PHYSICAL EXAMONATION

OF THE SPINE AND OTHER

EXTREMITIES
BR E N DA N KEA R N EY
I S M HST
7 T H P E R I OD

What is the physical examination of the

spine and extremities?
This is one of the first steps taken towards spinal
injury diagnosis before X-RAYS, or MRIs.
This examination is used to help diagnose symptoms
such as pain, or tingling, in order to locate what
vertebra/ Vertebra's injured.
It also gives the patient familiarity with their
symptoms, and increases their knowledge to monitor
their own symptoms for any variation.

Neurological and Muscular Examination

of the shoulder
This will be my main focus of the presentation because it directly pertains to the spine, my
mentors profession
The neurological portion of the examination permits assessment of the strength of each group
of muscles. It may also indicate the degree of motor weakness that might restrict range of
motion. In addition to the to the muscle testing, reflex and sensation tests allow for further
determination of the integrity of the nerve supply to the extremities.
Muscle testing works in direct conjunction with the neurological examination. Muscle testing in
the shoulder involves nine motions: (1) Flexion, (2) Extension, (3) abduction, (4) adduction, (5)
external rotation, (6) internal rotation, (7) scapular elevation (shoulder shrug), (8) scapular
retraction (position of attention), and (9), shoulder protraction (reaching).
These motions have been divided into distinct categories.

Primary and Secondary Flexors

Primary Flexors:
1) Anterior portion of the deltoid, Axillary nerve, C5
2) Coracobrachialis, musculocutaneous nerve, C5-C6
Secondary Flexors:
1) Pectoralis major (clavicular head)
Biceps
Anterior portion of the deltoid
Primary- Stand behind the patient and place your hand palm downward upon the acromion so that you
can stabilize the scapula and palpate the anterior portion of the deltoid as you test. Place your other hand
just proximal tot eh elbow, wrapping your fingers around the anterior aspect of the arm and the biceps
muscle. When the elbow is flexed at 90 degrees, instruct the patient to begin flexion of the shoulder. As
he or she begins, gradually increase your resting pressure until you determine the maximum resistance he
or she can overcome. Test the opposite shoulder to make a comparison on your findings.

Primary and Secondary Extensors

Primary extensors:
1) Latissimus dorsi, thoracodorsal nerve, C6, C7, and C8
2) Teres major, lower scapular nerve, C5 and C6
Posterior portion of the deltoid, axillary nerve, C5, C6
Second Extensors:
1) Teres minor
2) Triceps
Stay behind the patient and keep your stabilizing hand on his or her acromion. Place your thumb on the
posterior aspect of the shoulder so that during the active extension you can palpate the posterior portion
of the deltoid for tone. Place your resting hand just proximal to the posterior aspect of the elbow joint
with the thenar eminence and palm against the posterior portion of the humerus. Then ask the Patient to
flex his or her elbow and to slowly extend their arm posteriorly. As the patients shoulder moves into
extension gradually increase pressure until you can determine the maximum amount of resistance the
patient can overcome.

Primary and Secondary Abductors

Primary Abductors:
1) Middle portion of the deltoid, axillary nerve, C5, C6
2) Supraspinatus, suprascapular nerve, C5, C6
Secondary Abductors:
1) Anterior and posterior portions of the deltoid
2) Serratus anterior (by direct action on the scapula)
Remain behind the patient. Continue to stabilize the acromion, but slide your hand slightly laterally so
that while you stabilize the shoulder girdle you can also palpate the middle portion of the deltoid. Keep
your other hand proximal to the elbow joint, but move it from the posterior aspect of the humerus to the
lateral aspect so that maximum resistance can be applied. Your palm should now be pressed against the
lateral epicondyle and supracondylar line of the humerus, with your fingers wrapped around the anterior
aspect of the arm. Then ask the patient to abduct his arm, and , as he or she moves it into abduction,
gradually increase resisting pressure until you determine the maximum resistance that he or she can over
come.

Primary and Secondary Adduction

Primary Adduction:
1) Pectoralis major, medial and lateral anterior thoracic nerve, C5, C6, C7
2) latissimuss dorsi, thoracodorsal nerve, C6, C7
Secondary Adductors:
1) Teres major
2) Anterior portion of the deltoid
Remain behind the patient, with your stabilizing hand upon the acromion and your resting hand proximal
the elbow joint. Since the pectoralis major muscle is a primary adductor, move your stabilizing hand
anteriorly and inferiorly on the acromion so that you can palpate the pectoralis major as it is tested.
Instruct the patient to place his arm in a few degrees of abduction and shift your resting hand so that your
thumb rests against the medial aspect of the humerus. Then as the patient to begin abduction while you
gradually increase the degree of resisting pressure, until you determine the maximum amount of
resistance he or she can overcome.

Primary and secondary External Rotation

Primary External Rotators:
1) Infraspinatus, suprascapular nerve, C-5, C6
2) Teres minor, branch of the auxiliary nerve, C-5
Secondary External Rotators:
3)Posterior portion of the deltoid
Move to the patients side and have them bend their elbow to a 90 degree angle, with his or her forearm
in a neutral position. Stabilize the extremity by holding his o her flexed elbow into the waste. This will
prevent the patient from substituting adduction for pure external rotation. Move your resisting hand to
the patients wrist, so that your thenar eminence rest upon the dorsal surface to provide maximum
resistance. Instruct the patient to rotate their arm outward. As he or she moves into external rotation,
gradually increase the pressure of resistance until you determine the maximum amount of reistance the
patient can overcome.

Primary and secondary Internal rotation

Primary internal rotation:
1) Subscapular, upper and lower scapular nerves, C5, C6
2) Pectoralis major, medial and lateral anterior thoracic nerves, C5, C6, C7, T1
3) Latissimus dorsi, thoracodorsal nerve, C6, C7
4)Trese major, lower scapular nerve, C5, C6
Secondary internal rotator:
Anterior portion of the deltoid
Remain at the patients side and instruct them to hold his or her elbow at a 90 degree angle of flexion as
you continue to stabilize their upper arm by holding his or her elbow to the waist. This will prevent the
patient from substituting adduction for pure internal rotation. Maintain your stabilizing hand just proximal
to the wrist, but shift it so that your fingers will wrap around the volar surface of the wrist, with your palm
over the radial styloid process. Then ask the patient to gradually rotate his or her arm around the front of
his body and, as he or she does so, slowly increase resisting against his wrist.

Primary and secondary scapular

elevation
Primary elevators:
1) Trapezius, spinal accessory nerve, or cranial nerve XL
2) Levator scapulae, C3, C4, and frequently branches from the dorsal scapula nerve, C5
Secondary elevators:
1) Rhomboid major
2) Rhomboid minor
Stand behind the patient and place one hand upon each acromion. The lateral position of your hands
allows the trapezius to work freely and gives your hands a firm, boney base of support. Instruct the
patient to shrug his or her shoulders, and slowly increase downward resisting pressure until you
determine the maximum resistance he or she can overcome.

Primary and secondary Scapular

retraction
Primary retractors:
1) Rhomboid major, dorsal scapular nerve, C5
2) Rhomboid minor, dorsal scapular nerve, C5
Secondary retractor:
Trapezius
Stand in front of the patient and place your hand upon his or her shoulders with the palms anterior to the
acromion and the fingers on the shoulders posterior aspect. Your finger should remain behind the
shoulder so that they can provide the moving force when you attempt to push or bend the shoulders
around the fulcrum of your thumb. Ask the patient to throw his or her shoulders back to maximum
retraction, then slowly apply pressure with your finger trying to bend the shoulder forward around your
thumb.

Primary Scapular Protraction

Primary protractor (reaching):
Serratus anterior, long thoracic nerve, C5, C6, C7
To prepare the patient instruct them to flex his or her arm to a 90 degree, then to flex his elbow so that
his or her hand touches his or her shoulder. Place one hand over his or her spine to stabilize the trunk to
prevent substitution of the trunk rotation for pure shoulder protraction. Place your resting hand cupping
under the elbow. Then ask him to force his bent elbow forward. As he or she protracts their shoulder,
gradually increase your resistance against this forward movement until you determine the maximum
resistance he or she can overcome.

Work cited
The only source I used was a book Dr. Santos gave me called The Physical Examination Of The
Spine And Extremities, Written by Stanley Hoppenfield, MD