes and relaxes fist several times and then squeezes fist tight to force blood out of palm. Examiner applies pressure over radial and ulnar arteries. Examiner then releases one artery. Hand should immediately flush red. Repeat for other artery.

0> N !l TREATMENT OPTIONS fOR THE WRIST AND HAND Special Condition Hx/Symptoms Hypothenar hammer syndrome Hx of using palm of hand to push, (\"dunker's hand,\" injury to ulnar pound, or twist arteryl Pt reports coldness in fingers and palm Pt reports tenderness over hypothenar Scaphoid Fx eminence Hx of FODSH injury Pt points to pain in anatomic \" snuff box Presier's disease (osteonecrosis/ Hx of FDDSH injury T avascular necrosis of scaphoid) \" Pt points to pain In anatomic \"snuff box\" L Kienbock's disease (osteonecrosis/ Hx of FODSH injury avascular necrosis of lunate) Pt points to pain over area of lunate Lunate dislocation Trauma to hand in hit or fall 0> W

Signs/Objective Findings Treatment Options Positive Allen's test Acute: rest from AGG R/D other conditions such as thoracic outlet syndrome, Raynaud's disease, or Subacute/chronic: modify activity with return Buerger's disease to sport If not improving, may require surgery Tenderness to palpation in anatomic \"snuff box Acute: immobilization in short arm spica Limited/painful wrist motion cast for a stable, nondisplaced Fx; surgery Distal pole of scaphoid may be tender for displaced Fx on palmar surface May be revealed on radiograph; not Postop: protective splinting, scar always able to tell on radiograph until mobilization, edema prevention, ARDM, osteonecrosis/avascular necrosis has isometric wrist/finger flex and ext wrist begun radial and ulnar deviation, progressing to isotonic PREs and functional strengthening activities, progressive hand weight-bearing activities lin later phases) Post casting: same as after surgery, except no scar mobilization Tenderness to palpation in anatomic Resection of scaphOid \"snuff box\" Prosthetic scaphoid implant also possible Limited/painful wrist motion Vascularized bone graft surgery Decreased grip strength Radiograph shows \"fat strap\" in middle Postop: protective splinting, scar of scaphoid where bone resorption is mobilization, edema prevention, ARDM, occurring isometric wrist/finger flex and ext, wrist radial and ulnar deViation, progressing to Dorsal tenderness over lunate with isotonic PREs and functional strengthening localized swelling activities, progressive hand weight-bearing Decreased grip strength activities (in later phases) Radiograph becomes mottled, and lunate Immobilization for 2-3 mo progressively deforms, eventually fusing May require resection of lunate and to radius implantation of a prosthetic lunate May be apparent in AP view as a Postop: protective splinting, scar wedge-shaped mass and in lat view in mobilization, edema reduction, ARDM, which capitate does not articulate with isometric wriSt/finger flex and ext, wrist \"cup\" of lunate (which is rotated radial and ulnar deviation, progressing to anteriorly out of its normal position) isotonic PREs and functional strengthening activities, progressive hand weight-bearing activities lin later phasesI Refer Pt to orthopedic surgeon (olllilllli I ....

• TREATMENT OPTIONS FOR THE WRIST AND HAND Contm' ued Special Condition Hx/Symptoms Gamekeeper's/skier's thumb Hx of traumatic ext or abd of thumb Pt points to pain over ulnar side of A MCP joint d Rheumatoid arthritis in hand Pt C/O pain and inflammation Atraumatic Stenosing tenosynovitis of APL PI reports aching pain above radial sty- and EPB (de Ouervain's diseasel loid that radiates down hand and up arm AGG: wrist and thumb motion

Signs/Objective Findings Treatment Options Instability of UCL of thumb Grade I: aggressive nonoperative Acute: ulnar side of MCP joint tender, rehabilitation swollen Grade II and III: surgery Chronic: UCL instability and functional Rehabilitation the same for nonoperative difficulty; volar subluxation of proximal and postoperative treatment: phalanx Thumb spica cast for 3 wk with MCP joint flexed 20--30 deg and IP joint left free to move to prevent scarring of extensor mechanism Removable splint afterward for 3 more wk, gentle AROM Continue to work on regaining full ROM; begin isometric strengthening, progressing to isotonics and functional strengthening activities Positive RF on blood test Rx based on stage Must R/O septic joints Control inflammation Tenosynovitis on dorsum of wrist where Preserve integrity and maintain function of extensor tendons cross all tissues Snapping or locking of tendon in sheath Focus on joint systems, not isolated joints with movement Respect pain Contracture Avoid deforming positions Deformities include ulnar deviation of dig- Conserve energy its, swan neck, boutonniere, mallet finger Maintain muscle strength and ROM Muscle weakness PI education Instability Acute: ice, NSAIDs, phonophoresis or ionto- Positive Finkelstein's test phoresis, may require cortisone/lidocaine Tenderness and crepitus in first extensor injection, splint to relax APL and EPB (15- compartment deg wrist ext. 40-deg carpometacarpal abd, R/O scaphoid Fx and carpometacarpal ar- 10 deg MP joint flex, and IP joint left freel thritis at thumb Subacute: isometrics for forearm and hand specific for pinch and grip strength Gentle passive stretch Intermittent release from splint AROM to tolerance and progress to isotonic PREs to increase forearm, grip, and pinching strength ( \"',,,/lid.

8l TREATMENT OPTIONS FOR THE WRIST AND HAND Continued Special Condition Hx/Symptoms S Carpal tunnel syndrome Insidious onset {compression of median nerve as it passes through carpal tunnel at Nocturnal burning pain in hand often wristi reported Pt reports loss of digital dexterity that interferes with ADLs Trigger thumb and trigger finger Pt may describe \"locking,\" \"catching:' or \"snapping\" of thumb or finger Iring I Ganglion cyst {at dorsoradlal or or middle finger most commoni volar radial wrist; can also occur Pt may C/O Sx being worse on at the flexor tendon sheath in the awakening and diminishing as Pt distal palm or dorsal DIP jointi \"limbers up\" digit PI reports painful lump/mass at Wrist Weight bearing such as push-ups aggravates Sx o :4 o~ -0 Q 5 WRI

Signs/Objective Findings Treatment Options Positive Phalen's test PI education lavoid repetitive wrist flex-ext Positive Tiners sign at wrist motions or prolonged wrist flexi Paresthesia in median nerve distribution NSAIDs of hand Forearm spl int to prevent constant wrist flex At later stages, Pt may have thenar {splint holds wrist in neutral to 30-deg extl atrophy and/or ape hand deformity Tendon gliding exercises\" R/D entrapment of median nerve at Wear splint 24 hr per day elbow or C6 radiculitis/radiculopathy Surgical decompression may be required if conservative Rx fails Palpation of proximal flexor tendon may be painful Refer Pt to orthopedic surgeon, who may \"Catching\" is usually palpable as tendon consider a steroid injection slides through pulley If problem persists, surgical release of tendon sheath may be performed Palpable, tender, solid mass at Wrist Splinting and relative rest If unresolving, refer PI to orthopedic surgeon for aspiration and possible surgical excision ST AND HAND

68 - - - - - - - - - - - - - - Bunt TJ, Malone JM, Moody M, et al: Frequency of vascular injury with blunt trauma-induced extremity injury. Am J Surg 160:226-228, 1990. Cailliet R: Hand Pain and Impairment. 3rd ed. Philadelphia, FA Davis, 1982. Fess EE, Philips CA: Hand Splinting: Principles and Methods, 2nd ed. St. Louis, CV Mosby, 1987. Hertling D, Kessler RM: Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods, 2nd ed. Philadelphia, JB Lippincott, 1990. Kahler DM, McCue FC: Metacarpophalangeal and proximal interphalangeal joint injuries of the hand, including the thumb. Clin Sports Med 11 :57-75, 1992. Korkala OL, Kuokkanen HOM, Eerola MS: Compression-staple fixation for fractures, non-unions, and delayed unions of the carpal scaphoid. J Bone Joint Surg Am 74:423-426, 1992. Lister G: The Hand: Diagnosis and Indications, 2nd ed. New York, Churchill Livingstone, 1984. U'I Newland CC: Gamekeeper's thumb. Orthop Clin North Am 2341-48,1992. :2: Philips CA: Rehabilitation of the patient with rheumatoid hand ::0 involvement. Phys Ther 691091-1098, 1989. (f) -1 Rutherford RB: Vascular Surgery, 4th ed. Philadelphia, WB lz> Saunders, 1995. o Spinner M, Spencer PS: Nerve compression lesions of the upper I extremity: A clinical and experimental review. Clin Orthop lz> 104:46-66,1974. o Wadsworth LT: How to manage skier's thumb. Phys Sports Med 20:69-78, 1992. Wilgis EFS, Yates AY: Wrist pain. In Nicholas JA, Hershman EB (eds): The Upper Extremity in Sports Medicine. St. Louis, CV Mosby, 1990.

m- - - - - - - - - - - - 6 9 THORACIC SPIN[ Subjective w Examination Z t Pt Hx (region specific): Does Q... coughing, sneezing, straining, or (f) anything that increases intradiscal and intrathecal pressure aggravate U the Sx? Sx with breathing? u • Does any particular posture aggravate Sx? Radicular Sx (dermatomal or sclerotomal)? (see <t: Appendices A and B) IT: • SO o t Review of systems (cardiovascular, gastrointestinal, pulmonary) I f-

70 - - - - - - - - - - - - - - - Objective Examination I. Standing A. R/O lumbar spine pathology B. R/O nonmusculoskeletal abnormalities and tumors of the renal, pulmonary, cardiovascular, and gastrointestinal systems C Observation 1. Gait 2. Posture (e.g, scoliosis, dowager's hump, kyphosis) D. AROM (note quality, pain) using methods such as fingertip to floor or down side of leg 0) or an inclinometer 1. Thoracic flex --l 2. Thoracic ext I 0 3. Thoracic sidebending ::0 n:t> E. Myotomal screening n 1. Ankle PF (Sl-S2): single leg-heel raise (f) \\J (see Chapter 10) z m II. Sitting A. R/O cervical spine pathology B. Observation 1. Function a. RFIS b. REIS C. AROM (note quality, pain) using methods such as inclinometer or estimation 1. Thoracic flex 2. Thoracic ext 3. Thoracic sidebending 4. Thoracic rot D. Myotomal screen* *Myotomal screen and reflexes are commonly included in a lumbar spine examination and are included here because pathology in the thoracic spine can impact the results of these tests.

--------------71 1. Shoulder elevation/shrug (C3-C4) zw 2. Shoulder abd (C5) 3. Elbow flex/wrist ext (C6) 0... 4. Elbow ext/wrist flex (C7) UJ 5. Thumb IP ext/finger flex (C8) 6. Finger add (T1) U 7. Hip flex (L1-L4) 8. Knee ext (L2-L4) u 9. Great toe ext (L5) (or supine) E. MSR <t 1. Knee jerk (L3-L4) a: 2. Hamstring (L5) 0 3. Ankle jerk (S 1) I F. Pathologic reflexes (if applicable*) f- 1. Babinski's 2. Clonus to G. Special tests (if applicable) 1. Dural irritation/nerve root involvement: slump test H. Sensation (dermatomes) (see Appendix A) III. Supine A. Myotomal screen 1. Ankle DF (L4-S1) B. Special tests (if applicable) 1. Dural/meningeal irritation-nerve root involvement: Brudzinski's sign, SLR (Lasegue's test), upper limb tensioll testing IV Sidelying A. Myotomal screen 1. Ankle inv (L5-S1) *Myotomal screen and reflexes are commonly included in a lumbar spine examination and are included here because pathology in the thoracic spine can impact the results of these tests.

3NldS JIJ SPECIAL TESTS FOR THE THORACIC SPINE Test Procedure Test Detects Pt sitting on edge o in neutral and with Slump test' Increased tension in dura/meninges full thoracic and lum spine maximally, an Brudzinski's sign' Dural or meningeal irritation Pt actively extends Nerve root involvement foot. Pt supine. Pt passiv chest.

J'v'tJOHl I 9 --:t ~ < n co » -0 co 0 s;::l\" w N L -0 ::J --0 N a OJ CD OJ n :g :g »a aa-<(f) ~ ::J D A .-+ -0 D n a :3 a.-+ OJ ::J OJ OJ < <a -<< <CDOJ .-+ CD OJ ::J ::J CD (f) A ~ (f) C D <:'\". 0 D <:'\". -0 ~ CD U;.-+ CD CD CD CD CD X OJ ::J OJ ::J < --0 .-+ CD C/) ::J -0 0 -0 ro0- ro <s;::Q) D Cr 0.. -I'> CD CD I ::J ~ C/) a (f) 0- N --(f) (f) S!!..- o ro::J C ~ .-+ (f) (Q ~ OJ D 0- D (f) ::J (Q D ~ ::J 0.. (Q C ::J ~ ::J <8.. (Q ~ CD -CX-D- X .-+ Positive Sign of table, with legs supported and hips Reproduction of Sx in back and radicular Sx h hands behind back. Pt slumps into mbar flex. Pt then flexes cervical Reproduction of Sx in back, and Pt nd examiner maintains overpressure. involuntarily flexes knees and hips to relieve back pain knee. Then examiner dorsiflexes PI's vely flexes neck by pulling head to

• TREATMENT OPTIONS FOR THE THORACIC SPINE Special Condition Hx/Symptoms S Scheuermann's disease (juvenile 12-18 yr old; M > F O kyphosis) Insidious onset of localized pain R w Costovertebral joint dysfunction Onset may be sudden or insidious M Postural dysfunction (R/O rib Fx if sudden traumal H , Unilateral Sx over costovertebral joint a AGG: deep breath P Ease: maintained pressure on back, c erect posture P Insidious onset a Pt may describe occupation that places L stress on thoracic spine (e.g., seamstress flexed over a sewing machine, computer operator without arm rests/support) Compression Fx Osteoporotic individual Sharp pain with or without signs of nerve root compression Flex increases Sx

Signs/Objective Findings Treatment Options Observable thoracic kyphosis Relative rest Radiographs show kyphosis and anterior Pt education/postural education wedging of vertebrae Back extensor strengthening May see tight hamstrings Hamstring stretching, if appropriate Having Pt rotate to side of pain Costovertebral joint mobilization aggravates Sx AROM exercises for thoracic spine Palpation of joint/PA glides at Postural education costovertebral joint may reproduce Sx Back extensor strengthening Pt demonstrates poor posture in sining Postural education and/or standing Help Pt solve ergonomic problems at work/ Localized tenderness home that are contributing to problem Back extensor strengthening, may consider scapular stabilization exercises and relaxation exercises such as shoulder rolls Diagnosis by radiograph This applies only to anterior compression Fx with posterior structures intact (most Flex is very painful common) Single thoracic compression Fx Spinal brace or support to help Pt maintain characterized by a prominent spinous ext and prevent flex (e.g., CASH or Jewett and wide interspinous space below brace, semirigid Taylor-type brace, prominent spinous process dorsolumbar corset) Multiple thoracic compression Fxs Pt education about positions/activities that characterized by progressive increase of are beneficial or potentially harmful kyphosis Encourage positions/activities that promote spinal ext and avoid flex Teach Pt to roll to side when gening out of bed Use a good lumbar support when sitting Walking and other weight-bearing activities to help prevent further demineralization of bone Active and passive ext exercises as soon as PI's pain is decreased to the point that these may be tolerated

76 - - - - - - - - - - - - - - References 1. Maitland GD: The slump test: Examination and treatment. Aust J Physiother 31 :215, 1985. 2. Brudzinski J: A new sign of the lower extremities in meningitis of children (neck sign). Arch Neurol 21 :217-218, 1969. Bibliography Grieve GP: Mobilisation of the Spine. Notes On Examination, Assessment, and Clinical Method, 4th ed. New York, Churchill Livingstone, 1984. Magarey ME: Examination of the cervical and thoracic spine. In Grant R (ed): Physical Therapy of the Cervical and Thoracic Spine. New York, Churchill Livingstone, 1994. en ---1 oI n:»0 n (f) \"\"U Z m

0 . - - - - - - 77 lUMBAR SPIN[ Subjective Examination • Pt Hx (region specific): Does coughing, sneezing, straining, or anything that increases intradiscal and intrathecal pressure aggravate the Sx? • Nature of pain: radicular Sx (dermatomal or sclerotomal)? (see Appendices A and B) • Specific postures that increase or decrease the pain • SO (night pain, bowel/bladder, saddle anesthesia, bilateral numbness and tingling in extremities) • Review of systems (gastrointestinal, urinary, cardiovascular, endocrine, neurologic)

78 - - - - - - - - - - - - - Objective Examination I. Standing A. Observation 1. Gait 2. Posture (e.g., lat shift, pelvic height! asymmetries, scoliosis, increased or decreased lumbar lordosis) 3. Function a. Toe walking (Sl-S2) b Heel walking (L4-S1) c. RFIS/REIS B. R/O non musculoskeletal abnormalities and tumors of the kidney and prostate, UTI, AAA, and ulcers ,- C. AROM (note quality, pain) using methods c such as estimation, inclinometer, tape ~ measure of excursion, and fingertips to floor »OJ or down side of leg :0 (J) 1. Lumbar flex \\J Z 2. Lumbar ext m 3. Lumbar sidebending 4. Lumbar rot D. Myotomal screen 1. Ankle PF (Sl-S2): single leg-heel raise (see Chapter 10J E. Special tests (if applicable) 1. Quadrant test II. Sitting A. Myotomal screen 1. Hip flex (L1-L4) 2. Knee ext (L2-L4) 3. Great toe ext (L5) (or supine) B. MSR 1. Knee jerk (L3-L4)

- - - - - - - - - - - - - - 79 2. Hamstring (L5) w 3. Ankle jerk (Sl) C. Pathologic reflexes Z 1. Babinski's 2. Clonus CL D. Special tests (if applicable) (J) 1. Tripod sign 2. Slump test a: E. Sensation (dermatomes) (see Appendix AJ III. Supine <! A. R/O hip pathology B. Observation (l) 1. Function: RFIL C. Myotomal screen 2 1. Ankle DF (L4-S1) D. Special tests (if applicable) =:> 1. Dural/meningeal irritation-nerve root --l involvement: Brudzinski's sign, SLR (Lasegue's test) ,... 2. SI joint: SI joint gapping 3. Leg length (apparent vs. true) a. Perform Wilson-Barstow maneuver first 4. Sx magnification a. Hoover's test b. Waddell's signs': superficial tenderness, rot and axial loading, distraction-SLR, regional sensation loss/weakness, overreaction IV Side lying A. Myotomal screen 1. Ankle inv (L5-S1) 2. Ankle ev (Sl) B. Special tests (if applicable) 1. SI approximation

3NldS 8\\;f8l • SPECIAL TESTS FOR THE LUMBAR SPINE I Test Detects Quadrant tests' Intervertebral narrowing/nerve root involvement (position of maximum intervertebral foramen narrowingi Slump test' Increased tension in dura/meninges ... Dural or memngeal Irritation Nerve root involvement :..:.0..

lAJnl L (J:) 0 <- »m 0 0 OJ II s: 0W (3 -'0 a-<~N e- II (/) ::J Q. OJ LJ <D ~ ~OJ 0- ::J <D 11 (IJ a::J .-+ OJ II A .-+ C <D :3<5(IJ .-+ () ::J ::J :( C 0 LJ ::J (3 <D OJ () < < -<< OJ <D (IJ ~. OJ OJ ::J () ~. a a<DII II <D .-+ ~ U; CD A <D <D <D ::J ::J <D ::J X <D (IJ 6-LJ .-+ (IJ <D ::::;; r :JJ .j:>. m CD <D OJ I ::J r ::J LJ (/) (IJ LJ N (IJ 0.. C ::J o' (Q OJ .-+ 0- ~CD <D (IJ .-+ Test Procedure I Positive Sign Pt standing. Pt extends spine while Sx reproduced down lower extremity to examiner stands behind to control same side movement and apply overpressure in ext while Pt laterally flexes and rotates to Reproduction of Sx in back and radicular the side of pain. Sx Pt sitting on edge of table with legs ReprodUction of Sx In back. and Pt supported and hips in neutral and with involuntarily flexes knee and hips to hands behind back. Pt slumps into full relieve back pain thoracic and lumbar flex. Pt then flexes cervical spine maximally. and examiner ((IlI,.wd ~ maintains overpressure. Pt actively extends knee. Then examiner dorsiflexes PI's foot Pt supine. Pt passively flexes neck by pulling head to chest

CXl N SPECIAL TESTS FOR THE LUMBAR SPINE Continued Test Detects SLR ILasegue's test1with ankle OF Dural/meningeal irritation Nerve root impingement due to disc variant~l protrusion or herniation I Dural/meningeal irritation Nerve root impingement due to disc Tripod sign' protrusion or herniation Babinski's reflex/sign' Upper motor neuron lesion Prone knee-bending test Ifemoral L2-L3 nerve root lesion nerve testI\" Symptom magnification or malingering Hoover's test\"· \" SI joint gapping test\" Sprain of anterior SI ligaments Si joint approximation test\" True leg length\" SI joint lesion dysfunction Sprain of posterior SI ligaments Leg length Apparent leg length\" Lat pelvic tilt Icould be AP rotatedI Wilson-Barstow maneuver\" Used for establishing symmetry before leg length measurement CXl W

Test Procedure Positive Sign Pt supine. Examiner passively raises PI's Reproduction of radicular pain when leg leg to where radicular Sx are is between 30 and 70 deg and pain reproduced. Leg is lowered slowly to reproduced again when foot is where pain is relieved. Examiner then dorsiflexed dorsiflexes PI's foot. PI extends trunk to relieve tension lor PI sits with both knees flexed 90 deg falls backward and supports body with over edge of table. Examiner passively UEsl extends one knee. This can be performed during routine portion of Pt involuntarily extends big toe and examination after checking MSRs. abducts Isplaysl other toes Pt supine. Examiner runs pointed object When knees return to 90 deg, Pt along plantar aspect of Pi's foot and exhibits decreased MSRs and muscle across metatarsal heads lat to med. weakness Pt prone. Examiner hyperflexes PI's knees Pt fails to lift leg or examiner does not bilaterally Iheels to buttocksl This feel pressure under opposite heel position is held 45-60 sec. Pt supine. Examiner places one hand under each heel and Pt is asked to perform a SLR one leg at a time. Pt supine. Examiner presses down and Increased pain/reproduction of Sx in out on ASISs simultaneously. unilateral gluteal/posterior thigh Reproduction of PI's Sx, pressure or pain PI sidelying. Examiner presses down on at SI joint (not at iliac crest or lumbar iliac crest. spinel Difference in measurements greater than PI supine. Examiner measures ASIS to 1-15 cm tip of med malleolus. Perform Wilson- Barstow maneuver first Isee below) Difference in measurements Relative length of tibia may be tested with PI prone and knee flexed 90 deg. No positive sign. Is used to ensure Examiner's thumbs placed on soles of symmetry before measuring leg length. feet. Note relative heights of thumbs. PI supine. Distance from tip of xiphoid process or umbilicus to tip of med malleolus. PI supine. Examiner stands at Pi's feet and palpates med malleoli with thumbs. PI flexes knees and then pushes off with heels to lift pelvis from table. Pt returns pelvis to table and examiner passively extends Pi's knees and compares positions of malleoli. Tape measure can then be used to measure from ASIS to distal portion of med malleolus.

J TREATMENT OPTIONS FOR THE LUMBAR SPINE Special Condition Hx/Symptoms Disc bulge or HNP Most common at L4-L5 and L5-S1 Recurrent episodes usually show progression of Sx into extremity with each episode AGG: any activity that increases intradiscal pressure (cough, sneeze, prolonged sitting! Ease: any activity that decreases intradiscal pressure (supine lying with leg supported, stand better than sit) Acute radiculitis/radiculopathy Radicular Sx in dermatomal pattern Inerve root becomes inflamed, (distal worse than proximal) causing compression that results in Constant, severe pain ischemia and loss of nerve root conduction [i.e., paresthesia, AGG: cough, sneeze, forward flex decreased MSRs, muscle weaknessll 00 (Jl

Signs/Objective Findings Treatment Options Guarded/restricted movement Acute: attempt to correct lat shift if Loss of lumbar lordosis present and initiate McKenzie ext Lat trunk shift exercises (if they do not peripheralize Positive SLR test/Lasegue's test SX)17 Mayor may not have objective neurologic signs (ie, decreased MSRs, Maintain lumbar lordosis and avoid strength, and sensation in a specific positions that increase intradiscal dermatomal pattern! pressure during healing Flex increases and may peripheralize Sx Elastic lumbosacral corset to reduce Sustained or repeated ext decreases intradiscal pressure and/or may centralize Sx Positioning for pain relief, lumbar roll Moist heat or ice for anesthetic effect Interferential electrical stimulation to help in pain modulation Lumbar traction or positional traction Subacute/chronic: progress to back strengthening/stabilization exercises Aerobic training (walking, cycling, pool therapy) after Sx have centralized and decreased Pt looks ill Pt education (posture, lifting, maintaining neutral position during ADLs) Movement severely limited (may stand Total management may be 6-12 wk with one knee flexed to decrease stretch Refer Pt to orthopedic surgeon or on nerve root) neurosurgeon for progressive neurologic deficits Positive tension signs (SLR test. slump test, or Brudzinski's sign! Requires caution Objective neurologic signs with Acute: bed rest (1-2 d maximum!. ice, radiculopathy leg, decreased MSRs, Meds muscle weakness) Evaluate whether ext helps Sustained lumbar traction R/O piriformis syndrome Positional traction Monitor neurologic system each visit Should see improvement in 7-10 d Subacute/chronic: When ready, begin functional rehabilitation and educate Pt in proper body mechanics, protection, and strengthening of lumbosacral and abdominal muscles If progressive neurologic deficits occurring, refer Pt to orthopedic surgeon or neurosurgeon. TC,m/illlled

co O'l 11 TREATMENT OPTIONS FOR THE LUMBAR SPINE Contmued Special Condition Hx/Symptoms Lumbar spondylosis 10001 Central LBP; may radiate into buttocks Does not radiate into extremity Ibut can if disc height IS decreased to where it causes encroachment of intervertebral foramenj Nature of pain: often a deep constant ache AGG: activities that increase intradiscal pressure Ease: positions that reduce pressure on disc and moist heat AM stiffness that is eased with movement Spondylolysis/spondylolisthesis; Most common site is L5-S1 defect involving pars interarticularis, Onset can usually be traced to vigorous slippage of vertebral body occurring activity or trauma involving forceful ext with spondylolisthesis Sx may be local or referred Pt may have hyperlordosis Ease: flex or sitting Spinal stenosis Male> female (2:1j Hx of LBP for several years Burning, numbness/tingling that radiates distally May report B/B Sx and/or saddle anesthesia AGG: prolonged standing and walking, lumbar extension

Signs/Objective Findings Treatment Options Neurologic findings usually normal General mobility exercise le.g., supine lumbar rotI unless foraminal Confirmed by decreased disc space on encroachment is present radiograph Appropriate modality for pain modulation Dsteophytes/spurring at vertebral bodies may also be seen on radiographs Flexibility exercises Limited lumbar ROM Initially, exercise in direction opposite of that which aggravates Sx (flex vs. extI May consider manual or mechanical traction Joint mobilization techniques may be beneficial in presence of marked hypomobility Aerobic training le.g., pool, cycle, walkj Elastic lumbosacral corset to reduce intradiscal pressure Pt education, especially to avoid prolonged periods of sitting and other activities that increase intradiscal ressure Radiograph shows defect IFx line across Acute: modalities, prescribe corset. and neck of \"Scottie dog\" in oblique/Scottie discuss with MD dog viewl Bone scan may confirm if this is Acute spondylolysis may heal with suspected clinically but is unable to be immobilization Ibone scans helpful to determined by radiograph because it is distinguish between patients who have in stress-reaction stage before Fx or it is an established nonunion and those in a small or partial Fx whom healing is still progressing and Exquisitely TIP with central PAIVMs over who may therefore benefit from area of defect immobilizationj\" Ext increases Sx, and flex decreases Sx Subacute/chronic: Flex exercises and Must differentiate from Sx of vascular abdominal strengthening claudication Radiographs may help confirm Back care and postural education Avoid heavy labor/lifting and vigorous physical activity le.g., flag football, soccer, wrestling I If this is first time Pt has been seen for this, consider an orthopedic consultation Fusion may be indicated in some Pts\" 19 Pt education Flex exercises Lumbar traction Elastic lumbosacral corset Carefully tailored aerobic exercise program Ibike, walk, swiml Refer Pt to orthopedic surgeon or neuro- surgeon if Pt has progressive neurologic signs (B/B, saddle anesthesia, declining MSRs, progressive LE weaknessj {out\",,, 1/ ~

(Xl (Xl I TREATMENT OPTIONS FOR THE LUMBAR SPINE Continued Special Condition Hx/Symptoms Apophyseal/facet joint impingement Sharp, unilateral, well-localized pain limpingement of synovial and capsular tissue between facet joint PI may report a sudden unguarded surfacesI movement involving ext, sidebending, and/or rot Apophyseal/facet joint sprain H/O moderate to severe trauma le.g., twistingl Sharp, unilateral, well-localized pain Ankylosing spondylitis (characterized Pt typically 20-35 years old at time of by progressive joint sclerosis and onset ossification of ligaments first appearing in SI joints and spreading First noticed as vague LBP and stiffness to lumbar and thoracic spine and that is worse at waking and eased with ribs; severe cases can affect exercise cervical spine and hipsl Intermittent Sx Episodes may last weeks or months Onset of each acute episode seems insidious, unrelated to exertion or activities (Xl <D

Signs/Objective Findings Treatment Options PI has difficulty standing erect Acute: rest. ice, and other pain- PI in a protective posture modulating modalities, lumbosacral Neurologic status is normal corset TIP over involved apophyseal/facet joint Responds well to early mobilization or Subacute/chronic: progressive AROM, traction joint mobilization, traction, and/or ftex exercises Ito open up facets!. back care Pt has difficulty standing erect education Pt in a protective posture Neurologic status is normal Treated more conservatively than facet TIP over involved apophyseal/facet joint joint impingement because of likely Poor response to early mobilization or effusion around joint traction Acute: modalities, painfree movement. lumbosacral corset. and rest Subacute: gradually increase mobility and may perform gentle mobilization Guard against loss of normal lordosis from prolonged maintenance of protective posture Loss of lumbar lordosis Pt education is crucial. Encourage PI to avoid heavy lifting work. Let PI know Increasing rounding of thoracic and that spine will eventually stiffen in a cervical spines way that does not interfere with sedentary work and that pain is Laboratory tests reveal elevated controllable. sedimentation rates Instruct PI in positioning and postural Radiographs may be helpful in Ox only exercises to resist gradual development after several years, with earliest of a flexed spine abnormalities seen in SI joints Emphasize passive and active ext exercises Pt should use lumbar roll when sitting to encourage ext Encourage Pt to sleep on a firm mattress, to avoid lying flexed or in a fetal-type position, and to avoid using more than one pillow in supine position Lumbar support, medication, and modalities may be helpful during acute episodes TCOlltill,u,t!

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91 References wz 1. Waddell G. Main CJ, Morris EW. et al. Chronic low-back 0::: pain, psychologic distress, and illness behavior. Spine 9.209-213, 1984 Ul 2. Corrigan B, Maitland GD. Practical Orthopaedic Medicine. a: Boston. Butterworths, 1985. <co! 3. Maitland GD. The slump test Examination and treatment. 2 Aust J Physiother 31215,1985 . =:J 4. Brudzinski J. A new sign of the lower extremities in meningitis of children (neck sign). Arch Neurol 21.217-218, 1969. -.J 5. Wilkins RH, Brody IA. Lasegue's sign. Arch Neurol ..... 2U19-220, 1969. 6. Charnley J. Orthopedic signs in the diagnosis of disc protrusion with special reference to the straight-leg-raising test. Lancet U 86-192. 1951. 7. Scham SM, Taylor TKF. Tension signs in lumbar disc prolapse. Clin Orthop 75195-203. 1971 . 8. American Orthopaedic Association. Manual of Orthopaedic Surgery. Chicago. American Orthopedic Association, 1972. 9. Dodd J, Kelly JP. Trigeminal system. In Kandel ER, Schwartz JH, Jessell TM (eds). Principles of Neural Science, 3rd ed. New York, Elsevier Science Publishing, 1991. 10. Herron LD, Pheasant HC Prone knee-flexion provocative testing for lumbar disc protrusion. Spine 5.65-67, 1980. 11. Hoover CF. A new sign for the detection of malingering and functional paresis of the lower extremities. JAMA 5U46-747, 1908. 12. Arieff AJ, Tigay EL, Kurtz JF, et al. The Hoover sign. An objective-sign of pain and/or weakness in the back or lower extremities. Arch Neurol 5.673-678, 1961 . 13. Magee DJ. Orthopedic Physical Assessment, 3rd ed. Philadelphia, WB Saunders, 1997. 14. Adams JC Outline of Orthopaedics, 9th ed. London, Churchill Livingstone, 1968. 15. Hoppenfeld S. Physical Examination of the Spine and Extremities. Norwalk, CT, Appleton & Lange, 1976. 16. Woerman AL. Evaluation and treatment of dysfunction in the lumbar-pelvic-hip complex. In Donatelli R, Wooden MJ (edsL Orthopaedic Physical Therapy. New York, Churchill Livingstone, 1989. 17. McKenzie RA The Lumbar Spine: Mechanical Diagnosis and Therapy. Wellington, New Zealand, Spinal Publications, 1991. 18. Hensinger RN. Current concepts review spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Am 7U098-1105, 1989. 19. Pedersen AK, Hagen R. Spondylolysis and

92 - - - - - - - - - - - - - - spondylolisthesis: Treatment by internal fixation and bone-grafting of the defect. J Bone Joint Surg Am 70: 15-24, 1988. Bibliography Grieve GP: Common Vertebral Joint Problems. New York, Churchill Livingstone, 1981. Hertling D, Kessler RM: Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods, 2nd ed. Philadelphia, JB Lippincott, 1990. Kisner C, Colby LA: Therapeutic Exercise: Foundations and Techniques, 2nd ed. Philadelphia, FA Davis, 1990. McKenzie RA: The Lumbar Spine: Mechanical Diagnosis and Therapy. Wellington, New Zealand, Spinal Publications, 1991. Saunders HD, Saunders R: Evaluation, Treatment and Prevention of Musculoskeletal Disorders: Spine, 3rd ed, vol. 1. Chaska, MN, Educational Opportunities, 1993. Schonstrom N: Lumbar spinal stenosis. In Twomey LT, Taylor JR (eds): Physical Therapy of the Low Back. New York, Churchill Livingstone, 1994. r Sinaki M, Lutness MP, Iistrup DM, et al: Lumbar spondylolisthesis: C Retrospective comparison and three-year follow-up of two S »OJ conservative treatment programs. Arch Phys Med Rehabil :0 70:594-598, 1989. (/) \"\"U Z m

m - - - - - - - - - - - -93 I!I HIP Subjective Examination t Pt Hx (region specific): H/O trauma, \"snapping,\" \"popping,\" or \"grinding\" t SQ, if applicable 0... I

94 - - - - - - - - - - - - - - Objective Examination I Standing A. R/O spine or SI joint pathology B. Observation 1. Gait 2. Posture a. Leg length (i.e., PSIS/ASIS level) 3. Function (e.g., squat) C. Special tests 1. Trendelenburg's test II Sitting A. AROM 1. Hip ER (40-50 deg) 2. Hip IR (35-45 deg) co B. GMMT 1. Hip flex (test sidelying if status poor or I worse) IJ 2. Hip ER/IR (test supine if status poor or worse) III. Supine A. R/O knee pathology B. Observation C. AROM 1. Hip flex (120-130 deg) 2. Hip abd (40-45 deg) 3. Hip add (20-30 deg) 4. Hamstring length D. Special tests (as applicable) 1. DJD/hip joint pathology: Scouring test, Faber's test (vs. SI joint) 2. Hip flexor length test: Thomas's test 3. Piriformis syndrome: sign of the buttock 4. Stress fracture: percussion test 5. Leg length (apparent vs. true): perform